Endometriosis often leads to a decrease in Quality of Life (QoL), due to its impact on various aspects of women’s lives, such as social life, mental health, sex life, and working capacity. Although previous studies have assessed QoL in women with endometriosis, few studies have explored the impact of different clinical variables on QoL. The aim of this study was to investigate how women with endometriosis perceive their QoL, and to analyze which clinical factors are associated with QoL.The Endometriosis Health Profile-30 and the ENDOCARE Questionnaire were distributed to 1000 women diagnosed with endometriosis from 10 different clinics across Sweden. The responses from 476 women were included in univariate and multivariable regression analyses, where the clinical factors were correlated with overall QoL and QoL dimensions.The women participating in this study reported a low QoL. The clinical factors that showed a significant correlation with overall QoL were age at first onset of endometriosis symptoms , having more than 10 visits to general practitioners before referral to a gynecologist , current or previous mental health issues  patient-centeredness  and use of opioids .This study shows that opioid use and mental health issues were associated with a worse QoL, whereas a higher degree of patient-centeredness was associated with a better QoL. The association between opioid use and a worse QoL might not entirely be caused by the opioid use itself but also by symptom severity and mental health issues. An improved patient-centeredness and more focus on taking care of mental health issues would reasonably result in a better QoL for women with endometriosis. Endometriosis is a chronic disease that affects approximately 10% of women during their reproductive years . The conEndometriosis often has a negative impact on Quality of Life (QoL) as it affects several aspects of women’s lives, including social life, mental health, sex life, and working capacity –11. PrevWhether clinical factors such as having a responsible gynecologist to care for endometriosis, a plan for regular follow-ups, diagnostic delay, and experienced level of patient-centeredness, may affect QoL thus remains unknown. It is crucial to investigate the potential impact of different clinical variables on QoL in women with endometriosis since a better understanding can form a basis for targeted improvement of endometriosis care. Therefore, the aim of this study was to investigate how women with endometriosis perceive their QoL, and to analyze which clinical factors are associated with QoL.This is a cross-sectional study conducted on a national sample of women with diagnosed endometriosis. Participants were recruited from three university hospitals, five county hospitals, and two district hospitals in Sweden.A contact person from each of the participating clinics obtained a list of social security numbers for 150 women aged 18 and older who were diagnosed with endometriosis (ICD-10 codes N80.1-N80.9) and had visited the clinic during the last five years due to endometriosis-related symptoms. From each list, 100 women were randomly selected and invited to participate in the study via an invitation letter including patient information, a link, and a QR code to access the digital survey. The survey included clinical and sociodemographic questions as well as validated instruments to measure QoL and patient-centeredness. Women who chose to participate provided informed consent by completing the survey, and a reminder was sent to those who did not respond within three weeks. Data was collected in September 2021.The EHP-30 is an instrument used to measure QoL, consisting of 30 items divided into 5 different dimensions: Pain (11 items), Control and Powerlessness (6 items), Emotional Well-being (6 items), Social Support (4 items) and Self-Image (3 items). The items are answered on a 5-point Likert scale. The scores in each dimension generate a sum score ranging from 0 to 100, where a higher score indicates a worse QoL. Each sum score is calculated by using the following formula: Sum of scores for each item in the dimension / (4 (maximum score per item) x no. of items in the dimension). Besides the sum scores for each dimension, an overall score for the five dimensions combined is calculated using the same formula.The EHP-30 is considered a valid, reliable, and disease-specific instrument , 15 thatThe ECQ is an instrument that allows women to rate their experience with different organizational aspects of healthcare and grade the importance of these aspects. It can be used to compare patient-centeredness between different clinics and to identify targets for improvement . ECQ is The instrument consists of two parts. The first part includes 21 questions about background data, such as age, education, employment status, and endometriosis-related symptoms. The second part consists of 38 statements about different situations and aspects of the care the woman receives. She grades her agreement with the statements and the importance of the aspect on two 4-point Likert scales . The ECQFrom EHP-30, a total QoL sum score was calculated, and sum scores for each of the 5 different dimensions. The total patient-centeredness score was calculated from the 10 dimensions of the ECQ. Missing answers were omitted from the calculations. Demographic data and clinical variables were presented as frequency and percentage for nominal data, and mean and standard deviation for interval data.To identify clinical risk factors for low QoL, both univariate linear regression and multiple regression analyses were conducted. In the univariate regressions, clinical factors were assessed for their association with total QoL scores. Clinical factors with a p-value less than 0.2  in the uThe following clinical factors were included in the regression analysis: ‘age at first symptoms of endometriosis’, ‘diagnostic delay’ (time from symptom onset to diagnosis), ‘endometriosis severity’, ‘>10 visits to general practitioners before referral to a gynecologist’, ‘having a responsible gynecologist to care for endometriosis’, ‘ever tried to conceive for > 12 months’, ‘previous or current mental health issues’, ‘usage of hormonal treatment’, ‘usage of opioids’, and ‘patient-centeredness’. The variable regarding number of visits to general practitioners before referral to a gynecologist was dichotomized using the cutoff value of > 10 as the answers ranged between 0 and 1000. The variable regarding severity was dichotomized as minimal/mild and moderate/severe.The clinical factor ‘usage of opioids’ was created by reviewing all free-text answers to determine which pain medications were used. ‘Patient-centeredness’ was determined by calculating the total patient-centeredness score from the ECQ. The other clinical factors included in the analysis were derived from answers in the first part of the ECQ.2. The data analysis was performed in IBM SPSS Statistics version 28.The level of significance was set to p < 0.05. Regression coefficients (β) represent the mean change in the outcome variable  for every 1-unit change in the independent variable . The explained variance of the multiple regression model was presented with adjusted RA total of 476 women completed the digital survey, resulting in a response rate of 48%. Background information and clinical factors are presented in Table The results from the EHP-30 are presented in Table Table The results for the QoL dimensions were similar to the associations with overall QoL, with some exceptions. ‘Having a responsible gynecologist to care for endometriosis’ was significantly associated with the ‘control and powerlessness’ and ‘pain’ dimensions, and ‘usage of hormonal treatment’ was significantly associated with the ‘pain’ dimension.2 for the model was 0.34, meaning that 34% of the variance in overall QoL scores was explained by the clinical factors included in the model. The VIF was less than 5 for all variables, suggesting that there was no considerable multicollinearity between any of the factors [The multivariate linear regression results are presented in Table  factors .Previous or current mental health issues was associated with worser overall QoL , and this was the factor with the strongest association with QoL. Further, usage of opioids was associated with significantly worse overall QoL , as was lower patient-centeredness . Having >10 visits to general practitioners before referral was also associated with a worse overall QoL . Additionally, younger age at first symptoms of endometriosis was associated with worse overall QoL . The only non-significant clinical factor in the multiple regression against overall QoL was diagnostic delay.Regarding the QoL dimensions, using opioids was associated with worse outcomes in the ‘pain’ , ‘control and powerlessness’  and ‘social support’  