Applying symptom appraisal models to understand sociodemographic differences in responses to possible cancer symptoms: a research agenda

Subjective Cognitive Dysfunction in Chronic Illness: A Systematic Review and Meta-Synthesis

BACKGROUND

Qualitative studies have examined the experiences of subjective cognitive dysfunction in specific populations or specific disease stages, but there has not yet been a systematic synthesis and evaluation of findings related to perceptions of subjective cognitive dysfunction in nondementia-related chronic illnesses.

OBJECTIVE

The aim of this study was 2-fold: (1) to undertake a systematic review of experiences of subjective cognitive dysfunction in people with nondementia-related chronic disease and (2) to develop an explanatory framework to describe the experiences of living with subjective cognitive dysfunction.

METHODS

Four databases were systematically searched for studies on subjective cognitive dysfunction up to June 2023. Qualitative synthesis was conducted on the final sample (N = 25) using Sandelowski's adaptation of Nobilt and Hare's reciprocal transactional analysis method. Critical appraisal was completed using the Critical Appraisal Skills Programme checklist.

RESULTS

Through constant comparison of key concepts, findings were organized within 4 interrelated themes that informed a conceptual explanatory model of adapting to living with subjective cognitive dysfunction: (1) symptoms, (2) health care, (3) perceptions of self, and (4) relationships. Participants highlighted how subjective cognitive dysfunction affected interactions in health care settings and involved other symptoms that in turn complicated meaning, self-enhancement, and mastery.

CONCLUSIONS

Our model of the process of adapting provides a new way to conceptualize cognitive dysfunction in chronic illness and suggests opportunities for health care professionals to support patients and their families. The results highlight the need for more research to better understand the role of subjective cognitive dysfunction in nondementia-related chronic illnesses.The review protocol was registered in PROSPERO (CRD42021231410).

Estimating and Explaining the Differences in Health Care Seeking by Symptom Burden Among Persons With Presumptive Tuberculosis: Findings From a Population-Based Tuberculosis Prevalence Survey in a High-Burden Setting in India

Background

There is a lack of research evidence on the quantitative relationship between symptom burden and health care seeking among individuals with presumptive tuberculosis (TB).

Methods

Data were derived from a cross-sectional population-based TB survey conducted between February 2021 and July 2022 in 32 districts of India. Eligible and consented participants (age >15 years) underwent TB symptom screening and history elicitation. Fairlie decomposition analysis was used to estimate the net differences in health care seeking due to varied symptom burden-from 1+ burden (>1 symptom) to 4+ burden (>4 symptoms)-and decomposed by observable covariates based on logit models with 95% CIs.

Results

Of the 130 932 individuals surveyed, 9540 (7.3%) reported at least 1 recent TB symptom, of whom 2678 (28.1%; 95% CI, 27.1%-28.9%) reportedly sought health care. The net differences in health care seeking among persons with symptom burden 1+ to 4+ ranged from 6.6 percentage points (95% CI, 4.8-8.4) to 7.7 (95% CI, 5.2-10.2) as compared with persons with less symptom burden. The presence of expectoration, fatigue, and loss of appetite largely explained health care seeking (range, 0.9-3.1 percentage points [42.89%-151.9%]). The presence of fever, cough, past TB care seeking, weight loss, and chest pain moderately explained (range, 5.3%-25.3%) health care seeking.

Conclusions

Increased symptom burden and symptoms other than the commonly emphasized cough and fever largely explained health care seeking. Orienting TB awareness and risk communications toward symptom burden and illness perceptions could help address population gaps in health care seeking for TB.

Interoceptive awareness in a clinical setting: the need to bring interoceptive perspectives into clinical evaluation

Interoceptive awareness (IA) is crucial to understanding mental health. The Multidimensional Assessment of Interoceptive Awareness (MAIA) scale, available in approximately 30 languages, has gained global recognition for its research applicability. This review highlights the critical importance of integrating IA evaluation in clinical settings, advocating for the MAIA scale's potential as a screening tool. Through an examination of academic databases, including Scopus, PubMed, Google Scholar, and J-STOR, our analysis spans seven mental health domains: eating disorders (ED), depression, stress, anxiety, autism spectrum disorder (ASD), chronic pain, and suicide ideation (SI). Thirty-eight studies showed links between several dimensions of IA with different disorders. That is, ED was related to Body Trust and Self-Regulation; anxiety to Body Listening, Emotional Awareness, and Self-Regulation; depression to Noticing and Emotional Awareness; ASD to Trusting, Emotional Awareness, and Noticing; chronic pain to Not-Worrying and Self-Regulation; and SI with Trusting. These insights hold profound implications for both clinical practice and mental health research. Integrating IA assessments into standard clinical protocols has the potential to improve our understanding of pathology, enrich patient care, and enhance therapeutic strategies.

Symptoms of older orthopedic and rheumatic patients : A telephone survey about symptoms, symptom communication, treatment and further support after hospital discharge

BACKGROUND

In older multimorbid orthopedic and rheumatic patients, data on symptoms besides pain or reduced mobility are rarely published.

OBJECTIVE

We investigated patients' perspectives on their symptoms after hospital discharge.

MATERIAL AND METHODS

Orthopedic and rheumatic patients aged over 70 years were asked via telephone interviews about (i) their symptoms, (ii) communication, (iii) treatment, and (iv) support.

RESULTS

(i) The 60 participants (35 women and 25 men) reported a median of 6 (min-max: 1-14) different symptoms, of which 86% (356 of 415) had existed before hospitalization, (ii) patients did not communicate 28% (117) of symptoms to either healthcare professionals, family or friends and (iii) 52 (87%) patients desired improvement. Of the 280 most impairing symptoms, 19% (52) were not treated at all. (iv) Almost all patients (59; 98%) considered it easy to obtain support.

CONCLUSION

Remarkably, many symptoms were not communicated or treated despite the patients having been hospitalized.

Socioeconomic deprivation, medical services accessibility, and income-related health inequality among older Chinese adults: evidence from a national longitudinal survey from 2011 to 2018

BACKGROUND

Health inequality poses a challenge to improving the quality of life of older adults as well as the service system. The literature rarely explores the moderating role of medical services accessibility in the association between socioeconomic deprivation and health inequality.

OBJECTIVE

This study examines the socioeconomic deprivation and medical services accessibility associated with health inequality among older Chinese adults, which will contribute to the medical policy reform.

METHODS

Using data from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we analyse 14,232 older adults. This paper uses a concentration index (CI) to measure the income-related health inequality among the target population and employs a recentered influence function-concentration index-ordinary least squares (RIF-CI-OLS) model to empirically analyse the correlation between socioeconomic deprivation and health inequality among older Chinese adults. Based on the correlation analysis, we discuss the moderating effect of medical services accessibility.

RESULTS

We find that health inequality exists among older Chinese adults and that the relative deprivation in socioeconomic status (SES) is significantly associated with health inequality (β∈  [0.1109,  0.1909], P < 0.01). The correlation between socioeconomic deprivation and health inequality is moderated by medical services accessibility, which means that an increase in medical services accessibility can weaken the correlation between socioeconomic deprivation and health inequality.

CONCLUSION

China needs an in-depth reform of its medical services accessibility system to promote the equitable distribution of medical services resources, strengthen medical costs and quality management, and ultimately mitigate the SES reason for health inequality among older Chinese adults.

Investigating the role of symptom valorisation in tuberculosis patient delay in urban areas in Portugal

BACKGROUND

Diagnosis delay contributes to increased tuberculosis (TB) transmission and morbimortality. TB incidence has been decreasing in Portugal, but median patient delay (PD) has risen. Symptom valorisation may determine PD by influencing help-seeking behaviour. We aimed to analyse the association between symptom valorisation and PD, while characterising individuals who disregarded their symptoms.

METHODS

A cross-sectional study was conducted among TB patients in Lisbon and Oporto in 2019 - 2021. Subjects who delayed seeking care because they did not value their symptoms or thought these would go away on their own were considered to have disregarded their symptoms. PD was categorised using a 21-day cut-off, and a 30-day cut-off for sensitivity analysis. We estimated the effect of symptom valorisation on PD through a directed acyclic graph. Then, a multivariable regression analysis characterised patients that disregarded their symptoms, adjusting for relevant variables. We fitted Poisson regression models to estimate crude and adjusted prevalence ratios (PR).

RESULTS

The study included 75 patients. Median PD was 25 days (IQR 11.5-63.5), and 56.0% of participants had PD exceeding 21 days. Symptom disregard was reported by 38.7% of patients. Patients who did not value their symptoms had higher prevalence of PD exceeding 21 days compared to those who valued their symptoms [PR 1.59 (95% CI 1.05-2.42)]. The sensitivity analysis showed consistent point estimates but wider confidence intervals [PR 1.39 (95% CI 0.77-2.55)]. Being a smoker was a risk factor for symptom disregard [PR 2.35 (95% CI 1.14-4.82)], while living in Oporto [PR 0.35 (95% CI 0.16-0.75)] and having higher household incomes [PR 0.39 (95% CI 0.17-0.94)] were protective factors.

