Barriers to Seeking Help for Skin Cancer Detection in Rural Australia

'Being a farmer, I mostly always think there is something more important to do': A mixed methods analysis of the skin cancer detection practices of Australian farmers

ISSUE ADDRESSED

Farmers experience skin cancer and die from melanoma at significantly higher rates than the general Australian population. This study examined Australian farmers' engagement with self-skin examinations (SSE), participation in clinical skin examinations (CSE) by a health professional, and self-reported barriers to engagement with these important skin cancer detection practices.

METHODS

A cross-sectional, mixed-methods design was used. Australian farmers were recruited through an industry-based organisation representing livestock farmers. Farmers (N = 498; 22-89 years; 83.1% male) responded to a paper-based survey that included closed- and open-ended questions.

RESULTS

Farmers reported engagement with self-conducted SSE and routine CSE that was comparable to findings in the general population, but 29.4% of farmers reported that they had not sought a CSE as soon as possible after noticing changes to their skin. Farmers reported a range of barriers to SSE, including physical difficulties examining their skin, difficulties identifying changes in their skin, forgetfulness, and lack of motivation. Barriers to CSE included accessibility, cost, difficulties finding the right doctor, and avoidance and complacency.

CONCLUSIONS

There is a need to make clinical skin cancer detection more accessible to farmers, in addition to promoting self-skin examination and help-seeking behaviours within this at risk population. SO WHAT?: Novel approaches are needed to address systemic barriers faced by Australian farmers. These may include the use of teledermatology or artificial intelligence to assist with CSE. Remote training delivery methods may be also utilised to teach SSE skills to farmers who may be otherwise unable to access such opportunities.

Understanding farmers' barriers to health and mental health-related help-seeking: The development, factor structure, and reliability of the Farmer Help-Seeking Scale

PURPOSE

The aim of this research was to develop a contextually and culturally appropriate scale to assess farmers' barriers to health-related help-seeking.

METHODS

An initial pool of items was developed from the academic literature and input from an expert panel of farmers, rural academics, and rural clinicians. A draft 32-item questionnaire was then developed and sent to farmers registered with FARMbase, which is an Australian national farmer database.

FINDINGS

Two hundred and seventy-four farmers completed the draft questionnaire (93.7% male, 73.7% aged 56-75 years). An exploratory factor analysis identified 6 factors; "Health Issues are a Low Priority," "Concerns about Stigma," "Structural Health System Barriers," "Minimization and Normalization," "Communication Barriers," and "Continuity of Care.". Test-retest reliability was examined with a further 10 farmers (90% male, Mean age = 57, SD = 5.91), who completed the questionnaire twice (at 2- to 3-week intervals). Results indicated moderate-good test-retest reliability.

CONCLUSIONS

The resulting 24-item Farmer Help-Seeking Scale provides a measure of help-seeking that is specifically designed to capture the unique context, culture, and attitudes that can interfere with farmers' help-seeking, and inform the development of strategies to increase health-service utilization in this at-risk group.

Rural health dialogue for the sustainability of help-seeking behaviors among older patients: grounded theory approach

BACKGROUND

Help-seeking behaviors (HSBs) are essential for disease prevention and health promotion. Dialogues with peers and medical professionals can improve HSBs, both qualitatively and quantitatively. Rural communities lacking healthcare resources require effective HSBs for healthcare sustainability. The current study aimed to investigate the effect of health dialogues between medical professionals and rural citizens on their HSBs.

METHODS

All procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20,220,002). A grounded theory approach was employed for the health dialogue participants in rural communities. Health dialogues with family physicians were conducted once a month at rural community centers. The dialogues and focus group interviews were recorded and coded to investigate changes in participants' perceptions and behaviors regarding HSBs.

RESULTS

Twenty-one dialogues were conducted in two rural community centers, with a total of 112 participants. The average age of the participants was 70.2 years (standard deviation = 5.4), with 24% being males. Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue driving the realization of HSBs, reflection on personal HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, hence motivating safe and secure HSBs.

CONCLUSIONS

Mitigation of barriers between citizens and medical professionals and improvement of psychological safety in communities can drive effective HSBs in rural communities.

