Implementing radical cure diagnostics for malaria: user perspectives on G6PD testing in Bangladesh

BACKGROUND

The radical cure of Plasmodium vivax requires treatment with an 8-aminoquinoline drug, such as primaquine and tafenoquine, to eradicate liver hypnozoite stages, which can reactivate to cause relapsing infections. Safe treatment regimens require prior screening of patients for glucose-6-phosphate dehydrogenase (G6PD) deficiency to avoid potential life-threatening drug induced haemolysis. Testing is rarely available in malaria endemic countries, but will be needed to support routine use of radical cure. This study investigates end-user perspectives in Bangladesh on the introduction of a quantitative G6PD test (SD Biosensor STANDARD™ G6PD analyser) to support malaria elimination.

METHODS

The perspectives of users on the SD Biosensor test were analysed using semi-structured interviews and focus group discussions with health care providers and malaria programme officers in Bangladesh. Key emerging themes regarding the feasibility of introducing this test into routine practice, including perceived barriers, were analysed.

RESULTS

In total 63 participants were interviewed. Participants emphasized the life-saving potential of the biosensor, but raised concerns including the impact of limited staff time, high workload and some technical aspects of the device. Participants highlighted that there are both too few and too many P. vivax patients to implement G6PD testing owing to challenges of funding, workload and complex testing infrastructure. Implementing the biosensor would require flexibility and improvisation to deal with remote sites, overcoming a low index of suspicion and mutual interplay of declining patient numbers and reluctance to test. This approach would generate new forms of evidence to justify introduction in policy and carefully consider questions of deployment given declining patient numbers.

CONCLUSIONS

The results of the study show that, in an elimination context, the importance of malaria needs to be maintained for both policy makers and the affected communities, in this case by ensuring P. vivax, PQ treatment, and G6PD deficiency remain visible. Availability of new technologies, such as the biosensor, will fuel ongoing debates about priorities for allocating resources that must be adapted to a constantly evolving target. Technical and logistical concerns regarding the biosensor should be addressed by future product designs, adequate training, strengthened supply chains, and careful planning of communication, advocacy and staff interactions at all health system levels.

A Multinational European Study of Patient Preferences for Novel Diagnostics to Manage Antimicrobial Resistance

BACKGROUND

Novel diagnostics are needed to manage antimicrobial resistance (AMR). Patient preferences are important in determining whether diagnostic tests are successful in practice, but there are few data describing the test attributes which matter most to patients. We elicited patients' preferences for attributes of diagnostic tests that could be used to reduce unnecessary antibiotic use in primary care across seven European countries.

METHODS

We used an online stated preference survey, including a discrete choice experiment (DCE). The DCE explored how patients make trade-offs between three key attributes of diagnostic tests: the speed that results were available, confidence in the test results, and how convenient it is to take the test. Individuals were eligible to complete the survey if they had taken antibiotics within the last 2 years and were resident in Germany, Italy, Spain, France, Greece, the Netherlands or the United Kingdom (UK).

RESULTS

In total, 988 respondents completed the survey. The DCE responses illustrated that speed was the least important attribute in most countries. Responses from Germany and the Netherlands indicated that confidence was most important in these countries. Responses from the UK, France, Spain and Italy showed convenience as the most important attribute in these countries. Two attributes, confidence and convenience, were jointly favoured by respondents in Greece.

CONCLUSION

Patients in different European countries do not have the same preferences for the attributes of diagnostic tests to manage AMR in primary care. Failure to account for such differences during test development could reduce test uptake, result in continued overuse of antibiotics, and hamper marketisation.

[Inapparent charges for the assistance to nephropathic patient on dialysis]

The increasing technological effectiveness has undoubtedly produced an improvement in clinical parameters of dialysis patients, but this satisfactory therapeutic result did not follow an adequate improvement in mortality or in the perception of quality of life as per patients. Furthermore, dialysis treatment is often associated with "inapparent charges" that reduce the perception of well-being, independently of clinical changes. Thirty years ago, we carried out a national survey on inapparent charges, which represent frustrating aspects that negatively affect patients' perception of their quality of life. Thirty years later, it seemed important for us to repeat the survey to understand if Italian legislative remodeling have introduced changes in procedures and social aspects of dialysis, as preservation of quality of life is an important aspect of the replacement treatment.

"We'll call you when the results are in": Preferences for how medical test results are delivered

OBJECTIVE

Whether healthy or sick, adults undergo frequent medical testing; however, no guidelines currently exist as to how patients are informed of their medical test results. This short report provides an initial look at how healthcare professionals deliver medical test results and patient preferences regarding these procedures.

METHODS

We specifically focus on two options for delivery of results: (1) open-ended timing, in which patients are contacted without warning when test results become available; or (2) closed-ended timing, in which patients are provided with a specific day and time when they will learn their test results. Participants who underwent a recent medical test indicated which delivery method their healthcare professional provided and their preferred method.

RESULTS

Findings demonstrate a large discrepancy between actual and preferred timing, stemming from a general trend towards providing open-ended timing, whereas patient preferences were evenly split between the two options.

CONCLUSION

This study provides a first step in understanding the merits of two options for delivering medical test results to patients and suggests an opportunity to improve patient care.

