Comparing the effectiveness and cost-effectiveness of text-message reminders and telephone patient navigation to improve the uptake of faecal immunochemical test screening among non-responders in London: a randomised controlled trial protocol.

INTRODUCTION: Participation in bowel cancer screening is lower in regions where there is high ethnic diversity and/or socioeconomic deprivation. Interventions, such as text message reminders and patient navigation (PN), have the potential to increase participation in these areas. As such, there is interest in the comparative effectiveness of these interventions to increase bowel cancer screening participation, as well as their relative cost-effectiveness. METHODS AND ANALYSIS: This study will use a three-arm randomised controlled trial design to compare the effectiveness and cost-effectiveness of text message reminders and PN to increase the uptake of bowel cancer screening in London. Participants will be individuals who have not returned a completed faecal immunochemical test kit within 13 weeks of receiving a routine invitation from the London bowel cancer screening hub. Participants will be randomised (in a 1:1:1 ratio) to receive either (1) usual care (ie, 'no intervention'), (2) a text message reminder at 13 weeks, followed by repeated text message reminders at 15, 17 and 19 weeks (in the event of non-response) or (3) a text message reminder at 13 weeks, followed by PN telephone calls at 15, 17 and 19 weeks in the event of non-response. The primary endpoint will be participation in bowel cancer screening, defined as 'the return of a completed kit by week 24'. Statistical analysis will use multivariate logistic regression and will incorporate pairwise comparisons of all three groups, adjusted for multiple testing. ETHICS AND DISSEMINATION: Approvals to conduct the research have been obtained from University College London's Joint Research Office (Ref: 150666), the Screening Research, Innovation and Development Advisory Committee ('RIDAC', Ref: 2223 014 BCSP Kerrison), the Health Research Authority (Ref: 22/WM/0212) and the Confidentiality Advisory Group (Ref: 22/CAG/0140). Results will be conveyed to stakeholders, notably those managing the screening programme and published in peer-reviewed journals/presented at academic conferences. TRIAL REGISTRATION NUMBER: ISRCTN17245519.

Testing Behavioral Messages to Increase Recruitment to Health Research When Embedded Within Social Media Campaigns on Twitter: Web-Based Experimental Study.

BACKGROUND: Social media is rapidly becoming the primary source to disseminate invitations to the public to consider taking part in research studies. There is, however, little information on how the contents of the advertisement can be communicated to facilitate engagement and subsequently promote intentions to participate in research. OBJECTIVE: This paper describes an experimental study that tested different behavioral messages for recruiting study participants for a real-life observational case-control study. METHODS: We included 1060 women in a web-based experiment and randomized them to 1 of 3 experimental conditions: standard advertisement (n=360), patient endorsement advertisement (n=345), and social norms advertisement (n=355). After seeing 1 of the 3 advertisements, participants were asked to state (1) their intention to take part in the advertised case-control study, (2) the ease of understanding the message and study aims, and (3) their willingness to be redirected to the website of the case-control study after completing the survey. Individuals were further asked to suggest ways to improve the messages. Intentions were compared between groups using ordinal logistic regression, reported in percentages, adjusted odds ratio (aOR), and 95% CIs. RESULTS: Those who were in the patient endorsement and social norms-based advertisement groups had significantly lower intentions to take part in the advertised study compared with those in the standard advertisement group (aOR 0.73, 95% CI 0.55-0.97; P=.03 and aOR 0.69, 95% CI 0.52-0.92; P=.009, respectively). The patient endorsement advertisement was perceived to be more difficult to understand (aOR 0.65, 95% CI 0.48-0.87; P=.004) and to communicate the study aims less clearly (aOR 0.72, 95% CI 0.55-0.95; P=.01). While the patient endorsement advertisement had no impact on intention to visit the main study website, the social norms advertisement decreased willingness compared with the standard advertisement group (157/355, 44.2% vs 191/360, 53.1%; aOR 0.74, 95% CI 0.54-0.99; P=.02). The majority of participants (395/609, 64.8%) stated that the messages did not require changes, but some preferred clearer (75/609, 12.3%) and shorter (59/609, 9.7%) messages. CONCLUSIONS: The results of this study indicate that adding normative behavioral messages to simulated tweets decreased participant intention to take part in our web-based case-control study, as this made the tweet harder to understand. This suggests that simple messages should be used for participant recruitment through Twitter (subsequently rebranded X).

