Colorectal Cancer Knowledge and Screening Awareness in Syria: A Cross-Sectional Study

doi:10.21203/rs.3.rs-4969040/v1

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Colorectal Cancer Knowledge and Screening Awareness in Syria: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-4969040/v1

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Background:

Colorectal cancer (CRC) ranks as the third most common cancer globally, with rising incidence in developing countries due to lifestyle and dietary shifts. CRC often presents with late-stage symptoms, leading to higher mortality. Early detection through screening significantly improves survival rates. In Syria, CRC is the second most common cancer, but screening rates remain low, especially following the decade-long war. This study aims to assess the knowledge of CRC among Syrians to guide prevention and detection strategies.

Methods:

A cross-sectional online survey was conducted from September 27 to October 21, 2023, across six Syrian governorates: Damascus, Homs, Aleppo, Lattakia, Hama, and Tartous. A self-administered questionnaire, distributed via social media, assessed socio-demographics, CRC knowledge, and perceptions of screening methods. A total of 772 participants completed the survey. Statistical analysis was performed using SPSS v28.0, with a Chi-square test to explore differences in knowledge based on socio-demographic factors.

Results:

The study included 772 participants, 42.6% of them aged 30–35 years. The majority were female (64.4%) and married (56.3%). Only 27.8% considered themselves informed about CRC. While 54.8% had heard of colonoscopy, only 15.4% had undergone the procedure. Significant knowledge gaps were identified, particularly regarding the link between adenocarcinoma polyps and CRC (29.9%), the role of diet (33.2%), and the protective effect of aspirin (17.7%). Older individuals demonstrated higher awareness levels, particularly in recognizing CRC's hereditary nature and the potential for cure. Education and economic status were also strongly associated with better CRC knowledge, and males generally exhibited higher awareness than females.

Conclusion:

This study reveals significant gaps in CRC knowledge among Syrians, influenced by factors such as age, gender, education, and economic status. The findings underscore the urgent need for targeted health education and accessible screening programs to improve CRC awareness and reduce its incidence and mortality in Syria. Further research should address the study's limitations, including sampling bias and the cross-sectional design, to develop more effective public health interventions.

Colorectal cancer

Colon cancer

Colonoscopy

Awareness

Knowledge

Screening

Syria

Colorectal cancer (CRC) is the third most prevalent cancer globally, with incidence rates particularly high in developed countries. However, these rates are rising in developing nations as their lifestyle and diet increasingly mirror those of wealthier countries. (1)

Lifestyle factors such as the consumption of processed meat, dietary fiber intake, body mass index (BMI), physical activity levels, and smoking significantly influence the risk of developing CRC. Population attributable risk estimates suggest that approximately 60% of CRC cases in males and 50% in females could be prevented through healthy diet and lifestyle choices. (2)

CRC typically presents with symptoms such as abdominal discomfort, changes in bowel habits, bloody stools, fatigue, and weight loss. However, these symptoms often manifest only in the advanced stages of the disease, where mortality rates are significantly higher. (3)

Early detection through screening is crucial, as it allows for the identification of CRC and precancerous polyps in asymptomatic stages, thereby improving survival rates. The American Cancer Society recommends that average-risk adults begin CRC screening at age 45 and continue through age 75, with the frequency of screening depending on the method used. After age 75, the decision to continue screening should be individualized. Special guidelines apply to individuals at increased risk, such as those with a personal or family history of CRC, genetic conditions like Lynch syndrome and familial adenomatous polyposis, and those with inflammatory bowel disease. (4)

In Syria, the National Cancer Registry indicated that CRC was the second most common cancer in both males and females in 2009 (5). Statistics after the decade-long Syrian war are limited, but there is evidence that cancer cases, including CRC, are on the rise, while screening rates remain negligible (6)(7)(8). This underscores the urgent need to raise public awareness about CRC, its risk factors, and the importance of early detection through screening. Increased awareness could lead to more proactive health behaviors, such as seeking screening and adopting healthier lifestyles, ultimately reducing CRC incidence and mortality.

