Awareness of Colorectal Cancer and Associated Factors among Adult Patients in Jimma, South-West Ethiopia.

Background: Colorectal cancer (CRC) is the first commonest diagnosed cancer in men and the fourth commonest in women in Ethiopia. The most significant factors that may increase the risk of having CRC were modifiable. However, little is known about the awareness of CRC and associated factors among adult patients in study area. Therefore, the study aimed to assess the awareness of CRC and associated factors among adult patients in Jimma, South-West Ethiopia, 2020. Methods: The institution-based quantitative cross-sectional study design was conducted among 422 patients from March 8 to April 30, 2020. The study participants were recruited by a systematic random sampling method and data was collected semi-structured interviewer-administered questionnaires. Descriptive, bivariate, and multivariate logistic regression was implemented. The statistical level of significance was stated at p-value < 0.05. Result: A 100% response rate in this study was recorded. More than half (57.6%) of the study participants had low awareness of colorectal cancer. Smoking (78.2%) and bloody stool (49.3%) were the most known risk factors and symptoms. There is a significant association between awareness of colorectal cancer with gender, residency, monthly income, level of education, information sources, and heard about CRC. Conclusion: Overall awareness of patients towards CRC was inadequate. Participants with high levels of education and females had better awareness, however; the overall awareness of them was insufficient. Therefore, there is a need for awareness campaigns and health education for promoting colorectal cancer awareness.


Introduction
Cancer is an important global health problem in a developed and developing country that it is the most important cause of morbidity and mortality [1][2][3]. Furthermore, it affects the social and economic status of the population in the world [4]. It is expected to have grown to 18.1 million new cases and 9.6 million of the population died globally [2,5]. Cancer is proposed that an expected more than 20 million individuals will be identified, and around 13 million will be die in the year 2030 [6]. From this, the most commonly diagnosed cancers worldwide are colorectal cancer, lung, and breast cancers [7][8][9]. Cancer in sub-Saharan Africa (SSA) is on the rise caused by rapid population growth, higher life expectancy, and the adoption of unhealthy lifestyles, and a lack of awareness about cancer [4,10,11].
Colorectal cancer (CRC) is the third commonest confirmed cancer in males and the second commonest in females in the world. It has grown to 1.8 million cases (10.2%) with the biggest figure of deaths (881 000, 9.2%) in the globe [5,12]. Majority of CRC is classified as adenocarcinoma, which mostly begins as a benign tumor, and changed to cancerous, and that may attack normal tissue, which spreads into the distant organ [13][14][15][16][17]. An elderly person, sex, prior colon disease (IBD), DM-2, a person with a family history of the CRC and polyp may have a greater, the incidence of CRC [18][19][20][21][22][23] which is collectively known as non-modifiable risk factors of CRC [3]. It becomes the highest frequent risk factor of CRC in Kuwait [24]. However, modifiable factors such as lack of physical activity, smoking, alcohol drinking, obesity, low fiber diet, high red meat, and low fruit and vegetable intake in the diet are the most important known factor [3,[25][26][27]. It may increase the risk of having CRC by stimulating a multiplication of cancerous cell [15,28]. Modifiable factors were prevented by increasing awareness of the population about their life experience (lifestyle) [20,21,[29][30][31] For instance, the risk of CRC is reduced by 40% with the practice of regular physical activity (32,33) Similarly, CRC was the second commonest cancer in Malaysia; however, 18% of CRC could be reduced by increasing public awareness with the application of regular physical activity, decrease body weight and stop alcohol intake [34] while CRC may present with warning symptoms such as bloody stool, unexplained weight loss, change in bowel habit, anemia, lower abdominal lump, rectal bleeding, and chronic abdominal pain [14,[35][36][37].
