Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 14, 2018
REVIEW ARTICLE

Colorectal Cancer Screening: The Role of Psychological, Social and Background Factors in Decision-making Process



Giulia Cossu1, *, Luca Saba2, Luigi Minerba1, Mario Mascalchi3
1 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
2 Department of Radiology, AOU, University of Cagliari, Cagliari, Italy
3 Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy

Abstract

Since ColoRectal Cancer (CRC) remains the third cause of cancer death in the world, a better understanding of the reasons underlying poor adherence to and delay in undergoing CRC screening programs is important.

CRC screening decision-making process can be conceptualized as the relationship between intention and behavior and needs to be investigated including the impact on patients’ decision of a broad range of psychological factors and personal predisposition as fear of a positive screening test, poor understanding of the procedure, psychological distress, anxiety, anticipation of pain, feelings of embarrassment and vulnerability. Also socioeconomic, ethnic and sociological influences, and organizational barriers have been identified as factors influencing CRC screening adherence. Decision-making process can finally be influenced by the healthcare background in which the intervention is promoted and screening programs are carried out.

However, there is still a gap on the scientific knowledge about the influences of diverse elements on screening adherence and this deserves further investigations in order to carry out more focused and effective prevention programs.

Keywords: Cancer screening, Compliance, Barriers, Cancer fear, Cancer worry, Health anxiety, Embarrassment, Risk perception, Colorectal cancer.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 14
First Page: 63
Last Page: 69
Publisher Id: CPEMH-14-63
DOI: 10.2174/1745017901814010063

Article History:

Received Date: 16/12/2017
Revision Received Date: 08/02/2018
Acceptance Date: 19/02/2018
Electronic publication date: 21/03/2018
Collection year: 2018

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 1205
Abstract HTML Views: 775
PDF Downloads: 551
ePub Downloads: 307
Total Views/Downloads: 2838

Unique Statistics:

Full-Text HTML Views: 567
Abstract HTML Views: 283
PDF Downloads: 251
ePub Downloads: 161
Total Views/Downloads: 1262
Geographical View

© 2018 Cossu et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy; Tel: 3939223550; E-mail: giuliaci@hotmail.com




1. COLORECTAL CANCER SCREENING TESTS

Although its incidence and mortality have decreased over the past 20 years, ColoRectal Cancer (CRC) remains one of the leading causes of mortality and morbidity in the world [1Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65(2): 87-108.[http://dx.doi.org/10.3322/caac.21262] [PMID: 25651787] , 2Gandomani HS, Aghajani M, Mohammadian-Hafshejani A, Tarazoj AA, Pouyesh V, Salehiniya H. Colorectal cancer in the world: Incidence, mortality and risk factors. Biomed Res Ther 2017; 4(10): 1656-75.[http://dx.doi.org/10.15419/bmrat.v4i10.372] ]. According to guidelines, CRC screening tests are strongly recommended starting from 50 years of age for average risk individuals [3Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin 2009; 59(1): 27-41.[http://dx.doi.org/10.3322/caac.20008] [PMID: 19147867] -5Ruco A, Stock D, Hilsden RJ, et al. Evaluation of a risk index for advanced proximal neoplasia of the colon. Gastrointest Endosc 2015; 81(6): 1427-32.[http://dx.doi.org/10.1016/j.gie.2014.12.028] [PMID: 25771065] ] and should continue up to age 75 [6Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US preventive services task force recommendation statement, us preventive services task force. JAMA 2016; 315(23): 2564-75.[http://dx.doi.org/10.1001/jama.2016.5989] [PMID: 27304597] ].

The options currently offered for CRC screening include Fecal Occult Blood Test (FOBT), Flexible Sigmoidoscopy (FS), Optical Colonoscopy (OC) and the recently proposed CT Colonography (CTC). FOBT is probably the least expensive screening test and is also well accepted with participation rates of 48% to 63%. However, it has some limitations, such as the need to repeat the test every one/two years and the low sensitivity for large adenomas (≥10 mm) [7Sali L, Mascalchi M, Falchini M, et al. Reduced and full-preparation ct colonography, fecal immunochemical test, and colonoscopy for population screening of colorectal cancer: A randomized trial. J Natl Cancer Inst 2015; 108(2): djv319.[http://dx.doi.org/10.1093/jnci/djv319] [PMID: 26719225] ]. In spite of being the most complete diagnostic test for CRC and colorectal adenomas, OC shows low acceptance as a screening test. CTC is a highly sensitive and minimally invasive procedure for the detection of cancer (96%) and large adenomas (90%) and has a low risk of complications [7Sali L, Mascalchi M, Falchini M, et al. Reduced and full-preparation ct colonography, fecal immunochemical test, and colonoscopy for population screening of colorectal cancer: A randomized trial. J Natl Cancer Inst 2015; 108(2): djv319.[http://dx.doi.org/10.1093/jnci/djv319] [PMID: 26719225] ]. The relationship between cost and effectiveness of CTC has been recently debated in order to assess whether and how to include it in the screening programmes [8Sali L, Grazzini G, Mascalchi M. CT colonography: role in FOBT-based screening programs for colorectal cancer. Clin J Gastroenterol 2017; 10(4): 312-9.[http://dx.doi.org/10.1007/s12328-017-0744-1] [PMID: 28447326] -13Mantellini P, Lippi G, Sali L, et al. Cost analysis of colorectal cancer screening with CT colonography in Italy. Eur J Health Econ 2017.[http://dx.doi.org/10.1007/s10198-017-0917-3] [PMID: 28681075] ]. CTC is expensive and requires the patient’s ability to complete a successful preparation similar to colonoscopy. However, its main drawback is the radiation dose delivered to the patient [14Prokop M. Cancer screening with CT: Dose controversy. Eur Radiol 2005; 15(Suppl. 4): D55-61.[http://dx.doi.org/10.1007/s10406-005-0145-2] [PMID: 16479648] ]. In particular, exposure to ionizing radiations has emerged as a general obstacle to participation in radiological screening of cancers, that is associated with practical and emotional barriers related to the fear of radiation [15Khayyat YM, Ibrahim EM. Public awareness of colon cancer screening among the general population: A study from the Western Region of Saudi Arabia. Qatar Med J 2014; 2014(1): 17-24.[http://dx.doi.org/10.5339/qmj.2014.3] [PMID: 25320688] , 16Ali N, Lifford KJ, Carter B, et al. Barriers to uptake among high-risk individuals declining participation in lung cancer screening: A mixed methods analysis of the UK Lung Cancer Screening (UKLS) trial. BMJ Open 2015; 5(7): e008254.[http://dx.doi.org/10.1136/bmjopen-2015-008254] [PMID: 26173719] ]. We carried out a computerized search on Google and PubMed database combining the search terms “cancer screening”, “compliance barriers” and “colorectal cancer” to assess studies that have tried to identify the main adherence barriers to CRC screening programs.

