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The Merck Manual--Second Home Edition logo
 
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Chapter 5. Prevention
Topics: Introduction | Value of Prevention | Components of Prevention | Barriers to Prevention
 
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Barriers to Prevention

There are a number of barriers to providing preventive care. These barriers can be divided into three categories: barriers involving health care professionals, patients, or health care systems. For example, a doctor may decide against ordering a mammogram, the patient may not go for the mammogram because she is afraid or forgets, or the insurance company may not pay for the mammogram and the patient cannot pay for it because it is too expensive. To be effective, a preventive medicine program has to overcome these barriers and be workable in real-world conditions.

Barriers involving health care professionals include the training of doctors and other health care professionals, which emphasizes acute care over preventive care. Other barriers include uncertainty as a result of conflicting recommendations, a perceived lack of time, sometimes a lack of interest, forgetfulness in the context of many other problems to deal with, little gratification from providing preventive care (since there is no immediate feedback or results to evaluate how well the preventive care has worked), and low reimbursement rates from health insurance companies or Medicare for preventive services.

Barriers involving patients include lack of knowledge as to what preventive services are needed along with ignorance of the potential benefits. People may doubt that a disease that has no symptoms can be detected or that anything can or should be done about it. The mass media often fuels the overall confusion by supplying conflicting messages about what preventive care is needed and how lifestyle actually affects health (for example, Is red wine a help or hindrance to health? Is it okay to eat bacon once in a while?). Also, patients may have other priorities, such as getting treatment for an existing medical problem, or may worry about any potential discomfort associated with the performance of a procedure. Economic factors often present barriers as well. Patients may be unable to afford preventive screening or treatment. In addition, a diagnosis may disqualify a person from receiving health, life, or disability insurance benefits (for example, if a policy does not cover preexisting conditions).

The greatest change regarding prevention will come from patients. Since the leading causes of death are related to lifestyle choices, people will have to change their behavior (for example, stop smoking, increase exercise, wear seat belts) to increase the number of years of healthy life. It is especially difficult for an adult to make a lifestyle change; dietary, smoking, and exercise habits become deeply embedded in a person's psyche early on.

People can increase their chances of receiving preventive services by knowing which ones are appropriate for them and requesting these services from their doctors and other health care professionals. Many managed care organizations are distributing pocket-sized health guides to better inform people about which preventive services they need, based on their risk factors.

Barriers involving the health care system encompass a broad range. Within a doctor's or other health care professional's office, there may be disorganized medical records, no systematic way to provide preventive services, and an inadequate system with which to determine which patient needs what type of preventive service. Additionally, people frequently move, making it difficult to assess what preventive service they have had and what service they may need. Many people do not have a primary care doctor or other health care professional to provide them with comprehensive, coordinated preventive care. More broadly, over 45 million people in the United States lack health insurance. Even for some people who do have health insurance, preventive services may not be covered.

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