In Sub-Saharan Africa, CRC is the commonest cancer that confirmed cases for 5.6% in males and 3.7% in females. In Eritrea, it becomes higher among males than females to lack awareness about CRC risk factors and symptoms among the population [10,38]. Therefore, increasing the awareness of the general population about CRC may lead to a decrease the prevalence of the disease and rising willingness to involve in cancer screening [39,40]. This is important to early diagnosis, and treatment which may increase the survival rate [41,42] CRC is the third most common cancer in Ethiopia [6]. It becomes prevalent to account (12.2%) in males and (4.4%) in females [43]. The organization of healthy in Ethiopia mostly focused on the switch of communicable disease and, there is insufficient screening center, treatment facilities, and, unwell organized referral [6]. Therefore, non-communicable disease (NCD) like colorectal cancer is increasing rapidly [6]. So that today CRC in Ethiopia, become the first highest in men (19%), and fourth-highest for women (5%) [44]. Therefore, increasing awareness of colorectal cancer among the population has an unlimited influence on the prevention of disease, early diagnosis, and treatments and termination of disease prevalence.
The study conducted in the different country showed that the awareness score of the Bahraini population reaches to (56%), among this (63%) of the score was taken by participants who have higher education but it was still low score [18] while in Malaysia participants who had awareness about CRC symptoms (91.9%) and risk factors (53.6%) [45] Similar study done in Jordan indicate that the awareness of CRC among the population was low, however, females and participants who learn health-linked education had high awareness [46] Gender, age, marital status, educational level, income, family history of CRC, heard about CRC, and source of information were the most predictors of awareness of CRC [24,47,48]. Females, age above 50 years and higher income participants had high awareness which is significantly associated with awareness of CRC [18,31,49,50]. However, there is a limitation of study which assessed the awareness of CRC and its associated factors among adult patients in Ethiopia. Similarly, there is a potential gap considered in the current study area. Though, increasing the awareness of people about lifestyle modification, predictors' identification, and recognizing warning signs and symptoms may important to reduce colorectal cancer morbidity and mortality. In addition to this, it is an indispensable primary phase to ensure their health well-being and experience of a healthy lifestyle to decline CRC prevalence. The finding of this research will be used as a baseline tool for researchers, policymakers to design policies, plans, and intervention programs for down hilling prevalence of CRC in the public. Ultimately, this study will help the patients in reducing increased health care costs, reduce hospital stay in the case of CRC, and improves the quality of life. Generally, awareness of colorectal cancer-related factors and warning symptom is crucial among the population in Ethiopia. Therefore, this study aims to assess the awareness of colorectal cancer and associated factors among adult patients in Jimma, South-West, Ethiopia.

