Knowledge of early gastric cancer screening among adults ≥45 years in China: Who, when, and how

DOI: https://doi.org/10.21203/rs.3.rs-2107113/v1

Abstract

Objective

Gastric cancer remains the fifth most diagnosed cancer and the fourth leading cause of cancer-related death worldwide. A better understanding of gastric cancer or early screening is crucial in disease prevention. In our country, the understanding of gastric cancer is still relatively lacking. Howere, little is known about the knowledge of early gastric cancer screening, especially among the ≥ 45-year population in China. This study aimed to evaluate knowledge of early gastric cancer screening and associated factors in the population ≥ 45 years in Shijiazhuang, China, 2022.

Methods

A cross-sectional study was conducted in public places in Shijiazhuang, China, through the distribution of structured questionnaires. From 1 August 2022 to 10 August 2022, 1200 subjects over 45 were enrolled in the study. The descriptive and logistic regression analyses were performed using SPSS version 26.0.

Results

A total of 1053 respondents participated in the study with a response rate of 88%.Only 17.5% of respondents had good early gastric cancer screening knowledge. In terms of specific screening knowledge, 64.0% of participants agreed that gastroscopy is the gold standard for early gastric cancer screening(how). However, only 19.9% were aware of the starting age of early screening (when), and less than 50% correctly identified the target group (who) from the H. pylori infection population (lowest,20.5%) to individuals with gastric diseases (highest,47.6%). Independent factors related to higher screening knowledge included female sex(OR = 1.55, 95% CI = 1.01–2.38),higher education level(OR = 4.03, 95% CI = 2.68–6.06), being with a personal/family experience of gastric diseases(OR = 1.68, 95% CI = 1.12–2.52).

Conclusion

In China, people ≥ 45 years have poor knowledge about early gastric cancer screening, especially a lack of awareness of specific information, including starting age(when)and target group༈who༉. Sex, education level, and personal/family experience of gastric diseases were found to be independent predictors of the early screening knowledge of respondents. Therefore, males aged 45 years and older, those with low education levels, and those without a personal/family experience of gastric diseases could be a key group in early screening education.

Introduction

Gastric cancer (GC) is one of the most common malignant tumors of the digestive tract [1]. The past decades have seen a rapid decrease in the incidence of GC due to improved dietary habits and treatment for H. pylori infection [2–3]. However, GC remains the fifth most diagnosed cancer and the fourth leading cause of cancer death worldwide. Approximately one million new cases and 769,000 deaths occurred globally in 2020, with more than half of the new cases and deaths occurring in China [4]. One of the most striking reasons for the shockingly high mortality is that more than 80% of GC cases in China are diagnosed at an advanced stage when the prognosis is poor [5–6].

Mortality can be further reduced by early diagnosis in population-based screening programs using endoscopic techniques [7, 8]. As a result, the 5-year survival rate has increased to about 75.4% in Korea and 80.1% in Japan over the past decades [9, 10]. Due to the large population base and relatively limited medical resources, early detection relies on opportunistic screening only in China, resulting in a poor overall 5-year survival rate of approximately 30% [11].To promote the effect of GC screening, the first official guidelines for GC screening released in July 2022 provided evidence-based recommendations for the high-risk group(who), starting age(when), method (how ) of screening programs and recommended that men and women aged 45 years or older receive screening for GC [12].

Despite this, the reported participation rates for this screening program remain low, suggesting barriers to receiving screening [13, 14]. A cross-sectional study [15] found that poor knowledge of risk factors and warning signs of GC significantly influences an individual's screening behavior. Similar studies for cervical cancer screening [16] reported that a general lack of awareness of early screening, including high-risk groups, methods, and timing, also contributed to the low screening rate. Hence, a better understanding of diseases or early screening is crucial for improving screening adherence.

However, the current perceptions of early GC screening are primarily unclear among individuals ≥ 45 years since most research has been concentrated on general population investigation regarding risk factors and warning signs of GC [17, 18]. This study aimed to assess knowledge of early GC screening and associated factors among individuals ≥ 45 years. This study may be an excellent time to reconsider what information should be included in educational lists presented to the public and who should be targeted for educational campaigns. Importantly, findings would provide a basis for designing new evidence-based educational programs and formulating screening-promoting strategies for GC.

Setting And Sample

This cross-sectional, descriptive study was conducted between 1 August 2022 and 10 August 2022 among adults ≥ 45 years in Shijiazhuang, China. The minimum calculated sample size was 896, which was determined using the formula  in which the standard deviation was 4.65 (∂) based on the knowledge level of the pilot group, the significance level was 0.05 (α), and the allowable error was 0.3 (δ). Considering a nonresponse rate of 30%, a target sample of 1200 was finally determined.

