Search

Introduction: An understanding of contextual factors that influence whether general practitioners advise their patients to be screened for colorectal cancer (CRC) might guide interventions to increase screening participation from its persistently low rate. We report on the use of a theory-based tool to explore contextual factors that might influence implementation of a novel quality improvement (QI) intervention to increase CRC screening in general practice (CRC-QI). The objective was to identify and incorporate strategies into the intervention that will enable flexible implementation across different practice settings., Study Type: A qualitative study to explore contextual facilitators of, and barriers to, the implementation of a novel CRC-QI intervention., Methods: Eighteen staff, from three self-nominated general practices, participated in focus group discussions. The Consolidated Framework for Implementation Research (CFIR), which included constructs relevant to CRC screening in primary care, guided the formative evaluation. Findings were aligned to the CFIR model using a deductive thematic analysis., Results: Contextual facilitators of, and barriers to, the implementation of the CRC-QI intervention were identified in each CFIR domain and CRC-relevant construct. Five consistent themes were identified that potentially influence elements of the CRC-QI intervention: priority setting and incentives, information technology, patient-level barriers, clinical practice, and the National Bowel Cancer Screening Program (NBCSP). Participants proposed that incentive payments and NBCSP policy changes (outer-setting strategies) would facilitate organisational change (inner-setting strategies) and the effective implementation of the CRC-QI intervention., Conclusion: There may be an opportunity to better engage general practice in CRC screening via outer-setting constructs that support existing clinical practice. For example, improvements to the National Cancer Screening Register and Quality Improvement Incentive - Practice Incentives Program (PIP) could be made without altering the NBCSP design., Competing Interests: None declared

Background: Understanding factors causing variation in family physicians/general practitioners (GPs) screening knowledge, understanding and support of organised population-based colorectal cancer (CRC) programs can direct interventions that maximise the influence of a CRC screening recommendation from a GP. This study aims to assess contextual factors that influence knowledge and quality improvement (QI) practice directed to CRC screening in Australian general practice., Methods: A convenience sample of anonymous general practice staff from all Australian states and territories completed a web-based survey. Multivariate analyses assessed the association between CRC screening knowledge and QI-CRC practice scores and patient, organisational and environmental-level contextual factors.  Results: Of 1,013 survey starts, 918 respondents (90.6%) completed the survey. Respondents less likely to recommend FOBT screening had lower knowledge and QI practice scores directed to CRC screening. Controlling for individual and practice characteristics, respondents' rating of the Australian National Bowel Cancer Screening Program (NBCSP) support for preventive care, attending external education, and sufficient practice resources to implement QI practice (generally) were the strongest factors associated with QI practice directed towards CRC screening. Knowledge scores were less amenable to the influence of contextual factors explored., Conclusion: More active engagement of family medicine/general practice to improve screening promotion could be achieved through better QI resourcing without changing the fundamental design of population-based CRC screening programs.

Primary health care (PHC) plays a vital support role in organised colorectal cancer (CRC) screening programs by encouraging patient participation and ensuring timely referral for diagnostic assessment follow up. A systematic scoping review of the current evidence was conducted to inform strategies that better engage the PHC sector in organised CRC screening programs. Articles published from 2005 to November 2019 were searched across five databases. Evidence was synthesised and interventions that specifically require PHC involvement were mapped to stages of the CRC screening pathway. Fifty-seven unique studies were identified in which patient, provider and system-level interventions align with defined stages of the CRC screening pathway: namely, identifying/reminding patients who have not responded to CRC screening (non-adherence) (n=46) and follow up of a positive screen referral (n=11). Self-management support initiatives (patient level) and improvement initiatives (system level) demonstrate consistent benefits along the CRC screening pathway. Interventions evaluated as part of a quality-improvement process tended to report effectiveness; however, the variation in reporting makes it difficult to determine which elements contributed to the overall study outcomes. To maximise the benefits of population-based screening programs, better integration into existing primary care services can be achieved through targeting preventive and quality care interventions along the entire screening pathway.

