Awareness about Risk Factors of Colorectal Cancer among Employees at Minia University

Introduction

Cancer is the second major cause of death following heart diseases; it is a class of diseases characterized by uncontrolled cell growth and begins with a loss of tumor suppressor ability in the cell cycle due to genetic mutations (Szollosi et al., 2020). Such growths also invade the surrounding tissue and may metastasize to distant locations (Bashir et al., 2020).

Colorectal Cancer (CRC) is a type of gastrointestinal malignancy originating from either the colon or the rectum; they are often grouped together because of the many biologically and clinically common features (Van et al., 2019). The exact causes of the vast majority of CRCs remain unknown; it could be based on numerous genetic and environmental changes. Most CRCs are sporadic but can arise from inherited cancer syndromes, inflammatory conditions, and modifiable lifestyle factors (Sierra et al., 2016).

Colorectal Cancer (CRC) can be diagnosed by a combination of measures include taking a health history, physical examination, complete blood count, blood chemistry tests, stool tests like a guaiac fecal occult blood test or fecal immunochemical test, double-contrast barium enema, sigmoidoscopy, colonoscopy, biopsy, digital rectal examination, cell and tissue studies, CT scan, ultrasound, MRI, chest X-ray, and PET scan (Anusha et al., 2016).

Over eighty six percent (86 (% of those diagnosed with CRC under the age of 50 are asymptomatic, and the disease is being diagnosed at later stages, in symptomatic patients, the disease may generate changes in bowel motility (e.g., diarrhea or constipation), occult or evident colorectal bleeding, as well as abdominal discomfort, cramping, unexplainable weight loss, weakness, and fatigue, especially in patients with advanced-stage CRC (Mattiuzzi et al., 2019).

There are several risk factors for CRC; the individual risk of CRC is essentially dependent on non-modifiable dispositional factors such as age, sex, and family history (Ma et al., 2018). Modifiable risk factors of CRC are related to lifestyles such as lack of physical activity, obesity (overweight), unhealthy food (excessive red meat, processed meat, fatty diet, low fruits and vegetables, and low intake of calcium, fiber, milk, whole-grain, and vitamin D), excessive smoking (tobacco smoking), and excessive alcohol consumption (Surya et al., 2020).

Colorectal cancer (CRC) affects men and women of all racial and ethnic groups and is most often found in those aged fifty (50) years or older; its incidence in males is significantly higher than that in females (Pradhan et al., 2020). Patients with a personal CRC history or adenomatous polyps of the colon are at risk for the future development of colon cancer, also diabetes mellitus together with obesity, radiation, chronic or repeated episodic inflammatory insults to the intestinal mucosa have a clear mechanistic role in the development of CRC (Powell et al., 2020).

Colorectal Cancer (CRC) is a preventable disease, and it is estimated that about 75% of CRC cases could be avoided with a healthy lifestyle. Most cancer prevention strategies are primary or secondary, the primary prevention goal is to prevent cancer from starting by reducing individual risk, and it focuses on lifestyle changes, health education, and risk factors related to chemoprevention (lee, 2018).

Secondary prevention enables slow-growing lesions to be diagnosed at early stages, focusing on reducing further complications, disabilities, or suffering and it includes early diagnosis, screening methods. Tertiary prevention aims to prevent recurrence or progression of the disease and focuses on efforts to prevent cancer formation in patients that have previously been treated (i.e., cancer survivors) (Tran et al., 2019).

Treatment of CRC involves three main options, surgery, chemotherapy, and radiation therapy, either alone or as adjuvant treatment, it depends on the disease stage. Earlier stages of disease (stages I through III) are referred to as localized colorectal cancers and are generally treated with surgery (with or without chemotherapy), but stage IV cancer is called advanced colorectal cancer and is generally treated with palliative chemotherapy (Berghella et al., 2019).

Postoperative follow-up included clinical examination, serum carcinoembryonic antigen (CEA) levels, and abdominal ultrasound every three (3) months during the first two (2) years and then every six (6) months for two (2) years. A thoraco-abdominopelvic CT scan is performed every 6 months for the first 2 years and then every year for three (3) years, while colonoscopy was done after one (1) year, and if it was normal, it was repeated after three (3) years (Farhat et al., 2019).

