Machine Translated by Google

Brazilian Research in Pediatric Dentistry and Integrated Clinic 2019; 19:e5109

DOI: http://doi.org/10.4034/PBOCI.2019.191.120
ISSN 1519-0501

ORIGINAL ARTICLE

Sociodemography, Oral Health Status and Behaviors Related to Oral

Health Literacy

Nurhidayah Muhd Noor1, Haslina Rani2, Ahmad Shuhud Irfani Zakaria3, Nurul Asyikin Yahya4, S. Nagarajan MP Sockalingam5

1Centre for Family Oral Health, Faculty of Dentistry, The National University of Malaysia, Kuala Lumpur, Malaysia.
0000-0003-4240-783X
2Centre for Family Oral Health, Faculty of Dentistry, The National University of Malaysia, Kuala Lumpur, Malaysia.
0000-0001-7660-4095
3Centre for Family Oral Health, Faculty of Dentistry, The National University of Malaysia, Kuala Lumpur, Malaysia.
0000-0003-3715-9181
4Centre for Family Oral Health, Faculty of Dentistry, The National University of Malaysia, Kuala Lumpur, Malaysia.
0000-0001-9497-4508
5Centre for Family Oral Health, Faculty of Dentistry, The National University of Malaysia, Kuala Lumpur, Malaysia.
0000-0002-7976-5115

Author to whom correspondence should be addressed: Haslina Rani, Center for Family Oral Health, Faculty of Dentistry, The National
University of Malaysia, Kuala Lumpur, Malaysia. Phone: +603 9289-7750. E-mail:
hr@ukm.edu.my.

Academic Editors: Alessandro Leite Cavalcanti and Wilton Wilney Nascimento Padilha

Received: 20 March 2019 / Accepted: 18 July 2019 / Published: 09 August 2019

Abstract

Objective: To assess the relationships of socio-demography, self-reported oral health status, and behavior with oral
health literacy (OHL) among adults. Material and Methods: A cross-sectional study was conducted during a mega
carnival in Kuala Lumpur. Socio-demographic, oral health status, and oral health behavior data were obtained using
a questionnaire, and OHL was determined by a validated Malay version of the 14-item Health Literacy in Dentistry
Scale (HeLD-14). A total of 165 data of participating adults were tested using Pearson's correlation, Independent t-
test and One-way ANOVA with a significance level set at p<0.05. Results: The mean age of participants was 30.4
years (SD 9.7 years). Malay HeLD-14 scores were higher among those who were from better socio-economic class
(household income within the top 20% of the population) (p<0.005) those with good self-reported oral health status
(good oral health status, no active cavities) (p<0.005) and those with good oral health behaviors (brushed daily,
flossed daily, does not vape) (p<0.05). Conclusion: Household income, self-reported oral health status, and behaviors
were significantly associated with oral health literacy. Therefore, oral health literacy assessment is vital to help tailor
appropriate oral health education and care.

Keywords: Health Education; Health Literacy; Attitude to Health; Oral Health.

