How equitable are colorectal cancer screening programs which include FOBTs? A review of qualitative and quantitative studies

Tailored recruitment interventions to improve bowel cancer screening in Arabic and Mandarin speaking groups: Modelled cost-effectiveness

BACKGROUND

Effective bowel cancer screening is freely available in Australia, however, there are inequities in utilisation amongst non-English speakers at home. This study estimates the health impacts and cost-effectiveness of recruitment interventions targeted at Arabic and Mandarin speaking populations in Victoria, Australia to increase bowel cancer screening participation.

METHODS

A Markov microsimulation model simulated the development of bowel cancer, considering National Bowel Cancer Screening Program participation rates. Culturally specific recruitment interventions e.g., community education and tailored paid media for 50-74-year-olds were compared to usual practice. A cost-utility analysis was conducted over a 50-year time horizon from a healthcare perspective, to estimate the cost per quality-adjusted life year (QALY) based on plausible effectiveness levels. Costs are in 2019 Australian dollars.

RESULTS

Intervention costs were $6.90 per person for the Arabic speaking group and $3.10 for Mandarin speakers. The estimated cost/QALY was $2,781 (95% uncertainty interval [UI]: $2,144─$3,277) when screening increased by 0.2% in the Arabic group, and an estimated 5-6 additional adenoma and cancer cases were detected. In the Mandarin group, the estimated cost/QALY was $1,024/QALY (95%UI: $749─$1,272) when screening increased by 1.1%, and an estimated 18-23 additional adenoma and cancer cases were detected.

CONCLUSIONS

Culturally specific recruitment interventions to increase bowel cancer screening are inexpensive and likely to be cost-effective. Improvements in capturing language spoken at home by the National program would facilitate more precise estimates of the effectiveness and cost-effectiveness of these interventions.

Association Between Socioeconomic Status and Adherence to Fecal Occult Blood Tests in Colorectal Cancer Screening Programs: Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Screening adherence is important in reducing colorectal cancer (CRC) incidence and mortality. Disparity in CRC screening adherence was observed in populations of different socioeconomic status (SES), but the direction and strength of the association remained unclear.

OBJECTIVE

We aimed to systematically review all the observational studies that have analyzed the association between SES and adherence to organized CRC screening based on fecal occult blood tests.

METHODS

We systematically reviewed the studies in PubMed, Embase, and Web of Science and reference lists of relevant reviews from the inception of the database up until June 7, 2023. Individual SES, neighborhood SES, and small-area SES were included, while any SES aggregated by geographic areas larger than neighbors were excluded. Studies assessing SES with any index or score combining indicators of income, education, deprivation, poverty, occupation, employment, marital status, cohabitation, and others were included. A random effect model meta-analysis was carried out for pooled odds ratios (ORs) and relative risks for adherence related to SES.

RESULTS

Overall, 10 studies, with a total of 3,542,379 participants and an overall adherence rate of 64.9%, were included. Compared with low SES, high SES was associated with higher adherence (unadjusted OR 1.73, 95% CI 1.42-2.10; adjusted OR 1.53, 95% CI 1.28-1.82). In the subgroup of nonindividual-level SES, the adjusted association was significant (OR 1.57, 95% CI 1.26-1.95). However, the adjusted association was insignificant in the subgroup of individual-level SES (OR 1.46, 95% CI 0.98-2.17). As for subgroups of the year of print, not only was the unadjusted association significantly stronger in the subgroup of early studies (OR 1.97, 95% CI 1.59-2.44) than in the subgroup of late studies (OR 1.43, 95% CI 1.31-1.56), but also the adjusted one was significantly stronger in the early group (OR 1.86, 95% CI 1.43-2.42) than in the late group (OR 1.26, 95% CI 1.14-1.39), which was consistent and robust. Despite being statistically insignificant, the strength of the association seemed lower in studies that did not adjust for race and ethnicity (OR 1.31, 95% CI 1.21-1.43) than the overall estimate (OR 1.53, 95% CI 1.28-1.82).

CONCLUSIONS

The higher-SES population had higher adherence to fecal occult blood test-based organized CRC screening. Neighborhood SES, or small-area SES, was more competent than individual SES to be used to assess the association between SES and adherence. The disparity in adherence between the high SES and the low SES narrowed along with the development of interventions and the improvement of organized programs. Race and ethnicity were probably important confounding factors for the association.

Factors influencing organised faecal occult blood test screening participation in culturally and linguistically diverse populations: a scoping review

OBJECTIVE

This review aims to provide a comprehensive overview of the literature examining factors influencing participation in organised faecal occult blood test (FOBT) screening programmes in culturally and linguistically diverse populations. This article addresses gaps in the literature by providing a mixed methods review of the multilevel influences on FOBT screening in culturally and linguistically diverse (CALD) populations. This review was guided by the question "What are the factors influencing participation in organised FOBT screening programs in CALD populations?"

STUDY DESIGN

Scoping review.

METHODS

A scoping review methodology was used to summarise the available evidence. A thematic analysis of the included studies was undertaken to identify factors influencing organised FOBT screening participation in CALD populations from the literature.

RESULTS

FOBT screening participation was lower by ethnicity, religion, birthplace and language spoken. Barriers to screening included, faecal aversion, fatalism, fear of cancer, language and literacy barriers, difficulty accessing translated materials and low colorectal screening knowledge and awareness. CALD populations also had lower perceived benefits, susceptibility and cues to action, higher perceived barriers and greater perceived external health locus control than non-CALD populations. Facilitators of screening included positive attitudes to screening, general practitioner recommendations and social support. Group education sessions and narrative-based screening information were found to increase screening participation.

CONCLUSION

This review highlights the range of interrelated factors influencing participation in organised FOBT screening programmes in CALD populations and proposes multicomponent interventions to address low screening uptake. Features of successful community-level interventions should be explored further. Narratives show promise for engaging CALD populations. Accessibility of screening information should be addressed at the system level. Leveraging the general practitioner relationship in promoting FOBT screening programmes may also be an effective strategy to target 'hard-to-reach' populations.

Patient attitudes towards changes in colorectal cancer surveillance: An application of the Health Belief Model

OBJECTIVE

This is to determine whether health beliefs regarding colorectal cancer (CRC) screening could predict discomfort with a change to CRC surveillance proposing regular faecal immunochemical tests (FIT) instead of colonoscopy.

METHODS

Eight hundred individuals enrolled in a South Australian colonoscopy surveillance programme were invited to complete a survey on surveillance preferences. Responses were analysed using binary logistic regression predicting discomfort with a hypothetical FIT-based surveillance change. Predictor variables included constructs based on the Health Belief Model: perceived threat of CRC, perceived confidence to complete FIT and colonoscopy (self-efficacy), perceived benefits from current surveillance and perceived barriers to FIT and colonoscopy.

RESULTS

A total of 408 participants (51%) returned the survey (complete data n = 303; mean age 62 years, 52% male). Most participants (72%) were uncomfortable with FIT-based surveillance reducing colonoscopy frequency. This attitude was predicted by a higher perceived threat of CRC (OR = 1.03 [95% CI 1.01-1.04]), higher colonoscopy self-efficacy (OR = 1.34 [95% CI 1.13-1.59]) and lower perceived barriers to colonoscopy (OR = 0.92 [95% CI 0.86-0.99]).

