Colonoscopy Screening Behavior in First-Degree Relatives of Colorectal Cancer Patients: A Qualitative Study Based on the Theory of Planned Behavior

Abstract

To investigate the factors influencing the colonoscopy screening behavior of first-degree relatives of colorectal cancer patients and to provide a basis for formulating screening intervention strategies. In this study, 15 first-degree relatives of colorectal cancer patients in the Department of Medical Oncology of a tertiary hospital in Baoding City from May to July 2024 were selected as the research subjects, and face-to-face semi-structured interviews were conducted. The theme was analyzed and summarized based on the theory of planned behavior and Colaizzi’s 7-step analysis method. Results of this study identified 12 themes from 3 aspects. For behavioral attitudes, 4 themes emerged: (1) Negative screening emotions caused by psychological stress, (2) Lack of awareness of the importance of screening due to cognitive biases, (3) Screening behavior caused by fatalistic views is systematically underestimated, and (4) Affirm the value of early screening. For subjective norms (The impact of external information on screening behavior), 4 themes emerged: (1) Family support, (2) Advice from a healthcare professional, (3) information support from online media, (4) Personal experience and suggestions from friends. For perceived behavior control, 4 themes emerged: (1) Unbearable pain and embarrassment, (2) Busyness of life and work, (3) Medical treatment process and transportation convenience, and (4) Screening costs. The colonoscopy screening behavior of first-degree relatives of colorectal cancer patients is affected by behavioral attitudes, subjective norms (The impact of external information on screening behavior), and perceived behavior control. Clinical medical staff should correct their behavioral cognitive biases from the perspective of first-degree relatives, use positive belief factors to avoid wrong cognition, pay attention to a variety of sources of support, stimulate the self-efficacy of first-degree relatives, and create a suitable environment for colonoscopy screening, to promote the change of colonoscopy screening behavior of first-degree relatives.

Keywords

colorectal cancer first-degree relatives colonoscopy screening behavior Theory of Planned Behavior qualitative study

What do we already know about this topic?

First-degree relatives of patients with colorectal cancer are at high risk for colorectal cancer, but compliance with colonoscopy screening is low in this group.

How does your research contribute to the field?

Through the theory of planned behavior, the factors influencing colonoscopy screening behavior of first-degree relatives of colorectal cancer patients were discussed in depth to provide basis for formulating screening intervention strategies.

What are your research’s implications toward theory, practice, or policy?

Clinical medical staff should correct their behavioral cognitive biases from the perspective of first-degree relatives, use positive belief factors to avoid wrong cognition, pay attention to a variety of sources of support, stimulate the self-efficacy of first-degree relatives, and create a suitable environment for colonoscopy screening, to promote the change of colonoscopy screening behavior of first-degree relatives.

Introduction

The incidence of colorectal cancer (CRC) is increasing year by year.¹ According to statistics, in 2020, the incidence and mortality rate of colorectal cancer in the world ranked third and second among malignant tumors, respectively,² In 2022, it ranked third in the incidence of malignant tumors and second in mortality worldwide.³ Most colorectal cancer patients have no apparent symptoms in the early stage, and it takes about 10 to 15 years from adenomatous polyps to cancer, which provides sufficient time for early diagnosis, clinical intervention, and treatment of the disease.^4,5 Colonoscopy is an essential means for diagnosing early CRC and precancerous lesions, and is recognized as the “gold standard” for diagnosing and treating intestinal lesions.^6
-8 Studies have shown that identifying high-risk groups for colorectal cancer and performing regular colonoscopy can effectively improve the early diagnosis rate of colorectal cancer and reduce its mortality rate.^9
-11