2. REASONS FOR NON-ADHERENCE TO COLORECTAL CANCER SCREENING

Despite evidence suggesting that 90% of CRC incidence and 60% of deaths can be prevented through screenings [17Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: A review of current guidelines, practices, and prospects. CA Cancer J Clin 2007; 57(2): 90-104.[http://dx.doi.org/10.3322/canjclin.57.2.90] [PMID: 17392386] , 18Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58(3): 130-60.[http://dx.doi.org/10.3322/CA.2007.0018] [PMID: 18322143] ], 38% of adults aged 50 years and older have never had a sigmoidoscopy/colonoscopy and 79% have never had a FOBT [19Bynum SA, Davis JL, Green BL, Katz RV. Unwillingness to participate in colorectal cancer screening: Examining fears, attitudes, and medical mistrust in an ethnically diverse sample of adults 50 years and older. Am J Health Promot 2012; 26(5): 295-300.[http://dx.doi.org/10.4278/ajhp.110113-QUAN-20] [PMID: 22548424] ]. Better understanding of the reasons for poor adherence and delay in undergoing screening programs is important in the context of the significant challenge represented by the reduction of CRC incidence and morality [3Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin 2009; 59(1): 27-41.[http://dx.doi.org/10.3322/caac.20008] [PMID: 19147867] , 18Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58(3): 130-60.[http://dx.doi.org/10.3322/CA.2007.0018] [PMID: 18322143] ]. Usually, the CRC screening strategies include FOBT as first exam and OC as further work-up procedure. As it has been underlined, colonoscopy participation rates can be significantly lower than FOBT, and even when FOBT is positive, some patients can refuse to continue the screening process declining OC [20Sali L, Grazzini G, Ventura L, et al. Computed tomographic colonography in subjects with positive faecal occult blood test refusing optical colonoscopy. Dig Liver Dis 2013; 45(4): 285-9.[http://dx.doi.org/10.1016/j.dld.2012.11.008] [PMID: 23266193] , 21Szczepura A, Johnson M, Orbell S, et al. 2003.].

Reasons underlying non-adherence to CRC screening are diverse and include socioeconomic, ethnic and sociological influences [22von Wagner C, Baio G, Raine R, et al. Inequalities in participation in an organized national colorectal cancer screening programme: Results from the first 2.6 million invitations in England. Int J Epidemiol 2011; 40(3): 712-8.[http://dx.doi.org/10.1093/ije/dyr008] [PMID: 21330344] ], organizational barriers [23Murdock A, Rodgers C, Lindsay H, Tham TC. Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. J R Soc Med 2002; 95(6): 284-6.[http://dx.doi.org/10.1177/014107680209500605] [PMID: 12042374] , 24Sanasi-Bhola K, Williams CD, Burnside C, et al. Age, sex, marital status and adherence to scheduled out-patient endoscopy. Gastroenterology 2011; 140(5)] and General Practitioner (GP) endorsement bent [25Raine R, Duffy SW, Wardle J, et al. Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening. Br J Cancer 2016; 114(3): 321-6.[http://dx.doi.org/10.1038/bjc.2015.413] [PMID: 26742011] ]. Also a male gender, long waiting time for appointment and psychiatric illnesses have been reported as factors that are implicated in colonoscopy non-adherence [26Beydoun HA, Beydoun MA. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control 2008; 19(4): 339-59.[http://dx.doi.org/10.1007/s10552-007-9100-y] [PMID: 18085415] -28Blumenthal DM, Singal G, Mangla SS, Macklin EA, Chung DC. Predicting non-adherence with outpatient colonoscopy using a novel electronic tool that measures prior non-adherence. J Gen Intern Med 2015; 30(6): 724-31.[http://dx.doi.org/10.1007/s11606-014-3165-6] [PMID: 25586869] ].

However, a lower educational level has been found to be associated with low colonoscopy compliance. Finally, obese patients have been shown to be more likely to be non-compliant than non-obese patients [29Anderson JC, Fortinsky RH, Kleppinger A, Merz-Beyus AB, Huntington CG III, Lagarde S. Predictors of compliance with free endoscopic colorectal cancer screening in uninsured adults. J Gen Intern Med 2011; 26(8): 875-80.[http://dx.doi.org/10.1007/s11606-011-1716-7] [PMID: 21499823] ]. Therefore, it is necessary that promotional CRC screening activities take into greater account these factors that predispose some types of patients to poor adherence.

