Introduction
Cancer is the most important cause of illness and death that affects the social and economic status of societies. Colorectal cancer (CC) is the third most common cancer after lung and breast cancers, the second most common cause of cancer death in women, and the third most common cancer in men. Social marketing is one of the audience-oriented behavioral patterns that takes into account the views and opinions of the target group about a behavior or health service. By identifying the barriers and facilitators of the behaviors/services, it strengthens the resulting benefits and reduces related costs and barriers so that people find it profitable to perform/provide and do it voluntarily. The purpose of this study was to investigate the opinions of Iranian older adults about CC screening based on the social marketing approach.

Materials and Methods
This qualitative study was conducted using the content analysis method and based on the social marketing approach. The data were collected through in-depth semi-structured interviews by considering four main elements of social marketing (product, price, place, promotion). By using a purposive sampling method, 30 older adults with maximum demographic and socio-economic diversity were selected from different areas of Mashhad, Iran. Interviews continued until data saturation. Data collection period was from May 2021 to Feb 2022. The inclusion criteria were age over 60 years old, living in Mashhad, Iranian nationality or Persian speaking, physical ability to participate in the interview, and having consent to enter the study. The exit criterion was the unwillingness to continue the interview. The duration of each interview was 60-90 minutes. In-depth semi-structured interviews with eight healthcare personnel were another part of the qualitative study. They were selected from the comprehensive health centers in Mashhad. Graneheim and Lundman’s method was used to analyze the content of qualitative data, which includes the following steps: Preparation of data, identifying the meaning units and creating primary codes, categorizing these codes, and identifying main themes. ATLAS.t software, version 9 was used to conduct the data analysis.

Results
The mean age of older adults was 68.1±4.8 years. Most of them was female. 
The product (CC screening) was the first theme with one sub-theme of “importance of CC screening”. Older adults perceived the important role of screening in the timely diagnosis of CC and preventing the disease from progressing. From the point of view of healthcare personnel, due to the high incidence of CC, early diagnosis of the disease was also very important to start treatment. 
The price of CC screening was the second theme, with four sub-themes of lack of awareness, mental/psychological barriers, belief barriers, and personal barriers. Based on the first sub-theme, inadequate health literacy, insufficient knowledge of the disease and the fact that CC can be prevented or treated with timely and early detection, and lack of knowledge of the existence of free, fast and non-invasive diagnostic tests in comprehensive health service centers were the main reasons perceived by older adults for the low number of referrals for CC screening. Laziness, fear of a positive diagnosis, indifference and forgetfulness, and feelings of shame and embarrassment were the mental/psychological barriers to CC screening. Belief in God's will and destiny were the belief barriers. Lack of time and concern about the costs were the personal barriers. From the point of view of healthcare personnel, lack of awareness was the most important barrier. 
The place for CC screening was the third theme with two sub-themes of suitable places to receive information and suitable places to perform the screening. The best places to receive information related to CC were comprehensive health centers and the suitable places for screening were home, comprehensive health centers, hospitals, and laboratories. 
The forth theme was promotion with two sub-themes of influential people/organizations and advertising. The influential people were doctors and health care providers in comprehensive health centers, who can encourage people to perform CC screening by carrying out innovative methods such as sending invitation letters or test kits. Transmission of information through some channels such as mass media, virtual networks and billboard ads were related to the advertising sub-theme.

Conclusion
According to Iranian older adults, the most important barriers to CC screening were lack of knowledge of the disease and screening, fear of screening results, and concern about the cost of screening. To increase CC screening in older adults, special attention to these modifiable barriers is needed. Health literacy can help older adults to acquire and process CC-related information and make the best health-related decisions. Their awareness of CC and how to prevent it should be improved by developing educational programs to increase their tendency towards CC screening. 

Ethical Considerations

Compliance with ethical guidelines
 This study was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (Code: IR.MUMS.FHMPM.REC.1400.008).

Funding
This article was a extracted from PhD thesis of Samira Olyani, approved by Mashhad University of Medical Sciences and financially supported by Mashhad University of Medical Sciences, Mashhad. Iran (Grant No.: 991804). 

Authors' contributions
Writing, review & editing, and project management: Samira Olyani and Nooshin Peyman; Methodology: Samira Olyani, Nooshin Peyman, Jamshid Jamali, Mehralsadat Mahdizadeh; Software, data analysis and interpretation: Samira Olyani and Hossein Ebrahimipour; Conceptualization: All authors;

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the Mashhad University of Medical Sciences for the support and all participants for their cooperation in this research.




 

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