Perceptions and motivations for healthy lifestyles among first-degree relatives of colorectal cancer patients: A qualitative study

Perceptions and motivations for healthy lifestyles among first-degree relatives of colorectal cancer patients: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perceptions and motivations for healthy lifestyles among first-degree relatives of colorectal cancer patients: A qualitative study Wenxia Wang, Shuyan Fang, Shuang Zhang, Meng He, Xiangning Zhu, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2544870/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Compelling data indicate that adherence to healthy lifestyles can potentially prevent 20–70% of colorectal cancer (CRC) cases and deaths. As a major population in the development of CRC, the lifestyle behaviour of first-degree relatives (FDRs) of CRC patients is attracting more attention. Objective To understand the knowledge of first-degree relatives (FDRs) about colorectal cancer (CRC) and healthy lifestyles and explore their perceptions of and motivations for healthy lifestyles for CRC prevention. Methods A qualitative descriptive study using inductive thematic analysis was performed. Sixteen FDRs of CRC patients were recruited using purposive sampling. Face-to-face semi-structured interviews were conducted to gain insight into FDRs’ perceptions and motivations regarding healthy lifestyles for CRC prevention. Results Limited knowledge of CRC makes FDRs less likely to emphasise the prevention of CRC through a healthy lifestyle. Influenced by the culture of Chinese medicine and life experience, the participants gradually developed a perception of healthy lifestyles with Chinese characteristics. The participants’ ability to maintain a healthy lifestyle was greatly influenced by family duty-related factors. Conclusions Social culture and family duty-related factors should be taken into consideration when undertaking health interventions or education programmes on healthy lifestyles for FDRs of CRC patients. Encouraging nurses to act as liaisons between the government, hospitals, and the community and providing them with professional and communication skills to enhance their skills has great potential for nurses to deliver health education and management for communities at risk of CRC. Colorectal Neoplasms First-degree relatives Lifestyle Primary prevention Nursing Figures Figure 1 1 Introduction According to the 2020 Global Cancer Statistics report, colorectal cancer (CRC) ranks third and fourth among all malignancies in incidence and mortality, respectively [ 1 ]. In 2030, there will be 2.2 million new cases and 1.1 deaths of colorectal cancer globally, with a 60% increase in the global economic burden [ 1 ]. Especially, the risk of CRC increases with the number of degree relatives and at 1.87 is substantially higher among first-degree relatives (FDRs) than in the general population[ 2 ]. The probability of getting colorectal cancer increases by up to five times in individuals with two or more FDRs with CRC history at the same time [ 3 ]. The risk of developing colorectal cancer in its early stages rises by 16.57 times versus the general population [ 3 ]. Focused attention and effective preventive measures for this population can effectively reduce the incidence of CRC. A growing number of people are interested in lifestyle management since it prevents CRC, in addition to the effectiveness of secondary prevention measures such as colonoscopy in lowering the prevalence of the disease [ 4 ]. Numerous studies have examined how CRC incidence and lifestyle factors interact. Five healthy lifestyle factors—a good diet, proper physical activity, a healthy weight, not smoking, and moderate alcohol consumption—suggest a negative connection with CRC, according to the results of various large retrospective and prospective cohort studies[ 4 – 6 ]. A total of 20–70% of CRC cases can be prevented by following five healthy lifestyles [ 5 , 6 ]. Guidelines for CRC prevention through a healthy lifestyle have also been released by the World Cancer Research Fund (WCRF)[ 7 ], and the American Institute for Cancer Research[ 8 ]. A variety of factors affect people’s ability to behave healthily. For patients with a family history of CRC or adenomatous polyps, studies [ 9 – 12 ] have undertaken one or two lifestyle behavioural interventions or health education. The findings revealed a complicated interaction between risk perception and willingness to change lifestyle, as well as challenges with implementation, low adherence, short-term maintenance of healthy lifestyles, and erratic motivation for behaviour change. The timing, content, and availability of health-related information are among the factors that are mentioned, along with education, health literacy, and self-efficacy. Additionally, qualitative research [ 13 , 14 ] for those who had positive CRC-related tests also revealed that lifestyle behaviours are influenced by personal characteristics (e.g, age, health status, perceived benefits, life attitude, and habits), environmental factors (e.g, workplace limitations, inadequate social support, and infrastructure to promote behavioural change), culture and cost, employment constraints, health status, perceived benefits, and habits. These findings show that individuals’ motivations for adopting a healthy lifestyle to lower their risk of CRC may be complicated and multifaceted. The FDRs of CRC patients know little about living a healthy lifestyle to prevent CRC. Indirect cancer experience or family history is strongly correlated with developing awareness [ 15 ]. However, the current state of behaviour towards a healthy lifestyle for CRC is not favourable[ 2 , 7 , 8 ], with issues such as poor diet (for example, excessive intake of fat and red meat, inadequate fruit, vegetables, and dietary fibre), lack of physical activity, obesity, excessive alcohol consumption, and smoking. Several studies have proven that in addition to dietary factors, they are not well-informed about the relationship between other lifestyle factors and CRC [ 11 , 15 ]. Lack of knowledge hampers prevention efforts. A careful assessment of FDRs attitudes towards adopting healthy lifestyles and digging into the complex motivations for their lifestyle change offers compelling evidence for the development of effective interventions to support lifestyle modification and direction for public prevention policy. To achieve an understanding of the complexity of closely linked individual features, qualitative methods such as interviews are used [ 16 ]. The purpose of this study was to investigate how FDRs perceive and are motivated to maintain a healthy lifestyle using a qualitative approach to the following questions: 1) How knowledgeable are FDRs about CRC and a healthy lifestyle? 2) How do they perceive the prevention of CRC through pursuing healthy lifestyles? 3) What possible facilitating factors and barriers influence them to undertake healthy lifestyles? 2 Methods 2.1 Setting The study was conducted at the Department of Gastroenterology Surgery of a large general hospital in XX (name of city), China from December 2021 to February 2022. People who come to this large general hospital have a different knowledge of disease and complex life experiences. 2.2 Participants The participants were recruited using purposive sampling. We identified potential participants who met the following inclusion criteria: 1) age > 18 years with informed consent and voluntary participation; and 2) the FDRs of CRC patients, such as their parents, children, and siblings. Details of the study, including the identity of the researchers, the purpose and methods of the study, and others concerned were presented to potential participants by telephone or face-to-face. To establish trust, we approached participants through the health professionals they were most familiar with. We ensured that they them informed and invited to attend safely (not at the ward) since some participants were worried that CRC patients would be impacted if they learned more about the disease. After contacting 21 potential participants, 16 volunteered to join this study. Those who declined to participate cited a lack of interest, fear of the unstable emotional impact of their CRC relatives caused by suspicion, and the length of the interview delaying caring. 2.3 Data collection Only one interviewer and one participant engaged in face-to-face semi-structured interviews in the department’s standard communication room to minimise interviewees being distracted by the environment. To earn the trust of the identified participants, three interviewers, female registered nurses with training in systematic qualitative research, had at least three conversations with them before the interview. We prepared predeveloped research questions based on prior literature and the study goals We then conducted pre-interviews to ensure that the questions were open-ended and simple to understand (supplementary material 1). The interviewer avoided questioning in a sentence tone as much as possible and instead used terms such as “Can you tell me more?” “What do you think?” and “What occurred then?” to create a relaxed atmosphere. The interviewer simply captured keywords and nonverbal cues when participants were encouraged to talk freely about their experiences. The interviewer then asked the participants whether they had any relevant clarification concerns or discussion before ending, as well as told them that they were welcome to add to this topic at any time. After the participant’s consent, the full interview was recorded using the mobile phone’s designed recording software. The interviewer then verified the verbatim transcription within 48 hours of the interview’s completion. Only one interview was conducted with each participant lasting 37 to 76 minutes. Even though the 13th interviewer had reached data saturation, we kept going and interviewed three more people to ensure data enrichment. 2.4 Data analysis A descriptive exploratory design was used to explore participants’ insights into the research topic based on their life experiences. Six steps of an inductive thematic analysis were applied to analyse the data [ 17 ] using QSR's NVivo software. The first four steps were individually performed by the first three female authors (all are registered nurses). In the fifth step -defining and naming themes, all three authors generated three themes and shared them to refine and define the seven subthemes. The first author further developed and merged the themes in the sixth phase to construct a scholarly report (an example of the analysis in Table 1 ). Any questions were discussed within the group until they reached a consensus or were referred to Y, who was skilled in qualitative research. To demonstrate the influence of the researcher’s theoretical knowledge and life experience on the data analysis and to help understand the themes that emerged, the first author wrote reflective memos on the entire process. Participants were not involved in any of the processes of data analysis. Table 1 Analysis process examples Data Code Subtheme Definition As I am an only child, I thought that when my wife and I get old, we cannot rely on my children. My children can’t rely on others when we pass away either. All we can do is rely on ourselves. (N-2) Stay healthy to reduce the children’s burden of parenting in the future Family duties promote awareness of one’s health Family duties: lifestyle perspectives and/or those factors that influence behavioural change caused by the practice and/or undertaking of some responsibility or obligation of the family Gosh, I’m just daily life, how else can I take care of my health? You still have to work which is for you there. Also, don’t you live? There are so many things to do with money! (N-13) Too busy running a life and earning a living Family duties consume energy However, for me, you cannot control everything, many people smoke and drink, for example, he also lives to 90, 80 or 100 and so on. This thing is still not a preventive thing for me. (N-11) Cancer fatalism Cancer can’t be prevented everywhere The impact on lifestyle behaviour change is produced by the idea of those who individually consider uncontrollable factors as objective and difficult to change. 3 Findings The 16 study participants included six females and ten males. The age range was 33–39 years (more details in Table 2 ). Table 2 Interviewee characteristics Participant No. Sex Age Education Residence Work Income/RMB History of disease N-1 Male 39 College degree Urban Company manager >10000 Hypertension N-2 Male 48 Undergraduate Urban Insurance salesman >10000 Haemorrhoids N-3 Female 38 Undergraduate Urban Teacher 2001–5000 Hip replacement N-4 Female 33 Primary school Urban Housewife Prefer not to say Recurrent diarrhoea Ovarian endometriosis cyst N-5 Male 48 Junior high school Urban Highway maintenance workers 5001–10000 None N-6 Male 40 Junior high school Rural Farmer ≤ 2000 None N-7 Male 40 High School Rural Farmer 5001–10000 None N-8 Male 49 Junior high school Urban Cater >10000 None N-9 Female 40 Junior high school Rural Farmer ≤ 2000 None N-10 Male 36 Primary school Urban Factory workers 5001 − 1000 Henoch-Schönlein purpura N-11 Male 36 Junior high school Rural Farmer 2001–5000 Gastropathy N-12 Male 45 Less than primary school Rural Farmer 2001–5000 Recurrent diarrhoea N-13 Female 41 Junior high school Rural Farmer Instability None N-14 Female 42 College degree Urban Service industry 2001–5000 Ovarian endometriosis cyst N-15 Male 48 Junior high school Urban Train driver 2001–5000 Gastric bleeding, Herniated disc N-16 Female 40 Junior high school Urban Housewife Prefer not to say Uterine fibroids Three overarching themes were developed in an in-depth analysis: 1) limited disease knowledge and individualised self-awareness of CRC risk; 2) diverse attitudes towards healthy lifestyles for CRC prevention, and 3) factors that affect life behaviour modification/maintenance. We summarise the quotations related to each finding in Table 3 Table 3 Themes and quotes Themes Subthemes Quotes 3.1 Limited disease knowledge and individualised self-awareness for CRC risk 3.1.1 “Don’t know much about it” — little knowledge of CRC Quote-1: I don’t feel like this is much because in the bowel, the bowel cancer thing it’s not much. (N-13) Quote-2: But I think I’ve heard that it also seems to have something to do with heredity... I don’t have an idea, I just feel that it’s the intestinal end that should have something to do with eating. (N-6) Quote-3: It’s just that there were neighbours or friends or whatever who used to talk about ... However, sometimes you don’t pay attention to it, and you forget about these afterwards. (N-15) Quote-4: I think it’s more or less related to temporary things. The fact that he’s quite angry. I don’t know about anything else, but he just yells at my mother, always argues, and is Quote-5: I used to be confused that I ate less than others but I was fat. Then I thought maybe it was just my poor metabolism… (N-3) 3.1.2 Measuring self-CRC risk with/with diverse perspectives Quote-6: My diet, which I pay attention to in all areas, is specified as (not too high). This seems to be related to all aspects of diet. (N-15) Quote-7: We don’t even think about that...these things are no worries because I don’t have a physical problem, I guess... (N-11) Quote-8: I think I’m just not in good health, I think I’m just easy to get these whatever diseases...because I just always feel like I’m not in good health. (N-16) Quote-9: Gee, I’m burnt out, what’s the point of doing all these (maintaining a healthy life)? There’s still work to be done... (N-13) Quote-10: It’s the gynaecology one, I think. I want to get it checked out. I had a polyp on my endometrium. Then, I thought I’d go and have it checked out to see what it looked like. (N-4) 3.1.3 Multiple efforts to improve the quality and efficiency of prevention strategies Quote-11: You give him ten questions or twenty questions and he can judge for himself whether his health is good or bad, or whether he is already at risk, right? You can inform him through this questionnaire if there is already a risk. I’m already having these problems, so I should mention that I’m aware of them. (N-3) Quote-12: If it was a doctor or nurse I knew or was introduced to by someone close to me, then I would believe what they said. (N-6). Quote-13: I feel that the person to do this thing should have a high national or international profile or could be tracked. (N-2) 3.2 Diverse attitudes towards healthy lifestyles for CRC prevention 3.2.1 Individually perceptions of healthy lifestyles Quote-14: Maybe it’s related to diet. For example, you get a lot of spicy or other bad food ...just keep good habits, don’t eat anything irritating, it’s not good for your stomach. (N-10) Quote-15: That is safer, for example, meat with no leanness-enhancing agent or animals is fed with natural plants… (N-1) Quote-16: Keep early hours and don’t stay up late or overexert your body. In particular, for people who are my age, 70 percent is appropriate and should not eat too full...