38 Chapter 2 on their specific insurance plan. Since screening programmes may exacerbate socioeconomic and ethnic health differences,58 future studies are also needed that address this topic. In this review we not only looked at the three Dutch CSPs individually, but also compared the outcomes of these CSPs. This allowed us to compare characteristics of non-attenders and determinants of participation. Of the three Dutch CSPs, cervical cancer screening shows the lowest attendance rates. In the literature some explanations were offered for why women often fail to attend the cervical CSP. However, a possible explanation for the low uptake might be that a cervical examination remains a greater taboo compared to examination of the breast. An additional explanation might be the concrete appointment arranged by the breast CSP, whereas in the cervical CSP women have to make an appointment with their GP themselves. An advantage of the CRC CSP compared to the cervical CSP is that the CRC faeces test can be completed at home. In 2017 a self-sampling test for HPV infection was introduced within the cervical CSP. The self-sampling test has shown to have high concordance with physician-taken sampling for hrHPV detection and was found to be highly acceptable to women.59 It would be interesting to see the effect of this self-test on participation rates among the different cervical CSP attendance groups. While the self-sampling test appears promising, we think there is still room for improvement. Women are only informed about the possibility of a self-sampling test in the initial invitation letter from the screening organisation. An application form to actually order the self-sampling test is only attached when a re-invitation has to be sent. Therefore, women themselves still have to take the initiative in order to receive a selfsampling test at home. It would be more logical to include an application form with the initial invitation letter and to include the self-sampling test together with the re-invitation for women who have not yet responded to the first letter. A similar proposal has already (partly) been made by the Health Council of the Netherlands.60 Besides the different tests used in the three Dutch CSPs, there are also clear differences in the occurrence of the different cancers. Per year 700-800 women are newly diagnosed with cervical cancer, whereas the incidence of breast and CRC is far higher at 16.000 and 13.000 cases per year, respectively. A higher incidence means that people are more likely to be aware of breast and CRC, or to know someone who has had breast or CRC compared to cervical cancer. In conclusion, although the three CSPs in the Netherlands generally have high attendance rates, large differences are present between different regions and subpopulations. The I-Change model highlighted many knowledge gaps in determinants of (non-)participation and identified opportunities for improvement. Current studies tend to focus on attendances rates and the general characteristics of (non-)attenders, but rarely provide in depth information on determinants of (non-)participation. We therefore feel that more
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