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Table 1 Table of included studies

From: Influences of cancer symptom knowledge, beliefs and barriers on cancer symptom presentation in relation to socioeconomic deprivation: a systematic review

Study Method Sample Country Tumour site Socio-economic measure Measures: Knowledge (K), Beliefs (B), Perceived barriers (PB), Perceived facilitators (PF), Symptomatic Presentation (SP) Measure of association between variables of interest and socioeconomic indicator (qualitative studies not applicable) Quality appraisal
Brain et al. (2014) [28] Hypothetical Quantitative 1043 women. Aged 50 years and over Wales Ovarian Postcode, education K: Recognition (mean, 6.85 symptoms)
B: Cancer worry
PB: Emotional and practical barriers
SP: Sought medical help in under 3 weeks (n = 898)
K: Lower education associated with lower knowledge (F(2, 1005) = 8.23, p < 0.001); higher deprivation (postcode) associated with lower knowledge (F3,886 = 2.82, p < 0.05)
B: NR
PB: NR
SP: Higher education associated with longer time to SP, (OR = 2.64, p ≤ 0.001); NS difference between deprivation by postcode and anticipated delay (X2(3) = 6.73, p > 0.05) NS
Good
Brouha et al. (2005) [76] Retrospective Quantitative 189 men and women. Mean age: 59 years Holland Oral and Pharyngeal Education, income K: Symptom interpretation (‘cancer’, n = 2), misattribution of symptoms to dental problems delayed SP
PB: Symptom did not interfere with daily life
PF: Persistence of symptom, development of new symptom
SP: Mean time to symptom presentation (pharyngeal, 45 days; oral, 28 days)
K: NR
PB: NR
PF: NR
SP: Education and income not associated with time to SP (statistics NR)
Medium
Burgess et al. (1998) [45] Retrospective Qualitative 185 women. Mean age: 54 years UK Breast Occupation K: Symptom interpretation (46 % thought their symptom indicated cancer)
B: Fear
PF: Symptom disclosure, appearance of new symptoms, appointment booked with GP for another reason
SP: Waited over 3 months to seek medical help (19 %)
  Medium
Burgess et al. (2000) [67] Retrospective Qualitative 158 women. Mean age: 53 years UK Breast Occupation PB: Life events
SP: Waited over 3 months to seek medical help (18 %)
  Medium
Burgess et al. (2001) [43] Retrospective Qualitative 46 women. Mean age: 54.1 years UK Breast Occupation K: Symptom interpretation (‘lump’ most attributed to cancer)
B: Consequences of treatment
PB: Not wanting to bother the doctor, poor health service utilisation, competing life priorities
PF: Symptom disclosure, change in symptom
SP: Waited over 3 months to seek medical help (n = 31)
  Medium
Cameron and Hinton (1968) [58] Retrospective Quantitative 83 women UK Breast Education, husband’s occupation K: Symptom interpretation
B: Fear, worry
SP: 61 % sought medical help within 1 month
K: NR
B: NR
SP: Higher education associated with shortest time to SP for lump symptoms (x2 = 6.6, p < 0.05); Higher social group (husband’s occupation) associated with shortest time to SP (x2 = 3.02, p < 0.01)
Poor
Caplan (1995) [44] Retrospective Quantitative 162 women US Breast Income, education, employment PB: Fluctuating symptoms, relationship with GP
SP: Waited over 2 months to seek medical help (n = 27)
PB: NR
SP: Lower socioeconomic group (various indices) associated with longer time to SP, but NS: High vs low income (OR 2.56, 95 % CI: 0.68-8.64*); High vs low education (OR 1.07, 95 % CI: 0.41-2.77*); Working vs non-working (OR 0.72, 95 % CI: 0.27-1.99*)
Poor
