Evidence-based Strategies to Reduce Socioeconomic Gradient of Uptake in NHS Bowel Cancer Screening Programme

Key Contextual Factors

• The NHS Bowel Cancer Screening Programme routinely invites all adults aged 60 to 74.   People from deprived backgrounds are likely to be struggling with multiple challenges, making it difficult to them to prioritise cancer screening.
• The research was co-designed with researchers (led by UCL, also QMUL, Imperial College London), The NHS Bowel Cancer Screening Programme Hub Directors and staff, GPs and patient representatives.

Key Components/Steps

• 18 focus groups were conducted with individuals eligible for screening and from a range of socio-economic backgrounds in London and South Yorkshire.
• Interviews were recorded, transcribed and analysed using thematic analysis.
• Four interventions were designed to increase the extent to which people from all social backgrounds could engage with the screening offer.
• The interventions aimed to: increase the credibility of the message source (GP Endorsement, GPE); provide a behavioural prompt to re-engage with the programme (Enhanced Reminder letter, ER); and simplify educational messages (‘gist’ and ’narrative’ interventions).
• The wording on the GP endorsement letter as well as the recruitment strategy to gain consent from GP practices had been developed together with a Primary Care Advisory Group. 
• The enhancement of the reminder was based on feedback from participants who had previously contributed to a focus group exploring reasons for non-uptake of bowel screening.
• Randomised mailed surveys were sent to screening naive individuals, to examine the impact of the Gist and narrative interventions on CRC screening knowledge attitudes and intention to complete screening and provided proof of principle for both interventions.
• Four separate two-arm, cluster-randomised controlled trials were conducted between 2012 and 2013 in individuals who were invited routinely by the BCSP in England.
• The trial design was a time-defined, cluster-randomisation to either the existing, standard invitation/information materials (usual care: control arm) or the standard materials supplemented with one of the intervention materials (intervention arms).
• The Enhanced Reminder showed a stronger increase in uptake in the most compared with the least deprived quintile.
• The Enhanced Reminder also had a modest but significant positive impact on overall uptake.
• The GP endorsement had a modest but significant positive impact on overall uptake but no effect on the socioeconomic gradient.
• The Gist and Narrative trials showed no effect on the SES gradient in uptake or overall uptake.

Main Impacts / Added Value

• Complete a screening test in England each year if the letter inviting them to take part was endorsed by their GP, and reminder letters included enhanced text reiterating the screening offer. 
• This higher take-up would allow an estimated 91 additional people who have bowel cancer being identified each year. It could also result in high or medium-risk polyps, (which might become cancerous), being detected in up to 245 additional people; this could potentially avoid them developing the disease by having them removed. 

Lessons Learned

• Co-designing interventions with key stakeholders from the NHS Bowel Cancer Screening Programme meant that successful strategies (e.g., enhanced reminder and GP endorsement) were implemented seamlessly.
• The modifications to the standard invitation and reminder letters incurred small set up costs with no additional running costs incurred per person invited to screening. Thus, although the interventions have a moderate effect on uptake amongst people from more deprived backgrounds, when introduced at the population level.
• Both modifications have remained in place despite the change from guaiac to immunochemical home-based stool test and resulting modifications to invitation materials.

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