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Awareness of Colorectal Cancer Risk Factors in Palestine: Where Do We Stand?

Awareness of Colorectal Cancer Risk Factors in Palestine: Where Do We Stand? original reports abstract CANCER PREVENTION AND CONTROL Awareness of Colorectal Cancer Risk Factors in Palestine: Where Do We Stand? 1,2 3 4 2 Mohamedraed Elshami, MD, MMSc ; Mohammad F. Dwikat ; Ibrahim Al-Slaibi, MD ; Mohammed Alser, MD ; 5 6 7 8 8 9 Balqees M. Mohamad, MD ; Wejdan S. Isleem ; Adela Shurrab, MD ; Bashar Yaghi ; Yahya Ayyash Qabaja ; Shoruq A. Naji ; 8 8 8 6 3 8 Fatima K. Hmdan ; Mohammed M. Ayyad ; Raneen R. Sweity ; Remah T. Jneed ; Khayria A. Assaf ; Maram E. Albandak ; 6 8 6 10 6 6 Mohammed M. Hmaid, MD ; Iyas I. Awwad ; Belal K. Alhabil ; Marah N. Alarda ; Amani S. Alsattari ; Moumen S. Aboyousef ; 6 8 11 6 12 13 Omar A. Aljbour ; Rinad AlSharif ; Christy T. Giacaman ; Ali Y. Alnaga ; Ranin M. Abu Nemer ; Nada M. Almadhoun ; 14 6 15 Sondos M. Skaik ; Bettina Bottcher, MD, PhD ; and Nasser Abu-El-Noor, PhD PURPOSE To assess the public awareness level of colorectal cancer (CRC) risk factors in Palestine and identify factors associated with the good awareness level. MATERIALS AND METHODS Adult Palestinians were recruited using convenience sampling from hospitals, primary health care centers, and public locations in 11 governorates. The recognition of 11 CRC risk factors was evaluated using a translated-into-Arabic version of the validated bowel cancer awareness measure. Participants were given one point for each correctly recognized risk factor. The awareness level was determined by the number of CRC risk factors recognized: poor (0-3), fair (4-7), and good awareness (8-11). RESULTS A total of 4,877 participants, of 5,254 approached, completed the questionnaire (response rate = 92.3%). The final analysis included 4,623 questionnaires, 2,700 from the West Bank and Jerusalem (WBJ) and 1,923 from the Gaza Strip. Participants from the WBJ were older, gained higher monthly income, and had more chronic diseases than participants from the Gaza Strip. The most recognized modifiable CRC risk factor was not doing 30 minutes of moderate physical activity five times a week (n = 3,846, 83.2%), whereas the least recognized was having a diet low in fiber (n = 1,985, 42.9%). The most recognized nonmodifiable CRC risk factor was having a bowel disease (n = 3,320, 71.8%), whereas the least recognized was having diabetes (n = 1,581, 34.2%). Only 1,840 participants (39.8%) demonstrated good awareness of CRC risk factors. Participants from the Gaza Strip were more likely than participants from the WBJ to have good awareness (46.5.0% v 35.0%). Female sex, knowing someone with cancer, and completing postsecondary education were all associated with good awareness. CONCLUSION Awareness of CRC risk factors was found to be low in Palestine. There is a substantial need to raise awareness of CRC risk factors through educational campaigns and programs. JCO Global Oncol 8:e2200070. © 2022 by American Society of Clinical Oncology Licensed under the Creative Commons Attribution 4.0 License INTRODUCTION fruits and vegetables as well as fiber in the diet, smoking, and drinking alcohol. On the other hand, the Colorectal cancer (CRC) is the third most common nonmodifiable risk factors include older age, family malignancy worldwide. CRC was responsible for 1, history, inflammatory bowel disease, and diabetes. 931,590 new cancer cases (about 10% of all new cases) and 935,173 cancer-related deaths (9.4% of all Implementing screening programs has been proven to cancer-related deaths) in 2020. In Palestine, cancer substantially improve survival and prognosis of pa- ASSOCIATED 5,6 accounted for 14.1% of total reported deaths and was tients with CRC. However, previous studies dem- CONTENT the third leading cause of death in 2020. CRC is the onstrated that patients’ lack of information regarding Appendix second most common malignancy with an incidence CRC risk factors may affect their participation in Author affiliations rate of 13.6 per 100,000 general population in the screening programs and therefore may lead to late and support 7,8 information (if West Bank and Jerusalem (WBJ) and 11.5 per 100, diagnosis and lower survival rates. Moreover, almost 2,3 applicable) appear at 000 general population in the Gaza Strip. In addi- one third of all cancers can be prevented by following a the end of this tion, CRC is the second leading cause of cancer- healthy diet, maintaining physical activity, and having article. 3 9 related deaths (13.9%). a normal body mass index. This highlights the im- Accepted on April 29, portance of good awareness of CRC risk factors. 2022 and published at CRC risk factors can be classified into modifiable and ascopubs.org/journal/ nonmodifiable risk factors. The modifiable risk factors The awareness of CRC risk factors was found to be low go on June 13, 2022: include physical activity, body mass index, the amount in the Gaza Strip. Nonetheless, there is an unmet DOI https://doi.org/10. 1200/GO.22.00070 of processed and red meat ingested, the amount of need to measure the public awareness across Palestine 1 Elshami et al CONTEXT Key Objective Colorectal cancer (CRC) is responsible for a significant number of cancer diagnoses and deaths in Palestine, making it a major public health problem. Therefore, this national study assessed the public awareness of CRC risk factors and examined the sociodemographic factors associated with good awareness. Knowledge Generated The awareness level of CRC risk factors was relatively low with only 39.8% of participants displaying good awareness. Factors associated with good awareness included living in the West Bank and Jerusalem, completing postsecondary education, and knowing someone with cancer. Relevance Poor public knowledge of CRC risk factors may play a role in the diagnosis of CRC at advanced stages because of delayed seeking of medical advice, ultimately leading to a lower survival rate. Systematic educational campaigns and programs aiming to promote awareness of CRC are needed and should be tailored to address the knowledge gaps among the public. to establish a baseline for future standardized educational included data collection sites. Exclusion criteria were interventions by health authorities and policy makers. having a citizenship other than Palestinian, visiting on- Therefore, this study aimed to (1) assess the awareness level cology departments in PHCs and hospitals at the time of of CRC risk factors in Palestine, (2) compare the CRC risk data collection, and studying or working in a health factors’ awareness level between the WBJ versus the Gaza care–related field. Strip, and (3) examine factors associated with good Data Collection and Measurement Tool awareness of CRC risk factors. A translated-into-Arabic version of the Bowel Cancer MATERIALS AND METHODS Awareness Measure (BoCAM) was used for data collection. Study Design and Population The original BoCAM was developed by University College London and Cancer Research, UK. It is a validated tool for This was a national cross-sectional study conducted be- assessing public CRC awareness. Two bilingual health tween July 2019 and March 2020. There are 16 gover- care professionals translated the questionnaire from En- norates in Palestine: 11 are located in the WBJ and five in the glish to Arabic, and then it was back translated into English Gaza Strip. In 2019, the number of adults in Palestine by another two bilingual health care professionals. All these reached approximately 2.6 million. This made up 51.6% of the total Palestinian population (about 5 million). There- were experts in clinical research and survey design. In fore, Palestinian adults (≥ 18 years) residing in the WBJ or addition, five independent specialists in the fields of public the Gaza Strip were the target population. Participants were health, coloproctology, and gastroenterology reviewed the recruited from governmental hospitals, primary health care questionnaire subsequently to ensure content validity and centers (PHCs), and public spaces across Palestine. accuracy of translation. After that, a pilot study was con- ducted (n = 25) to test the clarity of questions in the Arabic Sampling Methods BoCAM. The data collected from the pilot study were not Palestinians in the WBJ and the Gaza Strip receive their health included in the final analysis. The questionnaire’s internal care services in governmental facilities, nongovernmental or- reliability was assessed using Cronbach’s α, which was ganizations, the United Nations Relief and Works Agency acceptable with a value of .89. facilities, and private health care providers. Nevertheless, The questionnaire consisted of two sections. The first people rely mostly on governmental hospitals because of the section covered the sociodemographic characteristics relatively low-cost health insurance, which allows them to use 3 of participants including age, sex, marital status, level of health services at no cost or with low co-payments. Therefore, education, employment status, monthly income, place of convenience sampling was used to recruit participants from 11 residence, having a chronic health condition, following a governmental hospitals, 12 PHCs, and public spaces in the vegetarian diet, and knowing someone with cancer. The corresponding 11 governorates (seven in the WBJ and four in second section assessed the participant’s recognition of 11 the Gaza Strip) of the 16 governorates in Palestine. Public CRC risk factors on the basis of a five-point Likert scale spaces included parks, malls, trade streets, mosques, (strongly disagree, disagree, not sure, agree, and strongly churches, downtown areas, transportation stations, and others. agree). Of the 11 CRC risk factors, 10 were adopted from Inclusion and Exclusion Criteria 13 the original BoCAM, and smoking cigarettes was added The inclusion criteria to take part in the study were being an as it was deemed important given its high prevalence in the adult (≥ 18 years) Palestinian and visiting one of the Palestinian community. 