Kathryn A. Robb

Public awareness of cancer in Britain: a population-based survey of adults

Objective:To assess public awareness of cancer warning signs, anticipated delay and perceived barriers to seeking medical advice in the British population.Methods:We carried out a population-based survey using face-to-face, computer-assisted interviews to administer the cancer awareness measure (CAM), a newly developed, validated measure of cancer awareness. The sample included 2216 adults (970 males and 1246 females) recruited as part of the Office for National Statistics Opinions Survey using stratified probability sampling.Results:Awareness of cancer warning signs was low when open-ended (recall) questions were used and higher with closed (recognition) questions; but on either measure, awareness was lower in those who were male, younger, and from lower socio-economic status (SES) groups or ethnic minorities. The most commonly endorsed barriers to help seeking were difficulty making an appointment, worry about wasting the doctors time and worry about what would be found. Emotional barriers were more prominent in lower SES groups and practical barriers (e.g. too busy) more prominent in higher SES groups. Anticipated delay was lower in ethnic minority and lower SES groups. In multivariate analysis, higher symptom awareness was associated with lower anticipated delay, and more barriers with greater anticipated delay.Conclusions:A combination of public education about symptoms and empowerment to seek medical advice, as well as support at primary care level, could enhance early presentation and improve cancer outcomes.

Interventions to promote cancer awareness and early presentation: Systematic review

Background:Low cancer awareness contributes to delay in presentation for cancer symptoms and may lead to delay in cancer diagnosis. The aim of this study was to review the evidence for the effectiveness of interventions to raise cancer awareness and promote early presentation in cancer to inform policy and future research.Methods:We searched bibliographic databases and reference lists for randomised controlled trials of interventions delivered to individuals, and controlled or uncontrolled studies of interventions delivered to communities.Results:We found some evidence that interventions delivered to individuals modestly increase cancer awareness in the short term and insufficient evidence that they promote early presentation. We found limited evidence that public education campaigns reduce stage at presentation of breast cancer, malignant melanoma and retinoblastoma.Conclusions:Interventions delivered to individuals may increase cancer awareness. Interventions delivered to communities may promote cancer awareness and early presentation, although the evidence is limited.

Development of a measurement tool to assess public awareness of cancer.

Objective:We aimed to develop and validate a measurement tool to assess cancer awareness in the general population: the cancer awareness measure (CAM).Methods:Items assessing awareness of cancer warning signs, risk factors, incidence, screening programmes and attitudes towards help seeking were extracted from the literature or generated by expert groups. To determine reliability, the CAM was administered to a university participant panel (n=148), with a sub-sample (n=94) completing it again 2 weeks later. To establish construct validity, CAM scores of cancer experts (n=12) were compared with those of non-medical academics (n=21). Finally, university students (n=49) were randomly assigned to read either a cancer information leaflet or a leaflet with control information before completing the measure, to ensure the CAM was sensitive to change.Results:Cognitive interviewing indicated that the CAM was being interpreted as intended. Internal reliability (Cronbachs α=0.77) and test–retest reliability (r=0.81) were high. Scores for cancer experts were significantly higher than those for non-medical academics (t(31)=6.8, P<0.001). CAM scores were higher among students who received an intervention leaflet than the control leaflet (t(47)=4.8, P<0.001).Conclusions:These studies show the psychometric properties of the CAM and support its validity as a measure of cancer awareness in the general population.

Patient delay in presentation of possible cancer symptoms: the contribution of knowledge and attitudes in a population sample from the United kingdom.

