Ethics

Ethical approval for the study 2021−349 was obtained by the the University of Toulouse Ethics Committee (CER – Comité d’Éthique de la Recherche) on 8 of March 2021 and the DECODE trial was registered on ClinicalTrials.gov with the trial registration number 2020-A01687-32. The Ethics Committee approved a classification of ‘verbal consent required’ for the trial as the main trial was testing a combined health literacy training intervention for GPs and a patient leaflet and video for patients and deemed verbal consent appropriate. We assigned an inclusion number to each participant in the DECODE trial. This enabled us to link sociodemographic and literacy data to the qualitative data from the interview for patients who had verbally agreed to participate.

Of the 32 items of the COREQ checklist, item 23, which concerned the return of transcripts to participants, and item 28, concerning the verification of feedback by participants, were not applied in the process of collecting and analyzing the qualitative data of this study.

Design

The present study is a cross-sectional qualitative study involving interviews with GPs and patients. GPs and patients were asked about the acceptability of the brochure and video aspect of the intervention, while GPs were also asked about the online training [24].

All methods and results are reported using the COnsolidated criteria for REporting Qualitative (COREQ) research checklist (Additional file 1 COREQ checklist).

Brochure and video

The intervention for patients consisted of two components: 1) a pictorial brochure and 2) an online video produced by the French National Cancer Institute (INCa) that provided practical information on how to conduct the CRC screening test [25].

The printed brochure focused on the main steps of the CRC self-test but also delved into the significance of testing, the target population, and the optimal timing to undertake the test. The brochure was developed using a participatory approach, involving a community advisory group made up of patient experts, citizens, and representatives from cancer prevention institutions [26]. Particular attention was paid to the language used and how the messages were perceived, receiving feedback from individuals who were not at ease with the French language. Verbal consent to participate in the qualitative study was obtained by telephone with participants informed that they were free to stop the interview at any time and they had the right to ask that the interview not be recorded. In addition, we asked the participants to give verbal consent for the interviews to be recorded.

Setting and participants

Data collection

Data were collected via semi-structured telephone and videoconference (via Zoom or Teams platforms) interviews, depending on the participants’ preferences (both GPs and patients). The interview guides were developed based on Normalization Process Theory (NPT) [28], a theoretical model that assists in understanding the integration of complex interventions into standard healthcare practices. The interview guides (appendix 1) comprised 10 questions for patients and 21 for GPs, with follow-up questions if required. All Interviews lasted between 30 and 50 minutes. All data were collected between January 2023 and December 2023.

Interviews with GPs were performed by two researchers (AB and GC) who each interviewed 11 GPs. The GP interview guide questions gathered information on their views regarding the use and potential impact on clinical practice of the intervention, specifically the brochure and video materials given to patients. The topics covered included participants’ opinions on the facilitators and barriers to implementing the intervention, feedback from patients and colleagues, recommendations for regular use and ideal procedural integration, and the likelihood of future utilization.

Patients’ interviews were performed by one researcher (CC). The questions focused on their experiences with the brochure and video, their opinions on the content of those materials, preferences regarding the delivery of the intervention, and suggestions for improving engagement with CRC screening.

In particular, the question posed to the GP in the interview guide was: ‘What did your patients think of the brochure and the video?’ (see Appendix 1). Similarly, patients were asked: ‘What do you think of the brochure?’ and ‘What do you think of the video?’. These questions helped identify differences or similarities in perceptions regarding the information tools.

Data analysis

The interviews were recorded either online or using a dictaphone and transcribed using an external transcription company (AMK, France). The transcripts were anonymised, with only the socio-demographic (age, gender) and literacy data (for patients) linked to them. The transcripts were thematically coded and analyzed using Nvivo 14 software. Each interview was double-coded. Two researchers independently coded each GP interview transcript (AB and GC) and two others independently coded the patient interview transcripts (CC and CA) using a framework analytic approach [29,30]. In both cases, a codebook was created containing all the potential codes. Sub-codes were grouped to identify the primary codes relevant to our research questions. The qualitative analysis adopted a reflective approach [31] by attempting to deconstruct the discursive data as objectively as possible in order to limit the impact of their own representations on the thematic analyses. Quotes from the interviews were selected to represent the concepts, ideas, or perspectives most effectively. Those incorporated in this article were deliberately drawn from a diverse range of participants.

