• Ulrik Deding
  • Anna Sharon Henig
  • Ann Salling
4. term, Public Health, Master (Master Programme)
Background: Colorectal cancer screening was introduced in Denmark in 2014 and included an initial screening, testing for blood in a stool sample, and a following colonoscopy if blood were found. This master thesis revolved around the initial screening. Inequality in participation by sociodemographic predictors, may lead to inequalities in the benefits of participation for some subgroups. The problem statement therefore asked, how the development of interventions can reduce inequalities in participation and increase overall uptake of initial screening procedure, as well as how these interventions can be implemented and evaluated.
Methods: The methodological framework for this thesis is mixed methods. In the mixed methods study, three substudies are included; statistical analysis, document analysis and semi-structured interviews. Interventions were developed, using a combined analysis of the results from the substudies. Using logistic regression analyses, the risk of non-participation, were estimated for each sociodemographic variable. From this a target population was found. Seven semi-structured interviews with participants and a document analysis contributed to the substance of the interventions. This was done by interpreting the results, using the Health Belief Model as theoretical framework. Leavitt’s diamond was applied, in an analysis of change, to uncover organisational changes and consequences of intervention implementation.
Results: From 93,500 invited citizens, 62,995 (67.37%) participated in colorectal cancer screening. Single individuals had the lowest participation proportion (54.2%). Logistic regression analyses showed that singles had an increased risk of non-participation (OR 1.63 CI95% 1.56;1.70), compared to individuals with a registered partner, after adjustment for gender, age, educational level, income and immigration status. Semi-structured interviews resulted in six categories: Decision made previous to invitation, relation to sender, practical circumstances, use of the invitation material, thoughts of risk, and social circle. Interpretation of interviews, using the Health Belief Model, showed that non-participation could be due to a lack of cues to action and limited reflections. The document analysis assessed that the documents did not supplement each other well as a combined decision aid and alterations are therefore needed.
The overall mixed methods analysis resulted in four intervention strategies: 1) distribution of an advance notification letter, 2) inviting geographical areas simultaneously, 3) general practitioner involvement and 4) revised invitation letter. The analysis of change resulted in changes in technology, structure, people, tasks and surroundings. Evaluation could be conducted using process evaluation, in which the identified elements from Leavitt’s diamond could be incorporated as evaluator measures, for both process- and implementation goals.
Conclusion: Inequality in participation was evident in the region of Northern Jutland, Denmark, as singles had a 1.63-fold risk of non-participation, compared to individuals with a registered partner. Thereby singles do not obtain the benefits of screening, to the same extend. By giving singles additional cues to action and enhancing reflections, the overall uptake may be increased and inequality decreased. Four interventions were suggested to accomplish this. These interventions will cause organisational changes. The effects of the interventions must be evaluated continuously while implementation is occurring.
Publication date7 Jun 2017
Number of pages275
ID: 259304228