CONCLUSIONS

Health beliefs regarding colonoscopy and perceived threat of CRC may be important to consider when changing CRC surveillance protocols. If guideline changes were introduced, these factors should be addressed to provide patients reassurance concerning the efficacy of the alternative protocol.

Socioeconomic differences in participation and diagnostic yield within the Dutch national colorectal cancer screening programme with faecal immunochemical testing

Background

CRC mortality rates are higher for individuals with a lower socioeconomic status (SES). Screening could influence health inequalities. We therefore aimed to investigate SES differences in participation and diagnostic yield of FIT screening.

Methods

All invitees in 2014 and 2015 in the Dutch national CRC screening programme were included in the analyses. We used area SES as a measure for SES and divided invitees into quintiles, with Quintile 1 being the highest SES. Logistic regression analysis was used to compare the participation rate, positivity rate, colonoscopy uptake, positive predictive value (PPV) and detection rate across the SES groups.

Results

Participation to FIT screening was significantly lower for Quintile 5 (67.0%) compared to the other Quintiles (73.0% to 75.1%; adjusted OR quintile 5 versus quintile 1: 0.73, 95%CI: 0.72–0.74), as well as colonoscopy uptake after a positive FIT (adjusted OR 0.73, 95%CI: 0.69–0.77). The detection rate per FIT participant for advanced neoplasia gradually increased from 3.3% in Quintile 1 to 4.0% in Quintile 5 (adjusted OR 1.20%, 95%CI 1.16–1.24). As a result of lower participation, the yield per invitee was similar for Quintile 5 (2.04%) and Quintile 1 (2.00%), both being lower than Quintiles 2 to 4 (2.20%-2.28%).

Conclusions

Screening has the potential to reduce health inequalities in CRC mortality, because of a higher detection in participants with a lower SES. However, in the Dutch screening programme, this is currently offset by the lower participation in this group.

Barriers and facilitators to participate in the colorectal cancer screening programme in Flanders (Belgium): a focus group study

OBJECTIVE

In Flanders (Belgium), a population-based colorectal cancer (CRC) screening programme offers a faecal immunochemical test (FIT) biennially to Flemish citizens aged 50-74 years. A FIT uptake of only 51,5% in 2018 is significantly lower among men, lower income groups and among people with other than the Belgian nationality.The objective of this study was to identify attitudes, barriers and facilitators to participate in the Flemish CRC screening programme.

METHODS

Qualitative study using focus group discussions (FGDs) with non-participants in the Flemish CRC screening programme. Four FGDs were held with non-migrant Flemish population groups, and four were held with Turkish migrants (41 participants).

RESULTS

Feeling healthy, fear of cancer and embarrassment to talk about CRC screening emerged as common barriers in all FGDs. Having other priorities (non-migrant group) and a lack of understanding mainly due to a language barrier (Turkish migrants) differed between the two groups. Providing face-to-face information, information in group and GP recommendation were perceived as important facilitators to CRC screening in both groups. More publicity and making CRC screening more of a routine (non-migrant group) and offering translated information (Turkish migrants) were the suggested facilitators that differed between the groups.

CONCLUSIONS

Several common and some group-specific barriers and facilitators appeared to play a role in the decision to participate in the CRC screening programme. In order to improve informed decision making and participation in the CRC screening programme in Flanders, the options of more GP involvement, targeted information events, and adapted reminder letters are currently being explored.

Public Health: Prevention

Nowadays, colorectal cancer prevention strategies play an essential role in reducing the incidence and mortality of the cases. A well-designed and establishment of the clinical pathway of screening programme needed in all country. Types of screening tools used may vary between the country with the use of FOBT and colonoscopy. The standard guideline related to screening programme such as for high-risk group should be emphasized more as compared to the low-risk group. The uptake of screening for CRC should be highlighted more as the program have showed a significantly reduction of the cases and mortality. The barrier of CRC screening uptake mainly due to poor awareness, discomfort, low physician recommendation, low socioeconomic and improper screening programme. Therefore others prevention strategies beside screening program such as health education and interactive intervention strategies need to be empower.

Inequalities in participation in colorectal cancer screening programmes: a systematic review

BACKGROUND

Colorectal cancer (CRC) is a major public health problem due to its incidence and mortality. Screening programmes help decrease its impact on the population through early detection. However, the uneven distribution of social determinants of health can cause inequalities. The aim of this study is to identify the social inequalities in the participation in CRC screening programmes.

METHODS

A systematic review of the literature was carried out, searching in both health and social databases for papers published since 2000 in English, Spanish, Portuguese and French. The search strategies combined terms regarding screening, CRC, participation and social inequalities. Included papers were quantitative or qualitative primary studies analyzing gender and socioeconomic inequalities in the participation in CRC screening programmes implemented by public and private health-care providers and addressing 45- to 75-year-old population.

RESULTS

A total of 96 studies, described in 102 articles, were included. Most were quantitative observational studies and analyzed population-based screening programmes. They were carried out mainly in the UK (n=29) and the USA (n=18). Participation in screening programmes varied from 1.1% to 82.8% using several methods. A total of 87 studies assessed participation by sex and one focussed on men, but only two provided an analysis from a gender perspective. Although men are at a higher risk of developing CRC, they generally were less likely to participate in screening programmes. Screening attendance was higher among the least deprived areas.

CONCLUSIONS

Gender and socioeconomic inequalities in CRC screening participation should be addressed through the design of tailored interventions with a multidimensional focus.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

BACKGROUND

Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain.

AIM

To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme.

OBJECTIVES

The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level.

DESIGN

Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases.

SETTING

Local authorities in England.

PARTICIPANTS

Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England.

INTERVENTIONS

The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other.

MAIN OUTCOME MEASURES

Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality.

RESULTS

The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis.

LIMITATIONS

Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run.

CONCLUSIONS

Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making.

FUTURE WORK

Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019132087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

Does the Flemish colorectal cancer screening programme reach equity in FIT uptake?

BACKGROUND

To investigate colorectal cancer (CRC) screening rates by the faecal immunochemical test (FIT) according to sociodemographic characteristics and nationality.

METHODS

Men and women, aged 56-74, invited to participate in the Flemish CRC screening programme in 2013 and 2014 were included in this study. We analysed the association between CRC screening uptake and sex, age, (first and current) nationality and several proxies for socio-economic status (SES). The statistical analysis was based on descriptive analyses and logistic regression models.

RESULTS

A total of 1 184 426 persons were included in our analysis. The overall screening uptake was 52.3%, uptake varied by sex, age, nationality and SES. Lower participation rates were associated with the youngest and oldest age categories (56-60 and 70-74) and being male. All nationalities other than Belgian or Dutch were significantly less screened. Lower uptake of screening was also associated with several proxy's for low SES, such as having an allowance for being disabled, not being able to work, being an extended minor and having a social allowance/minimum wage. The descriptive analysis showed a 27% difference in CRC screening uptake between the (early) retired and the people entitled to a minimum wage.

CONCLUSIONS

There is a significant difference between screening uptake and demographic and socio-economic variables in the first 2 years of the population-based screening programme in Flanders. Based on the study results, implementing strategies to improve participation in those subgroups is needed.

