45

British Journal of Health Psychology (2013), 18, 4564

2012 The British Psychological Society
www.wileyonlinelibrary.com

The Model of Pathways to Treatment:

Conceptualization and integration with existing
theory
S. E. Scott*1, F. M. Walter2,3, A. Webster3, S. Sutton4
and J. Emery2,3
1

Unit of Social & Behavioural Sciences, Dental Institute, Kings College London, UK
Primary Care Unit, University of Cambridge, UK
3
General Practice, School of Primary, Aboriginal and Rural Health Care, University
of Western Australia, Australia
4
Behavioural Science Group, Institute of Public Health, University of Cambridge, UK
2

Background. Studying and understanding pathways to diagnosis andtreatment is vital for

the development of successful interventions to encourage early detection, presentation,
and diagnosis. An existing framework posited to describe the decisional and behavioural
processes that occur prior to treatment (Andersen et al.s General Model of Total Patient
Delay) does not appear to match the complex and dynamic nature of the pathways into and
through the health care system or provide a clear framework for research. Therefore a
revised descriptive framework, the Model of Pathways to Treatment, has been proposed.
Purpose. This paper presents the concepts and definitions of the Model of Pathways to
Treatment and specifies how the model can encompass existing psychological theory, with
particular focus on the Appraisal and Help-seeking intervals. The potential and direction
for future work is also discussed.

Statement of contribution
What is already known on this subject?
The use of theory is often lacking in existing research into delays in presentation, diagnosis and
treatment of illness.
What does this study add?
A detailed account of the concepts and definitions of a revised framework: the Model of Pathways
to Treatment.
Specification of how the Model of Pathways to Treatment can encompass existing psychological
theory such as the Common Sense Model of Illness Self-regulation and Social Cognitive Theory.

*Correspondence should be addressed to S. E. Scott, Unit of Social & Behavioural Science, Dental Practice & Policy Department,
Dental Institute, Kings College London, Caldecot Road, London SE5 9RW, UK (e-mail: suzanne.scott@kcl.ac.uk).
DOI:10.1111/j.2044-8287.2012.02077.x

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S.E. Scott et al.

Prompt diagnosis and treatment can reduce mortality, improve prognosis, lower anxiety,
minimize complaints, prevent spread of communicable disease, and reduce the duration
of hospital stay for a wide range of diseases (see Scott, 2007). It follows that studying
pathways to diagnosis and treatment is important for patients and health care
professionals (HCPs) and for health care systems.
Research analysing pathways to treatment has mainly focused on cancer and
myocardial infarction, but there is a growing literature on diagnostic and management
pathways for other conditions including sexually transmitted infections (Pitts, Woolliscroft, Cannon, Johnson, & Singh, 2000), stroke (Mandelzweig, Goldbourt, Boyko, &
Tanne, 2006), rheumatoid arthritis (Sheppard, Kumar, Buckley, Shaw, & Raza, 2008),
tuberculosis (Godfrey-Faussett et al., 2002), and mental health problems (Hamilton-West,
Milne, Chenery, & Tilbrook, 2010; Roness, Mykletun, & Dahl, 2005). Although, overall,
the use of theory is lacking in this field (Walter, Webster, Scott, & Emery, 2011), the most
widely used psychological model that is specific to health care utilization and receipt of
health care treatment is the General Model of Total Patient Delay1 (Andersen, Cacioppo, &
Roberts, 1995), based on an earlier model proposed by Safer, Tharps, Jackson, and Leventhal
(1979). The Andersen model is a five-stage model describing the decisional processes and
potential for delays prior to treatment. In the Andersen model, appraisal delay is the time
between the point at which a person first detects an unexplained symptom until s/he
concludes s/he is ill; illness delay is the time between inferring illness and deciding to seek
medical help; behavioural delay represents the time between a person deciding an illness
requires medical care and deciding to act on this decision; scheduling delay is the time
between deciding to act on the decision to seek help and actually attending an appointment,
and treatment delay is the time between the first appointment with a HCP and the onset of
treatment. The Andersen model highlights the role of appraisal (or misattribution) of a
symptom as a key determinant of delay in seeking help.
A systematic review of the application of the Andersen model to delays in cancer
diagnosis (Walter et al., 2011) found support for this model in that there were identifiable
stages between the detection of a symptom, the first presentation to a HCP, diagnosis, and
initiation of treatment. In particular there was strong evidence to support the existence
and importance of appraisal delay and some evidence to support scheduling delay. For
instance, with regard to appraisal delay, Andersen et al. reported that this interval
accounted for the majority of the total time to treatment for women diagnosed with
gynaecological cancer and in those being investigated for breast symptoms. Similarly,
misattribution of symptoms, either to previously benign conditions (irritable bowel
syndrome) or concurrent conditions (menopause, stress), and non-recognition of the
seriousness of the symptoms, have been found to make an important contribution to delay
in seeking help among women diagnosed with ovarian cancer (Evans, Ziebland, &
McPherson, 2007).
There was also evidence to support the existence and importance of treatment delay,
although it was reported that this phase does not adequately describe the steps between
first presentation to a HCP leading to diagnosis and ultimately initiation of treatment.
However, the systematic review found illness delay to be difficult to distinguish from
appraisal delay and it was unclear whether behavioural delay exists as a separate stage.
The review revealed important differences in the way the Andersen model has been
understood and applied, with different definitions, lack of specification of time intervals
1

Referred to as the Anderson model throughout the remainder of this paper.

