INTRODUCTION:

Cancer is one of the most significant non communicable health problem throughout the world and its prevalence is increasing rapidly.¹ The International Agency for Research on Cancer (IARC), the specialized cancer agency of the World Health Organization estimated that global burden rises to 14.1 million new cases and 8.2 million cancer deaths in 2012. Prevalence estimates for 2012 show that there were 32.6 million people (over the age of 15 years) alive who had had a cancer diagnosed in the previous five years. The most commonly diagnosed cancers worldwide were those of the lung (1.8 million, 13.0% of the total), breast (1.7 million, 11.9%), and colorectal (1.4 million, 9.7%).

The most common causes of cancer death were cancers of the lung (1.6 million, 19.4% of the total), liver (0.8 million, 9.1%), and stomach (0.7 million, 8.8%). Projections based on the GLOBOCAN 2012 estimates predict a substantive increase to 19.3 million new cancer cases per year by 2025, due to growth and ageing of the global population.

More than half of all cancers (56.8%) and cancer deaths (64.9%) in 2012 occurred in less developed regions of the world, and these proportions will increase further by 2025.²

India is experiencing a rapid health transition with a rising burden of non communicable diseases causing significant morbidity and mortality, both in urban and rural population. It is estimated that there are 2 million cancer patients in India with 0.7 million new cases each year.

Cancer is the third greatest cause of death with 0.4 million deaths per annum, and is thus a major public health problem in India.³Facilities for screening and proper management of cancer patients are grossly limited in developing countries and also more than two third of cancer patients are already in advanced and incurable stage at the time of diagnosis.

BACKGROUND OF THE STUDY:

The National Awareness and Early Diagnosis Initiative (NAEDI) consist of several work streams to help ensure delivery of the Cancer Reform Strategy. One of these has focused on developing a validated measure of public awareness of cancer signs and attitudes to help seeking, and benchmarking current levels on a national basis to provide a baseline against which to evaluate policy initiatives designed to improve awareness.⁴

There were so many researchers who have conducted their study in this field. K Robb, Stubbings S, Ramirez A, Macleod U, Austoker J , Waller J etal conducted a population-based survey in adults regarding public awareness of cancer, Britain in the year 2009. Stratified probability sampling was used to select 2216 samples. Results revealed that recall (open question) was good for the classic tumour symptom of lump/swelling (68%), but very poor for all other symptoms (e.g.5% for a sore that does not heal). Overall, men recalled 2.0 (±1.7) signs and women recalled 2.4 (±1.6) (t (2194)¼6.43, Po0.001). Recognition (closed items) gave a considerably higher score than recall. Change in the appearance of a mole and lump/swelling were the most recognised (both 94%), and even the least recognised sign (a sore that does not heal) was acknowledged by over 60% of participants. Women recognised 7.4(±2.0) signs compared with men’s 7.0 (±2.2) (t (2195)¼4.99Po0.001). While participants recognised 7.3 (±2.0) warning signs, while respondents from other ethnic backgrounds recognised 6.2 (±2.9) (t(2195)¼6.22, Po0.001). In relation to age, respondents aged 55–64 years reported the most (7.8±1.7).⁴

S Puri, C Mangat, V Bhatia, A Kaur, Kohlurban D conducted a descriptive cross sectional study to determine the knowledge, attitudes and behaviors regarding common cancers in urban and slum dwellers of Chandigarh in the year 2007. Individuals aged 18 years and above in the study area was selected and the sample size was 1323. Results revealed that about 3/4th of respondents could correctly name the common cancers but the knowledge about preventive modes of cancer was lacking as only 2.5% (23) of urban population and none among slum population knew about Pap smear. None of the respondent could enumerate all the warning symptoms of cancer. 3/4^th (307, 22.7%) of respondents knew about the tobacco as a risk factor for cancer followed by alcohol. There is a great need for increasing the awareness in masses by collaborative action of public health specialists, health professionals and via Information, Education and Communication (IEC) activities. ⁵

