Scholarly article on topic 'How readable are Australian paediatric oral health education materials?'

How readable are Australian paediatric oral health education materials? Academic research paper on "Clinical medicine"

CC BY
0
0
Share paper
Academic journal
BMC Oral Health
OECD Field of science
Keywords
{""}

Academic research paper on topic "How readable are Australian paediatric oral health education materials?"

Oral Health

RESEARCH ARTICLE Open Access

How readable are Australian paediatric oral health education materials?

Amit Arora1,2,3*, Andy SF Lam2, Zahra Karami2, Loc Giang Do4 and Mark Fort Harris1

Abstract

Background: The objective of this study was to analyse the readability of paediatric oral health education leaflets available in Australia.

Methods: Forty paediatric oral health education materials were analysed for general readability according to the following parameters: Thoroughness; Textual framework; Terminology; and Readability (Flesch-Kincaid grade level (FKGL), Gunning Fog index (Fog) and Simplified Measure of Gobbledygook (SMOG)).

Results: Leaflets produced by the industry were among the hardest to read with an average readability at the 8th grade (8.4 ±0.1). The readability of leaflets produced by the commercial sector was at the 7th grade (7.1 ± 1.7) and the government at the 6th grade (6.3 ± 1.9). The FKGL consistently yielded readabilities 2 grades below the Fog and SMOG indexes. In the content analyses, 14 essential paediatric oral health topics were noted and Early Childhood Caries (ECC) was identified as the most commonly used jargon term.

Conclusion: Paediatric oral health education materials are readily available, yet their quality and readability vary widely and may be difficult to read for disadvantaged populations in Australia. A redesign of these leaflets while taking literacy into consideration is suggested.

Keywords: Dental caries, Oral health, Health literacy, Health communication, Leaflets

Background

Dental caries in children is an international public health problem [1]. Despite improvements in oral health over the last 20 years, dental caries is identified as one of the most prevalent chronic diseases of childhood especially for those from a disadvantaged background [2-4]. The most recent Child Dental Health Survey of Australia in 2007 reported that 46 percent of the 6-year-olds had one or more decayed, missing or filled primary tooth and 10 percent of those examined were found to have 10 primary teeth affected [5]. Data from the United Kingdom (UK) and the United States of America (USA) show a similar picture [6,7]. If left untreated, childhood caries can lead to reduced growth, nutritional and sleep problems, problems with eating, speaking, and learning, as well as the potential to disrupt family life [1].

* Correspondence: amit.arora@unsw.edu.au

1Centre for Primary Health Care and Equity, Faculty of Medicine, UNSW Australia, Room 345, Level3, AGSM Building, Gate 11, Botany Street, Randwick, NSW 2052, Australia

2Faculty of Dentistry, University of Sydney, Westmead, NSW, Australia Fulllist of author information is available at the end of the article

Bio Med Central

A history of childhood caries is the most reliable predictor of future caries development which presents a large financial burden for the local health services and individual families [8,9]. It is therefore essential to prevent childhood caries before the subsequent need of resource intensive clinical interventions and treatments.

Parents are often the child's first teachers and play a significant role in maintaining their child's overall health by transferring health-related habits to their children. One possible solution to promote healthy habits in children is to motivate parents during the child's early years of life as habits developed during the primary socialisation process are likely to be carried forward into adulthood [10-12]. However, developing good dental habits during early childhood is a complex process and is largely dependent on a broad range of individual, family and community level factors [13].

The dental professional team, government health departments and industry partners play a role in educating parents to support developing good dental habits. In order for parents to implement preventive oral health

© 2014 Arora et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

routine for their children, they must have adequate functional oral health literacy i.e. a person's ability to read and understand written oral health education materials [14]. Although there is evidence that patients generally prefer written information [15,16], it is often noted that leaflets are poorly designed [17,18]. For example, it was noted elsewhere that the reading skills of parents of paeda-tric patients were several grades lower than their reported highest level of education [19]. As a result some authors [14,20,21] have suggested that the value of health education literature may be compromised by an individuals' literacy skills and that this may hinder his/her ability to obtain, understand and act upon the key health messages.

