In search of the cancer candidate: can lay epidemiology help?

Unpacking the Lay Epidemiology of Cervical Cancer: A Focus Group Study on the Perceptions of Cervical Cancer and Its Prevention among Women Late for Screening in Norway

Nonattendance for cervical cancer screening is often understood in terms of a lack of 'appropriate' or 'correct' knowledge about the risks and prevention of the disease. Few studies have explored how lay persons-the users themselves-interpret and contextualise scientific knowledge about cervical cancer. In this study, we address the following research question: How is the epidemiology of cervical cancer and its prevention discussed among women who are late for cervical cancer screening in Norway? We completed nine focus group interviews (FGIs) with 41 women who had postponed cervical screening. The analyses were both inductive and explorative, aiming to unpack the complexity of lay understandings of cervical cancer. Interactive associations expressed in the FGIs reflected multiple understandings of aetiology and risk factors, screening, and interpretations of responsibility for acquiring cervical cancer. The term 'candidacy' was employed to provide an enhanced understanding of lay reasoning about the explanations and predictions of cervical cancer, as reflected in the FGIs. Both interpretations of biomedical concepts and cultural values were used to negotiate acceptable and nuanced interpretations of candidacy for cervical cancer. Uncertainties about risk factors for acquiring cervical cancer was an important aspect of such negotiations. The study's findings provide an in-depth understanding of the contexts in which screening may be rendered less relevant or significant for maintaining health. Lay epidemiology should not be considered inappropriate knowledge but rather as a productive component when understanding health behaviours, such as screening attendance.

'It's not within my control': local explanations for the development of lung cancer in China

Rates of lung cancer in China are rising rapidly, creating an urgent need for prevention. Effective prevention measures require understanding local beliefs and perceptions about the risk for developing lung cancer. This article explores the explanations that Chinese lung cancer patients and their families give about the aetiology of their disease. Fifty-three interviews were conducted among lung cancer patients and their family members at a large tumour hospital in southern China. Participants presented a complex multifactorial explanation of lung cancer associating their disease with risks like tobacco use, occupational exposures, environmental pollution, lifestyle changes, and personal characters. While these are all standard risk factors commonly associated with lung cancer, participants presented them within a larger contextual frame of structural issues that impede their ability to change their behaviours. Using a social ecological model, we demonstrate how China's socio-cultural environment shapes assumptions about the risk of lung cancer with particular reference to work, home, social situations, and the natural environment.

"Lifestyle, finitude, or inequality?": Illness explanation in Kathlyn Conway's and Arthur Frank's cancer memoirs

The lifestyle model, which attributes etiological power and moral responsibility to the individual, is dominant in health promotion discourse. While sociologists rightly critique this model's individualistic outlook, there has been insufficient distinction between the two anti-individualistic models that commonly inform their work: the well-known "sociological model" and the culturally influential but under-conceptualized model tentatively called the "finitude model." Not only is there insufficient awareness of the different etiological causes (inequality and human fragility) and political orientations (redistribution and recognition) underlying the sociological and finitude models, but there is also insufficient recognition of how the finitude model may inform illness explanation. To raise awareness about the existence and analytical utility of the finitude model, I elucidate its core assumptions through a brief review of some influential texts in late-modern health politics. Further, I illustrate the empirical utility of the notion of the finitude model by analyzing how it is used to explain illness in Arthur Frank's and Kathlyn Conway's influential cancer memoirs. Thematic analysis of the memoirs produces two major findings. First, Frank and Conway rely on the finitude model to claim victimhood and blame the blamers. Second, they seem unaware of the double-edged character of such a model, which tends to downplay how social inequality shapes health. My analysis reveals the one-sidedness of both the finitude and sociological models, and that any illness explanation therefore needs to integrate both anti-individualistic models to challenge the lifestyle model successfully.

Patient and practitioner views on cancer risk discussions in primary care: a qualitative study

Background

It is estimated that nearly 600 000 cancer cases in the UK could have been avoided in the past 5 years if people had healthier lifestyles, with the principle modifiable risk factors being smoking, obesity, alcohol consumption, and inactivity. There is growing interest in the use of cancer risk information in general practice to encourage lifestyle modification.