PRACTICE IMPLICATIONS

The findings from this study provide first steps toward the development of guidelines for delivering test results in ways that maximize the quality of patient care.

Does the Centers for Disease Control and Prevention's Recommendation of Opt-Out HIV Screening Impact the Effect of Stigma on HIV Test Acceptance?

HIV/AIDS-related stigma is a key factor impeding patient utilization of HIV testing services. To destigmatize HIV testing, the Centers for Disease Control and Prevention recommended an 'opt-out' screening strategy aimed at all patients in all clinical settings, regardless of HIV risk. This study assessed whether opt-out screening as compared to opt-in screening was associated with increased uptake of HIV testing among patients with HIV/AIDS-related stigma concerns. This study included 374 patients attending two Los Angeles ambulatory care clinics. Stigma items were grouped into three constructs: Blame/isolation, abandonment, and contagion. Individuals endorsing the blame/isolation subscale (AOR = 0.52; 95 % CI 0.29-0.92; p\0.05) and abandonment subscale (AOR = 0.27; 95 % CI 0.13-0.59; p\0.01) were significantly less likely to accept an HIV test. Additionally, the opt-out model did not counter the negative effects of stigma on HIV test acceptance. These findings indicate that stigma remains a barrier to HIV testing, regardless of the opt-out screening approach.

Brief Report: Relationship and Demographic Factors Associated With Willingness to Use an In-Home Rapid HIV Test to Screen Potential Sex Partners Among a US Sample of HIV-Negative and HIV-Discordant Male Couples

With dyadic data from a US Internet sample of 275 HIV-negative and 58 discordant male couples, we assessed HIV-negative partnered men's attitudes toward using an in-home rapid HIV test (HT) to screen potential new sex partners and associated factors by multivariate multilevel modeling. HIV-negative partnered men were "likely" to use an HT for screening purposes. More positive attitudes were associated with being in a mixed/nonwhite relationship; having an open sexual agreement. Less positive attitudes were associated with both partners being well educated. These findings may highlight how to make the most of HTs as risk-reduction screening tool among at-risk male couples.

HIV-negative partnered men's attitudes toward using an in-home rapid HIV test and associated factors among a sample of US HIV-Negative and HIV-discordant male couples

BACKGROUND

Many men who have sex with men acquire HIV while in a same-sex relationship. Studies with gay male couples have demonstrated that relationship characteristics and testing behaviors are important to examine for HIV prevention. Recently, an in-home rapid HIV test (HT) has become available for purchase in the United States. However, HIV-negative partnered men's attitudes toward using an HT and whether characteristics of their relationship affect their use of HTs remain largely unknown. This information is relevant for the development of HIV prevention interventions targeting at-risk HIV-negative and HIV-discordant male couples.

METHODS

To assess HIV-negative partnered men's attitudes and associated factors toward using an HT, a cross-sectional Internet-based survey was used to collect dyadic data from a national sample of 275 HIV-negative and 58 HIV-discordant gay male couples. Multivariate multilevel modeling was used to identify behavioral and relationship factors associated with 631 HIV-negative partnered men's attitudes toward using an HT.

RESULTS

HIV-negative partnered men were "very likely" to use an HT. More positive attitudes toward using an HT were associated with being in a relationship of mixed or nonwhite race and with one or both men recently having had sex with a casual male partner. Less positive attitudes toward using an HT were associated with both partners being well educated, with greater resources (investment size) in the relationship, and with one or both men having a primary care provider.

CONCLUSIONS

These findings may be used to help improve testing rates via promotion of HTs among gay male couples.

Validation of a clinically useful measure of children's state anxiety before medical procedures

PURPOSE

Assessment of children's anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Children's Anxiety Meter-State (CAM-S), a brief measure of state anxiety.

DESIGN AND METHODS

Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure.

RESULTS

Children's (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings.

PRACTICE IMPLICATIONS

Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.

Using picture schedules in medical settings for patients with an autism spectrum disorder

Autism is a neurobiological disorder that compromises ability to communicate and can be accompanied by anxiety, particularly for those in unfamiliar settings with unknown people. To improve communication, children with autism often relate well to pictures; however the literature describes no studies of picture schedules for patients with autism in medical settings. Our pilot project demonstrates how picture schedules for medical settings can relieve anxiety in children with autism and suggests that this approach should be employed as an innovative way to interact with patients with autism.

Willingness-to-pay for predictive tests with no immediate treatment implications: a survey of US residents

We assessed how much, if anything, people would pay for a laboratory test that predicted their future disease status. A questionnaire was administered via an internet-based survey to a random sample of adult US respondents. Each respondent answered questions about two different scenarios, each of which specified: one of four randomly selected diseases (Alzheimer's, arthritis, breast cancer, or prostate cancer); an ex ante risk of developing the disease (randomly designated 10 or 25%); and test accuracy (randomly designated perfect or 'not perfectly accurate'). Willingness-to-pay (WTP) was elicited with a double-bounded, dichotomous-choice approach. Of 1463 respondents who completed the survey, most (70-88%, depending on the scenario) were inclined to take the test. Inclination to take the test was lower for Alzheimer's and higher for prostate cancer compared with arthritis, and rose somewhat with disease prevalence and for the perfect versus imperfect test [Correction made here after initial online publication.]. Median WTP varied from $109 for the imperfect arthritis test to $263 for the perfect prostate cancer test. Respondents' preferences for predictive testing, even in the absence of direct treatment consequences, reflected health and non-health related factors, and suggests that conventional cost-effectiveness analyses may underestimate the value of testing.

