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Abstract
Background The National Health Service Bowel Cancer Screening Programme (NHS BCSP) aims to detect individuals who have precancerous polyps or early stage cancer, when it is easier to treat. To be effective, a screening uptake of at least 52% is required. Variations in uptake by demographic characteristic are reported and the aim of this study was to better understand who participates in the NHS BCSP, to inform action to address inequalities in screening uptake.
Methods Invitation-level data for the Derbyshire population were supplied by the NHS BCSP Eastern Hub for the period 1 April 2014 to 31 March 2016. Data were linked by postal code to the Mosaic Public Sector Segmentation tool. Descriptive analysis using 14 groups and 61 types within Mosaic was undertaken to offer insight into the demographic, lifestyle and behavioural traits of people living in small geographies against their screening uptake, with a particular focus on identifying population groups with an uptake below 52% and so at risk of health inequalities.
Results 180 176 screening invitations were dispatched with an overall uptake of 60.55%. Six Mosaic groups have an uptake below the 52% acceptable level: urban cohesion, rental hubs, transient renters, family basics, vintage value and municipal tenants. These groups are characterised by high levels of social-rented accommodation, multicultural urban communities and transient populations.
Conclusion Segmentation tools offer an effective way to generate novel insights into bowel cancer screening uptake and develop tailored strategies for working with identified communities to increase participation.
- segmentation tools
- health promotion
- cancer
- screening
- health inequalities
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Introduction
Bowel cancer is the second most common cause of death from cancer in the UK and it is the fourth most common cancer overall; 1 in 14 men and 1 in 19 women will be diagnosed with bowel cancer during their lifetime.1 Men, and particularly those men living in more deprived quintiles, are at greater risk of developing bowel cancer; people in more deprived groups are significantly more likely to die from bowel cancer than people in less deprived groups.2 Men and women of white ethnicity are at significantly greater risk of developing bowel cancer; however, there is no difference in bowel cancer survival after one and 3 years between different ethnic groups.3
Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16%.4 In England, the National Health Service Bowel Cancer Screening Programme (NHS BCSP) is a nationally coordinated programme that aims to identify bowel cancer at an early stage before it becomes symptomatic. The screening programme invites men and women aged 60–74 who are registered with an NHS general practice (a family doctor) and with a functioning bowel to complete a faecal occult blood test (FOBt) every 2 years. A test kit with detailed instructions of how to complete the test is posted to the individual at home, for them to collect faecal samples to return by post using a prepaid envelope. Non-responders to the initial invite to participate in screening are sent one reminder letter. People found to have abnormal tests are then referred to their local screening centre for further assessment with most going on to have a colonoscopy. People whose FOBt proves to be normal are advised in writing that they will be sent another kit in 2 years if they are still under 75. Patients aged ≥75 years can self-refer for screening.
