Does the design of the NHS Diabetes Prevention Programme intervention have fidelity to the programme specification? A document analysis.

AIMS: To assess fidelity of the Healthier You: NHS Diabetes Prevention Programme (NHS-DPP), a behavioural intervention for people in England at high risk of developing type 2 diabetes, to the specified programme features. METHODS: Document analysis of the NHS-DPP programme specification, including National Institute for Health and Care Excellence (NICE) PH38 diabetes prevention guidance. This was compared with the intervention design (framework response documents and programme manuals) from all four independent providers delivering the NHS-DPP. Documents were coded using the Template for Intervention Description and Replication framework (describing service parameters) and the Behaviour Change Technique Taxonomy v1. RESULTS: Providers demonstrated good fidelity to service parameters of the NHS-DPP. The NHS-DPP specification indicated 19 unique behaviour change techniques. Framework responses for the four providers contained between 24 and 32 distinct behaviour change techniques, and programme manuals contained between 23 and 45 distinct behaviour change techniques, indicating variation in behaviour change content between providers' intervention documents. Thus, each provider planned to deliver 74% of the unique behaviour change techniques specified, and a large amount of behaviour change content not mandated. CONCLUSIONS: There is good fidelity to the specified service parameters of the NHS-DPP; however, the four providers planned to deliver approximately three-quarters of behaviour change techniques specified by the NHS-DPP. Given that behaviour change techniques are the 'active ingredients' of interventions, and some of these techniques in the programme manuals may be missed in practice, this highlights possible limitations with fidelity to the NHS-DPP programme specification at the intervention design stage.

Perceptions and experiences of taking oral medications for the treatment of Type 2 diabetes mellitus: a systematic review and meta-synthesis of qualitative studies.

AIMS: To explore patients' perceptions and experiences of taking oral medications for the pharmacological management of Type 2 diabetes mellitus. METHODS: Cinahl, EMBASE, Medline and PsycINFO databases were searched in 2014 to identify qualitative studies exploring patients' perceptions or experiences of taking medications for the management of Type 2 diabetes. Key concepts and themes were extracted and synthesized using meta-ethnography. RESULTS: Eight studies were included. Primary study findings were synthesized to develop three higher-order constructs that moved beyond the results of individual studies. The first construct, Medications for diabetes: a necessary evil, outlines how patients' negative perceptions of medication risks co-exist with a resounding view that medications are beneficial. Passive patients but active experimenters highlights the contrast between patients' passive acceptance of medication prescriptions and the urge to actively experiment and adjust doses to optimize medication use in daily life. Finally, Taking oral medication for Type 2 diabetes: a unique context describes features specific to the Type 2 diabetes medication experience, including lack of symptoms and the perceived relationship between medication and diet, which may influence adherence. CONCLUSIONS: Medication-taking for Type 2 diabetes is a unique adherence context, which requires the development of condition-specific interventions. The present findings indicate patients understand the need for medications but adjust dosage and timing in their daily lives. This review suggests providers should acknowledge patient preferences in the development of management strategies, and highlights an opportunity to direct the motivation evident in patients' experimentation towards potentially more beneficial medication-taking behaviours.

Effects of interventions promoting monitoring of medication use and brief messaging on medication adherence for people with Type 2 diabetes: a systematic review of randomized trials.

AIMS: To assess the impact of interventions promoting the monitoring of medication use and brief messaging to support medication adherence in patients with Type 2 diabetes mellitus, and to investigate the extent of theory use to guide intervention development. METHODS: We systematically searched for controlled trials, published from 1990 onwards in Medline, Embase, CINAHL, PsycINFO and the Cochrane library, that evaluated interventions based on monitoring and brief messaging to support medication adherence in patients with Type 2 diabetes, to examine the effectiveness of such interventions. RESULTS: A total of 11 trials, comparing 15 interventions, were identified. Only a small minority presented a low risk of bias. Three interventions were based on delivering brief messages, six were based on monitoring medication adherence, and six used both strategies. Messaging interventions included the use of short message service text messages, web-based feedback, and messages delivered through monitoring devices. Monitoring interventions included remote self-reporting of medication and telephone calls with healthcare staff. Improvements in medication adherence were observed in six interventions, although effect sizes were generally moderate. Only two interventions improved both adherence and clinical outcomes. A meta-analysis of five trials (eight interventions) combining monitoring and messaging strategies showed that the pooled difference in medication adherence between intervention and control was moderate and not statistically significant [standardized mean difference = 0.22 (95% CI -0.05; 0.49)]. Only four trials were based on explicit theoretical frameworks. CONCLUSIONS: Although interventions based on messaging and monitoring have the potential to improve medication adherence in patients with Type 2 diabetes, evidence of their efficacy is limited and additional high-quality, theory-based research is needed.

