100 Chapter 4 Later studies were conducted to reveal the decision processes regarding screening participation,17, 18 but detailed understanding of the perspectives of potential participants remains limited. Furthermore, the underlying beliefs and motives to participate in CSPs could differ between subgroups in the population, for example, between people living in urban and rural regions.19,20 Since attendance rates in the largest cities of the Netherlands are especially low, we decided to focus on urbanized regions. The aim of this study, therefore, was to explore the perspectives concerning cancer screening uptake among inhabitants of The Hague, a highly urbanized region in the Netherlands. Insight in the mechanisms underlying these perspectives could probably be leveraged or applied to promote participation in non-attenders in high urbanized regions. Methods This study was conducted using Q-methodology, a mixed-methods approach designed to provide insight in perspectives on a specific topic in a given population.21, 22 Q-methodology can be used for a wide range of subjects, and always has to do with the systematic study of subjectivity.23-26 We conducted the study online due to restrictions following the Covid-19 pandemic. In brief, respondents were presented with a set of opinion statements on beliefs and motivations for participating in a CSP and were instructed to rank them according to agreement. Qualitative data was gathered by asking respondents to explain their ranking of the statements and by follow-up interviews with several selected respondents. Byperson factor analysis was used to identify significant clusters of correlations among the rankings of statements by respondents. The assumption underlying this analysis is that respondents with similar perspectives on participating in CSPs will rank the statements similarly. For each identified factor, a weighted average ranking of the statements was computed, which was the basis for interpretation and description of the factor as a perspective on cancer screening participation. Selected respondents for each of the factors were invited for a follow-up interview to validate the interpretation of the factors and to obtain additional qualitative data for describing the perspectives.21, 22 Statement set development To develop a comprehensive set of statements, representing all the aspects that may be relevant for respondents to express their perspective on the topic, the first two authors (TB, FB) reviewed a large variety of scientific, empirical, and popular literature on motives and beliefs potentially influencing the decision to participate in populationbased CSPs. The scientific literature was reviewed systematically and published previously.16 To structure the statements, and to make sure the set of statements would
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