Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trial

Background: Bowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes. Objective: To reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group. Design: Workstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention. Methods: Interventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome. Results: The gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; all p-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10; p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20; p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06; p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11; p = 0.001). All interventions were inexpensive to provide. Limitations: In line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect. Conclusions: Enhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information. Future work: Socioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated. Trial registration: Current Controlled Trials ISRCTN74121020. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information

What is the state of the art in energy and transport poverty metrics? A critical and comprehensive review

This review investigates the state of the art in metrics used in energy (or fuel) and transport poverty with a view to assessing how these overlapping concepts may be unified in their measurement. Our review contributes to ongoing debates over decarbonisation, a politically sensitive and crucial aspect of the energy transition, and one that could exacerbate patterns of inequality or vulnerability. Up to 125 million people across the European Union experience the effects of energy poverty in their daily lives. A more comprehensive understanding of the breadth and depth of these conditions is therefore paramount. This review assessed 1,134 articles and critically analysed a deeper sample of 93. In terms of the use of metrics, we find that multiple indicators are better than any single metric or composite. We find work remains to be conducted in the transport poverty sphere before energy poverty metrics can be fully unified with those of transport poverty, namely the stipulation of travel standards. Without such standards, our ability to unify the metrics of both fields and potentially alleviate both conditions simultaneously is limited. The difficulties in defining necessary travel necessitate the further use of vulnerability lenses and holistic assessments focused on energy and transport services

CRC CancerStats Large bowel - UK

SIGLEAvailable from British Library Document Supply Centre-DSC:99/41169 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Lung cancer and smoking - UK

Replaces Factsheet no. 11/1992SIGLEGBUnited Kingdo

CRC cancer stats Survival: England and Wales 1971-1995

SIGLEAvailable from British Library Document Supply Centre-DSC:m01/15748 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Spcial children Special needs; a summary report

Report of a survey carried out by ASH (Action on Smoking and Health) Scotland and funded by the Cancer Research CampaignAvailable from British Library Document Supply Centre-DSC:98/14810 / BLDSC - British Library Document Supply CentreSIGLEGBUnited Kingdo

Annual report 1990

Incorporates the 1991 handbookSIGLEAvailable from British Library Document Supply Centre- DSC:1137.4(1990) / BLDSC - British Library Document Supply CentreGBUnited Kingdo