Multimorbidity prevalence and patterns and their associations with health literacy among chronic kidney disease patients.

BACKGROUND: Health literacy is the ability to deal with information related to one's health. Patients with low health literacy have poor disease-management skills for chronic diseases, such as chronic kidney disease (CKD). This could influence the number and combination of their diseases. METHODS: We included adult patients with CKD stages 1-5 from the Lifelines Study (n = 2,742). We assessed the association between low health literacy and the number and patterns of comorbidities, considering them globally and stratified by age and sex, using multinomial logistic regression and latent class analysis, respectively. RESULTS: Low health literacy was associated with a higher number of comorbidities in the crude models, and after adjustment for age, sex, eGFR, smoking, and BMI. In the crude model, the OR for low health literacy increased from 1.71 (1.25-2.33) for two comorbidities to 2.71 (2.00-3.68) for four comorbidities. In the fully-adjusted model, the associations remained significant with a maximum OR of 1.70 (1.16-2.49) for four comorbidities. The patterns of multimorbidity were similar for low and adequate health literacy, overall and by sex, bur tended to be different for patients older than 65. Older patients with low health literacy had higher comorbidity prevalence and a relatively greater share of cardiovascular, psychiatric, and central nervous system diseases. CONCLUSIONS: Among CKD patients, low health literacy is associated with more multimorbidity. Health literacy is not associated with patterns of multimorbidity in younger patients, but a difference was observed in older ones. Improving low health literacy could be an intervention efficient also in decreasing multimorbidity in CKD patients.

The courses of objective physical activity and the association with sleepiness during a 2-week-on/2-week-off offshore shift rotation: an observational repeated-measures study.

BACKGROUND: Offshore workers are assumed to have poor health behaviours, but no studies have yet examined physical activity (PA) during a full offshore shift rotation period, including both work and at home periods. Furthermore, the relationship of PA with sleepiness, a prevalent safety hazard offshore, is not known. This study aimed to examine (1) the courses of objectively measured PA in offshore workers during pre-, offshore and post-offshore periods, and (2) the association between PA and self-reported sleepiness. METHODS: An observational repeated measures study was conducted among 36 offshore workers during a full 2-week on/2-week off offshore shift rotation. Objective PA was assessed using Daytime Activity Averages (DAA) from actigraph recordings. Sleepiness was assessed using next-morning Karolinska Sleepiness Scale (KSS) scores. The courses of PA over time were analysed with Linear Mixed Models (LMM). Parallel LMM were used to assess the longitudinal relationship between PA and sleepiness, both on a between-person and within-person level. RESULTS: The courses of PA were not significantly different between the pre-, offshore, and post-offshore periods. In addition, between-person trends of PA and sleepiness were not associated (p ranges between 0.08─0.99) and PA did not affect next-morning sleepiness on a within-person level (p = 0.15). CONCLUSIONS: PA levels during the offshore working period were not different from PA levels at home. Furthermore, PA was not associated with next-morning sleepiness. Further research should focus on different levels of PA including its intensity level.

Accelerometer Measured Sedentary and Physical Activity Behaviors of Working Patients after Total Knee Arthroplasty, and their Compensation Between Occupational and Leisure Time.

Purpose Objective measurements of sedentary and physical activity (PA) behavior are scarce among working-age patients who undergo total knee arthroplasty (TKA). Aim was to assess sedentary and PA behaviors using accelerometers and to identify compensation effects between occupational and leisure time of sedentary and PA behavior. Methods One year post-TKA, 51 patients wore an ActiGraph(GT3x) accelerometer for 7 days. Sedentary time, prolonged sedentary bouts (≥ 30 min) and PA (light-intensity and moderate-to-vigorous PA) were examined. Compliance with the guideline of > 150 min moderate-to-vigorous PA per week was calculated. Compensation effects were analyzed using multilevel models, splitting effects into routine and within-day compensation, stratifying by physical and non-physical jobs. The routine compensation effects are the ones of interest, representing habitual compensation during a week. Results Participants spent 60% of time in sedentary bouts and 17% in prolonged sedentary bouts, with 37% of PA spent in light-intensity and 3% in moderate-to-vigorous activity. About 70% of patients met the PA guideline. Routine compensation effects were found for workers in physical jobs, who compensated for their occupational light-intensity PA with less light-intensity PA during leisure time. Workers in non-physical jobs did not compensate for their occupational prolonged sedentary bouts, as these continued during leisure time. Conclusion This study showed that working TKA patients are highly sedentary 1 year after surgery, but most met the PA guideline. Especially those with non-physical jobs do not compensate for their occupational prolonged sedentary bouts. This stresses the need to stimulate PA among TKA patients not complying with the guidelines and those with non-physical jobs.

