Barriers to community health programs

Similarly, Taylor et al. As a result, adjustment to these changes was considered the priority. Similarly, Brennan et al. A stable organization, as opposed to re-organization, therefore supports implementation within community nursing. In addition, flexibility and the autonomy to adapt the innovation encouraged community nurses to adopt it.

Organizational infrastructure and change was an important barrier, with community nurses claiming they were preoccupied with, and prioritized, these changes. Quality of the included studies varied. Across the qualitative studies, sample sizes are small, limiting generalizability. Authors of qualitative studies often compensated for the lack of external validity by adopting strategies to increase trustworthiness, such as member checking and triangulation.

However, findings from the included qualitative studies in this review have been corroborated with results from the quantitative papers. Overall the quality of the included quantitative studies was higher than the qualitative or mixed-methods studies. Due to the nature of the research design, sample sizes are larger and there is greater external validity amongst the quantitative studies. For example, Sherman et al. Sherman et al.

In contrast, the surveys and tools used by Paquay et al. Variation in the quality of studies, designs and samples implies implementation science in community nursing requires development. Authors using different terms to describe the same phenomena cause confusion.

Implementation strategies in the literature are seldom labelled and researchers do not provide rationales for the strategies used. This review attempts to provide some harmony by presenting an overview and synthesis of strategies, barriers and facilitators.

It is clear from the included studies, and may even be assumed, that community nursing is patient-focussed. Community nurses were therefore less likely to adopt the innovation if, by integrating it into their routine practice, existing nurse—client relations could be negatively affected.

In addition, the trend across the quantitative studies to include patients as participants suggests that end-user adoption may influence implementation. This finding may be a result of selection bias, as papers were included if they reported on the implementation of an innovation designed to enhance care.

Yet our analysis also suggests that community nursing practice is driven by other factors, which may promote or inhibit implementation. This underlines the importance of working in partnership with practitioners to identify research questions and develop interventions. Training and an on-going education phase on how to use and integrate the innovation was a key facilitator found across the included papers.

However, embedding this training through experience is challenging Taylor et al. Continued support is needed, which can be difficult when managing a busy caseload. A lack of time is a widely reported barrier to engagement with, and implementation of, EBP.

Taylor et al. Although researchers are able to offer support, clinical buy-in and drive from the nurses who have, or wish to, adopt the innovation, is required. Giving nurses the flexibility to use and adapt the innovation, and the need for managers to be on board to allow the time and investment of resources to implement it, were both facilitators.

However, findings collectively from the included studies suggest that nurses make decisions as individuals. Context clearly plays a key role here. While community nurses deliver care, they also organize it and are often responsible for their caseload Sales, Implementing an innovation is not an exception to this; nurses are an active component within the process, and it is arguably through the process of reflection and critical thinking that change occurs Griffiths, As Doran et al.

This could contribute to successful implementation or not, as community nurses have a degree of autonomy and can therefore decide to adopt an innovation. This may mean adoption in community nursing is rather individualistic and therefore haphazard. Many of the studies included other healthcare settings or participants in their analysis, such as General Practitioners; secondary care settings; and manager Annells et al.

There is also evidence that the wider organizational context can facilitate or inhibit the adoption of EBP. Working in a constantly changing environment makes mainstreaming an innovation difficult. As Taylor et al. Furthermore, evidence from the included papers suggested innovations that required the re-organization of teams also resulted in resistance from adopters, which in turn created a barrier to implementation.

The included papers, and literature elsewhere Harrod et al. As discussed, adoption of an innovation is reliant on the decision of the community nurse. There is little evidence, however, to suggest that nurses introduce innovations themselves after engaging with EBP. This may be a result of a lack of availability of relevant research in primary care, lack of skills to appraise evidence, or the lack of awareness of change mechanisms Bryar and Bannigan, Furthermore, in practice, implementation is trial and error and nurses may not have the confidence to trial the innovation.

Managers are more likely to grant time, and support implementation efforts, if the innovation meets organizational goals, for example national targets, and if it is compatible with their values. This illustrates that evidence-based nursing not only depends on the availability of evidence, patient preferences and the clinical expertise of the nurse, but also the organizational resources available Closs, This suggests that community nurses have more freedom to decide if they wish to engage with top-down implementation than to introduce an innovation without management instructions.

