Basic knowledge of cancer risk factors, signs and symptoms is essential for early detection as well as early presentation to medical services. This is especially important in low-resource settings as the Gaza Strip, where no systematic screening program exists, and early presentation with symptoms is the main pathway to early diagnosis and potential cure in cancer treatment. The knowledge level of cancer symptoms and risk factors in Gaza ranged from poor to fair. A minority of the participants showed good level of recognition of cancer signs, symptoms and risk factors. However, when asking open-ended questions to name cancer signs, symptoms or risk factors, all participants were very challenged and more than 95% in all groups showed poor recall. In general, adults displayed higher awareness than adolescents and females demonstrated better knowledge than males.
In concordance with other studies, knowledge of cancer risk factors as well as signs and symptoms improved with age [10, 11, 22-25]. This is not surprising as informal learning through experiences in life and exposure to public education programs increases with age. Kyle et al. found that 66.9% of British adolescents (vs 71.9% in this study) believed cancer was not related to age [26]. Recently, the Palestinian Ministry of Health reported an increase of cancer incidence rates from 73.6 per 100,000 general population in 2012 to 89.0 in 2016 [2]. This increase has been a focus of discussion among the Gaza population and might possibly have led to the understanding of increasing cancer cases in all age groups. Furthermore, causes for increasing rates are still under investigation, but have been linked in the general public to the repeated wars on Gaza, increased awareness of the public and presentation to healthcare professionals with symptoms as well as increased awareness of possible signs and symptoms among doctors.
Similar to this study, adolescents and adults in previous studies most frequently reported unexplained mass/lump as a cancer symptom [17, 23, 26, 27]. This could be due to perceiving having a mass as a concerning sign of something unusual. It might also be linked to the linguistic link of ‘tumour’, which represents a mass, to cancer. However, less than 53% of both adults and adolescents recognized other cancer symptoms, which is similar to participants in China, India, the United Kingdom (UK) and Oman [17, 24, 28, 29].
Recognition of cancer symptoms was found to be similar in Australia, Canada, Denmark, Norway, Sweden and the UK, when investigated by the International Cancer Benchmarking Partnership [27]. However, survival rates varied with the UK and Denmark lagging behind. Reasons for this were thought to be greater barriers experienced by participants, resulting in later first presentation to the doctor [26, 27]. This in turn would increase the ‘patient interval’, the time elapsing from the first symptom to presentation to a doctor, leading to more advanced stages at the time of diagnosis [9, 30, 31]. Therefore, reducing barriers for first presentation is as important as improving knowledge and awareness of cancer symptoms [9, 32-35]. Barriers can be emotional, like being worried about possible results, embarrassment or fear to see a doctor, service-related such as difficulty getting an appointment with a doctor, or practical like being too busy to see a doctor or difficulty with arranging transport [9-11]. However, negative beliefs also have a strong impact, such as the conviction that there is no cure for cancer or the treatment is worse than the actual disease [23, 32, 33, 35]. Such negative thoughts have been found to vary greatly, within countries in different areas as well as among different countries, which has been coined the ‘place effect’ [34, 36, 37]. This ‘place effect’ might have an especially strong influence in the Gaza Strip, which is a geographically relatively isolated area, suffering from a 13-year siege, restricting travel and information exchange [38]. Furthermore, cancer remains connected to poor outcomes locally. Such beliefs might be a further factor promoting late presentation. When people believe that the visit to the doctor will not improve their outlook or prognosis, they are more likely to delay or avoid such visits [32, 33, 35].
Adolescents were extremely poor in recognition of cancer risk factors with only 2.8% having a good level of recognition. However, adults also showed poor recognition with 12.4% demonstrating a good level of knowledge. The discrepancy between the age groups was found despite the fact that health-related content had been introduced in schools over the last decades, raising expectations that adolescents might at least be nearly as good as adults in recognition of risk factors. The school curriculum content might be reflected in the fact that more adolescents than adults knew that ‘smoking’ and ‘eating less than five portions of fruit and vegetables a day’ were risk factors for cancer, both of which are facts actually ‘taught’ at school. In most studies ‘smoking’ was the most commonly recognized risk factor [18, 23, 24, 29, 39-41]. Smoking enjoyed worldwide high publicity as a cancer risk factor and it is interesting that adolescents were better at recognizing this risk factor than adults. However, except for smoking as a risk factor, general awareness rates were poor in this study compared to other studies, which showed proportions of 60-88% recognizing smoking, 21-50% recognizing ‘eating less than five portions of fruit and vegetables a day’ and around 30% recognizing the importance of exercise, compared to 76.7%, 17.8% and 25.0% respectively in this study [18, 22, 29, 41]. This discrepancy could be due to the fact that a number of awareness campaigns have been done on factors such as smoking, exercise and healthy diet in the localities of these other studies [27, 40, 42-44]. However, so far, no sustained public awareness campaigns on the potential negative impact of modifiable lifestyle factors on cancer have been evaluated as to their impact on public knowledge or awareness in the Gaza Strip. Although around half of all cancer in the U.S. have been attributed to modifiable factors, such as smoking, lack of exercise and unhealthy diets by the American Cancer Society [45], this has not been translated into major interventions in low-income settings, such as Gaza. Therefore, an urgent need exists to include low- and middle-income countries in such efforts.
Strengths and limitations
This study took a large and representative sample from the Gaza population, including all five governorates. Moreover, it included adolescents from government schools, opening an unprecedented view on their awareness and knowledge around cancer. However, as this study aimed at assessing knowledge and awareness of cancer, it could not directly link awareness levels to actual outcomes. For this, another study design will be needed. In addition, adult participants were recruited from among hospital visitors which might have caused a degree of selection bias, as these people might have displayed a greater degree of health-seeking behaviour, possibly based on greater baseline health awareness. Furthermore, the paucity of sociodemographic data, such as level of education, which could influence the cancer awareness level, made analysis and examination of other factors influencing cancer awareness very challenging.
Implications for practice
For greater impact, raising awareness has to be combined with careful promotion or reinforcement of positive beliefs and information of possible chances of cure [33, 35]. Raising such awareness among adolescents could be a useful future investment and give an opportunity for early preventive measures. Kyle et al showed that a school-based educational intervention resulted in improving the recall and recognition of most of the cancer signs and symptoms even after six months from the intervention [26]. Such an intervention might be especially effective when combined with addressing negative beliefs. By reducing negative beliefs and increasing awareness in the younger age-group, a sustained effect on reduction of late presentation might be achieved, which could have a pronounced effect in low-resource settings, such as the Gaza Strip, in improving the quality of life and increasing survival of cancer sufferers. Currently, survival rates are poor in Palestine with 60% of deaths due to breast cancer in 2016 (643 of 1072 deaths) having been judged as ‘prematurely’ [46]. Such poor survival has its main reasons in the lack of systematic and organized screening programs and late presentation to healthcare professionals. Therefore, educational intervention in younger age groups could make a fundamental difference to survival and quality of life in cancer patients in the Gaza Strip. Furthermore, interventions to improve public awareness of cancer symptoms have been shown to be more effective when delivered to individuals rather than with a population-based approach, such as in public awareness campaigns [25, 47-50]. Therefore, in low-resource settings, lacking systematic and well-organized screening programs, where early diagnosis is essential to improve survival, a population-based approach should be combined with more tailored individualized education for better results [32, 35, 43, 47]. The effects from such interventions could be pronounced and sustainable, when involving younger age groups, such as adolescents [24], as reflected in this study, by the better knowledge demonstrated by adolescents of some risk factors, included in their health-related school curriculum.