(N-14) Quote-17: So, I usually feel that I start to sweat, I’m going to feel the sweat pouring down and I can’t (run) at this point. I couldn’t run anymore when my heart rate was up to 130–140. (N-2) Quote-18: For example, you have to be in good mind. Because it makes you powerful and all the disease goes away. After you have a lot of stress or be nervous, you just don’t sleep well, then your organs will be impacted. If you have a good mind, everything will be better. (N-11) Quote-19: I feel that the amount of alcohol we consume is still okay. I also don’t think it’s a good idea to gobble up the food all time. (N-10) Quote-20: ...the inhaled nicotine may go from the mouth to the stomach and then reach the intestines. Staying somewhere could potentially cause disease to occur in this. (N-1). Quote-21: It’s related to the physique. The body’s acupuncture points are all on the feet. If your hands and feet are cold, you’ll be in trouble and you’ll get sick sooner. (N-12) Quote-22: ...Trying to do fewer things that are bad for health, such as cold things I cannot eat. At least let’s be good to our bodies. (N-11) 3.2.2 Attitudes towards the role of healthy lifestyles in CRC prevention Quote-23: Because he did farm work in rural. Suddenly he had been urban for ten years. He is so lazy that he can’t even get downstairs. Also, life is getting better, and eating a lot. The digestive system is under a lot of stress. He doesn’t move which has bad effects on the immune system. (N-1) Quote-24: Exercising vigorously will make uric acid high. My urea is not high when I’m not exercising. Since I don’t eat seafood and don’t drink much alcohol, my uric acid should be normal. (N-2) Quote-25: I’ve been walking for six months and my knees hurt. (N-1) Quote-26: ...Anyway, I don’t know if everyone here is drinking, I specify yes...it’s drinking that has affected my health badly. (N-12) Quote-27: We are at a higher risk of developing high blood pressure because of regular drinking. (N-1) Quote-28: I think it has something to do with eating hot and cold, but I haven’t found anything to do with smoking and drinking first. (N-15) Quote-29: Because so far, the effect of this smoking on me has probably been a bit of pharyngitis... it is not so serious. (N-2) Quote-30: I think that’s fate. It’s impossible to say that you can control everything. If you quit smoking, can you be sure that you will not suffer from disease? Even if you develop a disease in the future, is it truly directly related to smoking? (N-2) Quote-31: I’ve had it checked and it’s fine. I have my annual medical checkup... (N-1) Quote-32: I check it once a year. If there is a polyp, I have it removed in time. So it’s not likely to develop into cancer. There is no tendency for it to turn into that cancer. (N-8) 3.33.3 Factors that affect life behaviour modification/maintenance 3.3.1“There are old and young at home”—family duty leads to health-nurturing practices Health consciousness enhances the priority given to self-care Quote-33: Because I’m not too young this year, I just have to take care of myself in terms of health care. (N-50) Quote-34: It’s just that I don’t want to be a burden. Right now, like us, we have an old man and young children. My daughter-in-law and I have both parents, at least thus far, we have to keep healthy because our parents are not very healthy. (N-2) Quote-35: What about chewing and swallowing slowly? I used to gobble it up, and I’ve learned since I got enteritis. Like cold or hot food you eat, it’s not good. The only way to nurture your health is like this. (N-12) Quote-36: I just go to exercise when I feel uncomfortable or tired. (N-8) External support from a relaxed work/life Quote-37: Because of the work, the previous work was manual labour which took a lot of time and energy. After changing work, it is quite easy and relaxing. (N-14) Quote-38: I don’t have that much stress in my life or at work, I mainly take care of my daughter. In my spare time, if I have the energy I do my work, but if don’t I put it aside. (N-2) Quote-39: My parents’ ideas about health influenced me by calling me every day or urging me to watch TV programmes, telling me that it was not good to do this or that. (N-3) Good lifestyle preferences/habits promote healthy behaviours Quote-40: I walked 10,000 steps and I feel quite proud of myself... I walked seven kilometres a day at that time and I had set a goal for myself to do it for six months. (N-1) Quote-41: I have a teddy at home and would like to take it for a walk after I went back for dinner. (N-15) 3.3.2“There are old and young at home” ——Exhausted by family duties “The feeling of being overwhelmed” ——Pressures produced by work/life Quote-42: Perhaps I have seen a lot of things, and I only want to raise the people who raised me and raise the people I would raise. I didn’t think about ourselves... At some age, because you don’t have health problems, there is no time to think about yourself. I just think about making money. (N-11) Quote-43: You have to try to survive and take care of a family. Even if you want to pay more attention (to your body), you’ll have trouble doing it sometimes due to these things. (N-14) Quote-44: I quit smoking for a while, truly, I quit for a while, but then work is often outside where all are smoking. I got hooked and didn’t quit. (N-5) Quote-45: Some people don’t smoke, but you will find that people who smoke and drink are better at work. As an interpersonal lubricant, people who smoke and drink have more opportunities to connect with others at work. (N-20) “I can’t get cancer”——healthy fit weakened awareness of prevention Quote-46: I don’t usually go for flu fluids because of a cold. I only get a cold once or twice a year, and sometimes I just get over it on my own. (N-7) Quote-47: I didn’t have a disease ever, so I felt that I wouldn’t have been so unlucky to get sick. I probably have that fluke mentality...(N-6) “Cancer cannot be prevented everywhere” Quote-48: It’s not like at home, where you have nothing to do or can watch TV or sit and eat an apple or an orange, but you cannot achieve this at the factory. (N-5) Quote-49: However, for me, you cannot control everything, many people smoke and drink, for example, he also lives to 90, 80 or 100 and so on. This thing is still not a preventive thing for me. (N-11) Addictive pastimes/preferences hamper behaviour change Quote-50: That’s the one flaw I keep, probably the most serious one. Because no matter how capable a person is, it is difficult to do everything, and it is not always possible to control his/her habits perfectly, which is quite normal. (N-2) Quote-51: I just always feel tired. The business is still losing money, and there are always various reasons to drink anyway. Sometimes I think I should stop thinking about it and stop drinking. However, if I don’t drink, I think about everything, and it’s very stressful. After drinking, I don’t think about it anymore and I sleep well. (N-8) Quote-52: I’ve thought about doing a bland diet too. But it hardly satisfies me. I eat a lot of onion and garlic at home every day, I just like to eat that way. (N-15) Quote-53: The boys are good at smoking and drinking, while you girls may like eating some fruit nothing to do, that belongs to a hobby. I do not like that stuff (fruits). (N-10) 3.1 Limited disease knowledge and individualised self-awareness for CRC risk Single and fragmented access to knowledge limited FDR’s systematic and scientific understanding of CRC, which forced them to measure their CRC risk from multiple perspectives based on their diverse life experiences. They called for a coordinated effort to broaden and improve the advocacy efforts for CRC so that they could access accurate and authoritative information on CRC prevention. 3.1.1 “Don’t know much about it” — little knowledge of CRC The first reaction of all participants was that they “didn’t know much about it”, and some even said that it was the first time they had heard of it when asked about their knowledge of CRC. Misunderstanding the causes of CRC, confusion about disease types (e.g., CRC and haemorrhoids), and concern about whether cancer equalled death and cancer fatalism presented the current picture of many participants’ understanding of CRC (quote 1, 2). Many people first heard about CRC from chatting about the disease experience of someone unfamiliar and they tended to concentrate on the treatment and prognosis. It raised concerns about their health that were not alarming and persistent, thus making it difficult to inspire them to mirror deeply and desire to learn more about CRC (quote 3). Participants increased their CRC knowledge by consulting doctors or searching the internet. However, the knowledge was partial or superficial. Some identified age, physical fitness, immunity, irregular sleep, and personality/temporary as potential risk factors. A few vaguely reported the influence of obesity and factors related to physical activity on CRC were made when it referred to lifestyle factors other than diet (quote 4, 5). 3.1.2 Measuring self-CRC risk with/with a diverse perspective Lack of diverse and effective access to knowledge led to little knowledge of CRC among FDRs. Based mainly on their individual experiences, such as health conditions, medical examinations, lifestyle, environment and exposure to disease information, participants had varied perspectives on assessing their risk of CRC. Those individuals who were unconcerned about their CRC risk believed that there was no family history of CRC and that it was difficult to explain whether they carried a genetic risk based on one CRC member. Even though CRC was associated with the abovementioned factors, they reported that they did not have the same risk factors in their daily lives or had made modifications (quote 6). Those who maintained regular screening habits developed a better awareness of health but valued the effectiveness of secondary prevention. Despite intestinal issues such as diarrhoea, the accumulating negative results of screening led participants to underestimate the severity of their potential health issues. They didn’t want to worry about what had not happened that might cause extra panic and anxiety, especially because they were already attempting to change bad behaviour that would cause intestinal discomfort. Those who were well and had no health issues reported that there was “ no need to worry about the future ” (quote 7). On the other hand, a minority of participants were aware that they might have a higher risk of CRC than others. In addition to family genetic factors, they described that they shared the same living conditions as their immediate CRC relatives and that they were also susceptible to intestinal discomfort or were usually sicker than those surrounding them. All considered, they said they would like to learn more about CRC and took their risk seriously (quote 8, 9). Some participants were very focused on their role as caregivers or other health problems that made them feel anxious and fearful and, thus, did not have a mind to think about their CRC risk (quote 10). 3.1.3 Multiple efforts to improve the quality and efficiency of prevention strategies A hospital-centred, government-supported system of hospital responsibility and parallel promotion in collaboration with communities to enable the widespread dissemination of disease information was called for by the participants to be optimised in light of the challenges. Health professionals were urged to fully utilise counselling opportunities to deliver scientific prevention information and to guide patients and their family members to concentrate on CRC prevention. Furthermore, a large number of medical students were advised to integrate CRC health education as a social practice activity, with questionnaires and other forms to evaluate and categorise people’s knowledge and offer acceptable guidance to ensure the viability and targeting of disease education (quote 11). Many participants on internet platforms call for trustworthy and traceable health information. To increase the rationality and authority of health information, they suggested that the publisher or advocate should be a trustworthy and authoritative person, such as a doctor who was well-known or who could be easily identified (quote 12, 13). 3.2 Diverse attitudes towards healthy lifestyles for CRC prevention FDRs shared their perceptions of healthy lifestyles and diverse attitudes including beliefs, doubts, and uncertainties about the importance of lifestyles in CRC prevention, based on differences in knowledge of CRC disease, life experience, and sociocultural influences. 