By APRIL BOYKIN, LCSW

Health care avoidance is a type of patient disengagement that impedes an individual's health behaviors or causes them to delay obtaining health care, and thus can negatively influence well-being. According to the NIH and other sources, 30 percent to 40 percent of people report avoiding medical care even when they think they should go to a doctor. As medical providers, we know that health outcomes are greatly improved when patients comply with medical recommendations, maintain regular health care schedules, and seek help right away when experiencing concerns about their health. Unfortunately, many of our patients avoid care and only show up when they are in an acute situation. As a result, they experience a worsened prognosis, have fewer treatment options, and have more difficulty responding to treatment, especially in the areas of mental health, heart disease, strokes, cancers, arthritis, urinary incontinence, and infectious disease. When the avoided healthcare is finally accessed, more radical treatment is often required, hospital stays are prolonged, institutionalization may be necessary, and there are higher associated costs. Understanding the psychology behind medical care avoidance can improve health outcomes and decrease costs.

What causes avoidance of healthcare? Many of the causes are apparent; lack of adequate healthcare coverage, costly copays, out-of-pocket expenses, lack of access to providers in a geographic area, and time constraints all keep people from seeking care. In 2018 NORC found that a significant number of people are more afraid of the cost of medical care than they are of a severe illness. All these reasons are substantial and create a Public Health Crisis in themselves. But there are other reasons for medical avoidance, which we will explore in this article. Many people who avoid medical care suffer anxiety, fear of death, and fear of being diagnosed with a life-altering condition, among other things. These fears are pervasive and debilitating and cause mental and emotional anguish as people struggle to reconcile fears of being ill with fears of seeking treatment.

Who makes up medical avoiders, and what are the reasons? In “Predictors of Avoiding Medical Care” (Medical Care Journal 2014), the authors found that people who avoid medical care are characterized by low health self-efficacy. They tend to have less experience with quality care, have difficulty expressing concerns, and fail to get help to resolve their uncertainty about their health. Frequently they do not have their fears attended to by a medical provider. They frequently have no consistent primary care physician, have a negative self-concept, engage in risky behaviors like smoking or drinking, and have a fatalistic attitude about cancer. They also reported that the reasons for avoiding medical care are: preference for self-care or alternative care, dislike or distrust of health care providers, fear or dislike of medical treatments, time and money, the experience of prejudice in healthcare, discomfort with body exams or body-shaming experiences, fear of having a severe issue or hearing bad news, and thoughts of dying. 

It is apparent that for medical care avoiders 1) feeling as if they have no control and are not understood, 2) past negative medical experiences or trauma, and 3) being discounted due to prejudices, weight, or risky activities are the most common categories we should address to improve patient health outcomes.

Interventions to prevent patient delay in obtaining healthcare and improving health outcomes:

No control or Not Understood:

• Choices - When patients feel overwhelmed by what is happening to them it is easy to avoid doing anything at all. Giving a patient a simple choice, such as “do you want your blood work in one week or two? Do you want an open CAT Scan or are you okay with a closed?” Giving options helps give the patient a level of control.
• Active Listening - When our patients demonstrate fears it is easy to want to tell them “don’t worry, everything will be fine” or to even become frustrated or want to ignore the behavior. But when someone feels heard they are more likely to be open to recommendations and behavior changes. When a patient is struggling engage them with active listening skills. Listen, rephrase what was said, and wait for confirmation that you got it right before offering suggestions or problem solving.
• Validation - There is no quicker tool to help deescalate someone who is expressing a high level of emotion, than to tell them that what they are concerned about “makes sense.” “It makes sense that you are concerned about getting another cancer diagnosis,” or “it makes sense that you are frustrated going through more diagnostic testing.” And even for irrational fears, “it makes sense that because you worry about going into the hospital and never coming out you don’t want this procedure.” Once validated, you remove the barrier and have space to explain the treatment recommendations.

Past Experiences

• Trauma Informed Practice - Many people have experienced sexual and physical violence and continue to be reactive in expected and unexpected ways. This is a common reason for avoiding medical care. The vulnerability one experiences when seeking healthcare can trigger a reaction. It has become common practice to discreetly ask or put in your paperwork a question that addresses what might cause or trigger panic or fear in the patient. If you are not yet doing this, please do. Perhaps saying something along the lines of, “We understand that all of our patients have had many different life experiences, some experiences may make seeking medical care uncomfortable. Please note here if you need us to be aware of anything, such as difficulty with touch, high levels of anxiety or fear, etc. “
• Past Bad Experiences - Many people have experienced a medical trauma, a difficult procedure, a poor outcome, or a negative reaction from care providers for themselves or a loved one. These past negative experiences often create a psychological barrier to care.

Discounted:

• Prejudices - Our country has a long history of disparities in healthcare. This awareness must be integrated into how we practice and discussed with the patient if it impacts the patient’s hesitancy, avoidance, or fear of obtaining appropriate medical care.
• Weight and Body Shaming - While weight can be a significant health issue, patients who feel out of control with their weight often avoid seeking medical care because of fears of being shamed, blamed, and made to feel as if they are a bad person because of it. Taking a body positive approach at any weight will help patients feel connected to their practitioner so they will be more likely to participate in interventions. Motivational Interviewing (MI) techniques are great for this population.
• Risky Behaviors - Similarly patients who smoke, drink, use recreational drugs, or even abuse these substances still need medical care. The risk of being shamed, blamed or ridiculed keeps many people away from treatment. MI techniques are great for these issues too.
• Alternative Care - Some people have a preference for alternative treatments. Consider working with patient’s alternative treatments by incorporating them in the treatment plan, rather than rejecting them outright, unless contraindicated.

At some point most of us have put off or skipped a procedure, and then fought with our own fears to reel ourselves back in to medical compliance and good self-care. Realistically, not everyone can. If you have patients that have high anxiety around any healthcare issue, procedure, or compliance, please don’t forget the benefit of counseling. There are trauma reducing techniques, phobia protocols, and other tools that mental health practitioners have that will help patients manage their fear and help them become more actively engaged in their own healthcare.

April Boykin is a Licensed Clinical Social Worker and cofounder of Counseling Resource Services (CRS). Established in 2013, CRS is a community-based in-home integrated behavioral health agency serving the aged and disabled population in Central Florida. As a mental health counselor, she has provided individual, family and caregiver counseling to children, teens and adults.   She can be reached at april@counselingresourceservices.com