Gender differences in consulting a general practitioner for common symptoms of minor illness

ROCCA cohort study: Nationwide results on safety of Gam-COVID-Vac vaccine (Sputnik V) in the Republic of San Marino using active surveillance

BACKGROUND

Gam-COVID-Vac is the world's first registered vector vaccine against COVID-19 based on a combination of two heterologous adenoviruses. It was chosen by the Republic of San Marino as the main tool in its vaccination campaign, which started on 25 February 2021. Our aim was to build up on the ROCCA study, focused on the older population, by describing adverse effects following immunisation (AEFIs) rates and characteristics in all age groups for the first time in a real-world context.

METHODS

An active surveillance study on recipients of at least one dose of the Gam-COVID-Vac vaccine was conducted. Participants were administered online questionnaires through live/phone interviews with physicians, by e-mail or by scanning a QR code at different points in time after the first dose: one week (Q1) one month (Q2), and three months (Q3) between March and August 2021.

FINDINGS

Overall, 6190 vaccine recipients were recruited. Mean age was 52·4 ± 18·2 years. After the first dose, systemic reactions were reported by 57·5% of the participants, while injection site reactions were reported by 46·7%. The most common AEFIs were pain at the injection site, fatigue and headache. Grade 3 or 4 AEFIs were reported by 0·8% and 0·3% of the participants, respectively. After the second dose, systemic reactions were reported by 63·1% of the participants, while injection site reactions by 54·7%. The most common AEFIs were malaise, pain at injection site and myalgia. Grade 3 or 4 AEFIs were reported by 2·7% and 1·1% of the participants, respectively. Multivariate analysis showed younger age, being a woman and food allergies are risk factors for more severe AEFIs.

INTERPRETATION

Our results confirm a good tolerability profile for the population aged 18 and over providing useful data for vaccination campaigns ongoing in countries planning to use Gam-COVID-Vac.

FUNDING

None.

Uraemic symptom burden and clinical condition in women and men of ≥65 years of age with advanced chronic kidney disease: results from the EQUAL study

BACKGROUND

The epidemiology and prognosis of chronic kidney disease (CKD) differ by sex. We aimed to compare symptom prevalence and the clinical state in women and men of ≥65 years of age with advanced CKD receiving routine nephrology care.

METHODS

The European QUALity study on treatment in advanced chronic kidney disease (EQUAL) study follows patients from six European countries of ≥65 years of age  years whose estimated glomerular filtration rate (eGFR) dropped to ≤20 mL/min/1.73 m2 for the first time during the last 6 months. The Dialysis Symptom Index was used to assess the prevalence and severity of 33 uraemic symptoms. Data on the clinical state at baseline were collected from medical records. Prevalence was standardized using the age distribution of women as the reference.

RESULTS

The results in women (n = 512) and men (n = 967) did not differ with age (77.0 versus 75.7 years) or eGFR (19.0 versus 18.5). The median number of symptoms was 14 [interquartile range (IQR) 9-19] in women, and 11 (IQR 7-16) in men. Women most frequently reported fatigue {39% [95% confidence interval (CI) 34-45]} and bone/joint pain [37% (95% CI 32-42)] as severe symptoms, whereas more men reported difficulty in becoming sexually aroused [32% (95% CI 28-35)] and a decreased interest in sex [31% (95% CI 28-35)]. Anaemia [73% (95% CI 69-77) versus 85% (95% CI 82-87)] was less common in women than in men, as were smoking history and cardiovascular comorbidity. However, a diagnosis of liver disease other than cirrhosis, psychiatric disease and mild malnutrition were more common among women.

CONCLUSIONS

Women in secondary care with an incident eGFR ≤20 mL/min/1.73 m2 reported a higher symptom burden, while their clinical state was considered similar or even more favourable as compared with men.

Sex and gender influence symptom manifestation and survival in multiple system atrophy

To evaluate the influence of sex and gender on clinical characteristics and survival in multiple system atrophy (MSA), we reviewed MSA patients with autonomic testing 1998-2012. Of 685 patients, 52% were male. Median survival overall was 7.3 years for males, 7.6 years for females. Survival from diagnosis was 2.9 years in males, 3.8 years in females. Females were more likely to initially manifest motor symptoms. Males were more likely to have orthostatic intolerance and early catheterization. In conclusion, our data show longer survival from diagnosis in females and slight overall survival benefit which may be related to initial motor manifestations.

A review of sex-related differences in colorectal cancer incidence, screening uptake, routes to diagnosis, cancer stage and survival in the UK

Background

Colorectal cancer (CRC) is an illness strongly influenced by sex and gender, with mortality rates in males significantly higher than females. There is still a dearth of understanding on where sex differences exist along the pathway from presentation to survival. The aim of this review is to identify where actions are needed to improve outcomes for both sexes, and to narrow the gap for CRC.

Methods

A cross-sectional review of national data was undertaken to identify sex differences in incidence, screening uptake, route to diagnosis, cancer stage at diagnosis and survival, and their influence in the sex differences in mortality.

Results

Overall incidence is higher in men, with an earlier age distribution, however, important sex differences exist in anatomical site. There were relatively small differences in screening uptake, route to diagnosis, cancer staging at diagnosis and survival. Screening uptake is higher in women under 69 years. Women are more likely to present as emergency cases, with more men diagnosed through screening and two-week-wait. No sex differences are seen in diagnosis for more advanced disease. Overall, age-standardised 5-year survival is similar between the sexes.

Conclusions

As there are minimal sex differences in the data from routes to diagnosis to survival, the higher mortality of colorectal cancer in men appears to be a result of exogenous and/or endogenous factors pre-diagnosis that lead to higher incidence rates. There are however, sex and gender differences that suggest more targeted interventions may facilitate prevention and earlier diagnosis in both men and women.

Healthcare-seeking behaviour in case of influenza-like illness in the French general population and factors associated with a GP consultation: an observational prospective study

Background

GP consultation rates for influenza-like illness (ILI) are poorly known in France and there is a paucity of literature on this topic. In the few articles that have been published, the results are heterogeneous.

Aim

The aim of the present study was to estimate the proportion of ILI inducing a GP consultation, and to assess its determinants.

Design & setting

Participants of a French web-based cohort study who reported ≥1 ILI episode between 2012 and 2015 were included. Sociodemographic characteristics, access to health care, and health status variables were collected.

Method

Healthcare-seeking behaviour was analysed and factors associated with a GP consultation identified using a conditional logistic regression.