Objective: Regular screening for colorectal cancer (CRC) can substantially improve outcomes. This study investigated how measuring regret expected from failing to screen might lead to stronger screening intentions. Five potential moderators were evaluated: perceived threat, psychological reactance, prior screening participation, concurrently measuring faecal aversion (FA) and anticipated regret (AR). Design: A 2 (AR measured pre/post intention) × 2 (FA measured pre/post intention) single blind parallel randomised controlled trial was used. Australians aged 45 and over completed an online survey measuring AR, FA, intention, theory of planned behaviour variables and potential moderators. Main outcome measures: The primary outcome was CRC screening intention. Results: Eight hundred and three participants were randomised, with 666 analysed. Measuring AR prior to intention unexpectedly resulted in a significantly lower intention to screen ( d  = 0.18, 95% CI [0.03, 0.33]) compared to measuring after intention. Trait reactance predicted a significantly lower intention when it was at least 0.52 SD above the mean; other moderators were not supported. Conclusion: The processes underlying anticipated regret manipulations must be better understood in order to have practical value in health promotion. More research is required to determine how to minimise or avoid the apparent negative effects of psychological reactance in CRC screening communication. Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12618001098224 http://www.ANZCTR.org.au/ACTRN12618001098224.aspx.

Background: Colorectal cancer (CRC) is the third most common cancer worldwide. Age is the strongest non-modifiable risk factor but it is estimated that over half of CRC cases are linked with lifestyle factors such as diet. The Biomarkers Of RIsk of Colorectal Cancer (BORICC) Study recruited 363 participants in 2005 to investigate the effects of lifestyle factors on biomarkers of CRC risk., Aim: In the present BORICC Follow-Up (BFU) Study, we are using a longitudinal study design to investigate the effects of ageing (12+ years) and lifestyle factors on biomarkers of CRC risk and on healthy ageing., Methods: BFU Study participants attended a study visit at North Tyneside General Hospital (UK) for collection of biological samples, including blood and rectal biopsies, and information collected included anthropometric measurements, a Health & Medications Questionnaire, physical activity and sedentary behaviour, and habitual diet. Furthermore, musculoskeletal function was assessed by heel bone densitometry, timed up and go and hand grip strength as markers of healthy ageing. The BFU Study outcomes will be similar to those measured at baseline in the BORICC Study, such as DNA methylation and mitochondrial function, with additional measurements including the gut microbiome, faecal short-chain fatty acid concentrations and expression of genes associated with CRC., Results: Participants' recruitment to BFU Study and all sample and data collection have been completed. Forty-seven of the original BORICC participants were re-recruited to the BFU Study (mean age 67 years, 51% female). The recruits included 37 initially healthy participants and 10 participants who had adenomatous polyps at baseline. Approximately 70% of participants were over-weight or obese., Conclusion: Ultimately, identifying lifestyle factors that can reduce CRC risk, and understanding the underlying mechanisms for the effects of lifestyle and ageing on CRC risk, could lead to early prevention strategies.

Colorectal cancer (CRC) is the third most common cancer globally. CRC risk is increased by obesity, and by its lifestyle determinants notably physical inactivity and poor nutrition. Obesity results in increased inflammation and oxidative stress which cause genomic damage and contribute to mitochondrial dysregulation and CRC risk. The mitochondrial dysfunction associated with obesity includes abnormal mitochondrial size, morphology and reduced autophagy, mitochondrial biogenesis and expression of key mitochondrial regulators. Although there is strong evidence that increased adiposity increases CRC risk, evidence for the effects of intentional weight loss on CRC risk is much more limited. In model systems, energy depletion leads to enhanced mitochondrial integrity, capacity, function and biogenesis but the effects of obesity and weight loss on mitochondria in the human colon are not known. We are using weight loss following bariatric surgery to investigate the effects of altered adiposity on mitochondrial structure and function in human colonocytes. In summary, there is strong and consistent evidence in model systems and more limited evidence in human subjects that over-feeding and/or obesity result in mitochondrial dysfunction and that weight loss might mitigate or reverse some of these effects.

