The impact of supplementary narrative-based information on colorectal cancer screening beliefs and intention

Didactic and narrative persuasion: An experiment to promote colorectal cancer screening

We tested whether a didactic and a narrative video (i.e. educational content and personal stories versus irrelevant information) could boost colorectal cancer (CRC) screening intention directly and through cognitive predictors of CRC screening behavior. We also tested whether exposure to a story changed participants' affective forecasting, reducing the perception of negative emotions associated with CRC screening (disgust, embarrassment, and fear). The study was conducted online with a between-participants design and recruiting a convenience sample (N = 375). We found that, compared with watching the control video, being exposed to the narrative video about CRC screening was indirectly associated with greater screening intention via vicarious experience and positive attitudes, whereas watching the didactic video was positively associated with CRC screening intention only among participants who had received an invitation letter but did not get screened, and among those yet to receive an invitation to screen. In the latter group, screening intention was boosted through positive attitudes. Our findings do not confirm that stories change affective forecasting, but narration likely fosters messages acceptance through vicarious experience. We also found support for the effectiveness of physicians' recommendations in promoting CRC screening, an intervention that might be effectively administered through a generalized, cost-effective video.

Psychosocial Predictors of Colorectal Cancer Screening Intention: An Experiment on the Invitation Letter

BACKGROUND

In Italy, attendance rates for colorectal cancer (CRC) screening are suboptimal. The present work analysed cognitive and emotional predictors of CRC screening intention and tested an intervention on a real invitation letter to improve CRC screening intention, both directly and in interaction with the predictors of our model.

METHODS

Our model included variables from the theory of planned behaviour and the emotional barriers to bowel screening scale. We applied six changes to an invitation letter used in Italy to avoid the repetition of words like 'faeces', 'blood', or 'occult' and reduce the prompting of disgust. The 228 participants were randomly assigned to a between-participants design (original letter vs. manipulated letter).

RESULTS

Disgust hindered CRC screening intention, while embarrassment, fear, and subjective norms (i.e., perception of the social pressures to attend CRC screening) were not associated with intention to screen. More positive attitudes towards CRC screening were associated with a higher intention to screen. The positive association between perceived behavioural control and CRC screening intention was stronger for participants who read the letter with fewer (vs. more) references to bodily waste. Letter manipulation did not affect intention to screen.

CONCLUSIONS

The disgust associated with faecal matter is a critical factor in determining CRC screening attendance, and it should be acknowledged as such in public policies. Until new screening tests avoiding the activation of this emotional reaction are concretely available, public campaigns should improve CRC screening participation by boosting both positive attitudes towards screening and patients' perceived behavioural control.

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.

Bringing fictional characters to life: reflections on co-creating a comic book with members of the public

There are growing calls for cancer screening to become more personalised by considering a range of risk factors, rather than a one-size-fits-all, age-based approach. The aim of this public involvement was to co-create a comic book about bowel cancer screening to be used as a visual elicitation tool in research focus groups with members of the public and healthcare professionals, as part of the At Risk study, to discuss their attitudes toward personalised bowel cancer screening, which would involve considering different risk factors. This article critically reflects on the co-creation process to develop the comic book, benefits and challenges, and some lessons learned to inform other researchers considering a similar approach. In total, ten public contributors (5 men and 5 women) from two public involvement networks participated in two successive online workshops to develop six fictional characters, two for each level of bowel cancer risk (low, moderate and high risk). This tool was then used in the At Risk study comprising five focus groups involving 23 participants, including members of the public (n = 12) and healthcare professionals (n = 11). The co-created comic book was a generally well-received research tool able to generate discussion about a complex topic, bowel cancer risk, in an accessible way. It was suggested that the comic book may also be extended beyond the research context to inform bowel cancer screening decisions and raise awareness of risk factors.

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.

The role of disgust as an emotional barrier to colorectal cancer screening participation: a systematic review and meta-analysis

OBJECTIVE

Worldwide colorectal cancer (CRC) screening rates are suboptimal. This systematic review and meta-analysis examine the role of disgust in CRC screening avoidance.

