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Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer
  1. N Hall1,2,
  2. L Birt3,4,
  3. C J Rees5,6,
  4. F M Walter3,
  5. S Elliot7,
  6. M Ritchie6,
  7. D Weller8,
  8. G Rubin1
  1. 1School of Pharmacy, Medicine and Health, Durham University, Stockton on Tees, UK
  2. 2Faculty of Applied Sciences, University of Sunderland, Sunderland, UK
  3. 3Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  4. 4University of East Anglia, Norwich, UK
  5. 5South Tyneside NHS Foundation Trust, South Shields, UK
  6. 6South of Tyne NHS Bowel Cancer Screening Centre, Queen Elizabeth Hospital, Gateshead, UK
  7. 7Lay Member of Steering Committee, Gateshead, UK
  8. 8Cancer Research Centre, Edinburgh University, Edinburgh, UK
  1. Correspondence to Professor Greg Rubin; g.p.rubin{at}


Objective Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening.

Design Qualitative analysis of semistructured in-depth interviews and written accounts.

Participants and setting People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location.

Results 20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life.

Conclusions Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.

  • screening
  • colorectal
  • cancer
  • flexible-sigmoidoscopy
  • non-participation

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Twitter Follow Greg Rubin at @GregRubin4

  • Contributors GR was the chief investigator. GR, CJR, FMW and DW made substantial contribution to the conception and design of the study. NH and LB undertook review of literature, recruitment, data collection and data analysis. All authors were involved in the conduct of the study and reviewing data. NH wrote the draft of the manuscript, and all authors contributed to developing this draft and approving the submitted paper. GR is the guarantor.

  • Funding This study was funded by The Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis, which receives funding for a research programme from the Department of Health Policy Research Programme. It is a collaboration between researchers from seven institutions (Queen Mary University of London, UCL, King's College London, London School of Hygiene and Tropical Medicine, Hull York Medical School, Durham University and Peninsula Medical School). Grant number: PR-UN-0409-10041.

  • Competing interests None declared.

  • Ethics approval NHS Bromley NRES Committee (14/LO/0207).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data sets are held by the chief investigator ( Data sharing consent was not obtained. All data are anonymised with a low risk of identification.

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