REVIEW ARTICLE /SYNTHÈSE
Awareness about Cancer in the 12 Governorates of Jordan:
A Correlational, Comparative Study
Degré de sensibilisation vis-à-vis du cancer dans les 12 gouvernorats de Jordanie : une étude comparative corrélationnelle
M.M. Ahmad
Received: 11 October 2014; Accepted: 1 February 2015
© Lavoisier SAS 2015
Abstract Aim: This study was designed to examine the awareness of the Jordanian population about the signs and symptoms of cancer.
Methods: A stratified random sampling technique was used in order to produce a reliable estimate for the population’s knowledge about cancer in the 12 governorates of Jordan.
A representative sample of 2,962 adult educated individuals completed the study questionnaire.
Results: The highest level of awareness about the signs and symptoms of cancer was“having an unusual lump or swell- ing anywhere on your body,”which was reported by about three-quarters of the participants, and the lowest awareness was reported by almost 30% of the participants as having
“A wound that won’t heal.”Interestingly, there was no sig- nificant association between doing screening for cancer and the demographic variables, namely, age, gender, education, and income.
Conclusions: The findings of this study provide data that will help in identifying gaps in the knowledge regarding the signs and symptoms of cancer and how it is linked to participants’ age, education level, gender, and income. They confirm the necessity for additional research tailored to each type of can- cer to raise awareness level in the community.
KeywordsAwareness · Cancer · Jordan · Knowledge · Signs and symptoms
RésuméObjectif: Cette étude a été conçue afin d’examiner le niveau de sensibilisation de la population jordanienne aux signes et symptômes du cancer.
Méthodes: L’utilisation d’une technique d’échantillonnage aléatoire stratifié a permis de produire une évaluation fiable
des connaissances de la population au sujet du cancer dans les 12 gouvernorats de Jordanie. Un échantillon représentatif de 2 962 personnes adultes et instruites a répondu au ques- tionnaire de l’étude.
Résultats : Le plus haut niveau de conscience au sujet des signes et symptômes du cancer était « avoir une protubér- ance ou un gonflement inhabituel n’importe où sur le corps », signalé par près de trois quarts des participants. Le niveau le plus bas, indiqué par environ 30 % des participants, était avoir « une plaie qui ne guérit pas ». Il est intéressant de noter qu’il n’y avait aucun lien significatif entre le fait de faire un dépistage du cancer et les variables démographi- ques, telles que l’âge, le genre, l’éducation et les revenus.
Conclusions: Les conclusions de cette étude fournissent des données qui permettront d’identifier les écarts dans la connais- sance des signes et symptômes du cancer et de comprendre l’influence de l’âge, du niveau d’éducation, du genre et des revenus des participants. Les résultats confirment la néces- sité de recherches supplémentaires adaptées à chaque type de cancer afin d’élever le niveau de sensibilisation dans la communauté.
Mots clésSensibilisation · Cancer · Jordanie · Connaissance · Signes & symptômes
Introduction
According to WHO, cancer is the uncontrolled growth and spread of cells. It can affect almost any part of the body [1].
The growths often invade surrounding tissues and can metastasize to distant sites. Cancer is a collection of diseases that can cause many signs and symptoms [2]. These signs and symptoms will vary based on the location of cancer and its size [1,3]. With the metastasis of cancer, a group of signs and symptoms arise [4]. It is important to emphasize that there is no single manifestation which is entirely linked to
M.M. Ahmad (*)
Faculty of Nursing, the University of Jordan, Amman 11942, Jordan
e-mail : [email protected], [email protected] DOI 10.1007/s11839-015-0502-x
cancer. For example, symptoms such as coughing or tired- ness, are high likely triggered by something other than can- cer [5,6].
The number of patients with cancer is expected to escalate to nine million by 2015 [7]. In developed countries, about half of patients with cancer die of the disease, while in devel- oping countries, about 80% of patients with cancer reached late stages and died [4,8]. In Jordan, as one of the developing countries, cancer is the second leading cause of death after heart diseases [9,10]. Furthermore, there are many factors that prevent effective cancer prevention and early detection in Jordan, such as knowledge gaps and lack of awareness programs [11].
Lack of awareness about cancer contributes to a delay in presentation for cancer symptoms and may lead to a delay in cancer diagnosis [12,13]. The more the delay in seeking health advice, the more likely it contributes to being at late stage at the time of diagnosis [7]. Low awareness about can- cer manifestations is a risk factor for patients’delay in seek- ing help [14–16].
