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Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: An integrative literature review
Accepted Manuscript Title: Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: An integrative literature review Author: Julia Morris David Preen Angelita Martini PII: DOI: Reference:
S0738-3991(16)30210-5 http://dx.doi.org/doi:10.1016/j.pec.2016.05.012 PEC 5344
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
11-12-2015 25-4-2016 14-5-2016
Please cite this article as: Morris Julia, Preen David, Martini Angelita.Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: An integrative literature review.Patient Education and Counseling http://dx.doi.org/10.1016/j.pec.2016.05.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: an integrative literature review
Authors Julia Morris Research Associate, Center for Health Services Research, School of Population Health, The University of Western Australia Address: 35 Stirling Hwy, Crawley 6009, Western Australia Email: [email protected] Phone: +61405732352
David Preen Chair in Public Health, School of Population Health, The University of Western Australia Address: 35 Stirling Hwy, Crawley 6009, Western Australia Email: [email protected] Phone: +610864881307 Corresponding Author at: Angelita Martini Senior Lecturer, Center for Health Services Research, School of Population Health, The University of Western Australia Address: 35 Stirling Hwy, Crawley 6009, Western Australia Email: [email protected] Phone: +610864882989
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Abstract Objective: This paper reviewed the relationship between non-clinical, client-oriented promotional campaigns to raise bowel cancer awareness and screening engagement. Method: An integrative literature review using predefined search terms was conducted to summarise the accumulated knowledge. Data was analysed by coding and categorising, then synthesized through development of themes. Results: Eighteen of 116 studies met inclusion criteria. Promotional campaigns had varying impact on screening uptake for bowel cancer. Mass media was found to moderately increase screening, predominately amongst “worried well”. Small media used in conjunction with other promotional activities, thus its effect on screening behaviours was unclear. One-on-one education was less effective and less feasible than group education in increasing intention to screen. Financial support was ineffective in increasing screening rates when compared to other promotional activities. Screening engagement increased because of special events and celebrity endorsement. Conclusion: Non-clinical promotional campaigns did impact uptake of bowel cancer screening engagement. However, little is evident on the effect of single types of promotion and most research is based on clinician-directed campaigns. Practice Implications: Cancer awareness and screening promotions should be implemented at community and clinical level to maximize effectiveness. Such an approach will ensure promotional activities are targeting consumers, thus strengthening screening engagement.
Keywords: bowel cancer, CRC, screening, promotion, campaign, intervention.
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1. Introduction Bowel or colorectal cancer is the third most common cancer in the world [1], with nearly 1.4 million new cases and 694,000 estimated deaths in 2012 [2]. The incidence of bowel cancer is increasing in certain countries where risk was historically low [3]. Bowel cancer is one of Australia’s most common cancers and it is estimated that by 2016, there will be almost 18,000 newly diagnosed cases of the disease [4]. Every week, around 80 Australians die from bowel cancer [5]. Fortunately, bowel cancer is one of the most curable types of cancer if it is found early [5]. Currently, early detection is the best protection against bowel cancer for those at risk of the disease. Methods for early detection include the faecal occult blood test (FOBT), colonoscopy, and endoscopy. Several randomised controlled trials have demonstrated that [6] colorectal cancer mortality can be reduced by 15–33% through regular bowel screening using FOBT [7]. Australia is one of a few countries, along with the United Kingdom, France, and Germany, to implement a nationwide government-funded FOBT screening program that enables the detection of bowel cancers prior to sufferers becoming symptomatic [5]. Despite the efforts of Australia’s national screening program, bowel cancer screening rates are at the suboptimal rate of 36% [8]. The highest rate of participation was by people aged 65 years (41.6%), followed by those aged 55 years (33.2%). The lowest rate of participation was among 50 year-olds (27.4%) [6]. The burden of the disease is often undermined [9], and many people avoid being screened [10] due to a variety of issues. Among 40 – 70 year olds, only 53% have knowledge of the symptoms indicative of bowel cancer [4]. Roughly 50% of adults are unaware of the age at which screening should commence [4], and do not understand the need for regular screening [9] due to the nature of the disease. Furthermore, 50% of adults in the aforementioned cohort are unaware that bowel cancer affects both men and women [4], which is similar to a common misconception that women are protected from the disease because of their gender [9]. Evidently, raising awareness and promoting the prevention of bowel cancer has a number of challenges. Barriers that stop people from screening for bowel cancer can be resolved [9] through interventions that educate consumers about the benefits of early detection through screening [11]. Promotional activities are necessary as raising awareness regarding cancer is likely to lead to an increase in screening participation, and eventually a decrease in related mortality rates [8, 12]. The purpose of promotional activities is to motivate change and maintain positive health behaviours at the population level [13, 14]. In regards to bowel cancer, the level of impact and effectiveness of promotional activities is not entirely clear [8]. However, the effect of awareness activities has been demonstrated for other health behaviours [14]. For example, there is strong empirical evidence that mass media campaigns reduce smoking prevalence and promote quitting [15]. Furthermore, public health campaigns aimed at reducing coronary heart disease are estimated to be responsible for a 30% reduction in cholesterol over 30 years [16]. Given these examples, the benefit of cancer awareness raising activities should not be underestimated [16], and instead warrants further investigation. Several researchers have attempted to evaluate the effectiveness of promotional campaigns in raising awareness and motivating screening, for bowel and other cancers [13, 17-39]. Outcomes of such research have varied. This paper sought to review the existing published evidence regarding the relationship of non-clinical promotional campaigns aimed at increasing colorectal (CRC) screening uptake and screening engagement. By focusing on non-clinical initiatives, we will review campaigns that have potential to be initiated at the community or lay health worker level. Community-level campaigns are an important strategy in increasing screening rates and reducing disparities among population groups [40]. This paper sought to evaluate initiatives that are not based on psychosocial or behaviour change models (e.g. Health Behaviour Model) or interventions directed to or from healthcare providers and physicians, such as the use of client reminders or mailed FOBT kits. Instead, this paper will focus on the efficacy of marketing and communication promotional campaigns that motivate and enable clients to increase control over and improve their health [41] in terms of CRC prevention and detection. These will include small and mass media campaigns, celebrity endorsements, special events and group/one-on-one education. For discussion purposes, comparisons will be made to promotional campaigns advocating for other cancer screening. As bowel cancer is also known as CRC these terms will be used interchangeably. 2. Methods 2.1 Literature Search An integrative literature review was undertaken in this paper as it aims to create new understandings of a topic through a process that involves reviewing, critiquing and synthesising representative literature [42]. The identification and analysis of literature was completed in two stages by two investigators.
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First, a search of peer-reviewed literature published between 1995 and 2015 was performed using predefined key search terms: ‘bowel cancer’; ‘colorectal cancer’; ‘CRC’; ‘screen’; ‘screening’; ‘FOBT’; ‘faecal occult blood test’; ‘colonoscopy’; ‘endoscopy’; ‘promotion’; ‘promotional activity’; ‘activities; campaign’; ‘intervention’; ‘group education’; ‘one-on-one education’; ‘celebrity’; ‘education’; ‘special event’; ‘small media’; ‘mass media’; ‘media’; ‘lay health’; ‘expense’; ‘cost’; and ‘out of pocket’. Databases were searched through the University of Adelaide and The University of Western Australia Libraries’ electronic databases that included PubMed, Science Direct, BioMed Central, Wiley, BMC Cancer, ProQuest, Elsevier, OvidSP, and EBSCO. Additional targeted searches were carried out using Google and Google Scholar to access relevant literature missed by the main databases. Reference lists of retrieved literature were examined in order to find further suitable articles. 2.2 Inclusion criteria The second stage of the integrative review involved a preliminary reading of 116 relevant articles retrieved in the literature search to determine their suitability for inclusion. This stage was completed by two of the investigators. Inclusion criteria were peer-reviewed literature that was written in English, published in the last 20 years (1995 – 2015) from international and national sources. Evidence was included if it reported the use of promotional campaigns to raise bowel cancer awareness and resulting screening behaviours (i.e. increase or decrease in screening, no change). Outcomes had to be measured in actual screening rates, or intention to screen, rather than projected or estimated rates. Research often measured screening outcomes for various cancers and therefore studies that considered colorectal alongside other cancers (e.g. colorectal and cervical) were included. Studies were assessed and included if impact was only measured through promotional campaigns. Studies were discarded if they considered only clinician-based interventions; directed to or from healthcare providers or physicians. Studies were also discarded if interventions were tailored on the basis of psychosocial or behaviour change models. Other outcomes measured in the studies (e.g. attitude change or increased knowledge) were also reported. 'Grey' literature has been included in the discussion. Through this process, 18 studies were identified that met the inclusion criteria. Due to the limited number of studies in the area, multiple methodologies and study designs were considered. 2.3 Data analysis The third stage of the integrative literature review was a thematic analysis [15] completed by two investigators. The 18 retrieved studies were initially coded to facilitate the distinction of key elements and features. These codes were then classified and reassembled into a coherent order, from which converging and diverging patterns in the literature were identified. The codes were counted and formatted, and similar codes were grouped together under themes. Finally, the research team examined and validated conclusions drawn under each major theme 2.4 Synthesis of results The aforementioned data analysis resulted in the identification of seven promotion campaigns: mass media; small media; group education; one-on-one education; financial support; special events; and celebrity endorsement. All included intervention components or activities are described in Table 1.