Background: Participation at the recommended intervals is critical for screening to be effective in reducing colorectal cancer (CRC) incidence. This study describes patterns of screening participation over four rounds of fecal immunochemical testing (FIT) to identify whether demographic variables and prior screening satisfaction are significantly associated with patterns of re-participation., Methods: Baseline surveys were mailed to 4000 South Australians randomly selected from the electoral-roll. Respondents (n = 1928/48.2%) were offered four annual FIT rounds. Screening participation and satisfaction at each round were recorded., Results: Study participation was 58.5, 66.9, 73.1 and 71.4% respectively over four rounds. Three participation patterns were described: consistent participation (43.1%), consistent non-participation (26.4%) and inconsistent participation (changeable; 30.5%), including intermittent and sustained change patterns. Sustained change described those who changed participatory behavior and then maintained for at least two rounds (n = 375/19.5%). Older people, and those not working were most likely to sustain participation. Younger invitees, especially men, were more likely to change participatory behavior and sustain the change. People with higher disadvantage, less education, not working and with no prior (pre-trial) screening experience were more likely to start participating and drop out. People dissatisfied with a prior screening test, including finding aspects embarrassing or unpleasant, were also more likely not to participate in annual screening or to drop out., Conclusions: The findings identify those at risk of non- or inconsistent participation in rescreening. They should aid targeting of interventions for demographic groups at risk and ensuring screening experiences are not perceived as unpleasant or difficult.

Men's participation in cancer screening may be influenced by their thinking style. Men's need for cognition (NFC) and faith in intuition were measured to explore whether they varied by demographic variables or predicted screening behavior. Australian males ( n = 585, aged 50-74 years) completed surveys about past screening and were subsequently offered mailed fecal occult blood tests (FOBTs). Demographic predictors included age, socioeconomic status, educational attainment, and language spoken at home. The screening behaviors were self-reported prostate cancer screening (prostate-specific antigen testing and digital rectal examinations [DREs]), and colorectal cancer screening (self-reported FOBT participation and recorded uptake of the FOBT offer). Analysis comprised principal component analysis and structural equation modelling. NFC was positively related to demographic variables education, socioeconomic status, and speaking English at home. Faith in intuition was negatively related to educational attainment. NFC predicted variance in self-reported DRE participation ( r = .11, p = .016). No other relationships with thinking style were statistically significant. The relationship of NFC to DRE participation may reflect the way certain attributes of this screening method are processed, or alternatively, it may reflect willingness to report participation. The relationship of thinking style to a range of healthy behaviors should be further explored.

Objective . Bowel cancer is currently the second leading cause of cancer-related death in Australia and screening participation is suboptimal. This study examined the role of emotion in the form of anticipated regret (AR) and its relationship to screening intentions. Methods . N = 173 persons aged 45 to 80 years completed a survey measuring demographic variables, readiness to screen, relative importance of health by comparison to other life priorities, satisfaction with current health, and AR if not participating in future bowel cancer screening. Results . AR was a significant predictor of future screening intentions. Those with higher levels of AR were seven times more likely (OR = 7.18) to intend to screen in the future compared to those with lower AR. This relationship was not compromised when controlling for other variables including gender and satisfaction with one's health. AR levels were significantly lower in people who had been screened previously and in those with full health insurance. Conclusions . These results demonstrate that AR is uniquely related to future bowel cancer screening intentions. Future studies should continue to consider this as a useful target for behavioural interventions and identify new ways of delivering these interventions to improve their reach., Competing Interests: The authors declare that there is no conflict of interests regarding the publication of this paper.

