On 2015 Jul 22, BSH Cancer Screening, Help-Seeking and Prevention Journal Club commented:

The HBRC journal club read with interest this paper that uses an innovative qualitative method to examine the barriers to colorectal cancer (CRC) screening experienced by people from medically under-served areas in the US. The paper offers an account of how macro level factors, such as the socio-political context, combine with individual level factors to determine uptake of CRC screening.

The authors used a participatory research method and PhotoVoice technique to engage participants in the research project, which took place over several months and included training sessions, group meetings, and individual meetings. We felt that one of the strengths of this approach was that it allowed rapport to be built over time, and that participants could express themselves in ways other than by just verbalising their thoughts and feelings. The photos taken by participants served as the “jumping off point” for the group discussions, which we felt helped obtain a richer picture of what people have to go through in order to obtain screening. Using each participant’s photos as a catalyst for the discussions may have encouraged a more evenly distributed participation across participants, because each participant was expected to contribute to the meetings. Although many of the barriers mentioned in this paper focused on the costs of colonoscopy screening and may therefore not necessarily generalise to healthcare contexts that use different screening methods or are free at the point of delivery, such as in the UK, some of the opportunity costs mentioned by participants did resonate with the journal club and may be more widely applicable. For example, those undergoing flexible sigmoidoscopy screening in the UK may also be faced with the opportunity cost of having to take (potentially unpaid) time off work.

We felt the authors could have commented more on the possible limitations of their study. The chosen study method required a great deal of commitment and active participation from participants. Although the researchers note that the Photovoice method may address shortcomings of other qualitative work in this field, which “may simply generate ‘impression management discourses’”, we felt that the method does not necessarily circumvent these discourses, but may just elicit more “crafted” image discourses. In addition, the high level of commitment expected from participants in the current study may mean that only those who were most highly motivated and health conscious self-selected to participate, which may limit the generalisability of the study findings. The authors chose to focus on the obstacles experienced by those who had been screened, but those may not necessarily be the same as the obstacles faced by people who have not screened. The HBRC journal club would encourage further study in samples of participants who are not engaged with screening. We also felt that the results were presented in a way that suggested a broad consensus among participants and wondered whether there were any dissenting voices? Some of us felt that a greater emphasis could have been placed on the experience of facilitators to screening uptake, although some felt that this was adequately addressed by discussing the importance of social support around the time of screening. Finally, we felt that the paper formed a good illustration of some of the barriers and facilitators to CRC screening that we already know about, but some of us felt that it did not offer many new insights, and wondered whether the wealth of data collected in the study could have generated any novel insights? We recognise that journal requirements may only allow for a limited discussion of all findings in a study, and we would argue that online supplements could make a valuable contribution to convey the results of this type of study, for example, as a photo gallery with accompanying quotations.

In sum, the HBRC journal club really enjoyed reading this paper and feel that the Photovoice method is a great method for doing explorative research in certain groups, because of the high level of active involvement of participants in the research project, and the meaning and value added by their pictures which may complement verbal explanations of behaviour. This study shows that decisions about screening are not just up to the individual, but are made in a socio-political context that can help or hinder individuals to obtain screening, and has important implications for policy making in preventive healthcare.

Conflicts of interest. We report no conflict of interests and note that the comments produced by the group are collective and not the opinion of any one individual.

On 2015 Jul 22, BSH Cancer Screening, Help-Seeking and Prevention Journal Club commented:

The HBRC journal club read with interest this paper that uses an innovative qualitative method to examine the barriers to colorectal cancer (CRC) screening experienced by people from medically under-served areas in the US. The paper offers an account of how macro level factors, such as the socio-political context, combine with individual level factors to determine uptake of CRC screening.

The authors used a participatory research method and PhotoVoice technique to engage participants in the research project, which took place over several months and included training sessions, group meetings, and individual meetings. We felt that one of the strengths of this approach was that it allowed rapport to be built over time, and that participants could express themselves in ways other than by just verbalising their thoughts and feelings. The photos taken by participants served as the “jumping off point” for the group discussions, which we felt helped obtain a richer picture of what people have to go through in order to obtain screening. Using each participant’s photos as a catalyst for the discussions may have encouraged a more evenly distributed participation across participants, because each participant was expected to contribute to the meetings. Although many of the barriers mentioned in this paper focused on the costs of colonoscopy screening and may therefore not necessarily generalise to healthcare contexts that use different screening methods or are free at the point of delivery, such as in the UK, some of the opportunity costs mentioned by participants did resonate with the journal club and may be more widely applicable. For example, those undergoing flexible sigmoidoscopy screening in the UK may also be faced with the opportunity cost of having to take (potentially unpaid) time off work.

We felt the authors could have commented more on the possible limitations of their study. The chosen study method required a great deal of commitment and active participation from participants. Although the researchers note that the Photovoice method may address shortcomings of other qualitative work in this field, which “may simply generate ‘impression management discourses’”, we felt that the method does not necessarily circumvent these discourses, but may just elicit more “crafted” image discourses. In addition, the high level of commitment expected from participants in the current study may mean that only those who were most highly motivated and health conscious self-selected to participate, which may limit the generalisability of the study findings. The authors chose to focus on the obstacles experienced by those who had been screened, but those may not necessarily be the same as the obstacles faced by people who have not screened. The HBRC journal club would encourage further study in samples of participants who are not engaged with screening. We also felt that the results were presented in a way that suggested a broad consensus among participants and wondered whether there were any dissenting voices? Some of us felt that a greater emphasis could have been placed on the experience of facilitators to screening uptake, although some felt that this was adequately addressed by discussing the importance of social support around the time of screening. Finally, we felt that the paper formed a good illustration of some of the barriers and facilitators to CRC screening that we already know about, but some of us felt that it did not offer many new insights, and wondered whether the wealth of data collected in the study could have generated any novel insights? We recognise that journal requirements may only allow for a limited discussion of all findings in a study, and we would argue that online supplements could make a valuable contribution to convey the results of this type of study, for example, as a photo gallery with accompanying quotations.

In sum, the HBRC journal club really enjoyed reading this paper and feel that the Photovoice method is a great method for doing explorative research in certain groups, because of the high level of active involvement of participants in the research project, and the meaning and value added by their pictures which may complement verbal explanations of behaviour. This study shows that decisions about screening are not just up to the individual, but are made in a socio-political context that can help or hinder individuals to obtain screening, and has important implications for policy making in preventive healthcare.

Conflicts of interest. We report no conflict of interests and note that the comments produced by the group are collective and not the opinion of any one individual.