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Does Thinking about Personal Health Risk Increase Anxiety?
Journal of Health Psychology
Abstract
This study aimed to examine the effect on anxiety about health of a self-referent health questionnaire, in which people were asked to respond to questions about personal risk factors. Participants were randomly allocated into one of two experimental conditions (completing a self-referential assessment of their current health, or personality), with dependent variables measured before and after the experimental manipulation. Dependent variables included general and disease-specific (CHD, Stroke and Diabetes) anxiety and need for reassurance. Analysis of covariance suggested that participants who completed the health-focused questionnaire significantly increased in their anxiety ratings about Heart Disease, Stroke and Diabetes relative to those who completed the personality-focused assessment. There was no effect on general anxiety ratings. The results have important implications for measurement procedures commonly employed in health psychology, as they suggest that asking participants to rate factors related to health risk may lead to other psychological changes. It is important that subsequent research identify the duration of such effects.
... 12,13 The evidence in both of these areas is summarised in Boxes 1 and 2. In addition, there is evidence from randomised studies showing that people who complete questionnaires about the consequences of health conditions have higher anxiety levels than people who have not completed such questionnaires. 18,19 Furthermore, when people complete questionnaires about anxiety for the first time, they score more highly than when they are measured subsequently. 18,20,21 Other measurement procedures widely employed to assess outcomes in RCTs (e.g. ...
... Accordingly, current knowledge suggests that trials with health-related behaviours as outcomes of interest are most at risk of bias from MR. Although not investigated to the same extent, there is also evidence that completing health-focused questionnaires increases anxiety, 19 and so study outcomes related to anxiety are also likely to be at risk of bias from MR. ...
Background
Measurement can affect the people being measured; for example, asking people to complete a questionnaire can result in changes in behaviour (the ‘question–behaviour effect’). The usual methods of conduct and analysis of randomised controlled trials implicitly assume that the taking of measurements has no effect on research participants. Changes in measured behaviour and other outcomes due to measurement reactivity may therefore introduce bias in otherwise well-conducted randomised controlled trials, yielding incorrect estimates of intervention effects, including underestimates.
Objectives
The main objectives were (1) to promote awareness of how and where taking measurements can lead to bias and (2) to provide recommendations on how best to avoid or minimise bias due to measurement reactivity in randomised controlled trials of interventions to improve health.
Methods
We conducted (1) a series of systematic and rapid reviews, (2) a Delphi study and (3) an expert workshop. A protocol paper was published [Miles LM, Elbourne D, Farmer A, Gulliford M, Locock L, McCambridge J, et al. Bias due to MEasurement Reactions In Trials to improve health (MERIT): protocol for research to develop MRC guidance. Trials 2018; 19 :653]. An updated systematic review examined whether or not measuring participants had an effect on participants’ health-related behaviours relative to no-measurement controls. Three new rapid systematic reviews were conducted to identify (1) existing guidance on measurement reactivity, (2) existing systematic reviews of studies that have quantified the effects of measurement on outcomes relating to behaviour and affective outcomes and (3) experimental studies that have investigated the effects of exposure to objective measurements of behaviour on health-related behaviour. The views of 40 experts defined the scope of the recommendations in two waves of data collection during the Delphi procedure. A workshop aimed to produce a set of recommendations that were formed in discussion in groups.
Results
Systematic reviews – we identified a total of 43 studies that compared interview or questionnaire measurement with no measurement and these had an overall small effect (standardised mean difference 0.06, 95% confidence interval 0.02 to 0.09; n = 104,096, I ² = 54%). The three rapid systematic reviews identified no existing guidance on measurement reactivity, but we did identify five systematic reviews that quantified the effects of measurement on outcomes (all focused on the question–behaviour effect, with all standardised mean differences in the range of 0.09—0.28) and 16 studies that examined reactive effects of objective measurement of behaviour, with most evidence of reactivity of small effect and short duration. Delphi procedure – substantial agreement was reached on the scope of the present recommendations. Workshop – 14 recommendations and three main aims were produced. The aims were to identify whether or not bias is likely to be a problem for a trial, to decide whether or not to collect further quantitative or qualitative data to inform decisions about if bias is likely to be a problem, and to identify how to design trials to minimise the likelihood of this bias.
