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Practice pointer - Consultations for people from minority groups

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  • Evidence Based Health-Care

Abstract

This article provides practical suggestions on ways to improve communication with people from minority ethnic and faith groups
PRACTICE
PRACTICE POINTER
Consultations for people from minority groups
Aziz Sheikh,
1
Rashid Gatrad,
2
Sangeeta Dhami
3
This article provides practical suggestions
on ways to improve communication with
people from minority ethnic and faith groups
Most developed societies are ethnically, linguistically,
and religiously diverse, and recent trends in migration
mean that this diversity is set to increase. Irrespective of
background, most people want (and most health
professionals aim to provide) high quality care that is
accessible and sensitively delivered. For many people
in minority groups, the care sought and the profes-
sional knowledge base, skills, and competencies
needed to deliver such care are no different from
those needed for people from the majority population,
but insomeinstancesstandardapproaches may need to
be modified to achieve comparable outcomes. Making
the effort to do so is important for ethical and legal
reasons, but also because it will be appreciated and
remembered. Conversely, failures in communication
often have a lasting negative effect on the doctor-
patient relationship; in particular, such failures can
erode trust, not only in the clinician, but also in the
health service in general.
Challenges to delivering culturally competent and
sensitive care
The NHS was created to serve the needs of a more
homogeneous society than we have at present. Data on
variations in quality of care, persistent health inequal-
ities, and lower satisfaction with healthcare provision
show that the NHS has difficulty in adapting to meet the
needs of minority populations, particularly if these
needs differ from those of mainstream society.
1
This
challenge is greatest when delivering care to older
people who have recently migrated from parts of the
world with very different societal structures; those who
are not entitled to stay permanently; and those with
limited English.
Most healthcare professionals will also have had little
training in understanding the complex association
between culture, health, and healthcare delivery,
thereby increasing the risk of cultural misunderstand-
ings and diminishing the potential for creatively
exploring the development of individually tailored
care plans, often out of fear of making a cultural faux
pas.
2
Summary of the evidence for interventions
Ethnic minorities remain marginalised from many
research projects, and the few studies that do include
them usually fail to present ethnic specific subgroup
analyses.
3
Furthermore, much of the more focused
work on these populations has been descriptive or
qualitative, mostly aimed at understanding disease
burden and illness experiences. Thus, rigorous experi-
mental studies to guide management decisions are
lacking. Most of our suggestions are therefore based on
low level evidence
expert opinion or uncontrolled
studies. At present, we have no indication that more
robust evidence to guide practice will be forthcoming
in the near future.
Strategies and approaches to enhancing delivery of care
Practice profiling
Few practices have reliable data on patients ethnic
origin, religion, or other important information
such
as main language spoken
which makes it difficult to
obtain a reliable overview of the populations being
served. The recently introduced quality and outcomes
framework point for recording the ethnic origin of
newly registered patients is a small, but none the less
welcome, incentive that should help initiate a culture of
collecting and, in due course, using such data to help
determine needs and to audit care.
4
In the meantime,
however, you can acquire an overview of the practice
population using National Statistics online Neighbour-
hood statistics, which include data on ethnic origin,
religion, and more than 50 other datasets of potential
interest. We recommend using the recently introduced
postcode defined super output areas because these
can easily be mapped on to the practice area.
5
Improving access to care
Despite experiencing worse outcomes for a range of
conditions, some ethnic minority groups have lower
attendance at health services. Similar problems have
also been described for uptake of some preventive
health services, such as cervical smear testing and
bowel cancer screening. These problemscan be mostly
overcome, but they often require innovative
1
Division of Community Health
Sci ences, GP Section, U niversity
of Edinburgh EH8 9DX
2
Department of Paediatrics,
Manor Hospital, Walsall WS2 2PS
3
Edinburgh, EH17 8U E
Correspondence to: A Sheikh
aziz.sheikh@ed.ac.uk
Cite this as:
BMJ
2008;337:a273
doi:10.1136/bmj.a273
BMJ | 5JULY2008| VOLUME 337 51
For the full versions of these articles see bmj.com
approaches that include working with local commu-
nities to formulate solutions. For example, a multi-
faceted, community based intervention in Walsall,
which included working with religious centres and
local community leaders to increase awareness of the
importance of attendance, resulted in a dramatic and
sustained reduction in non-attendance to paediatric
services.