3. Results 3.1 Search Results Study source, aims, study design, and outcomes of the 18 studies that met inclusion criteria are summarised in Table 2. Of the 18 studies identified [24, 27, 29, 34, 43-56], 12 investigated a single promotional activity [24, 27, 29, 34, 43, 45, 46, 48, 50, 51, 55, 56], and six were multi-component activities [44, 47, 49, 52-54]. Four studies used mass media [24, 43, 51, 53], two used small media [47, 54], nine used group education [44-46, 48-50, 54-56], four used one-on-one education [44, 47, 49, 52], one used financial support [44], four used special events [29, 47, 52, 54], and two considered celebrity endorsement [27, 34]. All mass media interventions also incorporated small media components [25, 43, 51, 53, 57]. Eight studies were culturally targeted: seven specifically focused on whether adapting the interventions changed screening outcomes [44-50] whilst another focused on culturally respectful methods to increase CRC awareness [55]. Five studies were based on culturally adapted group education [45, 46, 48, 50, 55], and the remaining three multi-component interventions [44, 47, 49]. 3.2 Promotional campaigns Results of the various promotional campaigns varied, as did the methodological approaches of the studies. The results of each type of promotional campaign identified in the literature are discussed in turn. 3.2.1 Mass media
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Studies using mass media campaigns reported a subsequent increased screening uptake in the investigated populations [24, 43, 51, 53]. Snowball et al. [53] reported a small increase, and Bethune et al. [43] reported an increase that was not statistically significant. Peacock et al. [51] found that the increased screening (59%) was mostly among the “worried well”- individuals who were symptomless and healthy but pursued screening. On the other hand, Cooper et al. [24] found that the frequency of exposure to the mass media campaign was positively linked to screening participation and knowledge. Three of the four mass media campaigns detected a significant increase in referrals to health practitioners [43, 51, 53]. 3.2.2 Small media Small media was used in two studies alongside special events [47, 54]. Neither study measured the direct effect of small media on screening behaviour. 3.2.3 Group education Group education was used as a standalone activity in six studies [45, 46, 48, 50, 55, 56], and alongside other strategies in three multi-component campaign studies [44, 47, 49, 54]. In each of the multicomponent interventions, the effect of the group education was measured. Blumenthal et al. [44] found group education was the most successful in increasing screening rates (33.9%) compared to the other components (one-on-one education (25.4%) and financial support (22.2%)). The special event that integrated group education found that 53.2% of those who participated in the component expressed a future intention to screen [54]. Larkey et al. [49], found no significant difference in group and one-onone education increasing screening rates, but deemed group education as more feasible. Studies that used group education as a standalone component had variable results [45, 46, 48, 50, 55, 56]. In one study [45], intention to screen was high among people participated in group education (63%), especially if they were previously non-adherent (68%). In another study [55], 31% of participants screened following the intervention and had other positive outcomes in increased physical activity (44%) and intent to discuss screening with family and friends (65%) and their doctor (24%). Conversely, intention to screen was lower (30%), but still statistically significant in a third study [46], and two studies [48, 50] reported an improvement in screening rates, but at a suboptimal level (4% and 10% increase respectively). Finally, one study showed that group education combined with peer support and personal narratives increased motivation to screen at one month, but no effect in actual screening rates was found at 6 months [56]. 3.2.4 One-on-one education One-on-one education was used in multi-component initiatives [44, 47, 49, 52] and its implementation was only evaluated in two of these initiatives. When compared to group education, one-on-one education was less effective in increasing screening uptake [44] and deemed less feasible [49].
3.2.5 Financial support Only one study considered financial support in promoting CRC screening [44]. Participants who received compensation for screening were more likely to screen than participants in the control group (22.2% and 17.7% respectively), but less likely to screen than participants who received group or oneon-one education (33.9% and 25.4% respectively). 3.2.6 Special events Screening rates increased across the four studies that measured the impact of special events [29, 47, 52, 54]. Three studies measured screening outcomes post-event [47, 52, 54]. In one follow-up study, colorectal screening had increased in men (36%) and women (40%) [47]. In another study, 45% completed a FOBT, 29% completed a colonoscopy, 1% had a flexible sigmoidoscopy, and 2% had both FOBT and sigmoidoscopy [54]. In the third study, screening for CRC by FOBT had the highest uptake (29.4%) compared to other cancers (breast exams (15.7%); Pap test (3.9%)) [52]. In the fourth study that measured impact of special events on screening, all participating patients were screened by flexible sigmoidoscopy [29]. However, the purpose of this special event was an onsite screening fair, in which all patients who attended were screened [29]. 3.2.7 Celebrity endorsement Both studies evaluating celebrity endorsements had positive results in terms of promoting engagement with screening for CRC [27, 34]. Larson et al. [34] discovered that of the 52% of adults who reported exposure to celebrity CRC screening endorsements, only 37% indicated it influenced their likelihood to screen. However, these findings may have been influenced by self-report bias. Interestingly, in this study, higher educational attainment was linked to greater exposure to celebrity endorsements, and more favourable reactions [34]. In the other study considering celebrity endorsements, there was a significant increase in CRC screening in the United States following the campaign, and this increase lasted for nine months [27]. Finally, women had greater rates of exposure to celebrity endorsements [34] and higher screening rates than men [27].
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4. Discussion and Conclusion 4.1 Discussion The effectiveness of each mass media campaign was variable. Two studies reported no change in rates of CRC following campaign implementation, despite an increase in screening [43, 51]. Although this suggests more proactivity in screening behaviour, it also indicates that people who are not at risk may be encouraged to screen through mass media. The Community Guide concludes that there is insufficient evidence to support the implementation of mass media campaigns to increase CRC screening rates [38], a finding reiterated in another review [58].Surprisingly, mass media has been found to have impact on other health behaviours regarding cancer. In New South Wales, Australia, mass media campaigns resulted in a 15% increase (16,700 people) in cervical screening among women [36]. In the United Kingdom, bowel cancer advertisements were linked to a 48% increase in general practitioner (GP) visits and a 32% increase in urgent referrals to hospitals [59]. Mass media campaigns have also impacted health behaviours, but only in the short-term. For example, the National Breast Cancer Awareness Month (NBCAM) has successfully promoted early detection [31], but this effect was significant in the period of 1993 to 1995, when advocacy around increased awareness of the disease was expanding rapidly [31]. Mass media campaigns aimed at fighting skin cancer through the promotion of sun protection in Australia have managed to contribute to short-term prevention, but these effects were not sustained [39]. Such a short-term impact was demonstrated in Bethune et al.’s study [43], in which an uptake in referrals and screening dropped off at 3 months and 1 month respectively. Evidently, the effectiveness of mass media interventions is contentious and requires further investigation. Small media’s impact on CRC screening was not measured as a standalone component in any of the studies reviewed. Because of this, it is difficult to determine its direct effect on influencing screening behaviour. Understandably, small media is used in conjunction with other strategies [8, 38], as the provision of videos or printed materials would likely be integrated into larger interventions (e.g. group education sessions or other targeted campaigns). A review by Austoker et al. [18] established that there was insufficient evidence regarding the provision of small media at the community level for promoting cancer awareness. In contrast, a review by Baron et al. [19] found that small media is found to successfully increase mammography and Pap smear screening. This review also concluded that small media is linked to improving CRC screening via FOBT, but its efficacy is undetermined for other procedures (i.e. colonoscopy, sigmoidoscopy, double contrast barium enema) [19]. Additionally,
Australia’s Department of Health suggest that provision of targeted small media will likely increase participation in bowel cancer screening [8]. With the exception of one study [56], each of the promotional activities that used group education (either as standalone or in multi-component programs) was culturally targeted. This was evidently due to the considered cultures valuing the social support aspect [48, 49], storytelling [55], language tailoring [54], which group education can offer. Moreover, group education is flexible in its delivery location and format [10], evident in group education being delivered through theatre groups [46], participants’ homes [50] and community centres and churches [45]. In this review, it appeared that group education had mostly positive results in increasing screening engagement [44-46, 54, 55] although some studies had substandard rates of engagement [48, 50] or found no increase at all [56]. Despite evidence in support of education for increasing screening uptake for breast and cervical cancer screening, other reviews have concluded that there is insufficient evidence regarding its application for CRC screening [38, 60]. One-on-one education appeared to be less effective when compared to group education in increasing CRC screening rates [44, 49]. However, participants in both group and one-on-one education conditions made significant gains in knowledge regarding cancer and its prevention and increased rates among previously non-adherent participants [44, 49]. Although two studies evaluated special events with one-on-one education components, the effect of the education component were not directly measured [47, 52], thus it cannot be definitively established whether its addition directly impacted screening participation.
