Abstract
Background
Screening of colorectal cancer (CRC) is a national policy of Thailand to support early cancer detection. However, most of the Thai average-risk population does not have access to screening. This study aimed to investigate the prevalence of access to CRC screening of the average-risk population in Thailand and examine the factors influencing access to CRC screening based on Andersen’s behavioral model.
Methods
This cross-sectional study was conducted in seven primary healthcare centers in all regions of Thailand. A sample of 530 Thai average-risk population aged 50 to 70 years was recruited and completed a survey to identify predisposing, enabling, and need factors, and access to CRC screening was determined. Logistic regression was applied to analyze factors influencing access to CRC screening.
Results
The prevalence of access to CRC screening in this study was 51.5%. The reception of information were the most significant enabling factors for access to CRC screening. The odds ratio of access to CRC screening increased by 4.23 times when the reception of information score increased by one unit (p < 0.001) when adjusted for other variables. In addition, awareness was a significant predisposing factor, and comorbidity was a significant need factor.
Conclusions
The prevalence of access to CRC screening in Thailand remains lower than the global average screening rate for CRC. This study informs reception of information is crucial to promote access to CRC screening by advising CRC screening among the average-risk population, particularly people who have less comorbidity. Relevant information materials should be developed and disseminated to the public to raise awareness among the population.
Keywords: Access to care, Average-risk population, Colorectal cancer screening, Primary healthcare centers, Situational analysis
Background
Colorectal cancer (CRC) ranks third in the world in prevalence, making up 7.9% of all cancers. In 2022, the number of new cases was 1,926,425 [1]. In 2050, it has been estimated that the number of new cases will rise to 3,573,811 [2]. In Thailand, the prevalence of CRC were also increased. CRC was the most commonly found of all cancers, ranking second among males and third among females, accounting for 19.0% and 10.1%, respectively [3]. In 2025, it is estimated that the number of new cases of CRC will be 19,064, and the number will continue to rise [4].
Globally, CRC ranks second among all cancers in both mortality and economic burden, accounting for 9.3% and 10.9%, respectively [5, 6]. Mortality rates have significantly increased in low- and middle-income countries [7]. In Thailand, the annual cost of CRC care is projected to rise steadily over the next 25 years, leading to a cumulative expenditure of 323 billion Thai baht [8]. Therefore, CRC is a major problem in the health system of Thailand.
CRC is typically asymptomatic in its early stages, often leading to delayed diagnosis. Nearly half of patients (46.1%) are diagnosed at stage 4, and 26.6% at stage 3 [3]. Diagnosis at these advanced stages results in a five-year survival rate of only 16.2%. In contrast, early detection at a localized stage yields a significantly higher five-year survival rate of 91.5% [9]. At the same time, CRC screening aims to detect precancerous lesions or early-stage cancer before clinical symptoms emerge, enabling timely diagnosis and treatment [10, 11]. A study on screening for CRC has shown that screening increases the chance of detecting CRC twofold compared to a lack of screening [12]. Moreover, screening could reduce stages 3 and 4 of CRC by 8–27% [13]. These findings highlight the critical role of screening in improving early detection in CRC.
The United Nations has announced its Sustainable Development Goals, which focus on the reduction of untimely deaths caused by Non-Communicable Diseases (NCDs) by 33.3% by the year 2030 [14], which is in congruence with the World Health Organization’s global action plan for the prevention and control of NCDs [15]. CRC is considered as one of the NCDs. Thus, in a global action plan, a specification of population-based CRC screening in people aged over 50 years old should be implemented using fecal occult blood test (FOBT) or other methods as deemed appropriate to ensure timely treatment [16].
