Family Practice Vol. 21, No. 1 © Oxford University Press 2004, all rights reserved.
Doi: 10.1093/fampra/cmg107, available online at www.fampra.oupjournals.org
Printed in Great Britain
“You can’t prevent everything anyway”
A qualitative study of beliefs and attitudes about
refusing health screening in general practice
Karen-Dorthe Bach Nielsena, Lise Dyhrb, Torsten Lauritzena,c and
Kirsti Malterudb,d
Nielsen K-DB, Dyhr L, Lauritzen T and Malterud K. “You can’t prevent everything anyway.”
A qualitative study about beliefs and attitudes of refusing health screening in general practice.
Family Practice 2004; 21: 28–32.
Objective. The aim of this study was to explore beliefs and attitudes about refusing health
screening in general practice.
Methods. In 1991, in Ebeltoft, Denmark people aged between 30 and 50 years were invited to
participate in a 5-year randomized, controlled, population-based project testing the value of
health screenings and health discussions in general practice. In 1994, non-participants who
declined the offered health screening but expressed willingness to be contacted in the future
were asked to participate in a qualitative interview. They were drawn by stratified purposeful
sampling which reflected variation in perceived health, body mass index, age and sex. The
sample comprised six men and 12 women
Results. Some had not participated because they were busy, felt healthy or had recently been
examined. The non-participants emphasized the limitations of health screening and did not
want possible risk factors to be revealed, or their feeling of good health to be disturbed. They
stressed the individual’s own responsibility for maintaining good health and believed that a
positive attitude promoted health. They would contact their GP if they had symptoms.
Conclusion. Non-participants have rational views on risk factor testing and on their own
responsibility for maintaining health. Non-attendance was due to a conscious choice which
included consulting their own GP.
Keywords. Attitude to health, general practice, multiphasic screening, personal autonomy,
qualitative research.
Introduction
about how well those invited to attend understand the
purpose of health screening and its potential impact.
Whether the non-participants reveal reluctance to
spare the time necessary for screening, whether they
reveal absent-mindedness or indifference, or whether
they have actually made a conscious choice is unknown.
Only a few factors behind non-participants’ reasons for
declining2–4 and beliefs concerning health5–8 have been
reported. Pill and Stott9 found that non-participants were
not really interested, had just forgotten, were undergoing
a crisis at work or at home, or currently attended a
doctor; others felt screening was inappropriate.
In 1991, a random sample of 2000 people aged
30–50 years were invited to participate in a five-year
population-based randomized, controlled health promotion study in Ebeltoft, Denmark.10,11 The invitation was
signed by the addressee’s own GP and included
information about the study aim, follow-up after one
and five years, and the randomization of participants
into two intervention groups and a control group. The
Health screening involves an inherent risk of falsepositive and false-negative results, or a risk of a false
sense of security.1 Furthermore, not all risk factors
revealed by screening will in fact develop into disease.
Health screenings in general practice may in the future
be offered routinely. Thus, medicine needs to know more
Received 17 February 2003; Revised 8 August 2003; Accepted
8 September 2003.
aThe
Ebeltoft Health Promotion Project, Ebeltoft,
bDepartment of General Practice and Research Unit, Institute
of Public Health, University of Copenhagen, cThe Department
of General Practice, University of Aarhus, Denmark and
dSection for General Practice-Department of Public Health
and Primary Health Care, University of Bergen, Norway.
Correspondence to Karen-Dorthe Bach Nielsen, The Ebeltoft
Health Promotion Project, Nørreport 4, DK-8400 Ebeltoft,
Denmark; E-mail: [email protected]
28
“You can’t prevent everything anyway”
latter group was only asked to fill in questionnaires.
Participants in one intervention group were given a
general health screening and written feedback including
a call to see the GP if major health problems
were revealed. Participants in the other intervention
group were given the same health screening and
written feedback including a planned health discussion regardless of the results of the health screening. A
one-page questionnaire was enclosed with the
invitation, containing additional questions on
demography, lifestyle, height and weight, and a question
on self-assessed health. The questionnaire was returned
by 85% and, of those, 118 persons declined to participate but expressed willingness to be contacted in the
future.
A study approaching non-participants was undertaken in 1994 to explore their personal views on the
invitation and health screenings. The aim of this paper is
to report non-participants’ beliefs and attitudes behind
their declining the invitation to participate in health
screening.
Methods
A qualitative interview study design was chosen.
A stratified, purposeful sample12 of 47 persons was
drawn from a total of 118 decliners and they were invited
to be interviewed. The sample was intended to reflect
variation according to perceived health, body mass
index (BMI), age and sex. Eleven persons did not reply
either to the request or to a reminder, while 18 actively
answered ‘no’. Eighteen of the non-participants (six men
and 12 women) agreed to participate in the current
study.
An interview guide13 based on open-ended questions
was compiled concerning what made the informants
decline the offer of a health screening; description of their
health, including any influence of their own illness or
illness among relatives/friends/colleagues; considerations
about keeping fit and healthy and what makes people ill;
and their definition of and opinion of health promotion
and health screenings in general and how relevant is it.
The interviewer often repeated the informants’ expressions to ensure correct interpretation.
K-DBN, who settled as a GP in Ebeltoft two years
after the health promotion study started, conducted
all the audio-taped interviews and the main analysis.
Nine informants were interviewed in their own homes,
one by phone, and eight at the researcher’s office in one
of the health clinics in Ebeltoft. At the time of the
interview, one of the informants was a patient of
K-DBN. The interviews lasted on average 70 min. On
average, 75% of each interview was transcribed while the
remainder was summarized. A secretary transcribed the
interviews, placing the summarized sections in the
appropriate places within the transcript.
29
Following each interview, the interviewer recorded
her observations about the circumstances of the interview, impressions of the opinions expressed, ideas to
modify the questions and topics to focus on in future
interviews as field notes. A few days later, the audiotape was re-played and the sections to be transcribed
were noted. A summary of each interview was made and
read by all to get a sense of the material as a whole
according to Malterud’s principles.12 In each summary,
parts of the text were identified and coded without predefined categories. The codes from all the summaries
were compared and the categories developed. After
transferring the entire transcriptions to the computer
program NUD*IST,14 each interview was listened to,
read and coded according to the categories established.
The coded parts of the text were re-read and compared with the original recordings and the entire
transcripts. The categories were corrected for overlap;
units containing too little information were omitted
and connections between related units were established. Finally, the overall message of the interviews was
expressed in more general terms.
Permission to conduct the study was given by the
Scientific Ethics Committee of Aarhus and the Danish
Board of Registration.
Results
The informants indicated positive attitudes towards
health screening and realized that others might want to
take the opportunity to undergo screening, or even
needed to do so. Several of them presented obvious
reasons for not participating, such as being too busy with
their job or family, actual health problems, or because
they were involved in major life events. Others felt that
a screening would not shed any new light on their state
of health. They were fit or had recently undergone a
health check related to symptoms or a known disease.
In addition, all the interviews revealed reflections and
hesitations interpreted as the informant’s more real, basic
or ideologically substantiated reasons for not participating. The informants knew that health screenings do not
include all health-related disorders and feared the
consequences if risk factors or diseases were revealed.
The informants stressed the individual’s own responsibility for maintaining and restoring good health and
would contact their GP if their body told them to do so.
These findings will be elaborated in more detail below.
“You can’t prevent everything anyway”
Informants realized that a health screening could not give
reassurance about all the inner organs. Accidents,
infections, appendicitis or rheumatism cannot be foreseen.
With regard to cancer, heart attacks or diabetes,
informants also doubted the usefulness of health
screenings, because if one were predisposed to such
30
Family Practice—an international journal
diseases, they were likely to occur anyway. They knew
that being given a ‘blank’ health screening today gave
no guarantee that a disease would not start developing
tomorrow.
“… a health screening like that is a bit… sort of
tricky … I mean, you get a false feeling of security in
a way. There are things you can’t check up on. One
can go along to the health screening but you have no
guarantee that you won’t get ill anyway…” (N14).
Several informants gave the example of people who
had become ill or died young despite giving up smoking,
alcohol or unhealthy food. They told stories about
people who had been drinking, smoking and eating
whatever they liked and yet enjoyed good health and
lived to a ripe old age. Thus, the informants questioned
whether too many restrictions were a good thing, hinting
that they might be unhealthy or spoil one’s happiness.
“You never know what it can lead to”
Several informants had considered the possible
consequences of the risk factors that screening might
reveal. Some were aware of their predisposition to
disease because of smoking, being overweight or having
relatives who suffered from heart diseases or diabetes.
They also pointed out that these things were not on their
minds all the time, which might have affected their
quality of life in a negative way. They considered
themselves healthy and did not want this feeling to be
disturbed. The waiting time between the test and result
could make them anxious. A slim woman said she could
begin to doubt her own feeling of being healthy while she
was waiting for the screening result. Others feared that
an abnormal test result might make them hysterical,
terrified or mentally unbalanced. There might be no cure
for the disease revealed, or the suggested treatment
could have side effects, or at worst cause death.
“… I wouldn’t want to know that I had something or
other, you know … like we’ve talked about … that
something might break out in many years’ time, or
under certain circumstances … why should I want
to know, it wouldn’t make me any happier … on the
contrary.” (N12).
“It’s not only doctors who can do something”
Instead of wanting others to look into possible threats to
their health and ‘labelling’ them as ill, the informants
emphasized that it was up to the individuals themselves
to lead a good and healthy life.
“… I don’t think you’ll be able to influence
everyone. At the end of the day I think I’m the best
person to do something about my own health.” (N2).
They stressed the importance of autonomy and the
individual’s incontestable right to determine his own
lifestyle himself and even to enjoy risky habits.
“… I know very well that I’m overweight … I’ve
also been told that I smoke too much. But I feel fine
about it… If I felt bad every time I went and bought
a pack of cigarettes and said to myself you really
shouldn’t do that, I think it would be bad.” (N7).
Receiving more than one invitation made some feel
that the authorities were being over-officious. They also
underlined the risk of giving people a guilty conscience
and the negative effects on one’s quality of life. The
informants neither wanted nor needed the doctor to ask
them to cut down on smoking or lose weight unless they
had asked for advice. Telling them to do so might simply
irritate them and make them more reluctant to try.
Nevertheless, they agreed that individuals should be
made aware of, and also take into account, for example
advice concerning the effects of smoking and drinking
too much or of eating unhealthy food. If something
happened to their well-being or health, they might
change their views on how to maintain their health or
alter their lifestyle. Each individual must do what he
feels is right and use common sense, not live too wildly,
and avoid unnecessary dangers.
The informants also suggested various alternatives to
health screenings. You must keep your body fit and treat
it well, brush your teeth, get enough sleep, dress
properly and use good footwear, think about your
posture, exercise, get fresh air, eat plenty of vegetables
and good meat, have a job, use environmentally friendly
washing powder or use alternative medicines when ill.
They discussed the mind as a powerful tool to maintain
good health. The mind can make you ill, cure you, keep
you well or kill you. A women stated that someone who
feels well, is not so likely to catch a disease. It is
important to avoid stress and be positive. This makes you
stronger and gives you a chance of a better and longer
life. ‘Belief’ was also mentioned frequently; not faith, but
the conviction that certain drugs were efficacious, or that
a particular way of life would help.
“I go and see my doctor when I need to”
Several informants presented statements disapproving
of people consulting the doctor with minor problems,
instead of taking responsibility themselves. In their
opinion, the doctor’s time should be saved for those who
really needed it, for example older or sick people. They
themselves would never go to the doctor unless they
were feeling ill. Some discussed the concept of listening
to their body, which would tell them if it was necessary to
take action. Still others said they would have to have
their back to the wall and feel their health was giving out
completely before going to see the doctor. Although
there were different thresholds for seeking the doctor’s
assistance, none of the informants doubted that they
would ask their GP if symptoms occurred.
“… The body can sometimes give you signals … so
you feel something’s up … then I think you should
“You can’t prevent everything anyway”
take action, you shouldn’t just run to the doctor over
every little thing, but if you feel that there’s been
something going on for quite a while … then you
should do something about it …” (N11).
Discussion
The non-participants did not want possible risk factors
to be revealed or their feeling of good health to be
disturbed. They stressed the individual’s autonomy and
their own responsibility for maintaining health, and
believed that a positive attitude promoted good health.
If any symptoms arose, they would contact their GP. The
fact that the informants expressed trust in their GP,
but declined the offer of a health check nonetheless,
indicates the strength of their decision not to attend.
This seems to be a very conscious choice.
The informants had reflected on screening, considered
its value and taken into account that such checks might
be of benefit to others. In Pill and Stott’s study,4 only 3%
of 236 non-attenders rejected the concept of health
screening outright, 85% agreed that a health screening
was ‘very worthwhile’ and 73% agreed that it ‘should be
done quite frequently’. Both in the present study and the
study of in Pill and Stott, all the informants had declined
a health check, but nevertheless expressed a positive
attitude to the offer. Questionnaires offer only a limited
choice of answers and may thus give a misleading
impression, suggesting that all respondents are happy
about health checks despite not participating themselves. A qualitative interview design offers a more
detailed and nuanced picture of informants’ attitudes.
In the course of the interview, the informants had the
opportunity to reflect on their considerations, and none
seemed to have problems remembering their arguments
for non-attendance. The reasons might also still be fresh
in their memory because in the small town of Ebeltoft10
their friends, family and colleagues were among those
invited, who had been health screened twice since they
received the invitation 3 years previously. The original
invitees who had declined the health check but
expressed willingness to be contacted gave us an excellent opportunity to obtain hitherto unknown information.
