Result card

  • ORG4: What kind of co-operation and communication of activities have to be mobilised?

What kind of co-operation and communication of activities have to be mobilised?

Authors: Principal investigators: Valentina Prevolnik Rupel, Nika Berlic Investigators: Dominika Novak Mlakar, Taja Čokl, Plamen Dimitrov, Marta López de Argumedo

Internal reviewers: Americo Cicchetti, Daniela D'Angela, Marco Marchetti

Acknowledgments: /

Analysis of selected studies extracted from the basic literature search. Seven articles were found to be relevant to this question and one document with guidelines. 


Communication is the primary tool for educating people about cancer risks and motivating them to seek out screening for early detection of cancer. Promotion of early cancer detection and screening often involves the use of communication campaigns, educational materials, and behavioural intervention programs {14}. There are positive effects of intrapersonal, interpersonal, group, organizational, and societal communications on cancer screening behaviours {15}.

Within the communication it is extremely important that the information is transferred and communicated to the information’s receiver in a proper way. Cancer communication messages must be therefore designed and delivered to match the communication skills, needs, and pre-dispositions of specific audiences. To influence entrenched health behaviours, messages need to be relevant and compelling, with health information that provides direction and rationale for making the best health-related decisions and adopting health-preserving behaviours {14}. A key component of CRC screening programmes, therefore, is the information and education provided about CRC and CRC screening tests and procedures: people who use CRC screening services should receive, through an appropriate communication, accurate and accessible information that reflects the most current evidence about the CRC screening test and its potential contributions to reducing illness as well as information about its risks and limitations {4}.

Co-operation and communication activities take place at different levels and between several actors. If we focus only on screening process itself, the following two relationships are the most important: a) patient/ participant and health personnel (i.e. medical and administration personnel), b) health personnel in intra- and inter-organizational level.

Provision of balanced, unbiased and quantified information about CRC (e.g. incidence, risk factors and symptoms) and CRC screening (benefits, harms and risk factors) is crucial for helping patients in making informed decisions. It is important that scientific evidence is used to develop patient information materials, and that this evidence is easily accessible for public consultation {4}. Several countries have patient information materials available on the national institution's web site. Receiving balanced, unbiased and quantified information related to CRC and CRC screening may be not sufficient for patients to make informed decisions; patients need also to be able to understand the information provided, to make a decision and to carry out their decision. Barriers/obstacles to informed decision making (IDM) may exist and may be related to:

·         the setting and the organisation of the CRC screening programme, such as the access and the availability of the screening service and the access and the availability of the screening information,

·         the knowledge, attitudes and practice of the CRC screening provider(s) and

·         the patient themselves: age, gender, physical or mental health problems, occupation, education or abilities to read or understand information.


To ensure participation in screening process and its suitable embodiment, with adequate communication process, European guidelines highlight the following recommendations {4}:

·         Developing communication strategies for an organised CRC screening programme is important to ensure that as many of the target population as possible receive the relevant information to be able to make informed decisions about whether or not they wish to attend for CRC screening.

·         Any framework developed to communicate CRC screening information must enable subjects to make an informed decision and should be underpinned by the four ethical principles of autonomy, non-maleficence, beneficence and justice;

·         CRC screening programmes should provide balanced, quantified and unbiased information about CRC (e.g. incidence, risk factors and symptoms) and CRC screening (benefits, harms and risks). Scientific evidence should be used to develop patient information materials and should be easily accessible for public consultation.

·         CRC screening programmes should identify the barriers, needs and facilitators to informed decision making of their target population (including specific groups). The information materials produced, including written instructions on how to use the FOBT kit or perform the bowel cleansing procedure, and the intervention(s) used must conform to these identified information needs and facilitators. The public should be involved in the entire process; from identifying barriers, needs and facilitators to developing information materials.

·         To communicate CRC screening information, including written instructions on how to use the FOBT kit or perform the bowel cleansing procedure, the language and text format used should be easy to understand and illustrations may be used. Ideally, written information (including written instructions) should not be the only source of information and should be complemented by visual communication instruments and/or oral interventions.

Organised screening programmes generally have three distinct "communication" phases throughout the CRC screening process, where information (general or person-specific information) can be provided to participants. For a CRC FOBT screening programme the following figure illustrates these three phases and the corresponding communication tools {4}:

·         The invitation phase: people are invited to participate in screening. Information for this screening phase is generally provided through invitation letters and leaflets. Written instructions on how to use the FOBT kit are usually provided with the kit;

·         The reporting results phase: people are notified of the results of their screening test. Information conveyed during this phase may be very sensitive and the communication tools must be carefully crafted to address the people‘s information needs;

·         The follow-up phase: only for people with a positive FOBT result, who require further assessment (colonoscopy). Usually information about colonoscopy is notified at the same time as positive results. This phase also involves information about management of the colonoscopy procedure;

In the invitation phase different contact strategies can be used: mailed contacts, mailed contacts and screening kits, office visit or all three together.

Figure 5: Communication tools in FOBT-CRC screening

pdf10936.ORG-4 Figure 5

Communication among professionals is essential in order to ensure that all the information coming from the prognostic tests is available quickly and is correctly interpreted. To achieve and maintain an effective communication between the various professionals of a colorectal multidisciplinary team it is essential that they participate to different training courses, which should be focused on good inter-professional communication. Joint courses given for the multidisciplinary team may facilitate this goal. Good communication should be carried out between the members of the screening team with agreed terminology, regular meetings and clinical discussions {4}. What is also extremely important is that the tasks among health personnel are clearly organized. The study of Rowe et al. indicates that the lack of communication and teamwork between the nurses and residents highly affected the rates of implementation of colorectal cancer screening {16}.

