Drivers of Colorectal Cancer Screening in the Gaza Strip, Palestine Territory: A Qualitative Study

Drivers of Colorectal Cancer Screening in the Gaza Strip, Palestine Territory: 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 Drivers of Colorectal Cancer Screening in the Gaza Strip, Palestine Territory: A Qualitative Study Abdelrazeq Beram, Md Mizanur Rahman, Yoke Yong Chen, Asri bin Said, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9142249/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Colorectal cancer (CRC) is a growing public health concern in the Gaza Strip, where late-stage diagnosis and low screening rates contribute to preventable mortality. Cultural, logistical, and systemic barriers complicate screening uptake, necessitating a deeper understanding of multi-level drivers to inform targeted interventions. We aimed to explore multi-level drivers and facilitators influencing CRC screening uptake in Gaza through a qualitative analysis of perspectives from patients, families, community leaders, healthcare providers, and policy-makers, identifying actionable themes and subthemes. Methods: We conducted a multi-level qualitative research design. Data were collected through a series of focus group discussions. Participants included patients, family members, community representatives, healthcare providers, and policy-makers in the Gaza Strip. Thematic analysis was done by identifying and categorising drivers of major themes and corresponding subthemes. Results Our analysis identified several multi-level drivers of CRC screening in Gaza. Cultural alignment (We are Muslims… no myths), financial incentives, and clinician guidance motivated participation at the individual level. Families fostered support through encouragement ( no hindering traditions ) and media /workshops. Communities leveraged religious leaders ( mosques spread health messages ), peer testimonials, and media campaigns. Organisations promoted screening via paid leave, telemedicine, and NGO partnerships ( 60% uptake via mobile units ). Policy-makers prioritised affordability, awareness campaigns ( national policies influence decisions ), and legislative mandates. Systemic integration of culturally aligned strategies, trusted networks (families, leaders), and education across levels emerged as pivotal to enhancing CRC screening uptake and reducing mortality. Conclusion The success of CRC screening is attributed to aligning interventions with cultural values, leveraging trusted networks, and systemic integration. A coordinated approach across individual, familial, community, organisational, and policy levels is critical to enhancing CRC screening uptake and reducing mortality. Colorectal Cancer Screening Multi-level Drivers Qualitative Study Socio-cultural Factors Gaza Strip Figures Figure 1 Introduction Colorectal cancer (CRC) ranks as one of the most prevalent cancers worldwide, being the third most commonly diagnosed cancer and the second leading cause of cancer-related deaths, according to global statistics from 2020, which estimated 1.93 million new cases and approximately 935,000 deaths attributable to CRC [ 1 ]. The rising incidence of colorectal cancer has been associated with various risk factors, including dietary habits, age, and genetic predispositions [ 2 – 4 ]. In developed countries, aggressive screening programs have resulted in improved early detection rates and survival outcomes; for instance, early-stage detection can lead to a five-year survival rate of around 90% [ 5 , 6 ]. However, screening rates remain suboptimal globally, particularly in low- and middle-income countries such as Palestine, where cultural, logistical, and systemic barriers hinder uptake [ 7 ]. A systematic review highlighted that adherence to CRC screening is critically influenced by health education, access to healthcare services, and community support mechanisms [ 8 ]. In conflict-affected areas, multiple drivers significantly influence cancer screening behaviours, with particular emphasis on healthcare accessibility, cultural beliefs, and emotional barriers. Economic hardships and deteriorating healthcare infrastructure often limit individuals’ access to screening services, thus heightening the urgency for targeted educational interventions [ 9 , 10 ]. Family support, community endorsements, and recommendations from healthcare providers serve as key motivators for individuals hesitant to seek screening due to cultural stigma or fear of diagnosis [ 11 , 12 ]. Additionally, the role of media campaigns and community initiatives in increasing awareness and addressing misconceptions about cancer and its treatment is crucial for promoting screening uptake [ 13 , 14 ]. Understanding these motives within the context of conflict can inform comprehensive strategies to improve health outcomes through enhanced screening practices. The framework of this study centres around a qualitative approach that captures the multi-level influences on colorectal cancer screening in the Gaza Strip, Palestine, given the region’s unique challenges, including systemic barriers to healthcare access, cultural beliefs surrounding illness, and the psychological impacts of prolonged conflict. This study is positioned to explore how these elements interact to affect cancer screening behaviours [ 9 – 11 ]. By engaging diverse stakeholders, including patients, healthcare providers, and community leaders, the study seeks to identify actionable themes and subthemes that can inform tailored interventions. Therefore, this study aims to explore the multi-level drivers and facilitators influencing colorectal cancer screening uptake in the Gaza Strip, providing insights that could inform targeted health interventions and improve screening rates in similar settings. Methods Study design This study employs a qualitative, multi-level exploratory design to investigate the drivers of colorectal cancer screening in the Gaza Strip, Palestine. The social-ecological model (SEM) uniquely suits this multi-level qualitative study as it aligns with the complex interplay of factors influencing colorectal cancer (CRC) screening in Gaza. SEM examines health behaviours through nested systems—individual, interpersonal, organisational, community, and policy levels—recognising that CRC screening is shaped by cultural norms, familial dynamics, community resources, institutional policies, and legislative frameworks [ 15 , 16 ]. Participant selection and sampling A purposive sampling strategy guided the selection of participants for this qualitative This study used purposive sampling to recruit diverse participants (varying in age, gender, education, and occupation) across Gaza’s regions, ensuring representation of those with direct CRC screening experiences. The approach enriched data by capturing cultural, logistical, and systemic drivers through varied perspectives. Targeting individuals, families, community leaders, healthcare providers, and policy-makers, the strategy prioritised depth and context-specific insights. This method enabled a nuanced understanding of regional disparities, informing equitable strategies to improve CRC screening in Gaza’s conflict-affected setting. Inclusion criteria Participants in this study included: Individuals aged 18 years and above, the target demographic for CRC screening. Family members with experience in health-related decision-making or influencing community health perceptions. Individuals directly impacting healthcare delivery, such as administrators, or involved in policy formulation, such as legislators, for cancer screening. Exclusion criteria Participants were excluded if they did not meet the individual level’s age criteria. Participants lacking relevant experience or roles at the family, community, organisation, or policy levels were excluded. Individuals unable to participate in interviews due to health issues or other constraints were excluded. Data collection Data were collected through nine focus group discussions (FGDs), with two FGDs each at the individual, family, community, and organisational levels, and one FGD at the policy level. Each session included 5–7 participants, ensuring diverse representation while maintaining interactive dialogue. FGDs were chosen to facilitate dynamic exchanges, allowing participants to build on shared experiences and uncover nuanced socio-cultural, familial, and systemic drivers of colorectal cancer (CRC) screening. This method is particularly suited to Gaza’s collectivist culture, where group interactions often yield richer insights than individual interviews. By structuring FGDs across multi-level stakeholders, the study captured interwoven perspectives, revealing how cultural norms, familial roles, organisational policies, and legislative frameworks collectively shape screening behaviours. A semi-structured interview guide was developed specifically for this study, informed by the Social-Ecological Model and existing literature on colorectal cancer screening, and is provided as Supplementary File 1. Data analysis Thematic analysis followed a structured five-step process. First, audio responses were transcribed and translated from Arabic to English, with researchers verifying consistency between recordings and texts. Second, open and axial coding was conducted collaboratively, with codes assigned and validated by an independent researcher to ensure reliability. Third, AI-assisted theme generation was employed: codes were uploaded to ChatGPT, which grouped them into preliminary themes and subthemes, guided by researcher prompts [ 17 , 18 ]. Fourth, iterative refinement ensured themes’ precision, with ChatGPT consolidating codes into broader categories adjusted for contextual relevance[ 19 – 21 ]. Finally, themes and subthemes were finalised through researcher consensus, aligning with the study’s multi-level framework [ 22 , 23 ]. This hybrid approach balanced AI efficiency with human expertise, enhancing rigour and depth (Fig. 1). Trustworthiness Trustworthiness was ensured through systematic validation and adherence to qualitative rigour [ 24 , 25 ]. Credibility was achieved via triangulation: two researchers independently coded data, resolving discrepancies through discussion [ 26 , 27 ], while an external validator cross-checked codes. Dependability relied on meticulous documentation of steps, including verifying Arabic-to-English transcription accuracy [ 28 ] and transparent coding protocols. Confirmability involved iterative refinement of AI-generated themes (ChatGPT) with researcher oversight to align outputs with raw data, balancing technological efficiency with human interpretive depth [ 27 , 29 ]. Transferability was strengthened through thick descriptions of Gaza’s socio-political context, enabling applicability assessments in similar settings [ 24 , 30 ]. Final themes, consolidated through consensus, aligned with the social-ecological framework [ 27 ], reflecting the interplay of individual, familial, and policy-level drivers. This study innovatively merged AI-assisted analysis with traditional qualitative rigour, echoing calls to integrate emerging tools while upholding trustworthiness standards [ 31 ]. The research underscores the feasibility of maintaining rigour in complex, conflict-affected environments by prioritising methodological transparency, contextual richness, and collaborative validation. Figure 1 Schematic diagram of thematic analysis Ethical considerations In our qualitative study on cancer screening in the Gaza Strip, we prioritized ethical considerations to ensure all participants’ dignity, rights, and well-being. The research adhered to rigorous ethical standards, beginning with formal approval from the Research Ethics Committee of Universiti Malaysia Sarawak (Ethics Reference Number: FME/23/63), ensuring compliance with institutional review board guidelines. Informed consent was obtained from every participant, with detailed information in Arabic to address language barriers and guarantee true comprehension of the study’s purpose, procedures, risks, benefits, and data usage. Participation was entirely voluntary, and participants were informed of their right to withdraw at any time without repercussions. Identifying details were anonymized during transcription to safeguard privacy and confidentiality, and data were securely stored with restricted access. Interviews and focus groups were conducted in private settings to protect participants, particularly given the sensitive nature of discussions about cancer screening in a conflict-affected region. These measures were integral to building trust, maintaining research integrity, and upholding ethical responsibility throughout the study. Results Characteristics of the participants The study included 57 participants across five stakeholder groups (individuals, families, community members, organisations, policy-makers) in Gaza. Participants ranged in age from 45 to 85 years (mean = 59.2), with policy-makers being the oldest subgroup (mean = 60.2). Males dominated participation (77.2%), particularly in community (12/14) and policy (5/5) groups. Education levels varied: 35.1% held bachelor’s degrees, while 15.8% had PhDs. Policy-makers were exclusively highly educated (4 physicians, 1 PhD), whereas individuals included participants with no formal schooling (7%). Geographically, participants represented all Gaza regions, with Gaza City having the highest representation (28.1%). Occupations ranged from retirees (15.8%) and housewives (7%) to administrators (17.5%) and community leaders (22.8%). This diversity ensured multi-sectoral perspectives, blending grassroots experiences (e.g., housewives) with institutional expertise (e.g., policy-makers, administrators) (Table 1 ). Table 1 Characteristics of the FGDs participants Characteristics Individual (n = 14) Family (n = 14) Community (n = 14) Organisation (n = 10) Policy (n = 5) Total (N = 57) % Age in years Min, Max 63.0(10.5) 50, 85 60.4(7.3) 50, 72 57.6(8.3) 45, 70 53.8(3.4) 50, 59) 60.2(6.6) 50, 67 59.2(8.3) 45, 85 Gender Male 10 10 12 7 5 44 77.2 Female 4 4 2 3 0 13 22.8 Education No schooling 3 1 0 0 0 4 7.0 High school 3 2 0 0 0 5 8.8 Diploma 0 2 1 0 0 3 5.3 Bachelor 6 7 3 4 0 20 35.1 Master 2 2 1 4 0 9 15.8 Physician 0 0 3 0 4 7 12.3 PhD 0 0 6 2 1 9 15.8 Residence Dier Al Balah 4 3 3 2 1 13 22.8 Gaza 4 4 4 2 2 16 28.1 Khan Yunis 2 3 2 2 0 9 15.8 North Gaza 2 2 3 2 1 10 17.5 Rafah 2 2 2 2 1 9 15.8 Occupation Employee 8 0 0 0 0 8 14.0 Housewife 3 1 0 0 0 4 7.0 Retired 3 6 0 0 0 9 15.8 Community activist 0 1 1 0 0 2 3.5 Lawyer, religious leader 0 3 0 0 0 3 5.3 Retired employee 0 3 0 0 0 3 5.3 Community leaders and members 0 0 13 0 0 13 22.8 Administrator 0 0 0 10 0 10 17.5 Directors and higher officials 0 0 0 0 5 5 8.8 Drivers of Colorectal Cancer Screening The drivers of colorectal cancer (CRC) screening in Gaza reflect a multi-level framework. At the individual level, cultural norms (e.g., absence of stigma) and motivators like financial incentives and clinician recommendations were critical. Families provided supportive environments through active encouragement and leveraged media/workshops to normalise screening. Community efforts highlighted the role of religious leaders and peer testimonials, while institutions like mosques and schools integrated health education. Organisations promoted screening via workplace policies (e.g., paid leave) and partnerships with NGOs. At the policy level, legislative mandates and affordability strategies were integral. Across all levels, systemic integration of culturally aligned interventions, trusted networks, and education emerged as pivotal drivers of screening uptake (Table 2 ). Table 2 Themes and subthemes of drivers of colorectal cancer screening Level Theme Subthemes Frequency Individual Level Cultural Context & Influences Absence of Negative Beliefs 1 Affirmation of Cultural/Religious Norms 1 Motivators for Screening Education & Early Detection 1 Financial Incentives 1 Awareness & Early Detection 1 Doctor/Clinic Recommendations 2 Positive Screening Experiences Success Stories of Early Detection 2 Family Level Absence of Barriers No Hindering Traditions 1 Diverse Views 1 Family Support Active Encouragement 5 Reassuring Communication 4 Awareness Strategies Media/Digital Outreach 7 Educational Workshops 7 Community Level Leadership & Policy Religious/Educational Advocacy 6 Media Campaigns 7 Resource Utilisation Mosque/School Integration 2 Peer Testimonials 7 Organisational Level Workplace Policies Paid Leave/Telemedicine 2 Stakeholder Commitment 1 Partnerships NGO/Insurer Collaborations 2 Mandatory Health Evaluations 1 Policy Level Awareness & Accessibility Public Awareness Campaigns 1 Affordability Policies 1 Legislative Action Early Detection Mandates 1 Findings of Thematic Analysis Individual level At the individual level , cultural and religious norms were foundational drivers, with participants affirming that CRC screening aligns with their values. “ We are Muslims and do not believe in myths regarding CRC screening” (Ahmed Ryan, 61M) , reflecting the absence of negative beliefs and affirmation of cultural/religious norms . One participant noted that education and financial incentives further motivated participation: “ A small financial return could motivate screening” (Jameil, 63M) . Clinician recommendations and awareness campaigns emphasised early detection’s benefits, such as “ the importance of early detection of cancer” (Abeer, 58F). Positive experiences , including success stories like “ many positive stories where early detection cured the disease” (Aymen, 51M) , reinforced trust in screening. Collectively, cultural alignment, practical motivators, and first-hand success narratives emerged as critical drivers of individual engagement. Family level Supportive dynamics and proactive communication emerged as key facilitators at the family level . The absence of barriers was evident, with participants noting “ no family values or traditions hinder CRC screening” (Sami Abu Ajwa, 56M) and acknowledging diverse views “ Families have different opinions depending on culture” – Talha Baloush, 51M) . Active encouragement played a pivotal role, as families motivated members through support, especially with cancer histories: “ Families support screening, particularly if there’s a family history” (Hamdan Alhour, 65M) . Reassuring communication alleviated fears, such as explaining “ the benefits of screening and early detection” (Sameia Almjaida, 60F) . Awareness strategies thrived through media/digital outreach , like “ hashtags reaching all residents” (Adel, 55M) and educational workshops , where families learned that “ screening is routine preventive care” (Fadwa Al-Najjar, 71F) . Open dialogue, encouragement, and targeted education within families collectively normalised CRC screening and fostered participation. Community level At the community level , leadership and resource mobilisation were central to promoting CRC screening. Religious and educational advocacy leveraged trusted platforms, as “ mosques and religious centres spread health messages through weekly sermons” (Raft, 66M) and schools integrated CRC education into curricula “teaching families about early detection” Tyiseir, 59M) . Media campaigns amplified awareness via culturally resonant strategies, such as “local media sharing real-life success stories” (Khetam, 52F) and social media hashtags reaching younger generations (Adel, 55M) . Peer testimonials