With eight administrative districts involved in Shijiazhuang, we randomly chose two community sites from each district and randomly visited 75 individuals from each site. Assisted by community health personnel from the eight districts, we interviewed 1200 individuals at various community sites. The inclusion criteria were (a) age ≥ 45 years, and (b) ability to communicate verbally. (c) without a previous history of gastric cancer. Of the 1200 individuals who received the questionnaire, 1098 responded; however, 45 respondents completed less than 50% of the questionnaire. Thus, a total of 1053 participants participated in our analysis.

Study Instrument

The questionnaire includes 16 items divided into two main sections: Sociodemographic characteristics(6 items) and knowledge of early gastric cancer screening (10 items ). (1)Demographic characteristics, including sex, age, educational level, marital status, monthly income, and personal/family experience of gastric diseases. ༈2༉Knowledge of early gastric cancer screening, including general information and specific detail-who should be screened, when, and how to screen. Participants were asked to answer whether the following items were accurate, mainly including the judgment. Each item provides dichotomous response options (true or false, scored with 1 or 0, respectively). Total scores ranged from 0 to 10 points and were divided into three levels: high knowledge, 7–10 points; moderate knowledge, 4–6 points; and low knowledge, 0–3 points.

The questionnaires were derived from related guidelines of GC screening and reference articles and were scientifically validated by gastroenterology medical and epidemiology faculty [19, 20]. All articles listed were identified by the National Center for Clinical Medicine of Digestive Diseases.

Data Processing And Analysis

All data were analyzed using SPSS V.26.0.Demographic characteristics and responses to each question were described using frequencies and percentages. Univariate logistic regression was used to determine the relationship between sociodemographic characteristics and early screening scores. Variables with a p-value ≤ 0.15 in the univariate logistic regression were entered into the multivariate logistic regression analysis to investigate the independent factors influencing scores. A two-tailed p-value of < 0.05 was considered statistically significant. For each early screening scores model, response options for the dependent variable were categorized as “Low/moderate scores” and “high scores." The results of the multivariate analysis were presented using OR and 95% CI. A two-tailed p-value < 0.05 was considered statistically significant.

Results

Demographic characteristics of the participants

The demographic characteristics of the 1053 participants in this survey are shown in Table 1.

Table 1

Sociodemographic characteristics of participants (n = 1053)

Characteristics

Number (%)

Gender

  

Female

687(65.2)

Male

366(34.8)

Age(years)

  

45–54

221(21.0)

55–64

381(36.2)

≥ 65

451(42.8)

Educational Level

  

Uneducated or elementary school

195(18.5)

High school

753(71.5)

College or above

105(10.0)

Marital status

  

Single

54(5.1)

Married

999(94.9)

Monthly income

  

<¥3000

741(70.4)

¥3000–5000

238(22.6)

>¥5000

74(7.0)

Personal/family experience of gastric diseases

Yes

248(23.6)

No

805(76.4)

 

Knowledge of Early Gastric Cancer screening

Table 2 presents the participants’ knowledge of the early gastric cancer screening. Of the 1053 participants, 418 (39.7%), 494(46.9%), and141(13.4%) had low, moderate, and high knowledge of early gastric cancer screening, respectively. In terms of specific knowledge of screening, 64.0% of participants agreed that gastroscopy is the gold standard for early gastric cancer screening(how). However, only 19.9% were aware of the starting age of early screening(when), and less than 50% correctly identified the target group (who), such as the H. pylori infection population(lowest,20.5%) and people with unhealthy lifestyles (highest,43.6%).

Table 2

Participants’ knowledge about early gastric cancer screening(n = 1053)

Questions

Correct sample,

N(%)

95%CI

1. General knowledge

    

①Early gastric cancer had no apparent symptoms usually.

322(30.6)

0.28 to 0.34

②The survival rate of early GC is much greater than that of advanced GC.

404(38.4)

0.59 to 0.65

③Regular screening helps to detect gastric cancer early.

607(57.6)

0.55 to 0.61

2. Specific knowledge

2.1 Who should be screened at screening age?

    

①H.pylori  infection population

216(20.5)

0.18 to 0.23

②People with a history of GC in first-degree relatives

419(39.8)

0.37 to 0.43

③Peole with unhealthy lifestyle habits (such as high salt, pickled diet, smoking, heavy drinking, etc.)

459(43.6)

0.41 to 0.47

④Peole living with a high incidence of gastric cancer area

490(46.5)

0.44 to 0.50

⑤Peole with gastric diseases (such as chronic atrophic gastritis, gastric ulcer, gastric polyps, etc.)

503(47.8)

0.45 to 0.51

2.2. When to screen?

    

The starting age for early gastric cancer screening in China is 45.

210(19.9)

0.78 to 0.82

2.3. How to screen?

    

Gastroscopy is the gold standard for early GC screening.

