151
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Cook C, Brunton M, Pukepuke T, Tan AL. Exploring communication during the journey from noticing bodily changes to a diagnosis of endometrial cancer. J Clin Nurs 2017; 27:1262-1275. [DOI: 10.1111/jocn.14173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Catherine Cook
- School of Nursing; Massey University; Albany New Zealand
| | - Margaret Brunton
- School of Communication Journalism & Marketing; Massey University; Auckland New Zealand
| | | | - Ai Ling Tan
- Department of Gynaecology Oncology; Auckland City Hospital; Auckland New Zealand
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152
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King-Okoye M, Arber A, Faithfull S. Routes to diagnosis for men with prostate cancer: men's cultural beliefs about how changes to their bodies and symptoms influence help-seeking actions. A narrative review of the literature. Eur J Oncol Nurs 2017; 30:48-58. [PMID: 29031313 DOI: 10.1016/j.ejon.2017.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/16/2017] [Accepted: 06/21/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE To examine the findings of existing studies in relation to men's cultural beliefs about changes to their bodies relevant to prostate cancer and how these affect interpretation of bodily changes and help-seeking actions. METHOD We undertook a narrative review of studies conducted from 2004 to 2017 in 6 databases that highlighted men's beliefs and help-seeking actions for bodily changes suggestive of prostate cancer. RESULTS Eighteen (18) studies reflecting men from various ethnicities and nationalities were included. The belief that blood and painful urination were warning signs to seek medical help delayed help-seeking among men compared to men that did not experience these symptoms. The belief that urinary symptoms such as dribbling, cystitis and urinary hesitancy were transient and related to ageing, normality and infection significantly delayed symptom appraisal and help-seeking. Men also held the belief that sexual changes, such as impotence and ejaculation dysfunction were private, embarrassing and a taboo. These beliefs impeded timely help-seeking. Cultural beliefs, spirituality and the role of wives/partners were significant for men to help appraise symptoms as requiring medical attention thus sanctioning the need for help-seeking. CONCLUSIONS This review underscores a critical need for further empirical research into men's beliefs about bodily changes relevant to prostate health and how these beliefs affect their interpretation of symptoms and subsequent help-seeking actions.
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Affiliation(s)
- Michelle King-Okoye
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
| | - Anne Arber
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Sara Faithfull
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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153
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Emery JD, Gray V, Walter FM, Cheetham S, Croager EJ, Slevin T, Saunders C, Threlfall T, Auret K, Nowak AK, Geelhoed E, Bulsara M, Holman CDJ. The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia. Br J Cancer 2017; 117:1459-1469. [PMID: 28926528 PMCID: PMC5680459 DOI: 10.1038/bjc.2017.310] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/19/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022] Open
Abstract
Background: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia. Methods: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. Primary outcome: total diagnostic interval (TDI). Results: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI −0.06–0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI −0.18–0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI. Conclusions: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.
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Affiliation(s)
- Jon D Emery
- Department of General Practice and The Centre for Cancer Research, The University of Melbourne, Melbourne, VIC, Australia.,School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Victoria Gray
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Population Health, The University of Western Australia, Crawley, WA, Australia.,Education and Research Division, Cancer Council Western Australia, Subiaco, WA, Australia
| | - Fiona M Walter
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK.,General Practice and Primary Health Care Academic Centre, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Shelley Cheetham
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Emma J Croager
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Terry Slevin
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Christobel Saunders
- School of Surgery, The University of Western Australia, Crawley, WA, Australia
| | - Timothy Threlfall
- Western Australia Cancer Registry, The Department of Health of Western Australia, Perth, WA, Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia, The University of Western Australia, Albany, WA, Australia
| | - Anna K Nowak
- School of Medicine, The University of Western Australia, Crawley, WA, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Elizabeth Geelhoed
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Freemantle, WA, Australia
| | - C D'Arcy J Holman
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
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154
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Mills K, Birt L, Emery JD, Hall N, Banks J, Johnson M, Lancaster J, Hamilton W, Rubin GP, Walter FM. Understanding symptom appraisal and help-seeking in people with symptoms suggestive of pancreatic cancer: a qualitative study. BMJ Open 2017; 7:e015682. [PMID: 28871013 PMCID: PMC5588944 DOI: 10.1136/bmjopen-2016-015682] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Pancreatic cancer has poor survival rates due to non-specific symptoms leading to later diagnosis. Understanding how patients interpret their symptoms could inform approaches to earlier diagnosis. This study sought to explore symptom appraisal and help-seeking among patients referred to secondary care for symptoms suggestive of pancreatic cancer. DESIGN Qualitative analysis of semistructured in-depth interviews. Data were analysed iteratively and thematically, informed by the Model of Pathways to Treatment. PARTICIPANTS AND SETTING Pancreatic cancer occurs rarely in younger adults, therefore patients aged ≥40 years were recruited from nine hospitals after being referred to hospital with symptoms suggestive of pancreatic cancer; all were participants in a cohort study. Interviews were conducted soon after referral, and where possible, before diagnosis. RESULTS Twenty-six interviews were conducted (cancer n=13 (pancreas n=9, other intra-abdominal n=4), non-cancer conditions n=13; age range 48-84 years; 14 women). Time from first symptoms to first presentation to healthcare ranged from 1 day to 270 days, median 21 days. We identified three main themes. Initial symptom appraisal usually began with intermittent, non-specific symptoms such as tiredness or appetite changes, attributed to diet and lifestyle, existing gastrointestinal conditions or side effects of medication. Responses to initial symptom appraisal included changes in meal type or frequency, or self-medication. Symptom changes such as alterations in appetite and enjoyment of food or weight loss usually prompted further appraisal. Triggers to seek help included a change or worsening of symptoms, particularly pain, which was often a 'tipping point'. Help-seeking was often encouraged by others. We found no differences in symptom appraisal and help-seeking between people diagnosed with cancer and those with other conditions. CONCLUSIONS Greater public and healthcare professional awareness of the combinations of subtle and intermittent symptoms, and their evolving nature, is needed to prompt timelier help-seeking and investigation among people with symptoms of pancreatic cancer.
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Affiliation(s)
- Katie Mills
- Department of Public Health and Primary Care, The Primary Care Unit, University of Cambridge, Cambridge, UK
| | - Linda Birt
- Department of Public Health and Primary Care, The Primary Care Unit, University of Cambridge, Cambridge, UK
| | - Jon D Emery
- Department of General Practice, Primary Care Cancer Research, University of Melbourne, Carlton, Victoria, Australia
| | - Nicola Hall
- Evaluation Research Development Unit, School of Medicine, Pharmacy & Health, Durham University, Bristol, UK
| | - Jonathan Banks
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Margaret Johnson
- Department of Public Health and Primary Care, The Primary Care Unit, University of Cambridge, Cambridge, UK
| | - John Lancaster
- Department of Public Health and Primary Care, The Primary Care Unit, University of Cambridge, Cambridge, UK
| | - William Hamilton
- Department of Primary Care Diagnostics, College House, St Luke’s Campus, University of Exeter, Exeter, UK
| | - Greg P Rubin
- Evaluation Research Development Unit, School of Medicine, Pharmacy & Health, Durham University, Bristol, UK
| | - Fiona M Walter
- Department of Public Health and Primary Care, The Primary Care Unit, University of Cambridge, Cambridge, UK
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155
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Lewis L, Marcu A, Whitaker K, Maguire R. Patient factors influencing symptom appraisal and subsequent adjustment to oesophageal cancer: A qualitative interview study. Eur J Cancer Care (Engl) 2017; 27. [PMID: 28857296 DOI: 10.1111/ecc.12745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 02/06/2023]
Abstract
Oesophageal cancer (EC) is characterised by vague symptoms and is often diagnosed at an advanced stage, leading to poor outcomes. Therefore, we aimed to investigate whether there might be any patient factors contributing to delay in EC diagnosis, and focused on the symptom appraisal and help-seeking strategies of people diagnosed with EC in the UK. Semi-structured interviews were conducted with 14 patients aged >18 years with localised EC at point of diagnosis. Purposive sampling was used to include patients from 1 to 9 months post-diagnosis. Analysis of the interviews identified three main themes: Interpreting symptoms, Triggers to seeking help and Making sense of an unfamiliar cancer. Findings suggested that participants normalised symptoms or used previous health experiences as a means to interpret their symptoms. The majority of participants were not alarmed by their symptoms, mainly because they had very little knowledge of EC specific symptoms. Lack of knowledge also influenced participants' sense-making of their diagnosis. The findings highlight that the process of symptom appraisal in EC is likely to be inaccurate, which may hinder early presentation and thus diagnosis. Public health campaigns communicating EC specific symptoms, however, could shorten the appraisal period and lead to earlier diagnosis.
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Affiliation(s)
- Liane Lewis
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Afrodita Marcu
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Katriina Whitaker
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Roma Maguire
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
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156
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Brousselle A, Breton M, Benhadj L, Tremblay D, Provost S, Roberge D, Pineault R, Tousignant P. Explaining time elapsed prior to cancer diagnosis: patients' perspectives. BMC Health Serv Res 2017; 17:448. [PMID: 28659143 PMCID: PMC5490154 DOI: 10.1186/s12913-017-2390-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/15/2017] [Indexed: 11/10/2022] Open
Abstract
Background Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients’ prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal. Methods This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment. Results Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients’ experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization. Conclusions This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.
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Affiliation(s)
- Astrid Brousselle
- Département des Sciences de la Santé Communautaire, Centre de recherche - Hôpital Charles-Le Moyne, Université de Sherbrooke, 150 Place Charles LeMoyne bureau 200, Longueuil, Quebec, Canada.
| | - Mylaine Breton
- Département des Sciences de la Santé Communautaire, Centre de recherche - Hôpital Charles-Le Moyne, Université de Sherbrooke, 150 Place Charles LeMoyne bureau 200, Longueuil, Quebec, Canada
| | | | - Dominique Tremblay
- École des Sciences Infirmières, Centre de recherche - Hôpital Charles-Le Moyne, Université de Sherbrooke, Longueuil, Quebec, Canada
| | - Sylvie Provost
- Direction de Santé Publique de Montréal, Institut de Recherche en Santé Publique de l'Université de Montréal, Montreal, Quebec, Canada
| | - Danièle Roberge
- Département des Sciences de la Santé Communautaire, Centre de recherche - Hôpital Charles-Le Moyne, Université de Sherbrooke, 150 Place Charles LeMoyne bureau 200, Longueuil, Quebec, Canada
| | - Raynald Pineault
- Direction de Santé Publique de Montréal, Institut de Recherche en Santé Publique de l'Université de Montréal, Montreal, Quebec, Canada.,Institut National de Santé Publique, Montreal, Canada
| | - Pierre Tousignant
- Direction de Santé Publique de Montréal, McGill University Health Centre, Montreal, Quebec, Canada.,Institut National de Santé Publique, Montreal, Canada
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157
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Prior JA, Ranjbar H, Belcher J, Mackie SL, Helliwell T, Liddle J, Mallen CD. Diagnostic delay for giant cell arteritis - a systematic review and meta-analysis. BMC Med 2017; 15:120. [PMID: 28655311 PMCID: PMC5488376 DOI: 10.1186/s12916-017-0871-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/09/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Giant cell arteritis (GCA), if untreated, can lead to blindness and stroke. The study's objectives were to (1) determine a new evidence-based benchmark of the extent of diagnostic delay for GCA and (2) examine the role of GCA-specific characteristics on diagnostic delay. METHODS Medical literature databases were searched from inception to November 2015. Articles were included if reporting a time-period of diagnostic delay between onset of GCA symptoms and diagnosis. Two reviewers assessed the quality of the final articles and extracted data from these. Random-effects meta-analysis was used to pool the mean time-period (95% confidence interval (CI)) between GCA symptom onset and diagnosis, and the delay observed for GCA-specific characteristics. Heterogeneity was assessed by I 2 and by 95% prediction interval (PI). RESULTS Of 4128 articles initially identified, 16 provided data for meta-analysis. Mean diagnostic delay was 9.0 weeks (95% CI, 6.5 to 11.4) between symptom onset and GCA diagnosis (I 2 = 96.0%; P < 0.001; 95% PI, 0 to 19.2 weeks). Patients with a cranial presentation of GCA received a diagnosis after 7.7 (95% CI, 2.7 to 12.8) weeks (I 2 = 98.4%; P < 0.001; 95% PI, 0 to 27.6 weeks) and those with non-cranial GCA after 17.6 (95% CI, 9.7 to 25.5) weeks (I 2 = 96.6%; P < 0.001; 95% PI, 0 to 46.1 weeks). CONCLUSIONS The mean delay from symptom onset to GCA diagnosis was 9 weeks, or longer when cranial symptoms were absent. Our research provides an evidence-based benchmark for diagnostic delay of GCA and supports the need for improved public awareness and fast-track diagnostic pathways.