Impact of socioeconomic status and road distance to hospital on perforated appendicitis rates at a large rural referral centre

BACKGROUND

Socioeconomic status and distance from hospital have been shown to be associated with poor surgical outcomes related to acute appendicitis. Indigenous populations experience greater socioeconomic disadvantages and poorer healthcare access than their non-Indigenous counterparts. This study aims to determine whether socioeconomic status and road distance from hospital are predictors of perforated appendicitis. It will also compare surgical outcomes of appendicitis between Indigenous and non-Indigenous populations.

METHODS

We performed a 5-year retrospective study of all patients who underwent appendicectomy for acute appendicitis at a large rural referral centre. Patients were identified using the hospital database for theatre events coded as appendicectomy. Regression modelling was used to determine if socioeconomic status and road distance from hospital were associated with perforated appendicitis. The outcomes of appendicitis between Indigenous and non-Indigenous populations were compared.

RESULTS

Seven hundred and twenty-two patients were included in this study. The rate of perforated appendicitis was not significantly impacted by socioeconomic status (OR 0.993, 95% CI 0.98-1.006, P = 0.316) or road distance from hospital (OR = 0.911, 95% CI 0.999-1.001, P = 0.911). Indigenous patients did not have a significantly higher rate of perforation compared to non-Indigenous patients (P = 0.849) despite having overall lower socioeconomic status (P = 0.005) and longer road distance from hospital (P = 0.025).

CONCLUSION

Lower socioeconomic status and longer road distance from hospital were not associated with an increased risk of perforated appendicitis. Indigenous populations have poorer socioeconomic status and longer road distance to hospital but did not have higher rates of perforated appendicitis.

Stressors, Barriers and Facilitators Faced by Australian Farmers When Transitioning to Retirement: A Scoping Review

Farms in Australia are largely family owned and managed. Complex interactions between farming history, traditions, family, business, succession, identity and place can lead to difficulties in planning for retirement for farmers. Due to the significant implications of this for farmers' health and wellbeing, there is a clear need to determine how farmers may be best supported through the work-to-retirement transition. This scoping review summarises the literature on Australian farmers' retirement experiences and the stressors they face during this transition. Barriers and facilitators that may hinder or help farmers were also explored. The relevant peer-reviewed literature was identified through database searching and the grey literature was collected via a web-based search. Seven studies were included in the review. Poor health and diminishing capacity to work was identified as a key stressor related to retirement. Other drivers of stress (i.e., pressure to live up to farming ideals, perceiving retirement as a threat to self-identity and financial concerns) overlapped with barriers to retirement. Farmers identified gradual transition, strong social networks, variety in interests and activities and early financial and succession planning as key facilitators of retirement. Findings will help inform the development of interventions to assist Australian farmers through this challenging stage of their lives.

Persisting Cancer in Black Salve Treated Skin Lesions: Results of a Large 5 Year Retrospective Analysis of Australian Histopathology Specimens

BACKGROUND

To date there has been minimal research on the use of black salve escharotics. Whether cancer persistence is a frequent finding in treatment areas, the types of lesion being treated by patients, whether rural patients are more likely to use black salve and whether current government prevention initiatives are succeeding are all issues needing investigation.

METHODS

This study was a large national retrospective black salve pathology case series from 2015 to 2019. Five private pathology companies with 1471 collection centers located in 5 of the 8 Australian states and Territories provided de-identified skin pathology report information where black salve treatment had been documented in the pathology request.

RESULTS

Over the 5-year period 409 patients had treated 475 lesions with black salve. Benign lesions were present at the treatment site in 18% of cases; persisting cancer was found in 34.2% of the remaining black salve treated areas. The majority of treatment areas were located on the head and neck. Black salve caused necrosis of normal tissue when treating benign lesions, refuting claims of cancer specificity. Likelihood of black salve use increased with rurality based on Modified Monash (MM) scores. Black salve use, despite regulatory efforts, appears to be increasing with specimen numbers more than doubling from 2015 to 2019.

