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Assessment of the knowledge and awareness of colorectal cancer among undergraduate students in Saudi Arabia: a survey based study 1

*Zaid Sayedalamin, 2Abdulaziz Alandijani, 3Majed Almutairi, 4Abdullah Alreheli, 5Majd Alnawwar, 6Mohammed Lamfon, 7Mohamed Magdi Atta

1, 2, 3,4,5,6

House Officer, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, KSA 7 Professor, Department of Medicine, Rabigh Medical College, King Abdulaziz University, Jeddah, KSA Correspondence*: Zaid Sayedalamin Faculty of Medicine, King Abdulaziz University, Jeddah, KSA Email: [email protected], phone no. 00966548000796

Abstract Introduction The cancer mortality statistics in Saudi Arabia have been significantly elevated in recent years. According to the Saudi Cancer Registry, the colorectal cancer ranked first among male population and third among female population. The aim of this study is to assess the level of knowledge and awareness of colorectal cancer among undergraduate students from different faculties at King Abdulaziz University. Materials and Methods A cross-sectional study was conducted in King Abdul-Aziz University – Jeddah – Saudi Arabia during February 2014. The data analyzed by SPSS v21. Results A total of 523 students answered the questionnaire (mean age of 21.49±2.47 years). Majority of the students (82.3%) were heard about colorectal cancer. However, approximately (30-40%) of the students had received information material regarding colorectal cancer within their school curriculum and Hospital respectively. More than half of students (68.2%) recognized that colorectal cancer is a preventable disease. Majority (77.0%) did not know any type of tests that help in detecting colorectal cancer. Half of the students (52.0%) were able to recognize that family history is one of the risk factors of colorectal cancer and for age were (59.4%) of the participants answered it correctly.

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Conclusion The findings of this study revealed that the knowledge and awareness of colorectal cancer early warning signs, symptoms of cancer risk factors among undergraduate students at King Abdul-Aziz University, Jeddah, Saudi Arabia were variable in different faculties, but overall were low. It warrants an extensive health education campaign on colorectal cancer as it is one of the commonest cancers in Saudi Arabia.

Keywords: Colon cancer, awareness, attitude, KSA

{Citation: Zaid Sayedalamin, Abdulaziz Alandijani, Majed Almutairi, Abdullah Alreheli, Majd Alnawwar, Mohammed Lamfon, Mohamed Magdi Atta. Assessment of the knowledge and awareness of colorectal cancer among undergraduate students in Saudi Arabia: a survey based study.

American Journal of Research

Communication, 2016, 4(3): 141-155} www.usa-journals.com, ISSN: 2325-4076.

Introduction The cancer mortality statistics in Saudi Arabia have been significantly elevated in recent years. According to the Saudi Cancer Registry, the colorectal cancer ranked first among male population and third among female population. In 2009, a total of 1109 cases of cancer were diagnosed and registered, half of the cases were 617 (55.6%) males and 492 (44.4%) females. The median age at diagnosis was 56 years among females and 60 years among males[1]. Colorectal cancer is considered one of the leading causes of death worldwide, in United State, is considered the second leading cause of death. According to the national statistics, in U.S 2013,

it is

estimated that there will be 142,820 new cases diagnosed and 50,830 deaths due to this disease[2]. The community has a crucial role in increasing the awareness of the risk factors and warning signs on common diseases such as colorectal cancer. This process will provide adequate knowledge about the disease may lead the general population to involve in the cancer screening[3]. The colorectal cancer is one of the preventable diseases, there are a different ways of the prevention such as life style modification

