UNIVERSIDADE ESTADUAL DE CAMPINAS FACULDADE DE ODONTOLOGIA DE PIRACICABA
STHEFANIE DEL CARMEN PEREZ PUELLO
AVALIAÇÃO DA LITERACIA EM SAÚDE
EVALUATION OF HEALTH LITERACY
Piracicaba 2018
STHEFANIE DEL CARMEN PEREZ PUELLO
AVALIAÇÃO DA LITERACIA EM SAÚDE
EVALUATION OF HEALTH LITERACY
Dissertação apresentada à Faculdade de Odontologia de Piracicaba da Universidade Estadual de Campinas como parte dos requisitos exigidos para a obtenção do título de Mestra em Odontologia na área de Saúde Coletiva.
Dissertation presented to the Piracicaba Dental School of the University of Campinas in partial fulfillment of the requirements for the degree of Master in Dentistry, in Collective Heatlh area.
Orientador: Profa. Dra. Marília Jesus Batista de Brito Mota Coorientador: Profa. Dra. Maria da Luz Rosário de Sousa
Este exemplar corresponde à versão final da dissertação defendida pe- la aluna Sthefanie del Carmen Perez Puello e orientada pela Profa. Dra. Marília Jesus Batista de Brito Mota.
Piracicaba 2018
DEDICATÓRIA
Dedico este trabalho primeiramente a Deus e à Virgem Maria por sempre derramar sua infinita misericórdia sobre mim e abençoar cada passo que dou. A os meus pais, Clemente e Kety e meus irmãos Angélica, Clemente, Mariangel e Fabian que sempre me ensinaram com amor, me apoiaram e tem se esforçado para me ajudar e me acompanhar a realizar meus sonhos.
A meu amado namorado, Cristhian Madrid Troconis pelo amor, apoio, motivação e dedicação para me acompanhar a realizar este sonho que começou sendo meu e hoje é nosso.
Aos meus avós Luisa, Plinio, Ligia e Clemente, que desde a infância me receberam como sua filha, me guiaram e me ensinaram com muito amor para dar o melhor de mim dia a dia.
A os meus tios, tias, primos e primos, especialmente meus tios Plinio e Guido e minhas tias, Mabel e Shirley, por suas orações e por sempre me ensinar e motivar.
Muito obrigada a todos, na proximidade ou na distância, vocês sempre me deram força e motivação para alcançar esta grande conquista. Que Deus nos abençoe sempre.
AGRADECIMENTOS
À Universidade Estadual de Campinas; à Faculdade de Odontologia de Piracicaba FOP-UNICAMP; à Profa. Dra. Cínthia Pereira Machado Tabchoury, Presidente da Coordenadoria dos Programas de Pós-Graduação da Faculdade de Odontologia de Piracicaba, pelo apoio.
As agências de fomento a pesquisa CNPq (Conselho Nacional de Desenvolvimento Cientifico e Tecnológico) pela concessão de bolsa de Mestrado e a FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo) pela concessão do auxílio a pesquisa.
Aos docentes do Programa de Pós-graduação em Odontologia da FOP-UNICAMP que compartilham com muita qualidade e excelência seus conhecimentos e experiências.
Aos docentes Profa. Dra Débora Dias da Silva Harmitt, Prof. Dr. Pedro Bordini Faleiros, Profa. Dra. Jaqueline Vilela Bulgareli, Profa. Dra. Maria Paula Rando Meirelles e Profa. Dra. Maria José Duarte Osis pela disponibilidade para participar da banca da 1ª fase e 2ª fase de qualificação e defesa dessa dissertação e as sugestões que enriqueceram nosso trabalho. A minha orientadora Profa Dra. Marília Jesus Batista de Bito Mota, muito obrigada pelo acolhimento, confiança e motivação para o desenvolvimento desta dissertação. Pelo exemplo de dedicação e intercâmbio de experiências e conhecimento que me ajudaram para meu crescimento acadêmico e pessoal. A minha coorientadora Profa. Dra. Maria da Luz Rosário de Sousa, muito obrigada pelo acolhimento, confiança e doação de experiências, conhecimento e paciência. Pela dedicação e motivação para atingir com positivismo os objetivos.
Aos professores Profa. Dra. Shyrley Díaz Cárdenas, Prof. Dr. Farith González Martínez, Profa. Dra. Katherine Arrieta Vergara, Profa. Dra. Ketty Ramos Martinez e Profa. Dra. Lizelia Alfaro Zola por me incentivar e apaixonar pela odontologia preventiva, saúde da comunidade, saúde pública e a prevenção e promoção da saúde. Muito obrigada pela orientação, amizade e ensinamentos ao longo de minha jornada acadêmica.
A meu amigo Manoelito Ferreira Silva Junior, Doutorando em Odontologia área de concentração em Saúde Coletiva, pela paciência, intercâmbio de conhecimentos e ajuda para a realização da pesquisa.
Agradeço aos amigos que a FOP-UNICAMP me deu, meus amigos "estrangeiros", obrigada pela amizade, disposição, ajuda e apoio.
A meus colegas de turma de Mestrado e doutorado em Odontologia, área de concentração Saúde Coletiva por me acolher, ajudar e intercambiar experiências e conhecimentos.
À secretária Eliana Aparecida de Mônaco do Departamento de Odontologia Social da FOP-UNICAMP, pela disposição e ajuda.
Aos voluntários que aceitaram participar da pesquisa e compartilhar suas respostas que sem dúvida foram muito importantes.
RESUMO
A literacia em saúde (LS) é a habilidade de obter informações em saúde e tomar decisões baseadas no conhecimento adquirido. Estudos de LS têm evidenciado a associação entre baixa literacia e piores indicadores de saúde. Os objetivos do estudo foram: 1) Revisar sistematicamente a evidência científica sobre a associação entre literacia em saúde bucal (LSB) e a autopercepção da condição de saúde bucal (ACSB); e, 2) Avaliar a LS e validade de critério do questionário
14-items Health Literacy Scale (HLS-14) em adultos e idosos brasileiros. A
revisão sistemática seguiu os critérios do guia Preferred Reporting Items for
Systematic Reviews and Meta-Analyzes (PRISMA) e realizou-se uma busca
sistemática nas bases de dados: ScienceDirect, Embase, Scopus,
Medline/Pubmed, OvidSP, EBSCO-HOST e ISI web of science utilizando as
palavras chave "Self-reported oral health", "Self-rated oral health" e "Oral Health
Literacy". Foram incluídos artigos de estudos observacionais (transversal ou
longitudinal) em inglês, sem restrição do ano de publicação e faixa etária. A escala Newcastle Ottawa foi utilizada para análise de viés dos estudos. Para avaliar a validade de critério do questionário de LS foi desenvolvido um estudo populacional em uma amostra proveniente de uma coorte de adultos e idosos (23-70 anos) de Piracicaba, São Paulo, Brasil, coletado em 2017. Foi aplicado o questionário HLS-14 em versão validada no Brasil que avalia a LS em três dimensões: Literacia funcional (LFun), Literacia comunicativa (LCom) e Literacia crítica (LCrí). Foi utilizado instrumento do estudo para avaliar as dimensões da LS: capacidade de leitura avaliada através da bula de Dipirona (LFun), a compreensão das indicações de uma receita medica de Diclofenaco de sódio (LCom), autorreconhecimento de sua condição de saúde bucal por imagens e a compreensão de um material educativo de saúde bucal específico para cada condição de saúde bucal (LCrí). Na revisão sistemática, utilizou-se a estatística descritiva (frequência e porcentagem) reportada nos estudos. No estudo transversal foram obtidas frequências, porcentagens, mediana e desvio padrão, coeficiente de correlação de Kendall´s Tau para a concordância entre os instrumentos (p<0,05), teste qui-quadrado (p<0,05) para análise bivariada e estabelecer associações das dimensões dos questionários utilizados na avaliação da LS. Dos 128 artigos encontrados na busca primária da revisão sistemática, 8 foram incluídos para análise final. A maioria dos estudos evidenciou associação entre LSB e ACSB. Em relação a avaliação da LS e validade de critério, a amostra foi constituída de 117 adultos e idosos. Houve concordância entre HLS-14 e o protocolo de avaliação do estudo só para a dimensão LFun. Na mensuração do protocolo de avaliação do pesquisador, evidenciou-se associação entre alta LS e questões da LFun e LCom relacionadas a leitura do trecho e compreensão da informação contida na receita médica. Evidenciou-se associação entre alta LCri e autorreconhecimento da condição de saúde bucal (p<0,01), ter o conhecimento de 2 ou mais informações em saúde geral e bucal contidas no material educativo (p<0,01). Concluiu-se que os pacientes com baixo nível de LSB apresentaram ACSB negativa, o que poderia interferir nos comportamentos de autocuidado. O questionário HSL-14 demonstrou validade de critério para mensurar LFun, porém não para a avaliação da LCom e LCrí.
