2025 年 3 巻 2 号 p. 78-83
Breast and cervical cancers are leading causes of mortality among female, yet screening participation in Japan remains below 50%. The impact of positive psychological factors such as gratitude on screening attendance is unexplored. This cross-sectional analysis targeted females without a history of cancer. Breast cancer screening attendance was 48.6% Among 6,070 females aged 40–69, while cervical cancer screening attendance was 46.0% among 11,550 females aged 20–69. Middle tertile and upper tertile of gratitude trait were associated with higher prevalence ratios for screening attendance in both cancer types. This study highlights the need for further research into the role of positive psychological factors in promoting preventive health behaviors.
This paper examines whether higher gratitude traits are associated with cancer screening participation among females. The data were derived from an ongoing cohort study (JACSIS, Japan COVID-19 and Society Internet Survey). A web-based, self-administered survey was conducted between September and October 2022, targeting approximately 2.2 million panelists from an Internet research company (Rakuten Insight, Inc., Tokyo, Japan). The survey was concluded when the number of responses reached 32,000. All respondents provided web-based informed consent at registration and received a nominal incentive for survey completion.
The outcomes were breast cancer screening (BCS) and cervical cancer screening (CCS) attendance. Participants were asked if they had attended cancer screenings over the past two years, and responses were dichotomized into those who underwent and those who did not. The details of the questionnaire are shown in Appendix 1. Breast and cervical cancer are leading causes of cancer incidence and mortality among females1). Cancer screening plays a pivotal role in early detection and subsequent treatment. In Japan, BCS and CCS is recommended biennially for females aged 40 and above and 20 and above, respectively. Despite the goal of achieve at least 60% participation, the participation rate remains below 50% in Japan2). A substantial body of literature confirms that female cancer screening rates are linked to various sociodemographic factors3,4), such as age, income, educational background, and marital status. Sociodemographic factors are not easily modifiable, highlighting the need to examines other determinants, such as psychological factors5). However, research on psychological factors related to cancer screening attendance has predominantly focused on negative elements such as fear and anxiety6). To date, there has been no research examining positive factors, such as gratitude.
Gratitude trait is characterized as a life orientation towards noticing and appreciating the positive in the world7). Gratitude is considered a factor that influences various aspects of human well-being8,9). In clinical settings, patients with cardiovascular diseases who had higher levels of gratitude demonstrated higher medical adherence10). In non-clinical settings, grateful individuals are more likely to feel less stress, engage in preventive health behaviors, and seek healthcare when needed9,11,12). Although the relationship between gratitude and cancer screening attendance remains unclear, these findings suggest that gratitude may be linked to proactive health behaviors. One’s sense of gratitude can be enhanced through gratitude intervention, commonly involving recording daily feelings of gratitude. A typical method is called a gratitude journal, in which individuals regularly reflect on and write down things they are grateful for11). Gratitude interventions have been reported to assist in maintaining and enhancing the well-being of breast cancer patients13,14). Although the results of gratitude intervention are mixed, they are a low-cost and easily accessible method that anyone can use, making them a promising approach for promoting physical health15) as well as psychological health16). However, it is important to note that this study does not aim to establish a causal relationship between gratitude and screening participation, and further research is needed to explore the underlying mechanisms.
The explanatory variable of interest was the gratitude trait, assessed using the Japanese version of Gratitude Questionnaire. The scale consists of five items with a seven-point rating scale from 1 (strongly disagree) to 7 (strongly agree)17,18). The item “Long amounts of time can go by before I feel grateful for something or someone.” was omitted from original version due to cultural relevance17). The possible score ranges from 5 to 35. Three categories (lower, middle, and upper) were created based on tertile.
