ORIGINAL RESEARCH

published: 07 February 2022

doi: 10.3389/froh.2021.732882

Association Between Mental Health

and Oral Health Status and Care
Utilization
Tamanna Tiwari 1*, Abigail Kelly 2 , Cameron L. Randall 3 , Eric Tranby 2 and
Julie Franstve-Hawley 2
1
School of Dental Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States, 2 CareQuest
Institute for Oral Health, Boston, MA, United States, 3 Department of Oral Health Sciences, University of Washington School
of Dentistry, Seattle, WA, United States

Studies have shown that mental health and oral health may be correlated, with
associations demonstrated between mental health problems and tooth loss, periodontal
disease, and tooth decay. The COVID-19 pandemic had alarming implications for
individuals’ and communities’ mental and emotional health. This study examined the
associations between mental health status, oral health status, and oral healthcare
utilization and highlighted the impact of COVID-19 on mental health. Additionally,
this study examines specific sociodemographic factors that may amplify oral health
disparities. A nationally representative survey was conducted to capture attitudes,
experiences, and behaviors related to oral health, mental health, and unmet oral health
needs. Eighteen percent of respondents were categorized as having poor mental health.
Edited by:
Gustavo G. Nascimento, Visiting the dentist in the last year was more common amongst individuals with good
Aarhus University, Denmark mental health. From the logistic regression model, mental health status, age group,
Reviewed by: race/ethnicity, education, and last dental visit were all significantly associated with of oral
Noha Gomaa,
health status. Mental health status, age group, and income groups were all significantly
Western University, Canada
Sonia Nath, associated with unmet oral health need. Future work should focus on the mental-oral
University of Adelaide, Australia health association, including determining ways to improve oral healthcare utilization and
*Correspondence: oral health status among people with poorer mental health.
Tamanna Tiwari
[email protected] Keywords: mental health, oral health, stress, anxiety, psychology, values

Specialty section:
This article was submitted to INTRODUCTION
Oral Health Promotion,
a section of the journal Individuals with mental illnesses are more likely than those without to have suboptimal oral health
Frontiers in Oral Health
[1]. Although the nature of this relationship has not been extensively evaluated, a few studies have
Received: 29 June 2021 shown a relationship between oral health and mental health, or vice versa [2–4].
Accepted: 09 December 2021 One systematic review has addressed the association between poor oral health and common
Published: 07 February 2022
psychological disorders (e.g., a diagnosis of depression, generalized anxiety disorder, panic
Citation: disorder, obsessive-compulsive disorder, post-traumatic stress disorder, or a phobia) [2]. The study
Tiwari T, Kelly A, Randall CL, Tranby E demonstrated a significant association between common mental health disorders and tooth loss;
and Franstve-Hawley J (2022)
individuals with common psychological disorders had higher rates of decayed, missing, and filled
Association Between Mental Health
and Oral Health Status and Care
teeth surfaces than controls. Overall, the researchers concluded that the rates of dental decay and
Utilization. tooth loss were higher for patients with common mental disorders as compared to the general
Front. Oral. Health 2:732882. population [2]. Other studies have shown a relationship between poor oral health (e.g., chronic
doi: 10.3389/froh.2021.732882 periodontitis, tooth erosion) and severe mental illness and eating disorders [3, 4].

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Tiwari et al. Mental Health and Oral Health