ABSTRACT
Health literacy (HL) is the ability to obtain health information and make decisions based on the acquired knowledge. Studies on HL have found evidence of the relationship between low literacy and worse health indicators. Therefore, the objectives of this research were: 1) To systematically review scientific evidence regarding the association between oral health literacy (OHL) and self-perceived oral health status (SROH); 2) To evaluate HL and the criterion validity of the 14-items Health Literacy Scale questionnaire (HLS-14) in Brazilian adults and elderly patients. First, the systematic review was conducted based on PRISMA guideline and systematically searching on ScienceDirect, Embase, Scopus, Medline /
Pubmed, OvidSP, EBSCO-HOST and ISI web of science databases using the
keywords "Self-reported oral health" "Self-rated oral health" and "Oral Health Literacy". Observational studies (transverse or longitudinal) published in English were included, without restriction in publication year and age group. For bias analysis, the Newcastle Ottawa Scale was used. To evaluate the criterion validity of the LS questionnaire, the study was conducted in 2017, in a sample from a cohort of adults and elderly patients (23-70 years) from Piracicaba, São Paulo, Brazil. The HLS-14 questionnaire developed by Suka et al was validated in Brazil to was evaluated HL in their three dimensions: Functional Literacy (FunL), Communicative Literacy (ComL) and Critical Literacy (CriL). Then, the study instrument was employed to evaluate the dimensions of HL: reading ability evaluated through Dipirone's label (FunL), understanding the indications of a medical prescription of Sodium Diclofenac (ComL), self-recognition of its health status and understanding an oral health education material specific for each oral health condition (CriL). In the systematic review the data analysis was performed by descriptive statistics (frequency and percentage) reported in the studies. In the cross-sectional study, descriptive statistics were obtained to obtain frequencies, percentages, median and standard deviation, Kendall's Tau correlation coefficient for agreement between the instruments (p <0.05), chi-square test (p <0, 05) for bivariate analysis and to establish associations of the dimensions of the questionnaires used in the HL evaluation. In the primary search for systematic review, 128 articles were found, of which 8 were included for final analysis. Most studies of them evidenced association between OHL and SROH. Regarding the cross-sectional study, the sample was 117 adults and elderly patients. There was agreement between HLS-14 and the study evaluation protocol only for the FunL dimension. In the measurement of the researcher's evaluation protocol, there was an association between high HL, FunL and ComL questions related to reading section and understanding the information contained in the medical prescription. There was an association between high CriL and self-reported oral health status (p <0.01), two or more knowledges on general and oral health information contained in the educational material (p <0.01). It was concluded that patients with low OHL level presented negative SROH which could interfere with self-care behaviors. Finally, the HSL-14 questionnaire was validated to measure FunL, but not for the evaluation of LCom and LCrí.
SUMÁRIO
Pág.
1 INTRODUÇÃO
2 ARTIGOS
2.1. Artigo: Associação entre literacia em saúde bucal e autopercep- ção da condição de saúde bucal: revisão sistemática.
2.2. Artigo: Validade do questionário 14-itens health literacy scale (HLS-14) em adultos e idosos no Brasil.
3 DISCUSSÃO 12
4 CONCLUSÃO 13
REFERENCIAS 18
APÊNDICES 18
APÊNDICE 1 - Termo de consentimento livre e esclarecido (TCLE) APÊNDICE 2 - Questionário sobre acesso às informações gerais e em saúde e avaliação da literacia em saúde na prática
APÊNDICE 3 – Material educativo em saúde bucal
ANEXOS 82
ANEXO 1 - Parecer consubstanciado do comitê de ética em pesquisa ANEXO 2 -Questionário 14-items health literacy scale (HLS-14) ANEXO 3 –Relatório de similaridade software Turnitin
36 13 105 17 17 66 68 82 69 74 74 12 98 77 98 103 105
1 INTRODUÇÃO
Com o advento de novas tecnologias de comunicação, a sociedade contemporânea tem acesso a uma ampla variedade de informações, dentre elas, as relacionadas à saúde. Embora haja atualmente uma maior acessibilidade e facilidade para encontrar informações em saúde, nem sempre são de fácil compreensão ou de fontes confiáveis, o que pode prejudicar a vida das pessoas. Sendo assim, os indivíduos não devem ter apenas a habilidade de saber pesquisar informações e reconhecer fontes confiáveis, como também de compreendê-las e aplicá-las em ações práticas do seu dia a dia, e assim, impactar positivamente na sua saúde (Nielsen-Bohlman, Panzer, Kindig, 2004; Mancuso, 2008).
A Literacia em Saúde (LS) refere-se à capacidade cognitiva e social que determinam as motivações e as capacidades dos indivíduos para ter acesso, compreender e usar as informações de forma que promovam e mantenham uma boa saúde (WHO, 1998). Nesta perspectiva, a literacia em saúde (LS) evidencia um enfoque multidimensional, implicando que o indivíduo seja capaz de entender seu contexto de saúde, adquira habilidades para se empoderar e ser independente dos profissionais da saúde para se cuidar e participar ativamente no controle de fatores que podem gerar doenças (UNESCO, 2005; Schulz et al., 2013).
No campo de estudo da LS, são abordados diferentes tipos: literacia funcional, comunicativa e crítica. A literacia funcional refere-se às habilidades básicas de leitura e escrita para situações do cotidiano, como ter domínio de informações sobre riscos de saúde e a utilização de serviços de saúde. A maioria dos trabalhos publicados sobre LS aborda basicamente esta habilidade avaliada principalmente através da leitura de termos médicos ou odontológicos (Stucky et al., 2011; Kamberi et al., 2013; Junkes et al., 2015). A literacia comunicativa representa as habilidades cognitivas mais avançadas em conjunto com habilidades sociais que possibilitam as pessoas e as comunidades a agirem de modo independente. Trata-se da habilidade de extrair informações de diferentes meios de comunicação e aplicar a nova informação para situações pessoais, promovendo mudança nas circunstâncias. Finalmente, a literacia crítica, que avalia a habilidade de analisar criticamente as informações disponíveis, e
usá-las para exercer maior controle sobre os eventos da vida e situações, trata-se do processo de empoderamento dos indivíduos (Ishikawa et al., 2008). Há a necessidade de mais trabalhos na literatura que abordem a literacia comunicativa e a literacia crítica considerando que são habilidades mais avançadas e de grande importância para desenvolver no paciente hábitos e comportamentos que favoreçam o cuidado de sua saúde (Sykes et al., 2013)
Estudos tem evidenciado a relação entre baixa literacia em saúde com piores indicadores de saúde (Berkman et al, 2011; Divaris et al., 2011; Singh, Coyne, Wallace, 2015). Alguns estudos demonstram que baixa literacia em saúde aumenta o número de hospitalizações e uso de cuidados de emergência, menor utilização de medicina preventiva, redução da utilização de serviços de saúde preventiva e fraca adesão a protocolos terapêuticos o que onera os sistemas de saúde (Bennett et al., 2009; Santesmases-Masana et al., 2017).
