Katriina Whitaker is Lead for Cancer Care in the School of Health Sciences at the University of Surrey. Katriina was awarded a prestigious Cancer Research UK postdoctoral research fellowship (2012-2015) to explore cancer symptom appraisal in everyday life. Her ongoing programme of work focuses on early diagnosis and cancer, with a particular interest in healthcare-seeking and health inequalities.
Katriina is a Chartered Psychologist and was made a Fellow of the British Psychological Society in 2017. Katriina chairs the Early Diagnosis sub-group of the NCRI’s Primary Care Clinical Studies Group (CSG) and is an expert panel member for Cancer Research UK's Early Diagnosis Review Panel and Tenovus Cancer Care Psychosocial Advisory Committee. She also sits on Editorial Boards for the European Journal of Cancer Care and Psycho-Oncology.
- Early diagnosis and cancer
- Cancer knowledge, attitudes and beliefs
- Health psychology
- Health inequalities
- Impact of COVID-19 on early diagnosis and cancer care
Principal Investigator. Health Foundation. October 2020-October 2021. With co-investigators Dr Cath Taylor, Professor Naomi Fulop, Dr Georgia Black, Dr Cecilia Vindrola.
Co-investigator. UKRI. June 2020-December 2021. With Professor Kate Brain (PI) andDr Jo Waller, Professor Graham Moore, Dr Victoria Whitelock
Katie Robb (University of Glasgow)
Jo Waller (King's College London)
Georgia Black (University College London)
Peter Vedsted (Aarhus University, Denmark)
Yoryos Lyratzopoulos (University College London)
Una Macleod (Hull York Medical School)
Fiona Walter (University of Cambridge)
Peter Murchie (University of Aberdeen)
Kate Brain (University of Cardiff)
Naomi Fulop (University College London)
Cecilia Vindrola (University College London)
Hardeep Singh (Baylor College of Medicine)
Indicators of esteem
February 2017- current. Fellow of the British Psychological Society (BPS)
May 2016-current. Member of the Psycho-Oncology Journal Affiliate Editorial Board
February 2016-current. Member of the National Cancer Research Institute (NCRI) Primary Care Clinical Study Group (CSG).
August 2015-current: Member of the National Cancer Research Institute (NCRI) Primary Care Early Diagnosis sub-group.
April 2015-current: Expert Panel Member, Early Diagnosis Panel of Population Research Committee, Cancer Research UK.
April 2015-current: Committee member of IPOS Communications and Publications Committee.
March 2015-current: Editorial Board Member, European Journal of Cancer Care.
November 2014-current: Honorary Senior Research Fellow, Epidemiology and Public Health, University College London.
November 2013-current: Scholar, Editorial Board, British Journal of Health Psychology
Jan 2012-current: Chartered member (CPsychol) of British Psychological Society (BPS).
- Understanding primary care nurses’ contribution to cancer early diagnosis (Hanna Skrobanski; supervised by Katriina Whitaker and Emma Ream)
- The role of illness-related rumination in psychological and physical health outcomes in those living with cancer (Sarah Beck; supervised by Mark Cropley, Simon Evans and Katriina Whitaker)
MSc and BSc student supervision
Module lead for Cancer in Society
von Wagner, C., Good, A., Whitaker, K.L., Wardle, J. (2011). Psychosocial determinants of socioeconomic inequalities in cancer screening participation: A conceptual framework. Epidemiologic Reviews, 33, 135-147.
Whitaker, K.L., Scott, S., Winstanley, K., Macleod, U., Wardle, J. (2014). Attributions of cancer ‘alarm’ symptoms in a community sample. PLOS One, 9 (12):e114028, DOI: 10.1371/journal.pone.0114028
Whitaker, K.L., Macleod, U., Winstanley, K., Scott, S., Wardle, J. (2015). Help-seeking for cancer ‘alarm’ symptoms: a qualitative interview study. British Journal of General Practice, 65(631); e96-e105.
Whitaker, K.L., Scott, S., Wardle, J. (2015) Applying symptom appraisal models to understand socio-demographic differences in responses to possible cancer symptoms: A research agenda. British Journal of Cancer, 112, Suppl 1: S27-S34, doi: 10.1038/bjc.2015.39.
