Process evaluation of a national initiative to detect cancer early in Scotland.

BACKGROUND: Process evaluations of government-led cancer programmes help to understand whether, how and why these programmes work, ensuring accountability and informing the design of future initiatives. We report on a process evaluation of the Detect Cancer Early (DCE) Programme, launched by the Scottish Government in 2012, and provide recommendations for similar initiatives elsewhere. METHODS: A mixed-methods process evaluation informed by psychological and complexity theories was carried out to understand how the DCE Programme operated, and the extent to which its aims were met. Stakeholders involved in developing or managing the programme or providing care for patients were interviewed or completed an online questionnaire investigating implementation assumptions, mechanisms of impact, contextual barriers and facilitators, and unanticipated outcomes. Interviews were analysed using framework analysis; questionnaire data were summarised using descriptive statistics, bivariate and content analysis. Results were integrated to address the evaluation questions. RESULTS: 25 stakeholders were interviewed; 53 completed the questionnaire. Participants supported DCE's focus on early cancer detection, but engagement and sense of ownership were affected by limited communication about the Programme, its activities and outcomes. While increased demand for diagnostic services drove activities, there was frustration when strategies attracted the worried well. Some performance targets were perceived to be unachievable and not clinically relevant. DCE's timescales were often seen as not conducive to long-term changes. CONCLUSIONS: We identified several factors that may have influenced acceptability and implementation of DCE activities, and the ability to show Programme impact. Process evaluations of cancer programmes are still scarce, and we urge researchers and policymakers to publish results where available.