Background
Methods
Study population and setting
Three-step invitation strategy for stage one: HRA participation
-
Step one: eligible patients were invited by a personalised, GP-signed letter. Enclosed were the HRA and an information brochure (both with ethnic specific pictures), a tape measure for measuring waist circumference, a reply card declining participation, and a stamped return envelope addressed to the GP. The formulation was simplified to fit the generally lower health literacy levels of our target population. Turkish and Moroccan patients received Turkish or Arabic versions, respectively, in addition to the Dutch materials. After two weeks of non-response, patients received a reminder package. A detailed description of the (cultural) adaptations made in the invitation, HRA, and information brochure can be found in Additional file 2.
-
Step two: after another two weeks of non-response, patients were called by a trained research assistant on behalf of the GP. Turkish and Moroccan patients were called by Turkish, Arabic, and Berber (which is an oral only language) speaking research assistants. The conversation was structured by a script supporting patients in making an informed decision about (non-)participation. When a participant decided to participate, the HRA was immediately completed by telephone and the HRA risk score was calculated by the research assistant. The national telephone directory was consulted when telephone numbers were missing, unlisted, or inoperative. Patients were approached with a maximum of four call attempts.
-
Step three: after four failed call attempts, patients were invited face-to-face when visiting their GP for an unrelated consultation. GPs received a pop-up in the electronic patient file of a non-responding patient. The GPs followed a short version of the telephone script to help patients make an informed decision about (non-)participation. When a participant decided to participate, the HRA was immediately completed at the GP practice and the HRA risk score was calculated by the practice nurse. The face-to-face invitation period lasted six months, which was deemed long enough since ethnic minorities and native Dutch patients with a low SES are known to consult the GP up to once or twice a month [24, 25]. If patients had not visited the practice within this period, they were classified as final non-responders.
Stage two: PC participation among high-risk individuals
Measures
Covariates
Data analysis
Results
Demographics
Total (n = 1644) | Dutch with low SES (n = 437) | Turkish (n = 353) | Moroccan (n = 344) | Surinamese (n = 510) | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
n | % | mean (SD) | n | % | mean (SD) | n | % | mean (SD) | n | % | mean (SD) | n | % | mean (SD) | p value | |
Gender | ||||||||||||||||
Male | 882 | 54 | 220 | 50 | 192 | 54 | 210 | 61a | 260 | 51 | .011 | |||||
Female | 762 | 46 | 217 | 50 | 161 | 46 | 134 | 39 | 250 | 49 | ||||||
