TOPIC: A Qualitative Study of Beliefs and Attitudes about Refusing Health Screening in General Practice

Health screening is a test performed to individuals before any symptoms appear. This is said to be important in early detection of existing diseases and conditions like diabetes and hypertension as to mention some [1]. There many studies conducted to check if health screening can enhance health care utilization and one of those is the study conducted by Thomsen et al (2005). They mentioned also that health screening can also help detect and lessen the risk to have the disease. On the other hand, the benefit of heath screening does that mean that there would be an increase usage of primary health care. Moreover, there was a noticeable reduction of daytime consultation rate [2].

The study conducted by Nielsen, K. et al (2004) was a replication of the study conducted in Ebeltoft, Denmark. Their were 2000 people who was included in a five-year population-based randomized, controlled health promotion study. However, Nielsen, K. et al (2004) uses the qualitative study instead to know the reason behind the non-participants decline to participate in the health screening. In the study, the researchers used the “stratified, purposeful sample of 47 persons who was drawn from a total of 118 decliners”. They were invited for an interview. However, only 18 out of the 47 person contacted who consented to the study. The result of the interview revealed that their beliefs and attitudes of submitting oneself to health screening would give them false sense of security and stressed the importance of autonomy. They would only go to their doctor if they have some symptoms. Autonomy is the right of patients to create their own decision about their health. This right does not allow the caregivers to make their decision for the patient, what they can do is only to educate them [3].


The participants in this qualitative study are ages between 30 to 50, which are categorized as under middle adulthood [4]. Starting at the age of 30, physical changes start to occur. Physical aspects like strength, muscle mass, and organ reserve decreases [5]. With the decline in physical changes happening in this age group, they are prone to heart diseases, cancer and obesity [6].


In conclusion, doctors and other health care professionals can only educate patients on the pros of health screening. But in the end the patient’s decision will be followed or that patient's autonomy must be exercised and respected.


Reference:
1. http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus &query=health+screening

2. Thomsen, JL et al. (2005). Effects of Preventive Health Screening on Long-term Primary Health Care Utilization. A Randomized Controlled Trial. Family Practice, 22, Retrieved April 6, 2005, from http://fampra.oxfordjournals.org/cgi/content/full/22/3/242? maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=health+screening&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT

3. http://www.ask.com/bar?q=autonomy+of+patients&page=1&qsrc=2106&ab=4&u=http%3A%2F%2Fwww.medterms.com%2Fscript%2Fmain%2Fart.asp%3Farticlekey%3D13551

4. http://www.mc.maricopa.edu/dept/d46/psy/dev/mid_adult/

5. http://www.mc.maricopa.edu/dept/d46/psy/dev/Spring99/midadult/ index.html

6. http://www.mc.maricopa.edu/dept/d46/psy/dev/Fall98/Mid_Ad/MidAd.html

Different levels of prevention occur as disease progresses. There are three levels of prevention:
a) Primary prevention focuses on decreasing the risk of exposure of an individual and community to a certain disease.

b) Secondary prevention emphasizes early detection of a disease, including its complications and to limit future disability.

c) Tertiary prevention focuses in rehabilitating and individual and restore them to an optimal level of functioning.

Quote:

The result of the interview revealed that their beliefs and attitudes of submitting oneself to health screening would give them false sense of security and stressed the importance of autonomy. They would only go to their doctor if they have some symptoms.

Screening refers to the early detection of individuals with unrecognized disease or with early stages of disease. However, there are reasons why some people won’t submit themselves for health screening. These include socioeconomic status and cultural and language differences that can contribute to low health literacy, which in turn, has a great impact in patient compliance.

Quote:

Autonomy is the right of patients to create their own decision about their health. This right does not allow the caregivers to make their decision for the patient, what they can do is only to educate them

I agree with this line. It’s true that everyone has the right to make their own decisions and they have the right to exercise their autonomy. Patients have the capacity for reflective self-awareness and that includes assessment of their own competencies. In turn, we should focus on these positive behaviors. As health care providers, we consider ourselves as a part of the interpersonal environment which exerts influence on patients as well as making a difference in their health attitude.

References:
a. Kozier, B (2004). Fundamentals of Nursing (7th ed.). New Jersey: Pearson Education Inc

b. Grootendorst DC, Jager KJ, Zoccali C, Dekker FW. Screening: Why, When, and How from http://www.biowizard.com/pmabstract.php?pmid=19536087

c. Shaw SJ, Huebner C, Armin J, Orzech K, Vivian J. The Role of Culture in Health Literacy and Chronic Disease Screening and Management from http://www.ncbi.nlm.nih.gov/pubmed/18379877?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_ DefaultReportPanel.Pubmed_RVDocSum

A Qualitative study of beliefs and attitudes about refusing health screening in general practice

Health screening may have both negative and positive effects to the client who is having the screening. Informed choice in screening is also very important as what in every procedure consent of the client is always needed. Present orientation about the screening practices plays an important role for the clients to be comfortable with the health screening to be done.

