The prospect of predictive testing for personal risk: attitudes and decision making

Shared decision-making, health choices and the menopause

Summary

The growing influence of the mass media on public understanding of health care matters has increased both information and misinformation in patients seeking help with menopausal symptoms. The use of shared decision-making strategies provides the opportunity to engage the patient in taking some responsibility for their own treatment. It also allows the identification and correction of any distortions in the perceived balance of evidence for and against any particular treatment. Shared decision-making balances the need to respect patients’ values and autonomy with the drive towards evidence-based medicine and clinical cost-effectiveness. Although ways of achieving such a balance are much discussed, the current need is for research which can identify effective strategies that allow the principles of “shared decision-making” and “evidence-based patient choice” to be validated and applied in clinical practice. Previous research focused on hormone replacement therapy indicates that the patient's decision is the outcome of the way they balance the pros and cons of taking (or not taking) it, and that their satisfaction with the decision is strongly associated with the perception that they have been given information about the full range of treatment available. It therefore seems likely that patients will respond more positively to consultations which include discussion of hormone replacement therapy alongside alternative strategies such as natural remedies and dietary/lifestyle changes. Psychological factors influencing treatment choice and the decision making process are discussed, and clinical and research implications for clinical practice in the menopause clinic examined.

Lay Attitudes toward Genetic Testing for Susceptibility to Inherited Diseases

One of the most important issues facing legal and medical policy makers in the coming years will be whether to employ populationbased testing for genetic markers of inherited diseases. Two hundred and twenty-six randomly selected individuals from Easton, Pennsylvania completed a mail questionnaire that was designed to assess the general public’s attitudes toward many of the personal and societal issues surrounding genetic testing for disease susceptibility. Respondents were generally optimistic about the potential benefits of genetic testing, and their attitudes about genetic testing were associated with their personal interest in getting a genetic test. Respondents were more likely to be interested in undergoing genetic testing for disease susceptibility if they might have some control over the targeted disease (i.e. there was a cure) and if the test was highly predictive of their chances of developing the disease. Respondents were wary of granting access to genetic testing results to anyone other than doctors and family members, and they did not want the government, religious leaders, or the courts involved in regulating genetic testing. These results have important implications for psychologists, genetic scientists, bioethicists, and legal scholars who are grappling with the many issues related to population-based genetic testing for inherited diseases.

Genetic Testing for Breast and Ovarian Cancer Predisposition: Cancer Burden and Responsibility

The purpose of this study was to explore experiences of cancer in the family and motivation for predictive genetic testing among women at increased risk of developing breast and/or ovarian cancer due to their family history. Fifteen women were interviewed prior to receiving their genetic test results. A grounded theory approach was adopted to analyse the interview transcripts. The findings indicated that experiences of cancer in the family play an important role in formulating beliefs about one’s own risk and motivation for predictive genetic testing. A sense of responsibility for one’s own health and the need to take action either to prevent cancer or detect cancer at as early a stage as possible, as well as a feeling of responsibility towards children and other family members was apparent. The findings raise the question of whether there is any real choice available to these women and whether there is a negative impact on family dynamics.

Factors Influencing Anticipated Decisions about Sunscreen Use

The present study examined influences on the decision-making processes relevant to sun-damage preventive behaviour, namely sunscreen use. Participants were randomly assigned to a positive, a negative or a control group and underwent two successive experimental manipulations: (1) information and (2) focus.They made pre-experimental, post-information and post-focus ratings of likelihood of using sunscreen and susceptibility to skin cancer.The results suggested that decision making changes as a function of the information present, and the information which individuals focus on at the time of decision making.The findings are described with particular emphasis on the implications for future intervention strategies.

Helping patients to reach decisions regarding their treatment: Do 'non-directive' approaches cause systematic bias?

OBJECTIVES

Many patients want help in considering medical information relevant to treatment decisions they have to make or agree to. The present research investigated whether focussing on particular issues relevant to a medical treatment decision (using an apparently non-directive procedure) could systematically bias a treatment decision.

DESIGN AND METHODS

In a randomized design, participants (community volunteers, n = 146) were given standard information about treatment of cardiac risk factors by medication (statins). There were four experimental interventions in which the participants focussed on the likely personal relevance of subsets of the information previously given (positive, negative, or mixed aspects) or on irrelevant information. Participants were asked to rate their anticipated likelihood of accepting treatment before and after the experimental intervention.

