The Sunrise Enabler was also de- veloped to help researchers discover multiple and Leininger (1991b buy pamelor 25mg fast delivery anxiety vs heart attack, 1995) has developed speciﬁc cri- diverse holistic lifeways related to culture care ex- teria to evaluate qualitative research generic pamelor 25 mg on-line anxiety symptoms jittery, including periences and practices purchase 25mg pamelor fast delivery anxiety 300mg. Because qualitative studies holistic yet speciﬁc factors inﬂuencing care in cul- have very different meanings and purposes buy pamelor 25 mg otc anxiety symptoms for xanax, goals, tures under study within ethnohistorical, language, and outcomes from quantitative studies, the nurse social structure, and environmental contexts researcher is required to use qualitative criteria to (Leininger, 1991b, 1995, 1997). Credibility: Refers to direct evidence from the must be clearly stated to provide guidance to assist people and the environmental context as truths nurses in providing culturally congruent and rele- to the people. Themes are the dominant ﬁnding from evidence from the people who can ﬁrmly and the analysis, and thematic statements require much knowingly conﬁrm the data or ﬁndings. Meaning-in-context: Refers to meaningful or un- the emic and etic raw data and holistic ﬁndings. Recurrent patterning: Refers to documented evi- The general research process of conducting an dence of repeated patterns, themes, and acts ethnonursing study is presented as a guide. The over time, reﬂecting consistency in lifeways or process may be modiﬁed to ﬁt with the research patterned behaviors. Saturation: Refers to in-depth evidence of taking ﬂexible so the researcher can move with the people in all that can be known or understood about and be open to make allowances or change plans in phenomena or a domain of inquiry under study accord with naturalistic developments. Transferability: Refers to whether the ﬁndings and processing research data, modiﬁcations in the from the study will have similar (not identical) research plan often become necessary. The phases meanings and relevance in a similar situation or of the ethnonursing research method developed by context (Leininger, 1997, p. Identify the general intent or purpose(s) of your fully and explicitly in a systematic and continuous study with a focus on the domain(s) of inquiry process while obtaining data or observing inform- phenomenon under study, area of inquiry, or re- ants over periods of time. Identify the potential signiﬁcance of the study to Four Phases of Ethnonursing advance nursing knowledge and practice. Review available literature on the domain or Leininger (2002) has developed the phases of phenomena being studied. The four phases provide for systematic on- ning to the end with the following general going data analysis, which occurs from the begin- phases or sequence of factors in mind: ning of data collection until completion of the ﬁnal a. Consider the research site, community, and analysis and written report of the research ﬁndings. Explore and gradually gain entry (with essen- gram or similar ones can be used to assist the re- tial permissions and/or informed consent) to searcher with large-volume data analysis. The ﬁrst the community, hospital, or country where two phases of data analysis are focused on obtain- the study is being done. The third phase of data related to gatekeepers’ expectations, language, analysis requires that the researcher identify recur- political leaders, location, and other factors. Select and appropriately use the ethnonurs- ing and synthesizing major themes derived from ing enablers with the research process; for ex- the previous sequential three phases. A research ample, Leininger’s stranger to trusted friend mentor skilled in the ethnonursing method can guide, observation participation reﬂection help the researcher reﬂect on the major phases and guide, and others. Maintain trusting and favorable relationships made it imperative that nurses understand different with the people conferring with ethnonursing cultures to work and care for people who have di- research experts to prevent unfavorable devel- verse and similar values, beliefs, and ideas about opments. This is a continuous process from the goal of the Theory of Culture Care Diversity and beginning to the end and requires the use of Universality is to improve or maintain health and qualitative research criteria to conﬁrm ﬁnd- well-being by providing culturally congruent care ings and credibility factors. Maintain continuous data processing on the of the client, family, or cultural group. The sunrise computer and with ﬁeld journals, depicting enabler serves as a cognitive map depicting the active analysis and reﬂections and discussions seven culture and social structure dimensions that with research mentor(s). Computer-assisted inﬂuence care, which in turn inﬂuence the health data analysis with large volumes of qualitative and/or illness of clients. Frequently present and reconﬁrm ﬁndings or folk care and professional care, and provides a with the people studied to check credibility focus on both types of care for the provision of cul- and conﬁrmability of ﬁndings. Do ﬁnal analysis and writing of research