Geographic variation in compliance with Australian colorectal cancer screening programs: the role of attitudinal and cognitive traits

Introduction: Colorectal cancer (CRC) patients in regional and rural areas tend to be diagnosed at a more advanced stage than metropolitan patients and have poorer 5-year survival rates. Environmental and cultural factors in non-metropolitan areas often facilitate a more reactive approach to health care, which can result in lower participation in preventative health measures such as screening for early signs of cancer. Individual differences in attitudes and cognitive styles can also act as barriers to cancer screening. Currently, evidence regarding geographical disparity in CRC screening is inconclusive and based largely on test return in nationwide screening programs as opposed to compliance with program guidelines. This study investigates the effect of attitudinal and cognitive traits on compliance with, as opposed to participation in, population CRC screening programs in rural, regional and metropolitan environments. Methods: A representative cross-section of recipients (n=371, 71% female) of a faecal occult blood test as part of the National Bowel Cancer Screening Program were surveyed in 2017 (mean age = 6126, standard deviation = 7.05). Participants were asked if they completed and returned the kit or had a valid reason not to (ie prior screening). Postcodes were used to identify participants as metropolitan, regional or rural using the Australian Standard Geographical Classification system. Fatalism, minimisation of problems and resignation (MPR), need for control and self-reliance, and consideration of future consequences (CFC) were measured as traits known to effect health-related help-seeking behaviour. Program compliance rates were compared between rural, regional and metropolitan areas, and logistic regression models with interaction terms were applied to test the differential effects of attitudinal and cognitive factors on program compliance across metropolitan, regional and rural groups. Results: Compliance was significantly lower in regional compared to metropolitan areas (odds ratio (OR)=0.49, 95% confidence interval (CI)=0.29-0.84). Rural status significantly moderated the effect of MPR (OR=0.28, 95%CI=0.11-0.71) and CFC (OR=6.66, 95%CI=1.80-24.63) on compliance and regional status significantly moderated the effect of CFC on compliance (OR=341, 95%CI=1.37-8.44). Simple slopes analyses showed that high MPR was associated with lower bowel screening program compliance in rural (OR=0.26, 95%CI=0.11-0.59) and regional (OR=0.60, 95%CI=0.38-0.95) areas, but not in metropolitan areas. High CFC was associated with higher bowel screening program compliance in rural (OR=4.46, 95%CI=1.39-14.47) and regional (OR=2.30, 95%CI=1.19-4.43), but not metropolitan, areas. Conclusions: Sub-optimal compliance rates are evident in non-metropolitan areas with intervention most needed in regional areas where compliance is lowest, leaving residents at a potentially higher risk of CRCs going undetected. Efforts to increase CRC screening in rural and regional areas should promote the consideration of one's future and discourage attitudes that minimise health issues. This research highlights the way in which individual attitudes and thinking styles may impact preventive health behaviours differently in non-metropolitan communities.