internship season

May 16, 2015 by

In the crazy wrap up of the semester, it’s been difficult to work on all of my online writing projects, but now that it’s summer I will have more time- in theory. Because  summer and for SPH students transitioning into second year, that means it’s internship season. We are all dispersed to new locations across Michigan, the United States and across the globe to see what public health looks like in action. It’s incredibly exciting and I cannot wait to see the wonderful work my classmates and colleagues will accomplish and learn this summer. It will be a summer of growth and challenge, that’s for certain.

My internship is with the University of Michigan’s MHealthy- a branch of their human resources department devoted to Health and Wellness of employees of the university. I am very excited to begin my work on projects and interventions, specifically in the Stress Management and Risk Reduction department. If there’s one thing I know as a student, it’s stress!

Some of my classmate-friends are headed out of the country! Check out Jhordan’s awesome blog documenting her summer in Chile. Another friend is already in Thailand, and a third is headed to India at the end of this month.

I will attempt to keep you all up to speed on my internship here on the SPH blog, but to also write about a few things that I learned in my last few weeks of second semester- like meeting a former Surgeon General of the U.S., potentially starting a new student org and UMMA’s student art night. I hope you’re all well, and happy summer! :)

Diptheria, Listeria….Hypsteria?!

April 1, 2015 by

aparnaIt’s hard to believe that my first year as a grad student is coming to an end!

Throughout the last few months, I have found so many reasons to rediscover my love for Ann Arbor, none of which include the ridiculous cold of course!

Compared to my experience as an undergrad student here, I’ve loved my grad experience a lot more. Any of you who are thinking about coming here from U of M – DO IT! It seems kind of crazy to think that anywhere on campus can be thought of as “small,” but that is exactly what SPH has been for me – a small, close knit community of friends, colleagues, faculty and staff that all work together for the betterment of the community.

I’ve enjoyed my experience in extracurricular activities here – most notably PHAST! You can read all about our experiences in Texas on the Frontlines Blog! It was great to see how a few months in the classroom could be turned into first hand knowledge a stone’s throw from Mexico.

IMG_3914 (It says PHAST 15 in the sand)

Another reason to love being a grad student here – everyone is so, so funny! Of course, as an epidemiology student, we’ve talked about all the main epidemic players – Ebola, Listeria, vaccine-preventable illness…but leave it to UMSPH to come out with breaking news on the latest epidemic – Hypsteria!

I’ll publish another post reflecting fully on my first year’s experience as well as preparations for my summer internship, but for now, watch the video to see why “Go Blue” is the only place you’ll ever need to go!

Speaking Plainly

March 31, 2015 by


I’ve found that when you’re passionate and knowledgeable, succinct writing is a challenge. Greater challenge still is when you are writing for a wider audience and you want those few words to be interesting and meaningful.  Writing in the Health Communication field certainly checks off all of these boxes in my mind, so I was happily anticipating my conversation with HBHE alum Holly Derry– who is a Behavioral Science Team Leader at the Center for Health Communications Research here at the University of Michigan- because I knew she’d be able to shed some light on the topic. I also wanted to know something of her background, because everyone here at U of M has a fascinating career journey.

 PK: What is your background- where did you obtain your MPH? Did you do a lot of Health Communication research during your time in school?
HD: I got my MPH from UM SPH in 1997 (I’m old!). I tried to take as many health comm classes as I could, but fewer were offered at that time, compared to now. Back then, the major focus of HBHE was more in the community organizing side of things, so I had fewer options. Still, Vic Strecher had just started, so it picked up eventually. Since then, I’ve audited some classes – Ken’s Health Comm class, Brian’s Sticky class, and Ken’s MI class.

PK: What drew you to the field of Health Communication research? What made you chose CHCR as a place of work?

HD: I was a psych major in undergrad and had always had my eye on clinical psych… until I did a semester-long stint at a crisis hotline calling center (with no training) and felt like I was in WAY over my head. Around that same time, I was taking a health psych class, and it really felt right. Then, I started to look into MPH programs (I didn’t even know they existed until then)… and got into UM. Once at UM, I met Vic Strecher at orientation (literally day 1!!), and he sold me on the principal behind CHCR: get all the people who develop health interventions  (designers, programmers, writers) under the same roof so they work together, speak the same language, and learn from each other. I was hooked. My second year of grad school (1996), I worked here at CHCR as a student… and then got a full-time job after I graduated.
 PK: Is there a specific population or topic you are particularly interested in?