Because of the willingness for future contact, our
informants may have been more positively inclined
towards health promotion and research than the rest of
the non-participants who, due to ethical reasons, could
not be interviewed. The informants’ awareness that the
interviewer was a doctor may have made them inclined
to be kinder and less critical than would otherwise
have been the case, if the researcher was a stranger;
alternatively, on the contrary, the fact that the interviewer was a doctor and a representative of the health
system may have provoked informants to reveal
and express more negative attitudes towards health
promotion. Others15 have considered GPs’ influence on
31
informants’ expressions, but our informants were able
to correct the interviewer if they were wrongly or
insufficiently interpreted. The informant who was a
patient of the interviewer did not differ from the other
interviewees.
Our study was designed to elicit a broad range of
information and perspectives on personal attitudes
towards the offered health checks which revealed the
presence or otherwise of risk factors. In the case of nonparticipants, the only concrete information of this
kind concerned BMI. The literature indicates that
individuals’ self-assessed health is consistently associated with variables such as functional ability, number of
medical diagnoses and physical as well as mental
symptoms.16 To ensure a balance among respondents
who rated themselves fairly healthy and those who
considered themselves very healthy, BMI as well as selfassessed health was taken into account in selecting
informants. Thus, individuals of normal weight as well as
those who were overweight were included. Though it
has been shown16 that not all respondents use the same
frame of reference when answering questions concerning self-rated health and although the BMI was selfreported, the present study was thought to include the
best and the broadest possible parameters to use for
inclusion to describe attitudes among non-participants
on the whole. The informants were not asked to relate
their feelings about their personal perceived health or
BMI, nor were these factors used as a perspective during
the analysis.
The informants’ straightforward reasons, business,
good health or recent examination, were similar to those
of other studies.2–4,9 The informants approved of the
health screening limits. Like the GPs, the nonparticipants know that a health screening cannot
guarantee a healthy life. Instead, they emphasize the
individual’s responsibility to keep fit, to deal with minor
illnesses and not to misuse the health system by
consulting the doctor when one is not actually ill. They
were keen to safeguard their autonomy. Nikku17
mentions that one ethical dilemma in health promotion
is the conflict between two important values: that of
promoting health and that of the individual’s right to
autonomy. Autonomy may be violated when that
individual has other preferences. “He may prefer a
hazardous life instead of quiet behaviour with long
life-expectancy. The paternalistic actor may view a
long healthy life as the best choice and suppose that
everybody else does the same.” Autonomy discussed in
this way is referred to by Nessa and Malterud18 as a
patient’s right to informed consent or their medicoethical right to set limits to medical intervention. Our
informants put limits on their doctor and the authorities
to intervene with their lifestyle, which draws parallels to
a study5 where non-participants were less likely to accept
the legitimacy of a GP’s concern about the individual’s
smoking habits or fitness problems. In agreement with
32
Family Practice—an international journal
an interview study on lay opinions of health and healthy
lifestyles,19 our informants were aware of health risks such
as being overweight, smoking and drinking, but weighted
these risks against their quality of life which they found
could be negatively influenced by too many restrictions or
suggested further examination or medical treatment.
They deny being influenced by nocebo,20 and present a
strong conviction that a positive attitude and one’s own
will are very important factors in staying healthy.21 In this
view, it is not surprising that the non-participants declined
physically orientated procedures such as health screening.
Their concept of good health embraces more factors than
can be revealed in a laboratory.
Thomas and co-workers found, like us, that nonparticipants agreed with the statement that “a general
health screening is a waste of time unless you have
symptoms”.7 However, our findings are inconsistent
with Pill and Stott’s conclusions.9 Our informants do not
consult their doctor unless they have symptoms.
Implications
The views expressed by non-participants in this study
run counter to the growing tendency in the health system
to screen asymptomatic persons. The informants are
rational in their perception about the limitations of
screening, and their autonomy must be respected. The
non-participants’ attitude is not one of indifference and
is in accordance with lay evaluations. They do consult
their GP if and when they find it necessary.
3
4
5
6
7
8
9
10
11
12
13
14
Acknowledgements
We thank A Hilligsøe, E Therkildsen and J Sørensen for
extensive and brilliant administrative assistance, and
S Laird and H Hjorth Petersen for revision of the
English texts. Financial support was given by the Danish
Research Foundation and Development Fund, General
Practitioners’ Education and Development Fund,
Danish College of General Practitioners Sara Krabbe
Scholarship, Lundbeck Scholarship and Magda and
Svend Aage Friederichs’ Scholarship, the Danish Heart
Foundation and the Medical Women’s Danish
Association.
15
16
17
18
19
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