Client-centered Services Research Articles

Assessing Satisfaction of Children in out-of-Home Care: Development of Korean out-of-Home Care Satisfaction Scale

In order to offer client-centered services, it is important to measure children’s service satisfaction and reflect their needs to out-of-home care practices and policies. However, a reliable measure that assesses children’s satisfaction about out-of-home care is not found in Korea. This study aimed to develop a Korean out-of-home care satisfaction scale. The study sample consisted of 484 children from institutional care, group homes, and foster homes in Korea. Half of the sample was chosen randomly for exploratory factor analysis (EFA) based on 16 items from the Korean Foster Care Improvements Project. The other half of the sample was used for confirmatory factor analyses (CFA). EFA yielded two-factor structures that consist of eight items for each factor. Confirmatory factor analyses supported the two-factor structures with reasonable fit, and all items loaded significantly on the factors. The Korean out-of-home care satisfaction scale could be used as a tool to assess children’s satisfaction with out-of-home care services, which could allow social workers to reflect children’s needs immediately into practice and help policymakers make more informed decisions about out-of-home care services and programs.

Home care services for older persons. The views of older persons and family members: A realistic evaluation.

The aim of the present study was to evaluate client-centred care in older persons' home care services from the perspective of older persons and family members. The following research questions were addressed: How do home care older persons and family members perceive client-centered care in their home care services? What kind of social mechanisms are realized when home care services are implemented? Several older persons are dependent on home care services for their continued living at home. The fundamental value and best practice of home care is the client-centred care in services. The research method was realistic evaluation. Six families with six older person clients of home care and seven family members were interviewed. In the present study, the interview contained three themes (1) content and services of the home care, (2) activities and practices of the home care and (3) development of client centredness in home care. Research data were analysed with deductive content analysis. Home care service should be based on analysis of older person's individual life situation. Social mechanisms such as interaction, participation, trust and adaptation are realised in implementation of home care services. The most significant outcomes of client-centred service were timely availability of services, safe care relationship and continuity of care, ability to influence on own services and appropriate price of services. Significant factors in quality of service were unhurriedness, kindness and competence of professionals. Social mechanisms, such as participation, trust, adaptation and interaction, should be taken in account in care relationship in home care. Client centredness and methods for evaluating it should be defined in practical work. Client-centeredness competence should also be included in all stages of professional education of home care.

Workshop series for occupational therapists using the US Agency for Healthcare Research and Quality’s Health Literacy Universal Precautions Toolkit and other supported tools

Objective: Health literacy is the ability to access, understand, evaluate and communicate information in a manner that promotes, maintains and improves health care in a variety of settings across the life span. Health professionals, including occupational therapists (OTs), need to consider health literacy in order to optimise client-centred interventions that promote self-management of chronic conditions, health and wellness. The goal of this small-scale cohort study was to determine if a health literacy workshop series for OTs could improve their working knowledge of health literacy, and increase their self-perceived ability to identify, assess and implement client-centred interventions to at-risk patients. Design: Over a 6-week period, six OT professionals participated in a customised workshop series, incorporating elements of the US Agency for Healthcare Research and Quality’s (AHRQ) Health Literacy Universal Precautions Toolkit (the Toolkit) and other AHRQ-supported health literacy resources. Method: A one-group, pre–posttest mixed methods design was used to measure outcomes. Results: Results of this study suggests that participation in a health literacy education programme featuring the Toolkit and other AHRQ-supported tools can improve OTs’ self-perceived ability to identify, assess and provide client-centred services to their patients. Responses to open-ended questions both pre-and post-intervention align with the literature in that health care professionals, like OTs, can benefit from customised health literacy training to improve client-centred care by implementing specific health literacy strategies into their clinical practice.

Whole Person Care in Under-resourced Communities: Stakeholder Priorities at Long-Term Follow-Up in Community Partners in Care.

