187 General discussion enhance the health of marginalized women in these cities. Regarding our findings in Chapter 6 it would be interesting to see whether the results would differ if new or more interviews were conducted with GPs practicing in (more) rural regions of the Netherlands. Implications for researchers, clinicians, and policymakers The studies presented in this thesis can yield various implications for different stakeholders involved in the field of the Dutch cancer screening programmes (CSPs). In the following sections, I will delve into our findings, outlining their specific relevance for researchers, clinicians (GPs and other primary healthcare providers), and policy makers. Implications for researchers In the preceding chapters, comprehensive recommendations for further research have been provided based on the individual studies conducted. The main common denominator is that we showed that still more detailed information is needed on screening-eligible individuals residing in lower socioeconomic status (SES) neighbourhoods. People living in these lower SES-neighbourhoods happen to be at a higher risk of developing screening-specific tumours, wherefore potentially the greatest health benefits can be achieved in these subpopulations. Although our research showed interesting findings concerning differences, future researchers should look further into these issues. Appropriate methodologies suitable for people with lower SES are needed to make that possible. For this purpose collaboration with a knowledge institute like Pharos is highly recommendable.27 Building upon the findings in Chapter 5 and existing international literature, it is strongly advocated to make use of proactive, face-to-face strategies to engage with individuals in low(er) SES-neighbourhoods.28, 29 A related recommendation would be that future researchers take factors as ‘(low) literacy’ and ‘health illiteracy’ into account. As we highlighted in Chapter 2 these factors seem to be of high importance when it comes to screening attendance. Here it is worth mentioning that currently in the Netherlands, 2.5 million individuals (aged ≥16 years) have low literacy skills, and one in four (25%) Dutch people possess limited health skills.30 Both low literacy as health illiteracy are known to be more prevalent among those with lower educational attainment, elderly, and migrants.31, 32 In addition are these issues known to have a burden on health outcomes, among others also on the incidence of cancer.33 Knowing this, the new changes to the cervical CSP (for instance sending self-tests) might be less appropriate for people who have low literacy levels, possess low health literacy skills. It is precisely among these groups that you hope to optimize the attendance rates but might not benefit at all from the innovations in the CSP. Subsequent and related are also cultural factors, as a recent study among Moroccan-Dutch women clearly showed. 7
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