Winter 2012: Guest Perspective

Integrating Health Literacy in Dental Education

Dushanka V. Kleinman, D.D.S., M.Sc.D., Associate Dean for Research and Academic Affairs at the University of Maryland School of Public Health and former Chief Dental Officer of the U.S. Public Health Service

Upon first hearing the phrase "health literacy" years ago, I thought I understood its meaning. The words were not intimidating. They lent themselves to immediate interpretation based on my personal experiences as both a consumer and a health professional. With my initial impression of familiarity, I wondered why there was such a focus on health literacy. Was this focus a strategy to revitalize health education, an essential core of public and professional health care services that had been lost? Was this focus a strategy to empower patients, clients, and the public at a time of increasing health care volume and often conflicting messages about health promotion and disease prevention? Was this focus a strategy to reinvent our complex health delivery systems?

Well, time has passed, and I now realize how naïve I was. The simplicity of the words, "health literacy," belies the complexity of their meaning and of health literacy's impact on health.

I was fortunate. I had strong and vocal teachers and mentors who guided me through the health literacy maze. Under the leadership of individuals such as Alice M. Horowitz, R.D.H., M.A., Ph.D., then a Senior Scientist at the National Institute for Dental and Craniofacial Research (NIDCR); Rima Rudd, M.S.P.H., Sc.D, Senior Lecturer at Harvard and Cynthia Baur, Ph.D., then Senior Health Communication and E-Health Advisor for the Office of Disease Prevention and Health Promotion in the Department of Health and Human Services (DHHS), I came to learn about the scope and dimensions of health literacy.

Health literacy involves a multiplicity of skills: reading, speaking, speech comprehension, writing, basic mathematics, and listening-all in the context of health. I learned that the populations that are most at risk include the elderly, the poor, and those with a high school or less education. I learned about the critical role health professionals can play by communicating to patients in a manner they find acceptable, can understand, and can act upon. I learned about the barriers created by the forms and processes that third parties impose and by the design and operations of our health care facilities. I have seen the effects of the loss of health education in our schools. And, I have learned about the need for deliberate research in this content area.

It was not hard to see that those of us in the oral health profession had a lot to gain by investing in and practicing the basic principles of health literacy. Our profession has a strong grounding in prevention science-a luxury not available to some other professions. However, this scientific knowledge needs to be transmitted to others so that they can do their part, whether they be patients, family members, policymakers, or students being trained to enter our profession.

To do this, we must overcome several challenges. Findings from studies in the past decade reveal a lack of knowledge about oral health prevention among the elderly, the poor, and caretakers and parents of young children; limited use of recommended communication practices by dental professionals; and limited knowledge about oral health among other health professionals positioned to support patients. It is our responsibility as health professionals to ensure that we have the skills to support our patients, their families, our communities, and policymakers so they become fully informed, fully engaged, and fully capable of taking action to support health. To play this role, we must also earn their trust and keep them informed as scientific knowledge evolves.

A cascade of events continues to build the scientific foundation of our understanding of health literacy and the public's and profession's awareness of its importance. Among those initiatives that are ripe for action:

Two IOM reports on oral health, released in 2011, also reflect the need to reduce oral health disparities. Each of these events and initiatives has revealed another dimension of the integral role health literacy plays in a world where challenges to health maintenance and promotion abound.

I have come to the conclusion that health literacy is an essential strategy-perhaps the essential strategy-our country needs to promote health, improve the quality of care, and control and lower health care costs. Today I am a health literacy groupie, following the emergence of scientific knowledge on our understanding of and ability to act on health information and knowing that we are just at the beginning of the research agenda. This knowledge makes me wonder. What about those who have not had an opportunity to learn about health literacy, but think they know what it means and discount its integral role in health?

There is no question we need to integrate health literacy into the formal curriculum of health professions students. Educators must take the lead, but they need to be trained. The 2010 DHHS National Action Plan to Improve Health Literacy, offers specific suggestions for improving health care delivery, and the 2011 IOM report Advancing Oral Health in America calls for professional education in best practices in patient-provider communication skills to improve oral health behaviors. These reports can serve as guides, but we need more. At my university, the Herschel S. Horowitz Center for Health Literacy has developed a formal course in health literacy that is educating graduate students in public health, health communications, library science, and ethnography. We need to extend this type of effort to all of our dental schools and dental hygiene programs, through formal courses and clinical and community experiences. We also need to work interprofessionally, in education and in practice settings, to make sure the care we provide is integrated and lays a strong common foundation for our patients.

We are in the midst of health care reform initiatives that require-no, mandate-communication using plain language so everyone can take advantage of opportunities. Our current understanding of the social determinants of health tells us that where we live, play, learn, and work affects our health-­so does our level of health literacy. It appears that health literacy is inextricably linked to improving oral health outcomes, especially among our most vulnerable. Professional schools can have a substantial impact on closing the disparities gap if they make health literacy an integral part of their educational programs.