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Affiliation(s)
- James A Prior
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK.
| | - Hoda Ranjbar
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - John Belcher
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Toby Helliwell
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - Jennifer Liddle
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK.,Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christian D Mallen
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
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158
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Simons G, Lumley S, Falahee M, Kumar K, Mallen CD, Stack RJ, Raza K. The pathway to consultation for rheumatoid arthritis: exploring anticipated actions between the onset of symptoms and face-to-face encounter with a healthcare professional. BMC Musculoskelet Disord 2017; 18:258. [PMID: 28615051 PMCID: PMC5471998 DOI: 10.1186/s12891-017-1619-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/06/2017] [Indexed: 11/25/2022] Open
Abstract
Background When people first experience symptoms of rheumatoid arthritis (RA) they often delay seeking medical attention resulting in delayed diagnosis and treatment. This research assesses behaviours people might engage in prior to, or instead of, seeking medical attention and compares these with behaviours related to illnesses which are better publicised. Methods Thirty-one qualitative interviews with members of the general public explored intended actions in relation to two hypothetical RA vignettes (with and without joint swelling) and two non-RA vignettes (bowel cancer and angina). The interviews were audio-recorded and transcribed. Analysis focused on intended information gathering and other self-management behaviours in the interval between symptom onset and help-seeking. Results Participants were more likely to envision self-managing symptoms when confronted with the symptoms of RA compared to the other vignettes. Participants would look for information to share responsibility for decision making and get advice and reassurance. Others saw no need for information seeking, perceived the information available as untrustworthy or, particularly in the case of bowel cancer and angina, would not want to delay seeking medical attention. Participants further anticipated choosing not to self-manage the symptoms; actively monitoring the symptoms (angina/ bowel cancer) or engaging in self-treatment of symptom(s). Discussion These results help define targets for interventions to increase appropriate help-seeking behaviour for people experiencing the initial symptoms of RA, such as educational interventions directed at allied healthcare professionals from whom new patients may seek information on self-management techniques, or the development of authoritative and accessible informational resources for the general public.
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Affiliation(s)
- Gwenda Simons
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK.
| | - Sophie Lumley
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - Marie Falahee
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - Kanta Kumar
- Faculty of Medical and Human Sciences, School of Nursing, University of Manchester, Manchester, UK
| | - Christian D Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Rebecca J Stack
- College of Business Law & Social Sciences, School of Social Sciences, Nottingham Trent University, Nottingham, UK; Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - Karim Raza
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK; Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, UK
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159
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Carolan C, Smith A, Davies G, Forbat L. Seeking, accepting and declining help for emotional distress in cancer: A systematic review and thematic synthesis of qualitative evidence. Eur J Cancer Care (Engl) 2017; 27:e12720. [DOI: 10.1111/ecc.12720] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 11/27/2022]
Affiliation(s)
- C.M. Carolan
- Faculty of Health Sciences and Sport; University of Stirling (Western Isles Campus); Stornoway UK
- NHS Western Isles; Stornoway UK
| | - A. Smith
- Faculty of Health Sciences and Sport; University of Stirling (Western Isles Campus); Stornoway UK
| | - G.R. Davies
- PGT Tertiary & Higher Education; Faculty of Arts, Humanities and Business; Lews Castle College UHI; Stornoway UK
| | - L. Forbat
- Palliative Care; Australian Catholic University and Calvary Health Care; Australian Catholic University; Canberra ACT Australia
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160
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Sheringham J, Sequeira R, Myles J, Hamilton W, McDonnell J, Offman J, Duffy S, Raine R. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf 2017; 26:449-459. [PMID: 27651515 DOI: 10.1136/bmjqs-2016-005679] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/24/2016] [Accepted: 08/18/2016] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Lung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations. METHODS A factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors ('patients'). GP participants made management decisions online for six 'patients', whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each 'patient' had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression. RESULTS GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that 'patients' had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger 'patients' (AOR=0.52; 95% CI 0.39 to 0.7) and black 'patients' than white (AOR=0.68; 95% CI 0.48 to 0.95). CONCLUSIONS GPs were not more likely to investigate 'patients' with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.
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Affiliation(s)
| | | | - Jonathan Myles
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
| | - William Hamilton
- University of Exeter, Peninsula College of Medicine and Dentistry, Exeter, UK
| | - Joe McDonnell
- Department of Public Health, London Borough of Waltham Forest, London, UK
| | - Judith Offman
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
| | - Stephen Duffy
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
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161
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Fles R, Bos ACRK, Supriyati, Rachmawati D, Waliyanti E, Tan IB, Haryana SM, Schmidt MK, Dewi FST. The role of Indonesian patients' health behaviors in delaying the diagnosis of nasopharyngeal carcinoma. BMC Public Health 2017; 17:510. [PMID: 28545416 DOI: 10.1186/s12889-017-4429-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 05/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With an estimated 13,000 newly diagnosed patients per year, nasopharyngeal carcinoma (NPC) is one of the most common types of cancer in males in Indonesia. Moreover, most patients are diagnosed at an advanced stage of the disease. This study aimed to explore the health behaviors of patients diagnosed with NPC and the possible causes of patient delay in NPC diagnosis. METHODS A qualitative research method was used to gain better insight into patient behaviors. Twelve patients were interviewed using semi-structured interview guidelines. All interviews were recorded, transcribed verbatim and analyzed according to a standard content analysis framework. RESULTS Most patients had limited knowledge regarding NPC and its causes. Fifty percent of the patients had a delay of six months from the onset of symptoms to diagnosis. The main reason for this delay was the lack of awareness among the patients, which was influenced by their environment, economic status, family, culture, and religion. The perceived barriers to seeking medical help included direct non-medical costs not covered by health insurance, complex and time-consuming insurance and referral systems, and negative experiences in the past. Health insurance did motivate people to seek medical help. CONCLUSION This study provides additional insight into patients' motivations to delay seeking medical help and can facilitate the design of NPC education programs. To improve awareness of the abovementioned causes for delay, community-based education programs are highly warranted and should focus on the recognition of NPC symptoms and possible solutions to overcome the main barriers at an earlier disease stage.
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162
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Kummer S, Walter FM, Chilcot J, Scott S. Measures of psychosocial factors that may influence help-seeking behaviour in cancer: A systematic review of psychometric properties. J Health Psychol 2017; 24:79-99. [PMID: 28810457 DOI: 10.1177/1359105317707255] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Advanced stage cancer is frequently attributed to delays in presentation to a healthcare professional. To reduce undue delay, it is imperative to understand the reasons underlying help-seeking behaviour and to measure those using valid and reliable tools. This systematic review aimed to identify how studies have measured psychosocial factors affecting time to presentation for (potential) cancer symptoms. A total of 35 studies were included. Most studies failed to use valid and reliable tools, and predominantly provided inconclusive results regarding psychosocial factors and time to presentation when no or minimal psychometric evidence was present. Consequently, measure selection and future measure development should be guided by psychometric principles.
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Biezen R, Brijnath B, Grando D, Mazza D. Management of respiratory tract infections in young children-A qualitative study of primary care providers' perspectives. NPJ Prim Care Respir Med 2017; 27:15. [PMID: 28258279 DOI: 10.1038/s41533-017-0018-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/01/2017] [Accepted: 02/10/2017] [Indexed: 11/24/2022] Open
Abstract
Respiratory tract infections in young children are the most common cause of general practice visits in Australia. Despite the availability of clinical practice guidelines, the treatment and management of respiratory tract infections in young children is inconsistent. The aim of the study was to explore the management of respiratory tract infections in young children from a multi-disciplinary perspective using across-sectional qualitative research design based on the theoretical domains framework and the Capability, Opportunity and Motivation-B model. In-depth interviews were conducted with 30 primary care providers to explore their knowledge, views and management of respiratory tract infections in young children. Interviews focused on symptomatic management, over-the-counter medications and antibiotic use, and data were thematically analysed. Our findings showed that factors such as primary care providers’ time constraints, parental anxiety, general practitioners’ perception of what parents want, perceived parental pressure, and fear of losing patients were some of the reasons why primary care providers did not always adhere to guideline recommendations. Primary care providers also provided conflicting advice to parents concerning over-the-counter medications and when children should resume normal activities. Overall, this study showed that complex interactions involving emotional and psychological factors influenced the decision making process of primary care providers’ management of respiratory tract infections in young children. A team care approach with consistent advice, and improved communication between primary care providers and parents is vital to overcome some of these barriers and improve guideline adherence. The findings of this research will inform the development of interventions to better manage respiratory tract infections in young children. The emotions and psychology of both parents and clinicians influence how respiratory tract infections (RTIs) are managed in young children. Researchers in Australia, led by Ruby Biezen from Monash University, interviewed 30 primary care clinicians about their views on how to care for children with RTIs, such as the common cold. The interviews focused on symptomatic management, over-the-counter medications and antibiotic use. Despite the availability of best-practice guidelines, clinicians did not always follow the recommendations owing to factors such as time constraints, parental anxiety, perceived parental pressure, and fear of losing patients. These are some of the reasons why clinicians sometimes advise or prescribe unnecessary medications. The authors suggest that a team approach involving multiple healthcare professionals who deliver consistent advice could improve guideline adherence.