Socio-cognitive determinants of colorectal cancer screening uptake: An application of intervention mapping approach

Background: Fecal occult blood test (FOBT) is one of the common screening tests for colorectal cancer. This study was designed to determine the socio-cognitive determinants related to FOBT uptake for colorectal cancer screening based on intervention mapping (IM).

Methods: A total of 500 individuals aged over 50 years were randomly selected to participate in this study in Kermanshah, Iran, in 2016. Data were collected by interviews based on a questionnaire and analyzed by SPSS16 using bivariate correlation, linear, and logistic regression models.

Results: Of the 500 respondents, 468 (93.6%) signed the consent form and voluntarily participated in the study. Almost 11.1% of the participants had a history of FOBT uptake. Socio-cognitive variables accounted for 38% of the variation in the outcome measure of the intention to uptake FOBT. Perceived self-efficacy (OR = 3.345 & 95% CI: 1.342, 8.339), perceived susceptibility (OR = 2.204& 95% CI: 1.320, 3.680), attitude (OR = 1.674& 95% CI: 1.270, 2.137), and perceived severity (OR = 1.457& 95% CI: 0.954, 2.224) were the strongest predictors of fecal occult blood test uptake.

Conclusion: IM-based analysis of behavior may provide insights to design interventions for modifying individuals’ beliefs about the usefulness of FOBT uptake to prevent colorectal cancer.

Testing behavioral interventions to optimize participation in a population-based colorectal cancer screening program in Catalonia, Spain

The aim of the study was to measure the effect of three cost-neutral behavioral interventions on participation compared to the standard invitation letter in a population-based colorectal cancer screening program in 2014. For that purpose, a four-arm randomized field trial was conducted among 5077 individuals aged 50 to 69 years. Over an 8-week period, each week was randomly allocated to the intervention or the control conditions. Individuals assigned to the intervention conditions additionally received a prompt to write down the date to pick up the screening test in a pharmacy. Two of the three intervention groups also included an additional paragraph in the invitation letter on either: 1) the high proportion of individuals participating regularly (social norms condition) or 2) the importance of regular participation (benefit condition). We measured screening participation before and after receiving a reminder letter six weeks after the screening invitation. An overall 8.0 percentage point increase in CRC screening was achieved as a direct result of receiving a reminder letter; however none of the intervention strategies influenced participation. The only significant difference was found for newly invited individuals. There, participation rates decreased from 34.9% to 24.2% when the invitation mailing mentioned the importance of regular participation (OR: 0.60; 95% CI: 0.38-0.95). While none of the intervention strategies improved participation rates we found that praising the benefit of regular screening may discourage individuals who have never been invited before as the continuous behavior may be perceived as a large request. Nevertheless, the reminder letter boosted participation rates independently of the intervention assigned.

Better Ask Than Tell: Responses to mHealth Interrogative Reminders and Associations With Colorectal Cancer Screening Subsequent Uptake in a Prospective Cohort Intervention

BACKGROUND

Text message (short message service, SMS) interrogative reminders were adopted in population screening for the early detection of colorectal cancer (CRC).

OBJECTIVE

This study aims to examine responses to text message (SMS) reminders and associate responses with senders' characteristics, message type (interrogative/declarative), and subsequent screening uptake.

METHODS

We conducted a prospective cohort intervention. Text message (SMS) reminders to undergo CRC screening, randomized into interrogative and declarative phrasing, were sent to nonadherent 40,000 women and men (age 50-74 years) at CRC average risk. We analyzed recipient responses by message phrasing, recipient characteristics, and for content, the latter predicting subsequent CRC screening per program database.

RESULTS

While interrogative text message (SMS) reminders elicited 7.67% (1475/19,227) responses, declarative ones elicited 0.76% (146/19,262) responses. Text message (SMS) responses were content analyzed and grouped into attitudes toward CRC screening (1237/1512, 81.8% positive) and intention to screen (1004/1512, 62.6%). Text message (SMS) respondents screened significantly more than nonrespondents after 6 months (415/1621, 25.6% vs 3322/36,868, 9.0%; χ12=487.5, P<.001); 1 year (340/1621, 21.0% vs 4711/36,868; χ12=91.5, P<.001); and 2 years (225/1621, 13.9% vs 3924/36,868; χ12=16.9, P<.001) following the reminders. In a multivariable logistic regression among text message (SMS) respondents, screening after 6 months was significantly predicted by older age, past sporadic screening, attitudes, and intentions.

CONCLUSIONS

Interrogative text message (SMS) reminders reached previously uninvolved sectors in the CRC target population-men, sporadic-screenees, and the "never-tested" before. This novel application resulted in a population-level, incrementally enhanced screening. Asking patients about their future health behavior may be relevant for enhancing other health behaviors in preventive medicine and clinical settings.

The Role of Access to a Regular Primary Care Physician in Mediating Immigration-Based Disparities in Colorectal Screening: Application of Multiple Mediation Methods

BACKGROUND

Colorectal cancer screening participation is lower among recent immigrants than among Canadian-born individuals. We assessed whether this screening disparity is mediated by access to regular primary care physicians (PCP).

METHODS

Pooling years 2003 to 2014 of the Canadian Community Health Survey, lifetime screening in respondents aged 50 to 75 years of age who immigrated in the previous 10 years (n = 1,067) was compared with Canadian-born respondents (N = 102,366). Regression- and inverse probability weighting-based methods were used to estimate the total effect (TE) and controlled direct effect (CDE) of recent immigration on never having received either a stool- or endoscopic-based screening test. The proportion of the TE that would be eliminated if all had a PCP was computed using these estimates [proportion eliminated (PE) = (TE - CDE)/(TE - 1)]. Analyses were stratified by visible minority status and adjusted for income, rurality, age, sex, marital status, education, and exposure to a provincially organized colorectal screening program.

RESULTS

The prevalence of never having been screened was 71% and 57% in visible minority and white recent immigrants, respectively, and 46% in white Canadian-born respondents. If all had regular PCPs, there would be no reduction in the screening inequality between white recent immigrants and Canadian-born (null PE), and the inequality between visible minority immigrants and white Canadian-born may increase by 6% to 13%.

CONCLUSIONS

Ensuring all have regular PCPs may lead to greater screening gains among Canadian-born than recent immigrants.

IMPACT

Improving access to PCPs may increase colorectal screening overall, but not reduce immigration-based disparities screening. Alternative interventions to reduce this disparity should be explored.