674(64.0)

0.61 to 0.67

Total knowledge level (10 points)

    

Low (0–3)

418(39.7)

  

Moderate(4–6)

494(46.9)

  

High(7–10)

141(13.4)

  

 

Factors Associated with early gastric cancer screening knowledge

Table 3 presents a univariate analysis of factors associated with early GC screening knowledge. In the univariate logistic regression, age (OR = 0.66, 95% CI = 0.53–0.83 ), education level (OR = 5.21, 95% CI = 3.56–7.61 ), monthly income (OR = 1.80, 95% CI = 1.40–2.32), and personal/family history of gastric diseases (OR = 2.47, 95% CI = 1.70–3.59 ) were significantly associated with early screening knowledge .

Table 4 presents a multivariate analysis of factors associated with early screening knowledge. These variables with p-value ≤ 0.15 in the univariate analysis were entered into the multivariate logistic regression model. The independent variables associated with screening knowledge included sex ( OR = 1.55, 95% CI = 1.01-2.38 ), education level ( OR = 4.03, 95% CI = 2.68- 6.06 ), and personal/family experience of gastric diseases (OR = 1.68, 95% CI = 1.12–2.52) .

Table 3

Factors determining knowledge of early gastric cancer screening (n=1053)

Variable

Low/moderate,

N(%)

Higher,

N(%)

OR

P-value

95%CI

Gender

    

0.71

0.08

0.48 to 1.05

Female

586(64.3)

101(71.6)

      

Male

326(35.7)

40 (28.4)

      

Age(years)

    

0.66

< 0.001*

0.53 to 0.83

45–54

179(19.6)

42(29.8)

      

55–64

324(35.5)

57(40.4)

      

≥ 65

409(44.8)

42(29.8)

      

Educational Level

    

5.21

< 0.001*

3.56 to 7.61

Uneducated or elementary school

187(20.5)

8(5.7)

      

High school

667(73.1)

86(61.0)

      

College or above

58(6.4)

47(33.3)

      

Marital status

    

0.88

0.75

0.41 to 1.91

Single

46(5.0)

8(5.7)

      

Married

866(95.0)

133(94.3)

      

Monthly income

    

1.80

< 0.001*

1.40 to 2.32

<¥3000

662(72.6)

79(56.0)

      

¥3000–5000

197(21.6)

41(29.1)

      

>¥5000

53(5.8)

21(14.9)

      

personal/family experience of gastric diseases

2.47

< 0.001*

1.70 to 3.59

Yes

192(21.1)

56(39.7)

      

No

720(78.9)

85(60.3)

      


Table 4

Multivariate analysis of factors associated with early screening knowledge(n=1053)

Characteristics

Group

B

SE

Wald x2

P-value

OR

95%CI

Gender

Female

0.44

0.22

4.01

0.04＊

1.55

1.01 to 2.38

 

Male

 

 

 

 

1(Ref）

 

Age（years）

 

-0.14

0.13

1.25

0.26

0.87

0.68 to 1.11

Educational Level

 

1.39

0.21

45.00

<0.001＊

4.03

2.68 to 6.06

Monthly income

 

0.23

0.16

2.10

0.15

1.26

0.92 to 1.71

personal/family history of gastric diseases

Yes

0.52

0.21

6.22

0.01＊

1.68

1.12 to 2.52

 

No

 

 

 

 

1(Ref）

 

Note:1=reference group;* = Significant at p = <0.05 level

Discussion

In China, the continuous data from 22 registries collected between 2000 and 2015 by the National Cancer Center showed that GC incidence increased with age and increased significantly after the age of 40 years [ 21]. With our country in the aging stage, it is more cost-effective to delay the screening age appropriately. The latest guidelines for GC screening in China recommend implementing early GC screening for those aged 45 years and older with risk factors and help to reduce mortality from gastric cancer in China. To achieve this goal, public education should be undertaken as a high level of public awareness of screening knowledge is required [22, 23]. Therefore, it is essential to determine current perceptions of screening programs among individuals ≥ 45 years. The present study provides insights into current knowledge and factors associated with knowledge about screening in this population.

Early gastric cancer screening knowledge

In this study, only 17.5% had high knowledge of early gastric cancer screening, signifying poor awareness among Chinese people aged 45 years and older. Moreover, participants had more significant cognitive deficits in screening-general and screening-specific knowledge.

For the “general knowledge" questions, only 30.6% reported that early gastric cancer has no specific symptoms. The frustrating result may be a consequence of the emphasis of educational interventions being placed on the identification of warning symptoms, ignoring the fact that most GC cases at an early stage can have no alarm symptoms [24]. Moreover, the misconception may mislead people not to screen until the symptoms appear and contribute to the high rate of advanced-stage diagnosis of GC in Chinese patients [25]. Fortunately, over half of the participants agreed that regular screening helps to detect gastric cancer early(57.6%). This indicated that respondents demonstrated reasonable awareness about the key benefits of early screening, slightly lower than those reported in the study regarding lung cancer screening [26].

