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PubMed2001

Electro-convulsive therapy practices in the community.

BACKGROUND: Controlled studies have demonstrated that variations in electro-convulsive therapy (ECT) technique impacts on efficacy and cognitive side effects. However, there is little information on the extent of variation in how ECT is practiced in community settings in the United States. METHODS: A survey of practice patterns was conducted at ECT facilities in the greater New York City metropolitan area. RESULTS: The 59 facilities varied considerably in many aspects of ECT practice, often clearly departing from the standards in the field. The more intensive the form of ECT used at facilities, the less likely was cognitive status assessed following the treatment course. CONCLUSION: There is marked variability in the nature of ECT practices in community settings. The extent to which this variability impacts on the benefits and risks of ECT needs to be examined.

Adolescent↗

PubMed2003

Screening for disability in a community: the 'ten questions' screen for children, in Bondo, Kenya.

BACKGROUND: Although the need for early identification and interventions of disabilities is evident, the current state of routine screening practice in Kenya needs intensive training of screeners before more rigorous techniques are introduced. OBJECTIVE: To compare the precision and practical utility of the 'ten questions' and EARC screens among the 2- 9 year olds in a community setting. METHOD: In this analytical comparative cross-sectional survey of two disabilities screening methods. multiphase sampling and multistage data collection procedures were employed. Quantitative research utilizing structured interview checklist was used for data collection. It described the prevalence rates of different types of disabilities using both methods. It analyzed the precision and practical utility of the two methods in a community setting. RESULTS: 64 of the 399 children under study were disabled (50.5% male and 49.5% female). The 'ten questions' picks up only those problems that are of great concern to families. EARC services are a more definite case defining process of measuring the existence and degree of disability in children. It screens the children who are severely disabled leaving out the mildly disabled and medical conditions which, when left untreated, could lead to possible disablement. CONCLUSION: Parents need to be sensitized about symptoms requiring the ten questions that can be used to screen out the potentially disabled children and the Education Assessment and Resource Centres (EARC) be used to diagnose the type and degree of the disability and refer the ill children for treatment. The basic needs of disabled children could be met in the community and do not require highly specialized personnel. They need to be localized and accessible.

Child↗

PubMed1998

Postwar experiences and treatment-seeking behavior in a community counselling setting.

Previous research investigating the impact of postwar experiences on Vietnam veterans has focused on veteran morbidity. This emphasis has meant that the impact of these factors on treatment-seeking behavior has received little empirical attention. This study examined the association between postwar factors and treatment-seeking behavior in a sample of 692 Australian Vietnam veterans. Logistic regression analyses were used to compute the odds ratios associated with postwar experiences and self-referral to a community-based counselling service. Results suggest that veterans who reported experiencing negative feelings toward others when they first arrived home were more likely to seek treatment. Other factors, such as a veteran's perception of societal attitudes and the reception they received, were not associated with treatment-seeking behavior.

Adaptation, Psychological↗

PubMed2003

How often do patients with psychosis fail to adhere to treatment programmes? A systematic review.

BACKGROUND: Studies that assess the rates of psychotic patients who fail to adhere to treatment programmes have generated heterogeneous results, with estimates ranging from 24 to 90%. This paper presents findings from a systematic review on adherence to treatment by patients with psychosis. Its purpose is to provide an overall estimate of treatment non-adherence in community psychiatric services, and to analyse and study patient characteristics explaining the between-study heterogeneity in rates of non-adherence. METHOD: A systematic review of published studies that report rates of non-adherence with medication and scheduled appointments by psychotic patients in community settings has been undertaken. RESULTS: A total of 103 studies were included in this systematic review. Eighty-six of these studies were suitable for data re-analysis. The overall weighted mean rate of non-adherence, calculated in a sample of 23 796 patients, was 25.78%. A linear regression analysis of non-adherence rates on background characteristics showed that sample size was negatively associated with non-adherence rates, while first-contact cases and low-adherence cases, in comparison with ongoing cases, were associated with higher non-adherence rates. Factors associated with poor compliance included: lack of insight; positive symptoms; younger age; male gender; history of substance abuse; unemployment; and low social functioning. CONCLUSIONS: Approximately one in four patients with psychosis fails to adhere with treatment programmes. Preventive evidence-based clinical interventions should be routinely implemented in community settings to reduce patient non-adherence.