Aim

To explore the views and experiences of patients and practitioners in relation to cancer prevention and cancer risk discussions in general practice.

Design & setting

Qualitative study among patients and practitioners in general practices in Glasgow, UK.

Method

Semi-structured interviews were conducted with nine practitioners (five GPs and four practice nurses, recruited purposively from practices based on list size and deprivation status), and 13 patients (aged 30–60 years, with two or more specified comorbidities).

Results

Currently, cancer risk discussions focus on smoking and cancer, with links between alcohol and/or obesity and cancer rarely made. There was support for the use of the personalised cancer risk tool as an additional resource in primary care. Practitioners felt practice nurses were best placed to use it. Use in planned appointments (for example, chronic disease reviews) was preferred over opportunistic use. Concerns were expressed, however, about generating anxiety, time constraints, and widening inequalities.

Conclusion

Health behaviour change is complex and the provision of information alone is unlikely to have significant effects. Personalised risk tools may have a role, but important concerns about their use remain, particularly in areas of socioeconomic disadvantage.

Revisiting Candidacy: What Might It Offer Cancer Prevention?

The notion of candidacy emerged three decades ago through Davison and colleagues’ exploration of people’s understanding of the causes of coronary heart disease. Candidacy was a mechanism to estimate one’s own or others risk of disease informed by their lay epidemiology. It could predict who would develop illness or explain why someone succumbed to it. Candidacy’s predictive ability, however, was fallible, and it was from this perspective that the public’s reticence to adhere to prevention messages could be explained, as ultimately anybody could be ‘at-risk’. This work continues to resonate in health research, with over 700 citations of Davison’s Candidacy paper. Less explored however, is the candidacy framework in its entirety in other illness spheres, where prevention efforts could potentially impact health outcomes. This paper revisits the candidacy framework to reconsider it use within prevention. In doing so, candidacy within coronary heart disease, suicide prevention, diabetes, and cancer will be examined, and key components of candidacy and how people negotiate their candidacy within differing disease contexts will be uncovered. The applicability of candidacy to address modifiable breast cancer risk factors or cancer prevention more broadly will be considered, as will the implications for public health policy.

Construction of meanings during life-limiting illnesses and its impacts on palliative care: Ethnographic study in an African context

OBJECTIVE

Knowledge about how people make meaning in cancer, palliative, and end-of-life care is particularly lacking in Africa, yet it can provide insights into strategies for improving palliative care (PC). This study explored ways in which cancer patients, their families, and health care professionals (HCPs) construct meaning of their life-limiting illnesses and how this impact on provision and use of PC in a Nigerian hospital.

METHODS

This ethnographic study utilised participant observation, informal conversations during observation, and interviews to gather data from 39 participants, comprising service users and HCPs in a Nigerian hospital. Data were analysed using Spradley's framework for ethnographic data analysis.

RESULTS

Meaning-making in life-limiting illness was predominantly rooted in belief systems. Most patients and their families, including some HCPs, perceived that cancer was caused by the devil, mystical, or supernatural beings. They professed that these agents manifested in the form of either spiritual attacks or that wicked people in society used either poison or acted as witches/wizards to inflict cancer on someone. These beliefs contributed to either nonacceptance of, or late presentation for, PC by most of patients and their families, while some professionals depended on supernatural powers for divine intervention and tacitly supporting religious practices to achieve healing/cure.

CONCLUSIONS

Findings revealed that cultural and religious world views about life-limiting illnesses were used in decision-making process for PC. This, therefore, provided evidence that could improve the clinicians' cultural competence when providing PC to individuals of African descent, especially Nigerians, both in Nigerian societies and in foreign countries.

