Before the consultation: why people do (or do not) go to the doctor

Understanding access to general practice through the lens of candidacy: a critical review of the literature

BACKGROUND

Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished.

AIM

To characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy.

DESIGN AND SETTING

Qualitative review guided by the principles of critical interpretive synthesis.

METHOD

We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework.

RESULTS

A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed.

CONCLUSION

The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.

'I saw it on Facebook!' Assessing the influence of social media on patient presentation to a melanoma screening clinic

BACKGROUND

The motivations for patients presenting to melanoma screening clinics (MSCs) with concerning skin lesions are poorly understood. Social media (SoMe) refers to online platforms designed to facilitate sharing of information with billions of users worldwide. There is evidence of patients posting skin lesion 'selfies' on SoMe, influencing internet searches. Interventions through SoMe may have positive impacts on health seeking behaviour.

AIM

To identify the influence of SoMe on patients presenting to an MSC service, and to establish whether patients have been exposed to SoMe posts on skin cancer, from medical authorities or the public.

METHOD

For this pilot study, qualitative data were collected from patient questionnaires over 7 consecutive weeks at MSCs in Newcastle upon Tyne hospitals. Questions involved demographics, factors influencing attendance, use of SoMe and exposure to content on skin lesions on SoMe.

RESULTS

Questionnaires were collected from 249 patients across a range of ages. Self-examination of lesions was the most common driver. One person in the study population described SoMe as having motivated their attendance, while 30 patients recalled seeing posts from health authorities regarding skin cancer. Qualitative data indicated that patients could be influenced by targeted public health campaigns on SoMe.

CONCLUSIONS

This study suggests that SoMe is not currently a major conscious driver to attend an MSC, even among SoMe-familiar populations. However, the fact that SoMe is ubiquitous in society, in conjunction with our qualitative data, may suggest that current strategies for SoMe melanoma information delivery are not of requisite quality to break through to target populations.

Justifications for using complementary and alternative medicine reported by persons with musculoskeletal conditions: A narrative literature synthesis

BACKGROUND

Complementary and alternative medicine (CAM) is very popular with patients frequently combining it with orthodox health care. The high prevalence of CAM use and satisfaction with CAM reported by patients directly challenges an orthodox system that can only approve such use if it results from the application of biomedical concepts and science. Studies highlighting this as a cultural, sociological and historical phenomenon emphasise the value of choice for consumers of health care. Musculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We postulated that the reasons people give for using or not using CAM for musculoskeletal conditions, would therefore indicate the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations. Therefore, this study aims to investigate people's reasons for choosing or avoiding CAM for non-traumatic musculoskeletal conditions.

METHODS

A systematic search and narrative synthesis was conducted of published qualitative and quantitative studies related to CAM and non-traumatic musculoskeletal conditions.

RESULTS

We identified 169 relevant papers detailing 152 separate studies, from which 1486 justifications were extracted concerning CAM use. Content analysis resulted in 11 distinct categories across four themes: practical aspects of care, clinical effectiveness, non-clinical outcomes of care, and a person's philosophy of illness and care. People provided similar rationales for both using and avoiding CAM, emphasising that, whilst CAM is perceived by many patients with musculoskeletal conditions to fill gaps in care (such as practitioner time or quality of the therapeutic relationship), orthodox care also seeks to deliver these aspects of care. However, people who used CAM also highlighted its alignment with their general philosophy and ideas about illness and health care, and often emphasised CAM's capacity to give them control over their condition and its treatment.

CONCLUSION

Currently, CAM appears to have a significant role for patients with common painful long-term conditions in providing choices to enable individual needs to be met.

Characterization of Septal and Punctate Scarring in Peyronie's Disease

OBJECTIVE

To characterize patients with isolated septal scarring (ISS) and punctate scarring (PS) in Peyronie's disease (PD) and to highlight the importance of duplex ultrasonography in the workup of patients with PD.

MATERIALS AND METHODS

Data from all men undergoing duplex ultrasonography at London Health Sciences Center for PD or erectile dysfunction over a 3-year period were retrospectively reviewed.

RESULTS

Our cohort included 722 patients with duplex ultrasound. ISS were demonstrated in 217 patients (30%), and PS in 197 (27%), with 72 (33%) and 148 (75%), respectively, having a normal physical examination. In both ISS and PS groups, more than half of patients also had associated erectile dysfunction. Predictive factors for ISS on multivariate analysis included trauma history (odds ratio [OR] 1.90, P = .04) and age (OR 1.02, P = .01). Patients with ISS were more likely to have dorsal curvature (OR 3.81, P <.01).

CONCLUSION

Limited data exist in the literature regarding ISS and PS in PD. Our study illustrates that one-third of ISS and three-quarters of PS would have remained unrecognized without duplex ultrasonography, and it highlights its importance in the workup and subsequent management of these patients. Further studies are needed to better understand and to determine the at-risk patient and the associated clinical implications of ISS and PS, and to ultimately provide optimized and individualized management strategies.

Outcome of a grocery voucher incentive scheme for low-income tuberculosis patients on directly observed therapy in Singapore

INTRODUCTION

The 'DOT & Shop' scheme is sponsored by SATA CommHealth, a local non-governmental organisation. It was launched in July 2009, in collaboration with Singapore's Tuberculosis Control Unit (TBCU). Under this scheme, grocery vouchers are disbursed to low-income patients with tuberculosis (TB) at each clinic visit if they have been adherent to directly observed therapy (DOT). This study aimed to determine the effect of this incentive scheme on treatment completion rates and to report the characteristics of patients who were non-adherent to the scheme.