3.2.1 Individually perceptions of healthy lifestyles Shaped by the life experiences of CRC patients and themselves, as well as social and cultural influences, participants had developed their perceptions of a healthy lifestyle, which primarily included a healthy diet, routine, stable life course, moderate exercise, mental/emotional peace, quitting smoking and drinking, and maintaining physical fitness. FDRs interpreted healthy lifestyles as covering all aspects of their personal lives. Most individuals equated a regular lifestyle, i.e., eating on time, regular rest/no late nights, and a stable life course to a healthy or normal lifestyle. They evaluated dietary health in terms of food safety (i.e., chemicals such as pesticides and additives in food), the nature of the food (i.e., light and warm, non-spicy and irritating, and fresh food in Chinese Medicine Thought), and eating habits (i.e., appropriate and regular, coarse grain and meat and vegetable matching, balanced nutrition). The measure was vague or based on their own experience, for example, a light diet based on their own tastes (quote 14, 15,16). Influenced by the immediate CRC family’s lack of exercise habits and the social culture that “sports were the source of all life”, they agreed that regular exercise was essential to living a healthy lifestyle since it accelerates metabolism and guards against obesity. However, the proper duration and intensity were not established (quote 17). The pressure of a high-paced life and the theory in Chinese medicine that “anger punishes ourselves” drew the attention of some participants. Taking into account the personality traits of CRC patients, they believed that psychological or emotional imbalances could cause hormonal changes and thus affect health. They agreed that a healthy life involved relieving psychological problems and maintaining emotional stability (quote 18). Those who were particularly concerned about their diarrhoea after drinking felt that it was a responsible action for their health to maintain moderate drinking and smoking but with no set guidelines on what defines moderation (quote 19, 20). In addition, by combining Chinese physique theory and Western medicine’s immunology, participants believed that a healthy lifestyle needed to be rooted in a healthy body, although how to maintain it was uncertain (quote 21, 22). 3.2.2 Attitudes towards the role of healthy lifestyles in CRC prevention Although all FDRs had established their own insights into healthy lifestyles, attitudes about the effectiveness of different aspects of healthy lifestyles on CRC prevention differed. First, based on the belief that “disease came from the mouth” and that the stomach was the primary organ of dietary digestion, all participants accepted the beneficial influence of a good diet on CRC prevention. The experience of personal daily dietary and CRC’s immediate family suffering from the disease confirmed the rationality of these beliefs (quote 23). Second, the individuals’ perspectives on the value of physical activity in CRC prevention varied. Those who had positive effects, such as weight-loss and increased metabolism agreed that physical activity was beneficial for CRC prevention and noted that insufficient exercise was the main cause of disease in the CRC family (quote 23). However, most participants did not agree with the above ideas. Based on personal perceptions and life experiences, they described physical activity and obesity as being strongly associated with cardiovascular disease but not with CRC. The uncomfortable reactions of increased uric acid and knee abrasion after exercise led them further to dismiss the preventive effect of physical activity (quote 24, 25). Those who had experienced alcohol-related intestinal complications supported the benefit provided by quitting drinking and even believed that their intestinal problems were directly related to excessive alcohol. However, their perceived standard drinking amount did not meet the guidelines. Only a few were uncertain, based on the contradictory experiences of nondrinking relatives who had CRC and their already perceptions. However, those with no relevant experience were more exposed to information on the cardiovascular effects of alcohol but had about the preventive effects of CRC and, thus, doubted its prevention effect on CRC (quote 26, 27). As the idea that smoking was bad for your health was well established, most believed that quitting smoking could prevent all diseases, not only CRC. However, those who were addicted to smoking were more convinced of the link between smoking and lung cancer and believed that smoking could not cause other serious health problems (quote 28, 29). In addition, two participants expressed a negative fatalistic belief that life and death were fate and that any acquired effort could not change the outcome of whether an individual was ill or not (quote 30). Although participants were doubtful and cautious about the role of a healthy lifestyle, they all highlighted CRC screening for secondary prevention and considered early detection and treatment to be the key to CRC prevention (quote 31, 32). 3.3 Factors that affect life behaviour modification/maintenance Although not all FDRs expressed support for the role of healthy lifestyles in CRC prevention, they showed varying interest and reported facilitators and barriers that influenced them to modify/maintain their lifestyle behaviours (Fig. 1). 3.3.1 “There are old and young at home”—family duty leads to health-nurturing practices Positive health consciousness inspired by family duty was a core motivating factor for behaviour change among those individuals who were interested in a healthy lifestyle. Their strong sense of family duty drove them to focus on themselves. A relaxed work and life provided external support for maintaining good habits or hobbies in their daily lives. Health consciousness enhances the priority given to self-care Most FDRs reported a sense of health urgency caused by ageing. With ageing, they were forced to pay more attention to their health due to a sense of overwhelming physical decline. On the other hand, the discomfort caused by poor behaviours was beyond their tolerance and led them to change their behaviour. A few younger participants without similar experiences, also expressed that they would be more cautious of their health at some age (quote 33). They together shared the belief that “ I would raise the people who raised me and raised the people I would raise ” and “ I would not burden my parents or children ” (quote 34) Additionally, the experience of caring for a close relative or friend who had CRC provided strong persuasive information for participants to develop a belief in healthy lifestyles to prevent CRC (quote 35). Meanwhile, health issues caused by poor behaviours drew their attention to lifestyle (quote 36). The Abovementioned experiences provided a strong motivation for FDRs to alter their behaviour to maintain health. External support from a relaxed work/life Without financial pressure and working relaxation provided individuals with more energy to care for themselves and enjoy life based on the excellent performance of family duties. Additionally, a few reported that without time and space limitations from work, daily life provided them with more space for their healthy habits (quote 37, 38). Furthermore, a healthy environment in life or at work may also positively orient their behaviour towards health (quote 39). Good lifestyle preferences/habits promote healthy behaviours To take better care of their families, a few individuals actively displayed their self-efficacy to achieve a healthy lifestyle by creating opportunities such as actively setting exercise goals, constantly exploring fun and safe ways to exercise, and always cooking their meals. The sense of pleasure and fulfilment that came with reaching a goal also motivated them to adhere to healthy behaviours over time (quote 40). Furthermore, some individuals had developed good hobbies, such as having pets to increase physical activity and using tea or fruit as an alternative to smoking and drinking (quote 41). 3.3.2 “There are old and young at home” ——Exhausted by family duties A strong sense of family duty was a double-edged sword. On the one hand, it motivated some individuals to keep fit, while on the other hand, it consumed the energy of others who were too busy to take care of their health. The low health consciousness they generally had made them seldom consider the health benefits of some behaviours or wonder about the need to modify poor behaviours. Other complex factors were also linked to this low health consciousness. “The feeling of being overwhelmed” —— Pressures brought by work/life The mental pressure of the double task of taking care of the family and earning money made some participants feel “ cornered ” (N-16). This hard life consumed almost all of their energy and they generally said they “ didn’t have the time ” to consider whether their lifestyle was healthy (quote 42, 43). Work or life, limitations including intense work, long hours, poor infrastructure in rural areas, lack of without available resources, and the prevalence of tobacco and alcohol in the culture, greatly weaken their desire to change behaviour (quote 44, 45). “I can’t get cancer”——healthy fit weakened awareness of prevention Those who were young and had never experienced health problems had broad “ flukes minds ” and believed that “ people got sick at a certain age ” (N-6). Consequently, they believed that they were not yet at the stage of worrying about their health and that their priority at present was to earn money to support their families, thus ignoring the importance of prevention. Although the exposure to disease in the immediate CRC family and their history of bowel disease raised some concerns about their own risk, the negative results of medical examinations convinced participants that they did not need to worry about their health. The negative result also served as a health certificate for the abovementioned individuals who held flukes (quote 46, 47). Cancer cannot be prevented everywhere Some participants considered that the factors that contributed to CRC were complex and varied which could not be prevented anytime and anywhere. Adding to the limitations of the work or life environment, they totally agreed that cancer was not preventable (quote 48). Furthermore, fatalistic individuals believed that “ all people eat grains and “it was normal to get sick ”. An individual couldn’t change destined things through acquired actions (quote 49). Addictive pastimes/preferences hamper behaviour change Those who viewed smoking and drinking as hobbies described that these unhealthy behaviours made them relaxed and happy, and argued that “ humans were not perfect ” (quote 50). They interpreted bad behaviours as part of their imperfect character. Participants who were addicted to smoking and drinking reported that the annoyance and pain caused by changing their behaviour forced them to give up halfway through. Under the great pressure of work or life, they may also choose to smoke and drink as a pastime to numb themselves and escape from reality (quote 51). Changing long-established habits was also considered to be extremely difficult (quote 52). Those who described preferences related to gender commonly believed that men always smoked and drank alcohol but women preferred fruit and vegetables (quote 53). 4 Discussion This study focuses on the perceptions and attitudes of the FDRs of CRC patients towards healthy lifestyles to prevent CRC and the factors contributing to maintaining a healthy lifestyle. The findings suggest that FDRs generally lack knowledge of CRC, especially in terms of prevention. This is also reflected in their diverse attitudes towards healthy lifestyles. A strong sense of family duty has a two-way direction on their behavioural change. Subjective perception and agreement are the foundation for all life behavioural changes. Although the rapidly developing internet technology has greatly accelerated the spread of health information, we found that there is still a significant knowledge gap among the FDRs of CRC patients about CRC and its lifestyle factors, which have serious impacts on their attitude towards CRC prevention. The reasons revealed in this study echo other studies [ 18 , 19 ]. They reported that 1) it was difficult to motivate individuals to pay attention to health promotion if it overlooked individual differences, and 2) participants seriously questioned the authority and validity of online promotion. Enhancing awareness of FDRs by addressing the vagueness and difficulty of distinguishing between true and false health information should be placed as a public health policy priority [ 19 ]. A fundamental step to address the above issues is safeguarding the identity of the publisher and the authority and specificity of health information. The extent of personal knowledge determines the direction and degree of behavioural change [ 20 ]. This finding is in line with previous a study[ 21 ] that disease knowledge is associated with a family history of CRC and/or indirect cancer experience. The indirect experience of relatives with CRC and their bowel problems in this study provided an excellent opportunity to increase FDRs’ knowledge and stimulate behaviour modification. Encouraging CRC survivors to act as prevention advocates by properly disclosing the risk of the disease to their relatives and sharing the importance of a healthy lifestyle [ 21 ] will not only help FDRs accurately assess their CRC risk and improve their compliance and success with behavioural change but also provide a direction for resolving the current conflict between standardised health care and personalised care [ 19 , 21 ]. Participants have developed a healthy lifestyle based on the characteristics of Chinese medicine culture. On the one hand, this comes from a review of their personal and CRC relatives’ life experiences, and on the other hand, it is closely related to their exposure to social culture, especially the influence of the culture of Chinese medicine. Chinese medicine emphasises that “all illnesses are born from Qi”, which includes stability and a positive attitude towards everything in daily life[ 22 ]. This is also supported by other epidemiological studies [ 23 , 24 ] which indicate that emotionally unstable people have a higher risk of death. Although participants’ perceptions of healthy lifestyles have Chinese characteristics, they are the same as those recommended by international guidelines [ 7 ] For example, the guidelines recommend a healthy diet based on adequate quantity and variety every day. This is in line with the Chinese philosophy of Huangdi’s Canon of Medicine, which states that “the five grains are nourishing, the five fruits are helpful, the five types of meat from animals are beneficial, and the five vegetables are enriching”. It identifies the intake of protein, carbohydrates, various minerals, and other ingredients from grains, fruits, meats, and vegetables to achieve a healthy and moderate diet. Understanding the reasons for participants’ lifestyle behaviours in the context of their social backgrounds and providing knowledgeable guidance from the cultural perspective they have inherited is more likely to be successful in raising awareness and changing unhealthy behaviours. Family duty affects FDR’s lifestyle changes in both positive and negative ways. Considering their family duties, those who hold the idea that “good health is over wealth” reported that taking care of their health is responsible for themselves and their family. Consequently, they usually show good health awareness and are motivated to use their subjective efficacy to change poor lifestyle behaviours. Conversely, strong family duties also lead individuals to work hard to create good material conditions but they pay little attention to their health. No history of disease and negative test results further undermine their awareness of prevention. Future intervention recruitment or health education could build on the participants’ sense of family duty to increase involvement and adherence. The maintenance of a healthy lifestyle requires material support, and one of the reasons for the different impacts of family duties on participants’ behaviour, as the abovementioned, is their different economic abilities. Similar to the findings of other studies, this research shows that individuals with better financial conditions are usually less stressed at work and in life. Higher economic status and sufficient energy provide dual support for achieving a healthy lifestyle. Conversely, limited material support and the pressure of family duties interact with each other in a vicious process that affects participants’ attitudes towards a healthy lifestyle and behavioural changes. This is also supported by other studies with different populations [ 25 ]. Therefore, when implementing education about healthy lifestyles or lifestyle interventions, considering an individual’s material status may be key to successful delivery. 