Improving National Bowel Screening participation through primary care engagement: a quality improvement report
John McMenamin
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Abstract
The National Bowel Screening Programme (NBSP) in Aotearoa New Zealand aims to reduce bowel cancer mortality through early detection. Despite this, participation remains lower among Māori and Pacific peoples. In 2023 and 2024, primary care-led campaigns were introduced to support general practices to engage eligible patients in screening discussions.
General practices had varied levels of engagement with reminder systems and resources, and many lacked consistent processes for incorporating screening into routine consultations. To address this, tailored materials and practice support tools were provided.
Campaign participation included a substantial number of New Zealand practices, including engagement of Very Low-Cost Access (VLCA) clinics. Overall, the volume of faecal immunochemical test (FIT) kit requests more than doubled over 2 years; however, return rates remained modest, highlighting the need for additional follow-up strategies.
Future efforts should focus on expanding reminder systems, enhancing practice workflows, and incorporating outreach support to increase kit completion rates.
Structured primary care interventions can boost screening uptake, particularly among equity priority groups. Sustained improvements in screening participation will depend on system integration and continued support for practices and communities.
Keywords: Bowel cancer screening, FIT kit, health equity, Māori health, opportunistic screening, Pacific health, practice-based intervention, primary care.
WHAT GAP THIS FILLS |
What is already known: Māori and Pacific peoples in Aotearoa New Zealand have historically lower participation rates in the National Bowel Screening Programme, despite the programme’s proven effectiveness in reducing bowel cancer mortality. Opportunistic conversations initiated by trusted primary care providers, especially general practitioners, are known to increase screening participation and are supported by existing reminder and faecal immunochemical test (FIT) kit request systems in general practice. |
What this study adds: This study shows that structured primary care campaigns can increase FIT kit requests, particularly among Māori and Pacific patients, with a 134% increase over 2 years. The study also highlights the persistent gap between increased FIT kit requests and actual kit return rates, underscoring the need for targeted follow-up interventions and further system support to improve patient follow-through. |
Background and context
The National Bowel Screening Programme (NBSP) is a publicly funded initiative in Aotearoa New Zealand offering free biennial bowel screening to eligible individuals aged 60–74 years. The programme aims to reduce bowel cancer mortality through early detection. Eligible participants receive a faecal immunochemical test (FIT) kit by mail and are encouraged to complete and return it for analysis. Coordination of kit distribution and follow-up is managed by a National Coordination Centre (NCC), with oversight from Te Whatu Ora – Health New Zealand. The programme has proven effective in reducing bowel cancer morbidity;1 however, Māori and Pacific peoples have consistently been underserved by the programme with lower participation rates since its implementation, limiting full benefit from the programme’s life-saving potential.2 Public media campaigns have helped improve Māori and Pacific people’s participation by reinforcing consumer-tested key messages, such as the test being ‘free, quick, clean, and easy to do at home’ (Unpublished NBSP Campaign Report Puhimoana Ariki Collective 2023). Healthcare professionals, particularly general practitioners (GPs), are consistently identified as trusted sources of information for Māori and Pacific peoples, and studies highlight their role in encouraging screening participation.3–5 A sector analysis of cancer screening programmes within New Zealand primary care has encouraged the use of opportunistic interventions, and during the NBSP implementation phase, it was demonstrated that that opportunistic conversations with GPs can boost patient participation.6,7
In 2023, the NBSP developed a primary care-based campaign, resulting in insights gained from that project being applied to a follow-up campaign in 2024. The campaigns sought to encourage primary care teams to discuss screening opportunistically with eligible Māori and Pacific patients. Resources were developed with the Māori and Pacific media campaign team and included an educational flip chart based on consumer-tested messages. In 2024, in response to practice requests, demonstration kits were provided as a means of explaining and familiarising patients with the screening test. Most practices had reminder tools with the practice management software (PMS) that identified the screening status of the patient whose notes were open. Where available, practices were also encouraged to use appointment scanner tools to identify patients on appointment lists eligible for screening. Most practices had access to and requested tests for patients using an electronic FIT kit request tool.8
Assessment of the problem
Opportunistic reminders are widely available in New Zealand general practice and include a portal (the tuku tool) to request a bowel screening kit for patients. Baseline portal data identify variable use of reminders among providers and health districts, highlighting opportunities to increase opportunistic conversations by providing additional resources to practices.
