Email updates

Keep up to date with the latest news and content from BMC Public Health and BioMed Central.

Open Access Research article

Gender differences in attitudes impeding colorectal cancer screening

Paul Ritvo12*, Ronald E Myers3, Lawrence Paszat45, Mardie Serenity6, Daniel F Perez12 and Linda Rabeneck78

Author Affiliations

1 School of Kinesiology and Health Science, York University, 136 Chemistry Building, 4700 Keele Street, Toronto, ON M3J 1P3, Canada

2 Research, Prevention and Cancer Control, Cancer Care Ontario, 505 University Avenue, Toronto, ON M5G 2L7, Canada

3 Division of Population Science, Department of Medical Oncology, Thomas Jefferson University, 1020 Walnut Street, Philadelphia, PA 19107, USA

4 Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada

5 Institute for Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada

6 Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada

7 Prevention and Cancer Control, 620 University Avenue, Toronto, ON M5G 2L7, Canada

8 Department of Medicine, University of Toronto, 1 Kings College Circle, Toronto, ON M5S 1A8, Canada

For all author emails, please log on.

BMC Public Health 2013, 13:500  doi:10.1186/1471-2458-13-500

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2458/13/500


Received:9 November 2012
Accepted:8 April 2013
Published:24 May 2013

© 2013 Ritvo et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.

Methods

N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.

Results

Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Conclusions

Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders receive identical procedures and confront comparable risks reduced by similar proportions. CRCS is an important context for examining male–female differences in disease-preventive behaviour, because it significantly reduces mortality via early detection (greater likelihood of effective, curative treatment) and prevention (colonoscopy-detected polyps are removable before they become malignant tumours) [1]. Because increased CRCS uptake rates are statistically proportional to reduced mortality [2-7], international efforts are aimed at increasing CRCS rates (e.g. in Canada, United States, Australia, United Kingdom, France, Israel, India, and Italy). Amidst the continual search for approaches that increase uptake, there is acknowledgment that obstructive attitudes impede CRCS [8-13]. Accordingly, precisely identifying screening-obstructive attitudes is necessary for devising interventions to overcome them.

Existing data suggest the obstructive attitudes that stop or delay CRCS and other preventive health behaviours differ by gender [9,14-21]. Accordingly, identification of gender-specific obstructions can be used to more precisely target and resolve the cognitions that impede use of life-improving, life-saving procedures. In addressing how males and females approach CRCS differently, the basic findings of poorer male health (than females), reflected in higher mortality rates [22,23] and the identification of male gender as a significant mortality risk are linked to the less frequent use of health services [24-27]. Even when males progress to health care contacts, they unfortunately spend less time during doctor visits than women, receiving less advice about risk factor reduction [24,27-30]. Male–female CRCS comparisons can help shed light on these deficits in male health care help-seeking given the greater acceptance of and use of health care services by women, and higher screening levels across female socioeconomic-ethnic groups [31,32]. The factors described above likely contributed to a recent finding in a population-based study of CRCS in 1013 adults (aged 50 years and above) where a larger proportion of males (55%) than females (46%) had never heard of Fecal Occult Blood Testing (FOBT), the typical entry-level CRCS modality [33,34].

Female-specific CRCS research, on the other hand, indicates aversion (when compared to men) to both endoscopic screening (internal scoping in flexible sigmoidoscopy or colonoscopy) and FOBT (fecal sampling) [35-45]. In the same population-based study cited above, of the individuals reporting FOBT awareness, 26% of females vs. 17% of males were not considering obtaining FOBT screening [33]. This pattern of greater female FOBT rejection was also found in a patient sample of primary care practice attendees in the US, by Myers et al. [46]. Other findings, however, have identified advantages for males. For example, more men than women attended screening (73% versus 67%) in a large UK community trial of Flexible Sigmoidoscopy (N = 5462) although the higher male attendance was partially explained by the lower levels of socioeconomic deprivation, higher levels of marital status and lower perceived screening barriers in male study participants [16]. Male gender was found to be a significant positive factor for screening uptake (CRC) in accordance with guideline recommendations in an Australian study within a population-based sample of First Degree Relatives (FDRs) of CRC-diagnosed individuals [47]. These male-advantage findings, however, are countered by results from a review of intervention studies meeting moderate methodological rigour where two trials with gender-based analyses demonstrated better effects in females than males [48-50], while in five other trials, no gender-based differences were found [51-55]. Another review focused specifically on participation equity in colorectal cancer screening amongst population subgroups: eight studies were identified that explored gender inequity in access/utilization of CRC screening, and in six of these a higher rate of screening participation was found amongst women compared to men, although screening test type, participant type (membership in high versus low risk groups), and age were found to interact with gender [56]. Two studies demonstrated partial results in that women were more likely to undertake FOBT but less likely to undertake invasive endoscopy or colonoscopy than males [57,58]. In still another review of studies [59] aimed at ascertaining CRC screening rates and impacting factors, 10 randomized trials [60-69] and seven non-randomized studies [70-76] were identified with FOBT screening outcomes while 8 studies were identified with sigmoidoscopy [69,71,76-81] and 2 with colonoscopy outcomes [79,82]; no systematic male–female differences emerged from these studies [59]. Altogether, while there seems a female advantage to some degree, the varying results suggest a need to better understand attitudinal obstacles for both sexes in the detailed descriptions that can be derived from qualitative findings.

Because better understandings of male–female reactions to CRCS can be useful in increasing uptake and informing other health promotion efforts, we undertook a qualitative, interview-based study to pinpoint gender-specific obstructive attitudes. Having directly completed survey studies on gender-related CRCS differences [33,34], we opted for qualitative study to more thoroughly investigate differences via semi-structured interviews, using a population-based recruitment. The transcribed interviews were analyzed to focally identify attitudinal obstructions related to three standard screening modalities (FOBT, Flexible Sigmoidoscopy, Colonoscopy) with the intent of deriving data useful in specifically tailoring CRCS promotions to each gender. As this study was undertaken in Canada, it is important to note that the Canadian Association of Gastroenterology recommended in a 2010 update [83] of their 2004 screening recommendations [84] that individuals of average risk participate in one or both of the following screening regimes: 1) FOBT every 1–2 years or 2) Flexible Sigmoidoscopy every 10 years or longer, with colonoscopy used when judged necessary. Recommendations for screening vary by region and are continuously reviewed, but generally follow a similar approach to Cancer Care Ontario’s Colon Cancer Check, (used here as an example) that individuals 50–75 years of age perform an FOBT every 1–2 years or receive a colonoscopy approximately every five to ten years depending on baseline risk.

Methods

Telephone-based, semi-structured interviews (SSIs) were undertaken by trained interviewers to explore gender differences in attitudes towards CRCS. The SSI questions addressed three screening modalities accessible free-of-charge through Ontario’s screening program: a) FOBT; b) Flexible sigmoidoscopy; and c) Colonoscopy, and focused on 5 attitudinal domains selected to reflect attitudes that would obstruct or facilitate screening uptake, accenting frequently-cited obstructive perceptions (e.g. pain and anxiety) and conscious gender differences (and those the subject was not consciously aware of).

1) Screening Experience at the Time of Interview

2) Key Barriers to CRC Screening Adherence

3) Key Factors Predicting CRC Screening Adherence

4) Experience of Pain and Anxiety Reponses related to CRC Screening

5) Experience of Gender – Differences in CRC Screening

Standard descriptions and explanations of screening modalities were provided when participants indicated knowledge deficits, following the goal of helping participants respond from informed perspectives (based on their personal view of necessary information). This supplementation of current knowledge was carefully undertaken to avoid communicating biases favouring specific attitudes. (See Table 1 for Semi-structured interview schedule).

