36 Chapter 2 Discussion This systematic review describes all known determinants of (non-)participation for the three Dutch cancer screening programmes (CSP). Studies tend to describe the more general characteristics of (non-)attenders, but rarely provide in depth information on other factors of (non-)participation. The I-Change model proofed to be a useful tool in mapping current knowledge on cancer screening attendance and revealed knowledge gaps regarding determinants of (non-)participation at the CSPs. Many studies reported on predisposing and information factors giving a general well understanding of these determinants. Factors on awareness, motivation, ability, and barriers were less often studied. By using a theoretical framework designed to explain health behaviour, the I-Change model47, we could systematically summarize and merge all information from the identified studies. Similar to other reviews, we were only able to take published literature into account, which could result into a publication bias. We choose for a health behaviour model since screening attendance can be seen as health behaviour. The I-Change model is a widely used and accepted theoretical framework to evaluate health behaviour.20-22,48 The I-Change model states that behaviours are determined by a person’s motivation or intention to carry out a behaviour, which is in turn the result of a person’s intentions, abilities, and barriers. Attitudes, social influences, and self-efficacy expectations influence a person’s motivation and are determined by various distal factors, such as predisposing (e.g., current lifestyle), information (e.g., source of delivery), and awareness (e.g. knowledge) factors. To the best of our knowledge this is the first review to use this approach to summarize available information on determinants of participation in CSPs. The I-Change model allowed us to identify knowledge gaps and so highlight opportunities for improvement. For a CSP to be effective high participation rates are essential. The attendance rates for the two long-term CSP programmes in the Netherlands, cervical and breast cancer, are declining. The attendance rates of the cervical CSP are especially low and are below the 70% target which is seen by the WHO as the minimum effective rate. Furthermore, attendance rates show wide variation between regions and subpopulations. Lower attendance rates were found among those belonging to a low-SES group, living in more urban regions and among people who were not born in the Netherlands (in some studies referred to as ‘non-native Dutch’ and in others as ‘non-Western immigrants’). These figures are in line with earlier published reviews.49-51 Furthermore, younger women show lower attendance rates at the cervical CSP, and men in general show lower attendance
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