CONCLUSIONS

Patients undergoing histopathological assessment of black salve treatment areas have high rates of cancer persistence. Patients are applying black salve to benign lesions and lesions in cosmetically sensitive areas. Rural patients have higher proportional rates of black salve use. The increasing incidence of black salve pathology specimens suggests current Australian black salve public health initiatives are failing.

Why people fail to participate in annual skin cancer screening: creation of the perceptions of annual skin cancer screening scale (PASCSS)

Objectives

Many studies show that most people, even at-risk individuals, do not undergo routine clinical skin cancer screening, and many questions remain unanswered regarding the participation (or lack thereof) in annual skin cancer screening. Perhaps the largest unanswered question is the most essential: why do people fail to undergo annual skin cancer screening? We provide an avenue to answer this question by creating the Perceptions of Annual Skin Cancer Screening Scale (PASCSS).

Methods

In Study 1, we conduct a qualitative investigation to identify potential scale dimensions and items (n=233). In Study 2, we test the validity and psychometric properties of our initial item list via exploratory factor analysis (n=406). In Study 3, we further test the psychometric properties of our item list via confirmatory factor analysis (n=587).

Results

These three studies provide strong support for the validity and psychometric properties of our item list, resulting in the PASCSS. The PASCSS includes 48 items and 12 dimensions that each represent unique perceptions regarding annual skin cancer screening.

Conclusions

We encourage future authors to utilize the PASCSS to identify those most at risk for failing to participate in annual skin cancer screening as well as develop adaptive interventions that can target these participants.

"We're Lucky to Have Doctors at All"; A Qualitative Exploration of Australian Farmers' Barriers and Facilitators to Health-Related Help-Seeking

This study aimed to explore barriers and facilitators that impact on farmers' help-seeking behaviours for health and mental health concerns. Fifteen semi-structured interviews were conducted with farmers (12 male; age 51.7 ± 12.6 years) from three rural regions in South Australia. Interviews explored demographic and farm-related characteristics, perceptions of individual (and where relevant family) health and mental health concerns and experiences, and perceived barriers of health support-seeking. Thematic analysis was used to identify key themes. Four key themes were identified relating to help-seeking; personal attitudes and beliefs, farm-related barriers, health system barriers and the provision of support from family and friends. Dominant personal attitudes included valuing independence, strength and privacy. Farm related barriers included the 'farm comes first' and the fact that 'farm work is never done'. Health system barriers included issues relating to availability of choice and access, professionals (lack of) understanding of farm life, and time and financial costs of accessing care. Provision of support from family and friends involved informal help and advice, including facilitating access to professional support. Multiple attitudinal, structural, and farm-related issues affect farmers' help-seeking. Professionals who understand farm work practices and routines are valued by farmers and this is likely to facilitate access to care. Workforce development programs and community programs that involve farmers' perspectives as consumers and co-designers, using evidence-based strategies, may assist in strengthening these relationships.

A qualitative descriptive study of a novel nurse-led skin cancer screening model in rural Australia

Background

People residing in rural areas have higher rates of skin cancer and face barriers to accessing care. Models of skin cancer care addressing the specific needs of rural communities and overcoming specific challenges are required, but literature is scarce. This study aimed to describe the elements of a nurse-led skin cancer model in rural Victoria using qualitative methodology and programme logic to inform implementation and ongoing sustainability.

Methods

Qualitative descriptive design. Semi-structured interviews were conducted with key stakeholders involved in the skin cancer model, namely health service executive management, clinical staff, and administration staff. Interviews were audio-recorded and transcribed verbatim. Transcripts were thematically analysed independently by two researchers before themes were compared and refined. A programme logic model was developed to organise themes into contextual elements, inputs, activities and anticipated outcomes; it was also used as a visual tool to aid discussions with key stakeholders. Member checking of the logic model occurred to verify interpretation. This programme logic model will be refined throughout the implementation phase, and again after three years of service delivery.

