The role of primary care providers

Primary health care providers can be effective media for improving awareness of the risk of cancer and of the benefits of screening, for increasing confidence in the screening test method and for countering the reluctance to collect faecal samples. In many European countries this provider is the general practitioner (GP), but other trusted health professionals, such as community nurses for example, may play a similar role. 

Primary health care providers should be trained to deliver evidence-based information on screening and there should be a consensus on the programme protocol before starting the programme. 

Role of GPs/family physicians 

The involvement of GPs in screening can be very effective in improving compliance, according to the findings of several studies from different countries (Launoy et al. 1993; Tazi et al. 1997; Grazzini et al. 2000; Brawarsky et al. 2004; Federici et al. 2006; Sewitch et al. 2007; Seifert et al. 2008), but the effect is dependent upon the GP's own willingness to get involved. The findings of studies conducted in the context of opportunistic screening showed that the probability of not receiving a GP recommendation for CRC screening was highest among those with a low socioeconomic status (SES) (Brawarsky et al. 2004; Wee, McCarthy & Phillips 2005; Klabunde, Schenck & Davis 2006; Schenck, Klabunde & Davis 2006). These findings suggest that inadequate provider counselling represents an important determinant of the SES gradient in screening uptake. Compliance was shown to be closely linked to practitioner motivation also in the context of organised programmes

Knowledge of GP attitudes and preferences is therefore crucial in enhancing participation. A study based on semi-structured questionnaires addressed to 32 GPs in England (Woodrow et al. 2006) indicated that for GPs to effectively promote screening they must have adequate information prior to the start of a screening programme. The evidence should be based specifically on the effectiveness of the screening programme, and information on the proportion of false negatives and the proportion of false positives. 

Interventions aimed to promote provider involvement  

Provider education has been identified as a potentially effective intervention to promote CRC screening utilisation, even if the implementation of organisational measures may be necessary to achieve an impact of educational efforts (Stone et al. 2002). This conclusion is supported by the results of recent experimental studies: educational seminars offered to physicians did not show an effect on rates of CRC screening (Walsh et al. 2005), while a reminder note to the physician to direct his patients to perform an FOBT was more effective than a mail reminder and as effective as a phone reminder for the patients.

Even if GPs are not delivering kits, or not collecting or reading the test cards, they should be aware of how the programme, and in particular the invitation scheme, is structured. They can advise noncompliers about screening, which is important for older people, or for those with lower socio-economic status, and they can offer counselling for patients with positive tests. To facilitate this task, GPs should receive the results of screening and assessment tests performed by their patients 

Summary of evidence 

 Primary health care providers appear to be effective media for improving awareness of the risk of cancer and the benefits of screening, and increasing confidence in and countering the reluctance to take the screening test (I). 

 Educational interventions are less effective than organisational changes in improving the impact of physicians’ counselling on their patients’ screening rates (I).