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

Digital tools to support informed decision making among screening invitees in a vulnerable position for population-based cancer screening: A scoping review

BACKGROUND

Individuals in a vulnerable position are generally less inclined to participate in population-based cancer screening. Digital tools, such as educational videos, narratives or decision aids, show promise in reaching and informing these invitees by tailoring information needs based on their preferences. This review aims to provide an overview of design features and reported outcomes of digital tools intended to support informed decision making among screening invitees in a vulnerable position.

METHODS

The review was conducted according to the Preferred Reporting Items for Scoping Reviews guidelines. We searched PubMed, Scopus/MEDLINE and Web of Science and included studies when the effectiveness of the digital tool was assessed and focussed on reaching and/or informing screening invitees in a vulnerable position for breast, cervical or colorectal cancer screening. For each included study, the study population, type of digital tool, the development process, reported design features and reported effects were extracted.

FINDINGS

We found 448 articles, and finally 13 were included in this review after reading full text. Study designs included randomised controlled trials (n = 5), pre-post-test design (n = 7) and experimental design (n = 1). Six different types of digital tools were identified: decision aids (n = 6), educational programs (n = 3), narrative video (n = 1), text-messaging intervention (n = 1), animation video (n = 1), and iPad program (n = 1). A population specific design was applied in 12/13 interventions, such as avoiding jargon and using a voice over function. Reported outcomes measures regarding reaching and informing the target population were: knowledge, attitude, screening intention, self-efficacy, susceptibility, feeling informed, values clarity, and screening uptake. All digital tools reported a significant improvement on at least one of the reported outcome measures.

PRINCIPAL CONCLUSIONS

The use of digital tools seems to contribute to reach or inform screening invitees in a vulnerable position for cancer screening. However, insufficient evidence was found regarding the development process of the tools and their effects on outcome measures related to reaching and informing the screening invitees in a vulnerable position. Future research may look in to combining multiple digital tools and animated visual information in combination with spoken text to improve reaching and informing screening invitees in a vulnerable position.

Co-designing planning interventions to facilitate participation in mail-out bowel cancer screening

BACKGROUND

Population mail-out bowel cancer screening programs save lives through prevention and early detection; however, their effectiveness is constrained by low participation rates. Many non-participants are "intenders"; that is, they intend to screen but fail to do so, often forgetting or procrastinating. This study aimed to co-design interventions to increase screening participation among intenders in the Australian National Bowel Cancer Screening Program.

METHODS

Three semi-structured interviews, and one online cross-sectional survey, were conducted between August 2021 and December 2022. Interviews with people who had completed and returned their latest screening kit ("completers") were first conducted to identify the planning strategies they had used. Using survey data, logistic regressions were conducted to analyse strategies predictive of participants having returned their latest bowel cancer screening kit. Then, intenders were interviewed to explore their opinions of these strategies and worked with researchers to adapt these strategies into prototype interventions to facilitate screening participation. All interviews were analysed using the framework approach of codebook thematic analysis.

RESULTS

Interview participants who returned their kit shared their effective planning strategies, such as putting the kit in a visible place or by the toilet, planning a time at home to complete the kit, and using reminders. Survey participants who reported using such strategies were more likely to have completed their screening kit compared to those who did not. Prototype interventions developed and endorsed by intenders included providing a prompt to place the kit or a sticker near the toilet as a reminder, a deadline for kit return, the option to sign up for reminders, and a bag to store the sample in the fridge.

CONCLUSIONS

These novel, consumer-led interventions that are built upon the needs and experience of screening invitees provide potential solutions to improve participation in population bowel cancer screening.

Socioeconomic differences in discrepancies between expected and experienced discomfort from colonoscopy and colon capsule endoscopy

Background

Social inequalities in colorectal cancer screening participation are evident. Barriers to screening participation include discomfort from diagnostic modalities. We aimed to describe the discomfort experienced from colonoscopy and colon capsule endoscopy (CCE) and investigate the discrepancy between expected and experienced discomfort stratified by socioeconomic status.

Methods

A randomised controlled trial was conducted offering half of the colorectal cancer screening invitees the choice between CCE and colonoscopy after a positive faecal immunochemical test. This paper includes those who elected to undergo CCE. A positive CCE elicited referral for a therapeutic colonoscopy. Participants reported their discomfort from CCE and from any following colonoscopies in electronically distributed questionnaires. Discomfort was measured using visual analogue scales and compared between socioeconomic subgroups determined by educational level and income.

Results

The experienced discomfort from CCE and colonoscopy differed significantly between educational levels but not income levels. The bowel preparation contributed the most to the experienced discomfort in both CCE and colonoscopy. The discrepancy between expected and experienced discomfort from colonoscopy increased with increasing educational and income levels. A similar trend was seen in CCE between educational levels but not income levels.

Conclusions

None of the results indicated a higher discomfort in lower socioeconomic subgroups. Regardless of the investigation modality, the bowel preparation was the main contributor to experienced discomfort. The discrepancy between expected and experienced discomfort did not seem to be larger in lower socioeconomic subgroups, indicating that this is not a major barrier causing inequalities in screening uptake. This is the first study investigating individual discomfort discrepancy in both CCE and colonoscopy, while being able to stratify by socioeconomic status.

Attitudes to multi-cancer early detection (MCED) blood tests for population-based screening: A qualitative study in Great Britain

BACKGROUND

Trials are underway to test the clinical utility of multi-cancer early detection (MCED) blood tests for screening asymptomatic individuals. We sought to understand the acceptability of MCED blood test screening and potential barriers and facilitators to participation among the general public.

METHODS

We conducted eleven semi-structured online focus groups with 50-77-year-olds (n = 53) in April-November 2022. Participants were purposefully sampled to include a mix of socio-economic and ethnic backgrounds as well as people who would not want 'a blood test for cancer'. Participants were shown information about MCED blood tests. Transcripts were analysed using reflexive thematic analysis.

RESULTS

Participants showed enthusiasm for MCED screening. Perceived benefits included procedural familiarity and the potential to screen for many cancers. Enthusiasm was driven by beliefs that cancer is a real and increasing risk (both at population level and personally with age) and that early detection reduces treatment burden and cancer mortality. Some felt they would not want to know if they had cancer. The potential for MCED tests to raise anxiety was a concern, especially in a false-positive scenario. Participants wanted to avoid unpleasant and unnecessary procedures. The initial blood test was deemed "less invasive" than current screening tests, but potential follow-up procedures were a concern. Views on MCED screening were influenced by wider factors including dislike of uncertainty, desire for choice and control over one's health, and existing relationships with the NHS.

CONCLUSION

The introduction of MCED screening is likely to be appealing due to the simplicity and familiarity of the primary test procedure. Test accuracy needs to be high to facilitate acceptability and should be communicated from the outset. Some people would rather not know if they have cancer, and MCEDs will not appeal to all.

Impact of family history of cancer on colorectal cancer screening: a propensity score-matched analysis from the Health Information National Trends Survey (HINTS)

BACKGROUND

Early detection of colon cancer leads to better survival outcomes. This can be achieved through colorectal cancer (CRC) screening. People with a family history of cancer (FHC) have increased risk of developing CRC. Increasing screening in this group will reduce CRC mortality. This study evaluated CRC screening in people with FHC.

METHODS

The study used data from the Health Information National Trends Survey (HINTS) 5, cycle 3. This is an annual cross-sectional survey with a nationally representative sample of American adults. The objective was to study the association between FHC and performing CRC screening. Propensity score matching was used to create a matched population with variables that constituted beliefs in cancer from the survey. Replication procedure, which is based on repeated sampling and allows for accurate computation of standard errors, was used for calculating statistical tests. Multivariable models were fitted in the matched population to assess the association between FHC and performing CRC screening.

RESULTS

People with FHC were 14% (OR = 1.14; 95% CI: 0.81-1.60) more likely to perform CRC screening than those without FHC, even though not statistically significant. Age in years (OR = 1.14; 95% CI: 1.12-5.27) had increased likelihood of performing CRC screening, while other races such as American Indians/Alaskan Natives (except African Americans) compared to Caucasians (OR = 0.49; 95% CI: 0.29-0.84) had significantly decreased likelihood of performing CRC screening.

