A comprehensive evaluation of the different steps in the CRC screening is crucial for improving the quality of the process [20]. In programs where community pharmacies are the mainstay for delivery and collection, it is paramount to use a common information system to collect data, examine the timing of FITs distribution and check for errors. We focused on the analysis of pharmacy collaboration and kits distribution and return time to identify opportunities for improvement. In our cancer screening setting the engagement of community pharmacies is high. Eight out of ten pharmacies participated in the CRC screening program providing broad accessibility to pick-up and return FIT kits. Our findings contrast with other studies where the major barrier was poor collaboration of pharmacists to screening [21, 22]. This discrepancy may be explained by several unique features of our program: pharmacies have a training package; the CRC screening service is coordinated by the Official College of Pharmacists and the service is reimbursed. These conditions ensure that pharmacists are well suited and organized for the screening approach. The representation of collaborating pharmacies on a map provides a visual and prompt tool to highlight some suboptimal areas in which improvement interventions can be designed.
Successful and widespread involvement of community pharmacies in a CRC screening program provides additional user engagement data points, which can enable a more nuanced understanding of CRC screening behavior and inform new opportunities for targeted interventions and quality improvement. For example, we identified three broad categories of screening-eligible individuals: (1) those who picked up and returned a FIT kit; (2) those who picked up, but did not return the kit; and (3) those who did not pick up a kit. These could then be conceptualized using stage-based behavior change theories to inform targeted interventions, such as the Transtheoretical Model of Behavior Change (TTM) which has been used to understand and predict enhance of health-promoting behaviors [23], the Precaution-Adoption Process Model (PAPM) that focuses on reaching high-resistant groups [24], or the Health Action Process Approach (HAPA) [25].
When it comes to understanding screening participation for CRC, we identified two groups of non participants (i.e. the individuals who received the invitation but did not pick up a FIT kit and those who received an invitation and picked up the FIT kit but did not return it). In particular, more than half individuals who received an invitation did not pick up a FIT kit, whereas only a small proportion of those who picked up a FIT kit did not return it (5.5%). Low participation jeopardizes the benefits of the screening program and actions to improve participation improvement should be taken to achieve a participation rate of at least 45%, as recommended by the European Guidelines for Quality assurance in CRC Screening and Diagnosis [20]. Analyzing process outcomes can inform a more nuanced approach to improve screening participation. For example, it will be important to explore whether involvement of community pharmacies has become an unintentional barrier, as an additional step to CRC screening, for invitees who did not pick up a FIT kit. Our data can also be used to design and implement strategies targeted to individuals who demonstrate concern for screening by picking up a FIT kit at the pharmacy, which are more likely to be successful than strategies addressing to all non-participants [26].
Such interventions will enable balancing of promotion and improvement of participation in screening programs with the choice of individuals to be screened and other ethical aspects of screening. Moutel et al [27] highlighted the need to design strategies to improve participation taking into account the ethical aspects of individuals, such as the identification of subgroups with low participation, allowing the design of targeted actions. Improving cost-effectiveness of screening can also be addressed using targeted strategies, aiming to decrease the proportion of people who do not return the FIT kits as well as those who need more than one kit to complete the screening.
The time for returning the FIT kits to the pharmacy also provides important information that can be used to develop and implement targeted strategies for improvement. We identified several characteristics associated with differences in FIT completion times, which highlight population subgroups that may need additional support to complete screening. The median time of 3 days to return a complete kit in our study was shorter than the median time from order to return of 13 days reported in a study in the USA [28]. Interestingly, recent CRC screening and older age was associated with higher completion of FITs in that study, similar to ours. Overall, our results suggest that community pharmacists could assume a greater role in CRC screening, as part of an integrated screening program team and by providing key screening process data that enable a better understanding of CRC screening behavior, which in turn can help inform targeted intervention strategies to better address acceptance and appropriateness of cancer screening in real-world settings [29].
However, to enable the development and sustainability of such targeted strategies and appropriately document their implications for CRC screening, it is crucial that these programs are comprehensively evaluated employing study designs that can capture both effectiveness and implementation outcomes[30].
Strengths and limitations
To the authors’ knowledge, this is the first study evaluating the time between distribution and collection of FIT kits through community pharmacies after an individual receives an invitation letter to participate in an organized, population-based CRC screening program. Another strength of this study is that the evaluation of the role of pharmacies could allow designing targeted interventions to assess the feasibility of their implementation to improve screening. However, the authors are aware of some limitations of the study. There were a proportion of screening-eligible individuals who did not return the kit within the analysis period, but participated later. We were unable to discern if the returned kits were the same or if additional kit(s) were required.