The Ministry of Public Health (MOPH) of Thailand has proposed the National Cancer Control Program to implement an organized national screening program. CRC screening is prioritized at primary healthcare centers to ensure convenient access for the general population [17]. Moreover, the National Cancer Institute (NCI) has designed a service plan for cancer, including CRC [18]. The NCI has developed an organized CRC screening program for the average-risk population, both male and female, who are between 50 and 70 years of age to coincide with national policy. The average-risk population will be screened for CRC using the FOBT by fecal immunochemical test (FIT) in the beginning. If the result is negative, they will be advised to do the screening every two years. However, if the result is positive, they will be referred to the hospital specified in the health district for a colonoscopy for diagnosis [19].
In Thailand, screening of CRC in the average-risk population is free of charge, and each healthcare setting receives funding from the National Health Security Office [20]. Invitations to participate in the CRC screening program are extended through public health campaigns to promote, educate, and raise awareness among the average-risk population. These efforts are advice led by nurses and community health officers at primary healthcare centers. Additionally, community leaders and village health volunteers receive training on CRC screening to further disseminate information to the public through various channels, including discussions led by VHVs, presentations during village meetings by local leaders, and announcements via community loudspeakers [19]. Conversely, in Western countries such as France, invitations for CRC screening are mailed directly to the target population from centralized offices [21]. Although Thailand’s screening for CRC is a national policy with clearly defined guidelines and financial support, only 9.74% of the Thai average-risk population has access to the screening with the FIT test [22].
A variety of factors influence the decision to participate in CRC screening. In Asian countries, the obstacles were lack of knowledge, fear of the procedure, fear of discomfort, worry about the result, lack of awareness, high expense, and absence of gastrointestinal symptoms. The facilitators were health literacy and awareness of screening, perceived risk and severity of disease, family history of cancer, and physician suggestions [23]. In addition, a previous study in one province of Thailand revealed that non-participation in CRC screening was associated with low educational attainment, agricultural background, higher family income, absence of constipation and diarrhea, and low family support [24]. However, the studies on factors related to the health service system are also limited. As for Thailand, there were limited evidence on factors influencing access to CRC screening in the average-risk population which depicts an overall situation of the country.
A situation analysis of access to healthcare can be explained using Andersen’s behavioral model of health service use. The model is a conceptual framework used to analyze, monitor, and evaluate access to healthcare, which, in turn, can predict the use of healthcare services. The main components include predisposing factors, which influence enabling factors, and health needs, respectively. All of these factors have an influence on health behaviors [25–27], which in the current study refers to access to CRC screening of the average-risk population. The model has been extensively used in many cancer screening studies to examine the factors influencing the use of healthcare services and cancer screening [28–31]. Thus, this study aimed to investigate the prevalence of access to CRC screening among the average-risk population in Thailand and examine the factors influencing access to CRC screening using Andersen’s behavioral model.
Method
Study design
This was a cross-sectional study conducted from January 2023 to April 2024.
Study participants and setting
The average-risk population of CRC includes both males and females aged 50 years and older who have no family history of CRC or familial adenomatous polyposis (FAP), and no personal history of CRC, inflammatory bowel disease, or pre-existing polyps in the colon or rectum. Additionally, individuals in this group exhibit no active symptoms related to the colon or rectum. Despite the absence of symptoms, individuals at average risk should undergo CRC screening during the asymptomatic phase to enable early detection [10, 32].
Participants in this study was Thai average-risk population of CRC aged 50–70 years. The inclusion criteria were: (1) no history of CRC, inflammatory bowel disease, or pre-existing polyps in the colon or rectum; and (2) resided in the health service responsible area of a selected primary healthcare center for at least 2 years. The exclusion criteria consisted of: (1) had a first-degree relative (parent, sibling, or child) with CRC; (2) had a family history of FAP; and (3) had a cognitive impairment assessed by the Mini-Cog Thai version, score ≤ 3 points.
The sample size (n = 530) was estimated based on a previous similar study of the prevalence of participating in CRC screening (37%), an odds ratio (2.0) associated with gender, used as an independent variable aligned with this study [33], and an effect size (0.16) [34]. This study specifies the power of the test of 0.95 at the alpha significance level of 0.05 and chooses to test the two-tailed hypothesis. The G*power program for power analysis was used to calculate the potential sample size of multivariable logistic regressions.