Age (years) | 1644 | 100 | 50 (7.00) | 437 | 100 | 52 (6.27)b | 353 | 100 | 51 (5.55) | 344 | 100 | 51 (6.32) | 510 | 100 | 47 (7.57)c | <.001 |
Age (cat.) | ||||||||||||||||
35-45 | 259 | 16 | 14 | 3 | 8 | 2 | 15 | 4 | 222 | 44 | ||||||
45-50 | 595 | 36 | 160 | 37 | 164 | 46 | 147 | 43 | 124 | 24 | ||||||
50-55 | 392 | 24 | 118 | 27 | 97 | 27 | 93 | 27 | 84 | 16 | ||||||
55-60 | 213 | 13 | 75 | 17 | 48 | 14 | 44 | 13 | 46 | 9 | ||||||
60-65 | 120 | 7 | 45 | 10 | 26 | 7 | 27 | 8 | 22 | 4 | ||||||
65+ | 65 | 4 | 25 | 6 | 10 | 3 | 18 | 5 | 12 | 2 | ||||||
SES score (score) | 1644 | 100 | −2.14 (2.46) | 437 | 100 | −0.39 (1.55) | 353 | 100 | −3.32 (2.28) | 344 | 100 | −2.30 (2.43) | 510 | 100 | −2.73 (2.43) | <.001d |
SES score (cat.) | ||||||||||||||||
> 0 | 470 | 29 | 231 | 53 | 48 | 14 | 82 | 24 | 109 | 21 | ||||||
0 till −2 | 386 | 24 | 151 | 35 | 57 | 16 | 91 | 26 | 87 | 17 | ||||||
−2 till −4 | 267 | 16 | 34 | 8 | 66 | 19 | 52 | 15 | 115 | 23 | ||||||
< −4 | 521 | 32 | 21 | 5 | 182 | 52 | 119 | 35 | 199 | 39 |
Response
Postal | Telehonea | ||||
---|---|---|---|---|---|
Response | Odds ratio (95 % CI) | Response | Odds ratio (95 % CI) | ||
Total group (n = 1644) | 41 % (n = 681) | 46 % (n = 443) | |||
Univariate analyses | |||||
Ethnicity | Dutchc (n = 437) | 49 % (n = 214) | 1.00 | 57 % (n = 126) | 1.00 |
Turkish (n = 353) | 45 % (n = 158) | 0.84 (0.64-1.12) | 47 % (n = 91) | 0.67 (0.46-0.99)* | |
Moroccan (n = 344) | 39 % (n = 134) | 0.67 (0.50-0.89)* | 40 % (n = 84) | 0.51 (0.35-0.75)** | |
Surinamese (n = 510) | 34 % (n = 175) | 0.54 (0.42-0.71)** | 42 % (n = 142) | 0.57 (0.40-0.80)** | |
Gender | Malec (n = 882) | 39 % (n = 343) | 1.00 | 42 % (n = 225) | 1.00 |
Female (n = 762) | 44 % (n = 338) | 1.25 (1.03-1.53)* | 51 % (n = 218) | 1.48 (1.14-1.91)* | |
Age | 35-45 (n = 259) | 27 % (n = 70) | 0.51 (0.37-0.70)** | 46 % (n = 87) | 0.90 (0.63-1.28) |
45-50c (n = 595) | 42 % (n = 250) | 1.00 | 49 % (n = 168) | 1.00 | |
50-55 (n = 392) | 45 % (n = 176) | 1.12 (0.87-1.45) | 49 % (n = 106) | 1.02 (0.72-1.43) | |
55-60 (n = 213) | 46 % (n = 98) | 1.18 (0.86-1.61) | 44 % (n = 51) | 0.84 (0.55-1.28) | |
60-65 (n = 120) | 48 % (n = 58) | 1.29 (0.87-1.91) | 36 % (n = 22) | 0.58 (0.33-1.02) | |
65+ (n = 65) | 45 % (n = 29) | 1.11 (0.66-1.85) | 25 % (n = 9) | 0.35 (0.16-0.77)* | |
GP practiceb | Dutchc (n = 361) | 50 % (n = 179) | 1.00 | 61 % (n = 111) | 1.00 |
Mix (n = 193) | 54 % (n = 105) | 1.21 (0.86-1.72) | 56 % (n = 49) | 0.80 (0.48-1.35) | |
Non-Western (n = 1090) | 36 % (n = 397) | 0.58 (0.46-0.74)** | 41 % (n = 283) | 0.44 (0.32-0.62)** | |
SES score | >0c (n = 470) | 46 % (n = 217) | 1.00 | 54 % (n = 137) | 1.00 |
0 till −2 (n = 386) | 41 % (n = 160) | 0.83 (0.63-1.08) | 47 % (n = 106) | 0.75 (0.52-1.07) | |
−2 till −4 (n = 267) | 39 % (n = 104) | 0.74 (0.55-1.01) | 35 % (n = 57) | 0.46 (0.30-0.68)** | |
< −4 (n = 521) | 38 % (n = 200) | 0.73 (0.56-0.94)* | 45 % (n = 143) | 0.68 (0.49-0.95)* | |
Multivariate analyses | |||||