The model of pathways to treatment

47

measured, and variation in wording used to ask patients about the different time
intervals. The review concluded that there is a need for a model that can be consistently
applied with clear definitions, not only of the time intervals, but also of the processes
occurring during each interval. These need to have sufficient validity that they can be
identified by patients, clinicians, and researchers to allow the collection of comparable
data between studies and across populations and health care systems. The systematic
review also suggested that it may be more appropriate to describe time intervals rather
than delay because not only is delay value laden but it is also inaccurate as many
patients seek help promptly. This echoes previous calls to abandon the term delay
(Corner, Hopkinson, & Roffe, 2006; de Nooijer, Lechner, & de Vries, 2001a; Turris &
Finamore, 2008).
A recent discussion of the challenges of methods and models for studying help-seeking
behaviour provided additional critique of the Andersen model (Scott & Walter, 2010).
While recognizing that this model provides an important development from atheoretical
approaches to studying health care use, a number of conceptual problems with the
Andersen model were highlighted (see Box 1). Furthermore, Petrie and Weinman (2003)
have noted that the Andersen model does not specify how delays occur at each stage or
how people progress from one stage to another.
In summary, the Andersen model does not appear to match the complex and
dynamic nature of the pathways into and through the health care system or provide a
clear framework for research. Therefore a revised descriptive framework, the Model of
Pathways to Treatment, has been proposed (see Figure 1) (Walter et al., 2011). The
aim of this paper is to present the first detailed account of concepts and definitions
used within the Model of Pathways to Treatment. Further, the paper considers the
model from a psychological perspective and focuses on patient factors in the Appraisal
and Help-seeking intervals in order to demonstrate how the model can encompass
existing psychological theory. By increasing understanding of the factors that result in
delays in diagnosis and treatment, the model can be used to identify targets for
interventions in order to encourage early detection, presentation, and treatment of
illness, and therefore improve prognosis. Finally, the potential and direction for future
work is discussed.

Model of Pathways to Treatment: Concepts and definitions

The Model of Pathways to Treatment presents events, processes, and intervals that may
occur in the period prior to start of medical treatment and identifies the factors that may
contribute to the duration of each interval. The Model of Pathways to Treatment does not
specify a set sequence or irreversible route. Thus, there is a range of possible pathways to
treatment. Although many individuals will begin their pathway to diagnosis and treatment
by becoming aware of a bodily change, there is no particular starting point and not all
events will be experienced in one symptom or disease episode. For instance, those with
screen-detected disease may enter the pathway at the consultation with a HCP during a
screening programme and may be asymptomatic. In the case of patients with vague or
multiple symptoms, an individual may consult a HCP but a diagnosis may not be reached;
in other cases a diagnosis may be reached but no treatment is available or offered, or the
treatment is ineffective. After consulting a HCP, patients may need to monitor symptoms
and reconsider seeking help if symptoms persist or change. This forward & backward
movement is reflected in the bi-directional arrows in the model.

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S.E. Scott et al.

Box 1. Problems with the Andersen model as identified by Scott and Walter (2010)
Issue
Starting point

Linear progression

Position of Andersen model

Problem

The starting point of the model is

detection of unexplained signs
or symptoms. This infers that
detection of a bodily change and
an initial assessment of the
expectedness of that somatic
information has already taken
place.
A linear stage model where all
patients will pass through all the
stages in the same order and
only pass through each stage
once during a symptom
episode.

For many diseases the late

detection of somatic
information and its dismissal as
normal represents a major
part of the delay in seeking help.

Alternative
responses to
seeking help

Alternative ways of coping with

symptoms are not presented.

The role of
emotion

The model identifies cognitive

decisions throughout the
pathway to diagnosis but
provides no account for the
role of emotion.

Illness inference

The model assumes that patients

must infer illness in order to
seek help.

In reality, it appears that the

process is more dynamic, the
stages are not an immutable
sequence, and there are
alternative pathways to
diagnosis (e.g., screening
programmes, opportunistic
detection by HCP)
There are many alternatives to
seeking help such as ignoring
symptoms, monitoring
progress, hoping symptoms will
resolve naturally,
self-medication, adaptations to
lifestyle, seeking lay advice.
Emotion can affect self-diagnosis,
attention to and interpretation of
somatic states, and
behavioural decisions, and may
also be a target for
self-regulation (e.g., seeking
care may be a distress-reducing
strategy).
Some patients do not infer illness
yet still decide to seek medical
attention.

Events
Events are defined as key time points in the pathways to treatment. The Model of
Pathways to Treatment specifies five events that are recognizable from both the lay and
HCP perspective:
 Detection of bodily change(s) represents the time point when a person becomes
aware of somatic information. In this context, somatic information refers to both
bodily sensations (e.g., nausea, pain, fatigue) and visible alterations (e.g., rash,
change in the shape or colour of a mole, blood in stools), regardless of the meaning
assigned to the change, whether or not it can be observed by others, or whether the
change turns out to be an indicator of disease. Such bodily changes can arise from
normal bodily processes as well as disease, emotions, and environmental conditions
(Gijsbers van Wijk & Kolk, 1997; Kolk, Hanewald, Schagen, & Gijsbers van Wijk,

The model of pathways to treatment

49

Figure 1. The model of pathways to treatment.