First-degree relatives of colorectal cancer patients are at high risk of developing the disease,^12,13 including the patient’s blood parents, children, and siblings. Results of a meta-analysis¹³ show that the risk probability of CRC in first-degree relatives is 1.76 times higher than that of the general population, and it tends to be younger. Current guidelines and research Colonoscopy screening is recommended for first-degree relatives, starting at age 40 or 10 years younger than the earliest diagnosis of colorectal cancer in the family.^7,12,14
-16 In 2023, the Shanghai Anti-Cancer Association provided a more detailed recommendation regarding the age and interval for colonoscopy screening in first-degree relatives of colorectal cancer patients. For individuals with 1 first-degree relative diagnosed with colorectal cancer (onset before age 60) or 2 or more first-degree relatives diagnosed with colorectal cancer (at any age), it is recommended to begin screening at age 40 (or 5-10 years earlier than the age of the youngest affected family member) and to undergo colonoscopy every 5 years.¹⁶ The American College of Gastroenterology screening guidelines suggest that first-degree relatives of colorectal cancer patients should begin screening at age 40 or 10 years before the age at which the youngest relative was diagnosed (whichever comes first), with colonoscopy repeated every 5 years thereafter.¹⁷ However, the study results show that this group’s screening participation is not optimistic, and the colonoscopy screening rate of first-level relatives in developed countries such as Europe and the United States is about 45% to 75%.^18,19 A study by Almanzar et al²⁰ showed that colonoscopy screening rates in first-degree relatives were 50%. In contrast, less than 25% of first-degree relatives participated in colonoscopy screening in China.^21
-26 Recently, Tian²⁷ conducted a survey of 416 first-degree relatives of colorectal cancer patients, finding that only 56 had completed colonoscopy screening, while 360 had not, resulting in a colonoscopy screening adherence rate of 13.46%. Similarly, Zhao²⁸ surveyed 277 first-degree relatives, with 48 having undergone colonoscopy, yielding a screening adherence rate of 17.3%. It can be seen that the colonoscopy screening rate of first-degree relatives in China is significantly lower than that of developed countries such as Europe and the United States.

Although various systematic reviews have synthesized factors influencing colorectal cancer screening,²⁹ studies specifically analyzing the factors affecting colonoscopy screening behavior in first-degree relatives are scarce.³⁰ Compared to other high-risk groups or colorectal cancer patients, first-degree relatives often remain asymptomatic in the early stages of the disease and require greater motivation to undergo invasive screening procedures, as they may believe screening is only necessary after symptoms appear.³¹ Additionally, colonoscopy is more invasive and complex compared to fecal-based screening methods, which may result in different influencing factors. Therefore, it is necessary to explore the factors that influence colonoscopy screening behavior in first-degree relatives.

The theory of planned behavior (TPB) by Ajzen³² was proposed in 1991. This theory believes that behavioral intention is the most direct influencing factor of individual behavior, and behavioral intention results from synthesizing 3 factors: attitude toward the behavior, subjective norm, and perceptual behavior control.³³ attitude toward the behavior refers to the positive or negative attitude of an individual toward a particular behavior, subjective norm refers to the external pressure that an individual feels on whether to take a specific behavior and perceptual behavioral control refers to the overall assessment of the degree of controllability of the facilitating or hindering factors in the implementation of the behavior. This theory has been developed and is widely used in studying various behaviors at home and abroad. It can explain the influence of personal, psychological, and social factors on executing a specific behavior.^34,35

In China, studies on colonoscopy screening behavior of first-degree relatives are mainly based on quantitative studies, which cannot be comprehensively explored in depth, and there is a lack of theoretical guidance. Based on the TPB framework, this study used the method of qualitative research to analyze the real feelings of first-degree relatives of colonoscopy screening from 3 aspects: attitude toward the behavior, subjective norm, and perceived behavior control, to provide a basis for formulating an intervention program based on improving the colonoscopy screening behavior of first-degree relatives and promote the change of colonoscopy screening behavior of first-degree relatives.

Methods

Participants

The first-degree relatives of CRC patients admitted to the Department of Medical Oncology of a tertiary hospital in Baoding City from May to July 2024 were selected as the study subjects by the objective sampling method. Inclusion Criteria: Age ≥ 18 years; voluntary participation in this study; Be aware and be able to express one’s views clearly. Exclusion Criteria: Have severe cognitive impairment or a history of prior psychiatric illness; Have a history of other significant diseases; Language communication barrier. Following the principle of maximum difference in sampling, first-degree relatives with significant differences in age, education level, and occupation were selected for inclusion in the study. The ethical review materials for this study (including the Ethical Review Application Form, Proposal, Informed Consent Form, Principal Investigator’s CV and Qualification Certificates, Feasibility, Safety, Scientific Validity, and Budget of the Project, as well as the Relevant Management Policies and Risk Prevention Plan) were submitted to the Ethics Committee of Hebei University Affiliated Hospital on October 26, 2023. After 2 rounds of revisions, the study received approval from the hospital’s Ethics Committee on November 29, 2023 (Approval No.: HDFYLL-KY-2023-175). All study subjects gave informed consent and voluntarily participated in this study. Based on the principle that no new topics appeared in the interview and the information was saturated.