Future implementation within the context of community nursing therefore requires a facilitated approach, acknowledging both top-down and bottom-up techniques. Continued support, including collaborative working and the use local champions, were identified to be both implementation strategies and facilitators, promoting the adoption of an innovation.

The other identified implementation strategies and facilitators require further testing. Future research could evaluate how these facilitators could be used to effectively overcome barriers. There is a lack of research based on rigorous conceptual frameworks. Theory is seldom used when implementing an innovation.

There are a plethora of frameworks and theories relevant to implementation research that can be used to guide implementation processes and consider sustainability Tabak et al. There is a need to test theories in a community nursing context. Furthermore, more effort should be made to understand how sustainability of implementation can be achieved van Achterberg, As a result of limited funding, follow-up periods after the introduction of new EBP are often short and implementation science researchers are required to work within the resources available to them.

We therefore suggest that future research be undertaken around the continued adoption of EBP within community nursing; and the use of identified strategies to sustain a change of practice within this context.

There are a number of limitations to this review, mainly relating to scope. Only English Language papers were reviewed and the quality of the papers varied. The included papers come from a wide range of countries with differing healthcare systems. However, by adopting a Critical Interpretive Synthesis approach we have attempted to be critical and clarify effective implementation strategies in a diverse and confused field. In particular, the post hoc implementation strategies offered in the included studies are attempts by the authors to explain what did or did not work.

There may be alternative explanations, and more appropriate names. More testing is therefore required. This review reveals the importance of support strategies when implementing EBP in community, including regular meetings and updates from the researcher, the allocation of resources and managerial support.

This included training and time to become familiar with the innovation. More testing of the identified strategies and facilitators is required. The review findings support the emerging consensus that implementation research reports should describe an evaluation of its process Hulscher et al. Synthesis of the data was amended by G. All authors contributed to drafting and revising the article, and approved the final manuscript.

National Center for Biotechnology Information , U. Prim Health Care Res Dev. Published online Aug 2. Author information Article notes Copyright and License information Disclaimer. E-mail: ku. This article has been cited by other articles in PMC.

Abstract Aim To appraise and synthesize empirical literature on implementation of evidence within community nursing. Background There is an international consensus that evidence-based practice can improve outcomes for people using health and social care services.

Methods Systematic mixed-studies review, synthesizing quantitative and qualitative research. Results In total, 22 papers were reviewed. Conclusion Implementation is an expanding area of research; yet is challenged by a lack of consistency in terminology and limited use of theory.

Introduction For decades, evidence-based practice EBP has been an aspiration for health service providers. Method As the topic area of this review is context-sensitive, a design that provides a practical understanding of the phenomenon is required. Open in a separate window. Figure 1. Table 1 Search key with Boolean operators. Quality appraisal The 22 included studies were appraised using the assessment template for disparate data developed by Hawker et al.

Table 2 Summary of the included studies. Qualitative: observations; interviews; registered adverse events and system failures; web-based survey Post-implementation 30 Paquay et al. Pre—post-implementation 28 Sherman et al. Qualitative: focus groups. Pre-implementation 33 Smith et al. Box 1 Assessment form Hawker et al. Abstract and title 2. Introduction and aims 3. Method and data 4. Sampling 5. Data analysis 6. Ethics and bias 7. Findings and results 8.

Implications and usefulness Total. Data abstraction and synthesis Key areas of each of the included papers were extracted by A. Results Nine qualitative papers, seven quantitative and six mixed-method studies were identified Table 2.

Figure 2. Relationship between implementation strategies, facilitators and barriers. Implementation strategies Training and support strategies Training nurses on how to use the innovation before it is implemented contributed to successful adoption. EHRs can be used to:.

The following resources can help address provider barriers and develop a streamlined referral process to DSMES services. For additional resources, visit the Educating Providers and Establishing a Referral Network sections of the toolkit.

Individual barriers to access and participation include: The following resources provide additional information to help DSMES services address barriers to participation:. Skip directly to site content Skip directly to page options Skip directly to A-Z link. Public health leadership also requires an appreciation of the processes and values of government in the United States.

The continuing evolution of public health constantly raises new challenges to public health personnel, requiring updating of knowledge and skills. Many educational paths can lead to careers in public health, but the most direct is to obtain a degree from a school of public health. Schools of public health were established in major private universities early in the century. They now number 25—7 in private universities and 18 in public.