Depressed individuals may require help from different agencies to address health and social needs, but how such coordination occurs in under-resourced communities is poorly understood. This study sought to identify priorities of Latino and African American depressed clients, explore whether service providers understand client priorities, and describe how providers address them. Between October 2014 and February 2015, we interviewed 104 clients stratified by depression history and 50 representatives of different programs in health and social community agencies who participated in Community Partners in Care, a cluster-randomized trial of coalition-building approaches to delivering depression quality improvement programs. Clients were queried about their most pressing needs; program representatives identified their clients' needs and explained how they addressed them. Physical and mental health were clients' top priorities, followed by housing, caring for and building relationships with others, and employment. While persistently depressed clients prioritized mental health, those with improved depression prioritized relationships with others. Program representatives identified housing, employment, mental health, and improving relationships with others as clients' top priorities. Needs assessment, client-centered services, and linkages to other agencies were main strategies used to address client needs. Depressed clients have multiple health and social needs, and program representatives in under-resourced communities understand the complexity of clients' needs. Agencies rely on needs assessment and referrals to meet their clients' needs, which enhances the importance of agency partnership in "whole person" initiatives. Our results illustrate agency capacity to adopt integrated care models that will address clients' multiple needs through multi-sector collaboration and describe potential strategies to help reach the goal of whole person care.

‘When I don't have money to buy the drugs, I just manage.’—Exploring the lived experience of persons with physical disabilities in accessing primary health care services in rural Ghana

The United Nations Convention on the Rights of Persons with Disabilities recognizes the rights of persons with disabilities' access to health care, including primary health care (PHC). However, growing evidence indicates that individuals in rural areas generally experience health access issues, and these issues are even worse for those with physical disabilities. Knowledge about such experiences is critical for policy design and clinical practice to promote PHC access for persons with physical disabilities in rural areas. This study seeks to explore the experiences of persons with physical disabilities in accessing PHC services in the predominantly rural Upper West Region of Ghana. We conducted semi-structured interviews with 18 participants living with physical disabilities, and used both deductive and inductive approaches to analyze the data. Participants shared experiences at three broad levels: the health system level, individual level and health-seeking behaviors level. Within the health system level, we identified three main categories: service availability (presence of health facilities, deficient drug supply and lack of providers), acceptability (positive and negative attitudes of providers and perceived high and low quality of care) and accommodation (inaccessible health facilities and equipment). The experiences at the individual level included financial constraints and mobility to health care facilities. Health-seeking behaviors related to how the individual reacted and responded to access barriers, which included searching for traditional healing, resorting to self-medication, making sacrifices in managing their conditions and relying on spiritual means. The information provided in this study is potentially important to policy makers and PHC providers as it presents evidence on the barriers and facilitators to PHC access in a rural setting. In particular, understanding individuals' experiences and how they develop health-seeking behaviors to overcome access barriers will be critical for policy design and client-centered service delivery in rural Ghana and potentially other low- and middle-income countries.

Relationship marketing strategy

PurposeThe purpose of this paper is to explore how strategies are put in place to formulate policies regarding the introduction and implementation of relationship marketing (RM) in the health sector, and how RM strategies are designed as part of the curricula for the training of prospective health professionals in Ghana.Design/methodology/approachData were gathered using interviews and documentary review. A purposive sampling technique was used to recruit policy makers and health educationists in Accra for in-depth interviews. Qualitative interviews were analysed using framework analysis.FindingsThe findings revealed that, currently, there is no policy framework on RM in the health sector nor included in the curricula of health training institutions in the country.Research limitations/implicationsDue to limited time and funding constraints, the study could not include many policy makers, educationists, health providers, facilities and regions outside the Greater Accra region of Ghana. This means that the authors missed out on useful insights from other relevant policy makers/educationists who would have added to the knowledge that this study contributes. There were still some areas that this study could not cover, including the lack of an exploration of the perceptions of health providers and patients.Practical implicationsEvidence from the current research provides the basis for scaling up of a similar study to the whole country to address the perennial RM or quality of care/patient satisfaction issues persisting in health facilities in the country. The outcome of this large-scale study would help to confirm the findings of the current study on the adoption and incorporation of RM into both policy framework and curricula of health training institutions in Ghana. The findings would culminate in the preparation and utilisation of guidelines on RM for client-centred service delivery in the health sector of the country.Social implicationsThis paper argues that RM orientation could enable health professionals to improve upon their healthcare service performance and quality of care so as to enhance patient satisfaction.Originality/valueThe study recommends that RM should be adopted by health policy makers and designers of curricula for health training institutions.