In 2006, the Adult Literacy and Life Skills Survey in Australia documented that 59 percent of the population aged between 15 and 74 years scored below a level of literacy regarded as optimal for health maintenance [22]. The Australian Bureau of Statistics (ABS) Report also noted that people with lower levels of health literacy often belong to one or more of the following categories: lower socioeconomic class, lower income and/or education, migrants from non-English-speaking countries and living farther from metropolitan cities [22]. It has also been concluded elsewhere that lower levels of health literacy is associated with higher use of expensive care, emergency services and increased rate of hospitalizations [23]. Further, a recent systematic review reviewed the impact of parental health literacy on child health outcomes and concluded that lower levels of parental literacy were associated with poor child health outcomes [24].

Despite the current research on general health literacy, very few studies have examined oral health literacy. Jackson introduced the scope of the problem of lower level of parental oral health literacy and child oral health outcomes and suggested several methods of improving communication between the dental professional team and the parents [25]. Studies conducted in the UK and the USA reported that public dental education materials were difficult to read for their respective population [26-28]. However, to date none have investigated the readability of paediatric dental education materials in Australia. Therefore, the aim of this study was to examine the content and general readability of paediatric oral health education materials available in Australia.

Methods

We contacted Australian State and Territory Health Department's; industry partners; and commercial organisations for all possible oral health education leaflets (n = 40) pertinent to paediatric oral health. Two were produced by the Australian Dental Association (ADA); six were from commercial organisations such as Colgate-Palmolive, Macleans and Oral B; and the majority were published by State/Territory Health Departments. The leaflets were

appraised based on their textual framework, thoroughness, use of jargon terms and readability.

Textual framework

Textual framework was assessed using three parameters:

• physical attributes;

• the use of relevant/instructional pictures; and

• the use of headings, subheadings and percentage of bulleted text.

The physical attributes of the leaflets were noted in terms of the format (e.g.: booklet, tri-fold brochure, or a flyer), and the number of pages.

The leaflets were given a score of "yes" for the use of relevant pictures if they followed the principle of dual code theory (visual and verbal elements in parallel) [29]. Examples included pictures of tooth brushing technique, illustration of the amount of toothpaste recommended for brushing children's teeth, and pictures of cariogenic foods and drinks to avoid.

Each leaflet was examined for the use of headings, subheadings and the percentage of bulleted text using the Kool's macro- and micro-coherence model of communication [30].

Thoroughness/content

Each leaflet was appraised for the presence of information on topics within the scope of paediatric dentistry and the evidence base for the messages they delivered. These included: Early Childhood Caries and/or dental caries; diet; dental visits; tooth-brushing; fluoride; toothpaste use; non-nutritive behaviours; gum care; use of sipper cups; flossing; teething; trauma; tooth eruption and fissure sealants.

Use of jargon text

Each leaflet was screened for the use of professional jargon. We identified a list of terms reported by other authors [28,31] as well as those present in the leaflets we studied.

Readability analyses

The readability of each leaflet was calculated using three widely used indices in analysing health care materials: the Flesch-Kincaid grade level (FKGL), the Gunning Fog index (Fog) and the Simplified Measure of Gobbledygook (SMOG) [32]:

FKGL = (0.39 x ASL) + (11.8 x ASW) -15.59

Fog = 0.4(ASL + percentage of PSW)

SMOG = 3 + VPSW count

ASL = average sentence length ASW = average syllable per word

PSW = polysyllable word or word with more than 2 syllables

PSW count = number of PSW in a 30-sentence sample

All three formulae yield a numerical value that represents the grade level, or number of years of formal education required to comprehend the corresponding passage.

The content of all leaflets were entered into an automated online program to calculate their readabilities using the above formulae [33]. Abbreviations such as "e.g." were edited to allow the automated program to perform the word and sentence counts correctly. The word and sentence count obtained by the online program were also confirmed manually.