DESIGN

A systematic literature search was conducted. In all, 46 studies were included in the review. Among these, 16 studies were compared with a meta-analytical approach in order to 1) estimate the effect size of state disgust on screening intention and attendance; 2) examine whether methodological characteristics moderate the effect of state disgust on screening behaviour; 3) estimate the effect sizes of trait disgust and type of exam kit on state disgust.

RESULTS

In the reviewed studies, state disgust was often associated with CRC screening and especially with CRC screening avoidance. The meta-analysis confirmed low-to-moderate negative effects of state disgust on screening intention and attendance. Population sampling strategy was the only significant moderator of the effect of state disgust on screening attendance, i.e. studies that used convenience (versus random/representative) samples found a significantly lower effect size. Trait disgust and type of exam kit exerted a large and a moderate-to-large positive effect, respectively, on state disgust.

CONCLUSIONS

Disgust can boost CRC screening avoidance. Further studies and interventions must be designed to help patients in overcoming this emotional barrier.

Evidence-based health information about pulmonary embolism: Assessing the quality, usability and readability of online and offline patient information

Objective

Pulmonary embolism (PE) is the third most common cardiovascular disease worldwide. However, public awareness is considerably lower than for myocardial infarction or stroke. Patients suffering from PE complain about the lack of (understandable) information and express high informational needs. To uncover if reliable information is indeed scarce, this study evaluates the quantity and quality of existing patient information for tertiary prevention using an evidence-based health information paradigm.

Methods

We conducted a quantitative content analysis (n = 21 patient information brochures; n = 67 websites) evaluating content categories addressed, methodical quality, usability, and readability.

Results

Results show that there is not enough patient information material focusing on PE as a main topic. Existing patient information material is mostly incomplete, difficult to understand, and low in actionability as well as readability.

Conclusion

Our systematic analysis reveals the need for more high-quality patient information on PE as part of effective tertiary prevention.

Innovation

This is the first review analyzing content, methodical quality, readability, and usability of patient information on PE. The findings of this analysis are guiding the development of an innovative, evidence-based patient information on PE aiming to support patients' informational needs and their self-care behavior.

Supporting adjuvant endocrine therapy adherence in women with breast cancer: the development of a complex behavioural intervention using Intervention Mapping guided by the Multiphase Optimisation Strategy

BACKGROUND

Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST).

METHODS

Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively.

RESULTS

The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 24-1 fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components.

CONCLUSIONS

We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions.

Web-Based Behavioral Intervention Utilizing Narrative Persuasion for HIV Prevention Among Chinese Men Who Have Sex With Men (HeHe Talks Project): Intervention Development

Background

In the era of potent antiretroviral therapy, a high level of condomless anal intercourse continues to drive increases in HIV incidence in recent years among men who have sex with men. Effective behavior change strategies for promoting HIV-preventive behaviors are warranted. Narrative persuasion is a novel health communication approach that has demonstrated its persuasive advantages in overcoming resistance to counterattitudinal messages. The efficacy of narrative persuasion in promoting health behavior changes has been well documented, but critical research gaps exist for its application to HIV prevention.

Objective

In this study, we aimed to (1) capitalize on narrative persuasion to design a web-based multisession intervention for reducing condomless anal intercourse among men who have sex with men in Hong Kong (the HeHe Talks Project) by following a systematic development process; and (2) describe the main components of the narrative intervention that potentially determine its persuasiveness.

Methods

Persuasive themes and subtopics related to reducing condomless anal intercourse were initially proposed based on epidemiological evidence. The biographic narrative interview method was used to elicit firsthand experiential stories from a maximum variation sample of local men who have sex with men with diverse backgrounds and experiences related to HIV prevention; different types of role models were established accordingly. Framework analysis was used to aggregate the original quotations from narrators into collective narratives under 6 intervention themes. A dedicated website was finally developed for intervention delivery.

Results

A series of video-based intervention messages in biographic narrative format (firsthand experiential stories shared by men who have sex with men) combined with topic-equivalent argumentative messages were produced and programmed into 6 intervention sessions. The 6-week intervention program can be automatically delivered and monitored online.

Conclusions

We systematically created a web-based HIV prevention intervention derived from peer-generated stories. Strategies used to enhance the efficacy of the narrative intervention have been discussed within basic communication components. This paper describes the methods and experiences of the rigorous development of a narrative communication intervention for HIV prevention, which enables replication of the intervention in the future.