Results

Of the 6023 ILI episodes reported, 1961 (32.6%) led to a GP consultation, with no difference between those at risk of influenza complications and those not (P = 0.42). A GP consultation was more frequent for individuals living in a rural area (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.02 to 1.43); those with a lower educational level (OR = 1.43, 95% CI = 1.18 to 1.74); those using the internet to find information about influenza (OR = 1.63, 95% CI = 1.30 to 2.03); patients presenting with worrying symptoms (fever, cough, dyspnoea, sputum, or asthenia); patients having a negative perception of their own health status (OR = 1.51, 95% CI = 1.07 to 2.13; and those having declared a personal doctor (OR = 2.86, 95% CI = 1.72 to 4.76). A GP consultation was less frequent for individuals using alternative medicine (OR = 0.68, 95% CI = 0.58 to 0.78).

Conclusion

This study allows the identification of specific factors associated with GP consultation for an ILI episode. These findings may help to coordinate health information campaigns and to raise awareness, especially among individuals at risk of influenza complications.

Prospective daily diary study reporting of any and all symptoms in healthy adults in Pakistan: prevalence and response

OBJECTIVES

Prevalence of symptoms in everyday life and how people respond to these symptoms is little studied outside Western culture and developed countries. We sought to use modified diary methods to explore the prevalence of and responses to symptoms in Pakistan.

DESIGN

Prospective daily survey of symptoms and response.

SETTING

8 cities across four provinces in Pakistan.

PARTICIPANTS

Stratified intercept in each city to recruit 153 participants of which 151 completed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Each day for 30 days, participants were prompted by text message (short message service (SMS)) to complete a symptom diary. On days where symptoms were experienced, participants also reported how they responded. Prevalence was adjusted to population age and gender distributions.

RESULTS

92% of participants experienced symptoms (adjusted prevalence 94%, 95% CI 91% to 97%), with musculoskeletal pain (83%, adj. 84%, 95% CI 84% to 90%) and respiratory symptoms (75%, adj. 77%, 95% CI 71% to 84%) the most prevalent types of symptoms. Self-medication and use of home remedies and traditional medicines were the most common responses. Seeking professional help or using conventional medicine were less common, and self-medication responses included the use of antibiotics without prescription. The range of home remedies and traditional medicines was very diverse.

CONCLUSIONS

While symptom experience in Pakistan was similar to Western countries, home remedies were much more frequently used to respond to symptoms. Understanding how people respond and manage their experience of symptoms outside formal healthcare is important for designing effective policy and interventions, and this needs to be understood within the broader context including the cultural and economic setting, the health system and other structural determinants of health.

Nurse Practitioners and Men's Primary Health Care

Though life expectancy sex differences are decreasing in many Western countries, men experience higher mortality rates at all ages. Men are often reluctant to seek medical care because health help-seeking is strongly linked to femininity, male weakness, and vulnerability. Many men are also more likely to access emergency care services in response to injury and/or severe pain instead of engaging primary health care (PHC) services. Nurse practitioners are well positioned to increase men's engagement with PHC to waylay the pressure on emergency services and advance the well-being of men. This article demonstrates how nurse practitioners can work with men in PHC settings to optimize men's self-health and illness prevention and management. Four recommendations are discussed: (1) leveling the hierarchies, (2) talking it through, (3) seeing diversity within patterns, and (4) augmenting face-to-face PHC services. In terms of leveling the hierarchies nurse practitioners can engage men in effectual health decision making. Within the interactions detailed in the talking it through section are strategies for connecting with male patients and mapping their progress. In terms of seeing diversity with in patterns and drawing on the plurality of masculinities, nurse practitioners are encouraged to adapt a variety of age sensitive assessment tools to better intervene and guide men's self-health efforts. Examples of community and web based men's health resources are shared in the augmenting face-to-face PHC services section to guide the work of nurse practitioners. Overall, the information and recommendations shared in this article can proactively direct the efforts of nurse practitioners working with men.

Using e-health in perioperative care: a survey study investigating shortcomings in current perioperative care and possible future solutions

Background

An e-health care program has previously shown to have a positive effect on return to work, quality of life and pain in patients who underwent gynaecological surgery. Plausibly, providing the care program to a population undergoing other types of surgery will be beneficial as well. The objectives of this study are to evaluate patients’ opinions, needs and preferences regarding the information and guidance supplied to patients during the perioperative period, to investigate whether e-health may be of assistance and to explore if gender specific needs exist.

Methods

A questionnaire was sent to all patients between 18 and 75 years (n = 362), who underwent various forms of abdominal surgery between August 2013 to September 2014 in a university hospital in the Netherlands. The questionnaire contained questions about the current situation in perioperative care and questions about patients’ preferences in an e-health care program. Gender differences were evaluated.

Results

Two hundred seven participants (57.2%) completed the survey. The majority of the participants were relatively satisfied with the perioperative care they received (68.6%). Most reported shortcomings in perioperative care concerning the supply of information regarding the resumption of activities and guidance during the recovery course. An e-health care program was expected to be of added value in perioperative care by 78% of the participants; a website was reported as most useful. In particular practical functions on a website focusing on the preparation to surgery and monitoring after surgery were appraised to be highly valuable. Overall, women had slightly more needs for extra information and support during the perioperative course than men.

Conclusions

In abdominal surgery, there is a need for an e-health care program, which should focus mainly on the supply of information about the resumption of activities as well as guidance in the postoperative course.

Initial basal cell carcinomas diagnosed in the National Campaign for Skin Cancer Prevention are smaller than those identified by the conventional medical referral system

BACKGROUND

Basal cell carcinoma is the malignant tumor most often diagnosed in the National Campaign for Skin Cancer Prevention (NCSCP). Little is known about the profile of these lesions compared to the profile of lesions diagnosed by conventional routes of public dermatological care.

OBJECTIVE

To identify if basal cell carcinomas identified in prevention campaigns and referred to surgery are smaller than those routinely removed in a same medical institution.

METHODS

Cross-sectional study including tumors routed from 2011-2014 campaigns and 84 anatomopathological reports of outpatients.

RESULTS

The campaigns identified 223 individuals with suspicious lesions among 2,531 examinations (9%), with 116 basal cell carcinomas removed. Anatomopathological examinations revealed that the primary lesions identified in the national campaigns were smaller than those referred to surgery by the conventional routes of public health care (28 [13-50] x 38 [20-113] mm², p <0.01). On the other hand, after a mean follow-up of 15.6 ± 10.3 months, 31% of cases identified in campaigns showed new basal cell carcinoma lesions.

STUDY LIMITATIONS

Retrospective study and inaccuracies in the measurements of the lesions.

CONCLUSIONS

The NCSCP promotes an earlier treatment of basal cell carcinomas compared to patients referred to surgery by the conventional routes of public health care, which can result in lower morbidity rates and better prognosis.

Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries

Background

Some people have a lower threshold to seek care for certain symptoms than others. This study aims to investigate what factors are associated with patients’ propensity to seek care. In addition, this study explores whether patients’ propensity to seek care is associated with their actual health care utilization. We hypothesized that higher scores for propensity to seek care will lead to more general practitioners (GP) consultations, but to lower rates of avoidable hospitalization.

Methods

Propensity to seek care and GP utilization were measured by the Patient Experience Questionnaire of the QUALICOPC study, a survey among 61,931 patients that recently visited GP services in 34 countries. Propensity to seek care was estimated by two questions: one question focusing on health care seeking behavior for serious symptoms and the other question focused minor complaints. Data on country level rates of avoidable hospitalization for CHF, COPD, asthma and diabetes were obtained from the OECD health care quality indicators project.

Results

Beside patient characteristics, various organizational factors, such as better accessible and continuous primary care, and better experienced communication between patient and GPs was associated with a higher propensity to seek care for both severe and minor complaints. A higher propensity to seek care was associated with a slightly higher health care utilization in terms of GP visits, with no differences between the severity of the experienced symptoms (OR 1.08 for severe complaints and OR 1.05 for minor complaints). At country level, no association was found between propensity to seek care and rates of avoidable hospitalization for CHF, COPD, asthma and diabetes, possibly due to low statistical power at country level.

Conclusions

The organization of primary care and patients’ perceived communication with their GP were found to be highly correlated with patients’ decision to seek health care for minor or severe complaints, suggesting that characteristics of healthcare systems directly influence patients’ care seeking behavior, potentially leading to overuse or underuse of health services. However, we also observed that patients’ propensity to seek care is only weakly associated with more GP use.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1119-2) contains supplementary material, which is available to authorized users.

Self-reported symptoms and healthcare seeking in the general population--exploring "The Symptom Iceberg"

BACKGROUND

Research has illustrated that the decision-making process regarding healthcare seeking for symptoms is complex and associated with a variety of factors, including gender differences. Enhanced understanding of the frequency of symptoms and the healthcare seeking behaviour in the general population may increase our knowledge of this complex field. The primary objective of this study was to estimate the prevalence of self-reported symptoms and the proportion of individuals reporting GP contact, in a large Danish nationwide cohort. A secondary objective was to explore gender differences in GP contacts in response to experiencing one of the 44 predefined symptoms.

METHODS

A Danish nationwide cohort study including a random sample of 100,000 individuals, representative of the adult Danish population aged 20 years or above. A web-based questionnaire survey formed the basis of this study. A total of 44 different symptoms covering a wide area of alarm symptoms and non-specific frequently occurring symptoms were selected based on extensive literature search. Further, items regarding contact to the GP were included. Data on socioeconomic factors were obtained from Statistics Denmark.

RESULTS

A total of 49,706 subjects completed the questionnaire. Prevalence estimates of symptoms varied from 49.4% (24,537) reporting tiredness to 0.11% (54) reporting blood in vomit. The mean number of reported symptoms was 5.4 (men 4.8; women 6.0). The proportion of contact to the GP with at least one symptom was 37%. The largest proportion of GP contacts was seen for individuals reporting blood in the urine (73.2%), whereas only 11.4% of individuals with increase in waist circumference reported GP contact. For almost 2/3 of the symptoms reported, no gender differences were found concerning the proportion leading to GP contacts.

CONCLUSION

Prevalence of symptoms and GP contacts are common in this overview of 44 different self-reported symptoms. For almost 2/3 of the reported symptoms no gender differences were found concerning the proportion leading to GP contacts. An enhanced understanding of healthcare seeking decisions may assist healthcare professionals in identifying patients who are at risk of postponing contact to the GP and may help development of health campaigns targeting these individuals.

Gender comparisons in non-acute cardiac symptom recognition and subsequent help-seeking decisions: a mixed methods study protocol

INTRODUCTION

Coronary heart disease (CHD) is one of the leading causes of death in both men and women worldwide. Despite the common misconception that CHD is a 'man's disease', it is now well accepted that women endure worse clinical outcomes than men following CHD-related events. A number of studies have explored whether or not gender differences exist in patients presenting with CHD, and specifically whether women delay seeking help for cardiac conditions. UK and overseas studies on help-seeking for emergency cardiac events are contradictory, yet suggest that women often delay help-seeking. In addition, no studies have looked at presumed cardiac symptoms outside an emergency situation. Given the lack of understanding in this area, an explorative qualitative study on the gender differences in help-seeking for a non-emergency cardiac events is needed.

METHODS AND ANALYSIS

A purposive sample of 20-30 participants of different ethnic backgrounds and ages attending a rapid access chest pain clinic will be recruited to achieve saturation. Semistructured interviews focusing on help-seeking decision-making for apparent cardiac symptoms will be undertaken. Interview data will be analysed thematically using qualitative software (NVivo) to understand any similarities and differences between the way men and women construct help-seeking. Findings will also be used to inform the preliminary development of a cardiac help-seeking intentions questionnaire.

ETHICS AND DISSEMINATION

Ethical approvals were sought and granted. Namely, the University of Westminster (sponsor) and St Georges NHS Trust REC, and the Trust Research and Development Office granted approval to host the study on the Queen Mary's Roehampton site. The study is low risk, with interviews being conducted on hospital premises during working hours. Investigators will disseminate findings via presentations and publications. Participants will receive a written summary of the key findings.

Social welfare utilization and needs of older adults in Taiwan: survey research

BACKGROUND

The demand for long-term care for older adults has escalated sharply. A good policy dedicated to the welfare of older adults has improved their quality of life. The purpose of this study was to explore the social welfare utilization and needs of older adults and compare their differences among age groups, genders, and functional dependency levels.

METHODS

Three hundred eighty-four stratified, random-sampled Taiwanese community-dwelling older adults were recruited for this survey research. Participants rated their utilization of and needs for the 30 social welfare services provided by the government on a Likert-type scale.

RESULTS

The most widely used and needed social welfare services by the older adults were senior monetary stipend and a subsidy for the national health insurance premium. Young-old, male, and functionally independent older adults had more knowledge of the social welfare services than their counterparts.

CONCLUSIONS

While designing a comprehensive social welfare system, differing needs of different age groups, genders, and functional dependency levels should be taken into consideration.

