Family Practice Vol. 16, No. 1, 28-32
© Oxford University Press 1999
Patients' perceptions of medical urgency: does deprivation matter?
UMDS Department of General Practice, 5 Lambeth Walk, London SE11 6SP, UK.
Campbell JL. Patients' perceptions of medical urgency—does deprivation matter? Family Practice 1999; 16: 28–32.
Received 11 June 1998; Accepted 7 October 1998.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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Background. Consultation behaviour is recognized as having numerous determinants, but patients' perceptions of medical urgency have been neglected as a variable of potential importance.
Objectives. We aimed to describe the variation in patients' perceptions of medical urgency, and to investigate the influence of socio-economic deprivation on such perceptions. We also aimed to investigate the association between patients' perceptions of urgency and their perception of doctor availability.
Methods. We carried out a questionnaire survey (incorporating 10 clinical vignettes) of patients attending one of 17 participating practices during a 1-week study period. A medical urgency score was calculated for each patient, and compared for patients sharing similar characteristics. The setting was West Lothian, Scotland.
Results. Patients' perceptions of medical urgency as measured by the urgency score were normally distributed amongst a sample of 4999 patients attending their GP. Whilst socio-economic deprivation was a significant determinant of perceptions of medical urgency, the effect was small and can probably be discounted as an important variable determining such perceptions. An association was observed between patients' perceptions of doctor availability following a non-urgent consultation request and a heightened sense of medical urgency.
Conclusions. Further work is required to explain the differences in the population with regard to perceptions of medical urgency, and to examine the association between patients' perceptions of the seriousness of symptoms and the urgency of consultation requests.
Keywords. Consultation behaviour, deprivation, health beliefs, medical urgency, patients' perceptions..
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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Whilst the experience of symptoms is a universal phenomenon, it is recognized that in only a minority of cases is that experience translated into a request for medical care.1 Rosenstock's health belief model2 is one of a number of possible theoretical frameworks for considering the circumstances under which that transition occurs. Although such a model provides a useful framework for considering consultation behaviour,3,4 use of accident and emergency services5 or in relation to uptake of screening programmes,6–9 it is not clear what factors might influence the manner in which the request for care is delivered. Studies of general practice workload have identified that not only is the total workload of importance in planning practice administration, but also the manner in which that workload is presented. For example, patients seen as ‘extras’ impose particular strain on general practice appointments systems,10,11 which thus require a degree of flexibility in their operation.12 It remains unclear, however, what factors might influence the degree of urgency which patients may associate with a request for a consultation. Whilst it has been suggested that patients from larger practices may have poorer perceptions of doctor availability than patients from smaller practices,13 the relationship between such perceptions and perceptions of medical urgency has not yet been defined. In this study, socio-economic deprivation and perception of doctor availability are explored as possible factors associated with patients' perceptions of medical urgency.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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A 1-week questionnaire survey was conducted of all patients attending 17 volunteer West Lothian practices who all operated an appointment system and who were all contributing to a study of GP availability.13 Questions were asked regarding the age and sex of responders, their employment status (1, in paid employment; 2, unemployed), housing tenure (1, owner occupied; 2, council or rented accommodation) and car ownership (1, access to car; 2, no access to car). A measure of deprivation was calculated for each individual by adding scores for employment, housing tenure and car ownership. Adults attending with children of less than 16 years of age completed the questionnaire on their behalf. In order to help clarify whether the sample of responders was representative of the local population, information obtained regarding car and home ownership was compared with equivalent data from the 1991 census for the 20 postcode sectors of West Lothian.
A medical urgency score was calculated for each individual on the basis of their response to 10 case vignettes describing common clinical situations (see Appendix). Responders were asked how soon they felt the patient outlined in the vignette should be seen by their family doctor. Responses were made using a 5-point scale [immediately (1), same day, within 2 days, within 7 days, no need to see doctor (5)]. Scores were corrected for the number of valid responses then extrapolated to a maximum potential score of 50.
Patients' perceptions of doctor availability were calculated using their reports of how soon they thought they could be seen by a doctor from their practice following an urgent or non-urgent appointment request (asked separately). Responses were made using a 5-point scale (same day, day after, 2–7 days later, more than 7 days later, don't know).
