{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T12:46:58Z","timestamp":1785847618597,"version":"3.56.0"},"reference-count":44,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:00:00Z","timestamp":1785801600000},"content-version":"unspecified","delay-in-days":34,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100010665","name":"H2020 Marie Sk\u0142odowska-Curie Actions","doi-asserted-by":"publisher","award":["956673"],"award-info":[{"award-number":["956673"]}],"id":[{"id":"10.13039\/100010665","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2026,7,7]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Persistent somatic symptoms (PSS) are prevalent across Europe. As little is known about affected patients\u2019 healthcare experience and its relationship with symptom outcomes, these were explored in a cross-sectional survey across four European countries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This cross-sectional online survey was distributed in Germany, Italy, the Netherlands and Poland (04\/2023\u201305\/2024). The survey included adults aged \u226518 years with PSS (Patient Health Questionnaire-15 \u226510) who had used healthcare services in the past year. Healthcare factors were assessed across four dimensions: availability, affordability, accessibility and adequacy. Multinomial logistic regression examined associations between healthcare factors and symptom course (improvement, persistence and deterioration). Duration of untreated illness was also compared across countries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 595 participants (87% female) included in regression analyses, 13% reported improvement, 70% persistence and 17% deterioration. Duration of untreated illness was longest in Poland, followed by Italy, the Netherlands and Germany (48, 24, 12 and 3 months, respectively, p&lt;0.001). After adjusting for age, gender and country, nearly all healthcare factors were associated with higher odds of symptom persistence and deterioration across countries, including difficulty accessing services (persistence OR 1.39 (95%\u2009CI 1.12 to 1.75); deterioration OR 1.84 (95%\u2009CI 1.39 to 2.44)), financial difficulties (persistence OR 1.60 (95%\u2009CI 1.25 to 2.05); deterioration OR 2.17 (95%\u2009CI 1.59 to 2.96)), postponing care due to costs (persistence OR 1.54 (95%\u2009CI 1.07 to 2.19); deterioration OR 2.53 (95%\u2009CI 1.67 to 3.86)), dissatisfaction with insurance (persistence OR 1.26 (95%\u2009CI 1.03 to 1.54); deterioration OR 1.57 (95%\u2009CI 1.19 to 2.06)) and poor clinician\u2013patient communication (persistence OR 1.19 (95%\u2009CI 1.11 to 1.26); deterioration OR 1.25 (95%\u2009CI 1.16 to 1.34)). Country-specific effects were found only for insurance satisfaction, with dissatisfaction linked to worse outcomes in Germany (persistence OR 1.87 (95%\u2009CI 1.19 to 2.93); deterioration OR 4.02 (95%\u2009CI 2.09 to 7.74)).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Across four European countries, patients with PSS reported that their symptoms did not improve despite receiving care. This was the case even in countries with substantially shorter treatment delays, suggesting that early access alone may not be sufficient. Barriers related to access, affordability and communication were associated with worse outcomes, highlighting key areas for improvement across healthcare systems.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2025-004470","type":"journal-article","created":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T11:55:16Z","timestamp":1785844516000},"page":"e004470","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Patients\u2019 perspectives on healthcare factors and symptom course in persistent somatic symptoms: findings from a cross-sectional survey in four European countries"],"prefix":"10.1136","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3500-3829","authenticated-orcid":false,"given":"Aleksandra","family":"Kustra-Mulder","sequence":"first","affiliation":[{"name":"Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Liebau","sequence":"additional","affiliation":[{"name":"Unabh\u00e4ngiger Service f\u00fcr Umfragen Methoden und Analysen GmbH (USUMA), Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georg","family":"Grewer","sequence":"additional","affiliation":[{"name":"Unabh\u00e4ngiger Service f\u00fcr Umfragen Methoden und Analysen GmbH (USUMA), Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Judith G M","family":"Rosmalen","sequence":"additional","affiliation":[{"name":"Departments of Psychiatry and Internal Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fiammetta","family":"Cosci","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, University of Florence, Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanna","family":"Rymaszewska","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences, Wroc\u0142aw University of Science and Technology, Wroc\u0142aw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernd","family":"L\u00f6we","sequence":"additional","affiliation":[{"name":"Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelika","family":"Weigel","sequence":"additional","affiliation":[{"name":"Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,4]]},"reference":[{"key":"2026080404550433000_4.3.e004470.1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(24)00623-8"},{"key":"2026080404550433000_4.3.e004470.2","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1007\/s10654-024-01109-5","article-title":"Prevalence of functional disorders across Europe: a systematic review and meta-analysis","volume":"39","author":"Rometsch","year":"2024","journal-title":"Eur J Epidemiol"},{"key":"2026080404550433000_4.3.e004470.3","doi-asserted-by":"crossref","DOI":"10.1016\/j.lanepe.2024.101140","article-title":"The overlooked burden of persistent physical symptoms: a call for action in European healthcare","volume":"48","author":"Toussaint","year":"2025","journal-title":"Lancet Reg Health Eur"},{"key":"2026080404550433000_4.3.e004470.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychores.2013.08.011"},{"key":"2026080404550433000_4.3.e004470.5","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1097\/PSY.0000000000001145","article-title":"Predictors of Persistent Somatic Symptoms in the General Population: A Systematic Review of Cohort Studies","volume":"85","author":"Kitselaar","year":"2023","journal-title":"Psychosom Med"},{"key":"2026080404550433000_4.3.e004470.6","doi-asserted-by":"publisher","DOI":"10.3399\/BJGP.2021.0566"},{"key":"2026080404550433000_4.3.e004470.7","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jpsychores.2018.01.011","article-title":"Duration of untreated illness in patients with somatoform disorders","volume":"107","author":"Herzog","year":"2018","journal-title":"J Psychosom Res"},{"key":"2026080404550433000_4.3.e004470.8","unstructured":"Tikkanen R , Osborn R , Mossialos E , et al . 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