Transcript Factors influencing low uptake of breast screening services in Dundee

Factors influencing low uptake
of breast screening services in
Dundee
Dr Rosemary Millar: StR NHS Tayside
Dr Julie Cavanagh: CPHM
Dr Elizabeth Magee: Public Health
Officer
Background
Aims
Literature Review
Focus Groups
Conclusions
Breast Cancer
Important public health problem
1.38 million cases worldwide
Variation between countries
Numerous risk factors
Lifestyle and environmental factors
probable given change in risk following
migration
Breast cancer (C50), European AgeStandardised Incidence and Mortality Rates ,
Females, Great Britain, 1975- 2008
Downloaded from http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/ access Aug 2011
140
Incidence Rates
Mortality Rates
100
80
60
40
20
0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
Rate per 100,000 population
120
Year of diagnosis/death
Reverse Gradient in Incidence
Cancer of the Female Breast (ICD-10 C50)
Age standardised incidence and mortality rates by SIMD 2006 deprivation quintile, females
140.0
120.0
Rate per 100,000
100.0
80.0
Incidence
Mortality
60.0
40.0
20.0
1 (Least deprived)
2
3
Deprivation quintile
4
5 (Most deprived)
Breast Screening
Three yearly screening programme,
established 1988
Women aged 50-64 until 2003 when age
extended to 70
High uptake needed if programme to
reduce morbidity and mortality
Minimum screening uptake standard, 70%
with target of 80%
Scottish average 76.2%, Tayside 80.3%
Scatter plot showing the relationship between breast screening
uptake and percentage of patients for LEAST deprived SIMD
quintiles for Dundee GP practices.
Breast screening uptake (%)
Scatter Plot of percentage breast screening uptake by proportion of
patients in the least deprived SIMD quintiles (4 and 5) for each Dundee
GP practice over 3 rounds.
90
80
70
60
50
40
30
20
10
0
Round 5: 2002-04
Round 6: 2005-07
Round 7: 2008-10
0
10
20
30
40
50
60
70
80
90
100
Proportion of patients in SIMD 4 and 5 ( least deprived) for each
Dundee GP practice
Data from Patient Data Base, NHS Tayside via Business Objects (Tayside,
Fife & Forth Valley Consortium, excluding any Grampian patients - linked
to A-CHI System)
Extracted July 2010
Scatter plot showing the relationship between breast screening
uptake and percentage of patients for MOST deprived SIMD
quintiles for Dundee GP practices.
Breast screening uptake (%)
Scatter Plot of percentage breast screening uptake by proportion of
patients in the most deprived SIMD quintiles (1 and 2) for each Dundee
GP practice over 3 rounds
90
80
70
60
50
40
30
20
10
0
Round 5: 2002-04
Round 6: 2005-07
Round 7: 2008-10
0
10
20
30
40
50
60
70
80
90
100
Proportion of patients in SIMD 1 and 2 ( most deprived) for each
Dundee GP practice
Data from Patient Data Base, NHS Tayside via Business Objects (Tayside,
Fife & Forth Valley Consortium, excluding any Grampian patients - linked
to A-CHI System)
Extracted July 2010
Screen detected compared to
symptomatic breast cancer
Screen detected cancers higher probability of
being smaller, lower grade, node negative, in the
EPG/GPG, oestrogen receptor positive and less
likely to be HER2 positive (true across all
deprivation quintiles and ages)
Screening reduces inequalities???
Survival rates higher for women with screen
detected cancer compared to symptomatic
Aims
Identify barriers and facilitators to
attending breast screening
Methods
Literature review to identify barriers and
facilitators to uptake
Invitations to all non attending Dundee
women from 2 GP practices to attend
focus groups
Results of literature review
15 papers on barriers and facilitators,
including 2 systematic reviews although
majority descriptive studies
13 papers on interventions to improve
uptake including 2 systematic reviews, 1
meta analysis, 2 Cochrane reviews and 2
RCT’s
Literature review findings:
Barriers and Facilitators
Socioeconomic deprivation
Sociodemographic factors
Attitudes and beliefs
Previous experience breast screening
Access to services
Literature review findings:
Interventions to improve uptake
Combined, access enhancing interventions and
individual directed interventions achieved the
best improvement in uptake 26.9% [9.9%43.9%]
Interventions to improve uptake
contd.
IMPROVE ACCESSIBILITY
Mailed invitation letter:- OR 1.66 [1.43-1.92]
Mailed education material:- OR 2.81 [1.96 -4.02]
Letter of invitation combined with phone call:OR 2.53 [2.02-3.18]
Phone call:- OR 1.94 [1.70-2.23]
Training activities plus a reminder:- OR 2.46
(1.72-3.50]
Reduce travel distance
Removal of financial barriers
Interventions to improve uptake
contd.
SYSTEM EFFECTS
More accurate patient registers
Financial incentives to GP’s with practice
screening lead
Enhance screening service with increased
capacity for calls and customer service
improvements
Interventions to improve uptake
contd.
UNDERSTANDING AND INFORMED
CONSENT
Personalised risk information helps a little
Person to person communication
Tailored telephone counselling
Focus Groups
We undertook focus groups with our target
population to discover what their perceived
barriers were.
Selected 2 GP practices with deprived
catchments, who were shortly to be screened
All women who had missed their most recent
appointment had an invitation letter included
with their reminder letter from SBSS.
400 letters posted over 2 separate rounds in
early 2011
£10 offered as token of appreciation to cover
transport cost
Awareness raising
Posters published in
house and delivered
to local shops near to
the surgeries.
Displayed in
participating surgeries
and concourse of
Ninewells Hospital.
Posted to top ten
frequented
pharmacies for each
practice
Subject recruitment
11 respondents indicated a willingness to
attend, with 6 in the first tranche and 5 in
the second.
2 groups held: 5 attendees in March 2011,
however only 2 of the 6 attended the
second group in June 2011
Both researcher and scribe attended the
first group, and researchers only for the
second group
Consent forms signed
Main themes:
Barriers and Facilitators
Fear and Anxiety
•
•
•
•
Fear of the process
Fear of outcome/bad news
Worry about radiation
Delay inducing anxiety
Individual and Life
Circumstances:
• Issues of childcare/
dependants/ carers make it
hard to attend
appointments
• Work
responsibilities/Forgetting
• Poor health
• Loss of a friend or relative
through breast cancer
Access
• Transport
• Parking at Hospital
• Mobile location not
convenient
• Weather
Ardent Non attenders
Main Themes: Group perception of
what helps?
Mobile units
Recall service
Current advertising and marketing
Changing attitudes
Breast screening information
Group Ideas for the Future
Local Champions for screening
Mobile units in the heart of communities
Drop in service
More education about breast cancer
Organisational changes
Conclusions
Focus group findings in keeping with those
from the literature review
We can look at interventions to increase
uptake
Cost is a prime barrier to further interventions
Further work needed to determine the
possible yield of extra cancers to ascertain
whether further interventions to increase
uptake would be cost effective.
Any questions?