1 Volume 23 2024 e241338 Original Research Braz J Oral Sci. 2024;23:e241338http://dx.doi.org/10.20396/bjos.v23i00.8671338 1 Department of Community and Preventive Dentistry, Faculty of Dentistry, Universitas Brawijaya, Indonesia. 2 Department Oral Biology, Faculty of Dentistry, Universitas Brawijaya, Indonesia. Corresponding author: Yuanita Lely Rachmawati, Department of Community and Preventive Dentistry, Faculty of Dentistry, Universitas Brawijaya, Jl. Veteran Lowokwaru, Malang City, Indonesia. E-mail: yuanita.rachmawati.fk@ ub.ac.id. Editor: Dr. Altair A. Del Bel Cury Received: October 29, 2022 Accepted: May 27, 2024 Sociodemographics, oral health literacy, and caries experience related to daily performance among adolescents Yuanita Lely Rachmawati1* , Dyah Nawang Palupi Pratamawari1 , Merlya Balbeid1 , Viranda Sutanti2 Low health literacy in adolescents can negatively impact their health status and quality of life. Objective: This study aims to verify the impact of sociodemographics, caries experience and oral health literacy (OHL) on the quality of life among adolescents aged 11–12. Methods: A cross-sectional study with a cluster sampling design was conducted on public elementary schools in a district of Batu City in January 2020. Self-administered questionnaires regarding sociodemographics, OHL, and child-oral impact on daily performance (C-OIDP) were administered to respondents. Caries examinations were performed by three independent examiners using the decayed, missing, and filled teeth (DMF-T) index after informed consent was received. The data was analyzed with a comparative test and logistic regression with a significance level of < 0.05. Results: 346 students followed the study, with a response rate of 92.22%. The majority of parents were not college-educated. 71.1% of respondents were 12 years old, 85.3% had caries, and 55.3% had a high total OHL score. There was a significant difference between low- and high-quality daily performance in the OHL score and caries experience categories (p=0.006 and p=0.008, respectively). Multivariate analysis showed that the fathers’ education, caries experience, and OHL were associated with the quality of daily performance. Conclusions: Health literacy, caries experience, and parental education contribute to the quality of adolescents’ daily performance. Adolescents with few caries and high OHL have a better quality of daily performance. Keywords: Health literacy. Oral health. Adolescent. Quality of life. https://orcid.org/0000-0003-3966-0551 https://orcid.org/0000-0003-4180-6396 https://orcid.org/0000-0002-2706-670X https://orcid.org/0000-0002-9408-4932 2 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 Introduction Adolescence is a psychological transition period in which individuals reject received norms and create their own styles and terms1. This period is associated with health vulnerabilities due to unjustified behaviour, low of prevention activities and a desire to defy parents2. Studies show that adolescents with low oral health literacy (OHL) are more disposed to behaviors and practices that pose an adverse risk to their health, along with improper medical treatment and poor oral hygiene2, which can negatively affect oral health. Thus, high OHL may contribute to oral health dispari- ties in the adolescent population3,4. Ratzan and Parker5 (2000) define health literacy as the degree to which individ- uals can obtain, process, and understand basic health information and services needed to make appropriate health decisions. Higher health literacy and skills lead to better health knowledge and behaviors and clinical outcomes6. Understanding adolescent health literacy is very important because, during adolescence, health behavior that will be present throughout an individual’s life is formed. Good lit- eracy skills can help adolescents to find the necessary health information. Ado- lescents will become independent users of the health system in the future, and adolescents with good health literacy can help to reduce poor health levels caused by low health literacy in adults7,8. Quality of life is described as an individual’s perception of their position in life in the context of the culture and value systems in which they live, along with their goals, expectations, standards, and concerns9. Rates and determinants of quality of life in adults have been well reported in developed countries. However, studies on the quality of life in developing countries are lacking, especially for children and adolescents10. Middle-school age is a necessary transitional period from childhood to maturity that is very important for individuals’ physical, psychological, and social adaptation. Throughout these years, adolescents’ physical and mental health and quality of life can affect their lives; accordingly, studying quality of life during mid- dle-school age is crucial10. Evidence that links poor health literacy with poor quality of life among patients in medical/clinical settings is growing11,12. However, whether health literacy significantly affects the quality of life in student and adolescent populations is rarely reported10. In Indonesia, several studies have been conducted on the quality of life health-related to oral health and oral health literacy in adolescents. However, there is a lack of stud- ies that identify the relationship between the two. The Indonesian OHL and child-oral impact on daily performance (C-OIDP) question- naire showed valid and reliable properties to be used among 12-15 years old school children in Jakarta, Indonesia13,14. Previous studies in Jakarta showed that the preva- lence of caries in adolescents aged 12–13 was 73.9%15. A review of health literacy in adolescents stated that more research is needed to determine effective evaluations for health literacy in adolescents6. This study aimed to determine the impact of caries 3 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 experience, OHL, and sociodemographics on quality of daily performance in adoles- cents aged 11–12 years in Batu City, East Java Province, Indonesia. Material and Methods The study was conducted in January 2020 with a cross-sectional study design. A clus- ter sampling design was used to select an elementary school in Batu City, one of the districts in the province of East Java, Indonesia. Batu City has four sub-districts. Four public elementary schools were randomly selected in each district, and one grade-six class was randomly selected as a sample in each school because there were three to four classes in each school. All the students in the class were recruited as respondents. The estimated sam- ple size was calculated using G*Power 3.1.9.4 with a statistical t-test. Based on a significance level of 5%, a statistical power of 95%, and an estimated effect size of 0.41 ( assuming the average difference is considered significant between low and high quality-of-life scores), 326 participants were required. Allowing for a 10% attrition rate, 358 participants had to be recruited. A cross-sectional survey was con- ducted by recruiting 375 students from selected sixth-grade classes. The study was approved by the Ethics Committee of the State Polytechnic of Health, Malang-In- donesia, No.:538/KEPK-POLKESMA/2019. Written informed consent was obtained from the caregivers/parents before continuing the study protocol. Measures Two self-administrated questionnaires were used in this study: a questionnaire that was adapted to Indonesian OHL and C-OIDP13,14 and socio-demography ques- tions such as age, gender, and parental education. The age categories were 11 and 12 years old, the parents’ educational categories were college and non-college, and caries experience categories were caries and caries-free. An oral examination was performed to collect caries data using the decayed, missing, and filled teeth (DMF-T) index. Caries were evaluated according to oral health surveys from the World Health Organization (WHO)16. Three examiners who were not relevant to the data analysis conducted the caries examinations using the DMF-T index. The examiner performed a kappa agreement to ensure reliability with a minimum score of 0.8. The data obtained from the questionnaire were inputted by two coders trained by a dentist with experi- ence in community research for two days. Oral Health Literacy The number of questions used follows the short-form version of the health literacy dental scale, with seven question items that are valid and reliable in the Indonesian version, based on a previous study13,17. The OHL questionnaire’s questions focused on the difficulties/limitations of obtaining health information, divided into five domains: communication, receptivity, understanding, utilization, and support. The respondents’ options used a five-point Likert-type scale ranging from “without difficulty” to “unable to do”. The scores were coded from one to five, and the possible final scores ranged from seven to thirty-five. Higher scores indicated preferable OHL. Oral health literacy 4 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 was categorized as high and low, with the median as a cut-off point. A total score of less than 34 was categorized as low OHL, and a total score equal to or more than 34 was classified as high OHL. Quality of Daily Performance To measure the respondent’s quality of life, or what we named quality of daily per- formance, the research used C-OIDP, which was valid and reliable in the Indone- sian version of the previous study14. Child-oral impact on daily performance is a socio-dental health indicator that measures social effects, based on oral conditions that use a theoretical model of oral health conditions. The questionnaire consists of eight questions to assess daily performances (eating, cleaning, speaking, pain, emotion, smiling, school activities, and social)18. The questions were adminis- tered, and the participants were asked to rate the severity of their oral impact on a four-point Likert scale (“none at all” = 