Table 1. Semi-structured interview schedule

Participants were males and females, 50 years and above, with no prior history of CRC screening, initially contacted by random-digit-dialing who consented to study participation by phone and mail contacts. All were eligible for free-of-charge CRC screening in Ontario and each subject was assessed, using a standard interview, for CRCS screening decision stage using the following criteria: Stage 1 (never heard of the screening modality); Stage 2 (aware but not currently considering screening); Stage 3 (aware, decided against screening); Stage 4 (aware, undecided); and Stage 5 (decided to undergo screening). This staging schema, which derives from the Precaution Adoption Process Model, has been used to characterize persons eligible for CRCS according to their attitudinal proximity to action [85]. As no participants demonstrated Stage 3 (aware but decided against), the remaining stages were clustered, for reporting purposes, into unaware (Stage 1), undecided (Stage 2 and Stage 4) and decided to do (Stage 5) (see Table 2 below).

Table 2. Subject demographics and staging

Interviews were often undertaken in two sessions, when respondents indicated needs to meet other schedule demands or reported levels of fatigue that impeded responses. The mean interview time was 1.8 hours with a range of 0.56 hours to 2.5 hours.

Care was taken to assure that participants could take the time needed to carefully consider all response options before describing experiences. All interviews were undertaken in English. Of the 81 interviews undertaken, 68 were divided into two or more sessions.

Ethics

Approval was obtained from the Research and Ethics Board at the University Health Network in Toronto, Ontario.

Data analysis

The demographic characteristics of the interview participants and their screening stages were tabulated (see Table 1). All interviews were audio-recorded and transcribed verbatim. The constant comparative method was used to identify key themes representing attitudes and preferences that differentiated male–female participants, with the coding of each interview’s content to identify all phrases, key words, and expressed concepts. NVivo 8 qualitative analysis software [86] aided coding the comparisons between expressed concepts identified by participants. The constant comparative method is used to denote a grounded-theory approach that analyzes interview phenomena from the ground-up, focusing on themes that emerge directly from data review, while minimizing the interpretative biases of investigators vulnerable to pre-existing theoretical orientations.

The transcripts of male and female participants were coded together, and then codes and themes were compared with respect to gender. Two unblinded team members coded all transcripts, with periodic discussions between coders and the principal investigator used to mediate discrepancies and derive final codes. Two individuals (one coder and one-non-coder) identified common themes in the data. Finally, two investigators reviewed the common themes and identified those most representative of the gender differences observed. These selections were then reviewed by all investigators and, n some cases, the descriptive terms for theme identifiers were revised.

Results

As seen in Table 1, 49 females and 32 males of screening eligible age were interviewed about each screening modality and staged re: readiness-to-screen. A higher percentage of males were unaware of each modality at the start of interviews, although a higher percentage of females were aware but undecided. Nearly equal percentages of males and females had already decided to do FOBT, although appreciably higher proportions of females had decided to do flexible sigmoidoscopy or colonoscopy. Staging differences were minimal in males for all three modalities, while females appeared to favour both forms of endoscopy over FOBT in their readiness-to-screen.

Dominant obstructive-cognitive themes - females

Bodily intrusion

Subsumed under this first theme were oral and rectal sub-themes, related primarily to colonoscopy and flexible sigmoidoscopy, and to a lesser degree, FOBT. The most notable references were to the oral ingestion of laxative mixture, perceived as directly intrusive as the actual endoscopic procedure. While the intrusion of scoping was perceived to be buffered by tranquilizing medication, laxative ingestion was seen as not buffered and as resulting in diarrhoea, gastric distress and numerous bathroom visits. In terms of scoping intrusion, most participants had difficulty imagining the level of pain relief that rendered an endoscopic procedure relatively painless. FOBT, in contrast, was seen as indirectly intrusive, given its potential unsanitariness and the messiness of managing fecal matter, resulting in exposures to pathogens no less intrusive because they originated in one’s own body.

“The purging aspect of it (ingestion of laxative mixture)… you’re the best friend of the toilet …a 24 hour process…”

(referring to colonoscopy)

“…she said it was too painful …couldn’t stand it…. it was hell … every time…I imagine she wasn’t put totally out…”

(referring to colonoscopy)

“…there’s so much discomfort and so much problems, that it should done in a hospital, not…a doctor’s office….it would be…. Intimidating…”

(referring to colonoscopy)

“…you have to drink a terrible amount of soapy stuff … so you throw it up… then you …try to get the rest… down… it’s the preparation…

(referring to colonoscopy)

“…just unsanitary….if … not done properly…you’d be contaminating things….right? …just unpleasant.”

(referring to FOBT)

“…it sounds gross. It isn’t anything I would ever choose to do….”

(referring to FOBT)

“…not something I’d like to do…I’m put off by it…”

(referring to FOBT)

Perforation anxiety

Separate concerns were verbalized about perforation. Women, undisturbed by the intrusiveness issues described above, expressed anxieties specific to perforation injury. Minimal distinction was made between colonoscopy and flexible sigmoidoscopy

“… somebody could…rip your colon or you could get an infection or something else … you wouldn’t run the risk of that.”

(referring to colonoscopy)

“… it sounds like it could really hurt. That’s… pretty serious…when you have … an anaesthetic….something …. to really consider.

(referring to colonoscopy)

“There have been …cases where there’s … damage to the intestinal system”

(referring to colonoscopy)

Embarrassment

While both males and females identified embarrassment, there was a more personalized and intense expression of embarrassment in relation to medical professionals by females.

“…I’ll just….wear a mask, or paper bag over my head so he doesn’t recognize me…”

(referring to flexible sigmoidoscopy)

“Of course, the ‘con’ would be embarrassment. I can see a lot of people …shying away …. because it’s such a personal thing. Once you have a baby though, I mean ‘hello’ (embarrassment is no longer the obstacle)”

“..I really don’t think …most doctors like doing a rectal examination. And I don’t blame them.”

“..I’ll go to the dentist and have him look down your throat…the other end… that’s very private…”

(referring to flexible sigmoidoscopy and colonoscopy)

Dominant obstructive themes - males

Avoidant procrastination with underlying fatalism

While few male respondents with regular family doctors challenged their physician’s knowledge or intent in promoting screening, resistance frequently took the form of blunting and procrastinating the task of obtaining screening. This was sometimes associated with a vague but persistent notion of being fated for untreatable cancer.

“The advantage of not getting screened…. is to keep your head in the clouds.”

“What you don’t know, doesn’t hurt you….”

“I’ll call it the fear factor… do I really want to know that there’s something wrong?”

“I have this terrible thing (idea) that … it’ll kill you anyway….it’ll get you in the end… so I’d rather not [get screened] now and live my life the way I do…”

“My physician is right in suggesting it….but I keep putting it off…” (referring to colonoscopy)

“I think that men …avoid it (colorectal screening) more… because men don’t like to do …health-related things….I think men are, what’s the word I’m looking for… lazy when it comes to health issues…they believe… it’s never going to happen to them until it’s too late (referring to colorectal screening, generally)

Q. ….if you find yourself delaying health enhancing behaviours or health screening, what is the experience like?

A: “Just being lazy I guess….you know, not feeling it is that important….lazy procrastination…” (referring to colorectal screening, generally)

Unnecessary health care

Males, particularly those who did not maintain regular physician contact, saw CRC screening as an unnecessary component of health care. They tended to see non-symptomatic illness or illness risk as unworthy of attention. Only illnesses with disabling symptoms were seen as necessitating action. While several male respondents saw cancer and CRC, particularly, as frightening diseases, they did not sustain the idea that screening could reduce or prevent CRC impact.

