Article

Benefits and barriers to participation in colorectal cancer screening: A protocol for a systematic review and synthesis of qualitative studies

BMJ Open (Impact Factor: 2.27). 01/2014; 4(2):e004508. DOI: 10.1136/bmjopen-2013-004508
Source: PubMed

ABSTRACT

Colorectal cancer (CRC) poses a serious health problem worldwide. While screening is effective in reducing CRC mortality, participation in screening tests is generally suboptimal and social inequities in participation are frequently reported. The goal of this review is to synthesise factors that influence an individual's decision to participate in CRC screening, and to explore how those factors vary by sex, ethnicity and socioeconomic status.
A primary search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, PsycINFO, and a secondary search of grey literature and articles taken from references of included articles (from inception to July 2013).
A systematic review and Meta-study synthesis of qualitative studies that address perceived benefits and barriers to participation in CRC screening tests among adults 50 years of age or older.
The two-staged Meta-study methodology by Paterson will be used to conduct this review. In stage 1, similarities/differences, patterns and themes will be identified across three levels of analysis while preserving the context of original studies. In stage 2, synthesis will extend beyond the analysis to generate new theory of the phenomenon through a process called Meta-synthesis.
This review offers to generate a framework to better understand benefits and barriers that affect decision-making to participate in CRC screening among different sectors of the population. This framework will be a relevant tool for policy makers in framing educational materials, for patient-centered communication, and for researchers interested in the science of equity. This review is registered in PROSPERO (registration number: CRD42013005025).

Full-text

Available from: Gladys Honein, Mar 27, 2014
Benets and barriers to participation
in colorectal cancer screening: a protocol
for a systematic review and synthesis
of qualitative studies
Gladys N Honein-AbouHaidar,
1,2
Monika Kastner,
2,3
Vincent Vuong,
1
Laure Perrier,
2
Linda Rabeneck,
4,5,6,7
Jill Tinmouth,
3,6,7,8
Sharon Straus,
2,3,7,9
Nancy N Baxter
1,2,3,6
To cite: Honein-
AbouHaidar GN, Kastner M,
Vuong V, et al. Benefits and
barriers to participation
in colorectal cancer
screening: a protocol for a
systematic review and
synthesis of qualitative
studies. BMJ Open 2014;4:
e004508. doi:10.1136/
bmjopen-2013-004508
Prepublication history and
additional material for this
paper is available online. To
view these files please visit
the journal online
(http://dx.doi.org/10.1136/
bmjopen-2013-004508).
Received 20 November 2013
Revised 7 February 2014
Accepted 10 February 2014
For numbered affiliations see
end of article.
Correspondence to
Dr Gladys N
Honein-AbouHaidar;
gladys.honein@mail.utoronto.
ca
ABSTRACT
Introduction:
Colorectal cancer (CRC) poses a serious
health problem worldwide. While screening is effective
in reducing CRC mortality, participation in screening
tests is generally suboptimal and social inequities in
participation are frequently reported. The goal of this
review is to synthesise factors that influence an
individuals decision to participate in CRC screening,
and to explore how those factors vary by sex, ethnicity
and socioeconomic status.
Data sources: A primary search of Cumulative Index
to Nursing and Allied Health Literature (CINAHL),
MEDLINE, EMBASE, PsycINFO, and a secondary search
of grey literature and articles taken from references of
included articles (from inception to July 2013).
Design: A systematic review and Meta-study synthesis
of qualitative studies that address perceived benefits
and barriers to participation in CRC screening tests
among adults 50 years of age or older.
Review methods: The two-staged Meta-study
methodology by Paterson will be used to conduct this
review. In stage 1, similarities/differences, patterns and
themes will be identified across three levels of analysis
while preserving the context of original studies. In
stage 2, synthesis will extend beyond the analysis to
generate new theory of the phenomenon through a
process called Meta-synthesis.
Discussion: This review offers to generate a
framework to better understand benefits and barriers
that affect decision-making to participate in CRC
screening among different sectors of the population.
This framework will be a relevant tool for policy
makers in framing educational materials, for patient-
centered communication, and for researchers
interested in the science of equity. This review is
registered in PROSPERO (registration number:
CRD42013005025).
INTRODUCTION
Colorectal cancer (CRC) poses a serious
health problem worldwide. CRC is the second
most common cause of cancer death in the
USA,
1
Canada,
2
the UK,
34
Germany,
5
Australia
6
and Japan.
