Evidence on increasing bowel screening uptake

A returned FOBt bowel screening kit

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Increasing bowel screening uptake across the UK is a priority as it is currently low and there are considerable inequalities between areas and demographics.

A growing evidence base has highlighted a number of interventions that can be used to increase uptake of FOBt bowel screening, while promoting informed consent.

We have summarised the findings of all the projects that we're aware of that have been able to publish robust evaluations but there is considerable additional activity underway locally besides the projects covered here. Let us know if you are aware of or are involved in projects that could provide further evidence of good practice.

Overview of the evidence base

The available evidence shows that a number of interventions increase bowel screening uptake and others where there wasn't a clear increase in uptake.

Increases uptake

More evidence needed

  • GP endorsement letter
  • Enhanced patient leaflet
  • Telephone advice*
  • CRUK London campaign (advertising, kit enhancement & flyer
  • Face to face health promotion*
  • Enhanced reminder letter
  • Community awareness activities
  • Personal screening stories
  • Numerical/pictorial information
  • Concise summarised 'gist' information
  • Implementation intention style tips in the NHS kit instructions**
  • Research questionnaire (decreased uptake)
  • Text reminders

*Only tested in combination with other elements

**Small increase in the most deprived group, but offset by decrease in the least deprived group

Interventions shown to increase uptake

Sending a letter from an individual’s GP endorsing the screening programme or an enhanced patient leaflet alongside the screening kit people receive have been shown to have the largest effects of any interventions used in isolation, increasing uptake by around 6%. The increase in uptake is around twice as large when they are combined, increasing uptake by up to 12%[1].

Telephone advice and face to face health promotion have also been shown to increase uptake by around 8% and 5% respectively, when used in combination with a GP endorsement letter which was sent 2 weeks after their screening due date[2]. The project that incorporated these activities took place in areas of low socio-economic status and high ethnic diversity so these approaches may be able to help address inequalities in bowel screening uptake.

 

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References

[1] Hewitson P, Ward A, Heneghan C, et al. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Brit J Cancer 2011;9;105(4):475-80.

[2] Shankleman J, Massat N, Khagram L et al. Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas Brit J Cancer 2014;23;111(7):1440-7.

[3] White B, Power E, Ciurej M, et al. Piloting the Impact of Three Interventions on Guaiac Faecal Occult Blood Test Uptake within the NHS Bowel Cancer Screening Programme, BioMed Research International 2015 doi 10.1155/2015/928251

A peer reviewed study by Hewitson et al, found that sending a letter from an individual’s GP endorsing the screening programme alongside the screening kit, increases bowel screening uptake by up to 6%[1] and by up to 12%[1] when sent in combination with an enhanced patient information leaflet.

Invitations to take part in bowel screening are generally posted by bowel screening hubs and don’t involve GP practices. GPs involvement in bowel screening in the UK can therefore be limited to receiving a copy of the results letters sent to their patients. However, research has shown that GP involvement in bowel screening increases uptake[1,2]. An effective way to do this is to work with screening hubs and GP practices to provide people with a personalised letter from their GP endorsing screening and offering further information, alongside their screening kit.

A more recent study by Raine et al. provided further evidence for the effectiveness of GP endorsement in increasing bowel screening uptake. This large scale study, which included 80% of GP practices in England, added a simple GP endorsement banner to the standard screening invitation letter. Overall uptake increased by 0.7%, which although appears to be a small increase, could mean up to 40,000 extra people screened if rolled out on a national scale.[3]

Practical tip

GP endorsement letters should ideally be electronically signed by the GP and on practice-headed paper; letters sent on behalf of the practice are less effective[1]

 
References

[1] Hewitson P, Ward A, Heneghan C, et al. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Brit J Cancer 2011;9;105(4):475-80.

[2] Cole S, Young G, Byrne D, et al. Participation in screening for colorectal cancer based on a faecal occult blood test is improved by endorsement by the primary care practitioner. J Med Screen 2002;9(4):147-52.

[3] Raine R, Duffy SW, Wardle J et al Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening. Br J Cancer. 2016 Feb 2;114(3):321-6

A peer reviewed study by Hewitson et al, found that sending an enhanced leaflet with the screening kit increases bowel screening uptake by around 6%[1], and by up to 12% [1]when sent in combination with a GP endorsement letter.

