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A feasibility study of provider-level implementation strategies to improve access to colorectal cancer screening for patients with schizophrenia: ACCESS2 (N-EQUITY 2104) trial

Implementation Science Communications volume 5, Article number: 2 (2024) Cite this article

Abstract

Background

People with schizophrenia have a lower colorectal screening rate than the general population. A previous study reported an intervention using case management to encourage colorectal cancer screening for patients with schizophrenia in psychiatric outpatient settings. In this feasibility study, we developed provider-level implementation strategies and evaluated the feasibility of conducting a definitive trial in terms of the penetration of the intervention assessed at the patient level. Additionally, we examined the fidelity of strategies to implement the intervention at the provider level in a routine clinical psychiatric setting.

Methods

This was a multicenter, single-arm feasibility study with medical staff at psychiatric hospitals in Japan. The provider-level implementation strategies developed in this study included three key elements (organizing an implementation team appointed by the facility director, interactive assistance using a clear guide that outlines who in the hospital should do what, and developing accessible educational materials) to overcome major barriers to implementation of the intervention and four additional elements (progress monitoring, joint meetings and information sharing among participating sites, adaptation of encouragement methods to specific contexts, and education of on-site staff), with reference to the elements identified in the Expert Recommendations for Implementing Change (ERIC). The feasibility of the strategies was evaluated by the proportion of patients who were eligible for encouragement (patients with schizophrenia aged 40, 50, or 60) who received encouragement. We set the goal of providing encouragement to at least 40% of eligible patients at each site.

Results

Two public and four private psychiatric hospitals in Okayama and Shimane prefectures participated in this study. Regarding fidelity, all elements of the strategies were conducted as planned. Following the procedures in the guide, each team prepared and provided encouragement according to their own facility and region. Penetration, defined as the proportion of eligible patients who received encouragement, ranged from 33.3 to 100%; five of the six facilities achieved the target proportion.

Conclusions

The provider-level implementation strategies to implement encouragement were feasible in terms of penetration of the intervention assessed at the patient level. The results support the feasibility of proceeding with a future definitive trial of these strategies.

Trial registration

jRCT, jRCT1060220026. Registered on 06/04/2022.

Peer Review reports

Background

Schizophrenia is considered to be one of the most serious mental illnesses. People with schizophrenia have a life expectancy that is 13–15 years shorter than that of the general population [1]. Reducing this health disparity is a global challenge. Cancer is a leading cause of death in people with schizophrenia, who have higher cancer mortality rates than the general population [2, 3]. Delayed diagnosis of cancer has been suggested to be one of the factors contributing to high cancer mortality rate in this population [4].

Cancer screening, which has been shown to be effective in the early detection of cancer and reduction of cancer mortality, is one of the basic components of cancer control [5]. However, people with schizophrenia have lower cancer screening rates than the general population [6,7,8]. Therefore, it is necessary to establish a strategy to deliver cancer screening to people with schizophrenia. Among various types of health screening, cancer screening has a high level of evidence of effectiveness [9,10,11], and cancer has a severe disease burden [12]. Therefore, implementing cancer screening is considered to be a high priority [13].

A Cochrane review by Barley et al. reported that there were no randomized controlled trials of interventions designed to encourage uptake of cancer screening among people with severe mental illness [14]. To the best of our knowledge, only two single-arm trials have been conducted to examine interventions to encourage breast cancer screening [15] and lung cancer screening [16] for people with severe mental illness. Thus, there is an urgent need to establish evidence for interventions to encourage cancer screening among people with schizophrenia and to implement effective interventions in routine health care.

Irwin et al. suggested that patient-, provider-, and systems-level factors contribute to low cancer screening rates among people with schizophrenia [17]. At the patient level, symptom severity is reported to be associated with nonreceipt of cancer screenings, suggesting the need to support patients with schizophrenia on the basis of their impairments [6]. At the systems level, in Japan, cancer screening is not offered at psychiatric outpatient clinics. In a previous study, patients with schizophrenia who did not have current visits to outpatient clinics for any physical illnesses were found to be less likely to receive cancer screening than those who did [6]. Therefore, psychiatric providers are expected to encourage patients with schizophrenia to undergo cancer screening [6, 17].

On the basis of the context identified in our previous observational studies investigating cancer screening uptake among patients with schizophrenia in Japan [6, 18], we developed an intervention using case management to encourage patients with schizophrenia to undergo colorectal cancer (CRC) screening in psychiatric outpatient settings [19]. In our proposed intervention, medical staff provide education and navigation of CRC screening to patients with schizophrenia [19]. We tested the intervention in a randomized controlled trial, revealing that the intervention increased CRC screening uptake among patients with schizophrenia compared with usual care [20].