The aim of this paper is to assess the knowledge of CRC among Syrians and to guide strategies for improving CRC prevention and detection efforts in the country.

1.1 Study Design, Setting, and Participants:

A cross-sectional online survey was conducted using the self-selection method across six Syrian governorates: Damascus, Homs, Aleppo, Lattakia, Hama, and Tartous. The survey took place from September 27, 2023, to October 21, 2023, using a self-administered questionnaire distributed as a Google Form on social media platforms. The sample size was calculated using Co-pilot, a well-established statistical method powered by AI tools (9) due to the unknown population size. Specifically, the sample size (N) was estimated using the formula:

N = Z² x P x (1-P)

e²

Where Z represents the z-score, set at 1.96 for a 95% confidence level, P represents the population proportion, set at 0.5 for this study, and e is the margin of error, set at 0.05 or 5%. The calculated sample size was N = 384. Nevertheless, responses were received from 772 individuals who completed the questionnaire, which included sections on socio-demographics, knowledge, and information about colorectal cancer.

Data were collected from five different regions in Syria to ensure the diversity and representativeness of the sample within the Syrian population. All participants were informed that their participation was voluntary, responses were recorded anonymously, and they could withdraw from the study at any time. The inclusion criteria were Syrian participants aged 30 and above who were willing to complete the questionnaire.

1.2 Study Tool:

A self-administered questionnaire in Arabic was used, adapted from a previously published study to fit the cultural context of Syrian society (10). The questionnaire was translated into Arabic by a specialized medical translator to ensure accuracy and comprehensibility for all respondents. The internal consistency of the instrument was good (Cronbach’s alpha = 0.86). The questionnaire consisted of six socio-demographic questions (sex, age, social status, working status, educational level, and economic level), as well as questions assessing knowledge of symptoms and management of colorectal cancer, knowledge about colonoscopy, and participants' opinions on the study. It also included questions on intestinal stoma, diet, and the effect of low-dose acetylsalicylic acid on colorectal cancer.

1.3 Statistical Analysis:

Data were analyzed using the Statistical Package for Social Sciences (SPSS) v28.0. Categorical variables were presented as frequencies and percentages. To determine differences between knowledge questions and socio-demographic variables, a Chi-square test of independence was performed.

1.4 Ethical Considerations:

The study protocol was approved by the Research Ethics Committee of Damascus University, Faculty of Medicine (MD-020624-247). Informed consent was obtained from participants prior to their participation. The study did not include participants younger than 30 years old.

The study included 772 participants, 42.6% of them aged 30–35 years. The majority were female (64.4%) and aged between 30–35 years (42.6%) (Fig. 1). Most respondents were married (56.3%) and employed (62.3%), reflecting a population largely engaged in work and family life. The socioeconomic status of the participants varied, with 46.9% reporting a median economic status and 48.6% holding a bachelor's degree as the highest level of education (Table 1).

Table 1

General characteristics of the sample.
Characteristics		Count (n) [N = 772]	Percentage (%)
Gender	Male	275	35.6
Gender	Female	497	64.4
Age Groups (years)	30–35	323	42.6
	36–40	125	16.2
	41–45	122	15.8
	46–50	81	10.5
	51–55	50	6.5
	56–60	30	3.9
	Above 60	35	4.5
Economic Status	Bad	107	13.9
	Median	362	46.9
	Good	259	33.5
	Excellent	44	5.7
Educational Level	Elementary school	39	5.1
	Middle school	56	7.3
	High school	96	12.4
	Technical institute	105	13.6
	Bachelor	375	48.6
	Master	66	8.5
	Doctorate	23	3
	Illiterate	12	1.6
Work Status	Employed	481	62.3
Work Status	Unemployed	291	37.7
Marital Status	Single	229	29.7
	In a relationship	17	2.2
	Engaged	40	5.2
	Married	435	56.3
	Divorced	25	3.2
	Widower	26	3.3