This review only found one study relating to reducing costs for colorectal cancer screening [44]. Although participants who received financial support had similar screening rates to those who received one-on-one education (22.2% and 25.4% respectively) [44], the Community Guide has concluded that there is insufficient evidence regarding the reduction of out-of-pocket costs for CRC screening [38].
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Although screening rates across the four considered studies were positive, none of the studies had over a 50% increase in actual screening outcomes [29, 47, 52, 54]. In a review by Escoffery et al. [30], it was mentioned that although short-term outcomes such as gains in knowledge may occur, there is little evidence in support of special events’ long-term effectiveness. This was an alternative finding to results of another considered study, as 53.2% of special event participants indicated their intention to have regular screening, but at 12 months, 45% had completed FOBT and 29% had completed colonoscopy [54]. Also of relevance are the safety concerns regarding special events. Although this type of philanthropy may assist the uninsured and underserved populations, they also provoke safety issues regarding the adequacy of procedures, handling of complications and ensuring adherence to optimal standards [29].
Celebrity endorsements had positive outcomes for intention to screen [34] and screening rates [27]. Moreover, when compared to prostate and breast screening, celebrity endorsements influenced CRC screening rates the most (31%, 25% and 37% respectively) [34]. Given this evidence, there clearly is some benefit of celebrity endorsement in promotional campaigns, if certain criterion (e.g. relevance) is satisfied.
There were some limitations to this paper. The dearth in literature regarding non-clinician initiated promotional campaigns’ impact on bowel cancer screening made it difficult to draw any conclusions. Moreover, the studies differed greatly in terms of their methodologies. Additionally, ambiguity exists around measuring the outcome of promotional campaigns. Whilst most studies measure behaviour in response to an invitation to undergo screening [14] many have limitations in terms of measuring what participants engaged in screening. For example, one study (not included in this paper) estimated screening participation from aggregate data from practices within the geographic area of where the study was implemented [61]. Due to the confidentiality restraints, they were unable to identify which screeners had been exposed to the intervention [61]. Such measurement suggests that more robust evidence is required to support arguments regarding campaign effectiveness. Moreover, many attempts to promote bowel screening have failed to systematically evaluate their strategies, or even base their approach on behavioural theories or models [14]. These shortcomings have ultimately undermined the effectiveness and measuring of outcomes in bowel cancer screening activities.
4.2 Conclusion This paper sought to review the relationship between community-focused promotional activities to raise bowel cancer awareness and screening engagement. From the available literature, it was difficult to establish what component of campaigns effectively increased screening engagement. Several studies utilized multi-component interventions, and there was considerable variability across reported findings. The dearth of literature regarding non-clinical promotional activities highlights that research has mostly focused on clinician-led campaigns or psychosocial/behavioural interventions. Despite the importance of such activities, more efforts need to be placed on researching community-led campaigns that are easy to adopt, feasible, and potentially support the reduction of CRC and other cancers at a community level.
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Whilst other cancers (breast, cervical, prostate) have reasonable evidence in terms of promotional campaigns and screening, there is an absence of evidence regarding promotional campaigns for CRC awareness and screening. Evidently, further research is required. More evidence is needed to identify what parts of the population are responsive to certain campaigns, and how to make campaigns work depending on the target audience.
4.3 Practice Implications Further research is required regarding the dual approach of promotional activities and clinical interventions. Standalone non-clinical promotion of CRC awareness and screening may undermine campaign effectiveness, whereas linking it to a clinical setting may increase its legitimacy and importance. Moreover, the promotion of CRC screening by health professionals will likely lead to increased screening rates among consumers. For example, the provision of written or telephone client reminders regarding screening appointments have been effective for increasing FOBT, mammography, and Pap smear test screening. A key driver of screening engagement is the provision of client-oriented promotional activities directed from both community and health care settings.
Conflict of Interest Statement: All authors have seen and approved the manuscript being submitted. They warrant that the article is the authors' original work, has not received prior publication and is not under consideration for publication elsewhere.
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1 Snowball, J., M. Young, and S. Halloran, PWE-092 Will the national awareness and early diagnosis initiative (NAEDI) have an impact on bowel cancer screening activity? Gut, 2012. 61(Suppl 2): p. A334-A335. Wu, T.-Y., et al., Effective Colorectal Cancer Education for Asian Americans: A Michigan Program. Journal of Cancer Education, 2010. 25(2): p. 146-152. Cueva, M., et al., Telenovela: an innovative colorectal cancer screening health messaging tool. Int J Circumpolar Health, 2013. 72: p. 21301. Hwang, K.O., et al., Online narratives and peer support for colorectal cancer screening: a pilot randomized trial. Am J Prev Med, 2013. 45(1): p. 98-107. Cooper, C.P., C.A. Gelb, and K. Lobb, Celebrity appeal: reaching women to promote colorectal cancer screening. J Womens Health (Larchmt), 2015. 24(3): p. 169-73. Decker, K.M. and H. Singh, Reducing inequities in colorectal cancer screening in North America. Journal of Carcinogenesis, 2014. 13: p. 12. Tiffany, C., et al., Improving Awareness and Uptake Rates in Bowel Cancer Screening across Cheshire and Merseyside, in Evaluation of a bowel cancer screening awareness campaign for Cheshire and Merseyside Public Health Network. 2012, ChaMPs: University of Chester. p. 156. Brouwers, M.C., et al., Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline. Implement Sci, 2011. 6: p. 112. Shankleman, J., et al., Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas. Br J Cancer, 2014. 111(7): p. 1440-7.
12 Table 1: Types of promotions identified Mass Media Mass media involves communicating educational and motivational information about screening through television, radio, newspaper, magazines, and billboards. Small Media Small media refers to videos and printed materials designed to educate and motivate people to screen for cancer. Small media can be tailored to an individual, or to a target audience. Group Education Often conducted by health professionals or trained lay people, education regarding cancer and screening information is conveyed to groups in various settings. One-on-One Education Similar to group education, but offered to individuals in person or over the phone. Financial Support Minimisation or removal of economic barriers that impede screening. Special Events Special events seek to raise awareness and encourage screening, especially among those who are uninsured or underserved. Special events include gatherings, fairs, cultural events, and so on. Celebrity Endorsement Celebrity endorsement and advocating on behalf of campaigns for cancer screening.