2 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine 10,18-22 Participants were invited for a face-to-face interview to on the basis of previous studies. Results of the bivariable complete the questionnaire. The Kobo Toolbox, an easy-to- analyses are provided in Appendix Tables A1 and A2. use and secure tool that can be accessed via smartphones, To evaluate the awareness level among study participants was used to collect data. Before starting data collection, about CRC risk factors, a scoring system was used. Similar data collectors received training to learn how to use the 22-27 scoring systems were also used in previous studies. The Kobo Toolbox and how to approach participants and fa- total score (ranging from 0 to 11) was calculated and clas- cilitate their completion of the questionnaire. sified into three categories on the basis of the number of CRC risk factors recognized: poor (0-3), fair (4-7), and good Ethics Approval and Consent to Participate awareness (8-11). The awareness level of CRC risk factors Before data collection, ethical approval had been sought among participants from the WBJ versus the Gaza Strip was from the Research Ethics Committee at the Islamic Uni- compared using Pearson’s chi-square test. This was followed versity of Gaza, the Human Resources Development de- by running bivariable and multivariable logistic regression partment at the Palestinian Ministry of Health, and the analyses to test the association between having good Helsinki Committee in the Gaza Strip. In addition, the awareness of CRC risk factors and participant characteristics. participants had a thorough explanation about the study Complete case analysis was used to handle missing data as including its purpose and objectives with the focus that they occurred completely at random. Data were analyzed their participation is completely voluntary. Written informed using Stata software version 16.0 (StataCorp, College consent was obtained from each participant before starting Station, TX). the questionnaire, and data were collected anonymously. RESULTS Statistical Analysis Participant Characteristics The American Cancer Society recommends starting CRC A total of 4,877 participants, of 5,254 approached, com- screening at age 45 years for people at average risk of pleted the questionnaire (response rate = 92.3%). The final developing CRC. Therefore, the continuous variable of analysis included 4,623 questionnaires (254 excluded: 44 age was classified into two categories using this cutoff: did not meet the inclusion criteria and 210 had missing 18-44 years and ≥ 45 years. In Palestine, the minimum data): 2,700 from the WBJ and 1,923 from the Gaza Strip. wage is 1,450 Israeli new shekel (NIS) (about $450 US Among all participants, the median age [interquartile dollars), and therefore, monthly income was classified range] was 31.0 years [24.0-43.0] and 1,879 (40.6%) were into two categories using that as a cutoff: , 1,450 NIS males (Table 1). Participants from the WBJ were older, and ≥ 1,450 NIS. gained higher monthly income, and had more chronic The median [interquartile range] was used to summarize diseases than participants from the Gaza Strip. continuous, non-normally distributed variables, and the Recognition of CRC Risk Factors Kruskal-Wallis test was used to perform a baseline com- parison between participants from the WBJ versus the Gaza The most recognized modifiable CRC risk factor was not Strip. Frequencies and percentages were used to sum- doing 30 minutes of moderate physical activity five times a marize categorical variables, and Pearson’s chi-square test week (n = 3,846, 83.2%), whereas the least recognized was used for baseline comparisons. was having a diet low in fiber (n = 1,985, 42.9%; Table 2). This was found in the responses of participants from both The prompt recognition of each CRC risk factor was the WBJ and the Gaza Strip. The most recognized non- assessed using a question on the basis of a five-point Likert modifiable CRC risk factor was having a bowel disease scale, with strongly agree or agree deemed as a correct (n = 3,320, 71.8%), whereas the least recognized was answer and strongly disagree, disagree, or not sure deemed having diabetes (n = 1,581, 34.2%). This was also noticed as an incorrect answer. CRC risk factors were further in both the WBJ and the Gaza Strip. classified into two main categories: (1) modifiable and (2) Good Awareness and Its Associated Factors nonmodifiable risk factors. Recognizing each CRC risk factor was described using frequencies and percentages A total of 1,840 participants (39.8%) displayed good with comparisons performed by Pearson’s chi-square test. awareness of CRC risk factors (Table 3). Participants from Bivariable and multivariable logistic regression analyses the Gaza Strip were more likely than participants from the were then used to examine the association between the WBJ to have a good level of awareness (46.5.0% v 35.0%). recognition of each CRC risk factor and participant char- The multivariable analysis showed that postsecondary acteristics. The multivariable analyses adjusted for age education and knowing someone with cancer were asso- group, sex, educational level, occupation, monthly income, ciated with an increase in the likelihood of having good place of residency, marital status, having a chronic disease, awareness of CRC risk factors (Table 4). Conversely, male following a vegetarian diet, knowing someone with cancer, sex and living in the WBJ were associated with a decrease and site of data collection. This model was determined a priori in the likelihood of having good awareness. JCO Global Oncology 3 Elshami et al TABLE 1. Characteristics of Study Participants Characteristic Total (N = 4,623) The Gaza Strip (n = 1923) The WBJ (n = 2,700) P Age, years, median [IQR] 31.0 [24.0-43.0] 30.0 [24.0-40.0] 32.0 [24.0-44.0] , .001 Age group, years, No. (%) 18-44 3,608 (78.1) 1,579 (82.1) 2,029 (75.1) , .001 45 or older 1,015 (21.9) 344 (17.9) 671 (24.9) Male sex, No. (%) 1,879 (40.6) 710 (36.9) 1,169 (43.3) , .001 Educational level, No. (%) Secondary or below 2,217 (47.9) 946 (49.2) 1,271 (47.1) .16 Postsecondary 2,406 (52.1) 977 (50.8) 1,429 (52.9) Occupation, No. (%) Unemployed/housewife 2,067 (44.7) 1,112 (57.8) 955 (35.4) , .001 Employed 1,898 (41.1) 563 (29.3) 1,335 (49.4) Retired 96 (2.1) 29 (1.5) 67 (2.5) Student 562 (12.1) 219 (11.4) 343 (12.7) Monthly income ≥ 1,450 NIS, No. (%) 3,039 (65.7) 559 (29.1) 2,480 (91.9) , .001 Marital status, No. (%) Single 1,414 (30.5) 548 (28.5) 866 (32.1) .032 Married 3,067 (66.4) 1,316 (68.4) 1,751 (64.8) Divorced/widowed 142 (3.1) 59 (3.1) 83 (3.1) Having a chronic disease, No. (%) 906 (19.6) 314 (16.3) 592 (21.9) , .001 Following a vegetarian diet, No. (%) 560 (12.1) 386 (20.1) 174 (6.4) , .001 Knowing someone with cancer, No. (%) 2,395 (51.8) 1,007 (52.4) 1,388 (51.4) .52 Site of data collection, No. (%) Public spaces 1,450 (31.4) 491 (25.5) 959 (35.5) , .001 Hospitals 1,659 (35.9) 690 (35.9) 969 (35.9) PHCs 1,514 (32.7) 742 (38.6) 772 (28.6) Abbreviations: IQR, interquartile range; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. TABLE 2. Recognition of Colorectal Cancer Risk Factors Total (N = 4,623) The Gaza Strip (n = 1,923) The WBJ (n = 2,700) Risk Factor No. (%) No. (%) No. (%) P Modifiable risk factors Not doing 30 minutes of moderate physical activity five times a week 3,846 (83.2) 1,610 (83.7) 2,236 (82.8) .42 Smoking cigarettes 3,478 (75.2) 1,534 (79.8) 1,944 (72.0) , .001 Drinking alcohol 3,418 (73.9) 1,511 (78.6) 1,907 (70.6) , .001 Not eating five portions of fruits and vegetables a day 3,274 (70.8) 1,363 (70.9) 1,911 (70.8) .94 Being overweight 3,105 (67.2) 1,294 (67.3) 1,811 (67,1) .88 Eating red meat once a day or more 2,468 (53.4) 1,139 (59.2) 1,329 (49.2) , .001 Having a diet low in fiber (eg, fruits and vegetables) 1,985 (42.9) 951 (49.5) 1,034 (38.3) , .001 Nonmodifiable risk factors Having a bowel disease (eg, inflammatory bowel disease) 3,320 (71.8) 1,467 (76.3) 1,853 (68.6) , .001 Having a close relative with bowel cancer 2,596 (56.2) 1,132 (58.9) 1,464 (54.2) .002 Being over 70 years old 2,127 (46.0) 929 (48.3) 1,198 (44.4) .008 Having diabetes 1,581 (34.2) 776 (40.4) 805 (29.8) , .001 Abbreviation: WBJ, West Bank and Jerusalem. 4 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine TABLE 3. Awareness Level of Colorectal Cancer Risk Factors Among Study Participants Total (N = 4,623) The Gaza Strip (n = 1,923) The WBJ (n = 2,700) Level No. (%) No. (%) No. (%) P Poor (0-3 risk factors) 400 (8.7) 111 (5.8) 289 (10.7) , .001 Fair (4-7 risk factors) 2,383 (51.5) 918 (47.7) 1,465 (54.3) Good (8-11 risk factors) 1,840 (39.8) 894 (46.5) 946 (35.0) Abbreviation: WBJ, West Bank and Jerusalem. Association Between Recognizing Modifiable CRC Risk especially in low- and middle-income countries, such as Factors and Participant Characteristics Palestine, where no CRC screening program exists. This study provides baseline information on the existing Male participants were less likely than female participants awareness about CRC risk factors in Palestine, a low-resource to recognize four of seven modifiable CRC risk factors setting, to facilitate future improvements through educational (Table 5). In addition, participants from the WBJ were less interventions. likely than participants from the Gaza Strip to recognize four of the seven modifiable CRC risk factors. In concordance with previous studies from Iran, the United Arab Emirates, Hungary, and the United Kingdom, this On the other hand, participants who knew someone with 19,31-33 study found low awareness of CRC risk factors. By cancer were more likely than those who did not to recognize contrast, studies from Turkey, Norway, the United States, four of the seven modifiable CRC risk factors. Moreover, and Spain found better awareness levels than this participants with postsecondary education were more likely 18,34-36 study. Possible contributing factor to the higher to recognize three of the seven modifiable CRC risk factors. awareness in these studies could be the availability of Association Between Recognizing Nonmodifiable CRC established national screening programs in these coun- Risk Factors and Participant Characteristics tries, which has been shown to motivate participants to adopt healthier behaviors including those related to Participants from the WBJ were less likely than participants 37,38 CRC. To date, there is no national screening program from the Gaza Strip to recognize all nonmodifiable CRC risk for CRC in Palestine, and this warrants future consideration factors (Table 6). Male participants were less likely than to reduce CRC-related mortality. female participants to recognize having a bowel disease (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) and having a The good recognition of low physical activity as a modifiable close relative with bowel cancer (OR = 0.53; 95% CI, 0.45 CRC risk factor might be the result of several campaigns to 0.62) as CRC risk factors. conducted in Palestine to promote physical activity among 39,40 the Palestinian population. Conversely, having a diet low On the contrary, participants recruited from hospitals were in fibers was the least recognized modifiable risk factor more likely than participants recruited from public spaces despite the fact that this region (Mediterranean and West to recognize all nonmodifiable CRC risk factors except Asia) is known for its fiber-rich diet, which has been reported having diabetes for which the opposite was found. Par- to reduce the risk of developing CRC. The westernization of ticipants eligible for CRC screening (age ≥ 45 years) were the diet in the region over recent years might be an ex- more likely to recognize being over 70 years old (OR = 1.28; 95% CI, 1.08 to 1.51) as a CRC risk factor. pression of this low awareness of the potential impact of diet on various diseases. In fact, changes in diet have led to increased incidences of obesity in many low- and middle- DISCUSSION income countries; urban and rural populations in the Middle A previous study showed that CRC risk factors related to East, sub-Saharan Africa, and South Asia, from the poorest lifestyle behaviors were responsible for 50% of CRC cases to the wealthiest, appear to have witnessed rapid increases in in the United Kingdom, whereas another study from the obesity and overweight. Despite several diabetes cam- United States demonstrated that 20%-40% of cancer cases paigns in Palestine, having diabetes was the least recog- and 50% of cancer-related deaths could be prevented by nized nonmodifiable risk factor, as also in Qatar, Ethiopia, healthy lifestyle choices. The main predictors of survival 12,45-47 and the United Kingdom. Therefore, awareness among patients with CRC include advanced stage and late campaigns should focus more on the long-term conse- presentation. Survival rates of CRC can be increased up to quences of diabetes including the potential to develop CRC. 90% if diagnosed at an early stage. CRC screening has been shown to improve patient outcomes. However, pa- The higher level of awareness among women in this study is 10,45,48 