In terms of knowledge and awareness of colorectal cancer (CRC), 27.8% of participants considered themselves informed about the disease. However, only 29.9% correctly identified a link between adenocarcinoma polyps and CRC, and 35.9% believed that CRC could be an inherited disease. A significant portion of respondents lacked clarity on key aspects of CRC; for instance, 25.5% believed that CRC has no possibility of being completely cured, while 38% were uncertain about the effectiveness of surgical treatments. In addition, awareness of diet as a risk factor of CRC was limited, with only 33.2% recognizing the role of diet in increasing CRC risk. Furthermore, only 17.7% were aware of the potential protective role of aspirin in reducing CRC risk (Table 2).

Table 2

Survey results.
Question		DEFINITELY NOT		RATHER NOT	NEITHER POSITIVE NOR NEGATIVE	RATHER YES	DFEFINITELY YES
Do you consider yourself an informed person, with awareness of colorectal cancer?		97(12.5%)		168(21.8%)	293(38%)	188(24.4%)	26(3.4%)
According to your knowledge, is there a proven link between the presence of adenocarcinoma polyps in the large intestine and the possibility of colorectal cancer development?		68(8.8%)		128(16.6%)	348(45.1%)	188(24.4%)	40(5.5%)
Do you think that colorectal cancer is an inherited disease?		70(9.1%)		193(25%)	232(30.1%)	227(29.4%)	50(6.5%)
Does colorectal cancer in your immediate family put you at an increased risk for developing colorectal cancer?		95(12.3%)		184(23.8%)	266(34.5%)	188(23.6%)	45(5.8%)
Do you think colorectal cancer is a malignant neoplastic disease?		182(23,6%)		247(32%)	218(28.2%)	96(12.4%)	29(3.8%)
Do you agree with the statement that colorectal cancer is a disease with no possibility to be completely cured?		149(19.3%)		236(30.6%)	240(31.1%)	107(13.9%)	40(5.2%)
Can colorectal cancer be treated surgically?		45(5.8%)		111(14.4%)	293(38%)	261(33.8%)	62(8%)
Can colorectal cancer be completely cured?		62(8%)		135(17.5%)	308(39.9%)	206(26.7%)	61(7.9%)
Do you agree with the statement that colorectal cancer can be completely cured in any case in all cases?		105(13.6%)		221(28.6%)	281(36.4%)	122(15.8%)	43(5.6%)
Is a fecal occult blood test helpful in detecting colorectal cancer?		69(8.9%)		132(17.1%)	300(38.9%)	216(28%)	55(7.1%)
Do you think inflammatory bowel diseases can be linked to the development of colorectal cancer?		69(8.9%)		154(19.9%)	283(36.7%)	223(28.9%)	43(5.6%)
In case of having colorectal cancer, would you agree to undergo a colostomy to have a permanent intestinal stoma if that would be required?		85(11%)		148(19.2%)	247(32%)	248(32.1%)	44(5.7%)
Do you think that the type of diet can affect the development of colorectal cancer?		67(8.7%)		123(15.9%)	328(42.5%)	206(26.7%)	48(6.2%)
Do you think that taking regular small doses of aspirin may protect against colorectal cancer?		100(13%)		155(22.1%)	381(49.4%)	97(12.6%)	39(5.1%)
	Yes		No
Have you ever had any tests for colorectal cancer?	80(10.4%)		692(89.6%)
Have you ever looked for information about colorectal cancer?	252(32.6%)		520(67.4%)
Do you know what a screening is?	197(25.5%)		575(74.5%)
Do you know what an intestinal stoma (fecal fistula) is?	322(41.7%)		450(58.3%)
Do you pay attention to the appearance of stool, bearing in mind that a change in the appearance of stool or finding e.g. blood in it may be one of colorectal symptoms?	491(63.6%)		281(36.4%)

Colonoscopy was known to 54.8% of the respondents. However, only 15.4% of participants had actually undergone a colonoscopy, with the majority of these procedures being performed without anesthesia (Table 3). Despite the low utilization, there was a willingness to undergo the procedure if recommended by a healthcare provider, with 86.4% of participants indicating they would follow their doctor's advice. Additionally, 62.5% believed that colonoscopy is helpful in detecting and treating CRC, yet 55.3% perceived the procedure as painful, 38.6% found it embarrassing, and 16.4% considered it an unsafe examination. Moreover, 34.1% were unaware of the need for preparation prior to the procedure (Table 3).

