PUBLIC AWARENESS OF RISK FACTORS AND SCREENING FOR COLORECTAL CANCER AMONG SAUDI ARABIA POPULATION, 2016

* Ibrahim Ahmed Alzahrani , Mather Jafar Alabduljabbar, Mariam Jaber Aljehani, Asma Mushabab Alahmari 3 , Mohammad Mustafa Aljafar 4 , Ahmad Hamdan Almohammadi 1 and Amal M. Ayoub Omar 1 . 1. Medical intern, Taibah University. 2. Medical intern, Ibn Sina National College. 3. Medical student, Almaarefa colleges. 4. Medical intern, Saudi University. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


Objectives: -
 To estimate the prevalence of public awareness of early screening for colorectal cancer (CRC).  To assess the knowledge and attitude about early screening among KSA population regarding CRC.  To identify the Awareness of population about the symptoms and risk factor of CRC.  To know the barrier of screening.

Methodology: -
Based on the nature of the study, and the objectives sought to be achieved, and the data to be obtained, and based on the questions that study sought to answer them, the study used descriptive analytical approach which is based on the study of the phenomenon, as it is in reality, and contribute to describe it accurately as it illustrates its characteristics through information gathering, analysis and interpretation, and then apply the results in the light. one of this approach features that it does not stop at the end of information gathering about certain phenomenon classifying and organizing it in order to investigate different aspects of the phenomenon, but it goes to reach conclusions contribute to the understanding of reality through the analysis of the phenomenon, interpretation, and then reaching meaningful generalizations which make the study increase the credit of knowledge on the phenomenon, and contribute to the development and reality of phenomenon destination and improve it.

Tool of the study: -
The questionnaire consists of five main parts of questions. The first part includes demographic questions as (sex, age, Educational level, Region, Living location, Monthly income). And the second part includes questions related to the awareness about the symptoms and risk factor of colorectal cancer. The third part includes questions related to the awareness of early screening for colorectal cancer. The fourth part includes questions related to Knowledge and attitude of colorectal cancer early screening. While include questions related to barrier of colorectal cancer early screening.

Statistical methods: -
The statistical analysis program (SPSS v.22) was been used in the study in data entry and analysis, with the use of necessary statistical methods to achieve the objectives of the study. The following statistical methods were used:  Frequencies.

Population & Sample of the Study: -
The study population includes all KSA population (31.52) million till the year of research, a sample of (4977) persons were chosen randomly, and answered the electronic questionnaire, table (1) shows their properties according to their personal data. It is noticed that 44.2% of them were living in the middle area of KSA, and most of them were living in the cities. And according to their monthly income; 48.6% of them had less than (5000) Riyal monthly, while 23.7% of them had from (5000-10000) Riyal monthly, and the rest of them had more incomes than mentioned. The next diagram shows that. 100.0 The next diagram clarifies some of the disease symptoms, and the percentage of that the participants'' thought it is really one of the symptoms or not, the most important symptom was "blood with stool" with a percentage of 29%, then "quick weight loose" with a percentage of 19%, 14% of them thought that "stomach ache" is a symptom of colorectal cancer, and the same percentage for those who thought that "body weakness" is a symptom of the disease.

Personal data
2043 And the next diagram shows some factors that may increase the risk probability of colorectal cancer, and the proportion of respondents believe all of them; as we note that the most important of those things from the viewpoint of the participants are "inflammatory and ulceration of the colon," and "the type of food, then" a family member infected with the disease earlier ".
The next table shows the participants' distribution according to their belief which category is the most at risk of colorectal cancer, where we note that 29.3% thought that men are more at risk of developing this type of cancer, while 24.2% thought the equal chance of injury between the sexes in this type of cancer. 100.0 The next diagram shows the symptoms that the participants thought it's appearance requires early colorectal tumor checkup; the most important symptoms were "blood with stool", "body weakness". The next table shows the participants' distribution according to whether they made the early colorectal tumor checkup or not after they heard about it or advised to do that; 5.2% of them made the early checkup, while 94.8% of them didn't. The next diagram shows some ways of early colorectal cancer detection and the participants' knowledge about these ways, we notice that the most common known way to detect the disease in KSA is "Colonoscopy" and "Screening blood in the stool sample".

Frequency
And when asking the participants about the most accurate tests; 39.8% answered "Colonoscopy", and 9.4% barium X-dye of the intestines, while 6.9% answered abdominal CT, and 5.8% "examining blood in a stool sample". While found 38.1% of participants have no knowledge about the most accurate tests for the detection of colorectal cancer. 100.0 And according to the reasons that might prevent the participants from having the required tests, the most important reasons were "the fear of the test results", and "fear of the tests" and the financial position. The next diagram shows the answers' distribution on the question. The next table shows the participants' distribution according to the reason behind the lack of an early screening for colon cancer, where we note that 35.6% of participants answered that the lack of awareness for the disease and tests is preventing them from conducting the examination, while 29.6% said that the reason behind the lack of an examination is lazing and being busy, while the others responded by other causes. 100.0 Also, when they were asked about whether they are people who have to early screening, and they have a clearer idea of early screening, will they do and advise those around them to do it? The majority of them replied that they would do so, while the remaining participants said that they wouldn't.

