|Year : 2019 | Volume
| Issue : 10 | Page : 3140-3146
Assessing knowledge on preventive colorectal cancer screening in Saudi Arabia: A cross-sectional study
Marwan Al-Hajeili1, Hassan K Abdulwassi2, Faisal Alshadadi2, Lujain Alqurashi2, Mohmmad Idriss2, Lamis Halawani2
1 Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Submission||29-Jun-2019|
|Date of Decision||22-Aug-2019|
|Date of Acceptance||10-Sep-2019|
|Date of Web Publication||31-Oct-2019|
Dr. Hassan K Abdulwassi
Prince Majid Rd, Jeddah-22252
Source of Support: None, Conflict of Interest: None
Context: According to the Saudi Cancer Registry's 2014 Cancer Incidence Report, colorectal cancer (CRC) is the leading form of malignant cancer among Saudi men and ranks third among women. Raising awareness about CRC risk factors could lead to a significant decline in incidence of disease. Aims: To assess CRC awareness and evaluate the main barriers that might prevent individuals' participation in screening. Settings and Design: A self-administered survey was conducted over two days as part of a CRC awareness campaign in Jeddah, Saudi Arabia in March, 2018. Methods and Materials: The survey addressed issues regarding knowledge of CRC and available screening methods. The survey also examined barriers that might make one reluctant to undergo preventative screening. Stata/SE 15.0 was used for all statistical analyses. Statistical Analyses: Continuous variables were described with frequencies and percentages. Stepwise linear regression models were constructed to predict CRC knowledge and barriers. Results: Out of 422 participants, 50.2% were men. Most respondents were between 15–35 years old (65.8%). Multivariate analysis revealed that gender was a significant predictor of CRC knowledge. Furthermore, the variables of education and family history of CRC significantly predicted subjects' awareness of colonoscopic screenings. The most common barriers for seeking screening included fear of the procedure, absence of clinical symptoms, and fear of the results. Conclusions: Our results highlight deficits in public CRC knowledge and their awareness of preventative measures. These shortcomings were found to be mainly related to education level. Specific barriers affecting screening decisions were also identified; intensive efforts on awareness to overcome these obstacles will be required.
Keywords: Awareness, colon cancer, colonoscopy, colorectal cancer, Saudi Arabia, screening
|How to cite this article:|
Al-Hajeili M, Abdulwassi HK, Alshadadi F, Alqurashi L, Idriss M, Halawani L. Assessing knowledge on preventive colorectal cancer screening in Saudi Arabia: A cross-sectional study. J Family Med Prim Care 2019;8:3140-6
|How to cite this URL:|
Al-Hajeili M, Abdulwassi HK, Alshadadi F, Alqurashi L, Idriss M, Halawani L. Assessing knowledge on preventive colorectal cancer screening in Saudi Arabia: A cross-sectional study. J Family Med Prim Care [serial online] 2019 [cited 2020 Jul 15];8:3140-6. Available from: http://www.jfmpc.com/text.asp?2019/8/10/3140/269972
| Introduction|| |
According to the Saudi Cancer Registry's 2014 Cancer Incidence Report, colorectal cancer (CRC) is the leading form of malignant cancer among Saudi men and ranks third among women. Thus, CRC poses a significant health risk to Saudi nationals, who constitute 11.5% of newly diagnosed cancer cases in 2014. CRC is the third-most common form of malignant cancer among men, and the second among women worldwide, leading to approximately 694,000 deaths annually. Men are predominantly affected with an age-standardized rate (ASR) of 10.6/100,000 as compared with 8.2/100,000 among women with a ratio of 127:100, respectively. Variations within Saudi Arabia reveal that the highest rates are in the Eastern region, followed by Riyadh, Makkah, Qassim, and Tabuk. The median age at diagnosis in Saudi Arabia is 60 for men and 57 for women, as compared with worldwide figures of 68 for men and 72 for women (for colon cancer) and 63 for both men and women (for rectal cancer) according to the SEER Cancer Statistics Review (CSR) 1975–2014. The overall CRC survival rate among Saudi residents is 44.6%, which is lower than in many other countries (i.e., 60% in the United States).
