Participants’ and non-participants’ views of workplace-based colorectal cancer screening in Japan: a secondary qualitative study

Abstract

Background

Colorectal cancer (CRC) screening is one of the main causes of death in high-income countries. In Japan, cancer screening programmes are delivered by different insurers, and these programmes are based mainly on communities and workplaces. Although several surveys have suggested participation rates are higher in workplace-based programmes, the experiences and views of participants and non-participants are poorly understood.

Methods

We conducted a secondary qualitative analysis of transcripts from interviews with people who shared their experiences and/or views of employer-based CRC screenings. By using a qualitative database called DIPEx-Japan, we purposely selected participants who had been on social insurance which indicated they were eligible for workplace-based cancer screening. We excluded (i) individuals with a history of inflammatory colorectal diseases; (ii) individuals who stated that they had been exclusively on National Health Insurance; and (iii) individuals who did not mention workplace-based screening. We conducted a thematic analysis for the selected interviews.

Results

We selected 24 cases for analysis. The participants were encouraged to attend workplace-based CRC screening alongside other annual legislated health check-ups or by offering financial assistance to attend comprehensive general health check-ups in hospitals that also include screening by default. Two interviewees who had not attended workplace-based screening said that it was not provided as a mandatory option. The participants often lacked the information required to make an informed choice regarding their participation in workplace-based screening. Several interviewees who had not attended further examinations explained that they were not informed of the necessity or purpose of the screening. Follow-up strategies varied across employers. However, there was an indication that interviewees who had an established relationship with healthcare professionals expressed their willingness to take up further examinations if needed and continued to participate in screening after their retirement.

Conclusions

Workplace-based cancer screening programmes may improve uptake of cancer screening because of their mandatory arrangements. However, better communication is needed to explain the risks and benefits of screening which will support their decisions to take up further examinations or encourage continuous participation in screening.

Background

Cancer screening is a public health strategy aimed at detecting cancers to reduce cancer-related mortality [1]. It requires additional resources to facilitate and coordinate care, as well as to provide evidence-based, effective screening while inviting the appropriate target population to address preventable deaths [1]. Colorectal cancer (CRC) is the most commonly diagnosed cancer and the second leading cause of cancer-related death in Japan, Europe, and North America [2]. For colorectal cancer screening, the guaiac faecal occult blood test (gFOBT) has proven effective, and the National Cancer Centre Japan recommends annual colorectal cancer screening for people aged 40 years and over via a faecal immunochemical test (FIT) [3, 4]. However, participation rates in Japan have remained lower than those in other high-income countries despite the growing number of cancer patients [5].

Under Japan’s social health insurance system, employees and their families are eligible for employer-based social insurance, whereas others (e.g., those running their own businesses) under the age of 75 years are covered by National Health Insurance, which is organised by local governments [6]. In Japan, cancer screening programmes have been delivered in communities under the Health Promotion Act (2002), alongside workplace-based screenings voluntarily provided as part of their employee benefits [7, 8]. Employees and families covered by social insurance are often invited to participate in both community-based and workplace-based cancer screening.

In Japan, employers are obliged to provide annual health check-ups to employees under the Industrial Safety and Health Act (1972). In addition, as insurers for social health insurance, they are required to deliver annual specific check-ups (tokutei-kenshin) to employees aged 40 years and over, which detect the risk of developing non-communicable diseases, including hypertension and dyslipidaemia, under the Act on Assurance of Medical Care for Elderly People (1983). Although, workplace-based cancer screening is not mandated nor regulated by legislation, it is often included in addition to these mandatory checkups [8]. According to recent surveys of Japanese employers, the format and delivery of workplace-based cancer screening varies considerably across employers [9–12]. For example, some firms deliver cancer screening in addition to mandatory health check-ups while other firms offer voluntary financial support to employees so that employees can receive comprehensive general health check-ups, including cancer screening, in hospitals with partnerships [12].

