Integrating LGBTIQ health personnel in the workplace: A literature review

Aim Lesbian, Gay, Bisexual, Transgender (LGBTIQ) issues have attracted attention in the popular media. The purpose of this study was to explore the workplace acceptance and experiences of LGBTIQ health and medical practitioners. Methods A systematic search of academic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were research papers published in English, which focused on workplace acceptance and experiences of LGBTIQ health personnel. Both authors abstracted data from all eligible papers. Results Thirty-three papers were included in this review. Evidence indicated that LGBTIQ health personnel experienced discrimination from their patients, heterosexual colleagues and within the LGBTIQ community. Positive contribution of LGBTIQ health personnel include improved patient care and role models for LGBTIQ peers. Inclusive policy is required for LGBTIQ health personnel workforce retention. Conclusions There has been improvement in the acceptance and experiences of LGBTIQ health personnel in recent times. An inclusive workplace policy of LGBTIQ embraces and celebrates the value of diversity.

Family Health Support Centers: challenges and opportunities from the perspective of primary care professionals in the city of Sao Paulo, Brazil

Family Health Support Centers (NASF) were created in Brazil to increase the case-resolution capacity of primary healthcare. Prior to their implementation in the West Side of the city of Sao Paulo, Brazil, a series of workshops were held for primary healthcare professionals to prepare a proposal for such centers. Hermeneutic analysis was used to study the transcribed material. The thematic categories were: role, constitution, and functioning of the NASF, relationship with family health teams, and interdisciplinarity. The participants' expected the NASF to be an empowering device for comprehensiveness of care, intervening in an existing culture of unnecessary referrals while fostering linkage with other levels of care. The participants also expected the NASF to contribute to the discussion on health professionals' training and stimulating reflection with policy-makers on health indicators based exclusively on the number of consultations. These indicators fail to reflect the impact on the services' activities and the quality of care offered to the population in the coverage area.

Health promotion in palliative care : the case for conceptual congruence

This article provides a critical review of the literature relevant to the conceptual foundations of health promoting palliative care. It explores the separate emergence and evolution of palliative care and health promotion as distinct concerns in health care, and reviews the early considerations given to their potential convergence. Finally, this article examines the proposal of health promoting palliative care as a specific approach to providing end of life care through a social model of palliative care. Research is needed to explore the impact for communities, health care services and policy when such an approach is implemented within palliative care organisations.

Determinants of infant and young child feeding practices in Nepal : secondary data analysis of demographic and health survey 2006

Background: Childhood undernutrition and mortality are high in Nepal, and therefore interventions on infant and young child feeding practices deserve high priority. Objective. To estimate infant and young child feeding indicators and the determinants of selected feeding practices. Methods: The sample consisted of 1,906 children aged 0 to 23 months from the Demographic and Health Survey 2006. Selected indicators were examined against a set of variables using univariate and multivariate analyses. Results. Breastfeeding was initiated within the first hour after birth in 35.4% of children, 99.5% were ever breastfed, 98.1% were currently breastfed, and 3.5% were bottle-fed. The rate of exclusive breastfeeding among infants under 6 months of age was 53.1%, and the rate of timely complementary feeding among those 6 to 9 months of age was 74.7%. Mothers who made antenatal clinic visits were at a higher risk for no exclusive breastfeeding than those who made no visits. Mothers who lived in the mountains were more likely to initiate breastfeeding within 1 hour after birth and to introduce complementary feeding at 6 to 9 months of age, but less likely to exclusively breastfeed. Cesarean deliveries were associated with delay in timely initiation of breastfeeding. Higher rates of complementary feeding at 6 to 9 months were also associated with mothers with better education and those above 35 years of age. Risk factors for bottle-feeding included living in urban areas and births attended by trained health personnel. Conclusions: Most breastfeeding indicators in Nepal are below the expected levels to achieve a substantial reduction in child mortality. Breastfeeding promotion strategies should specifically target mothers who have more contact with the health care delivery system, while programs targeting the entire community should be continued.

Anticipated behaviours of emergency prehospital medical care providers during an influenza pandemic

Introduction: Emergency prehospital medical care providers are frontline health workers during emergencies. However, little is known about their attitudes, perceptions, and likely behaviors during emergency conditions. Understanding these attitudes and behaviors is crucial to mitigating the psychological and operational effects of biohazard events such as pandemic influenza, and will support the business continuity of essential prehospital services. ----- ----- Problem: This study was designed to investigate the association between knowledge and attitudes regarding avian influenza on likely behavioral responses of Australian emergency prehospital medical care providers in pandemic conditions. ----- ----- Methods: Using a reply-paid postal questionnaire, the knowledge and attitudes of a national, stratified, random sample of the Australian emergency prehospital medical care workforce in relation to pandemic influenza were investigated. In addition to knowledge and attitudes, there were five measures of anticipated behavior during pandemic conditions: (1) preparedness to wear personal protective equipment (PPE); (2) preparedness to change role; (3) willingness to work; and likely refusal to work with colleagues who were exposed to (4) known and (5) suspected influenza. Multiple logistic regression models were constructed to determine the independent predictors of each of the anticipated behaviors, while controlling for other relevant variables. ----- ----- Results: Almost half (43%) of the 725 emergency prehospital medical care personnel who responded to the survey indicated that they would be unwilling to work during pandemic conditions; one-quarter indicated that they would not be prepared to work in PPE; and one-third would refuse to work with a colleague exposed to a known case of pandemic human influenza. Willingness to work during a pandemic (OR = 1.41; 95% CI = 1.0–1.9), and willingness to change roles (OR = 1.44; 95% CI = 1.04–2.0) significantly increased with adequate knowledge about infectious agents generally. Generally, refusal to work with exposed (OR = 0.48; 95% CI = 0.3–0.7) or potentially exposed (OR = 0.43; 95% CI = 0.3–0.6) colleagues significantly decreased with adequate knowledge about infectious agents. Confidence in the employer’s capacity to respond appropriately to a pandemic significantly increased employee willingness to work (OR = 2.83; 95% CI = 1.9–4.1); willingness to change roles during a pandemic (OR = 1.52; 95% CI = 1.1–2.1); preparedness to wear PPE (OR = 1.68; 95% CI = 1.1–2.5); and significantly decreased the likelihood of refusing to work with colleagues exposed to (suspected) influenza (OR = 0.59; 95% CI = 0.4–0.9). ----- ----- Conclusions:These findings indicate that education and training alone will not adequately prepare the emergency prehospital medical workforce for a pandemic. It is crucial to address the concerns of ambulance personnel and the perceived concerns of their relationship with partners in order to maintain an effective prehospital emergency medical care service during pandemic conditions.

A survey of the Queensland healthcare workforce : attitudes towards dementia care and training

Background Positive attitudes of healthcare staff towards people with dementia promote higher quality care, although little is known about important factors that underlie positive attitudes. Key aims of this project were to explore the relationships between staff attitudes towards dementia, self-confidence in caring for people with dementia, experience and dementia education and training. Method A brief online survey was developed and widely distributed to registered nurses and allied health professionals working in Queensland in 2012. Regression analyses were performed to identify important predictors of self-confidence in caring for people with dementia and positive attitudes towards people with dementia. Results Five hundred and twenty-four surveys were completed by respondents working in a range of care settings across Queensland. Respondents were predominantly female (94.1%), and most were registered nurses (60%), aged between 41 and 60 years (65.6%). Around 40% regularly worked with people with dementia and high levels of self-confidence in caring for this population and positive attitudes towards people with dementia were reported. The majority of respondents (67%) had participated in a dementia education/training activity in the past 12 months. More experience working with people with dementia predicted greater self-confidence while recent participation in a dementia education/training and higher self-confidence in caring for a person with dementia significantly predicted more positive attitudes towards people with dementia. Conclusion These results confirm the importance of self-confidence and dementia education in fostering positive attitudes and care practices towards people with dementia. Our results also indicate that the demand for ongoing dementia education is high amongst health care workers and it is recommended that regular dementia education/ training be provided and promoted for all healthcare personnel who work with people with dementia.

