Interventions to promote participation

A systematic review (Stone et al. 2002), assessed the effectiveness of the following on improving screening participation: regulatory and legislative actions (outside the medical care organisation), financial incentives for providers or patients, organisational change (changes in clinical procedures or facilities and infrastructures), reminders for providers and screenees, provider feedback, education and visual materials. The most effective was the implementation of organisational changes that made delivery of these services a routine part of patient care (establishing separate clinics devoted to screening, involving nursing or clerical staff in the delivery of services, adoption of monitoring and quality improvement approaches), reducing, or eliminating costs for the individual or establishing a system of reminders. 

Removing financial barriers

Experimental studies conducted in the context of breast cancer screening showed that reduced charges for screening are effective in encouraging uptake among disadvantaged groups (Jepson et al. 2000). Sending an FOBT with a postage-paid envelope for returning the sample resulted in a significantly higher uptake, compared to non-postage (Jepson et al. 2000). The return rate was highly significant for medically uninsured people in one of the studies (Miller & Wong 1993). Offering a free FOBT in addition to educational intervention was superior to the educational intervention alone in promoting completion of screening (Plaskon & Fadden 1995). Offering financial incentives to subjects invited for screening was not found to have an impact on participation 

Delivering information about screening 

Although the organisation of screening within health services emerges as the most important determinant of uptake, factors related to culture, values and beliefs may still play a role. Also, provision of information is clearly necessary to enable subjects to make an informed choice.

 Data from the National Health Interview Survey (NHIS) consistently indicate that lack of awareness of CRC represents one of the main determinants of the underutilisation of screening. 

Data from people recruited in the UK sigmoidoscopy trial (Wardle et al. 2004) who were requested to express their intention to attend screening suggest that part of the explanation of the socio-economic status (SES) gradient may be the difference in beliefs and expectations. Lower social groups evaluated the offer of a screening test, which had been publicised identically and was provided free of charge , at a convenient location and time, to all social groups, as being more frightening and less beneficial, than higher social groups. In England, with overall population participation at 60% despite free testing, the uptake rate of the FOBT programme is lower in deprived areas and among ethnic minorities (von Wagner et al 2009). Rural areas were shown to have a lower participation rate than urban areas (Launoy et al. 1993; Giorgi Rossi P. et al. 2005). 

Therefore, the way the population is informed about the potential benefits and harms of screening is of particular importance. Strategies aimed at improving population knowledge and awareness of CRC and screening should target health professionals as well as individuals

Information conveyed with the invitation 

A systematic review of methods aimed at enhancing screening rates concluded that educational interventions are less effective than organisational changes and should not be the first choice (Stone et al. 2002). Findings from more recent studies (Harris et al. 2000; Lipkus, Green & Marcus 2003; Robb et al. 2006; Costanza et al. 2007) support such a conclusion. When individuals interested in screening were requested to actively seek further information and a referral to screening from their providers, an information brochure was observed to have no impact, but the number of screening requests in-creased significantly when the GP delivered an FOBT request form together with the information pamphlet. 

 The content and format of the information material sent with the invitation may influence a subject’s decision to undertake screening.  An individually tailored interactive multimedia programme at the physician’s office seemed more efficacious in increasing readiness to undergo screening, as compared to the same intervention not individually tailored (Jerant et al. 2007). 

Interventions that use visual instruments to enhance appeal and clarity are more effective: adding illustrations about the polyp-cancer process and the removal of the polyps during FS to written material was associated with a significant increase in knowledge and understanding (Brotherstone et al. 2006). Culturally and linguistically appropriate approaches promoting FOBT can enhance screening practice in groups of low-income and less acculturated minority patients