The minimum acceptable standard for NHS BCSP uptake is 52%, where uptake is defined as the percentage of people adequately screened within 6 months of invitation.5 The 52% acceptable standard is the average uptake level below which the screening programme is unlikely to be effective.6 The Department of Health has set an achievable target of 60% and the Public Health England ambition is to work towards 75% uptake in eligible populations.7 In England, average uptake of the screening programme is 59.0%8 although evidence suggests that there are large variations between communities,9 10 including a steep social gradient in uptake.11 Average uptake in Derbyshire (including Derby city) in 2016–2017 was 61.8%.7
Piloting of the NHS BCSP and research published during early roll-out of the programme from 2006 onwards identified gender, socioeconomic and ethnic inequalities in programme uptake. Screening uptake is higher in women than men, but of those who participate a higher proportion of men have abnormal screening test results.9 11–13 Socioeconomically deprived groups have lower screening uptake10 12 as do ethnic minority groups and in particular people from the Indian subcontinent.9 14 Additionally, people who do not participate the first time they are invited for screening are significantly less likely to respond to future bowel cancer screening invitations; in one study, only 13.5% of previous non-responders aged 60–69 years participated.9 This evidence is of particular concern given that cancer registry data suggest that men and people living in more deprived areas are significantly more likely to develop bowel cancer and have worse survival outcomes.2
Specific factors that influence NHS BCSP uptake include lack of knowledge about colorectal cancer and the screening programme, which is more pronounced in adults from ethnic minorities,15 as well as low health literacy and misunderstanding screening programme instructions.16–18 Cancer screening programmes are designed to encourage people to make an informed choice about whether or not to participate; however, 63% of the eligible population who have never been screened for bowel cancer also report not having read the information booklet posted to them to enable them to make an informed choice about participation.19 Additional barriers include disgust at collecting and storing faecal samples, embarrassment at taking the test, concern about the implications of screening test results and further diagnostic tests that may be required, and a lack of symptoms that reduces the perceived importance of the screening test.15 18 20 Further, that the screening test is completed at home rather than in a formal health setting also reduces its perceived importance.20
Evidence-based interventions that can increase uptake of the NHS BSCP include a general practitioner (GP) endorsement letter, an enhanced patient leaflet, telephone advice (in combination with other measures), face-to-face health promotion (in combination with other measures) and an enhanced reminder letter.4 21 22 Uptake is generally increased further where multiple strategies are used.23 A number of other interventions are used, such as community awareness raising activities and the use of pictorial information leaflets; however, evaluation of these interventions tends to examine the impact on screening intentions but not the follow-through to screening uptake.24 25
Existing evidence on variations in uptake of the NHS BCSP is limited to demographic characteristics such as age and gender, and there are gaps with key variables, such as ethnicity, not routinely captured by the programme. Supported by the evidence base,11 we perceived that using a market segmentation tool to better understand the characteristics of non-participants would support the development of a more targeted programme of work to increase screening uptake. The aim of this study was to better understand which population groups have a screening uptake below the 52% acceptable level by linking screening invite data to the Mosaic Public Sector Segmentation Tool (Mosaic).26 Mosaic segments the population into 15 groups and 66 types—small geographies with different demographic, lifestyle and behavioural traits.26 This information was used to identify communities in which uptake is below the acceptable 52% level, and to design appropriate strategies to support those communities to increase screening uptake and so reduce inequalities in access to bowel cancer screening.
Methods
Setting
Derbyshire is a large (2625 km2) and demographically mixed county in the East Midlands region of England with a population of 1.043 million.27 It comprises Derby city (population 256 203), a number of small towns (populations between 20 000 and 100 000) and large rural areas scattered with isolated properties and small and medium sized villages. Derby city is one of the 20% most deprived authorities in England, 25% of the population are non-white British, and life expectancy for men and women is lower than the England average. There is a 10.2-year gap in life expectancy for men and an 8.3-year gap for women between the most and least deprived parts of the city.28 Derbyshire county has a mix of both deprived and affluent rural communities and towns, with overall life expectancy below the England average and an 8.2-year gap for men and 6.4-year gap for women between the most and least deprived areas in the county.29
Study population
This paper presents data on invitations to the NHS BCSP for the GP registered, age-eligible population (60–74 years) in Derbyshire. Two years of data (1 April 2014 to 31 March 2016) including over 180 000 invitations to screening are included for analysis. BCSP individuals are invited for the first time on their 60th birthday (their due date), with subsequent screening invitations sent 2 years after the previous episode closure date.
Market segmentation tools
Market segmentation tools are typically used to help organisations to understand their customer base, for example, digital behaviour and buying habits. There are several commercially available market segmentation tools in England. Derby city council has a licence to the Experian Mosaic Public Sector segmentation tool, which is used locally to better understand various aspects of how we work with and support communities to live healthy lives. The tool is composed of information sourced from various national datasets, including the census and consumer research, and applies it at a local level.26 Experian has categorised these data points to form 15 summary groups and 66 detailed types of citizen. These group and type categories are assigned to every residential postal code in the UK, with the category used describing the majority of the population living in that postal code area. The Mosaic tool, similar to other available market segmentation products, offers detailed insight into demographic, lifestyle and behavioural traits of the population (see table 1). Such tools are used widely by business but, in comparison, have had limited applications to date in public health.