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Marcu A, Black G, Vedsted P, Lyratzopoulos G, Whitaker KL. Educational differences in responses to breast cancer symptoms: A qualitative comparative study. Br J Health Psychol 2017; 22:26-41. [PMID: 27680898 DOI: 10.1111/bjhp.12215] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 08/12/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advanced stage at diagnosis for breast cancer is associated with lower socio-economic status (SES). We explored what factors in the patient interval (time from noticing a bodily change to first consultation with a health care professional) may contribute to this inequality. DESIGN Qualitative comparative study. METHODS Semi-structured interviews with a sample of women (≥47 years) from higher (n = 15) and lower (n = 15) educational backgrounds, who had experienced at least one potential breast cancer symptom. Half the participants (n = 15) had sought medical help, half had not (n = 15). Without making breast cancer explicit, we elicited women's sense-making around their symptoms and help-seeking decisions. RESULTS Containment of symptoms and confidence in acting upon symptoms emerged as two broad themes that differentiated lower and higher educational groups. Women from lower educational backgrounds tended to attribute their breast symptoms to trivial factors and were reticent in using the word 'cancer'. Despite 'knowing' that symptoms could be related to cancer, women with lower education invoked lack of medical knowledge - 'I am not a doctor' - to express uncertainty about interpreting symptoms and accessing help. Women with higher education were confident about interpreting symptoms, seeking information online, and seeking medical help. CONCLUSIONS Our findings suggest that knowledge of breast cancer alone may not explain socio-economic differences in how women respond to breast cancer symptoms as women with lower education had 'reasons' not to react. Research is needed on how to overcome a wider spectrum of psycho-social factors to reduce future inequality. Statement of contribution What is already known on this subject? Seven of ten breast cancers in the UK are diagnosed after people contact their doctor with symptoms. Women from lower socio-economic backgrounds are more likely to be diagnosed with advanced disease. There is little evidence related to potential drivers of this SES inequality. What does this study add? We qualitatively explored socio-economic (SES) differences in help-seeking for breast symptoms. Women with higher education were more confident about interpreting symptoms and navigating health care. Women with lower education were more reluctant to seek help due to fear of cancer.
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Affiliation(s)
- Afrodita Marcu
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Georgia Black
- Department of Applied Health Research, University College London, UK
| | - Peter Vedsted
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Faculty of Health, Aarhus University, Denmark
| | - Georgios Lyratzopoulos
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, UK
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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Chambers D, Booth A, Baxter SK, Johnson M, Dickinson KC, Goyder EC. Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews. Health Serv Deliv Res 2016. [DOI: 10.3310/hsdr04350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BackgroundCurrent NHS policy favours the expansion of diagnostic testing services in community and primary care settings.ObjectivesOur objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.Review methodsWe performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.ResultsWe identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.ConclusionsIn the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.LimitationsWe have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.Future workThere is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan K Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine C Dickinson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth C Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Parsonage RK, Hiscock J, Law RJ, Neal RD. Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data. Br J Gen Pract 2017; 67:e49-56. [PMID: 27872084 DOI: 10.3399/bjgp16X688357] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/17/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Earlier cancer diagnosis is crucial in improving cancer survival. The International Cancer Benchmarking Partnership Module 4 (ICBP4) is a quantitative survey study that explores the reasons for delays in diagnosis and treatment of breast, colorectal, lung, and ovarian cancer. To further understand the associated diagnostic processes, it is also important to explore the patient perspectives expressed in the free-text comments. AIM To use the free-text data provided by patients completing the ICBP4 survey to augment the understanding of patients' perspectives of their diagnostic journey. DESIGN AND SETTING Qualitative analysis of the free-text data collected in Wales between October 2013 and December 2014 as part of the ICBP4 survey. Newly-diagnosed patients with either breast, ovarian, colorectal, or lung cancer were identified from registry data and then invited by their GPs to participate in the survey. METHOD A thematic framework was used to analyse the free-text comments provided at the end of the ICBP4 survey. Of the 905 patients who returned a questionnaire, 530 included comments. RESULTS The free-text data provided information about patients' perspectives of the diagnostic journey. Analysis identified factors that acted as either barriers or facilitators at different stages of the diagnostic process. Some factors, such as screening, doctor-patient familiarity, and private treatment, acted as both barriers and facilitators depending on the context. CONCLUSION Factors identified in this study help to explain how existing models of cancer diagnosis (for example, the Pathways to Treatment Model) work in practice. It is important that clinicians are aware of how these factors may interact with individual clinical cases and either facilitate, or act as a barrier to, subsequent cancer diagnosis. Understanding and implementing this knowledge into clinical practice may result in quicker cancer diagnoses.
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168
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Winstanley K, Renzi C, Smith CF, Wardle J, Whitaker KL. The impact of body vigilance on help-seeking for cancer 'alarm' symptoms: a community-based survey. BMC Public Health 2016; 16:1172. [PMID: 27871273 PMCID: PMC5117619 DOI: 10.1186/s12889-016-3846-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/15/2016] [Indexed: 12/19/2022] Open
Abstract
Background The act of detecting bodily changes is a pre-requisite for subsequent responses to symptoms, such as seeking medical help. This is the first study to explore associations between self-reported body vigilance and help-seeking in a community sample currently experiencing cancer ‘alarm’ symptoms. Methods Using a cross-sectional study design, a ‘health survey’ was mailed through primary care practices to 4913 UK adults (age ≥50 years, no cancer diagnosis), asking about symptom experiences and medical help-seeking over the previous three months. Body vigilance, cancer worry and current illness were assessed with a small number of self-report items derived from existing measures. Results The response rate was 42% (N = 2042). Almost half the respondents (936/2042; 46%) experienced at least one cancer alarm symptom. Results from logistic regression analysis revealed that paying more attention to bodily changes was significantly associated with help-seeking for cancer symptoms (OR = 1.44; 1.06-1.97), after controlling for socio-demographics, current illness and cancer worry. Being more sensitive to bodily changes was not significantly associated with help-seeking. Conclusions Respondents who paid attention to their bodily changes were more likely to seek help for their symptoms. Although the use of a cross-sectional study design and the limited assessment of key variables preclude any firm conclusions, encouraging people to be body vigilant may contribute towards earlier cancer diagnosis. More needs to be understood about the impact this might have on cancer-related anxiety.
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Affiliation(s)
- Kelly Winstanley
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Cristina Renzi
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Claire Friedemann Smith
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Jane Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Katriina L Whitaker
- School of Health Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK.
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Whitaker KL, Macleod U, Winstanley K, Scott SE, Wardle J. Help seeking for cancer 'alarm' symptoms: a qualitative interview study of primary care patients in the UK. Br J Gen Pract 2015; 65:e96-e105. [PMID: 25624313 DOI: 10.3399/bjgp15X683533] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Delay in help seeking for cancer ‘alarm’ symptoms has been identified as a contributor to delayed diagnosis. Aim To understand people’s help-seeking decision making for cancer alarm symptoms, without imposing a cancer context. Design and setting Community-based, qualitative interview study in the UK, using purposive sampling by sex, socioeconomic status, and prior help seeking, with framework analysis of transcripts. Method Interviewees (n = 48) were recruited from a community-based sample (n = 1724) of adults aged ≥50 years who completed a health survey that included a list of symptoms. Cancer was not mentioned. Participants reporting any of 10 cancer alarm symptoms (n = 915) and who had consented to contact (n = 482) formed the potential pool from which people were invited to an interview focusing on their symptom experiences. Results Reasons for help seeking included symptom persistence, social influence, awareness/fear of a link with cancer, and ‘just instinct’. Perceiving the symptom as trivial or ‘normal’ was a deterrent, as was stoicism, adopting self-management strategies, and fear of investigations. Negative attitudes to help seeking were common. Participants did not want to be seen as making a fuss, did not want to waste the doctor’s time, and were sometimes not confident that the GP could help. Conclusion Decision making about cancer alarm symptoms was complex. Recognition of cancer risk almost always motivated help seeking (more so than the fear of cancer being a deterrent), assisted by recent public-awareness campaigns. As well as symptom persistence motivating help seeking, it could also have the reverse effect. Negative attitudes to help seeking were significant deterrents.
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170
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Wagland R, Brindle L, Ewings S, James E, Moore M, Rivas C, Esqueda AI, Corner J. Promoting Help-Seeking in Response to Symptoms amongst Primary Care Patients at High Risk of Lung Cancer: A Mixed Method Study. PLoS One 2016; 11:e0165677. [PMID: 27814375 PMCID: PMC5096702 DOI: 10.1371/journal.pone.0165677] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/14/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Lung cancer symptoms are vague and difficult to detect. Interventions are needed to promote early diagnosis, however health services are already pressurised. This study explored symptomology and help-seeking behaviours of primary care patients at 'high-risk' of lung cancer (≥50 years old, recent smoking history), to inform targeted interventions. METHODS Mixed method study with patients at eight general practitioner (GP) practices across south England. Study incorporated: postal symptom questionnaire; clinical records review of participant consultation behaviour 12 months pre- and post-questionnaire; qualitative participant interviews (n = 38) with a purposive sample. RESULTS A small, clinically relevant group (n = 61/908, 6.7%) of primary care patients was identified who, despite reporting potential symptoms of lung cancer in questionnaires, had not consulted a GP ≥12 months. Of nine symptoms associated with lung cancer, 53.4% (629/1172) of total respondents reported ≥1, and 35% (411/1172) reported ≥2. Most participants (77.3%, n = 686/908) had comorbid conditions; 47.8%, (n = 414/908) associated with chest and respiratory symptoms. Participant consulting behaviour significantly increased in the 3-month period following questionnaire completion compared with the previous 3-month period (p = .002), indicating questionnaires impacted upon consulting behaviour. Symptomatic non-consulters were predominantly younger, employed, with higher multiple deprivation scores than their GP practice mean. Of symptomatic non-consulters, 30% (18/61) consulted ≤1 month post-questionnaire, with comorbidities subsequently diagnosed for five participants. Interviews (n = 39) indicated three overarching differences between the views of consulting and non-consulting participants: concern over wasting their own as well as GP time; high tolerance threshold for symptoms; a greater tendency to self-manage symptoms. CONCLUSIONS This first study to examine symptoms and consulting behaviour amongst a primary care population at 'high- risk' of lung cancer, found symptomatic patients who rarely consult GPs, might respond to a targeted symptom elicitation intervention. Such GP-based interventions may promote early diagnosis of lung cancer or other comorbidities, without burdening already pressurised services.
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Affiliation(s)
- Richard Wagland
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom
| | - Lucy Brindle
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom
| | - Sean Ewings
- Southampton Statistical Sciences Research Institute, Faculty of Social, Human and Mathematical Sciences, Highfield, University of Southampton, Southampton, United Kingdom
| | - Elizabeth James
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom
| | - Mike Moore
- Faculty of Medicine, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom
| | - Carol Rivas
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom
| | - Ana Ibanez Esqueda
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom
| | - Jessica Corner
- Executive Office, The Nottingham University, University Park, Nottingham, NG7 2RD, United Kingdom
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Varela-Centelles P, López-Cedrún JL, Fernández-Sanromán J, Seoane-Romero JM, Santos de Melo N, Álvarez-Nóvoa P, Gómez I, Seoane J. Key points and time intervals for early diagnosis in symptomatic oral cancer: a systematic review. Int J Oral Maxillofac Surg 2016; 46:1-10. [PMID: 27751768 DOI: 10.1016/j.ijom.2016.09.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 09/11/2016] [Accepted: 09/27/2016] [Indexed: 11/29/2022]
Abstract
The aim of this study was to identify key points and time intervals in the patient pathway to the diagnosis of oral cancer, from the detection of a bodily change to the start of treatment. A systematic search of three databases was performed by two researchers independently. Articles reporting original data on patients with symptomatic primary oral or oropharyngeal squamous cell carcinoma that was pathologically confirmed were included. These articles had to include an outcome variable of 'diagnostic delay', 'time interval', or 'waiting time to diagnosis', or report time intervals from first symptom to treatment. Furthermore, the outcome variable had to have a clearly defined start point and end point, with the time measurement presented as a continuous or categorical variable. A total of 1175 reports were identified; 28 articles on oral cancer studies and 13 on oral and oropharyngeal cancer studies were finally included. These papers showed poor quality in terms of questionnaire validation, acknowledgement of biases influencing time-point measurements, and strategies for verification of patient self-reported data. They also showed great heterogeneity. The review findings allowed the definition of key points and time intervals within the Aarhus framework that may better suit the features of the diagnostic process of this neoplasm, particularly when assessing the impact of waiting time to diagnosis.