Engaging high-risk groups in early lung cancer diagnosis: a qualitative study of symptom presentation and intervention preferences among the UK's most deprived communities

OBJECTIVES

People at high-risk for lung cancer-current/former smokers, aged 40+ years, with serious lung comorbidity (ie, chronic obstructive pulmonary disease) and living in highly deprived areas-are more likely to delay symptom presentation. This qualitative study aimed to understand the influences on early presentation with lung cancer symptoms in high-risk individuals and intervention preferences.

METHODS

Semi-structured qualitative interviews with 37 high-risk individuals (without a cancer diagnosis), identified through seven GP practices in socioeconomically deprived areas of England, Scotland and Wales (most deprived 20%). A symptom attribution task was used to explore lung symptom perception and help seeking, developed using Leventhal's Common Sense Model. Four focus groups with 16 high-risk individuals and 12 local stakeholders (healthcare professionals and community partners) were conducted to explore preferences for an intervention to promote early lung cancer symptom presentation. Data were synthesised using Framework analysis.

RESULTS

Individual and area level indicators of deprivation confirmed that interview participants were highly deprived. Interviews. Preoccupation with managing 'treatable' short-term conditions (chest infections), led to avoidance of acting on 'inevitable and incurable' long-term conditions (lung cancer). Feeling judged and unworthy of medical help because of their perceived social standing or lifestyle deterred medical help seeking, particularly when difficult life circumstances and traumatic events led to tobacco and alcohol addiction. Focus groups. Participants recommended multifaceted interventions in community venues, with information about lung cancer symptoms and the benefits of early diagnosis, led by a trained and non-judgemental facilitator.

CONCLUSIONS

This study was novel in engaging a high-risk population to gain an in-depth understanding of the broader contextual influences on lung cancer symptom presentation. Perceived lack of health service entitlement and complex lives facilitated avoidance of recognising and presenting with lung cancer symptoms. Community-based interventions have the potential to empower disadvantaged populations to seek medical help for lung symptoms.

Alcohol and breast cancer risk: Middle-aged women's logic and recommendations for reducing consumption in Australia

BACKGROUND

We aimed to understand the factors shaping alcohol consumption patterns in middle-aged women (45-64), and to identify participant-driven population- and policy-level strategies that may be used to addresses alcohol consumption and reduce breast cancer risk.

METHODS

Semi-structured interviews (n = 35) were conducted with 'middle-aged' women conversant in English and living in South Australia with no history of breast cancer diagnosis. Data were deductively coded using a co-developed framework including variables relevant to our study objectives. Women were asked about their current level of awareness of the association between alcohol and breast cancer risk, and their personal recommendations for how to decrease consumption in middle-aged Australian women.

RESULTS

Women discussed their previous efforts to decrease consumption, which we drew on to identify preliminary recommendations for consumption reduction. We identified a low level of awareness of alcohol and breast cancer risk, and confusion related to alcohol as a risk for breast cancer, but not always causing breast cancer. Participants suggested that education and awareness, through various means, may help to reduce consumption.

CONCLUSIONS

Participants' description of strategies used to reduce their own consumption lead us to suggest that campaigns might focus on the more salient and immediate effects of alcohol (e.g. on physical appearance and mental health) rather than longer-term consequences. Critical considerations for messaging include addressing the personal, physical and social pleasures that alcohol provides, and how these may differ across socio-demographics.

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.

Lung cancer diagnosed following an emergency admission: exploring patient and carer perspectives on delay in seeking help

PURPOSE

Compared to others, patients diagnosed with lung cancer following an emergency, unplanned admission to hospital (DFEA) have more advanced disease and poorer prognosis. Little is known about DFEA patients' beliefs about cancer and its symptoms or about their help-seeking behaviours prior to admission.

METHODS

As part of a larger single-centre, prospective mixed-methods study conducted in one University hospital, we undertook qualitative interviews with patients DFEA and their carers to obtain their understanding of symptoms and experiences of trying to access healthcare services before admission to hospital. Interviews were recorded and transcribed. Framework analysis was employed.

