A case management occupational health model to facilitate earlier return to work of NHS staff with common mental health disorders: a feasibility study.

BACKGROUND: The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders. OBJECTIVE: The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety). DESIGN: A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual. PARTICIPANTS: Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder. INTERVENTION: The intervention involved early referral to occupational health combined with standardised work-focused case management. CONTROL/COMPARATOR: Participants in the control arm received care as usual. PRIMARY OUTCOME: The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker's functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial. RESULTS: Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites. HARMS: No adverse events were reported. LIMITATIONS: The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised. CONCLUSION: All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14621901. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 12. See the NIHR Journals Library website for further project information.

Anxiety and depression are common causes of sickness absence in the NHS. This can harm patient care. Previous research has shown that offering early support to NHS staff on sick leave with a common mental health disorder is important to aid recovery and rehabilitation. However, it is not currently known how best to support staff in returning to work. The purpose of this research was to test the feasibility of a large-scale study to see if specially trained occupational health nurses would be effective in getting NHS staff with these problems back to work quicker. We reviewed the recent scientific literature and did a survey of NHS occupational health departments to find out what was currently offered to such staff. We developed a new work-focused case management intervention and trained six occupational health nurses to deliver it. We recruited 24 NHS staff who were on sick leave with a common mental health disorder (such as depression or anxiety) and allocated 11 to receive the new intervention and the rest to receive usual support. Participants were invited to complete three questionnaires and we collected information from the participating occupational health sites. We also interviewed participants, managers, human resource staff and occupational health nurses to find out what they thought about being involved in the study. We found that the new case management intervention had potential benefits. However, it would not be possible to run a trial to evaluate the intervention until a better way can be found to encourage the early referral of sick staff to occupational health.

Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study.

BACKGROUND: Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES: To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS: A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN: A parallel-group, cluster randomised controlled trial. SETTING: The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS: All registered patients were included. MAIN OUTCOME MEASURES: The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY: A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS: There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS: The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS: This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK: Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95232781. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.

The overuse of antibiotics to treat infections is contributing to the rise of antibiotic resistance in bacteria. A trial was carried out to evaluate whether or not interventions delivered through general practice computer systems may be used to reduce antibiotic prescribing for self-limiting respiratory tract infections (RTIs). The study was carried out in 79 UK general practices. The study tested the effect of a webinar to introduce the trial interventions, which included monthly feedback reports of data for respiratory consultations and antibiotic prescriptions, as well as computer-delivered decision support tools. These interventions were specially developed for this study and were pre-tested with general practitioners and practice nurses. Over the 12-month intervention period, the antibiotic-prescribing rate was about 12% lower in the intervention trial arm than in the control arm. There was no effect of intervention in children aged < 15 years or adults aged ≥ 85 years, but antibiotic prescribing was reduced by about 16% in adults aged between 15 and 84 years. Assuming this was caused by the intervention, one antibiotic prescription was avoided per year for every 62 patients aged between 15 and 84 years and registered with a trial practice. The study found no evidence that the intervention might increase the risk of 12 bacterial infections. In addition, a follow-up study of 610 UK general practices not included in the trial was conducted. The study found that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it may be possible to observe about one more case of pneumonia per year and one more case of peritonsillar abscess per decade, but no increase in other infections is likely. It can be concluded that electronically delivered interventions, including feedback of antibiotic-prescribing data for specific indications, may have the potential to reduce unnecessary antibiotic prescribing; however, antimicrobial stewardship interventions need to be tailored to particular age groups.

Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial.

OBJECTIVES: To evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections. DESIGN: Open label, two arm, cluster randomised controlled trial. SETTING: UK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017. PARTICIPANTS: 79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care. INTERVENTIONS: AMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial. MAIN OUTCOME MEASURES: Primary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported. RESULTS: The trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13). CONCLUSIONS: Electronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation. TRIAL REGISTRATION: ISRCTN95232781.

Comparing and contrasting responses to tobacco control and obesity policies: a qualitative study.