Results

Eight stakeholders participated in interviews. Thematic analysis identified three major themes: the influence of the local rural context, the elements of the model, and “making it happen’. These major themes and accompanying sub-themes were mapped to the programme logic model by contextual elements (rural locale, health service access barriers, burden of disease), key inputs (promotion, human resources including appropriate nurse training and leadership) and ‘making it happen’ (governance including referral pathways, flexible and sustained funding, and partnerships). The anticipated outcomes identified include skin cancer care delivered locally, timely access, career development for nurses, and decreased skin cancer burden.

Conclusion

An initiative that is place-based and community driven in response to consumer demand addresses key system barriers to earlier detection of skin cancers. It is anticipated to result in flow-on reductions in skin cancer disease burden. Programme logic was useful to both describe the initiative and as a visual tool for discussions, with the potential to inform wider health service efforts to address system barriers and bottlenecks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08411-6.

Factors related to help-seeking for cancer medical care among people living in rural areas: a scoping review

Despite the importance of timely diagnosis and access to treatment, previous studies have not adequately explored help-seeking behavior in cancer treatment among rural and remote residents. The barriers preventing help-seeking behavior also remain unclear. To address this research gap, this study conducted a scoping review to suggest a framework for eliminating barriers and facilitating help-seeking for cancer treatment among rural and remote residents. To conduct the scoping review, three English medical databases (PubMed, MEDLINE, and CINAHL) were examined for the keywords "rural," "remote," "cancer," and "help-seeking." The research objectives and study designs, participants, and excerpts describing help-seeking of the selected papers were recorded in a data charting form. Descriptions of help-seeking behavior were organized and summarized according to their meaning and integrated into factors using thematic analysis. All extracted factors related to help-seeking were sorted into four main themes according to the Ecological Model of Health Behavior, the theoretical lens for this scoping review: (1) Intrapersonal; (2) Interpersonal; (3) Groups, culture, and organizations; and (4) Policy/environment. Factors were categorized as barriers and facilitators of help-seeking. A total of 13 papers were analyzed. Intrapersonal factors such as self-reliance, symptom appraisal, and fatalism, were identified as barriers to help-seeking, whereas presentation of abnormal and serious symptoms facilitated help-seeking. Interpersonal factors such as lack of understanding of family members, influence of surrounding people, role obligations, and lack of trust in experts hindered help-seeking, whereas understanding from surrounding people such as family and friends, promoted help-seeking. Groups, cultural, and organizational factors such as prejudice, social stigma, shame, lack of anonymity, and social norms acted as barriers to help-seeking. Policy-related barriers to help-seeking included lack of medical services and physical distance from medical institutions, leading to a time burden. The study discussed the identified factors from a rural context. Future studies should consider the identified barriers and facilitators according to the four main themes in rural areas when formulating interventions to promote help-seeking. Our findings can offer a theoretical foundation to develop actionable policies, preventive strategies, and relevant interventional tools that may facilitate oncological service utilization in rural areas.

Self-reported skin cancer-related behaviours in rural Victoria: results from repeat cross-sectional studies in 2001-2003 and 2016-2018

OBJECTIVE

To assess whether self-reported use of sun-protective measures and skin examination have changed between 2001 and 2018 in a rural setting.

METHODS

Repeat cross-sectional survey of randomly selected households in four rural Victorian towns. People aged 16 years and older were eligible to participate. Logistic regression was used to identify demographic factors associated with sun-protective measures and skin examination.

RESULTS

Overall, 5,328 participated in 2001-2003 and 2,680 in 2016-2018. Among participants who go out in the sun, the mean number of reported sun-protective measures (2.6±1.3 vs. 2.6±1.6, p=0.867) and the proportion of participants reporting usually/always using sun protection (65.1% vs. 63.9%, p=0.307) were unchanged between the two surveys. However, an increased proportion of participants reported avoiding the sun when outdoors in the more recent survey (from 18.8% to 34.3%, p<0.001). Avoiding the sun was associated with being older, female, of European origin and having post-secondary school education. Skin examination rates increased between the two surveys (32.7% to 40.8%, p<0.001). Skin examinations were associated with older age groups, European origin and post-secondary school education and being male.

CONCLUSIONS

Given the small changes in sun protection over time, updated skin cancer campaigns are needed to encourage increased sun-protective behaviours and skin examinations among rural residents. Implications for public health: Results suggest that updated health promotion campaigns targeted to rural areas are warranted.