CONCLUSIONS

These findings emphasise the importance of symptom valorisation in timely TB diagnosis. Patients who did not value their symptoms had longer PD, indicating a need for interventions to improve symptom recognition. Our findings also corroborate the importance of the socioeconomic determinants of health, highlighting tobacco as a risk factor both for TB and for PD.

Social cognitive theory to improve symptom appraisal and help-seeking among patients with autoimmune rheumatic diseases: A qualitative study

AIM

Social cognitive theory (SCT) has been successfully employed to improve symptom appraisal and help-seeking among patients with various conditions but is yet to be applied in the context of autoimmune rheumatic diseases (ARDs). This study aimed to explore the applicability of SCT in and possible approaches to improving symptom appraisal and help-seeking of patients with ARDs, one of the key barriers to earlier diagnosis.

METHODS

Semi-structured interviews were conducted with 33 ARD patients with a prolonged pre-diagnosis interval (>3 months). We coded the transcripts deductively using SCT as the overarching framework and inductively for approaches identified from the interviews.

RESULTS

All six main concepts of SCT (behavioral capacity, expectations, self-efficacy, observational learning, reinforcements, and reciprocal determinism) were observed in the three stages of symptom appraisal and help-seeking (detection, interpretation, and response) of patients with ARDs. While many participants reported that they were able and confident to detect their symptoms, they lacked the behavioral capacity and self-efficacy to interpret symptoms correctly, which resulted in delayed help-seeking and diagnosis. Possible approaches to address this suggested by participants (such as education of the general population) could improve behavioral capacity and self-efficacy in symptom interpretation and enhance expectations, observational learning, reinforcements, and reciprocal determinism in symptom response.

CONCLUSION

Lack of behavioral capacity and self-efficacy was observed in symptom interpretation of patients with ARDs, which resulted in delayed help-seeking. Approaches could target the behavioral capacity and self-efficacy for symptom interpretation to facilitate early help-seeking and, in turn, earlier diagnosis among individuals with possible ARDs.

Evaluation of the association of area-level socioeconomic deprivation and breast cancer recurrence by oestrogen receptor subtypes in Scotland

BACKGROUND

Women from socioeconomically deprived areas have lower breast cancer (BC) incidence rates for screen-detected oestrogen receptor (ER) + tumours and higher mortality for select tumour subtypes. We aimed to determine if ipsilateral breast cancer recurrence (IBR) differs by Scottish Index of Multiple Deprivation (SIMD) quintile and tumour subtype in Scotland.

METHODS

Patient data for primary invasive BC diagnosed in 2007-2008 in Scotland was analysed. Manual case-note review for 3495 patients from 10 years post-diagnosis was used. To determine the probability of IBR while accounting for the competing risk of death from any cause, cumulative incidence functions stratified by ER subtype and surgery were plotted. Multivariable Cox Proportional Hazards models were used to estimate the association of SIMD accounting for other predictors of IBR.

RESULTS

Among 2819 ER + tumours, 423 patients had a recurrence and 438 died. SIMD was related to death (p = 0.018) with the most deprived more likely to have died in the 10-year period (17.7% vs. 12.9%). We found no significant differences by SIMD in prognostic tumour characteristics (grade, TNM stage, treatment, screen-detection) or risk of IBR. Among 676 patients diagnosed with ER- tumours, 105 died and 185 had a recurrence. We found no significant differences in prognostic tumour characteristics by SIMD except screen detection with the most deprived more likely than the least to have their tumours detected from screening (46.9% vs. 28%, p = 0.03). Among patients with ER- tumours, 50% had mastectomy and the most deprived had increased 5-year IBR risk compared to the least deprived (HR 3.03 [1.41-6.53]).

CONCLUSIONS

IBR is not a major contributor to mortality differences by SIMD for the majority of BC patients in our study. The lack of inequities in IBR are likely due to standardised treatment protocols and access to healthcare. The association with socioeconomic deprivation and recurrence for ER- tumours requires further study.

Patient-reported mental health and well-being trajectories in oncology patients during radiation therapy: an exploratory retrospective cohort analysis using the Ontario Cancer Registry

PURPOSE

Mental health and well-being trajectories are not expected to be homogeneous in diverse clinical populations. This exploratory study aims to identify subgroups of patients with cancer receiving radiation therapy who have different mental health and well-being trajectories, and examine which socio-demographic, physical symptoms, and clinical variables are associated with such trajectories.

METHODS

Retrospective analysis of radiation therapy patients diagnosed with cancer in 2017 was conducted using data from the Ontario Cancer Registry (Canada) and linked with administrative health data. Mental health and well-being were measured using items from the Edmonton Symptom Assessment System-revised questionnaire. Patients completed up to 6 repeated measurements. We used latent class growth mixture models to identify heterogeneous mental health trajectories of anxiety, depression, and well-being. Bivariate multinomial logistic regressions were conducted to explore variables associated with the latent classes (subgroups).

RESULTS

The cohort (N = 3416) with a mean age of 64.5 years consisted of 51.7% females. Respiratory cancer was the most common diagnosis (30.4%) with moderate to severe comorbidity burden. Four latent classes with distinct anxiety, depression, and well-being trajectories were identified. Decreasing mental health and well-being trajectories are associated with being female; living in neighborhoods with lower income, greater population density, and higher proportion of foreign-born individuals; and having higher comorbidity burden.

CONCLUSIONS

The findings highlight the importance of considering social determinants of mental health and well-being, in addition to symptoms and clinical variables, when providing care for patients undergoing radiation therapy.

Symptom appraisal and help seeking in males with symptoms of possible prostate cancer: a qualitative study with an ethnically diverse sample in London

BACKGROUND

Prostate cancer mortality in Black males is disproportionately high. This problem may be overcome by reducing delays in the pathway to diagnosis, particularly those occurring before initial medical help seeking. A greater understanding of symptom appraisal and help seeking could support the development of targeted interventions for improving early presentation among Black males.

AIM

To provide an in-depth understanding of males' pre-consultation experiences following the onset of symptoms of possible prostate cancer, identifying both general trends as well as potential differences that may exist between Black and White males.

DESIGN AND SETTING

Qualitative study of 18 males (nine Black, nine White) in London, UK, who had recently seen their GP with urinary symptoms, erectile dysfunction, or haematuria.

METHOD

Semi-structured interviews from a previous multi-methods study of primary care use by males with symptoms of possible prostate cancer were analysed using thematic framework analysis.

RESULTS

Symptoms were often interpreted by patients as unimportant. Most delays occurred due to the absence of reasons to seek help, which, in Black males, often stemmed from poor awareness of prostate cancer. This lack of awareness could have been a consequence of their reluctance to seek health information and discuss health issues with others in their social network. Friends and relatives played an important role in symptom appraisal and help seeking.

CONCLUSION

Cognitive biases, cultural stigmas, and everyday interpersonal interactions should be important areas at which to target strategies seeking to reduce delays and improve early presentation in males with possible prostate cancer, particularly Black males.

Symptom perceptions in functional disorders, major health conditions, and healthy controls: A general population study

Background

The present study investigated differences in symptom perceptions between individuals with functional disorders (FD), major health conditions, and FDs + major health conditions, respectively, and a group of healthy individuals. Furthermore, it investigated the relevance of FDs among other health-related and psychological correlates of symptom perceptions in the framework of the Common Sense Model of Self-Regulation (CMS).

Method

This cross-sectional study used epidemiological data from the Danish Study of Functional Disorders part two (N = 7,459 participants, 54% female, 51.99 ± 13.4 years). Symptom perceptions were assessed using the Brief Illness Perception Questionnaire (B-IPQ) and compared between the four health condition groups. Multiple regression analyses were performed to examine associations between symptom perceptions, FDs, and other health-related and psychological correlates from the CMS framework.

Results

Individuals with FDs (n = 976) and those with FDs + major health conditions (n = 162) reported less favorable symptom perceptions compared to the other two groups, particularly regarding perceived consequences, timeline, and emotional representations (effect size range Cohen’s d = 0.12-0.66). The presence of a FD was significantly associated with all B-IPQ items, even in the context of 16 other relevant health-related and psychological correlates from the CMS framework, whereas symptom presence last year or last week was not.

Conclusion

In the general population, symptom perceptions seem to play a more salient role in FD than in individuals with well-defined physical illness. Symptom perceptions should therefore be targeted in both primary and secondary interventions for FDs.

What are the similarities and differences in lung cancer symptom appraisal and help-seeking according to smoking status? A qualitative study with lung cancer patients

OBJECTIVE

Lung cancer in never-smokers represents a growing proportion of patients. The relationship between smoking status, symptom appraisal and help-seeking behaviour is complex. Little is known about cancer symptom-related health behaviours according to smoking status. The aim of the study was to explore lung cancer patients' experiences of a lung cancer diagnosis, identifying differences by smoking history.