Comparative optimism for severity of negative health outcomes.

People tend to be comparatively optimistic (i.e., believe that negative outcomes are less likely for themselves than for typical others) regarding their susceptibility to negative health outcomes. The present study investigates the extent to which perceptions of the severity of these health outcomes show similar comparative optimism. A student sample (study 1; N = 200) and a healthy non-student adult sample (study 2; N = 257) completed self-report measures of susceptibility, severity, worry, control and experience in relation to negative health outcomes. Participants in both studies demonstrated significant levels of comparative optimism for both perceived likelihood and severity of health outcomes. Comparative optimism concerning severity was very strongly associated (r = 0.85 to 0.89) with comparative optimism concerning susceptibility. In addition to being comparatively optimistic over their chances of experiencing negative health outcomes, people are also comparatively optimistic regarding how severe the health outcomes will be.

Experience of hypoglycaemia is associated with changes in beliefs about diabetes in patients with type 2 diabetes.

AIM: Hypoglycaemia may have a detrimental impact on quality of life for patients with Type 2 diabetes. There are few clinical studies exploring the impact of experiencing hypoglycaemia on beliefs about diabetes and health status. The aim of this study was to explore associations between experience of hypoglycaemia and changes in diabetes beliefs and self-reported health status in patients with non-insulin-treated Type 2 diabetes using a blood glucose meter. METHODS: One-year prospective cohort analysis of 226 patients recruited to a randomized trial evaluating the impact of self-monitoring of blood glucose. Self-reported hypoglycaemia over 1 year was categorized into three groups: (1) no experience of hypoglycaemia; (2) blood glucose measurements < 4 mmol/l with no associated symptoms of hypoglycaemia (grade 1); and (3) symptomatic hypoglycaemia (grade 2 and 3). Measures of beliefs about diabetes (Revised Illness Perception Questionnaire) and health status (EuroQol-5D) were assessed at baseline and 1 year. Differences in mean changes over 1 year were explored with analyses of covariance. RESULTS: There was a significant increase in mean score in beliefs about personal control (1.14; 95%CI 0.14-2.14) among those experiencing grade 1 hypoglycaemia compared with those not experiencing hypoglycaemia. There were no significant differences in changes in health status between groups, with small overall changes that were inconsistent between groups. CONCLUSIONS: This study does not provide support for a long-term adverse impact on beliefs about diabetes or health status from the experience of mild symptomatic hypoglycaemia, in well-controlled, non-insulin-treated patients with Type 2 diabetes using self-monitoring of blood glucose.

What do people think about when they answer the Brief Illness Perception Questionnaire? A 'think-aloud' study.

OBJECTIVES: The Brief Illness Perception Questionnaire (Brief IPQ) is a commonly used questionnaire that aims to assess patients' illness beliefs. There is, however, no direct information on how people interpret and respond to this questionnaire, nor on the nature and extent of problems people have when completing it. The present study describes the problems that patients encounter when completing the Brief IPQ. DESIGN: Cross-sectional observational study. METHODS: A 'think-aloud' method was employed with two samples: 6 patients attending a preoperative exercise programme in secondary care, and 11 patients receiving physiotherapy in primary care. RESULTS: In total, 88 problems were identified, mostly (N= 45) consisted of participants re-reading a question or stumbling in reading it. In 8 cases, participants misinterpreted a question. The pattern of findings was striking similar across the two samples. The questions about identity, personal control, illness coherence, and causal attributions yielded most difficulties (18, 16, 16, and 11 problems, respectively). CONCLUSIONS: Given that the Brief IPQ assesses each construct with a single item, the number of problems people have with completing it is particularly problematic, and calls into question the content validity of this measure. Further developmental work with this questionnaire may be needed to better quantify and resolve the problems identified.

What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour--and are they the same?

There is convincing evidence that targeting self-efficacy is an effective means of increasing physical activity. However, evidence concerning which are the most effective techniques for changing self-efficacy and thereby physical activity is lacking. The present review aims to estimate the association between specific intervention techniques used in physical activity interventions and change obtained in both self-efficacy and physical activity behaviour. A systematic search yielded 27 physical activity intervention studies for 'healthy' adults that reported self-efficacy and physical activity data. A small, yet significant (P < 0.01) effect of the interventions was found on change in self-efficacy and physical activity (d = 0.16 and 0.21, respectively). When a technique was associated with a change in effect sizes for self-efficacy, it also tended to be associated with a change (r(s) = 0.690, P < 0.001) in effect size for physical activity. Moderator analyses found that 'action planning', 'provide instruction' and 'reinforcing effort towards behaviour' were associated with significantly higher levels of both self-efficacy and physical activity. 'Relapse prevention' and 'setting graded tasks' were associated with significantly lower self-efficacy and physical activity levels. This meta-analysis provides evidence for which psychological techniques are most effective for changing self-efficacy and physical activity.

