**4. Colorectal cancer screening uptake**

Participation in screening has varied greatly among different regions. The Netherlands showed the highest participation rate (68.2%) and some areas of Canada showed the lowest (16%). Participation rates were highest among women and in programs that used the iFOBT test. The iFOBT test has been the most widely test used in screening program worldwide nowadays. The advent of this test has increased participation rates and the detection of positive results [13].

In a large scale study conducted in Asia Pacific region, 27% of respondents aged 50 years and older had undergone previous CRC testing; the Philippines (69%), Australia (48%), and Japan (38%) had the highest participation rates, whereas India (1.5%), Malaysia (3%), Indonesia (3%), Pakistan (7.5%), and Brunei (13.7%) had the lowest rates [21].

### **5. Barriers for colorectal cancer screening**

Community with cancer tends to present to cancer services in the later stages of the disease, and this late presentation has severe, often fatal, consequences. Therefore, increasing awareness about cancer signs and symptoms could contribute to earlier presentation and improvements in cancer outcomes Despite the prevalence of colorectal cancer and the many screening tests available, the number of people going for these screening tests are very low [22]. This is rather alarming and many studies have been conducted worldwide to discover and analyze the causes of low turnout for colorectal cancer screening [23].

### **5.1 Poor knowledge of CRC symptoms and risk factors**

A majority of the studies found that the largest barrier towards colorectal cancer screening is poor knowledge of the general public towards the risk factors,

symptoms and screening tests available for CRC. A recent multi-center, international study involving 14 countries or regions in the Asia Pacific region reported considerable deficiencies in knowledge of CRC symptoms and risk factors, and suggested that this could lead to poor uptake of CRC screening tests. One research indicates that there is a lack of awareness among community about CRC symptoms, i.e. only 40.6% of 2379 participants recognized 'blood in stool' as a warning sign for CRC. Other causes of delayed detection and diagnosis include denial, negative perceptions of the disease, the over-reliance on traditional medicine, misperceived risk, emotional barriers and negative perceptions towards screening. Cancer awareness campaigns and their evaluation are sparse in low- and middle-income countries.

Many stated that they were too busy, or the tests were too time consuming. Thirdly, there is limited access to centers that provide such screening tests [23]. The most common barrier for screening is because FOBT test is unavailable in the primary care clinic. FOBT is in fact easily available and free in certain health care facilities but only few health clinics have this test. In most of the primary care health clinics, the test needs to be sent to nearest hospital laboratory and because of that it

Majority of patients will come to primary care as their first consult. Wellness clinic has been implemented in primary care clinics. This clinic is meant for patients to come for screening. However, the programme in the certain clinic is mainly targeting on screening cardiovascular risk factors such as diabetes, hypertension and hypercholesterolaemia. Little is done for cancer screening. Cervical cancer screening has the highest patient uptake (43%) because of the incorporation of Pap smear programme in maternal and child health clinic which is run in primary care

There are many people who do not perceive that they are at risk of getting CRC. This low perceived risk is attributable to several factors, such as not having a family history of CRC, not experiencing any signs or symptoms, living a healthy or lowrisk lifestyle or being free from health problems in general [23]. Another barrier that many studies report is the negative perception towards screening methods, with a more negative view towards more invasive procedures such as endoscopicbased procedures. Among the negative views reported were fear, pain experienced or perceived pain towards screening procedures, feeling of embarrassment, health damage, inconvenience and lack of confidence in screening efficacy. Fear of test result is a common barrier for any test. It is especially when most people relate cancer to untreatable and fatal disease. A study in Italy also showed the same finding where being concern with the test result is the most important reason of

Throughout the world there are widespread differences in CRC screening implementation status and strategy. Differences can be attributed to geographical variation in CRC incidence, economic resources, healthcare structure and infrastructure to support screening such as the ability to identify the target population at risk and cancer registry availability. Despite well-developed CRC screening guidelines, implementation of screening is markedly different among countries and regions worldwide [26]. What is more, there is also inequitable access to CRC screening, at least in relation to socioeconomic status and ethnicity. The mecha-

**Table 1** showed some evidence from previous studies on CRC screening and intervention modalities. Mixed of intervention through telephone counseling, a mail invitation, email/text-message reminder, health talk, video and brochure are some intervention has been done and showed a positive finding on CRC screening uptake. The government needs to take action for CRC screening programme and

become tedious and not commonly ordered [25].

*DOI: http://dx.doi.org/10.5772/intechopen.94396*

**5.4 Patient's negative perception towards CRC screening**

facilities [25].

*Public Health: Prevention*

patient's noncompliance.

nism, however, is not well understood [27].

**6. Intervention related to CRC screening**

**5.5 Others factor**

**9**

Studies from Hong Kong, Australia and USA also reported low levels of knowledge of CRC [22]. Other than that, those with poor educational backgrounds are more likely to have language and communication barriers, and have a harder time understanding materials or recommendations. Also identified being the male gender to have poorer CRC knowledge, as females have better health knowledge due to their traditional role as carers. With particular focus to a multiracial country, the language barrier becomes a prominent problem. Subjects have complained of the limited language diversity in cancer screening awareness material, hence result in poorer understanding. This in particular would be a problem for the older generation, as many are less multilingual than the younger generation; and this becomes a large problem as CRC has a higher prevalence among those above 50 years of age [23]. Few Asian countries have established nationwide CRC awareness and screening programs, with Taiwan, Korea, Singapore and Japan being the only Asian countries that have existing national CRC screening guidelines and programs [23].

## **5.2 Lack of physician's recommendation**

Another major factor of poor knowledge within the population is the severe lack of physician's recommendation to do CRC screening [23]. In Asia Pacific region, countries with low CRC screening participation were found to have the lowest physician recommendation rate [21]. According to an American study, failure of a clinician to suggest screening was identified as the most important barriers to CRC screening [24].