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Appendix Table 2: Studies considering non-clinical promotional activities that aim to promote CRC screening 1995-2015 Year
Author, Country Resnick [52] USA
Aim of study
Promotion activity
Aim of promotion
Promotion delivery
Study Design
Participants
Impact of a ‘wellness day’ on promoting screening
Type: Special event; One-on-one education
Promote screening and knowledge regarding breast, cervical and colorectal cancer
Special event: retirement community health fair offering free screening and one-to-one education
Quantitative Screening participation rates recorded at event
51 adults (>90 yrs)
2003
Cram et al. [27] USA
Type: Celebrity endorsement
Promote colorectal screening rates
Televised colonoscopy of US Today Show host Katie Couric
Significant increase in colonoscopies following promotional campaign and effect was sustained for 9 months; uptake was greater among women
Larson et al. [34] USA
Type: Celebrity endorsement
Promote colorectal screening rates among adults with no history of cancer
Any celebrity endorsement seen or heard by participants pertaining to promoting screening for breast, prostate, or colorectal cancer
Quantitative Screening rate comparison via Clinical Outcomes Research Initiative (CORI) and managed care data Quantitative Questionnaire administered via telephone (random cold calling)
Adult population data (30-64 yrs)
2005
Impact of celebrity endorsement on population screening rates Impact of celebrity endorsement on screening
500 adults (>40 yrs)
2006
Gellert et al. [47] USA
Impact of cultural health festival on promoting screening among native Hawaiians
Title: Ohana Day Type: Special event; One-on-one education; Small media *Culturally adapted
Promote cancer screening (mammography, prostate, colorectal) and health behaviours
Mixed method Baseline registration form Unstructured telephone interview at 6 month follow-up
73 adults (>40 yrs)
2006
Larkey [48] USA
Impact of education and social support group led by lay health person (LHP) on screening
Promote breast, cervical and colorectal screening among Latina women
Mixed method Baseline and postintervention surveys Unstructured interviews
509 females (>18 yrs)
4% of previously non-adherent women screened and mammography and pap tests increased by 31% and 39% respectively among the previously non-adherent. Cancer prevention behaviour improved.
2010
Blumentha l et al.,
Trial of 3 community
Title: Las Mujeres Saludables (“Healthy Women”) Type: Group education *Culturally adapted Type: Group education; One-
Special event: 30-minute physician appointments & screening, cancer education/brochures, follow up screening/treatment, Hawaiian music, nutritional lunch, children’s education sessions and games Facilitated by LHP
52% reported exposure to CRC endorsements: 59% reported it had no effect, 37% reported increased likelihood to screen; exposure was higher in women (60%) than men (42%); educational attainment linked to exposure and reactions; 63% of men were exposed to prostate endorsement, but 63% reported it having no influence; 71% of women were exposed to mammography endorsements, but only 25% were influenced to screen Increase in colorectal cancer screening increased among men (pre= 39%, post=75%) and women (pre=36%, post=76%). Mammography and clinical breast exams also increased (18%; 13% respectively).
Facilitated by community health
Quantitative Pre- and post-intervention
369 adults (>50 yrs)
Group education led to most screening (33.9%), followed by one-on-one
2000
Promote colorectal screening among
Results Highest uptake of colorectal cancer screening: 15 FOBT returned (29.4%), followed by breast exams (15.7%) and pap tests (3.9%)
12
Appendix
[44] USA
interventions to increase screening
on-one education; Financial support *Culturally adapted
African Americans with no history of CRC
workers One-on-One Education Group Education Financial Support Control Group Special event: health fair facilitated by a cultural community coordinator and medical students, and included brochures, educational seminars, subsidised FOBT kits Special event: free FS screening in standard medical clinic which was transformed into an endoscopy unit Facilitated in person through CRC script read aloud or listened to by adults in Reader’s Theatre group
questionnaires
2010
Wu et al. [54] USA
Impact of health fair on CRC screening and knowledge for Asian Americans
Type: Special event; Group education Small media *Culturally adapted
Promote CRC knowledge and screening rates
2011
Elmunzer et al. [29] USA
Feasibility of screening in health fair for uninsured patients
Type: Special event
Administer free FS screening to uninsured and previously nonadherent patients
2012
Cueva et al. [46] USA
Type: Group education *Culturally adapted
Promote screening and conversation about CRC
2012
Larkey et al. [49] USA
Impact of theatre script in changing screening behaviour among Alaskan Natives and American Indians Impact of group versus individual education on Latina women’s screening behaviour
Type: Group education; Oneon-one education *Culturally adapted
Promote breast, cervical, and colorectal screening among Latina women
2012
Moralez et al. [50]USA
2012
Snowball, Young & Halloran [53] UK
Impact of home based group education intervention led by LHP Impact of bowel cancer screening campaign on screening engagement
Type: Group education *Culturally adapted
2013
Cueva et al. [55] USA
Impact of short movie in changing screening
education (25.4%), Financial Support (22.2%), Control (17.7%). Education participants had significant gains in knowledge compared to Financial and Control groups. 53.2% of educational seminar attendees reported intention to screen. At 12 months, 45% had completed FOBT, 29% completed a colonoscopy, 1% had a flexible sigmoidosocopy, and 2% had both FOBT and sigmoidoscopy. Of 76 scheduled patients, 47 presented to the fair and underwent FS; fair was deemed feasible at a cost of $6531.75 or $126 per patient
Quantitative Baseline and post-event questionnaires Post-event mailed/telephone survey
304 adults (>50 yrs)
Quantitative Screening participation rates recorded at event
52 adults (>50 yrs)
Qualitative Open dialogue conversation Post-intervention written evaluations
159 adults (>18 yrs)
30% reported intention to screen; other positive outcomes in changes to health behavior (77%) and more comfort in discussing screening (90%).
Facilitated by LHP Social support group (SSG) Individually prevention classes (IND)
Quantitative Structured interviews Pre- and post-intervention questionnaires
509 females (>18 yrs)
Promote CRC screening and knowledge
Home health parties (HHPs)
Quantitative Pre- and post-intervention surveys
61 adults (50-59 yrs)
Type: Mass media
Increase screening engagement
Television Radio Newspapers Printed educational information to GP’s
Quantitative Screening rate comparison to previous year via South Hub Strategic Health Authority
Population data
Type: Group education *Culturally
Promote screening awareness and knowledge and
25-minute telenova-style movie based on conversations around
Mixed method Written post-test evaluation with open-
305 adults (>18 yrs)
Both IND and SSG did not significantly affect screening behaviours or maintenance but increased breast, cancer, and colorectal screening among previously non-adherent women. SSG was deemed more feasible 10% increase in number of colonoscopies and sigmoidoscopies following intervention and reported improved cancer knowledge and beliefs. Small increase in screening uptake among those who were participating for the first time compared with those who had participated before. 48% increase in GP attendance for symptoms 31% had cancer screening, 78% of who were over 50 years; 44% increased physical activity; 65%
13
Appendix
behaviour
adapted
conversation about CRC
CRC that incorporated Alaskan cultural values
ended and closed-caption questions
Impact of education, narratives, and peer support in changing screening behaviours Impact of government campaign on bowel cancer detection
Type: Group education
Promote CRC screening through education alongside personal narratives and peer support
Participants received education alongside narratives and peer support (Enhanced Group) or standalone (Basic Group)
Quantitative Baseline and post-test questionnaire
306 adults (50-75 yrs)
Title: Be Clear on Cancer Type: Mass media
Encouraged adults over the age 55 with bowel symptoms to seek primary care
Poster Television Radio Newspaper
Adult population data (>40 yrs)
2013
Hwang et al. [56] USA
2013
Bethune et al. [43] UK
2013
Peacock et al. [51] UK
Impact of campaign facilitated by UK government on bowel cancer detection
Title: Be Clear on Cancer Type: Mass media
Encouraged adults over the age 55 with bowel symptoms to seek primary care
Poster Television Radio Newspaper
Quantitative Screening rate comparison via Peninsular Cancer Network, Open Exeter database, and South West Strategic Health Authority Quantitative Screening rate comparison via Royal Derby Hospital’s database
2014
Cooper, Gelb & Hawkins [24] USA
Title: Screen for Life: A National Colorectal Cancer Action Campaign Type: Mass media
Raise awareness of CRC for adults over 50 years
Television Radio Print media
Quantitative Online HealthStyles Fall survey
1714 adults (>50 years)
2014
Crookes et al. [45] USA
Association between exposure to screening information and screening participation and knowledge Impact of culturally adapted and communitybased group education on promoting CRC screening
Title: Witness Project of HarlemCRC and Esperanza y VidaCRC Type: Group education *Culturally adapted
Promote CRC screening among Black and Latino adults
Facilitated by program staff
Quantitative Pre- and post-program surveys
638 adults (>50 yrs)
Adult population data (>30 yrs)
reported intent to discuss CRC screening with family and friends and 24% with doctor Enhanced Group reported improved motivation for screening at 1 month compared to Basic Group, but there was no difference at 6 months.