Carter-Harris et al. (2015) [69] Retrospective Qualitative 11 men (n = 4) and women (n = 7). Age range: 40-76 years US Lung Education, employment K: Symptom interpretations (one participant was alarmed at symptoms)
PB: Vague and intermittent nature of symptoms
PF: Worsening of symptoms, good relationship with GP
SP: Immediate (n = 1)
  Medium
Chonjnacka-Szawlowska et al. (2013) [36] Retrospective
Quantitative
301 men (n = 186) and women (n = 115). Mean age: 42.3 years Poland All Education K: Recall, mean: 1.51
B: Fatalism and cancer curability
SP: Mean time to symptom presentation: 6 months and 10 days; stage of cancer
K: NR
B: NR
SP: NS correlation between education and stage of cancer (statistics NR)
Medium
Coates et al. (1992) [42] Retrospective Quantitative 735 women (410 black and 325 white). Age range: 20 to 79 US Breast Education, occupation, poverty index (income/no of people in household) K: Symptom interpretation
B: Fatalism
PB: Symptom disclosure, other comorbid conditions, appointment with doctor booked for another reason
SP: Median time to symptom presentation (black women, 16 days; white women, 14 days)
K: NR
B: NR
PB: NR
SP: Higher education associated with shorter time to SP (Mantel-cox 1.43, 95 % CI: 1.11-1.86, p < 0.05); Low deprivation (poverty index) associated with shorter time to SP (Mantel-Cox 1.24, 95 % CI: 1-1.54, p < 0.05)
Good
Cockburn et al. (2003) [54] Retrospective Quantitative 1332 men (40 %) and women (60 %). Aged 40 years and over Australia Colorectal (Bowel) Education K: Recall (25 % could not recall any symptoms), symptom interpretation
B: Benefits of early diagnosis
SP: 306 had experienced a symptom, 31.9 % did not seek medical help
K: Higher education associated with higher K of symptoms (PR 0.93, 95 % CI: 0.89-0.96*)
B: Higher education more likely to hold positive beliefs about the benefits of early diagnosis (statistics NR)
SP: NR
Medium
Esteva et al. (2013) [70] Retrospective Quantitative 795 men (n = 489) and women (n = 291) Spain Colorectal Social class, education K: Symptom interpretation (‘not serious’, 65.6 %)
PF: Symptom disclosure, good relationship with GP (trust)
SP: Median time to symptom presentation (19 days)
K: NR
SP: NS association between social class and time to SP (statistics NR), NS association between education and time to SP (statistics NR)
Medium
Facione and Facione (2006) [59] Retrospective Qualitative 28 women. Mean age: 42.34 years US Breast Income, education, health insurance K: Symptom interpretation
B: Fear, fatalism, benefits of early diagnosis
PB: Worry about losing relationship with partner if diagnosed with cancer
PF: Symptom disclosure
SP: Sought medical help after 3 months (n = 15)
  Medium
Facione et al. (2002) [56] Hypothetical Quantitative 669 women. Mean age: 46.95 years US Breast Income, education, health care insurance K: Recognition (10 % recognised all or all but one symptoms)
B: Fatalism
PB: Difficulties with access, prejudice in health care, concerns about deportation, use of alternative therapies
SP: Likely to delay (23.7 %).
K: Higher education associated with higher symptom recognition (F3,690 = 32.32, p < 0.001)
B: NR
PB: NR
SP: Lack of insurance associated with longer time to SP (Cramer’s V = 0.187, p < 0.001); Lower education associated with longer time to SP (Cramer’s V = 0.288, p < 0.001); Lower income associated with longer time to SP (Cramer’s V = 0.291, p < 0.001)
Good
Facione et al. (1997) [84] Hypothetical Quantitative 352 African American or Black women. Mean age: 38.6 years US Breast Income, Education, Employment B: Fear, fatalism
PB: Poor health service utilization
SP: 11.6 % = strong disposition to SP.