Limitation
The main limitation was the shortage of high-quality evidence regarding the extent of measurement reactivity, with some notable exceptions, and the circumstances that are likely to bring it about.
Conclusion
We hope that these recommendations will be used to develop new trials that are less likely to be at risk of bias.
Future work
The greatest need is to increase the number of high-quality primary studies regarding the extent of measurement reactivity.
Study registration
The first systematic review in this study is registered as PROSPERO CRD42018102511.
Funding
Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council–National Institute for Health Research Methodology Research Programme.
... The most compelling evidence of MR is found in two areas: (a) the question-behaviour effect, where measurement in the form of asking questions about behaviour, produces small changes in the behaviour being asked about [3,5,6], and (b) the effects of measuring physical activity using pedometers (particularly where step counts can be read by participants) producing increases in physical activity [7,8]. In addition, there is also evidence from randomised studies showing that completing questionnaires about the consequences of illness results in people reporting higher anxiety levels than people who have not completed them [9]. Other measurement procedures widely employed in RCTs, such as assessing bodyweight, are also used as intervention techniques in their own right, as they are seen to be effective at producing behaviour change [10]. ...
Objective:
This study (MEasurement Reactions In Trials) aimed to produce recommendations on how best to minimise bias from measurement reactivity in randomised controlled trials of interventions to improve health.
Study design and setting:
The MERIT study consisted of: (a) an updated systematic review that examined whether measuring participants had effects on participants' health-related behaviours, relative to no-measurement controls, and three rapid reviews to identify: (i) existing guidance on measurement reactivity; (ii) existing systematic reviews of studies that have quantified the effects of measurement on behavioural or affective outcomes; and (iii) studies that have investigated the effects of objective measurements of behaviour on health-related behaviour; (b) an Delphi study to identify the scope of the recommendations; and (c) an expert workshop in October 2018 to discuss potential recommendations in groups.
Results:
Fourteen recommendations were produced by the expert group to: (a) identify whether bias is likely to be a problem for a trial; (b) decide whether to collect data about whether bias is likely to be a problem; (c) design trials to minimise the likelihood of this bias.
Conclusions:
These recommendations raise awareness of how and where taking measurements can produce bias in trials, and are thus helpful for trial design.
... For example, it appears that when people complete anxiety questionnaires on multiple occasions, they score higher on the first occasion of measurement [10]. By contrast, when anxiety measures are placed at the end of questionnaires this results in higher anxiety scores than when they are placed at the beginning of questionnaires [11]. In addition to the effects of answering questions, there is also some evidence that objective research assessments, such as electronic monitoring of behaviour may produce similar reactions [12]. ...
Background
There is now clear systematic review evidence that measurement can affect the people being measured; much of this evidence focusses on how asking people to complete a questionnaire can result in changes in behaviour. Changes in measured behaviour and other outcomes due to this reactivity may introduce bias in otherwise well-conducted randomised controlled trials (RCTs), yielding incorrect estimates of intervention effects. Despite this, measurement reactivity is not currently adequately considered in risk of bias frameworks. The present research aims to produce a set of guidance statements on how best to avoid or minimise bias due to measurement reactivity in studies of interventions to improve health, with a particular focus on bias in RCTs.
Methods
The MERIT study consists of a series of systematic and rapid reviews, a Delphi study and an expert workshop to develop guidance on how to minimise bias in trials due to measurement reactivity. An existing systematic review on question-behaviour effects on health-related behaviours will be updated and three new rapid reviews will be conducted to identify (1) existing guidance on measurement reactivity; (2) systematic reviews of studies that have quantified the effects of measurement on outcomes relating to behaviour and affective outcomes in health and non-health contexts and (3) trials that have investigated the effects of objective measurements of behaviour on concurrent or subsequent behaviour itself. A Delphi procedure will be used to combine the views of experts with a view to reaching agreement on the scope of the guidance statements. Finally, a workshop will be held in autumn 2018, with the aim of producing a set of guidance statements that will form the central part of new MRC guidance on how best to avoid bias due to measurement reactivity in studies of interventions to improve health.
Discussion
Our ambition is to produce MRC guidance on measurement reactions in trials which will be used by future trial researchers, leading to the development of trials that are less likely to be at risk of bias.
Electronic supplementary material
The online version of this article (10.1186/s13063-018-3017-5) contains supplementary material, which is available to authorized users.