Sherin R, Lam K.P, Nair KS, Tiwari VK, Harneet K, Bacchu S conducted a study to assess the level of awareness and knowledge about cancer and associated risk factors among households in selected states of India in the year 2007. In the study 3070 households were interviewed from six states viz, West Bengal, Kerala, Madhya Pradesh, Rajasthan and Mizoram. Results revealed that knowledge of cancers other than those related to tobacco was very low (prostrate 8%, colon 11%) among the communities, with a poor awareness of warning signs and symptoms. The knowledge varied from state to state. It is found that the major source of information related to cancers was television (38%) followed by friends and relatives (36%). In Conclusion, it is important to create awareness among community through educational programs on cancer. ⁶

NEED FOR THE STUDY:

Awat F, Anoshirvan K, Mohsen H, Zohreh P, Jamshid J conducted a cross-sectional interview-based survey aimed at investigating the awareness level about warning signs of cancer and its determinants in an Iranian general population ( sample size 2500) in the year 2013. Results revealed that a small (18.8%) proportion of the respondents had high level of knowledge, and 54.5% had moderate awareness, and 26.7% had low level of awareness. Most effective predictors for awareness were educational attainment, sex, and marital status. ⁷

According to the World Health Organisation (WHO), most cases of cancer are detected only in the advanced stages, when they are untreatable (ICMR, 2004). This is especially true in developing countries. Unfortunately, in developing country like India there is lack of awareness among people about the various risk factors and preventive aspects of these common cancers, like early detection through screening and treatment of precancerous lesions. Awareness of public about warning signs of cancer in relation to early detection and prevention has been surveyed in a few countries, poor knowledge among them³. Education on risk factors, early warning signals and their management are lacking. Cancer screening is not practised in an organized fashion in any part of India (Nair, 2004).

It is well documented that many of these cases of cancer can be tackled to a large extent by simple cost-effective methods that emphasize on primordial, primary and tertiary levels of prevention. The promotion of preventive strategies can be done by giving impetus to public awareness activities and early detection and screening programmes. Many studies done in developed countries shows a strong association between early reporting for detection and treatment in the community. Undoubtedly primary and secondary preventive activities decrease the burden of cancer patients to the hospital and minimize human suffering.

The overall level of knowledge about warning signs of cancer among the public is low, particularly about some specific signs. Accordingly, educational and intervention programmes, with special attention placed on particular at-risk populations, to increase awareness about the disease leading to its early diagnosis are needed. Early detection and immediate treatment is the most effective way to reduce the burden of cancer and improve survival.⁸

STATEMENT OF THE PROBLEM:

Assessment of public awareness of cancer warning signs among rural population, Kochi. Kerala.

PURPOSES OF THE STUDY:

Study assesses the public awareness of cancer warning signs among rural population

OBJECTIVES OF THE STUDY:

1. To assess the public awareness of cancer warning signs among rural population

2. To find association between awareness and selected socio demographic variables

DEFINITION OF TERMS:

· Knowledge: it is the knowledge or skills acquired through experience or study or being taught.

In this study, it is the understanding about the warning signs of cancer through experiences or education.

· Warning signs of cancer: It refers to any signs that inform the danger regarding group of diseases characterized by abnormal growth of cells, ability to invade tissues and distant organs.

In this study, it refers to the understanding of one person regarding the signs and symptoms that may cause cancer.

ASSUMPTIONS:

1. Breast cancer, cervical cancer and skin cancer can be prevented by early identification and reporting signs and symptoms.

2. Attitude towards the prevention are influenced by different variables such as age, education, residential background, type of family and educational status of parents.

RESEARCH METHODOLOGY

Research methodology is a design to develop or refine methods of obtaining, organizing, or analyzing data. Research methods are the steps, procedures, and strategies for gathering and analyzing data in a study.