Antipsychotic Agents↗

PubMed2003

Community/hospital indicators in South African public sector mental health services.

BACKGROUND: The need to balance resources between community and hospital-based mental health services in the post-deinstitutionalisation era has been well-documented. However, few indicators have been developed to monitor the relationship between community and hospital services, in either developed or developing countries. There is a particular need for such indicators in the South African context, with its history of inequitable services based in custodial institutions under apartheid, and a new policy that proposes the development of more equitable community-based care. Indicators are needed to measure the distribution of resources and the relative utilisation of community and hospital-based services during the reform process. These indicators are potentially useful for assessing the implementation of policy objectives over time. AIMS OF THE STUDY: To develop and document community/hospital indicators in public sector mental health services in South Africa. METHODS: A questionnaire was distributed to provincial mental health coordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels, annual patient admissions to hospitals and annual patient attendances at ambulatory care facilities. The information was supplemented by consultations with mental health coordinators in each of the 9 provinces. Population data were obtained from preliminary findings of the 1996 census. The community/hospital indicator measuring staff distribution was defined as the ratio of staff employed in community settings to all staff, expressed as a percentage. The community/hospital indicator measuring patient service utilisation was defined as the ratio of the annual ambulatory care attendance rate per 100,000 population to the sum of this rate and the annual hospital admission rate per 100,000 population, expressed as a percentage. RESULTS: Of psychiatric public sector staff, 25% are located in community settings in South Africa (provincial range: 11-70%). If hospital outpatient services are included in the definition of ' 'hospital' ', this figure is reduced to 17% (provincial range: 3-56%). In terms of service utilisation, 66% of patient contacts with mental health services occur through ambulatory care services in South Africa (provincial range: 44-93%). DISCUSSION: Community/hospital staff distribution indicates an overemphasis on centralised hospital-based care in most provinces and inadequate hospital care in certain provinces. Patterns of patient service utilisation indicate an over-reliance on central hospital-based services and substantial unmet need. The findings draw attention to problems in information systems for mental health care in South Africa. IMPLICATIONS FOR HEALTH POLICIES: The community/hospital indicators developed for this study form a useful measure for assessing the implementation of mental health policy over time. For the South African context, the community/hospital indicators are a measure of the extent of resource redistribution from hospital to community services and changing patterns of service utilisation over time. Currently, patterns of resource distribution and service utilisation are inconsistent with government policy. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed into the development of mental health information systems, refining service indicators and improving methodologies for assessing the implementation of mental health policies in service delivery.

Cross-Sectional Studies↗

PubMed1998

Changes in self-rated health, disability and contact with services in a very elderly cohort: a 6-year follow-up study.

OBJECTIVES: To study the relationships between global self-rated health, reported physical symptoms and depressive symptoms and the receipt of community services by very elderly people, and to examine changes in these variables over time. DESIGN: Three-wave study with follow-up at 2.4 and 6 years after first interview. Structured interview, incorporating cognitive examination (Mini-Mental State Examination) and enquiring specifically about overall self-rated health, physical symptoms and depressive symptoms. SETTING: Community setting in city of Cambridge, UK. PARTICIPANTS: 2609 were initially recruited: all patients aged 75 years and over from lists of six general practices (and one in three from a seventh practice). At 2.4 years, 1173 individuals re-examined and at 6 years 628 individuals. MEASUREMENTS: General health self-rated in comparison to others of similar age and individual physical and depressive symptoms self-rated as present or absent. Symptoms were added to produce physical health and depressive symptom scores. Data presented from cross-sectional analysis of 6-year sample; also examined longitudinal data from all three waves of study for ageing and cohort effects. Finally the effect of health variables on the receipt of services was examined. Statistics used included chi(2) and non-parametric statistics for continuous data, also odds ratios for likelihood of receiving services. RESULTS: At 6 years, 70% rated their overall health as good or very good. Overall self-rated health showed both ageing and cohort effects, improving with increasing age and especially with more recent cohort. Reported physical symptoms increased with ageing. Depression scores also increased with ageing but the relationship between depressive symptoms and ageing was less clear-cut. Receipt of services was associated with poor self-rated health and reported physical symptoms as well as with ageing. Higher depression scores at 2.4 years were associated with increased service receipt at 6 years, indicating a lag between the symptoms and the service response. Individuals in the more recent cohort were less likely to receive services, but those who did so received more frequent contact. CONCLUSIONS: Although very elderly people have a high prevalence of reported physical symptoms, they often rate their overall health as good. There was a stronger relationship between ageing and physical symptoms than with depressive symptoms. Symptoms of both kinds influenced the likelihood of receiving services, although there was a lag between depressive symptoms and service response. Cohort effects on service receipt may reflect changes in public service policy.