Frequency
Percent Yes 4363 87. 7  No  614  12.3  Total  4977 100.0 Finally, when the participants were asked about the best ways to spread awareness among people about early screening for colorectal cancer, most of the answers were that the best way is through social networking sites, and awareness campaigns in public places, the curriculum and the internet, TV and others, the next diagram shows the distribution of participants' answers about each of the previous methods.

Test Hypotheses:
The next table illustrates the participants' early colorectal check extent according to their personal information. We conclude that there is a relation between sex, age, educational level, monthly income variables and the participants' early colorectal check extent, but there is no effect of the region or living place variables. We conclude from the next table that there is a relation between whether the person conducting early screening for colorectal cancer and the belief that cancer of the colon and rectum can be prevented, as well as a relationship between whether the person conducted the check and the extent of his belief that colorectal cancer can be detected early, before the appearance of symptoms, There is a relationship between whether the person conducting early screening and the belief that colorectal cancer can be treated if detected, and finally a relationship between whether the person conducted early screening and the belief that early screening for colon cancer and early detection gives treatment a chance to be more effective.

Discussion: -
Colorectal cancer (CRC) is the fourth leading cause of death worldwide [7]. It is well recognized that lack of cancer awareness in the community can have deleterious effects on time to presentation and, unsurprisingly therefore, on overall survival [8,9,10,11]. And the vast majority of cases and deaths from colorectal cancer can be prevented by applying existing knowledge about cancer prevention [12]. Therefore, this study conducted to assess public awareness of risk factors and screening for colorectal cancer among Saudi Arabia population.
The respondents showed low level of awareness about the symptoms and risk factor of colorectal cancer. The main sources of information for respondents were personal attention, followed by social media and internet. Despite its importance, awareness campaigns represent the source of information for 6.1% just. This shows the lack and dereliction of awareness campaigns related to colorectal cancer. Many previous studies showed found low levels of knowledge of CRC, including awareness of its symptoms and risk factors in many countries. In Hong Kong [13]. In West Malaysia [14]. Western Australians [15]. Iranians [16]. American Indians [17]. An ethnically diverse population in Australia [18].
At the current study, most of the respondents heard about colorectal cancer before. While 24.2% didn't hear about it before. This finding so close to study conducted by Bukhari et al., at Makah found that 23% of targeted population not hear about Colorectal cancer [19]. Colorectal cancer is the second most common cancer in Saudi Arabia [20].