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Affiliation(s)
- P Varela-Centelles
- Galician Health Service, EOXI Lugo, Cervo e Monforte, Lugo, Spain; Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - J L López-Cedrún
- Service of Oral and Maxillofacial Surgery, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - J Fernández-Sanromán
- Service of Oral and Maxillofacial Surgery, Povisa Hospital, Vigo (Pontevedra), Spain
| | - J M Seoane-Romero
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - N Santos de Melo
- Departamento de Odontologia, Faculdade de Ciências da Saúde, Universidade de Brasília, Campus Universitário, Asa Norte, Brasília DF, Brazil
| | - P Álvarez-Nóvoa
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - I Gómez
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - J Seoane
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain.
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Marcu A, Lyratzopoulos G, Black G, Vedsted P, Whitaker KL. Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study. Psychooncology 2016; 25:1191-1197. [PMID: 27218858 DOI: 10.1002/pon.4177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 05/06/2016] [Accepted: 05/17/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Stage at diagnosis of breast cancer varies by socio-economic status (SES), with lower SES associated with poorer survival. We investigated associations between SES (indexed by education), and the likelihood of attributing breast symptoms to breast cancer. METHOD We conducted an online survey with 961 women (47-92 years) with variable educational levels. Two vignettes depicted familiar and unfamiliar breast changes (axillary lump and nipple rash). Without making breast cancer explicit, women were asked 'What do you think this […..] could be?' After the attribution question, women were asked to indicate their level of agreement with a cancer avoidance statement ('I would not want to know if I have breast cancer'). RESULTS Women were more likely to mention cancer as a possible cause of an axillary lump (64%) compared with nipple rash (30%). In multivariable analysis, low and mid education were independently associated with being less likely to attribute a nipple rash to cancer (OR 0.51, 0.36-0.73 and OR 0.55, 0.40-0.77, respectively). For axillary lump, low education was associated with lower likelihood of mentioning cancer as a possible cause (OR 0.58, 0.41-0.83). Although cancer avoidance was also associated with lower education, the association between education and lower likelihood of making a cancer attribution was independent. CONCLUSION Lower education was associated with lower likelihood of making cancer attributions for both symptoms, also after adjustment for cancer avoidance. Lower likelihood of considering cancer may delay symptomatic presentation and contribute to educational differences in stage at diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Afrodita Marcu
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Georgios Lyratzopoulos
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Georgia Black
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Peter Vedsted
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Faculty of Health, Aarhus University, Denmark
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Tejeda S, Gallardo RI, Ferrans CE, Rauscher GH. Breast cancer delay in Latinas: the role of cultural beliefs and acculturation. J Behav Med 2016; 40:343-351. [PMID: 27572092 DOI: 10.1007/s10865-016-9789-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/22/2016] [Indexed: 01/07/2023]
Abstract
Cultural beliefs about breast cancer may act as a barrier to Latina women seeking preventive services or timely follow-up for breast symptoms regardless of access. This study examines the association between factors and breast cancer cultural beliefs and the extent to which cultural beliefs are associated with delays in breast cancer care. Participants who were Latina, ages 30-79, and had been diagnosed with a primary breast cancer were examined (n = 181). Interviews included a 15-item cultural beliefs scale spanning beliefs inconsistent with motivation to seek timely healthcare. Self-reported date of symptom discovery, date of first medical presentation, and date of first treatment were used to construct measures of prolonged patient, clinical, and total delay. Logistic regression with model-based standardization was used to estimate crude and confounder-adjusted prevalence differences for prolonged delay by number of cultural beliefs held. Women held a mean score of three cultural beliefs. The belief most commonly held was, "Faith in God can protect you from breast cancer" (48 %). Holding three or more cultural beliefs was associated with lower acculturation, lower socioeconomic status and less access to care (p < 0.01). After adjusting for age, education, income, acculturation, trust, and insurance, likelihood of prolonged total delay remained 21 percentage points higher in women who held a higher number cultural beliefs (p = 0.02). Cultural beliefs may predispose Latina women to prolong delays in seeking diagnosis and treatment for breast symptoms. Cultural beliefs represent a potential point of intervention to decrease delays among Latina breast cancer patients.
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Affiliation(s)
- Silvia Tejeda
- School of Public Health, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Rani I Gallardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Carol Estwing Ferrans
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Garth H Rauscher
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 West Taylor Street (M/C 923), Chicago, IL, 60612, USA.
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Wilson A, Coleby D, Regen E, Phelps K, Windridge K, Willars J, Robinson T. Service factors causing delay in specialist assessment for TIA and minor stroke: a qualitative study of GP and patient perspectives. BMJ Open 2016; 6:e011654. [PMID: 27188815 PMCID: PMC4874118 DOI: 10.1136/bmjopen-2016-011654] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke. DESIGN Qualitative study using semistructured interviews, analysis by constant comparison. SETTING Leicester, UK. PARTICIPANTS Patients diagnosed with TIA or minor stroke, at hospital admission or in a rapid-access TIA clinic (n=42), general practitioners (GPs) of participating patients if they had been involved in the patients' care (n=18). DATA Accounts from patients and GPs of factors contributing to delay following action to seek help from a healthcare professional (HCP). RESULTS The following categories of delay were identified. First, delay in assessment in general practice following contact with the service; this related to availability of same day appointments, and the role of the receptionist in identifying urgent cases. Second, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out-of-hours services, walk-in centres and the emergency department. Third, delays in referral after a suspected diagnosis; these included variable use of the ABCD(2) (Age, Blood pressure, Clinical features, Duration, Diabetes) risk stratification score and referral templates in general practice, and referral back to the patients' GP in cases where he/she was not the first HCP consulted. CONCLUSIONS Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice, this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.
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Affiliation(s)
- Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Dawn Coleby
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kate Windridge
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Tom Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Whitaker KL, Cromme S, Winstanley K, Renzi C, Wardle J. Emotional responses to the experience of cancer 'alarm' symptoms. Psychooncology 2016; 25:567-73. [PMID: 26358401 PMCID: PMC4832579 DOI: 10.1002/pon.3964] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/03/2015] [Accepted: 08/12/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To qualitatively explore associations between emotional responses to experience of cancer 'alarm' symptoms and help-seeking in a community sample of adults. METHOD Interviewees (n = 62) were recruited from a community sample (n = 2042) of adults aged ≥50 years, who had completed a health survey that included a list of cancer alarm symptoms. Participants who had reported an alarm symptom both at baseline and 3-month follow-up (n = 271), and who had consented to contact (n = 215), constituted the pool for invitations to interview. RESULTS Over a third of participants (37%) described an emotional response to their symptom experience. In all these cases, there was evidence of awareness of the risk of cancer. Emotional responses were usually either classified as mild ('worry') or severe ('fear'). Worry was often described in the context of a desire to seek medical help, either to rule out cancer or to minimise patient delay. In contrast, the 'fear' group described associations with death, the perceived incurability of cancer, and the consequence of a cancer diagnosis. Where the emotional reaction was fear, medical contact was seen as something to be avoided either because it had no value or because it was preferable not to be told a diagnosis. CONCLUSION In this community sample, worry about the possibility of cancer was associated with help-seeking, either for reassurance or as part of a 'sensible' strategy to deal with the risk. In contrast, fear was associated with avoiding help-seeking or even thinking about cancer, which could lead to prolonged help-seeking intervals.
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Affiliation(s)
- K L Whitaker
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, UK
| | - S Cromme
- Health Behaviour Research Centre, Epidemiology and Public Health, University College London, UK
| | - K Winstanley
- Health Behaviour Research Centre, Epidemiology and Public Health, University College London, UK
| | - C Renzi
- Health Behaviour Research Centre, Epidemiology and Public Health, University College London, UK
| | - J Wardle
- Health Behaviour Research Centre, Epidemiology and Public Health, University College London, UK
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176
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Phillips LA, Cohen J, Burns E, Abrams J, Renninger S. Self-management of chronic illness: the role of 'habit' versus reflective factors in exercise and medication adherence. J Behav Med 2016; 39:1076-1091. [PMID: 26980098 DOI: 10.1007/s10865-016-9732-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 03/04/2016] [Indexed: 12/22/2022]
Abstract
Non-adherence to health behaviors required for chronic illness self-management is pervasive. Advancing health-behavior theory to include behavioral initiation and maintenance factors, including reflective (e.g., belief- and feedback-based) and automatic (e.g., habit-based) mechanisms of adherence to different treatment-related behaviors could improve non-adherence prediction and intervention efforts. To test behavioral initiation and maintenance factors from an extended common sense self-regulation theoretical framework for predicting medication adherence and physical activity among patients with Type 2 diabetes. Patients (n = 133) in an in-person (n = 80) or online (n = 53) version of the study reported treatment-related (1) barriers, (2) beliefs and experiential feedback (reflective mechanisms of treatment-initiation and short-term repetition), and (3) habit strength (automatic mechanism of treatment-maintenance) for taking medication and engaging in regular physical activity at baseline. Behaviors were assessed via self-reports (n = 133) and objectively (electronic monitoring pill bottles, accelerometers; n = 80) in the subsequent month. Treatment-specific barriers and habit strength predicted self-reported and objective adherence for both behaviors. Beliefs were inconsistently related to behavior, even when habits were "weak". Experiential feedback from behavior was not related to adherence. Among patients with Type 2 diabetes diagnosis, medication and physical activity adherence were better predicted by their degree of automatic behavioral repetition than their beliefs/experiences with the treatment-actions. Habit strength should be an intervention target for chronic illness self-management; assessing it in practice settings may effectively detect non-adherence to existing treatment-regimens. However, future research and further refining of CS-SRM theory regarding the processes required for such habit development are needed.
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Affiliation(s)
- L Alison Phillips
- Department of Psychology, Iowa State University, W112 Lagomarcino Hall, Ames, IA, 50011, USA.
| | - Joshua Cohen
- Division of Endocrinology, Medical Faculty Associates, The George Washington University, 22nd & I Street, NW, 3rd Floor, Washington, DC, 20037, USA
| | - Edith Burns
- Division of Geriatrics and Gerontology, Department of Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA
| | - Jessica Abrams
- Department of Psychology, The George Washington University, 2125 G Street NW, Washington, DC, 20052, USA
| | - Steffi Renninger
- Department of Psychology, The George Washington University, 2125 G Street NW, Washington, DC, 20052, USA
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Renzi C, Whitaker KL, Winstanley K, Cromme S, Wardle J. Unintended consequences of an 'all-clear' diagnosis for potential cancer symptoms: a nested qualitative interview study with primary care patients. Br J Gen Pract 2016; 66:e158-70. [PMID: 26852794 PMCID: PMC4758495 DOI: 10.3399/bjgp16x683845] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/30/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Nine out of 10 patients undergoing urgent cancer investigations receive an 'all-clear' diagnosis. AIM A qualitative approach was used to evaluate the impact of investigations that did not result in cancer diagnosis on subsequent symptom attribution and help seeking for recurrent or new possible cancer symptoms. DESIGN AND SETTING A survey of symptoms, help seeking, and past investigations was sent to 4913 individuals aged ≥50 years from four UK general practices. Of 2042 responders, 62 participants were recruited still reporting at least one cancer 'alarm' symptom in a 3-month follow-up survey for a nested in-depth interview study (ensuring variation in sociodemographic characteristics). METHOD Framework analysis was used to examine the in-depth semi-structured interviews and identify themes related to previous health investigations. RESULTS Interviewees were on average 65 years old, and 90% reported investigations within the previous 2 years. Most often they reported gastrointestinal, urinary, and respiratory symptoms, and 42% had waited ≥3 months before help seeking. Reassurance from a previous non-cancer diagnosis explained delays in help seeking even if symptoms persisted or new symptoms developed months or years later. Others were worried about appearing hypochondriacal or that they would not be taken seriously if they returned to the doctor. CONCLUSION An all-clear diagnosis can influence help seeking for months or even years in case of new or recurrent alarm symptoms. Considering the increasing number of people undergoing investigations and receiving an all-clear, it is paramount to limit unintended consequences by providing appropriate information and support. Specific issues are identified that could be addressed.