dimensions. Having previous or current mental health issues was associated with worse outcomes in the ‘emotional wellbeing’ , ‘social support’  and ‘self-image’  dimensions respectively. Further, having a responsible gynecologist to care for endometriosis was associated with worse outcomes in the ‘pain’  and ‘control and powerlessness’  dimensions, while diagnostic delay was associated with worse outcomes in the ‘pain’  and ‘emotional wellbeing’  dimensions. Having > 10 visits in primary care before referral was only associated with worse outcome in the ‘self-image’  dimension, and usage of hormonal treatment was associated with better outcome in the ‘pain’ dimension . Finally, lower patient centeredness and younger age at first symptoms of endometriosis were associated with worse outcomes in all dimensions.To the best of our knowledge, this is the first study to use an endometriosis-specific instrument to measure QoL and assess how clinical factors affect QoL in women with endometriosis. In comparison with previous studies , 23 the A prior study found that anxiety and depression were associated with worse QoL , which iAnother clinical factor that showed a strong correlation to QoL was the usage of opioids. More specifically, there were significant associations between using opioids and scoring worse in the ‘pain’, ‘control and powerlessness’ and ‘social support’ dimensions. Scoring worse in the ‘pain’ dimension suits well since women who are prescribed opioids typically experience more pain, and pelvic pain has been shown to decrease QoL in other studies , 13. MorHaving a responsible gynecologist to care for endometriosis was significantly correlated to the ‘pain’ and ‘control and powerlessness’ dimensions. It can be speculated that only the more severe cases of endometriosis have a responsible gynecologist, and that these women experience more pain than the average endometriosis population. Similar to the arguments about opioid use, having a responsible gynecologist might also reflect a higher disease burden, and thereby a diminished sense of control over your situation. Yet, a recent study identified having a responsible gynecologist to care for treatment and follow-up as the single most important factor for experiencing high patient-centeredness .A lower age at first symptoms of endometriosis was associated with a worse QoL. Earlier research has shown that younger women with endometriosis tend to experience more symptoms  and repoA higher degree of patient-centeredness was associated with a better QoL, which is consistent with previous qualitative studies showing the importance of patient-centered factors for women’s health . Apers eIn our study population, 52.5% of the women had a higher education, which is similar to the Swedish population of the same gender and age . AdditioThe response rate of 47.6% in our study is considered acceptable. We were able to obtain a large sample size, allowing for more precise conclusions that can be applicable to the general endometriosis population. Additionally, a strength of our study is that only women with diagnosed endometriosis were included. In some other studies, self-reported endometriosis is used, making it more difficult to interpret the results for the endometriosis population.Since the study was conducted in Sweden, the results may not be generalizable to populations in other countries, as healthcare systems and cultural factors may differ. Furthermore, our study design only allows for correlations to be drawn, and not causality. Therefore, it is not possible to determine whether the factors identified in our study directly influence QoL or are simply associated with it. As with all self-reported surveys, there may be a risk of response bias, as women may be hesitant to report sensitive information or may not fully understand the questions being asked. Finally, another limitation of this study is the possibility of recall bias, as some answers to questions may be more difficult to recall accurately than others, which could impact the validity of the results. For example, both diagnostic delay and the number of visits to general practitioners before referral to a gynecologist are factors that can be affected by recall bias, as it requires the woman to remember events that may have happened many years ago.Several clinical factors showed a significant correlation with QoL, especially mental health issues, opioid prescription, and patient-centeredness. Mental health issues and opioid prescription was associated with a worse QoL, whereas a higher degree of patient-centeredness was associated with a better QoL. The association between opioid use and a worse QoL might not entirely be caused by the opioid use itself but also by symptom severity and mental health issues. An improved patient-centeredness and more focus on taking care of mental health issues would reasonably result in a better QoL for women with endometriosis.


On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs.We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients’ management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists.The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers.Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication’s timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.The online version contains supplementary material available at 10.1186/s12877-023-04131-6. Generally, senior citizens use five or more prescription medications daily . While aHealthcare sector transitions increase the risk of information loss, misunderstandings, unclear treatment responsibilities, and medication errors –17. MediIn Denmark, all patient-prescribed medications are listed in the “Fælles Medicinkort”, an online Shared Medication Record (SMR) accessible by patients and healthcare professionals across sectors –22.The patients are central to ensuring correct medication, as they are often responsible for buying, remembering and taking their medication . One DanResearch shows that patients experience medication errors, misunderstandings, discontinuity, information loss, and other obstacles after sector transitions –17, 25. This study explored the medication challenges that older patients treated with five or more drugs met.We performed qualitative semi-structured focus group interviews (FGI’s) among patients, relatives, and healthcare professionals to represent experiences from various central actors. FGI’s are beneficial in exploring an informant’s knowledge and perspectives . In addiInclusion was based on consecutive sampling among patients admitted to the Emergency Department at Hospital Sønderjylland for ten days in April, May, and June 2021. In addition, the healthcare professionals were included by purposeful sampling inviting specific people from the primary and secondary healthcare sectors from the same uptake area.Patients admitted acutely to the emergency department were invited to participate if they were 72 years or older and managed five or more medications themselves or with the help of a relative. The first author identified patients that matched the age inclusion criteria and excluded patients with known dementia. Then, the last author assessed if the patient met the inclusion criteria, e.g. examined how many medications the patient took daily and contacted the nurse responsible for the patient to confirm that the patient matched the inclusion criteria. Next, the nurse asked the patient if the first author (THM) could contact them regarding the research project. If the patients accepted, THM approached them, informed them, and invited them to participate. If the patient agreed to participate, the interviewer (THM) informed them in more detail verbally and in writing about the details of the study.Patients who agreed to participate were invited to participate in a focus group interview with other patients at a later date. Overall 31 patients were eligible. One patient were not invited due to confusion. In addition some patients were either discharged or transferred to another department before they were contacted. A total of 10 patients, here of three with a spouse, accepted the invitation to the FGIs. One of these died before the FGI and another did not show up. In the FGI with the relatives’ one of the patients were too ill to participate while the spouse participated.Hospital staff were invited by an internal email sent to the relevant departments. An email was sent to head nurses at the departments of geriatric, internal medicine, and emergency at Hospital Sønderjylland, asking if they could contribute to the study by allowing one of their nurses to participate. Consultants from the same departments were invited directly by email. Hospital and local pharmacists were also invited to participate directly by mail. Homecare nurses were invited via an email to the municipalities