Even within the context of evidence based
Even within the context of evidence-based interventions for tobacco screening, the science is imperfect. For example, patients who screen positive for current smoking should receive cessation counseling and prescribed known effective nicotine replacement therapy based on the Public Health Services Guidelines for Tobacco Cessation (US Public Health Service, 2008). Despite having evidence-based interventions, a recent CDC report indicated that smoking cessation remains low and little progress has been made since 2005 with respect to receiving advice to quit and use of counseling and medication (https://www.cdc.gov/mmwr/volumes/65/wr/mm6552a1.htm?s_cid=mm6552a1_w). Furthermore, it Clotrimazole takes on average 10–12 attempts before smokers can successfully quit (US Public Health Service, 2008). Even in the face of successful quitting, relapse can and does occur (US Public Health Service, 2008). The nature of smoking behavior can make the response to evidence-based interventions difficult. The low prevalence of cessation reported by the CDC is surmised to be due partly to the low use of evidence-based cessation treatments (Centers for Disease Control and Prevention, 2017). This example underscores the importance of realizing that while there are evidence-base interventions in conjunction with recommended healthcare screenings, they may not always be carried out with fidelity and they do not necessarily lead to the desired outcomes immediately.
Etic and emic in biomedicine: a dual approach to ACEs screening Finkelhor raises very important and practical issues related to “widespread” ACEs screening, especially given our current healthcare system in the U.S. has a focus on the biomedical model or the etic view of health (Loustaunua & Sobo, 1997). The etic perspective relies on objective criteria; the observer on the outside looking in (Loustaunua & Sobo, 1997). Indeed, our current allopathic medical and healthcare systems are very much etic focused science, thus formative medical training and evidence-based interventions in knowing “what to do” about subjective view of illnesses and life experiences (e.g. ACEs) is deficient. Felitti (1993) changed this way of viewing health. He utilized the emic approach to systematically understand from the perspective of patients why they were dropping out of a weight management clinic when they were successfully losing weight. He took the time to conduct individual in depth clinical interviews to understand the problem from their perspective. It is from his initial observations, using the emic approach, that the ACE Study commenced. Nonetheless, healthcare is yet slow to realize the contribution of early life experiences to health and well-being across the lifespan. Tink, Tink, Turin, and Kelly (2017) surveyed medical school residents and reported that more than half never had any formal training on screening for childhood adversities, although 80% of the residents believed that screening for ACEs should be part of their role (Tink et al., 2017). The deficiency of formative training and evidence-based interventions is due largely to the fact that the biomedical model currently lacks emphasis on the psychosocial dimensions of well-being. We must recognize, however, that the field of nursing does the best job of understanding illness and health using both etic and emic perspectives (Loustaunua & Sobo, 1997).
Surveillance, universal screening, and diagnostic screening There are three key methods using the etic approach to assess population-level health: surveillance, universal screening, and diagnostic screening. Surveillance is public health practice, which utilizes ongoing systematic data collection to monitor disease occurrence and to identify disease risk factors across populations. Universal screening utilizes a brief standardized instrument among census patient population to identify individuals at significant risk of having a negative health condition. The results of universal screening indicate the presence of risk characteristics for disease or disability, but do not provide a diagnosis. Finally, diagnostic screening utilizes a detailed process with assessments that involve not only the use of standardized tools, but clinical observations and clinical history as a means to define symptoms and make a clinical diagnosis. Given the three key methods, “widespread” screening of ACEs, may be best understood as ACEs surveillance or universal ACEs screening. Both of these approaches do not diagnose individuals, but rather detect disease and related risk factors to understand exposure in the target population (Gordis, 2014). These public health practices naturally use an etic perspective, because they depend upon objective methods of assessment.