Health Literacy in Dentistry and Navajo Nation Community Health Representatives

By Steven P. Geiermann, Mae-Gilene Begay, Lindsey Robinson, and Sharon Clough
June 23, 2016 | Commentary

In this paper we discuss the importance of the efforts of community health representatives (CHRs) to improve general health on the Navajo reservation and describe the need for new efforts focused on preparing CHRs to act
as catalysts for helping improve the oral health in their communities.

Community health representatives extend health care beyond traditional clinic walls. They represent the “eyes, ears, hands, and feet” of the health care delivery system providing continuity of care to many individuals because health care practitioners are often limited, we believe, by their inability to assess and address the needs of their patients outside of the traditional clinic or hospital setting. CHRs offer health promotion and disease prevention information and services to many who may be challenged by poverty, transportation, compromising chronic diseases, or an inability to fully comprehend what actions their health care providers are recommending for them.

Health literacy is the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Ratzan and Parker, 2001). Often, coming from the communities in which they provide service, CHRs are the ongoing communications bridge between patients and their health care provider. CHRs assist individuals to understand their specific health conditions, what treatment options are being offered to maintain or improve their health, and what lifestyle changes are being called for; at the same time, they answer questions and concerns that could otherwise jeopardize patients’ compliance. In addition to educating patients and the communities in which they reside, CHRs can educate providers about community needs and the culture within that community, thus improving the quality of care and reducing costs (IOM, 2002).

American Indian/Alaska Native (AI/AN) communities experience an incidence of cardiovascular disease, obesity, hypertension, hyperlipidemia, and diabetes far beyond that of the overall U.S. population (Begay et al., 2016). The same is true for oral diseases. In recent Indian Health Service surveys, “AI/AN adult dental patients suffer disproportionately from untreated dental caries, with twice the prevalence of untreated caries as the general U.S. population and more than any other racial/ethnic group” (Phipps and Ricks, 2016). These same adult patients “are more likely to have severe periodontal disease than the general U.S. population” (Phipps and Ricks, 2016). When compared to other population groups in the United States, AI/AN preschool children have the highest level of tooth decay; it is more than four times higher than white nonHispanic children (Phipps and Ricks, 2015).

In March 2014, representatives of the American Dental Association were asked to present a long-term comprehensive oral health plan that could be incorporated into the Navajo Nation’s 10-Year Health and Wellness Plan. This oral health plan emphasized community-based prevention across the lifespan, while enhancing infrastructure, capacity, community, and partnerships, building on what was already in place and making connections among all oral health stakeholders. We believe that CHRs are well positioned to be catalysts for improving the oral health of the Navajo people. They are trusted members of the community and have access to those most in need of assistance.

CHRs are the first line of “offense” in addressing and getting ahead of existing health problems, while offering tribal members a better way to maintain and safeguard their overall health. The Navajo CHRs have realized that oral health is not elective; it is an integral part of an interdisciplinary approach to improving overall health. We believe that adding an oral health component into their individual and community education, case management, and patient navigation would make a difference in the lives of the people they strive to serve, from pregnant women and their children to revered elders.

At this time, the Navajo CHRs’ own oral health awareness and understanding are not sufficient to provide a health-literate explanation of the importance of good oral health actions to their people. A basic knowledge of oral health must, we believe, be incorporated into the knowledge base of all CHRs. Mae-Gilene Begay, the director of the Navajo Nation Community Health Representative Program, has envisioned a plan that could provide the necessary knowledge through a variety of educational opportunities and collaborations, including the following:

  • Utilizing the Smiles for Life: A National Oral Health Curriculum (Clark et al., 2010) to increase the CHRs’ general awareness and appreciation of the importance of oral health to overall health; [space height=”10″]
  • Partnering with medical and hospital leadership to support the importance of oral health to overall health; [space height=”10″]
  • Training specific CHRs as community dental health coordinators (Grover 2016); these new members of the dental team function as community health workers with dental knowledge, with a small number of them acting as role models and an oral health resource for CHRs working within specific communities; and [space height=”10″]
  • Educating tribal leadership to support oral health as an essential element of health care for their people. [space height=”10″]


In our opinion, this multifactorial approach of educating CHRs about oral health and improving the oral health literacy of those who would be interacting with and within the community is still a work in progress. It does follow, however, the recommendation of Richard Carmona, former U.S. surgeon general, who said, “One approach to health literacy is to train community health workers [representatives]. . . . We need these knowledgeable people to serve as connectors between community members and health care professionals. As members of the community, they are able to promote health among groups that have traditionally lacked understanding about
health and the health care system” (Carmona, 2003).


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  1. Begay, M. G., R. Hutchinson, M. Merinao, S. Selig, S. Sehn, J. Malolne, C. Hamann, and S. Shin. 2013. Community outreach and patient empowerment: A collaborative initiative for chronic disease management in Navajo Nation. Community Investments 25(2):22–25. [space height=”10″]
  2. Carmona, R. H. 2003. Health literacy in America: The role of health care professionals. Presentation to the American Medical Association House of Delegates, Chicago, IL. [space height=”10″]
  3. Clark, M. B., A. B. Douglass, R. Maier, M. Deutchman, J. M. Douglass, W. Gonsalves, H. Silk, J. W. Tysinger, A. S. Wrightson, R. Quinonez, M. Dolce, and J. Bowser 2010. Smiles for life: A national oral health curriculum. 3rd ed. Society of Teachers of Family Medicine. [space height=”10″]
  4. Grover, Jane S. 2016. Community dental health coordinators. American Dental Association. June. [space height=”10″]
  5. Institute of Medicine (IOM). 2002. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press. [space height=”10″]
  6. Phipps, K. R., and T. L. Ricks. 2015. The oral health of American Indian and Alaska Native children aged 1–5 years: Results of the 2014 HIS oral health survey. Indian Health Service Data Brief. Rockville, MD: Indian Health Service. [space height=”10″]
  7. Phipps, K. R., and T. L. Ricks. 2016. The oral health of American Indian and Alaska Native adult dental patients: Results of the 2015 HIS oral health survey. Indian Health Service Data Brief. Rockville, MD: Indian Health Service. [space height=”10″]
  8. Ratzan, S. C., and R. M. Parker. 2000. Introduction. In National Library of Medicine current bibliographies in medicine: Health literacy, edited by C. R. Selden, M. Zorn, S. C. Ratzan, and R. M. Parker. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services. [space height=”10″]



Suggested Citation

Geiermann, S. P., M. Begay, L. Robinson, and S. Clough. 2016. Health Literacy in Dentistry and Navajo Nation Community Health Representatives. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. doi: 10.31478/201606e

Author Information

Steven P. Geiermann, DDS, is senior manager of access, community oral health infrastructure, and capacity for the American Dental Association. Mae-Gilene Begay, MSW, is program director of the Navajo Nation CHR/outreach program for the Navajo National Department of Health. Lindsey Robinson, DDS, is the Thirteenth District trustee of the American Dental Association and a member of the Roundtable on Health Literacy. Sharon Clough, RDH, MS Ed, is manager of preventive health activities at the American Dental Association.

The authors are participants in the activities of the Roundtable on Health Literacy, Action Collaborative on Health Literacy: A Potential Pathway to Connecting Dental Health to General Health of the National Academies of Sciences, Engineering, and Medicine.


The views expressed in this Perspective are those of the authors and not necessarily of the authors’ organizations or of the National Academy of Medicine (NAM). The Perspective is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of, nor is it a report of, the NAM or the National Academies of Sciences, Engineering, and Medicine. Copyright by the National Academy of Sciences. All rights reserved.

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