METHOD

This was a qualitative study involving telephone interviews with 40 lung cancer patients (20 never smokers, 11 former smokers and 9 current smokers). We used framework analysis to analyse the data using the Common Sense Model of Illness Self-Regulation as a theoretical framework, developed after initial analysis.

RESULTS

All patients were likely to delay seeking help for symptoms in primary care regardless of smoking history, but for different reasons. Smoking history was instrumental to how individuals perceived and responded to early symptoms of lung cancer. Differences in interpretation and coping responses to new symptoms seemed to be caused by the higher presence of comorbidities due to smoking, and perceptions of the current state of health. Individuals with a smoking history reported acting with urgency in seeking help and follow up, whereas patients who experienced low levels of concern were more easily reassured by clinicians, resulting in delays.

CONCLUSIONS

Never and former smokers perceive, interpret, and respond to symptoms of lung cancer differently to smokers. However, few people attribute their lung symptoms to cancer initially, even with a smoking history. Interventions that drive increased urgency and vigilance in never smokers may be effective.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

Approaches to improving symptom appraisal: a systematic literature review

OBJECTIVES

Poor symptom appraisal (detection, interpretation and response to symptoms) plays a major role in prolonged prediagnosis interval in various health conditions. Theories and models have been proposed to study the symptom appraisal process but how they could be employed to improve symptom appraisal remains unclear. We therefore aimed to review approaches to improving symptom appraisal in the literature and to develop a theoretical framework that could guide the development of approaches to improving symptom appraisal among individuals in the general population.

DESIGN

Systematic review.

DATA SOURCES

Medline, Web of Science, PsycINFO, Embase, CINAHL and Scopus were searched from inception to 30 March 2021.

ELIGIBILITY CRITERIA

We included original articles in English in which approaches to improve the detection, interpretation or response to symptoms for symptomatic individuals were described. We excluded articles in which approaches were developed to improve symptom appraisal among healthcare professionals.

DATA EXTRACTION AND SYNTHESIS

A predefined data extraction form was used to extract the development, characteristics and evaluation of approaches to improving symptom appraisal. This formed the basis for the narrative synthesis.

RESULTS

Of 19 046 publications identified from the literature search, 112 were selected for full-text review and 29 approaches comprising provision of knowledge of symptoms/signs and additional components (eg, symptom self-examination and comparison) for symptom appraisal were included in the synthesis. Less than half (41.4%) of these approaches were developed based on theories/models. Interestingly, despite the variety of theories/models adopted in developing these approaches, the components of these approaches were similar.

CONCLUSION

Symptom appraisal is an essential process in a patient's journey that can be targeted to facilitate early diagnosis but is largely unstudied. Building on the literature, we proposed a theoretical framework and approaches to improving symptom appraisal. This could facilitate early identification of a variety of health conditions in the general population.

TRIAL REGISTRATION NUMBER

CRD42021279500.

Distinguishing symptom patterns in adults newly diagnosed with cancer: a latent class analysis

CONTEXT

Socio-demographic differences, including place of residence, socio-economic status, ethnicity, and gender, have been associated with various inequities in cancer care outcomes.

OBJECTIVES

The aims were to distinguish subgroups of patients with different symptom patterns at the time of the initial oncology visit and determine which clinical and socio-demographic variables are associated the different symptom patterns.

METHOD

Responses to the Edmonton Symptom Assessment Scale- revised and clinical and socio-demographic variables were obtained via the Ontario Cancer Registry and linked health data files. Latent class analyses were conducted to identify and compare the subgroups.

RESULTS

The cohort (n = 216,110) with a mean age of 64.5 years consisted of 54.1% women. The analyses identified six latent classes (proportions ranging from 0.09 to 0.31) with distinct symptom patterns, including: 1) many severe symptoms, 2) many less severe symptoms, 3) predominantly mild symptoms, 4) severe psychosocial symptoms, 5) severe somatic symptoms, 6) few symptoms. The subgroups were associated not only with clinical differences (diagnoses and functional status), but also with various socio-demographic (age, sex) and community characteristics (neighborhood income, proportion of foreign born, rurality).

CONCLUSION

The results indicated that there were substantial differences in symptom patterns at the time of the initial oncology visit, which were associated with both clinical diagnoses and socio-demographic differences. These results point to the importance of taking the social situation of patients into account, and not just diagnosis, to better understand differences in symptom patterns of people living with cancer.

Patient-reported diagnostic intervals to colorectal cancer diagnosis in the Midland region of New Zealand: a prospective cohort study

BACKGROUND AND OBJECTIVES

New Zealand (NZ) has high rates of colorectal cancer (CRC) but low rates of early detection. The majority of CRC is diagnosed through general practice, where lengthy diagnostic intervals are common. We investigated factors contributing to diagnostic delay in a cohort of patients newly diagnosed with CRC.

METHODS

Patients were recruited from the Midland region and interviewed about their diagnostic experience using a questionnaire based on a modified Model of Pathways to Treatment framework and SYMPTOM questionnaire. Descriptive statistics were used to describe the population characteristics. Chi-square analysis and logistic regression were used to analyse factors influencing diagnostic intervals.

RESULTS

Data from 176 patients were analysed, of which 65 (36.9%) experienced a general practitioner (GP) diagnostic interval of >120 days and 96 (54.5%) experienced a total diagnostic interval (TDI) > 120 days. Patients reporting rectal bleeding were less likely to experience a long TDI (odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.14-0.78) and appraisal/help-seeking interval (OR, 0.19, 95% CI: 0.06-0.59). Patients <60 were more likely to report a longer appraisal/help-seeking interval (OR, 3.32, 95% CI: 1.17-9.46). Female (OR, 2.19, 95% CI: 1.08-4.44) and Māori patients (OR, 3.18, 95% CI: 1.04-9.78) were more likely to experience a long GP diagnostic interval.

CONCLUSION

NZ patients with CRC can experience long diagnostic intervals, attributed to patient and health system factors. Young patients, Māori, females, and patients experiencing change of bowel habit may be at particular risk. We need to increase symptom awareness of CRC for patients and GPs. Concentrated efforts are needed to ensure equity for Māori in access to screening, diagnostics, and treatment.

Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review

BACKGROUND

The cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults.

AIM

To explore the effect of older age on patients' appraisal of possible cancer symptoms and their decision to seek help for these symptoms.

DESIGN AND SETTING

Mixed-methods systematic review.

METHOD

MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines.

RESULTS

Eighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors' time, and patient self-management of symptoms.

CONCLUSION

This review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly.

Adherence to behaviours associated with the test, trace, and isolate system: an analysis using the theoretical domains framework

BACKGROUND

The UK's test, trace, and isolate system are key measures to reduce the impact and spread of COVID-19. However, engagement with and adherence to guidance on testing, self-isolation, and providing details of contacts can be low and interventions are needed. This qualitative study aimed to identify the key factors affecting adherence to test, trace, and isolate behaviours using the Theoretical Domains Framework (TDF).

METHODS

We conducted six online focus groups between October 2020 and February 2021 with people living in Sheffield who came into close contact with others in work or social settings (N = 30). The focus groups explored capability, opportunity, and motivational barriers to adherence to test, trace, and isolate behaviours. Framework analysis was used to code the data into TDF domains.

RESULTS

There is a complex relationship between the factors affecting COVID-19 symptom identification, testing, and self-isolation. People who perceived significant barriers to testing and self-isolation were less likely to interpret potential symptoms as COVID-19, and perceiving barriers to self-isolation reduced the likelihood of requesting a test. Concerns about the negative consequences of self-isolation for themselves and others were common and also influenced willingness to pass on details of contacts. There was a lack of trust in the Test and Trace system, with people wanting further evidence of being at risk of infection.

CONCLUSIONS

Communications and interventions to increase adherence to test, trace, and isolate strategies need to consider the interplay of these behaviours and their influences and target them collectively. Efforts to promote testing should focus on the range of barriers to self-isolation, especially increasing financial and practical support, and include new messaging to promote symptom identification.

Is My Cough a Cold or Covid? A Qualitative Study of COVID-19 Symptom Recognition and Attitudes Toward Testing in the UK

Objective: Key to reducing the spread of COVID-19 in the UK is increased use of the NHS Test and Trace (NHSTT) system. This study explored one of the main issues that determine whether people engage with NHSTT, how people understand symptoms that may indicate the presence of COVID-19 and that should trigger a request for a test.

Methods: In this qualitative study, a series of semi-structured telephone interviews were conducted with 40 people (21 members of the general population, 19 students). There was nearly an equal split between male and female participants in both samples. Data were collected between 30 November and 11 December 2020 and explored using thematic analysis. There was substantial similarity in responses for both populations so we combined our results and highlighted where differences were present.