A multistage sampling method was used for the sampling, consisting of four following steps: (1) select seven provinces in all regions of Thailand according to proportions of the number of provinces in each region, including (1) North Region (17 provinces): Phayao Province (2) Northeast Region (20 provinces): Nakhon Ratchasima Province and Buri Rum Province (3) Central Region (25 provinces): Ratchaburi Province, Chai Nat Province, and Chon Buri Province; and (4) South Region (14 provinces): Chumphon Province; (2) select one district per province; and (3) select seven primary healthcare centers, one per district. All of these steps use a simple random sampling method by drawing lots. Next, (4) select participants from each primary healthcare center using a simple random sampling method by a table of random numbers. We selected the average-risk population who applied to participate in the research project in a random order.
Study measures
The primary investigator implemented data collection using a structured survey containing 80 questions addressed predisposing, enabling, and need factors and access to CRC screening, as illustrated in Fig. 1. Predisposing factors included age, sex, marital status, educational background, employment status, knowledge, and awareness. Knowledge was assessed using the knowledge of CRC and screening questionnaire developed by Chaiarch et al. [35]. The instrument consisted of 25 items with three answers: yes (1), no (0), and uncertain (0). Total scores were 0–25 points. A higher score indicates higher knowledge of CRC and screening. The scores are 0 to 8, scores indicate “low”, 9 to 16, scores indicate “moderate”, and 17 to 25, scores indicate “high”. The items showed good internal consistency (Kuder-Richardson = 0.80). Additionally, awareness was assessed using the awareness of self-care of CRC questionnaire, which was developed by Charoenchit [36]. Instrument had 12 items on a 4-point Likert scale with scores ranging from 0 to 3 points. The total score ranged from 0 to 36 points. A higher score indicates higher awareness of CRC and screening. The scores are 0 to 18, scores indicate “low”, 19 to 27 scores indicate “moderate”, and 28 to 36, scores indicate “high”. The items showed good internal consistency (Cronbach’s alpha = 0.80).
Fig. 1.
Diagram to summarize the model of access to colorectal cancer screening based on the behavioral model of health service use of Andersen et al. (2013)
Enabling factors included family income, rights to medical reimbursement, usual healthcare service setting, annual physical examination, and reception of information. Reception of information was assessed using the reception of information on the CRC screening questionnaire. This instrument was adapted from the questionnaire used in the study on CRC and screening awareness and sources of information in the Hungarian population of Gede et al. [37]. The instrument consisted of 2 items in Yes (1) or No (0) format and 3 multiple-choice items, each with only one correct answer, which was 1 point. The questionnaire’s total score was 0–5. A higher score indicates a higher received amount of information. The scores are 0 to 1; a score indicates “low”, 2 to 3 scores which indicates “moderate”, and 4 to 5 scores indicate “high”. The items showed good internal consistency (Cronbach’s alpha = 0.72).
The needs factors included comorbidity and abnormality of bowel movement. Comorbidity was assessed using Charlson’s comorbidity index (CCI), with 23 diseases or conditions according to their severity. The total score ranged from 0 to 42 points, with a higher score indicating higher severity comorbidities [38]. The CCI, a standard tool, has been widely used in many population groups. Additionally, access to CRC screening was assessed using three criteria in a yes-or-no response format relating to the use of CRC screening services, namely received FIT in the past two years or received other screening methods using flexible sigmoidoscopy in the past five years or colonoscopy in the past ten years, based on the CRC screening guidelines of Thailand [10]. If the access criteria of the average-risk population were answered ‘yes’ to all three questions, it meant an individual had access to CRC screening.
