The estimating level of awareness and knowledge of colorectal cancer among general population in Al-Ahsa Region, Saudi Arabia

Background: Colorectal cancer (CRC) is a type of cancer that affects the colon. Globally, CRC is one of the most common types of cancer in the world among both genders. The east of Saudi Arabia, Al Ahsa, is reported by the Saudi Cancer Registry to have the highest incidence. This study aimed to assess the knowledge and awareness of CRC signs and symptoms among the general population in Alahsa, Saudi Arabia. Methods: A cross-sectional study was conducted from August 2022 to February 2023, utilizing a survey based on a previous study by Bakry et al. The sample size was 384 participants, with data collected through an online Google questionnaire. This survey covered demographics, CRC awareness, knowledge, and risk factors. Result: 385 out of 457 of the participants which is represented as 84% answered the questionnaire correctly. The majority were males, aged over 45, residing in the Al Hassa region, with over half having university education or degrees. In addition, most participants were married, and over 80% had heard of CRC. Twelve individuals had been diagnosed with CRC, and 91 had a family history of the disease. Surprisingly, more than 90% of participants demonstrated excellent knowledge of CRC. The correlation analysis indicated that younger participants were more aware of CRC ( p = 0.042), but no significant associations were found between excellent awareness levels and gender, educational level, or marital status. Conclusion: There is an excellent level of awareness of CRC signs and symptoms among the general population in Alahsa. This reflects the excellent knowledge and education among the general population. Leading us to expect early medical help if anyone experiences CRC symptoms.


Introduction
Colon is a tube-like, muscular organ that ranges from 139.7 to 169.0 cm in length [1].The colon is functioning in water and nutrient absorption as a part of the human's digestive system.As the transient time of the colon is the longest among other parts of the digestive system, the majority of the nutrients and electrolytes absorbed by the gastrointestinal tract are absorbed by the colon.Other functions of the colon include the formation and storage of stool and fecal enzyme activation [2].
Colon cancer, often known as colorectal cancer (CRC), is a type of cancer.Globally, CRC is one of the most common types of cancer in the world for both genders [3].It represents the third most common malignancy in the world.Moreover, it represents the fourth leading cause of cancer-related deaths worldwide in both genders [4].Several risk factors of CRC are avoidable, such as sedentary lifestyles and nutrition deficiency.On the other hand, other unavoidable risk factors include age and family history.CRC has several symptoms associated with it such as chronic abdominal pain, rectal bleeding, chronic change in bowel habits, unexplained weight loss, fever, weakness, and fatigue.Also, some disorders may relate to CRC such as infection, irritable bowel syndrome, inflammatory bowel disease, and hemorrhoids [5].
Since 2002, the incidence of CRC started to increase [6], and in 2004, the World Health Organization in Saudi Arabia announced that the death rate from CRC reached 8.3% [7], and in 2018, the death rate from CRC reached 15.2% [8].CRC is the second most common cancer among the Saudi population.1,033 is the number of cases that were reported in Saudi Arabia, in 2010, which represents only 10.4% of the newly diagnosed patients [9].1,908 cases were accounting for 12.2% of all newly diagnosed cases, in the year 2018, as reported by the Saudi cancer incidence report.It is the most common cancer among Saudi males 1,045 (15.3%) and third among Saudi females 863 (9.8%).The age-standardized rate (ASR) was 13.9/100,000 for males and 11.3/100,000 for females [10].
Most patients seek medical help in a late-stage of this disease with a survival rate lower than the survival rate all over the world [11] and the eastern of Saudi Arabia, Al Ahsa, is reported by Saudi Cancer Registry to have the highest incidence [6].Early detection of CRC is related directly to low mortality.CRC is considered a preventable type of cancer if detected and treated early [12].However, if diagnosed late, it may be associated with many complications such as iron deficiency anemia [13].Poor quality of life in patients in the late stages and palliative phase has been reported including pain, constipation, depression, and insomnia [14].This study aims to assess and highlight the knowledge and awareness of CRC signs and symptoms among the general population in Alahsa.

Subjects and Methods
This cross-sectional study was conducted in Al-Ahsa, Saudi Arabia, from August 2022 to February 2023, using a survey that was developed and used in a previous study by Bakry et al. [15].The study was carried out after obtaining ethical approval from the King Faisal University's research ethics committee on October 11, 2022.The sample size was 384 participants determined by the Richard Geiger equation, with a margin error determined as 5%, and a confidence level of 95%, and the data were collected randomly using an online questionnaire made by Google.The questionnaire was classified into two parts.We first collected the educational and demographic information of participants.Then, we gathered general information on CRC awareness, knowledge, and risk factors.The data was entered into the Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY).Continuous variables were expressed as mean ± standard deviation and Categorical variables were expressed as percentages.The chi-square test was used for categorical variables.A univariate analysis was used to estimate the odds ratio with 95% CI.A p-value < 0.05 was considered statistically significant.

