RESUMEN

Chagas [shah-guhs] disease, caused by the Trypanosoma cruzi parasite, presents a growing concern for health care providers overseeing perinatal care in the United States due to existing and expanding vector-borne transmission and population migration. This life-threatening disease can be transmitted vertically during pregnancy, although adequate testing and treatment can effectively reduce morbidity and mortality caused by Chagas disease. This article presents an overview of the disease burden in the United States and its implications for perinatal care providers including recommended testing and treatment practices and the information needed for patient education and shared decision-making regarding the management of care for individuals at risk of Chagas disease. Being informed about Chagas disease and its implications is needed for all individuals providing perinatal care and is especially critical for those overseeing the care of refugee and immigrant populations.

RESUMEN

Background/aim: In this study, we aimed to evaluate the self-reported practice of physicians working in primary health care institutions in Elazig Province about smoking cessation counseling. Materials and methods: The population of this cross-sectional study consisted of 262 physicians working in primary health care institutions in Elazig. We aimed to reach the entire population without using the sample selection method and we successfully reached 95.42% (250 people) of the population. A questionnaire form was used for data collection. The data obtained were evaluated by frequency, percentage, mean ± standard deviation, median and minimum-maximum, and binary logistic regression analysis. Results: The mean age of the physicians was 40.86 ± 10.58 years and 68.0% of them were male. Among them, 30.4% (n = 76) were current smokers, 17.6% (n = 44) were former smokers and 52.0% (n = 130) were never smokers. The physicians' frequency of applying the steps of smoking cessation counseling was as follows: 38.8% "Ask", 81.6% "Advice", 68.4% "Assess", 66.8% "Assist", 31.2% "Arrange". Additionally, 16.0% of the physicians received smoking cessation counseling training. Those who had not smoked at least 100 cigarettes in their life applied the "Advice" (p = 0.026) step more frequently. Those who received smoking cessation counseling training applied the following steps more frequently: "Ask" (p = 0.024), "Assist" (p = 0.025), and "Arrange" (p = 0.001). Conclusion: It is seen that the smoking frequency of primary care physicians in Elazig Province is the same as that of the general population, and the frequency of smoking cessation counseling is far behind the target. Physician population is an important target group that should not be ignored in the fight against smoking. In order to increase the frequency of physicians' smoking cessation counseling practice, there is a need to increase the number of physicians who receive smoking cessation counseling training.

Asunto(s)

RESUMEN

OBJECTIVE: The purpose of this study was to implement a 2-phase approach to rapidly increase the number of annual wellness visits (AWVs) and build a sustainable model at 3 study units (Mayo Clinic in Rochester, Minnesota, and clinics in 2 regions of Mayo Clinic Health System), which collectively serve approximately 80 000 patients who qualify for an AWV annually. METHODS: In the rapid improvement phase, beginning in July 2022, goals at the facilities were reoriented to prioritize AWVs, educate staff on existing AWV resources, and create low-effort workflows so that AWVs could be incorporated into existing patient appointments. Staff at all 3 study units worked independently and iterated quickly. In the second phase, all study units collaborated to design and implement a best-practice solution while they leveraged the engagement and lessons learned from the first phase and invested in additional system elements and change management to codify long-term success. RESULTS: The number of AWVs completed monthly increased in each study unit. In the rapid improvement phase, the number of AWVs increased but then plateaued (or decreased at some study units). In April 2023, the final scheduled outreach automation and visit tools were implemented, and the number of AWVs was sustained or increased, while outreach and scheduling times were decreased. The number of completed AWVs increased from 1148 across all study units in the first 6 months of 2022 to 14 061 during the first 6 months of 2023. CONCLUSIONS: The lessons learned from this project can be applied to other health systems that want to provide more patients with AWVs while improving operational efficiency. The keys are to have a clear vision of a successful outcome, engage all stakeholders, and iterate quickly to find what works best for the organization.

