Determinants of Oral Health Literacy Among Middle-Aged and Older Adults with Diabetes: A Cross-Sectional Comparative Study

Determinants of Oral Health Literacy Among Middle-Aged and Older Adults with Diabetes: A Cross-Sectional Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determinants of Oral Health Literacy Among Middle-Aged and Older Adults with Diabetes: A Cross-Sectional Comparative Study Chiu-Ling Huang¹, Ching-Wen Liu², Yong-Chuan Chen³ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7993942/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted 18 You are reading this latest preprint version Abstract Background Oral health literacy (OHL) is a critical determinant of oral health and self-care, particularly for individuals with diabetes who are at increased risk of oral complications. Although interprofessional education is increasingly integrated into diabetes management, little is known about how OHL differs across healthcare settings in Taiwan. This study compared OHL levels among middle-aged and older adults with diabetes attending diabetes education clinics and general dental clinics. Methods A cross-sectional comparative study was conducted between February and December 2024 in southern Taiwan. A total of 187 adults aged ≥ 45 years with type 2 diabetes participated, including 115 from a diabetes education clinic and 72 from a dental clinic. Data were collected through face-to-face questionnaires, including demographic characteristics and the validated Mandarin version of the Oral Health Literacy–Adult Questionnaire (OHL-AQ). Descriptive statistics, chi-square tests, independent-samples t-tests, and ordinal logistic regression were performed using SPSS version 22.0. Results The overall mean OHL score was 11.37 ± 2.86. Participants attending diabetes education clinics demonstrated significantly higher OHL than those visiting dental clinics (12.21 ± 2.44 vs. 10.11 ± 3.04; p < 0.001). Significant group differences were also observed in reading comprehension, numeracy, and listening comprehension (all p < 0.05). Ordinal logistic regression indicated that attending a diabetes education clinic was associated with greater odds of higher OHL (OR = 3.69; 95% CI 1.97–6.93; p < 0.001). Female sex and higher education level (college or above) were also positively associated with adequate OHL (p < 0.01). Conclusions Middle-aged and older adults with diabetes attending diabetes education clinics had significantly better oral health literacy than those visiting dental clinics. The findings highlight the value of interprofessional health education and suggest that incorporating oral health promotion into diabetes education may improve health outcomes. Tailored strategies targeting men and individuals with lower education levels are warranted to reduce literacy disparities. Oral health literacy Diabetes mellitus Health promotion Interprofessional education Health disparities Taiwan Background Diabetes is one of the most significant public health challenges of our time, affecting more than 537 million adults worldwide ( 1 ). According to the 2017–2020 Nutrition and Health Survey in Taiwan, an estimated 2.19 million adults aged 18 years and older were diagnosed with diabetes, representing a prevalence rate of 11.1% ( 2 ). Individuals with diabetes are at risk of chronic exposure to hyperglycemia. Although hyperglycemia does not directly cause specific oral diseases, it can increase susceptibility to infections and lead to a series of oral complications, such as gingivitis and periodontitis. If poorly controlled, these conditions may progress to tooth mobility and even premature tooth loss ( 3 , 4 ). Oral health literacy (OHL) refers to the ability of individuals to obtain, comprehend, evaluate, and apply oral health–related information to make appropriate health decisions ( 5 , 6 ). Studies have reported a negative correlation between age and OHL ( 7 ). According to demographic statistics from the Ministry of the Interior, by the end of 2024, individuals aged 45 years and older accounted for more than 50% of the population in Taiwan ( 8 ). Furthermore, previous studies have indicated that patients with diabetes generally exhibit lower OHL and engage in less optimal oral health behaviors ( 9 ). In Taiwan, the prevalence of diabetes among adults aged 45–64 years was 15.6% for men and 9.9% for women, while among those aged 65 and above it was 23.9–27.8% for men and 23.1–31.4% for women ( 2 ). These findings indicate that, with an aging population and a rising prevalence of diabetes, OHL among middle-aged and older adults with diabetes is likely to become an important national public health issue. Research has demonstrated that regular dental examinations and interventions for patients with diabetes can effectively reduce the occurrence of oral complications ( 3 , 10 ). In clinical practice, one study reported that for every additional diabetic patient seen per week, the probability of dental hygienists providing extra oral health education increased by about 3%; moreover, patients who attended follow-up visits every six months received 86% more oral health education time ( 11 ). In Taiwan, in addition to regular dental clinics providing such services, many medical institutions have established diabetes education clinics where multidisciplinary professionals deliver structured health education and disease management services. However, there remains a paucity of domestic studies specifically addressing OHL in diabetic patients and even fewer comparing patients’ OHL across different care settings (e.g., diabetes education clinics vs. general dental clinics). Therefore, the present study aimed to investigate differences in OHL among middle-aged and older diabetic patients attending diabetes education clinics and dental clinics in southern Taiwan, with the goal of providing empirical evidence to inform the development of integrated patient care models. Methods Study Design This study adopted a cross-sectional comparative design to investigate and compare OHL performance among middle-aged and older adults with type 2 diabetes across two healthcare settings: diabetes education clinics and general dental clinics. Participants and Sample Size The study population consisted of type 2 diabetic patients attending a diabetes education clinic at a regional teaching hospital in southern Taiwan and those visiting a community-based dental clinic. Inclusion criteria were: ( 1 ) aged 45 years or older; ( 2 ) able to communicate in Mandarin or Taiwanese with clear consciousness; ( 3 ) no severe visual impairment and capable of independently reading the questionnaire; ( 4 ) willingness to participate and provision of written informed consent. Exclusion criteria included: ( 1 ) illiteracy or major psychiatric disorders; ( 2 ) hospitalization within the past three months. The