ﬁnd- clashes, cultural illnesses, and other unfavorable ings soon after completing the study. Prepare published findings in appropriate general ideas are kept in mind as one uses ﬁndings journals. To provide a different focus from traditional nurs- Again, ﬂexibility exists with the ethnonurs- ing, Leininger developed the unique three modes of ing data processing, but the above steps help to care to incorporate theory ﬁndings (refer to sunrise conceptualize the process and thus promote the re- enabler, Figure 20–1). The three modes are: culture searcher’s ability to perform a systematic investiga- care preservation or maintenance; culture care ac- tion that has credibility and meets other qualitative commodation or negotiation; and culture care evaluation criteria. The theorist has pre- dicted that the researcher can use ethnoresearch Culture Care Theory ﬁndings to guide nursing judgments, decisions, and actions related to providing culturally congruent and Nursing Practice care (Leininger, 2002). Leininger prefers not to use Over the past ﬁve decades, the culture care theory, along with the ethnonursing method, have been Leininger prefers not to use the phrase used by nurse researchers to discover knowledge nursing intervention because this term that can be and has been used in nursing practice. Instead, the term nursing ac- research colleagues have used the culture care the- tions and decisions is used, but always with the ory and the ethnonursing method to focus on the clients helping to arrive at whatever actions or de- care meanings and experiences of 100 cultures cisions are planned and implemented. The modes (Leininger, 2002); they discovered 187 care con- ﬁt with the clients’ or peoples’ lifeways and yet are structs in Western and non-Western cultures therapeutic and satisfying for them. The nurse can (Leininger, 1998), as reported in the Journal of draw upon scientiﬁc nursing, medical, and other Transcultural Nursing (1989 to 1999). Active helping-assisting or facilitative acts; active helping; participatory involvement with clients is essential presence (being physically there); understanding to arrive at culturally congruent care with one or all (beliefs, values, lifeways, and environmental); con- of the three action modes in order to meet clients’ nectedness; protection (gender related); touching; care needs in their particular environmental con- and comfort measures (McFarland, 2002). The use of these modes in nursing care is care constructs are the most critical and important one of the most creative and rewarding features of universal or common ﬁndings to consider in nurs- transcultural and general nursing practice with ing practice, but care diversities must also be con- clients of diverse cultures. Although many of these dominant care It is most important (and a shift in nursing) to constructs may be found in certain cultures, diver- carefully focus on the holistic dimensions, as de- sities will also be found. The ways in which culture picted in the sunrise enabler, to arrive at therapeu- care is applied and used in speciﬁc cultures will re- tic culture care practices. All the factors in the ﬂect both similarities and differences among (and sunrise enabler (which include worldview and sometimes within) different cultures. Next, three technological, religious, kinship, political-legal, ethnonursing studies will be reviewed with focus economic, and educational factors, as well as cul- on the ﬁndings, which have implications for nurs- tural values and lifeways, environmental context, ing practice. The culture care theory, along with the ﬁndings relevant to the culture care of Lebanese the ethnonursing method, are powerful means for Muslim Americans using Leininger’s three modes new directions and practices in nursing. Incorpo- of nursing decisions and actions to provide cultur- rating culture speciﬁc care into client care is essen- ally congruent and responsible care. The study fo- tial to practice professional care and to be licensed cused on the care for Lebanese Muslims in the as registered nurses. Luna’s research Luna found that female modesty was an impor- ﬁndings and the nursing practice implications re- tant cultural care value for Lebanese women; this lated to the home and community context in the was reﬂected in requests by female clients to have late 1980s remain important as health care shifts only female nurses, physicians, and other care- from hospital care services to home or community givers. Luna discovered that attending a clinic in a care practice was accomplished by nurses negotiat- Midwestern United States urban context was often ing for these women to have female caregivers a new and different approach to health care for whenever possible, which would promote health, Lebanese Muslim women, especially during preg- well-being, and client satisfaction with care. Luna’s study revealed that cluding Lebanese Muslim men in health teaching many women relied on the traditional midwife in and discharge planning, Luna discovered a way to Lebanon for home deliveries. The routine of use culture care preservation that recognized the monthly and weekly visits to the prenatal clinic was family as a unit, rather than focusing on the