Whitaker, K.L., Friedemann Smith, C., Winstanley K., Wardle, J. (2016). What prompts help-seeking for cancer ‘alarm’ symptoms? A primary care based survey. British Journal of Cancer, 114, 334-339, doi: 10.1038/bjc.2015.445
Davies, H., Marcu, A., Vedsted, P., Whitaker, K.L (2018). Is lower symptom recognition associated with socioeconomic inequalities in help-seeking for potential breast cancer symptoms? Psycho-Oncology, 27 (2), 626-632.
Lower socioeconomic status (SES) is associated with a higher risk of late-stage cancer diagnosis. A number of explanations have been advanced for this, but one which has attracted recent attention is lower patient knowledge of cancer warning signs, leading to delay in help-seeking. However, although there is psychometric evidence of SES differences in knowledge of cancer symptoms, no studies have examined differences in ?cancer suspicion? among people who are actually experiencing a classic warning sign.
A ?health survey? was mailed to 9771 adults (~50 years, no cancer diagnosis) with a symptom list including 10 cancer ?warning signs?. Respondents were asked if they had experienced any of the symptoms in the past 3 months, and if so, were asked ?what do you think caused it?? Any mention of cancer was scored as ?cancer suspicion?. SES was indexed by education.
Nearly half the respondents (1732/3756) had experienced a ?warning sign?, but only 63/1732 (3.6%) mentioned cancer as a possible cause. Lower education was associated with lower likelihood of cancer suspicion: 2.6% of respondents with school-only education versus 7.3% with university education suspected cancer as a possible cause. In multivariable analysis, low education was the only demographic variable independently associated with lower cancer suspicion (odds ratio (OR) = 0.34, confidence interval (CI): 0.20?0.59).
Levels of cancer suspicion were low overall in this community sample, and even lower in people from less educated backgrounds. This may hinder early symptomatic presentation and contribute to inequalities in stage at diagnosis.
1724). Over half the respondents (915/1724; 53%) had experienced an 'alarm' symptom, and 20 (2%) cited cancer as a possible cause. Cancer attributions were highest for 'unexplained lump'; 7% (6/87). Cancer attributions were lowest for 'unexplained weight loss' (0/47). A higher proportion (375/1638; 23%) were concerned their symptom might be 'serious', ranging from 12% (13/112) for change in a mole to 41% (100/247) for unexplained pain. Just over half had contacted their doctor about their symptom (59%), although this varied by symptom. Alarm symptoms were appraised as more serious than non-alarm symptoms, and were more likely to trigger help-seeking. CONCLUSIONS: Consistent with retrospective reports from cancer patients, 'alarm' symptoms experienced in daily life were rarely attributed to cancer. These results have implications for understanding how people appraise and act on symptoms that could be early warning signs of cancer.
We examined associations between different chronic morbidities and help-seeking for possible cancer symptoms.
Postal survey of individuals aged>50 years in England. Participants could report prior morbidities in respect of 12 pre-defined conditions. Among patients experiencing possible cancer symptoms we examined associations between specific morbidities and self-reported help-seeking (i.e. contacted versus not contacted a GP) for each alarm symptom using regression analyses.
Among 2042 respondents (42% response rate), 936 (46%) recently experienced one of 14 possible cancer symptoms considered in our analysis. Of them, 80% reported one or more morbidities, most frequently hypertension/hypercholesterolemia (40%), osteomuscular (36%) and heart diseases (21%). After adjustment for socio-demographic characteristics, patients with hypertension/hypercholesterolemia were more likely to report help-seeking for possible cancer symptoms, such as unexplained cough (OR=2.0; 95%CI 1.1-3.5), pain (OR=2.2; 95%CI 1.0-4.5) and abdominal bloating (OR=2.3; 95%CI 1.1-4.8). Urinary morbidity was associated with increased help-seeking for abdominal bloating (OR=5.4; 95%CI 1.2-23.7) or rectal bleeding (OR=5.8; 95%CI 1.4-23.8). In contrast, heart problems reduced help-seeking for change in bowel habits (OR=0.4; 95%CI 0.2-1.0).
Comorbidities are common and may facilitate help-seeking for possible cancer symptoms, but associations vary for specific symptom-comorbidity pairs. The findings can contribute to the design of future cancer symptom awareness campaigns.
Background: Presenting to primary care with potential cancer symptoms is contingent on one?s ability to recognize potentially serious symptoms. We investigated differences between smokers and non-smokers in symptoms experienced, awareness and consulting of potential respiratory, head and neck cancer symptoms.
