Patient Contact With the Practice

The initial engagement of today’s patient with an eye care practice likely takes form online. A new patient may have undertaken an Internet search based on locality or desired clinical services, and/or received a recommendation from a current patient. A returning patient is likely to use Internet search to locate a phone number or online booking capacity. The returning patient may be contacting the practice of their own volition – to book an eye examination or order contact lenses – or may have received an examination recall. The mode of contact should provide sufficient information for the prospective or returning patient to confirm their course of action – for example information on contact lens options and fitting and how to contact the practice.

Regardless of the mode of contact for a new or returning patient, the first opportunity for discussion is typically a phone conversation. Practice staff must be provided guidance and a system for ensuring correct utilization of the ECP’s appointment book, which is the ‘engine’ driving the eye care practice. Practice staff can be trained to ask specific questions about the patient’s intention for their appointment – for example is it for spectacles, or contact lenses, or an eye health concern – to ensure pertinent information is passed onto the ECP prior, or at the time of the appointment. Practice staff are also best prepared for questions frequently asked by patients, to ensure informative conversations and conversion into appointment bookings. The ECP can be instrumental in providing informal education or ‘sound bites’ on clinical questions posed by patients to practice staff, as a process of training or as the need arises. Typical questions patients may ask specific to contact lens practice, for which practice staff should be prepared, include:

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  Can I get contact lenses at my appointment?

  
  
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  How much are contact lenses?

  
  
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  I’ve been told I can’t wear contact lenses before – is that true?

  
  
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  Am I suitable for contact lenses?

  
  
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  How long does it take to get contact lenses?

Providing clear, succinct communication on these typical patient questions is important to form and maintain the relationship between the patient and the practice, setting the tone and expectations for the patient’s in-person interaction with the practice team at the time of attendance. Table 40.1 provides an outline of considerations in preparing communication for practice staff to answer these frequently asked questions, along with brief options from which to build practice-specific answers.

If taking an appointment booking via telephone, the practice staff member booking the appointment should gather information enough to contact the patient to confirm their appointment. Gathering the patient’s full name and a contact phone number is typically sufficient, to allow for a confirmation of the appointment a day or two before the date of the booking. For a previous patient returning to the practice, this would involve confirmation of this information to ensure contact can be made. A confirmation of the appointment can be made either via phone call, or a single or bulk mobile/cell phone SMS service, which is facilitated by many practice management software packages.

Whilst collecting the patient’s name and telephone contact details is necessary, it is ideal to also collect their date of birth, which assists with the identification of the patient when they eventually arrive at the practice and even with the patient flow if pretesting processes vary for patients of different age groups. It is ideal to also gather the name of a parent or guardian in the case of booking an appointment for a child or adult requiring guardianship. This makes the first presentation of the patient and their parent or guardian a more welcoming experience. Finally, it is also ideal to collect an email address. This allows for additional information to be sent to the patient to introduce them to the practice – for example, a map to find the practice, guidance on travel and/or car parking and information on services and fees. Collecting an email address also permits an additional contact method to confirm the appointment prior to the booking date, if telephone contact proves unsuccessful.

Patient Arrival Into the Practice

The patient should be immediately greeted and attended to on arrival. In the frequent case of practice staff being otherwise busy with a phone call or another patient, a simple acknowledgement with eye contact can ensure the patient has been recognized.

Practice processes on patient arrival will differ for new versus returning patients. In either case, patient contact details are required. New patients, or patients returning after a significant period – for example 2 years or more – may be provided a questionnaire on their vision, eye health and general health history and visual demands, to assist the ECP in addressing all needs and facilitate an optimized optical dispensing process. This is often termed a ‘welcome to the practice’ form, which serves the purpose of gathering necessary patient identification, contact details and health information, as well as asking questions to lead towards identifying all vision correction and eye health management solutions to serve the patient’s wants and needs.

A ‘welcome to the practice form’ is likely to include the following questions:

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  Patient details – full legal name, preferred name, date of birth, gender and parent/guardian name in the case of children, or adults under care or guardianship.

  
  
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  Patient contact details – physical address, email address and telephone number.

  
  
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  Health insurance information – for example identification numbers in national health schemes and/or private health insurance membership as relevant to the eventual billing of consultation and product fees.