Coding the two sets of interviews

Due to the different sets of interviews conducted and the different objectives, several main codes and sub-codes were identified. For GPs interview analysis, we selected codes that encompassed aspects related to the implementation of the intervention, including the barriers and benefits associated with the use of the brochure and the video, suggestions for their enhancement, facilitators aiding implementation, as well as factors such as time constraints and the diffusion of the intervention.

For the patient interview analysis, codes related to patients’ experiences with the use of the brochure and video, their opinions on, and levels of comprehension of, the content of the materials and their suggestions for improving engagement with CRC screening. The codes related to the barriers and benefits associated with both the use of the brochure and the video were also included. Only the codes we considered most relevant for our cross-analysis with the GP interviews were included in the results.

1. Demographics characteristics of participants

A total of 22 General Practitioners (GPs) and 24 patients participated in the interviews. All the 32 GPs in the intervention arm were initially invited. There were different reasons for non-participation: some GPs had already withdrawn from the trial, some retired or moved to another region.

For patients, the main reasons for not agreeing to take part in the interview were generally a lack of interest in taking part or a lack of time. Of the patients who initially agreed to participate (90 patients), 71% did not respond to requests from the qualitative interview researcher.

The detailed characteristics of the GPs and patients included are shown in Tables 1 and 2.

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Table 1. GPs characteristics.

https://doi.org/10.1371/journal.pone.0329639.t001

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Table 2. Patients characteristics.

https://doi.org/10.1371/journal.pone.0329639.t002

22 GPs were interviewed of which 13 were women and 9 were men with ages ranging from 29 to 62 years (median age of 35). Five or six GPs from each region participated from multidisciplinary GP practices. Eleven interviews conducted via each method (telephone and videoconference) and the duration of interviews ranged from 30 to 60 minutes.

A total of 24 patients were interviewed, 15 women and 9 men, aged from 54 to 67 with a median age of 62 years old. Heterogeneous social (shown by monthly household incomes, highest educational attainment and EPICES scores) and literacy levels (NVS [32] and SILS [33] scores) were represented.

2. Patients and GPs prefer video over brochure for clarity, humor, and effective messaging

The video and brochure, both designed to promote CRC screening, were perceived by patients and GPs as serving different roles. The brochure was viewed as a useful reminder for patients to use at home, while the video was regarded as a tutorial-style tool. However, while the video was valued for its clarity and engaging approach, the brochure was often underutilized, with some GPs finding it redundant. This section explores how each tool was received and the reasons behind the clear preference for the video.

1. a). Video: A Pedagogical and Engaging Tool

The video was widely appreciated by both patients and GPs for its ability to clearly explain the screening process. More than 21 out of 22 GPs considered it an effective communication tool, especially for patients who struggle with reading French.

“So, for me, the video is to ensure that the patient sees it ‘in real life’ in a rather pleasant and modern way without encountering any barriers.” – GP [3]

Patients also emphasized the benefits of the visual format, particularly for demonstrating the test procedure, making it easier to understand.

“Well, with video, you can... you... you understand because the man is... he’s filming himself in action. So it’s... it’s... it’s very meaningful, it’s very meaningful. And even if you don’t understand all the words, I think that by seeing the person do it, you come to... to understand.” – Patient [1]

The inclusion of subtitles in the video further enhanced accessibility, catering to individuals with hearing impairments. However, two GPs expressed concerns about the lack of inclusivity in the video’s portrayal, emphasizing the need for diverse representation to resonate with a broader audience.

1. b). Humor as a tool to normalize CRC screening

The humorous tone of the video was widely praised by both patients and GPs for its ability to alleviate anxiety and normalize discussions about CRC. The actor portrayed the process of using the toilet for the test in a humorous way by blending actions, words, and mimics, which amused patients during the display of video, according to the GPs. The video’s vivid depiction of stools provided a more approachable angle to a typically uncomfortable topic, as reported by GPs. Furthermore, two-thirds of the patients (n = 16) emphasized the significance of the light-hearted tone adopted in the video. The main character’s humorous and de-dramatizing demeanor was appreciated. This approach effectively addressed some patients’ fears regarding CRC, a topic often deemed « taboo » or sensitive. By injecting humor, the video successfully normalized the situation, making it more palatable for patients.

“I found it very approachable and I thought the guy was, he was very simple and he expresses himself very well and in fact, it de-dramatizes a lot. There’s even a touch of humor at one point when he’s on the throne.”- Patient [15].

This perception was shared by GPs, who noted that humor helped reduce patient stress and make the screening process feel less intimidating. Several GPs reported that patients often laughed or smiled while watching the video, which created a more relaxed atmosphere during consultations.