Average urgency scores were compared for groups of patients with similar characteristics using t-tests and analysis of variance. Distributions of scores were compared using chi-square tests, and correlation between variables was examined using Spearmans' rho.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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During the 1-week study period, the 17 practices participating in the study saw 8220 patients, from whom 4999 completed questionnaires were obtained (average practice response rate 61%, range 36–97%). Questionnaire responders were representative of the West Lothian population with regard to car and home ownership.14 Patients under 16 years or over 65 years were underrepresented in the sample compared with the local population (13.0 versus 22.4% aged under 16 years; 7.3 versus 10.9% aged >65 years). In line with the known higher consultation rate for women compared with men, there was an excess of women in the questionnaire sample compared with the local population (65.1 versus 51.4%).
Responders provided responses to all 10 of the vignettes in 4160 (83.2%) of cases, and for nine of the vignettes in a further 296 (5.9%) of cases. Patients' medical urgency scores had an approximately normal distribution (mean 24.8, s.d. 5.4). There was no difference in average medical urgency scores between male and female patients (24.7 versus 24.9, P not significant). Average medical urgency scores were significantly lower (representing a heightened sense of urgency) for those patients who were unemployed, who lived in council accommodation or who did not have access to a car, than the scores of those who were employed, who lived in owner-occupied accommodation, or who had access to a car (Table 1
). Actual differences in scores between these groups of patients were, however, small.
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There was evidence of a small but significant relationship between urgency scores and deprivation with the most underprivileged patients having the most heightened sense of medical urgency (Table 2
). There was also a relationship between medical urgency scores and reported perception of doctor availability following a non-urgent consultation request (Table 3). Responders with higher perceptions of doctor availability following a non-urgent consultation request also had a significantly higher perception of medical urgency (lower average urgency score). There was no association between socio-economic deprivation and patients' perception of doctor availability.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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What factors are of importance in influencing patients' perceptions of medical urgency? This study aimed to address that question with particular reference to the potential influence of socio-economic deprivation. The results of a questionnaire survey of a sample of patients attending their GP are reported. An urgency score was calculated for each patient. This was derived from responses to a question on how soon the subjects of a short series of clinical vignettes should be able to see their doctor. The overall response rate of 61% was judged to be satisfactory, and the results were judged to be generalizable on the basis that the sample of responders was representative of the local population in respect of car and home ownership.
Numerous studies have examined the decision taken to consult a doctor. Rosenstock's health belief model,2 suggests that such behaviour is predictable and occurs as a result of a set of core beliefs which have been refined through time. Mechanic15 identified 10 variables associated with seeking medical advice, one of which was the perceived seriousness of the symptoms experienced. In a review of literature relating to ‘why people consult the doctor’, Campbell and Roland3 identified a considerable number of factors influencing that decision. They identify the importance of socio-economic, demographic and family factors, as well as access issues in the decision making process. Hopton et al.16 noted the importance of considering the psychosocial context in which out-of-hours care takes place, and the importance of previous experiences with health services and contacts with health professionals in users' explanations of current use in the health service. Accepting this, one would have to exercise caution in an over-simplistic analysis of patients' perceptions of medical urgency, and recognize the importance of contextualizing these perceptions within the conditions prevailing for a given patient at a point in time.
Quantitative17–19 and qualitative20 methodologies have been used to examine the decision to consult in children and their families. Wyke et al.17 showed that a doctor was likely to be consulted if symptoms were judged to be severe, or if the (cough) symptom had affected the child's behaviour. In follow-up work she went on to investigate the relationship between socioeconomic status, reported symptom severity and the reactions of parents to hypothetical sets of symptoms. Parents of children from deprived families reported worse coughs than other parents, and these authors concluded that children from such families suffer from worse respiratory illness than those from non-deprived families. Kai's work,20 carried out in a disadvantaged inner-city-setting, examined the concerns of parents about their pre-school children when they were acutely ill. Parents' concerns were expressed within the con-text of ‘keenly felt pressure, emphasising parents' responsibility to protect their children from harm’, and related to parents' sense of personal control when faced with illness in their children, and to the perceived threat posed by an illness in those children.