However, there seems to be a gap in the scientific literature especially on the psychosocial factors that might influence patient’s decision to undergo or refuse CRC screening. In particular, knowledge of the psychological effects on participating in CRC screening is limited and there are few studies, with mixed and contradictory results, that have tried to aassess which psychological aspects such as fear can affect the probability that patients undergo specific screening and how much participants may experience psychological stress from participation even after a long time [30Kirkøen B, Berstad P, Botteri E, et al. Psychological effects of colorectal cancer screening: Participants vs individuals not invited. World J Gastroenterol 2016; 22(43): 9631-41.[http://dx.doi.org/10.3748/wjg.v22.i43.9631] [PMID: 27920484] ].

3. PSYCHOLOGICAL FACTORS

In general, fear of a positive test, poor understanding of the procedure, psychological distress, anxiety, anticipation of pain, feelings of embarrassment and vulnerability can determine a poor adherence to cancer screening [23Murdock A, Rodgers C, Lindsay H, Tham TC. Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. J R Soc Med 2002; 95(6): 284-6.[http://dx.doi.org/10.1177/014107680209500605] [PMID: 12042374] , 31Mladen DM, Dragoslav MP, Sanja Z, Bozidar B, Snezana D. Problems in screening colorectal cancer in the elderly. World J Gastroenterol 2003; 9(10): 2335-7.[http://dx.doi.org/10.3748/wjg.v9.i10.2335] [PMID: 14562405] , 32McLachlan SA, Clements A, Austoker J. Patients’ experiences and reported barriers to colonoscopy in the screening context: A systematic review of the literature. Patient Educ Couns 2012; 86(2): 137-46.[http://dx.doi.org/10.1016/j.pec.2011.04.010] [PMID: 21640543] ].

However, according to some studies, cancer fear itself can act both as a facilitator and a deterrent to screening participation for breast [33Sutton S, Bickler G, Sancho-Aldridge J, Saidi G. Prospective study of predictors of attendance for breast screening in inner London. J Epidemiol Community Health 1994; 48(1): 65-73.[http://dx.doi.org/10.1136/jech.48.1.65] [PMID: 8138773] , 34Consedine NS, Morgenstern AH, Kudadjie-Gyamfi E, Magai C, Neugut AI. Prostate cancer screening behavior in men from seven ethnic groups: the fear factor. Cancer Epidemiol Biomarkers Prev 2006; 15(2): 228-37.[http://dx.doi.org/10.1158/1055-9965.EPI-05-0019] [PMID: 16492909] ], prostate [34Consedine NS, Morgenstern AH, Kudadjie-Gyamfi E, Magai C, Neugut AI. Prostate cancer screening behavior in men from seven ethnic groups: the fear factor. Cancer Epidemiol Biomarkers Prev 2006; 15(2): 228-37.[http://dx.doi.org/10.1158/1055-9965.EPI-05-0019] [PMID: 16492909] ] and ovarian cancer [35Drescher C, Holt SK, Andersen MR, Anderson G, Urban N. Reported ovarian cancer screening among a population-based sample in Washington state. Obstet Gynecol 2000; 96(1): 70-4.[PMID: 10862845] ] cancers. According to some Authors, cancer fear could promote adherence to screening since the latter can be viewed as a means for seeking reassurance, while for other Authors, cancer fear would be associated with elusive or fatalistic views that are deterrent to screening [36Champion VL, Skinner CS, Menon U, et al. A breast cancer fear scale: Psychometric development. J Health Psychol 2004; 9(6): 753-62.[http://dx.doi.org/10.1177/1359105304045383] [PMID: 15367754] -38Hay JL, Buckley TR, Ostroff JS. The role of cancer worry in cancer screening: A theoretical and empirical review of the literature. Psychooncology 2005; 14(7): 517-34.[http://dx.doi.org/10.1002/pon.864] [PMID: 15490428] ]

Regarding CRC screening, fear before undergoing screening was associated with higher adherence, while fear during screening was associated with lower adherence in a sample of elderly adults in Singapore [39Wong RK, Wong ML, Chan YH, Feng Z, Wai CT, Yeoh KG. Gender differences in predictors of colorectal cancer screening uptake: A national cross sectional study based on the health belief model. BMC Public Health 2013; 13: 677.[http://dx.doi.org/10.1186/1471-2458-13-677] [PMID: 23879593] ] and in a sample of Hispanic Americans [40Jandorf L, Ellison J, Villagra C, et al. Understanding the barriers and facilitators of colorectal cancer screening among low income immigrant hispanics. J Immigr Minor Health 2010; 12(4): 462-9.[http://dx.doi.org/10.1007/s10903-009-9274-3] [PMID: 19621259] ]. However, this ambivalent relationship between cancer fear and adherence to CRC and other cancer screening was not found in other studies [41Moser RP, McCaul K, Peters E, Nelson W, Marcus SE. Associations of perceived risk and worry with cancer health-protective actions: Data from the Health Information National Trends Survey (HINTS). J Health Psychol 2007; 12(1): 53-65.[http://dx.doi.org/10.1177/1359105307071735] [PMID: 17158840] , 42Llanos AA, Pennell ML, Young GS, Tatum CM, Katz ML, Paskett ED. No association between colorectal cancer worry and screening uptake in Appalachian Ohio. J Public Health (Oxf) 2015; 37(2): 322-7.[http://dx.doi.org/10.1093/pubmed/fdu031] [PMID: 24850101] ]. The main factor that would require greater insight seems to be how fear can lead to a specific behavioral response facilitating, hindering or delaying people from undergoing the screening test.

