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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 7  |  Page : 41-46

Relationship between health literacy and toothbrushing practice among young adults

Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla, Thailand

Date of Web Publication17-Jan-2020

Correspondence Address:
Dr. Angkana Thearmontree
Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla 90112.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_163_19

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Aims and Objectives: The aim of this study was to access the relationship between health literacy and toothbrushing practice in young adults. Materials and Methods: This cross-sectional analytical study consisted of 218 respondents: college (except dental students) and noncollege students. All respondents completed a general health literacy questionnaire using the Newest Vital Sign (NVS) and the specific health literacy (SHL) questionnaire comprising questions on access, knowledge, and attitudes on toothbrushing. Respondents’ regular toothbrushing practice was evaluated by using a video camera recording. All the analyses were performed by using the t-test, analysis of variance, Pearson correlation or Spearman rank correlation, and multiple linear regression statistical technique. Results: The mean scores of NVS and SHL were significantly different among the education groups (P < 0.001). Toothbrushing practice showed significantly (P < 0.05) correlations with gender, education, access, attitude, and SHL, but not with the NVS. The correlation of toothbrushing practice and SHL as well as access remained significant in multiple linear regression models after adjusting for gender and education (P < 0.05). Conclusion: Health literacy had a significant correlation with toothbrushing practice when measured with SHL. Access and SHL were the most influencing factors for toothbrushing practice in this study.

Keywords: Access, Attitude, Health Literacy, Knowledge, Toothbrushing

How to cite this article:
Rizqi TR, Thearmontree A. Relationship between health literacy and toothbrushing practice among young adults. J Int Oral Health 2020;12, Suppl S1:41-6

How to cite this URL:
Rizqi TR, Thearmontree A. Relationship between health literacy and toothbrushing practice among young adults. J Int Oral Health [serial online] 2020 [cited 2020 Sep 26];12, Suppl S1:41-6. Available from:

  Introduction Top

Health literacy is an important factor for successful access to care and services, self-care for chronic conditions, and maintenance of health and wellness.[1] American Medical Association defined health literacy as “the constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment.”[2] WHO[3] specifically defined health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.” Similar to WHO, Sørensen et al.[4] integrated the 17 definitions of health literacy to be “people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course.” These three definitions showed two different perspectives of health literacy: general[2] and specific[3],[4] health literacy.

WHO[1] stated four subdimensions of health literacy: accessing, understanding, appraisal, and communication. Accessing is the individual’s ability to seek, find, and receive health information. Understanding is the individual’s ability to learn the health information that is accessed. Appraisal is the individual’s ability to define, filter, and evaluate the health information that has been accessed. Communication is the individual’s ability to use the information to make appropriate health decisions. These subdimensions will directly influence health behaviors and health outcomes.[1]

Most of the available health literacy instruments were developed based on the definition of general health literacy, which is a measurement of basic skills such as reading, reading comprehension, and numerical ability.[5] One of them is the Newest Vital Sign (NVS). The NVS uses the nutritional facts on an ice-cream label and questions based on the label.[6] It is easier, is more comfortable to use, and takes less time as compared to other general health literacy instruments that measure the same things.[7] It was also reported that NVS is the most comprehensive and practical health literacy instrument.[8]

The availability of specific health literacy (SHL) instruments is limited or the instruments are usually too specific to each health outcome. Because of the strengths and limitations of health literacy measurements, McCormack et al.[9] recommend to use multiple health literacy instruments in a single study.

Many studies on health literacy and oral health found a positive correlation.[10],[11] Most studies used general health literacy instruments. Health literacy was associated with oral health behaviors such as oral health conditions,[11],[12],[13] self-rated oral health,[14] failing to show for dental appointments,[15] dental checkup, self-checking with a mirror, and toothbrushing frequency.[11],[16] There is no study on health literacy related to toothbrushing practice (TBP). To the best of our knowledge, this may be the first study on this issue.

The objective of this research was to study the relationship between health literacy and TBP in young adults using general and SHL instruments. Information about health literacy and its relationship with TBP will lead the oral health personnel to learn whether health literacy affects TBP in daily life and how people get the information about proper toothbrushing. This information will help the development of the oral health promotion program for improving the effectiveness of TBP in the future.

