OM DENNE EPISODE
Today, we’re speaking to Dr Tori Ford, a qualitative researcher based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford.
Title of papers: ‘Accumulative Experiences: Navigating Healthcare for Recurrent Vulvovaginal Thrush from Patient and Clinician Perspectives’ and ‘It’s not just thrush, it’s recurrent thrush’: Patient and Clinician Perspectives on Diagnosing Recurrent Vulvovaginal Candidiasis’.
Available at: https://doi.org/10.3399/BJGP.2025.0437 and https://doi.org/10.3399/BJGP.2025.0531
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
Hi, and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors of the journal. Thanks again for listening to this podcast today.
In today's episode, we're speaking to Dr. Tori Ford, who is a qualitative researcher based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We're going to talk today about two linked papers that she and her team have published here in the bjgp.
The first one is titled Accumulative Navigating Healthcare for Recurrent Vulvovaginal Thrush from Patient and Clinician Perspectives. And the second paper is it's not just thrush, it's recurrent thrush.
Patient and Clinician Perspectives on Diagnosing Recurrent Vulva Vaginal Candidiasis. So, Tori, thanks very much for joining us here today.
And this might come from a slightly unscientific perspective, but my feeling is that I'm seeing a lot more recurrent thrush in practice. And we know that it's incredibly common. I think, despite that, it's not something we hear discussed very often in primary care research.
So my first question is, what made you want to study it?
Speaker B
So, like you say, recurrent thrush is an increasingly common condition. We know that 1.2 million women in the UK live with it, 6% of people globally, and I just happen to have been one of them.
So my paper came out of lived experience of living with recurrent thrush over many years and having a diagnostic journey of, you know, seeing different healthcare professionals looking for answers. And like you say, those feelings of shame and stigma that keep you feeling alone were all too familiar for me.
So that's what actually led me into starting my PhD, looking at recurrent thrush and then wanting to hear other patient experiences as well.
Speaker A
And we're looking at two of your papers here that were published in the bjgp, and they're both looking at the patient and the clinician perspective.
And one thing that comes through really strongly in both papers is that recurrent thrush is often treated as if it's just repeated acute episodes rather than a condition in its own right. Why do you think that that distinction matters to patients and probably to clinicians as well, or should do?
Speaker B
I think when we hear about thrush, it's often something that's seen as trivial or mundane, and that's often because it's through this lens of acute, transient, episodic, episod, and most of the time it is right. 75% Of people with Vaginas will have thrush at some point in their life.
It's usually self managed over the counter with pharmacy care and symptoms resolved within a few days.
But where recurrent thrush differs is when those symptoms keep coming back so that itching, burning pain and irritation becomes sometimes cyclical, sometimes repetitive. And I spoke to three or two patients who all had different durations of heat know, happening every two weeks, every month.
And what they often found was because they were accessing fragmented care.
So, you know, going to the pharmacy, sometimes going to the gp, sometimes maybe seeing sexual health, it was often seen as again, that mundane, one off, trivial case. And it was really hard to trace those patterns across care, especially due to a lack of continuity. Right.
If you're trying to track a pattern but nobody is following you up, it's really difficult to, to capture those. So I think it's a few layers of one.
I explore how these sort of social dimensions keep it seen as something maybe less long term, but then also in the ways that sort of care was fragmented made it harder for those patterns to be picked up and then to transition the care moving away from, you know, acute one off prescriptions of an antifungal medication to something that required repeat, repetitive, enduring, you know, testing, treatment, retesting of treatments.
Speaker A
Absolutely. And I think what's interesting is that your papers describe recurrent thrush as something that's accumulative and cyclical over time.
And you mentioned that it's not just these sort of one off episodes. Can you explain what patients meant by that?
Speaker B
Yeah.
So often, I think when we talk about healthcare, journeys are presented in a way that's quite linear and straightforward that, you know, you see a healthcare professional, you get treatment, you go home, you start to feel better. But with recurrence, something interesting happens where people aren't, you know, returning to the start.
It's not that you go back to a blank page and then restart your healthcare journey every time you're carrying with you everything, everything that's amassed through healthcare encounters, what you've seen online, what you discuss with friends, and that is all carrying through to those consultations.
And I think what was really important there was acknowledging that for many people there was a lot to unpack there and often they felt that it wasn't being acknowledged in those clinical spaces. It was seen as, oh, it's just thrush. And that's why in one of the papers the title is, it's not just thrush, it's recurrent thrush.