Association of Support for Oral Health Research - APESB

Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

Introduction

Despite advances in the health sector, almost all countries in the world spend a huge cost on
health treatment annually. The burden of diseases seems to increase by year and remain a global
battle. According to the WHO Global status report on noncommunicable diseases 2010,
noncommunicable diseases deaths are projected to increase by 15% globally between 2010 and 2020
(to 44 million deaths) [1]. The WHO Global Health Expenditure Atlas reported that in 2011, US$6.9
trillion was spent on health [2].
A systematic review on Global Burden of Untreated Caries revealed the data that in 2010,
untreated cavities in permanent teeth affected 35% of the global population, or 2.4 billion people [3].
Also, a recent study has calculated the global financial burden based on the treatment cost of dental
diseases from 168 countries, which accounted for 172 billion US dollars [4]. The global number of
disability-adjusted life years (DALYs) due to oral diseases rose from 11.3 million DALYs in 1990 to 19.0
million DALYs in 2016 [5]. The disability-adjusted life year (DALY) measures health loss due to both
fatal and non-fatal disease burden. As treating and curing existing health conditions are not cost-
efficient, the world is now looking into a more holistic approach to combat this problem. One of the main
strategies is by enhancing preventive measures that contribute to significant effects on health outcomes
[1].
Health literacy was first defined by The World Health Organization in 1998 as, ''Cognitive and
social skills which determine the motivation and ability of individuals to gain access to,
understand, and use the information in ways which promote and maintain good health”. Health literacy
is a concept that suggests that health status would be improved if people can access health information
and have the capacity to use it effectively. On that account, health literacy skills are
critical to empowering people's ability to promote and improve their health [6]. Currently, the spike of
attention in health literacy is precipitated by the significant association between health literacy and
outcomes. Low health literacy is associated with limited health knowledge, unhealthy lifestyles,
underuse of preventive services, low health status, and high hospital admission rates. People without
health literacy skills to consider sensitive health decisions in their lives are more vulnerable and have
poorer health outcomes [7].
Furthermore, looking at the complexity of the healthcare system, it is well understood by how
low health literacy is associated with poor health. Furthermore, low health literacy may also cause a
negative psychological effect. People with low health literacy skills reported a sense of shame about
their skill level [8]. As a result, they may hide reading or vocabulary difficulties to maintain their dignity
[9]. A study by Bress 2013 revealed that health literacy skills impact a person's health more than age,
income, employment status, education level, and racial or ethnic group [10].
More than a decade after health literacy was defined by WHO, oral health literacy (OHL) was
given its first definition by the Healthy People 2010, and is in agreement with the definition for general
health literacy: “The degree to which individuals have the capacity to obtain, process and understand
basic health information and services needed to make appropriate oral health decisions”

2
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

[6]. Since then, many studies have been conducted to investigate the association between low levels of
OHL and poor oral health outcomes, compromised self-care behavior, difficulties to understand
health instructions or failure to see the importance of preventive dental procedures using a range of
validated OHL instrument available to a different range of population in the world [11].
To date, there are four studies on oral health literacy in the Malaysian population [12-15].
All studies translated and adapted OHL tools from English to Malay, and all tools included components of
reading or comprehension. Apart from the Malay Dental Health Literacy Assessment (DHLA) instrument,
other existing studies on Malay OHL tools [13-15] did not report how the
reliability and validity of the tools used were established. As for the Malay DHLA, the reliability of the tool
used was 0.67, slightly lower than the accepted values of Cronbach Alpha that is between 0.7
to 0.9 [16].
Evaluating improved public understanding and their oral health literacy level becomes an important
agenda for the nation in order to achieve the National Oral Health Goals 2020 with oral health status
among Malaysians [17]. However, looking at the current situation of oral health literacy studies conducted
in the country, it is evident that they are still inadequate to address the aforementioned national agenda.
The time was right to conduct this study with the objective to evaluate the relationships of self-reported
oral health status, oral health behavior and
sociodemography with the level of OHL using a simple OHL tool suitable for a multilingual country.
Findings from this study not only add on to the body of knowledge and provide current
evidence on oral health literacy, but it may also provide valuable information on socio-demography, oral
health behavior and self-reported oral health status related to oral health literacy that is important for
designing preventive and interventional approaches in oral health care.

Material and Methods

Study Design and Sample

A cross-sectional study was conducted in July 2018 during a mega carnival held in Kuala Lumpur.
Only Malaysian adults age 18 to 59 were invited to participate. Those who were not able to understand
instructions on how to answer the questionnaire, and those who could not engage in
Malay were excluded. Self-administered questionnaires were given to the respondents to be answered
and were retrieved immediately. Informed consent was obtained from all those who participated. A total of
165 participants' data were used for analyses.

Instrument

A translated and validated Malay version of the 14 items Health Literacy in Dentistry
(HeLD-14) was used to evaluate the level of OHL. The Health Literacy in Dentistry (HeLD) scale is
an oral health literacy measurement tool that estimates an individual's capacity to obtain, process or
interpret, and understand basic oral health information and services needed to make appropriate oral
health-related decisions. The 14 items in the form represent seven conceptual domains: access,