  
  
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  Health history information – questions relevant to the general eye care practice, specific to its scope. For example, this may include known allergies and medications taken; any history of general health conditions which affect eye health such as diabetes. If there is a concern of protecting the confidentiality of patient health information, these questions can instead be asked in the verbal case history between ECP and patient.

  
  
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  Eye history information – the ECP may elect to ask questions that form part of a typical case history. Simple and useful examples could include if the patient currently wears glasses or contact lenses; and if they are interested in wearing contact lenses, which can help to raise the discussion in the consultation room. Further detail is likely best gathered verbally in the case history discussion between ECP and patient, to protect the confidentiality of patient health information.

  
  
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  Consent section – this may include a question of consent to contact other relevant health practitioners with the patient’s permission in the course of their care; consent to be contacted for marketing purposes or other elements of consent as required by the setting and region of the eye care practice.

The ‘welcome to the practice’ form should ideally be comprehensive but not too long to present a frustrating barrier to the patient and a logistical barrier to patient flow. It is also important to keep in mind that a patient presenting to an ECP practice may have impaired or under-corrected vision such that the print size should be no smaller than the typical print size, and larger if possible. It is useful for a practice staff member to check back with a patient filling out a ‘welcome to the practice’ form to ascertain any difficulties and provide assistance if needed. This ensures the patient has an experience supportive of their needs from their initial moments in the practice.

The ‘welcome to the practice’ form could be provided to the patient on their arrival into the practice as a hand-written paper form; an electronic form on a mobile tablet such as an iPad; or even emailed to the patient prior to their appointment with facility for simple completion and electronic return to the practice. Due to the pertinence to the examination process and also the requirement to keep this information on file, especially if a signature of informed consent has been recorded, frequently a hand-written paper form works most easily to be filled out by the patient, handed to the ECP, and then subsequently scanned onto the patient’s electronic record file. Completion at the time of arrival, whether by paper or electronic means, allows for optimized workflow and ensures the patient does not overlook providing the information in the case of a pre-emailed form. Completion within the practice also ensures the maintenance of information security of health information.

If the practice process includes some pre-ECP examination diagnostic testing – for example retinal imaging – then the patient should be informed of this and the process is undertaken as soon as possible.

Handover From Practice Staff to the Eye Care Practitioner

During initial interaction with the patient on arrival, pertinent information on the patient’s intent for the eye examination, and specific questions, may be discussed. This is increasingly likely as the practice staff member spends more time with the patient, for example in undertaking diagnostic testing. The handover process from practice staff to ECP should allow the opportunity for this information to be passed to the ECP. This may take place verbally and informally in discussion between the ECP and practice staff member, and/or formally via written information provided by the patient on a ‘welcome to the practice’ form.

Practice staff may have also had the opportunity to discuss the patient’s current spectacle or contact lens correction, including any limitations or issues; and/or to have selected new spectacle frames pending the outcome of the eye examination. Communicating this information is vital to meet patient needs and to ensure opportunities for optical dispensing are identified. Finally, practice staff undertaking diagnostic pretesting may have specific information on the outcomes or limitations of the pretesting to highlight with the ECP prior to the eye examination. This ensures the ECP has the best possible clinical data available and can identify where additional diagnostic testing may be required either before or after the ECP’s time with the patient in the consultation room.

Handover From the Eye Care Practitioner to the Practice Staff

After the eye examination has been completed, an ECP will typically have identified several measures for the management of the vision and eye health of the patient. The ECP will also have determined when the patient should next return for follow-up or routine care. Collaboration between the ECP and practice staff is imperative to ensure that these recommendations and instructions are realized after the examination, and for clinical messaging within the consultation room to be reinforced in the dispensary and/or at the patient’s final interactions before departing the practice.

Dependent on the practice setting and the skill level of the practice staff, the information provided between ECP and practice staff will vary in scope. For example, a handover between an optometrist and a qualified dispensing optician would likely involve technical detail on spectacle or contact lenses to be dispensed, whilst between an ECP and administration staff may comprise information on billing and when to schedule the next appointment. With regard to contact lens practice, clear messaging between the ECP and practice staff member on when the next contact lens appointment is required is imperative. This is especially important for new wearers, where it has been found that 25% of lens wear discontinuations (drop-outs) occur within the first month and almost 50% in the first 2 months ( ). Ensuring that the patient adheres to the ECP’s determined follow-up schedule, especially for new wearers, can help to reduce the risk of drop-out. ECPs can facilitate this by explaining when and why the next contact lens appointment is required, and practice staff can support this by booking these short-term appointments on handover to ensure patient commitment to successful and healthy contact lens wear.

