Barriers and facilitators to population participation in colorectal cancer screening: an umbrella review

Colorectal cancer is the third most common malignancy and the second leading cause of cancer-related death globally. Colorectal cancer screening reduces incidence and mortality by detecting precancerous lesions or early-stage tumors, but low participation, particularly among asymptomatic groups, limits its public health value. Implementation Science and the Theoretical Domains Framework help identify health behavior barriers and facilitators, while Behavior Change Techniques support targeted intervention design. This umbrella review aimed to 1) identify behavioral barriers and facilitators of population engagement in colorectal cancer screening using the Theoretical Domains Framework; 2) develop theory-informed implementation strategies by combining the framework-derived factors with Behavior Change Techniques to improve screening participation, with stratification by screening program type. Following Joanna Briggs Institute umbrella review methodology and PRISMA guidelines, and registered in PROSPERO (CRD420251057739), key databases (PubMed, Web of Science, etc.) were searched in June 2025 for reviews on screening barriers/facilitators. Quality was assessed via Meta Quality Appraisal Tool and Assessment of Multiple Systematic Reviews, evidence confidence via GRADE-CERQual. Barriers/facilitators were categorized by the 14-domain framework, stratified by “organized screening programs” and “opportunistic/mixed screening programs”, and Intervention Mapping matched factors with Behavior Change Techniques for strategy development. 1,513 records were identified, with 24 eligible reviews (20 systematic, 4 narrative) covering 612 studies. Overlap was negligible (Corrected Covered Area 0.6%), 67% of reviews were low-quality (insufficient bias control). Stratification identified 11 organized screening programs and 13 opportunistic/mixed programs. Top influencing framework domains (48% cumulative) were: 1) Environmental Context and Resources (organized programs: service accessibility barriers; opportunistic programs: economic burden); 2) Optimism (cancer fatalism, unrealistic risk views); 3) Social Influences (physician recommendations, family support). Fourteen domain-specific strategies (e.g., tailored education, economic incentives) were developed, with stratified adaptations for different program types. A conceptual framework diagram summarizes the core logic of “TDF domain - barrier type - BCTs - stratified strategies”. This review identifies eight key findings, with core conclusions (three dominant Theoretical Domains Framework domains, program type-specific stratified barriers) of high evidence strength and marginal domain conclusions of low evidence strength. It confirms multi-level colorectal cancer screening barriers with program type-specific differences and provides a theory-driven “barriers-techniques-strategies” framework. Despite variable quality of included reviews and Western bias, the findings offer reliable guidance for targeted interventions and policy. Future research should empirically test the strategies in randomized controlled trials and explore their applicability in low-resource regions.