From barriers to participation: co-creating an effective reminder letter for breast cancer screening among underserved women in Flanders.

backgroundWith over 2 million cases diagnosed annually, breast cancer is a leading cause of cancer-related disability and mortality worldwide. Despite global efforts to implement screening programs, uptake rates vary widely across settings due to socioeconomic factors and accessibility challenges. In 2022 in Flanders (Belgium), breast cancer screening participation in municipalities with an income below the poverty line was 15% lower than average.

methodsTo tackle the limited participation of underserved women in the breast cancer screening program in Flanders, a culturally sensitive approach was used to investigate factors influencing screening participation and to realize a tailored reminder letter to be tested in a later phase. Working closely with community organizations, 33 women aged 50-69 (29 of whom were non-native Dutch speakers) with low-socioeconomic status were identified to participate in the study. Through an iterative process comprising 3 focus group discussions, 3 Delphi-consultations with sector experts, 1 co-creation session and a final member check, critical insights were gathered.

resultsKey barriers included low health literacy and limited understanding of preventive care concepts. Once participants were effectively informed about the breast cancer screening program, they displayed increased help-seeking behaviors in relation to health, underscoring the importance of clear communication in fostering willingness to consider screening. An evaluation of the standard invitation letter employed in the program revealed several challenges related to readability and comprehension. These included the excessive text length, the use of complex vocabulary and grammar beyond an A2 level, slogans unrelated to the mammography appointment (e.g., 'We do it and what do you do?'), and the use of generic visuals. At the same time, simplifying the vocabulary to A1-A2 levels, employing straightforward sentence structures, and incorporating relevant visuals enhanced understandability and fostered interest in breast cancer prevention. Utilizing a color palette associated with breast cancer and featuring logos of local authorities instilled a sense of credibility and trustworthiness. Based on this feedback, a revised reminder letter was developed. The final communication was concise and included essential details such as time and place for screening and a QR code providing translation into 12 languages.

conclusionsSimplifying vocabulary, grouping related information, and providing direct links and language options improved the clarity and accessibility of the reminder letter, thereby fostering help-seeking behaviors related to breast cancer screening.