Some of clients don't know about the possible benefits and harms that most subjects on the study were fearful about. Some of them don't want to find out if there is a pre-existing illness within their bodies and are afraid of the stresses that will bring about to them. They also think that waiting for the results will made them feel anxious. So all should determine the pros and cons of a screening before it will be offered, and autonomy should be given to participants as whether they will be participating or not.

In a study in England, there mentioned that giving the possible particpants the possible side effects and benefits made most people to decline the invitation of health screening. In therefore comes hand in hand that when an informed choice id given most like that people tend not to participate in the screening event.

1. Rachel Crockett, Timothy M. Wilkinson, and Theresa M. Marteau (2008),
Social Patterning of Screening Uptake and the Impact of Facilitating Informed Choices: Psychological and Ethical Analyses, Health Care Analysis, 16(1): 17–30.

2. Les Irwig, Kirsten McCaffery, Glenn Salkeld, and Patrick Bossuyt (2006), Screening and choice: Informed choice for screening: implications for evaluation, British Medical Journal, 13; 332(7550): 1148–1150.

3.Eleanor Mann, A Toby Prevost, Simon Griffin, Ian Kellar, Stephen Sutton, Michael Parker, Simon Sanderson, Ann Louise Kinmonth, and Theresa M Marteau (2009), Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): trial protocol, Biomed Central, 9: 63.

Quote:

Their beliefs and attitudes of submitting oneself to health screening would give them false sense of security and stressed the importance of autonomy. They would only go to their doctor if they have some symptoms. Autonomy is the right of patients to create their own decision about their health. This right does not allow the caregivers to make their decision for the patient, what they can do is only to educate them.

The health care provider is always at a loss in this situation. Let’s put it this way; say, you are the health care provider. Your patient refuses screening. You are at a loss because you know that the screening procedure will penultimately benefit from whatever result the screening will yield. You just know it, because you have an in-depth knowledge of the procedure. But you know that you can never impose your belief upon the patient who has, as the Patient Bill of Rights has conferred upon him/her, the right to autonomy in health care decisions. What do you do?
It is a widely agreed fact that we as health care providers could not impose our decisions upon our patients because they have autonomy. The situation is furthermore complicated especially if the disease being tested is life-threatening, such as Huntington’s disease, for which in the decision hangs the life of a human being. In an analysis made by Duncan et al (November 2006) the issue is viewed in greater depth; “the decision about whether to provide a prenatal test in this scenario therefore must be based on who is deemed to have the greater right. Is the future individual's right to decide about testing for paramount, or is the right of the parents to have prenatal diagnosis irrespective of the condition being tested for, or the action taken in response, more important?... We consider that the future individual's rights outweigh the parents' rights and that prenatal testing for Huntington's disease should not be offered. By avoiding prenatal testing for adult onset disorders when no preventive treatments exist, the autonomy of the future individual is preserved. Individuals can decide for themselves if and when to have predictive testing. By these arguments, not offering prenatal testing is no different from not offering predictive testing for a child too young to make an informed decision about such testing. The rights of a pregnant woman are of great importance and are paramount when no third party has an equal or greater right. If the ethical consequences dictate that it is preferable not to offer such a test, however, the fact that the test is prenatal rather than being a test on an individual outside the womb does not make it any more justifiable. ”[1]
But we can enable our patients to help them make a better, wiser choice by better informing them (informed choices). An informed choice or decision a client’s thoughtful decision based on accurate understanding of the full range of options and their possible results [2]. The very main reason why they refuse is because they do not fully understand the benefits, risks, advantages and disadvantages of the procedure. In a study by Nijs et al (2000), “in refusing or attending population-based prostate cancer screening, urological complaints but also knowledge, attitudes and socio-demographic factors seem to play a role.” We are better informed than they are, we have the credibility as health care providers to dispel their doubts. We should offer them, according to Mann et al. (2009), choices that are neither deceived nor coerced, and based on the following principles: 1.) should be informed by best current evidence, and 2.) should reflect the decision-makers’ values. [3]

1 - Rony E Duncan, Bennett Foddy, Martin B Delatycki, Analysis and Comment, Ethical debate, Refusing to provide a prenatal test: can it ever be ethical? From the British Medical Journal, retrieved June 22, 2009, retrieved from the www.bmj.com
2 – The new GATHER guide to counselling, Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins School of Public Health, accessed June 22, 2009 retrieved from www.infoforhealth.org
3 - Eleanor Mann, A Toby Prevost, Simon Griffin, Ian Kellar, Stephen Sutton, Michael Parker, Simon Sanderson, Ann Louise Kinmonth, and Theresa M Marteau, Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): trial protocol, lifted from the Bio Med Central Public Health, accessed June 22, 2009, retrieved from www.pubmedcentral.nih.gov
[i]

I agree with the article which promotes health screening for right management for the disease condition.