“I think it’s great when patients laugh while watching it because it’s a topic that can be a bit stressful, of course, we’re talking about cancer screening, but actually, almost every time, they laugh. [...] I think it makes it less dramatic [...] So, they seemed a bit more... well, a bit reassured [...] to say: ‘Well, actually, it’s fine, it’s really not complicated’.” – GP [3]

1. c). Brochure: underutilization and misunderstanding

Despite the brochure’s potential, GPs mentioned that they often underutilized it. More than two-thirds (n = 14) indicated that they had not used it and had simply handed it over without much conviction. Seven GPs cited their familiarity with the existing brochure in the French screening kit as a reason for this underuse.

“(...) it’s true that I didn’t find the brochure very user-friendly. But I’m telling you, I was so used to the other one that maybe I also had a mental block.” – GP [5]

Almost half of GPs (n = 9) expressed the opinion that the study brochure was redundant and 1 GP felt the screening kit brochure was redundant. Consequently, there were suggestions to combine the two brochures into a single, more streamlined resource to reduce paperwork for both patients and practitioners.

“Combining the two, because it’s a lot of paperwork for them, you know.” – GP [7]

From the patients’ perspective, the brochure’s content was still considered too dense, which tended to water down the key messages:

“...you can’t say it’s poorly done, but I find it packed with a lot, a lot of information. For example, I preferred the video a hundred times over this” Patient [14]

Several misunderstandings were also raised, such as the images of the colon and intestine not being explicit enough, or words that were not understood, such as “literacy”, misunderstood by at least two respondents:

“Everything is complicated, the terms are complicated, so there you go, we really need a lot more diagrams, and bigger diagrams.” Patient [13]

However, among the respondents, 10 said they had used the DECODE brochure to talk about colorectal cancer screening with those around them (family, colleagues), and 13 are planning to do so:

“I had already had it in my hand [...] I think a year ago, as my mum had just had a positive test result [...] she was really worried [...] we had looked at it together, I had tried to reassure her a little “ Patient [14].

“Oh yes, of course (regarding sharing the brochure) [...] if, for example, at work, someone was to bring up the subject with me [...] I would easily be able to tell them that there are tools that are very well suited for this and that they can check out.” Patient [12].

1. d). A preference for the video over the brochure

Most patients preferred the video due to its educational nature and ease of understanding, particularly regarding the self-test procedure. They appreciated the visual demonstration provided by the video, which simplified complex concepts and made the process more accessible:

“(...) by reading, I find it much less accessible than video” – Patient [6]

As expressed by almost half of patients (n = 10), communicating orally and mimicking technical and medical information allowed for greater understanding and accessibility of the information.

“Well, maybe the video will explain what the brochure doesn’t, how to properly follow the sampling method. The sampling method, eh, it does the... it’s well shown how... how you have to do it simply and quickly “ - Patient [4]

Almost all the GPs (n = 21) echoed patients’ preferences for the video, highlighting its ability to facilitate communication, promote understanding, and serve as a memory aid for medical professionals during consultations:

“The fact that there was also the video, it’s true that it was still, let’s say, an additional comfort. It allowed me not to forget anything.” – GP [11]

According to half of the GPs (n = 11), the highly visual format of the video, resembling a tutorial, was well-suited not only for “patients struggling with reading French” but also generally appeared suitable for all audiences.

Overall, while both the video and brochure had their merits, the video emerged as the preferred tool for promoting CRC screening due to its clarity, accessibility, humor and ability to engage and reassure patients effectively.

3. Integration of the DECODE intervention into primary care consultations: duration, challenges, and patient preferences

1. a). Consultation context and time constraints

The integration of the DECODE intervention into consultations varied among GPs and circumstances. Factors such as the accumulated delay of consultations throughout the day, and the reasons for the patient’s visit, influenced the time dedicated to presenting the intervention. The brochure and video were typically presented during routine or follow-up consultations, usually towards the end or occasionally before the clinical examination (n = 20). A minority of GPs sometimes offered it in the waiting room (n = 2) before or after the consultation, to save time. The duration of the intervention, both showing the video and providing the brochure, ranged from 5 to 10 minutes, which is significant given that consultations lasted between 15–30 minutes. Challenges arose when consultations were rushed or disrupted, leading to difficulty in prioritizing CRC screening discussions.