For medical staff to provide the intervention described above in routine clinical psychiatric settings, it is necessary to establish provider-level implementation strategies. A manual for providing encouragement for CRC screening was developed in the previous randomized controlled trial [20]. In our previous study (the ACCESS study) [20], providers were involved as the research team because the intervention study was designed to change patient behavior in a clinical trial setting. However, provider-level implementation strategies for offering the intervention in routine practice have not been developed. Additionally, a qualitative study conducted in conjunction with a previous randomized controlled trial indicated challenges in implementing the intervention in routine clinical settings [21]. Adaptation of the intervention to increase its feasibility in routine clinical settings is also needed.

To provide encouragement to patients with schizophrenia to engage in CRC screening under routine clinical settings, we developed provider-level implementation strategies and adapted the intervention. A recent review noted incomplete specification of implementation strategies in the mental health literature [22]. Therefore, we incorporated elements of implementation strategies from an existing pool of implementation strategies identified in the Expert Recommendations for Implementing Change (ERIC) [23] and defined their specifications to increase replicability and develop a useful set of implementation strategies. To the best of our knowledge, no previous studies have reported provider-level implementation strategies for interventions to encourage cancer screening uptake for people with severe mental illness. However, several review articles have examined studies reporting implementation strategies for psychosocial interventions for people with severe mental illness in psychiatric settings [24, 25].

This feasibility study addressed several areas of uncertainty [26,27,28] about a future definitive trial with the primary endpoint of CRC screening uptake among patients with schizophrenia. Whether psychiatric hospitals adopting the strategies will actually be able to provide encouragement to their patients with schizophrenia is currently uncertain and should be evaluated. Therefore, in this feasibility study, we first evaluated the penetration of the intervention assessed at the patient level (i.e., the proportion of eligible patients who received encouragement via the provider-level implementation strategies). Second, we qualitatively described the fidelity of the implementation strategies (i.e., the way in which each element of the strategies was conducted in accordance with the planned specifications).

Methods

Trial design

This was a multicenter, single-arm trial with the medical staff of a psychiatric hospital. The study was approved by the institutional ethics committee of Okayama University. This study was registered in the Japan Registry of Clinical Trials (ID: jRCT1060220026).

Setting (cancer screening in Japan)

In Japan, the Ministry of Health, Labour and Welfare recommends the following five cancer screenings: annual fecal occult blood test (FOBT) for CRC screening and chest X-ray for lung cancer screening for people aged 40 and older, biannual upper gastrointestinal X-ray or upper endoscopy for gastric cancer screening for people aged 50 and older, biannual mammography for breast cancer screening for people aged 40 and older, and biannual Papanicolaou (PAP) smear test for people aged 20 years and older [29].

In Japan, local governments provide population-based cancer screening. Municipal cancer screening programs cover unemployed people, employees of small- to medium-sized companies, and self-employed individuals. For people with severe mental illness, municipal cancer screening programs are the primary opportunity to undergo cancer screenings.

Municipal cancer screenings are not provided year-round, and each municipality has a specific period during which the screenings are provided. Although the content of the cancer screening tests is similar in all municipalities, there are differences among municipalities in the way the tests are provided. For example, in some municipalities, residents receive the FOBT kit at the clinic and bring it to the clinic, whereas in other municipalities, residents receive the FOBT kit by mail and submit it by mail. Additionally, some municipalities provide free coupons, whereas others do not. Furthermore, the procedures for obtaining free coupons vary between municipalities.

Participants

This study included two public and four convenient private psychiatric hospitals in Okayama and Shimane prefectures. The Department of Psychiatry at Okayama University and Shimane University undertake ongoing clinical and educational collaborations with a number of psychiatric hospitals, including the six hospitals included in this study. Hospitals of different sizes and in different cities were included to assess the feasibility of provider-level implementation strategies. We explained the current study to the hospital directors, who agreed with the importance of encouraging cancer screening, and obtained their agreement to participate in the study. All of these facilities are standard psychiatric hospitals in Japan and do not provide cancer screening tests. Consent to participate in the study was obtained from the director of each hospital. Staff members participating in a team to implement the encouragement of CRC screening at each hospital were targeted for the research intervention, and consent was obtained from individual staff members.