4.1 Limitations The following shortcomings in this study cannot be ignored. First, selection bias was introduced during purposive sampling. We preferred individuals who were interested in this study; those who declined to participate may present a completely different perspective. Second, the participants were also taking on the role of caregivers when interviewed, and their varying emotions caused by the severity of the CRC patients’ illness may have influenced their perceptions of the topic. Third, despite having been fully identified before the interview and assured that there was no connection to their CRC relative, some interviewees were concerned about affecting their relative’s treatment and may have expressed what they perceived to be a positive view, contradicting their true feelings. 4.2 Conclusion As a result of limited knowledge of CRC, FDRs are unlikely to emphasise preventing CRC through healthy lifestyles. Influenced by the culture of Chinese medicine and life experience, participants have gradually developed a perception of healthy lifestyles with Chinese characteristics. Participants’ ability to maintain healthy lifestyles was greatly influenced by family duty-related factors. Social culture and family duty-related factors should be taken into consideration when undertaking health interventions or education programs on lifestyles for first-degree relatives of CRC. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions Conceptualization: [Wenxia Wang], [Shuyan Fang], [Shuang Zhang], [Dongfei Ma], [Xiangfei Meng], [Sun Jiao], Methodology: [Meng He], [Xiangning Zhu], [Yueyang Dong], [Yanjie Zhao], [Wenxia Wang], Formal analysis and investigation: [Wenxia Wang], [Shuyan Fang], [Shuang Zhang], Writing - original draft preparation: [Wenxia Wang], [Shuyan Fang] , [Sun Jiao], Writing - review and editing: [Wenxia Wang], , [Sun Jiao], Resources: [Shizheng Gao], [Shengze Zhi], [Juanjuan Sun], [Dongpo Song], Supervision: [Dongfei Ma], [Xiangfei Meng], [Sun Jiao]. Ethics approval This study was approved by the Ethics Committee of the School of Nursing, Jilin University (No: 2021112401). After carefully reading the information regarding the study’s purpose and context and assuring that their answers and identity would remain anonymous, each participant signed the informed consent form. The researcher explained to the participants that their involvement would have any impact on the care provided to their CRC relatives and made it obvious that they could quit the study at any time. Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish The authors affirm that human research participants provided informed consent for publication. References Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin . May 2021,71(3):209-249. doi:10.3322/caac.21660 Mehraban Far P, Alshahrani A, Yaghoobi M. Quantitative risk of positive family history in developing colorectal cancer: A meta-analysis. World journal of gastroenterology . Aug 14 2019,25(30):4278-4291. doi:10.3748/wjg.v25.i30.4278 Roos VH, Mangas-Sanjuan C, Rodriguez-Girondo M, et al. Effects of Family History on Relative and Absolute Risks for Colorectal Cancer: A Systematic Review and Meta-Analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association . Dec 2019,17(13):2657-2667.e9. doi:10.1016/j.cgh.2019.09.007 Wang K, Ma W, Wu K, et al. Healthy lifestyle, endoscopic screening, and colorectal cancer incidence and mortality in the United States: A nationwide cohort study. PLoS Med . Feb 2021,18(2):e1003522. doi:10.1371/journal.pmed.1003522 Wu Y, Li Y, Giovannucci E. Potential Impact of Time Trend of Lifestyle Risk Factors on Burden of Major Gastrointestinal Cancers in China. Gastroenterology . Dec 2021,161(6):1830-1841.e8. doi:10.1053/j.gastro.2021.08.006 Knudsen MD, Wang L, Wang K, et al. Changes in Lifestyle Factors After Endoscopic Screening: A Prospective Study in the United States. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association . Jun 2022,20(6):e1240-e1249. doi:10.1016/j.cgh.2021.07.014 Clinton SK, Giovannucci EL, Hursting SD. The World Cancer Research Fund/American Institute for Cancer Research Third Expert Report on Diet, Nutrition, Physical Activity, and Cancer: Impact and Future Directions. J Nutr . Apr 1 2020,150(4):663-671. doi:10.1093/jn/nxz268 Rock CL, Thomson C, Gansler T, et al. American Cancer Society guideline for diet and physical activity for cancer prevention. CA Cancer J Clin . Jul 2020,70(4):245-271. doi:10.3322/caac.21591 Lee KW, Kim HB, Lee SH, Ha HK. Changes in Weight and Health-Related Behavior Using Smartphone Applications in Patients With Colorectal Polyps. Journal of nutrition education and behavior . May 2019,51(5):539-546. doi:10.1016/j.jneb.2019.02.002 Vrieling A, Visser A, Hoedjes M, et al. Increasing awareness and knowledge of lifestyle recommendations for cancer prevention in Lynch syndrome carriers: Randomized controlled trial. Clinical genetics . Jan 2018,93(1):67-77. doi:10.1111/cge.13076 Hatami T, Noroozi A, Tahmasebi R, Rahbar A. Effect of Multimedia Education on Nutritional Behaviour for Colorectal Cancer Prevention: An Application of Health Belief Model. Malays J Med Sci . Nov 2018,25(6):110-120. doi:10.21315/mjms2018.25.6.11 Fisher A, Craigie AM, Macleod M, Steele RJC, Anderson AS. The impact of social deprivation on the response to a randomised controlled trial of a weight management intervention (BeWEL) for people at increased risk of colorectal cancer. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association . Jun 2018,31(3):306-313. doi:10.1111/jhn.12524 Dowswell G, Ryan A, Taylor A, et al. Designing an intervention to help people with colorectal adenomas reduce their intake of red and processed meat and increase their levels of physical activity: a qualitative study. BMC cancer . Jun 18 2012,12:255. doi:10.1186/1471-2407-12-255 Stead M, Caswell S, Craigie AM, Eadie D, Anderson AS. Understanding the potential and challenges of adenoma treatment as a prevention opportunity: insights from the BeWEL formative study. Preventive medicine . Jan 2012,54(1):97-103. doi:10.1016/j.ypmed.2011.10.017 Prichard I, Lee A, Hutchinson AD, Wilson C. Familial risk for lifestyle-related chronic diseases: can family health history be used as a motivational tool to promote health behaviour in young adults? Health promotion journal of Australia : official journal of Australian Association of Health Promotion Professionals . Aug 2015,26(2):122-128. doi:10.1071/he14104 Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today . Feb 2004,24(2):105-12. doi:10.1016/j.nedt.2003.10.001 Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology . 2006/01/01 2006,3(2):77-101. doi:10.1191/1478088706qp063oa Kocaballi AB, Berkovsky S, Quiroz JC, et al. The Personalization of Conversational Agents in Health Care: Systematic Review. J Med Internet Res . Nov 7 2019,21(11):e15360. doi:10.2196/15360 Mannion R, Exworthy M. (Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare. Int J Health Policy Manag . Jun 1 2017,6(6):301-304. doi:10.15171/ijhpm.2017.35 Vraga EK. Expert organizations can be effective in correcting health misinformation on social media. Accessed 10/26/17, blogs.lse.ac.uk/usappblog/2017/10/26/expert-organizations-can-be-effective-in-correctinghealth-misinformation-on-social-media/ Dijk SW, Duijzer EJ, Wienold M. Role of active patient involvement in undergraduate medical education: a systematic review. BMJ Open . Jul 27 2020,10(7):e037217. doi:10.1136/bmjopen-2020-037217 Yang LM. [Medico-psychology in Huang di nei jing (Yellow Emperor's Inner Canon)]. Zhonghua Yi Shi Za Zhi . Jan 2004,34(1):21-6. Steca P, D'Addario M, Magrin ME, et al. A Type A and Type D Combined Personality Typology in Essential Hypertension and Acute Coronary Syndrome Patients: Associations with Demographic, Psychological, Clinical, and Lifestyle Indicators. PloS one . 2016,11(9):e0161840. doi:10.1371/journal.pone.0161840 Fickley CE, Lloyd CE, Costacou T, Miller RG, Orchard TJ. Type A behavior and risk of all-cause mortality, CAD, and CAD-related mortality in a type 1 diabetic population: 22 years of follow-up in the Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes Care . Oct 2013,36(10):2974-80. doi:10.2337/dc13-0266 Gragnano A, Simbula S, Miglioretti M. Work-Life Balance: Weighing the Importance of Work-Family and Work-Health Balance. International journal of environmental research and public health . Feb 1 2020,17(3)doi:10.3390/ijerph17030907 Additional Declarations No competing interests reported. Supplementary Files supplementarymaterial1COREQChecklist.pdf supplementarymaterial2Examplesofinterviews.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Introduction","content":"\u003cp\u003eAccording to the 2020 Global Cancer Statistics report, colorectal cancer (CRC) ranks third and fourth among all malignancies in incidence and mortality, respectively [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2030, there will be 2.2\u0026nbsp;million new cases and 1.1 deaths of colorectal cancer globally, with a 60% increase in the global economic burden [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Especially, the risk of CRC increases with the number of degree relatives and at 1.87 is substantially higher among first-degree relatives (FDRs) than in the general population[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The probability of getting colorectal cancer increases by up to five times in individuals with two or more FDRs with CRC history at the same time [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The risk of developing colorectal cancer in its early stages rises by 16.57 times versus the general population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Focused attention and effective preventive measures for this population can effectively reduce the incidence of CRC.\u003c/p\u003e \u003cp\u003eA growing number of people are interested in lifestyle management since it prevents CRC, in addition to the effectiveness of secondary prevention measures such as colonoscopy in lowering the prevalence of the disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Numerous studies have examined how CRC incidence and lifestyle factors interact. Five healthy lifestyle factors\u0026mdash;a good diet, proper physical activity, a healthy weight, not smoking, and moderate alcohol consumption\u0026mdash;suggest a negative connection with CRC, according to the results of various large retrospective and prospective cohort studies[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A total of 20\u0026ndash;70% of CRC cases can be prevented by following five healthy lifestyles [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Guidelines for CRC prevention through a healthy lifestyle have also been released by the World Cancer Research Fund (WCRF)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the American Institute for Cancer Research[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA variety of factors affect people\u0026rsquo;s ability to behave healthily. For patients with a family history of CRC or adenomatous polyps, studies [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] have undertaken one or two lifestyle behavioural interventions or health education. The findings revealed a complicated interaction between risk perception and willingness to change lifestyle, as well as challenges with implementation, low adherence, short-term maintenance of healthy lifestyles, and erratic motivation for behaviour change. The timing, content, and availability of health-related information are among the factors that are mentioned, along with education, health literacy, and self-efficacy. Additionally, qualitative research [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] for those who had positive CRC-related tests also revealed that lifestyle behaviours are influenced by personal characteristics (e.g, age, health status, perceived benefits, life attitude, and habits), environmental factors (e.g, workplace limitations, inadequate social support, and infrastructure to promote behavioural change), culture and cost, employment constraints, health status, perceived benefits, and habits. These findings show that individuals\u0026rsquo; motivations for adopting a healthy lifestyle to lower their risk of CRC may be complicated and multifaceted.\u003c/p\u003e \u003cp\u003eThe FDRs of CRC patients know little about living a healthy lifestyle to prevent CRC. Indirect cancer experience or family history is strongly correlated with developing awareness [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, the current state of behaviour towards a healthy lifestyle for CRC is not favourable[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], with issues such as poor diet (for example, excessive intake of fat and red meat, inadequate fruit, vegetables, and dietary fibre), lack of physical activity, obesity, excessive alcohol consumption, and smoking. Several studies have proven that in addition to dietary factors, they are not well-informed about the relationship between other lifestyle factors and CRC [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Lack of knowledge hampers prevention efforts. A careful assessment of FDRs attitudes towards adopting healthy lifestyles and digging into the complex motivations for their lifestyle change offers compelling evidence for the development of effective interventions to support lifestyle modification and direction for public prevention policy. To achieve an understanding of the complexity of closely linked individual features, qualitative methods such as interviews are used [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The purpose of this study was to investigate how FDRs perceive and are motivated to maintain a healthy lifestyle using a qualitative approach to the following questions: 1) How knowledgeable are FDRs about CRC and a healthy lifestyle? 2) How do they perceive the prevention of CRC through pursuing healthy lifestyles? 3) What possible facilitating factors and barriers influence them to undertake healthy lifestyles?\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted at the Department of Gastroenterology Surgery of a large general hospital in XX (name of city), China from December 2021 to February 2022. People who come to this large general hospital have a different knowledge of disease and complex life experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003eThe participants were recruited using purposive sampling. We identified potential participants who met the following inclusion criteria: 1) age\u0026thinsp;\u0026gt;\u0026thinsp;18 years with informed consent and voluntary participation; and 2) the FDRs of CRC patients, such as their parents, children, and siblings. Details of the study, including the identity of the researchers, the purpose and methods of the study, and others concerned were presented to potential participants by telephone or face-to-face. To establish trust, we approached participants through the health professionals they were most familiar with. We ensured that they them informed and invited to attend safely (not at the ward) since some participants were worried that CRC patients would be impacted if they learned more about the disease. After contacting 21 potential participants, 16 volunteered to join this study. Those who declined to participate cited a lack of interest, fear of the unstable emotional impact of their CRC relatives caused by suspicion, and the length of the interview delaying caring.