Specific to soft disposable contact lens practice, typically ‘trial’ or sample contact lenses are first fitted before the prescription is finalized. It is important to ensure that the patient has the correct type and volume of trial lenses for the interval to the next contact lens appointment. Sometimes the correct trial lenses will need to be ordered after adjustment on initial fitting, and/or additional trial lenses may need to be ordered and delivered to the patient within the initial trial period. In either case, the ECP should communicate this to the practice staff member if they will be ordering the trial lenses. Discussion of the intended process between ECP, practice staff member and the patient can be useful to confirm and clarify the contact lens fitting and follow-up process for the patient and allow the patient to ask any last questions of the ECP before the conclusion of this contact.

Contact Lens Instruction Appointment

The neophyte contact lens wearer must be instructed on how to apply and remove their contact lenses, and appropriately clean and care for them. On average, the time allocated for this should be approximately 45 minutes for a new child wearer (12 years of age or less) and around 30 minutes for teen and adult wearers ( ). Depending on the preferences and ECP available chair time in the practice, this may be undertaken by the ECP or an appropriately qualified or trained practice staff member. The instruction appointment is a crucial time to establish confidence and enthusiasm for contact lens wear in the new wearer, so a clear process should be established to manage and counsel any patient-experienced difficulties with handling or initial discomfort. Consideration of support materials to provide the patient both during and after their instruction appointment includes the provision of information sheets and/or demonstration videos covering:

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  How to apply and remove their specific type of lenses?

  
  
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  How to clean the lenses, lens case and other handling items (e.g. removal plungers for gas-permeable lenses)?

  
  
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  Other ongoing cleaning processes (e.g. specific protein removal treatments for gas-permeable or planned replacement soft or hybrid lenses).

  
  
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  How to identify normal adaptation symptoms as distinct from abnormal contact lens complication symptoms and what to do about each?

  
  
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  A clear process for emergency contact in case of a red, painful eye or vision loss in contact lens wear, including after-hours instruction (e.g. an after-hours emergency number for the practice or direction to another health service where more suitable).

A simple mnemonic for contact lens safety and self-identification of complications is when you wear your contact lenses, your eyes should look good, feel good and see well; and, if in doubt, take them out. The patient should clearly and strongly be encouraged to contact the practice as soon as possible if any of these conditions are not met – if their eyes are red, sore or vision is blurred.

Whilst each of these steps in the patient learning how to handle and manage their contact lenses can be delivered verbally and with demonstration, reinforcement with written or video instruction is advised to support what can be an overwhelming process for a neophyte wearer.

Dispensing and Ordering Contact Lenses

The intended clinical goal of contact lens fitting is to ensure the patient follows through with successful contact lens wear and hence orders the finalized contact lens prescription. In the case of soft disposable contact lens practice, this is represented as the patient placing an order for a 6- or 12-month supply of the lenses. If the ECP has just finalized the prescription in a new or refitted wearer, or confirmed the prescription in an ongoing wearer, they can assist this process through confirming the volume required to last the patient until their next required examination.

Contact Lens Aftercare

Contact lens aftercare serves a variety of clinical and commercial purposes. From the clinical standpoint, appropriate aftercare preserves ocular health, maintains good vision, ensures good lens fit and optimizes comfort. It allows the ECP to discuss the patient’s contact lens wear suitability to their lifestyle, convenience and cost requirements. Crossing over into the intersection between clinical and commercial purposes, aftercare helps to ensure the contact lenses have been supplied as prescribed; the replacement frequency is appropriate; that patients are educated on the risks and alternatives to Internet purchase; and to confirm that the patient has a suitable back-up or part-time spectacle correction ( ).

A matrix for deciding the frequency of contact lens aftercare has been devised by and is discussed in detail in Chapter 37 . This matrix is based on the realities of today’s contact lens materials, care systems and contact lens wearer safety in combination with the appropriate duration of a valid contact lens prescription based on patient age, contact lens type and other factors of clinical presentation. Other circumstances specific to the individual patient could necessitate more frequent aftercare, for example in a lens wearer with a compromised cornea or ocular surface; at risk of poor compliance; or in complex cases such as very young children, high ametropia, after an adverse event or postocular surgery ( ). New wearers should be followed up additionally within the first 2 months of wear given that 50% of drop-outs occur in this time frame ( ).

