Improving the Uptake of Colorectal Cancer Screening by Better Informing Non-Responders: The Work of Field Nurses in Primary Healthcare Settings

Key Contextual Factors

• National prevention and screening programs were activated in Croatia in 2007.
• A network of experts has been involved in the implementation of these programs, led by the Ministry of Health and Croatian Institute of Public Health, and coordinated by county coordinators.
• Field nurses are part of primary healthcare service provider team and these activities are a part of their regular work, with their own diagnostic-therapeutic procedures.
• Field nurses are managed locally, by health centers.

Key Components/Steps

• The program was implemented as part of the national prevention and screening programs since its inception in 2007, with further elaboration in 2015.
• Organization of training for field nurses includes raising awareness of their own contribution to quality improvement of the screening program and the approach to improve response rates by: initiating conversations with the target population group, identifying persons in need of help and advice, distributing testing kits, checking the list of people who never respond, submitting information to the county public health institutes, providing support and organizing group health education.
• Cooperation between field nurses and program coordinators and implementation stakeholders (county institutes of public health, general practitioners, specialists)
• Good information technology support (e.g., for collecting the (non-)response data)
• Available educational materials
• Evaluation is conducted with predefined reports which automatically generate the data in the database
• Once a non-respondent is identified, nurses access addresses and visit them, educate them on the program, and encourage them to participate and complete the stool occult blood test. They explain how to take specimens and teach them that there is not just cancer that can be detected, but also polyps as possible precancerous lesions. They give them an envelope with a questionnaire and 3 test-cards. The envelope is addressed to the specific county institute of public health, and postal expenses are covered by the State. In some rural areas where they do not have post cases, nurses even pick up cards with specimens and send it to public health institute.
• All the ethical/privacy issues are aligned with Croatian Personal Data Protection Law, and the registry is properly encrypted.
• The program involves already employed field nurses who perform these tasks as part of their workplace, so they do not receive additional pay for this type of work.

Main Impacts / Added Value

• The program reaches and motivates individuals who do not respond to screening invitations
• This type of health care is provided in the home of the individual, which therefore makes it accessible to all, and especially to the most vulnerable groups.
• Many people who no longer live in Croatia or have changed their address, but still are in the primary invitation database, are detected thanks to the field nurses. Field nurses check this information so their participation gets postponed until they return or until the new address is updated. This leads to a more accurate denominator for total number of screen eligible people and thus gives us a more realistic response rate (10% or more).
• Field nurses can update the screening participation database, but they usually refer it to the local coordinator. They fill that motivation as diagnostic therapeutic procedure (DTP) in their nursing application which is connected to central health database (CEZIH). According to that, local and national coordinators get data on how much of their activities has had an effect on the submission of stool specimens for CRC screening.

Lessons Learned

• The key success factor is teamwork between field nurses, county institutes of public health and general practitioners, and good organization of patronage care in terms of non-responder’s identification, as well as a personalized relationship that field nurses establish with their patients
• In order to provide the best possible care and response in terms of the CRC screening program, team members need to critically review challenging situations through dialogue and collaboration to arrive at optimal solutions
• System support is an imperative and coordinating institutions should continuously seek feedback from all key stakeholders involved in the process.
• Participation rates increased between 25% and 50% (meaning that the person accepted the invitation and got test cards) in counties where field nurses are involved in the screening process. However, the rate of people who actually submitted a specimen is not more than 32% to 35% in these counties. We observed that people mostly submit a specimen if they know a family member, friend or neighbour had and/or died from CRC.
• Involvement of field nurses in the implementation of the CRC screening program needs to be planned (and implemented) from the very beginning
• It is easier to implement programs like this in smaller countries

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