1. Pre-notification increases uptake in colorectal cancer screening: a randomised controlled trial Gillian Libby, Jane Bray, Jennifer Champion, Linda Brownlee, Janice Birrell, Dermot Gorman, Emilia Crighton, Callum Fraser, Robert Steele

2. Introduction National programme of colorectal cancer screening using a guaiac faecal occult blood test (gFOBT) commenced in Scotland in 2007 Eligible participants sent a test kit by post to complete at home and return to a central laboratory for analysis

3. Uptake 2000-2007 A demonstration pilot of the screening programme in Scotland – uptake 54.4% Potential benefit of the screening test to reduce mortality from colorectal cancer depends on the level of uptake

4. Increasing response rates A Cochrane review of strategies to increase response rates to postal questionnaires found the odds of response were substantially higher using pre- notification (OR 1.5) However, the English arm of the colorectal cancer screening pilot used a pre-notification letter but uptake was 51% after two rounds of the pilot

5. Aim To test uptake of the screening test with 1.a pre-notification letter alone 2.pre-notification letter + information booklet 3.usual invitation (no pre-notification) in screening population overall first and subsequent rounds by Gender Age Deprivation.

6. Method: Study Population The screening programme in 10 of the 14 health boards by April 2009 One health board sent their own pre-notification letter and therefore did not take part in the study The study population 59,953 eligible people from the nine health boards sent a screening kit between 13/04/09 and 29/05/09. Were followed for the return of their kit to 27/11/09.

7. Method: Intervention Invitees were randomised to one of three groups 1.A pre-notification letter sent 2 wks ahead of gFOBT kit 2.A pre-notification letter and ‘Know the Facts’ booklet sent 2 wks ahead of gFOBT kit 3.Usual invitation as per the screening programme Participants were not informed that they were taking part in a randomised study Ethics approval obtained from Fife, Forth Valley and Tayside Research Ethics Service.

8. Method: Stats Sample size 20,000 subjects in each group 3% - 5% change in uptake detectable in SIMD 1 to 5 80% power at the 5% signficance level Analysis Chi-squared tests - compared uptake Logistic regression - assessed impact of interventions independently of other factors that could influence uptake

9. Baseline Characteristics n(%)

10. Uptake

11. Uptake for men by age group

12. Uptake for women by age group

13. Uptake for men by deprivation

14. Uptake for women by deprivation

15. Logistic regression of predictors of uptake

16. Conclusions Pre-notification significantly increased uptake in a national programme of colorectal cancer screening using gFOBT. Increase was seen in all age groups, for both men and women and in all deprivation groups There was no statistically significant difference in the impact on uptake of the letter + booklet compared to the letter alone except for women in the most deprived group

17. Health Behaviour Models Health Behaviour Change Model Pre-notification moves individual a step along their pathway between no knowledge of screening and uptake of test Health Belief Model Cues to action will be successful. Receipt of a pre- notification letter, activates the preparedness of individuals to react ( participate) and that this reaction can be estimated in some measurable behaviour, (uptake) Results consistent with both these proposed models of behaviour.

18. From research to practise… Dear Colleagues I am pleased to advise that the PM PMG approved the IT changes required for the implementation of the pre-notification letter. This will be delivered within the next release. Dates to be confirmed. Kind regards Tracey Tracey Curtis Assistant Programme Manager National Services Division NHS National Services Scotland Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB