Barriers to the implementation of colorectal cancer screening in Serbia: a stakeholder-driven assessment

Abstract Background To investigate the barriers that hamper the Serbian colorectal cancer (CRC) screening program to operate in alignment with evolving European Union screening quality and coverage priorities. Methods The study is based on a structured stakeholder-informed qualitative assessment using a standardized framework developed within the EU-TOPIA-EAST project. The framework consists of a stepwise assessment including: (1) a comprehensive description of national CRC screening activities; (2) identification of key barriers based on their impact on program effectiveness and equity; and (3) detailed analysis of selected barriers. In each step, standardized templates were completed by Serbian stakeholders (program coordinators, clinicians, researchers, and a patient representative) using policy documents, local administrative data, published literature, and expert judgment. Results were consolidated through iterative analysis, a national multi-stakeholder workshop and discussion with international experts. Results Sixteen initial barriers identified through template-based data collection by local stakeholders ( n = 6) were consolidated into eleven after merging similar topics. Finally, nine barriers were defined after a workshop also attended by six screening experts, five of whom had also participated in the data-collection phase. National-level barriers included limited integration across care levels due to not fully developed IT systems, implementation not meeting EU recommendations, incomplete invitation of the target population, weak non-segmented public promotion, and patient deterrents to follow-up colonoscopy. Regional-level barriers included large geographic variation in access to screening, insufficient awareness and risk perception, overburdened public colonoscopy facilities, and insufficient colonoscopy coverage. Conclusions The study demonstrates how a standardized EU-TOPIA-based framework can be adapted for stakeholder-led implementation assessment in resource-constrained screening settings. Collectively, stakeholders perceived these barriers as disrupting the continuity of the screening pathway and contribute to unequal access. Quantitative studies using stratified programme data are required to determine the extent of these inequalities and their effects on outcomes.