6
Although these improvements p robably
result from the intervention, this cannot be concluded
with certainty because this study had no control groups.
Creating a welcoming atmosphere
It is important to create a welcoming atmosphere, and
this can be achieved by paying attention to simple
matters such as using clear signs and translating the
most important information into the main languages
spoken by the practice population. An example of a
useful sign to display in a range of relevant languages is
one explaining that all efforts will be made to enable
patients to see a doctor of the sex of their choice.
Similarly, a well labelled box for comments and
suggestions can also be useful. Some practices now
have reading materials available in key languagesin the
waiting room. None of these endeavours needs to be
onerous or expensive because, in our experience, if
approached,members of the local community will help
their practice with basic translating and pass magazines
and books that they no longer need on to their surgery.
Providing a water jug in the surgery toilet and
recognising major religious festivals (with something as
simple as a poster in the waiting room, as is now
commonplace in schools) are other inexpensive
initiatives that convey an appreciation of minority
cultures.
Staff training
Although diversity training is now available for many
hospital based staff, access to such training is more
limited in primary care. Such training is important,
however, not least because of the implications of the
Race Relations (Amendment) Act,
7
and it should leave
staff with a clear understanding that
although often
well intentioned
a we treat everyone the same
approach is the foundation of institutional discrimina-
tion, which was defined by Sir William Macpherson as,
The collective failure of an organisation to provide an
appropriate and professional service to people because
of their colour, cultureor ethnic origin. It can beseen or
detected in processes, attitudes and behaviour which
amount to discrimination through unwitting prejudice,
ignorance, thoughtlessnes s and racist stereotyping
which disadvantage minority ethnic people.
8
Staff also need to be made aware of the dangers of
(often heated) public debates about multiculturalism
affecting quality of care
everyone needs to under-
stand that, irrespective of personal beliefs, the essential
principle of serving in the patients best interests must
never be compromised. Practice based significant
event audits might provide a vehicle for such diversity
training.
4
Details of some of the better known training
courses can be found on the NHS Specialist Library for
Ethnicity and Health.
9
Responding to diversity in the consultation
Communication
Genuine attempts to put people at ease transcend
linguistic and cultural divides and will (eventually) be
understood. Is there anything important that I need to
know about you, your beliefs, or your customs? is a
helpful open question that is likely to be well received
by all, irrespective of background.
Responding to the language needs of people with poor
English
People with limited English are dependent on an
interpreter to convey anything more than the simplest
of messages, and
given that making a diagnosis
depends very much on taking the patients history
this need must not be overlooked. A professional
interpreter is preferable, but this may not be possible,
particularly for unscheduled appointments, home
visits, and out of hours care. Many clinicians therefore
continue to use family translators; other advantages of
using a family member include the greater opportunity
for continuity and shared understanding. None the less,
it is still better to use a professional interpreter to
prevent misunderstanding information given, breach-
ing confidentiality, and deliberate censoring of infor-
mation. T hese problems are compoun ded if the
translator is a child, and this practice can seldom, if
ever, be condoned. When access to a professional
interpreter is not possible, we suggest using a profes-
sional telephone based interpreting service such as
Language Line,
10
which provides immediate real time
professional support. On a practical note, it requires
access to a speakerphone. Details of language needs
should also be given when referring patients to hospital
or other agencies, so that appropriate provision can be
made.
ADDITIONAL EDUCATIONAL RESOURCES
Bhopal RS. Ethnicity, race and health in multicultural societies. Oxford: Oxford University
Press, 2007.
Gatrad AR, Brown E, Sheikh A. Palliative care for South Asians: Muslims, Hindus and Sikhs.
London: Quay, 2006.
Helman CG. Culture, health and illness. London: Hodder Arnold, 2007.
Henley A, Schott J. Culture, religion and patient care in a multi-ethnic society. London: Age
Concern England, 1999.
Kai J, ed. Ethnicity, health and primary care. Oxford: Oxford University Press, 2003.
Kai J, ed. Valuing diversity. 2nd ed. London: Royal College of Genera l Practitioners, 2006.
Kleinman A. Patients and healers in the context of culture. Berkeley: University of California
Press, 1980.
Sheikh A, Gatrad AR. Caring for Muslim patients. 2nd ed. Oxford: Radcliff e Press, 2007.