Provider-level implementation strategies

In developing the provider-level implementation strategies used in this study, researchers (M. F.1, Y. Y., M. I.; psychiatrists) and medical staff who provided encouragement to engage in CRC screening in a prior study discussed the barriers to providing encouragement in routine practice. This discussion suggested the following major barriers to implementation of encouragement: (i) staff engagement with encouragement, (ii) the degree to which methods of behavior and tasks for conducting the encouragement are developed in advance, and (iii) access to knowledge and information. A strategy development team composed of the researchers mentioned above and an implementation science expert (TS) discussed and identified the following elements as key strategies to overcome these barriers: (a) organizing an implementation team appointed by the facility director, (b) interactive assistance using a clear guide that outlines who in the hospital should do what, and (c) developing educational materials that are accessible to busy medical staff. During this discussion, the team considered findings regarding implementation strategies presented in previous studies to promote the uptake of evidence-based psychosocial interventions for people with severe mental illness [24]. In addition, the strategy development team discussed and identified elements of the implementation strategy identified in ERIC [23] that were considered to be useful and feasible in this setting. The following four elements were also incorporated to develop a set of provider-level implementation strategies in the current study: (d) progress monitoring, (e) joint meetings and information sharing among participating sites, (f) adaptation of the encouraging methods to the specific context, and (g) education of on-site medical staff. The specification of the implementation strategies was predefined with actor, action, target of actions, temporality, implementation outcome affected, and justifications, in accord with Proctor’s Reporting Framework domains (shown in Table 1) [30]. Depending on the element of the strategy, the actors could be the researchers or the implementation team at each hospital.

Table 1 Provider-level implementation strategies
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A guide for encouraging cancer screening at psychiatric institutions

A guide was developed that outlines what facility directors and implementation teams should do to implement the encouragement of cancer screening at each facility (Supporting file; a guide for encouraging cancer screenings at psychiatric institutions in English and Japanese). This guide describes the process in four steps: (i) the director organizes a team to implement the encouragement of cancer screening, (ii) the implementation team prepares the encouragement in accordance with the guide, (iii) the implementation team educate staff, and (iv) staff provide encouragement for patients to engage in CRC screening using case management.

Development and distribution of educational materials

Educational materials for learning about cancer screening and a method of encouragement using case management were developed. The materials consisted of the following: (i) an overview of cancer screening, (ii) cancer screening provided by municipalities, and (iii) the method of encouragement using case management. Nine videos of 3–5 min in length were made available on our research website for staff at each facility to view at any time. Each of the materials was also made available as a downloadable pdf file.

Intervention using case management to encourage colorectal cancer screening

The method of cancer screening encouragement using case management has been described in detail in previous papers [19, 20]. The elements of the intervention were described according to the Template for Intervention Description and Replication (TIDieR) (shown in Supporting Table 1) [31]. Case managers (nurses or mental health social workers working in the outpatient department of each hospital) provide counseling sessions for eligible patients. This intervention aimed to educate and guide patients regarding CRC screening. The first session includes the following three components: (i) education for CRC screening, (ii) assistance in making decisions and an appointment for CRC screening, and (iii) assistance in obtaining a coupon for free screening. Follow-up sessions are generally scheduled in conjunction with outpatient visits after an initial session but may be skipped on the basis of the clinical judgment of the case manager.

In the current study, the intervention used in a previous study was adapted to increase its feasibility in routine clinical settings. Our previous study suggested that providing encouragement using case management for all patients with schizophrenia over 40 years of age in a single year under routine practice would be difficult in terms of human resources [21]. Therefore, after preliminary interviews with participating facilities, the strategy was adapted to provide encouragement to patients with schizophrenia who were aged 40, 50, or 60 years old each year. Patients of other ages would be reminded of the screening with a simple flyer. The goal was to continue this implementation strategy annually over time to provide encouragement to all target patients. In addition, the strategy allows each facility to adjust the extent to which it offers encouragement on the basis of the number of eligible patients and the facility’s resources. For example, some hospitals could offer encouragement to patients every 5 years of age (i.e., at 40, 45, 50, 55, or 60 years old). By starting with the number of eligible patients according to each facility’s resources, the feasibility of offering encouragement can be increased.

Data collection and outcome measures

Primary outcome

As a measure of the penetration of the intervention using case management to encourage CRC screening at the patient level, the proportion of patients who were eligible for the intervention (patients with schizophrenia aged 40, 50, or 60 years old) who received at least one session for encouragement was calculated. Whether or not patients received encouragement was determined retrospectively from their medical records. If encouragement was not provided, the reason was recorded. The guide required providers to document whether they provided encouragement in each patient’s medical record. The denominator for calculating this proportion was the number of patients with schizophrenia aged 40, 50, or 60 years old with at least two visits to the facility between June and December 2022. This definition was chosen because encouragement was provided to patients who continued to visit each facility as their primary psychiatric clinic.