In patients with depression and anxiety, past research Randomly selected U.S. households were sampled using area
documented the association between the use of oral health probability and address-based sampling, with a known, non-zero
services and tooth loss [5]. Many depressive symptoms, such probability of selection from the NORC National Sample Frame.
as anhedonia or lack of motivation, feelings of worthlessness, Sampled households were contacted by U.S. mail, telephone, and
and fatigue, may adversely affect adults’ behaviors related to field interviewers. The survey was internally piloted at CareQuest
oral hygiene maintenance [5]. Several studies demonstrated Institute, as well as initially piloted by NORC on a sample size
similar results related to depression, dental behaviors, and the of 500. A sampling unit of 16,986 was used with a final sample
management of dental diseases such as periodontal disease [6– size or weight sample was 5,320 with a final weighted cumulative
8]. These studies highlight the public health implications of response rate of 5.2%. All data presented account for appropriate
mental health on oral health outcomes and the potential cycle of sample weights. This sample size was decided in collaboration
relationship oral health has with mental health (and vice versa). with NORC in order to obtain a margin of error of under 2 while
Greater risk for dental decay and tooth loss can lead to more having sufficient sub-sample sizes. The margin of error for this
frequent pain experience, social isolation, and low self-esteem, survey is 1.86%.
and reducing quality of life and in turn possibly being associated Self-rated mental health items asked that participants be asked
with poorer mental and overall health [9]. to rate their mental health as excellent, very, good, good, fair,
The COVID-19 pandemic had alarming implications for and poor, and for the analysis, it was dichotomized to poor
individuals’ and communities’ mental and emotional health [10]. (fair, poor) or good (excellent, very good, good). Self-rated oral
Factors including isolation and feelings of uncertainty negatively health status (dependent variable) asked participants to rate
impacted mental health and included effects such as increased their oral health status as either excellent, very, good, good, fair,
anxiety, loneliness, depression, insomnia, and in some cases, self- and poor. Unmet oral health needs (dependent variable) were a
harm [10]. A large portion of the population experienced job dichotomized variable and asked if the participant had unmet
loss and economic difficulties exacerbated mental health issues needs (yes/no). The information on unmet needs was collected
[11, 12]. by asking the respondents, “have you had an unmet oral health
The pandemic took a toll on oral health as well: dental need in the last year?” The survey also collected information
practices were closed for a long period of time, elective dental on several independent variables, including, participants’ age,
procedures were postponed, and access to preventive care was gender, race/ethnicity, household income, education, if they live
delayed [13]. Many groups were disproportionately affected by in metro or non-metro areas, and health insurance coverage.
the pandemic, including populations with a higher risk for poor Other oral health-related questions included the last visit to the
oral health, those with other chronic diseases and comorbidities, dentist and if the participants had dental insurance.
low socioeconomic groups, and minority populations [14]. Descriptive statistics were conducted to summarize the
Although several studies reviewed the relationship between percent and frequencies for the independent variables. Data are
the pandemic and mental or oral health individually, none presented by unweighted frequencies and weighted percentages.
have examined the association between mental and oral health Bivariate analyses were run to examine relationships between
during the pandemic [11–14]. This study aimed to identify self-rated mental health status and oral health status and unmet
the associations between mental health, oral health, and oral need by age group, income, race/ethnicity, and gender using
healthcare utilization during the COVID-19 pandemic as well as Chi-Square tests. Multivariable logistic regression models were
specific sociodemographic factors that may amplify disparities. used for each outcome of interest, including a respondent’s self-
rated oral health status and having unmet oral health needs.
Covariables included self-rated mental health, age group, gender,
METHODS income group, race/ethnicity, education level, metro/non-metro,
occurrence of last dental visit, health insurance status, and
A nationally representative cross-sectional survey (n = 5,320) dental insurance status. All variables of interest were included
was conducted in January and February 2021 to assess consumer in the model, and those with p-values of <0.05 were considered
attitudes, experiences, and behaviors related to oral health. This significant. Appropriate weights were applied to all analyses.
study was deemed exempt by the WCG IRB. Additional analyses included examining COVID-19 effects on
The survey called the State of Oral Health Equity in America life changes and mental health and oral health care utilization.
2021 contained items related to oral health knowledge, dental COVID-19 life changes were examined by asking if individual
care experiences, interprofessional care, insurance, and social events had occurred for a respondent within the last year,
determinants of health. The survey included ∼150 questions. The and cross-tabulated with the dichotomized mental health self-
questions were developed by an internal team at the CareQuest assessment variable.
Institute comprised of knowledge experts on payer, provider, and
patients’ experiences with oral health.
The survey was administered to adults 18 years and older RESULTS
by the non-partisan research organization National Opinion
Research Center (NORC) at the University of Chicago, using Table 1 describes the mental health status of the entire sample.
the AmeriSpeak panel. AmeriSpeak is a probability-based panel Those with poor mental health were disproportionately affected
designed to be representative of the U.S. household population. by life changes since the COVID-19 pandemic began. About

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Tiwari et al. Mental Health and Oral Health

