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Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.106 n.7 Madrid Jul./Aug. 2014




Reasons for participating in the Valencian Community Colorectal Cancer Screening Programme by gender, age, and social class

Motivos de participación en el Programa de Prevención del Cáncer Colorrectal de la Comunidad Valenciana según sexo, edad y clase social



Ana Molina-Barceló1,2, Dolores Salas-Trejo1,3, Rosana Peiró-Perez1,3,4, Mercedes Vanaclocha1, Elena Pérez1,3 and Susana Castán1,3

1Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO). Valencia, Spain.
2Universidad de Valencia. Valencia, Spain.
3Dirección General de Salud Pública (DGSP). Valencia, Spain.
4Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP). Madrid, Spain

This study has received a grant of 4,950 € from the Regional Health Authorities of the Valencian Community through the call for Grants for the "Fomento de la Investigación Sanitaria en la Comunitat Valenciana" (Ref. number: 053/2010).





Objective: To know the reasons to participate or not in a colorectal cancer (CCR) screening programme and to analyze the differences by sex, age and social class.
Methods: Cross-sectional study by a telephone survey directed to a sample of men and women aged between 50-74 year old, participants (n = 383) and non participants (n = 383) in the CCR screening programme of Valencian Community. Descriptive analysis and logistic regression models estimating the Odds Ratio (p < 0.05).
Results: The main reasons to participate are "it is important for health" (97.9 %) and "the test is easy" (97.6 %); and to non participate are "no CCR symptoms" (49.7 %) and "didn't receive invitation letter" (48.3 %). Women are more likely not to participate if the reason was to consider the "test unpleasant" (OR: 1.82; IC: 1.00-3.28), and men if the reason was "lack of time" (OR 0.51; IC: 0.27-0.97); persons 60 or more years old if the reason was "diagnostic fear" (OR: 2.31; IC: 1.11-4.80), and persons 50-59 years old if was "lack of time" (OR 0.44; IC: 0.23-0.85); non manual social class persons if the reason was "lack of time" (OR: 2.66; IC: 1.40-5.10); manual women if the reason was "embarrassment to perform the test" (OR: 0.37; IC: 0.14-0.97); and non manual men if was "lack of time" (OR: 4.78; IC: 1.96-11.66).
Conclusions: There are inequalities in the reasons for not participating in CCR screening programmes by sex, age and social class. It would be advisable to design actions that incorporate specific social group needs in order to reduce inequalities in participation.

Key words: Socioeconomic factors. Early detection of cancer. Colorectal neoplasm. Gender identity. Patient participation. Patient compliance.


Objetivo: conocer los motivos para participar o no participar en un Programa de Prevención de Cáncer Colorrectal (PPCCR) y analizar las diferencias de sexo, edad y clase social.
Métodos: estudio transversal mediante encuesta telefónica a una muestra de hombres y mujeres entre 50 y 74 años, participantes (n = 383) y no participantes (n = 383) en el PPCCR de la Comunidad Valenciana. Análisis descriptivo y de regresión logística calculando las Odds Ratio (p < 0,05).
Resultados: los motivos de participación mayoritarios son "es importante para su salud" (97,9 %) y "la prueba es sencilla" (97,6 %); y los de no participación la "ausencia de síntomas de CCR" (49,7 %) y "no recibió la carta de invitación" (48,3%). Es más probable que las mujeres no participen por el motivo "prueba desagradable" (OR 1,82; IC: 1,00-3,28), y los hombres por "falta de tiempo" (OR 0,51; IC: 0,27-0,97); las personas de 60 y más años por "miedo al diagnóstico" (OR 2,31; IC: 1,11-4,80), y las de 50-59 años por "falta de tiempo" (OR 0,44; IC: 0,23-0,85); las de clase social no manual por "falta de tiempo" (OR 2,66; IC: 1,40-5,10); las mujeres de clase social manual por "vergüenza a hacerse la prueba" (OR 0,37; IC: 0,14-0,97); y los hombres de clase social no manual por "falta de tiempo" (OR 4,78; IC: 1,96-11,66).
Conclusiones: existen desigualdades en los motivos de no participación por sexo, edad y clase social. Sería recomendable diseñar acciones que incorporen las necesidades específicas de diferentes grupos sociales para reducir las desigualdades en la participación.

Palabras clave: Factores socioeconómicos. Detección precoz del cáncer. Cáncer colorrectal. Identidad de género. Participación en programas de salud.



Social inequality in health refers to avoidable and unfair differences in health between socially, economically, demographically, or geographically defined population groups (1). In the case of cancer, social inequalities include inequalities in health along the continuum of the disease throughout the course of life, including issues of prevention, incidence, prevalence, detection and treatment, survival and mortality rates, and disease burden (2).

