Raising awareness

cancer is the second most common cancer killer in the UK. A clinical specialist
nurse in bowel care describes how OH can help develop an awareness in the
workplace, By Sue Frost

This article describes the background and progress to date of a project to
promote healthy bowel awareness in the workplace. The work, funded by Coloplast
Ltd, is being carried out from the University of Birmingham.

Bowel cancer is the second most common cancer killer in the UK, with more
than 35,000 people diagnosed with the disease each year, and 16,000 deaths per
year – which equates to around 43 people dying every day.1 Unfortunately,
evidence suggests that many people are not aware of the signs and symptoms of
the disease.2,3,4

I have spent 17 years helping people diagnosed with bowel cancer, in my role
as a bowel care clinical nurse specialist, and this experience has highlighted
the difficulties and challenges associated with a lack of knowledge of the
signs and symptoms of the disease.

It was also clear that embarrassment and denial could lead to a delayed
diagnosis. Many patients had symptoms for several months and some even for
years, but had chosen not to seek help at an early stage, because they were
unaware of a potential problem, because they were too embarrassed to seek
advice, or because they hoped the symptoms would go away. This is unfortunate,
as many would have been in a position to be treated and cured during the early
stages, but for a significant number, a cure was not possible by the time they
were diagnosed.

In the late 1990s, I felt a more proactive stance was required to influence
the knowledge and attitude of our local community regarding bowel cancer and
disease. So in 1997, along with a colleague, I set up a registered charity (The
Holly Trust) in our local area. It is dedicated to raising local awareness of
the disease, and funds to help those diagnosed. The charity’s founders included
ex-patients and nurses with an interest in the subject.

One of the major difficulties the charity encountered was how to get the
information across to the public in the most effective way. After designing our
own bowel cancer awareness leaflets, we organised many events. One such example
was to hand out the leaflets at our local shopping centre, but this only seemed
to capture the interest of a certain number of people, and in fact, a small
number even looked offended when they saw what the leaflets were about.

Despite successfully raising funds and promoting bowel cancer issues in the
local community, there was a need to find a way of getting the information
across to the public in a more effective manner.

In 1997, Lynn Faulds-Wood – former Watchdog presenter, and now an
investigative reporter on GMTV – co-founded the bowel cancer charity, the
Crocus Trust. She then moved on to the charity Beating Bowel Cancer, and now
runs her own charity, Lynn’s Bowel Cancer Campaign. We discussed the
possibility of setting up a project to work with occupational health nurses

As a patron of the Association of Occupational Health Nurses (AOHNP),
Faulds-Wood knows they are in a unique position to gain access to the general
public at work. Having already done some work on this with the Institute of
Occupational Health at the University of Birmingham, Faulds-Wood now felt the
project would benefit from someone running it full-time. We believed this was
an excellent platform to start addressing issues about healthy bowel awareness
and a great opportunity to work with OHNs. It is acknowledged that they have
many priorities in their working day, which includes political processing,
policy making, programme development, research, health service provision,
counselling and teaching.5 So to include healthy bowel awareness, it had to be
promoted in the most time and cost-effective manner.

The workplace, along with schools, hospitals and neighbourhoods, was
identified as a vehicle for health promotion by the World Health Organisation,
offering the ideal setting to support the promotion of health to a large group
of people.6 This is particularly relevant to cancer prevention activities,
because the majority, including bowel cancer, are related to lifestyle, and are
therefore potentially preventable.7 Cutler asserts that nurses are ‘key
players’ in cancer prevention. 8

A proposal was developed and accepted by the university, and the project,
entitled ‘Promoting Healthy Bowel Awareness in the Workplace’, was further
developed as a higher-degree project.

The project

The overall aim of the project is to develop and explore the capacity for
promoting healthy bowel awareness within the workplace. The project has four

Stage one:

– To nationally assess OHNs’ current knowledge, attitudes and practice
regarding healthy bowel awareness in the workplace.

Stage two:

– To develop and implement a healthy bowel awareness learning and development
programme with three occupational health departments.

Stage three:

– To support individual OHNs/departments to develop and implement their own
healthy bowel awareness intervention, within their own workplace.

Using a postal survey, assess workforce knowledge, attitudes and behaviour
regarding healthy bowels and bowel cancer for both pre- and post intervention.
The pre- and post- intervention survey will also be carried out by an OH
department which does not carry out a bowel awareness intervention to enable
the comparison of survey results from intervention and non-intervention

Stage four:

– Interview consenting OHNs to evaluate the development, implementation and
impact of the project.

Project progress

After gaining ethical approval for the overall project, stage one has now
been completed. Stage two is currently in progress – three OH departments have
been randomly chosen and agreed to participate in the intervention group, and
one has been randomly chosen and agreed to participate in the non-intervention
group. A pilot of the workforce questionnaire is in progress.

Preliminary results of stage one are discussed below, and the final results
will be published at a later date. 9

Stage one – survey of OHNs regarding the practice and perception of
healthy bowel awareness in the workplace

A postal questionnaire, including an invitation letter and participant
information sheet, was sent to 969 OHNs from three data sources: an OHN
database held at the Institute of Occupational Health, University of
Birmingham, a database set up by Faulds-Wood, and a randomly selected group of
OHNs from a generated list of companies in the UK and Ireland.

The survey consisted of mainly quantitative and some quantitative questions
regarding knowledge and attitude concerning bowel cancer and participation,
attitude and experience regarding health promotion.

