Download Predictors of Health Care Seeking for Irritable Bowel Syndrome and

THE AMERICAN JOURNAL OF GASTROENTEROLOGY
© 2001 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
Vol. 96, No. 5, 2001
ISSN 0002-9270/01/$20.00
PII S0002-9270(01)02352-8
Predictors of Health Care Seeking for Irritable Bowel
Syndrome and Nonulcer Dyspepsia: A Critical Review
of the Literature on Symptom and Psychosocial Factors
Natasha A. Koloski, B.A. (Hons), Nicholas J. Talley, M.D., Ph.D., F.R.A.C.P., F.A.C.G., and
Philip M. Boyce, M.D., F.R.A.N.Z.C.P.
Departments of Medicine and Psychological Medicine, University of Sydney, Nepean Hospital, Penrith, New
South Wales, Australia
OBJECTIVES: Health care use is a costly outcome of the
irritable bowel syndrome (IBS) and nonulcer dyspepsia
(NUD), but the predictors of this behavior remain poorly
defined. We aimed to systematically review the literature to
determine which symptoms and psychosocial factors drive
health care seeking in these disorders.
METHODS: A broad based MEDLINE and Current Contents
search between 1966 and 2000 identified 44 relevant publications. References from these articles were also reviewed.
RESULTS: The literature suggests that symptom severity is
an important factor, but only explains a small proportion of
the health care seeking behavior associated with these disorders in population-based studies. Psychosocial factors including life event stress, psychological morbidity, personality, abuse and abnormal illness attitudes and beliefs have
been found to characterize those that seek help versus those
that do not. The role of other psychosocial factors such as
social support, coping style and knowledge about illness are
as yet undetermined.
CONCLUSIONS: A model for health care seeking for IBS and
NUD, with an emphasis on psychosocial factors is presented, but remains to be tested. (Am J Gastroenterol 2001;
96:1340 –1349. © 2001 by Am. Coll. of Gastroenterology)
INTRODUCTION
Understanding the role of psychosocial factors in health care
seeking for irritable bowel syndrome (IBS) and nonulcer
dyspepsia (NUD), both common functional disorders of the
gastrointestinal tract (1–3), is appropriately growing in importance. The personal and economic costs associated with
health care use for IBS and NUD are significant (4, 5) in
terms of work absenteeism (6), inappropriate medical investigation (7), unnecessary surgery (8), medication use (9,
10), repeated consultation to health care professionals (11),
and reduced quality of life (12, 13). In the United States, the
medical costs associated with IBS are estimated to be $8
billion annually (14). We aimed to describe health care
seeking in IBS and NUD and to evaluate predictors of health
care seeking including symptoms and psychosocial factors.
Such knowledge may help plan means of reducing some of
the costs of consulting, and help direct future research.
ISSUES RELATED TO ASCERTAINMENT
We performed a MEDLINE and Current Contents Search
between 1966 and August 2000 using the Mesh terms “irritable bowel syndrome” and “functional dyspepsia” and
“health care seeking.” Other synonyms for health care seeking were also used in our searches and included “health care
use,” “health care utilization,” “help seeking,” and “medical
care utilization.” This produced a total of 44 papers. The
reference lists from all relevant studies located in this process were then used to trace other studies to provide systematic coverage of relevant studies in this area.
SIGNIFICANCE OF HEALTH
CARE SEEKING IN IBS AND NUD
Studies in the US, United Kingdom, and New Zealand have
identified rates of health care seeking for IBS symptoms of
around 10 –50%, suggesting that a large proportion of individuals with IBS are nonconsulters (those individuals who
have not sought health care for IBS or NUD over a specified
period of time) (1, 6, 15–23). The majority of these studies,
however, evaluated volunteers (6, 15, 16, 18, 19). The
significant demand that this minority group of individuals
with IBS and NUD make upon the health care system,
however, is significant (4 – 6). For example, Sandler et al.
report that up to 3.5 million visits to physicians occur each
year in the US for IBS (10). Repeated consultations for IBS
and NUD symptoms are also common in general practice
(11), and up to half of all referrals to specialist gastroenterologists are for functional gastrointestinal disorders (24, 25).