Persuasive Effects of Message Framing and Narrative Format on Promoting COVID-19 Vaccination: A Study on Chinese College Students

During a public health crisis, the provision and dissemination of health-related information are important for the relevant authorities to keep the public informed. By using different types of message framing, the authorities can effectively guide and persuade people to adopt health-related behaviors (such as vaccination). In this study, a web-based experiment using a 2 × 2 (message framing: gain framing versus loss framing) × (message presentation: narrative versus non-narrative) design was conducted to investigate the effects of different message frames on vaccination promotion. In total, 298 college students were recruited to participate in this study. The results suggest that, for message framing, loss-framed (vs. gain-framed) messages lead to higher intentions to get vaccinated. Furthermore, compared with non-narrative messages, narrative messages are more persuasive in promoting vaccination behavior. However, the interaction effect between gain-loss message framing and narrative framing is not significant. Additionally, perceived severity, perceived benefits, and perceived costs mediate the effect of narrative framing on behavioral intentions. In other words, compared with non-narrative messages, narrative messages lead to higher levels of perceived severity and perceived benefits, and a lower level of perceived costs, which in turn increase intentions to get vaccinated. This paper provides insightful implications for both researchers and practitioners.

Do Personal Stories Make Patient Decision Aids More Effective? An Update from the International Patient Decision Aids Standards

BACKGROUND

This article evaluates the evidence for the inclusion of patient narratives in patient decision aids (PtDAs). We define patient narratives as stories, testimonials, or anecdotes that provide illustrative examples of the experiences of others that are relevant to the decision at hand.

METHOD

To evaluate the evidence for the effectiveness of narratives in PtDAs, we conducted a narrative scoping review of the literature from January 2013 through June 2019 to identify relevant literature published since the last International Patient Decision Aid Standards (IPDAS) update in 2013. We considered research articles that examined the impact of narratives on relevant outcomes or described relevant theoretical mechanisms.

RESULTS

The majority of the empirical work on narratives did not measure concepts that are typically found in the PtDA literature (e.g., decisional conflict). Yet, a few themes emerged from our review that can be applied to the PtDA context, including the impact of narratives on relevant outcomes (knowledge, behavior change, and psychological constructs), as well as several theoretical mechanisms about how and why narratives work that can be applied to the PtDA context.

CONCLUSION

Based on this evidence update, we suggest that there may be situations when narratives could enhance the effectiveness of PtDAs. The recent theoretical work on narratives has underscored the fact that narratives are a multifaceted construct and should no longer be considered a binary option (include narratives or not). However, the bottom line is that the evidence does not support a recommendation for narratives to be a necessary component of PtDAs.

A Model-Based Meta-Analysis of Willingness to Participate in Cancer Screening

Although early screening tests are beneficial for the detection and treatment of cancers, many people have failed to participate in screening tests. The present study aims to explore the theoretical underpinning of low participation in screening programs using the method of meta-analytic structural equation modeling. It was found that the health belief model is the most adopted theoretical framework. Moreover, the intended uptake of screening was positively predicted only by cues to action, health literacy, and perceived susceptibility. As a result, a health intention model, including the three significant variables, is proposed. The practical implications of the findings are that health communication campaigns should focus on enlightening and engaging the public through all necessary means to raise awareness and transfer knowledge in relation to screening procedures as well as cancers per se.

Preferences for different diagnostic modalities to follow up abnormal colorectal cancer screening results: a hypothetical vignette study

OBJECTIVES

In England, a significant proportion of people who take part in the national bowel cancer screening programme (BCSP) and have a positive faecal occult blood test (FOBt) result, do not attend follow-up colonoscopy (CC). The aim of this study was to investigate differences in intended participation in a follow-up investigation by diagnostic modality offered including CC, CT colonography (CTC) or capsule endoscopy (CE).

SETTING

We performed a randomised online experiment with individuals who had previously completed an FOBt as part of the English BCSP.

