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Self-Referral Reminders for Flexible-Sigmoidoscopy Non-participants

Program Synopsis

Designed to increase colorectal cancer screening among adults that have not responded to a screening invitation, this intervention involves mailing a series of follow-up reminder letters that outline the process for self-referral along with bowel cancer and screening educational materials (a 2-page leaflet or 12-page booklet). The study showed increases in completing flexible sigmoidoscopy screening and in making an appointment for flexible sigmoidoscopy screening.

Program Highlights

Purpose: The program is designed to increase colorectal cancer screening among adults (2018).
Age: 40-65 Years (Adults)
Sex: Female, Male
Race/Ethnicity: Asian, Black (not of Hispanic or Latino Origin), White (not of Hispanic or Latino Origin)
Program Focus: Awareness Building and Behavior Modification
Population Focus: Un- and/or Under-Screened People
Program Area: Colorectal Cancer Screening
Delivery Location: Clinical, Home
Community Type: Urban/Inner City
Program Materials

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Implementation Guide

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Featured Profile

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Program Scores

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In the United States, colorectal cancer is the second-leading cause of cancer-related death. Approximately 50,000 people die from colorectal cancer each year. Screening can detect colorectal cancer at an early stage to maximize the potential for treatment to be effective. Further, the detection and removal of polyps can prevent colorectal cancer from developing. The U.S. Preventive Services Task Force recommends regular screening beginning at age 50 and continuing until age 75 using high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy. Despite these recommendations, only 65% of U.S. adults are up to date with colorectal cancer screening. Common barriers to colorectal cancer screening include attitudes and beliefs as well as the cost of the tests. Interventions designed to promote colorectal cancer screening are needed.

Self-Referral Reminders for Flexible Sigmoidoscopy Non-Participants provides screening reminders to adults who are eligible for colorectal cancer screening but have not already responded to a screening invitation. The program targets adults aged 56 to 59 in England who have received an invitation for a free flexible sigmoidoscopy at 55 offered by the National Health Service (NHS), but have not undergone screening. Based on the Behavior Change Wheel and Behavior Change Technique Taxonomy, which can be used to identify targets for change and the behavioral techniques likely to affect them, the program aims to increase flexible sigmoidoscopy uptake among previously non-participating adults through reminder letters and educational material.  

Through England’s NHS, 55-year-olds receive a standard information booklet (described below) and an invitation letter providing a flexible sigmoidoscopy screening (often referred to in England as ‘bowel scope screening’) appointment. Program participants—those who do not undergo screening within 12 months of receiving this initial letter—receive a follow-up reminder letter, which outlines the process for self-referral, accompanied by educational material (either the same standard information booklet or a theory-based leaflet, described below). Another reminder letter is sent 4 weeks later to those who have not responded (again, outlining the process for self-referral). Patients are re-assessed for eligibility 12 months after the first reminder letter (i.e. 24 months after the initial invitation), and those who are still eligible receive a second self-referral reminder letter and educational material. A final follow-up reminder letter is sent 4 weeks later to those who remain unresponsive. The standard information booklet, theory-based leaflet, and reminder letters are described below:

- The standard information booklet was developed following guidelines established by the NHS informed choice initiative. The 12-page illustrated booklet provides information on bowel cancer, bowel scope screening, symptoms of bowel cancer, statistics on bowel cancer, and contact information to schedule an appointment.

-- The two-page theory-based leaflet provides photographs and testimonials of individuals who previously had a bowel screening, an endorsement from a primary care physician, statistics on bowel cancer, benefits of screening, and contact information to schedule an appointment. Published by Partners in Creation, the leaflet is tailored for the local community.

-- Reminder letters, two pages in length, provide information on the risks of bowel cancer and facts on bowel scope screening. Recipients are provided instructions on how to schedule an appointment. On an enclosed form, participants can indicate their preference for a male or female practitioner and the time of day for an appointment. Participants receive a pre-addressed, stamped envelope to return their completed form. Once the response is received, an administrator contacts the participant to schedule an appointment. Participants can also call to make an appointment directly.

Implementation Guide

The Implementation Guide is a resource for implementing this evidence-based program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded on the Program Materials page.

-- Time to modify the educational material and letters for the implementer’s local area
-- Approximately 1 hour to prepare the mailings each week (printing the letters and inserting a letter, educational material, and return envelope in each mailing)

The intervention was designed for adults aged 56 to 59, but it can be adapted for use with any adults who are eligible for flexible sigmoidoscopy screening in their local area and have not been screened.

This intervention is intended to be implemented in clinic and home settings.

Required resources to implement the program include the following:
-- Reminder Letter
-- Follow-up Reminder Letter
-- Theory-Based Leaflet
-- National Health Service (NHS) Standard Information Booklet

For costs associated with this program, please contact the developer, Robert Kerrison. (See products page on the EBCCP website for developer contact information.)


A randomized controlled trial in England compared two interventions (reminder letters plus standard information booklet and reminder letters plus theory-based leaflet) against a control condition with no reminders or educational material. Residents of two diverse neighborhoods in London were randomized to one of the three groups. Per NHS procedures (prior to the study), participants received an invitation letter around their 55th birthday to undergo a free flexible sigmoidoscopy screening. A year after they were invited to receive free screening, they were eligible to participate in the study if they had not undergone screening, were still registered with a general practice inside the included neighborhoods, and were alive. Intervention participants received the reminder letters and either the standard information booklet or theory-based leaflet, depending on their group assignment. Control group participants only received the initial invitation sent by the National Health Service around their 55th birthday; they did not receive follow-up reminder letters or educational material as part of the study.

The study enrolled 1,383 participants, all adults who had not undergone free NHS screening within 1 year of receiving an invitation. Each of the three groups had 461 participants. After the delivery of the 12-month follow-up reminder to the intervention participants, 119 participants (8.6%) had been screened, 8 (0.6%) had died, and 38 (2.8%) were no longer registered with the participating local medical practices. The remaining 1,218 (88%) were included in the second round of reminders and the 24-month follow-up analysis. All these participants were 57 years old, and more than half (53.4%) were female.

The main outcome measures examined whether participants completed flexible sigmoidoscopy screening and made an appointment for flexible sigmoidoscopy screening. Outcome data were collected at 12- and 24-month follow-up through the Bowel Cancer Screening System (electronic medical records). The data collected originated from general practices and were obtained following legal protocol. The analysis for the outcome of completed flexible sigmoidoscopy screening was conducted specifically for the purposes of this summary. The outcome reported in the article, attended an appointment, included individuals who were not screened, although there were minimal differences between the percentage who made an appointment and the percentage who participated in screening. The outcomes from the 12- and 24-month follow-up are combined in the analysis.

Graph of Study Results

  • Over the course of the 24 months, a greater proportion of participants in the reminder plus theory-based leaflet group completed screening than participants in the reminder plus standard booklet group (p≤ .01) and control group (p≤ .001). A greater proportion of participants in the reminder plus standard booklet group completed screening than participants in the control group (p≤ .001).


Graph of Study Results

  • Over the course of the 24 months, a greater proportion of participants in the reminder plus theory-based leaflet group made an appointment than participants in the reminder plus standard booklet group (p≤ .001) and control group (p≤ .001). A greater proportion of participants in the reminder plus standard booklet group made an appointment than participants in the control group (p≤ .001).

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Updated: 03/29/2023