Article Text

Original research
What are common barriers and helpful solutions to colorectal cancer screening? A cross-sectional survey to develop intervention content for a planning support tool
  1. Marie Kotzur1,
  2. Sara Macdonald1,
  3. Ronan E O'Carroll2,
  4. Rory C O'Connor1,
  5. Audrey Irvine3,
  6. Robert J C Steele4,
  7. Kathryn A Robb1
  1. 1School of Health & Wellbeing, University of Glasgow, Glasgow, UK
  2. 2Psychology, University of Stirling, Stirling, UK
  3. 3NHS Tayside, Dundee, UK
  4. 4Surgery and Oncology, University of Dundee, Dundee, UK
  1. Correspondence to Professor Kathryn A Robb; Katie.Robb{at}glasgow.ac.uk

Abstract

Objective Colorectal screening using faecal immunochemical tests (FITs) can save lives if the people invited participate. In Scotland, most people intend to complete a FIT but this is not reflected in uptake rates. Planning interventions can bridge this intention-behaviour gap. To develop a tool supporting people willing to do colorectal screening with planning to complete a FIT, this study aimed to identify frequently experienced barriers and solutions to these barriers.

Design This is a cross-sectional study.

Setting Participants were recruited through the Scottish Bowel Screening Programme to complete a mailed questionnaire.

Participants The study included 2387 participants who had completed a FIT (mean age 65 years, 40% female) and 359 participants who had not completed a FIT but were inclined to do so (mean age 63 years, 39% female).

Outcome measures The questionnaire assessed frequency of endorsement of colorectal screening barriers and solutions.

Results Participants who had not completed a FIT endorsed significantly more barriers than those who had completed a FIT, when demographic, health and behavioural covariates were held constant (F(1,2053)=13.40, p<0.001, partial η2=0.01). Participants who completed a FIT endorsed significantly more solutions than those who did not (U=301 585.50, z=−3.21, p<0.001, r=0.06). This difference became insignificant when covariates were controlled. Participants agreed on the most common barriers and solutions regardless of screening history. Barriers included procrastination, forgetting, fear of the test result, screening anxiety, disgust and low self-efficacy. Solutions included hand-washing, doing the FIT in private, reading the FIT instructions, benefit of early detection, feelings of responsibility, high self-efficacy and seeing oneself as a person who looks after one’s health.

Conclusion This survey identified six barriers and seven solutions as key content to include in the development of a planning tool for colorectal screening using the FIT. Participatory research is required to codesign an engaging and accessible planning tool.

  • Gastrointestinal tumours
  • PREVENTIVE MEDICINE
  • PUBLIC HEALTH
  • SOCIAL MEDICINE

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this study

  • Collaboration with the Scottish Bowel Screening Programme enabled targeted recruitment of a large sample evenly matched in sex and socioeconomic status across participant groups.

  • Participants who had not completed screening were significantly older and more ethnically diverse than those who had, but this did not affect outcome measures.

  • Despite efforts to recruit similar numbers of people who had and had not completed screening, the proportions of participants who had completed screening were much larger due to an error.

Background

Colorectal cancer is the third most common cancer and second most common cause of cancer death globally.1 2 In the UK and in Scotland, it is the second biggest cancer killer, responsible for over 16 600 and 1700 deaths annually, respectively.3 4 Colorectal cancer screening can save lives and reduce healthcare spending.5

In November 2017, the Scottish Bowel Screening Programme replaced the Faecal Occult Blood Test (FOBt, samples collected at home over 3 days) with the Faecal Immunochemical Test (FIT). The FIT requires participants to take one faecal sample and mail it for testing. People aged 50–74 years are invited to complete a FIT every 2 years. In a survey of a convenience sample of 200 Scottish adults, 85% of people reported intending to complete a FIT and rated it easier to complete and less disgusting than FOBt used previously.6 While uptake rose to 63%,7 a gap remains between screening intentions and participation. A major reason may be that people are ‘not getting round to it’8 which is consistent with previous work on ‘inclined abstainers,’9 showing that a proportion of people intending to do screening fail to do it. This explanation seems particularly likely for colorectal screening which, unlike other screening tests, is self-completed at home10: in a recent Australian survey 64% reported intentions to do the FIT.11