... To illustrate this point, studies on patients' understanding of genetic risk information and its psychological, behavioral, and social impact on decision making and behavior change are needed. In this regard, it is critical to evaluate the psychosocial impact of genetic testing and to determine the duration of any adverse psychological effects (Lister, Rode, Farmer, & Salkovskis, 2002). Methodological rigor is essential to adequately characterize psychosocial response as many studies lack baseline information on the psychological functioning of their participants. ...
Behavioral telehealth, health informatics, organ and tissue transplantation, and genetics are among the areas that have been affected by advances in technology and medicine. These areas illustrate the opportunities and the challenges that new developments can pose to health psychologists. Each area is discussed with respect to implications for practice, research, public policy, and education and training: recommendations are provided.
Objectives To determine how college students perceive their risk of developing diabetes over their life course, with specific emphasis on their beliefs about the influence of inherited versus behavioral risk factors.
Methods An Internet-based survey instrument was administered to students of a major university and was analyzed for perceived risk of developing common chronic diseases. 703 students responded to the survey. A bivariate ordered probit regression model was used to simultaneously predict perceived risk for both ten-year absolute risk of diabetes and lifetime absolute risk of diabetes.
Results Ten-year absolute risk and lifetime absolute risk were both increased when the respondent self-identified with a race other than white (β = 0.422, p = 0.000 and β = 0.334, p = 0.000, respectively), and when the respondent had an increasing number of family members with diabetes (β = 0.330, p = 0.000 and β = 0.450, p = 0.000, respectively). Beliefs linking behavioral risk factors to perceived risk of developing diabetes across the life course were not statistically significant.
Conclusion Behavioral risk factors were not statistically significant predictors of perceived risk for developing diabetes across the life course. Inherited risk factors, such as race and number of family members with diabetes, were statistically significant predictors of perceived risk of developing diabetes across the life course. Evidence-based interventions about the role of behavioral risk factors in developing diabetes are needed.
Autism spectrum disorders (ASDs) are an issue of significant and growing importance to the field of public health. The prevalence of ASDs is rising, and these disorders significantly impact the quality of life of affected persons and their families. Though the etiology of ASDs has long been poorly understood, in recent years, studies are revealing genetic and environmental risk information about ASDs, with much more risk information expected to follow from scientific studies currently underway. The availability of this risk information raises questions about whether and how it should be communicated to individuals, families, and the public at large. One ethical issue of particular concern with ASD risk communication is the possibility that it may cause inadvertent harm to risk message recipients. Here we review the emerging picture of ASD risk, discuss some ways in which it may lead to inadvertent harm, and suggest some future directions for risk communication research and practice that might help to address this issue.
Zusammenfassung. Das „Multidimensional Inventory of Hypochondriacal Traits (MIHT)” (Longley, Watson & Noyes, 2005) ist eine Selbstbeurteilungsskala zur mehrdimensionalen Erfassung von Krankheitsangst (KA) in der Allgemeinbevolkerung. Das MIHT basiert auf kognitiv-behavioralen Modellvorstellungen zur KA und umfasst vier Subskalen: Die kognitive Subskala erfasst die „hypochondrische Entfremdung”, die aus der Uberzeugung resultiert, an einer schweren Erkrankung zu leiden. Die behaviorale Subskala erfragt die Suche nach Ruckversicherungen und sozialer Unterstutzung. Die affektive Subskala erfasst Krankheitssorgen und die perzeptuelle Subskala eine habituelle Aufmerksamkeitslenkung auf korperliche Empfindungen. Die Faktorenstruktur und verschiedene Aspekte der externen Validitat einer deutschsprachigen Version des MIHT wurden anhand von zwei studentischen Stichproben gepruft. Explorative und konfirmatorische Faktorenanalysen belegen in guter Ubereinstimmung mit der englischen Version die vierfaktorielle Subska...
There is evidence from laboratory studies that anxiety scores are elevated by completing questionnaires about health problems for the first time. This limits interpretation of the common finding that people receiving risk information from screening programs show elevated anxiety (as assessed by questionnaire) in the short-term, which subsides over time. We examine the extent to which postal questionnaire studies are affected by this potential measurement artifact.