HD: I’m fairly agnostic about the population and topic I work on – my general interest is tailoring the approach, technology, and (of course) messages to ANY topic and population. And frankly, this is what keeps my job interesting… for example:  thinking about designing an intervention for 65-year-old type 2 diabetics vs. 12-year-old girls in an after school exercise program.

PK: Do you have any tips/resources for me as an aspiring content/health comm writer about writing in plain language? [plain language: is communication your audience can understand the first time they read or hear it. read more about it here]

HD: I’m so excited you’re asking this question! It means you’re thinking about it – which is more than can be said for a LOT of others!!
1. It’s very difficult to switch from plain language writing (for lay people) and writing for your professors or funders. That said, *everyone appreciates plain language*… so writing plainly is ALWAYS a good thing. You’ll elaborate more and be less worried about multi-syllabic words in academic writing… but using the inverted pyramid and active voice are always always always good things.
2. I went to a health literacy workshop in Maine a few years back. It was helpful and had some good hands-on practice… it’s pricey, though, so you may want to wait to ask your first employer to send you to this or something like it.
3. Read “Letting go of the words.” Then read it again. Live it. Love it. Memorize it. Spread the word!!
4. If you need to target a certain reading level, I recommend using the SMOG test for reading level. It’s free and highly recommended by literacy experts. (Technically, experts recommend another one first – maybe Flesh-Kincaid? or Fog? can’t remember – but it’s expensive.) There are tons of websites where you can copy and paste your text and get a SMOG reading level. I use this one  Do NOT use Word’s built-in reading level calculator, if you can avoid it.
5. NCI offers this 1-hour online training, which isn’t bad. If you’re already fairly good, it may not be that helpful… but it’s only an hour (and it’s free)!
6. Please never ever ever call it “dumbing it down.” If you’re dumbing it down, you’re not doing it right. Plain language is about taking complicated ideas and wording and structuring them in a way that’s accessible to a wider audience. It’s partially about word choice… but it’s also about formatting it in a way that matches how people actually read.
7. Other resources (you probably already know about these):
8. If someone wants you to get down to 3rd grade reading level, be skeptical. In my experience, this request comes from either a) committees, or b) people who don’t really understand plain language and literacy issues, or c) both. If an audience’s reading level is concerning (low) enough, you probably shouldn’t be using written words at all. Instead, consider audio or video delivery. If people are literate… then an 8th grade level feels reasonable. Any less than that will alienate stronger readers and be stilted / awkward to read. Of course, this is an oversimplification and definitely represents a soap-box of mine… but there it is.

PK: How much has technology become a part of the health communications you create? Are the majority of your experimental interventions technology now?

HD: Technology is as integral as the words I write in our programs. I could write the best words in the world, but if they’re on a brochure in a grocery store lobby, no one will read them. If it’s on a device in their pocket… now we’re in business.
And yes, all of our interventions are tech-based. They have always been computer-based, because the tailoring we do starts from a computer-operated system. But back in the day, our tailoring system would generate print materials individualized for a particular person and then be mailed off. Now, we have a system that will deliver our tailored content in any way we can imagine – it will call people using IVR (interactive voice recognition), or deliver content to texts, websites, and mobile apps.

PK: Do you have a mentor or colleague in your professional life that has been influential?

HD: There are a LOT of people who have been influential in my career… At SPH, Ken Resnicow and Brian Zikmund-Fisher remain influential. Brian also works with Angie Fagerlin (at CBSSM –Center for Bioethics and Social Sciences in Medicine at the University of Michigan), and I’ve learned a ton from them and their research. Between these 3, they’re the ones I go to when I need advice or have questions.

PK: What are some trends you have noticed in the health communication field that would be important for me to be aware of/keep an eye as I go forward in my career?