The reassuring value of diagnostic tests: a systematic review

OBJECTIVE

This review is a narrative synthesis of the RCTs which studied the efficacy of using diagnostic tests to reassure patients.

METHODS

We searched for RCTs that examined the level of reassurance after diagnostic testing in outpatients. We used PubMed, Psychinfo, Cochrane Central, Ongoing Trials Database and Scopus.

RESULTS

We found 5 randomized controlled trials that included 1544 patients. The trials used different diagnostic tests (ECG, radiography of lumbar spine, MR brain scan, laboratory tests, MR of lumbar spine) for different complaints (e.g. chest pain, low back pain and headache). Four out of 5 RCTs did not find a significant reassuring value of the diagnostic tests. One study reported a reassuring effect at 3 months which had disappeared after one year.

CONCLUSION

Despite the sparse and heterogeneous studies, the results point in the direction of diagnostic tests making hardly any contribution to the level of reassurance. We recommend further studies on the use of diagnostic tests and other strategies to reassure the patient.

PRACTICE IMPLICATIONS

A clear explanation and watchful waiting can make additional diagnostic testing unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test information about normal test results.

[Procedural sedation with propofol in non-painful interventions in children]

Propofol is the sedative of choice in our hospital for all procedural sedations in children older than 3 months. Data were collected from all patients who underwent PSA with propofol in the period from November 2007 to December 2009. The procedure was performed by a paediatrician experienced in airway management, sedation and paediatric IC, and a specialized nurse. Patient characteristics, American Society of Anesthesiologists (ASA) classification, vital parameters and propofol dosage were registered on specially designed forms. Patient data were analyzed and compared with data from a non-matched historical cohort of patients who in the past had undergone PSA with chloral hydrate.

RESULTS

204 procedural sedations with intravenous propofol were performed in 196 patients. The mean cumulative induction dose was 3.39 mg/kg (SD: 1.34) and the mean maintenance dose was 4.05 mg/kg/h (SD: 2.23). The success rate was 99.5%, compared to 88.6% in the cohort that had received PSA with chloral hydrate. 1 procedure was aborted because of desaturation due to an obstructed airway, for which a jaw thrust was performed. No complications were observed in 199 procedures (97.5%). In 4 procedures a mild and transient desaturation (85-89%) occurred.

CONCLUSION

The results suggest that propofol can be used safely and is effective for procedural sedation in selected children, provided that PSA is performed by experienced and trained staff.

Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications

Conforming to a medical disease model rooted in phenomenology and natural science, psychiatry classifies mental disorders according to signs and symptoms considered to be stable and homogeneous across individuals. Scientific studies addressing the validity of this classification are scarce. Following a seminal paper by Robins and Guze in 1970, validity of categories has been sought in specific criteria referring to symptoms and prognosis, aggregation in families, and "markers", preferentially laboratory tests. There is, however, a growing misfit between the model and empirical findings from studies putting it to the test. Diagnostic categories have not been shown to represent natural groups delineated from the normal variation or from each other. Aetiological factors (genetic and/or environmental), laboratory aberrations, and treatment effects do not respect categorical boundaries. A more adequate description of mental problems may be achieved by: 1) a clear definition of the epistemological frame in which psychiatry operates, 2) a basic rating of the severity of intra- and interpersonal dysfunctions, and 3) empirical comparisons to complementary rather than exclusive dimensions of inter-individual differences in context-specific mental functions, treatment effects, and laboratory findings. Such a pluralistic understanding of mental health problems would fit empirical models in the neurosciences and postmodern notions of subjectivity alike. It would also clarify the assessment of dysfunction and background factors in relation to the requisites for penal law exemptions or insurance policies and make them empirically testable rather than dependent on expert opinion on issues such as whether a specific dysfunction is "psychiatric", "medical", or ascribable to "personality".

Interactive, culturally sensitive education on colorectal cancer screening

BACKGROUND

Increasing colorectal cancer screening (CRCS) can have a substantial positive impact on morbidity and mortality.

OBJECTIVES

The purpose of this report is to describe the development and feasibility testing of a computer-based, theory-guided educational program designed to increase CRCS.

RESEARCH DESIGN

This mixed-methods study used focus groups and subsequent randomized controlled trial design.

SUBJECTS

Participants (N = 199) were randomized to an intervention or control group; 75% were African American; mean age was 57.36 (SD = 6.8); 71% were male.

MEASURES

Previously validated measures on knowledge, beliefs, and screening test adherence were used to establish pre- and post-intervention perceptions. Feasibility was measured by response and completion rates, and participants' perceptions of the program.