Results: Participants generally had good knowledge of the main symptoms of COVID-19 (high temperature, new, persistent cough, anosmia) but had low confidence in their ability to differentiate them from symptoms of other illnesses. Attribution of symptoms to COVID-19 was most likely where the symptoms were severe, many symptoms were present, symptoms had lasted for some time and when perceived risk of exposure to infection was high due to previous contact with others. Participants felt encouraged to engage in testing where symptoms were present and had persisted for several days, though, many had concerns about the safety of testing centres and the accuracy of test results. Students had mixed feelings about mass asymptomatic testing, seeing it as a way to access a more normal student experience, but also a potential waste of resources.

Conclusions: This study offers novel insights into how people attribute symptoms to COVID-19 and barriers and facilitators to engaging with NHSTT. Participants had positive views of testing, but there is a need to improve not just recognition of each main symptom, but also understanding that even single, mild symptoms may necessitate a test rather than a “wait and see” approach, and to address concerns around test accuracy to increase testing uptake.

Application of Socio-Economic and Health Deprivation Indices to study the relationships between socio-economic status and disease onset and outcome in a metropolitan area subjected to aging, demographic fall and socio-economic crisis

Aims

Genoa is a city affected by a deep economic, demographic and social involution. The association between disease onset and outcome and socioeconomic status (SES) was assessed in the mortality by cause in two periods, using indices referred to the distribution of deprivation in the population defined in a ten-years span (2001 to 2011).

Material and Methods

Two Socio-Economic and Health Deprivation Indices (SEHDIs), computed at census tract level (2001 and 2011 Censuses), were applied to analyse the SMRs by cause, age (0-64 and 65+ years) and gender of the five normalised groups of deprivation individuated in the two population distribution. The associations between SES and onset of disease was described in the mortality 2008-11 using the index referred to 2001 population. The second index, referred to 2011 population, described the associations between SES and disease outcomes in the mortality 2009-13. Two ANOVAs evaluated the statistical significance (p < 0.05) of differences in death distribution among groups.

Results

The population at medium-high deprivation increased in Genoa between 2001 and 2011. The mortality by age and gender showed different trends. Not significant trends (NS) in both periods regarded only the younger (respiratory diseases in both sexes, prostate cancer, diabetes in women). Linearly positives (L↑) trends in both periods were observed only in men (all cancers and lung cancers, overall mortality and cardiovascular diseases in younger, diabetes in older). Not linear trends (NL) in both periods interested both sexes for flu and pneumonia, women for lung cancer, old women for overall mortality and respiratory diseases, old men for colorectal cancers. Instead, L↑ trends in the final phases of disease interest all cancers in the elderly (NS trend at the disease onset), all cancers and breast cancer in young women, diabetes and colorectal cancers in young men (NL trends at the disease onset). On the contrary, L↑ trends at the disease onset and NL trends in the final phases regarded cardiovascular diseases in elderly, overall mortality, respiratory diseases and prostate cancer in old men, diabetes and colorectal cancers in old women. Finally, NL trends at the disease onset regarded colorectal cancers in young women (NS trend in the final phases) and breast cancer in the older (linearly negative trend, L↓, in the final phases).

Discussion

Deprivation trends confirmed the literature about populations shifting towards poverty. Aging-linked social risks were revealed, reflecting the weakening of social-health care, which worsened in elderly if alone. Serious problems in younger singles or in the single-parent families arose. Cardiovascular diseases, all cancers and colorectal cancers trends confirmed the advantage of less deprived when diseases are preventable and curable. Prostate and breast cancers trends reflected the rising incidence and increasing problems in care. The need of corrective interventions in social and health policies was emerging, aimed to support in a targeted way a population in an alarming condition of socio-economic deterioration.

The multiple mediating effects of cancer threat appraisal and quality of life on the association between mindfulness and depression for colorectal cancer survivors

OBJECTIVE

This study explored the multiple mediating effects of cancer threat appraisal, functional status, and symptom distress on the association between mindfulness and depression in colorectal cancer (CRC) patients at the transition stage after completing cancer treatments.

METHODS

A total of 90 CRC survivors who received cancer treatments within 3 months participated in this cross-sectional study. The functional status and symptom distress (EORTC-C30 and EORTC CR29), dispositional mindfulness (Five Facet Mindfulness Questionnaire), cancer threat appraisal ( Constructed Meaning Scale), and depressive symptoms (Beck Depression Inventory-II scale) were collected. The mediation and moderation analyses were conducted using the PROCESS macros for SPSS.

RESULTS

Survivors' dispositional mindfulness (γ = -0.49, p < 0.001) and cancer threat appraisal (γ = -0.59, p < 0.001) were significantly associated with depressive symptoms. Simple mediation analysis indicated that cancer threat appraisal mediated the relationship between dispositional mindfulness and depression (β = -0.02, 95% CI = -0.04 to -0.001). The multiple mediated analysis identified the path between dispositional mindfulness and depression via cancer threat appraisal and colorectal symptom distress (β = -0.01, 95% CI = -0.03 to -0.01). In the mediated moderation model, the path between dispositional mindfulness and depression via colorectal function was moderated by cancer threat appraisal (β = -0.02, 95% CI = -0.05 to -0.004).

CONCLUSIONS

The two cognitive mechanisms of reducing CRC survivors' depression are as follows: (1) dispositional mindfulness reducing the appraisal of cancer as a threat and increasing positive perceptions of CRC symptoms and (2) the cancer threat appraisal buffered the impacts of CRC's mindfulness and colorectal function on depressive symptoms. Developing mindfulness with cognitive training is recommended for improving depressive symptoms among CRC patients in the transition period.

Anticipated delay in help-seeking for cancer symptoms: Findings from a nationwide study of Malaysian adults

BACKGROUND

To investigate the relationship between anticipated delay in help-seeking and cancer symptom recognition and the extent to which this relationship varied according to socio-demographic and health-related characteristics.

METHODS

A cross-sectional telephone survey was conducted of 1895 adults aged ≥40 years who were randomly selected across Malaysia and interviewed using the Awareness and Beliefs about Cancer questionnaire, which was previously validated and culturally adapted by the research team. Logistic regression analysis was used to test the associations between anticipated delay for help seeking >2 weeks and socio-demographic and health-related variables.

RESULTS

Anticipated delay in help-seeking was reported for persistent cough (19.3 %), rectal bleeding (6.1 %) and breast changes (2.5 %). Difficulty in accessing a doctor was associated with anticipated delayed help-seeking for breast changes and rectal bleeding (adjusted ORs 7.58; 95 % CI 1.98, 28.94 and 2.37; 95 % CI 1.21, 4.66, respectively); not recognising the symptom 'unexplained bleeding' as a colorectal cancer warning sign was associated with anticipated delayed help-seeking for rectal bleeding (adjusted OR 1.54; 95 % CI 1.03, 2.31); and ethnicity was associated with anticipated delay for rectal bleeding and persistent cough.

CONCLUSIONS

Generally, anticipated delay to help-seeking for cancer symptoms in Malaysia (a middle-income country) appeared to be a less significant problem compared to other countries including high-income countries. There appeared to be a significant association between social variation indicators in Malaysia and anticipated delay in help-seeking.

Perceived barriers to seeking cancer care in the Gaza Strip: a cross-sectional study

BACKGROUND

Several factors might contribute to the delay to get cancer care including poor cancer awareness and having barriers to seeking help. This study described these barriers in Gaza and their association with recalling and recognizing cancer symptoms and risk factors.

METHODS

A cross-sectional study was conducted in Gaza. Adult visitors (≥18 years) to the largest three governmental hospitals and adolescent students (15-17 years) from ten high schools were recruited. A translated-into-Arabic version of the validated Cancer Awareness Measure (CAM) was used to collect data in face-to-face interviews. It described demographic data, barriers to seek cancer care as well as recall and recognition of cancer symptoms and risk factors. Responses were compared between adults and adolescents as well as males and females.

RESULTS

Of 3033 participants approached, 2886 completed the CAM (response rate= 95.2%). Among them, 1429 (49.5%) were adult (702 females; 49.1%) and 1457 (50.5%) were adolescent (781 females; 53.6%). The mean age± standard deviation (SD) of adult and adolescent participants was 33.7±11.7 years and 16.3±0.8 years, respectively. Emotional barriers were the most common barriers with 'feeling scared' as the most reported barrier (n=1512, 52.4%). Females and adolescents were more likely to report 'feeling scared' as a barrier than males and adults, respectively. Higher recall scores for cancer symptoms were associated with lower likelihood to report 'embarrassment', 'worry about wasting doctor's time' and 'difficulty arranging transport'. This was also seen for recalling risk factors, where 'embarrassment' and all practical barriers showed significant inverse associations with higher scores. In addition, greater recognition scores of cancer risk factors were inversely associated with reporting 'embarrassment' and 'feeling scared'.