in the uptake area. General practitioners (GPs) and nurses employed in general practice were invited by an email to the general practices familiar to the authors and also welcomed other colleagues from the uptake area.At startup, the informants were informed verbally and in writing about the study’s details and asked to sign a consent form.Five FGI were conducted with various healthcare professionals, and in FGI E a patient and a relative were also included:FGI A − 2 chief physicians , 1 hospital nurse (Emergency Department), and 1 hospital-employed pharmacist.FGI B − 5 nurses from general practice.FGI C − 2 homecare nurses, 1 homecare assistant, and 2 pharmacists.FGI D − 2 GPs.FGI E − 1 GP, 1 homecare nurse, 1 hospital-employed pharmacist, 1 patient, and 1 relative.Three FGI were conducted with patients as well as patients and relatives:FGI F − 2 patients and 3 relatives.FGI G − 2 Patients.FGI H − 3 patients.If possible, we wanted to carry out an FGI with health professionals, patients, and relatives. Hence the patient and the relative in FGI E also participated in FGI F with patients and relatives. Furthermore, the patient and relative were invited to FGI E after participation in FGI F, because they could enrich the dialogue by interacting with the healthcare professionals  Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/Pill organizers.Relative D: Remembering medication, we have an alarm on our phone because we have a vegetable garden, and when you walk around in the garden, you forget what time it is, so I always have an alarm reminder.In general, patients and relatives do not experience problems remembering their medicine, but if they are not in their home environment or are focused on something else, medication can sometimes be forgotten. One strategy used was a telephone alarm as a reminder:Relative X: Yes, that’s what I’m thinking about too. What you can forget about it is that if you are on holiday in a hotel and you have to eat but have forgotten your pills. You have to remember to have them with you every time.Disruptions of routines, for example, during holidays, can cause forgetfulness:Pharmacist Y:… and it’s not that easy. I just had a course of penicillin for 8 days, and again and again I forgot it, I’m at work in the morning, I forgot it. In the afternoon I was busy, I forgot it again, so I only had one tablet all day. It happens, it’s really hard to remember. “God, I forgot it again”, and I give advice every single day, every single second behind the counter, “remember to take your medication” right?These experiences match healthcare professionals’ experiences that without a routine, patients often forget, e.g. a penicillin regimen: A routine support to remember to take the medication is useful. Therefore, younger and more active people primarily benefit from medication reminders on the telephone.There is a big difference in how patients manage their medication. Some store the medication in a bag they take out as needed, others distribute them into small containers the night before, and some store them in the kitchen cupboard. Interestingly none of the informants used a telephone app to manage medications.Patient M: My wife controls my medication because we have those pillboxes.Relative K: Well, every Friday it must be refilled. And I sit down and put the medication in the right boxes. Then in the morning, he gets it (the pillbox), swallows the pills when he eats.Many women manage their own medication, whilst men, tend to receive help from a partner:Relative D: Yes, my husband, needed to take a new kind (of medication) and he also has a bad kidney, and then he read that kidney patients should not take them. So that’s why he didn’t take them. And so when we came to the hospital for control, we told them. Then they said, well such a small dose, you can tolerate, it’s only 4mg or something like that. But still, he damn well did not want them. But he had to do it anyway, because it helped the kidney test results, after all.Some of the patients are intentionally non-compliant and one patient decided not to take the newly prescribed medication after reading the package leaflet:Patient Y: …when I read the leaflet I was thinking, oh my God, I can get a bowel obstruction or constipation. Then I put it up on the shelf because I’d had one before (bowel obstruction), I knew I wouldn’t dare, whilst I was on so much medication, I thought they might affect each other negatively. I had to tell them that I hadn’t taken this powder, but I kept to the diet in another way. It achieves the same.As one patient explained:After reading the package leaflet, the patients were concerned about the side effects and therefore chose to avoid taking the medication.Patient Y: … when I was taking a diuretic, I said that I knew the dose was too high - and after I told them, they said, OK let’s reduce the dosage now.Another patient described that after a minor operation, he stopped using a new painkiller (morphine) after experiencing uncomfortable side effects such as vomiting and chose to use paracetamol and accept a degree of pain. However, other patients seek professional advice before altering their medication.Thus, intentionally choosing non-compliance is a phenomenon relatively common among patients.Patient E: About 7 pills in the morning and 4 or 5 at night. It is written there on the shelf, just like in the pharmacy. But that’s also the problem, the moment you come to the pharmacy, they change the boxes. Then you have to change your whole system of rows. There are a lot of copy products and it’s rare to get the same original pills. They are often out of stock when you come in. Then you get some new ones- so you have to change… and the labelling on the packet says nothing… It has been really troublesome. I think it’s really difficult.One patient explains that dealing with polypharmacy in everyday life is difficult. She describes an ingenious system in her kitchen cupboard, where the medication boxes are arranged in a row with names, numbers, and times written on shelf stickers under the boxes:General practitioner L: It is a big challenge…from the general practice perspective. There is a constant shift between medical brands because of the price, and the pharmacy is obliged to take the cheaper product. The medication then looks different, the packaging is different, and it does confuse older people extremely.This patient had been through many assessments at several hospitals and many changes in medication. If the prescribed medication is out of stock, she often has to buy a generic product resulting in a different brand, name, and packing, which is confusing for the patient. This was described well by one of the general practitioners:Primary Care Nurse 4: It’s quite a cocktail they sometimes come up with. And some become confused, but I think it’s more due to the names. I think the hospital is good at printing medication lists and giving the patient the medication (to ensure they have enough until they manage to get to a pharmacy (ed)). I actually think most people get it. Nevertheless, the problem is that it is just not called the same.A treating physician or pharmacist often gives patients a medication list. It is a great help for the patient and enables them to track their medication. However, it can confuse patients when the medication has a name that does not correspond with the patient’s medication list. For example, a nurse from general practice explains:General practitioner 2: Maybe you should write the generic and alternative names on the list of medications that’s handed out to the patients because it’s definitely a huge problem.A general practitioner also acknowledges the problem and suggests an addition to the list:This simple, practical solution may reduce the patients’ confusion when they are given copy medication instead of the prescribed medication, which is a problem that preoccupies and confuses patients.Relative K: You aren’t really told how long the time should be in-between. At the moment, he gets quite a lot of medication in the morning, lunch is around 12 − 1 o’clock, but when he gets these lunch tablets does that harmonize with the fact that it is so soon after he has received his morning tablets? Because M, you like to sleep until 9–9: 30, so lunch is between 12 − 1. So we asked if it was OK? That’s good enough, they said… I just think...Many patients expressed doubt about the timing of the medication intake when instructions indicate 3 or 4 times a day.Relative D: Now I have also brought my husband’s medication list with me. The first page says morning, noon, evening, and night, and that’s fine - then I know when he should have them. But then further down there is just one capsule daily, and another that does not say when… it just says the dosage and nothing else.As the quote shows, morning is not