Thirty-three women were approached to take part in the interview study. Twenty-seven agreed and 21 (aged 21–64 years [median age 40 years]) were interviewed before data saturation was reached (one tape failure meant that 20 interviews were analysed). Reasons for refusal included being too busy or unavailable for interview.
The characteristics of participating women in this study were similar to the trial cohort: married 65% versus 73% respectively; past cystitis: 88% versus 85%; number of concurrent medical problems: 3.0 versus 2.6; age leaving education: 17.6 versus 17.6 years; and severity of urinary frequency symptoms at baseline mean: 3.5 versus 3.5. Seven women were in the symptoms score group, nine in the empirical delayed group, and two each in symptoms score and MSU groups. Women were selected for interview who had been asked to delay taking antibiotics, in order to obtain their views on the delay strategy. This would not apply to women in the immediate empiric antibiotic group.
The interviews took place in the context of a trial of GP management, and consequently excluded women who did not consult their GP. The non-consulters may have included women whose self-care was effective, some whose symptoms were not severe or prolonged, and possibly some women who wished to avoid antibiotics. By the time of the interviews, most of the participants were no longer experiencing symptoms and reported being free of infection.
Patient experiences of UTI and the journey to the GP
In their interviews women recounted their experiences from symptom onset and their attempts to self-manage, through to their final decision to attend a GP. The duration and type of symptoms experienced prior to consulting are summarised in and .
Summary of volunteered problems and complaints
Duration of symptom/sign prior to GP visit.
Interviewees reported a process of evaluation whereby they appraised their symptoms and decided upon a diagnosis, which enabled them to target self-care. The initiation of self-care was followed by a period of monitoring which led most to conclude that self-care had in fact failed to work fully or in a timely fashion (this was true for all but two women who had decided from the outset that they required antibiotic medication). Failed self-care led women to re-evaluate their needs and consider whether their symptoms had begun to interfere with work and leisure activities, and for many this also included evaluating their fears that their experience may indicate something more serious than a UTI. It was at this juncture that women reported having to meet their re-evaluated needs by seeking GP help. This paper focuses on four common triggers to this process.
Triggers for seeking GP care
Failure to alleviate symptoms through lay remedies
Failure to alleviate their symptoms through self-care was by far the commonest cited rationale for consulting (interviews 2, 7–12, 16, and 18):
‘I tried self-medication which didn't work …’ (interview 10: 5–6)
‘… Prior to [the GP visit] I had taken, done the usual thing, drink plenty of fluid, that didn't work, so I'd been into the chemist and bought one of the over-the-counter remedies. That didn't work, so that's when I went to the doctor in the end …’ (interview 16: 8–11)
It is worth noting that when describing their pathways to the doctor, interviewees went to considerable (narrative) lengths to portray themselves as responsible consumers of health services. For example, in the following exemplary extract, the interviewee's language works to portray her as having acted reasonably when faced with illness:
‘… I just drank lots and lots of fluids and … cranberry juice … but it wasn't making any difference at all … so I went to the doctor …’
‘I think I must have gone through … there was at least 3 days where all I drank was cranberry juice and it made no difference … never been [to doctors for a UTI] before but I just thought at this point enough is enough.’ (interview 14: 53–65; author's emphasis)
Sometimes the corollary of a ‘failed’ attempt to self-care was the simple ‘dragging on’ or eventual escalation of symptoms.
