Ulighed i deltagelse ved kolorektal cancerscreening i Region Nordjylland

Inequality in participipation for colorectal cancer screening in the Region of Northern Jutland, Denmark

Deding, Ulrik ; Henig, Anna Sharon ; Salling, Ann

4. semester

Folkesundhedsvidenskab, Kandidat

2017

2017-06-07

275

Danmark indførte i 2014 et landsdækkende tarmkræftscreeningsprogram. Det starter med, at man sender en afføringsprøve ind; hvis prøven viser blod, bliver man tilbudt en koloskopi (kikkertundersøgelse af tarmen). Dette speciale undersøger ulighed i, hvem der deltager i den første del af screeningen. Ulighed kan betyde, at nogle grupper ikke får samme gavn af programmet. Formålet er at pege på, hvordan udviklingstiltag kan mindske ulighed og øge den samlede deltagelse, samt hvordan de kan gennemføres og evalueres. Studiet bruger en mixed methods-tilgang med tre delundersøgelser: en statistisk analyse, en dokumentanalyse og semistrukturerede interviews. Med en statistisk model (logistisk regression) blev risikoen for ikke at deltage beregnet ud fra sociodemografiske forhold. Det gjorde det muligt at udpege målgruppen for tiltag. Syv semistrukturerede interviews med deltagere i programmet og en dokumentanalyse bidrog til indholdet i tiltagene. Interviewene blev fortolket med Health Belief Model (en teori om, hvad der motiverer mennesker til at handle på sundhedsoplysninger), og dokumentanalysen tog højde for health literacy (evnen til at finde, forstå og bruge sundhedsinformation). Leavitts systemmodel blev brugt til at analysere, hvilke organisatoriske ændringer tiltagene kan medføre. Af 93.500 inviterede borgere i 2014–2015 deltog 62.995 (67,37 %) i screeningen. Deltagelsen var lavest blandt enlige (54,2 %). En multivariat logistisk regressionsanalyse viste, at enlige havde øget risiko for ikke at deltage (odds ratio 1,63; 95 % KI 1,56–1,70) sammenlignet med samlevende, efter justering for køn, alder, uddannelse, indkomst og immigrationsstatus. Interviewene pegede på seks temaer: beslutning truffet på forhånd, forholdet til afsender, praktiske forhold, brug af invitationsmaterialet, risikovurderinger og påvirkning fra omgangskredsen. Health Belief Model-fortolkningen peger på, at manglende signaler til handling og begrænset refleksion kan bidrage til ikke-deltagelse. Dokumentanalysen vurderede, at materialerne ikke spiller godt sammen som et samlet beslutningsværktøj og bør revideres. Den samlede analyse førte til fire foreslåede tiltag: 1) udsendelse af en forhåndsmeddelelse, 2) geografisk opdelte invitationsområder, 3) samtale med egen læge og 4) et revideret invitationsbrev. En forandringsanalyse viste, at tiltagene vil påvirke teknologi, struktur, aktører, opgaver og omgivelser. Effekten kan følges med en procesevaluering, hvor elementer fra Leavitts model bruges til at definere proces- og evalueringsmål. I Region Nordjylland er der ulighed i deltagelse mellem enlige og samlevende; enlige har 1,63 gange så høj risiko for ikke at deltage og får derfor i mindre grad gavn af programmet. Ved at give enlige tydeligere signaler til handling og støtte til refleksion kan deltagelsen muligvis øges og ulighed mindskes. De fire tiltag ovenfor foreslås, og deres effekt bør løbende evalueres under implementering.

Denmark introduced a nationwide colorectal cancer screening program in 2014. It begins with a mailed stool test; if blood is found, a colonoscopy (a camera examination of the bowel) is offered. This thesis examines inequality in who takes part in the first step of screening. Such inequality can mean that some groups benefit less from the program. The aim is to identify measures that can reduce inequality and increase overall participation, and to outline how to implement and evaluate them. The study used a mixed-methods design with three components: statistical analysis, document analysis, and semi-structured interviews. A statistical model (logistic regression) estimated the risk of not participating based on sociodemographic factors, which helped identify the target group. Seven semi-structured interviews with participants in the program and a document analysis informed the content of the measures. Interviews were interpreted using the Health Belief Model (a theory about what motivates people to act on health information), and the document analysis considered health literacy (the ability to find, understand, and use health information). Leavitt’s system model was used to assess organizational implications of implementing the measures. Of 93,500 invited citizens in 2014–2015, 62,995 (67.37%) participated. Participation was lowest among people living alone (54.2%). Multivariable logistic regression showed that people living alone had a higher risk of non-participation (odds ratio 1.63; 95% CI 1.56–1.70) compared with those living with a partner, adjusted for sex, age, education, income, and immigration status. The interviews yielded six themes: decision made in advance, relationship to the sender, practical issues, use of the invitation materials, thoughts about risk, and influence of the social network. Interpreted through the Health Belief Model, non-participation may be linked to missing cues to action and limited reflection. The document analysis found that the materials do not complement each other well as a decision aid and should be adapted. The combined analysis led to four proposed measures: 1) sending a pre-notification, 2) inviting by geographic areas, 3) a conversation with the person’s general practitioner, and 4) a revised invitation letter. A change analysis indicated impacts on technology, structure, actors, tasks, and environment. Effects can be monitored with a process evaluation using elements from Leavitt’s model to set process and evaluation goals. In the North Denmark Region there is inequality in participation between people living alone and those living with a partner; people living alone have 1.63 times the risk of not participating and therefore may benefit less. Providing clearer cues to action and supporting reflection among people living alone may increase participation and reduce inequality. The four measures are proposed, and their effects should be evaluated continuously during implementation.

[Dette resumé er genereret ved hjælp af AI]

screening ; colorectal cancer ; inequality

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