Improved rural health through a collaborative model of care – qualitative findings

INTRODUCTION Health disparity between urban and rural regions in Australia is well-documented. In the Wheatbelt catchments of Western Australia there is higher incidence and rate of avoidable hospitalisation for chronic diseases. Structured care approach to chronic illnesses is not new but the focus has been on single disease state. A recent ARC Discovery Project on general practice nurse-led chronic disease management of diabetes, hypertension and stable ischaemic heart disease reported improved communication and better medical administration.[1] In our study we investigated the sustainability of such a multi-morbidities general practice –led collaborative model of care in rural Australia. METHODS A QUAN(qual) design was utilised. Eight pairs of rural general practices were matched. Inclusion criteria used were >18 years and capable of giving informed consent, at least one identified risk factor or diagnosed with chronic conditions. Patients were excluded if deemed medically unsuitable. A comprehensive care plan was formulated by the respective general practice nurse in consultation with the treating General Practitioner (GP) and patient based on the individual’s readiness to change, and was informed by available local resource. A case management approach was utilised. Shediaz-Rizkallah and Lee’s conceptual framework on sustainability informed our evaluation.[2] Our primary outcome on measures of sustainability was reduction in avoidable hospitalisation. Secondary outcomes were patients and practitioners acceptance and satisfaction, and changes to pre-determined interim clinical and process outcomes. RESULTS The qualitative interviews highlighted the community preference for a ‘sustainable’ local hospital in addition to general practice. Costs, ease of access, low prioritisation of self chronic care, workforce turnover and perception of losing another local resource if underutilised influenced the respondents’ decision to present at local hospital for avoidable chronic diseases regardless. CONCLUSIONS Despite the pragmatic nature of rural general practice in Australia, the sustainability of chronic multi-morbidities management in general practice require efficient integration of primary-secondary health care and consideration of other social determinants of health. What this study adds: What is already known on this subject: Structured approach to chronic disease management is not new and has been shown to be effective for reducing hospitalisation. However, the focus has been on single disease state. What does this study add: Sustainability of collaborative model of multi-morbidities care require better primary-secondary integration and consideration of social determinants of health.

"But we’re already doing it!" Examining conceptual blurring between health promotion and palliative care

Over the past decade, an increasing number of palliative care service providers have attempted to integrate health promotion into their organisational practice. A key factor in the success of this endeavour has been the recognition by these providers of the conceptual ‘fit’ between two seemingly disparate approaches to health care. When informed of the elements of health promotion, palliative care professionals have expressed their recognition in their declaration: ‘But we’re already doing it!’ (Rosenberg 2007). Yet it appears that this association between the two suggests that health promotion in palliative care organisations is being understood in poorly defined ways. ‘Health promotion’ can be incorrectly assumed to be synonymous with ‘health education’; ‘death education’ can be understood to be synonymous with providing information about palliative care resources. Whilst these activities may be worthwhile within themselves, their presence in the activities of an organisation does not constitute the practice of health promoting palliative care (HPPC) (Kellehear 1999)...

Hospital care in Iran : an examination of national health system performance

This study examines hospital care system performance in Iran. We first briefly review hospital care delivery system in Iran. Then, the hospital care system in Iran has been investigated from financial, utilization, and quality perspectives. In particular, we examined the extent to which health care system in Iran protects people from the financial consequence of health care expenses and whether inpatient care distributed according to need. We also empirically analyzed the quality of hospital care in Iran using patient satisfaction information collected in a national health service survey. The Iranian health care system consists of unequal access to hospital care; mismatch between the distribution of services and inpatients' need; and high probability of financial catastrophe due to out-of-pocket payments for inpatient services. Our analysis indicates that the quality of hospital care among Iranian provinces favors patients residing in provinces with high numbers of hospital beds per capita such as Esfahan and Yazd. Patients living in provinces with low levels of accessibility to hospital care (e.g. Gilan, Kermanshah, Hamadan, Chahar Mahall and Bakhtiari, Khuzestan, and Sistan and Baluchestan) receive lower-quality services. These findings suggest that policymakers in Iran should work on several fronts including utilization, financing, and service quality to improve hospital care.