Determinants of unmet need for family planning among married women of reproductive age in Burundi: a cross-sectional study

BackgroundHigh unmet need for family planning (32.4%) characterized Burundi in 2010. However, there has not been any study examining the relationship between unmet need and associated factors in Burundi. The present study aims at determining the demographic, socioeconomic and other factors underlying the unmet need for contraception among married women aged 15-49 in Burundi.MethodsThis study used data from the 2010 Burundi Demographic and Health Survey. Total unmet need, unmet need for spacing and for limiting were used as outcomes and demographic, socioeconomic and other factors as independent variables. After a descriptive analysis of the study population (n = 5421), the association between the three outcomes and the independent variables were analysed using logistic regression. Odds ratios with their 95% confidence intervals were calculated with statistical significance at p < 0.05.ResultsThis study showed that the likelihood of total unmet need decreased with age after 35+, with an adjusted Odds Ratio = 0.586 and 95% CI = 0.423-0.811, compared to women aged 15-24. Women with 4-5 and 6+ living children had higher odds [aOR = 1.850 (1.322-2.590) and 2.390 (1.616-3.534) respectively]. Odds of unmet need were lower among women with primary [aOR = 0.741 (0.618-0.888)] and secondary education [aOR = 0.555 (0.399-0.771)]. Women whose husband desired more children than them [aOR = 1.824 (1.411-2.358)] and those ignoring the husband’s desired children [aOR = 2.700 (2.176-3.350)] had higher odds than those desiring the same number as the husband. Women who had experienced the death of 1+ sons had higher odds [aOR = 1.285 (1.038-1.591)]. Middle [aOR = 0.670 (0.530-0.846)] and rich [aOR = 0.664 (0.541-0.817)] compared to poor, women living in the North [aOR = 0.611 (0.412-0.904)] compared to those from Bujumbura, had lower odds. Rural women had higher odds [aOR = 1.373 (1.018-1.852)] and those who had visited a health facility [aOR = 0.765 (0.608-0.961)] or had access to TV [aOR = 0.562 (0.375-0.843)] had lower odds.ConclusionTackling the unmet need for FP in Burundi requires scaling-up male involvement, promoting spousal communication, client-centred services, greater use of media, women’s education, child survival, and pro-poor policies.

Feasibility of Integrating Occupational Therapy Into a Care Coordination Program for Aging in Place.

We examined the feasibility and benefit of integrating occupational therapy into a long-term services and supports (LTSS) care coordination program for aging in place. Clients referred to occupational therapy during a 16-wk trial were evaluated with the In-Home Occupational Performance Evaluation and received education on strategies for aging in place. Clients who indicated readiness for change were assisted in setting personalized goals with goal attainment scaling and received four additional occupational therapy visits. Of the program's feasibility benchmarks, 87% were met. Twenty-three clients were referred, and 16 clients were evaluated; 37.5% of those evaluated indicated readiness for change, establishing 18 goals with 100% goal attainment. Integration of occupational therapy into an LTSS care coordination program was feasible. Benefits of adding occupational therapy included a performance-based evaluation that revealed personal factors as barriers to aging in place and gave access to a client-centered service to maximize independence.

An early evaluation of an integrated, recovery orientated approach to severe and persisting mental health problems

Introduction: Partners in Recovery (PIR) is a national program run in 48 Australian local areas from 2012 until 2016. PIR aims to better support people with severe and persistent mental illness who have chronic and complex needs, through integrating health and other services in a recovery orientated approach aimed to be embedded in future practice through systems change. Recovery orientated practice recognises the strengths of service users and empowers them within the mental health system, emphasising shared decision making and respecting the self-determined goals of the consumer.We undertook a multiple methods evaluation of the early implementation of this program in an area to the west of Sydney. We worked with a Reference Group to develop a Program Logic Model (PLM) and assigned indictors. Using a combination of document review, surveys and interviews with consumers, carers and service providers and managers, we measured success in achieving the agreed indicators.Short description of practice change implementedWith funding from the Australian government, the Nepean Blue Mountains Medicare Local (a primary health care organisation west of Sydney) joined in a collaboration with partner organisations as well as consumers with severe and persisting mental health problems and their carers. PIR aims to improve outcomes through better coordination and integration of health and other services. A key longer term aim of the program is enduring systems change, both in terms of promoting recovery focussed care and improved and lasting collaborations across organisations to better achieve the consumers’ goals for recovery.Memoranda of Understanding and inter-organisational agreements assisted in aligning goals and priorities between the different agencies and regular meetings facilitated planning and review of activities across partner organisations. Care Facilitators were employed to assist consumers to access the required support available through the various participating organisations. Training was provided for staff of all partner organisations.Key findings: At the time of our evaluation PIR had been in operation for two years. Organisational structures had been developed and staff were employed according to the needs identified. Enrolment in the program initially occurred more rapidly than anticipated as consumers responded to promotional activities. Many of those enrolled reported improved access to services, although transport, housing, social opportunities and access to some specialist mental health services were noted particularly by staff, to remain challenges for some. Certain population groups in the area, including those living at a greater distance from urban centres, the homeless, those with drug and alcohol as well as mental health diagnoses and culturally diverse groups including Aboriginal and Torres Strait islander peoples appeared to be less well served by PIR.Highlights: This approach to integration of services for those with severe and persisting mental health problems was facilitated by the strong leadership provided by the Primary Care Organisation and the alignment of vision between most of the partner organisations. Challenges occurred where partner organisations were less familiar with and committed to a recovery approach to care. Though training was provided, organisational culture made change difficult in some organisations. Support Facilitators from one organisation will be placed in another organisation in an attempt to influence culture and understandings of participating organisations. Consumers and carers reported improved access to services and were keen to participate in leadership and peer support roles in the future. Staff and management of partner organisations reported improved access to services for their clients as a result of enhanced referral pathways and establishment of collaborative partnerships. However PIR was said to be a “work in progress” and many expressed concern about the short term nature of the current program.Conclusion: PIR in the Nepean Blue Mountains area of Sydney has provided an integrated client-centered service which has relevance in other settings. The PLM approach provided a useful framework for describing the program as well as for conducting an early evaluation of the program and indicating potential opportunities for further development. Our evaluation continues to inform program development.

