1. 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

2. BackgroundAims Literature Review Focus Groups Conclusions

3. 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

4. Breast cancer (C50), European Age- Standardised Incidence and Mortality Rates, Females, Great Britain, 1975- 2008 D ownloaded from http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/ access Aug 2011 http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/

5. Reverse Gradient in Incidence

6. 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%

7. Scatter plot showing the relationship between breast screening uptake and percentage of patients for LEAST deprived SIMD quintiles for Dundee GP practices. 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

8. Scatter plot showing the relationship between breast screening uptake and percentage of patients for MOST deprived SIMD quintiles for Dundee GP practices. 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

9. 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

10. Aims Identify barriers and facilitators to attending breast screening

11. 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

12. 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

13. Literature review findings: Barriers and Facilitators Socioeconomic deprivation Sociodemographic factors Attitudes and beliefs Previous experience breast screening Access to services

14. 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%]

15. 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

16. 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

17. Interventions to improve uptake contd. UNDERSTANDING AND INFORMED CONSENT Personalised risk information helps a little Person to person communication Tailored telephone counselling

18. 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

19. 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

20. 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

21. Main themes: Barriers and Facilitators Fear and Anxiety Fear of the process Fear of the process Fear of outcome/bad news Fear of outcome/bad news Worry about radiation Worry about radiation Delay inducing anxiety Delay inducing anxiety Individual and Life Circumstances: Individual and Life Circumstances: Issues of childcare/ dependants/ carers make it hard to attend appointments Issues of childcare/ dependants/ carers make it hard to attend appointments Work responsibilities/Forgetting Work responsibilities/Forgetting Poor health Loss of a friend or relative through breast cancerAccess Transport Parking at Hospital Mobile location not convenient Weather Ardent Non attenders Ardent Non attenders

22. Main Themes: Group perception of what helps? Mobile units Recall service Current advertising and marketing Changing attitudes Breast screening information

23. 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

24. 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.

25. Any questions?