indi- incongruent with what these clients had experi- vidual. In the United States, ization of the family should be preserved as a social prenatal care in the clinic context involved long structure feature, which acknowledges males for waiting periods with the husband missing work to their roles in family care continuity rather than take his wife to each appointment. Examination by being narrowly interpreted as males always being in a male physician was culturally incongruent for the control. Negative stereotypes held by nurses about women, so culture care negotiation and repatterning the Arab males’ reluctance to participate in the was essential for culturally congruent care. Luna birth process were also discovered, often presenting described the clinic as culturally decontextualized a barrier to giving nursing care. To counter this, for clients and their families because the prenatal Luna suggested the nurses use culture care preser- care and the environmental clinic context in which vation to maintain and support the generic culture the care was provided were not congruent with the care practices of men, which included surveillance, clients’ cultural values, beliefs, and practices (Luna, protection, and maintenance of the family. Luna discovered some dominant and uni- Still another ﬁnding from Luna’s study was the versal care constructs for Lebanese Muslim men, discovery of the importance of religious rituals to which included surveillance, protection, and main- many Muslim clients as an essential component of tenance of the family. For Lebanese women, the providing care within their cultural context (Luna, dominant and universal care constructs included 1989, 1994). Luna found that some Muslims pray emphasizing the positive attributes of educating three to ﬁve times a day, and others do not pray at the children and maintaining a family caring envi- all. During the culturalogical assessment (in the ronment according to the precepts of Islam.
One of the most famous research studies in Psychologists believe that attachment serves to help this area was performed by Harry Harlow pamelor 25 mg otc anxiety forum. As the above studies infant monkeys in a cage with two surrogate mother show discount pamelor 25 mg without a prescription anxiety symptoms mimic ms, if presented with a strange situation purchase pamelor 25mg with amex anxiety wrap for dogs, an infant will dolls: one made of wire holding a bottle of milk and the either avoid or engage in exploration pamelor 25mg without prescription anxiety symptoms for teens, chiefly dependent other made of soft cloth. Addition- view, the monkey should have developed an attachment ally, it has been shown that lack of attachment in early to the wire mother because she was the source of food. In 1971, researchers separated a group of cloth mothers, suggesting that the need for comfort and monkeys from their mothers for six days and then ana- warmth are more important, or more psychologically in- lyzed their behaviors two years later in comparison to a grained, than the need for food. The group that had been separated was observed to be far Later experiments with monkeys also revealed the more reticent in exploratory behaviors than the control effects secure attachments had on infants. Still other studies indicate that cognitive function- ment, strange foreign objects were introduced to a cage ing in children is enhanced among “securely attached” with an infant monkey. Becoming Attached: Unfolding the Mysteries of Attention deficit/ the Infant-Mother Bond and Its Impact on Later Life. It affects their perfor- Attention describes the focusing of perceptive mance in school or at work, depending on their age, and awareness on a particular stimulus or set of stimuli that it affects them socially. A state of attention may be produced initially in ings or while socializing with friends after work. Particu- many ways, including as a conscious, intentional deci- larly stressful situations, or those requiring the sufferer sion, as a normal function of social interaction, or as a to concentrate for prolonged periods of time, often will reaction to an unexpected event. They may fidget in their demonstrate the effects of their attention in the form of chairs, sharpen their pencils multiple times, flip the cor- apparent misperceptions. For example, the relative size ners of the pages back and forth, or talk to a neighbor. As situations become increasingly hyperactivity-impulsivity components, and so they may familiar or similar to situations previously experienced experience difficulties regulating both attention and ac- by an individual, the actions of that individual become tivity. Moreover, and correlates of attention, and the capacity to achieve or these difficulties interfere with age-appropriate behav- to maintain a state of attention may be limited by a num- ioral expectations across settings such as home, play- ber of mental or physical dysfunctions. In the 1950s rate stimulus elements, or the amount of stimulus materi- and 60s, children exhibiting these symptoms were either al, that can be perceived and remembered after a brief diagnosed as minimally brain damaged or labeled as be- presentation. This man is performing