2003). In contrast, the term symptom is used to denote bodily changes that have
been appraised to be something abnormal (rather than fluctuations of normal bodily
processes or responses to the environment) (French, Scott, & Powell, in press). It is
acknowledged that the time of first symptom is open to bias and may differ
according to the perspective and context in which it is asked (see Weller et al., 2012
for further discussion and guidance).
 Perceives reason(s) to discuss symptom with HCP represents the time point at
which an individual believes they have a motive to consult a HCP about their
symptom, and thus considers seeking help from a HCP. The term symptom is used
here to represent the translation from a bodily change to something perceived as
abnormal. It is emphasized that this event is the perception of a reason and as such is
subjective rather than a normative need that is defined by HCPs (see Bradshaw,
1972).
Reasons for discussing symptoms with HCPs are likely to be cognitive (i.e., beliefs
about symptoms, e.g., something is wrong/serious), the consequences of symptoms
(e.g., interference of symptoms with ones ability to work (Zola, 1973)), perceived
inability to cope with symptoms (e.g., persistence, failure of self-medication) or
emotional (e.g., anxiety, concern, need for reassurance). The presence of a reason to
seek help will normally arise from the outcome of appraisal and self-management (see
Appraisal interval), but is also dependent on situational, contextual, and social factors.
For example, having an existing pre-booked appointment or having symptoms that
become noticeable to others may trigger the perceived need for health care (Hale,
Grogan, & Willott, 2007; Scott, Grunfeld, Auyeung, & McGurk, 2009). It is important
to note that perceiving a reason to discuss a symptom with a HCP may involve
inferring illness and this will be a common reason for discussing symptoms with HCP.
However, the model does not depend on this, and therefore inferring illness does not
have to occur prior to help seeking: some consultations are for preventative care or for

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S.E. Scott et al.

administrative reasons (Armstrong, 2011). It is also of note that perceiving a reason to

seek help does not equate to having an intention to seek help. Incorporating
reasons into the model is advantageous: it places focus on triggers to seeking help
rather than solely barriers (as has traditionally been the case). This may be more
ecologically valid as individuals do not always appear to be looking to seek help and
then fail to do so because of the presence of barriers. Instead, action is initiated if there
is a trigger or reason for seeking help (which then may be stopped or not acted upon if
barriers are present).
 First consultation with HCP represents the initial discussion of symptoms with a
HCP. If asymptomatic, screen-detected disease or opportunistically detected symptoms or disease are being studied, the first consultation with a HCP represents the
attendance at the screening appointment. HCPs are considered to be providers of
clinical services, who have the capacity to diagnose, order investigations, and provide
or engage with providers of treatment (Weller et al., 2012). In this sense, consultation
with non-health care specialists (such as traditional healers) is considered a form of
self-management. In line with the Aarhus statement (Weller et al., 2012), it is
important to consider two perspectives for the timing of this event: that of the patient
and that of the provider. For example, a patient with lung cancer may have had a
chronic persistent cough lasting 10 or more years. This patient may indicate that their
first presentation to a HCP was the first time they ever mentioned the cough to their
doctor; however a HCP might indicate that the first consultation to primary care was
the first time that the cough prompted consideration of a diagnosis of cancer (Weller
et al., 2012).
 Diagnosis represents the timing of a formal diagnosis. Diagnosis marks the end of
the diagnostic journey and the start of investigations and decisions about treatment. As
with the first consultation with HCP there are a number of perspectives to consider
for this event. For instance, diagnosis of cancer could include when a tissue/
histological diagnosis is made or reported back to the specialist, when the diagnosis is
discussed at a multi-disciplinary meeting or when diagnosis is discussed with the
patient. The Model of Pathways to Treatment does not stipulate which of these
perspectives should be used, but, in line with the Aarhus statement (Weller et al.,
2012), studies reporting the timing of diagnosis should be explicit about how that
date is measured and what it actually means with respect to the diagnostic journey
within that health system.
 Start of Treatment represents the initiation of curative or palliative management of
symptoms. The start of treatment may lead to subsequent symptom appraisal and help
seeking. For instance, treatment regimes may or may not result in diminishment of
symptoms or could have side effects resulting in new symptoms, which would be open
to symptom appraisal and possibly further consultation with a HCP, and further
treatment. This emphasises the need for a cyclical and dynamic framework. In some
situations no treatment will be offered or available, symptoms may resolve prior to the
initiation of treatment, or treatment will be declined. In such cases the decision not to
treat would mark the end of the Pre-treatment interval.
Of course there are many additional events that may occur throughout the pathway to
treatment and beyond (e.g., the occurrence of a bodily change; arrangement and travel to
an appointment, consultations and investigations, referral to specialist care, visit specialist
care, and negotiation of a treatment plan, completion of treatment (Bairati, Fillion, Meyer,
Hery, & Larochelle, 2006; Dang-Tan et al., 2008; Davies, van der, & Cranston, 2007; Evans

The model of pathways to treatment

51

et al., 2007; Molassiotis, Wilson, Brunton, & Chandler, 2010)), yet the five events
specified by the Model of Pathways to Treatment are deemed to be key across the
spectrum of health care provision. Identifying further events would result in more and
shorter intervals; we do not consider they would be useful or meaningful as they may be
too acute, ill-defined, or variable to measure accurately or consistently across diseases,
patient groups, or different health care systems.

Intervals
Intervals are defined as the time periods between events. Importantly, the term interval
is used rather than delay for reasons described above.
 The Appraisal interval represents the time from detection of a bodily change to
perceiving a reason to discuss symptoms with a HCP.
 The Help-seeking interval describes the time from perceiving a reason to discuss
symptoms with a HCP to the first consultation with a HCP about their symptoms.
 The Diagnostic interval describes the time between the first appointment with a HCP
and the formal diagnosis being made.
 The Pre-treatment interval describes the time between formal diagnosis and initiation
of treatment.
For researchers who wish to assess the time from the detection of bodily changes to the
first consultation, date of diagnosis or start of treatment, we suggest that these time
intervals are referred to as the time to presentation, time to diagnosis, and time to
treatment, respectively.