Study Design, Area, and Population
The institutional-based quantitative cross-sectional study design was employed from March to April 2020 at Jimma University Medical Center (JUMC) placed in Jimma town, which is located 354 kilometers from the capital Addis Ababa within the southwest of Ethiopia. It is one of the largest institutions giving service for cancer treatment and care in Ethiopia. It has a total bed capacity of around 675 with nearly 1900 hospital staff. All adult (18 years and above) volunteer adult patients who had been attending adult medical and surgical outpatient clinic of JUMC during the data collection period were included, except patients who had a history of CRC, mentally ill, chronically ill, critically sick, visual and hearing disorder, and unable to speak during the data collection period. The net sample of 422 was employed using a systematic random sampling technique. This sample size yielded with considering marginal error (d) = 5%, and 95% confidence level, α=0.05. The sampling frame for the systematic sampling technique was the HMIS case registry book. For all cases, K was 35 and between 1 and 35. The first comer patient took as a primary sample then every 35 intervals until getting the 14 samples with each day at the selected adult outpatient clinic.

Data Collection Tools and Procedures
Data was collected using an interviewer-administered structured questionnaire. The data instrument included two parts. Part one: as socio-demographic data including information related factors. Part two comprised Cancer Awareness Measure questions (CAM) which adapted from the University College London and Cancer Research in the UK in 2008 and were intended to examine the general public's awareness of CRC in the United Kingdom with some modifications after serious literature review [51] and using question with "Yes or No" answers, where "Yes" indicated for the exact response which scores 1. A participant got an excellent mark of twenty out of twenty when the whole questions were responded to exactly. An accumulative mark of respondent's on awareness of CRC ranging from (0-20) which was acquired by the accumulation of exact response to the 20-item questionnaire. A total mark of 15 or more (≥75%) was referred to as the participants were attaining high awareness; whereas participants who score less than 15 (<75%) were attaining low awareness [19,41,48,51,52]. For this study, the instruments on awareness of colorectal cancer were interpreted to Amharic version, then local language Afan Oromo via a back to back translation approach. The instrument was certified before being used in this work as defined in the section. The certification result revealed that there was 96% consent between the Amharic, Afan Oromo, and English instruments. To assure the quality of data, the following measures were taken. The questionnaire was adopted from the CAM questionnaire. Its Cronbach's alpha coefficient was 0.84 and the content validity index was 0.7 (Nasaif and Al Qallaf, 2018). A Pre-test was conducted on 42 adult patients in Shenen Gibe General Hospital in Jimma Zone one week before the actual data collection and the questionnaire had been checked for its clarity, understandability, and simplicity. After the pre-test, the questionnaires were reviewed and reformatted based on the inputs and comments generated by seniors. After this, the internal consistency (Cronbach's-α) in this study was 0.90 which can be considered adequate. Both the principal investigator and recruited supervisors had been responsible for supportive supervision on the spot and on reviewing all filled questionnaires on daily basis. Data collectors and supervisors were enrolled in training for two days on the objective of the study, instrument, and data collection procedures by the principal investigator.
The supervisors were checking the questionnaire for completeness and closely supervise data collectors and presented to the principal investigators. Moreover, the collected data was coded, cleaned, and explored by the principal investigator before analysis.

Data Entry, Analysis, and Presentation
The assembled data was checked its completeness and consistencies before data entry. Answers in each question were labeled for easiness of data entrance. The coded data were entered into Epi data version 4.6.0 and exported to SPSS version, 25 was used for data analysis. Descriptive analysis, bivariate, and multivariate logistic regression models were carried out to describe and identify factors that affect awareness of CRC. The AOR was used to determine the strength of association and statistically significance at 95% confidence interval (CI). Then significant factors with p-value < 0.25; CI-95 % in bivariate analysis were entered into multivariate logistic regression models to control the effect of confounding factors, and the statistical test of association was considered significant at a p-value of <0.05. Then the result of the study was presented in figures and tables.

Ethical Consideration
An ethical clearance letter was gained from the institutional Review Board (IRB) of Addis

Socio-demographic characteristics of participants
A total of 422 with response rate (100%) patients participated in this study. Table 1  school while (n = 74, 17.5%) attended college and above. About more than half of (n = 240, 56.9%) of participants earn monthly income lower than 3000 Ethiopian birrs, and (n = 248, 58.8%) of participants heard about colorectal cancer. Only (n = 17, 4%) of participants had a family history of CRC and more than half (237, 56.2%) of the participants responded that CRC is a preventable disease (Table 1). More than one third (n = 74, 29.8%) of the participants had received information regarding CRC from mass media followed by social media (n = 55, 22.2%) ( Figure 1).

Awareness of participants toward Colorectal Cancer
The study finding indicates that more than three fourth (n=330, 78.2%) of participants thought that the commonest modifiable agent that was a risk of CRC were smoking followed by alcohol consumption (n=327, 77.5%) however, the least factors that were recognized by participants were aging (n=150, 35.5%) and DM-2 (n=137, 32.5%). Similarly, (n=248, 58.8%) of participants known that lack of vegetables and fruits intake in the diet may increase the risk of CRC. Two hundred eight (n=208, 49.3%) of participants understood that blood in stool was the commonest warning symptom of CRC followed by chronic abdominal pain (n=203, 48.1%), and change in bowel habit (n=199, 47.2%) and more than one third (n=164, 38.9%) of participants said that anemia is the warning symptoms of CRC. However, the least symptom of CRC that was understood by (n=143, 33.9%) of patients was a lump in the lower abdomen (Table2). The

Factors associated with awareness of colorectal cancer
The finding of this study revealed that gender, monthly income, residency, level of education, heard about CRC, information sources, and family history of CRC are identified as factors associated with awareness toward colorectal cancer among patients.