a straightforward concept, and when the patient gets up late, there is a relatively short time between morning and lunch medication. Therefore, patients and relatives would like more precise statements about how the medication is best taken, even if it only regards one pill per day in combination with other kinds of medication:Patients need to be given a recommended timetable when taking multiple prescriptions to relieve anxiety about possible interactions with other medications.Relative K:… at the pharmacy, they said that these two medications don’t match together well, and they could perhaps find another one. ” Well, what’s best for you, is what you need. ” . It’s as if no one wants to go in and revise it. Once you get a diagnosis …., then you get some pills that you keep getting. They just get prescribed all the time. No one goes in and revises… It can be a little frustrating sometimes. Also when you see how bad he gets, because he can’t keep his balance. It’s hard to get a clarification somewhere about it.The combination of many different doctors, pharmacist alerts to medication interactions, and warnings on package leaflets combined with symptoms results in confusion and insecurity among patients and relatives:…Patient M: And then he  says, “Well, I can’t do that”, or “No, it was (prescribed at ed.) the heart department”. “I can’t deal with that, you’ll have to call the hospital, the cardiac department ”. So, I did. Then the cardiac department says, “Your own doctor could do that.“ So you just get thrown back and forth”.Patients with polypharmacy are very concerned about side effects and adverse drug reactions, stemming from combining medications; hence they search for better options for a medical review. However, patients often experience doctors’ reluctance to reconsider or change prescriptions if initiated by other doctors.Patient M: I asked if taking all those tablets on the medication list was necessary. I asked my own doctor and here in Aabenraa at the hospital. And they said, “Well, these are the tablets you have to take.“Although general practitioners and hospital physicians take responsibility and adhere to the medication list, it is not always sufficient reassurance for the patient:Relative K: It’s a bit annoying. You’re left with a feeling of “argh”. Well, I don’t mean to say that they don’t know what they are doing, but sometimes you think, it’s some kind of “oops” (random ed.) the lot of it.The fear of medication interactions can weaken patients’ and relatives’ trust in doctors:In attempting to navigate between many different and divergent, contradictory pieces of information, patients’ and relatives’ trust in information from health professionals can be eroded. Interestingly, all participating patients and relatives expressed a degree of insecurity regarding their medication.Patient Y: When I came home from the hospital and had been through extensive heart surgery, they filled me with medication to get me up (on my feet (ed.)) again. We went to the municipality’s homecare team and got them to pack my tablets. And that meant that they packed my medication in pill organizers a month at a time.Dose dispensing using blisters delivered from the pharmacy or pill organizers packed by the municipality’s homecare team are options available to the patient to reduce medication errors. A few patients had tried pre-packed pill organizers and indicated they were satisfied with the solution, but none had tried dose dispensing using blisters.Interviewer: okay, so they come in small packages? Morning, lunch, night, etc. Right?Patient Y: Yes, morning, lunch, and evening. It works damn well.Relative X: And if there are changes to the medication, they fix that too. Mostly, if it’s just one (pill ed), and I know which pill it is, then I remove It from the pill organizer, but otherwise, the municipality comes and does it.Although the patient and his relative are competent, there is an obvious risk of incorrect medication. This risk is present for all patients that manage their own medication but is higher for patients managing multiple prescriptions.M (mixed FGI): We are so happy that we have the nurses to pack my medication, it’s worth its weight in gold. It is so important to know the timing of the medication.Patients expressed satisfaction with dose packing in pill organizers by the homecare team:Primary Care Nurse 4: We would rather not use it. When the medication is changed, it takes 14 days before the changes take effect.Chief Physician M: Dose dispensing. … it’s a bloody nuisance, as far as we are concerned, because it is a huge problem when you’re hospitalized, and we need to make  changes. There can be a huge expense associated with it, especially if the patients have just got a new roll .No patients experienced or mentioned the cost of having the medicine packed by the homecare. While no patients had tried dose dispensing using blisters delivered from the pharmacy, this solution was mentioned by healthcare professionals who stated that dose-dispensing using blisters could either delay changes in the medication or be expensive for the patient if the blister-packed medication is thrown away:Thus, healthcare professionals find that dose dispensing using blisters can be expensive if pre-packed medication must be repackaged or thrown away, for example, because of changes to a patient’s medication or may delay adjustments to changes hence risking incorrect medication. However, for patients in contact with the municipality, homecare can be helpful and provide professional packaging of medication in pill organizers free of charge.This study furthers our understanding of why older patients with polypharmacy continue to have issues regarding medication management and often ask for a medication review. First of all, this study shows that older patients and nurses request an accurate indication of the timing of the medication. Despite all patients’ interest in managing their medication, information describing adverse events and harm from various sources results in confusion and, for some patients, intentional non-adherence. Therefore, many older patients request medication reviews simply for reassurance about correct medication and the opportunity to obtain more explicit guidelines, such as the most optimal time to take the medication, to minimize the risk of interactions. In addition, the pharmacy’s legal obligation to supply the cheapest medication results in constant changes in the brand names of medications contributing to the confusion of patients and many requests for medication reviews. Hence the medication lists handed out to the patients might be improved by adding the names of the generic and alternative medications.Medication management is a task that must be fitted into daily routines and differs substantially between patients . For exaMedication lists are important for patients to track what medication they are using. A treating physician or pharmacist often hands out the medication list to the patient. However, it can confuse patients when the medication has a name that does not correspond with the patient’s medication list due to generic substitution.Previous research has shown that patients become confused and uncertain when original-brand name medication is substituted for a cheaper generic medication, increasing the risk of the patient making medication errors –36. ThisFor frail older patients with difficulties managing their medication, the opportunity for assistance from the municipalities’ home care is vital. Patients with suspected declining mental function risk losing their ability to manage medication and should be offered help.In this study, the timing of medication was important for patients and relatives with specific requests for more precise instructions about when medication should be taken to ensure optimum treatment and avoid interactions. Patients request a recommendation for a specific time, even if the medication only needs to be taken once a day. In Denmark, instructions for prescribed medication commonly state that the medication should be taken, for example, morning, noon, and evening. Extra information about timing could be provided in writing regarding when medication should be taken, e.g. every 8 h with a deviation of +/-2 h or combined after dialogue with the patient about specific, suitable times and added to the medication list. In addition, a graphic illustration of medication timing for polypharmacy patients may improve understanding. However, improving this factor should be tested in a rigorous research design to see if it can improve medication adherence.Studies show that patients are often concerned about the side effects and interactions with other prescribed medications , 38. MedPatients and relatives describe needing an overview of possible side effects and interactions. This