Awareness plays a vital role in the early diagnosis and improving the survival rate of CRC patients, it has been directly related to the screening program participation. National policies and programs should be focused on prevention by raising awareness, reducing exposure to cancer risk factors, providing information and support to adopt healthy lifestyles (Saranrittichai et al., 2020), in order to raise interest in awareness and prevention of colorectal cancer, president Bill Clinton designated March as national colorectal cancer awareness month that started in the year 2000 (Pantel et al., 2020).

Community Health Nurse (CHN) plays an important role in preventive healthcare measures, especially those who work in primary care offices and community clinics. Through education, CHN can improve awareness of younger people and those with a lower level of education who had poor awareness of lifestyle risk factors for CRC, especially since this group stands to benefit most from risk reduction (Abuadas et al., 2019).

In primary prevention, community health nurses (CHNs) play a key role in identifying patients at CRC risk, providing new information about risk factors and the rising incidence in younger patients to help prevent and identify CRC at earlier, more treatable stages. CHNs play an important role in CRC secondary prevention through education, and thus increasing screening rates in asymptomatic high-risk populations in the community, initiate prompt treatment, arrest progression, and prevent associated disability (Al-Sharif et al., 2018), also they need to implement tertiary prevention at the community level by establishing working partnerships with community leaders and stakeholder organizations to prevent CRC complications, they help to find out the patient and do home visits to provide care and health education on CRC management, palliative care and healthy lifestyle (Saranrittichai et al, 2020).

Significance of the study

Colorectal Cancer(CRC) is a leading cause of mortality and morbidity throughout the world and its incidence is steadily rising in developing nations, thus representing a major public health problem (Rawla et al., 2019). Globally, it is the third most common malignant neoplasm, with nearly 1.8 million new cases in 2018; its global burden is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030 (Araghi et al., 2019).

The relative frequency of CRC in Egypt is about 9–12% with high male predominance 3:1. According to the Egypt National Cancer Registry, age-specific incidence rates of CRC per 100,000 were 6.3 for males and 4.3 for females in 2009. According to Minia Cancer Registry in 2011, the crude incidence rate of CRC was about 3.4 per 100,000 populations in the Minia governorate (Mahfouz et al, 2014). The incidence rate in Egypt is 5.1% in males and 4.7% in females (El-Din et al., 2020).

Aim of the study

The current study aimed to assess awareness about risk factors of colorectal cancer among employees at Minia University.

Research questions

1. What is the level of awareness about risk factors of colorectal cancer among employees at Minia University?
2. Is there a relationship between socio-demographic characteristics and the level of awareness about risk factors of colorectal cancer among employees at Minia University?

Subject and Methods

Research Design:

Across-sectional descriptive design was used to achieve the aim of the present study.

Setting:

This study was conducted at Minia University. Minia University has consisted of twenty (20) faculties, five (5) faculties (Faculty of Medicine – Faculty of Early Childhood Education - Faculty of Tourism and Hotels–Faculty of Science -Faculty of Nursing) were randomly selected to participate in this study.

Subjects:

According to the National Cancer Registry, the prevalence of colorectal cancer in Egypt (12٪), the total number of the employees at Minia University (2276) in 2020, as stated by the central personnel administration of Minia University, The sample size was estimated to fulfill the aim of the study, with a 95% level of confidence and a study power of 80%. By using the Epi-info computer software program the required sample size was (365) were selected by using convenient sampling as follows:

Inclusion Criteria:

• The white-collar employees and blue-collar employees within the selected faculties of Minia University.

Exclusion Criteria:

• Employees who took time off work for over 3 months.

Tool for Data Collection:

Data were collected through a structured questionnaire that was adopted from another instrument developed by Cancer Research UK, University College London, and Oxford University in 2007-2008 and updated in 2011(Power et al., 2011), and some modifications were done by the investigator. It consisted of two parts:

I-First part: Interviewing questionnaire:

 It covered the data related to the participants (name, age, gender, residence, education, occupation, marital status, and CRC family history).

II-Second part: Bowel / colorectal cancer awareness assessment:

The questionnaire has consisted of thirty (30) items and addressed general awareness about CRC {fourteen (14) items}, risk factors {twelve (12) items}, treatment, and follow-up {four (4) items}.

Scoring System: - according to (Simon, 2010) (Su, 2013), (Mhaidat, 2018).         