Objective: Emerging blood-based screening technologies for bowel cancer may improve screening participation compared to at-home stool sampling. This study assessed the impact of different screening delivery scenarios with increasing health system interactions on sampling preferences and likelihood of screening participation., Methods: N=1,561 persons aged 45 to 74 years completed a behavioural survey measuring demographics, readiness to screen, overall collection method preference, and proposed participation in stool and blood methods across four screening scenarios differing in terms of the number of required health system interactions., Results: Overall, respondents preferred a blood test (79.6%) compared to a stool test (20.4%). However, increasing health system interactions had a strong impact on the likelihood of participating in either sampling method (p<0.001). Moreover, likelihood of participating in each of the four blood-screening scenarios was significantly lower than the current at-home stool sampling approach (all p<0.001)., Conclusions: Blood-based screening methods require increased contact with the health system but these interactions have negative impact on screening likelihood. All blood-based scenarios showed lower screening likelihood ratings than the current at-home FIT approach. Thus, blood-based screening may not resolve suboptimal screening participation rates in Australia., (© 2016 Public Health Association of Australia.)

Background: In Australia, bowel cancer screening participation using faecal occult blood testing (FOBT) is low. Decision support tailored to psychological predictors of participation may increase screening. The study compared tailored computerised decision support to non-tailored computer or paper information. The primary outcome was FOBT return within 12 weeks. Additional analyses were conducted on movement in decision to screen and change on psychological variables., Methods: A parallel, randomised controlled, trial invited 25,511 people aged 50-74 years to complete an eligibility questionnaire. Eligible respondents (n = 3,408) were assigned to Tailored Personalised Decision Support (TPDS), Non-Tailored PDS (NTPDS), or Control (CG) (intention-to-treat, ITT sample). TPDS and NTPDS groups completed an on-line baseline survey (BS) and accessed generic information. The TPDS group additionally received a tailored intervention. CG participants completed a paper BS only. Those completing the BS (n = 2270) were mailed an FOBT and requested to complete an endpoint survey (ES) that re-measured BS variables (per-protocol, PP sample)., Results: FOBT return: In the ITT sample, there was no significant difference between any group (χ (2)(2) = 2.57, p = .26; TPDS, 32.5%; NTPDS, 33%; and CG, 34.5%). In the PP sample, FOBT return in the internet groups was significantly higher than the paper group (χ (2)(2) = 17.01, p < .001; TPDS, 80%; NTPDS, 83%; and CG, 74%). FOBT completion by TPDS and NTPDS did not differ (χ (2)(1) = 2.23, p = .13). Age was positively associated with kit return. Decision to screen: 2227/2270 of the PP sample provided complete BS data. Participants not wanting to screen at baseline (1083/2227) and allocated to TPDS and NTPDS were significantly more likely to decide to screen and return an FOBT than those assigned to the CG. FOBT return by TPDS and NTPDS did not differ from one another (OR = 1.16, p = .42). Change on psychosocial predictors: Analysis of change indicated that salience and coherence of screening and self-efficacy were improved and faecal aversion decreased by tailored messaging., Conclusions: Online information resources may have a role in encouraging internet-enabled people who are uncommitted to screening to change their attitudes, perceptions and behaviour., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12610000095066.

Background: Social cognitive variables are often examined for their association with initial participation in colorectal cancer screening. Few studies have examined the association of these variables with adherence to multiple screening offers i.e., rescreening. This study aimed to describe patterns of participatory behaviour after three rounds of screening using faecal immunochemical tests (FIT) and to determine social cognitive, demographic and background variables predictive of variations in adherence., Methods: Participants were 1,540 men and women aged 50 to 75 living in South Australia who completed a behavioural survey measuring demographic (for example, age, gender) and social cognitive variables relevant to FIT screening (for example, perceived barriers, benefits, self-efficacy). The survey was followed by three, free FIT screening offers mailed on an annual basis from 2008 to 2010. Patterns of participation after three screening rounds were described as one of five screening behaviours; 1) consistent re-participation (adherent with all screening rounds), 2) consistent refusal (adherent with no screening rounds), 3) drop out (adherent with earlier but not later rounds), 4) intermittent re-participation (adherent with alternate rounds) and 5) delayed entry (adherent with later but not initial round(s)). Univariate (Chi Square and Analysis of Variance) and multivariate (Generalised Estimating Equations) analyses were conducted to determine variables predictive of each category of non-adherence (those that did not participate in every screening offer, groups 2, 3, 4 and 5) relative to consistent re-participation., Results: Significant social cognitive predictors of non-adherence were; less self-efficacy (drop out and consistent refusal), greater perceived barriers (drop out) and lower levels of response efficacy (consistent refusal). Demographic predictors of non-adherence included; male gender (delayed entry), younger age (intermittent, delayed and consistent refusal), less frequent GP visits (intermittent re-participation) and 'ancillary only' private health insurance (drop out). Less satisfaction with screening at baseline predicted drop out, consistent refusal and delayed entry., Conclusions: Different combinations of demographic and behavioural variables predicted different patterns of rescreening adherence. Rescreening interventions may benefit from a targeted approach that considers the different needs of the population subgroups. Satisfaction with past FOBT screening measured prior to the study screening offers was an important predictor of adherence.