Aged↗

PubMed2004

Prevalence of COPD in Greece.

OBJECTIVES: The prevalence of COPD in Greece is unknown. The aim of this study was to determine the prevalence and trends of COPD among adults in Greece. METHODS: This study involved 888 randomly identified adults (475 men and 413 women) aged > 35 years, and smokers of at least 100 cigarettes, in a population-based, multiregional, cross-sectional descriptive design. The selected individuals reflected the urban/rural population distribution in Greece and, within each study region, the age group and gender of the community setting. The diagnosis of COPD was based on clinical and spirometric data including reversibility test (DeltaFEV(1) < 15%). RESULTS: The overall prevalence of COPD in the population aged > 35 years with a smoking history of > 100 cigarettes per lifetime was 8.4%. The gender-standardized COPD prevalence was 11.6% for men and 4.8% for women. The COPD prevalence by community setting was as follows: Athens, 6%; other urban areas, 10.1%; semiurban areas, 8.5%; and rural areas, 9.1%. Smoking intensity and age were significantly associated with higher COPD prevalence in both men and women. CONCLUSIONS: COPD is a substantial health problem in Greece, although prevalence rates are lower than expected when the high smoking rates are taken into account. The high proportion of the patients with mild COPD who were unaware of their illness highlights the need to increase public awareness of COPD.

Adult↗

PubMed2002

Economic issues and antibiotic resistance in the community.

BACKGROUND: Inappropriate antibiotic use is generally considered to be the primary cause of antibiotic resistance in the community. Multiple economic factors, at the level of physicians, patients, healthcare organizations, and pharmaceutical companies, foster poor antibiotic use. OBJECTIVE: To describe the influence of economic factors on the use and development of antibiotics and to evaluate the extent to which the cost of resistance is important in the economic evaluation of antibiotic products. DATA SOURCES: Literature identified through MEDLINE (1966-May 2001), bibliographies from relevant articles, government reports, and proceedings from conferences about antibiotic resistance. DATA SYNTHESIS: Economic factors at all levels of the healthcare system contribute to the inappropriate use of antibiotics in the community setting. Relatively little economic research has been published on antibiotic resistance, and very few cost-effectiveness analyses of antibiotic treatment alternatives have explicitly included the cost of resistance. CONCLUSIONS: A better understanding of economic factors that influence the prescribing, marketing, and development of antibiotics could lead to more successful efforts at curtailing the growth of antibiotic resistance in the community setting.

Animals↗

PubMed2000

Family intervention for schizophrenia.