OBJECTIVE: To explore people's perceptions of, and responses to, obesity and tobacco policies with a particular focus on motivation; and to compare and contrast responses to explore the potential for translating learning across domains. DESIGN: A theoretically informed comparative qualitative study involving semi-structured interviews with two groups of participants (smokers and ex-smokers; those who have previously or are currently attempting to lose weight). Data were analysed inductively using thematic analysis and interpreted through the lens of Self-Determination Theory. SETTING: Community-based. PARTICIPANTS: Interviews were conducted with five smokers and four ex-smokers around tobacco policy, and seventeen people acting to control their weight around obesity policy. RESULTS: Three primary themes were identified. (i) Participants believed social norms to be crucial to supporting health behaviour change and responses to policy; not smoking was perceived as socially normal, whereas being physically active and eating healthily were perceived to go against social norms. (ii) Policies influencing the physical environment were perceived to support stopping smoking (e.g. smoke-free laws, advertising bans), but to undermine attempts to lose or control weight (e.g. high visibility, availability and low cost of energy-dense foods). (iii) While policies for both domains were considered necessary and legitimate, both groups found policy interventions neither motivating nor undermining of their sense of autonomy. CONCLUSIONS: The results suggest those trying to lose weight respond similarly to obesity-related policy as smokers do to tobacco policy. Environmental interventions are perceived to be more helpful than appealing to people's motivation to change for their own sake.

Juicy June: a mass-participation snack-swap challenge-results from a mixed methods feasibility study.

BACKGROUND: Improving diet as a means of reducing the development of disease states and obesity is a public health priority. Although a growing number of countries have adopted policies to improve dietary patterns at the population level, as yet there are no established means of successfully bringing about change, suggesting that new approaches are needed. This study aimed to investigate the feasibility and proof of concept of a theoretically informed healthy eating intervention based on the model of successful month-long alcohol reduction or stop smoking campaigns (i.e. a mass-participation 'challenge' format). METHODS: The study was a mixed methods feasibility trial and proof of concept of an online intervention. Adults were recruited to take part in a month-long 'Juicy June' challenge in which they nominated one unhealthy daily snack and committed to replace this with fruit or vegetables. Behaviour change techniques to promote motivation, increase self-efficacy, promote social support, self-regulation and habit formation were integrated into materials provided off- and online to support dietary change. A Facebook group was used to provide information, encouragement and foster social support. Diet quality was assessed before and after the intervention. Reasons for taking part, adherence to the snack swap, use of the intervention materials and experience of taking part were explored using quantitative and qualitative measures. RESULTS: Ninety-one adults of whom 42% were either overweight or obese took part. Over the 4-week intervention period, participants consumed their intended fruit/vegetable snack on average 5 days/week; however, they still consumed their target unhealthy snack on average 2 days/week. Adherence to the snack swap was stable over the 4-week intervention period. The use of specific behaviour change tools (e.g. self-monitoring) was low. Sixty-seven percent of participants accessed the online Facebook forum, but there were no user-generated posts or content. CONCLUSIONS: The study demonstrated that the concept of a novel snack swap mass participation campaign is acceptable and feasible. Further piloting to explore how to promote greater engagement with men and ethnic minority groups and how to promote social support and maximise engagement with behaviour change techniques would be valuable.

Body Mass Index and Incident Type 1 and Type 2 Diabetes in Children and Young Adults: A Retrospective Cohort Study.