Although colorectal cancer screening is recommended by major policy-making organizations, rates of screening remain low. Studies examine different communication tool options to increase knowledge on colorectal cancer screening and also to its participation.

The study of Yoo et. al. {15} utilizes the Health Belief Model (HBM) that predicts individuals’ cancer screening behaviours. Building on the HBM, the study investigated how communication factors influence CRC screening. They have found out that media use for health information and interpersonal health communication had direct effects on both perceived CRC threat and positive expectations for CRC screening. The mass media has the capacity to disseminate effective, large scale, strategic messages for the promotion of cancer prevention. While mass communication is relatively more important in increasing awareness and knowledge of cancer-related risks, interpersonal communication channels provide rapid and continuous feedback, making them instrumental in persuading people to engage in a specific behaviour, including cancer-preventive behaviours. New communication technologies, especially the Internet, can be understood as integrated communication outlets that combine the broad reach of mass communication with the persuasive capabilities of interpersonal communication. The result of this study reveals that although communication factors were not found to have a direct impact on the stool blood test, they indirectly influenced the stool blood test through their influence on key components of the HBM. The use of mass media for obtaining health information positively affected perceived CRC threat that, in turn, led to positive expectations for CRC screening which finally resulted in the use of the stool blood test. In addition, mass media use for obtaining health information positively influenced the use of new media for seeking health information which, in turn, created positive expectations for colon cancer screening. The positive expectations ultimately resulted in the use of the stool blood test. Because communication factors are crucial determinants of these perceptions, it is essential to produce effective communication messages, which outline the risk of CRC as well as the benefits of CRC screening. The lack of awareness of the need for CRC screening and lack of knowledge about CRC is still the greatest barriers that make individuals do not be screened. Thus, health care providers need to be educated regarding appropriate communication approaches to encourage people to get screened for CRC. In addition, health campaign researchers should develop a variety of risk communication strategies to promote CRC screening. Irrespective of the evidence of positive impact of mass media and new media on individual’s behaviour, certain concerns about effective communication of colon cancer still persist. With the explosive growth of communication channels and the subsequent abundance of health information available to the general public, it may be difficult for people to judge the quality of the information they are exposed to. The Internet, in particular, has a strong potential to disseminate inaccurate or misleading cancer information. On the Internet, half of the links on CRC are commercially oriented – containing information on goods or private health services – while less than 1% of the available colon cancer information is being provided by healthcare professionals. The problem of cancer information overload is as overwhelming for the general public as well as physicians or patients. Because of the overwhelming amount of cancer information, individuals who paid less attention to, and who are less trusting of cancer information may overlook critical cancer information, and may not believe important or credible information. Therefore, those who are overwhelmed with cancer prevention information may require cancer messages that are structured as clearly, and as accurately as possible.

Kim et. al. in their study developed a patient-directed, computer-based decision aid about colorectal cancer screening and investigate whether it could increase patient interest in screening. A computer-based aid, which they have developed, differs from several other decision aids for CRC screening in that patients were able to interact with the aid via its modular format and choose to view information based on their knowledge needs. It is interactive and takes approximately 25 minutes of patient time. This computer-based decision aid on colorectal cancer screening increased patient interest in screening and subjectively improved knowledge about screening options {17}. The exactly same results were found from the study of Miller et. al. Through a randomized controlled trial they have measured the effectiveness of a web-based colorectal cancer screening in a mixed-literacy population. The results have shown that the CRC screening decision aid, called CHOICE (Communicating Health Options through Interactive Computer Education) increased test preferences and patients’ readiness to receive screening, irrespective of literacy level {18}.

A study of Cueva et. al. {19} reveals interesting interpersonal communication tool to provide CRC screening information, model ways to talk about CRC screening, increase comfort with talking about CRC, and encourage healthy lifestyle choices. It is called: “Readers’ Theatre”, a 25 minutes long script that was developed with and for Alaska Native and American Indian Community Health Workers (CHWs) and the people in their communities. Readers’ Theatre, within the context of this study, was the coming together of a group of adults to read aloud a written theatre script. Participants eagerly embraced this CRC Readers’ Theatre as a cancer communication tool. Readers’ Theatre created a comfortable, supportive environment of trust for adult learners to ask questions and discuss concerns, making learning relevant and meaningful. As reported by participants, Readers’ Theatre increased their knowledge, comfort talking about CRC, and appeared to serve as a catalyst for positive intent to change behaviour. The power of Readers’ Theatre as an innovative health communication tool lies in its ability to connect with people both affectively and cognitively, to share information in culturally respectful ways, to offer diverse perspectives, to actively engage participants in cancer-related conversations, and to serve as a springboard for action.

As already mentioned, patients are more likely to be screened, if this is recommended by the primary health provider. Therefore it is of great importance that providers have the information and access to the latest screening guidelines. The results, presented in the study of Redmond et. al. on effective communication of colorectal cancer screening information to primary care providers suggests that an effective dissemination of colorectal cancer screening information requires multiple approaches, which includes: e-mail from a trusted source, scientific journal articles, professional conferences and media campaigns. In addition, the information is well received when delivered periodically by trusted sources, such as medical colleagues, professional organizations and societies, and national research and advocacy agencies. Importantly, providers indicated that they would prefer receiving colorectal cancer screening update prior to the public to be best prepared for questions they receive from their patients. An ideal partner to venue and disseminate information is through comprehensive national programmes {20}.



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