Patients' experience of using colonoscopy as a diagnostic test after a positive FOBT/FIT: a systematic review of the quantitative literature.

OBJECTIVES: Faecal occult blood testing (FOBT) and faecal immunochemical testing (FIT) are among the most used screening modalities for colorectal cancer (CRC). Colonoscopy is also widely used as a screening and diagnostic test for adults with a positive FOBT/FIT. Patient experience of colonoscopy is an important component for most CRC screening programmes. Individuals with negative experiences are less likely to engage with colonoscopy in the future and can deter others from attending colonoscopy when invited. This review synthesised data on patient experience with colonoscopy, following a positive result, to provide insights into how to improve patient experience within the English Bowel Cancer Screening Programme. METHODS: MEDLINE, EMBASE and PsycINFO were searched for quantitative questionnaire studies evaluating patient-reported experience with colonoscopy, following a positive screening FOB/FIT result. The search was limited to studies published between 2000 and 2021 (ie, when the first FOBT/FIT screening programmes for CRC were introduced). Data-driven and narrative summary techniques were used to summarise the literature. RESULTS: In total, six studies from the UK (n=4), Spain (n=1) and the Netherlands (n=1) were included in the review (total participants: 152 329; response rate: 68.0-79.3%). Patient experiences were categorised into three 'stages': 'pre-colonoscopy', 'during the test' and 'post-colonoscopy'. Overall, patients reported a positive experience in all six studies. Bowel preparation was the most frequently endorsed issue experienced pre-test (experienced by 10.0-41.0% of individuals, across all studies), pain and discomfort for during the test (experienced by 10.0-21.0% of participants) and abdominal pain and discomfort after the test (these were experienced by 14.8-22% of patients). CONCLUSION: This review highlighted that patient-reported experiences associated with colonoscopy were generally positive. To improve the colonoscopy experience, bowel screening centres should investigate means to: make bowel preparation more acceptable, make colonoscopy less painful and reduce post-colonoscopy symptoms.

Inequalities in cancer screening participation between adults with and without severe mental illness: results from a cross-sectional analysis of primary care data on English Screening Programmes.

BACKGROUND: People with severe mental illness (SMI) are 2.5 times more likely to die prematurely from cancer in England. Lower participation in screening may be a contributing factor. METHODS: Clinical Practice Research Datalink data for 1.71 million, 1.34 million and 2.50 million adults were assessed (using multivariate logistic regression) for possible associations between SMI and participation in bowel, breast and cervical screening, respectively. RESULTS: Screening participation was lower among adults with SMI, than without, for bowel (42.11% vs. 58.89%), breast (48.33% vs. 60.44%) and cervical screening (64.15% vs. 69.72%; all p < 0.001). Participation was lowest in those with schizophrenia (bowel, breast, cervical: 33.50%, 42.02%, 54.88%), then other psychoses (41.97%, 45.57%, 61.98%), then bipolar disorder (49.94%, 54.35%, 69.69%; all p-values < 0.001, except cervical screening in bipolar disorder; p-value > 0.05). Participation was lowest among people with SMI who live in the most deprived quintile of areas (bowel, breast, cervical: 36.17%, 40.23%, 61.47%), or are of a Black ethnicity (34.68%, 38.68%, 64.80%). Higher levels of deprivation and diversity, associated with SMI, did not explain the lower participation in screening. CONCLUSIONS: In England, participation in cancer screening is low among people with SMI. Support should be targeted to ethnically diverse and socioeconomically deprived areas, where SMI prevalence is greatest.

Barriers to colonoscopy in UK colorectal cancer screening programmes: Qualitative interviews with ethnic minority groups.