B: NR
PB: NR
SP: Stronger disposition to SP associated with lower education (r = 0.19, p < 0.01) and lower income (r = 0.32, p < 0.001)
Medium
Facione and Dodd (1995) [83] Retrospective Qualitative 39 women. Mean age: 49.6 years US Breast Income, education K: Symptom interpretation
B: Fear
PB: Competing life priorities
PF: Appearance of new symptom, worsening of symptoms, symptom disclosure
SP: 59 % sought medical help within 1 week
  Medium
Fitzpatrick et al. (1998) [57] Hypothetical Quantitative 280 men. Mean age: 53.7 years Ireland Prostate Health insurance, occupation B: Fear
PB: Poor health service utilisation, dislike of doctors, embarrassment
SP: 81 % would seek medical help if developed urinary symptoms
B: NR
PB: NR
SP: Non-manual social class associated with higher willingness to attend GP with symptoms (OR 1.8, p < 0.05**)
Good
Forbes et al. (2011) [29] Hypothetical Quantitative 1515 women from various ethnic groups (White, South Asian, Black). Aged 30 years and over UK Breast Postcode (IMD) K: Recognition (18 % recognised 5 or more non-lump symptoms)
PB: self-efficacy, worry what the doctor might find, embarrassment, worry about wasting doctors time, difficulty getting an appointment
SP: 73 % would seek help within 1 week
K: Differences between ethnic groups for cancer awareness not due to IMD score or lower level of education (statistics NR)
PB: Differences between ethnic groups for PB not due to IMD score (statistics NR)
SP: NR
Good
Forbes et al. (2014) [64] Retrospective Quantitative 1999 men (n = 1077) and women (n = 922). Aged 50 or over UK All Postcode K: Symptom interpretation
PB: 48 % of patients reported at least one barrier
SP: Delay over 3 months (n = 21 %)
B: NR
PB: NR
SP: Lowest socioeconomic group associated with longest time to SP (1.51, 95 % CI: 1.18-1.88*)
Good
Freidman et al. (2006) [38] Retrospective Quantitative 124 women. Mean age: 44.3 years US Breast Employment, education B: Fear
PB: Worry what the symptom might be, difficulty getting an appointment, cost, denial
SP: Mean time to symptom presentation (9 months)
B: NR
PB: NR
SP: Lower education associated with longest time to SP (Fishers Exact test, p < 0.01**)
Medium
Goldsen et al. (1957) [61] Retrospective Quantitative 727 men and women US All Income, education and occupation K: Symptom interpretation (20 % thought symptoms indicated cancer)
B: Cancer worry, fatalism
PB: Poor health service utilization, symptom not noticed
PF: Symptom disclosure
SP: 51.3 % sought medical help under 30 days
K: NR
B: NR
PB: NR
PF: NR
SP: Lower income, education and occupation associated with longest time to SP (statistics NR)
Medium
Gould et al. (2010) [39] Retrospective Qualitative 14 women. Aged range: 30 to 69 years Canada Breast Education, employment, income K: Symptom interpretation (poor for non-lump symptoms)
B: Fear
PB: Previous benign disease, watchful waiting, competing life priorities
PF: Symptom disclosure, already have another appointment booked.
SP: All women waited 8+ weeks
  Medium
Grant et al. (2010) [82] Retrospective Qualitative 15 men (n = 7) and women (n = 8). Aged 45 years and under Scotland Oral Postcode K: Symptom interpretation
PB: Self-medication
PF: Already had an appointment booked
SP: Sought medical help within 8 weeks (n = 8)
  Medium
Greer (1974) [68] Retrospective Quantitative 160 women with stage I or stage II cancer. Aged 70 years and under UK Breast Social Class K: Symptom interpretation
B: Fear, fatalism
PB: Embarrassment
SP: 64 % sought medical help within 1 month
K: NR
B: NR
PB: NR
SP: NS difference between time to SP and social class (statistics NR)
Poor
Hunter et al. (2003) [30] Hypothetical Quantitative 546 women. Mean age: 47 years UK Breast Occupation K: Recognition (good, mean 6.65)
B: Beliefs about treatment
SP: 58.6 % would seek immediate medical help.