One possible explanation for the above inconsistencies could be the low uniformity and accuracy of tools used to measure and examine “cancer fear” in its different aspects. Usually, history of psychiatric illness, defined as mood, anxiety, and/or psychotic [28Blumenthal DM, Singal G, Mangla SS, Macklin EA, Chung DC. Predicting non-adherence with outpatient colonoscopy using a novel electronic tool that measures prior non-adherence. J Gen Intern Med 2015; 30(6): 724-31.[http://dx.doi.org/10.1007/s11606-014-3165-6] [PMID: 25586869] ] or panic [43Chung YW, Han DS, Yoo KS, Park CK. Patient factors predictive of pain and difficulty during sedation-free colonoscopy: A prospective study in Korea. Dig Liver Dis 2007; 39(9): 872-6.[http://dx.doi.org/10.1016/j.dld.2007.04.019] [PMID: 17652041] -45Sly JR, Edwards T, Shelton RC, Jandorf L. Identifying barriers to colonoscopy screening for nonadherent African American participants in a patient navigation intervention. Health Educ Behav 2013; 40(4): 449-57.[http://dx.doi.org/10.1177/1090198112459514] [PMID: 23086556] ] disorder, has shown a potential correlation with low adherence to screening and has been assessed using standard instruments.

However fear of undergoing medical examinations and of being affected by specific pathologies may include other psychological features as worry of receiving a positive screening test result, discomfort associated with the invasiveness of the screening tests, some cognitive and affective factors and anxiety predisposition. Accordingly, it is reasonable to assume that specific tools need to be developed considering all the diverse psychological elements that can be involved. In general, the fear of receiving a CRC diagnosis needs to be better understood as a multi-dimensional construct with its cognitive, biological, affective and behavioural components [46Arne Ö. Fear and Anxiety: Overlaps and Dissociations Handbook of emotions 3rd ed. 3rd ed.2008., 47Vrinten C, Waller J, von Wagner C, Wardle J. Cancer fear: Facilitator and deterrent to participation in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2015; 24(2): 400-5.[http://dx.doi.org/10.1158/1055-9965.EPI-14-0967] [PMID: 25634890] ]. A review that took into account inhomogeneous definitions and measurement strategies has pointed out that ‘worry about cancer’, ‘cancer-related distress’, ‘intrusive and avoidant thoughts about cancer’, and ‘effects of cancer-related thoughts on mood and daily activities’ are some of the main elements with which the fear of cancer has been operationalised [38Hay JL, Buckley TR, Ostroff JS. The role of cancer worry in cancer screening: A theoretical and empirical review of the literature. Psychooncology 2005; 14(7): 517-34.[http://dx.doi.org/10.1002/pon.864] [PMID: 15490428] ]. Three aspects of cancer fear: cognitive, affective and psychobiological aspects and their association with different behavioural effects [47Vrinten C, Waller J, von Wagner C, Wardle J. Cancer fear: Facilitator and deterrent to participation in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2015; 24(2): 400-5.[http://dx.doi.org/10.1158/1055-9965.EPI-14-0967] [PMID: 25634890] ]. It has also been observed that cognitive/affective aspects of cancer fear (cancer as greatest health fear, worry about cancer) may exert their effects at different stages in the decisional process. They were significant facilitators of screening intention because of the desire of being reassured, while to think about cancer can lead to a more visceral negative response that can be a deterrent at the action stage. As outlined by other Authors, the relationship between intention and behaviour needs to be better understood as well as the role of factors that can influence intention and action [48Sheeran P. Intention-behavior relations: A conceptual and empirical review. Eur Rev Soc Psychol 2002; 12: 1-36.[http://dx.doi.org/10.1080/14792772143000003] ].

4. HEALTHCARE BACKGROUND FACTORS

Decision-making process can also be influenced by the healthcare background in which the intervention is promoted and how preventive measurements are presented and screening actions are performed. Full knowledge of the different CRC screening examinations available and their different invasiveness level can also be a relevant factor for adherence. However, research results are not yet exhaustive on these aspects and further studies are required.

Since the CRC screenings remain an elective and voluntary medical procedure and the rate of deaths attributable to low rate of compliance to CRC screening are not negligible, some studies have been carried out with the aim to evaluate efficacy of some preventive health measures. For instance, patient navigation and community health liaisons were developed and trained to guide candidates through screening colonoscopy using a direct endoscopy referral system [49Lebwohl B, Neugut AI, Stavsky E, et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol 2011; 45(5): e47-53.[http://dx.doi.org/10.1097/MCG.0b013e3181f595c3] [PMID: 21030874] ]. They proved to be effective in helping patients to overcome barriers to CRC screening, but with an effect of small size [50Leone LA, Reuland DS, Lewis CL, et al. Reach, usage, and effectiveness of a Medicaid patient navigator intervention to increase colorectal cancer screening, Cape Fear, North Carolina, 2011. Prev Chronic Dis 2013; 10: E82.[http://dx.doi.org/10.5888/pcd10.120221] [PMID: 23701719] , 51Ali-Faisal SF, Colella TJ, Medina-Jaudes N, Benz Scott L. The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials. Patient Educ Couns 2017; 100(3): 436-48.[http://dx.doi.org/10.1016/j.pec.2016.10.014] [PMID: 27771161] ].