A scoring system for colorectal cancer awareness was used where each correct answer {(yes) or (agree or strongly agree in Likert scale questionnaire)} were given one point and incorrect answer {(No) or (strongly disagree, disagree, neither in Likert scale questionnaire)} were given a zero score.

Regarding negative questions, {(yes) or (agree or strongly agree in Likert scale questionnaire)} were given zero scores as a false answer, but {(No) or (strongly disagree, disagree, neither in Likert scale questionnaire)} were given one point as a correct answer.

Each question will be rated (zero) for the wrong answer, and (1) for the right answer, the knowledge score will be calculated by summing the scores for all questions (30 questions) thus the overall score ranged from (0-30).

The level of Awareness was classified as:

• Up to 17 (<60%) considered poor,
• from 18-24 (>60-80%) considered fair,
• And from 25-30 (>8o-100%) considered good.

Validity:

The tool was submitted to a jury of five panels of experts in the community health field to test the content validity of the tools (four experts at Minia University, Faculty of nursing, and one expert at Minia University, faculty of medicine, community health, and preventive medicine department).

The tools were examined for content coverage, the sequence of items, clarity, relevance, applicability, wording, length, format, and overall appearance. Some modifications were done.

Reliability:

 The reliability of the tool was performed to confirm the consistency of the tool. The internal consistency was measured to identify the extent to which the items of the tool measured what it was intended to measure. The internal consistency of the tool was assessed with Cronbach's alpha coefficient. Cronbach's α coefficient of 0.00 indicates no reliability, and a coefficient of 1.00 indicates perfect reliability. However, a reliability coefficient of 0.9 is acceptable.

Ethical consideration:

The preliminary written approval was approved by the research ethics committee of the faculty of nursing, Minia University.  Oral informed consent was obtained from participants after explaining the nature and benefits of the study. Each assessment sheet was coded and participants’ names will not appear on the sheets for the purpose of privacy and confidentiality. Participants were assured that they could withdraw at any time from the current study. Measures were taken to protect participants’ ethical rights.

Pilot study:-

A pilot study was performed on 37 workers (10%) before beginning to collect data to assess the effectiveness and applicability of the questionnaire, as well as to determine the best time to collect data. They were included in the study.

Administrative design

Before starting data collection, five formal letters were issued from faculty of nursing, Minia University, to the deans of faculty of medicine, faculty of early childhood education, faculty of tourism and hotels, faculty of science, and faculty of nursing to gain the administrative approval.

The Preparatory Phase:

A review of the related literature which covered various aspects of the research problem was done, using different books, journals, and websites, to get knowledge of colorectal cancer including definition, causes, risk factors, diagnosis, treatment, and prevention.

Field Work:

Meeting with employees in small groups with suitable recommended distance in-between persons as a protective measure, and explaining the objectives of the study to gain their cooperation.

 Oral consent was taken; the purpose and the nature of the study were explained by the investigator through direct personal communications before starting to participate in the study.

Employees were interviewed per day from 9 AM to 1 PM in two days each week for 6 months from July 2020 to December 2020 within a range of 25 to 30 minutes for every employee with an average of eight employees per day. The white-collar employees filled the questionnaire by themselves, but the blue-collar employees’ questionnaires were filled in by the investigator after explanation for the sake of the accuracy of the questionnaire. Steps to protect the moral rights of participants were taken.

Statistical Design:

Data were analyzed using version 20 of the Statistical Software Package for Social Sciences (SPSS), Numerical data were expressed as mean and SD. Quantitative data were expressed as frequency and percentage. For quantitative data, a comparison between two variables was done using a t-test, and a comparison between more than two variables used the ANOVA test. Relations between different numerical variables were tested using the Pearson correlation.

Limitation of the study:

• Relative lack of employees’ cooperation.
• Some employees’ unwilling to participate in the study.
• As coronavirus (COVID-19) was declared a pandemic by the world health organization (WHO), Minia University has taken suitable measures to control it as social distances, reduce the number of employees on work, and new safeguards to minimize the risk of infection, so it was difficult to go there and take data, losing some time and thus impact my research.

Results

Table 1: Distribution of the studied employees as regarding sociodemographic characters (n=365).