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and cancer screening regularly and these ways are contribute in reducing the incidence of the colorectal cancer[4]. The risk factors that are correlated with cancer most of them are avoidable, such as, sedentary lifestyles (lack of physical activity, obesity, excessive smoking and excessive alcohol), nutrition deficiency (low dietary fiber, high saturated fat intake) and infections[5]. Certain of the most important risk factors such as family history and age cannot be modified[6]. Colorectal cancer may cause one symptom or more such as, chronic change in bowel habits, rectal bleeding, chronic abdominal pain, weakness and fatigue, fever and unexplained weight loss. There are some condition may related to CRC, such as irritable bowel syndrome, inflammatory bowel disease, infection or hemorrhoids [7]. Despite the increasing in the incidence of colorectal cancer, health education roles about colorectal cancer is not emphasized by Ministry of Health in compare with other cancers such as breast and lung cancer. Ministry of Health did not established national screening program for the colorectal cancer, therefore, it's important to activate the role of health promotion and enhance the level of awareness toward colorectal cancer in the Saudi Population. Hence, our aim of this study is to assess the level of the knowledge and awareness of colorectal cancer among students from different faculties at King Abdulaziz University, Saudi Arabia. Method and Materials A cross-sectional study was conducted in King Abdul-Aziz University – Jeddah – Saudi Arabia in different faculties during February 2014. The faculties were randomly selected. In recruiting the student participants, convenience sampling with informed consent was applied before filling the questionnaire. The students were recruited with these inclusion criteria: 1) aged 18-25 years; 2) a current undergraduate student. Ethical clearance to conduct the present study was obtained from the Rabigh Medical College, Research Ethics Committee. Research Instrument: The questionnaire was adapted from surveys identified in relevant literature, containing 28 items. The colorectal cancer awareness questionnaire consisted of: Awareness section (early colorectal cancer signs and symptoms), (colorectal cancer risk factors) and Knowledge section.

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Statistical Analyses Data were analyzed using the SPSS version 21.0. Descriptive statistics (e.g. mean and standard deviation) were used to describe continuous variables, while categorical variables were presented in frequencies and percentages. Independent sample t-test was used to determine the mean score differences of the awareness, knowledge sections between genders and faculties. Statistical significance was determined at p < 0.05. Results A total of 523 undergraduate students answered the questionnaire. The students were within the age range of 18-25 years (mean age of 21.49±2.47 years). Majority of the participants were females (63.0%). In addition, approximately half (53%) of the participants were from medical college. Table 1.Demographic Characteristics (n=513) Description

N (%)

Age ˂ 20 years old

203 (38.7)

˃ 20 years old

320 (61.2)

Gender Male

194 (37.0)

Female

331 (63.0)

Faculty Medical

316 (56.8)

Non-medical

209 (43.2)

Level of Education 1st year

62 ( 11.8)

2n year

147 (28.0)

3rd year

106 (20.2)

th

4 year

84 (16.0)

5th year

60 (11.4)

6th year

66 (12.6)

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Knowledge Sections

The Knowledge section consisted of sex items that are assessing the level of knowledge of colorectal cancer. Majority of the students (82.3%) were heard of colorectal cancer as showed in Figure1. However, approximately (30-40%) of the students had received information material regarding colorectal cancer within their school curriculum followed by social media (20.4%), nearly (40%) from other sources such as TV, Hospital and Journalism. More than half of the students (68.2%) were recognized that colorectal cancer is a preventable disease. Regarding colorectal cancer screening tests, only (33.6%) had awareness on colorectal cancer screening tests, while (77.0%) did not know or heard of any type of tests or examination that help in detecting colorectal cancer in early stage, Figure2. The recommended age to start screening in average-risk population (50-60 years old) were recognize in Figure3, by only (6.5%), while (33.0%) of the students choose (20-30 years old), (18.3%) were choose (40-50 years old). Last question in the knowledge section were to assess their impression regarding colorectal cancer, half of the participants (56.8%) they think that colorectal cancer is a disease can be cured, while (29.0%) choose that colorectal cancer is a fatal disease, rest of them do not know.

Figure1. Have you Ever Heard About Colorectal Cancer Female

Mele

13.14% 4.57%

49.90%

Yes

32.38%

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No

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Figure2. Have you ever heard about any tests used in detection of colorectal cancer Male

44.38%

22.67%

18.67%

No

Female

14.29%

Yes

Figure3. The recommended age to start screening in average-risk population

11.62% 3.43%

20-30 years old 30-40 years old

6.48%

32.95%

40-50 years old 50-60 years old

18.29%

Above 70 years old

27.24%

I don't know

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Figure4. Do you think that colon cancer is a preventable disease Male

Female 40.57% 27.62%

22.48% 9.33%

No

-

Yes

Awareness of Risk Factors and Warning Signs Sections

The Awareness regarding risk factors section there were items on modifiable risk factors (diet, body weight management and lifestyle) and non-modifiable risk factors (age and family history). Half of the students (52.0%) were able to recognize that family history is one of the risk factors of colorectal cancer, while (25.7%) they did not think that family history of colorectal cancer may influenced the rate of incidence and (22.3%) did not know. The age considered one of non-modified risk factors, however, (59.4%) of the participants answered it correctly, while (26.7%) did not think that and (13.9%) did not know. Approximately 60-70% of the participants answered correctly for most of the diet, body weight management and lifestyle items are considered as risk factor of colorectal cancer. The most recognized symptoms and warning signs were blood in stool (60.0%) followed by unexplained fever and weight loss (59.2%) and persistent unexplained chronic abdominal pain (53.1%).