"She'll Be Right, Mate": A Mixed Methods Analysis of Skin Cancer Prevention Practices among Australian Farmers-An At-Risk Group

This study examined Australian farmers’ engagement with skin cancer prevention behaviours and explored what made it hard for them to be ‘SunSmart’ (barriers), and what could be done to make prevention easier (facilitators). In total, 498 farmers (83.1% male, 22–89 years, 50.8% grain, sheep, or cattle farmers) participated. The least frequently performed SunSmart behaviours (reported as never practiced during summer) were using SPF 30+ sunscreen (16.6%), wearing protective sunglasses (10.5%), and wearing protective clothing (8.6%). Greater engagement (i.e., higher scores on scale from Never to Always) with SunSmart behaviours was explained by gender (female), educational attainment (trade or technical college certificate vs. high school), personal skin cancer history, and skin sun sensitivity. Barriers reported by farmers related to personal preferences (e.g., short-sleeved rather than long-sleeved clothing), comfort, and perceived impracticality of sun protection. Farmers’ solutions included making protective clothing and sunscreen more appropriate for farm work (e.g., by making clothing more breathable). A personal health scare was the most reported motivation for skin cancer prevention. Findings highlight the need for increased access to sun-protective clothing and sunscreen that is suitable for wearing when working on farms, complemented by culturally appropriate health education messaging, to encourage more farmers to perform SunSmart behaviours.

Invasive and in situ squamous cell carcinoma of the skin: a nationwide study in Iceland

BACKGROUND

The worldwide incidence of cutaneous squamous cell carcinoma (cSCC) is increasing.

OBJECTIVES

To evaluate the tumour burden of in situ and invasive cSCC in Iceland, where the population is exposed to limited ultraviolet radiation.

METHODS

This whole-population study used the Icelandic Cancer Registry, which contains records of all in situ and invasive cSCC cases from 1981 to 2017. Incidence of cSCC was evaluated according to age, anatomical location, residence and multiplicity, and trends were assessed using joinpoint analysis. Age-standardized rates (WSR) and age-specific incidence rates per 100 000 person-years were calculated, along with cumulative and lifetime risks.

RESULTS

Between 1981 and 2017, in situ cSCC WSR increased from 1·2 to 19·1 for men and from 2·0 to 22·3 for women. Invasive cSCC WSR rose from 4·6 to 14 for men and from 0·3 to 13·2 for women. The average number of in situ cSCC lesions was 1·71 per woman and 1·39 per man. Women developed more in situ cSCCs than invasive cSCCs in almost all anatomical locations, whereas men developed more invasive cSCCs, mostly on the head and neck. The rates of in situ cSCC were higher in Reykjavik compared with rural areas. Furthermore, women more commonly developed multiple in situ lesions. For lip cSCCs, invasive lesions occurred more frequently than in situ lesions among both sexes. Joinpoint analysis showed that in situ cSCC in women exhibited the most rapid incidence increase.

CONCLUSIONS

cSCC has become an increasingly significant public health problem in Iceland. Tanning bed use and travelling abroad may contribute to skin cancer development. Public health efforts are needed to stem the behaviours leading to this rapid rise in cSCC.

Sociodemographic Predictors of Attitudes to Support Seeking From a Medical Doctor or Other Health Provider Among Rural Australians

BACKGROUND

Rural Australians experience higher prevalence of several chronic diseases than metropolitan Australians and are less likely to access supportive health services. This study explored associations of sociodemographic factors and barriers to support seeking for health in a sample of rural South Australians.

METHODS

Participants (n = 610) from three rural regions participated in a computer-assisted telephone interview (CATI), based on the Barriers to Help Seeking Scale. Each participant reported on barriers in one of three health contexts: 'general' physical health, skin cancer, and mental health. Sociodemographic factors included gender, age, highest education, region of residence, and presence of chronic conditions. Chi-squared Automatic Interaction Detection (CHAID) determined independent associations of sociodemographic factors and barrier categories (high, medium and low importance).