In Australia, a different but even more costly picture has
emerged, with ⬎70% of IBS and NUD individuals in the
general population seeking health care (11, 26, 27). Similarly, in a large nonpatient population study in Italy, 66% of
people consulted their physician for symptoms consistent
with IBS, although only 18% visited the gastroenterologist
(28). A high rate of physician consultations for IBS have
AJG – May, 2001
also been reported by Singapore residents (29) and by native
African medical students (30), although population data are
lacking to confirm the latter finding. Data collected from
national health surveys in the US also show that up to 90%
of people with unexplained gastrointestinal symptoms have
consulted a physician (31, 32), although these results conflict with some regional US population-based studies (1,
20).
Table 1 summarizes the consultation rates for IBS and
NUD. The apparent discrepancy in health care seeking
among studies may be the result in part of sampling issues;
volunteer samples, for example, may not be representative
of the general population. Alternatively, these differences
may be the by-product of a country’s or region’s unique
health care system. This has never been studied specifically
in IBS and NUD, but the evidence would suggest that this
is a plausible explanation. For example, in Australia, where
access to health care is essentially free, higher rates are
observed compared with countries such as the US that
operate on a fee-for-service basis. The discrepancy in consultation rates may also plausibly depend on the definition
applied. If a restrictive classification approach is used (e.g.,
Rome I), the symptoms of IBS, for example, have been
shown to be more severe than if more liberal criteria such as
Manning are applied (36), which may, in turn, positively
influence health care seeking.
MEASURING HEALTH CARE SEEKING
Table 1 illustrates the heavy reliance on self-report indicators of physician consultation to define health care seeking
for IBS and NUD. The only exceptions were by Kettell et
al., who determined consultation rates from general practitioner case notes between 1988 and 1990 (22), and a few
studies that assessed other types of health care use including
“folk remedies” and visits to the gastroenterologist (18, 28).
Although such consistency promotes comparisons among
studies, there is clearly a need for data on the use of other
health care, especially alternative health care. Self-report
data need to be cross-checked with medical records to
determine the accuracy of using this kind of approach before
we can gain an understanding of the true nature of health
care seeking behavior for these disorders.
CONCEPTUALIZING A ROLE FOR
PSYCHOSOCIAL FACTORS IN HEALTH CARE SEEKING
To understand health care seeking, we will present the
evidence on the importance of symptom and psychosocial
factors in IBS and NUD. A conceptual model that helps
explain health care seeking behavior is then proposed based
on the available evidence.
Symptom Characteristics Linked to Health Care Seeking
Support for the contention that individuals with IBS and
NUD seek health care simply because their symptoms are
worse is inconclusive (1, 11, 16, 17, 21–23, 26 –28, 37– 40).
Health Care Seeking for IBS
1341
It is generally accepted that abdominal pain is more severe
in both men and women with IBS and NUD who seek health
care than those that do not (21, 27), particularly among
adolescents (37), middle-aged (1), and older persons (20),
and chronic clinic attenders (38). Reports of more severe
abdominal pain by IBS and NUD consulters versus nonconsulters have come from valid health status indicators such as
physician diagnosis (38) and bowel symptom questionnaires
(20, 39), as well as from visual analog scales measuring
patient-perceived severity (22, 41). The duration of abdominal pain in terms of its weekly occurrence (26, 28) and of
other abdominal complaints such as visible abdominal distension (22, 26) and bloating, especially in women (21),
may also contribute to the decision to seek health care, but
not all studies agree (20, 40).
Despite the evidence that abdominal pain is at least responsible for some of the health care seeking in these
disorders, no studies have been able to show that abdominal
pain accounts for a significant proportion of the variance in
health care seeking (1, 11, 16, 23, 26, 27). Thus, in a
volunteer study in the US that statistically controlled for the
effects of symptom severity, differences in terms of psychosocial characteristics between IBS consulters and nonconsulters were still observed (39).
Symptoms of irregular bowel habit with respect to frequency and consistency of stool may also motivate a person
to seek health care (28, 39, 42), but not all studies agree. The
subgrouping of IBS into constipation-predominant and diarrhea-predominant types did not contribute to the understanding of health care seeking behavior in a US study (17).
In contrast, Gaburri et al. evaluated a random Italian population and found that frequent consulters were those with
predominately diarrhea-type symptoms of IBS (28). The
presence of multiple symptoms of IBS has also been directly
linked to subsequent health care seeking among subjects
registered with a general practitioner in the UK (21), but this
was not confirmed in a US population– based study (17).