tients with low CRC awareness were found to be less likely consistent with previous studies. This might be at- to undergo CRC screening. The contribution of CRC risk tributed to the fact that women use health care services factor awareness to these behavioral changes and prac- more often (eg, for maternity care) than men and, thus, tices highlights the need for good public awareness, come in contact with health care providers more frequently. JCO Global Oncology 5 Elshami et al TABLE 4. Bivariable and Multivariable Logistic Regression Analyzing Factors Associated With Having a Good Awareness of Colorectal Cancer Risk Factors Good Awareness Characteristic COR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref 45 or older 1.16 (1.01 to 1.33) .042 1.18 (1.00 to 1.41) .060 Sex Female Ref Ref Ref Ref Male 0.66 (0.58 to 0.74) , .001 0.66 (0.56 to 0.77) , .001 Educational level Secondary or below Ref Ref Ref Ref Postsecondary 1.05 (0.94 to 1.19) .390 1.22 (1.07 to 1.39) .004 Occupation Unemployed/housewife Ref Ref Ref Ref Employed 0.73 (0.64 to 0.83) , .001 1.00 (0.85 to 1.19) .960 Retired 0.76 (0.50 to 1.16) .200 0.97 (0.61 to 1.54) .910 Student 0.68 (0.56 to 0.82) , .001 0.90 (0.71 to 1.14) .370 Monthly income , 1,450 NIS Ref Ref Ref Ref ≥ 1,450 NIS 0.72 (0.63 to 0.81) , .001 0.99 (0.84 to 1.18) .930 Marital status Single Ref Ref Ref Ref Married 1.30 (1.14 to 1.49) , .001 1.15 (0.98 to 1.35) .100 Divorced/widowed 1.59 (1.13 to 2.25) .009 1.23 (0.84 to 1.80) .290 Residency The Gaza Strip Ref Ref Ref Ref The WBJ 0.62 (0.55 to 0.70) , .001 0.62 (0.53 to 0.73) , .001 Having a chronic disease No Ref Ref Ref Ref Yes 1.09 (0.94 to 1.26) .280 1.02 (0.86 to 1.21) .790 Knowing someone with cancer No Ref Ref Ref Ref Yes 1.25 (1.11 to 1.40) , .001 1.19 (1.05 to 1.35) .005 Following a vegetarian diet No Ref Ref Ref Ref Yes 1.13 (0.94 to 1.35) .190 0.93 (0.77 to 1.12) .450 Site of data collection Public spaces Ref Ref Ref Ref Hospitals 1.10 (0.95 to 1.27) .200 1.08 (0.93 to 1.26) .330 PHCs 1.21 (1.04 to 1.40) .013 0.98 (0.83 to 1.15) .770 Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Adjusted for age group, sex, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, following a vegetarian diet, and site of data collection. 19,50 Therefore, women might have more opportunities to gain Furthermore, this study, as previous studies, found that information from health care providers on health-related participants with higher education were more likely to topics, including CRC, which might motivate them to adopt display better awareness. Therefore, future CRC awareness more protective behaviors than men. campaigns should target people with lower education. 6 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine JCO Global Oncology 7 TABLE 5. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors Not Eating Five Portions Not Doing 30 Minutes of Moderate of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day a a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 0.80 (0.64 to 1.01) .060 0.98 (0.80 to 1.19) .830 1.04 (0.86 to 1.27) .690 1.16 (0.96 to 1.40) .130 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 1.47 (1.19 to 1.81) , .001 0.52 (0.43 to 0.62) , .001 0.56 (0.47 to 0.67) , .001 1.04 (0.88 to 1.23) .670 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 0.82 (0.69 to 0.97) .022 0.95 (0.82 to 1.10) .460 1.06 (0.92 to 1.22) .440 1.15 (1.00 to 1.33) .044 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Ref Ref Employed 1.33 (1.07 to 1.66) .011 1.13 (0.93 to 1.38) .210 0.99 (0.82 to 1.20) .940 1.13 (0.94 to 1.36) .180 Retired 1.26 (0.66 to 2.38) .480 0.99 (0.61 to 1.61) .970 0.96 (0.59 to 1.56) .860 1.88 (1.07 to 3.32) .028 Student 1.28 (0.96 to 1.71) .100 0.91 (0.70 to 1.17) .450 0.97 (0.75 to 1.25) .800 1.19 (0.93 to 1.52) .160 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 1.10 (0.88 to 1.38) .400 1.23 (1.00 to 1.50) .047 1.14 (0.94 to 1.39) .190 1.02 (0.85 to 1.23) .840 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.26 (1.02 to 1.55) .029 1.14 (0.95 to 1.36) .160 1.13 (0.94 to 1.34) .190 1.17 (0.99 to 1.38) .070 Divorced/widowed 1.38 (0.83 to 2.29) .210 1.26 (0.80 to 2.00) .330 0.87 (0.57 to 1.34) .540 1.16 (0.77 to 1.76) .480 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.86 (0.70 to 1.06) .170 0.59 (0.49 to 0.71) , .001 0.60 (0.50 to 0.73) , .001 1.04 (0.87 to 1.24) .650 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.28 (1.02 to 1.62) .036 0.93 (0.77 to 1.13) .460 1.01 (0.84 to 1.22) .910 0.95 (0.79 to 1.14) .560 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.27 (1.08 to 1.49) .003 1.12 (0.98 to 1.29) .110 1.16 (1.02 to 1.33) .029 1.05 (0.92 to 1.20) .490 (Continued on following page) Elshami et al 8 © 2022 by American Society of Clinical Oncology TABLE 5. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Not Eating Five Portions Not Doing 30 Minutes of Moderate of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day a a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.31 (1.01 to 1.71) .041 1.03 (0.82 to 1.30) .800 0.77 (0.62 to 0.96) .018 1.65 (1.32 to 2.07) , .001 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 0.79 (0.65 to 0.97) .023 0.93 (0.79 to 1.11) .440 0.82 (0.69 to 0.97) .018 0.95 (0.81 to 1.12) .560 PHCs 1.06 (0.86 to 1.31) .590 0.94 (0.78 to 1.14) .540 1.05 (0.87-1.26) .610 1.41 (1.19 to 1.68) , .001 Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref 45 or older 1.25 (1.04 to 1.50) .017 1.23 (1.04 to 1.46) .018 1.17 (0.99 to 1.39) .070 Sex Female Ref Ref Ref Ref Ref Ref Male 0.90 (0.77 to 1.07) .240 0.78 (0.67 to 0.91) .002 0.68 (0.58 to 0.80) , .001 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Postsecondary 1.22 (1.06 to 1.39) .005 0.94 (0.83 to 1.07) .340 1.26 (1.11 to 1.44) , .001 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Employed 1.05 (0.88 to 1.26) .580 1.00 (0.84 to 1.18) .990 0.02 (0.86 to 1.21) .810 Retired 1.09 (0.67 to 1.78) .730 0.80 (0.51 to 1.25) .320 1.57 (1.00 to 2.46) .050 Student 0.88 (0.70 to 1.12) .310 0.92 (0.73 to 0.15) .460 0.84 (0.67 to 1.06) .150 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 0.92 (0.77 to 1.10) .380 0.95 (0.80 to 1.32) .590 1.30 (1.09 to 1.55) .003 Marital status Single Ref Ref Ref Ref Ref Ref Married 0.95 (0.80 to 1.12) .540 0.93 (0.80 to 1.09) .380 1.09 (0.92 to 1.27) .320 Divorced/widowed 1.09 (0.71 to 1.65) .700 0.70 (0.48 to 1.02) .070 1.01 (0.70 to 1.49) .950 (Continued on following page) Awareness of Colorectal Cancer Risk Factors in Palestine JCO Global Oncology 9 TABLE 5. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Residency The Gaza Strip Ref Ref Ref Ref Ref Ref The WBJ 0.96 (0.81 to 1.14) .650 0.67 (0.57 to 0.79) , .001 0.54 (0.46 to 0.63) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Yes 0.94 (0.80 to 1.13) .520 1.05 (0.89 to 1.23) .600 1.02 (0.86 to 1.21) .810 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Yes 1.25 (1.10 to 1.42) .001 1.31 (1.16 to 1.48) , .001 0.89 (0.79 to 1.01) .070 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Yes 0.59 (0.49 to 0.71) , .001 0.82 (0.68 to 1.00) .039 1.21 (1.00 to 1.46) .051 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Hospitals 1.54 (1.31 to 1.80) , .001 1.21 (1.04 to 1.40) .014 0.88 (0.76 to 1.03) .110 PHCs 1.24 (1.05 to 1.46) .010 1.03 (0.88 to 1.20) .740 0.80 (0.69 to 0.94) .007 Abbreviations: AOR, adjusted odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Adjusted for age group, sex, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, following a vegetarian diet, and site of data collection. Elshami et al TABLE 6. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Nonmodifiable Colorectal Cancer Risk Factors Having a Close Relative With Having a Bowel Disease Bowel Cancer Being Over 70 Years Old Having Diabetes a a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 1.16 (0.96 to 1.40) .140 0.90 (0.76 to 1.07) .240 1.28 (1.08 to 1.51) .005 1.03 (0.87 to 1.24) .710 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 0.70 (0.59 to 0.84) , .001 0.53 (0.45 to 0.62) , .001 0.88 (0.75 to 1.03) .110 1.00 (0.85 to 1.18) .990 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 1.11 (0.96 to 1.28) .160 1.25 (1.10 to 1.42) .001 1.04 (0.92 to 1.19) .530 1.05 (0.91 to 1.20) .520 Occupation Unemployed/ Ref Ref Ref Ref Ref Ref Ref Ref housewife Employed 1.01 (0.84 to 1.22) .930 1.05 (0.88 to 1.24) .600 0.94 (0.79 to 1.11) .470 0.94 (0.79 to 1.12) .520 Retired 0.84 (0.52 to 1.36) .480 1.36 (0.87 to 2.14) .180 1.03 (0.66 to 1.61) .890 0.73 (0.45 to 1.19) .210 Student 1.01 (0.79 to 1.29) .960 0.82 (0.65 to 1.03) .080 0.82 (0.66 to 1.03) .090 0.87 (0.68 to 1.10) .240 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 1.06 (0.88 to 1.29) .530 1.18 (1.00 to 1.40) .060 1.16 (0.98 to 1.37) .100 0.88 (0.73 to 1.04) .140 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.04 (0.87 to 1.23) .680 1.11 (0.95 to 1.30) .190 0.92 (0.78 to 1.08) .290 1.01 (0.85 to 1.19) .940 Divorced/widowed 1.16 (0.74 to 1.80) .520 1.17 (0.80 to 1.72) .420 0.81 (0.55 to 1.18) .270 0.95 (0.64 to 1.41) .800 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.68 (0.57 to 0.82) , .001 0.75 (0.64 to 0.88) .001 0.71 (0.61 to 0.84) , .001 0.66 (0.56 to 0.78) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.10 (0.91 to 1.33) .320 1.13 (0.96 to 1.34) .140 0.94 (0.80 to 1.12) .500 0.11 (0.93 to 1.31) .260 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.31 (1.15 to 1.50) , .001 1.06 (0.94 to 1.19) .380 1.05 (0.93 to 1.18) .430 1.01 (0.89 to 1.14) .900 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.23 (0.98 to 1.53) .070 1.01 (0.84 to 1.23) .890 0.48 (0.39 to 0.58) , .001 0.94 (0.77 to 1.14) .500 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 1.22 (1.04 to 1.44) .015 1.23 (1.06 to 1.43) .006 1.36 (1.17 to 1.58) , .001 0.73 (0.63 to 0.86) , .001 PHCs 1.09 (0.92 to 1.30) .340 0.82 (0.70 to 0.96) .012 1.08 (0.92 to 1.26) .350 0.77 (0.65 to 0.91) .002 Abbreviations: AOR, adjusted odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Adjusted for age group, sex, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, following a vegetarian diet, and site of data collection. 