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Affiliation(s)
- Cristina Renzi
- Health Behaviour Research Centre, University College London, London
| | | | - Kelly Winstanley
- Health Behaviour Research Centre, University College London, London
| | - Susanne Cromme
- Health Behaviour Research Centre, University College London, London
| | - Jane Wardle
- Health Behaviour Research Centre, University College London, London
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178
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Friedemann Smith C, Whitaker KL, Winstanley K, Wardle J. Smokers are less likely than non-smokers to seek help for a lung cancer 'alarm' symptom. Thorax 2016; 71:659-61. [PMID: 26911574 PMCID: PMC4941149 DOI: 10.1136/thoraxjnl-2015-208063] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/04/2016] [Indexed: 11/24/2022]
Abstract
Background The majority (>85%) of lung cancer cases are linked with smoking, and prognosis is poor because it is often diagnosed at a late stage. One contributor to late-stage diagnosis could be patient delay in help-seeking. We investigated the help-seeking behaviour of smokers and non-smokers for a recent lung cancer alarm symptom. Methods A health survey was sent to 4913 men and women aged >50 years through through General Practice. It included questions on symptoms experienced in the past 3 months (from a checklist), help-seeking (Yes/No) for each symptom and demographic characteristics including smoking status. Univariable and multivariable binary logistic regression analyses were used to assess the association between smoking status and help-seeking for a cough or hoarseness. Results Among 2042 participants (42% response rate), 280 (14%) reported ‘cough or hoarseness’ in the past 3 months; of whom 22% were current smokers. Being a smoker was associated with reduced likelihood of help-seeking (OR 0.44; 95% CI 0.23 to 0.83), even after adjusting for demographic factors (OR 0.46; 95% CI 0.21 to 1.00). Conclusions Delay in help-seeking in smokers for a symptom that is potentially indicative of lung cancer is a cause for concern. Future research could usefully address the psychological mechanisms through which help-seeking in smokers is hindered.
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Affiliation(s)
- C Friedemann Smith
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - K L Whitaker
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - K Winstanley
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - J Wardle
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
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179
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Whitaker KL, Smith CF, Winstanley K, Wardle J. What prompts help-seeking for cancer 'alarm' symptoms? A primary care based survey. Br J Cancer 2016; 114:334-9. [PMID: 26794277 PMCID: PMC4742581 DOI: 10.1038/bjc.2015.445] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 11/25/2015] [Accepted: 11/30/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Encouraging prompt help-seeking for cancer symptoms can help shorten the patient interval and improve timely diagnosis. We explored factors associated with help-seeking in a primary care sample reporting 'alarm' symptoms. METHODS A questionnaire was mailed to 9771 adults (⩾ 50 years of age and no cancer diagnosis) and 3766 (39%) returned it. Our sample included 1732 adults reporting at least one cancer 'alarm' symptom; with a total of 2726 symptoms. Respondents completed questions relating to help-seeking, demographic and symptom characteristics (e.g., type, knowledge, concern, interference and attribution). RESULTS Over a third of people who reported a cancer 'alarm' symptom in the past 3 months had not sought help from a doctor. An unexplained lump (odds ratio (OR) 2.46, 1.42-4.26) and persistent unexplained pain (OR 1.79, 1.19-2.69) were associated with increased likelihood of help-seeking. Symptom concern (OR 3.10, 2.19-4.39) and interference (OR 3.06, 2.15-4.36) were associated with an increased likelihood of seeking help independently of symptom type. People who were not working (OR 1.41, 1.09-1.83), were married/cohabiting rather than single (OR 1.38, 1.10-1.74) and were older (60-69 years) rather than younger (50-59 years; OR 1.33, 1.02-1.75) were more likely to have sought help. CONCLUSIONS Our findings highlighted symptom type and symptom characteristics as key drivers of help-seeking. We also found that there may be specific demographic groups where encouraging help-seeking might be warranted.
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Affiliation(s)
- K L Whitaker
- School of Health Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - C Friedemann Smith
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
| | - K Winstanley
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
| | - J Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
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180
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Mwaka AD, Garimoi CO, Were EM, Roland M, Wabinga H, Lyratzopoulos G. Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda. BMJ Open 2016; 6:e007690. [PMID: 26801459 PMCID: PMC4735146 DOI: 10.1136/bmjopen-2015-007690] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 11/21/2015] [Accepted: 11/23/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine patient and primary healthcare factors and stage at diagnosis in women with cervical cancer in Northern Uganda with the intention to identify factors that are associated with advanced stages in order to inform policies to improve survival from cervical cancer in low income and middle income countries. DESIGN Cross-sectional hospital-based study. SETTING Tertiary, not-for-profit private hospital in postconflict region. PARTICIPANTS Consecutive tissue-diagnosed symptomatic patients with cervical attending care. Of 166 patients, 149 were enrolled and analysed. PRIMARY OUTCOME Cervical cancer stage at diagnosis. RESULTS Most women were diagnosed at stages III (45%) or IV (21%). After controlling for age, marital status, educational attainment and number of biological children, there was evidence for association between advanced stage at diagnosis and pre-referral diagnosis of cancer by primary healthcare professionals (adjusted OR (AOR)=13.04:95% CI 3.59 to 47.3), and financial difficulties precluding prompt help seeking (AOR=5.5:95% CI 1.58 to 20.64). After adjusting for age, marital status and educational attainment, women with 5-9 biological children (AOR=0.27:95% CI 0.08 to 0.96) were less likely to be diagnosed with advanced stage (defined as stages III/IV) cancer. In this pilot study, there was no statistical evidence for associations between stage at diagnosis, and factors such as age at diagnosis and marital status. CONCLUSIONS This study is a first attempt to understand the descriptive epidemiology of cervical cancer in rural Ugandan settings. Understanding individual patient factors, patients' behavioural characteristics and healthcare factors associated with advanced stage at diagnosis is essential for targeted effective public health interventions to promote prompt health seeking, diagnosis at early stage and improved survival from cervical cancer.
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Affiliation(s)
- Amos Deogratius Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Christopher Orach Garimoi
- Department of Community Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Martin Roland
- Department of Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Henry Wabinga
- Department of Pathology, Kampala Cancer Registry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Georgios Lyratzopoulos
- Department of Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK
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181
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Abstract
OBJECTIVES The aim of this study was to explore and understand women's pathways to breast cancer diagnosis and factors influencing this journey. DESIGN AND SETTING Indepth interviews were conducted with clients at a tertiary level breast cancer clinic in Cape Town, South Africa. A thematic analysis was performed underpinned by the theoretical concepts of the Model of Pathways to Treatment framework. PARTICIPANTS 20 women were interviewed within 1 week of being diagnosed with breast cancer. RESULTS The average time between discovery of bodily changes to breast cancer diagnosis was 8.5 months. Deficits in breast self-awareness and knowledge of breast cancer symptoms delayed women's interpretation of bodily changes as being abnormal. All women first noticed breast lumps; however, many did not perceive it as abnormal until additional symptoms were present. General good health, attribution of symptoms to ageing, and past benign breast disease resulted in women being complacent about bodily changes. Disclosure to family members served as a trigger to seek healthcare. The initial type of primary level care services women accessed was influenced by perceptions of care each service provided, finances, structural factors, and personal safety related to the physical location of services. CONCLUSIONS Symptom appraisal and interpretation contributed significantly to delayed presentation. To improve timely diagnosis of breast cancer, interventions that increase women's confidence in detecting breast changes, improve knowledge of breast cancer symptoms, address myths, and encourage prompt help-seeking behaviour are required.
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Affiliation(s)
- Jennifer Moodley
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Women's Health Research Unit, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lydia Cairncross
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Thurandrie Naiker
- Department of Radiation Oncology, University of Cape Town, Cape Town, South Africa
| | - Mariette Momberg
- Women's Health Research Unit, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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182
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Hall N, Birt L, Banks J, Emery J, Mills K, Johnson M, Rubin GP, Hamilton W, Walter FM. Symptom appraisal and healthcare-seeking for symptoms suggestive of colorectal cancer: a qualitative study. BMJ Open 2015; 5:e008448. [PMID: 26453591 PMCID: PMC4606388 DOI: 10.1136/bmjopen-2015-008448] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Timely diagnosis of colorectal cancer is important to improve survival. This study explored symptom appraisal and help-seeking among patients referred to specialist services with symptoms of colorectal cancer. DESIGN Qualitative in-depth interview study. SETTING AND PARTICIPANTS Participants were recruited on referral to gastroenterology clinics (North East and East of England); interviews were conducted soon after referral. We purposively sampled participants to ensure a range of accounts in terms of age, sex, diagnosis and geographical location. METHODS Data collection and analysis were underpinned by the Model of Pathways to Treatment. Framework analysis was used to explore the data within and across cases, focusing on patient beliefs and experiences, disease factors and healthcare influences. RESULTS 40 participants were interviewed (aged 43-87 years, 17 women, 18 diagnosed with colorectal cancer). Patients diagnosed with and without colorectal cancer had similar symptom pathways. We found a range of interacting and often competing biopsychosocial, contextual and cultural influences on the way in which people recognised, interpreted and acted on their symptoms. People attempted to 'maintain normality' through finding benign explanations for their symptoms. Bodily changes were appraised within the context of usual bowel patterns, comorbidities and life events, and decisions to seek help were made in relation to expectations about the course of symptoms. The 'private nature' of colorectal cancer symptoms could affect both their identification and discussions with others including healthcare professionals. Within the context of the National Health Service, people needed to legitimise appropriate use of healthcare services and avoid being thought of as wasting doctors' time. CONCLUSIONS Findings provide guidance for awareness campaigns on reducing stigma around appraising and discussing bowel movements, and the importance of intermittent and non-specific symptoms. Altering perceptions about the appropriate use of health services could have a beneficial effect on time to presentation.
