Background: Mammography screening can reduce breast cancer mortality, but most women are unaware that it can cause overdetection of inconsequential disease, leading to overdiagnosis and overtreatment. Our objective was to determine whether including overdetection information in a decision aid improved informed choice about breast screening among women around age 50 years.
Objective: Human papillomavirus (HPV) testing has been proposed for inclusion in the UK cervical screening programme. While testing may bring some benefits to the screening programme, testing positive for HPV, a sexually transmitted virus, may have adverse social and psychological consequences for women. The aim of this study was to examine the social and psychological impact of HPV testing in the context of cervical cancer screening. Method: In-depth interviews generating qualitative data were carried out with 74 women participating in HPV testing in England between June 2001 and December 2003. Purposive sampling was used to ensure heterogeneity in age, ethnic group, marital status, socioeconomic background, cytology, and HPV results among participants. Results: Testing positive for HPV was associated with adverse social and psychological consequences, relating primarily to the sexually transmitted nature of the virus and its link to cervical cancer. Women described feeling stigmatised, anxious and stressed, concerned about their sexual relationships, and were worried about disclosing their result to others. Anxiety about the infection was widespread, but the impact of testing positive varied. The psychological burden of the infection related to women's relationship status and history, their social and cultural norms and practices around sex and relationships, and their understanding of key features of HPV. Conclusion: HPV testing should be accompanied by extensive health education to inform women and to de-stigmatise infection with the virus to ensure that any adverse impact of the infection on women's wellbeing is minimised.H uman papillomavirus (HPV) testing has the potential to change conventional methods of cytological screening. Five million women take part in cervical screening each year in the United Kingdom alone and any changes to incorporate HPV testing would have a widespread impact. HPV triage testing for women with mild cervical abnormalities has received much attention and is fast becoming part of routine care in the United States. [1][2][3][4][5][6] In the United Kingdom, trials of HPV triage testing and primary screening are currently under way to inform potential changes to the national screening programme. [7][8][9] Although HPV testing offers potential advantages over conventional cervical screening, 1 3 it may have implications for the psychological wellbeing of women who participate. 10The psychological effects of an abnormal smear result are well researched 11 12 ; however, the sexually transmitted nature of HPV infection means it may cause additional anxiety and distress. At present women have very little understanding of HPV and its association with cervical cancer, 13-15 therefore any information given as part of HPV testing is likely to change their understanding of cervical cancer, which may in turn impact on their psychological response. Research investigating the psychosocial consequences of other sexually transmitted infections (STIs) suggests the impact of diagnosis can be extrem...
asymptomatic, presymptomatic, or even oligosymptomatic, has also been well established, 6,7 despite claims to the contrary by Abbas and Pittet. With high viral titres in the oral fluid of such carriers well documented and a substantial proportion of speech droplets of oral fluid now shown to remain airborne for many minutes, inhalation of such particles represents a direct route to the nasopharynx. Retrospective analyses of indoor superspreader events further support the role of speech droplets in airborne transmission. 8 We declare no competing interests.
Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients' independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals' autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients' treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients' autonomy. These understandings support recognition of the value of good patient-professional relationships and can enrich the specification of the principle of respect for autonomy.KEY WORDS: personal autonomy; professional-patient relations; clinical ethics; relationship-centred care.
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