Spitzer J. Caring for Jewish patients. Oxford: Radcliffe Press, 2003.
SzczepuraA,JohnsonM,GumberA,JonesK,ClayD,ShawA.An overview of the research
evidence on ethnicity and communication in healthcare. London: Department of Health,
2005. www2.warwick.ac.uk/fac/med/research/csri/ethnicityhealth/research/
communications review.p df.
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52 BMJ | 5JULY2008| VOLUME 337
Some people who cannot read English may also have
difficulty in reading their mother tongue, in which case
translated written materials are not helpful; multi-
lingual audiovisual materials are now beginning to be
developed for such people. Simply assuming that
written translated materials will be unhelpful i s
however inappropriate because some people will be
literate in their mother tongue; others will often have
access to someone who can read to them.
One of the main practical challenges facing busy
clinicians is how to access translated materials.This has
been difficult in the past, but access is now improving
through the NHS Specialist Library for Ethnicity and
Health, which is making high quality materials
available online. It also lists dates of key religious
festivals and provides practical support and advice by
responding to questions posed by professionals.
9
Understanding and respecting social norms: gender
considerations
Most people from minority groups will not care
whether their clinician is a man or a woman, except
in certain contexts
such as when discussing sexual
problems, or when the patient perceives an intimate
examination is needed. But even in such cases, if this
request is difficult to facilitate, most will, if given an
adequate explanation, accept this.
Societal norms about dealings with the opposite sex
may affect the consultation in other ways. It is, for
example, unusual for South Asians to shake hands with
members of the opposite sex. Therefore, we do not
initiate a handshake with someone of the opposite sex
from these groups but will respond if a hand is
extended. Misunderstandings can also be caused by
lack of eye contact, which is considered by some to be
modest behaviour and should therefore not be taken as
an insult.
Conclusions
Effect ively responding to diversity is challenging,
typically requiring additional resources, time, and
skills from practices and professionals who are often
already stretched on accoun t of serving deprived
communities. When thinking how best to cater for
minority groups, practices should take into account
both organisational considerations and the individual
doctor-patient encounter. Sensitively responding to
the challenge of diversity can be deeply rewarding,
because we are not only responding to those who are
often most marginalised and in need of our help, but
helping to develop services that are more responsive to
the needs of our patients in general.
Thanks to Hilary Pinnock and Mark Joh nson for their construct ive
comments on an earlier draft of this paper.
Competing interests: AS chai rs the National Clinical Assessment Service
s
Equality and Diversity Forum.
Provenance and peer review: Commissioned; externally peer reviewed.
1NazrooJY.The health of Britain
s ethnic minorities. London: Policy
Studies Institute, 1997.
2 Sheikh A, Grant E, Murray S, Worth A, Bhopal R, Kendall M, et al. Final
report to chief scientist
s office: developing services to meet the end-
of-life care needs of South Asian Sikh and Muslim patients and their
families in Scotland. Edinburgh: University of Edinburgh, 2007.
3 Sheikh A, Netuveli G, Kai J, Panesar SS. Comparison of reporting of
ethnicity in US and European randomised controlled trials. BMJ
2004;329:87-8.
4 Department of Health. Summary of GMS contract review negotiations
2005/2006.
5 National Statistics. Neighbourhood statistics. http://neighbourhood.
statistics.gov.uk/dissemination/LeadHome.do;
jsessionid
=
ac1f930dce6211203f6ad724852a18cb449f8d04abb.
e38OaNuRbNuSbi0LbxeKaN0MbhuOe6fznA5Pp7ftolbGmkTy?
bhcp
=
1.
6 Gatrad AR. A completed audit to reduce hospital outpatients non
attendance rates. Arch Dis Child 2000;82:59-61.
7 Race Relations (Amendment) Act 2000. www.opsi.gov.uk/ACTS/
acts2000/20000034.htm.
8MacphersonW.The Stephen Lawrence Inquiry. www.archive.official-
documents.co.uk/document/cm42/4262/4262.htm.
9 NHS National Library for Health. Ethnicity and Health Specialist
Library. www.library.nhs.uk/ethnicity/.