“There are times when I would have wanted to do it, and we had already spent 40 minutes, you think, ‘Well, I won’t do it today, you know.” – GP [1]

Even though GPs faced these challenges, patients still expressed a clear preference for receiving the DECODE brochure and video during consultations with their GP or another healthcare professional, valuing the opportunity for discussion and finding the presence of a healthcare professional reassuring and valuable. Most patients were not interested in using the QR code for home access before or after the consultation with their GP.

“If we receive this kind of document by post, it’s likely to end up in the garbage can. On the other hand, if a doctor shows them to us, it’s much more valuable and I think it’s more likely to make an impression.” – Patient [22]

This sense of direct engagement with a healthcare professional was particularly important for patients who found that a conversation helped simplify complex information and ease concerns about screening.

“... I found it very useful …it makes things a lot easier to understand…. we need someone to talk to us from time to time, even if we have intellectual abilities, to talk to us simply as if almost to a child, to de-dramatize something that isn’t so, but that might seem so even to more... more educated people.” – Patient [19]

1. b). Time as a necessary investment and a key barrier

All GPs emphasized the importance of investing time in explaining screening procedures to patients. They believed that this investment not only enhanced patient understanding and acceptance but also strengthened the patient-healthcare professional relationship. GPs who initially hesitated to allocate time for patient prevention have recognized the value of thorough discussions in facilitating patient involvement and adherence to screening protocols.

“Yeah, it was kind of time-consuming, but you know, at the same time, I can’t say I didn’t like it. It’s a drawback, but it’s linked to any intervention, really. When you want to do it right, it takes time, you know... and for us, we’re always dealing with these time management issues every day.” – GP [8]

GPs who previously opted to simply hand out testing kits without dedicating time to explain it to patients have recognized the critical role of patient education and involvement in the screening protocol. Initially concerned that thorough test discussions would overly extend consultations, these practitioners had discovered that integrating test presentation seamlessly into patient encounters was feasible without significantly elongating visits. Their participation in the DECODE trial has led to a shift in perspective, demonstrating that presenting the test need not demand a substantial time commitment.

“I also think that participating in this study makes you realize that the time it takes to explain to patients how to do colorectal cancer screening isn’t necessarily as significant as you might think. So, realizing that through practice probably makes us more likely to... to do it more often later on, you know.” – GP [10]

1. c). Using the video to optimize time

The brief three-minute video component of the intervention was viewed as an opportunity for time optimization, allowing GPs to attend to other tasks while patients viewed it.

“Ultimately, the video saves us time because during that time, we can do other things in the patient’s file, you know... It’s just a matter, I think, of organizing ourselves to... to use it, you know. And knowing that at some point, there will be a time when the patient will be watching the video, and so we will do something else at that time. His prescription, a paper, filling out the paper.” – GP [7]

Moreover, GPs perceived the video as an investment that could potentially save time in the long run by motivating more patients to undergo screening and reducing the need for follow-up reminders.

“In essence, when the video is useful and justified, it’s not a waste of time. On the contrary, it actually saves us time in the long run.” – GP [5]

The importance of the interaction between the patient and GP was highlighted from both perspectives. Despite the time required, the GPs who had adopted it were aware of the importance of talking verbally with patients about screening, and of using their time efficiently in the consultation. However, they also acknowledged that, in a busy practice, time constraints often made it difficult to consistently engage in detailed discussions, forcing them to prioritize certain aspects of care over others.

4. Improve prevention by disseminating tools and delegating preventive tasks to meet GPs’ time constraints and patient preferences

1. a). Delegation of preventive tasks to other healthcare professionals

In response to their time constraints and to patient preferences, GPs considered delegating preventive tasks to other healthcare professionals, such as nurses or medical assistants. The influx of patients, the urgency, and the complexity of their situations at times, as well as the high mental burden for caregivers in contact with vulnerable populations, were all arguments put forward to justify the delegation of prevention tasks.

“Doing it during...during consultations is fine, but often, we’ll lack a bit of time and we’ll be less thorough than if we had dedicated time. That’s why, currently, unable to do it ourselves given the current state of pressure (...) the number of... patients to see, integrating the medical assistant, the nurse practitioner, that can be interesting with dedicated consultations with them (...) ideally, at the moment, that’s what I’m thinking about.” – GP [10].

The GPs who had already implemented this system (= 2) noted improved patient care for screening through delegation as dedicated consultations with nurses often resulted in better attendance and outcomes.