Processes
Processes are defined as the cognitive, emotional, behavioural, organizational, or
structural actions that occur within intervals, the outcome of which may lead to the
next event.
 Processes within the Appraisal interval: During the Appraisal interval, bodily
changes are assessed and responses other than seeking help (e.g., self-medication)
may be initiated. There is an abundance of evidence that appraisal is important in the
decision to seek help, with misinterpretation being a key factor in delays in seeking
help for symptoms of cancer and myocardial infarction (Corner et al., 2006; Smith,
Pope, & Botha, 2005; Turris & Finamore, 2008). There is also increasing evidence that
self-management plays a key role in the pathway to diagnosis and has the potential to
increase the time taken to seek help (Kaur, Lopez, & Thompson, 2006; Mesfin,
Newell, Walley, Gessessew, & Madeley, 2009). Self-management can take many
forms, including actively monitoring symptoms, self-medication, adaptations to
lifestyle, and seeking lay advice. The social and cultural context is highly relevant
during this interval. For instance, symptoms may be noticed by others, and family and
friends may help to make sense of symptoms and assist in self-management. In the
diagram of the Model of Pathways to Treatment the processes in the Appraisal
interval are named patient appraisal and self-management. It is recognized that many
individuals will not be a patient at this stage nor may ever become one during that

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S.E. Scott et al.

symptom episode: the term is simply used to distinguish it from appraisal by HCPs
during the Diagnostic interval.
 Processes within the Help-seeking interval: During the Help-seeking interval, the
decision to seek help is made and arrangements to do so are put in place. The processes
within this interval emphasize that perceiving a reason to discuss symptoms with a HCP
does not necessarily mean that a person will want or intend to seek help or make the
decision to seek help. There may be competing priorities such as work or caring duties,
expectations about seeking care, or issues concerning availability or accessibility of
care provider.
 Processes within the Diagnostic interval: During the Diagnostic interval, a HCP
appraises a patients presenting history, symptoms, signs, and other risk factors in order
to make a judgement about the possible diagnosis. On some occasions, this may require
clinical investigations or referral from one health care provider to another for further
clinical diagnostic tests. The processes within the Diagnostic interval include the
arrangement of these separate appointments and investigations. This is dependent on
the availability and arrangement of the health care system and also involves patients
input and decisions surrounding attendance at separate appointments and acceptance
of further investigations.
The HCP appraisal process can be subject to error and biases that may result in
misdiagnosis, dismissal of symptoms, or no diagnosis being reached. For example,
availability biases can result in consideration of only the most common or plausible
explanation, commission biases create a (sometimes unnecessary) need to act, and
confirmation biases can lead to a search for evidence that supports ideas and dismissal
of evidence that does not (Groopman, 2007). If misdiagnosis occurs or if no diagnosis is
reached, patients are often asked to re-attend, should symptoms persist or get worse.
This is known as safety netting, and returns the patient into the Appraisal interval (Evans
et al., 2007).
 Processes within the Pre-treatment interval: During the Pre-treatment interval
treatment is discussed, planned, and scheduled. In some cases this may also involve
further investigations (e.g., pre-operative tests prior to surgery). As with the Diagnostic
interval, this is dependent on the availability and arrangement of the health care system
and also involves patients input and decisions. Of course, treatment is not always
available or accepted and as such the pathway may not continue to the delivery of
treatment.
Contributing factors
Contributing factors are defined as features of the patient, HCP, health care system, and
disease that influence processes and, in turn, the timing of events and duration of intervals.
The Model of Pathways to Treatment specifies three main types of contributing factor.
Patient factors represent both the individual and the social and cultural context in which
they exist (e.g., demographics, previous experience, co-morbidities, cognitions, and
emotions). Health care provider and system factors represent aspects of the health care
services that can impact both patient and professional decisions and behaviour (e.g.,
access to generalist and/or specialist health care including diagnostic procedures, health
care policy). Disease factors are the clinical and physiological aspects of the condition
(e.g., the disease site and development). Although there will be some overlap, different
factors will influence different processes. For instance, the factors that influence the
detection and interpretation of somatic information may be different from those that
influence help-seeking decisions (de Nooijer, Lechner, & de Vries, 2003). The influence of

The model of pathways to treatment

Threat
(Symptoms)

Illness
representation

Coping Procedure
(Danger control)

(Re)appraisal

Emotional
Response

Coping Procedure
(Fear control)

(Re)appraisal

53

Heuristics

Figure 2. Leventhals Common Sense Model of Illness Self-regulation.

contributing factors precedes the detection of bodily changes and extends beyond the
start of treatment. For example, in line with theories of symptom perception, the quantity
and quality of competing external and internal information, selective attention to the
body, and negative affect may determine whether a person becomes aware of a bodily
change (Pennebaker, 1982; van Wijk & Kolk, 1997).
Contributing factors determine the speed and direction by which an individual
progresses through the pathway to treatment, and therefore are crucially important to
understanding delays in diagnosis and treatment. Unfortunately much of the existing
research into the pathways to diagnosis and treatment has been atheoretical, and in turn
researchers have studied different factors and in different combinations, leading to a
disparate literature. However, contributing factors can be understood through existing
psychological theory of health behaviour. For example, the Common Sense Model of
Illness Self-regulation (Leventhal, Meyer, & Nerenz, 1980) and social cognitive theory
(Bandura, 1986, 1997) offer insight into the factors that influence the processes within
the Appraisal interval and Help-seeking interval. These are now discussed in turn.