Methods: Smokers and non-smokers aged over 50 from Yorkshire general practice lists were sent a postal questionnaire asking about symptoms, consulting and awareness of cancer symptoms. Data were analysed using STATA14.
Results: Response rate after one reminder was 30.5% (1205/3954). Smoking status was associated with experience of cough (p
Conclusion: Our findings suggest that current smokers are more likely to experience cough, breathlessness and tiredness, but are less likely to consult for cough than never-smokers. To increase cancer awareness and promote consulting among smokers, innovative interventions improving symptom recognition and empowering smokers to seek help are required.
Socioeconomic inequalities in recognising signs and symptoms of cancer may result in inequalities in timely help-seeking and subsequent prognosis of breast cancer. We explored the mediating role of symptom attribution and concern on the relationship between level of education and help-seeking for potential breast cancer symptoms.
Women aged e47 years (n=961) were purposively recruited (by education) to complete an online vignette-based survey that included nipple rash and axillary lump (in separate vignettes) as potential symptoms of breast cancer. Women completed questions relating to medical help-seeking (Yes/No), cancer attribution, symptom concern, cancer avoidance, family history and demographics.
Women with low education and mid-education attributed nipple rash less often to cancer (26% and 27% mentioned cancer) than women with a degree or higher (40%). However, women with a degree or higher (63%) or mid-education (64%) were less likely to anticipate seeking help for the nipple rash than women with no formal qualifications (73%). This association was statistically significant in the 60-69 year old age group. There was no significant association between education and help-seeking for axillary lump. Mediation analysis adjusting for potential confounders confirmed that the association between education and help-seeking for nipple rash was fully mediated by symptom concern.
Socioeconomic inequalities in stage at diagnosis and survival of breast cancer may not always be explained by lower likelihood of suspecting cancer and subsequent impact on help-seeking. Reducing inequalities in stage at diagnosis will involve understanding a broader range of bio-psycho-social factors (e.g. comorbidities, healthcare system factors).
?Candidacy? is concerned with the way people consider their eligibility for accessing health services. We used the Candidacy Framework to explore how the doctor-patient relationship can influence perceived eligibility to visit their General Practitioner (GP) among people experiencing cancer alarm symptoms.
We carried out a secondary analysis of qualitative interviews with 29 women and 33 men, aged e50 years experiencing cancer alarm symptoms, recruited through primary care. Interviews focused on symptom experience, help-seeking and primary care use. Framework analysis was used to analyse transcripts with a focus on GP-patient interactions.
Perceived (im)permeability of services acted as a barrier to help-seeking, due to limited availability of appointments, time-limited communication and difficulties asserting candidacy. There was also a focal role of communication in building a positive doctor-patient relationship, with some participants describing resisting offers of appointments as a result of previous negative GP adjudication. These factors not only influenced the current consultation but had longer-term consequences for future consultation.
Candidacy provides a valuable theoretical framework to understand the interactional factors of the doctor-patient relationship which influence perceived eligibility to seek help for possible cancer alarm symptoms. We have highlighted areas for targeted interventions to improve patient-centred care and improve earlier diagnosis.
People engage in health information-seeking online when experiencing unusual or unfamiliar bodily changes. It is not well understood how people consult the Internet for health information after the onset of unfamiliar symptoms and before receiving a potential diagnosis, and how online information-seeking can help people appraise their symptoms. This lack of evidence may be partly due to methodological limitations in capturing in real time the online information-seeking process.
We explored women?s symptom attribution and online health information-seeking in response to a hypothetical and unfamiliar breast change suggestive of cancer (nipple rash). We also aimed to establish the feasibility of capturing in real time the online information-seeking process with a tool designed to track participants? online searches and visited websites, the VIZZATATM browser tracker.
An online survey was completed by 56 cancer-free women (Mage = 60.34 years, SD = 7.73 years) responding to a scenario asking them to imagine noticing a red scaly rash on the nipple. Participants were asked to make symptom attributions when presented with the scenario (Time1) and again after seeking information online (Time2). The online tracking tool, embedded in the survey, was used to capture in real time participants? search terms and accessed websites.