Reducing Risk of Contact Lens Drop-Out

Various surveys have been undertaken to ascertain why patients cease to wear contact lenses, with around 25% of new wearers discontinuing within the first 12 months ( ). This represents a significant investment in ECP and patient time, and patient funds, in a process that is ultimately futile. Parents of children (8–12 years) who discontinue contact lens purchase most commonly cite that their child prefers wearing glasses, with the second most common reason being expense. Parents of teens (13–17 years) cite expense as the primary reason for drop-out. These reasons do not correlate with the child’s reported visual or comfort outcomes, indicating independence of parental decision-making from their child’s contact lens-wearing experience. Children and teens themselves typically report nonvisual or comfort reasons for discontinuation, such as ‘I want to give my eyes a break’ or ‘I don’t have enough time to put them on’ ( ).

Across contact lens wearers of all ages, most drop-outs at 1 month are due primarily to poor distance vision, with handling problems and inconvenience equal runner-up reasons. At 3 months, the primary reason is discomfort and at 12 months it is cost ( ). This highlights the importance first of additional aftercare for the new wearer within the first 2 months to manage any issues with vision, handling and comfort, and second of ensuring lens suitability to the long-term contact lens-wearing patient at each aftercare. In children, confirming that the child prefers wearing contact lenses to glasses and reaffirming the functional and confidence benefits of paediatric contact lens wear ( ) is helpful to combat drop-out. Ensuring parents understand the costs of ongoing lens replacement and clinical care is also crucial, to be first detailed at the initial appointment and reiterated at aftercare where suitable.

Key Messages for Practice Staff on Contact Lenses

The level of training and qualification of the practice staff will determine their capacity to support contact lens-wearing patients from answering questions in phone calls through to undertaking the contact lens instruction appointment. In the case of an ECP seeking to provide simple information about contact lenses to practice staff to lead through to further discussion in the consultation room, the following key points can be discussed. This would represent the minimum education that a practice staff member would require to support contact lens fitting within the practice.

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  Contact lenses are safe for children and adults to wear, and offer many benefits from vision correction to increased confidence and ability to participate in daily activities.

  
  
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  Many types of contact lenses are available for a variety of different prescriptions and visual needs, and even for part-time or occasional wear.

  
  
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  The ECP will explain options to the patient during their eye examination.

From this simplified basis the ECP, either as owner/manager or as part of the practice team, can further educate practice staff on the types and modalities of available soft disposable contact lenses, the capacity of the practice to fit specialty contact lenses, and outline prescription and other characteristics which indicate suitability for contact lens wear. Additional useful information can be to explain care and maintenance systems and replacement schedules. Staff should be advised to avoid providing clinical advice and to ask for the assistance of the ECP to answer patient questions outside this realm of knowledge, guiding the patient to book an eye examination for more complicated concerns. Further knowledge of this sort can equip practice staff to have more detailed conversations with current and prospective contact lens wearers, deal with common wearer questions without excessive impost on the ECPs’ time, and further support both the logistical and clinical aspects of contact lens practice.

In addition to the above, each member of the practice team should be trained and competent in the preferred process for appointment booking. Some practices prefer to identify at the time of booking whether the appointment will relate to contact lenses. Other practices will instead book appointment types in a consistent structure, with the ECP determining whether and what type of future appointments are required for contact lens fitting after the initial assessment. Approaches to typical patient questions asked during the appointment booking process are detailed in Table 40.1 . Finally, each practice staff member should be trained in the practice’s process for expired contact lens prescriptions. This includes consideration of situations such as when it is acceptable to reorder contact lenses on the patient’s request close to, but not exceeding, the expiry date; when a patient must be encouraged to book another examination before further supply; and how to balance safety issues of expired prescriptions with the patient need for contact lenses and any potential short-term supply authorization until the next eye examination occurs.