The analysis excluded those with invalid responses (see Appendix 2), males, individuals aged 39 years or younger (for BCS) or individuals aged 19 years or younger (for CCS), individuals aged 70 years or older, those with a history of any type of cancer or currently undergoing treatment, and those with missing data for any of the variables investigated. The flowchart for eligible respondents for analysis is shown in Appendix 3. Modified Poisson regression analysis with robust error variance was used to estimate Prevalence ratios (PRs) and 95% confidence intervals (CIs). The following factors were used to adjust possible confounders based on a previous study3,4), age group, marital status, educational attainment, household annual income, employment status, smoking habit, drinking habit, psychological distress measured by the K6 scale19), having a regular physician, and area of residence. Variance inflation factors were checked to assess multicollinearity among the explanatory variables, and all values were below 10. A PR greater than 1 indicates higher screening attendance likelihood. The analysis used IBM SPSS Statistics for Windows, Version 29 (IBM Corp., Armonk, NY), with statistically significance at p-values less than 0.05.
This study followed the Declaration of Helsinki guidelines and received approval from the ethics committee of the Osaka International Cancer Institute (approval number: 20084-6), and Institute of Medicine, University of Tsukuba (approval number: 1737).
Among 6,070 females analyzed for BCS (mean age 53.8 ± 8.9), 48.6% underwent screening. After adjusting for other variables, there was a statistically significant association between BCS attendance and level of gratitude trait. Compared to lower tertile of gratitude trait, the PR was 1.13 (95% CI, 1.06–1.21) for middle tertile of gratitude trait, and 1.09 (95% CI, 1.01–1.16) for upper tertile of gratitude trait (Table 1).
| Explanatory variable | Total, n | Screening rate, % | Adjusted PR | 95% CI |
|---|---|---|---|---|
| Overall | 6,070 | 48.6 | ||
| Gratitude Questionnaire score | ||||
| Lower tertile (5–21) | 1,917 | 42.7 | 1.00 | Reference |
| Middle tertile (22–26) | 2,122 | 51.6 | 1.13 | 1.06–1.21 |
| Upper tertile (27–35) | 2,031 | 51.1 | 1.09 | 1.01–1.16 |
| Age group | ||||
| 40–49 | 2,278 | 49.4 | 1.03 | 0.96–1.10 |
| 50–59 | 1,885 | 50.7 | 1.07 | 0.999–1.15 |
| 60–69 | 1,907 | 45.6 | 1.00 | Reference |
| Marital status | ||||
| Married | 4,103 | 49.9 | 1.02 | 0.96–1.08 |
| Single/Divorced/Widowed | 1,967 | 45.9 | 1.00 | Reference |
| Educational background | ||||
| 4-year College/University/Graduate | 1,914 | 54.2 | 1.11 | 1.05–1.17 |
| Others | 4,156 | 46.0 | 1.00 | Reference |
| Household income | ||||
| Less than 4 million JPY | 1,643 | 41.2 | 1.00 | Reference |
| 4–8 million JPY | 1,790 | 50.9 | 1.18 | 1.09–1.27 |
| 8 million JPY and over | 1,066 | 60.2 | 1.31 | 1.21–1.43 |
| I don’t know./Prefer not to answer. | 1,571 | 45.8 | 1.10 | 1.01–1.19 |
| Employment status | ||||
| Not working | 2,455 | 42.6 | 1.00 | Reference |
| Working | 3,615 | 52.7 | 1.22 | 1.15–1.30 |
| Smoking habit | ||||
| Never/Ex- smoker | 5,341 | 49.4 | 1.19 | 1.09–1.29 |
| Occasionally/Daily smoker | 729 | 42.4 | 1.00 | Reference |
| Drinking habit | ||||
| Never/Ex- drinker | 3,293 | 46.6 | 0.94 | 0.89–0.99 |
| Occasionally/Daily drinker | 2,777 | 50.9 | 1.00 | Reference |
| Psychological distress | ||||
| K6 score <5 | 3,903 | 50.3 | 1.07 | 1.01–1.13 |
| K6 score ≥5 | 2,167 | 45.5 | 1.00 | Reference |
| Having a regular physician | ||||
| Yes | 3,057 | 53.5 | 1.24 | 1.18–1.31 |
| No | 3,013 | 43.6 | 1.00 | Reference |
| Area of residence | ||||
| Hokkaido/Tohoku | 718 | 46.5 | 0.96 | 0.88–1.05 |
| Kanto | 2,043 | 51.2 | 1.00 | Reference |
| Tokai/Hokuriku | 999 | 48.5 | 0.96 | 0.89–1.03 |
| Kinki | 1,103 | 47.0 | 0.93 | 0.87–1.00 |
| Chugoku/Shikoku | 529 | 46.7 | 0.94 | 0.85–1.04 |
| Kyushu/Okinawa | 678 | 47.1 | 0.95 | 0.87–1.04 |
PR, prevalence ratio; CI, confidence interval.