Effects of an entertaining, culturally targeted narrative and an appealing expert interview on the colorectal screening intentions of African American women

Universal screening for colorectal cancer (CRC) is recommended for individuals 50-75 years of age, but screening uptake is suboptimal and African Americans have suffered persistent racial disparities in CRC incidence and deaths. We compared a culturally tailored fictional narrative and an engaging expert interview on the ability to increase intentions to be screened for CRC among African American women. In a post-only experiment, women (N = 442) in face-to-face listening groups in African American churches heard audio recordings of either a narrative or an expert interview. Questionnaires were completed immediately afterward and 30 days later. Women who heard narratives reported stronger intentions to be screened with a home stool blood test than women who heard the interview; the effect lasted at least 30 days. Culturally tailored, fictional narratives appear to be an effective persuasive strategy for reducing racial disparities in CRC outcomes.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Decision-making in fecal occult blood test compliance: A quali-quantitative study investigating motivational processes

The qualitative-quantitative study investigates the co-existence of barriers and levers to FOBT screening in 5894 individuals reluctant to be screened, identifying operational motivational patterns that may increase screening compliance. Co-occurrence analysis was performed according to three motivational conditions (barriers, levers, or both).Cluster analysis then identified motivational predictors of effective screening. One quarter of the individuals who had refused screening nevertheless expressed at least one motivation towards FOBT. As such, co-existence of barriers and levers within the same individual demonstrates ambivalence tendencies. Intrinsic motivations appear to be the most likely to increase FOBT compliance. This study finds that certain factors well-known to improve CRC screening compliance generally, may not have much impact on reluctant individuals due to ambivalence and contextual nuances. Several practical recommendations to encourage screening participation are offered, such as focusing on levers rather barriers, providing tailored education to improve awareness and readiness, and fostering intrinsic motivation with relevant approaches.

Ethical issues with colorectal cancer screening-a systematic review

RATIONALE, AIMS, AND OBJECTIVES

Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening.

METHODS

An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments.

RESULTS

A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease.

CONCLUSION

A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.

Equity in social care for people with intellectual disabilities? A cross-sectional study examining the distribution of social care funding across local authorities in England

Many people with intellectual disabilities rely on social care provision, though little research has looked at how access to such provision is distributed nationally. Evidence from children's services suggests that there are large discrepancies between local authorities (LAs) in terms of the resources expended on interventions with children and families, which can be explained by variations linked to geographical location, namely the level of socioeconomic deprivation between LAs, constituting 'child welfare inequalities'. This study explored relationships between resources allocated to community services for people with intellectual disabilities in England and geographical factors, including deprivation, rurality and political leadership in the LAs where these individuals reside. Data were sourced from publicly available reports of spending of 151 English councils with adult social services responsibilities (CASSRs) for 2013-2014 and from CASSR index of multiple deprivation (IMD) scores and rurality for the same period. We found that more deprived LAs supported more people with intellectual disabilities, per 100,000 of population. We did not find effects for rurality or political party. However, it was not the case that more deprived LAs allocated more funds for expenditure on this group. These findings point to inequities in the distribution of social care resources for people with intellectual disabilities in England, as although more deprived LAs support more people with intellectual disabilities, they do not spend proportionally larger sums of money on this group. We discuss possible explanations for these findings and highlight the need for more research, particularly investigations about allocation of resources within LAs and more detailed explorations of how structural factors such as socioeconomic status of service users effects service access at the local level.

The relationship between ethnicity, social deprivation and late presentation of colorectal cancer

INTRODUCTION

Tumour staging at time of presentation is an important factor in determining survival in colorectal cancer. The aim of this paper is to investigate the relationship between ethnicity and deprivation in late (Stage IV) presentation of colorectal cancer.

METHODS

Data from the Thames Cancer Registry comprising 77,057 colorectal cancer patients between the years 2000 and 2012 were analysed.

RESULTS

A total of 17,348 patients were identified with complete data, of which 53.9% were male. Patients from a Black Afro/Caribbean background were diagnosed with CRC at a much younger age than the White British group (median age 67 compared with 72, p<0.001). In multiple regression, ethnicity, deprivation and age were positive predictors of presenting with advanced tumour stage at time of diagnosis. Black patients were more likely to present with Stage IV tumours than white patients (OR 1.37, 95% CI 1.18-1.59, p<0.001). Social deprivation was also a predictor of Stage IV cancer presentation, with the most deprived group (Quintile 5) 1.26 times more likely to be diagnosed with Stage IV cancer compared with the most affluent group (CI 1.13-1.40, p<0.001). Sub-group analyses demonstrated that Black & Affluent patients were still at greater risk of Stage IV CRC than their White & Affluent counterparts (OR 1.24, 95% CI 1.11-1.45, p=0.023). Patients with rectal cancer were less likely to present with Stage IV CRC (OR 0.66, 95% CI 0.61-0.71, p<0.001).

CONCLUSION

Racial and age related disparities exist in tumour presentation in the United Kingdom. Patients from black and socially deprived backgrounds as well as the elderly are more likely to present with advanced tumours at time of diagnosis.

Cancer beliefs in ethnic minority populations: a review and meta-synthesis of qualitative studies

People from ethnic minorities often experience poorer cancer outcomes, possibly due to later presentation to healthcare and later diagnosis. We aimed to identify common cancer beliefs in minority populations in developed countries, which can affect symptom appraisal and help seeking for symptomatic cancer. Our systematic review found 15 relevant qualitative studies, located in the United Kingdom (six), United States (five), Australia (two) and Canada (two) of African, African-American, Asian, Arabic, Hispanic and Latino minority groups. We conducted a meta-synthesis that found specific emotional reactions to cancer, knowledge and beliefs and interactions with healthcare services as contributing factors in help seeking for a cancer diagnosis. These findings may be useful to inform the development of interventions to facilitate cancer diagnosis in minority populations.

The role of area-level deprivation and gender in participation in population-based faecal immunochemical test (FIT) colorectal cancer screening

This study aimed to investigate the effects of sex and deprivation on participation in a population-based faecal immunochemical test (FIT) colorectal cancer screening programme. The study population included 9785 individuals invited to participate in two rounds of a population-based biennial FIT-based screening programme, in a relatively deprived area of Dublin, Ireland. Explanatory variables included in the analysis were sex, deprivation category of area of residence and age (at end of screening). The primary outcome variable modelled was participation status in both rounds combined (with "participation" defined as having taken part in either or both rounds of screening). Poisson regression with a log link and robust error variance was used to estimate relative risks (RR) for participation. As a sensitivity analysis, data were stratified by screening round. In both the univariable and multivariable models deprivation was strongly associated with participation. Increasing affluence was associated with higher participation; participation was 26% higher in people resident in the most affluent compared to the most deprived areas (multivariable RR=1.26: 95% CI 1.21-1.30). Participation was significantly lower in males (multivariable RR=0.96: 95%CI 0.95-0.97) and generally increased with increasing age (trend per age group, multivariable RR=1.02: 95%CI, 1.01-1.02). No significant interactions between the explanatory variables were found. The effects of deprivation and sex were similar by screening round. Deprivation and male gender are independently associated with lower uptake of population-based FIT colorectal cancer screening, even in a relatively deprived setting. Development of evidence-based interventions to increase uptake in these disadvantaged groups is urgently required.

Influence of a screening navigation program on social inequalities in health beliefs about colorectal cancer screening

The aim of the study was to test whether a screening navigation program leads to more favorable health beliefs and decreases social inequalities in them. The selected 261 noncompliant participants in a screening navigation versus a usual screening program arm had to respond to health belief measures inspired by the Protection Motivation Theory. Regression analyses showed that social inequalities in perceived efficacy of screening, favorable attitude, and perceived facility were reduced in the screening navigation compared to the usual screening program. These results highlight the importance of health beliefs to understand the mechanism of screening navigation programs in reducing social inequalities.

Reducing income-related inequities in colorectal cancer screening: lessons learned from a retrospective analysis of organised programme and non-programme screening delivery in Winnipeg, Manitoba

OBJECTIVE

We examined organised colorectal cancer (CRC) screening programme and non-programme faecal occult blood test (FOBT) use from 2008 to 2012 for individuals living in Winnipeg, Manitoba, by area-level income.

