Table 3.

Participant quotes of perceived barriers to colorectal cancer screening

Code	Informant	Quote
Health policy level
Budget constraints	Endoscopy medical personnel	We are historically used to investing in resources for treatment of advanced colon cancer, palliative care, chemotherapy, radiotherapy, studies for staging and follow-up, but we have not invested in prevention and diagnostics. We need to guarantee the funding of programs like this, and find out how much they can actually expand otherwise the effort will be useless. Its funding needs to be guaranteed by Seguro Popular or something of the sort for the (screening) program to keep running.
Lack of interest of decision makers	Endoscopy medical personnel	This kind of program could fail due to the lack of support of decision makers. I see that many authorities are not interested in colorectal cancer, they don’t think for a minute about the possibility of having a prevention program. Some authorities in our hospital are aware of the relevance of this, but not all...
Insufficient promotion of CRC screening	Endoscopy medical personnel	The main challenge is that more people need to get into the program. We need a lot of promotion, a lot of promotion, a lot of promotion, we need to increase the number of participants, yes!
Social context level
Poverty	Male lay participant	I owed the payment of two months of my water service. So I saved money, about 1000 pesos (USD 50), but still I could not pay it. Somebody told me I could get a discount with my elderly person card, but it turned out that it only works for transportation. I had to pay 2026 pesos... I told him I have nothing more, so I just paid what I could and I still owe 1026 pesos.
	Primary care personnel: doctor	The people are humble, they are very noble people... but when you talk to them about their children’s nutrition and insist that they need to feed their malnourished children, they cannot stand it, they ask you: what can I feed them if I only have an egg for each day?
Beliefs: gender	Male lay participant	Men my age and older, it is very difficult that they will agree (to having a colonoscopy), because they are going to say that they are being raped. They will say: at this age they are going to rape me with the finger? No, you are crazy, I tell you the truth.
	Female lay participant	We are far from many things, because first we start under the assumption that us women are destined to be nothing more than a housewife, and if you have a controlling and jealous husband, forget it, how do you think you are going to go get this test done?
Beliefs: cancer	Female lay participant	I was told by a doctor that sometimes women can get colorectal cancer because when you are in labor you push a lot, and pushing so hard brings problems in the colon.
Health literacy	Primary care personnel: doctor	The patients have low levels of school education, people with maximum 3 years of primary school, so we face many complications because they do not understand how to take the treatment or how to take samples for lab tests.
Conditional participation in health programs	Primary care personnel: doctor	Above all, I have seen it happen a lot in the pap smear tests. It is very common that the results are not picked up, despite the fact that they are visited at their homes, that they receive phone calls... it is a lack of interest because they have already received the money and everything they can get and that’s it.
Insecurity (violence)	Primary health care: social worker	I feel, well not feel, I have perceived that many people, maybe approximately sixty percent, has had or has a relative in jail, and I don’t think that it’s without reason. In the area there has been violence... any act or infraction committed by their relatives or themselves is because there has been violence.
Cultural diversity	Primary health care: social worker	In this particular area there are several different cultures, I see it within the same group of people. One lady behaves differently from the other and suddenly there are many cultural shocks, right? Because there is one that says: “this is how things are done,” and there is another one that says: “no, how can you think that?”... I think this makes it difficult to form community groups in this health center... this is a particular situation that I see in this area.
Floating population	Primary health care: social worker	While the patients are from this health center, as long as they do not change residence there is no problem for the follow-up ... but it is common that they move, change their address. So you go looking for them and they are gone and you don’t know where they moved to... we have to deliver results and they are no longer there.
Organizational level (health services)
Tests costs	Male lay participant	If the cost of the tests is covered by Seguro Popular or if the cost is low, it is most likely to be done, if it is not covered or if the cost is very high, it is difficult for a patient to perform it.
Experiences of abuse in health services	Male lay participant	It is true that security guards are sometimes very bad, completely inhuman, right? They say: you are not from around here, you need to show me your health service identity card, if not then look elsewhere... If it is already a hardship to get to one hospital, then imagine having to move from one place to another.
Experiences of abuse in health services	Primary health care: social worker	If they would explain to the patient what they are going to do to him, the patient would be relaxed, he would know that there is not going to be a bigger problem, right? But no, they go “let’s see, get on here, take your clothes off, hold on and shut up!”
Poor quality of health services	Primary care personnel: doctor	As health personnel, we have to keep up-to-date in our medical knowledge, but when they send us to training for this, it further reduces our time for patient care
Doctor-patient communication problems	Male lay participant	I did not understand. I got confused. Apparently the doctor sent me to pathology, and he sent me to do some chest studies, and some study of my entire skeleton. But I got a bunch of papers and did not understand what they were for. I thought that I had to bring back those same papers when I came back to the hospital in my next visit. It was not like that... they were for the studies. Now I pay more attention to what this is and that... They give you so many different papers.
Lack of CRC knowledge	Primary care personnel: doctor	I think we need more information, we need more in the sense that maybe, well in my case, I do not know anything about the disease and about the test, I do not know about which one is the best. I think the specialist that has to do the study would be the proctologist, but I do not have more information, nothing more. I would say that in my service we require more information.
