CHAPTER 9 Screening, risk assessment, immunisation and surveillance

In Chapter 9 we move to the far end of the continuum of health promotion approaches outlined in Chapter 1 and examine some of the medical approaches to health promotion. There is a range of strategies used in this approach. The four best known medical approaches to health promotion are: immunisation; screening for specific diseases, including non-communicable diseases; individual risk factor assessment; and surveillance.

When these strategies are underpinned by a Primary Health Care philosophy, then medical approaches to health promotion fit best with the Ottawa Charter for Health Promotion action area of reorientation of health care.

There are limitations to medical approaches to health promotion. Control over health is often maintained by health professionals and the principles of social justice, equity, community control and working for social change that impact on health and wellbeing are not necessarily taken into consideration.

Medical approaches to health promotion have produced important gains in health. Clearly, we must identify individual risk to diseases to promote health and prevent disease, and address those diseases that cause human suffering.

When the medical approach to health promotion is used alone, it is known as selective Primary Health Care. Selective Primary Health Care is more limited than comprehensive Primary Health Care, discussed in Chapter 1, because control over health is maintained by health professionals who often concentrate on disease and do not necessarily take the social context of people’s lives into consideration. When we only address disease, we risk continually trying to fix the end result of the problem instead of addressing the root causes of diseases or the social conditions that perpetuate disease and other suffering.

Surveillance and screening for specific diseases usually falls under the jurisdiction of national governments whereas risk assessment is usually carried out in primary care services, such as community health centres and with primary care providers, such as community health nurses, general medical practitioners and allied health professionals. It is important to note that these services may or may not foster the Primary Health Care principles of social justice, consumer control over decision-making or collaboration with other health and welfare workers to deal effectively with health issues.

IMMUNISATION, SCREENING, INDIVIDUAL RISK FACTOR ASSESSMENT AND SURVEILLANCE

Immunisation

There are national immunisation programs in many countries that aim to reduce the spread of vaccine-preventable diseases across targeted populations. To control a vaccine-preventable disease, a sufficient pool of people must be immunised against the disease to prevent spread of that disease in the wider population. There have been some spectacular results in this regard, such as the global eradication of smallpox.

There are a number of factors that need to be taken into consideration to obtain a sufficient pool of people to prevent a disease. Political will and substantial resources are required to prevent the spread of disease. In Australia, the Australian Technical Advisory Group on Immunisation advises the national government in the implementation of the National Immunisation program. The group assists the National Health and Medical Research Council (NHMRC) to produce immunisation guidelines for health departments and health professionals. The Australian Immunisation Handbook, 9th edition 2008 (NHMRC & Department of Health and Ageing 2008) provides information about vaccines and diseases and vaccination practice, but even with this investment, immunisation programs have not been able to reach a sufficient pool of people to prevent the spread of some diseases. For example, the New South Wales Department of Health (NSW Health) issued a health alert warning people, especially parents, to be on the lookout for the symptoms of Pertussis (whooping cough) following an increase in cases across New South Wales in 2008. This is a vaccine-preventable disease but there are regular outbreaks. According to NSW Health there were almost 3000 cases reported between January and September of 2008, which was more than double the number for the same period in 2007 (NSW Health 2008). This begs the question, ‘What else do we need to consider?’

In Australia, the responsibility for providing immunisation programs rests with Environmental Health Officers and Maternal and Child Health Nurses in local government, and with private general medical practitioners. General (medical) practitioners have identified structural barriers within their practice to engaging in health promotion activities. These barriers include lack of initial and continuing education in health promotion, low financial incentives and lack of time in consultations (James et al 2003; Baum 2008).

Some vaccination programs are more acceptable to vulnerable population groups or parents than others and these factors will have an impact on vaccination rates. For example, research concerning the acceptability of vaccines for sexually transmitted infections demonstrated that perceived susceptibility of the disease and perceived benefits of receiving a vaccine to prevent a disease were important factors to consider (Dickson-Swift et al 2008). Cost, efficiency, physician recommendation, attitudes towards vaccination, knowledge, parental approval and geographical location are also important factors in the acceptability of vaccines (Dickson-Swift et al 2008). These potential barriers and enablers to vaccine up-take, and obtaining a sufficient pool to prevent a disease, need to be taken into consideration in developing immunisation programs.