The tracking tool captured the search terms and accessed websites of most of the participants (46/56, 82%). For the rest (n=10, 18%), there was evidence of engagement in online information-seeking, e.g. medical terminology and cancer attribution at Time2, despite their searching activity not being recorded. Twenty five participants considered cancer as a potential cause for the nipple rash at Time1, yet only one of these used ?cancer? as a search term. Most participants (n=40, 87%) used rash-related search terms, particularly ?nipple rash? and ?rash on nipple?. The majority (41/46, 89%) accessed websites containing breast cancer information, with the NHS webpage ?Paget?s disease of the nipple? being the most visited one. At Time2, after engaging in the Internet search task, more participants attributed the nipple rash to breast cancer than at Time1, n=37 (66.1%) vs. n=25 (44.6%), although a small number of participants (n=6) changed from making a cancer attribution at Time1 to a non-cancer one at Time2.
Making a cancer attribution for an unfamiliar breast change did not necessarily translate into cancer-termed searches. Equally, not all Internet searches led to a cancer attribution. The findings suggest that online information-seeking may not necessarily help women who experience unfamiliar breast cancer symptoms understand their condition. Despite some technical issues, this study showed that it is feasible to use an online browser tracking tool to capture in real time information-seeking about unfamiliar symptoms.
The incidence of lung cancer is four?times higher in people with Chronic Obstructive Pulmonary Disease (COPD) compared to the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help?seeking for potential lung cancer symptoms.
We conducted qualitative interviews with men (n=17) and women (n=23) aged 40?83 with COPD. Topic guides drew on the Integrated Symptom?Response Framework and covered symptom experience, interpretation, action, recognition, help?seeking, evaluation and re?evaluation. We used the Framework Method to analyse the data.
Participants said they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help?seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently but increased risk of lung cancer was not discussed.
Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms.
Background The Faster Diagnosis Standard (FDS) is to be introduced in England in 2020. This standard is a new policy in which patients should have cancer ruled out or diagnosed within 28 days of referral.
Aim To explore public attitudes towards the FDS within the context of their recent referral experiences.
Design and setting Four 90-minute focus groups (two in Guildford, two in Bradford).
Method Participants aged >50 years without a current cancer diagnosis (N = 29), who had completed certain diagnostic tests, for example, ultrasound, and received results within the last 6 months were recruited. Age, education, and sex were evenly distributed across groups through purposive sampling.
Results The largest cause of concern was the waiting process for obtaining test results. Most had experienced swift referral, and it was difficult for participants to understand how the new standard could impact upon time progressing through the system. Responsibility for meeting the standard was also a concern: participants did not see their own behaviours as a form of involvement. The GP?s role was conceptualised by patients as communicating about their referral, establishing patients? preferences for information, and continued involvement at each stage of the referral process. The standard legitimised chasing for test results, but 28 days was considered too long.
Conclusion Patients should be asked what they would like to know about their referral. GPs should be more transparent about the referral process and the potential for a lack of clarity around next steps.
Purpose: Primary care nurses can contribute to cancer early diagnosis. The objective of this systematic review was to identify, appraise and synthesise evidence on primary care nurses? contribution towards cancer early diagnosis in developed countries.
Method: The following databases were searched in September 2017: MEDLINE, PsychINFO, CINAHL, SCOPUS, and EMBASE. Data were extracted on nurses?: knowledge of cancer; frequency of 'cancer early diagnosis-related discussions' with patients; and perceived factors influencing these discussions. Studies were appraised using the Mixed Methods Appraisal Tool.
Results: Twenty-one studies were included from: United States, United Kingdom, Ireland, Spain, Turkey, Australia, Brazil and Middle East. Studies were mostly of low quality (one did not meet any appraisal criteria, 15 met one, four met two, and one met three). Nurses? knowledge of cancer, and their frequency of ?cancer early diagnosis-related discussions?, varied across countries. This may be due to measurement bias or nurses? divergent roles across healthcare systems. Commonly perceived barriers to having screening discussions included: lack of time, insufficient knowledge and communication skills, and believing that patients react negatively to this topic being raised
Conclusions: Findings suggest a need for nurses to be adequately informed about, and have the confidence and skills to discuss, the topic of cancer early diagnosis. Further high-quality research is required to understand international variation in primary care nurses? contribution to this field, and to develop and evaluate optimal methods for preparing them for, and supporting them in, this.
Background: Most cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations.
Objective: To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis.
Research design: Qualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors.
Subjects: 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England.
Results: We found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem?s significance. ?Disagreements? may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient, or misaligned emotional factors such as patients? unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (e.g. non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm.
Conclusions: Our findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation, and the subsequent impact on the diagnostic process.