study was conducted from February to December 2024. Convenience sampling was used, with an anticipated total of 200 participants (100 from each setting). Sample size was estimated based on expected differences in mean OHL scores between groups, with a significance level of α = 0.05 and statistical power set at 0.8. Data Collection Procedures Data were collected through structured questionnaires administered during clinic visits, with trained research assistants providing face-to-face assistance. Prior to completion, participants were informed about the study’s purpose, content, and confidentiality measures, and written informed consent was obtained. A pilot test was conducted beforehand to ensure comprehension and feasibility of the questionnaire. Instruments The questionnaire consisted of two parts: Demographic and health-related variables : including sex, age, education level, monthly income, employment status, daily oral hygiene practices, presence of missing teeth, denture use, duration since diabetes diagnosis, and glycemic control. Oral Health Literacy–Adult Questionnaire (OHL-AQ) : Developed by Naghibi Sistani et al., the instrument has demonstrated acceptable reliability (Cronbach’s α = 0.72; test–retest ICC = 0.84) ( 12 ). The Mandarin version was translated, validated, and authorized by Ho et al. ( 13 ). The questionnaire consists of 17 items, each scored 1 point for a correct response, yielding a total score range of 0–17. Scores are categorized as follows: 0–9 = “Inadequate,” 10–11 = “Marginal,” and 12–17 = “Adequate.” The instrument includes four domains: Reading comprehension (6 items) : assessing understanding of basic oral health information. Numeracy (4 items) : evaluating the ability to follow instructions regarding prescribed medications or mouth rinses. Listening comprehension (2 items) : assessing comprehension of post-extraction care instructions read aloud by research staff. Appropriate decision-making (5 items) : assessing judgment regarding appropriate oral health behaviors in different scenarios. Statistical Analysis All data were processed and analyzed IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) . Descriptive statistics were used to present participants’ demographic characteristics and OHL scores (mean, standard deviation, and percentage). Independent-samples t-tests were applied to compare the mean OHL scores between the two groups, while chi-square tests were used to analyze differences between categorical variables. OHL levels were categorized into three groups (inadequate, marginal, adequate). Ordinal logistic regression analysis was employed to adjust for potential confounding variables. All statistical analyses were two-tailed, with a significance level set at α = 0.05. Ethical Considerations This study was reviewed and approved by the Institutional Review Board of Yuan’s General Hospital (IRB No. YGHIRB-20230919B). All participants provided written informed consent. All personal data were treated with strict confidentiality throughout the study. Clinical trial registration Clinical trial number: not applicable. Results A total of 196 patients were recruited; after excluding nine invalid questionnaires, 187 middle-aged and older adults with type 2 diabetes were included in the final analysis. Of these, 115 participants were from the diabetes education clinic group and 72 from the dental clinic group. The overall mean age was 62.2 years (SD = 8.8), and 50.8% were male. There were no significant differences in demographic characteristics between the two groups, including sex, age, HbA1c level, education, employment, and household income (Table 1 ). Table 1 Comparison of Demographic Characteristics Between Groups Variable Dental Clinic (n = 72) Diabetes Education Clinic (n = 115) p-value Sex 0.17 Male 32 (44.4%) 63 (54.8%) Female 40 (55.6%) 52 (45.2%) Age (years, mean ± SD) 63.51 ± 8.89 61.38 ± 8.66 0.11& HbA1c (mean ± SD) 7.00 ± 0.87 7.01 ± 1.06 0.96& Education 0.97 ≤ Junior high 28 (38.9%) 43 (37.4%) Senior high 22 (30.6%) 35 (30.4%) ≥ College 22 (30.6%) 37 (32.2%) Employment 0.34 Yes 29 (40.3%) 54 (47.4%) No 43 (59.7%) 60 (52.6%) Household income 0.09 NT $ 1,000,000 14 (19.4%) 10 (8.7%) Note. # Chi-square test; & Independent t test; $ One missing value. The overall mean OHL score of participants was 11.37 (SD = 2.86). The diabetes education clinic group had a significantly higher mean score of 12.21 (SD = 2.44), compared with 10.11 (SD = 3.04) in the dental clinic group (p < 0.001) (Table 2 ). When classified by OHL level, 63.5% of the diabetes education clinic group reached the “adequate” level, compared to only 34.7% of the dental clinic group. There was a significant difference in the distribution of OHL levels between the two groups (p < 0.001) (Table 2 ). Among the four OHL domains, the diabetes education clinic group scored higher in decision-making (M = 3.65, SD = 0.93) than the dental clinic group (M = 3.38, SD = 1.07), although this difference was not statistically significant (p = 0.07). In contrast, the diabetes education clinic group demonstrated significantly reading comprehension (M = 3.50, SD = 1.47 vs. M = 2.72, SD = 1.43; p < 0.001), numeracy (M = 3.13, SD = 0.82 vs. M = 2.64, SD = 1.05; p = 0.001), and listening comprehension (M = 1.94, SD = 0.24 vs. M = 1.38, SD = 0.74; p < 0.001) than the dental clinic group (Table 2 ). Table 2 Comparison of Oral Health Literacy Scores Between Groups Dental Clinic (n = 72) Diabetes Education Clinic (n = 115) P-value Total OHL score 10.11 ± 3.04 12.21 ± 2.44 < 0.001&* OHL level, n (%) < 0.001#* Inadequate 31 (43.1) 21 (18.3) Marginal 16 (22.2) 21 (18.3) Adequate 25 (34.7) 73 (63.5) Dimensions Reading 2.72 ± 1.43 3.50 ± 1.47 < 0.001&* Numeracy 2.64 ± 1.05 3.13 ± 0.82 0.001&* Decision-Making 3.38 ± 1.07 3.65 ± 0.93 0.07& Listening 1.38 ± 0.74 1.94 ± 0.24 < 0.001&* Note. # Chi-square test; & Independent t test; * p < 0.05; Inadequate (0–9), Marginal ( 10 – 11 ), Adequate ( 12 – 17 ) Further analysis using an ordinal logistic regression model was conducted to examine the factors influencing oral health literacy. The results showed that clinical setting was a significant factor: participants in the diabetes education clinic had 3.69 times higher odds of achieving a higher OHL level than those in the dental clinic group (OR = 3.69, 95% CI: 1.97–6.93, p < 0.001). Sex was also significant, with male participants having 0.39 times the odds of adequate OHL than females (OR = 0.39, 95% CI: 0.20–0.77, p = 0.006). Regarding education, participants with a college degree or higher had 4.60 times the odds of adequate OHL than those with junior high school or below (OR = 4.60, 95% CI: 1.93–10.94, p = 0.001) (Table 3 ). Other variables (HbA1c, age, senior high school education, employment status, and household income) were not significantly associated with OHL (p > 0.05) (Table 