Triaging Contact Lens Emergency Appointments

A key role of practice staff in a contact lens practice is to answer common patient questions about contact lenses, as described above and in Table 40.1 , to facilitate booking an eye examination for further evaluation by the ECP. In a contact lens practice, staff should also be trained and competent in asking patients questions to appropriately triage a patient suffering a contact lens adverse event. The mnemonic used to educate patients on the normal contact lens experience of your eyes should look good, feel good and see well; and if in doubt, take them out can be similarly utilized for staff training. If a patient telephone to make an appointment, an astute practice team member can ask the following:

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  Are your eyes red or sore?

  
  
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  Is your vision blurred?

  
  
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  For how long have you noticed this?

  
  
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  Have you removed your contact lenses?

The key indicators of urgency are pain and discomfort, and/or severity of vision loss (whether painful or not). A simple and compassionate rule of thumb is that the more distressed the patient appears to be in the discussion, the sooner an appointment should be booked with the ECP. If the practice staff member is unsure of urgency, the answers to questions 1–3 communicated to the ECP will help in the determination. The intent of question 4 is that a contact lens wearer suffering an adverse event should be counselled to remove their contact lenses wherever possible. It may not be possible in the case of a specialty contact lens wearer – for example a person with keratoconus who does not achieve functional acuity with spectacles – or in patients who do not have suitable backup spectacles for other reasons. When it is suitable to do so, both the ECP and practice staff can highlight and address this issue for patient clarity (if a backup correction is not possible) or patient safety (where a backup correction is possible but not yet undertaken by the patient).

Cost-Per-Wear Modelling

Simple messaging on the cost of contact lenses can be established by considering the cost of contact lenses over a year, or per wear. Depending on the practice setting, this may be calculated and provided by a central administrative body in a large company, or can be determined by an owner-operator ECP. Modelling total cost includes professional fees, solutions and drops required as well as the contact lens product. In comparing replacement modality, determined a cost-per-wear model and found that 2-weekly and monthly replacement lenses were similar, with cost-per-wear reducing with increasing days of wear per week. Daily disposable contact lens cost-per-wear was similar to reusable lenses was around 5 days per week for spherical lenses, and around 4 days per week for toric and multifocal contact lenses. This was modelled based on both typical Australian ( ) and UK ( ) costs in the early 2010s, and whilst a variety of individual practice factors could render these figures inaccurate today, it provides a useful framework for providing simple cost information to patients, particularly if daily disposables are indicated but cost is a concern of either ECP or patient.

Determining a cost-per-wear model for simple patient communication doesn’t need to result in a specific number; rather, a range of cost-per-day for full-time wear will help the patient to grasp costs with the caveat that the final figure depends on their individual prescription and other suitability factors. The owner-operator ECP may strategically consider pricing disposable contact lenses of the same replacement modality similarly, to allow the selection of the best lens suitable to the patient independent of cost. This will depend on the commercial reality of cost price comparison across brands. In large corporate practice, preferred supplier relationships typically exist which skew fitting choices to particular brands. In today’s contact lens practice where numerous excellent options exist in prescription availability, modality and comfort outcomes across contact lens suppliers, this should not prove a barrier to successful disposable soft contact lens practice. It can be a barrier for patients with higher prescriptions or in need of specialty contact lenses, in which case intra-professional referral should be encouraged, in the patient’s best interests. It is not in the best interests of the patient, or the contact lens industry in general, to fit contact lenses resulting in sub-standard vision, comfort or ocular health outcomes when better options are available either within or outside the practice to which the patient presents.

Adopting a Clinical-Leading Model

With the increasing commoditization of disposable contact lenses, through wide accessibility of online ordering and oftentimes without a valid prescription, the challenge falls to each individual ECP to educate their patients on the reality of contact lenses as medical devices and the importance of proper fitting, prescription finalization and aftercare. Where the ECP has no influence on the fees charged to patients for either professional services or products, it is still important to educate patients on the importance of compliance with contact lens replacement and aftercare appointments, along with the potential for new innovations in both contact lenses and general eye care to encourage continuous clinical engagement with the practice.

Where the ECP has the influence to do so, appropriate fees and charges for professional services (appointment chair time) should be established. Developing a fees schedule is a complex task, again involving a balance between charging enough to cover the realistic costs of running the business with what the market is willing to pay and how potential competition will be viewed by the patient-customer. In many primary eye care settings across many countries, eye examination fees are viewed as a loss-leader to spectacle and contact lens retail sales. Moving away from this to a specialty model focused on clinical service is a challenge and relies primarily on intent to differentiate through products (e.g. specialty contact lenses), investment in technology, providing a comprehensive service, higher-level training of the ECP or other. In today’s retail-competitive environment, this differentiation between a clinical leading and not a product or cost-leading message must be clearly communicated to the patient and reinforced at each point of contact with the practice; in each step of the patient journey and in all internal and external marketing. This is further detailed in the next section. Transparent and logical messaging on costs – of professional fees, products and other services – are required in the clinical-leading model regardless of what level of fees are established.

