Awareness of prostate cancer and its associated factors among Ethiopian men, 2021: A cross-sectional study


 Background: Prostate cancer is a common type of cancer in men worldwide. It is the world's second most diagnosed disease and the fifth leading cause of cancer-related deaths. In Ethiopia, it is the 3rd most common type of cancer. Awareness of Prostate cancer is key to early detection and prevention. The major risk factors for prostate cancer can be controlled by increasing public awareness. Objective: We aimed to describe what they knew about prostate cancer by asking questions about prostate cancer-related awareness and we also investigated possible relationships between the variables.Methods: In 2021, we conducted a cross-sectional study among a systematic sample of men attending the Tikur Anbessa Specialized Hospital in the Urology unit. We used a researcher-administered questionnaire to collect the data and Descriptive statistics and linear regressions were used for the analysis. The strength of the association between the variables was described using the unstandardized β with a 95% Confidence interval. Results: A total of 250 patients were approached with a response rate of 241(96.4%), with a mean score of awareness of prostate cancer risk factors of 41.2%, symptoms 43.8%, screening 44.7%, and prevention 49.5% respectively. Families with average monthly income >8900ETB (β=2.6, 95%CI:1.1-4.1, P=0.001), heard about prostate cancer (β=5.6, 95%CI:1.5-9.6, P=0.011), having a regular source of care every six months and above (β=4.3, 95%CI: 2.5-6.1, P<0.001), three times, admission history (β=5.4, 95%CI:1.3-9.5, P=0.009), and health care providers (β=10.7, 95%CI 6.6-14.8, P<0.001) as the major source of information followed by the media (β=9.6, 95%CI 5.4-13.8, P<0.001) were significantly associated with awareness of prostate cancer.Conclusion: Prostate cancer is one of the most important health-related problems among men worldwide. Therefore, a well-planned health education program should be implemented to address the observed awareness gaps.

According to the Global Burden of Cancer 2018 report, it accounts for approximately, 1,276,106 new cases and causes 358,989 deaths (3.8% of all deaths due to most male cancers) (9). The real cause of prostate cancer is elusive but, it has risk factors, including aging, family history, and race as nonmodi able risk factors (10), However, physical inactivity, smoking, alcohol consumption, and overweight are controllable risk factors (11,12). The symptoms of prostate cancer may develop gradually, decreased urine ow, frequency, and di cult urination, blood in the urine, painful ejaculation, di cult erection, and bone and pelvic pain (13,14).
The awareness of prostate cancer in men of African descent in the USA, Caribbean, and Sub-Saharan Africa has low levels of information in contrast to American Hispanic men (15,16). A study conducted in, Italy about the awareness of prostate cancer, and 82.1% of the respondents were aware of the existence of prostate cancer. A study conducted in Turkey and Benin showed that the study participants scored 71% and 34 % regarding awareness of prostate cancer (17,18).
In Nigeria Anambra state, 74.1% of participants were aware of the presence of prostate cancer, and 76.1% were aware of one or more symptoms of the disease (19). Among men attending a urology unit In South Africa, 45.4% were aware of prostate cancer and only 11 % were aware of the three major symptoms related to prostate cancer (20). In Uganda, 50.2% of respondents were unaware of any risk factors for prostate cancer but only 9% were aware of the PSA test (21). In a study conducted in Sokoto, Nigeria only 5% of respondents were aware of prostate cancer (22). Similar research was conducted in southwest Nigeria; 47.5 % of respondents were aware of prostate cancer, while 25.1% were aware of the PSA test (23). In a study conducted in Rwanda, 80% were aware of the presence of prostate cancer 64% did not recognize the risk factors of prostate cancer, 68 % were aware of prostate cancer prevention measures, and 64% were aware of prostate cancer tests through PSA testing (24).
In Ethiopia, prostate cancer has recently become more common among men, and it is quietly growing across the country, followed by leukemia and colon cancer, which is the third most common cancer among men (3,4,25). Overall, the prevalence of prostate cancer is reduced by 10%-40%, by raising awareness of lifestyle modi cation, recognizing the risk factors, prevention, and regular screening of prostate cancer, and also improves the survival of the patients (26,27). As a result, the use of this research was to determine the status of awareness of prostate cancer and its related variables among men going to the Urology unit at TASH in Addis Ababa, Ethiopia, in 2021.