In addition, there is a severe knowledge imbalance in specific screening details. For the question “how to screen," over half of the participants agreed that gastroscopy is the gold standard for early GC screening(64.0%). However, little is known about “who should be screened," even though identifying the risk group can help determine whether further early screening is urgently needed [27].In terms of H.pylori, which is known to be a significant cause of GC, previous studies showed that the nationwide average prevalence of H. pylori in China was estimated to be 59% in the general population during 2001–2014 [28].To our disappointment, only about a fifth of respondents thought people ≥ 45 years with H. pylori should be screened(20.5%). This finding shows impaired cognition of H. pylori, which is in agreement with other results [29, 30].

Regarding the question concerning “when to screen," only 19.9% knew that the starting age of early GC cancer screening in China is 45 years old, although all participants reached this screening age. Essentially, those most in need of screening are those least likely to be aware of the participation they should take to reduce risk potentially. Similar patterns have been observed in previous studies on risk factor awareness [31, 32]. There may be two reasons why this group lacks access to health-promoting information. Firstly, the relatively low figure may be attributed to the lack of national GC screening programs and awareness campaigns. Secondly, with the development of the Internet and the advent of the new media era, most middle-aged and older adults still tend to rely on traditional media, such as television and newspapers, with less access to Knowledge of GC screening [33]. Thus, considering the different groups, educational initiatives need to tailor information delivery to the intended recipients using diversified information media to tackle inequalities in awareness.

Factors associated with early gastric cancer screening knowledge

Education level was the most important independent factor associated with early GC screening scores, similar to that among other counterparts [34, 35]. Not surprisingly, it is well known that highly educated individuals will receive more disease-related education. Similarly, such groups were more likely to work in high-wage jobs, and financial unconstraints led to more significant health self-consciousness.

Further, in agreement with other studies, women had better GC screening knowledge than men, which may be worrisome because GC risk is approximately two to three times higher in men than women [36]. This may be explained by the fact that women tend to be family caregivers and thus typically come into frequent contact with the healthcare system and get more opportunities to learn health-related knowledge [37]. The result suggests that men or being with a low education level should be a key group in early GC screening education.

Aside from sociodemographic characteristics, personal/family experience of gastric diseases was a significant independent factor associated with early GC screening knowledge, in line with another study [38].On the one hand, personal experience of gastric diseases can identify people with a higher-than-usual chance of having GC. For people at an increased risk, healthcare professionals may recommend more frequent screening starting at an earlier age and provide more up-to-date information about screening [39].On the other hand, knowing information about family health history could be an excellent time to discuss these issues and pay attention to the disease, leading to an initiative to gain more knowledge about the disease[40]. Thus, individuals with personal or family experience of gastric diseases may have a higher level of knowledge about early GC screening.

Study limitations and strengths

This is the first knowledge survey focusing on early GC screening, including screening details (who, when, how) and targeting individuals within the screening age range. In addition, the study had a response rate of 88%, which might decrease nonresponse bias. Such high response rates can be attributed to support from community service centers, experienced interviewers, shorter survey duration, and a gift incentive. Our study also has some limitations. Firstly, the personal/family experience of gastric diseases was self-reported; thus, the possibility of bias in recall accuracy information could not be eliminated. Second, using a cross-sectional design to identify knowledge of screening and associated factors may imply some risk of information concealment. Therefore, future research incorporating qualitative interviews or mixed-method studies should be taken into consideration for future research.

Conclusions

This study indicates that a significant proportion of people ≥ 45 years did not know enough about early GC screening, especially a lack of awareness about specific information, including the starting age(when) and the target group༈who༉. Educational initiatives are needed to raise awareness of GC screening among individuals within the screening age range and to increase early GC screening, mainly because this group benefits the most from early screening. Moreover, males aged 45 years and older, those with low education levels, and those without a personal/family experience of gastric diseases could be a key group in early screening education.

Abbreviations

GC: Gastric cancer; CI: Confidence interval; OR: Odds ratio; ref: reference group

Declarations

Acknowledgments

We acknowledge and appreciate the cooperation of study participants as well as community health services Center for their valuable contribution.

Authors’ contributions

All authors conceived and designedthe study. Shuping Zhao and Xiaoci He collected the data and conducted the analysis. Xiaoci He drafted the work. All authors have read and approved the final manuscript.

Funding

The study was funded by the Hebei province medical scientific research plan(NO.20210653 ).

Availability of data and materials

Datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The second hospital of Hebei Medical University's ethical committee approved the study before enrolling participants（Reference number 2022-R137). All participants obtained written informed consent to participate in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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