Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials
Author(s)
Type
Report
Abstract
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; all
p
-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.
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; all
p
-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.
Date Issued
2017-04-01
Citation
Health Technology Assessment, 2017
ISSN
2050-4322
Publisher
NIHR Journals Library
Journal / Book Title
Health Technology Assessment
Copyright Statement
© Queen’s Printer and Controller of HMSO 2017. This work was produced by Raine et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement
is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre,
Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre,
Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Sponsor
University College London Hospitals NHS Foundation
Cancer Research UK
Identifier
https://www.ncbi.nlm.nih.gov/books/NBK425325/pdf/Bookshelf_NBK425325.pdf
Grant Number
Programme G526
A16894
Publication Status
Published online