Background: The continuum of resistance model contends that respondents lie at one end of a continuum and non-respondents at the other with respect to factors demonstrated to impact on screening participation., Purpose: The aim of this study was to explore the validity of this model for the prediction of participation in colorectal cancer screening., Method: People aged 50 to 74 years were asked to complete a survey (n = 1,250). Eligible respondents (n = 376, 30 %) were invited to complete a faecal occult blood test (FOBT). The cutoff period for the determination of participation rates was 12 weeks, with a reminder sent at 6 weeks., Results: FOBTs were returned by n = 196 people (132 within 6 weeks, 64 following a reminder). Participation was generally influenced by the same variables in both the first 6 weeks and the second 6 weeks, consistent with the continuum of resistance model. These variables were having known someone with bowel cancer and the social cognitive factor, perceptions of barriers to screening. There is a suggestion, however, that other factors may be differentially associated with early, late and non-participants., Conclusion: Participation in screening appears somewhat consistent with the continuum of resistance model in that early and late participants respond to some of the same factors. This suggests that the same messages are relevant to early, late and non-screeners, but further consideration of what other factors may be influencing discrete stages of readiness to participate is necessary.

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, and an ideal target for early detection and prevention through cancer screening. Unfortunately, rates of participation in screening are less than adequate. In this article we explore why people who were offered a fecal immunochemical test for CRC decided to participate or not, and for those who did participate, what influenced them to take action and complete the test. We conducted four focus groups and 30 telephone interviews with 63 people. The main reason people decided to screen was "wanting to know" their CRC status, which operated on a continuum ranging from wanting to know, through varying degrees of ambivalence, to not wanting to know. The majority of participants expressed ambivalence about CRC screening, and the main cue to action was the opportunity to screen without being too inconvenienced.

Background: Men have a significantly increased risk of being diagnosed with, and dying from, colorectal cancer (CRC) than women. Men also participate in fecal occult blood test (FOBT) screening at a lower rate than women. This study will determine whether strategies that target men's attitudes toward screening, and matched to stage of readiness to screen, increase men's FOBT participation compared to a standard approach., Methods/design: Eligible trial participants will be a national sample of 9,200 men aged 50 to 74 years, living in urban Australia and randomly selected from the Australian electoral roll. Trial participants will be mailed an advance notification letter, followed 2 weeks later by an invitation letter and a free fecal immunochemical test (FIT) kit. The intervention is a factorial design, randomized controlled trial (RCT) with four trial arms, including a control. The content of the advance notification and invitation letters will differ by trial arm as follows: 1) standard advance notification and standard invitation (control arm); 2) targeted advance notification and standard invitation; 3) standard advance notification and targeted invitation; and 4) targeted advance notification and targeted invitation. The standard letters will replicate as closely as possible the letters included in the Australian National Bowel Cancer Screening Program (NBCSP). Modified advance notification and invitation letters will incorporate additional messages to target men in the precontemplation (advance notification) and contemplation stages (invitation). The primary outcome is return of the completed FIT within 12 weeks of invitation. Analysts will be blinded to trial assignment and participants will be blinded to the use of varying invitational materials. Subsamples from each trial arm will complete baseline and endpoint surveys to measure the psychological impact of the intervention, and qualitative interviews will be conducted to evaluate attitudes toward the intervention., Discussion: The outcomes of this study will have implications for the way FOBT screening is offered to men. Findings will help to identify how invitations for men to screen should be framed and delivered in order to maximize participation., Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12612001122842.