Among 11,550 females analyzed for CCS (mean age 42.6 ± 14.0), 46.0% underwent screening. After adjusting for other variables, a statistically significant association was found between CCS attendance and gratitude trait level. Compared to lower tertile of gratitude trait, the PR was 1.07 (95% CI, 1.02–1.13) for middle tertile of gratitude trait, and 1.09 (95% CI, 1.04–1.15) for upper tertile of gratitude trait (Table 2).
| Explanatory variable | Total, n | Screening rate, % | Adjusted PR | 95% CI |
|---|---|---|---|---|
| Overall | 11,550 | 46.0 | ||
| Gratitude Questionnaire score | ||||
| Lower tertile (5–21) | 3,617 | 40.5 | 1.00 | Reference |
| Middle tertile (22–26) | 4,055 | 47.1 | 1.07 | 1.02–1.13 |
| Upper tertile (27–35) | 3,878 | 50.0 | 1.09 | 1.04–1.15 |
| Age group | ||||
| 20–29 | 2,435 | 36.9 | 0.94 | 0.87–1.02 |
| 30–39 | 3,045 | 50.6 | 1.12 | 1.04–1.20 |
| 40–49 | 2,278 | 52.5 | 1.25 | 1.16–1.33 |
| 50–59 | 1,885 | 48.0 | 1.16 | 1.08–1.25 |
| 60–69 | 1,907 | 40.5 | 1.00 | Reference |
| Marital status | ||||
| Married | 7,345 | 51.0 | 1.25 | 1.18–1.31 |
| Single/Divorced/Widowed | 4,205 | 37.3 | 1.00 | Reference |
| Educational background | ||||
| 4-year College/University/Graduate | 4,990 | 49.6 | 1.11 | 1.06–1.15 |
| Others | 6,560 | 43.3 | 1.00 | Reference |
| Household income | ||||
| Less than 4 million JPY | 2,891 | 37.4 | 1.00 | Reference |
| 4–8 million JPY | 3,795 | 49.8 | 1.17 | 1.10–1.24 |
| 8 million JPY and over | 2,143 | 58.7 | 1.27 | 1.19–1.36 |
| I don’t know./Prefer not to answer. | 2,721 | 39.8 | 1.00 | 0.94–1.07 |
| Employment status | ||||
| Not working | 3,889 | 42.0 | 1.00 | Reference |
| Working | 7,661 | 48.0 | 1.18 | 1.13–1.23 |
| Smoking habit | ||||
| Never/Ex- smoker | 10,433 | 46.4 | 1.09 | 1.01–1.17 |
| Occasionally/Daily smoker | 1,117 | 42.3 | 1.00 | Reference |
| Drinking habit | ||||
| Never/Ex- drinker | 6,686 | 45.4 | 0.98 | 0.95–1.02 |
| Occasionally/Daily drinker | 4,864 | 46.8 | 1.00 | Reference |
| Psychological distress | ||||
| K6 score <5 | 6,932 | 47.6 | 1.03 | 0.98–1.07 |
| K6 score ≥5 | 4,618 | 43.6 | 1.00 | Reference |
| Having a regular physician | ||||
| Yes | 5,317 | 51.7 | 1.23 | 1.19–1.28 |
| No | 6,233 | 41.1 | 1.00 | Reference |
| Area of residence | ||||
| Hokkaido/Tohoku | 1,243 | 45.7 | 1.01 | 0.95–1.08 |
| Kanto | 1,894 | 44.6 | 1.00 | Reference |
| Tokai/Hokuriku | 2,214 | 44.6 | 0.92 | 0.87–0.98 |
| Kinki | 991 | 43.5 | 0.94 | 0.89–0.996 |
| Chugoku/Shikoku | 1,175 | 46.2 | 0.93 | 0.86–0.999 |
| Kyushu/Okinawa | 4,033 | 48.1 | 0.99 | 0.92–1.06 |
PR, prevalence ratio; CI, confidence interval.