3 ). In addition, the threshold parameters for distinguishing between inadequate and marginal OHL levels were not statistically significant. Table 3 Ordinal Logistic Regression Analysis of Factors Associated with Oral Health Literacy OR (95% CI) p Clinical setting (Diabetes education clinic vs. Dental clinic) 3.69 [1.97, 6.93] < 0.001* HbA1c 0.89 [0.66, 1.21] 0.466 Sex (Male vs. Female) 0.39 [0.20, 0.77] 0.006* Age 0.98 [0.94, 1.03] 0.427 Education Senior high vs. Junior high or below 1.78 [0.83, 3.82] 0.140 College or higher vs. Junior high or below 4.60 [1.93, 10.94] 0.001* Employment (Yes vs. No) 1.51 [0.73, 3.12] 0.264 Household income (≥ NT $ 450,000 vs. < NT $ 450,000) 0.78 [0.38, 1.59] 0.492 Discussion This study investigated differences in oral health literacy (OHL) among middle-aged and older adults with diabetes in southern Taiwan across different clinical settings. The results indicated that patients attending diabetes education clinics scored significantly higher in overall OHL and in three domains—reading comprehension, numeracy, and listening comprehension—than those attending dental clinics (p < 0.05). Compared with the study by Ho et al. (2020), in which OHL levels among adults aged 65 and older were 42.1% inadequate, 17.5% marginal, and 40.4% adequate ( 13 ), the distribution in the dental clinic group of this study was 43.1%, 22.2%, and 34.7%, respectively. This suggests a lower proportion of “adequate” OHL in the dental clinic group. Such differences may be partly attributable to the uneven distribution of dental manpower and healthcare resources in Taiwan. According to statistics from the Ministry of Health and Welfare, about 52.8% of dentists are concentrated in northern Taiwan. Furthermore, the proportion of dentists practicing in private dental clinics increased from 78.4% in 1986 to 85.6% in 2018 ( 14 ). These findings show that dentistry in Taiwan is primarily clinic-based, and that dental resources are relatively scarce in the south. Differences in manpower and resources may restrict the time available for oral health education and interprofessional collaboration in southern clinics, thereby reducing patients’ opportunities to receive oral health education. Previous studies have shown that urban–rural disparities indeed affect the oral health and oral health–related quality of life (OHRQoL) of patients with diabetes ( 15 ), and that oral health education for diabetic patients can significantly improve glycemic control and oral disease management ( 16 ). Epidemiological evidence has also suggested a bidirectional relationship between chronic oral diseases and diabetes ( 17 ). Combining prior evidence with the findings of this study, it can be inferred that uneven distribution of dental manpower may reduce oral health education capacity and limit patients’ access to education, which in turn negatively affects OHL and health outcomes. These findings highlight the necessity of integrating oral health education into chronic disease management and supporting policy to strength the oral health education capabilities of dental services in southern Taiwan. The diabetes education clinic in this study was located in a regional teaching hospital in southern Taiwan. Such clinics typically involve interprofessional teams consisting of physicians, nurses, dietitians, and other professionals. Patients are thus able to obtain disease-related knowledge and self-care skills from multiple perspectives, which helps improve OHL. The results of this study further support the view that integrated interprofessional education can enhance OHL in patients with chronic diseases. Non-dental healthcare providers (e.g., nurses and health educators) play an important role in oral health promotion, and interprofessional education models are both feasible and effective in practice. This finding is consistent with the better OHL performance observed in the diabetes education clinic group ( 18 – 20 ). Regression analysis in this study also revealed that sex and education level were significant influencing factors. Male patients had significantly lower OHL compared with females, and participants with a junior high school education or below had significantly lower OHL than those with a college degree or higher. These results are consistent with previous studies in Taiwan, which also indicated that older male adults and those with lower education levels had poorer OHL, suggesting that education and sex are important determinants ( 21 , 22 ). Additionally, research in rural areas has shown that using easy-to-read educational materials for individuals with lower education levels significantly improved OHL, providing a practical example for implementation ( 23 ). The interaction between education and health literacy should also be considered: even with lower education, higher health literacy can promote better oral health behaviors ( 24 ). Therefore, future interventions targeting men and those with lower education should adopt simplified and more accessible educational materials and interactive strategies to reduce literacy gaps. Nevertheless, this study has several limitations. First, convenience sampling may have introduced selection bias, and caution is needed when generalizing results to the broader population. Second, the cross-sectional design limits causal inference. Third, this study included only one hospital and one dental clinic in southern Taiwan, and thus these findings may be influenced by the specific characteristics of the study settings. Future studies should involve multi-center designs with larger sample sizes and further explore the long-term effects of different interventions on OHL and clinical oral health outcomes among diabetic patients. In summary, this study demonstrates that diabetes education clinics have a positive effect on OHL. We recommend promoting interprofessional collaboration for oral health education in dental clinics and providing tailored support for high-risk groups, such as men and those with lower education levels, to enhance both oral health and overall disease management. Declarations Ethics approval and consent to participate This study was reviewed and approved by the Institutional Review Board of Yuan’s General Hospital, Taiwan (Approval No. YGHIRB-20230919B). All participants provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions Chiu-Ling Huang: Conceptualization, data collection, data analysis, manuscript drafting. Ching-Wen Liu: Study design, supervision, methodology validation, critical manuscript revision, corresponding author. Yong-Chuan Chen: Clinical consultation, data interpretation, and manuscript review. All authors read and approved the final manuscript. Acknowledgements The authors express sincere gratitude to the diabetes education team and dental clinic staff at Yuan’s General Hospital for their assistance in data collection. Declaration of the use of artificial intelligence The authors used ChatGPT (OpenAI, San Francisco, CA, USA) to assist in English language refinement and formatting of the manuscript. All intellectual content, analyses, and conclusions are solely those of the authors. References Holman N, Wild SH, Gregg EW, Valabhji J, Sattar N, Khunti K, National Diabetes Audit Research Group. Comparison of mortality in people with type 1 and type 2 diabetes by age of diagnosis: An incident population-based study in England and Wales. Lancet Diabetes Endocrinol. 