Methods And Materials
Study design Study period Study setting The institutional-based quantitative cross-sectional study design was conducted from February 8 to March 8,2021, at Tikur Anbessa Specialized Hospital, Addis Ababa Ethiopia. It is located in the Ethiopian capital city of Addis Ababa. It is the largest and most well-known public hospital in Ethiopia, which was established in the early 1960s. The TASH is a center of teaching and referral hospital with approximately 800 hundred inpatient beds. It is the only cancer referral hospital in Ethiopia. This study was conducted at the outpatient department of the Urology unit at the TASH. Urologists, Residents, Surgeons, and Nurses work together to complete daily tasks (28,29).
Population, Sample size determination, and sampling procedure After obtaining ethical clearance (36/21SNM) and permission from the urology unit, we conducted a study among men aged 18 years and older. The sample size for this cross-sectional study was calculated according to the Cochran and William guidelines (30), using the single proportion and correction formula by assuming a 5% marginal error, 95% con dence interval, and 50% population percentage, because the proportion of awareness of prostate cancer has not yet been determined in Ethiopia. In 2020, an average of 535 men (N=535) visited the clinic monthly with an average of 27 visits per day. This resulted in 250 patients (n=250). The average monthly population of 2020 of male patients in the Urology Unit of TASH was [N = 535], and 27 patients were observed daily. In all cases, [n = 250] each day, an average of 13 patients was sampled to maximize the representative sample. A systematic sampling technique was used to select the sample (n=250) using the patient's appointment logbook as a sampling frame. The rst patient logged for the day was selected and then every two intervals until the sample size had been realized; Hence, the Urology unit provided health care services to patients who had prostate and prostaterelated health problems.

Data collection
Data were collected using a researcher-administered questionnaire. The questionnaire was adapted from the literature (24,31) and the cancer awareness measurements (CAM) toolkit version 2.1 from the University of London (32). The contents of the questionnaire included socio-demographic characteristics, information-related factors, patient-related factors, and awareness of prostate cancer items. Items in the questionnaire included yes/no questions. The questionnaire was initially developed in English and then translated into Amharic and reviewed by a senior oncologist and senior researcher in the eld of study. The questionnaire was pretested in another patient unit using 5% (n=13) of the sample size. Problems with clarity, accuracy and permitted time were identi ed. Once addressed, the internal consistency (Cronbach's-α) of this study was 0.88 which, is considered adequate. Two registered nurses were recruited and trained to assist with data collection under the supervision of the rst author. The data were collected in a quiet room attached to each unit. An information sheet was read to all eligible participants and written consent was obtained from all participants.

Study Variables
The dependent variable was the awareness of prostate cancer. The independent variables in this study were socio-demographic (Age, place of residence, marital status, higher level of education, occupational status, and monthly income) sources of information (healthcare provider, friends, media, and others), and patient-related factors (Family history of prostate cancer, admission history and having a regular source of care). The level of awareness of prostate cancer respondents' scores was assessed using the 28 yes or no items of the awareness questionnaire. The total score was calculated out of 100, with a range of 0 to 100. Awareness was scored as the proportion (percentage) of the correct answers. Higher scores indicate better awareness.

Data Quality Management
To manage the quality of data the following measures were taken, the questionnaire was adapted with modi cation from the Cancer awareness measurement (CAM) and published research. The pre-test was performed and the required corrections were made. The primary investigator provided training to the data collectors. There was supervision, daily, and checking the data collection questionnaire.