In line with our hypothesis, the results indicated that females with lower levels of gratitude trait tended to have lower attendance rates for BCS and CCS. The results are in accordance with previous findings that individuals with higher levels of gratitude trait have been known to engage in healthier behaviors more frequently11,12). Several theories have been proposed to explain the underlying reasons for this concordance7). One such theory is the schematic hypothesis, which suggests that individuals with a high gratitude trait develop cognitive structure that prioritize their health and well-being, potentially fostering greater adherence to preventive measures. However, these are theoretical frameworks rather than direct evidence of causality. Future research should further investigate how gratitude might influence health behaviors and whether interventions promoting positive psychological factor could contribute to increased cancer screening participation.
Some limitations should be noted. Firstly, the nature of the self-administered survey may have led to recall bias and reporting bias. Second, cross-sectional design does not allow for conclusions on the direction of causality. Third, the participants were registered panelists of an Internet research company. Fourth, unmeasured confounding factors, such as health literature may play role in the observed relationships. Lastly, this study only targeted residents of Japan. The cultural differences in the concept and perception of gratitude may affect how gratitude influences health behaviors. The cancer screening systems also vary by region, which could affect the generalizability of the findings.
This study revealed an association between BCS and CCS participation and level of gratitude trait. The results highlight the importance of considering positive psychological factors in health behaviors. While previous research has focused on sociodemographic determinants and fear-based motivations, our findings suggest that gratitude may also play a role. Although this study does not directly inform causal relationships, it provides a foundation for future research on how psychological traits influence health behaviors.
We thank all the respondents for participating. We appreciate valuable feedback from the JACSIS study group researchers. ChatGPT (https://chat.openai.com/) was used for English proofreading after writing the manuscript by our own ideas and words. The authors are full responsible for the final version of documents.
This study (JACSIS2022) was supported by the Japan Society for the Promotion of Science KAKENHI Grants (grant number 21H04856 (T. T.); 20K10467; 20K19633 (D. H.); 20K13721), the Japan Science and Technology Agency Grant Number JPMJPF2017, the Health Labor Sciences Research Grant 21HA2016 and 23EA1001, the grant for 2021–2022 Strategic Research Promotion (No.SK202116) of Yokohama City University and the research program on “Using Health Metrics to Monitor and Evaluate the Impact of Health Policies,” conducted at the Tokyo Foundation for Policy Research. The findings and conclusions of this article are the sole responsibility of the authors and do not represent the official views of the research funders.
All the author contributed to the study conception and design. T. T leaded data acquisition. D. H. performed the statistical analysis, interpretated the results, and drafted the initial manuscript. All the authors contributed to the interpretation of the results, and critical review of the manuscript. All the authors have read and approved to submit the final version of manuscript.
A. O. receives personal fees from MNES Inc, Kyowa Kirin Inc., and Taiho Pharmaceutical Co., Ltd., outside the submitted work. T. T. received financial support for research (research fundings, consulting fees or lecture fees) from Daiichi Sankyo Healthcare Co., Ltd., Johnson & Johnson K.K., Data Seed Inc., Workout-Plus LLC and EMMA Co., Ltd.