METHODS

Participants (n=953) were randomly allocated to receive one of three online vignettes asking participants to imagine they had received an abnormal FOBt result, and that they had been invited for a follow-up test. The follow-up test offered was either: CC (n=346), CTC (n=302) or CE (n=305). Participants were then asked how likely they were to have their allocated test or if they refused, either of the other tests. Respondents were also asked to cite possible emotional and practical barriers to follow up testing. Multivariable logistic regression models were used to investigate intentions.

RESULTS

Intention to have the test was higher in the CTC group (96.7%) compared with the CC group (91.8%; OR 2.64; 95% CI 1.22 to 5.73). CTC was considered less 'off-putting' (OR 0.66, 95% CI 0.47 to 0.94) and less uncomfortable compared with CC (OR 0.51, 95% CI 0.34 to 0.77). For those who did not intend to have the test they were offered, CE (39.7%) or no investigation (34.5%) was preferable to CC (8.6%) or CTC (17.2%).

CONCLUSIONS

Alternative tests have the potential to increase attendance at diagnostic follow-up appointments.

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.

Development of an intervention to facilitate implementation and uptake of diabetic retinopathy screening

BACKGROUND

'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence.

METHODS

First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness.

RESULTS

We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients.

CONCLUSIONS

Using the example of an intervention to improve DRS uptake, this study illustrates an approach to integrate theory with user involvement. This process highlighted tensions between theory-informed and stakeholder suggestions, and the need to apply the Theoretical Domains Framework (TDF)/BCT structure flexibly. The final intervention draws on the trusted professional-patient relationship, leveraging existing services to enhance implementation of the DRS programme. Intervention feasibility in primary care will be evaluated in a randomised cluster pilot trial.

The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London

OBJECTIVE

Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London.

METHODS

A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake.

RESULTS

Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01).

CONCLUSION

This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.

Preference for Deliberation and Perceived Usefulness of Standard- and Narrative-Style Leaflet Designs: Implications for Equitable Cancer-Screening Communication

BACKGROUND

In the UK, cancer-screening invitations are mailed with information styled in a standard, didactic way to allow for informed choice. Information processing theory suggests this "standard style" could be more appealing to people who prefer deliberative thinking. People less likely to engage in deliberative thinking may be disenfranchised by the design of current standard-style information.

PURPOSE

To examine the distribution of preference for deliberative thinking across demographic groups (Study 1) and explore associations between preference for deliberative thinking and perceived usefulness of standard- and narrative-style screening information (Study 2).

METHODS

In Study 1, adults aged 45-59 (n = 4,241) were mailed a questionnaire via primary care assessing preference for deliberative thinking and demographic characteristics. In Study 2, a separate cohort of adults aged 45-59 (n = 2,058) were mailed standard- and narrative-style leaflets and a questionnaire assessing demographic characteristics, preference for deliberative thinking, and perceived leaflet usefulness. Data were analyzed using multiple regression.

RESULTS

In Study 1 (n = 1,783) and Study 2 (n = 650), having lower socioeconomic status, being a women, and being of nonwhite ethnicity was associated with lower preference for deliberative thinking. In Study 2, the standard-style leaflet was perceived as less useful among participants with lower preference for deliberative thinking, while perceived usefulness of the narrative-style leaflet did not differ by preference for deliberative thinking.

CONCLUSIONS

Information leaflets using a standard style may disadvantage women and those experiencing greater socioeconomic deprivation. More work is required to identify design styles that have a greater appeal for people with low preference for deliberative thinking.

Storytelling as a research tool and intervention around public health perceptions and behaviour: a protocol for a systematic narrative review

INTRODUCTION

There is a growing trend to use storytelling as a research tool to extract information and/or as an intervention to effect change in the public knowledge, attitudes and behaviour (KAB) in relation to public health issues, primarily those with a strong element of disease prevention. However, evidence of its use in either or both capacities is limited. This protocol proposes a systematic narrative review of peer-reviewed, published literature on the use of storytelling as a research tool within the public health arena.