7
It is estimated that by
2013, 142 820 new CRC cases and 50 830 CRC
deaths will occur in the USA,
1
and 23 900 new
CRC cases and 9200 CRC deaths will occur in
Canada.
2
Screening for CRC can reduce the burden
of the disease. Screening tests for CRC include
faecal occult blood testing (guaiac FOBT) and
faecal immunochemical test (FIT), exible sig-
moidoscopy, colonoscopy, CT colonography
(CTC) and faecal DNA testing. Several of
these tests are effective in reducing the inci-
dence of, and in some instances, the mortality
from the disease. Three landmark randomised
controlled trials (RCTs) demonstrated that
Strengths and limitations of this study
This will be the first synthesis of qualitative
studies to investigate why individuals undergo
colorectal cancer (CRC) screening, their percep-
tions of and experiences with CRC screening and
which aspects of screening are valued and cul-
turally acceptable.
The work will advance the science of conducting
Meta-study reviews by rigorously executing its
steps in the context of our research question and
to document this process extensively in our final
report.
The work will advance the science of equity by
identifying the determinants of social inequities
in CRC screening participation.
Findings from this Meta-study will be used to
generate a framework to better understand the
perceived benefits and barriers that affect individ-
ual decision-making of CRC screening.
Findings may be limited to individuals from dif-
ferent ethnic minorities living in developed coun-
tries, which may limit the transferability of our
findings to the overall ethnic population.
Honein-AbouHaidar GN, Kastner M, Vuong V, et al. BMJ Open 2014;4:e004508. doi:10.1136/bmjopen-2013-004508 1
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Page 1
biennial use of guaiac FOBT coupled with colonoscopy in
persons who tested positive was associated with a reduction
in CRC mortality by 15%.
810
Screening for CRC is a complex process, and many
publicly funded healthcare systems have implemented an
organised, population-based approach for screening such
as in the UK,
11
most provinces in Canada,
12
19 of the 27
European Union (EU) countries,
13
Japan
14
and Korea.
15
Population-based organised screening programmes
involve inviting a dened population at average risk for
the disease (ie, people who do not have CRC, or strong
family history of CRC, or medical conditions that put
them at higher risk of developing CRC such as Crohns
disease or ulcerative colitis) to attend screening. The
success of a high-quality organised, population-based
CRC screening programme depends on adequate uptake
as well as social equity in uptake.
16
Early evaluation indi-
cates an overall low participation and social inequity in
participation. Participation in CRC screening tends to be
lower among ethnic minorities,
11 1719
low socioeconomic
status individuals
11 2022
and among men.
20 2224
While social inequities in uptake are well described in
the literature,
25 26
what is missing is a clear understand-
ing of why CRC screening is or is not appealing to indi-
viduals, aspects of screening that are valued and those
that are culturally acceptable. Qualitative studies are
important sources for this information. To date, a wide
range of qualitative studies have elicited views on the
perceived benets and barriers to participation in
screening from a range of ethnic and socioeconomic
groups in various countries. The in-depth analyses in
these studies reveal the complexity of social factors that
affect an individuals decision to participate in screen-
ing. For example, studies have shown that difculties in
doing screening tests at home (ie, FOBT) and the per-
ceived need for screening while having no symptoms of
colorectal disease are the main barriers for participation
across different population groups.
27 28
In certain cul-
tures, men perceive colonoscopy as embarrassing, inva-
sive and an affront to their masculinity.
2224 2937
Women, in general, believe that their experience with
other cancer screening tests such as mammography
encourages them to do CRC screening,
38
and because
they often assume the role of caregiver in a family, they
value the importance of self-care and early detection in
order to prevent personal and family suffering.
22
Less
education, consistently equated with poorer health liter-
acy skills, is often cited as the main barrier for CRC
screening among low SES individuals. Poor health liter-
acy is associated with reduced ability to obtain, process
and understand health information,
22
and the likeli-
hood of engaging in preventive health behaviours such
as CRC screening.
3941
Other reported factors inuen-
cing participation in CRC screening among certain
ethnic populations include maintaining a positive
energy (qi) and spirit ( jing shen), as well as the belief
that moderation of exercise and diet were enough to
control the toxins and prevent CRC.
19
Systematic reviews of quantitative studies have focused
on investigating the efcacy of CRC screening tests,
42 43
the determinants of CRC screening participation
25 26
and the effectiveness of interventions to increase screen-
ing participation.
