Psychological impact of predicting individuals' risks of illness: a systematic review

Impact of being placed at risk of Creutzfeldt-Jakob disease: a qualitative study of blood donors to variant CJD cases and patients potentially surgically exposed to CJD

BACKGROUND

The study objective was to describe the emotional and behavioural responses to Creutzfeldt-Jakob disease (CJD) risk notification.

METHODS

A qualitative study using 11 participants' interviews, which were analysed thematically with Framework Analysis.

PARTICIPANTS

Six participants purposively selected from people exposed to surgical instruments used previously on patients with or at risk of CJD (any type; n = 60), and 5 participants from a cohort of blood donors to patients who subsequently developed variant CJD (n = 110).

RESULTS

Notification was initially a shocking event, but with no lasting emotional impact. Those notified were convinced they were at extremely low risk of CJD and coped by not thinking about the information. Disclosure outside the immediate family was limited by fears of stigma. All expressed concern about the possibility of onward transmission and agreed notification was appropriate. Individual adherence to public health precautions varied from those who did nothing, apart from not donating blood, to those who consistently followed all advice given. This variation was informed by an assumption that information was always shared among health professionals.

CONCLUSIONS

Factors contributing to minimising emotional distress following notification of CJD risk were evident. We found little evidence of sustained emotional distress. However, implementation of behaviours to minimise onward transmission, particularly in health care settings, was variable - this requires further investigation.

A simple risk score using routine data for predicting cardiovascular disease in primary care

BACKGROUND

Population-based screening for cardiovascular disease (CVD) risk, incorporating blood tests, is proposed in several countries.

AIM

The aim of this study was to evaluate whether a simple approach to identifying individuals at high risk of CVD using routine data might be effective.

DESIGN OF STUDY

Prospective cohort study (EPIC-Norfolk).

SETTING

Norfolk area, UK.

METHOD

A total of 21 867 men and women aged 40-74 years, who were free from CVD and diabetes at baseline, participated in the study. The discrimination (the area under the receiver operating characteristic curve [aROC]), calibration, sensitivity/specificity, and positive/negative predictive value were evaluated for different risk thresholds of the Framingham risk equations and the Cambridge diabetes risk score (as an example of a simple risk score using routine data from electronic general practice records).

RESULTS

During 203 664 person-years of follow-up, 2213 participants developed a first CVD event (10.9 per 1000 person-years). The Cambridge diabetes risk score predicted CVD events reasonably well (aROC 0.72; 95% confidence interval [CI] = 0.71 to 0.73), while the Framingham risk score had the best predictive ability (aROC 0.77; 95% CI = 0.76 to 0.78). The Framingham risk score overestimated risk of developing CVD in this representative British population by 60%.

CONCLUSION

A risk score incorporating routinely available data from GP records performed reasonably well at predicting CVD events. This suggests that it might be more efficient to use routine data as the first stage in a stepwise population screening programme to identify people at high risk of developing CVD before more time- and resource-consuming tests are used.

Who attends a UK diabetes screening programme? Findings from the ADDITION-Cambridge study

AIMS

One of the factors influencing the cost-effectiveness of population screening for Type 2 diabetes may be uptake. We examined attendance and practice- and individual-level factors influencing uptake at each stage of a diabetes screening programme in general practice.

METHODS

A stepwise screening programme was undertaken among 135, 825 people aged 40-69 years without known diabetes in 49 general practices in East England. The programme included a score based on routinely available data (age, sex, body mass index and prescribed medication) to identify those at high risk, who were offered random capillary blood glucose (RBG) and glycosylated haemoglobin tests. Those screening positive were offered fasting capillary blood glucose (FBG) and confirmatory oral glucose tolerance tests (OGTT).

RESULTS

There were 33 539 high-risk individuals invited for a RBG screening test; 24 654 (74%) attended. Ninety-four per cent attended the follow-up FBG test and 82% the diagnostic OGTT. Seventy per cent of individuals completed the screening programme. Practices with higher general practitioner staff complements and those located in more deprived areas had lower uptake for RBG and FBG tests. Male sex and a higher body mass index were associated with lower attendance for RBG testing. Older age, prescription of antihypertensive medication and a higher risk score were associated with higher attendance for FBG and RBG tests.

CONCLUSIONS

High attendance rates can be achieved by targeted stepwise screening of individuals assessed as high risk by data routinely available in general practice. Different strategies may be required to increase initial attendance, ensure completion of the screening programme, and reduce the risk that screening increases health inequalities.

Health improvement and prevention study (HIPS) - evaluation of an intervention to prevent vascular disease in general practice

Background

The Health Improvement and Prevention Study (HIPS) study aims to evaluate the capacity of general practice to identify patients at high risk for developing vascular disease and to reduce their risk of vascular disease and diabetes through behavioural interventions delivered in general practice and by the local primary care organization.

Methods/Design

HIPS is a stratified randomized controlled trial involving 30 general practices in NSW, Australia. Practices are randomly allocated to an 'intervention' or 'control' group. General practitioners (GPs) and practice nurses (PNs) are offered training in lifestyle counselling and motivational interviewing as well as practice visits and patient educational resources. Patients enrolled in the trial present for a health check in which the GP and PN provide brief lifestyle counselling based on the 5As model (ask, assess, advise, assist, and arrange) and refer high risk patients to a diet education and physical activity program. The program consists of two individual visits with a dietician or exercise physiologist and four group sessions, after which patients are followed up by the GP or PN. In each practice 160 eligible patients aged between 40 and 64 years are invited to participate in the study, with the expectation that 40 will be eligible and willing to participate. Evaluation data collection consists of (1) a practice questionnaire, (2) GP and PN questionnaires to assess preventive care attitudes and practices, (3) patient questionnaire to assess self-reported lifestyle behaviours and readiness to change, (4) physical assessment including weight, height, body mass index (BMI), waist circumference and blood pressure, (5) a fasting blood test for glucose and lipids, (6) a clinical record audit, and (7) qualitative data collection. All measures are collected at baseline and 12 months except the patient questionnaire which is also collected at 6 months. Study outcomes before and after the intervention is compared between intervention and control groups after adjusting for baseline differences and clustering at the level of the practice.

Discussion

This study will provide evidence of the effectiveness of a primary care intervention to reduce the risk of cardiovascular disease and diabetes in general practice patients. It will inform current policies and programs designed to prevent these conditions in Australian primary health care.

Trial Registration

ACTRN12607000423415

The influence of long-term awareness of hyperlipidemia and of 3 years of dietary counseling on depression, anxiety, and quality of life

OBJECTIVE

The purpose of this study is to investigate the long-term effects of participation in a cardiovascular screening program and of dietary counseling on self-reported psychosocial outcomes and health concerns.

METHODS

High-risk subjects (n=563) with hyperlipidemia from the Oslo Diet and Antismoking Study (1972-1977) were reexamined after 25 years and randomly assigned to a new 3-year prospective 2x2 factorial placebo-controlled study in 1997 of n-3 polyunsaturated fatty acids and/or dietary counseling. Hospital Anxiety and Depression Scale (HADS), Life Satisfaction Index (LSI), and a new questionnaire on health concerns and behavior in response to risk information were collected at the 25-year follow-up. Hospital Anxiety and Depression Scale and LSI were evaluated at the end of the 3-year Diet and Omega-3 Intervention Trial on atherosclerosis (DOIT) in 505 subjects.

RESULTS

Twenty-five years after the screening program, HADS-anxiety was similar to the Norwegian norms (3.3 vs. 3.5), while HADS-depression was significantly lower (3.6 vs. 4.1, P<.01). Patients reported that 25 years of awareness of hyperlipidemia had influenced health concerns through a moderate change in diet habits, some restriction in life conduct, but an improvement of the total life situation. After a novel 3-year intervention in DOIT, there was no difference between the dietary counseling and control group with regard to anxiety, depression, or life satisfaction, but HADS-anxiety increased significantly (4.0 vs. 3.3, P<.001) in both groups.