Table 1 summarizes the socio-demographic characteristics of the Studied Participants. The age of participants ranged between 23 and 59 years (mean 39.5 ± 11.413 years), females constituted 55.1%, while 66.3% of the studied employees lived in urban areas and the vast majority of them (84.9%) were married. Regarding educational level, 32.3 were highly educated; also 60.8% of them were white-collar employees and 39.2% are blue-collar employees. Positive family history of CRC was found among 3.3% of the studied participants.

Table 2: Frequency distribution of questions directed to employees regarding general awareness about CRC (n=365).

Table 2: shows that about two thirds (74.8%) of the participants have heard about CRC, more than half of them agreed that it is a leading cause of death from cancer, but the majority of the study participants (94.0%) thought that women and men are at the same level of CRC risk. Regarding CRC causes, (44.1%) have believed that CRC causes were known, (59.2%) of studied employees considered that colorectal cancer can be prevented.

The most commonly known CRC signs were bleeding from the back passage and blood in the stool (69 % for each) whereas not completely emptied bowel after defecation was the least common (9.3 %). 60.8 % of the studied employees thought that persistent pain in the abdomen is a symptom, but (44.1%) of the studied employees thought that a change in bowel habits is not a sign of CRC. about two-thirds of the studied employees had the intention to visit a doctor if they had any of the signs and symptoms, but more than half of them (65.5%) didn’t know about screening tests, the age for CRC screening (64.1 %), and 59.7 % of them believed that no necessary for CRC screening if no sign or symptom would be present.

Table 3: Frequency distribution of the studied participants regarding CRC risk factors’ awareness (n=365).

Table 3 describes the individual items constituting the knowledge grid to measure participants’ awareness about CRC risk factors; the most frequently recognized CRC risk factor washaving a history of excessive smoking (n = 268; 73.4%), and diabetes was the least recognized (n = 146; 40.0%). About half of the participants gave a correct answer for CRC age-related risk. Among 365 participants, about (66.3%), (62.2 %) and (61.9 %) participants believed that having a bowel disease, having a close relative with bowel cancer, and excessive alcohol consumption were related to CRC risk respectively.

The studied employees who have recognized that a low fiber diet was a risk factor for CRC disease only made up a ratio of 56.2 %, just over half of the participants have supposed that obesity (55.1 %) and low physical activity (53.4) were related to CRC risk. On the other hand, less than half of the participants agreed that a diet low in fruits and vegetables (47.9 %), x-ray (47.4 %), and excessive red and processed meat intake (42.7%) were associated with CRC occurrence.

Table 4: Frequency distribution of the studied participants regarding CRC Treatment and follow up (n=365).

Table 4 shows participants’ awareness about treatment and follow-up; about two-thirds of them correctly answered questions 1, 2, and 3 about CRC treatment choices, compliance, and the importance of good nutrition during treatment. The vast majority of the participants (84.1) had a good awareness of the importance of follow-up.

Fig.1: Total knowledge score of participants about colorectal cancer (n=365).

Fig.1 depicts the participant’s level of knowledge about CRC; shows that over half of the participants (56.7 %) had poor awareness about CRC cancer, while about quarter of them (27.4%) were knowledgeable, only 15.9 % of the studied employees had good awareness level about CRC.

Table 5: Relation between the studied participants’ socio-demographic data and knowledge score on colorectal cancer (n=365)

Table 5 shows the relationship between demographic characteristics of participants and overall knowledge of CRC; from the descriptive analysis, female participants and married participants had a higher score of knowledge regarding CRC. However, the differences were not statistically significant. It should be noted that a difference was only statistically significant at the level .05 with the residence as participants from urban areas scored significantly better (P=0.001) than those from rural areas. White-collar employees had better knowledge scores than blue-collar employees in this study with significant differences (P= 0.00), and those with CRC family history were more knowledgeable than those without a family history (p=0.006).

Table 6: The Relationship between the age of studied employees and their Knowledge Score (n=365).

Table 6 shows that participants with fair knowledge score had a higher age mean than others (40.19±11.489 years), good with a mean age of 39.05±12.272 years, and poor with a mean age of 39.29±11.167. P-value was not significant.

Fig.2: Relation between the studied participants’ level of education and knowledge score on colorectal cancer (n=365)

Fig.2 indicates the significant association between better knowledge score level and higher educational level (P=0.00).

Fig.3 shows the significant association between the residence in urban areas and better knowledge score level and (P=0.001).