CONCLUSION

FHC was not significantly associated with having a colorectal cancer screening test. Public health advocacy should be directed towards increasing awareness of CRC screening among people with FHC.

Anticipatory anxiety and participation in cancer screening. A systematic review

OBJECTIVES

To synthesize current evidence on the association between anticipatory anxiety, defined as apprehension-specific negative affect that may be experienced when exposed to potential threat or uncertainty, and cancer screening to better inform strategies to maximize participation rates.

METHODS

Searches related to cancer screening and anxiety were conducted in seven electronic databases (APA PsycINFO, Scopus, Web of Science, Embase, Cochrane Library, PubMed, CINAHL), with potentially eligible papers screened in Covidence. Data extraction was conducted independently by multiple authors. Barriers to cancer screening for any type of cancer and relationships tested between anticipatory anxiety and cancer screening and intention were categorized and compared according to the form and target of anxiety and cancer types.

RESULTS

A total of 74 articles (nparticipants  = 119,990) were included, reporting 103 relationships tested between anticipatory anxiety and cancer screening and 13 instances where anticipatory anxiety was reported as a barrier to screening. Anticipatory anxiety related to a possible cancer diagnosis was often associated with increased screening, while general anxiety showed no consistent relationship. Negative relationships were often found between anxiety about the screening procedure and cancer screening.

CONCLUSION

Anticipatory anxiety about a cancer diagnosis may promote screening participation, whereas a fear of the screening procedure could be a barrier. Public health messaging and primary prevention practitioners should acknowledge the appropriate risk of cancer, while engendering screening confidence and highlighting the safety and comfort of screening tests.

Bowel cancer knowledge gaps evident among Irish residents: results of a national questionnaire survey

BACKGROUND

The extent of knowledge of bowel cancer, its symptoms and risk factors are unknown in Irish residents. An understanding of bowel cancer awareness may be useful in aiding healthcare professionals, and policy makers develop improved bowel cancer awareness programmes and public health initiatives in Ireland.

AIMS AND METHODS

A 22-question online questionnaire survey was designed to gather data to assess residents' awareness of bowel cancer, its symptoms, and risk factors and to determine reasons for not participating in BowelScreen Ireland.

RESULTS

There were 449 participants (329 women, 119 men and 1 'prefer not to say'). The majority of participants were aged 35-49 years (42.8%), and 82.6% had completed a third level qualification. Irish residents (non-healthcare professionals/scientists (NHCP/S)) recalled on average less than three warning signs/symptoms. Among NHCP/S the most well-recalled protective diet and lifestyle choices were active lifestyle/exercise (62.1%), a fibre rich diet (45.4%) and no/low alcohol consumption (32.1%). Many were unable to recall red and processed meat as risk factors with only 10.7% and 4.9%, respectively, citing these foods. However, prompted awareness was superior with 71.1% agreeing or strongly agreeing that consumption of red and processed meat is a risk factor. 43.4% said they would be 'fairly confident' in recognising a sign/symptom, but more than a third (38.7%) reported they were 'not very confident'.

CONCLUSION

This survey emphasises the need to improve the awareness of bowel cancer as gaps in this specific cancer knowledge were evident among Irish residents.

The Barriers to Bowel Cancer Screening Scale: Examining Structural Validity, Measurement Invariance, and Criterion Validity

OBJECTIVE

The success of national cancer screening programs, such as the National Bowel Cancer Screening Program (NBCSP) in Australia, depends on public participation, which is currently an alarming 43.5% for the NBCSP. Understanding the barriers that impede screening participation requires valid measurement instruments. This study aims to cross-validate such an instrument with a new, large, and varied sample, as well as assess measurement invariance across subsamples at a greatest risk of nonparticipation (ie, testing whether the scale functions in similar ways across groups).

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional sample of 1158 participants from the target screening population (50-74 years) provided demographic information, responses to the Barriers to Home Bowel Screening (BB-CanS) scale, and information on their previous screening participation.

RESULTS

Both the full and the brief versions of the BB-CanS scale showed good model fit for the full sample and for gender and age subsamples. Despite the inter-factor correlations being high, the unidimensional and bi-factor models exhibited poorer fit. Improvement in fit was observed with scale refinement involving the removal of 7 items. All versions of the BB-CanS scale were invariant across gender and age subsamples. Age and gender differences emerged across several barriers and variance in all 4 barriers significantly predicted prior screening participation.

CONCLUSION

The BB-CanS scale is a valid measure of 4 highly correlated barriers to home bowel cancer screening: disgust relating to screening, avoidance of test outcomes, practical difficulty (or challenges), and the need for a sense of greater autonomy. All versions of the instrument measure the equivalent construct across age and gender groups. Observed differences in barriers across at-risk groups provide targets for future intervention.

Barriers for Participation in the Danish Colorectal Cancer Screening Program: a Qualitative Study

PURPOSE

The participation rate in the Danish National Screening Program for Colorectal Cancer is around 60%. Since early detection of cancer through the colorectal cancer screening program (CRCS) reduces mortality rates, it is important to understand why people do not participate. The aim of this study was therefore to examine in depth why some people do not participate in the Danish CRCS program.

METHODS

Individual semi-structured interviews were conducted with 18 people who had not participated in the national CRCS program. Data was analyzed using an inductive hermeneutic approach.

RESULTS

The analysis uncovered three main themes describing barriers to screening: (a) the accountability for ensuring personal health covered the following sub-themes: (i) when invitation is out of sight it is out of mind, (ii) aversion against own stool sample collection, and (iii) the perceived risk of getting colorectal cancer (CRC); (b) attitudes towards the healthcare system and its organization covered the following sub-themes: (i) positivity towards CRCS, (ii) trust in the healthcare system, (iii) lack of internal communication in the healthcare system, and (iv) wish for involvement of the general practitioner (GP); (c) knowledge about disease and screening covered the following sub-themes: (i) knowledge about CRC and CRCS, (ii) wish for information via new channels, and (iii) CRC is rarely something you talk about.

CONCLUSION

Among the informants included in this study, lack of participation in the CRCS program was not due to an active opt-out, as most informants had intentions of participating. The informants thought it would motivate them to participate if their GP would remind them of the screening program.

[Actitudes e imágenes sociales sobre el cribado de cáncer colorrectal. Una aproximación exploratoria mediante grupos de discusión.]

OBJECTIVE

The screening for colorectal cancer (CRC) through the fecal occult blood test (FOBT) has achieved high implementation in Spain, although participation rates are still not optimal. At the same time, available data show significant differences in participation both among autonomous communities and among different sociodemographic groups, which raises various equity issues. This study aimed to conduct an exploratory analysis from a qualitative perspective on the attitudes, perceptions, and social images that the target population for colorectal cancer screenings holded regarding them, as well as the barriers and areas for improvement identified through these.

METHODS

This study was designed using a qualitative research approach, through the conduct of four focus groups in May 2022, with a total of twenty-six participants (equal number of men and women) aged fifty to sixty-nine years. The participants were residents of the Community of Madrid, Catalonia, Andalusia, and the Basque Country (in both large and small cities), with varying educational levels and different previous experiences of participation in the CRC screening program.

RESULTS

Different conceptualizations of prevention were identified, but none that encompassed cancer (especially colorectal cancer) as an element to be incorporated into daily practices since its occurrence is primarily associated with chance. In addition to the lack of knowledge about CRC compared to other types of cancer (such as breast or prostate cancer), various attitudinal barriers to participation in the CRC screening program were perceived. These included the rejection of being part of the older age group (targeted by the test), fear of waiting for the results, lack of reliability, or the sense of being able to postpone the moment.

CONCLUSIONS

This study highlights the need for interventions aimed at promoting the attitude with which the invitation to participate is received and interpreted. It also emphasizes the importance of incorporating colon cancer into the dominant framework of concerns, raising awareness about the significance of early detection, and addressing potential sources of inequity. These interventions should address the broader conceptualization of the role of prevention observed among individuals with higher cultural capital and the greater normalization of screening programs found among women due to their previous experience with breast cancer screening.