Predictors of anxiety and depression among people attending diabetes screening: a prospective cohort study embedded in the ADDITION (Cambridge) randomized control trial.

OBJECTIVE: This study aimed to identify factors predicting anxiety and depression among people who attend primary care-based diabetes screening. DESIGN: A prospective cohort study embedded in the ADDITION (Cambridge) randomized control trial. METHODS: Participants (N= 3,240) at risk of diabetes were identified from 10 primary care practices and invited to a stepwise screening programme as part of the ADDITION (Cambridge) trial. Main outcome measures were anxiety and depression at 12 months post-screening assessed using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Hierarchical linear regressions showed that demographic, clinical, and psychological variables collectively accounted for 52% of the variance in HADS anxiety scores and 53% of the variance in HADS depression scores 12 months after diabetes screening. Screening outcome (positive or negative for diabetes) was not related to differences in anxiety or depression at 12 months. Higher number of self-reported (diabetes) symptoms after first attendance was associated with higher anxiety and depression at 12-month follow-up, after controlling for anxiety and depression after first attendance. CONCLUSION: Participants in a diabetes screening programme showed low scores on anxiety and depression scales after first appointment and 1 year later. Diagnosis of diabetes was shown to have a limited psychological impact and may be less important than symptom perception in determining emotional outcomes after participation in diabetes screening.

An intervention to promote walking amongst the general population based on an 'extended' theory of planned behaviour: a waiting list randomised controlled trial.

Theory of planned behaviour (TPB) studies have identified perceived behavioural control (PBC) as the key determinant of walking intentions. The present study investigated whether an intervention designed to alter PBC and create walking plans increased TPB measures concerning walking more, planning and objectively measured walking. One hundred and thirty UK adults participated in a waiting-list randomised controlled trial. The intervention consisted of strategies to boost PBC, plus volitional strategies to enact walking intentions. All TPB constructs were measured, along with self-reported measures of action planning and walking, and an objective pedometer measure of time spent walking. The intervention increased PBC, attitudes, intentions and objectively measured walking from 20 to 32 min a day. The effects of the intervention on intentions and behaviour were mediated by PBC, although the effects on PBC were not mediated by control beliefs. At 6 weeks follow-up, participants maintained their increases in walking. The findings of this study partially support the proposed causal nature of the extended TPB as a framework for developing and evaluating health behaviour change interventions. This is the first study using the TPB to develop, design and evaluate the components of an intervention which increased objectively measured behaviour, with effects mediated by TPB variables.

Blood glucose self-monitoring in type 2 diabetes: a randomised controlled trial.

OBJECTIVES: To determine whether self-monitoring of blood glucose (SMBG), either alone or with additional instruction in incorporating the results into self-care, is more effective than usual care in improving glycaemic control in non-insulin-treated diabetes. DESIGN: An open, parallel group randomised controlled trial. SETTING: 24 general practices in Oxfordshire and 24 in South Yorkshire, UK. PARTICIPANTS: Patients with non-insulin-treated type 2 diabetes, aged > or = 25 years and with glycosylated haemoglobin (HbA1c) > or = 6.2%. INTERVENTIONS: A total of 453 patients were individually randomised to one of: (1) standardised usual care with 3-monthly HbA1c (control, n = 152); (2) blood glucose self-testing with patient training focused on clinician interpretation of results in addition to usual care (less intensive self-monitoring, n = 150); (3) SMBG with additional training of patients in interpretation and application of the results to enhance motivation and maintain adherence to a healthy lifestyle (more intensive self-monitoring, n = 151). MAIN OUTCOME MEASURES: The primary outcome was HBA1c at 12 months, and an intention-to-treat analysis, including all patients, was undertaken. Blood pressure, lipids, episodes of hypoglycaemia and quality of life, measured with the EuroQol 5 dimensions (EQ-5D), were secondary measures. An economic analysis was also carried out, and questionnaires were used to measure well-being, beliefs about use of SMBG and self-reports of medication taking, dietary and physical activities, and health-care resource use. RESULTS: The differences in 12-month HbA1c between the three groups (adjusted for baseline HbA1c) were not statistically significant (p = 0.12). The difference in unadjusted mean change in HbA1c from baseline to 12 months between the control and less intensive self-monitoring groups was -0.14% [95% confidence interval (CI) -0.35 to 0.07] and between the control and more intensive self-monitoring groups was -0.17% (95% CI -0.37 to 0.03). There was no evidence of a significantly different impact of self-monitoring on glycaemic control when comparing subgroups of patients defined by duration of diabetes, therapy, diabetes-related complications and EQ-5D score. The economic analysis suggested that SMBG resulted in extra health-care costs and was unlikely to be cost-effective if used routinely. There appeared to be an initial negative impact of SMBG on quality of life measured on the EQ-5D, and the potential additional lifetime gains in quality-adjusted life-years, resulting from the lower levels of risk factors achieved at the end of trial follow-up, were outweighed by these initial impacts for both SMBG groups compared with control. Some patients felt that SMBG was helpful, and there was evidence that those using more intensive self-monitoring perceived diabetes as having more serious consequences. Patients using SMBG were often not clear about the relationship between their behaviour and the test results. CONCLUSIONS: While the data do not exclude the possibility of a clinically important benefit for specific subgroups of patients in initiating good glycaemic control, SMBG by non-insulin-treated patients, with or without instruction in incorporating findings into self-care, did not lead to a significant improvement in glycaemic control compared with usual care monitored by HbA1c levels. There was no convincing evidence to support a recommendation for routine self-monitoring of all patients and no evidence of improved glycaemic control in predefined subgroups of patients.