Existem poucos trabalhos abordando a LS, por ser um tema recentemente estudado no Brasil, no estudo de Apolinário et al. (2014), a literacia funcional foi avaliada através da mensuração das habilidades de leitura, escrita e frequência de uso dos computadores, segundo as características sociodemográficas, por meio do instrumento Multidimensional Screener of Functional Health Literacy. A pesquisa contou com 322 participantes da cidade de São Paulo-SP e foi encontrada uma associação significativa entre o nível educativo e os menores escores no instrumento (Apolinário et al., 2014), porém o instrumento avaliou a LS apenas na dimensão funcional. Sendo a LS uma habilidade multidimensional, é importante que um questionário de mensuração contenha mais dimensões para avaliar as habilidades envolvidas. Por isso, além de medir a habilidade de leitura e compreensão, o questionário deveria avaliar a capacidade de comunicação e julgamento das informações que o indivíduo possui.
Neste sentido, existem ferramentas mais atuais de avaliação da Literacia em Saúde, como o instrumento Health Literacy Scale 14 (HLS-14) desenvolvido por Suka et al., (2013) e validado no Brasil (Marques, 2017) que avalia as dimensões funcional, comunicativa e crítica envolvidas na pesquisa da LS. O questionário consiste em avaliar se o indivíduo é capaz de obter informações relacionadas à saúde de várias fontes, se consegue extrair a informação necessária, se pode compreender e comunicar as informações obtidas, e ainda considerar a
credibilidade da informação para tomar decisões com base nas informações obtidas. No entanto, durante sua utilização tem apresentado dificuldades na mensuração das dimensões mais avançadas, a literacia comunicativa e crítica, relacionadas principalmente com as habilidades de compreensão e aplicação das informações em saúde que geram mudanças no comportamento dos individuos (Van der Vaart R et al., 2012). Ressalta-se a importância de avaliar a validade de critério do questionário, que é a validade relacionada à capacidade do instrumento de mensurar itens especificos e de interesse de un constructo (Pilatti et al., 2010). Assim, a avaliação das habilidades mais avançadas através de elementos práticos como leitura de receitas médicas ou bulas, permitem observar na prática a compreensão e análise crítica das informações em saúde. A LS tem ganhado considerável atenção em saúde pública, sendo considerada pela Organização Mundial da Saúde (OMS) como uma das cinco estratégias chaves para a promoção da saúde (Petersen et al., 2010), mas poucos estudos têm sido feitos sobre literacia em saúde bucal. A literacia em Saúde Bucal (LSB) tem como definição: O grau em que os indivíduos têm a capacidade de obter, processar e compreender a informação de saúde bucal básica e condições necessárias para tomar decisões de saúde adequadas (National Institute of Dental and Craniofacial Research, 2005).
Ueno et al. (2013) avaliaram o nível de literacia em saúde bucal e sua associação com condições de saúde bucal, utilizando um questionário próprio e fazendo exames bucais em uma população do Japão. Os resultados mostraram que, voluntários com níveis altos de literacia em saúde escovavam os dentes e as próteses com mais frequência, faziam o autoexame bucal no espelho, frequentavam com mais regularidade ao dentista, tinham melhor higiene bucal, maior presença de dentes naturais e menor índice de cárie dentária. Esses resultados indicam que a LSB está associada a diferenças em comportamentos de saúde bucal e estado clínico de saúde oral.
Estudos desenvolvidos por Jones et al. (2014), Parker & Jamieson (2010) e Jamieson et al. (2013), utilizaram o Rapid Estimation of Adult Literacy in Dentistry (REALD-30) como instrumento para avaliar a LSB. Os estudos foram unânimes em constatar que os níveis mais baixos de LSB foram associados com autopercepção da condição de saúde (ACSB) negativa. Neste sentido, a baixa LSB pode estar associada à baixa capacidade de processar e compreender
informações de saúde bucal, além de pouco autorreconhecimento de sua própria condição de saúde.
Considerando que os estudos reportaram associação entre o nível de LSB e a ACSB é importante investigar esta associação e evidenciar se os indivíduos que apresentam maiores informações em saúde bucal podem se conhecer melhor, exercer maior controle nas suas escolhas em saúde e aplicar melhores hábitos de autocuidado que permitirão a prevenção de doenças bucais (Guo et al., 2014) através de intrumentos que utilizem outras dimensões além da literacia funcional.
Estudos evidenciaram dados importantes para a compreensão da literacia em saúde (LS), literacia em saúde bucal (LSB) e a autopercepção da condição de saúde bucal (ACSB) (Parker & Jamieson 2010; Jamieson et al. 2013; Jones et al., 2014; Guo et al., 2014) reportando resultados diversos e abordagens diferentes e por isso a necessidade de uma revisão sistemática para conhecer sobre esta relação bem como a validade de critério de um questionário para mensurar a literacia em saúde e suas dimensões.
A presente dissertação de mestrado foi desenvolvida no formato de dois artigos com os objetivos: 1) Revisar sistematicamente a evidência científica sobre a associação entre LSB e ACSB; e, 2) Avaliar a LS e a validade de critério do questionário 14-items Health Literacy Scale (HLS-14) validado no Brasil, em uma população de adultos e idosos, para as três dimensões: Literacia Funcional, Literacia Comunicativa e Literacia Crítica.
2 ARTIGOS
2.1. ASSOCIATION BETWEEN ORAL HEALTH LITERACY AND SELF-REPORTED ORAL HEALTH STATUS: A SYSTEMATIC REVIEW.
Artigo submetido à Revista Journal of Dental Research (Anexo 3)
Sthefanie del Carmen Perez Puello 1
Shyrley Díaz Cárdenas 2
Farith González Martínez 3
Manoelito Ferreira Silva Junior 1,4
Maria da Luz Rosário de Sousa 1
Marília Jesus Batista 1,5
1. Department of Social Dentistry. Community Health. Piracicaba Dentistry School. University of Campinas (FOP / UNICAMP). Piracicaba, São Paulo, Brazil. 2. Department of Social and Community Dentistry. Faculty of Dentistry. University of Cartagena. Cartagena, Bolivar, Colombia.
3. Department of Research. Faculty of Dentistry. University of Cartagena. Cartagena, Bolivar, Colombia.
4. Department of Dentistry. University of Ponta Grossa. Ponta Grossa, Paraná, Brazil.
5. Department of Community Health. Faculty of Medicine of Jundiaí. Jundiaí, São Paulo, Brazil.
Correspondence Author:
Profa. Dr. Marília Jesus Batista de Brito Mota
Piracicaba Dentistry School. University of Campinas. Limeira Avenue, 901. CEP 13414-018. Piracicaba-SP, Brazil.
ABSTRACT
Objective: To systematically review the scientific evidence on the association between oral health literacy (OHL) and self-reported oral health status (SOH). Materials and method: Systematic searches were conducted by two researchers in the following databases: ScienceDirect, Embase, Scopus, Medline / Pubmed, OvidSP, EBSCO-HOST and ISI Web of Science, using the keywords "Self-reported oral health", "Self-rated oral health" and " Oral Health Literacy", between March and August 2017. Articles of observational studies (transverse or longitudinal) written in English were included without restriction regarding the year of publication and age group. The risk of bias was assessed using the Newcastle Ottawa scale for cross-sectional and cohort studies. Results: In the primary search, 128 articles were found, of which 8 were included for final analysis. Most of the studies were cross-sectional, and the majority of the participants were adult females aged between 15 and 80 years. The instrument most used to measure OHL was REALD-30 and the SOH was evaluated according to the categories excellent, very good, good, fair or poor. In most studies, the risk of bias was low (n = 6). The high level of OHL presented an association with excellent, very good or good SOH in most articles (n = 7), and the only study that found no association was conducted with an adolescent age group. Conclusion: The available scientific evidence suggested an association between the OHL level and SOH. Therefore, it is recommended that the OHL level should be assessed by health professionals considering that it may interfere with SOH and consequently in self-care behaviors.