The organisational context of nursing care in stroke units: A case study approach

Background Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. Design A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Findings Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

Patterns of care: Primary research in mental health nursing

The foundation of mental health nursing has historically been grounded in an interpersonal, person-centred process of health care, yet recent evidence suggests that the interactional work of mental health nursing is being eroded. Literature emphasises the importance of person-centred care on consumer outcomes, a model reliant upon the intimate engagement of nurses and consumers. Yet, the arrival of medical interventions in psychiatry has diverted nursing work from the therapeutic nursing role to task-based roles delegated by medicine, distancing nurses from consumers. This study used work sampling methodology to observe the proportion of time nurses working in an inpatient mental health setting engage in specific activities. The observations of this study determined that nurses' time is accounted for 31.65% in direct care, 51.63% in indirect care and 16.71% in service related activities.

Self-reported bruxism : Associated factors among media personnel with or without irregular shift work

Tutkimuksen kohderyhmänä oli mediatyöntekijöitä, joiden toimenkuva on viime vuosina muuttunut yhä kuormittavammaksi epäsäännöllisen vuorotyön sekä jatkuvien teknisten, organisatoristen ja taloudellisten tekijöiden ristipaineessa. Väitöskirjatutkimus on osa laajempaa tutkimushanketta, joka suunniteltiin selvittämään epäsäännöllisen vuorotyön mahdollisia haittoja. Tutkimusta tukivat taloudellisesti Työsuojelurahasto ja Suomen Hammaslääkäriseura Apollonia sekä resurssipanostuksin Hammaslääketieteen laitos (HY), Työterveyslaitos ja Yleisradio Oy. Bruksismi on tahdosta riippumatonta hampaiden narskuttelua tai yhteenpuristamista. Hampaiden narskuttelu on rytmistä jaksoittain toistuvaa puremalihasten toimintaa, joka esiintyy nukkuessa -tavallisimmin kevyen unen ja havahtumisjaksojen yhteydessä. Valveilla ollessa bruksismi on terveillä ihmisillä lähinnä hampaiden yhteenpuristamista. Yleisen käsityksen mukaan toistuvaa unibruksismia esiintyy noin 10 %:lla ja valveilla tapahtuvaa hampaiden yhteenpuristamista noin 20 %:lla. Aiemmin bruksismi kuului kansainvälisen unihäiriöluokituksen (ICSD 1997) mukaan unen erityishäiriöihin, mutta tuorein luokitus (ICSD 2005) listaa sen unen liikehäiriöihin. Väitöstutkimuksen yleisenä tavoitteena oli kartoittaa koetun bruksismin ja uni- valvehäiriöiden yhteyttä. Tutkimus oli poikittainen vertailututkimus epäsäännöllistä vuorotyötä ja säännöllisiä päivävuoroja tekevien välillä. Mielenkiinto kohdistui myös bruksismin ja kasvojen