The most common barrier was "unavailability of the test". The two most common patient factors are "patient in a hurry" and "poor patient awareness". This may be related to the low availability of the test in the primary care setting and poor awareness and understanding of the importance of colorectal cancer screening among patients.

### **5.3 Lack of access of CRC screening**

A notable category of barriers that people face that hinders them from CRC screening participation is access barriers. One of them is financial constraints. Another is time constraint. In a busy clinic, long patient waiting time may lead to patient in a hurry and refusal despite being recommended. It is known that the conventional gFOBT is troublesome and embarrassing for patients to do. Another drawback of the test is patient has to be on certain food restriction and the test has to be repeated at least twice. Therefore, many countries have now moving towards using immunological test since it is less troublesome and better detection rate [25].

### *Public Health: Prevention DOI: http://dx.doi.org/10.5772/intechopen.94396*

symptoms and screening tests available for CRC. A recent multi-center, international study involving 14 countries or regions in the Asia Pacific region reported considerable deficiencies in knowledge of CRC symptoms and risk factors, and suggested that this could lead to poor uptake of CRC screening tests. One research indicates that there is a lack of awareness among community about CRC symptoms, i.e. only 40.6% of 2379 participants recognized 'blood in stool' as a warning sign for CRC. Other causes of delayed detection and diagnosis include denial, negative perceptions of the disease, the over-reliance on traditional medicine, misperceived risk, emotional barriers and negative perceptions towards screening. Cancer awareness campaigns and their evaluation are sparse in low- and middle-income

Studies from Hong Kong, Australia and USA also reported low levels of knowledge of CRC [22]. Other than that, those with poor educational backgrounds are more likely to have language and communication barriers, and have a harder time understanding materials or recommendations. Also identified being the male gender to have poorer CRC knowledge, as females have better health knowledge due to their traditional role as carers. With particular focus to a multiracial country, the language barrier becomes a prominent problem. Subjects have complained of the limited language diversity in cancer screening awareness material, hence result in poorer understanding. This in particular would be a problem for the older generation, as many are less multilingual than the younger generation; and this becomes a large problem as CRC has a higher prevalence among those above 50 years of age [23]. Few Asian countries have established nationwide CRC awareness and screening programs, with Taiwan, Korea, Singapore and Japan being the only Asian countries that have existing national

Another major factor of poor knowledge within the population is the severe lack of physician's recommendation to do CRC screening [23]. In Asia Pacific region, countries with low CRC screening participation were found to have the lowest physician recommendation rate [21]. According to an American study, failure of a clinician to suggest screening was identified as the most important barriers to CRC

The most common barrier was "unavailability of the test". The two most common patient factors are "patient in a hurry" and "poor patient awareness". This may be related to the low availability of the test in the primary care setting and poor awareness and understanding of the importance of colorectal cancer screening

A notable category of barriers that people face that hinders them from CRC screening participation is access barriers. One of them is financial constraints. Another is time constraint. In a busy clinic, long patient waiting time may lead to patient in a hurry and refusal despite being recommended. It is known that the conventional gFOBT is troublesome and embarrassing for patients to do. Another drawback of the test is patient has to be on certain food restriction and the test has to be repeated at least twice. Therefore, many countries have now moving towards using immunological test since it is less troublesome and better

CRC screening guidelines and programs [23].

**5.2 Lack of physician's recommendation**

**5.3 Lack of access of CRC screening**

countries.

*Colorectal Cancer*

screening [24].

among patients.

detection rate [25].

**8**

Many stated that they were too busy, or the tests were too time consuming. Thirdly, there is limited access to centers that provide such screening tests [23]. The most common barrier for screening is because FOBT test is unavailable in the primary care clinic. FOBT is in fact easily available and free in certain health care facilities but only few health clinics have this test. In most of the primary care health clinics, the test needs to be sent to nearest hospital laboratory and because of that it become tedious and not commonly ordered [25].

Majority of patients will come to primary care as their first consult. Wellness clinic has been implemented in primary care clinics. This clinic is meant for patients to come for screening. However, the programme in the certain clinic is mainly targeting on screening cardiovascular risk factors such as diabetes, hypertension and hypercholesterolaemia. Little is done for cancer screening. Cervical cancer screening has the highest patient uptake (43%) because of the incorporation of Pap smear programme in maternal and child health clinic which is run in primary care facilities [25].

### **5.4 Patient's negative perception towards CRC screening**

There are many people who do not perceive that they are at risk of getting CRC. This low perceived risk is attributable to several factors, such as not having a family history of CRC, not experiencing any signs or symptoms, living a healthy or lowrisk lifestyle or being free from health problems in general [23]. Another barrier that many studies report is the negative perception towards screening methods, with a more negative view towards more invasive procedures such as endoscopicbased procedures. Among the negative views reported were fear, pain experienced or perceived pain towards screening procedures, feeling of embarrassment, health damage, inconvenience and lack of confidence in screening efficacy. Fear of test result is a common barrier for any test. It is especially when most people relate cancer to untreatable and fatal disease. A study in Italy also showed the same finding where being concern with the test result is the most important reason of patient's noncompliance.

### **5.5 Others factor**

Throughout the world there are widespread differences in CRC screening implementation status and strategy. Differences can be attributed to geographical variation in CRC incidence, economic resources, healthcare structure and infrastructure to support screening such as the ability to identify the target population at risk and cancer registry availability. Despite well-developed CRC screening guidelines, implementation of screening is markedly different among countries and regions worldwide [26]. What is more, there is also inequitable access to CRC screening, at least in relation to socioeconomic status and ethnicity. The mechanism, however, is not well understood [27].
