State Activities: North Carolina
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1 IOM Roundtable on Oral Health Literacy State Activities: North Carolina Kimon Divaris D.D.S., Ph.D. Departments of Pediatric Dentistry & Dental Research, School of Dentistry, University of North Carolina-Chapel Hill Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina-Chapel Hill Research supported by grant from the National Institute of Dental and Craniofacial Research PI: Dr. Jessica Y. Lee. NIDCR Grant #RO1DE
2 Outline A framework for oral health literacy Proximal and distal determinants Where does (oral) health literacy fit it? The Carolina Oral Health Literacy (COHL) project Description Results: adults oral health Results: children s oral health Work in progress Future directions & potential impact
3 Oral health determinants Caries Periodontitis Orofacial trauma Cancers of the head & neck
4 Oral health determinants Caries Periodontitis Common characteristics: Prevalent Socio-economic clustering Behavioral risk factors Genetic factors Others
5 Oral health determinants Fisher-Owens et al., Pediatrics, 2007
6 Oral health determinants Desirable properties from a dental public health standpoint: Measures that reach a wide proportion of the population; ideally those most in need Effective; long-lasting Affordable ( cost-effective ) Easy to implement Others.. Determination of high-risk subjects/groups Identification of modifiable factors
7 Where does oral health literacy fit in? 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
8 Where does oral health literacy fit in? NIDCR working group, JPHD, 2005 Macek et al., JPHD, 2010 Lee et al., AJPH, 2011
9 The Carolina Oral Health Literacy (COHL( COHL) ) project Prospective cohort study Enrolled 1405 child-caregiver dyads at baseline ( ) Non-random WIC sites in NC Purposeful quota sampling (African Americans, American Indians) Clients of WIC (income <185 %FPL and Medicaid-eligible) Healthy children (ASA I or II) less than 60 months old Primary caregiver present at WIC appointment Data sources Structured interviews (caregivers) Medicaid eligibility, enrollment, claims Clinical examinations on a subset of children (ancillary studies) Lee et al., JPHD, 2011
10 The Carolina Oral Health Literacy (COHL( COHL) ) project Measures Socio-demographic Oral health knowledge questions Perceived oral and general health status (self and child) Perceived treatment needs and services utilization Oral health-related quality of life (OHIP-14 & ECOHIS) Dental neglect (DNS) General self-efficacy (GSEF) Health Literacy: Word-recognition-based test: REALD-30 Comprehension-based test: Newest Vital Signs (NVS) Lee et al., JPHD, 2011
11 Lee et al., JPHD, 2011
12 Lee et al., JPHD, 2011
13 Oral health-related quality of life (OHRQoL) differences [mean difference and prevalence ratios (PR) with corresponding 95% confidence limits (CL)] between participants with "low" (< 13 REALD-30; referent category) and "high" ( 13 REALD-30) oral health literacy in the Carolina Oral Health Literacy study (N = 1,278) "Low" literacy (< 13 REALD-30) "High" literacy ( 13 REALD-30) Difference 1 [mean (95% CL)] Prevalence Ratio 1 [(PR (95% CL)] N = 316 (25%) N = 962 (75%) Crude Adjusted 2 Adjusted 2 OHRQoL (OHIP-14 estimates) Prevalence 45.3 (39.7, 50.8) 33.4 (30.4, 36.4) 11.9 (0.04, 0.20) 7.4 (-1.4, 16.2) 1.17 (1.00, 1.37) Severity 12.4 (11.0, 13.8) 10.1 (9.4, 10.7) 2.3 (1.9, 2.8) 1.2 (0.7, 1.6) 1.11 (1.07, 1.16) Extent 1.87 (1.52, 2.22) 1.19 (1.04, 1.33) 0.68 (0.52, 0.85) 0.36 (0.19, 0.54) 1.34 (1.20, 1.50) 1: Mean differences and ratios of OHIP-14 impacts were calculated using the "high literacy" category as referent. 2: Adjusted differences and ratios were obtained using a Poisson model controlling for race, age, education level and dental attendance. Divaris et al., HQLO, 2011
14 Oral health-related quality of life (OHRQoL) differences [mean difference and prevalence ratios (PR) with corresponding 95% confidence limits (CL)] between participants with "low" (< 13 REALD-30; referent category) and "high" ( 13 REALD-30) oral health literacy in the Carolina Oral Health Literacy study (N = 1,278) "Low" literacy (< 13 REALD-30) "High" literacy ( 13 REALD-30) Difference 1 [mean (95% CL)] Prevalence Ratio 1 [(PR (95% CL)] N = 316 (25%) N = 962 (75%) Crude Adjusted 2 Adjusted 2 OHRQoL (OHIP-14 estimates) Prevalence 45.3 (39.7, 50.8) 33.4 (30.4, 36.4) 11.9 (0.04, 0.20) 7.4 (-1.4, 16.2) 1.17 (1.00, 1.37) Severity 12.4 (11.0, 13.8) 10.1 (9.4, 10.7) 2.3 (1.9, 2.8) 1.2 (0.7, 1.6) 1.11 (1.07, 1.16) Extent 1.87 (1.52, 2.22) 1.19 (1.04, 1.33) 0.68 (0.52, 0.85) 0.36 (0.19, 0.54) 1.34 (1.20, 1.50) 1: Mean differences and ratios of OHIP-14 impacts were calculated using the "high literacy" category as referent. 2: Adjusted differences and ratios were obtained using a Poisson model controlling for race, age, education level and dental attendance. Divaris et al., HQLO, 2011
