Patterns of consultation and treatment for heartburn: ®ndings from aSingaporean community survey

K. Y. HO*, J . Y. KANG  & A. SEOWàDepartments of *Medicine and àCommunity and Family Medicine, National University of Singapore, Singapore;

and  James Paget Hospital, Great Yarmouth, Norfolk, UK

Accepted for publication 29 March 1999

INTRODUCTION

Gastro-oesophageal re¯ux disease (GERD) is widely

believed to be uncommon in the Asian populations. In

support of that belief, recent studies from Singapore

showed that the frequencies of re¯ux oesophagitis in

patients presenting for endoscopy,1 symptomatic gastro-

oesophageal re¯ux in pregnant women,2 and proven

gastro-oesophageal re¯ux in hospital outpatients3 are

lower among Singaporeans than their Western coun-

terparts. However, such patients represent a small

proportion of all subjects with GERD; it has been

estimated by a Western investigator that only about

5% of heartburn sufferers ever consult a physician for

their symptoms.4

We had previously reported the results of a community

survey and shown that the prevalence of frequent

re¯ux-type symptoms among community individuals in

Singapore was as low as 2%.5 The symptoms were more

common among Indians than Chinese or Malays. The

aims of the present paper were threefold: to determine

the healthcare seeking behaviour of subjects with

heartburn in Singapore, to describe the way in which

these heartburn sufferers used the various medications

available for re¯ux, and to determine whether ethnic

differences exist in either of these practices.

SUMMARY

Background: The prevalence of re¯ux-type symptoms

among community individuals in Singapore is low.

Aim: To describe the healthcare-seeking behaviour of

those subjects with heartburn.

Methods: A cross-sectional survey, using a reliable and

valid questionnaire, was carried out on a race-strati®ed

random sample of residents, aged 21±95 years, in a

Singaporean town; 93% responded (n� 696).

Results: The ethnic-adjusted prevalence of heartburn for

the past 1-year was 4.6%. Sixteen (30%) of the 53

heartburn sufferers had sought consultation for their

symptoms. They were more likely to have severe

heartburn (P < 0.001), and to have complained of

nocturnal awakening due to heartburn (P < 0.05) than

those who did not present to medical attention. Ethnic

origin did not in¯uence the consultation pattern. Only

18 (34%) of the 53 heartburn sufferers received

pharmacological therapy for their symptoms. The most

commonly used medication was antacid. Medication

use was associated with symptom severity (P < 0.05),

but not ethnicity.

Conclusions: Heartburn is uncommon in the general

population of Singapore. Few heartburn sufferers seek

medical attention, and most do not receive medications

for symptomatic control. The decision to seek medical

advice and/or to medicate was generally linked to

symptom severity, but not to ethnicity.

Correspondence to: Dr Khek-Yu Ho, Department of Medicine, National

University Hospital, Lower Kent Ridge Road, Singapore 119074.E-mail: mdchoky@nus.edu.sg

Aliment Pharmacol Ther 1999; 13: 1029±1033.

Ó 1999 Blackwell Science Ltd 1029

MATERIALS AND METHODS

Questionnaire

We have previously reported the development of the

Gastrointestinal Symptoms Questionnaire and have

shown that it is a reliable and valid measure of

gastrointestinal symptoms.5 Our questionnaire con-

tained a total of 121 response items, of which 24 were

speci®cally concerned with re¯ux-type symptoms in the

past year. Other items covered included socio-demo-

graphic characteristics, physician visits, past illness, and

health habits (smoking, alcohol, and medication use).

Appropriate sections were translated into Chinese and

Malay languages.

Subjects

More than 85% of Singaporean households live in low

cost, high rise apartments in public housing areas, and

the rest in private apartments or houses. Jurong, a town in

the west of Singapore, was chosen for the study as it

typi®es the rest of the country in comprising mostly public

housing. It has a population of approximately 56 000, of

whom 71% are Chinese, 20% are Malays and 8% are

Indians.6 The distribution by ethnic composition, age,

gender, apartment size, household income, and level of

education was very similar to the national average.6 The

latter three socio-demographic characteristics are con-

sidered good indicators of socio-economic status in

Singapore. All Singaporean adults aged 21 and older

are legally required to register for election. From a

sampling frame of all the registered electors of Jurong

for 1990 (n�35 873), equal numbers of subjects

belonging to each of the three ethnic groups were

obtained by way of a race-strati®ed disproportionate

random sampling procedure. This was to ensure stable

statistical estimates for the minority groups of Malays and

Indians. The sample population thus consisted of 316

Chinese, 318 Malays and 319 Indians.

Survey design

Before the survey, a letter was sent to all the eligible

individuals outlining the purpose of the study and

requesting their participation. All respondents were

interviewed at their homes by a team of interviewers,

mostly nurses, trained by the same physician (KYH),

who administered the questionnaire in the languages

usually understood and spoken by the respondents.