2022;10(2):95–7. 10.1016/S2213-8587(21)00243-4 . Pan W-H. National Nutrition and Health Survey in Taiwan 2017–2020. Health Promotion Administration, Ministry of Health and Welfare. Published 2020. Accessed February 20, 2025. https://www.hpa.gov.tw/File/Attach/15562/File_18775.pdf Surlari Z, Ciurcanu OE, Budala DG, Butnaru O, Luchian I. An update on the interdisciplinary dental care approach for geriatric diabetic patients. 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Easy-to-read health education material improves oral health literacy of older adults in rural community-based care centers. Gerodontology. 2023;40(1):73–80. 10.1111/ger.12680 . Koyama S, et al. Combined associations of education and health literacy with preventive dental visits in patients with diabetes: A cross-sectional study in Japan. BMC Oral Health. 2024;24(1):77453. 10.1186/s12903-024-07745-3 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 04 Jan, 2026 Reviews received at journal 04 Jan, 2026 Reviews received at journal 01 Jan, 2026 Reviews received at journal 30 Dec, 2025 Reviewers agreed at journal 28 Dec, 2025 Reviews received at journal 27 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviews received at journal 26 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviewers invited by journal 01 Dec, 2025 Editor invited by journal 28 Nov, 2025 Editor assigned by journal 17 Nov, 2025 Submission checks completed at journal 17 Nov, 2025 First submitted to journal 30 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:07:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":844349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7993942/v1/0bbacc3c-7c8f-4f96-937a-c917b6e895da.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determinants of Oral Health Literacy Among Middle-Aged and Older Adults with Diabetes: A Cross-Sectional Comparative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eDiabetes is one of the most significant public health challenges of our time, affecting more than 537\u0026nbsp;million adults worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). According to the 2017\u0026ndash;2020 Nutrition and Health Survey in Taiwan, an estimated 2.19\u0026nbsp;million adults aged 18 years and older were diagnosed with diabetes, representing a prevalence rate of 11.1% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIndividuals with diabetes are at risk of chronic exposure to hyperglycemia. Although hyperglycemia does not directly cause specific oral diseases, it can increase susceptibility to infections and lead to a series of oral complications, such as gingivitis and periodontitis. If poorly controlled, these conditions may progress to tooth mobility and even premature tooth loss (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOral health literacy (OHL) refers to the ability of individuals to obtain, comprehend, evaluate, and apply oral health\u0026ndash;related information to make appropriate health decisions (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Studies have reported a negative correlation between age and OHL (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). According to demographic statistics from the Ministry of the Interior, by the end of 2024, individuals aged 45 years and older accounted for more than 50% of the population in Taiwan (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, previous studies have indicated that patients with diabetes generally exhibit lower OHL and engage in less optimal oral health behaviors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In Taiwan, the prevalence of diabetes among adults aged 45\u0026ndash;64 years was 15.6% for men and 9.9% for women, while among those aged 65 and above it was 23.9\u0026ndash;27.8% for men and 23.1\u0026ndash;31.4% for women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These findings indicate that, with an aging population and a rising prevalence of diabetes, OHL among middle-aged and older adults with diabetes is likely to become an important national public health issue.\u003c/p\u003e\u003cp\u003eResearch has demonstrated that regular dental examinations and interventions for patients with diabetes can effectively reduce the occurrence of oral complications (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In clinical practice, one study reported that for every additional diabetic patient seen per week, the probability of dental hygienists providing extra oral health education increased by about 3%; moreover, patients who attended follow-up visits every six months received 86% more oral health education time (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In Taiwan, in addition to regular dental clinics providing such services, many medical institutions have established diabetes education clinics where multidisciplinary professionals deliver structured health education and disease management services. However, there remains a paucity of domestic studies specifically addressing OHL in diabetic patients and even fewer comparing patients\u0026rsquo; OHL across different care settings (e.g., diabetes education clinics vs. general dental clinics).\u003c/p\u003e\u003cp\u003eTherefore, the present study aimed to investigate differences in OHL among middle-aged and older diabetic patients attending diabetes education clinics and dental clinics in southern Taiwan, with the goal of providing empirical evidence to inform the development of integrated patient care models.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study adopted a cross-sectional comparative design to investigate and compare OHL performance among middle-aged and older adults with type 2 diabetes across two healthcare settings: diabetes education clinics and general dental clinics.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants and Sample Size\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of type 2 diabetic patients attending a diabetes education clinic at a regional teaching hospital in southern Taiwan and those visiting a community-based dental clinic. Inclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) aged 45 years or older; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) able to communicate in Mandarin or Taiwanese with clear consciousness; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) no severe visual impairment and capable of independently reading the questionnaire; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) willingness to participate and provision of written informed consent. Exclusion criteria included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) illiteracy or major psychiatric disorders; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) hospitalization within the past three months.