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 Table of Contents  
Year : 2018  |  Volume : 9  |  Issue : 4  |  Page : 101-104

Improving Oral Health Literacy in the Digital Age: Recommendations for a Collaboration Between the Dental Profession and Voice-Activated Virtual Assistants

School of Dentistry, West Virginia University, Morgantown, West Virginia, USA

Date of Web Publication29-Jan-2019

Correspondence Address:
Bailey M Hollihan
School of Dentistry, West Virginia University, Morgantown, West Virginia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_56_18

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Within the healthcare system, patients continue to take on a larger role in managing their health. However, due to the low prevalence of health literacy among the US adult population, many patients are unable to make appropriate medical decisions. The Internet is further contributing to the problem. Patients are looking to the Internet, which can include extremely complex or inaccurate text, when they have questions about their health more often than speaking with their providers. This presents the risk for patients to become confused, misled, or even believe false information about their health. In order for patients to manage their health successfully, they must develop health literacy. This will be possible through advancements in internet technology that will provide the patients with clear, credible health information.

Keywords: American Dental Association, dentistry, health information, internet, websites

How to cite this article:
Hollihan BM. Improving Oral Health Literacy in the Digital Age: Recommendations for a Collaboration Between the Dental Profession and Voice-Activated Virtual Assistants. Dent Hypotheses 2018;9:101-4

How to cite this URL:
Hollihan BM. Improving Oral Health Literacy in the Digital Age: Recommendations for a Collaboration Between the Dental Profession and Voice-Activated Virtual Assistants. Dent Hypotheses [serial online] 2018 [cited 2023 Jun 2];9:101-4. Available from:

  Introduction Top

“Hey Siri, what’s the weather forecast for today?”

“Hey Siri, what’s the traffic like downtown?”

“Hey Siri, what’s the score of the Mountaineer’s game?”

Am I sounding like an Apple commercial yet? Let’s try this one…

“Hey Siri, should I get an amalgam or a composite restoration in my tooth?”

Now that’s something you don’t hear people asking Siri every day. But, I wonder, has technology advanced so much that we can get the same answers that our dentist or doctor would provide from a computerized device? Recent studies would say no. When asked simple questions related to physical and mental health, voice-activated virtual assistants such as Siri, Google Assistant, Cortana, and S Voice responded inconsistently and incompletely.[1] However, as patients become more involved in managing their health and making medical decisions, the need for this technology appeals.

For centuries, it was held that only a physician could truly understand symptoms and draw appropriate conclusions. Medical practice was established on the conceptions that, not only should the physicians have full control over their patients’ heath, but they should protect their patients from information regarding their conditions or treatment options. In recent years, conversely, there has been a tremendous shift away from preceding paternalistic ideals. Currently, an individual’s specific health needs and desired health outcomes directly influence the measures taken by providers. Patients are making the important decisions. However, with this role comes a great deal of responsibility. Remember, in the past, physicians made the health decisions, because they were knowledgeable and capable of making those decisions. Patients, therefore, have the implicit obligation to become knowledgeable and capable—to develop health literacy—in order to make appropriate decisions concerning their health. Unfortunately, many adults in the United States, today, have a low health literacy.

  Health Literacy in the United States Top

Literacy is traditionally described as the ability to read and write. Although that definition is accurate, literacy actually encompasses much more. Individuals who consider themselves well literate typically have a solid foundation of knowledge, whether be it basic or advanced, in a variety of areas. This foundation enables them to not only read and write, but it allows them to communicate and interact with the public as well as learn and understand new concepts. The National Center for Education Statistics considers literacy necessary to “participate in the society, to achieve one’s goals and to develop one’s knowledge and potential.”[2]

The latest information assessing adult literacy was collected by the Program for the International Assessment of Adult Competencies (PIAAC) under the Organization for Economic Cooperation and Development (OECD). Consisting of three data collection periods, PIAAC was designed to measure the literacy, numeracy, and problem-solving skills of adults aging from 16 to 65 years overtime.[2] In 2012, PIAAC was launched in 24 participating countries, including the United States. Nine countries joined the study in 2014, and five additional countries contributed in 2017. Through an analysis of data collected, the OECD reported that the United States had one of the greatest numbers of adults, 18%, scoring a Level 1 or below in literacy proficiency which was higher than the international average of 16%. In addition, it was reported that the scores of adults in the United States have remained relatively unchanged between reports, whereas other countries have progressed.