The present feasibility study sets a goal of providing encouragement to at least 40% of eligible patients at each site, which constituted the study’s progression criteria [27, 28]. On the basis of our previous ACCESS study [20], we estimated that 15% of eligible patients were deemed by their primary psychiatrists to be inappropriate for encouragement because of their medical condition, 20% could not be contacted because of the timing of patient visits or because the outpatient departments were overly busy, and 40% of eligible patients refused or omitted the encouragement. Thus, we estimated that 0.85 × 0.8 × 0.6 × 100 = 40.8% of eligible patients would receive encouragement. If the penetration of the intervention in this study was similar to that in the previous ACCESS study conducted under ideal settings, we considered that we could proceed to a definitive trial.

Secondary outcomes

The way in which each element of the provider-level implementation strategies was conducted was described as the fidelity assessment of the implementation strategies of this study. These descriptions were based on transcripts of meetings between the researchers and the implementation teams, as well as interviews with the implementation teams after the encouragement ended.

Variables

The following information about the participating facilities was obtained from the directors: number of beds, number of psychiatrists for outpatient services, number of non-physician staff for outpatient services, average number of outpatients per day from June to December in 2022, and number of patients with schizophrenia aged 40, 50, or 60 years old who were targeted for providing encouragement in the study.

Data analysis

Primary outcome

For each of the participating facilities, the number of patients who were eligible for encouragement (outpatients with schizophrenia aged 40, 50, or 60 years old) and the number of patients who received encouragement were reported. The proportion of eligible patients who received encouragement was calculated.

Secondary outcomes

Two researchers (M. F.1 and Y. Y.) discussed and summarized how each element of the provider-level implementation strategies was conducted on the basis of meeting records and interviews with the implementation team. For each element, these summaries were qualitatively described.

Results

Background data for participating facilities

Background data for the participating facilities are shown in Table 2. Three facilities from Okayama Prefecture (Hosp. 1–3) and three from Shimane Prefecture (Hosp. 4–6) participated; Hosp. 1 and Hosp. 4 are public psychiatric hospitals and are the core hospitals for psychiatric care in the prefecture. The other private hospitals also provide both outpatient and inpatient psychiatric care to residents of the surrounding municipalities.

Table 2 Background data for participating facilities
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Primary outcome: proportion of eligible patients who received encouragement using case management

Table 3 shows the number of patients who were eligible for encouragement and the proportion of eligible patients who received the encouragement for each facility. The number of patients ranged from 2 at the facility with the lowest number to 67 at the facility with the highest number. The percentage of patients who received encouragement ranged from 33.3 to 100%. Five of the six facilities achieved a proportion of more than 40%.

Table 3 Proportion of eligible patients who received encouragement using case management
Full size table

Secondary outcomes: description of how the provider-level implementation strategies were conducted

Table 4 shows how each element of the strategies was conducted. All elements were conducted in accordance with the specifications. Implementation teams were organized by facility directors at all participating facilities. Following the procedures in the guide, each team prepared and provided encouragement according to their own facility and region.

Table 4 Description of how the provider-level implementation strategies were conducted
Full size table

Discussion

This study developed provider-level implementation strategies to implement evidence-based interventions to encourage CRC screening in patients with schizophrenia in a routine psychiatric clinical setting. The results showed that the elements of the provider-level implementation strategies were conducted according to the pre-defined implementation strategies, and all participating sites provided the CRC screening encouragement using case management according to the guide. To the best of our knowledge, no previous studies have reported provider-level implementation strategies for encouraging cancer screening uptake for patients with severe mental disorders on the basis of implementation science. An important strength of the current study is that we developed a set of strategies by combining existing implementation strategies and detailed their specifications using implementation strategy taxonomies.

The provider-level implementation strategies in this study enabled five of the six facilities to achieve the target proportion of encouragement provision. In addition, the fidelity of the implementation strategies was good, as shown qualitatively in Table 4. One facility did not reach the target proportion. This facility had a higher number of outpatients per day compared with other facilities, and relatively fewer outpatient staff resources, which might have been related to this result. During progress monitoring, the implementation team in this facility reported that outpatient staff resources were scarce because of work related to the COVID-19 pandemic, and it was difficult to secure staff to provide encouragement for CRC screening. This provider-level implementation strategy might show even better feasibility if the human resource burden caused by the COVID-19 pandemic is reduced.

A number of previous studies have reported implementation strategies for psychosocial interventions for people with severe mental illness in psychiatric settings, although the content of these interventions differs from that in the present study. Islam et al. reported a systematic review of factors affecting the implementation of supported self-management interventions for people with severe mental health problems in secondary mental health care settings [25]. Menear et al. reported a review of implementation strategies to promote the uptake of evidence-based psychosocial interventions for people with severe mental illness [24]. In the current study, we developed provider-level implementation strategies for implementing a psychosocial intervention to encourage CRC screening in psychiatric settings. Therefore, there are many points that can be compared with the findings of implementation strategies obtained in the previous studies mentioned above.

