Anne Dorte Lerche Helgestad is a medical doctor with a background in clinical oncology. The overall aim of Anne Dorte's PhD study is to explore cross-program synergies in the three cancer screening programs in Denmark. First by identifying shared demographic and socioeconomic profiles of non-participants in all three cancer screening programs, second by analyzing if level of health literacy predicts non-participation in all three cancer screening programs and finally by using high participation rates in breast cancer screening as a lever to increase participation in colorectal and cervical cancer screening programs in Denmark.

Project title: Cross-program synergies in the three cancer screening programs in Denmark: Can we kill three birds with one stone?

Project period:  June 2021 – May 2024

Supervisors:

• Prof. Berit Andersen, University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital

• Mette Bach Larsen, University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital

Contact information:

• E-mail: annesper@rm.dk 
• Tel.:  +45 7842 0178

Camilla Rahr Tatari holds a Master of Science in Public Health. Her research area is cancer screening participation seen from the socially vulnerable citizen's perspective. 

The aim of Camillas PhD study is to explore perceptions, attitudes and experience with cancer and identify barriers towards cancer screening among some of the most vulnerable groups of people in Denmark. Furthermore, Camilla will investigate the potential for developing tailored interventions to increase uptake in cervical, breast, and colorectal cancer screening for these groups and thereby reduce health disparities and mortality related to cancer.

The purpose is to ensure informed choice about screening participation among all citizens in the target groups for screening for cervical cancer, breast cancer, and colorectal cancer. The overall research approach is exploratory qualitative research and includes interviews, focus groups, and field work.

Project title: A qualitative study of cancer screening participation among socially vulnerable citizens: potential for a tailored intervention

Project period: August 2020 – July 2024

Supervisors:          

• Prof. Berit Andersen, Department of Public Health Programmes, Randers Regional Hospital
• Pia Kirkegaard, Senior Researcher, MA, PhD, Department of Public Health Programmes, Randers Regional Hospital

Contact information:

• E-mail: CATATA@rm.dk
• Tel.: +45 7842 0178  
• Link to profile at Aarhus University

Pernille Thordal Larsen has a nursing background in abdominal surgery and a Master's Degree in Health Science. Pernille's research focus is register-based cohort studies within cancer screening. 

The aim of Pernille's PhD study is to evaluate the recommendations in the Danish national colorectal cancer screening program for citizens who have a positive Faecal Immunochemical Test (FIT) and a subsequent colonoscopy with no colorectal cancer findings. The overall aim is to ensure quality and resource efficiency in the health care system. 

Project title: TIMING: Timely follow-up in colorectal cancer screening

Project period: June 2020 – May 2024

Supervisors:          

• Ass. Prof. Sisse Helle Njor, Department of Public Health Programmes, Randers Regional Hospital
• Prof. Berit Andersen, Department of Public Health Programmes, Randers Regional Hospital

Contact information:

• E-mail: penlar@rm.dk
• Tel.: +45 7842 0268
• Link to profile at Aarhus University 

Rikke Stokholm holds a Master of Science in Public Health. The aim of Rikke's PhD study is to scientifically define the concept of knowledge in cancer screening. Knowledge is the foundation for making an informed choice about (non)participation in cancer screening. It is therefore important that health authorities offer comprehensible and useful self-administered information materials providing the residents with sufficient knowledge to support them in making their informed choice about participation. 

Project title: Defining and measuring knowledge in cancer screening – is there a need for new information materials?

Project period: February 2022 - January 2025

Supervisors:

• Prof. Berit Andersen, University Re-search Clinic for Cancer Screening, Public Health Programmes, Randers Regional Hospital
• Senior Researcher Mette Bach Larsen, University Research Clinic for Cancer Screening, Public Health Programmes, Randers Regional Hospital
• Prof. Adrian Edwards, Division of Population Medicine, Cardiff University, Wales

Contact information:

• E-mail: RISTOK@rm.dk
• Tel.: +45 7842 0268
• Link to profile at Aarhus University

Vibe Munk Bertelsen is a medical doctor and a PhD student. The aim of Vibe's PhD study is to improve the diagnosis of precancerous cervical lesions. Vibe's project includes a double-blinded study to investigate if the diagnosis of cervical precancerous lesions can be improved among elderly women aged ≥ 50 years by providing pretreatment with vaginal estrogen prior to the colposcopic examination.  

Project title: Improving diagnostics in cervical dysplasia - testing new technology, evaluating pre-diagnostic treatment and evaluating present procedures

Project period: September 2021 – August 2024 (currently on maternity leave)

Supervisors:          

• Ass. Prof. Pinar Bor, Department of Gynaecology and Obstetrics, Randers Regional Hospital and Department of Clinical Medicine, Aarhus University
• Prof. Lone Kjeld Petersen, Department of Obstetrics and Gynaecology, Odense University Hospital
• Dr. Berit Booth, Department of Obstetrics and Gynaecology, Regional Hospital West Jutland 
• Dr. Mette Tranberg, Department of Public Health Programmes, Randers Regional Hospital

Contact information:

• E-mail: vibebert@rm.dk
• Tel.: +45 7842 0187
• Link to profile at Aarhus University 

Martin examined the quality of the colonoscopies offered to the participants subsequent to a fecal sample positive for blood in the national colorectal cancer screening programme.

