Although conceptual frameworks illustrating possible pathways linking health literacy to health outcomes or status have been developed in medicine,^12,14,17 little progress has been made to develop such pathways between OHL and oral health status. Macek et al.³⁵ recently proposed a conceptual model linking word recognition and conceptual knowledge, decision making, and communication skills with oral health outcomes. Although this does not represent an exhaustive model, we theorize that OHL likely exerts effects on avoidance of care (oral dental neglect) (Figure 1), which may or may not be mediated or modified by individual or systemic characteristics, along the lines of the Paasche-Orlow and Wolf model.¹⁷ Because the links of OHL with oral health status and dental neglect have not been examined by any previous investigation to our knowledge, we embarked upon this investigation to establish this link. Due to the absence of any data linking SE with OHL, we sought to examine this association and empirically investigate the role of SE as a mediator or modifier³⁶ of the association between OHL and dental neglect and oral health status, without conducting any comprehensive pathway analyses. The aims of the present study were to: 1) Determine the association of OHL with oral health status and dental neglect, and 2) Explore the role of self-efficacy as a mediator or modifier of the association between literacy and oral health status.

The overall distribution of REALD-30 and DNS scores is illustrated in Figure 2. OHL scores were normally distributed (X²=1.53, df=2, P>0.05) with mean=15.8 (SD=5.3), range=0–30 and DNS scores were positively skewed with mean=11.9 (SD=3.2), and range=6–23. SE scores were negatively skewed with mean=33.4 (SD=4.1), range=15–40, they were positively correlated with DNS, and did not show any important pattern of association with OHL. Factor analysis confirmed that DNS items loaded on one principal factor (Eigenvalue=1.5). Cronbach’s alpha for DNS and SE was 0.62 and 0.81 respectively. Figure 2 also illustrates the bivariate relationships of SE with OHL and DNS. The panel includes two histograms that illustrate the univariate distribution of OHL and DNS. Polynomial fit functions (red dotted lines) and 95% confidence limits (green dotted lines) of the association of SE with OHL and DNS are overlaid on these histograms. These functions indicate the corresponding SE score mean and 95% CL for each level of OHL and DNS on the supplemental right vertical axis. Pairwise Spearman’s correlation coefficients among these three measures were: rho_DNS,SE=−0.26 (95% CL=−0.31, −0.20); rho_REALD-30,SE=0.10 (95% CL=0.04, 0.15); rho_REALD-30,DNS=−0.02 (95% CL=−0.08, 0.04).