26 44 45
However, no synthesis of qualita-
tive studies exists to investigate why individuals undergo
CRC screening or not, their perceptions of and experi-
ences with CRC screening and which aspects of screen-
ing are valued and culturally acceptable. A well-designed
synthesis of qualitative studies is needed to achieve a
greater conceptual understanding of the perceived bar-
riers and benets associated with participation in CRC
screening. This understanding is a necessary step to
direct intervention designs to raise overall participation,
reduce inequities in participation and eventually reduce
mortality from CRC.
The Meta-study approach, a commonly used method
to synthesise qualitative studies, was the most suitable
approach to answer our research question. We consid-
ered other methods such as the Realist review (which
seeks to understand what works for whom, under what
circumstances and why) and Meta-ethnography (which
aims to uncover a new theory to explain a range of nd-
ings), neither focuses on the experiences of people spe-
cically nor considers the quality of included studies as
part of the analysis.
The objectives of our study are to systematically review
the literature for qualitative evidence that explores the
factors that inuence the decision of individuals aged
50 years or over at average risk for CRC to participate in
CRC screening, and how those factors vary by sex, ethni-
city and SES. Our secondary aim will be to generate a
framework to better understand the perceived benets
and barriers that affect individual decision-making.
METHODS
Synthesis methodology
We will use the Meta-study methodology to conduct our
review, which is a systematical, analytical and synthesis
research method pioneered by Paterson et al.
46
We
selected this methodology because it was the most suit-
able to answer our research question. Meta-study is a
multifaceted, systematical knowledge synthesis method
aimed at better understanding how people construct
knowledge.
47
In the context of our study, this is related
to better understanding the determinants of CRC
screening test participation. More specically, it is an
interpretive qualitative research approach in the con-
structivist paradigm (ie, the role of the investigator is to
understand how people construct knowledge about the
phenomenon under study).
48
The aims of Meta-study
are to analyse and synthesise what has been reported
in the literaturethese are considered distinct. Analysis
involves identifying commonalities, differences, patterns
and themes in a body of qualitative research (ie, what is
typically done in a qualitative systematic review). Synthesis
extends beyond analysis to identify truths about the
2 Honein-AbouHaidar GN, Kastner M, Vuong V, et al. BMJ Open 2014;4:e004508. doi:10.1136/bmjopen-2013-004508
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phenomenon under study by considering how the
primary researchers interpreted the data (ie, Meta-data),
the design and quality of studies (Meta-method) and the
theoretical frameworks or perspectives used in these
research reports (Meta-theory). To answer our research
questions, we need to go beyond the analysis of existing
literature, as CRC screening is complex, and currently, it
is unknown why people do or do not undergo CRC
screening. We hypothesise that there may be underlying
factors involved in an individuals perceptions and
experiences well beyond CRC as a disease itself that
inuences their decision to undergo diagnostic testing
(eg, cultural beliefs). Meta-study will allow us to extend
beyond the typical analysis phase because it considers
the triangulation of the raw data (meta-data) and its
quality (meta-method) as well as the theoretical under-
pinnings of this data (meta-theory). This level of synthe-
sis called Meta-synthesis will lead to a new
understanding of CRC and screening decisions (eg, col-
onoscopy) beyond what would be discovered in a quali-
tative systematical review (which tends to focus entirely
on the primary research ndings).
The proposed ow of our Meta-study methods is
represented in gure 1. Our Meta-study will be guided
by the reporting standards as outlined in the ENTREQ
criteria (Enhancing Transparency in Reporting the
Synthesis of Qualitative Research).
49
This is a 21-item
checklist grouped into ve main domains: introduction,
methods and methodology, literature search and selec-
tion, appraisal and synthesis of ndings. The protocol
has been registered in the PROSPERO database (regis-
tration number: CRD42013005025, available at http://
www.crd.york.ac.uk/PROSPERO).
Eligibility criteria
We developed our eligibility criteria from our research
questions. The review will use the following PICOS
(Population, Intervention, Context, Outcomes and
Study design) elements: (1) Population: Adults aged
50 years or over referred for CRC screening; exclusion
criteria are studies investigating participants previously
diagnosed with CRC; a hereditary, personal or family
history of CRC (eg, Familial Adenomatous Polyposis
(AFP) and hereditary non-polyposis CRC (HNPCC));
Figure 1 Flow of proposed
Meta-study methods.