10 Language Line Services. www.languageline.co.uk/.
Summary of recommendations
Carry out a practice profile to understand the demographic
profile of the patients served
Investigate whether problems with access to care exist
andifsohowtheycanbeminimised
Create an inclusive welcoming atmosphere
Ensure that staff have diversity training
Be aware of cultural
blind spots
Provide interpreting services
Provide translated written materials
Try to understand and respect different social norms
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BMJ | 5JULY2008| VOLUME 337 53
... A substantial and growing proportion (∼20% at present) of the German population has a migration background. 1 Provision of a high quality of care regardless of cultural background is challenging both for physicians and policymakers. 2 Currently, migrants often receive poorer care than the indigenous population. [3][4][5][6] In Germany, migrants are frequently poorly informed and underuse preventive healthcare services. ...
... However, high-quality studies on healthcare interventions for migrants are lacking. 2 Patient engagement and empowerment are central issues in current debates on improving healthcare, 8 especially for chronic illnesses and mental disorders. 9 A fundamental strategy to promote patient engagement and Strengths and limitations of this study ▪ High internal and external validity of the study design. ...
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Objectives To evaluate the usefulness of culture-sensitive patient information material compared with standard translated material. Design Multicentre, double-blind randomised controlled trial. Setting 37 primary care practices. Participants 435 adult primary care patients with a migration background with unipolar depressive disorder or non-specific chronic low back pain were randomised. Patients who were unable to read in the language of their respective migration background were excluded. Sufficient data were obtained from 203 women and 106 men. The largest group was of Russian origin (202 patients), followed by those of Turkish (52), Polish (30) and Italian (25) origin. Interventions Intervention group: provision of culture-sensitive adapted material. Control group: provision of standard translated material. Main outcome measures Primary outcome: patient-rated usefulness (USE) assessed immediately after patients received the material. Secondary outcomes: patient-rated usefulness after 8 weeks and 6 months, symptoms of depression (PHQ-9), back pain (Back Pain Core Set) and quality of life (WHO-5) assessed at all time points. Results Usefulness was found to be significantly higher (t=1.708, one-sided p=0.04) in the intervention group (USE-score=65.08, SE=1.43), compared with the control group (61.43, SE=1.63), immediately after patients received the material, in the intention-to-treat analysis, with a mean difference of 3.65 (one-sided 95% lower confidence limit=0.13). No significant differences were found for usefulness at follow-up (p=0.16, p=0.71). No significant effect was found for symptom severity in depression (p=0.95, p=0.66, p=0.58), back pain (p=0.40, p=0.45, p=0.32) or quality of life (p=0.76, p=0.86, p=0.21), either immediately after receiving the material, or at follow-up (8 weeks; 6 months). Patients with a lower level of dominant society immersion benefited substantially and significantly more from the intervention than patients with a high level of immersion (p=0.005). Conclusion Cultural adaptation of patient information material provides benefits over high quality translations. Clinicians are encouraged to use culture-sensitive material in their consultations, particularly with low-acculturated patients. Trial registration number German Register for Clinical Trials: DRKS00004241, Universal Trial Number: U1111-1135-8043, Results.
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Background: Germany has 16 million people with a migration background. Health care for these patients is part of routine work in family medicine. Nevertheless, there is hardly any research on these patients' experience in family medicine. Methods: Three focus groups with a total of 39 participants Turkish ethnic origin but with different social and migration-generative background were organized in German language. The discussions were audiotaped, transcribed and coded according to Mayring in a content-analytic way. This was done independently by the researchers in a first step; then a categorical system was developed in a consensus process. Intentionally we worked in a multicultural and multi-professional team. Results: Misunderstandings, prejudices and discrimination were often mentioned by the participants (P) as being based on their migration background. Unequal care was experienced by most P. Participants stressed that empathy was often missing in the doctor-patient-relationship - resulting in no trust in the relationship, anxieties, insecurity and doctor hopping. P wished to be seen and treated as individuals with equal rights. Relevant "culture-specific" problems were not mentioned - except when being seen as instrumentalized for discrimination. They wished competence in intercultural communication to be integrated in continuous medical education to reduce discrimination. Conclusions: Different from other countries intercultural communication and competence is not part of continuous medical education in Germany. Intercultural communication should focus on the variability of individuals and not on the construction of "rules" for the appropriate behaviour in contact with people from "different cultures".
