This research project is being run by the University of Stirling on behalf of the East of Scotland Breast Screening service based at Ninewells hospital in Dundee and is funded by a grant from NHS Tayside. This project has the full support of both the Scottish Breast Screening Programme Board and the Detect Cancer Early Programme.
Breast cancer accounts for almost 30% of all cancers and is the second leading cause of cancer deaths in women in Scotland. Breast screening can detect some cancers which are too small to be felt by self-examination, and early detection is associated with reduced mortality risk. The Scottish Breast Screening Programme is a nationwide, free at point of delivery screening service, to which all women aged between 50 and 70 years are invited to attend every 3 years. Currently over three-quarters of invited women regularly attend a screening. However, women from more deprived areas are much less likely to attend: for example, in the 3 years from 2010-2012, only 63% of women in the most deprived area attended the East of Scotland Breast Screening programme versus 81% in the least deprived.
Barriers to breast screening
A small qualitative survey, aimed at eliciting factors associated with low uptake in women, was previously conducted by members of our research group in NHS Tayside. Women from two GP practices who had not taken up their invitation to attend their most recent screening appointment were invited to attend focus groups in a local community centre; seven women took part in 2 focus groups. Barriers to breast screening emerging from the focus groups included: fear and anxiety (e.g. of the process, potential outcome, radiation levels, waiting for results), life issues (e.g. being carers or working and finding it hard to get away, poor health) and access (e.g. transport, parking, location, weather). Participants also suggested that reminders, peer-led support and advice, and more mobile units might be helpful. The barriers generated from this research will be used as the basis for eliciting and addressing barriers and concerns in the current study.
Recent research has suggested that reminders (telephone or letter) and brief, personalised interventions addressing barriers to attendance may be helpful in increasing uptake.
We will employ a brief telephone reminder and support intervention, whose purpose is to elicit and, if applicable, address any inaccurate beliefs women have about breast screening. We will test whether this intervention will lead to an increase in the uptake of breast screening amongst women who did not take up their invitation to attend a first appointment, in a randomised controlled trial with 600 women. The primary outcome will be attendance at breast screening within 3 months of the reminder letter.
It is estimated that increasing breast cancer screening uptake to the level found in higher socio-economic women (i.e. approximately 80%) across all socio-economic groups could translate into approximately 49-57 additional cancers diagnosed across Scotland annually, with an extra 7-33 lives saved. This equates to a 20% increase in the lowest uptake groups in NHS Tayside. If this simple telephone support intervention leads to a significant increase in breast screening uptake, this would represent a rare example of a theoretically-driven, relatively simple psychological intervention that could result in earlier detection of breast cancer amongst an under-served group of women.
Prof Ronan O’Carroll was the Principal Investigator for this research.
Kerry Gracie was appointed as Research Assistant on the TELBRECS trial and was responsible for the day-to-day running of the trial during the intervention stage. She conducted all of the interviews.
Dr Julie Chambers was project manager for the trial; she conducted the randomisation procedure, collected follow-up attendance data, and carried out the analysis. She remained blind to treatment arm until the Intention-to-Treat analysis was completed.
The research ran from December 2013 to April 2015. The interviews were completed in July 2014 and the follow-up data collection was completed in October 2014.
As noted above, there are many reasons why women do not attend breast screening appointments. Asking people to consider the negative emotional consequences of not carrying out a health behaviour such as attending a screening, i.e. anticipated regret (AR), can lead to more choosing to take part.
The research questions were:
1) Is a simple, telephone reminder intervention, aimed at addressing the barriers and concerns of women in socially-deprived areas regarding attending a screening at the East of Scotland Breast Cancer Screening Service, feasible and acceptable to participants?
2) Can sufficient telephone numbers be obtained to make the project viable?
3) Can this brief, telephone intervention increase uptake in non-attendees from socially-deprived areas?
4) Does adding AR to the telephone intervention further increase uptake of screening in non-attendees?
Participants who were due to be sent a reminder letter after a missed screening appointment were randomly allocated to one of four groups: 1) no telephone call (control), 2) telephone reminder (TEL-REM), 3) telephone support (TEL-SUPP) and 4) telephone support plus anticipated regret (TEL-SUPP-AR). The aim of the two TEL-SUPP arms was to discover and help address any barriers women had which made it difficult for them to attend screening. Primary outcomes were a) making an appointment for breast screening and b) attending a screening. Secondary outcomes included intention to make an appointment and reported barriers to attendance. As telephone numbers are not routinely held on the screening database, the feasibility of obtaining telephone numbers was also an important secondary outcome.
