A total of 30 community members and 20 healthcare providers participated in the study. Participant characteristics are summarized in Tables 1 and 2. Following the PRECEDE-PROCEED model, we organized our findings into two broad categories: (1) barriers and (2) facilitators of CRC screening. Additionally, each barrier and facilitator was classified within a level of the Social Ecological Model. Figure 1 summarizes our findings. It represents the perceived barriers and facilitators for participation in a CRC screening program in this community at the different levels of the Social Ecological Model, where all levels interact with each other. Representative examples of participants’ quotes for the most relevant codes are presented in Tables 3 and 4.
Perceived Barriers to CRC screening
Health policy barriers
Barriers at this level were identified only by healthcare providers employed at the Endoscopy Unit at INCan, who reported numerous barriers to the expansion and sustainability of INCan’s current CRC screening program. Identified barriers included: budget constraints, lack of interest from policy makers leading to insufficient promotion of CRC screening, and dissemination of inaccurate information about CRC in mass media campaigns.
Social context barriers
Poverty was the most commonly perceived barrier to uptake of CRC screening, as reported both by community participants who would be the targets of screening and the primary healthcare providers who serve this population. Participants in all groups consistently brought up concerns about costs of tests and described living conditions that prevail in the area and the daily difficulties that patients face to cover basic needs (e.g., drinking water, food, and medicines). Among elderly male participants, most complained about the difficulty finding work at their age. Among the female participants, several reported being completely dependent on government programs for food and medical care.
Belief systems about cancer, health in general, and medical treatments were identified as another social context barrier. For example, community participants spoke about the commonly shared fatalistic view of cancer as a death sentence accompanied by suffering, pain, and expensive treatments that have a negative economic impact on the family. They also spoke about a common attitude of carelessness towards one’s health, reflecting the perception that many take health for granted. They shared the observation that many do not prioritize preventive health care and postpone health service utilization until symptoms are severe. Moreover, the role of gender with regard to beliefs about health was consistently mentioned by participants from all groups, with the shared impression that men are less likely to utilize healthcare services than women. Many attributed this to men being less concerned about health than women. Additionally, community participants thought that having a colonoscopy would be harder for men to accept due to the anal penetration associated with the procedure, with possible sexual associations. One more barrier related to gender beliefs that could potentially affect the uptake of colonoscopy by women in Mexico is machismo or a sense of masculine pride that includes control over the female partner. Some participants described the possibility that some men may forbid their wives from seeking medical care, particularly if the doctor is a male and the consultation could require a woman to show intimate parts of her body.
Numerous participants in all groups perceived the lack of knowledge about CRC and CRC screening among community and primary healthcare participants as a relevant barrier. In particular, community participants lacked even basic knowledge about CRC and saw lack of knowledge as a barrier to participation in screening. Few community participants had heard of colonoscopy and knowledge of the procedure was limited. None of our community participants had heard about FIT as an option for CRC screening. The primary health care personnel possessed little knowledge about CRC and options for screening.
Finally, there were characteristics of the community that primary healthcare providers perceived as barriers for a successful implementation of a CRC screening program. The health workers perceived the population they serve as poorly educated. They described it was challenging for them to understand instructions for participation in diagnostic tests, for management of chronic conditions (e.g., diabetes), and therefore for adhering to treatment and follow-up. Also, the primary healthcare providers perceived the community as accustomed to participating in health programs in response to incentives (e.g. food parcels), which is a common practice with the delivery of social programs in Mexico. The primary care participants also described street violence as a barrier to provide outreach in certain neighborhoods. They also commented on the community’s cultural diversity, with migrants from different ethnic origins, which in their view further complicates the primary care personnel’s usual outreach activities. Finally, primary care providers reported that it is common for a significant proportion of community turnover due to migration from and to other states in Mexico or even change of residence within the city, and this could pose challenges to successful follow-up of individuals with positive FIT results.
Health service organization barriers
Community participants perceived the following potential barriers to participation in CRC screening: (1) previous experiences of patient abuse or mistreatment in healthcare; (2) poor quality of health services; and (3) challenges in doctor-patient communication. Several participants, including primary care physicians, shared negative personal experiences as patients in public health services that have subsequently prevented them from seeking care. These included perceived poor quality of care as well as stories of patient abuse where participants felt they were discriminated against due to their low-income status or appearance. Finally, community participants complained about not getting satisfactory explanations from healthcare providers about their health conditions, details for the rationale of medical recommendations related to screening and treatment, and wording that is easy to understand. Also, they said they wished doctors were more empathetic towards their life experiences.