CONCLUSION

Compared to the general population, screening-positive subjects did not have increased mental distress 25 years after screening, and beneficial health behavior persisted. Dietary counseling did not affect psychosocial outcomes.

Anticipated longevity among lay people screened for cardiovascular risk factors: A cross-sectional questionnaire study

Background: In terms of mental health and quality of life previous studies have largely failed to show long-term effects of cardiovascular risk information. Such information may still have an impact of a more subtle nature. We aimed to explore the potential impact of cardiovascular risk information on lay people’s anticipations of their own longevity. Methods: In 2002 11,284 Norwegians were invited to take part in a health survey. Participants (n = 6,845) received comprehensive written information about their personal risk factors for cardiovascular disease. About six months later we selected 752 high risk and 996 low risk individuals for a cross-sectional survey. Participants were mailed a questionnaire and informed about the life expectancy for women and men in Norway. Subsequently they were asked whether they expected to live longer, shorter than or approximately as long as the mean figures. Results: The response rate was 75% (n = 1,314). Whereas 210 respondents (16%) expected to live shorter than the mean, 198 (15%) expected to live longer. In a multivariate regression model high risk of cardiovascular disease (CVD) was associated with lower anticipated longevity (odds ratio 2.4, 95% confidence interval 1.7—3.3). Other predictors of low anticipation were use of lipid lowering drugs and a family history of heart attack before the age of 60. Higher age, male sex, better education and good self-reported health were associated with high anticipations. Conclusions: A CVD risk label was only moderately associated with lay people’s anticipated longevity. The majority expected to live as long as the mean, regardless of risk status.

Using family history information to promote healthy lifestyles and prevent diseases; a discussion of the evidence

Background

A family history, reflecting genetic susceptibility as well as shared environmental and behavioral factors, is an important risk factor for common chronic multifactorial diseases such as cardiovascular diseases, type 2 diabetes and many cancers.

Discussion

The purpose of the present paper is to discuss the evidence for the use of family history as a tool for primary prevention of common chronic diseases, in particular for tailored interventions aimed at promoting healthy lifestyles. The following questions are addressed: (1) What is the value of family history information as a determinant of personal disease risk?; (2)How can family history information be used to motivate at-risk individuals to adopt and maintain healthy lifestyles in order to prevent disease?; and (3) What additional studies are needed to assess the potential value of family history information as a tool to promote a healthy lifestyle?

Summary

In addition to risk assessment, family history information can be used to personalize health messages, which are potentially more effective in promoting healthy lifestyles than standardized health messages. More research is needed on the evidence for the effectiveness of such a tool.

Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): randomised trial

OBJECTIVE

To compare the effect of an invitation promoting informed choice for screening with a standard invitation on attendance and motivation to engage in preventive action.

DESIGN

Randomised controlled trial.

SETTING

Four English general practices.

PARTICIPANTS

1272 people aged 40-69 years, at risk for diabetes, identified from practice registers using a validated risk score and invited to attend for screening.

INTERVENTION

Intervention was a previously validated invitation to inform the decision to attend screening, presenting diabetes as a serious potential problem, and providing details of possible costs and benefits of screening and treatment in text and pie charts. This was compared with a brief, standard invitation simply describing diabetes as a serious potential problem.

MAIN OUTCOME MEASURES

The primary end point was attendance for screening. The secondary outcome measures were intention to make changes to lifestyle and satisfaction with decisions made among attenders.

RESULTS

The primary end point was analysed for all 1272 participants. 55.8% (353/633) of those in the informed choice group attended for screening, compared with 57.6% (368/639) in the standard invitation group (mean difference -1.8%, 95% confidence interval -7.3% to 3.6%; P=0.51). Attendance was lower among the more deprived group (most deprived third 47.5% v least deprived third 64.3%; P<0.001). Interaction between deprivation and effect of invitation type on attendance was not significant. Among attenders, intention to change behaviour was strong and unaffected by invitation type.

CONCLUSIONS

Providing information to support choice did not adversely affect attendance for screening for diabetes. Those from more socially deprived groups were, however, less likely to attend, regardless of the type of invitation received. Further attention to invitation content alone is unlikely to achieve equity in uptake of preventive services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 73125647.

Estimating the population impact of screening strategies for identifying and treating people at high risk of cardiovascular disease: modelling study

OBJECTIVE

To estimate the potential population impact of different screening strategies for identifying and treating people at high risk of cardiovascular disease, including strategies using routine data for cardiovascular risk stratification, in light of the UK government's recommended national strategy to screen all adults aged 40-74 for cardiovascular risk.

DESIGN

Modelling study using data from a prospective cohort, EPIC-Norfolk (European Prospective Investigation of Cancer-Norfolk).

SETTING

An English county.

PARTICIPANTS

16,970 men and women aged 40-74 and free from cardiovascular disease and diabetes at baseline.

MAIN OUTCOME MEASURES

The main outcomes were the population attributable fraction, the number needed to screen to prevent one new case of cardiovascular disease, the number needed to treat to prevent one new case of cardiovascular disease, and the number of new cardiovascular events that could be prevented. Relative risk reductions for estimated treatment effects were derived from meta-analyses of clinical trials or guidelines from the National Institute for Health and Clinical Excellence.

RESULTS

1362 cardiovascular events occurred over 183 586 person years of follow-up. Compared with the recommended government strategy, a stepwise screening approach using a simple risk score incorporating routine data could prevent a similar number (lower to upper estimates) of new cardiovascular events annually in the United Kingdom (26,789, 20,778 to 36,239) and 25,134 (19,450 to 34,134), respectively) but requiring only 60% of the population to be invited to attend a vascular risk assessment. A similar number of cardiovascular events (25,016, 19,563 to 33,372) could also be prevented by inviting everyone aged 50-74 for a vascular assessment. Using a participant completed Finnish diabetes risk score questionnaire or anthropometric cut-off points for risk prestratification was less effective.

CONCLUSIONS

Compared with the UK government's recommended national strategy to screen all adults aged 40-74 for cardiovascular risk, an approach using routine data for cardiovascular risk stratification before inviting people at high risk for a vascular risk assessment may be similarly effective at preventing new cases of cardiovascular disease, with potential cost savings.

A Randomized Evaluation of Loss and Gain Frames in an Invitation to Screening for Type 2 Diabetes

A randomized controlled trial in two general practices in Cambridgeshire compared the effect of loss and gain framed messages in an invitation to screening for type 2 diabetes on uptake and subsequent anxiety and self-rated health. High risk individuals aged 40—69 years were randomized to receive loss ( n = 57) or gain ( n = 59) framed screening invitations. A postal questionnaire was sent to all participants, including non-attenders, after six weeks. There were no significant differences in attendance, mean state anxiety, self-rated health or illness representation between the loss and gain frame arms. Framing of information in diabetes screening invitations does not influence uptake.

Are people with negative diabetes screening tests falsely reassured? Parallel group cohort study embedded in the ADDITION (Cambridge) randomised controlled trial

OBJECTIVE

To assess whether receiving a negative test result at primary care based stepwise diabetes screening results in false reassurance.

DESIGN

Parallel group cohort study embedded in a randomised controlled trial.

SETTING

15 practices (10 screening, 5 control) in the ADDITION (Cambridge) trial.

PARTICIPANTS

5334 adults (aged 40-69) in the top quarter for risk of having undiagnosed type 2 diabetes (964 controls and 4370 screening attenders).

MAIN OUTCOME MEASURES

Perceived personal and comparative risk of diabetes, intentions for behavioural change, and self rated health measured after an initial random blood glucose test and at 3-6 and 12-15 months later (equivalent time points for controls).