HD: Mobile. Mobile. Mobile. We have to think about smaller devices (less real estate for the info we provide). We have to imagine that people aren’t reading our carefully-crafted paragraphs while comfortably seated in their quiet, private offices and giving us their undivided attention. They’re at a bus stop. They’re in a meeting. They’re at a red light. They’re having a conversation at the same time. They steal minutes (or seconds) to check something between (or while) doing other things… and so how do get our intervention to be the thing they check – to track what they eat, their exercise, whether they’ve taken their meds, etc. For that matter, how can we get the device to track things automatically so they don’t have to answer so many questions?
Related, how much information will people read at any one time? How do you craft an intervention that’s responsive to people’s reading styles? On the internet (as you’ll learn if you read “Letting go of the words,”) people skim and scan. This is why plain language is SO IMPORTANT. Use headings. Use the inverted pyramid. Step away from “walls of text.”
I think some answers to these questions include:
– use fewer words (say the right things, not all the things)
– find teachable moments (say the right things at the right time)
– infographics (say more with fewer words by using images)

Thanks very much to Ms. Derry for letting me interview her. I hope this helps anyone interested in Health Communications or any other potential writers out there- speaking plainly is not as hard as you may think! 

Economic development and health outcomes: The case of the Dominican Republic

March 24, 2015 by


The World Bank classifies the Dominican Republic (DR) as an upper-middle income economy with a $5,770 gross national income per capita (WB, 2015). The country is one of the top performers in terms of economic growth in Latin America. Paradoxically, after analyzing main social indicators one wonders why this economic development has not been translated into notable social progress over the years. In this blog I will focus on public health.

Aiming towards universal health coverage would contribute to reducing the incidence of catastrophic health expenditure. High health costs often have severe consequences in increasing poverty headcounts. In the DR there are important obstacles that prevent the country from reaching universal health coverage, such as very low government health expenditures and a big informal sector. Public health expenditure was 2.4% of GDP (WB, 2015) on average during 2000-2012, one of the lowest in Latin America.

Despite some achievements in health outcomes over the last decade, basic public health indicators such as infant mortality rate remain way above the Latin American average and worse than countries with similar levels of economic development like Costa Rica. In 2013, it stood at 23.6 per 1,000 live births, as compared to 8.4 per 1,000 live births in Costa Rica (WB, 2015).

Meeting the goals of the 2001 health reform and achieving universal health coverage is not an impossible task. For example, Thailand has had a universal health coverage scheme since 2002, when it had similar levels of public health spending as DR has today. It is a matter of designing the correct payment incentives based on performance indicators to improve quality in the system. Also, reforms should be piloted focusing on the most vulnerable populations that are affiliated to the national health insurance, SENASA. Currently, 29% of the population is affiliated through the subsidized regime (SISALRIL, 2015), but its expansion has been low given that it relies directly on budgetary appropriations. There is a significant opportunity for improvement if the mixed subsidized-contributive regime is fully developed, which allows for more poor people to be targeted into the subsidized regime.

The Dominican Republic is an amazing country with very favorable economic prospects. It is time to revisit the organization of the public health system and contribute to build a bridge between the status of upper-middle income country and its social indicators.

Being a graduate student instructor (GSI) v. graduate student research assistant (GSRA)

March 1, 2015 by

amy I have been fortunate enough to experience being both a graduate student instructor (GSI) and graduate student research assistant (GSRA) for the biostatistics department within my two years here. I was a GSI my first three semesters, and am currently a GSRA this last semester. While I think many graduate students incoming to UM, reputed as a large public research institution, are rearing to partner with faculty and partake in discovery, I see distinct pros and cons to both positions:

Pros and cons of being a GSI:


UM’s Center for Research on Learning and Teaching offers GSI resources

Pro:  Meeting new people. As a GSI my first semester–a time when everyone is a stranger!–I became close to four of my biostatistics classmates through long homework grading sessions, helping one another field questions during office hours, and managing class policy and administrative issues; moreover, I instantly met at least 70 fellow public health students from other, diverse departments within the School of Public Health (SPH), students with whom I would’ve never crossed paths if I were not their instructor. Because I met all these colleagues of mine on day 1, since then I’ve been able to smile, stop, and chat in the hallways when I frequently see a familiar face. It has made SPH a much more friendly place.

Pro: A fixed schedule. GSI-ing, as opposed to GSRA-ing, is a much more organized job affair in that there are dedicated times for your teaching responsibilities and you will rarely spend more hours than expected attending to them. Aside from the occasional request to meet outside of class for an extra tutoring session or overly in-depth homework question in email form (difficult to answer when that question is quantitative), GSI-ing doesn’t tend to spill outside the boundaries of your two laboratory sections, 2-3 office hours, and grading sessions.