Q. And what would you see as major barriers in obtaining enough knowledge (about CRC screening)?

A. “Lack of interest…if I go read everything on everything, hell, I’d be very busy. So, basically, you know, if you don’t have any kind of symptoms, I’m not going to pursue it….”

Q. What would influence you to get CRC screening?

A. Probably symptoms…I think.

(Referring to colorectal screening, generally)

“…you know unless you absolutely feel …there was something wrong and it should be checked out, I would be highly reluctant to go through it…”

(Referring to flexible sigmoidoscopy and colonoscopy)

Uncomfortable vulnerability

Males also indicated discomfort with the exposure of CRC screening, but more frequently mentioned the ‘position of vulnerability’ in screening, rather than being directly embarrassed in front of a specific health professional. In contrast to the personalized embarrassment of females, males seem to object to being in a vulnerable role position.

“A lot of the guys I know that have it done, they won’t say anything about it…. the females, they talk about it….there’s humility on the female side…females are smarter when it comes to health… because they don’t let their pride or sense of invasion affect them, whereas males do…it’s macho vs. humility.”

“There’s something about that area for men… it’s very vulnerable….putting yourself in that position (when being screened)…”

(Referring to colonoscopy)

“I think males would be more afraid of the body invasion than a female….because [of the] super-macho image whereas women do not have that super-macho image. They have the feeling of, if I’m sick, I want it fixed, whereas for a man, it’s ‘Hey, I'm fine.’

(Referring to colorectal screening generally)

Discussion

The study focused on better understanding the attitudinal obstructions identified by respondents re: CRCS uptake. We specifically focused on gender divergent obstructions manifested in 4 decision-making stages, applied to 3 CRC screening modalities (FOBT, flexible sigmoidoscopy, and colonoscopy). We recruited individuals at: Stage 1 (never heard of the screening modality); Stage 2 (aware but not currently considering screening); Stage 4 (aware but undecided); and Stage 5 (decided to undergo screening).

The conceptual framework was comprehensive and its implementation required adjustments guided by three observations: 1) the great majority of respondents did not articulate as many differences as assumed observable; 2) respondents tended to adopt similar attitudes towards flexible sigmoidoscopy and colonoscopy; 3) interviewees were rarely in a divergent stage re: one modality (e.g. colonoscopy) vs. another (e.g. FOBT) (See Table 1).

The observation that participants, randomly contacted according by RDD, demonstrated attitudes less differentiated than expected, may reflect their true status, given the limits of cognitive nuance on selected topics. Some potential differentiation might have been diminished by socially desirable responding. Participants viewed the research as focused on CRC screening promotion and, at times, seemed reluctant to express responses indicating negative attitudes and rejections of CRC screening.

The gender differences observed were neither closely tied to screening stage nor modality. Women, as predictable from previous findings, reported more consistent physician relationships and appeared more knowledgeable about CRC screening, and better able to articulate views on screening and screening decisions [21,24,87-90]. Men reported less consistent physician relationships, were less knowledgeable and often kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Male-health researchers have speculated that masculine-specific values, constructed during male-to-male social interactions, significantly reduce male health [23,28,29,91-98]. Some hypothesize traditional masculine roles as ‘health hazards’ [94] based on observations that redundant tendencies towards stoicism and emotional suppression, transmitted during masculine-role socialization, are particularly influential in illness and health-related behaviours[93]. Adherence to other masculine role characteristics, like excessive self-reliance and dominance, further impede appropriate health service accessing [21,87,88,92,94,98,99].

The specific kind of vague processing observed in male participants aligns with the blunting construct where anxiety-provoking situations are distanced emotionally and processed ambiguously, with fragmentation of content and timing [100-103]. Rather than acknowledge anxiety and the need to decide, men blunt by distancing anxiety-provoking issues, denying their possible importance and ambiguously referring to timelines for effective action. The blunting construct overlaps with the construct of alexithymia, which defines a more general deficiency in understanding, processing, and describing emotions [104-107]. Males have a higher prevalence of alexithymia (than females) and, when combined with typical socialization patterns, alexythymic-factors can contribute to a greater tendency towards poor screening health practices [104,107,108].

According to both blunting and alexythymic perspectives, when emotions related to decision-making remain ambiguous, actions on one’s behalf (involving confrontation with risk, distress and anxiety) are impeded [107,109,110]. Avoidant procrastination appeared to be a fundamental male characteristic with respect to CRCS. In literature on male socialization, adherence to a ‘stoic’ role impedes disease prevention, as anxiety (about potential disease) is often a motivational factor in protective actions [111,112]. While few males expressed a rejection of CRC screening, males, generally, were less expressively favourable to screening than females. When they demonstrated favourable attitudes, they often saw themselves as simply adhering to physician directions.

Past female-specific CRCS research has indicated aversion (when compared to men) to endoscopic screening (internal scoping in flexible sigmoidoscopy or colonoscopy) and FOBT (fecal sampling without internal scoping) [35-45]. Comparatively speaking, women were observed to more frequently arrive at definite screening decisions, based on protecting personal health, or a delay because procedures were perceived too distressing. Men, in contrast, were reluctant to express outright screening rejections, instead vaguely describing themselves as ‘in the process of’ decision-making and action.

The impeding female attitudes were related to high levels of distress over the physically intrusive, anxiety provoking aspects of CRCS. Anxiety-sensitivity is an applicable construct within current psychological literature, describing a state where problems are avoided because of fears of anxiety-related sensations, based on cognitions about harmful anxiety effects [113-120]. When impeded by anxiety-sensitivity, people hyper-react to immediate stress, feeling stressors do more harm than the good derived from stress-mastery. When gender differences have been tested regarding anxiety-sensitivity, females demonstrate a higher prevalence, with respect to the global construct and tend to score high specifically, on the physical concerns subscale that measures potential physical harm related to anxiety experiences [121]. This describes the state of female participants who rejected screening, not solely because of intrusiveness, perforation fears or embarrassment, but because the associated anxiety-related distress seemed too powerful to even attempt mastery. While lower level anxieties (i.e. worry) may be conducive to screening adherence, as indicated in a recent study on the facilitating effects of worry in breast screening, levels perceived by females as extreme appear to impede screening [122].

Women who have not had CRCS-related endoscopy frequently state as reasons the fear of pain, the fear of positive results, embarrassment, inconvenience, expense and the absence of physician recommendation [8,19,42,123,124]. References to pain are better understood in light of an established finding that females regularly report more pain/discomfort with endoscopy (than men) linked to anatomical differences, although this finding does not account for sedation effects which may attenuate such differences [40]. Additional factors that appear contributive to female endoscopy rejection revolve around embarrassment. Many females prefer female endoscopists [41,43-45,125] and some investigators suggest the availability of more female endoscopists would yield higher screening rates, supported by evidence that women who prefer female endoscopists are less likely to screen [125]. This preference could be addressed by medical schools and residency programs offering fellowships, salary incentives, or other recruitment motivators for female physicians to receive specialty training in gastroenterology.

In terms of CRCS awareness, women have the advantage of more exposure to cancer screening than men, given the recommendations of annual/bi-annual cervical screening (Pap testing) and breast screening (annual/biannual mammography) [126,127]. Existing data supported the facilitative character of these cancer screening modalities as several studies indicate women who participate in breast cancer screening are more likely to participate in CRCS [43,126,128-130].

