C von Wagner

Psychosocial Determinants of Socioeconomic Inequalities in Cancer Screening Participation: A Conceptual Framework

Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.

Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England.

Background:Introduction of organised, population-based, colorectal cancer screening in the United Kingdom using the faecal occult blood test (FOBT) has the potential to reduce overall colorectal cancer mortality. However, socio-economic variation in screening participation could exacerbate existing inequalities in mortality.Methods:This study examined FOBT uptake rates in London, England in relation to area-level socio-economic deprivation over the first 30 months of the programme during which 401 197 individuals were sent an FOBT kit. Uptake was defined as return of a completed test kit within 3 months. Area-level deprivation in each postcode sector was indexed with the Townsend Material Deprivation Index. Analyses controlled for area-level household mobility, ethnic diversity and poor health, each of which was associated with lower return rates.Results:The results showed a strong socio-economic gradient in FOBT uptake, which declined from 49% in the least deprived quintile of postcodes to 38% in the middle quintile and 32% in the most deprived quintile. Variation in socio-economic deprivation between sectors accounted for 62% of the variance in return rates, with little attenuation as a result of controlling for ethnic diversity, household mobility or health status.Conclusion:These results highlight the need to understand the causes of socio-economic gradients in screening participation and address barriers that could otherwise increase disparities in colorectal cancer survival.

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

Background:Screening for bowel cancer using the guaiac faecal occult blood test offered by the NHS Bowel Cancer Screening Programme (BCSP) is taken up by 54% of the eligible population. Uptake ranges from 35% in the most to 61% in the least deprived areas. This study explores reasons for non-uptake of bowel cancer screening, and examines reasons for subsequent uptake among participants who had initially not taken part in screening.Methods:Focus groups with a socio-economically diverse sample of participants were used to explore participants’ experience of invitation to and non-uptake of bowel cancer screening.Results:Participants described sampling faeces and storing faecal samples as broaching a cultural taboo, and causing shame. Completion of the test kit within the home rather than a formal health setting was considered unsettling and reduced perceived importance. Not knowing screening results was reported to be preferable to the implications of a positive screening result. Feeling well was associated with low perceived relevance of screening. Talking about bowel cancer screening with family and peers emerged as the key to subsequent participation in screening.Conclusions:Initiatives to normalise discussion about bowel cancer screening, to link the BCSP to general practice, and to simplify the test itself may lead to increased uptake across all social groups.

Patient experiences of colonoscopy, barium enema and CT colonography: a qualitative study

Previous studies of patient experience with bowel screening tests, in particular CT colonography (CTC), have superimposed global rating scales and not explored individual experience in detail. To redress this, we performed qualitative interviews in order to characterize patient expectations and experiences in depth. Following ethical permission, 16 patients undergoing CTC, 18 undergoing colonoscopy and 15 undergoing barium enema agreed to a semi-structured interview by a health psychologist. Interviews were recorded, responses transcribed and themes extracted with the aim of assimilating individual experiences to facilitate subsequent development and interpretation of quantitative surveys of overall satisfaction with each diagnostic test. Transcript analysis identified three principal themes: physical sensations, social interactions and information provision. Physical sensations differed for each test but were surprisingly well tolerated overall. Social interactions with staff were perceived as very important in colouring the whole experience, particularly in controlling the feelings of embarrassment, which was critical for all procedures. Information provision was also an important determinant of experience. Verbal feedback was most common during colonoscopy and invariably reassuring. However, patients undergoing CTC received little visual or verbal feedback and were often confused regarding the test outcome. Barium enema had no specific advantage over other tests. Qualitative interviews provided important perspectives on patient experience. Our data demonstrated that models describing the quality of medical encounters are applicable to single diagnostic episodes. Staff interactions and information provision were particularly important. We found advantages specific to both CTC and colonoscopy but none for barium enema. CTC could benefit greatly from improved information provision following examination.

Socioeconomic inequalities in colorectal cancer screening uptake: does time perspective play a role?