TABLE 1 | Mental health and COVID from the State of Oral Health Equity Survey TABLE 1 | Continued
2021 (n = 5,296).
Good mental Poor mental p-value*
Good mental Poor mental p-value* health 4,379 health 917
health 4,379 health 917 (81.9%) (18.1%)
(81.9%) (18.1%)
5 or more years ago 352 (7.4%) 136 (16.8%)
Covid life changes 461 (10.8%) 159 (16.1%) 0.0007 Never 37 (1.5%) 10 (2.1%)
Job related variables
Dental insurance status 0.1245
Lost Job
Started a new job did not like 112 (2.9%) 55 (6.7%) <0.0001 Insured 3049 (70.5%) 622 (67.0%)
Started a new job you liked 281 (6.7%) 90 (9.7%) 0.0242 Not insured 1314 (29.5%) 293 (33.0%)
Taken a new job below your 148 (3.3%) 56 (6.6%) 0.0008 Health insurance status 0.0427
education Insured 3998 (91.2%) 804 (88.1%)
Taken an additional Job 154 (3.3%) 48 (4.0%) 0.3805 Not insured 368 (8.8%) 107 (11.9%)
Been worried to lose your job 445 (10.8%) 152 (15.6%) 0.0016 Oral health status <0.0001
Home related variables 306 (7.5%) 135 (14.5%) <0.0001
Excellent 324 (8.4%) 18 (2.7%)
Missed rent or mortgage
Very good 1418 (32.7%) 89 (9.5%)
Been threatened with foreclosure 98 (2.1%) 66 (7.3%) <0.0001
Bought a home 173 (3.8%) 30 (3.5%) 0.7186 Good 1726 (39.6%) 277 (28.7%)
Had to move 214 (5.1%) 95 (9.7%) <0.0001 Fair 683 (14.5%) 357 (41.0%)
Study sample characteristics 0.0191 Poor 217 (4.6%) 174 (18.0%)
Gender Unmet needs <0.0001
Female 2052 (50.4%) 532 (56.3%) Yes 2312 (52.8%) 651 (69.2%)
Male 2327 (49.6%) 385 (43.7%) No 2067 (47.2%) 266 (30.8%)
Age group <0.0001 Oral health symptoms treatment <0.0001
18–29 560 (17.5%) 231 (35.0%) Went to the dentist 1019 (44.5%) 218 (30.6%)
30–44 1196 (25.0%) 307 (25.1%) Went to the ED 36 (1.8%) 18 (2.8%)
45–59 923 (24.8%) 199 (22.5%) Did nothing 1249 (53.4%) 412 (66.3%)
60+ 1700 (32.6%) 180 (17.5%)
* Allvariables are reported at weighted n (unweighted %); p-value results from
Race/ethnicity 0.3684
Chi-square test.
Asian 97 (5.0%) 13 (4.4%)
Black 646 (12.0%) 118 (11.6%)
2+ 115 (2.3%) 41 (3.4%)
Hispanic 748 (16.0%) 199 (19.5%) 16% of respondents with poor mental health had lost their
Other 63 (1.4%) 13 (0.9%) job, compared to 11% with good mental health (p = 0.0007).
White 2710 (63.4%) 533 (60.2%) Those with poor mental health were also 5% more likely to be
Household income <0.0001 worried about losing their current job (p = 0.0016). Compared
Less than $30,000 1066 (24.9%) 380 (41.8%) to those with good mental health, those with poor mental health
$30,000–$60,000 1236 (25.9%) 262 (27.0%) were twice (14.5 vs. 7.5%, p < 0.0001) as likely to have missed
$60,000–$100,000 1157 (25.2%) 172 (17.9%) a mortgage payment. Since the pandemic began 5% of the
$100,000 or more 920 (24.0%) 103 (13.4%) respondents will poor mental health more likely to have been
Education <0.0001
threatened with eviction or foreclosure (2 vs. 7%, p < 0.0001),
Less than HS 196 (8.8%) 63 (14.3%)
and had to move at double the rate (5 vs. 10%, p < 0.0001).
HS graduate or equivalent 806 (26.3%) 211 (34.9%)
Table 1 also provides the description of the overall sample
Some college/associates degree 2103 (27.3%) 459 (29.4%)
is provided. Eighteen percent of respondents rated their mental
health as poor, and 82% rated it as good. Females were 4%
Bachelor’s degree 746 (21.8%) 131 (14.3%)
more likely to rate their mental health as poor compared to men
Post graduate study 528 (15.8%) 53 (7.1%)
(20 vs. 16%, p = 0.0191). About 35% of respondents age 18–
Region 0.4633
29 years reported poor mental while only 17% reported good
Non-metro area 697 (16.5%) 165 (17.8%)
mental health. Those who had poor mental health were over
Metro area 3682 (83.5%) 752 (82.2%)
three times more likely to rate their oral health as poor compared
Last dental visit <0.0001
to those with good mental health (18 vs. 4.6%, p < 0.0001).
Less than 6 months ago 1931 (44.9%) 300 (30.8%)
Those who had poor mental health were less likely to be insured
Between 6 months to 1 year ago 885 (19.9%) 171 (18.5%)
compared to those who reported good mental health (88 vs. 91%,
More than a year and less than two 690 (15.3%) 162 (17.7%)
p < 0.0001). Sixty-nine percent of respondents with poor mental
years ago
health reported having one or more unmet oral health needs
More than 2 and less than 5 years 480 (11.1%) 138 (14.1%)
ago compared to 53% of those with good mental health reporting the
same (p < 0.0001). Of those who had an unmet oral health need,
(Continued) those with self-rated good mental health were much more likely