Key-words: Health Literacy, Oral Health Literacy, Self-reported Oral Health, Oral Health, Systematic review.
INTRODUCTION
The oral health-disease process is influenced by multiple factors1. Thus,
proposals with multidimensional approaches that generated greater empowerment of individuals seem to have had greater impact on oral health prevention and promotion2. In this sense, oral health literacy (OHL) refers to
individuals’ ability to seek, analyze and apply information related to oral health, which allows them to maintain their health, participate actively in preventive programs and make use of health services3. From these aspects, health literacy
has been highlighted by the World Health Organization (WHO) as one of the five keys to health promotion2.
Studies have shown that OHL was associated with aspects of health and education, but was also influenced by culture, society, disparities in health and self-care habits, and therefore, has become a valuable marker of autonomy and self-management in the field of health education research4,5.
A low level of OHL has been associated with health behaviors, such as increased visits to the dental service due to emergencies and pain; but it has also been associated with oral health conditions such as the presence of biofilm, dental caries, periodontal disease, and a greater impact on oral health-related quality of life (OHRQoL)6-8. The promotion of patients’ access to health
information is capable of influencing their knowledge and concept of health, thereby improving their general health and oral health outcomes, and therefore, their self-perception of oral health status9,10. Furthermore, individuals with the
capacity for critical evaluation of health information can be empowered by stimulating their autonomy, motivation and effective action in healthy self-care choices and habits11.
Self-perception of the oral health status (SOH) is a multidimensional and multifactorial concept that includes self-assessment of changes in function, aesthetics, presence of pain, psychological and psychosocial dimensions of diseases and oral disorders12,13. SOH is a reliable subjective indicator of oral
health and is associated with oral clinical indicators14. Moreover, with the use of
this indicator, it is possible to show how individuals feel about their own health, and from this perception, how they can be empowered to seek participation in preventive strategies, health services and adherence to treatments15.
The associated verification of OHL and SOH can indicate whether the individuals’ self-perception of their oral health status is compatible with the reality of their health, and whether this knowledge has any impact on better self-care actions16. According to Locker et al.17 and Mejia and Arnfield, 18 SOH was
associated with the need for self-perceived treatment, poor oral health care, difficulty in communicating with health professionals, and low demand for health services. The negative self-perception of oral health status with low levels of OHL is not well understood19,20. Taking into account that OHL is a modifiable indicator
that can empower individuals and improve their SOH, it is important to investigate whether there is association between these two easily measurable markers. The objective of the present study was to systematically review the available scientific evidence on the association between oral health literacy (OHL) and self-perception of oral health status (SOH).
MATERIALS AND METHODS
The present systematic review was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) 21. It was recorded in the International Prospective Register
of Systematic Reviews (PROSPERO) under protocol number CRD42017075010 in the month of August 2017 and may be verified at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=75010
Eligibility criteria
The Patients, Intervention, Comparison and Result (PICO) strategy was used to establish the following question about the problem: Do patients with low oral health literacy present negative self-perceived oral health status?
Inclusion criteria
Articles with observational methodological design studies (transverse or longitudinal), without restriction on the year of publication and age group, published in English, and that evaluated the association between SOH and the OHL level using validated questionnaires, were included.
From the analysis of this systematic review, we excluded case reports or series of clinical cases, narrative reviews of the literature, letters to the editor, conference summaries, articles with another type of methodological design or studies that used non validated questionnaires.
Search strategy
In March 2017, systematic electronic searches were conducted by two authors (S.P.P. and S.D.C) in 7 databases: ScienceDirect, Embase, Scopus, Medline / Pubmed, OvidSP, EBSCO-HOST and ISI Web of Science. The searches were updated in August 2017 using the same search strategies.
Table 1, specifies the strategies applied in the different databases. In addition, manual searches were performed by reading the reference list of selected articles to identify other potentially eligible studies that could meet the inclusion criteria described in this systematic review.
Table 1 - Search strategy used in March 2017 (Updated August 2017) Medline/Pubmed
#1 (Self-reported[All Fields] AND ("oral health"[MeSH Terms] OR
("oral"[All Fields] AND "health"[All Fields]) OR "oral health"[All Fields])) AND (("oral health"[MeSH Terms] OR ("oral"[All Fields] AND "health"[All Fields]) OR "oral health"[All Fields]) AND ("literacy"[MeSH Terms] OR "literacy"[All Fields]))
#2 (Self-rated[All Fields] AND ("oral
health"[MeSH Terms] OR ("oral"[All Fields] AND "health"[All Fields]) OR "oral health"[All Fields])) AND (("oral health"[MeSH Terms] OR ("oral"[All Fields] AND "health"[All Fields]) OR "oral health"[All Fields]) AND
("literacy"[MeSH Terms] OR "literacy"[All Fields]))
ISI Web of Science
#1 TOPIC: ((Self-rated oral health) AND (Oral health literacy))
Timespan: All years. Indexes: SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, ESCI.
#2 TOPIC: ((Self-reported oral health) AND
(Oral health literacy))
Timespan: All years. Indexes: SCI-EXPANDED, SSCI, A&HCI, S, CPCI-SSH, ESCI.
Embase
#1 'self-reported oral health':ti,ab,kw AND 'oral health
literacy':ti,ab,kw
#2 'self-rated oral health':ti,ab,kw AND 'oral
health literacy':ti,ab,kw
OvidSP
#1 ('self-reported oral health' and 'oral health literacy').ab,kw,ti. #2 ('Self-rated oral health' and 'oral health
literacy').ab,kw,ti.
#1(self-reported oral health) AND (oral health literacy) #2(self-rated oral health) AND (oral health
literacy)
ScienceDirect
#1ABSTR-KEY(Self-reported oral health) and
TITLE-ABSTR-KEY(Oral health literacy).
TITLE-ABSTR-KEY(Self-rate oral health ) and TITLE-ABSTR-KEY(Oral health literacy).
Scopus
#1 TITLE-ABS-KEY("Self-reported oral health") AND ("oral health
literacy")
#2 TITLE-ABS-KEY ( "Self-rated oral health"
) AND TITLE-ABS-KEY ( "oral health literacy" )
Selection of studies
Two authors (S.P.P. and S.D.C) organized the titles of articles in spreadsheets using the program Microsoft Office Excel 2017 (Microsoft Corporation, Redmond, Washington, USA). The titles were read and the articles were repeated. Subsequently, titles and abstracts were reviewed independently and when the abstracts contained incomplete information for their classification, the full text was searched. The articles that met all inclusion criteria were evaluated by reading the full text.
Data Extraction
The categories analyzed were: methodological design, sample size (n), study sample, age group of the participants, instrument used to evaluate OHL. The main methodological data of the included studies were: author, year of publication, country of study; for the SOH, variables adjusted during the statistical analysis, and results regarding the association between SOH and OHL.
Risk of bias
The two authors independently assessed the risk of bias in the studies using the Newcastle-Ottawa Scale for cohort studies22. In the case of studies with a
transverse methodological design, the scale was adapted into 7 items divided into 3 sections for evaluation as follows: sample selection (population definition, sample calculation) (3 points), comparability of population groups, adjustment of confounding factors) (2 points) and results (Determination of the result, determination, training and validity of the questionnaire and non-response rate)
(3 points). Studies with a general score of 1 to 3 were considered to be at high risk, however, studies with 4 to 8 points presented low risk of bias.