could easily be built into an app assisting patients in remembering their medication. However, our FGI’s also show that the participants aged 72 or older chose not to use an app for medication management. A study from 2014 indicated promising results when an app was used for patients aged 65 and above . HoweverInterestingly, some patients choose to discontinue medication based on information from package leaflets and wait until a future appointment with the physician to discuss the decision . SimilarA systematic review of interventions to increase medication compliance showed that verbal and verbal/written information was the most effective . The autThe patients and relatives do not report significant problems in remembering to take their medication except when routines are interrupted or they are preoccupied, which is similar to other studies that reported that age itself is not a predictor of non-adherence . HoweverWhile medication management is a practice that must be fitted into everyday life, it is also the subject of many considerations, concerns, and wishes among patients and relatives. The patients in this study who had tried dose dispensing in pill organizers packed by the home care team were satisfied with the service. Whilst there were no patients that had tried dose dispensing using blisters. Blister-paced dose dispensing also makes adjustments difficult, especially during a pre-packed period. Other studies also show that dose dispensing can make it difficult for the primary care sector to maintain an overview of the patient’s medication after discharge from hospital . AnotherWhile the medication lists greatly help the participating, well-functioning patients, patients request more guidance and knowledge about their medication. Our study indicates that this should include suggestions for when the medication can be taken, combined with intervals showing how much the patient can deviate from this schedule. Nurses also requested this knowledge, which may reduce the number of phone calls to the GPs. In addition, the medication list could be supplemented with a list of generic medications that can replace the prescribed medication helping the patient to maintain an overview of which generic medication can replace the prescribed medication. This solution could be created digitally as an app. The design and applicability of these elements should be examined in a rigorous future research design examining whether lists of side effects and interactions help the patient establish an overview and increase confidence in the medications and perhaps reduce patients’ desires for a medication review.Patients were interviewed after discharge from the hospital. However, they were asked if they would participate in the study during their hospitalization where they were informed verbally and provided with patient-oriented information material. After discharge, the patient was contacted by telephone by THM to arrange the FGI. Hence, the patients had the opportunity not to participate. Approaching the patients at the hospital may be a limitation if patients felt obliged to participate. However, the patients had many other opportunities to decline participation.Bias may occur if the informants do not speak their minds and may always affect FGI’s. Hence the surroundings and meeting facilities may influence the participants, and the participants may have affected each other. Therefore, it is important to ensure good meeting facilities and a good dialogue, ensuring that different opinions and experiences are heard without judgments. The meeting rooms at the hospital were arranged as classic meeting rooms without hospital characteristics, and neither interview nor analysis shows that the informants were affected by the environment. One of the FGI’s comprised of a patient and relative as well as a GP, pharmacist, homecare nurse, and in the FGI the patient may have felt insecure and refrained from speaking out. However, the patient and the relative did not seem affected and spoke freely, and the atmosphere was friendly and relaxed. Their participation is considered to be a strength as they participated and enriched the discussion in the group. However, their participation may also have caused healthcare professionals to moderate their opinions of patients, treatments, or medications to avoid offending the patient and relative. THM is a trained researcher in qualitative methods and ensured that the participants had good opportunities to speak their minds by asking open-ended questions and additional non-biased clarifying questions. THM ensured that all voices were heard and all experiences and opinions were accepted and debated properly. As a sociologist, THM had no prior expectations regarding patient medications and the possible problems facing older patients after discharge from hospital or knowledge of medication challenges forhealthcare professionals.A strength of this study is that patients and relatives managed medication daily and were mentally well functioning. They answered relevantly and clearly and participated in the dialogue with the interviewer and the other informants expressing experiences and feelings. A limitation of the study is that frail senior citizens may be underrepresented,and patients taking no particular interest in their medication might be expected to decline participation in the FGI’s. However, the participants had a high degree of knowledge about their conditions and were willing to discuss the central problems of polypharmacy. Patients are probably the best informants to highlight the factors preoccupying this target group. Another limitation is that all participating patients were Danish, so the results may not represent issues relevant to older patients of other ethnic backgrounds.FGI’s allow participants to challenge, elaborate, and clarify questions illuminating the informants’ opinions. Likewise, FGI’s, including patients and healthcare professionals, create a platform for listening to a unique dialogue. Including healthcare professionals enables the perspectives of weaker patients or patients with no particular interest in their medication to be included.Physicians must prioritize giving information regarding when medication should be taken, including an acceptable timespan deviation to reduce patient concern about potential medication interactions. Timing of the medication is also requested by hospital and homecare nurses,. Medication lists are helpful to well-functioning patients and may be supplemented by a list of generic medications that can replace the prescribed medication helping the patient to maintain an overview of the medication. However, information from different actors compared with information from package leaflets, may lead to intentional non-adherence. Therefore, patients often request a thorough medication review to ensure an overview of the medication, side effects, interactions, and timing. Future studies should address whether the patients may benefit from a list or an app including more information about these aspects. In addition, the design and applicability of these elements should be examined in a future rigorous research design which could explore whether lists of side effects and interactions help the patient establish an overview, increase confidence in the medications, and perhaps reduce patients’ desires for a medication review.Below is the link to the electronic supplementary material.Supplementary Material 1


Dear Editor,,,First, we would like to thank the authors of the letter: “Drugs available through the Farmácia Dose Certa program and Beers criteria: a further analysis” for their comments. Our group has been working on polypharmacy, the Beers-Fick criteria and adverse drug effects among the geriatric population for many years.Due to space restrictions, we decided to consider only the first Beers-Fick criterion “drugs or drug classes that should generally be avoided for people over 65 years of age, because they are ineffective or have a high risk of unnecessary adverse effects when a safer alternative is available”. The second criterion, which should be considered according to specific known conditions, would be very complex for this paper, because for each medical condition, there is a full range of drugs that must be avoided. For instance, those with stress incontinence may not use the following drugs: alpha-blockers , anticholinergics, tricyclic antidepressants  and long-acting benzodiazepines.In order to ease the interpretation of our article, we decided to include only the first Beers-Fick criterion. Nevertheless, a further article dealing with the second criterion could be also helpful.We believe that our paper has fostered discussion about whether geriatric patients should be treated more carefully than the general population, in public healthcare programs.