Referrals significantly increased following the campaign, but this effect stopped after 3 months. No change in number of cancers detected. Endoscopies increased for 1 month, but effect was not significant. Referrals significantly increased by 59% (201 patients) following the campaigns launch, but no change in rates of CRC. Increase in screening via ultrasound, VC, barium enema, rigid sigmoidoscopy, and colonoscopy. MRI, CT, and flexible sigmoidoscopy rates decreased. Screening participation and knowledge increased with reported frequency of exposure to screening information. News reports, advertisements and health care providers were more common sources of information. 63% of previously non-adherent adults reported intention to screen following the personal testimony 68% of previously non-adherent adults reported intention to screen following attending the program.
S0738-3991(16)30210-5 http://dx.doi.org/doi:10.1016/j.pec.2016.05.012 PEC 5344
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
11-12-2015 25-4-2016 14-5-2016
Please cite this article as: Morris Julia, Preen David, Martini Angelita.Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: An integrative literature review.Patient Education and Counseling http://dx.doi.org/10.1016/j.pec.2016.05.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: an integrative literature review
Authors Julia Morris Research Associate, Center for Health Services Research, School of Population Health, The University of Western Australia Address: 35 Stirling Hwy, Crawley 6009, Western Australia Email: [email protected] Phone: +61405732352
David Preen Chair in Public Health, School of Population Health, The University of Western Australia Address: 35 Stirling Hwy, Crawley 6009, Western Australia Email: [email protected] Phone: +610864881307 Corresponding Author at: Angelita Martini Senior Lecturer, Center for Health Services Research, School of Population Health, The University of Western Australia Address: 35 Stirling Hwy, Crawley 6009, Western Australia Email: [email protected] Phone: +610864882989
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Abstract Objective: This paper reviewed the relationship between non-clinical, client-oriented promotional campaigns to raise bowel cancer awareness and screening engagement. Method: An integrative literature review using predefined search terms was conducted to summarise the accumulated knowledge. Data was analysed by coding and categorising, then synthesized through development of themes. Results: Eighteen of 116 studies met inclusion criteria. Promotional campaigns had varying impact on screening uptake for bowel cancer. Mass media was found to moderately increase screening, predominately amongst “worried well”. Small media used in conjunction with other promotional activities, thus its effect on screening behaviours was unclear. One-on-one education was less effective and less feasible than group education in increasing intention to screen. Financial support was ineffective in increasing screening rates when compared to other promotional activities. Screening engagement increased because of special events and celebrity endorsement. Conclusion: Non-clinical promotional campaigns did impact uptake of bowel cancer screening engagement. However, little is evident on the effect of single types of promotion and most research is based on clinician-directed campaigns. Practice Implications: Cancer awareness and screening promotions should be implemented at community and clinical level to maximize effectiveness. Such an approach will ensure promotional activities are targeting consumers, thus strengthening screening engagement.
Keywords: bowel cancer, CRC, screening, promotion, campaign, intervention.
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1. Introduction Bowel or colorectal cancer is the third most common cancer in the world [1], with nearly 1.4 million new cases and 694,000 estimated deaths in 2012 [2]. The incidence of bowel cancer is increasing in certain countries where risk was historically low [3]. Bowel cancer is one of Australia’s most common cancers and it is estimated that by 2016, there will be almost 18,000 newly diagnosed cases of the disease [4]. Every week, around 80 Australians die from bowel cancer [5]. Fortunately, bowel cancer is one of the most curable types of cancer if it is found early [5]. Currently, early detection is the best protection against bowel cancer for those at risk of the disease. Methods for early detection include the faecal occult blood test (FOBT), colonoscopy, and endoscopy. Several randomised controlled trials have demonstrated that [6] colorectal cancer mortality can be reduced by 15–33% through regular bowel screening using FOBT [7]. Australia is one of a few countries, along with the United Kingdom, France, and Germany, to implement a nationwide government-funded FOBT screening program that enables the detection of bowel cancers prior to sufferers becoming symptomatic [5]. Despite the efforts of Australia’s national screening program, bowel cancer screening rates are at the suboptimal rate of 36% [8]. The highest rate of participation was by people aged 65 years (41.6%), followed by those aged 55 years (33.2%). The lowest rate of participation was among 50 year-olds (27.4%) [6]. The burden of the disease is often undermined [9], and many people avoid being screened [10] due to a variety of issues. Among 40 – 70 year olds, only 53% have knowledge of the symptoms indicative of bowel cancer [4]. Roughly 50% of adults are unaware of the age at which screening should commence [4], and do not understand the need for regular screening [9] due to the nature of the disease. Furthermore, 50% of adults in the aforementioned cohort are unaware that bowel cancer affects both men and women [4], which is similar to a common misconception that women are protected from the disease because of their gender [9]. Evidently, raising awareness and promoting the prevention of bowel cancer has a number of challenges. Barriers that stop people from screening for bowel cancer can be resolved [9] through interventions that educate consumers about the benefits of early detection through screening [11]. Promotional activities are necessary as raising awareness regarding cancer is likely to lead to an increase in screening participation, and eventually a decrease in related mortality rates [8, 12]. The purpose of promotional activities is to motivate change and maintain positive health behaviours at the population level [13, 14]. In regards to bowel cancer, the level of impact and effectiveness of promotional activities is not entirely clear [8]. However, the effect of awareness activities has been demonstrated for other health behaviours [14]. For example, there is strong empirical evidence that mass media campaigns reduce smoking prevalence and promote quitting [15]. Furthermore, public health campaigns aimed at reducing coronary heart disease are estimated to be responsible for a 30% reduction in cholesterol over 30 years [16]. Given these examples, the benefit of cancer awareness raising activities should not be underestimated [16], and instead warrants further investigation. Several researchers have attempted to evaluate the effectiveness of promotional campaigns in raising awareness and motivating screening, for bowel and other cancers [13, 17-39]. Outcomes of such research have varied. This paper sought to review the existing published evidence regarding the relationship of non-clinical promotional campaigns aimed at increasing colorectal (CRC) screening uptake and screening engagement. By focusing on non-clinical initiatives, we will review campaigns that have potential to be initiated at the community or lay health worker level. Community-level campaigns are an important strategy in increasing screening rates and reducing disparities among population groups [40]. This paper sought to evaluate initiatives that are not based on psychosocial or behaviour change models (e.g. Health Behaviour Model) or interventions directed to or from healthcare providers and physicians, such as the use of client reminders or mailed FOBT kits. Instead, this paper will focus on the efficacy of marketing and communication promotional campaigns that motivate and enable clients to increase control over and improve their health [41] in terms of CRC prevention and detection. These will include small and mass media campaigns, celebrity endorsements, special events and group/one-on-one education. For discussion purposes, comparisons will be made to promotional campaigns advocating for other cancer screening. As bowel cancer is also known as CRC these terms will be used interchangeably. 2. Methods 2.1 Literature Search An integrative literature review was undertaken in this paper as it aims to create new understandings of a topic through a process that involves reviewing, critiquing and synthesising representative literature [42]. The identification and analysis of literature was completed in two stages by two investigators.
