Participation in colorectal cancer screening programmes (CRCSP) has been shown to have benefits for health but also adverse effects.1 Informing the population of both benefits and harms of screening helps to encourage informed decision-making, however the foundations for doing so are yet to be established.2

Informed decision-making in health has been defined by several authors3,4 and despite the fact that no validated measurement exists,5 the majority agree that it must be based on accessible, up-to-date, relevant and unbiased information about the disease and the benefits and risks of making the decision.

Informed participation is considered in this study as the relationship between participation in CRCSP and the level of knowledge of the benefits and harms of participating in such programmes. In order to increase both participation and informed decision-making in these programmes (from now on informed participation), on the basis of European recommendations6 knowledge of the factors that influence both participation and knowledge is of the utmost importance. There is much evidence supporting that men participate less than women in such programmes7 but little is known about if they are also less informed and if this influences their participation.

Within the context of the Valencian Community (VC, Spain) Colorectal Cancer Screening Programme (CRCSP) a study was performed to evaluate the factors influencing participation. Gender inequalities in the reasons for participating in that programme have been identified.8 This paper aims to further examine the factors that influence informed participation in the VC CRCSP from a gender perspective.

The majority of the study subjects were participants in the CRCSP (51.1%, n=401), 55.2% of whom were women (n=229) and 46.5% men (n=172). The majority were uninformed (56.5%, n=435), 52.2% of whom were women (n=212) and 61.3% men (n=223).

Table 1 shows that both participating in CRCSP along with being informed are statistically related (p <0.05). The variables sex, education level, participation in the Breast Cancer Screening Programme (BCSP) (women only), future intention to participate, valuation of the information received and GP information are related both to participation as well as to being informed.

The multivariate analysis (Table 2) shows that there is a greater probability of participation by women (OR: 1.52; 95%CI: 1.06-2.19), being 60 and over (OR: 1.64; 95%CI: 1.14-2.36), living with a partner (OR: 2.12; 95%CI: 1.18-3.79), with future intention to participate in CRCSP (OR: 6.51; 95%CI: 4.13-10.25), considering information to be sufficient (OR: 2.54; 95%CI: 1.65-3.91), receiving GP information (OR:1.64; 95%CI: 1.05-2.55) and being informed (OR: 1.54; 95%CI: 1.08-2.21). Analyses stratified by sex show that men, unlike women, are more likely to take part in screening if they are 60 and over (OR: 2.39; 95%CI: 1.36-4.20) and live with a partner (OR: 6.08; 95%CI: 1.80-20.48). With regards being informed, the probability increases in the case of women (OR: 1.49; 95%CI: 1.06-2.09), people with family responsibilities (OR: 2.01; 95%CI: 1.35-2.99), having relatives and friends with cancer (OR: 2.01; 95%CI: 1.30-3.10), high level of prevention practices (OR: 1.73; 95%CI: 1.10-2.71), had participated in CRCSP (OR: 1.82; 95%CI: 1.29-2.58) and of the opinion that the information conveyed is sufficient (OR: 2.03; 95%CI: 1.35-3.08); and decreased if people have low education level (OR: 0.63; 95%CI: 0.44-0.91). Men, unlike women, are more informed if they have family responsibilities (OR: 2.53; 95%CI: 1.39-4.63) and consider the information conveyed to be sufficient (OR: 2.74; 95%CI: 1.46-5.14).

Being a woman, receiving information from a general practitioner and being informed of the disease and the programme are related to participation in CRCSP.

The gender analysis shows that women participate more in CRCSP than men, with similar results in the majority of studies.7,11 Therefore “inverse prevention”12 is taking place in the VC CRCSP, since there is greater incidence and mortality from CRC among men.13 The influence of traditional gender roles in health, such as greater self-care in women and poorer perception of vulnerability among men,14 could be an explanation of these gender inequalities in participation.

This study contributes to improving knowledge about gender differences in the factors related to participation in CRCSP programmes. Men are more likely to participate if they live with a partner, according to the results of other studies that point out the dependence of men on their female partners when carrying out the cancer screening tests.15. And women tend to participate more if they have previously attended BCSP, in line with other studies.16 A positive experience in BCSP and the characteristics of these women may be possible explanations of this relationship. Collaboration between both cancer screening programmes to enhance participation of women and men would be advisable.

The results of this study show a relationship between knowledge about the disease and the programme, and participation in CRCSP. Whereas some studies had not found this relationship17 others had underlined low knowledge as one of the obstacles to participation.18 This relationship should be interpreted with caution as knowledge was measured after participation in the programme and could be conditioned by this. But, in any case, it supports the importance of promoting informed participation. This study also shows that receiving GP information increase participation, highlighting the importance of primary health care involvement in promoting such programmes.19

Finally, the study shows that women, people with high educational level, and having family responsibilities are better informed of CRCSP, with the latter situation statically significant only for men. Gender equity in family care responsibilities could contribute to increasing CRCSP knowledge among men, and therefore to enhancing informed participation in such programmes.

Unbiased information about the CRC and screening programmes involving primary health care professionals, considering specific strategies directed at men and women could enhance informed participation with a gender equity perspective.

Mª José López.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

A. Molina-Barceló, R. Peiró-Pérez and D. Salas designed the study. The data was collected by L. Guaita. M. Vanaclocha and G. Vallés performed the analysis of the data. A. Molina-Barceló drafted the manuscript and all the authors contributed to the interpretation of the result, critically revised the work and approved the final version to be published.

This study has received a grant of 4,950 € from the Regional Health Authorities of the Valencian Community through the call for Grants for the Fomento de la Investigación Sanitaria en la Comunitat Valenciana (Ref. number: 053/2010).

None.