16 Chapter 1 Objective and outline of this thesis The overall aim of this thesis was to identify cues that might contribute to optimizing the current attendance rates of the cancer screening programmes (CSPs) in the Netherlands, with a focus on the potential role of primary care. We explicitly use the term ‘optimize’, as it was not our intention to conduct studies with the main aim of increasing screening attendance. The presented studies in this thesis have the overarching goal to identify ways to screen screening-eligible people at highest risk, i.e., people who are a priori most likely to develop (one of) the screening-specific tumours. We stated our hypothesis as follows: where current CSPs handle a ‘one-size-fits-all’ approach, with a limited role for primary care and GPs, it may be more beneficial, also with respect to the sustainability of the CSPs, to shift to a more targeted approach for subpopulations at relatively higher risk, and with targeted and/or more sophisticated involvement of primary care health professionals and healthcare centres to support such a new approach. In order to test this hypothesis, we conducted several studies using different research designs and focussing on most relevant stakeholders (screening-eligible people and GPs) and the determinants of participating. The challenges mentioned in this introduction concerning CSP participation, and as illustrated by the case of the Janssen family will be addressed in this thesis. Presented studies are part of the Screening the CITY project, whereby CITY is also an acronym for: ‘Cancer screening In The Hague. The influence of social and cultural determinants and health literacY on decision making’. Chapter 2 provides a systematic overview of the literature regarding determinants of attendance and non-attendance at the CSPs in the Netherlands. This study served as an ideal starting point for this thesis by identifying current knowledge, and knowledge gaps. In Chapter 3 we compared the CSPs aiming at breast and colorectal cancer in the city of The Hague, in order to understand the background of differing attendance rates and incidence data over a longer period of time. Hereto we gained a data-driven understanding of where possible future optimalisation strategies would be needed most. Chapter 4 presents in-depth perspectives and beliefs of screening-eligible people in The Hague, concerning cancer screening attendance. Through these perspectives and beliefs, we learned what is (most) important to screening-eligible people when it comes to participating in CSPs. In Chapter 5 we described how important and effective a targeted proactive primary care approach can be for a specific subpopulation. We were able to conduct a cross-sectional intervention study among marginalized women in the city of Rotterdam. Chapter 6 describes the perceptions and beliefs of GPs concerning their role and involvement in the CSPs of the Netherlands. Finally, Chapter 7 summarizes the findings of this thesis and discusses methodologic considerations, implications, and recommendations for future research.
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