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First, a search of peer-reviewed literature published between 1995 and 2015 was performed using predefined key search terms: ‘bowel cancer’; ‘colorectal cancer’; ‘CRC’; ‘screen’; ‘screening’; ‘FOBT’; ‘faecal occult blood test’; ‘colonoscopy’; ‘endoscopy’; ‘promotion’; ‘promotional activity’; ‘activities; campaign’; ‘intervention’; ‘group education’; ‘one-on-one education’; ‘celebrity’; ‘education’; ‘special event’; ‘small media’; ‘mass media’; ‘media’; ‘lay health’; ‘expense’; ‘cost’; and ‘out of pocket’. Databases were searched through the University of Adelaide and The University of Western Australia Libraries’ electronic databases that included PubMed, Science Direct, BioMed Central, Wiley, BMC Cancer, ProQuest, Elsevier, OvidSP, and EBSCO. Additional targeted searches were carried out using Google and Google Scholar to access relevant literature missed by the main databases. Reference lists of retrieved literature were examined in order to find further suitable articles. 2.2 Inclusion criteria The second stage of the integrative review involved a preliminary reading of 116 relevant articles retrieved in the literature search to determine their suitability for inclusion. This stage was completed by two of the investigators. Inclusion criteria were peer-reviewed literature that was written in English, published in the last 20 years (1995 – 2015) from international and national sources. Evidence was included if it reported the use of promotional campaigns to raise bowel cancer awareness and resulting screening behaviours (i.e. increase or decrease in screening, no change). Outcomes had to be measured in actual screening rates, or intention to screen, rather than projected or estimated rates. Research often measured screening outcomes for various cancers and therefore studies that considered colorectal alongside other cancers (e.g. colorectal and cervical) were included. Studies were assessed and included if impact was only measured through promotional campaigns. Studies were discarded if they considered only clinician-based interventions; directed to or from healthcare providers or physicians. Studies were also discarded if interventions were tailored on the basis of psychosocial or behaviour change models. Other outcomes measured in the studies (e.g. attitude change or increased knowledge) were also reported. 'Grey' literature has been included in the discussion. Through this process, 18 studies were identified that met the inclusion criteria. Due to the limited number of studies in the area, multiple methodologies and study designs were considered. 2.3 Data analysis The third stage of the integrative literature review was a thematic analysis [15] completed by two investigators. The 18 retrieved studies were initially coded to facilitate the distinction of key elements and features. These codes were then classified and reassembled into a coherent order, from which converging and diverging patterns in the literature were identified. The codes were counted and formatted, and similar codes were grouped together under themes. Finally, the research team examined and validated conclusions drawn under each major theme 2.4 Synthesis of results The aforementioned data analysis resulted in the identification of seven promotion campaigns: mass media; small media; group education; one-on-one education; financial support; special events; and celebrity endorsement. All included intervention components or activities are described in Table 1.
3. Results 3.1 Search Results Study source, aims, study design, and outcomes of the 18 studies that met inclusion criteria are summarised in Table 2. Of the 18 studies identified [24, 27, 29, 34, 43-56], 12 investigated a single promotional activity [24, 27, 29, 34, 43, 45, 46, 48, 50, 51, 55, 56], and six were multi-component activities [44, 47, 49, 52-54]. Four studies used mass media [24, 43, 51, 53], two used small media [47, 54], nine used group education [44-46, 48-50, 54-56], four used one-on-one education [44, 47, 49, 52], one used financial support [44], four used special events [29, 47, 52, 54], and two considered celebrity endorsement [27, 34]. All mass media interventions also incorporated small media components [25, 43, 51, 53, 57]. Eight studies were culturally targeted: seven specifically focused on whether adapting the interventions changed screening outcomes [44-50] whilst another focused on culturally respectful methods to increase CRC awareness [55]. Five studies were based on culturally adapted group education [45, 46, 48, 50, 55], and the remaining three multi-component interventions [44, 47, 49]. 3.2 Promotional campaigns Results of the various promotional campaigns varied, as did the methodological approaches of the studies. The results of each type of promotional campaign identified in the literature are discussed in turn. 3.2.1 Mass media
5
Studies using mass media campaigns reported a subsequent increased screening uptake in the investigated populations [24, 43, 51, 53]. Snowball et al. [53] reported a small increase, and Bethune et al. [43] reported an increase that was not statistically significant. Peacock et al. [51] found that the increased screening (59%) was mostly among the “worried well”- individuals who were symptomless and healthy but pursued screening. On the other hand, Cooper et al. [24] found that the frequency of exposure to the mass media campaign was positively linked to screening participation and knowledge. Three of the four mass media campaigns detected a significant increase in referrals to health practitioners [43, 51, 53]. 3.2.2 Small media Small media was used in two studies alongside special events [47, 54]. Neither study measured the direct effect of small media on screening behaviour. 3.2.3 Group education Group education was used as a standalone activity in six studies [45, 46, 48, 50, 55, 56], and alongside other strategies in three multi-component campaign studies [44, 47, 49, 54]. In each of the multicomponent interventions, the effect of the group education was measured. Blumenthal et al. [44] found group education was the most successful in increasing screening rates (33.9%) compared to the other components (one-on-one education (25.4%) and financial support (22.2%)). The special event that integrated group education found that 53.2% of those who participated in the component expressed a future intention to screen [54]. Larkey et al. [49], found no significant difference in group and one-onone education increasing screening rates, but deemed group education as more feasible. Studies that used group education as a standalone component had variable results [45, 46, 48, 50, 55, 56]. In one study [45], intention to screen was high among people participated in group education (63%), especially if they were previously non-adherent (68%). In another study [55], 31% of participants screened following the intervention and had other positive outcomes in increased physical activity (44%) and intent to discuss screening with family and friends (65%) and their doctor (24%). Conversely, intention to screen was lower (30%), but still statistically significant in a third study [46], and two studies [48, 50] reported an improvement in screening rates, but at a suboptimal level (4% and 10% increase respectively). Finally, one study showed that group education combined with peer support and personal narratives increased motivation to screen at one month, but no effect in actual screening rates was found at 6 months [56]. 3.2.4 One-on-one education One-on-one education was used in multi-component initiatives [44, 47, 49, 52] and its implementation was only evaluated in two of these initiatives. When compared to group education, one-on-one education was less effective in increasing screening uptake [44] and deemed less feasible [49].
3.2.5 Financial support Only one study considered financial support in promoting CRC screening [44]. Participants who received compensation for screening were more likely to screen than participants in the control group (22.2% and 17.7% respectively), but less likely to screen than participants who received group or oneon-one education (33.9% and 25.4% respectively). 3.2.6 Special events Screening rates increased across the four studies that measured the impact of special events [29, 47, 52, 54]. Three studies measured screening outcomes post-event [47, 52, 54]. In one follow-up study, colorectal screening had increased in men (36%) and women (40%) [47]. In another study, 45% completed a FOBT, 29% completed a colonoscopy, 1% had a flexible sigmoidoscopy, and 2% had both FOBT and sigmoidoscopy [54]. In the third study, screening for CRC by FOBT had the highest uptake (29.4%) compared to other cancers (breast exams (15.7%); Pap test (3.9%)) [52]. In the fourth study that measured impact of special events on screening, all participating patients were screened by flexible sigmoidoscopy [29]. However, the purpose of this special event was an onsite screening fair, in which all patients who attended were screened [29]. 3.2.7 Celebrity endorsement Both studies evaluating celebrity endorsements had positive results in terms of promoting engagement with screening for CRC [27, 34]. Larson et al. [34] discovered that of the 52% of adults who reported exposure to celebrity CRC screening endorsements, only 37% indicated it influenced their likelihood to screen. However, these findings may have been influenced by self-report bias. Interestingly, in this study, higher educational attainment was linked to greater exposure to celebrity endorsements, and more favourable reactions [34]. In the other study considering celebrity endorsements, there was a significant increase in CRC screening in the United States following the campaign, and this increase lasted for nine months [27]. Finally, women had greater rates of exposure to celebrity endorsements [34] and higher screening rates than men [27].