OBJECTIVE: People from ethnic minority backgrounds are less likely to attend colonoscopy, following faecal immunochemical test screening, and are more likely to be diagnosed with colorectal cancer at an advanced stage as a result. The aim of this research was to explore the barriers and facilitators to attending colonoscopy, perceived by ethnic minority groups living in the United Kingdom. METHODS: Semi-structured online and telephone interviews were conducted with thirty men and women of Black-African (n = 5), Black-Caribbean (n = 5), South Asian (n = 10) and White British (n = 10) descent. Participants were eligible for screening, but had not necessarily been invited for colonoscopy. All interviews were conducted in the participant's first language and were assessed using Framework-analysis, in line with a conceptual framework developed from previous interviews with healthcare professionals. RESULTS: Five thematic groups of barriers and facilitators were developed: 'Locus of control', 'Cultural attitudes and beliefs', 'Individual beliefs, knowledge and personal experiences with colonoscopy and cancer', 'Reliance on family and friends' and 'Health concerns'. Differences were observed, between ethnic groups, for: 'Locus of control', 'Cultural attitudes and beliefs' and 'Reliance on family and friends'. Black and South Asian participants frequently described the decision to attend colonoscopy as lying with 'God' (Muslims, specifically), 'the doctor', or 'family' (Locus of control). Black and South Asian participants also reported relying on friends and family for 'language, transport and emotional support' (Reliance on family and friends). Black-African participants, specifically, described cancer as 'socially taboo' (Cultural attitudes and beliefs). CONCLUSIONS: The results highlight several targets for culturally-tailored interventions to make colonoscopy more equitable.

Patient experience and satisfaction with symptomatic faecal immunochemical testing: an explanatory sequential mixed-methods evaluation.

BACKGROUND: Recent evidence suggests that faecal immunochemical testing (FIT) can rule out colorectal cancer (CRC) in symptomatic adults. To date, there has been little research exploring experiences of FIT for this population. AIM: To explore patient experience and satisfaction with FIT in an 'early adopter' site in England. DESIGN: Explanatory sequential mixed-methods approach combining mailed quantitative surveys with semi-structured telephone interviews. METHOD: Multivariate logistic regression was used to analyse quantitative data. Thematic analysis was used to assess qualitative transcripts. RESULTS: The survey had 260 responders, and it found that satisfaction with FIT was high (88.7%). Compared with test satisfaction, the proportion of responders satisfied with their GP consultation and how they received their results was lower (74.4% and 76.2%, respectively). Multivariate analysis showed that increased area-level deprivation and not receiving an explanation of the purpose of the test were associated with lower satisfaction with the GP consultation (both P-values <0.05), while increased area-level deprivation and not receiving results from the GP were associated with lower satisfaction with receiving results (both P-values <0.05). Interviews with responders (n = 20) helped explain the quantitative results. They revealed that 'not knowing the purpose of the test' caused 'anxiety' and 'confusion', which led to dissatisfaction. 'Not receiving results from GP' was considered 'unacceptable', as this left patients with a 'niggling doubt' and lack of diagnosis or assurance that they did not have cancer. CONCLUSION: Patient satisfaction with symptomatic FIT is high. Efforts to improve satisfaction should focus on ensuring that patients understand the purpose of the test and always receive their test results.

Barriers and facilitators to colonoscopy for cancer detection: patient and practitioner perspectives.

OBJECTIVE: To further understand the barriers and facilitators to attending colonoscopy examination following a positive routinely offered stool test result, from the perspective of patients and Specialist Screening Practitioners (SSPs). METHODS: Qualitative semi-structured interviews were conducted. Participants (N = 32) were patients (n = 20) who, as part of the Bowel Cancer Screening Programme (BCSP) in England, were invited to attend a colonoscopy examination, and SSPs (n = 12), who worked for the BCSP in England. Framework analysis included inductive and deductive coding. RESULTS: Anxiety was as a key barrier cited by patients and SSPs, arising from the moment the patient received the invitation letter. Notably, procedural-related anxieties centred upon the fear of pain and discomfort and test invasiveness. The role of family, friends and the SSP were recognised by patients and SSPs to facilitate participation. Many patients, yet not SSPs, emphasised an obligation to attend all medical test invitations. CONCLUSION: Practically orientated strategies suggested by patients and SSPs address the patient barriers identified. These include earlier information to patients on the option of sedation for pain relief, earlier notification of potential financial support for patients unable to fund their own travel costs, and fewer uses of the term cancer within written materials.

Testing the Effectiveness of an Animated Decision Aid to Improve Recruitment of Control Participants in a Case-Control Study: Web-Based Experiment.

BACKGROUND: Participation in case-control studies is crucial in epidemiological research. The self-sampling bias, low response rate, and poor recruitment of population representative controls are often reported as limitations of case-control studies with limited strategies to improve participation. With greater use of web-based methods in health research, there is a further need to understand the effectiveness of different tools to enhance informed decision-making and willingness to take part in research. OBJECTIVE: This study tests whether the inclusion of an animated decision aid in the recruitment page of a study website can increase participants' intentions to volunteer as controls. METHODS: A total of 1425 women were included in a web-based experiment and randomized to one of two experimental conditions: one in which they were exposed to a simulated website that included the animation (animation; n=693, 48.6%), and one in which they were exposed to the simulated website without the animation (control; n=732, 51.4%). The simulated website was adapted from a real website for a case-control study, which invites people to consider taking part in a study that investigates differences in purchasing behaviors between women with and without ovarian cancer and share their loyalty card data collected through 2 high street retailers with the researchers. After exposure to the experimental manipulation, participants were asked to state (1) their intention to take part in the case-control study, (2) whether they would be willing to share their loyalty card for research, and (3) their willingness to be redirected to the real website after completing the survey. Data were assessed using ordinal and binary logistic regression, reported in percentages (%), adjusted odds ratio (AOR), and 95% confidence intervals. RESULTS: Including the animation in the simulated website did not increase intentions to participate in the study (AOR 1.09; 95% CI 0.88-1.35) or willingness to visit the real study website after the survey (control 50.5% vs animation 52.6%, AOR 1.08; 95% CI 0.85-1.37). The animation, however, increased the participants' intentions to share the data from their loyalty cards for research in general (control 17.9% vs animation 26%; AOR 1.64; 95% CI 1.23-2.18). CONCLUSIONS: While the results of this study indicate that the animated decision aid did not lead to greater intention to take part in our web-based case-control study, they show that they can be effective in increasing people's willingness to share sensitive data for health research.

Why are most colorectal cancers diagnosed outside of screening? A retrospective analysis of data from the English bowel screening programme.

OBJECTIVE: Despite several interventions to increase participation in England, most colorectal cancers (CRCs) are diagnosed outside of the screening programme. The aims of this study were to better understand why most CRCs are diagnosed externally, the extent to which this is due to suboptimal uptake of screening, and the extent to which it is due to other factors, such as false-negative test results. SETTING / METHODS: We performed a clinical audit of 1011 patients diagnosed with CRC at St Mark's Hospital (Harrow, UK) between January 2017 and December 2020. Data on the diagnostic pathway and screening history of individuals were extracted from the bowel cancer screening system and assessed using descriptive statistics. RESULTS: 446/1011 (44.1%) patients diagnosed with CRC were eligible for screening at the time of diagnosis. Of these, only 115/446 (25.8%) were diagnosed through screening. Among those diagnosed via non-screening pathways, 210/331 (63.4%) had never taken part in screening, 31/331 (9.4%) had taken part but were not up to date, and 89/331 (26.9%) had taken part and were up-to-date (of these, 82/89 [92.2%] had received a normal or weak positive test result, and 5/89 [5.6%] had received a positive result and declined colonoscopy). CONCLUSION: Nearly two-thirds of screening eligible patients diagnosed through a non-screening pathway had never taken part in screening. This represents the single largest source of inefficiency within the screening programme, followed by missed findings and inconsistent participation. Given the improved outcomes associated with screen-detected cancers, there is a strong public health mandate to encourage participation.

Demographic and psychological predictors of community pharmacists' cancer-related conversations with patients: a cross-sectional analysis and survey study.