Symptom type, duration, or escalation
Some described how their decision to seek medical help resulted from this episode being qualitatively different from previous experiences or that their bodies were ‘not right’:
‘… I think I said to the doctor at the time y'know it wasn't horrendous it was just niggling and I just knew it wasn't right’ (interview 2: 88–90)
‘This time was different.’ (interview 12: 8)
‘I woke up with really bad stabbing pains in my back, um, and it just felt different … so I went to the doctor. It didn't feel the same …’ (interview 8: 18–19)
Relative to previous episodes, the index episodes were sometimes experienced as out of the ordinary or ‘not normal’ in terms of duration:
‘I've had it a couple of times before and it's gone within a couple of days, but this was just dragging on …’ (interview 12: 32–36)
‘Normally if it's going to shift, it'll shift quite quickly, you know, you get some sort of feeling that it's going to be moving on and you're going to be OK. But this time I didn't so I thought, you know, I'm going to the doctor …’ (interview 10: 9–12)
And, sometimes in terms of severity:
‘I've had them before but never as bad as [this one] …’ (interview 14: 35)
Most participants explicitly noted the escalation of symptoms as a key trigger to consult:
‘It started mild, then got worse so that's why I went to the doctor.’ (interview 18: 14)
Some mentioned their concern that worsening symptoms may indicate something more serious necessitating medical attention. In such circumstances, interviewees' reports oriented to help seeking as the most reasonable course of action:
‘It wasn't getting better it was getting steadily worse and I thought “well I want to nip this”, because you never know really, I had a pain in my back as well … and I wasn't sure if it was y'know kidneys … so I thought I better go then.’ (interview 5: 141–148)
While there was a sense that participants sought medical help when they just could no longer tolerate pain, the situation was more complex than a ‘single question of pain’.9
Impeding normal functioning and the fulfilment of social roles
As described in Zola's work on pathways to the doctor,9
it was clear that participants did not appeal to symptoms alone, but the perceived implications of the symptoms were also a driver for help seeking. One such implication was a ‘perceived interference with vocational or physical activity’. Some of the participants referred to their child care duties:
‘… I started drinking cranberry juice, and I drink a lot of water at work anyway, but it just didn't get any better, and having children I didn't want to feel any more poorly than I was feeling … so I decided to go to the doctor …’ (interview 9: 14–19)
Most, however, appealed to a reason that is ‘straight out of the protestant ethic’ or to a duty to stay well in order to fulfil their roles in the community.9
Indeed, participants commonly invoked a classic Parsonian argument for help seeking,10
that is, they not only sought a speedy recovery, but they did so in order to enable the fulfilment of their social roles:
‘… it was making it difficult to work, um, and I was teaching classes as well.’ (interview 8: 19–20)
‘I was in pain quite a lot and I couldn't just get on with my normal day-to-day things … I went to work but it was very difficult. So I went to the doctor's …’ (interview 12: 11)
Pain combined with interruption to everyday life provided a powerful rationale for help seeking:
‘It just got worse and worse and it got to the stage where I couldn't go to work and I was just in agony.’ (interview 11: 28)
Work responsibilities and failure to fulfil them was the dominant precursor to help seeking, with only one interviewee reporting that the frequent need to void hampered her leisure activities as well as her work (interview 14: 202–211).
Participants also described the impact of their symptoms on life in general:
‘I was just to the point, you know, it, it stops life doesn't it … it stops normal living and that's when I went.’ (interview 17: 6–10)
‘Debilitating’ symptoms were described as eventually leading to a break point where ‘enough was enough’, and the trigger for help seeking was activated:
‘… it sort of became more and more debilitating and it was realising how debilitating it could be … the effects of having it became … quite big … it was affecting how I was feeling generally, like emotionally and physically.’ (interview 14: 203–207)
Concern that it might be a serious illness or become serious
An additional trigger to help seeking was concern that the implications of their experience might be more significant than their best initial hunch or lay diagnoses might suggest. ‘Passing blood
’ (interview 11) was one of the commonest cited causes for concern:
‘… actually I did have blood in my urine, which made me go to the doctor's 'cause I … Yeah, I got a bit worried about that, certainly 'cause of my age …’ (interview 19: 143–144; aged 43 years)
‘There was a lot of blood in my water and, um, I got a really big fright with that and that is what prompted me to go and see the doctor … I just went, “ohhhh, there's got to be something wrong here” …’ (interview 15: 6–12)
‘I'd had some bleeding as well, so I — I felt that it was a little more of a problem than could just be treated with — with fluids basically, so there was concern for that’ (interview 6: 81–84)
Fear that infection might ‘spread to the kidneys’ also reportedly acted as a catalyst for help seeking:
‘I'm always aware that it could spread to my kidneys and I could end up having kidney infections and feeling really desperate. So I decided to go to the doctor …’ (interview 9: 14–19)
‘By the Monday the backache was quite nasty so I'm thinking “oh that's it I've got a kidney … thingy bob”.’ (interview 1: 196–198)
Interviewee 1 also, unusually, expressed a fear about cancer, while another spoke in general terms about the fear caused by the severity of the pain:
‘[I was in] terrible pain and [it was] frightening.’ (interview 8: 86–87)
For another interviewee the recurring nature of her symptoms led her to worry about her health in general, and consequentially she sought reassurance:
‘I had [an infection] back in February … and I just got concerned that there may be something fundamentally wrong with my system that needed to be looked at …’ (interview 15: 75–77)
One interviewee alone expressed how her fear of worsening symptoms had prompted her to seek help in a preventative fashion. When asked by the interviewer whether her symptoms were severe, she responded thus:
‘Well I was trying to catch them before they got too severe [exhaling/laughter] funnily enough!’ (interview 7: 19–20)