Decision-making on colorectal cancer screening in Curaçao - interviews with the target population

BACKGROUND

During the first year of the population based colorectal cancer (CRC) screening program on Curaçao, about 20% of invitees participated. This study explored the target population's perceptions and awareness on CRC (screening), beliefs on the program provision, their preferences and information needs for informed decision-making.

METHODS

Semi-structured interviews with 23 individuals, who were not yet invited for CRC screening, were recorded, transcribed, coded and analyzed.

RESULTS

CRC (screening) was discussed in the context of personal health, where own responsibility and food were important. Cancer was perceived as an unpredictable disease that causes suffering and leads to death and was also associated with fear. Despite being aware of the program, most respondents were not familiar with the screening procedure. Provision of the screening program was regarded positively and as an opportunity to contribute to health improvement. This seemed related to the expressed trust in the Caribbean Prevention Center (program organizer). Respondents preferred to make independent decisions about CRC screening participation. A personal approach, visual aids and media were the preferred sources of information.

CONCLUSION

The results of our interviews suggest that it may be beneficial to provide information on CRC screening in Curaçao within the context of personal health. While including sensitivity to fears and respect for the autonomy of the target population. Finally, electronic media maybe useful in supporting informed decision-making.

Exploring non-participation in colorectal cancer screening: A systematic review of qualitative studies

INTRODUCTION

Worldwide, colorectal cancer is a major public health issue. Despite the existence of screening programmes in many countries, global uptake remains low. This meta-ethnography aimed to analyse qualitative literature to explore attitudes towards colorectal cancer screening and reasons for non-participation in eligible people that do not participate when invited.

METHODS

Systematic searches were conducted in five databases in May 2021. Critical appraisal of included studies was performed using the CASP checklist for qualitative studies.

FINDINGS

Thirteen studies were included. Three main themes and eight sub-themes were developed across studies: (1) Differences in motivation, with non-participants expressing a lack of knowledge and varying levels of intention to participate but not feeling screening was personally necessary; (2) Active aversion to screening expressed by fear, discomfort, disgust or not wanting to know; and (3) Contextual barriers of the healthcare system such as practical constraints or poor relationships with healthcare professionals.

CONCLUSION

Findings suggest multiple pathways to non-participation including ambivalence, aversion to the process and consequences of screening or lack of support. Persuasive messages and prompts to action to target ambivalence, reassurance regarding the screening procedures to target negative reactions, and increased support from healthcare professionals may be beneficial in increasing screening uptake.

Individuals With a Family History of Colorectal Cancer Warrant Tailored Interventions to Address Patient-Reported Barriers to Screening

INTRODUCTION

Population health interventions to increase colorectal cancer (CRC) screening rates often exclude individuals with a family history of CRC, and interventions to increase screening in this high-risk group are rare. We aimed to determine the screening rate and barriers and facilitators to screening in this population to inform interventions to increase screening participation.

METHODS

We performed a retrospective chart review and cross-sectional survey of patients excluded from mailed fecal immunochemical test (FIT) outreach because of a family history of CRC in a large health system. We used χ 2 , Fisher exact, and Student t tests to compare demographic and clinical characteristics of patients overdue and not overdue for screening. We then administered a survey (mailed and telephone) to overdue patients to assess barriers and facilitators to screening.

RESULTS

There were 296 patients excluded from mailed FIT outreach, and 233 patients had a confirmed family history of CRC. Screening participation was low (21.9%), and there were no significant demographic or clinical differences between those overdue and not overdue for screening. There were 79 survey participants. Major patient-reported barriers to screening colonoscopy were patient forgetfulness (35.9%), fear of pain during colonoscopy (17.7%), and hesitancy about bowel preparation (29.4%). To facilitate screening colonoscopy, patients recommended reminders (56.3%), education about familial risk (50%), and colonoscopy education (35.9%).

DISCUSSION

Patients with a family history of CRC who are excluded from mailed FIT outreach have low screening rates and report multiple mutable barriers to screening. They warrant targeted efforts to increase screening participation.

Subsequent participation in organized FIT based screening following screen-derived colonoscopy - A Danish nationwide cohort study

Introduction

In the Danish National Colorectal Cancer (CRC) screening program, participants with screen-detected low-risk adenomas are invited to a new faecal immunochemical test (FIT) screening after two years. However, participation rate in next FIT screening is unknown. We aimed to investigate this subsequent participation rate within the Danish CRC screening program.

Methods

This nationwide register-based study included participants aged 50-72 years registered with FIT screening in the Danish CRC screening program between January 1, 2016, and June 30, 2017. Participants were included if their index FIT was negative or if it was positive and the subsequent colonoscopy detected low-risk adenomas. Invitees were categorized as subsequent participants if they returned a FIT within 135 days following the invitation to screening. We estimated the relative risk for participation depending on screening outcome, age, and sex.

Result

415,107 with a negative result and 5,550 with low-risk adenomas were included. 86.0% (85.9;86.1) of the invitees with a negative result participated in the subsequent screening, while 71.8% (70.6;73.0) of the invitees with low-risk adenomas participated subsequently. The risk of participation in the subsequent screening was significantly lower among all age groups of men and women with low-risk adenomas compared to similar groups with negative results.

Conclusion

Invitees with low-risk adenomas detected at their initial colonoscopy are less likely to participate in the subsequent screening than invitees with negative results. This association was found in all age groups and for both sexes. Further studies are necessary to assess whether non-attendance is more pronounced in specific subgroups.

Psychological distress and bowel cancer screening participation

OBJECTIVE

To better understand barriers to participation in mail-out bowel cancer screening programs, two survey studies tested the relationship between psychological distress and self-reported bowel cancer screening.

METHODS

First, a nationally representative sample of Australians N = 5421 completed measures of bowel cancer screening and psychological distress (using the Kessler Psychological Distress Scale; K10). Second, N = 479 completed a survey measuring participation in the National Bowel Cancer Screening Program (NBCSP) and psychological distress using the Depression, Anxiety and Stress Scale. In both studies, logistic regressions were conducted to test relationships between psychological distress and self-reported screening participation.

RESULTS

Study one found that psychological distress had a significant quadratic effect on having ever screened for bowel cancer, where screening rates were similar for those with low, moderate, or high levels of distress, but were lower for those with very high levels of distress. In study two, depression scores had a negative linear relationship with NBCSP participation (higher depression levels were associated with lower screening participation), and anxiety had a quadratic effect whereby NBCSP participation rates were higher with increasing levels of anxiety except in the severe category, where participation was significantly lower.

CONCLUSIONS

Findings indicate that psychological distress has a complex relationship with screening, and those with extreme levels of distress consistently show lower participation rates. Special efforts to encourage screening may be required for those experiencing extreme psychological distress and mental health disorders.

Self-Reported Reasons for Inconsistent Participation in Colorectal Cancer Screening Using FIT in Flanders, Belgium

Background: In Flanders, the uptake in the population-based colorectal cancer (CRC) screening program (using fecal immunochemical test, FIT) is suboptimal (~50%). This study explored the reasons for inconsistent participation in FIT screening among irregular participants in Flanders. Methods: An online survey with both open questions and fixed statements was sent to irregular participants (2016–2018) in the Flemish CRC screening program. A reminder email followed eight weeks after the first email. Data analysis used both qualitative and quantitative approaches. Post-stratification weights based on gender, age group, and the first two digits of the postcode were employed to reduce non-response bias. Results: In total, 5328 out of 19,592 irregular participants responded to the survey. While the main reasons not to participate were related to ‘postponing participation’ and ‘having other priorities’, the main reasons to participate were related to the importance of (preventive) health checks. The role of general practitioners (GPs) in promoting CRC screening also emerged as an important theme among the respondents’ answers (based on fixed statements). Conclusions: The study reported the main reasons for inconsistent participation in FIT screening for CRC in Flanders. The findings are helpful in guiding tailored interventions to increase FIT screening uptake in the region.

Development and psychometric evaluation of the Aversion to Bowel Cancer Screening Scale

OBJECTIVE

Avoidance of colorectal cancer (CRC) screening is well documented with emotional barriers deterring screening intention and uptake. However, the assessment of such aversion is limited by the available instruments focusing on siloed emotions or screening procedures, limiting relevance to the complete process of decision-making in the CRC context.