10 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine This study highlights the importance of establishing contin- with medical backgrounds might have reduced the number of uous educational interventions to raise the awareness about participants with a presumably good awareness. Nonetheless, risk factors and signs and symptoms of CRC in Palestine. their exclusion was intended to make this study more relevant These interventions should focus on different aspects of CRC as a measure of the public awareness. including its relationship with some chronic diseases (eg, In conclusion, the awareness level of CRC risk factors was diabetes) and with different diets (eg, fiber-low) as the public relatively low, with only 39.8% of participants showing good awareness about these important risk factors was found to be awareness. In general, participants from the Gaza Strip had low. Raising awareness of CRC risk factors may enhance early a higher awareness level than those from the WBJ. The presentation and, hence, early detection of CRC. Moreover, factors associated with having good awareness of CRC risk good awareness of CRC may facilitate the potential imple- factors were having postsecondary education and knowing mentation of CRC screening as part of future health policy. someone with cancer. The most recognized CRC risk factor The use of convenience sampling limits the generalizability of was not doing 30 minutes of moderate physical activity five the findings. However, the large number of participants, the times a week, whereas the least recognized was having high response rate, and the recruitment from different geo- diabetes. Campaigns and programs aiming to increase graphical areas may mitigate this. Furthermore, the exclusion awareness of CRC risk factors are needed and should be of visitors or patients in oncology departments and participants tailored to address the knowledge gaps among the public. AFFILIATIONS AUTHOR CONTRIBUTIONS Division of Surgical Oncology, Department of Surgery, University Conception and design: Mohamedraed Elshami, Mohammad F. Dwikat, Hospitals Cleveland Medical Center, Cleveland, OH Ibrahim Al-Slaibi, Mohammed Alser, Bettina Bottcher, Nasser Abu-El- Ministry of Health, Gaza, Palestine Noor Faculty of Medicine, An-Najah National University, Nablus, Palestine Administrative support: Mohamedraed Elshami, Ibrahim Al-Slaibi, Almakassed Hospital, Jerusalem, Palestine Mohammed Alser Beit Jala Governmental Hospital (Al-Hussein), Bethlehem, Palestine Provision of study materials or patients: Mohamedraed Elshami, Ibrahim Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine Al-Slaibi, Mohammed Alser Palestine Medical Complex, Khanyounis, Palestine Collection and assembly of data: All authors Faculty of Medicine, Al-Quds University, Jerusalem, Palestine Data analysis and interpretation: Mohamedraed Elshami, Mohammad F. Faculty of Pharmacy, Al-Azhar University of Gaza, Gaza, Palestine Dwikat, Bettina Bottcher, Nasser Abu-El-Noor Faculty of Dentistry, Arab American University, Palestine, Jenin Manuscript writing: All authors Faculty of Nursing and Health Sciences, Bethlehem University, Final approval of manuscript: All authors Bethlehem, Palestine Accountable for all aspects of the work: All authors Faculty of Allied Medical Sciences, Arab American University, Jenin, Palestine AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF Faculty of Medicine, Al-Azhar University, Gaza, Palestine INTEREST Faculty of Medicine, Al-Quds Abu Dis University Al-Azhar Branch of The following represents disclosure information provided by authors of Gaza, Gaza, Palestine 15 this manuscript. All relationships are considered compensated unless Faculty of Nursing, Islamic University of Gaza, Gaza, Palestine otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the CORRESPONDING AUTHOR subject matter of this manuscript. For more information about ASCO’s Mohamedraed Elshami, MD, MMSc, Division of Surgical Oncology, conflict of interest policy, please refer to www.asco.org/rwc or ascopubs. Department of Surgery, University Hospitals Cleveland Medical Center, org/go/authors/author-center. 11100 Euclid Ave, Lakeside 7100, Cleveland, OH 44106; Twitter: Open Payments is a public database containing information reported by @MElshamiMD; e-mail: mohamedraed.elshami@gmail.com. companies about payments made to US-licensed physicians (Open Payments). EQUAL CONTRIBUTION No potential conflicts of interest were reported. M.E. and M.F.D. contributed equally as a first coauthor to this work. B.B. and N.A.-E.-N. contributed equally as a senior coauthor to this work. ACKNOWLEDGMENT The authors would like to thank Mr Majdeddin MohammedAli for his useful feedback and all study participants for taking part in the study. 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Cancer Control 28:10732748211033550, 2021 12 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine 47. Kerrison RS, Prentice A, Marshall S, et al: Ethnic inequalities in older adults bowel cancer awareness: Findings from a community survey conductedin an ethnically diverse region in England. BMC Public Health 21:513, 2021 48. Xu L, Odum M: Cancer awareness and behavioral determinants associated with cancer prevention-a quantitative study among young adults in rural settings. J Cancer Educ 34:562-570, 2019 49. Evans REC, Brotherstone H, Miles A, et al: Gender differences in early detection of cancer. J Mens Health Gend 2:209-217, 2005 50. Taha H, Jaghbeer MA, Shteiwi M, et al: Knowledge and perceptions about colorectal cancer in Jordan. Asian Pac J Cancer Prev 16:8479-8486, 2015 nn n JCO Global Oncology 13 Elshami et al 14 © 2022 by American Society of Clinical Oncology APPENDIX TABLE A1. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors Not Doing 30 Minutes of Moderate Not Eating Five Portions of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P COR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 0.99 (0.82 to 1.19) .900 0.98 (0.84 to 1.15) .830 1.00 (0.85 to 1.17) .970 1.15 (0.98 to 1.34) .080 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 1.42 (1.20 to 1.66) , .001 0.53 (0.46 to 0.60) , .001 0.52 (0.46 to 0.60) , .001 0.96 (0.84 to 1.09) .520 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 0.89 (0.76 to 1.03) .120 0.90 (0.78 to 1.02) .100 0.96 (0.84 to 1.10) .550 1.11 (0.98 to 1.26) .100 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Ref Ref Employed 1.40 (1.18 to 1.66) , .001 0.69 (0.59 to 0.79) , .001 0.63 (0.55 to 0.73) , .001 1.04 (0.91 to 1.19) .590 Retired 1.50 (0.82 to 2.71) 1.190 0.55 (0.35 to 0.85) .007 0.57 (0.37 to 0.89) .013 1.97 (1.16 to 3.35) .013 Student 1.08 (0.85 to 1.38) .530 0.63 (0.51 to 0.78) , .001 0.70 (0.56 to 0.85) .001 1.00 (0.82 to 1.23) .990 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 1.03 (0.88 to 1.21) .690 0.81 (0.70 to 0.94) .005 0.80 (0.69 to 0.92) .002 1.01 (0.89 to 1.16) .850 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.16 (0.98 to 1.37) .090 1.32 (1.14 to 1.52) , .001 1.27 (1.10 to 1.46) .001 1.18 (1.03 to 1.35) .019 Divorced/widowed 1.15 (0.72 to 1.84) .550 1.55 (1.02 to 2.37) .042 1.13 (0.77 to 1.67) .540 1.14 (0.78 to 1.66) .510 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.94 (0.80 to 1.10) .420 0.65 (0.57 to 0.75) , .001 0.66 (0.57 to 0.75) , .001 1.00 (0.88 to 1.13) .940 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.23 (1.00 to 1.51) .045 0.97 (0.82 to 1.14) .690 1.02 (0.86 to 1.20) .860 1.04 (0.88 to 1.22) .660 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref (Continued on following page) Awareness of Colorectal Cancer Risk Factors in Palestine JCO Global Oncology 15 TABLE A1. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Not Doing 30 Minutes of Moderate Not Eating Five Portions of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P COR (95% CI) P Yes 1.24 (1.06 to 1.45) .007 1.22 (1.06 to 1.39) .004 1.29 (1.13 to 1.47) , .001 1.03 (0.91 to 1.17) .660 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.20 (0.94 to 1.54) .140 1.28 (1.03 to 1.59) .024 1.02 (0.83 to 1.25) .840 1.65 (1.33 to 2.04) , .001 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 0.82 (0.68 to 0.99) .036 0.91 (0.78 to 1.07) .270 0.82 (0.70 to 0.96) .013 0.91 (0.78 to 1.06) .240 PHCs 0.97 (0.80 to 1.18) .770 1.22 (1.03 to 1.45) .022 1.34 (1.13 to 1.59) .001 1.33 (1.13 to 1.57) .001 Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref 45 or older 1.24 (1.06 to 1.44) .006 1.20 (1.03 to 1.37) .015 1.11 (0.97 to 1.28) .130 Sex Female Ref Ref Ref Ref Ref Ref Male 1.01 (0.89 to 1.14) .900 0.79 (0.70 to 0.88) , .001 0.73 (0.65 to 0.83) , .001 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Postsecondary 1.09 (0.96 to 1.23) .170 0.85 (0.76 to 0.96) .007 1.21 (1.07 to 1.36) .002 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Employed 1.03 (0.90 to 1.18) .630 0.78 (0.69 to 0.88) , .001 0.82 (0.73 to 0.93) .003 Retired 1.18 (0.75 to 1.85) .470 0.70 (0.46 to 1.05) .080 1.30 (0.86 to 1.96) .210 Student 0.83 (0.69 to 1.01) .070 0.76 (0.63 to 0.92) .004 0.76 (0.63 to 0.92) .004 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 0.96 (0.84 to 1.09) .550 0.72 (0.64 to 0.81) , .001 0.87 (0.77 to 0.99) .029 Marital status Single Ref Ref Ref Ref Ref Ref Married 1.08 (0.95 to 1.24) .240 1.12 (0.99 to 1.27) .080 1.18 (1.04 to 1.35) .010 Divorced/widowed 1.37 (0.94 to 2.02) .110 1.03 (0.73 to 1.45) .890 1.16 (0.82 to 1.64) .410 (Continued on following page) Elshami et al 16 © 2022 by American Society of Clinical Oncology TABLE A1. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P Residency The Gaza Strip Ref Ref Ref Ref Ref Ref The WBJ 0.99 (0.87 to 1.12) .880 0.67 (0.59 to 0.75) , .001 0.63 (0.56 to 0.71) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Yes 1.05 (0.90 to 1.23) .500 1.11 (0.96 to 1.29) .150 1.03 (0.89 to 1.20) .650 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Yes 1.27 (1.13 to 1.44) , .001 1.35 (1.20 to 1.52) , .001 0.92 (0.82 to 1.03) .170 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Yes 0.56 (0.47 to 0.67) , .001 0.91 (0.77 to 1.09) .320 1.49 (1.25 to 1.78) , .001 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Hospitals 1.58 (1.36 to 1.84) , .001 1.24 (1.08 to 1.43) .003 0.87 (0.76 to 1.01) .060 PHCs 1.24 (1.07 to 1.44) .005 1.20 (1.04 to 1.38) .014 0.93 (0.81 to 1.08) .350 Abbreviations: COR, crude odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Awareness of Colorectal Cancer Risk Factors in Palestine TABLE A2. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Nonmodifiable Colorectal Cancer Risk Factors Having a Close Relative With Having a Bowel Disease Bowel Cancer Being Over 70 Years Old Having Diabetes Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P COR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 1.16 (0.99 to 1.36) .070 0.98 (0.85 to 1.13) .780 1.24 (1.08 to 1.43) .002 0.99 (0.85 to 1.14) .870 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 0.67 (0.59 to 0.77) , .001 0.61 (0.54 to 0.69) , .001 0.97 (0.87 to 1.09) .650 0.94 (0.83 to 1.07) .360 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 0.98 (0.87 to 0.12) .800 1.16 (1.03 to 1.30) .015 0.97 (0.86 to 1.08) .560 1.01 (0.89 to 1.14) .890 Occupation Unemployed/ Ref Ref Ref Ref Ref Ref Ref Ref housewife Employed 0.74 (0.64 to 0.85) , .001 0.79 (0.70 to 0.90) , .001 0.92 (0.81 to 1.04) .190 0.86 (0.76 to 0.98) .029 Retired 0.70 (0.45 to 1.08) .110 0.91 (0.60 to 1.37) .640 1.10 (0.73 to 1.66) .630 0.69 (0.44 to 1.09) .110 Student 0.77 (0.63 to 0.95) .014 0.70 (0.58 to 0.84) , .001 0.79 (0.66 to 0.96) .017 0.84 (0.69 to 1.03) .100 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 0.76 (0.67 to 0.88) , .001 0.96 (0.85 to 1.08) .510 0.98 (0.86 to 1.10) .700 0.70 (0.61 to 0.79) , .001 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.19 (1.04 to 1.37) .013 1.24 (1.09 to 1.40) .001 1.07 (0.95 to 1.22) .260 1.03 (0.90 to 1.17) .710 Divorced/widowed 1.53 (1.02 to 2.31) .041 1.40 (0.98 to 1.98) .060 1.07 (0.76 to 1.51) .700 1.03 (0.72 to 1.48) .870 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.68 (0.60 to 0.78) , .001 0.83 (0.74 to 0.93) .002 0.85 (0.76 to 0.96) .008 0.63 (0.56 to 0.71) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.16 (0.98 to 1.37) .080 1.10 (0.95 to 1.28) .200 1.05 (0.90 to 1.21) .540 1.04 (0.89 to 1.21) .630 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.33 (1.17 to 1.52) , .001 1.09 (0.97 to 1.22) .150 1.10 (0.98 to 1.23) .110 1.04 (0.92 to 1.17) .600 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.36 (1.10 to 1.67) .004 1.13 (0.94 to 1.35) .190 0.49 (0.41 to 0.59) , .001 1.15 (0.96 to 1.38) .140 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 1.17 (1.00 to 1.37) .044 1.17 (1.01 to 1.35) .032 1.45 (1.26 to 1.67) , .001 0.79 (0.68 to 0.92) .002 PHCs 1.27 (1.08 to 1.49) .003 1.00 (0.87 to 1.16) .970 1.14 (0.99 to 1.32) .070 0.88 (0.75 to 1.02) .080 Abbreviations: COR, crude odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. JCO Global Oncology 17 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JCO: Global Oncology Wolters Kluwer Health

Awareness of Colorectal Cancer Risk Factors in Palestine: Where Do We Stand?