SETTING

Winnipeg, Manitoba, a region with universal healthcare and an organised CRC screening programme.

PARTICIPANTS

Individuals who had a non-programme FOBT were identified from the Provincial Medical Claims database. Individuals who had a programme FOBT were identified from the provincial screening registry. Census data were used to determine average household income based on area of residence.

STATISTICAL ANALYSIS

Trends in age-standardised FOBT rates were examined using Joinpoint Regression. Logistic regression was performed to explore the association between programme and non-programme FOBT use and income quintile.

RESULTS

FOBT use (non-programme and programme) increased from 32.2% in 2008 to 41.6% in 2012. Individuals living in the highest income areas (Q5) were more likely to have a non-programme FOBT compared with those living in other areas. Individuals living in areas with the lowest average income level (Q1) were less likely to have had programme FOBT than those living in areas with the highest average income level (OR 0.80, 95% CI 0.77 to 0.82). There was no difference in programme FOBT use for individuals living in areas with the second lowest income level (Q2) compared with those living in areas with the highest. Individuals living in areas with a moderate-income level (Q3 and Q4) were more likely to have had a programme FOBT compared with those living in an area with the highest income level (OR 1.12, 95% CI 1.09 to 1.15 for Q3 and OR 1.10, 95% CI 1.07 to 1.13 for Q4).

CONCLUSIONS

Inequities by income observed for non-programme FOBTs were largely eliminated when programme FOBTs were examined. Targeted interventions within organised screening programmes in very low-income areas are needed.

Impact of gender on decisions to participate in faecal immunochemical test-based colorectal cancer screening: a qualitative study

OBJECTIVE

Faecal immunochemical tests (FITs) are increasingly being used in population-based colorectal cancer-screening programmes. Uptake of FIT is lower in men than women; however, the reasons for this are not well understood. We aimed to explore gender differences in influences on decisions to participate in FIT screening.

METHODS

This is a qualitative study using in-depth face-to-face interviews of four groups of screening invitees (male and female screening users and male and female screening non-users), purposively sampled from the database of a population-based FIT screening programme. Recruitment continued until saturation was reached. Interviews were audio recorded and transcribed verbatim. Thematic analysis using the framework approach was employed with the theoretical domains framework guiding analysis.

RESULTS

Forty-seven screening invitees were interviewed. Six theoretical domains influenced screening uptake: 'environmental context and resources', 'beliefs about capabilities', 'beliefs about consequences', 'emotions', 'social influences' and 'knowledge'. Male non-users were often fatalistic, less knowledgeable and misinformed about cancer and FIT screening compared with other groups. Female non-users expressed negative attitudes, beliefs and emotions towards FIT screening, cancer, social influences and the medical profession and were over-confident about their health.

CONCLUSIONS

Negative attitudes and emotions to screening dominated non-user decision-making but differed by gender. Opportunities to improve uptake in men and women exist. Greater national discussions on the benefits of FIT screening, and development of screening materials tackling negative attitudes and beliefs while recognising male/female differences, may improve screening uptake. Copyright © 2016 John Wiley & Sons, Ltd.

Institutional (mis)trust in colorectal cancer screening: a qualitative study with Greek, Iranian, Anglo-Australian and Indigenous groups

INTRODUCTION

Colorectal cancer (CRC) has the second highest cancer mortality rate in Australia. The Australian National Bowel Cancer Screening Program (NBCSP) aims to increase early detection of CRC by offering free Faecal Occult Blood Testing (FOBT), although uptake is low for culturally and linguistically diverse (CALD) groups.

AIM OF PAPER

To present data on trust and mistrust in the NBCSP by population groups with low uptake and thus to highlight areas in need of policy change.

METHODS

A qualitative study was undertaken in South Australia, involving interviews with 94 people from four CALD groups: Greek, Iranian, Anglo-Australian, and Indigenous peoples.

RESULTS

Our study highlights the complexities of institutional trust, which involves considerations of trust at interpersonal, local and national levels. In addition, trust and mistrust was found in more abstract systems such as the medical knowledge of doctors to diagnose or treat cancer or the scientific procedures in laboratories to test the FOBTs. The object of institutional (mis)trust differed between cultural groups - Anglo-Australian and Iranian groups indicated a high level of trust in the government, whereas Indigenous participants were much less trusting.

CONCLUSION

The level and nature of trust in the screening process varied between the CALD groups. Addressing program misconceptions, clarifying the FOBT capabilities and involving medical services in collecting and transporting the samples may increase trust in the NBCSP. However, broader and more enduring mistrust in services and institutions may need to be dealt with in order to increase trust and participation.

Longitudinal Rates of Colon Cancer Screening Use in Winnipeg, Canada: The Experience of a Universal Health-Care System with an Organized Colon Screening Program

OBJECTIVES

We examined trends in colorectal cancer (CRC) screening (fecal occult blood test (FOBT), colonoscopy, and flexible sigmoidoscopy (FS)) and differences in CRC screening by income in a population with an organized CRC screening program and universal health-care coverage.

METHODS

Individuals who had an FOBT, colonoscopy, or FS were identified from the provincial Physician Claims database and the population-based colon cancer screening registry. Trends in age-standardized rates were determined. Logistic regression was performed to explore the association between CRC screening and income quintiles by year.

RESULTS

Up-to-date CRC screening (FOBT, colonoscopy, or FS) increased over time for men and women, all age groups, and all income quintiles. Up-to-date CRC screening was very high among 65- to 69- and 70- to 74-year-olds (70% and 73%, respectively). There was a shift toward the use of an FOBT for CRC screening for individuals in the lower income quintiles. The disparity in colonoscopy/FS coverage by income quintile was greater in 2012 than in 1995. Overall, there was no reduction in disparities by income in up-to-date CRC screening nor did the rate of increase in up-to-date CRC screening or FOBT use change after the introduction of the organized provincial CRC screening program.

CONCLUSIONS

CRC screening is increasing over time for both men and women and all age groups. However, a disparity in up-to-date CRC screening by income persisted even with an organized CRC screening program in a universal health-care setting.

Social inequalities in a population based colorectal cancer screening programme in the Basque Country

BACKGROUND

While it is known that a variety of factors (biological, behavioural and interventional) play a major role in the health of individuals and populations, the importance of the role of social determinants is less clear. The effect of social inequality on population-based screening for colorectal cancer (CRC) could limit the value of such programmes. The present study aims to determine whether such inequalities exist.

METHODS

Data was obtained from the population-based screening programme administered in the Autonomous Community of the Basque Country, Spain, with a target population aged 50 to 69, first invited to participate between 2009 and 2011. The magnitude of inequality was analysed using the odds ratio (taking the least disadvantaged socioeconomic quintile as the reference population), the population attributable risk and the relative index of inequality, based on the regression, which is the ratio of the rates in the most and least disadvantaged socioeconomic groups.

