Journal of Modern Medical

Introduction
Oral health literacy refers to the ability of people to acquire, process and understand oral health information and services, which is necessary for making appropriate decisions related to oral and dental care. Researchers believe that the level of oral health literacy has a direct relationship with the oral health behaviors. People with low level of oral health literacy show less attention to positive behaviors related to maintaining oral health and usually do not have a good oral health status. Attitude is one of the factors related to oral and dental health. With the increase in age and level of education, the positive attitude towards oral and dental health increases, and a positive attitude can lead to the improvement of oral and dental health behaviors. Some studies have reported the direct and significant relationship between oral and dental health literacy and attitude towards oral and dental health and have suggested the necessity of improving oral health literacy to improve attitude, and some have indicated the relationship between attitudes and oral and dental behaviors. Considering the need to know the current state of oral health behaviors in the society, the present study aims to investigate the oral health literacy of the students of Ahvaz Jundishapur University of Medical Sciences (AJUMS) and measure its relationship with the attitude towards oral health and oral health behaviors.

Methods
This is a descriptive cross-sectional survey. The study population consists of all students of AJUMS in the academic year of 2021-2022 (n=6851). using Cochran’s formula, the sample size was determined to be 363. The samples were selected randomly. The data collection tool was a questionnaire with 45 items and four sections of demographic information (3 items), oral health literacy (23 items), attitude towards oral health (7 items) and oral health behaviors (9 items). Health literacy items were answered by correct (1 point) or incorrect (0 points). Attitude items were rated on a five-point Likert scale from 1= very low to 5= very high. Health behavior items were answered by yes or no. The prepared questionnaire was given to experts to determine face and content validity, and after confirmation, it was distributed among 50 students to determine reliability. The K21 formula was used to measure the reliability of oral health literacy. The value of r2 was 0.765, indicating the reliability of the oral health literacy subscale. Cronbach’s α was used to measure the reliability of the oral health attitude and oral health behavior subscales. The obtained value of 0.841 indicated the reliability of the subscales. To investigate the relationship between oral health literacy and attitude towards oral health, Spearman’s correlation test was used. Data analysis was done in SPSS software, version 26, using descriptive, statistics, correlation test, Kolmogorov-Smirnov test, and Mann Whitney U tests

Results
The overall score of oral health literacy showed that 81.1% of students had high oral health literacy. Regarding the attitude towards oral health, the overall mean score was 2.84. The mean scores of attitude components are presented in Table 1. All students were using a toothbrush to clean their teeth, 96.2% used a toothbrush and toothpaste, and 69.7% used oral hygiene tools such as mouthwash and dental floss. Moreover, 74.2% of students did not have bad breath. It was also reported that 62% of students went to the dentist only when they had a toothache and 72% of students took care of their teeth like other parts of their body. 



To investigate the relationship between oral health literacy and attitude towards oral health, Spearman’s correlation test was used. A correlation coefficient of -0.158 (P=0.001) indicated the existence of a significant inverse relationship between oral health literacy and attitude towards oral health. Therefore, the higher oral health literacy level in students can lead to more positive attitude towards oral health. Table 2 shows the results of comparing the difference in oral health literacy scores between students in terms of oral health behaviors. Mann-Whitney U test was used to compare the differences in attitude towards oral health based on health behaviors. The results showed a significant difference in attitude between students referred to a dentist only during toothache (statistics=1568, P=0.006).



Conclusion
Most of the AJUMS students have high oral health literacy. There is a negative and significant relationship between their oral health literacy and attitude towards oral health. The high dental costs (which is one of the big problems caused by the lack of health insurance coverage), is a factor related to the negative attitude of students towards oral and dental health. Most of the AJUMS students have oral and dental health behaviors, and there is a significant difference in health literacy between students with different oral health behaviors.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (Code: IR.AJUMS.REC.1398.477). 

Funding
This research was supported by the Ahvaz Jundishapur University of Medical Sciences (Grant No: U-98139).

Authors' contributions
Conceptualization: Zivar Sabaghinejad and Fatima Baji; Instrument making: Zivar Sabaghinajad; Instrument standardization: Sepehr Sepasi; Data collection: Arezu Karimzadeh Barde`i; Data analysis: Fatima Baji; Writing the article: Zivar Sabaghinejad, Arezu Karimzadeh Barde`i and Sepher Sepasi.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors are grateful to the Ahvaz Jundishapur University of Medical Sciences Vice-Chancellor’s Office for Research.





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