A sample of 1700 individuals from one general practice in the south west of England, stratified by sex, was randomly selected from the practice list. The practice was selected as it contained a group of individuals from a wide range of socioeconomic backgrounds. The selection was made using census profiles of several practices, including the enumeration district value for three census indicators (Townsend, Jarmen, and Carstairs). The scores were calculated based on enumeration district values that define the geographical areas of the practice population. Using this information, it was possible to identify a practice with two branches — one that was situated in a relatively deprived area and the other in a relatively affluent location.
How this fits in
There is evidence for age inequality in access to cardiology services. A stereotype exists of the older stoical patient who has a reluctance to seek medical help. This study indicated a reported increasing willingness with increasing age to contact healthcare services. Inequity in access to cardiology services by age is not likely to be due to the patient's illness behaviour.
The patient list was reviewed by the GPs to exclude any person with terminal or serious psychiatric illness. From this sample, 1500 individuals were randomly selected to participate in the survey; however, correct address details were only available for a subset of 1287 individuals (based largely on information from post office returns). After two attempts to contact responders, following the initial mail shot, a total of 911 completed questionnaires was received (response rate 71%). Responders were slightly older than non-responders, and were more likely to be female.
The questionnaire contained a short vignette, describing a scenario that could be related to CHD, in which the protagonist (‘Chris’) experienced an episode of chest pain on exertion (Box 1
). The scenario was designed to be sex neutral, so that the clinical symptoms could reflect a range of possible diagnoses and actions that could be taken in response. Further details of the vignette are available elsewhere.13
Box 1. Vignette.
Chris is 55 years old and has generally good health, but is overweight and doesn't do much exercise. Chris's grandchildren have come to stay for the weekend. Later that evening one of the grandchildren has a headache. Chris starts carrying the child up the stairs to the bedroom. Suddenly, Chris feels a pain in the chest. The pain is so bad that Chris feels a bit sick and has to put the child down. After about 5 minutes, the pain wears off and Chris feels fine. Chris has had the pain once before, following a large meal.
Responders were asked to record how they would react if they themselves were experiencing the symptoms described in the vignette. They were able to specify whether they would call or attend the GP, and how likely they were to do so (selecting from definitely, probably, unlikely, or not at all). For the outcome, responders were dichotomised into stating they would definitely/probably access the GP, compared to unlikely or not at all.
Data were collected on date of birth, and a responder's age at the time of completing the questionnaire was calculated. A categorical variable was created that divided responders into 10-year age bands (under 40 years, 40–49 years, 50–59 years, 60–69 years, and 70 years and over).
A range of other variables were collected and have been included in the analysis, as in previous analysis they have been shown to be important predicting factors of reported healthcare seeking.13
These include a measure of socioeconomic position (socioeconomic index), which was derived from data on car ownership, education, housing tenure, household utilities, and consumer durables. These variables were dichotomised to a score of 0 (more affluent position) or 1 (less affluent position); the scores on each of these factors were added to produce five categories (0–4); however, due to low numbers, groups 3 and 4 were aggregated. A score of 0 reflects the most affluent group compared to group 3, the most deprived. Responders were also asked to rate the degree of anxiety they would experience relating to the symptoms described (dichotomised into very worried versus reasonably worried, slightly worried, and not worried at all); their self-diagnosis of the likely origin of the pain (dichotomised into pain originating from the heart compared to other sources); to select from a list of chronic illnesses (including heart conditions, diabetes, high blood pressure); and about their attitudes to doctors and to health.
Responses to the symptom vignette were compared across age groups, stratified by sex. Proportions reporting they would contact the GP for each age group were calculated, and differences in proportions tested using χ2. The impact of age on reported healthcare seeking was then explored using multivariable logistic regression. Odds ratios were calculated to compare the odds of reporting intended contact with the GP for each increasing age band compared to the reference category. Unadjusted and adjusted analyses (model including socioeconomic index, anxiety, and origins of pain) were performed, and possible interactions between sex and age were tested. All analysis was conducted on complete data using Stata (version 8).