The use of the strategy of organizing an implementation team appointed by the facility director, which was the first of the key strategies in this study, appeared to be useful. In two previous reviews [24, 25], identifying and appointing a champion to manage the implementation of the interventions and organizing an implementation team were also identified as facilitators of the interventions. A review by Islam et al. reported that senior leadership is important, and that a lack of senior support can be a barrier [25], particularly when there are competing demands for resources [32]. In the current study, no staff were hired to provide encouragement for CRC screening, and existing resources in the outpatient setting were used to provide encouragement. Thus, the provision of encouragement may be in competition with other duties. The positioning of the implementation team’s activities under the leadership of the facility director would have allowed for encouragement to be implemented at all participating facilities under such circumstances. In addition, the fact that the implementation team was composed of members from multiple professions who were able to lead the hospital’s stakeholders was considered a facilitating factor for implementation in the current study. Islam et al.’s review reported that the lack of involvement of multidisciplinary staff was a barrier to the implementation of interventions [25]. The current findings reaffirm the importance of support from senior leadership and multidisciplinary involvement in organizing an implementation team.

The second of the key strategies, interactive assistance using a clear guide that outlines who in the hospital should do what, was also considered effective. The extent to which the plans and methods of behavior and tasks for implementing interventions are prepared in advance is relevant to facilitating effective implementation [33]. In the present study, the implementation team at each facility followed the guide and reviewed the implementation process tailored to their site and was able to educate on-site medical staff and provide encouragement to engage in CRC screening. The guide includes the third of the key strategies: the provision of educational materials that are accessible to busy medical staff. In two previous reviews [24, 25], educational strategies, including the distribution of educational materials, training, and supervision, were identified as a core strategy or facilitator in implementation studies of psychosocial interventions. The encouragement of cancer screening is within the scope of support provided in daily clinical practice. Therefore, as in our previous study, the implementation teams and medical staff at each site were able to learn about the method of encouragement and deliver it using the educational materials provided with the guide, without any special training provided by outside organizations. In terms of feasibility, it is important to develop educational strategies that are minimally burdensome and accessible to providers, taking into account the nature of the intervention, the skills of the providers, and the settings.

In the current study, the intervention was adapted prior to implementation to improve the feasibility under routine clinical settings. Two previous review articles reported that adaptability of the intervention and the ability to take a flexible approach were important features for improving implementation [24, 25]. As described in the “Methods” section, we adapted the intervention to provide encouragement using case management for a small number of eligible patients on the basis of the number of patients at each site. When an intervention is complex, taking an incremental approach to implementing the intervention increases the likelihood of success [33]. All participating hospitals were particularly busy during the period of this study because of the COVID-19 pandemic. Therefore, implementation of encouragement was likely to place a heavy burden on routine medical care. Operating the encouragement flexibly and gradually expanding the provision were considered a useful strategy for the implementation team.

Implications

In a series of studies conducted in our research group, including the current study, we developed an effective intervention to encourage patients with schizophrenia to undergo CRC screening in psychiatric outpatient settings [20], as well as outlining provider-level implementation strategies to implement the intervention in routine care settings. The elements required for direct support for patients may be common across health systems, although this intervention to encourage CRC screening was developed in Japan. The intervention using case management and provider-level implementation strategies might be applicable in similar settings, where there are healthcare providers who provide ongoing support to patients with schizophrenia. Additionally, the intervention and implementation strategies were developed for people with mental disorders and could potentially be adapted to encourage cancer screening for people with intellectual disabilities.

Importantly, the proportion of patients who received encouragement varied widely among the participating facilities. The results indicated that the proportions were low in relatively busy facilities with high outpatient volumes. Modifying the implementation strategies to improve the percentage of encouragement provided at such facilities is a challenge for future studies. It may be useful for each facility to consider extending the period for which encouragement is offered, depending on the progress of encouragement.

In addition, to scale up encouragement to engage in CRC screening in accordance with the guide developed in this study, it will be necessary to develop implementation strategies to encourage psychiatric facilities to adopt this approach on a regional or national basis. To this end, it may be desirable to incorporate external settings that promote the implementation of encouragement as multi-level implementation strategies.