Thesis: Colonoscopy performance indicators, Quality of screening colonoscopies in the Central Denmark Region

Summary: The national Danish colorectal cancer screening program was introduced in 2014. The quality of the program highly depends on the quality of the screening colonoscopies offered to the participants subsequent to a fecal sample positive for blood. To assess the quality of the screening colonoscopies, it is very important to identify suitable performance indicators.
Martin studied the evidence concerning colonoscopist dependent performance indicators through a systematic review. The results revealed that colonoscopists having the highest adenoma detection rate, the highest rate of colonoscopies with cecal intubation and a withdrawal time of 6 minutes or more had the lowest incidence of interval cancers among their patients. Martin then investigated the quality of the data available in the Central Denmark Region concerning the quality of the screening colonoscopies. The data showed to be of high quality, and was subsequently used to assess the quality of the screening colonoscopies by means of the above mentioned colonoscopists dependent performance indicators along with other relevant performance indicators and quality indicators. Finally, Martin examined the value of further educating colonoscopists by means of performance indicators. 

Defended: October 28, 2019

Assessment committee:

• Peter Christensen, Professor, Department of Surgery, Aarhus University Hospital, Central Denmark Region, Denmark
• Brendan John Moran, Professor, Basingstoke Hospital North Hampshire Foundation Trust Aldermaston Road, United Kingdom
• Øyvind Holme, Associate Professor, University of Oslo, Institute of health and Society, Faculty of Medicine, Oslo, Norway

Supervisors:

• Berit Andersen, Professor, Head of Department, Department of Public Health Programmes, Randers Regional Hospital
• Søren Laurberg, Professor, MD, DMSc, Mave- og tarmkirurgi, Aarhus Universitetshospital
• Rune Erichsen, MD, ph.d., Mave- og tarmkirurgi, Aarhus Universitetshospital

Pernille investigated how citizens accept a newly developed decision aid and if a decision aid is able to increase the proportion of citizens making an informed choice of whether or not to participate in the colorectal cancer screening programme.

Thesis: To screen or not to screen - A decision aid to support informed decision making in colorectal cancer screening

Summary: 

All Danish citizens aged 50 to 74 years are invited to take up screening once every second year. Upon receiving the invitation, it is important, that the citizens can make an informed decision about screening uptake. The informed decision should be based on personal values and access to relevant knowledge. 
Decision aids are information materials developed to support informed decision making by presenting objective information on benefits and harms regarding health-related choices. They increase the reader’s knowledge and the extend to which choices made are informed. The decision to take up colorectal cancer screening is made without any contact to health care professionals, and decision aids must therefore be self-administered.  
Pernille developed and evaluated a web-based decision aid targeted to citizens with lower educational attainment. The decision aid was developed and tested in several steps involving both health care professionals and citizens from the target population. By using a simple layout and presenting information using both text and figures in combination with read-more options, diverging information needs were embraced, resulting in a decision aid well accepted, comprehensible and usable by citizens with lower educational attainment.
Pernille assessed the general level of knowledge, attitudes and worries about colorectal cancer screening in 53-74-year-old unscreened Danish citizens and examined whether health literacy was associated with these outcomes. She reached a 71% response rate by sending out questionnaires to more than 10,000 citizens. In general, Danish citizens eligible but not yet invited to screening have high levels of knowledge about, a positive attitude towards and few worries about colorectal cancer screening. This tendency did not seem to be associated with health literacy.
Pernille then tested the effectiveness of the developed decision aid on informed choice, as assessed by changes in knowledge, attitudes and screening uptake. She also investigated if the decision aid affected the level of decisional conflict or worries about colorectal cancer screening in a randomised controlled design. Screening uptake was statistically insignificantly increased by 7.6% points in the intervention group compared with the control group, but neither knowledge nor attitudes were affected by the decision aid. The level of decisional conflict decreased in the intervention group compared with the control group. The same tendency was observed for worry scores, but not at a statistically significant level.

