An Observational Cross-Sectional Study on Cancer Awareness and Beliefs about Carcinogens among Saudi Women

Public knowledge about the risk factors of cancer is essential to ensure an effective prevention program. This study aims to explore the knowledge of the general Saudi population about cancer and carcinogens and to determine the misconceptions about carcinogens to help create appropriate evidence-based prevention awareness programs. A questionnaire of 63 questions related to biographic data, source of knowledge, risk factors, and the burden of cancer was distributed online. The internet was the most sought source for cancer-related information (75.2%). The inclusion of cancer-related subjects in the educational curriculum was believed to be the best way to educate children about cancer (48.4%). Knowledge about cancer risk factors was good overall for 10 out of the 27 risk factors assessed in the study, with cigarette smoking being the most well-known risk factor (91.5%), followed by hookah smoking (85.6%), and nuclear waste exposure (80%). However, only 16.3% of participants were aware of the risk associated with Oral Contraceptive Pills (OCPs), and less than half of the participants knew the risk associated with poor physical activity. About 45% (44.9%) believed that envy and spiritual causes are associated with cancer. Most of the study participants (70%) considered cancer to be a significant health issue in Saudi, mainly due to the increasing incidence rate (44%). Conclusion: This study showed a good level of awareness regarding cancer risk factors and environmental carcinogens, which could serve as a roadmap for future awareness programs and studies targeted at the knowledge of other risk factors for cancer.


Introduction
Cancer is a spectrum of diseases characterized by the uncontrolled proliferation of abnormal cells of any organ or tissue with the ability to invade adjacent and distant structures. According to World Health Organization (WHO), it is the second leading cause of death worldwide [1]. The international agency for research on cancer (IARC) states that globally, the number of new cases in 2020 reached 19,292,789, resulting in an estimated annual cost of USD 1.16 trillion, with death cases of 9,958,133 [2]. Among these numbers, the most prevalent types were breast cancer, lung cancer, prostate cancer, and colon cancer [2].
In Saudi Arabia, the incidence of different types of cancers has increased over the past decade [3]. In 2016, the number of reported new cases in the country reached 17,602 cases as breast, colorectal, and thyroid cancers accounted for the most cases in descending order [4].
A review paper published in 2019 indicated that new cancer cases in Saudi Arabia could reach 151,719 cases by 2025, and the number of deaths expected for the same year is estimated to be 30,718 [5]. Another correlating study conducted between 1999 and 2015 estimated that the number of cancer cases in the country has increased by 136% and is projected to increase by 63% by the year 2030 [6].
There are many known oncogenic factors, many of which are fortunately preventable. Most cancers are associated with modifiable and lifestyle-related risk factors such as cigarette smoking, alcohol consumption, physical inactivity, obesity, and dietary habits. Thus, cancer incidence can be reduced by following lifestyle-changing programs [7].
In the last 40 years, the socioeconomic situation in Saudi Arabia has improved drastically. People's habits have evolved as a consequence of this social development and transition, shifting towards a sedentary lifestyle, processed food intake, and obesity [3], unaware of their association with cancer [8,9]. Another supporting study showed that 82.6% of 26,000 families surveyed across the 13 administrative regions of the country did not practice physical activity as stated by physical activity guidelines [9].
The current trends in the number of cases and the increasing prevalence of risk factors place a tremendous demand on health care resources and predict an even greater burden on health care systems in the future, both locally and globally. They also represent an opportunity for both the global health care systems and Saudi health authorities to implement preventative strategies and educative campaigns that consider the prevalent risk factors, of which 30-50% are preventable (WHO).The present study aimed at exploring the knowledge of the general Saudi population about cancer and carcinogens and determining the misconceptions about carcinogens in order to help create a culturally appropriate evidence-based prevention awareness program.

Study Design and Sample
This cross-sectional observational survey was conducted to evaluate Saudi women's awareness of cancer and carcinogens. The study was approved by the King Saud University Institutional Review Board. Based on the Saudi female census of 2018, which was equivalent to 10,192,732 females, the sample size was estimated to be 385 (confidence level of 95% and a confidence interval of 5%). The sample was collected through convenient sampling.

Questionnaire
The questionnaire was first developed and validated by Ahmad et al. at King Hussein Institute for Biotechnology and Cancer (KHIBC) [10] It was reviewed by the knowledge, awareness, attitude survey advisory committee, the research team from the Center of Consultation (COC) at the University of Jordan and the Department of Statistics (DOS). The survey was then translated to Arabic using forward and back-translation, modified to the goals of this study and reviewed for consistency through a pilot of 50 participants. The questionnaire contains two sections: the first section collects sociodemographic data, and the second evaluates respondents' awareness of carcinogens [10,11]. The questionnaire was then transformed into a self-administered electronic survey.