RESULTS

A linear mixed effects model with control for clustering by practice found no significant differences between controls and people who screened negative for diabetes in perceived personal risk, behavioural intentions, or self rated health after the first appointment or at 3-6 months or 12-15 months later. After the initial test, people who screened negative reported significantly (but slightly) lower perceived comparative risk (mean difference -0.16, 95% confidence interval -0.30 to -0.02; P=0.04) than the control group at the equivalent time point; no differences were evident at 3-6 and 12-15 months.

CONCLUSIONS

A negative test result at diabetes screening does not seem to promote false reassurance, whether this is expressed as lower perceived risk, lower intentions for health related behavioural change, or higher self rated health. Implementing a widespread programme of primary care based stepwise screening for type 2 diabetes is unlikely to cause an adverse shift in the population distribution of plasma glucose and cardiovascular risk resulting from an increase in unhealthy behaviours arising from false reassurance among people who screen negative. Trial registration Current controlled trials ISRCTN99175498.

Factors influencing parental decision about genetics evaluation for their deaf or hard-of-hearing child

PURPOSE

To identify factors that are associated with why parents of deaf children who have had GJB2/GJB6 testing as part of a genetics research study do or do not take their children for genetics evaluation.

METHODS

Self-administered questionnaire was completed by parents of a deaf child participating in a GJB2/GJB6 testing study.

RESULTS

A total of 30 parents (representing 24 children) completed the questionnaire; 11 of 24 children (46%) underwent a genetics evaluation. Compared with parents who did not take their child for a genetics evaluation, those who did were more likely to (1) have supportive pediatricians, (2) feel it was important or would be helpful to their child, (3) recall the recommendation for evaluation, (4) have family members who wanted the child to have an evaluation, and (5) be Hispanic or Asian. Genetic test results, knowledge of genetics evaluation, psychosocial factors, language concerns, or structural factors were not substantively associated with attending a genetics evaluation.

CONCLUSION

Parental perceptions, family environment, and pediatricians play a role in decisions regarding genetics evaluation. Because genetic testing for deafness likely will occur outside of traditional genetics clinics and without comprehensive genetics evaluation, efforts to increase pediatricians' awareness of the usefulness of genetics evaluation may be essential to ensure appropriate care for deaf and hard-of-hearing children as recommended by the American College of Medical Genetics.

Additional patient outcomes and pathways in evaluations of testing

Before medical tests are introduced into practice, they should be properly evaluated. Randomized trials and other comprehensive evaluations of tests and test strategies can best be designed based on an understanding of how tests can benefit or harm patients. Tests primarily affect patients' health by guiding clinical decision making and downstream management, such as the decision to order more tests or to start, stop, or modify treatment. In this article, the authors demonstrate that tests can have additional effects on patient outcome, which may be cognitive, emotional, social, or behavioral. They present a framework to help researchers and policy makers consider the cognitive, emotional, social, and behavioral effects of testing. These additional effects may be important themselves and may also influence the clinical outcomes of testing through different pathways. The authors provide examples from test evaluations in the literature to illustrate how these additional effects can be important in the evaluation of testing or indeed any health intervention.

Screening for risk of cardiovascular disease is not associated with mental distress: the Inter99 study

OBJECTIVE

To analyze mental distress in relation to participation in lifestyle intervention.

METHODS

In 2000-2001 a total of 1948 consecutive participants, living in the suburbs of Copenhagen, were asked to complete a short version of SCL-90-R (anxiety, depression, and somatization) before screening, immediately after screening, and one and 10 months after screening. The screening classified participants into high or low risk individuals. High risk individuals received personal lifestyle counselling and were randomized to either group-based counselling (A) or referred care (B). Multilevel regression models taking into account repeated measurements and missing data at follow-up were performed.

RESULTS

Before screening, high risk individuals had higher scores on anxiety, depression, and somatization than low risk individuals. All categories of participants decreased in scores after screening. The scores increased after 1 month, but were still significantly lower than before screening. After 10 months, low risk individuals and high risk individuals in group A still had significantly lower scores (except for depression) compared with pre-screening levels, whereas high risk individuals in group B reached the pre-screening level (except for anxiety).

CONCLUSION

Screening for risk of cardiovascular disease followed by health counselling does not give rise to mental distress, but has a temporary beneficial effect.

Screening for type 2 diabetes is feasible, acceptable, but associated with increased short-term anxiety: a randomised controlled trial in British general practice

Background

To assess the feasibility and uptake of a diabetes screening programme; to examine the effects of invitation to diabetes screening on anxiety, self-rated health and illness perceptions.

Methods

Randomised controlled trial in two general practices in Cambridgeshire. Individuals aged 40–69 without known diabetes were identified as being at high risk of having undiagnosed type 2 diabetes using patient records and a validated risk score (n = 1,280). 355 individuals were randomised in a 2 to 1 ratio into non-invited (n = 238) and invited (n = 116) groups. A stepwise screening programme confirmed the presence or absence of diabetes. Six weeks after the last contact (either test or invitation), a questionnaire was sent to all participants, including non-attenders and those who were not originally invited. Outcome measures included attendance, anxiety (short-form Spielberger State Anxiety Inventory-STAI), self-rated health and diabetes illness perceptions.

Results

95 people (82% of those invited) attended for the initial capillary blood test. Six individuals were diagnosed with diabetes. Invited participants were more anxious than those not invited (37.6 vs. 34.1 STAI, p-value = 0.015), and those diagnosed with diabetes were considerably more anxious than those classified free of diabetes (46.7 vs. 37.0 STAI, p-value = 0.031). Non-attenders had a higher mean treatment control sub-scale (3.87 vs. 3.56, p-value = 0.016) and a lower mean emotional representation sub-scale (1.81 vs. 2.68, p-value = 0.001) than attenders. No differences in the other five illness perception sub-scales or self-rated health were found.

Conclusion

Screening for type 2 diabetes in primary care is feasible but may be associated with higher levels of short-term anxiety among invited compared with non-invited participants.

Trial registration

ISRCTN99175498

Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea

Purpose

The experience of patients with cancer often involves symptoms of fatigue, anorexia, depression, and dyspnea.

Methods

We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel.

Results

For fatigue, providers should screen patients at the initial visit, for newly identified advanced cancer, and at chemotherapy visits; assess for depression and insomnia in newly identified fatigue; and follow up after treatment for fatigue or a secondary cause. For anorexia, providers should screen at the initial visit for cancer affecting the oropharynx or gastrointestinal tract or advanced cancer, evaluate for associated symptoms, treat underlying causes, provide nutritional counseling for patients undergoing treatment that may affect nutritional intake, and follow up patients given appetite stimulants. For depression, providers should screen newly diagnosed patients, those started on chemotherapy or radiotherapy, those with newly identified advanced disease, and those expressing a desire for hastened death; document a treatment plan in diagnosed patients; and follow up response after treatment. For general dyspnea, providers should evaluate for causes of new or worsening dyspnea, treat or symptomatically manage underlying causes, follow up to evaluate treatment effectiveness, and offer opioids in advanced cancer when other treatments are unsuccessful. For dyspnea and malignant pleural effusions, providers should offer thoracentesis, follow up after thoracentesis, and offer pleurodesis or a drainage procedure for patients with reaccumulation and dyspnea.

Conclusion

These standards provide a framework for evidence-based screening, assessment, treatment, and follow-up for cancer-associated symptoms.

Laypersons' understanding of relative risk reductions: randomised cross-sectional study

Background

Despite increasing recognition of the importance of involving patients in decisions on preventive healthcare interventions, little is known about how well patients understand and utilise information provided on the relative benefits from these interventions. The aim of this study was to explore whether lay people can discriminate between preventive interventions when effectiveness is presented in terms of relative risk reduction (RRR), and whether such discrimination is influenced by presentation of baseline risk.