METHODS

To address this gap, psychometric properties of the newly developed Aversion to Bowel Cancer Screening Scale (ABCSS) were assessed using data from 640 CRC screening eligible asymptomatic community members. Item review and piloting reduced 179 items to the initial 29-item scale. Using a holdout sample technique, exploratory and confirmatory factor analysis, reliability and validity checks were conducted.

RESULTS

A three-factor model (Fecal Occult Blood Test [FOBT] Aversion, Colonoscopy Aversion and Health Conscientiousness) with 21 items was identified. Analyses of the 21-item ABCSS indicated excellent reliabilities for the scale and subscales (α = .91 to .95). Correlations with relevant existing measures, intention and behaviour indicated good construct validity.

CONCLUSION

The ABCSS is a valid measure of aversion to CRC screening for asymptomatic community members facing the decision to undertake CRC screening. This instrument may provide a more comprehensive understanding of the decision-making process for CRC screening.

The role of need for control and self-reliance in gender and age differences in bowel cancer screening participation

OBJECTIVE

To examine the relationships between need for control and self-reliance and barriers to bowel cancer screening to better understand the reasons for lower bowel cancer screening adherence in males and younger individuals.

METHODS

Participants (n = 506) aged between 54 and 75 years old completed an online survey measuring demographic information, the four-factor Barriers to Home Bowel Cancer Screening Scale (BB-CanS) and a measure of Need for Control and Self-Reliance (NCSR). Model fit statistics were compared for seven path models testing the relationships between NCSR and BB-CanS factors and the moderating and mediating effects of age and gender.

RESULTS

Models where age and gender were included as moderators showed the best fit. When compared to females and those under 60 years of age, stronger positive associations between NCSR and BB-CanS factors were evident among males (β_avoidance  = 0.539, p < 0.001); β_disgust  = 0.558, p < 0.001; β_difficulty  = 0.489, p < 0.001; β_autonomy  = 0.619, p = 0.002) and those over 60 years of age (β_avoidance  = 0.400, p < 0.001); β_disgust  = 0.462, p < 0.001; β_difficulty  = 0.447, p < 0.001; β_autonomy  = 0.378, p < 0.001.

CONCLUSIONS

When encouraging males and people aged 60 years and over to participate in bowel cancer screening, public health messages may benefit from conveying preventative health behaviour and cancer screening participation as actions that reflect self-control and self-reliance.

A health action process approach for developing invitee endorsed interventions to increase mail-out bowel cancer screening

Theory‐based, user‐informed interventions are needed to increase the low participation rates of population‐based faecal occult blood test (FOBT) bowel cancer screening. This study investigated the theoretical fit of the health action process approach (HAPA) for home FOBT screening and measured screening invitees' attitudes towards different intervention strategies. A cross‐sectional sample (n = 377), aged 50–74 years, participated in this study. Two scales were created for this study. The process approach to mail‐out screening (PAMS) scale measured HAPA constructs, and the user ratings of mail‐out screening interventions (UR‐MSI) scale measured attitudes towards different intervention strategies. Structural equation modelling was used to assess the fit of PAMS scale responses to the HAPA model, and descriptive statistics were calculated for UR‐MSI responses. PAMS results showed acceptable model fit, CFI = .968, RMSEA = .050 and explained 49.9% of the variation in FOBT screening participation. Positive ratings of interventions ranged from 20.47%, an intervention prompting planning to complete the FOBT kit, to 72.25%, an intervention promoting the positive health outcome associated with FOBT screening. Intervention strategies should be combined such that they target all factors specified within the HAPA model. User‐informed intervention design should be used to effectively facilitate FOBT uptake in the community.

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.

Mail-out bowel cancer screening: Identifying the behavioural stumbling blocks

OBJECTIVE

To describe the actions taken by recipients of mail-out faecal occult blood test (FOBT) kits and to identify the points at which progress towards kit completion typically stops. Differences according to gender, age, and screening intention were also examined.

METHODS

1599 people completed an online survey identifying the actions they took upon receiving an FOBT kit. Latent class analysis was conducted to identify latent subgroups of participants that reported similar actions. Differences between gender, age, and intention status were assessed using non-invariance testing.

RESULTS

Four latent subgroups of FOBT invitees were identified: those who complete and return their FOBT kit ('completers'); those who bring the kit into their house but go no further ('ignorers'); those who open the package and read the bowel cancer information materials but go no further ('readers'); and those who read the instructions but do not place the kit near the toilet and do not complete their FOBT kit ('leavers'). Non-completers who intended to use the kit were most likely to be in the 'leavers' class, while those who had no intention were most likely to be in the 'readers' class.

CONCLUSIONS

Distinct subgroups of non-responders exist among bowel cancer screening invitees, suggesting different behaviour change interventions are needed to facilitate participation. Some invitees, especially those with high participatory intention, are likely to benefit from prompts to take the kit into the toilet, while others, with little participatory intention, often read the invitation materials presenting an opportunity to intervene with health messages.

Understanding patient factors to increase uptake of cancer screening: a review

Early detection of cancer through organized screening is a central component of population-level strategies to reduce cancer mortality. For screening programs to be effective, it is important that those invited to screening participate. However, uptake rates are suboptimal in many populations and vary between screening programs, indicating a complex combination of patient factors that require elucidation to develop evidence-based strategies to increase participation. In this review, the authors summarize individual-level (sociodemographic and psychosocial) factors associated with cancer screening uptake and evidence for the effectiveness of behavioral interventions to increase uptake. The authors reflect on current trends and future directions for behavioral cancer screening research to overcome challenges and address unmet needs in reducing cancer mortality.

Facilitators and barriers to participation in population-based colorectal cancer screening programme from the perspective of healthcare professionals: Qualitative research study

OBJECTIVE

High participation determines the success of colorectal cancer screening programmes in reducing incidence and mortality. The factors that determine participation must be studied from the perspective of professionals that implement the programme. The aim was to identify factors that facilitate or hinder the participation of the invited people in the bowel cancer screening programme of the Basque Country (Spain) from professional's perspective.

METHODS

Qualitative design based on individual interviews and focus groups. Thirty-eight primary care professionals who implement the programme participated (administrative staff, nurses and general practitioners). Thematic analysis was performed.

RESULTS

Professionals show high satisfaction with the programme, and they believe firmly in its benefits. Facilitators for participation include professionals' commitment to the programme, their previous positive experiences, their optimistic attitude towards the prognosis of cancer and their trust in the health system and accessibility. Barriers include invitees' lack of independence to make decisions, fear of a positive test result and patient vulnerability and labour mobility of the health professionals.

CONCLUSIONS

Professionals show a high degree of involvement and identify primary care is an appropriate place to carry out disease prevention. They identify the closeness to patients, the personal attitude and the characteristics of the health system as key factors that influence participation.

The integrated screening action model (I-SAM): A theory-based approach to inform intervention development

Screening can reduce deaths if the people invited participate. However, good uptake is hard to achieve, and our current approaches are failing to engage the most vulnerable. A coherent model of screening behaviour to guide our understanding and intervention development is yet to be established. The present aim was to propose an Integrated Screening Action Model (I-SAM) to improve screening access. The I-SAM synthesises existing models of health behaviour and empirical evidence. The I-SAM was developed following: i) an appraisal of the predominant models used within the screening literature; ii) the integration of the latest knowledge on behaviour change; with iii) the empirical literature, to inform the development of a theory-based approach to intervention development. There are three key aspects to the I-SAM: i) a sequence of stages that people pass through in engaging in screening behaviour (based on the Precaution Adoption Process Model); ii) screening behaviour is shaped by the interaction between participant and environmental influences (drawing from the Access Framework); and iii) targets for intervention should focus on the sources of behaviour - 'capability', 'opportunity', and 'motivation' (based on the COM-B Model). The I-SAM proposes an integrated model to support our understanding of screening behaviour and to identify targets for intervention. It will be an iterative process to test and refine the I-SAM and establish its value in supporting effective interventions to improve screening for all.

