112 Chapter 4 Discussion The aim of this study was to explore the perspectives concerning cancer screening uptake among inhabitants of highly urbanized regions, where participation rates are particularly low. While earlier studies described general characteristics of (non-)attenders, insight in the underlying beliefs and motivations of potential participants regarding cancer screening participation remained limited.16-18 This study is the first to investigate these underlying beliefs and motivations with respect to cancer screening participation for all three Dutch CSPs together. This provides us insights into the perspectives towards participation in screening in general. Three perspectives were identified using Q-methodology: “positive about participation”, “thoughtful about participation” and “fear drives participation”. The first and third perspective partly overlap in their inclination to participate in CSPs, but significantly differ in the underlying motivation for participating in the CSPs. The second and third perspectives were most distinct from each other. Both the respondents of the first perspective (positive about participation) and third perspective (fear drives participation) are likely to participate in CSPs. In the first perspective the motivation and awareness elements of the I-Change model were found to be central. A positive attitude does seem to be linked directly to screening attendance. In literature, attitude is described to be strongly related with intention, and intention, to be medium-strongly related with screening attendance.43 An overall positive attitude towards the CSPs has been identified as the default among screening eligible people.19, 44-45 Together with this positive attitude, respondents of the first perspective participated since it is the social norm, and thereby (probably) also their personal norm. It is known that screening eligible people often feel a kind of moral obligation to attend, and such feelings are recognized as significant predicators for screening attendance.19, 46 Remarkable was that interviewees with this perspective were not always able to provide correct information on the CSPs and the potential medical follow-up testing. We therefore questioned whether their decision to partake in the CSPs was (always) the result of a well-informed choice, as has been earlier studied by Douma et al., in relation to the publics’ opinion on attending in the colorectal CSP.47 Thereby, is it known that the benefits regarding CSP participation are most often overestimated (and presented).48, 49 In the third perspective motivation elements of the I-Change model were the most important. Respondents attended the CSPs based on feelings of fear and unpleasantness. Such negative emotions were earlier already described as to both facilitate as deter cancer screening attendance.50-52 In an earlier study we identified feelings of inconvenience, insecurity and anxiety towards the screening tests and outcomes, as determinants of low or non-attendance.16 In this study, respondents with the third perspective revealed that an underlying fear, such as worrying to die from
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