Con: Student conduct issues. It is uncomfortable to encounter multiple assignments that are suspiciously identical, or seemingly copied from the solution manual. One might think that there is some satisfaction to catching cheating incidents, but I don’t think any teacher relishes the experience. No one likes to stir up drama surrounding academic dishonesty when the vast majority of students are attending class and diligently attempting assignments, struggling or not.

Pros and cons of being a GSRA:


Pro: Learning and applying new methodology. Research has allowed me to move past the theory of statistical methods emphasized in coursework to actually applying these analyses to real-life clinical investigations run by epidemiologists, professors, and physicians in SPH, the UM Health System, and health centers across the nation. It’s eye-opening interacting closely with one or two faculty members on a professional as opposed to instructive level, seeing how they approach problems and gaining insight into harsh work-life balance of academia.

Pro: A flexible schedule. Just as how GSI-ing is nice in that one’s schedule is very strict, GSRA-ing is nice for the very opposite reason in that one’s schedule is quite flexible. If you have a slew of midterms coming up, it’s okay to delay some research tasks for a few days and catch up later, while abandoning one’s section as a GSI is clearly not an option. GSRA-ing involves more time-management skills, but accordingly more leeway in when and where you do your work.

Con: More hours. I can only speak for my own experience, but GSRA-ing has required many more hours per week than GSI-ing. It’s easy to get absorbed in a coding problem, or sit for hours muddling through a “dirty” dataset. While research work is open-ended and thus intriguing, it leaves less time to complete the traditional but mandatory homework assignments and studying for courses.

Retail Clinics and population health

February 20, 2015 by


Retail clinics (RCs) initiated as a response of the market to unmet needs of healthcare consumers for accessible, convenient, and cost-effective basic health services. As the clinics become a popular means of treating minor medical conditions at lower costs, they have established a niche in the health care system based on their convenience and accessibility for both insured and uninsured patients. Retail clinics are typically located in store chains that patients already visit on a regular basis, such as CVS, Walgreens and Wal-Mart.


The clinics can operate under three different business models: 1) the clinic is owned and operated by the parent store that houses it; 2) an independent company owns the clinic and partners with a retail store to house it; and 3) an integrated model where the clinic is owned by a hospital, a physician group, or another health care provider. Nearly three-quarters of clinics follow the first model (RAND, 2010).

The rapid expansion of RCs is attributed to costumers’ favorable response to the model. Convenient hours and locations are major factors in choosing the clinics. RCs generally employ a nurse practitioner or a physician assistant with off-site supervision by physician medical directors, providing services at accessible locations, shorter wait times, and lower costs.


Despite being a relatively new phenomenon, these clinics have the potential to increase access to basic health services to the underserved population. RCs have the necessary infrastructure –capacity for 17 million visits a year (Bureau of National Affairs, 2009)– to alleviate the shortage of primary care physicians that is intensified by the increase in demand for health services as a result of the 11.4 million newly insured under the Affordable Care Act. However, retail clinics have faced financial barriers to establishing contractual relationships with Medicaid. Also, they have to deal with state-level regulatory constraints including scope of practice laws and prohibitions against the corporate practice of medicine. These restrictions tend to limit the clinics’ ability to operate in medically underserved areas (Bartlett, 2011).

Massachusetts became the first state that adjusted its regulatory framework to fit RCs into their health system, by enacting in 2008 new regulations that specify the medical conditions and age groups that may be treated at the clinics. This proactive approach to design a tailored regulation for the operation of RCs is a good example for other states to consider how to better integrate RCs with traditional models of care. States Departments of Health play an important role in the development of this model, which has the potential to improve population health outcomes and decrease healthcare costs.

Day in the life: grad school

February 19, 2015 by

amyI’ve always found “day in the life” posts in the blogosphere fascinating, since they are a peek into someone else’s schedule, habits, hobbies. Here’s the previous Friday (pardon the delay) of my charmed biostatistics graduate student life:

7:01am – Alarm goes off. As an early bird, I am usually pretty awake by this time anyway. I clamber out of bed, go through the morning routine, eat a hearty bowl of oatmeal, and enter the tundra leave for school.

7:58am – At the bus stop. Shortly after I snap this photo the bus comes rolling in and I make a mad dash down the rest of the path. Nothing like a sprint in the morning to wake one up!