Perceived social capital and binge drinking in older adults: The Health and Retirement Study, US data from 2006-2014.

OBJECTIVE: Social capital has been described as having both positive influences as well as negative influences ("the dark side") on health behaviors. We sought to test the association of perceived social capital on the risk of binge drinking among older adults, using a longitudinal design. METHODS: We used HRS (Health and Retirement Study) data, a nationally representative sample of US adults aged ≥50 years evaluated every two years (from 2006 to 2014). We investigated the relationship between perceived social capital (neighborhood social cohesion and neighborhood physical disorder, positive social support and negative social support) and binge drinking over time, with a multilevel structural equation modelling (MSEM) approach, modelling number of binge-drinking days as hurdle negative binomial. We used MSEM estimating the associations at person level (overall) and within waves. RESULTS: The sample included 19,140 individuals. At baseline mean age was 66.8 (SD 10.3). Over time, the number of binge drinking days decreased. Negative social support increased the average number of binge drinking days among those who drink, where one unit increase was associated with an increase of 37 % in the expected number of days binge drinking in the same wave. The association of positive social support on the number of binge drinking days was stronger for females (-0.59 (SE = 0.12)), while neighborhood social cohesion was significantly associated with binge drinking in females (-0.05 (SE = 0.01)), but not in males. CONCLUSIONS: Negative social support favored binge drinking. Positive social support and neighborhood social cohesion are protective factors for binge drinking, especially for women.

One-year trajectories of mental health and work outcomes post return to work in patients with common mental disorders.

BACKGROUND: We investigated one-year trajectories of symptom recovery, work functioning and the return to work percentage (RTW%) among patients with common mental disorders (CMDs). METHODS: Data were used from a cluster-randomised controlled trial evaluating a problem-solving intervention for CMD patients (N = 158) who had returned to work. Information on anxiety and depressive symptoms, work functioning and RTW% was collected at baseline and 3, 6 and 12 months follow-up. Latent class growth analyses were used to identify trajectories for the four outcomes and investigate how these trajectories clustered in higher order latent classes. Additionally, we investigated the relation between patient characteristics and class membership. RESULTS: We identified four trajectories for all four outcomes and derived three higher order latent classes: slow recovery (42% [66/158]) (high anxiety and depressive symptoms, moderate to low work functioning and fast RTW); fast recovery (25% [40/158]) (low anxiety and depressive symptoms, high work functioning and fast RTW); and gradual recovery (33% [52/158] (decreasing anxiety and depressive symptoms, increasing or low work functioning and fast RTW). Participants with a higher work engagement and readiness to stay at work were more likely to belong to the fast recovery class. LIMITATIONS: Due to the relatively small sample size, some trajectories consisted of few participants. Symptom severity was self-reported. CONCLUSIONS: Many CMD patients experience high levels of mental health symptoms and work functioning problems during the year post RTW. Creating realistic recovery expectations (for both patients and their environments) could be important for successful and sustainable recovery and work participation.

Beyond Return to Work: The Effect of Multimorbidity on Work Functioning Trajectories After Sick Leave due to Common Mental Disorders.