Unfortunately, in a developing country like Jordan, there is a lack of awareness among people about the manifesta- tions of common cancers [8]. Awareness about the warning signs of cancer was surveyed in a few countries, and results revealed poor knowledge among the population [6,17].
Therefore, the purpose of this study was to examine the awareness level about the signs and symptoms of cancer among a national sample in Jordan.
Methods Sample
This study used stratified sampling technique in order to obtain a random sample representative to all governorates in Jordan. The ratio of male to female participants in the study in comparison to the actual ratio of the Jordanian pop- ulation in each governorate was almost the same [18]. The sample size in this survey was 2,962 participants. The inclu- sion criteria of the sample consisted of: the participant being (1) at least 18 years of age; and (2) able to read and write in Arabic. Individuals who were illiterates were excluded from participation.
Survey instrument
The survey tool was developed to comprehensively evaluate population perceptions regarding cancer. Specifically, the tool includes parts regarding demographic variables and awareness about the signs and symptoms of cancer. Interna- tional references and instruments were used to guide the development of the tool [19,20]. In our study, face and con-
tent validity of the tool were established by a panel of 10 experts in the field of epidemiology, cancer, public health, and experts from the Department of Statistics. The reliability of the awareness tool in this study had a Cron- bach’s alpha of .88.
Preparations for data collection
Almost sixty qualified field workers were recruited to imple- ment the study. The survey interviewers were recruited based on experience, education, and familiarity with the geo- graphic areas. All the interviewers were females with bacca- laureate degrees. All field workers attended a two-week workshop with theoretical and practical training. Then, a pilot study was conducted to test the interviewers’qualifica- tions, survey tool clarity, and the sampling technique.
Data collection and processing
Data collection began directly after training and piloting.
Data collection took two months through face-to-face inter- views at the interviewees’homes. The time of each interview was about an hour. The Statistical Package for Social Sciences (SPSS) was used to run univariate and bivariate analyses [21]; the analysis techniques included correlational analysis and analysis of variance (ANOVA) followed with Scheffe post-hoc analyses.
Ethical considerations
The purpose of the study, benefits, and risks were explained to participants before each interview. All participants were assured that their participation was voluntary and that they can withdraw from the study at any time if they decided to do so. A code number to each participant was assigned to assure the confidentiality of the obtained data. The Institutional Review Board at the University of Jordan granted the ethical approval for the study. As appreciation to the study sample, pamphlets with information about the signs and symptoms of cancer, available resources in the country, and contact numbers with hot lines were provided to participants at the end of interviews.
Results Participants
The participants’demographic characteristics are presented in Table 1. The number of males was 1,593 (53.8%), which is almost the same as the national male percentage (51.5%) [18]. The median age of the respondents was 35 years (range = 18–86). About three-quarters of the study sample
were married. Less than 15% of the participants had a house- hold monthly income of more than 600 Jordanian Dinar (JD) (1 JD = 1.4 United States Dollar).
The correlations between common practices related to the awareness about cancer and the participants’ demographic characteristics are presented in Table 2. Doing routine health check-ups were positively correlated with participants’ age, education, and income. However, doing screening specifi- cally for cancer did not show any significant correlation with the demographic variables. Hearing about “palliative care”showed significant positive correlations (.15, .10, .10) respectively with education, income, and gender.
The most common signs and symptoms that may be asso- ciated with cancer are presented in Table 3. The participants showed the highest level of awareness was“An unusual lump or swelling anywhere on your body”(76.2%), and the lowest awareness was“A wound that won’t heal”(29.8%). Further- more, 72% reported that a change in the size, shape or color of a mole indicated presence of cancer.
The youngest individuals in the sample had less aware- ness about the signs and symptoms of cancer than the middle age groups. No differences in this awareness were based on the marital status. However, the highly educated participants had more awareness about the signs and symptoms of cancer than the less educated group. Furthermore, the higher the income level, the better the awareness about cancer. No dif- ferences were found between males and females on this awareness level (Table 4).
Discussion
In this study, the participants reported a low to moderate level of awareness about the common signs and symptoms of cancer. Lack of awareness about cancer is considered a
Table 1 Demographics for participants (N= 2,962).