Raising awareness about CRC risk factors could lead the general population to be more involved in screening as a result of increased knowledge about the disease itself., Factors leading to incremental risk include a sedentary lifestyle, obesity, excessive alcoholism, smoking, a low fiber diet, red and processed meat consumption, age, and a family history of CRC.,,, The inadequacy of public knowledge regarding CRC has been shown to contribute to the disease's manifestation and severity. It delays a patient's presentation time which can worsen outcomes., It has been noted that an impediment to this timing is linked to a lack of public knowledge regarding clinical CRC symptoms. Identifiable symptoms include alterations in bowel habits, hematochezia, melena, abdominal discomfort, fatigue, and an unexplained reduction in weight. Other attributable factors include certain beliefs and financial barriers. Disease prevention in the form of screening substantially limits CRC development via early recognition of precancerous polyps., Among several suggested screening programs for various diseases, CRC is an optimal candidate for early screening programs considering its common presentation and protracted disease course. Available methods include direct visualization of lesions through a flexible sigmoidoscopy and colonoscopy and secondary methods such as a fecal occult blood test.,,, Owing to variation in the median age at presentation in Saudi Arabia, screening should begin when residents are 45 years old. This contrasts with the globally recommended age of 55 years for men and 60 years for women.,
In recent years, primary care physicians have played an important role in the diagnosis and prevention of several disorders in the gastrointestinal tract. The role of primary care physicians is also of importance in the case of CRC. With proper screening programs, the rate of CRC could be markedly reduced.
National screening programs are one key way to prevent disease. In Czech Republic, for example, a general trend toward earlier CRC detection developed after an organized screening program was implemented in 2000.
The goals of this study were to assess knowledge about CRC in Saudi Arabia, gauge awareness of screening methods, and identify the main barriers that might prevent individuals from participating in screening programs.
| Subjects and Methods|| |
We conducted a cross-sectional study with a representative random sample of 422 Saudi residents in the city of Jeddah. A survey was conducted with visitors of the largest shopping mall in the western region of Saudi Arabia over a two-day period. This was part of a colorectal cancer awareness campaign during March 2018. The survey was in Arabic and completed before respondents entered the campaign exhibit. The questions were designed by members of the Gastrointestinal Oncology Unit in King Abdulaziz University Hospital (KAUH) in consultation with relevant literature.
A scoring system was designed to assess participants' CRC knowledge and relevant lifestyle choices that impact CRC risk. Correct answers were given one point. A questionnaire consisting of 14 items assessing the prevalence of CRC in Saudi Arabia, risk factors, symptoms, and other factors was administered [Table 1]. Some items had more than one right answer. For example, each correct risk factor for CRC identified (e.g. age, polyps) by the participant was awarded one point with a maximum score of 26 points indicating the highest score in CRC knowledge. Predictors of CRC knowledge included socio-demographic data (age, nationality, gender, education level, income, and place of residence) and a presence of personal or family history of CRC. Barriers hindering screening included fear of the procedure, fear of the results, discomfort, cost, and absence of symptoms.
Before the analysis, the dataset was prepared and checked for missing data. The analyses of the present study were performed using Stata/SE 15.0. Continuous variables were described with frequencies and percentages. Stepwise linear regression models were run to predict knowledge of CRC knowledge and barriers for seeking screening. A P value of less than 0.05 was determined to be statistically significant.