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Affiliation(s)
- N Hall
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
| | - L Birt
- Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - J Banks
- School of Social & Community Medicine, University of Bristol, Bristol, UK
| | - J Emery
- Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK Department of General Practice, University of Melbourne, Carlton, Victoria, Australia
| | - K Mills
- Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | | | - G P Rubin
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
| | - W Hamilton
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - F M Walter
- Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK Department of General Practice, University of Melbourne, Carlton, Victoria, Australia
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183
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Abstract
OBJECTIVE To explore patients' experiences from initial symptoms to receiving a diagnosis of gout. DESIGN Data from in-depth semistructured interviews were used to construct themes to describe key features of patients' experiences of gout diagnosis. PARTICIPANTS AND SETTING A maximum variation sample of 43 UK patients with gout (29 men; 14 women; age range 32-87 years) were recruited from general practices, rheumatology clinics, gout support groups and through online advertising. RESULTS Severe joint pain, combined with no obvious signs of physical trauma or knowledge of injury, caused confusion for patients attempting to interpret their symptoms. Reasons for delayed consultation included self-diagnosis and/or self-medication, reluctance to seek medical attention, and financial/work pressures. Factors potentially contributing to delayed diagnosis after consultation included reported misdiagnosis, attacks in joints other than the first metatarsophalangeal joint, and female gender. The limitations in using serum uric acid (SUA) levels for diagnostic purposes were not always communicated effectively to patients, and led to uncertainty and lack of confidence in the accuracy of the diagnosis. Resistance to the diagnosis occurred in response to patients' beliefs about the causes of gout and characteristics of the people likely to be affected. Diagnosis prompted actions, such as changes in diet, and evidence was found of self-monitoring of SUA levels. CONCLUSIONS This study is the first to report data specifically about patients' pathways to initial consultation and subsequent experiences of gout diagnosis. A more targeted approach to information provision at diagnosis would improve patients' experiences.
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Affiliation(s)
- Jennifer Liddle
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Edward Roddy
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Christian D Mallen
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Samantha L Hider
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Suman Prinjha
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Jane C Richardson
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
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184
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Whitaker KL, Winstanley K, Macleod U, Scott SE, Wardle J. Low cancer suspicion following experience of a cancer 'warning sign'. Eur J Cancer 2015; 51:2473-9. [PMID: 26264167 PMCID: PMC4622962 DOI: 10.1016/j.ejca.2015.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/03/2015] [Accepted: 07/11/2015] [Indexed: 01/03/2023]
Abstract
Aim Lower socioeconomic status (SES) is associated with a higher risk of late-stage cancer diagnosis. A number of explanations have been advanced for this, but one which has attracted recent attention is lower patient knowledge of cancer warning signs, leading to delay in help-seeking. However, although there is psychometric evidence of SES differences in knowledge of cancer symptoms, no studies have examined differences in ‘cancer suspicion’ among people who are actually experiencing a classic warning sign. Methods A ‘health survey’ was mailed to 9771 adults (⩾50 years, no cancer diagnosis) with a symptom list including 10 cancer ‘warning signs’. Respondents were asked if they had experienced any of the symptoms in the past 3 months, and if so, were asked ‘what do you think caused it?’ Any mention of cancer was scored as ‘cancer suspicion’. SES was indexed by education. Results Nearly half the respondents (1732/3756) had experienced a ‘warning sign’, but only 63/1732 (3.6%) mentioned cancer as a possible cause. Lower education was associated with lower likelihood of cancer suspicion: 2.6% of respondents with school-only education versus 7.3% with university education suspected cancer as a possible cause. In multivariable analysis, low education was the only demographic variable independently associated with lower cancer suspicion (odds ratio (OR) = 0.34, confidence interval (CI): 0.20–0.59). Conclusion Levels of cancer suspicion were low overall in this community sample, and even lower in people from less educated backgrounds. This may hinder early symptomatic presentation and contribute to inequalities in stage at diagnosis.
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Affiliation(s)
- Katriina L Whitaker
- School of Health Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK.
| | - Kelly Winstanley
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
| | - Una Macleod
- Centre for Health and Population Sciences, Hull York Medical School, Hull HU6 7RX, UK.
| | - Suzanne E Scott
- Unit of Social and Behavioural Sciences, King's College London Dental Institute, London SE5 9RW, UK.
| | - Jane Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
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185
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Black G, Sheringham J, Spencer-Hughes V, Ridge M, Lyons M, Williams C, Fulop N, Pritchard-Jones K. Patients' Experiences of Cancer Diagnosis as a Result of an Emergency Presentation: A Qualitative Study. PLoS One 2015; 10:e0135027. [PMID: 26252203 PMCID: PMC4529308 DOI: 10.1371/journal.pone.0135027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 07/16/2015] [Indexed: 12/11/2022] Open
Abstract
Introduction Cancers diagnosed following visits to emergency departments (ED) or emergency admissions (emergency presentations) are associated with poor survival and may result from preventable diagnostic delay. To improve outcomes for these patients, a better understanding is needed about how emergency presentations arise. This study sought to capture patients' experiences of this diagnostic pathway in the English NHS. Methods Eligible patients were identified in a service evaluation of emergency presentations and invited to participate. Interviews, using an open-ended biographical structure, captured participants' experiences of healthcare services before diagnosis and were analysed thematically, informed by the Walter model of Pathways to Treatment and NICE guidance in an iterative process. Results Twenty-seven interviews were conducted. Three typologies were identified: A: Rapid investigation and diagnosis, and B: Repeated cycles of healthcare seeking and appraisal without resolution, with two variants where B1 appears consistent with guidance and B2 has evidence that management was not consistent with guidance. Most patients’ (23/27) experiences fitted types B1 and B2. Potentially avoidable breakdowns in diagnostic pathways caused delays when patients were conflicted by escalating symptoms and a benign diagnosis given earlier by doctors. ED was sometimes used as a conduit to rapid testing by primary care clinicians, although this pathway was not always successful. Conclusions This study draws on patients' experiences of their diagnosis to provide novel insights into how emergency presentations arise. Through these typologies, we show that the typical experience of patients diagnosed through an emergency presentation diverges significantly from normative pathways even when there is no evidence of serious service failures. Consultations were not a conduit to diagnosis when they inhibited patients’ capacity to appraise their own symptoms appropriately and when they resulted in a reluctance to seek further healthcare. Recommendations The findings also point to potentially avoidable breakdowns in the diagnostic process. In particular, to encourage patients to return to the GP if symptoms escalate, a stronger emphasis is needed on diagnostic uncertainty in discussions between patients and doctors in both primary and secondary care. To improve appropriate access to rapid investigations, systems are needed for primary care to communicate directly with secondary care at the time of referral.
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Affiliation(s)
- Georgia Black
- UCL Department of Applied Health Research, UCL, London, England
| | - Jessica Sheringham
- UCL Department of Applied Health Research, UCL, London, England
- * E-mail:
| | - Vicki Spencer-Hughes
- LKSS Public Health Training Programme & Public Health Service, Lambeth and Southwark Local Authorities, London, England
| | | | | | | | - Naomi Fulop
- UCL Department of Applied Health Research, UCL, London, England
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186
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Seoane J, Alvarez-Novoa P, Gomez I, Takkouche B, Diz P, Warnakulasiruya S, Seoane-Romero JM, Varela-Centelles P. Early oral cancer diagnosis: The Aarhus statement perspective. A systematic review and meta-analysis. Head Neck 2015; 38 Suppl 1:E2182-9. [PMID: 25783770 DOI: 10.1002/hed.24050] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mortality is linked to diagnostic intervals in certain cancers. As symptom perception is conditioned by tumor site, a specific study on oral cancer is needed. METHODS This study's inclusion criteria were original data, symptomatic primary oral squamous cell carcinoma, and exposure of interest, diagnostic interval, or diagnostic delay. The outcome of interest was survival and disease stage. A meta-analysis was undertaken to investigate the relationship between intervals to diagnosis, TNM classification, and survival in oral cancer. RESULTS Regarding referral delay, the results present no heterogeneity and showed a risk increase in mortality of 2.48 (range = 1.39-4.42). The larger the diagnostic delay, the more advanced the stage at diagnosis. High quality studies reveal a higher risk increase than low quality studies (odds ratio [OR] = 2.44; 95% confidence interval [CI] = 1.36-4.36 vs OR = 1.53; 95% CI = 1.26-1.86). CONCLUSION A longer time interval from first symptom to referral for diagnosis is a risk factor for advanced stage and mortality of oral cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2182-E2189, 2016.
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Affiliation(s)
- Juan Seoane
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - Pablo Alvarez-Novoa
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - Iria Gomez
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - Bahi Takkouche
- Department of Preventive Medicine, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - Pedro Diz
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - Saman Warnakulasiruya
- Department of Oral Medicine, King's College, Dental Institute, London, United Kingdom
| | - Juan M Seoane-Romero
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - Pablo Varela-Centelles
- Stomatology Department, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain.,Galician Health Service, EOXI Lugo, Cervo e Monforte de Lemos, Lugo, Spain
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187
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Abstract
OBJECTIVE To explore women's experiences of symptoms potentially indicative of gynaecological cancer in a community-based sample without imposing a cancer perspective. DESIGN A qualitative interview study with thematic analysis of transcripts. PARTICIPANTS 26 women aged ≥30 years, who had experienced a symptom that might indicate gynaecological cancer in the past 3 months, were recruited using a screening questionnaire distributed online and in community settings. SETTING London, UK. RESULTS Women attributed gynaecological symptoms to existing illnesses/conditions or considered themselves to be predisposed to them, either through their 'genes' or previous personal experience. Normalising symptoms by attributing them to demographic characteristics (eg, age, sex) was common, as was considering them a side effect of hormonal contraception. When women raised cancer as a possible cause, they often dismissed it as unlikely. Responses to symptoms included self-management (eg, self-medicating, making lifestyle changes), adopting a 'lay system of care', or consulting a healthcare professional. Triggers to help-seeking included persistent, painful or debilitating symptoms, concern about symptom seriousness, and feeling that help-seeking was legitimised. Barriers to help-seeking included lack of concern, vague symptoms, unusual symptom location, competing time demands, previous negative experiences with the healthcare system, and not wanting to be perceived as a time-waster. CONCLUSIONS Attributions of symptoms potentially indicative of a gynaecological cancer were varied, but most often involved women fitting symptoms into their expectations of what was 'normal'. Normalising acted as a barrier to seeking help from a healthcare professional, alongside competing time demands and negative attitudes towards help-seeking. These barriers may lead to later diagnosis and poorer cancer survival. Our findings could be used to inform the development of interventions to encourage appropriate help-seeking.
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Affiliation(s)
- E L Low
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London (UCL), London, UK
| | - K L Whitaker
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - A E Simon
- Centre for Health Services Research, City University, London, UK
| | - M Sekhon
- Centre for Health Services Research, City University, London, UK
| | - J Waller
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London (UCL), London, UK
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188
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Balasooriya-Smeekens C, Walter FM, Scott S. The role of emotions in time to presentation for symptoms suggestive of cancer: a systematic literature review of quantitative studies. Psychooncology 2015; 24:1594-604. [PMID: 25989295 DOI: 10.1002/pon.3833] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 03/30/2015] [Accepted: 04/03/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Emotions may be important in patients' decisions to seek medical help for symptoms suggestive of cancer. OBJECTIVES The aim of this systematic literature review was to examine quantitative literature on the influence of emotion on patients' help-seeking for symptoms suggestive of cancer. The objectives were to identify the following: (a) which types of emotions influence help-seeking behaviour, (b) whether these form a barrier or trigger for seeking medical help and (c) how the role of emotions varies between different cancers and populations. METHODS We searched four electronic databases and conducted a narrative synthesis. Inclusion criteria were studies that reported primary, quantitative research that examined any emotion specific to symptom appraisal or help-seeking for symptoms suggestive of cancer. RESULTS Thirty-three papers were included. The studies were heterogeneous in their methods and quality, and very few had emotion as the main focus of the research. Studies reported a limited range of emotions, mainly related to fear and worry. The impact of emotions appears mixed, sometimes acting as a barrier to consultation whilst at other times being a trigger or being unrelated to time to presentation. It is plausible that different emotions play different roles at different times prior to presentation. CONCLUSIONS This systematic review provides some quantitative evidence for the role of emotions in help-seeking behaviour. However, it also highlighted widespread methodological, definition and design issues among the existing literature. The conflicting results around the role of emotions on time to presentation may be due to the lack of definition of each specific emotion.