856 women were randomised to treatment groups and analysed as allocated. Compared to control, more women in the telephone intervention groups made an appointment (Control: 8.8%, TEL-REM: 20.3%, TEL-SUPP: 14.1%; TEL-SUPP-AR: 16.8%, χ2(3)=12.0, p=.007) and attended breast screening (Control: 6.9%, TEL-REM: 16.5%, TEL-SUPP: 11.3%; TEL-SUPP-AR: 13.1%, χ2(3) = 9.8, p=.020). The odds of making or attending an appointment were approximately double across the three intervention groups compared to the control group.
Telephone numbers were obtained for 70% of eligible women in the reminder lists (n=856/1219), although n=108 (13%) of these proved invalid when telephoned. Of the 404 women who were successfully telephoned, 68 proved ineligible and 247 agreed to take part in the intervention. Intervention participants were more likely to make (17% versus 10%, χ2(1)=7.0, p=.008) and attend (13% versus 7%, χ2(1)=5.5, p=.019) an appointment than non-participants, but there was no difference in attendance between the three telephone groups.
Difficulties were experienced in contacting women, with almost 200 women either not answering their phone or putting the phone down; we expect this may stem from the current climate of cold-calling sales techniques. We were unable to begin our introduction by establishing that this was a bona fide call or leave any message on answerphones because our ethics agreement required us to verify that we were speaking to the correct person before disclosing the purpose of the call. This may have resulted in women choosing to ignore what they assumed was another marketing call. Importantly, these restrictions would not apply to calls made directly from the breast screening unit, potentially resulting in a higher number of contacted women.
Women in the two telephone support groups (n=115) expressed a wide range of barriers to attendance, including fear of the process or outcome, and practical difficulties of attending appointments. The most frequently reported barrier (over 31% of women) was anticipated pain or discomfort of the procedure, which was equally expressed by those who had previously attended an appointment and those who had never attended. Only 8% of participants who anticipated pain/discomfort and 5% of those who reported their attendance was affected by work issues attended screening in the current round.
Almost all women in the two TEL-SUPP treatment arms (n=112/115, 97%) said they did not mind being telephoned and over 65% (n=74) said they had found the phone call helpful; indicating the telephone intervention was acceptable to participants.
A simple telephone reminder increased attendance at breast screening in women who had not attended their initial appointment by approximately two-fold compared to a reminder letter alone. Although there were no differences between the three telephone intervention groups, adopting a telephone reminder as standard would also provide an opportunity to address practical barriers such as appointment location or simple misunderstandings such as not being aware that breast cancer risk increases with age.
Implications for Practice or Policy
A simple telephone intervention was successful at doubling the uptake of breast screening after a reminder. The intervention could be implemented from the breast screening service, providing telephone numbers could be obtained and sufficient resources are available. The difficulties experienced with time and cold-calling issues are likely to be much less problematic with direct calls from the breast screening service; thus the intervention may be much more effective when conducted by staff at the screening centre.
The findings are now published:
Chambers J, Gracie K, Millar R, Cavanagh J, Archibald D, Cook A and O'Carroll R (2015). A pilot randomised controlled trial of telephone intervention to increase breast cancer screening uptake in socially deprived areas in Scotland (TELBRECS). Journal of Medical Screening, Online First, available at http://dx.doi.org/10.1177/0969141315608212.
Although we did not find any evidence that the telephone support intervention provided any additional benefits over a simple reminder, the low number of participants who took part in the support intervention means we cannot conclude that it did not. A further intervention, which reduces the burden of reading the information sheet/obtaining consent, perhaps by sending these materials in advance, is required in order to provide a fair test of the telephone support compared to the telephone reminder treatment groups.
A wealth of data on the views of women from lower socio-economic areas was collected during the two TEL-SUPP treatment group interviews, in contrast to very small numbers taking part in previous focus groups. Analysis of this data is outwith the scope of the current project, thus funding is being sought to conduct a full qualitative analysis of the interview material, which would examine relationships between barriers and attendance, as well as carrying out a detailed assessment of the effectiveness of the intervention at addressing barriers at an individual level.
If you have any queries about the project or would like any further information, please do not hesitate to contact Dr Julie Chambers (e-mail) or Professor Ronan O'Carroll (e-mail).