The ASCEND Study: Strategies to Reduce the Social Gradient in Bowel Cancer Screening

Funder

Amount

Duration

National Institute for Health Research
£1,111,826
Mar 2011 - Mar 2015

Key contact: Professor Rosalind Raine

Background

  • Bowel cancer is the second commonest cause of cancer death in the UK.
  • Early diagnosis improves survival and in the light of this the NHS has established the Bowel Cancer Screening Programme (BCSP).
  • The BCSP offers screening using a stool testing kit (the faecal occult blood test or FOBt) to 60-69 year olds (and is being extended to include those up to 74 years), every two years. Five regional Hubs co-ordinate the Programme.
  • Recent data show that only 53% of those offered screening take it up and that this varies from more than 60% in the most socially advantaged areas of the country to less than 35% in the most disadvantaged areas.

Aim

To reduce socio-economic inequalities in bowel cancer screening uptake in England without compromising uptake in any socio-economic group.

Objectives

  • Work stream 1: To explore psycho-social and cultural determinants of low uptake of the gFOBt in the general population and in South Asian communities.
  • Work stream 2: To develop and test four theoretically-based interventions designed specifically to reduce the socio-economic gradient in bowel cancer screening uptake.
  • Work stream 3: To use a RCT design to evaluate the effectiveness and cost effectiveness of each individual intervention within the BCSP.

Study Protocol (pdf version)

Project team

Co-Principal Investigators:

Professor Rosalind Raine

Professor Jane Wardle

Co-Investigators:

Professor Wendy Atkin (Imperial College London)

Dr Christian von Wagner

Professor Stephen Duffy (Queen Mary University of London)

Professor Allan Hackshaw

Professor Stephen Halloran (BCSP Southern Hub)

Mr Neil Stubbs (BCSP Southern Hub)

Dr Graham Handley (BCSP North-East Hub)

Professor Richard Logan (BCSP Eastern Hub)

Dr Sandra Rainbow (BCSP London Hub)

Dr Stephen Smith (BCSP Midlands & North-West Hub)

Professor Steve Morris

Dr Austin Obichere (North Central London Bowel Cancer Screening Centre)

Mr Roger Band (Patient Representative)

Study team:

Dr Lesley McGregor

Dr Cecily Palmer

Dr Gemma Vart

Dr Samuel Smith (Queen Mary University of London)

Ms Mary Thomas

Mrs Rosemary Howe (Kings College London)

Dr Ines Kralj-Hans (Kings College London)

Dr Francesca Solmi

Professor Sue Moss (Queen Mary University of London)

Dr Nicholas Counsell

Ms Julia Snowball (BCSP Southern Hub)

Workstream One

We conducted 18 focus groups with individuals eligible for screening and from a range of socio-economic backgrounds in London and South Yorkshire, in order to explore reasons for non-uptake of bowel cancer screening.

Read more - Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study

In addition, we carried out interviews with individuals who acted as key informants for a diverse number of South Asian communities in London. South Asian communities were chosen because they make up the largest ethnic minority group in England (approximately 7% of the population). Key informants were purposively sampled to ensure representation from the three dominant faith backgrounds (Islam, Hinduism and Sikhism). Interviews were recorded, transcribed and analysed using thematic analysis.

Findings are currently being drafted for publication.

Summary findings

Workstream Two

Intervention 1: a ‘gist’ leaflet

We designed a leaflet summarising the key screening information in language suited to respondents with lower health literacy, and we tested the leaflet for readability and comprehensibility via a number of small qualitative studies with users. We then conducted a multi-centre parallel RCT with screening-naïve individuals (N=4452), to examine the impact of the leaflet on intentions to complete screening.

The development and testing of a brief (‘gist-based’) supplementary colorectal cancer screening information leaflet

The effect of a supplementary (‘gist-based’) information leaflet on colorectal cancer knowledge and screening intention: a randomized controlled trial. Journal of Behavioral Medicine

Intervention 2: a ‘narrative’ leaflet

We conducted 20 narrative style interviews with individuals who had some experience of taking part in bowel cancer screening, in order to produce a narrative leaflet based on their ‘stories’. We designed the leaflet and tested it via a number of focus groups and interviews. We then conducted a RCT with screening-naïve individuals (N=4125), to examine the impact of the leaflet on screening intentions.

Intervention 3: General Practice Endorsement

This intervention involved inserting an additional line of text of endorsement by the individual’s GP that would appear on the BCSP invitation materials. We then invited all GPs across England to endorse the BCSP.

Intervention 4: Enhanced Reminder

We developed text to be included in an Enhanced Reminder letter to be sent as part of the BCSP screening invitation materials. The text aimed to address specific concerns that inhibit test completion particularly among those with lower socio-economic circumstances, including lack of awareness of bowel cancer and lack of perceived benefits of bowel cancer screening.

Workstream Three

National, cluster-randomised trials compared ‘usual care’ with each of the four intervention strategies (summarised in work stream 2) designed to target known barriers to uptake among people with lower socio-economic circumstances.