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Affiliation(s)
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Suzanne Scott
- Unit of Social and Behavioural Sciences, King's College London Dental Institute, London, UK
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189
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Thylén I, Ericsson M, Hellström Ängerud K, Isaksson RM, Sederholm Lawesson S. First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study. BMJ Open 2015; 5:e007059. [PMID: 25900460 PMCID: PMC4410112 DOI: 10.1136/bmjopen-2014-007059] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE It is unknown into what extent patients with ST-elevation myocardial infarction (STEMI) utilise a joint service number (Swedish Healthcare Direct, SHD) as first medical contact (FMC) instead of Emergency Medical Services (EMS) and how this impact time to diagnosis. We aimed to (1) describe patients' FMC; (2) find explanatory factors influencing their FMC (ie, EMS and SHD) and (3) explore the time interval from symptom onset to diagnosis. SETTING Multicentred study, Sweden. METHODS Cross-sectional, enrolling patients with consecutive STEMI admitted within 24 h from admission. RESULTS We included 109 women and 336 men (mean age 66±11 years). Although 83% arrived by ambulance to the hospital, just half of the patients (51%) called EMS as their FMC. Other utilised SHD (21%), contacted their primary healthcare centre (14%), or went directly to the emergency room (14%). Reasons for not contacting EMS were predominantly; (1) my transport mode was faster (40%), (2) did not consider myself sick enough (30%), and (3) it was easier to be driven or taking a taxi (25%). Predictors associated with contacting SHD as FMC were female gender (OR 1.92), higher education (OR 2.40), history of diabetes (OR 2.10), pain in throat/neck (OR 2.24) and pain intensity (OR 0.85). Predictors associated with contacting EMS as FMC were history of MI (OR 2.18), atrial fibrillation (OR 3.81), abdominal pain (OR 0.35) and believing the symptoms originating from the heart (OR 1.60). Symptom onset to diagnosis time was significantly longer when turning to the SHD instead of the EMS as FMC (1:59 vs 1:21 h, p<0.001). CONCLUSIONS Using other forms of contacts than EMS, significantly prolong delay times, and could adversely affect patient prognosis. Nevertheless, having the opportunity to call the SHD might also, in some instances, lower the threshold for taking contact with the healthcare system, and thus lowers the number that would otherwise have delayed even longer.
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Affiliation(s)
- Ingela Thylén
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Maria Ericsson
- Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Karin Hellström Ängerud
- Department of Cardiology, Heart Centre and Department of Nursing, Umeå University, Umeå, Sweden
| | - Rose-Marie Isaksson
- Department of Research, Norrbotten County Council, Luleå, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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190
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Abstract
The diagnosis of cancer is a complex, multi-step process. In this paper, we highlight factors involved in missed opportunities to diagnose cancer more promptly in symptomatic patients and discuss responsible mechanisms and potential strategies to shorten intervals from presentation to diagnosis. Missed opportunities are instances in which post-hoc judgement indicates that alternative decisions or actions could have led to more timely diagnosis. They can occur in any of the three phases of the diagnostic process (initial diagnostic assessment; diagnostic test performance and interpretation; and diagnostic follow-up and coordination) and can involve patient, doctor/care team, and health-care system factors, often in combination. In this perspective article, we consider epidemiological 'signals' suggestive of missed opportunities and draw on evidence from retrospective case reviews of cancer patient cohorts to summarise factors that contribute to missed opportunities. Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation. Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda. We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.
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Affiliation(s)
- G Lyratzopoulos
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
- Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - P Vedsted
- Department of Public Health, Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, DK-Bartholins Allé, 8000 Aarhus, Denmark
| | - H Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston TX 77030, US
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191
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Whitaker KL, Scott SE, Wardle J. Applying symptom appraisal models to understand sociodemographic differences in responses to possible cancer symptoms: a research agenda. Br J Cancer 2015; 112 Suppl 1:S27-34. [PMID: 25734385 PMCID: PMC4385973 DOI: 10.1038/bjc.2015.39] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Sociodemographic inequalities in the stage of diagnosis and cancer survival may be partly due to differences in the appraisal interval (time from noticing a bodily change to perceiving a reason to discuss symptoms with a health-care professional). A number of symptom appraisal models have been developed describing the psychological factors that underlie how people make sense of symptoms, although none explicitly focus on sociodemographic characteristics. METHODS We therefore conducted a conceptual review synthesising all symptom appraisal models, and focus on potential links with sociodemographics that could be the focus of future research. RESULTS Common psychological elements across nine symptom appraisal models included knowledge, attention, expectation and identity, all of which could be sensitive to sociodemographic factors. For example, lower socioeconomic status (SES), male sex and older age are associated with lower health literacy generally and lower cancer symptom knowledge. Limited attentional resources, lower expectations about health and lack of social support also hamper symptom interpretation, and would be likely to be more prevalent in those from lower SES backgrounds. Symptom heuristics ('rules of thumb') may lead to symptoms being normalised because they are common within the social network, potentially disadvantaging older populations. CONCLUSIONS A better understanding of the processes through which people interpret their symptoms, and the way these processes differ by sociodemographic factors, could help guide the development of interventions with the aim of reducing inequalities in cancer outcomes.
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Affiliation(s)
- K L Whitaker
- Faculty of Health and Medical Sciences, School of Health Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - S E Scott
- Unit of Social and Behavioural Sciences, King's College London Dental Institute, London SE5 9RW, UK
| | - J Wardle
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London WC1E 6BT, UK
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192
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Walker D, Hamilton W, Walter FM, Watts C. Strategies to accelerate diagnosis of primary brain tumors at the primary-secondary care interface in children and adults. CNS Oncol 2015; 2:447-62. [PMID: 25054667 DOI: 10.2217/cns.13.36] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This article presents a shared view from practitioners with special interests in diagnosing and managing primary brain tumors in both primary and secondary care, in adult and pediatric disciplines; it examines the complexity of identifying whether it would be of benefit and feasible to try to identify those with brain tumors earlier, how this could be achieved and what evidence exists to justify such an approach. The experience of the HeadSmart Campaign in childhood brain tumor, using awareness as a method for driving service change, is used to illustrate how diagnostic practice can be changed across the primary and secondary care interface. This article highlights the importance of focusing upon the needs of patients with primary brain tumors as they represent a significant set of life-threatening and disabling diseases with significant implications for cancer and palliative services.
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Affiliation(s)
- David Walker
- Children's Brain Tumor Research Centre, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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193
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Scott SE, Birt L, Cavers D, Shah N, Campbell C, Walter FM. Patient drawings of their melanoma: a novel approach to understanding symptom perception and appraisal prior to health care. Psychol Health 2015; 30:1035-48. [PMID: 25674833 DOI: 10.1080/08870446.2015.1016943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This pilot study investigated the use of patient drawings to explore patient experiences of symptoms of melanoma prior to health care use. DESIGN Patients (n = 63) with melanoma were interviewed within 10 weeks of diagnosis. Participants were asked to draw what their melanoma had looked like when they first noticed it, and to make additional drawings to depict changes as it developed. MAIN OUTCOME MEASURE The size and features of the drawings were compared between participants and with clinical data (thickness of the melanoma; histological diameter; clinical photographs). RESULTS Eighty-four percent of participants were able to produce at least one drawing. This facilitated discussion of their lesion and recall of events on the pathway to diagnosis. Common features of the drawings related to the view, presence of shading, inclusion of sections and the shape and border of the lesion. There was potential for disparity between the details in awareness resources and the perceptions of patients. The drawings resembled the clinical photographs and the size of the drawings was positively associated with the histological diameter, but did not differ according to tumour thickness. CONCLUSION Asking patients to make drawings of their melanoma appears to be an acceptable, inclusive, feasible and insightful methodological tool.
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Affiliation(s)
- S E Scott
- a Unit of Social & Behavioural Sciences , Kings College London Dental Institute , London , UK
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194
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Abstract
OBJECTIVE To explore the pathway to diagnosis of type 1 diabetes (T1D) in children. DESIGN Questionnaire completed by parents. PARTICIPANTS Parents of children aged 1 month to 16 years diagnosed with T1D within the previous 3 months. SETTING Children and parents from 11 hospitals within the East of England. RESULTS 88/164 (54%) invited families returned the questionnaire. Children had mean±SD age of 9.41±4.5 years. 35 (39.8%) presented with diabetic ketoacidosis at diagnosis. The most common symptoms were polydipsia (97.7%), polyuria (83.9%), tiredness (75.9%), nocturia (73.6%) and weight loss (64.4%) and all children presented with at least one of those symptoms. The time from symptom onset to diagnosis ranged from 2 to 315 days (median 25 days). Most of this was the appraisal interval from symptom onset until perceiving the need to seek medical advice. Access to healthcare was good but one in five children presenting to primary care were not diagnosed at first encounter, most commonly due to waiting for fasting blood tests or alternative diagnoses. Children diagnosed at first consultation had a shorter duration of symptoms (p=0.022) and children whose parents suspected the diagnosis were 1.3 times more likely (relative risk (RR) 1.3, 95% CI 1.02 to 1.67) to be diagnosed at first consultation. CONCLUSIONS Children present with the known symptoms of T1D but there is considerable scope to improve the diagnostic pathway. Future interventions targeted at parents need to address the tendency of parents to find alternative explanations for symptoms and the perceived barriers to access, in addition to symptom awareness.
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Affiliation(s)
| | - Matthew J Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Hannah Zhu
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, UK
| | - Fiona M Walter
- The Primary Care Unit, University of Cambridge, Cambridge, UK
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195
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Taber JM, Leyva B, Persoskie A. Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med 2015; 30:290-7. [PMID: 25387439 DOI: 10.1007/s11606-014-3089-1] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/24/2014] [Accepted: 10/20/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Many studies have examined barriers to health care utilization, with the majority conducted in the context of specific populations and diseases. Less research has focused on why people avoid seeking medical care, even when they suspect they should go. OBJECTIVE The purpose of the study was to present a comprehensive description and conceptual categorization of reasons people avoid medical care. DESIGN Data were collected as part of the 2008 Health Information National Trends Survey, a cross-sectional national survey. PARTICIPANTS Participant-generated reasons for avoiding medical care were provided by 1,369 participants (40% male; M age =48.9; 75.1% non-Hispanic white, 7.4% non-Hispanic black, 8.5% Hispanic or Latino/a). MAIN MEASURES Participants first indicated their level of agreement with three specific reasons for avoiding medical care; these data are reported elsewhere. We report responses to a follow-up question in which participants identified other reasons they avoid seeking medical care. Reasons were coded using a general inductive approach. KEY RESULTS Three main categories of reasons for avoiding medical care were identified. First, over one-third of participants (33.3% of 1,369) reported unfavorable evaluations of seeking medical care, such as factors related to physicians, health care organizations, and affective concerns. Second, a subset of participants reported low perceived need to seek medical care (12.2%), often because they expected their illness or symptoms to improve over time (4.0%). Third, many participants reported traditional barriers to medical care (58.4%), such as high cost (24.1%), no health insurance (8.3%), and time constraints (15.6%). We developed a conceptual model of medical care avoidance based on these results. CONCLUSIONS Reasons for avoiding medical care were nuanced and highly varied. Understanding why people do not make it through the clinic door is critical to extending the reach and effectiveness of patient care, and these data point to new directions for research and strategies to reduce avoidance.