Objectives Patients with common mental disorders (CMDs) often suffer from comorbidities, which may limit their functioning at work. We assessed the longitudinal impact of multimorbidity, defined as two or more co-occurring chronic health conditions, on work functioning over time among workers who had returned to work after sick leave due to CMDs. Methods Prospective cohort study of 156 workers followed for 1 year after return to work from sick leave due to CMDs. A multimorbidity score was computed by counting severity-weighted chronic health conditions measured at baseline. Work functioning was measured at baseline and at 3, 6 and 12 months follow-up with the Work Role Functioning Questionnaire. Work functioning trajectories, i.e. the course of work functioning after return to work over time, were identified through latent class growth analysis. Results A total of 44 % of workers had multimorbidity. Four work functioning trajectories were identified: one (12 % of the workers) showed increasing work functioning scores during follow-up, whereas the other trajectories showed low, medium and high scores (23, 41 and 25 %, respectively) that remained stable across time points. Although multimorbidity did not predict membership in any trajectory, within the increasing score trajectory levels of work functioning were lower among those with high baseline multimorbidity score (p < 0.001). Conclusions Over time, multimorbidity negatively impacts work functioning after return to work from sick leave due to CMDs.

Self-reported health-related quality of life in kindergarten children: psychometric properties of the Kiddy-KINDL.

OBJECTIVES: To assess the psychometric properties of the German self-reported version of the Kiddy-KINDL that measures Health Related Quality of Life (HRQoL) in 3 to 5 year old kindergarten children. STUDY DESIGN: The population of the study comprised baseline data of a longitudinal study whose main aim is to investigate self-reported health outcomes in young children (N = 317). METHODS: Missing values, the distribution of data, internal consistency (Cronbach's alpha and Guttman's lambda), and reliability (split half and two weeks test-retest) were analysed. To assess discriminant validity, mean differences were tested splitting the sample regarding socio-emotional competences (VBV 3-6), age and gender. Structural validity was investigated with Confirmatory Factor Analysis (CFA). RESULTS: Mean HRQoL was 69.79 (SD 16.84). Overall missing values were 8.1%, overall Cronbach's alpha was 0.75 and overall Guttman's lambda was 0.77; for the whole scale Spearman-Brown test for split half reliability resulted in 0.80 and ICC for test-retest in 0.83. Discriminant validity investigation differentiated groups with high and low socio-emotional competence and those children who were 4.5 years or older, compared to the younger ones. Differences between boys and girls were also found. CFA suggested two main dimensions: physical and socio-emotional. CONCLUSION: This preliminary validation of the Kiddy-KINDL in very young children shows satisfactory psychometric properties. However, results of the Cronbach's alpha, Guttman's lambda and the CFA depicted problems, mainly in the psychological dimension. Due to these we recommend to use the Kiddy-KINDL as an instrument with only two dimensions. Further studies in general population samples are needed.

[One year prevalence of mental disorders comorbidity and associated socio-demographic risk factors in the general population of Spain. Results of the ESEMeD-Spain study]. / Prevalencia-año de la comorbilidad de los trastornos mentales y factores de riesgo sociodemográficos asociados en la población general de España. Resultados del estudio ESEMeD-España.

INTRODUCTION: Comorbidity among mental disorders in the general population is common, affecting more than the 50 % of individuals with a lifetime mental disorder. In Spain, there are no data describing it or its associated risk factors. METHOD: The ESEMeD-Spain study is an epidemiological study assessing mental disorders in a sample of 5,473 individuals from the general population of Spain aged 18 years or older. The aims of the present study were to evaluate the frequency of mental disorders comorbidity in Spain (assessed with the Composite International Diagnostic Interview: CIDI 3.0) and associated sociodemographic risk factors. Response rate was 78.6%. RESULTS: Mood disorders showed the highest comorbidity frequency. Analysing specific disorders, generalized anxiety disorder, dysthymic and panic disorders showed the highest comorbidity percentages. Female gender, ages above 24 years old and being previously married were found to be risk factors associated to the presence of comorbid mood and anxiety disorders. CONCLUSIONS: As it has been suggested for other European countries and for the United States, in the general population of Spain mental disorders, specially mood disorders, are frequently comorbid. When treating mental disorders, comorbidity should be taken into account.

[Mental health care use in the Spanish general populations. Results of the ESEMeD-Spain study]. / Utilización de los servicios de salud mental en la población general española. Resultados del estudio ESEMeD-España.

