Patient's travel distance to specialised cancer diagnostics and the association with the general practitioner's diagnostic strategy and satisfaction with the access to diagnostic procedures: an observational study in Denmark.

BACKGROUND: Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP's suspicion of cancer, we investigated the association between: 1) cancer patient's travel distance to the first specialised diagnostic facility and the GP's diagnostic strategy and 2) cancer patient's travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations. METHOD: This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient's travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP's satisfaction with the waiting times and the available investigations were assessed from GP questionnaires. RESULTS: When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using 'wait-and-see' approach and 'medical treatment' as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20-3.28). CONCLUSION: A insignificant tendency to use 'wait-and-see' and 'medical treatment' were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.

Negative cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking: an international cancer benchmarking partnership (ICBP) study.

BACKGROUND: Understanding what influences people to seek help can inform interventions to promote earlier diagnosis of cancer, and ultimately better cancer survival. We aimed to examine relationships between negative cancer beliefs, recognition of cancer symptoms and how long people think they would take to go to the doctor with possible cancer symptoms (anticipated patient intervals). METHODS: Telephone interviews of 20,814 individuals (50+) in the United Kingdom, Australia, Canada, Denmark, Norway and Sweden were carried out using the Awareness and Beliefs about Cancer Measure (ABC). ABC included items on cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking for cough and rectal bleeding. The anticipated time to help-seeking was dichotomised as over one month for persistent cough and over one week for rectal bleeding. RESULTS: Not recognising persistent cough/hoarseness and unexplained bleeding as cancer symptoms increased the likelihood of a longer anticipated patient interval for persistent cough (OR = 1.66; 95%CI = 1.47-1.87) and rectal bleeding (OR = 1.90; 95%CI = 1.58-2.30), respectively. Endorsing four or more out of six negative beliefs about cancer increased the likelihood of longer anticipated patient intervals for persistent cough and rectal bleeding (OR = 2.18; 95%CI = 1.71-2.78 and OR = 1.97; 95%CI = 1.51-2.57). Many negative beliefs about cancer moderated the relationship between not recognising unexplained bleeding as a cancer symptom and longer anticipated patient interval for rectal bleeding (p = 0.005). CONCLUSIONS: Intervention studies should address both negative beliefs about cancer and knowledge of symptoms to optimise the effect.

Measurement properties of the Danish version of the Awareness and Beliefs about Cancer (ABC) measure.

BACKGROUND: The International Cancer Benchmarking Partnership aims to study international differences in cancer survival and the possible causes. Participating countries are Australia, Canada, Norway, Sweden, Denmark and the UK and a particular focus area is differences in awareness and beliefs about cancer. In this connection, the Awareness and Beliefs about Cancer (ABC) measure has been translated into multiple languages. The aim of this study is to appraise the translation process and measurement properties of the Danish version of the ABC measure. METHODS: The translation process included forward and backward translations and a pilot-test. Data quality was assessed using survey data from 3000 Danish respondents and content validity indexes were calculated based on judgments from ten academic researchers. Construct validity was determined by a confirmative factor analysis (CFA) and exploratory factor analyses (EFA) using survey data and a known group comparison analysis including 56 persons. Test-retest reliability was assessed based on responses from 123 person whom completed the interview twice with an interval of 2-3 weeks. RESULTS: The translation process resulted in a Danish ABC measure conceptually equivalent to the English ABC measure. Data quality was acceptable in relation to non-response to individual items which was maximum 0.3%, but the percentage of respondents answering 'don't know' was above 3% for 16 out of 48 items. Content validity indexes showed that items adequately reflected and represented the constructs to be measured (item content validity indexes: 0.9-1.0; construct content validity indexes: 0.8-1.0). The hypothesised factor structure could not be replicated by a CFA, but EFA on each individual subscale showed that six out of seven subscales were unidimensional. The ABC measure discriminated well between non-medical academics and medical academics, but had some difficulties in discriminating between educational groups. Test-retest reliability was moderate to substantial for most items. CONCLUSIONS: The Danish ABC measure is a useful measurement that is accepted and understood by the target group and with accepted measurement criteria for content validity and test-retest reliability. Future studies may further explore the factorial structure of the ABC measure and should focus on improving the response categories.