METHODS AND ANALYSIS

Medline, EMBASE, PsycINFO, ERIC (Educational Resources Information Center), Web of Science, Art and Humanities database (ProQuest), Scopus and Google Scholar will be searched for studies that look at the use of storytelling in the research of pressing current public health issues, for example, vaccinations, antimicrobial resistance, climate change and cancer screening. The review will synthesise evidence of how storytelling is used as a research tool to (a) gain insights into KAB and (b) to effect change in KAB when used as an intervention. Included studies will be selected according to carefully defined criteria relevant to public health issues of interest, and data from qualitative, quantitative and mixed-methods studies will be extracted with a customised data extraction form. A narrative synthesis will be performed according to Economic and Social Research Council guidance from Popay, J, 2006.The study protocol follows the recommendations by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P).

ETHICS AND DISSEMINATION

Formal ethical approval is not required for this study, as no primary data will be collected. Dissemination will involve publishing results of this study in relevant peer-reviewed journal(s). Where possible, the study results will also be presented as posters or talks at relevant medical conferences and meetings.

PROSPERO REGISTRATION NUMBER

CRD42019124704.

Market segmentation tools provide insights into demographic variations in bowel cancer screening uptake

Background

The National Health Service Bowel Cancer Screening Programme (NHS BCSP) aims to detect individuals who have precancerous polyps or early stage cancer, when it is easier to treat. To be effective, a screening uptake of at least 52% is required. Variations in uptake by demographic characteristic are reported and the aim of this study was to better understand who participates in the NHS BCSP, to inform action to address inequalities in screening uptake.

Methods

Invitation-level data for the Derbyshire population were supplied by the NHS BCSP Eastern Hub for the period 1 April 2014 to 31 March 2016. Data were linked by postal code to the Mosaic Public Sector Segmentation tool. Descriptive analysis using 14 groups and 61 types within Mosaic was undertaken to offer insight into the demographic, lifestyle and behavioural traits of people living in small geographies against their screening uptake, with a particular focus on identifying population groups with an uptake below 52% and so at risk of health inequalities.

Results

180 176 screening invitations were dispatched with an overall uptake of 60.55%. Six Mosaic groups have an uptake below the 52% acceptable level: urban cohesion, rental hubs, transient renters, family basics, vintage value and municipal tenants. These groups are characterised by high levels of social-rented accommodation, multicultural urban communities and transient populations.

Conclusion

Segmentation tools offer an effective way to generate novel insights into bowel cancer screening uptake and develop tailored strategies for working with identified communities to increase participation.

How narratives influence colorectal cancer screening decision making and uptake: A realist review

BACKGROUND

Although narratives have been found to affect decisions about preventive behaviours, including participation in cancer screening, the underlying mechanisms of narratives remain unclear.

OBJECTIVE

The purpose of this study was to summarize and synthesize existing literature on narrative interventions in the context of colorectal cancer screening. Our main research question was as follows: How, when and for whom do narratives work context of decision making about colorectal cancer screening participation?

METHODS

We undertook a realist review to collect evidence on narratives in the context of colorectal cancer screening. A search of the literature was performed in Embase, MEDLINE/PubMed, Cinahl and PsycINFO. We included empirical evaluations (qualitative or quantitative) of narrative interventions. In total, 15 studies met the inclusion criteria. A content-based taxonomy of patient narrative types in decision aids formed the basis for our initial programme theory.

MAIN RESULT

We identified four mechanisms: (a) process narratives that address perceived barriers towards screening lead to improved affective forecasting, (b) experience narratives that demonstrate the screening procedure lead to increased self-efficacy, (c) experience narratives that depict experiences from similar others lead to more engagement and (d) outcome narratives that focus on outcomes of colorectal cancer (CRC) screening decision decrease or increase fear of colorectal cancer. The evidence was limited on which narrative type may facilitate or bias informed decision making in colorectal cancer screening.

DISCUSSION AND CONCLUSION

The findings indicate the importance of more detailed descriptions of narrative interventions in order to understand how mechanisms may facilitate or bias informed decision making in colorectal cancer screening.

Barriers to bowel scope (flexible sigmoidoscopy) screening: a comparison of non-responders, active decliners and non-attenders

BACKGROUND

Participation in bowel scope screening (BSS) is low (43%), limiting its potential to reduce colorectal cancer (CRC) incidence and mortality. This study aimed to quantify the prevalence of barriers to BSS and examine the extent to which these barriers differed according to non-participant profiles: non-responders to the BSS invitation, active decliners of the invitation, and non-attenders of confirmed appointments.