These differences may in part be the result of cultural
influences.
The evidence overall supports the notion that symptoms
have an important influence on health care seeking but do
not explain the majority of consultation behavior. Thus, it
seems reasonable to suggest that other factors including
psychosocial and demographical characteristics as well as
the health care system itself (in particular, access to health
care resources, distance from health care, appointment systems, and ability to pay) (43– 45) must also be considered
before a complete understanding of this complex phenomenon can be obtained.
Psychosocial Characteristics
STRESS. A link between stress and gastrointestinal symptoms compatible with IBS and NUD has long been suspected (46). More recently, this view has been extended to
explain why only some individuals with IBS and NUD use
health care (22, 39, 40, 47). A British research group inter-
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Koloski et al.
AJG – Vol. 96, No. 5, 2001
Table 1. Epidemiological Studies of Health Care Seeking for IBS and NUD
Reference
Thompson and Heaton,
1980 (9)
Drossman et al., 1982 (15)
Sample
UK medical and
clerical staff
aged 17–91 yr
US student and
hospital
employees
Data Collection
Medium
Definition of IBS/NUD
Survey
Survey
Sandler et al., 1984 (16)
US students and
hospital
employees
Survey
Gaburri et al., 1989 (28)
Survey
Italian medical
students/employees
and rural
nonselected
subjects
Abdominal pain relieved Physician visit for
with defecation
abdominal
pain (ever)
Physician visit for
Alternating bowel
bowel
dysfunction and more
complaints
than one of
(ever)
abdominal pain,
constipation, or
diarrhea
Physician visit for
Alternating bowel
bowel
pattern, abdominal
symptoms
pain, constipation
(ever)
and/or diarrhea
Constipation or diarrhea Physician visits
(past year)
and at least six
episodes of abdominal
pain relieved by
defecation in the last
year
Gastroenterologist
visits (past
year)
Physician visits
Abdominal pain ⬎6
for stomach
times in past year that
and/or bowel
was relieved by a
disturbance
bowel movement on
at least half of the
occasions
Physician visits for
Chronic constipation/
abdominal pain
diarrhea and/or IBS
or disturbed
Manning (ⱖ2
defecation over
symptoms)
past year
Physician visits for
IBS Manning criteria
gastrointestinal
(ⱖ3 symptoms) and
symptoms over
frequent abdominal
past year
pain
IBS Manning criteria
Physician visits
(ⱖ3 symptoms)
ever for IBS:
Women
Men
Welch, 1990 (19)
New Zealand blood Survey
donors
Talley et al., 1991 (1)
US population aged Survey and
30–64 yr
medical records
Talley et al., 1992 (20)
US population aged Survey and
ⱖ65 yr
medical records
Heaton et al., 1992 (21)
Subjects registered
with a family
physician in
Bristol in the
UK
Subjects from
general
practitioner lists
in the UK
Survey
Survey and GP
case notes
examined
Abdominal pain ⬎6
times in the past year
IBS Manning criteria
(ⱖ2 symptoms)
US Health
maintenance
organization
members
Survey
Abdominal pain ⬎6
times in past year ⫹
Manning criteria (ⱖ3
symptoms)
Kettel et al., 1992 (22)
Longstreth and WoldeTsadik, 1993 (33)
viewed consulters and nonconsulters with NUD; the former
had experienced significantly more stressful or threatening
life events over the previous 6 months (40). In IBS, the
Definition of
Health Care
Seeking
Health Care
Seeking Rate
13.6%
50%
38%
66%
18%
17%
14%
23%
58.6%
50.0%
33%
General
practitioner
visits for
abdominal
problems
Physician visits for 3.2 visits
stomach and/or
bowel symptoms
in past year
continued
results are less clear cut. Higher mean negative life event
scores distinguished consulters from nonconsulters in one
study in the UK (22), but the reverse was true in another
AJG – May, 2001
Health Care Seeking for IBS
1343
Table 1. (continued)
Reference
Drossman et al., 1993 (6)
Sample
US household
volunteers
Data Collection
Medium
Survey
Definition of IBS/NUD
Rome I for IBS/NUD
Talley et al., 1994 (34)
US population aged Survey
30–49 yr
IBS Manning criteria