Asunto(s)

RESUMEN

INTRODUCTION: People with intellectual disability are less likely to participate in breast screening than people without intellectual disability. They experience a range of barriers to accessing breast screening, however, there is no consensus on strategies to overcome these barriers. Our objective was to reach consensus on the strategies required for accessible breast screening for people with intellectual disability. METHODS: Fourteen experts participated in a modified on-line Delphi that used Levesque's model of health care access as the theoretical framework. At the end of each round descriptive and thematic analyses were completed. Data was then triangulated to determine if consensus was reached. RESULTS: After 3 rounds, 9 strategies were modified, 24 strategies were added and consensus was reached for 52 strategies across the 5 dimensions of access. Key areas of action related to (i) decision making and consent, (ii) accessible information, (iii) engagement of peer mentors, (iv) service navigators, and (v) equipping key stakeholders. CONCLUSIONS: The resulting strategies are the first to articulate how to make breast screening accessible and can be used to inform health policy and quality improvement practices.

Asunto(s)

RESUMEN

BACKGROUND: Stark disparities exist in maternal and child outcomes and there is a need to provide timely and accurate health information. OBJECTIVE: In this pilot study, we assessed the feasibility and acceptability of a health chatbot for new mothers of color. METHODS: Rosie, a question-and-answer chatbot, was developed as a mobile app and is available to answer questions about pregnancy, parenting, and child development. From January 9, 2023, to February 9, 2023, participants were recruited using social media posts and through engagement with community organizations. Inclusion criteria included being aged ≥14 years, being a woman of color, and either being currently pregnant or having given birth within the past 6 months. Participants were randomly assigned to the Rosie treatment group (15/29, 52% received the Rosie app) or control group (14/29, 48% received a children's book each month) for 3 months. Those assigned to the treatment group could ask Rosie questions and receive an immediate response generated from Rosie's knowledgebase. Upon detection of a possible health emergency, Rosie sends emergency resources and relevant hotline information. In addition, a study staff member, who is a clinical social worker, reaches out to the participant within 24 hours to follow up. Preintervention and postintervention tests were completed to qualitatively and quantitatively evaluate Rosie and describe changes across key health outcomes, including postpartum depression and the frequency of emergency room visits. These measurements were used to inform the clinical trial's sample size calculations. RESULTS: Of 41 individuals who were screened and eligible, 31 (76%) enrolled and 29 (71%) were retained in the study. More than 87% (13/15) of Rosie treatment group members reported using Rosie daily (5/15, 33%) or weekly (8/15, 53%) across the 3-month study period. Most users reported that Rosie was easy to use (14/15, 93%) and provided responses quickly (13/15, 87%). The remaining issues identified included crashing of the app (8/15, 53%), and users were not satisfied with some of Rosie's answers (12/15, 80%). Mothers in both the Rosie treatment group and control group experienced a decline in depression scores from pretest to posttest periods, but the decline was statistically significant only among treatment group mothers (P=.008). In addition, a low proportion of treatment group infants had emergency room visits (1/11, 9%) compared with control group members (3/13, 23%). Nonetheless, no between-group differences reached statistical significance at P<.05. CONCLUSIONS: Rosie was found to be an acceptable, feasible, and appropriate intervention for ethnic and racial minority pregnant women and mothers of infants owing to the chatbot's ability to provide a personalized, flexible tool to increase the timeliness and accessibility of high-quality health information to individuals during a period of elevated health risks for the mother and child. TRIAL REGISTRATION: ClinicalTrials.gov NCT06053515; https://clinicaltrials.gov/study/NCT06053515.

RESUMEN

OBJECTIVES: Regular physical activity throughout life is generally recommended to prevent dementia; however, there is little evidence regarding the association between lifetime physical activity and mild cognitive impairment (MCI), which often precedes dementia. This study aimed to examine the association of lifetime physical activity and their transitions with late-life MCI. DESIGN: A population-based case-control study. SETTING AND PARTICIPANTS: A total of 2968 Japanese community-dwelling older adults aged ≥70 years without dementia. METHODS: We evaluated the participants' early-, mid-, and late-life physical activity habits and categorized their transitions across life stages. Cognitive functions in late life were assessed for memory, attention, executive function, and processing speed; functional impairment in one or more cognitive domains was defined as MCI. RESULTS: Regular physical activity in early life was not significantly associated with late-life MCI [odds ratio (OR), 0.80; 95% CI, 0.63-1.02], although those in mid-life (OR, 0.64; 95% CI, 0.51-0.81) and late-life (OR, 0.74; 95% CI, 0.59-0.91) were associated with lower odds of late-life MCI. Compared with nonexercisers, participants who acquired new habits of physical activity during mid- or late-life (OR, 0.71; 95% CI, 0.55-0.91) and those who maintained physical activity throughout their life span (OR, 0.61; 95% CI, 0.42-0.87) had lower odds of late-life MCI; those who stopped regular activity during mid- or late-life did not (OR, 0.79; 95% CI, 0.58-1.06). CONCLUSIONS AND IMPLICATIONS: While physical activity throughout the life span is associated with the lowest odds of MCI, starting regular physical activity, even later in life, confers a benefit and should be encouraged as a "lifelong approach" to MCI risk reduction.