BACKGROUND: It has been showed that people with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of their emotions. Psychosocial interventions designed to reduce these levels of expressed emotions within families now exist for mental health workers. These interventions are proposed as adjuncts rather than alternatives to drug treatments, and their main purpose is to decrease the stress within the family and also the rate of relapse. OBJECTIVES: To estimate the effects of family psychosocial interventions in community settings for the care of those with schizophrenia or schizophrenia-like conditions compared to standard care. SEARCH STRATEGY: Electronic searches of the Cochrane Library (Issue 2, 1998), the Cochrane Schizophrenia Group's Register (June 1998), EMBASE (1981-1995) and MEDLINE (1966-1995) were undertaken and supplemented with reference searching of the identified literature. SELECTION CRITERIA: Randomised or quasi-randomised studies were selected if they focused on families of people with schizophrenia or schizoaffective disorder and compared community-orientated family-based psychosocial intervention of more than five sessions to standard care. DATA COLLECTION AND ANALYSIS: Data were reliably extracted, and, where appropriate and possible, summated. Peto odds ratios (OR), their 95% confidence intervals (CI) and number needed to treat (NNT) were estimated. The reviewers assume that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption. MAIN RESULTS: Family intervention may decrease the frequency of relapse (one year OR 0.57 CI 0.4-0.8, NNT 6.5 CI 4-14). The trend over time of this main finding is towards the null and some small but negative studies may not have been identified by the search. Family intervention may decrease hospitalisation and encourage compliance with medication but data are few and equivocal. Family intervention does not obviously effect the tendency of individuals/families to drop out of care. It may improve general social impairment and the levels of expressed emotion within the family. This review provides no data to suggest that family intervention either prevents or promotes suicide. REVIEWER'S CONCLUSIONS: Clinicians, researchers, policy makers and recipients of care cannot be confident of the effects of family intervention from the findings of this review. Further data from already completed trials could greatly inform practice and more trials are justified as long as their participants, interventions and outcomes are generalisable to routine care.

Family Therapy↗

PubMed2003

Impact of lowering the screening and confirmation cutoff values for urine drug testing based on dilution indicators.

Many clinical and forensic toxicology laboratories establish criteria for identifying a random urine specimen submitted for drug screening as being "normally concentrated" or "dilute" by incorporating creatinine analysis and/or specific gravity measurement into their testing protocols. The objective of this study is to describe the importance of urine creatinine analysis and specific gravity measurements in the Correctional Service of Canada (CSC) drug-testing program. The CSC program uses the Substance Abuse and Mental Health Services Administration (SAMHSA) creatinine cutoff value (20 mg/dL) mandated for workplace drug testing in the United States. In the CSC program, urine specimens must have a creatinine concentration <20 mg/dL and specific gravity value </=1.003 to be considered dilute. The CSC program also incorporates lower drug/drug metabolite screening and confirmation cutoff values (dilution protocol) for specimens that are administratively defined as dilute. Seventy-nine hundred and twelve urine specimens from 2000 to 2002 (6.8% of total workload) were defined as dilute. Twenty-six percent of all dilute specimens (n = 2054) screened positive for one or more drugs using the SAMHSA cutoff values. The screening-negative dilute specimens were taken through the dilution protocol scheme with lower screening cutoff values and confirmation cutoff concentrations at the lower limits of quantification (LLOQ) for each method. Over 1100 of the 5858 dilute urine specimens (18.8%) confirmed positive for one or more drugs in 2000 to 2002 when taken through the dilution protocol scheme. CSC workload is separated based on whether specimens are referred from institutions or from community settings (such as parolee programs). The positive rate for dilute specimens averaged 18.2% from CSC institutions and 22.3% from specimens collected from parolee specimens in 2000 to 2002. The drugs most often confirmed in dilute specimens from institutions were cannabinoids (annual positive rate ranged from 13.7 to 18%) and codeine and/or morphine (ranged from 0.2 to 2.8%). The drugs most often confirmed in dilute urine specimens from community settings in 2000-2002 were cannabinoids (annual positive rate ranged from 10.3 to 12.5%) and cocaine metabolite (ranged from 6.6 to 10.3%). In conclusion, one can reduce the false-negative rate for drugs of abuse in urine drug testing programs by incorporating lower screening and confirmation cutoff (eg, LLOQ) concentrations for dilute specimens that screen negative for drugs of abuse when using the SAMHSA mandated screening and confirmation cutoff concentrations.

False Negative Reactions↗

PubMed2001

The health care crisis: impact on surgery in the community hospital setting.

