Table 4 Study themes, sub-themes, codes, and sample participant excerpts

Perceived barriers to patient help-seeking for signs and symptoms of concern

Healthcare system-related barriers to help-seeking

• High cost of a GP visit

GP, CP, PHN, PN

“Where I’m working, we have a huge volume of patients with medical cards, and I’d find that they’re much more ready. They want to talk to you. They want to show you everything and they’re nearly asking you, ‘Should I go to the GP? I think I’ll call the doctor…It’s a different environment or it’s a different ethos” (CP2)

• Waiting times to see a GP and time constraint

GP, CP, PHN, PN

“I’m suffering myself. I’m trying to find a GP. Just for myself with a GP and I’ve asked over 15 practices around…and nothing” (PN1)

• Bad experiences with mis/delayed diagnosis, and chest X-ray failure to detect lung cancer

GP, PHN, PN

“They [family] had great faith in their GP and they were very happy with him generally, but they just felt that he was not acting on the fact that she was deteriorating so quick, on how they would like it to proceed. And they felt they had to circumvent him” (PHN1)

Patient-related barriers to help-seeking

• Embarrassment, guilt, and fear of judgement due to smoking history

GP, CP, PHN, PN

“If people are smokers, they feel that perhaps I brought this on myself and I’ve nobody to blame but myself. So, bury their head in the sand” (PN2)

• Emotional factors: cancer fear, denial, and anger

GP, CP, PHN, PN

“Our patients are very busy. Their heads and their lives are very full just running around sorting stuff out…they literally haven’t got the bandwidth for contemplating something major like that [cancer diagnosis]. They just don’t want to think about it, so they just act like it’s not happening…then it’s up to us to pick it up…” (GP5)

• Sociodemographic factors: educational level, drug use, homelessness, and being male and older

GP, CP, PHN, PN

“It’s always the wife who rings up, isn’t it? [laughter] to the public health nurse centre…especially with the older male, you tend to get a bit of that. So that’s something I would have experienced…” (PHN4)

The impact of the COVID-19 pandemic on patient help-seeking

• Stigma and embarrassment relating to cough

CP, PN

“That’s a huge thing at the moment that I’m recognising. If someone comes in with a cough that’s totally unrelated to COVID, they nearly feel embarrassed. So, I think in this instance, that might be a barrier to presentation as well for people on a practical level” (CP2)

• Lack of in-person contact with healthcare professionals

GP, CP, PN

“I’ve so many patients who are just getting antibiotic prescriptions emailed in and it’s the patients who aren’t going to the GP because they’re supposed to be cocooning and they’re not even getting seen. So, they’re not even having their chest listened to and they’re having antibiotic prescriptions sent over and I’m not even seeing them because there’s a family member coming in to pick it up. So, I think that’s a real barrier” (CP1)

• COVID-19-related health issues prioritised

CP, PHN, PN

“When COVID started, nobody knew where we were and what was happening. Clinics were being cancelled. Patients were ringing us going: ‘This clinic has been cancelled. What do I do now? Where do I go? I need advice on my inhalers.’ Everybody was stuck. I think we’re still a bit stuck” (PN1)

• Fear of contracting or transmitting COVID-19 in healthcare settings

CP, PHN, PN

“Because of the COVID scares in hospital infections, people have definitely put off accessing treatment for any symptoms. It’s not just specific to lung cancer and talking amongst ourselves in the practice, I’m in a primary care centre, we would definitely associate three or four sudden deaths in the past six months, that was really missed care because of COVID where they’ve put off accessing care and it turned out that other things happened, whether it was an MI [myocardial infarction] or whatever…” (PHN1)

Facilitating early patient presentation for signs and symptoms of concern

Recommendations to promote patient help-seeking

• Patient education

GP, PN

“They [patients] may not be fully aware that GPs have a vital access to lung cancer treatment, and I think maybe emphasising that, they probably see lung cancer as being more a hospital-based thing and not seeing the GP as the gateway to that secondary care” (GP2)

• Accessibility of additional and free services for LC health checks/health screening and diagnosis

GP, CP, PHN, PN

“What we did when we started, it is we sent out a message to all of our patients in that category and we offered them a free screening service, FREE in big letters because people like to get things for free” (PN1)

• The positive role of family, GP, and community supports

GP, CP, PHN, PN

“The home helps are quite good. You’ve a lot of people living alone in our area and the only one that they see or may be in contact with that they’d confide in. The family obviously would be in contact, but they maybe God knows where. They’re not on the ground. And I find home helps are brilliant. They would ring up and they’re saying that they are a little bit concerned seemingly…even people that actually deliver the meals on wheels. That sounds probably a little bit mad, but like that’s the only port of contact for a lot of these people living on their own. But they seem to be on the alert a lot…their role is nearly underestimated…” (PN2)

Perspectives on previous patient-focussed campaigns

• Risk of information overload in both campaigns

GP, CP, PHN, PN

“I like the poster [Be Clear on Cancer]. I find the leaflets, although I find them interesting and I think medical people would read through it, I think they’re actually quite wordy for people who aren’t medically minded” (PHN1)

• Mixed views on the visuals of both campaigns

GP, CP, PHN, PN

“I liked the green [Be Clear on Cancer]…I think green is a colour of calm…” (PN2)

“It [Detect Cancer Early leaflet] draws your attention…eye catching and identifiable” (GP4)

• The risks and benefits of using patient, doctor, and celebrity profiles in both campaigns

GP, CP, PHN, PN

“The NHS England one [Be Clear on Cancer] just has sort of random doctors on it. I’ve never heard of them. Can’t really identify with them. This [Detect Cancer Early] is more eye catching and it’s got Fergie [Alex Ferguson] on it, so immediately you’re going to pay attention and it’s got the symptoms on it. It’s nice. It’s accessible. It’s not overly text driven. It’s a slicker leaflet. It resonates with you better plus just simple things like the photo, it draws your attention. The other one is sort of sterile and you can’t really engage with it on the same level” (GP4)

• The benefits of the catchy slogan and strapline of the “Detect Cancer Early” campaign

GP, CP, PHN, PN

“The take-home message [Detect Cancer Early] is catch it earlier and you’ve got a better chance. Don’t get scared, get checked and it doesn’t have to mean game over. It’s not what it used to be. I like that one” (GP3)

“You’re not wasting anyone’s time [Be Clear on Cancer]. That’s a very useful point actually. That’s really good. Your GP wants to see you. There’s lots that can be done to treat lung cancer these days, especially if it’s found early” (GP1)

• Practicality and usability of leaflets for patients queried

GP, CP, PHN, PN

“Leaflet was too long, and that patients would get bogged down in the detail of it” (GP3)

“The card for the wallet I’d say will be in there and that’s where it’ll stay, to be honest with you [Laughter]” (PHN4)