Data collection procedure
This study complies with the Declaration of Helsinki and was performed according to ethics committee approval by the Human Research Ethics Committee of the Faculty of Nursing Mahidol University in Thailand (Number 2023/799.2808). Participants were recruited in primary healthcare centers and assessed for eligibility. An information sheet was distributed, and written informed consent was obtained when the participants agreed to join the study. The Thai version of the paper-based survey was completed via face-to-face interviews conducted by the data collectors. The primary investigator was the person who implemented data collection. The primary investigator enrolled in interview training and practiced with the mentor before implemented the data collection. Each survey was completed in approximately 35 to 45 min.
Statistical analysis
Statistical testing was two-sided, and the level of significance was at α = 0.05. The data collected from the sample group were analyzed using IBM SPSS 23.0 (IBM Corp., Armonk, NY). Participant characteristics were analyzed using descriptive statistics. Means and percentages were used to describe continuous variables and proportions; frequency and percentages were used with binary and categorical variables. Participant characteristics between the two access groups (access and non-access to CRC screening) were compared using non-parametric chi-square tests for binary or categorical independent variables and parametric t-tests for continuous independent variables. Simple logistic regression was performed to evaluate the total effect of independent variables. Then, multiple logistic regression was used to evaluate factors that influenced access to CRC screening and adjusted for extraneous variables. Finally, forward selection was used to select variables and build the final model for access to CRC screening.
Results
Prevalence of access to CRC screening
Participants were 530 Thai average-risk population at the seven primary healthcare centers in all regions of Thailand. The prevalence of access to CRC screening in this study was 51.5%.
Participants’ characteristics
Participants were 530 Thai average-risk population aged 50 to 70 years with a mean age of 61 years (SD = 5.7). The majority were female (73.4%), married (69.4%), had an elementary or lower educational attainment (66.6%), and employed (65.1%). More than half had a high level of knowledge (53.0%), a high level of awareness (56.8%), and a family income equal to or less than 20,000 Thai baht (~ US$549) (59.4%). More than three-fourths (78.1%) used the universal health coverage scheme. Approximately half of the participants had a regular primary healthcare center (46.8%), had a history of annual physical examination (49.2%), and more than half had comorbidities (57.4%). The mean score of the severity of comorbidities was 0.9 score (SD = 1.0). Only 13.8% had abnormalities of bowel movement.
Most participants (39.1%) had a low level of reception of information on CRC screening. The mean score of reception of information on CRC screening was 2.1 scores (SD = 1.6). The participants had a mean score of knowledge of CRC and screening of 16.2 scores (SD = 4.6). The participants’ mean score of awareness of CRC was 28.1 scores (SD = 6.0). (Table 1).
Table 1.
Characteristics of the Thai average-risk population (n = 530)
| Mean (SD) / n (%) | |
|---|---|
| Predisposing factors | |
| Age (years) | 60.5 (5.7) |
| Sex | |
| Male | 141 (26.6%) |
| Female | 389 (73.4%) |
| Marital status | |
| Single | 40 (7.5%) |
| Married | 368 (69.4%) |
| Widowed | 74 (14.0%) |
| Divorced | 27 (5.1%) |
| Separated | 21 (4.0%) |
| Educational background | |
| Elementary education or lower | 353 (66.6%) |
| Early secondary education | 66 (12.5%) |
| High school education or vocational certificate | 62 (11.7%) |
| Diploma | 16 (3.0%) |
| Bachelor’s degree or higher | 33 (6.2%) |
| Employment status | |
| Unemployed | 185 (34.9%) |
| Employed | 345 (65.1%) |
| Knowledge (scores) | 16.2 (4.6) |
| Low level (0–8) | 30 (5.7%) |
| Moderate level (9–16) | 219 (41.3%) |