The experiences of women who have accessed a perinatal and infant mental health service: a qualitative investigation

ABSTRACTBackground: Client feedback is an essential part of service evaluation and can aid both the development and delivery of client-centred services. The current study is an investigation into the experiences of women who have accessed a perinatal infant mental health (PIMH) service. The purpose of the service is to support vulnerable women to connect with and care for their infant, however it is not well understood how effectively the service supports the needs of the consumers.Method: One hundred and seventy-six women, discharged from the service within the past 36 months were invited to participate in the study. Forty of the discharged consumers were able to participate in a semi-structured telephone interview. Interviews were transcribed verbatim and interpreted using thematic analysis.Results: One superordinate theme, the service as a ‘Lifesaver’ and four subordinate themes describing the way in which the service met the needs of the participants were identified. More specifically, the themes included supportive counselling, trauma counselling, specialist interventions and assertive outreach. Overall, it was found that trusting therapeutic relationships with a regular clinician facilitated a safe environment conducive to counselling, which allowed for reflections on trauma, mental health and parenting.Implications: Findings from this study highlight the positive impact of PIMH services on consumers with a particular emphasis on the importance of the consumer–clinician relationship. Importantly, it was also found that dealing with past trauma was critically important for the women to enable them to move on with their lives as mothers.

Carnivalization as a new mode of collaboration

Purpose The purpose of this paper is to develop a conceptual model of carnivalization. The paper aims to widen the understanding of client initiated attempts to break away from a conflict of motives between conventional models and new ways of acting in service provision. Carnivalization emerges when the standard script falls apart and the actors start to construct unexpected meanings for the activity and create innovative solutions for the conflict of motives, which leads to new mode of collaboration. Design/methodology/approach The study analyzed the key features and significance of carnivalization in home care service encounters. The theoretical–methodological framework of the study draws on Bakhtin’s dialogical theorizing and cultural–historical activity theory. The analysis traces the processual movement from standard script toward carnivalization. Findings The key features of carnivalization involve conflict of motives between the actors, client initiatives, multiple chronotopes, artifact and role mediation, different modes of collaboration and the intertwinement of seemingly disconnected objects of collaboration. The findings indicate that carnivalization can enhance a new type of client–service provider collaboration. It can become an especially significant mode of collaboration for transforming an activity in which a historically established, stabilized script dominates the interaction. This paper suggests that the carnivalization type of collaboration should be deliberately fostered via organizational interventions to develop client-centered services. Originality/value As a consequence of the study, a new conceptual model is proposed for the analysis and promotion of carnivalization that can be applied in different organizational contexts.