OBJECTIVE This study examined the role of time perspective in explaining inequalities in colorectal cancer screening attendance. We tested a path model predicting that (a) socioeconomic status (SES) would be associated with consideration of future consequences (CFC), (b) CFC would be associated with perceived benefits/barriers, and (c) barriers and benefits would be associated longitudinally with screening attendance. METHOD Data for these analyses came from the control arm (n = 809) of an intervention to increase screening uptake. Participants between 55 and 64 years were offered screening as part of the U.K. Flexible Sigmoidoscopy (FS) Trial. They completed a questionnaire that included demographic and psychological variables. Subsequent screening attendance was recorded. RESULTS There was clear evidence of SES differences in attendance, with 56% in the most deprived tertile attending their FS appointment, compared with 68% in the middle tertile and 71% in the least deprived tertile (p < .01). Lower SES was associated with lower CFC, higher perceived barriers, and lower perceived benefits (p < .05 for all). Higher CFC, higher perceived benefits, and lower perceived barriers were associated with attendance (p < .01 for all). CFC mediated the association between SES and perceived benefits/barriers, while perceived benefits/barriers mediated the association between CFC and attendance. CONCLUSION SES differences in CFC contribute to SES differences in the perceived barriers and benefits of screening, which, in turn, contribute to differences in attendance. Interventions that take CFC into account, for example, by emphasizing short-term benefits, could promote equality in screening participation.

Socioeconomic variation in uptake of colonoscopy following a positive faecal occult blood test result: a retrospective analysis of the NHS Bowel Cancer Screening Programme

Background:Bowel cancer is a serious health burden and its early diagnosis improves survival. The Bowel Cancer Screening Programme (BCSP) in England screens with the Faecal Occult Blood test (FOBt), followed by colonoscopy for individuals with a positive test result. Socioeconomic inequalities have been demonstrated for FOBt uptake, but it is not known whether they persist at the next stage of the screening pathway. The aim of this study was to assess the association between colonoscopy uptake and area socioeconomic deprivation, controlling for individual age and sex, and area ethnic diversity, population density, poor self-assessed health, and region.Methods:Logistic regression analysis of colonoscopy uptake using BCSP data for England between 2006 and 2009 for 24 180 adults aged between 60 and 69 years.Results:Overall colonoscopy uptake was 88.4%. Statistically significant variation in uptake is found between quintiles of area deprivation (ranging from 86.4 to 89.5%), as well as age and sex groups (87.9–89.1%), quintiles of poor self-assessed health (87.5–89.5%), non-white ethnicity (84.6–90.6%) and population density (87.9–89.3%), and geographical regions (86.4–90%).Conclusion:Colonoscopy uptake is high. The variation in uptake by socioeconomic deprivation is small, as is variation by subgroups of age and sex, poor self-assessed health, ethnic diversity, population density, and region.

Communication about colorectal cancer screening in Britain: public preferences for an expert recommendation

Background:Informed decision-making approaches to cancer screening emphasise the importance of decisions being determined by individuals’ own values and preferences. However, advice from a trusted source may also contribute to autonomous decision-making. This study examined preferences regarding a recommendation from the NHS and information provision in the context of colorectal cancer (CRC) screening.Methods:In face-to-face interviews, a population-based sample of adults across Britain (n=1964; age 50–80 years) indicated their preference between: (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision. Other measures included trust in the NHS and preferences for information on benefits and risks.Results:Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%). Men were more in favour of a recommendation than women (86% vs 81%). Trust in the NHS was high overall, but the minority who expressed low trust were less likely to want a recommendation.Conclusion:Most British adults want full information on risks and benefits of screening but they also want a recommendation from an authoritative source. An ‘expert’ view may be an important part of autonomous health decision-making.