Work overload	Primary care personnel: doctor	We’re only a nurse, a doctor, a social worker and a lot of people, so obviously you cannot cope with the care required by all the patients who come. You have to organize your times, because there are so many activities to cover. You know that if a procedure gets a bit complicated or takes you a little extra time, you will not be able to perform two or three pap smears. I would like to be able to organize my activities, but there is so much to be done by one person, and also there is so much administrative work.
Lack of supplies	Primary care personnel: doctor	In primary care clinics sometimes we a feel our hands are tied, because sometimes we do not even have medicines, so to do specific studies is very difficult.
Insufficient infrastructure	Primary health care: social worker	We are very tight as you can see, there are no spaces, obviously the planning of this unit was a result, as in many cases, of an emergency situation, and there is no planning for the future, they do not have that kind of vision, that the population is going to keep growing.
Lack of personnel	Primary care personnel: doctor	I was in a health center and the nurse was suddenly called to cover a different nursing activity, she was called from one day to the next. So, if you have programmed activities with a nurse, you cannot perform them as planned because suddenly they have sent him/her to another site.
Lack of interest	Primary health care: social worker	I am sincere, if someone is not interested, it will not work. For example: there is a partner who proposes a new program, but if the health care personnel is not interested, how are they going to collaborate with the program?
Distant medical appointments	Male lay participant	And then, you have available appointment slots for consultations at the hospital in more than a month’s time. Now, for example, there are no slots available until March of next year, there are no available slots since October.
Long waiting time	Male lay participant	It takes a whole day at the health center to get an appointment, one has to spend all day there.
Administrative procedures	Primary care personnel: doctor	Lately I don’t go to my social security clinic anymore because there is too many people, they cannot see us all. One arrives, takes a turn, and they send you to stand in line to wait to see a doctor, but not your family doctor. If you bring studies you do not see your doctor, you have to see another one, it’s such a big mess! So, what is the point of going there?
Interpersonal level
Peers’ fear of colonoscopy	Primary health care doctor	Well, it’s fear, right? Fear of the procedure. More if a neighbor or relative tells them that colonoscopy is very painful. I think that would be a barrier.
Individual level
Fear of colonoscopy	Female lay participant	But that study is dangerous, right? You can die there or something? ... because they put a tube all the way up to here... I’m afraid I could die.
Fear of finding out about a serious disease	Female lay participant	I believe that when people already have certain symptoms and they need to have the study done, they have fear to be told they have a disease. That is what happened to my son-in-law. He was afraid to be told that he had cancer... that they could find he had something bad.
Embarrassment of having a colonoscopy	Female lay participant	I would be embarrassed that a doctor sees me, that a doctor introduces a camera, through my rectum.
Lack of time for use of health services	Male lay participant	Those comments are very frequent among my friends ... “They fired me from work, I went to the doctor, and it turns out that they fired me and right now I am unemployed.” So I think: I have a job and I will take care of it. So that’s what worries me, you can do the study, but how are you going to detect an illness in your body if you can’t skip work or you can lose it? For example, now I have about four or five years since in this job which was hard to find.
Procrastination	Female lay participant	I have invited people to many programs and they tell me, oh yes, let’s see, some day, once I decide then I’ll go, let me see when I have time.
Disinterest towards health	Primary health care: social worker	I also believe, sorry to be very rough, but I think that some patients have no strength. You call them for follow-up and referral and: “I haven’t been able to go, I am not interested, the hospital is too far away”. I tell them, it’s your health, I mean cancer is a priority, but people do not come, even if they have dysplasia or BIRADs 4, they don’t come. They make up a thousand excuses.
Preference for traditional medicine	Primary health care: social worker	Many times there are people who have already arrived here from the countryside and they are not used to the use of medicines, they want to return to natural treatments, naturists, herbs, teas. There are diabetic who say “I am going with a naturist doctor and he tells me that he will cure me”… They swear that they are going to be cured of diabetes and when they come back to see us they come in very uncontrolled states.
Distrust in public medical services	Male lay participant	Why go to IMSS (main public institution available for the formally insured)? If they don’t give an adequate answer to one’s illness, then why see them? It’s better this way. I prefer to look for a doctor close-by. Even if I have to pay, it is better quality and it doesn’t take all day long to get an appointment
Reluctance to use health services	Male lay participant	Because one as a man has a little bit of pain and we think that it will disappear, and we continue working, but you don’t know if there is a disease that is advancing, it is progressing. It is until it is well advanced that you regret you didn’t seek care earlier.
Low perceived risk of CRC	Male lay participant	Well, one as a man does not know, because the ladies get breast cancer. I’ve heard only women with cancer, not men.
Non-acceptance of biopsy	Endoscopy medical personnel	There were 8 patients who still did not come to schedule their colonoscopy study, so I started to communicate with them and one of them told me that she already knew about the program, but she did not want a colonoscopy because she doesn’t want a biopsy.
Lack of self-care	Primary health care: social worker	Thirty percent do not return for their results, they do not do it because of indifference, lack of self-care, they are not responsible of their own health.
Low self-esteem	Female lay participant	We carry so much as women, so much stress. Illnesses are for us so if we, as women, do not love ourselves, then we’ll die tomorrow.