(ⱖ2 symptoms)
Holtmann et al., 1994 (23)
German population Survey
aged 18–65 yr
Frequent dyspepsia: pain
centered in upper
abdomen ⬎6 times in
past year
Olubuyide et al., 1995 (30) Native African
Survey
medical students
IBS Manning criteria
(ⱖ2 symptoms)
Talley et al., 1995 (17)
Abdominal pain and
IBS Manning criteria
(ⱖ2 symptoms)
US population aged Survey
20–95 yr
Zuckerman et al., 1996 (18) Hispanic and non- Survey
Hispanic hospital
and medical
employees
Hahn et al., 1997 (32)
Talley et al., 1997 (26)
Talley et al., 1998 (27)
US population
ⱖ18 yr
Australian
population aged
ⱖ18 yr
Australian
population
ⱖ18 yr
IBS Rome I
National Health
IBS Rome and Manning
Interview survey
criteria
Survey
Survey
IBS Rome I criteria
NUD, Rome I
Ho et al., 1998 (29)
Residents in
Singapore, aged
21–95 yr
Survey
Abdominal pain and
Manning criteria (ⱖ2
symptoms)
Norton et al., 1999 (35)
First-year
psychology
students in
Canada
Survey
NUD, Rome I
Definition of Health
Care Seeking
Physician visits for GI
symptoms
IBS: past year
ever
NUD: past year
ever
Physician visits for
abdominal pain or
bowel problems
(ever)
Physician visits for
the evaluation or
treatment of
abdominal pain in
past year.
Medical advice for
IBS symptoms in
past year
Physician visits for
abdominal pain or
disturbed defecation
in the past year
Physician visits for
complaints:
Hispanics
non-Hispanics
Self treatment:
Hispanics
non-Hispanics
Doctor visits:
Rome
Manning
Hospital admissions:
Rome
Manning
Physician visits for
abdominal
symptoms:
past year
ever
Medical care for
abdominal pain or
discomfort:
past year
ever
Medical advice for
gastrointestinal
symptoms in past
year
Physician visits in
past 6 mo (mean)
Health Care
Seeking Rate
1.64 visits
45.8%
1.62 visits
60.6%
60%
33.3%
68%
25%
13.8%
28.2%
5.5%
2.2%
88.5%
85.5%
19.0%
12.7%
73%
79%
70%
74%
84.2%
2.75
GP ⫽ general practitioner.
volunteer study by Drossman et al. (39). This unexpected
difference in the latter study was explained by the lower
rating by IBS patients on the intensity of these negative
events, leading the authors to suggest that “IBS patients tend
to minimize the impact of negative experiences in their life.”
In addition, these IBS patients also reported fewer positive
1344
Koloski et al.
life events (39). The generalizability of these findings, however, is limited by the use of volunteers in these studies.
PERSONALITY TRAITS. Neuroticism, characterized by
an individual’s tendency to have an exaggerated responsiveness to physiological changes, may theoretically exert an
influence in the recognition and reporting of symptoms (48).
In two population-based studies conducted recently in Australia, neuroticism was not found to be predictive of health
care seeking for functional gastrointestinal disorders including IBS and NUD (11, 26). Another study found personality
traits identified from the Minnesota Multiphasic Personality
Inventory (MMPI) including hypochondriasis, depression,
and hysteria distinguished between IBS patients and nonpatient volunteers in the US, even when symptom severity
was controlled (39). Future research using more comprehensive measures of personality traits is required before the
potential contribution of personality on health care seeking
is ruled out.
PSYCHOLOGICAL MORBIDITY. Psychiatric diagnoses
(particularly, anxiety, depression, and somatization) have
been shown to have a powerful influence on health care
seeking (49). Psychological disorders may produce physical
symptoms that are mistakenly assumed to be related to the
physical health of patients and it is these physical complaints that are often brought to the physician’s attention
(50). For example, anxiety can result in gastrointestinal
symptoms such as diarrhea, whereas depression may alter
eating patterns (51). Somatization is another psychological
disorder that results in the increased use of health care (52).
This is because somatizers express their psychological distress through bodily symptoms, particularly in stressful
times (50).