Background: Qualitative studies implicate knowledge of cancer symptoms and attitudes towards help-seeking as important factors in patient delay. The present study uses quantitative data from a population-based survey to test the hypotheses that (a) a greater knowledge of early cancer symptoms is associated with a higher likelihood of having appraised a symptom as possibly due to cancer, and (b) more negative attitudes towards help-seeking are associated with a lower likelihood of having sought medical advice for that symptom. Methods: Two thousand and seventy-one adults were asked whether they had experienced a symptom that they worried might be cancer in the past 3 months, and if so, whether they had seen a doctor. Respondents also completed the Cancer Awareness Measure (CAM) assessing symptom knowledge and barriers to help-seeking. Results: Two hundred and thirty-six (11.4%) respondents reported having experienced a possible cancer symptom. In logistic regression analyses controlling for age, sex, and self-rated health, higher CAM symptom knowledge scores were associated with a greater likelihood of having experienced a possible cancer symptom (odds ratio = 1.09; 95% confidence interval, 1.01-1.17). Of those who had experienced a symptom, 75% (177/236) had seen a doctor. Higher scores on the CAM barriers scale were associated with being less likely to have seen a doctor (odds ratio, 0.74; 95% confidence interval, 0.63-0.87). Conclusions: Better knowledge of the signs and symptoms of cancer might help people recognize possible cancer symptoms and therefore reduce appraisal delay, whereas more positive attitudes towards help-seeking might reduce behavioral delay. Impact: Campaigns to educate the public about cancer symptoms and reduce help-seeking barriers could play a role in promoting early diagnosis. Cancer Epidemiol Biomarkers Prev; 19(9); 2272–7. ©2010 AACR.

Awareness of cancer symptoms and anticipated help seeking among ethnic minority groups in England

Objective:Little is known about ethnic differences in awareness of cancer-warning signs or help-seeking behaviour in Britain. As part of the National Awareness and Early Diagnosis Initiative (NAEDI), this study aimed to explore these factors as possible contributors to delay in cancer diagnosis.Methods:We used quota sampling to recruit 1500 men and women from the six largest minority ethnic groups in England (Indian, Pakistani, Bangladeshi, Caribbean, African and Chinese). In face-to-face interviews, participants completed the newly developed cancer awareness measure (CAM), which includes questions about warning signs for cancer, speed of consultation for possible cancer symptoms and barriers to help seeking.Results:Awareness of warning signs was low across all ethnic groups, especially using the open-ended (recall) question format, with lowest awareness in the African group. Women identified more emotional barriers and men more practical barriers to help seeking, with considerable ethnic variation. Anticipated delay in help seeking was higher in individuals who identified fewer warning signs and more barriers.Conclusions:The study suggests the need for culturally sensitive, community-based interventions to raise awareness and encourage early presentation.

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.

Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study:

Objectives Evidence from existing UK screening programmes indicates disparities in uptake rates between UK ethnic minorities and the white majority population. The aim of this study was to explore barriers to the uptake of flexible sigmoidoscopy (FS) screening among UK ethnic minority populations. Specifically, beliefs about bowel cancer, perceived barriers to the test and ideas about ways to increase uptake were investigated. Methods Nine focus groups were conducted with a total of 53 participants from African-Caribbean, Gujarati Indian, Pakistani and white British communities. The topic guide was based on the Health Belief Model. Discussions were subject to framework analysis. Results Most participants expressed limited awareness of bowel cancer and cited this as a barrier to screening attendance. Anxiety regarding the invasiveness of the test, the bowel preparation and fear of a cancer diagnosis were common barriers across all ethnic groups. Language difficulties, failure to meet religious sensitivities and the expression of culturally influenced health beliefs were all discussed as specific barriers to uptake. Ethnically tailored health promotion and general practitioner involvement were recommended as ways of overcoming such barriers. Conclusions The study was the first attempt to qualitatively explore barriers to FS bowel cancer screening in UK ethnic minorities. Most barriers were shared by all ethnic groups but health educators should supplement approaches designed for the majority to incorporate the specific needs of individual minority groups to ensure equitable access.