15 Adjusted 1 'problem' rate ratios (PRR) of OHIP-14 severity (cumulative score) corresponding to one standard deviation change in OHL PRR 2 95% CL Entire sample , 0.98 Race White , 1.11 African American , 0.96 American Indian , : Zero-inflated negative binomial model, including terms for age, education level and dental attendance. 2: Estimates corresponds to the relative change in OHIP-14 cumulative score for one standard deviation increase in OHL. Divaris et al., HQLO, 2011
16 Adjusted 1 'problem' rate ratios (PRR) of OHIP-14 severity (cumulative score) corresponding to one standard deviation change in OHL PRR 2 95% CL Entire sample , 0.98 Race White , 1.11 African American , 0.96 American Indian , : Zero-inflated negative binomial model, including terms for age, education level and dental attendance. 2: Estimates corresponds to the relative change in OHIP-14 cumulative score for one standard deviation increase in OHL. Divaris et al., HQLO, 2011
17 The relationship between general self-efficacy and OHL and dental neglect. Lee et al., AJPH, 2011
18 Lee et al., AJPH, 2011
19 Lee et al., AJPH, 2011
20 Lee et al., AJPH, 2011
21 OH Literacy OH Status
22 OH Literacy OH Status OHRQoL
23 OH Literacy OH Status OHRQoL Education SES Social support
24 OH Literacy OH Status OHRQoL Education SES Social support
25 OH Literacy OH Knowledg e OH Behaviors Dental attendance OH Status Others? OHRQoL Education SES Social support
26 Self-care attitudes OH Knowledg e OH Literacy OH Behaviors Dental attendance OH Status Selfefficacy Others? OHRQoL Education SES Social support
27 Self-care attitudes Results OH Knowledg e CHILDREN S OH Status OH Literacy OH Behaviors Dental attendance OH Status Selfefficacy Others? OHRQoL Education SES Social support
28 Vann et al., JDR, 2010
29 Vann et al., JDR, 2010
30 Vann et al., JDR, 2010
31 Divaris et al., AOS, 2011
32 Divaris et al., AOS, 2011
33 Divaris et al., AOS, 2011
34 Divaris et al., AOS, 2011
35 Measures of correlation (Spearman s rho and Kendall s Tau c) between caregivers assessment of their children s oral health status (measured with the NHANES self-reported item) and their clinically-determined treatment needs (measured with the caries severity index), overall and within levels of caregivers and children s age, caregivers oral health literacy and education, as well as by study site. N* (%) Mean (± SD) Range Rho (95% CL ) P-value Kendall s Tau c Entire sample 108 (100) 0.44 (0.26, 0.62) < Homogeneity test result Caregivers age NS <29 years 55 (51) 24.3 (2.8) (0.25, 0.74) < years 53 (49) 36.6 (6.7) (0.16, 0.66) Children s age * 2 years 47 (44) 27.8 (2.4) (0.44, 0.83) < <2 years 61 (56) 16.5 (4.0) (0.01, 0.57) Caregivers oral health literacy NS REALD-30 <13 15 (14) 8.1 (4.2) (-0.20, 0.89) REALD (86) 21.6 (4.6) (0.26, 0.66) < Study site * Dental School clinic 55 (51) 0.74 (0.63, 0.86) < Community clinic 53 (49) 0.13 (-0.17, 0.43) Caregivers education NS High school diploma/ged or less 42 (39) 0.51 (0.25, 0.77) < Some technical/college, or higher 65 (61) 0.44 (0.19, 0.68) < * Column figures may not add to total due to missing information in some strata. CL: Confidence limits, computed with bootstrapping (10,000 repetitions). P-values correspond to Spearman s rank correlation coefficient rho. The homogeneity test statistic was calculated as follows: X 2 = [(rho statum1 -rho common ) 2 / se 2 stratum1 ] + [(rho stratum2 -rho common ) 2 / se 2 stratum2 ]. The critical P-value threshold for 5 post-hoc tests, using α=0.20and a Sidak correction was P<0.04. Divaris et al., under review
36 Caregiver s OH Literacy Self-care attitudes Selfefficacy Child OH Knowledg e Child OH Behaviors Dental home Others? CHILDREN S OH Status Child Family OHRQoL Education SES Social support
37 Caregiver s OH Literacy Self-care attitudes Selfefficacy Child OH Knowledg e Child OH Behaviors Dental home Others? Caregiver s OH Status CHILDREN S OH Status Child Family OHRQoL Education SES Social support
38 Work in progress Is caregivers health literacy associated with interruptions in their children s Medicaid enrollment? May depend on the type of enrollment disruption ( gap ) Does caregivers oral health literacy affect their children s entry and navigation in the dental care system? Caregivers REALD-30 scores: Comprehensive exam: 15.9; No dental officebased visit: 15.6; Emergency care: 15.0 Does caregiver s oral health literacy affect their children s dental utilization? Does caregiver s oral health literacy affect the cost of their children s dental care (preventive, restorative, emergency, hospital-based)? How stable are (oral) health literacy and our measurements?
39 Future directions Refinement of low literacy and at risk terms Feasibility of OHL rapid assessment in the clinic Two-stage REALD; short forms; computerized modules Tailoring of messages to appropriate literacy level o o o Dental office Dentists involvement is necessary Community A role for dental public health Determining appropriate message delivery vehicles and strategic target populations Community-based Partnerships with family medicine, pediatrics, and more Determine whether (functional) oral health literacy is modifiable and what approaches may work best: Information provision/reinforcement Motivational interviewing Experiential learning
40
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