Several studies have shown a high prevalence of psychological disorders (39, 53– 60), including anxiety (61, 62) and
depression (63), in persons with IBS. All of these studies,
however, were confined to IBS patients presenting to a
health care facility for symptoms. For example, Smith et al.
evaluated the diagnostic value of psychosocial characteristics in a consecutive sample of 97 new patients presenting to
a gastroenterology clinic and normal controls (54). They
failed to find a difference between patients diagnosed with
IBS and those with organic disease on a range of psychological measures, although both groups were psychologically more impaired than controls (54). Other data also
suggest that psychosocial factors are not causally linked to
IBS, but drive health care seeking behavior (39).
These findings, however, have not been replicated in
studies in other countries (11, 26, 27, 64), giving support to
the notion that psychological morbidity may, in part, be
related to the pathophysiology of these disorders. Recent
population based-studies in Australia have failed to identify
anxiety, depression, or somatic distress as significant predictors of physician visits for IBS and NUD symptoms (11,
26, 27). In a New Zealand study, similar levels of anxiety,
AJG – Vol. 96, No. 5, 2001
depression, obsession– compulsion, and interpersonal sensitivity were found among IBS outpatients and among IBS
nonpatients and controls obtained from a blood donor unit
(65). Unfortunately, the sample was nonrandom and consisted mostly of female outpatients, and thus referral and
gender biases may have been in operation. Based on the
evidence it would seem that psychological morbidity is a
feature of patients presenting to referral centers, but only
further population studies using standardized psychological
instruments and assessing types of health care users can
address this hypothesis.
ABUSE. Available data suggest that there is a relationship
between a history of physical or sexual abuse and health
care use, including surgical procedures, for functional gastrointestinal disorders such as IBS (34, 66 – 69). For example Talley et al., in a population survey of Olmsted County
residents in the US aged 30 – 49 yr, found that those subjects
with higher rates of physician use for gastrointestinal symptoms were those who had a history of self-reported physical
or sexual abuse (34). The association between abuse and
health care use is particularly strong among subjects presenting to referral practices for functional gastrointestinal
disorders (67– 69). A potential deficiency in these studies is
the reliance on data obtained via self-report, which may
underestimate this association. This may be particularly true
in light of data suggesting that few patients presenting for
health care actually report a history of abuse to their treating
physician (69). On the other hand, the validity of selfreported abuse has also been questioned (70), and so the
importance of this factor remains to be clarified.
ABNORMAL ILLNESS BEHAVIOR. Illness behavior is
defined as how an individual perceives, evaluates, and acts
upon symptoms (71). It is a heavily interpretative process
involved in the decision to seek health care (71). Inherent
within this process is the involvement of individuals’
knowledge about their health, and their beliefs and attitudes
about their vulnerability to illness, the seriousness of their
symptoms, and the efficacy of treatment.
The way in which an individual reacts to symptoms may
often originate in childhood and probably can be transmitted
from one generation to the next (72, 73). Social learning of
illness behavior has been found to occur in IBS (74), primarily through encouragement of the sick role (75) and
modeling of illness behavior by parents (73–75). For example, Levy et al. found that children of IBS parents consulted
ambulatory and outpatient services for gastrointestinal
symptoms as well as general health concerns more often
than matched controls (75).
Abnormal illness behavior has been observed in adults
with nonorganic abdominal pain who have a psychiatric
diagnosis (76). These patients have been found to worry
excessively about their health and bodily functions in contrast to nonpatients (39, 76). One study in the US using the
abnormal illness behavior questionnaire found that patients
AJG – May, 2001
with NUD who had a psychiatric disorder showed excessive
concern about their health, reported more persistent and
severe symptoms, and did not respond to reassurance from
their physician compared with patients with organic disease
(76). Other evidence for abnormal illness behavior in IBS
and NUD comes from reportedly high consultation rates for
a range of problems unrelated to these disorders, such as
influenza symptoms or back pain (15).
The need to gain information about a symptom can drive
health care seeking behavior (77). Lydeard and Jones found
that among 69 NUD subjects who had consulted their general practitioner in the past 6 months and 66 NUD subjects
who had not, no differences about knowledge of the anatomy of the gastrointestinal tract or about the nature of peptic
ulceration and its treatment were identified between the two
groups (40). Level of knowledge as a determinant of consulting behavior remains to be examined in IBS. This information could prove useful for future educational campaigns to help reduce inappropriate health care use for
non–life threatening illnesses such as IBS and NUD, which
may in turn reduce the development of iatrogenic disorders,
including unnecessary abdominal surgery (7, 8).