Hospitals and health systems across the United States are in crisis. The causes of this crisis are multiple, and they reflect the interplay among reduced operating margins, workforce issues, the technology explosion, consumerism, and leadership. They affect hospitals of every type and location. In aggregate, they profoundly influence our trifold mission of patient care, education, and research. Departments of surgery have a disproportionate effect on hospital financial viability, and therefore, surgical leaders must work with other clinical and administrative leaders to manage these issues. This article is a personal view of how this crisis has affected our community-based academic medical center, William Beaumont Hospital, Royal Oak, Mich.

Delivery of Health Care↗

PubMed2005

HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years.

OBJECTIVE: To describe trends in HIV prevalence among injecting drug users in England and Wales between 1990 and 2003. METHODS: Analysis of surveillance data from voluntary unlinked anonymous cross-sectional surveys collecting oral fluid samples and behavioural information from injecting drug users recruited from both drug agency (n = 24,304) and community settings (n = 3628). RESULTS: HIV prevalence in England and Wales declined from 5.9% in 1990 to 0.6% in 1996 and then remained stable until 1999, after which it increased to 1.4% in 2003. Few HIV infections were detected among short-term injectors between 1994 and 1999, but in recent years prevalence among this group has increased. Other factors associated with higher odds of HIV infection were being recruited in London and from community settings, and ever having had a voluntary confidential HIV test. Incidence estimated through a force of infection model was 2.8% per annum among those injecting for less than a year in London between 1998 and 2003. CONCLUSIONS: These data suggest that incidence and prevalence of HIV may have increased, whereas other indicators suggest an increase in risk behaviour. It is critical that harm reduction measures are reinvigorated, and evolve in response to changes in drug use risk behaviours and policy.

Adolescent↗

PubMed2006

Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting.

BACKGROUND: The reclassification of prescription only medicines to pharmacy and general sales list medicines (also known as non-prescription medicines) provides the public with greater access to medicines that they can purchase for self-care. There is evidence that non-prescription medicines may be associated with inappropriate supply. This study investigated factors predicting evidence-based (guideline compliant) supply or non-supply of non-prescription medicines. METHOD: Secondary analysis of results from a randomised controlled trial of educational interventions to promote the evidence based supply of non-prescription medicines. Ten actors made simulated patient (customer) visits to 60 community pharmacies using seven scenarios reflecting different types of presentations. The dependent variable was appropriate (guideline compliant) supply of antifungal medication for treatment of vaginal candidiasis. RESULTS: No significant association was shown between guideline compliant behaviour and pharmacy type or location, or with the actor making the visit. The likelihood of guideline compliant outcome was significantly greater with symptom presentations than with condition or product presentations (p < 0.001). The likelihood of a guideline compliant outcome increased (a) as more information was exchanged (p < 0.001), (b) with the use of WWHAM (a mnemonic frequently used by medicine counter assistants during consultations for non-prescription medicines) (p < 0.001); (c) when specific WWHAM questions were used (including "description of symptoms" (p < 0.001) and "whether other medication was currently being used" (p < 0.001); and (d) in consultations involving solely pharmacists compared with those involving only medicine counter assistants (p = 0.017). After adjustment for presentation type, a significant association persisted between appropriate outcome and consultations with WWHAM scores of 2 and > or = 3, respectively. CONCLUSIONS: The nature and extent of information exchange between pharmacy staff and customers has a strong influence on the guideline compliant supply of non-prescription medicines. Future interventions to promote the safe and effective use of non-prescription medicines should address the apparent deficit in communication between pharmacy staff in general, and medicine counter assistants in particular, which may reflect both pharmacy staff skills and customer expectations.

Adult↗

PubMed1999

Community physicians who provide terminal care.