Demographics Categories N %
Age 18–29 951 32.1
30–39 893 30.1
40–49 604 20.4
50–59 234 7.9
≥60 280 9.4
Gender Male 1,593 53.8
Female 1,369 46.2
Marital status Single 625 21.1
Married 2,200 74.3
Divorce & widow 137 4.6
Education Up to 6th grade 380 12.8
7th to 12th grade 1,638 55.3
>12th grade 944 31.9
Income <300 1,295 43.7
300–599 1,198 40.4
≥600 448 15.1
Table 2 Correlations between demographics and cancer practices and awareness.
Demographics Did you do routine health check-up?
Have you ever been screened for cancer?
Have you ever heard about palliative care?
Age .15* .01 .01
Education .12* .08 .15*
Income .13* .07 .10*
Gender −.05 −.05 .10*
*P< .01.
Table 3 Participants’knowledge about the signs and symptoms of cancer (N= 2,962).
Signs and symptoms Yes (%)
Irregular bowel motions between diarrhea and constipation
1,368 (46.4) An unusual lump or swelling anywhere
on your body
2,257 (76.2) A persisting mouth or tongue ulcer 1,654 (55.8) A wound that won’t heal 883 (29.8)
Problems passing urine 1,435 (48.4)
Blood in your urine 1,701 (57.4)
Blood in your stool 1,697 (57.3)
Persistent difficulty in swallowing 1,631 (55.1) A persisting cough or croaky voice 1,597 (53.9)
Persistent indigestion 1,593 (53.8)
A change in the size, shape, or color of a mole
2,146 (72.4) Unexplained weight loss or loss of appetite 2,055 (69.4)
Heavy night sweating 991 (33.4)
An unexplained pain or ache that lasts long 1,779 (60.1) Changes in skin/rash/blemish/sunspot/blotch 2,249 (75.9) Tiredness/fatigue that lasts long 1,571 (53.0)
dangerous issue, which precludes the early diagnosis and complicate the process of treatment and the outcome of the disease [1,22]. The level of awareness of the signs and symp- toms of cancer is important because individuals can take pre- cautions that may prevent reaching advanced stages of can- cer [23]. In a study by Kyle et al. [13], when participants were asked about their awareness of the signs and symptoms of cancer, most of them said there are many, but when they were to list those signs and symptoms, the majority did not recall more than two. A lump or a swelling could be a sign of cancer was the most reported. These results are consistent with our findings where most of the signs and symptoms where only recognized by less than half of the sample.
Knowledge of screening and a frequent check-up for spe- cific types of cancer, such as breast, colorectal, and prostate cancer, is considered an important element for cancer aware- ness [24,25]. Furthermore, there were high similarities between the results of our study and what was found by Raj et al. [3] regarding the awareness of the signs and symp- toms of cancer in India. However, in our study, when parti- cipants were asked whether they agreed or disagreed with a list of potential symptoms, there was still high recognition of a lump more than any other sign or symptom. Added to this, at least a quarter of respondents did not believe that unex- plained persistent pain, a persistent cough, or a sore that will not heal could be signs of cancer. These answers reflect clearly the deficit in the public awareness about the signs and symptoms of cancer in Jordan.
Studies have shown a variation between the level of knowledge about cancer and age. As individuals become
older, they are expected to develop a more accurate view of health and illness [26,27]. This result is consistent with our finding that getting older increases the awareness about the signs and symptoms of cancer. In confirmation with this, the youngest group (18–29 years of age) showed less aware- ness than the middle age group (30–49). This could be due to the small sample in the last two groups of age categories in this study, in addition to the large standard errors.
Saskia et al. [6] found an inverse relationship between the educational level and the awareness of cancer risk factors.
On the other hand, education increases individuals’knowl- edge and provides them with the necessary information to deal with health problems [22,28]. Thus, and consistent with this expectation, we found that the group with the high- est education (above high school) had a significant differ- ence in the awareness level about cancer than the other two groups with lower education levels.
Furthermore, a higher level of income enables individuals to get access to more educational resources [15]. In this study, the higher the income, the better the awareness about cancer among the participants. Studies showed that the cost of some critical cancer tests such as a mammogram was the reason for not performing it [22,29]. This reflects that the lack of knowledge on the importance of some exam- inations as well as the financial burden, both preclude from taking preventive measures against cancer.
Contradiction was found in the literature regarding the relationship between gender and awareness about cancer.
While some studies reported lower levels of awareness of risks of cancer among men than women [30,31], yet Saskia Table 4 Awareness about the signs and symptoms of cancer and participants’demographics (N= 2,962).