Workplaces are often considered effective platforms for health promotion, including cancer education and cancer screening interventions [13–15]. Several surveys in Japan have also reported higher cancer participation rates in workplace-based cancer screening programmes than in community-based programmes [16, 17]. A recent study surveyed 704 employers in Japan, ranging from small firms to large firms, to investigate how employers promote workplace-based cancer screening to increase uptake [10]. Almost half of the respondents reported their cancer screening participation rates. Employers who implemented supportive measures to promote cancer screening tended to achieve higher participation rates compared to those who implemented few or no such measures [10]. However, in Japan, there is a limited understanding of the quality of workplace-based cancer screening and how it is delivered in practice because of the lack of a quality assurance system [18]. In particular, the experiences and views of both participants and non-participants in workplace-based cancer screening are poorly understood. To facilitate effective workplace-based cancer screening, it is important to understand the experiences of the target population of such programmes.

This study aims to explore the experiences and views of employees and their families regarding their participation in workplace-based cancer screening.

Methods

We conducted a secondary qualitative analysis using the Data Archive of Health and Illness Narratives managed by the Database of Individual Patient Experience Japan (DIPEx-Japan). This archive, developed on the basis of the DIPEx project in the UK, holds interview recordings featuring diverse narratives collected mainly from patients and their families. It covers various clinical conditions, such as cancer, chronic pain, and dementia, with the aim of enhancing the understanding of patients’ perspectives and contributing to the delivery of patient-centred healthcare [19]. For participant recruitment in the original study, the DIPEx-Japan employed maximum variation sampling. They advertised the study through newspapers, television, and social media, in addition to distributing leaflets at public events to recruit participants. Furthermore, they approached healthcare organisations and patient groups through their advisory committee, which included clinicians, academics, patients, and family members (DIPEX-Japan, personal communication, 2 May, 2025). Specifically for the group sharing views and experiences related to CRC screening, they also drew a snowballing sampling and approached participants from other related cohort studies to ensure the inclusion of individuals with diverse occupations, types of social health insurance, and socioeconomic backgrounds (DIPEX-Japan, personal communication, 2 May, 2025). The archive contains 35 interview recordings from people who shared their views of and/or experiences with CRC screening [20]. The semi-structured interviews were conducted by experienced qualitative researchers in Japan in 2011. The interview topics focused on participants’ experiences of diagnosis and/or treatment of a specific condition, including any perceived changes in their lives since the diagnosis, reactions or support from family, friends, and financial challenges faced. Details of the interview process and the development of the archive has been published elsewhere [21].

To understand the views of both participants and non-participants regarding workplace-based CRC screening, the present study purposefully sampled all the index interviews where the interviewees discussed their experiences and views of workplace-based screening from a total of 35 interviews. For sampling, we first reviewed the summaries of each interview published online to identify eligible participants, followed by a screening of the full transcripts of potential cases. The interviews were included if the interviewees were aged between 30 and 74. The exclusion criteria were as follows: (i) had a history of inflammatory colorectal diseases; (ii) were exclusively on National Health Insurance; and (iii) did not mention workplace-based screening.

Verbatim transcripts of the selected index interviews were retrieved from the archive. Thematic analysis of the selected interview transcripts was conducted by an experienced qualitative researcher in health economics (YH) and an experienced health service researcher specialising in cancer screening (CH). The two researchers familiarised themselves with the selected transcripts and through multiple readings and also independently coded each transcript inductively with the assistance of NVivo 14. The emerging codes and categories were analysed thematically [22]. The coding framework was discussed between the two researchers to reach an agreement to ensure an alignment with our research question was reached. The analysis was performed in the original language, Japanese, to enable the researchers to fully grasp the meanings and contexts of the interviewees’ spoken words [23]. The researcher (YH), who is a bilingual in Japanese and English, translated direct quotes for use in the writing-up stage.

Results

In total, 24 out of 35 subjects were selected for this secondary qualitative analysis from the database. During the sampling process, four cases were excluded because of the interviewees’ age (75 years and over), and six others were excluded because the participants were enrolled exclusively in National Health Insurance, indicating that they had not been invited to employer-based screening. One case was excluded due to insufficient information regarding the type of colorectal cancer screening programme (e.g., community-based vs. employer-based programme).