For this reason, both decision aids and patient navigation have been tested as complementary interventions for promoting CRC screening adherence by influencing the decision process both on a practical/behavioral and cognitive level including patients awareness, knowledge and preferences [52Reuland DS, Brenner AT, Hoffman R, et al. Effect of combined patient decision aid and patient navigation vs. usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial. JAMA Intern Med 2017; 177(7): 967-74.[http://dx.doi.org/10.1001/jamainternmed.2017.1294] [PMID: 28505217] ]. Increasing the patient’s knowledge using advanced visual media through local campaigns was found to be associated with higher acceptance rates for screening colonoscopies [53Albrecht H, Gallitz J, Hable R, et al. The offer of advanced imaging techniques leads to higher acceptance rates for screening colonoscopy: A Prospective Study. Asian Pac J Cancer Prev 2016; 17(8): 3871-5.[PMID: 27644632] ]. Moreover, a community-focused education program has been evaluated as a potential prevention action to reduce poor adherence and make the patient an active participant in their care [54Tucker A, Tucker SP. Increasing colorectal cancer screening compliance through community education. Gastroenterol Nurs 2012; 35(6): 416-9.[http://dx.doi.org/10.1097/SGA.0b013e318274b236] [PMID: 23207784] ]. The program has provided instruction on CRC prevention and screening through flyer distribution, newspaper advertisements, radio advertisements, and publicly displayed poster to allow patients to keep information and make an appointment showing increasing compliance [54Tucker A, Tucker SP. Increasing colorectal cancer screening compliance through community education. Gastroenterol Nurs 2012; 35(6): 416-9.[http://dx.doi.org/10.1097/SGA.0b013e318274b236] [PMID: 23207784] ]. Culturally, targeted educational programs about CRC for Blacks and Latinos including education about screening, peer testimony given by a colonoscopy-adherent person, and pre- and post-knowledge assessment have also been realized [55Crookes DM, Njoku O, Rodriguez MC, Mendez EI, Jandorf L. Promoting colorectal cancer screening through group education in community-based settings. J Cancer Educ 2014; 29(2): 296-303.[http://dx.doi.org/10.1007/s13187-013-0599-1] [PMID: 24385340] ].

Colonoscopy is one of the main CRC screening tests that requires compliance to the procedure, as well as the ability to complete a successful colonoscopy preparation. For this reason, some authors have assessed the role that communication and understanding of basic health information during the process can have for patients adherence. The use of an educational pamphlet has been found to reduce the anxiety levels before colonoscopy, to determine a better colon preparation and to have effect on the quality and the amount of medications used during the procedure [56Shaikh AA, Hussain SM, Rahn S, Desilets DJ. Effect of an educational pamphlet on colon cancer screening: A randomized, prospective trial. Eur J Gastroenterol Hepatol 2010; 22(4): 444-9.[http://dx.doi.org/10.1097/MEG.0b013e328333fca6] [PMID: 19940781] ]. A web-based multimedia program illustrates to patients information material before colonoscopy can increase knowledge, decrease anxiety, procedure time and medication requirements [57Parker S, Zipursky J, Ma H, Baumblatt GL, Siegel CA. A web-based multimedia program before colonoscopy increased knowledge and decreased anxiety, sedation requirement, and procedure time. J Clin Gastroenterol 2017.[http://dx.doi.org/10.1097/MCG.0000000000000958] [PMID: 29095417] ].

Since colonoscopy is usually done with sedation to reduce anxiety and discomfort in patients during the examination, some studies have evaluated the capability of listening to music, as an alternative method to reduce pain during the procedure [58Andrada JM, Vidal AA, Aguilar-Tablada TC, et al. Anxiety during the performance of colonoscopies: Modification using music therapy 2004.[http://dx.doi.org/10.1097/00042737-200412000-00024] -60Ko CH, Chen YY, Wu KT, et al. Effect of music on level of anxiety in patients undergoing colonoscopy without sedation. J Chin Med Assoc 2017; 80(3): 154-60.[http://dx.doi.org/10.1016/j.jcma.2016.08.010] [PMID: 27889459] ]. Other alternative methods, such as showing a relaxing video, have been tested in order to evaluate their effects on patient anxiety, pain and experience during colonoscopy with an improved satisfaction especially among patients with a high pre-procedural anxiety score [61Umezawa S, Higurashi T, Uchiyama S, et al. Visual distraction alone for the improvement of colonoscopy-related pain and satisfaction. World J Gastroenterol 2015; 21(15): 4707-14.[http://dx.doi.org/10.3748/wjg.v21.i15.4707] [PMID: 25914482] ]. Finally, in order to evaluate possible benefits of hypnosis during colonoscopy, some authors performed a pilot study selecting the time for procedure, number of vasovagal events, and recovery time as outcomes [62Elkins G, White J, Patel P, Marcus J, Perfect MM, Montgomery GH. Hypnosis to manage anxiety and pain associated with colonoscopy for colorectal cancer screening: Case studies and possible benefits. Int J Clin Exp Hypn 2006; 54(4): 416-31.[http://dx.doi.org/10.1080/00207140600856780] [PMID: 16950684] ]. The results have suggested that hypnosis can be an effective method to manage anxiety and pain associated with colonoscopy and can reduce the need for sedation, recovery time and vasovagal events.

CONCLUSION

The CRC screening decision-making process conceptualized as the relationship between intention and behaviour needs to be better understood by examining the impact of a broad range of factors on screening adherence and future prevention programs. In particular, since there is a gap on the scientific knowledge about psychological factors and personal predisposition elements underlying patients’ decision, further studies of these elements are necessary.