And that's a quote from One of the participants who was speaking about the importance of labeling and distinguishing this condition, especially in terms of the impacts it had on people's lives and also the approaches and pathways that would be needed to properly treat it.
Speaker A
And this is an issue that we see across clinical care and women's healthcare. But a lot of participants described feeling dismissed or not listened to.
And I wanted to just get your perspective from your wider sort of work in this area is how much of that reflected wider issues in women's health care, do you think?
Speaker B
Yeah, I mean, we know there's increasing conversations, right, with the women's health strategy, with the Cumberlage report, about how people's pain is often dismissed based on their gender. And that definitely came across in the studies. But I think what was interesting was that both patients and clinicians were aware of this.
And something that is quite interesting was in the diagnostic paper, we look at sort of those moments where there were sort of miscommunication or differing expectations between patients and clinicians, clinicians, where clinicians were, you know, operating on a standard guideline that requires two swabs, two positive swabs for a thrush within a year to diagnose recurrent thrush.
But when that wasn't communicated to the patient, of being told we need to accumulate these number of swabs, what the patients thought was happening was, oh, they're swabbing me again, they're not listening to me, they don't believe me.
So it was interesting where the dismissal was often in those moments of, you know, it wasn't healthcare professionals saying, this isn't important, or please don't come see me about this. It was really in those sort of small details where patients were operating on one framework and clinicians on another.
And there were these gaps in communication. And that's why our papers seek to address some of those gaps with some recommendations as well.
Speaker A
Yeah, and as you mentioned, one of the papers is called it's not just thrush, it's recurrent thrush.
And I wonder what you felt were the key challenges around actually recognizing recurrence in primary care, as opposed to it just being a, a one off episode.
Speaker B
There's multiple layers to this, I think, in terms of the. The papers are sort of split in terms of the diagnostic journey and then the healthcare journey.
But that's sort of an artificial split in some ways, because what we saw a lot was, you know, patients trying to seek out continuity of care to get someone to notice the pattern that they were starting to see and assign a label to it and we saw some hesitancy with this in clinicians who said, you know, I'm not going to use the term recurrence because that sounds like it's something serious or sounds like it's chronic. And they saw that being helpful.
But then for patients they found that really challenging because they said, you know, they just see it as thrush, they just see it as a one off case, they're not recognizing it when often the clinicians had, you know, made note of it, but they didn't feel that using that label would be helpful to patients. So simple things like that, even just the language that we use can make such a big difference in helping people feel seen.
And then the diagnostic journey. So the tests that we have are not perfect.
There's also a lot of problems with self treatment before testing that wasn't always disclosed by participants. So these cycles right of you have symptoms, you make a doctor's appointment, the symptoms are unbearable is what we heard all the time.
So people went and self treated over the counter with, with pharmaceuticals, over the counter antifungals, or even off the shelf at pharmacies, different options or supermarkets, and then would go in, be swabbed for a test, the test would come up negative. And then it was really hard to build a case, right. For recurrent thrush when there wasn't sort of that EV evidence there.
But often what patients weren't doing was sharing that they had self treated. Because often for patients, they don't know all the factors that go into a test or they're not going to know what influences it.
And then there was a lot of difficulty. Right. Often we hear vulval itching and we go right to thrush.
But there's so many other conditions along the way of lichen sclerosis, of dermatological conditions, of vulvodynia that also need to be addressed and identified. So trying to have those moments where clinicians could be ruling out, you know, is it thrush, is it not thrush? And then is it recurrent thrush?
And having that second question be front of mind was really important because it does change people's trajectories.
And we heard from people that, you know, were able to get that recognition early on and were able to get appropriate treatment and have symptoms resolved. So we know it's possible, but we know that that recognition is challenging.
Speaker A
Yeah, and you touched on this a bit earlier, but continuity seems really important in both of these papers and you've just spoken about recognition and I wonder what your thoughts are about recurrent thrush and how it's almost exposing sort of this issue around fragmented care really.
Speaker B
So clearly, I think continuity was one of the most interesting topics to explore and it was fascinating seeing how clinicians were seen fragmented systems and trying to overcome them.
So, you know, some clinicians who said, I want to see you again, I'm going to book you into a clinic, I want you to come back on this date, we're going to figure this out together and how valuable that was for patients and other times where, you know, maybe a GP wasn't in a position to be offering follow up appointments in that same way they could offer informational continuity. So that looked like writing notes to sexual health, that looked like sharing notes with patients, sharing test results with patients.