Limitations

First, participating facilities were able to provide encouragement using cases in a single year, but it is not known whether this encouragement could be provided on an ongoing basis in subsequent years. This study is ongoing, and results will be obtained in the future regarding the sustainability of providing encouragement. Second, the costs and economic outcomes of implementing the encouragement in this study were not evaluated, although the intervention was developed to be implemented within current clinical settings without additional resources. Our previous ACCESS study revealed the average time required to provide encouragement. Third, it is not known whether patients who received encouragement to engage in CRC screening in this study were screened for CRC. Because individual consent from the patient is required to obtain information regarding the patient’s CRC screening participation in a clinical study, the evaluation of participation was omitted in this study for pragmatic reasons. Fourth, receipt of the encouragement was determined retrospectively from the medical records. Thus, the accuracy with which the providers documented the encouragement was unclear. Fifth, at some participating hospitals, the number of patients who were eligible for the encouragement was very small, which could lead to overestimation of the proportion of eligible patients who received encouragement.

Conclusion

The current results indicated that the provider-level implementation strategies developed in this study to implement encouragement using case management for CRC screening among patients with schizophrenia were feasible in terms of penetration of the intervention assessed at the patient level. These findings support the feasibility of proceeding with a future definitive trial of the strategies. Although the strategies appeared to be feasible, the proportion of patients who received encouragement varied widely among participating facilities. To increase this proportion, it may be desirable to consider possible modifications in the implementation strategies.

Availability of data and materials

An anonymous analyzed data set will be made available to researchers upon reasonable request to the corresponding author.

Abbreviations

CRC:

Colorectal cancer

ERIC:

Expert Recommendations for Implementing Change

FOBT:

Fecal occult blood test

References

  1. Hjorthoj C, Sturup AE, McGrath JJ, Nordentoft M. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiat. 2017;4(4):295–301.

    Article  Google Scholar 

  2. Zhuo C, Tao R, Jiang R, Lin X, Shao M. Cancer mortality in patients with schizophrenia: systematic review and meta-analysis. Br J Psychiatry. 2017;211(1):7–13.

    Article  PubMed  Google Scholar 

  3. Ni L, Wu J, Long Y, Tao J, Xu J, Yuan X, et al. Mortality of site-specific cancer in patients with schizophrenia: a systematic review and meta-analysis. BMC Psychiat. 2019;19(1):323.

    Article  Google Scholar 

  4. Kisely S, Crowe E, Lawrence D. Cancer-related mortality in people with mental illness. JAMA Psychiat. 2013;70(2):209–17.

    Article  Google Scholar 

  5. World Health Organization. Cancer control: knowledge into action: WHO guide for effective programmes: module 3: early detection. Geneva: World Health Organization; 2007.

    Google Scholar 

  6. Fujiwara M, Inagaki M, Nakaya N, Fujimori M, Higuchi Y, Hayashibara C, et al. Cancer screening participation in schizophrenic outpatients and the influence of their functional disability on the screening rate: a cross-sectional study in Japan. Psychiatry Clin Neurosci. 2017;71(12):813–25.

    Article  PubMed  Google Scholar 

  7. Solmi M, Firth J, Miola A, Fornaro M, Frison E, Fusar-Poli P, et al. Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4,717,839 people. Lancet Psychiat. 2020;7(1):52–63.

    Article  Google Scholar 

  8. Thomsen MK, Jorgensen MD, Pedersen L, Erichsen R, Sorensen HT, Mikkelsen EM. Mental disorders, participation, and trajectories in the Danish colorectal cancer programme: a population-based cohort study. Lancet Psychiat. 2023;10(7):518–27.

    Article  Google Scholar 

  9. OECD. OECD reviews of public health: Japan: a healthier tomorrow. Paris: OECD Publishing; 2019.

    Book  Google Scholar 

  10. Krogsboll LT, Jorgensen KJ, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev. 2019;1(1):CD009009.

    PubMed  Google Scholar 

  11. World Health Organization. Regional Office for Europe. A short guide to cancer screening: increase effectiveness, maximize benefits and minimize harm. 2022. https://apps.who.int/iris/handle/10665/351396. Accessed 26 Jul 2023.

  12. Kocarnik JM, Compton K, Dean FE, Fu W, Gaw BL, Harvey JD, et al. Cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life years for 29 cancer groups from 2010 to 2019: a systematic analysis for the global burden of disease study 2019. JAMA Oncol. 2022;8(3):420–44.

    Article  PubMed  Google Scholar 

  13. Huppert JS, Fournier AK, Bihm JL, Chang CS, Miller TL, Nourjah P, et al. Prioritizing evidence-based interventions for dissemination and implementation investments: AHRQ’s model and experience. Med Care. 2019;57(10 Suppl 3):S272–7.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Barley EA, Borschmann RD, Walters P, Tylee A. Interventions to encourage uptake of cancer screening for people with severe mental illness. Cochrane Database Syst Rev. 2016;9:CD009641.