Honein-AbouHaidar GN, Kastner M, Vuong V, et al. BMJ Open 2014;4:e004508. doi:10.1136/bmjopen-2013-004508 3
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and a history of inammatory bowel disease (eg, ulcera-
tive colitis and Crohns disease); (2) Intervention: We will
identify all articles investigating perceptions of CRC
screening as well as those investigating CRC as a disease
; (3) Context: We will investigate any variations in percep-
tions by sex, ethnicity, SES and other factors inuencing
CRC screening behaviour; (4) Outcomes: Perceptions
related to CRC as a disease, causes of CRC, benets and
barriers to CRC screening and any other contextual
factors that motivate or inuence peoples decision to
participate in CRC screening; (5) Study design : We will
include all qualitative studies and mixed-methods studies
with a qualitative component. We will exclude experi-
mental, observational and any non-empirical studies (ie,
not based on observation or experience, opinion-driven
or no hypothesis testing) such as editorials, letters, com-
mentaries and narrative reviews.
Information sources
We will conduct a systematic search in the following elec-
tronic databases from inception to July 2013: MEDLINE,
EMBASE, the Cumulative Index to Nursing and Allied
Health Literature (CINAHL), PsycINFO and Social
Science Abstracts (SSA). We will conduct a secondary
search of the grey literature (unpublished) from sources
such as Cancer Care Ontario and the National Health
System Bowel Cancer Screening Programme. We will
also search the reference lists of included articles and
identify other articles through contact with experts in
the eld and linkages with our team members (eg,
Cancer Care Ontario). There will be no language restric-
tions in our searches. We anticipate completing the
review by April 2014.
Search strategy
Literature searching will be conducted by an experienced
information specialist. The search strategy for the main
database (MEDLINE) will be peer reviewed by another
experienced information specialist using the PRESS check-
list (ie, Peer Review of Electronic Search Strategies).
50
The
resulting retrieval yield will be limited to qualitative studies
and mixed methods with a qualitative component using
the optimised search strategy lter for qualitative studies
of selected databases: MEDLINE,
51
EMBASE,
52
PsycINFO
53
and CINAHL.
54
The draft search strategy for
MEDLINE is available in online supplementary appendix
2. For the other databases, the search strategies are avail-
able from the authors on request.
Study selection
We will rst perform a calibration exercise to ensure reli-
ability of screening. Using the inclusion/exclusion cri-
teria available in online supplementary appendix 1, two
reviewers will independently screen a random sample of
citations (2550 citations) using our online Synthesi.SR
Tool (proprietary online systematic review software
developed for our Knowledge Synthes is Center at
St. Michaels Hospital).
55
We will calculate inter-rater
agreement for study inclusion using per cent agreement,
and repeat our pilot screening exercise until we reach at
least 90% agreement at which point investigators will
independently review titles and abstracts of potentially
relevant articles in duplicate (level 1 screening). For
level 2 screening, we will follow a similar calibration exer-
cise as described for level 1 screening to identify full-text
articles. Conicts will be resolved through research team
consensus for both levels of screening.
Data collection process
Two reviewers will abstract data independently using a
standardised data collection form. The form will rst be
pilot tested on a random sample of 510 included
studies and modied accordingly. Data abstraction will
begin only if agreement is at least 95% among the two
abstractors. We will extract data on study characteristics
(eg, rst author and citation) and qualitative study
quality criteria according to the CASP tool (Critical
Appraisal Skills Programme), which includes a 10-item
checklist to assess the clarity of research aims, appropri-
ateness of methodology and recruitment strategy, data
collection, ethical considerations including the relation-
ship between researcher and participants, the rigour of
analysis, clear statement of ndings and the value of the
research.
56
All data abstraction will be conducted using
our online Synthesi.SR Tool, which provides a platform
to resolve conicts between reviewers directly in the
system. Discrepancies will be reviewed and resolved by
discussion among the team. The reporting of our review
will be guided by the ENTREQ criteria.
49
Data synthesis
We will perform a two-staged synthesis of the data (ie,
Analysis and Synthesis) with the goal of creating a new
interpretation of the phenomenon under investigation
(ie, a new understanding of CRC and screening deci-
sions; gure 1).
Stage 1 (Analysis of data=Meta-data+Meta-method
+Meta-theory)
We will identify the similarities and differences, patterns
and themes across three levels of analysis.
46 47 57
Level 1
Meta-data analysis: this will involve the interpretive
analysis of research ndings from primary studies to
identify similarities and discrepancies among them using
any one of several qualitative data analytical approaches
(eg, line of argument; grounded theory; thematic ana-
lysis). The type of analysis method we select will be
driven by the data that will emerge. In the context of
our work, we anticipate that this will likely involve using
thematical analysis to group themes (such as the
benets and barriers to CRC screening) according to
sex, SES or other factors that emerge, and then noting
the similarities and differences between them. Level 2
Meta-method: This level of analysis will examine how
the research methods and procedures in primary studies
were used to generate and interpret data and shape the
4 Honein-AbouHaidar GN, Kastner M, Vuong V, et al. BMJ Open 2014;4:e004508. doi:10.1136/bmjopen-2013-004508
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ndings. It will include a process of appraising each
included study according to the CASP tool for quality
assessment of qualitative studies.
