Preventive dental visits and health literacy in patients with diabetes: a nationwide cross-sectional study

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Preventive dental visits and health literacy in patients with diabetes: a nationwide cross-sectional study Kyoko Saito , Yuki Kawai , Hirono Ishikawa , Takahiro Tabuchi , View ORCID Profile Keisuke Kuwahara doi: https://doi.org/10.1101/2024.07.01.24309770 Kyoko Saito 1 Teikyo University Graduate School of Public Health , Tokyo, Japan 2 Kato Clinic of Internal Medicine , Tokyo, Japan RD, MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yuki Kawai 1 Teikyo University Graduate School of Public Health , Tokyo, Japan 3 Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine , Yokohama, Japan MD, PhD, MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site Hirono Ishikawa 1 Teikyo University Graduate School of Public Health , Tokyo, Japan PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Takahiro Tabuchi 4 Cancer Control Center, Osaka International Cancer Institute , Osaka, Japan MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Keisuke Kuwahara 1 Teikyo University Graduate School of Public Health , Tokyo, Japan 5 Department of Public Health, Yokohama City University School of Medicine 6 Department of Health Data Science, Graduate School of Data Science, Yokohama City University PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Keisuke Kuwahara For correspondence: kkuwahara{at}yokohama-cu.ac.jp Abstract Full Text Info/History Metrics Supplementary material Preview PDF Abstract Aim This cross-sectional study examined the association between health literacy and preventive dental visits in patients with diabetes. Methods We used cross-sectional data from the Japan COVID-19 and Society Internet Survey (JACSIS), a web-based nationwide survey. The participants were 1,441 patients reporting to have diabetes in 2020. Health literacy was measured using the validated scales for health literacy. Preventive dental visits in the past 12 months were self-reported. We estimated the multivariable-adjusted prevalence ratio (PR) for preventive dental visits. Results Over 50% of the patients had preventive dental visits in the past 12 months, and approximately one-third had high health literacy. Compared with the low health literacy group, the high health literacy group was more likely to engage in preventive dental visits (the multivariable-adjusted PR associated with high health literacy: 1.12 [95% confidence interval: 1.01 to 1.23]). Similar results were obtained when health literacy was treated as a continuous variable. Conclusions The present data from the JACSIS showed that health literacy was positively associated with preventive dental visits among patients with diabetes. 1. Introduction Diabetes is a growing social and public health issue globally ( 1 ) including Japan ( 2 ). Recent statistics estimated that 537 million people worldwide ( 1 ) and 10 million in Japan ( 2 ) have diabetes. In patients, poor oral health, as indicated by periodontal disease, has been associated with an increased risk of diabetic complications, including cardiovascular complications, retinopathy, end-stage renal disease, and even deaths ( 3 ). Therefore, the development of effective strategies to prevent periodontal disease is needed for patients with diabetes. Both self-care and professional care are important for the prevention of periodontal diseases ( 4 ). Therefore, regular dental visits are recommended for patients, particularly those with diabetes ( 4 ). For example, the Centers for Disease Control and Prevention ( 5 ) recommend getting a dental examinations at least once a year for patients with diabetes. The American Diabetes Association ( 6 ) also recommends comprehensive dental and periodontal examination for initial care management. However, the rate of dental visits among patients with diabetes remains low (e.g., 43% in Japan ( 7 ) and 61% in the US ( 8 )), which are lower than those of patients without diabetes ( 8 ). This suggests an urgent need to identify modifiable factors that may promote dental visits among patients with diabetes. Recently, health literacy has gained much attention in promoting behavioral changes ( 9 ). According to the World Health Organization (WHO), health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways that promote and maintain good health’. Based on this definition, Nutbeam ( 10 ) proposed a health literacy model that includes three levels and assumes both individual and population benefits at each level: (i) functional/basic literacy, (ii) communicative/interactive literacy, and (iii) critical literacy. The existing literature has shown that among patients with diabetes, health literacy is associated with self-care behaviors for diabetes ( 11 ), glycemic control ( 12 ) and retinopathy ( 13 ). Thus, health literacy may be associated with dental visits in patients with diabetes. To date, only one cross-sectional study has examined this association ( 14 ). Furthermore, although a preventive approach is important in dentistry (4; 5; 15), the previous study ( 14 ) did not distinguish preventive dental visits from traditional curative approaches. In addition, validity of measuring health literacy was unclear in that study ( 14 ). Therefore, we examined the association between health literacy and preventive dental visits using a validated questionnaire for health literacy among patients with diabetes in Japan. 