memory-improving exercises to overcome his attention deficit difficulties. Symptoms must be (e) appearing to be “constantly on the go,” or (f) exces- present in at least two settings, and there must be clear sive talking. Impulsivity may be related to hyperactive evidence of interference with academic, social, or occu- behavior and may be manifest as (a) impatience or blurt- pational functioning. Finally, the symptoms must not be ing out answers before the question has been finished, due to other neuropsychiatric disorders such as perva- (b) difficulty in waiting for one’s turn, and (c) frequent sive developmental disorder, schizophrenia or other interruptions or intrusions. The ficient care, (h) being distracted by background noises or most prevalent type is the Combined Type, in which in- events, or (i) being forgetful in daily activities. Hyperactivity may be seen as (a) fidgety behavior or difficulty sitting still, (b) excessive running or climbing It is important that a careful diagnosis be made be- when not appropriate, (c) not remaining seated when fore proceeding with treatment, especially with medica- asked to, (d) having difficulty enjoying quiet activities, tion. Paul Dworkin, a physician with special interests ings on younger patients are less clear. Pharmaco- studies have found prevalence ranging from four to nine logical treatment can be effective in many cases. Children clude enhancement of attention span, decrease in impul- who have a history of abuse or neglect, multiple foster sivity and irrelevant behavior, and decreased activity. If the causes of a child’s disruptive turbance, headache, and gastro-intestinal distress. Tics or inattentive behavior are not understood, the child may may also appear and should be monitored carefully. Psy- be punished, ridiculed, or rejected, leading to potential re- chotic reactions are among the more severe side effects. A child who medication may interfere with physical growth and feels that he or she is unable to perform to expectations no weight gain. These effects are thought to be ameliorated matter what type of effort is put forth may begin to feel by “medication breaks” over school vacations and week- helpless or depressed. Brain chemistry is giving instructions, making sure that they are well paced implicated by the actions of the medications that reduce with cues to remind the child of each one. Attitude and behavior Special assistance may not be limited to educational Attitude is a feeling, belief, or opinion of approval settings. Inatten- action or reaction that occurs in response to an tion, shifting activities every five minutes, difficulty event or internal stimuli (i. Under other circumstances, that same man ly offer courses in discipline and behavior management. There are also a number of popular Ideally, positive attitudes manifest well-adjusted be- books that are informative and helpful. For example, someone may re- main in an abusive and potentially deadly domestic situa- Doreen Arcus, Ph. Behavior can be influenced by a number of factors Further Reading beyond attitude, including preconceptions about self and Barkley, R. Attention Deficit Hyperactivity Disorder: A others, monetary factors, social influences (what peers Handbook for Diagnosis and Treatment. New York: Guil- and community members are saying and doing), and dord Press, 1990. Driven to Distraction: Recog- about improving the public school system in their town, nizing and Coping with Attention Deficit Disorder from but if it means a hefty increase to their property taxes, Childhood through Adulthood. New York: Simon and they may vote against any improvements due to the po- Schuster, 1994. The Hyperactive Child, Adolescent, and Adult: At- supporter, showing that their actions (i. New York: attending parent-teacher organization meetings) are Oxford University Press, 1987. Cognitive therapy attempts to change irrational Further Information ways of thinking. One research study found that antismoking cam- Advertising, political campaigns, and other persuasive paigns targeted at teenagers can have a higher success media messages are all built on the premise that behavior rate when adolescent peers are used as instructors. Paula Ford-Martin The fields of social and behavioral psychology have researched the relationship between attitude and behav- ior extensively. The more psychologists can understand Further Reading the relationship between attitude and behavior and the Byrne, Donn and Robert A. The important social problems such as racism, gender bias, psychology of attitudes. It is also a key part of public health edu- cation initiatives, particularly in the case of preventive Attitudes and attitude change medicine. Campaigns promoting positive attitudes to- An attitude is a predisposition to respond cogni- wards prenatal care, abstinence from drug use, smoking tively, emotionally, or behaviorally to a particular cessation, sunscreen use, organ donations, safe sex, can- object, person, or situation in a particular way. In effect, social Attitudes have three main components: cognitive, af- marketing is “selling” attitudes and beliefs and ideally fective, and behavioral. The cognitive as- Changing behavior to influence attitudes pects of