Kettel et al., in a multivariate study, showed that both
symptom severity and anxiety about the potential serious
nature of IBS symptoms (including fear of cancer) accounted for 85% of the variance between IBS consulters and
nonconsulters (22). Consulting behavior in NUD has been
linked to beliefs about the possibility of symptoms being
attributable to potentially serious or fatal diseases including
stomach cancer and heart disease (40), but were not independent predictors of frequent consultation in a study of
family practice patients (78). Nonconsulters, in contrast,
tended to dismiss their NUD symptoms as trivial and “normal” (40). Despite some limitations in these studies (such as
the use of small sample sizes and the lack of validated
measures assessing beliefs), there remains consensus that
concern about symptoms is a driving force behind patients’
decisions to consult health care practitioners. Whether embarrassment about symptoms is likely to play a role in
avoiding health care seeking for these disorders is a potential area for future research.
Beliefs about the efficacy of conventional treatments by
IBS and NUD sufferers has not received much attention, but
one study in the US found that Hispanic individuals were
less likely to visit a physician for IBS symptoms and were
more likely to self-treat bowel symptoms with folk remedies
than were non-Hispanic white persons (18). The sample
used, however, was restricted to medical employees. Verhoef et al. found that patients attending a gastroenterologist
for functional gastrointestinal disorders were more likely to
seek alternative medical care than were patients with organic diseases, and were less satisfied with conventional
medicine (79). This finding, however, may reflect selection
bias inasmuch as patients attending specialist clinics have,
by definition, had more experience with the health care
system. In contrast, a strong physician–patient relationship
Health Care Seeking for IBS
1345
(as indicated by documentation of a patient’s psychosocial
history and notation about reassurance regarding the diagnosis, for example) reduces health care use by IBS patients
(80), and thus potentially represents an important costeffective treatment strategy, but confirmatory data are lacking. Thus, the learning of abnormal illness behavior may
ultimately result in “influencing whether a person with IBS
perceives the condition as requiring medical care, or a pain
in the gut not worthy of further attention or to be self
treated” (39).
SOCIAL SUPPORT. Social factors are assumed to be involved in the process of seeking health care in several ways.
First, interpretation of symptoms often lends itself to a
process known as a lay referral network. This is a process by
which preliminary formulations about the cause, diagnosis,
and treatment of a person’s symptoms are discussed among
the symptomatic individual’s closest social support (81).
This may well be the case in IBS and NUD, as gastrointestinal symptoms are quite commonly experienced in the
community (1–3). Lydeard and Jones examined the lay
referral process in subjects with NUD (40). Consulters with
NUD talked about their problems within their social network as a source of advice, in contrast to NUD nonconsulters who preferred to gain advice from books and the media
(40). The relationship of loneliness as well as the negative
social effects of divorce and bereavement on health care
seeking behavior among individuals with IBS and NUD
remains undetermined.
COPING SKILLS. Coping is another moderator of health
care seeking behavior that, unfortunately, has received little
investigation in IBS and NUD. Drossman et al. evaluated
coping ability as part of a multivariate study on determinants
of health care seeking for IBS. They found that nonpatients
with IBS exhibited greater coping capabilities under stress,
as shown on the ego strength scale of the Minnesota Multiphasic Personality Inventory, than did IBS patients (39).
Abused women with IBS presenting to an outpatient clinic
were found to employ ineffectual coping strategies such as
catastrophizing (68). Coping seems to be an area that warrants further investigation in unbiased populations.
SOCIODEMOGRAPHIC CHARACTERISTICS. Once a
symptom has been recognized and interpreted as requiring
health care intervention, sociodemographic factors such as
gender, age, and cultural background may determine, in
part, which individuals with abdominal pain and bowel
symptoms will actually visit the physician.
Epidemiological as well as specialist and general practice
figures show a higher preponderance of IBS in women
compared with men in western countries (21, 82, 83). Although this may be true, it has also been suggested that
women are more likely to notice and to remember their
symptoms than are men (21). Whether this leads to greater
symptom reporting by women, however, is unclear. Drossman et al. found that more women consult health care
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Koloski et al.
AJG – Vol. 96, No. 5, 2001
Figure 1. Proposed health care seeking model for irritable bowel syndrome and nonulcer dyspepsia.
practitioners for IBS symptoms than do men in the US (6).