Most people in Singapore use English in addition to their

ethnic language, so in most cases the interview could be

conducted effectively in English. Written informed

consent was obtained from all respondents. Approval

was also obtained from the Ethics Committee, National

University Hospital, Singapore and the Jurong Town

Council.

De®nitions

Heartburn was de®ned as a retrosternal burning

sensation or ache in the last year. The severity of

symptoms were graded as mild (symptoms which can be

ignored if the subjects do not think about them),

moderate (symptoms which cannot be ignored but the

subjects can continue their daily activities), and severe

(symptoms which interfere with daily activities). Fre-

quent psychosomatic symptoms were de®ned as the

presence of either headaches, backaches, cough or

wheeze, breathing dif®culty, insomnia, fatigue or de-

pression or a combination of any of these more than

once per week on average in the past 1 year.7

Statistical analysis

The questionnaire was coded for analysis, and data

were entered into a personal computer and analysed

using the Statistical Package for the Social Sciences for

Windows (SPSS, Chicago, IL). Because of the dispropor-

tionate sampling by race, the population prevalence rate

of heartburn was estimated by directly adjusting the

observed race-speci®c proportions of affected patients in

our sample to the demographic characteristics of the

1990 Singaporean population aged > 20 years.6 Chi-

squared, Fisher's exact and Kruskal±Wallis tests were

carried out where appropriate for the data, and P-values

< 0.05 were regarded as signi®cant.

RESULTS

Response rate

Among the 953 selected subjects, 88 could not be

contacted despite multiple attempts, 82 had moved

away, nine could not be interviewed because of

language dif®culty, eight were away during the survey

period, and three had died. A further seven subjects

could not be interviewed because their apartments were

found to be vacant, leaving 756 eligible subjects. Of

1030 K. Y. HO et al.

Ó 1999 Blackwell Science Ltd, Aliment Pharmacol Ther 13, 1029±1033

these, 50 persons refused to participate whilst the rest

(n�706) were successfully interviewed, within a space

of 3 months, giving a response rate of 93%. Ten

questionnaires were subsequently excluded from the

analysis when it was discovered that the respondents

were neither Chinese, Malay nor Indian.

Demographics

The median age of the 696 respondents was 37 years

(range 21±95 years) with 51.3% being men. As a result

of the sampling procedure used, the three ethnic

subgroups (236 Chinese, 233 Malay, 227 Indian) in

the sample population were approximately equally

distributed by gender. However, compared with Malays

and Indians, the Chinese in our sample contained a larger

proportion of older persons. The mean � s.d. of the Chinese,

Malays and Indians were 41.6 � 0.9, 38.9 � 0.9

(P < 0.01 vs. Chinese) and 38.5 � 0.8 (P < 0.01 vs.

Chinese), respectively. This discrepancy is a re¯ection of

the actual age distribution in the Singaporean adult

population.6

Characteristics of heartburn

Overall, 53 (8%; eight Chinese, 19 Malay, 26 Indian) of

the sample reported having heartburn in the preceding

year, corresponding to an ethnically-adjusted preva-

lence of 4.6%. Of the subjects with heartburn, the

symptom occurred less than once a month, about once

a month, and more than once a month in 33 (62%), 12

(23%), and eight (15%), respectively. The severity of

heartburn was mild in 29 (55%), moderate in 18 (34%),

and severe in six (11%), of the symptomatic subjects.

Nocturnal awakening due to heartburn occurred in

only 12 (23%) subjects.

Consultation pattern

Sixteen (30%) of the heartburn sufferers had previously

sought consultation for their symptoms. These had

more severe heartburn (P < 0.001) (Table 1), and were

more likely to have complained of nocturnal awakening

due to heartburn (P < 0.05) than those who did not

present to medical attention. The two groups, however,

did not differ in terms of ethnic background, age,

gender, marital status, socio-economic status (i.e.

housing status, income level and educational quali®ca-

tion), frequency or duration of symptom, or presence of

frequent psychosomatic symptoms. A degree of over-

lapping consultation types was evident, with the great

majority (69%) of heartburn sufferers having been seen

by primary care physicians only, 25% by both primary

care physicians and specialist gastroenterologists, and

the remainder by specialists only. None of the subjects

had visited a traditional practitioner. Respondents with

severe heartburn were more likely to have sought

specialist help than those with milder symptoms

(P < 0.05) (Table 1).

Treatment pattern

Only 18 (34%) of the 53 heartburn sufferers received

some form of pharmaceutical therapy for their symp-

toms. The range of medications used by our heartburn

sufferers is summarized in Table 2. Compared with

subjects who had not visited a physician for their

heartburn, those who had seen a physician were more

likely to have been given drug treatment (P < 0.001).

The most commonly used medication was antacid. This

was also the most common medication prescribed to

patients presenting to all types of medical practitioners.