"I'm not doing that." An in-depth examination of nonparticipation in mail-out bowel cancer screening programs

Despite a clear association between the early detection of bowel cancer and increased survival, participation in mail-out screening programs is poor. Several key barriers to participation have been identified, yet research has failed to examine the specific cognitions, actions, and individual contexts from which barriers emerge. The purpose of the current study was to gain a detailed understanding of the actual experience of kit receipt from the perspective of nonparticipants including their opinion on interventions that may be effective in promoting participation. Demographic differences in reasons for nonparticipation are also examined. Opt-out data from a national program was analyzed to detect demographic differences in reasons for nonparticipation. Qualitative interviews were conducted in a sample of "at risk" nonparticipants. Thematic analysis was conducted using an inductive phenomenological approach. Older, higher SES, male and previously screened participants were more likely to provide a medical reason for opting out of participation. Four key themes emerged from interview data. The first reflected intention; whereby participants were either intenders (i.e., they planned to participate) or refusers. Subsequent themes reflected practicalities, emotional reactions, and necessity. Differences between intenders and refusers within these themes as well as opinions regarding interventions were identified. Interventions involving interactions with health professionals, autonomous decision making, and those which emphasize the positive outcomes of screening may encourage refusers to participate in mail-out bowel cancer screening programs. Messages that reinforce the importance of screening or provide a practical reminder may be more useful for intenders.

Ethnic disparities in the uptake of colorectal cancer screening: An analysis of the West London population

AIM

Colorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poorer uptake in ethnic minority groups. The aim of this work was to evaluate the relationship between ethnicity and uptake of CRC screening in West London.

METHOD

Results of CRC screening from the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Clinical commissioning group collaborative between 2012 and 2017 were retrospectively analysed. These five clinical commissioning groups (CCGs) are located in West London. Compliance with screening according to ethnic group was evaluated compared with White British as the control.

RESULTS

A total of 155 038 individuals were screened. White British individuals had the highest compliance (52.6%). A maximum difference in compliance of 8.2% was seen between CCGs. The odds of being less likely to participate were significant (p < 0.05) in all ethnic minorities except for Asian Chinese on univariate and multivariate analysis (adjusted OR 1.091, p = 0.88).

CONCLUSION

This is the largest retrospective study focusing on the role of ethnicity in the uptake of CRC screening in England. Poor uptake of screening in all ethnic minorities in West London, with the exception of Asian Chinese individuals in particular, is a novel finding. A mandate to routinely collect ethnicity data, the use of a single more diverse census and further intervention are needed to understand this disparity and reduce health inequity.

Barriers to home bowel cancer screening

OBJECTIVE

To develop and test a psychometric instrument for measuring common barriers to completing and returning home bowel cancer screening kits.

METHODS

One hundred and ten items were reviewed by an expert panel (n = 15) and presented in an online cross-sectional survey with 427 Australian adults. Exploratory factor analysis was used to identify an optimal factor solution of latent barrier types and aggregated factor scores were examined and compared between demographic groups.

RESULTS

Common barriers included having already been screened (32.3%), forgetting about the kit (24.4%), and a lack of planning (21.8%). Barriers reflecting hygiene concerns were also endorsed by over 15% of the sample. Four clear barrier types were evident reflecting disgust, avoidance, lack of autonomy, and physical difficulties.

CONCLUSIONS

Findings support calls to apply multi-faceted interventions strategies that address a broad range of barrier types, particularly that which encourage planning, and prompt and facilitate easy stool collection.

Factors Related to Non-participation in the Basque Country Colorectal Cancer Screening Programme

Background: Despite the high participation rates in the Basque Country, colorectal cancer screening programme (Spain), there is still a part of the population that has never participated. Since it is essential to ensure equal access to health services, it is necessary to identify the determinants of health and socio-economic factors related to non-participation in the screening programme. Methods: Cross sectional descriptive study including all invited population in a complete round between 2015 and the first trimester of 2017. Health risk factors available in medical records and their control have been analyzed using univariate and multivariate analyses. Results: 515,388 people were invited at the programme with a 71.9% of fecal immunochemical test participation rate. Factors that increase the risk of non-participation are: being men (OR = 1.10, 95% CI 1.09-1.12); younger than 60 (OR = 1.18, 95% CI 1.17-1.20); smoker (OR = 1.20, 95% CI 1.18-1.22); hypertensive (OR = 1.14, 95% CI 1.12-1.15) and diabetic (OR = 1.40, 95% CI 1.36-1.43); having severe comorbidity (OR = 2.09, 95% CI 2.00-2.19) and very high deprivation (OR = 1.15, 95% CI 1.12-1.17), as well as making <6 appointments to Primary Care in 3 years (OR = 2.39, 95% CI 2.33-2.45). Still, the area under the curve (AUC) indicates that there are more factors related to non-participation. Conclusions: The participation in the Basque Country colorectal cancer-screening Programme is related to some risk factors controlled by Primary Care among others. Therefore, the involvement of these professionals could improve, not only the adherence to the CRC screening, but also other health styles and preventive interventions.

Factors affecting patient adherence to publicly funded colorectal cancer screening programmes: a systematic review

OBJECTIVES

Colorectal cancer (CRC) is the third most common cancer. Many countries in Europe have already implemented systematic screening programmes as per the recommendations by the European Union. The impact of screening is highly dependent on participation rates. The aim of the study was to identify barriers, facilitators and modifiers to participation in systematised, stool sample-based, publicly financed CRC screening programmes.

STUDY DESIGN

Systematic review.

METHODS

A systematic search in PubMed, Embase, MEDLINE, CINAHL, Cochrane CENTRAL, Google Scholar and PsycINFO was undertaken. We included both qualitative and quantitative studies reporting on barriers and facilitators (excluding sociodemographic variables) to participation in stool sample-based CRC screening. Barriers and facilitators to participation were summarised and analysed.

RESULTS

The inclusion criteria were met in 21 studies. Reported barriers and facilitators were categorised into the following seven themes (examples): psychology (fear of cancer), religion (believing cancer is the will of God), logistics (not knowing how to conduct the test), health-related factors (mental health), knowledge and awareness (lack of knowledge about the test), role of the general practitioner (being supported in taking the test by the general practitioner), and environmental factors (knowing someone who has participated in a screening programme). Six studies reported that non-participation was not due to a negative attitude towards screening for CRC.

CONCLUSION

Many barriers to screening were found. It is important to work with peoples' fear of screening. Moreover, this review suggests that it might be possible to increase participation rates, if the population-wide awareness and knowledge of potential health benefits of CRC screening are increased and proper logistical support is provided.

Determinants of non-participation in colon examination following positive stool sample in colorectal cancer screening

BACKGROUND

Social inequalities has been shown for participation in colorectal cancer screening and recently in the initial stool sample blood test. If these differences persist at follow-up colon examination after a positive stool test, it would suggest that social inequality in screening may be greater than the inequality observed in initial stool sample blood test.

METHODS

All data were derived from national registers. Using logistic regression analyses, odds of non-participation for follow-up colon examination were estimated based on age group, educational level, income quartile, immigration status and marital status in men and in women, who had participated in initial stool sample test for blood with a positive result.

RESULTS

Among 20 849 men and 16 565 women invited for follow-up colonoscopy in the period 2014-15, 10.63 and 11.37%, respectively, did not attend. In men, odds of non-participation were higher in the eldest, those with lower income and lower educational level, in immigrants and in singles. Odds ratio (OR) in males of highest income quartile was 0.54 [95% confidence interval (CI) 0.46; 0.63] compared with lowest income quartile. In women, the differences were not as large. OR in females of highest income quartile was 0.73 (95% CI 0.61; 0.87) compared with lowest income quartile.

CONCLUSION

Sociodemographic differences in odds of non-participation exist in follow-up colon examination in the Danish colorectal cancer screening. Differences were evident in all subgroups of the male population. The same patterns were seen in women. Social inequalities in participation for follow-up colon examination can increase overall social inequality and consequently, lead to health disparities.