INTRODUCTION: Between 17% and 30% of the world population suffers from a mental disorder in a given year and only a small proportion of them established contact with health services. This information is not available concerning the Spanish population. This study aims to describe the health services utilization related with mental disorders in Spain, as well as to identify factors related with such utilization. METHODS: The ESEMeD-Spain is an epidemiological study carried out on a representative sample of the Spanish adult general population, with a sample size of 5,473 individuals. We used the Composite International Diagnostic Interview (version 3.0) to collect information concerning mental disorders symptoms, health services utilization related with mental health, and administered treatments, with a 12 months time frame. RESULTS: 57% of those suffering from a mood disorder, 30.3 % of those suffering from an anxiety disorder and 71.7% of those suffering from both contacted health services in the year they suffered the disorder. Psychiatrists were the most frequently consulted professionals when a 12 month mental disorder was present, with the exception of anxiety disorders or comorbid mood-anxiety disorders. A 30.8% of those with any 12 month mental disorder who did consult were not prescribed with any treatment. Variables significantly related to 12 month health services utilization were age, gender, marital status, and mental disorders. CONCLUSIONS: A large proportion of individuals suffering from mental disorders do not use health services or, if indeed use them, do not receive any type of treatment.

[Psychotropic medications use in Spain. Results of the ESEMeD-Spain study]. / Uso de fármacos psicotrópicos en España. Resultados del estudio ESEMeD-España.

INTRODUCTION: Psychotropic drugs are frequently used in the population and account for a big share of the Spanish health budget. This study aims to describe the patterns of use of psychotropic drugs in the Spanish general population and its relationship with mental health. METHODS: A stratified, multistage, clustered area, probability sample design was used and 5,473 non-institutionalized individuals older than 18 were randomly selected among the Spanish population. They were administered the Spanish version of the World Health Organization- Composite International Diagnostic Interview (CIDI 3.0). Information on previous 12-months psychiatric symptoms and psychotropic drugs use was obtained. The proportion of individuals using psychotropic drugs was estimated and stratified according mental health diagnosis. Multivariate analyses were carried out in order to assess the influence of sociodemographic factors on use. RESULTS: 16% of the sample had used some psychotropic drug. Benzodiacepines (11.4 %) and antidepressants (4.7%) were the most commonly used and the most common combination (1.8%). Women showed the highest use of any drug (odds ratio [OR]: 2.1; 95 confidence interval [CI]: 1.7-2.5), benzodiacepines (OR: 2.3; 95 CI: 1.9-2.8), antidepressants (OR: 2.2; 95 CI: 1.6-3.1) and antipsychotics (OR: 1.9; 95 CI: 1.2-3.0). The odds of use did increase with age, and was related with the presence and number of mental disorders. CONCLUSIONS: Use of psychotropic drugs in the Spanish general population is high, although many individuals with mental disorders remain untreated. Gender and age showed an association with psychotropic drug use independent of mental health.

12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: Comorbidity patterns of 12-month mood, anxiety and alcohol disorders and socio-demographic factors associated with comorbidity were studied among the general population of six European countries. METHOD: Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional psychiatric epidemiological study in a representative sample of adults aged 18 years or older in Belgium, France, Germany, Italy, the Netherlands and Spain. The diagnostic instrument used was the Composite International Diagnostic Interview (WMH-CIDI). Data are based on 21 425 completed interviews. RESULTS: In general, high associations were found within the separate anxiety disorders and between mood and anxiety disorders. Lowest comorbidity associations were found for specific phobia and alcohol abuse-the disorders with the least functional disabilities. Comorbidity patterns were consistent cross-nationally. Associated factors for comorbidity of mood and anxiety disorders were female gender, younger age, lower educational level, higher degree of urbanicity, not living with a partner and unemployment. Only younger people were at greater risk for comorbidity of alcohol disorder with mood, anxiety disorders or both. CONCLUSION: High levels of comorbidity are found in the general population. Comorbidity is more common in specific groups. To reduce psychiatric burden, early intervention in populations with a primary disorder is important to prevent comorbidity.

Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: The European Study of Epidemiology of Mental Disorders (ESEMeD) project was designed to evaluate the prevalence, the impact and the treatment patterns in Europe. This paper presents an overview of the methods implemented in the project. METHOD: ESEMeD is a cross-sectional study in a representative sample of 21 425 adults, 18 or older, from the general population of Belgium, France, Germany, Italy, the Netherlands and Spain. The Composite International Diagnostic Interview (WMH-CIDI) was administered by home interviews from January 2001 to August 2003 using Computer Assisted Personal Interview (CAPI) technology. Data quality was controlled to ensure reliability and validity of the information obtained. RESULTS: Response rate varied from 78.6% in Spain to 45.9% in France. Less than 4% of the individuals had errors in the checking procedures performed. CONCLUSION: The sampling methodologies, comprehensive psychiatric instruments and quality control procedures used have rendered the ESEMeD database a unique and important source of information about the prevalence, the disability burden and unmet medical needs of mental disorders within Europe.

Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: To describe the 12-month and lifetime prevalence rates of mood, anxiety and alcohol disorders in six European countries. METHOD: A representative random sample of non-institutionalized inhabitants from Belgium, France, Germany, Italy, the Netherlands and Spain aged 18 or older (n = 21425) were interviewed between January 2001 and August 2003. DSM-IV disorders were assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview (WMH-CIDI). RESULTS: Fourteen per cent reported a lifetime history of any mood disorder, 13.6% any anxiety disorder and 5.2% a lifetime history of any alcohol disorder. More than 6% reported any anxiety disorder, 4.2% any mood disorder, and 1.0% any alcohol disorder in the last year. Major depression and specific phobia were the most common single mental disorders. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders. CONCLUSION: ESEMeD is the first study to highlight the magnitude of mental disorders in the six European countries studied. Mental disorders were frequent, more common in female, unemployed, disabled persons, or persons who were never married or previously married. Younger persons were also more likely to have mental disorders, indicating an early age of onset for mood, anxiety and alcohol disorders.

Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: This manuscript examines the impact of mental health state and specific mental and physical disorders on work role disability and quality of life in six European countries. METHOD: The ESEMeD study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an in-home computer-assisted interview. Common mental disorders, work loss days (WLD) in the past month and quality of life (QoL) were assessed, using the WMH-2000 version of the CIDI, the WHODAS-II, and the mental and physical component scores (MCS, PCS) of the 12-item short form, respectively. The presence of five chronic physical disorders: arthritis, heart disease, lung disease, diabetes and neurological disease was also assessed. Multivariate regression techniques were used to identify the independent association of mental and physical disorders while controlling for gender, age and country. RESULTS: In each country, WLD and loss of QoL increased with the number of disorders. Most mental disorders had approximately 1.0 SD-unit lower mean MCS and lost three to four times more work days, compared with people without any 12-month mental disorder. The 10 disorders with the highest independent impact on WLD were: neurological disease, panic disorder, PTSD, major depressive episode, dysthymia, specific phobia, social phobia, arthritis, agoraphobia and heart disease. The impact of mental vs. physical disorders on QoL was specific, with mental disorders impacting more on MCS and physical disorders more on PCS. Compared to physical disorders, mental disorders had generally stronger 'cross-domain' effects. CONCLUSION: The results suggest that mental disorders are important determinants of work role disability and quality of life, often outnumbering the impact of common chronic physical disorders.

Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: Comprehensive information about access and patterns of use of mental health services in Europe is lacking. We present the first results of the use of health services for mental disorders in six European countries as part of the ESEMeD project. METHOD: The study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an computer-assisted interview done at home. The 21 425 participants were asked to report how frequently they consulted formal health services due to their emotions or mental health, the type of professional they consulted and the treatment they received as a result of their consultation in the previous year. RESULTS: An average of 6.4% of the total sample had consulted formal health services in the previous 12 months. Of the participants with a 12-month mental disorder, 25.7% had consulted a formal health service during that period. This proportion was higher for individuals with a mood disorder (36.5%, 95% CI 32.5-40.5) than for those with anxiety disorders (26.1%, 95% CI 23.1-29.1). Among individuals with a 12-month mental disorder who had contacted the health services 12 months previously, approximately two-thirds had contacted a mental health professional. Among those with a 12-month mental disorder consulting formal health services, 21.2% received no treatment. CONCLUSION: The ESEMeD results suggest that the use of health services is limited among individuals with mental disorders in the European countries studied. The factors associated with this limited access and their implications deserve further research.