For instance, following government and organizational directives, the pandemic influenced: who can interact with whom; when they can do it; and how, including the information they are (not) privy to, the resources they can(not) access, and when. These changes can compromise the organizational practices of a health service, morale, and the wellbeing of those affiliated with the service, such as staff members (including volunteers) as well as patients and carers.COVID-19—the term that changed the world. The COVID-19 pandemic shaped our personal lives, our professional lives, our educational and recreational pursuits, as well as how we die and grieve . HoweverAlthough change within health services can be slowed, if not stopped by bureaucracy and politics (among other factors), COVID-19 illustrated how swiftly change can happen in health services in the face of a global crisis. The world quickly became a village, as organizations across the government, university, private, and not-for-profit sectors collaborated and colluded to navigate and manage the pandemic. This might have been partly helped by similar challenges that many nations and health systems share, including aging populations , the incHowever, COVID-19 also amplified the differences between nations and health systems. Consider, for instance: the different shades of government involvement in healthcare—while some nations benefit from a healthy public health system, others do not ; the disIn response to the rapid spread of COVID-19, this Research Topic represents a complement of formative and thought-provoking articles that collectively advance the research and practice of health service management and leadership. The Research Topic offers opportunities to capture, learn from, and inspire managerial and leadership practices that have helpfully navigated this precarious period. It includes international exemplars to demonstrate what it takes and can take to manage and lead a health service to ultimately weather storms, like COVID-19.The importance and urgency of this Research Topic follow extant research, from which three key points are apparent. First, there are likely to be COVID-like pandemics in the future, partly due to the Anthropocene epoch –11. SecoGuo et al. demonstrated the use of virtual models to redesign the intrahospital transportation of patients thought to have COVID-19 to ultimately curtail transmission. Processes were also the focus of a scoping review—specifically, Best and Williams considered healthcare supply chain management and how personal protective equipment is sourced during pandemics. They concluded that, although little was learnt from previous pandemics, and despite the paucity of research from low- and middle-income nations, “planning… collaboration and relationship building” are pivotal when sourcing personal protective equipment during a pandemic. Dadich and Mellick Lopes also contributed a review—however, theirs is a lexical review; that is, an analysis of discourse to determine how words travel together. Following their lexical review of 36 articles on leadership during a pandemic, they offered two key findings— “First… leadership discourse was often associated with a single leader, rather than multiple leaders… This reinforces the way in which leadership is often attributed to an individual, rather than to a team of leaders”. Second, discourse about leadership was “somewhat disconnected from… stakeholders, including colleagues and patients, and relationships with these stakeholders”. Given these findings, they argued that there were considerable opportunities to advance scholarship on leadership during a pandemic. Naamati-Schneider and Gabay also considered the power of discourse—specifically, they examined metaphors of war in effective and ineffective coping among medical directors of COVID-19 wards in public hospitals. They found that “Effective coping was facilitated by war metaphors that created a sense of mission and meaningfulness at both the organizational and the individual levels. War metaphors that generated a sense of isolation and sacrifice intensified helplessness and fear, which undermined coping”. Their research has important implications for how information about pandemics is communicated and how others support can be bolstered and sustained. Specifically, they argued for “metaphors, analogies, and words that emphasize ideology and values that empower ”; furthermore, they proposed “avoiding metaphors, analogies, and words that emphasize distress and isolation”.The Research Topic is comprised of myriad article types, collectively presenting arguments about health service management and leadership during the COVID-19 pandemic. For instance, in their brief research report, Naamati-Schneider and Gabay, others also contributed original research. Consider, for instance, Petrie et al.'s ethnographic research to investigate innovation in rural health across four nations. Among their findings, they discovered the value of “absorptive capacity… community connections, and… some level of ignorance of the barriers to innovation”. Yet they called for future research to “understand how vulnerable or marginalized populations were supported, and to see how local services managed their relationships with provincial health departments, distant specialists, and other external actors”. In their original research article, Di Pumpo et al. demonstrated the value of queueing theory to maximize safety at, and the performance of COVID-19 vaccination sites. Notably, they verified how modeling premised on queueing theory helps to “quantify ahead of time the outcome of organizational choices on both safety and performance”. Dellve and Williamsson also offered original research to this Research Topic through their investigation of development work in aged care. Specifically, they considered “ongoing development work at the strategic and operational levels, noting the importance of this work for trustworthy operational management work”. They found differences between strategic-level development leaders and operational-level leaders. While the former “focused the strengthening of old adults' capabilities”, the latter “approached strengthening employees' capability”. Given aging populations worldwide and, relatedly, the growing strain on aged care services, this study has direct international relevance. Qian et al. offered the last original research article, the focus of which was a comparison of government policy and community participation to manage the spread of COVID-19. This interesting study concluded that government policy and community participation assumed different roles at different times—“although the government played a leading role in setting up policies, the broader participation of community fever clinics… and the general public were especially crucial in winning the battle against COVID-19 in the long run”.Like Lee and Wong who argued that, to manage a global pandemic, governance arrangements are required that “enable organic and responsive processes for all actors in society”—this can include hybrid modes where “(1) the state… undertakes coordination based on the consensus of actor-networks, (2) the market… is repurposed with a high-risk investment of the state, and (3) the network… is steered by traditional principles of public governance”. Amu et al. offered another perspective article focused on sub-Saharan Africa. They contended that “Long-lasting abysmal health system financing and insufficient government investment… pose major challenges to the effective health systems functioning amid the COVID-19 pandemic”—furthermore, they called for research to examine and improve responses to COVID-19 in sub-Saharan Africa. Finally, Balconi et al. co-authored an opinion article on monitoring strategies and intervention policies to enhance and protect advanced neuroscientific research, post COVID-19, in Italy. Drawing on an applied example—the MIRNA project—the authors demonstrated the value of a uniform approach to reinstate pre-pandemic practices. The example revealed the benefit of “standardized and shared practices… to ensure that R&D [research and development] overcomes this crisis and potential future challenges, while also protecting the public health and all actors involved in the strategic research field of basic, clinical and applied neurosciences”.Complementing the aforesaid articles are perspective and opinion articles. The perspective articles include that by Each contribution to this Research Topic highlights international efforts in response to a common challenge—COVID-19. And given the prospect of future pandemics, the value of the lessons presented in this Research Topic are likely to have value in the longer term. In the interim, the challenge for scholars, policymakers, as well as those who deliver and manage healthcare is to advance current understandings of health service management and leadership, to ensure that we garner and build on what we have collectively learnt through this international experience.AD wrote the editorial. SB, GM, and TW reviewed and approved the editorial. All authors contributed to the article and approved the submitted version.


Frailty is a condition in which the individual is in a vulnerable state at increased risk of adverse health outcomes and/or dying when exposed to a stressor […] Frailty is either physical or psychological or a combination of the 2 components and is a dynamic condition that can improve or worsen over time”  and present very different profiles. This difference in profiles should be considered and should not lead to the exclusion of some older adults through inclusion or exclusion criteria. For instance, as recently reported by Brach et al. , researcdesigns that are applied to experiments in which one entity is observed repeatedly during a certain period of time under different levels of at least one independent variable” [ or of individual-level failures, in order to better adjust and regulate the care. SCEDs should target frail older adults suffering from pathologies such as osteoarticular, sensorimotor, sensory, cognitive, and emotional diseases, and those who are typically excluded from group-based studies. This would make it possible to extend existing data on the effects of physical activity in frail older adults.NA: Conceptualization, Writing—original draft, Writing—review & editing. IC: Writing—review & editing. CA: Writing—review & editing.