Table 3

Survey results.
	Yes	No
Do you know what colonoscopy is?	424(54.8%)	348(45.1%)
	Yes, under general anesthesia		Yes, without anesthesia		No
Have you ever had a colonoscopy? (all age groups)	44(5.7%)		75(9.7%)		653(84.6%)
30–35	12		25		292
36–40	10		18		97
41–45	7		16		99
46–50	8		9		64
51–55	2		1		47
56–60	1		3		26
60<	4		3		28
	Yes (under anesthesia)	Yes (does not matter whether the test would be performed under anesthesia or without it)		Yes (without anesthesia)	No
Would you undergo colonoscopy if your doctor told you it is necessary to have this examination?	394(51%)	188(24.4%)		85(11%)	105(13.6%)
Would you undergo a second colonoscopy if your doctor told you to repeat this examination?	337(43.7%)	183(23.7%)		88(11.4%)	164(21.1%)
	DEFINITELY NOT	RATHER NOT	NEITHER POSITIVE NOR NEGATIVE		RATHER YES	DEFINITELY YES
Do you think that colonoscopy is helpful in detecting and treating colorectal cancer?	32(4.2%)	48(6.2%)	210(27.2%)		395(51.2%)	87(11.3%)
Do you think that colonoscopy is an examination that can protect against colorectal cancer?	34(4.4%)	103(13.3%)	272(35.2%)		303(39.2%)	60(7.8%)
Do you think colonoscopy is a painful examination?	35(4.5%)	84(10.9%)	226(29.3%)		356(46.1%)	71(9.2%)
Do you think colonoscopy is a shameful, embarrassing examination?	110(14.2%)	183(23.7%)	181(23.4%)		239(31%)	59(7.6%)
Do you think that colonoscopy requires anesthesia for the patient?	48(6.2%)	66(8.5%)	256(33.2%)		327(42.4%)	75(9.7%)
Do you think that a colonoscopy is a safe examination?	43(5.6%)	83(10.8%)	264(34.2%)		311(40.3%)	71(9.2%)
	Yes (diet and laxative)	I do not know	No
Do you think the patient has to prepare for colonoscopy in a special way?	465(60.2%)	44(5.7%)	263(34.1%)

The statistical analysis (Table 4) revealed significant associations between CRC knowledge and various demographic factors. Gender differences were observed, with males generally demonstrating higher awareness levels. The data showed that 34% of males accurately recognized the link between polyps and CRC, compared to 27% of females. Additionally, 42% of females were uncertain about whether CRC is curable, in contrast to 36% of males. Furthermore, 38% of males acknowledged the role of diet in CRC, compared to 30% of females.