normalised screening by humanising its benefits: “Survivors sharing experiences help reduce fear” (Khetam, 52F) . Institutions like mosques and schools served as hubs for education, bridging gaps in accessibility. The synergy of trusted leadership, innovative outreach, and survivor-led advocacy created a community-wide culture prioritising CRC screening. Organisational Level Workplace policies and strategic partnerships were instrumental in promoting CRC screening at the organisational level. One participant noted that paid leave and telemedicine reduced logistical barriers and that “flexible work policies and telemedicine consultations encourage employees to prioritise screenings” (Areej Safi, 51F). Stakeholder commitment ensured program viability, as “ management committed to implementing regulations and logistics” (Maher Nasman, 58M). Collaborations with NGOs and insurers expanded access, exemplified by “mobile units providing free colonoscopies increased screening rates by 60%” * (Rafat Almajdlawi, 54M). Mandatory health evaluations institutionalised screening, achieving “85% compliance via annual employee checks” (Mohammad Yaghi, 52M). These efforts combined policy innovation, resource allocation, and cross-sector partnerships to create a workplace culture prioritising preventive care. Policy-Level At the policy level , strategic initiatives focused on awareness, affordability, and legislation were critical to advancing CRC screening. Public awareness campaigns reshaped perceptions, as noted by: “National policies influence public decisions through widespread appeals, (Sobhi Skeik, 65M)” emphasising screening as a health priority. Affordability policies addressed financial barriers by advocating for “policies to ensure accessible and affordable screening (Samer Abu Zer, 50M)”. Legislative mandates institutionalised early detection, exemplified by “Legislative Early Detection Programs (Samer Abu Zer, 50M)” and call all for “integrating screening into healthcare systems (Yehia Abed, 67M)”. Together, these policies created a cohesive framework, ensuring systemic support and equitable access to CRC screening. Discussion Our analysis indicates that cultural and religious norms can positively influence attitudes toward colorectal cancer (CRC) screening, contrasting with findings documenting cultural taboos obstructing screening uptake in certain contexts [ 32 ]. Participants noted that framing CRC screening as aligned with Islamic health preservation values enhances acceptance and mitigates barriers such as fatalism and privacy concerns [ 33 ]. This highlights the potential of faith-sensitive interventions, such as involving religious leaders in awareness campaigns, a strategy supported by relevant literature [ 34 ]. Consequently, policy-makers are encouraged to prioritise collaborations with religious institutions to utilise cultural capital in normalising preventive care [ 33 ]. Our findings underscore that leadership and resource mobilisation at the community level are instrumental in promoting colorectal cancer (CRC) screening. Religious and educational advocacy, as evidenced by the use of mosques and schools to deliver health messages and integrate screening education, reflects strategies that have proven effective in faith-based community interventions [ 35 ]. Media campaigns employing culturally resonant approaches, including local storytelling and social media outreach, amplify awareness and promote screening uptake [ 36 ]. In addition, the involvement of families as catalysts in normalising CRC screening—by providing support and dispelling misconceptions—differs markedly from contexts where familial resistance has been identified as a barrier, thereby positioning familial cohesion as a robust model for preventive care [ 36 ]. The findings demonstrate that a grassroots approach is key to fostering community trust and enhancing colorectal cancer (CRC) screening uptake. Trusted community institutions, particularly mosques and schools, serve as effective platforms for disseminating health messages. Religious centres employing health promotion strategies can significantly bolster public health communication by leveraging established channels of community trust [ 37 ]. Concurrently, educational institutions can integrate CRC awareness into their curricula, reinforcing early detection practices and aligning health education with cultural values. Peer testimonials enhance this effect by humanising the screening process and mitigating fear. Vu et al. [ 38 ] pertain more generally to women’s health interventions and might not directly support claims about CRC screening. This approach contrasts with top-down methods, which often lack contextual sensitivity, aligning culturally tailored, agent-led interventions for health literacy promotion among Muslim communities [ 39 ]. Consequently, the synergy of trusted leadership, innovative outreach, and survivor-led advocacy creates a robust, community-driven framework for CRC screening. Organisational-level strategies to promote colorectal cancer (CRC) screening illustrate the synergistic benefits of workplace policies and strategic partnerships. NGO-driven mobile units providing free colonoscopies exemplify scalable interventions that can overcome infrastructural deficits in low-resource settings. However, the increase in screening rates does not directly support the broader principle of mobile units enhancing screening access, which is endorsed in community-based cancer prevention literature [ 40 ]. In parallel, flexible work policies—such as telemedicine consultations and paid leave—mitigate employee logistical barriers, enhancing participation in preventive health services [ 41 ]. Furthermore, workplace wellness programmes, which may include mandatory health evaluations, have demonstrated potential benefits in institutionalising preventive healthcare practices. The integration of these approaches underscores the importance of cross-sector collaborations that blend policy innovation, resource allocation, and community-based efforts to create a sustainable culture of preventive care [ 42 ]. The policy-level analysis reveals that strategic initiatives integrating affordability mandates, legislative mandates, and awareness campaigns can significantly advance colorectal cancer (CRC) screening. Affordability policies, which aim to reduce financial barriers by ensuring accessible and affordable screening, are essential in facilitating equitable uptake, as evidenced by frameworks addressing socioeconomic disparities in CRC outcomes [ 43 ]. Legislative actions that institutionalise early detection—through mandates and screening integration into healthcare systems forge durable policy support that underpins these initiatives [ 44 ]. Moreover, widespread public awareness campaigns reshape perceptions and elevate CRC screening as a health priority by mobilising national platforms to communicate public health messages effectively [ 44 ]. However, gaps persist in settings with limited infrastructure, such as Gaza, where systemic funding and integrated policy frameworks remain challenges. Successful case studies, such as those conducted in various healthcare institutions, demonstrate how robust policy support coupled with adequate infrastructure can drive high screening compliance and equitable access. Ultimately, the interplay among affordability measures, legislative action, and awareness strategies creates a multi-level synergy with cultural, familial, and community drivers reinforcing policy-level efforts essential for establishing a supportive ecosystem for preventive care in similar low-resource and conflict-affected settings. This study’s strengths lie in its multi-level qualitative design. It captures diverse perspectives from patients, families, community leaders, organisations, and policy-makers, a critical approach for understanding CRC screening drivers in Gaza’s complex socio-political context. Including culturally resonant themes (e.g., religious advocacy, family dynamics) enriched contextual insights, offering actionable strategies tailored to local realities. However, limitations must be acknowledged. The sample exhibited a gender imbalance, with males dominating participation (77.2%), particularly in community and policy groups, potentially skewing perspectives and overlooking gender-specific barriers faced by women. Selection bias may exist, as participants were recruited through institutional networks, possibly excluding marginalised voices. While the qualitative focus provided depth, it limits generalizability beyond Gaza’s unique setting. Nevertheless, these limitations are counterbalanced by the study’s granular exploration of multi-level drivers, which provides a foundation for context-specific interventions in similar conflict-affected regions. Conclusion The study highlights the critical role of multi-level drivers—cultural alignment, family support, community leadership, organisational policies, and legislative action—in enhancing CRC screening in Gaza. Integrating these culturally resonant strategies fosters a supportive ecosystem, which is crucial for improving screening uptake and reducing mortality. Prioritise faith-sensitive campaigns engaging religious leaders; expand family-centred education and community-led media outreach; implement workplace policies; advocate for affordable screening mandates. Future research should address gender disparities and validate scalable models in conflict-affected regions. Declarations Ethics approval and consent to participate: The study was approved by the Universiti Malaysia Sarawak (Ethics Reference Number: FME/23/63) and was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all adult participants and from caregivers of children or individuals unable to provide consent independently. Participation was voluntary, and confidentiality and anonymity were maintained throughout the study. Consent for publication: Not applicable. This manuscript does not contain any identifying images or other personal or clinical details of participants that compromise anonymity. Availability of data and materials: Datasets are available from the corresponding author upon reasonable request, in accordance with data transparency and ethical guidelines. Competing interests: The author declares no competing interest. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contributions: MR and AB led data curation, analysis, methodology, and visualisation. AB and SA managed investigation, project administration, and resources. MR supervised the study and drafted the manuscript. CY and AS contributed to validation, critical review, and editing. All authors conceptualised the study collaboratively and all authors approved the final version. Acknowledgements We sincerely thank all participants—patients, families, community leaders, healthcare workers, and policy-makers in Gaza—who generously shared their time and insights despite the demanding circumstances of conflict and resource constraints. Special thanks to healthcare administrators and management for their unwavering commitment to facilitating this research amid challenging conditions. We acknowledge Universiti Malaysia Sarawak (UNIMAS) for their academic support and ethical oversight. This study was conducted under the approval of the UNIMAS Ethics Committee (Reference Number: FME/23/63), whose guidance ensured the ethical integrity of this work. References Fan Y, Zhang X, Tong Y, Chen S, Liang J. 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Abu-El-Noor N, Aljeesh Y, Aliwaini S, Alhamss S, Darwish R, Abu-El‐Noor MK. Identifying Priorities and Needs to Improve Oncology Research in the Gaza Strip, Palestine. J Multidisciplinary Healthc. 2023;16:2529–41. Rohan EA, Boehm J, DeGroff A, Glover-Kudon R, Preissle J. Implementing the CDC's Colorectal Cancer Screening Demonstration Program: Wisdom From the Field. Cancer. 2013;119(S15):2870–83. Bamidele O, Ali N, Papadopoulos C, Randhawa G. Exploring Factors Contributing to Low Uptake of the NHS Breast Cancer Screening Programme Among Black African Women in the UK. Divers Equality Health Care. 2017;14(4):212–9. Kruse-Diehr AJ, Cegelka D, Combs C, Wood R, Holtsclaw E, Stapleton JL, Williams LB. Using the Consolidated Framework for Implementation Research to Identify Church Leaders’ Perspectives on Contextual Determinants of Community-Based Colorectal Cancer Screening for Black Kentuckians. Implement Sci Commun. 2024;5(1):83. Katz ML, Reiter PL, Fickle D, Heaner S, Sim C, Lehman A, Paskett ED. Community Involvement in the Development and Feedback About a Colorectal Cancer Screening Media Campaign in Ohio Appalachia. Health Promot Pract. 2010;12(4):589–99. Abu-Ras W, Aboul‐Enein BH, Almoayad F, Benajiba N, Dodge E. Mosques and Public Health Promotion: A Scoping Review of Faith-Driven Health Interventions. Health Educ Behav. 2024;51(5):677–90. Vu M, Muhammad H, Peek ME, Padela AI. Muslim Women’s Perspectives on Designing Mosque-Based Women’s Health Interventions—An Exploratory Qualitative Study. Women Health. 2017;58(3):334–46. Khalid A, Haque S, Alvi S, Ferdous M, Genereux O, Chowdhury N, Turin TC. Promoting Health Literacy About Cancer Screening Among Muslim Immigrants in Canada: Perspectives of Imams on the Role They Can Play in Community. J Prim Care Community Health 2022, 13. Jandorf L, Fatone A, Borker PV, Levin M, Esmond WA, Brenner B, Butts GC, Redd WH. 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Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 02 May, 2026 Reviewers agreed at journal 02 May, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviews received at journal 10 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor assigned by journal 02 Apr, 2026 Editor invited by journal 25 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 24 Mar, 2026 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9142249","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619100015,"identity":"ba91206c-8955-4166-b6c6-6a566b0b9026","order_by":0,"name":"Abdelrazeq Beram","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDACCQYGaYYKGzkDMM/AglgtZ9KMDRiYQVokiNTC2HIocQNYCwMRWvhnNx+8XdhwIH07e//RDT8KJBj427sT8Fty51iy9cwdd3J39hxmu9kDdJjEmbMb8FtzI8dMmvfMs9wNN5LZbvAAtRhI5OLXIn8j/5s0b9vhdAOglpt/iNFicCOHDaQlAaTlNlG2GN45Zmw940ya4YYzh81uyxhI8BD0i9zt5oe3Cyps5A2ONz67+eaPjRx/ey8B76MDHtKUj4JRMApGwSjACgBhpErzsVcnGAAAAABJRU5ErkJggg==","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":true,"prefix":"","firstName":"Abdelrazeq","middleName":"","lastName":"Beram","suffix":""},{"id":619100018,"identity":"33f3bfc1-dbdd-469e-91dd-598ad087ef26","order_by":1,"name":"Md Mizanur Rahman","email":"","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":false,"prefix":"","firstName":"Md","middleName":"Mizanur","lastName":"Rahman","suffix":""},{"id":619100020,"identity":"04d3b715-5ff3-4206-96a5-c6856b37291a","order_by":2,"name":"Yoke Yong Chen","email":"","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":false,"prefix":"","firstName":"Yoke","middleName":"Yong","lastName":"Chen","suffix":""},{"id":619100023,"identity":"66f8d99a-cbc0-4c24-a48a-04ab36754003","order_by":3,"name":"Asri bin Said","email":"","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":false,"prefix":"","firstName":"Asri","middleName":"bin","lastName":"Said","suffix":""},{"id":619100024,"identity":"58d2b272-b3cb-4c91-b8a1-d9674b810274","order_by":4,"name":"Samer Abuzerr","email":"","orcid":"","institution":"University College of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Samer","middleName":"","lastName":"Abuzerr","suffix":""}],"badges":[],"createdAt":"2026-03-16 23:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9142249/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9142249/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106725657,"identity":"012ffcd2-58e0-4836-be2c-64bd6fe061dc","added_by":"auto","created_at":"2026-04-12 18:33:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":256792,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of thematic analysis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9142249/v1/4f9482629097525a5b79f0bb.png"},{"id":106727127,"identity":"d90f1d4f-80e5-4aa1-812c-9408bda8a3ca","added_by":"auto","created_at":"2026-04-12 18:38:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1371152,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9142249/v1/03d38773-cc5f-4d14-b17f-2a8054000950.pdf"},{"id":106534804,"identity":"17ccbc46-4b67-4184-9892-40a6a8b31060","added_by":"auto","created_at":"2026-04-09 15:06:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19053,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9142249/v1/86a84227e1fdb33c2c4cc22b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Drivers of Colorectal Cancer Screening in the Gaza Strip, Palestine Territory: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer (CRC) ranks as one of the most prevalent cancers worldwide, being the third most commonly diagnosed cancer and the second leading cause of cancer-related deaths, according to global statistics from 2020, which estimated 1.93\u0026nbsp;million new cases and approximately 935,000 deaths attributable to CRC [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The rising incidence of colorectal cancer has been associated with various risk factors, including dietary habits, age, and genetic predispositions [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In developed countries, aggressive screening programs have resulted in improved early detection rates and survival outcomes; for instance, early-stage detection can lead to a five-year survival rate of around 90% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, screening rates remain suboptimal globally, particularly in low- and middle-income countries such as Palestine, where cultural, logistical, and systemic barriers hinder uptake [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A systematic review highlighted that adherence to CRC screening is critically influenced by health education, access to healthcare services, and community support mechanisms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn conflict-affected areas, multiple drivers significantly influence cancer screening behaviours, with particular emphasis on healthcare accessibility, cultural beliefs, and emotional barriers. Economic hardships and deteriorating healthcare infrastructure often limit individuals\u0026rsquo; access to screening services, thus heightening the urgency for targeted educational interventions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Family support, community endorsements, and recommendations from healthcare providers serve as key motivators for individuals hesitant to seek screening due to cultural stigma or fear of diagnosis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, the role of media campaigns and community initiatives in increasing awareness and addressing misconceptions about cancer and its treatment is crucial for promoting screening uptake [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Understanding these motives within the context of conflict can inform comprehensive strategies to improve health outcomes through enhanced screening practices.