Determine the Interview Outline

An and Vincent³⁴ proposes that the following 3 factors influence an individual’s behavioral intention. What are the benefits and disadvantages of attitude toward the behavior, that is, behavior? Subjective norms: What factors influence behavior by individuals, societies, and groups? Perceptual Behavior Control: What are the facilitators and barriers that exist when an individual performs a certain behavior? Building on the literature review, the researchers used the theoretical framework of planned behavior to guide the development of an interview outline, which was reviewed in collaboration with 2 experts. A pre-interview was then conducted with the first-degree relatives of the 2 cases to identify any issues. Based on insights from these pre-interviews, the final interview outline was refined and finalized. The interview begins with “Can you describe your relative’s experience with the disease?” At the beginning, the outline of the interview is as follows. How much do you know about CRC or colonoscopy screening, and can you tell us more about it? What do you think are the benefits of having a colonoscopy? Harm? Which individuals or groups influence your colonoscopy screening? What are the specific reasons? What factors motivate you to have regular colonoscopy? What about the blockers? Is there anything else you’d like to add?

Data Collection

Data were collected through semi-structured interviews. The interview site was the instrument placement room of the nurse’s station, and there were no other personnel at the scene except for 2 interviewers (ZRH and CS) and 1 first-degree relative to ensure that the interview environment was quiet and private. Before the interview, explain the purpose of the study and the principle of confidentiality, sign the informed consent form, and start recording and recording after asking for the patient’s consent, and first use a short questionnaire to understand the basic situation of the patient, including gender, age, marital status, education level and whether colonoscopy screening has been done; Subsequently, the interviews were conducted, and the interview time of each first-degree relative was about 30 min, and the relevant questions were explored in depth according to the answers and specific situations of the first-degree relatives during the interview, to avoid the inducing effect of the subjective opinions of the interviewers on the interviewees. By the time the interviews reached the 14th and 15th interviewees, no new subjects were precipitated, indicating that the data was saturated and the interviews were stopped.

Data Analysis

Data organization and analysis were conducted simultaneously. Within 24 h after each interview, 2 researchers (ZRH and CS) repeatedly listened to the audio recordings and transcribed them verbatim. The transcripts were then sent to the participants for verification. All 15 participants confirmed that they had no objections to the transcripts, ensuring the completeness and accuracy of the study data. using MAXQDA 20.4 software, 2 researchers (ZRH and DC) using the Colaizzi 7-step analysis method³⁶ Conduct data analysis: Familiarization; Identifying significant statements; Formulating meanings; Clustering themes; Developing an exhaustive description; Producing the fundamental structure; Seeking verification of the fundamental structure. If there are differences of opinion on the theme of the refinement, the research team will discuss it together and finalize the theme.

Quality Control

The interviewees were composed of 2 graduate students (ZRH and CS) who had been working in clinical practice for more than 5 years, and before data collection, they took the initiative to care about the physical condition of first-degree relatives and establish a relationship of trust with the research subjects; Appropriate use of questioning, empathy and other techniques when collecting data; The data were analyzed by 2 graduate students (ZRH and DC) with more than 5 years of clinical work and rich experience in qualitative research. During data analysis, the researcher suspends his personal opinions, immerses himself in the textual materials, reads repeatedly, thinks deeply, and reports at the weekly research group meeting, In case of disagreement, the research group members discuss and reach a consensus. All members of the research team have undergone training in qualitative research courses and possess substantial experience. The entire process of data collection, organization, and analysis was conducted under the guidance of a professor with extensive experience in qualitative research.

Results

Fifteen first-degree relatives participated in this study, coded as N1 to N15 (see Table 1). The average age of the participants was 45.5 years, and all were married. Their educational levels ranged from primary school to undergraduate degrees. Seven participants were from urban areas, 5 had employee medical insurance, and 3 had religious beliefs. Only 1 first-degree relative (6.7%) had previously undergone colonoscopy screening, and 8 first-degree relatives (53.3%) had plans to undergo colonoscopy screening.

Table 1.

Participants’ Characteristics (n = 15).