3
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

understanding, support, utilization, economic barriers, receptivity, and communication. Each item
was scored using a 5-point Likert scale ranging from 1 (“without any difficulty”) to 5 (“Unable to
do”). After re-coding of 5 to 0, 4 to 1, 3 to 2, 2 to 3, and 1 to 4, the possible range of summary scores
is from 0-56 (HeLD-14). Higher scores indicate higher oral health literacy.
The original English version of HeLD-14 was translated to Malay language using a forward
and backward technique to produce cross-cultural adaptation [18]. The forward translation was done
by two certified translators. The two translated versions were reviewed by a questionnaire development
committee comprising five dental specialists. The committee harmonized the translated versions to
produce a preliminary forward translation version. This preliminary translated
version was then translated back to English by two dentists who are fluent in both languages.
As the backward translation was semantic with the original English version of HeLd-14, the
preliminary forward translation version was pre-tested on 30 adults at the Dental Faculty, The
National University of Malaysia, Kuala Lumpur. The feedback by the respondents was used for the
face and content validity of the questionnaire. A final review was done, and the definitive version of
Malay HeLD-14 was approved by the questionnaire development committee.
Cronbach's alpha was used to assess the internal consistency of the instrument. The overall
value for the Cronbach's alpha coefficient was 0.77, which is considered a satisfactory level of
reliability for research instruments. Further, a test-retest reliability test was done on the same 23
respondents who participated in the pre-test after one week. The Intra-Class Correlation (ICC) was
used to evaluate test-retest reliability. The ICC value for the total score of the Malay HeLD-14 was
0.761, with a 95% CI (Confidence Interval) from 0.444 to 0.898, which showed good agreement
between the test-retest results. The Malay version HeLD-14 questionnaire is available upon request
from the corresponding author.
Self-administered questionnaire was used to assess socio-demographic data (age, residential
area, gender, race, household income, educational level); self-reported oral health status (overall oral
health status, periodontal disease, cavities, tooth-loss, malocclusion); and oral health behaviors
(toothbrushing, flossing, mouth rinsing, snacking, smoking, vaping and dental visit). These specific
oral health behaviors indicators were adapted from a previous study [19].

Statistical Analysis
The statistical analysis of descriptive statistics and relationships of socio-demography, oral
health status, and behaviors with OHL were conducted using SPSS, version 24 (IBM Corp., Armonk,
New York, USA). Pearson's correlation, independent sample t-test, and one-way ANOVA were used
with a significance level set at p<0.05.

Ethical Approval

4
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

Research and ethical approvals were obtained from the Research and Ethics Committee of
UKM (Ref No: UKM PPI/111/8/JEP-2018-052) and National Medical Research Register (NMRR) of the
Ministry of Health Malaysia (Research ID: 43617).

Results

The mean age of the participants was 30.4 years (SD=9.7 years). More than half of the
participants were females (53.3%), Malays (54.5%), from the middle-income bracket, M40 (62.4%)
and, diploma or degree and above holders (57.6%).

Socio-demography and OHL

The mean OHL evaluated by the Malay HeLD-14 was 45.9 (SD=10.1, median= 49.0, range
10-56). Table 1 shows the relationships between socio-demographic variables and OHL scores.
Significant differences of OHL scores were noted between races (p<0.001) where Malays scored the
highest of compared to others. For household income, participants with household income within the
top 20% of the country's population (T20) had the highest OHL score while those in the bottom 40%
(B40) scored the lowest (p<0.005). Pearson's correlation between OHL and age shows a low
correlation (ÿ=0.201; p<0.01).

Table 1. Mean score of HeLD-14 by socio-demographic characteristics.

Variables N % OHL Scores F statistic p-values
Mean SD (df)
Gender
Male 77 46.7 45.4 10.61 0.39 0.533
Female 88 53.3 46.4 9.73 1; 163
Race

Malay 90 54.5 48.7 8.91 7.50 <0.001b

Chinese 52 31.5 43.4 9.07 3; 161
Indian 17 10.3 38.2 13.79
Others 6 3.6 48.2 9.56
Household Income

Bottom 40% of Population, B40 (<RM3855) 46 27.9 41.1 12.16 7.63 <0.005b

Middle 40% of Population, M40 (RM3856-RM8135) 103 62.4 47.7 8.74 2; 162

Top 20% of Population, T20 (>RM8135) 16 9.7 48.1 7.91

Educational Level
Never Attend School 1 0.6 36.0 - 0.341 0.796

Completed Primary School 6 3.6 45.7 6.71 3; 161

Completed Secondary School 63 38.2 45.7 11.57

Diploma, or Degree and Above 95 57.6 46.1 (9.34)

aOne-way ANOVA test; bAll 3 and 4 pairs of mean OHL score are significantly different by post-hoc test (Games-Howell's procedure); SD:
Standard Deviation; df: Degrees of freedom.

Self-Reported Oral Health Status and OHL

Table 2 shows the relationships between self-reported oral health status and OHL scores.
Participants with lower OHL scores rated themselves as having poor oral health status (p<0.005) and
having carious teeth (p<0.05).