Issue Addressed: This study used the Transtheoretical Model of Behaviour Change (TTM) to describe reparticipation in colorectal cancer (CRC) screening according to social cognitive and background variables., Methods: A random sample of men and women aged 50-74 years living in South Australia completed a questionnaire measuring TTM stage and attitudes toward screening using a faecal occult blood test (FOBT). Participants were categorised according to four stages of readiness to rescreen: action, maintenance, relapse and inconsistent. Multivariate techniques were used to determine predictors of lower readiness stages compared with maintenance., Results: Of the 849 study participants, 29.9% were either non-adherent or had no intentions to maintain adherence (inconsistent and relapse). Compared with maintenance rescreeners, relapse participants reported less: social influences to screen (RR=0.86, p<0.001); satisfaction with prior screening (RR=0.87, p=0.03), self-efficacy (RR=0.96, p=0.01); and screening benefits (RR=0.84, p<0.001). Relapse participants were also more likely to not have private health insurance (RR=1.33, p=0.04) and be unaware of the need to repeat screening (RR=1.41, p=0.02). Inconsistent screeners were less likely to have planned when they will next rescreen (RR= 0.84, p=0.04) and reported greater barriers to rescreening (RR=1.05, p=0.05). Action participants were younger (RR= 0.98, p=<0.001), reported less social influences to screen (RR=0.94, p<0.001) and were less likely to have known someone who has had CRC (RR=0.82, p=0.01)., Conclusions: Social cognitive, demographic and background variables significantly differentiated screening maintenance from lower readiness stages.

Background: There is little information on longitudinal patterns of participation in faecal occult blood test (FOBT) based colorectal cancer (CRC) screening or on demographic or behavioural factors associated with participation in re-screening. The lack of an agreed system for describing participatory behaviour over multiple rounds also hampers our ability to report, understand and make use of observed associations. Our aims were to develop a system for describing patterns of participatory behaviour in FOBT-based CRC screening programs and to identify factors associated with particular behavioural patterns., Method: A descriptive framework was developed and applied to a data extract of screening invitation outcomes over two rounds of the NBCSP. The proportion of invitees in each behaviour category was determined and associations between behaviour patterns and demographic and program factors were identified using multivariate analyses., Results: We considered Re- Participants, Dropouts, Late Entrants and Never Participants to be the most appropriate labels for the four possible observed participatory categories after two invitation rounds. The screening participation rate of the South Australian cohort of the NBCSP remained stable over two rounds at 51%, with second round Dropouts (10.3%) being balanced by Late Entrants (10.5%). Non-Participants comprised 38.7% of invitees. Relative to Re-Participants, Dropouts were older, more likely to be female, of lower SES, had changed their place of residence between offers had a positive test result in the first round. Late Entrants tended to be in the youngest age band., Conclusions: Specific demographic characteristics are associated with behavioural sub-groups defined by responses to 2 offers of CRC screening. Targeted group-specific strategies could reduce dropout behaviour or encourage those who declined the first invitation to participate in the second round. It will be important to keep first round participants engaged in order to maximise the benefit of a CRC screening program.