RESULTS

Before feasibility testing, the program was presented to 2 focus groups. Changes were made to the program based on discussion, leading to a visually appealing, easy to understand and navigate, self-paced program. In the RCT pilot test that followed, of the participants in the intervention group, 80% said the education helped them decide to get CRCS; 49% agreed it helped them overcome barriers; 91% agreed it was useful, 68% thought it raised new concerns about cancer, but only 30% said it made them worry about CRC; 95% agreed their doctor's office should continue giving such education, and 99% said they would inform family about the program.

CONCLUSIONS

The response rate of 83% demonstrated feasibility of conducting colorectal cancer education in the primary care setting; overall the program was well received; participants averaged 23 minutes to complete it. Participants sought no help from attending data collectors and navigated the revised touch screen program with ease. Computer-based education is feasible in primary care clinics.

"If everyone does it, it's not a big deal." Young people talk about chlamydia testing

AIMS

This study aimed to explore young people's attitudes to chlamydia testing. Data were gathered to inform the development of a clinical trial aimed at increasing chlamydia testing among 16-24 year olds.

METHODS

Four single sex focus groups were conducted with 16-24 year old males and females (n=28), and one with health professionals working with this age-group (n=7). A semi-structured interview schedule was used to discuss barriers to chlamydia testing, methods of accessing testing, communicating information about chlamydia and ideas about ways to encourage testing.

RESULTS

Reasons for not seeking testing included fear, stigma, denial of personal risk, and a lack of knowledge about chlamydia and about testing procedures. Better education and a need to 'normalise' testing were suggested as ways to increase test-uptake. Preferences for places to seek testing varied among participants, but all groups supported routinely offered chlamydia testing when visiting the doctor for other reasons. Participants also favoured the concept of home-testing.

CONCLUSIONS

Young people identified a number of barriers to chlamydia testing, as well as ways to increase testing. These findings can be used to inform the development of much needed new initiatives to control chlamydia in New Zealand.

Costs and consequences of the US Centers for Disease Control and Prevention's recommendations for opt-out HIV testing

BACKGROUND

The United States Centers for Disease Control and Prevention (CDC) recently recommended opt-out HIV testing (testing without the need for risk assessment and counseling) in all health care encounters in the US for persons 13-64 years old. However, the overall costs and consequences of these recommendations have not been estimated before. In this paper, I estimate the costs and public health impact of opt-out HIV testing relative to testing accompanied by client-centered counseling, and relative to a more targeted counseling and testing strategy.

METHODS AND FINDINGS

Basic methods of scenario and cost-effectiveness analysis were used, from a payer's perspective over a one-year time horizon. I found that for the same programmatic cost of US$864,207,288, targeted counseling and testing services (at a 1% HIV seropositivity rate) would be preferred to opt-out testing: targeted services would newly diagnose more HIV infections (188,170 versus 56,940), prevent more HIV infections (14,553 versus 3,644), and do so at a lower gross cost per infection averted (US$59,383 versus US$237,149). While the study is limited by uncertainty in some input parameter values, the findings were robust across a variety of assumptions about these parameter values (including the estimated HIV seropositivity rate in the targeted counseling and testing scenario).

CONCLUSIONS

While opt-out testing may be able to newly diagnose over 56,000 persons living with HIV in one year, abandoning client-centered counseling has real public health consequences in terms of HIV infections that could have been averted. Further, my analyses indicate that even when HIV seropositivity rates are as low as 0.3%, targeted counseling and testing performs better than opt-out testing on several key outcome variables. These analytic findings should be kept in mind as HIV counseling and testing policies are debated in the US.

Late HIV diagnosis: bad medicine and worse public health

The author discusses a new study that models the impact of the CDC's new recommendation of opt-out HIV testing in all health care encounters in the US for persons 13-64 years old.

[The increased availability of self-tests for medical analyses]

A marked increase in the availability of diagnostic tests for use at home has been observed in recent years. There are regulations concerning the development and application of these tests. The question whether the increased use of self-tests is a positive or negative development cannot be answered easily. In some cases serious diseases may be detected in people who are reluctant to consult a physician. In other cases false negative test results may delay necessary treatment. Further exploration of the use, sensitivity, specificity, benefits and harms of specific tests is warranted.

Reassuring patients about normal test results

Face to face communication strategies are effective

The clinical context and patient participation in post-diagnostic consultations

OBJECTIVE

Although patient participation is an important feature of patient-centered health care, few studies have examined how the clinical context affects patient involvement in medical encounters. This investigation examined the way patients communicate with physicians in two diverse post-diagnostic settings, post-angiogram consultations and initial lung cancer visits.

METHODS

From transcripts and audiorecordings of post-angiogram consultations (n=88) and initial lung cancer visits (n=62) within a VA hospital in the United States, three measures of patient participation were coded--number of active participation behaviors (questions, acts of assertiveness, and expressions of concern), proportion of patients' utterances in the form of active participation, and conversational involvement (ratio of patient utterances to physician plus patient utterances). Mixed linear regression procedures assessed the independent effects of the clinical setting, physicians' facilitative communication (partnership-building and supportive talk), and patients' age, education, and ethnicity on patient participation.