Results

Textual framework

Table 1 provides an overview of the leaflets. The leaflets ranged from single page handouts, to tri-fold brochures, to eight page booklets. Out of the 40 leaflets, only four did not have relevant pictures, one from the ADA and three from New South Wales (NSW) Health. All leaflets used headings and sub-headings to display information and majority of them used 50 percent or more of bulleted text. Five used no bulleted text and 11 were entirely based on bulleted text.

Content analyses

Fourteen paediatric oral health topics were noted from the leaflets. These were: Early Childhood Caries/Dental Caries; Diet; Dental visits; Tooth brushing; Fluoride; Toothpaste amount; Non-nutritive behaviors; Gum care; use of Sipper cup; Flossing; Teething; Trauma; Tooth eruption; Fissure sealants.

Table 2 shows the coverage of topics by each leaflet. Four topics namely prevention of dental caries, diet, dental visits and tooth brushing were covered in over 75 percent of the leaflets. Dental caries prevention in particular was covered by over 90 percent of the leaflets. On the other hand, less than 20 percent of the leaflets had information on the use of fissure sealants, tooth development, trauma, flossing and teething. Only six leaflets covered 10 or more topics of interest.

Some leaflets stood out from others. One leaflet produced by the ADA: "Dental care for babies and young children", provided the most comprehensive information, covering all topics except for dental trauma. Of all the commercial leaflets, one produced by Colgate-Palmolive: "Oral Health for children 3-12 years" covered 11 topics of interest. Amongst the government produced leaflets, two produced by Western Australia (WA) Health Department covered 11 topics. Two leaflets produced by Health Department of Northern Territory (NT), one by Health Department of Victoria (VIC), and

one by Health Department of South Australia (SA) only covered two topics. Also, noteworthy NSW Health's publication "Keep Smiling while you are pregnant", one of the few paediatric oral health publications provided pre-natal oral health information for women.

The content analysis identified instances of incomplete or conflicting information. Specifically, most leaflets suggested parents to use a "pea-sized" amount of child fluoride toothpaste for cleaning their child's teeth. However, two leaflets were generic and did not mention the amount of toothpaste to be used for cleaning their child's teeth. Further, the recommended age of supervised toothbrushing varied across leaflets which was noted to be confusing. Most leaflets recommended that children should be supervised for brushing until they are eight years old. However, two leaflets mentioned the age of six and nine years, respectively.

Use of jargon text

A list of 19 commonly used dental jargon terms were noted in the paediatric oral health leaflets. Of the list of jargon text, some commonly used terms were ECC, primary teeth, sealants and fluoride.

List of jargon terms section

Alignment

Antimicrobial

Appliance

Biofilm

Calcify

Dental caries

Disclosing tablets

Early childhood caries

Enamel

Fluoride

Gingivitis

Mouthguards

Nursing bottle caries

Orthodontics

Pits and fissures

Primary teeth

Sealants

Symptoms Readability analyses

Figure 1 shows the findings of readability indices for the leaflets. The lowest reading grade level was achieved by two leaflets entitled "Do give your child, Don't give your child" and "Give your child's teeth a healthy start" created by the NT and SA Health Departments, respectively. Their reading levels, based on Flesch-Kincaid, were noted at 1st grade (1.2 and 1.5, respectively) and both these publications use relevant pictures and easy-to-read

Table 1 Summary of physical attributes of Australian paediatric oral health leaflets