In applying these findings to screening promotion, the data suggest males should be supported in taking definitive ‘stands’ on screening, given tendencies to ambiguously procrastinate. Tailored promotion may already perform this function (by engaging individuals in systematic decision-making). But the injunction to ‘screen now, not later’ can additionally counteract tendencies to delay and render ambiguous screening timelines. On the other hand, from responses observed, males seem to require a concerted effort aimed at alerting them to the need for disease prevention practices altogether. They seem mired in thinking that only symptomatic and disabling medical problems require care. If this finding is accurate, a deliberate effort to change these fundamental attitudes in support of preventive care is required. For females, their readily expressed anxieties and anxiety-sensitivity could be counteracted by injunctions to focus on the relatively limited interval of distress involved (‘just a few hours could save your life’). With the higher proportions of breast screening adherence, reference could be made to similarly overcoming CRCS anxieties (‘if your breasts are screened, why not your colon?). Other themes worth emphasizing in counteracting female obstructive cognitions are the very low risks associated with colonoscopy, especially when compared to the sizeable associated reductions in CRC risks. This theme can be amplified by referring to the extensive training of colonoscopists and the fact that variably sized colonoscopes can overcome the differences associated with female anatomical factors. In terms of FOBT, emphasis on the specific design features of kits that emphasize cleanliness and prevention of contamination are important. Once again, statistics verifying that these features effectively reduce risks of infection would be further reassuring.

Fatalism, in our data, appears an obstructing attitudinal factor in CRCS in males, confirming existing data suggesting fatalism is an important negative factor in cancer screening in males and females. Current literature suggests elderly individuals, members of ethnic minorities, and individuals from lower socioeconomic backgrounds are particularly susceptible to fatalistic perspectives that prevent or retard cancer-prevention. As our data accented fatalism in males, it’s notable that other studies have also detected a relatively high prevalence of fatalism in males that impedes health preventive and precautionary behaviours [131]. The precision of measurement of fatalistic attitudes has been aided by the development and psychometric validation of instruments like the Powe Fatalism Inventory [132] and further study with more precise investigation is warranted. From our perspective, fatalism could be a factor that influences men to procrastinate and render ambiguous screening schedules and activities. On the other hand, according to the theory of cognitive dissonance, the behavioural delays of screening might reciprocally contribute to the attitude that screening is ineffective, in rationalizing the lack of attentiveness and precaution manifested behaviourally.

In terms of study limitations, the original conceptual framework motivated a plan apportioning 15 participants per gender and screening stage for a total of 120 interviewees (60 males and 60 females). We were only able to recruit and consent about two-thirds of the sample target (N = 81) and were especially hampered by the difficulty of recruiting males. In terms of the obtained sample, we acknowledge that a mean age of 63.7 years (for females) and 65.2 years (for males) may appear to indicate too much emphasis on the more senior decades of CRC screening-eligibility, considering the need for attention devoted to people in their first decade of screening eligibility. The skew in our data was related to being specifically required to not enact an upper limit age by the Canadian Institute for Health Research and can be considered a study limitation. This sampling limitation, however, relates to the concept of saturation in qualitative research which is defined by the threshold reached in data collection when no new information is identified on a specific topic, within a defined subject group. When saturation is reached, additional interviews only yield redundant data rather than novel findings. One controversy regarding saturation involves how many additional participants should be interviewed to confirm no additional information is forthcoming. For example, after concluding 5 interviews that indicate saturation has been reached, a 6th interview might yield novel data. While the subsamples of interviewees (32 males and 49 females) seemed sufficient to achieve saturation, and saturation was observed in the overall gender-specific samples, the participants recruited per screening stage and gender were typically less than N = 15 (the number of interviews often associated with saturation). It is possible then that had we recruited greater numbers of participants, saturation would have been further confirmed, in terms of gender per screening stage. This level of precision awaits future studies that likely will confront the difficulties we encountered. The response rate of contacted individuals through RDD was low (< 2%) meaning that 100 calls yield 2 eligible, consented participants and a total greater than 4000 calls were necessary.

Conclusion

Marked differences were observed in obstructive CRCS cognitions per gender. While females articulated reservations about CRCS-associated distress, males suppressed negative views but ambiguously related to the task of completing screening. Their procrastination sometimes masked a deeper fatalism about cancer disease and disbelief in the preventive-protective elements of screening. While both genders cited embarrassment as an obstacle, female perceptions were personalized (identifying a health provider) while males more generally referred to vulnerability without envisioning a specific person encountered.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

PR, REM, LP, DP and LR drafted the manuscript. PR and DP conducted analyses. PR, REM, LP and LR drafted semi-structured interview questions. All authors read and approved the final manuscript.

Grant support

This research was supported by an operating grant from the Canadian Institutes of Health Research.

References

  1. Imperiale TF, Glowinski EA, Lin-Cooper C, Larkin GN, Rogge JD, Ransohoff DF: Five-year risk of colorectal neoplasia after negative screening colonoscopy.

    N Engl J Med 2008, 359(12):1218-1224. PubMed Abstract | Publisher Full Text OpenURL

  2. Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JM, Parkin DM, Wardle J, Duffy SW, Cuzick J: Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial.

    Lancet 2010, 375(9726):1624-1633. PubMed Abstract | Publisher Full Text OpenURL

  3. Brosnan CA: Review: colorectal cancer screening with the faecal occult blood test reduced colorectal cancer mortality.

    Evid Based Nurs 2007, 10(4):112. PubMed Abstract | Publisher Full Text OpenURL

  4. Hewitson P, Glasziou P, Watson E, Towler B, Irwig L: Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update.

    Am J Gastroenterol 2008, 103(6):1541-1549. PubMed Abstract | Publisher Full Text OpenURL

  5. Kerr J, Day P, Broadstock M, Weir R, Bidwell S: Systematic review of the effectiveness of population screening for colorectal cancer.

    N Z Med J 2007, 120(1258):U2629. PubMed Abstract OpenURL

  6. Littlejohn C, Hilton S, Macfarlane GJ, Phull P: Systematic review and meta-analysis of the evidence for flexible sigmoidoscopy as a screening method for the prevention of colorectal cancer.

    Br J Surg 2012, 99(11):1488-1500. PubMed Abstract | Publisher Full Text OpenURL

  7. Logan RF: Review: faecal occult blood test screening reduces risk of colorectal cancer mortality.

    Evid Based Med 2009, 14(1):15. PubMed Abstract | Publisher Full Text OpenURL

  8. McLachlan SA, Clements A, Austoker J: Patients’ experiences and reported barriers to colonoscopy in the screening context–a systematic review of the literature.

    Patient Educ Couns 2012, 86(2):137-146. PubMed Abstract | Publisher Full Text OpenURL

  9. Friedemann-Sanchez G, Griffin JM, Partin MR: Gender differences in colorectal cancer screening barriers and information needs.

    Health Expect 2007, 10(2):148-160. PubMed Abstract | Publisher Full Text OpenURL

  10. Getrich CM, Sussman AL, Helitzer DL, Hoffman RM, Warner TD, Sanchez V, Solares A, Rhyne RL: Expressions of machismo in colorectal cancer screening among New Mexico Hispanic subpopulations.

    Qual Health Res 2012, 22(4):546-559. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  11. McQueen A, Vernon SW, Meissner HI, Klabunde CN, Rakowski W: Are there gender differences in colorectal cancer test use prevalence and correlates?

    Cancer Epidemiol Biomarkers Prev 2006, 15(4):782-791. PubMed Abstract | Publisher Full Text OpenURL

  12. McQueen A, Bartholomew LK, Greisinger AJ, Medina GG, Hawley ST, Haidet P, Bettencourt JL, Shokar NK, Ling BS, Vernon SW: Behind closed doors: physician-patient discussions about colorectal cancer screening.