No	Age	Gender	Education level	Place of residence	Type of health insurance	First-degree relatives	Religious beliefs	Have you had a colonoscopy	Whether there is a colonoscopy screening program
N1	53	Male	H	City	Employee medical insurance	Son	No	No	Yes
N2	54	Male	H	Countryside	NCMS	Son	No	No	No
N3	32	Male	M	Countryside	NCMS	Son	No	No	Yes
N4	32	Female	H	Countryside	NCMS	Daughter	No	No	Yes
N5	36	Female	M	Countryside	Employee medical insurance	Daughter	No	No	Yes
N6	42	Male	J	City	Employee medical insurance	Son	No	No	Yes
N7	40	Male	T	City	NCMS	Son	Buddhism	No	No
N8	39	Female	M	Countryside	NCMS	Daughter	No	No	No
N9	50	Female	U	City	Employee medical insurance	Daughter	No	No	Yes
N10	59	Male	U	City	Employee medical insurance	Son	No	Yes	Yes
N11	28	Female	J	City	NCMS	Daughter	No	No	Yes
N12	65	Male	P	Countryside	NCMS	Father	Christ	No	No
N13	46	Female	M	City	NCMS	Sister	No	No	No
N14	52	Male	P	Countryside	NCMS	Son	No	No	No
N15	55	Female	M	Countryside	NCMS	Brother	Buddhism	No	No

Note. P = primary school; M = middle school; H = high school; T = technical secondary school; J = junior college; U = undergraduate; NCMS = new rural cooperative medical system.

Results of this study identified 12 themes from 3 aspects and presented in Table 2.

Table 2.

Summary of Identified Themes and Subthemes.

Theme	Subtheme
Attitude toward the behavior	Negative screening emotions caused by psychological stress
	Lack of awareness of the importance of screening due to cognitive biases
	Screening behavior caused by fatalistic views is systematically underestimated
	Affirm the value of early screening
Subjective norms (The impact of external information on screening behavior)	Family support
	Advice from a healthcare professional
	Information support from online media
	Personal experience and suggestions from friends
Perceived behavior control	Unbearable pain and embarrassment
	Busyness of life and work
	Medical treatment process and transportation convenience
	Screening costs

Theme 1: Attitude Toward the Behavior

Negative Screening Emotions Caused by Psychological Stress

After experiencing a diagnosis and complex comprehensive treatment, some first-degree relatives have a heavy psychological burden, resulting in psychological reactions such as anxiety, fear, and uncertainty.

“I’m scared of being screened for cancer. Both old people and children need to be looked after, and if it turns out to be cancer, I don’t know what to do, and I’ll be even more anxious.” (N12)

“Because I have this disease very. . .. . . Not only the patients but also their families are under pressure.” (N1)

“We rural people are more afraid of physical examinations, and we may live for three years if we are not diagnosed with cancer, and if we find out, we may be doomed that year, and the psychological impact of this disease is too great.” (N14)

Lack of Awareness of the Importance of Screening due to Cognitive Biases

Due to the influence of traditional concepts and educational level, some first-degree relatives have cognitive bias toward colonoscopy screening and do not realize the importance of colonoscopy screening, and the wrong cognitive concept leads to their reluctance to undergo colonoscopy screening.

Specifically, some first-degree relatives lack a proper understanding of colorectal cancer, believing that “no symptoms” means “no disease,” and therefore they do not see the need for colonoscopy screening.

“I don’t think you need to check if you don’t have symptoms, and you should focus on exercising more.” (N10)

“I don’t have my dad’s symptoms (frequent toilet visits), so I didn’t consider getting a colonoscopy.” (N8)

Some first-degree relatives think that “young” is “healthy,” and believe that only elderly people will suffer from colorectal cancer, and young people will not suffer from this disease, so they refuse to do colonoscopy screening.

“I recommend that the old people around me do (colonoscopy), the younger I do not recommend, from my point of view, I think I am still relatively young, and I plan to do this test after the age of 50.” (N5)

Due to the lack of knowledge about colorectal cancer, some first-degree relatives believe that colorectal cancer is not hereditary.

“My brother is more than 40 years old this year, I am 50 years old, I am older than him, I think it has nothing to do with genetics.” (N15)

“I think I have a minimal chance of suffering from this disease, because there is nothing wrong with our family. My father’s brothers and sisters do not have this disease. I feel there is no heredity. My father got the disease because he was too tired.” ( N4)

Influenced by traditional ideas, some first-degree relatives believe that normal routine physical examination indicators represent good health, so there is no need to do colonoscopy screening.

“Since my father had the disease, I have drawn blood to test for a series of cancer-related antigens, and the physical examination results are mostly within the normal range, so I have no plans to do this colonoscopy.” (N2)

Some first-degree relatives believe that as long as the living habits are good, they will not get cancer.

“My brother is caused by his bad eating habits; he likes to eat spicy food, likes to smoke and drink, and I have good living habits, so I think as long as I maintain good living habits and a positive and optimistic attitude, I will not get bowel cancer, so there is no need to have a colonoscopy.” (N13)

Screening Behavior Caused by Fatalistic Views is Systematically Underestimated

Influenced by fatalistic views, some first-degree relatives believe that a person’s fate is predestined and that whether or not a person is sick is controlled by fate, denying the significance and value of colonoscopy screening.