alueen kivun mahdolliseen yhteyteen. Lisäksi tutkimuksessa selvitettiin joidenkin tunnetusti unen laatua huonontavien psykososiaalisten, neurologisten ja fysiologisten tekijöiden yhteyttä koettuun bruksismiin. Tutkimuksen kohderyhmän muodosti 750 Yleisradion epäsäännöllistä vuorotyötä tekevää työntekijää. Vertailuryhmänä käytettiin samansuuruista satunnaistetusti valittua kaltaistettua Yleisradion työntekijäjoukkoa, joka tekee samankaltaista työtä, mutta säännöllisenä päivätyönä. Kohderyhmälle lähetettiin kyselylomakkeet, jotka kartoittivat koetun bruksismin lisäksi mm. tutkittavien taustatiedot, yleisen terveydentilan, yleisiä koettuja stressioireita ja tuntemuksia, kipuoireita, sekä unen laatua. Lisäksi esitettiin jaksamista ja työympäristöä koskevia kysymyksiä. Kyselyyn vastasi kaikkiaan 874 henkilöä. Kokonaisvastausprosentti oli 58,3 % (53,7 % miehiä). Epäsäännöllistä vuorotyötä tekevien vastausprosentti oli 82,3 % ja säännöllistä päivätyötä tekevien ryhmässä 34,3 %. Työtehtävät sisälsivät ohjelmien toimitus- ja tuottamistyötä, teknistä tuotanto- ja tukityötä, sekä esimies- ja hallintotyötä. Miesten keski-ikä vuorotyöryhmässä oli 45,0 (± 10,6) vuotta ja naisten keski-ikä 42,6 (± 10,7) vuotta, vastaavat luvut päivätyötä tekeville olivat 47,4 (± 9,7) ja 45,5 (± 10,1) vuotta. Vuorotyötä tekevistä oli miehiä 56,6 %, päivätyöryhmässä miehien osuus oli 46,7 %. Usein koettua bruksismia havaittiin koko tutkimusjoukossa 10,6 %:lla. Bruksismin esiintyvyydessä ei ollut merkitsevää eroa epäsäännöllistä vuorotyötä ja päivätyötä tekevien välillä. Kun bruksismia ja stressiä arvioitiin suhteessa tyytyväisyyteen nykyiseen työaikamuotoon, molemmat olivat merkitsevästi vallitsevimpia niillä, jotka halusivat vaihtaa nykyistä työaikamuotoaan. Epäsäännöllistä vuorotyötä tekevät lisäksi ilmoittivat kokevansa enemmän stressiä kuin päivätyötä tekevät sekä olivat tyytymättömämpiä työaikamuotoonsa. Tutkittavista henkilöistä katkonaista unta esiintyi 43,6 %:lla sekä 36,2 % koki unensa virkistämättömäksi. Kasvokipua esiintyi 19,6 %:lla. Usein toistuva bruksaus sekä tyytymättömyys työaikamuotoon olivat erittäin merkitsevästi yhteydessä unihäiriöiden sekä riittämättömän unen oireiden kanssa. Bruksismi ja katkonainen uni osoittautuivat myös kasvokivun taustatekijöiksi. Tutkimus osoitti, että koetulla bruksismilla oli merkitsevä yhteys unihäiriöihin, kasvokipuun, koettuun stressiin ja ahdistuneisuuteen, nuorempaan ikään, runsaampiin hammaslääkäri- ja lääkärikäynteihin sekä siihen että oli tyytymätön työaikamuotoonsa (itse työaikamuoto ei ollut merkitsevä tekijä). Tutkimuksen yhtenä johtopäätöksenä todettiin, että koettu bruksismi voi terveillä työikäisillä henkilöillä olla osa stressaavaa tilannetta ja siihen liittyvää käyttäytymistä. Tämän tiedostaminen terveydenhuollossa voisi olla hyödyllistä.