Detection of Extracolonic Pathologic Findings with CT Colonography: A Discrete Choice Experiment of Perceived Benefits versus Harms

PURPOSE To determine the maximum rate of false-positive diagnoses that patients and health care professionals were willing to accept in exchange for detection of extracolonic malignancy by using computed tomographic (CT) colonography for colorectal cancer screening. MATERIALS AND METHODS After obtaining ethical approval and informed consent, 52 patients and 50 health care professionals undertook two discrete choice experiments where they chose between unrestricted CT colonography that examined intra- and extracolonic organs or CT colonography restricted to the colon, across different scenarios. The first experiment detected one extracolonic malignancy per 600 cases with a false-positive rate varying across scenarios from 0% to 99.8%. One experiment examined radiologic follow-up generated by false-positive diagnoses while the other examined invasive follow-up. Intracolonic performance was identical for both tests. The median tipping point (maximum acceptable false-positive rate for extracolonic findings) was calculated overall and for both groups by bootstrap analysis. RESULTS The median tipping point for radiologic follow-up occurred at a false-positive rate greater than 99.8% (interquartile ratio [IQR], 10 to >99.8%). Participants would tolerate at least a 99.8% rate of unnecessary radiologic tests to detect an additional extracolonic malignancy. The median tipping-point for invasive follow-up occurred at a false-positive rate of 10% (IQR, 2 to >99.8%). Tipping points were significantly higher for patients than for health care professionals for both experiments (>99.8 vs 40% for radiologic follow-up and >99.8 vs 5% for invasive follow-up, both P < .001). CONCLUSION Patients and health care professionals are willing to tolerate high rates of false-positive diagnoses with CT colonography in exchange for diagnosis of extracolonic malignancy. The actual specificity of screening CT colonography for extracolonic findings in clinical practice is likely to be highly acceptable to both patients and health care professionals. Online supplemental material is available for this article.

Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening

Background:There is a socioeconomic gradient in the uptake of screening in the English NHS Bowel Cancer Screening Programme (BCSP), potentially leading to inequalities in outcomes. We tested whether endorsement of bowel cancer screening by an individual’s general practice (GP endorsement; GPE) reduced this gradient.Methods:A cluster-randomised controlled trial. Over 20 days, individuals eligible for screening in England from 6480 participating general practices were randomly allocated to receive a GP-endorsed or the standard invitation letter. The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation.Results:We enrolled 265 434 individuals. Uptake was 58.2% in the intervention arm and 57.5% in the control arm. After adjusting for age, sex, hub and screening episode, GPE increased the overall odds of uptake (OR=1.07, 95% CI 1.04–1.10), but did not affect its socioeconomic gradient. We estimated that implementing GPE could result in up to 165 more people with high or intermediate risk colorectal adenomas and 61 cancers detected, and a small one-off cost to modify the standard invitation (£78 000).Conclusions:Although GPE did not improve its socioeconomic gradient, it offers a low-cost approach to enhancing overall screening uptake within the NHS BCSP.

Patients' & Healthcare Professionals' Values Regarding True- & False-Positive Diagnosis when Colorectal Cancer Screening by CT Colonography: Discrete Choice Experiment

Purpose To establish the relative weighting given by patients and healthcare professionals to gains in diagnostic sensitivity versus loss of specificity when using CT colonography (CTC) for colorectal cancer screening. Materials and Methods Following ethical approval and informed consent, 75 patients and 50 healthcare professionals undertook a discrete choice experiment in which they chose between “standard” CTC and “enhanced” CTC that raised diagnostic sensitivity 10% for either cancer or polyps in exchange for varying levels of specificity. We established the relative increase in false-positive diagnoses participants traded for an increase in true-positive diagnoses. Results Data from 122 participants were analysed. There were 30 (25%) non-traders for the cancer scenario and 20 (16%) for the polyp scenario. For cancer, the 10% gain in sensitivity was traded up to a median 45% (IQR 25 to >85) drop in specificity, equating to 2250 (IQR 1250 to >4250) additional false-positives per additional true-positive cancer, at 0.2% prevalence. For polyps, the figure was 15% (IQR 7.5 to 55), equating to 6 (IQR 3 to 22) additional false-positives per additional true-positive polyp, at 25% prevalence. Tipping points were significantly higher for patients than professionals for both cancer (85 vs 25, p<0.001) and polyps (55 vs 15, p<0.001). Patients were willing to pay significantly more for increased sensitivity for cancer (p = 0.021). Conclusion When screening for colorectal cancer, patients and professionals believe gains in true-positive diagnoses are worth much more than the negative consequences of a corresponding rise in false-positives. Evaluation of screening tests should account for this.