Internal Marketing

Internal marketing consists of the messaging which occurs within the practice during the patient’s visit. This includes general patient information and education available in the practice; the tone and content of conversations had about products and services; and examination information and follow-up provided. This could involve a variety of supportive materials such as forms and brochures, video information screens within the practice, information posters about both product and service elements, promotion messaging, and supportive clinical information provided to the patient in hard-copy or electronically during or subsequent to the eye examination. Internal marketing typically communicates detail on available products and services. It also ideally educates the patient on the dispensing and/or examination process as well as on their own vision and eye health conditions. Using pictures in health communication, in conjunction with text and verbal explanation, has been shown to improve patient attention, recall and compliance ( ).

External Marketing

External marketing comprises all elements of communication with the patient when they are outside of the practice. For today’s practice, a key element of this is the online presence of the practice for both prospective and current patients to engage with and learn about the people, products and services involved. Today’s health care patient has frequently engaged with information on the Internet prior to visiting a health professional, and perhaps even decided to attend that practice based on the online messaging. The online presence includes a practice website and social media accounts with which patients engage for personal information such as Facebook and Instagram. ECPs who hold influence over the external, online marketing of their place of practice should consider the scope and volume of educational content, mix with promotional content and any applicable regulations in their region, for example relating to health advertising and/or allowance of patient testimonials. The mixture of content ranging from promotional to clinical and educational should be aligned with the intended positioning of the practice. Social media marketing can be utilized not just to expand brand awareness but also to improve clinical care, enhance patient education and even advance medical research ( ). The online presence should also provide a method for patients to communicate with the practice after-hours and at their convenience, even if not in real time – such as the ability to send emails, social media messages, and undertake services such as online appointment booking or ordering a contact lens supply.

External marketing also includes direct communication with patients in between their eye examinations. This includes email newsletters which serve the purpose of educating and maintaining contact with patients, continuing the long-term relationship with the practice and its people over time. The most important element of external marketing, considered a component of clinical care, is the patient recall letter to indicate when and why the patient’s next eye examination should be booked. The importance of the recall letter cannot be overstated as the lifeblood of the eye care practice. First and foremost, it serves a crucial role in the continuity of patient care by delivering on the professional responsibility of provision of ongoing service. In some jurisdictions, it is a regulatory requirement of the primary ECP, and indeed other health providers, to provide appropriate evidence of recall for continued clinical management. Setting an appropriate time frame for the patient’s next eye examination, dependent on their condition and required management, can be an issue of duty of care and even professional negligence in situations where patients suffer adverse outcomes.

The recall letter can be provided as suitable to the preferred communication of the patient and practice, for example as an email, written letter or SMS. Relevant regulations or advice from professional organizations may advise the number and form of recall contacts that must be attempted before the duty-of-care has been appropriately discharged. It should include the patient’s name, the date (or approximate) of their next required eye examination and contact details for the practice. Electronic recalls may include connection through to online booking to remove convenience barriers for patient uptake. A variety of electronic and hard-copy mediums can be utilized to maximize engagement. Astute patient database management can allow for more customized recall letters to be sent, for example explaining the type of eye examination required and/or information on that patient’s specific correction type or eye condition.

Whilst both internal and external marketing elements are important in ongoing communication and contact with patients, the level of engagement with each will vary based on the practice lifecycle and patient retention rates. Practice at the earlier stage of its lifecycle, or with high patient turnover (low retention), will rely heavily on external marketing to build traction, awareness and share in their market. Aside from the methods of external marketing described above (primarily online), marketing to attract new patients or remind current patients of the practice branding and position could include media such as print, radio and television advertisement; direct mail in a local area and speaking engagements. A well-established practice with a loyal patient base, or with strong market awareness and positioning, may focus more on internal marketing to retain patients and encourage word-of-mouth referral, which has been shown a powerful tool for utilization of health services and even uptake of specific health care recommendations ( ).