Methods

The study was a randomised cross-sectional interview survey of a representative sample (n = 1,519) of lay people with mean age 59 (range 40–98) years in Denmark. In addition to demographic information, respondents were asked to consider a hypothetical drug treatment to prevent heart attack. Its effectiveness was randomly presented as RRR of 10, 20, 30, 40, 50 or 60 percent, and half of the respondents were presented with quantitative information on the baseline risk of heart attack. The respondents had also been asked whether they were diagnosed with hypercholesterolemia or had experienced a heart attack.

Results

In total, 873 (58%) of the respondents consented to the hypothetical treatment. While 49% accepted the treatment when RRR = 10%, the acceptance rate was 58–60% for RRR>10. There was no significant difference in acceptance rates across respondents irrespective of whether they had been presented with quantitative information on baseline risk or not.

Conclusion

In this study, lay people's decisions about therapy were only slightly influenced by the magnitude of the effect when it was presented in terms of RRR. The results may indicate that lay people have difficulties in discriminating between levels of effectiveness when they are presented in terms of RRR.

Completing a postal health questionnaire did not affect anxiety or related measures: randomized controlled trial

OBJECTIVE

There is evidence from laboratory studies that anxiety scores are elevated by completing questionnaires about health problems for the first time. This limits interpretation of the common finding that people receiving risk information from screening programs show elevated anxiety (as assessed by questionnaire) in the short-term, which subsides over time. We examine the extent to which postal questionnaire studies are affected by this potential measurement artifact.

STUDY DESIGN AND SETTING

Participants were 964 patients at high risk of undiagnosed diabetes, registered at five general practices. A two-group randomized experimental design was used, with the experimental group (n=484) receiving an initial questionnaire concerning screening for diabetes, and the control group (n=480) not receiving this questionnaire. Outcomes were assessed by an identical questionnaire 3 months later.

RESULTS

There were no significant differences in questionnaire scores at three months between the two groups on any of the outcome measures, including anxiety, symptoms, perceptions of diabetes severity, and perceived diabetes risk.

CONCLUSION

These results suggest that the problems associated with the use of anxiety questionnaires that are found in laboratory studies do not occur in postal studies: the observed changes in anxiety after receiving screening results are therefore unlikely to be artifactual.

Critiques of the risk concept--valid or not?

The increasing use of the risk concept in healthcare has caused concern among medical doctors, especially general practitioners (GPs). Critics have claimed that risk identification and intervention create unfounded anxiety, that the concept of risk is not useful at the individual patient level, that patients' risk concept is different from an epidemiological one, that resources are better spent elsewhere, or that commercial interests take advantage of risk information to promote sales. In this paper the authors discuss the concept of risk and address the critique. There is evidence that commercial interests promote risk interventions, that patients may misunderstand risk information, and that risk information can cause unnecessary anxiety. The authors have found no empirical data on the amount of time primary healthcare providers spend on risk interventions, and have not identified any valid arguments that risk information is not useful for the individual patient. Decision-making under uncertainty is a core element of medical practice, and GPs need to be suitably trained to inform patients such that they make good decisions when they are faced with uncertainty. The concept of risk is therefore useful for GPs, and in fact a key issue. It is concluded that risk critique should be based on sound theory and empirical data. Critics may do well in making clear distinctions between facts and value judgements.

Interventions to improve risk communication in clinical genetics: systematic review

OBJECTIVE

Effective risk communication may enable clients to participate effectively in decision-making about their health and health care. A systematic review of existing literature on risk communication in genetics, and its effects on key outcomes for clients, was undertaken.

METHOD

Systematic searching of six electronic databases and data extraction from included studies; narrative synthesis of results.

RESULTS

Twenty-eight studies were included, principally from cancer genetics. Sixteen communication interventions have been evaluated, generally showing improvements in cognitive outcomes for users, such as knowledge, understanding and risk perception, and without adverse effects on anxiety, cancer-related worry and depression. However, often it was the supportive or emotional elements of counselling that provided benefits to users, rather than the informational or educational elements. Similar results were found in 12 further studies of decision aids which also appear to achieve shorter consultations that can focus more on the supportive elements of counselling.

CONCLUSION

For both communication models and decision aids, the supportive or emotional elements of counselling provided more benefits to users than the informational or educational elements.

PRACTICE IMPLICATIONS

Debate is required on how to strike a balance between the medical model, its agenda and perceived requirements to disclose or discuss a range of issues and the sometimes competing goals of addressing users' concerns, needs for support, issues of loss and relationship problems.

Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature

BACKGROUND

Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms.

METHODS

We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers.

RESULTS

11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions.

CONCLUSION

Our review provides preliminary evidence that physicians' knowledge of global CHD risk scores may translate into modestly increased prescribing of cardiovascular drugs and modest short-term reductions in CHD risk factors without clinical harm. Whether these results are replicable, and translate across other practice settings or into improved long-term CHD outcomes remains to be seen.

The impact of perceived hypertension status on anxiety and the white coat effect

BACKGROUND

The white coat effect can lead to overdiagnosis of hypertension and unnecessary pharmacologic treatment. Mechanisms underlying the white coat effect remain poorly understood but are critical to improving the accuracy of clinic blood pressure measurement.

PURPOSE

This study investigated whether perceived hypertension status was associated with state anxiety levels during a clinic visit and the magnitude of the white coat effect, independent of true blood pressure status.

METHODS

This observational study included 214 normotensive and mildly hypertensive participants who were 18 to 80 years old, had no cardiac history, and were willing to discontinue antihypertensive medications for 8 weeks. Participants underwent 36 hr ambulatory blood pressure monitoring and physician blood pressure measurement. Outcome measures were state anxiety reported during the clinic visit and the white coat effect.

RESULTS

An analysis of covariance indicated that participants who perceived themselves as hypertensive reported greater state anxiety (p<.001) and showed larger white coat effects (ps<.01) compared with those who perceived themselves as normotensive. True hypertension status based on ambulatory blood pressure was not related to either outcome. Anxiety accounted for approximately 19% of the association between perceived hypertension status and the white coat effect.

CONCLUSIONS

These findings suggest that the perception of being hypertensive is associated with greater anxiety during clinic blood pressure measurement and a larger white coat effect, independent of the true blood pressure level. Anxiety appears to be a mechanism by which perceived hypertension status contributes to the white coat effect.

Assessment of the psychological effects of genetic screening for hereditary hemochromatosis

Discovery of genetic variants of the HFE gene has made it possible to screen for hereditary hemochromatosis. However, genetic screening raises ethical, legal, social, and psychological questions, which need to be addressed. To assess the psychological impact on individuals undergoing genetic screening for hereditary hemochromatosis and to determine the effects of providing different levels of information to the participants. Male residents, aged 30-50 years (n = 10,993) were invited to a genetic screening for hereditary hemochromatosis. Carriers of the gene variants H63D, S65C, and C282Y were offered additional biochemical screening using serum ferritin and transferrin saturation. Psychological factors were evaluated through questionnaires before and after genetic and biochemical screening. According to genotype, participants were divided into three groups with different risks profiles for having/developing clinical hemochromatosis (at-risk, uncertain risk, no risk). Before completion of the questionnaires, 929 participants received only genetic information and 366 received both genetic and biochemical information. At-risk participants receiving only genetic information generally displayed negative reactions to the test result, whereas participants receiving both genetic and biochemical information were more satisfied and had fewer negative psychological reactions to the test result. Genetic screening is more readily accepted by subjects when genetic information is supported by biochemical measurements, especially in participants with a risk of clinical disease.