Demographics Mean Standard
deviation (SD)
Test statistics Post-hoc Scheffe
Age 1. 18–29 8.48 4.55 F= 4.42** 1 < 2*
2. 30–39 9.14 4.48 1 < 3*
3. 40–49 9.28 4.63
4. 50–59 9.39 4.81
5.≥60 9.23 4.55
Marital status Single 8.65 4.84 F= 2.27
Married 9.06 4.51
Divorce & widow 9.30 4.45
Education Up to 6th grade 8.34 4.70 F= 18.54** 1 < 3**
7th to 12th grade 8.71 4.58 2 < 3**
>12th grade 9.71 4.45
Income <300 8.17 4.64 F= 38.49** 1 < 2**
300–599 9.56 4.37 1 < 3**
≥600 9.82 4.55 2 < 3**
Gender Male 8.82 4.71 T =−2.06*
Female 9.17 4.41
*P< .05; **P< .01.
et al. [6] found no relationship between awareness of cancer risks and gender. In this study, female individuals demon- strated a higher level of awareness about cancer than males. This could be due to the number of women who per- form breast self-exam or clinical breast exams during the middle and old ages of life. Indeed, it is recommended for women in Jordan to do clinical breast exams at the average risk ages (20–40 years) every 1–3 years, while women at ages 40 and older should have them done yearly [32,33].
The variations within the literature regarding the relation- ships between cancer awareness and the categories within the demographic variables could be attributed to many fac- tors. Awareness about cancer was measured in different ways. In one of the few trials found in the literature, the knowledge scale was reported to have been validated [25].
In addition, studying variables such as education or age without considering the effect of gender may give confusing results.
Knowing the relationship between cancer and the demo- graphic variables will ensure public awareness toward help- ing people to understand the potential health consequences for late diagnosis, and will encourage them to take risk- reducing measures [34]. In this study, doing routine health check-ups had significant positive correlations with age, education, and income. On the other hand, being screened for cancer did not show any significant relationship with the demographic variables. Also, being female, high education, and high income were positively associated with “some awareness about palliative care.”
In conclusion, this study highlights the gap in awareness about cancer manifestations in a Jordanian national sample.
It is highly likely that there are inadequate activities in the country on promoting cancer awareness. Analyses of this study revealed that the knowledge of the signs and symp- toms of cancer is almost low among the public. However, this conclusion varies across participants according to age, level of education, and income level. These evidences sug- gest that additional research tailored to each type of cancer is needed to raise awareness level in the community in a more specific approach.
Recommendations
The results indicate that there is a lack of knowledge about cancer among the participants, and they could, if improved, support the prevention and early detection of cancer. The dis- seminated information should be more appropriately tailored to a population of differing health literacy levels. Facilitating access to care, especially to the poor, needs to be endorsed. It is also recommended to have standardized and validated mea- sures of cancer awareness for each type of cancer. Further- more, more research is needed to raise the community’s
awareness about cancer with a more specific approach rele- vant to individuals’age, education level, and income. Finally, although the percentage of illiterates (1.2%) who was excluded in this study is small, this could add to the limita- tions of the study.
Acknowledgment The authors acknowledge the partial funding from the University of Jordan.
Conflict of interest statement:the author declares no con- flict of interest.
References
1. WHO (2014) Health topics: Cancer. WHO. http://www.who.int/
topics/en/
2. ACS (2014) ACS Guidelines on nutrition and physical activity for cancer prevention. American Cancer Society. http://www.
cancer.org
3. Raj, Piang, Nair, et al (2012) Awareness regarding risk factors, symptoms and treatment. Asian Pac J Cancer Prev 13:4057–62 4. Cancer Information Resource Foundation (2013) The angels of
hope. Peachtree City, Georgia: the Angels of Hope Cancer Infor- mation Resource Foundation
5. Tawalbeh, Ahmad (2014) The effect of cardiac education on knowledge and adherence to healthy lifestyle. Clin Nurs Res 23:245–58
6. Saskia, Jo, Martin, et al (2009) Awareness of lifestyle risk factors for cancer and heart disease among adults in the UK. Patient Educ Couns 74:221–7
7. The world health report (2012) A safer future: Global public health security in the 21st century. WHO. http://www.who.int/
whr/2007/en/
8. Jordan Cancer Registry (2010) Cancer incidence in Jordan.
Amman: Ministry of Health, Directorate of Non-Communicable Diseases
9. Ministry of Health (2012) Ministry of Health strategic plan 2013- 2017. MoH, Amman. http://www.moh.gov.jo/en/Pages/default.
aspx
10. Ahmad, Alasad, Nawafleh (2010) Nursing care and quality of life among Jordanian patients with cancer. Leadersh Health Serv 23:233–43
11. Ahmad, Al-Gamal, Othman, Nasrallah (2011) Knowledge, atti- tudes and practices towards cancer prevention and care in Jordan.