RESULTS

The rating of acceptance of treatment was significantly increased by positive focussing; negative focussing did not significantly alter the decision rating.

CONCLUSIONS

The results partially replicate similar studies in health screening decisions. Reasons for the differences in results from those obtained in screening studies are considered. It is suggested that negative focussing may have less effect in decisions in which there are few risks. Statement of contribution What is already known on this subject? Decision-making in the context of health behaviour change has been widely described, but there are few experimental studies testing hypothesised strategies. 'Non-directiveness' is often regarded as desirable because it supposedly allows exploration of the decision without influencing it. Previous studies on health screening (but not treatment) have shown that health decision outcomes can be systematically influenced by the way in which a 'non-directive' intervention is implemented. This can be accounted for by a modified subjective expected utility theory previously applied to both health screening and child vaccination decisions. What does this study add? The hypothetical decision about whether or not, in future, to take statins for elevated cholesterol levels was influenced by positive but not by negative focussing. Results were consistent with the theoretical framework. This study extends previous work on influences on the decision to undertake health screening and vaccination to treatment offered as secondary prevention. 'Non-directive' approaches to helping facilitate decisions can modify those decisions, and as such cannot be regarded as non-directive.

Bioethical issues of preventing hereditary diseases with late onset in the Sakha Republic (Yakutia)

BACKGROUND

Prenatal diagnosis of congenital and hereditary diseases is a priority for the development of medical technologies in Russia. However, there are not many published research results on bioethical issues of prenatal DNA testing.

OBJECTIVE

The main goal of the article is to describe some of the bioethical aspects of prenatal DNA diagnosis of hereditary diseases with late onset in genetic counselling practice in the Sakha Republic (Yakutia) - a far north-eastern region of Russia.

METHODS

The methods used in the research are genetic counselling, invasive chorionic villus biopsy procedures, molecular diagnosis, social and demographic characteristics of patients.

RESULTS

In 10 years, 48 (76%) pregnant women from families tainted with hereditary spinocerebellar ataxia type 1 and 15 pregnant women from families with myotonic dystrophy have applied for medical and genetic counselling in order to undergo prenatal DNA testing. The average number of applications is 7-8 per year. There are differences in prenatal genetic counselling approaches.

CONCLUSION

It is necessary to develop differentiated ethical approaches depending on the mode of inheritance, age of manifestation, and clinical polymorphism of hereditary disease.

Classifying the reasons men consider to be important in prostate-specific antigen (PSA) testing decisions: evaluating risks, lay beliefs, and informed decisions

BACKGROUND

Despite uncertainty regarding the benefits of prostate cancer screening, many men have had a prostate-specific antigen (PSA) test.

PURPOSE

This study aims to identify classes of reasons guiding men's decisions about prostate cancer screening and predict reasoning approaches by family history and prior screening behaviour.

METHODS

First-degree relatives of men with prostate cancer (n = 207) and men from the general population (n = 239) of Australia listed reasons they considered when deciding whether to have a PSA test.

RESULTS

Responses were coded into 31 distinct categories. Latent class analysis identified three classes. The evaluation of risk information cues class (20.9 %) contained a greater number of men with a family history (compared with control and overcome cancer/risk class; 52.7 %). Informed decisions and health system class (26.5 %) included a lower proportion of men who had had a PSA test and greater proportions of highly educated and married men.

CONCLUSION

Understanding the reasons underlying men's screening decisions may lead to a more effective information provision and decision support.

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.

An experimental investigation of factors involved in the decision to undertake genetic testing for schizophrenia

BACKGROUND

The psychological issues surrounding genetic testing, particularly decision-making processes, are not well understood. Previous studies suggest that apparently "nondirective" strategies intended to help individuals consider the consequences of undergoing predictive testing for physical illness can influence the decision.

AIMS

To investigate the influence of selectively focussing on different aspects of previously provided information concerning genetic testing for schizophrenia.

