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Oral Health Literacy and Dental Public Health Instructor guide This course presents an overview of the definition of health literacy, the role of oral health literacy in promoting oral health and access to dental care in both private practice and in public health settings, ways to improve communication with patients, and oral health literacy are measured. It includes discussion of how oral health literacy may influence long-term oral health outcomes, and how literate sensitive communication approaches can be integrated into private and public health organizations. The course provides four 1-hour power-point presentations as well as classroom discussions, classroom activities, test questions and take home activities/assessments. Depending on the number of activities and classroom discussions, that entire length may take longer than four hours. Competency Addressed: 1. Demonstrate the ability to communicate and collaborate with relevant stakeholders in order to advocate for oral and general health. The students at the completion of the course will be able to: 1. Define health literacy & oral health literacy for the health care provider and dental public health professional 2. Understand the individual, community and public health implications of low oral health literacy 3. Explain the association between health, health literacy, health beliefs and culture 4. Explain strategies to communicate more clearly with patients, the public, or community 5. Identify aspects of an oral health literate organization and be able to suggest ways to implement oral health literate best practices 6. Describe ways to identify low health literacy through various measurement strategies Lecture 1: Health Literacy, Oral Health Literacy and Public Health Literacy Objective: Define and describe health literacy, oral health literacy, and public health literacy The lecture provides an overview on definitions of health literacy, oral health literacy, 1 and public health literacy, presents the various domains of health literacy, and how they function within the health care system. Classroom discussion: The course opens with a 6-minute video followed by a classroom discussion about videoed patients talking about the problems they have in getting health services within the health care system. Lead a discussion on how problems in understanding one’s care and medications and in how to treat ones’ medical and dental problems can lead to poor health. The National Assessment of Adult Literacy (NAAL) is presented as a national survey that contains a component designed to measure health literacy. Sample NAAL questions are given that are applicable to health providers, one on understanding a trend graph, and one on a medicine label dosing. Possible Classroom activity: Although NAAL survey questions use open-ended format, possible responses have been provided on the slides and students may be asked to respond using clickers (if available) to demonstrate that there can be a range of responses, even among well-educated individuals. Note, one classroom discussion could form around patients’ understanding of prescription dose instructions. Demographic results of the NAAL survey are provided. Classroom discussion: Before showing the slide, ask the students which groups they think will have lower levels of health literacy. Ask them what percentage of the population has below basic or basic health literacy. Lecture 2: Association of low health literacy and health, dental outcomes, health beliefs and culture Objectives: Understand the individual, community and public health implications of low oral health literacy Explain the association between health, health literacy, health beliefs and culture The associations of low health literacy and systemic and oral health are provided to encourage discussion about the public health implications of low oral health literacy. Classroom discussion on Disparities and Clinical implications of Health Literacy: Individuals with low oral health literacy may have the most need for oral health care and be the least likely to access it. This has implications for community-based programs such as dental sealant programs, screening programs, and oral health education programs. Individuals with low oral health literacy: may not see the benefits of 2 participation, may not understand consent forms, may fail to show for appointments. Discuss the implications of low health literacy and the need to communicate about health prevention and dental procedures. A brief overview of the complex relationship between health literacy, health beliefs, and cultural competency is presented. A wide variety of cultural, ethnic and religious health beliefs may impact the behavior of an individual and in turn affect personal health outcomes as well as if and when an individual accesses care. Classroom Activity: Divide students into teams Each team selects an oral disease (e.g. periodontitis, smoking and oral cancer) and discusses the implications associated with poor health literacy, culture and health beliefs and managing the disease. Note: Valerio et al reported on patients’ lack of understanding of the association between type 2 diabetes and oral health (Diabetes Research and Clinical Practice 93(2011) 159-165). Macek reported that nearly 1/3 of adults in Baltimore were at the lowest level of oral health knowledge among questions on smoking and periodontal disease, and oral cancer (JPHD 70(2010) 197-2-4) Discuss the health communication issues the health care professionals face related to assuring adequate oral health promotion and disease management to people of differing health literacy, culture and health beliefs. Consider the risk that a person will provide inaccurate information on a health history form due to a lack of understanding about the importance of the association. Each team will report on their discussion and management strategies for the health professionals. Classroom of Home activity: Cultural Competency Activity CALIFORNIA LEGISLATURE— 2013–2014 REGULAR SESSION Introduced by Assembly Member Mitchell on February 19, 2013 Title: AB-459 Public contracts: healthy and sustainable food. “Existing law regulates various aspects of the provision of food and beverages in vending machines, including requiring a vendor that operates or maintains a vending machine on designated state property to offer food and beverages in the vending machine that meet accepted nutritional guidelines, as defined, in accordance with certain content percentages. “(see complete text at http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140AB459 ) Task: Review AB-459 and describe why this is or is not a culturally competent bill that is presented in literate sensitive language. Consider whether you, as a DPH would advocate 3 for or against this Bill. Lecture 3: Identify aspects of a health literate organization and be able to suggest ways to implement oral health literate best practices Objectives: Explain and describe strategies to communicate more clearly with patients, the public or the community Identify aspects of an oral health