Ethnicity | Dutchd (n = 437) | 49 % (n = 214) | 1.00 | 57 % (n = 126) | 1.00 |
Turkish (n = 353) | 45 % (n = 158) | 1.43 (0.98-2.08) | 47 % (n = 91) | 1.11 (0.68-1.82) | |
Moroccan (n = 344) | 39 % (n = 134) | 0.88 (0.64-1.22) | 40 % (n = 84) | 0.66 (0.43-1.01) | |
Surinamese (n = 510) | 34 % (n = 175) | 1.23 (0.83-1.81) | 42 % (n = 142) | 0.93 (0.57-1.89) |
GP practice | Ethnicity | % (n) | Response, %a (n) | HRA participation, %b (n) |
---|---|---|---|---|
Dutch low SES (n = 362) | Dutch | 74 % (n = 270) | 82 % (n = 221) | 70 % (n = 154) |
Turkish | 3 % (n = 10) | 80 % (n = 8) | 63 % (n = 5) | |
Moroccan | 21 % (n = 75) | 80 % (n = 60) | 60 % (n = 36) | |
Surinamese | 2 % (n = 7) | 86 % (n = 6) | 50 % (n = 3) | |
Total
|
100 % (n = 362)
|
81 % (n = 295)
|
67 % (n = 198)
| |
Mix (n = 194) | Dutch | 49 % (n = 95) | 88 % (n = 84) | 64 % (n = 54) |
Turkish | 9 % (n = 18) | 83 % (n = 15) | 53 % (n = 8) | |
Moroccan | 39 % (n = 76) | 74 % (n = 56) | 66 % (n = 37) | |
Surinamese | 3 % (n = 5) | 80 % (n = 4) | 100 % (n = 4) | |
Total
|
100 % (n = 194)
|
82 % (n = 159)
|
65 % (n = 103)
| |
Non-Western (n = 1091) | Dutch | 6 % (n = 73) | 58 % (n = 42) | 57 % (n = 24) |
Turkish | 30 % (n = 325) | 72 % (n = 235) | 58 % (n = 137) | |
Moroccan | 18 % (n = 194) | 55 % (n = 106) | 56 % (n = 59) | |
Surinamese | 46 % (n = 499) | 63 % (n = 315) | 61 % (n = 193) | |
Total
|
100 % (n = 1091)
|
64 % (n = 698)
|
59 % (n = 413)
|
Stage one: HRA participation
Postal (response n = 681) | Telephone (response n = 443) | ||||
---|---|---|---|---|---|
Participation | Odds ratio (95 % CI) | Participation | Odds ratio (95 % CI) | ||
Total group (n = 1152) | 66 % (n = 448) | 59 % (n = 260) | |||
Univariate analyses
| |||||
Ethnicity | Dutcha (n = 347) | 76 % (n = 163) | 1.00 | 55 % (n = 69) | 1.00 |
Turkish (n = 258) | 58 % (n = 91) | 0.43 (0.27-0.66)** | 65 % (n = 59) | 1.52 (0.87-2.65) | |
Moroccan (n = 222) | 60 % (n = 81) | 0.48 (0.30-0.76)* | 56 % (n = 47) | 1.05 (0.60-1.83) | |
Surinamese (n = 325) | 65 % (n = 113) | 0.57 (0.37-0.89)* | 60 % (n = 85) | 1.23 (0.76-2.00) | |
Gender | Malea (n = 576) | 64 % (n = 218) | 1.00 | 55 % (n = 123) | 1.00 |
Female (n = 576) | 68 % (n = 230) | 1.22 (0.89-1.68) | 63 % (n = 137) | 1.40 (0.96-2.05) | |
Age | 35-45 (n = 161) | 63 % (n = 44) | 0.86 (0.49-1.49) | 57 % (n = 50) | 0.75 (0.44-1.28) |
45-50a (n = 427) | 66 % (n = 166) | 1.00 | 64 % (n = 108) | 1.00 | |
50-55 (n = 287) | 66 % (n = 117) | 1.00 (0.67-1.51) | 54 % (n = 57) | 0.65 (0.39-1.06) | |
55-60 (n = 156) | 67 % (n = 66) | 1.04 (0.64-1.72) | 51 % (n = 26) | 0.58 (0.31-1.09) | |
60-65 (n = 83) | 59 % (n = 34) | 0.72 (0.40-1.29) | 55 % (n = 12) | 0.67 (0.27-1.63) | |
65+ (n = 38) | 72 % (n = 21) | 1.33 (0.57-3.13) | 78 % (n = 7) | 1.94 (0.39-9.66) | |
GP practice | Dutcha (n = 295) | 79 % (n = 141) | 1.00 | 51 % (n = 57) | 1.00 |
Mix (n = 159) | 72 % (n = 76) | 0.71 (0.40-1.23) | 55 % (n = 27) | 1.16 (0.59-2.28) | |
Non-Western (n = 698) | 58 % (n = 231) | 0.38 (0.25-0.57)** | 62 % (n = 176) | 1.56 (1.00-2.43)* | |