Data analysis
Data were analyzed using descriptive statistics (frequency and percentage) reported in the studies. In addition, the variables considered in the adjustment of confounding factors were reported with the purpose of observing their possible effect on the association. Considering the heterogeneity of the selected studies relative to the sample size (n), questionnaires used for evaluating OHL, and the application of different statistical tests, it was not possible to perform a meta-analysis.
RESULTS
Search and selection of articles
In the systematic electronic searches 128 articles were found. After excluding articles in duplicate (n = 65), 63 articles were evaluated. After reading the titles and abstracts, 54 articles were excluded for the following reasons: the development phase of the validation of the health literacy questionnaire or OHL, non-associated assessment of the OHL or SOH, evaluated only oral health condition or articles that reported on other topics. Thus, considering the inclusion criteria, we selected 8 articles that evaluated the association between the level of oral health literacy (OHL) and self-perception of the oral health status (SOH) for data synthesis. Figure 1 describes the search process of the articles.
Characteristics of the studies
Table 2 presents the most important methodological aspects of the selected articles. Most of the studies were conducted in Australia (n=3) 16,19,23, in
the United States (n=2) 10,25 in the United States and Australia (n=1)26 and were
published between 200710 and 201616. As regards the type of methodological
design, only one of the studies was longitudinal (Yi Guo, 2014)25. The sample
size varied between 10110 and 179925 participants. In the studies, the majority of
the participants were adults and the elderly10,16,19,23-26 and the age varied between
1520 and 80 years10. In addition, the most commonly used instrument for
evaluating oral health literacy was REALD-30 (Rapid Estimate of Adult Literacy
health status was evaluated using the categories: excellent, very good, good, fair and poor10, 23-26; and for statistical analysis, in most of the articles selected the
categories were dichotomized into high SOH (excellent, very good and good) and low (regular and poor) 10, 20,23-26.
Figure 1. Flow diagram (PRISMA) 21 describing the process of selection of
Table 2. Methodological aspects of the included articles that evaluated the association between the level of oral health literacy and the self-perception of the oral health status.
AUTHOR (YEAR) COUNTRY TYPE OF STUDY SAMPLE SIZE STUDY SAMPLE AGE GROUP OF PARTI-CIPANTS (YEARS) INSTRUME NT TO EVALUATE OHL SOH EVALUA-TION CATE-GORIES VARIABLES OF THE ADJUSTED MODEL RESULTS Naghibi et al. (2013) Tehran, Iran Cross sectional 1031 Adults and elderly 18-65 OHL-AQ Excellent, very good, good, regular and poor -Older age -Low level of education -Small living area in square meters per person -Poor brushing behavior Low level of OHL was associated with independent negative SOH due to socioeconomic and demographic variables. Negative SOH was also associated with poor brushing habits. Ueno et al. (2015) Tokyo, Japan Cross sectional 162 Adolescent 15-16 OHL visual instrument Very good, good, regular, not good, bad
NR
There was no association between OHL level and the SOH. However, the OHL level was associated with clinical state of oral health. Jones et al. (2014) Adelaide, Australia Cross
sectional 468 Adults <38 e >38 REALD 30
Excellent, very good, good, regular and poor - Age older than 38 years -No health card -Avoided the dentist due to the cost -Patient was not aware of how to visit on an emergency basis - Poor knowledge about oral disease prevention
OHL level was associated with negative SOH, not knowing about the toothbrushing routine and cause of oral diseases. Parker and Jamieson (2010) Adelaide, Australia Cross sectional 468 Adults and
elderly 17-72 REALD 30 Fair and bad
- Age older than 38 years -Government medical attention chart -Economic difficulties to pay for the dental appointment -Went to the consultation because of dental problems - Poor brushing frequency Showed the association between low level of OHL and negative SOH, in addition to going to the dental consultation for emergency or pain. Guo et al. (2014) Florida,
USA Cohort 1799 Adults >25
Own instrument Excellent, very good, good, regular and poor -Age -Gender -Race? -Education -Financial security - Either had a regular dentist, or did not Low level of OHL was associated with negative SOH and poor communication with the dentist.
Jamieson et al. (2013) Adelaide, Australia and USA Cross sectional 722 Adults and elderly AUST-IND: 17-72 AME-IND:18-57 REALD 30 Excellent, very good, good, regular and poor NR There was an association between low level of OHL and negative SOH.
Individuals who presented negative SOH and low OHL level reported a greater need for restorative or surgical treatment. Jones et al. (2016) Port. Augusta, Australia Cross
sectional 278 Adults <38 e >38 HELD-14
Excellent, good, bad -Age -Sex -Educational level -Income -Visit to the dentist
Low OHL level was associated with Negative SOH. In addition, the patients who showed this association also had a low level of self-efficacy. Jones el al. (2007) North Carolina, USA Cross sectional 101 Adults and elderly 18-80 REALD-30 Excellent, very good, good, regular and poor - SOH - Incorrect knowledge - Age ≥ 40 years Regular or negative SOH, incorrect knowledge and few visits to the dentist were observed in individuals with low OHL level
OHL-AQ: Oral health literacy adult questionnaire
REALD-30: Rapid Estimate of Adult Literacy in Dentistry-30 HELD-14: 14-item Health Literacy in Dentistry
OHL: Oral Health Literacy
SOH: Self-perception of the oral health status AUST-IND: Indígenous Australians
AME-IND: Indigenous Americans NR: Not repoted
Risk assessment of bias
The risk of bias is presented in table 3. Most of the studies did not perform a sample calculation10, 16, 19, 20, 26, and the sample was not representative of the
study population 10,16,19,20,23,26. However, most of the studies used analysis with
adjusted models to control for possible confounding factors between the association of SOH and OHL10, 16, 19, 23-25 and most presented low risk of bias10, 16, 19, 23- 25.
Table 3. Quality evaluation of the cross-sectional studies according to the Newcastle-Ottawa modified scale 22 on the association between SOH and OHL.
Selection Comparability Determination of the result Author (Year) Case defini-tion Sample calcula-tion Representati-veness Confusion adjust-ment Determination of result Validity Non- respon-se rate Score (0-8) Naghibi et
al. (2013) Yes Yes Yes Adjusted A Yes N 7 Ueno et al.
(2015) Yes Not Not
Not
adjusted A Yes N 3 Jones et al.
(2014) Yes Yes Not Adjusted A Yes N 6 Parker et
Jamieson et al. (2013)
Yes Not Not Not
adjusted A Yes N 3 Jones et al.
(2016) Yes Not Not Adjusted A Yes N 5 Jones et al.
(2007) Yes Not Not Adjusted A Yes N 5
A: Self-perception.
Validity: Determination, training and validity of the questionnaire. N: Not Reported.
Table 4. Quality evaluation of the cohort study according to the modified Newcastle-Ottawa scale. 22
Selection Comparability Determination of the result Auth or (Year) Represen ta-tiveness Selection of non-exposed Stabilit y Result Comparabilit y of cohorts Evaluatio n of the result
Follow-Up Adequa-cy Scor e (0-8) Yi Guo (2013 )
Not Yes Yes Yes Yes Yes Yes Yes 7
Representativeness: Representativeness of the exposed cohort Stability: stability of the exposure when recontact
Result: Outcome of interest was not at the beginning of the study Follow-Up: Was Follow-Up Long Enough for Outcomes to Occur. Adequacy: Adequacy of Follow Up of Cohorts.