Description of the full range of mosaic groups and types
Data
The NHS England BCSP Eastern Hub provided anonymised invitation-level data to the public health team at Derby city council for analysis. Data provided related to individual invitations to participate in the screening programme. All personal identifiers (eg, individual names and NHS numbers) were removed.
The Hub used full postal code data at source to link to lower layer super output area (LSOA mean population=1600) in order to determine level of deprivation, as well as to enable linkage to the market segmentation tool. The public health team received a dataset with postal codes and individual identifiers removed. Data for each screening invitation included:
Gender.
Age at invite.
Episode sequence number (first, second, third, etc, round invitation).
Invitation count (number of invitations dispatched to date, including current invite).
LSOA (derived by the hub using postal code data).
General practice code (linked to Clinical Commissioning Group (CCG)).
Mosaic segmentation code (assigned by the Hub using postal code-level data).
Adequate screen (used to calculate uptake).
Abnormal result.
Analysis
All 15 Mosaic groups were present in the dataset, however, due to the small sample size (n=31) the city prosperity (group C) was not included in the analysis. Of the 66 Mosaic types, 61 were present within the dataset. Descriptive analysis by group and type was completed to offer insight into the characteristics of people living in small geographies against their screening uptake, with a particular focus on population subgroups with an uptake below the acceptable level of 52%.
Results
Demographic characteristics
Between April 2014 and March 2016, 180 176 invitations to screen were dispatched to people registered with a Derbyshire county or Derby city general practice. A total of 109 099 screens were adequately completed, an uptake rate of 60.55% (see table 2. Uptake was significantly higher in women (62.70%; 95% CI 62.39% to 63.02%) than men (58.34%; 95% CI 58.01% to 58.66%). Uptake also increased with age, from 57.40% at age 60–64 years to 62.82% at 65–69 years and 62.42% at 70–74 years. Screening participants living in the least deprived 10% of areas classified by Index of Multiple Deprivation (IMD) were most likely to participate with an uptake of 69.75% (95%CI 69.09% to 70.4%) while those in the most deprived 10% had the lowest uptake at 44.68% (95%CI 43.92% to 45.45%).
Uptake by demographic characteristics (1 April 2014 to 31 March 2016)
Population segmentation: Mosaic groups
Screening uptake varies across the Mosaic groups (figure 1). The highest uptake is recorded for prestige positions (group B) (71.59%; 95% CI 70.79% to 72.38%) followed by senior security (group F) (69.42%; 95% CI 68.79% to 70.05%). Groups with the lowest uptake include urban cohesion (group I) (40.42%; 95% CI 36.49% to 40.42%) and municipal tenants (group O) (43.85%; 95% CI 41.17% to 43.85%). Six groups have an uptake below the 52% acceptable level: urban cohesion, rental hubs, transient renters, family basics, vintage value and municipal tenants. Table 1 provides a brief description of each of these groups, which are characterised by higher levels of deprivation and a greater likelihood of renting accommodation.
Screening uptake by Mosaic group.