CONTEXT: Little is known about the association between obesity and temporal trends in the incidence of diabetes in children and young adults. OBJECTIVE: We examined the recent incidence of types 1 and 2 diabetes in relation to a high body mass index (BMI) in UK children and young adults. DESIGN: Cohort and nested case-control. SETTING: A total of 375 general practices that contribute to the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS: A total of 369,362 participants aged 2 to 15 years at BMI measurement in CPRD from 1994 to 2013. INTERVENTION: None. MAIN OUTCOME MEASURES: Incident type 1 diabetes (T1D) and type 2 diabetes (T2D) diagnoses up to age 25 years. RESULTS: A total of 654 incident cases of T2D and 1318 T1D cases were found. The incidence of T2D per 100,000 persons annually increased from 6.4 in 1994 to 1998 to 33.2 in 2009 to 2013; and that for T1D increased from 38.2 to 52.1 per 100,000 persons during the same period. The incidence of T2D increased in both overweight (85th to 95th percentile for age- and sex-specific BMI; P = 0.01) and obese (≥95th percentile; P < 0.01) individuals from 1994 to 2013. Obese individuals, who constituted 47.1% of T2D cases, had a markedly greater risk of incident T2D [odds ratio, 3.75; 95% confidence interval (CI), 3.07 to 4.57], with an incidence rate ratio of 4.33 (95% CI, 3.68 to 5.08) compared with the normal BMI category. No positive linear association was found between obesity (greater BMI) and incident T1D cases. CONCLUSIONS: Increasing obesity has contributed to the increasing incidence of T2D but not T1D among UK children and young adults, with a fourfold greater risk of developing T2D in obese individuals.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol.

INTRODUCTION: Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. METHODS AND ANALYSIS: 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. ETHICS AND DISSEMINATION: Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. TRIAL REGISTRATION NUMBER: ISRCTN95232781; Pre-results.

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records.

OBJECTIVE:  To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs). DESIGN:  Cohort study. SETTING:  610 UK general practices from the UK Clinical Practice Research Datalink. PARTICIPANTS:  Registered patients with 45.5 million person years of follow-up from 2005 to 2014. EXPOSURES:  Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients. MAIN OUTCOME MEASURES:  Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice. RESULTS:  From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome were similar in frequency at low prescribing and high prescribing practices. CONCLUSIONS:  General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre's syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

Can media images of obese people undermine health messages? An experimental study of visual representation and risk perception.

BACKGROUND: Images depicting morbidly obese models [i.e. body mass index (BMI) >40] often accompany media articles about the health risks of being overweight (i.e. BMI 25-30). Little is known about the effect of this mismatch on people's understanding of risk, and perceptions of message relevance. METHODS: In total, 563 participants (291 overweight/obese and 272 healthy weight) were randomly allocated to read a health message about the risk of heart disease posed by being overweight, presented alongside (i) a photo of an overweight model, (ii) a morbidly obese model or (iii) no photo. Between-group differences in the primary outcomes of message relevance, and the body size perceived to be 'at risk', were assessed, and the potential moderating effects of motivation, weight concern and existing risk knowledge explored. RESULTS: Overweight and obese participants in the exaggerated (morbidly obese) image condition interpreted health risks to relate to a larger body size than those who saw no image (F(2, 290) = 4.06, P = 0.02). There was no experimental effect on perceived personal relevance (F(2, 290) = 0.25, P = 0.38). No significant moderation effects were detected, and there was no effect of study condition in healthy weight participants for either outcome. CONCLUSION: The findings suggest that the use of morbidly obese models in messages regarding the health risks of being overweight may undermine the impact of these messages among those who they most aim to reach; the reader may perceive a reduced risk of being 'only' overweight, and that a higher weight is needed for the negative effects of excess weight to occur.

Knowledge of lung cancer symptoms and risk factors in the U.K.: development of a measure and results from a population-based survey.

OBJECTIVES: To develop and validate a lung cancer awareness measure (Lung CAM) and explore the demographical and social predictors of lung cancer awareness in the general population. METHODS STUDY 1: Symptoms and risk factors for lung cancer were identified from the medical literature and health professional expertise in an iterative process. Test-retest reliability, internal reliability, item analyses, construct validity and sensitivity to changes in awareness of the Lung CAM were assessed in three samples (total N=191). RESULTS STUDY 1: The Lung CAM demonstrated good internal (Cronbach's α=0.88) and test-retest reliability (r=0.81, p<0.001). Validity was supported by lung cancer experts scoring higher than equally educated controls (t(106)=8.7, p<0.001), and volunteers randomised to read lung cancer information scoring higher than those reading a control leaflet (t(81)=3.66, p<0.001). METHODS STUDY 2: A population-based sample of 1484 adults completed the Lung CAM in a face-to-face, computer-assisted interview. RESULTS STUDY 2: Symptom awareness was low (average recall of one symptom) and there was little awareness of risk factors other than smoking. Familiarity with cancer, and being from a higher socioeconomic group, were associated with greater awareness. CONCLUSIONS: Using a valid and reliable tool for assessing awareness showed the UK population to have low awareness of lung cancer symptoms and risk factors. Interventions to increase lung cancer awareness are needed to improve early detection behaviour.