| High level (17–25) | 281 (53.0%) |
| Awareness (scores) | 28.1 (6.0) |
| Low level (9–18) | 36 (6.8%) |
| Moderate level (19–27) | 193 (36.4%) |
| High level (28–36) | 301 (56.8%) |
| Enabling factors | |
| Family income (Thai baht) | |
| < 10,000 | 157 (29.6%) |
| 10,000–20,000 | 158 (29.8%) |
| 20,001–30,000 | 99 (18.7%) |
| 30,001–40,000 | 57 (10.8%) |
| 40,001–50,000 | 25 (4.7%) |
| >50,000 | 34 (6.4%) |
| Rights to medical reimbursement | |
| Universal health coverage | 414 (78.1%) |
| Government reimbursements | 66 (12.5%) |
| Social security insurance | 45 (8.5%) |
| Self-payment or private health insurance | 5 (0.9%) |
| Usual healthcare service setting | |
| Primary healthcare centers | 248 (46.8%) |
| Community hospitals | 134 (25.3%) |
| General hospitals | 60 (11.3%) |
| Center hospitals | 65 (12.3%) |
| Private clinics or private hospitals | 23 (4.3%) |
| Annual physical examination | |
| No | 269 (50.8%) |
| Yes | 261 (49.2%) |
| Reception of information (scores) | 2.1 (1.6) |
| Low level (0–1) | 207 (39.1%) |
| Moderate level (2–3) | 196 (37.0%) |
| High level (4–5) | 127 (23.9%) |
| Needs factors | |
| Comorbidity (scores) | 0.9 (1.0) |
| Abnormality of bowel movement | |
| No | 457 (86.2%) |
| Yes | 73 (13.8%) |
Factors associated with access to CRC screening
Participant characteristics for both access and non-access to CRC screening groups are shown in Table 2. All characteristics were comparable between access statuses. Characteristics of access and non-access to CRC screening showed significant differences by sex, knowledge, awareness, usual healthcare service setting, annual physical examination, reception of information, and comorbidity. Other characteristics were not significantly different between access and non-access groups.
Table 2.
Participant characteristics, crude and adjusted odds ratio of access to CRC screening (n = 530)
| Access to CRC screening | Crude | Adjusteda | ||||
|---|---|---|---|---|---|---|
| Yes (n = 273) |
No (n = 257) |
OR | p- value | OR (95% CI) |
p- value | |
| Predisposing factors | ||||||
| Knowledge (scores) Mean (SD) | 17.30 (4.2) | 15.1 (4.8) | 1.16 | < 0.001 | 1.11 (1.06–1.16) | < 0.001 |
| Awareness (scores) Mean (SD) | 30.8(4.6) | 25.2 (5.9) | 1.22 | < 0.001 | 1.22 (1.18–1.28) | < 0.001 |
| Enabling factors | ||||||
| Usual healthcare service setting No. (%) | ||||||
| Primary healthcare centers (#) | 123 (49.6) | 125 (50.4) | 1 | 1 | ||
| Community hospitals | 80 (59.7) | 54 (40.3) | 1.51 | 0.060 | 1.51 (0.98–2.34) | 0.061 |
| General hospitals | 36 (60.0) | 24 (40.0) | 1.52 | 0.150 | 1.52 (0.83–2.81) | 0.178 |
| Center hospitals | 24 (36.9) | 41 (63.1) | 0.60 | 0.070 | 0.55 (0.30–1.01) | 0.054 |
| Private clinics or private hospitals | 10 (43.5) | 13 (56.5) | 0.78 | 0.575 | 0.82 (0.31–2.16) | 0.689 |
| Annual physical examination No. (%) | ||||||
| No (#) | 107 (39.8) | 162 (60.2) | 1 | 1 | ||
| Yes | 166 (63.6) | 95 (36.4) | 2.65 | < 0.001 | 2.52 (1.76–3.60) | < 0.001 |
|
Reception of information (scores) Mean (SD) |
3.2 (1.1) | 0.9 (1.2) | 4.48 | < 0.001 | 4.98 (3.87–6.41) | < 0.001 |
| Needs factors | ||||||
| Comorbidity (scores) Mean (SD) | 1.1 (1.0) | 0.7 (0.9) | 1.60 | < 0.001 | 1.64 (1.34–1.99) | < 0.001 |
a Adjusted for age, sex, marital status, educational background, occupation, family income, rights to medical reimbursement, and abnormality of bowel movement
# Reference group
Simple logistic regression explored the total effect each independent variable showed significant predictors by sex, marital status, knowledge, awareness, annual physical examination, reception of information, and comorbidity; other variables were not significant. Multiple logistic regression assessed the influencing factors of access to CRC screening showed that knowledge, awareness, annual physical examination, reception of information, and comorbidity were significant predictors. The adjusted model was controlled for age, sex, marital status, educational background, occupation, family income, rights to medical reimbursement, and abnormality of bowel movement (Table 2).
