Last reviewed: 28 March 2024
Last reviewed: 28 March 2024
Bowel cancer screening uptake is lower than other national cancer screening programmes, and there are inequalities between areas and across different demographic groups. In the UK, although gaps in data availability persist, there is evidence that the following groups may be less likely to participate in bowel cancer screening:
People with lower socioeconomic status
Men
People from non-white ethnic communities
People who do not read or write English or where English isn’t their first language
People with learning disabilities
People with physical disabilities
People with sensory impairment
People with severe mental illness
People invited for the first time
Taking part in screening is an individual choice, but it must be a choice that is equally available to all.
We believe it is crucial to reduce inequalities in cancer screening uptake and as a minimum ensure that interventions do not exacerbate inequalities. We have developed a guide that offers practical tips to help reduce inequalities, as well as signposting to further resources and information.
Reducing inequalities in cancer screeningUnderstanding who is not attending screening and the barriers preventing them from participating is important when looking at ways to support engagement with the programme. The reasons for non-attendance may be complex and several factors may be at play.
The latest evidence, barriers, and resources to support discussions with your patients around informed participation in bowel cancer screening:
Fear and denial around the test outcome
A misconception that the test is not applicable if you don’t have any apparent symptoms of bowel cancer
Concerns around the practicalities and cleanliness of the test
Individual perceived risk being low or consideration of future consequences of bowel cancerThe fact that it takes place away from the usual health care settings
Low health literacy and numeracySome people face barriers further on in the screening pathway after receiving a positive FIT result and may decide not to attend further tests such as a follow-up investigative colonoscopy.
Health professionals play an important role in providing information to support people to make an informed decision about attending any further tests. Barriers have been researched
:Concerns about the procedure (concerns about doing the bowel preparation and fear about pain and discomfort)
Anxiety and denial about what might be found
Cognitive abilities and ability to make an informed decision
Perceived risk and perceived mortality
There is evidence to suggest that inequalities in screening colonoscopy attendance exist, with some groups experiencing more barriers to attending, including those from a non-white ethnic minority, and/or from areas of higher deprivation
.To help overcome these barriers and improve uptake, primary care health professionals and the wider practice team can be available to have conversations with patients about what a colonoscopy is and what it involves. They should be able to discuss what a person might expect before, during and after their appointment, and able to talk through any concerns a patient may have around attending a colonoscopy. To support you with these conversations, access our patient-facing information on colonoscopies.
Evidence suggests that there are interventions that can support an increase in participation of bowel cancer screening, while promoting informed consent. Research shows that primary care involvement can significantly increase participation in bowel cancer screening
.Our bowel cancer screening good practice guide(PDF) offers practical advice, which primary care professionals across the UK can use to support people to make an informed decision about participating in bowel cancer screening. The guide also contains a sample telephone script, a GP-endorsed letter template, and a template text message reminder, which you can use to engage with your eligible patients.
A GP-endorsed letter, or enhanced patient leaflet alongside the screening kit appear to have the largest effect on bowel cancer screening uptake. When combined, these interventions increase uptake by up to 12%
.A study by Raine et al. provides further evidence for the effectiveness of GP endorsement in increasing bowel cancer screening uptake. This large-scale study included 80% of GP practices in England, added a simple GP endorsement banner to the standard screening invitation letter. Overall uptake increased by 0.7%, which although appears to be a small increase, could mean up to 40,000 extra people screened if rolled out nationally
.The Practice Endorsed Additional Reminder Letter (PEARL) project similarly assessed the impact of GP-endorsement on bowel screening uptake, this time in the context of a reminder letter. Overall, bowel screening uptake was 3% higher in practices which used the intervention, compared to other practices which did not
.Shown to increase uptake by around 8% and 5% respectively, when used in combination with a GP endorsement letter which was sent 2 weeks after their screening due date
. The project that incorporated these activities took place in areas of low socio-economic status and high ethnic diversity, suggesting potential to address inequalities in screening uptake.Enhanced reminder letters with a banner have not only shown to increase uptake, but also reduce the socio-economic gradient in bowel screening uptake
. The enhanced version of the leaflet directly addresses perceived barriers to completing the test and provides practical tips.This strategy is supported by previous research showing that providing detailed instructions on the collection, storage and return of screening kits can increase the proportion of people taking part
. The content was developed with advice from an expert steering group and was extensively piloted.Download the data on Increasing bowel screening uptake through local interventions (XLSX).
Evidence has suggested that text reminders increase uptake in first time invitees, although it does not appear to improve overall uptake. The use of text reminders is increasing, and further evaluation will enable us to understand their role in supporting bowel screening uptake
.For example, iPlato have been funded by the NHS and Small Business Research Institute (SBRI) to address uptake inequalities and improve bowel cancer screening uptake in South East London, in partnership with the South East London Cancer Alliance (SELCA). We hope this research will build our understanding of the role of text messages in bowel cancer screening uptake.
Text reminders have also been shown to be effective in other cancer screening programmes.
In Phase 1 of the Improving Bowel Cancer Screening Project, all GP practices in Pennine Lancashire were asked to contact 5+ patients who had not responded to their screening invitation. They chose to either telephone or send a letter, or discuss opportunistically face to face during a consultation.
The practices were asked to review these patients 3-4 months later to see if they had subsequently attended, and review the result. GPs were also provided with an information pack and training.