Psychological theory within the Appraisal and Help-seeking intervals

The Appraisal interval and the Common Sense Model of Illness Self-regulation
According to the Common Sense Model of Illness Self-regulation (CSM) (see Figure 2) and
related theories (e.g., psychophysiological comparison theory, (Andersen et al., 1995;
Cacioppo, Andersen, Turnquist, & Petty, 1986)), following the detection of a bodily
change/somatic information there is an initial (and automatic) assessment of its
expectedness in the current context and the level of interference (including the salience
and personal relevance as well as the consequences of the symptoms). Those bodily
changes that are expected or do not exceed a threshold of interference will be normalized
and dismissed. This saves cognitive effort of appraising each bodily change (Cacioppo
et al., 1986) and allows functioning to continue (Bradley, Calvert, Pitts, & Redman, 2001).
These (normally adaptive) processes provide extra potential for delays in diagnosis of lifethreatening disease: late detection of somatic information and its dismissal as normal
represents a major part of the delay in seeking help (Kaur et al., 2006).
When bodily changes are unexpected or exceed a threshold of interference, they are
deemed abnormal, and thus a symptom. This activates a more comprehensive symptom
appraisal (a psychophysiological comparison with memories of prior symptom episodes,
other peoples past experience, and illness schemas) to explain and provide meaning to
the symptom (Cacioppo et al., 1986). This in turn is used to plan and implement ways of

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S.E. Scott et al.

coping (e.g., symptom monitoring, self-medication, visiting a HCP) (Leventhal, Brissette,

& Leventhal, 2003).
The CSM posits that various rules or heuristics are used in forming interpretations:
these are outlined in Table 1. In this context, heuristics are said to be rules of thumb that
either automatically, or with deliberate thought, affect decisions relating to the meaning of
symptoms and/or whether symptoms merit medical care (Leventhal, Forster, & Leventhal,
2007).
The CSM posits that the heuristics lead individuals to form a representation about
symptoms. There are five domains of the cognitive representations: identity, timeline,
consequences, control, and cure. The CSM also identifies a parallel emotional response to
health threats. Each domain is represented on two levels: abstract (i.e., what is expected
according to schema) and experiential (i.e., what actually happens). Individuals may
begin with only one or two domains and expand to others, leading to an increasingly
elaborate representation of the health threat.

Coping
Within CSM, the term coping refers to specific behavioural reactions to health threats
(e.g., seeking medical help, self-treatment, monitoring symptoms) rather than general
categories of coping (such as problem- or emotion-focused coping). Key to CSM is that
cognitive and emotional representations of the symptom episode encompass if-then rules
in that certain representations will inform the selection of coping responses (e.g., IF I
believe my headache is due to dehydration, THEN I will drink water) (Mora et al., 2002).
The coping responses have features of the five domains and are on two levels (expected
and experiential). Coping responses can reduce the threat itself (danger control) or the
negative emotions associated with the threat (fear control).
Although a coping response may be implemented to gain more information about the
symptom episode in order to inform the working diagnosis (e.g., wait to see if symptoms
get worse or go away, to gauge seriousness or interference, or to demonstrate the need for
a HCP (Galdas, Cheater, & Marshall, 2007; Moloczij et al., 2008; Smith et al., 2008),
responses mainly arise because of aspects of the cognitive or emotional representation of
the symptom(s) (MacInnes, 2006). For example, those who believe symptoms are signs of
muscular problems, previous or existing health problems, the menopause, aging, or a
minor health condition (identity; consequences) that is perceived to be within their own
control (cure/control) and is not a cause for concern (emotion) are more likely to use selfmedication than to seek help (Asch, Leake, Anderson, & Gelberg, 1998; de Nooijer,
Lechner, & de Vries, 2001a; Khraim & Carey, 2009; Molassiotis et al., 2010; Moloczij
et al., 2008). In contrast, individuals vwho interpret symptoms as a serious condition
(identity; consequences) or at least one that requires HCP intervention to resolve (cure/
control), or have symptoms that are invoking a level of interference (consequences) and
concern (emotion), are more likely to seek help promptly (Mandelzweig et al., 2006).
However, there is also the potential for an individual who is concerned about symptoms
(or embarrassed or ashamed) to avoid or delay seeking help (i.e., through hoping
symptoms will resolve, denial) as a way of fear control (de Nooijer, Lechner, & de Vries,
2001b; Turris & Finamore, 2008).
The self-regulatory system within the CSM includes evaluation of whether or not
implemented strategies are successful in achieving goals. An appraisal that coping has
failed to ameliorate the symptoms can lead to changes in coping procedures (e.g., decision
to seek help) or alterations in the cognitive and emotional representations. Thus, a coping