SES score | >0a (n = 364) | 70 % (n = 152) | 1.00 | 54 % (n = 74) | 1.00 |
0 till −2 (n = 268) | 71 % (n = 113) | 1.03 (0.66-1.61) | 56 % (n = 59) | 1.07 (0.64-1.78) | |
−2 till −4 (n = 169) | 71 % (n = 74) | 1.06 (0.63-1.76) | 63 % (n = 36) | 1.46 (0.77-2.75) | |
< −4 (n = 351) | 55 % (n = 109) | 0.51 (0.34-0.77)** | 64 % (n = 91) | 1.49 (0.92-2.40) | |
Multivariate analyses
| |||||
Ethnicity | Dutchb (n = 347) | 76 % (n = 163) | 1.00 | 55 % (n = 69) | 1.00 |
Turkish (n = 258) | 58 % (n = 91) | 0.94 (0.50-1.76) | 65 % (n = 59) | 1.09 (0.53-2.22) | |
Moroccan (n = 222) | 60 % (n = 81) | 0.71 (0.41-1.23) | 56 % (n = 47) | 0.93 (0.52-1.66) | |
Surinamese (n = 325) | 65 % (n = 113) | 1.31 (0.69-2.49) | 60 % (n = 85) | 0.88 (0.45-1.71) |
Stage two: HRA risk result and PC participation
HRA risk score | Participation in PCa | ||||
---|---|---|---|---|---|
High | Odds ratio (95 % CI) | Yes | Odds ratio (95 % CI) | ||
Total group (n = 714) | 29 % (n = 207) | 59 % (n = 123) | |||
Univariate analyses
| |||||
Ethnicity | Dutchc (n = 232) | 35 % (n = 82) | 1.00 | 46 % (n = 38) | 1.00 |
Turkish (n = 150) | 37 % (n = 56) | 1.09 (0.71-1.67) | 68 % (n = 38) | 2.44 (1.20-4.97)* | |
Moroccan (n = 132) | 30 % (n = 40) | 0.80 (0.50-1.26) | 68 % (n = 27) | 2.41 (1.09-5.31)* | |
Surinamese (n = 200) | 15 % (n = 29) | 0.31 (0.19-0.50)** | 69 % (n = 20) | 2.57 (1.05-6.32)* | |
Gender | Malec (n = 344) | 38 % (n = 130) | 1.00 | 63 % (n = 82) | 1.00 |
Female (n = 370) | 21 % (n = 77) | 0.43 (0.31-0.60)** | 53 % (n = 41) | 0.67 (0.38-1.18) | |
Age | 35-45 (n = 95) | 2 % (n = 2) | 0.14 (0.03-0.61)* | 0 % (n = 0) | - |
45-50c (n = 277) | 13 % (n = 36) | 1.00 | 67 % (n = 24) | 1.00 | |
50-55 (n = 174) | 28 % (n = 48) | 2.55 (1.57-4.13)** | 69 % (n = 33) | 0.91 (0.36-2.29) | |
55-60 (n = 93) | 55 % (n = 51) | 8.13 (4.75-13.92)** | 53 % (n = 27) | 0.51 (0.23-1.16) | |
60-65 (n = 47) | 91 % (n = 43) | 71.97 (24.37-212.50)** | 58 % (n = 25) | 0.63 (0.27-1.49) | |
65+ (n = 28) | 96 % (n = 27) | 180.75 (23.82-1371.33)** | 52 % (n = 14) | 0.49 (0.19-1.29) | |
GP practiceb | Dutchc (n = 198) | 31 % (n = 62) | 1.00 | 53 % (n = 33) | 1.00 |
Mix (n = 103) | 37 % (n = 38) | 1.28 (0.78-2.12) | 50 % (n = 19) | 0.88 (0.39-1.97) | |
Non-Western (n = 413) | 26 % (n = 107) | 0.77 (0.53-1.11) | 66 % (n = 71) | 1.73 (0.91-3.29) | |
SES score | >0c (n = 227) | 29 % (n = 65) | 1.00 | 55 % (n = 36) | 1.00 |
0 till −2 (n = 173) | 32 % (n = 56) | 1.19 (0.78-1.83) | 55 % (n = 31) | 1.00 (0.49-2.05) | |
−2 till −4 (n = 112) | 31 % (n = 35) | 1.13 (0.69-1.85) | 60 % (n = 21) | 1.21 (0.52-2.78) | |
< −4 (n = 202) | 25 % (n = 51) | 0.84 (0.55-1.29) | 69 % (n = 35) | 1.76 (0.82-3.80) | |
Multivariate analyses
| |||||
Ethnicity | Dutchd (n = 232) | 35 % (n = 82) | 1.00 | NA | NA |
Turkish (n = 150) | 37 % (n = 56) | 1.59 (0.93-2.70) | NA | NA | |
Moroccan (n = 132) | 30 % (n = 40) | 0.92 (0.52-1.63) | NA | NA | |
Surinamese (n = 200) | 15 % (n = 29) | 0.54 (0.28-1.01) | NA | NA |