Interventions to Improve Bowel Cancer Screening Uptake in Ireland: a 2x2 Factorial Trial

Study Overview
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Brief Summary
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High uptake is vital to population-based screening. BowelScreen (Irelands national organised population-based colorectal cancer screening programme) has not achieved recommended screening uptake targets. In Ireland sending the test kit in the screening invitation reminder may be an important strategy in targeting non-responders and would address a key difference between Ireland and other international screening programmes with higher uptake. In addition, few studies have focused on behavioural barriers to screening participation. Founded upon the MRC Guidelines for the Development of Complex Interventions, our systematic, theoretically-informed investigation of FIT screening participation has begun to identify behavioural antecedents to screening participation in Ireland. This study will implement a multilevel evidence-based, theoretically-informed intervention which includes the automatic inclusion of the test kit in the screening reminder, alone and in combination with an intervention to influence individuals' screening participation. This multilevel intervention will provide recommendations for the screening invitation delivery, potentially bringing the programme closer to recommended uptake targets (50%) and in the long-term influence reductions in bowel cancer incidence and mortality in Ireland.

Detailed Description
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To achieve population-level health gains, colorectal cancer screening programmes require high uptake. Guidelines recommend uptake of 65%-75%. In Ireland, faecal immunochemical test (FIT)-based screening uptake is considerably lower than this (around 40%), despite FIT being recommended as the screening test of choice given its potential to deliver higher uptake than other tests. As well as being suboptimal overall, uptake in Ireland is significantly lower among males and lower socioeconomic groups the very groups at higher underlying risk of colorectal cancer. While improving overall uptake is important, focus is also needed on reducing differentials in uptake; left unchecked these may lead to further disparities in health outcomes among those most at risk. The main difference between Ireland's screening programme and programmes with higher uptake is that BowelScreen does not send the test kit with the screening invitation: invitees are required to contact a call-centre, consent to participate and request the kit. Uptake in Ireland is 10-30% lower than Scotland, the Netherlands and England and, indeed, in a pilot screening programme in Dublin that also sent the test automatically. Internationally, various strategies to improve uptake have been tested. Some studies report increases using advance notification letters, postal mailing of home-based testing kits, and telephone contacts but many studies have been negative. Recent UK research points to potential in intervening among non-responders to the initial screening invitation, but few intervention studies have focussed on non-responders. An important limitation of existing studies is that most investigators failed to base their interventions on an understanding of what influences individuals' decisions about screening participation/non-participation. A range of barriers to uptake have been identified and include fatalism, poor knowledge, being poorly informed about cancer and screening and holding negative attitudes, beliefs and emotions towards FIT screening. Following the MRC Framework for the Development of Complex Interventions and being theoretically informed, this work has the explicit intention of informing future interventions. This proposal seeks to test efficacy in increasing uptake of two interventions among non responders: 1) including a test kit with the current reminder, and 2) an evidence-based and theoretically informed behavioural intervention (e.g. modified reminder letter, modified accompanying leaflet).

Official Title
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Interventions to Improve Bowel Cancer Screening Uptake in Ireland: a 2x2 Factorial Trial

Conditions
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Colorectal Cancer

Intervention / Treatment
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* Behavioral: Behaviorally enhanced reminder letter


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All new invitees of Irelands National BowelScreen Programme Individuals aged 60-64 Exclusion Criteria: All individuals who are within the screening age range of Irelands national bowel screening programme are eligible to be included.

Ages Eligible for Study
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Minimum Age: 60 Years
Maximum Age: 64 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Screening
Allocation: Non-Randomized
Intervention Model: Factorial Assignment
Interventional Model Description: This study is a 2x2 factorial design non-randomised control trial. This design will test main effects of each intervention and investigate whether the two interventions interact (25). Individuals between the ages of 60-62 (new invitees) will be sampled from invitees who do not respond to the initial screening invitation and allocated to one of four trial arms using batch randomisation. The four trial arms will be: Usual care - Standard reminder and no test kit Standard reminder plus test kit Theoretically informed behavioural intervention (modified reminder letter) at reminder and no test kit Theoretically informed behavioural intervention at reminder with test kit The main effect of the test kit is estimated by comparing 2+4 vs 1+3; main effect of behavioural intervention is estimated from 3+4 vs 1+2.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Usual care<br>Standard reminder letter only | |
| Experimental: Enhanced reminder letter only<br>Behaviorally enhanced reminder letter | Behavioral: Behaviorally enhanced reminder letter<br>* Behavioral interventions to increase FIT-based colorectal cancer screening uptake<br>* Other names: Behaviorally enhanced reminder letter and direct mailing of FIT kit;|
| Experimental: Usual care plus test kit<br>Standard reminder letter plus test kit | Behavioral: Behaviorally enhanced reminder letter<br>* Behavioral interventions to increase FIT-based colorectal cancer screening uptake<br>* Other names: Behaviorally enhanced reminder letter and direct mailing of FIT kit;|
| Experimental: Enhanced reminder plus test kit<br>Behaviorally enhanced reminder letter plus test kit | Behavioral: Behaviorally enhanced reminder letter<br>* Behavioral interventions to increase FIT-based colorectal cancer screening uptake<br>* Other names: Behaviorally enhanced reminder letter and direct mailing of FIT kit;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Uptake | Participation rate in each arm | 3 months from intervention delivery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Uptake by deprivation, sex and age | Participation rate in each arm by deprivation, sex and age | 3 months from intervention delivery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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colorectal cancer, Fecal Immunochemical test, cancer screening, Uptake, Participation