Histamine2-receptor antagonists (H2RA) were used only

by subjects who had previously consulted a specialist.

Medication use was associated with symptom severity

(P < 0.05), but not with ethnicity, symptom frequency,

symptom duration, presence of frequent psychosomatic

symptoms, age, gender, or socio-economic status. Of the

37 symptomatic subjects who did not seek medical

attention, only ®ve (14%) reported having taken

antacids with or without traditional remedies.

DISCUSSION

Heartburn has long been recognized as the classical

symptom of GERD. In the West, heartburn is a very

Table 1. Severity of symptom in heartburn sufferers by con-

sultation type

No consultation

Primary care

physician only

Specialist with

or without primary

care physician

(n = 37) (n = 11) (n = 5)

Mild 26 (70) 3 (27) 0

Moderate 7 (19) 7 (64) 4 (80)

Severe 4 (11) 1 (9) 1 (20)

P < 0.01.Percentages are in parenthesis; n = number of patients.

HEALTHCARE SEEKING BEHAVIOUR FOR HEARTBURN IN SINGAPORE 1031

Ó 1999 Blackwell Science Ltd, Aliment Pharmacol Ther 13, 1029±1033

common symptom. A large population-based survey in

the United States found that 18% of respondents

experienced heartburn at least weekly.4 In another study

of the general population in the United States, 44% of

adults reported having heartburn at least once a month.8

In the present study, an interviewer-administered survey

was carried out in 696 Asian subjects, selected at random

within groups strati®ed for ethnicity, from the electoral

roll. The questionnaire used has previously been shown

to be a reliable and valid measure of heartburn in

Singapore.5 A 12-month period prevalence of heartburn,

adjusted for ethnicity, of 4.6% was established. This is

much lower than those of Western populations.4, 8

Heartburn in our symptomatic subjects was often

infrequent and mild compared with Western subjects,4

consistent with the lower prevalence.

Our results con®rm the notion that people seeking

medical attention represent the tip of the iceberg of

people with re¯ux disease,9 with only a third of our

subjects having sought medical advice about their

heartburn. Greater heartburn severity and the occur-

rence of nocturnal awakening were associated with a

greater likelihood to consult. These ®ndings differ from

those of Western investigators who found that symptom

severity and frequency were poor predictors of the

likelihood to visit a physician.10 The reason for the

discrepancy is uncertain but culturally motivated

variations in health seeking behaviour may account

for some of the differences. Our subjects who had

consulted a physician for evaluation of their heartburn

were no more likely to have complained of frequent

psychosomatic symptoms than those who did not

consult a physician. The decision to seek medical advice

was not linked to ethnicity, age, or socio-economic

status, and this probably re¯ects the ready access to

medical facilities in Singapore.

Despite the wide use of traditional herbal treatments in

Singapore, none of our heartburn sufferers had con-

sulted a traditional practitioner for their symptoms.

Possible reasons for the non-utilization of traditional

medical care include the easy availability of Western

treatments for heartburn in Singapore, and their high

ef®cacy.

Most heartburn sufferers in Singapore do not present for

medical attention, as has been discussed, and neither

have they used self-medication. This practice, which

applies equally to Chinese, Malays and Indians, probably

re¯ects the generally mild nature of heartburn in this

country. Among subjects who received pharmacological

therapy for their heartburn, less than 12% were taking

H2RA, medications available only on prescription in

Singapore. Most were treated with antacids alone. The

preference for antacids may be explained in part by their

ready availability over-the-counter in Singapore, and in

part by their low cost, reasonable ef®cacy for mild-to-

moderate heartburn, and/or good safety pro®le.

In conclusion, this study provides some of the ®rst

population-based data on medical consultation and

treatment patterns of heartburn in Asia. It shows that

heartburn is uncommon in the general population of

Singapore. When present, it is often infrequent and

mild. Few heartburn sufferers seek medical attention,

and most do not receive medications for symptomatic

control. The decision to seek medical advice is linked to

symptom severityÐa ®nding that is at variance with

some of the Western experiences.

ACKNOWLEDGEMENTS

The study was supported by the Academic Research

Grant (RP900364) from the National University of

Singapore and Janssen Pharmaceutical (Singapore).

No consultation

Primary care

physician only

Specialist with or without

primary care physician

(n = 37)* (n = 11) (n = 5)

No medication 32 (60) 3 (6) 0

Antacid 5 (9) 6 (11) 3 (6)

H2-receptor 0 0 2 (4)

antagonist

Traditional 1 (2) 1 (2) 0

medicine

Paracetamol 0 1 (2) 0

*One patient reported taking both antacid and traditional medicine.Percentages (of all heartburn sufferers) are in parenthesis; n = no of patients.

Table 2. Treatment by consultation type in

53 heartburn sufferers

1032 K. Y. HO et al.

Ó 1999 Blackwell Science Ltd, Aliment Pharmacol Ther 13, 1029±1033

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