No. Publisher

Source

Format

Relevant % Bulleted

picture text

7 tips for hea l thy baby teeth 2-page No 100

Denta l care for babies and young chil dren 4-page booklet Yes 25

Bright Smi les at Home 6-page trifold Yes 75

Oralhealth for infants and toddlers 8-page 4-fold Yes 10

Zero to six pre-school 6-page trifold Yes 25

oralhealth for children 3-12 8-page 4-fold Yes 15

Teaching your child good brushing habits 6-page trifold Yes 10

How do I care for my child's teeth? 2-page single Yes 80

Tooth Tips for parents, grandparents & carers 2-page Yes 100

Tooth Tips for parents, grandparents & carers 2-page Yes 80

Stay Wellfact sheet for parents 2-page Yes 50

Play Wellfact sheet for parents 2-page Yes 40

Eat Wellfact sheet for parents 2-page Yes 30

Drink Wellfact sheet for parents 2-page Yes 10

Clean Wellfact sheet for parents 2-page Yes 20

How to brush your child's teeth 1-page single Yes 100

Give your child's teeth a healthy start 6-page trifold Yes 0

Cleaning your child's teeth 1-page Yes 0

Do give you child, Don't give your child 1-page Yes 0

Healthy mouths for kids under 5 6-page trifold Yes 100

Teach your baby to drink from a cup 6-page trifold Yes 50

Eat Well Drink WellClean Well Play WellStay Well 6-page trifold No 100

Caring for babies' teeth 2-page single No 50

Lift the Lip 3-page bifold Yes 75

Tooth Smart 6-page trifold No 100

Good Oral Health for Children 6-page trifold Yes 100

Keeping smiling while you are pregnant 6-page trifold Yes 100

Healthy Mouths for AboriginalPeople 6-page trifold Yes 100

don't rot your baby's teeth 1-page single Yes 75

Looking after Young Mouth 13-page booklet Yes 50

Caring for your child's smile 1-page single Yes 100

Give your child's teeth a healthy start 6-page trifold Yes 0

DO give you child, Don't give your child 1-page Yes 0

Solid Kids have Healthy Teeth 0-2 Years Old 6-page trifold Yes 75

Solid Kids have Healthy Teeth 2-5 Years Old 6-page trifold Yes 75

Caring for your child's smile (0-6 Years) 1- page Yes 100

Thumbsucking and Dummies 4-page bifold Yes 40

Teething 4-page bifold Yes 30

Your Child's First Dental Visit 4-page bifold Yes 40

Brushing Toddler's Teeth 4-page bifold Yes 20

ADA ADA Co gate Co gate Co gate Co gate Macl eans Ora l B

9 Dental Hea lth Services

10 Dental Hea lth Services

11 Dental Hea lth Services

12 Dental Hea lth Services

13 Dental Hea lth Services

14 Dental Hea lth Services

15 Dental Hea lth Services

16 Dental Hea lth Services

Northern Territory Government Northern Territory Government Northern Territory Government

20 NSW Hea lth

21 NSW Hea lth

22 NSW Hea lth

23 NSW Hea lth

24 NSW Hea lth

25 NSW Hea lth

26 NSW Hea lth

27 NSW Hea lth

28 NSW Hea lth

Queens l and Hea l th Queens l and Hea l th SA Hea l th SA Hea l th SA Hea l th

34 WA Dental Hea lth Services

35 WA Dental Hea lth Services

36 WA Dental Hea lth Services

37 WA Dental Hea lth Services

38 WA Dental Hea lth Services

39 WA Dental Hea lth Services

40 WA Dental Hea lth Services

Industry

Commercia C C C C C

Government G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G

text. Another easy-to-read leaflet was the NSW Health's publication, "Tooth Smart". This 6-page booklet registered at a 2nd grade reading level (FKGL score of 1.8)

and was entirely based on bulleted text. Four leaflets, three by VIC Health Department and one by Colgate-Palmolive, yielded a FKGL score of 8. The most

Table 2 Thoroughness and content of Australian paediatric oral health leaflets*

Leaflet number ECC** Diet Visits Brushing Fluoride Tooth-paste Behaviours Gum care Sippy cups Flossing Teething Trauma Eruption Sealants