2. Methods 2.1. Study design and data source This cross-sectional study analyzed the baseline data of the Japan “COVID-19 and Society” Internet Survey (JACSIS), a web-based, self-reported questionnaire survey (16; 17). A total of 224,389 panelists aged 15 to 79 years from an internet research agency in Japan (Rakuten Insight, Inc.) were selected from approximately 2.2 million panelists, and asked about their willingness to participate in the survey. Eligible participants were selected using random sampling stratified by age, sex, and prefecture to represent the Japanese demographic composition. Questionnaires were distributed from August 25, 2020 to September 30, 2020; 28,000 respondents aged 15-79 years participated in this survey. 2.2. Participants Of the 28,000 participants, we sequentially excluded 2,518 participants who provided invalid responses or met other exclusion criteria as with previous studies (17; 18); first, we excluded 1,955 participants providing invalid responses, using a dummy item stating: “Please choose the second option from the bottom.” We then excluded 422 participants who provided artificial or unnatural responses, defined as the use of recreational substances and medications, including sleeping pills, legal opioids, illegal opioids, organic solvents, designer drug, cannabis, cocaine. Lastly, we excluded 141 participants having all listed chronic diseases, including cancer, ischemic heart disease, stroke, diabetes, asthma, mental disorders, and so on. We additionally excluded one participant who reported an implausible body height (<100 cm). Of the remaining 25,481 participants (12,808 women and 12,673 men) aged 15-79 years (mean 48.8 years), we extracted the data of 1,441 participants aged 40-79 years who reported currently having diabetes. We restricted the participants to those aged 40 years or older because measurement of blood glucose levels and hemoglobin A1c levels are mandatory in this age group in the annual health checkups ( 19 ). We expected that the validity of self-reports on diabetes in this group would be better than that in younger groups. For sensitivity analyses, we additionally included 258 adults who reported to have diabetes in the past but not at the time of the study. As diabetes is not a curable disease, we expected that the participant characteristics would be somewhat different between those who reported having diabetes currently and those who had diabetes in the past but not currently. 2.3. Measurement of health literacy Health literacy was measured using the Communicative and Critical Health Literacy (CCHL) scale which has been validated in Japanese ( 20 ). This scale measures communicative and critical health literacy, and comprised three items for communicative health literacy (items i–iii) and two items for critical health literacy (items iv–v). These items asked whether the participant were able to (i) collect health-related information from various sources, (ii) extract the information he wanted, (iii) understand and communicate the obtained information, (iv) consider the credibility of the information and (v) make decisions based on the information, specifically in the context of health-related issues ( 20 ). Each item is assessed using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). We then calculated the total health literacy score by summing the score of each of the five responses divided by five, yielding scores of 1-5, where higher scores indicate greater health literacy. We reclassified the participants scoring less than 4 points as those with “low health literacy,” and participants scoring 4-5 points as those with “high health literacy” ( 20 ). 2.4. Measurement of past one years’ preventive dental visits To measure preventive dental visits, respondents were asked, “In the past year, have you visited a dental clinic?” Dental visits included periodic checkups, dental cleaning, and tartar removal, but excluded visits for the treatment of cavities. Response options were “Yes” or “No.” The questionnaire on preventive dental visits was similar to those used in previous studies ( 21 – 23 ). 2.5. Other Covariates The participants reported their socio-demographic factors such as age, sex, educational attainment, marital status, living arrangements, employment status, and annual household income in the past year ( 17 ) as well as health-related data, such as personal history of diseases, self-rated health, and body weight and height. History of diabetes was reported through four response options: none, having diabetes in the past but not currently, having diabetes currently with receiving treatment, having diabetes currently without treatment. In Japan, self-reported diabetes has been validated by using a similar question ( 24 ). Self-rated health was measured using 5-point scale (25; 26) and participants were classified into two groups: good (1-3 points) and poor (4-5 points) (25; 26). Body mass index (BMI; kg/m 2 ) was calculated using body weight and height. BMI was reclassified as underweight (<18.5 kg/m 2 ), normal weight (18.5 to <25.0 kg/m 2 ), and overweight (≥25.0 kg/m 2 ). 