How risk is perceived, constructed and interpreted by clients in clinical genetics, and the effects on decision making: systematic review

As an individual's understanding of their genetic risk may influence risk management decisions, it is important to understand the ways in which risk is constructed and interpreted. We systematically reviewed the literature, undertaking a narrative synthesis of 59 studies presenting data on the ways in which individuals perceive, construct and interpret their risk, and the subsequent effects. While most studies assessed perceived risk quantitatively, the combined evidence suggests individuals find risk difficult to accurately quantify, with a tendency to overestimate. Rather than being a stand-alone concept, risk is something lived and experienced and the process of constructing risk is complex and influenced by many factors. While evidence of the effects of perceived risk is limited and inconsistent, there is some evidence to suggest high risk estimations may adversely affect health and lead to inappropriate uptake of medical surveillance and preventative measures by some individuals. A more focused approach to research is needed with greater exploration of the ways in which risk is constructed, along with the development of stronger theoretical models, to facilitate effective and patient-centered counseling strategies.

Are lifestyle changes achieved after participation in a screening programme for Type 2 diabetes? The ADDITION Study, Denmark

AIMS

To examine the impact on health-related lifestyle of conducting a targeted stepwise diabetes screening programme.

METHODS

A total of 4731 people aged 40-69 years were offered stepwise diabetes screening in part of the Danish arm of the ADDITION-study in the county of Aarhus, Denmark. The screening comprised two main steps: identification of high-risk individuals by a mailed risk score questionnaire, and subsequent testing of high-risk individuals by their general practitioner. Questionnaires on physical exercise [International Physical Activity Questionnaire (IPAQ), short form], smoking habits and alcohol consumption were mailed to the target population 1 month prior to the offer of screening, and at 12 months' follow-up. At follow-up, additional questions regarding perceived changes in dietary habits, smoking, alcohol consumption and exercise were included. Three pairs of comparison groups were analysed.

RESULTS

One year after screening, smokers who underwent further testing reduced smoking by one daily cigarette more than people at low risk of diabetes. The rate of smokers was not reduced, and the result was not confirmed by data regarding perceived change. Alcohol intake and exercise were unchanged. Data on perceived changes showed that more people undertook increased exercise in the group at low risk than in the further examined group, but this was not seen when comparing high-risk attenders with non-attenders. Dietary habits were unchanged, except that slightly more people in the group with an abnormal test result reported increase of fruit and vegetable intake and reduction of fat intake compared with the group with a normal test result.

CONCLUSION

Only minor and inconsistent impacts on lifestyle was observed 1 year after screening.

Patients' experiences of screening for type 2 diabetes: prospective qualitative study embedded in the ADDITION (Cambridge) randomised controlled trial

OBJECTIVES

To provide insight into factors that contribute to the anxiety reported in a quantitative study of the psychological effect of screening for type 2 diabetes. To explore expectations of and reactions to the screening experience of patients with positive, negative, and intermediate results.

DESIGN

Prospective qualitative interview study of patients attending a screening programme for type 2 diabetes.

SETTING

Seven general practices in the ADDITION (Cambridge) trial in the east of England.

PARTICIPANTS

23 participants (aged 50-69) attending different stages in the screening process.

RESULTS

Participants' perceptions changed as they progressed through the screening programme; the stepwise process seemed to help them adjust psychologically. The first screening test was typically considered unimportant and was attended with no thought about its implications. By the final diagnostic test, type 2 diabetes was considered a strong possibility, albeit a "mild" form. After diagnosis, people with screen detected type 2 diabetes tended to downplay its importance and talked confidently about their plans to control it. Participants with intermediate results seemed uncertain about their diagnosis, and those who screened negative were largely unaware of their remaining high risk.

CONCLUSIONS

This study helps in understanding the limited psychological impact of screening for type 2 diabetes quantified previously, in particular by the quantitative substudy of ADDITION (Cambridge). The findings have implications for implementing such a screening programme in terms of timing and content.

Psychological impact of screening for type 2 diabetes: controlled trial and comparative study embedded in the ADDITION (Cambridge) randomised controlled trial

OBJECTIVE

To quantify the psychological impact of primary care based stepwise screening for type 2 diabetes.

DESIGN

Controlled trial and comparative study embedded in a randomised controlled trial.

SETTING

15 practices (10 screening, five control) in the ADDITION (Cambridge) trial in the east of England.

PARTICIPANTS

7380 adults (aged 40-69) in the top fourth for risk of having undiagnosed type 2 diabetes (6416 invited for screening, 964 controls).

INTERVENTIONS

Invited for screening for type 2 diabetes or not invited (controls), incorporating a comparative study of subgroups of screening attenders. Attenders completed questionnaires after a random blood glucose test and at 3-6 months and 12-15 months later. Controls were sent questionnaires at corresponding time points. Non-attenders were sent questionnaires at 3-6 months and 12-15 months.

MAIN OUTCOME MEASURES

State anxiety (Spielberger state anxiety inventory), anxiety and depression (hospital anxiety and depression scale), worry about diabetes, and self rated health.

RESULTS

No significant differences were found between the screening and control participants at any time-for example, difference in means (95% confidence intervals) for state anxiety after the initial blood glucose test was -0.53, -2.60 to 1.54, at 3-6 months was 1.51 (-0.17 to 3.20), and at 12-15 months was 0.57, -1.11 to 2.24. After the initial test, compared with participants who screened negative, those who screened positive reported significantly poorer general health (difference in means -0.19, -0.25 to -0.13), higher state anxiety (0.93, -0.02 to 1.88), higher depression (0.32, 0.08 to 0.56), and higher worry about diabetes (0.25, 0.09 to 0.41), although effect sizes were small. Small but significant trends were found for self rated health across the screening subgroups at 3-6 months (P=0.047) and for worry about diabetes across the screen negative groups at 3-6 months and 12-15 months (P=0.001).

CONCLUSIONS

Screening for type 2 diabetes has limited psychological impact on patients. Implementing a national screening programme based on the stepwise screening procedure used in the ADDITION (Cambridge) trial is unlikely to have significant consequences for patients' psychological health.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99175498 [controlled-trials.com].

[Psychological distress in applicants for genetic screening for colorectal cancer]

Introduction. The development of a DNA based diagnostic test has allowed for the genetic screening of many hereditary diseases. In addition to the identification of the deleterious gene, this screening process has led to the recognition of developing illnesses at high risk. In recent years, a number of genes predisposing to an inherited cancer syndrome have been identified.

AIM OF THE STUDY

Our purpose in this study was to determine whether subjects at risk who test for inherited colorectal cancer, are likely to develop a higher level of psychological distress than the norm, taking into consideration the particular history of this familial disease.

METHODS

The demographic and psychosocial aspects of our population was described using: 1) the State Trait Anxiety Inventory (STAI), 2) the Center for Epidemiologic Studies Depression (CES-D), 3) a perceived risk for the gene carrier, 4) subjective perception of personal vulnerability and 5) the role of the medical status (affected or not), which places the subject in either predisposition or predictive testing.

RESULTS

Results show that our population had a higher predisposition for depressive disorders (chi2=9,3. p=0.002) and a significantly higher state of anxiety (chi2=9,3. p=0.002), prior to genetic counselling, compared with other populations. We found no evidence in the medical status, nor the perceived risk. However, the assessment of one's own personal vulnerability is related to psychological distress.

DISCUSSION

These results highlight the particular vulnerability of subjects undergoing genetic testing as well as showing the pertinence of proposing psychological help throughout the process of these new specific diagnoses.

An Investigation of the Role of Non–Work-Time Behavior in Buffering the Effects of Work Strain

OBJECTIVE

In this exploratory study, we investigated the extent to which common leisure time behaviors, which generate positive feelings of fulfillment and personal reward, are significant in alleviating work-induced stress between successive work periods. We tested the hypotheses that such activities increase recovery from stress directly, and also by improving sleep quality, thereby alleviating maladaptive outcomes from work strain.

METHOD

An on-line survey study was completed by a heterogeneous sample of 314 workers in diverse occupations, in good health.

RESULTS

Non-work-time behaviors play a significant role in mediating maladaptive outcomes from work strain. Multivariate analysis of these relationships indicates both direct and indirect effects, the latter being associated with mediating sleep quality. Respondents reporting higher levels of active leisure activities, exercise, and creative (hobby) and social activity, reported significantly better sleep, recovery between work periods, and lower chronic maladaptive fatigue symptomology.