RESULTS

Privacy was a high-importance barrier in the mental health context, particularly among participants of age < 63 years. The tendency to minimise and normalise health issues was also a high-importance barrier in the mental health context. In the physical health context, those with a chronic condition were more likely to perceive normalisation as a barrier than those without a chronic condition. Need for control and self-reliance was a high-importance barrier in the mental health context and a low-importance barrier in the skin cancer context, particularly among participants < 63 years. Structural factors and distrust of providers were high-importance barriers among those who did not complete secondary education, regardless of context.

CONCLUSION

This study highlights the importance of a nuanced approach to promoting help-seeking in rural Australians, with message content and delivery tailored to specific health conditions and demographic circumstances.

Cancer-related help-seeking in cancer survivors living in regional and remote Australia

OBJECTIVES

To measure rates of detection via screening, perceived self-imposed delays in seeking medical attention, and support seeking in a sample of regional and remote people with a cancer diagnosis and to test whether an association exists between these behaviours and minimising problems and resignation, a need for self-control and reliance and fatalism. Correlations and binary logistic regressions were conducted to test the associations between demographic characteristics, attitudes and behaviours.

RESULTS

Females were more likely to have had their cancer detected via screening (OR = 10.02, CI = 3.49-28.78). Younger participants (r = -0.103, p = 0.009) were slightly more likely to seek at least one form of support and online support was sought more often by younger patients (r = -0.269, p < 0.001), females (r = 0.152, p < 0.001), those from higher socio-economic (SES) areas (r = 0.100, p = 0.012), and those with higher education levels (r = 0.247, p < 0.001). Younger (r = -0.161, p < 0.001), and female (r = 0.82, p = 0.013), participants were also slightly more likely to seek support specifically through cancer support groups. No significant relationships between minimising problems and resignation, needs for control and self-reliance or fatalism and detection via screening, support seeking, or perceived self-imposed delays to seeking medical attention were apparent, with the exception that those with higher fatalism (predetermined health) were slightly less likely to report seeking support or information online (OR = 0.79, CI = 0.65-0.95) and slightly more likely to report using Cancer Council's support services (OR = 1.24, CI = 1.02-1.52).

CONCLUSIONS

Strategies to improve the accessibility and appropriateness of support available for regional and remote cancer patients should consider interventions that remove barriers to access associated with age, gender, and education as opposed to those which address the attitudinal traits measured here.

Can adopting skin cancer preventive behaviors among seafarers be increased via a theory-based mobile phone-based text message intervention? A randomized clinical trial

BACKGROUND

One of the main occupational hazards for seafarers is the long exposure to sunlight. This study aimed to determine the efficacy of a mobile phone-based text message intervention in adopting skin cancer preventive behaviors among a sample of seafarers in Genaveh port located in Bushehr province, Iran.

METHODS

In this randomized controlled trial, 136 seafarers were randomly selected and assigned to the intervention (n = 68) or a control groups (n = 68). As a theoretical basis, we followed the Protection Motivation Theory (PMT) variables to develop the text messages. The data related to PMT variables and skin cancer preventive behaviors were collected through a questionnaire. Forty-five text messages were designed, pre-tested and sent to the seafarers' phones in the intervention group in 45 days. Both groups were followed up 1 month after the intervention. Data collected in the two stages were analyzed using paired-samples t-test, ANCOVA, and Chi-square tests.

RESULTS

Following the intervention, the mean scores of adopting skin cancer preventive behaviors (p = 0.001), perceived self-efficacy (p = 0.01), protection motivation (p = 0.02), and fear (p = 0.001) were significantly higher in the intervention group than the control group. There was significant reduction in the response costs (p = 0.05) and perceived rewards (p = 0.01) scores in the intervention group compared with the control group after the intervention. However, there were no significant differences in the perceived vulnerability (p = 0.14), perceived severity (p = 0.09), and response efficacy (p = 0.64) between the two groups after the intervention.

CONCLUSIONS

The results of the study indicated the effectiveness of mobile phone-based text message intervention for increasing skin cancer preventive behaviors in Iranian seafarers.