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55

1. Heuristics influencing the interpretation of symptoms

Heuristic
Symmetry rule

Location rule

Pattern rule

Rate of
change rule
Severity rule

Novelty rule

Duration rule

Age-illness rule
Stress-illness
rule
Optimistic bias

Stereotypes

Prevalence rule

Similarity rule

Description
There is a bi-directional relationship between symptoms and labels in that
experiencing symptoms leads to a search for an illness label and illness labels
produce an expectation of symptoms (Diefenbach & Leventhal, 1996).
The area of the body in which symptoms arise influences their interpretation (e.g.,
oral pain is toothache, and breathlessness is connected to the lungs (rather
than the heart).
Diffuse, ambiguous symptoms lead to greater numbers of comparisons; in turn,
there is more chance of error and more susceptibility to changed
interpretations. Such symptoms are less likely to be interpreted as indicators of
illness or in need of prompt medical care (Burgess et al., 2006; Cacioppo et al.,
1986; Horne et al., 2000; Macleod et al., 2009; Smith et al., 2005).
Those symptoms that are worsening, unstable, or increasing in number, and
symptoms that have a sudden rather than gradual onset, can indicate illness and
provide motivation to seek help promptly (Nyawata & Topping, 2006).
Symptoms that are extreme or severe (rather than mild or vague) and disrupt
functioning indicate the need for care. (Howell et al., 2008; Leventhal et al., 2005;
Mechanic, 1978, 1992; Mora et al., 2002; Safer et al., 1979; Smith et al., 2005).
Symptoms that are new, different, or incongruent (unexpected) with underlying
schema rather than familiar, common, or similar to a co-existing chronic illness
can be a key motivator to seek help (Molassiotis et al., 2010).
Symptoms that are persistent or prolonged (compared to previous experience or
expectations), rather than short lived or intermittent, can indicate a level of
seriousness, which in turn, can be a reason for urgently seeking help (Cacioppo
et al., 1986; Leventhal et al., 2003; Mora et al., 2002; Scott et al., 2007; Smith
et al., 2008; Smith et al., 2005).
As individuals grow older, they increasingly attribute sensations to the ageing
process rather than to illness (Diefenbach & Leventhal, 1996).
Ambiguous symptoms are often discounted during times of acute stress and are
more likely to be attributed to stress rather than physical illness (Cameron
et al., 1995; Leventhal & Crouch, 1997).
Individuals have a generally optimistic bias in that their interpretations, in keeping
with previous experience, and will tend to make innocuous explanations rather
than those that are life threatening (Cacioppo et al., 1986).
Illness schemas (and in turn symptom interpretations) are often governed by
stereotypes (Lalljee et al., 1993; Moloczij et al., 2008). For instance, the male
coronary candidate is often embedded in illness schemas. Subsequently, when
women experience cardiac-like symptoms, cardiac causes tend not to be
considered and there is no urgency to seek help (Davison et al., 1991; Dracup
et al., 2006; Martin et al., 2004).
Symptoms that are perceived to be prevalent in the community are more likely to
be considered less threatening (i.e., minor rather than serious). Conversely,
symptoms that are seen to be rare are more likely to invoke concern and act as
a motivator to seek help (Croyle & Jemmott, 1991).
Perceived susceptibility or vulnerability to illness can emerge from perceived
similarity in exposure, temperament, physical characteristics between the self
and those with a certain illness (Walter et al., 2004), and this in turn can
influence symptom interpretation (Higginson, 2008; Molassiotis et al., 2010;
Smith et al., 2005).

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response of seeking help (or at least the motivation to do so, i.e. perception of a reason to
seek help) may be the result of ineffective self-treatment (Sheppard et al., 2008; Walsh,
1995; Zola, 1973).

Social context
Self-regulation is dependent on input and expertise from others, including family, friends,
and neighbours as well as HCPs (Prior, Evans, & Prout, 2011). Individuals may actively
seek the advice of friends or family, or may receive advice if symptoms are (or become)
noticeable by others (Cornford & Cornford, 1999; Friedson, 1961; Levine, 1999;
Molassiotis et al., 2010; Moloczij et al., 2008; St Claire, 2003). Social and cultural factors
influence individuals symptom/illness representations via provision of linguistic labels
for differentiating and categorizing the array of events that constitute illness and
determining whether ones experiences are normal (Leventhal et al., 2003). For instance,
social contacts can help an individual predict how one should expect to feel, determine
the need for care, and get permission to seek care (see section on Social Cognitive Theory
for more discussion of social sanctioning). The socially learnt schema or abstract
representations built from input from others may not always concur with experiential
representations. For instance, Bauman and Leventhal (1985) present the case of
conflicting illness representations of hypertension whereby a nurse acknowledges that
hypertension is asymptomatic (abstract schema) yet based on her own illness episodes
(experiential knowledge) she believes she can tell when her own blood pressure is raised
(when she has a headache or warm face).
For some conditions, early disclosure of symptoms to significant others is associated
with prompt use of health services (Burgess et al., 2006); however this is not always the
case. Lay advice may consist of recommending self-treatment rather than seeking help
from a HCP (Alonzo, 1986; Dracup et al., 2006). Social influence and input can alter selfregulatory processes but they do not define it: individuals can attend to or ignore input.
The self remains the primary agent of self-regulation (Leventhal et al., 2003).

The Help-seeking interval and Social Cognitive Theory (SCT)

If a person perceives a symptom as something that will recover naturally or with the
assistance of home remedies, they are unlikely to perceive a reason to discuss the
symptom with a HCP and thus will not consider seeking help or form an intention to do so.
As such, perceiving a reason to seek help (and the perceived urgency to do so) creates the
precursor or precondition to seek help. However, additional influences determine
whether this translates into help-seeking behaviour. Social Cognitive Theory (SCT;
Bandura 1986, 1997: Figure 3) offers a theoretical model that can be used to understand
and investigate the processes and anticipatory factors that influence behaviour occurring
within the Help-seeking interval.