Of the 244 responses returned, 38 could not be included, predominantly
because the nurse no longer worked in the department. The remaining 206 were
analysed. The findings are outlined below.


Just over three-quarters of the respondents worked full-time. Respondents
were providing a service, in total, for more than a million of the UK’s working

It was clear that the knowledge regarding bowel cancer signs and symptoms
was fairly high. Just over half the respondents correctly ranked bowel cancer
as the second biggest cancer killer in the UK. Nearly all the respondents could
name a way that could reduce the chances of getting bowel cancer, and name at
least one symptom of the disease. In contrast, when asked about predisposing
factors associated with bowel cancer, a quarter could not name any factor at

There seemed to be some confusion over what to do when a client shows symptoms
that may indicate bowel cancer. The majority opted to advise the client to see
their GP immediately or at the earliest convenient stage. In fact, the
Department of Health referral guidelines for colorectal cancer advise it is
safe to watch symptoms for up to six weeks before seeing a doctor.10

Information leaflets regarding bowel cancer are available from many sources,
including the national bowel cancer charities, but only a third of the
respondents had accessed these.

Embarrassment is the biggest barrier to people contacting OHNs with
bowel-related problems. Healthy bowel awareness activities had been undertaken
by just over a quarter of the respondents.

Of those that had not taken part in an activity, time constraints and other
activities taking priority were given as the major reason.

More than half the respondents said they had taken part in another cancer
health promotion activity, with lung, testicular, prostate, skin, and cervical
cancer being stated the most frequently.

Many respondents said they felt bowel cancer was important, but did not have
the time to promote it. Some said funding was also an issue, and a minority did
not feel it was a priority at all.


The survey indicates that the OHNs who responded to the survey have a fairly
high knowledge of the disease and its signs and symptoms. There also seems to
be a genuine interest in the subject, and its importance is acknowledged.

The major barrier in the promotion of healthy bowel awareness appears to be
time constraints, and the fact that other activities take priority. Some
departments have taken part in healthy bowel awareness promotion, but almost
three-quarters have not had the time or funding. Information leaflets are
available, but not all departments have them.

It is not appropriate to make recommendations for practice at stage one of
the study, as work is still in progress. However, the work raises this
question: how can the OHN incorporate healthy bowel awareness into current
practice, with minimal time and financial implications? Many nurses say they
incorporate questions about bowel function in their routine employee screening.
This would seem to be an ideal opportunity to discuss the preventative
measures, and signs and symptoms, maybe using a leaflet from one of the
charities. Leaflets in the department may be useful, as these can be accessed
without necessarily speaking with someone face-to-face.

Preventative measures do require behavioural change, and to support and
encourage this, some nurses had collaborated with other areas, such as the
workforce canteen, who were able to offer a more healthy diet choice.

Such collaborations are a positive step to both reinforcing and creating
sustainable changes of the health of a workforce.


Bowel cancer is a disease with high incidence and high mortality rates. OHNs
are in a unique position to be able to disseminate knowledge and encourage and
support behaviour change where appropriate. The aim of the project discussed in
this article is to deliver a model for the design and implementation of an
intervention to facilitate this. It is clear that time constraints are a major
factor in the lack of healthy bowel awareness in many occupational health
departments, and although they recognise it is a priority, mandatory
requirements have to take precedence.

The progress of the project will be reported in the future, so that other
OHNs can utilise the results in their own workplace in the most time and cost
effective manner.

Sue Frost RGN, postgraduate student, School of Health Sciences, University
of Birmingham


My supervisors, Dr Sandy Herron-Marx, Professor Collette Clifford, and Dr
Barbara Mullan; Lynn Faulds-Wood; the OH nurses who responded to the survey in
stage one, and to those who were randomly selected and agreed to take part in
the next stages of the project; Coloplast Limited; Sarah Wheeler, Bowel care
CNS; Good Hope Hospital NHS Trust, Sutton Coldfield; and The Holly Trust.


1. CancerStats Large bowel – UK (2003) Cancer Research UK

2. Pullyblank, AM, Cawthorn, SJ and Dixon, AR (2002), Knowledge of cancer
symptoms among patients attending one-stop breast and rectal bleeding clinics.
European Journal of Surgical Oncology, 28 (5), 511-515

3. Yardley, C, Glover, C and Allen-Mersh, T G (2000) Demographic factors
associated with knowledge of colorectal cancer symptoms in a UK
population-based survey. Ann R Coll Surg Engl, 82 205-209

4. Camilleri-Brennan, J and Steele, RJC (1999) A comparative study of
knowledge and aware-ness of colorectal and breast cancer. European Journal of
Surgical Oncology, 25 580-583

5. Parker-Conrad, JE (2002) A century of practice: Occupational Health
Nursing. AAOHN Journal, 50 (12), 357-541

6. World Health Organisation (1997) The Jakarta declaration on Health
promotion into the 21st century. WHO publications

7. Doll, R and Peto, R.(1981) The causes of cancer: quantitative estimates
of avoidable risks of cancer in the United States today. J Natl Cancer Inst.,
66 1191-1308

8. Cutler, L (1999) The contribution of nursing to cancer prevention.
Journal of Advanced Nursing, 29 (1), 169-177

9. Frost, SE, Herron-Marx, S, Clifford, CM, Mullan, B, (2004) The promotion
of healthy bowel awareness in the workplace: a survey of Occupational health nurses
(in progress)

10. Executive, N. (2000) Referral Guidelines for Colorectal cancer.
Department of Health, London


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