Research ArticleResearch

A qualitative evaluation of strategies to increase colorectal cancer screening uptake

Jill Tinmouth, Paul Ritvo, S. Elizabeth McGregor, Danielle Claus, George Pasut, Ronald E. Myers, Crissa Guglietti, Lawrence F. Paszat, Robert J. Hilsden and Linda Rabeneck
Canadian Family Physician January 2011; 57 (1) e7-e15;

Abstract

Objective To obtain data that could be used to optimize the content and design of the targeted, mailed invitations that Ontario’s provincewide colorectal cancer (CRC) screening program plans to use to increase screening uptake; to identify other strategies to increase CRC screening uptake; and to describe the effects of this qualitative work on a subsequent quantitative pilot study.

Design Qualitative study using semistructured focus groups.

Setting Four different Ontario communities.

Participants Six focus groups comprising a total of 62 participants.

Methods Six focus groups were conducted in 4 different Ontario communities. For 3 of the communities, participants were recruited from the general population by a private marketing firm, using random-digit dialing, and received a small honorarium for participating. In Sault Ste Marie, participants were convenience samples recruited from a large primary care practice and were not offered compensation. Responses were elicited regarding various strategies for promoting CRC screening. Findings represent all responses observed as well as recommendations to program planners based on focus groups observations.

Main findings Key themes identified included the importance of receiving a CRC screening invitation from one’s family physician; a desire for personalized, brief communications; and a preference for succinct information in mailed materials. Strong support was indicated for direct mailing of the CRC screening kit (fecal occult blood test). Our findings substantially influenced the final design and content of the envelope and letter to be mailed in the subsequent quantitative pilot study.

Conclusion We report strong support from our focus groups for a succinct, personalized invitation for CRC screening from one’s own family physician. We have also shown that qualitative evaluation can be used to provide decision makers with pertinent and timely knowledge. Our study is highly relevant to other public health programs, particularly other Canadian jurisdictions planning organized CRC screening programs.

Colorectal cancer (CRC) is the third most common cancer in the world and the fourth leading cause of cancer-related death.1 Screening is critical to prevent CRC-related mortality, as early detection is associated with improved prognosis. Colonoscopy, flexible sigmoidoscopy, barium enema, or fecal occult blood testing (FOBT) can be used to screen for CRC, although only FOBT has been shown to decrease CRC incidence and mortality2–4 in randomized controlled trials.

Fecal occult blood testing is easy, safe, and economical (ie, inexpensive and requiring minimal human resources),5 while colonoscopy or flexible sigmoidoscopy are more costly, risky, burdensome, resource-intensive, and not as well supported by the evidence. Among the 14 countries of the International Cancer Screening Network that have implemented organized national or regional CRC screening programs, 13 use FOBT or another stool-based test, while only Norway uses endoscopy (ie, flexible sigmoidoscopy).6,7

Recently, Ontario launched an organized provincewide CRC screening program, ColonCancerCheck. Through this program, FOBT is offered to those at average risk and colonoscopy is offered to those at increased risk based on family history. Family physicians play a critical role in the program and are responsible for patient outreach and education, initiating screening activities, and receiving and acting on results.

Canadian CRC screening rates are low. In 2008, just 40% of eligible Canadians were up-to-date with CRC screening using FOBT or endoscopy, and only 23% were up-to-date using FOBT alone.8 Several strategies have been used to increase CRC screening uptake. According to a systematic review by the US Task Force on Community Preventive Services, client reminders (letters, postcards, or telephone calls to alert clients to obtain cancer screening) are effective.9 ColonCancerCheck plans to issue mailed, targeted CRC screening invitations to eligible Ontarians, inviting them to contact their family physicians to arrange CRC screening. The most effective design and content of such targeted invitations, however, are unknown.

The aims of our study were to inform the content and design of a mailed invitation to participate in a CRC screening program, to identify additional strategies that might increase CRC screening uptake by eligible persons, and to apply the results from this qualitative work to a subsequent quantitative pilot study of mailed, targeted CRC screening invitations.

METHODS

We conducted semistructured focus groups (FGs) to explore the attitudes, beliefs, and emotional and behavioural responses of screening-eligible adults to possible materials (envelopes, letters, informational materials, FOBT kits) and strategies being considered for a large-scale mailed, targeted CRC screening invitation pilot study, which is intended for eventual province-wide implementation. Approval was obtained from the Research Ethics Board at Sunnybrook Health Sciences Centre in Toronto, Ont, and the Group Health Centre in Sault Ste Marie, Ont.