Awareness of cancer symptoms and anticipated patient interval for healthcare seeking. A comparative study of Denmark and Sweden.

Background Recent epidemiologic data show that Denmark has considerably poorer survival from common cancers than Sweden. This may be related to a lower awareness of cancer symptoms and longer patient intervals in Denmark than in Sweden. The aims of this study were to: 1) compare population awareness of three possible symptoms of cancer (unexplained lump or swelling, unexplained bleeding and persistent cough or hoarseness); 2) compare anticipated patient interval when noticing any breast changes, rectal bleeding and persistent cough; and 3) examine whether potential differences were noticeable in particular age groups or at particular levels of education in a Danish and Swedish population sample. Method Data were derived from Module 2 of the International Cancer Benchmarking Partnership. Telephone interviews using the Awareness and Beliefs about Cancer measure were conducted in 2011 among 3000 adults in Denmark and 3070 adults in Sweden. Results Danish respondents reported a higher awareness of two of three symptoms (i.e. unexplained lump or swelling and persistent cough or hoarseness) and a shorter anticipated patient interval for two of three symptoms studied (i.e. any breast changes and rectal bleeding) than Swedish respondents. Differences in symptom awareness and anticipated patient interval between these countries were most pronounced in highly educated respondents. Conclusion Somewhat paradoxically, the highest awareness of symptoms of cancer and the shortest anticipated patient intervals were found in Denmark, where cancer survival is lower than in Sweden. Thus, it appears that these differences in symptom awareness and anticipated patient interval do not help explain the cancer survival disparity between Denmark and Sweden.

Awareness of sunburn in childhood, use of sunbeds and change of moles in Denmark, Northern Ireland, Norway and Sweden.

BACKGROUND: Malignant melanoma (MM) is increasing rapidly in Northern Europe. To reduce incidence and mortality through earlier diagnosis, public awareness of MM is important. Thus, we aim to examine awareness of risk factors and a symptom of MM, and how awareness varies by country and socio-demographic factors in Denmark, Northern Ireland (NI), Norway and Sweden. METHODS: Population-based telephone interviews using the 'Awareness and Beliefs about Cancer' measure were conducted in 2011 among 8355 adults ≥50 years as part of the International Cancer Benchmarking Partnership Module 2. Prevalence ratios (PRs) with 95% confidence intervals were calculated. RESULTS: In these four countries, lowest awareness was found for 'sunburn in childhood' (63%), whereas awareness was high for 'use of sunbeds' (91%) and 'mole change' (97%). Lack of awareness of 'sunburn in childhood' was more prevalent among respondents from Norway [PR = 1.38 (1.28-1.48)] but less prevalent among respondents from Northern Ireland (NI) [PR = 0.78 (0.72-0.85)] and Sweden [PR = 0.86 (0.79-0.93)] compared with respondents from Denmark. Lack of awareness of 'use of sunbeds' was more prevalent among respondents from Norway [PR = 2.99 (2.39-3.74)], Sweden [PR = 1.57 (1.22-2.00)], and NI [PR = 1.65 (1.30-2.10)] compared with respondents form Denmark. Being a man, age ≥70, living alone, and having lower education, were each independently associated with lack of MM-awareness. CONCLUSIONS: The results indicate relatively low awareness of 'sunburn in childhood' as a risk factor for MM, and important disparities in MM-awareness across countries and socio-demographic groups. Improved and more directed initiatives to enhance public MM-awareness, particularly about 'sunburn in childhood', are needed.

Barriers to healthcare seeking, beliefs about cancer and the role of socio-economic position. A Danish population-based study.