Ethnic disparities in knowledge of cancer screening programmes in the UK

Objective The aim of the study was to examine awareness of the three National Cancer Screening Programmes (breast, cervical, bowel) among white and ethnic minority groups in the UK. Setting Data were from two surveys in which the screening questions were added: (i) the Office of National Statistics (ONS) Opinions Survey, carried out in September and October 2008; and (ii) the EthnibusTM survey of the main ethnic minority groups in England, conducted in October and November 2008. Methods The ONS sample consisted of 2216 adults selected using stratified probability sampling to obtain a population-representative sample. The EthnibusTM sample was obtained by quota sampling and included 1500 adults from the six largest ethnic minority groups in England (Indian, Pakistani, Bangladeshi, Caribbean, African and Chinese). Participants completed questions on awareness of cancer screening programmes as part of the wider Cancer Awareness Measure (CAM) in home-based, face-to-face interviews. Results Awareness of breast and cervical cancer screening was high in the white ONS participants (89% breast and 84% cervical), lower in the ONS ethnic minority sample (74% for both breast and cervical) and lowest in the EthnibusTM sample (69% breast and 66% cervical). Ethnic disparities persisted after controlling for age, gender and occupational group. In both groups, knowledge of breast and cervical screening was lower among men and more socioeconomically deprived groups. Awareness of the new bowel cancer screening programme was less than 30% in both white and ethnic minority groups. Conclusions Ethnic disparities in knowledge of breast and cervical cancer screening should be addressed. Strategies to engage ethnic minority and socioeconomically deprived groups in bowel cancer screening should be instigated to avoid the emergence of disparities.

Ethnic differences in participation in flexible sigmoidoscopy screening in the UK

Objectives The aim of the study was to examine ethnic differences in participation in colorectal cancer screening by flexible sigmoidoscopy (FS). It assessed both intentions to be screened and actual screening uptake, and considered whether demographic, health and psychosocial factors mediated the ethnic differences. The setting of this study follows a subset of participants from the UK FS Trial. Methods A postal questionnaire assessed ethnicity, demographic characteristics, health, attitudes to screening and FS screening intentions. Data on screening intentions were available for 17,333 adults aged 55–64 years (Sample 1). Screening uptake was recorded in a subsample of 4303 respondents who were subsequently randomized to receive an invitation to screening (Sample 2). Results Screening intentions in Sample 1 were equally high across all the ethnic groups (>80% [13,724/17,042] reported they were interested). In contrast, attendance (Sample 2) was considerably lower among Asians (54% [43/79]) compared with White (69% [2843/4123]) or Black (80% [33/41]) respondents. Multivariate analysis showed that potential explanatory factors, including socioeconomic deprivation, poor health and fearful and fatalistic attitudes did not account for the lower screening attendance among Asians. Conclusion Further research is required to identify explanations for the gap between intentions and behaviour in UK Asians if any future FS screening programme is to be introduced equitably.

Flexible Sigmoidoscopy Screening for Colorectal Cancer: Uptake in a Population-based Pilot Programme:

Objective The aim of this study was is to examine uptake of population-based, flexible sigmoidoscopy (FS) screening delivered by nurses in a socioeconomically and ethnically diverse area of London, England. Methods All adults aged 58 and 59 years registered at 34 general practices in North London (n = 2260) were mailed an invitation to attend FS screening at the local hospital. Results In total, 45% (1024/2260) accepted the invitation and attended, 5% (114/2260) accepted the invitation but failed to attend, 5% (111/2260) accepted the invitation but were unable to attend within the time-frame of the pilot study, 7% (165/2260) declined the offer, 27% (602/2260) did not respond, and 11% (244/2260) were ineligible or did not receive the invitation. Among those eligible to be screened, the uptake rate was 51% (1024/2016). Uptake did not differ by gender, but people living in the most affluent quintile of areas had a substantially higher uptake rate (63%) than those living in the most deprived quintile (38%). Conclusion Uptake of FS screening delivered as a population-based programme was over 50% among the eligible population in a socioeconomically and ethnically diverse area of London. Disparities in uptake should be addressed to avoid exacerbating health inequalities.