The debates

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in Bedfordshire and aimed to evaluate the effectiveness of health checks by nurses in
general practice in reducing risk factors for cardiovascular disease. All subjects received
an initial health check and the intervention group received an additional follow-up
health check after one year (further results were also collected for subjects over a fouryear period). The health checks involved the nurse recording information about personal
and family history of heart disease, stroke, hypertension, diabetes and cancer. Information about smoking history, alcohol consumption and habitual diet, height, weight,
serum cholesterol concentration and blood pressure was also recorded. The nurses were
also instructed to counsel patients about risk factors and to negotiate priorities and
targets for risk reduction. The re-examination was briefer than the original health check
but it involved re-measurement of the same profile and lifestyle factors. The results
showed a lower cholesterol level (by 2.3 per cent) in the intervention group than the
control group, lower systolic (2.5 per cent) and diastolic (2.4 per cent) blood pressure,
and no differences in body mass index, or smoking prevalence or quit rates. The authors
concluded that using health checks to reduce smoking may be ineffective as the
effectiveness of health information may be diluted if the health check attempts to change
too many risk factors at once. They suggested that the reduction in blood pressure
was probably due to an accommodation effect, suggesting that the health checks were
ineffective. Muir et al. (1994: 312) also concluded that, although the health checks did
appear to reduce serum cholesterol concentration, ‘it is disappointing that the difference
. . . was smaller in men than in women in view of the greater effect of cholesterol
concentration on absolute risk in men’ and they questioned whether such a shift in
concentration could be sustained in the long term in the light of a previous trial
in Oxfordshire. Therefore, although the results of the OXCHECK study suggested some
reduction in risk factors for cardiovascular disease, the authors were fairly pessimistic in
their presentation of these reductions.
Both of the above studies suggested that screening and minimal interventions are
not cost-effective, as the possible benefits are not worthy of the amount of time and
money needed to implement the programmes.
The effects of screening on the psychological state of
the individual
The third problem with screening concerns its impact on the individual’s psychological
state.
The debates
Early evaluations of screening included an assessment of screening outcome in terms
of the patients’ understanding and recall of their diagnosis, not in terms of possible
negative consequences (Sibinga and Friedman 1971; Reynolds et al. 1974). Recent discussions of the effects of screening, however, have increasingly emphasized negative
consequences. McCormick (1989), in a discussion of the consequences of screening,
suggested that ‘false positive smears in healthy women cause distress and anxiety
that may never be fully allayed’ (McCormick 1989: 208). Grimes (1988) stated that
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‘Promotion of health inevitably results in the awareness of sickness’ and suggested that
screening results in introspection. Skrabanek (1988) specifically expressed an awareness
of the negative consequences of screening in his statement that ‘the hazards of screening
are undisputed: they include false positives leading to unnecessary investigations
and treatments, with resulting iatrogenic morbidity both physical and psychological’
(Skrabanek 1988: 1156). He was supported by Marteau (1989), who commented that
‘a positive result in any screening test is invariably received with negative feelings’.
The research: the psychological impact of screening
The negative sequelae of screening have been described as ‘the intangible costs’
(Kinlay 1988) but research suggests that they are indeed experienced by the individuals
involved. These psychological sequelae can be a result of the various different stages of
the screening process:
1 The receipt of a screening invitation.
2 The receipt of a negative result.
3 The receipt of a positive result.
4 The effect of any subsequent interventions.
5 The existence of a screening programme.
1 The receipt of a screening invitation. Research indicates that sending out invitations to enter into a screening programme may not only influence an individual’s
behaviour, but also their psychological state. Fallowfield et al. (1990) carried out a
retrospective study of women’s responses to receiving a request to attend a breast
screening session. Their results showed that 55 per cent reported feeling worried
although 93 per cent were pleased. Dean et al. (1984) sent a measure of psychological morbidity to women awaiting breast screening and then followed them up six
months later. The results showed no significant increases in psychological morbidity.