“Human life is destined by God, when to get sick and what kind of disease is born is all planned by God, screening and treatment are useless.” (N12)

“The fortune-teller once said my father would have a disaster at this age. This year it happened (suffering from intestinal cancer), ah, from the moment of birth, God has arranged people’s life.” (N14)

“Colorectal cancer may be related to the feng shui of my younger brother’s family. The location of their house is not good, and they got sick just after they finished building it.” (N15)

Affirm the Value of Early Screening

Most first-degree relatives have a positive attitude toward colonoscopy screening, believing that colonoscopy screening can achieve early diagnosis and treatment, which can save medical costs, gain comfort, and not leave regrets in life.

“Early detection is certainly better than late detection. If you detect it late, like in my father’s case, it was already in the late stage by the time it was discovered. No matter how good the treatment is, it would only last for at most two to three years. But if it is detected early, when the condition is still mild, it can be treated, and survival for more than 10 years, or even 20 years, is possible. So, I believe screening is necessary. It’s just like catching a cold. When it’s mild, medication works quickly, but when it becomes severe, medication can no longer control it.” (N3)

“Early detection and early treatment are crucial. In my mother’s case, it was not detected early, and that is my greatest regret.” (N1)

“For less severe illnesses, 10,000 yuan might be enough for a cure. But if you delay and let it become more serious, whether it can be cured, 10,000 yuan will not be sufficient.” (N3)

“I’m not worried about (the test results). I believe that when facing challenges, you should approach them with a positive attitude. For instance, if something is detected during the screening, you should be thankful it was caught early. And if nothing is found, you shouldn’t feel that the money was wasted; you should be grateful that you’re healthy.” (N9)

Theme 2: Subjective Norms (The Impact of External Information on Screening Behavior)

Family Support

During the interview, it was learned that the colonoscopy screening behavior of first-degree relatives was influenced by their children and lovers, and they were encouraged and reminded to undergo colonoscopy screening.

“My child kept asking me to do (colonoscopy) and even asked me to do all the (examinations) again, including gastrointestinal endoscopy.” (N1)

“My wife works in the hospital, and my son is a dentist. They all recommended that I do colonoscopy screening; they think early detection and treatment are good for my health. They asked me to go to the hospital to see, and I believe their advice.” (N10)

Advice From a Healthcare Professional

Healthcare workers are essential transmitters of health information, and their recommendations are an important factor influencing first-degree relatives to undergo colonoscopy screening.

“The doctor did not recommend. After all, the patient they see is not me. I am just a family member; he did not need to tell me this. If the doctor recommends a colonoscopy, I will be more attentive and do it.” (N3)

“The doctor recommended this genetic test. We considered it, and then we carefully consulted the doctor. He suggested that first-degree relatives should undergo a colonoscopy. I think the doctor’s opinion is quite important.” (N4)

Information Support From Online Media

The publicity of the online media has prompted first-degree relatives to increase their knowledge of colonoscopy screening, making them more willing to undergo it.

“I saw a video on my phone that said once that section (of the colon polyp) is removed through surgery, there won’t be any more issues, and it won’t progress to the late stage. I’ve also watched videos from the hospital. I’m thinking of getting one done when I have time.” (N5)

“Since my father was diagnosed with this disease, I searched on Baidu using my phone and found out that it can be hereditary. It is recommended that children get checked. Once things calm down, I plan to get a colonoscopy.” (N6)

Personal Experience and Suggestions From Friends

Friend’s personal experience and advice also influenced the colonoscopy screening behavior of first-degree relatives.

“One of my classmates in Beijing had a colonoscopy two days ago and made two polyps, and [she suggested to me] that this should be checked early.” (N9)

“One of my colleagues, she has rectal cancer, she is 28 years old, quite young, he regrets not having a physical examination earlier, the last time I went to see her, she suggested me to do a colonoscopy, I think now young people should pay more attention to their bodies, there is no harm in checking more.” (N11)

“When my friends got together, they said that this tumor was hereditary, and suggested that we go to the hospital for examination, and I think more relieved to have it checked.” (N2)

Perceived Behavior Control

Unbearable Pain and Embarrassment

Colonoscopy screening is an invasive operation, which will inevitably bring physical pain, psychological tension, and fear to the person being examined.

