摘要：Objectives. We examined the associations of oral health literacy (OHL) with oral health status (OHS) and dental neglect (DN), and we explored whether self-efficacy mediated or modified these associations. Methods. We used interview data collected from 1280 female clients of the Special Supplemental Nutrition Program for Women, Infants and Children from 2007 to 2009 as part of the Carolina Oral Health Literacy Project. We measured OHL with a validated word recognition test (REALD-30), and we measured OHS with the self-reported National Health and Nutrition Examination Survey item. Analyses used descriptive, bivariate, and multivariate methods. Results. Less than one third of participants rated their OHS as very good or excellent. Higher OHL was associated with better OHS (for a 10-unit REALD increase: multivariate prevalence ratio = 1.29; 95% confidence interval = 1.08, 1.54). OHL was not correlated with DN, but self-efficacy showed a strong negative correlation with DN. Self-efficacy remained significantly associated with DN in a fully adjusted model that included OHL. Conclusions. Increased OHL was associated with better OHS but not with DN. Self-efficacy was a strong correlate of DN and may mediate the effects of literacy on OHS. According to the most recent National Assessment of Adult Literacy Survey, nearly half (43%) of adults in the United States are at risk for low literacy. 1 Consumer health information is frequently written at or above the 10th-grade reading level, meaning that approximately 90 million adult Americans with low health literacy skills struggle to understand fundamental health information such as consent forms, instructions, and drug labels. 2 “Health literacy” refers to the ability to perform basic reading and numerical tasks necessary to navigate the health care environment and act on health care information. 3 Healthy People 2010 defines health literacy as [t]he degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. 4 (pp11–15) Individuals with low health literacy skills often have poorer health knowledge and health status, unhealthy behaviors, less utilization of preventive services, higher rates of hospitalizations, increased health care costs, and ultimately poorer health outcomes than do those with higher literacy levels. 5 – 11 Health literacy has been shown to function as a mediator between socioeconomic factors, such as race and education, and health behaviors and health outcomes, 12 – 14 partly explaining health disparities. 15 , 16 Paasche-Orlow and Wolf proposed a conceptual model of causal pathways between health literacy and health outcomes in which the effect of literacy on health outcomes is mediated by patient-level and extrinsic factors grouped as (1) access to and utilization of health care, (2) provider–patient interaction, and (3) self-care. 17 Although these pathways have yet to be validated, a recent report by Osborn et al. 18 suggested that self-efficacy, which refers to a person's belief in their own competence, and self-care do indeed mediate the effect of health literacy on health status. Previous investigations had not found any association between health literacy and self-efficacy. 19 , 20 The body of literature linking literacy to overall health continues to grow, but studies linking literacy to dental health are relatively new. Oral health literacy (OHL) has been defined as the degree to which individuals have the capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions and act on them. 21 The network of proximal and distal factors affecting oral health is complex and is not understood completely. These factors include genetic and environmental factors, 22 sociodemographics, 23 – 25 and personality. 26 – 28 Although OHL represents one's ability to understand and process relevant health information, other characteristics may modify one's resulting decisions or actions. In this context, recent attention has focused on the role of oral health behaviors 29 , 30 because, unlike most other factors affecting oral health, behaviors are readily amenable to change. 31 The construct of self-efficacy beliefs is considered to represent an important link between health knowledge, health behaviors, and health outcomes, 32 and it correlates well with other personality characteristics related to health behaviors. 33 Because self-efficacy is a significant determinant of health-related actions initiated or avoided by individuals, its consideration in the oral health context has been advocated. 31 , 34 Although conceptual frameworks illustrating possible pathways linking health literacy to health outcomes or health status have been developed in medicine, 12 , 14 , 17 little progress has been made in developing such pathways between OHL and oral health status (OHS). Macek et al. 35 recently proposed a conceptual model linking word recognition and conceptual knowledge, decision-making, and communication skills with oral health outcomes. Although this model is not exhaustive, we theorize that OHL likely exerts effects on avoidance of care (i.e., dental neglect [DN]; Figure 1 ), which may or may not be mediated or modified by individual or systemic characteristics along the lines of the Paasche-Orlow and Wolf model. 17 Open in a separate window FIGURE 1— Conceptual model of the association of self-reported OHS with OHL, self-efficacy, and dental neglect among female WIC participants (n = 1280): Carolina Oral Health Literacy study, North Carolina, 2007–2009. Note . NHANES = National Health and Nutrition Examination Survey; OHL = oral health literacy; OHS = oral health status; REALD = Rapid Estimate of Adult Literacy in Dentistry; WIC = Supplemental Nutrition Program for Women, Infants and Children. Dashed arrow represents effects of OHL on OHS. Solid arrows represent pathways explored and hypothesized to mediate the effect of OHL on OHS. Education and other socioeconomic and unknown or unmeasured factors are also believed to confound or mediate this association (arrows omitted for parsimony). To the best of our knowledge, no previous investigation has examined the links of OHL with OHS and DN, so we sought to establish these links. Because of the absence of any data linking self-efficacy with OHL, we also sought to examine this association and to empirically investigate the role of self-efficacy as a mediator or modifier 36 of the association between OHL and DN and OHS, without conducting any comprehensive pathway analyses.