1, “very little” = 2, “pretty much” = 3, and “quite a lot” = 4). A sum was made of the values obtained for the 8 performances, which resulted in a number between 8 and 32. The median was used as the cut-off point to determine the low and high quality of life categories. Respondents with a total score of less than 31 were categorized as having low-quality daily performance. If the total score was equal to or more than 31, they were classified as having a high quality of daily performance. Data Analysis Variables of gender, age, parental education, caries experience, and OHL were analyzed descriptively. All variables were also tested for the mean difference against low and high C-OIDP using the chi-square. Multivariate logistic regression analysis was used to determine whether sex, age, parental education, caries expe- rience, and OHL contributed to C-OIDP. All analyses used a two-sided significance level of 5%. Result Three hundred seventy-five students participated, and 346 completed the question- naire using Google Forms, so the response rate was 92.22%. Cronbach’s alpha of items questionnaire health literacy dental scale and C-OIDP yielded 0.761 and 0.768. The three examiners’ agreement was 0.94 for DMF-T by the Kappa test. Table 1 shows the participants’ attributes. The percentage of female participants was 51.2%, and the percentage of male participants was 48.8%. Most of the parents (both fathers and mothers) were not college-educated; 71.1% of the respondents were 12 years old, 85.3% had caries experience, and 55.3% had a high total score of OHL. There were no significant differences regarding gender, age, and the mother’s edu- cation on quality of life (p<0.05), but there were significant differences regarding the father’s education, caries experience, and OHL. 5 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 Table 1. The difference in sociodemographic, caries experience, and OHL based on the quality of daily performance among adolescents in Batu City, 2020 Variable n (%) Quality of daily performance p-value (low) < 31 (high) >=31 Sex Man 177 (51.2) 95 (53.7) 82 (46.3) 0.051 Woman 169 (48.8) 73 (43.2) 96(56.8) Age (years) 11 97 (28.3) 43 (44.3) 54 (55.7) 0.344 12 246 (71.7) 123 (50) 123 (50) Father education Non-Collage 224 (83.0) 95 (42.4) 129 (57.6) 0.002* Collage 122 (17.0) 73 (59.8) 49 (40.2) Mother education Non-Collage 224 (82.7) 101 (45.1) 123 (54.9) 0.081 Collage 122 (17.3) 67 (54.9) 55 (45.1) Caries experience Free 51 (14.7) 16 (31.4) 35 (68.6) 0.008* With caries 295 (85.3) 152 (51.5) 143 (48.5) Oral health literacy Low 155 (44.7) 88 (56.8) 67 (43.2) 0.006* High 191 (55.3) 80 (41.8) 111 (58.1) *Chi-Square, significant level p<0.05 Table 2 displays the mean total score of OHL of respondents with low and high qual- ity of life, respectively 31.72 and 32.90. Respondents with low and high-quality daily performance scores showed a significant difference (p<0.05) in OHL. Higher OHL was associated with high quality of life. There was a significant difference between respondents with low and high quality of daily performance in the domains of OHL: receptivity, understanding, and one question on utilization. There was no statistical difference in the domains of communication, support, and one question on utilization. Table 2. The mean difference in OHL based on the quality of daily performance among adolescents in Batu City, 2020 Variable Quality of daily performance p-value(low) < 31 (high>=31 Mean (SD) Mean (SD) Total score oral health literacy (7-35) 31.72 (3.79) 32.90 (3.03) 0.001* Communication Question 1 (1-5) 4.52 (0.85) 4.63 (0.83) 0.113 Continue 6 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 Continuation Receptivity Question 2 (1-5) 4.44 (0.82) 4.75 (0.52) <0.001* Question 3 (1-5) 4.45 (0.91) 4.67 (0.62) 0.031* Understanding Question 4 (1-5) 4.47 (0.91) 4.64 (0.83) 0.013* Utilization Question 5 (1-5) 4.63 (0.68) 4.75 (0.55) 0.081 Question 6 (1-5) 4.63 (0.65) 4.76 (0.53) 0.025* Support Question 7 (1-5) 4.55 (0.93) 4.67 (0.81) 0.248 *Mann-Whitney, significant level p<0.05 Table 3 follows multivariate logistic analysis performed on the quality of daily perfor- mance with independent variables: gender, age, the father’s education, the mother’s education, caries experience, and OHL. The results showed that the father’s educa- tion, caries experience, and OHL were associated with a quality of daily performance (p<0.05). Adolescents that have fathers with high education levels have a 2.83 times higher quality of daily performance. Those with caries tend to have a 2.25 times lower quality of daily performance. Adolescents with high OHL have a possibility of a 52% higher quality of daily performance. Table 3. Multivariate logistic regression model of quality of daily performance among adolescents in Batu City, 2020 p-value OR 95% CI for Exp(B) Lower Upper Sex Man (ref) Woman 0.128 0.705 0.449 1.106 Age (years) 11 (ref) 12 0.786 0.932 0.560 1.551 Father education Non Collage (ref) Collage 0.007* 2.834 1.329 