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003e Only one interviewer and one participant engaged in face-to-face semi-structured interviews in the department\u0026rsquo;s standard communication room to minimise interviewees being distracted by the environment. To earn the trust of the identified participants, three interviewers, female registered nurses with training in systematic qualitative research, had at least three conversations with them before the interview. We prepared predeveloped research questions based on prior literature and the study goals We then conducted pre-interviews to ensure that the questions were open-ended and simple to understand (supplementary material 1). The interviewer avoided questioning in a sentence tone as much as possible and instead used terms such as \u0026ldquo;Can you tell me more?\u0026rdquo; \u0026ldquo;What do you think?\u0026rdquo; and \u0026ldquo;What occurred then?\u0026rdquo; to create a relaxed atmosphere. The interviewer simply captured keywords and nonverbal cues when participants were encouraged to talk freely about their experiences. The interviewer then asked the participants whether they had any relevant clarification concerns or discussion before ending, as well as told them that they were welcome to add to this topic at any time. After the participant\u0026rsquo;s consent, the full interview was recorded using the mobile phone\u0026rsquo;s designed recording software. The interviewer then verified the verbatim transcription within 48 hours of the interview\u0026rsquo;s completion. Only one interview was conducted with each participant lasting 37 to 76 minutes. Even though the 13th interviewer had reached data saturation, we kept going and interviewed three more people to ensure data enrichment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data analysis\u003c/h2\u003e \u003cp\u003eA descriptive exploratory design was used to explore participants\u0026rsquo; insights into the research topic based on their life experiences. Six steps of an inductive thematic analysis were applied to analyse the data [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] using QSR's NVivo software. The first four steps were individually performed by the first three female authors (all are registered nurses). In the fifth step -defining and naming themes, all three authors generated three themes and shared them to refine and define the seven subthemes. The first author further developed and merged the themes in the sixth phase to construct a scholarly report (an example of the analysis in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Any questions were discussed within the group until they reached a consensus or were referred to Y, who was skilled in qualitative research. To demonstrate the influence of the researcher\u0026rsquo;s theoretical knowledge and life experience on the data analysis and to help understand the themes that emerged, the first author wrote reflective memos on the entire process. Participants were not involved in any of the processes of data analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis process examples\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eData\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAs I am an only child, I thought that when my wife and I get old, we cannot rely on my children. My children can\u0026rsquo;t rely on others when we pass away either. All we can do is rely on ourselves.\u003c/em\u003e (N-2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStay healthy to reduce the children\u0026rsquo;s burden of parenting in the future\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily duties promote awareness of one\u0026rsquo;s health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFamily duties: lifestyle perspectives and/or those factors that influence behavioural change caused by the practice and/or undertaking of some responsibility or obligation of the family\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGosh, I\u0026rsquo;m just daily life, how else can I take care of my health? You still have to work which is for you there. Also, don\u0026rsquo;t you live? There are so many things to do with money!\u003c/em\u003e (N-13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eToo busy running a life and earning a living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily duties consume energy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHowever, for me, you cannot control everything, many people smoke and drink, for example, he also lives to 90, 80 or 100 and so on. This thing is still not a preventive thing for me. (N-11)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer fatalism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCancer can\u0026rsquo;t be prevented everywhere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe impact on lifestyle behaviour change is produced by the idea of those who individually consider uncontrollable factors as objective and difficult to change.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3 Findings","content":"\u003cp\u003eThe 16 study participants included six females and ten males. The age range was 33\u0026ndash;39 years (more details in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterviewee characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWork\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIncome/RMB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHistory of disease\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCollege degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompany manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026gt;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInsurance salesman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026gt;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHaemorrhoids\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2001\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHip replacement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRecurrent diarrhoea\u003c/p\u003e \u003cp\u003eOvarian endometriosis cyst\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHighway maintenance workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5001\u0026ndash;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5001\u0026ndash;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCater\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026gt;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFactory workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5001\u0026thinsp;\u0026minus;\u0026thinsp;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHenoch-Sch\u0026ouml;nlein purpura\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2001\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGastropathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLess than primary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2001\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRecurrent diarrhoea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInstability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCollege degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eService industry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2001\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOvarian endometriosis cyst\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTrain driver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2001\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGastric bleeding, Herniated disc\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN-16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUterine fibroids\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree overarching themes were developed in an in-depth analysis: 1) limited disease knowledge and individualised self-awareness of CRC risk; 2) diverse attitudes towards healthy lifestyles for CRC prevention, and 3) factors that affect life behaviour modification/maintenance. We summarise the quotations related to each finding in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"12\" rowspan=\"13\"\u003e \u003cp\u003e3.1 Limited disease knowledge and individualised self-awareness for CRC risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e3.1.1 \u0026ldquo;Don\u0026rsquo;t know much about it\u0026rdquo; \u0026mdash; little knowledge of CRC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-1: I don\u0026rsquo;t feel like this is much because in the bowel, the bowel cancer thing it\u0026rsquo;s not much. (N-13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-2: But I think I\u0026rsquo;ve heard that it also seems to have something to do with heredity... I don\u0026rsquo;t have an idea, I just feel that it\u0026rsquo;s the intestinal end that should have something to do with eating. (N-6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-3: It\u0026rsquo;s just that there were neighbours or friends or whatever who used to talk about ... However, sometimes you don\u0026rsquo;t pay attention to it, and you forget about these afterwards. (N-15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-4: I think it\u0026rsquo;s more or less related to temporary things. The fact that he\u0026rsquo;s quite angry. I don\u0026rsquo;t know about anything else, but he just yells at my mother, always argues, and is\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-5: I used to be confused that I ate less than others but I was fat. Then I thought maybe it was just my poor metabolism\u0026hellip; (N-3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e3.1.2 Measuring self-CRC risk with/with diverse perspectives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-6: My diet, which I pay attention to in all areas, is specified as (not too high). This seems to be related to all aspects of diet. (N-15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-7: We don\u0026rsquo;t even think about that...these things are no worries because I don\u0026rsquo;t have a physical problem, I guess... (N-11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-8: I think I\u0026rsquo;m just not in good health, I think I\u0026rsquo;m just easy to get these whatever diseases...because I just always feel like I\u0026rsquo;m not in good health. (N-16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-9: Gee, I\u0026rsquo;m burnt out, what\u0026rsquo;s the point of doing all these (maintaining a healthy life)? There\u0026rsquo;s still work to be done... (N-13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-10: It\u0026rsquo;s the gynaecology one, I think. I want to get it checked out. I had a polyp on my endometrium. Then, I thought I\u0026rsquo;d go and have it checked out to see what it looked like. (N-4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3.1.3 Multiple efforts to improve the quality and efficiency of prevention strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-11: You give him ten questions or twenty questions and he can judge for himself whether his health is good or bad, or whether he is already at risk, right? You can inform him through this questionnaire if there is already a risk. I\u0026rsquo;m already having these problems, so I should mention that I\u0026rsquo;m aware of them. (N-3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-12: If it was a doctor or nurse I knew or was introduced to by someone close to me, then I would believe what they said. (N-6).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-13: I feel that the person to do this thing should have a high national or international profile or could be tracked. (N-2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"17\" rowspan=\"18\"\u003e \u003cp\u003e3.2 Diverse attitudes towards healthy lifestyles for CRC prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e3.2.1 Individually perceptions of healthy lifestyles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-14: Maybe it\u0026rsquo;s related to diet. For example, you get a lot of spicy or other bad food ...just keep good habits, don\u0026rsquo;t eat anything irritating, it\u0026rsquo;s not good for your stomach. (N-10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-15: That is safer, for example, meat with no leanness-enhancing agent or animals is fed with natural plants\u0026hellip; (N-1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-16: Keep early hours and don\u0026rsquo;t stay up late or overexert your body. In particular, for people who are my age, 70 percent is appropriate and should not eat too full...(N-14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-17: So, I usually feel that I start to sweat, I\u0026rsquo;m going to feel the sweat pouring down and I can\u0026rsquo;t (run) at this point. I couldn\u0026rsquo;t run anymore when my heart rate was up to 130\u0026ndash;140. (N-2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-18: For example, you have to be in good mind. Because it makes you powerful and all the disease goes away. After you have a lot of stress or be nervous, you just don\u0026rsquo;t sleep well, then your organs will be impacted. If you have a good mind, everything will be better. (N-11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-19: I feel that the amount of alcohol we consume is still okay. I also don\u0026rsquo;t think it\u0026rsquo;s a good idea to gobble up the food all time. (N-10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-20: ...the inhaled nicotine may go from the mouth to the stomach and then reach the intestines. Staying somewhere could potentially cause disease to occur in this. (N-1).