attitude are generally measured by surveys, inter- In 1955, clinical psychologist and educator George views, and other reporting methods, while the affective Kelly introduced his psychology of personal constructs. Behavior, on the other vidual looks at the world through his or her own unique hand, may be assessed by direct observation. Behavior does not always conform to a person’s feel- These constructs change and adapt as the individual is ings and beliefs. At the heart of may be suppressed because of a competing attitude, or in Kelly’s theory is the idea that individuals can seek new deference to the views of others who disagree with it. A experiences and practice and adapt new behaviors in classic theory that addresses inconsistencies in behavior order to change their attitudes (or constructs) towards the and attitudes is Leon Festinger’s theory of cognitive dis- world.
The signs and symptoms of hypoglycemia are vague and could be caused by other conditions purchase pamelor 25 mg with mastercard anxiety symptoms sore throat. To determine whether you have hypoglycemia cheap 25 mg pamelor overnight delivery anxiety related to, your doctor can check your blood sugar levels and perform a glucose-tolerance test cheap pamelor 25 mg online anxiety disorders symptoms quiz. Heavy drinking can block glucose production and promote the release of insulin buy 25mg pamelor with mastercard anxiety symptoms kidney, factors that will lower your blood sugar levels and induce hypoglycemia. When having an alcoholic beverage, do so with a meal as food delays the absorption of alcohol. Drinking a glass of juice or taking glucose tablets or candy will raise blood sugar levels within a few minutes. Those with diabetes or who are prone to hypogly- cemia should carry some form of sugar with them at all times. Those with severe symptoms who are unable to take anything by mouth will require immediate medical attention, which involves intravenous glucose or an in- jection of glucagon. If hypoglycemia is severe and untreated, it can result in serious consequences such as coma, heart problems, and death. If the hypoglycemia is not caused by diabetes or overproduction of insulin, it is important to work with your doctor to determine the underlying causes and develop a treatment. For example, if it is caused by a medication you are taking, your doctor may recommend changing the medication. If it is due to a tumour or glandular disor- der, a surgical procedure may be necessary. Those with organ disease or other serious health problems need to work with their health care provider for speciﬁc recommendations. Dietary Recommendations Foods to include: • Eat quality proteins (tofu, eggs, ﬁsh, and poultry) and healthy fats (ﬁsh, nuts, and seeds) with your carbohydrates as this will slow down the rate of digestion. Those that break down quickly have a high glycemic index and those that break down slowly have a low glycemic index. Foods to avoid: • Alcohol can impair blood sugar control and trigger hypoglycemia by interfering with normal glucose utilization and increasing insulin secretion. Lifestyle Suggestions • Regular exercise helps to improve blood sugar control and improve insulin sensitivity. Have a light snack 30 minutes before exercising to sustain your energy levels and prevent hypoglycemia. Top Recommended Supplements B-vitamins: Play a role in metabolizing carbohydrates and converting blood glucose into energy. Look for a B-complex that provides 20–50 mg each of B1, B2, B3, B5, and B6 and 100 mcg of vitamin B12. Fibre: Soluble ﬁbre forms a gel in your stomach and slows the rate of digestion and absorp- tion. Vitamin C: Plays an important role in blood sugar regulation; levels are depleted by chronic stress, which is a factor in hypoglycemia. Eat small, frequent meals of low-glycemic carbohydrates along with quality pro- teins and fats. It produces two hormones, triiodothyronine (T3) and thyroxine (T4), which circulate through your bloodstream and control metabolic activity in every cell in the body, from your heartbeat to body temperature to how fast you burn calories. Hypothyroid- ism or underactive thyroid occurs when the thyroid gland cannot produce enough thyroid hormones to meet the body’s demands. This causes all bodily functions to slow down and you feel tired, sluggish, achy, and gain weight. However, today people are encouraged to reduce salt intake for health reasons (hypertension), and most of the salt that we get comes from processed foods that contain non-iodized sodium, so it is possible that low iodine levels are again partly contributing to thyroid disease. The most common cause of hypothyroidism is Hashimoto’s disease, which is an autoimmune disorder in which the body makes antibodies that attack the thyroid gland. Hypothyroidism can also result from treatment of Graves’ disease (hyperthyroid- ism) with radioactive iodine, which destroys the thyroid gland, leaving it unable to produce hormones, and from surgical removal of the thyroid gland due to thyroid cancer. These glands are involved in the regulation of the thyroid gland and the amount of thyroid hormone that is released. Hypothyroidism is easily treated today with thyroid hormones, supplements, and various