RESULTS

The target population comprised 242,394 people, with the test kit successfully sent to 95.1 % (230,510). The overall response rate was 64.3 % (67.1 in women and 61.4 % men). Among women, the highest participation was in the third quintile (71.5 %) and the lowest in the first - the least disadvantaged (65.7 %). The lowest and highest rates of people with identified lesions were in the second and fourth quintiles (14.7/1000 and 17.0/1000 respectively). Among men, the response rate was lowest in the fifth - most disadvantaged - quintile (60.2 %). The highest rate of identified lesions was in the fifth quintile; 38 % higher than the first (55.7/1000 compared to 41.0/1000).

CONCLUSIONS

Sex and socioeconomic group influence the rate of participation in the CRC programme and the rate of lesions found in the participants. Any public health programme is morally and ethically obliged to strive for equity and effectiveness. Improving participation of men and socially disadvantaged groups should be taken in account.

Uptake of colorectal cancer screening among Ontarians with intellectual and developmental disabilities

Under-screening for cancer may contribute to a greater disease burden in individuals with intellectual and developmental disabilities (IDD) as their life expectancy increases. In 2008, the province of Ontario launched Canada’s first population-based colorectal cancer screening program. Our objectives were to compare the proportions of Ontarians with and without IDD who have undergone colorectal cancer screening and to examine factors associated with screening uptake among Ontarians with IDD. Records for Ontario residents 50–64 years of age were linked across various administrative health and social services datasets to identify individuals with IDD and to select a random sample of the age-equivalent Ontario population without IDD as a comparison group. Logistic regression models were fit to examine the odds of screening uptake among individuals with IDD while controlling for age, sex, urban or rural residence, neighbourhood income quintile, expected use of health care resources, and being enrolled with or seeing a physician in a patient enrolment model (any of several primary care practice models designed to improve patient access and quality of care in Ontario), and to examine the association between these variables and colorectal cancer screening in the IDD population. The odds of having had a fecal occult blood test in the previous two years and being up-to-date with colorectal tests were 32% and 46% lower, respectively, for Ontarians with IDD compared to those without IDD. Being older, female, having a greater expected use of health care resources, and being enrolled with or seeing a physician in a primary care patient enrolment model were all significantly associated with higher odds of having been screened for colorectal cancer in the IDD population. These findings underscore the need for targeted interventions aimed at making colorectal cancer screening more equitable.

Equivalence of outcomes for rural and metropolitan patients with metastatic colorectal cancer in South Australia

OBJECTIVE

To compare the management and outcome of rural and metropolitan patients with metastatic colorectal cancer (mCRC) in South Australia.

DESIGN, SETTING AND PATIENTS

Retrospective cohort study of patients with mCRC submitted to the South Australian mCRC registry between 2 February 2006 and a cut-off date of 28 May 2012.

MAIN OUTCOME MEASURES

Differences in oncological and surgical management and overall survival (calculated using the Kaplan-Meier method) between city and rural patients.

RESULTS

Of 2289 patients, 624 (27.3%) were rural. There was a higher proportion of male patients in the rural cohort, but other patient characteristics did not significantly differ between the cohorts. Equivalent rates of chemotherapy administration between city and rural patients were observed across each line of treatment (first line: 56.0% v 58.3%, P = 0.32; second line: 23.3% v 22.5%, P = 0.78; and third line: 10.1% v 9.3%, P = 0.69). A higher proportion of city patients received combination chemotherapy in the first-line setting (67.4% v 59.9%; P = 0.01). When an oxaliplatin combination was prescribed, oral capecitabine was used more frequently in rural patients (22.9% v 8.4%; P < 0.001). No significant difference was seen in rates of hepatic resection or other non-chemotherapy treatments between cohorts. Median overall survival was equivalent between city and rural patients (14.6 v 14.9 months, P = 0.18).

CONCLUSION

Patterns of chemotherapy and surgical management of rural patients with mCRC in SA are equivalent to their metropolitan counterparts and lead to comparable overall survival. The centralised model of oncological care in SA may ensure rural patients gain access to optimal care.

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.

Colorectal cancer screening in first nations people living in Manitoba

BACKGROUND

Because the burden of colorectal cancer (CRC) seems to be increasing in First Nations, it is important to better understand CRC screening utilization. The objective of this study was to describe CRC screening among First Nations living in Manitoba.

METHODS

The Federal Indian Register was linked to two provincial databases. A negative binomial model was used to compare the probability of First Nations having a fecal occult blood test (FOBT), colonoscopy, or flexible sigmoidoscopy (FS) with all other Manitobans.

RESULTS

First Nations who lived in Winnipeg were significantly less likely to have had a FOBT in the previous 2 years than all other Manitobans who lived in Winnipeg [rate ratio (RR) = 0.40; 95% confidence intervals (CI), 0.37-0.44]. There was no difference in the likelihood of having a colonoscopy or FS for First Nations individuals who resided in northern Manitoba compared with all other Manitobans (RR, 1.04; 95% CI, 0.91-1.19). However, First Nations who lived in the rural south or urban areas were less likely than all other Manitobans to have had a colonoscopy or FS (RR, 0.81, 95% CI, 0.75-0.87, rural south; RR, 0.86, 95% CI, 0.81-0.92, urban).

CONCLUSIONS

First Nations living in Winnipeg were significantly less likely to be screened for CRC using the FOBT. Colonoscopy and FS use depended on area of residence.

IMPACT

First Nations experience barriers that impede the use of CRC screening. Further research is needed to understand these barriers to extend the benefit of CRC screening to this population. Cancer Epidemiol Biomarkers Prev; 24(1); 241-8. ©2014 AACR.

Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project

Background

There is growing interest in theory-driven, qualitative and mixed-method approaches to systematic review, such as realist and meta-narrative review. These approaches offer the potential to expand the knowledge base in policy-relevant areas. However, the quality of such reviews can be difficult to assess.

Objectives

The aim of this project was to produce methodological guidance, publication standards and training resources for those seeking to undertake realist and/or meta-narrative reviews.

Methods/design

We (1) collated and summarised existing literature on the principles of good practice in realist and meta-narrative systematic reviews; (2) considered the extent to which these principles had been followed by published and in-progress reviews, thereby identifying how rigour may have been lost and how existing methods could be improved; (3) used an online Delphi method with an interdisciplinary panel of experts from academia and policy, to produce a draft set of methodological steps and publication standards; (4) produced training materials with learning objectives linked to these steps; (5) refined these standards and training materials prospectively on real reviews in progress, capturing methodological and other challenges as they arose; (6) synthesised expert input, evidence review and real-time problem analysis into more definitive guidance and standards; and (7) disseminated outputs to audiences in academia and policy.

Results

An important element of this study was the establishment of an e-mail mailing list to bring together researches in the field (www.jiscmail.ac.uk/RAMESES). Our literature review identified 35 and nine realist and meta-narrative reviews respectively. Analysis and discussion within the project team produced a summary of the published literature, and common questions and challenges into briefing materials for the Delphi panel, comprising 37 and 33 members (for realist and meta-narrative reviews respectively). Within three rounds this panel had reached a consensus on 19 (realist) and 20 (meta-narrative) key publication standards, with an overall response rate of 90% and 91% respectively. The Realist And Meta-narrative Evidence Syntheses – Evolving Standards (RAMESES) publication standards for realist syntheses and meta-narrative reviews were published in open-access journals and quickly became highly accessed. The RAMESES quality standards and training materials drew together the following sources of data: (1) personal expertise as researchers and trainers; (2) data from the Delphi panels; (3) feedback from participants at training sessions we ran; and (4) comments made on RAMESES mailing list. The quality standards and training materials are freely available online (www.ramesesproject.org).