Among the selected participants, ten interviewees were female. The mean age of all the interviewees was 55.9 years. Three interviewees were retired at the time of the interviews but still discussed their experience with workplace-based screening.

Almost all the interviewees participated in CRC screening at least once either through workplace-based check-ups or private comprehensive check-ups with financial support from their employers. Among the 24 selected patients, 11 had been diagnosed with CRC, either through cancer screening (n = 5) or due to relevant symptoms (n = 6) (Table 1).

Table 1.

Summary of the interviewees

Participants (n = 24)
Employee		17 (70.8)
Family of employee		4(16.7)
Retired		3 (12.5)
Age (mean, range)
55.9 (40–72)
Gender
Female		10 (41.7)
Male		14 (58.3)
Region
Shuto-ken (Greater Tokyo)		9 (37.5)
Kanto		5 (20.8)
Kansai		3 (12.5)
Tohoku		3 (12.5)
Chubu		1 (4.1)
Tokai		3 (12.5)
Participation in Employer-based CRC screening
Participated	Workplace-based screening	13 (54.1)
	Private comprehensive health check-ups (with employer financial support)	5 (20.8)
	Private comprehensive health check-ups (unclear arrangement)	4 (16.7)
Never participated	Workplace-based screening	2 (8.3)
Diagnosis of CRC
No		13 (54.2)
Diagnosed as CRC	Diagnosed by screening	5 (20.8)
	Diagnosed by symptoms	6 (25)

Workplace-based CRC screening

Twenty out of the 24 interviewees stated that FIT was included by default as part of their legislated annual general health check-ups or as part of comprehensive health check-ups that they opted to undergo with financial support from their employers.

A-6: [Workplace-based CRC screening] starts from a certain age. It’s probably from 35 to 40. An FIT has always been provided since then. (…) It was not something I chose by myself.

C-1: A comprehensive general check-up takes place annually, and I take [an FIT] regardless of whether I like it or not.

Financial support from their employers enabled employees to undergo comprehensive health check-ups at collaborative clinics or hospitals or with their own preferred providers, and this support often started after employees reach a certain age.

A-7: It has been over 20 years since I was 35. An FIT was included in the annual comprehensive general health check-ups. (…) At first, my employer fully reimbursed the fee for the comprehensive general health check-up, but since I imagine the insurer has a tight budget, they covered part of the fee including the support for female cancer screening for about the past ten years.

Comprehensive health check-ups were often preferred owing to the broader range of tests, including serum tumour marker tests. Several participants explained that more detailed tests offered them greater reassurance. For example, one of the participants described opting for a colonoscopy as part of a comprehensive health check-up instead of an FIT.

A-3: Usually, a comprehensive health check-up only includes a barium exam for the stomach and an FIT. However, I heard [the hospital I went to] provides gastric endoscopy and colonoscopy, so that sounded better to me. I believe a more detailed screening is better, so I took it.

Several participants who underwent workplace-based cancer screening described the perceived benefits of screening as reassurance due to early detection or from negative results. Most of these participants had been either diagnosed with cancer through screening or had a family member or friend who had experienced cancer.

C-2: When you don’t have any symptoms and then take up a screening, the data may show you a difference before it becomes evident. If you can detect it early, like myself, you can recover fully and live your life as normal without any barriers. That’s a benefit.

Two other interviewees also expressed trust in healthcare providers and technology as motivating factors for participating in CRC screening. In contrast, none of the participants explicitly mentioned benefits specific to workplace-based CRC screening, although the convenience and ease of access were highlighted in the context of further examination and treatment.

Lack of communication

Although including CRC screening as a default option might have improved uptake, participants indicated that there was a lack of communication about the screening process. While most participants recalled being informed about how to collect and submit samples, some were not aware of the purpose of FITs or did not recall being informed about the risks and benefits of participation.

A-7: In my mind, it’s reassuring to take up a comprehensive general check-up anyway, so I haven’t really thought about what this exam is exactly for. (…) I hadn’t thought that FIT is for bowel cancer at all.

A-9: I haven’t associated checking stool with investigating cancer, so I haven’t taken it seriously when doing the test. However, for example, if there is any problem with your bowel movement, then people would take the test more seriously. I wasn’t particularly worried about my bowels, and [FIT] was included [in the check-ups].

One of the participants expressed a mixed feeling over the effectiveness of CRC screening when they felt it was set up as a mandatory option.

A-2: I imagine [an FIT] is included in a comprehensive general health check-up because it’s effective to a certain degree. I wouldn’t take it of course if it’s not included in the check-up, indicating that it’s not effective. (…) Or this perhaps may be provided, for example, just because it’s highly profitable for doctors.

This lack of communication appeared to contribute to a hesitancy to undergo further examinations after receiving a positive result. Eleven participants mentioned being advised to undergo further tests by doctors because of their positive FIT results. While six of them proceeded for further examinations, others declined due to confidence in their health or a lack of awareness that the FIT was part of a CRC screening. Some expressed regret that they might have listened to doctors if they clarified the risk.

C-6: I believed that it must be just a haemorrhoid and that I would never get a cancer. That was my belief or maybe hope. I also didn’t have any symptoms at all, such as poor bowel movement. So, I’ve left [the positive results] almost for three years.

C-9: I repeatedly said this, but my premise was like I would never get cancer. I believed that even though 99 out of 100 people around me get cancer, I believed that I’m the only one who wouldn’t get one. That was my belief.

Follow-up strategies

Follow-up strategies after FITs appeared to vary across employers. Most interviewees reported receiving result letters and reminders to visit their family doctors or preferred clinics for further examinations. Some participants were advised in person by their line managers or occupational health physicians.

C-2: The results of comprehensive general check-ups (supported by employers) are reported to my employer. I mean the result of FIT. However, I undertook further exams in the hospital that are not related to them, so they weren’t informed about it.

Q2: Is there any case where your company checks whether someone took a further exam after a positive result?

C-2: No, they don’t do that.

One of the participants emphasised the need for a systematic approach to follow-ups, suggesting better coordination between participants, family doctors, hospitals, and testing centres.

A-6: There needs to be someone who follows up on the results of the comprehensive general check-up rather than just sending off the letter. (…) I think it would be beneficial if the information is shared between the community-based clinic, general hospital, and examination laboratory centre. (…) Establishing such a network would be necessary in the future.

In contrast, some interviewees felt that active follow-ups after screening might be effective in encouraging people who received a positive result. For example, one of the participants who continued to participate in cancer screening after retirement explained that his family doctor recommended regular participation in cancer screening.

A-8: Actually, the results are sent to us by mail. As I have taken check-ups at the same hospital for a long time, they show me a chart comparing with the last year and two years ago. Then, I bring this result to my family doctor for follow-up.

A-6: As you mentioned, I think we need someone who follows up on the results from the comprehensive general check-ups rather than just sending away the report to participants. One way could be suggesting that participants should undergo further examination. That might be an option. Another way could be sharing patients’ information among family doctors, general hospitals, and laboratories, although there might be issues of privacy. (…) I believe we need to build such networks in the future.

This finding also highlighted the importance of underlying relationships with patients and doctors. One participant explained his hesitance to listen to his family doctor because they changed every two years and lacked continuity.

C-9: My family doctor changes once every two years.

(…)

C-9: The doctor might have told me to take it (the further examination), but I didn’t take it very seriously. It was not like the doctor forced me to do. Now I think about it, several doctors might have recommended that, but I really didn’t take it seriously, so it was too late. I’ve ended up ignoring the result.

Non-participation

Among the selected cases, there were five interviewees who shared their experiences of not taking up workplace-based screening. Out of 24 interviewees, only two interviewees had never participated in CRC screenings. Both of them explained that FIT was not included as a mandatory option for workplace-based check-ups.