Health screenings are a good place to start, says Ruth Townsend, Alaska Regional Hospital's director of cardiac rehab, diabetes and nutrition center. Health screening and testing make it possible for common diseases to be detected, prevented and/ or treated.

Townsend says. "The screenings can be a warning for people. If they identify a problem, they can follow up with their physician."

Reference:
Importance of health screening and testing: assuring a healthier future. (2007, October 7). Alaska Business Monthly Publication. http://goliath.ecnext.com/coms2/gi_0199-7220550/Importance-of-health-screening-and.html

Quote:

In conclusion, doctors and other health care professionals can only educate patients on the pros of health screening. But in the end the patient’s decision will be followed or that patient's autonomy must be exercised and respected.

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There has been a constant struggle on Nurse-Patient Advocacy VS Patient Autonomy for years. And though I agree that patients should exercise Autonomy in their daily living, I still believe that it would not hurt to be advised by health providers regarding the benefits of seeking Primary and Secondary Prevention in one's health practices. However, health providers, especially Nurses, should be reminded of the extent of health education they give to their clients so as not to compromise the right to Autonomy.


The nurse, though battling with Patient Autonomy, is still responsible in minimizing his clients' nonadherence to health prevention. There are three levels of preventions that should be emphasized by the health provider to his client as cited on a study by Lindsley and Rapoff in 2007:







Besides focusing on these three levels of prevention, there are also other factors on which the nurse can develop in order to further strengthen Nurse-Patient Advocacy in the presence of Patient Autonomy. In a study reflecting "Patient Advocacy: Barriers and Facilitators" by authors Negarandeh et al. in 2006, they presented four significant factors in facilitating a deeper Nurse-Patient Advocacy. These are:







The above claims, therefore, recommends that although Patient Autonomy should be considered before caring out health care, it is also the nurse's responsibility to create and strengthen the Nurse-Patient Advocacy through other ways such as deepening Nurse-Patient relationship and advancing one's knowledge and skills in the nursing practice.





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REFERENCES:


1. Rapoff, M.; Lindsley, C. 2007. Improving adherence to medical regimens for juvenile rheumatoid arthritis. Pediatric Rheumatology Online. Retrieved June 22, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1887529&tool=pmcentrez

2. Negarandeh, R.; Oskouie, F.; Ahmadi, F.; Nikravesh, M. & Hallberg, I.R. 2006. Patient advocacy: barriers and facilitators. BMC Nursing Online. Retrieved June 22, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1420298&tool=pmcentrez

Comment:
The right of the patient to refuse or follow treatment should be respected, May it be in terms of doing procedures or screening. Their right shouldn’t be recognized so as to avoid discretion in the part of the patient and with the health care provider. When the right of the patient is observed, in return there will be a great partnership between the health care provider and the client; this could also make way to the cooperativeness of the client.


Norman L. Keltner, Lee Hilyard Schwecke, Carol E. Bostrom, Psychiatric Nursing, (5th ed.) p.39,Singapore, Elsevier Inc.

According to American Hospital Association (AHA), the patient has the right to refuse a recommended treatment plan given by the health care provider even though they are informed of the possible consequence of the action. This is the 3rd right written in the AHA’s Patients Bill of Rights which was adopted in 1973 and revised on October 21, 1992

“The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or transfers to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.”

REFERENCE: American Hospital Association (1998). A Patient Bill of Rights. Retrieved last June 23, 2009 from, http://www.patienttalk.info/AHA-Patient_Bill_of_Rights.htm

Early screening in any stages of life is important. Subjecting oneself into it would give you knowledge on whether where your health status is. It’s good if you have a positive health status but just in case you’re already at risk, you will be able to do something about it. It might help you to be inspired to have a healthy lifestyle and keep away from bad health habits. Yet, if you are not convinced in this kind of process you have the right. As what have said in the previous comments, in which autonomy is


“…the right of patients to create their own decision about their health. This right does not allow the caregivers to make their decision for the patient, what they can do is only to educate them.”