BACKGROUND: There is increasing interest in the role of community pharmacy in the early diagnosis and prevention of cancer. This study set out to examine how often community pharmacists (CPs) encourage patients to spot or respond to potential signs and symptoms of cancer, and how often they help people to make an informed decision about taking part in bowel cancer screening. METHODS: Data from 400 UK CPs, who completed the 2018 Cancer Research UK Healthcare Professional Tracker survey, were analysed. The primary outcomes were: 'how often CPs encourage patients to spot or respond to potential signs and symptoms of cancer' and 'how often CPs encourage eligible people to make an informed decision to participate in bowel cancer screening'. Associations between behaviours and demographic and psychological variables (Capability, Opportunity and Motivation) were assessed using multivariate logistic regression. RESULTS: Most (n = 331, 82.8%) CPs reported occasionally, frequently or always encouraging patients to spot or respond to potential signs and symptoms of cancer, while only half (n = 203, 50.8%) reported occasionally, frequently or always helping people make an informed decision to participate in bowel cancer screening. Female sex (aOR: 3.20, 95%CI: 1.51, 6.81; p < 0.01) and increased Opportunity (aOR: 1.72, 95%CIs: 1.12, 2.64; p < 0.05) and Motivation (aOR: 1.76, 95%CIs: 1.37, 2.27; p < 0.001) were associated with encouraging patients to spot or respond to potential signs and symptoms of cancer; all three psychological variables were associated with helping people to make an informed decision to participate in bowel cancer screening (Capability: aOR: 1.39, 95%CIs: 1.26, 1.52, p < 0.001; Opportunity: aOR: 1.44, 95%CIs: 1.11, 1.87; p < 0.01; Motivation: aOR: 1.45, 95%CIs: 1.05, 2.00; p < 0.05). CONCLUSIONS: Most CPs encourage patients to spot or respond to potential cancer symptoms, while only half help them make an informed decision to participate in bowel cancer screening. A multifaceted approach, targeting multiple COM-B components, is required to change these behaviours.

Effectiveness of behavioural economics-based interventions to improve colorectal cancer screening participation: A rapid systematic review of randomised controlled trials.

•We searched PubMed, PsycInfo and EconLit for RCTs that evaluated BE interventions in CRC screening.•We identified 1027 papers for title and abstract review. 30 studies were eligible for the review.•The most frequently tested BE intervention was incentives, followed by default principle and salience.•Default-based interventions were most likely to be effective. Incentives had mixed evidence.•BE remains a promising field of interest in relation to influencing CRC screening behaviours.

Patients' and physicians' experiences with remote consultations in primary care during the COVID-19 pandemic: a multi-method rapid review of the literature.

BACKGROUND: During the COVID-19 pandemic, many countries implemented remote consultations in primary care to protect patients and staff from infection. AIM: The aim of this review was to synthesise the literature exploring patients' and physicians' experiences with remote consultations in primary care during the pandemic, with the further aim of informing their future delivery. DESIGN & SETTING: Rapid literature review. METHOD: PubMed and PsychInfo were searched for studies that explored patients' and physicians' experiences with remote consultations in primary care. To determine the eligibility of studies, their titles and abstracts were reviewed, before the full article. Qualitative and quantitative data were then extracted from those that were eligible, and the data synthesised using thematic and descriptive synthesis. RESULTS: A total of 24 studies were eligible for inclusion in the review. Most were performed in the US (n = 6, 25%) or Europe (n = 7, 29%). Patient and physician experiences were categorised into perceived 'advantages' and 'issues'. Key advantages experienced by patients and physicians included 'reduced risk of COVID-19' and 'increased convenience', while key issues included 'a lack of confidence in or access to required technology' and a 'loss of non-verbal communication' which degraded clinical decision-making. CONCLUSION: This review identified a number of advantages and issues experienced by patients and physicians using remote consultations in primary care. The results suggest that, while remote consultations are more convenient and protect patients and staff against COVID-19, they result in the loss of valuable non-verbal communication, and are not accessible to all.

Testing Enhanced Active Choice to Optimize Acceptance and Participation in a Population-Based Colorectal Cancer Screening Program in Malta.