Systematic reviews demonstrate that interventions supporting people to plan how to enact a behaviour can change the behaviour of inclined abstainers.12 Planning support interventions have been shown to be more effective than other approaches, such as self-monitoring,13 and have high adherence rates.14 Planning support promotes behaviour change using ‘if-then’ plans.15 They are often embedded in planning support tools16 encouraging people to plan better by offering a solution where a key barrier (‘if’) is linked with an appropriate solution (‘then’), for instance: “If I am tempted to eat when I am at a party”—“then I will tell myself that if I try hard enough I can keep from overeating”.16

Behavioural theories, such as the Integrated Screening Action Model (I-SAM), show that a range of individual and environmental factors may hinder or facilitate screening participation.17 We aimed to establish the most relevant content for a planning support tool to overcome barriers to colorectal screening using the FIT, by identifying frequently experienced barriers and the solutions perceived as most helpful among people invited to complete a FIT and intending to do so. As the FIT is relatively new to Scotland, little is known about people’s experience with this test which continues to rely on faecal self-sampling at home and research is required to establish what barriers remain and how people who complete colorectal screening overcome them.

This study seeks to answer five research questions in a cross-sectional survey to inform the development of planning support tool:

  1. What are the most common perceived barriers to completing a FIT among people willing to do so?

  2. How frequently are colorectal screening barriers experienced by people who have or have not completed a FIT?

  3. What are the most common solutions used to overcome colorectal screening barriers among people who have completed a FIT?

  4. What are the most common solutions to overcome colorectal screening barriers suggested by people who have not completed a FIT, but are willing to do so?

  5. Are sociodemographic characteristics associated with differences in reporting colorectal screening barriers and solutions for a FIT?

Method

Recruitment

To recruit a well-stratified sample, we planned to invite potential participants based on colorectal screening history (completed a FIT vs not completed a FIT), sex (female vs male), age (50–62 years vs 63–74 years), area-based socioeconomic status (SES), and location in Scotland (Greater Glasgow and Clyde health board vs other health board). Area-based SES was derived from the Scottish Index of Multiple Deprivation based on home postcodes (40% most affluent vs 40% most deprived).18

We collaborated with the Scottish Bowel Screening Centre who used the sampling frame to identify eligible potential participants (see online supplemental table S1) and send them a questionnaire.

We aimed to recruit 1000 people who had completed a FIT and 1000 people who had not completed a FIT. Based on our previous work, we anticipated low response rates from people who had not completed a FIT by oversampling this group. We therefore planned to send questionnaires to 1250 people who had completed a FIT and 5000 people who had not completed a FIT. However, due to an error, we sent 4482 people who had completed a FIT and 5000 who had not a questionnaire between January and May 2019. People who did not complete a FIT who had not returned questionnaires or declined participation in the study were sent reminder questionnaires after 3 weeks.

Materials

The questionnaire was designed with public and patient involvement (PPI) input to be easy to read. The questionnaire is available in online supplemental file 2.

Health and experience of cancer

We measured perceived general health with one item Would you say that for someone of your age your own health in general is: with response options: poor, fair, good, excellent.19 Based on questions by Miles et al,20 we also asked participants whether they, their close family, or friends had ever had cancer, and if so, what type.

Intentions and past FIT completion

The questionnaire showed an image of the FIT kit and then assessed past screening behaviour with two items: Have you received a new bowel screening test like the one pictured above? (response options: yes, no, not sure) and If yes, did you complete and post the new test? (response options: yes, no, not applicable).

We assessed future screening intentions with one item adapted from McCaffery and coauthors21: If you receive a new bowel screening test in the future, will you do the test? with response options: definitely not; probably not; yes, probably; yes, definitely. Participants who selected definitely not or probably not were excluded from the study in line with eligibility criteria (see online supplemental table S1).

We also assessed self-efficacy for completing a FIT with one item: How easy or hard do you think the new bowel screening test is to do? with six response options: very easy, easy, neither easy nor hard, hard, very hard, and don’t know.

Barriers and solutions

Barrier and solution items were developed based on semistructured interviews with people who had and had not completed a FIT in previous research.22

To assess colorectal screening barriers, 33 barrier items were presented (see online supplemental file 2) with response options on a five-point Likert-scale from 1, strongly disagree to 5, strongly agree. Participants were also asked, Is there anything else that makes bowel screening hard for you? Please can you describe:

Similarly, 25 solution items (see online supplemental file 2) were presented with response options on a five-point Likert-scale from 1, strongly disagree to 5, strongly agree. Participants were also asked: Can you think of any other ways that bowel screening could be made easier? Please can you describe:

Responses to barrier and solution items were dichotomised as follows: Strongly disagree, Disagree, and Not sure were grouped into a Not endorsed category; Strongly agree and Agree were grouped into an Endorsed category.