The World Health Organization (WHO) has recently devoted special attention to oral health and oral health care recommending the latter becoming part of universal health coverage (UHC) so as to reduce oral health inequalities across the globe. In this context, as countries consider acting on this recommendation, it is essential to develop a monitoring framework to measure the progress of integrating oral health/health care into UHC. This study aimed to identify existing measures in the literature that could be used to indicate oral health/health care integration within UHC across a range of low-, middle- and high-income countries.A scoping review was conducted by searching MEDLINE via Ovid, CINAHL, and Ovid Global Health databases. There were no quality or publication date restrictions in the search strategy. An initial search by an academic librarian was followed by the independent reviewing of all identified articles by two authors for inclusion or exclusion based on the relevance of the work in the articles to the review topic. The included articles were all published in English. Articles concerning which the reviewers disagreed on inclusion or exclusion were reviewed by a third author, and subsequent discussion resulted in agreement on which articles were to be included and excluded. The included articles were reviewed to identify relevant indicators and the results were descriptively mapped using a simple frequency count of the indicators.The 83 included articles included work from a wide range of 32 countries and were published between 1995 and 2021. The review identified 54 indicators divided into 15 categories. The most frequently reported indicators were in the following categories: dental service utilization, oral health status, cost/service/population coverage, finances, health facility access, and workforce and human resources. This study was limited by the databases searched and the use of English-language publications only.This scoping review identified 54 indicators in a wide range of 15 categories of indicators that have the potential to be used to evaluate the integration of oral health/health care into UHC across a wide range of countries.The online version contains supplementary material available at 10.1186/s12903-023-02906-2. In 2015, the Member States of the United Nations (UN) set Universal Health Coverage (UHC) as one of the targets to be achieved by 2030 as a part of the Sustainable Development Goals (SDGs) agreement (Target 3.8) [Countries are making progress towards UHC, and governments have set different strategies to move towards this goal . These sThe 2017 Global Burden of Disease (GBD) study reports indicated that around 3.5 billion people are affected by oral diseases globally, including untreated caries in permanent teeth as the most common non-communicable disease (NCD) . Severe Along the same lines of the UHC strategies, in 2020, a The Lancet Commission on Global Oral Health  was estaIn 2021, the WHO published specific resolutions on oral health during their 148th session, and in the World Health Assembly resolution WHA74.5, explicitly mentioned repositioning oral health as part of the global health agenda in the context of the UHC . The resAround the same time but as a separate initiative, the World Dental Federation , which comprises national associations of dentists across the globe, published the “FDI Vision 2030” report addressing the assimilation of good quality, essential oral health services into the general medical health care system in every country by the year 2030 . This viTaken together, these separate initiatives of a Lancet Commission, the WHO and the FDI indicate that there is a strong world view to integrate oral health care into general health care and into UHC.WHO/WB framework in the rest of this article) to monitor the implementation and progress of UHC in health systems [To evaluate UHC implementation in a country, recommendations have been made on setting up a monitoring framework based on various elements . The sug systems . This WH systems . Most of systems . HoweverIn this context, the aim of this project was to identify indicators that that have the potential to demonstrate the extent to which oral health care is integrated within general health care and UHC across a broad range of low-, middle-, and high-income countries.A scoping review “provides a preliminary assessment of the potential size and scope of available research literature. It aims to identify the nature and extent of research evidence ” . This scSix hundred and eleven 611) document records were identified through searching the above-mentioned databases. The exclusion of the duplicates resulted in 415 records. Two team members screened the 415 articles’ titles and abstracts independently to explore the documents potentially relevant to the aim of the study and the research question. Following this primary title/abstract screening, 114 articles were removed from the search list as they were either unrelated to the primary concept of the study or in languages other than English. The result was that 301 articles were fully reviewed by two team members independently. The goal of this project was to identify indicators that could be used to measure a health care system’s progress towards integrating oral health care into UHC. In view of this, we included articles with indicators of service utilization, insurance coverage, care expenses, health facility access, health status, health care providers, knowledge of health, availability and acceptability of services, need and demand for dental care, health policies, fluoride, oral hygiene, and Infection control. The search strategy shown in Table 1 documenOnce the articles to be included were agreed, a data extraction was developed and piloted. The two reviewers appraised ten articles and evaluated their results to ensure the process’s reliability by identifying differences and reaching agreement on how to report these differences through the process. The data extracted from each article were: the articles’ DOI/web address; publication year; country of origin; and a detailed description of the indicator(s). This process was performed independently by two reviewers. Relevant indicators were then extracted from included articles. Ultimately, the data were collected and descriptively mapped based on a simple frequency count of the indicators.No ethical approval was needed as this study was based on already published data.Reviewing the 83 included articles resulted in distinct categories of indicators relevant to the topic of interest. Included articles were published in English and covered a wide range of 32 low-, middle- and high-income countries, although work from only one low-income country was identified among these countries. The publication dates spanned 1995 to 2021.This scoping review identified a total of 54 different indicators. In particular, 34 indicators were classified under 14 main categories, describing indicator definitions, specific terms used to represent indictors, and variations by which indicators were measured in the studies. Six indicators were not assigned to any categories, and 14 indicators did not have specific definitions or clear examples. Different potential sources of data collection have been suggested in the table of results. These sources were: individuals in the population, dental professionals and government staff including public health officials.Among the 14 defined categories, “dental service utilization” and “oral health status” were the categories with the highest numbers of potential indicators and/or the categories with indicators repeated most often. In the selected articles, “dental service utilization” included two indicators that were mentioned a total of 65 times in various formats among a wide range of high- to low-income countries. In addition, this category encompasses the most frequently monitored indicator, which is “Visiting a dentist in the past 12 months”. In the category “oral health status”, eight indicators were stated 58 times in various countries.“Coverage” was a category with three indicators: “cost coverage”, “service coverage”, and “population coverage”. These indicators were reported 26 times in various formats among countries with diverse socioeconomic statuses. Financial coverage and out-of-pocket costs are indicated by “cost coverage”. “Service coverage” refers to the type of services covered by a plan and the term “population coverage” refers to which groups in the population are covered by a plan.Another three indicators that were classified as the “finances” category were: “costs for the provider”, “costs/expenses for the patient”, and “funding sources”, which were stated 22 times in several countries. “Health facility access” included three indicators named “geographic access”, “health facility access”, and “home care”. These indicators were mentioned 21 times in different countries.The remaining categories of the identified indicators were “workforce”, “knowledge of oral health”, “fluoride”, “oral hygiene”, “availability and acceptability of services”, “need and demand for dental care”, “diet”, “policies” and “infection control”. The indicators classified under these categories were reported fewer times and in a limited number of countries compared to the aforementioned indicators. The results have been comprehensively demonstrated in Table In recent years, special attention has been directed by a range of international organizations and groups to oral health care and its integration into UHC. To ensure progress is made in this integration process, it is important to have a monitoring framework incorporating relevant indicators. This framework should be adaptable to monitor progress in a range of low-, middle-and high-income countries. It should also be simple, practical, and comprehensive to cover all relevant oral health care domains. Currently, there is no such framework available to monitor the implementation of oral health care into the UHC, although this is being developed as part of the preparation of a global oral health action plan by the WHO. This framework and the aforementioned WHO plan need to use relevant indicators to track how the integration process is progressing in countries across the