Screening programmes for colorectal cancer (CRC) are being progressively implemented in all the Autonomous Communities of Spain, following the Council Recommendations of the European Union (3). Reducing CRC mortality depends largely on the percentage of participation in these detection programmes (4), with a minimum participation of 45 % considered acceptable, although levels of 65-70 % are recommended (5). Ensuring equal access to these programmes is likewise considered to be a high priority (6) in order to help reduce social inequalities in cancer, and therefore in overall health.

The Valencian Community (VC) in Spain has implemented a Colorectal Cancer Screening Programme (CRCSP) with a percentage of participation that does not reach that recommended by the European Commission and which is higher for women than for men (7). To increase the participation rate and ensure equal access to this programme, it is necessary to understand the factors that influence these inequalities in participation.

In terms of a theoretical model dealing with the social determinants of health inequalities (8), most research on the factors influencing participation have focused on analysing the structural factors related to the known axes of inequality, namely gender, age, and social class (9,10). Other studies have analysed the intermediary factors related with the knowledge, beliefs, attitudes, and organizational characteristics of the programmes, as well as motives for participating (11-14). All these factors contribute to social inequalities with regard to participation in these programmes, usually placing groups in the less favoured social strata at a disadvantage (15).

Dealing with and influencing the social determinants of inequalities in cancer is complex and requires a multidisciplinary approach (16). Most published research has analysed structural factors and intermediary factors separately, neglecting the influence they can exert on each other. The objective of the present study is to see how structural factors (the inequalities axes of gender, age, and social class) influence intermediary factors (motivations to participate or not in the programmes). To this end, we sought to determine the reasons both for participation and non-participation in the CRCSP of the VC and to analyse the differences by gender, age, and social class. Our broader aim was to gain insight into the social inequalities with regard to participation in these programmes in order to design strategies to reduce barriers by incorporating the needs of various social groups.


Materials and methods

Study scope

The study was conducted within the context of the CRCSP of the VC, an organized programme (7) that began in 2005 which is gradually being implemented throughout the VC. It is aimed at asymptomatic men and women between 50 and 69 years of age; the screening test used is a biennial faecal occult blood test (FOBT). The process of inviting subjects to participate involves sending a letter to the home of each individual patient together with an information leaflet and an acceptance card. People who agree to participate must send the pre-stamped acceptance card by post in order to receive the materials and instructions necessary for collecting the stool sample at home. The stool sample must then be brought to the patient's Primary Care Center and deposited in the special collection boxes provided for that purpose (7). The population data used to generate the list of prospective subjects comes from the Population Information System (PIS) that includes all individuals registered as residents of VC.


This was a cross-sectional study in which a telephone survey was conducted on a representative sample of the target population of the screening programme. The subjects had been invited to participate in the CRCSP between October, 2009, and September, 2010, in the health care areas of Castellón, Sagunto, Valencia, and Denia (Spain).

The study subjects were men and women between 50 and 74 years of age. The sample included participants in the programme, that is, those who carried out and delivered the FOBT, as well as non-participants. Those who had suffered CRC or any other type of cancer were excluded, as were those diagnosed with polyps and/or who were being monitored due to a family history of cancer.

Stratified random sampling through simple affixation was carried out according to programme participation (yes/no). The resulting sample size, assuming an alpha error of 5 %, an accuracy of 5 %, and a probability of 50 % for the different variables considered, totalled 766 subjects (383 participants and 383 non-participants). Within each stratum the sampling was performed via quotas depending on the population size of each health care area, sex, and age.

Study variables

An ad hoc questionnaire was designed by a group of experts using the results of a previous qualitative study conducted within the context of the programme (17) as well as other questionnaires found in the literature (18). The questionnaire was pre-tested on a sample of convenience in order to check the wording of the questions and the duration. A pilot test was also carried out with a sample group of study subjects (15 participants and 15 non-participants) to assess the feasibility of the questionnaire.

The questionnaire consists of a total of 23 questions related to socio-economic variables, knowledge and access to information about the disease and the programme, previous preventive practices, and reasons for participation or non-participation. The analysis presented in this article focuses specifically on the questions referring to the socio-economic variables of age, sex, and social class, as well as those questions pertaining to the reasons for participating or not in the programme (Fig. 1).



Age was categorized into two groups, 50 to 59 or 60 or older; sex, men or women; and social class, manual or non-manual, following the abbreviated classification system of the Spanish Society of Epidemiology (19) and integrating the concept of dominant social class (20). Variables related to the reasons for participation or non-participation in the programme were collected through closed multiple choice questions and were categorized as yes or no (example: "Did you participate in the programme because you believe that it is important for your health?"). Questions about the reasons for participation were given only to those who had participated in the programme while questions on the motives for not participating where only given to non-participants.