CONCLUSION

Active and fulfilling non-work-time behaviors are more significant in maximizing recovery from work strain than is commonly recognized. This effect is arguably due to the downregulation of stress-induced brain arousal, and stimulation of the pleasure-reward brain neurophysiology. Consistent recovery from work strain between work periods may represent a crucial factor in avoiding work-related "loss spirals" leading to maladaptive health outcomes, which can be particularly relevant to workers in inherently stressful occupations.

Patients' understanding of genetic susceptibility testing in mainstream medicine: qualitative study on thrombophilia

BACKGROUND

UK and US policy initiatives have suggested that, in the future, patients and clinicians in mainstream medicine could use genetic information to prevent common illnesses. There are no studies on patients' experience and understanding of the process of testing for common genetic susceptibilities in mainstream medicine.

METHODS

Qualitative interviews with 42 individuals who had undergone testing for a genetic susceptibility for deep vein thrombosis in primary and secondary care in the UK.

RESULTS

Some participants, often from higher social classes, had a good understanding of the test and its implications. They had often sought additional information on thrombophilia from relatives and from the Internet. Others, often from less privileged backgrounds, had a poorer understanding of the test--seven individuals were unaware of having had the genetic test. Features of genetic information led to misunderstandings: (i) at referral, (ii) when communicating results, and (iii) when making sense of the implications of testing. Participants' accounts indicated that non-specialist doctors may feel obliged to refer a patient for a genetic test they know little about, because a patient requests it after a relative had tested positive. Sometimes a referral for a genetic test was lost under information overload when multiple tests and issues were considered. The inconsistent and informal ways of communicating test results--for example by phone--in mainstream medicine also led to confusion. Participants did not generally overestimate their risk, but some were uncertain about whether they were taking the right preventive actions and/or whether their children were at risk. Information about genetic susceptibilities was difficult to make sense of, as it related to ambiguous risks for participants and family members, complicated and unfamiliar terminology and multiple genes and preventive strategies.

CONCLUSION

Policy visions of clinicians and patients in mainstream medicine seeking and using genetic information at their own initiative may not be realistic. Patients need more direct support in making sense of genetic information, if this information is to bring the anticipated health benefits, and not fuel health inequalities or create ethical problems. Clinicians in secondary and primary care need guidance to help them introduce genetic tests, communicate their results and explain their implications.

Uptake rates for breast cancer genetic testing: a systematic review

PURPOSE

Individuals and families dealing with the possibility of hereditary cancer risk face numerous decisions, including whether to obtain genetic testing. The purpose of this article is to determine what is known about the rate at which people obtain cancer genetic testing.

METHODS

Using MEDLINE, CINAHL, and PSYCHINFO plus reviewing reference lists of relevant articles, we identified 40 studies in May 2002 that addressed breast cancer-related decisions, enrolled adult participants, were published in 1990 or more recently, were peer-reviewed primary clinical studies, addressed genetic testing either alone or in combination with genetic counseling, and reported rates at which participants showed interest in and/or underwent cancer genetic testing. Information regarding study design, participants, and genetic testing uptake rates was recorded. Each article was reviewed for methodologic quality using a flexible quality review system applicable to all study types.

RESULTS

Of the 40 studies, 25 provided information about hypothetical genetic testing decisions, 14 about real decisions, and 1 about both. Mean hypothetical uptake was 66% (range, 20-96%) and real uptake was 59% (range, 25-96%). Multivariate logistic regression analyses found that decision type (real/hypothetical), personal and family history of breast cancer, and variability in sampling strategy, recruitment setting, and criteria for real and hypothetical uptake were independently associated with uptake. Our systematic review identified additional explanations for uptake variability (investigator influences, small sample sizes, variability in target populations, lack of clearly described sampling strategies, sampling methods open to bias, and variability in reporting associated risk factors).

CONCLUSION

In addition to clinical characteristics, research methodologic issues are likely to be major determinants of variability in published breast cancer genetic testing uptake rates. An understanding of these issues will clarify to clinicians why their clinical experience may not be congruent with published rates and help guide future research.

Psychological outcomes of patients with screen-detected type 2 diabetes: the influence of time since diagnosis and treatment intensity

OBJECTIVE

The objective of this study was to investigate how time since diagnosis and treatment intensity influence psychological outcomes in patients with screen-detected type 2 diabetes.

RESEARCH DESIGN AND METHODS

A 2 x 2 factorial cross-sectional design was used to examine psychological outcomes in 196 patients with screen-detected diabetes diagnosed 3-33 months previously who were receiving usual care or intensive multifactorial pharmacological treatment. Outcomes included anxiety, depression, diabetes-related distress, perceived seriousness and vulnerability, self-efficacy, and self-care. Multivariate analysis was used to examine variations in outcomes based on time since diagnosis (<1 vs. 2-3 years) and treatment intensity.

RESULTS

Most patients reported little distress, low perceived seriousness and vulnerability, high self-efficacy, and low self-care, but outcomes varied considerably across conditions. Time effects were found for perceived vulnerability, which increases significantly with time since diagnosis. Time x treatment interactions were found for anxiety, diabetes-related distress, and self-efficacy; notably, intensively treated patients showed more distress and less self-efficacy in the 1st year, and usual-care patients reported more distress and less self-efficacy 2-3 years after diagnosis.

CONCLUSIONS

Screen-detected patients generally do not experience much difficulty with their condition in the first few years, but early and intensive treatment can influence patients' psychological outcomes, leading to relatively more anxiety and less self-efficacy in the 1st year after diagnosis but not necessarily improving self-care. This suggests that intensive treatments confront patients with their diabetes earlier on whereas milder treatments may delay confrontation. This finding should be taken into account in the development and timing of psychological interventions for patients with newly diagnosed diabetes.

Routinely collected general practice data aids identification of people with hyperglycaemia and metabolic syndrome

AIMS

To assess the performance of a risk score comprising data routinely available in general practice records (age, gender, body mass index, family history of diabetes, smoking habits and prescribed anti-hypertensive drugs or steroids) in detecting diabetes, impaired glucose tolerance and metabolic syndrome.

METHODS

In a population-based, cross-sectional study in a semi-rural general practice in Jutland, Denmark, Cambridge Risk Scores were calculated for 1355 patients without known diabetes (69% response rate) who completed questionnaires and underwent anthropometric measurement and an oral glucose tolerance test.

RESULTS

Prevalences of diabetes, impaired glucose tolerance and metabolic syndrome were 2.29% (95% CI: 1.56-3.23), 6.64% (95% CI: 5.38-8.10) and 13.4% (95% CI: 11.5-15.2), respectively. Area under the ROC curve for the risk score and diabetes was 83.8% (75.9-91.7) and for metabolic syndrome [European Group for the Study of Insulin Resistance (EGIR)] was 78.1% (74.6-81.6). Twenty per cent of the population had a risk score above 0.246; at this threshold the sensitivity to detect diabetes was 71.0% (53.4-83.9), the specificity 81.2% (79.0-83.2), positive predictive value 8.1% (6.6-10.0) and likelihood ratio 3.77 (2.94-4.85). For metabolic syndrome (EGIR) corresponding values for sensitivity were 50.3% (43.1-57.5), specificity 84.7% (82.5-85.6), positive predictive value 33.6% (28.2-39.4), and likelihood ratio 3.28 (2.69-4.00).

CONCLUSIONS

Undiagnosed hyperglycaemia and metabolic syndrome are common. The Cambridge Risk Score is a practical first step in a screening procedure to identify individuals with these disorders who might benefit from diagnostic testing or to direct preventive interventions.