2.6. Ethics statement As described previously ( 17 ), the present study was conducted in accordance with the ethical standards of the 1975 Declaration of Helsinki, as revised in 2013. Written informed consent was obtained from all participants before they responded to the online questionnaire. The study protocol, including the informed consent procedure, was approved by the ethics committees of the Osaka International Cancer Institute (no. 20084) and Teikyo University (no. 20-148-3). The Internet Survey Agency complies with the Act on the Protection of Personal Information in Japan. The data were anonymized; thus, the researchers did not have access to information that could identify individual participants. The participants were provided a credit point as an incentive for participation in this study. 2.7. Statistical analysis Participant characteristics according to preventive dental visits are shown as numbers (%). We used Poisson regression to estimate multivariable-adjusted prevalence ratios (PRs) and the 95% confidence intervals (CIs) of preventive dental visits based on health literacy. We adjusted for age (years, continuous), sex, education attained (junior high school, high school, vocational school/technical college/junior college, university or higher, and others), marital status (married, unmarried, divorced, and widowed), living arrangement (living alone and living with someone), working status (currently working, unemployed or students, and retired), annual household income in 2019 (<3 million yen, 3 to <5 million yen, 5 to <7 million yen, ≥7 million yen, unclear, and do not want to answer), self-rated health status (good and poor), and BMI (<18.5, 18.5 to <25.0, and ≥25.0 kg/m 2 ). Health literacy was treated as a dichotomous variable (low and high) and as a continuous variable. We also performed two sensitivity analyses. First, we conducted a stratified analysis by age (<65 years and ≥65 years) as older adults would have more dental or periodontal problems. Second, we conducted the sensitivity analyses by changing the definition of having diabetes as having diabetes currently or in the past. All analyses were performed using R4.1.3. or Stata 18.0. Statistical significance was set at p<0.05 (two-sided). 3. Results Of the 1,441 participants who reported currently having diabetes, more than half had gone for preventive dental visits (n = 773, 53.6%). The average scores of health literacy was 3.5 (standard deviation: 0.7); approximately one in three patients (n = 508, 35.3%) had high health literacy. Table 1 shows the characteristics of the participants according to the number of preventive dental visits. Those who had preventive dental visits were slightly older, married or living with someone, likely to have a higher education and higher income, and not engaged in any work. They were also likely to report good self-rated health status and tended to have normal weight. View this table: View inline View popup Table 1. Participant characteristics according to preventive dental visits among 1,441 diabetic patients Table 2 shows the relationship between preventive dental visits and health literacy. View this table: View inline View popup Table 2. Prevalence ratios and 95% confidence intervals of preventive dental visits by health literacy among diabetic patients Participants with high health literacy were more likely to have had a preventive dental visit as compared to those with low health literacy; crude PR of preventive dental visit was 1.18 (95% CI: 1.08 to 1.30) for high health literacy group compared with low health literacy group. This relationship was slightly attenuated, but remained significant after additional adjustment for several covariates (aPR=1.12, 95% CI: 1.01, 1.23). A 1-point increase in health literacy was also significantly associated with preventive dental visits (aPR = 1.09). Analysis stratified by age groups showed similar point estimates, although some results were not statistically significant. As shown in Supplementary Tables 1, after enrolling 258 participants who reported having diabetes in the past but not currently, the associations were slightly weakened and some results became non-significant. 4. Discussion 4.1. Discussion In this cross-sectional study, health literacy was positively associated with preventive dental visits among patients with diabetes in Japan. The sensitivity analyses supported the main results. To the best of our knowledge, this is the first study to examine the relationship between health literacy and preventive dental visits in patients with diabetes. Although there is no directly comparable study, our findings of significant and positive associations between health literacy and preventive dental visits are in line with at cross-sectional study by Rafferty et al ( 14 ). This study showed that individuals with low health literacy had lower adjusted odds ratios for dental visits; however, it did not distinguish between dental visits for preventive and treatment purposes, neither did it use any validated scales to assess health literacy. The present study using validated scales for health, underscores the importance of health literacy for patients with diabetes in promoting dental visits for preventive purposes. 