METHODS

Individuals invited for BSS between March 2013 and December 2015, across 28 General Practices in England, were sent a questionnaire. Questions measured initial interest in BSS, engagement with the information booklet, BSS participation, and, where applicable, reasons for BSS non-attendance. Chi-square tests of independence were performed to examine the relationship between barriers, non-participant groups and socio-demographic variables.

RESULTS

1478 (45.8%) questionnaires were returned for analysis: 1230 (83.2%) attended screening, 114 (7.7%) were non-responders to the BSS invitation, 100 (6.8%) were active decliners, and 34 (2.3%) were non-attenders. Non-responders were less likely to have read the whole information booklet than active decliners (x2 (2, N = 157) = 7.00, p = 0.008) and non-attenders (x2 (2, N = 101) = 8.07, p = 0.005). Non-responders also had lower initial interest in having BSS than either active decliners (x2 (2, N = 213) = 6.07, p = 0.014) or non-attenders (x2 (2, N = 146) = 32.93, p < 0.001). Overall, anticipated pain (33%) and embarrassment (30%) were the most commonly cited barriers to BSS participation. For non-attenders, however, practical, appointment-related reasons were most common (27%).

CONCLUSIONS

Interventions to improve BSS uptake should be more nuanced and use targeted strategies to address the specific needs of each group.

Assessing emotions conveyed and elicited by patient narratives and their impact on intention to participate in colorectal cancer screening: A psychophysiological investigation

In the context of colorectal cancer screening, we aimed to compare the effectiveness of different emotion-laden narratives, to investigate the specific emotions elicited at both subjective and physiological levels, and to test the effects of emotions explicitly expressed by the narrative character. Study 1 used a between-participants design comparing four conditions: relief-based narrative, regret-based narrative, control (test-uptake only) narrative, and standard invitation material (no-narrative condition). Study 2 used a mixed design, with the narrative content as a within-participants factor and whether emotions were expressed by the narrative character or not as between-participants factor. The main outcome measures were: intention to undergo testing (Studies 1 and 2), knowledge, risk perception, proportion of informed choices (Study 1), subjective emotional responses, changes in skin conductance, heart rate, and corrugator muscle activity (Study 2). In Study 1, relative to the non-narrative condition (51%), only the relief-based narrative significantly increased intention to undergo testing (86%). Relative to the standard invitation material, the narrative conditions did not decrease knowledge, alter risk perception, or decrease the proportion of informed choices. In Study 2, the relief-based narrative elicited the lowest self-reported negative affect, and received greater implicit attention, as suggested by the larger heart rate decrease. Making the emotions experienced by the narrative character explicit decreased negative affect, as indicated by the lower skin conductance and corrugator responses during reading. Our findings provide support for the use of a relief-based narrative with emotions expressed by the character in addition to the standard information material to promote colorectal cancer screening.

Persuasion, Adaptation, and Double Identity: Qualitative Study on the Psychological Impact of a Screen-Detected Colorectal Cancer Diagnosis

The NHS Bowel Cancer Screening Programme (BCSP) is aimed at reducing colorectal cancer (CRC) mortality through early detection within a healthy population. This study explores how 5 people (three females) experience and make sense of their screen-detected diagnosis and the psychological implications of this diagnostic pathway. A biographical narrative interview method was used, and transcripts were analysed using a thematic analysis with a phenomenological lens. Themes specifically relating to posttreatment experience and reflections are reported here: Do it: being living proof, Resisting the threat of recurrence, Rationalising bodily change, and Continuing life-"carrying on normally." Participants described their gratefulness to the BCSP, motivating a strong desire to persuade others to be screened. Furthermore, participants professed a duality of experience categorised by the normalisation of life after diagnosis and treatment and an identification of strength post cancer, as well as a difficulty adjusting to the new changes in life and a contrasting identity of frailty. Understanding both the long- and short-term impacts of a CRC diagnosis through screening is instrumental to the optimisation of support for patients. The results perhaps highlight a particular target for psychological distress reduction, which could reduce the direct and indirect cost of cancer to the patient.

