Barriers and facilitators to colorectal cancer screening intention and uptake: understanding and addressing patient and practitioner perspectives

Population-based asymptomatic screening tests can prevent bowel cancer and detect it at an earlier stage. NHS England launched a population-based screening programme for bowel cancer in 2006, called the Bowel Cancer Screening Programme (BCSP). A review by NHS England reported that the BCSP saves almost 9000 lives each year, through early diagnosis and prevention of bowel cancer. Yet levels of uptake of bowel cancer screening in England remain suboptimal. This thesis aimed to further understand the barriers and facilitators to participation in colorectal cancer (CRC) screening and to find potential ways to address these. Specifically, the understudied areas of CRC screening barriers and facilitators, flexible sigmoidoscopy and positive FIT follow-up colonoscopy examination in England were investigated. Through the synthesis of qualitative literature (Study 1) and interviews with patients and nurses (Study 2), patient anxiety was identified as a major barrier to participation in flexible sigmoidoscopy and positive FIT follow-up colonoscopy screening, experienced by patients throughout the screening pathway. Recommendations made by patients and Specialist Screening Practitioners (SSPs) to reduce patient anxiety included suggestions such as the earlier notification of the option for sedation to reduce any patient concerns of pain and discomfort (Study 2). The test of these suggested modifications to the BCSP invitation letter were however found to not be beneficial to patient reported expected levels of anxiety or behavioural intentions to screen (Study 3). Future research ought to seek feedback on tailored invitation materials based on people’s past screening experiences and do so among under-represented groups. The research undertaken in this thesis also experimented with the use of self-affirmation inductions as a novel theory-based intervention to improve responses to bowel cancer screening information materials, yet findings showed no effects on participant expected levels of anxiety, message acceptance or behavioural intentions to screen (Study 4). Cumulatively, the research findings from this thesis improve understanding of the effectiveness or otherwise of different novel interventions aimed at addressing key patient barriers to different modalities of CRC screening to improve uptake. The findings are promising and highlight the need for future research to endeavour to replicate the current results in larger and more representative samples.