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According to our results only 16.4% reported that CRC is the second most common cancer in Saudi Arabia. While 63.6% reported that they don't know the order of colorectal cancer. This is in line with results of Bukhari et al., who's reported that 66% not know that colorectal cancer is common in Saudi Arabia [19]. The symptoms of colorectal cancer include; rectal bleeding, change in bowel habit and abdominal pain. They may also present with systemic symptomsanorexia, significant weight loss, fatigue and symptoms of anemiafeatures usually suggestive of advanced disease. In question regarding to respondents' knowledge of colorectal cancer symptoms, the most symptom reported by respondents at this study was "blood with stool" by 29%. McVeigh et al., found at their study that (62%)identified blood in the bowel motion as a worrying symptom [21]. This difference show the low level of knowledge about CRC symptoms at our study.
Colorectal cancer risk factors include; age, familial and hereditary factors, as well as environmental lifestyle-related risk factors such as physical inactivity, obesity, smoking, and alcohol consumption [12]. the most risk factor reported by responders at this study was "inflammatory and ulceration of the colon,"by 32%. In Saudi Arabia, colorectal cancer ranking first most common cancer among men (10.6%) and third among women (8.9%) [20]. This perhaps because of the prevalence of smoking among men more than it among women. But in our study only 29.3% thought that men are at risk of colorectal cancer more than women.
The U.S. Preventive Services Task Force (USPSTF) and American Cancer Society strongly recommend that clinicians screen all men and women 50 years of age or older who are at average risk for colorectal cancer. The individuals who are considered at high risk because of a history of suggestive familial polyposis or hereditary nonpolyposis colorectal cancer or those with a personal history of ulcerative colitis may need to be screened earlier than age 50 [22]. In this study, there was poor public awareness knowledge and attitude about early screening for colorectal cancer. Our finding in line with Zubaidi et al., study in KSA that found there existed large knowledge gaps when it came to CRC screening, symptoms, risk factors, and detection [23]. Whereas the most of our respondents 67% had never heard about early colorectal detection. This finding confirm Bukhari et al., study in Makah fining that most respondents didn't hear about early screening of Colorectal 52% [19]. This is considered a source of concern because the diagnosis of earlier stage disease has the potential to improve survival. The source of information about early colorectal detection at our study for the category whose heard about it was personal attention and Social media and internet, while the awareness campaigns represent the source of information for 17.6% of them. Given the awareness campaigns related to breast cancer, for example the highly successful "Pink Ribbon" campaign and the introduction of "Breast Cancer Awareness Month" annually every October has led to dramatic increase in motivation for patients to attend for screening, and have therefore resulted in an increased rate of detection of breast cancers [24]. This indicates the active role of awareness campaigns in the early screening of cancer and the need to employ it larger in relation to colorectal cancer. Although Saudi Arabia has the available resources for diagnostic and therapeutic procedures, there is lack of a consistent organized screening program for CRC screening [23].
CRC screening should be initiated at 50 years of age [23]. But according to or results only 9.8% knew that, this result similar to Alamin et al., finding by study for undergraduate students at KSA [25]. This show a low level of knowledge about CRC screening compared to other study for Greek medical students that's present majority of their participants (83%) were able to identified the recommended age [26]. But this difference may be due to the difference in the target group at studies, the latter was belonging to medical students.
According to our results only 5.2% of the respondents had the early CRC screening after hearing about it. Less than half of this group were committed to the scheduled screening. Which means that there is a need for more effort to urge the community to make the early CRC screening. The vast majority of our respondents didn't know the CRC screening centers in their cities. This was confirmed by a study in Mecca and found that the most didn't know where the place of colorectal cancer screening is [19].
In our study the most common known way to detect the disease in KSA is "Colonoscopy", and it is the most accurate way by responders believe, the main reason for the preference of most of the respondents of this method is that they do not know anything about other screening methods. Most of our respondents do not have any reasons preventing them from having the early screening for colorectal cancer. In many of the studies reported that the financial burden is the most common obstacle of CRC screening programs [27,28,29]. But this does not apply to the Kingdom of Saudi where health care is publicly funded in government hospitals, in addition to a proportion of 2052 population being health insured. Nonetheless, access to health care facilities can be difficult due to long waiting times in public hospitals [30].
Lack of awareness for the diseased and tests were the reason of preventing one third the respondents from having the early screening. As well the majority reported that they will do the early screening if they have a clearer idea about it. And 61.2% reported that they would have this early screening if they had any of its risk factors. This close to the results of study in KSA [30], and other in Palestine [31].
According to our results there was a relationship between having early CRC screening and gender, whereas males having early screening more than females. In general, men have been more willing to participate than women [32,33]. This could be because men are aware that lifestyle risk factors are more strongly associated with cancer in men than in women [34], or more likely reflects men's tendency to believe that cancer risk is modifiable [35]. This does not comply with another studies by Almadi et al., and Qumseya et al., found that no differences seen between males and females with regard to the willingness to undergo early CRC screening, nor was there a difference between both genders in the chosen screening method [30,31].
There was relationship between having early CRC screening and age of respondents. This is consistent with previous analysis reported by the NHIS in 2000 and 2005 [32,36].
There was relationship between having early CRC screening and educational level. Most studies agree that CRC screening is increased in highly educated participants [37]. This is logical because it is increasing educational level is increasing awareness and then realize the need to conduct the CRC screening.
There was relationship between having early CRC screening and monthly income. One of the most important factors for predicting participation in CRC screening is socioeconomic deprivation, highlighted by the recent NHIS survey showing a progressive participation with a higher annual family income [36]. As well as economic level, may affect the level of education of individuals and hence the awareness of the importance of screening.

Conclusion: -
There was a low level of awareness about the symptoms and risk factor of colorectal cancer. As well as for CRC,early screening there waspoor public awareness, knowledge and attitude. Awareness campaigns did not play a significant role in educating the community about CRC symptoms, risk factor, and early screening. Also, there wasn't a notable tendency to hold CRC early screening. According to our results there was a relationship between having early CRC screening and gender, age, educational level, and monthly income. But having early CRC screening didn't affected by region or living place.

Recommendations: -
 Awareness campaigns should be conducted in abundance.  Distribution of pamphlets containing symptoms and risk factor of colorectal cancer.  Send mobile messages containing locations of screening centers by provinces.  Should be directed to the media to awareness about CRC.  Urged population to maintain a balanced diet rich in fiber, do physical activity continuously, maintain a healthy weight, and avoid smoking.  Urged population to commitment to conduct the CRC screening in a timely manner.