Opt-out strategies have been shown to improve participation in cancer screening; however, there are ethical concerns regarding the presumed consent. In this study, we tested an alternative opt-in strategy, called: "enhanced active choice," in which the response options summarize the consequences of the decision. The study was conducted as part of the Maltese colorectal cancer screening program, which offers men and women, aged 60-64, a "one-off" fecal immunochemical test (FIT). A total of 8349 individuals were randomly assigned to receive either an invitation letter that featured a standard opt-in strategy (control condition), or an alternative letter with a modified opt-in strategy (enhanced active choice condition). Our primary outcome was participation three months after the invitation was delivered. Additionally, we also compared the proportion who said they wanted to take part in screening. We used multivariable logistic regression for the analysis. Overall, 48.4% (N = 4042) accepted the invitation and 42.4% (N = 3542) did the screening test. While there were no statistically significant differences between the two conditions in terms of acceptance and participation, enhanced active choice did increase acceptance among men by 4.6 percentage points, which translated to a significant increase in participation of 3.4 percentage points. We conclude that enhanced active choice can improve male screening participation. Given the higher risk of CRC in men, as well as their lower participation screening, we believe this to be an important finding.

Barriers and facilitators to colonoscopy following fecal immunochemical test screening for colorectal cancer: A key informant interview study.

OBJECTIVES: People who are referred for colonoscopy, following an abnormal colorectal cancer (CRC) screening result, are at increased risk of CRC. Despite this, many individuals decline the procedure. The aim of this study was to investigate why. METHODS: As little is currently known about non-attendance at follow-up colonoscopy, and follow-up of abnormal screening results is a nurse-led process, we decided to conduct key informant interviews with Specialist Screening Practitioners ([SSPs] nurses working in the English Bowel Cancer Screening Program). Interviews were conducted online. Transcripts were assessed using inductive and deductive coding techniques. RESULTS: 21 SSPs participated in an interview. Five main types of barriers and facilitators to colonoscopy were described, namely: Sociocultural, Practical, Psychological, Health-related and COVID-related. Key psychological and sociocultural factors included: 'Fear of pain and discomfort associated with the procedure' and 'Lack of support from family and friends'. Key practical, health-related and COVID-related factors included: 'Family and work commitments', 'Existing health conditions as competing priorities' and 'Fear of getting COVID-19 at the hospital'. CONCLUSIONS: A range of barriers and facilitators to follow-up colonoscopy exist. Future studies conducted with patients are needed to further explore barriers to colonoscopy. PRACTICE IMPLICATIONS: Strategies to reduce non-attendance should adopt a multifaceted approach.

Improving postal survey response using behavioural science: a nested randomised control trial.

BACKGROUND: Systematic reviews have identified effective strategies for increasing postal response rates to questionnaires; however, most studies have isolated single techniques, testing the effect of each one individually. Despite providing insight into explanatory mechanisms, this approach lacks ecological validity, given that multiple techniques are often combined in routine practice. METHODS: We used a two-armed parallel randomised controlled trial (n = 2702), nested within a cross-sectional health survey study, to evaluate whether using a pragmatic combination of behavioural science and evidenced-based techniques (e.g., personalisation, social norms messaging) in a study invitation letter increased response to the survey, when compared with a standard invitation letter. Participants and outcome assessors were blinded to group assignment. We tested this in a sample of women testing positive for human papillomavirus (HPV) at cervical cancer screening in England. RESULTS: Overall, 646 participants responded to the survey (response rate [RR] = 23.9%). Logistic regression revealed higher odds of response in the intervention arm (n = 357/1353, RR = 26.4%) compared with the control arm (n = 289/1349, RR = 21.4%), while adjusting for age, deprivation, clinical site, and clinical test result (aOR = 1.30, 95% CI: 1.09-1.55). CONCLUSION: Applying easy-to-implement behavioural science and evidence-based methods to routine invitation letters improved postal response to a health-related survey, whilst adjusting for demographic characteristics. Our findings provide support for the pragmatic adoption of combined techniques in routine research to increase response to postal surveys. TRIAL REGISTRATION: ISRCTN, ISRCTN15113095 . Registered 7 May 2019 - retrospectively registered.

Testing messages from behavioral economics to improve participation in a population-based colorectal cancer screening program in Cyprus: Results from two randomized controlled trials.

•Behavioral economic-based interventions have been suggested to increase uptake in CRC screening programmes.•This study tested the effectiveness of six behavioral economic-based messages in two field trials.•None of the messages increased screening participation.

Ethnic inequalities in older adults bowel cancer awareness: findings from a community survey conducted in an ethnically diverse region in England.