56
A third reviewer will
be available to settle discrepancies between reviewers for
applying the CASP criteria. Level 3Meta-theory: This
level of analysis examines the theories that underpin the
study authors framing of their research questions, their
criteria for inclusion and their conceptual framework
for interpretation. It is the level at which the theoretical
perspectives in qualitative reports can be interrogated to
explain the phenomenon under study. We will review
each report to identify the theoretical perspective used
and the schools of thought around CRC screening,
and to determine how context may inuence such
perspectives.
Stage 2 (Synthesis of data=Meta-synthesis)
In stage 2, synthesis will extend beyond the three
levels of analysis to generate a new and expanded theor y
of the phenom enon through a process called Meta-
synthesis. In contrast to the three-level analytic stage,
Meta-synthesis is a creative, dynamic and interactive
process that dees codication.
46
It involves interpret-
ing the inuence of method and theory variation in the
ndings to produce a new understanding of the phe-
nomenon. For example, we will determine these inu-
ences by documenting how each study performs their
data analysis (eg, thematic analysis of semistructured
interviews=Meta-data analysis); whether they used a the-
oretical framework to drive their study (eg, the Health
Belief Model=Meta-theory); and to determine the study
quality (eg, the CASP criteria=Meta-method). Once we
collect this data from all studies, we will be able to tri-
angulate this data from individual studies to reveal a
new, collective understanding of CRC screening partici-
pation. This interpretation will be documented during
data extractions. To reduce the potential of bias intro-
duced from such an interpretive process, two investiga-
tors will independently perform this interpretation,
which will be discussed and nalised with input of the
entire research team. We will use ndings informed by
the three-level analysis to develop a framework that
shows the perceived bene ts and barriers of CRC screen-
ing participation according to sex, SES, cultural beliefs
and other factors that may emerge.
Discussion and dissemination
We will use ndings from our in-depth analysis of
qualitative studies to generate a framework to better
understand the benets and barriers that affect decision-
making to participate in CRC screening among different
sectors of the population. We anticipate that this frame-
work will be relevant for a wide range of knowledge
users: policy makers will be able to use the framework as
a tool to frame educational materials to address barriers
to CRC screening; and physicians may use it as a tool in
patient-centered communication or in group education
sessions in order to engage culturally heterogeneous
population into a discussion on CRC screening. This
review also offers advancement in the science of equity
by identifying the determinants of social inequities in
CRC screening participation. Using the anticipated
framework, researchers may also design novel interven-
tions to address those inequities, which may lead to
improved quality in practice and advancement in
evidence-based decision-making. Furthermore, synthesis
of available qualitative evidence of barriers to participa-
tion in CRC screening currently does not exist.
Therefore, our ndings may trigger other systematic
reviews of gaps in information that we may identify. We
will also advance the knowledge of conducting
Meta-study reviews by rigorously executing its steps in
the context of our research question and to document
this process extensively in our nal report.
Our study may also have some limitations. As with any
qualitative studies, our work may be susceptible to
threats to internal validity (ie, credibility), external valid-
ity (ie, transferability) and reliability (dependability).
57
We will address potential threats to credibility by pilot
testing the data abstraction forms and involving group
team discussions throughout the interpretation of nd-
ings. The knowledge produced in our review may not be
transferable to other people or settings. For example,
ndings may be limited to individuals from different
ethnic minorities living in developed countries, which
may limit the transferability of our ndings to the
overall ethnic population. However, we will abstract a
detailed account of the population and setting of each
included qualitative study to maximise the potential for
transferability of our ndings. To limit the potential of
biases that may be introduced by investigators with
respect to the dependability and conformability of our
work, we will standardise procedures, methods and ana-
lysis strategies across all aspects of the review process.
We will ensure broad dissemination of this synthesis
review to include publication in open access journals as
well as conference presentations. We will also plan to
hold a meeting with our key stakeholders (ie, clinicians,
researchers, people with CRC and decision-makers) to
discuss the ndings, to generate key messages most rele-
vant to each and to discuss the next steps including the
development of educational materials that will address
gaps in CRC screening participation.
