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We investigated the incidence of stroke among Iranian pilgrims during the 2007 Hajj ceremony, and found that the overall incidence was lower as compared to what was seen in the general population of Mashhad, Iran. This pattern is likely attributable to the pre-pilgrimage medical screening performed by the Hajj and Pilgrimage Organization of Iran. The screening program for the Hajj is simple, comprising evaluation of blood pressure, diabetes and other vascular risk factors. In suspected cases of vascular disorders, electrocardiography is performed with referral for cardiology or neurology consultation. Candidates with severe dementia, uncontrollable cancer, severe disabling stroke and recent (less than 3 months) myocardial infarction are excluded from participation in the Hajj ceremony. Therefore, it can be argued that such enhanced screening system may have reduced to some degree the stroke risk factors by selecting individuals devoid of severe and life-threatening disease. The finding implies a research hypothesis whether population-based screening programs would reduce stroke in communities. This simple screening could be tested in the general population with the aim of treating these risk factors to prevent vascular events. It is also possible that the pilgrims with the knowledge of having the upcoming trip would be more conscious about their health status. In other words, people participating in the Hajj are healthier than the general population, similar to what is observed in the healthy migrant effect .
This study has some limitations. Any occurrence of stroke would have health planning implications; however, in order to have a comparable group with the MSIS subjects, we evaluated only first ever strokes rather than all strokes. Although the pre-pilgrimage medical screening may have resulted in overall lower first-ever stroke rates in Iranian pilgrims, it may have imposed an unavoidable selection bias, once comparing the Hajj pilgrims with the general population of Mashhad, Iran. The latter group comprises those with diverse socio-economical status and underlying factors that may affect their health. Mashhad is the second populous metropolitan of Iran and a religious centre that attracts many migrants from all parts of the country. The MSIS has been so far the only comprehensive population-based study of stroke in Iran. Although the result of this study cannot readily be generalized to the whole country, other unpublished local data suggest comparable cerebrovascular risk profile in other cities, similar to what was found in the MSIS. This gives us some confidence that Mashhad can be regarded as representative of the urban population of Iran and the MSIS results can provide a good proxy of the national incidence of urban population, but not the rural population. It should also be noted that the baseline information and risk profile were only available from the Hajj pilgrims with first-ever stroke, not all the pilgrims. Therefore, the comparison between demographic and pre-morbid risk factors of all Hajj pilgrims and the general population of Mashhad, Iran was not possible. In addition, we were unable to evaluate the processes and outcomes of care for Hajj pilgrims with stroke.
Little data exists on the factors associated with health care seeking behaviour for primary symptoms of colorectal cancer (CRC). This study aimed to identify individual, provider and psychosocial factors associated with (i) ever seeking medical advice and (ii) seeking early medical advice for primary symptoms of colorectal cancer (CRC).
The seriousness of symptoms, importance of early detection, and prompt consultation must be articulated in health messages to at-risk persons. This study identified modifiable factors, both individual and provider-related to consultation behaviour. Effective health promotion efforts must heed these factors and target sub-groups less likely to seek early medical advice.
Based on existing literature relating to the barriers and facilitators of medical advice seeking, an a priori investigation of the following items selected from the HCS databank were assessed: Socio-demographic and lifestyle characteristics, i.e. age, gender, education, marital status, country of birth, household income, retirement, private health insurance status, tobacco or alcohol use; Clinical characteristics i.e. general practice visits per year, previous cancer diagnosis (excluding CRC), body mass index, and co-morbidity (e.g. high cholesterol, hypertension, asthma, diabetes); and Psychosocial characteristics i.e. physical health, assessed using the physical health component summary score (PCS) on the short form health survey (SF-36)  and mental health, assessed using the Kessler Psychological Distress Scale (K-10) . The PCS is a physical health summary score aggregated from the physical functioning, role-physical, bodily pain and general-health scales on the SF-36 . Predictors ascertained from respondents at the time of survey completion included: trigger for seeking medical advice, symptom characteristics, first degree relative diagnosed with CRC, family history of CRC discussed with doctor, and ever received screening advice from doctor.
Of the 1075 respondents to the rectal bleeding question, 332 (31%) reported ever experiencing this symptom with 60 (18%) respondents never having consulted a doctor. Additional file 2 presents the univariate (Pearson χ2) associations between socio-demographic, clinical and psychosocial characteristics and ever seeking medical advice for rectal bleeding. Multiple logistic regression modelling identified the following significant predictors of ever seeking medical advice for rectal bleeding: being male and persons that had ever received screening advice from a doctor or other health professional (See Table 2).
Male persons were significantly more likely to seek medical advice for rectal bleeding. This finding is inconsistent with previous literature that has indicated males are less likely to present for medical care across a wide-trajectory of health issues [64, 65]. Nonetheless, previous community-based studies relating to medical consultation for bowel related symptoms have generally indicated no gender difference [6, 66]. Further, a systematic review of delay in diagnosis of CRC highlighted that sex had no impact on presentation times . Future exploration of the barriers to help seeking for rectal bleeding among female persons and addressing such behaviours in public awareness campaigns may assist in improving overall consultation rates.
The present study identified that persons experiencing rectal bleeding who had ever received screening advice from a doctor or other health professional were significantly more likely to have ever sought medical advice. For this finding, the exact temporal sequencing of events was not ascertained, making extrapolation of exact cause and effect difficult. Intuitively persons may have experienced rectal bleeding, consulted a doctor and received screening advice after symptom episode. Alternatively persons may have received screening advice prior to symptom episode, with recollection of such a conversation prompting the increased likelihood of medical consultation. This temporal sequencing issue also relates to our finding that discussion of family history, regardless of whether the respondent was informed of increased risk, resulted in increased likelihood of ever consulting a doctor for change in bowel habit. Future research is required that clarifies the sequence and timing of such events.
The current study indicated that persons with private health coverage were significantly more likely to seek early medical advice for rectal bleeding. Such a finding is not surprising, given that persons without health insurance are known to have limited access to medical care  and poorer health outcomes [70, 71] compared to privately insured persons. For this group it is proposed that increased morbidity and mortality of CRC is a result of restricted access to medical and surgical care [70, 72]. In relation to CRC, health insurance status heavily influences access to care, screening and long-term outcomes [70, 72, 73]. Previous research has indicated that persons without health insurance are more likely to present with advanced cancer . For CRC, uninsured and Medicaid populations have been found to be at greater risk of developing post-operative complications and in-hospital mortality compared to those privately insured . More recent research also highlights longer pre- and post-presentation times for CRC patients without private health insurance . Restricted access to health care or more concerning, lack of any medical advice seeking for those without private health insurance raises significant issues relating to possible delayed diagnosis, worse overall health, and advanced disease progression.
Previous community and population-based studies have identified that perceived symptom seriousness is an important factor in eliciting medical consultation for rectal bleeding [44, 45]. Studies that have examined retrospective recall of cancer patients have commonly identified that failure to recognise symptom seriousness is a significant factor associated with patient delay . Previous population-based studies have indicated that failure to consult or delay (> 3 months) in seeking medical advice for rectal bleeding is due to an underestimation of symptom seriousness [6, 43]. A similar finding has been demonstrated for patients recruited in the general practitioner setting . The current study indicated that persons perceiving their symptom as serious were more likely to see a doctor at an earlier time point (< 2 weeks). This finding suggests that perception of symptom seriousness is not just an important factor for medical consultation but also contributes to earlier presentation time. Intuitively future health messages directed a