RESULTS

Not only was their less talk in the post-angiogram consultations compared with the lung cancer visits, heart patients also were less conversationally involved (accounted for 25% of the talk) than were lung cancer patients (45% of the talk) and their doctors used proportionally less facilitative talk than did the lung cancer physicians. In both settings, patients were more conversationally engaged when proportionally more of the physicians' talk was facilitative.

CONCLUSIONS

The clinical context has a profound effect on patient participation. However, within individual settings, physicians can increase patient involvement by using partnering and supportive communication.

PRACTICE IMPLICATIONS

Clinicians and administrators should assess clinical practices that restrict patient involvement in ways that could affect quality of decision-making.

HIV testing practices in Jamaica

OBJECTIVES

Prevention programmes often promote HIV testing as one possible strategy for combating the spread of the disease. The objectives of the present study were to examine levels of HIV testing practices in a large sample of Jamaicans and the relationships among HIV testing, sociodemographic variables and HIV-related behaviours.

METHODS

A total of 1800 persons, aged 15-49 years, were surveyed between May and August 2004 using a household-level, interviewer-administered questionnaire. The questionnaire included HIV-related knowledge, attitudinal and behavioural items. For the present analyses, data from 1558 sexually experienced persons were examined.

RESULTS

Approximately 38% of the sexually experienced sample reported a history of HIV testing. Hierarchical logistic regression analyses revealed that adults, females, persons with post-high school education and married persons were more likely to report previous HIV testing. Also, those who had attended an HIV/AIDS education workshop or discussion and those who reported knowing persons living with HIV/AIDS were more likely to report previous testing. However, HIV testing was not associated with condom use or with the number of sexual partners.

CONCLUSIONS

The lack of significant findings establishing a relationship between testing and risky sexual behaviours should not negate the importance of HIV testing. Being informed regarding personal HIV serostatus is one of the first steps in self-protection. Effective messages and programmes promoting HIV testing need to be developed and implemented in Jamaica, in order to educate people about how to assess their level of risk with respect to contracting HIV infection.

Routine HIV testing in Botswana: a population-based study on attitudes, practices, and human rights concerns

BACKGROUND

The Botswana government recently implemented a policy of routine or "opt-out" HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults.

METHODS AND FINDINGS

We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1-1.9), higher education (AOR = 2.0, 95% CI = 1.5-2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3-2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1-2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2-2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5-0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45-0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%).

CONCLUSIONS

Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

Knowledge, attitudes, and perceptions about breast cancer and breast cancer screening among Hispanic women residing in South Central Pennsylvania

The purpose of this investigation was to assess the knowledge, attitudes, and perceptions about breast cancer, and screening behaviors among Hispanic women in Pennsylvania. Eight focus groups were conducted with Hispanic women to obtain answers to the questions of interest. Results, based on content analysis, showed that cultural factors, such as family and fatalism, influence breast cancer knowledge and screening among this group. In addition, these women had some misconceptions regarding breast cancer and breast cancer detection screening. Most participants reported that they would like to receive breast cancer education in Spanish from health care providers or health educators. These results can help health professionals, including health educators, in the development of suitable breast cancer education and screening promotion programs for Hispanic women.

Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers

BACKGROUND

Current evidence does not support an annual screening physical examination for asymptomatic adults, but little is known about primary care provider (PCP) attitudes and practices regarding an annual physical examination.

METHODS

We conducted a postal survey (32 items) of attitudes and practices regarding the annual physical examination (in asymptomatic patients 18 years or older) of a random sample of PCPs (specializing in internal medicine, family practice, and obstetrics/gynecology) from 3 geographic areas (Boston, Mass; Denver, Colo; and San Diego, Calif).

RESULTS

Respondents included 783 (47%) of 1679 PCPs. Overall, 430 (65%) of 664 agreed that an annual physical examination is necessary. Three hundred ninety-three (55%) of 712 disagreed with the statement that national organizations do not recommend an annual physical examination, and 641 (88%) of 726 perform such examinations. Most PCPs agreed that an annual physical examination provides time to counsel patients about preventive health services (696/739 [94%]), improves patient-physician relationships (693/737 [94%]), and is desired by most patients (572/737 [78%]). Most also believe that an annual physical examination improves detection of subclinical illness (545/738 [74%]) and is of proven value (461/736 [63%]). Many believed that tests should be part of an annual physical examination, including mammography (44%), a lipid panel (48%), urinalysis (44%), testing of blood glucose level (46%), and complete blood cell count (39%).

CONCLUSIONS

Despite contrary evidence, most PCPs believe an annual physical examination detects subclinical illness, and many report performing unproven screening laboratory tests. Primary care providers do not appear to accept recommendations that annual physical examinations be abandoned in favor of a more selective approach to preventing health problems.

Symptom reporting by functional dyspeptics during the water load test

INTRODUCTION

Reporting of symptoms and visceral sensations in functional dyspepsia is subjective and influenced by such factors as somatization and depression. To better understand the role of these factors in symptom reporting, somatization, somatosensory amplification, alexithymia, and depression were evaluated in patients with functional dyspepsia undergoing a water load test.