Perceptions of Gangs and Crews by Justice-Involved Youth and Implications for Best Practice Work

ABSTRACTGangs and crews are at center stage when discussing youth violence. According to client-centered best practices in the social service arena, distinguishing between gangs and crews is not important for developing a trusting relationship; yet these terms are a master status for those agencies aimed at enforcement and suppression. Social service providers must navigate these different landscapes, particularly in light of their increasing involvement in multistakeholder violence-reduction partnerships. However, the voices of youth themselves have been left out of the mix. Perceptions of youth identified as gang affiliated or at risk for gang membership are used to empirically investigate how these best practices tensions should be navigated by service providers. Semistructured interviews with 41 youth involved in an employment program show that crews are perceived as less violent and less dangerous than gangs, and youth actively resisted the gang label, even though there were no differences in criminal records between self-identified gang and crew members. Implications for the important role of service providers in providing client-centered services and bringing forward youth voices into collaborative partnerships are discussed, as are future research needs relating to linking youth voices to best practice work.

A Preliminary Look at Knowledge, Attitudes, and Personal Use of Complementary/Alternative Medicine (CAM) Among Occupational Therapy Practitioners

Abstract Date Presented 4/16/2015 This preliminary study aimed to describe the knowledge, attitudes, and personal use of complementary/alternative medicine (CAM) among occupational therapy practitioners in the United States. Further research is needed to investigate potential knowledge gaps and attitudes that could interfere with providing client-centered and holistic occupational therapy services.

Performance of the measures of processes of care for adults and service providers in rehabilitation settings.

IntroductionIn recent years, client-centered care has been embraced as a new philosophy of care by many organizations around the world. Clinicians and researchers have identified the need for valid and reliable outcome measures that are easy to use to evaluate success of implementation of new concepts.ObjectiveThe current study was developed to complete adaptation and field testing of the companion patient-reported measures of processes of care for adults (MPOC-A) and the service provider self-reflection measure of processes of care for service providers working with adult clients (MPOC-SP(A)).DesignA validation studySettingsIn-patient rehabilitation facilities.Main outcome measuresMPOC-A and measure of processes of care for service providers working with adult clients (MPOC-SP(A)).ResultsThree hundred and eighty-four health care providers, 61 patients, and 16 family members completed the questionnaires. Good to excellent internal consistency (0.71–0.88 for health care professionals, 0.82–0.90 for patients, and 0.87–0.94 for family members), as well as moderate to good correlations between domains (0.40–0.78 for health care professionals and 0.52–0.84 for clients) supported internal reliability of the tools. Exploratory factor analysis of the MPOC-SP(A) responses supported the multidimensionality of the questionnaire.ConclusionMPOC-A and MPOC-SP(A) are valid and reliable tools to assess patient and service-provider accounts, respectively, of the extent to which they experience, or are able to provide, client-centered service. Research should now be undertaken to explore in more detail the relationships between client experience and provider reports of their own behavior.

The national trajectory project of individuals found not criminally responsible on account of mental disorder. Part 5: how essential are gender-specific forensic psychiatric services?

To state the sociodemographic characteristics, mental health histories, index offence characteristics, and criminal histories of male and female forensic psychiatric patients. Clinicians and researchers advocate that mental health and criminal justice organizations implement gender-specific services; however, few studies have sampled forensic patients to evaluate the extent to which men's and women's treatment and management needs are different. Data were collected from Review Board files from May 2000 to April 2005 in the 3 largest Canadian provinces. Using official criminal records, participants were followed for 3 to 8 years, until December 2008. The final sample comprised 1800 individuals: 15.6% were women and 84.4% were men. There were few demographic differences, but women had higher psychosocial functioning than men. Both men and women had extensive mental health histories; women were more likely diagnosed with mood disorders and PDs and men were more likely diagnosed with schizophrenia spectrum disorders and SUDs. The nature of the index offence did not differ by gender, except women were more likely to have perpetrated murders and attempted murders. For offences against a person, women were more likely to offend against offspring and partners and less likely to offend against strangers, compared with men. Women had significantly less extensive criminal histories than men. Not criminally responsible on account of mental disorder-accused women have a distinct psychosocial, clinical, and criminological profile from their male counterparts, which may suggest gender-specific assessment, risk management, and treatment in forensic services could benefit patients. The findings are also consistent with traditional models (Risk-Need-Responsivity) and ultimately demonstrate the importance of individual assessment and client-centred services.