In contrast, results from a UK study suggest that once men
acknowledge that symptoms are present, they are just as
likely as women to consult a physician for them (21).
Moreover, in countries such as India and Sri Lanka, more
men seem to present for care, although population-based
data are unavailable (84 – 88).
There are very few studies on age or the cultural and
socioeconomic status of consulters versus nonconsulters
with IBS or NUD. In a recent population survey in Australia, Talley et al. found increasing age to be a highly significant predictor of health care seeking (11). However, the
inclusion of age in an overall model of health care seeking
for IBS only explained a small amount of the variance,
suggesting that other factors contribute to the decision to
seek health care. Country of birth was also not significantly
associated with health care use in Australia. No effect of
socioeconomic indicators such as educational level on
health care use for IBS were observed in an Australian study
(11), but fewer consulters with NUD had continued with
full-time education after leaving school than had nonconsulters in the UK (40).
FUTURE DIRECTIONS: A CONCEPTUAL MODEL FOR THE
ROLE OF PSYCHOSOCIAL FACTORS IN CONSULTING
FOR IBS AND NUD
Based on our systematic review of the literature, we propose
a conceptual model to explain health care seeking for these
disorders that places significant importance on the role of
psychosocial factors. The literature suggests that consultation for IBS and NUD may be divided into three categories;
nonconsulters, and sporadic and frequent consulters. Although it is generally agreed in the literature that symptom
factors play an integral role in driving health care seeking
behavior, we postulate that particular psychosocial factors
may be most influential in determining levels of health care
use for these disorders, as shown in Figure 1.
We postulate that nonconsulters will possess greater coping abilities and symptom embarrassment, and unfavorable
attitudes and beliefs toward health. Individuals who consult
health care only sporadically will experience higher levels
of psychological distress, more recent life event stress, and
poorer psychosocial adjustment to illness. Of those who are
frequent consulters, the presence of comorbid anxiety and
depression, a history of physical or sexual abuse, higher
levels of neuroticism, and poor social support may be the
primary reasons behind frequent consultation. Transition
across categories could be the result of changes in these
psychosocial determinants over time. This model requires
prospective testing.
CLINICAL IMPLICATIONS
The evidence presented in this review has important implications for clinical practice. First, the physician needs to
consider the patient’s physical symptoms within a broader
psychosocial context, if optimal patient care is to be provided. Determining why a patient has consulted and addressing issues such as fear of serious disease must be part
of the management. Conventional treatments for IBS or
NUD may be greatly hampered if a patient’s psychological
distress remains untreated.
Second, the physician can help play a key role in positively modifying a patient’s subsequent health care seeking
behavior. Jones and Kennedy (89) argue that this may be
achieved if the physician gains a thorough understanding of
the patient’s beliefs and anxieties about the potential seriousness of their NUD symptoms, as well as their cognitions
and expectations about illness during the initial consultation.
Treatments directed toward reducing abnormal illness behavior (such as physician reassurance), in addition to treating bowel symptoms, may help curb some of the heavy costs
associated with frequent consultation. The efficacy of these
approaches, however, remains to be evaluated.
CONCLUSION
Health care use is a very costly outcome of IBS and NUD.
Although the severity of the symptoms clearly plays some
part in the decision to seek health care, psychosocial factors
including stress, psychological morbidity, personality,
abuse, and abnormal illness-related attitudes, beliefs, and
behavior have been found to characterize those who seek
health care for IBS and NUD versus those that do not. Other
AJG – May, 2001
psychosocial factors that may be important in driving health
care seeking include knowledge about the condition, as well
as social support and coping, but these have not been studied
in IBS and NUD. The development of a conceptual model
for health care seeking for IBS and NUD may help explain
more fully the continuum of health care seeking behavior
observed in these disorders, but requires prospective evaluation.
ACKNOWLEDGMENT
Supported by the National Health and Medical Research
Council of Australia.
Health Care Seeking for IBS
17.
18.
19.
20.
21.
Reprint requests and correspondence: Professor Nicholas J.
Talley, Department of Medicine, Clinical Sciences Building, Nepean Hospital, P.O. Box 63, Penrith NSW 2751, Australia.
Received Aug. 11, 2000; accepted Jan. 3, 2001.
22.
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