The bus stop is the shelter straight ahead

8:15am  – It’s my stop. I get off the bus and walk the short distance to my office, which is in the basement of the School of Public Health II (SPH II), on the right. Unfortunately, the cool medieval building in front is Kinesiology, not part of SPH. I must be feeling anxious about a project due early next week, since I cram in some coding before my class at 8:40am instead of dilly-dallying on the internet as usual.


SPH is divided into SPH I, the Tower, Crossroads (the archway area), and SPH II

8:40am – Environmental Health 540: Maternal and Child Nutrition. Today we have a guest speaker, a gestational diabetes counselor from the UM hospital. As a biostats student, I really relish any non-quantitative courses I get to take as a breather from all the math-y stuff. I’ve built my cognate around reproductive health, as I find the physiological and social adaptations of pregnancy incredible.


Reppin’ it during class

10:30am  – Class gets out. Squeeze in some gym time. I’m usually an early-evening exerciser, but on Fridays I need to move early or else I go stir-crazy in my three-hour class in the afternoon. The Central Campus Recreation Building (CCRB) is only a few minutes’ walk away from SPH.


Try taking a photo on a treadmill some time. It’s difficult!

In general, I enjoy running outdoors, but…


Well hey, if they’ve paved a path everything is okay, right?

12:30pm – Lunch time! I normally bring lunch to school every day, but on this rare occasion I must visit the Glass House, our cafe situated conveniently within SPH I, for some midday fuel. It’s definitely a soup kind of day. I bring the food back with me to the office (plus ten minutes since I forgot a spoon and must make a return trip–sigh) and eat while chatting with an officemate.


1:10pm – Biostatistics 880: Statistics With Missing Data. This is a PhD-level class and thus a little overwhelming, but I feel privileged to be able to take it with an expert in the field. I get a tad sentimental thinking about how this is my last semester of school, and feel some pressure to make the most of it so no senioritis for me.

3:48pm – Class ends. I descend back to my office and crank away at my project.

5:40pm – Time to go home!


6:15pm – Arrive back at my apartment. Eat dinner. It’s the weekend–joy :)

Internship, Funding, Classes…Oh My!

January 30, 2015 by

aparna Hard to believe that almost an entire month has gone by since second semester started! It’s been a whirlwind of internship funding applications, internship conundrums in general and group projects for class galore. The Global Health Epid track has been super exciting thus far and I love the focus that my classes this semester have on preparing us for our field experiences this summer! Going abroad comes along with its own challenges – funding applications, budgets, housing and food solutions, and letters of recommendation are all any of us can think about right now as we scramble to prepare our proposals to secure the money to go on the adventures of our lives.

Fortunately, everyone here is super helpful and there have been lots of workshops to help guide us along, not to mention the amount of support we get from our professors…at least we’re prepared for everything that comes our way in a few months!

One of my favorite classes this semester has us studying the intersection between epidemiology and culture. In undergrad, I took a medical anthropology course, which I really, really loved, and I’m excited that I get to take a similar class again! Of course, data is the most common word in the language of epidemiology, but this class really puts a new spin on it and relates the projects back to the communities in which we will be immersing ourselves.
I will be going to India for my internship to work with an organization called iKure. International internships are usually secured in the first semester and the second semester is usually devoted to finding funding. I am excited to work with the rural population around Kolkata this summer to study trends in data already collected and to do some descriptive epidemiology to understand health trends in this particular population. Spending the rest of the semester preparing for this is going to be a lot of fun!

My other class this semester that is preparing me for “the real world,” is the Public Health 615 Course – part of PHAST’s Texas Spring Break trip! A group of nine of us are heading down to Brownsville, TX in early March to work with UT – PanAm professors on various projects. The class meets once a week and we spend our time diving into the work we will be doing in about a month! All of us will be writing in more detail about those adventures on the SPH Frontlines blog, so stay tuned…

It’s been a great month so far and can’t wait to see what else comes my way this semester!  Stay warm and, as always, feel free to reach out with any questions!