This study was approved (Reference No. 379-18) by the Research Committee of the Unit of Biomedical Ethics of King Abdul-Aziz University (28/5/2018). Oral consent to use data for research purposes was obtained from all participants.
| Results|| |
As shown in [Table 2], 212 study participants (50.24%) were men and most of our respondents (65.8%) participants were between 15 and 35 years old. Of these, 342 respondents (80.85%) were Saudi nationals. Most participants, 348 (83.05%) worked in a nonmedical field. The majority reported having a bachelor's degree (63.83%). In terms of health insurance, 210 (49.65%) had insurance coverage, 141 (33.34%) dealt with medical expenses privately, and 72 (17.02%) were covered by the government. Most participants, 68.72% lived in the western region, followed by 18.96% in the north, 5.69% in the central regions, 4.03% in the south, and 2.61% in the east.
[Table 3] illustrates multivariate analyses predicting CRC knowledge. Gender emerged as a significant predictor (P = 0.02) for determining whether individuals had knowledge of CRC as a medical disease. In terms of screening test knowledge, there was a significant association between education level (P = 0.001) and region of residence (P = 0.022). However, specific knowledge about colonoscopies, per se, was associated with gender (P = 0.038), an education level (P < 0.001), and a family history of CRC (P = 0.004). Regarding fecal blood test knowledge, education level was a significant predictor (P = 0.038). For knowledge of risk factors, income predicted the likelihood of identifying age as a risk factor (P = 0.008) and nationality predicted the knowledge of genetic mutations as a risk factor (P = 0.022).
Knowledge about additional symptoms (i.e. blood in stool, change in bowel habits, loss of appetite, and abdominal pain) and the remaining risk factors (polyps, alcohol consumption, red meat, low fiber diet, Inflammatory Bowel Disease (IBD), and leading a sedentary lifestyle) were not significantly predicted by our selected factors. [Table 4] presents the regression analysis for predicting barriers in undergoing a colonoscopy. Nationality was the only variable that predicted fear of the procedure (P = 0.005) while age was the only predictor for fearing the test results (P = 0.053). The absence of any barrier in performing preventative screening was influenced by one's education level (P = 0.032). No significant predictors were observed for cost, discomfort, and absence of symptoms.
| Discussion|| |
According to our results, women had more knowledge of CRC as a disease and colonoscopies as a screening method than men which is consistent with past studies., In terms of education level, results revealed that higher educational attainment was predictive of CRC knowledge and its screening modalities. Additionally, the absence of any barriers in performing preventative screening was highly influenced by one's education level. These results are consistent with past research.,, Furthermore, CRC knowledge was assessed using a scoring system with mean knowledge of 8.05 out of 26 across our sample—which is rather low. However, this result is consistent with other studies, namely, Koo et al. This study showed a low mean knowledge of symptoms and risk factors in countries across Asia with the lowest knowledge scores in India, Malaysia, and Singapore (mean = 0.00 from 9), and lowest risk factor knowledge scores in India, Malaysia, Singapore, Korea, and Brunei (mean = 0.00 from 9). We also observed that the most relevant factor for predicting knowledge was education level. Higher education levels predicted an increase in knowledge score of 0.566 and a P value of 0.073. This corresponds to a study from Wardle et al. revealed that participants with higher education attainment demonstrated great knowledge scores about CRC (P ≤ 0.001).
The presence of a personal or family history of CRC was predictive of knowing that a colonoscopy as a key screening method. This could be because having a relative with CRC would make someone more likely to gain knowledge about the disease and its prevention. In our study, age had a significant impact on one's hesitance to receive a colonoscopy out of fear of its results while in a study from Galal et al., fear of the result was significantly associated with gender, which was not the case in the present study. Furthermore, higher CRC knowledge was significantly related to higher income. This could be attributed to respondents having easier access to information. In the present study, the majority of participants (71%) stated a willingness to pay for screening based on a physician's recommendation. This is in contrast to what was observed by Deng et al.where only 37.5% of patients agreed to be screened voluntarily, 41.3% reported that they would be screened after a doctor's recommendation, and 21.3% refused to be screened. Furthermore, our study revealed an association between the geographical region of residence and a willingness to be screened at one's own expense. While other studies found that participation in a screening program is directly related to disease awareness.