5
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

Table 2. Mean score of HeLD-14 by self-reported oral health status.

Variables OHL Scores Mean N
Difference % t statistic p-valueb
Mean SD (95% CI) (df)
Oral Health Status
Good 150 90.9 46.6 9.27 7.8 (2.5, 13.1) 2.91 <0.005
Bad 15 9.1 38.8 15.09 (163)
Gum Disease
Yes 31 18.8 47.4 9.58 1.8 (-2.2, 5.8) 0.89 0.374
Node 134 81.2 45.6 10.26 (163)
Tooth Decay
Yes 60 36.4 43.6 11.43 -3.6 (-6.8, -0.4) -1.77 <0.05
Node 105 63.6 47.2 9.11 (163)
Tooth Loss
Yes 60 36.4 46.8 11.14 1.5 (-1.8, 4.7) 0.90 0.368
Node 105 63.6 45.3 9.52 (163)
Bad Breath
Yes 37 22.4 43.4 10.34 -3.2 (-6.9, 0.5) -1.7 0.090
Node 128 77.6 46.6 9.99 (163)
Poor Teeth Alignment
Yes 77 46.7 45.8 9.08 -0.2 (-3.3, 2.9) -0.1 0.907
Node 88 53.3 46.0 11.01 (163)
bIndependent t-test; SD: Standard deviation; CI: Confidence interval; df: Degrees of freedom.

Oral Health Behaviors and OHL

Table 3 shows the relationships between oral health behaviors and OHL scores. Higher OHL
scores were observed in those who brushed twice or more per day (p<0.001), flossed (p<0.05),
rinsed (p<0.01), non-vapers or past-vapers (p<0.05) and those who visited the dental clinic once or more
per year (p<0.005).

Table 3. Mean score of HeLD-14 by oral health behaviors.

Variables N% OHL Scores Mean difference F statistic p-values
Mean SD (95% CI) (df)
Brushing Habit
< 2 Times Daily 15 9.1 34.3 13.39 -12.8 (-17.8, 7.7) 3.96 <0.001

2 Times or More Daily 150 90.9 47.1 9.01 (163)

Toothpaste
Not Using Toothpaste or Using 17 10.3 43.4 9.97 -2.8 (-7.9, 2.3) 0.02 0.277

Non-Fluoridated Toothpaste
Using Fluoridated Toothpaste 148 89.7 46.2 10.14 (163)
Flossing
Never Floss 86 52.1 44.2 10.54 -3.5 (-6.6, -0.4) 0.45 <0.05
Use Floss 79 47.9 47.7 9.38 (163)
Mouth Rinse
Never Use Mouth Rinse 76 46.1 43.5 10.60 -4.4 (-7.5, -1.3) 3.43 <0.01
Use Mouth Rinse 89 53.9 47.9 9.30 (163)
Snacking Between Meals
< 2 Times Daily 147 89.1 45.9 9.91 -0.3 (-5.3, 4.7) 0.32 0.903

2 Times or More Daily 18 10.9 46.2 12.09 (163)

Smoking Status
Current Smoker 29 17.6 45.6 11.28 -0.3 (-4.4, 3.8) 0.99 0.875
Non-Smoker or Past Smoker 136 82.4 46.0 9.91 (163)
Vaping Status
Current Vaper 7 4.2 38.3 15.72 -7.9 (-15.6, -0.3) 2.95 <0.05

Non-Vaper or Past Vaper 158 95.8 46.2 9.75 (163)

6
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

Alcohol Drinking Status

Drink Alcohol 21 12.7 42.2 10.00 -4.2 (-8.8, 0.5) 0.70 0.077

Never Drink or Not Anymore 144 87.3 46.4 10.07 (163)

Dental Visit
Less Than Once Per Year 108 65.5 44.0 10.14 -5.4 (-8.6, -2.2) 2.46 <0.005
Once or More Visit Per Year 57 34.5 49.4 9.20 (163)
cIndependent t-test; SD: Standard Deviation; CI: Confidence Interval; df: Degrees of freedom.