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Tiwari et al. Mental Health and Oral Health

to seek care. Forty-five percent of respondents with good mental health in the U.S. annually [15]. The National Institute of Mental
health said they visited the dentist to address their symptoms; 2% Health also reports that the prevalence of mental illness is
said they went to the emergency department (E.D.) and 53% said higher in females compared to males and that young adults aged
they did nothing. Only 31% of respondents with poor mental 18–25 years have the highest prevalence (30%) of any mental
health went to a dentist to address their symptoms; 3% went to illness compared to all other age groups [15, 16]. Given that
the E.D., and 66% did nothing (p < 0.0001). our data were collected during the COVID-19 pandemic, we
Table 2 provides the results of the logistic regression model used a probability-based panel and our results were consistent
oral health status. Respondents with self-rated good mental with national data, our results are reliable to make national
health had low odds of rating their oral health as “poor” (OR = level conclusions.
0.22; 95% CI = 0.18, 0.26). Respondents aged 45–59 years had Poor oral health status among the respondents was associated
high odds of rating their oral health as ’poor’ (OR = 1.20 95% CI with poor mental health, age, socioeconomic status, and not
= 1.0, 1.4). Respondents who self -reported belonging to more visiting the dentist at regular intervals. There is much evidence
than two races were more likely to rate their oral health as poor that socioeconomic status is closely associated with oral health
(OR = 1.33 95% CI = 0.91, 1.94). status, irrespective of the socioeconomic measure used [17, 18].
The odds of respondents rating their oral health as “poor” A recent National Health and Nutrition Examination Survey
decreased with increased levels of education (H.S. graduate or study reported that age, race/ethnicity, education, and family
equivalent OR = 0.89, 95% CI = 0.66, 1.20; Vocational/tech income were significantly associated with the oral health status
school/some college/associates OR = 0.88, 95% CI = 0.67, 1.18; of Americans [18]. In this study, whites rated their oral health
Bachelor’s degree OR = 0.75, 95% CI = 0.55, 1.02; Postgrad as poor more often compared to those from other racial groups.
study/professional degree OR = 0.59, 95% CI = 0.42, 0.83). These results are similar to those from previous studies which
In addition, respondents who had an income of over $30,000 have found that racial minorities perceive less need for oral health
had lower odds of rating their oral health as “poor” and as the services and have lower health literacy, thus often not rating their
income increased the odds decreased ($30,000 to under $60,000, oral health as poor [19, 20].
OR 0.96; $60,000 to under $100,000, OR = 0.69; $100,000 or There is a paucity of research on the association between poor
more OR = 0.55) Respondents who had visited the dentist in the mental health and poor oral health status. However, a few studies
last 6 months (OR = 0.65, 95% CI = 0.31, 1.31) and between 6 in this area shed light on possible underlying reasons for this
months and a year (OR = 0.97, 95% CI = 0.48, 1.99) had lower association. Low prioritization of oral health, low recognition
odds of rating their oral health as “poor.” of the association between poor oral and mental health by
Table 3 provides the results of the logistic regression model healthcare providers, and lack of alternative service models in
for unmet oral health needs. Respondents with self-rated good dental settings for those with heightened fear and anxiety and/or
mental health had low odds of having an unmet oral health need mental health problems have been identified as some of the
(OR = 0.55, 95% CI = 0.45, 0.69). Those in the highest two underlying reasons for this association [1, 2].
income groups ($60,000 to under $100,000, OR = 0.0.76, 95% CI Unmet oral health needs of the respondents were associated
= 0.88, 1.31; $100,000 or more, OR = 0.76, 95% CI = 0.59, 0.97) with poor mental health, income, and utilization of dental
had low odds of having an unmet oral health need. Respondents care. Over 65% of the respondents who endorsed poor mental
aged 30–44 years (OR = 1.27 95% CI = 1.05, 1.53) and 45–59 health reported doing nothing about their oral health symptoms.
years (OR = 1.35 95% CI = 1.11, 1.65) had high odds of rating Evidence suggests that individuals who have experienced a
their oral health as “poor.” mental health disorder underutilize dental services. Reasons such
as stigma, shame, helplessness, low self-esteem, lack of income
and health insurance, dental fear/anxiety/phobia, and restlessness
DISCUSSION in the dental waiting environment contribute to underutilization
[21, 22]. In addition, individuals who have experienced a mental
This is the first study to evaluate the relationship between oral health disorder may have confusion and difficulty recalling
health and mental health during the COVID-19 pandemic and instructions, fostering mistrust between dental providers and
contributes to a larger but still underdeveloped body of literature patients [21, 23]. Also, individuals with poor mental health
on the association between oral and mental health, generally. Our are more likely to belong to low-socioeconomic groups, be
survey of a representative sample of U.S. households found that unemployed, and have substantial comorbidities, and these
about 20% of respondents reported poor mental health. About factors could contribute to and exacerbate the underutilization
35% of younger respondents (i.e., aged 18–25 years) and 43% of dental services [24]. Other essential aspects of underutilization
of females reported poor mental health. Respondents with low of dental care among individuals with mental health issues are
income and less education also reported poor mental health. perceived need for treatment, motivation to visit the dentist,
Respondents who reported poor mental health were more likely and social and physical environmental barriers such as clinic
to be facing financial and emotional hardships and were more location, the flexibility of the providers, and clinic hours [25].
likely to have had COVID-19. Apart from patient-level factors, structural, organizational, and
Our results are consistent with national statistics. According environmental factors such as limited specialized expertise of oral
to the National Alliance on Mental Illness and the National health providers in working with patients with mental health
Institute of Mental Health, 21% of all adults report poor mental problems as well as lack of interprofessional integration between