Results
This study analyzed the data of more than 400 participants from the public to assess their understanding and knowledge regarding CRC.The majority of the participants were more than 45 years old, male in gender, and living in the Al Hassa region.Furthermore, more than half were in their university years or had obtained a university degree, married participants were the majority, and more than 80% had heard of CRC before.In addition, 12 individuals were diagnosed with CRC, and 91 had a family history of CRC.Interestingly, more than 90% of the participants had excellent knowledge of CRC.Further details about the demographic characteristics are presented in Table 1.The level of awareness of the participants is depicted in Figure 1.
Furthermore, the authors assessed the participants' knowledge regarding CRC through several questions.Table 2 details the questions and the frequency of correct answers per each question.
The authors further analyzed the correlation between a better awareness score and the demographic characteristic by performing a univariate analysis.Moreover, the authors found that the younger the participant, the more aware they would be of CRC, with a p-value of 0.042.Furthermore, no association was found between excellent awareness levels and gender, educational level, or marital status.Further details about the univariate analysis are presented in Table 3.

Discussion
This study of general population at Alahsa region suggests the level of knowledge among the participants in Alahsa papulation is excellent which represent 385 of 457 participants.However, there is a study conducted in Makkah showed poor level knowledge and awareness among the participants which represent 163 of 227 participants.Furthermore, there is study conducted in Jeddah [15] also showed a poor level of knowledge and awareness among the participants.The current study covers large range of age from 18 years old to more than 45 years old which give large view of the population.However, there is study conducted in Makkah [15] which covered small range of age from 19 to 30 years old which tried to focus on small papulation.There are slight differences in CRC awareness in correlation to the age.Overall older participants (46 -older) are less aware of CRC.In contrast to a study conducted in Jeddah which showed older participants (50 -older) [9].were more aware of CRC and another study showed higher awareness of CRC in those between 50 and 59 years  [16].On the other hand, younger age group is associated with higher knowledge about CRC.In a study conducted in Riyadh, Saudi Arabia [5], different results were noticed as the lowest correct answer was in the younger age group (20-29 years 51.5%; p = 0.002).However, this study shows that male participants are more than females participants.This is similar to limited number of studies in which male represent a higher proportion than female.However, Different ratio in other studies with more females participants is noticed [17][18][19].On the contrary, several studies showed a higher proportion of female participants [19][20][21].Furthermore, there is slight difference between gender and the awareness of CRC in this study.86.8% of female participants have excellent awareness of CRC and 84,7% of male participants have excellent awareness of CRC.This finding similar with a study conducted in the United States [22].In contrast, several studies reported higher awareness of CRC in male participants [15,23,24].It is found that there is no significant influence of gender on knowledge about CRC.Otherwise, the same study that was conducted in Riyadh [5,18,25] showed that female participants had better knowledge and awareness about CRC than male participants.Similar to the current study, a study that was conducted in Jeddah [5], showed that  majority of participants (68%) were aware that CRC is a preventable disease.Married participants made higher percentage (73.9%).This contrasts with a study conducted in Umm Al-Qura University health colleges, where a higher percentage of participants were single.
In the current study, there is a clear correlation between individuals who have heard about CRC (88%), which is in agreement with the majority of participants (62.7%) in the previous Umm Al-Qura University study.More than half of participants (55.5%) reported the correct answer when asked if chronic abdominal pain was related to CRC or not.This is an agreement with the findings from the Umm Al-Qura study, where 51.7% of the participants answered correctly [15] In addition, this study shows about 2.6% of the participants have been already diagnosed with CRC and 19.9% of them have a family history of CRC which could explain the high awareness of CRC sign and symptoms.In a study conducted in Tabuk, 3.1% of participants were already diagnosed with CRC [26].Another study showed 2.5% of its participates have been diagnosed with a family history of colon cancer, 2% lynch syndrome, 1% colon polyps, and 1% with rectal cancer [27].Furthermore, 81.6% of our participants have a knowledge that family  history as a one of the risk factors of CRC.In addition, a study in Kuwait revealed 73.5% of its participants knew that family history is a risk factor [28].A lower number is noticed in Aseer region with only 47.6% [29].Also, the findings of this study reveal more correct answers in participants with family history of CRC.This finding was in agreement with several previous studies [4,6,16].participants in this study are divided into three groups concerning the level of education (school education, corporation /institution, and high education).The majority (65.4%) of the participants have university's education.There was no significant association between level of education and CRC awareness.However, those who have high school's education slightly less aware of CRC.This disagrees with a study conducted in Jeddah were many significant associations according to the level of education [9].According to the results of the present study, among 475 participants 387 are aware of prevention of CRC.

Conclusion
Based on the survey results, more than 90% of the study participants had an excellent awareness of CRC signs and symptoms.A higher level of awareness can be observed in younger participants resulting in a wider knowledge of CRC, with no significant differences between educational level, gender, or marital status.The most frequently identified information was "There is test help in detecting CRC early" while the least was "CRC commonly found in Saudi Arabia."Despite the high level of awareness, which was unexpected, there were some gaps in participants awareness.Thus, future educational interventions need to be conducted to fill these gaps and improve early detection and management of CRC patients.

Table 3 .
Association between level of knowledge and demographic data (N = 457).