Defended: April 5, 2019

Assessment committee:

• Annelli Sandbæk, Professor, Head of Research Unit for General Practice, Research Unit for General Practice, Institute of Public Health, Aarhus University
• Dawn Stacey, Professor, School of Nursing, University of Ottowa, School of Epidemiology and Public Health, Ottowa, Canada & Ottowa Hospital Research Institute, Ottowa, Canada
• Jesper Bo Nielsen, Professor, Head of Institute of Public Health
  Institute of Public Health, University of Southern Denmark

Supervisors:

• Berit Andersen, Professor, Head of Department, Department of Public Health Programmes, Randers Regional Hospital
• Mette Bach Larsen, Senior researcher,  Department of Public Health Programmes, Randers Regional Hospital
• Pia Kirkegaard, Senior researcher, Department of Public Health Programmes, Randers Regional Hospital
• Adrian Edwards, Professor, Head of Department, Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, England

Sara investigated the interplay between childhood HPV vaccination attendance and subsequent routine cervical cancer screening attendance among different sub-populations in Denmark. The main focus of the project was patterns and reasons for combined non-attendance (un-vaccinated and un-screened), as non-attendees are considered potentially at high risk for developing cervical cancer.

Thesis: Non-attendance in Danish cervical cancer prevention programmes

Summary: Cervical cancer is a major global threat to women's health. However, in many western countries, like Denmark, women are offered organised and free-of-charge HPV vaccination and cervical cancer screening programmes. Women are recommended to attend both programmes. Women who attend neither vaccination nor screening (combined non-attendees) constitute a high risk group which needs to be identified and reasons for their non-attendance better understood.
The first birth cohorts vaccinated against HPV reached screening age (23 years) during 2016, thus making it possible to identify combined non-attendees, to investigate predictors for non-attendance and to understand the factors influencing non-attendance.
In her PhD, Sara found that girls who did not attend HPV vaccination were less likely to attend cervical cancer screening. She also identified that combined non-attendees were more often socioeconomically disadvantaged and of ethnic minority background. Those who attended both HPV vaccination and cervical cancer screening were more often socioeconomically advantaged and native Danes. Further, her study showed that almost one third of young women with ethnic minority background did neither attend HPV vaccination nor cervical cancer screening in comparison to one tenth of native Danes. Among women with ethnic minority backgrounds, she also found a variation in non-participation among women from different geographical regions. Middle-Eastern and North African countries had the highest degree of combined non-attendance.
Finally, she investigated by means of an interview study the perception of HPV vaccination and cervical cancer screening among a group of Middle-Eastern and North African women. She found that their barriers to attend the programmes were rather complex involving cognitive, emotional as well as socio-cultural barriers on a personal, interpersonal, organisational, and community level.

Defended: September 4, 2020

Assessment committee:

• Jo Waller, Reader in Cancer Behavioural Science. Cancer prevention Groups, Faculty of Life Science & Medicine. Kings College London.
• Maria Kristiansen, Associate Professor, Research group leader, Department of Public Health, University of Copenhagen.
• Lotte Ørneborg Rodkjær (Chair), Associate Professor, Department of Public Health, Aarhus University

Supervisors:

• Assoc. Prof. Lene Seibæk, Department of Clinical Medicine, Aarhus University
• Prof. Jan Blaakær, Department of Obstetrics and Gynaecology, Odense University Hospital
• Prof. Lone Kjeld Petersen, Department of Obstetrics and Gynaecology, Odense University Hospital
• Prof. Berit Andersen, Department of Public Health Programmes, Randers Regional Hospital

Susanne evaluated the adherence to recommendations for follow-up after abnormal findings in the Danish breast and cervical cancer screening programmes as well as the derived resource use. 

Thesis: Adherence to recommendations for follow-up in breast- and cervical cancer screening in Denmark

Summary: Timely and appropriate follow-up is crucial for the effectiveness of cancer screening programmes. However, there is a lack of knowledge on how  the entire pathways of follow-up after abnormal screening results perform,  whether the pathways follow recommendations and the derived resource use. In her PhD, Susanne mapped the entire pathways of follow-up after abnormal findings in the cervical and breast cancer screening programmes  using national health registries. The mapping showed that less than half of the women had follow-up in accordance with the national recommendations following an abnormal cervical cancer screening. In contrast, the majority of women had follow-up in accordance with the national recommendations after abnormal breast cancer screening. Furthermore, follow-up after cervical cancer screening was excessively long in many cases and the use of diagnostic tests and procedures higher than expected.

The results call for a more systematic monitoring of follow-up after abnormal screening and more evidence to develop guidelines on how to terminate these excessively long follow-up pathways in the cervical cancer screening program.

Defended: August 31, 2021

Assessment committee:

• Solveig Hofvind, Professor, Cancer Registry of Norway, Section for Breast Screening, Oslo, Norway
• Marianne Waldstrøm, Associate Professor, Institute of Regional Health Research, University of Southern Denmark, Denmark
• Rikke Søgaard (Chair), Professor, Department of Public Health, Aarhus University, Denmark

Supervisors:

• Prof. Berit Andersen, Department of Public Health Programmes, Randers regional Hospital
• Assoc. Prof. Sisse Helle Njor, Department of Public Health Programmes, Randers regional Hospital
• Senior Epidemiologist Matejka Rebolj, Cancer Prevention Group, King's College London