Pre-notification increases uptake in colorectal cancer screening:a randomised controlled trial

Gillian Libby, Jane Bray, Jennifer Champion, Linda Brownlee, Janice Birrell, Dermot

Gorman, Emilia Crighton, Callum Fraser, Robert Steele

Introduction

National programme of colorectal cancer screening using a guaiac faecal occult blood test (gFOBT) commenced in Scotland in 2007 Eligible participants sent a test kit by post to complete at home and return to a central laboratory for analysis

Uptake

2000-2007 A demonstration pilot of the screening programme in Scotland – uptake 54.4%

Potential benefit of the screening test to reduce mortality from colorectal cancer depends on the level of uptake

Increasing response rates

A Cochrane review of strategies to increase response rates to postal questionnaires found the odds of response were substantially higher using pre-notification (OR 1.5)

However, the English arm of the colorectal cancer screening pilot used a pre-notification letter but uptake was 51% after two rounds of the pilot

Aim

To test uptake of the screening test with

1. a pre-notification letter alone 2. pre-notification letter + information booklet 3. usual invitation (no pre-notification)

in

• screening population overall • first and subsequent rounds

by

• Gender• Age • Deprivation.

Method: Study Population

• The screening programme in 10 of the 14 health boards by April 2009

• One health board sent their own pre-notification letter and therefore did not take part in the study

The study population

• 59,953 eligible people from the nine health boards• sent a screening kit between 13/04/09 and 29/05/09. • Were followed for the return of their kit to 27/11/09.

Method: Intervention

Invitees were randomised to one of three groups

1. A pre-notification letter sent 2 wks ahead of gFOBT kit

2. A pre-notification letter and ‘Know the Facts’ booklet sent 2 wks ahead of gFOBT kit

3. Usual invitation as per the screening programme

Participants were not informed that they were taking part in a randomised study

Ethics approval obtained from Fife, Forth Valley and Tayside Research Ethics Service.

Method: Stats

Sample size 20,000 subjects in each group 3% - 5% change in uptake detectable in SIMD 1 to 580% power at the 5% signficance level

AnalysisChi-squared tests - compared uptakeLogistic regression - assessed impact of interventions independently of other factors that could influence uptake

Baseline Characteristics n(%)

Uptake

Uptake for men by age group

Uptake for women by age group

Uptake for men by deprivation

Uptake for women by deprivation

Logistic regression of predictors of uptake

Conclusions

• Pre-notification significantly increased uptake in a national programme of colorectal cancer screening using gFOBT.

• Increase was seen in all age groups, for both men and women and in all deprivation groups

• There was no statistically significant difference in the impact on uptake of the letter + booklet compared to the letter alone except for women in the most deprived group

Health Behaviour Models• Health Behaviour Change Model

Pre-notification moves individual a step along their pathway between no knowledge of screening and uptake of test

• Health Belief Model Cues to action will be successful. Receipt of a pre-notification letter, activates the preparedness of individuals to react ( participate) and that this reaction can be estimated in some measurable behaviour, (uptake)

Results consistent with both these proposed models of behaviour.

From research to practise…

Dear Colleagues  

I am pleased to advise that the PM PMG approved the IT changes required for the implementation of the pre-notification letter.  This will be delivered within the next release.  Dates to be confirmed. 

 Kind regardsTracey   Tracey Curtis Assistant Programme ManagerNational Services DivisionNHS National Services Scotland Gyle Square 1 South Gyle CrescentEdinburgh EH12 9EB