4.2. Strengths and limitations The strengths of this study include the large-scale sample of more than 1,000 patients with diabetes, use of a validated health literacy scale, and adjustment for many potential confounders. However, the results of this study should be interpreted in light of the following limitations. First, because of its cross-sectional design, it was not possible to confirm causality. Second, because we did not use objective measurements of glycemic conditions, patients with undiagnosed diabetes were not included in our analyses. Third, the validity of self-reported preventive dental visits was unclear, though previous studies have used similar self-reported questionnaires on dental visits (27; 28). Fourth, since the participants were recruited through an online survey, they were more likely to have better health literacy than the general populations. However, the CCHL scores in our study were not significantly different from those in previous studies ( 29 ), in which participants were recruited via mails. Fifth, although we adjusted for many potential confounders, unmeasured confounding factors including access to medical care may have affected the results. Finally, all participants were Japanese patients with diabetes. Therefore, caution should be exercised when generalizing the present findings to populations from other countries. 4.1. Conclusion We found that health literacy was significantly associated with preventive dental visits among patients with diabetes in Japan. Healthcare professionals in diabetes care should consider patients’ health literacy levels to promote preventive dental visits. Further research is needed to confirm the present results using a longitudinal design and to determine whether health literacy education can promote preventive dental visits and prevent serious complications among patients with diabetes. Funding The conduct of JACSIS 2020 was supported by JSPS KAKENHI Grant Numbers: JP17H03589, JP19K10671, JP19K10446, JP19K19439, JP18H03107, JP18H03062, JP21H04856, JP20H03919, Research Support Program to Apply the Wisdom of the University to tackle COV19 Related Emergency Problems, University of Tsukuba, and Health Labor Sciences Research Grant (grant numbers: 19FA1005, 19FG2001). Data Availability The data used in the present are not deposited in a public repository due to the containing of personally identifiable or potentially sensitive information. In accordance with the ethical guidelines’ regulations in Japan, dissemination of the data is restricted by the Research Ethics Committee of the Osaka International Cancer Institute. Any inquiries regarding the data use should go to Dr Takahiro Tabuchi, tabuchitak{at}gmail.com . More details of data availability can be found on the website of JACSIS ( https://jacsis-study.jp/howtouse/ ). 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Share Preventive dental visits and health literacy in patients with diabetes: a nationwide cross-sectional study Kyoko Saito , Yuki Kawai , Hirono Ishikawa , Takahiro Tabuchi , Keisuke Kuwahara medRxiv 2024.07.01.24309770; doi: https://doi.org/10.1101/2024.07.01.24309770 Share This Article: Copy Citation Tools Preventive dental visits and health literacy in patients with diabetes: a nationwide cross-sectional study Kyoko Saito , Yuki Kawai , Hirono Ishikawa , Takahiro Tabuchi , Keisuke Kuwahara medRxiv 2024.07.01.24309770; doi: https://doi.org/10.1101/2024.07.01.24309770 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Endocrinology (including Diabetes Mellitus and Metabolic Disease) Subject Areas All Articles Addiction Medicine (573) Allergy and Immunology (865) Anesthesia (304) Cardiovascular Medicine (4457) Dentistry and Oral Medicine (445) Dermatology (383) Emergency Medicine (610) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1517) Epidemiology (15244) Forensic Medicine (30) Gastroenterology (1132) Genetic and Genomic Medicine (6620) Geriatric Medicine (669) Health Economics (1002) Health Informatics (4557) Health Policy (1372) Health Systems and Quality Improvement (1615) Hematology (543) HIV/AIDS (1272) Infectious Diseases (except HIV/AIDS) (15936) Intensive Care and Critical Care Medicine (1106) Medical Education (624) Medical Ethics (147) Nephrology (670) Neurology (6635) Nursing (346) Nutrition (999) Obstetrics and Gynecology (1148) Occupational and Environmental Health (957) Oncology (3348) Ophthalmology (980) Orthopedics (369) Otolaryngology (421) Pain Medicine (436) Palliative Medicine (130) Pathology (665) Pediatrics (1696) Pharmacology and Therapeutics (693) Primary Care Research (714) Psychiatry and Clinical Psychology (5463) Public and Global Health (9257) Radiology and Imaging (2210) Rehabilitation Medicine and Physical Therapy (1371) Respiratory Medicine (1198) Rheumatology (598) Sexual and Reproductive Health (716) Sports Medicine (532) Surgery (714) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a03628b41c6c73c1',t:'MTc4MDA2NDYyNw=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();