Synthesis of results
Association between OHL and SOH
Of the 8 articles selected, 7 studies were conducted in the age group of adults and the elderly and showed an association between OHL and SOH10, 16, 19, 23-26, but only one study that used a visual instrument to evaluate OHL and
developed SOH in a population of adolescents showed no association (p=0.382). Research on vulnerable populations of Australian and Native Americans was associated with a low level of literacy in oral health and negative self-perception of oral health status 16,19,23,26. In addition, three studies in adult populations of
different socioeconomic levels24, 25 and who were attended at a private dental
DISCUSSION
This systematic review aimed to evaluate the scientific evidence on the association between the level of oral health literacy (OHL) and self-perception of oral health status (SOH)\. It has added knowledge not studied in previously published systematic reviews that presented focus on the revision of the measurement instruments available for health literacy27 or OHL28, and the
association of OHL with clinical conditions of oral health29.
Of the articles included in the present review, the earliest publication year was 200710.. This demonstrated that OHL was still a recent issue and may play
a strategic role in the performance of skills in individual and collective oral health care30. The measurement of these skills may help identify individuals with
difficulties in understanding information, 31 and therefore should be better
educated, because they have the capacity for managing their own commitment to health, by understanding the drug, prescription inserts and use of preventive services32. In addition, studies have demonstrated the association between the
level of OHL, clinical aspects of oral health and their impact on quality of life8. In
general, the studies selected in the present systematic review suggested that there was an association between the level of OHL and SOH10, 16, 19, 23-26; that is,
adults and elderly individuals who had negative SOH had low levels of OHL. Only one study did not show this association 20, and the authors related these results
to the instrument used to evaluate the SOH and the level of OHL. Although this instrument was validated, easy to apply and low cost, the evaluation was very subjective because it was a visual scale of drawings and depended on the participant's artistic and representative skills20.
The comparison of studies is difficult, because there are a large number of instruments for measuring OHL in the literature28. However, the most commonly
used scale was the Rapid Estimate of Adult Literacy in Dentistry-30 (REALD-30)
10, 19, 23, 26. Evaluation by the REALD-30 instrument is made by reading 30
different dentistry terms (Cronbach's Alpha = 0.87) 33 and it has been validated
in Turkey34, Brazil35, Saudi Arabia36, Hong Kong37, United States33, among other
countries. Some studies have pointed out a limitation in this instrument - it only evaluates the functional domain through the ability to read - considering the multiple abilities involved in the OHL. Because an individual can read the words does not always indicate that he/she has greater understanding, and that he/she
has the ability to seek, analyze and apply information for the maintenance of his/her own health38,39. Population studies that measure OHL with the help of
multidimensional instruments, and evaluate its three levels (Functional Literacy, Communicative Literacy and Critical Literacy) and the different abilities involved40
are encouraged.
In the present systematic review, only one study presented longitudinal follow-up. This study was developed with 1799 North American adults and the authors observed that patients who presented a high level of OHL had better SOH and showed good communication with their dentists, thus allowing the development and implementation of correct habits of self-care in oral health25.
Professional-patient communication with the use of terms that are easy to understand and compatible with the OHL level of individuals is relevant to promote understanding of oral diseases and decision making41 that favor the
implementation of good habits, patient empowerment and higher rates of successful treatments.
Most of the studies did not perform a sample calculation16, 19, 20, 26; did not
report the non-response rate16,19,23,24,25, and had samples that were not
representative of the population10,16,19,20,26. This could have affected the power of
the study and observation of the expected phenomenon, which made it difficult to generalize the results in the target population42. Some studies addressed the
indigenous population, which demonstrated the interest of researchers in assessing factors that influenced the disparities of health in vulnerable groups16,19,23,26. Although most of the studies selected were classified as having
low risk of bias10,16,19,23-25, as discussed earlier, the studies had limitations and
their results need to be interpreted with caution.
The association between OHL and SOH involves several factors, taking into consideration that SOH is a modifiable, subjective measure that can be influenced by the individual's level of knowledge, ideal oral health standard, social, cultural and behavioral factors43, 44. Abilities measured by health literacy
that allow individuals to seek, analyze and apply information suggest a better self-knowledge of their own oral health conditions, generating self-care behaviors and practices more applicable to their health and disease prevention38, 16. This ability
- called literacy - is also modifiable and can be relevant to empower individuals and make them more critical of all currently available sources of health
information, thereby increasing the demand for preventive services and early identification of health conditions11, 19, 45, 46, this suggested a possible handling of
the role of social sectors. Likewise, some studies have reported an association between lack of information on oral diseases during OHL assessment, as well as low SOH23.
The main limitations of this systematic review were the low comparability between the studies selected either due to the characteristics of the sample or the instrument used. In addition, two studies presented a high risk of bias20,26 and
although most of the selected studies showed an association, only one had a representative population24. The use of instruments that researchers find difficult
to interpret could generate bias in the results of the research. Moreover, instruments that evaluated the OHL only by the level of the participants’ reading skills omitted other skills that are also important for carrying out a multidimensional evaluation. The present study encourages new researches to be conducted with longitudinal methodological design; representative samples of the target population; use of instruments that evaluate OHL by means of multiple constructs; control of confounding factors that vary in the different populations and can interfere in the levels of both OHL and SOH, such as sociodemographic and cultural variables.
The association between SOH and OHL brings extremely relevant knowledge to public health, as it suggested that individuals who have greater health literacy, have a better knowledge of their state of health, and oral health. Thus, they have a closer perception of the reality of their health condition, and are capable of acquiring the information most appropriate for their case, thereby promoting better health management. Thus, interventions and population strategies that invest in improving levels of health literacy are of great value to achieve better health promotion results.
CONCLUSION
Considering the limitations of this systematic review, the available scientific evidence suggested an association between the level of Oral Health Literacy and the self-perception of the oral health status; that is, low SOH was associated with low levels of OHL and vice versa. Therefore, it is recommended that health professionals should consider the level of OHL, especially in public
health services, since it interfered with SOH, and could consequently influence health behaviors and oral health conditions. This may interfere positively in the improvement of access to health information by individuals, their autonomy and self-management of their health, and become a feasible means of health promotion.
ACKNOWLEDGMENT
We are grateful for the financial support of the Foundation for Research Support of the State of São Paulo (FAPESP) through research assistance under number 2016 / 26171-4 and National Council for Scientific and Techno-logical Development (CNPq, process number #132516/2016-0).
REFERENCES
1. Petersen PE, Kwan S. The 7th WHO Global conference on health promotion - towards integration of oral health. Community Dent Health. 2010; 27:129-36. 2. Sheiham A, Alexander D, Cohen L, Marinho V, Moysés S, Petersen PE, et al. Global oral health inequalities: task group-implementation and delivery of oral health strategies. Adv Dent Res. 2011; 23(2): 259-67.
3. Horowitz AM, Kleinman DV. Oral health literacy: a pathway to reducing oral health disparities in Maryland. J Public Health Dent. 2012; 72: S26–30.
4. National Institute of Health (NIH). The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the national institute of dental and craniofacial research, national institutes of health. J Public Health Dent. 2005; 65(3): 174-82.
5. Horowitz AM, Kleinman DV. Oral health literacy: the new imperative to better oral health. Dent Clin North Am. 2008; 52(2): 333–44.
6. Wehmeyer MM, Corwin CL, Guthmiller JM, Lee JY. The impact of oral health literacy on periodontal health status. J Public Health Dent. 2014; 74(1): 80–7. 7. Naghibi Sistani MM, Virtanen JI, Yazdani R, Murtomaa H. Association of oral health behavior and the use of dental services with oral health literacy among adults in Tehran, Iran. Eur J Dent. 2017; 11(2): 162-7.