The final model of influencing factors that were associated with access to CRC screening was selected by forward selection. The final model comprised the awareness, reception of information, and comorbidity. The odds ratio of access to CRC screening increased by 1.16 times when the awareness score increased one unit (OR = 1.16, 95%CI 1.10–1.23, p < 0.001) when adjusted for other variables. The odds ratio of access to CRC screening increased by 4.23 times when the reception of information score increased one unit (OR = 4.23, 95%CI 3.30–5.43, p < 0.001) when adjusted for other variables. The odds ratio of access to CRC screening increased by 1.75 times when the CCI score increased one unit (OR = 1.75, 95%CI 1.30–2.36, p < 0.001) when adjusted for other variables (Table 3).
Table 3.
Final-model by using multiple logistic regression with forward selection (model selection)
| OR | 95% CI | p-value | |
|---|---|---|---|
| Awareness (scores) | 1.16 | (1.10–1.23) | < 0.001 |
| Reception of information (scores) | 4.23 | (3.30–5.43) | < 0.001 |
| Comorbidity (scores) | 1.75 | (1.30–2.36) | < 0.001 |
Likelihood ratio test: X2(3) = 402.92, p < 0.001; Nagelkerke R2 = 0.710
Discussion
The study explored the prevalence of access to CRC screening of the average-risk population in Thailand and examined the factors influencing access to CRC screening based on Andersen’s behavioral model. Among the Thai population participants in this study, more than half (51.50%) had access to CRC screening. The access to CRC screening identified in this study is significantly higher than that reported in the Health Data Center database [22]. The prevalence of access to CRC screening in the Thai average-risk population remains lower than the global average screening rate for CRC, which stands at 54.0%, or classified by continents including South America (90.19%), Asia-Pacific (55.25%), Europe (52.72%), and North America (45.57%) [39].
Participants who received more information about CRC screening had an increased chance of accessing screening. Receiving information about disease and screening allows the average-risk population to have accurate knowledge and understanding, affecting their decision to participate in screening. The dissemination of information through public media affects the decision to receive cervical cancer screening services in Thailand [40]. A study in Hong Kong found that receiving information about CRC prevention and screening through booklets was a channel for the average-risk population to participate in screening [28]. Information makes people aware of the risk of CRC and helps them perceive the benefits of screening. It was an incentive to participate in screening [41, 42].
In contrast, previous studies show that many individuals hesitate to undergo screening due to fear of positive tests, creating a screening barrier [23, 31, 42–45]. However, adopting a proactive strategy towards the average-risk population by consistently encouraging individuals, even in the face of initial refusals, can effectively shift their perspectives [43]. In Thailand, village health volunteers play a vital role in public outreach, encouraging community members to undergo CRC screening. They serve as knowledgeable leaders in sharing information, thanks to training provided by healthcare professionals [46]. Thus, the promotion of health information dissemination through village health volunteers plays a vital role in strengthening Thailand’s healthcare system.