\u003c/p\u003e \u003cp\u003eThe framework of this study centres around a qualitative approach that captures the multi-level influences on colorectal cancer screening in the Gaza Strip, Palestine, given the region\u0026rsquo;s unique challenges, including systemic barriers to healthcare access, cultural beliefs surrounding illness, and the psychological impacts of prolonged conflict. This study is positioned to explore how these elements interact to affect cancer screening behaviours [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. By engaging diverse stakeholders, including patients, healthcare providers, and community leaders, the study seeks to identify actionable themes and subthemes that can inform tailored interventions. Therefore, this study aims to explore the multi-level drivers and facilitators influencing colorectal cancer screening uptake in the Gaza Strip, providing insights that could inform targeted health interventions and improve screening rates in similar settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employs a qualitative, multi-level exploratory design to investigate the drivers of colorectal cancer screening in the Gaza Strip, Palestine. The social-ecological model (SEM) uniquely suits this multi-level qualitative study as it aligns with the complex interplay of factors influencing colorectal cancer (CRC) screening in Gaza. SEM examines health behaviours through nested systems\u0026mdash;individual, interpersonal, organisational, community, and policy levels\u0026mdash;recognising that CRC screening is shaped by cultural norms, familial dynamics, community resources, institutional policies, and legislative frameworks [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant selection and sampling\u003c/h3\u003e\n\u003cp\u003e A purposive sampling strategy guided the selection of participants for this qualitative This study used purposive sampling to recruit diverse participants (varying in age, gender, education, and occupation) across Gaza\u0026rsquo;s regions, ensuring representation of those with direct CRC screening experiences. The approach enriched data by capturing cultural, logistical, and systemic drivers through varied perspectives. Targeting individuals, families, community leaders, healthcare providers, and policy-makers, the strategy prioritised depth and context-specific insights. This method enabled a nuanced understanding of regional disparities, informing equitable strategies to improve CRC screening in Gaza\u0026rsquo;s conflict-affected setting.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eParticipants in this study included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIndividuals aged 18 years and above, the target demographic for CRC screening.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFamily members with experience in health-related decision-making or influencing community health perceptions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIndividuals directly impacting healthcare delivery, such as administrators, or involved in policy formulation, such as legislators, for cancer screening.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eParticipants were excluded if they did not meet the individual level\u0026rsquo;s age criteria.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParticipants lacking relevant experience or roles at the family, community, organisation, or policy levels were excluded.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIndividuals unable to participate in interviews due to health issues or other constraints were excluded.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected through nine focus group discussions (FGDs), with two FGDs each at the individual, family, community, and organisational levels, and one FGD at the policy level. Each session included 5\u0026ndash;7 participants, ensuring diverse representation while maintaining interactive dialogue. FGDs were chosen to facilitate dynamic exchanges, allowing participants to build on shared experiences and uncover nuanced socio-cultural, familial, and systemic drivers of colorectal cancer (CRC) screening. This method is particularly suited to Gaza\u0026rsquo;s collectivist culture, where group interactions often yield richer insights than individual interviews. By structuring FGDs across multi-level stakeholders, the study captured interwoven perspectives, revealing how cultural norms, familial roles, organisational policies, and legislative frameworks collectively shape screening behaviours. A semi-structured interview guide was developed specifically for this study, informed by the Social-Ecological Model and existing literature on colorectal cancer screening, and is provided as Supplementary File 1.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThematic analysis followed a structured five-step process. First, audio responses were transcribed and translated from Arabic to English, with researchers verifying consistency between recordings and texts. Second, open and axial coding was conducted collaboratively, with codes assigned and validated by an independent researcher to ensure reliability. Third, AI-assisted theme generation was employed: codes were uploaded to ChatGPT, which grouped them into preliminary themes and subthemes, guided by researcher prompts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Fourth, iterative refinement ensured themes\u0026rsquo; precision, with ChatGPT consolidating codes into broader categories adjusted for contextual relevance[\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Finally, themes and subthemes were finalised through researcher consensus, aligning with the study\u0026rsquo;s multi-level framework [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This hybrid approach balanced AI efficiency with human expertise, enhancing rigour and depth (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTrustworthiness\u003c/h3\u003e\n\u003cp\u003eTrustworthiness was ensured through systematic validation and adherence to qualitative rigour [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Credibility was achieved via triangulation: two researchers independently coded data, resolving discrepancies through discussion [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], while an external validator cross-checked codes. Dependability relied on meticulous documentation of steps, including verifying Arabic-to-English transcription accuracy [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and transparent coding protocols. Confirmability involved iterative refinement of AI-generated themes (ChatGPT) with researcher oversight to align outputs with raw data, balancing technological efficiency with human interpretive depth [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Transferability was strengthened through thick descriptions of Gaza\u0026rsquo;s socio-political context, enabling applicability assessments in similar settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Final themes, consolidated through consensus, aligned with the social-ecological framework [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], reflecting the interplay of individual, familial, and policy-level drivers. This study innovatively merged AI-assisted analysis with traditional qualitative rigour, echoing calls to integrate emerging tools while upholding trustworthiness standards [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The research underscores the feasibility of maintaining rigour in complex, conflict-affected environments by prioritising methodological transparency, contextual richness, and collaborative validation.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure 1\u003c/strong\u003e \u003cp\u003eSchematic diagram of thematic analysis\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eIn our qualitative study on cancer screening in the Gaza Strip, we prioritized ethical considerations to ensure all participants\u0026rsquo; dignity, rights, and well-being. The research adhered to rigorous ethical standards, beginning with formal approval from the Research Ethics Committee of Universiti Malaysia Sarawak (Ethics Reference Number: FME/23/63), ensuring compliance with institutional review board guidelines. Informed consent was obtained from every participant, with detailed information in Arabic to address language barriers and guarantee true comprehension of the study\u0026rsquo;s purpose, procedures, risks, benefits, and data usage. Participation was entirely voluntary, and participants were informed of their right to withdraw at any time without repercussions. Identifying details were anonymized during transcription to safeguard privacy and confidentiality, and data were securely stored with restricted access. Interviews and focus groups were conducted in private settings to protect participants, particularly given the sensitive nature of discussions about cancer screening in a conflict-affected region. These measures were integral to building trust, maintaining research integrity, and upholding ethical responsibility throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the participants\u003c/h2\u003e \u003cp\u003eThe study included 57 participants across five stakeholder groups (individuals, families, community members, organisations, policy-makers) in Gaza. Participants ranged in age from 45 to 85 years (mean\u0026thinsp;=\u0026thinsp;59.2), with policy-makers being the oldest subgroup (mean\u0026thinsp;=\u0026thinsp;60.2). Males dominated participation (77.2%), particularly in community (12/14) and policy (5/5) groups. Education levels varied: 35.1% held bachelor\u0026rsquo;s degrees, while 15.8% had PhDs. Policy-makers were exclusively highly educated (4 physicians, 1 PhD), whereas individuals included participants with no formal schooling (7%). Geographically, participants represented all Gaza regions, with Gaza City having the highest representation (28.1%). Occupations ranged from retirees (15.8%) and housewives (7%) to administrators (17.5%) and community leaders (22.8%). This diversity ensured multi-sectoral perspectives, blending grassroots experiences (e.g., housewives) with institutional expertise (e.g., policy-makers, administrators) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eCharacteristics of the FGDs participants\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=\"left\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividual (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOrganisation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePolicy\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003cp\u003eMin, Max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.0(10.5)\u003c/p\u003e \u003cp\u003e50, 85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.4(7.3)\u003c/p\u003e \u003cp\u003e50, 72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.6(8.3)\u003c/p\u003e \u003cp\u003e45, 70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.8(3.4)\u003c/p\u003e \u003cp\u003e50, 59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.2(6.6)\u003c/p\u003e \u003cp\u003e50, 67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59.2(8.3)\u003c/p\u003e \u003cp\u003e45, 85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDier Al Balah\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhan Yunis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth Gaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRafah\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity activist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLawyer, religious leader\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity leaders and members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministrator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirectors and higher officials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8.8\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 \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDrivers of Colorectal Cancer Screening\u003c/h2\u003e \u003cp\u003eThe drivers of colorectal cancer (CRC) screening in Gaza reflect a multi-level framework. At the individual level, cultural norms (e.g., absence of stigma) and motivators like financial incentives and clinician recommendations were critical. Families provided supportive environments through active encouragement and leveraged media/workshops to normalise screening. Community efforts highlighted the role of religious leaders and peer testimonials, while institutions like mosques and schools integrated health education. Organisations promoted screening via workplace policies (e.g., paid leave) and partnerships with NGOs. At the policy level, legislative mandates and affordability strategies were integral. Across all levels, systemic integration of culturally aligned interventions, trusted networks, and education emerged as pivotal drivers of screening uptake (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\u003eThemes and subthemes of drivers of colorectal cancer screening\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eIndividual Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCultural Context \u0026amp; Influences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbsence of Negative Beliefs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAffirmation of Cultural/Religious Norms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMotivators for Screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducation \u0026amp; Early Detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinancial Incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAwareness \u0026amp; Early Detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoctor/Clinic Recommendations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive Screening Experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuccess Stories of Early Detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eFamily Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAbsence of Barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo Hindering Traditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiverse Views\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFamily Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eActive Encouragement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReassuring Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAwareness Strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedia/Digital Outreach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducational Workshops\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eCommunity Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLeadership \u0026amp; Policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReligious/Educational Advocacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedia Campaigns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResource Utilisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMosque/School Integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeer Testimonials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eOrganisational Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWorkplace Policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePaid Leave/Telemedicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStakeholder Commitment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartnerships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNGO/Insurer Collaborations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMandatory Health Evaluations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePolicy Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAwareness \u0026amp; Accessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic Awareness Campaigns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAffordability Policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLegislative Action\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEarly Detection Mandates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\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 \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFindings of Thematic Analysis\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eIndividual level\u003c/h2\u003e \u003cp\u003eAt the \u003cb\u003eindividual level\u003c/b\u003e, cultural and religious norms were foundational drivers, with participants affirming that CRC screening aligns with their values.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe are Muslims and do not believe in myths regarding CRC screening\u0026rdquo; (Ahmed Ryan, 61M)\u003c/em\u003e, reflecting the \u003cb\u003eabsence of negative beliefs\u003c/b\u003e and \u003cb\u003eaffirmation of cultural/religious norms\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eOne participant noted that \u003cb\u003eeducation and financial incentives\u003c/b\u003e further motivated participation: \u0026ldquo;\u003cem\u003eA small financial return could motivate screening\u0026rdquo; (Jameil, 63M)\u003c/em\u003e. Clinician recommendations and awareness campaigns emphasised early detection\u0026rsquo;s benefits, such as \u0026ldquo;\u003cem\u003ethe importance of early detection of cancer\u0026rdquo; (Abeer, 58F).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePositive experiences\u003c/b\u003e, including success stories like \u0026ldquo;\u003cem\u003emany positive stories where early detection cured the disease\u0026rdquo; (Aymen, 51M)\u003c/em\u003e, reinforced trust in screening. Collectively, cultural alignment, practical motivators, and first-hand success narratives emerged as critical drivers of individual engagement.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFamily level\u003c/h2\u003e \u003cp\u003eSupportive dynamics and proactive communication emerged as key facilitators at the \u003cb\u003efamily level\u003c/b\u003e. The \u003cb\u003eabsence of barriers\u003c/b\u003e was evident, with participants noting \u0026ldquo;\u003cem\u003eno family values or traditions hinder CRC screening\u0026rdquo; (Sami Abu Ajwa, 56M)\u003c/em\u003e and acknowledging \u003cb\u003ediverse views\u003c/b\u003e \u0026ldquo;\u003cem\u003eFamilies have different opinions depending on culture\u0026rdquo; \u0026ndash; Talha Baloush, 51M)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eActive encouragement\u003c/b\u003e played a pivotal role, as families motivated members through support, especially with cancer histories: \u0026ldquo;\u003cem\u003eFamilies support screening, particularly if there\u0026rsquo;s a family history\u0026rdquo; (Hamdan Alhour, 65M)\u003c/em\u003e. \u003cb\u003eReassuring communication\u003c/b\u003e alleviated fears, such as explaining \u0026ldquo;\u003cem\u003ethe benefits of screening and early detection\u0026rdquo; (Sameia Almjaida, 60F)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAwareness strategies\u003c/b\u003e thrived through \u003cb\u003emedia/digital outreach\u003c/b\u003e, like \u0026ldquo;\u003cem\u003ehashtags reaching all residents\u0026rdquo; (Adel, 55M)\u003c/em\u003e and \u003cb\u003eeducational workshops\u003c/b\u003e, where families learned that \u0026ldquo;\u003cem\u003escreening is routine preventive care\u0026rdquo; (Fadwa Al-Najjar, 71F)\u003c/em\u003e. Open dialogue, encouragement, and targeted education within families collectively normalised CRC screening and fostered participation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCommunity level\u003c/h2\u003e \u003cp\u003eAt the \u003cb\u003ecommunity level\u003c/b\u003e, leadership and resource mobilisation were central to promoting CRC screening. \u003cb\u003eReligious and educational advocacy\u003c/b\u003e leveraged trusted platforms, as \u0026ldquo;\u003cem\u003emosques and religious centres spread health messages through weekly sermons\u0026rdquo; (Raft, 66M)\u003c/em\u003e and schools integrated CRC education into curricula \u003cem\u003e\u0026ldquo;teaching families about early detection\u0026rdquo; Tyiseir, 59M)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMedia campaigns\u003c/b\u003e amplified awareness via culturally resonant strategies, such as \u003cem\u003e\u0026ldquo;local media sharing real-life success stories\u0026rdquo; (Khetam, 52F)\u003c/em\u003e and \u003cem\u003esocial media hashtags reaching younger generations (Adel, 55M)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePeer testimonials\u003c/b\u003e normalised screening by humanising its benefits: \u003cem\u003e\u0026ldquo;Survivors sharing experiences help reduce fear\u0026rdquo; (Khetam, 52F)\u003c/em\u003e. Institutions like mosques and schools served as hubs for education, bridging gaps in accessibility. The synergy of trusted leadership, innovative outreach, and survivor-led advocacy created a community-wide culture prioritising CRC screening.