It is well-known that primary care physicians play a major role in disease prevention and prompt diagnosis. Our findings should help primary care physicians in Saudi Arabia to target patients that are expected to have less knowledge about CRC, namely, low-income patients and patients with lower educational levels. Primary care physicians should take more time with those patients to educate them about the risks and prevention of CRC. Moreover, talking to older patients and exploring their fears about the colonoscopy procedure is essential since we found that older patients fear the results of the colonoscopy and this stops them from pursuing it.
An assessment of the effects of educational campaigns on CRC awareness could have been better evaluated if participants' knowledge had been resurveyed after the campaign (not just before) to assess the effectiveness of the campaign.
While there are clear guidelines for CRC screening in Saudi Arabia, there is no organized national screening program. Thus, we encourage policymakers to consider implementing a unified national program for educating the public about CRC.
The authors would like to acknowledge the great efforts of all the students that participated in this study: Budoor Salman, Maram Alnabulsi, Mariyah Gamlo, Riyadh Shati, Maryam Enani, Mariam Ageel, Afnan Saeed, Marwah Rambo, Wafa Saber, Samaher Ismail, and Faisal Kaki for their valuable efforts and active role in data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Shahrani Z, Al-Rawaji A, Al-Madouj A, Hayder M. Cancer Incidence Report 2014. Saudi Cancer Registry; 2017.
World Health Organization. World Health Statistics. Geneva, World Health Organization; 2012.
Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Kosary CL, et al
. SEER cancer statistics review, 1975-2014. National cancer institute; based on November 2016 SEER data submission, posted to the SEER web site, April 2017.
Zubaidi AM, AlSubaie NM, AlHumaid AA, Shaik SA, AlKhayal KA, AlObeed OA. Public awareness of colorectal cancer in Saudi Arabia: A survey of 1070 participants in Riyadh. Saudi J Gastroenterol 2015;21:78-83.
] [Full text]
Su TT, Goh JY, Tan J, Muhaimah AR, Pigeneswaren Y, Khairun NS, et al
. Level of colorectal cancer awareness: A cross sectional exploratory study among multi-ethnic rural population in Malaysia. BMC Cancer 2013;13:376.
Schliemann D, Su TT, Paramasivam D, Donnelly M. Effectiveness of mass and small media campaigns to improve cancer awareness and screening rates in Asia: A systematic review. J Glob Oncol 2019;5:1-20.
Imran M, Sayedalamin Z, Alsulami SS, Atta M, Baig M. Knowledge and awareness of colorectal cancer among undergraduate students at King Abdulaziz University, Jeddah, Saudi Arabia: A survey-based study. Asian Pac J Cancer Prev 2016;17:2479-83.
Liu PH, Wu K, Ng K, Zauber AG, Nguyen LH, Song M, et al
. Association of obesity with risk of early-onset colorectal cancer among women. JAMA Oncol 2019;5:37-44.
Bradbury KE, Murphy N, Key TJ. Diet and colorectal cancer in UK Biobank: A prospective study. Int J Epidemiol 2019;dyz064. doi: 10.1093/ije/dyz064.
Wong MC, Ding H, Wang J, Chan PS, Huang J. Prevalence and risk factors of colorectal cancer in Asia. Intest Res 2019;17:317-29.
McVeigh TP, Lowery AJ, Waldron RM, Mahmood A, Barry K. Assessing awareness of colorectal cancer symptoms and screening in a peripheral colorectal surgical unit: A survey based study. BMC Surg 2013;13:20.
Alzaidi EA, Asrar SA, Alhumoud AM. Beliefs and knowledge about cancer among educated Saudi women in Riyadh city. EJPMR 2016;3:571-6.
Arafa MA, Farhat K. Colorectal cancer in the Arab world--screening practices and future prospects. Asian Pac J Cancer Prev 2015;16:7425-30.
Ustundag H, Zengin N, Andsoy II, Gul A. Awareness of health sciences students about colorectal cancer risk factors. Eur J Cancer Care (Engl) 2019;28:e13016.