Focus group participants

Six 2-hour FG sessions were conducted in 4 communities in Ontario (large and small cities, representing different parts of the province) in June and July of 2009. Two single-sex FGs (1 each of women only and men only) were held in each of Toronto and Sault Ste Marie, and 1 with both men and women was held in each of Peterborough and Sudbury. In Toronto, Peterborough, and Sudbury, participants were recruited from the general population by a private marketing firm, using random-digit dialing and received a small honorarium ($75) for participating. In Sault Ste Marie, participants were convenience samples recruited from a large primary care practice and were not offered compensation. Informed consent was obtained by investigators before the actual sessions.

Each FG consisted of screening-eligible adults aged 50 years and older. Among the subjects recruited through random-digit dialing, we sought to balance the groups by age (< 65 years, ≥ 65 years), employment status (working, retired, or at home), and previous screening experience (screened, never screened). We also endeavoured to ensure adequate urban-rural, educational, and ethnocultural representation.

Materials tested

All FGs were moderated by a psychologist (P.R.) experienced in conducting cancer-prevention qualitative interview studies. During each session, the moderator presented 4 different versions of screening invitations. The first letter was a full page, and the 3 other letters were shorter half-page versions. The shorter letters were paired with a separate multicoloured, double-sided brochure, a separate full-page fact sheet, or a 5-bullet fact box located beneath the text of the letter. While all letters included both the ColonCancerCheck program logo and family physician’s name in an italicized font, none incorporated the physician’s actual signature. In addition, different envelopes with various return-address options were presented. Using interview-guided questions, opinions and preferences regarding content and design of the materials were carefully elicited. Emphasis was placed on features that would most attract individuals to open mailed envelopes and read materials, as well as help them to comprehend key messages. Also, the moderator explored the content that would be most understandable, informative, and effective in persuading them to pursue CRC screening. The moderator also sought responses to additional promotional strategies to increase screening uptake. The interviews were recorded and transcribed verbatim; detailed notes were also made during the sessions.

Data analysis

The demographic characteristics of the FG members were tabulated. Where appropriate, the median or the number and proportion were reported.

As the FG analyses were intended to inform a quantitative pilot study of materials and processes being considered for large-scale implementation, there were 2 analytic components: to responsibly guide the pilot study by responding to specific questions posed by program planners and to rigorously represent all findings. For the first component, which required rapid reporting to meet program planners’ timelines, we relied heavily on our detailed notes and preliminary analyses to make recommendations. The nature of this process generally required advising a single option based on the level of support in the FGs rather than representing all findings as is more traditional in qualitative research.

For the second component, we used the verbatim transcripts of the interviews. The constant comparative method was used to identify key themes representing varying attitudes and preferences,10 with the coding of the content of each FG carried out on a line-by-line basis to identify all phrases, key words, and expressed concepts. NVivo 8 qualitative analysis software aided the process of coding the comparisons between expressed concepts identified by participants.

FINDINGS

Focus groups

The characteristics of the 62 FG attendees are described in Table 1. For each topic explored (envelope, letter, and directly mailed FOBT kits), our analyses revealed several key themes. We have organized these themes under 2 headings: those that were incorporated into our advice to the pilot study planners and those that are included so as to represent all data collected.

View this table:
Table 1.

Characteristics of the focus group attendees, by group: N = 62.

Envelope content and design

Program planners were interested in the responses of FG attendees to screening invitations with return-address options that included the name of the family physician, the provincial colorectal cancer screening program, or both.

Advice to program planners: Based on FG responses, we recommended that only the family physician’s name appear on the outside of the envelope. The key themes supporting this recommendation included that participants believed the physician’s name indicated that the contents were important, but the combination of the physician and provincial program names elicited strong negative responses, including anxiety and privacy concerns.

Obviously, if I see it’s from my doctor, I’d want to see [it] right away.”

(FG 3, Peterborough)

I like the idea of the doctor’s name on it because that makes it more personal, and, quite frankly, whether it’s good news or bad news, I want to hear it.

(FG 5, Sudbury)

There is so much junk mail that if your doctor’s name is there you will open it right away.

(FG 2, Toronto)

[Having the provincial logo on the envelope is an] invasion of privacy as far as I’m concerned. You’re telling too much. That’s my personal business. Nobody else should know.

(FG 3, Peterborough)

This causes a lot of people … even the postman [who] is gossiping at some time to your neighbours [to think] “There’s something wrong with that guy.”

(FG 2, Toronto)

If I saw the word ColonCancerCheck from my doctor, I wouldn’t open that up for about a week. I wouldn’t even call and I’d ditch the letter and make sure I ditch it in a good spot. I’d gradually work on trying to think about opening it, because I don’t want to read what’s on the inside .... That would scare the hell out of me.