    J Gen Intern Med 2009, 24(11):1228-1235. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  13. McQueen A, Vernon SW, Rothman AJ, Norman GJ, Myers RE, Tilley BC: Examining the role of perceived susceptibility on colorectal cancer screening intention and behavior.

    Ann Behav Med 2010, 40(2):205-217. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  14. Rosen AB, Schneider EC: Colorectal cancer screening disparities related to obesity and gender.

    J Gen Intern Med 2004, 19(4):332-338. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  15. Farraye FA, Wong M, Hurwitz S, Puleo E, Emmons K, Wallace MB, Fletcher RH: Barriers to endoscopic colorectal cancer screening: are women different from men?

    Am J Gastroenterol 2004, 99(2):341-349. PubMed Abstract | Publisher Full Text OpenURL

  16. Wardle J, Miles A, Atkin W: Gender differences in utilization of colorectal cancer screening.

    J Med Screen 2005, 12(1):20-27. PubMed Abstract | Publisher Full Text OpenURL

  17. Brawarsky P, Brooks DR, Mucci LA: Correlates of colorectal cancer testing in Massachusetts men and women.

    Prev Med 2003, 36(6):659-668. PubMed Abstract | Publisher Full Text OpenURL

  18. Weinberg DS, Miller S, Rodoletz M, Egleston B, Fleisher L, Buzaglo J, Keenan E, Marks J, Bieber E: Colorectal cancer knowledge is not associated with screening compliance or intention.

    J Cancer Educ 2009, 24(3):225-232. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  19. Weinberg DS, Turner BJ, Wang H, Myers RE, Miller S: A survey of women regarding factors affecting colorectal cancer screening compliance.

    Prev Med 2004, 38(6):669-675. PubMed Abstract | Publisher Full Text OpenURL

  20. Beeker C, Kraft JM, Southwell BG, Jorgensen CM: Colorectal cancer screening in older men and women: qualitative research findings and implications for intervention.

    J Community Health 2000, 25(3):263-278. PubMed Abstract | Publisher Full Text OpenURL

  21. Mahalik JR, Good GE, Englar-Carlson M: Masculinity scripts, presenting concerns, and help seeking: implications for practice and training.

    Prof Psychol Res Pr 2003, 34:123-131. OpenURL

  22. Månsdotter A, Lundin A, Falkstedt D, Hemmingsson T: The association between masculinity rank and mortality patterns: a prospective study based on the Swedish 1969 conscript cohort.

    J Epidemiol Community Health 2009, 63(5):408-413. PubMed Abstract | Publisher Full Text OpenURL

  23. Kruger DJ: Socio-demographic factors intensifying male mating competition exacerbate male mortality rates.

    Evol Psychol 2010, 8(2):194-204. PubMed Abstract OpenURL

  24. Addis ME, Mahalik JR: Men, masculinity, and the contexts of help seeking.

    Am Psychol 2003, 58(1):5-14. PubMed Abstract | Publisher Full Text OpenURL

  25. Tudiver F, Talbot Y: Why don’t men seek help? Family physicians’ perspectives on help-seeking behavior in men.

    J Fam Pract 1999, 48(1):47-52. PubMed Abstract OpenURL

  26. Good GE, Wood PK: Male Gender Role Conflict, Depression, and Help Seeking: Do College Men Face Double Jeopardy?

    J Couns Dev 1995, 74(1):70-75. Publisher Full Text OpenURL

  27. Burkitt G: Strategies for dealing with men in general practice.

    Aust Fam Physician 1999, 28(8):773-774. PubMed Abstract OpenURL

  28. Courtenay WH: Constructions of masculinity and their influence on men’s well-being: a theory of gender and health.

    Social Science &amp; Medicine 2000, 50(10):1385-1401. PubMed Abstract | Publisher Full Text OpenURL

  29. Schofield T, Connell RW, Walker L, Wood JF, Butland DL: Understanding men’s health and illness: a gender-relations approach to policy, research, and practice.

    J Am Coll Health 2000, 48(6):247-256. PubMed Abstract | Publisher Full Text OpenURL

  30. Sabo D: Men’s health studies: origins and trends.

    J Am Coll Health 2000, 49(3):133-142. PubMed Abstract | Publisher Full Text OpenURL

  31. Walsh J, Nguyen T, Nguyen L, Pasick R, McPhee SJ: Healthy colon, healthy life (ruot lanh, song khoe): patient and physician factors associated with colorectal cancer screening among vietnamese americans in a county medical care system.

    J Health Care Poor Underserved 2009, 20(1):74-89. PubMed Abstract | Publisher Full Text OpenURL

  32. Walsh JM, Salazar R, Kaplan C, Nguyen L, Hwang J, Pasick RJ: Healthy colon, healthy life (colon sano, vida sana): colorectal cancer screening among Latinos in Santa Clara.

    California. J Cancer Educ 2010, 25(1):36-42. Publisher Full Text OpenURL

  33. Ritvo P, Myers R, Del Giudice ME, Pazsat L, Cotterchio M, Howlett R, Mai V, Brown P, Sullivan T, Rabeneck L: Fecal occult blood testing: people in Ontario are unaware of it and not ready for it.

    Can Fam Physician 2009, 55(2):176-177.

    e174

    PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  34. Ritvo P, Myers R, Del Giudice ML, Pazsat L, Campbell PT, Howlett RI, Mai V, Sullivan T, Tiro J, Rabeneck L: Factorial validity and invariance of a survey measuring psychosocial correlates of colorectal cancer screening in Ontario, Canada–a replication study.

    Cancer Epidemiol Biomarkers Prev 2008, 17(11):3279-3283. PubMed Abstract | Publisher Full Text OpenURL

  35. Walsh JM, Posner SF, Perez-Stable EJ: Colon cancer screening in the ambulatory setting.

    Prev Med 2002, 35(3):209-218. PubMed Abstract | Publisher Full Text OpenURL

  36. McMahon LF Jr, Wolfe RA, Huang S, Tedeschi P, Manning W Jr, Edlund MJ: Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population.

    Med Care 1999, 37(7):712-717. PubMed Abstract | Publisher Full Text OpenURL

  37. Trauth JM, Ling BS, Weissfeld JL, Schoen RE, Hayran M: Using the transtheoretical model to stage screening behavior for colorectal cancer.

    Health Educ Behav 2003, 30(3):322-336. PubMed Abstract | Publisher Full Text OpenURL

  38. Codori AM, Petersen GM, Miglioretti DL, Boyd P: Health beliefs and endoscopic screening for colorectal cancer: potential for cancer prevention.

    Prev Med 2001, 33(2 Pt 1):128-136. PubMed Abstract | Publisher Full Text OpenURL

  39. Kim WH, Cho YJ, Park JY, Min PK, Kang JK, Park IS: Factors affecting insertion time and patient discomfort during colonoscopy.

    Gastrointest Endosc 2000, 52(5):600-605. PubMed Abstract | Publisher Full Text OpenURL

  40. Thiis-Evensen E, Hoff GS, Sauar J, Vatn MH: Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps.

    Gastrointest Endosc 2000, 52(5):606-610. PubMed Abstract | Publisher Full Text OpenURL

  41. Saunders BP, Fukumoto M, Halligan S, Jobling C, Moussa ME, Bartram CI, Williams CB: Why is colonoscopy more difficult in women?