Work-family conflict, health services and medication use among dual-income couples in Europe

Combination pressure or work-life imbalance is linked to adverse health. However, it remains unclear how work-family conflict is related to healthcare utilisation. Does work-family conflict function as a barrier or as a facilitator in relation to the use of health services and prescription medication? Lack of time may prevent people from visiting a doctor when they feel unwell. However, combination pressure can also be expected to intensify the use of health services, as the need for a quick fix is prioritised. Further, do women and men differ in their susceptibility to medicalisation and time pressure resulting from work-life imbalance? This article investigates the use of health services and prescription medication of dual-income couples with children, based on data from 23 countries in the European Social Survey round 2 (N(women) = 3755; N(men) = 3142). It was found that medical services and prescription medications are used more frequently in dual-income couples experiencing work-to-family spillover, but for women only this is irrespective of their self-reported health. Family-to-work spillover does not result in increased health service or medication use for either men or women. While women opt for a medical response to work-life imbalance, men's reluctance to seek formal health support is confirmed.

An observational study of public and private general practitioner consultations in the Republic of Ireland

BACKGROUND

The reasons why patients visit their general practitioner (GP) is vital information for fund holders and policy makers. GP consultations in the Republic of Ireland are either paid by the patient on a fee-per-service basis (private patients) or by the state [general medical service (GMS) card holders], and information related to primary care consultations is limited.

OBJECTIVES

The aim of this study was to conduct an observational study of GMS and private consultations within general practice in Ireland.

DESIGN

This is a cross-sectional study of general practitioner consultations.

METHODS

GPs within existing Continued Medical Education (CME) groups were invited to participate. Participating GPs gathered data on 100 consecutive consultations between September 2008 and April 2010.

RESULTS

There were 16,899 consultations recorded; 53.8 % (9,095) were GMS patients. Patients ≥65 years accounted for 23.69 % of consultations (n = 3,822). Respiratory illnesses accounted for the highest proportion of consultations (3,886, 23.0 %), followed by routine check-ups (15.4 %). GMS patients were more likely to consult for a repeat prescription (OR = 4.04, 95 % CI 2.93-5.57) and were also more likely to consult to review their treatment (OR = 2.33, 95 % CI 1.68-3.22) compared to private patients.

CONCLUSION

This study displays the consultation behaviour of patients in Ireland. It suggests that inequalities may exist in access to primary care services in ROI; however, more research is required to examine this further. There is insufficient information available on primary healthcare utilisation. Key issues such as the lack of unique patient identifiers and the lack of extractable data from GP practices in ROI need to be addressed.

Collectivism/individualism and its relationship to behavioral and physiological immunity

The interaction between the behavioral and physiological immune systems provides fertile ground for research. Here, we examine the interactions between fear of disease, collectivism/individualism, disgust, visual perception and salivary IgA. First, we parsed collectivism/individualism into ancestry and psychological processes and examined their relationships to fear of disease. Both ancestral and psychological collectivists scored higher on a test of hypochondria than individualists. Additionally, in two studies we exposed participants to slides of diseased, injured or healthy individuals. Diseased and injured stimuli were rated as equally disgusting, while diseased stimuli were rated as more disgusting than healthy stimuli. We measured salivary IgA in participants before and after they viewed the stimuli. Participants provided information on their ancestral collectivism or individualism. Salivary IgA levels increased after participants viewed images of diseased or injured individuals. Participants with collectivist ancestry tended to react to the diseased and injured images with an increase in IgA, while levels of IgA remained the same or decreased in individualists in one study but we failed to replicate the effect in the second study. An increased salivary IgA response to potentially diseased individuals is adaptive, because salivary IgA plays an important role in protecting individuals from contracting an infection. The response may be related to increased preoccupation with disease states.

Do men consult less than women? An analysis of routinely collected UK general practice data

OBJECTIVE

To examine whether gender differences in primary care consultation rates (1) vary by age and deprivation status and (2) diminish when consultation for reproductive reasons or common underlying morbidities are accounted for.

DESIGN

Cross-sectional study of a cohort of patients registered with general practice.

SETTING

UK primary care.

SUBJECTS

Patients (1 869 149 men and 1 916 898 women) registered with 446 eligible practices in 2010.

PRIMARY OUTCOME MEASURES

Primary care consultation rate.

RESULTS

This study analyses routinely collected primary care consultation data. The crude consultation rate was 32% lower in men than women. The magnitude of gender difference varied across the life course, and there was no 'excess' female consulting in early and later life. The greatest gender gap in primary care consultations was seen among those aged between 16 and 60 years. Gender differences in consulting were higher in people from more deprived areas than among those from more affluent areas. Accounting for reproductive-related consultations diminished but did not eradicate the gender gap. However, consultation rates in men and women who had comparable underlying morbidities (as assessed by receipt of medication) were similar; men in receipt of antidepressant medication were only 8% less likely to consult than women in receipt of antidepressant medication (relative risk (RR) 0.916, 95% CI 0.913 to 0.918), and men in receipt of medication to treat cardiovascular disease were just 5% less likely to consult (RR=0.950, 95% CI 0.948 to 0.952) than women receiving similar medication. These small gender differences diminished further, particularly for depression (RR=0.950, 95% CI 0.947 to 0.953), after also taking account of reproductive consultations.

CONCLUSIONS

Overall gender differences in consulting are most marked between the ages of 16 and 60 years; these differences are only partially accounted for by consultations for reproductive reasons. Differences in consultation rates between men and women were largely eradicated when comparing men and women in receipt of medication for similar underlying morbidities.

Importance of local data on occurrence and outcomes of renal cell cancer

Background:

In comparatively socioeconomically deprived areas male cancer mortality is often above the national average. Given this, we explored the pattern of presentation and outcomes of men with conventional clear cell renal cell carcinoma (CCRCC) undergoing nephrectomy at a North East of England regional tertiary referral centre.

Patients and methods:

A retrospective review of CCRCC patients treated with nephrectomy between 2004 and 2008 was performed. Risk of progression for men and women was calculated using Mayo, Memorial Sloan-Kettering (MSK) and Kattan prognostic scores. Outcomes of disease free progression and overall survival were measured.

Results:

292 patients with complete local follow up were identified that had undergone radical nephrectomy for conventional clear cell histology. The median (range) follow up was 36 months (10–65 months), and men accounted for 64% of these cases. At presentation, 45% of cases presented with stage III–IV (>T2, N0/1, M0/1) disease compared with 32% nationally (BAUS cancer registry). At diagnosis men had more advanced tumours compared with women (54% vs. 22% for stage >T2, N0/1, M0/1; p < 0.001) and had higher risk of progression based on prognostic scores ( p < 0.01) despite similar risk factors and clinical symptoms. Early outcome analysis comparing men to women revealed both lower disease-free survival (82% vs. 89%) and overall survival (87% vs. 93%) in men at 24 months ( p < 0.01). However, stage for stage comparisons between men and women demonstrated no significant difference in survival.