BACKGROUND: Most dying patients are treated by physicians in community practice, yet studies of terminal care rarely include these physicians. OBJECTIVE: To examine the frequency of life-sustaining treatment use and describe what factors influence physicians' treatment decisions in community-based practices. METHODS: Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, cirrhosis, or stroke completed interviews about end-of-life care in community settings. RESULTS: Eighty percent of eligible family and 68.8% of eligible physicians participated (N = 165). Most physicians were trained in primary care and 85.4% were primary care physicians for the decedents. Physicians typically knew the decedent a year or more (68.9%), and 93.3% treated them for at least 1 month before death. In their last month of life, 2.4% of decedents received cardiopulmonary resuscitation, 5.5% received ventilatory support, and 34.1% received hospice care. Family recalled a discussion of treatment options in 78.2% of deaths. Most discussions (72.1%) took place a month or more before death. Place of death, cancer, and having a living will were independent predictors of less aggressive treatment before death. Physicians believed that advanced planning and good relationships were the major determinants of good decision making. CONCLUSIONS: Community physicians use few life-sustaining treatments for dying patients. Treatment decisions are made in the context of long-term primary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influence the dying experience.

Advance Care Planning↗

PubMedDate not supplied

Management of a dehisced abdominal wound with VAC therapy.

The management of large cavity wounds has always posed particular challenges for nurses and clinicians. The National Institute for Clinical Excellence (NICE, 2001) suggests that the number of difficult-to-heal surgical wounds may increase in the future and that increased knowledge and expertise should be available across primary and secondary care. Recent research into wound healing has tended to focus on the biology of wound healing and manipulation of the healing processes with new dressings technology and other clinical and cost-effective treatments. Vacuum-assisted closure (VAC) is an innovation that is being given increasing attention. In Northampton, one patient nursed in the community setting has recently benefited from the technology to accelerate healing of a deep abdominal cavity. This article considers the historical management of cavity wounds and presents a case study. The feelings of the patient and the experiences of the district nurses in overcoming management problems are discussed. The case has proved to be the catalyst for a collaborative initiative across primary and secondary care services to ensure that all patients requiring the treatment are able to receive it in the community setting as well as in the hospital, when they are ready for discharge. It is recognized in Northampton that there are several applications for VAC in wound management and that the treatment has many benefits for patients and for those managing finite NHS resources.

Abdominal Injuries↗

PubMed2005

Early practical experience and the social responsiveness of clinical education: systematic review.

OBJECTIVES: To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence. DESIGN: A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001. DATA SOURCES: Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration. SELECTION OF STUDIES: All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication. RESULTS: Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations. CONCLUSION: Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Attitude of Health Personnel↗

PubMed1981

Interface of psychiatric clinical specialists in a community hospital setting.

In the beginning a question was posed, "Is clinical specialization an effective nursing role in the general hospital setting? In conclusion, we believe that the experience has shown it is, when certain factors are operating. These factors are a supportive nursing administration coupled with our collaborative efforts. The most significant of these changes has been strengthening nursing identity through peer support and the nurse-to-nurse consultation process.

Hospitals, Community↗

PubMed2001

Barriers to uptake of services for coronary heart disease: qualitative study.

OBJECTIVES: To identify factors within the South Yorkshire coalfields that influence use of health services by people with angina. DESIGN: Qualitative study using semistructured individual and group interviews. SETTING: General practice and community settings in Barnsley and Rotherham health authorities. PARTICIPANTS: 14 patients with stable angina and nine primary care staff had individual interviews plus five community groups and one group of general practitioners. MAIN OUTCOME MEASURES: Barriers to accessing health services. RESULTS: A complex web of factors was identified that prevented, delayed, or facilitated referral to secondary care. Delay, denial, and self management by patients meant that the full extent of symptoms often remained hidden from general practitioners, resulting in a delayed or missed referral. Barriers identified fell into six categories: structural, personal, social and cultural, past experience and expectations, diagnostic confusion, and knowledge and awareness. CONCLUSIONS: Many of the factors influencing referral operate before general practitioners become involved. Community development could be one way of tackling inequalities and promoting sustainable change. Structural changes are needed to improve access and increase the acceptability of general practice services. Primary care staff should be educated to detect underreporting of symptoms and promote appropriate referral.

Aged↗