    PubMed  Google Scholar 

  15. Weinstein L, LaNoue M, Hurley K, Payton C, Sifri R, Myers R. Feasibility pilot outcomes of a mammography decision support and navigation intervention for women with serious mental illness living in supportive housing settings. J Prim Care Community Health. 2019;10:2150132719867587.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Flores EJ, Neil JM, Tiersma KM, Pappano CR, Mulligan C, Van Alphen MU, et al. Feasibility and acceptability of a collaborative lung cancer screening educational intervention tailored for individuals with serious mental illness. J Am Coll Radiol. 2021;18(12):1624–34.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Irwin KE, Henderson DC, Knight HP, Pirl WF. Cancer care for individuals with schizophrenia. Cancer. 2014;120(3):323–34.

    Article  PubMed  Google Scholar 

  18. Inagaki M, Fujiwara M, Nakaya N, Fujimori M, Higuchi Y, Hayashibara C, et al. Low cancer screening rates among Japanese people with schizophrenia: a cross-sectional study. Tohoku J Exp Med. 2018;244(3):209–18.

    Article  PubMed  Google Scholar 

  19. Fujiwara M, Inagaki M, Shimazu T, Kodama M, So R, Matsushita T, et al. A randomised controlled trial of a case management approach to encourage participation in colorectal cancer screening for people with schizophrenia in psychiatric outpatient clinics: study protocol for the J-SUPPORT 1901 (ACCESS) study. BMJ Open. 2019;9(11):e032955.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Fujiwara M, Yamada Y, Shimazu T, Kodama M, So R, Matsushita T, et al. Encouraging participation in colorectal cancer screening for people with schizophrenia: a randomized controlled trial. Acta Psychiatr Scand. 2021;144(4):318–28.

    Article  PubMed  Google Scholar 

  21. Yamada Y, Fujiwara M, Shimazu T, Etoh T, Kodama M, So R, et al. Patients’ acceptability and implementation outcomes of a case management approach to encourage participation in colorectal cancer screening for people with schizophrenia: a qualitative secondary analysis of a mixed-method randomised clinical trial. BMJ Open. 2022;12(6):e060621.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Hooley C, Amano T, Markovitz L, Yaeger L, Proctor E. Assessing implementation strategy reporting in the mental health literature: a narrative review. Adm Policy Ment Health. 2020;47(1):19–35.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Menear M, Briand C. Implementing a continuum of evidence-based psychosocial interventions for people with severe mental illness: part 1-review of major initiatives and implementation strategies. Can J Psychiatry. 2014;59(4):178–86.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Islam S, Appleton R, Hutchings-Hay C, Lloyd-Evans B, Johnson S. A systematic review of influences on implementation of supported self-management interventions for people with severe mental health problems in secondary mental health care settings. PLoS One. 2023;18(2):e0282157.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Kistin C, Silverstein M. Pilot studies: a critical but potentially misused component of interventional research. JAMA. 2015;314(15):1561–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ. 2016;355:i5239.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Pearson N, Naylor PJ, Ashe MC, Fernandez M, Yoong SL, Wolfenden L. Guidance for conducting feasibility and pilot studies for implementation trials. Pilot Feasibility Stud. 2020;6(1):167.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hamashima C. Cancer screening guidelines and policy making: 15 years of experience in cancer screening guideline development in Japan. Jpn J Clin Oncol. 2018;48(3):278–86.

    Article  PubMed  Google Scholar 

  30. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci. 2013;8:139.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.

    Article  PubMed  Google Scholar 

  32. Coulthard K, Patel D, Brizzolara C, Morriss R, Watson S. A feasibility study of expert patient and community mental health team led bipolar psychoeducation groups: implementing an evidence based practice. BMC Psychiatry. 2013;13:301.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We thank Junko Arakane, Yuko Nakamura, Masumi Kurooka, Kozue Okazaki, Toshihiko Takeda, Rieko Yamashita, Hiromi Takahashi, Toshie Maeda, Miwako Horii, Noriko Makita, Naoe Ohara, Hiroyuki Shoji, Yuko Akano, Hitomi Ishida, Taeko Ichinotani, Mai Kawakami, Chie Kiduki, Myu Kobayashi, Tomoka Takiyama, Aya Jinushi, Yuko Chiura, and all the staff of the outpatient services at the Okayama Psychiatric Medical Center, Zikei Hospital, Shimane Prefectural Psychiatric Medical Center, Seiwakai Nishikawa Hospital, Sekizen Hospital, and Konan Hospital for their support with the study. We thank Sakura Hino for logistical assistance. This study was reviewed and approved by the National Center Consortium in Implementation Science for Health Equity (N-EQUITY) from the Japan Health Research Promotion Bureau (JH) Research Fund (2019-(1)-4), and JH Project fund (JHP2022-J-02). We thank Benjamin Knight, MSc., from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Funding

This work was supported by the Research for Promotion of Cancer Control Programs from the Japanese Ministry of Health, Labour and Welfare (21EA1013 and 23EA1031, PI: M Inagaki).