1 Y Y Y Y Y - Y - - Y - - - -

2 Y Y Y Y Y Y Y Y Y Y Y - Y Y

3 - Y Y Y Y - - - - Y - - - Y

4 Y Y Y Y Y Y Y - - - Y - Y -

5 Y Y Y Y Y Y Y Y - - Y - Y -

6 Y Y Y Y Y Y Y - - Y - Y Y Y

7 Y Y Y Y Y Y - - - - - - - -

8 Y Y Y Y Y Y Y Y - Y - Y - -

9 Y Y Y Y - - - - Y - Y - Y -

10 Y Y Y Y Y Y Y - - -- -- -

11 - - Y - - - Y - - -- -- Y

12 - - Y - - - - - - -- Y- -

13 Y Y Y - - - - - - -- -- -

14 Y Y Y - Y - - - - -- -- -

15 Y - Y Y Y Y - - - -- -- -

16 Y - - Y - Y - - - -- -- -

17 Y Y Y Y Y - Y - Y -- -- -

18 - - - Y Y - - - - -- -- -

19 Y Y - - - - - - - -- -- -

20 Y Y - Y - - - - Y -- -- -

21 Y Y - - - - - - Y -- -- -

22 Y Y Y Y Y Y - Y Y -- Y- Y

23 Y Y Y Y Y Y Y - - -- -- -

24 Y Y Y Y Y Y - Y - -- -- -

25 Y Y Y Y - - - - Y -- -- -

26 Y Y Y Y Y - - - - -- -- -

27 Y Y Y Y - Y - - - Y- -- -

28 Y Y Y Y Y Y - Y - Y- Y- -

29 Y Y Y Y Y Y Y - Y -- -- -

30 Y Y Y Y Y Y Y Y - -Y -- -

31 Y Y Y Y Y Y - - - -- -- -

32 Y Y Y Y Y - Y - Y -- -- -

33 Y Y - - - - - - - -- -- -

34 Y Y Y Y Y Y Y Y Y -Y Y- -

35 Y Y Y Y Y Y Y Y Y Y- Y- -

36 Y Y Y Y Y Y Y Y Y -- -- -

37 Y Y Y - - - Y - - -- -- -

38 Y - Y Y Y Y - Y - -Y -Y -

39 Y - Y Y Y - - - - -- -- -

40 Y - - Y Y Y - Y - -- -- -

*"Y" refers to a Yes.

**Early Childhood Caries.

Figure 1 Readability indices scores of Australian paediatric leaflets.

thorough leaflet that covered 13 out of 14 topics had a FKGL score of 6.5 but a Fog score of 9.5 and SMOG score of 9.3. The FKGL formula consistently yielded 2 to 3 grade levels below the Fog and SMOG formulae scores.

The average of the grade levels calculated by the FKGL, Fog and SMOG formulae were used to compare the readabilities of the leaflets. Among them, those produced by the commercial industry had a readability ranging from 5th to the 9th grade; those produced by the ADA had readability at the 8th or 9th grade; and those produced by State/Territory Health Departments had a readability ranging from the 3rd to the 9th grade. The average readability of leaflets from ADA was 8th grade (Mean-8.4, SD-0.1); commercial industry was 7th grade (Mean-7.1, SD -1.7); and those from the State/Territory Health Departments was 6th grade (Mean-6.3, SD-1.9).

Discussion

Educating parents on child oral health related issues is one of the most important steps during the primary socialisation process. Leaflets form an important link in the chain of communication between oral health professionals, the parents and the child. As noted in this study, although many paediatric oral health leaflets exist in Australia, they vary in content and readability. It was noted that leaflets that were adequate in terms of low literacy demand often had minimal information on child oral health. Conversely, the leaflets that had comprehensive information required higher literacy skills, which may be difficult for parents from disadvantaged backgrounds or those from linguistically diverse communities. Our results suggest that is likely that leaflets with simple messages and low literacy demand are read by more people compared to comprehensive leaflets.

The present study utilised three measures of readability assessment (FKGL, Fog, and SMOG) due to their simplicity and widespread use [32]. The grade levels calculated by FKGL were lower compared to Fog and SMOG, while the difference between Fog and SMOG were small (Figure 1). It is pertinent to note that these formulae are validated against the McCall- Crabs Passages [32]. These differences are noted because the FKGL predicts the grade level based on 75 percent comprehension, while the Fog and SMOG predict the grade level based on 90 percent and 100 percent comprehension respectively. Although other methods to assess the readability of education materials such as the SAM method (Suitability Assessment of Materials) are available [27], these were deemed inappropriate for this study as some leaflets contained less than 100 words.