Self-monitoring of blood glucose changed non-insulin-treated Type 2 diabetes patients' beliefs about diabetes and self-monitoring in a randomized trial.

AIMS: To determine whether differences in beliefs about diabetes and its treatment resulted from different intensities of self-monitoring of blood glucose (SMBG) in non-insulin treated patients with Type 2 diabetes in the Diabetes Glycaemic Education and Monitoring (DiGEM) trial. METHODS: Patients (n = 453) were randomized to usual care, less-intensive SMBG and more intensive SMBG. Beliefs about diabetes were measured with a standard questionnaire (the revised Illness Perceptions Questionnaire; IPQ-R). Changes in beliefs were analysed using analysis of covariance (ancova) with adjustment for baseline values. Mediation analyses assessed whether differences in behavioural outcomes between groups could be attributed to differences in beliefs. RESULTS: Completed questionnaires were returned by 339 patients (74.8%). Respondents were mean (+/- sd) age 65.9 +/- 10 years and with diabetes duration of 4.8 +/- 4.7 years (median 36, range 1-384 months). Concerns about the consequences of diabetes increased in both self-monitoring groups, relative to control subjects [P = 0.004; Cohen's d standardized effect size = 0.19 less intensive and d = 0.36 more intensive monitoring]. No other beliefs about diabetes differed between groups. Beliefs about the importance of self-testing increased in both self-monitoring groups relative to the usual-care group (P < 0.001; d = 0.57 less intensive and d = 0.63 more intensive monitoring). Changes in psychological well-being did not differ between groups, but control patients reported greater increases in general (P = 0.014) and specific (P < 0.001) dietary adherence than did patients in the self-monitoring groups. These outcomes were not mediated by intervention-related changes in beliefs. CONCLUSIONS: Despite changes in some beliefs about diabetes differing between groups there were no corresponding changes in self-reported health behaviours. This suggests that changes in illness beliefs resulting from SMBG do not cause changes in diabetes-related health behaviours.

Psychological costs of inadequate cervical smear test results.

The purpose of the study is to investigate, for the first time, the psychological impact of an inadequate smear test result. A prospective questionnaire design was used, and the setting was a single English cervical screening laboratory. Two groups of women receiving either a normal test result (n=226) or either a first or nonconsecutive inadequate smear test result (n=180) participated. The main outcome measures included State anxiety (STAI) and concern about test result, assessed within 4 weeks of receipt of results, and attendance for a repeat cervical smear within 3 months. Compared to women with normal test results, women with inadequate smear test results had higher state anxiety (P=0.025), were more concerned about their results (P<0.001), perceived themselves to be at higher risk of cervical cancer (P=0.016), and felt less satisfied with the information they had received about their test results (P<0.001). The only predictor of attendance for a repeat smear test following an inadequate smear test result was state anxiety (P=0.011): nonattenders had higher levels of state anxiety in response to their initial test results. In conclusion, in this first study to assess the psychological impact of receiving an inadequate smear test result, we have shown that it raises state anxiety and concern to levels similar to those found in women with abnormal smear test results. Of particular concern is that anxious women are less likely to attend for a repeat smear test within the recommended time frame. Given the millions of women each year receiving this test result, research is now needed to ascertain how the anxiety associated with this result can be avoided.