Author information

Authors and Affiliations

  1. Department of Neuropsychiatry, Okayama University Hospital, Okayama, Japan

    Masaki Fujiwara & Yuto Yamada

  2. Department of Nursing, Shimane University Hospital, Izumo, Japan

    Tsuyoshi Etoh

  3. Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, National Cancer Center, Tokyo, Japan

    Taichi Shimazu & Miyuki Odawara

  4. Okayama Psychiatric Medical Center, Okayama, Japan

    Masafumi Kodama & Norihito Yamada

  5. Zikei Hospital, Okayama, Japan

    Takahiro Asada & Shigeo Horii

  6. Shimane Prefectural Psychiatric Medical Center, Izumo, Japan

    Takafumi Kobayashi

  7. Seiwakai Nishikawa Hospital, Hamada, Japan

    Teruo Hayashi

  8. Sekizen Hospital, Tsuyama, Japan

    Yoshitaka Ehara

  9. Konan Hospital, Matsue, Japan

    Kenji Fukuda

  10. Department of Gastroenterology, Okayama Saiseikai General Hospital, Okayama, Japan

    Keita Harada

  11. Division of Survivorship Research, National Cancer Center Institute for Cancer Control, National Cancer Center, Tokyo, Japan

    Maiko Fujimori & Yosuke Uchitomi

  12. Division of Screening Assessment and Management, National Cancer Center Institute for Cancer Control, National Cancer Center, Tokyo, Japan

    Hirokazu Takahashi

  13. Department of Biostatistics and Data Management, Sapporo Medical University, Sapporo, Japan

    Shiro Hinotsu

  14. Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan

    Naoki Nakaya

  15. Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Shimane, 693-8501, Japan

    Masatoshi Inagaki

Authors
  1. Masaki Fujiwara
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  2. Yuto Yamada
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Contributions

Conception, MF1, YY, TE, TS, MK, NY, TA, SH1, TK, TH, YE, KF, KH, MF2, MO, HT, SH2, NN, YU, and MI. Design of the work, MF1, YY, TS, MF2, NN, SH2, YU, and MI. Acquisition, MF1, YY, TE, MK, NY, TA, SH1, TK, TH, YE, KF, and MI. Analysis, MF1, YY, TE, and MI. Interpretation of the data, MF1, YY, TE, TS, MK, NY, TA, SH1, TK, TH, YE, KF, KH, MF2, MO, HT, SH2, NN, YU, and MI. Writing—original draft, MF1, TS, MO, and MI. All authors revised the manuscript and approved the final version.

Corresponding author

Correspondence to Masatoshi Inagaki.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the institutional ethics committee of Okayama University (RIN2202-002). Consent to participate in the study was obtained from the director and the implementation team member at each participating hospital.

Consent for publication

Not applicable.

Competing interests

M. F.1 has received honoraria for lectures from Mochida. Y. Y. has received honoraria for lectures from Meiji, Sumitomo Pharma, and Lundbeck. N. Y. has received grants from Eisai and Otsuka and has received honoraria for lectures from Eisai, Otsuka, Takeda, MSD, UCB, Viatris, Sumitomo Pharma, and Meiji. M. I. has received grants from Astellas, Eisai, Otsuka, Shionogi, Daiichi Sankyo, Sumitomo Pharma, Takeda, Mitsubishi Tanabe Pharma, Nihon Medi-Physics, Pfizer, Fujifilm, and Mochida and has received honoraria for lectures from EA Pharma, Meiji, MSD, Viatris, Eisai, Otsuka, Sumitomo Pharma, Takeda, Eli Lilly, Nippon Shinyaku, Pfizer, Mochida, Janssen, and Yoshitomiyakuhin. The other authors declare that they have no competing interests.

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Supplementary Information

Additional file 1: Supporting file.

A guide for encouraging cancer screening at psychiatric institutions.

Additional file 2: Supporting Table 1.

Intervention using case management to encourage CRC screening.

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Fujiwara, M., Yamada, Y., Etoh, T. et al. A feasibility study of provider-level implementation strategies to improve access to colorectal cancer screening for patients with schizophrenia: ACCESS2 (N-EQUITY 2104) trial. Implement Sci Commun 5, 2 (2024). https://doi.org/10.1186/s43058-023-00541-0

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Keywords

Implementation Science Communications

ISSN: 2662-2211