TRIAL REGISTRATION

Iranian Registry for Clinical Trial (the link to trial: https://www.irct.ir/trial/7572 ). Registered 16 July, 2016. Prospectively registered.

Basal cell carcinoma: an emerging epidemic in women in Iceland

BACKGROUND

An epidemic of basal cell carcinoma (BCC) has led to a significant healthcare burden in white populations.

OBJECTIVES

To provide an update on incidence rates and tumour burden in an unselected, geographically isolated population that is exposed to a low level of ultraviolet radiation.

METHODS

This was a whole-population study using a cancer registry containing records of all cases of BCC in 1981-2017. We assessed BCC incidence according to age, residence and multiplicity and assessed trends using join-point analysis. Age-standardized and age-specific incidence rates were calculated along with cumulative and lifetime risks.

RESULTS

During the study period, the age-standardized incidence rates increased from 25·7 to 59·9 for men, and from 22·2 to 83·1 for women (per 100 000). Compared with the single-tumour burden, the total tumour burden in the population was 1·72 times higher when accounting for multiplicity. At the beginning of the study period, the world-standardized rates in men and women were similar, but by the end of the study period the rates were 39% higher in women (83·1 per 100 000, 95% confidence interval 77·9-88·3) than in men (59·9 per 100 000, 95% confidence interval 55·6-64·2). This increase was most prominent in women on sites that are normally not exposed to ultraviolet radiation in Iceland: the trunk and legs.

CONCLUSIONS

This is the only reported population in which the incidence of BCC is significantly higher in women than in men. The period of notable increase in BCC lesions correlates with the period of an increase in tanning beds and travel popularity. The high multiplicity rates suggest that the total tumour burden worldwide might be higher than previously thought. What is already known about this topic? Basal cell carcinoma (BCC) is becoming an increasing healthcare burden worldwide, especially in white populations. Recent population studies have reported a rapid increase in incidence among younger individuals, especially women. What does this study add? Iceland is the only reported population in which the incidence of BCC is significantly higher in women than in men, and there does not seem to be a clear relationship between latitude and BCC incidence in Europe. Men might be comparatively protected in the northern low-ultraviolet environment, with tanning beds and travel abroad likely playing important roles in the observed incidence increase, especially in women. The high multiplicity rates suggest that the total tumour burden worldwide might be higher than previously thought. Linked Comment: Pandeya. Br J Dermatol 2020; 183:799-800.

Help-seeking behaviour for cancer symptoms: an evolutionary concept analysis

BACKGROUND

Cancer survival largely depends on its early diagnosis. Therefore, assessing help-seeking behaviours among people with potential symptoms of cancer is essential.

AIM

This study aimed to analyse the concept of help-seeking behaviour for cancer symptoms.

METHODS

This concept analysis was conducted using Rodger's evolutionary method. An online literature search was conducted in the PubMed, Scopus and Cochrane databases to find relevant articles published from 2000 to 2017 in English peer-reviewed journals. In total, ninety articles were included in the study. Through thematic analysis, the data were analysed for the definitions, attributes, antecedents and consequences of the concept of help-seeking behaviour for cancer symptoms.

RESULTS

The concept of help-seeking behaviour for cancer symptoms includes a chain of behaviours and is defined as the process of informed decision-making for seeking medical help and using healthcare services after the detection of the first potential cancer symptoms. The attributes of the concept of help-seeking behaviour for cancer symptoms include process, problem-centeredness, intentional action and interpersonal interaction. Antecedents of the concept of help-seeking behaviour for cancer symptoms were broadly categorised as its facilitators and barriers, among which old age, young age, marriage, low education level, positive family history of cancer, fear over cancer, low perceived threat, symptom disclosure to significant others are both facilitator and barrier. The consequences of the concept of help-seeking behaviour for cancer symptoms were also broadly categorised in the two main categories of positive consequences and adverse consequences.

CONCLUSIONS

Help-seeking behaviour is a multidimensional time-dependent and context-bound concept which is usually defined based on the concept of time in order to facilitate its measurement. It is generally used for assessing patients' delay in seeking medical help. The findings of this study provide better understanding about the concept of help-seeking behaviour for cancer symptoms and its implications for research and practice.