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196
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Tiwana R, Rowland J, Fincher M, Raza K, Stack RJ. Social interactions at the onset of rheumatoid arthritis and their influence on help-seeking behaviour: A qualitative exploration. Br J Health Psychol 2015; 20:648-61. [PMID: 25728224 DOI: 10.1111/bjhp.12134] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 01/05/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To explore how social interactions at the onset of rheumatoid arthritis (RA) influence help-seeking behaviour from the perspectives of those with RA and their significant others (family and friends). METHODS Nineteen semi-structured qualitative interviews were undertaken with people recently diagnosed with RA and their significant others. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS Significant others' initial appraisals of symptoms led them to provide practical support with daily activities rather than advice to seek help. People with RA described difficulties in communicating the severity of their symptoms and often attempted to hide their symptoms from others. Significant others also reacted negatively, expressing disbelief and dismissing symptoms. On occasion, early symptoms were even described as the catalyst for the breakdown of relationships. On reflection, significant others expressed guilt about their initial reactions and wished that they had recognized the need for intervention earlier. When symptoms had advanced and were more obvious, significant others often strongly advised that help should be sought and, in some cases, physically escorted the patient to their medical appointment. In many instances, people with RA described significant others as the catalyst for eventually seeking help. CONCLUSIONS Significant others play an important role in influencing help-seeking behaviour; this has implications for theoretical models of help-seeking and the development of help-seeking interventions. A negative consequence of social interactions resulted from a lack of understanding and knowledge about RA among significant others, highlighting the need for greater public awareness about the early symptoms of RA.
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Affiliation(s)
| | - John Rowland
- Patient Research Partner, Birmingham Rheumatology Research Patient Partnership, University of Birmingham, UK
| | - Marie Fincher
- Patient Research Partner, Birmingham Rheumatology Research Patient Partnership, University of Birmingham, UK
| | - Karim Raza
- Centre for Translational Inflammation Research, University of Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rebecca J Stack
- Centre for Translational Inflammation Research, University of Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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197
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Mwaka AD, Okello ES, Wabinga H, Walter FM. Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country. BMC Womens Health 2015; 15:15. [PMID: 25783641 PMCID: PMC4337099 DOI: 10.1186/s12905-015-0167-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 01/20/2015] [Indexed: 12/22/2022]
Abstract
Background Symptomatic cervical cancer patients in low- and middle-income countries usually present with late stage disease and have poor survival. We explored the views of cervical cancer patients on their symptom appraisal and interpretations, and their help-seeking including lay consultations. Methods We conducted an in-depth interview study in two northern Ugandan hospitals. Theoretical models underpinned the study guide for data collection and analysis. We used thematic analysis techniques, informed by the theoretical concepts in the Model of Pathways to Treatment. Sub-themes and themes were identified through consensus among investigators. Results Eighteen women aged 35–56 years, recently diagnosed with cervical cancer were interviewed. Their first symptoms included abnormal vaginal bleeding, offensive vaginal discharge and lower abdominal pain. Most participants did not perceive themselves to be at risk for cervical cancer and they usually attributed the initial symptoms to normal bodily changes or common illnesses such as sexually transmitted diseases. Lay consultations with husbands, relatives and friends were common and often influenced decisions and timing for seeking care. Prompt help-seeking was frequently triggered by perceived life threatening symptoms such as heavy vaginal bleeding or lower abdominal pain; symptom burden sufficient to interfere with patients’ work routines; and persistence of symptoms in spite of home-based treatments. Participants did not promptly seek care when they perceived symptoms as mild; interpreted symptoms as due to normal bodily changes e.g. menopause; and attributed symptoms to common illnesses they could self-manage. Their cancer diagnosis was often further delayed by long help-seeking processes including repeated consultations. Some healthcare professionals at private clinics and lower level health facilities failed to recognize symptoms of cervical cancer promptly therefore delayed referring women to the tertiary hospitals for diagnosis and treatment. Conclusion Ugandan patients with symptomatic cervical cancer often misattribute their gynaecological symptoms, and experience long appraisal and help-seeking intervals. These findings can inform targeted interventions including community awareness campaigns about cervical cancer symptoms, and promote prompt help-seeking in Uganda and other low- and middle-income countries with high incidence and mortality from cervical cancer.
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Affiliation(s)
- Amos Deogratius Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda,
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Renzi C, Whitaker KL, Wardle J. Over-reassurance and undersupport after a 'false alarm': a systematic review of the impact on subsequent cancer symptom attribution and help seeking. BMJ Open 2015; 5:e007002. [PMID: 25652803 PMCID: PMC4322204 DOI: 10.1136/bmjopen-2014-007002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/16/2015] [Accepted: 01/19/2015] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES This literature review examined research into the impact of a previous 'all-clear' or non-cancer diagnosis following symptomatic presentation ('false alarm') on symptom attribution and delays in help seeking for subsequent possible cancer symptoms. DESIGN AND SETTING The comprehensive literature review included original research based on quantitative, qualitative and mixed data collection methods. We used a combination of search strategies, including in-depth searches of electronic databases (PubMed, EMBASE, PsychInfo), searching key authors and articles listed as 'related' in PubMed, and reference lists. We performed a narrative synthesis of key themes shared across studies. PARTICIPANTS The review included studies published after 1990 and before February 2014 reporting information on adult patients having experienced a false alarm following symptomatic presentation. We excluded false alarms in the context of screening. PRIMARY AND SECONDARY OUTCOME MEASURES We evaluated the effect of a 'false alarm' on symptom attribution and help seeking for new or recurrent possible cancer symptoms. RESULTS Overall, 1442 papers were screened and 121 retrieved for full-text evaluation. Among them, 19 reported on false alarms and subsequent symptom attribution or help seeking. They used qualitative (n=14), quantitative (n=3) and mixed methods (n=2). Breast (n=7), gynaecological (n=3), colorectal (n=2), testicular (n=2), and head and neck cancers (n=2) were the most studied. Two broad themes emerged underlying delays in help seeking: (1) over-reassurance from the previous 'all-clear' diagnosis leading to subsequent symptoms being interpreted as benign, and (2) unsupportive healthcare experiences in which symptoms were dismissed, leaving patients concerned about appearing hypochondriacal or uncertain about the appropriate next actions. The evidence suggested that the effect of a false alarm can persist for months and even years. CONCLUSIONS In conclusion, over-reassurance and undersupport of patients after a false alarm can undermine help seeking in the case of new or recurrent potential cancer symptoms, highlighting the need for appropriate patient information when investigations rule out cancer.
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Affiliation(s)
- Cristina Renzi
- Department of Epidemiology and Public Health, University College London, Health Behaviour Research Centre, London, UK
| | - Katriina L Whitaker
- Department of Epidemiology and Public Health, University College London, Health Behaviour Research Centre, London, UK
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, Health Behaviour Research Centre, London, UK
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Birt L, Hall N, Emery J, Banks J, Mills K, Johnson M, Hamilton W, Walter FM. Responding to symptoms suggestive of lung cancer: a qualitative interview study. BMJ Open Respir Res 2014; 1:e000067. [PMID: 25553249 PMCID: PMC4265089 DOI: 10.1136/bmjresp-2014-000067] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 11/04/2022] Open
Abstract
Background Late diagnosis of lung cancer can impact on survival rates. Patients delay seeking help for a number of reasons. This study explored symptom appraisal and help-seeking decisions among patients referred to specialist respiratory services with symptoms suggestive of lung cancer. Methods In-depth qualitative interviews with patients as soon as possible after referral, ideally before diagnosis and mainly within 10 weeks, explored factors impacting on their pathways prior to referral. Framework analysis, underpinned by the Model of Pathways to Treatment, was used to explore the data with particular focus on patients’ beliefs and experiences, disease factors and healthcare professional influences. Results 35 patients were interviewed (aged 41–88 years, 15 women, 17 with lung cancer). All described similar presenting symptoms and triggers to seek help. Appraisal of symptoms was influenced by whether they had a lung comorbidity; seriousness of symptoms was interpreted within the context of previous illness experiences. Help-seeking was triggered when: symptoms failed to respond as expected; there was an increased awareness of symptoms of lung cancer; the public nature of a cough meant others were able to endorse help-seeking. Almost half visited the general practitioner (GP) two or more times before referral; during this period they reinterpreted initial symptoms and appraised new symptoms. The meaning given to symptoms changed over time and many became increasingly concerned they may have lung cancer. The GP played a role in ensuring timely further help-seeking but often there was little guidance on how to monitor symptoms or when to reconsult. Conclusions Patients diagnosed with and without lung cancer had similar symptom pathways. Findings provide guidance for lung cancer awareness campaigns on the importance of social networks in endorsing patient help-seeking. The importance of appropriate advice, monitoring and safety-netting procedures by GPs for people presenting with symptoms suggestive of lung cancer is also highlighted.
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Affiliation(s)
- Linda Birt
- Department of Public Health & Primary Care , University of Cambridge , Cambridge , UK
| | - Nicky Hall
- School of Medicine, Pharmacy & Health, Durham University , Durham , UK
| | - Jon Emery
- General Practice & Primary Care Academic Centre, University of Melbourne , Melbourne , Australia
| | - Jon Banks
- School of Social & Community Medicine, University of Bristol , Bristol , UK
| | - Katie Mills
- Department of Public Health & Primary Care , University of Cambridge , Cambridge , UK
| | | | | | - Fiona M Walter
- Department of Public Health & Primary Care , University of Cambridge , Cambridge , UK ; General Practice & Primary Care Academic Centre, University of Melbourne , Melbourne , Australia
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Whitaker KL, Scott SE, Winstanley K, Macleod U, Wardle J. Attributions of cancer 'alarm' symptoms in a community sample. PLoS One. 2014;9:e114028. [PMID: 25461959 PMCID: PMC4252079 DOI: 10.1371/journal.pone.0114028] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023] Open
Abstract
Background Attribution of early cancer symptoms to a non-serious cause may lead to longer diagnostic intervals. We investigated attributions of potential cancer ‘alarm’ and non-alarm symptoms experienced in everyday life in a community sample of adults, without mention of a cancer context. Methods A questionnaire was mailed to 4858 adults (≥50 years old, no cancer diagnosis) through primary care, asking about symptom experiences in the past 3 months. The word cancer was not mentioned. Target 'alarm' symptoms, publicised by Cancer Research UK, were embedded in a longer symptom list. For each symptom experienced, respondents were asked for their attribution (‘what do you think caused it'), concern about seriousness (‘not at all’ to ‘extremely’), and help-seeking (‘did you contact a doctor about it’: Yes/No). Results The response rate was 35% (n = 1724). Over half the respondents (915/1724; 53%) had experienced an ‘alarm’ symptom, and 20 (2%) cited cancer as a possible cause. Cancer attributions were highest for ‘unexplained lump’; 7% (6/87). Cancer attributions were lowest for ‘unexplained weight loss’ (0/47). A higher proportion (375/1638; 23%) were concerned their symptom might be ‘serious’, ranging from 12% (13/112) for change in a mole to 41% (100/247) for unexplained pain. Just over half had contacted their doctor about their symptom (59%), although this varied by symptom. Alarm symptoms were appraised as more serious than non-alarm symptoms, and were more likely to trigger help-seeking. Conclusions Consistent with retrospective reports from cancer patients, ‘alarm’ symptoms experienced in daily life were rarely attributed to cancer. These results have implications for understanding how people appraise and act on symptoms that could be early warning signs of cancer.
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