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-21: It\u0026rsquo;s related to the physique. The body\u0026rsquo;s acupuncture points are all on the feet. If your hands and feet are cold, you\u0026rsquo;ll be in trouble and you\u0026rsquo;ll get sick sooner. (N-12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-22: ...Trying to do fewer things that are bad for health, such as cold things I cannot eat. At least let\u0026rsquo;s be good to our bodies. (N-11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e3.2.2 Attitudes towards the role of healthy lifestyles in CRC prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-23: Because he did farm work in rural. Suddenly he had been urban for ten years. He is so lazy that he can\u0026rsquo;t even get downstairs. Also, life is getting better, and eating a lot. The digestive system is under a lot of stress. He doesn\u0026rsquo;t move which has bad effects on the immune system. (N-1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-24: Exercising vigorously will make uric acid high. My urea is not high when I\u0026rsquo;m not exercising. Since I don\u0026rsquo;t eat seafood and don\u0026rsquo;t drink much alcohol, my uric acid should be normal. (N-2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-25: I\u0026rsquo;ve been walking for six months and my knees hurt. (N-1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-26: ...Anyway, I don\u0026rsquo;t know if everyone here is drinking, I specify yes...it\u0026rsquo;s drinking that has affected my health badly. (N-12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-27: We are at a higher risk of developing high blood pressure because of regular drinking. (N-1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-28: I think it has something to do with eating hot and cold, but I haven\u0026rsquo;t found anything to do with smoking and drinking first. (N-15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-29: Because so far, the effect of this smoking on me has probably been a bit of pharyngitis... it is not so serious. (N-2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-30: I think that\u0026rsquo;s fate. It\u0026rsquo;s impossible to say that you can control everything. If you quit smoking, can you be sure that you will not suffer from disease? Even if you develop a disease in the future, is it truly directly related to smoking? (N-2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-31: I\u0026rsquo;ve had it checked and it\u0026rsquo;s fine. I have my annual medical checkup... (N-1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote-32: I check it once a year. If there is a polyp, I have it removed in time. So it\u0026rsquo;s not likely to develop into cancer. There is no tendency for it to turn into that cancer. (N-8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e3.33.3 Factors that affect life behaviour modification/maintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3.3.1\u0026ldquo;There are old and young at home\u0026rdquo;\u0026mdash;family duty leads to health-nurturing practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHealth consciousness enhances the priority given to self-care\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-33: Because I\u0026rsquo;m not too young this year, I just have to take care of myself in terms of health care. (N-50)\u003c/p\u003e \u003cp\u003eQuote-34: It\u0026rsquo;s just that I don\u0026rsquo;t want to be a burden. Right now, like us, we have an old man and young children. My daughter-in-law and I have both parents, at least thus far, we have to keep healthy because our parents are not very healthy. (N-2)\u003c/p\u003e \u003cp\u003eQuote-35: What about chewing and swallowing slowly? I used to gobble it up, and I\u0026rsquo;ve learned since I got enteritis. Like cold or hot food you eat, it\u0026rsquo;s not good. The only way to nurture your health is like this. (N-12)\u003c/p\u003e \u003cp\u003eQuote-36: I just go to exercise when I feel uncomfortable or tired. (N-8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eExternal support from a relaxed work/life\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-37: Because of the work, the previous work was manual labour which took a lot of time and energy. After changing work, it is quite easy and relaxing. (N-14)\u003c/p\u003e \u003cp\u003eQuote-38: I don\u0026rsquo;t have that much stress in my life or at work, I mainly take care of my daughter. In my spare time, if I have the energy I do my work, but if don\u0026rsquo;t I put it aside. (N-2)\u003c/p\u003e \u003cp\u003eQuote-39: My parents\u0026rsquo; ideas about health influenced me by calling me every day or urging me to watch TV programmes, telling me that it was not good to do this or that. (N-3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eGood lifestyle preferences/habits promote healthy behaviours\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-40: I walked 10,000 steps and I feel quite proud of myself... I walked seven kilometres a day at that time and I had set a goal for myself to do it for six months. (N-1)\u003c/p\u003e \u003cp\u003eQuote-41: I have a teddy at home and would like to take it for a walk after I went back for dinner. (N-15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e3.3.2\u0026ldquo;There are old and young at home\u0026rdquo; \u0026mdash;\u0026mdash;Exhausted by family duties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026ldquo;The feeling of being overwhelmed\u0026rdquo; \u0026mdash;\u0026mdash;Pressures produced by work/life\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-42: Perhaps I have seen a lot of things, and I only want to raise the people who raised me and raise the people I would raise. I didn\u0026rsquo;t think about ourselves... At some age, because you don\u0026rsquo;t have health problems, there is no time to think about yourself. I just think about making money. (N-11)\u003c/p\u003e \u003cp\u003eQuote-43: You have to try to survive and take care of a family. Even if you want to pay more attention (to your body), you\u0026rsquo;ll have trouble doing it sometimes due to these things. (N-14)\u003c/p\u003e \u003cp\u003eQuote-44: I quit smoking for a while, truly, I quit for a while, but then work is often outside where all are smoking. I got hooked and didn\u0026rsquo;t quit. (N-5)\u003c/p\u003e \u003cp\u003eQuote-45: Some people don\u0026rsquo;t smoke, but you will find that people who smoke and drink are better at work. As an interpersonal lubricant, people who smoke and drink have more opportunities to connect with others at work. (N-20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026ldquo;I can\u0026rsquo;t get cancer\u0026rdquo;\u0026mdash;\u0026mdash;healthy fit weakened awareness of prevention\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-46: I don\u0026rsquo;t usually go for flu fluids because of a cold. I only get a cold once or twice a year, and sometimes I just get over it on my own. (N-7)\u003c/p\u003e \u003cp\u003eQuote-47: I didn\u0026rsquo;t have a disease ever, so I felt that I wouldn\u0026rsquo;t have been so unlucky to get sick. I probably have that fluke mentality...(N-6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026ldquo;Cancer cannot be prevented everywhere\u0026rdquo;\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-48: It\u0026rsquo;s not like at home, where you have nothing to do or can watch TV or sit and eat an apple or an orange, but you cannot achieve this at the factory. (N-5)\u003c/p\u003e \u003cp\u003eQuote-49: However, for me, you cannot control everything, many people smoke and drink, for example, he also lives to 90, 80 or 100 and so on. This thing is still not a preventive thing for me. (N-11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAddictive pastimes/preferences hamper behaviour change\u003c/b\u003e\u003c/p\u003e \u003cp\u003eQuote-50: That\u0026rsquo;s the one flaw I keep, probably the most serious one. Because no matter how capable a person is, it is difficult to do everything, and it is not always possible to control his/her habits perfectly, which is quite normal. (N-2)\u003c/p\u003e \u003cp\u003eQuote-51: I just always feel tired. The business is still losing money, and there are always various reasons to drink anyway. Sometimes I think I should stop thinking about it and stop drinking. However, if I don\u0026rsquo;t drink, I think about everything, and it\u0026rsquo;s very stressful. After drinking, I don\u0026rsquo;t think about it anymore and I sleep well. (N-8)\u003c/p\u003e \u003cp\u003eQuote-52: I\u0026rsquo;ve thought about doing a bland diet too. But it hardly satisfies me. I eat a lot of onion and garlic at home every day, I just like to eat that way. (N-15)\u003c/p\u003e \u003cp\u003eQuote-53: The boys are good at smoking and drinking, while you girls may like eating some fruit nothing to do, that belongs to a hobby. I do not like that stuff (fruits). (N-10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Limited disease knowledge and individualised self-awareness for CRC risk\u003c/h2\u003e \u003cp\u003eSingle and fragmented access to knowledge limited FDR\u0026rsquo;s systematic and scientific understanding of CRC, which forced them to measure their CRC risk from multiple perspectives based on their diverse life experiences. They called for a coordinated effort to broaden and improve the advocacy efforts for CRC so that they could access accurate and authoritative information on CRC prevention.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 \u0026ldquo;Don\u0026rsquo;t know much about it\u0026rdquo; \u0026mdash; little knowledge of CRC\u003c/h2\u003e \u003cp\u003eThe first reaction of all participants was that they \u0026ldquo;didn\u0026rsquo;t know much about it\u0026rdquo;, and some even said that it was the first time they had heard of it when asked about their knowledge of CRC. Misunderstanding the causes of CRC, confusion about disease types (e.g., CRC and haemorrhoids), and concern about whether cancer equalled death and cancer fatalism presented the current picture of many participants\u0026rsquo; understanding of CRC (quote 1, 2).\u003c/p\u003e \u003cp\u003eMany people first heard about CRC from chatting about the disease experience of someone unfamiliar and they tended to concentrate on the treatment and prognosis. It raised concerns about their health that were not alarming and persistent, thus making it difficult to inspire them to mirror deeply and desire to learn more about CRC (quote 3).\u003c/p\u003e \u003cp\u003eParticipants increased their CRC knowledge by consulting doctors or searching the internet. However, the knowledge was partial or superficial. Some identified age, physical fitness, immunity, irregular sleep, and personality/temporary as potential risk factors. A few vaguely reported the influence of obesity and factors related to physical activity on CRC were made when it referred to lifestyle factors other than diet (quote 4, 5).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Measuring self-CRC risk with/with a diverse perspective\u003c/h2\u003e \u003cp\u003eLack of diverse and effective access to knowledge led to little knowledge of CRC among FDRs. Based mainly on their individual experiences, such as health conditions, medical examinations, lifestyle, environment and exposure to disease information, participants had varied perspectives on assessing their risk of CRC.\u003c/p\u003e \u003cp\u003eThose individuals who were unconcerned about their CRC risk believed that there was no family history of CRC and that it was difficult to explain whether they carried a genetic risk based on one CRC member. Even though CRC was associated with the abovementioned factors, they reported that they did not have the same risk factors in their daily lives or had made modifications (quote 6).\u003c/p\u003e \u003cp\u003eThose who maintained regular screening habits developed a better awareness of health but valued the effectiveness of secondary prevention. Despite intestinal issues such as diarrhoea, the accumulating negative results of screening led participants to underestimate the severity of their potential health issues. They didn\u0026rsquo;t want to worry about what had not happened that might cause extra panic and anxiety, especially because they were already attempting to change bad behaviour that would cause intestinal discomfort. Those who were well and had no health issues reported that there was \u0026ldquo;\u003cem\u003eno need to worry about the future\u003c/em\u003e\u0026rdquo; (quote 7).\u003c/p\u003e \u003cp\u003eOn the other hand, a minority of participants were aware that they might have a higher risk of CRC than others. In addition to family genetic factors, they described that they shared the same living conditions as their immediate CRC relatives and that they were also susceptible to intestinal discomfort or were usually sicker than those surrounding them. All considered, they said they would like to learn more about CRC and took their risk seriously (quote 8, 9).\u003c/p\u003e \u003cp\u003eSome participants were very focused on their role as caregivers or other health problems that made them feel anxious and fearful and, thus, did not have a mind to think about their CRC risk (quote 10).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Multiple efforts to improve the quality and efficiency of prevention strategies\u003c/h2\u003e \u003cp\u003eA hospital-centred, government-supported system of hospital responsibility and parallel promotion in collaboration with communities to enable the widespread dissemination of disease information was called for by the participants to be optimised in light of the challenges. Health professionals were urged to fully utilise counselling opportunities to deliver scientific prevention information and to guide patients and their family members to concentrate on CRC prevention. Furthermore, a large number of medical students were advised to integrate CRC health education as a social practice activity, with questionnaires and other forms to evaluate and categorise people\u0026rsquo;s knowledge and offer acceptable guidance to ensure the viability and targeting of disease education (quote 11).\u003c/p\u003e \u003cp\u003eMany participants on internet platforms call for trustworthy and traceable health information. To increase the rationality and authority of health information, they suggested that the publisher or advocate should be a trustworthy and authoritative person, such as a doctor who was well-known or who could be easily identified (quote 12, 13).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Diverse attitudes towards healthy lifestyles for CRC prevention\u003c/h2\u003e \u003cp\u003eFDRs shared their perceptions of healthy lifestyles and diverse attitudes including beliefs, doubts, and uncertainties about the importance of lifestyles in CRC prevention, based on differences in knowledge of CRC disease, life experience, and sociocultural influences.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Individually perceptions of healthy lifestyles\u003c/h2\u003e \u003cp\u003eShaped by the life experiences of CRC patients and themselves, as well as social and cultural influences, participants had developed their perceptions of a healthy lifestyle, which primarily included a healthy diet, routine, stable life course, moderate exercise, mental/emotional peace, quitting smoking and drinking, and maintaining physical fitness.\u003c/p\u003e \u003cp\u003eFDRs interpreted healthy lifestyles as covering all aspects of their personal lives. Most individuals equated a regular lifestyle, i.e., eating on time, regular rest/no late nights, and a stable life course to a healthy or normal lifestyle. They evaluated dietary health in terms of food safety (i.e., chemicals such as pesticides and additives in food), the nature of the food (i.e., light and warm, non-spicy and irritating, and fresh food in Chinese Medicine Thought), and eating habits (i.e., appropriate and regular, coarse grain and meat and vegetable matching, balanced nutrition). The measure was vague or based on their own experience, for example, a light diet based on their own tastes (quote 14, 15,16).\u003c/p\u003e \u003cp\u003eInfluenced by the immediate CRC family\u0026rsquo;s lack of exercise habits and the social culture that \u0026ldquo;sports were the source of all life\u0026rdquo;, they agreed that regular exercise was essential to living a healthy lifestyle since it accelerates metabolism and guards against obesity. However, the proper duration and intensity were not established (quote 17).