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eOrganisational Level\u003c/h2\u003e \u003cp\u003eWorkplace policies and strategic partnerships were instrumental in promoting CRC screening at the organisational level. One participant noted that \u003cb\u003epaid leave and telemedicine\u003c/b\u003e reduced logistical barriers and that \u003cem\u003e\u0026ldquo;flexible work policies and telemedicine consultations encourage employees to prioritise screenings\u0026rdquo; (Areej Safi, 51F).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eStakeholder commitment\u003c/b\u003e ensured program viability, as \u0026ldquo;\u003cem\u003emanagement committed to implementing regulations and logistics\u0026rdquo; (Maher Nasman, 58M).\u003c/em\u003e Collaborations with NGOs and insurers expanded access, exemplified by \u003cem\u003e\u0026ldquo;mobile units providing free colonoscopies increased screening rates by 60%\u0026rdquo; * (Rafat Almajdlawi, 54M).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eMandatory health evaluations\u003c/b\u003e institutionalised screening, achieving \u003cem\u003e\u0026ldquo;85% compliance via annual employee checks\u0026rdquo; (Mohammad Yaghi, 52M).\u003c/em\u003e These efforts combined policy innovation, resource allocation, and cross-sector partnerships to create a workplace culture prioritising preventive care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePolicy-Level\u003c/h2\u003e \u003cp\u003eAt the \u003cb\u003epolicy level\u003c/b\u003e, strategic initiatives focused on \u003cb\u003eawareness, affordability, and legislation\u003c/b\u003e were critical to advancing CRC screening.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePublic awareness campaigns\u003c/b\u003e reshaped perceptions, as noted by: \u003cem\u003e\u0026ldquo;National policies influence public decisions through widespread appeals, (Sobhi Skeik, 65M)\u0026rdquo;\u003c/em\u003e emphasising screening as a health priority.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAffordability policies\u003c/b\u003e addressed financial barriers by \u003cem\u003eadvocating for \u0026ldquo;policies to ensure accessible and affordable screening (Samer Abu Zer, 50M)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLegislative mandates\u003c/b\u003e institutionalised early detection, exemplified by \u003cem\u003e\u0026ldquo;Legislative Early Detection Programs (Samer Abu Zer, 50M)\u0026rdquo;\u003c/em\u003e and call all for \u003cem\u003e\u0026ldquo;integrating screening into healthcare systems (Yehia Abed, 67M)\u0026rdquo;.\u003c/em\u003e Together, these policies created a cohesive framework, ensuring systemic support and equitable access to CRC screening.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur analysis indicates that cultural and religious norms can positively influence attitudes toward colorectal cancer (CRC) screening, contrasting with findings documenting cultural taboos obstructing screening uptake in certain contexts [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Participants noted that framing CRC screening as aligned with Islamic health preservation values enhances acceptance and mitigates barriers such as fatalism and privacy concerns [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This highlights the potential of faith-sensitive interventions, such as involving religious leaders in awareness campaigns, a strategy supported by relevant literature [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Consequently, policy-makers are encouraged to prioritise collaborations with religious institutions to utilise cultural capital in normalising preventive care [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings underscore that leadership and resource mobilisation at the community level are instrumental in promoting colorectal cancer (CRC) screening. Religious and educational advocacy, as evidenced by the use of mosques and schools to deliver health messages and integrate screening education, reflects strategies that have proven effective in faith-based community interventions [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Media campaigns employing culturally resonant approaches, including local storytelling and social media outreach, amplify awareness and promote screening uptake [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In addition, the involvement of families as catalysts in normalising CRC screening\u0026mdash;by providing support and dispelling misconceptions\u0026mdash;differs markedly from contexts where familial resistance has been identified as a barrier, thereby positioning familial cohesion as a robust model for preventive care [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings demonstrate that a grassroots approach is key to fostering community trust and enhancing colorectal cancer (CRC) screening uptake. Trusted community institutions, particularly mosques and schools, serve as effective platforms for disseminating health messages. Religious centres employing health promotion strategies can significantly bolster public health communication by leveraging established channels of community trust [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Concurrently, educational institutions can integrate CRC awareness into their curricula, reinforcing early detection practices and aligning health education with cultural values. Peer testimonials enhance this effect by humanising the screening process and mitigating fear. Vu et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] pertain more generally to women\u0026rsquo;s health interventions and might not directly support claims about CRC screening. This approach contrasts with top-down methods, which often lack contextual sensitivity, aligning culturally tailored, agent-led interventions for health literacy promotion among Muslim communities [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Consequently, the synergy of trusted leadership, innovative outreach, and survivor-led advocacy creates a robust, community-driven framework for CRC screening.\u003c/p\u003e \u003cp\u003eOrganisational-level strategies to promote colorectal cancer (CRC) screening illustrate the synergistic benefits of workplace policies and strategic partnerships. NGO-driven mobile units providing free colonoscopies exemplify scalable interventions that can overcome infrastructural deficits in low-resource settings. However, the increase in screening rates does not directly support the broader principle of mobile units enhancing screening access, which is endorsed in community-based cancer prevention literature [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In parallel, flexible work policies\u0026mdash;such as telemedicine consultations and paid leave\u0026mdash;mitigate employee logistical barriers, enhancing participation in preventive health services [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Furthermore, workplace wellness programmes, which may include mandatory health evaluations, have demonstrated potential benefits in institutionalising preventive healthcare practices. The integration of these approaches underscores the importance of cross-sector collaborations that blend policy innovation, resource allocation, and community-based efforts to create a sustainable culture of preventive care [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe policy-level analysis reveals that strategic initiatives integrating affordability mandates, legislative mandates, and awareness campaigns can significantly advance colorectal cancer (CRC) screening. Affordability policies, which aim to reduce financial barriers by ensuring accessible and affordable screening, are essential in facilitating equitable uptake, as evidenced by frameworks addressing socioeconomic disparities in CRC outcomes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Legislative actions that institutionalise early detection\u0026mdash;through mandates and screening integration into healthcare systems forge durable policy support that underpins these initiatives [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Moreover, widespread public awareness campaigns reshape perceptions and elevate CRC screening as a health priority by mobilising national platforms to communicate public health messages effectively [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, gaps persist in settings with limited infrastructure, such as Gaza, where systemic funding and integrated policy frameworks remain challenges. Successful case studies, such as those conducted in various healthcare institutions, demonstrate how robust policy support coupled with adequate infrastructure can drive high screening compliance and equitable access. Ultimately, the interplay among affordability measures, legislative action, and awareness strategies creates a multi-level synergy with cultural, familial, and community drivers reinforcing policy-level efforts essential for establishing a supportive ecosystem for preventive care in similar low-resource and conflict-affected settings.