The making of the Canadian legal profession: a hybrid heritage

The Canadian legal profession emerged from the confluence of two distinct traditions: the American and the English. The colonies of British North America followed the pre-revolutionary American model of a unified legal profession, according to which all lawyers could practise as barristers and solicitors. American and Canadian lawyers pursued a client- and market-driven, eclectic type of practice that was receptive to innovations – such as the large law firm, the contingency fee, and university legal education – that were strongly resisted in England. On the governance side, however, Canadian lawyers created an indigenous but English-inflected model whereby professional self-governance was delegated to a statutorily-created body that had the power to compel all lawyers to join if they wished to practise law. With their commitment to client-centred service and strong governance, Canadian lawyers long enjoyed a cooperative and productive relationship with provincial governments, unlike the adversarial one characteristic of the United States or the long benign neglect of the legal professions by the English state. It is argued that this historical pattern may help to explain the continuing strength of the self-governance model in Canada at a time when it is being questioned and radically reformed elsewhere in the common law world.

A Cross Sectional Study on Associated Factors of Depression among Type 2 Diabetic Outpatients in Black Lion General Specialized Hospital, Addis Ababa, Ethiopia

Background: Depression is a common comorbidity among patients with type 2 diabetes. The emotional consequences of diabetes have been scrutinized by a number of investigative teams and there were varying reports about the association of depression and type 2 diabetes. However, there is limited data about this in Ethiopia. Objective: To assess the associated risk factors of co-morbid depression among type 2 diabetic out patients presenting to Black Lion General Specialized Hospital, Addis Ababa, Ethiopia. Method: A cross-sectional study was conducted on a random sample of 276 type 2 diabetic outpatients from Black Lion General Specialized Hospital. Systematic random sampling technique was used to get each individual respondents. Data regarding patient characteristics were collected using structured interviewer administered questionnaire and health related information were collected from patient chart. Association between depression and type 2 diabetes among patients were explored using multiple logistic regression model. Result: Totally 264 study participants were interviewed with a response rate of 95.6%. Of whom those interviewed participants 53.0% were female, 69.3% were married, 80.7% were Orthodox Christian, and 57.2% were Amhara. The mean + standard deviation age at diagnosis and current age of the subjects were 43.9 + 10.9 and 55.9 + 10.9 years respectively. The statistically significant risk factors was poor social support (odds ratio 14.7, 95% CI 1.94-111.89, p-value 0.01). Conclusion: This study demonstrated that depression is a common co-morbid health problem in type 2 diabetic out-patients. Poor social support was the risk factor significantly associated with depression among type 2 diabetes patients. In a setting where recognition, screening and treatment levels remain low, health care providers need to focus their efforts on diagnosing, referring and effectively treating co-morbid depression in order to deliver rights-based and client-centered services for people in real needs.

청소년 상담을 위한 마음의 병 온톨로지 설계에 관한 연구

Youths express their own negative experiences and feelings come from their deeply wounded mind. They seek the root cause of these wounded hearts from other people or external environment. Youths revisited the past to heal painful memories. This study designed ontology in order to provide information about the causes and symptoms of illness of the mind for youth counseling. Application ontology enables high-volume and intricate knowledge not only to get set up systematically but also to be stored as the meaningful information. It is also very useful as an integrating tool of the existing complex counseling nomenclature. And ultimately, through revitalization of the sharing and reuse of materials, it becomes possible to provide client-centered counseling services. Therefore, this study built ontology of the mind-illness as a way to analyze the causes and symptoms of the disease in the client mind for providing personalized youth counseling services.

A Focus on Health Beliefs: What Culturally Competent Clinicians Need to Know

Health beliefs influence a variety of health-related behaviors and should be regarded as an important dimension of cultural variability. Such variability may explain disparities in health-care access, compliance, and treatment outcomes for persons from culturally and linguistically diverse (CLD) backgrounds. Cultural competence and client-centered service delivery require recognition of the effects of divergent health beliefs during clinical encounters. Assumptions derived from the Health Beliefs Model (HBM) can inform research to uncover communication-specific health beliefs held by persons from diverse populations. We conclude this article with a research protocol used to survey African American adults' knowledge and assumptions about communication processes and disorders.

Health trainers can help people manage long-term conditions

Health trainers work with disadvantaged groups in most parts of England to support people to make beneficial changes to their lifestyle. They are lay people who engage with communities rather than expect people to come to them and who provide a client-centred service where the individual decides when, what and how they want to change. Nurses work with health trainers to increase the support available to people with long-term conditions to self-manage and provide help to people found to be at risk following life checks or screening. Feedback from clients is positive, and health professionals are increasingly aware of how such trainers can complement their services. Managing a lay workforce presents challenges but this is an effective service for clients who struggle to change without support.