Table 2.

Barriers and facilitators to uptake and provision, with evidence

Barriers to uptake			Facilitators to uptake
Acceptability
B1	Fear of result and impact	“So, some people might have a fear of the unknown… they just don’t want to know and the fear of knowing and where do we go from here and what’s happens to me, ken what happens to them as an individual then.” (Public, male, 60y/o)	F1	Perceived benefits	I1: “Preventions better than cure, ae?” I2: “Aye” I3: “Aye prevention that’s the main one.” (Community group discussion) “Me personally, my personal opinion on it would be, I would want to know and I’d want to get the treatment as quick as I could get treatment, that’s my personal opinion.” (public, male, 60y/o)
B2	Guilt & Stigma	“I think there is always the battle to try to engage smokers without guilt or stigma, and we know that there's still a huge amount of that present, and I think if you start saying smokers come and get screened for cancer, that's off putting to a large swathes of the very population we want to capture, and we know there's a stigma attached to it.” (Respiratory consultant)
B3	Attitude	“…the apathy of the public or my apathy, I better not just say mine because I can mention my wife and she turned 60 two years and I had to get her told to do her bowel screening, she wasn’t doing it. And it was just purely because she didn’t think it mattered. And how you get round that apathy I do not know.“ (Public, male, 65y/o)
B4	Mental health & anxiety	“So, I work with a few people who have got agoraphobia and are scared of leaving the house, so if they absolutely need to go to the 5GP then they will but the chances of them going for a blood test, they’re probably not going to, they’re probably going to say I don’t need to go to that. In their view it’s probably not going to be life or death although actually it could be. Unless they’ve got something really quite severe at that moment in time, the chances of them going are pretty slim, mainly due to their anxiety.” (Community links worker)
B5	Hesitation around Covid 19	“Yes, I definitely think I would, especially for the COVID thing, you’re not wanting anyone in the practice.” (Public, male, 72y/o)	F2	Trust in HCP	“I think that going to the GP would be the easiest for me. They know what they’re doing and they do it very efficiently, so I’m quite happy with that idea.” (public male, 86y/o) “…someone to, suppose it was a district nurse or a pharmacist, suppose you went along to the pharmacist and the pharmacist showed you how to do it. I think that would be very good for the first time.” (public, male, 65y/o)
B6	Lack of engagement with healthcare	“… I don’t like to bother my doctors and that, ken, you feel as though you’re a nuisance unless you’re feeling really unwell. So, to do it by myself for myself, I think that’s a great idea, as long as you’re able to do that of course, which I am obviously.” (Public, male, 72y/o)
Convenience/accessibility
B7	Lifestyle (keeping appointments)	“So, they might say to yes I’ll go and do that but you don’t know what somebody’s lifestyle is when you’re sending these things out, so if they’ve got a chaotic lifestyle or they’ve got a busy lifestyle they might not turn up at a doctors surgery, if they make an appointment that way or for a nurse or even a pharmacist.” (Public, male, 60y/o)	F3	Immediacy	“but a local pharmacy is a good options, it’s the sort of thing where you can see someone say oh yeah, I’ll just have a go of that, if it can be done there and then. It’s almost the immediacy of it.” (GP)
B8	Travel (mobility & rurality)	“So, yeah and I would say because of the rural communities as well, people might find it hard to travel because well just look at Keith itself, Keith’s just a small town but when you look at Keith on the map it’s quite large but it’s rural, absolutely rural.” (Public, male, 60y/o) “Probably another age group, or group you would need to consider would be elderly people, especially if there was fraility. Ordinarily the GP would do a home visit, as opposed to them coming in to the practice.” (Community Links Worker)	F4	Part of community	R: So this is just talking about the test of course but for the actual test do you think it would also help to have maybe the lung check in places like this? In social clubs or… I2: Aye you could do that, cause you might get a lot more folk coming to it and if there’s someone here to do the test, it’s beneficial to the company as well. Cause you could get a test through the door and just think “aw” but if there’s someone here to do it and there’s other people doing it as well, then you’re gonna do it. Same with the blood test, you can do the blood test at the same time. (Community group discussion)
B9	Literacy	“The thing is, it’s maybe sad to say but there’s all sorts of people in the country that have different levels of education and some people just don’t fully understand what some of the things mean, that’s why it’s got to be in simple terms and well if there’s a helpline to phone so be it.” (Public, male, 65y/o)	F5	Convenience and options	“A visual trigger, like I have to do this but at the same time an option like the if you’re not comfortable doing this at home, then maybe you can get it done somewhere else. And then the option that maybe returning it by post or if you’re more comfortable handing it in to a specific drop off point. I don’t know if it would be possible to do it that way” (Community group discussion)