Discussion:

Men in the North East of England presented later with more advanced CCRCC. The reason for this remained undefined in this study. This pattern is consistent with reports of adverse male cancer-related outcomes in deprived areas and highlights the importance of local data in planning local health care.

Utilization of In-Hospital Care among Foreign-Born Compared to Native Swedes 1987-1999

In previous longitudinal studies of mortality and morbidity among foreign-born and native-born Swedes, increased mortality and dissimilarities in mortality pattern were found. The aim of this study is to describe, compare, and analyse the utilization of in-hospital care among deceased foreign- and Swedish-born persons during the years 1987-1999 with focus on four diagnostic categories. The study population consisted of 361,974 foreign-born persons aged 16 years and upward who were registered as living in Sweden in 1970, together with 361,974 matched Swedish controls for each person. Data from Statistics Sweden (SCB) and the National Board of Health and Welfare Centre for Epidemiology, covering the period 1970-1999, was used. Persons were selected if they were admitted to hospital during 1987-1999 and the cause of death was in one of four ICD groups. The results indicate a tendency towards less health care utilization among migrants, especially men, as regards Symptoms, signs, and ill-defined conditions and Injury and poisoning. Further studies are needed to explore the possible explanations and the pattern of other diseases to see whether migrants, and especially migrant men, are a risk group with less utilization of health care.

Assessment of cardiovascular risk factors prior to NHS Health Checks in an urban setting: cross-sectional study

OBJECTIVES

To assess the completeness of cardiovascular disease (CVD) risk factor recording and levels of risk factors in patients eligible for the NHS Health Check.

DESIGN

Cross-sectional study.

SETTING

Twenty-eight general practices located in Hammersmith and Fulham, London, UK.

PARTICIPANTS

42,306 patients aged 40 to 74 years without existing cardiovascular disease or diabetes.

MAIN OUTCOME MEASURES

MEASUREMENT AND LEVEL OF CVD RISK FACTORS: blood pressure, cholesterol, body mass index (BMI), blood glucose and smoking status.

RESULTS

There was a high recording of smoking status (86.1%) and blood pressure (82.5%); whilst BMI, cholesterol and glucose recording was lower. There was large variation in BMI, cholesterol, glucose recording between practices (29.7-91.5% for BMI). Women had significantly better risk factor recording than men (AOR = 1.70 [1.61-1.80] for blood pressure). All risk factors were better recorded in the least deprived patient group (AOR = 0.79 [0.73-0.85] for blood pressure) and patients with diagnosed hypertension (AOR = 7.24 [6.67-7.86] for cholesterol). Risk factor recording varied considerably between practices but was more strongly associated with patient than practice level characteristics. Age-adjusted levels of cholesterol and BMI were not significantly different between men and women. More men had raised blood glucose, blood pressure and BMI than women (29.7% [29.1-30.4] compared to 19.8% [19.3-20.3] for blood pressure).

CONCLUSIONS

Before the NHS Health Check, CVD risk factor recording varied considerably by practice and patient characteristics. We identified significant elevated levels of raised CVD risk factors in the population eligible for a Health Check, which will require considerable work to manage.

Ascertaining the size of the symptom iceberg in a UK-wide community-based survey

BACKGROUND

The symptom iceberg describes the phenomenon that most symptoms are managed in the community without people seeking professional health care. The size of the iceberg for many symptoms is unknown, as is their association with personal characteristics, including history of a chronic disease.

AIM

To ascertain the size of the symptom iceberg in the UK.

DESIGN OF STUDY

A UK-wide community-based postal survey.

SETTING

Urban and rural communities across the UK.

METHOD

A postal survey was sent to an age- and sex-stratified random sample of 2474 adults, aged 18-60 years, drawn from 20 practices around the UK. Questions were aimed at investigating adults' experiences of 25 different symptoms in the previous 2 weeks.

RESULTS

The number of symptoms experienced by one individual in the previous 2 weeks ranged from 0 to 22 (mean 3.66). Of the symptoms examined, the three most common were: feeling tired/run down; headaches; and joint pain. Univariate analysis found symptom prevalence to be significantly associated with a wide range of participant characteristics. However, after adjustment, many of these associations no longer remained significant for a number of the symptoms. Presence of a chronic condition, age, and employment status were the three factors most commonly associated with the 2-week prevalence of symptoms. Reported symptom characteristics (severity, duration, interference, and time off work) varied little by sex or age.

CONCLUSION

Symptoms in the UK community are common. Symptom prevalence was associated with a number of participant characteristics, although the extent of this association was less than has been reported in previous research. This study provides an important current baseline prevalence of 25 symptoms in the community for those who do, and do not, have a chronic condition.

Revisiting the symptom iceberg in today's primary care: results from a UK population survey

BACKGROUND

Recent changes in UK primary care have increased the range of services and healthcare professionals available for advice. Furthermore, the UK government has promoted greater use of both self-care and the wider primary care team for managing symptoms indicative of self-limiting illness. We do not know how the public has been responding to these strategies. The aim of this study was to describe the current use of different management strategies in the UK for a range of symptoms and identify the demographic, socio-economic and symptom characteristics associated with these different approaches.

METHODS

An age and sex stratified random sample of 8,000 adults (aged 18-60), drawn from twenty general practices across the UK, were sent a postal questionnaire. The questionnaire collected detailed information on 25 physical and psychological symptoms ranging from those usually indicative of minor illness to those which could be indicative of serious conditions. Information on symptom characteristics, actions taken to manage the symptoms and demographic/socio-economic details were also collected.

RESULTS

Just under half of all symptoms reported resulted in respondents doing nothing at all. Lay-care was used for 35% of symptoms and primary care health professionals were consulted for 12% of symptoms. OTC medicine use was the most common lay-care strategy (used for 25% of all symptom episodes). The GP was the most common health professional consulted (consulted for 8% of all symptom episodes) while use of other primary care health professionals was very small (each consulted for less than 2% of symptom episodes). The actions taken for individual symptoms varied substantially although some broad patterns emerged. Symptom characteristics (in particular severity, duration and interference with daily life) were more commonly associated with actions taken than demographic or socio-economic characteristics.

CONCLUSION

While the use of lay-care was widespread, use of the primary care team other than the GP was low. Further research is needed to examine the public's knowledge and opinions of different primary care services to investigate why certain services are not being used to inform the future development of primary care services in the UK.