6.043 Mother education Non Collage (ref) Collage 0.398 0.723 0.340 1.535 Caries experience Free (ref) With caries 0.016* 2.255 1.166 4.361 Oral health literacy Low (ref) High 0.004* 0.520 0.332 0.816 *Significant p<0.05 7 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 Discussion This study showed that adolescents with high OHL scores were higher than those with low OHL. However, cross-tabulation described an association between high OHL scores and high-quality daily performance scores. Adolescents with high OHL have a possibility of a 52% higher quality of daily performance. The conse- quence of health literacy on health outcomes in a previous study found that stu- dents with lower health literacy had a higher risk of obtaining lower quality-of-life scores. In addition, students with low health literacy scores tended to have lower quality-of-life scores than students with more adequate health literacy scores10,19. Studies show several reasons adolescents with good health literacy levels have a higher quality of life than those with poor health literacy levels. Adolescents with significant levels of health literacy may be more aware of how to seek health-re- lated information from health professionals, caregivers, teachers, and friends. With solid comprehension of health information, they make the right decisions regarding their health to improve their quality of life. In contrast, those with lower health liter- acy are limited in obtaining information, communicating with health care providers, understanding and complying with the advice given by health services, and making the right health-related decisions. As such, they require adequate information to make decisions10,20. The prevalence of caries among adolescents was relatively high, with the same result as the previous study15. Although not statistically significant, those with lower or mar- ginalized OHL tended to have more caries, and those with caries tend to have a low quality of daily performance. Adolescents with low levels of health literacy are more likely to engage in risky behavior, as well as smoking, excessive alcohol consumption, modest physical activity, and unwholesome food intake, all of which have a significant association with low quality of life21. Adolescents with low health literacy levels and poor quality of life will have more material and mental problems22. Low OHL levels can hamper prevention- and treatment-seeking efforts23. Previous research found that individuals with lower OHL levels reported more significant experience and need for treatment24. Students may explain this need to recognize dental and oral health terms so that they only partially understand the information they read4. Although more than half of the respondents had a high literacy score, the caries prev- alence rate was also high. The average DMF-T index score was three, for children aged 12 years according to the WHO is in the moderate category16. A high health literacy score that is not in line with the oral condition of adolescents may explain why the child’s decision to get treatment is very dependent on the parents’ decision. The decision of parents to take care of their children’s dental health is influenced by their level of education, the economic condition of the family, and the parents’ OHL7. In this study, most parents were not college-educated, and descriptively, respondents with high C-OIDP scores received more support from their families to visit the dentist. This result could be explained by the fact that parental education affects their OHL, which also has implications for their children’s oral health decisions. The current study showed that the father’s education determined the respondents’ quality of daily performance. Higher further education levels double the possibility of 8 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 having a higher quality of daily performance. The health literacy of parents/caregivers influences the health status of their children, according to one study. Child health literacy and parent/caregiver health literacy have a significant relationship25,26. Chil- dren can decide to engage in good health behavior based on information from their parents. Our findings showed that the father’s education contributed to the respondent’s oral health and quality of life, unlike other results, which show that the mother’s education plays a role in the adolescent’s quality of life27,28. The explana- tion is probably specific to Indonesia; as in other developing countries, the father is the head of the family and makes decisions concerning issues such as health treatment. Studies in Colombia have shown that the father’s role in the family exhibits several changes, such as being more effective and engaging in childcare. These roles traditionally belong to mothers29. Increasing the father’s role can be one solution to implementing a child’s oral health programs, such as inviting the father to participate in oral health education activities at