Enhancing qFIT bowel screening uptake in deprived areas

Bowel cancer accounts for around 16,000 deaths annually.¹ Much of its death toll comes from late diagnosis — catching it early dramatically improves survival. Many people mistake the signs of bowel cancer for other problems such as irritable bowel syndrome (IBS), and symptoms are often silent until late.

The introduction of the quantitative faecal immunochemical test (qFIT) across the UK from 2017 was intended to shift this balance. Non-invasive and home-based, it is highly specific, with evidence showing a 21% reduction in the risk of being diagnosed at a late stage.² The Scottish bowel screening programme technically meets its target, with 66% of people returning their kits between 2022 and 2024 — above the 60% threshold.³ But this headline figure hides a stark divide. Uptake in the most deprived areas (Scottish Index of Multiple Deprivation ranks 1 and 2) is just 52.9%, compared with 74.7% in the most affluent neighbourhoods.³

This is what Andrea Williamson and colleagues have termed missingness: The systematic absence of certain groups from health data, services, and outcomes.⁴ Those who do not return their kits are not a random group — they are often the very patients carrying the highest burden of multimorbidity, psychosocial stress, and premature mortality.

Why might this gap persist? Health literacy is an important factor. Around 10 million UK adults struggle to understand and act on health information.⁵ This is more common in areas with lower educational attainment and fewer community resources.⁶ Patients may be unsure why the test matters or how to complete it. Cultural and practical barriers compound the problem. Migrant and minority ethnic groups — who are disproportionately concentrated in deprived areas — often face additional barriers, from lower awareness of bowel cancer to cultural sensitivities around stool sampling.^7,8

The result is a perfect storm: lower health literacy, reduced access to resources, cultural barriers, and embarrassment about the test itself. A recent study found that 26% of patients who declined screening cited disliking the procedure as their reason for non-participation.⁹ Such “non-compliant” individuals are part of a wider pattern of exclusion that drives health inequality.

Addressing missingness requires active effort. Initiatives such as “Call for a Kit,” launched in Lancashire in 2015, have demonstrated real impact. Patients who had not returned their kits were invited to a consultation with a health promotion team member, where the test was explained clearly and anxieties addressed. The result was remarkable: 71.5% of those attending went on to return their kit.¹⁰ By targeting those most likely to be excluded, this intervention reduced the gap and gave more people access to early detection.

And yet, we have to be honest about the limits of what GPs can achieve alone. In a Danish study, only 2.1% of participants said their main reason for taking part was that “my doctor recommended it.”⁹ Many of the barriers — cultural, practical, systemic — lie beyond the consultation room. Population-level campaigns have a crucial role to play. NHS England’s 2023 “Your next poo could save your life” campaign used television, radio, social media, and public transport to normalise the conversation. Following the campaign, uptake in London rose from 63% to 69%.¹¹ Interventions like this work partly because they reduce missingness: they make the invisible visible, bringing harder-to-reach groups into the screening process.

Bowel cancer screening has advanced significantly, particularly with the move from g-FOBT to qFIT.¹² The challenge now is to turn strong evidence into fair outcomes. Tackling missingness must be central to this — not just raising overall numbers, but closing the gap. National campaigns and local programmes such as “Call for a Kit” show what is possible. The next step is to make sure that wherever a person lives, they have the same chance to catch bowel cancer early — and the same chance to survive.