8. Batista MJ, Lawrence HP, Sousa M LR. Oral health literacy and oral health outcomes in an adult population in Brazil. BMC Public Health. 2018; 18: 60. 9. Sykes S, Wills J, Rowlands G, Popple K. Understanding critical health literacy: a concept analysis. BMC Public Health.2013; 13: 150.
10. Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc. 2007; 138(9):1199-208.
11. Crondahl K, Karlsson LE. The nexus between health literacy and empowerment: a scoping review. Sage Open. 2016; 6(2): 1-7.
12. Gilbert GH, Duncan RP, Heft MW, Dolan TA, Vogel WB. Multidimensionality of oral health in dentate adults. Med Care. 1998; 36(7): 988-1001.
13. Locker D. Self-esteem and socio-economic disparities in self-perceived oral health. J Public Health Dent. 2009; 69(1): 1-8.
14. Zaitsu T, Ueno M, Shinada K, Ohara S, Wright FA, Kawaguchi Y. Association of clinical oral health status with self-rated oral health and GOHAI in Japanese adults. Community Dent Health. 2011; 28(4): 297-300.
15. Mattila A, Ghaderi P, Tervonen L, Niskanen L, Pesonen P, Anttonen V, et al. Self-reported oral health and use of dental services among asylum seekers and immigrants in Finland-a pilot study. Eur J Public Health. 2016; 26(6):1006-10. 16. Jones K, Brennan DS, Parker EJ, Mills H, Jamieson L. Does self-efficacy mediate the effect of oral health literacy on self-rated oral health in an Indigenous population? J Public Health Dent. 2016; 76(4): 350-5.
17. Locker D, Maggirias J, Wexler E. What frames of reference underlie self-ratings of oral health? J Public Health Dent. 2009; 69(2): 78-89.
18. Mejia G, Armfield JM, Jamieson LM. Self-rated oral health and oral health-related factors: the role of social inequality. Aust Dent J. 2014; 59(2): 226-33. 19. Parker EJ, Jamieson LM. Associations between indigenous Australian oral health literacy and self-reported oral health outcomes. BMC Oral Health. 2010; 26: 10:3.
20. Ueno M, Zaitsu T, Ohnuki M, Takayama A, Adiatman M, Kawaguchi Y. Association of a visual oral health literacy instrument with perceived and clinical oral health status in Japanese adolescents. Int J Health Promot Educ. 2015; 53(6): 303-14.
21. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009; 21:b2535.
22. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [webpage on the Internet] Ottawa, ON: Ottawa Hospital Research Institute; 2011. [acesso
2017 ago 20]. Available
from:http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
23. Jones K, Parker EJ, Jamieson LM. Access, literacy and behavioural correlates of poor self-rated oral health amongst an indigenous south Australian population. Community Dent Health. 2014; 31(3): 167-71.
24. Naghibi Sistani MM, Yazdani R, Virtanen J, Pakdaman A, Murtomaa H. Determinants of oral health: does oral health literacy matter? ISRN Dent. 2013; 2013:249591.
25. Guo Y, Logan HL, Dodd VJ, Muller KE, Marks JG, Riley JL. 3rd. Health literacy: a pathway to better oral health. Am J Public Health. 2014; 104(7):e85-91.
26. Jamieson LM, Divaris K, Parker EJ, Lee JY. Oral health literacy comparisons between Indigenous Australians and American Indians. Community Dent Health. 2013; 30(1): 52-7.
27. Altin SV, Finke I, Kautz-Freimuth S, Stock S. The evolution of health literacy assessment tools: a systematic review. BMC Public Health. 2014; 14: 1207. 28. Parthasarathy DS, McGrath CP, Bridges SM, Wong HM, Yiu CK, Au TK. Efficacy of instruments measuring oral health literacy: a systematic review. Oral Health Prev Dent. 2014; 12(3):201-7.
29. Firmino RT, Ferreira FM, Paiva SM, Granville-Garcia AF, Fraiz FC, Martins CC. Oral health literacy and associated oral conditions: A systematic review. J Am Dent Assoc. 2017; 148(8): 604-13.
30. Wynia MK, Osborn CY. Health Literacy and Communication Quality in Health Care Organizations. J Health Commun. 2010; 15; 102-15.
31. Koh HK, Berwick DM, Clancy CM, Baur C, Brach C, Harris LM, Zerhusen EG: New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly 'crisis care'. Health Aff (Millwood). 2012; 31(2):434-43.
32. Loueng JL, Fitz AL, Maack BJ, Miller DR. Evaluation of health literacy tools for correct prescription understanding. J Am Pharm Assoc (2003). 2015; 55(3):273-7.
33. Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: the REALD-30—a brief communication. J Public Health Dent. 2007; 67(2): 94-8.
34. Peker K, Köse TE, Güray B, Uysal Ö, Erdem TL. Reliability and validity of the Turkish version of the Rapid Estimate of Adult Literacy in Dentistry (TREALD-30). Acta Odontol Scand. 2017; 75(3):198-207.
35. Junkes MC, Fraiz FC, Sardenberg F, Lee JY, Paiva SM, Ferreira FM. Validity and Reliability of the Brazilian Version of the Rapid Estimate of Adult Literacy in Dentistry – BREALD-30. PLoS ONE. 2015; 10(7): e0131600.
36. Tadakamadla SK, Quadri MF, Pakpour AH, Zailai AM, Sayed ME, Mashyakhy M, et al. Reliability and validity of Arabic Rapid Estimate of Adult Literacy in Dentistry (AREALD-30) in Saudi Arabia. BMC Oral Health.2014; 14: 120.
37. Wong HM, Bridges SM, Yiu CK, McGrath CP, Au TK, Parthasarathy DS. Development and validation of Hong Kong Rapid Estimate of Adult Literacy in Dentistry. J Investig Clin Dent. 2012; 3(2):118-27.
38. Guzys D, Kenny A, Dickson-Swift V, Threlkeld G. A critical review of population health literacy assessment. BMC Public Health. 2015; 15: 215.
39. Suka M, Odajima T, Kasai M, Igarashi A, Ishikawa H, Kusama M, Nakayama T,Sumitani M, Sugimori H. The 14-item health literacy scale for Japanese adults (HLS-14). Environ Health Prev Med. 2013; 18(5):407-15.
40. American Medical Association: Health literacy: report of the Council on Scientific Affairs. JAMA. 1999; 281(6): 552–7.
41. Macek MD, Haynes D, Wells W, Bauer-Leffler S, Cotten P, Parker RM. Measuring conceptual health knowledge in the context of oral health literacy: preliminary results. J Public Health Dent . 2010; 70(3):197-204.
42. Kadam P, Bhalerao S. Sample size calculation. Int J Ayurveda Res. 2010; 1(1):55-7.
43. Pinelli C, De Castro Monteiro Loffredo L. Reproducibility and validity of self-perceived oral health conditions. Clin Oral Investig. 2007; 11(4):431-7.
44. Olutola BG, Ayo-Yusuf O A. Socio-Environmental Factors Associated with Self-Rated Oral Health in South Africa: A Multilevel Effects Model. Int J Environ Res Public Health.2012; 9(10): 3465–83.
45. Rudd R, Horowitz A. The role of Health Literacy in achieving oral health for elders. J Dent Educ. 2005; 69(9): 1018-21.
46. Jackson RD, Eckert GJ. Health Literacy in an Adult Dental Research Population: A Pilot Study. J Public Health Dent. 2008, 68(4):196-200.