CONCLUSIONS

The most commonly perceived barriers to seeking cancer care were 'feeling scared' and 'feeling worried about what the doctor might find', followed by practical and service barriers. Females and adolescents were more likely to report 'fear' as a barrier to seek medical advice. Having a higher recall of cancer symptoms and risk factors was inversely associated with reporting most barriers. To improve patient outcome, early presentation can be facilitated by targeting barriers specific to population groups.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.

Awareness and help-seeking for early signs and symptoms of lung cancer: A qualitative study with high-risk individuals

PURPOSE

Lung cancer is the most common malignancy and the leading cause of cancer death globally. Lung cancer incidence and mortality are highest among socioeconomically deprived individuals. This study explored awareness and help-seeking for early signs and symptoms of lung cancer among high-risk individuals.

METHODS

Participation was sought from multiple community centres and organisations in high-incidence and socioeconomically deprived areas in Ireland. Semi-structured focus groups were conducted with individuals at risk for lung cancer. Data were analysed using thematic analysis.

RESULTS

Five focus groups were conducted with 46 participants. Two themes were identified: (i) lung cancer awareness, beliefs, and experiences and (ii) help-seeking for early signs and symptoms of lung cancer. Participants had fragmented knowledge of lung cancer and associated this malignancy with death. Symptom change, persistence, seriousness, and family history of lung cancer served as triggers to help-seeking. General practitioners were identified as the first point of contact for symptoms of concern, yet their presumed negative attitudes towards smokers served as barriers to help-seeking. Other barriers included symptom misappraisal, fear, denial, use of self-help measures, being inherently a non-help seeker, and machoism and stoicism among men.

CONCLUSION

Study findings offer guidance regarding lung cancer knowledge gaps and barriers to help-seeking that ought to be considered in public health interventions aimed to promote lung cancer awareness and early detection.

CLINICAL IMPLICATIONS

This study highlights the need for healthcare professionals to adopt a non-judgmental approach during consults for symptoms indicative of lung cancer. This can potentially help detect lung cancer early.

Parent's perspectives of the pathway to diagnosis of childhood cancer: a matter of diagnostic triage

BACKGROUND

Early diagnosis is crucial for the treatment of childhood cancer as it in some cases can prevent progression of disease and improve prognoses. However, childhood cancer can be difficult to diagnose and barriers to early diagnosis are multifactorial. New knowledge about factors influencing the pathway to diagnosis contribute to a deeper understanding of the mechanisms that influence this time span. Qualitative research in the field is sparse but can be expected to lead to additional useful insights that could contribute to efforts shorten time to diagnosis. The purpose of this study was to explore parents' experiences of the pathway to diagnosis in the time between their noticing bodily or behavioural changes and their child's diagnosis.

METHODS

The study is a qualitative interview study carried out in large Danish hospital. Thirty-two interviews with a total of 46 parents of children with cancer were included for analysis. The children were diagnosed with haematological cancers (n = 17), solid tumours (n = 9) or brain tumours (n = 6). Data were analysed applying the theoretical model of pathways to treatment and an inductive-deductive approach. A revised 'diagnostic triage' model was developed and validated by member checking.

RESULTS

The pathway to diagnosis was influenced by various factors which we present as consistent parts of a new diagnostic triage model. Each factor impacts the level of urgency assigned to bodily and behavioural changes by parents, general practitioners and specialists. The model of diagnostic triage was developed and validated to understand mechanisms influencing time from the point parents notice changes in their child to diagnosis. The model identifies dynamic movement between parental triage in everyday life and professional triage in a healthcare system, both affecting appraisal and case escalation according to: 1) the nature of bodily and behavioural changes, 2) parental intuition, 3) social relations, 4) professional-child-parent interaction, and 5) specialist-child-parent interaction.

CONCLUSIONS

Diagnostic triage is a model which explains mechanisms that shape the pathway to diagnosis. It is a contribution aimed at supporting the clinical diagnostic process, that ultimately could ensure more timely testing, referral and diagnosis, and also a novel theoretical framework for future research on diagnostic pathways.

The role of chronic conditions in influencing symptom attribution and anticipated help-seeking for potential lung cancer symptoms: a vignette-based study

BACKGROUND

Very little is known about the influence of chronic conditions on symptom attribution and help-seeking for potential cancer symptoms.

AIM

To determine if symptom attribution and anticipated help-seeking for potential lung cancer symptoms is influenced by pre-existing respiratory conditions (often referred to as comorbidity), such as asthma or chronic obstructive pulmonary disease (COPD).

DESIGN & SETTING

A total of 2143 adults (1081 with and 1062 without a respiratory condition) took part in an online vignette survey.

METHOD

The vignette described potential lung cancer symptoms (persistent cough and breathlessness) after which questions were asked on symptom attribution and anticipated help-seeking.

RESULTS

Attribution of symptoms to cancer was similar in participants with and without respiratory conditions (21.5% and 22.1%, respectively). Participants with respiratory conditions, compared with those without, were more likely to attribute the new or changing cough and breathlessness to asthma or COPD (adjusted odds ratio [OR] = 3.64, 95% confidence interval [CI] = 3.02 to 4.39). Overall, 56.5% of participants reported intention to seek help from a GP within 3 weeks if experiencing the potential lung cancer symptoms. Having a respiratory condition increased the odds of prompt help-seeking (OR = 1.25, 95% CI = 1.04 to 1.49). Regular healthcare appointments were associated with higher odds of anticipated help-seeking.

CONCLUSION

Only one in five participants identified persistent cough and breathlessness as potential cancer symptoms, and half said they would promptly seek help from a GP, indicating scope for promoting help-seeking for new or changing symptoms. Chronic respiratory conditions did not appear to interfere with anticipated help-seeking, which might be explained by regular appointments to manage chronic conditions.

Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness

The Middle-Range Theory of Self-Care of Chronic Illness has been used widely since it was first published in 2012. With the goal of theoretical refinement in mind, we evaluated the theory to identify areas where the theory lacked clarity and could be improved. The concept of self-care monitoring was determined to be underdeveloped. We do not yet know how the process of symptom monitoring influences the symptom appraisal process. Also, the manner in which self-care monitoring and self-care management are associated was thought to need refinement. As both of these issues relate to symptoms, we decided to enrich the Middle-Range Theory with knowledge from theories about symptoms. Here, we propose a revision to the Middle-Range Theory of Self-Care of Chronic Illness where symptoms are clearly integrated with the self-care behaviors of self-care maintenance, monitoring, and management.

A Proposal to Improve the Early Diagnosis of Symptomatic Cancers in the United States

Many people are diagnosed with cancer after presenting with signs and symptoms of their disease to a healthcare provider. Research from developed countries suggests that, in addition to indicating later-stage disease, symptoms can also indicate earlier-stage disease, leading to investment in research and quality improvement efforts in the early detection of symptomatic cancers. This approach, labeled early diagnosis of symptomatic cancers, focuses on identifying cancer at the earliest possible stage in patients with potential signs and symptoms of cancer, and subsequently diagnosing and treating the cancer without delay. In the United States, early detection has focused on cancer screening, with relatively less research focused on early diagnosis of symptomatic cancers. In this commentary, we propose that research focused on early diagnosis of symptomatic cancers provides an important opportunity to achieve more earlier-stage cancer diagnoses in the United States. We highlight the potential of these efforts to improve cancer outcomes, and outline a research agenda to improve early diagnosis of symptomatic cancers in the United States focused on defining and describing pathways to cancer diagnosis, identifying signs and symptoms that can be used to promote early cancer detection, and developing interventions to improve early diagnosis of symptomatic cancers.

Factors Associated with the Detection of Childhood and Adolescent Cancer in Primary Health Care: A Prospective Cross-Sectional Study

Background

The treatment of childhood cancer has achieved important advances evidencing a significant increase in overall survival; however, the diagnosis of these cases still seems late. Among the main causes for the delay in diagnosis are the issues related to the health system and the first professional who performs the care. The objective of this study is to evaluate the knowledge of primary care physicians and nurses about the most common signs and symptoms of pediatric cancers, as well as the factors related to the obtained scores.

Methods

This is a prospective cross-sectional study, developed in municipalities in the northeastern region of Brazil. Fifty-one professionals (physicians and nurses) were interviewed through a questionnaire structured as a quiz game about knowledge, training and attitudes regarding the signs and symptoms of childhood cancer. Multiple linear regression analysis was used to evaluate the effect of professional characteristics on the number of correct answers on the implemented questionnaire on knowledge of childhood and adolescent cancer.

Results

In the bivariate analysis, the results indicated that the type of employment relationship influences the number of correct answers in the questionnaire used. However, when adjusted for covariates, only the professional category, which means being a medical professional, showed a significant effect on the number of correct answers (β=-7.50, p=0.001).