Article
Full-text available
• This report was commissioned by the Department of Health following a number of earlier reviews of issues relating to ethnicity and health carried out jointly by the University of Warwick and De Montfort University (Johnson et al 1999, Szczepura et al 1999, Atkinson et al 2001). • The study complements the work programme developed by the Centre for Evidence in Ethnicity Health & Diversity (CEEHD), funded by the ESRC at the two universities, and builds upon earlier work undertaken for the Department of Health and NHS Executive, to extend knowledge of the relevance of linguistic diversity in the context of the NHS. • The aim of the present study was to identify and review the available research evidence on 'ethnicity and communication' in areas relevant to ensuring effective provision of mainstream services (e.g. via interpreter, advocacy and translation services); provision of services targeted on communication (e.g. speech and language therapy, counselling, psychotherapy); consensual/ participatory activities (e.g. consent to interventions), and; procedures for managing and planning for linguistic diversity. • Since April 2001, following the implementation of the Race Relations Amendment Act 2000, there has been a statutory duty laid upon all UK health service agencies to ‘have due regard to the need to eliminate unlawful discrimination’, and to make explicit consideration of the implications for racial equality of every action or policy. This literature overview should therefore be viewed in the light of this major new requirement. • The literature indicates strong linkages between population diversity (in particular ethnic diversity) and variations in service uptake, outcomes and involvement in decision-making, much of this mediated by issues of ‘communication’. • Defining ‘ethnicity’ and ‘ethnic groups’ is not a simple matter. In essence, the concept of ‘ethnicity’ recognises that people identify themselves with a social grouping on cultural grounds including not only language, but also lifestyle, religion, food and origins (see Annex 1). Furthermore, in a world of migration and mixing, it is essential to recognise that these cultures and societies are dynamic rather than fixed. • The total UK black and minority ethnic (BME) population is relatively large and rising. In the 2001 Census it was 4.6 million, or 7.9%, having risen from a figure of 5.5% in 1991 and 4.2% in 1981. In England, the proportion of minority ethnic origin rises to 9.1%, of whom just over half (4.6% of the population) are of south Asian origins while people of Caribbean and African origin make up 2.3% of the English population. The minority ethnic population has a more youthful age structure than the white population, so population growth will remain rapid over the coming years. • The black and minority ethnic population is not evenly distributed but is largely concentrated in Greater London, West Midlands Metropolitan County, West Yorkshire, and Greater Manchester. Relatively few live in rural areas. Some specific ethnic groups are even more localised. • Recent estimates suggest over three hundred languages are used as ‘mother tongues’ in London. Speaking a language does not necessarily imply literacy. • The majority of studies on the language capability and literacy of minority ethnic groups in the UK have explored the ‘preferred’ or ‘home’ language of South Asian populations. Estimates of language capacity and literacy are available from different sources for both adults and children for different population groups (see Annex 2). For the three main resident South Asian ethnic groups (Indian, Pakistani, Bangladeshi), ability to speak English declines with increasing age, is lesser for women than men, and is much less for those born outside the UK. At the same time, those who have acquired English as a second language do get older, and often lose this ‘learned’ ability. • Many asylum seekers and refugees will have poor levels of literacy in the English language, but no information on their language needs is available. Seasonal or migrant workers form another group of increasing significance, but it is difficult to gather information on these groups. • Thus, the NHS faces a constantly changing picture of language needs with the migration of new groups, including refugees, combined with the language learning process undergone by settlers. • Several approaches have been identified within the NHS for overcoming language barriers where verbal communication is required as part of the delivery of services (see Annex 3). Apart from the provision of interpreter or advocacy services for situations in which verbal communication is required, translation of written or taped (including video) material may also be required. • This review has revealed a considerable and expanding literature in the field of ethnicity and health and issues directly, or indirectly, related to communication. Our searches produced over 3,000 potential papers for review. • Extensive evidence is emerging from countries and regions that experience population diversity (including the USA, Australia, Canada and the United Kingdom) on the requirement for cultural competence as well as linguistic competence in health care organisations (see Annex 2). • As part of the review process we have examined all this literature and identified key findings for the UK under the following 7 specific headings which can be related to practice areas and policy directions. 1. Meeting language needs (interpreter/ advocacy services): Despite substantial evidence in favour of providing proper language support, and demonstration of adverse effects linked to its absence, there is a lack of consistent, universal provision or adequate resourcing of such services in the UK. Indeed, there is little research into cost-effectiveness internationally, or into the direct clinical implications of introducing adequate services. Training is needed, for both users and providers of health care services, in overcoming language barriers. Similar problems are faced in all societies, and do not appear to be time-limited. The growth of globalisation may lead to increasing need, but offers possibilities (e.g. by international telephone linkages) of international solutions. More needs assessment may be required, but should be tied to guaranteed resourcing and evaluation, and adequate time and resources allocated to ensure that initiatives are fully worked through. 