Population segmentation: mosaic types
Each Mosaic group is composed of 3–6 types of citizen (see table 1). Types with the lowest uptake include large family living (33.02%; 95% CI 30.73% to 35.38%), renting rooms (36.32%; 95% CI 34.24% to 38.45%), single essentials (36.99%; 95% CI 34.36% to 39.68%) and flatlet seniors (39.46%; 95% CI 37.05% to 41.91%). These are all significantly lower than the acceptable uptake of 52%. Table 3 shows the Mosaic types with an uptake below 52%, as well as the percentage of people in each of these Mosaic types who are age eligible for the BCSP, that is, the proportion of each type estimated to be aged 60–74 years. Mosaic types with a low screening uptake and in which a large proportion of the community are eligible for screening (ie, groups in which to focus efforts to increase screening uptake in order to have the largest absolute impact at a population level) include Pocket Pensions (46.89%; 95% CI 45.60% to 48.19%), Estate Veterans (47.03%; 95% CI 45.23% to 48.83%) and Community Elders (47.52%; 95% CI 42.42% to 52.65%).
Mosaic types with a screening uptake below the 52% acceptable level and an invitation count >100*
Discussion
Key findings
Examining overall uptake of the NHS BSCP using a segmentation tool has provided practicable insights into populations in which uptake is particularly low. Analysis identified wide variations in uptake by demographic characteristics such as ethnicity, housing tenure and socioeconomic status. These findings align to previous research that identified lower uptake in certain groups including men, areas of higher deprivation and people from black and minority ethnic communities.9 12–14 30
Uptake in the 61 Mosaic types ranged from 33.02% in large family living to 83.87% in uptown elite. Communities with particularly low uptake can be characterised as:
Diverse, multicultural groups in central urban locations.
Transient renters, who may miss screening invitations due to frequent relocations.
Older adults living in social-rented housing.
Uptake is also significantly lower than average among older adults living, often alone, in small and low value privately rented or owner occupied housing. These findings enable public health practitioners to focus efforts to increase uptake in novel ways. Market segmentation tools can support targeted work, for example, providing insight into the best means of communicating with different communities and factors of importance to the community (eg, faith, family, technology).
While many Mosaic types with low screening uptake have higher levels of deprivation, segmentation provides a much greater understanding of the broader characteristics of the population with a low uptake than does analysis using demographic data. For example, we use IMD at LSOA to measure deprivation across Derby and Derbyshire. However, one LSOA comprised many postal codes and so can have multiple Mosaic types within it. Across Derbyshire and Derby city, there are a large number of LSOAs with over 10 different Mosaic types; therefore, using IMD alone masks variation between small geographies.
Implications for practice
Using population segmentation tools can provide a more nuanced understanding of population subgroups in which cancer screening uptake is low. Based on previous research, interventions to improve uptake have typically focused on awareness raising and information events in general practices with low uptake and particularly those in more deprived areas. The additional insight gained from segmenting the study population enables us to explore initiatives to reduce inequalities in uptake that focus on, for example, multicultural urban neighbourhoods and those with high levels of social-rented housing.
In Derbyshire information generated through market segmentation has supported the development of materials, targeted to specific communities, which use information on the local Mosaic types to understand how best to engage with older adults around the BCSP. This work is being piloted at the time of writing and draws on marketing information available through the Mosaic segmentation tool.
Strengths and limitations
This work has generated novel insights into inequalities in bowel cancer screening uptake by combining screening invitation data for Derbyshire with the Mosaic Public Sector Segmentation tool. The analysis of a large dataset incorporating mapping to Mosaic group and type is particularly valuable given the limited amount of demographic information that is routinely recorded in the NHS BCSP and has enabled subgroup analysis to develop a better understanding of local variations in uptake. Additionally, the data used for analysis were linked at the postal code level, providing granularity in understanding of the characteristics of the population living in very small geographies.
Market segmentation tools generally calculate the proportion of the population living in each area, appended to UK postal codes, that is, likely to belong to each segment of the tool. As such we cannot be certain that everyone in each area identifies with their respective segment and so there is a risk of ecological fallacy. A level of caution should be used when using Mosaic or any other segmentation tool to develop actions to improve screening uptake; for example, checking with other sources of data on a particular area to make sure that the segmentation findings appear logical.