Background: Population screening reduces mortality from colorectal cancer, yet factors associated with uptake of screening are incompletely understood., Purpose: The purpose of the study was to determine demographic and psychosocial factors associated with participation in faecal occult blood test (FOBT)-based colorectal cancer (CRC) screening in an average risk community programme in Adelaide, South Australia., Method: A questionnaire consistent with the Preventive Health Model was used to determine demographic and psychosocial differences between previous FOBT-based screening participants (n = 413, response rate 93.2%) and non-participants (n = 481, response rate 47.9%). Results were analysed by univariate and multivariate generalised linear modelling, and factors associated with participation were identified., Results: Factor analysis of psychosocial items revealed an optimal three-factor solution (knowledge, faecal aversion, belief in the value of screening). Following multivariate analyses, two psychosocial and two demographic factors remained as predictors of FOBT screening behaviour: (1) items related to faecal aversion (Aversion), relative risk (RR) = 0.61, CI = 0.55-0.69, (2) perceptions about the value of screening (Value), RR = 1.45, CI = 1.13-1.85, (3) age band 65-69 (Age, five age bands, relative to age 50-54), RR = 1.43, CI = 1.16-1.76 and FOBT type (Test; three tests, Hemoccult, FlexSure, InSure randomly assigned, relative to Hemoccult: FlexSure: RR = 1.41, CI = 1.17-1.71, InSure: RR = 1.76, CI = 1.47-2.11., Conclusions: The psychosocial factors associated with non-participation in FOBT-based CRC screening are amenable to interventions designed to improve participation. The small relative risks values associated with each predictor, however, raise the possibility that additional factors are likely to influence screening participation.

Background: Previous research points to differences between predictors of intention to screen for colorectal cancer (CRC) and screening behavior, and suggests social ecological factors may influence screening behavior. The aim of this study was to compare the social cognitive and social ecological predictors of intention to screen with predictors of participation., Methods: People aged 50 to 74 years recruited from the electoral roll completed a baseline survey (n = 376) and were subsequently invited to complete an immunochemical faecal occult blood test (iFOBT)., Results: Multivariate analyses revealed five predictors of intention to screen and two predictors of participation. Perceived barriers to CRC screening and perceived benefits of CRC screening were the only predictor of both outcomes. There was little support for social ecological factors, but measurement problems may have impacted this finding., Conclusions: This study has confirmed that the predictors of intention to screen for CRC and screening behaviour, although overlapping, are not the same. Research should focus predominantly on those factors shown to predict participation. Perceptions about the barriers to screening and benefits of screening are key predictors of participation, and provide a focus for intervention programs.

Background: Australia has a comparatively high incidence of colorectal (bowel) cancer; however, population screening uptake using faecal occult blood test (FOBT) remains low. This study will determine the impact on screening participation of a novel, Internet-based Personalised Decision Support (PDS) package. The PDS is designed to measure attitudes and cognitive concerns and provide people with individually tailored information, in real time, that will assist them with making a decision to screen. The hypothesis is that exposure to (tailored) PDS will result in greater participation in screening than participation following exposure to non-tailored PDS or resulting from the current non-tailored, paper-based approach., Methods/design: A randomised parallel trial comprising three arms will be conducted. Men and women aged 50-74 years (N = 3240) will be recruited. They must have access to the Internet; have not had an FOBT within the previous 12 months, or sigmoidoscopy or colonoscopy within the previous 5 years; have had no clinical diagnosis of bowel cancer. Groups 1 and 2 (PDS arms) will access a website and complete a baseline survey measuring decision-to-screen stage, attitudes and cognitive concerns and will receive immediate feedback; Group 1 will receive information 'tailored' to their responses in the baseline survey and group 2 will received 'non-tailored' bowel cancer information. Respondents in both groups will subsequently receive an FOBT kit. Group 3 (usual practice arm) will complete a paper-based version of the baseline survey and respondents will subsequently receive 'non-tailored' paper-based bowel cancer information with accompanying FOBT kit. Following despatch of FOBTs, all respondents will be requested to complete an endpoint survey. Main outcome measures are (1) completion of FOBT and (2) change in decision-to-screen stage. Secondary outcomes include satisfaction with decision and change in attitudinal scores from baseline to endpoint. Analyses will be performed using Chi-square tests, analysis of variance and log binomial generalized linear models as appropriate., Discussion: It is necessary to restrict participants to Internet users to provide an appropriately controlled evaluation of PDS. Once efficacy of the approach has been established, it will be important to evaluate effectiveness in the wider at-risk population, and to identify barriers to its implementation in those settings., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12610000095066.