Data processing and Analysis
The study was computed using descriptive statistics and linear regression analyses using the epi data version of 4.6.0 software to prevent data entry errors and exported to SPSS version 26 for further statistical analyses. Recoding, categorizing, computing, and other statistical analyses were made. Descriptive analyses (mean, standard deviation, frequency, and percentage) were used to analyze the independent variables. Tables and graphs were used to show the ndings. The awareness of prostate cancer score was recorded as a continuous scale in SPSS and scored according to the proportion of correct answers. First, a simple linear regression was performed to select the candidate variables for multiple linear regression. All variables with a p-value < 0.25 during simple linear regression were selected for the multiple linear regression. After the multiple linear regression analysis, variables with a p-value less than 0.05 were statistically signi cant with awareness of prostate cancer. The strength of the association between the independent and dependent variables was described using the unstandardized β with 95% CI. Finally, multicollinearity was checked by examining both tolerance and Variance in ation factors (VIF). Multicollinearity was calculated, indicating how much of the variability of the listed independent variables was not determined by the other predictor variables in the given model. All of the tolerance scores in the model were >0.10 and the Variance in ation factor (VIF) values were below 10, implying that multicollinearity could not exist. The R square statistic in the model also described a variance 0.8 of which determines the appropriateness of the model used.

Results
Socio-demographic characteristics of the respondents A total of 250 patients approached and 241 participated in this study resulting in a response rate of 96.4%. Nearly three-fourths of the respondents 180 (74.7%) were from urban areas. The mean age of the respondents was 52.3 (SD ± 13.6) years with a minimum and maximum age of 28 to 97 years respectively. Regarding marital status, more than half 157 (65.1%) were married. In terms of the educational level of the study participants, 106 (44%) had college and above. About 103 (42.7%) respondents were employed. Almost half of the respondents' 114 (47.3%) monthly income was between, and 2251-8900 ETB. The majority of participants 141 (58.5%) had heard about prostate cancer and health care providers as the major source of information 69 (48.9%) followed by the media, and 56 (39.7%) [ Table 1].
The patient-related factors of the respondents About 54 (22.4%) respondents had a family history of prostate cancer while 105 (43.6%) of respondents had a regular source of care for their health, and from those participants, almost half, 116 (48.1%) of them had an admission history of the health institution [ Table 2].   Table 3].