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Table 2. Distribution of awareness of risk factors and warning Signs among medical and non-medical students Do you think that the incidence of colon cancer is influenced by family history?

Medical Students

Yes

No

I don't know

36.76

12.76%

10.67%

12.95%

11.62%

%

Non-medicine

15.24

Students

%

Do you think that the age considered one of the risk factors?

Medical Students Non-medicine Students

Yes

No

I don't know

40.00

13.52%

6.67%

13.14%

7.24%

% 19.43 % Do you think that blood in stool is one of the symptoms related to colon cancer?

Medical Students Non-medicine Students

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Yes

No

I don't know

38.67

7.24%

14.29%

5.14%

13.33%

% 21.33 %

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Barriers in Seeking Medical Advice

In the Barriers in seeking medical advice section, the different barriers were categorized into three groups, namely emotional, practical and service barriers. The main barrier category that was identified practical barriers, too busy to make time (43.3%).was emotional barriers, which included scared and worried about what the doctor may find (37.6%) and embarrassed (19.1%) shows in Figure5. Other barriers to highlight included two practical barriers, was emotional barriers, which included scared and worried about what the doctor may find (37.6%) and embarrassed (19.1%). Independent t-test was conducted to compare the awareness and knowledge between males and females and medical students with non-medical students. Females had significantly higher scores compared to their male counterparts in the knowledge section (t (331) = -2.46, p < 0.01) and awareness section (t (311) = -1.77, p < 0.07). Results also showed that medical students had significantly higher awareness and knowledge compared to students from non-medical faculties.

Figure5. Barriers in Seeking Medical Advice

Scared and worried Embarrassed Too busy to make time

37.60%

43.30%%

19.10%

Discussion: -

Knowledge Sections:

This study investigated the knowledge, awareness and barriers in seeking medical advice among undergraduate university students. The overall results revealed that the

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majority of the students had low awareness and knowledge levels. Understanding and recognizing public awareness regarding CRC may provide valuable information to incorporate the policy decision for prevention, early diagnosis and improvement of survival for CRC[3]. In the current study, gender was significantly associated with awareness of colorectal cancer; the females had significantly higher scores compared to their male counterparts in the knowledge section and the findings of this study were in agreement with a study that have been carried out in Malaysia undergraduate students on the awareness and knowledge levels of cancer[8]. However, based on the findings of this study, students who were female and from medical faculties demonstrated significantly higher awareness, knowledge and attitude scores compared to males and non-medical students. These results were in agreement to the findings of another study on cancer knowledge, attitude and practices which was carried out among undergraduate students in Malaysians[8]. The score differences between genders may be due to the fact that females are more involved in cancer detection actions, particularly because cancer prevention campaigns have focused mainly on breast and cervical cancers which involves only females [9]. Results from the current study demonstrated that a near half of the participants have been heard about colorectal cancer through the study curriculum, while the role of media and public health were insufficient in raising awareness of the population. Hence, it is important that the Healthcare professionals should take this opportunity to play an active role communicating the messages for colorectal cancer prevention through the mass media. Despite the increasing in the incidence of colorectal cancer, health education regarding the CRC is not highlighted by the Ministry of Health yet, comparing to other cancers such as lung and breast cancer. In contrast, the Ministry of Health did not established national screening program for the colorectal cancer, therefore, it's important to activate the role of health promotion and investigate the level of awareness toward colorectal cancer in the Saudi Population. In Malaysia, rural community have the access to the television and this should be used for education tool. A study in Malaysia has shown one of the best methods in educating the rural population was via mass media for example television where ninety seven per cents of the population received information regarding severe acute respiratory syndrome during the outbreak via television [10]. Majority of the students (68.2%) had positive attitudes towards cancer and cancer prevention, which is essential for behavioral Sayedalamin, et al., 2016: Vol 4(3)

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modification, and the findings of this study were in agreement with a study that have been carried out in Malaysia also demonstrated similar findings, in which university students had positive attitudes towards cancer prevention[11]. The recommended age to start screening in average-risk population (50-60 years old) were recognize by only (6.5%) of the participants, which demonstrate a low level of knowledge compared to similar study that's present majority of their participants (83%) were able to identified the recommended age[12]. Regarding colorectal cancer screening tests, there was poor awareness of CRC tests which only (33.6%) had awareness of screening tests, and the findings of this study were in agreement with a study that have been carried out in Greek students also demonstrated similar findings[12].