It looked like pulling up the guidelines and actually working through together, you know, what the steps were, what the timelines were being realistic. So many times patients thought the start of the journey, I'm going to go in, there's going to be a magic cure and I'm going to be okay.
And they actually really valued when clinicians said, it's an ongoing journey, it's going to take time, but we're going to work it up together. And that really helped patients keep coming back.
In the paper about accumulative experiences, we talk about that of not only is it about the times where recurrent thrush care needed to be different than acute care, but also about those really important moments where you could be making those differences, you could be making those transitions and acknowledging it and building that continuity. Because I think, yeah, with acute conditions, you have acute conditions and you have chronic conditions and recurrence falls somewhere in between.
In this really interesting space where chronic conditions often are, have quite established guidelines, they've got secondary care involved, they've got sort of continuity built into them, right. With the chronicity and then acute cases, you've got the one off self managed, often treated as quite trivial conditions.
And then recurrence is interesting because it kind of spans both of those and jumps between them in different ways.
And we saw that a lot and it helped kind of expose that fragmentation, right, of people that would go see the pharmacist and they would say, how many episodes have you had in the last year? And then the patients would say, you know, I've had four or more, which is the definition of recurrent thrush.
And often pharmacists were aware of that and would say, oh, you're going to have to go see your GP to get this medication. And then the patients reported going to see their GP who said, oh, you can just treat this over the counter with pharmacy care.
And sort of these loops that were occurring between GP and pharmacy, which were really interesting. And then seeing also where sexual health could fit in as well.
Speaker A
Yeah.
And thinking about that, as you say, patients moved between pharmacies, general practice and sexual health services, but how well connected did those pathways feel? Or did they not feel well connected at all?
Speaker B
No, I think by design the pharmacy, sexual health and GP practices are kept quite separate and I think there's good reasons for doing that. For example, in sexual health you can access care anonymously, you don't have to share any personal information.
They by design don't share notes with your primary care professional.
There's different systems that are set up that are in practice, right, to protect patient privacy, to make people feel comfortable, to help, maybe reduce some shame and stigma. But at the same time that can make it really difficult when people are accessing care in many different spaces.
And we saw that quite often and people aren't speaking to one another.
And I think the best care we saw was when people were able to reach across those lines and say to the patients, you know, in sexual health, would you mind if I maybe looped in your primary care professional? Would that be okay? Or asking directly about when was last time you self treated, when was last time you were using over the counter remedies?
Have you been reading things online when you can sort of have that whole picture? And joint up care was really incredible.
And something we saw too was in the diagnostics paper where GPs were able to say, you know, I'm not able to see, you know, microscopy, I'm not able to offer the same level of testing that somewhere like sexual health might be. Would you reopen? Exploring that option and sort of signposting people to different places was really powerful.
But that, that wasn't one obvious to patients or clinicians always. It really differed by region and commissioning and what was available. And then also patients reported feeling really confused.
If you know, who am I supposed to see, in what order, in what combination and what is sort of the appropriate route. So trying to figure out those, those questions as well.
Speaker A
And I wonder what your thoughts are after doing this research and even from your own lived experience. But for gps, listening to this, what do you think are the practical take home messages from, from this body of work that you've done?
Speaker B
So the first thing that we're recommending for GPS is to be asking patients about recurrence.
We heard from patients saying that sometimes they didn't disclose how many episodes they'd have because they said I just wasn't asked the right question. And I think that's how it often gets treated. As acute cases, we really have been recommending prioritizing continuity of care whenever possible.
But when it's not thinking about creative ways of having informational continuity, whether that looks like writing letters, having patient approved note sharing, providing patients with their own notes so they can follow up with practitioners as well as.
And then also in terms of the diagnostic routes of making sure that you're asking patients about self treatment before doing testing, offering patient initiated self swabs whenever possible, and also acknowledging some of the limitations that exist within our current health systems and also within testing and making sure that you're recognizing both the cumulative impacts that people have with recurrent thrush, but also ruling out other conditions and sort of not falling into that trap where any vulval itch falls into recurrent thrush.
So it's a complex condition, but there's some, like I've been saying, there's some really simple changes in terms of communication, but also in just having a scan of what resources are available and what services might be able to be best suited to treat these conditions as well.