Genetic nurse counsellors can be an acceptable and cost-effective alternative to clinical geneticists for breast cancer risk genetic counselling. Evidence from two parallel randomised controlled equivalence trials

This study compared genetic nurse counsellors with standard services for breast cancer genetic risk counselling services in two regional genetics centres, in Grampian region, North East Scotland and in Cardiff, Wales. Women referred for genetic counselling were randomised to an initial genetic counselling appointment with either a genetic nurse counsellor (intervention) or a clinical geneticist (current service, control). Participants completed postal questionnaires before, immediately after the counselling episode and 6 months later to assess anxiety, general health status, perceived risk and satisfaction. A parallel economic evaluation explored factors influencing cost-effectiveness. The two concurrent randomised controlled equivalence trials were conducted and analysed separately. In the Grampian trial, 289 patients (193 intervention, 96 control) and in the Wales trial 297 patients (197 intervention and 100 control) returned a baseline questionnaire and attended their appointment. Analysis suggested at least likely equivalence in anxiety (the primary outcome) between the two arms of the trials. The cost per counselling episode was 11.54 UK pounds less for nurse-based care in the Grampian trial and 12.50 UK pounds more for nurse-based care in Cardiff. The costs were sensitive to the grade of doctor (notionally) replaced and the extent of consultant supervision required by the nurse. In conclusion, care based on genetic nurse counsellors was not significantly different from conventional cancer genetic services in both trial locations.

Predictive genetic testing in young people for adult-onset conditions: where is the empirical evidence?

Predictive genetic testing in young people for severe, adult-onset conditions is advised against in current guidelines. Despite this, there has been considerable debate regarding the issue. Some perceive such testing as too potentially harmful to allow. Others perceive it as an opportunity for the promotion of benefit, an opportunity even for the prevention of harm. The only way to resolve this theoretical debate is to collect empirical data related to the effects of such testing when it occurs. However, more than 15 years after the debate began, there is virtually no such empirical evidence available. The reasons for this lack of evidence appear to relate to the rarity of such testing, which when it occurs is not studied systematically. Additionally, clinicians performing such tests may feel vulnerable in sharing the outcomes, given that such testing is contrary to current recommendations. We propose a way forward that entails the provision of tests to mature minors, where clinicians deem this appropriate. These tests should be performed as part of an international research collaboration, facilitated by one leading group.

Supporting parents who have a child referred for genetic investigation: the contribution of health visitors

AIM

This paper reports a study of the views of health visitors in relation to their role in supporting parents of children referred for genetic investigations.

BACKGROUND

An increasing number of children are likely to be referred for genetic investigations as our understanding of genetic inheritance develops and a wider range of tests becomes available. Internationally, there are growing expectations that nurses will be able to discuss the referral and testing processes with parents, as well as facilitate informed decision-making. However, previous studies have highlighted the limited support received from staff in primary care services by parents of children referred for genetic investigation.

METHODS

A questionnaire survey of 345 health visitors was undertaken in 11 community health and social services trusts in Northern Ireland. Questionnaires were distributed at health visitor team meetings and returned in prepaid envelopes. Data collection occurred in 2003.

FINDINGS

Completed questionnaires were returned by 194 health visitors (56.2% response rate). Many were unsure of the location of their Regional Clinical Genetics Service and reported limited contact with these services. The majority of health visitors were not informed that children on their caseload had a forthcoming appointment, or that they had attended an appointment with a geneticist. Health visitors did not routinely visit parents of children referred for genetic investigation to discuss the appointment, and they reported limited confidence in supporting parents in relation to genetic investigations.

CONCLUSION

Improved communication links are needed with Regional Clinical Genetics Services and to ensure that health visitors are informed when children on their caseload have been referred for genetic investigation. In addition, steps need to be taken to increase the coordination of support to parents provided by health visitors and staff within regional genetic services.

A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation

Theory-based intervention programmes to support health-related behaviour change aim to increase health impact and improve understanding of mechanisms of behaviour change. However, the science of intervention development remains at an early stage. We present a causal modelling approach to developing complex interventions for evaluation in randomized trials. In this approach a generic model links behavioural determinants, causally through behaviour, to physiological and biochemical variables, and health outcomes. It is tailored to context, target population, behaviours and health outcomes. The development of a specific causal model based on theory and evidence is illustrated by the ProActive programme, supporting increased physical activity among individuals at risk of Type 2 diabetes. The model provides a rational guide to appropriate measures, intervention points and intervention techniques, and can be tested quantitatively. Causal modelling is critically compared to other approaches to intervention development and evaluation, and research directions are indicated.

To Test or Not To Test? Moderators of the Relationship Between Risk Perceptions and Interest in Predictive Genetic Testing

The moderating effects of motivational factors (illness prevention vs. emotional reassurance), regulatory focus (health vs. illness orientations), and cancer anxiety on the relationship between risk perceptions and women's interest in predictive genetic testing for breast cancer were studied among 102 women with no history of breast cancer. Risk perceptions per se were unrelated to testing interests. Perceptions of higher personal risk for developing breast cancer were positively related to women's interest in testing only among women whose dominant motivation was not emotional reassurance, who were not oriented towards ruling-out disease, and who were not highly anxious about breast cancer. These findings pointed to conditions under which risk perceptions may enhance screening behaviors, and other conditions under which they may not.

Psychological, Behavioral, and Interpersonal Impact of Human Papillomavirus and Pap Test Results

BACKGROUND

The purpose of this study was to explore the short-term psychological, behavioral, and interpersonal impact of human papillomavirus (HPV) and Pap results in adolescent and young adult women.

METHODS

Sexually active young women 14-21 years of age were recruited using a purposeful sampling strategy from a hospital-based teen health center. Participants underwent HPV DNA and Pap testing at baseline. At a follow-up visit 2 weeks later, they received test results and participated in individual interviews designed to examine the impact of test results. Interview data were analyzed using framework analysis, a qualitative analytical method.

RESULTS

The mean age of the 100 participants was 17.2 years, and 82% were black. Fifty-one percent were HPV positive, and 23% had abnormal Pap tests. Psychological responses consisted of affective reactions to abnormal results, empowerment through knowledge of results, and self-confidence to prevent future disease. Personal behavioral intentions encompassed safe sexual behaviors, partner monitoring, and return for screening. Anticipated interpersonal consequences focused on the impact of communication about test results on relationships. Psychosocial and behavioral responses were influenced by the personal meaning participants derived from HPV and Pap results (e.g., perceptions of personal risk and anticipated stigma), cognitive understanding of test results, and such factors as coping mechanisms, locus of control, and relationship quality.

CONCLUSIONS

An understanding of young women's responses to HPV and Pap test results may help guide clinical interventions designed to prevent possibly harmful psychosocial and interpersonal responses to HPV and Pap testing but promote healthy sexual behaviors and regular screening.

Living with a hereditary disease: persons with muscular dystrophy and their next of kin

This qualitative study describes conceptions and experiences of the hereditary aspect of muscular dystrophy (MD) from both the patients' and the next of kin's perspective. Different diagnoses of MD are included: dystrophia myotonica, myopathia distalis tarda hereditaria, Becker MD, facioscapulohumeral MD, limb-girdle MD, Emery-Dreifuss and undetermined proximal MD (Duchenne MD is not included). Interviews were conducted with 46 persons with MD and 36 next of kin. The interviews were subjected to inductive content analysis. Only two in each group did not spontaneously mention anything related to the fact that MD is disease with dominant or recessive inheritance. It was found that heredity has a prominent place in the thoughts and feelings of the family. These thoughts were classified as Becoming aware of MD and its hereditary nature, looking into the pedigree, acquiring an understanding of MD, thoughts about genetic testing, interpreting the risk, whether to have children or not, feelings related to the future, and feelings of responsibility and guilt. Families with MD need medical information and the opportunity for genetic testing as well as support and counseling in coming to terms with living with a hereditary disease, whether or not that includes a decision to take a test.