The use of formula based readability assessment provided useful information on only one aspect of readability i.e. the level of education required to comprehend the leaflet. Other aspects such as font size, font colour, the use of bold and italics text, use of bulleted text; use of instructional pictures; use of simplified sentences, and sentence length which contribute to the overall readability [28,34,35] are not assessed by the readability indices. However, in this study, some of these aspects such as the use of bold and bullet text and the use of pictures were assessed. It has also been noted elsewhere that readability formulae should only be used as a guide to assess the reading difficulty of a text as they do not take into account other factors that can influence comprehension [36] such as the use of active and passive verbs, the way the information is organised on a page and the reader's motivation and level of prior knowledge [37]. Blinkhorn and Verity [38] noted that dental professionals

use professional terminology that may be incomprehensible to a common person and that readability formulae may therefore underestimate the difficulty of a text.

The content analyses of Australian leaflets revealed the prevalence of conflicting health education messages as noted by other researchers [31]. It is noteworthy that research in experimental psychology and marketing highlights that humans have a cognitive preference for picture-based, rather than text-based information: the so-called picture superiority effect [39,40]. Although majority of the leaflets had relevant pictures, it was surprising to note that some leaflets did not have photographs to convey important messages to parents of young children such as how to brush the child's teeth and the amount of toothpaste to be used. Similar to other studies [27,28,31], the present study identified aspects of oral hygiene instruction such as how to brush teeth that were not covered by majority of the leaflets. Pictures have been a useful tool in health sciences to covey health messages and would be useful for Australian dental professionals to convey the correct information about toothpaste use and other aspects of oral hygiene using illustrations as it is reported that patients retain more health information to visual presentations [40,41].

Although there is no gold standard tool to assess a patient's oral health literacy at this stage, several instruments are being developed as research in this aspect of oral health is increasing relatively [21]. It is now noted that oral health literacy is an important link between health behaviours and oral health outcomes [20]. Although there is evidence that improving patients' literacy can improve health outcomes [42], it is still unclear if improving patient education materials can lead to better health outcomes [43]. However, it is pertinent to note that producers of dental health education materials should be aware of several parameters when designing leaflets. These include general readability of leaflets; coverage of important health topics with simple and consistent messages; the use of pictures to convey health messages; and avoiding the use of jargon terms. Health education leaflets that are clear, concise, consistent and thorough are a simple way to bridge the communication gap between the oral health professional, parent and the child.

The present study has several limitations; although several criteria were used to evaluate the readability of the leaflets, there were some aspects of the general readability that were not assessed. These include the use of bright colours, use of active and passive verbs, the use of italics to emphasize information, and the advantageous use of white space [34]. Second, the list of dental jargon terms noted in this study were subjective. However, it is important to note that other authors have noted similar words in their studies [28,31]. Thirdly, although all possible Australian sources were searched to collect leaflets,

it may be possible that some paediatric oral health leaflets were inadvertently missed. Finally, the current evaluation does not include the opinion of the parents which will be prudent to re-design of the leaflets in future.

Conclusions

Australian paediatric oral health education materials are readily available, yet their quality and readability vary widely. Leaflets produced by local Health Departments are more readable compared to commercial and industry counterparts. The results show that a large number of paediatric dental leaflets may be difficult to read for disad-vantaged populations in Australia. A redesign of these leaflets while taking literacy into consideration is suggested.

Competing interests

The authors declare that they have no competing interests. Authors' contributions

AA conceptualised the study. AA, ZK, ASFL collected allthe leaflets and conducted the content analysis. LD and MH was consulted in case of any discrepancy. Allauthors wrote the draft version of the manuscript and approved the finalversion.

Acknowledgements

This study was supported by the Australian NationalHealth and Medical Research CouncilProject Grant (1033213) and Dr Amit Arora is supported by NHMRC Early Career Fellowship (1069861).