Table 4

Correlation between knowledge and other variables.
	Chi-square test p-value
Knowledge questions	Knowledge* Gender	Knowledge* Education	Knowledge* Economic Status	Knowledge* Age
Do you consider yourself an informed person, with awareness of colorectal cancer?	0.13	0.19	0.01	0.816
According to your knowledge, is there a proven link between the presence of adenocarcinoma polyps in the large intestine and the possibility of colorectal cancer development?	0.001	0.5	0.01	0.91
Do you think that colorectal cancer can be an inherited disease?	0.3	0.2	0.01	0.033
Does colorectal cancer in your immediate family put you at an increased risk for developing colorectal cancer?	0.004	0.28	0.26	0.032
Do you think colorectal cancer is a malignant neoplastic disease?	0.004	0.02	0.065	0.008
Do you agree with the statement that colorectal cancer is a disease with no possibility to be completely cured?	0.001	0.09	0.19	0.548
Can colorectal cancer be treated surgically?	0.04	0.04	0.04	0.121
Can colorectal cancer be completely cured?	0.002	0.009	0.01	0.012
Do you agree with the statement that colorectal cancer can be completely cured in any case?	0.001	0.01	0.01	0.008
Is fecal occult blood test helpful in detecting colorectal cancer?	0.001	0.01	0.01	0.394
Do you think inflammatory bowel diseases can be linked to the development of colorectal cancer?	0.03	0.65	0.17	0.19
In case of having colorectal cancer, would you agree to undergo colostomy to have permanent intestinal stoma if that would be required?	0.02	0.17	0.67	0.226
Do you think that the type of diet can affect the development of colorectal cancer?	0.01	0.08	0.001	0.247
Do you think that taking regular small doses of aspirin may protect against colorectal cancer?	0.001	0.01	0.13	0.086

Education level was a strong predictor of CRC knowledge; respondents with a bachelor's degree or higher were more likely to be informed about the disease, recognize its malignant nature, and understand the role of surgical treatment. They were also more aware of the usefulness of fecal occult blood test in detecting CRC and the potential role of aspirin in preventing CRC. Economic status also played a role, with participants in higher economic strata exhibiting greater awareness in most aspects of the disease (Table 4).

The data also confirmed that CRC knowledge levels significantly varied among different age groups (Table 4). Higher awareness levels were observed in older individuals in the population. For instance, 37% of people aged 30–35 did not believe that CRC could be hereditary, compared to 24% of those aged 50–55 and 29% of those over 60 (Fig. 2). Similarly, 29% of individuals aged 30–35 doubted that CRC could be cured, a significantly higher percentage than older individuals in the study (Fig. 3).

The findings of this study reveal significant gaps in the awareness and knowledge of colorectal cancer (CRC) among the Syrian population, which are influenced by various sociodemographic factors.

A concerning finding is that only 27.8% of respondents considered themselves informed about CRC, with 12.5% feeling "definitely not" informed and 21.8% "rather not" informed. That highlights a substantial knowledge deficit regarding CRC. A significant portion of the population was unsure about the proven links between adenocarcinoma polyps and CRC (45.1%), inflammatory bowel diseases and CRC (36.7%), and diet and CRC (42.5%). Additionally, 35% of respondents were unaware of the hereditary risk associated with CRC. This lack of awareness can be attributed to insufficient public health education and outreach. Similar findings have been reported in neighboring developing countries such as Lebanon, Egypt, Jordan, and Iraq, where public health education is similarly limited (11–14).

Our study also demonstrated limited knowledge about CRC detection and treatment methods. A high percentage (84%) of respondents aged 45 and older had never undergone tests for CRC, a figure comparable to Lebanon (11) but slightly lower than in Saudi Arabia and Iraq (14, 15). The primary barrier appears to be the lack of knowledge about colorectal cancer screening (16). Other contributing factors include misconceptions about the screening methods, financial restraints, living in distant villages with restricted access to healthcare, fear of being diagnosed with cancer, and self-neglect. Only 54.8% of respondents knew what a colonoscopy was, and even fewer had undergone the procedure (15.4%). Moreover, a significant number of respondents were not aware of the usefulness of fecal occult blood tests (38.9% were neutral or uninformed). That indicates an urgent need for improved health education and better access to screening services.

In addition, we found significant associations between knowledge levels and sociodemographic factors such as gender, education, and economic status. Understandably, higher education levels correlated with better knowledge about the treatment of CRC surgically. Financial status also played a role, with those in better economic standing being more informed about CRC. There were statistically significant differences in knowledge between genders. For instance, 34% of males correctly identified the association between polyps and CRC compared to 27% of females. 42% of females did not know whether CRC can be cured, compared to 36% of males. In addition, regarding the impact of diet on CRC, 38% of males answered affirmatively, compared to 30% of females. This increased knowledge among males could be due to more educational and public engagement opportunities for men in many societies, including Syria. Traditional gender roles may also limit women's access to health information and healthcare services, as men might have more freedom to attend educational sessions, access media, and participate in community discussions about health.