Self-efficacy
When a person perceives a reason to discuss a symptom with a HCP whether or not they
decide to actually seek help (and the time it takes them to do so) will be determined, in
part, by their self-efficacy (perceived ability) to discuss the symptoms and get help. If the
barriers to seeking help appear insurmountable or help is perceived as unavailable, no
intention will be formed. SCT suggests that socio-structural barriers may be either

The model of pathways to treatment

57

Outcome expectations
Physical
Social
Self-evaluative
Proximal
goals

Self-efficacy

Behaviour

Impediments
&
opportunities

Figure 3. Banduras Social Cognitive Theory.

personal, or aspects of the health care system. Personal barriers may include a lack of time
to visit a HCP, problems arranging travel to HCP, or general lethargy (e.g., due to
depression) (Bunde & Martin, 2006). Health care system barriers include accessibility,
affordability, availability, acceptability, and accommodation, including trust in HCPs
(Dracup et al., 2006; Elzawawy, Elbahaie, Dawood, Elbahaie, & Badran, 2008; Kaur et al.,
2006; Penchansky & Thomas, 1981; Scanlon et al., 2006). These factors vary across
countries according to particular aspects of their health care system. On the other hand
socio-structural opportunities such as having a pre-booked appointment or free health
screening may encourage prompt help seeking via making health care utilization easier
and thus enhancing self-efficacy to seek help. Self-efficacy is developed through previous
experience (mastery), vicarious experience provided by social models, and social
persuasion. As such an individuals previous behaviour, their prior experiences with
HCPs, and their social context will impact upon present and future confidence to seek
help.

Outcome expectations
A persons intention (conceptualized as a goal in SCT) to seek help and the strength of the
goal commitment is not solely formed through self-efficacy beliefs and socio-structural
barriers/opportunities. Bandura maintains that outcome expectations (perceived consequences of action) are also highly significant (Bandura, 1997). Unless people believe that
help seeking can produce desired effects (e.g., a HCP will enable symptom relief or reduce
anxiety), they will have little incentive to act in that way.
Bandura specifies three categories of outcome expectancies: physical, social, and selfevaluative.
 Physical outcome expectancies that could act as incentives to seek help (and thus
lead to prompt help-seeking) include the belief that seeking help would reassure and
reduce anxiety/uncertainty, provide pain relief or resolve symptoms, or improve
prognosis (i.e., it is best to seek help sooner rather than later). In contrast, physical
outcome expectancies that may disincentivize or delay help seeking include the belief
that seeking help could result in: pain/suffering, or, being diagnosed with a disease that
could lead to death (and as such instil fear of dying or leaving relatives); unwanted or
unpleasant treatment /examinations/investigations; or embarrassment (if it turns out to
be false alarm or because symptoms are in sensitive/sexual areas) (Burgess et al., 2006;

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S.E. Scott et al.

Dracup et al., 2006; Elzawawy et al., 2008; Leydon, Bynoe-Sutherland, & Coleman,
2003; Scanlon et al., 2006; Smith et al., 2005; Turris & Finamore, 2008). The act of
seeking help or the possibility of being diagnosed with an illness may also be seen as an
action that could disrupt ones life or prevent someone from carrying out their duties
and lead a person to continue to self-manage symptoms even though they may be
debilitating (Elzawawy et al., 2008; Sheppard et al., 2008).
 Social outcome expectancies involve social sanctions and social reactions that
action is thought to evoke. There are many social sanctions or actual social reactions
that could impact the timeliness of help-seeking behaviour. For example, a person may
delay consulting a HCP because they think that they may be seen as weak, neurotic, or a
time waster if minor symptoms turn out to be due to minor illness, or that help seeking
will burden or bother the doctor, family members, or friends (Albarran, Clarke, &
Crawford, 2007; Corner et al., 2006; Dracup et al., 2006; Facione & Facione, 2006;
Galdas et al., 2007; Khraim & Carey, 2009; Smith et al., 2005). For certain diseases such
as sexually transmitted infections or mental health problems, seeking help may be
prevented or delayed by fear of disapproval, rejection, or being discredited by family
members or friends (i.e., stigma) (Ireland, Reid, Powell, & Petrie, 2005; Scanlon et al.,
2006). Seeking help may also be seen as inappropriate or unacceptable because of
received (or perceived) lay advice not to seek help. Alternatively, seeking help may be
sanctioned because a HCP (previous or current) or family/friends have offered advice or
requested them to do so (Alonzo, 1986; Smith et al., 2005). When individuals are
confident that they have a legitimate concern and/or a set criteria has been reached
(e.g., high pain threshold/proof of self-treatment not working) help seeking may not
require direct social sanctioning (Alonzo, 1986; Galdas et al., 2007; Moloczij et al.,
2008). Help seeking may also circumnavigate sanctioning if the HCPs time can be used
more effectively (e.g., by waiting until more than one concern is present) (Scott et al.,
2009; Smith et al., 2008).
 Self-evaluative outcome expectancies. Bandura suggests that individuals do not
always behave according to how they think other people want them to behave.
Individuals also regulate their behaviour via self-evaluation and self-sanctions. Thus,
some outcome expectancies are related to impact on self-worth and self-satisfaction. If
seeking help is thought to be a threat to pride, self-identity or ones sense of
independence, then this may hinder or prevent the presentation of symptoms to HCPs
(Chapple, Ziebland, & McPherson, 2004; Moloczij et al., 2008; Smith et al., 2008).
Conversely, a belief that visiting a HCP will reinforce their perception of being someone
who takes care of their health, or that seeking help will allow them to stay healthy and
take care of themselves, may be an incentive to seek help promptly.
Outcome expectancies about alternative actions (e.g., self-management) may also be
considered. This could explain the role of anticipated regret on help-seeking behaviour
(de Nooijer et al., 2003). It is also important to recognize that a decision to seek help based
on weighing up outcome expectancies is not necessarily rational. People make faulty
judgements by having inadequate information or misreading events, having erroneous
conceptions about themselves or the world around them, or not fully considering
different choices.
It is widely recognized that intentions do not always lead to action (Sheeran, 2002).
SCT posits that outcome expectations and self-efficacy also have an additional direct
influence on behaviour. Furthermore, the degree to which goals govern performance is
influenced by goal proximity. Bandura noted that distal goals alone are far too removed in

The model of pathways to treatment

59

time to provide effective incentives and guides for present action. This has relevance to
help-seeking behaviour: when seeking help is not seen to be urgent, competing priorities
such as childcare, co-morbidities, jobs, or holidays may also lead to an intention not being
acted upon and replaced by a different course of action (Facione & Facione, 2006; Kaur
et al., 2006; Scanlon et al., 2006; Scott, Grunfeld, Main, & McGurk, 2006; Smith et al.,
2005).

