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The Association Between Oral Health Literacy And Cho et al. BMC Public Health (2020) 20:1074 https://doi.org/10.1186/s12889-020-08550-7 RESEARCH ARTICLE Open Access The association between oral health literacy and oral health behaviors in North Korean defectors: a cross-sectional study Han-A Cho1, Ae-Jung Im2, Yu-Ri Sim3, Han-Byoel Jang3 and Hee-Jung Lim3* Abstract Background: The present study aimed to investigate the association between oral health literacy and oral health behaviors among North Korean defectors. Methods: This study involved the collection of self-reported questionnaires from 123 North Korean defectors visited a dental clinic that offered complimentary services, to receive dental treatment in a metropolitan area of South Korea from December 2017 to April 2018. Oral health literacy was measured with the Test of Korean Functional Health Literacy in Dentistry (TOKFHLiD), which consists of 30 items concerning verbal oral health literacy and 42 items concerning functional oral health literacy (28 items for reading comprehension and 14 items for numeracy). In addition, the questionnaire contains 15 and 14 items related to demographic characteristics and oral health behaviors (interest, lifestyle, diet, prevention), respectively, for a total of 101 items. Results: The mean oral health literacy score was 44 (out of a maximum possible score of 72). Oral health literacy and oral health behaviors were positively correlated (r = 0.526, P < 0.001), and oral health literacy also had a significant effect on oral health behaviors (Beta = 0.26, 95% CI: 0.04–0.33). However, although functional oral health literacy had a significant effect on oral health behaviors (Beta = 0.20, 95% CI: 0.01–0.43), verbal oral health literacy did not (Beta = 0.13, 95% CI: − 0.06-037). Conclusions: Educational interventions are needed to improve oral health literacy, and thus oral health behaviors, as a part of the health promotion measures undertaken to facilitate the stable adjustment of North Korean defectors in South Korean society. Keywords: North Korean defector, Oral health behavior, Oral health literacy, Health education Background various policies to promote the stable settlement of From their first arrivals in the 1990s, the North Korean North Korean defectors in South Korea. Per the Medical defector population in South Korea grew to approxi- Care Assistance Act of the National Basic Living Secur- mately 10,000 in 2007, and to 31,827 defectors as of ity Act, North Korean defectors are provided healthcare August 2018 [1]. The South Korean government enacted benefits and are subject to reduced medical costs in local the North Korean Refugees Protection and Settlement public hospitals [2, 3]. Furthermore, the Korea Hana Support Act in 1997 and has continuously implemented Foundation provides treatment for chronic major condi- tions and general diseases, traditional Korean medical * Correspondence: [email protected] treatment, and dental treatment (e.g., complete den- 3Department of Dental Hygiene, Graduate School of Public Health Science, Eulji University, 553 Sanseong-daero, Sujeong-gu, Seongnam 13135, Republic tures) [3]. The Hana Clinic of Hanawon, a settlement of Korea support center for North Korean defectors, provides Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 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 in a credit line to the data. Cho et al. BMC Public Health (2020) 20:1074 Page 2 of 9 primary care (internal medicine, traditional Korean factors associated with oral health literacy in adults [17], medicine, dentistry, urology, obstetrics and gynecology, oral health literacy of mothers in multicultural families pediatrics, neurology), as well as secondary and tertiary [18], and the development of tools for assessing oral care via partnerships with hospitals and volunteers [4]. health literacy [13]. To date, no studies have examined Nevertheless, North Korean defectors still face difficul- the relationship between oral health literacy and oral ties in using health services due to a lack of relevant sup- health behaviors in North Korean defectors. It is import- port; therefore, meeting their medical needs should be ant to accurately understand and discuss oral health and considered a priority to promote their adjustment to life oral health literacy, since such a multi-perspective study in South Korea [5]. has the potential to address the health-related needs of The total number of cases of care provided by the North Korean defectors, who are increasing as vulner- Hana Clinic to North Korean defectors from 1999 to able groups. Elucidation of the relationship between 2016 was 333,626, with dental care comprising approxi- these two measures of oral health would help to address mately 20% of the cases (2nd most frequently provided the oral health-related needs of North Korean defectors. type of care) [4]. The number of people requiring treat- Thus, the objective of the present study was to investi- ment for periodontal disease (code 3), based on the gate the level of oral health literacy among North Community Periodontal Index of Treatment Needs, has Korean defectors and its association with oral health be- been reported to be higher among the North Korean haviors. Based on these findings, we aimed to provide defector population [6]. Among female North Korean foundational data for the development of customized defectors, approximately 81% are currently in need of education programs, tailored to the verbal comprehen- dental treatment, but only 28% were reported to have sion level of North Korean defectors, and implement undergone dental treatment [7]. Some factors that hin- relevant strategies in order to promote their adjustment der the use of healthcare services include difficulties to South Korean society. with “understanding doctor’s or nurses’ explanation,” “communicating opinions to the doctor during consult- Methods ation about a disease,”“care procedure,” and “taking Study design and participants drugs or getting treatment.” This calls for special atten- This study was a cross-sectional survey of self-reported tion to the health management of this vulnerable part of questionnaires completed by North Korean defectors. It the population [8]. Although South Koreans and North was conducted from December 2017 to April 2018 at a Koreans use a similar language, communication difficul- dental clinic that provided complimentary dental ser- ties caused by differences in cultural background consti- vices to North Korean defectors in a metropolitan area tute the greatest difficulty for North Koreans in their use of South Korea (Seongnam, Gyeonggi-do). Eligibility was of medical services. This indirectly suggests that there limited to adults who received at least one treatment at may be a barrier hindering the use of dental health ser- this dental clinic. Among a total of 132 questionnaires, 9 vices and the acquisition of oral health information. with incomplete responses were excluded, resulting in a Therefore, identifying these difficulties using instru- total of 123 questionnaires included in the final analysis. ments for measuring oral health literacy may provide In accordance with the Declaration of Helsinki, the Insti- data useful for the promotion of oral health in North tutional Review Board of Eulji University reviewed and Korean defectors. approved the study protocol, including the consent pro- Oral health literacy refers to the ability to search for, cedure (IRB-2018-5). understand, and use relevant information amid a sea of oral health-related information [9], and it is assessed Questionnaire items and structure using some of the most commonly used oral health liter- The association between oral health literacy and oral acy assessment scales, such as the two versions of the health behaviors among North Korean defectors was Rapid Estimate of Adult Literacy in Dentistry, REALD- measured using a modified and adapted version of 30 [10] and REALD-99 [11]; the Test of Functional the questionnaire used by Kim [13]andLee[19]. The Health Literacy in Dentistry (TOFHLiD) [12]; and the tools used have been confirmed for reliability and Oral Health Literacy Instrument (OHLI) [10], and its validity [20]. Korean version (OHLI-K) [13]. Most previous studies re- Oral health literacy was divided into verbal oral health garding the health of North Korean defectors were fo- literacy and functional oral health literacy, and the latter cused on the association between mental health and was further divided into reading comprehension and nu- physical health [14], while other
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