113 Perspectives on cancer screening participation cancer, could also be a motivator for screening attendance. Exclusive for this perspective are the comments of the respondents on all knowing people who actually suffered or died as a consequence of cancer. This implies respondents experienced the effects of a cancer diagnosis directly, and therefore feel more susceptible to be diagnosed with cancer. This is most probably also influencing the risk perception of these people. Several health behaviour modules, including the I-Change model, postulate that risk perception motivates screening attendance. In literature there is no consensus regarding this topic, however most recent studies report on, a small positive association of risk perception and screening attendance.53-55 A last distinctive component of the third perspective is their tendency to be less open for external influence and guidance. This could be an important issue when trying to reach out to people holding this perspective, for example by healthcare professionals or policy makers. People within the second perspective (thoughtful about participation) appeared to be more hesitant in making a decision about participating in cancer screening. Therefore, they can be considered critical regarding CSP participation. Key in this perspective are the awareness and information elements of the I-Change model. In contrast to the other two perspectives respondents doubted the effectivity of CSPs and think potential consequences of screening (inter alia false-positive and false-negative test outcomes) participation are more important. These finding relate to the protection motivation theory of Rogers, in which response efficacy and response cost are acknowledged as having an effect on screening attendance.29 Answers in the post-ranking questions suggested respondents were better informed on the possible consequences of the CSPs. This perspective might be related to a need for autonomy as described in a recent study.56 However, our qualitative data, in particular, revealed that participants think about the potential disadvantages of participating and know that screening is not always conclusive. For this reason, we think our participants are more “thoughtful about participation” than that they have a need for autonomy. Unique in this perspective is the role respondents see for their GP as advisor. Previous studies showed that involvement of primary care leads to an increase of screening attendance rates,57, 58 in particular among lower socioeconomic and minority groups.59, 60 This primary care involvement could therefore also be preferred by people who are (more) thoughtful on participation, and thus might be independent of the socioeconomic position in society. Due to several (practical) choices this study has some limitations. First, a Q-methodology study has an exploratory nature and can be used to identify and describe the main perspectives on a topic in a certain population. The sampling strategy used in Q-methodology studies, is however not informative about how common these perspectives are among people eligible for cancer screening participation in general 4
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