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4. Discussion and Conclusion 4.1 Discussion The effectiveness of each mass media campaign was variable. Two studies reported no change in rates of CRC following campaign implementation, despite an increase in screening [43, 51]. Although this suggests more proactivity in screening behaviour, it also indicates that people who are not at risk may be encouraged to screen through mass media. The Community Guide concludes that there is insufficient evidence to support the implementation of mass media campaigns to increase CRC screening rates [38], a finding reiterated in another review [58].Surprisingly, mass media has been found to have impact on other health behaviours regarding cancer. In New South Wales, Australia, mass media campaigns resulted in a 15% increase (16,700 people) in cervical screening among women [36]. In the United Kingdom, bowel cancer advertisements were linked to a 48% increase in general practitioner (GP) visits and a 32% increase in urgent referrals to hospitals [59]. Mass media campaigns have also impacted health behaviours, but only in the short-term. For example, the National Breast Cancer Awareness Month (NBCAM) has successfully promoted early detection [31], but this effect was significant in the period of 1993 to 1995, when advocacy around increased awareness of the disease was expanding rapidly [31]. Mass media campaigns aimed at fighting skin cancer through the promotion of sun protection in Australia have managed to contribute to short-term prevention, but these effects were not sustained [39]. Such a short-term impact was demonstrated in Bethune et al.’s study [43], in which an uptake in referrals and screening dropped off at 3 months and 1 month respectively. Evidently, the effectiveness of mass media interventions is contentious and requires further investigation. Small media’s impact on CRC screening was not measured as a standalone component in any of the studies reviewed. Because of this, it is difficult to determine its direct effect on influencing screening behaviour. Understandably, small media is used in conjunction with other strategies [8, 38], as the provision of videos or printed materials would likely be integrated into larger interventions (e.g. group education sessions or other targeted campaigns). A review by Austoker et al. [18] established that there was insufficient evidence regarding the provision of small media at the community level for promoting cancer awareness. In contrast, a review by Baron et al. [19] found that small media is found to successfully increase mammography and Pap smear screening. This review also concluded that small media is linked to improving CRC screening via FOBT, but its efficacy is undetermined for other procedures (i.e. colonoscopy, sigmoidoscopy, double contrast barium enema) [19]. Additionally,
Australia’s Department of Health suggest that provision of targeted small media will likely increase participation in bowel cancer screening [8]. With the exception of one study [56], each of the promotional activities that used group education (either as standalone or in multi-component programs) was culturally targeted. This was evidently due to the considered cultures valuing the social support aspect [48, 49], storytelling [55], language tailoring [54], which group education can offer. Moreover, group education is flexible in its delivery location and format [10], evident in group education being delivered through theatre groups [46], participants’ homes [50] and community centres and churches [45]. In this review, it appeared that group education had mostly positive results in increasing screening engagement [44-46, 54, 55] although some studies had substandard rates of engagement [48, 50] or found no increase at all [56]. Despite evidence in support of education for increasing screening uptake for breast and cervical cancer screening, other reviews have concluded that there is insufficient evidence regarding its application for CRC screening [38, 60]. One-on-one education appeared to be less effective when compared to group education in increasing CRC screening rates [44, 49]. However, participants in both group and one-on-one education conditions made significant gains in knowledge regarding cancer and its prevention and increased rates among previously non-adherent participants [44, 49]. Although two studies evaluated special events with one-on-one education components, the effect of the education component were not directly measured [47, 52], thus it cannot be definitively established whether its addition directly impacted screening participation.
This review only found one study relating to reducing costs for colorectal cancer screening [44]. Although participants who received financial support had similar screening rates to those who received one-on-one education (22.2% and 25.4% respectively) [44], the Community Guide has concluded that there is insufficient evidence regarding the reduction of out-of-pocket costs for CRC screening [38].
7
Although screening rates across the four considered studies were positive, none of the studies had over a 50% increase in actual screening outcomes [29, 47, 52, 54]. In a review by Escoffery et al. [30], it was mentioned that although short-term outcomes such as gains in knowledge may occur, there is little evidence in support of special events’ long-term effectiveness. This was an alternative finding to results of another considered study, as 53.2% of special event participants indicated their intention to have regular screening, but at 12 months, 45% had completed FOBT and 29% had completed colonoscopy [54]. Also of relevance are the safety concerns regarding special events. Although this type of philanthropy may assist the uninsured and underserved populations, they also provoke safety issues regarding the adequacy of procedures, handling of complications and ensuring adherence to optimal standards [29].
Celebrity endorsements had positive outcomes for intention to screen [34] and screening rates [27]. Moreover, when compared to prostate and breast screening, celebrity endorsements influenced CRC screening rates the most (31%, 25% and 37% respectively) [34]. Given this evidence, there clearly is some benefit of celebrity endorsement in promotional campaigns, if certain criterion (e.g. relevance) is satisfied.
There were some limitations to this paper. The dearth in literature regarding non-clinician initiated promotional campaigns’ impact on bowel cancer screening made it difficult to draw any conclusions. Moreover, the studies differed greatly in terms of their methodologies. Additionally, ambiguity exists around measuring the outcome of promotional campaigns. Whilst most studies measure behaviour in response to an invitation to undergo screening [14] many have limitations in terms of measuring what participants engaged in screening. For example, one study (not included in this paper) estimated screening participation from aggregate data from practices within the geographic area of where the study was implemented [61]. Due to the confidentiality restraints, they were unable to identify which screeners had been exposed to the intervention [61]. Such measurement suggests that more robust evidence is required to support arguments regarding campaign effectiveness. Moreover, many attempts to promote bowel screening have failed to systematically evaluate their strategies, or even base their approach on behavioural theories or models [14]. These shortcomings have ultimately undermined the effectiveness and measuring of outcomes in bowel cancer screening activities.
4.2 Conclusion This paper sought to review the relationship between community-focused promotional activities to raise bowel cancer awareness and screening engagement. From the available literature, it was difficult to establish what component of campaigns effectively increased screening engagement. Several studies utilized multi-component interventions, and there was considerable variability across reported findings. The dearth of literature regarding non-clinical promotional activities highlights that research has mostly focused on clinician-led campaigns or psychosocial/behavioural interventions. Despite the importance of such activities, more efforts need to be placed on researching community-led campaigns that are easy to adopt, feasible, and potentially support the reduction of CRC and other cancers at a community level.
8
Whilst other cancers (breast, cervical, prostate) have reasonable evidence in terms of promotional campaigns and screening, there is an absence of evidence regarding promotional campaigns for CRC awareness and screening. Evidently, further research is required. More evidence is needed to identify what parts of the population are responsive to certain campaigns, and how to make campaigns work depending on the target audience.
4.3 Practice Implications Further research is required regarding the dual approach of promotional activities and clinical interventions. Standalone non-clinical promotion of CRC awareness and screening may undermine campaign effectiveness, whereas linking it to a clinical setting may increase its legitimacy and importance. Moreover, the promotion of CRC screening by health professionals will likely lead to increased screening rates among consumers. For example, the provision of written or telephone client reminders regarding screening appointments have been effective for increasing FOBT, mammography, and Pap smear test screening. A key driver of screening engagement is the provision of client-oriented promotional activities directed from both community and health care settings.
Conflict of Interest Statement: All authors have seen and approved the manuscript being submitted. They warrant that the article is the authors' original work, has not received prior publication and is not under consideration for publication elsewhere.
9
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12 Table 1: Types of promotions identified Mass Media Mass media involves communicating educational and motivational information about screening through television, radio, newspaper, magazines, and billboards. Small Media Small media refers to videos and printed materials designed to educate and motivate people to screen for cancer. Small media can be tailored to an individual, or to a target audience. Group Education Often conducted by health professionals or trained lay people, education regarding cancer and screening information is conveyed to groups in various settings. One-on-One Education Similar to group education, but offered to individuals in person or over the phone. Financial Support Minimisation or removal of economic barriers that impede screening. Special Events Special events seek to raise awareness and encourage screening, especially among those who are uninsured or underserved. Special events include gatherings, fairs, cultural events, and so on. Celebrity Endorsement Celebrity endorsement and advocating on behalf of campaigns for cancer screening.
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Appendix Table 2: Studies considering non-clinical promotional activities that aim to promote CRC screening 1995-2015 Year
Author, Country Resnick [52] USA
Aim of study
Promotion activity
Aim of promotion
Promotion delivery
Study Design
Participants
Impact of a ‘wellness day’ on promoting screening
Type: Special event; One-on-one education
Promote screening and knowledge regarding breast, cervical and colorectal cancer
Special event: retirement community health fair offering free screening and one-to-one education
Quantitative Screening participation rates recorded at event
51 adults (>90 yrs)
2003
Cram et al. [27] USA
Type: Celebrity endorsement
Promote colorectal screening rates
Televised colonoscopy of US Today Show host Katie Couric
Significant increase in colonoscopies following promotional campaign and effect was sustained for 9 months; uptake was greater among women
Larson et al. [34] USA
Type: Celebrity endorsement
Promote colorectal screening rates among adults with no history of cancer
Any celebrity endorsement seen or heard by participants pertaining to promoting screening for breast, prostate, or colorectal cancer
Quantitative Screening rate comparison via Clinical Outcomes Research Initiative (CORI) and managed care data Quantitative Questionnaire administered via telephone (random cold calling)
Adult population data (30-64 yrs)
2005
Impact of celebrity endorsement on population screening rates Impact of celebrity endorsement on screening
500 adults (>40 yrs)
2006
Gellert et al. [47] USA
Impact of cultural health festival on promoting screening among native Hawaiians
Title: Ohana Day Type: Special event; One-on-one education; Small media *Culturally adapted
Promote cancer screening (mammography, prostate, colorectal) and health behaviours
Mixed method Baseline registration form Unstructured telephone interview at 6 month follow-up
73 adults (>40 yrs)
2006
Larkey [48] USA
Impact of education and social support group led by lay health person (LHP) on screening
Promote breast, cervical and colorectal screening among Latina women
Mixed method Baseline and postintervention surveys Unstructured interviews
509 females (>18 yrs)
4% of previously non-adherent women screened and mammography and pap tests increased by 31% and 39% respectively among the previously non-adherent. Cancer prevention behaviour improved.