Currently, an NHS bowel cancer screening leaflet 'The Facts' is sent with the test kit. The leaflet provides over 20 pages of information on bowel cancer symptoms, statistics and details of possible test outcomes and treatment options.

For practical tips on carrying out the test people are referred to the instructions provided with the kit and there is a short section on perceived barriers to completing it, such as embarrassment and unpleasantness.

The enhanced version of the leaflet directly addresses perceived barriers to completing the test and provides practical tips. This strategy is supported by previous research showing that providing detailed instructions on the collection, storage and return of screening kits can increase the proportion of people taking part[2,3]. The content was developed with advice from an expert steering group and was extensively piloted.

References

[1] Hewitson P, Ward A, Heneghan C, et al. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Brit J Cancer 2011;9;105(4):475-80.

[2] Stokamer CL, Tenner CT, Chaudhuri J, et al. Randomised controlled trial of the impact of intensive patient education on compliance with feacal occult blood testing. J Gen Intern Med. 2005;20(3):278-82.

[3] Miller DP Jr, Kimberly JR Jr, Case LD et al. Using a computer to teach patients about feacal occult blood screening. A randomised trial.  J Gen Intern Med. 2005;20(11):984-8.

A peer reviewed study by Shankleman et al, found that phoning potential participants to provide information about bowel screening and offering to answer questions, used in combination with a GP endorsement letter two weeks after people were due to return their screening kit, increases bowel screening uptake by around 8%[1].

The project took place in areas of low socio-economic status and high ethnic diversity showing that this approach could help to address inequalities in bowel screening uptake.

Unlike the other cancer screening programmes, participation in FOBt bowel screening does not involve any contact with a health professional. Providing the opportunity to speak to a trained advocate from a person’s own GP practice provides an opportunity to increase awareness and understanding of bowel screening and overcome barriers to participation. Advocates should be bi-lingual in areas where English may not be a first language.

In the study people received a letter on GP practice headed paper, two weeks after they were due to return their screening kit. The letter endorsed screening, provided information and notified them that they would receive a call offering information about screening. GP endorsement letters alone have been shown to increase uptake when provided with the screening kit and are likely to be important to the success of this intervention[2].

Practical tips

  • Consider enlisting the help of a community organisation with experience of telephone outreach
  • Exclude subjects whose records show a bowel cancer diagnosis, palliative care needs or that they have opted out of the programme
  • Use trained advocates (can be non-medical) who should be bi-lingual in areas with language barriers
  • Use a standardised script for the calls and to answer common questions
  • Consider combining this with other interventions such as a GP endorsement letter

References

[1] Shankleman J, Massat N, Khagram L et al. Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas Brit J Cancer 2014;23;111(7):1440-7.

[2] Hewitson P, Ward A, Heneghan C, et al. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Brit J Cancer 2011;9;105(4):475-80.

A peer-reviewed study by White et al found that a kit enhancement pack (mailed separately to the NHS test kit and containing a poo catcher and gloves), combined with outdoor advertising and a CRUK endorsement flyer (inserted inside an NHS test kit mailing) was effective in increasing bowel cancer screening uptake by 6.1% in ages 60-69 and 7.3% in ages 70-74.[1]

The pilot also showed that an endorsement flyer in the screening kit combined with the kit enhancement pack or with local advertising also endorsing screening increased uptake by 1.7% and 2.2% respectively in ages 60-69. Those combinations of intervention did not increase uptake in ages 70-74. The study also found that the endorsement flyer alone did not increase uptake in either age group.

The kit enhancement pack provided a practical aide within the standard kit in the form of a ‘poo catcher’, which slides over the toilet seat and is used to catch a bowel movement, along with latex-free gloves. The kit enhancement pack is therefore likely to be particularly helpful for people who have physical difficulties collecting samples or are put off by significant feelings of disgust.