However, as a health care provider, thorough explanation is needed. An individual should be able to know the advantages and disadvantages of heath screening and the importance of undergoing to that certain procedure. On the contrary, coercion is not a choice in encouraging an individual. Further,


“These include socioeconomic status and cultural and language differences that can contribute to low health literacy, which in turn, has a great impact in patient compliance.”

Culture is defined by Brunner and Suddarth (2004) as patterns of behavior, beliefs, and values that can be attributed to a particular group of people. Therefore, this will influence the individual’s reaction, judgment, and actions.



Reference:
Brunner, L.S. & Suddarth, D.S. (2004). Brunner and Suddarth textbooks of medical- surgical Nursing 10th edition. Lippincott Williams & Wilkins.

It's good that there are people who understand their autonomy as clients. If they say that there is nothing wrong with their own body, well who knows better but themselves?
But to what extent did they assess themselves to come to that conclusion? Are they optimists or in denial?

I'm all for adequate patient education and patients should be too. How can one have a sound decision with his own health without knowing what needs to be known?

Screening adds reassurance and peace of mind whatever the result may be. But to others the waiting and the result may not give them the answer they want or expecting. To some, after learning of their fairly normal or healthy status finds it as an excuse to go on with their unhealthy vices instead of changing lifestyle.

Health screening is a good way to assess one's health status. If one can afford it, I'd say go for it. If not it is understandable, but it would not hurt to at least consult a health provider to be educated and to make an informed decision.

Karen-Dorthe Bach Nielsen; Lise Dyhr; Torsten Lauritzen; Kirsti Malterud. (2009). “Couldn't you have done just as well without the screening?”
A qualitative study of benefits from screening as perceived by people without a high cardiovascular risk score.
Scandinavian Journal of Primary Health Care. Retrieved June 23, 2009 from http://www.informaworld.com/smpp/section?content=a909304659&fulltext=713240928

Health screening refers to a test or exam done to find a condition before symptoms begin. Screening tests may help find diseases or conditions early, when they are easier to treat. Some conditions that doctors commonly screen for include

* Breast cancer and cervical cancer in women
* Colorectal cancer
* Diabetes
* High blood pressure
* High cholesterol
* Osteoporosis
* Prostate cancer in men

Health screening is beneficial to human’s health because it is one way of preventing any disease or conditions before it could destroy our body. As the quote says “ prevention is better than cure”. But health as healthcare professionals we can not force any clients to undergo this process because they have their right to autonomy and that their decisions are more important than ours.

Decisions could better talked over with the client and the healthcare professional, because clear communication between the client and the healthcare professional is key to quality health care.


References:

1. Foundation for health in Aging “ Talking to your healthcare providers”. Retrieved June 23, 2009 from http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch
2.http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&query=health+screening&x=0&y=0

A screening test is a test for a particular disease given to patients who have no symptoms. Screening tests are generally cheap; they are designed to be sensitive, but not as specific. Additionally, the disease or diseases being screened for are uncommon in the general population of patients who receive the screening test.

Early detection will help to prevent further complications. It is always good to be pvented than cure.

I got this list from a study by Andermann and colleagues,

Wilson and Jungner classic screening criteria1
1. The condition sought should be an important health problem.
2. There should be an accepted treatment for patients with recognized disease.
3. Facilities for diagnosis and treatment should be available.
4. There should be a recognizable latent or early symptomatic stage.
5. There should be a suitable test or examination.
6. The test should be acceptable to the population.
7. The natural history of the condition, including development from latent to declared disease, should be adequately understood.
8. There should be an agreed policy on whom to treat as patients.
9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
10. Case-finding should be a continuing process and not a “once and for all” project.

This is about a review of the health screening criteria over the past 40 years, where a lot of factors really affects the screening practices of every individial.

Synthesis of emerging screening criteria proposed over the past 40 years
The screening programme should respond to a recognized need.
The objectives of screening should be defined at the outset.
There should be a defined target population.
There should be scientific evidence of screening programme effectiveness.
The programme should integrate education, testing, clinical services and programme management.
There should be quality assurance, with mechanisms to minimize potential risks of screening.
The programme should ensure informed choice, confidentiality and respect for autonomy.
The programme should promote equity and access to screening for the entire target population.
Programme evaluation should be planned from the outset.
The overall benefits of screening should outweigh the harm.

Over the years battle regarding health screening programs are present. Nvertheless, political debate also happens, in this very serious matter.
In another study I had read by Patel and colleagues says that with the utilization of targeted and systematic approach, ethnic people really have a demand regarding health care services from a primary to secondary level. And further work should be done to achieve optimum level of health screening among these ndividuals.

References:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2647421&tool=pmcentrez
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2222625&tool=pmcentrez