Asunto(s)

RESUMEN

Preventive health care use can reduce the risk of disease, disability, and death. Thus, it is critical to understand factors that shape preventive care use. A growing body of research identifies structural sexism as a driver of population health, but it remains unknown if structural sexism is linked to preventive care use and, if so, whether the relationship differs for women and men. Gender performance and gendered power and resource allocation perspectives lead to competing hypotheses regarding these questions. This study explores the relationship between structural sexism and preventive care in gender-stratified, multilevel models that combine data from the Behavioral Risk Factor Surveillance System with state-level data (N = 425,454). We find that in states with more structural sexism, both men and women were less likely to seek preventive care. These findings support the gender performance hypothesis for men and the gendered power and resource allocation hypothesis for men and women.

Asunto(s)

RESUMEN

Innovative midwifery-led collaborative care models have the potential to build on grassroots approaches to make transformative change within systems that work with families. Rainier Valley Midwives operates the Bundle Birth Project, a successful program that serves communities who are at higher risk for poor birth outcomes and face barriers to adequate medical, prenatal, and postpartum care, including Black, Indigenous, and persons of color. This project offers wraparound perinatal care services to provide a missing community of support to traditionally marginalized families before, during, and after birth while also bridging the gaps between midwives and physicians who attend births in different settings. By strengthening and formalizing the relationships between different types of perinatal providers including community-based doulas and lactation support professionals, this midwifery-led initiative improves the continuity and quality of care available to families including immigrant, refugee, and families of color in south Seattle, Washington.

Asunto(s)

RESUMEN

OBJECTIVES: We evaluate the rates and limitations of women's adherence to low molecular weight heparin (LMWH) after cesarean section (CS) in the Gaza Strip. METHODS: Women who underwent CS were recruited consecutively. Communication offered to women, adherence to Venous thromboembolism (VTE), and its limiting factors were surveyed. RESULTS: 281 women participated (mean age 27.9 years). 51.95% fully adhered to VTE prophylaxis. Causes of suboptimal adherence were: 51.1% did not feel VTE prophylaxis was important, 37.8% due to high drug cost, and 11.1% didn't receive a prescription for LMWH at discharge. Poor communication was evident as 48.8% of the sample did not receive any instructions about the technical method of LMWH injection, 45.6% did not receive any information about the clinical significance of heparin, and 74.7% were unaware of LMWH side effects. CONCLUSION: There is inadequate adherence to VTE prophylaxis after CS among Gaza women, mostly due to a lack of appropriate communication but also due to drug costs.

Asunto(s)

RESUMEN

OBJECTIVE: The EUSCREEN project concerns the study of European vision and hearing screening programmes. Part of the project was the development of a cost-effectiveness model to analyse such programmes. We describe the development and usability of an online tool to enable stakeholders to design, analyse or modify a newborn hearing screening (NHS) programme. DESIGN: Data from literature, from existing NHS programmes, and observations by users were used to develop and refine the tool. Required inputs include prevalence of the hearing impairment, test sequence and its timing, attendance, sensitivity, and specificity of each screening step. Outputs include the number of cases detected and the costs of screening and diagnostics. STUDY SAMPLE: Eleven NHS programmes with reliable data. RESULTS: Three analyses are presented, exploring the effect of low attendance, number of screening steps, testing in the maternity ward, or screening at a later age, on the benefits and costs of the programme. Knowledge of the epidemiology of a staged screening programme is crucial when using the tool. CONCLUSIONS: This study presents a tool intended to aid stakeholders to design a new or analyse an existing hearing screening programme in terms of benefits and costs.