BACKGROUND: Cancer-related health behaviours may be affected by barriers to healthcare seeking and beliefs about cancer. The aim was to assess anticipated barriers to healthcare seeking and beliefs about cancer in a sample of the Danish population and to assess the association with socio-economic position. METHODS: A population-based telephone interview with 3000 randomly sampled persons aged 30 years or older was performed using the Awareness and Beliefs about Cancer measure from 31 May to 4 July 2011. The Awareness and Beliefs about Cancer measure includes statements about four anticipated barriers to healthcare seeking and three positively and three negatively framed beliefs about cancer. For all persons, register-based information on socio-economic position was obtained through Statistics Denmark. RESULTS: Two anticipated barriers, worry about what the doctor might find and worry about wasting the doctor's time, were present among 27% and 15% of the respondents, respectively. Overall, a high proportion of respondents concurred with positive beliefs about cancer; fewer concurred with negative beliefs. Having a low educational level and a low household income were strongly associated with having negative beliefs about cancer. CONCLUSION: The fact that worry about what the doctor might find and worry about wasting the doctor's time were commonly reported barriers call for initiatives in general practice. The association between low educational level and low household income and negative beliefs about cancer might to some degree explain the negative socio-economic gradient in cancer outcome.

Awareness of risk factors for cancer: a comparative study of Sweden and Denmark.

BACKGROUND: Sweden and Denmark are neighbouring countries with similarities in culture, healthcare, and economics, yet notable differences in cancer statistics. A crucial component of primary prevention is high awareness of risk factors in the general public. We aimed to determine and compare awareness of risk factors for cancer between a Danish and a Swedish population sample, and to examine whether there are differences in awareness across age groups. METHODS: Data derive from Module 2 of the International Cancer Benchmarking Partnership. Telephone interviews were conducted with 3000 adults in Denmark and 3070 in Sweden using the Awareness and Beliefs about Cancer measure. Data reported here relate to awareness of 13 prompted risk factors for cancer. Prevalence ratios with 95 % confidence intervals were calculated to examine associations between country, age, and awareness of risk factors. RESULTS: Over 90 % of respondents in both countries recognized smoking, use of sunbeds and ionizing radiation as risk factors for cancer. Lowest awareness (<50 %) was found for HPV-infection, low fruit and vegetable intake and alcohol intake. Swedish respondents reported higher awareness than Danish respondents for ten of the 13 risk factors studied. Respondents from Denmark reported higher awareness only regarding low fruit and vegetable intake and use of sunbeds. Low physical activity was the only risk factor for which there was no difference in awareness between the countries. A decline in awareness was generally seen with increasing age in both countries, but deviating patterns were seen for alcohol intake, red/processed meat, obesity and age 70+. CONCLUSIONS: This study supports findings from other European studies that generally demonstrate modest public awareness of many established cancer risk factors. Efforts should be made to improve awareness of the cancer risk factors HPV-infection, low fruit and vegetable intake and alcohol intake, which showed particularly low awareness in both countries. Previous studies indicate that repeated, broad campaigns are successful, and suggest that a multimedia approach is used.

Symptom attributions in patients with colorectal cancer.

BACKGROUND: Symptoms of cancer may be interpreted differently by different patients before the diagnosis. This study investigated symptom attributions in Danish patients with colorectal cancer and the potential associations with symptom type, socio-demographic characteristics and patient interval. METHODS: Data were collected among incident colorectal cancer patients (n = 577, response rate 64.2 %), who were asked to think back on the time before their diagnosis when completing the questionnaire. The questionnaire comprised a Danish version of the revised Illness Perception Questionnaire (IPQ-R) with questions on 19 symptom attributions. These 19 attribitutions were categorised into five causal groups for statistical analyses. The patient interval (i.e. the time from the patient's first symptom experience to presentation to the healthcare system) was assessed in the same questionnaire. Data on socio-demographic characteristics were obtained by using nationwide registers from Statistics Denmark. RESULTS: Patients who experienced 'blood in stool' as the most important symptom were more likely to attribute this to cancer (PR(ad) 1.94, 95 % CI 1.46-2.58) and benign somatic causes (PR(ad) 1.36, 95 % CI 1.05-1.76), such as haemorrhoids, compared to patients who did not perceive this symptom as the most important. Socio-demographic characteristics were also associated with symptom attribution. Patients with higher educational levels were less likely to attribute their most important symptom to psychological causes (PR(ad) 0.57, 95 % CI 0.34-0.96) than patients with lower educational levels. Patients with rectal cancer attributed their most important symptom to a benign somatic cause more often than patients with colon cancer (PR(ad) 1.34, 95 % CI 1.02-1.77). [corrected]. CONCLUSIONS: Symptom attribution in patients was associated with aspects of socio-demography and with the symptom type perceived by the patient as the most important. No significant associations were found between symptom attributions and patient interval. These results have implications for general practice as symptom attributions may prompt patients to present symptoms in a certain way and thereby influence the general practitioner's assessment of presented symptoms.