school, providing dental health examination reports, and assigning tasks to supervise the children’s dental home care. These findings can be considered in policymaking and the planning of health pro- grams, especially for adolescents, as they are a vulnerable generation with various risk factors, such as destructive behavior, and often reject recommended habits2,7,30. Policies to improve adolescent oral health is critical in Indonesia, considering that the prevalence of caries in this study was relatively high. An increase in OHL in ado- lescents can simultaneously improve two things: quality of life and oral health out- comes. Including OHL in the school curriculum, providing dental health education, regular screening, and dental hygiene practices can improve OHL. Due to adolescents’ inability to fully make decisions and their dependence on their parents, along with increasing OHL in adolescents, improved OHL in parents should also be pursued. The cross-sectional method, which cannot measure the causal relationship between variables due to the simultaneous measurement of exposure and outcome, was a limitation of this study. Dental visit data was not collected as an outcome, which could provide insight into individuals’ health literacy. Additionally, parents’ literacy and socioeconomic data were not recorded as determinants affecting adolescents’ oral health outcomes. The sample in this study was only taken from one region, so it does not describe the condition of adolescents in Indonesia more broadly. Future studies must explore more variables that could play a role and expand the sample population’s area. The evidence shows that health literacy significantly affects the quality of life. However, the effects on adolescents’ quality of life are rarely reported. This current study shows that the prevalence of caries in adolescents is still high. OHL in adolescents may affect their quality of life and oral health conditions. Ado- lescents with high quality-of-life scores also had high OHL scores. Adolescents with marginalized OHL tended to have more caries. The results of this study show that fathers’ education, caries experience, and OHL are determinants of adolescents’ quality of life. Considering that the prevalence of caries was relatively high, policy to improve OHL in adolescents is essential. Including dental health education in the school curriculum, optimizing school health programs, and including parents in school health programs could be effective solutions. 9 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 In conclusion, health literacy, caries experience, and parental education contribute to the quality of life. Adolescents with low caries experience and high OHL had a better quality of daily performance. Adolescents are not yet fully independent; parents still have a significant influence on the decisions they make in their lives, so pediatric den- tists must involve parents when providing information to them. Acknowledgments The authors thank the Head of Health Office Batu City and staff for supporting the survey. Funding This study had financial support from Universitas Brawijaya. Conflict of interest The authors have no conflict of interest to declare. Data availability Data sets related to this article will be available upon request. Author Contribution Yuanita Lely Rachmawati: conceptualization, methodology, formal analysis, writing-original draft prepared. Dyah Nawang Palupi Pratamawari: project administration, supervision, writing-review and editing. Merlya Balbeid: validation, resources, writing-review and edit- ing. Viranda Sutanti: visualization, data curation, software, writing-review and editing. All authors actively participated in two distinct criteria related to authorship. Reference 1. Antunes JL, Peres MA, Frias AC, Crosato EM, Biazevic MG. [Gingival health of adolescents and the utilization of dental services, state of São Paulo, Brazil]. Rev Saude Publica. 2008 Apr;42(2):191-9. Portuguese. doi: 10.1590/s0034-89102008000200002. 2. Macek MD, Haynes D, Wells W, Bauer-Leffler S, Cotten PA, Parker RM. Measuring conceptual health knowledge in the context of oral health literacy: preliminary results. J Public Health Dent. 2010 Summer;70(3):197-204. doi: 10.1111/j.1752-7325.2010.00165.x.  3. 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 May;102(5):923-9. doi: 10.2105/AJPH.2011.300291. Epub 2011 Nov 28.  4. Dutra LDC, de Lima LCM, Neves ÉTB, Gomes MC, de Araújo LJS, Forte FDS, et al. Adolescents with worse levels of oral health literacy have more cavitated carious lesions. PLoS One. 2019 Nov;14(11):e0225176. doi: 10.1371/journal.pone.0225176. 5. Ratzan S, Parker R. Introduction. In: Selden CR, Zorn M, Ratzan Sc, Parker RM, editors. National library of medicine current bibliographies in medicine: health literacy. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000. 10 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 6. Perry EL. Health literacy in adolescents: an integrative review. J Spec Pediatr Nurs. 2014 Jul;19(3):210-8. doi: 10.1111/jspn.12072.  