Demographic characteristics

Demographic characteristics included: age; gender; marital status; ethnic group.20 We assessed individual SES as an aggregate score of housing arrangement (rent from local authority/housing association, rent from private landlord, own your home/have a mortgage, other), car ownership, education level.23 24

Procedure

Potential participants received a mailed invitation letter, a 10-page questionnaire, and a prepaid reply envelope. The reminder included another questionnaire and prepaid reply envelope.

Analysis

Analyses were carried out using IBM SPSS Statistics V.28. Data from ineligible participants who did not meet the inclusion criteria were excluded from the analysis. Less than 5% of cases had missing data for demographic and behavioural characteristics, except for individual SES with 14.99% of cases missing data. Missing data for barriers and solution items were greater with 16.24% and 10.31% of cases, respectively. Cases with missing data were excluded test wise. χ2 tests were used to compare demographic characteristics of included participants and those who did not return a questionnaire.

Analyses comparing the demographic and behavioural characteristics of participant who completed a FIT and those who did not were performed using χ2 and Mann-Whitney U tests. Ethnicity was dichotomised for χ2-testing because several categories contained fewer than five participants. Self-efficacy responses were also dichotomised for χ2-testing.

Frequency analyses were carried out to rank barriers and solutions by the proportion of participants who completed a FIT and those who did not who endorsed each item. We used Mann-Whitney U tests to compare frequency of endorsed barriers and solutions between participants who completed a FIT and those who did not. To do this, the number of endorsed barriers and solutions was counted for each participant. We used analysis of covariance to assess whether significant differences in the number of endorsed barriers and solutions persisted when demographic, health, and behavioural sample characteristics (see table 1) were held constant.

Table 1

Demographic, health-related and colorectal screening characteristics

Patient and public involvement

Two patient and public representatives provided feedback on the design of the study and reviewed all participant-facing documents and materials to be accessible and engaging. Participant will be sent a summary of the findings if they have requested this.

Results

Sample

Of 2904 completed questionnaires, 156 responses were excluded (n=130 reported no intention to complete a FIT or had not answered this question; n=21 reported having colorectal cancer, and n=5 were aged younger than 50 years). Our study included 2387/4482 participants who had complete a FIT (response rate 53.3%) and 359/5000 participants who had not completed a FIT (response rate 7.2%).

Compared with those who did not return a questionnaire, included participants were more likely to have completed a FIT (30.7% vs 87.2%, p<0.001), to reside in a health board other than NHS Greater Glasgow and Clyde (48.7% vs 55.1%, p<0.001), and to be more affluent (39.0% vs 50.5%, p<0.001). Contrary to those who did not return a questionnaire, included participants were more likely to be older if they had completed a FIT than if they had not completed a FIT (59.6% vs 49.6%). There was no significant difference in sex between those who did not return a questionnaire and included participants.

Demographic and behavioural characteristics are shown in table 1. The age of the total sample ranged from 50 to 75 years with a mean age of 63.4 years (SD: 7.3 years). There were no significant differences between participants who completed a FIT and those who did not in sex, area-based SES, or having ever had cancer; however, screening participants who did not complete a FIT were significantly older than those who did. Participants who did not complete a FIT were significantly more likely to have a lower individual SES score, report poor or fair health, to be single, divorced/separated or widowed, to be unsure whether their family or friends had cancer, and to be from an ethnic background other than white than participants who completed a FIT.

Although area-based SES and individual SES had differing associations with screening history, area-based SES was significantly associated with individual SES, χ2(4)=461.65, p<0.0001. Therefore, subsequent analyses used area-based SES only.

Past FIT experience and colorectal screening intentions

Participants who completed a FIT (90.4%) were twice as likely to recall having received a FIT in the post as participants who did not complete a FIT (54.0%; table 1).

All participants reported intentions to do a FIT in the future as this was an eligibility criterion. Participants who completed a FIT (95.4%) were significantly more likely than those who did not (67.1%) to report they would definitely do a FIT in the future. Participants who completed a FIT were also significantly more likely to report that the FIT was easy to complete (88.4%) compared with participants who did not complete a FIT (51.3%)

Most common barriers and solutions

Table 2 shows the proportion of participant who completed a FIT and participant who did not complete a FIT who endorsed each barrier. The barrier items are grouped into seven types, based on their face-value meaning, and ranked from most to least frequently endorsed by participants who did not complete a FIT. Participants most frequently endorsed practical, emotional, and self-efficacy barriers, regardless of screening history. Across barrier types, participant who had and had not completed a FIT agreed on the six most important barriers.

Table 2

Frequency of barriers endorsed

Table 3 shows the proportion of participants who had and had not completed a FIT who endorsed each solution, ranked from most to least frequently endorsed by those who had not completed a FIT. Similar to barrier items, there were seven types of solutions, according to their face-value meaning. Solutions that improved self-image and increased the perceived efficacy of the FIT were on average most often endorsed by participants, regardless of screening history. Eight solutions were each endorsed by more than 80% of participants who had not completed a FIT. Seven of these were each also endorsed by over 90% of participants who had completed a FIT, suggesting general agreement on the most helpful solutions to FIT barriers.

Table 3

Frequency of endorsed solutions

Demographic and behavioural differences in endorsed barriers and solutions

Participants who had not completed a FIT endorsed significantly more barriers (Mdn.=2) compared with participants who had (Mdn.=0, U=410 791.50, z=14.59, p<0.01, r=0.30). This difference remained significant in ANCOVA controlling for age, sex, marital status, family history of cancer, intention to do a FIT, and perceived ease of doing a FIT (F(1, 2053)=13.40, p<0.001, partial η2=0.01), as shown in table 4. The following groups endorsed significantly more barriers in the multivariable analysis: younger participants, women, those who were single, who were unsure whether their friends or family had had cancer, with weaker intention to do a FIT, and those who thought the FIT was not easy to complete endorsed significantly more barriers (see online supplemental table S2).

Table 4

Analysis of covariance of number of endorsed barriers and solutions

Participants who had not completed a FIT endorsed significantly fewer solutions (Mdn.=18) compared with those who had (Mdn.=19), U=301 585.50, z=−3.21, p<0.001, r=0.06). This difference was not significant in ANCOVA with demographic and behavioural characteristics (F(1, 2143)=0.40, p=0.53; η2=0.00; see table 4). The number of solutions endorsed, however, was related to several covariates: more deprived participants, with stronger intention to complete a FIT, who thought the FIT was easy to complete, and women endorsed more solutions (see online supplemental table S2).

Discussion

The results suggest that participants who had not completed a FIT perceived significantly more barriers than participants who had. Participants who had not completed a FIT also found significantly fewer solutions helpful than those who had. This difference in solutions, however, was not significant when demographic, health and behavioural characteristics were held constant.

The I-SAM identifies six categories of influences that hinder or facilitate cancer screening across individual and environmental contexts: automatic motivation, reflective motivation, psychological capability, physical capability, social opportunity and physical opportunity.17 Our findings show that people who intended to do colorectal screening experienced similar types of barriers regardless of their screening history, and they also agreed on the most important specific barriers. These included practical barriers (capability): not ‘getting around’ to completing a FIT and forgetting to do a FIT; emotional barriers (automatic motivation): feeling worried about the result of the FIT, anxiety in response to thinking about screening, and disgust; and also low self-efficacy (psychological capability) in not being used to doing a test like the FIT.

Similarly, participants, regardless of screening history, agreed that solutions related to identity (social opportunity) and increased perceived efficacy of the FIT (reflective motivation) were most helpful. Seven solutions were considered helpful by almost all participants regardless of screening history. These related to handwashing, finding bowel cancer early, feeling responsible for one’s health, seeking privacy when doing a FIT, reading the FIT instructions, emphasising how easy the FIT is to do, and seeing oneself as a person who looks after one’s health. Although the I-SAM categories of the most endorsed barriers appear to differ from those of endorsed solutions, figure 1 demonstrates that these solutions can address the most commonly experienced barriers. The figure shows that four of the six included barriers can be addressed by more than one solution; and that five of the seven included solutions may address more than one barrier. This is crucial to the development of a planning support tool for colorectal screening using the FIT, as multiple possible combinations will allow users of the tool to create their own plans which are acceptable to them.16 Recent research indicates that suggesting specific action plans to those invited to complete a FIT was less acceptable to screening eligible participants than other interventions.25 Supporting people with planning rather than providing plans directly may be more engaging.