Discussion

This study was conducted at a popular non-health related mega carnival in Kuala Lumpur
instead of at clinics or health care facilities set. This is to reduce bias as the utilization of health care

facilities is a sign of having good health literacy [20]. The HeLD-14 comprises seven domains (access,
understanding, support, utilization, economic barriers, receptivity, and communication)
[21]. It was chosen for this study for its reliability, validity, and cultural suitability to assess oral health
literacy [21]. Further, it can capture the three concepts of health literacy considered critical [20]. The
three concepts are (i) basic/functional OHL for everyday life; for example, sufficient basic skills in
reading and writing; ii) communicative/interactional, for example, the ability to extract and apply new
information; and (iii) critical health literacy, for example, the ability to manage oral
health-related information and/or to have control over oral health-related situations.

Compared to other earlier tools a such as Rapid Estimate of Adult Literacy in Dentistry
(REALD) or Test of Functional Health Literacy in Dentistry (ToFHLiD), which are mainly on word
recognition, numeracy, and reading skills, HeLD-14 assesses multi-dimensional aspects in OHL and
was validated to have a good psychometric property. The tool was also cross-culturally adapted by other
countries such as India [22], Indonesia [23,24], and the United States of America [25]. The advantage
of HeLD-14 is, it is a simple, sensitive, comprehensive, easy to use and low-cost assessment tool that
aims to capture a person's ability to seek, understand and use oral health information and then being
able to access and benefit from oral health care services [26].
This is particularly important when conducting a health literacy study in multicultural and
multilingual nations like Malaysia. Education in Malaysia is unique as it inherited the divide-and-rule
system from the colonial era where one particular language is used as the primary teaching medium
such as Malay, or Chinese, or Tamil, or English medium schools while other languages may
be taught as subjects. This division caused language segregation among Malaysians, making Malaysia
one of those rare countries in South East Asia, where not all her citizens can understand or
use the national language well [27]. This unique identity of a multilingual nation explains why a tool like
HeLD-14 may be more suitable over other existing tools available in the country [12-15].
It is simple enough for everyone to answer regardless of the level of understanding of the medium of
instruction, and yet able to measure all dimensions of oral health literacy. Further, the Malay HeLD-
14 used has a better reliability score compared to existing OHL tools in Malay [12].
Looking at the socio-demographic background, those whose household income falls in the
top 20% of the country's population had a significantly higher score of OHL compared to others
income-brackets. This supports findings reported by others where income influences OHL [28-31].

7
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

The difference by race was also evident as OHL scores were significantly higher among Malays
(54.5%), followed by others (Iban, Kadazan) (3.6%), Chinese (31.5%) and Indian (10.3%). However,
this finding could not be supported, as there was no data from other literature comparing OHL and
races in Malaysia. As in most studies [30,32], there was no significant difference in OHL level found
between genders. For the level of education, even though the OHL score increased from the lower to
the upper level of education, the difference was not significant.
Caries and periodontal disease among adults remain to be global challenges. According to the
National Oral Health Survey of Adults in Malaysia [33], the prevalence of dental caries and periodontal
disease among adults are 88.9% and 94.0% respectively. Lower OHL level would result
in poor oral health status [34]. Our study strengthened this finding where those with lower OHL
scores self-reported to have poor oral health status (9.1%) and decayed teeth (36.4%). However, there
was no significant difference in OHL of those who reported having gum disease and those who did
not. This might be due to the fact that periodontal disease is a silent disease, and it is more difficult
to self-detect compared to cavities. However, when assessing oral health literacy among patients, it
would be best to conduct an intra-oral examination to confirm self-reported oral health status as well
as assess their relationships.
Oral health literacy is the key determinant of good oral health status. People with adequate
oral health literacy will have the cognitive, literacy as well as social skills to make decisions on their
oral health such as exercising good oral health habits as recommended and proper service utilization
[20]. These are in line with our study, as those who practice good oral hygiene habits such as
brushed at least two times per day, flossed and used a mouth rinse, had higher OHL scores compared
to those without the habits. Further, one's ability to have a regular dental check-up or seek dental
treatment is crucial to the improvement of oral health status [33]. The ability for service navigation or
utilization is one of the main aspects of oral health literacy [20]. Some studies have reported that
Those who were able to go for regular dental visits have higher OHL level [29,34,35]. Our study
strengthened these findings, where those who reported visiting the dentist at least once a year have a
higher OHL score.
There are limitations to this study that should be considered when looking at the findings.
Sampling was limited to convenient sampling. Careful measures were taken to ensure the
proportions of participants resemble Malaysian population in terms of racial and income distribution.
However, more efforts need to be taken to include participants from the bottom 40% and top 20%
income brackets as income has been proven to be a risk factor for poor health literacy [28-31].
Future studies should include an oral examination to confirm the self-reported oral health status
among the subjects and assess their relationships with OHL. Despite these limitations, this study has
valuable strength. Using a simplified tool that can capture the multidimensional aspect in OHL, it
gives an insight of OHL and its relationships with the socio-demography, self-reported oral health
status, and behaviors in a multilingual population.