K: NR
NR: NR
SP: Socioeconomic group not associated with time to SP (F(1,518) = 0.29, p > 0.05)
Medium
Kakagia et al. (2013) [34] Retrospective Quantitative 513 men (n = 56.5 %) and women (n = 43.5 %). Mean age: 67.5 years Greece Skin Education, ethnicity, area of residence K: Symptom interpretation
B: Fear, fatalism
PB: Other serious comorbidities, poor health service utilisation, dislike of doctors and hospitals, transport issues, worry about wasting doctors time, embarrassment, competing life demands
PF: Symptom disclosure, active encouragement to seek medical help
SP: Mean time to symptom presentation (3.9 months)
K: NR
B: NR
PB: NR
PF: NR
SP: Longer time to SP associated with lower socioeconomic group (OR 1.89, 95 % CI: 0.9-3.8. p < 0.001) and lower education (OR 3.01, 95 % CI: 1.6-5.6, p < 0.001)
Medium
Lam et al. (2009) [63] Retrospective Qualitative 37 women. Age range 20-81 years Hong Kong Breast Employment, education K: Symptom interpretation
B: fear, fatalism
PB: Watchful waiting, poor general health service utilisation, cost, competing life priorities, embarrassment
PF: Persistence of symptoms, appearance of new symptom, symptom disclosure, symptom interfering with daily life, appointment booked for another reason
SP: Waited over 3 months to seek medical help (n = 14)
  Medium
Li et al. (2012) [65] Retrospective Quantitative 425 women. Mean age: 51.97 years Hong Kong Breast Employment, education B: Fear
PB: Cost, gender of doctor, unsure where to seek medical help, competing life priorities, no history of breast problems, symptom disclosure
PF: Symptom disclosure
SP: Median time to symptom presentation (14 days)
B: NR
PB: Symptom disclosure for women with lower education less likely to translate into immediate SP (x2 = 6.4, d.f. = 2, p < 0.05)
PF: NR
SP: Longer time to SP associated with higher education (OR 3.35, 95 % CI:1.19-9.42, p < 0.05) and full time employment (OR 2.52, 95 % CI: 1.18-5.36, p < 0.05)
Good
Loehrer et al. (1991) [71] Retrospective Qualitative 128 men (n = 33) and women (n = 95). Mean age: 63 years US All Employment, income, education B: Curability of cancer, cancer is contagious, surgery causes cancer to spread
SP: Poor for non-specific symptoms
  Medium
Low et al. (2013) [31] Hypothetical Quantitative 1000 women. Mean age: 47 years UK Ovarian Education, car ownership, home ownership K: Recall (poor, mean 0.6) and recognition (good, mean 6.3)
PB: Mean number of barriers endorsed (2.2), emotional, practical and service barriers
SP: Varied by symptom, most would seek help under 2 weeks
K: NR
PB: NR
SP: Higher socioeconomic group associated with longer time to SP (beta = 0.12, SE 0.05, p < 0.001**)
Good
Magarey et al. (1977) [72] Retrospective Quantitative 64 women. Age in years: less than 40 (n = 13), 40-60 (n = 28), over 60 (n = 23). Australia Breast Education PB: Denial, anxiety
SP: Most sought medical help within 2 weeks (n = 35)
PB: NR
SP: Education not associated with time to SP (statistics NR)
Poor
Marlow et al. (2014) [78] Hypothetical Qualitative 54 women from ethnic minority groups living with a comparison of white women. Age range: 25-64 years UK Breast and Ovarian Employment, education, living arrangement K: Recall (good for lumps/ bleeding, poor for other symptoms)
B: Fear, fatalism, benefits of early diagnosis
PB: Poor relationship with GP, emotional barriers, practical barriers, service barriers, competing life priorities
PF: Symptom disclosure
SP: Varied: days to months. All sought help within 3 months.
  Medium
McCaffery et al. (2003) [50] Hypothetical Quantitative 1637 men (n = 763) and women (n = 874). Age range: 16-74 years UK Colorectal Education K: Recall (poor)
B: Fear
SP: 92.8 % would anticipate seeking medical help if noticed blood in stool for more than 2 weeks.