King Hussein Institute for Biotechnology and Cancer, Amman 12. Ahmad, Al-Gamal (2014) Predictors of cancer awareness among
older adult individuals in Jordan. Asian Pac J Cancer Prev 15:10927–32
13. Kyle, Forbat, Hubbard (2012) Cancer awareness among adoles- cents in Britain: a cross-sectional study. BMC Public Health 12:580. DOI: 10.1186/1471-2458-12-580
14. MacDonald, Macleod, Mitchell (2004) Factors influencing patient and primary care delay in the diagnosis of cancer (project M0005101440). University of Glasgow, Department of Health, Glasgow
15. Tawalbeh, Ahmad (2013) Personal resource questionnaire: a sys- tematic review. J Nur Res 21:170–7
16. Ahmad, Dardas, Dardas, Ahmad (2014) Colorectal cancer in Jordan: prevention and care. Glob Health Promot. DOI:
10.1177/1757975914547712
17. Valentinya, Kemmlerb, Staudera (2012) Age, sex and gender impact multidimensional geriatric assessment in elderly cancer patients. J Geriatr Oncol 3:17–23
18. DOS (2013) Kingdom indicators. DOS, Amman
19. Behavioral risk factor surveillance system (BRFSS) (2009) Behavioral risk factor surveillance system questionnaire. Center for Disease Control and Prevention
20. JCUSH (2004) Joint Canada/United States survey of health (JCUSH). Statistics Canada, Ottawa, Ontario, Canada
21. IBM Corporation (2012) IBM SPSS statistics for Windows, Ver- sion 21.0. NY: IBM Corp
22. Gu, Chan, He, et al (2013) Chinese women’s motivation to receive future screening: the role of social-demographic factors, knowledge and risk perception of cervical cancer. Eur J Oncol Nurs 17:154–61
23. Qalawa, Mohamed, Eltayb (2013) Cancer awareness among non- medical university students in Sudan. Int J Adv Res 1:93–110 24. Ahmad, Dardas, Ahmad (2014) Cancer prevention and care: a
national sample from Jordan. J Cancer Educ. DOI: 10.1007/
s13187-014-0698-7
25. Boundouki, Humphris, Field (2004) Knowledge of oral cancer, distress and screening intentions: longer term effects of a patient information leaflet. Patient Educ Couns 53:71–7
26. Mupepi, Sampselle, Johnson (2011) Knowledge, attitudes, and demographic factors influencing cervical cancer screening behav- ior of Zimbabwean women. J Women’s Health 20:943–52 27. Ahmad, Musil, Zauszniewski, Resnick (2005) Prostate cancer:
appraisal, coping, and health status. J Gerontol Nurs 31:34–43 28. Dardas, Ahmad (2013) Coping strategies as mediators and mod-
erators between stress and quality of life among parents of chil- dren with autistic disorder. Stress & Health. doi: 10.1002/
smi.2513
29. Tsu-Yin, Hsing-Fang, Brady (2008) Demographics and percep- tions of barriers toward breast cancer screening among Asian- American women. Women Health 48:261–81
30. Austoker, Bankhead, Forbes, et al (2009) Interventions to pro- mote cancer awareness and early. Br J Cancer 101:S31–S9 31. Bauer, Göhlmann, Sinning (2006) Gender differences in smoking
behavior, IZA discussion paper no. 2259. Forschungsinstitut, zur Zukunft der Arbeit, Institute for the Study of Labor
32. Ahmad (2014) Exploring the less Privileged Population’s Knowl- edge and Awareness about Cancer in Jordan. Int J Sci: Basic Appl Res 18:321–9
33. Jordan Breast Cancer Program (JBCP) (2012) Early detection and screening. Amman. http://www.jbcp.jo/
34. Hall, Weinman, Marteau (2004) The motivating impact of inform- ing women. Health Psychol 23:419–24