Data were collected between January and February, 2011 (between 5 and 16 months after receiving the invitation to participate in the programme), and recorded in an Access database designed for this purpose. Each subject received a maximum of 3 calls made at different times. The interviews were conducted by trained interviewers. All participants in the study gave their informed consent orally. The study was approved by the Ethics Committee for Clinical Research of the General Directorate of Public Health of Valencian Community.

Statistical analysis

A descriptive analysis was performed using the frequencies and percentages of participants and non-participants in the programme in terms of their sex, age, and social class. Similarly, a descriptive analysis of the reasons for participation and non-participation in the programme was carried out.

To understand the relationship between the reasons for participation and non-participation and the variables of sex, age, and social class, we performed separate bivariate analyses of the reasons for participation and non-participation, calculating the chi-square values. Multiple logistic regression models for the dependent variables of sex, age, and social class were adjusted for the independent variables of the reasons for participation on the one hand, and on the other hand, the motives for not participating in the programme, which were found to have a significant association according to the results of the chi-square test. The model for social class was conducted both for the total sample as well as stratified by sex.

The results of the chi-square analyses are shown as p-values while those of the logistic regression models are given in terms of odds ratio (OR) and confidence interval (CI) at 95 %. The level of significance was taken to be 0.05. All analyses were carried out with the aid of the statistics program R.



A total of 785 questionnaires were sent out with a response rate of 59.61 % (Fig. 2).



Table I gives a description of the sample, from which it can be observed that the majority of participants in the programme were women (57.1 %), people aged 60 and over (58.4 %), and people belonging to the manual social class (51.1 %). On the other hand, non-participants in the programme people were mostly men (51.6 %), between 50 and 59 years of age (50.70 %), also from the manual social class (51.1 %).



The main reasons for participating in the programme (Table II) were as follows: Consider that "the test is important for their health" (97.9 %), that "the test is simple to perform" (97.6 %), that "CRC can be cured if detected early" (93.6 %), and that they wanted "to rule out the possibility of CRC" (92.6 %). The main reasons for non-participation were the "absence of CRC symptoms" (49.7 %) and that they "did not receive the invitation letter" (48.3 %).



The analyses of the reasons for participation and non-participation by sex, age, and social class (Table II) showed that the motives for participating were not statistically significant different in terms of sex or social class, but that there were statistically significant differences between the two age groups (p < 0.05), especially with regard to the motive of having a "primary care physician's recommendation". Regarding the reasons for non-participation, statistically significant differences (p < 0.05) were observed with regard to sex for the following reasons: "lack of time," "unpleasant nature of the test," "fear of a CRC diagnosis," and "embarrassed about performing the test." With regard to age the reasons that showed significant differences were "lack of time," "unpleasant nature of the test," "fear of a cancer diagnosis," and "embarrassed about performing the test." By social class the main differences were noted in the motive "lack of time." The analysis of the reasons for non-participation of women and men in terms of social class (Table III) showed statistically significant differences (p < 0.05) for women for the reason "embarrassed about performing the test"; for men the differences were observed for the reason "lack of time."



Since the only statistically significant differences found among participants in the programme were according to age, only one model for the age variable (adjusted for sex and social class) was performed. This model (data not shown in a table) it can be observed that when the reason for participating was "primary care physician's recommendation" the participants were more likely to be 60 years of age or older (OR: 1.665, CI: 1.03-2.669).

For non-participants, multiple logistic regression models for sex, age, and social class (Fig. 3) were performed. Analysis of the relationship between sex and the reasons for non-participation (Fig. 3A) revealed that it was more likely for women not to participate due to their perception that "the test is unpleasant" (OR: 1.82, CI: 1.00-3.28), whereas men were more likely not to participate due to a "lack of time" (OR: 0.51, CI: 0.27-0.97). The analysis of the relationship between age and the reasons for non-participation (Fig. 3B) showed that it was more likely for people aged 60 and older not to participate for "fear of a CRC diagnosis" (OR: 2.31, CI: 1.11-4.80) while people aged 50-59 tended not to be involved because of a "lack of time" (OR: 0.44, CI: 0.23-0.85). Finally, in the analysis of the relationship between social class and the reasons for non-participation (Fig. 3C), it can be observed that out of the total sample, people from the non-manual social class were more likely not to participate due to a "lack of time" (OR: 2.66, CI: 1.40-5.10); however, when stratified by sex, women from the manual social class were more likely not to participate on the grounds that they were "embarrassed about performing the test" (OR: 0.37, CI: 0.14-0.97) while men from the non-manual social class did not participate due to a "lack of time" (OR: 4.78, CI: 1.96-11.66).




This study shows that the reasons for participating in the CRCSP of the VC are broadly similar across the total population, with the main reasons for participation being that "it's important for my health" and that "the test is simple to perform". On the other hand, the reasons for non-participation vary by gender, age, and social class, with the majority of non-participants citing the "absence of CRC symptoms" and the fact that they "did not receive the invitation letter."