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© 2022 by American Society of Clinical Oncology
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10.1200/go.22.00070
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original reports abstract CANCER PREVENTION AND CONTROL Awareness of Colorectal Cancer Risk Factors in Palestine: Where Do We Stand? 1,2 3 4 2 Mohamedraed Elshami, MD, MMSc ; Mohammad F. Dwikat ; Ibrahim Al-Slaibi, MD ; Mohammed Alser, MD ; 5 6 7 8 8 9 Balqees M. Mohamad, MD ; Wejdan S. Isleem ; Adela Shurrab, MD ; Bashar Yaghi ; Yahya Ayyash Qabaja ; Shoruq A. Naji ; 8 8 8 6 3 8 Fatima K. Hmdan ; Mohammed M. Ayyad ; Raneen R. Sweity ; Remah T. Jneed ; Khayria A. Assaf ; Maram E. Albandak ; 6 8 6 10 6 6 Mohammed M. Hmaid, MD ; Iyas I. Awwad ; Belal K. Alhabil ; Marah N. Alarda ; Amani S. Alsattari ; Moumen S. Aboyousef ; 6 8 11 6 12 13 Omar A. Aljbour ; Rinad AlSharif ; Christy T. Giacaman ; Ali Y. Alnaga ; Ranin M. Abu Nemer ; Nada M. Almadhoun ; 14 6 15 Sondos M. Skaik ; Bettina Bottcher, MD, PhD ; and Nasser Abu-El-Noor, PhD PURPOSE To assess the public awareness level of colorectal cancer (CRC) risk factors in Palestine and identify factors associated with the good awareness level. MATERIALS AND METHODS Adult Palestinians were recruited using convenience sampling from hospitals, primary health care centers, and public locations in 11 governorates. The recognition of 11 CRC risk factors was evaluated using a translated-into-Arabic version of the validated bowel cancer awareness measure. Participants were given one point for each correctly recognized risk factor. The awareness level was determined by the number of CRC risk factors recognized: poor (0-3), fair (4-7), and good awareness (8-11). RESULTS A total of 4,877 participants, of 5,254 approached, completed the questionnaire (response rate = 92.3%). The final analysis included 4,623 questionnaires, 2,700 from the West Bank and Jerusalem (WBJ) and 1,923 from the Gaza Strip. Participants from the WBJ were older, gained higher monthly income, and had more chronic diseases than participants from the Gaza Strip. The most recognized modifiable CRC risk factor was not doing 30 minutes of moderate physical activity five times a week (n = 3,846, 83.2%), whereas the least recognized was having a diet low in fiber (n = 1,985, 42.9%). The most recognized nonmodifiable CRC risk factor was having a bowel disease (n = 3,320, 71.8%), whereas the least recognized was having diabetes (n = 1,581, 34.2%). Only 1,840 participants (39.8%) demonstrated good awareness of CRC risk factors. Participants from the Gaza Strip were more likely than participants from the WBJ to have good awareness (46.5.0% v 35.0%). Female sex, knowing someone with cancer, and completing postsecondary education were all associated with good awareness. CONCLUSION Awareness of CRC risk factors was found to be low in Palestine. There is a substantial need to raise awareness of CRC risk factors through educational campaigns and programs. JCO Global Oncol 8:e2200070. © 2022 by American Society of Clinical Oncology Licensed under the Creative Commons Attribution 4.0 License INTRODUCTION fruits and vegetables as well as fiber in the diet, smoking, and drinking alcohol. On the other hand, the Colorectal cancer (CRC) is the third most common nonmodifiable risk factors include older age, family malignancy worldwide. CRC was responsible for 1, history, inflammatory bowel disease, and diabetes. 931,590 new cancer cases (about 10% of all new cases) and 935,173 cancer-related deaths (9.4% of all Implementing screening programs has been proven to cancer-related deaths) in 2020. In Palestine, cancer substantially improve survival and prognosis of pa- ASSOCIATED 5,6 accounted for 14.1% of total reported deaths and was tients with CRC. However, previous studies dem- CONTENT the third leading cause of death in 2020. CRC is the onstrated that patients’ lack of information regarding Appendix second most common malignancy with an incidence CRC risk factors may affect their participation in Author affiliations rate of 13.6 per 100,000 general population in the screening programs and therefore may lead to late and support 7,8 information (if West Bank and Jerusalem (WBJ) and 11.5 per 100, diagnosis and lower survival rates. Moreover, almost 2,3 applicable) appear at 000 general population in the Gaza Strip. In addi- one third of all cancers can be prevented by following a the end of this tion, CRC is the second leading cause of cancer- healthy diet, maintaining physical activity, and having article. 3 9 related deaths (13.9%). a normal body mass index. This highlights the im- Accepted on April 29, portance of good awareness of CRC risk factors. 2022 and published at CRC risk factors can be classified into modifiable and ascopubs.org/journal/ nonmodifiable risk factors. The modifiable risk factors The awareness of CRC risk factors was found to be low go on June 13, 2022: include physical activity, body mass index, the amount in the Gaza Strip. Nonetheless, there is an unmet DOI https://doi.org/10. 1200/GO.22.00070 of processed and red meat ingested, the amount of need to measure the public awareness across Palestine 1 Elshami et al CONTEXT Key Objective Colorectal cancer (CRC) is responsible for a significant number of cancer diagnoses and deaths in Palestine, making it a major public health problem. Therefore, this national study assessed the public awareness of CRC risk factors and examined the sociodemographic factors associated with good awareness. Knowledge Generated The awareness level of CRC risk factors was relatively low with only 39.8% of participants displaying good awareness. Factors associated with good awareness included living in the West Bank and Jerusalem, completing postsecondary education, and knowing someone with cancer. Relevance Poor public knowledge of CRC risk factors may play a role in the diagnosis of CRC at advanced stages because of delayed seeking of medical advice, ultimately leading to a lower survival rate. Systematic educational campaigns and programs aiming to promote awareness of CRC are needed and should be tailored to address the knowledge gaps among the public. to establish a baseline for future standardized educational included data collection sites. Exclusion criteria were interventions by health authorities and policy makers. having a citizenship other than Palestinian, visiting on- Therefore, this study aimed to (1) assess the awareness level cology departments in PHCs and hospitals at the time of of CRC risk factors in Palestine, (2) compare the CRC risk data collection, and studying or working in a health factors’ awareness level between the WBJ versus the Gaza care–related field. Strip, and (3) examine factors associated with good Data Collection and Measurement Tool awareness of CRC risk factors. A translated-into-Arabic version of the Bowel Cancer MATERIALS AND METHODS Awareness Measure (BoCAM) was used for data collection. Study Design and Population The original BoCAM was developed by University College London and Cancer Research, UK. It is a validated tool for This was a national cross-sectional study conducted be- assessing public CRC awareness. Two bilingual health tween July 2019 and March 2020. There are 16 gover- care professionals translated the questionnaire from En- norates in Palestine: 11 are located in the WBJ and five in the glish to Arabic, and then it was back translated into English Gaza Strip. In 2019, the number of adults in Palestine by another two bilingual health care professionals. All these reached approximately 2.6 million. This made up 51.6% of the total Palestinian population (about 5 million). There- were experts in clinical research and survey design. In fore, Palestinian adults (≥ 18 years) residing in the WBJ or addition, five independent specialists in the fields of public the Gaza Strip were the target population. Participants were health, coloproctology, and gastroenterology reviewed the recruited from governmental hospitals, primary health care questionnaire subsequently to ensure content validity and centers (PHCs), and public spaces across Palestine. accuracy of translation. After that, a pilot study was con- ducted (n = 25) to test the clarity of questions in the Arabic Sampling Methods BoCAM. The data collected from the pilot study were not Palestinians in the WBJ and the Gaza Strip receive their health included in the final analysis. The questionnaire’s internal care services in governmental facilities, nongovernmental or- reliability was assessed using Cronbach’s α, which was ganizations, the United Nations Relief and Works Agency acceptable with a value of .89. facilities, and private health care providers. Nevertheless, The questionnaire consisted of two sections. The first people rely mostly on governmental hospitals because of the section covered the sociodemographic characteristics relatively low-cost health insurance, which allows them to use 3 of participants including age, sex, marital status, level of health services at no cost or with low co-payments. Therefore, education, employment status, monthly income, place of convenience sampling was used to recruit participants from 11 residence, having a chronic health condition, following a governmental hospitals, 12 PHCs, and public spaces in the vegetarian diet, and knowing someone with cancer. The corresponding 11 governorates (seven in the WBJ and four in second section assessed the participant’s recognition of 11 the Gaza Strip) of the 16 governorates in Palestine. Public CRC risk factors on the basis of a five-point Likert scale spaces included parks, malls, trade streets, mosques, (strongly disagree, disagree, not sure, agree, and strongly churches, downtown areas, transportation stations, and others. agree). Of the 11 CRC risk factors, 10 were adopted from Inclusion and Exclusion Criteria 13 the original BoCAM, and smoking cigarettes was added The inclusion criteria to take part in the study were being an as it was deemed important given its high prevalence in the adult (≥ 18 years) Palestinian and visiting one of the Palestinian community. 