“During the period, I saw a non-painless one, and after doing it, that person was not good, crying and shouting that I would never do it again. I was also afraid of pain. Even if it was painless when the anesthetic passed, I felt that it would hurt. so I don’t want to do that (colonoscopy).” (N6)

“I’m scared that mirror is poking my gut out.” (N15)

In addition, some first-degree relatives think it would be embarrassing to expose their private parts in front of others.

“I’d rather have a CT or B-ultrasound. I think it would be embarrassing for the doctor to touch my private parts.” (N13)

The complicated bowel preparation and the unpleasant-tasting laxatives also hinder first-degree relatives from undergoing colonoscopy screening.

“This colonoscopy requires a laxative to drink in advance, and the laxative is terrible. My father was vomiting and diarrhea after drinking the laxative, which made him feel uncomfortable, and I don’t want to drink it.” (N3)

Busyness of Life and Work

The busyness of life and work affects the colonoscopy screening behavior of first-degree relatives, and they have no time to take care of themselves due to taking care of their families, busy work, and social pressure.

“I haven’t considered (getting a colonoscopy), and I’m not in the mood for such a checkup. With the patient (my father) suffering so much, how could I even think about getting a colonoscopy? How could I have the energy to take care of myself?” (N8)

“Where do I have that time? I am usually busy with work, have a mortgage and a car loan, do not dare to ask for leave, and have to take care of my family and send my children to school. There is no time to do colonoscopy.” (N13)

“Where is the time? Ever since my father was diagnosed, I can say that I haven’t spent a single day at home. I’ve been constantly in the hospital, going to Beijing, Baoding, and Shijiazhuang to collect test results.” (N3)

Medical Treatment Process and Transportation Convenience

The complexity of the medical treatment process affects the colonoscopy screening behavior of first-degree relatives.

“My father found an acquaintance to go to the central hospital for a colonoscopy, otherwise he couldn’t get it in a day, and it would be difficult to make an appointment for this examination.” (N4)

“From the bottom of my heart, I feel that this kind of private is not as reliable as the public (hospital), but the public distance is far away, and it is difficult to make an appointment, and it is more troublesome to queue up.” (N7)

In addition, respondents mentioned that the ease of travel to and from healthcare facilities has had a massive impact on their participation in colonoscopy screening.

“My home is rural, far away from the county hospital, and the transportation is not very convenient, so I feel that it is very troublesome to come to the hospital.” (N12)

Screening Costs

Due to the cost of colonoscopy screening, some first-degree relatives refuse to be screened because they cannot afford the expensive examination.

“That colonoscopy costs a lot of money, and the outpatient colonoscopy is not reimbursed, and I am a farmer in a rural area and have no job, so how can I have spare money to do a colonoscopy.” (N14)

In addition, some first-degree relatives are influenced by workplace health checkups and medical insurance reimbursement, which makes them more inclined to undergo colonoscopy screening.

“This medical insurance policy is quite good. We are all employees, and the insurance covers a portion of the cost, so getting a colonoscopy doesn’t cost much.” (N9)

“Our workplace provides health checkup cards every year, and there is an option for a colonoscopy. I’m thinking of getting one during the checkup; otherwise, it would be a waste not to use it.” (N6)

Discussion

This study explores the factors influencing colonoscopy screening behavior in first-degree relatives of colorectal cancer patients based on the Theory of Planned Behavior. The results show that their screening behavior is influenced by 3 key factors: attitude toward the behavior, subjective norms (the impact of external information on screening behavior), and perceived behavioral control. By conducting an in-depth analysis of the barriers, the study aims to promote improvements in first-degree relatives’ behavioral intentions and increase their proactive participation in colonoscopy screening. This can be achieved by: changing their health beliefs and fostering a correct understanding of health, emphasizing the importance of multiple sources of support to strengthen their internal motivation, and enhancing their sense of self-efficacy while creating a conducive environment for screening.