Cancer awareness and socio-economic position: results from a population-based study in Denmark.

BACKGROUND: Differences in cancer awareness between individuals may explain variations in healthcare seeking behaviour and ultimately also variations in cancer survival. It is therefore important to examine cancer awareness and to investigate possible differences in cancer awareness among specific population subgroups. The aim of this study is to assess awareness of cancer symptoms, risk factors and perceived 5-year survival from bowel, breast, ovarian, and lung cancer in a Danish population sample and to analyse the association between these factors and socio-economic position indicators. METHODS: A population-based telephone survey was carried out among 1,000 respondents aged 30-49 years and 2,000 respondents aged 50 years and older using the Awareness and Beliefs about Cancer measure. Information on socio-economic position was obtained by data linkage through Statistics Denmark. Prevalence ratios were used to determine the association between socio-economic position and cancer awareness. RESULTS: A strong socio-economic gradient in cancer awareness was found. People with a low educational level and a low household income were more likely to have a lower awareness of cancer symptoms, cancer risk factors and the growing risk of cancer with age. Furthermore, men and people outside the labour force tended to be less aware of these factors than women and people within the labour force. However, women were more likely than men to lack awareness of the relationship between age and cancer risk. No clear associations were found between socio-economic position and lack of awareness of 5-year survival from bowel, breast, ovarian, and lung cancers. CONCLUSIONS: As cancer awareness has shown to be positively associated with cancer-related behaviour, e.g. healthcare seeking, consideration must be given to tackle inequalities in cancer awareness and to address this issue in future public health strategies, which should be targeted at and tailored to the intended recipient groups.

A validation study of the psychometric properties of the Groningen Reflection Ability Scale.

BACKGROUND: Reflection, the ability to examine critically one's own learning and functioning, is considered important for 'the good doctor'. The Groningen Reflection Ability Scale (GRAS) is an instrument measuring student reflection, which has not yet been validated beyond the original Dutch study. The aim of this study was to adapt GRAS for use in a Danish setting and to investigate the psychometric properties of GRAS-DK. METHODS: We performed a cross-cultural adaptation of GRAS from Dutch to Danish. Next, we collected primary data online, performed a retest, analysed data descriptively, estimated measurement error, performed an exploratory and a confirmatory factor analysis to test the proposed three-factor structure. RESULTS: 361 (69%) of 523 invited students completed GRAS-DK. Their mean score was 88 (SD = 11.42; scale maximum 115). Scores were approximately normally distributed. Measurement error and test-retest score differences were acceptable, apart from a few extreme outliers. However, the confirmatory factor analysis did not replicate the original three-factor model and neither could a one-dimensional structure be confirmed. CONCLUSIONS: GRAS is already in use, however we advise that use of GRAS-DK for effect measurements and group comparison awaits further review and validation studies. Our negative finding might be explained by a weak conceptualisation of personal reflection.

Time from first symptom experience to help seeking for colorectal cancer patients: Associations with cognitive and emotional symptom representations.

