Factors associated with initial participation in a population-based screening for colorectal cancer in Catalonia, Spain: A mixed-methods study M. García a,b, ⁎, J.M. Borràs a,c,d , N. Milà a,b , J.A. Espinàs a,c , G. Binefa a,b , E. Fernández a,b,d , A. Farré e , M. Pla e , A. Cardona e , V. Moreno b,d,f a Cancer Prevention and Control Group, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain b Catalan Institute of Oncology-ICO, L'Hospitalet de Llobregat, Barcelona, Spain c Catalan Cancer Plan, Catalan Health Government, Barcelona, Spain d University of Barcelona, Department of Clinical Sciences, L'Hospitalet de Llobregat, Barcelona, Spain e Chair in Qualitative Research, Dr. Robert Foundation, Universitat Autónoma de Barcelona, Bellaterra, Spain f Colorectal Cancer Group, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain abstract article info Available online 2 February 2011 Keywords: Colorectal cancer Mass screening Participation Objective. To identify barriers and facilitators associated with participation in the first round of a population-based program for colorectal cancer (CRC) in Catalonia, Spain and to identify strategies for motivating and supporting behavioral change. Material and methods. A two-part, mixed-methods design was used. In first place, a prospective study of individuals aged 50–69 years (n = 1961) was conducted in 2006–2007. Secondly, focus groups were undertaken with participants and non-participants of the CRC screening, in 2008. Results. Intention to participate was an important determinant of participation (82.9% vs 65.9%, OR = 2.56, 95%CI:1.95–3.36) in addition to knowledge about CRC and its early detection. Respondents who reported that CRC may be asymptomatic in early stages enrolled in the screening program more frequently than those who thought CRC is always symptomatic (49.4% vs 44.8%, OR:1.82; 95%CI:1.3–2.6). Barriers for participation mentioned in focus groups were competing perceived for other health problems and other demands as well as misunderstanding about personal relevance of the screening. Conclusion. Individuals' perceptions of CRC are amenable to change through education-based interventions. Increasing public knowledge related to the burden of CRC and its preventive potential may be an effective way for improving participation in a population-based screening program. © 2011 Elsevier Inc. All rights reserved. Introduction In 2000, a biennial screening pilot program for colorectal cancer (CRC) using fecal occult blood test was implemented in Catalonia, Spain (Peris et al., 2007). The participation, although remarkably low, has been increasing from 17.2% to 31.2% over successive rounds. Thus, factors influencing participation were considered the main aspects to assess in our country to promote an effective application of CRC screening. In 2007, it was proposed to extend the Catalan CRC screening pilot program in a non-urban area, an opportunity to prospectively identify factors related with initial participation and to identify strategies for supporting behavior change. Material and methods This study was designed as a two-stage, mixed-methods project with quantitative and qualitative approaches. A prospective study was conducted in a representative sample of the eligible population for CRC screening, men and women aged 50–69 years old (n = 9749). Subjects (1006 men and 955 women) were interviewed using telephone interview in 2006, prior to be invited to the CRC screening program. Data were collected using a computer-assisted telephone inter- viewing (CATI) software. Study variables included socio-demographic characteristics, health- related variables, and psychosocial variables. Eight months after conducting the phone interview, the entire eligible population was invited to participate in a CRC screening program with biennial fecal occult blood test (FOBT). Bivariate and multivariate logistic regression models were performed. In 2008, a total of six focus groups were conducted (n = 33). Groups were separated by sex to enable candid discussions about CRC screening procedures. We devised an intensive sampling strategy maximizing the variation in dimensions relevant to the analysis: sociodemographic factors (age, gender, level of education, civil status and working status) and the Preventive Medicine 52 (2011) 265–267 ⁎ Corresponding author at: Cancer Prevention and Control Unit; Catalan Institute of Oncology; Av. Gran Via 199-203; 08908 L'Hospitalet de Llobregat. Fax: + 34 93 260 79 56. 0091-7435/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2011.01.012 Contents lists available at ScienceDirect Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed