Rural/urban differences in accounts of patients’ initial decisions to consult primary care

Abstract

In the UK, patients in urban areas consult primary health care more than rural patients for both trivial and serious conditions. This study, involving focus groups and interviews, examined rural/urban differences in accounts of patients’ intentions around initial decisions to consult general practice. Findings suggest ‘relationships’ between doctors and patients and easier access to appointments could affect consulting in rural areas, while decision-making for urban patients tended to be more consumerist. Perceptions about access to different health services meant rural patients’ decision-making in out-of-hours emergencies was complex. Rural/urban differences in demand could be affected by change in UK primary care provision.

Introduction

In the UK, patients in urban areas consult primary health care more than rural patients for both trivial and serious conditions (Carr–Hill et al., 1997). Australia has lower general practitioner (GP) activity levels in small rural locations (Britt et al., 2001), while in the US primary care physician consulting rates are similar across rural and urban areas (Aday et al., 2001). In a context where health services are portrayed as plagued by inappropriate demand (Hallam, 1994; Snooks et al., 1998), patterns of apparently lower service utilisation in rural areas might be seen as commendable, representing a model for urban services to emulate. However, internationally, there are concerns that lower consultation rates may be associated with poorer health outcomes for certain conditions, including asthma, diabetes and some cancers (Liff et al., 1991; Campbell et al., 2000; Wilson, 1984; Jones, 1996).

Lower rural consultation rates may be due to better health or unmet need (Watt, 1995). They are often attributed to poor physical access to health services (Carr-Hill et al., 1997). A ‘distance decay’ effect has been described for both urban and rural patients (Whitehouse, 1985; Jones et al., 1998), with increasing distance from a service predicting lower use.

While a body of evidence shows distance decay as a relevant influence on access and utilisation, it has been suggested that rurality might independently affect consulting rates (Watt & Sheldon, 1993). Models of influences on utilisation could illuminate study of this idea. These are numerous and some combine many factors, encompassing social and organisational issues as well as location. Andersen and Newman (1973) noted 28 determinants of an individual's health service utilization and Cummings et al. (1980) listed 99 factors that could affect ‘health actions’. However, by their very complexity, these models are difficult to test empirically and they are perhaps most helpful in conceptualising the various features pertinent to consulting decisions. The relevance of socio-economic factors in consulting has been tested. For example, Field and Briggs (2001) conducted a panel survey of service utilisation by asthmatics and diabetics at 13 locations in Northamptonshire, UK and found higher consultation rates for females, the very young and very old, students, the unemployed and non-manual workers. Although distance to the surgery was an important barrier, it was modulated by access to a car.

Social functioning and context is thought to affect help-seeking (Bury, 1997). In his classic study of ethnic groups in New York, Zola (1973) suggested the patients’ natural state is to delay consulting and therefore visiting the doctor must be prompted by some event. He suggested five triggers to consulting were interpersonal crisis, interference with social relationships or activities, sanctioning and considering symptoms over time. Freidson (1970) suggested social networks influenced consulting, but evidence is mixed. In a study of uptake of antenatal services, McKinlay (1973) found that knowledge of services and confidence were more relevant than lay referral; however, following interviews with more than 100 patients, Cornford and Cornford (1999) concluded that ‘lay conversations’ affected general practice consulting. Qualitative studies of consulting for heart disease have suggested that social status differences between patients and doctors and cultural acceptance of poor health may lead patients to delay consulting (Richards et al., 2002). Research has indicated associations between frequent attendance and psychosocial factors (Bellon et al., 1999; Scaife et al., 2000; Little et al., 2001). Family influence (Little et al., 2001), habituation to using services (Neal et al., 2001) and variations in the patient–doctor relationship (Neal et al., 2000) have been implicated. Pinpointing precise influences on help-seeking continues to be an illusive holy grail, in spite of a large literature. Campbell and Roland's (1996) review concluded that ‘a complex mix’ of physical, psychological and social factors affected consulting.

Few studies have considered the relevance of socio-cultural factors to differences in consulting among rural and urban residents. This is perhaps surprising given an often-touted assumption that rural people are more stoical and fatalistic than their urban counterparts (Deaville, 2001) and this hinders their uptake of services. In a qualitative study of Scottish cancer patients, Bain and Campbell (2000) found that rural patients had ‘less demanding expectations’. A perception of long-term rural residents being less demanding was confirmed by interviews with health professionals in a similar geographical area (Iversen et al., 2002). While the presence of ‘stoicism’ may be borne out by some evidence, the concept remains poorly defined and identifying more accurately what is different about rural patients’ consulting decisions is an area worthy of investigation.

This study looked specifically at initial decisions to consult for symptoms possibly indicative of heart disease and cancer, two priority areas for the Scottish National Health Service (The Scottish Office, 1999). Studies of consulting for heart problems suggest initial delay (Dracup et al., 1995) and reservations about calling emergency services (Leslie et al., 2000; Ruston, 2001) are common. Cancer studies indicate that perceptions of symptoms, attitudes to consulting, interactions with others, fear, beliefs about treatment, failure to prioritise health and a perception of self-induced illness affect consulting (Sheikh and Ogden, 1998; Ramirez et al., 1999; Burgess et al., 2001).

Given this background, the study described here, which took place in 2001–2002, sought to explore the extent to which rural and urban patients’ differed in their accounts of initial decision-making about primary care consulting. This could illuminate whether ideas about particular socio-cultural attitudes affecting rural consulting were valid or whether other locational factors influenced consulting. This is important to understand if possible inequities in service use are to be addressed.