  Materials and Methods Top

This study was an analytical cross-sectional study. The respondents consisted of 218 young adults aged 20–25 years. The sample size was calculated based on the table of approximate sample size by Polit and Beck,[17] with r = 0.2,[18] α = 0.05, and power = 0.80; the minimum sample size required was 194. The samples were divided into three groups based on their education level and field of study: noncollege young adults (n = 72), college students in health-related fields (excluding dental students, n = 74), and college students in nonhealth-related fields (n = 72). The college students were collected from one university and noncollege young adults were collected from one community in Yogyakarta, Indonesia during July to September 2017. The purposive sampling was used to select the community in this study. This village was chosen because of its location, which is not too far from the capital city of Yogyakarta. In addition, the young adults in this village can easily access health information same as college students do. By reducing the gaps in obtaining health information hopefully could decrease bias in this study. The inclusion criteria of the study were the one who had ability to read and write, who was not a student in Faculty of Dentistry, who was not on orthodontic treatment, and who was willing to join the study.

The respondents were asked to brush their teeth using their regular practice in a private area without being accompanied by the researcher. The respondent’s TBP was recorded using a video camera, which covered only the mouth area without exposing the face to prevent face recognition. The TBP was evaluated and scored using the video and checklist by one examiner who did not know which group of the subject belongs to. Scoring of the toothbrushing considered six variables: technique, coverage, sequence, force, duration, and tongue brushing.

The acceptable toothbrushing techniques in this study were horizontal scrub in the occlusal area and Bass, modified Bass, and Roll techniques in all other areas. The total observed areas were 16. The details of the toothbrushing scoring are as follows:

  1. Technique: brushing with appropriate technique in 12–16 areas (2 points), 8–11 areas (1 point), and <8 areas (0 point).

  2. Coverage: brushing all areas (1 point) and not brushing all areas (0 point).

  3. Sequence: brushing systematically or brushing from one area to another area continuingly, and not jumping over (1 point), not systematically or not brushing continuingly and jumping over (0 point).

  4. Force: brushing gently (1 point), too hard or too soft (0 point).

  5. Duration: brushing ≥2min (1 point) and <2min (0 point).

  6. Tongue brushing: yes (1 point) and no (0 point).

The total scores of all variables ranged from 0 to 7.

Health literacy in this study was measured using two types of instruments. The first was general health literacy using the NVS.[6] To increase reliability, one question about the percentage of daily calories value was deleted and the Cronbach’s α was increased from 0.599 to 0.614. This number is considered to be acceptable.[19] In addition, NVS with five questions is more valid because it could differentiate health literacy level between health- and nonhealth-related college groups, whereas the original NVS with six questions could not. Finally, NVS with five questions showed the best performance with both criterion validity and reliability. One point was given for the correct answer and 0 point for the incorrect answer. The scores of the NVS ranged from 0 to 5.

The second type was developed basically from the definition of health literacy by the Sørensen et al.[4] and WHO[3] which was called the “SHL.” The SHL included the following three domains:

  1. Access (accessing and communication)

  2. Knowledge (understanding)

  3. Attitude (appraisal) on toothbrushing.

Access to toothbrushing information contained two questions that were the ability to access and follow toothbrushing information. Knowledge had seven questions that were related to appropriate toothbrushing time, frequency, technique, duration, and the function of toothbrushing. Attitude on toothbrushing was about the respondent’s perception of the importance and proper toothbrushing. Attitude contained eight questions with a 4-point Likert scale (strongly agree to strongly disagree). Consequently, the scores of all domains were combined for a total score of the SHL.

All questionnaires including SHL and toothbrushing checklist were validated by two experts (face validity). Back translations from English to Indonesian were then performed. Pilot testing of all instruments were conducted on 15 young adults who were similar to the study samples. Criterion validity on the education groups was used to check the validation of the health literacy instruments, NVS and SHL, based on the previous studies.[11],[20] The instruments’ validities will be presented in the result and discussion sections.