Figure 1

Common barriers and solutions matched.

Akin to existing evidence, younger and single participants and those with low self-efficacy experienced more screening barriers.8 26 Previous research shows that people with family or friends with cancer are more likely to complete screening.27 28 Our findings suggest that they may experience fewer barriers to screening than people who are unsure whether their family or friends have had cancer. Women reported more barriers, which is not reflected in the UK literature,26 29 but matches lower uptake rates among women of FOBt and colonoscopy.30 Yet, women endorsed significantly more solutions than men. Together with higher FIT uptake, these findings suggest that women may more successfully overcome FIT barriers. While reported intention to complete colorectal screening is frequently not translated into screening uptake,9 it is unsurprising that people with stronger intentions reported fewer barriers and found more solutions helpful. Similarly, people who perceive the FIT as easy to complete may think this way because they have more solutions to overcoming FIT barriers. The greater number of solutions endorsed among people living in deprived areas is contrary to consistently lower colorectal screening uptake in this group.26 30 This finding may suggest that people living in deprived areas who complete the FIT engage in more problem-solving than people living in affluent areas. Consequently, people living in deprived areas who do not complete the FIT may need more support with this same problem-solving.

Strengths and limitations

Collaborating with the Scottish Bowel Screening Centre on participant recruitment allowed us to recruit a sample evenly matched in sex and SES across people who had and had not completed a FIT. Participants who had not completed a FIT in our study were significantly more ethnically diverse and older than those who had. This difference is contrary to international evidence that screening uptake is lower among younger people, yet the difference in age appeared to be insufficiently large to mask the established association of younger age and greater perceived barriers.8 26 Ethnicity was not associated with the number of barriers or solutions endorsed by either group, but future research should confirm this lack of association in a more ethnically diverse sample. Despite our efforts to recruit similar numbers of participants who had and had not completed a FIT, our sample contains a much larger proportion of those who had completed a FIT. This is partly due to the erroneous invitation of additional participants who had completed a FIT, but also to the much larger difference in response rates among them (53%) and those who had not completed a FIT (7%) than anticipated. G*Power31 calculations, however, found the total sample size to be large enough for sufficient statistical power of our analyses.

The large number of barriers (33 items) and solutions (25 items) in the questionnaire, may have produced order effects and fatigue in participants. Although PPI feedback did not critique the length of the questionnaire, fatigue may explain the larger number of missing data in these sections.

Implications

Among people who are willing to participate in colorectal screening using the FIT, those who complete a FIT and those who do not, appear to experience the same screening barriers, providing an opportunity to learn from people who complete a FIT about how to overcome these barriers. Our findings suggest that those who complete a FIT and those who do not, agree on the most helpful solutions to overcoming these barriers. Nevertheless, people who do not complete a FIT, despite being willing to do so, may benefit from additional support in enacting the solutions identified in our survey. Planning interventions may provide this support. The present study has informed the development of a brief planning support tool which we will evaluate in a large-scale trial within the Scottish Bowel Screening Programme.32

Conclusions

This study has identified six barriers and seven solutions as key content for a planning support tool for colorectal screening using the FIT. While there is strong evidence for screening barriers and facilitators, little previous research has linked barriers to facilitators, or solutions, that can overcome them. Our findings provide the basis for the development of a planning support tool for colorectal screening which we will evaluate in the next phase of our research.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study received ethical approval from the NHS Research Ethics Committee York and Humber – South Yorkshire, reference 17/YH/0439. Return of a completed questionnaire indicated consent to participate in the study.

Acknowledgments

We wish to thank Mary Cameron and Lucy Robertson for their support of our work as patient and public representatives contributing to the development of the research and reviewing all participant-facing materials.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors All authors were involved in the conception of the study and development of the study protocol. AI facilitated participant recruitment. MK carried out the data collection and analysis under supervision of KR. The findings were discussed with all of the author team. MK drafted the manuscript and all authors contributed revisions. KR is guarantor.

  • Funding This work was supported by the Scottish Government, Chief Scientist Office grant number HIPS/17/23.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.