194 Chapter 7 Chapter 5 explores potential strategies for addressing unique barriers faced by a small, in particular, high-risk subgroup in participating in a CSPs. Lastly, Chapter 6 reveals that primary healthcare providers (GPs) themselves are inclined to be (more) involved in the current CSPs, hence potentially serving as key enablers for incorporating PHM principles within the screening programmes. As the studies within this thesis show, we believe that the current CSPs could benefit from making use of PHM principles, in which primary healthcare providers are given a more prominent and proactive role. As the studies in the thesis are all conducted in highly urbanised regions of the Netherlands, it would make sense to see if a pilot-study can be set-up within this region. Effective integration of PHM principles should be done in close collaboration with the national screening organization, primary healthcare provider organizations, and ideally with some level of political support. For risk stratification I envision a prediction tool, based on characteristic out of the Electronic Health Records (EHR) that provide insight into the degree of risk an individual faces concerning one of the screening specific tumours, similar to the frailty index score for the elderly.80 Conclusion This thesis provides additional evidence that the current population-based cancer screening programmes (CPSs) of the Netherlands could be further optimized, in particular regarding the screening uptake of people living in highly urbanized and/or low(er) socioeconomic status (SES) neighbourhoods. Our findings suggest that nonattendance in these lower SES-neighbourhoods is associated with more unfavourable, relatively late-stage, tumour diagnosis. Given that participation in cancer screening is not solely based on rational decision-making, primary healthcare providers could play an important role in educating and advising individuals who are eligible for participation in the CPSs. We found that both screen-eligible people and general practitioners (GPs), support the idea of a more targeted GP-involvement in the CSPs. Based on the findings of this thesis, we recommend that a proactive primary care approach would be suitable to enhance the current cancer screening uptake, with the ultimate goal to screen (sub) populations who are highest at risk of developing the screening-specific tumours.
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