Impact of the introduction of a new policy of direct faecal immunochemical home screening test provision in a national bowel screening programme, both during and outside of advertising campaigns

BACKGROUND

BowelScreen, The National Bowel Screening Programme in Ireland, offers free colorectal screening to persons aged 60-69 through a home Faecal Immunochemical Test (FIT) kit. 40.2% uptake in the first screening round was below the programme standard (≥50.0%). To improve uptake, an intervention saw FIT kits sent directly to previously screened clients rather than by the usual invitation process comprising a letter of invitation followed by a FIT kit if requested. The intervention proved successful and was fully implemented into the programme for subsequent clients. Despite the improved uptake it was noted over time that the unsatisfactory FIT rate was approaching the programme standard (≤3%). The aim of this study is to compare uptake by two invite methods occurring contemporaneously alongside advertising and to compare unsatisfactory rates before and after full FIT-Direct implementation.

METHODS

Percentage uptake and 95% confidence intervals (CI) were calculated for each invite method before and after advertising and compared using two-proportion z-tests. Rate ratios and 95% CI compared the unsatisfactory FIT rate before and after full-FIT Direct implementation.

RESULTS

Uptake was significantly higher amongst FIT-Direct compared with Usual-Invite clients during (91.0% vs 84.9%, p < 0.0001) and outside advertising (93.8% vs 85.3%, p < 0.0001). The unsatisfactory FIT rate was 2.3 times higher (95% CI: 1.84-2.92, p < 0.0001) after full FIT-Direct implementation compared with before.

CONCLUSIONS

The FIT-Direct intervention had an overall positive effect on uptake. After adjusting for advertising, uptake of FIT was higher outside advertising periods. Monitoring of the unsatisfactory rate is ongoing; a communication enhancement strategy may be required should this persist.

Sociodemographics and their impacts on risk factor awareness and beliefs about cancer and screening: results from a cross-sectional study in Newfoundland and Labrador

Background

Our objective was to examine cancer risk factor awareness and beliefs about cancer treatment, outcomes, and screening, and how these are mediated by sociodemographic variables, among Newfoundland and Labrador residents.

Methods

Participants aged 35 to 74 were recruited through Facebook advertising, and a self-administered online questionnaire was used to collect data. Descriptive statistics, Spearman rank correlations, and multivariate logistic regression analyses were performed.

Results

Of the 1048 participants who responded and met the inclusion criteria for this study, 1019 were selected for this analysis. Risk factor recognition was generally good, though several risk factors had poor awareness: being over 70 years old (53.4% respondents aware), having a low-fiber diet (65.0%), and drinking more than 1 unit of alcohol per day (62.8%). Our results showed that the participants’ awareness of risk factors was significantly associated with higher income level (r_s = 0.237, P <  0.001), higher education (r_s = 0.231, P <  0.001), living in rural regions (r_s = 0.163, P <  0.001), and having a regular healthcare provider (r_s = 0.081, P = 0.010). Logistic regression showed that among NL residents in our sample, those with higher income, post-secondary education, those in very good or excellent health, and those with a history of cancer all had higher odds of having more positive beliefs about cancer treatment and outcomes. Those with a history of cancer, and those with very good or excellent health, also had higher odds of having more positive beliefs about cancer screening. Finally, compared to Caucasian/white participants, those who were non-Caucasian/white had lower odds of having more positive beliefs about cancer screening.

Conclusion

Among adults in NL, there was poor awareness that low-fiber diets, alcohol, and age are risk factors for cancer. Lower income and education, rural residence, and not having a health care provider were associated with lower risk factor awareness. We also found a few associations between sociodemographic factors and beliefs about cancer treatment and outcomes or screening. We stress that while addressing awareness is necessary, so too is improving social circumstances of disadvantaged groups who lack the resources necessary to adopt healthy behaviours.

Implementation Strategies for Interventions Aiming to Increase Participation in Mail-Out Bowel Cancer Screening Programs: A Realist Review

Background: Bowel cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death, with 1,849,518 new cases of bowel diagnosed and 880,792 deaths reported globally in 2018 alone. Survival can be improved through early detection via national mail-out bowel cancer screening programs; however, participation remains low in many countries. Behavior change is therefore required to increase participation. This realist review aims to (a) identify the behavior change techniques (BCTs) used in each intervention, (b) understand the mechanisms of action (MoAs) responsible for the BCT effectiveness, and (c) apply a behavior change model to inform how MoAs can be combined to increase screening participation.

Methods: We systematically reviewed the literature for interventions aiming to increase participation in mail-out bowel cancer screening. We used a four-stage realist synthesis approach whereby (1) interventions were extracted from each study; (2) BCTs applied in each intervention were identified and coded using the BCT Taxonomy-v1; (3) the Theory and Techniques Tool was used to link BCTs to their MoA; and (4) BCTs and MoAs were categorized according to their effectiveness and what Health Action Process Approach (HAPA) stage of change they would affect.

Results: We identified 68 intervention trials using 26 unique BCTs and 13 MoAs to increase participation. Sixteen BCTs and 10 MoAs were identified within the interventions that successfully increased participation rates. Interventions targeting both stages of the HAPA model had a higher success rate (80%) than those targeting one stage of change (51%). When targeting only one stage, interventions targeting the volitional stage had a higher success rate (71%) than interventions targeting only the motivational stage of change (26%).

Conclusion: Importantly, this review identified a suite of BCTs and MoAs effective for increasing participation in mail-out bowel cancer screening programs. With increased participation in bowel cancer screening leading to improved survival, our findings are key to informing the improvement of policy and interventions that aim to increase screening using specific strategies at key stages of health decision-making.

Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City

Background

Colorectal cancer (CRC) incidence and mortality are increasing in many low- and middle-income countries (LMICs), possibly due to a combination of changing lifestyles and improved healthcare infrastructure to facilitate diagnosis. Unfortunately, a large proportion of CRC cases in these countries remain undiagnosed or are diagnosed at advanced stages, resulting in poor outcomes. Decreasing mortality trends in HICs are likely due to evidence-based screening and treatment approaches that are not widely available in LMICs. Formative research to identify emerging opportunities to implement appropriate screening and treatment programs in LMICs is, therefore, of growing importance. We sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality.

Methods

We performed a qualitative study with semi-structured individual and focus group interviews with different CRC screening stakeholders, including 30 lay people at average risk for CRC, 13 health care personnel from a local public clinic, and 7 endoscopy personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data were analyzed using the constant comparison method, under the theoretical perspectives of the social ecological model (SEM), the PRECEDE-PROCEED model, and the health belief model.

Results

We identified barriers and facilitators for implementation of a FIT-based CRC screening program at several levels of the SEM. The main barriers in each of the SEM levels were as follows: (1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; (2) at the health services organization level: a lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; and (3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests.

Conclusions

This study's findings suggest that multi-level CRC screening programs in middle-income countries such as Mexico should incorporate complementary strategies to address barriers and facilitators, such as (1) provision of free screening tests, (2) education of primary healthcare personnel, and (3) promotion of non-fear-based CRC screening messages to the target population, tailored to address common lay beliefs.

Why colorectal screening fails to achieve the uptake rates of breast and cervical cancer screening: a comparative qualitative study

BACKGROUND

In Scotland, the uptake of clinic-based breast (72%) and cervical (77%) screening is higher than home-based colorectal screening (~60%). To inform new approaches to increase uptake of colorectal screening, we compared the perceptions of colorectal screening among women with different screening histories.

METHODS

We purposively sampled women with different screening histories to invite to semistructured interviews: (1) participated in all; (2) participated in breast and cervical but not colorectal ('colorectal-specific non-participants'); (3) participated in none. To identify the sample we linked the data for all women eligible for all three screening programmes in Glasgow, Scotland (aged 51-64 years; n=68 324). Interviews covered perceptions of cancer, screening and screening decisions. Framework method was used for analysis.

RESULTS

Of the 2924 women invited, 86 expressed an interest, and 59 were interviewed. The three groups' perceptions differed, with the colorectal-specific non-participants expressing that: (1) treatment for colorectal cancer is more severe than for breast or cervical cancer; (2) colorectal symptoms are easier to self-detect than breast or cervical symptoms; (3) they worried about completing the test incorrectly; and (4) the colorectal test could be more easily delayed or forgotten than breast or cervical screening.