METHODS

This descriptive study used data from the TBCU medical social worker database and the National TB Registry.

RESULTS

From July 2009 to December 2012, a total of 883 TB patients were enrolled in the scheme. The overall treatment completion rates of the patients before (July 2006-June 2009) and after (July 2009-December 2012) the implementation of the scheme improved from 85.3% to 87.2% (p = 0.02). Patients under this scheme had a higher treatment completion rate (90.0%) than those not under this scheme (86.4%) (p < 0.01). It was found that the non-adherent patients were more likely to be of Malay ethnicity, younger and unemployed.

CONCLUSION

We demonstrate the salutary effect of a non-governmental organisation-funded grocery voucher incentive scheme for low-income TB patients on DOT in Singapore.

Sexual attitudes, norms, condom use, and adherence of Hispanic and non-Hispanic undergraduate students: a cross-sectional study of three community colleges in southwestern US

OBJECTIVE

To measure the sexual attitudes, norms, condom use, and adherence of Hispanic and non-Hispanic undergraduate students in three community colleges in the southwestern US.

METHODS

A previously validated instrument was used in this study (sexual risk behavior beliefs and self-efficacy survey). Statistical analyses included chi-square and one-way analysis of variance with post hoc multiple comparisons using the Statistical Program for the Social Sciences.

RESULTS

The study participants included 234 first and second year community college students. Nearly 91% of them were sexually active and 95% reported healthy sexual attitudes. However, only 29% reported adhering to consistent condom use. More females believed that condoms should always be used, even if the two people knew each other very well, when compared to males (P=0.04). Hispanic female participants were less confident they could abstain from sex when compared to non-Hispanics (P=0.00). Non-Hispanic females were more confident they could use or explain to their partner how to use a condom correctly and go to the store to buy condoms than their Hispanic female (P=0.01) and male counterparts (P=0.00).

CONCLUSION

Our study findings indicate that adherence to consistent condom use was low among Hispanic college students. This may help explain why they are more likely to report unwanted pregnancies and sexually transmitted infections. There is a documented need to introduce culturally sensitive health promotion programming specifically designed to meet the needs of this at-risk and understudied population.

Opportunistic Screening for CVD Risk Factors: The Dubai Shopping for Cardiovascular Risk Study (DISCOVERY)

BACKGROUND

Comprehensive cardiovascular disease risk factor (CVDRF) screening programs are limited in the developing world. Simplifying screening can increase its utility.

OBJECTIVES

The present study aims to estimate the burden of CVDRF in volunteers and the yield of newly discovered CVDRF comparing different sites and nationalities using this screening method.

METHODS

Voluntary point-of-care CVDRF screening was conducted in 4 shopping malls, 9 health care facilities, and 3 labor camps in 5 cities in the United Arab Emirates. Follow-up for newly diagnosed diabetes mellitus, hypertension, and dyslipidemia was made 1 month after screening to inquire about physician consultation, confirmation of diagnosis, and lifestyle changes.

RESULTS

A total of 4,128 subjects were screened (43% at malls, 36% at health care facilities, and 22% at labor camps). Subjects were relatively young (38 ± 11 years), predominantly male (75%), and of diverse nationalities (United Arab Emirates: 7%, other Arabs: 10%, South Asians: 74%, other Asians: 5%, and other nationalities: 5%). CVDRF were frequent (diabetes mellitus: 32%, hypertension: 31%, dyslipidemia: 69%, current smokers: 21%, obesity: 20%, and central obesity: 24%). Most subjects (85%) had ≥1 CVDRF, and many (17%) had ≥3 CVDRF. A new diagnosis of diabetes mellitus, hypertension, or dyslipidemia was uncovered in 61.5%, with the highest yield (74.0%) in labor camps. At follow-up of those with new CVDRF, positive lifestyle changes were reported in 60%, but only 33% had consulted a doctor; of these, diagnosis was confirmed in 63% for diabetes mellitus, 93% for hypertension, and 87% for dyslipidemia.

CONCLUSIONS

In this relatively young and ethnically diverse cohort, CVDRF burden and yield of screening was high. Screening in these settings is pertinent and can be simplified.

Socioeconomic Position and Health-Seeking Behavior for Hearing Loss Among Older Adults in England

OBJECTIVE

To examine whether socioeconomic position (SEP) is associated with progression in the health-seeking process for hearing loss.

METHOD

Logistic regression of data from a cross-sectional survey representative of noninstitutionalized, 50 years and older population of England (ELSA wave 2, 2004). Using self-reported hearing difficulty as starting point, we examined the association between SEP and health-seeking behaviors in 6 stages leading to hearing aid acquisition and use.

RESULTS

Higher SEP was associated with lower odds of self-reported hearing difficulty, adjusted odds ratio [OR] = 0.87 (95% confidence interval [CI] 0.83-0.91, p < .001). There was marginal negative association between higher SEP and receiving hearing aid recommendation (adjusted OR = 0.88, 95% CI 0.78-0.99, p = .05). SEP was not associated with any other stage of health-seeking behavior.

DISCUSSION

Among the noninstitutionalized older population of England, SEP-related inequalities exist in the prevalence of self-reported hearing loss. However, SEP is not strongly associated with progression in the remaining stages of health-seeking process during and after an individual's contact with the health system.