Participants were 964 patients at high risk of undiagnosed diabetes, registered at five general practices. A two-group randomized experimental design was used, with the experimental group (n=484) receiving an initial questionnaire concerning screening for diabetes, and the control group (n=480) not receiving this questionnaire. Outcomes were assessed by an identical questionnaire 3 months later.
There were no significant differences in questionnaire scores at three months between the two groups on any of the outcome measures, including anxiety, symptoms, perceptions of diabetes severity, and perceived diabetes risk.
These results suggest that the problems associated with the use of anxiety questionnaires that are found in laboratory studies do not occur in postal studies: the observed changes in anxiety after receiving screening results are therefore unlikely to be artifactual.
This study aimed to determine how college students perceive their risk of developing diabetes over their life course, with specific emphasis on their beliefs about the influence of inherited versus behavioral risk factors. A bivariate ordered probit regression model was used to simultaneously predict perceived risk for 10-year absolute risk of diabetes and lifetime absolute risk of diabetes. Ten-year and lifetime absolute risk were both increased when the respondent self-identified with a race/ethnicity other than non-Hispanic white (β = 0.42, p < .001 and β = 0.33, p = .004, respectively), and when the respondent had an increasing number of family members with diabetes (β = 0.33, p < .001 and β = 0.45, p < .001, respectively). Beliefs linking behavioral risk factors to perceived risk of developing diabetes across the life course were not statistically significant. The absence of significant association between perceptions of behavioral risk as factors for developing diabetes and perceived risk for diabetes over the life course supports the need for educational interventions about behavioral and genetic causes of diabetes among the college-aged population.
Measurement reactivity is defined as being present where measurement results in changes in the people being measured. The main aim of this review is to provide an overview of the current state of knowledge concerning the extent and nature of psychological measurement affecting people who complete the measures. Other aims are to describe how this may affect conclusions drawn in health psychology research and to outline where more research is needed.
Narrative review.
Several studies, using a variety of methods, have found measurement procedures to alter subsequent cognition, emotion, and behaviour. In many instances, the effects obtained were of up to medium size. However, the extent to which such studies are representative is not clear: do other studies which find no reactive effects of measurement not exist or do they exist but are not reported?
Although measurement reactivity can yield medium-sized effects, our understanding of this phenomenon is still rudimentary. We do not know the precise circumstances that are likely to result in measurement reactivity: we cannot predict when problems are more likely to arise. There is a particular absence of studies of the mechanisms by which measurement reactivity arises. There is a need for a systematic review of this literature, which should aim to quantify the extent of measurement reactivity effects and to provide a firmer evidence base for theorizing about the sources of reactivity.
The effects of arthritis are complex and largely interdependent. Pain may produce physical disability, which in turn can produce social disability and changes in HRQOL. Joint and muscle disuse resulting from physical disability produces muscle atrophy, bone density loss, and may lead to further pain. People with arthritis should be encouraged to manage their own illness and take responsibility for their own care in the long term. Both physical and manual therapies may appropriate for people with arthritis, depending upon their readiness to adopt self-management strategies. ASMPs, based on Lorig's work, are offered through arthritis foundations in many countries around the world. These programs have been well evaluated, and shown to improve both physical and psychological well-being in people with arthritis. Furthermore, these programs appear to reduce the direct healthcare costs associated with arthritis care (Lorig et al 1993). ASMPs are of greatest use to people in the action and maintenance stages of change (Kerns & Rosenberg 2000). Therapists can use consultations as a vehicle for communication with clients, and to assist them in the transition from practitioner-driven to client-driven care, from the early to later stages of change. Practitioners of the passive (usually manual) therapies are advised to use deliberate tactics such as mutually agreed care contracts to prevent client dependence.
This study tested the impact on response and psychological measures of different follow-up schedules for participants in a study screening for type 2 diabetes risk.
Participants were randomly allocated either to limited follow-up (n=213), with a single questionnaire at 1 year, or to intensive follow-up (n=218), with questionnaires sent 1, 6, and 12 months after screening.
There were no statistically significant differences between the groups at 1 year in either response rate (P=.08) or change from baseline to 1-year follow-up in scores on the short form of the Spielberger State Anxiety Inventory (SSAI-SF; P=.13), although there was a statistically significant but small difference between the groups in the change score of the 12-item Well-Being Questionnaire (WBQ-12; P=.003). The proportion of participants completing a WBQ-12 measure at 1 year was significantly greater in the intensive follow-up group (P=.03).