\u003c/p\u003e \u003cp\u003eThe pressure of a high-paced life and the theory in Chinese medicine that \u0026ldquo;anger punishes ourselves\u0026rdquo; drew the attention of some participants. Taking into account the personality traits of CRC patients, they believed that psychological or emotional imbalances could cause hormonal changes and thus affect health. They agreed that a healthy life involved relieving psychological problems and maintaining emotional stability (quote 18).\u003c/p\u003e \u003cp\u003e Those who were particularly concerned about their diarrhoea after drinking felt that it was a responsible action for their health to maintain moderate drinking and smoking but with no set guidelines on what defines moderation (quote 19, 20).\u003c/p\u003e \u003cp\u003eIn addition, by combining Chinese physique theory and Western medicine\u0026rsquo;s immunology, participants believed that a healthy lifestyle needed to be rooted in a healthy body, although how to maintain it was uncertain (quote 21, 22).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Attitudes towards the role of healthy lifestyles in CRC prevention\u003c/h2\u003e \u003cp\u003eAlthough all FDRs had established their own insights into healthy lifestyles, attitudes about the effectiveness of different aspects of healthy lifestyles on CRC prevention differed.\u003c/p\u003e \u003cp\u003eFirst, based on the belief that \u0026ldquo;disease came from the mouth\u0026rdquo; and that the stomach was the primary organ of dietary digestion, all participants accepted the beneficial influence of a good diet on CRC prevention. The experience of personal daily dietary and CRC\u0026rsquo;s immediate family suffering from the disease confirmed the rationality of these beliefs (quote 23).\u003c/p\u003e \u003cp\u003eSecond, the individuals\u0026rsquo; perspectives on the value of physical activity in CRC prevention varied. Those who had positive effects, such as weight-loss and increased metabolism agreed that physical activity was beneficial for CRC prevention and noted that insufficient exercise was the main cause of disease in the CRC family (quote 23).\u003c/p\u003e \u003cp\u003eHowever, most participants did not agree with the above ideas. Based on personal perceptions and life experiences, they described physical activity and obesity as being strongly associated with cardiovascular disease but not with CRC. The uncomfortable reactions of increased uric acid and knee abrasion after exercise led them further to dismiss the preventive effect of physical activity (quote 24, 25).\u003c/p\u003e \u003cp\u003eThose who had experienced alcohol-related intestinal complications supported the benefit provided by quitting drinking and even believed that their intestinal problems were directly related to excessive alcohol. However, their perceived standard drinking amount did not meet the guidelines. Only a few were uncertain, based on the contradictory experiences of nondrinking relatives who had CRC and their already perceptions. However, those with no relevant experience were more exposed to information on the cardiovascular effects of alcohol but had about the preventive effects of CRC and, thus, doubted its prevention effect on CRC (quote 26, 27).\u003c/p\u003e \u003cp\u003eAs the idea that smoking was bad for your health was well established, most believed that quitting smoking could prevent all diseases, not only CRC. However, those who were addicted to smoking were more convinced of the link between smoking and lung cancer and believed that smoking could not cause other serious health problems (quote 28, 29).\u003c/p\u003e \u003cp\u003eIn addition, two participants expressed a negative fatalistic belief that life and death were fate and that any acquired effort could not change the outcome of whether an individual was ill or not (quote 30).\u003c/p\u003e \u003cp\u003eAlthough participants were doubtful and cautious about the role of a healthy lifestyle, they all highlighted CRC screening for secondary prevention and considered early detection and treatment to be the key to CRC prevention (quote 31, 32).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Factors that affect life behaviour modification/maintenance\u003c/h2\u003e \u003cp\u003eAlthough not all FDRs expressed support for the role of healthy lifestyles in CRC prevention, they showed varying interest and reported facilitators and barriers that influenced them to modify/maintain their lifestyle behaviours (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 \u0026ldquo;There are old and young at home\u0026rdquo;\u0026mdash;family duty leads to health-nurturing practices\u003c/h2\u003e \u003cp\u003ePositive health consciousness inspired by family duty was a core motivating factor for behaviour change among those individuals who were interested in a healthy lifestyle. Their strong sense of family duty drove them to focus on themselves. A relaxed work and life provided external support for maintaining good habits or hobbies in their daily lives.\u003c/p\u003e \u003cp\u003eHealth consciousness enhances the priority given to self-care\u003c/p\u003e \u003cp\u003eMost FDRs reported a sense of health urgency caused by ageing. With ageing, they were forced to pay more attention to their health due to a sense of overwhelming physical decline. On the other hand, the discomfort caused by poor behaviours was beyond their tolerance and led them to change their behaviour. A few younger participants without similar experiences, also expressed that they would be more cautious of their health at some age (quote 33). They together shared the belief that \u0026ldquo;\u003cem\u003eI would raise the people who raised me and raised the people I would raise\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eI would not burden my parents or children\u003c/em\u003e\u0026rdquo; (quote 34)\u003c/p\u003e \u003cp\u003eAdditionally, the experience of caring for a close relative or friend who had CRC provided strong persuasive information for participants to develop a belief in healthy lifestyles to prevent CRC (quote 35). Meanwhile, health issues caused by poor behaviours drew their attention to lifestyle (quote 36). The Abovementioned experiences provided a strong motivation for FDRs to alter their behaviour to maintain health.\u003c/p\u003e \u003cp\u003eExternal support from a relaxed work/life\u003c/p\u003e \u003cp\u003eWithout financial pressure and working relaxation provided individuals with more energy to care for themselves and enjoy life based on the excellent performance of family duties. Additionally, a few reported that without time and space limitations from work, daily life provided them with more space for their healthy habits (quote 37, 38).\u003c/p\u003e \u003cp\u003eFurthermore, a healthy environment in life or at work may also positively orient their behaviour towards health (quote 39).\u003c/p\u003e \u003cp\u003eGood lifestyle preferences/habits promote healthy behaviours\u003c/p\u003e \u003cp\u003eTo take better care of their families, a few individuals actively displayed their self-efficacy to achieve a healthy lifestyle by creating opportunities such as actively setting exercise goals, constantly exploring fun and safe ways to exercise, and always cooking their meals. The sense of pleasure and fulfilment that came with reaching a goal also motivated them to adhere to healthy behaviours over time (quote 40).\u003c/p\u003e \u003cp\u003eFurthermore, some individuals had developed good hobbies, such as having pets to increase physical activity and using tea or fruit as an alternative to smoking and drinking (quote 41).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 \u0026ldquo;There are old and young at home\u0026rdquo; \u0026mdash;\u0026mdash;Exhausted by family duties\u003c/h2\u003e \u003cp\u003eA strong sense of family duty was a double-edged sword. On the one hand, it motivated some individuals to keep fit, while on the other hand, it consumed the energy of others who were too busy to take care of their health. The low health consciousness they generally had made them seldom consider the health benefits of some behaviours or wonder about the need to modify poor behaviours. Other complex factors were also linked to this low health consciousness.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The feeling of being overwhelmed\u0026rdquo; \u0026mdash;\u0026mdash; Pressures brought by work/life\u003c/p\u003e \u003cp\u003eThe mental pressure of the double task of taking care of the family and earning money made some participants feel \u0026ldquo;\u003cem\u003ecornered\u003c/em\u003e\u0026rdquo; (N-16). This hard life consumed almost all of their energy and they generally said they \u0026ldquo;\u003cem\u003edidn\u0026rsquo;t have the time\u003c/em\u003e\u0026rdquo; to consider whether their lifestyle was healthy (quote 42, 43).\u003c/p\u003e \u003cp\u003eWork or life, limitations including intense work, long hours, poor infrastructure in rural areas, lack of without available resources, and the prevalence of tobacco and alcohol in the culture, greatly weaken their desire to change behaviour (quote 44, 45).\u003c/p\u003e \u003cp\u003e\u0026ldquo;I can\u0026rsquo;t get cancer\u0026rdquo;\u0026mdash;\u0026mdash;healthy fit weakened awareness of prevention\u003c/p\u003e \u003cp\u003eThose who were young and had never experienced health problems had broad \u0026ldquo;\u003cem\u003eflukes minds\u003c/em\u003e\u0026rdquo; and believed that \u0026ldquo;\u003cem\u003epeople got sick at a certain age\u003c/em\u003e\u0026rdquo; (N-6). Consequently, they believed that they were not yet at the stage of worrying about their health and that their priority at present was to earn money to support their families, thus ignoring the importance of prevention.\u003c/p\u003e \u003cp\u003eAlthough the exposure to disease in the immediate CRC family and their history of bowel disease raised some concerns about their own risk, the negative results of medical examinations convinced participants that they did not need to worry about their health. The negative result also served as a health certificate for the abovementioned individuals who held flukes (quote 46, 47).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCancer cannot be prevented everywhere\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants considered that the factors that contributed to CRC were complex and varied which could not be prevented anytime and anywhere. Adding to the limitations of the work or life environment, they totally agreed that cancer was not preventable (quote 48).\u003c/p\u003e \u003cp\u003eFurthermore, fatalistic individuals believed that \u0026ldquo;\u003cem\u003eall people eat grains and \u0026ldquo;it was normal to get sick\u003c/em\u003e\u0026rdquo;. An individual couldn\u0026rsquo;t change destined things through acquired actions (quote 49).\u003c/p\u003e \u003cp\u003eAddictive pastimes/preferences hamper behaviour change\u003c/p\u003e \u003cp\u003eThose who viewed smoking and drinking as hobbies described that these unhealthy behaviours made them relaxed and happy, and argued that \u0026ldquo;\u003cem\u003ehumans were not perfect\u003c/em\u003e\u0026rdquo; (quote 50). They interpreted bad behaviours as part of their imperfect character.\u003c/p\u003e \u003cp\u003eParticipants who were addicted to smoking and drinking reported that the annoyance and pain caused by changing their behaviour forced them to give up halfway through. Under the great pressure of work or life, they may also choose to smoke and drink as a pastime to numb themselves and escape from reality (quote 51). Changing long-established habits was also considered to be extremely difficult (quote 52).\u003c/p\u003e \u003cp\u003eThose who described preferences related to gender commonly believed that men always smoked and drank alcohol but women preferred fruit and vegetables (quote 53).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study focuses on the perceptions and attitudes of the FDRs of CRC patients towards healthy lifestyles to prevent CRC and the factors contributing to maintaining a healthy lifestyle. The findings suggest that FDRs generally lack knowledge of CRC, especially in terms of prevention. This is also reflected in their diverse attitudes towards healthy lifestyles. A strong sense of family duty has a two-way direction on their behavioural change.\u003c/p\u003e \u003cp\u003eSubjective perception and agreement are the foundation for all life behavioural changes. Although the rapidly developing internet technology has greatly accelerated the spread of health information, we found that there is still a significant knowledge gap among the FDRs of CRC patients about CRC and its lifestyle factors, which have serious impacts on their attitude towards CRC prevention. The reasons revealed in this study echo other studies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. They reported that 1) it was difficult to motivate individuals to pay attention to health promotion if it overlooked individual differences, and 2) participants seriously questioned the authority and validity of online promotion. Enhancing awareness of FDRs by addressing the vagueness and difficulty of distinguishing between true and false health information should be placed as a public health policy priority [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A fundamental step to address the above issues is safeguarding the identity of the publisher and the authority and specificity of health information.\u003c/p\u003e \u003cp\u003eThe extent of personal knowledge determines the direction and degree of behavioural change [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This finding is in line with previous a study[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] that disease knowledge is associated with a family history of CRC and/or indirect cancer experience. The indirect experience of relatives with CRC and their bowel problems in this study provided an excellent opportunity to increase FDRs\u0026rsquo; knowledge and stimulate behaviour modification. Encouraging CRC survivors to act as prevention advocates by properly disclosing the risk of the disease to their relatives and sharing the importance of a healthy lifestyle [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] will not only help FDRs accurately assess their CRC risk and improve their compliance and success with behavioural change but also provide a direction for resolving the current conflict between standardised health care and personalised care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants have developed a healthy lifestyle based on the characteristics of Chinese medicine culture. On the one hand, this comes from a review of their personal and CRC relatives\u0026rsquo; life experiences, and on the other hand, it is closely related to their exposure to social culture, especially the influence of the culture of Chinese medicine. Chinese medicine emphasises that \u0026ldquo;all illnesses are born from Qi\u0026rdquo;, which includes stability and a positive attitude towards everything in daily life[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This is also supported by other epidemiological studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] which indicate that emotionally unstable people have a higher risk of death. Although participants\u0026rsquo; perceptions of healthy lifestyles have Chinese characteristics, they are the same as those recommended by international guidelines [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] For example, the guidelines recommend a healthy diet based on adequate quantity and variety every day. This is in line with the Chinese philosophy of Huangdi\u0026rsquo;s Canon of Medicine, which states that \u0026ldquo;the five grains are nourishing, the five fruits are helpful, the five types of meat from animals are beneficial, and the five vegetables are enriching\u0026rdquo;. It identifies the intake of protein, carbohydrates, various minerals, and other ingredients from grains, fruits, meats, and vegetables to achieve a healthy and moderate diet. Understanding the reasons for participants\u0026rsquo; lifestyle behaviours in the context of their social backgrounds and providing knowledgeable guidance from the cultural perspective they have inherited is more likely to be successful in raising awareness and changing unhealthy behaviours.