Knowing CRC is crucial because it affects the possibility that an individual will engage in prevention behaviors for early cancer treatment detection and success [24]. This study explored the health behaviors, knowledge, screening, and attitudes toward colorectal cancer among Iraqi people in Sulaymaniyah/ Iraq and found that while more than half were smokers, the minority of participants had healthy behaviors like low rate of alcohol and fatty foods consumption and had high a low-fiber diet. As alcohol is officially banned due to religious and cultural factors, Iraq has one of the low rates of drinking compared to non-Muslim countries [25], perhaps, prohibition and culture may have a factor in the low use of alcohol. On the contrary, more than half of the participants were smokers. Similarly, some studies conducted in Iraq indicated the percentage of smokers is high and smoking has become a permanent habit in adults. The problems are associated with tobacco smoking behavior related to post-war conflicts and the social and cultural environment [26,27]. An unhealthy diet and a diet rich in red meat are important risk factors for CRC. As fiber increases stool volume and reduces transit time and contact with possible carcinogens [28], consumption of red meat and processed meat contribute to CRC, while a diet high in fruits, vegetables, fiber, and antioxidants may be responsible for a protective effect. Therefore, there is a need for healthcare-led lifestyle counseling that promotes a healthy lifestyle and raises awareness among Iraqi adults. We also found a minority of adults performed a colonoscopy and a sigmoidoscopy and had a family history of CRC, while many Iraqi people heard colorectal screening tests. The finding of this study was similar findings of other studies conducted in various developed, developing, and undeveloped countries such as Turkey [24], the Kingdom of Bahrain [29], Pakistan [30], Ethiopia [23], Saudi Arabia [31] and the USA [32]. Although the study population was 50 years, and older and most had heard of CRC screening tests, the low screening rate may be because they had no complaints about the gastrointestinal tract. However, education should be given that screening tests are vital in early cancer diagnosis, not just in case of complaints since CRC is one of the most common cancers in Sulaymaniyah Province [9].
The results of this present study indicated that most Iraqi adults had low basic knowledge of CRC risk factors and symptoms. In contrast, they had moderate knowledge of screening methods which is in alignment with some of the surveys which include various populations conducted by Hamza et al. [23], Baran et al. [24], Nasaif et al. [29], and Al-Thafar et al. [33] in different parts of the world. This might be related to the fact that there is a difference in the socioeconomic and sociodemographic status of the respondents, the study population, the country, the health system regarding CRC screening and access to the information related to CRC and its risk factors, which the difference in the level of knowledge of CRC might explain. For instance, the study respondents in this study were adult patients, while respondents in the Pakistan study included only young university students and might be getting awareness through the educational curriculum, or a study in Turkey included only women.
In this study, we reported that Iraqi adults believe that it is better to detect CRC early through screening and that they have the same chances of getting CRC as other people. Several previous studies have obtained similar findings to the present results. For instance, Hasan et al. [30] reported that almost all their respondents agreed that ‘early detection of CRC through colonoscopy is associated with high survival rates. Furthermore, we found that participant fears that screening method procedures would be painful and/or embarrassing constituted the most reported. In parallel, previous studies conducted in countries such as the USA, the Republic of Kazakhstan, Lebanon, and Saudi Arabia supported our findings that the most reported reasons for the attitudes toward CRC screening were uncomfortable, painful, or embarrassing [31, 34-36]. Similarly, a systematic review of the literature has revealed that fear commonly acted as a barrier to participation in CRC screening [37]. Consequently, participants’ fears demonstrate that health education should be focused on not only informing in the absence of knowledge but also correcting misperceptions.
We found that participants were more likely to have low knowledge if they were 70 and above. This result is not consistent with some studies done in Pakistan that were found age is not related to this factor in knowledge level [30], in Saudi Arabia that were found the older participants more likely to have correct knowledge [31] and in Lebanon that were indicated older participants (above 50 years of age) knowledge about cancer had twice the odds of being aware of the need for CRC [34]. This result may be because our study population aged 70 years and over was older than in the other studies. We also found participants were more likely to have high knowledge if they graduated from high school and were retired. This result is consistent with some studies done in Bahrain [29], Ethiopia [23], Saudi Arabia [31,38], the USA [32], and Turkey [24]. Although there is no study showing that retirement positively affects the level of knowledge, the possible interference for this might be that Iraqi adults with joined university and above might get information quickly and be more aware of the importance of CRC screening heard CRC screening tests on the internet and social media. This might increase knowledge of CRC risk factors, symptoms, and screening. Thus, particular emphasis should be given to those Iraqi adults with lower-level education when designing health training.
In health behavioral theories, the risk is not just affected by cognition, and desirable attitudes are also linked with low-risk perception. Positive attitudes toward cancer motivate people to maintain healthy behavior [39]. Thus, understanding personal behavior and discovering factors affecting an individual’s decision is desirable in screening attendance. In line with this, we found that Iraqi participants were more likely to have low knowledge if they had no idea about related questions linked to attitudes. Two studies conducted in Iraq showed that most had low susceptibility to cancer risk and low perceived severity but good perceived benefits of screening. Perceived susceptibility to cancer along with its psychological factors and behavior were important contributors to self-perceived health; there was an association between attitudes and knowledge [38,40]. Therefore, public health policy should also focus on people’s attitudes toward CRC screening behaviors.
We reported that Iraqi adults were more likely to have low knowledge if they had any idea and responded incorrectly to all twelve questions related to CRC risk factors. Previous studies illustrated that the lack of knowledge of CRC is a barrier to screening adherence [41,42]. Similarly, Hassan et al. [30] emphasized a lack of knowledge regarding the risk factors associated with CRC screening behaviors and essential obstacles to adequate screening attendance in their study. Jillson et al. [35] focused on the association between knowledge, and the willingness to screen and they found consistent findings like our study. Therefore, increasing knowledge of CRC risk factors in adults is crucial for better prevention and early detection.
Strengths and limitations
To our knowledge, this is the first comprehensive study to have explored the Iraqi population’s health behaviors, knowledge, screening, and attitudes toward CRC and possible predictors that may affect their knowledge. A strength of this study is we used a relatively large sample. We carefully adjusted for factors to help evaluate how sociodemographic factors, attitudes, and specific knowledge, like risk factors, were associated with participants' overall knowledge. Despite our best efforts, there are still some limitations to our study. Firstly, our sample size is from a single city, which does not represent Iraqi public knowledge. The information about knowledge of CRC was gathered from a self-administered questionnaire, so we cannot eliminate bias. Secondly, our participants were restricted to individuals who came to one hospital in Sulaymaniyah. The results could not be generalized to all Iraqi adults and cannot be representative of the whole Iraqi population. Therefore, we recommend further study designs based on different rural and urban settings.