A-1: I haven’t had an opportunity [to take an FIT]. In workplace-based check-ups, CRC screening was not included, so I happened not to take it. I am not keen to take it either, so I wouldn’t participate it unless someone forces me to.

C-12: I remember an FIT was optional, so I was thinking that they are only looking at whether the stool contains blood and it doesn’t necessarily mean the bowels are bleeding or it could be positive if I have a nose bleeding or other gastric problems. I didn’t think positive results of FIT matter, so I haven’t taken it seriously and have not taken part in it.

Similarly, three other participants also shared their experience of not taking part in employer-based cancer screening. One of them stated her previous employer did not offer CRC screening along with annual health check-ups. Two other female interviewees also stated their unwillingness to participate in cancer screening provided either by communities or the workplace because of their caregiving responsibilities for their children. These interviewees explained that they returned to undergo CRC screening again after they reached certain ages.

A-9: After I quit my job and gave birth, I hardly ever went for check-ups. Well, it’s almost like I haven’t done it at all, including comprehensive health check-ups. And… um, since I’m getting older, and [people said] I should make an appointment [for check-ups] because the company offers financial assistance. Still, I often find it quite bothersome (to make an appointment). Well, I’m also busy, but I was kind of avoiding it. However, after turning 40, I started to think maybe I should properly get checked. So, I’ve been getting them regularly for about 3–4 years now.

Discussion

The present study conducted a secondary qualitative analysis of 24 interview transcripts in which the interviewees shared their views and experiences with workplace-based CRC screening in Japan. To our knowledge, this qualitative study appeared to be the first to explore the participants’ and non-participants’ views and experiences of employer-based colorectal cancer screening in Japan. The findings indicated that workplace-based CRC screening was often delivered alongside a legislative annual health check-up and that employees undergo screening because they perceived that it was mandatory. Financial assistance also encouraged them to take up comprehensive general health check-ups that also included CRC screening by default. However, there was a perceived lack of communication between cancer screening participants and providers regarding the process and risks and benefits of cancer screening in general. This insufficient communication appeared to lead to a hesitancy in taking up further examinations because of a lack of knowledge about screening.

A strength of this study is that, by using an existing qualitative database, we were able to identify and examine the experiences and views of both participants and non-participants, enabling us to better understand the barriers and motivations for participating in workplace-based cancer screening. However, the main limitations of this study include the use of relatively old data. Although legislation related to the delivery of employer-based cancer screening programmes has not changed, the Ministry of Health, Labour, and Welfare (MHLW), Japan, published guidance on workplace-based cancer screening in 2018 [7]. In addition to the influence of the COVID-19 pandemic on people’s workstyle, several changes have been introduced since the original data collection. Future studies are needed to understand how this policy and the COVID-19 pandemic have affected participants’ experiences with such screenings [18]. Additionally, this study investigated the interviewees’ perspectives of workplace-based screenings, and there were no attached details of their employers or of how cancer screening programmes have been delivered at the workplace in practice. Although five interviewees shared their experiences of not undertaking workplace-based colon cancer screening, only two interviewees who had never attended workplace-based cancer screening. To understand the barriers to undertaking workplace-based screening, future studies may need to explore more of the views of non-participants.

Nevertheless, this study has several important implications for the implementation of workplace-based cancer screening. First, the uptake of workplace-based CRC screening was encouraged by offering screening alongside other annual legislated general check-ups. Although the original data collection for the archive was conducted in 2011, this finding resonates with a more recent report published in 2022 [24]. According to a survey of residents in Tokyo, the most common reason for participating in a cancer screening was that it was included as part of a general health check-up or private comprehensive check-up [24]. Similarly, the most frequently cited reasons for not undergoing cancer screening was that it was not included as an option in these check-ups [24]. This suggests that a perceived obligation to participate in screening may contribute to improving screening uptake [24]. Additionally, invitations from employers may have been more effective for employees than those from community-based screening programmes. A recent meta-ethnography study looked into factors related to cancer screening attendance and argued that the existing relationship may be an important factor in motivating cancer screening uptake [25].