Asunto(s)

RESUMEN

The 2008 economic recession may have affected health-related indicators differently depending on the living environment. We analyze health-related indicators in Spain using data from four Spanish health surveys (2006, 2011, 2014, and 2017, 95 924 individuals aged ≥16 years). In 2006-2011, physical activity decreased among men and women, while in 2006-2017, physical activity only decreased among urban women. Daily vegetable intake, except in rural women, increased in 2006-2011 but decreased in 2006-2017 in all groups. Smoking decreased among urban women in 2006-2011 and 2006-2014 but only decreased among men, and even increased among rural women, in 2006-2017. In 2006-2017, obesity increased among men and urban women, good self-rated health status increased in all groups and flu vaccination declined. Blood pressure and cholesterol control decreased in urban women in 2006-2011 but increased in 2006-2017 in all groups, as well as mammographic and cytological control. Our findings highlight the differential impact of the economic recession on health-related lifestyles according to sex and place of residence, underscoring the need for targeted health policies to address evolving health disparities over time.

Asunto(s)

RESUMEN

BACKGROUND: Blood cancer survivors are at increased risk for second primary malignancies, cardiovascular diseases, and infections. Little is known about preventive care in blood cancer survivors. METHODS: Our questionnaire-based study included blood cancer patients diagnosed at the University Hospital of Essen before 2010, with a ≥ 3-year interval from the last intense treatment. One section of the retrospective study covered preventive care (cancer screening, cardiovascular screening, vaccination). RESULTS: Preventive care was delivered by a general practitioner for 1100 of 1504 responding survivors (73.1%), by an oncologist for 125 (8.3%), by a general practitioner together with an oncologist for 156 (10.4%), and by other disciplines for 123 (8.2%). Cancer screening was more consistently performed by general practitioners than by oncologists. The converse was true for vaccination, with particularly high vaccination rates in allogeneic transplant recipients. Cardiovascular screening did not differ between care providers. Cancer and cardiovascular screening rates in survivors eligible for statutory prevention programs were higher than in the general population (skin cancer screening 71.1%; fecal occult blood testing 70.4%; colonoscopy 64.6%; clinical breast examination 92.1%; mammography 86.8%; cervical smear 86.0%; digital rectal examination 61.9%; blood pressure test 69.4%; urine glucose test 54.4%; blood lipid test 76.7%; information about overweight 71.0%). The Streptococcus pneumoniae vaccination rate was higher (37.0%) and the influenza vaccination rate was lower (57.0%) than in the general population. CONCLUSIONS: Utilization of preventive care is high among German blood cancer survivors. To ensure widespread delivery and avoid redundancy, communication between oncologists and preventive care providers is essential.

Asunto(s)

RESUMEN

BACKGROUND: Sublingual varices (SV) and their predictive potential for other clinical parameters is a much studied topic in oral medicine. SVs have been well studied as predictive markers for many common diseases such as arterial hypertension, cardiovascular disease, smoking, type 2 diabetes mellitus and age. Despite many prevalence studies, it is still unclear how the reliability of SV inspection affects its predictive power. The aim of this study was to quantify the inspection reliability of SV. METHODS: In a diagnostic study, the clinical inspection of 78 patients by 23 clinicians was examined for the diagnosis of SV. Digital images of the underside of the tongue were taken from each patient. The physicians were then asked to rate them for the presence of sublingual varices (0/1) in an online inspection experiment. Statistical analysis for inter-item and inter-rater reliability was performed in a τ-equivalent measurement model with Cronbach's [Formula: see text] and Fleiss κ. RESULTS: The interrater reliability for sublingual varices was relatively low with κ = 0.397. The internal consistency of image findings for SV was relatively high with α≈ 0.937. This shows that although SV inspection is possible in principle, it has a low reliability R. This means that the inspection finding (0/1) of individual images often cannot be reproduced stably. Therefore, SV inspection is a difficult task of clinical investigation. The reliability R of SV inspection also limits the maximum linear correlation [Formula: see text] of SV with an arbitrary other parameter Y. The reliability of SV inspection R = 0.847 limits the maximum correlation to [Formula: see text] (SV, Y) = 0,920-a 100% correlation was a priori not achievable in our sample. To overcome the problem of low reliability in SV inspection, we propose the RA (relative area) score as a continuous classification system for SV, which normalises the area of visible sublingual veins to the square of the length of the tongue, providing a dimensionless measure of SV. CONCLUSIONS: The reliability of the SV inspection is relatively low. This limits the maximum possible correlation of SV with other (clinical) parameters. SV inspection reliability is an important indicator for the quality of SV as a predictive marker. This should be taken into account when interpreting previous studies on SV and has implications for future studies. The RA score could help to objectify the SV examination and thus increase its reliability.