Discussion
This is the first study investigating the awareness of CRC and its associated factors among the population in Ethiopia. Increasing awareness toward CRC is a cornerstone for better prevention, early detection, and care of patients with advanced colorectal cancer and cancer-related complications. Unlike this, it increases the prevalence of advanced disease and CRC-related mortality. Hence, this study assesses awareness of CRC and its associated factors among patients The overall score of awareness of patients attending Jimma university medical center was 42.40%. This indicates more than half of participants have low awareness about colorectal cancer which will contribute to unhealthy lifestyle practice, which leads to increases in the incidence of CRC. This finding is lower than the finding of studies conducted in the Kingdom of Bahrain which is 56% [18]. This might be due to the difference in socio-economic status and organizational policies and access to the information-related to CRC, and its risk factors. The result of this study is also lower than the finding of studies conducted in Pakistan [53] which is 66.6%. This discrepancy might be due to differences in the study population in which the Pakistan study included only young university students and might be getting awareness through the educational curriculum. Conversely, this finding is also lower than the study done in Malaysia which is 91.9% and 53.6% of symptoms and risk factors of CRC respectively. 45 This higher score difference might be explained by the fact that information access in Malaysia encompassed in the educational curriculum from nursery through higher secondary education and telemedicine also giving service and application in urban area [54,55].
In general, the finding of the current result about awareness of CRC regarding risk factors and symptoms become inadequate (low). This result is consistent with a study done in Jordan [46] which is awareness of colorectal cancer symptoms and risk factors among participants were (32.8%) and (16.5%) respectively.
The current study showed that participants who are female had a high awareness about CRC which is consistent with the finding of the study conducted in the Gaza strip [56] and, Jordan [46]. This discrepancy between genders might be due to females might had more exposure to cancer-related health education or information connected to their reproductive health service encounter compared to their male counterparts and also might be due to females give attention to their health and have the desired discussion however CRC is still frequent in men. This result is supported by the different studies done around the globe [18,49,50,56].
The commonest risk factors that aware by participants were smoking cigarettes 78.2% and alcohol consumption (77.5%). This result is almost in line with the study done in Gaza strip [56] which is (76.7%). Conversely, this finding is higher than the study in Kuwait which is almost each to (70%) [4]. This might be due to differences in governmental health policy and accessibility of public health education about the effects and consequences of smoking and alcohol consumption. Conversely, the symptom that was least aware by participants was DM-2 (32.5%). However, DM-2 is strong, significant associated with awareness of CRC (P = 0.000, P < 0.05). This is almost consistent with the studies conducted in Kuwait [24] which are 31%. The result shows low awareness of participants about DM-2 as a risk of CRC. This would underline the need for public awareness about diabetes from the time when it is a significant risk factor of CRC. This result is supported by the study done in Roman [57]. It also increases late diagnosis and tendency to poor outcome after treatment [58].
This study reported that awareness of participant's that lack of physical exercise is risk factors for CRC were 56.6%. This result shows higher than the study conducted in Kuwait [24] which is 50%. This might be due to awareness of physical activity increase due to governmental action that starting mass sport that reduces chronic illness. Conversely, the study result is lower than the study done in the Kingdom of Saudi Arabia [47] which is 66%. This might be due to governmental action on practicing physical activity was limited to some urban area of the country. Besides, this discrepancy might be due to individual behaviors like using their own automobile, being busy, standards of lifestyle, and lack of time.
This study showed that almost half (49.3%) of participants were aware of blood in stool, and change in bowel habits (47.2%). This finding is higher than the study conducted in Madinah, Saudi Arabia [49] which is (45.9%) and (34.8%) respectively. This difference might be due to knowing the anatomical position that symptom experienced and peoples might be considering chronic hemorrhoid leads to CRC as the same symptom. Conversely, the result was lower than the study done in Kuwait [24] which is (55%) and (56%) respectively. The possible justification might be due to the level of education difference among study participants that might be contributed to this result. In which 73% of participants join higher education in Kuwaiti study.