literate organization and be able to suggest ways to implement oral health literate best practices We now shift our attention to the health care organization and define and provide a framework for the attributes of a health literate organization. Describe how private and public health organizations can become more health literate using the Health Literacy Universal Precautions Toolkit and consider the recommendations for communication with patients. These guidelines pertain to spoken, written and verbal communications and highlight the best practices of each. Consider simple clues that the health care professional can use to identify a person with potentially low health literacy, for example they may take a longer time than most patients filling out forms. Present strategies to communicate more effectively, such as developing forms or other patient educational materials, using symbols and shapes , etc. Classroom discussions and classroom or home Activities: 1. Classroom panel discussion: How do private practices and dental public health providers address oral health literacy? Invite local dentists, ideally both private practitioners and those providing care in community clinics, to be a part of the panel discussion. Students would then explore how organizations address oral health literacy. As you lead the discussion, the following points should be brought out: The comprehensive skills needed to attain good oral health What sort of literacy ‘tasks’ (prescription management, oral health behaviors, selection of treatment options like sealants) do patients need to perform in order to make appropriate oral health decisions? The importance of good patient-provider communications How can you improve verbal and non-verbal communications between patients and staff/providers? What are important considerations in selecting/creating written materials in the office? 4 How do you know that patients understand your recommendations? 2. The influence of culture on the dental practice-- How does culture influence the adoption on your recommendations for preventative strategies? The people we live and work with often influence our health beliefs and practices. How do social support networks at the individual and community levels affect dental practice? How could an organization identify the barriers to care? 3. Classroom activity: Practice patient provider communication using the “teachback” or Ask Me 3 methods. Allow 7-10 minutes for activity and 15 minutes for discussion. Have students divide into pairs One student, the “provider” explains to the other student, “the patient” how to clean their teeth or the post-operative care following an extraction The other student is prompted to use their own words to explain what they have been told, to “teach-back” The students then reverse roles, with the “provider” explaining postoperative care following fluoride varnish to the “patient’s parent” Use open ended questions to facilitate discussion: How do you know if patients understand what you are suggesting they do? How do you know if patients will follow your recommendations? Have the student teams report out to the class. 4. Classroom or Home Activity: Look at examples of different patient education systems that have written patient materials (e.g. ADA, CDC, NIDCR) or videos that describe dental procedures. Talk about how well or poorly the material fits with the objectives of a health literate or ‘literate sensitive’ education material. 5. Classroom or Home Activity: Take a school form used in the clinic and assess how ‘literate sensitive’ the form is and/or measure the reading level. Revise it to be more compliant, if needed and present this to the school clinic director with your recommendations. 6. Classroom or Home Activity: Examine how often patients Fail To Show in the school dental clinic. Discuss reasons that may result in failing to show for appointments. Ideas may include: Communication factors, No telephone or computer, Not understanding the importance of cancelling an appointment, Difficulty managing aspects of personal life, Cost, Lack of social support or is concerned they may not have resources for care. 5 Lecture 4: Health Literacy Measurement Objective: Describe ways to identify low health literacy through various measurement strategies A variety of health literacy and oral health literacy instruments for individual and community groups are provided. Instruments can help the DPH professional to understand the individual’s or the community’s health literacy and whether they have difficulty understanding health information. Even highly educated people may not have accurate information about oral health or general health. For example, in the REALM-D, people with 16+ years of education had near perfect scores on Lists 1 and 2, and for List 3 missed, on average 3 fewer terms than people with 12 years of education or less (Screening for oral health literacy in an urban dental clinic. Atchison, et al. .JPHD 70(2010)269-275.) Classroom discussion: Discusses the challenges to understanding one’s patients’ or community’s health literacy and communication capabilities. As health literacy competency refers to both the patient and health care provider, health literacy measures must the address a broad range of skills. The following questions could guide a discussion about the responsibility of a dentist or DPH professional in understanding the health literacy of their ‘patient’. Why might a dental health care provider want to measure his or her patients’ oral health literacy? How might one act if s/he doesn’t know a patient’s oral health literacy and needs to give postoperative instructions? What other aspects of health literacy are critical in dental care? What about the oral health literacy of the dental team, including front desk, chairside and reception? Suggest alternative ways to measure individual health literacy as well as assess the competencies of the provider or system. Describes the associations between low health literacy and oral health outcomes for the dental health care professional. Optional exercise for expanded lecture 6 2. Classroom activity: Oral health literacy instruments. Allow 5-7 minutes for administration and 15 minutes for discussion. Have students divide into pairs and test an instrument (NVS, REALMD) The Newest Vital Sign slides are set up for use of interactive clicker instruments. Although traditionally provided in open response mode, likely responses are provided in slides to use for class discussion. Allow students to reverse roles if time allows. What can the instrument inform the clinician about his or her patient’s ability to take in information or respond to treatment? Which tests would be practical to use in a clinical setting vs. which tests are more applicable for research? How might the instrument help inform a public health needs assessment? How might this instrument help a community advisory group develop, implement and/or evaluate a dental program? How might this instrument assist a dental clinic director or a director overseeing several clinics to develop an organizational approach to oral health literacy? 7