Numerous strategies have been used to improve vaccination rates. Reminding people has proven to be successful (Jacobson Vann & Szilagyi 2005). A Cochran review of 47 studies in minority countries found that immunisation rates improved in both children and adults by reminding them to be immunised. Reminding people by telephone, letters, or speaking to people personally improved vaccination rates. Telephone reminders are the most effective and the more people who are reminded the greater the rates of vaccination. Reminders worked whether they were from private doctors, medical centres or public health departments (Jacobson Vann & Szilagyi 2005). In Australia, considerable effort has been made by many local governments to increase the immunisation rates in their municipality. These strategies include asking parents what needs to be done to facilitate attendance at immunisation sessions for children. Family friendly times and venues have emerged to meet the needs of some communities as a result of including the community in the planning of these programs. This has resulted in increased immunisation rates within these municipalities.

Screening

The aim of a screening procedure in health promotion is to identify specific conditions in targeted groups before symptoms appear.

Screening involves the systematic use of a test or investigatory tool to detect individuals at risk of developing specific disease that is amenable to prevention or treatment.

(State Government of Victoria 2003a: 45)

Priorities for screening at a population level differ from country to country. Common health promotion screening procedures in Australia include screening for hearing and eyesight in children, screening for breast and cervical cancer in women, and screening for bowel cancer in adults over 50 years. Screening criteria are developed to guide health services in their decision-making about providing screening services.

Criteria for a government to establish and fund a public screening service includes information about the disease, the test, follow-up and treatment, and the cost effectiveness (Wilson & Jugner 1968; Robinson & Elkan 1996; Goel 2001). The disease, must be one that has a definite effect on length or quality of life, and the progression from the latent or early symptomatic stage of the disease must be well understood. The test must be safe, simple, reasonably accurate and acceptable to the providers and population. False positive results and false negative results can cause immeasurable damage to the individual. Follow-up and treatment procedures must be in place and acceptable. Follow-up for positive results must be available quickly and treatment for early detection effective. The cost of screening a population or sub-group of the population, follow-up and treatment must be something the community can afford (Wilson & Jugner 1968; Robinson & Elkan 1996; Goel 2001).

Effectiveness of screening

There is controversy over the effectiveness of some screening procedures. For example, while the benefits of mammography screening for women over 50 years of age have been demonstrable, screening for younger women is disputed, and further there is no evidence that breast self-examination is effective in reducing mortality from breast cancer (Weller 1997 in Baum 2008). Prostate and colorectal cancer screening is also contested (Baum 2008).

… relevant information, such as information about the increased risk of diagnosis with screening, is often counterintuitive. Benefits are relatively rare and often delayed, and the screening process can involve a whole series of interventions. The harms of screening are poorly understood by the public, and screening tests are often viewed uncritically.

(Barratt et al 2004: 507–10)

Screening decisions are complex, and according to Barratt et al (2004: 507–10) health workers need to be aware of the potential risks in public screening:

leads to over-detection and over-treatment

may include invasive follow-up investigations and treatments

harm is immediate and benefits are delayed

few people experience benefits from screening compared with the number who would be expected to benefit from most treatments

individual values and preferences are critical to screening decision-making

evidence base for screening decision aids is often limited

public attitude is that early detection and or prevention must be good

little regulation is in place to protect consumers from aggressive marketing, and there may be strong financial incentives to get people to participate in screening.

Decision aids for policy-makers, health professionals and consumers have been suggested by Barratt et al (2004: 507–10) and include:

present the chances of having pseudo-disease as well as clinically important disease detected by screening

give information about the whole of the early detection and treatment process

present balanced information about the cumulative chance of benefits and harms over equivalent time frames

present very small numbers by using large and consistent denominators, for example, outcomes per 1000 or per 10 000 people screened

screening decision aids need to accommodate flexibility in labelling the outcomes of screening as benefits or harms

explicitly declare where high quality evidence is lacking

use ranges or some other method to convey uncertainty in numerical estimates

explain that there is a choice and the reasons why people might decide to decline screening

information about financial gains to the organisation offering the screening test may need to be included in decision aids.

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