Cervical screening among migrant women: a qualitative study of Polish, Slovak and Romanian women in London, UK.

OBJECTIVE: To explore awareness of and participation in cervical screening services in women from Poland, Slovakia and Romania living in London, UK. METHODS: Three qualitative studies were carried out in London in 2008-2009: an interview study of professionals working with Central and Eastern European migrants (n=11); a focus group study including three Polish, one Slovak and one Romanian focus group; and an interview study of Polish (n=11), Slovak (n=7) and Romanian (n=2) women. RESULTS: Awareness of the cervical screening programme was good, but understanding of the purpose of screening was sometimes limited. Some women were fully engaged with the UK screening programme; others used screening both in the UK and their countries of origin; and a third group only had screening in their home countries. Women welcomed the fact that screening is free and that reminders are sent, but some were concerned about the screening interval and the age of the first invitation. CONCLUSIONS: Migrant women from Poland, Slovakia and Romania living in London vary in their level of participation in the National Health Service Cervical Screening Programme. More needs to be done to address concerns regarding screening services, and to ensure that language is not a barrier to participation.

Assessing awareness of colorectal cancer symptoms: measure development and results from a population survey in the UK.

BACKGROUND: This paper describes the development of a Cancer Awareness Measure for colorectal (CRC) cancer (Bowel/Colorectal CAMa) (study 1) and presents key results from a population-representative survey using the measure (study 2). METHODS: STUDY 1: Items were taken from the literature and reviewed by expert groups. A series of three validation studies assessed reliability and validity of the measure. To establish test-retest reliability, 49 people over 50 years of age completed the Bowel/Colorectal CAM on two occasions (range 9-14 days, mean 13.5 days). Construct validity was assessed by comparing responses from bowel cancer experts (n = 16) and the lay public (n = 35). Lastly, a brief intervention study tested sensitivity to change with participants (n = 70) randomly allocated to be given a control leaflet or an intervention leaflet and their responses were compared. STUDY 2: 1520 respondents completed the Bowel/Colorectal CAM in a population survey carried out by TNS-British Market Research Bureau International (TNS-BMRB) in March 2010. RESULTS: STUDY 1: Internal reliability (Cronbach's alpha = 0.84) was high. Test-retest reliability was over r = 0.7 for warning signs, risk factors and age people are first invited for screening, but lower (between 0.6 and 0.7) for other items (lifetime risk, awareness of bowel cancer screening, age at risk). Bowel cancer experts achieved higher scores than equally educated controls (54.7 [4.3] vs. 42.9 [5.7]; P < 0.001) demonstrating the measure has construct validity and intervention participants showed higher knowledge than controls (51.4 [5.9] vs. 42.9 [5.7]; P < 0.001) suggesting the measure is sensitive to change. STUDY 2: Respondents recalled on average, one CRC sign and one risk factor. There was particularly low prompted awareness of the signs 'lump in the abdomen' (64%) and 'tiredness' (50%) and several lifestyle risk factors for CRC, e.g. exercise (37%).Respondents from more affluent groups had consistently higher knowledge of signs and risk factors compared to those from more deprived groups. CONCLUSIONS: The Bowel/Colorectal CAM meets accepted psychometric criteria for reliability and construct validity and should therefore provide a useful tool for assessment of CRC awareness. The population survey revealed low awareness of several CRC signs and risk factors and emphasises the importance of continuing public education, particularly about the link between lifestyle behaviours and CRC.