101 Perspectives on cancer screening participation be comprehensive, the Integrated Change model (I-Change model, Figure 1) was used as theoretical framework for structuring the development of the statement set.27 The I-Change model is a health behaviour model, constructed out of several earlier well recognized health behaviour theories, such as: the Health Belief Model, Protection Motivation Theory, Theory of Planned Behaviour and Precaution Adoption Process.28-31 The I-Change model states that health behaviour is determined by underlying motivations and intentions, and was previously used to study different kinds of health behaviours.32-35 Since screening attendance can be seen as a (preventive) health behaviour, the elements of the I-Change model provide a useful structure for identifying the aspects that may be relevant for decisions whether or not to participate in a CSP: information, awareness, motivation, ability, intention and barriers. Since predisposing factors (elements) of the I-Change model are more distal factors, more indirectly associated with screening participation, we thought them to be less relevant for including in a Q-study. Four researchers (TB, FB, MC and VN) developed an initial set of 45 statements based on the collected scientific, empirical, and popular literature. Two external experts were asked to evaluate whether the statement set covered all relevant aspects for the decision to participate in population-based CSPs. Based on their feedback, several adjustments were made; some statements were merged or deleted because they covered similar topics (n=9), some were considered as irrelevant and thus deleted (n=3), and the wording of several statements was revised. Thereafter, we consulted the knowledge institute Pharos (the Centre of Expertise on Health Disparities) to make sure the statements were clear and easily readable for the target population,36 leading to further reduction of the number of statements (n=2) and minor adjustments to language use. This iterative process resulted in a set of 31 statements. To test the comprehensiveness and clarity of the statement set, a pilot study was conducted among two potential study respondents. Based on their feedback, we finalized the set of opinion statements for the main study. 4
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