(FG 2, Toronto)

Representing all FG responses: Some participants also believed that receiving letters from their family physicians, even without the program name, would cause anxiety because communications were generally conducted by telephone.

I’d say “What the heck is wrong now that he’s writing me?”

(FG 5, Sudbury)

If that was mailed to me from my doctor, I wouldn’t open that up for a week, maybe a month.

(FG 5, Sudbury)

Letter content and design

Additional questions pertained to the design and content of the letter (described above) to be sent during the planned quantitative study.

Advice to program planners: A key theme was that a brief, direct letter was preferred. Based on this strong preference and on the participants’ specific reactions to the example letters provided, we recommended the shorter letter with the 5-bullet fact box.

I’ll go with [the brief letter] because it’s nice and short and ... to the point. It has complete information.

(FG 2, Toronto)

I like the little boxes with the brief points. If you want to know more ... you can definitely find out more. When you get too many sheets, you tend to either ignore or drift over. When it’s all on 1 sheet, you’ve got it right there. It’s brief; it’s to the point ... it says what it needs to.

(FG 6, Sault Ste Marie)

Representing all FG responses: Again, the FG questions about the 4 letter options elicited a spectrum of responses. All versions received some support from participants; however, an important theme was that some thought that all versions of the letters were misleading because their physicians did not actually personally write them.

This is not a letter from my doctor. If I open that up and find out it’s a mass mailing by ColonCancerCheck .... I think you’ve played on my concern .... and my relationship with my doctor. You’ve used that to get me to open that letter.

(FG 6, Sudbury)

I would first go, “Wait a minute; my doctor doesn’t write me? … Have I gotten on some list somewhere?” Something like that.

(FG 1, Toronto)

Too short of a letter with little information? I need more information.

(FG 2, Toronto)

Mailing the FOBT kit directly to those eligible for screening

While some organized CRC screening programs mail FOBT kits directly,11,12 ColonCancerCheck currently asks patients to visit their family physicians to obtain kits. Both researchers and program planners were interested in FG attendees’ reactions to direct mailing of FOBT kits.

Advice to program planners: We recommended that kit mailing be considered as a second phase of activity, as an important theme was that a “priming communication,” such as a media campaign or a mailed notice about the campaign, should precede the direct mailing. Participants in more rural settings (ie, Sudbury, Peterborough) were most supportive of directly mailed FOBT, perhaps reflecting the inconvenience of traveling to the doctor and the relative paucity of doctors in these settings.

If you’re going to actually end up doing this anyway, then give them a little tip off .... When it comes, it’s like, “Oh, okay. This is what I was told about.”

(FG 2, Toronto)

You would have to send something back to the program saying “Yes, send me the kit.” Then you would feel better about getting the kit, and then you’d be ready to do your own thing .... I just would feel better that I’m part of the decision-making process.

(FG 2, Toronto)

Representing all FG responses: Participants emphasized the immediacy, practicality, and the universality achieved, including for patients without regular physicians, by direct mailing with adequate priming.

Best idea you’ve had all day.

(FG 5, Sudbury)

Just to reach people do you think it could be an advantage? A lot of people don’t know about it and there’s, I’m certain, lots of people [who] don’t have family physicians. I think it’s more available and everybody [could] be reached.

(FG 1, Toronto)

Effect of qualitative findings on quantitative pilot study

Before the study reported here was carried out, a longer, more detailed letter was planned for mailing in an envelope that carried the ColonCancerCheck logo along with the family physician’s name (Figure 1). After our results were communicated to program planners, a revised letter (brief, with a bulleted fact box) was mailed in an envelope that carried the physician’s name alone (Figure 2). Program planners had not originally intended to include FOBT kits in the mailing and did not do so as a result of our study. However, our findings stimulated considerable interest such that further studies of the use of directly mailed FOBT in more difficult to reach populations are planned.

Figure 1.
Figure 1.

Planned invitation for colorectal cancer screening before the study

Figure 2.
Figure 2.

Invitation for colorectal cancer screening after the study

DISCUSSION

The objective of this qualitative study was to report on recommendations made to program planners conducting a quantitative feasibility assessment of a large-scale mailed invitation for CRC screening that is intended for eventual provincewide implementation. Our recommendations included that screening-eligible individuals should receive mailed CRC screening invitations from their own family physicians and that information should be presented in a succinct, clear, easily read format. Additionally, we identified direct mailing of FOBT kits, after a “priming communication,” as a potentially powerful strategy to improve screening uptake. On each of these topics, we also reported on the full spectrum of FG responses.

