Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis

Abstract

Background: Barriers experienced by patients influence the uptake of colorectal cancer (CRC) screening. Prior research has quantified how often patients encounter these challenges but has generally not revealed their complex perspective and experience with barriers.

Purpose: This mixed-methods study was conducted to understand current perspectives on CRC screening.

Methods: A two-part, mixed-methods study was conducted of primary care patients recruited from Virginia Ambulatory Care Outcomes Research Network practices. First, in June-July 2005 a survey was mailed to 660 patients aged 50-75 years posing an open-ended question about "the most important barrier" to CRC screening. Second, beginning in October 2005, seven gender- and largely race-specific focus groups involving 40 patients aged 45-75 years were conducted. Beginning in October 2005, survey verbatim responses were coded and quantitatively analyzed and focus group transcripts were qualitatively analyzed.

Results: Responses to the open-ended survey question, answered by 74% of respondents, identified fear and the bowel preparation as the most important barriers to screening. Only 1.6% of responses cited the absence of physician advice. Focus group participants cited similar issues and other previously reported barriers, but their remarks exposed the intricacies of complex barriers, such as fear, lack of information, time, the role of physicians, and access to care. Participants also cited barriers that have little documentation in the literature, such as low self-worth, "para-sexual" sensitivities, fatalism, negative past experiences with testing, and skepticism about the financial motivation behind screening recommendations.

Conclusions: Mixed-methods analysis helps to disaggregate the complex nuances that influence patient behavior. In the present study, patients explained the web of influences on knowledge, motivation, and ability to undergo CRC screening, which clinicians and policymakers should consider in designing interventions to increase the level of screening.

Figure 1

Top patient-reported barriers; open-ended questionnaire response of the most important reasons why people do not have CRC screening Barriers were not grouped into seemingly similar categories. Rather, particular attention was paid to staying true to the natural language used by respondents in open-ended question verbatim.