CONCLUSION

Our comparative approach suggested targets for future interventions to increase colorectal screening uptake including: (1) reducing fear of colorectal cancer treatments; (2) increasing awareness that screening is for the asymptomatic; (3) increasing confidence to self-complete the test; and (4) providing a suggested deadline and/or additional reminders.

Autonomous and informed decision-making: The case of colorectal cancer screening

INTRODUCTION

It is increasingly considered important that people make an autonomous and informed decision concerning colorectal cancer (CRC) screening. However, the realisation of autonomy within the concept of informed decision-making might be interpreted too narrowly. Additionally, relatively little is known about what the eligible population believes to be a 'good' screening decision. Therefore, we aimed to explore how the concepts of autonomous and informed decision-making relate to how the eligible CRC screening population makes their decision and when they believe to have made a 'good' screening decision.

METHODS

We conducted 27 semi-structured interviews with the eligible CRC screening population (eighteen CRC screening participants and nine non-participants). The general topics discussed concerned how people made their CRC screening decision, how they experienced making this decision and when they considered they had made a 'good' decision.

RESULTS

Most interviewees viewed a 'good' CRC screening decision as one based on both reasoning and feeling/intuition, and that is made freely. However, many CRC screening non-participants experienced a certain social pressure to participate. All CRC screening non-participants viewed making an informed decision as essential. This appeared to be the case to a lesser extent for CRC screening participants. For most, experiences and values were involved in their decision-making.

CONCLUSION

Our sample of the eligible CRC screening population viewed aspects related to the concepts of autonomous and informed decision-making as important for making a 'good' CRC screening decision. However, in particular the existence of a social norm may be affecting a true autonomous decision-making process. Additionally, the present concept of informed decision-making with its strong emphasis on making a fully informed and well-considered decision does not appear to be entirely reflective of the process in practice. More efforts could be made to attune to the diverse values and factors that are involved in deciding about CRC screening participation.

Decision-making styles in the context of colorectal cancer screening

BACKGROUND

Our study examined the use of decision-making styles, as identified by Scott and Bruce (1995) (i.e. differentiating between a rational, intuitive, dependent, avoidant and spontaneous decision-making style), within the context of colorectal cancer (CRC) screening participation. In the field of cancer screening, informed decision-making is considered important, which follows the Rational Decision model. Subsequently, gaining more insight into decision-making styles being used in real life, could improve support to people when making their screening decision. In addition, we examined whether the decision-making style that people used was associated with their experienced decisional conflict.

METHODS

An online survey was carried out among a sample of first-time CRC screening invitees (1282 respondents, response rate 49%). We assessed people's decision-making styles, CRC screening participation, education level, self-reported health literacy, and decisional conflict, and examined the possible associations between them.

RESULTS

In our study, people who had to decide about CRC screening scored high on using both a rational and intuitive decision-making style. Respondents scoring higher on using a spontaneous or dependent decision-making style were more likely to have participated in CRC screening, while respondents scoring higher on using an avoidant decision-making style were more likely not to have participated in CRC screening. However, differences were small. Generally, people in our study experienced low decisional conflict.

CONCLUSION

Our eligible CRC screening population scored high on using both a rational and intuitive decision-making style. To optimise support to people, public education materials could be appealing more to the intuitive processes at hand. That being said, the current education materials aimed at informed/rational decision-making do not necessarily seem to create a problem, as people generally experienced low decisional conflict. Possible concerns regarding the use of a spontaneous, dependent or avoidant decision-making style could be that these styles might be contributing to less informed decisions. However, it is relevant to consider that the found differences are small and that any possible concern applies to a relatively small group of people.

Patient perspectives on colorectal cancer screening and the role of general practice

Background

Colorectal cancer (CRC) is the second most frequent cause of cancer death in Australia. Early detection can reduce incidence and mortality. General practice-based initiatives have been proposed to improve CRC screening rates but to date have had modest impact. As there is limited research into the patient experience of CRC screening decision making, this study explored patient perspectives on CRC screening and the potential role for general practice.

Methods

Ten participants, aged between 50 and 74, from a general practice in South Australia were recruited by practice staff. Semi-structured interviews were conducted. Concurrent data collection and analysis were performed, guided by interpretative phenomenological analysis.

Results

Two key themes were evident: attitudes toward screening and potential roles for general practice. Participants structured the experience of screening in terms of being proactive, ambivalent or avoidant. Roles for general practice centred on tasks as educators, trusted advisors, monitors and screeners. Mixed views on whether general practice involvement was necessary prompted consideration of additional sources of health information and motivation around screening.

Conclusions

Exploration of the patient experience provides insight into how participants make sense of screening and perceived roles for general practice (or other agents) in screening. There is satisfaction with current Government-driven processes but perceived value in general practice playing a complementary part in increasing screening rates. A multifaceted strategy, accounting for attitudes, is required to improve screening and population health outcomes.

Ways to use interventions to increase participation in mail-out bowel cancer screening: a systematic review and meta-analysis

The impact of colorectal cancer can be reduced through nationwide fecal occult blood test (FOBT) screening. Unfortunately, participation in screening programs are low with interventions only increasing participation modestly.

This meta-analysis explores if intervention effectiveness can be increased by targeting specific subpopulations with specific interventions or by combining interventions. Six databases were searched for studies aiming to increase participation in mail-out FOBT screening. To investigate if interventions are more effective for certain subpopulations, the difference in (log) Risk Ratios (RRs) between alternate subpopulations (male vs. female; low vs. high Socioeconomic Status (SES); &lt;65 vs. ≥65 years) was assessed. To investigate if interventions should be combined, uptake rates for single interventions were compared to uptake rates for combined interventions. Cochrane Collaboration tools were used to assess the risk of bias.

Searches found 3,436 articles, with 32 meeting the inclusion criteria. These contained 30 trials that reported uptake rates within subpopulations and 17 trials that combined interventions. Most differences in intervention effects between subpopulations were nonsignificant. Combining interventions led to greater participation, RR = 1.06, confidence interval [1.03; 1.10]. As interventions rarely affect subpopulations differently, targeting them at specific subpopulations may be an ineffective strategy. While individual interventions show modest effects, these results indicate that future programs might overcome this by combining interventions together. Care is needed when selecting interventions to combine as adding some interventions (e.g., additional print materials) can reduce the effectiveness of a combined strategy. Future research should examine methods for effectively combining interventions in nationwide programs to maximize participation.

Do people with a different goal-orientation or specific focus make different decisions about colorectal cancer-screening participation?

Objective

Previous studies have shown that having promotion-oriented goals (e.g. wanting to become healthy) or prevention-oriented goals (e.g. wanting to avoid getting ill) can affect people’s health-related decisions and behaviour by emphasising aspects and information that seem relevant in light of what they want to achieve. However, this issue has not yet been researched regarding colorectal cancer (CRC) screening. With our study, we aimed to examine the relationship between people’s goal-orientation or focus on advantages or disadvantages and their CRC screening participation, as this could provide insights for supporting people in making this complex decision.

Methods

An online survey was carried out among a sample of first-time CRC screening invitees (1282 respondents, response rate 49%). We assessed people’s goal-orientation (i.e. promotion-orientation and prevention-orientation), focus on the advantages or disadvantages of CRC screening, screening participation and main considerations (e.g. cancer is a serious illness) concerning their screening decision.

Results

Generally, CRC screening participants scored higher on both promotion-orientation and prevention-orientation than non-participants. Both CRC screening participation and non-participation were not associated with a dominant goal-orientation. CRC screening participants did show a dominant focus on the advantages of CRC screening. Mediation analysis showed support for our premise that the relationship between people’s goal-orientation or focus on advantages or disadvantages and their screening participation could be (partially) mediated by people’s main considerations concerning CRC screening.

Conclusion

CRC screening participants and non-participants differed in their goal-orientation and focus on advantages or disadvantages. CRC screening participation appears to be associated with a focus on the advantages of CRC screening, which could impede the making of an informed decision. CRC screening non-participation appears not to be associated with any clear goal-orientation or focus, or we have not yet managed to capture this, which could be either beneficial or problematic for making an informed decision.