During the early decades of their existence, they concentrated on training people with degrees in the health and related professions physicians, nurses, engineers, dentists, and others to become public health professionals. In recent years, however, as the mandate of public health has broadened and as public health problems and their solutions have become more complex, the schools have responded to this evolution by recruiting individuals from the behavioral sciences, from mathematics, from the biological sciences, and from other relevant fields and disciplines, as well as health professionals.

Institute of Medicine, Conference, March Modern schools of public health serve important dual roles: that of a public health research institute and that of a public health educational facility. These roles reflect the great successes of public health in developing new knowledge and applying that knowledge in a social and political context to the benefit of the population.

The complexity of modern issues in public health requires that the field continue to develop new technologies delivered in new ways. These technologies require both fundamental and applied research before they can be implemented as public health programs in an agency setting. Schools of public health have traditionally operated to serve this basic and applied research function, linking knowledge generation with practical problem-solving.

Meeting the challenges to public health described in this report will require a strengthening of this linkage. The schools can build on their previous efforts to work cooperatively with agencies in evaluating public health programs and in assisting in their initial implementation.

Many schools of public health are located in research universities and therefore have specific responsibilities to the academic objectives of their institutions as well as to their fields of professional practice. This situation is by no means limited to public health, but characterizes graduate professional education in medicine, dentistry, engineering, law, and other fields.

Each of these areas must accept the dual responsibility to develop knowledge and techniques of use to the profession and to produce well-trained professional practitioners. Many observers feel that some schools of public health have in recent years become somewhat isolated from the field of public health practice.

The result of this changing emphasis may be that some schools no longer place a sufficiently high value on the training of professionals for work in health agencies. The variation in public health practice noted earlier in this report and the limitations on employment opportunities in health agencies for well-trained professionals, restricting opportunities for graduates, have inhibited desirable responses by the educational institutions to the needs of practice.

This situation is exacerbated by the fact that most public health workers have not had appropriate formal professional public health training. However, we lack sufficient knowledge about the public health workforce and its needs and opportunities.

Recognizing the importance of these and other issues relating to the education and training of public health personnel, the committee sponsored an invitational conference in Houston in March in cooperation with the University of Texas School of Public Health.

The conference brought together public health educators, practitioners, and other concerned individuals to consider the future of education and training for public health. It helped identify issues, clarify consensus and areas of disagreement, and provide a broader input into the committee's deliberations.

The proceedings of that conference will be published separately from this report. Technical expertise in public health is not evenly distributed among jurisdictions. Some of the larger states have considerable internal expertise. Others lack such expertise. The consultation role of the Centers for Disease Control and the larger state public health agencies help fill this need, but important gaps remain.

For example, in one of the states we visited, an assignee from the Centers for Disease Control was carrying out an important epidemiological study. When his short-term assignment was completed, however, the expertise necessary for essential assessment activities was no longer present on the staff. Public hearing participants reported that cut-backs in federal staffs, especially at the regional office level, have reduced the federal consultative capacity. This problem is further exacerbated by the lack of trained experts in such fields as epidemiology.

Previous studies have shown persistent deficits in their availability. Institute of Medicine, Conference, March In some jurisdictions, low salaries and unrewarding professional environments would inhibit the attraction of such expertise even if a sufficient aggregate supply existed. Our inquiries indicate that public health seems to suffer from a poor image or lack of attention even when its success in the solving of specific problems is highly publicized and commended.

We were told by state and local elected officials that the general population often cannot identify the benefits they have received through public health activities. Public health, in this regard, suffers from its successes. Such achievements as a safe water supply, the disappearance of many childhood infectious diseases, reduction of the incidence of stroke, fewer childhood poisonings, reductions in lead poisoning, and control of food-borne infections are taken for granted until a problem occurs.

Also, the identification of public health programs with means-tested welfare programs adds to the perception that public health concerns are not an integral part of the entire community. Some of the public may have additional negative views of public health based on perceived interference with private freedoms and a moralistic tone of public health pronouncements. For example, smokers may resent efforts of public health authorities to limit smoking in public places.

Other important interest groups, such as the tobacco industry, may oppose public health actions and question the competence of public health agencies because those actions may interfere with the economic interests of the group. Although the broader medical community can and does identify with such public health issues as smoking, injury control, infectious disease control, and dietary change related to cardiovascular disease and cancer, many physicians look down on public health, as an organized activity, believing it to be second rate or meddlesome.