Studies with minority ethnic communities worldwide reveal important differences in the content of beliefs about cancer and attitudes towards screening. Current initiatives in colorectal cancer (CRC) screening highlight the importance of identifying any illness-specific beliefs that might influence participation rates within the targeted age-range. We conducted semi-structured interviews with 20 Italian-Australians aged between 50 and 78 years, living in Adelaide, South Australia. Qualitative data from the interviews were analysed using framework analysis. Participants articulated specific beliefs about the nature of cancer, risk factors, prevention possibilities, and variety of potential barriers and benefits to faecal occult blood testing (FOBT). Although participants'beliefs overlapped with conventional medical models of cancer, the results also demonstrated the presence of specific cultural perceptions that might influence FOBT participation. Our results suggest that models used to inform communication about cancer need to be sensitive to culture specific concerns. Within the context of the older Italian-Australian community, there is a suggestion that self and response efficacy may be serious barriers to screening behavior and that bi-lingual, verbal delivery of information may be the most effective mode of communication to increase screening participation.

Objective: To describe the distribution of a population in southern urban Adelaide in terms of readiness to screen for colorectal cancer (CRC) by Faecal Occult Blood Test (FOBT) or colonoscopy according to the stages in the Transtheoretical Model (TTM) of behaviour change and to compare the stages according to demographic variables., Methods: A random sample of 664 South Australians aged 50 to 74 were surveyed in June 2006. Chi-squared analyses were performed to determine if statistically significant differences on demographic variables existed between participants at different stages of readiness to screen., Results: The precontemplation and contemplation stages when combined equated to more than half of the total respondents. Several significant differences were identified between the stages. Those in both the precontemplation and contemplation stages were older than those in the remaining stages and also had a significantly higher proportion of women when compared to the action stage. In the precontemplation stage there were significantly more respondents for whom English was a second language, and low levels of private health insurance, whereas the contemplation stage had the highest proportion of Australian-born respondents. Interestingly, levels of private health insurance were also low among those who intended to screen with colonoscopy., Conclusions and Implications: The majority of the population were not found to have progressed beyond contemplation. Certain demographic characteristics varied significantly between people at different stages of readiness to screen for CRC.

Objectives: To determine the impact of novel invitation strategies on population participation in faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening., Setting: A community screening programme in Adelaide, South Australia., Methods: In total, 2400 people aged 50-74 years were randomly allocated to one of four CRC screening invitation strategies: (a), Control: standard invitation-to-screen letter explaining risk of CRC and the concept, value and method of screening; (b) Risk: invitation with additional messages related to CRC risk; (c) Advocacy: invitation with additional messages related to advocacy for screening from previous screening programme participants and (d) Advance Notification: first, a letter introducing CONTROL letter messages followed by the standard invitation-to-screen. Invitations included an FIT kit. Programme participation rates were determined for each strategy relative to control. Associations between participation and sociodemographic variables were explored., Results: At 12 weeks after invitation, participation was:, Control: 237/600 (39.5%); Risk: 242/600 (40.3%); Advocacy: 216/600 (36.0%) and Advance Notification: 290/600 (48.3%). Participation was significantly greater than CONTROL only in the Advance Notification group (Relative risk [RR] 1.23, 95% confidence interval [CI] 1.06-1.43). This effect was apparent as early as two weeks from date of offer; Advance Notification: 151/600 (25.2%) versus, Control: 109/600 (18.2%, RR 1.38, 95% CI 1.11-1.73)., Conclusions: Advance notification significantly increased screening participation. The effect may be due to a population shift in readiness to undertake screening, and is consistent with the Transtheoretical Model of behaviour change. Risk or lay advocacy strategies did not improve screening participation. Organized screening programmes should consider using advance notification letters to improve programme participation.

To better understand the personal barriers that limit participation in faecal occult blood test (FOBT) screening for colorectal cancer, non-participants from a recent screening initiative were sent detailed questionnaires, defining their reasons for not participating, as well as how to make screening more attractive. The important barrier was procrastination. The type of FOBT kit offered influenced the reasons for not participating. Convenient FOBT and greater general practitioner involvement may be important for optimizing community acceptance of FOBT-based screening.