B10	Number of interactions	“…if you want to tie it into normal or routine phlebotomy, (…) it's not actually done in practice. (…) They’d need to come and pick [information] up at our practice and then they need to take it to a completely different Health Centre to get the blood sample actually taken, which could create an issue.” (GP)
Awareness
			F6	Embed conversations in community	“I think, the more you can make lots and lots of different organisations, so other people who may interact with that person, so the more you can make them aware of it, then the more they are likely to encourage them. So, even talking to the likes of housing associations, food banks, citizen advice bureau, money advice places because they are places supporting those individuals day to day and I think those are the organisations those individuals have a bit more trust in. Obviously they trust the doctor and they listen to the doctor but if they are having day to day conversations with somebody at the foodbank or someone like their housing officer or someone else from the housing, and they just spark up a conversation about it, I think that’s actually just as worthwhile, as a poster up in the health centre for example.” (Community links worker)
			F7	National/targeted campaign	“Yeah, the tele is good, I’m not really in to social media, I don’t want to get involved with that but definitely the radio and tele is quite a big thing, aye and you could do it on local tele as well, you don’t have to do it nationally. Anything that can bring it up, I don’t know about posters or that I dunno whether people look at things, not so sure about that one. But definitely the radio and maybe even in the papers, the local papers.” (public, male 72y/o) “…lung cancer is a big issue around here, since it’s an area of high deprivation and certainly patients are very aware of the possibility of lung cancer because lots of them smoke and things like the Alex Ferguson campaign advert about if you ever cough for more than 4 weeks, come and see your GP and get a chest x-ray, and that picked up a lot of interest in our patients.” (Practice nurse)
Reminders and Endorsements
			F8	Trusted sources	“I guess you’d be writing to them or maybe, so sometimes we’ve been involved in studies and the practice sends out the letter. So you give us the letter and we send out the letter on your behalf so it looks like it’s coming from us, a personal recommendation from us and I think that helps that they know us.” (GP)
	Barriers to provision			Facilitators to provision
Acceptability
PB1	Staff capacity (Time & workload)	“There's a big concern about the big workload on physicians so, and partly because of other diseases that may come to the fore because of CTs that are done.” (Respiratory Consultant)	PF1	Buy-in to blood test & screening	“so, I think it was just a whole bunch of people coming together that were quite enthusiastic and also because everybody believed what we were doing. So, that helps that you buy in to the product, as opposed to cynically doing it because you have another project to do.” (Consultant radiologist)
PB2	Complications around Covid 19	“because practices have, we are having to clean our rooms before and after patients and we can’t have lots of people in the waiting room. So, we can’t have lots of clinicians with patients waiting at the same time. So, we’ve only got room for 2 patients to wait.” (GP)	PF2	Incentives	“(in) pharmacies, a lot of things are basically, they're driven through funding so… I will kind of be told try to get some more flu jabs, as we will make more money by doing more flu jabs in a day. That kind of thing.” (Community pharmacist) “You know sometimes there’s a payment per patient or something like that.” (GP)
PB3	Attitudes to blood test & uptake	“It’s really difficult engaging them to come in for that (cervical smear), no matter what we do… Yep, it’s terrible in this area for people not taking up screening to be honest with you. It’s offered to them on a plate.” (Practice nurse)
PB4	Hesitations about logistics and follow up	“And the barriers really going forwards because obviously going forwards is slightly different than what it was. It is how the capacity and obviously there are lots of different bits to this but I can speak to the radiology… and it’s just continuously depressing data but the Scottish data, there is 1 in 3 radiology jobs are unfilled.” (Consultant Radiologist)
Convenience/Accessibility
			PF3	Streamline process and ensure capacity	“We use a computer system in greater glasgow called ordercoms, so that we go on to, so the computer system we use you can tick whatever blood test you want. And if it was on there, you could tick that, so that would be milli seconds.” (GP)
			PF4	Training	“I think the only thing would be training around lung cancer, because especially in community pharmacy we work a lot more with business numbers and targets and things and less clinical…” (Community pharmacist)