It is also necessary that studies take also into consideration the environmental factors that can interfere or facilitate the decision-making process and their specific peculiarities including healthcare background and the characteristics of families, communities, cities and neighborhoods where the interventions are promoted and screening programs are carried out.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65(2): 87-108.[http://dx.doi.org/10.3322/caac.21262] [PMID: 25651787]
[2] Gandomani HS, Aghajani M, Mohammadian-Hafshejani A, Tarazoj AA, Pouyesh V, Salehiniya H. Colorectal cancer in the world: Incidence, mortality and risk factors. Biomed Res Ther 2017; 4(10): 1656-75.[http://dx.doi.org/10.15419/bmrat.v4i10.372]
[3] Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin 2009; 59(1): 27-41.[http://dx.doi.org/10.3322/caac.20008] [PMID: 19147867]
[4] Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US multi-society task force on colorectal cancer. Gastroenterology 2012; 143(3): 844-57.[http://dx.doi.org/10.1053/j.gastro.2012.06.001] [PMID: 22763141]
[5] Ruco A, Stock D, Hilsden RJ, et al. Evaluation of a risk index for advanced proximal neoplasia of the colon. Gastrointest Endosc 2015; 81(6): 1427-32.[http://dx.doi.org/10.1016/j.gie.2014.12.028] [PMID: 25771065]
[6] Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US preventive services task force recommendation statement, us preventive services task force. JAMA 2016; 315(23): 2564-75.[http://dx.doi.org/10.1001/jama.2016.5989] [PMID: 27304597]
[7] Sali L, Mascalchi M, Falchini M, et al. Reduced and full-preparation ct colonography, fecal immunochemical test, and colonoscopy for population screening of colorectal cancer: A randomized trial. J Natl Cancer Inst 2015; 108(2): djv319.[http://dx.doi.org/10.1093/jnci/djv319] [PMID: 26719225]
[8] Sali L, Grazzini G, Mascalchi M. CT colonography: role in FOBT-based screening programs for colorectal cancer. Clin J Gastroenterol 2017; 10(4): 312-9.[http://dx.doi.org/10.1007/s12328-017-0744-1] [PMID: 28447326]
[9] Zorzi M, Fedato C, Grazzini G, et al. [Screening for colorectal cancer in Italy, 2010 survey]. Epidemiol Prev 2012; 36(6)(Suppl. 1): 55-77.[PMID: 23293271]
[10] Kapidzic A, Grobbee EJ, Hol L, et al. Attendance and yield over three rounds of population-based fecal immunochemical test screening. Am J Gastroenterol 2014; 109(8): 1257-64.[http://dx.doi.org/10.1038/ajg.2014.168] [PMID: 24980879]
[11] Sali L, Falchini M, Della Monica P, et al. CT colonography before colonoscopy in subjects with positive faecal occult blood test. Preliminary experience. Radiol Med (Torino) 2010; 115(8): 1267-78.[http://dx.doi.org/10.1007/s11547-010-0569-1] [PMID: 20680499]
[12] Sali L, Regge D. CT colonography for population screening of colorectal cancer: Hints from European trials. Br J Radiol 2016; 89(1068): 20160517.[http://dx.doi.org/10.1259/bjr.20160517] [PMID: 27542076]
[13] Mantellini P, Lippi G, Sali L, et al. Cost analysis of colorectal cancer screening with CT colonography in Italy. Eur J Health Econ 2017.[http://dx.doi.org/10.1007/s10198-017-0917-3] [PMID: 28681075]
[14] Prokop M. Cancer screening with CT: Dose controversy. Eur Radiol 2005; 15(Suppl. 4): D55-61.[http://dx.doi.org/10.1007/s10406-005-0145-2] [PMID: 16479648]
[15] Khayyat YM, Ibrahim EM. Public awareness of colon cancer screening among the general population: A study from the Western Region of Saudi Arabia. Qatar Med J 2014; 2014(1): 17-24.[http://dx.doi.org/10.5339/qmj.2014.3] [PMID: 25320688]
[16] Ali N, Lifford KJ, Carter B, et al. Barriers to uptake among high-risk individuals declining participation in lung cancer screening: A mixed methods analysis of the UK Lung Cancer Screening (UKLS) trial. BMJ Open 2015; 5(7): e008254.[http://dx.doi.org/10.1136/bmjopen-2015-008254] [PMID: 26173719]
[17] Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: A review of current guidelines, practices, and prospects. CA Cancer J Clin 2007; 57(2): 90-104.[http://dx.doi.org/10.3322/canjclin.57.2.90] [PMID: 17392386]
[18] Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58(3): 130-60.[http://dx.doi.org/10.3322/CA.2007.0018] [PMID: 18322143]
[19] Bynum SA, Davis JL, Green BL, Katz RV. Unwillingness to participate in colorectal cancer screening: Examining fears, attitudes, and medical mistrust in an ethnically diverse sample of adults 50 years and older. Am J Health Promot 2012; 26(5): 295-300.[http://dx.doi.org/10.4278/ajhp.110113-QUAN-20] [PMID: 22548424]
[20] Sali L, Grazzini G, Ventura L, et al. Computed tomographic colonography in subjects with positive faecal occult blood test refusing optical colonoscopy. Dig Liver Dis 2013; 45(4): 285-9.[http://dx.doi.org/10.1016/j.dld.2012.11.008] [PMID: 23266193]
[21] Szczepura A, Johnson M, Orbell S, et al. 2003.