The campaigns were structured around an observational, descriptive approach to assess the impact of the campaign. Practices were invited to participate through district NBSP leads and a national newsletter. The 2023 campaign offered two modes of engagement: active, which involved the use of flip charts to facilitate patient discussions, and passive, which involved displaying posters to raise awareness. Feedback from practices in 2023 led to the introduction of demonstration FIT kits in the 2024 campaign to better support patient understanding. Practices were provided with the resources but were free to decide on how to use them.
As this was a quality improvement project using de-identified patient data, patient consent and ethics approval was not required.
Results
Registration data were collected on practice enrolment and on the use of reminder systems. NBSP data were available for FIT kit requests, kits sent out and kits completed, allowing for comparisons across different health districts.
Of the 1,239 general practices in New Zealand, 379 (30.6%) enrolled in the 2023 campaign, with 264 (70%) opting to actively engage by using flip charts. In 2024, 290 practices (23.4%) enrolled, with active enrolment being the only option offered. A targeted focus in 2024 led to higher engagement among Very Low-Cost Access (VLCA) practices, with 34.9% participating, compared to 20.2% of non-VLCA practices. Although VLCA practices comprise only 22% of all New Zealand practices, they accounted for 32.8% of all campaign enrolments.
Among the 257 general practices that completed the 2024 survey, 74% reported using a reminder system to encourage patients to participate in bowel screening. Practices using these systems were more likely to engage patients in opportunistic conversations about screening, although the use of such systems varied across districts. Sixty practices reported having access to an appointment scanner, and of those, only 20 used it regularly for bowel screening. Most practices in 2024 (86.6%) expressed interest in using demonstration kits. However, although 65% indicated a willingness to follow up with patients to ensure completion of the FIT kit, over half (53%) reported limited resources would make this difficult.
The 2023 survey showed that 57% of respondents found flip charts helpful, 86% were willing to participate in future campaigns, 68% felt more confident discussing bowel screening, and 65% were confident advising patients on how to perform the test.
The baseline average monthly FIT kit requests prior to the campaigns was 1,683. During the May 2023 campaign, kit requests increased by 41.7%. Kit requests for Māori increased by 37%, and for Pacific people by 25%.
After the 2023 campaign, the kit requests remained 46% higher, averaging 2,455 kits per month from June 2023 to April 2024. The 2024 campaign saw a further 84% increase in FIT kit requests, rising from 2,455 to 3,939 kits per month. In summary, prior to the campaigns, the average number of monthly requests was 1,683. This increased to 2,136 during the 2023 campaign and further to 3,939 in May 2024, representing a 134% overall increase over 2 years. The increased request volumes was again sustained for the 3-month follow-up period from June to August 2024.
Monthly kit requests for Māori increased from May 2023 to May 2024 by 67%, and increased over the 2 years of campaigns by 98%; for Pacific people, there was an increase from May 2023 to May 2024 of 129%, and an increase over the 2 years of campaigns by 98%.
For the period over which kit request data are available (October 2022 to August 2024), VLCA practices requested 40% of the overall kits.
Kit requests varied by district, with all districts achieving an increase (details available5).
NCC declined an average of 22.8% of requests prior to the campaigns, but this reduced to 19.7% after the 2023 campaign and further to 18.5% after the 2024 campaign.
The kit return rate following a primary care request for the year after the first campaign in May 2023 averaged 18.5% per month. The return rate was higher for Māori at 20.6% but lower for Pacific peoples at 15.7%. The kit return rate for the 3 months of available follow-up data after May 2024 was 16.4%.
The average monthly kit return rate for VLCA practices in the year after the first campaign May 2023 was 20.3% and for non-VLCA practices, it was 23.8%.
To estimate the potential impact of opportunistic kit requests, the following calculations were made. During the May 2024 campaign, 101 kits were returned by Māori participants. If this rate was sustained over a 2-year screening cycle, it would result in an additional 2,424 kits returned beyond routine screening by Māori participants. This would represent an increase of 3.32% (2,424 out of 73,080 eligible) in screening participation for the Māori age-eligible population.
Similarly, for Pacific Peoples, 73 kits were returned by Pacific participants in the May 2024 campaign. Sustaining this rate over a 2-year screening cycle would lead to an additional 1,752 kits returned, representing a 6.4% (1,752 out of 27,330 eligible) increase in screening participation for the Pacific age-eligible population.