Publications

2016

2015

McGregor, L. M., von Wagner, C., Vart, G., Yuen, W. C., Raine, R., Wardle, J., & Robb, K. A. (2015). The impact of supplementary narrative-based information on colorectal cancer screening beliefs and intention. BMC Cancer, 15 (1). doi:10.1186/s12885-015-1167-3

Palmer, C. K., Thomas, M. C., McGregor, L. M., Von Wagner, C., & Raine, R. (2015). Understanding low colorectal cancer screening uptake in South Asian faith communities in England - A qualitative study Health behavior, health promotion and society. BMC Public Health, 15 (1). doi:10.1186/s12889-015-2334-9

Smith, S. G., Vart, G., Wolf, M. S., Obichere, A., Baker, H. J., Raine, R., Wardle, J., von Wagner, C. (2015). How do people interpret information about colorectal cancer screening: observations from a think-aloud study. Health Expect, 18 (5), 703-714. doi:10.1111/hex.12117

Solmi, F., Von Wagner, C., Kobayashi, L. C., Raine, R., Wardle, J., & Morris, S. (2015). Decomposing socio-economic inequality in colorectal cancer screening uptake in England. SOCIAL SCIENCE & MEDICINE, 134, 76-86. doi:10.1016/j.socscimed.2015.04.010

Wardle, J., von Wagner, C., Kralj Hans, I., Halloran, S. P., Smith, S. G., McGregor, L., Vart, G., Howe, R., Snowball, J., Handley, G., Logan, R. F., Rainbow, S., Smith, S., Thomas, M. C., Counsell, N., Morris, S., Duffy, S. W., Hackshaw, A., Moss, S., Atkin, W., & Raine, R. 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. Published online December 8, 2015 http://dx.doi.org/10.1016/PII

2014

Smith, Kobayashi, Wolf, Raine, Wardle, von Wagner. The associations between objective numeracy and colorectal cancer screening knowledge, attitudes and defensive processing in a deprived community sample. Journal of Health Psychology. Published online before print December 14, 2014, doi: 10.1177/1359105314560919.

Smith SG, Raine R, Obichere A, Wolf MS, Wardle J, von Wagner C. The effect of a supplementary (‘gist-based’) information leaflet on colorectal cancer knowledge and screening intention: a randomized controlled trial. Journal of Behavioral Medicine, DOI 10.1007/s10865-014-9596-z

Palmer CK, Thomas MC, von Wagner C, Raine R. Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study. British Journal of Cancer. 2014 Apr 1;110(7):1705-11. doi: 10.1038/bjc.2014.125

2013

2012

2011

Presentations

2014

  • Smith S. Examining the effect of a ‘gist-based' colorectal cancer screening information leaflet: A multi-centre parallel randomised controlled trial. (Presentation) Society for Behavioural Medicine, Philadelphia, April 2014. *Awarded “Meritous Student Abstract”*
  • McGregor LM. The impact of narratives on beliefs about bowel cancer screening in England. (Presentation) Division of Health Psychology annual conference in York, September 2014.
  • Von Wagner C. Decision-making and participation in bowel cancer screening: Challenges and interventions for low health literate individuals (Symposium). (Presentation) 12th International Conference on Communication in Healthcare, Amsterdam, The Netherlands, September, 2014.
  • Thomas MC. Exploring reasons for low uptake of bowel cancer screening within South Asian communities in London. (Poster presentation) UK Society for Behavioural Medicine, Nottingham, December, 2014.

2013

Palmer CK. An overview of the ASCEND study and a focus on the qualitative work re focus groups with non-responders. (Presentation) Bowel Cancer Screening Programme health improvement team for Greater Manchester, Bolton 2013.

McGregor L. Psychologically informed public health campaigns – reducing the social gradient in bowel cancer screening. (Presentation) Cross-Professional Conference: Psychologically minded services and interventions in physical healthcare: new pathways to better patient outcomes, Belfast, March, 2013.

McGregor L. The psychological impact of a bowel cancer diagnosis through screening: an interpretative phenomenological analysis. (Poster) Division of Health Psychology annual conference, Brighton, September 2013. Awarded poster prize.

Smith S. Examining the effect of a brief (‘gist-based’) supplementary colorectal cancer screening information leaflet: A multi-centre parallel randomised controlled trial. (Poster presentation) UK Society for Behavioural Medicine, Oxford, Dec. 2013.

2012

Raine R. An overview and achievements to date of the ASCEND study. (Presentation) Bowel Cancer Screening Programme Southern Hub’s Conference, 2012, Guildford.

Palmer CK. Accounting for non-uptake of bowel cancer screening: a qualitative exploration. (Presentation) Society for Social Medicine, London, Sept 2012.

Smith S. Perceptions of the English NHS Bowel Cancer Screening Programme information materials: A Think-Aloud study. (Presentation* National Cancer Research Institute (NCRI) prize awarded to give this presentation) NCRI conference, Liverpool, 2012.

Smith S. Perceptions of the English NHS Bowel Cancer Screening Programme Information Materials: A Think-Aloud Study. (Presentation) UK Health Literacy Conference, Southampton, May 2012, and at the Division of Health Psychology Annual Conference, Liverpool, September 2012.

McGregor L. Narrative leaflet dissemination and feedback workshop. (Presentation) Institute for Social Marketing, University of Stirling, May 2012.

2011

Von Wagner C. Introduction to the ASCEND Study. (Presentation) London Quality Assurance Annual Bowel Cancer Screening Study Day, September 2011, and at the Bowel Cancer Screening Programme Southern Hub’s Annual Conference, in Guildford, November 2011.

     

Funding

The ASCEND study is funded by an NIHR Programme Grant for Applied Research.

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