K: Higher education associated with higher symptom recall (x2 [4] = 73.98, p < 0.001)
B: Lower education associated with most negative beliefs (x2 [4] = 74.96, p < 0.001)
SP: NS association with education and SP intentions (statistics NR)
Good
Meechan et al. (2003) [46] Retrospective Mixed 85 women. Mean age: 38.9 years New Zealand Breast Education PB: Having a family member with cancer, low emotional response to symptom
PF: High emotional response to symptom
SP: Median time to symptom presentation (14 days)
PB: NR
PF: NR
SP: NS association between education and time to SP (t (83) = -1.26, p > 0.05)
Medium
Mor (1990) [74] Retrospective
Mixed
700 patients. Age range: 45 to 90 years US Lung, Breast and Colorectal Education, housing, income, education K: Symptom interpretation (best knowledge for breast cancer patients)
B: Fear (16.8 % of delayers)
PB: ‘’thought it would go away” (60.5 % of delayers), too busy (8.4 % of delayers)
SP: Waited over 3 months to seek medical help: lung (54.9 %), breast (56.2 %), colorectal (87.6 %)
K: NR
B: NR
PB: NR
SP: NS relationship between socioeconomic group and time to SP (statistics NR)
Medium
Oliveria et al. (1999) [37] Retrospective Quantitative 255 men and women. Aged 18 years and over US Melanoma Education, insurance K: Recognition (poor)
SP: Mean time to symptom presentation (2 months)
K: NR
SP: Education not associated with time to SP (statistics NR)
Medium
O’Mahony and Hegarty (2009) [47] Retrospective Quantitative 99 women. Mean age: 40 years Ireland Breast Employment, education K: Symptom interpretation
PB: Competing life priorities, emotional reactions to symptom (afraid, scared, unsure)
PF: Symptom disclosure, anxiety
SP: Waited over 1 month to seek medical help (n = 26)
K: NR
PB: NR
PF: NR
SP: Higher education associated with longer time to SP (statistics NR)
Medium
O’Mahony et al. (2011) [79] Retrospective Qualitative 10 women. Mean age: 40 years Ireland Breast Education, employment, insurance K: Most aware that a lump was a symptomof cancer
B: Fatalism, curability of cancer, fear
PB: Denial, competing life priorities
PF: Symptom disclosure, good perceived access to GP, good relationship with GP
SP: Sought medical help within 1 month (n = 6)
  Medium
Pedersen et al. (2011) [85] Retrospective Quantitative 901 men (n = 423) and women (n = 487). Mean age: 61.8 years Denmark All Education PF: Symptom disclosure, good partner support
SP: Median interval: 12 days
PF: NR
SP: NS association between education and time to SP: Lower secondary education and long SP (>55 days) (RRR 0.79, 95 % CI: 0.36-1.74, p > 0.05); tertiary education and long SP (>55 days) (RRR 1.30, 95 % CI: 0.55-3.08, p > 0.05)
Medium
Quaife et al. (2014) [32] Hypothetical Quantitative 6965 men (n = 4330) and women (n = 265). Aged 50 and over UK All Education K: Recognition (best for ‘lump’)
PB: Poor access health services
SP: Would wait 2+ weeks: (cough, n = 48.1 %; breast change, n = 8.2 %; rectal bleeding, n = 7.4 %)
K: Lower education associated with lower recognition for all 3 symptoms (x2, p < 0.05**)
PB: NR
SP: Lower education associated with shorter time to SP for cough (OR 0.61, 95 % CI: 0.54-0.68, p < 0.001) and breast changes (OR 0.68, 95 % CI: 0.52-0.89, p < 0.001). NS association with education and time to SP for rectal bleeding (OR 0.83, 95 % CI: 0.67-1.03, p > 0.05)
Good
Rauscher et al. (2010) [66] Retrospective Quantitative 438 women. Age range: 30 to 79 years US Breast Education, household income, health insurance status K: Breast lump misconceptions (20 % reported one or more misconception)
PB: Poor general health service utilisation
SP: Waited over 3 months to seek medical help (16 %)
K: Lower income and education associated with more breast lump misconceptions (x2, p < 0.001**)