Diagnosis: a liminal state for women living with lupus

Women with systemic lupus erythematosus (SLE or lupus) often experience a protracted diagnostic period in which their symptoms are treated as medically unexplained. Although they know they are ill, their symptoms have not been validated as indicative of disease by a health care professional. Consequently, the diagnostic period can be viewed as liminal, the middle stage in the rites of passage and what Turner (1969/1997) has labeled "betwixt and between." Drawing on the analysis of narratives solicited from 23 women recruited from online lupus support groups, I explore the gendered nature of diagnosis for women with lupus using van Gennep's (1960) rites of passage as a conceptual framework.

A Review of Men's Health and Masculinity

Men's health is a new and evolving area of specialty that goes beyond men's cancers and sexual activities. Men's health in the 21st century incorporates a broader conceptualization of health, health behaviors, and lifestyle choices. This new focus results from the fact that men continue to lag behind women in life expectancy and in health care use, a situation that is worse for minority men. Understanding how gender socialization and masculine ideology affects men's health is an important step toward providing effective care for men. In this article, the authors review these areas and then discuss each of the top actual causes of death for men: tobacco use, poor diet, alcohol use, and physical inactivity. They then discuss the important issue of steroid use among men. Throughout the review, the authors highlight racial and ethnic differences in health behaviors. Furthermore, they provide empirically supported clinical implications to assist clinicians who see men with health concerns in their practices. Finally, they offer suggestions for creating ways to include men in the health care system in hopes of improving their use.

Men, masculine identities, and health care utilisation

Seeking medical help early is critical for recovery, yet evidence indicates that men do not utilise general practitioner services as often as women. This paper draws on Connell's (1995) theory of hegemonic masculinity to critically examine how men's under-utilisation of medical services may be influenced by the social construction of masculine identities. Interviews with seven older rural men about their help-seeking behaviour, used a movie extract and hypothetical scenarios to stimulate discussion. Transcribed data were analysed using discourse analysis, which showed that in this particular social context, the men faced a dilemma when identifying with two conflicting subject positions: the virtuous regular health care user, and the masculine infrequent user of health care services. They solved this dilemma by positioning women as frequent and trivial users of health care and themselves as legitimate users of health care. By using biomedical and morality discourses in this way the men could maintain a masculine identity whilst also identifying as virtuous users of health care services. These results support the utility of hegemonic masculinity as a theoretical basis for examining the construction and maintenance of gendered identities by highlighting the complexity of multiple masculine identities.

Deterioration is not the only prospect for adolescents' health: improvement in self-reported health status among boys and girls from age 15 to age 19

AIM

To assess changes in the mental and physical health of adolescents between the ages of 15 and 19.

METHODS

The study included a four-year follow-up of 844 students from 31 secondary schools located in Kosice, Slovakia (response rate 45.6%). The 36-item short form (SF-36) scales were used to assess vitality and mental health, self-rated health, long-term well-being, long-standing illness, and the number of perceived health complaints at the age of 15 and four years later.

RESULTS

Both boys and girls reported significant deterioration in vitality (mean difference boys 5.3; girls 3.3; P=0.001) and mental health (mean difference boys 7.7; girls 5.7; P=0.001), while only boys reported deterioration in self-rated health (P=0.047). The proportion of boys who reported an improvement ranged from 8%-40%, while the proportion of girls who reported an improvement ranged from 8%-45%. Significantly more girls than boys reported an improvement in mental health (27% of boys vs 34% of girls) and vitality (32% of boys vs 39% of girls), while more boys than girls reported a deterioration in vitality(55% of boys vs 48% of girls)). These differences were trivial according to the effect size (Cohen's H<0.20).

CONCLUSION

Although significant deterioration in mental health and vitality was detected among both genders, with boys deteriorating more substantially in self-rated health than girls, the differences between the proportion of those with improved and those with deteriorated status were trivial in size.

Symptom experience and subsequent mortality: results from the West of Scotland Twenty-07 study

BACKGROUND

Associations between symptom experience and mortality have rarely been investigated. One study has suggested that the number of symptoms people experience may be an important predictor of mortality. This novel and potentially important finding may have important implications but needs to be tested in other cohorts.

METHODS

858 people aged around 58 years were interviewed by nurses in 1990/1 as part of the West of Scotland Twenty-07 Study. They were asked about the presence of symptoms in the last month from a checklist of 33 symptoms. Measures of morbidity included symptom type (respiratory, musculoskeletal, gastrointestinal, mental health, neurological, systemic) and symptom summary measures looking at the number and impact of symptoms (total number; number participants tended to have; number participants did not tend to have; number which restricted usual activities; number which led to GP consultation). Hazard ratios for thirteen-year all-cause mortality were calculated for symptom types, symptom summary measures, and self-assessed health with and without adjustment.

RESULTS

On unadjusted analysis, and after adjusting for gender, socio-economic status and smoking, mortality was elevated in individuals reporting respiratory, systemic and mental health symptoms. After additional adjustment for chronic conditions and self-assessed health, only the association between mental health symptoms and mortality remained significant. On unadjusted analysis, and after adjusting for gender, socio-economic status and smoking, mortality was elevated in individuals with many (> or = 6) symptoms in four of the symptom summary measures examined. These relationships were no longer significant after additional adjustment for chronic conditions and self-assessed health. A clear trend of increasing mortality as self-assessed health became poorer was observed. This pattern remained statistically significant after adjustment for gender, socio-economic status, smoking, chronic conditions and the total number of symptoms experienced.

CONCLUSION

Symptoms often thought of as minor may have important consequences later in life especially for those reporting mental health-related symptoms or those experiencing many symptoms. In this study however, self-assessed health appeared to be a better predictor of mortality than the type or number of symptoms experienced, even when the tendency to have and impact of the symptoms were taken into account.

Gender differences in health care use among the elderly population in areas of Norway and Finland. A cross-sectional analysis based on the HUNT study and the FINRISK Senior Survey

BACKGROUND

The aim of the study was to examine gender differences in the self-reported use of health care services by the elderly in rural and metropolitan areas of two Nordic countries with slightly different health care systems: Finland and Norway.

METHODS

Population based, cross-sectional surveys conducted in Nord-Tröndelag Norway (1995-97) and in rural and metropolitan areas of Finland (1997) were employed. In the Norwegian data, a total of 7,919 individuals, aged 65-74 years old were included, and the Finnish data included 1,500 individuals. The outcome variables comprised whether participants had visited a general practitioner or a specialist, or had received hospital care or physiotherapy during the past 12 months. Gender differences in the use of health care services were analysed by multiple logistic regression, controlling for health status and socio-demographic characteristics.

RESULTS

In Norway, elderly women visited a specialist or were hospitalised less often than men. In Finland, elderly women used all health care services except hospital care more often than men. In Norway, less frequent use of specialist care by women was not associated with self-reported health or chronic diseases.