Use Positive Belief Factors to Correct the Wrong Health Perception of First-Degree Relatives and Encourage Them to Participate in Colonoscopy Screening Actively

The results of this study showed that some first-degree relatives had a negative attitude toward screening due to excessive psychological pressure. Influenced by the ideology of “avoiding medical treatment and talking about cancer discoloration,” many first-degree relatives were worried that the adverse results of screening would bring tremendous pressure to their lives, so they showed adverse psychological reactions such as anxiety, fear, and uncertainty, which was similar to Zhang et al²⁵ the possible adverse consequences of screening can directly disrupt the current state of “health” and plunge them into fear and worry. In addition, cognitive biases can also lead to first-degree relatives not recognizing the importance of screening. The results of this study show that some first-degree relatives have cognitive biases due to a lack of understanding of the disease and equate the absence of uncomfortable symptoms with health.²² The results of a regular annual physical examination mean good health.³⁷ This results in lower screening adherence. The results of this study show that some first-degree relatives firmly believe in the fatalistic idea that fate is determined by heaven and think that the disease is related to the arrangement of God, and even if screening is carried out, there is no way to change it, which is similar to the research results of Zhang et al,²⁵ and the analysis may be due to the respondents’ low level of education and lack of knowledge related to the disease.²¹ “Early detection and early treatment” can not only reduce medical costs but also provide psychological comfort, which is consistent with the views of Tian²⁷ In summary, medical staff should strengthen the education of first-degree relatives on diseases and screening knowledge, focusing on people with low education levels. At the same time, the content of publicity and education should be targeted, actively pay attention to their psychological problems, cultivate the positive cognition and risk perception of first-degree relatives on the early screening of colorectal cancer, make them realize the importance of early screening of colorectal cancer, and popularize science to change the negative fatalistic attitude into a positive attitude.

Attaching Importance to Multiple Sources of Support Will Help to Enhance the Inner Strength of First-Degree Relatives and Improve Their Active Awareness of Participating in Colonoscopy Screening

The results of this study show that the support of family members, the personal experience and suggestions of friends, the advice of professional medical staff, and the publicity of online media have a role in promoting the participation of first-degree relatives in colonoscopy screening. Family members working in the medical profession are more aware of diseases and screening; therefore, their recommendations encourage screening colonoscopy in first-degree relatives, similar to Tan et al’s³⁷ findings. Friends with colorectal cancer will often mention the knowledge related to the disease, and talking about colorectal cancer-related topics among friends will also improve their understanding of colonoscopy screening.³⁸ Screening recommendations from healthcare professionals are an essential factor in promoting colorectal cancer screening, and high-risk groups who have been asked by physicians about a family history of colorectal cancer are more likely to receive early screening.^18,31 Fiala¹⁹ Studies have shown that physician recommendations have increased the willingness of first-degree relatives to be screened and are a contributing factor to colonoscopy screening.²⁶ First-degree relatives can enhance their awareness of diseases and colonoscopy through videos, Baidu, and other related knowledge, which will improve their compliance with colonoscopy screening.³¹ Wu et al’s³⁹ study showed that screening recommendations of medical staff and family members, enhanced publicity and education, and enhanced information support could effectively improve first-degree relatives’ awareness of colonoscopy screening, thus improving the compliance rate of first-degree relatives for early screening. Therefore, it is necessary to make use of the community, medical staff, family members, friends, and social media as a link to pay attention to and strengthen publicity and education, improve the understanding of first-degree relatives about the disease and early screening, improve their health literacy, and enable first-degree relatives to establish correct health beliefs about colonoscopy screening, to effectively improve the screening compliance rate of first-degree relatives of colorectal cancer patients.

Stimulate the Self-efficacy of First-degree Relatives, Create a Better Screening Environment, and Promote the Change in Their Screening Behavior

The results of this study showed that the characteristics of bowel preparation and the specificity of screening sites caused some first-degree relatives to feel pain⁴⁰ and embarrassment, which was consistent with the results of Sun²² and Shamim et al⁴¹ The results of the study are consistent. The main reason is that the adverse reactions experienced by screening will cause unpleasant experiences, which directly interfere with their emotions, attention, and ability to deal with things and indirectly affect the colonoscopy screening behavior of first-degree relatives. Self-efficacy is a psychosocial resource that can build the confidence of first-degree relatives in screening and improve their ability to participate actively in colonoscopy screening through various means. A study⁴² confirmed that the higher the self-efficacy, the greater the willingness to screen. Therefore, medical staff must understand the motivational factors of first-degree relatives to participate in colonoscopy screening and actively explore convenient and comfortable bowel preparation methods according to the characteristics of individual screening needs to continuously improve their colonoscopy screening skills and reduce patients’ suffering. In addition, there is a need to protect patient privacy and promote same-sex medical screening services (male doctors for male patients and female doctors for female patients). To encourage first-degree relatives to overcome psychological barriers, medical institutions can record vivid and easy-to-understand popular science videos on colonoscopy screening to publicize the benefits of early diagnosis, emphasize the specific process of colonoscopy and its safety, and eliminate their fears. To improve the self-efficacy of colonoscopy screening in first-degree relatives, thereby increasing the participation rate of colonoscopy screening.