PB: NR
SP: Longer time to SP associated with lower education (x2, p < 0.05**) and lower income (x2, p < 0.05**)
Medium
Richard et al. (2000) [77] Retrospective Quantitative 590 men (n = 250) and women (n = 340). Mean age: 51.2 years France Melanoma Residence, social level, education K: Symptom interpretation (‘not serious’, 34.8 %)
B: Fear
PB: No symptoms, competing life priorities (work and family commitments), melanoma not detected by participant
PF: Active encouragement from family
SP: Sought medical help within 2 months (51.9 %)
K: NS
B: NS
PB: Those with higher education more likely to self-detect melanoma (x2, p < 0.01**)
PF: NR
SP: NS association with and time to SP and socioeconomic group (statistics NR)
Medium
Rozniatowski et al. (2005) [73] Retrospective Quantitative 100 men (n = 84) and women (n = 16). Mean age: 57 years France Head and Neck Education, occupation PB: Low anxiety, poor general health service utilisation
PF: Symptom disclosure, active encouragement from partner to seek help
SP: The majority of patients waited over 1 week to seek medical help
K: NR
PB: NR
SP: NS association between socioeconomic group and time to SP (statistics NR)
Medium
Ristvedt et al. (2014) [33] Retrospective Quantitative 112 men (n = 55) and women (n = 57). Mean age: 59.3 years US Colorectal Income, area of residence, education, health insurance K: Symptom interpretation (70.5 % thought symptom serious within 13 weeks post onset)
SP: Median time to symptom presentation (10 weeks)
K: NR
SP: NS association between socioeconomic group (education and household income) and time to SP (statistics NR)
Medium
Ristvedt and Trinkhaus (2005) [9] Retrospective Quantitative 69 men (n = 42) and women (n = 27). Mean age: 61.3 years US Colorectal Education K: Symptom interpretation (‘not cancer’, 71 %)
PB: Personality (low trait anxiety), poor health service utilisation
SP: Mean time to symptom presentation (25 weeks)
K: NR
PB: NR
SP: Lower education associated with longer time to SP (Kaplan-Meier: median 15 weeks, 95 % CI: 9.0-26.0*); higher education associated with shorter time to SP (Kaplan-Meier: median 8 weeks, 95 % CI: 4.0-15.0*)
Medium
Robb et al. (2009) [19] Hypothetical Quantitative 2216 men (n = 968) and women (n = 1240) UK All Education, occupation K: Recall (poor, mean = 2.2) and recognition (good, mean = 7.2)
PB: Emotional and service barriers most endorsed
SP: Most would seek medical help within 2 weeks
K: Higher socioeconomic group (occupation) associated with highest knowledge (F (2,2015) = 20.31, p < 0.001)
PB: Lower socioeconomic group (occupation) associated with more emotional barriers endorsed: ‘worry what the doctor might find’ (x2 (1,1989) = 17.08, p < 0.001), ‘too embarrassed’ (x2 (1,1993) = 20.74, p < 0.001), ‘not confident to talk about symptom’ (x2 (1,1992) = 4.77, p < 0.05), NS association with ‘too scared’ (x2 (1,1977) = 1.82, p > 0.05); Higher socioeconomic group (occupation) associated with more practical barriers endorsed: ‘too busy’ (x2 (1,2005) = 59.0, p < 0.001), ‘other things to worry about’ (x2(1,1996) = 15.34, p < 0.001), ‘difficult to arrange transport’ (x2(1,2010) = 11.13, p < 0.001); NS association between socioeconomic group (occupation) and service barriers: ‘difficult to make appointment’ (x2 (1,1983) = 0.41, p > 0.05), ‘worried about wasting the doctors time’ (x2 (1,1995) = 1.44, p > 0.05), ‘difficult to arrange transport’ (x2 (1,1938) = 1.15, p > 0.05)
SP: Lower socioeconomic group (occupation) associated with shorter time to SP for unexplained bleeding (x2 (1,1991) = 5.82, p < 0.01), difficulty swallowing (x2 (1,1987) = 28.41, p < 0.001), lump (x2(1,1988) = 21.26, p < 0.001), change in mole (x2 (1,1967) = 24.24, p < 0.001), unexplained pain (x2(1,1965) = 20.24, p < 0.001), sore that does not heal (x2 (1,1977) = 35.84, p < 0.001), change in bowel/bladder habits (x2 (1,1982) = 56.87, p < 0.001), cough (x2 (1,1984) = 48.32, p < 0.001), unexplained weight loss (x2 (1,1963) = 77.73, p < 0.001)
