title: Barriers to cancer symptom presentation among people from low socioeconomic groups: a qualitative study.
abstract: Socioeconomic inequalities in cancer survival can in part be explained by long patient intervals among people from deprived groups; however, the reasons for this are unclear. This qualitative study explores the actual and anticipated barriers to cancer symptom presentation in the context of socioeconomic deprivation.
  
  
  
  Thirty participants were recruited through the International Cancer Benchmarking Partnership Welsh database (n = 20), snowball sampling (n = 8) and community partners (n = 2). Semi-structured qualitative interviews were conducted with symptomatic and asymptomatic adults over the age of 50 years, who were identified as being from a low socioeconomic group based on multiple individual and group level indicators. Transcripts were analysed using a Framework approach based on the COM-B model (Capability, Opportunity, Motivation-Behaviour).
  
  
  
  There was evidence of poor awareness of non-specific cancer symptoms (Capability), fearful and fatalistic beliefs about cancer (Motivation), and various barriers to accessing an appointment with the family physician (Opportunity) and full disclosure of symptoms (Capability). These in combination were associated with a lengthened patient interval among participants. Social networks (Opportunity) were influential on the formation of knowledge and beliefs about cancer. Participants' behavioural and normative beliefs were usually formed and reinforced by people they knew with cancer, and such beliefs were considered to lengthen the patient interval. Discussing symptoms with a family member or friend before a visit to the family physician was the norm, and could act as a barrier or facilitator depending on the quality of advice given (Opportunity). Economic hardship meant fulfilling basic day-to-day needs such as finding money for food were prioritised over medical help seeking (Opportunity).
  
  
  
  The complex interaction between individual characteristics and socio-environmental factors is important for understanding cancer symptom presentation behaviour, especially in the context of socioeconomic deprivation. Interventions targeted at deprived communities should take into account the wider social influences on symptom presentation behaviour.
authors.affiliation: Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK. mccutchanGM@cardiff.ac.uk.
authors.forename: Grace
authors.identifier: 0000-0002-8079-2540
authors.initials: G
authors.lastname: McCutchan
authors.affiliation: Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Wood
authors.affiliation: Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Smits
authors.affiliation: Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
authors.forename: Adrian
authors.initials: A
authors.lastname: Edwards
authors.affiliation: Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
authors.forename: Kate
authors.initials: K
authors.lastname: Brain
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001364:Awareness; D003469:Culture; D005239:Fear; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009369:Neoplasms / Q000150:complications*; D010342:Patient Acceptance of Health Care; D010821:Physicians, Family; D011203:Poverty; D036301:Qualitative Research; D012931:Social Environment; D012959:Socioeconomic Factors; D017741:Survivors
keywords: Cancer; Cancer awareness; Cancer beliefs; Help-seeking behaviour; Patient interval; Socioeconomic status; Symptom assessment; Symptom presentation