It's hard to reach the "hard-to-reach": the challenges of recruiting people who do not access preventative healthcare services into interview studies

In this article, we discuss the challenges faced in recruiting "hard-to-reach" groups for interview studies, specifically those who do not access preventative healthcare services. We do this by reflecting on the varying success of different recruitment methods we have used in two recent studies; one investigating ethnic disparities in human papillomavirus vaccination uptake and another exploring difference in cervical screening non-participation. Engaging new community groups to help with recruitment proved particularly difficult, as did recruiting online. Our most successful recruitment methods included recruiting through community groups with whom we had previously established relationships, recruiting through schools and re-contacting participants who previously completed a related survey. We conclude that successful recruitment is dependent on study awareness and engagement. We urge others to be transparent in reporting recruitment methods in order to benefit the qualitative research community and suggest that details are published as supplementary material alongside qualitative articles in future.

Why are the public so positive about colorectal cancer screening?

BACKGROUND

Colorectal cancer (CRC) screening is widely recommended. Earlier research showed that the general public are positive about CRC screening, as too the eligible CRC screening population. Among the eligible CRC screening population this positive perception has been shown to be associated with their perceptions of cancer, preventive health screening and their own health. It is unclear whether these concepts are also associated with the positive perception of the general public. Knowing this can provide insight into the context in which public perception concerning CRC screening is established. The aim of our study was to examine which main perceptions are associated with the public perception concerning CRC screening.

METHODS

An online survey was carried out in a Dutch population sample (adults 18+) among 1679 respondents (response rate was 56%). We assessed the public's perceptions concerning cancer, preventive health screening, own health, and the government, and examined their possible association with public opinion concerning CRC screening.

RESULTS

The public's positive attitude towards CRC screening is associated with the public's positive attitude towards preventive health screening in general, their perceived seriousness of cancer, their belief of health being important, and their trust in the government regarding national screening programmes.

CONCLUSION

Trust in the government and perceptions regarding the seriousness of cancer, preventive health screening and the importance of one's health seem to be important factors influencing how the public view CRC screening. The public are likely to process information about CRC screening in such a way that it confirms their existing beliefs of cancer being serious and preventive screening being positive. This makes it likely that they will notice information about the possible benefits of CRC screening more than information about its possible downsides, which would also contribute to the positive perception of CRC screening.

The NHS Bowel Cancer Screening Program: current perspectives on strategies for improvement

Colorectal cancer (CRC) is the third most common cancer in the UK. The English National Health Service (NHS) Bowel Cancer Screening Program (BCSP) was introduced in 2006 to improve CRC mortality by earlier detection of CRC. It is now offered to patients aged 60-74 years and involves a home-based guaiac fecal occult blood test (gFOBt) biennially, and if positive, patients are offered a colonoscopy. This has been associated with a 15% reduction in mortality. In 2013, an additional arm to BCSP was introduced, Bowelscope. This offers patients aged 55 years a one-off flexible sigmoidoscopy, and if several adenomas are found, the patients are offered a completion colonoscopy. BCSP has been associated with a significant stage shift in CRC diagnosis; however, the uptake of bowel cancer screening remains lower than that for other screening programs. Further work is required to understand the reasons for nonparticipation of patients to ensure optimal uptake. A change of gFOBt kit to the fecal immunochemical tests (FIT) in the English BCSP may further increase patient participation. This, in addition to increased yield of neoplasia and cancers with the FIT kit, is likely to further improve CRC outcomes in the screened population.

Approaching the Hard-to-Reach in Organized Colorectal Cancer Screening: an Overview of Individual, Provider and System Level Coping Strategies

BACKGROUND

Despite the proven effectiveness of colorectal cancer (CRC) screening on reduction of CRC mortality, the uptake of CRC screening remains low. Participation rate is one of determinants for the success of organized population-based screening program. This review aims to identify those who are hard-to-reach, and summarize the strategies to increase their screening rate from individual, provider and system levels.

METHODS

A systematic search of electronic English databases was conducted on the factors and strategies of uptake in CRC screening for the hard-to-reach population up to May 2017.

DISCUSSION

The coverage rate and participation rate are two indexes to identify the hard-to-reach population in organized CRC screening program. However, the homeless, new immigrants, people with severe mental illness, the jail intimates, and people with characteristics including lower education levels and/or low socioeconomic status, living in rural/remote areas, without insurance, and racial minorities are usually recognized as hard-to-reach populations. For them, organized screening programs offer a better coverage, while novel invitation approaches for eligible individuals and multiple strategies from primary care physicians are still needed to enhance screening rates among subjects who are hard-to-reach. Suggestions implied the effectiveness of interventions at the system level, including linkages to general practice; use of decision making tools; enlisting supports from coalition; and the continuum from screening to diagnosis and treatment.

CONCLUSION

Organized CRC screening offers a system access to approach the hard-to-reach populations. To increase their uptake, multiple and novel strategies from individual, provider and system levels should be applied. For policymakers, public healthcare providers and community stakeholders, it is a test to tailor their potential needs and increase their participation rates through continuous efforts to eliminate disparities and inequity in CRC screening service.

GP participation in increasing uptake in a national bowel cancer screening programme: the PEARL project

BACKGROUND

The NHS Bowel Cancer Screening Programme (BCSP) in England does not involve general practitioners (GPs). Uptake is ∼58%. The Practice Endorsed Additional Reminder Letter (PEARL) study piloted a GP-endorsed reminder letter.

METHODS

General practices in Wessex with uptake <55% (prevalent invitations) were invited to participate. Subjects who had been invited for screening, sent a standard 28-day BCSP reminder letter but had not returned a test kit within 30 days of the standard reminder were sent a second reminder letter bearing the GP's letterhead and signature. Uptake was compared between PEARL and non-PEARL practices by standardised uptake ratio (standardised for prior prevalent uptake and other confounders). In addition, 25 non-PEARL practices were matched with PEARL practices for prior prevalent uptake and number of invitees.

RESULTS

Twenty-five practices agreed to participate. A total of 3149 GP-endorsed reminders were sent. Uptake in the PEARL practices was 54% compared with 51% in the matched-control practices. The adjusted RR for uptake was 1.08 (95% CI: 1.05, 1.11, P<0.001) for all invitees and 2.18 (1.79, 2.66, P<0.001) for invitees who had not returned a kit following the standard reminder.

CONCLUSIONS

The GP-endorsed reminder was associated with significantly increased uptake among subjects not responding to the standard reminder letter.

Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials

Background

Bowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes.

Objective

To reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group.

Design

Workstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention.

Methods

Interventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome.

Results

The gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; allp-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10;p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20;p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06;p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11;p = 0.001). All interventions were inexpensive to provide.

Limitations

In line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect.

Conclusions

Enhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information.

Future work

Socioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated.

Trial registration

Current Controlled Trials ISRCTN74121020.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.

The Dutch public are positive about the colorectal cancer-screening programme, but is this a well-informed opinion?

BACKGROUND

Population-based colorectal cancer (CRC) screening is widely recommended, and members of the eligible screening population seem to be positive about it. However, it is not well known how people outside the eligible screening population view CRC screening, and whether they are supportive of the government providing this. Public opinion may affect people's personal views and their screening decision. The aim of our study was to examine the opinion of the Dutch general public regarding the national CRC screening programme.

METHOD

An online survey was carried out in a Dutch population sample of adults aged 18 and older, assessing level of support, personal attitude, collective attitude, perceived social norm, awareness, and knowledge regarding the CRC screening programme.

RESULTS

The response rate was 56% (n = 1679/3000). Generally, the Dutch public are positive about and supportive of the CRC screening programme. We found the biggest proportion of support (86%) when people were asked directly. A smaller proportion (48%) was supportive when people had to choose between other options concerning how the government could possibly deal with CRC. People report knowing more about the benefits of CRC screening than about its possible harms and risks. Many people found it difficult to answer the knowledge questions that asked about numerical information concerning CRC screening correctly.

CONCLUSION

People were less supportive of the CRC screening programme when having to choose between other options concerning dealing with CRC, and their support may not be based on a full comprehension of what CRC screening entails. Further research is needed to establish what knowledge people need in order to form a well-founded opinion.