Asunto(s)

RESUMEN

INTRODUCTION: A qualitative picture of the health care experiences prior to pregnancy can inform patient-centered strategies to optimize preconception health. This study describes health care utilization and experiences and how health care costs were covered in the year prior to pregnancy in a population of primarily Hispanic women with low income. METHODS: Pregnant participants were recruited from 5 Federally Qualified Health Center clinics. Semistructured interviews included questions about health care in the year prior to pregnancy. Transcripts were analyzed using a thematic approach that integrated deductive and inductive analysis. RESULTS: Most participants self-identified as Hispanic. Just under half were US citizens. All but one were Medicaid or Children's Health Insurance Program Perinatal coverage insurance during pregnancy and relied on a variety of strategies to cover prepregnancy health care costs. Almost all received health care during the year prior to pregnancy. Fewer than half reported an annual preventive visit. Health care needs that led to care-seeking included a prior pregnancy, chronic depression, contraception, workplace injury, a persistent rash, screening and treatment for sexually transmitted infection, breast pain, stomach pain (leading to gallbladder removal), and kidney infection. The ways in which study participants covered the costs of health care ranged in terms of sources and complexity. Although some participants described stable health care coverage, most reported changes throughout the year as they pieced together various health care coverage programs and out-of-pocket payments. When participants did seek health care prior to their current pregnancy, most described the experience in positive terms and focused on health care provider communication quality. Respect of patient autonomy was highly valued. DISCUSSION: Women with pregnancy-related health care coverage accessed care for a wide range of health care needs prior to pregnancy. Health care providers may consider strategies to respectfully introduce preconception care into any visit by an individual who could become pregnant.

Asunto(s)

RESUMEN

The Air Force seeks to maximize airman fitness and minimize threats to individual and unit readiness, such as domestic and sexual violence and suicide. The purpose of the Air Force's Task Force True North (TFTN) is to provide effective prevention and treatment programs to airmen in need by embedding health care providers directly into units. In this study, the authors identify potential courses of action (COAs) for expanding the TFTN program, including estimating each approach's associated manpower requirements, recruiting requirements, total costs, and implementation timelines. In developing these COAs, the authors analyzed embedded behavioral and physical health programs in the Army, Navy, Marine Corps, and U.S. Special Operations Command; developed a framework for analyzing mental, physical, and social squadron risk levels; developed personnel packages for low-, medium-, and high-risk squadrons; and estimated the costs of implementing these personnel packages under different timelines. In addition to detailing these COAs, the authors provide recommendations on best practices for the Air Force to follow as it expands the TFTN program.

RESUMEN

Objective: Children living in rural communities have disparate access to preventive health care, shifting the burden of care delivery to emergency services. This study examined the association of school-based telemedicine (SBT) and avoidable emergency department (ED) utilization in rural historically underserved pediatric patients served through an SBT program. Methods: A retrospective analysis was conducted using electronic medical records and claims data from a large integrated health care system serving as the majority health care provider in the area. Participants included all pediatric patients served through an SBT program between 2017 and 2020 across three rural North Carolina counties. The study was a quasi-experimental before/after design comparing 12-month time periods before and after a patient's index virtual care visit. A subset of patients served 12 months before the start of the coronavirus 2019 (COVID-19) pandemic in 2020 was extracted and analyzed separately for a sensitivity analysis. Results: The complete sample included 1,236 patients. The odds of having an avoidable ED visit were reduced by 33% between time periods, and the estimated count of visits was reduced by 26%. (Models were adjusted for race/ethnicity, gender, age, and insurance payer.) No significant differences in unavoidable ED utilization were observed. The sensitivity analysis showed similar trends. Conclusions: Results demonstrate that telemedicine can improve access to health care and may offset the burden of avoidable care through emergency health services. Policy changes and increased use during the COVID-19 pandemic have created an optimal environment for telemedicine expansion to reduce health care access disparities.

Asunto(s)

RESUMEN

BACKGROUND: This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation. DESIGN: We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey (n = 1,295); and (3) 10-year ASCVD risk prediction equations. MEASURES: The primary outcome measure was 10-year ASCVD risk. RESULTS: EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs. CONCLUSION: Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level.