METHODS

Sixty-seven controls and 103 patients with functional dyspepsia underwent a 5-min water load. Participants both recalled dyspeptic symptoms from the previous 2 wk and rated symptoms of nausea, fullness, and bloating during water load. Participants also completed the symptom checklist-90-R, somatosensory amplification scale, and the Toronto alexithymia scale.

RESULTS

Compared with controls, patients with dyspepsia had greater psychiatric distress and higher scores for somatosensory amplification and alexithymia. Patients with dyspepsia also reported fullness at significantly lower volumes of water and experienced greater symptoms during water load than controls. Receiver operator characteristics of water load volume and provoked symptoms suggested that water load (WL) volume was a better discriminator of patients with dyspepsia from controls. Patients with dyspepsia recalled significantly more symptoms in the 2 wk prior to study. Symptoms provoked during WL were not associated with measured psychiatric constructs in either controls or patients with dyspepsia whereas recalled symptoms in patients with functional dyspepsia were significantly associated with several measured psychiatric constructs.

CONCLUSIONS

Patients with functional dyspepsia report fullness at lower volumes of ingested water and develop more symptoms than do controls. Water load volume better discriminates patients with dyspepsia from controls than does symptoms provoked during water load. Provoked symptoms in dyspepsia are not associated with measured psychiatric constructs but recalled symptoms are.

Psychological costs of inadequate cervical smear test results

The purpose of the study is to investigate, for the first time, the psychological impact of an inadequate smear test result. A prospective questionnaire design was used, and the setting was a single English cervical screening laboratory. Two groups of women receiving either a normal test result (n=226) or either a first or nonconsecutive inadequate smear test result (n=180) participated. The main outcome measures included State anxiety (STAI) and concern about test result, assessed within 4 weeks of receipt of results, and attendance for a repeat cervical smear within 3 months. Compared to women with normal test results, women with inadequate smear test results had higher state anxiety (P=0.025), were more concerned about their results (P<0.001), perceived themselves to be at higher risk of cervical cancer (P=0.016), and felt less satisfied with the information they had received about their test results (P<0.001). The only predictor of attendance for a repeat smear test following an inadequate smear test result was state anxiety (P=0.011): nonattenders had higher levels of state anxiety in response to their initial test results. In conclusion, in this first study to assess the psychological impact of receiving an inadequate smear test result, we have shown that it raises state anxiety and concern to levels similar to those found in women with abnormal smear test results. Of particular concern is that anxious women are less likely to attend for a repeat smear test within the recommended time frame. Given the millions of women each year receiving this test result, research is now needed to ascertain how the anxiety associated with this result can be avoided.

Women's preferences for and views on decision-making for diagnostic tests

It is unclear whether the Control Preferences Scale (CPS) provides a suitable framework for eliciting women's preferences for involvement in decision-making about diagnostic tests. The aims of this study were to assess the appropriateness of the role label approach for eliciting preferences for decision-making about diagnostic tests and to elicit women's preferences for, and views about, decision-making for diagnostic tests. In-depth, face-to-face, semi-structured interviews were conducted with 37 women who had previously participated in a population-based telephone survey. Analysis of the interview transcripts revealed that qualitative questions may be a more sensitive methodology for eliciting preferences than the role label approach as exemplified by the CPS. The analysis identified a number of issues associated with decision-making for diagnostic tests, including defining what a decision is, the rationale for the preference and factors that influence the preferred role such as the perceived seriousness of the test and potential outcomes. The role label approach used to elicit preferences for involvement in decision-making may be too simplistic. It may not fully capture the complexity of women's thoughts about test decision-making, including how they define a decision and what factors affect their preference.

"Seeing the baby": pleasures and dilemmas of ultrasound technologies for primiparous Australian women

The practice of obstetric ultrasound scans has undergone significant expansion in the last two decades and is now a standard part of many women's antenatal care in Australia as elsewhere. This article reviews recent evidence about the value of obstetric ultrasound, summarizing debates and contradictions in research literature and practitioner guidelines. Pregnant women's interpretations of the significance of ultrasound are examined through multiple interviews with 34 study participants. We find that ultrasound has become an integral part of women's embodied experience of pregnancy, with its own pleasures and dilemmas. The increasing use of the technology has augmented the role of scientific biomedicine in the government of pregnancy. This must be understood in the light of trends toward individualized risk management in which the pregnant woman increasingly takes responsibility for the successful outcome of the pregnancy, in a context where pregnancy is discursively constructed as a risky domain of gendered experience in contemporary Australian society.

Development and validation of the EBS: a measure to assess women's experience at all stages of the breast screening process

This short report describes the systematic development and validation of the EBS (Experiences of Breast Screening) measure to assess women's experience of the breast screening process. For the NHS Breast Screening Programme to be successful attendance must be high and remain high at subsequent rounds. The aim of the EBS is to identify areas of the screening process that can be improved to achieve greater adherence to subsequent screening rounds. The EBS was developed using the available evidence, expertise of health professionals, pilot interviews and a pilot postal survey. The validity, reliability and acceptability were demonstrated from the results of a multi-centre postal survey, resulting in a final 21-item measure.

