Women’s barriers for contacting general practice when experiencing gynecological cancer symptoms: a population-based study

Stage at diagnosis is one of the most important prognostic factors for cancer survival, [1] and for most types of cancer including the gynecological cancers, prolonged diagnostic interval is strongly associated with more advanced stage at diagnosis [2]. Therefore, referral guidelines for general practice have been introduced to expedite the diagnostic process for different gynecological cancers. These guidelines suggest fast track referral of women with alarm symptoms of malignancy, e.g. postmenopausal bleeding or bleeding during intercourse [3, 4]. However, a prerequisite for referral is that the symptoms are presented to the general practitioner (GP) which is not always the case, and the literature suggests that especially women with gynecological malignancies have prolonged time from symptom presentation to GP contact [5]. Several studies have shown that the decision of healthcare seeking arises in a complex interplay of symptom characteristics and numerous socioeconomic and psychosocial factors related to the individual [6‐10]. In a previous study, we found that socioeconomic characteristics such as increasing age, high educational level and immigrant status are associated with GP contact when experiencing gynecological alarm symptoms [11]. From studies of healthcare-seeking we know that different barriers exist for contacting the GP when experiencing an alarm symptom such as being embarrassed, worrying about wasting the GP’s time, being afraid of what the GP might find and being too busy to consult the GP [12, 13]. Differences in barriers for healthcare-seeking may vary between socioeconomic groups and could be a key to understand why socioeconomic factors are associated with GP contact when experiencing gynecological alarm symptoms [14].

Thus, the aim of this paper is to analyze associations between four common barriers towards contacting the GP regarding specific gynecological cancer alarm symptoms, age and socioeconomic status.

We conducted a nationwide population-based cohort study. A sample of 100 000 individuals aged 20 years or older was randomly selected from the general population using the Danish Civil Registration System (CRS). In the CRS each Danish resident is registered with a unique identification number together with information about the resident´s date of birth, sex, cohabitation status, migration etc. Each of the sampled individuals received an invitational letter explaining the purpose of the study. The invitation also contained a unique login for a secure webpage giving access to the questionnaire. Those without Internet access had the opportunity to complete the questionnaire by telephone interview. Recipients who had not responded within two weeks were sent a reminder letter. After another two weeks, a private telemarketing company contacted non-respondents. The data collection took place from June to December 2012.

A total of 26 466 women participated in the survey, which comprises 54.4% of the eligible participants. Of these 24 683 had answered all relevant items and had no missing register data in Statistics Denmark (Fig. 1). Participants’ median age was 51 years (interquartile range (IQR) 39–63), compared to 53 years (IQR 37–71) for non-participants.

Between 1.25% (post-menopausal bleeding) and 2.49% (pain during intercourse) of the women indicated that they did not wish to answer the questions.

Some 2782 (11.3%) of the respondents reported at least one newly-onset gynecological alarm symptom. Of those, 2181 (78.4%) had not contacted their GP (Table 1).

The proportions of women without GP contact ranged from 64.6% (postmenopausal bleeding) to 78.1% (pain during intercourse) (Table 2).

Between 32.3% (bleeding during intercourse) and 45.3% (postmenopausal bleeding) of the respondents reported no barriers for GP contact. The proportions of reported barriers ranged from 7.5% for being too embarrassed (pelvic pain) to 26.8% for being too busy (bleeding during intercourse). Overall, being too busy to go to the doctor was the most commonly reported predefined barrier, which was reported by between 20.2% (pelvic pain) and 26.8% (bleeding during intercourse). Between 26.2% (pain during intercourse) and 33.4% (pelvic pain) reported “other” barriers (Table 3).

Women aged 40–59 years had lower odds of reporting “being too embarrassed” (OR_adj 0.5, 95%-CI: 0.4–0.7) and reporting “worried about wasting the GP’s time” (OR_adj 0.7; 95%-CI 0.5–0.8) compared to the youngest age group. Further, women aged 60 + years of age had lower odds of reporting “worried about wasting the GP´s time”(OR_adj 0.5; 95%-CI 0.3–0.9) and lower odds of reporting “being too busy” (OR_adj 0.1, 95%-CI:0.1–0.3) compared to the youngest age group (Table 4).

Women outside the workforce had higher odds of reporting “worried what the GP might find” (OR_adj 1.5, 95%-CI: 1.0–2.3) compared to those working, while women on disability pension had lower odds of reporting “being to busy” compared to those working (OR_adj 0.2, 95%-CI: 0.1–0.5) (Table 4).

Compared to those with a low income, women with middle and high income had lower odds of reporting “being too embarrassed” (OR_adj 0.6, 95%-CI: 0.4–0.8 and OR_adj 0.4, 95%-CI: 0.2–0.7, respectively) and “wasting the GP´s time” (OR_adj 0.7, 95%-CI: 0.5–0.9 and OR_adj 0.5, 95%-CI: 0.4–0.8, respectively) (Table 4).

Immigrants and descendants of immigrants had higher odds of reporting “being too busy” (OR_adj 2.1, 95%-CI: 1.4–3.0) compared to those of Danish origin (Table 4).

Married/cohabiting women had lower odds of reporting “being too busy” compared to single women (OR_adj 0.8, 95%-CI: 0.6–1.0) (Table 4).

Women with high educational level had lower odds of reporting “being too embarrassed” and “worried what the GP might find” (OR_adj 0.5, 95%-CI: 0.3–0.9 and OR_adj 0.6, 95%-CI 0.4–1.0, respectively) compared to those with low educational level. Women with middle and high educational level had higher odds of reporting “other” compared to those with low educational level (OR_adj 2.4, 95%-CI: 1.5–4.0 and OR_adj 4.6, 95%-CI: 2.8–7.6) (Table 4).

Considering the role barriers play in diagnostic and treatment delay, knowledge about barriers towards GP contact is important to improve swift diagnosis. The high prevalence of the barriers involving either the women’s or the doctors’ time, may suggest low awareness of symptom significance among Danish women. It may also suggest worries about whether the doctor might think that the contact is unnecessary, worth noting in the context of doctor-patient relations.

The association of experiencing embarrassment or worries about wasting the GPs time with low socioeconomic status suggests more targeted and innovative initiatives to encourage GP visits, e.g. by means of social media accounts. These findings add to the increasing bank of knowledge pointing to the need for multifaceted interventions necessary for improving timely cancer diagnosis [31, 32].

We found that the majority of women reported barriers towards GP contact with gynecological alarm symptoms. Being too busy to contact the GP was the most prevalent reported barrier overall. Younger age, lower educational level, lower income and being single was in general associated with higher odds of reporting barriers. Women with low income and low educational level were more likely to report embarrassment and worrying about the GP might find.