Discussion

The production of these standards and guidance drew on multiple sources of knowledge and expertise, and a high degree of a consensus was achieved despite ongoing debate among researchers about the overall place of these methodologies in the secondary research toolkit. As with all secondary research methods, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency of studies. We anticipate that as more reviews are undertaken, further refinement will be needed to the publication and quality standards and training materials.

Limitations

The project’s outputs are not definitive and in the future updating and further development is likely to be needed.

Conclusion

An initial set of publication standards, quality standards and training materials have been produced for researchers, users and funders of realist or meta-narrative reviews. As realist and meta-narrative reviews are relatively new approaches to evidence synthesis, methodological development is needed for both review approaches.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Participation and detection rates by age and sex for colonoscopy versus fecal immunochemical testing in colorectal cancer screening

PURPOSE

To compare two strategies for colorectal cancer screening: one-time colonoscopy versus fecal immunochemical testing (FIT) (and colonoscopy for positive) every 2 years, in order to determine which strategy provides the highest participation and detection rates in groups of sex and age.

METHODS

This analysis was performed with data from the first screening round within the COLONPREV study, a population-based, multicenter, nationwide trial carried out in Spain. Several logistic regression models were applied to identify the influence of the screening test on participation rates and detection of proximal and distal neoplasms, as well to identify the influence of age and sex: women aged 50-59 years, women aged 60-69 years, men aged 50-59 years, and men aged 60-69 years.

RESULTS

Participation was higher in women than in men, especially among women aged 50-59 years (25.91 % for colonoscopy and 35.81 % for FIT). Crossover from colonoscopy to FIT was higher among women than men, especially among those aged 60-69 years (30.37 %). In general, detection of any neoplasm and advanced adenoma was higher with colonoscopy than with FIT, but no significant differences were found between the two strategies for colorectal cancer detection. Detection of advanced adenoma in both arms was lower in women [specifically in women aged 50-59 years (OR 0.31; 95 % CI 0.25-0.38) than in men aged 60-69 years]. Women aged 50-59 years in the colonoscopy arm had a higher probability of detection of advanced adenoma (OR 4.49; 95 % CI 3.18-6.35), as well as of detection of neoplasms in proximal and distal locations (proximal OR 19.34; 95 % CI 12.07-31.00; distal OR 11.04; 95 % CI 8.13-15.01) than women of the same age in the FIT arm. These differences were also observed in the remaining groups but to a lesser extent.

CONCLUSION

Women were more likely to participate in a FIT-based strategy, especially those aged 50-59 years. The likelihood of detection of any neoplasm was higher in the colonoscopy arm for all the population groups studied, especially in women aged 50-59 years. Distinct population groups should be informed of the benefits of each screening strategy so that they may take informed decisions.

Attitudes and beliefs of non-participants in a population-based screening programme for colorectal cancer

BACKGROUND

Uptake of colorectal cancer screening programmes needs to be improved or at least maintained in order to achieve projected reductions in mortality and morbidity. Understanding the origins of non-participation in screening is therefore important.

OBJECTIVE

To explore the beliefs and experiences of individuals who had not responded either to their screening invitation or reminder.

DESIGN

A qualitative study using in-depth interviews with non-participants from England's population-based colorectal cancer screening programme. Data collection and analysis were carried out using a grounded theory approach, with an emphasis on the constant comparison method, and continued until saturation (27 interviews).

FINDINGS

The interviews provided an in-depth understanding of a range of reasons and circumstances surrounding non-participation in screening, including contextual and environmental influences as well as factors specific to the screening test. Non-participation in screening was not necessarily associated with negative attitudes towards screening or a decision to not return a kit. Reasons for non-participation in screening included not feeling that participation is personally necessary, avoiding or delaying decision making, and having some degree of intention to take part but failing to do so because of practicalities, conflicting priorities or external circumstances. Beliefs, awareness and intention change over time.

DISCUSSION AND CONCLUSIONS

A range of approaches may be required to improve screening uptake. Some non-participants may already have a degree of intention to take part in screening in the future, and this group may be more responsive to interventions based on professional endorsement, repeat invitations, reminders and aids to making the test more practical.

Ambivalence and its influence on participation in screening for colorectal cancer

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, and an ideal target for early detection and prevention through cancer screening. Unfortunately, rates of participation in screening are less than adequate. In this article we explore why people who were offered a fecal immunochemical test for CRC decided to participate or not, and for those who did participate, what influenced them to take action and complete the test. We conducted four focus groups and 30 telephone interviews with 63 people. The main reason people decided to screen was "wanting to know" their CRC status, which operated on a continuum ranging from wanting to know, through varying degrees of ambivalence, to not wanting to know. The majority of participants expressed ambivalence about CRC screening, and the main cue to action was the opportunity to screen without being too inconvenienced.

Comparing barriers to colorectal cancer screening with barriers to breast and cervical screening: a population-based survey of screening-age women in Great Britain

Objective

Uptake of cancer screening tends to be lower for colorectal cancer (CRC) than cervical or breast cancer. Dislike of the test itself has often been identified as a barrier to CRC screening with the Faecal Occult Blood (FOB) test, but there have been no head-to-head comparisons of the three tests.

Methods

Women aged 50–80 ( n = 890) were recruited in spring 2012 as part of a population-based TNS Research International survey in Great Britain. Those in the eligible age range were asked if they had ever participated in breast, cervical or CRC screening. For each screening test, women who had never participated were asked for their ‘main reason’ using a checklist of barriers.

Results

Among eligible women, 67%, 83% and 90% reported ever having been screened for CRC, cervical and breast cancer respectively. More socioeconomically deprived women were less likely to report any screening, and single women were less likely to report CRC or breast screening than married women. Age was not associated with participation. Overall there were few differences between tests in the reported barriers, but dislike of the test was endorsed more often for CRC screening.

Conclusion

This was the first study to compare barriers to participation in organised screening programmes for CRC, breast and cervical cancer. Cancer screening tests share many barriers, but dislike of the test appears to be a stronger barrier to CRC screening. Women who are non-participants in more than one programme may have more global barriers to screening, such as cancer fatalism. The findings suggest that uptake of CRC screening could be improved by targeting the unpleasantness of stool sampling.

Gender differences in attitudes impeding colorectal cancer screening

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.

Methods

N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.

Results

Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Conclusions

Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).

Individual- and provider-level factors associated with colorectal cancer screening in accordance with guideline recommendation: a community-level perspective across varying levels of risk

BACKGROUND

Participation rates in colorectal cancer screening (CRC) are low. Relatively little is known about screening uptake across varying levels of risk and across population groups. The purpose of the current study was to identify factors associated with (i) ever receiving colorectal cancer (CRC) testing; (ii) risk-appropriate CRC screening in accordance with guidelines; and (iii) recent colonoscopy screening.

METHODS

1592 at-risk persons (aged 56-88 years) were randomly selected from the Hunter Community Study (HCS), Australia. Participants self-reported family history of CRC was used to quantify risk in accordance with national screening guidelines.