Author affiliations
1
Department of Surgery, St. Michaels Hospital, Toronto, Ontario, Canada
2
Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario,
Canada
3
Institute of Health Policy, Management, and Evaluation, University of
Toronto, Toronto, Ontario, Canada
4
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario,
Canada
5
Vice-President, Prevention and Cancer Control, Cancer Care Ontario, Toronto,
Ontario, Canada
6
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
7
Department of Medicine, University of Toronto, Toronto, Ontario, Canada
8
Scientist at Sunnybrook Research Institute, Toronto, Ontario, Canada
9
Department of Medicine, University of Calgary, Toronto, Ontario, Canada
Honein-AbouHaidar GN, Kastner M, Vuong V, et al. BMJ Open 2014;4:e004508. doi:10.1136/bmjopen-2013-004508 5
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Page 5
Contributors GHA and NB helped conceive the study; GHA, NB, MK and VV
conceived the study design. GHA and MK helped draft the protocol. LP
developed and executed the search strategy and edited the draft protocol. All
authors helped editing the draft protocol, read and approved the final
manuscript.
Funding This research was supported through a Cancer Care Ontario
research grant and Canadian Cancer Society Research Institute award (grant
number 2011-700803).
Competing interests NB holds the Cancer Care Ontario Health Services
Research Chair.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Unpublished study data such as the search
strategies for the other databases (EMBASE, CINAHL, PsycINFO, SSA) are
available on request to the corresponding author.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/3.0/
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    • "Public education is most cost-effective for communicating general knowledge, but its benefit is restricted largely by the fact that there exists a huge disparity between knowledge and behavior [27,28]. Similarly, although a large number of researches have revealed that screening for high-risk groups and some drugs and treatment prevention are highly cost-effective under research conditions , these measures are seldom in use in routine practices of cancer prevention and control [28]; even used, the effectiveness often turned out to be far less from expected34353637383940. Although the huge gap between the actual application of proven preventions and expectations may be attributed to a variety of reasons, lacking personalized behavior promotion may have plaid an important role [41]. "
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  • [Show abstract] [Hide abstract] ABSTRACT: The big gap between efficacy of population level prevention and expectations due to heterogeneity and complexity of cancer etiologic factors calls for selective yet personalized interventions based on effective risk assessment. This paper documents our research protocol aimed at refining and validating a two-stage and web- based cancer risk assessment tool, from a tentative one in use by an ongoing project, capable of identifying individuals at elevated risk for one or more types of the 80% leading cancers in rural China with adequate sensitivity and specificity and featuring low cost, easy application and cultural and technical sensitivity for farmers and village doctors. The protocol adopted a modified population-based case control design using 72, 000 non-patients as controls, 2, 200 cancer patients as cases, and another 600 patients as cases for external validation. Factors taken into account comprised 8 domains including diet and nutrition, risk behaviors, family history, precancerous diseases, related medical procedures, exposure to environment hazards, mood and feelings, physical activities and anthropologic and biologic factors. Modeling stresses explored various methodologies like empirical analysis, logistic regression, neuro-network analysis, decision theory and both internal and external validation using concordance statistics, predictive values, etc..
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    [Show abstract] [Hide abstract] ABSTRACT: : Protocols of systematic reviews and meta-analyses allow for planning and documentation of review methods, act as a guard against arbitrary decision making during review conduct, enable readers to assess for the presence of selective reporting against completed reviews, and, when made publicly available, reduce duplication of efforts and potentially prompt collaboration. Evidence documenting the existence of selective reporting and excessive duplication of reviews on the same or similar topics is accumulating and many calls have been made in support of the documentation and public availability of review protocols. Several efforts have emerged in recent years to rectify these problems, including development of an international register for prospective reviews (PROSPERO) and launch of the first open access journal dedicated to the exclusive publication of systematic review products, including protocols (BioMed Central's Systematic Reviews). Furthering these efforts and building on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, an international group of experts has created a guideline to improve the transparency, accuracy, completeness, and frequency of documented systematic review and meta-analysis protocols--PRISMA-P (for protocols) 2015. The PRISMA-P checklist contains 17 items considered to be essential and minimum components of a systematic review or meta-analysis protocol.This PRISMA-P 2015 Explanation and Elaboration paper provides readers with a full understanding of and evidence about the necessity of each item as well as a model example from an existing published protocol. This paper should be read together with the PRISMA-P 2015 statement. Systematic review authors and assessors are strongly encouraged to make use of PRISMA-P when drafting and appraising review protocols.
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