Good
Samet et al. (1988) [62] Retrospective Quantitative 800 men (n = 396) and women (n = 404). Mean age: 72.2 years US All Education, income PB: Poor general health service utilisation, poor access
SP: Most sought medical help within 2 months
PB: NR
SP: Longer time to SP associated with lower income for breast and colorectal cancer (x2, p < 0.05**) and lower education for all tumour sites (x2, p < 0.05**)
Medium
Schmid-Wendter (2002) [40] Retrospective Quantitative 233 men (n = 109) and women (n = 109). Mean age: 54.5 years Germany Melanoma Education K: Previous knowledge of melanoma, symptom interpretation
B: Fear
PB: Lesion not visible, too busy
SP: Sought medical help within 1 month (15.5 %)
K: Higher education more likely to have knowledge about melanoma (x2, p < 0.001**)
B: NR
PB: NR
SP: NR
Medium
Siminoff et al. (2014) [35] Retrospective Mixed methods 252 men (n = 132) and women (n = 120). Mean age: 58 years (range 25 to 94 years) US Colorectal Education, Employment, Income K: Symptom interpretation (39.7 % did not think symptom was serious)
PB: Financial barriers (28.6 %), fear of diagnostic tests (24.3 %), embarrassment (11.9 %)
SP: Mean appraisal delay (4.8 months)
K: NR
PB: NR
SP: NS association between time to SP and socioeconomic group (statistics NR)
Medium
Simon et al. (2010) [49] Retrospective Quantitative 236 men (n = 968) and women (n = 1240). 11.4 % (n = 236) had experienced a symptom in the past 3 months UK All Occupation K: Recognition (better knowledge if experienced a symptom previously); symptom interpretation (worry symptom might be cancer)
PB: Emotional and practical barriers
SP: Symptom experience: 11.4 % experienced symptom in past 3 months (75 % consulted a GP about symptom)
K: NS association between symptom interpretation and socioeconomic group (statistics NR)
PB: NR
SP: NS association between SP and socioeconomic group (statistics NR)
Good
Smith and Anderson (1985) [51] Retrospective Quantitative 82 women. Age range: 20 to 54 years US Ovarian Income, education, occupation K: Symptom interpretation (‘cancer’, 10 %)
B: Fear
PB: Previous benign diagnosis
SP: Median time to symptom presentation (4 weeks)
K: NS association between symptom interpretation and socioeconomic group (statistics NR)
B: NR
PB: NR
SP: NR
Medium
Temoshok et al. (1983) [75] Retrospective Quantitative 106 men and women. Age range: 18 to 72 years. US Melanoma Education, occupation K: Previous knowledge of melanoma
B: Melanoma not a serious disease
PF: Lesion visible (face and neck)
SP: Mean time to symptom presentation (4 months)
K: No association with knowledge and occupation (statistics NR)
B: NR
PF: NR
SP: No association with time to SP and occupation (statistics NR)
Poor
Tod et al. (2008) [80] Retrospective Qualitative 20 men (n = 12) and women (n = 8). UK Lung Occupation K: Symptom interpretation (poor, symptoms usually interpreted as acute conditions)
B: Fear, fatalism
PB: If previously given up smoking (thought risk of lung cancer was nil), worry about the wasting doctors time, previous bad experiences with health system, blame, stigma, stoicism, poor health service utilisation
PF: Active encouragement from family member
SP: Range in time to symptom presentation (0 to 24 months)
  Good
Tomlinson et al. (2012) [60] Retrospective Quantitative 87 men (n = 56) and women (n = 31). Mean age: 65 years. Canada Colorectal Education K: Symptom interpretation
PB: Self medication
SP: Waited over 1 month to seek medical help (51 %)
K: NR
PB: NR