“So, sometimes, often, they don’t come just to talk about that. However, when I schedule them with the nurse to discuss this, it’s quite surprising, they come more easily. And well, the nurses have time slots... The Asalée nurse [qualified advanced nurse practitioner], she has one-hour slots, you know.” – GP [8]

This GP also observed that the nurse achieved better screening results: “She’s trained in motivational interviewing.

So, she had completely mind-blowing success rates for tests, you know. She easily beats me on... on these success rates. So... so in this case, it’s an appointment with her, actually. And she shows the video, because I’m overwhelmed. I have a three-week wait.“

According to this GP, there was indeed a connection between the time spent discussing screening and the patient actually taking the test. The presence of a qualified advanced nurse practitioner, the ASALÉE nurse, a specialist of therapeutic education whose role is to facilitate and improve the care of patients suffering from a chronic pathology, certainly enhanced the probability that the patient undertook the screening test.

I really have the impression that when we have dedicated time, when we take the time, when we watch the video, well, it works... it works better. [...] And in fact, I think there’s also a... a proportional effect in terms of time spent and success, you know. So typically, the Asalée nurse, with 45 minutes to an hour, has a better chance than me.“- GP [8]

However, setting up dedicated prevention consultations, whether with a GP or another health professional, was considered ideal but difficult to achieve due to logistical challenges and patient engagement.

“In an ideal world, I think it would be great if we had the opportunity to present what screening is and the tools in a more collective time (...) it would be even richer because, well already, it allows reaching several people at the same time and it allows for interaction between the people present. (...) After, we know that it’s not always easy because to get people to come for collective time, they already have to have an interest in coming (...)”. - GP [11]

1. b) Expanding awareness and increasing accessibility of CRC screening

To improve prevention, some of the patients had suggested sharing information on CRC to younger people in order to raise awareness as early as possible. Several patients were spontaneously surprised by the age range targeted by the screening procedures [i.e., 50–74], mistakenly thinking that CRC only concerned this age group, which could minimize awareness of the consequences of CRC before age 50 and after age 74.

“Yes, I wouldn’t worry about introducing the tools to... to my wife but also to my children, I think they need to be made aware too.” – Patient [12],

Another patient shared concerns about the upper age limit for screening, questioning why people over 74 were no longer eligible.

“I was recently concerned by the fact that this test was limited in terms of age, i.e., that from the age of 74... 74, 75, you were no longer eligible...” – Patient [9] NVS score = 3, SILS score = Occasionally, EPICES score = 23,67.

Furthermore, to increase the visibility and accessibility of the video and brochure, and enable healthcare professionals to integrate the two components into the routine consultation, several patients suggested showing the video and having copies of the brochure in waiting rooms in GPs’ offices.

“And I thought that even in GPs’ waiting rooms, why not, uh, make some broadcasts of the video or... of this order as... as general information so that, well... here, “to trivialize this kind of... of examination which allows a follow-up finally of... finally, all that relates to prevention, I find that it is nevertheless a neglected sector by..., the whole medical system, unfortunately.” – Patient [6]

Similarly, another patient emphasized the value of printed materials in waiting rooms, explaining that patients often look at available documents while waiting for their consultation.

“When we... when... when we’re waiting in... when we’re waiting in doctors’ waiting rooms, personally, I look at all the documents that are available to... to... and I think it [brochure and video] could fit into that framework.” – Patient [7]

In addition to disseminating the tools within the medical environment, other patients and some GPs also suggested disseminating the tools within the media and social networks for greater visibility and accessibility.

The presence of a nurse or other professional figure devoted to prevention could help GPs in taking charge of this part of the consultation. In France, this is a major difference between GPs practicing alone or with associates and multidisciplinary structures.

Characteristics of research team

The principal investigators (PIs) M-A Durand, PhD and A Lamouroux PhD are experienced public health researchers with backgrounds in health psychology, interventions and qualitative methodologies. The GPs interviews were conducted by trained researchers (G Cazorla, MSc and A Boirot, PhD) with the trial team. Patient interviews were conducted by a different researcher (C Casanova, PhD) of the same team, all trained in qualitative methodologies and analysis. No prior relationship between interviewers and patients or GPs were established before the interviews, and the only information given to patients and GP about the interviewer was that she was member of the research team of the study. In addition, the wider trial team supported the recruitment of GPs and patients to the qualitative study including the trial manager (NM Redmond, PhD) and the 4 regional Clinical Research Associates (M Kaou, MSc, Z Doukhi, MSc, M-C Addamiano, PhD, F Couranjou, MSc). Standardized procedures were used to support the recruitment and the wider team aided the qualitative study in data cleaning and data analysis.