Author details

Centre for Primary Health Care and Equity, Faculty of Medicine, UNSW Australia, Room 345, Level3, AGSM Building, Gate 11, Botany Street, Randwick, NSW 2052, Australia. 2Faculty of Dentistry, University of Sydney, Westmead, NSW, Australia. 3Sydney and Sydney South West LocalHealth District, Sydney, NSW, Australia. 4Australian Research Centre for Population OralHealth, University of Adelaide, Adelaide, SA, Australia.

Received: 21 May 2014 Accepted: 29 August 2014 Published: 2 September 2014

References

1. Arora A, Schwarz E, Blinkhorn AS: Risk factors for early childhood caries in disadvantaged populations. J Invest Clin Dent 2011, 2:223-228.

2. Do LG, Spencer AJ, Slade GD, Ha DH, Roberts-Thomson KF, Liu P: Trend of income-related inequality of child oral health in Australia. J Dent Res 2010, 89:959-964.

3. Crocombe LA, Stewart JF, Barnard PD, Slade GD, Roberts-Thomson K, Spencer AJ: Relative oral health outcome trends between people inside and outside capital city areas of Australia. Aust Dent J 2010, 55:280-284.

4. Australian Research Centre for Population Oral Health: Dental caries trends in Australian school children. Aust Dent J 2011, 56:227-230.

5. Mejia GC, Amarasena N, Ha DH, Roberts-Thomson KF, Ellershaw AC: Child Dental Health Survey Australia 2007: 30-Year Trends in Child Oral Health. Dental Statistics and Research Series No. 60. Cat. no. DEN 217. Canberra: AIHW; 2012.

6. Lader D, Chadwick B, Chestnutt I, Harker R, Morris J, Nuttal N, Pitts N, Steele J, White D: Children's Dental Health in the United Kingdom, 2003. London: Office for National statistics; 2004.

7. Beltran-Aguilar ED, Barker LK, Canto MT, Gooch BF, Griffin SO, Hyman J, Jaramillo F, Kingman A, Nowjack-Raymer R, Selwitz RH, Wu T: Surveillance for dental caries, dental sealants, tooth retention, edentulism and enamel fluorosis-United States, 1981-94 and 1999-2002. MMWR Surveill Summ 2005, 54:1-43.

8. Arora A, Scott JA, Bhole S, Do L, Schwarz E, Blinkhorn AS: Early Childhood feeding practices and dental caries in preschool children: a multi-centre birth cohort study. BMC Public Health 2011, 11:28.

9. Slack-Smith L, Colvin L, Leonard H, Kilpatrick N, Bower C, Brearley Messer L: Factors associated with dental admissions for children aged under

5 years in Western Australia. Arch Dis Child 2009, 94:517-523.

10. Blinkhorn AS: Influence of social norms on toothbrushing behavior of preschool children. Community Dent Oral Epidemiol 1978, 6:222-226.

11. Edmunds LD: Parents' perceptions of health professionals' responses when seeking help for their overweight children. Fam Pract 2005, 22:287-292.

12. Soubhi H, Potvin L: Homes and Families as Health Promotion Settings: Linking Theory and Practice. Thousand Oaks, CA: SAGE Publications; 2000.

13. Fisher-Owens SA, Gansky S, Platt L, Weintraub J, Soobader M, Bramlett M, Newacheck P: Influences on children's oral health: a conceptual model. Pediatr 2007, 120:e510-e520.

14. Institute of Medicine of the National Academies: Health Literacy. A Prescription to End Confusion. Washington, DC: National Academy Press; 2004. Available at: [http://iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx] last accessed 15 January 2014.

15. Weinman J: Providing written information for patients: psychological considerations. J Roy Soc Med 1990, 83:303-305.

16. George C, Waters W, Nicholas J: Prescription information leaflets: a pilot study in general practice. Br Med J 1983, 287:1193-1196.

17. Albert T, Chadwick S: How readable are practice leaflets? Br Med J 1992, 305:1266-1268.

18. Bennett J, Bridger P: Communicating with patients. Br Med J 1992, 305:1294.

19. Davis TC, Mayeaux EJ, Fredrickson D, Bocchini JA Jr, Jackson RH, Murphy PW: Reading ability of parents compared with reading level of pediatric patient education materials. Pediatr 1994, 93:460-468.