METHOD

Community participants (n = 120) rated how likely they would be to arrange to have a genetic test for schizophrenia if it were available, before and after being given detailed information about schizophrenia and the implications of testing. Participants were then randomly allocated to four groups, and were implicitly focused on the negative issues (negative group), the positive issues (positive group), both the negative and positive issues (all-focusing group) or schizophrenia-irrelevant health-related issues (control group). All issues on which the experimental groups focussed were included in the information provided and the form of questioning meets current definitions of nondirectiveness.

RESULTS

Hypothetical decisions whether to arrange a genetic test for schizophrenia were influenced by the issues on which participants had focused; the positive group were more likely to say they would be tested relative to the other groups.

CONCLUSIONS

Decisions about genetic testing for schizophrenia were influenced by the specific issues on which individuals were encouraged to focus at that time.

The Impact of Information Order on Intentions to Undergo Predictive Genetic Testing

As predictive genetic testing availability increases so does our need to understand factors associated with test uptake. This study tests whether the order positive and negative information about genetic testing for breast cancer is presented in affects intention to take a genetic test. Eighty-four women were randomly allocated into three groups: (1) positive then negative information; (2) negative then positive information; and (3) a control group. A significant effect was found in relation to perceived risk, attitudes towards genetic testing, perceived disadvantages of testing and intention. Our findings point to a primacy effect, whereby information presented first has the greatest effect.

Can we assume that research participants are utility maximisers?

The objective of this study was to experimentally examine by means of an information manipulation if respondents are adhering to the utility theory axiom of utility maximisation. A repeated measure experimental design was used. Assessments were conducted pre- and post-intervention with self-administered questionnaires. The study participants were 158 (142 after exclusions) first year undergraduate students, Bangor University (UK). The intervention-information manipulation-did not induce the hypothesised changes in the perceived pros and cons of, or desire for, genetic testing and counselling for breast cancer; correlation revealed a weak relationship between the pros and cons of and desire for testing and counselling. We conclude that there was no evidence of utility maximisation-the key tenet of utility theory-being used. Given the contradiction between the findings of this study and others, there is a need to conduct further research into utility maximisation.

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.

Narrative accounts of hereditary risk: knowledge about family history, lay theories of disease, and "internal" and "external" causation

In this study, the authors sought to examine how risk information is articulated in relation to health problems that people identify as personally important and relevant. The respondents were receptive to health education messages, using different types of information in relation to its personal relevance and as a resource for managing and exercising control over perceived risk. People were not fatalistic about disease risk, as reported in previous research. Instead, they were responsive to complex public health messages and actively engaged in rationalizing their health risks, although this did not necessarily result in behavioral change. Consequently, a theoretical distinction exists between taking responsibility for evaluating complex public health messages and taking responsibility for behavioral change. The authors conclude that people's rationalizations about health risks often mirror the medical model of disease, suggesting that they are responsive to, and not fatalistic toward, such public health information.

Perceptions and attitudes about HFE genotyping among college-age adults

PURPOSE

Examine young adults' attitudes about HFE genotyping.

METHODS

121 college students read about hemochromatosis, transferrin saturation measurement (iron test), and HFE genotyping. Interest in testing and knowledge and attitudes about genetic testing were assessed. Participants were randomly assigned to predict either their response to a positive HFE genotype (genotype group) or a positive iron test (phenotype group).

RESULTS

71% preferred the iron test, but most would undergo either test. Learning risk and early detection/prevention were the most commonly perceived benefits; limited information about health and negative emotional consequences were the most commonly perceived disadvantages. The genotype and phenotype groups did not differ in expected worry, perceived severity, perceived risk, and preventability of organ damage. After reading the description provided, participants answered 78% of knowledge questions correctly.

CONCLUSIONS

Young adults view HFE genotyping positively and report few disadvantages, but prefer the iron test for its information about current health. They appear to be receptive to public health screening for hemochromatosis.

Applying a cognitive behavioral model of health anxiety in a cancer genetics service

A cognitive-behavioral model of health anxiety was used to investigate reactions to genetic counseling for cancer. Participants (N = 218) were asked to complete a questionnaire beforehand and 6 months later. There was an overall decrease in levels of cancer-related anxiety, although 24% of participants showed increased cancer-related anxiety at follow-up. People who had a general tendency to worry about their health reported more cancer-related anxiety than those who did not at both time points. This health-anxious group also showed a postcounseling anxiety reduction, whereas the others showed no significant change. Participants with breast or ovarian cancer in their family were more anxious than participants with colon cancer in their family. Preexisting beliefs were significant predictors of anxiety, consistent with a cognitive-behavioral approach.