GP stress and patient dissatisfaction with nights on call: an exploratory study. GP stress and patient satisfaction.

OBJECTIVES: To compare the relative effects of being on or off duty at night on general practitioners' (GPs') levels of stress, and the satisfaction of their patients with daytime consultations surrounding these nights. DESIGN: A within-subjects, counterbalanced design was used. Two "on-call" and two "off-duty" nights were studied per GP over 4 weeks. SETTING: Primary health care in the UK. PARTICIPANTS: 26 GPs and their patients seen in consultations either side of nights studied. MAIN OUTCOME MEASURES: GPs completed validated stress questionnaires at the beginning and end of the consultation sessions immediately before and after nights on call and off duty. RESULTS: GPs experienced elevated levels of stress when on call, compared to when they were off duty. Patients seen in the consultation sessions before and after a night on call were less satisfied than patients seen before and after a night off duty. CONCLUSION: Being on call at night raised GP stress levels from at least the start of the afternoon consultation session before until the end of the morning consultation after the night on call. Daytime patient satisfaction is also reduced in periods surrounding nights on call.

Perceptions of multiple risk factors for heart attacks.

There is increasing evidence that in some diseases such as coronary heart disease, risk factors may interact synergistically, resulting in greater likelihood of disease than would be produced by the sum of the risk factors. These two studies aimed to examine the extent to which 210 undergraduate students and 28 heart attack patients perceive risk factors to combine synergistically. Respondents read one of four vignettes, describing information about risk factors (with high and low smoking and family history), and estimated a man's likelihood of a heart attack in a hypothetical case. In both studies an interaction was found with either a family history or smoking eliciting ratings of high likelihood of heart attack, providing no evidence of synergistic models. This finding may reflect respondents' beliefs or the insensitivity of this paper-and-pencil method in detecting synergistic effects.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care.

OBJECTIVE: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests. MAIN OUTCOME MEASURES: Response to call, time to visit, prescribing, and hospital admissions. RESULTS: 1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions. CONCLUSIONS: By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the United Kingdom: development of a patient questionnaire.

OBJECTIVE: To develop a reliable, valid measure of patient satisfaction with out of hours care suitable for large scale service evaluation. DESIGN: Focus group meetings and semistructured interviews with patients to identify issues of importance to patients and possible questionnaire items; interviews and two pilot studies to test and identify new questionnaire items; modification or removal of items to eliminate ambiguity and reduce non-response and skewed responses; questionnaire survey of out of hours care. SETTING: Greater Manchester and Leicester. SUBJECTS: 11 general practice patients participated in the focus groups and 28 in the semistructured interviews; 41 in the preliminary interviews; 41 and 378 in the postal pilots; and 1466 in the survey of out of hours care. RESULTS: A 32 item questionnaire was developed. Component analysis indicated seven scales (satisfaction with communication and management, doctor's attitude, continuity of care, delay until visit, access to out of hours care, initial contact person, telephone advice) related to overall satisfaction and containing issues identified as important to patients. Levels of reliability were satisfactory, Cronbach's alpha correlation coefficient exceeding 0.60 for all scales. CONCLUSION: A reliable, valid measure of patient satisfaction has been developed, suitable for large scale evaluation of out of hours care.

Mechanical control of greenhead flies (Diptera: Tabanidae) in a marsh environment.

The effectiveness of New Jersey box traps for the control of adult greenhead flies, Tabanus nigrovittatus, Macquart, T. conterminus Walker, was assessed at Wallops Island, Va. Trap shape and placement were tested. Shallow (0.45 m high) traps caught significantly fewer flies than cubic (0.60 m high) traps. Traps located in the inner two of four layers of traps caught fewer flies than traps in the outer layers.

Developing a sealant program: the Massachusetts approach.

This paper describes the program structure and strategies being used by the Massachusetts Department of Public Health to promote the utilization of sealants. The program design includes four components: clinical demonstration, consumer education, professional education, and reimbursement. Eighteen Massachusetts neighborhood health centers and six local health departments are participating in the clinical demonstration component. Since March 1984, dental personnel from these sites have applied sealants to 4,398 schoolchildren. The promotional theme "Save Teeth: Seal Them" has been incorporated into brochures designed to increase knowledge and awareness of consumers. Curriculum materials have been developed to educate dentists and dental hygienists to apply sealants and understand the rationale and scientific basis for their use. Since January 1984, 18 sealant educational sessions have been conducted statewide for 630 dental providers. Information is being presented to third-party carriers, some of whom have subsequently adopted a policy to include reimbursement for sealants.