Inter and intraexaminer reliability of TBP evaluation using the video was conducted on 15 respondents between the researcher and the expert and between two consecutive evaluations (one week apart). Kappa coefficients showed good reliability results for both inter and intraexaminers (κ = 0.785 and 0.873, respectively).

All statistical analyses were conducted using Statistical Package for the Social Sciences software version 17.0 (SPSS, Chicago, IL). Descriptive statistics were also used to describe the features of the data in the study. Differences of health literacy among demographic factors were explored using t-test and analysis of variance. The relationships between study variables were analyzed using Pearson or Spearman correlation and multiple linear regression analysis. All analyses were tested at the significance level of 0.05.

  Results Top

[Table 1] shows that the percentage of female respondents was higher than male respondents who participated in the study. The mean SHL score of female respondents was significantly higher than male respondents (P = 0.021). The mean scores of the NVS and SHL questionnaire were significantly different among those who were in different education groups (both two and three groups).
Table 1: Distribution of demographic characteristics and differences between their mean health literacy scores

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The mean scores and their standard variations, minimum, and maximum values of the main study variables were as follows: access = 1.73 ± 0.63 (0–2), knowledge = 4.22 ± 1.40 (0–7), attitude = 21.53 ± 1.42 (18–26), SHL = 27.47 ± 2.28 (21–34), NVS = 1.99 ± 1.46 (0–5), and TBP = 1.71 ± 0.88 (0–6). Interestingly, the mean score of TBP was low and nobody achieved a perfect score.

The relationships among the main variables are presented in [Table 2]. The NVS had a significant moderate correlation, whereas the SHL had a significant low correlation with education (r = 0.542 vs. 0.232). TBP and all variables except the NVS and knowledge showed significant low correlations (r = –0.144–0.215).
Table 2: Relationships among the main variables

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Two multiple linear regression models were developed to show the associations between the related factors and toothbrushing score [Table 3]. The first model comprised three components of the SHL, NVS, education, and gender, whereas the second model replaced the three components with the total score of SHL. The first model can explain the variance of TBP score more than the second model (11% vs. 8%). The results showed that after controlling for gender and education, access and the SHL still had significant correlation with TBP.
Table 3: Two multiple linear regression models of toothbrushing practice

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  Discussion Top

The sample of this study was composed of young adults aged 20–25 years. This age group was chosen because of their ability to make independent decisions. Three groups of education level were used because previous studies found that people with a higher education[21],[22] and studied in health-related fields[20] had better health literacy levels. The results of this study were consistent with those findings when using either NVS or SHL instruments.

To improve the reliability and validity of NVS, one question about the percentage of daily calories value was deleted because it was difficult to understand by the subjects. Cronbach’s α of the NVS was increased from 0.599 to 0.614, which is considered to be acceptable. The difference of health literacy among these education groups showed that the NVS with five questions and the SHL used in this study had good criterion validity.[19]

The NVS[6] was used instead of other general health literacy instruments because it does not only measure reading and numerical task ability but also it measures understanding of the information and decision-making. The NVS can be used in all population backgrounds because it is not related to grammar, phonetics, or any experiences of treatment.[7] A low level of health literacy measured by the NVS was found in this study, which is similar to a previous study in Japan.[23] The NVS might be too difficult for this population because they may be not familiar with reading a food label and numerical questions in the NVS.

The results showed that NVS in our study was not significantly different between genders, which were consistent with the previous studies.[14],[22] However, opposite result was found with the SHL in our study. There was a significantly higher health literacy level (SHL) in female respondents than male respondents, which were similar to some studies.[20],[21]

Bass, modified Bass, and Roll were identified as the acceptable toothbrushing techniques because they are known to effectively remove plaque, especially at the gingival area and are not harmful.[24],[25] In addition, the Ministry of Health, Indonesia suggests that all tooth areas should be brushed with rolling motions for at least 2min.[26] The sample in this study mostly failed to brush every area and tongue as well as brushed with inappropriate techniques and duration. Overall, they had low TBP scores, which meant they did not brush appropriately which corresponded with the study in East Java of Indonesia.[27]