lifestyle approaches. Many people do not realize that they have low thyroid because in the early stages the symptoms can be very mild and vague, such as fatigue. It may cause a large, pro- truding tongue, choking, yellowing of the skin and whites of the eyes, constipation, poor muscle tone, and excessive sleepiness. Doctors typically prescribe synthetic thyroid hormone (T4), such as Eltroxin or Synthroid. Too much thyroid hormone can cause symptoms of racing heart, increased appetite, insomnia, and shakiness. Some people do not convert T4 to T3 adequately and do better with a form of T3, which is called Cytomel. Natural thyroid hormones can be compounded by a pharmacist to provide T3 and T4 or just T3, depending on your needs. Compounded thyroid hormones are available through a compounding pharmacy with a doctor’s prescription. The advantage of this form is that the dosage can be tailored to your needs and many people do better with the natural over the synthetic form. Calcium and iron supplements may reduce the absorption of thyroid hormone, so take these products six hours away from your thyroid medication. A person may have no symptoms or vague symptoms, such as fatigue, dry skin, or H weight gain. Anyone at risk of hypothyroidism or who has any of the symptoms should consider testing beyond basic bloodwork. The thyroid regulates metabo- lism and low body temperature can indicate hypothyroidism. Here is what you do: • Place a digital thermometer, paper, and pen beside your bed. Iodine through food or supplements is helpful only if you are deﬁcient this nutrient. Cooking usually inactivates these goitrogens, so this is the rare case where cooked is preferred over raw. Other factors that may worsen the effects of soy on thyroid function are iodine deﬁciency, consumption of other goitrogens, and other problems synthesizing thyroid hormones. Until more is known, if you have hypothyroidism, limit intake of soy foods and avoid supplements containing soy. Drastically reducing your calorie intake can lower metabolism, which can make weight management more difﬁcult. Physical activity stimulates the thyroid to secrete more hormone and makes the body more sensitive to any thyroid hormone that is circulating. Top Recommended Supplements Compounded thyroid hormones: Provide the body with biologically active, natural hormones. Both T3 and T4 can be made into delayed-release capsules and tailored to your needs. Multivitamin/mineral complex: Many nutrients are required to produce thyroid hormone, such as vitamin C, E, A, and the B-vitamins. Many people are deﬁcient in selenium, which may hamper thyroid hormone levels, so a complete multivitamin can ensure that all essential nutrients requirements are met.
In terms of screening best pamelor 25mg anxiety 247, monitoring and surveillance of populations could be seen as a forum for not only examining individuals but controlling them generic pamelor 25mg on line anxiety symptoms nervous stomach. This argument is also made by Illich (1974) in his book Medical Nemesis pamelor 25mg line anxiety symptoms men, where he argued that medicine is taking over the responsibility for people’s health and creating a society of medical addicts order pamelor 25mg mastercard anxiety 4th hereford cattle. Screening epitomizes this shift towards social control in that not only are the ill seen by the medical profession but also the healthy as all individuals are now ‘at risk’ from illness (Armstrong 1995). Skrabanek (1988: 1155) argued that screening and the medicalization of health ‘serves as a justiﬁcation for State intrusion into people’s private lives, and for stigmatising those who do not conform’. The possibility that screening may exacerbate existing stigma of particular social groups is particularly relevant to the screening for genetic disorders. At present, society is constituted of a variety of individuals, some of whom have genetic deﬁcits such as Down’s syndrome, cystic ﬁbrosis and sickle-cell anaemia. Although these individuals may be subjected to stereotyping and stigma, society provides treatment and support and attempts to integrate them into the rest of the population. It is possible, however, that screening for such disorders would lead to terminations of pregnancy and a reduction in this stigmatized population. Although this would lead to fewer individuals with these disorders (this may be a positive consequence, as no one wants to suﬀer from sickle-cell anaemia) the individuals who are born with these problems may face increased stigma as they would be part of a greatly reduced minority existing in a world with reduced social provisions for support and treatment. Autonomy – the patient has a right to choose The third ethical principle is that of autonomy. This is based on the view that ‘mentally competent and mature individuals should make decisions about their own future, subject to the constraints required to ensure social order’ (Burke 1992). Proponents of screening argue that screening is central to promoting autonomy in that the individual has a right to have access to information about their health status. According to this model of screening, the doctor is the patient’s gatekeeper to relevant information. However, screening