2 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine 10,18-22 Participants were invited for a face-to-face interview to on the basis of previous studies. Results of the bivariable complete the questionnaire. The Kobo Toolbox, an easy-to- analyses are provided in Appendix Tables A1 and A2. use and secure tool that can be accessed via smartphones, To evaluate the awareness level among study participants was used to collect data. Before starting data collection, about CRC risk factors, a scoring system was used. Similar data collectors received training to learn how to use the 22-27 scoring systems were also used in previous studies. The Kobo Toolbox and how to approach participants and fa- total score (ranging from 0 to 11) was calculated and clas- cilitate their completion of the questionnaire. sified into three categories on the basis of the number of CRC risk factors recognized: poor (0-3), fair (4-7), and good Ethics Approval and Consent to Participate awareness (8-11). The awareness level of CRC risk factors Before data collection, ethical approval had been sought among participants from the WBJ versus the Gaza Strip was from the Research Ethics Committee at the Islamic Uni- compared using Pearson’s chi-square test. This was followed versity of Gaza, the Human Resources Development de- by running bivariable and multivariable logistic regression partment at the Palestinian Ministry of Health, and the analyses to test the association between having good Helsinki Committee in the Gaza Strip. In addition, the awareness of CRC risk factors and participant characteristics. participants had a thorough explanation about the study Complete case analysis was used to handle missing data as including its purpose and objectives with the focus that they occurred completely at random. Data were analyzed their participation is completely voluntary. Written informed using Stata software version 16.0 (StataCorp, College consent was obtained from each participant before starting Station, TX). the questionnaire, and data were collected anonymously. RESULTS Statistical Analysis Participant Characteristics The American Cancer Society recommends starting CRC A total of 4,877 participants, of 5,254 approached, com- screening at age 45 years for people at average risk of pleted the questionnaire (response rate = 92.3%). The final developing CRC. Therefore, the continuous variable of analysis included 4,623 questionnaires (254 excluded: 44 age was classified into two categories using this cutoff: did not meet the inclusion criteria and 210 had missing 18-44 years and ≥ 45 years. In Palestine, the minimum data): 2,700 from the WBJ and 1,923 from the Gaza Strip. wage is 1,450 Israeli new shekel (NIS) (about $450 US Among all participants, the median age [interquartile dollars), and therefore, monthly income was classified range] was 31.0 years [24.0-43.0] and 1,879 (40.6%) were into two categories using that as a cutoff: , 1,450 NIS males (Table 1). Participants from the WBJ were older, and ≥ 1,450 NIS. gained higher monthly income, and had more chronic The median [interquartile range] was used to summarize diseases than participants from the Gaza Strip. continuous, non-normally distributed variables, and the Recognition of CRC Risk Factors Kruskal-Wallis test was used to perform a baseline com- parison between participants from the WBJ versus the Gaza The most recognized modifiable CRC risk factor was not Strip. Frequencies and percentages were used to sum- doing 30 minutes of moderate physical activity five times a marize categorical variables, and Pearson’s chi-square test week (n = 3,846, 83.2%), whereas the least recognized was used for baseline comparisons. was having a diet low in fiber (n = 1,985, 42.9%; Table 2). This was found in the responses of participants from both The prompt recognition of each CRC risk factor was the WBJ and the Gaza Strip. The most recognized non- assessed using a question on the basis of a five-point Likert modifiable CRC risk factor was having a bowel disease scale, with strongly agree or agree deemed as a correct (n = 3,320, 71.8%), whereas the least recognized was answer and strongly disagree, disagree, or not sure deemed having diabetes (n = 1,581, 34.2%). This was also noticed as an incorrect answer. CRC risk factors were further in both the WBJ and the Gaza Strip. classified into two main categories: (1) modifiable and (2) Good Awareness and Its Associated Factors nonmodifiable risk factors. Recognizing each CRC risk factor was described using frequencies and percentages A total of 1,840 participants (39.8%) displayed good with comparisons performed by Pearson’s chi-square test. awareness of CRC risk factors (Table 3). Participants from Bivariable and multivariable logistic regression analyses the Gaza Strip were more likely than participants from the were then used to examine the association between the WBJ to have a good level of awareness (46.5.0% v 35.0%). recognition of each CRC risk factor and participant char- The multivariable analysis showed that postsecondary acteristics. The multivariable analyses adjusted for age education and knowing someone with cancer were asso- group, sex, educational level, occupation, monthly income, ciated with an increase in the likelihood of having good place of residency, marital status, having a chronic disease, awareness of CRC risk factors (Table 4). Conversely, male following a vegetarian diet, knowing someone with cancer, sex and living in the WBJ were associated with a decrease and site of data collection. This model was determined a priori in the likelihood of having good awareness. JCO Global Oncology 3 Elshami et al TABLE 1. Characteristics of Study Participants Characteristic Total (N = 4,623) The Gaza Strip (n = 1923) The WBJ (n = 2,700) P Age, years, median [IQR] 31.0 [24.0-43.0] 30.0 [24.0-40.0] 32.0 [24.0-44.0] , .001 Age group, years, No. (%) 18-44 3,608 (78.1) 1,579 (82.1) 2,029 (75.1) , .001 45 or older 1,015 (21.9) 344 (17.9) 671 (24.9) Male sex, No. (%) 1,879 (40.6) 710 (36.9) 1,169 (43.3) , .001 Educational level, No. (%) Secondary or below 2,217 (47.9) 946 (49.2) 1,271 (47.1) .16 Postsecondary 2,406 (52.1) 977 (50.8) 1,429 (52.9) Occupation, No. (%) Unemployed/housewife 2,067 (44.7) 1,112 (57.8) 955 (35.4) , .001 Employed 1,898 (41.1) 563 (29.3) 1,335 (49.4) Retired 96 (2.1) 29 (1.5) 67 (2.5) Student 562 (12.1) 219 (11.4) 343 (12.7) Monthly income ≥ 1,450 NIS, No. (%) 3,039 (65.7) 559 (29.1) 2,480 (91.9) , .001 Marital status, No. (%) Single 1,414 (30.5) 548 (28.5) 866 (32.1) .032 Married 3,067 (66.4) 1,316 (68.4) 1,751 (64.8) Divorced/widowed 142 (3.1) 59 (3.1) 83 (3.1) Having a chronic disease, No. (%) 906 (19.6) 314 (16.3) 592 (21.9) , .001 Following a vegetarian diet, No. (%) 560 (12.1) 386 (20.1) 174 (6.4) , .001 Knowing someone with cancer, No. (%) 2,395 (51.8) 1,007 (52.4) 1,388 (51.4) .52 Site of data collection, No. (%) Public spaces 1,450 (31.4) 491 (25.5) 959 (35.5) , .001 Hospitals 1,659 (35.9) 690 (35.9) 969 (35.9) PHCs 1,514 (32.7) 742 (38.6) 772 (28.6) Abbreviations: IQR, interquartile range; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. TABLE 2. Recognition of Colorectal Cancer Risk Factors Total (N = 4,623) The Gaza Strip (n = 1,923) The WBJ (n = 2,700) Risk Factor No. (%) No. (%) No. (%) P Modifiable risk factors Not doing 30 minutes of moderate physical activity five times a week 3,846 (83.2) 1,610 (83.7) 2,236 (82.8) .42 Smoking cigarettes 3,478 (75.2) 1,534 (79.8) 1,944 (72.0) , .001 Drinking alcohol 3,418 (73.9) 1,511 (78.6) 1,907 (70.6) , .001 Not eating five portions of fruits and vegetables a day 3,274 (70.8) 1,363 (70.9) 1,911 (70.8) .94 Being overweight 3,105 (67.2) 1,294 (67.3) 1,811 (67,1) .88 Eating red meat once a day or more 2,468 (53.4) 1,139 (59.2) 1,329 (49.2) , .001 Having a diet low in fiber (eg, fruits and vegetables) 1,985 (42.9) 951 (49.5) 1,034 (38.3) , .001 Nonmodifiable risk factors Having a bowel disease (eg, inflammatory bowel disease) 3,320 (71.8) 1,467 (76.3) 1,853 (68.6) , .001 Having a close relative with bowel cancer 2,596 (56.2) 1,132 (58.9) 1,464 (54.2) .002 Being over 70 years old 2,127 (46.0) 929 (48.3) 1,198 (44.4) .008 Having diabetes 1,581 (34.2) 776 (40.4) 805 (29.8) , .001 Abbreviation: WBJ, West Bank and Jerusalem. 4 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine TABLE 3. Awareness Level of Colorectal Cancer Risk Factors Among Study Participants Total (N = 4,623) The Gaza Strip (n = 1,923) The WBJ (n = 2,700) Level No. (%) No. (%) No. (%) P Poor (0-3 risk factors) 400 (8.7) 111 (5.8) 289 (10.7) , .001 Fair (4-7 risk factors) 2,383 (51.5) 918 (47.7) 1,465 (54.3) Good (8-11 risk factors) 1,840 (39.8) 894 (46.5) 946 (35.0) Abbreviation: WBJ, West Bank and Jerusalem. Association Between Recognizing Modifiable CRC Risk especially in low- and middle-income countries, such as Factors and Participant Characteristics Palestine, where no CRC screening program exists. This study provides baseline information on the existing Male participants were less likely than female participants awareness about CRC risk factors in Palestine, a low-resource to recognize four of seven modifiable CRC risk factors setting, to facilitate future improvements through educational (Table 5). In addition, participants from the WBJ were less interventions. likely than participants from the Gaza Strip to recognize four of the seven modifiable CRC risk factors. In concordance with previous studies from Iran, the United Arab Emirates, Hungary, and the United Kingdom, this On the other hand, participants who knew someone with 19,31-33 study found low awareness of CRC risk factors. By cancer were more likely than those who did not to recognize contrast, studies from Turkey, Norway, the United States, four of the seven modifiable CRC risk factors. Moreover, and Spain found better awareness levels than this participants with postsecondary education were more likely 18,34-36 study. Possible contributing factor to the higher to recognize three of the seven modifiable CRC risk factors. awareness in these studies could be the availability of Association Between Recognizing Nonmodifiable CRC established national screening programs in these coun- Risk Factors and Participant Characteristics tries, which has been shown to motivate participants to adopt healthier behaviors including those related to Participants from the WBJ were less likely than participants 37,38 CRC. To date, there is no national screening program from the Gaza Strip to recognize all nonmodifiable CRC risk for CRC in Palestine, and this warrants future consideration factors (Table 6). Male participants were less likely than to reduce CRC-related mortality. female participants to recognize having a bowel disease (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) and having a The good recognition of low physical activity as a modifiable close relative with bowel cancer (OR = 0.53; 95% CI, 0.45 CRC risk factor might be the result of several campaigns to 0.62) as CRC risk factors. conducted in Palestine to promote physical activity among 39,40 the Palestinian population. Conversely, having a diet low On the contrary, participants recruited from hospitals were in fibers was the least recognized modifiable risk factor more likely than participants recruited from public spaces despite the fact that this region (Mediterranean and West to recognize all nonmodifiable CRC risk factors except Asia) is known for its fiber-rich diet, which has been reported having diabetes for which the opposite was found. Par- to reduce the risk of developing CRC. The westernization of ticipants eligible for CRC screening (age ≥ 45 years) were the diet in the region over recent years might be an ex- more likely to recognize being over 70 years old (OR = 1.28; 95% CI, 1.08 to 1.51) as a CRC risk factor. pression of this low awareness of the potential impact of diet on various diseases. In fact, changes in diet have led to increased incidences of obesity in many low- and middle- DISCUSSION income countries; urban and rural populations in the Middle A previous study showed that CRC risk factors related to East, sub-Saharan Africa, and South Asia, from the poorest lifestyle behaviors were responsible for 50% of CRC cases to the wealthiest, appear to have witnessed rapid increases in in the United Kingdom, whereas another study from the obesity and overweight. Despite several diabetes cam- United States demonstrated that 20%-40% of cancer cases paigns in Palestine, having diabetes was the least recog- and 50% of cancer-related deaths could be prevented by nized nonmodifiable risk factor, as also in Qatar, Ethiopia, healthy lifestyle choices. The main predictors of survival 12,45-47 and the United Kingdom. Therefore, awareness among patients with CRC include advanced stage and late campaigns should focus more on the long-term conse- presentation. Survival rates of CRC can be increased up to quences of diabetes including the potential to develop CRC. 90% if diagnosed at an early