With the adult population having such a high prevalence of low literacy, it is unquestionable that serious consequences have arisen throughout society. Within the healthcare system, the same is true. Health literacy is key to a successful patient–provider dialogue. Individuals with low health literacy are often unable to understand basic health information which hinders their ability to navigate the healthcare system, understand doctors’ orders, and make appropriate decisions concerning their health. In addition, studies have found that adults with low health literacy are more likely to report poor health conditions than those with adequate literacy. These conditions include high blood pressure, diabetes, asthma, and HIV/AIDS.[3],[4] The same is true for oral health literacy (OHL). It has been found that individuals with low OHL are more likely to report low self-efficacy concerning their oral health status; in addition, increased OHL is associated with better oral health status, routine dental care, and better self-rated oral health.[5],[6],[7] Furthermore, individuals with higher OHL are more likely to practice appropriate caries prevention behavior.[8] Therefore, it is imperative to understand the factors contributing to the low health literacy and make changes that will enable patients to successfully manage their health.

  Patients’ Main Source of Health Information: The Internet Top

To consider the factors that contribute to low health literacy in the adult population, we need to start with where and how patients are obtaining their health information. Historically, when faced with a question, the only way to find a solution was to go straight to the source. In this case, that would be a dentist, physician, or other healthcare provider. However, as patients are becoming more in control of their health, they are seeking out answers on their own. In addition to questioning their provider, patients now rely on family members or friends, newspapers, magazines, radio, television, and, what has become the most popular source of health information, the Internet.[9] In addition, concerning online activity in general, a 2005 study, by authors Bradford Hesse, David Nelson, and Gary Kreps, found that health information seeking was by far the most commonly reported online activity, with 63.7% of participants indicating that they have searched for medical information online at least once in the past 12 months.[10]

The data investigated by Hesse et al. was acquired from the National Cancer Institute’s Health Information National Trends Survey (HINTS). Since 2003, the HINTS program has monitored the rapidly growing field of health communication. Mainly, HINTS tracks the ways that health information is accessed and utilized by patients.[11] Further research based on more recent HINTS data also supports the notion that the Internet is the most commonly used source for acquiring health information. Authors Wura Jacobs, Ann Amuta, and Kwon Chan Jeon compared HINTS data overtime using the 2011, 2012, 2013, and 2014 cycles. According to their findings, the highest percentage of participants reported that the Internet is the first place they would go for health information opposed to family and friends, healthcare providers, and traditional media.[9] These results were especially true in the 2014 cycle.

When examining the group, in this study, who chose the Internet as their first source; the participants were younger, had higher socioeconomic status (SES), and higher internet skills.[9] These relationships are not surprising because the younger generation is commonly considered more familiar with using the Internet corresponding to higher internet skills, and those with higher SES are more likely to have access to the Internet than those with low SES. A relationship that was surprising, however, is that participants who chose the Internet as their first source tended to have a higher level of education than those who did not make this selection. Although the authors did not remark on this relationship, I suggest that it is because most of the health information provided online is very complex. In addition, due to the prevalence of low health literacy, the reading level of certain online text is likely too difficult for the average person to comprehend. Results from a 2015 study, by authors Francesco Brigo, Willem Otte, Stanley Igwe, Frediano Tezzon, and Raffaele Nardone, concurred with this suggestion.

  The Internet’s Threat to Health Literacy Top

Through their research, Brigo et al. aimed to evaluate the health literacy level of eight popular health information websites. The authors specifically chose to include Wikipedia, a free online encyclopedia, in their review because Wikipedia has become the most popular reference of general information for internet users since its launch in 2001.[12] Methods for evaluating the websites included the use of six different quantitative readability scales. The scales assessed each site based on ease of comprehension as well as the estimated corresponding academic grade level needed to understand the information.[12]

According to their results, the eight websites yielded an average reading level of “difficult-to-fairly-difficult,” with text readability equivalent to an 11th academic grade level. This would require approximately 12 years of formal education to easily understand the material during the first read.[12] More alarmingly, the results for Wikipedia indicated a “difficult” reading level with text corresponding to a 15th academic grade level requiring 17 years of formal education to easily understand it. To gauge the significance of these findings, most US adults have difficulty reading at or above the 7th academic grade level.[4] So, understanding text provided by what is considered the most popular source of online information requires 10 years of education more than the average adult can understand. Unfortunately, understanding highly complex content is not the only obstacle internet users face. Website credibility is also a complication.

Consider Wikipedia once again. Containing approximately 48 million articles in 287 languages, the website appears to be a great place to obtain health information. However, the credibility of Wikipedia’s articles is virtually unknown. This is because the website has open access to the public for editing. In addition, according to the summary that the website provides, “obtaining formal peer review for edits is not necessary since the review is a communal function and everyone who reads an article and corrects it is a reviewer.” Therefore, the articles on Wikipedia may vary significantly in how reliable the content is, something that is true for all websites. It, then, becomes the individuals’ responsibility to gauge how accurate information appears before trusting it. Although several studies reveal that internet users prefer to believe information provided by reputable organizations and steer clear of websites that seem untrustworthy, other evidence reveals that individuals are unable to distinguish between reliable and unreliable sources during their searches.[13] So, patients are at risk of believing faulty information which inevitably reduces their health literacy. Therefore, appropriate intervention is essential to solve this problem.