Several studies revealed that most people had never received information about CRC screening and testing for FOBT, so they did not participate in screening [40, 47]. Individuals who had received information about CRC had a higher level of awareness than those who had never received such information [48]. Individual-level perception creates awareness of the disease and affects the decision to participate in screening [41]. A study of barriers to participation in CRC screening confirmed that lack of awareness about the disease and the benefits of screening were barriers to participation in screening by 13.3–36.8% [47, 49]. However, healthcare personnel in the primary healthcare center viewed a lack of awareness among the average-risk population as a barrier to participation in CRC screening, as high as 63.7% [50]. Previous studies have shown that reluctance to undergo CRC screening often stems from the perception that it is unnecessary, especially when individuals are asymptomatic [43, 44]. This can be explained by the tendency of people without abnormal symptoms not to prioritize preventive healthcare, frequently postponing seeking health services until symptoms become severe [42]. Therefore, policymakers should provide relevant information materials to raise awareness and overcome barriers to accessing CRC screening.
Participants with higher severity of comorbidity were more likely to access CRC screening. People with severe comorbidities need to see their doctor more often. Thus, there was an opportunity to receive information about CRC and advice on screening from healthcare personnel [49, 51]. For those with non-comorbidities or with less severe comorbidities, they followed up more distantly. There was less opportunity to receive advice from healthcare personnel and less awareness of the risk of cancer. Therefore, they did not attach importance to disease prevention and screening, resulting in much less participation in CRC screening than people with more severe comorbidities [42, 47, 52].
Limitations
The study limitation was the sampling method in the area. Researchers approached the participants who received healthcare services or when activities were in the centers, so people who do not use center services may not have a chance to participate in this study. Selection bias may affect the prevalence of access to CRC screening and some of the characteristics of the participants. However, we collected data on the usual healthcare service setting to demonstrate the nature of the participants’ regular use of health services. Moreover, the sample size calculation was limited by the availability of specific factors within a context consistent with this study. The gender-related factor used in the sample size estimation served only as a basic variable. Additionally, the reception of information in this study focused on the quantity of information, so the source of the information needs to be explored in the future in order to promote information about CRC screening. Finally, this study was conducted in a Thai population, which may limit the generalizability of this study to other populations with different policies and service deliveries of CRC screening. However, the findings would be generalized to population in low- and middle-income countries which share the similar contexts of socioeconomic status and health system background.
Conclusion
The prevalence of access to CRC screening in Thailand remains lower than the global average screening rate for CRC. This study found the predisposing, enabling, and need factors influencing access to CRC screening in the Thai average-risk population. Healthcare personnel played the most significant role in promoting access to CRC screening by advising CRC screening among the average-risk population, particularly people who have less comorbidity. Additionally, policymakers should provide relevant information materials about CRC screening and dissemination to the public. To reach a broad national audience, they should also develop campaigns encouraging the average-risk population to participate in CRC screening, thereby raising understanding and awareness among the population.
Acknowledgements
We would like to express our gratitude to all collaborating participants, including hospital directors, major advisors, co-advisors, statisticians, and the Srisavarindhira Thai Red Cross Institute of Nursing. We forever grateful for your support in this project.
Abbreviations
- CRC
Colorectal cancer
- CCI
Charlson’s comorbidity index
- FIT
Fecal immunochemical test
- FOBT
Fecal occult blood test
- FAP
Familial adenomatous polyposis
- MOPH
Ministry of Public Health
- NCI
National Cancer Institute
- NCDs
Non-communicable diseases
Author contributions
SP: Conception and design of the study, data acquisition, data analysis, interpretation of results, and preparation of the draft manuscript. TT: Design of the study, data analysis, interpretations of results, and critical revision of the draft manuscript. KU: Design of the study. CI: Design of the study. All authors read and approved the final manuscript.
Funding
Open access funding provided by Mahidol University
Data availability
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical certificate approval was received from Institutional Review Board, Faculty of Nursing, Mahidol University, project number IRB-NS2023/799.2808. In addition, this study received certificate approval and permissions from the director of each hospital. The informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.