Examining a series of children identified as frequent users of out-of-hours services in Glasgow, Morrison et al.18 (using a series of clinical vignettes based on a scale developed by Campion and Gabriel19 to assess mothers' perceptions of seriousness of clinical situations) have reported that children from poorer families are seen more frequently out-of-hours than are those from more affluent families. Mothers of children who were frequent users of services were not more likely to consider the vignette situations more serious than were the mothers of control children, but were more likely to make contact with a doctor. As in the studies referred to previously, contact with a doctor would be made when the symptoms were judged to represent an emergency, something they considered serious or something which they felt unable to cope with.
Thus, although numerous studies have examined determinants of consultation behaviour, none has examined the determinants of the degree of urgency attached to a consultation request or the relationship between the perceived seriousness of symptoms and perceived urgency.
In this study, an urgency score was calculated for each patient based on their response to their perception of medical urgency for each of 10 short clinical vignettes. Further validation of the instrument is planned, although the results obtained are in keeping with those referred to previously. Using the instrument described, patient scores adjusted for the number of valid responses were observed to have a normal distribution. Responders living in local authority accommodation, not owning a car or who were unemployed had higher scores for perceived medical urgency than did those who lived in owner-occupied accommodation, or who had access to a car, or who were in employment. Further support for this observation was obtained by the observation of an association between a measure of multiple deprivation and perceptions of urgency. Deprived patients thus appeared to have a heightened sense of medical urgency. Whether this is a cultural effect, a response to systematic variation in health education disadvantaging the poor, or the result of experiencing the increased morbidity known to be associated with deprivation21 cannot be determined from this study. It is tempting to suggest that some combination of these factors results in an increased sense of helplessness and a perceived requirement for urgent medical help. Although the differences between groups of patients were small, the possible impact on primary care workload might be evidenced through an increased frequency of requests to be fitted into appointments systems as ‘extras’ amongst poorer patients. Such a hypothesis would require testing in a further study.
Whilst a statistically significant difference was observed between medical urgency scores in relation to patients' perceptions of doctor availability following non-urgent consultation requests, the effect was weak, and can probably be discounted for practical purposes—variation in patients' perceptions of medical urgency accounted for only 1% of the variance in the perception of doctor availability in the non-urgent situation. It seems likely that other factors, perhaps relating to the organization and administration of the practice,13,22 are likely to have considerably greater influence on perceptions of doctor availability.
The decision to consult a doctor is recognized as a complex process having numerous determinants. This study has examined the issue of the perceived urgency of a variety of common clinical conditions. Urgency scores were normally distributed amongst a large sample of people attending their GP, and socio-economic deprivation had a persistent but weak effect on perception of medical urgency. Whilst seriousness of symptoms has been identified as a factor in the decision to consult a doctor, the association between individuals' perceptions of urgency and the decision to consult has been neglected. Further work is required to explain differences in the population with regard to the perceived urgency of symptoms, and to examine the association between perceptions of seriousness of symptoms and the urgency of consultation requests.
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Appendix: case vignettes |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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Subjects were asked to comment on how soon the following patients should expect to be seen by their family doctor. Responses were made using a 5-point scale (immediately (1), same day, within two days, within seven days, no need to see doctor (5)):
- Yourself, having pains in the front of the chest
- 25-year-old office clerk with a sore throat for 2 days
- 40-year-old labourer with itchy rash on hands
- Painful periods in a 20-year-old woman
- Chest pains in a 45-year-old man
- Headache and joint paints in a 65-year-old woman
- Recent sticky discharge (for 18 hours) from the eyes of an 8-month-old baby?
- Runny nose in a 15-year-old schoolboy
- If you have had diarrhoea for 2 days?
- If you had a minor cut from a broken bottle?
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Acknowledgments |
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Thanks are due to the GPs and reception staff from participating practices. This work was supported by funding from the Scottish Office and Tenovus (Scotland). This study received support from the Scottish Office, Chief Scientists Office.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix: case vignettesReferences |
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