\u003c/p\u003e \u003cp\u003eFamily duty affects FDR\u0026rsquo;s lifestyle changes in both positive and negative ways. Considering their family duties, those who hold the idea that \u0026ldquo;good health is over wealth\u0026rdquo; reported that taking care of their health is responsible for themselves and their family. Consequently, they usually show good health awareness and are motivated to use their subjective efficacy to change poor lifestyle behaviours. Conversely, strong family duties also lead individuals to work hard to create good material conditions but they pay little attention to their health. No history of disease and negative test results further undermine their awareness of prevention. Future intervention recruitment or health education could build on the participants\u0026rsquo; sense of family duty to increase involvement and adherence.\u003c/p\u003e \u003cp\u003eThe maintenance of a healthy lifestyle requires material support, and one of the reasons for the different impacts of family duties on participants\u0026rsquo; behaviour, as the abovementioned, is their different economic abilities. Similar to the findings of other studies, this research shows that individuals with better financial conditions are usually less stressed at work and in life. Higher economic status and sufficient energy provide dual support for achieving a healthy lifestyle. Conversely, limited material support and the pressure of family duties interact with each other in a vicious process that affects participants\u0026rsquo; attitudes towards a healthy lifestyle and behavioural changes. This is also supported by other studies with different populations [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Therefore, when implementing education about healthy lifestyles or lifestyle interventions, considering an individual\u0026rsquo;s material status may be key to successful delivery.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eThe following shortcomings in this study cannot be ignored. First, selection bias was introduced during purposive sampling. We preferred individuals who were interested in this study; those who declined to participate may present a completely different perspective. Second, the participants were also taking on the role of caregivers when interviewed, and their varying emotions caused by the severity of the CRC patients\u0026rsquo; illness may have influenced their perceptions of the topic. Third, despite having been fully identified before the interview and assured that there was no connection to their CRC relative, some interviewees were concerned about affecting their relative\u0026rsquo;s treatment and may have expressed what they perceived to be a positive view, contradicting their true feelings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Conclusion\u003c/h2\u003e \u003cp\u003eAs a result of limited knowledge of CRC, FDRs are unlikely to emphasise preventing CRC through healthy lifestyles. Influenced by the culture of Chinese medicine and life experience, participants have gradually developed a perception of healthy lifestyles with Chinese characteristics. Participants\u0026rsquo; ability to maintain healthy lifestyles was greatly influenced by family duty-related factors. Social culture and family duty-related factors should be taken into consideration when undertaking health interventions or education programs on lifestyles for first-degree relatives of CRC.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: [Wenxia Wang], [Shuyan Fang], [Shuang Zhang], [Dongfei Ma], [Xiangfei Meng], [Sun Jiao], Methodology: [Meng He], [Xiangning Zhu], [Yueyang Dong], [Yanjie Zhao], [Wenxia Wang], Formal analysis and investigation: [Wenxia Wang], [Shuyan Fang], [Shuang Zhang], Writing - original draft preparation: [Wenxia Wang], [Shuyan Fang] , [Sun Jiao], Writing - review and editing: [Wenxia Wang], , [Sun Jiao], Resources: [Shizheng Gao], [Shengze Zhi], [Juanjuan Sun], [Dongpo Song], Supervision: [Dongfei Ma], [Xiangfei Meng], [Sun Jiao].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the School of Nursing, Jilin University (No: 2021112401). After carefully reading the information regarding the study\u0026rsquo;s purpose and context and assuring that their answers and identity would remain anonymous, each participant signed the informed consent form. The researcher explained to the participants that their involvement would have any impact on the care provided to their CRC relatives and made it obvious that they could quit the study at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors affirm that human research participants provided informed consent for publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. \u003cem\u003eCA Cancer J Clin\u003c/em\u003e. May 2021,71(3):209-249. doi:10.3322/caac.21660\u003c/li\u003e\n\u003cli\u003eMehraban Far P, Alshahrani A, Yaghoobi M. Quantitative risk of positive family history in developing colorectal cancer: A meta-analysis. \u003cem\u003eWorld journal of gastroenterology\u003c/em\u003e. Aug 14 2019,25(30):4278-4291. doi:10.3748/wjg.v25.i30.4278\u003c/li\u003e\n\u003cli\u003eRoos VH, Mangas-Sanjuan C, Rodriguez-Girondo M, et al. Effects of Family History on Relative and Absolute Risks for Colorectal Cancer: A Systematic Review and Meta-Analysis. \u003cem\u003eClinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association\u003c/em\u003e. Dec 2019,17(13):2657-2667.e9. doi:10.1016/j.cgh.2019.09.007\u003c/li\u003e\n\u003cli\u003eWang K, Ma W, Wu K, et al. Healthy lifestyle, endoscopic screening, and colorectal cancer incidence and mortality in the United States: A nationwide cohort study. \u003cem\u003ePLoS Med\u003c/em\u003e. Feb 2021,18(2):e1003522. doi:10.1371/journal.pmed.1003522\u003c/li\u003e\n\u003cli\u003eWu Y, Li Y, Giovannucci E. Potential Impact of Time Trend of Lifestyle Risk Factors on Burden of Major Gastrointestinal Cancers in China. \u003cem\u003eGastroenterology\u003c/em\u003e. Dec 2021,161(6):1830-1841.e8. doi:10.1053/j.gastro.2021.08.006\u003c/li\u003e\n\u003cli\u003eKnudsen MD, Wang L, Wang K, et al. Changes in Lifestyle Factors After Endoscopic Screening: A Prospective Study in the United States. \u003cem\u003eClinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association\u003c/em\u003e. Jun 2022,20(6):e1240-e1249. doi:10.1016/j.cgh.2021.07.014\u003c/li\u003e\n\u003cli\u003eClinton SK, Giovannucci EL, Hursting SD. The World Cancer Research Fund/American Institute for Cancer Research Third Expert Report on Diet, Nutrition, Physical Activity, and Cancer: Impact and Future Directions. \u003cem\u003eJ Nutr\u003c/em\u003e. Apr 1 2020,150(4):663-671. doi:10.1093/jn/nxz268\u003c/li\u003e\n\u003cli\u003eRock CL, Thomson C, Gansler T, et al. American Cancer Society guideline for diet and physical activity for cancer prevention. \u003cem\u003eCA Cancer J Clin\u003c/em\u003e. Jul 2020,70(4):245-271. doi:10.3322/caac.21591\u003c/li\u003e\n\u003cli\u003eLee KW, Kim HB, Lee SH, Ha HK. Changes in Weight and Health-Related Behavior Using Smartphone Applications in Patients With Colorectal Polyps. \u003cem\u003eJournal of nutrition education and behavior\u003c/em\u003e. May 2019,51(5):539-546. doi:10.1016/j.jneb.2019.02.002\u003c/li\u003e\n\u003cli\u003eVrieling A, Visser A, Hoedjes M, et al. Increasing awareness and knowledge of lifestyle recommendations for cancer prevention in Lynch syndrome carriers: Randomized controlled trial. \u003cem\u003eClinical genetics\u003c/em\u003e. Jan 2018,93(1):67-77. doi:10.1111/cge.13076\u003c/li\u003e\n\u003cli\u003eHatami T, Noroozi A, Tahmasebi R, Rahbar A. Effect of Multimedia Education on Nutritional Behaviour for Colorectal Cancer Prevention: An Application of Health Belief Model. \u003cem\u003eMalays J Med Sci\u003c/em\u003e. Nov 2018,25(6):110-120. doi:10.21315/mjms2018.25.6.11\u003c/li\u003e\n\u003cli\u003eFisher A, Craigie AM, Macleod M, Steele RJC, Anderson AS. The impact of social deprivation on the response to a randomised controlled trial of a weight management intervention (BeWEL) for people at increased risk of colorectal cancer. \u003cem\u003eJournal of human nutrition and dietetics : the official journal of the British Dietetic Association\u003c/em\u003e. Jun 2018,31(3):306-313. doi:10.1111/jhn.12524\u003c/li\u003e\n\u003cli\u003eDowswell G, Ryan A, Taylor A, et al. Designing an intervention to help people with colorectal adenomas reduce their intake of red and processed meat and increase their levels of physical activity: a qualitative study. \u003cem\u003eBMC cancer\u003c/em\u003e. Jun 18 2012,12:255. doi:10.1186/1471-2407-12-255\u003c/li\u003e\n\u003cli\u003eStead M, Caswell S, Craigie AM, Eadie D, Anderson AS. Understanding the potential and challenges of adenoma treatment as a prevention opportunity: insights from the BeWEL formative study. \u003cem\u003ePreventive medicine\u003c/em\u003e. Jan 2012,54(1):97-103. doi:10.1016/j.ypmed.2011.10.017\u003c/li\u003e\n\u003cli\u003ePrichard I, Lee A, Hutchinson AD, Wilson C. Familial risk for lifestyle-related chronic diseases: can family health history be used as a motivational tool to promote health behaviour in young adults? \u003cem\u003eHealth promotion journal of Australia : official journal of Australian Association of Health Promotion Professionals\u003c/em\u003e. Aug 2015,26(2):122-128. doi:10.1071/he14104\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. \u003cem\u003eNurse Educ Today\u003c/em\u003e. Feb 2004,24(2):105-12. doi:10.1016/j.nedt.2003.10.001\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. \u003cem\u003eQualitative Research in Psychology\u003c/em\u003e. 2006/01/01 2006,3(2):77-101. doi:10.1191/1478088706qp063oa\u003c/li\u003e\n\u003cli\u003eKocaballi AB, Berkovsky S, Quiroz JC, et al. The Personalization of Conversational Agents in Health Care: Systematic Review. \u003cem\u003eJ Med Internet Res\u003c/em\u003e. Nov 7 2019,21(11):e15360. doi:10.2196/15360\u003c/li\u003e\n\u003cli\u003eMannion R, Exworthy M. (Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare. \u003cem\u003eInt J Health Policy Manag\u003c/em\u003e. Jun 1 2017,6(6):301-304. doi:10.15171/ijhpm.2017.35\u003c/li\u003e\n\u003cli\u003eVraga EK. Expert organizations can be effective in correcting health misinformation on social media. Accessed 10/26/17, blogs.lse.ac.uk/usappblog/2017/10/26/expert-organizations-can-be-effective-in-correctinghealth-misinformation-on-social-media/\u003c/li\u003e\n\u003cli\u003eDijk SW, Duijzer EJ, Wienold M. Role of active patient involvement in undergraduate medical education: a systematic review. \u003cem\u003eBMJ Open\u003c/em\u003e. Jul 27 2020,10(7):e037217. doi:10.1136/bmjopen-2020-037217\u003c/li\u003e\n\u003cli\u003eYang LM. [Medico-psychology in Huang di nei jing (Yellow Emperor\u0026apos;s Inner Canon)]. \u003cem\u003eZhonghua Yi Shi Za Zhi\u003c/em\u003e. Jan 2004,34(1):21-6.\u003c/li\u003e\n\u003cli\u003eSteca P, D\u0026apos;Addario M, Magrin ME, et al. A Type A and Type D Combined Personality Typology in Essential Hypertension and Acute Coronary Syndrome Patients: Associations with Demographic, Psychological, Clinical, and Lifestyle Indicators. \u003cem\u003ePloS one\u003c/em\u003e. 2016,11(9):e0161840. doi:10.1371/journal.pone.0161840\u003c/li\u003e\n\u003cli\u003eFickley CE, Lloyd CE, Costacou T, Miller RG, Orchard TJ. Type A behavior and risk of all-cause mortality, CAD, and CAD-related mortality in a type 1 diabetic population: 22 years of follow-up in the Pittsburgh Epidemiology of Diabetes Complications Study. \u003cem\u003eDiabetes Care\u003c/em\u003e. Oct 2013,36(10):2974-80. doi:10.2337/dc13-0266\u003c/li\u003e\n\u003cli\u003eGragnano A, Simbula S, Miglioretti M. Work-Life Balance: Weighing the Importance of Work-Family and Work-Health Balance. \u003cem\u003eInternational journal of environmental research and public health\u003c/em\u003e. Feb 1 2020,17(3)doi:10.3390/ijerph17030907\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Colorectal Neoplasms, First-degree relatives, Lifestyle, Primary prevention, Nursing","lastPublishedDoi":"10.21203/rs.3.rs-2544870/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2544870/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCompelling data indicate that adherence to healthy lifestyles can potentially prevent 20\u0026ndash;70% of colorectal cancer (CRC) cases and deaths. As a major population in the development of CRC, the lifestyle behaviour of first-degree relatives (FDRs) of CRC patients is attracting more attention.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo understand the knowledge of first-degree relatives (FDRs) about colorectal cancer (CRC) and healthy lifestyles and explore their perceptions of and motivations for healthy lifestyles for CRC prevention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive study using inductive thematic analysis was performed. Sixteen FDRs of CRC patients were recruited using purposive sampling. Face-to-face semi-structured interviews were conducted to gain insight into FDRs\u0026rsquo; perceptions and motivations regarding healthy lifestyles for CRC prevention.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eLimited knowledge of CRC makes FDRs less likely to emphasise the prevention of CRC through a healthy lifestyle. Influenced by the culture of Chinese medicine and life experience, the participants gradually developed a perception of healthy lifestyles with Chinese characteristics. The participants\u0026rsquo; ability to maintain a healthy lifestyle was greatly influenced by family duty-related factors.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSocial culture and family duty-related factors should be taken into consideration when undertaking health interventions or education programmes on healthy lifestyles for FDRs of CRC patients. Encouraging nurses to act as liaisons between the government, hospitals, and the community and providing them with professional and communication skills to enhance their skills has great potential for nurses to deliver health education and management for communities at risk of CRC.\u003c/p\u003e","manuscriptTitle":"Perceptions and motivations for healthy lifestyles among first-degree relatives of colorectal cancer patients: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-02-06 14:53:02","doi":"10.21203/rs.3.rs-2544870/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4fb69f8f-3878-4a2f-807b-50985d0bf7bc","owner":[],"postedDate":"February 6th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-02-09T06:44:31+00:00","versionOfRecord":[],"versionCreatedAt":"2023-02-06 14:53:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2544870","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2544870","identity":"rs-2544870","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}