At the primary care clinic level, the most prominent barriers perceived by our two groups of health care personnel participants (primary care and endoscopy unit) were: (1) lack of CRC knowledge among the primary care providers; (2) work overload in the primary care clinic; (3) insufficient infrastructure, personnel, and supplies; and (4) resistance to or lack of interest among primary care personnel in participating in new programs. The second barrier listed appeared to be a central issue: a majority of healthcare providers identified work overload as a significant problem, articulating that it would be very difficult to recommend screening during patient visits due to numerous competing medical priorities and short consultation times during patient visits. They also complained about having too much administrative workload, which reduces time for direct patient contact. Additionally, healthcare personnel referred to the daily challenges of doing their job in the midst of insufficient infrastructure, lack of supplies, and inadequate staff. Also, they perceived the lack of interest among staff and their resistance towards participation in new programs as an expression of fear regarding impact on an already heavy workload.
Finally, community participants described as potential barriers (apparently based on previous experiences), the long waiting times for referrals to other hospitals, complicated administrative procedures, and long distances for transportation to the health services. Although INCan is located only 10 km away from the community, distance was perceived by the community population as a barrier specific to getting a colonoscopy at the Endoscopy Unit of INCan, as public transportation is limited and can take much longer than private transportation.
At the interpersonal level, one of the endoscopists mentioned that negative colonoscopy experiences among peers might influence the uptake of this procedure. Among our community participants, nobody knew anyone who had a colonoscopy; however, one female participant narrated to the rest of the group a horrible experience with the sedation of her son during an endoscopic procedure and expressed her fear of submitting herself to something similar.
One of the most evident barriers was lack of awareness about CRC among community participants. A majority of participants openly acknowledged not knowing anything about CRC and were unable to identify the location of the colon. Once information on CRC, FIT-based screening, and colonoscopy was provided, the most commonly reported barrier was fear. Participants discussed the fear of finding out they have a serious disease like cancer. Three additional kinds of fear came up in relation with colonoscopy: (a) fear of pain; (b) fear of not knowing what to expect during the procedure; and (c) fear of embarrassment regarding the actual colonoscopy procedure, particularly among the male participants.
Community participants also reported lack of time for utilizing health services due to personal obligations and daily life activities. Male participants mentioned fear of losing their jobs, and female caretakers consistently put their families’ needs before their own. Respondents explained that community members have too many competing responsibilities, and preventive health care is not a priority.
According to participants, preferences for traditional rather than allopathic medicine, particularly among people who migrated from rural areas to Mexico City, were identified as a potential barrier to participation in CRC screening. Reluctance to use health services due to distrust of healthcare providers was consistently reported. Other barriers that were mentioned were lack of self-care, low self-esteem, procrastination, disinterest in health, and low perceived risk of CRC.
Perceived facilitators for participation in CRC screening
Health policy facilitators
Only health workers at the Endoscopy Unit identified facilitators at this level of the Social Ecological Model. In their opinion, mass media campaigns about the relevance and recommendations of CRC screening have potential to increase awareness in the target population.
Social context facilitators
Health workers at the primary care clinic perceive that the population they serve has been highly engaged in other health programs offered in the past. They perceive that this openness of the community to participate in health programs could facilitate uptake of CRC screening.
Health service organization facilitators
The main perceived facilitator for screening participation by all participants was that FIT kits and colonoscopy be offered at no cost. Another key facilitator identified by both healthcare personnel and community participants was promotion of CRC screening at community clinics. They hypothesized that people would participate in CRC screening if the primary care physicians were mandated to give information and request a CRC screening test from all their patients >50 years. Other relevant facilitators for FIT uptake were: (1) availability of the FIT kits at the local clinic; (2) possibility of reception of completed FIT samples at the local clinic; (3) good doctor-patient relationships with satisfactory communication skills among doctors; and (4) a history of positive experiences with health service utilization. For uptake of colonoscopy, the opportunity to have the procedure done by a physician of the same gender was seen as a facilitator.
Primary care personnel commented on the need for appropriate work environments. A majority reported that motivating the primary care personnel to participate in the CRC screening program would be a facilitator to successful implementation of the program. Finally, in order to improve their CRC screening knowledge and communication skills, primary care personnel suggested the use of short informative videos. They commented on the importance of observing others to learn medical procedures, which could also be applied to learning to communicate more effectively regarding the relevance of CRC screening.
Some community participants reported that knowing someone affected by cancer, particularly a family member or a close friend, would be a motivation to participate in cancer screening. Social support was also considered an important facilitator. Many reported that it would be easier for them to participate in screening if a family member or friend encouraged them to do so or shared with them a personal positive experience.
Almost all participants expressed that access to information on CRC and the benefits of screening is an important facilitator. The community participants were very interested in receiving more information about CRC screening and prevention. The information they received in the focus groups made them feel at risk (and this risk perception was accompanied by the knowledge that the cancer could be detected early and treated), and several mentioned this perception as a motivation to participate in CRC screening. Other potential facilitators were that the participants perceived sample collection for the FIT test and return of the kit to the health center as simple procedures. Knowing that the test could be done at the privacy of their homes was seen as an advantage. Finally, having personal experiences with serious illnesses came up as a facilitator. Some participants reflected upon their own negative health experiences and said that they were willing to participate in any screening activity that would prevent them from additional suffering due to health issues.