The one-on-one orientation of most medical training, the limited exposure to such population-based concepts as epidemiology, and the lack of experience during the training process with interdisciplinary collaboration contribute to this lack of a natural alliance between the physicians and public health. Finally, public health has both an enforcement negative and a facilitative positive aspect.

This sends mixed signals about the image of public health to various population and interest groups. We identify image as a problem not because we are concerned about the sensitivities of public health workers, but because we believe that these problems interfere with the capacity of public health agencies to mobilize the support of important constituencies, including the general public, for the public health mission.

The image problem may also limit recruitment of talented persons into the field of public health practice. In a free society, public activities ultimately rest on public understanding and support, not on the technical judgment of experts. Expertise is made effective only when it is combined with sufficient public support, a connection acted upon effectively by the early leaders of public health.

We have identified many aspects of the needed managerial capacity in the previous discussions, specifically under the label of leadership. Here, we reemphasize the complexity of the managerial tasks faced by the public health manager. We cannot think of a managerial responsibility that involves a wider range of skills, including not only the usual management and leadership skills for running a complex and interdisciplinary organization, but also the communication and constituency building skills of a public executive, and finally, but not least, access to up-to-date technical information, sometimes in emergency circumstances.

The high visibility and intense public interest that arises when a public health emergency occurs adds to the stress of these positions. Finally, the nature of public health decisions often places the manager at the center of a conflict among competing societal values and political forces.

The early progress of public health in this country was advanced by the fortuitous presence of individuals who combined these many managerial characteristics. The present challenge is how to assure the ready availability of managers with these capabilities. This is unlikely to occur without special attention and a plan for the development and support of a cadre of talented persons with appropriate educational preparation and experience.

Leadership development would be aided by adequate salary levels, particularly in the case of state and local health officers the current low salaries for many of these positions are documented in Chapter 4 and Appendix A. Modernizing benefit programs so that personnel could accept "promotions" involving a change of political jurisdiction without losing accumulated pension funds would also help with the career development of a management cadre.

The wide array of challenges facing public health and the strongly ingrained American belief in limited government make it unlikely that adequate financial support for public health activities will ever be available. In the competition with other important public functions, it is probably naive to think that the "right" distribution of available public funds exists. However, we would note these special problems for public health as compared with other public functions:.

This list could be expanded, but these problems illustrate the challenge of achieving adequate fiscal support for public health activities. What are the problems public agencies are having in fulfilling their unique functions—of assessment, policy development, and assurance?

Is the statutory base adequate to cope with a new and compelling issue? The intent of this section is to illustrate some of the problems by focusing on one, acquired immune deficiency syndrome AIDS , and tracing through the system, largely by means of quotations obtained in our site visits. The powers provided in statute are too restrictive, including outdated concepts of full isolation and quarantine that are inappropriate given the mode of transmission of AIDS.

Also there are no clear criteria to guide officials in exercising their powers. Due process procedures are sketchy or absent. This leaves too much room for unfettered administrative discretion about how to apply the law.

A modern public health law should remove the rigid distinctions between venereal and communicable disease and should enact strong, uniform confidentiality procedures. Otherwise, public health is left with a stick too big to wield. They're not confronting the position the doctor faces in informing people and their contacts about the disease—for instance, the wife of an AIDS patient. They tried to make knowing donation of infected blood a crime, but it didn't go anywhere.

We have little in the way of confidentiality. The new law makes knowing transmission of AIDS second-degree murder. Exercise of the assessment function is closely linked to the enabling structure put in place by statute.

Public health officials feel keenly the need to monitor the disease and mount effective programs to limit its spread. Pursuing these functions raises many political sensitivities. In addition, the speed with which the problem developed has public health struggling to keep up with changing dimensions and new technologies.

This makes long-range or even rather short-range planning a luxury agencies can't afford. Some health agencies are accused of overemphasizing surveillance at the expense of preventive efforts such as education.

They are secretive about sharing stats. I don't want names, but they'll only give out information on a countrywide basis. The hospitals are also tight lipped. The vital statistics give us the deaths.

We need to track sero-positive individuals and maintain confidentiality. On the other hand, there are scientific concerns about anonymous testing. These are new issues for disease control. No one has yet been able to take a broader system view of the AIDS problem. No one is thinking about how to fit the pieces together. The results are not getting into the hands of community physicians fast enough.

I would argue that prevention should take precedence. AIDS is extraordinarily controversial, and the political heat has been intense.

Pressure to do something fast, but not to infringe on the rights of high-risk groups, has health agencies struggling to balance basic knowledge development with the obligation to respond to immediate situations.

Among the many groups and individuals, public and private, engaged in fighting AIDS, health agencies have not taken a clear initiative in supplying leadership, and the public is unclear about what level of government it should look to for guidance or what it can appropriately and realistically expect any particular health agency to do.

Lack of public understanding about the real nature of the risk makes matters worse; on the other hand, as one person said: "If they knew they had practically no chance of getting it, then they really wouldn't give a damn.

It convened the hearing and put funding in place. Such leadership should have come from the Department of Health Services, but it hasn't. The department has held no hearings. The state health director knows less than I do about what's happening in the state.

I spend one-third of my time on it. Don't ask me what we're doing about diabetes or high blood pressure. I simply don't know. What gets done depends on the public mood.

Much better education of the general public is needed so they will accept future expenditures. Governments, too, can suffer a wasting disease; the gradual erosion of the coordinated leadership of the Public Health Service has created a void.

Surveillance of the nation's health is no longer the clear responsibility of any agency of government, nor is the surveillance of proposals for meeting crises. Isolated islands of excellence [CDC, NIH] do not alone constitute a national strategy to defend and promote the national health.

Public health officials at the state and local level are very much aware of their responsibility to make sure that AIDS is combated effectively. But they are hamstrung by the speed with which the problem has developed and the political heat it has generated, as well as by the difficulty of marshalling enough resources to do what they feel is needed. At present, they lack the technology either to cure AIDS or to control its spread through the definitive and simple means of a vaccine.

The fiscal implications of caring for AIDS patients are poorly understood because estimates of the potential number of cases are in dispute. In some places where there are large numbers of AIDS patients, the private sector—especially voluntary groups such as gay rights organizations—have taken the lead in providing treatment and counseling, with the health department struggling to keep track of what is being done. The nature of the problem makes the regulatory apparatus difficult to mobilize.

This discussion of how the public health system is coping with the AIDS epidemic illustrates many of the problems encountered by these agencies when confronted by such a major new challenge.

Other examples would have revealed different sets of problems, such as how to sustain a continuing effort to maintain high rates of childhood immunizations where prior success breeds complacency, liability concerns raise the price and threaten the availability of vaccines, and limited resources are diverted to new challenges.

Both types of examples, the new crisis and the continuing effort, support a central theme of this report—the essentiality and proved effectiveness of public health measures for improving and protecting the health of the public and the imposing array of problems that undermine the public health capacity to respond.

AIDS illustrates both—a strain on the public health system and remarkable accomplishments by the public health community in a short time. Response to a highly publicized crisis like AIDS cannot serve as the model for a sustained and effective public health effort addressed to the many health problems that, in the aggregate, dwarf the health impact of AIDS.

For example, the great increase in lung cancer took place more slowly and therefore lacked the dramatic impact of AIDS on the public consciousness, but it is a larger problem in terms of death and disability, and sustained public health effort can affect the magnitude of the disease burden. The same is true for such major sources of health deficits as injuries, substance abuse, and environmental pollutants.

That public health accomplishes so much is a tribute to the effectiveness of its techniques and the dedication of its workforce. Yet the problems and disarray that we have documented through our inquiries are a source of strong concern to the committee. The next chapter contains our recommendations to help overcome these problems, strengthen the public health capability, correct the disarray, and refocus public health on its important mission.

Turn recording back on. National Center for Biotechnology Information , U. Search term. These barriers include: lack of consensus on the content of the public health mission;. The Lack of Consensus on Mission and Content of Public Health Progress on public health problems in a democratic society requires agreement about the mission and content of public health sufficient to serve as the basis for public action.

Public Health Responsibility for Indigent Care Some public health workers are concerned when their agencies serve as providers of last resort for medical care of the indigent, or administer Medicaid or other financing programs. Relationship of Public Health to Environmental Health Many of the early accomplishments in the prevention of infectious disease were accomplished through public health management of water supply and sewage disposal.