Future directions
The Model of Pathways to Treatment can be used to direct future early diagnosis
research. There are a number of avenues that require further investigation. Firstly, due to
the overlap with the Andersen model and existing research into help-seeking behaviour,
the Model of Pathways to Treatment inherits some supporting evidence. However, there
needs to be further validation of the Model of Pathways to Treatment. This will include
assessment of the relative importance of the different contributing factors (including both
barriers and triggers) within the different intervals and across diseases (including mental
health). Future validation research could also include comparisons between patient and
HCP groups, health services and health care systems. Such research will require valid and
reliable measurement tools to measure both the intervals and contributing factors.
Measurement is an important but neglected issue within early diagnosis research and one
that requires focused attention (Scott & Walter, 2010; Weller et al., 2012).
There is also scope for experimental work to confirm, document, and influence the
heuristics and biases involved in symptom appraisal and interpretation. This includes
learning how heuristics interact with one another and under what circumstances, as well
as testing de-biasing strategies.
Community studies and studies of different patient groups with the same symptoms
would allow investigation of patient movement through the Model of Pathways to
Treatment in order to determine common pathways and entry points and to investigate the
proportion of patients who move through the intervals in a linear versus non-linear manner.
This paper has focused on the psychological processes involved in the Appraisal and
Help-seeking intervals. Future research could enhance understanding of the Diagnostic
and Pre-treatment intervals. It is possible that heuristics and biases in patients symptom
appraisal are also relevant to HCPs appraisal of symptoms within the Diagnostic interval.
Indeed, there is a growing body of research on clinicians decision making (e.g.,
Kostopoulou, Delaney, & Munro, 2008; Kostopoulou, Mousoulis, & Delaney, 2009), but
more attention is required on this area.
Finally, the ultimate purpose of increasing understanding of the factors that result in
delays in diagnosis and treatment is to identify targets for interventions in order to
encourage early detection, presentation, and treatment of illness, and therefore improve
prognosis. There is currently a dearth of effective interventions to encourage early
presentation and symptomatic diagnosis and many interventions that do exist are
methodologically flawed and not theory based (Austoker et al., 2009). Future
interventions could use the Model of Pathways to Treatment to underpin interventions
and the selection of outcome variables. This will involve mapping the contributing
factors to delayed diagnosis and treatment to behaviour change techniques (Michie,
Johnston, Francis, Hardeman, & Eccles, 2008). The CSM and SCT both provide ways of
intervening in addition to explaining behaviour. Through identifying biases and
heuristics that influence symptom appraisal, it is possible to also identify specific

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S.E. Scott et al.

de-biasing strategies that reduce errors in judgement that may be used in interventions
to encourage early presentation. In SCT the variables that form the prediction model
are the same ones that inform the intervention model (Bandura, 1998).

Summary and conclusion

This paper has introduced and outlined the Model of Pathways to Treatment, detailing
its concepts and specifying how existing psychological models such as Leventhals CSM
and Banduras SCT can underpin the Appraisal and Help-seeking intervals. The
underlying assumption of SCT is that there is a reciprocal relationship between the
environment, personal, and social determinants: this reflects the complex processes
involved in the decision to seek help. Both the CSM and SCT map self-regulatory
processes. This encapsulates the dynamic nature of symptom perception, interpretation,
and self-management: perceptions and responses may change over time, with a number
of reiterations. Of course there are many other psychological theories of health
behaviour: the Theory of Planned Behaviour (Ajzen, 1988), Protection Motivation
Theory (Rogers, 1983), the Health Action Process Approach (Schwarzer, 1992), and the
Health Belief Model (Becker, 1974) all propose factors influencing health behaviours.
Many of these models have constructs in common with those within SCT and therefore
may be applicable to the Model of Pathways to Treatment, particularly the Help-seeking
interval.
Theoretical frameworks of health behaviour provide a systematic approach to
improving understanding by building on existing knowledge and allowing hypothesis
generation. However, the vast majority of research on symptom appraisal and helpseeking behaviour has been atheoretical and has applied a range of different definitions
and different methods to collect and analyse data. Consequently, there is little consistency
across studies, making comparisons between and within conditions, patient groups, or
health care systems extremely difficult.
The Andersen model has been used to describe the decisions leading to health care use.
However, there are a number of problems with the Andersen model, which has limited its
success in application and uptake. This paper has detailed a revised descriptive
framework to address existing conceptual and operational problems with the Andersen
model. The Model of Pathways to Treatment provides a useful theoretical approach for
future studies to inform the measurement, description, and understanding of time to
diagnosis and treatment initiation. This provides scope for greater consistency in
reporting, better comparison of data across studies, an expansion of existing knowledge,
and the development of more effective interventions.

Acknowledgements
Many thanks to Professor John Weinman (Institute of Psychiatry, Kings College London) for his
useful comments on an earlier draft of this manuscript.

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Received 24 November 2011; revised version received 16 March 2012