Indigenous Australians include people who identify as being of Aboriginal or Torres Strait Islander descent, representing 2.5% of the total Australian population in 2006 [
1]. They are a diverse population, belonging to many distinct language groups and living in a wide variety of locations [
2]. The majority of Indigenous Australians live outside major cities, with 43% living in regional and 25% in remote areas.
Indigenous Australians suffer from poorer oral health than non-Indigenous Australians. National estimates indicate that Indigenous Australian adults have higher rates of total tooth loss, higher percentage of reported toothache, lower mean number of dental visits, are more likely to visit for a problem rather than for a check-up and receive a lower mean number of dental fillings compared to non-Indigenous Australians [
3]. Indigenous children experience, on average, twice the level of dental caries in both the deciduous and permanent dentitions with more untreated decay than their non-Indigenous counterparts [
4]. In addition, at all ages between 4 and 15 years, a greater percentage have experienced dental caries when compared with their non-Indigenous counterparts [
2]. Non-metropolitan Indigenous children and the more socially disadvantaged are even more severely positioned in terms of oral health outcomes [
5‐
7].
Previous work
Previous oral health research with Indigenous adults in Port Augusta has revealed important findings [
8‐
10]. Initial qualitative investigations identified a strong sense of powerlessness, with participants feeling a lack of control over their oral health and health care decisions, at both the individual and community level [
8]. There was a clear perception that behaviours promoting oral health were not widely practised and that significant barriers to dental care existed together with fatalistic views about oral health [
8]. In the later study, a convenience sample of 468 participants completed a self-report questionnaire, including the REALD-30 to measure oral health literacy [
10]. This study revealed associations between oral health literacy and self-reported oral health. Lower oral health literacy scores were associated with poor oral health literacy-related outcomes, including a belief that either that teeth didn’t need to be brushed or only needed to be brushed once a day; that cordial (flavoured sugary drink) was good for teeth; and that people didn’t have their own toothbrush, or that even if they owned a toothbrush had not brushed the previous day. Each of these oral health literacy-related outcomes was in turn associated with poor self-reported oral health. In addition to the research findings, this study demonstrated that conducting oral health research utilising self-report questionnaires was successful in this community.
Oral health literacy, like general health literacy, incorporates the capacity a person has to learn and use information about oral health in making decisions about their oral health. Developing adequate levels of health literacy may depend on external factors such as education, experiences in health settings and family attitudes; and individual factors such as cognitive ability and prior knowledge [
11]. Lower levels of health literacy are commonly found in people who have low levels of education and income or have a different first language [
12]. These characteristics are prevalent in the Australian Indigenous population.
Having poor oral health literacy can bring significant challenges. A recent study in the United States described how caregivers with low oral health literacy displayed low levels of oral health knowledge and poor self-reported oral health, which was reflected in their children who also had sub-optimal oral health with related poor oral care behaviours [
13].
Targeted interventions that used clear communication and tailored and supportive training techniques have had some success in improving health outcomes for people with low health literacy. One such intervention with diabetic participants reported enhanced and retained management skills with improved glycaemic control [
14]. To date, there have not been any studies which involve interventions targeting oral health literacy in Indigenous populations.
Like health literacy, a number of screening tools have been developed to determine levels of oral health literacy. Some health literacy tools have been criticised for being too narrow in their range of testing, or relying heavily on the participant’s ability to read [
15]. This might also apply to their equivalents in dentistry. The Rapid Estimate of Adult Literacy in Dentistry (REALD-30) is a 30 item questionnaire that screens the participant’s ability to read dental terminology with correct pronunciation [
16]. The Test of Functional Health Literacy in Dentistry (TOFHLID) tests reading comprehension and numeracy skills [
17]. These instruments have limited use in individuals who demonstrate low literacy and numeracy skills or where English is not their first language. These characteristics are not uncommon in older Indigenous Australians.
Given the limitations of health literacy screening tools, a new tool has recently been developed in Australia. The Health Literacy Measurement Scale (HeLMS) takes a broad approach to measuring health literacy, addressing many of the limitations of other health literacy tools [
18]. The HeLMS was developed using a health literacy conceptual framework developed from a patient perspective. Consisting of 29 items, each rated on a 5 point Likert scale, the HeLMS scores 8 domains: patient attitudes towards their health, understanding health information, social support, socio-economic considerations, accessing general practitioner health care services, communicating with health care professionals, being proactive and using health information [
18]. Using the HeLMS, people with chronic lower back pain were found to have lower scores for the domain assessing patient attitudes towards their health than those without chronic back pain, as well as lower scores for each item within that domain [
18].
Aims
This study assesses oral health literacy and self-reported oral health outcomes among rural-dwelling Indigenous adults and will determine if implementation of a functional, context-specific oral health literacy intervention improves oral health literacy-related outcomes. For the purposes of this study, oral health literacy-related outcomes include use of dental services, oral health knowledge, oral health self-care and oral health-related self-efficacy.
Specifically, the aims are to:
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Describe the extent of poor oral health literacy among rural dwelling Indigenous adults
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Describe the relationship between oral health literacy and oral health literacy-related outcomes
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Determine if a functional, context-specific oral health literacy intervention improves oral health literacy
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Determine if a functional, context-specific oral health literacy intervention improves oral health literacy-related outcomes