BACKGROUND: To date, research exploring the public's awareness of bowel cancer has taken place with predominantly white populations. To enhance our understanding of how bowel cancer awareness varies between ethnic groups, and inform the development of targeted interventions, we conducted a questionnaire study across three ethnically diverse regions in Greater London, England. METHODS: Data were collected using an adapted version of the bowel cancer awareness measure. Eligible adults were individuals, aged 60+ years, who were eligible for screening. Participants were recruited and surveyed, verbally, by staff working at 40 community pharmacies in Northwest London, the Harrow Somali association, and St. Mark's Bowel Cancer Screening Centre. Associations between risk factor, symptom and screening awareness scores and ethnicity were assessed using multivariate regression. RESULTS: 1013 adults, aged 60+ years, completed the questionnaire; half were of a Black, Asian or Minority ethnic group background (n = 507; 50.0%). Participants recognised a mean average of 4.27 of 9 symptoms and 3.99 of 10 risk factors. Symptom awareness was significantly lower among all ethnic minority groups (all p's < 0.05), while risk factor awareness was lower for Afro-Caribbean and Somali adults, specifically (both p's < 0.05). One in three adults (n = 722; 29.7%) did not know there is a Bowel Cancer Screening Programme. Bowel screening awareness was particularly low among Afro-Caribbean and Somali adults (both p's < 0.05). CONCLUSION: Awareness of bowel cancer symptoms, risk factors and screening varies by ethnicity. Interventions should be targeted towards specific groups for whom awareness of screening and risk factors is low.

Patient barriers and facilitators of colonoscopy use: A rapid systematic review and thematic synthesis of the qualitative literature.

Colonoscopy is the gold standard test in the diagnosis of colorectal cancer. Despite this, many people across the world decline the procedure when invited for screening, surveillance or diagnostic evaluation. The aim of this review was to characterise the barriers and facilitators of colonoscopy use described in the qualitative literature. We searched PubMed and PsychInfo for studies that explored barriers and facilitators of colonoscopy use. To determine the eligibility of studies, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search, which we expanded successively, until the number of new publications eligible after abstract review was <1% of the total number of publications identified. Papers were eligible if they: 1) focussed on an adult population, 2) used a qualitative research design and, 3) described at least one patient-related theme regarding colonoscopy use. We then extracted qualitative data from eligible papers and analysed using thematic synthesis. Fifty-seven studies met the inclusion criteria. Most explored barriers and facilitators of screening colonoscopy (n=53, 93.0%) and were conducted in the USA (n=48, 84.2%). Key psychological and social factors included: 'fear of pain and discomfort', 'concerns about doing the bowel preparation', and whether the test was recommended by the patient's physician. Key practical factors included cost, and whether colonoscopy was covered by the patient's healthcare insurance. Studies mostly focussed on screening colonoscopy in the USA, where there is no universal healthcare coverage. To better understand the barriers and facilitators in other contexts, further research is needed.

Use of a GP-endorsed non-participant reminder letter to promote uptake of bowel scope screening: A randomised controlled trial in a hard-to-reach population.

Previous research suggests that sending non-participants a reminder letter, 1 year after their initial invitation, can improve coverage for bowel scope screening (BSS), also known as flexible sigmoidoscopy screening. We hypothesised that adding a general practitioner's (GPs) endorsement to the reminder letter could improve coverage even further. We conducted a randomised controlled trial in North West London, UK. Participants were screening-eligible men and women who had not responded to their initial BSS invitation at least 12 months prior to the trial period. Eligible adults were randomised in a 1:1 ratio to receive either a GP-endorsed reminder letter, or a standard reminder letter from June to August 2019. Logistic regression models were used to test the effect of the GP endorsement on attendance at BSS, adjusting for sex, clinical commissioning group, and local area socioeconomic deprivation. In total, 1200 participants were enrolled into the study and randomised to either the control (n = 600) or the intervention (n = 600) group. Those who received the GP-endorsed reminder letter were only slightly more likely to attend BSS than those who received the standard reminder letter (4% vs. 3%); this difference was not statistically significant (Adjusted OR = 1.30; 95% CI: 0.69, 2.43). Adding a GP-endorsement to the annual reminder letter did not have an effect on attendance at BSS. One possible explanation for this is that the endorsement used was not personalised enough. Future research should examine stronger GP-endorsements or other methods to promote uptake.