Key findings:
Practices were incentivised to take part. Any that demonstrated innovative methods of increasing patient participation were eligible to apply for additional payment
Approximately 76 practices returned figures which were then collated and summarised 1,009 patients who had not initially participated in bowel screening were contacted
15.9% of patients subsequently requested replacement bowel screening kits and returned them to the screening hub
Subsequent participation was more likely if there had been face to face discussion (35%) than telephone advice (20%), letter (11%) or unknown method of contact (8%)
Location: Pennine Lancashire, Blackburn with Darwen and East Lancashire CCGs
Date: 2014/15
Contact: Dr Neil Smith, Cancer Clinical Lead, neil.smith2@nhs.net
Read the report on the bowel screening uptake project in Pennine Lancashire(PDF)
Read the presentation on the Pennine Lancashire bowel cancer screening initiative(PDF)
In Phase 2 of the project in Lancashire, more links were established between the Bowel Cancer Screening Programme hub (for the North West & Midlands) and each GP Practice via the EMIS web record system.
This enabled the direct electronic transfer of registered patients’ bowel screening results from the hub to each practice and also the option for practices to order a replacement test kit on behalf of a previous non-responder via email. Practices were similarly incentivised to take part in Phase 2 of the project.
Key findings:
Preliminary data (as at February 2017) shows that 729 requests were made for replacement kits and 317 patients (44%) completed them, 7 abnormal results were recorded from 38 practices
The project demonstrates that a large regional screening hub based in an acute hospital setting can work collaboratively with primary care professionals at a local level to achieve health improvement and a good outcome
Phase 3 of the project will build on the work already achieved, sharing evidential learning with others and expanding as appropriate
Location: Pennine Lancashire – Blackburn with Darwen and East Lancashire CCGs
Date: 2016/17
Contact: Dr Neil Smith, Cancer Clinical Lead, neil.smith2@nhs.net
Read the report on improving bowel cancer screening uptake in Lancashire(PDF)
The ‘Call for a Kit’ intervention was set up in Lancashire to address previous non-responders. Those who have not completed the kit are invited to an appointment at their GP practice with the BCSP health promotion team. They are shown the kit and a DVD on how to complete it. Questions and anxieties are addressed, and if they agree to complete the test and require a replacement kit, the team phone the screening hub and order a kit on their behalf.
Key findings:
84% of people invited to the clinic actually attend in person; 91% of people attending the clinic have a kit ordered; 58% of people who attended subsequently completed the kit
Gender specific clinics were also offered to patients, this worked well and helped subjects overcome issues around cultural dignity, discussing sensitive body parts and aided discussions on how to collect poo
The clinic offered 5 different languages to engage with patients who actually attended
Next steps include running the Call for a Kit clinics in next cohort of lowest uptake GP practices in each CCG
Location: Lancashire
Date: 2015/16
Contact: Shahida Hanif, BCSP Health Promotion Specialist, shahida.Hanif@bfwhospitals.nhs.uk
Read the Call for a Kit update report(PDF)
Read the Call for a Kit evaluation(PDF)
A community-led engagement campaign (the Cancer Collaborative) was set up in North East Lincolnshire to work with healthcare professionals and to raise awareness of the signs and symptoms of cancer. When the bowel screening programme started, the activity was extended to include messages around screening. It draws upon the local experiences and knowledge of communities and practitioners to identify a wide range of solutions that will work locally.
Key findings:
Marketing and community involvement materials were developed following audience testing
Badges and stickers which could be worn by health professionals were developed and used as a prompt for conversation with patients
Bowel screening uptake in North East Lincolnshire increased from 55.2% in 2008 to 59.9% in 2013
Consistent ‘reminding’ of the key messages to the local target population has been seen to increase uptake in bowel screening
In planning for the future, the team continue to monitor activity and work with primary care to focus on low uptake areas.
Location: North East Lancashire
Date: 2015
Contact: Julie Grimmer, Collaborative Programme Manager, julie.grimmer@nhs.net
Read the Early Presentation of Cancer Symptoms Programme in North East Lincolnshire report(PDF)
Four 99p Stores in Merseyside were chosen to run a bowel screening awareness campaign based on their central locations, and due to their diverse population customer group. The campaign included awareness messages printed on the reverse side of till receipts, which were used at the main till banks. The till receipt included messaging such as: ‘Over 60? Do your bit – return your screening kit. Bowel screening saves lives.’
Key findings:
Till receipt campaigns can be a low cost option to marketing awareness messages
There were a number of limitations with the project, which included: difficulties with evaluation e.g. linking increases in participation directly with the campaign, other campaigns running at the same time
It is recommended that healthcare partners pay close attention to contracting, ensuring all parties are clear on their commitments and expectations from the start.
Location: Merseyside
Date: 2014
Contact: Marie Coughlin, Screening and Immunisation Manager, marie.coughlin@nhs.net
Read the Till Receipt Awareness Campaign report(PDF)
The barber’s project in Blackburn with Darwen was developed, facilitated and delivered by Sadiq Patel who is a BCSP Community Engagement Officer. Ten barbers were recruited to take part in the pilot within two low uptake, high ethnic minority areas. The barbers were supported to plan one week’s bowel cancer screening campaign within their salons and record data on the numbers engaged. They also recorded the key issues raised by local communities.
Key findings:
The project was incentivised and barbers received an award once the project was completed
Trained volunteers were involved in raising awareness at the barber shops during peak times, including holding weekly information stands in each shop
Over 1,600 men were engaged within the salons by the ten barbers (1,099 of these men were below 60, and 671 were between 60-75)
The project allowed for 1,770 bowel screening materials to be distributed Utilising barbers in engaging with specific communities was seen to be worthwhile.
Location: Lancashire, Blackburn and Darwen CCG
Date: 2014
Contact: Sadiq Patel, BCSP Community Engagement Officer, Sadiq.Patel@bwdcvs.org.uk
Read the Darwen Barbers Pilot Project report(PDF)
Cancer Research UK (2020). Cancer in the UK 2020: Socio-economic deprivation(PDF) Accessed August 2023.
Public Health Wales (2022). Screening Division Inequalities Report 2020-21 Accessed August 2023
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