2010
Blumentha l et al.,
Trial of 3 community
Title: Las Mujeres Saludables (“Healthy Women”) Type: Group education *Culturally adapted Type: Group education; One-
Special event: 30-minute physician appointments & screening, cancer education/brochures, follow up screening/treatment, Hawaiian music, nutritional lunch, children’s education sessions and games Facilitated by LHP
52% reported exposure to CRC endorsements: 59% reported it had no effect, 37% reported increased likelihood to screen; exposure was higher in women (60%) than men (42%); educational attainment linked to exposure and reactions; 63% of men were exposed to prostate endorsement, but 63% reported it having no influence; 71% of women were exposed to mammography endorsements, but only 25% were influenced to screen Increase in colorectal cancer screening increased among men (pre= 39%, post=75%) and women (pre=36%, post=76%). Mammography and clinical breast exams also increased (18%; 13% respectively).
Facilitated by community health
Quantitative Pre- and post-intervention
369 adults (>50 yrs)
Group education led to most screening (33.9%), followed by one-on-one
2000
Promote colorectal screening among
Results Highest uptake of colorectal cancer screening: 15 FOBT returned (29.4%), followed by breast exams (15.7%) and pap tests (3.9%)
12
Appendix
[44] USA
interventions to increase screening
on-one education; Financial support *Culturally adapted
African Americans with no history of CRC
workers One-on-One Education Group Education Financial Support Control Group Special event: health fair facilitated by a cultural community coordinator and medical students, and included brochures, educational seminars, subsidised FOBT kits Special event: free FS screening in standard medical clinic which was transformed into an endoscopy unit Facilitated in person through CRC script read aloud or listened to by adults in Reader’s Theatre group
questionnaires
2010
Wu et al. [54] USA
Impact of health fair on CRC screening and knowledge for Asian Americans
Type: Special event; Group education Small media *Culturally adapted
Promote CRC knowledge and screening rates
2011
Elmunzer et al. [29] USA
Feasibility of screening in health fair for uninsured patients
Type: Special event
Administer free FS screening to uninsured and previously nonadherent patients
2012
Cueva et al. [46] USA
Type: Group education *Culturally adapted
Promote screening and conversation about CRC
2012
Larkey et al. [49] USA
Impact of theatre script in changing screening behaviour among Alaskan Natives and American Indians Impact of group versus individual education on Latina women’s screening behaviour
Type: Group education; Oneon-one education *Culturally adapted
Promote breast, cervical, and colorectal screening among Latina women
2012
Moralez et al. [50]USA
2012
Snowball, Young & Halloran [53] UK
Impact of home based group education intervention led by LHP Impact of bowel cancer screening campaign on screening engagement
Type: Group education *Culturally adapted
2013
Cueva et al. [55] USA
Impact of short movie in changing screening
education (25.4%), Financial Support (22.2%), Control (17.7%). Education participants had significant gains in knowledge compared to Financial and Control groups. 53.2% of educational seminar attendees reported intention to screen. At 12 months, 45% had completed FOBT, 29% completed a colonoscopy, 1% had a flexible sigmoidosocopy, and 2% had both FOBT and sigmoidoscopy. Of 76 scheduled patients, 47 presented to the fair and underwent FS; fair was deemed feasible at a cost of $6531.75 or $126 per patient
Quantitative Baseline and post-event questionnaires Post-event mailed/telephone survey
304 adults (>50 yrs)
Quantitative Screening participation rates recorded at event
52 adults (>50 yrs)
Qualitative Open dialogue conversation Post-intervention written evaluations
159 adults (>18 yrs)
30% reported intention to screen; other positive outcomes in changes to health behavior (77%) and more comfort in discussing screening (90%).
Facilitated by LHP Social support group (SSG) Individually prevention classes (IND)
Quantitative Structured interviews Pre- and post-intervention questionnaires
509 females (>18 yrs)
Promote CRC screening and knowledge
Home health parties (HHPs)
Quantitative Pre- and post-intervention surveys
61 adults (50-59 yrs)
Type: Mass media
Increase screening engagement
Television Radio Newspapers Printed educational information to GP’s
Quantitative Screening rate comparison to previous year via South Hub Strategic Health Authority
Population data
Type: Group education *Culturally
Promote screening awareness and knowledge and
25-minute telenova-style movie based on conversations around
Mixed method Written post-test evaluation with open-
305 adults (>18 yrs)
Both IND and SSG did not significantly affect screening behaviours or maintenance but increased breast, cancer, and colorectal screening among previously non-adherent women. SSG was deemed more feasible 10% increase in number of colonoscopies and sigmoidoscopies following intervention and reported improved cancer knowledge and beliefs. Small increase in screening uptake among those who were participating for the first time compared with those who had participated before. 48% increase in GP attendance for symptoms 31% had cancer screening, 78% of who were over 50 years; 44% increased physical activity; 65%
13
Appendix
behaviour
adapted
conversation about CRC
CRC that incorporated Alaskan cultural values
ended and closed-caption questions
Impact of education, narratives, and peer support in changing screening behaviours Impact of government campaign on bowel cancer detection
Type: Group education
Promote CRC screening through education alongside personal narratives and peer support
Participants received education alongside narratives and peer support (Enhanced Group) or standalone (Basic Group)
Quantitative Baseline and post-test questionnaire
306 adults (50-75 yrs)
Title: Be Clear on Cancer Type: Mass media
Encouraged adults over the age 55 with bowel symptoms to seek primary care
Poster Television Radio Newspaper
Adult population data (>40 yrs)
2013
Hwang et al. [56] USA
2013
Bethune et al. [43] UK
2013
Peacock et al. [51] UK
Impact of campaign facilitated by UK government on bowel cancer detection
Title: Be Clear on Cancer Type: Mass media
Encouraged adults over the age 55 with bowel symptoms to seek primary care
Poster Television Radio Newspaper
Quantitative Screening rate comparison via Peninsular Cancer Network, Open Exeter database, and South West Strategic Health Authority Quantitative Screening rate comparison via Royal Derby Hospital’s database
2014
Cooper, Gelb & Hawkins [24] USA
Title: Screen for Life: A National Colorectal Cancer Action Campaign Type: Mass media
Raise awareness of CRC for adults over 50 years
Television Radio Print media
Quantitative Online HealthStyles Fall survey
1714 adults (>50 years)
2014
Crookes et al. [45] USA
Association between exposure to screening information and screening participation and knowledge Impact of culturally adapted and communitybased group education on promoting CRC screening
Title: Witness Project of HarlemCRC and Esperanza y VidaCRC Type: Group education *Culturally adapted
Promote CRC screening among Black and Latino adults
Facilitated by program staff
Quantitative Pre- and post-program surveys
638 adults (>50 yrs)
Adult population data (>30 yrs)
reported intent to discuss CRC screening with family and friends and 24% with doctor Enhanced Group reported improved motivation for screening at 1 month compared to Basic Group, but there was no difference at 6 months.
Referrals significantly increased following the campaign, but this effect stopped after 3 months. No change in number of cancers detected. Endoscopies increased for 1 month, but effect was not significant. Referrals significantly increased by 59% (201 patients) following the campaigns launch, but no change in rates of CRC. Increase in screening via ultrasound, VC, barium enema, rigid sigmoidoscopy, and colonoscopy. MRI, CT, and flexible sigmoidoscopy rates decreased. Screening participation and knowledge increased with reported frequency of exposure to screening information. News reports, advertisements and health care providers were more common sources of information. 63% of previously non-adherent adults reported intention to screen following the personal testimony 68% of previously non-adherent adults reported intention to screen following attending the program.