  Providing Oral Health Literacy to Patients Top

As patients become more involved in the maintenance of their health, the need for adequate health education implores. Currently, individuals are relying less on their healthcare providers for health education due to the unprecedented amount of information that is now available via the Internet. The new trend of “Googling” symptoms or looking them up on Wikipedia may be convenient; however, many internet sources are highly complex or inaccurate and this poses a risk to readers’ health literacy.

As internet technology increasingly integrates with daily life, advancements ought to be made by software developers, researchers, and professional health associations, with the goal of providing health literacy to patients. It is my suggestion that the American Dental Association (ADA) appoint a committee of experts in oral health to collaborate with software companies including Apple, Google, and Amazon. The purpose of this collaboration would be to improve the content provided by the already popular virtual assistants Siri, Google Assistant, and Alexa. The success of this collaboration would depend on (a) the ADA Committee’s agreement on the recommended oral health content provided by virtual assistants and (b) the software companies’ willingness to accept the recommended oral health content. Through this collaboration, the virtual assistants will advance in their performance by providing medically relevant and accurate oral health information to the public. This information will provide OHL when it obeys the following: it is deemed reliable and is accepted by the ADA, it is consistent and relevant to what the person (or group) seeking information is asking, and it is considered intelligible and appropriate for a wide variety of populations and demographics. Through this technology, the ADA will insure that good, credible content is available to the public. The improvements will be especially beneficial to older adults, those with lower SES, lower educational level, and lower internet self-efficacy, minimizing the risk of increased health disparities. Ultimately, through advancements in internet technology, we can provide patients with clear, credible health information and increase OHL amongst the adult population.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Miner AS, Milstein A, Schueller S, Hegde R, Mangurian C, Linos E. Smartphone-based conversational agents and responses to questions about mental health, interpersonal violence, and physical health. JAMA Intern Med 2016;176:619-25.  Back to cited text no. 1
Program for the International Assessment for Adult Competencies (PIAAC). What Is PIAAC? Institute of Education Sciences, National Center for Education Statistics, U.S. Department of Education. Available from: [Last accessed on 25 Sept 2018]  Back to cited text no. 2
Marcus EN. The silent epidemic—The health effects of illiteracy. N Engl J Med 2006;355:339-41.  Back to cited text no. 3
Walsh TM, Volsko TA. Readability assessment of internet-based consumer health information. Respir Care 2008;53:1310-5.  Back to cited text no. 4
Lee JY, Divaris K, Baker AD, Rozier RG, Vann WF Jr. The relationship of oral health literacy and self-efficacy with oral health status and dental neglect. Am J Public Health 2012;102:923-9.  Back to cited text no. 5
Guo Y, Logan HL, Dodd VJ, Muller KE, Marks JG, Riley JL III. Health literacy: A pathway to better oral health. Am J Public Health 2014;104:85-91.  Back to cited text no. 6
Henderson E, Dalawari P, Fitzgerald J, Hinyard L. Association of oral health literacy and dental visitation in an inner- city emergency department population. Int J Environ Res Public Health 2018;15:1748.  Back to cited text no. 7
Horowitz AM, Kleinman DV, Wang MQ. What Maryland adults with young children know and do about preventing dental caries. Am J Public Health 2013;103:69-76.  Back to cited text no. 8
Jacobs W, Amuta AO, Jeon KC. Health information seeking in the digital age: An analysis of health information seeking behavior among US adults. Cogent Soc Sci 2017;3:1302785.  Back to cited text no. 9
Hesse BW, Nelson DE, Kreps GL, Croyle RT, Arora NK, Rimer BK et al. Trust and sources of health information the impact of the internet and its implications for health care providers: Findings from the first health information national trends survey. Arch Intern Med 2005;165:2618-24.  Back to cited text no. 10
Hints. It starts by asking the right questions. U.S. Department of Health and Human Services, National Cancer Institute. Available from: [Last accessed on 28 Sept 2018]  Back to cited text no. 11
Brigo F, Otte WM, Igwe SC, Tezzon F, Nardone R. Clearly written, easily comprehended? The readability of websites providing information on epilepsy. Epilepsy Behav 2015;44:35-9.  Back to cited text no. 12
Kammerer Y, Amann DG, Gerjets P. When adults without university education search the Internet for health information: The roles of Internet-specific epistemic beliefs and a source evaluation intervention. Comput Hum Behav 2015;48:297-309.  Back to cited text no. 13

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