Relationship of Public Health to Mental Health During most of its long history, the public function in mental health primarily was on care of the chronically ill mental patient, as illustrated by the large hospitals for the mentally ill. Impediments to the Essential Work of Public Health In its investigations, the committee found a number of problems impeding the ability of those charged with public health responsibilities to carry out the essential functions of assessment, policy development and leadership, and assurance of access to the benefits of public health.

Assessment and Surveillance A foundation stone for public health activities is an assessment and surveillance capacity that identifies problems, provides data to assist in decisions about appropriate actions, and monitors progress. Policy Development Policy development is the means by which problem identification, technical knowledge of possible solutions, and societal values join to set a course of action.

Environmental Protection Agency , One by-product of a systematic policy development process is the identification of gaps or uncertainties in the knowledge base that should guide decisions.

Assurance of Access to the Benefits of Public Health Assurance of the availability of the benefits of public health to all citizens reflects a primary reason for the existence of public health activities. Leadership for Public Health In its inquiries the committee found a number of problems that limit effective leadership for public health.

The Interaction of Technical Expertise and Political Accountability In exploring the making of public health decisions in particular states and localities, we observed that technical expertise bearing on some public health problems may not be appropriately considered by the political policymakers, leading to decisions that are technically inadequate.

Continuity of Leadership In many public health jurisdictions, rapid turnover of leadership has been a problem. National Leadership for Public Health The provision of appropriate national leadership for public health is closely related to the problems of governmental structure in our federal system as discussed earlier. Poor Relationships with the Medical Profession A particular problem for public health leadership is the lack of supportive relationships with the medical care profession.

Community Organization for Public Health Action In a free and diverse society, effective public health action for many problems requires organizing the interest groups, not just assessing a problem and determining a line of action based on top-down authority. Structure and Organization of Public Health In the United States, public sector functions must be performed in the midst of a deliberately complex set of organizational and jurisdictional relationships.

Organizational Separation of Environmental Health Programs, Mental Health Programs, and Indigent Care Programs In a previous section, we discussed the problems that are created for a perceived coherence of public health activities when environmental health, mental health, and indigent care programs are administered by separate agencies. Creation of Health and Human Services Superagencies As described in Appendix A , almost half of the states have created umbrella health and human services "super" agencies.

Lack of a Clear Delineation of Responsibilities Between Levels of Government The federal structure established in our Constitution deliberately introduces a degree of ambiguity and tension concerning the roles of the various levels of government. Deficits in the Capacity to Conduct Programs In carrying out its functions, public health must possess the fundamental capacity for effective actions.

Knowledge and its Application Effective public health actions must be based on accurate knowledge of health problem causation, distribution, and the effectiveness of interventions. The Need for Well-Trained Public Health Personnel Many sections of this report have mentioned the need for well-trained public health professionals who can bring to bear on public health problems the appropriate technical expertise, management and political skills, and a firm grounding in the commitment to the public good and social justice that gives public health its coherence as a professional calling.

Institute of Medicine, Conference, March Modern schools of public health serve important dual roles: that of a public health research institute and that of a public health educational facility. Distribution of Technical Expertise Technical expertise in public health is not evenly distributed among jurisdictions. Building Constituencies for Public Health Our inquiries indicate that public health seems to suffer from a poor image or lack of attention even when its success in the solving of specific problems is highly publicized and commended.

Managerial Capacity We have identified many aspects of the needed managerial capacity in the previous discussions, specifically under the label of leadership. The Lack of Fiscal Support The wide array of challenges facing public health and the strongly ingrained American belief in limited government make it unlikely that adequate financial support for public health activities will ever be available.

However, we would note these special problems for public health as compared with other public functions: an explicit reduction of federal support for public health activities;. How the Public Health System Works—Aids as an Example What are the problems public agencies are having in fulfilling their unique functions—of assessment, policy development, and assurance?

Site visit comments bear out this view. For example: "This state has strange confidentiality laws that make it difficult to target appropriate information to appropriate recipients.

Assessment Exercise of the assessment function is closely linked to the enabling structure put in place by statute. Assurance Public health officials at the state and local level are very much aware of their responsibility to make sure that AIDS is combated effectively. The State of Public Health This discussion of how the public health system is coping with the AIDS epidemic illustrates many of the problems encountered by these agencies when confronted by such a major new challenge.

Berkman, Lisa F. Oxford University Press: New York.