My Spell Check doesn’t recognize “Health Informatics”

January 18, 2015 by

My post title reflects microsoft word’s ignorance and also my own ignorance before I came to U of M.  At its most basic, health informatics studies, creates and utilizes technology to monitor, improve and communicate health information. This is a big undertaking and because of that, this field is rapidly expanding in knowledge and opportunities for individuals from a wide array of disciplines to contribute- Epidemiologists, Public Administrators,Information Technologists, Health Behavior specialists and many more.
In my introductory class for Health Informatics our study was as far ranging as the field itself. We studied the use of computers, programs, apps and tools within biomedical research, public health work, medical care, consumer healthcare and the work being done to improve health information infrastructure.

Health informatics in the United States is  rapidly growing partially because of the HITECH act passed by President Obama in 2009. This act provided money to the Department of Health and Human Services to fund hospitals and other medicare recipient agencies with the funding to implement electronic health records systems. Electronic health record (EHR) systems are medical files held in a set of interconnected computers and devices that allow doctors, practioners, and sometimes patients to edit and view those files. As a result, approximately 80% of all primary care facilities and hospitals in the United States now have digital medical records and computer systems to support them. Consequently, we now have the ability to more quickly exchange  health information within hospitals and primary care organizations, further improving quality of care by increasing communication speed amongst practitioners, decreasing drug interactions through timely notifications, and increasing medical computers’ ability to be a knowledge bank for everyone connected to them.

Public Health informatics was not included in the HITECH act, but that’s because it’s been ahead of the game for a while now. From 2000-2005 the CDC’s National Electronic Disease Surveillance System aided states in implementing their NEDSS system which would allow them to collect, forward and store the data that would  be reported to the CDC. 46 states are now a part of this system in which hospitals and doctors offices share a common network with local health departments, allowing them to pass on health data that eventually makes its way to the CDC. This is a great system, but not without its challenges, those being that not all states participate in the system and lack of interoperability. Interoperability is the ability of information from one computer system to be transferred to another computer system and have that information arrive in the way that it left. Think of it as a big game of telephone played between the local health department and the CDC computer system. Can the message “10 primary cases of varicella zoster virus this month” reach the CDC computers without it becoming “100 cases herpes zoster viruses this month” or “10 primary cases. Varicella zoster virus this month.”? That is a loose example of  measuring of interoperability.

If anything I have mentioned in this post has piqued your interest at all, I highly recommend seeking out more information on the exciting field of health informatics. There’s a place here for everyone, and there’s a lot of amazing work to be done!

Dental care for the underserved: the Michigan Community Dental Clinics (MCDC) approach

December 28, 2014 by


People with chronic diseases who are not well educated about their health status might delay health care, and they may gradually notice the bad consequences of this decision in the long term when it is usually too late and more expensive to access health services. In contrast, it is harder to delay care when people have dental problems that cause extreme toothaches. This will generally make people reach for an immediate visit to the dentist because it tends to be an unbearable discomfort. Now, what to do if your insurance does not cover dental care or if you are uninsured and low income? It is a very unfortunate situation faced by a lot of people who fall into these categories.

Access to dental care for Medicaid recipients and low-income uninsured persons is very limited. MCDC developed a social entrepreneur approach to address this important public health issue. The clinics offer dental care to adults and children on Medicaid, and to low income, uninsured individuals, integrating health education to modify health behavior in order to avoid dental visits under very painful emergencies, promoting preventive care. The model is unique because it meets two challenging goals at the same time: providing timely dental care to the underserved while maintaining a successful business model.

MCDC is a not for profit corporation that assists in the development of dental clinics by Local Public Health Departments (LHDs) in Michigan. It is a Private-Public partnership model: LHDs create the clinics based on MCDC requirements, and MCDC leases the clinics and provides qualified staff to manage the facilities, including the maintenance of dental equipment. MCDC receives an enhanced Medicaid dental services rate –through a mechanism created by the State of Michigan and Centers for Medicare and Medicaid Services– allowing for break even operation of the clinics. MCDC offers several programs including the Michigan Community Dental Plan for uninsured patients who are 300% below the Federal poverty line. These patients are charged with reduced fees that cover costs, and receive comprehensive dental services. In addition, the quality of services provided by the clinics is not compromised by this business scheme. The clinics are patient-centered, which is reflected in high patient satisfaction rates of 90% during 2013.

This interesting approach sets a good example for other providers to be able to include underserved populations in their practices. This way, quality dental care that places great emphasis in prevention meets an efficient and productive business model that could be escalated to other communities that have limited access to dental services.


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