This study showed many obstacles for first-degree relatives to participate in colonoscopy screening, such as the busy life and work, the medical treatment process and transportation convenience, and the cost of screening. Due to the pressure of life, being busy with work, taking care of patients, etc., first-degree relatives have no time to take care of themselves, which is similar to the research results of Paskett et al⁴³ Factors such as inconvenient transportation and complicated treatment procedures hinder first-degree relatives from undergoing colonoscopy screening; “It is far away from the hospital and needs to be picked up and dropped off by children” is an essential factor in his reluctance to undergo colonoscopy screening²⁵; The lack of convenient and credible medical facilities in the vicinity of their place of residence also hinders colonoscopy screening.²² The social status quo of “difficult and expensive medical treatment” still exists, and studies have proved that residents with urban employee medical insurance are more willing to pay for cancer screening. Including cancer screening in medical insurance reimbursement and reducing personal out-of-pocket expenses can promote the sustainable development of cancer screening.^44,45 Therefore, in the future screening work of colorectal cancer, it is still necessary to widely publicize the necessity of screening and early diagnosis and treatment of colorectal cancer, as well as the relevant medical insurance reimbursement policy. At the national level, it is also possible to explore appropriate reductions and exemptions for first-degree relatives for colonoscopy screening or include them in the outpatient medical insurance reimbursement program at the place of residence to encourage first-degree relatives to take the initiative to undergo colonoscopy screening. In addition, medical staff in rural and remote areas can be trained and guided through Internet technology to further optimize medical services in backward areas, shorten the distance for medical treatment, simplify the medical treatment process, and improve their participation rate in colonoscopy screening.

In summary, this study explored the factors influencing colonoscopy screening behavior in first-degree relatives using the Theory of Planned Behavior. Based on these findings, future research could develop a behavior change model for colonoscopy screening in first-degree relatives and design targeted intervention programs to encourage their participation in colonoscopy screening.

Strengths and Limitations of the Study

This study employed qualitative interviews, guided by the Theory of Planned Behavior, to comprehensively explore the perceptions of first-degree relatives regarding colonoscopy screening. The findings hold significant importance for the future development of a comprehensive colonoscopy screening program. However, there are some limitations. Although data saturation was achieved, the small sample size and the fact that all participants were first-degree relatives of patients from the same hospital may introduce bias, limiting the generalizability of the results to the entire province. Additionally, all participants were married, preventing the study from exploring the views of unmarried individuals regarding colonoscopy screening. Future research should expand the sample size and include participants from different regions, as well as unmarried first-degree relatives, to investigate their perspectives on colonoscopy screening.

Conclusions

Based on the theory of planned behavior, this study conducted qualitative interviews with 15 first-degree relatives to gain an in-depth understanding of their perception of colonoscopy screening behavior. It was found that the colonoscopy screening behavior of first-degree relatives was influenced by many factors.

Medical staff must start from the perspective of first-degree relatives, combine the characteristics of colonoscopy, the psychological status of first-degree relatives, family, and social support, and other factors, correct the cognitive bias of first-degree relatives on colonoscopy screening, strengthen communication and exchanges, attach importance to social support, and integrate Internet informatization for comprehensive management, reduce the obstacles to first-degree relatives’ participation in screening, and promote their active involvement in colonoscopy screening. Therefore, this study is of great significance for constructing a comprehensive colonoscopy screening program in the future.

Footnotes

Acknowledgements

We would like to appreciate all the participants in this study for their strong supports.

Author Contributions

Zhang Ruihuan: conceptualization, methodology, software, data curation, investigation, formal analysis, writing-original draft, writing-review and editing; Cong Fu: software, data curation, investigation, formal analysis, writing-original draft, writing-review and editing; Jing Yuan: supervision, project administration, resources and editing; Wenwen Li:supervision, resources; Chang Du: supervision, formal analysis, resources; Shuang Chen: Investigation; Kaihua Liu: investigation; Xiaoping Yin: conceptualization, data curation, supervision, project administration, resources, writing-review and editing. All authors have reviewed the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was funded by Hebei University Research and Innovation team (Innovative team for precise care and rehabilitation of patients with cancer No.IT2023C07).

Ethics Approval and Consent for Participation

Written and oral informed consent was obtained from all participants, and the study also received ethical approval from the Ethics Committee of the Affiliated Hospital of Hebei University, code HDFYLL-KY-2023-175.

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