    Gastrointest Endosc 1996, 43(2 Pt 1):124-126. PubMed Abstract OpenURL

  42. Eloubeidi MA, Wallace MB, Desmond R, Farraye FA: Female gender and other factors predictive of a limited screening flexible sigmoidoscopy examination for colorectal cancer.

    Am J Gastroenterol 2003, 98(7):1634-1639. PubMed Abstract | Publisher Full Text OpenURL

  43. Stockwell DH, Woo P, Jacobson BC, Remily R, Syngal S, Wolf J, Farraye FA: Determinants of colorectal cancer screening in women undergoing mammography.

    Am J Gastroenterol 2003, 98(8):1875-1880. PubMed Abstract | Publisher Full Text OpenURL

  44. Varadarajulu S, Petruff C, Ramsey WH: Patient preferences for gender of endoscopists.

    Gastrointest Endosc 2002, 56(2):170-173. PubMed Abstract | Publisher Full Text OpenURL

  45. Fidler H, Hartnett A, Cheng Man K, Derbyshire I, Sheil M: Sex and familiarity of colonoscopists: patient preferences.

    Endoscopy 2000, 32(6):481-482. PubMed Abstract | Publisher Full Text OpenURL

  46. Myers RE, Sifri R, Hyslop T, Rosenthal M, Vernon SW, Cocroft J, Wolf T, Andrel J, Wender R: A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening.

    Cancer 2007, 110(9):2083-2091. PubMed Abstract | Publisher Full Text OpenURL

  47. Courtney RJ, Paul CL, Carey ML, Sanson-Fisher RW, Macrae FA, D’Este C, Hill D, Barker D, Simmons J: A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients.

    BMC Cancer 2013, 13:13. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  48. van Roon AH, Hol L, Wilschut JA, Reijerink JC, van Vuuren AJ, van Ballegooijen M, Habbema JD, van Leerdam ME, Kuipers EJ: Advance notification letters increase adherence in colorectal cancer screening: a population-based randomized trial.

    Prev Med 2011, 52(6):448-451. PubMed Abstract | Publisher Full Text OpenURL

  49. Marcus AC, Mason M, Wolfe P, Rimer BK, Lipkus I, Strecher V, Warneke R, Morra ME, Allen AR, Davis SW, et al.: The efficacy of tailored print materials in promoting colorectal cancer screening: results from a randomized trial involving callers to the National Cancer Institute’s Cancer Information Service.

    J Health Commun 2005, 10(Suppl 1):83-104. PubMed Abstract | Publisher Full Text OpenURL

  50. Courtney RJ, Paul CL, Sanson-Fisher RW, Carey ML, Macrae FA, Yoong SL: Community approaches to increasing colorectal screening uptake: a review of the methodological quality and strength of current evidence.

    Cancer Forum 2012, 36(1):27-35. OpenURL

  51. Powe BD, Ntekop E, Barron M: An intervention study to increase colorectal cancer knowledge and screening among community elders.

    Public Health Nurs 2004, 21(5):435-442. PubMed Abstract | Publisher Full Text OpenURL

  52. Gimeno-Garcia AZ, Quintero E, Nicolas-Perez D, Parra-Blanco A, Jimenez-Sosa A: Impact of an educational video-based strategy on the behavior process associated with colorectal cancer screening: a randomized controlled study.

    Cancer Epidemiol 2009, 33(3–4):216-222. PubMed Abstract | Publisher Full Text OpenURL

  53. Basch CE, Wolf RL, Brouse CH, Shmukler C, Neugut A, DeCarlo LT, Shea S: Telephone outreach to increase colorectal cancer screening in an urban minority population.

    Am J Public Health 2006, 96(12):2246-2253. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  54. Ruffin MT, Fetters MD, Jimbo M: Preference-based electronic decision aid to promote colorectal cancer screening: results of a randomized controlled trial.

    Prev Med 2007, 45(4):267-273. PubMed Abstract | Publisher Full Text OpenURL

  55. Libby G, Bray J, Champion J, Brownlee LA, Birrell J, Gorman DR, Crighton EM, Fraser CG, Steele RJ: Pre-notification increases uptake of colorectal cancer screening in all demographic groups: a randomized controlled trial.

    J Med Screen 2011, 18(1):24-29. PubMed Abstract | Publisher Full Text OpenURL

  56. Javanparast S, Ward P, Young G, Wilson C, Carter S, Misan G, Cole S, Jiwa M, Tsourtos G, Martini A, et al.: How equitable are colorectal cancer screening programs which include FOBTs? A review of qualitative and quantitative studies.

    Prev Med 2010, 50(4):165-172. PubMed Abstract | Publisher Full Text OpenURL

  57. Ananthakrishnan AN, Schellhase KG, Sparapani RA, Laud PW, Neuner JM: Disparities in colon cancer screening in the Medicare population.

    Arch Intern Med 2007, 167(3):258-264. PubMed Abstract | Publisher Full Text OpenURL

  58. McGregor SE, Hilsden RJ, Li FX, Bryant HE, Murray A: Low uptake of colorectal cancer screening 3 yr after release of national recommendations for screening.

    Am J Gastroenterol 2007, 102(8):1727-1735. PubMed Abstract | Publisher Full Text OpenURL

  59. Subramanian S, Klosterman M, Amonkar MM, Hunt TL: Adherence with colorectal cancer screening guidelines: a review.

    Prev Med 2004, 38(5):536-550. PubMed Abstract | Publisher Full Text OpenURL

  60. Myers RE, Trock BJ, Lerman C, Wolf T, Ross E, Engstrom PF: Adherence to colorectal cancer screening in an HMO population.

    Prev Med 1990, 19(5):502-514. PubMed Abstract | Publisher Full Text OpenURL

  61. Myers RE, Ross E, Jepson C, Wolf T, Balshem A, Millner L, Leventhal H: Modeling adherence to colorectal cancer screening.

    Prev Med 1994, 23(2):142-151. PubMed Abstract | Publisher Full Text OpenURL

  62. Myers RE, Ross EA, Wolf TA, Balshem A, Jepson C, Millner L: Behavioral interventions to increase adherence in colorectal cancer screening.

    Med Care 1991, 29(10):1039-1050. PubMed Abstract | Publisher Full Text OpenURL

  63. Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, Ederer F: Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study.

    N Engl J Med 1993, 328(19):1365-1371. PubMed Abstract | Publisher Full Text OpenURL

  64. Thomas W, White CM, Mah J, Geisser MS, Church TR, Mandel JS: Longitudinal compliance with annual screening for fecal occult blood. Minnesota Colon Cancer Control Study.

    Am J Epidemiol 1995, 142(2):176-182. PubMed Abstract | Publisher Full Text OpenURL

  65. Park SI, Saxe JC, Weesner RE: Does use of the coloscreen self-test improve patient compliance with fecal occult blood screening?

    Am J Gastroenterol 1993, 88(9):1391-1394. PubMed Abstract OpenURL

  66. Friedman LC, Everett TE, Peterson L, Ogbonnaya KI, Mendizabal V: Compliance with fecal occult blood test screening among low-income medical outpatients: a randomized controlled trial using a videotaped intervention.

    J Cancer Educ 2001, 16(2):85-88. PubMed Abstract OpenURL

  67. Thompson RS, Michnich ME, Gray J, Friedlander L, Gilson B: Maximizing compliance with hemoccult screening for colon cancer in clinical practice.

    Med Care 1986, 24(10):904-914. PubMed Abstract | Publisher Full Text OpenURL

  68. Thompson NJ, Boyko EJ, Dominitz JA, Belcher DW, Chesebro BB, Stephens LM, Chapko MK: A randomized controlled trial of a clinic-based support staff intervention to increase the rate of fecal occult blood test ordering.

