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Informed choice: why measuring behaviour is important
  1. T M Marteau1,
  2. E Dormandy1,
  3. R Crockett1
  1. 1Health Psychology Section, Psychology Dept (at Guy’s), Institute of Psychiatry, King’s College London, 5th Floor, Thomas Guy House, Guy’s Campus, London Bridge, London SE1 9RT, UK
  1. Correspondence to:
    Prof. T M Marteau
    Professor of Health Psychology, Health Psychology Section, Guy’s Hospital, 5th Floor, Thomas Guy House, London Bridge, London SE1 9RT, UK;
  1. B O Olusanya2,
  2. L M Luxon2,
  3. S L Wirz2
  1. 2Institute of Child Health, and Great Ormond Street Hospital for Children NHS Trust, London, UK

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    Olusanya et al debate the principles of informed choice within the context of infant hearing screening.1 In doing so they draw on our conceptualisation and measure of informed choice. Unfortunately they draw an erroneous conclusion, namely that it is inappropriate to measure uptake as part of assessing informed choice. This is based on a misinterpretation of both our definition of informed choice and its measurement.

    Based on the decision making literature,2 we have proposed an operational definition of informed choice: “one that is based on relevant knowledge, consistent with the decision maker’s values and behaviourally implemented”.3 There are two types of informed choice: an informed choice to decline screening, where someone with good knowledge and negative attitudes towards themselves undergoing screening does not undergo screening; and an informed choice to accept screening where someone with good knowledge and positive attitudes towards themselves undergoing screening, undergoes screening. An assessment of informed choice therefore requires an assessment of knowledge, attitudes, and the consistency between attitudes and screening behaviour, to determine whether screening behaviour, usually referred to as uptake, reflects the attitudes of the person offered screening. This definition and model places no value on whether the choice made is to accept or to decline screening: both such choices can be informed and therefore represent a positive outcome of screening.

    Olusanya et al have also misinterpreted the policy of informed choice in the context of screening.4 The goal of an informed choice strategy for screening is not for everyone to have positive attitudes towards undergoing the procedure, but rather that people act consistently with their own values, not those of others, including healthcare professionals. There are some situations where there is one clear choice and healthcare professionals recommend a course of action; for example, the need for an emergency laparotomy or the need to reduce a diuretic dose in someone with a low serum potassium.5 Undergoing a screening test does not fall into this category.

    We hope this serves to clarify the misunderstanding that Olusanya and colleagues appear to be labouring under, with regard to both the concept of informed choice and its operationalisation.


    Authors’ reply

    Is negative parental attitude towards infant hearing screening justifiable?

    Marteau et al took exception to the following phrase in our paper:

    “Our model differs from the three-dimensional typology proposed by Marteau et al, which incorporated uptake as a measure of informed choice. In our view, uptake represents a consequence rather than the goal of informed choice and was therefore excluded as a measure.”

    and went on to raise the following issues which we wish to address in this reply:

    • That we drew on their conceptualisation and measure of informed choice in a way that misrepresented their definition and measure of informed choice

    • That the definition and the measure of informed choice must include a measure of uptake or “behaviour”

    • That the goal of informed choice is not for everyone to have positive attitudes towards undergoing the procedure, but rather that people act consistently with their own values (whatever they are).

    Firstly, our two-dimensional (knowledge and attitude) model was adapted from our previous work on the social change that underpins public health interventions.1 It preceded the three dimensional (knowledge, attitude, and uptake/behaviour) model by Marteau and colleagues2 and was first presented at an international conference in Manchester in 1999.3 It was conceived from an earlier work on the management of corporate change by Professor Paul Strebel of the International Institute for Management Development (IMD) in Switzerland as was acknowledged in the earlier report.1 We have simply contextualised that earlier model for infant hearing screening in this paper and highlighted the difference with a generic model.2 The authors’ subtle claim to originality is therefore presumptuous.

    The last two points on the definition, goal, and measure of informed choice are inter-related. The word “choice” in the context of our paper is defined as “the act of choosing” (Webster Collegiate Dictionary) rather than the actual choice that is made among available options. The expectation in any screening programme is that there is high uptake and that this is based on informed consent. But this must not be confused with the goal of our paper, which was to examine the route to informed choice/decision making. The General Medical Council (GMC) for instance stipulates that healthcare workers “must take appropriate steps to find out what patients want to know and ought to know about their condition and its treatment”.4 To suggest that parents should be allowed to act consistently with their values (whatever they are) shows a lack of understanding of the challenge of offering public health intervention, particularly where parental doubts exist.5–8 It also overlooks cases where parental perception towards non-life threatening conditions such as infant hearing loss may be nonchalant.1 The readiness or willingness to accept screening is reflected in parental attitude (positive or negative) towards screening. It is immoral to ignore a negative attitude towards a public health intervention that is in the patient’s best interest, especially when it emanates from personal or cultural values, or even unfavourable past experience.9 Moreover, an “assessment of the consistency between attitudes and screening behaviour” is an academic exercise that is irrelevant for our purpose. A recent article perhaps sums up the principle underlying our model: a doctor believes in facts, but a manager believes in perceptions.10

    In summary, our model is a simple and practical tool that is intended as a guide for healthcare workers to facilitate a positive attitude towards infant hearing screening in cross-cultural settings without attempting to coerce or frighten parents into giving consent. From this point, it is entirely the parents’ responsibility to give or withhold consent and to accept the consequences of that decision. Sadly, the authors failed to comprehend this crucial context, which perhaps explains their inability to relate their commentary to child health interventions or specifically to infant hearing screening. However, we are pleased to observe a common ground on this subject—that knowledge and attitude are key determinants of parental decision making (and perhaps also, readiness) for infant hearing screening.



    • Competing interests: none declared


    • Competing interests: none declared