Age also influenced awareness levels. For example, 37% of individuals aged 30–35 did not believe that CRC could be hereditary, compared to 24% of those aged 50–55 and 29% of those above 60. Similarly, 29% of individuals aged 30–35 did not think CRC could be cured, a significantly higher percentage than older individuals in the study. This disparity can be explained by the fact that CRC screening guidelines are recommended starting at age 45, leading to increased exposure to information about CRC among older age groups. Additionally, older adults may perceive themselves at higher risk for CRC, prompting them to seek more information. They also typically have more frequent interactions with the healthcare system for various age-related conditions, providing opportunities for healthcare providers to educate them about CRC. The increased knowledge among older individuals is consistent with findings from studies in Saudi Arabia and Lebanon (11, 15).

The study revealed prevalent misconceptions about CRC. For instance, 31.1% of respondents were neutral on whether CRC can be cured, and only 7.9% strongly believed it can be. Additionally, misconceptions about the necessity of anesthesia for colonoscopy (52.1% thought it was required) and the embarrassment associated with the procedure (38.6% found it embarrassing) were noted. These misconceptions could stem from cultural traditions and a lack of educational campaigns addressing these issues.

The data suggests that targeted health education programs could significantly improve awareness and knowledge about CRC. The correlation between higher education levels and better knowledge underscores the potential impact of educational interventions. Public health initiatives should focus on comprehensive and culturally sensitive educational campaigns to address the identified gaps and misconceptions.

This study is significant as it is the first of its kind in Syria, providing valuable insights into the current state of CRC awareness and knowledge. However, there are several limitations to acknowledge. First, the reliance on online questionnaires limits the sample to those with internet access and digital literacy, excluding many individuals, particularly in rural areas or from lower socioeconomic backgrounds. That introduces sampling and self-selection bias, as participants might already have a higher interest or awareness regarding health issues. Second, the cross-sectional design prevents the assessment of changes in knowledge or awareness over time and limits causal inferences. Third, the usage of self-reported data is associated with recall bias and inconsistencies in responses due to different interpretations of questionnaire questions, especially for medical or technical terms.

In conclusion, while this study highlights the urgent need for enhanced public health education and accessible screening programs to improve CRC awareness and knowledge among the Syrian population, these limitations suggest that further research using more diverse sampling methods and longitudinal designs would be beneficial. Addressing these gaps is crucial for effective prevention and early detection of colorectal cancer.

Ethics Approval and Consent to Participate:

The study followed the Declaration of Helsinki guidelines and received approval from Damascus University Research Ethics Committee (MD-020624-247). The questionnaire was anonymous, ensuring data confidentiality. Participants provided informed consent in Arabic before enrollment, with all agreeing on the introductory page before completing the online survey. They were fully informed of the study's aims and objectives, emphasizing the voluntary nature of their participation.

Consent for Publication:

All authors consent to the publication of this paper.

Availability of Data and Materials:

All data generated or analyzed during this study are included in this published article.

Competing Interests:

The authors declare that they have no competing interests.

Funding:

There was no funding source for this study.

Authors’ Contributions:

AA, RS, FN, SD, and HF participated in data collection & analysis and manuscript writing. YL supervised the study preparation, scientifically and academically. All authors read and approved the final manuscript.

Acknowledgments:

Not applicable.

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No competing interests reported.

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Colorectal Cancer Knowledge and Screening Awareness in Syria: A Cross-Sectional Study

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Background

Methods

1.1 Study Design, Setting, and Participants:

1.2 Study Tool:

1.3 Statistical Analysis:

1.4 Ethical Considerations:

Results

Discussion And Conclusion

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