A total of 14% of the study population (n=1543) had a negative attitude towards CRC screening. Men, older people, and those with South-Asian ethnic backgrounds were more likely to have negative attitudes; whereas Black-Caribbean people, those with multiple symptoms, and those with abdominal pain, bleeding, and tiredness were more likely to have a compliant attitude.
Our findings are consistent with the results of the UK CRC screening pilot study, indicating a negative attitude towards CRC screening among men and people in older age groups (Weller et al, 2007
). The influence of age was previously observed in the survey of opportunistically supplied FOBt kits by GPs, with 62% of patients aged 50–69 years returning kits compared with 54% aged 70 years or over (Hobbs et al, 1992
). People over the age of 70 years tend to perceive themselves as having a lower risk of CRC (Robb et al, 2004
), which could go some way towards explaining their less favourable attitude toward CRC screening.
In our study, females reported multiple symptoms significantly more frequently than male respondents. Nearly 60% of those who reported three or more symptoms were female; this could partly explain their more favourable attitude towards screening. On the other hand, the findings of the impact of gender on the uptake of bowel cancer screening have been equivocal. One recent systematic review of adherence to CRC screening found that women were less likely to comply (Subramanian et al, 2004
), whereas another found no difference in terms of age and gender in referral delay (Macdonald et al, 2006
). In our study, older age could not explain differences in attitudes between ethnic groups, as there were no significant differences in age distribution between the ethnic groups, except among those with an Indian ethnic background who were significantly younger than those with a white ethnic background. A UK CRC screening pilot report of the impact of ethnicity on screening uptake suggests that low uptake rates cannot be explained by differences in age, gender, or deprivation index (Szczepura et al, 2003
). Similar findings have been reported elsewhere: in a recent study conducted in the USA, ethnic minority groups reported lower CRC screening attendance than people with white ethnic backgrounds. The results remained significant after controlling for demographic factors (Jerant et al, 2008
). In our study, ethnicity was the strongest predictor of attitudes toward CRC screening after controlling for other factors, suggesting that negative attitudes toward screening are likely to be culturally influenced.
Our findings on the impact of ethnicity are in line with the results of the UK CRC screening pilot study, where a lower adherence for screening was reported among South-Asians compared with white and black participants (Szczepura et al, 2003
). Black participants also showed strongest intentions to attend for screening, which reflects a positive attitude towards CRC screening among the members of this ethnic group (Robb et al, 2008a
). In our study, Black-Caribbean respondents had a more favourable attitude towards CRC screening than white respondents. Considerably, more Caribbean respondents were women (65%), which could partly explain their more favourable attitude towards CRC screening. Some ethnic minority groups have also been found to be more likely to express fatalistic beliefs about cancer than people with white backgrounds (Subramanian et al, 2004
; Johnson et al, 2008
; Robb et al, 2008a
). A belief about ‘tempting fate' by undergoing cancer screening may therefore contribute to a negative attitude among some ethnic minority patients.
In our study, people with symptoms were more likely to have a positive attitude towards screening. People with multiple symptoms are also likely to perceive their risk of bowel cancer to be higher (Robb et al, 2004
) and are less likely to delay referral (Mitchell et al, 2008
). Patients tend to consult more quickly when their symptoms are, or are perceived to be, more serious, including the presence of pain or bleeding (Smith et al, 2005
; Macdonald et al, 2006
; Mitchell et al, 2008
). We found that people with abdominal pain, bleeding from the back passage, and tiredness were more likely to have a positive attitude to CRC screening. We have demonstrated that 38% of this community sample were experiencing symptoms and 88% of these had a positive attitude toward screening. If, on receipt of an invitation for bowel screening, those who have symptoms come forward for investigation, then screening may facilitate earlier diagnosis. Nevertheless, the role of screening is to identify asymptomatic disease. Interventions are required to ensure that those with symptoms present promptly for investigation.
The attribution of illness often arises when symptoms develop and begin physically restricting everyday life, especially among men (Smith et al, 2005
; Mastalski et al, 2008
). In our study, with the exception of tiredness, duration of symptoms was not associated with reported attitudes toward CRC screening.
South-Asians have been reported as being less aware of bowel cancer and less confident about the effectiveness of screening (Robb et al, 2008b
). According to a population-based study, non-white respondents viewed their risk of bowel cancer as lower than their peers (Robb et al, 2004
). There are ethnic differences in the risk of developing bowel cancer (Swerdlow et al, 1995
; Renehan et al, 2008
). People from lower-risk groups are therefore less likely to have direct experience of the disease among their family and friends; and are therefore less aware of the symptoms and signs of CRC. This could explain negative attitudes to CRC screening among some of the ethnic minority groups in our study.