Data Collection and Recruitment
The electronic questionnaire was shared through social media platforms to reach female participants from all over the kingdom. Inclusion criteria involved all adult Saudi women. Exclusion criteria were non-Saudis, males, minors, and those who did not complete the survey. Participants filled out the online surveys anonymously and voluntarily without incentives, and each participant had a unique IP address to prevent duplications. Data collection started on the 1 January 2021 and concluded at the completion of the sample size on the 22 January 2021.

Data Analysis
Data were exported for analysis using the Statistical Package for the Social Sciences; SPSS statistics for Windows, version 21.0 (SPSS Inc., Chicago, IL, USA). Categorical variables were expressed as percentages. The level of awareness was assessed as a score out of 28, where a higher score represents a higher level of awareness. Ordinal logistic regression was then used to assess the factors associated with awareness levels regarding carcinogens. A p-value less than 0.05 was considered significant.

Discussion
Awareness of cancer and carcinogens is considered a serious and important issue that affects public recognition, timely diagnosis, and prevention of the disease, especially with the increased number of cancer cases being reported in the last couple of decades in Saudi Arabia (136%) [6] and the lifestyle changes noticed in the country [3]. This highlights the need to assess the awareness, beliefs, and misconceptions about cancer and carcinogens. This study shows that most Saudi women understand that cancer is a significant and preventable health concern. Approximately half of the participants acknowledged the increasing incidence of cancer. Participants are also aware of the importance of psychological and social support for cancer patients.
The internet was the most used platform for obtaining cancer-related information. This finding is supported by (Algamdi et al.) [11] and (Ibrahim et al.) [12] who stated that the internet and social media are the most used sources for information. However, in contrast to (Alghamdi et al.) [11], our study found internet users to have the poorest knowledge about cancer among participants. Hence, social media platforms could be targeted for educating the public about cancer risks.
Regarding risk factors and carcinogens, respondents were aware of certain environmental and chemical carcinogens, most notably smoking. Many national (Sabi et al.) [13] (Alghamdi et al.) [11] (Ibrahim et al.) [12] (Ravichandran et al.) [14] and regional studies from the UAE (Ahmed et al.) [15], Oman (Alazri et al.) [16] and Lebanon (Kabalan) [17] showed that smoking was the most well-known risk factor. As (Alazri et al.) stated, this might be because smoking is culturally and religiously unacceptable in Muslim Gulf Arabian cultures. In addition, smoking is the most campaigned risk factor.
Radiation, contamination, and most chemical exposures were well-known factors too. However, when it comes to physical carcinogens, participants showed low awareness, with less than half attributing cancer to obesity and lack of physical activity, as well as poor knowledge about the risk of contraceptive pills, oncogenic viruses, and hair dyes. These results are concerning, given the higher tendency of obesity (Memish et al.) [18] and inactivity in Saudi females compared to Saudi males (Alhazza, A.) [19]. Another misconception noticed from the questionnaire was that approximately half of the respondents believed that envy or spiritual causes imposed a risk for cancer.
When comparing our study with similar observational studies, both regional and worldwide, the results were similar in almost all risk factors for cancer but varied in the knowledge of the risk of physical inactivity [16,20]. A study conducted in Riyadh showed similar knowledge about the risk of smoking and environmental carcinogens, which also noted poor knowledge about physical activity and obesity [13]. This was also supported by regional studies [16], which reported a similar pattern of awareness in Oman, with smoking being the most recognized risk factor, while only 30% knew the risk associated with physical inactivity [16]. In contrast, obesity and a lack of physical activity are well-known physical carcinogens among adults in Australia (more than 80%) [20].
Age was significantly associated with knowledge about cancer. Older women were more aware of cancer risk factors than younger women. This finding opposes (Ravichandran et al.) and (Ibrahim et al.), whose studies associated younger participants with better knowledge about cancer. Meanwhile, (Sabi et al.) concluded that age was not associated with cancer knowledge and attributed that to the availability of information to all ages through the internet. Higher education level was significantly associated with better cancer awareness. This is supported by (Ravichandran et al.) and (Alazri et al.) and contrasted by (Alghamdi et al.) who interestingly found that participants with higher education exhibited poorer knowledge.
This study was faced by few limitations. Recruitment was performed through convenient sampling by publishing the survey through social media channels, which could limit the generalizability of the results.
This study provides an insight into the level of cancer awareness among Saudi women and possible areas of improvement. In addition, it showed the internet as the preferred method of information delivery. This study could be used as a reference and a roadmap for awareness campaign programs and future national studies to improve the level of awareness and to strengthen screening programs.

Conclusions
The increasing number of cancer cases and the massive burden of cancer on health, society, and healthcare resources make awareness of cancer and carcinogens very important. There was a good level of knowledge among participants about cancer risk factors and environmental carcinogens. These results could help build awareness campaigns and educational programs based on the current knowledge, by targeting less known risk factors for cancer such as oncogenic viruses, physical activity, and obesity. In addition, educational material is best tangible through the internet and social media. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data used to support the findings of study can be available at reasonable request to the corresponding author.