world. This scoping review has identified oral health care indicators that could be used as part of a global monitoring framework for oral health care integration into UHC and general health care.WHO/WB framework has been used as the main framework in many countries, although these countries adjusted the framework to measure the progress of UHC in the desired health care scopes, based on the needs of their populations. These country-specific frameworks have many similarities but also have some differences in accordance with the different regions of the world in which they are being used [Different frameworks are being used to monitor UHC development in a range of countries and health systems. For instance, the ing used , 103.WHO/WB framework and its country-specific versions used in a range of countries such as Bangladesh, Iraq, South Africa, and India [WHO/WB framework focuses on NCD health status indicators such as “blood pressure”, “blood glucose”, and “cervical cancer prevalence” to monitor the general health status of the population [In the context of the review reported in this paper, it is interesting to note that we can see how most of the indicators we identified fit into these existing frameworks developed for a broad range of health services beyond oral health care. For instance, “visit an oral health care facility or an oral health professional” was the most frequently reported indicator in our scoping review and it is similar to an indicator such as the “number of antenatal and postnatal visits”, which was used in the nd India , 102–105pulation , 106. Sipulation , 107–109WHO/WB framework [WHO/WB framework to follow UHC implementation in health systems [On top of these examples, “Cost-, service-, and population-coverage” were coverage indicators reported numerously in the oral health care literature, and they are essentially the same as “coverage of the health services” and “financial protection”, which were the two main components used in the ramework . Further systems , 14. The systems . They enWHO/WB framework, and the aforementioned regional and country modified frameworks. Indicators related to the “need and demand for dental care”, “policies”, and “infection control” domains were also found in the oral health care literature that could not be found in the existing monitoring frameworks. Among other suggested indicators, these indicators might be used as future measures to assess the UHC progress, although some could not be measured as system variables (such as “diet”).As well as these examples of how oral health indicators mirror those of general health care indicators, additional ones can also be provided for indicators in “health facility access” and “workforce” categories. That said, it is important to note that some oral indicators we identified do not have general health care peers. “Fluoride exposure” and “oral hygiene” were oral health-related indicators that will not fit into the existing monitoring frameworks such as the Among the indicators identified in this review, there are a number that are relatively straightforward to collect, while others are more complex to both define and collect. Among the former group are indicators that have been used many times and can be collected relatively easily to monitor progress. For example, the “proportion of the population visiting a dental health care professional once a year” and “insurance coverage”. These are relatively straightforward to define and collect for instance through system administrative data or through self-complete surveys. However, there are a number of indicators we identified whose definition is unclear and may vary across countries, such as “awareness of oral health” and “need and demand for dental care”. These indicators illustrate well both the possibility of different definitions and the subsequently different means and so the feasibility of collecting the data. For example is the need for oral health care defined by clinicians , by people in the population (requiring a self-complete survey) or through administrative data (e.g. as defined by having had no consultation over a period of x years)? Added to the complexity of collecting such data is the expense, particularly for performing clinical examinations.This scoping review was conducted to identify potential oral health care-related indicators for monitoring the implementation of oral health care into UHC and general health care. The results of this study were limited as we only searched a few databases, and in particular, we did not search the so-called “grey literature” of government survey reports on oral health and oral health care, which contain many examples of the types of indicators we were searching for. Furthermore, the limited number of databases restricted the scope of this research in terms of identifying indicators in various sociocultural contexts. In addition, the list of countries that the identified indicators were drawn from featured just one low-income country. This finding may be attributed to the previously discussed limitations of the study or may suggest significant constraints related to scarcity of resources in low-income countries. Another limitation was that we included only publications written in English. Although the results covered a broad range of oral health care categories, some areas could be missing. Consulting professional experts in the field could help transcend this limitation. Indeed, we believe the indicators identified by this search are an initial step in identifying a collection of indicators relevant to a wide range of countries, which could be complemented by others that are more specific to countries in particular regions of the world or low-, middle- and high-income groups.WHO/WB framework, it seems we have included all the categories of indicators. Further studies, as well as interviews with experts, could be conducted with the aim of finding more indicators and choosing the most relevant ones to achieve a consensus on creating a practical and comprehensive monitoring framework for oral health care integration into UHC and general health care.There is a need for a monitoring framework to evaluate the progress of oral health care integration into UHC and general health care. This scoping review identified indicators in a wide range of oral health care domains relevant to the integration of oral health care into UHC and general health care. Many of these indicators were relevant to all forms of health care, including oral health care, whereas some were more specific for developing the oral health care monitoring framework. While it is possible that we missed some oral health care indicators in our review, when comparing our results with those of the Below is the link to the electronic supplementary material.Supplementary Material 1


Culture has been defined as “an internalized and shared framework … through which both the individual and the collective experience the world” . Cultura“Health” is defined by the WHO as “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity” . While hIn this era of democratization, without considering and understanding what the notion of health- as it relates to “disease” pathology- or “wellness” means to a group of people, digital health and wellness platforms risk falling short of their potential. Using what constitutes a diseased or pathological state that warrants care-seeking; not merely the diagnosis of “disease” alone. As George Engel In several cultures in Africa however, normalization of “unwellness” or a different perception of what wellness is (compared to the West) may impede a patient's acknowledgment of disease/pathology , 19, 20.The idea of digital health is modeled after the Western, individualistic model of care (further enforced by HIPAA laws), which centers disease as an individual experience. In many parts of the world however, the decision to seek care is one that is made not by the diseased person solely, but by their social institutions  . It is iAny social good algorithm  must be For a person to begin using healthcare digital technology the way it is intended for health  and wellness , developers must (1) as discussed, first understand how people define and conceptualize disease and wellness (2) gain the user's initial trust then (3) acculturate the people to digital health as another care-seeking option D in . DevelopIf they are going to check on me via the telephone, how will they assess me? There are times I feel pain, abdominal pain, side pain, you go and complain and they take a look at it…Sometimes a scan is performed...If you stay home [and opt for telehealth], you wouldn't have access to the scan and all that stuff. I think I prefer going in [person]” , a smart wristband that is designed to resemble a piece of jewelry commonly worn by women in this region , 29, 30.MomConnect –33 is anSuch innovations in women's digital health, designed with a culturally-tailored lens that ranges from the everyday bangle worn by the women, to language adaptations, are necessary to convince the end user of its utility and overall beneficence. The rapid adoption of the COEL bangle and MomConect demonstrate that they were created with not only a user-centered design, but also a culturally-centered framework. Unfortunately, both soon faced threats to their long-term sustainability and scalability due, mostly, to financial barriers. The bangle, for example runs between $12 and 15 US dollars, when the income of the target user is no more than $5 US Dollars a day . In the If governments are invested in the public's health, if they are invested in decreasing maternal morbidity and mortality, invested in reaching the Sustainable Development Goals of gender equality , good health and wellbeing , reduced inequalities , and sustainable communities , then, they must invest in women's digital health technology , 35. A sDigital inclusion has been deemed a social determinant of health that, if not addressed, can further deepen health disparities . The purIn this commentary, we identify gaps in the cultural adaptation of digital health tools , and recMA-O: conceptualization and writing—original draft. MA-O, MA, SR, LD, and SH: writing—review and editing. All authors contributed to the article and approved the submitted version.