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Tiwari et al. Mental Health and Oral Health

TABLE 2 | Association between Oral Health Status and Mental Health from the State of Oral Health Equity in America survey 2021.

Odds ratio 95% confidence limits p-value*

Self-rated mental health (ref: poor health) <0.0001

Poor 1.00
Good 0.22 0.18 0.26
Gender 0.1691
Male 1.00
Female 0.91 0.80 1.0
Age group 0.0002
60+ 1.00
18–29 0.73 0.59 0.89
30–44 0.92 0.78 1.09
45–59 1.20 1.00 1.44
Race/ethnicity 0.0046
White, non-Hispanic 1.00
2+, non-Hispanic 1.33 0.91 1.94
Asian, non-Hispanic 0.99 0.668 1.48
Black, non-Hispanic 0.93 0.76 1.15
Hispanic 0.78 0.65 0.94
Other, non-Hispanic 0.43 0.24 0.79
Education level 0.0024
Less than HS 1.00
HS graduate or equivalent 0.89 0.66 1.20
Vocational/tech school/some 0.88 0.67 1.18
college/associates
Bachelor’s degree 0.75 0.55 1.02
Post grad study/professional degree 0.59 0.42 0.83
Income group <0.0001
Less than $30,000 1.00
$30,000 to under $60,000 v 0.96 0.80 1.16
$60,000 to under $100,000 0.69 0.57 0.84
$100,000 or more 0.55 0.45 0.68
Metro 0.5041
Non-metro area 1.00
Metro area 0.94 0.79 1.12
Last dental visit <0.0001
Never 1.00
Less than 6 months ago 0.65 0.317 1.31
Between 6 months ago and one year ago 0.97 0.48 1.99
More than a year and less than two years 1.56 0.77 3.17
ago
More than 2 and less than 5 years ago 2.64 1.29 5.40
5 or more years ago 5.05 2.47 10.34
Health insurance status 0.2381
Yes 1.00
No 1.16 0.91 1.49
Dental insurance status 0.1038
Yes 1.00
No 0.87 0.74 1.03

* Multivariable logistic regression.