\u003c/p\u003e \u003cp\u003eThis study\u0026rsquo;s strengths lie in its multi-level qualitative design. It captures diverse perspectives from patients, families, community leaders, organisations, and policy-makers, a critical approach for understanding CRC screening drivers in Gaza\u0026rsquo;s complex socio-political context. Including culturally resonant themes (e.g., religious advocacy, family dynamics) enriched contextual insights, offering actionable strategies tailored to local realities. However, limitations must be acknowledged. The sample exhibited a gender imbalance, with males dominating participation (77.2%), particularly in community and policy groups, potentially skewing perspectives and overlooking gender-specific barriers faced by women. Selection bias may exist, as participants were recruited through institutional networks, possibly excluding marginalised voices. While the qualitative focus provided depth, it limits generalizability beyond Gaza\u0026rsquo;s unique setting. Nevertheless, these limitations are counterbalanced by the study\u0026rsquo;s granular exploration of multi-level drivers, which provides a foundation for context-specific interventions in similar conflict-affected regions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study highlights the critical role of multi-level drivers\u0026mdash;cultural alignment, family support, community leadership, organisational policies, and legislative action\u0026mdash;in enhancing CRC screening in Gaza. Integrating these culturally resonant strategies fosters a supportive ecosystem, which is crucial for improving screening uptake and reducing mortality. Prioritise faith-sensitive campaigns engaging religious leaders; expand family-centred education and community-led media outreach; implement workplace policies; advocate for affordable screening mandates. Future research should address gender disparities and validate scalable models in conflict-affected regions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Universiti Malaysia Sarawak (Ethics Reference Number: FME/23/63) and was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all adult participants and from caregivers of children or individuals unable to provide consent independently. Participation was voluntary, and confidentiality and anonymity were maintained throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any identifying images or other personal or clinical details of participants that compromise anonymity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDatasets are available from the corresponding author upon reasonable request, in accordance with data transparency and ethical guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMR and AB led data curation, analysis, methodology, and visualisation. AB and SA managed investigation, project administration, and resources. MR supervised the study and drafted the manuscript. CY and AS contributed to validation, critical review, and editing. All authors conceptualised the study collaboratively and all authors approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all participants\u0026mdash;patients, families, community leaders, healthcare workers, and policy-makers in Gaza\u0026mdash;who generously shared their time and insights despite the demanding circumstances of conflict and resource constraints. Special thanks to healthcare administrators and management for their unwavering commitment to facilitating this research amid challenging conditions. We acknowledge Universiti Malaysia Sarawak (UNIMAS) for their academic support and ethical oversight. This study was conducted under the approval of the UNIMAS Ethics Committee (Reference Number: FME/23/63), whose guidance ensured the ethical integrity of this work. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFan Y, Zhang X, Tong Y, Chen S, Liang J. Curcumin Against Gastrointestinal Cancer: A Review of the Pharmacological Mechanisms Underlying Its Antitumor Activity. Front Pharmacol. 2022;13:990475.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe L, Wu Y, Chen Y, Zhao C, Li W, Lu Y, Guo F. Dietary Intake Data for Patients With and Without Colorectal Cancer: A Logistic Lasso Regression Analysis. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Chang Z, Wang J, Ding K, Pan S, Hu H, Tang Q. Unhealthy Lifestyle Factors and the Risk of Colorectal Cancer: A Mendelian Randomization Study. 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Jnci J Natl Cancer Inst. 2014;106(4):dju032.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Colorectal Cancer Screening, Multi-level Drivers, Qualitative Study, Socio-cultural Factors, Gaza Strip","lastPublishedDoi":"10.21203/rs.3.rs-9142249/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9142249/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eColorectal cancer (CRC) is a growing public health concern in the Gaza Strip, where late-stage diagnosis and low screening rates contribute to preventable mortality. Cultural, logistical, and systemic barriers complicate screening uptake, necessitating a deeper understanding of multi-level drivers to inform targeted interventions. We aimed to explore multi-level drivers and facilitators influencing CRC screening uptake in Gaza through a qualitative analysis of perspectives from patients, families, community leaders, healthcare providers, and policy-makers, identifying actionable themes and subthemes. Methods: We conducted a multi-level qualitative research design. Data were collected through a series of focus group discussions. Participants included patients, family members, community representatives, healthcare providers, and policy-makers in the Gaza Strip. Thematic analysis was done by identifying and categorising drivers of major themes and corresponding subthemes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur analysis identified several multi-level drivers of CRC screening in Gaza. Cultural alignment (We are Muslims\u0026hellip; no myths), financial incentives, and clinician guidance motivated participation at the individual level. Families fostered support through encouragement (\u003cem\u003eno hindering traditions\u003c/em\u003e) and media /workshops. Communities leveraged religious leaders (\u003cem\u003emosques spread health messages\u003c/em\u003e), peer testimonials, and media campaigns. Organisations promoted screening via paid leave, telemedicine, and NGO partnerships (\u003cem\u003e60% uptake via mobile units\u003c/em\u003e). Policy-makers prioritised affordability, awareness campaigns (\u003cem\u003enational policies influence decisions\u003c/em\u003e), and legislative mandates. Systemic integration of culturally aligned strategies, trusted networks (families, leaders), and education across levels emerged as pivotal to enhancing CRC screening uptake and reducing mortality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe success of CRC screening is attributed to aligning interventions with cultural values, leveraging trusted networks, and systemic integration. A coordinated approach across individual, familial, community, organisational, and policy levels is critical to enhancing CRC screening uptake and reducing mortality.\u003c/p\u003e","manuscriptTitle":"Drivers of Colorectal Cancer Screening in the Gaza Strip, Palestine Territory: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 15:06:34","doi":"10.21203/rs.3.rs-9142249/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-12T20:35:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T12:41:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119983543791721064957604560287794382561","date":"2026-05-02T12:42:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335181860080819299682603848945774421198","date":"2026-05-02T07:04:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121903402052319922978572676176326847671","date":"2026-04-13T14:54:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-10T16:50:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286807178093048772583322859279983309266","date":"2026-04-06T17:11:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T15:48:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T15:47:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-25T13:52:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T18:29:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-24T18:22:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e253b534-35a8-4eee-b602-cb8531005b96","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-12T20:35:44+00:00","index":88,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T12:41:10+00:00","index":86,"fulltext":""},{"type":"reviewerAgreed","content":"119983543791721064957604560287794382561","date":"2026-05-02T12:42:23+00:00","index":85,"fulltext":""},{"type":"reviewerAgreed","content":"335181860080819299682603848945774421198","date":"2026-05-02T07:04:55+00:00","index":84,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T15:06:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 15:06:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9142249","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9142249","identity":"rs-9142249","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}