This study shows no important adverse effect of repeated questionnaire use on response rates or psychological outcomes and suggests that some measures may be more fully completed with intensive follow-up.
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.
Two experiments showed that self-reports of physical symptom frequency increase after people make abstract decisions about health connotations of common words. In Experiment 1, scores on a standardized symptom frequency inventory were substantially higher among subjects who completed the inventory after the decision task than among subjects who completed the inventory before the task. In Experiment Z similar increases were found in reports of discrete symptom episodes occurring within a specific time frame, and arousal and mood explanations were ruled out. Evidence was also obtained that manipulated accessibility of health cognitions (induced by the word decision task) and individual differences in propensity to report symptoms affect symptom reporting independently and that persons who consistently report higher levels of symptoms tend to make abstract decisions in the health domain more quickly. Discussion centers on implications for symptom measurement and on how the experimental results extend existing models of abnormal symptom reporting.
To examine the psychological effects of bone density measurement, 298 women were assessed two weeks before the bone density scan, immediately before the scan, after the results, a week later and three months later. For the group as a whole, ratings of anxiety and perceived vulnerability were lower at the three month follow-up than at the initial assessment. Women who received a low bone mineral density (BMD) result were more anxious and reported more osteoporosis-preventive behaviours at the three month follow-up than women who received a high BMD result; these differences had not been apparent at the initial assessment Women with low BMD results had higher ratings of perceived vulnerability after the scan, although for some of these ratings there were group differences before the scan. Women with a low BMD result showed a decrease in ratings of the seriousness of a below-average result, which may reflect minimization of the health threat
Research aimed at identifying genes contributing to the aetiology of
psychological disorders is in progress. This raises the possibility that
genetic testing for such genes might become available. In this paper the
possible psychological consequences of genetic testing for psychological
disorders are examined. It is proposed that genetic testing may cause
psychological and behavioural reactions that actually increase the
person’s risk of developing a psychological disorder or may maintain
existing problems. It is also suggested that cognitive-behavioural models
may be able to aid prediction of some of the likely consequences of testing
and identify people who are likely to react in particularly negative ways to
news of their genetic risk. If genetic tests for psychological disorders are developed, it is
important that research is carried out into the psychological and behavioural
effects of testing and ways of minimizing adverse effects, before such tests
become widely available.
Objectives. Increasing availability of predictive testing highlights the importance of understanding the decision-making process when people are confronted with the optionto have testing. The present study aimed to demonstrate experimentally the impact of (i) providing relatively positive versus relatively negative information, and (ii) focusing on positive or negative issues, on anticipated decisions regarding genetic testing. Method. Two experimental studies were carried out in order to investigate what influences the anticipated decision, one relating to breast cancer and the other heart disease. In each study, participants were randomly allocated to either the positive, the negative or the control group. There were two consecutive experimental manipulations. Firstly, participants were given further information on detecting and preventing the disease (positive group) and on the limitations of these methods (negative group). The control group received information about the common cold. Secondly, participants were encouraged to focus on positive (positive group) or negative (negative group) issues of predictive testing. The control group focused on statements referring to the common cold. Participants made pre-experimental and post-information and post-focusing ratings including how likely they would be to opt for the test. Results. Both information and the focusing manipulations separately modified the rating of anticipated likelihood of being tested in the expected direction. There was also a significant decrease of rated anxiety in the negative group. Conclusion. It appears that anticipated decisions are strongly influenced not only by the information received by the decision maker, but also by the factors on which the decision maker focuses at the time of the decision. This second result in particular has implications for the way in which pre-test counselling is carried out; counsellors may believe that they are being non-directive in their questioning when they are in fact directly and systematically influencing the decision whether or not to be tested.
Advances in medical technology such as those linked to the human genome project are increasing the potential for predictive testing for a wide range of health threats. There have not been comparable advances in understanding of the psychological factors involved in such testing. These factors and issues relating to them are examined, and it is suggested that a cognitive-behavioral approach to the understanding and management of adverse reactions to testing is likely to be particularly fruitful. The use of such an approach should result in the development of effective pre- and posttest interventions to prevent, minimize, and manage distress associated with screening.
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.