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Tiwari et al. Mental Health and Oral Health

TABLE 3 | Association between Unmet Oral Health Needs and Mental Health from the State of Oral Health Equity in America survey 2021.

Odds ratios 95% confidence limits p-value*

Self-rated mental health <0.0001

Poor 1.00
Good 0.55 0.45 0.69
Gender 0.1658
Male 1.00
Female 1.11 0.96 1.29
Age group 0.0144
60+ 1.00
18–29 1.14 0.91 1.44
30–44 1.27 1.05 1.53
45–59 1.35 1.11 1.65
Race/ethnicity 0.5080
White, non-Hispanic 1.00
2+ races, non-Hispanic 0.71 0.47 1.08
Asian, non-Hispanic 0.93 0.54 1.59
Black, non-Hispanic 0.98 0.78 1.23
Hispanic 0.89 0.73 1.09
Other, non-Hispanic 0.74 0.41 1.33
Education level 0.0506
Less than HS 1.00
HS graduate or equivalent 0.93 0.66 1.31
Vocational/tech school/some 0.99 0.72 1.36
college/associates
Bachelor’s degree 0.78 0.55 1.11
Post grad study/professional degree 0.74 0.51 1.08
Income group 0.0035
Less than $30,000 1.00
$30,000 to under $60,000 1.04 0.84 1.28
$60,000 to under $100,000 0.76 0.61 0.94
$100,000 or more 0.76 0.59 0.97
Metro 0.4323
Non-metro area 1.00
Metro area 1.07 0.88 1.31
Last dental visit 0.0002
Never 1.00
Less than 6 months ago 6.35 2.60 15.52
Between 6 months ago and one year ago 6.04 2.46 14.86
More than a year and less than two years 6.18 2.50 15.28
ago
More than 2 and less than 5 years ago 7.21 2.90 17.91
5 or more years ago 8.59 3.44 21.41
Health insurance status 0.1421
Yes 1.00
No 1.24 0.93 1.65
Dental insurance status 0.6331
Yes 1.00
No 0.96 0.80 1.15

* Multivariable logistic regression.

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Tiwari et al. Mental Health and Oral Health

dental services and general medical and mental health services raw data. Requests to access the datasets should be directed
can exacerbate the underutilization [25]. to [email protected].
Our study has some limitations. The results of the survey
are based on a cross-sectional survey, and all data were self-
reported by the participants. Though there are numerous self-
ETHICS STATEMENT
report instruments validated for the assessment of specific mental This study was deemed exempt by the WCG IRB. Written
health problems, the time and space limitations of the overall informed consent for participation was not required for this
survey design limited the number of mental health-related items study in accordance with the national legislation and the
that could be included. Thus, only a single item assessing general institutional requirements.
mental health was used. We plan to collect similar data in
2022 to keep the research continuum and work toward better
understanding the relationship between mental and oral health AUTHOR CONTRIBUTIONS
over time. Future studies will utilize more specific validated
measures because the mental health variable lacked specificity (as TT, AK, CR, ET, and JF-H contributed to the conception and
it did not provide diagnostic-level information). Despite these design, data analysis and interpretation, drafted, and critically
limitations, this study offers a significant contribution to the revised the manuscript. Data acquisition was done by AK, ET,
literature, highlighting the association between oral health status and JF-H. All authors gave final approval and agree to be
and poor mental health at the population level. Further research accountable for all aspects of the work.
is necessary to understand the mechanisms underlying these
associations and develop models of care that will promote oral FUNDING
health utilization by individuals with mental health problems.
CR received support from Grant K23DE028906 in preparation of
DATA AVAILABILITY STATEMENT the manuscript.

The datasets presented in this article are not readily available ACKNOWLEDGMENTS
because the raw dataset for this study is the property of the
CareQuest Institute for Oral Health. A request needs to be Madhuli Thakkar, BDS, MPH for help in data analysis, and
submitted to the corresponding author to get access to the code validation.

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this article, or claim that may be made by its manufacturer, is not guaranteed or
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(2017) 62:6–13. doi: 10.1111/adj.12429 Copyright © 2022 Tiwari, Kelly, Randall, Tranby and Franstve-Hawley. This is an
23. van der Zande MM, Exley C, Wilson SA, Harris RV. Disentangling a web of open-access article distributed under the terms of the Creative Commons Attribution
causation: an ethnographic study of interlinked patient barriers to planned License (CC BY). The use, distribution or reproduction in other forums is permitted,
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