RESULTS

Thirteen patients and 10 carers plus 3 bereaved carers took part in interviews. Three patient/carer dyads were interviewed together. Participants spoke about their symptoms and why they did not seek help sooner. They described complex and nuanced experiences. Some (n = 12) had what they recalled as the wrong symptoms for lung cancer and attributed them either to a pre-existing condition or to ageing. In other cases (n = 9), patients or carers realised with hindsight that their symptoms were signs of lung cancer, but at the time had made other attributions to account for them. In some cases (n = 3), a sudden onset of symptoms was reported. Some GPs (n = 6) were also reported to have made incorrect attributions about cause.

CONCLUSION

Late diagnosis meant that patients DFEA needed palliative support sooner after diagnosis than patients not DFEA. Professionals and lay people interpret health and illness experiences differently.

Understanding of a negative bowel screening result and potential impact on future symptom appraisal and help-seeking behaviour: a focus group study

Background

Colorectal cancer (CRC) screening using a faecal occult blood test (FOBt) has the potential to reduce cancer‐related mortality. Symptom vigilance remains crucial as a proportion of cancers will be diagnosed between screening rounds. A negative FOBt has the potential to influence how participants respond to future symptoms of CRC.

Objective

To explore (i) understanding of a negative FOBt and (ii) the potential impact of a negative FOBt upon future symptom appraisal and help‐seeking behaviour.

Design

Qualitative methodology utilizing focus groups with participants who received a negative FOBt within the National Bowel Cancer Screening Programme in Coventry and Lothian. Topics explored included: experience of screening participation, interpretation and understanding of a negative result, symptom awareness and attitudes towards help‐seeking.

Results

Four broad themes were identified: (i) emotional response to a negative FOBt, (ii) understanding the limitations of FOBt screening, (iii) symptom knowledge and interpretation and (iv) over‐reassurance from a negative FOBt. Participants were reassured by a negative FOBt, but there was variability in the extent to which the result was interpreted as an “all clear”. Some participants acknowledged the residual risk of cancer and the temporal characteristic of the result, while others were surprised that the result was not a guarantee that they did not have cancer.

Discussion and conclusions

Participants recognized that reassurance from a negative FOBt could lead to a short‐term delay in help‐seeking if symptoms developed. Screening programmes should seek to emphasize the importance of the temporal nature of FOBt results with key messages about symptom recognition and prompt help‐seeking behaviour.

Trust, choice and obligation: a qualitative study of enablers of colorectal cancer screening in South Australia

Colorectal cancer (CRC) has the second highest cancer prevalence and mortality rates in Australia. The Australian National Bowel Cancer Screening Program (NBCSP) aims to increase early detection of CRC by offering free faecal occult blood testing. The NBCSP aims to offer choice to consumers about whether or not to participate in screening. This article presents data on trust, choice and perceived obligation to participate in the NBCSP by population groups with low uptake. A qualitative study was undertaken in South Australia. We interviewed 94 people from four culturally distinct groups: Greek, Iranian, Anglo-Australian and Indigenous peoples. This article demonstrates the complexity of factors shaping the choice, or lack thereof, to participate in the NBCSP. Informed choice is based on adequate knowledge, although this varied among our participants, highlighting the need for more health education in appropriate languages. An obligation to participate was found in the Iranian and Anglo-Australian groups and resulted from an established personal relationship with the doctor, a sense of duty, the acknowledgement of government investment and appreciation. Overall, this article makes a link between trust, choice and obligation, adding to literature on the sociology of trust and medical screening and highlighting important issues in the need of a policy and practice to improve CRC screening rates.

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

BACKGROUND

Sociodemographic inequalities in the stage of diagnosis and cancer survival may be partly due to differences in the appraisal interval (time from noticing a bodily change to perceiving a reason to discuss symptoms with a health-care professional). A number of symptom appraisal models have been developed describing the psychological factors that underlie how people make sense of symptoms, although none explicitly focus on sociodemographic characteristics.

METHODS

We therefore conducted a conceptual review synthesising all symptom appraisal models, and focus on potential links with sociodemographics that could be the focus of future research.