Following the health beliefs model (21), the main reasons given by those who participated in the programme are related both to the perceived benefits of participation ("if detected early, CRC can be cured," "to rule out the possibility of CRC," and "it is important for my health") as well as with a perceived lack of barriers with regard to the programme and the test ("the test is simple to perform"). These results coincide with those from previous studies (17,22) in which the beliefs and attitudes associated with participation are associated with greater perceived benefits from and lower perceived barriers to participation. Although generally no differences in motivations for participation were observed when stratified by sex or social class, differences were found with regard to age, with older people more likely than younger subjects to take part upon "primary care physician's recommendation". This may be because older people make more use of health services (23), which in turn would contribute to an increased frequency of recommendations to participate in such programmes by primary health care professionals (24).

Regarding the main reasons for non-participation and once again taking the health belief model into account, there was a perception among non-participants of a low vulnerability to CRC ("absence of CRC symptoms"). These results coincide with those from other studies (25) and show a lack of knowledge about one of the basic criteria for participation in the programme, namely, the absence of symptoms. In addition, our results identify a perceived barrier with regard to the organization of the programme: The invitation procedure ("did not receive the invitation letter"). This is one of the main reasons identified in other studies (26) and constitutes a key element for participation (27). Even though the citing of this particular reason may be masking other motives the subjects did not want to mention, it would still be advisable to identify and reduce the source of possible errors in personal data extracted from the database population through the PIS system currently used by the CRCSP of the VC.

As this study was conducted in the first four health care areas to participate in the CRCSP and because this screening programme is still being progressively implemented, it would be advisable to extend this study to the new areas of implementation in order to analyze whether there are any geographical differences with regard to participation.

From the association found between being women and finding the test "unpleasant" as a reason for not participating in screening, coupled with the results of a study carried out in a similar context (17), it can be deduced that this may be related to a lack of information about the type of test used. The authors of the aforementioned study observed that there was a false belief that the screening programme consisted of a colonoscopy rather than a FOBT, which could condition how people viewed the test. Moreover, if looked at from a gender perspective, we could conclude that this reason may be related to the traditional stereotype of women purity (28), which makes women embarrassed and even ashamed about bodily functions such as defecation. This would, of course, add to the sense women have that the test is "unpleasant." Our results show that this reason is cited more often by women from the manual social class, that is, women whose occupations correspond to a lower educational and socioeconomic level. This may play a role both in the lack of information about the type of test used in the screening programme as well as the greater influence of traditional gender stereotypes.

The association found between being men and citing a "lack of time" as a reason for not participating in the screening can also be interpreted from a gender perspective, namely from a model of a gendered division of labour market. This dichotomy defines "men's work" as being "productive" whereas "women's work" is "reproductive," a division that assigns differentiated values and spaces to both (29). Health care issues have traditionally been associated with the reproductive sphere, to be assumed mostly by women (30). We can thus infer that this implicit assumption on the part of men -that they have a productive rather than a reproductive role- may contribute to the fact that men give less importance to their health care needs. This, in turn, leads to them devoting less time to healthy practices such as cancer screenings. This reason was cited more often by men in the non-manual social class, that is, men with a higher socio-economic level. This may be due to the fact that the men who belong to this social class have a better perception of their own state of health than men from less privileged social classes, which leads to a lower perception of their own vulnerability. Taken together, all of this causes men of this social class to dedicate less time to preventative health measures.

Taking our results into account, it can de advisable that a serious attempt should be made to raise public awareness about the benefits of participating in this type of screening programme, offering clear information about the nature of the test and highlighting the fact that one of the requirements for participation is the lack of CRC symptoms. It would also be recommendable to tailor the information to the intended audience, so that campaigns aimed at men highlight the importance of making preventative health measures a priority while messages aimed at women explain the exact nature of the test. It would also be beneficial to assess the invitation system of the programme as well as the possibility of including new invitation strategies (text messaging, the use of existing organizational structures for breast cancer screening, reminders through primary health care physicians, etc.).

This study adds to our knowledge of the complex interaction between social determinants and participation in CRCSPs in that it has found associations between structural and intermediary factors. This knowledge may thus contribute to raising participation levels in these programmes from an equity perspective, serving as a basis for designing intervention strategies that incorporate the specific needs of various social groups.



We are grateful to the technicians of the Valencian Community Colorectal Cancer Screening Programme for their cooperation and collaboration.



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Ana Molina Barceló.
Fundación para el Fomento de la Investigación Sanitaria y Biomédica
de la Comunitat Valenciana (FISABIO).
Avda. Cataluña, 21.
46020 Valencia, Spain

Received: 31-03-2014
Accepted: 23-06-2014

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