The psychological impact of human papillomavirus testing in women with borderline or mildly dyskaryotic cervical smear test results: 6-month follow-up

State anxiety (S-STAI-6), distress (GHQ-12), concern and quality of life (EuroQoL-EQ-5D) 6 months after human papillomavirus (HPV) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospective questionnaire study, with 6-month follow-up after the smear test result. Two centres participated in an English pilot study of HPV testing. Participants included two groups of women receiving abnormal smear test results: (tested for HPV and found to be (a) HPV positive (n=369) or (b) HPV negative (n=252)) and two groups not tested for HPV (those receiving (c) abnormal smear test results (n=102) or (d) normal smear test results (n=288)). There were no differences in anxiety, distress or health-related quality of life between the four study groups at 6 months. Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result, and were highest in the group untested for HPV. Predictors of concern across all groups receiving an abnormal smear test were perceived risk of developing cancer, being HPV positive or untested for HPV, sexual health worries and the smear being a woman's first smear test. The raised anxiety and distress observed in women immediately after being informed of an abnormal smear test result and that they are HPV positive was no longer evident at 6 months. Concern about the smear test result was however still raised in these women and those who tested negative for HPV, and particularly among those who did not undergo HPV testing.

Poorer self assessed health in a prospective study of men with screen detected abdominal aortic aneurysm: a predictor or a consequence of screening outcome?

STUDY OBJECTIVES

To assess the extent to which poorer self assessed health in men in whom an abdominal aortic aneurysm (AAA) is detected at screening is a consequence or a predictor of screening outcome.

DESIGN

Prospective study.

SETTING

Community based screening.

PARTICIPANTS

23 654 men who attended for AAA screening as part of the UK multicentre aneurysm screening study completed a measure of self assessed health before screening. A total of 1156 had an aneurysm detected. A sub-sample of screened men (571 with an aneurysm and 609 with a normal aorta) also completed the measure of self assessed health six weeks after screening.

MAIN RESULTS

Men in whom an aneurysm was detected at screening perceived their health to be poorer before screening than those with a normal aorta. Adjusting for risk factors for AAA made no difference to this

RESULT

self assessed health remained a strong predictor of having an aneurysm (odds ratio 1.7 comparing the extreme quartiles of self assessed health, 95% confidence intervals: 1.4 to 2.0). Men with an aneurysm also perceived their health to be poorer after screening had detected their aneurysms, but only to an extent in line with their pre-screening perceptions.

CONCLUSIONS

Self assessed health seems to predict having an aortic aneurysm, independently of known risk factors. This emphasises the importance of assessing baseline perceptions of health to prevent erroneously inferring that poorer self assessed health in those who screen positive is a consequence as compared with a predictor of screening outcome.

Fetal fibronectin test predicts delivery before 30 weeks of gestation in high risk women, but increases anxiety

OBJECTIVE

To assess efficacy of cervico-vaginal fetal fibronectin as a predictor of spontaneous preterm birth in a high risk antenatal population, and to evaluate the psychological impact of fetal fibronectin testing.

DESIGN

An observational study.

SETTING

The antenatal clinic at a tertiary referral hospital.

POPULATION

One hundred and forty-six pregnant women with known risk factors for spontaneous preterm birth.

METHODS

Women designated as 'at risk' for preterm delivery by clinical history were screened for fetal fibronectin at 24 and again at 27 weeks of gestation. Anxiety levels were assessed by questionnaire and compared with anxiety levels of 206 low risk women also tested for fetal fibronectin. Fetal fibronectin results were disclosed to the woman and her clinician.

MAIN OUTCOME MEASURES

Maternal anxiety and efficacy of the 24-week fetal fibronectin test to predict delivery before 30, 34 and 37 weeks of gestation.

RESULTS

Maternal anxiety was higher pretesting in those at high risk compared with low risk women undergoing the test. Among the high risk women, anxiety was raised to clinically significant levels in those receiving a positive fetal fibronectin screening test result. In all women, 5%, 9% and 21% delivered <30, <34 or <37 weeks of gestation, respectively. Nine percent (n= 13) tested positive for fetal fibronectin at 24 weeks. Predictive power for fetal fibronectin (24 weeks) was greatest for delivery <30 weeks of gestation, with a likelihood ratio of 15 for a positive test (6/13 positive women delivered before 30 weeks).

CONCLUSIONS

Fetal fibronectin was most efficient as a predictor of preterm spontaneous delivery <30 weeks of gestation, but was associated with high levels of anxiety.

The Finnmark Intervention Study: do community-based intervention programmes threaten self-rated health and well-being? Experiences from Båtsfjord, a fishing village in North Norway

AIM

Examine negative side-effects on self-rated health and well-being of a community-based intervention in a fishing community in the Norwegian Arctic.

METHOD

A cohort study with quasi-experimental design with one intervention community and three control communities from the same area. There was a baseline screening (1987), three years intervention (1988-1991) and a rescreening (1993). Of the invited (aged 20-62 years in 1987), 668 (64%) males and 656 (72%) females met at both screenings. The main outcome variables were self-rated health, mental health variables, and preoccupation with health. Those answering the relevant questions at both screenings were analysed. High-risk and low-risk males were analysed separately. There were too few females in the high-risk group to do separate analyses.

RESULTS

The main findings among the low-risk group were: Males in Batsfjord did not differ from males in the control communities. Among females, there was a reduction in the proportion depressed of 20.4% points in Batsfjord and 9.6% in the control communities (p adjusted=0.060). There was also a decrease in the proportion lonely of 19.2% points and 5.8% respectively (p adjusted=0.005). In the male high-risk group there was a decrease in the proportion lonely by 14.7% points in Batsfjord and an increase by 5.9% in the control communities (p adjusted=0.004).

CONCLUSION

We have not found that an intervention programme using local empowerment, mass strategies, and intervention on high-risk cases has serious negative side effects on self-rated health, well-being or preoccupation with health.

The Effect of Experiential Knowledge on Construction of Risk Perception in Hereditary Breast/Ovarian Cancer

The purpose of this study was to explore the connection between experiential knowledge of hereditary breast/ovarian cancer and understandings of personal cancer risk. Using a qualitative research design, the investigator conducted in-depth interviews with 53 individuals (45 female, 8 male) from families at high-risk for hereditary breast/ovarian cancer. Study results showed that two forms of experiential knowledge, empathetic and embodied knowledge, were integral to participants' constructions of their cancer risk. They also illustrated that knowledge derived from experience often took precedence over objective clinical estimates of risk. The paper discusses the clinical implications of these findings and suggests that counseling strategies, which expand upon patient's lived experience and knowledge of the disease, may enhance communication of genetic risk. Assessment of experiential knowledge promises to suggest new ways to frame genetic information that will enable people to better understand their objective risk or to modify exaggerated and/or inaccurate risk perceptions.

TRAF4 functions as an intermediate of GITR-induced NF-kappaB activation

Members of the tumor necrosis factor receptor (TNFR) family regulate the activation, differentiation, and function of many cell types, including cells of the immune system. TNFR-associated factors (TRAFs) function as adapter molecules controlling signaling pathways triggered by TNFR family members, such as activation of nuclear factor kappaB (NF-kappaB). Despite intensive research, the function of TRAF4 in signaling pathways triggered by TNFR-related proteins remains enigmatic. Intriguingly, our functional studies indicated that TRAF4 augments NF-kappaB activation triggered by glucocorticoid-induced TNFR (GITR), a receptor expressed on T cells, B cells, and macrophages. Further analyses revealed that TRAF4-mediated NF-kappaB activation downstream of GITR depends on a previously mapped TRAF-binding site in the cytoplasmic domain of the receptor and is inhibited by the cytoplasmic protein A20. GITR is thought to inhibit the suppressive function of regulatory T cells (Treg cells) and to promote activation of T cells. Taken together, our studies provide the first indications that TRAF4 elaborates GITR signaling and suggest that TRAF4 can modulate the suppressive functions of Treg cells.