Practical tips:

  • Consider working in collaboration with other organisations. This example was developed by CRUK and supported by NHS England (London), Public Health England, Department of Health and the Bowel Cancer Screening Programme (BCSP).
  • For local advertising use varied outlets, such as bus stops, pharmacy bags and digital screens in GP practices

 

References

[1] White B, Power E, Ciurej M, et al. Piloting the Impact of Three Interventions on Guaiac Faecal Occult Blood Test Uptake within the NHS Bowel Cancer Screening Programme, BioMed Research International 2015 doi 10.1155/2015/928251

A peer reviewed study by Shankleman et al, found that providing face-to-face health promotion sessions at an individual’s own GP practice, alongside pictorial and multi-lingual guides and non-latex gloves, increases bowel screening uptake by around 5%[1]. The sessions took place after people had received a GP endorsement letter two weeks after they were due to return their screening kit.

The project took place in areas of low socio-economic status and high ethnic diversity showing that this approach could help to address inequalities in bowel screening uptake.

Unlike the other cancer screening programmes, the standard FOBt bowel screening does not involve any contact with a health professional. Providing the opportunity to attend a health education session with trained advocates, as well as providing additional resources at a person’s own GP practice can help increase screening knowledge and overcome barriers to participation.

In the study people received a letter on GP practice headed paper, two weeks after they were due to return their screening kit. The letter endorsed screening, provided information and invited people to attend a group health information session at the GP practice premises. GP endorsement letters alone have been shown to increase uptake when provided with the screening kit and are likely to be important to the success of this intervention[2].

References

[1] Shankleman J, Massat N, Khagram L et al. Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas Brit J Cancer 2014;23;111(7):1440-7.

[2] Hewitson P, Ward A, Heneghan C, et al. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Brit J Cancer 2011;9;105(4):475-80.

Sending an enhanced reminder letter was shown to increase uptake in a peer-reviewed study. Bowel screening non-responders were sent a modified reminder letter, including a banner at the top of the page with the text ‘A reminder to you’ and an additional paragraph at the end reinstating the screening offer and providing detail of the screening helpline number. Overall uptake increased by 0.7%, and the results also suggest a reduction in the socio-economic gradient, showing a greater effect in the most deprived group.[1]

References

[1] Wardle J, von Wagner C, Kralj-Hans I et al 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. Lancet. 2016 Feb 20; 387(10020): 751–759.

Which interventions do we need more evidence for?

There is currently insufficient evidence to show that providing additional numerical and pictoral information to bowel screening information increases uptake.

A peer reviewed study by Pantawala et al, looked at adding numerical information (with supplementary pictograms) to the standard NHS bowel screening leaflet. The information aimed to highlight screening risks and benefits at an individual level, rather than at a population level e.g. ‘The screening programme will prevent 12 people, that is 1 in every 182 screened, from dying of bowel cancer’. The study found that the intervention did not affect desire to be screened, but suggested it might be useful in supporting decision making.[1]

Screening uptake was not looked at as part of this study, so it’s not possible to know if more people would go on to take part in screening. More large scale peer reviewed studies or evaluations that rigorously examine outcome measures such as uptake are therefore needed to determine the effectiveness of this approach.

References

[1] Patanwala IM, Brocklebank V, Inglis J, et al. A randomised questionnaire-based study on the impact of providing numerical information on colorectal cancer screening. JRSM Short Rep. 2011;2(6):48

There is currently insufficient evidence to show that providing a supplementary summary leaflet alongside the standard NHS bowel screening leaflet sent with the screening kit, increases bowel screening uptake.

A peer reviewed study by Smith et al, found that providing an additional leaflet with short, easy to read statements, giving readers ‘the gist’ of the information, did not appear to affect intention to participate. The affects were limited to giving those who read the summarised leaflet greater knowledge of screening.[1]

Screening uptake was not looked at as part of this study, so it’s not possible to know if more people would go on to take part in screening. More large scale peer reviewed studies or evaluations that rigorously examine outcome measures such as uptake are therefore needed to determine the effectiveness of this approach.

References

[1] Smith SG, Raine R, Obichere A, et al. The effect of a supplementary (gist-based) information leaflet on colorectal cancer knowledge and screening intention: a randomised controlled trial. J Behav Med. 2015;38(2):261-72.