2.1. VALIDADE DE CRITÉRIO DO QUESTIONÁRIO 14-ITENS HEALTH LITERACY SCALE (HLS-14) EM ADULTOS E IDOSOS NO BRASIL
CRITERION VALIDITY OF THE QUESTIONNAIRE 14-ITEMS HEALTH LITERACY SCALE (HLS-14) AMONG ADULTS AND ELDERLY IN BRAZIL
Manuscrito não submetido
Sthefanie del Carmen Perez Puello 1
Manoelito Ferreira Silva Junior 1,2
Maria da Luz Rosário de Sousa 1
Marília Jesus Batista 1,3
1. Departamento de Odontologia Social. Saúde Coletiva. Faculdade de Odontologia de Piracicaba. FOP/UNICAMP. Piracicaba, São Paulo, Brasil.
2. Departamento de Odontologia. Universidade Estadual de Ponta Grossa. Ponta Grossa, Paraná, Brasil.
3. Departamento de Saúde Coletiva. Faculdade de Medicina de Jundiaí. Jundiaí, São Paulo, Brasil.
Correspondência: Profa. Dra. Marília Jesus Batista de Brito Mota
Faculdade de Odontologia de Piracicaba. Universidade Estadual de Campinas. Avenida Limeira, 901. CEP 13414-018. Piracicaba-SP, Brasil.
Resumo
Objetivo: Avaliar a literacia em saúde e a validade de critério do questionário
14-items Health Literacy Scale (HLS-14) em adultos e idosos brasileiros.
Metodologia: Estudo transversal aninhado à coorte conduzido em 2017 em 117 adultos e idosos (23-70 anos) em Piracicaba, São Paulo, Brasil. Foi aplicado o questionário HLS-14 validado no Brasil para avaliar a literacia em saúde (LS) em suas três dimensões: Literacia funcional (LFun), Literacia comunicativa (LCom) e Literacia crítica (LCrí). Foi utilizado instrumento proposto pelo estudo para avaliar na prática os três tipos de literacia: a LFun pela capacidade de leitura dos participantes ao receber uma bula, a LCom pela compreensão das indicações de uma receita médica, a LCrí pelo autorreconhecimento de sua condição de saúde bucal por imagens e a compreensão de um material educativo específico da condição de saúde bucal. Foi aplicado um questionário do presente estudo (QE) para avaliar a validade de critério do questionário HLS-14. Para análise estatística as questões do questionário HSL-14 e do QE, foram dicotomizadas em alta (concordo muito e concordo) e baixa LS (nem concordo e nem discordo, discordo e discordo muito) e agrupada por dimensão Lfun, Lcom e LCrí. Foi realizada estatística descritiva, coeficiente de correlação de Kendall´s Tau (p<0,05), test qui-quadrado (p<0,05). Resultados: A maioria apresentou alta literacia.Houve concordância entre HLS-14 e o QE só para a dimensão LFun (p<0,01). Houve associação entre alto nível LS mensurado através do questionário HSL-14 com conseguir ler todo o trecho da bula (p<0,01) e não precisar de ajuda para ler (p<0,01) na entrevista. Na mensuração do QE evidenciou-se associação entre alta LS e conseguir ler todo o trecho da bula de remédio (p<0,01), não precisar de ajuda para ler (p<0,01), ter encontrado na receita todas as informações que precisava para tomar o medicamento (p<0,01), ter o conhecimento de 2 ou mais informações em saúde geral e bucal contidas no material educativo (p<0,01). Conclusão: O questionário HSL-14 apresentou validade de critério para mensurar LFun, porém não para a avaliação da LCom e Lcrí. É recomendada a implementação de instrumentos que ajudem na avaliação prática de habilidades avançadas como a compreensão e análise crítica das informações em saúde.
Estudos transversais; Adultos; Idosos; Saúde Bucal. ABSTRACT
Objective: To evaluate health literacy and the criterion validity of the 14-item Health Literacy Scale questionnaire (HLS-14) in a Brazilian population constituted by adult and elderly patients. Materials and methods: A cross-sectional study conducted in 2017 in a sample from a cohort study of adults and elderly patients (26 to 70 years) from Piracicaba, São Paulo, Brazil. The HLS-14 questionnaire validated in Brazil was used to evaluate health literacy (HL) in its three dimensions: functional Literacy (FunL), communicative Literacy (ComL) and critical Literacy (CriL). Another instrument was used to evaluate the three types of literacy: reading ability was evaluated through (FunL) medication leaflet, understanding the indications of a medical prescription (ComL) and self-recognition of their oral health status by images, and the understanding of a dental health education material specific to each oral health condition (CriL). The responses of each instrument were evaluated by an observer researcher. For the analysis, the HSL-14 questionnaire and the questionnaire of the present study (QE) were dichotomized in high (strongly agree and agree) and low HL. Descriptive statistics was conducted to calculate frequencies, percentages, median and standard deviation, Kendall's Tau correlation coefficient, chi-square test. Results: Most of participants presented high HL. A concordance was observed between the questionnaires for funL evaluation. There was an association between the high HL level measured by the HSL-14 questionnaire, which allowed reading the entire section of the medication leaflet (p <0.01) and did not need help reading (p <0.01). In the analysis of the QE, the association between high HL was found to be able to read the entire section of the medication leaflet (p <0.01), did not need help reading (p <0.01) (p <0.01), two or more knowledge on general and oral health information contained in the educational material (p <0.01). Conclusion: Finally, the HSL-14 questionnaire was validated to measure FunL, but not for the evaluation of LCom and LCrí, it is recommended to implement instruments that help to measure advanced skills such as the understanding and critical analysis of health information.
INTRODUÇÃO
A Literacia em Saúde (LS) é definida como um conjunto de habilidades cognitivas e sociais que implica, além de ler e escrever, procurar, analisar, compreender e aplicar informações para a manutenção da saúde do indivíduo1.
A LS tem sido reconhecida pela Organização Mundial da Saúde (OMS) como uma das cinco estratégias chaves para a promoção da saúde, e torna-se um importante marcador do empoderamento dos indivíduos, através de melhores escolhas em saúde e autonomia para cuidar de sua própria saúde e da comunidade2.
O baixo nível de LS está associado com maior dificuldade no acesso a serviços de saúde preventivo, taxas de hospitalização elevadas, baixa adesão ao tratamento médico e odontológico, impacto negativo na qualidade de vida e má condição de saúde geral3-5. Uma recente revisão sistemática evidenciou
associação entre baixo nível de LS e presença de cárie dentária, porém os resultados em relação a outras condições de saúde bucal como doença periodontal e perdas dentárias, por exemplo, foram controversos6. Outros
estudos desenvolvidos em adultos reportaram que a presença de doenças como gengivite e cárie dentária4, presença de biofilme7, perda dentária4 e visitas ao
dentista por urgência7 foram associadas a indivíduos com baixo nível de LS.
Para mensurar a LS, existe uma diversidade de instrumentos, no entanto, é preciso a compreensão aprofundada do seu constructo e dimensões. No seu contexto mais amplo, a literacia em saúde tem sido identificada através de três níveis ou dimensões, sendo elas: Literacia funcional (LFun): habilidades para ler e escrever informações básicas relacionadas à saúde; Literacia comunicativa (LCom): habilidade de pesquisa de informações em saúde e participação de atividades que lhe permitirão adquirir novos conhecimentos e aplicá-lo para seus cuidados; e, Literacia crítica (LCrí): habilidades que o indivíduo possui para analisar críticamente a informação de saúde e aplicá-los para melhorar sua vida e da comunidade8. No entanto, na atualidade a maioria dos instrumentos são
capazes apenas de mensurar a literacia no nível funcional8, através da leitura e
escrita de palavras relacionadas a saúde, sendo poucos os instrumentos que mensuram o nível crítico e comunicativo8,9. Ressalta-se que é um desafio avaliar
![Soberania alimentar: dimensões material, prático-política, utópica e contraposição à [des]ordem do Sistema Agroalimentar](data:image/gif;base64,R0lGODlhAQABAIAAAP///wAAACH5BAEAAAAALAAAAAABAAEAAAICRAEAOw==)