stage. CRC screening has been shown to improve patient outcomes. However, pa- The higher level of awareness among women in this study is 10,45,48 tients with low CRC awareness were found to be less likely consistent with previous studies. This might be at- to undergo CRC screening. The contribution of CRC risk tributed to the fact that women use health care services factor awareness to these behavioral changes and prac- more often (eg, for maternity care) than men and, thus, tices highlights the need for good public awareness, come in contact with health care providers more frequently. JCO Global Oncology 5 Elshami et al TABLE 4. Bivariable and Multivariable Logistic Regression Analyzing Factors Associated With Having a Good Awareness of Colorectal Cancer Risk Factors Good Awareness Characteristic COR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref 45 or older 1.16 (1.01 to 1.33) .042 1.18 (1.00 to 1.41) .060 Sex Female Ref Ref Ref Ref Male 0.66 (0.58 to 0.74) , .001 0.66 (0.56 to 0.77) , .001 Educational level Secondary or below Ref Ref Ref Ref Postsecondary 1.05 (0.94 to 1.19) .390 1.22 (1.07 to 1.39) .004 Occupation Unemployed/housewife Ref Ref Ref Ref Employed 0.73 (0.64 to 0.83) , .001 1.00 (0.85 to 1.19) .960 Retired 0.76 (0.50 to 1.16) .200 0.97 (0.61 to 1.54) .910 Student 0.68 (0.56 to 0.82) , .001 0.90 (0.71 to 1.14) .370 Monthly income , 1,450 NIS Ref Ref Ref Ref ≥ 1,450 NIS 0.72 (0.63 to 0.81) , .001 0.99 (0.84 to 1.18) .930 Marital status Single Ref Ref Ref Ref Married 1.30 (1.14 to 1.49) , .001 1.15 (0.98 to 1.35) .100 Divorced/widowed 1.59 (1.13 to 2.25) .009 1.23 (0.84 to 1.80) .290 Residency The Gaza Strip Ref Ref Ref Ref The WBJ 0.62 (0.55 to 0.70) , .001 0.62 (0.53 to 0.73) , .001 Having a chronic disease No Ref Ref Ref Ref Yes 1.09 (0.94 to 1.26) .280 1.02 (0.86 to 1.21) .790 Knowing someone with cancer No Ref Ref Ref Ref Yes 1.25 (1.11 to 1.40) , .001 1.19 (1.05 to 1.35) .005 Following a vegetarian diet No Ref Ref Ref Ref Yes 1.13 (0.94 to 1.35) .190 0.93 (0.77 to 1.12) .450 Site of data collection Public spaces Ref Ref Ref Ref Hospitals 1.10 (0.95 to 1.27) .200 1.08 (0.93 to 1.26) .330 PHCs 1.21 (1.04 to 1.40) .013 0.98 (0.83 to 1.15) .770 Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Adjusted for age group, sex, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, following a vegetarian diet, and site of data collection. 19,50 Therefore, women might have more opportunities to gain Furthermore, this study, as previous studies, found that information from health care providers on health-related participants with higher education were more likely to topics, including CRC, which might motivate them to adopt display better awareness. Therefore, future CRC awareness more protective behaviors than men. campaigns should target people with lower education. 6 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine JCO Global Oncology 7 TABLE 5. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors Not Eating Five Portions Not Doing 30 Minutes of Moderate of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day a a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 0.80 (0.64 to 1.01) .060 0.98 (0.80 to 1.19) .830 1.04 (0.86 to 1.27) .690 1.16 (0.96 to 1.40) .130 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 1.47 (1.19 to 1.81) , .001 0.52 (0.43 to 0.62) , .001 0.56 (0.47 to 0.67) , .001 1.04 (0.88 to 1.23) .670 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 0.82 (0.69 to 0.97) .022 0.95 (0.82 to 1.10) .460 1.06 (0.92 to 1.22) .440 1.15 (1.00 to 1.33) .044 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Ref Ref Employed 1.33 (1.07 to 1.66) .011 1.13 (0.93 to 1.38) .210 0.99 (0.82 to 1.20) .940 1.13 (0.94 to 1.36) .180 Retired 1.26 (0.66 to 2.38) .480 0.99 (0.61 to 1.61) .970 0.96 (0.59 to 1.56) .860 1.88 (1.07 to 3.32) .028 Student 1.28 (0.96 to 1.71) .100 0.91 (0.70 to 1.17) .450 0.97 (0.75 to 1.25) .800 1.19 (0.93 to 1.52) .160 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 1.10 (0.88 to 1.38) .400 1.23 (1.00 to 1.50) .047 1.14 (0.94 to 1.39) .190 1.02 (0.85 to 1.23) .840 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.26 (1.02 to 1.55) .029 1.14 (0.95 to 1.36) .160 1.13 (0.94 to 1.34) .190 1.17 (0.99 to 1.38) .070 Divorced/widowed 1.38 (0.83 to 2.29) .210 1.26 (0.80 to 2.00) .330 0.87 (0.57 to 1.34) .540 1.16 (0.77 to 1.76) .480 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.86 (0.70 to 1.06) .170 0.59 (0.49 to 0.71) , .001 0.60 (0.50 to 0.73) , .001 1.04 (0.87 to 1.24) .650 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.28 (1.02 to 1.62) .036 0.93 (0.77 to 1.13) .460 1.01 (0.84 to 1.22) .910 0.95 (0.79 to 1.14) .560 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.27 (1.08 to 1.49) .003 1.12 (0.98 to 1.29) .110 1.16 (1.02 to 1.33) .029 1.05 (0.92 to 1.20) .490 (Continued on following page) Elshami et al 8 © 2022 by American Society of Clinical Oncology TABLE 5. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Not Eating Five Portions Not Doing 30 Minutes of Moderate of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day a a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.31 (1.01 to 1.71) .041 1.03 (0.82 to 1.30) .800 0.77 (0.62 to 0.96) .018 1.65 (1.32 to 2.07) , .001 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 0.79 (0.65 to 0.97) .023 0.93 (0.79 to 1.11) .440 0.82 (0.69 to 0.97) .018 0.95 (0.81 to 1.12) .560 PHCs 1.06 (0.86 to 1.31) .590 0.94 (0.78 to 1.14) .540 1.05 (0.87-1.26) .610 1.41 (1.19 to 1.68) , .001 Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref 45 or older 1.25 (1.04 to 1.50) .017 1.23 (1.04 to 1.46) .018 1.17 (0.99 to 1.39) .070 Sex Female Ref Ref Ref Ref Ref Ref Male 0.90 (0.77 to 1.07) .240 0.78 (0.67 to 0.91) .002 0.68 (0.58 to 0.80) , .001 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Postsecondary 1.22 (1.06 to 1.39) .005 0.94 (0.83 to 1.07) .340 1.26 (1.11 to 1.44) , .001 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Employed 1.05 (0.88 to 1.26) .580 1.00 (0.84 to 1.18) .990 0.02 (0.86 to 1.21) .810 Retired 1.09 (0.67 to 1.78) .730 0.80 (0.51 to 1.25) .320 1.57 (1.00 to 2.46) .050 Student 0.88 (0.70 to 1.12) .310 0.92 (0.73 to 0.15) .460 0.84 (0.67 to 1.06) .150 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 0.92 (0.77 to 1.10) .380 0.95 (0.80 to 1.32) .590 1.30 (1.09 to 1.55) .003 Marital status Single Ref Ref Ref Ref Ref Ref Married 0.95 (0.80 to 1.12) .540 0.93 (0.80 to 1.09) .380 1.09 (0.92 to 1.27) .320 Divorced/widowed 1.09 (0.71 to 1.65) .700 0.70 (0.48 to 1.02) .070 1.01 (0.70 to 1.49) .950 (Continued on following page) Awareness of Colorectal Cancer Risk Factors in Palestine JCO Global Oncology 9 TABLE 5. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Residency The Gaza Strip Ref Ref Ref Ref Ref Ref The WBJ 0.96 (0.81 to 1.14) .650 0.67 (0.57 to 0.79) , .001 0.54 (0.46 to 0.63) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Yes 0.94 (0.80 to 1.13) .520 1.05 (0.89 to 1.23) .600 1.02 (0.86 to 1.21) .810 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Yes 1.25 (1.10 to 1.42) .001 1.31 (1.16 to 1.48) , .001 0.89 (0.79 to 1.01) .070 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Yes 0.59 (0.49 to 0.71) , .001 0.82 (0.68 to 1.00) .039 1.21 (1.00 to 1.46) .051 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Hospitals 1.54 (1.31 to 1.80) , .001 1.21 (1.04 to 1.40) .014 0.88 (0.76 to 1.03) .110 PHCs 1.24 (1.05 to 1.46) .010 1.03 (0.88 to 1.20) .740 0.80 (0.69 to 0.94) .007 Abbreviations: AOR, adjusted odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Adjusted for age group, sex, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, following a vegetarian diet, and site of data collection. Elshami et al TABLE 6. Multivariable Logistic Regression Analyzing Factors Associated With the Recognition of Nonmodifiable Colorectal Cancer Risk Factors Having a Close Relative With Having a Bowel Disease Bowel Cancer Being Over 70 Years Old Having Diabetes a a a a Characteristic AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 1.16 (0.96 to 1.40) .140 0.90 (0.76 to 1.07) .240 1.28 (1.08 to 1.51) .005 1.03 (0.87 to 1.24) .710 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 0.70 (0.59 to 0.84) , .001 0.53 (0.45 to 0.62) , .001 0.88 (0.75 to 1.03) .110 1.00 (0.85 to 1.18) .990 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 1.11 (0.96 to 1.28) .160 1.25 (1.10 to 1.42) .001 1.04 (0.92 to 1.19) .530 1.05 (0.91 to 1.20) .520 Occupation Unemployed/ Ref Ref Ref Ref Ref Ref Ref Ref housewife Employed 1.01 (0.84 to 1.22) .930 1.05 (0.88 to 1.24) .600 0.94 (0.79 to 1.11) .470 0.94 (0.79 to 1.12) .520 Retired 0.84 (0.52 to 1.36) .480 1.36 (0.87 to 2.14) .180 1.03 (0.66 to 1.61) .890 0.73 (0.45 to 1.19) .210 Student 1.01 (0.79 to 1.29) .960 0.82 (0.65 to 1.03) .080 0.82 (0.66 to 1.03) .090 0.87 (0.68 to 1.10) .240 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 1.06 (0.88 to 1.29) .530 1.18 (1.00 to 1.40) .060 1.16 (0.98 to 1.37) .100 0.88 (0.73 to 1.04) .140 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.04 (0.87 to 1.23) .680 1.11 (0.95 to 1.30) .190 0.92 (0.78 to 1.08) .290 1.01 (0.85 to 1.19) .940 Divorced/widowed 1.16 (0.74 to 1.80) .520 1.17 (0.80 to 1.72) .420 0.81 (0.55 to 1.18) .270 0.95 (0.64 to 1.41) .800 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.68 (0.57 to 0.82) , .001 0.75 (0.64 to 0.88) .001 0.71 (0.61 to 0.84) , .001 0.66 (0.56 to 0.78) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.10 (0.91 to 1.33) .320 1.13 (0.96 to 1.34) .140 0.94 (0.80 to 1.12) .500 0.11 (0.93 to 1.31) .260 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.31 (1.15 to 1.50) , .001 1.06 (0.94 to 1.19) .380 1.05 (0.93 to 1.18) .430 1.01 (0.89 to 1.14) .900 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.23 (0.98 to 1.53) .070 1.01 (0.84 to 1.23) .890 0.48 (0.39 to 0.58) , .001 0.94 (0.77 to 1.14) .500 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 1.22 (1.04 to 1.44) .015 1.23 (1.06 to 1.43) .006 1.36 (1.17 to 1.58) , .001 0.73 (0.63 to 0.86) , .001 PHCs 1.09 (0.92 to 1.30) .340 0.82 (0.70 to 0.96) .012 1.08 (0.92 to 1.26) .350 0.77 (0.65 to 0.91) .002 Abbreviations: AOR, adjusted odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Adjusted for age group, sex, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, following a vegetarian diet, and site of data collection. 