Additionally, data were provided for people registered with a GP in one of the four Derbyshire CCGs. This creates a number of potential challenges for fully understanding local need and for responding with initiatives to improve uptake in Derbyshire residents. For example, anyone who is not registered with a GP will be excluded from both the data and the BCSP and this may exacerbate health inequalities. Comparison of ONS midyear population estimates for 201527 with the January 2015 GP registrations for Derbyshire31 identifies a difference of approximately 2000 people (0.2% population). Groups less likely to be GP registered include transient populations (eg, Gypsy/Roma communities) and migrants.32 However, GP registration number for Derbyshire will include individuals who live on the border in neighbouring counties, and similarly some Derbyshire residents will be registered with GPs outside of Derbyshire. So, any initiatives that target screening uptake outside of the GP practice (eg, at a community level) may miss people who are registered with a Derbyshire GP but who live outside of Derbyshire.
Conclusion
Diverse, multicultural groups in central urban locations, transient renters who frequently relocate and older adults living in social rented housing have particularly low engagement in the NHS BCSP. Targeted interventions are required to improve uptake in these population subgroups to reduce health inequalities. Segmentation tools offer an effective way to generate novel insights into bowel cancer screening uptake and ways of working with identified communities to increase participation.
What is already known on this subject
Piloting of the NHS Bowel Cancer Screening Programme from 2006 onwards identified gender, socioeconomic and ethnic variations in uptake. The programme has now been operating for over a decade but some key demographic data that would inform efforts to reduce inequalities in uptake are not routinely captured and so cannot be considered when examining variations in programme uptake today. We linked screening invitation data to a market segmentation tool to provide insights into the characteristics of population groups with low uptake and to inform recommendations to address inequalities in screening uptake.
What this study adds
Using market segmentation tools can provide practicable insights into the populations in which bowel cancer screening uptake is low. Communities with particularly low uptake in our area include: (1) diverse, multicultural groups in central urban locations; (2) transient renters, who may miss screening invitations due to frequent relocations and (3) older adults living in social-rented housing.
Policy implications
The additional insight gained from segmenting the study population enables us to explore initiatives to reduce inequalities in uptake that focus on, for example, multicultural urban neighbourhoods and those with high levels of social rented housing. Further, market segmentation tools can provide insights into factors that are important to different communities (eg, faith, technology, etc.) and the best means of communicating with them.
Acknowledgments
Data for this study are based on information collected and quality assured by the PHE Population Screening Programmes. Access to the data was facilitated by the PHE Office for Data Release. We would like to thank NHS England North Midland for commissioning the analytical work and colleagues in the embedded Screening and Immunisations Team for collaborating with us to develop this work. Andrew Field and colleagues in the NHS BCSP Eastern Hub also provided invaluable support with accessing and understanding the data. For more in-depth information on the specific market segmentation tool used in this study, Mosaic Public Sector Segmentation, contact Experian 2019©: https://www.experian.co.uk/assets/marketing-services/brochures/mosaic-ps-brochure.pdf. Experian’s services are not intended to be used as the sole basis for any business decision. Experian Data are based on data which is provided by third parties, the accuracy and/or completeness of which it would not be possible and/or economically viable for Experian to guarantee. Experian’s services also involve models and techniques based on statistical analysis, probability and predictive behaviour. Experian is not able to accept any liability for any inaccuracy, incompleteness or other error in the Experian data or any failure of the services to achieve any particular result.
References
Footnotes
Contributors LG led the analysis and reporting of the work and is the overall content guarantor. LW conducted the data analysis and contributed to the reporting of the study. AB contributed to the planning and reporting of the study. JC co-led the planning, and contributed to the conduct and reporting of the study. SD contributed to the planning and reporting of the study. NR contributed to the planning and reporting of the study. AM co-led the planning, and contributed to the conduct and reporting of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval This project was approved by the Bowel Cancer Screening Programme Research Committee in May 2017 (approval ID: BCSPRAC_177_ODR1516_489).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.