The Importance of Written Information Packages in Support of Case-Finding Within Families at Risk for Inherited High Cholesterol

Inherited High Cholesterol is treatable, but highly underdiagnosed. To detect undiagnosed blood relatives at a presymptomatic stage, in the Netherlands written information packages are available to facilitate family communication. To investigate the role of those packages in the detection of carriers, we conducted a qualitative evaluation (plus-minus method combined with semistructured interviews with index patients and relatives). Our data suggest that interviewees approved the family approach for finding carriers, although reluctantly. The packages aided family disclosure by reducing hesitation. However, index patients only informed first-degree relatives and generally communicated the risk only once. This may be due to the cultural context and a limited understanding of genetics. For relatives the packages served as a cue to action and as a legitimation to gain access to a diagnostic cholesterol test. Despite the value of these written materials, they should not be used as the only communication between index patient and relatives.

Hereditary melanoma and predictive genetic testing: why not?

BACKGROUND

Since p16-Leiden presymptomatic testing for hereditary melanoma has become available in the Netherlands, the benefits and risks of offering such testing are evaluated. The current paper investigated why the non-participants were reluctant to participate in genetic testing.

METHODS

Sixty six eligible individuals, who were knowledgeable about the test but had not participated in genetic testing by January 2003, completed a self-report questionnaire assessing motivation, anxiety, family dynamics, risk knowledge and causal attributions.

RESULTS

Non-participants reported anxiety levels below clinical significance. A principal components analysis on reasons for non-participation distinguished two underlying motives: emotional and rational motivation. Rational motivation for non-participation was associated with more accurate risk knowledge, the inclination to preselect mutation carriers within the family and lower scores on anxiety. Emotional motivation for non-participation was associated with disease misperceptions, hesitation to communicate unfavourable test results within the family and higher scores on anxiety.

CONCLUSION

Rational and emotional motivation for non-participation in the genetic test for hereditary melanoma was found. Emotionally motivated individuals may be reluctant to disseminate genetic risk information. Rationally motivated individuals were better informed than emotionally motivated individuals. It is suggested that a leaflet is added to the invitation letter to enhance informed decision-making about genetic testing.

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.

The general public's information needs and perceptions regarding hereditary cancer: an application of the Integrated Change Model

The Integrated Change Model (the I-Change Model) was used to analyse the general public's need and perceptions concerning receiving information on the role of hereditary factors with regard to cancer. The results from a study in 457 Dutch adults showed that 25% correctly indicated the types of cancer where hereditary factors can play a role. Respondents, however, overestimated the role of hereditary factors causing breast cancer. Recognition of warning signs was low, as was the recognition of inheritance patterns. Participants wanted to know the types of cancer with hereditary aspects, how to recognise hereditary cancer in the family, personal risks and the steps to be taken when hereditary predisposition is suspected. The most popular information channels mentioned were leaflets, the general practitioner, and the Internet. Respondents interested in receiving information on heredity and cancer were more often female, had had experiences with hereditary diseases, had more knowledge, perceived more advantages, encountered more social support in seeking information, and had higher levels of self-efficacy. Education should outline the most important facts about hereditary cancer, how to get support, and create realistic expectations of the impact of genetic factors.

Evaluation of a decision-making aid for parents regarding childhood immunizations

This intervention study evaluates a decision-making aid for parents considering childhood immunizations. Participants (women in 3rd trimester of pregnancy, n = 100) rated likelihood of immunizing their child, anxiety, and perceptions of risk of the diseases and immunizations. Individuals were allocated to intervention group (received a decision aid) or control group (received standard care). Ratings were then repeated, and further ratings were obtained when the infant was 10 weeks old. The intervention compared with the comparison condition was associated with significant increase in likelihood of immunizing the infant on time, decreased perceptions of risks of immunizations, increased perceptions of risk of the diseases, reduced anxiety, and increased satisfaction. This intervention may form a useful basis for decision aids in health care settings.