[22] von Wagner C, Baio G, Raine R, et al. Inequalities in participation in an organized national colorectal cancer screening programme: Results from the first 2.6 million invitations in England. Int J Epidemiol 2011; 40(3): 712-8.[http://dx.doi.org/10.1093/ije/dyr008] [PMID: 21330344]
[23] Murdock A, Rodgers C, Lindsay H, Tham TC. Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic. J R Soc Med 2002; 95(6): 284-6.[http://dx.doi.org/10.1177/014107680209500605] [PMID: 12042374]
[24] Sanasi-Bhola K, Williams CD, Burnside C, et al. Age, sex, marital status and adherence to scheduled out-patient endoscopy. Gastroenterology 2011; 140(5)
[25] Raine R, Duffy SW, Wardle J, et al. Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening. Br J Cancer 2016; 114(3): 321-6.[http://dx.doi.org/10.1038/bjc.2015.413] [PMID: 26742011]
[26] Beydoun HA, Beydoun MA. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control 2008; 19(4): 339-59.[http://dx.doi.org/10.1007/s10552-007-9100-y] [PMID: 18085415]
[27] Holden DJ, Jonas DE, Porterfield DS, Reuland D, Harris R. Systematic review: Enhancing the use and quality of colorectal cancer screening. Ann Intern Med 2010; 152(10): 668-76.[http://dx.doi.org/10.7326/0003-4819-152-10-201005180-00239] [PMID: 20388703]
[28] Blumenthal DM, Singal G, Mangla SS, Macklin EA, Chung DC. Predicting non-adherence with outpatient colonoscopy using a novel electronic tool that measures prior non-adherence. J Gen Intern Med 2015; 30(6): 724-31.[http://dx.doi.org/10.1007/s11606-014-3165-6] [PMID: 25586869]
[29] Anderson JC, Fortinsky RH, Kleppinger A, Merz-Beyus AB, Huntington CG III, Lagarde S. Predictors of compliance with free endoscopic colorectal cancer screening in uninsured adults. J Gen Intern Med 2011; 26(8): 875-80.[http://dx.doi.org/10.1007/s11606-011-1716-7] [PMID: 21499823]
[30] Kirkøen B, Berstad P, Botteri E, et al. Psychological effects of colorectal cancer screening: Participants vs individuals not invited. World J Gastroenterol 2016; 22(43): 9631-41.[http://dx.doi.org/10.3748/wjg.v22.i43.9631] [PMID: 27920484]
[31] Mladen DM, Dragoslav MP, Sanja Z, Bozidar B, Snezana D. Problems in screening colorectal cancer in the elderly. World J Gastroenterol 2003; 9(10): 2335-7.[http://dx.doi.org/10.3748/wjg.v9.i10.2335] [PMID: 14562405]
[32] McLachlan SA, Clements A, Austoker J. Patients’ experiences and reported barriers to colonoscopy in the screening context: A systematic review of the literature. Patient Educ Couns 2012; 86(2): 137-46.[http://dx.doi.org/10.1016/j.pec.2011.04.010] [PMID: 21640543]
[33] Sutton S, Bickler G, Sancho-Aldridge J, Saidi G. Prospective study of predictors of attendance for breast screening in inner London. J Epidemiol Community Health 1994; 48(1): 65-73.[http://dx.doi.org/10.1136/jech.48.1.65] [PMID: 8138773]
[34] Consedine NS, Morgenstern AH, Kudadjie-Gyamfi E, Magai C, Neugut AI. Prostate cancer screening behavior in men from seven ethnic groups: the fear factor. Cancer Epidemiol Biomarkers Prev 2006; 15(2): 228-37.[http://dx.doi.org/10.1158/1055-9965.EPI-05-0019] [PMID: 16492909]
[35] Drescher C, Holt SK, Andersen MR, Anderson G, Urban N. Reported ovarian cancer screening among a population-based sample in Washington state. Obstet Gynecol 2000; 96(1): 70-4.[PMID: 10862845]
[36] Champion VL, Skinner CS, Menon U, et al. A breast cancer fear scale: Psychometric development. J Health Psychol 2004; 9(6): 753-62.[http://dx.doi.org/10.1177/1359105304045383] [PMID: 15367754]
[37] Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI. Fear, anxiety, worry, and breast cancer screening behavior: A critical review. Cancer Epidemiol Biomarkers Prev 2004; 13(4): 501-10.[PMID: 15066912]
[38] Hay JL, Buckley TR, Ostroff JS. The role of cancer worry in cancer screening: A theoretical and empirical review of the literature. Psychooncology 2005; 14(7): 517-34.[http://dx.doi.org/10.1002/pon.864] [PMID: 15490428]
[39] Wong RK, Wong ML, Chan YH, Feng Z, Wai CT, Yeoh KG. Gender differences in predictors of colorectal cancer screening uptake: A national cross sectional study based on the health belief model. BMC Public Health 2013; 13: 677.[http://dx.doi.org/10.1186/1471-2458-13-677] [PMID: 23879593]
[40] Jandorf L, Ellison J, Villagra C, et al. Understanding the barriers and facilitators of colorectal cancer screening among low income immigrant hispanics. J Immigr Minor Health 2010; 12(4): 462-9.[http://dx.doi.org/10.1007/s10903-009-9274-3] [PMID: 19621259]
[41] Moser RP, McCaul K, Peters E, Nelson W, Marcus SE. Associations of perceived risk and worry with cancer health-protective actions: Data from the Health Information National Trends Survey (HINTS). J Health Psychol 2007; 12(1): 53-65.[http://dx.doi.org/10.1177/1359105307071735] [PMID: 17158840]
[42] Llanos AA, Pennell ML, Young GS, Tatum CM, Katz ML, Paskett ED. No association between colorectal cancer worry and screening uptake in Appalachian Ohio. J Public Health (Oxf) 2015; 37(2): 322-7.[http://dx.doi.org/10.1093/pubmed/fdu031] [PMID: 24850101]