CONCLUSION

The findings revealed differences in self-reported use of secondary care among different genders in areas of Norway and Finland.

Self-managing and managing self: practical and moral dilemmas in accounts of living with chronic illness

BACKGROUND

Patient education self-management programmes draw on sociological understanding of experiencing single chronic illnesses, but health practitioners do not always recognize the tensions and ambiguities permeating individuals' management experiences, particularly for those with multiple morbidity. The aim of this study was to illuminate how people negotiate multiple chronic illness, and everyday life.

METHODS

A sample of 23 people in their early 50s was recruited from a community health survey in Scotland. The participants had four or more chronic illnesses and were interviewed twice. The qualitative data that were generated highlighted the impact of illness and associated management strategies, as people attempted to continue familiar lives. Analysis was based on constant comparison and informed by a narrative approach.

RESULTS

People used multiple techniques to manage symptoms and conveyed a moral obligation to manage 'well'. However, maintaining valued social roles, coherent identities and a 'normal life' were prioritized, sometimes over symptom containment. This led to tensions, and participants faced moral dilemmas as they self-managed.

DISCUSSION

Self-management policies, programmes and healthcare practitioners need to recognize the tensions that people experience as they negotiate symptoms, valued social roles, positive identities, and daily life. Addressing these issues may improve opportunities to support patients in particular contexts, and enhance self-management.

The use of an Internet-based Ask the Doctor Service involving family physicians: evaluation by a web survey

BACKGROUND

Internet consultation without a previous relationship between the doctor and the enquirer seems to be increasing in popularity. However, little is known about the advantages, disadvantages or other differences compared with regular health care when using this kind of service.

OBJECTIVE

To investigate how an Internet-based Ask the Doctor service out with any pre-existing doctor-patient relationship was used and evaluated by the enquirers.

METHODS

We recruited to a web-based survey users of the non-commercial Swedish Internet-based Ask the Doctor service run by family physicians. The survey was conducted between November 2001 and January 2002. Questions included both multiple choice and free text formats, and the results were analysed quantitatively and qualitatively.

RESULTS

The survey was completed by 1223 participants. It was mainly women who submitted questions to the service (29% men, 71% women) and also who participated in the survey (26% men, 74% women). Most participants (77%) wrote their question at home, and 80% asked on their own behalf. Almost half of the enquiries (45%) concerned a medical matter that had not been evaluated by a medical professional before. After reading the answer, 43% of the participants indicated that they would not pursue their question further having received sufficient information in the answer provided. The service was appreciated for its convenience and flexibility, but also for reasons to do with the mode of communication such as the ability to reflect on the written answer without having to hurry and to read it more than once.

CONCLUSION

In the present study, we found that an Internet-based Ask the Doctor service run by family physicians on the whole was evaluated positively by the participants both in terms of the answers and the service. Internet-based consultation may act as a complement to regular health care. In future studies, the cost-effectiveness, patient security, responsibilities of the Internet doctor and the role of Ask the Doctor services compared with regular health care should be evaluated.

‘It's caveman stuff, but that is to a certain extent how guys still operate’: men's accounts of masculinity and help seeking

It is often assumed that men are reluctant to seek medical care. However, despite growing interest in masculinity and men's health, few studies have focussed on men's experiences of consultation in relation to their constructions of masculinity. Those that have are largely based on men with diseases of the male body (testicular and prostate cancer) or those which have been stereotyped as male (coronary heart disease). This paper presents discussions and experiences of help seeking and its relation to, and implications for, the practice of masculinity amongst a diversity of men in Scotland, as articulated in focus group discussions. The discussions did indeed suggest a widespread endorsement of a 'hegemonic' view that men 'should' be reluctant to seek help, particularly amongst younger men. However, they also included instances which questioned or went against this apparent reluctance to seek help. These were themselves linked with masculinity: help seeking was more quickly embraced when it was perceived as a means to preserve or restore another, more valued, enactment of masculinity (e.g. working as a fire-fighter, or maintaining sexual performance or function). Few other studies have emphasised how men negotiate deviations from the hegemonic view of help-seeking.

Men and health help-seeking behaviour: literature review

AIM

This paper reviews the key research literature regarding men's health-related help seeking behaviour.

BACKGROUND

There is a growing body of research in the United States to suggest that men are less likely than women to seek help from health professionals for problems as diverse as depression, substance abuse, physical disabilities and stressful life events. Previous research has revealed that the principle health related issue facing men in the UK is their reluctance to seek access to health services.

METHOD

The investigation of men's health-related help seeking behaviour has great potential for improving both men and women's lives and reducing national health costs through the development of responsive and effective interventions. A search of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsychINFO and the Cochrane Library databases.

RESULTS

Studies comparing men and women are inadequate in explaining the processes involved in men's help seeking behaviour. However, the growing body of gender-specific studies highlights a trend of delayed help seeking when they become ill. A prominent theme among white middle class men implicates "traditional masculine behaviour" as an explanation for delays in seeking help among men who experience illness. The reasons and processes behind this issue, however, have received limited attention.

CONCLUSIONS

Principally, the role of masculine beliefs and the similarities and differences between men of differing background requires further attention, particularly given the health inequalities that exist between men of differing socio-economic status and ethnicity. Further research using heterogeneous samples is required in order to gain a greater understanding of the triggers and barriers associated with the decision making process of help seeking behaviour in men who experience illness.

Gender differences in the utilisation of optometric services in Victoria

Medicare and population data demonstrate clear gender differences in utilisation of health services. There are three broad hypotheses that may explain different utilisation rates of health services by gender: differences in access, differences in incidence and differences in attitudes in seeking health care between the genders. Men are 28 per cent less likely than women to see an optometrist in Victoria. Both women's and men's utilisation of optometric services in Victoria increase with age but there are clear gender differences apparent at every stage of life after childhood. These utilisation rates between genders are tested against incidence rates between genders for eye conditions. There are few noted gender differences apparent in the incidence or prevalence of ocular conditions. The data on the incidence of health conditions often has limitations, either in measurement tools or in differences in incidence between genders. These limitations are not as evident in eye care incidence data. Access and incidence differences do not adequately explain the differences in optometric service utilisation rates. This promotes the hypothesis that attitudinal differences in seeking health care between men and women are significant.