However, when asked in retrospect 30 per cent said that they had become anxious
after receiving the letter of invitation. Therefore, receiving a screening invitation may
increase anxiety. However, some research suggests that this is not always the case
(Cockburn et al. 1994).
2 The receipt of a negative result. It may be assumed that receiving a negative result
would only decrease an individual’s anxiety. Most research suggests that this is
the case and that a negative result may create a sense of reassurance (Orton et al.
1991) or no change in anxiety (Dean et al. 1984; Sutton et al. 1995). Further,
Sutton (1999) in his review of the literature on receiving a negative result following
breast cancer screening concluded ‘anxiety is not a significant problem among
women who receive a negative screening result’. However, some research points
towards a relationship between a negative result and an increased level of anxiety
(Stoate 1989) or residual levels of anxiety which do not return to baseline (Baillie
et al. 2000). Further, research indicates that even following negative results some
people attend for further tests even though these tests have not been clinically recommended (e.g. Lerman et al. 2000; Michie et al. 2002). Michie et al. (2003) used
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qualitative methods to explore why negative genetic results can fail to reassure. They
interviewed nine people who had received a negative result for familial adenomatous
polyposis (FAP) which is a genetic condition and results in polyps in the bowel which
can become cancerous if not detected and removed by surgery. They argued that
people may not be reassured by a negative result for two reasons. First, they may hold
a belief about the cause of the illness that does not directly map onto the cause being
tested for. In the case of FAP, people described how they believed that it was caused by
genetics but that genetics could change. Therefore although the test indicated that
they did not have the relevant genes this may not be the case in the future. Second,
they may show a lack of faith in the test itself. For FAP, people were sceptical about the
ability of a blood test to inform about a disease which occurred in the bowel.
3 The receipt of a positive result. As expected, the receipt of a positive result can be
associated with a variety of negative emotions ranging from worry to anxiety and
shock. In 1978, Haynes et al. pointed to increased absenteeism following a diagnosis
of hypertension and suggested that the diagnosis may have caused distress. Moreover,
an abnormal cervical smear may generate anxiety, morbidity and even terror
(Campion et al. 1988; Nathoo 1988; Wilkinson et al. 1990). Psychological costs
have also been reported after screening for coronary heart disease (Stoate 1989),
breast cancer (Fallowfield et al. 1990) and genetic diseases (Marteau et al. 1992).
In addition, levels of depression have been found to be higher in those labelled as
hypertensive (Bloom and Monterossa 1981). However, some research suggests that
these psychological changes may only be maintained in the short term (Reelick et al.
1984). This decay in the psychological consequences has been particularly shown
with the termination of pregnancy following the detection of foetal abnormalities
(Black 1989).
4 The psychological effects of subsequent interventions. Although screening is
aimed at detecting illness at an asymptomatic stage of development and subsequently
delaying or averting its development, not all individuals identified as being ‘at risk’
receive treatment. In addition, not all of those identified as being ‘at risk’ will develop
the illness. The literature concerning cervical cancer has debated the efficacy of
treating those individuals identified by cervical screening as ‘at risk’ and has
addressed the possible consequence of this treatment. Duncan (1992) produced a
report on NHS guidelines concerning the management of positive cervical smears.
This suggested that all women with more severe cytological abnormalities should be
referred for colposcopy, whilst others with milder abnormalities should be monitored
by repeat cervical smears. Shafi (1994) suggests that it is important to consider the
psychological impact of referral and treatment and that this impact may be greater
than the risk of serious disease. However, Soutter and Fletcher (1994) suggest that
there is evidence of a progression from mild abnormalities to invasive cervical
cancer and that these women should also be directly referred for a colposcopy. This
suggestion has been further supported by the results of a prospective study of 902
women presenting with mild or moderate abnormalities for the first time (Flannelly
et al. 1994). A study carried out in 1993 examined the effects of a diagnosis of
pre-cancerous changes of the cervix on the psychological state of a group of women
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