2. Health promotion materials: In health promotion there are various ‘models that work’ and an array of approaches and procedures for successful health promotion at the very local level. The issue for centralised programmes and policies of health promotion planning is to begin to encourage multiplicities of approach as the rule, rather than the exception to a 'one-size-fits-all' model of health information promotion. 3. 'Tele-consultation' services (e.g. NHS Direct, telemedicine, etc): The use of existing media, new media and an expanding arsenal of technological advancements for the dissemination of health information is in its infancy. More study is needed to ascertain the effectiveness of these technologies, particularly at the interface of information provision and minority ethnic groups. A single technological approach may prove ineffective, particularly in reaching diverse groups with varying language skills and competencies and/or differing cultural expectations of health information and service provision. 4. Procedures for managing and planning for linguistic diversity: The provision of language and cultural support services is still in a developmental phase, but the current situation has been arrived at in an ad hoc fashion. Internationally, many ways of managing services have been tried, but there is a lack of systematic evaluation to explore how such services might relate to the stakeholders and structures existing in the UK. A degree of consensus exists around the importance of working with communities locally, integrating cultural awareness and training for staff, and understanding the roles and abilities of different levels of language intermediary. Needs analysis is also seen as an essential element, but similarly, guidance on accepted best practice has yet to emerge. It seems likely that local solutions have been developed in the UK, but are not formally reported or evaluated. 5. Provision of services which diagnose and treat speech/language conditions: Bilingual children and older people need to be assessed and treated in their mother tongue by therapists who are both bilingual and culturally sensitive. Training should develop therapists’ cultural competencies and sensitivities in order to understand that language and communication disorders are culturally constructed within the often stressful environment of an adopted culture. 6. Provision of 'talking' therapies (i.e. counselling, psychotherapy): Empowerment is central to the expressed needs of carers and service users through their demands for information about available services, repeated over and over again in the literature. Individualised service provision that is sensitive to and expressive of cultural needs is highly valued by mental healthcare consumers and their families. Theoretical models need to be explored that will incorporate the multiplicity and diversity of service users, their beliefs and family values. Although interpretation and translation are important services, they do not represent an overall strategy for a proactive mental health system. 7. Other aspects of ethnicity and communication: For processes which require consent or participation of the patient effective communication is essential. A 'case study' issue was explored, by focusing on issues relating to organ and/or human tissue donation and transplantation, as illustrating the core issues of informed consent and providing evidence of effective interventions. Language differences and literacy or access to differing media are not the only considerations in this area; instead awareness of cultural issues other than language has particular significance in effective communication. We were unable to locate literature on informed consent in the context of research participation, and service planning consultation where the effectiveness of different approaches was discussed - other than papers stating that it had been an issue of concern, or that non-English speakers were excluded because of such concerns. • At the end of the review process, we were able to identify a number of underlying issues that underpin the literature in all the above areas, and to make a number of recommendations in order to improve linguistic and cultural competence in the NHS. • Overview: Communication requires attention to context, and the needs of the person seeking to transmit information, as well as the characteristics (language, literacy, culture) of the intended recipient. The messenger may be as importance as the message, and some health care workers may not feel comfortable in that role, with particular 'audiences'. Messages must be specifically tailored to their audience, taking religious and other beliefs and practices into account. Information from official sources may be of less impact unless fortified by personal experience and information from intra-community networks which establish a higher level of salience or 'emotional connectedness' with the issues being communicated. UK research and development is so far largely confined to descriptive, clinical, and exploratory work and does not yet include significant evaluation of interventions.
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An audit loop for patients failing to attend a paediatric outpatient department was completed by repeating the analysis three years after interventions were put into place. The 1995 study had shown non-attendance for clinic visits was 34%, varying from 32.5% for Europeans and 50% for Asian patients. A follow up study in 1998 showed a fall to 12.04% and 13.5%, respectively, with an overall rate of 12.3%. The Manor Hospital NHS Trust had the lowest non-attendance rate of the 30 hospitals in the West Midlands region for the year 1996-7.