Table 2.

Perceived barriers to lung cancer screening and illustrative participant quotes, by social ecological model level

Health care system level barriers
Cost of procedure	“I actually scheduled [a screening] and then they called me back and told me I needed to bring $300 with me. And I just didn’t have it for something that was not wrong with me.”
	“Insurance, you know. More than likely unless there is something that calls for [a CT scan], to just to go in and say you’d like to have one, on the safety side, insurance won’t pick it up.”
	“The cost, yeah. [Doctors] don’t just say, ‘Oh, let’s go have a CAT scan to see if you got cancer.’”
	“It probably comes from the insurance companies. Why should the doctor put you out that way because you may end up having to pay for the test in the first place because you smoke. Insurance companies don’t want to pay for anything.”
Confusion around test results	“A lot of times [screening tests] don’t really see things because like I just had a mammogram. Then they said, ‘We want you to go over here and get an ultrasound. Then we want you to go over here,’ you know.”
	“…you have just put me through all this mind bending and tests and running all over the place. I’ve been a stress mess. Tell me once and for all, do I have something or do I not? And I don’t believe that those tests can do that.”
Cultural level barriers
Fatalistic beliefs	“It’s part of the fear of having it done and then finding out that you do have it [lung cancer]. I don’t know if that’s true but everybody that I’ve come across, if they find out they have it then you’re going to have it in your mind, ‘Oh, my God, I have it. I’m going to die.’”
	“She said they thought they found, saw something…they wanted to run more tests. I just didn’t show back up because I feel like if it’s my time, I don’t want to know about it.”
	“[The CT]‘s the one I would feel comfortable with, but me, in general, I’m like what I don’t know won’t hurt me.”
Distrust in medical system	“I’m kind of like the person that thinks doctors and insurance companies are in cahoots anyway. And every time you go to the doctor, it doesn’t matter what you go for, they want you to have this test. They want you to have that test. They want you to be checked for this and that and I’ve done it for so many years. That’s why I don’t do it anymore unless it’s just absolutely necessary.”
	“I don’t trust [my doctor]…Mine’s the in and out, I’ll push you in, push you out, push you in, push you out…. He don’t got time for me. He don’t touch me….He won’t look at me. He prints out the [prescriptions] on a laptop. They’re shot straight to CVS. I’m in and out.”
	“It’s like if you’re not hurt in that area, it’s avoided…. You’re checking the blood and doing this and that, but if you’re not hurting in that particular area of the body, they’re not going to ask you. It’s like they want to spend less money on you as possible.”
Individual level barriers
Lack of knowledge	“...why haven’t we heard [about] it? I mean, in this age of the Internet and news, why is that something that’s not [known]. There’s plenty of medical shows on [television].”
Denial of risk	“I’m concerned about [lung cancer] but I don’t think about it…who knows if cigarettes actually cause that [cancer]? I mean, there’s a lot of people that have cancer that never smoked.”
	“I’m just getting ready to turn 50 and I keep thinking that’s not going to happen ‘til I’m over 70 or 80…So you just kind of, I guess, denial.”
	“I don’t want to know nothing else. Don’t hear no rattle. Don’t hear no bad news. I’m fine.”
Fear of screening procedure	“…when I had [a CT] they had to give me something to calm me because that little tube was too much enclosure….And I got claustrophobia.”
	“…an X-ray is… so much more relaxed. I don’t like MRIs and CAT scans…I’d rather stand in front of an X-ray machine any day.”