There is currently insufficient evidence to show that community awareness activities increase bowel screening uptake.

A variety of activities have been piloted locally, including interactive awareness events, information stands and posters in the local community, as well as training local champions (e.g. barbers, pharmacists and other local volunteers) to promote bowel screening, particularly to engage hard to reach communities.

No peer reviewed studies on these interventions have been carried out and due to challenges associated with evaluating these types of projects, the evaluations available have not been able to measure effects on uptake. Local evaluation projects typically report alternative (if any) outcome measures such as number of people engaged, materials distributed and volunteer hours utilised. More large scale peer reviewed studies or evaluations that rigorously examine outcome measures such as uptake are therefore needed to determine the effectiveness of this approach.

There is currently insufficient evidence to show that including personal stories from people who’ve taken part in screening alongside the standard information provided, increases bowel screening uptake.[1,2]

One peer reviewed study by McGregor et al, found that providing personal screening stories increases positive beliefs about bowel screening, leading to stronger screening intentions.[1]

Screening uptake was not looked at as part of this study, so it’s not possible to know if more people would go on to take part in screening.

Building on the these initial findings, a cluster randomised control trial found no difference in uptake between those receiving the additional narrative leaflet and those receiving standard screening information. However, it’s not known what effect sending the leaflet as a standalone item, or at alternative time points would have on uptake.[3]

References

[1] McGregor LM, von Wagner C, Vart G, et al. The impact of supplementary narrative-based information on colorectal cancer screening beliefs and intention. BMC Cancer. 2015;21;15:162

[2] Jensen JD, King AJ, Carcioppolo N, et al. Comparing tailored and narrative worksite interventions at increasing colonoscopy adherence in adults 50-75: a randomized contolled trial. Soc Sci Med. 2014;104:31-40

[3] McGregor LM, von Wagner C, Atkin W et al Reducing the Social Gradient in Uptake of the NHS Colorectal Cancer Screening Programme Using a Narrative-Based Information Leaflet: A Cluster-Randomised Trial. Gastroenterol Res Pract. 2016;2016:3670150

A peer reviewed study by Lo et al, found that adding practical tips on how to collect stool samples and adding encouraging language to the text of the standard NHS kit instructions did not increase overall bowel screening uptake. There was no overall difference in uptake between intervention and control groups. A small increase was observed in the most deprived group, but this was offset by a decrease in uptake within the least deprived group[1].

The study used the implementation intentions strategy to present the information, which encourages people to think about how they will complete an action and has been shown to support goal attainment in other settings.[2] The findings of this study suggest that further research is needed to determine whether this approach is suitable as a general strategy to promote bowel cancer screening.

The addition of these practical tips was designed to address common barriers to screening. Readers were encouraged to ‘get organised’, ‘get going’ and ‘don’t get put off’.  Practical tips such as using kitchen roll or a container to collect samples were included, as well as emphasising the medical benefits of taking part.

References

[1] Lo SH, Good A, Sheeran P et al. Preformulated implementation intentions to promote colorectal cancer screening: a cluster-randomised trial. Health Psychol. 2014;33(9):998-1002

[2] Wieber F, Thürmer JL, Gollwitzer PM. Promoting the translation of intentions into action by implementation intentions: behavioral effects and physiological correlates. Front Hum Neurosci 2015;14(9):395

A peer reviewed study by Watson et al, found that including a research questionnaire alongside a standard bowel screening kit can decrease bowel screening uptake by up to 5%[1].

The decrease in uptake may be due to the questionnaire adding a large volume of written information to the screening kits that the participants were sent. It is important to consider the impact that any materials you add to the screening kit may have on people’s decision to take part in screening.

A similar peer-reviewed study based in Scotland did not find any overall effect on uptake when sending a so-called ‘anticipated regret’ questionnaire alongside the bowel screening invitation letter. The intervention questionnaire combined a validated health belief questionnaire with two additional questions asking whether the participant felt they would ‘regret’ it if they did not complete the kit or ‘later wish they had done’.[2]

References

[1] Watson J, Shaw K, Macgregor M et al. Use of research questionnaires in the NHS Bowel Cancer Screening Programme in England: impact on screening uptake. J Med Screen. 2013;20(4):192-7.