Oral health behaviour, conditions and care among dentate elderly patients in Lithuania: preventive aspects

The present cross-sectional study aimed to assess oral health behaviour, dental and periodontal conditions, dental care, and their relationships among elderly dentate patients in Lithuania. The target population in the study were dentate patients aged 60 and older attending public dental services in Kedainiai, Lithuania. The data collection took place between the autumn of 1999 and the winter of 2001. Data were collected by means of a self-administered questionnaire for all (n=174) and a clinical examination targeting about half of the subjects (n=100). The questionnaire inquired about oral health behaviour, the life-first and also the most recent dental treatments, sources on and self-assessed knowledge of oral self-care, a self-reported number of teeth, and socio-demographic information. The clinical examination included basic dental and periodontal conditions. A total of 82 women and 92 men completed the questionnaire; their mean age was 69.2 and their average number of teeth was 16.2 (CI 95% 15.4-17.1). In all, 25% had 21 or more teeth and 32% indicated wearing removable dentures. The oral health behaviour, the participants reported, was poor: 30% reported twice daily toothbrushing, 57% responded that they always use fluoride toothpaste, 19% indicated daily interdental cleaning, nearly all said they take sugar in their coffee and tea, and 30% indicated going for check-ups. As the main source of information on oral self-care, the subjects indicated health professionals (82%), followed by social contacts (72%), broadcasted media (58%), and printed media (42%). A total of 34% assessed their knowledge of oral self-care as good, and their self-assessed knowledge correlated (r=0.52) with professional guidance they had received about oral self-care. In their most recent treatment, conservative (39%) and non-conservative (34%) treatments dominated, and preventive ones were the least reported (7%). Regarding guidance in oral self-care, 54% reported having received such about toothbrushing, 32% about interdental cleaning, and 33% had been given visual information. Clinical examinations revealed the presence of plaque, calculus, bleeding on probing and deepened pockets in all of the subjects; 70% of the subjects were diagnosed with pockets of 6mm and deeper, 94% with caries, and 73% with overhangs of restorations. Those subjects assessing their knowledge of oral self-care as good and reporting a higher intensity of guidance in oral self-care as received, indicated practicing the recommended oral self-care more frequently. Twice daily toothbrushing was associated with good self-assessed knowledge of oral self-care (OR 4.1, p<0.001) and a university education (OR 5.6, p<0.001). Those subjects with better oral health behaviour had a greater number of teeth. Having 21 or more teeth was associated with good self-assessed knowledge of oral self-care (OR 4.1, p=0.03). Better periodontal conditions were associated with a higher frequency of toothbrushing. The presence of periodontal pockets of 6mm and deeper was associated with the level of self-assessed knowledge of oral self-care being below good (OR=3.0, p=0.04) and the level of dental cleanliness being poor (OR=2.7, p=0.02). To conclude, oral health behaviour and conditions call for improvement in elderly subjects in Lithuania. To improve the oral health of their elderly dentate patients, dentists should apply all the available tools of chair-side prevention and active guidance. The latter would be an effective means of updating the knowledge of oral self-care and supporting recommended oral health behaviour. A preventive approach should be strongly emphasized in countries with limited resources for oral health care, such as Lithuania. Author’s address: Sonata Vyšniauskaite, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, P.O.Box 41, FI-00014 Helsinki, Finland. E-mail: sonata.vysniauskaite@helsinki.fi

Dental Service Utilization, Dental Health Production and Equity in Dental Care: the Finnish Experience

This thesis is grounded on four articles. Article I generally examines the factors affecting dental service utilization. Article II studies the factors associated with sector-specific utilization among young adults entitled to age-based subsidized dental care. Article III explores the determinants of dental ill-health as measured by the occurrence of caries and the relationship between dental ill-health and dental care use. Article IV measures and explains income-related inequality in utilization. Data employed were from the 1996 Finnish Health Care Survey (I, II, IV) and the 1997 follow-up study included in the longitudinal study of the Northern Finland 1966 Birth Cohort (III). Utilization is considered as a multi-stage decision-making process and measured as the number of visits to the dentist. Modified count data models and concentration and horizontal equity indices were applied. Dentist s recall appeared very efficient at stimulating individuals to seek care. Dental pain, recall, and the low number of missing teeth positively affected utilization. Public subvention for dental care did not seem to statistically increase utilization. Among young adults, a perception of insufficient public service availability and recall were positively associated with the choice of a private dentist, whereas income and dentist density were positively associated with the number of visits to private dentists. Among cohort females, factors increasing caries were body mass index and intake of alcohol, sugar, and soft drinks and those reducing caries were birth weight and adolescent school achievement. Among cohort males, caries was positively related to the metropolitan residence and negatively related to healthy diet and education. Smoking increased caries, whereas regular teeth brushing, regular dental attendance and dental care use decreased caries. We found equity in young adults utilization but pro-rich inequity in the total number of visits to all dentists and in the probability of visiting a dentist for the whole sample. We observed inequity in the total number of visits to the dentist and in the probability of visiting a dentist, being pro-poor for public care but pro-rich for private care. The findings suggest that to enhance equal access to and use of dental care across population and income groups, attention should focus on supply factors and incentives to encourage people to contact dentists more often. Lowering co-payments and service fees and improving public availability would likely increase service use in both sectors. To attain favorable oral health, appropriate policies aimed at improving dental health education and reducing the detrimental effects of common risk factors on dental health should be strengthened. Providing equal access with respect to need for all people ought to take account of the segmentation of the service system, with its two parallel delivery systems and different supplier incentives to patients and dentists.