RESULTS

1117 participants returned a questionnaire; 760 respondents were eligible for screening and analysis. Ever receiving CRC testing was significantly more likely for persons: aged 65-74 years; who had discussed with a doctor their family history of CRC or had ever received screening advice. For respondents "at or slightly above average risk", guideline-appropriate screening was significantly more likely for persons: aged 65-74 years; with higher household income; and who had ever received screening advice. For respondents at "moderately or potentially high risk", guideline-appropriate screening was significantly more likely for persons: with private health insurance and who had discussed their family history of CRC with a doctor. Colonoscopy screening was significantly more likely for persons: who had ever smoked; discussed their family history of CRC with a doctor; or had ever received screening advice.

CONCLUSIONS

The level of risk-appropriate screening varied across populations groups. Interventions that target population groups less likely to engage in CRC screening are pivotal for decreasing screening inequalities.

A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients

Background

The aim of this study was to determine the proportions and predictors of first-degree relatives (FDRs) of colorectal cancer (CRC) patients (i) ever receiving any CRC testing and (ii) receiving CRC screening in accordance with CRC screening guidelines.

Methods

Colorectal cancer patients and their FDRs were recruited through the population-based Victorian Cancer Registry, Victoria, Australia. Seven hundred and seven FDRs completed telephone interviews. Of these, 405 FDRs were deemed asymptomatic and eligible for analysis.

Results

Sixty-nine percent of FDRs had ever received any CRC testing. First-degree relatives of older age, those with private health insurance, siblings and FDRs who had ever been asked about family history of CRC by a doctor were significantly more likely than their counterparts to have ever received CRC testing. Twenty-five percent of FDRs “at or slightly above average risk” were adherent to CRC screening guidelines. For this group, adherence to guideline-recommended screening was significantly more likely to occur for male FDRs and those with a higher level of education. For persons at “moderately increased risk” and “potentially high risk”, 47% and 49% respectively adhered to CRC screening guidelines. For this group, guideline-recommended screening was significantly more likely to occur for FDRs who were living in metropolitan areas, siblings, those married or partnered and those ever asked about family history of CRC.

Conclusions

A significant level of non-compliance with screening guidelines was evident among FDRs. Improved CRC screening in accordance with guidelines and effective systematic interventions to increase screening rates among population groups experiencing inequality are needed.

Trial Registration

Australian and New Zealand Clinical Trial Registry: ACTRN12609000628246

Reasons for participation and nonparticipation in colorectal cancer screening: a randomized trial of colonoscopy and CT colonography

OBJECTIVES

We compared reported reasons for participation and nonparticipation in colorectal cancer (CRC) screening between colonoscopy and computed tomographic (CT) colonography in a randomized controlled trial.

METHODS

We randomly invited 8,844 people for screening by colonoscopy or CT colonography. On a questionnaire, invitees indicated reasons for participation or nonparticipation and indicated the most decisive reason.

RESULTS

The most frequently cited reasons to accept screening were early detection of precursor lesions and CRC, and contribution to science. The most frequently cited reasons to decline were the unpleasantness of the examination, the inconvenience of the preparation, a lack of symptoms, and "no time/too much effort." Among colonoscopy nonparticipants, elderly invitees cited inconvenience less often, and absence of symptoms more often, than did the group overall. The reason reported most frequently as the most decisive reason not to participate was the unpleasantness of the examination among colonoscopy nonparticipants, and "no time/too much effort" and lack of symptoms among CT colonography nonparticipants.

CONCLUSIONS

In light of these results, future screening programs could tailor the information provided to invitees.

Screening practices of Australian men and women categorized as "at or slightly above average risk" of colorectal cancer

PURPOSE

Australia has one of the highest incidences of colorectal cancer (CRC) in the world. In 2006, the federal government introduced a screening program consisting of a one-off fecal occult blood test offered to people turning 50, 55, or 65 years. We conducted a population-based study to estimate CRC screening practices existing outside the current program.

METHODS

A total of 1887 unaffected subjects categorized "at or slightly above average risk" of CRC were selected from the Australasian Colorectal Cancer Family Registry. We calculated the proportions of participants that reported appropriate, under- and over-screening according to national guidelines. We performed a logistic regression analysis to evaluate associations between over-screening and a set of socio-demographic factors.

RESULTS

Of 532 participants at average risk of CRC, eligible for screening, 4 (0.75 %) reported appropriate screening, 479 (90 %) reported never having been screened, 18 (3 %) reported some but less than appropriate screening, and 31 (6 %) reported over-screening. Of 412 participants aged 50 years or over, slightly above average risk of CRC, 1 participant (0.25 %) reported appropriate screening, 316 (77 %) reported no screening, and 11 (3 %) reported some but less than appropriate screening. Among participants under age 50 years, 2 % of those at average risk and 10 % of those slightly above average risk reported over-screening. Middle-aged people, those with a family history of CRC and those with a university degree, were more likely to be over-screened.

CONCLUSION

Overall, the level of CRC screening participation was low and the vast majority of screening tests undertaken were inappropriate in terms of timing, modality, or frequency.

Socioeconomic factors affecting colorectal, breast and cervical cancer screening in an Asian urban low-income setting at baseline and post-intervention

BACKGROUND

Inequalities in cancer screening are little studied in Asian societies. We determined whether area and individual measures of socio-economic status (SES) affected cancer screening participation in Singapore and prospectively evaluated an access-enhancing community-based intervention.

METHODS

The study population involved all residents aged >40 years in two housing estates comprising of owner-occupied (high-SES area) and rental (low-SES area) flats. From 2009 to 2011, non-adherents to regular screening for colorectal/breast/cervical cancer were offered free convenient screening over six months. Pre- and post-intervention screening rates were compared with McNemar's test. Multi-level logistic regression identified factors of regular screening at baseline; Cox regression analysis identified predictors of screening post-intervention.

RESULTS

Participation was 78.2% (1081/1383). In the low-SES area, 7.7% (33/427), 20.4% (44/216), and 14.3% (46/321) had regular colorectal, cervical and breast cancer screening respectively. Post-intervention, screening rates in the low-SES area rose significantly to 19.0% (81/427), 25.4% (55/216), and 34.3% (74/216) respectively (p<0.001). Area SES was more consistently associated with screening than individual SES at baseline. Post-intervention, for colorectal cancer screening, those with higher education were more likely to attend (p=0.004); for female cancer screening, the higher-income were less likely to attend (p=0.032).

CONCLUSIONS

Access-enhancing community-based interventions improve participation among disadvantaged strata of Asian societies.

Realist methods in medical education research: what are they and what can they contribute?

CONTEXT

Education is a complex intervention which produces different outcomes in different circumstances. Education researchers have long recognised the need to supplement experimental studies of efficacy with a broader range of study designs that will help to unpack the 'how' and 'why' questions and illuminate the many, varied and interdependent mechanisms by which interventions may work (or fail to work) in different contexts.

METHODS

One promising approach is realist evaluation, which seeks to establish what works, for whom, in what circumstances, in what respects, to what extent, and why. This paper introduces the realist approach and explains why it is particularly suited to education research. It gives a brief introduction to the philosophical assumptions underlying realist methods and outlines key principles of realist evaluation (designed for empirical studies) and realist review (the application of realist methods to secondary research).

DISCUSSION

The paper warns that realist approaches are not a panacea and lists the circumstances in which they are likely to be particularly useful.