[2] O'Carroll RE, Chambers JA, Brownleeb L et al Anticipated regret to increase uptake of colorectal cancer screening (ARTICS): A randomised controlled trial. SOC SCI MED 2015; 142: 118-127

The ‘Text Reminders in Colorectal Cancer Screening’ (TRICCS) randomised control trial is the first large scale trial of a text message reminder in the English Bowel Cancer Screening Programme. The study will involve patients from 180 GP practices in London, and aims to assess the effectiveness of a text message reminder to promote bowel screening uptake. The results are due to be published towards the end of 2016.[1]

[1] Hirst Y, Kerrison R, Kobayashi LC et al Text Reminders in Colorectal Cancer Screening (TRICCS): Protocol for a randomised controlled trial. BMC Public Health. 2016 Jan 25;16:74

Barriers to bowel screening participation

Considerable research has taken place to try and understand the barriers to bowel screening participation. A number of barriers have been identified, these include:

  • Fear and denial around the test outcome.[1-4]
  • A misconception that the test is not applicable if you don’t have any apparent symptoms of bowel cancer.[1,2,5,6]
  • Concerns around the practicalities and cleanliness of the test.[3,5-8]
  • Individual perceived risk being low or consideration of future consequences of bowel cancer.[2,3,6,7]
  • The fact that it takes place away from the usual health care settings.[1,3]
  • Low health literacy and numeracy.[9,10]
  • Gender - on the whole, males were less likely to take part in screening.[11,12]
  • Lower socioeconomic group.[12,13]

References

 [1] Palmer CK, Thomas MC, von Wagner C et al. Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study. Br J Cancer. 2014;110(7):1705-11.

[2] Ekberg M, Callender M, Hamer H et al. Exploring the decision to participate in the National Health Service Bowel Cancer Screening Programme. Eur J Cancer Prev. 2014;23(5):391-7.

[3] Chapple A, Ziebland S, Hewitson P et al. What affects the uptake of screening for bowel cancer using a faecal occult blood test (FOBt): a qualitative study. Soc Sci Med. 2008;66(12):2425-35.

[4] Miles A, Rainbow S, von Wagner C. Cancer fatalism and poor self-rated health mediate the association between socioeconomic status and uptake of colorectal cancer screening in England. Cancer Epidemiol Biomarkers Prev. 2011;20(10):2132-40.

[5] O'Sullivan I, Orbell S. Self-sampling in screening to reduce mortality from colorectal cancer: a qualitative exploration of the decision to complete a faecal occult blood test (FOBT). J Med Screen. 2004;11(1):16-22.

[6] Hall NJ, Rubin GP, Dobson C et al. Attitudes and beliefs of non-participants in a population-based screening programme for colorectal cancer. Health Expect. 2015;18(5):1645-1657.

[7] von Wagner C, Good A, Smith SG, et al. Responses to procedural information about colorectal cancer screening using faecal occult blood testing: the role of consideration of future consequences. Health Expect. 2012;15(2):176-86.

[8] Bennett K., von Wagner C, Robb, K. Supplementing factual information with patient narratives in the cancer screening context: a qualitative study of acceptability and preferences. Health Expect. 2015;18(6):2032-2041.

[9] Kobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing. Prev Med. 2014;61:100-5.

[10] Gale CR, Deary IJ, Wardle J et al. Cognitive ability and personality as predictors of participation in a national colorectal cancer screening programme: the English Longitudinal Study of Ageing. J Epidemiol Community Health. 2015;69(6):530-5.

[11] Taskila T, Wilson S, Damery S et al. Factors affecting attitudes toward colorectal cancer screening in the primary care population. Br J Cancer. 2009;21;101(2):250-5.

[12] Weller, DP and Campbell C. Uptake in cancer screening programmes: a priority in cancer control. Br J Cancer. 20093;101(Suppl 2):S55–S59.

[13] von Wagner C, Good A, Wright D et al. Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England. Br J Cancer. 2009;101:S60-S63.

It’s important to design activity to address these barriers wherever they may apply to the population eligible for screening in your area.

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