\u003c/p\u003e\u003cp\u003eThe study was conducted from February to December 2024. Convenience sampling was used, with an anticipated total of 200 participants (100 from each setting). Sample size was estimated based on expected differences in mean OHL scores between groups, with a significance level of α\u0026thinsp;=\u0026thinsp;0.05 and statistical power set at 0.8.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eData were collected through structured questionnaires administered during clinic visits, with trained research assistants providing face-to-face assistance. Prior to completion, participants were informed about the study\u0026rsquo;s purpose, content, and confidentiality measures, and written informed consent was obtained. A pilot test was conducted beforehand to ensure comprehension and feasibility of the questionnaire.\u003c/p\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003eThe questionnaire consisted of two parts:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDemographic and health-related variables\u003c/b\u003e: including sex, age, education level, monthly income, employment status, daily oral hygiene practices, presence of missing teeth, denture use, duration since diabetes diagnosis, and glycemic control.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eOral Health Literacy\u0026ndash;Adult Questionnaire (OHL-AQ)\u003c/b\u003e: Developed by Naghibi Sistani et al., the instrument has demonstrated acceptable reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.72; test\u0026ndash;retest ICC\u0026thinsp;=\u0026thinsp;0.84) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The Mandarin version was translated, validated, and authorized by Ho et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The questionnaire consists of 17 items, each scored 1 point for a correct response, yielding a total score range of 0\u0026ndash;17. Scores are categorized as follows: 0\u0026ndash;9 = \u0026ldquo;Inadequate,\u0026rdquo; 10\u0026ndash;11 = \u0026ldquo;Marginal,\u0026rdquo; and 12\u0026ndash;17 = \u0026ldquo;Adequate.\u0026rdquo; The instrument includes four domains:\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eReading comprehension (6 items)\u003c/b\u003e: assessing understanding of basic oral health information.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eNumeracy (4 items)\u003c/b\u003e: evaluating the ability to follow instructions regarding prescribed medications or mouth rinses.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eListening comprehension (2 items)\u003c/b\u003e: assessing comprehension of post-extraction care instructions read aloud by research staff.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAppropriate decision-making (5 items)\u003c/b\u003e: assessing judgment regarding appropriate oral health behaviors in different scenarios.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll data were processed and analyzed \u003cb\u003eIBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA)\u003c/b\u003e. Descriptive statistics were used to present participants\u0026rsquo; demographic characteristics and OHL scores (mean, standard deviation, and percentage). Independent-samples t-tests were applied to compare the mean OHL scores between the two groups, while chi-square tests were used to analyze differences between categorical variables. OHL levels were categorized into three groups (inadequate, marginal, adequate). Ordinal logistic regression analysis was employed to adjust for potential confounding variables. All statistical analyses were two-tailed, with a significance level set at α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003eThis study was reviewed and approved by the Institutional Review Board of Yuan\u0026rsquo;s General Hospital (IRB No. YGHIRB-20230919B). All participants provided written informed consent. All personal data were treated with strict confidentiality throughout the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinical trial registration\u003c/h3\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 196 patients were recruited; after excluding nine invalid questionnaires, 187 middle-aged and older adults with type 2 diabetes were included in the final analysis. Of these, 115 participants were from the diabetes education clinic group and 72 from the dental clinic group. The overall mean age was 62.2 years (SD\u0026thinsp;=\u0026thinsp;8.8), and 50.8% were male. There were no significant differences in demographic characteristics between the two groups, including sex, age, HbA1c level, education, employment, and household income (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Demographic Characteristics Between Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDental Clinic (n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDiabetes Education Clinic (n\u0026thinsp;=\u0026thinsp;115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32 (44.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63 (54.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40 (55.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52 (45.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63.51\u0026thinsp;\u0026plusmn;\u0026thinsp;8.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.38\u0026thinsp;\u0026plusmn;\u0026thinsp;8.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u0026amp;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHbA1c (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.96\u0026amp;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le; Junior high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28 (38.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43 (37.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (30.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35 (30.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; College\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (30.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37 (32.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29 (40.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54 (47.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43 (59.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60 (52.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousehold income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; NT\u003cspan\u003e$\u003c/span\u003e450,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34 (47.