Cross-cultural survey development: The Colon Cancer Screening Behaviors Survey for South Asian populations

OBJECTIVE

The objective of this work was to develop a survey that considered cultural relevance and diversity of South Asian populations, with the aim of describing or predicting factors that influence colorectal cancer screening intention and adherence. The scientifically rigorous approach for survey development informed the final phase of an exploratory mixed method study. This initial survey was later cross-culturally translated and adapted into the Urdu language, and thereafter, items were cognitively tested for conceptual relevance among South Asian immigrants.

RESULTS

The initial development of the Colon Cancer Screening Behaviours Survey for South Asian populations was completed using a number of steps. Development involved: the identification of key concepts and conceptual model; literature search for candidate measures and critical appraisal; and, expert consultation to select relevant measures. Five published surveys included measures that covered concepts relevant to South Asians and colorectal cancer screening behaviours. However, measures from these surveys missed content that emerged through parallel field work with South Asians, and additions were required along with item modifications. In the final stage, cross-cultural translation and adaptation into Urdu, and cognitive testing were completed. Future research will require an examination of proposed relationships, and psychometric testing of measures in the survey.

Cognitive testing of the Colon Cancer Screening Behaviours Survey with South Asian immigrants in Canada

Background

Methods

Results

Conclusions

Electronic supplementary material

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.

Inequalities in cancer screening participation: examining differences in perceived benefits and barriers

OBJECTIVE

Inequalities exist in colorectal cancer (CRC) screening uptake, with people from lower socioeconomic status backgrounds less likely to participate. Identifying the facilitators and barriers to screening uptake is important to addressing screening disparities. We pooled data from 2 trials to examine educational differences in psychological constructs related to guaiac fecal occult blood testing.

METHODS

Patients (n = 8576) registered at 7 general practices in England, within 15 years of the eligible age range for screening (45-59.5 years), were invited to complete a questionnaire. Measures included perceived barriers (emotional and practical) and benefits of screening, screening intentions, and participant characteristics including education.

RESULTS

After data pooling, 2181 responses were included. People with high school education or no formal education reported higher emotional and practical barriers and were less likely to definitely intend to participate in screening, compared with university graduates in analyses controlling for study arm and participant characteristics. The belief that one would worry more about CRC after screening and concerns about tempting fate were strongly negatively associated with education. In a model including education and participant characteristics, respondents with low emotional barriers, low practical barriers, and high perceived benefits were more likely to definitely intend to take part in screening.

CONCLUSIONS

In this analysis of adults approaching the CRC screening age, there was a consistent effect of education on perceived barriers toward guaiac fecal occult blood testing, which could affect screening decision making. Interventions should target specific barriers to reduce educational disparities in screening uptake and avoid exacerbating inequalities in CRC mortality.

Use of a 12 months' self-referral reminder to facilitate uptake of bowel scope (flexible sigmoidoscopy) screening in previous non-responders: a London-based feasibility study

BACKGROUND

In March 2013, NHS England extended its national Bowel Cancer Screening Programme to include 'one-off' Flexible Sigmoidoscopy screening (NHS Bowel Scope Screening, BSS) for men and women aged 55. With less than one in two people currently taking up the screening test offer, there is a strong public health mandate to develop system-friendly interventions to increase uptake while the programme is rolling out. This study aimed to assess the feasibility of sending a reminder to previous BSS non-responders, 12 months after the initial invitation, with consideration for its potential impact on uptake.

METHOD

This study was conducted in the ethnically diverse London Boroughs of Brent and Harrow, where uptake is below the national average. Between September and November 2014, 160 previous non-responders were randomly selected to receive a reminder of the opportunity to self-refer 12 months after their initial invitation. The reminder included instructions on how to book an appointment, and provided options for the time and day of the appointment and the gender of the endoscopist performing the test. To address barriers to screening, the reminder was sent with a brief locally tailored information leaflet designed specifically for this study. Participants not responding within 4 weeks were sent a follow-up reminder, after which there was no further intervention. Self-referral rates were measured 8 weeks after the delivery of the follow-up reminder and accepted as final.