Women teaching women's health: issues in the establishment of a clinical teaching associate program for the well woman check

The impact of screening programs for cervical cancer would be increased with the greater participation of currently underscreened women. Training for medical students and doctors in the fine technical and communication skills required in breast and gynaecological examinations would improve participation by increasing the confidence and skill of doctors in raising the issue of screening, thereby making the examination a more positive experience for women. Gynaecology Teaching Associate (GTA) programs, using specially trained standardized patients, have been used in over 90% of American and Canadian medical schools for more than ten years to provide such training. Australia has been slow to adopt this teaching method. A Clinical Teaching Associates in Gynaecology program (CTA) was first established in 1996 by the Department of Obstetrics and Gynaecology at the University of Queensland, building on the Pap test program from Adelaide. Other medical schools subsequently introduced such programs and in 2000, the Department of General Practice, University of Melbourne, established a CTA program based on the Queensland program, with a grant from PapScreen Victoria. This paper describes the methods of recruitment and training of CTAs, use of CTAs in the medical course, preliminary evaluation, and ethical and other issues in the Melbourne and Queensland University programs.

Perceptions of breast and cervical cancer risk and screening among Dominicans and Puerto Ricans in Rhode Island

This study explored perceptions of cancer, risk, and screening among Dominicans and Puerto Ricans in Rhode Island. Qualitative interviews were conducted with a community-based sample of 147 adults. Perceived risks for breast cancer were predominantly associated with carelessness about health care, trauma to the breast, and breastfeeding. Cervical cancer risks were mostly attributed to carelessness about health care and sexual behaviors. A strong sense of fatalism and embarrassment coexisted with positive beliefs about check-ups and screening. Participants cited confianza (trust, confidence) in their doctor, and their doctor's provision of information and explanations, as important factors in decreasing embarrassment and increasing their likelihood of getting screened. While familiarity with mammography and Pap testing was great among participants, many did not practice sustained, regular screening, and held misconceptions about tests and screening guidelines. Respondents' perceptions of having sufficient information often did not correspond to their having the accurate information necessary to promote informed screening decisions.

Preparation of the pediatric patient

Preparing a child for a short stay in the hospital involves the evaluation of its health status and its psychological preparation but also providing clear instructions for perioperative care to its parents. The success depends on the professionalism, flexibility and teaching skills of a dedicated team.

Gay men's HIV testing behaviour in Scotland

This paper reports on the social and demographic factors associated with HIV testing in gay men in Scotland. Trained sessional research staff administered a short self-complete questionnaire to men in gay bars during January and February 1999 in Glasgow and Edinburgh, Scotland. Questionnaires were completed by 2,498 men (response rate of 77.5%). Half (1,190; 50%) reported ever having been HIV antibody tested, with men in Edinburgh more likely to report testing. Testing was associated with being older (26 years plus), higher education, reporting one unprotected anal intercourse (UAI) partner, or six or more UAI partners, in the last year, genitourinary medicine clinic service use, and lifetime experience of sexually transmitted infections. There was no relationship between HIV testing and treatment optimism, or evidence of a "post-Vancouver" effect. Over a fifth of men who said that they knew their own HIV status at last UAI had never been tested. Current testing policy needs to be challenged if there is to be an increase in the number of gay men who know their HIV status and, if tested HIV-positive, to then access antiretroviral treatments.

'Getting checked and having the test': drug injectors' perceptions of HIV testing - findings from qualitative research conducted in England

If HIV and AIDS policy initiatives are to be successful in tackling the spread of infection it is important to understand more about the ways in which people perceive HIV and AIDS. HIV testing is a policy initiative that will work when people take the test and make appropriate changes to their behaviour as a result. This paper is based on a study that used in-depth interviews and a vignette with drug injectors to explore drug injectors' perceptions of HIV risk outside and inside prison. HIV testing was an integral part of drug injectors' perceptions of risk. Three main themes emerged from the analysis of these data: first, reasons for not taking a test; second, reasons for taking a test; and third, the impact of testing upon subsequent behaviour. The paper ends with a summary and conclusions highlighting implications for future research and policy development.

Women who are recalled for further investigation for breast screening: psychological consequences 3 years after recall and factors affecting re-attendance

BACKGROUND

In 1995-1996 a study was commenced investigating the experience of 'false-positive' women, i.e. who had undergone further investigations following routine breast screening and received a clear final result. These women were found to experience significantly greater adverse psychological consequences at 1 month, 5 months and 11 months after assessment compared with women who received a clear result after the initial basic mammogram. The present study follows up these 'false-positive' women 3 years later (at 35 months) just before being invited for their next routine breast screening. It investigates the effect of the previous experience of breast screening on adverse psychological consequences reported by false-positive women at this time, and explores factors that may be associated with the current adverse psychological consequences. Factors influencing attendance for the forthcoming appointment are reported, and the non-attendance rate is monitored.

METHODS

Women who had previously completed a questionnaire 1 month, 5 months and 11 months after their last breast screening 3 years ago, were invited to complete a postal questionnaire just before being invited to attend for their next routine mammogram 3 years later. Attendance for this appointment was monitored. A brief questionnaire was sent to non-attenders to ascertain their reasons for not attending.

