32 Chapter 2 With respect to the CRC CPS a study adding extra instructions and information and addressing specific concerns should be considered in order to improve informed decision making about participation.45 Since January 2018 a GP no longer receives an automatically generated message in case of a pathological result, although patients are encouraged to seek contact with their GP.27 Awareness factors Several studies identified the lack of knowledge as a determinant of non- or lowattendance.31,37,42,46 Cervical CSP non-attenders felt that they had a lower risk of developing cervical cancer and were more convinced that cervical cancer cannot be cured.31,40,44 A study among non-native Dutch found that all respondents recognized their susceptibility to CRC, but their knowledge of CRC and the CSP were limited.42 Attending the CSP was a low priority, and limited concerns about health in general and serious concerns regarding safety were additional reasons for non- or low-attendance.29,45,46 With respect to the cervical CSP, self-sampling might be a solution for non-attenders because of convenience and self-control.29 Most often non-attenders reported they forgot to schedule an appointment.29 At the CRC CSP non-attenders thought that mainly individuals in poor health and with (cancer) symptoms would benefit from the programme. Knowledge of potential harm associated with CRC CSP was also low.42 Motivational factors Non-attenders of the cervical CSP were less motivated, less often inclined to undergo future screening and experienced greater negative social influences. They reported negative role models and talked less with other people about the CSP.44 Self-efficacy was identified as an important determinant for CRC CSP attendance.42 A positive remark could be found in the quick uptake and adherence of the CRC CSP. A study by Toes-Zoutendijk underlined the importance of real-time monitoring. Only a few months after implementation of the CRC CSP, participation and positive test results were higher than predicted, whereas the positive predictive value was lower than predicted. To reduce the burden of unnecessary colonoscopies and improve colonoscopy capacity, the cut-off level for a positive FIT result was adjusted and a cut-off level of 47µg Hb/g faeces is currently being used in the Netherlands.43
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