10 © 2022 by American Society of Clinical Oncology Awareness of Colorectal Cancer Risk Factors in Palestine This study highlights the importance of establishing contin- with medical backgrounds might have reduced the number of uous educational interventions to raise the awareness about participants with a presumably good awareness. Nonetheless, risk factors and signs and symptoms of CRC in Palestine. their exclusion was intended to make this study more relevant These interventions should focus on different aspects of CRC as a measure of the public awareness. including its relationship with some chronic diseases (eg, In conclusion, the awareness level of CRC risk factors was diabetes) and with different diets (eg, fiber-low) as the public relatively low, with only 39.8% of participants showing good awareness about these important risk factors was found to be awareness. In general, participants from the Gaza Strip had low. Raising awareness of CRC risk factors may enhance early a higher awareness level than those from the WBJ. The presentation and, hence, early detection of CRC. Moreover, factors associated with having good awareness of CRC risk good awareness of CRC may facilitate the potential imple- factors were having postsecondary education and knowing mentation of CRC screening as part of future health policy. someone with cancer. The most recognized CRC risk factor The use of convenience sampling limits the generalizability of was not doing 30 minutes of moderate physical activity five the findings. However, the large number of participants, the times a week, whereas the least recognized was having high response rate, and the recruitment from different geo- diabetes. Campaigns and programs aiming to increase graphical areas may mitigate this. Furthermore, the exclusion awareness of CRC risk factors are needed and should be of visitors or patients in oncology departments and participants tailored to address the knowledge gaps among the public. AFFILIATIONS AUTHOR CONTRIBUTIONS Division of Surgical Oncology, Department of Surgery, University Conception and design: Mohamedraed Elshami, Mohammad F. Dwikat, Hospitals Cleveland Medical Center, Cleveland, OH Ibrahim Al-Slaibi, Mohammed Alser, Bettina Bottcher, Nasser Abu-El- Ministry of Health, Gaza, Palestine Noor Faculty of Medicine, An-Najah National University, Nablus, Palestine Administrative support: Mohamedraed Elshami, Ibrahim Al-Slaibi, Almakassed Hospital, Jerusalem, Palestine Mohammed Alser Beit Jala Governmental Hospital (Al-Hussein), Bethlehem, Palestine Provision of study materials or patients: Mohamedraed Elshami, Ibrahim Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine Al-Slaibi, Mohammed Alser Palestine Medical Complex, Khanyounis, Palestine Collection and assembly of data: All authors Faculty of Medicine, Al-Quds University, Jerusalem, Palestine Data analysis and interpretation: Mohamedraed Elshami, Mohammad F. Faculty of Pharmacy, Al-Azhar University of Gaza, Gaza, Palestine Dwikat, Bettina Bottcher, Nasser Abu-El-Noor Faculty of Dentistry, Arab American University, Palestine, Jenin Manuscript writing: All authors Faculty of Nursing and Health Sciences, Bethlehem University, Final approval of manuscript: All authors Bethlehem, Palestine Accountable for all aspects of the work: All authors Faculty of Allied Medical Sciences, Arab American University, Jenin, Palestine AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF Faculty of Medicine, Al-Azhar University, Gaza, Palestine INTEREST Faculty of Medicine, Al-Quds Abu Dis University Al-Azhar Branch of The following represents disclosure information provided by authors of Gaza, Gaza, Palestine 15 this manuscript. All relationships are considered compensated unless Faculty of Nursing, Islamic University of Gaza, Gaza, Palestine otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the CORRESPONDING AUTHOR subject matter of this manuscript. For more information about ASCO’s Mohamedraed Elshami, MD, MMSc, Division of Surgical Oncology, conflict of interest policy, please refer to www.asco.org/rwc or ascopubs. Department of Surgery, University Hospitals Cleveland Medical Center, org/go/authors/author-center. 11100 Euclid Ave, Lakeside 7100, Cleveland, OH 44106; Twitter: Open Payments is a public database containing information reported by @MElshamiMD; e-mail: mohamedraed.elshami@gmail.com. companies about payments made to US-licensed physicians (Open Payments). EQUAL CONTRIBUTION No potential conflicts of interest were reported. M.E. and M.F.D. contributed equally as a first coauthor to this work. B.B. and N.A.-E.-N. contributed equally as a senior coauthor to this work. ACKNOWLEDGMENT The authors would like to thank Mr Majdeddin MohammedAli for his useful feedback and all study participants for taking part in the study. 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Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors Not Doing 30 Minutes of Moderate Not Eating Five Portions of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P COR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 0.99 (0.82 to 1.19) .900 0.98 (0.84 to 1.15) .830 1.00 (0.85 to 1.17) .970 1.15 (0.98 to 1.34) .080 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 1.42 (1.20 to 1.66) , .001 0.53 (0.46 to 0.60) , .001 0.52 (0.46 to 0.60) , .001 0.96 (0.84 to 1.09) .520 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 0.89 (0.76 to 1.03) .120 0.90 (0.78 to 1.02) .100 0.96 (0.84 to 1.10) .550 1.11 (0.98 to 1.26) .100 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Ref Ref Employed 1.40 (1.18 to 1.66) , .001 0.69 (0.59 to 0.79) , .001 0.63 (0.55 to 0.73) , .001 1.04 (0.91 to 1.19) .590 Retired 1.50 (0.82 to 2.71) 1.190 0.55 (0.35 to 0.85) .007 0.57 (0.37 to 0.89) .013 1.97 (1.16 to 3.35) .013 Student 1.08 (0.85 to 1.38) .530 0.63 (0.51 to 0.78) , .001 0.70 (0.56 to 0.85) .001 1.00 (0.82 to 1.23) .990 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 1.03 (0.88 to 1.21) .690 0.81 (0.70 to 0.94) .005 0.80 (0.69 to 0.92) .002 1.01 (0.89 to 1.16) .850 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.16 (0.98 to 1.37) .090 1.32 (1.14 to 1.52) , .001 1.27 (1.10 to 1.46) .001 1.18 (1.03 to 1.35) .019 Divorced/widowed 1.15 (0.72 to 1.84) .550 1.55 (1.02 to 2.37) .042 1.13 (0.77 to 1.67) .540 1.14 (0.78 to 1.66) .510 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.94 (0.80 to 1.10) .420 0.65 (0.57 to 0.75) , .001 0.66 (0.57 to 0.75) , .001 1.00 (0.88 to 1.13) .940 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.23 (1.00 to 1.51) .045 0.97 (0.82 to 1.14) .690 1.02 (0.86 to 1.20) .860 1.04 (0.88 to 1.22) .660 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref (Continued on following page) Awareness of Colorectal Cancer Risk Factors in Palestine JCO Global Oncology 15 TABLE A1. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Not Doing 30 Minutes of Moderate Not Eating Five Portions of Fruits and Physical Activity Five Times a Week Smoking Cigarettes Drinking Alcohol Vegetables a Day Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P COR (95% CI) P Yes 1.24 (1.06 to 1.45) .007 1.22 (1.06 to 1.39) .004 1.29 (1.13 to 1.47) , .001 1.03 (0.91 to 1.17) .660 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.20 (0.94 to 1.54) .140 1.28 (1.03 to 1.59) .024 1.02 (0.83 to 1.25) .840 1.65 (1.33 to 2.04) , .001 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 0.82 (0.68 to 0.99) .036 0.91 (0.78 to 1.07) .270 0.82 (0.70 to 0.96) .013 0.91 (0.78 to 1.06) .240 PHCs 0.97 (0.80 to 1.18) .770 1.22 (1.03 to 1.45) .022 1.34 (1.13 to 1.59) .001 1.33 (1.13 to 1.57) .001 Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref 45 or older 1.24 (1.06 to 1.44) .006 1.20 (1.03 to 1.37) .015 1.11 (0.97 to 1.28) .130 Sex Female Ref Ref Ref Ref Ref Ref Male 1.01 (0.89 to 1.14) .900 0.79 (0.70 to 0.88) , .001 0.73 (0.65 to 0.83) , .001 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Postsecondary 1.09 (0.96 to 1.23) .170 0.85 (0.76 to 0.96) .007 1.21 (1.07 to 1.36) .002 Occupation Unemployed/housewife Ref Ref Ref Ref Ref Ref Employed 1.03 (0.90 to 1.18) .630 0.78 (0.69 to 0.88) , .001 0.82 (0.73 to 0.93) .003 Retired 1.18 (0.75 to 1.85) .470 0.70 (0.46 to 1.05) .080 1.30 (0.86 to 1.96) .210 Student 0.83 (0.69 to 1.01) .070 0.76 (0.63 to 0.92) .004 0.76 (0.63 to 0.92) .004 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 0.96 (0.84 to 1.09) .550 0.72 (0.64 to 0.81) , .001 0.87 (0.77 to 0.99) .029 Marital status Single Ref Ref Ref Ref Ref Ref Married 1.08 (0.95 to 1.24) .240 1.12 (0.99 to 1.27) .080 1.18 (1.04 to 1.35) .010 Divorced/widowed 1.37 (0.94 to 2.02) .110 1.03 (0.73 to 1.45) .890 1.16 (0.82 to 1.64) .410 (Continued on following page) Elshami et al 16 © 2022 by American Society of Clinical Oncology TABLE A1. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Modifiable Colorectal Cancer Risk Factors (Continued) Being Overweight Eating Red Meat Once a Day or More Having a Diet Low in Fiber Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P Residency The Gaza Strip Ref Ref Ref Ref Ref Ref The WBJ 0.99 (0.87 to 1.12) .880 0.67 (0.59 to 0.75) , .001 0.63 (0.56 to 0.71) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Yes 1.05 (0.90 to 1.23) .500 1.11 (0.96 to 1.29) .150 1.03 (0.89 to 1.20) .650 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Yes 1.27 (1.13 to 1.44) , .001 1.35 (1.20 to 1.52) , .001 0.92 (0.82 to 1.03) .170 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Yes 0.56 (0.47 to 0.67) , .001 0.91 (0.77 to 1.09) .320 1.49 (1.25 to 1.78) , .001 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Hospitals 1.58 (1.36 to 1.84) , .001 1.24 (1.08 to 1.43) .003 0.87 (0.76 to 1.01) .060 PHCs 1.24 (1.07 to 1.44) .005 1.20 (1.04 to 1.38) .014 0.93 (0.81 to 1.08) .350 Abbreviations: COR, crude odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. Awareness of Colorectal Cancer Risk Factors in Palestine TABLE A2. Bivariable Logistic Regression Analyzing Factors Associated With the Recognition of Nonmodifiable Colorectal Cancer Risk Factors Having a Close Relative With Having a Bowel Disease Bowel Cancer Being Over 70 Years Old Having Diabetes Characteristic COR (95% CI) P COR (95% CI) P COR (95% CI) P COR (95% CI) P Age group, years 18-44 Ref Ref Ref Ref Ref Ref Ref Ref 45 or older 1.16 (0.99 to 1.36) .070 0.98 (0.85 to 1.13) .780 1.24 (1.08 to 1.43) .002 0.99 (0.85 to 1.14) .870 Sex Female Ref Ref Ref Ref Ref Ref Ref Ref Male 0.67 (0.59 to 0.77) , .001 0.61 (0.54 to 0.69) , .001 0.97 (0.87 to 1.09) .650 0.94 (0.83 to 1.07) .360 Educational level Secondary or below Ref Ref Ref Ref Ref Ref Ref Ref Postsecondary 0.98 (0.87 to 0.12) .800 1.16 (1.03 to 1.30) .015 0.97 (0.86 to 1.08) .560 1.01 (0.89 to 1.14) .890 Occupation Unemployed/ Ref Ref Ref Ref Ref Ref Ref Ref housewife Employed 0.74 (0.64 to 0.85) , .001 0.79 (0.70 to 0.90) , .001 0.92 (0.81 to 1.04) .190 0.86 (0.76 to 0.98) .029 Retired 0.70 (0.45 to 1.08) .110 0.91 (0.60 to 1.37) .640 1.10 (0.73 to 1.66) .630 0.69 (0.44 to 1.09) .110 Student 0.77 (0.63 to 0.95) .014 0.70 (0.58 to 0.84) , .001 0.79 (0.66 to 0.96) .017 0.84 (0.69 to 1.03) .100 Monthly income , 1,450 NIS Ref Ref Ref Ref Ref Ref Ref Ref ≥ 1,450 NIS 0.76 (0.67 to 0.88) , .001 0.96 (0.85 to 1.08) .510 0.98 (0.86 to 1.10) .700 0.70 (0.61 to 0.79) , .001 Marital status Single Ref Ref Ref Ref Ref Ref Ref Ref Married 1.19 (1.04 to 1.37) .013 1.24 (1.09 to 1.40) .001 1.07 (0.95 to 1.22) .260 1.03 (0.90 to 1.17) .710 Divorced/widowed 1.53 (1.02 to 2.31) .041 1.40 (0.98 to 1.98) .060 1.07 (0.76 to 1.51) .700 1.03 (0.72 to 1.48) .870 Residency The Gaza Strip Ref Ref Ref Ref Ref Ref Ref Ref The WBJ 0.68 (0.60 to 0.78) , .001 0.83 (0.74 to 0.93) .002 0.85 (0.76 to 0.96) .008 0.63 (0.56 to 0.71) , .001 Having a chronic disease No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.16 (0.98 to 1.37) .080 1.10 (0.95 to 1.28) .200 1.05 (0.90 to 1.21) .540 1.04 (0.89 to 1.21) .630 Knowing someone with cancer No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.33 (1.17 to 1.52) , .001 1.09 (0.97 to 1.22) .150 1.10 (0.98 to 1.23) .110 1.04 (0.92 to 1.17) .600 Following a vegetarian diet No Ref Ref Ref Ref Ref Ref Ref Ref Yes 1.36 (1.10 to 1.67) .004 1.13 (0.94 to 1.35) .190 0.49 (0.41 to 0.59) , .001 1.15 (0.96 to 1.38) .140 Site of data collection Public spaces Ref Ref Ref Ref Ref Ref Ref Ref Hospitals 1.17 (1.00 to 1.37) .044 1.17 (1.01 to 1.35) .032 1.45 (1.26 to 1.67) , .001 0.79 (0.68 to 0.92) .002 PHCs 1.27 (1.08 to 1.49) .003 1.00 (0.87 to 1.16) .970 1.14 (0.99 to 1.32) .070 0.88 (0.75 to 1.02) .080 Abbreviations: COR, crude odds ratio; NIS, Israeli new shekel; PHC, primary health care center; WBJ, West Bank and Jerusalem. JCO Global Oncology 17

Journal

JCO: Global Oncology – Wolters Kluwer Health

Published: Jun 13, 2022

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