may also undermine an individual’s autonomy if it is construed as a form of social control and doctors are seen as ‘lifestyle police’. Justice – the equal distribution of resources The fourth ethical principle of justice refers to the need for an equal distribution of resources. In addition, the ‘inverse care law’ (Hart 1971), which suggests that those who seek out tests most frequently are often those who need them the least, when applied to screening, highlights a shifting of ﬁnances to the most healthy individuals in society. A cost-eﬀectiveness analysis involves assessing either how to achieve a set objective at minimum cost or how to use a ﬁxed resource to produce the best output. In terms of screening, this raises issues about the objectives of screening (to detect asymptomatic illness, which can be treated) and the degree of resources required to achieve these objectives (minimum interventions such as opportunistic weighing versus expensive interventions such as breast screening clinics). The economic considerations of screening have been analysed for diﬀerent pol- icies for cervical screening (Smith and Chamberlain 1987). The diﬀerent policies include: (1) opportunistic screening (oﬀer a smear test when an individual presents at the sur- gery); (2) oﬀer a smear test every ﬁve years; (3) oﬀer a smear test every three years; and (4) oﬀer a smear test annually. These diﬀerent policies have been oﬀered as possible solutions to the problem of screening for cervical cancer. The results suggest that annual screening in England and Wales would cost £165 million and would potentially prevent 4300 cancers, whereas smears every ﬁve years would cost £34 million and would potentially prevent 3900 cancers. Both studies indicated that intensive screening, counselling and health checks have only a moderate eﬀect on risk factors and the authors discuss these results in terms of the implications for government policies for health promotion through doctor-based interventions. The study involved 26 general practices in 13 towns in Britain and recruited 12,472 individuals aged 40–59 years. The practices within each town were paired according to socio-demographic characteristics and were randomly designated as either the intervention or the com- parison practice. Intervention practices were then randomly allocated either to a further comparison group or to an intervention group. This provided both an internal and external comparison with the subjects receiving the intervention. All intervention practices received screening, but only the intervention group of these practices received lifestyle counselling and follow-up within the one-year period. The screening process involved an appointment with a trained research nurse, who asked about demographic, lifestyle and medical factors and measured height, weight, carbon monoxide, blood pressure, blood glucose and blood cholesterol. The subjects in the intervention group also received lifestyle counselling and repeated follow-up. The counselling used a client-centred family approach and involved an assessment of the patients’ risk status, educational input and a booklet for the subject to document their personally negotiated lifestyle changes. All subjects were then oﬀered follow-up every 1, 2, 3, 4, 6 or 12 months, depending on their risk status. Outcome was measured at the follow-up in terms of changes in the main risk factors for coronary heart disease and the Dundee risk score, which is dependent on serum cholesterol concentration, systolic blood pressure, and previous and current smoking behaviour. Outcome was compared within the intervention practices, between the intervention practice and the internal comparison practice, and between the inter- vention practice and practices in the external comparison group. The results showed a 16 per cent reduction in overall risk score in the intervention practices at one year, a 4 per cent reduction in smoking, a small reduction in systolic (7 mmHg) and diastolic (3 mmHg) blood pressure and marginal reductions in weight (1 kg) and cholesterol concentrations (0. In addition, the greatest changes in risk status were reported in subjects with the highest risk levels. Although this intensive screening and intervention did result in changes in risk for coronary heart disease in the correct direction, Wood et al. The authors also concluded that the government sponsored health promotion clinics ‘would probably have achieved considerably less and possibly no change at all’ (Wood et al. 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 four- year period). The health checks involved the nurse recording information about personal and family history of heart disease, stroke, hypertension, diabetes and cancer. Informa- tion 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 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. 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. Recent dis- cussions 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). 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. Research indicates that sending out invita- tions to enter into a screening programme may not only inﬂuence an individual’s behaviour, but also their psychological state.