Testing behavioral interventions to optimize participation in a population-based colorectal cancer screening program in Catalonia, Spain

Prev Med. 2019 Feb:119:58-62. doi: 10.1016/j.ypmed.2018.12.013. Epub 2018 Dec 28.


The aim of the study was to measure the effect of three cost-neutral behavioral interventions on participation compared to the standard invitation letter in a population-based colorectal cancer screening program in 2014. For that purpose, a four-arm randomized field trial was conducted among 5077 individuals aged 50 to 69 years. Over an 8-week period, each week was randomly allocated to the intervention or the control conditions. Individuals assigned to the intervention conditions additionally received a prompt to write down the date to pick up the screening test in a pharmacy. Two of the three intervention groups also included an additional paragraph in the invitation letter on either: 1) the high proportion of individuals participating regularly (social norms condition) or 2) the importance of regular participation (benefit condition). We measured screening participation before and after receiving a reminder letter six weeks after the screening invitation. An overall 8.0 percentage point increase in CRC screening was achieved as a direct result of receiving a reminder letter; however none of the intervention strategies influenced participation. The only significant difference was found for newly invited individuals. There, participation rates decreased from 34.9% to 24.2% when the invitation mailing mentioned the importance of regular participation (OR: 0.60; 95% CI: 0.38-0.95). While none of the intervention strategies improved participation rates we found that praising the benefit of regular screening may discourage individuals who have never been invited before as the continuous behavior may be perceived as a large request. Nevertheless, the reminder letter boosted participation rates independently of the intervention assigned.

Keywords: Behavioral interventions; Colorectal cancer screening; Participation; Reminder letter; Uptake.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Colorectal Neoplasms / diagnosis*
  • Early Detection of Cancer*
  • Female
  • Humans
  • Male
  • Mass Screening*
  • Middle Aged
  • Occult Blood*
  • Patient Participation / statistics & numerical data*
  • Postal Service
  • Reminder Systems*
  • Spain