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66 (57.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNT\u003cspan\u003e$\u003c/span\u003e450,000\u0026ndash;1,000,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39 (33.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;NT\u003cspan\u003e$\u003c/span\u003e1,000,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (19.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (8.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e # Chi-square test; \u0026amp; Independent t test; $ One missing value.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e The overall mean OHL score of participants was 11.37 (SD\u0026thinsp;=\u0026thinsp;2.86). The diabetes education clinic group had a significantly higher mean score of 12.21 (SD\u0026thinsp;=\u0026thinsp;2.44), compared with 10.11 (SD\u0026thinsp;=\u0026thinsp;3.04) in the dental clinic group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). When classified by OHL level, 63.5% of the diabetes education clinic group reached the \u0026ldquo;adequate\u0026rdquo; level, compared to only 34.7% of the dental clinic group. There was a significant difference in the distribution of OHL levels between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmong the four OHL domains, the diabetes education clinic group scored higher in decision-making (M\u0026thinsp;=\u0026thinsp;3.65, SD\u0026thinsp;=\u0026thinsp;0.93) than the dental clinic group (M\u0026thinsp;=\u0026thinsp;3.38, SD\u0026thinsp;=\u0026thinsp;1.07), although this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.07). In contrast, the diabetes education clinic group demonstrated significantly reading comprehension (M\u0026thinsp;=\u0026thinsp;3.50, SD\u0026thinsp;=\u0026thinsp;1.47 vs. M\u0026thinsp;=\u0026thinsp;2.72, SD\u0026thinsp;=\u0026thinsp;1.43; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), numeracy (M\u0026thinsp;=\u0026thinsp;3.13, SD\u0026thinsp;=\u0026thinsp;0.82 vs. M\u0026thinsp;=\u0026thinsp;2.64, SD\u0026thinsp;=\u0026thinsp;1.05; p\u0026thinsp;=\u0026thinsp;0.001), and listening comprehension (M\u0026thinsp;=\u0026thinsp;1.94, SD\u0026thinsp;=\u0026thinsp;0.24 vs. M\u0026thinsp;=\u0026thinsp;1.38, SD\u0026thinsp;=\u0026thinsp;0.74; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than the dental clinic group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of Oral Health Literacy Scores Between Groups\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDental Clinic (n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDiabetes Education Clinic (n\u0026thinsp;=\u0026thinsp;115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal OHL score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026amp;*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOHL level, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001#*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInadequate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarginal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdequate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (34.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73 (63.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDimensions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReading\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026amp;*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumeracy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u0026amp;*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecision-Making\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.07\u0026amp;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eListening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026amp;*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e # Chi-square test; \u0026amp; Independent t test; * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Inadequate (0\u0026ndash;9), Marginal (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), Adequate (\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFurther analysis using an ordinal logistic regression model was conducted to examine the factors influencing oral health literacy. The results showed that clinical setting was a significant factor: participants in the diabetes education clinic had 3.69 times higher odds of achieving a higher OHL level than those in the dental clinic group (OR\u0026thinsp;=\u0026thinsp;3.69, 95% CI: 1.97\u0026ndash;6.93, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Sex was also significant, with male participants having 0.39 times the odds of adequate OHL than females (OR\u0026thinsp;=\u0026thinsp;0.39, 95% CI: 0.20\u0026ndash;0.77, p\u0026thinsp;=\u0026thinsp;0.006). Regarding education, participants with a college degree or higher had 4.60 times the odds of adequate OHL than those with junior high school or below (OR\u0026thinsp;=\u0026thinsp;4.60, 95% CI: 1.93\u0026ndash;10.94, p\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther variables (HbA1c, age, senior high school education, employment status, and household income) were not significantly associated with OHL (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In addition, the threshold parameters for distinguishing between inadequate and marginal OHL levels were not statistically significant.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOrdinal Logistic Regression Analysis of Factors Associated with Oral Health Literacy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical setting (Diabetes education clinic vs. Dental clinic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[1.97, 6.93]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHbA1c\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[0.66, 1.21]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.466\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male vs. Female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[0.20, 0.77]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[0.94, 1.03]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.427\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior high vs. Junior high or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[0.83, 3.82]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.140\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege or higher vs. Junior high or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[1.93, 10.94]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment (Yes vs. No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[0.73, 3.12]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.264\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold income (\u0026ge;\u0026thinsp;NT\u003cspan\u003e$\u003c/span\u003e450,000 vs. \u0026lt; NT\u003cspan\u003e$\u003c/span\u003e450,000)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e[0.38, 