Psychotropic drug utilization in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: To assess psychotropic drug utilization in the general population of six European countries, and the pattern of use in individuals with different DSM-IV diagnoses of 12-month mental disorders. METHOD: Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000), a cross-sectional psychiatric epidemiological study in a representative sample of 21 425 adults aged 18 or older from six European countries (e.g. Belgium, France, Germany, Italy, the Netherlands and Spain). Individuals were asked about any psychotropic drug use in the past 12 months, even if they used the drug(s) just once. A colour booklet containing high-quality pictures of psychotropic drugs commonly used to treat mental disorders was provided to help respondents recall drug use. RESULTS: Psychotropic drug utilization is generally low in individuals with any 12-month mental disorder (32.6%). The extent of psychotropic drug utilization varied according to the specific DSM-IV diagnosis. Among individuals with a 12-month diagnosis of pure major depression, only 21.2% had received any antidepressants within the same period; the exclusive use of antidepressants was even lower (4.6%), while more individuals took only anxiolytics (18.4%). CONCLUSION: These data question the appropriateness of current pharmacological treatments, particularly for major depression, in which under-treatment is coupled with the high use of non-specific medications, such as anxiolytics.

Female sterility in Ulmus minor (Ulmaceae): a hypothesis invoking the cost of sex in a clonal plant.

A high incidence of individuals with low seed set was found in two populations of the field elm Ulmus minor, a European tree that reproduces sexually and via vegetative propagation through root sprouting. One population was a seminatural stand, while the other was established by artificial propagation of genotypes sampled widely across Spain. The low seed set in both populations was due to both pre- and post-zygotic factors, the importance of which vary between genotypes. These factors included gynoecial malformations that produced a non-ovulated pistil, early gynoecial necrosis (i.e., necrosis before any opportunities for pollination), and seed abortion. Female sterility gave rise to two classes of individuals: trees that were largely female-sterile but dispersed normal quantities of viable pollen, and trees that dispersed both normal pollen and substantial numbers of seeds. Reduced production of protein-rich seeds may increase the resource availability for clonal propagation, helping to maintain female-sterile individuals with hermaphrodites.

[Serological prevalence and evaluation of the risk factors of bovine enzootic leukosis in the Bogotá savannah and the Ubaté and Chiquinquirá Valleys, Colombia]. / Prevalencia serológica y evaluación de los factores de riesgo de leucosis bovina enzoótica en la Sabana de Bogotá y los valles de Ubaté y de Chiquinquirá, Colombia.

The authors present the results of a study to determine the serological prevalence of the enzootic bovine leukosis virus among dairy cows in the Sabana de Bogotá region and the Ubaté and Chiquinquirá Valleys, the principal dairying areas of Colombia. Samples were taken from 919 animals selected at random from 420 farms in 51 municipalities, in accordance with a statistical sampling procedure developed previously, based on the cattle census maintained by the Animal Health and Disease Control Office of the Instituto Colombiano Agropecuario, and the recommendations for prevalence studies of the Pan American Health Organization. The double gel diffusion technique with gp-51 antigen was used. Serological prevalence averaged 45.28% (ranging from 42.07% to 48.49%) with a confidence level of 95%. In addition, a survey was conducted to determine how much those in charge of herds knew about the disease, and to establish the incidence of certain risk factors possibly associated with distribution of the causal agent. Data obtained from 232 completed questionnaires showed that only 54.6% of farms received professional assistance. Of these, 6.6% received constant assistance, 4.4% received visits every fortnight, 51.8% received monthly visits, 14% received visits every other month and 22.95% received occasional visits.