A third fewer people in England’s most deprived areas return their bowel cancer screening kits compared with those in the wealthiest areas, and this project will test four strategies to close that gap. Bowel cancer is the UK’s second most common cause of cancer death, and screening reduces mortality. Yet overall uptake sits at just 53%, dropping from 61% in the least deprived areas to 35% in the most deprived. The researchers will first identify which socioeconomic factors best explain these local variations. They will then develop and pilot four interventions: a simplified “gist” leaflet, a narrative leaflet, a GP endorsement on the invitation, and a second reminder for non-responders. Each will be tested individually in randomised controlled trials across the NHS Bowel Cancer Screening Programme hubs, then the most effective combination will be trialled nationally. If successful, the project could produce a cost-effective, evidence-based package that reduces the social gradient in screening without lowering uptake in any group. That would mean fewer late-stage diagnoses and fewer deaths from bowel cancer in the communities that currently benefit least from the programme.
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AIMTo reduce socioeconomic (SE) inequalities in bowel cancer screening uptake. OBJECTIVES To reduce SE inequalities in screening uptake without compromising uptake in any SE group, we will:1. Identify the SE variables that best explain small area level variations in screening uptake (Workstream [WS]1)2. Quantify SE inequality in screening uptake prior to the introduction of interventions to reduce inequalities (WS1)3. Monitor inequalities in uptake & uptake rates regionally & nationally throughout the study period (WS1)4. Develop & test 4 theoretically-based interventions to reduce the SE gradient in screening uptake (WS2)5. Use a randomised controlled trial (RCT) design to evaluate the effectiveness & cost effectiveness of each individual intervention within the NHS Bowel Cancer Screening Programme (BCSP) (WS3)6. Develop a complex intervention based on the best combination of the single interventions & investigate its effectiveness & cost-effectiveness in a national RCT across all 5 BCSP Hubs (WS4).BackgroundBowel cancer is the 2nd most common cause of cancer death in the UK. Population-based screening reduces mortality. In England 5 regional Hubs co-ordinate screening, using the faecal occult blood test (FOBt), to adults aged 60-69 & eventually to those aged up to 74. Screening uptake is 53%, but it varies from 61% to 35% in the least to most deprived areas respectively. This research will devise & evaluate strategies to reduce the SE gradient in uptake without compromising uptake in any SE group.Research PlansWS1: Identify the SE variables that best explain small area level variations in screening uptake, monitor SE inequalities in uptake & assess uptake trends.WS2: Develop & pilot 4 interventions designed to reduce inequalities. Two interventions will be based on the provision of additional information about the screening test (to supplement the existing leaflet) in forms that are associated with increased salience & comprehension in lower SE groups. These are a 'gist' & a 'narrative' information leaflet. One intervention will improve the credibility of the source (GP endorsement of screening invitation) & one will tackle practical & motivational barriers to participation (2nd reminder). Patient representatives, a User Panel & Hub staff will play a role in development. New materials will be pre-tested for impact on intentions using mixed SE, age-appropriate groups.WS3: Study 1 will comprise 4 RCTs of each of the 4 individual interventions against usual practice; tested in 2, 3 or 5 Hubs. Sample size is based on: a) reduced SE gradient in uptake & b) no reduction in uptake in any SE Group. We estimate an average effect size of 3% (5% increase in the most deprived Index of Multiple Deprivation (IMD) quintile & 1% in the least deprived). Each trial will have 13500 participants per arm (feasible as each Hub sends 25000–78000 invitations/month). Study 2 is a national survey of PCTs to ascertain usual practice & identify interventions planned or implemented.WS4: National RCT of a complex intervention combining the individual interventions that reduce the SE gradient in uptake without decreasing uptake in any group. We will also consider feasibility & the incremental cost of each intervention compared with usual practice. There are 6 possible options for the national evaluation depending on the results of WS3. Sample size: n=47300 per arm.Research TeamThe team includes Directors of the 5 English bowel cancer screening Hubs, NHS managers, users, & international experts in cancer screening trials, health psychology, bowel cancer epidemiology, health economics & health care inequalities.Research EnvironmentUCL, ICL & Barts are leading health research institutions (UCL & ICL rated 4th & 5th in international rankings); there is a strong PPI ethos based upon previous successful collaborations; NHS applicants work in research active environments.Outputsa) Enhanced database for monitoring SE variation in screening uptake; b) development
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