SP: NS association between education and time to SP (x2, p > 0.05**)
Medium
Trivers et al. (2011) [52] Hypothetical Quantitative 2991 women. 65 % were aged 45 years and over. US Gynaeco-logical Education, Income B: Concern about developing gynaecological cancer
PB: Being premenopausal
SP: 50 % of women would seek help for most symptoms
B: NR
PB: NR
SP: NS association between SP intentions and socioeconomic group (statistics NR)
Medium
Van Osch et al. (2007) [48] Hypothetical Quantitative 459 men (49 %) and women (51 %) over the age of 55. Mean age: 68.6 years. Netherlands All Education K: Recognition (low to moderate, mean: 6.2)
B: Benefits of early detection
SP: Fair. Inconsistent for urgent symptoms, good for prolonged symptoms
K: NR
B: NR
SP: Lower education associated with shorter time to SP (F (2,436) =6.084, p < 0.01)
Good
Waller et al. (2009) [53] Hypothetical Quantitative 1500 men and women from various ethnic minority groups. England All Occupation K: Recall (poor, mean: 1.2) and recognition (poor, mean: 4.7)
PB: Worry what doctor might find (most endorsed)
SP: African and Caribbean groups anticipated fastest time to symptom presentation
K: Higher socioeconomic group associated with higher recall (F(1,1487) = 6.12, p < 0.01) and higher recognition (F (1,1487) = 5.45, p < 0.05)
PB: NR
SP: NR
Good
Walter et al. (2014) [41] Retrospective
Qualitative
63 men (n = 31) and women (n = 32). Age range: 29-93 years. UK Melanoma Education K: Symptom attributions (initially attributed to benign skin conditions or normal life changes)
PB: Worry about wasting the doctors time, service barriers, competing life priorities, reassurance following symptom disclosure
PF: Family history of melanoma, perceptions of high risk, symptom disclosure, symptom noticed by another person
SP: Range 1-303 weeks
  Good
Whitaker et al. (2014) [55] Retrospective Quantitative 1724 men (n = 789) and women (n = 921) over the age of 50. Mean age: 64.4 years. England All Postcode, education, employment K: Symptom interpretations (2 % thought symptom was cancer, highest interpretation for ‘unexplained lump’), perceived seriousness of symptoms
SP: Symptom experience (53 % experienced at least 1 symptom in past 3 months). 59 % contacted GP about symptom
K: Unemployment associated with higher perceived seriousness of pain (OR 2.26, 95 % CI: 1.17-4.35, p < 0.05), tiredness (OR 2.11, 95 % CI:1.23-3.64, p < 0.05), sore throat (OR 3.56, 95 % CI: 1.10-11.45, p < 0.05) and chest pain (OR 3.56, 95 % CI: 1.10-11.45, p < 0.05). Lower education associated with higher perceived seriousness cough (OR 2.25, 95 % CI: 1.10-4.56, p < 0.05), tiredness (OR 2.46, 95 % CI:1.44-4.21, p < 0.05), headaches (OR 3.80, 95 % CI: 1.63-8.89, p < 0.05), shortness of breath (OR 2.34, 95 % CI: 1.11-4.97, p < 0.05), sore throat (OR 4.16, 95 % CI: 1.14-15.22, p < 0.05) and chest pain (OR 4.16, 95 % CI: 1.13-15.22, p < 0.05)
SP: NR
Good
Whitaker et al. (2015) [81] Retrospective Qualitative 48 men (n = 23) and women (n = 25) over the age of 50. Mean age: 64.4 years. England All Education, employment K: Symptom interpretations (symptoms normalised or associated with cancer)
PB: Stoicism, fear of diagnostic tests, worry about wasting doctors time, service barriers, negative attitudes towards HCPs, medical mistrust
PF: Development of new symptoms, persistence of symptoms, symptom disclosure, fear
SP: Varied per symptom: 33.3 % contacted GP with ‘persistent cough’, 100 % contacted GP with ‘unexplained bleeding’
  Good
  1. K = cancer symptom knowledge; B = beliefs about cancer; PB = perceived barriers to symptom presentation; PF = perceived facilitators to symptom presentation; SP = time to symptom presentation; NR = not reported; NS = not significant; *p-value not reported; **other statistics not reported