8
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

Conclusion

Household income, self-reported oral health status, and behaviors were significantly associated
with oral health literacy. Determination of oral health literacy is, therefore, vital to help tailor appropriate
oral health education and care for dental patients.

Authors' Contributions: NMN, HR, ASIZ, NAY, and SNMPS designed the study. NMN performed the data collection. NMN and HR

conducted the data analysis and interpretation. NMN and HR wrote the manuscript.

NMN, HR, ASIZ, NAY, and SNMPS reviewed the manuscript. All authors declare that they contributed to the critical review of intellectual

content and approval of the final version to be published.

Financial Support: This study was conducted using the Young Researchers Incentive Grant (GGPM-2017-

013) provided by The National University of Malaysia (UKM).

Conflict of Interest: The authors declare no conflicts of interest.

References
[1] World Health Organization. Global Status Report on Noncommunicable Diseases. Geneva: World Health
Organization; 2010.
[2] World Health Organization. WHO Global Health Expenditure Atlas. Geneva: World Health Organization; 2014.
[3] Kassebaum NJ, Bernabe E, Dahiya M, Bhandari B, Murray CJL, Marcenes W. Global burden of untreated caries: A
systematic review and metaregression. J Dent Res 2015; 94(5):650-8. https://doi.org/10.1177/0022034515573272
[4] Meier T, Deumelandt P, Christen O, Stangl GI, Riedel K, Langer M. Global burden of sugar-related dental diseases in 168
countries and corresponding health care costs. J Dent Res 2017; 96(8):845-54. https://doi.org/10.1177/0022034517708315

[5] GBD 2016 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 333
diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: A
systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390(10100):1260-1344. https://doi.org/
10.1016/S0140-6736(17)32130-X
[6] Horowitz AM, Kleinman D V. Oral health literacy: The new imperative to improve oral health. Dent Clin North Am
2008; 52(2):333-44. https://doi.org/10.1016/j.cden.2007.12.001
[7] Dickson-Swift V, Kenny A, Farmer J, Gussy M, Larkins S. Measuring oral health literacy: A scoping review of existing tools.
BMC Oral Health 2014; 14:148. https://doi.org/10.1186/1472-6831-14-148
[8] Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: The unspoken connection.
Patient Educ Couns 1996; 27(1):33-9. https://doi.org/10.1016/0738-3991(95)00787-3
[9] Baker DW, Parker RM, Williams MV, Pitkin K, Parikh NS, Coates W, et al. The health care experience of patients with low
literacy. Arch Fam Med 1996; 5(6):329-34. https://doi.org/10.1001/archfami.5.6.329
[10] Bress LE. Improving oral health literacy - The new standard in dental hygiene practice. J Dent Hyg 2013;
87(6):322-9.
[11] 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. https://doi.org/10.1016/j.adaj.2017.04.012

[12] Ismail A, Razak IA, Ab-murat N. The impact of anticipatory guidance on early childhood caries: A quasi-
experimental study. BMC Oral Health 2018; 18(126):1-8. https://doi.org/10.1186/s12903-018-0589-0
[13] Ismail AF, Ardini YD, Mohamad N, Bakar HA. Association between parental oral health literacy and children's oral
health status. Rev Latinoam Hipertens 2018; 13(3):312-6.
[14] Ying NY, Ming LS, Mohd-said S, Yusof N, Mohd-dom TN. Oral health literacy and behavior of health sciences university
students. J Dent Indonesia 2016; 22(2):56-62. https://doi.org/10.14693/jdi.v22i2.404
[15] Fabillah NSA, Mustapa N, Rohani MM, Esa R. Oral health literacy among carers of special needs children in Kuala
Terengganu, Malaysia. Ann Dent Univ Malaya 2015; 22(3):1-6. https://doi.org/10.22452/adum.vol22no1.3
[16] Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ 2011; 2:53-5.
https://doi.org/10.5116/ijme.4dfb.8dfd
[17] Ministry of Health. Oral Health Division. National Oral Health Plan for Malaysia 2011-2020. Putrajaya Ministry
Health, 2011.
[18] Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures:
Literature review and proposed guidelines. J Clin Epidemiol 1993; 46(12):1417-32.