7. DeWalt DA, Hink A. Health literacy and child health outcomes: a systematic review of the literature. Pediatrics. 2009 Nov;124 Suppl 3:S265-74. doi: 10.1542/peds.2009-1162B.  8. Ghaddar SF, Valerio MA, Garcia CM, Hansen L. Adolescent health literacy: the importance of credible sources for online health information. J Sch Health. 2012 Jan;82(1):28-36. doi: 10.1111/j.1746-1561.2011.00664.x.  9. The WHOQOL Group. The World Health Organization quality of life assessment (WHOQOL): Position paper from the World Health Organization. Soc Sci Med. 1995;41(10):1403-9. doi: 10.1016/0277-9536(95)00112-K. 10. Ran M, Peng L, Liu Q, Pender M, He F, Wang H. The association between quality of life(QOL) and health literacy among junior middle school students: a cross-sectional study. BMC Public Health. 2018 Oct;18(1):1183. doi: 10.1186/s12889-018-6082-5.  11. González-Chica DA, Mnisi Z, Avery J, Duszynski K, Doust J, Tideman P, et al. Effect of Health Literacy on Quality of Life amongst Patients with Ischaemic Heart Disease in Australian General Practice. PLoS One. 2016 Mar;11(3):e0151079. doi: 10.1371/journal.pone.0151079.  12. Wang C, Kane RL, Xu D, Meng Q. Health literacy as a moderator of health-related quality of life responses to chronic disease among Chinese rural women. BMC Womens Health. 2015 Apr;15:34. doi: 10.1186/s12905-015-0190-5. 13. Rahardjo A, Adinda S, Nasia AA, Adiatman M, Setiawati F, Septorini Y, et al. Oral health literacy in Indonesian adolescent. J Int Dent Med Res. 2015;8(3):123-7. 14. Arumrahayu W, Maharani DA, Adiatman M. An indonesian version of Child Oral Impact on Daily Performances (C-OIDP): Assessing validity and reliability. J Int Dent Med Res. 2018;11(3):1049-52. 15. Rachmawati YL, Maharani DA, Oho T. Cross-cultural adaptation and psychometric properties of the Indonesia version of the self-efficacy oral health questionnaire for adolescents. Int J Paediatr Dent. 2019 May;29(3):345-51. doi: 10.1111/ipd.12472.  16. World Health Organisation. Oral health surveys: basic methods. 5th ed. World Health Organization; 2013. 17. Jones K, Parker E, Mills H, Brennan D, Jamieson LM. Development and psychometric validation of a Health Literacy in Dentistry scale (HeLD). Community Dent Health. 2014 Mar;31(1):37-43.  18. Suchithra MS, Sreedharan S, Sanuba KS. Assessment of Psychometric Properties of Malayalam Version of COIDP Questionnaire. IOSR J Dent Med Sci. 2018;17(1):26-30. doi: 10.9790/0853-1701122630. 19. Lee SY, Tsai TI, Tsai YW, Kuo KN. Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey. BMC Public Health. 2010 Oct;10:614. doi: 10.1186/1471-2458-10-614.  20. Kim SH. Health literacy and functional health status in Korean older adults. J Clin Nurs. 2009 Aug;18(16):2337-43. doi: 10.1111/j.1365-2702.2008.02739.x.  21. Chisolm DJ, Manganello JA, Kelleher KJ, Marshal MP. Health literacy, alcohol expectancies, and alcohol use behaviors in teens. Patient Educ Couns. 2014 Nov;97(2):291-6. doi: 10.1016/j.pec.2014.07.019.  22. Ownby RL, Acevedo A, Jacobs RJ, Caballero J, Waldrop-Valverde D. Quality of life, health status, and health service utilization related to a new measure of health literacy: FLIGHT/VIDAS. Patient Educ Couns. 2014 Sep;96(3):404-10. doi: 10.1016/j.pec.2014.05.005.  23. Baskaradoss JK. The association between oral health literacy and missed dental appointments. J Am Dent Assoc. 2016 Nov;147(11):867-74. doi: 10.1016/j.adaj.2016.05.011. 11 Rachmawati et al. Braz J Oral Sci. 2024;23:e241338 24. Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on children’s oral health outcomes. Pediatrics. 2010 Jul;126(1):107-14. doi: 10.1542/peds.2009-2887. 25. Morrison AK, Schapira MM, Gorelick MH, Hoffmann RG, Brousseau DC. Low caregiver health literacy is associated with higher pediatric emergency department use and nonurgent visits. Acad Pediatr. 2014 May-Jun;14(3):309-14. doi: 10.1016/j.acap.2014.01.004.  26. Bridges SM, Parthasarathy DS, Wong HM, Yiu CK, Au TK, McGrath CP. The relationship between caregiver functional oral health literacy and child oral health status. Patient Educ Couns. 2014 Mar;94(3):411-6. doi: 10.1016/j.pec.2013.10.018. Epub 2013 Nov 5. 27. Najjar S, Nasim M, Al-Nasser L, Masuadi E. The impact of socio-economic and home environmental factors on oral health-related quality of life among children aged 11-14. Medicina (Kaunas). 2019 Oct;55(11):722. doi: 10.3390/medicina55110722.  28. Sun L, Wong HM, McGrath CPJ. The factors that influence oral health-related quality of life in 15-year-old children. Health Qual Life Outcomes. 2018 Jan;16(1):19. doi: 10.1186/s12955-018-0847-5. 29. Carrillo S, Bermúdez M, Suárez L, Gutiérrez MC, Delgado X. Father’s perceptions of their role and involvement in the family: a qualitative study in a colombian sample. Rev Costarric Psicol. 2016;35(2):161-78. doi: 10.22544/rcps.v35i02.03. 30. Schiavo JH. Oral health literacy in the dental office: the unrecognized patient risk factor. J Dent Hyg. 2011 Fall;85(4):248-55.