The Role of Test Accuracy in Predicting Acceptance of Genetic Susceptibility Testing for Alzheimer's Disease

A survey questionnaire regarding perceptions of risk and genetic susceptibility to Alzheimer's disease (AD) was completed by 518 offspring of AD cases from families with multiple affected, ascertained as part of a genetic linkage study of late onset AD. The questionnaire focused on respondents' perceptions of their own risk for AD as well as on the properties of real and hypothetical susceptibility tests, including error rates for false-positive and false-negative test results. Our findings showed that about 20% of the sample would refuse a susceptibility test with zero error rates, about 40% would accept tests with very high error rates in both directions, and the remainder would exercise some discrimination. Acceptance of high test error rates was significantly associated with male gender, low education, and high perceived lifetime risk of AD. In a previous paper related to this work, we showed that physicians caring for these families exercised much more discrimination in judging the acceptability of genetic tests they would offer to these same respondents. The findings show that there is a pressing need to educate the public, particularly those with relatives affected by a complex disease, to expect standards of accuracy for genetic tests comparable to those that prevail in other diagnostic and prognostic testing efforts in the broad field of clinical medicine.

Understanding and Predicting Parental Decisions About Early Childhood Immunizations

This research investigated the factors that influence decisions about immunizations. Women in the third trimester of pregnancy (N=195) rated their likelihood of immunizing their child; stated their reasons for and against immunizing; and rated their perceptions of the benefits and risks of immunization, feelings of responsibility, and anticipated regret if harm occurred. Immunization status was determined at follow-up. Stepwise regression analyses demonstrated that immunization decisions are strongly influenced by omission bias factors such as anticipated responsibility and regret variance (which explained more than 50% of variance). It is suggested that parents may benefit from antenatal decision aids that address omission bias and encourage them to assess benefits and risks of immunizations on the basis of scientific evidence.

Intentional and unintentional nonadherence: a study of decision making

Nonadherence to medical regimens is a major problem in health care. Distinguishing between intentional nonadherence (missing/altering doses to suit one's needs) and unintentional nonadherence (forgetting to take medication) may help in understanding nonadherence. Participants with respiratory conditions completed an anonymous questionnaire about (i) nonadherence; (ii) reasons for and against taking medications; and (iii) perceived style of the consultation in which their medication was first prescribed, as well as demographic and clinical variables. Consistent with the hypotheses, intentional nonadherence is predicted by the balance of individuals' reasons for and against taking medication as suggested by the Utility Theory, where these reasons include only those which the individual considers relevant and on which he/she focuses. Unintentional nonadherence is less strongly associated with decision balance, and more so with demographics. The research highlights the importance of (a) treating intentional and unintentional nonadherence as separate entities and (b) assessing individuals' idiosyncratic beliefs when considering intentional nonadherence.

A family history of breast cancer: women's experiences from a theoretical perspective

Individuals at increased risk of developing breast cancer due to their family history of the disease face a number of uncertainties. Personal cancer risk estimates are imprecise and current methods for early detection or prevention are not 100% effective. It is therefore not surprising that adverse psychosocial outcomes have been described within this population. Research attempting to predict the incidence of distress and dysfunction in individuals at increased risk of cancer has been largely a-theoretical and has overlooked a number of potentially important predictive variables. In particular, the influence of personal experience of cancer through involvement with affected relatives has been neglected. There are strong theoretical grounds for hypothesising that dimensions of personal experience may influence response to cancer risk. This paper discusses the potential impact of personal experience on risk perception, illness representations and decision-making. Systematic research in this area may improve predictions of outcome of cancer genetic counselling and inform the clinical process.

Is there a use for tailored print communications in cancer risk communication?

The manner of presentation of cancer risk information is critical to its understanding and acceptance by the individual recipient. Optimal communication of cancer risk information must effectively translate the technical meaning and subtleties of risk and its associated factors to a conceptual level understandable by the recipient. Tailored print communications (TPCs) may be an appropriate medium for cancer risk communication (CRC). TPCs are more refined than targeted communication materials. They are print materials created especially for an individual on the basis of knowledge about that person. The goal is to provide individually relevant and appropriate information. This review examines the nature of TPCs, assesses the use and potential of TPCs for the purpose of CRC, and highlights new directions in CRC. Articles dealing with TPCs were located by searching the MEDLINE(R) and PsychInfo(R) databases and seeking in-press articles. TPCs were identified for several areas of CRC, including dietary change, smoking cessation, mammography use, hormone replacement therapy, health risk appraisal, and genetic susceptibility to cancer. Although TPCs have been used in a number of different behavioral areas, they have not yet achieved their potential for CRC. The use of TPCs in the communication of cancer risk shows great promise, however, particularly as knowledge evolves regarding both the nature of risk and the most effective tailoring of health communication messages.

The effects of 'non-directive' questioning on an anticipated decision whether to undergo predictive testing for heart disease: an experimental study

This study investigates how individuals can be helped to make decisions about predictive genetic testing. Participants (n = 120) rated how likely they would be to opt for predictive testing for heart disease if it were available, and other variables such as anxiety about heart disease. They received information on predictive testing for heart disease and ratings were repeated. Participants were then randomly allocated to one of three groups and focused on the personal relevance of positive issues or negative issues which had been mentioned as part of the standardised information previously given. The third group focused on issues irrelevant to testing for heart disease. The form of questioning used in this focusing manipulation was intended to model the processes involved in non-directive questioning. Results showed a significant increase in likelihood of testing in the positive group, and a significant decrease in the negative group. There was also a significant decrease in rated anxiety about heart disease and perceived severity of an increased susceptibility to heart disease of the negative group relative to the positive and control groups. The results may have implications for the ways in which pre-test counselling is carried out.

The effect of nondirective questioning on women's decisions whether to undergo bone density screening: an experimental study

This study investigated the effects of nondirective counseling on health screening decisions. Ninety women (mean age = 51 years) received information about bone density screening and osteoporosis. They were then randomly allocated to 1 of 4 groups and were encouraged to focus on positive issues about bone density screening (positive group), on negative issues (negative group), on both positive and negative issues (all-focusing group), or on issues relating to the common cold (control group). Women were asked to rate how likely they would be to opt for bone density screening if they saw it available. After being informed that they could have bone density screening, actual uptake was assessed. It was found that the issues on which individuals focused significantly influenced their rate likelihood of opting for the scan. Rated likelihood of testing was significantly associated with whether individuals actually did opt for testing when it was subsequently offered to them.

Knowledge about genetic risk for breast cancer and perceptions of genetic testing in a sociodemographically diverse sample

Informed consent for genetic testing for breast-ovarian cancer susceptibility requires that women understand basic concepts about the inheritance of cancer susceptibility and the benefits and risks associated with genetic testing. Women awaiting routine medical services (N = 220) were surveyed about their knowledge of breast cancer and cancer genetics and their perceptions of genetic testing and personal risk. There were no racial differences in median income or mean level of education. Compared to Caucasian women, African American women knew significantly less about breast cancer and about genetic risk for breast cancer. African American women had different psychological, social, and economic concerns as evidenced by how they weighted the benefits and risks of genetic testing. This study is the first to assess several dimensions of informed consent for genetic testing among a sociodemographically diverse group. The findings should enable health professionals to target the African American and lower-income populations with the appropriate education and counseling.

An experimental study of influences on the perceived likelihood of seeking genetic testing: "nondirectiveness" may be misleading

It has been suggested that decision making involves the implicit weighing up of those advantages and disadvantages of possible options considered relevant at the time the decision is made. If this is so, the information that people have most readily available at the time of the decision would influence the decision outcome. The study reported here experimentally evaluates the effect of manipulating the issues on which individuals focus as a way of investigating subtle directive influences. Participants (n = 104) were interviewed about their anticipated likelihood of opting for testing for hereditary hemochromatosis. All participants were given standard information about hemochromatosis, including a description of the disorder as causing progressive damage over many years and an explanation that treatment is most effective if begun before the age of 30 years. Individuals were randomly allocated to groups according to age group (30 years and under, or over 30 years) and gender. Those allocated to the positive group were then encouraged to focus on positive aspects of the previously given information by considering the extent to which statements applied to them, whereas the negative group focused on negative aspects. The control group focused on an unrelated disease. Analyses of variance indicated that the focusing manipulation affected the likelihood of opting for testing. This effect interacted with age of respondent: in participants over 30, the positive group ratings of likelihood of testing increased, whereas in the negative group they decreased; in participants 30 and under, both the positive and negative groups showed an increased desire to be tested. The control group did not alter significantly. The relevance of these findings to "nondirective" approaches to genetic counseling is considered.