Title: STRATEGIES TO REDUCE THE SOCIAL GRADIENT IN BOWEL CANCER SCREENING: THE ASCEND PROJECT
Funder: Department of Health (England)

Abstract: AIM To 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). Background Bowel 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 Plans WS1: 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 Team The 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 Environment UCL, 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. Outputs a) Enhanced database for monitoring SE variation in screening uptake; b) development, evaluation & implementation of cost-effective interventions to reduce inequalities in screening uptake. Outcomes Reduction in SE inequalities in bowel cancer screening without reducing uptake in any SE group. Impact A 3% increase in average uptake (5% in the most deprived IMD quintile & 1% in the least) would result in 35175 more people being screened/yr (11366 in the most deprived quintile & 1932 in the least). National changes in service delivery will lead to improvements in survival & reduced inequalities. Public Involvement User applicant, user collaborators & charities (Beating Bowel Cancer, Age Concern, ContinYou) collaborated in proposal development. Together with User Panels, they will be involved in all WSs & particularly contribute to development of materials & dissemination. Justification for resources requested Reflects academic, NHS staff & user involvement required to develop, implement & evaluate interventions regionally & nationally.


Research activity codes: 4.4 POPULATION SCREENING
Health categories: CANCER AND NEOPLASMS