-

Awareness of Risk Factors Sections

Overall, the knowledge of colorectal risk factors among the undergraduates was poor with the exception of the diet, body weight. Poor knowledge was particularly regarding items related to modifiable risk factors (diet, body weight management and lifestyle) and non-modifiable risk factors (age and family history) this has been found previously [13-16]. Public health campaigns may focus on increasing the awareness of these risk factors as it is important to help the public better understand the link between lifestyle and cancer. Increasing public awareness in turn could motivate healthy lifestyle practices, which will contribute in lowering cancer incidence as well as other chronic diseases[17]. The community awareness may lead to increased healthy behaviors and that's could helping in reducing the overall burden of ill-health on the population [15]. In the current study, there have been higher differences in the gender awareness of colorectal risk factors; we found that females had higher awareness than males. That's reflect the females are more aware of the risk factors such as life style modification which is considered one of the strongly associated risk with cancer and that was against the similar study which was reflects that males had more aware of lifestyle as risk factor for cancer than females[18]. However, ironically, medical students demonstrated highly awareness of the relation between colorectal cancer and elderly than non-medical students witch most probably due to their study curriculum. Medical students also had higher awareness of diet, body weight management, and lifestyle and infections such as inflammatory bowel disease as risk factors for colorectal cancer, which reflect that medical students

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demonstrated better knowledge of colorectal cancer risk factors. That's will recommend that's the Ministry of Health should activate the role of public heath to raising the awareness of the community.

-

Awareness of Symptoms and Warning Signs Sections

The current study shows that most of the participants have low level of knowledge regarding and symptoms of colorectal cancer. More than (45%) of the participants could not recognize the warning signs. Among our study population only (50%) could identified the symptoms of colorectal cancer. Rashid et.al (2009), the abdominal pain was the third common clinical presenting symptoms in colorectal cancer patients in one of the teaching hospital in Malaysia[19]. In our study, the abdominal pain was the second most recognized signs followed by unexplained fever and weight loss. In addition, the most recognized symptoms were persistent blood in stool. Females knew more colorectal cancer symptoms than males. This has been consistent with other studies [13, 20, 21]. The education campaigns which targeting men could make an impact on the level of the knowledge between gender. Medical students showed higher knowledge of symptoms for colorectal cancer than non-medical which could reflect better knowledge of colorectal cancer from study curriculum and that's lead Ministry of Health to highlighting the role of public health and activate the campaigns of the common chronic diseases and encourage both sexes from different colleges and school levels into it. Awareness of warning signs and risk factors of colorectal cancer are associated with more positive attitude as well as the regular screening, and that's helping in reduce the incidence and mortality of colorectal cancer [22, 23].

-

Barriers in Seeking Medical Advice

In the Barriers in seeking medical advice section were include, emotional, practical and service barriers. In this study, participants have identified that several emotional and practical barriers as the main barriers in seeking medical advice when they notice a warning sign of cancer. This finding is similar to previous study carried out in Malaysia[8]. Among The practical barriers such as too busy to make time were the most endorsed barriers by the participants. These suggest that some participants may

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not feel that their symptom is important and deserving of any medical attention. The emotional barriers were also highly endorsed by the participants. This may imply that undergraduates are unaware of the early diagnosis benefits and efficacy of many cancer treatments [9].

-

Limitations

Certain limitations of this study should be noted. The half of the participants were medical students which may influenced the results, the response from non-medical students were low. Further research is needed with higher number of non-medical students with reliable and useful tool for assessing colorectal cancer awareness. Evaluating the effectiveness of education campaigns designed to improve the knowledge and awareness of the common diseases such as colorectal cancer.

Conclusions In conclusion, awareness and knowledge of the participants were significantly higher among female students and medical students. However Students need to be better oriented about colorectal cancer and general awareness of colorectal cancer need further enhancement. It warrants to establishing health education campaign to increase awareness as to encourage population to seek for medical advice on colorectal cancer as it is one of the commonest cancers in Saudi Arabia. This study provides a valuable basis of information toward the formulation of relevant cancer prevention strategies, especially within the scope of health education among the undergraduate students.

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