To improve earlier presentation with potential symptoms of cancer accurate data is needed on how people respond to these symptoms. It is currently unclear how self-reported medical help-seeking for symptoms associated with cancer by people from the community correspond to what is recorded in their general practice records, or how well the patient interval (time from symptom onset to first presentation to a health-professional) can be estimated from patient records.
Data from two studies that reviewed general practice electronic records of residents in Scotland, 1) the ?Useful Study?: respondents to a general population survey who reported experiencing symptoms potentially associated with one of four common cancers (breast, colorectal, lung, and upper gastro-intestinal) 2) the ?Detect Cancer Early? programme: cancer patients with one of the same four cancers. Survey respondents? self-reported help-seeking (yes/no) was corroborated; Cohen?s Kappa assessed level of agreement. Combined data on the patient interval was evaluated using descriptive analysis.
?Useful Study? respondents? self-report of help-seeking showed exact correspondence with general practice electronic records in 72% of cases (n=136, kappa 0.453, moderate agreement). Between both studies, 1269 patient records from 35 general practices were reviewed. The patient interval could not be determined in 44% (N=809) of symptoms presented by these individuals.
Patient self-report of help-seeking for symptoms potentially associated with cancer offer a reasonably accurate method to research responses to these symptoms. Incomplete patient interval data suggests routine general practice records are unreliable for measuring this important part of the patient?s symptom journey.
The majority of cancers are diagnosed following a decision to access medical help for symptoms. People from ethnic minority backgrounds have longer patient intervals following identification of cancer symptoms. This study quantified ethnic differences in barriers to symptomatic presentation including culturally?specific barriers. Correlates of barriers (e.g. migration status, health literacy and fatalism) were also explored.
A cross?sectional survey of 720 White British, Caribbean, African, Indian, Pakistani and Bangladeshi women aged 30?60 (n=120/group) was carried out in England. Barrier items were taken from the widely?used Cancer Awareness Measure; additional culturally?specific barriers to symptomatic presentation were included following qualitative work (11 in total). Migration status, health literacy and fatalism were included as correlates to help?seeking barriers.
Ethnic minority women reported a higher number of barriers (pÂ0.001, 2.6?3.8 more than White British women). Emotional barriers were particularly prominent. Women from ethnic minority groups were more likely to report 'praying about a symptom' (pÂ0.001, except Bangladeshi women) and 'using traditional remedies' (pÂ0.001,except Caribbean women). Among ethnic minority women, adult migration to the UK, low health literacy and high fatalistic beliefs increased likelihood of reporting barriers to symptomatic presentation. For example, women who migrated as adults were more likely to be embarrassed (OR=1.83,CI:1.06?3.15), worry what GP might find (OR=1.91,CI:1.12?3.26) and be low on body vigilance (OR=4.44,CI:2.72?7.23).
Campaigns addressing barriers to symptomatic presentation among ethnic minority women should be designed to reach low health literacy populations and include messages challenging fatalistic views. These would be valuable for reducing ethnic inequalities in cancer outcomes.
Aim. To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six ?red flag? symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups.
Methods. Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland.
Results. Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely.
Conclusion. Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.
Aim: We aimed to determine if symptom attribution and anticipated help-seeking for potential lung cancer symptoms is influenced by pre-existing respiratory conditions (often referred to as comorbidity) such as asthma or chronic obstructive pulmonary disease (COPD).
Design and Setting: 2 143 adults (1081 with and 1062 without a respiratory condition) took part in an online vignette survey.
Method: The vignette described potential lung cancer symptoms (persistent cough and breathlessness) after which questions were asked on symptom attribution and anticipated help-seeking.
Results: Attribution of symptoms to cancer was similar in participants with and without respiratory conditions (22%). Participants with respiratory conditions, compared to those without, were more likely to attribute the new or changing cough and breathlessness to asthma or COPD (adjusted odds ratio=3.64, 95% CI=3.02,4.39). Overall, 56.5% of participants reported intention to seek help from a GP within 3 weeks if experiencing the potential lung cancer symptoms. Having a respiratory condition increased the odds of prompt help-seeking (OR=1.25, 95% CI=1.04,1.49). Regular healthcare appointments was associated with higher odds of anticipated help-seeking.
Conclusions: Only 1 in 5 participants identified persistent cough and breathlessness as potential cancer symptoms, and half said they would promptly seek help from a GP, indicating scope for promoting help-seeking for new or changing symptoms. Chronic respiratory conditions did not appear to interfere with anticipated help-seeking, which might be explained by regular appointments to manage chronic conditions.