Asunto(s)

RESUMEN

Individuals with prediabetes living in hard-to-reach and underserved areas experience barriers to accessing traditional in-person preventive health services. The National Diabetes Prevention Program (DPP) is a preventive health care program designed to reduce the risk of developing type 2 diabetes. Although there have been increasing numbers of remote DPPs accessible, there are little data on the clinical outcomes of digital DPPs for members living in hard-to-reach and underserved areas. This study assessed whether living in a designated Health Professional Shortage Area (HPSA) and a rural versus urban area impacted the weight loss of N = 7266 members of a fully digital program called Lark DPP. Secondary analyses included between-group comparisons of program retention and member characteristics, demographics, and socioeconomics. Percent weight loss did not differ by HPSA (P = 0.16) or rural/urban status (P = 0.15), despite greater potential barriers for members residing in HPSAs (eg, highest starting body mass index, lowest income, lowest education). Mean percent weight loss for members residing in an HPSA and rural area was mean (M) = 4.75%, standard error (SE) = 0.09; for members in a non-HPSA, rural area M = 4.96%, SE = 0.16; for members in an HPSA, urban area M = 4.55%, SE = 0.13; and for members in a non-HPSA, urban area M = 4.77%, SE = 0.13. Members of a fully digital DPP achieved weight loss that did not differ by HPSA or urban/rural designation. Fully digital programs offer a solution to reduce the risk of type 2 diabetes in areas where residents may not otherwise have access to diabetes prevention services.

Asunto(s)

RESUMEN

INTRODUCTION: More than 25% of American adolescents live in immigrant families. This cohort of adolescents is a minority group with amplified health challenges. The purpose of this study was to provide an integrative review of quantitative research on the access and use of primary and preventive health care by adolescents in immigrant families. METHOD: Searches yielded 460 reports, 54 of them satisfied criteria for full-text review, and four publications met inclusion criteria. RESULTS: Research, albeit very limited, revealed that adolescents in immigrant families have poor access to and use of preventive health care. DISCUSSION: Lack of primary health care may prevent identification of health risks in immigrant adolescents and lead them to perceive that preventive health care is unnecessary. Researchers are challenged to develop and test health promotion interventions tailored for these adolescents. Study recruitment outside of high schools, the typical setting, is critical to advance knowledge and improve access for this vulnerable population.

Asunto(s)

RESUMEN

AIMS: To discover whether dental visiting behavior can be understood as a dichotomy of planned versus problem based, or whether there were a range of different types of understanding and patient behavior, recognizable as patterns of dental visiting behavior. METHODS: Secondary analysis drawing on 2 qualitative studies of patients' accounts of dental attendance and oral health, with 1) opportunistic interviews with people attending urgent dental care services (n = 43; including 19 with follow-up) and 2) home-based, in-depth interviews with people attending a dental practice with a mixture of improved or deteriorated/poor periodontal health (n = 25). RESULTS: Four distinguishable patterns of dental visiting were identified in patients' accounts: Accepting and Active Monitoring, as well as Ambivalent and Active Problem-based dental visiting behavior. Individuals' patterns were relatively stable over time but could shift at turning points. Accepting Monitors were characterized as accepting dentists' recommendations and dental practice policies relating to oral health and visits, whereas Active Monitors were more independent in judging how often to attend for preventive appointments, while still valuing anticipatory care. Ambivalent Problem-based visitors placed a relatively low value on anticipatory care for oral health maintenance and drifted into lapsed attendance, in part because of service-related factors. This contrasted with Active Problem-based visitors, for whom using services only in an emergency was a conscious decision, with low value placed on anticipatory care. CONCLUSION: This article demonstrates the dynamic nature of patterns of dental visiting where the dental system itself is partly instrumental in shaping patterns of utilization in an ecological way. Thus, service-related factors tend to combine with patients' behavior in expanding inequalities. This illuminates the reasons why risk-based recalls are challenging to implement as a dental policy. KNOWLEDGE TRANSFER STATEMENT: The results of this analysis can be used by clinicians and policymakers to inform policy around supporting uptake of preventive health care visits, contributing in particular to understanding how risk-based preventive visiting policies may be better adapted to patients' understanding of the purpose of visits, taking into account that this is in part shaped by service-related factors in an ecological way, arising from patients' and dental teams' expectations.

Asunto(s)