Strategies for quality improvement or change
The 2023 and 2024 campaigns had a sustained impact, resulting in an increase in kit request rates. However, the high decline rate by NCC (approximately 20%) revealed the previously unrecognised issue of negative FIT results not reaching the GP inbox and updating the reminder systems. This issue was investigated and corrected by updating laboratory GP addresses.
It was anticipated that demonstrating the kits would reduce participant anxiety about test completion, but although kit requests increased, the kit return rate did not. Informal feedback from practices suggested this may be caused by the time involved in using both the flip chart and demonstration kit. A reduced content flip chart and a streamlined demonstration kit have been developed for future campaigns.
Some regions and some individual practices achieved higher return rates than others, suggesting that further investigation into the factors contributing to this variability is indicated.
Kit return rates were higher for Māori participants, which likely reflects the campaign focus; future campaigns could continue to encourage participation by VLCA practices and in regions where Māori prevalence is higher. Overall, the kit return rates were low. This is understandable, in part, as the kits were only offered to patients who were not engaging in the current screening round. Nevertheless, it was anticipated that GP and nurse conversations would have more impact on kit completion. The effect of opportunistic kit requests on overall population participation in screening is dependent on both the total number of kits requested and their return rate. The campaigns have identified some options that could further increase kit requests.
The first option is to increase the use of reminders, including opportunistic visual reminders in practice management systems (PMS) and appointment scanning reminders. Practice education via the Primary Care Guide and feedback of PMS data to practices and Primary Health Organisations (PHOs) are actions that could help achieve this outcome.
Another supportive IT option includes the use of QR codes to share access to the on-line multiple language video resources on how to complete the FIT test.
Increasing kit requests could also result from expanding the number of participating practices through an active recruitment approach. A structured campaign registration project would be required.
A further option is to identify other staff with more time available within the practice to engage in conversations or to demonstrate the use of the kit. Specifically targeting healthcare assistants and kaiāwhina roles could be included in the next campaign. These roles could also include follow-up contact with patients who have had kits requested. A training module could support these extended roles.
The strengths of this project included high engagement of practices in the campaign, with over 20% of non-VLCA and 35% of VLCA practices involved. A key limitation of the study is the lack of detailed data on the specific roles and number of GPs and nurses actively engaging in opportunistic conversations, as well as limited reporting on how consistently flip charts and demonstration kits were used, making it difficult to fully assess their individual contributions to the observed outcomes. These limitations can be addressed in future campaigns.
Key lessons from the campaigns
Primary care engagement is effective at increasing bowel cancer screening kit requests and providing support to practices results in a sustained positive impact. Practices indicated they used reminder systems and were positive about the availability of additional resources. Demonstration kits have potential to help patients feel more comfortable about completing the test and although they were well received by practices, it remains unclear how well they were used in busy clinical environments.
Despite increased bowel cancer screening kit requests, many patients did not return completed kits. Further strategies are needed to improve kit return rates, including potential follow-up via text, phone calls or outreach kaimahi.
Conclusion
The 2023 and 2024 NBSP primary care campaigns successfully increased FIT kit requests, particularly among Māori and Pacific patients. However, return rates were modest, indicating the need for further interventions to support patient follow-through. Future campaigns should focus on increasing the number of practices engaged by providing additional resources to sustain their engagement, expanding the use of reminders, and strengthening practice and community-based follow-up.
By integrating these lessons into future strategies, the NBSP can continue to enhance equity in bowel cancer screening and improve early bowel cancer detection rates among priority populations.
Data availability
The data reported in this study are available at https://www.harc.org.nz/research-project/national-bowel-screening-programme-primary-care-campaign-may-2023-may-2024.
Conflicts of interest
The authors declare that they have contracted positions within Clinicians Screening, Prevention Directorate National Public Health Service, Te Whatu Ora Health New Zealand.
References
1 Te Whatu Ora – Health New Zealand. National Bowel Screening Programme monitoring report: January 2018 to December 2022; 2023. Available at https://www.tewhatuora.govt.nz/assets/Publications/Bowel-screening/National-Bowel-Screening-Programme-Monitoring-Report-January-2018-to-December-2022.pdf
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