[43] Chung YW, Han DS, Yoo KS, Park CK. Patient factors predictive of pain and difficulty during sedation-free colonoscopy: A prospective study in Korea. Dig Liver Dis 2007; 39(9): 872-6.[http://dx.doi.org/10.1016/j.dld.2007.04.019] [PMID: 17652041]
[44] Hu PH, Peng YC, Lin YT, Chang CS, Ou MC. Aromatherapy for reducing colonoscopy related procedural anxiety and physiological parameters: A randomized controlled study. Hepatogastroenterology 2010; 57(102-103): 1082-6.[PMID: 21410035]
[45] Sly JR, Edwards T, Shelton RC, Jandorf L. Identifying barriers to colonoscopy screening for nonadherent African American participants in a patient navigation intervention. Health Educ Behav 2013; 40(4): 449-57.[http://dx.doi.org/10.1177/1090198112459514] [PMID: 23086556]
[46] Arne Ö. Fear and Anxiety: Overlaps and Dissociations Handbook of emotions 3rd ed. 3rd ed.2008.
[47] Vrinten C, Waller J, von Wagner C, Wardle J. Cancer fear: Facilitator and deterrent to participation in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2015; 24(2): 400-5.[http://dx.doi.org/10.1158/1055-9965.EPI-14-0967] [PMID: 25634890]
[48] Sheeran P. Intention-behavior relations: A conceptual and empirical review. Eur Rev Soc Psychol 2002; 12: 1-36.[http://dx.doi.org/10.1080/14792772143000003]
[49] Lebwohl B, Neugut AI, Stavsky E, et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol 2011; 45(5): e47-53.[http://dx.doi.org/10.1097/MCG.0b013e3181f595c3] [PMID: 21030874]
[50] Leone LA, Reuland DS, Lewis CL, et al. Reach, usage, and effectiveness of a Medicaid patient navigator intervention to increase colorectal cancer screening, Cape Fear, North Carolina, 2011. Prev Chronic Dis 2013; 10: E82.[http://dx.doi.org/10.5888/pcd10.120221] [PMID: 23701719]
[51] Ali-Faisal SF, Colella TJ, Medina-Jaudes N, Benz Scott L. The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials. Patient Educ Couns 2017; 100(3): 436-48.[http://dx.doi.org/10.1016/j.pec.2016.10.014] [PMID: 27771161]
[52] Reuland DS, Brenner AT, Hoffman R, et al. Effect of combined patient decision aid and patient navigation vs. usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial. JAMA Intern Med 2017; 177(7): 967-74.[http://dx.doi.org/10.1001/jamainternmed.2017.1294] [PMID: 28505217]
[53] Albrecht H, Gallitz J, Hable R, et al. The offer of advanced imaging techniques leads to higher acceptance rates for screening colonoscopy: A Prospective Study. Asian Pac J Cancer Prev 2016; 17(8): 3871-5.[PMID: 27644632]
[54] Tucker A, Tucker SP. Increasing colorectal cancer screening compliance through community education. Gastroenterol Nurs 2012; 35(6): 416-9.[http://dx.doi.org/10.1097/SGA.0b013e318274b236] [PMID: 23207784]
[55] Crookes DM, Njoku O, Rodriguez MC, Mendez EI, Jandorf L. Promoting colorectal cancer screening through group education in community-based settings. J Cancer Educ 2014; 29(2): 296-303.[http://dx.doi.org/10.1007/s13187-013-0599-1] [PMID: 24385340]
[56] Shaikh AA, Hussain SM, Rahn S, Desilets DJ. Effect of an educational pamphlet on colon cancer screening: A randomized, prospective trial. Eur J Gastroenterol Hepatol 2010; 22(4): 444-9.[http://dx.doi.org/10.1097/MEG.0b013e328333fca6] [PMID: 19940781]
[57] Parker S, Zipursky J, Ma H, Baumblatt GL, Siegel CA. A web-based multimedia program before colonoscopy increased knowledge and decreased anxiety, sedation requirement, and procedure time. J Clin Gastroenterol 2017.[http://dx.doi.org/10.1097/MCG.0000000000000958] [PMID: 29095417]
[58] Andrada JM, Vidal AA, Aguilar-Tablada TC, et al. Anxiety during the performance of colonoscopies: Modification using music therapy 2004.[http://dx.doi.org/10.1097/00042737-200412000-00024]
[59] Bechtold ML, Perez RA, Puli SR, Marshall JB. Effect of music on patients undergoing outpatient colonoscopy 2006.[http://dx.doi.org/10.3748/wjg.v12.i45.7309]
[60] Ko CH, Chen YY, Wu KT, et al. Effect of music on level of anxiety in patients undergoing colonoscopy without sedation. J Chin Med Assoc 2017; 80(3): 154-60.[http://dx.doi.org/10.1016/j.jcma.2016.08.010] [PMID: 27889459]
[61] Umezawa S, Higurashi T, Uchiyama S, et al. Visual distraction alone for the improvement of colonoscopy-related pain and satisfaction. World J Gastroenterol 2015; 21(15): 4707-14.[http://dx.doi.org/10.3748/wjg.v21.i15.4707] [PMID: 25914482]
[62] Elkins G, White J, Patel P, Marcus J, Perfect MM, Montgomery GH. Hypnosis to manage anxiety and pain associated with colonoscopy for colorectal cancer screening: Case studies and possible benefits. Int J Clin Exp Hypn 2006; 54(4): 416-31.[http://dx.doi.org/10.1080/00207140600856780] [PMID: 16950684]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Advertisements


Webmaster Contact: info@benthamopen.com
Copyright © 2018 Bentham Open