RESULTS

The response rate was 77 per cent (387/505). Women who, at their last routine breast screening, had received a clear result after fine needle aspiration (FNA) at assessment, after a surgical biopsy or after a 6 month early recall appointment, all suffered significantly greater adverse psychological consequences at 1 month before returning for routine breast screening 3 years later than women who had received a clear result after the initial mammogram at their last routine breast screening. They were between 1.7 and 2 times more likely to suffer psychological consequences than women who received a clear result after their last mammogram. Women who had received a clear result at assessment without undergoing FNA reported higher psychological consequences than those who received a clear result after mammography, but the difference was not significant (relative risk 1.28, 95 per cent confidence interval 0.82-2.00). Fifteen per cent of those who had undergone assessment 3 years earlier did not attend their next routine breast screening appointment compared with 8 per cent of those who received a clear result after mammography (p = 0.035). Factors associated with adverse psychological consequences are reported.

CONCLUSION

Despite having received a final clear result during their previous routine breast screening 3 years ago, women who had undergone FNA, surgical biopsy or been placed on early recall suffered significantly greater adverse psychological consequences at 1 month before their next routine breast screening appointment than women who had received a clear result after their initial mammogram at their last routine breast screening. Having undergone further investigations did not necessarily motivate women to attend for their next routine appointment, with 15 per cent of these women not returning for routine screening 3 years on.

"It's just part of being a woman": cervical screening, the body and femininity

This paper explores the importance of cervical screening discourses in framing women's perceptions of femininity. In-depth interviews with 35 women -- which focused on experiences of, and feelings about, cervical screening -- highlighted how medical discourses embedded within the cervical screening programme shape the feelings of normalcy and sense of obligation associated with having smear tests. With the introduction of the invitation based call and re-call programme in the UK, cervical screening has moved from an ad hoc system to a programme of mass surveillance and regulation of women's bodies. The paper highlights the ways in which cervical screening discourses were negotiated, accepted and resisted by the women interviewed. Possible theoretical explanations as to why cervical screening discourses have become important in framing femininity are discussed. The paper concludes by suggesting that the meaning and objective of mass screening programmes must be brought into question and reconsidered by feminists and those involved with the planning, implementation, research and use of screening services.

Knowledge, behavior, and fears concerning breast and cervical cancer among older low-income Mexican-American women

INTRODUCTION

Although recent studies have documented the low participation level of Hispanic women in cancer screening, few have examined their predisposing knowledge and attitudes concerning cancer. We documented the knowledge and fears concerning cancer of an older population of Mexican-American women and how these factors relate to screening behavior and sociodemographic characteristics.

METHODS

The data are from baseline surveys conducted before the start of a community cancer awareness and prevention program. Nine hundred twenty-three Mexican-American women were interviewed in-person about their knowledge, attitudes, and Pap smear and mammogram screening practices.

RESULTS

Knowledge and attitude about cancer varied with age, education, type of health insurance, ability to speak English, and place of birth. Women 65 years of age and older were least knowledgeable of cancer-detection methods and screening guidelines. Those with only Medicare or Medicaid knew far less even compared to uninsured women. Women who did not speak English well were more likely not to know the cancer signs and symptoms, risk factors, and screening guidelines. Women who had knowledge of guidelines and detection methods were more likely to have had a recent screening. Older Mexican-American women with more fatalistic and fearful attitudes toward cancer were less likely to have had a recent Pap smear.

CONCLUSIONS

The low screening participation among Mexican-American women may be due to their limited awareness and knowledge about breast and cervical cancer screening examinations. Our study highlights the need for wide-scale cancer screening interventions consistent with Mexican-American beliefs.

Using focus group methodology to develop breast cancer screening programs that recruit African American women

Public communication campaigns are designed to increase the number of women who receive mammograms, breast examinations, and cervical exams. However, these campaigns have failed to recruit sufficient numbers of African American women. Focus group techniques were used to provide data to develop a communication campaign that would increase the knowledge, assess the attitudes, and change behaviors of African American women, aged 40-65, about the aforementioned preventive health practices. The discussions revealed that participants distrusted "clinics" and preferred being examined by "their own" or a private physician. Results further revealed that the personal influence of opinion leaders, combined with interpersonal contacts that encourage preventive care, help influence women to participate in mammography and cervical cancer screening.

The at-risk health status and technology: a diagnostic invitation and the 'gift' of knowing

In the past two decades, the medical model has extended its jurisdiction to cover a new medical entity-the at-risk health status-which is frequently accompanied by what I call a diagnostic invitation and the 'gift' of knowing. In cases, however, where the diagnosis may only reaffirm the risk but can provide no cure, the value of the 'gift' of knowing is questioned. The at-risk health status also can: (1) develop a symbiotic relationship with diagnostic technology, (2) become an organizing principle in individual and social behavior and (3) provide new tasks for clinical medicine. The perceived cost effectiveness of preventive measures, combined with the desire to use high-technology medicine, to achieve newly expanded definitions of health make it likely that the concept of the at-risk health status will be integrated into whatever health care plan is finally enacted for the United States. In light of the possible negative, as well as positive, effects of at-risk health labelling, American society needs to establish standards for the diagnostic invitation as a gift of knowing especially when the line between prevention and overuse is not always clear.