1.59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.492\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated differences in oral health literacy (OHL) among middle-aged and older adults with diabetes in southern Taiwan across different clinical settings. The results indicated that patients attending diabetes education clinics scored significantly higher in overall OHL and in three domains\u0026mdash;reading comprehension, numeracy, and listening comprehension\u0026mdash;than those attending dental clinics (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eCompared with the study by Ho et al. (2020), in which OHL levels among adults aged 65 and older were 42.1% inadequate, 17.5% marginal, and 40.4% adequate (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), the distribution in the dental clinic group of this study was 43.1%, 22.2%, and 34.7%, respectively. This suggests a lower proportion of \u0026ldquo;adequate\u0026rdquo; OHL in the dental clinic group. Such differences may be partly attributable to the uneven distribution of dental manpower and healthcare resources in Taiwan. According to statistics from the Ministry of Health and Welfare, about 52.8% of dentists are concentrated in northern Taiwan. Furthermore, the proportion of dentists practicing in private dental clinics increased from 78.4% in 1986 to 85.6% in 2018 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These findings show that dentistry in Taiwan is primarily clinic-based, and that dental resources are relatively scarce in the south. Differences in manpower and resources may restrict the time available for oral health education and interprofessional collaboration in southern clinics, thereby reducing patients\u0026rsquo; opportunities to receive oral health education.\u003c/p\u003e\u003cp\u003ePrevious studies have shown that urban\u0026ndash;rural disparities indeed affect the oral health and oral health\u0026ndash;related quality of life (OHRQoL) of patients with diabetes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and that oral health education for diabetic patients can significantly improve glycemic control and oral disease management (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Epidemiological evidence has also suggested a bidirectional relationship between chronic oral diseases and diabetes (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Combining prior evidence with the findings of this study, it can be inferred that uneven distribution of dental manpower may reduce oral health education capacity and limit patients\u0026rsquo; access to education, which in turn negatively affects OHL and health outcomes. These findings highlight the necessity of integrating oral health education into chronic disease management and supporting policy to strength the oral health education capabilities of dental services in southern Taiwan.\u003c/p\u003e\u003cp\u003eThe diabetes education clinic in this study was located in a regional teaching hospital in southern Taiwan. Such clinics typically involve interprofessional teams consisting of physicians, nurses, dietitians, and other professionals. Patients are thus able to obtain disease-related knowledge and self-care skills from multiple perspectives, which helps improve OHL. The results of this study further support the view that integrated interprofessional education can enhance OHL in patients with chronic diseases. Non-dental healthcare providers (e.g., nurses and health educators) play an important role in oral health promotion, and interprofessional education models are both feasible and effective in practice. This finding is consistent with the better OHL performance observed in the diabetes education clinic group (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRegression analysis in this study also revealed that sex and education level were significant influencing factors. Male patients had significantly lower OHL compared with females, and participants with a junior high school education or below had significantly lower OHL than those with a college degree or higher. These results are consistent with previous studies in Taiwan, which also indicated that older male adults and those with lower education levels had poorer OHL, suggesting that education and sex are important determinants (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Additionally, research in rural areas has shown that using easy-to-read educational materials for individuals with lower education levels significantly improved OHL, providing a practical example for implementation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The interaction between education and health literacy should also be considered: even with lower education, higher health literacy can promote better oral health behaviors (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Therefore, future interventions targeting men and those with lower education should adopt simplified and more accessible educational materials and interactive strategies to reduce literacy gaps.\u003c/p\u003e\u003cp\u003eNevertheless, this study has several limitations. First, convenience sampling may have introduced selection bias, and caution is needed when generalizing results to the broader population. Second, the cross-sectional design limits causal inference. Third, this study included only one hospital and one dental clinic in southern Taiwan, and thus these findings may be influenced by the specific characteristics of the study settings. Future studies should involve multi-center designs with larger sample sizes and further explore the long-term effects of different interventions on OHL and clinical oral health outcomes among diabetic patients.\u003c/p\u003e\u003cp\u003eIn summary, this study demonstrates that diabetes education clinics have a positive effect on OHL. We recommend promoting interprofessional collaboration for oral health education in dental clinics and providing tailored support for high-risk groups, such as men and those with lower education levels, to enhance both oral health and overall disease management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was reviewed and approved by the Institutional Review Board of Yuan’s General Hospital, Taiwan (Approval No. YGHIRB-20230919B). All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eChiu-Ling Huang:\u003c/strong\u003e Conceptualization, data collection, data analysis, manuscript drafting.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChing-Wen Liu:\u003c/strong\u003e Study design, supervision, methodology validation, critical manuscript revision, corresponding author.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eYong-Chuan Chen:\u003c/strong\u003e Clinical consultation, data interpretation, and manuscript review.