    Prev Med 2000, 30(3):244-251. PubMed Abstract | Publisher Full Text OpenURL

  69. Bejes C, Marvel MK: Attempting the improbable: offering colorectal cancer screening to all appropriate patients.

    Fam Pract Res J 1992, 12(1):83-90. PubMed Abstract OpenURL

  70. Thrasher JF, Cummings KM, Michalek AM, Mahoney MC, Moysich KB, Pillittere DM: Colorectal cancer screening among individuals with and without a family history.

    J Public Health Manag Pract 2002, 8(2):1-9. PubMed Abstract | Publisher Full Text OpenURL

  71. Burack RC, Liang J: The early detection of cancer in the primary-care setting: factors associated with the acceptance and completion of recommended procedures.

    Prev Med 1987, 16(6):739-751. PubMed Abstract | Publisher Full Text OpenURL

  72. Morrow GR, Way J, Hoagland AC, Cooper R: Patient compliance with self-directed Hemoccult testing.

    Prev Med 1982, 11(5):512-520. PubMed Abstract | Publisher Full Text OpenURL

  73. Spector MH, Applegate WB, Olmstead SJ, DiVasto PV, Skipper B: Assessment of attitudes toward mass screening for colorectal cancer and polyps.

    Prev Med 1981, 10(1):105-109. PubMed Abstract | Publisher Full Text OpenURL

  74. Chait M, Herbert E, Guthrie M, Flehinger B, Winawer S: The memorial sloan kettering cancer center-strang clinic program: a progress report.

    Front Gastrointest Res 1986, 10:102-111. OpenURL

  75. Lieberman DA, Weiss DG: One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon.

    N Engl J Med 2001, 345(8):555-560. PubMed Abstract | Publisher Full Text OpenURL

  76. Struewing JP, Pape DM, Snow DA: Improving colorectal cancer screening in a medical residents’ primary care clinic.

    Am J Prev Med 1991, 7(2):75-81. PubMed Abstract OpenURL

  77. Kelly RB, Shank JC: Adherence to screening flexible sigmoidoscopy in asymptomatic patients.

    Med Care 1992, 30(11):1029-1042. PubMed Abstract | Publisher Full Text OpenURL

  78. Pignone M, Harris R, Kinsinger L: Videotape-based decision aid for colon cancer screening. A randomized, controlled trial.

    Ann Intern Med 2000, 133(10):761-769. PubMed Abstract | Publisher Full Text OpenURL

  79. Winawer SJ, Flehinger BJ, Schottenfeld D, Miller DG: Screening for colorectal cancer with fecal occult blood testing and sigmoidoscopy.

    J Natl Cancer Inst 1993, 85(16):1311-1318. PubMed Abstract | Publisher Full Text OpenURL

  80. McCarthy BD, Moskowitz MA: Screening flexible sigmoidoscopy: patient attitudes and compliance.

    J Gen Intern Med 1993, 8(3):120-125. PubMed Abstract | Publisher Full Text OpenURL

  81. Hahn DL, Berger MG: Implementation of a systematic health maintenance protocol in a private practice.

    J Fam Pract 1990, 31(5):492-502.

    discussion 502–494

    PubMed Abstract OpenURL

  82. Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G: Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380.

    N Engl J Med 2000, 343(3):162-168. PubMed Abstract | Publisher Full Text OpenURL

  83. Leddin DJ, Enns R, Hilsden R, Plourde V, Rabeneck L, Sadowski DC, Signh H: Canadian Association of Gastroenterology position statement on screening individuals at average risk for developing colorectal cancer: 2010.

    Can J Gastroenterol 2010, 24(12):705-714. PubMed Abstract | PubMed Central Full Text OpenURL

  84. Leddin D, Hunt R, Champion M, Cockeram A, Flook N, Gould M, Kim YI, Love J, Morgan D, Natsheh S, et al.: Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation: Guidelines on colon cancer screening.

    Can J Gastroenterol 2004, 18(2):93-99. PubMed Abstract | Publisher Full Text OpenURL

  85. Myers RE, Bittner-Fagan H, Daskalakis C, Sifri R, Vernon S, Cocroft J, DiCarlo M, Katurakes AJ: A randomized controlled trial of tailored navigation and standard intervention in colorectal cancer screening.

    Cancer Epidemiol Biomarkers Prev 2013, 22(1):109-117.

    Epub 2012 Nov 1

    PubMed Abstract | Publisher Full Text OpenURL

  86. QSR: Nvivo 8 qualitative data analysis software. Victoria, Australia: QSR International Pty Ltd; 2008. OpenURL

  87. Macdonald J, Crawford DH: Recent developments concerning men’s health in Australia.

    Aust J Primary Health 2002, 8:77-82. OpenURL

  88. Denner BJ: MAN model: health promotion.

    Aust J Primary Health 2000, 6:230-240. Publisher Full Text OpenURL

  89. Dalziel A, Leishman J: Stop men losing out in the healthcare stakes: men are reluctant users of health services, particularly primary care.

    Practice Nurse 2003, 26:24. OpenURL

  90. Lumb PB: Why is men’s health and well-being policy not implemented in Australia?

    Int J Men’s Health 2003, 2:73-88. Publisher Full Text OpenURL

  91. Mansfield A, Addis M, Mahalik JR: Why won’t he go to the doctor?: the psychology of men’s health seeking.

    Int J Men’s Health 2003, 2:93-109. Publisher Full Text OpenURL

  92. Lee C, Owens G: The psychology of men’s health. Buckingham: Open University Press; 2002. PubMed Abstract OpenURL

  93. Seymour-Smith S, Wetherell M, Phoenix A: ‘My wife ordered Me to come!’: a discursive analysis of Doctors’ and Nurses’ accounts of Men’s Use of general practitioners.

    J Health Psychol 2002, 7(3):253-267. PubMed Abstract | Publisher Full Text OpenURL

  94. Macdonald J, Crawford DH, Gibbs L, Oliffe J: Promoting men’s health. In Hands-on health promotion. Edited by Moodie R, Hulme A. Melbourne: I.P. Communications; 2004. OpenURL

  95. Porter LE, Ku L: Use of reproductive health services among young men, 1995.

    J Adolesc Health 2000, 27(3):186-194. PubMed Abstract | Publisher Full Text OpenURL

  96. Garilov L, Garilova N: The biology of lifespan: a quantitative approach. Chur, Switzerland: Harwood Academic Publishers; 1991. OpenURL

  97. Cameron E, Bernades J: Gender and disadvantage in health: men’s health for a change.

    Sociol Health Illn 1998, 20:673-693. Publisher Full Text OpenURL

  98. Courtenay WH: Engendering health: a social constructionist examination of men’s health beliefs and behaviours.

    Psychol Men Masculinity 2000, 1:4-15. OpenURL

  99. Lee C, Owens RG: Issues for a Psychology of Men’s Health.

    J Health Psychol 2002, 7(3):209-217. PubMed Abstract | Publisher Full Text OpenURL

  100. Miller SM: Monitoring and blunting: Validation of a questionnaire to assess styles of information seeking under threat.

    J Pers Soc Psychol 1987, 52(2):345-353. PubMed Abstract | Publisher Full Text OpenURL

  101. Miller SM: Monitoring versus blunting styles of coping with cancer influence the information patients want and need about their disease. Implications for cancer screening and management.