OBJECTIVES: The aim was to assess the association between cognitive and emotional symptom representations prior to diagnosis and the length of the patient interval (i.e. the time from the first symptom is experienced until healthcare is sought) for colorectal cancer patients. METHOD: The study population included 436 newly diagnosed colorectal cancer patients. Questionnaire data were collected using the Danish Revised Illness Perception Questionnaire (IPQ-R), including cognitive and emotional symptom representations and information on the patient interval. RESULTS: High score in treatment control was associated with short patient interval (PR = 0.52, 95% CI: 0.31-0.89) and high score on the timeline cyclical dimension was associated with long patient interval (PR = 2.14, 95% CI: 1.29-3.57). Hence, patients with negative beliefs about the treatability of their symptoms and patients with strong beliefs about the cyclical nature of their symptoms were more likely to have a long patient interval. Assigning blood in stool as the most important symptom significantly interacted in the association between the patient interval and the two cognitive symptom representations consequence and personal control. CONCLUSION: The results indicate that aspects of symptom representations were associated with the patient's help-seeking. PRACTICAL IMPLICATIONS: These findings may help clinicians and public health planners shorten patient intervals.

Measurement properties of the Danish version of the Illness Perception Questionnaire-Revised for patients with colorectal cancer symptoms.

The aim of this study was to validate the measurement properties of the Danish version of the Illness Perception Questionnaire-Revised adapted to measure symptom representations among patients with colorectal cancer symptoms. A total of 488 colorectal cancer patients completed a questionnaire derived from the Illness Perception Questionnaire-Revised to retrospectively assess cognitive and emotional representations of experienced symptoms. A confirmatory factor analysis indicated no good comparative fit with the Illness Perception Questionnaire-Revised. Using exploratory factor analysis, a 7-factor structure was conducted, which fairly supported the Illness Perception Questionnaire-Revised. The modified Illness Perception Questionnaire-Revised is a promising tool for measuring symptom representations among Danish colorectal cancer patients.

An international measure of awareness and beliefs about cancer: development and testing of the ABC.

OBJECTIVES: To develop an internationally validated measure of cancer awareness and beliefs; the awareness and beliefs about cancer (ABC) measure. DESIGN AND SETTING: Items modified from existing measures were assessed by a working group in six countries (Australia, Canada, Denmark, Norway, Sweden and the UK). Validation studies were completed in the UK, and cross-sectional surveys of the general population were carried out in the six participating countries. PARTICIPANTS: Testing in UK English included cognitive interviewing for face validity (N=10), calculation of content validity indexes (six assessors), and assessment of test-retest reliability (N=97). Conceptual and cultural equivalence of modified (Canadian and Australian) and translated (Danish, Norwegian, Swedish and Canadian French) ABC versions were tested quantitatively for equivalence of meaning (≥4 assessors per country) and in bilingual cognitive interviews (three interviews per translation). Response patterns were assessed in surveys of adults aged 50+ years (N≥2000) in each country. MAIN OUTCOMES: Psychometric properties were evaluated through tests of validity and reliability, conceptual and cultural equivalence and systematic item analysis. Test-retest reliability used weighted-κ and intraclass correlations. Construction and validation of aggregate scores was by factor analysis for (1) beliefs about cancer outcomes, (2) beliefs about barriers to symptomatic presentation, and item summation for (3) awareness of cancer symptoms and (4) awareness of cancer risk factors. RESULTS: The English ABC had acceptable test-retest reliability and content validity. International assessments of equivalence identified a small number of items where wording needed adjustment. Survey response patterns showed that items performed well in terms of difficulty and discrimination across countries except for awareness of cancer outcomes in Australia. Aggregate scores had consistent factor structures across countries. CONCLUSIONS: The ABC is a reliable and valid international measure of cancer awareness and beliefs. The methods used to validate and harmonise the ABC may serve as a methodological guide in international survey research.

[People's cancer awareness and beliefs]. / Befolkningens viden og forestillinger om kræft.

Lack of awareness of cancer symptoms, cancer risk factors, and erroneous beliefs about cancer may influence delay in presentation of cancer symptoms and thereby treatment outcomes. This paper refers cancer awareness population studies (mainly from the UK) and describes associations between elements of the Health Belief Model and cancer-related health behavior. Denmark is part of the International Cancer Benchmarking Partnership which, inter alia, will examine whether differences in cancer survival across countries can be explained by different levels of cancer awareness and erroneous beliefs about cancer.