Discussion
Our study showed that the proportion of prostate cancer awareness was 45%. This study's awareness score was also lower than the results of a study conducted in Rwanda 75% (24). The major discrepancy among the previous studies and in our study might be due to Study in Rwanda was conducted directly on patients who have an appointment for prostate cancer, this is make difference in the individual awareness toward prostate cancer. In contrast, this nding is different from that of a study conducted in Benin (33). this indicated that a small score was reported in our study about prostate cancer awareness, which was only (34%). This difference may be related to the difference in the study population; the study was conducted on the general population but our study was conducted on patients who visited the urology department. This indicates that patients with speci c health problems are more aware than the general population (34).
This study demonstrated that families with a high monthly income had a signi cant impact on their awareness. This is supported by a study conducted in Denmark and Namibia, which explored a strong socioeconomic distribution in cancer awareness, with individuals with low family income having a poor awareness of symptoms, risk factors, prevention, and screening (35,36). Respondents with more income were more concerned about their health than those with lower incomes. Furthermore, economic development in one country is increasing school enrollment and educational attainment, which improves people's educational levels and health status. Furthermore, people with a high income were encouraged to learn more about their health and health-related status.
Regarding the sources of information about prostate cancer, 141 (58.5%) of the respondents had asked about prostate cancer from a different source. The respondents were heard about the existence of prostate cancer from different sources. Health care providers, media, and friends were signi cantly associated with the awareness of prostate cancer. Health care providers are the most common source of information, followed by the media (TV, radio, and social media). This is supported by another study conducted in the following countries which indicated that the main source of information was health care providers and the media. A study conducted in Saudi, and Rwanda, found that the main source of information was health care providers (24,37). In addition, a study conducted in Italy, Nigeria, and Uganda noticed that the main source of information was the media (19,21,31). This may be because the Ethiopian media did not provide adequate information and awareness of prostate cancer or health care providers provided more information than the media.
Nearly one-fourth of the respondents 22.4% had a family history of prostate cancer. Positive family history is a signi cant risk factor for prostate cancer and is signi cantly associated with awareness of prostate cancer. This is supported by different studies, the risk of prostate cancer rises the number of affected family members, with men with two or three rst-degree relatives having a vefold and elevenfold increased risk of developing prostate cancer, respectively. The aim of any type of cancer with a family history should have been to provide enough information to increase awareness about the disease's risk factors, symptoms, early detection, and prevention. It also allows for the implementation of an initial management plan and follow-up action for the possibility of a family member's susceptibility (38).
Furthermore, in this study, 43.5% of respondents who had a routine source of care were associated with prostate cancer awareness. The respondents who had a regular source of care every six months or more had a signi cant association with Awareness of prostate cancer. This study is in line with a study conducted at the Texas university (39). Periodic health assessments or examination is relevant to health professionals or health institutions where the person usually goes to his/her health and health-related conditions if he/she is ill or needs advice. When patients received regular and routine care services from health care providers, their awareness improved accordingly (39).
Nearly half of the participants 48.1% had a history of admission to a health facility for prostate and prostate-related problems, among those, who were admitted 3 times, admission history was signi cantly associated with awareness of prostate cancer as compared to those who had less frequent admission history. This nding is supported by previous studies conducted in South Africa (40). According to the European Charter on Patients' Rights (41), a patient's right to be aware of their health condition during admission is a basic human right and an important part of modern health care practice.
Frequent admission of patients also encourages awareness of patients concerning their health and health-related situations. Globally, during admission, the number of participants who were aware of the different factors of health care service factors ranged from 18.9% to 84.1% (40). As a result, patients who have had previous admissions are more aware of their wellbeing and health-related problems than those who have not. The relationship between health care providers and patients should include empowering patients to be more aware of their health and health-related issues.

Strength and limitation of the study
The study instrument was comprehensive, pretested, and modi ed before the data collection. The data were double entered and validated using the Epidata Version 4.6.0 entry before analysis. However, the ndings are restricted to a sample of Tikur Anbessa specialized hospital patients, thus limiting their generalizability to the whole country. Our study sample size was small, which limits our generalizability of the ndings on awareness of prostate cancer and its associated factors. Therefore, a large sample size is needed to incorporate other aspects of respondents' awareness of prostate cancer. The research may also be limited by the fact that these were based on the participants 'self-reports, which can increase social desirability bias.

Conclusion And Recommendations Of The Study
In conclusion, the proportion of awareness score among respondents of male patients attending Tikur Anbess specialized hospital was low relative to previous studies. More than half of the study participants had an awareness score below the mean value. Health care providers are the main source of information followed by the media. Families' average monthly income, heard about prostate cancer, having a regular source of care every six months or more, three-times, admission history, and source of information were all signi cantly associated with Prostate cancer awareness. This strong association between prostate cancer awareness and associated factors is essential for understanding and controlling the disease. Improving awareness of the cancer patients, by implementing a multidisciplinary team approach, promoting an awareness campaign, emphasize male patients with cancer, and conducting a further study with larger samples were recommended.
Declarations intellectual content; agreed on the journal to which the article would be submitted; gave nal approval of the version to be published; and agreed to be responsible for all aspects of the work.

Ethics approval and consent to participate
The study was conducted in accordance with the declaration of Helsinki. An ethical clearance letter was obtained from the ethics Institutional Review Board of Addis Ababa University, College of Health Sciences, school of nursing and midwifery (Protocol N 0 36/21SNM).
Availability of data and material The data are available from the corresponding author and will be provided upon reasonable request.

Source of funding
The cost of the study was covered by Addis Ababa University.

Consent for publication
Not applicable.  Figure 1 Overall awareness of prostate cancer among male patients in the Urology unit at TASH, Addis Ababa, Ethiopia, in 2021.