Conclusion

The type of employment relationship of medical professionals and nurses working in primary care had an influence on the number of correct answers for knowledge of childhood and adolescent cancer, but only the professional category (physician) was associated with the highest number when controlled by covariables, thereby justifying the need to improve the curricular training of nurses and greater investments in primary health care for continuing health education that includes infant and adolescent oncology.

Knowledge level of cancer symptoms and risk factors in the Gaza Strip: a cross-sectional study

BACKGROUND

In low-income settings, cancer is often diagnosed in advanced stages due to late presentation. Good public awareness of cancer signs and symptoms has a positive impact on the time patients take before they present to healthcare professionals. Therefore, this study examined public knowledge of cancer signs and symptoms as well as risk factors in Gaza.

METHODS

This was a cross-sectional study. Participants were recruited from adult visitors (≥18 years) to governmental hospitals covering all five governorates of Gaza, and adolescent students (15 to 17 years) from 10 high schools in corresponding locations. An Arabic version of the Cancer Awareness Measure (CAM) was completed in a face-to-face interview. It described demographic data and knowledge of: cancer prevalence, age-related risk, signs and symptoms as well as risk factors both in recall and recognition questions.

RESULTS

Of 3033 participants invited, 2886 completed the CAM (response rate = 95.2%). Adult mean age ± standard deviation was 33.7 ± 11.7 years and that of adolescents was 16.3 ± 0.8 years. Half of the participants (n = 1457, 50.5%) were adolescent (781 females; 53.6%) and 1429 (49.5%) were adult (702 females; 49.1%). About two thirds (n = 1885) thought about cancer as unrelated to age. Only 196 participants (6.8%) identified colorectal cancer as the most common cancer among men. Awareness of cancer signs/symptoms was poor to fair, where 'lump' was most commonly recognized (n = 2227, 77.2%) and 'change of bowel habit' the least (n = 670, 23.2%). Only 217 participants (7.5%) had a good level of recognizing risk factors with 'smoking' being the most identified and 'eating less than five portions of fruits and vegetables a day' the least. There was a higher likelihood for adults to identify most cancer signs/symptoms and risk factors than adolescents, except for recalling 'unexplained pain', 'persistent cough/hoarseness', 'non-healing ulcer', 'smoking', and 'eating less than five portions of fruits and vegetables a day'.

CONCLUSION

Public awareness of cancer signs/symptoms and risk factors needs to improve to facilitate early presentation and diagnosis in Gaza. Combining the delivery of public campaigns with tailored education to population groups, including the youth, may increase their knowledge and maintain its impact.

Cancer symptom awareness in the US: Sociodemographic differences in a population-based survey of adults

Symptom awareness may improve cancer outcomes by prompting timely help-seeking and diagnosis. Research in the UK has shown lower symptom awareness among sociodemographic groups at higher risk of poor cancer outcomes; however, no population-based surveys in the US have assessed whether cancer symptom awareness varies across sociodemographic groups. We therefore examined associations between sociodemographic factors and recognition of 11 cancer symptoms using a novel population-based survey of US adults. We conducted telephone interviews in 2014 with a population-representative sample of English-speaking adults (aged 50 and older) in the US (N = 1425) using an adapted Awareness and Beliefs about Cancer (ABC) survey. Socioeconomic status (SES) was indexed by education. Additional sociodemographic factors included gender, age, marital status, and race. We used multivariable logistic regression models to examine the association between sociodemographic factors and recognition of each symptom, adjusting for cancer experience. Participants recognized an average of 8.43 symptoms as potential signs of cancer. In multivariable analyses, less education consistently predicted lower recognition across the symptoms. As socioeconomic inequalities in cancer mortality widen, it is increasingly important to understand factors that may contribute to these disparities. Our results suggest that US adults of lower SES have lower cancer symptom awareness across symptoms, findings that echo results from other developed countries. With low rates of cancer screening, another approach to reducing cancer burden and disparities may be through greater symptom awareness for symptoms with lower awareness, though additional work is needed to identify mechanisms through which awareness may have its effects on cancer outcomes.

Regional indices of socio-economic and health inequalities: a tool for public health programming

OBJECTIVES

The aim was to provide an affordable method of computing socio-economic (SE) deprivation indices at the regional level, in order to reveal the specific aspects of the relationship between SE inequalities and health outcomes. The Umbria Region Socio-Health Index (USHI) was computed and compared with the Italian National Deprivation Index at the Umbria regional level (NDI-U).

METHODS

The USHI was computed by applying factor analysis to census tract SE variables correlated with general mortality and validated through comparison with the NDI-U.

RESULTS

Overall mortality presented linear positive trends in USHI, while trends in NDI-U proved non-linear or non-significant. Similar results were obtained with regard to specific causes of death according to deprivation groups, gender and age.

CONCLUSIONS

The USHI better describes a local population in terms of health-related SE status. Policy-makers could therefore adopt this method in order to obtain a better picture of SE-associated health conditions in regional populations and to target strategies for reducing health inequalities.

Ethnic differences in barriers to symptomatic presentation in primary care: A survey of women in England

OBJECTIVE

The majority of cancers are diagnosed following a decision to access medical help for symptoms. People from ethnic minority backgrounds have longer patient intervals following identification of cancer symptoms. This study quantified ethnic differences in barriers to symptomatic presentation including culturally specific barriers. Correlates of barriers (eg, migration status, health literacy, and fatalism) were also explored.

METHODS

A cross-sectional survey of 720 White British, Caribbean, African, Indian, Pakistani, and Bangladeshi women aged 30 to 60 (n = 120/group) was carried out in England. Barrier items were taken from the widely used cancer awareness measure; additional culturally specific barriers to symptomatic presentation were included following qualitative work (11 barriers in total). Migration status, health literacy, and fatalism were included as correlates to help-seeking barriers.

RESULTS

Ethnic minority women reported a higher number of barriers (P < .001, 2.6-3.8 more than White British women). Emotional barriers were particularly prominent. Women from ethnic minority groups were more likely to report "praying about a symptom" (P < .001, except Bangladeshi women) and "using traditional remedies" (P < .001, except Caribbean women). Among ethnic minority women, adult migration to the United Kingdom, low health literacy, and high fatalistic beliefs increased likelihood of reporting barriers to symptomatic presentation. For example, women who migrated as adults were more likely to be embarrassed (OR = 1.83; CI, 1.06-3.15), worry what the GP might find (OR = 1.91; CI, 1.12-3.26), and be low on body vigilance (OR = 4.44; CI, 2.72-7.23).

CONCLUSIONS

Campaigns addressing barriers to symptomatic presentation among ethnic minority women should be designed to reach low health literacy populations and include messages challenging fatalistic views. These would be valuable for reducing ethnic inequalities in cancer outcomes.

Self-care research: Where are we now? Where are we going?

BACKGROUND AND OBJECTIVE

The beneficial effects of self-care include improved well-being and lower morbidity, mortality, and healthcare costs. In this article we address the current state of self-care research and propose an agenda for future research based on the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019. The vision of this Center is a world where self-care is prioritized by individuals, families, and communities and is the first line of approach in every health care encounter. The mission of the Center is to lead the self-care research endeavor, improving conceptual clarity and promoting interdisciplinary work informed by a shared vision addressing knowledge gaps. A focused research agenda can deepen our theoretical understanding of self-care and the mechanisms underlying self-care, which can contribute to the development of effective interventions that improve outcomes.

METHODS

During conference discussions, we identified seven major reasons why self-care is challenging, which can be grouped into the general categories of behavior change and illness related factors. We identified six specific knowledge gaps that, if addressed, may help to address these challenges: the influence of habit formation on behavior change, resilience in the face of stressful life events that interfere with self-care, the influence of culture on self-care behavioral choices, the difficulty performing self-care with multiple chronic conditions, self-care in persons with severe mental illness, and the influence of others (care partners, family, peer supporters, and healthcare professionals) on self-care.

PLANS TO ACHIEVE RESULTS

To achieve the vision and mission of the Center, we will lead a collaborative program of research that addresses self-care knowledge gaps and improves outcomes, create a supportive international network for knowledge transfer and support of innovations in self-care research, and support and train others in self-care research. Beyond these specific short-term goals, important policy implications of this work are discussed.

Improving cancer symptom awareness and help-seeking among adults living in socioeconomically deprived communities in the UK using a facilitated health check: A protocol for the Awareness and Beliefs About Cancer (ABACus) Randomised Control Trial

BACKGROUND

Cancer survival is lower in socioeconomically deprived communities, partly due to low awareness of symptoms, negative beliefs and delayed help-seeking. We developed an interactive health check questionnaire facilitated by trained lay advisors. It entails 29 questions about background, lifestyle and health with tailored behaviour change advice. Personalised results are printed using a traffic light (red/amber/green) system, highlighting areas where action should be taken. This is an individually randomised control trial to test effectiveness of the health check on symptom recognition.

METHODS

A total 246 participants aged 40+ years will be recruited from community and healthcare settings in socioeconomically deprived areas of Yorkshire and South Wales. Participants will be randomised to receive the health check or standard care (1:1 ratio). Outcome measures include: adapted Awareness and Beliefs about Cancer (primary outcome), brief State Trait Anxiety Inventory, intentions and motivation to adopt recommended health behaviours (early symptom presentation, cancer screening and lifestyle behaviours), adapted Client Service Receipt Inventory, brief medical history/screening and demographic questionnaire at: baseline; 2-weeks; and 6-months post-randomisation. A purposive sample of intervention sessions will be audio-recorded (n = 24) and half will additionally be observed (n = 12). Semi-structured interviews will take place at 2-weeks (n = 30) and 6-months (n = 15-20) post-randomisation. The primary analysis will compare cancer symptom recognition scores between arms at 2-weeks. Secondary analysis will assess cancer beliefs, barriers/time to presentation, screening and lifestyle behaviours, anxiety and costs. A process evaluation will assess intervention fidelity, dose and contamination. The London-Surrey NHS Research Ethics Committee (Ref: 17/LO/1507) approved this trial.

DISCUSSION

This is a trial of a theoretically underpinned complex intervention which has undergone phase 1 and 2 development work. The findings will evaluate evidence about the effect of the health check on symptom awareness. Although there are few exclusion criteria there are limitations regarding the population we are able to reach, who may have even higher risks of late diagnosis and poor cancer prognosis. However, the health check has the potential to improve cancer symptom awareness and encourage early help-seeking behaviour in deprived populations, thereby reducing inequalities in longer term cancer outcomes.

TRIAL REGISTRATION

Retrospectively registered with ISRCTN (Ref: ISRCTN16872545 ) on 12.01.2018.

Enhancing Men's Awareness of Testicular Disorders Using a Virtual Reality Intervention: A Pre-Post Pilot Study

BACKGROUND

The incidence of benign and malignant testicular disorders is on the rise. Three literature reviews and one qualitative study found that men's awareness of testicular disorders was lacking, and their intentions to seek help for symptoms of testicular disease were low.

OBJECTIVES

The aim of the study was to enhance men's awareness of testicular disorders, help-seeking intentions for testicular symptoms, and intention and behavior to feel their testes.

METHODS

Men aged 18-50 years were recruited from a university and asked to engage in a three-level, educational, virtual reality experience. The Medical Research Council framework guided the development and pilot testing of the intervention. Knowledge, awareness, perceived risk, implementation intentions, help-seeking intentions, and behaviors were measured at pretest (T0), immediately posttest (T1), and 1 month posttest (T2).

RESULTS

Data were available from 49 participants. In comparison to T0, a significant increase in knowledge (mean difference [MD] = 3.5, 95% CI [2.8, 4.26]); testicular awareness (MD = 0.2, 95% CI [0.01, 0.41]); implementation intentions (MD = 0.6, 95% CI [0.33, 0.90]); and help-seeking intentions for testicular swelling (MD = 0.3, 95% CI [0.12, 0.51]), lumpiness (MD = 0.3, 95% CI [0.08, 0.46]), and pain (MD = 0.6, 95% CI [0.25, 1.01]) was noted at T1. This increase was maintained at T2. Participants who expressed an intention to feel their testes at T0 were more likely to report performing this behavior at T2.

DISCUSSION

The intervention succeeded in promoting knowledge, testicular awareness, implementation intentions, help-seeking intentions, and behaviors. A randomized controlled trial of the Enhancing Men's Awareness of Testicular Disorders intervention with a larger sample size is warranted.

The Preconscious Awareness to Action Framework: An Application to Promote Testicular Awareness

BACKGROUND

Health outcomes among men are markedly poorer than women. Testicular disorders can be life-threatening if left untreated. Few studies promoting awareness of testicular disorders have been underpinned by theory. Theory-based interventions are more likely to achieve positive health outcomes than interventions that lack a theoretical foundation.

OBJECTIVES

The purpose of the study is to present a theory-focused analysis of the preconscious awareness to action framework (PAAF), developed to enhance testicular awareness and help-seeking intentions and behaviors among men.

METHODS

The following approach was used to develop the PAAF: The empirical literature on men's awareness of testicular disorders was reviewed. A qualitative study was conducted to explore men's awareness of testicular disorders, help-seeking intentions for testicular symptoms, and preferred learning strategies in relation to testicular disorders and symptoms. An iterative narrative review process of the theoretical literature on health promotion and symptom appraisal was undertaken.

RESULTS

The PAAF comprises seven steps: preconscious awareness, unconscious awareness, conscious awareness, unconscious appraisal, conscious appraisal, intention, and behavior. The concept of testicular awareness was developed to familiarize men with their own testes and promote timely help-seeking.

DISCUSSION

Researchers are encouraged to use the PAAF to design health-promoting interventions aimed at enhancing testicular awareness, symptom appraisal, and help-seeking.

Making sense of bodily sensations: Do shared cancer narratives influence symptom appraisal?

Though new or altered bodily sensations are a common occurrence they rarely transition to biomedically defined symptoms. When they do, sensations are subject to an appraisal process that can culminate in help-seeking. The transition has particular relevance for cancer diagnoses. Studies of 'symptom appraisal' in cancer patients typically conclude that failure to regard sensations as serious or 'symptom misattribution' results in lengthier help-seeking intervals. Though multiple influences on appraisal processes are acknowledged, including the socio-cultural context, detailed description and analyses of how socio-cultural factors shape appraisal is lacking. In this paper we explore one substantial component of the sociocultural context, namely, publicly recognised shared cancer narratives, and their impact on appraisal. We undertook a secondary analysis of 24 interviews with Scottish colorectal cancer patients originally completed in 2006-2007. Our analysis showed that fear, death and severity dominated cancer narratives and were frequently restated throughout interviews. Yet, early bodily changes were often mild and vague, were commonly experienced in the context of 'feeling well' and failed to match preconceived ideas of what cancer 'feels like'. Moreover, few perceived themselves to be 'at risk' of cancer and diagnoses were characterised as 'shocking' events. Participants engaged in self-monitoring strategies and severe or painful changes prompted help-seeking. Far from misattributing symptoms, responses to bodily changes were sensible and measured; responses are particularly apt in relation to current policy rhetoric, which urges measured use of services. Our findings have resonance across healthcare settings as patients are required to negotiate a narrow and challenging space when making decisions to seek help. There is a pressing need for a more realistic approach to symptom appraisal in order to reduce help-seeking intervals. Future awareness campaigns should emphasise the importance of vague/minor bodily changes although this will necessitate discussions with health professionals on referral thresholds to achieve earlier detection.

Comparative symptom biochemistry between moderate and advanced heart failure

BACKGROUND

We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF).

OBJECTIVES

The purpose of this paper was to compare relationships between peripheral biomarkers of HF pathogenesis and physical symptoms between patients with advanced versus moderate HF.

METHODS

This was a two-stage phenotype sampling cohort study wherein we examined patients with advanced HF undergoing ventricular assist device implantation in the first stage, and then patients with moderate HF (matched adults with HF not requiring device implantation) in the second stage. Linear modeling was used to compare relationships among biomarkers and physical symptoms between cohorts.

RESULTS

Worse myocardial stress, systemic inflammation and endothelial dysfunction were associated with worse physical symptoms in moderate HF (n=48), but less physical symptom burden in advanced HF (n=48).

CONCLUSIONS

Where patients are in the HF trajectory needs to be taken into consideration when exploring biological underpinnings of physical HF symptoms.

Breast cancer awareness in the sub-Saharan African ABC-DO cohort: African Breast Cancer-Disparities in Outcomes study

A greater understanding of the nature and drivers of poor breast cancer (BC) awareness in sub-Saharan Africa (SSA) will inform much needed awareness programmes. We aimed to assess the level and nature of BC awareness in the multi-country African Breast Cancer-Disparities in Outcome (ABC-DO) cohort of women newly diagnosed with BC during 2014-2017. Awareness indicators were assessed during a baseline interview at/near diagnosis. Logistic/ordinal regression was used to estimate odds ratios (OR) for indicators of BC awareness in relation to woman-level characteristics for individual settings and then meta-analyzed. In the 1,451 women included, almost all Namibian non-black women (n = 104) knew of BC and its curability, while in Namibian black and Zambian women, one in 7 (~ 15%) had not previously heard of BC and 25-40% did not know it was curable. In Uganda and Nigeria awareness was lowest: one in four women had no BC awareness, and 2 in 3 had no knowledge of its cure potential. Low educational level, unskilled employment, low socioeconomic position, rural residence, older age, being unmarried, and in some settings HIV-positivity, were associated with lower BC awareness-e.g., having unskilled employment was associated with not having heard of BC (summary OR 3.37; 95% confidence interval (CI) 2.17-5.23), believing that it is incurable (2.43; 1.81-3.26), and not recognizing a breast lump symptom (1.85; 1.41-2.43) but with between-setting variation (I2 > 68% for all). The findings provide evidence of the level and difference in BC awareness and beliefs across different settings, highlighting the urgent need for context-specific education programmes in the SSA region.