Previous studies have used FG methodology to evaluate use of reminder letters and mailed materials to increase uptake of various preventive health services before their implementation13 or following actual reminder mailings.14–17 Several of these studies examined the design and content of materials being used for cancer screening,13 including breast14 and cervical17 screening. Similar to our findings, these studies reported that FG participants preferred brief, personalized reminder letters with access to additional factual information, rather than more detailed letters. We found that having the family physician’s name on the letter was particularly important; this is a finding that has been reported in 1 other study.14 Our FG attendees preferred notification before receiving a direct mailing of FOBT kits. This finding is substantiated by a recent controlled trial, which found that a priming strategy elicited greater uptake of CRC screening compared with direct mailing of the kit alone.18

The qualitative project reported here was intended to guide a subsequent, quantitative pilot study of mailed, targeted CRC screening invitations; as such, it illustrates an often unacknowledged role of FG methodology in clinical research. While an increasing number of researchers identify qualitative methods as their primary research strategy, these methods are also often used to inform the design and structure of initiatives targeting large-scale populations. In the latter instance, FGs play a critical role, but results are often not reported in scientific publications. This study demonstrates that qualitative methodology can be applied in pragmatic and scientifically rigorous manners simultaneously. To support both goals, we reported on the themes that supported advice regarding further program planning as well as reporting all other key themes identified in our comparative analysis. While this approach deviates from the theoretical foundations of qualitative analyses, we were able to translate relevant and timely high-quality research knowledge to program planners in order to considerably affect the structure of a real-world program.

Although we attempted to represent the diversity of responses to various CRC screening strategies and our participants represented a variety of perspectives (eg, region, income, previous screening experience), we recognize that our sample was predominantly white and spoke English sufficiently well to participate. Therefore, our findings might not be generalizable to certain groups.

Conclusion

Consistent with other studies of preventive health interventions, we found strong support for a succinct, personalized invitation for CRC screening from the family physician. This paper illustrates the importance and feasibility of using qualitative research to provide meaningful, effective, and timely guidance for public health programs, and is particularly relevant to other Canadian jurisdictions planning organized CRC screening programs.

Acknowledgments

This study was conducted with the support of the Ontario Institute for Cancer Research and Cancer Care Ontario through funding provided by the Government of Ontario. This work was also supported in part by a grant from the Canadian Institutes for Health Research (No. CST-85478).

Notes

EDITOR’S KEY POINTS

  • Colorectal cancer (CRC) screening can reduce mortality but requires broad uptake to be effective. Ontario’s provincewide CRC screening program plans to use large-scale targeted, mailed invitations to increase screening uptake. This study sought to solicit feedback on various strategies for promoting CRC screening, including the design content of mailed invitations.

  • Participants were generally in favour of concise, individualized communications from their family physicians, although many thought that having the provincial cancer agency logo appear on the envelope of mailed invitations raised privacy concerns, and some believed that using the family physician’s name was misleading.

  • Participants were also supportive of having fecal occult blood tests directly mailed to them, providing some sort of priming strategy was used to prepare them for the test’s arrival.

POINTS DE REPÈRE DU RÉDACTEUR

  • Le dépistage du cancer colorectal (CCR) peut réduire la mortalité mais il doit être largement utilisé pour être efficace. Le programme ontarien de dépistage du CCR a comme objectif d’utiliser une invitation postée à la grandeur de la province pour augmenter son utilisation. La présente étude voulait obtenir un feedback sur différentes stratégies pour promouvoir le dépistage du CCR, incluant le type de contenu des invitations postales.

  • Les participants étaient généralement favorables à des communications individualisées concises de leur médecin de famille, quoique plusieurs jugeaient que la présence du logo de l’agence provinciale du cancer sur l’enveloppe suscitait certaines inquiétudes par rapport à la confidentialité, alors que d’autres croyaient que l’utilisation du nom du médecin de famille portait à confusion.

  • Les participants souhaitaient aussi que les kits pour la recherche du sang occulte dans les selles leur soient postés directement, à condition qu’on utilise une quelconque stratégie de présentation pour les préparer a les recevoir.

Footnotes

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

  • Contributors

    All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission. Dr Ritvo moderated the focus groups and shares first authorship with Dr Tinmouth.

  • Competing interests

    None declared

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A qualitative evaluation of strategies to increase colorectal cancer screening uptake
Jill Tinmouth, Paul Ritvo, S. Elizabeth McGregor, Danielle Claus, George Pasut, Ronald E. Myers, Crissa Guglietti, Lawrence F. Paszat, Robert J. Hilsden, Linda Rabeneck
Canadian Family Physician Jan 2011, 57 (1) e7-e15;
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