The NVS had a positive correlation with the SHL, which meant that people who have better reading, numerical, and decision-making skills tend to have better specific health literacy on toothbrushing. No significant correlation was found between the results of the NVS and TBP. The reason for the absence of correlation is that to have good TBP, people may not need the ability to read, calculate, or make a decision as in the components of the NVS.[28] The SHL showed contrary results to the NVS. It showed a significant positive correlation with TBP. A previous study reported similar results whereby no significant correlation was found between health literacy using the general health literacy instrument (REALD-30) and self-rated oral health. However, the study found a correlation using the oral health literacy-related questionnaire.[14]

Although there were significant correlations between health literacy and the study variables, the correlation coefficients were rather low. This may be because the range of respondent’s age was narrow (20–25 years) and age had an effect on health literacy level. Therefore, the small variations of health literacy score were found.

The results of the regression analysis showed that after controlling for gender and education, access was the most influencing factor of TBP. People who received toothbrushing information and used the information would have better TBP. The second model showed that TBP was only correlated with the SHL and not with the NVS. This reflects that specific health literacy is more important than general health literacy for toothbrushing skill. Nevertheless, only 8% of the variance in TBP can be explained by this model. Other factors on TBP should be explored further.

TBP is known to be a skill-based behavior and long-established habit.[29] Unlike other simple behaviors such as dental checkup and self-checking with a mirror, it needs information, motivation, and skill.[30] Inappropriate TBP can be caused from lack of toothbrushing information, failure to follow the instructions, and difficulty in changing long-established habits.[24],[31] Previous studies showed that young adults have difficulties to follow toothbrushing instruction and have poor understanding of what is important while brushing.[31],[32] Other factors contribute to TBP such as dexterity, personal values, and preference.[24] The respondents in this study might find toothbrushing information, but could not follow it properly because of the limitations of those factors.

This study had some limitations. The sample was collected from university students and the community who represented a population with the same characteristics. The clinical outcome of TBP such as plaque scoring or cleanliness was not measured in this study. However, it has been proved that people who brush appropriately (appropriate technique, coverage, sequence, force, and duration) would have a lower level of plaque than those who do not.[33],[34],[35],[36]

In spite of some limitations, our study has much strength. The validity and reliability of data collection was carried out with good results to ensure the quality of the study. Second, video recording was used to help measure TBP instead of direct observation or using a questionnaire. The video observation could better reveal the real situation of daily TBP by the respondent and could be revised if needed. However, the awareness of being recorded certainly influenced the respondents.[37] But still the influences can be reduced as minimal as possible by leaving the respondents alone when they were brushing their teeth. The last and important strength is this study used two health literacy instruments to measure the effect of literacy on the specific oral health behavior such as TBP. This gave more insight into the effect of health literacy on TBP and the characteristics of the instruments to measure health literacy.

In conclusion, access to toothbrushing information and SHL were the most influencing factors for TBP in this study. However, only increased access to information would not be enough to cause people to have better TBP. Other factors such as skill building and motivation may be important.

The results from this study suggest improving health literacy on toothbrushing and access to toothbrushing information by using effective communication. Specific health literacy instrument may be used to detect the aspects of SHL on TBP (access, knowledge, and attitude) that need to be improved, so the proper intervention can be implemented. The methods and results of this study can be used for other similar complex behaviors. Further studies on these issues as well as studies in other populations with different cultural and socioeconomic backgrounds are needed.

Ethical policy and institutional review board statement

This study was approved by the Research Ethics Committee (REC) Faculty of Dentistry, Prince of Songkhla University, Thailand on 11 May 2017 (Approval number: MOE 0521.1.03/481) and the Medical and Health Research Ethics Committee (MHREC) Faculty of Medicine, Universitas Gadjah Mada, Indonesia on July 17, 2017 (Approval number: KE/FK/0772/EC/2017). The research had been conducted in full accordance with the World Medical Association Declaration of Helsinki.


The authors gratefully acknowledge Mr. Glenn Shingledecker for the valuable suggestions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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