    Cancer 1995, 76(2):167-177. PubMed Abstract | Publisher Full Text OpenURL

  102. Steptoe A, O’Sullivan J: Monitoring and blunting coping styles in women prior to surgery.

    Br J Clin Psychol 1986, 25(2):143-144. PubMed Abstract | Publisher Full Text OpenURL

  103. McQueen A, Vernon SW, Swank PR: Construct definition and scale development for defensive information processing: an application to colorectal cancer screening.

    Health Psychol 2013, 32(2):190-202. PubMed Abstract | Publisher Full Text OpenURL

  104. Levant RF, Hall RJ, Williams CM, Hasan NT: Gender differences in alexithymia.

    Psychology of Men & Masculinity 2009, 10(3):190-203. PubMed Abstract OpenURL

  105. Helmers KF, Mente A: Alexithymia and health behaviors in healthy male volunteers.

    J Psychosom Res 1999, 47(6):635-645. PubMed Abstract | Publisher Full Text OpenURL

  106. Lumley MA, Norman S: Alexithymia and health care utilization.

    Psychosom Med 1996, 58(3):197-202. PubMed Abstract | Publisher Full Text OpenURL

  107. Levant RF: Research in the psychology of men and masculinity using the gender role strain paradigm as a framework.

    Am Psychol 2011, 66(8):765-776. PubMed Abstract | Publisher Full Text OpenURL

  108. Levant R, Richmond K, Majors RG, Inclan JE, Rossello JM, Heesacker M, et al.: A multicultural investigation of masculinity ideology and alexithymia.

    Psychology of Men & Masculinity 2003, 4:91-99. PubMed Abstract OpenURL

  109. Coriale G, Bilotta E, Leone L, Cosimi F, Porrari R, De Rosa F, Ceccanti M: Avoidance coping strategies, alexithymia and alcohol abuse: a mediation analysis.

    Addict Behav 2012, 37(11):1224-1229. PubMed Abstract | Publisher Full Text OpenURL

  110. Iglesias-Rey M, Barreiro-de Acosta M, Caamano-Isorna F, Vazquez Rodriguez I, Lorenzo Gonzalez A, Bello-Paderne X, Dominguez-Munoz JE: Influence of alexithymia on health-related quality of life in inflammatory bowel disease: are there any related factors?

    Scand J Gastroenterol 2012, 47(4):445-453. PubMed Abstract | Publisher Full Text OpenURL

  111. Wisch AF, Mahalik JR, Hayes JA, Nutt EA: The impact of gender role conflict and counseling techniques on psychological help seeking in men.

    Sex Roles 1995, 33:77-89. Publisher Full Text OpenURL

  112. Good GE, Robertson JM, Fitzgerald LF, Stevens M, Bartels KM: The relation between Masculine Role Conflict and psychological distress in male university counselling center clients.

    J Couns Dev 1996, 75:44-49. Publisher Full Text OpenURL

  113. Haggerty J, Tudiver F, Brown JB, Herbert C, Ciampi A, Guibert R: Patients’ anxiety and expectations: how they influence family physicians’ decisions to order cancer screening tests.

    Can Fam Physician 2005, 51:1658-1659. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  114. Miles A, Wardle J: Adverse psychological outcomes in colorectal cancer screening: does health anxiety play a role?

    Behav Res Ther 2006, 44(8):1117-1127. PubMed Abstract | Publisher Full Text OpenURL

  115. Stewart SH, Karp J, Pihl RO, Peterson RA: Anxiety sensitivity and self-reported reasons for drug use.

    J Subst Abuse 1997, 9:223-240. PubMed Abstract | Publisher Full Text OpenURL

  116. Taylor S: Anxiety sensitivity: theoretical perspectives and recent findings.

    Behav Res Ther 1995, 33(3):243-258. PubMed Abstract | Publisher Full Text OpenURL

  117. Plehn K, Peterson RA: Measuring Anxiety Sensitivity. Mahwah: Lawrence Erlbaum Associates; 1999. OpenURL

  118. McNally RJ: Theoretical approaches to the fear of anxiety sensitivity. In Anxiety Sensitivity: Theory, Research and the Treatment of Fear of Anxiety. Mahwah: Lawrence Erlbaum Associates; 1999:3-13. OpenURL

  119. Taylor S, Cox BJ: An expanded anxiety sensitivity index: evidence for a hierarchic structure in a clinical sample.

    J Anxiety Disord 1998, 12(5):463-483. PubMed Abstract | Publisher Full Text OpenURL

  120. Evatt DP, Kassel JD: Smoking, arousal, and affect: the role of anxiety sensitivity.

    J Anxiety Disord 2010, 24(1):114-123. PubMed Abstract | Publisher Full Text OpenURL

  121. Stewart SH, Taylor S, Baker JM: Gender differences in dimensions of anxiety sensitivity.

    J Anxiety Disord 1997, 11(2):179-200. PubMed Abstract | Publisher Full Text OpenURL

  122. Zhang LR, Chiarelli AM, Glendon G, Mirea L, Knight JA, Andrulis IL, Ritvo P: Worry is good for breast cancer screening: a study of female relatives from the ontario site of the breast cancer family registry.

    J Cancer Epidemiol 2012, 2012:545062. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  123. Janz NK, Lakhani I, Vijan S, Hawley ST, Chung LK, Katz SJ: Determinants of colorectal cancer screening use, attempts, and non-use.

    Prev Med 2007, 44(5):452-458. PubMed Abstract | Publisher Full Text OpenURL

  124. Denberg TD, Melhado TV, Coombes JM, Beaty BL, Berman K, Byers TE, Marcus AC, Steiner JF, Ahnen DJ: Predictors of nonadherence to screening colonoscopy.

    J Gen Intern Med 2005, 20(11):989-995. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  125. Menees SB, Inadomi JM, Korsnes S, Elta GH: Women patients’ preference for women physicians is a barrier to colon cancer screening.

    Gastrointest Endosc 2005, 62(2):219-223. PubMed Abstract | Publisher Full Text OpenURL

  126. Bostick RM, Sprafka JM, Virnig BA, Potter JD: Knowledge, attitudes, and personal practices regarding prevention and early detection of cancer.

    Prev Med 1993, 22(1):65-85. PubMed Abstract | Publisher Full Text OpenURL

  127. Coughlin SS, Berkowitz Z, Hawkins NA, Tangka F: Breast and colorectal cancer screening and sources of cancer information among older women in the United States: results from the 2003 Health Information National Trends Survey.

    Prev Chronic Dis 2007, 4(3):A57. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  128. Burke W, Beeker C, Kraft JM, Pinsky L: Engaging women’s interest in colorectal cancer screening: a public health strategy.

    J Womens Health Gend Based Med 2000, 9(4):363-371. PubMed Abstract | Publisher Full Text OpenURL

  129. Harewood GC, Wiersema MJ, Melton LJ 3rd: A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy.

    Am J Gastroenterol 2002, 97(12):3186-3194. PubMed Abstract | Publisher Full Text OpenURL

  130. Menees SB, Inadomi J, Elta G, Korsnes S, Punch M, Aldrich L: Colorectal cancer screening compliance and contemplation in gynecology patients.

    J Womens Health (Larchmt) 2010, 19(5):911-917. Publisher Full Text OpenURL

  131. Miles A, Rainbow S, von Wagner C: Cancer fatalism and poor self-rated health mediate the association between socioeconomic status and uptake of colorectal cancer screening in England.

    Cancer Epidemiol Biomarkers Prev 2011, 20(10):2132-2140. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  132. Powe BD: Fatalism among elderly African Americans. Effects on colorectal cancer screening.

    Cancer Nurs 1995, 18(5):385-392. PubMed Abstract OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2458/13/500/prepub