RESULTS

Common psychological elements across nine symptom appraisal models included knowledge, attention, expectation and identity, all of which could be sensitive to sociodemographic factors. For example, lower socioeconomic status (SES), male sex and older age are associated with lower health literacy generally and lower cancer symptom knowledge. Limited attentional resources, lower expectations about health and lack of social support also hamper symptom interpretation, and would be likely to be more prevalent in those from lower SES backgrounds. Symptom heuristics ('rules of thumb') may lead to symptoms being normalised because they are common within the social network, potentially disadvantaging older populations.

CONCLUSIONS

A better understanding of the processes through which people interpret their symptoms, and the way these processes differ by sociodemographic factors, could help guide the development of interventions with the aim of reducing inequalities in cancer outcomes.

"I have never experienced any problem with my health. So far, it hasn't been harmful": older Greek-Australian smokers' views on smoking: a qualitative study

Background

Smoking tobacco products is one of the largest preventable health risk factors for older people. Greek-Australians have the highest prevalence of cigarette use in Australia for older people, but there is a lack of knowledge about Greek-Australian’s perspectives on smoking cessation. The purpose of this exploratory, qualitative study was to progress the knowledge base in this area.

Methods

A qualitative study was designed to gather information on participants’ perspectives about, and understanding of, their reasons for smoking and their attitudes to quitting. A snowball sampling technique was used to identify twenty Greek–Australian current smokers, aged ≥50 years. Semi-structured, face-to-face interviews were conducted with the assistance of a Greek translator. The audio-taped interviews were transcribed and then qualitative content analysis was used to categorise responses to the questions.

Results

Participants’ perspectives on three broad topics were identified in the interviews: perceived benefits of smoking, perceptions of smoking and its effect on health, and barriers to cessation. Smoking behaviour was described as contributing to tiredness, and stress, and yet also was also a source of enjoyment. Level of knowledge about smoking-related diseases and the risks of smoking was very low. The number of cigarettes smoked each day, type of smoking (i.e. pipe rather than cigarettes), and previous family history of smoking were identified as indicators that limited harm flows from smoking. Most participants had a positive attitude towards smoking and described their own life experience and cultural norms as supporting smoking acceptability. Low confidence in quitting was linked to advanced age.

Conclusion

Smoking among older Greek-Australian smokers has been associated with a number of influences and these need to be addressed in smoking cessation efforts targeted at this group. Promoting knowledge about the health impacts of smoking, changing attitudes towards smoking, and ultimately, decreasing tobacco consumption are critical to the maintenance of health among older Greek Australians. Cultural and experiential influences may increase the difficulty associated with changing these outcomes, but may also serve as a framework from which to develop and implement an educational intervention tailored for older Greek-Australians.

Public perceptions of cancer: a qualitative study of the balance of positive and negative beliefs

OBJECTIVES

Cancer's insidious onset and potentially devastating outcomes have made it one of the most feared diseases of the 20th century. However, advances in early diagnosis and treatment mean that death rates are declining, and there are more than 30 million cancer survivors worldwide. This might be expected to result in more sanguine attitudes to the disease. The present study used a qualitative methodology to provide an in-depth exploration of attitudes to cancer and describes the balance of negative and positive perspectives.

DESIGN

A qualitative study using semistructured interviews with thematic analysis.

SETTING

A university in London, UK.

PARTICIPANTS

30 participants (23-73 years), never themselves diagnosed with cancer.

RESULTS

Accounts of cancer consistently incorporated negative and positive views. In almost all respondents, the first response identified fear, trauma or death. However, this was followed-sometimes within the same sentence-by acknowledgement that improvements in treatment mean that many patients can survive cancer and may even resume a normal life. Some respondents spontaneously reflected on the contradictions, describing their first response as a 'gut feeling' and the second as a more rational appraisal-albeit one they struggled to believe. Others switched perspective without apparent awareness.

CONCLUSIONS

People appear to be 'in two minds' about cancer. A rapid, intuitive sense of dread and imminent death coexists with a deliberative, rational recognition that cancer can be a manageable, or even curable, disease. Recognising cancer's public image could help in the design of effective cancer control messages.