Galal YS, Amin TT, Alarfaj AK, Almulhim AA, Aljughaiman AA, Almulla AK, et al
. Colon cancer among older Saudis: Awareness of risk factors and early signs, and perceived barriers to screening. Asian Pac J Cancer Prev 2016;17:1837-46.
Loomans-Kropp HA, Umar A. Cancer prevention and screening: The next step in the era of precision medicine. NPJ Precis Oncol 2019;3:3.
Teixeira C, Martins C, Trabulo D, Ribeiro S, Cardoso C, Mangualde J, et al
. Colorectal cancer screening: What is the population's opinion. GE Port J Gastroenterol 2018;25:62-7.
Wieten E, Schreuders EH, Grobbee EJ, Nieboer D, Bramer WM, Lansdorp-Vogelaar I, et al
. Incidence of faecal occult blood test interval cancers in population-based colorectal cancer screening: A systematic review and meta-analysis. Gut 2019;68:873-81.
Wu WM, Wang Y, Jiang HR, Yang C, Li XQ, Yan B, et al
. Colorectal cancer screening modalities in Chinese population: Practice and lessons in Pudong New Area of Shanghai, China. Front Oncol 2019;9:399.
Alsanea N, Almadi MA, Abduljabbar AS, Alhomoud S, Alshaban TA, Alsuhaibani A, et al
. National guidelines for colorectal cancer screening in Saudi Arabia with strength of recommendations and quality of evidence. Ann Saudi Med 2015;35:189-95.
Mannucci A, Zuppardo RA, Rosati R, Leo MD, Perea J, Cavestro GM. Colorectal cancer screening from 45 years of age: Thesis, antithesis and synthesis. World J Gastroenterol 2019;25:2565-80.
Triantafillidis JK, Vagianos C, Gikas A, Korontzi M, Papalois A. Screening for colorectal cancer: The role of the primary care physician. Eur J Gastroenterol Hepatol 2017;29:e1-e7.
Suchanek S, Majek O, Vojtechova G, Minarikova P, Rotnaglova B, Seifert B, et al
. Colorectal cancer prevention in the Czech Republic: Time trends in performance indicators and current situation after 10 years of screening. Eur J Cancer Prev 2014;23:18-26.
Brandt HM, Dolinger HR, Sharpe PA, Hardin JW, Berger FG. Relationship of colorectal cancer awareness and knowledge with colorectal cancer screening. Colorectal Cancer 2012;1:383-96.
Khayyat YM, Ibrahim EM. Public awareness of colon cancer screening among the general population: A study from the Western Region of Saudi Arabia. Qatar Med J 2014;2014:17-24.
Othmani MAA, ALenzi SM, Atawi FAA, Omairi WAA, Shehri MAA, Merghani TH, et al
. Awareness of colorectal cancer in Tabuk City, Saudi Arabia. Int J Med Res 2017;3:112-5.
Koo JH, Leong RW, Ching J, Yeoh KG, Wu DC, Murdani A, et al
. Knowledge of, attitudes toward, and barriers to participation of colorectal cancer screening tests in the Asia-Pacific region: A multicenter study. Gastrointest Endosc 2012;76:126-35.
McCaffery K, Wardle J, Waller J. Knowledge, attitudes, and behavioral intentions in relation to the early detection of colorectal cancer in the United Kingdom. Prev Med 2003;36:525-35.
Deng SX, Gao J, An W, Yin J, Cai QC, Yang H, Li ZS. Colorectal cancer screening behavior and willingness: An outpatient survey in China. World J Gastroenterol 2011;17:3133-9.
Hadjipetrou A, Anyfantakis D, Galanakis CG, Kastanakis M, Kastanakis S. Colorectal cancer, screening and primary care: A mini literature review. World J Gastroenterol 2017;23:6049-58.
[Table 1], [Table 2], [Table 3], [Table 4]