Researchers at Homerton Hospital noticed that while black women are less likely to develop breast cancer than their white counterparts, when they are diagnosed with breast cancer it tends to be at a younger age, typically before the age of entry into the NHS Breast Screening Programme. Black women also tend to be diagnosed with the more severe and aggressive types of breast cancer. Evidence suggests for various social and cultural reasons Black women are less breast aware and less likely to seek help from medical professionals. In response to these issues Homerton Hospital commissioned a six-minute information film . There is a clear need to evaluate the effectiveness of the DVD in raising awareness of breast cancer, encouraging early presentation and thereby promoting improvements in the detection of and prognosis for breast cancer in black patients. This study consists of 2 phases, a pilot and a main study one. In the first stage of the project, we piloted the distribution of the DVD amongst black women aged 25-50 in four GP practices within NHS East London and the City (with two practices recruited to serve as intervention and two practices to serve as a control). A mixture of quantitative (analysis of consultation and referral rates) and qualitative (interviews with practice nurses and patient focus groups) methods were used to evaluate the DVD’s impact. The findings from this study informed the design of a full randomised trial evaluation, presenting the second stage of the project. The same mixed methods approach was used to analyze the data for the main study phase, with 10 GP practices being involved (five as intervention and five as control practices). Black women in London have in the past tended to be diagnosed with more advanced breast cancer at an earlier age than their white counterparts. A 7 minute DVD was developed to improve awareness of breast cancer among young black women in East London. The study, a fully randomized control trial evaluation, was divided into pilot and main study. Five local GP surgeries acted as intervention sites and distributed the DVD to registered patients who fit the study criteria; another five acted as control practices. The main aims of the study were to raise awareness of breast cancer within London’s black communities and to evaluate the DVDs impact on breast consultations and referrals. Quantitative methods were used to analyse shifts in consultation and referrals rates at six month intervals. Additionally, qualitative methods (focus groups with patients from the target population and interviews with practice nurses and GPs) to access the DVDs acceptability and communicative function.

With the assistance of members of NHS East London and the City will recruit 10 practices in the City and Hackney area (with an estimated black female population aged 25-50 of 1680). 5 practices will be selected at random from these 10. Using practice lists we will aim to post the DVD to all black women aged 25-50 registered at these 5 practices (excluding those who already have a previous diagnosis of breast cancer). The 5 practices who have not received the DVD will serve as control practices. This will allow us to evaluate the impact of the DVD. (Control practices will receive copies of the DVD to distribute once the study is complete for equity reasons.) The maximum age in our study reflects the age of entry into the national breast cancer screening programme (50). The minimum age has been selected as the earliest cases at Homerton include women as young as 25. Quantitative Evaluation Using the EMIS database we will analyse data on consultations regarding breast symptoms and referral rates for breast symptoms, by age and ethnicity for all participating GP practices for 6 months after the intervention and the corresponding 6 months from the previous year before the intervention. We will augment this with a manual audit of a random subset of GP consultations. Using this data we will evaluate the impact of the DVD on consultation and referral rates. Data will be analysed by poisson regression. In terms of data quality from the EMIS searches, we shall draw up a practice search protocol for a series of codes related to breast symptoms (for example including codes for mastalgia, and mastodynia as well as ‘breast pain’, and excluding consultations with codes specific to breast feeding problems. Qualitative Evaluation Within each of the 14 participating GP practices we will: 1) Conduct a focus group with members of the black female patient population, aged 25-50, around 1-2 months following the distribution of the DVD (to allow patients sufficient time to view the DVD but not so much time they will have forgotten receiving it). We will aim to recruit 8-10 participants from each practice. Recruitment will be facilitated by staff at the participating practices, in addition to advertising at those practices. 2) Interview a key healthcare worker in each practice (ideally one of those most closely involved with breast symptoms and breast awareness e.g. a practice nurse) for their perspective on general levels of breast awareness within their practice community, existing alternative interventions, and the effectiveness of the DVD. As health worker opinions are not the key focus of the project (but rather a means of gaining a more complete picture of the practice community and acknowledging the practice perspective/voice), and a larger sample has cost and recruitment concerns, it had been decided one worker per practice should be sufficient.