However, the present study also highlighted an ethical concern that participants in employer-based screening often perceived a lack of informed decision-making and communication with screening providers. Even when providing cancer screening alongside general health check-ups, informed decisions should be made, enabling employees and their families to make their own choice by understanding the risks and benefits of screening [26, 27]. Furthermore, this lack of communication between employees and providers appeared to be associated with poor attendance at further examinations. Recent studies on workplace-based cancer screening programmes have also revealed that offering cancer screening alone does not improve adherence, but information and education are needed to encourage their uptake [28]. Recent studies have also emphasised the importance of the use of in-person meetings or interactions [29, 30]. A recent Japanese study reported that active follow-up by occupational health staff with non-participants in screening and further examinations appeared to improve the uptake of workplace-based screening and further examinations [30].

Indeed, it is important to consider how workplace-based cancer screening can be used to provide information and influence employees’ decisions to participate. While a high participation rate is crucial for cancer screening, there is a growing recognition of the importance of informed decision-making [31], and more recently, shared decision-making is also considered valuable. Although the effects of shared decision-making on cancer screening uptake remain underexplored, a recent randomised control trial reported a higher uptake of cancer screening among people who experienced shared decision-making [32, 33]. Occupational health professionals can play a key role in facilitating such decision-making in workplaces [14, 34].

If employers lacks sufficient resources to collaborate with occupational health professionals, additional support may be needed to enable partnerships with local family practices or screening providers (e.g. local hospitals or private health check-ups providers) to continuously follow up on employees’ screening results and ensure their choices are being properly informed [12]. In this study, participants who have established a relationship between patients and family physicians seemed to be willing to attend further examinations or continue their participation after retirement. This finding is consistent with previous studies reporting the importance of direct recommendations from primary care physicians or their trusted family doctors [35–38]. In Japanese contexts, these communication and follow-up strategies could be integrated into the ongoing strategy for annual specific check-ups, which mandate consultations with occupational health professionals for employees deemed as high risk for developing non-communicable diseases.

Suggestions for future studies include quantitative analysis of screening uptake among different types of employers and qualitative studies to understand cancer screening uptake among participants who have changed employers.

Conclusions

Workplace-based CRC screening may encourage screening uptake by delivering it alongside annual, legislated general health check-ups. However, the current practice seemed to lack education, and participants were not informed about decisions when undergoing cancer screening. This was linked to a lack of adherence to follow-ups after positive results or a discontinuation of check ups after retirement. To increase the effectiveness of workplace-based screening, employers or insurers need to establish tailored cancer screening programmes that include better information and a more consistent follow-up. They may also use the existing relationships between employees and their family doctors.

Abbreviations

CRC

Colorectal cancer

FIT

 Faecal immunochemical test

FOBT

 Faecal occult blood test

Authors’ contributions

YH conducted the sampling, analysis, and writing; KS contributed to writing; CH conducted the study design, coordination and analysis; all the authors read and approved the final manuscript.

Funding

This study was funded by the Sciences Research Grants for Promotion of Cancer Control Programmes by the Ministry of Health, Labor and Welfare, Japan (grant number 20EA1024).

Yuri Hamashima’s time is supported by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West).

Data availability

The data analysed in the present study are available from DIPEx-Japan (https://www.dipex-j.org/) upon request and are subject to the required ethics application.

Declarations

Ethics approval and consent to participate

This study was approved by the ethics review board of Teikyo University (21 − 011), and written Informed consent was waived for the secondary analysis of publication data by DIPEx-Japan. No further ethical approvals were required for the secondary analysis. The study and all methods were conducted in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

Consent for publication

All participants included in this study provided written consent to DIPEx-Japan for their data to be used and presented for secondary research purposes and publication. The authors obtained approval for the final manuscripts from DIPEx-Japan.

Competing interests

The authors declare no competing interests.