'Reasonable access' to primary care: assessing the role of individual and system characteristics

Access to health care continues to be an important issue for health policy makers, researchers, service providers and consumers alike. In countries with universal health care coverage, services are generally free at the point of delivery which is intended to provide equitable access to care for all residents regardless of their individual situations. Past studies have pointed to the importance of individual characteristics such as age, gender, and socioeconomic status in shaping access to health care but much less is known about the role of health system characteristics. The purpose of this study is to explore, by means of qualitative research methods, the extent to which individual and system factors shape access to primary health care services for residents living in two contrasting neighbourhoods in Hamilton, Ont., Canada. Semi-structured, in-depth interviews were conducted with 40 men and women. The interviews probed participants about their experiences with primary care, barriers to receiving care and their general perceptions of the health care system. The interviews demonstrated the existence of many system-related barriers to receiving health care (e.g., wait times, geographic inaccessibility and quality of care) and some individual-related barriers (e.g., work or family responsibilities). While the findings revealed little difference between the neighbourhoods in terms of accessibility problems and barriers, differences between men and women were evident.

Gender and use of health care among older adults in Egypt and Tunisia

In Western industrialized countries, women report using health services more often than do men. We explore the applicability of existing theory to explain gender differences in use of health care among older adults in Egypt and Tunisia, where females have received less health care than males in early life. Findings show that women report visiting providers and using medications more often than do men; however, adjusted odds of visiting doctors are comparable for women and men in Tunisia and lower for women than men in Egypt. Odds of using health care are higher for women than men among those reporting no morbidity or functional impairment, but these relative odds diminish or reverse among those reporting multiple morbidities or severe impairments. The contributions of subjective and objective illness, quality of social support, and availability of services on gender differences in care in later life should be assessed in these and other settings where girls' excess mortality persists.

Frequent attendance, socioeconomic status and burden of ill health. An investigation in the west of Scotland

OBJECTIVES

To investigate whether associations between frequent attendance in general practice and socioeconomic circumstances remain significant after taking detailed account of underlying ill health, perceived social support and social isolation.

METHODS

Data from a community health survey of 1477 people in their late forties and late sixties living in the West of Scotland were examined for associations between frequent attendance, socioeconomic circumstances, self-reported ill health and social support using logistic regression. The main outcome measure was the probability of being a frequent attender (defined pragmatically after initial review of the distribution as 10+ visits a year) with 95% confidence intervals.

RESULTS

Frequent attendance was significantly associated with: greater numbers of serious conditions reported (adjusted odds ratio 1.47; 99% CI 1.09-1.98); higher levels of anxiety (adjusted OR 1.14; 1.04-1.25); and lower levels of self-assessed health (adjusted OR 0.67; 0.54-0.83). No measures of socioeconomic circumstance or social support remained significantly associated with frequent attendance when the greater burden of ill health in poorer and less well-supported groups was considered.

CONCLUSION

The higher levels of frequent attendance likely to be experienced by general practitioners serving populations in adverse social circumstances are likely to be explained by higher levels of health needs, and not solely by a greater readiness to consult for whatever reason. General practitioners working in deprived areas are likely to have to 'run to keep up' in dealing with such comorbidity, and ways of supporting them in the provision of optimum healthcare need to be considered.

The influence of sociodemographic characteristics on health care utilisation in a Swedish municipality

During recent years there has been a debate on factors that might influence health care utilisation, and the possibilities to predict such utilisation in order to facilitate the allocation of health care resources in the community. Currently only the age distribution in the population is usually used for such predictions. In this study the influence of a number of other sociodemographic characteristics on health care utilisation, in addition to age and sex, was assess in a small Swedish community. A postal questionnaire, containing questions on health care utilisation and a number of sociodemographic factors, was sent to a random, stratified sample of the population of Håbo municipality, Sweden. Out of the sampled 1312 subjects, 827 (63%) responded to the questionnaire. Subjects aged 65 years and above had higher odds for having consulted a physician, having been hospitalised and having a cost limitation card compared to those below age 65. Men had significantly lower odds than women for having consulted a physician, having visited other health care providers and having a cost limitation card. Singles, as compared to married subjects, had lower odds for all health care measures except having consulted a physician. Subjects with sick leave or disability pension, as compared to working subjects, had higher odds for most health care utilisation measures. A number of sociodemographic factors were thus associated with health care utilisation and might be considered in the health care resources allocation process.

Ethnicity, socio-economic position and gender--do they affect reported health-care seeking behaviour?

While the pursuit of equity of access to health care is a central objective of many health care systems, there is evidence that patients of ethnic minority descent, in lower socio-economic position (SEP) or of female gender are less likely than Whites, more affluent groups or men, respectively, to access secondary and tertiary medical care. However, it is unclear at which point in the chain of events leading from perception of need through attendance at primary/emergency care, to referral and receipt of secondary care, this inequality occurs. This study examined the influence of ethnicity, socio-economic position and gender on an individual's perception of the need and urgency for seeking health care. A random sample was selected from two large city General Practices in the UK who were sent postal questionnaires which included two clinical vignettes describing characters experiencing chest pain and discovering a lump in the armpit. The main outcome measure was response to the 'chest pain' and 'lump' vignettes in terms of immediate health care utilisation. The questionnaire survey (n=1350, response rate 66%) indicated that Black respondents, respondents from lower socio-economic groups and women were at least as likely to report immediate health care seeking in response to the clinical vignettes than White respondents, those from higher socio-economic groups or men. This finding was consistent across all scenarios after adjustment for interpretation of the vignette, access to health services and attitudes to health and health care. For example, those in the lowest SEP group were almost 60% more likely to report immediate care seeking in response to the lump vignette (OR 1.59, 95% CI 1.08-2.33) compared to those in the highest SEP group; and Black respondents 40% more likely (OR 1.41, 95% CI 0.92-2.17). This study suggests inequalities in access to health care by ethnicity, socio-economic position and gender are not related to patients in these groups failing to self-refer to primary or accident and emergency care, barriers must therefore occur at the level of health care provision.

A generation apart? Gender-related experiences and health in women in early and late mid-life

There have been a number of critiques in the last few years of the prevailing paradigm of research on gender and health, which dominated in the latter part of the 20th century. One such criticism has centred on the a historic and decontextualised way in which much evidence for gender differences has been used. In this paper we aim to show that, even within a relatively confined geographical locale over a relatively short period of time, there have been substantial changes in gender relations which are likely to have affected the experience, opportunities, and attitudes of women born in the early 1930s and early 1950s. We illustrate this using data from a study of inequalities in health in Scotland, which includes unusually rich longitudinal data on gender, including occupancy and experience of gender-related roles, attitudinal data on gender equality, and measures of gender role orientation (GRO). These are related to various dimensions of health and health behaviour. The data show substantial differences in the experiences of two generations of women, who are just 20 years apart in age, and a lack of consistency between measures of GRO and health. Whilst on the one hand these data suggest the importance of taking more account of the broader (social, historical or political) context, the analysis also highlights the methodological problems posed.