Gender, residency, level of education, monthly income, heard about CRC, information sources, positive family history of CRC, were identified as factors that significantly associated with awareness of colorectal cancer among patients in this study. Those patients who are living in urban areas were 54.5% less likely to have low awareness of colorectal cancer than those participants living in a rural area. This study finding is consistent with the study done in Malaysia [59]. The probable reason for this might be due to patients living in an urban area might have frequently get information through mass media (Television, Radio), social media, and they developed better awareness in using these types of information sources. Patients who cannot read and write, can read and write, and learn elementary school were almost three times, three times and two times more likely had low awareness towards colorectal cancer respectively as compared to those patients with higher educational levels. This result is consistent with the study done in Bahrain [18]. The possible justification for this might be patients with joined college and university might get information through curriculum and work experience about colorectal cancer, this might increase awareness of colorectal cancer toward risk factors and symptoms.
Those patients who earn a monthly income of 3000ETB and above were four times more likely had high awareness of colorectal cancer compared to those patients who earn below 3000ETB.
This indicates income is significantly associated with awareness of the patients as (P = 0.000, P < 0.05). This result is supported by the study done in Malaysia [45]. This might be related to those patients who earn better monthly income were more satisfied by their income to initiated in gathering information with different information systems like join in different social media like the internet at home, Facebook, YouTube, and telegrams and using mass media like television and radio.
Patients who heard about colorectal cancer were almost five times more likely to have high awareness of colorectal cancer compared to never hear about colorectal cancer. Similarly hearing about CRC is strong significantly associated with awareness of colorectal cancer (p = 0.00, p < 0.05, 95% CI). This finding is consistent with the study done in Madinah, Saudi Arabia [45].
The possible justification for this might be participants live in an urban area that may have access to health-related information or they may live nearby cancer awareness campaigns. This might be enhancing awareness about the important disease and increase personal disease preventive practice. Obtaining information through social media was two times more likely to have high awareness of colorectal cancer than those who get information through other sources. Sources of information via social media is statistically significant at (P = 0.017, P < 0.05). This result is consistent with the study conducted in Madinah, KSA [48] which is the most source of information that the participants used for increasing awareness about CRC followed by relatives (13%) curriculum (11%), and television (6%). The possible justification might be information that was required by participants was available anytime and anywhere if the internet was available. It might be also information through social media was not need a fixed period or time for obtaining information about CRC than others. In general, the information about CRC was significantly associated with awareness of colorectal cancer. This result is also supported by a study done in Saudi Arabia [47].

Conclusion
In conclusion, almost two-thirds of the study participants had low awareness about colorectal cancer. Similarly, the awareness of signs and symptoms of CRC among participants had very low compared to that of risk factors. Participants with high levels of education, high income, age more than 50 years, and females had better awareness of CRC, however, the overall situation is unhappy. Gender, residency, level of education, monthly income, heard about CRC, and sources of information were significantly associated with awareness of CRC. Maximizing awareness about CRC and associated factors play an important role in preventing and reducing the incidence of CRC. Therefore, the study finding recommended that initiating structured awareness campaigns and devoting an awareness month for this disease can maximize awareness about CRC. In addition to this, promoting these activities on mass media and social media will help address information to a wider range of audiences.

Limitation of the Study
The limitation of similar studies conducted in Ethiopia makes the comparison and discussion challenging. Finally, this study was the cross-sectional nature of the study design does not confirm the definitive cause and effect relationship between the variables.

Ethics approval and consent to participate
This study was reviewed and approved by an Institutional Review Board of the College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia (Protocol No: IRB/059/20/SNM). All participants provided written informed consent. The study was conducted in accordance with the Declaration of Helsinki.

Consent for publication
Not applicable

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the author on reasonable request.