20. Brug J, Steenhuis I, Van Assema P, de Vries H: The impact of a computer tailored intervention. Prev Med 1996, 84:783-787.

21. National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Public Health Service, U.S. Department of Health and Human Services: The invisible barrier: literacy and its relationship with oral health. A report of a work- group sponsored by the National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Public Health Service, Department of Health and Human Services.

J Public Health Dent 2005, 65:174-182.

22. Australian Bureau of Statistics: Health Literacy 2006 Australia. Canberra: Australian Bureau of Statistics; 2008. Available at: [http://www.abs.gov.au/ ausstats/abs@.nsf/mf/4233.0] Last accessed 5 December 2013.

23. Schumacher JR, Hall AG, Davis TC, Arnold CL, Bennett RD, Wolf MS, Carden DL: Potentially preventable use of emergency services: the role of low health literacy. Med Care 2013, 51:654-658.

24. DeWalt DA, Hink A: Health literacy and child health outcomes: a systematic review of the literature. Pediatr 2009, 124(Suppl 3):S265-S274.

25. Jackson R: Parental health literacy and children's dental health: implications for the future. Pediatr Dent 2006, 28:72-75.

26. Harwood A, Harrison JE: How readable are orthodontic patient information leaflets? J Ortho 2004, 31:210-219.

27. Kang E, Fields HW, Cornett S, Beck FM: An evaluation of pediatric dental patient education materials using contemporary health literacy measures. Pediatr Dent 2005, 27:409-413.

28. Alexander RE: Readability of published dental educational materials. J Am Dent Assoc 2000, 131:937-942.

29. Whittingham JR, Ruiter RA, Castermans D, Huiberts A, Kok G: Designing effective health education materials: experimental pre-testing of a theory brochure to increase knowledge. Health Educ Res 2008, 23:414-426.

30. Kools M, Ruiter RA, van de Wiel MW, Kok G: Increasing reader's comprehension of health education brochures: a qualitative study into how professional writers make texts coherent. Health Educ Behav 2004, 31:720-740.

31. Hendrickson RL, Huebner CE, Riedy CA: Readability of pediatric health materials for preventive dental care. BMC Oral Health 2006, 6:14.

32. Ley P, Florio T: The use of readability formulas in health care. Psych Health Med 1996, 1:7-28.

33. Edit Central. [http://www.editcentral.com/gwt1/EditCentral.html]

34. Alexander RE: Patient understanding of postsurgical instruction forms. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999, 87:153-158.

35. Osborne H: Health Literacy Consulting. [http://www.healthliteracy.com]

36. Meade CD, Smith CF: Readability formulas: cautions and criteria. Patient Educ Counsel 1991, 17:153-158.

Cutts M: The Plain English Guide. Oxford: Oxford University Press; 1996. Blinkhorn AS, Verity JM: Assessment of the readability of dental health education literature. Comm Dent Oral Epidemiol 1979, 7:195-198. Sansgiry SS, Cady PS, Adamcik BA: Consumer comprehension of information on over-the-counter medication labels: effects of picture superiority and individual differences based on age. J Pharmaceut Market Manag 1997, 11:63-76.

Morgaine KC, Carter AS, Meldrum AM, Cullinan MP: Design of an oral health information brochure for at-risk individuals. Health Educ J 2014, doi:10.1177/0017896913516095.

Gauld VA: Compliance and recall. J Roy Coll Gen Pract 1981, 83:298-300. Grosse RN, Auffrey C: Literacy and health status in developing countries.

Ann Rev Public Health 1989, 10:281-297.

Joint Commission on Accreditation of Health Care Organizations: Patient and family education. In Accreditation Manual for Hospitals. Chicago: Joint Commission on Accreditation of Health Care Organizations; 1996.

doi:10.1186/1472-6831-14-111

Cite this article as: Arora et al.: How readable are Australian paediatric oral health education materials? BMC Oral Health 2014 14:111.

Submit your next manuscript to BioMed Central and take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color figure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at www.biomedcentral.com/submit

Central