\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors express sincere gratitude to the diabetes education team and dental clinic staff at Yuan’s General Hospital for their assistance in data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of the use of artificial intelligence\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors used ChatGPT (OpenAI, San Francisco, CA, USA) to assist in English language refinement and formatting of the manuscript. All intellectual content, analyses, and conclusions are solely those of the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHolman N, Wild SH, Gregg EW, Valabhji J, Sattar N, Khunti K, National Diabetes Audit Research Group. Comparison of mortality in people with type 1 and type 2 diabetes by age of diagnosis: An incident population-based study in England and Wales. Lancet Diabetes Endocrinol. 2022;10(2):95\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2213-8587(21)00243-4\u003c/span\u003e\u003cspan address=\"10.1016/S2213-8587(21)00243-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePan W-H. National Nutrition and Health Survey in Taiwan 2017\u0026ndash;2020. Health Promotion Administration, Ministry of Health and Welfare. Published 2020. 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BMC Oral Health. 2024;24(1):77453. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12903-024-07745-3\u003c/span\u003e\u003cspan address=\"10.1186/s12903-024-07745-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Oral health literacy, Diabetes mellitus, Health promotion, Interprofessional education, Health disparities, Taiwan","lastPublishedDoi":"10.21203/rs.3.rs-7993942/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7993942/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOral health literacy (OHL) is a critical determinant of oral health and self-care, particularly for individuals with diabetes who are at increased risk of oral complications. Although interprofessional education is increasingly integrated into diabetes management, little is known about how OHL differs across healthcare settings in Taiwan. This study compared OHL levels among middle-aged and older adults with diabetes attending diabetes education clinics and general dental clinics.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional comparative study was conducted between February and December 2024 in southern Taiwan. A total of 187 adults aged\u0026thinsp;\u0026ge;\u0026thinsp;45 years with type 2 diabetes participated, including 115 from a diabetes education clinic and 72 from a dental clinic. Data were collected through face-to-face questionnaires, including demographic characteristics and the validated Mandarin version of the Oral Health Literacy\u0026ndash;Adult Questionnaire (OHL-AQ). Descriptive statistics, chi-square tests, independent-samples t-tests, and ordinal logistic regression were performed using SPSS version 22.0.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe overall mean OHL score was 11.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86. Participants attending diabetes education clinics demonstrated significantly higher OHL than those visiting dental clinics (12.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.44 vs. 10.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.04; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Significant group differences were also observed in reading comprehension, numeracy, and listening comprehension (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Ordinal logistic regression indicated that attending a diabetes education clinic was associated with greater odds of higher OHL (OR\u0026thinsp;=\u0026thinsp;3.69; 95% CI 1.97\u0026ndash;6.93; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Female sex and higher education level (college or above) were also positively associated with adequate OHL (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eMiddle-aged and older adults with diabetes attending diabetes education clinics had significantly better oral health literacy than those visiting dental clinics. The findings highlight the value of interprofessional health education and suggest that incorporating oral health promotion into diabetes education may improve health outcomes. Tailored strategies targeting men and individuals with lower education levels are warranted to reduce literacy disparities.\u003c/p\u003e","manuscriptTitle":"Determinants of Oral Health Literacy Among Middle-Aged and Older Adults with Diabetes: A Cross-Sectional Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 11:22:11","doi":"10.21203/rs.3.rs-7993942/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-05T03:39:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-04T05:56:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-01T09:19:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-30T19:09:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176739553371457839965449860787393694848","date":"2025-12-28T05:59:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-27T11:27:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113741293598531960737202497104952467084","date":"2025-12-26T13:37:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-26T11:02:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174655844034271478897762613443616838461","date":"2025-12-26T10:44:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288117448934727834011288163998103550983","date":"2025-12-26T10:15:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332842630782181721118169529217704624705","date":"2025-12-26T09:10:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250643127113595920237604864556237761308","date":"2025-12-26T07:20:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146821395024788697968961123471578473301","date":"2025-12-10T17:26:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-01T06:52:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-28T07:57:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-18T04:33:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-18T04:30:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-10-31T03:12:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3aeeeec3-a2ec-48c6-82d5-4aa387a49a04","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:05:05+00:00","versionOfRecord":{"articleIdentity":"rs-7993942","link":"https://doi.org/10.1186/s12903-026-07903-9","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-02-13 15:58:01","publishedOnDateReadable":"February 13th, 2026"},"versionCreatedAt":"2025-12-03 11:22:11","video":"","vorDoi":"10.1186/s12903-026-07903-9","vorDoiUrl":"https://doi.org/10.1186/s12903-026-07903-9","workflowStages":[]},"version":"v1","identity":"rs-7993942","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7993942","identity":"rs-7993942","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}