TEORIAS DE LA COMPRENSIÓN LECTORA:

In Scotland, the majority of persons chronically infected with Hepatitis C (HCV) remain undiagnosed and many of those diagnosed fail to reach and stay within HCV specialist care services.(Parkes, Roderick, Bennett-Lloyd, and Rosenberg 2006; The Scottish Government 2008) According to the Hepatitis C Action Plan for Scotland,(The Scottish Government 2008) nearly 50% of newly diagnosed infected persons, referred to HCV specialist centres, do not attend their appointment. Referral to an HCV specialist centre gives patients the opportunity to consult medical staff on appropriate courses of treatment, a differential diagnosis, expert clinical management, an assessment of the stage of infection and advice on precautionary measures to avoid secondary infection.(Brown 2002; Scottish Intercollegiate Guidelines Network 2006) For the 50% of patients that do not attend their referral or follow-up appointments, it becomes increasingly difficult for medical staff and policy makers to prevent complications of chronic HCV infection, which is a leading cause of liver cirrhosis and hepatocellular

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carcinoma worldwide.(Alter 2007; Perz and Alter 2006; Perz et al. 2006) Therefore, low rates of HCV specialist centre utilisation are a significant issue to address.

In order to improve rates of utilisation, policy makers need knowledge of what is causing the low uptake of referral, and for those patients that do attend their initial appointment, which factors are influencing continued follow-up. Gender could be important, with men reported to know more about HCV treatment than women,(Walley et al. 2005) but with women more likely to seek healthcare for HCV.(Gisbers van Wijk, van Vliet, and Kolk 1996; Temple-Smith, Stoove, Smith, O'Brien, Mitchell, Banwell, Bammer, Jolley, and Gifford 2007). Studies (Davis, Rhodes, and Martin 2004; Davis and Rhodes 2004; Fraenkel, McGraw, Wongcharatrawee, and Garcia-Tsao 2006; Munoz- Plaza, Strauss, Astone-Twerell, Jarlais, Gwadz, Hagan, Osborne, and Rosenblum 2008; Walley et al. 2005) have suggested that low awareness of HCV-related healthcare is an issue, particularly amongst patients with a history of intravenous drug use (IDU) of whom comprise a large proportion of the infected population in the UK (Hutchinson, Bird, and Goldberg 2005; Hutchinson et al. 2006), USA (Alter 2007; Armstrong et al. 2006) and Australia.(Shepard, Finelli, and Alter 2005). This may be partially influenced by a lack of HCV-related knowledge amongst GPs more generally (d'Souza et al. 2004; Ouzan et al. 2003a; Ouzan et al. 2003b; Rotily et al. 2002; Shehab, Sonnad, and Lok 2001) which means that whilst some patients are referred, the significance of attending the referral appointment is not being conveyed to all.

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Awareness of HCV amongst medical professionals could vary geographically. GPs who more frequently consult patients with a history of IDU, for instance in socioeconomically deprived, often inner city areas where prevalence tends to be high,(Craine, Walker, Carnwath, and Klee 2004; Hutchinson et al. 2004) are also likely to have knowledge of HCV protocol to convey to the patient. In more remote, rural areas where the diagnosis of HCV is less common,(Monnet et al. 2006; Monnet et al. 2008) it may be that GPs are less competent at interpreting hepatitis antibody test results or are lack knowledge of the correct protocol to communicate to the patient.(d'Souza et al. 2004; Hallinan, Byrne, Agho, and Dore 2007) Therefore, attendance of the first appointment could vary geographically, with lower rates of utilisation among patients living in more rural, remote areas.

Even for those patients that do attend their first appointment, however, geography may continue to be significant. For instance, patients required to travel much further to visit a specialist centre on a frequent basis and over a long period of time may find it more difficult to do so, compared with those patients that live closer.(Bentham and Haynes 1985; Joseph and Bantock 1982) A lack of geographic access can particularly influence utilisation rates amongst persons with limited transport options (e.g. the elderly).(Nemet and Bailey 2000) Low utilisation rates have frequently been associated with patients required to travel long distances and travel-times specialist healthcare centres for cardiac rehabilitation,(Ades, Waldmann, McCann, and Weaver 1992; Ades, Waldmann, Polk, and Coflesky 1992; Farley, Wade, and Birchmore 2003; Grace et al.

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2002; Lieberman, Meana, and Stewart 1998) pulmonary rehabilitation,(Sabit et al. 2008) alcoholism treatment aftercare,(Fortney et al. 1995) outpatient mental healthcare,(Schmitt, Phibbs, and Piette 2003) depression treatment,(Fortney, Rost, Zhang, and Warren 1999) outpatient drug treatment,(Beardsley et al. 2003) breast cancer treatment and aftercare,(Athas et al. 2000; Jones et al. 2008a; Meden, St. John- Larkin, Hermes, and Sommerschield 2002; Nattinger, Kneusel, Hoffmann, and Gilligan 2001) and veterans hospital use in the US.(Burgess and Defiore 1994; Mooney, Zwanziger, Phibbs, and Schmitt 2000) The commitment to making regular trips, the opportunity-cost of having to take time off work or finding help to look after dependents (Jordan, Roderick, Martin, and Barnett 2004; Nemet and Bailey 2000), and stoic attitudes towards seeking healthcare (especially for stigmatised infections, such as HCV) (Casey, Thiede Call, and Klingner 2001; Crisp et al. 2000; Day et al. 2006; Farmer et al. 2006; Fox, Blank, Rovnyak, and Barnett 2001; Fuller, Edwards, Procter, and Moss 2000; Wellstood, Wilson, and Eyles 2006) may all be amplified by living in remote, rural areas. So far, however, no similar study has been published for utilisation rates of HCV specialist centres.

Therefore, in the case of explaining what factors are associated with the low rates of utilisation of HCV specialist centres, it seems intuitive that patients with further to travel may be less likely to attend their first appointment, or if they do, will find it more difficult to keep up with subsequent appointments compared with patients that live closer to an HCV specialist centre. This chapter explores these hypotheses using data

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available within NHS Tayside (Scotland), where patients are referred to a single HCV specialist centre located in the city of Dundee and the surrounding topography and infrastructure exacerbates the remoteness of rural communities.