RESULTS

Of the 155 participants who received the 12 months' reminder (returned to sender, n=5), 30 (19.4%) self-referred for an appointment, of which 24 (15.5%) attended and were successfully screened. Attendance rates differed by gender, with significantly more women attending an appointment than men (20.7% vs 8.8%, respectively; OR=2.73, 95% CI=1.02-7.35, P=0.05), but not by area (Brent vs Harrow) or area-level deprivation. Of the 30 people who self-referred for an appointment, 27 (90%) indicated a preference for a same-sex practitioner, whereas three (10%) gave no preference. Preference for a same-sex practitioner was higher among women than men (χ(2)=7.78, P<0.05), with only 67% of men (six of nine) requesting a same-sex practitioner, compared with 100% of women (n=21).

CONCLUSIONS

Sending previous non-responders a 12 months' reminder letter with a brief information leaflet is a feasible and efficacious intervention, which merits further investigation in a randomised controlled trial.

Reducing the Social Gradient in Uptake of the NHS Colorectal Cancer Screening Programme Using a Narrative-Based Information Leaflet: A Cluster-Randomised Trial

Objective. To test the effectiveness of adding a narrative leaflet to the current information material delivered by the NHS English colorectal cancer (CRC) screening programme on reducing socioeconomic inequalities in uptake. Participants. 150,417 adults (59-74 years) routinely invited to complete the guaiac Faecal Occult Blood test (gFOBt) in March 2013. Design. A cluster randomised controlled trial (ISRCTN74121020) to compare uptake between two arms. The control arm received the standard NHS CRC screening information material (SI) and the intervention arm received the standard information plus a supplementary narrative leaflet, which had previously been shown to increase screening intentions (SI + N). Between group comparisons were made for uptake overall and across socioeconomic status (SES). Results. Uptake was 57.7% and did not differ significantly between the two trial arms (SI: 58.5%; SI + N: 56.7%; odds ratio = 0.93; 95% confidence interval: 0.81-1.06; p = 0.27). There was no interaction between group and SES quintile (p = 0.44). Conclusions. Adding a narrative leaflet to existing information materials does not reduce the SES gradient in uptake. Despite the benefits of using a pragmatic trial design, the need to add to, rather than replace, existing information may have limited the true value of an evidence-based intervention on behaviour.

Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials

BACKGROUND

Uptake in the national colorectal cancer screening programme in England varies by socioeconomic status. We assessed four interventions aimed at reducing this gradient, with the intention of improving the health benefits of screening.

METHODS

All people eligible for screening (men and women aged 60-74 years) across England were included in four cluster-randomised trials. Randomisation was based on day of invitation. Each trial compared the standard information with the standard information plus the following supplementary interventions: trial 1 (November, 2012), a supplementary leaflet summarising the gist of the key information; trial 2 (March, 2012), a supplementary narrative leaflet describing people's stories; trial 3 (June, 2013), general practice endorsement of the programme on the invitation letter; and trial 4 (July-August, 2013) an enhanced reminder letter with a banner that reiterated the screening offer. Socioeconomic status was defined by the Index of Multiple Deprivation score for each home address. The primary outcome was the socioeconomic status gradient in uptake across deprivation quintiles. This study is registered, number ISRCTN74121020.

FINDINGS

As all four trials were embedded in the screening programme, loss to follow-up was minimal (less than 0·5%). Trials 1 (n=163,525) and 2 (n=150,417) showed no effects on the socioeconomic gradient of uptake or overall uptake. Trial 3 (n=265 434) showed no effect on the socioeconomic gradient but was associated with increased overall uptake (adjusted odds ratio [OR] 1·07, 95% CI 1·04-1·10, p<0·0001). In trial 4 (n=168 480) a significant interaction was seen with socioeconomic status gradient (p=0·005), with a stronger effect in the most deprived quintile (adjusted OR 1·11, 95% CI 1·04-1·20, p=0·003) than in the least deprived (1·00, 0·94-1·06, p=0·98). Overall uptake was also increased (1·07, 1·03-1·11, p=0·001).

INTERPRETATION

Of four evidence-based interventions, the enhanced reminder letter reduced the socioeconomic gradient in screening uptake, but further reducing inequalities in screening uptake through written materials alone will be challenging.

FUNDING

National Institute for Health Research.