9
Machine Translated by Google

Res. Bras. Pediatric Dentistry Clin. Int. 2019; 19:e5109

https://doi.org/10.1016/0895-4356(93)90142-N
[19] Blizniuk A, Ueno M, Zaitsu T, Kawaguchi Y. Association between self-reported and clinical oral health status in
Belarusian adults. J Investig Clin Dent 2017; 8(2):1-6. https://doi.org/10.1111/jicd.12206
[20] Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication
strategies into the 21st century. Health Promot Int 2000; 15(3):259-67. https://doi.org/10.1093/heapro/15.3.259

[21] Jones K, Brennan D, Parker E, Jamieson L. Development of a short-form Health Literacy Dental Scale (HeLD-14).
Community Dent Oral Epidemiol 2015; 43(2):143-51. https://doi.org/10.1111/cdoe.12133
[22] Gomez MSS, Sujatha BK. Assessment of oral health literacy among patients attending Malabar dental college and
research center in Kerala: A cross sectional survey. J Indian Assoc Public Heal Dent 2015; 13(3):328-30. https://
doi.org/10.4103/2319-5932.165291
[23] Anton R, Adinda S, Nasia AA, Adiatman M, Setiawati F, Wimardhani YS, et al. Oral health literacy in Indonesian
adolescents. J Int Dent Med Res 2015; 8(3):123-7.
[24] Rahardjo A, Adiatman M, Wimardhani Y, Maharani DA. Health literacy in dentistry among undergraduate students in
Indonesia. Asian J Epidemiol 2016; 9(1-3):24-9. https://doi.org/10.3923/aje.2016.24.29
[25] Henderson E, Dalawari P, Fitzgerald J, Hinyard L. Association of oral health literacy and dental visitation in an inner-
city emergency department population. Int J Environ Res Public Health 2018; 15(8):E1748. https://doi.org/10.3390/
ijerph15081748
[26] Ju X, Brennan DS, Parker E, Chrisopoulos S, Jamieson L. Confirmatory factor analysis of the health literacy in
dentistry scale (HeLD) in the Australian population. Community Dent Health 2018; 35(3):140-7. https://doi.org/
10.1922/CDH_4325Ju08
[27] Tan PKW. The medium-of-instruction debate in Malaysia: English as a Malaysian language? Lang Probl Lang
Plan 2005; 29(1):47-66. https://doi.org/10.1075/lplp.29.1.04tan
[28] Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007;
138(9):1199-208. https://doi.org/10.14219/jada.archive.2007.0344
[29] Batista MJ, Lawrence HP, Sousa MDLR. Oral health literacy and oral health outcomes in an adult population in
Brazil. BMC Public Health 2017; 18(1):60. https://doi.org/10.1186/s12889-017-4443-0
[30] Minja IK, Astrom AN, Masalu JR. Prevalence and distribution of oral health knowledge according to sociodemographic,
behavioral and clinical characteristics in selected coastal districts of Tanzania. Tanzan J Health Res 2016;
18(3):1-13. https://doi.org/10.4314/thrb.v18i3.1
[31] Vilella KD, Alves SG, de Souza JF, Fraiz FC, Assunção LR. The association of oral health literacy and oral health
knowledge with social determinants in pregnant Brazilian women. J Community Health 2016; 41(5):1027-32.
https://doi.org/10.1007/s10900-016-0186-6
[32] Haridas R, SS, Ajagannanavar SL, Tikare S, Maliyil MJ, Kalappa AA. Oral health literacy and oral health status
among adults attending dental college hospital in India. J Int Oral Health 2014; 6(6):61-6.
[33] Ministry of Health. Oral Health Division. National Oral Health Survey of Adults 2010. Putrajaya: Ministry of Health
Malaysia; 2010.
[34] Ueno M, Takeuchi S, Oshiro A, Kawaguchi Y. Relationship between oral health literacy and oral health behaviors
and clinical status in Japanese adults. J Dent Sci 2013; 8(2):170-6. https://doi.org/10.1016/j.jds.2012.09.012
[35] 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. https://doi.org/10.1922/CDH_3025Jamieson06

10