37 Determinants of (non)attendance at the Dutch CSPs at the CRC CSP. The latter issue was also addressed in an earlier review on CRC CSPs worldwide by Navarro et al.52 While several studies have described attendance rates and the characteristics of (non-)attenders, in depth analyses of why people do or do not participate in a CSP are scarce. During our analysis it became clear that while many studies have focused on low attendance groups, little is still known on why these groups fail to attend CSPs and even less is known on why individuals from high attendance groups actually attend CSPs. When we considered various elements of the I-Change model, we were unable to find any studies on the sub-elements’ psychological factors (predisposing factors) and message factors (information factors). With respect to the other (sub)elements of the I-Change model, most were only addressed in one study and/or in relation to only one CSP. One study by Hartman et al. attempted to interpret knowledge derived from research on the cervical CSP to explain factors concerning the breast CSP.49 The sub-elements under the predisposing factors are most often reported as characteristics of the non-attenders. As our focus was on Dutch CSPs, determinants of (non-)participation described in international studies of CSPs were excluded. Although several countries have comparable CSP to the Netherlands, every country has own and unique screening programs adapted to their health system and population. As these inter-nation-differences would cause a problem comparing results we choose to focus only the Netherlands. Some international reviews, however, have focussed on determinants not yet studied in the Netherlands, for example the sex of the screener, the presence of symptoms and the existence of family conflicts.53-55 Additionally, lessons learned throughout this review might also be applicable to other European/Western countries. In the Netherlands, the involvement of the general practitioner (GP) in the CSPs has decreased over the past five years. However, it is clear, at least for the cervical CSP, that direct involvement of the GP results in higher attendance rates, especially among the high-risk groups (high cancer risk in known low-attendance groups).30,31,39 Whether this involvement should be (re)introduced is a matter of debate, but at the very least a more prominent GP role in informing and activating people to participate in CSPs could be further explored. The importance of such a role for GPs is highlighted in several international studies, with highest beneficial effects for the lower socioeconomic and minority groups.56, 57 It is often said that financial barriers are irrelevant in the Netherlands,34 but this is only partly true. While participation in a CSP is free, whenever follow-up research is needed, a patient will have to cover a part of the cost of follow-up research themselves, depending 2
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