Feasibility and acceptability of a cancer symptom awareness intervention for adults living in socioeconomically deprived communities

BACKGROUND

Cancer survival rates in the UK are lower in comparison with similar countries in Europe and this may be linked to socioeconomic inequalities in stage of cancer diagnosis and survival. Targeted cancer awareness interventions have the potential to improve earlier symptomatic diagnosis and reduce socioeconomic inequalities in cancer outcomes. The health check is an innovative, theory-based intervention designed to increase awareness of cancer symptoms and risk factors, and encourage timely help seeking among adults living in deprived communities.

METHODS

A prospective, non-randomised evaluation was undertaken to test the feasibility and acceptability of the health check for adults aged 40 years and over living in deprived areas of Wales. Primary outcomes included recruitment and retention of approximately 100 adults, reach to participants in the lowest deprivation quartile, and intervention acceptability. Secondary outcomes included self-reported cancer symptom recognition, help-seeking behaviours and state anxiety pre/post intervention.

RESULTS

Of 185 individuals approached, 98 (53%) completed the intervention. Sixty-six of 98 participants were recruited from community settings (67%) and 32 from healthcare settings (33%), with 56 (57%) from the lowest deprivation quartile. Eighty-three (85%) participants completed follow-up assessment. Participants recognised on average one extra cancer symptom post intervention, with improved recognition of and anticipated presentation for non-specific symptoms. State anxiety scores remained stable. Qualitative interviews (n = 25) demonstrated that the intervention was well received and motivated change.

CONCLUSIONS

Recruitment was feasible in community and healthcare settings, with good reach to adults from low socioeconomic groups. The health check intervention was acceptable and demonstrated potential for improved cancer awareness and symptom presentation, especially for non-specific symptoms, in communities most affected by cancer.

The effects of clinical and sociodemographic factors on survival, resource use and lead times in patients with high-grade gliomas: a population-based register study

Background

Previous studies indicate an effect of sociodemographic factors on risk for being diagnosed with, as well as on survival of cancer in general. Our primary aim was to analyse sociodemographic factors, resource use and lead times in health care after diagnosis with high grade malignant glioma (HGG) in a large population based cohort.

Methods

A register-based study using several unique high-coverage registries. All patients over the age of 18 diagnosed with HGG in the Swedish Stockholm–Gotland region between 2001 and 2013 (n = 1149) were included.

Results

In multivariable cox proportional hazard model of survival, older age, male sex and high tumour grade were associated with worse survival. No significant differences could be seen related to country of birth. A high disposable income was associated with better survival and fewer occasions of pre-diagnostic inpatient care. Older age and comorbidities were correlated with a significantly increased number of outpatient visits the year before HGG diagnosis. In addition, male sex, being born outside Sweden was associated to a higher number of outpatient visits the year after diagnosis in multivariable analysis. Leadtime from diagnosis (first suspicion on brain scan) to surgery showed that the oldest patients, patients with comorbidity and patients born outside Europe had to wait longer for surgery.

Conclusions

Sociodemographic factors like education, income and country of birth have impact on care processes both before and after the diagnosis HGG. This needs to be acknowledged in addition to important clinical factors like age, comorbidity and tumour grade, in order to accomplish more equal cancer care.

Development of a Behavior Change Intervention to Encourage Timely Cancer Symptom Presentation Among People Living in Deprived Communities Using the Behavior Change Wheel

Background

Targeted public awareness interventions are needed to improve earlier cancer diagnosis and reduce socioeconomic inequalities in cancer outcomes. The health check (intervention) is a touchscreen questionnaire delivered by trained lay advisors that aims to raise awareness of cancer symptoms and risk factors and encourage timely help seeking.

Purpose

This study aimed to apply the Behavior Change Wheel to intervention refinement by identifying barriers and facilitators to timely symptom presentation among people living in socioeconomically deprived communities.

Methods

Primary data (six focus groups with health professionals, community partners and public) and secondary data (systematic review of barriers and facilitators to cancer symptom presentation) were mapped iteratively to the Behavior Change Wheel.

Results

Barriers and facilitators were identified from the systematic review and focus groups comprising 14 members of the public aged over 40, 14 community partners, and 14 healthcare professionals. Barriers included poor symptom knowledge and lack of motivation to engage in preventive or proactive behaviors. Facilitators included cues/prompts to action, general practitioner preparedness to listen, and social networks. The following behavior change techniques were selected to address identified barriers and facilitators: information about health consequences, prompts/cues, credible sources, restricting physical and social environment, social support, goal setting, and action planning.

Conclusions

The Behavior ChangeWheel triangulated findings from primary and secondary data sources. An intervention combining education and enablement could encourage timely symptom presentation to primary care among people living in socioeconomically deprived communities. Social encouragement and support is needed to increase symptom knowledge, challenge negative cancer beliefs, and prompt decisions to engage with the healthcare system.

Drivers of advanced stage at breast cancer diagnosis in the multicountry African breast cancer - disparities in outcomes (ABC-DO) study

Breast cancer (BC) survival rates in sub-Saharan Africa (SSA) are low in part due to advanced stage at diagnosis. As one component of a study of the entire journey of SSA women with BC, we aimed to identify shared and setting-specific drivers of advanced stage BC. Women newly diagnosed in the multicountry African Breast Cancer-Disparities in Outcomes (ABC-DO) study completed a baseline interview and their stage information was extracted from medical records. Ordinal logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for advanced stage (I, II, III, IV) in relation to individual woman-level, referral and biological factors. A total of 1795 women were included from Nigeria, Uganda, Zambia, and the multiracial populations of Namibia and South Africa, 1091 of whom (61%) were stage III/IV. Stage was lower in women with greater BC knowledge (OR 0.77 (95% CI: 0.70, 0.85) per point on a 6 point scale). More advanced stage was associated with being black (4.00 (2.79, 5.74)), having attended Collapse

Key Words

• breast cancer
• stage at diagnosis
• sub-Saharan Africa
• survival

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MESH Headings

• Africa
• Breast Neoplasms/diagnosis
• Breast Neoplasms/pathology
• Female
• Health Services Accessibility
• Humans
• Logistic Models
• Middle Aged
• Neoplasm Staging/methods
• Odds Ratio
• Population Groups
• Prospective Studies
• Referral and Consultation

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Grants

• 001 World Health Organization
• R01 CA192627 NCI NIH HHS

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Affiliation(s)

Fiona McKenzie Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
Annelle Zietsman Windhoek Central HospitalWindhoekNamibia
Moses Galukande Makerere UniversityKampalaUganda
Angelica Anele Federal Medical CentreOwerriNigeria
Charles Adisa Abia State University Teaching HospitalAbaNigeria
Groesbeck Parham University of North CarolinaChapel HillUSA
Leeya Pinder University of North CarolinaChapel HillUSA
Herbert Cubasch University of the Witwatersrand, Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
Maureen Joffe University of the Witwatersrand, Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
Frederick Kidaaga Namibian Institute of PathologyWindhoekNamibia
Robert Lukande Makerere UniversityKampalaUganda
Awa U. Offiah Abia State University Teaching HospitalAbaNigeria
Ralph O. Egejuru Federal Medical CentreOwerriNigeria
Aaron Shibemba University Teaching HospitalLusakaZambia
Joachim Schuz Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
Benjamin O. Anderson Fred Hutchinson Cancer Research CenterSeattleWashingtonUSA
Isabel dos Santos Silva Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUK
Valerie McCormack Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance

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Socioeconomic Inequalities in Health and Perceived Unmet Needs for Healthcare among the Elderly in Germany

Research into health inequalities in the elderly population of Germany is relatively scarce. This study examines socioeconomic inequalities in health and perceived unmet needs for healthcare and explores the dynamics of health inequalities with age among elderly people in Germany. Data were derived from the Robert Koch Institute's cross-sectional German Health Update study. The sample was restricted to participants aged 50-85 years (n = 11,811). Socioeconomic status (SES) was measured based on education, (former) occupation, and income. Odds ratios and prevalence differences were estimated using logistic regression and linear probability models, respectively. Our results show that self-reported health problems were more prevalent among men and women with lower SES. The extent of SES-related health inequalities decreased at older ages, predominantly among men. Although the prevalence of perceived unmet needs for healthcare was low overall, low SES was associated with higher perceptions of unmet needs in both sexes and for several kinds of health services. In conclusion, socioeconomic inequalities in health exist in a late working age and early retirement but may narrow at older ages, particularly among men. Socially disadvantaged elderly people perceive greater barriers to accessing healthcare services than those who are better off.

Educational differences in responses to breast cancer symptoms: A qualitative comparative study

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.