Research approach

Quantitative approach was adopted for the study.

a) Research design : Non experimental descriptive design

b) Research setting : Njarackal panchayat

c) POPULATION

Target population

General population in Vyeen Block, Kochi.

Accessible population

General population attended medical camp on 29- 11- 2014 organized by the Government of Kerala at Njarackal Panchayat, Vyeen Block. Kochi

d) Sample & Sampling technique

· The sample size was 200.

· Non probability convenience sampling was used.

INCLUSION CRITERIA:

1. Persons who can read and understand Malayalam or English.

2. Persons within the age group of 18-70

EXCLUSION CRITERIA:

1. Persons who are working in the health care sector.

STUDY INSTRUMENT

Tool 1

Section A :

Socio demographic data

This section includes details of patients like age, sex, education, occupation

Section B:

Cancer awareness measure (Standardized questionnaire developed by Cancer Research- United Kingdom)

RESULTS:

In the present study, knowledge of nine possible warning signs of cancer that were reported either in the European Code Against Cancer or by the major cancer organizations was assessed. These warning signs include: (a) changes in bowel or bladder habits; (b) a sore that does not heal; (c) unusual bleeding or discharge; (d) thickening or lump in the breast or elsewhere; (e) obvious change in a wart or mole; (f) nagging cough or hoarseness; (g) unexplained loss of weight; (h) difficulty in swallowing, and (i) indigestion

The most important descriptive findings regarding the demographic characteristics of the respondents (n=200) were as follows: 62.5 % were women; 75% were married 26.5 % had high school education; 24 % had university attainments; 20.5 % had a family history of cancer; 17 % were smokers; and 31 % were alcohol drinkers.

Recall and recognition of cancer warning signs

Recall (open question) was good for the classic tumor symptom of lump/swelling (33.5%), but very poor for all other symptoms (e.g.4% for a sore that does not heal).

Table 1: Demographic characteristics of sample (n=200)

Age	N	%
18 – 37	65	32.5
38 – 57	113	56.5
> 58	22	11
Sex
Female	125	62.5
Male	75	37.5
Marital status
Married	188	94
Not married	12	6
Area of residence
Rural	192	96
Urban	8	4
Occupation
Employed/ Pensioner	102	51
Unemployed / Retired	98	49
Family history of cancer
Yes	41	20.5
No	158	79
Habit of smoking
Yes	34	17
No	166	83
Habit of alcohol drinking
Yes	62	31
No	138	69
Education
Primary	47	11.75
High school	105	52.5
University attainment	48	24

Recognition (closed items) gave a considerably higher score than recall. Unexplained pain (95%) and lump/swelling (80.5%) were the most recognized (both 94%), and even the least recognized sign (a sore that does not heal) was acknowledged by over 29% of participants.

Barriers to help seeking

The most widely endorsed barriers to consultation were economical problems 124(62%) difficulty, worry about what the doctor might find 113(56.5%), too scared 96(48%) and embarrassed 94(47%).

Table 2: Barriers to seeking Medical helps

	N	%
Too embarrassed	94	47
Too scared	96	48
Worried about wasting doctor’s time	14	7
Difficult to talk to doctor	12	6
Difficult to make appointment	6	3
Too busy	19	9.5
Other things to worry about	75	37.5
Worried what doctor might find	113	56.5
Not confident to talk about symptom	13	6.5
Economical problems	124	62

Table 3: Percentage saying that participants contact the doctor in < 1 week for each warning sign

Warning signs	N	%
Lump or swelling	97	48.5
Unexplained pain	72	36
Unexplained bleeding	129	64.5
Cough or hoarseness	89	44.5
Change in bowel/bladder habits	113	56.5
Difficulty swallowing	124	62
Change in appearance of a mole	84	42
Sore that does not heal	78	39
Unexplained weight loss	82	41

Anticipated delay:

The majority of respondents indicated that they would seek medical help in < 2week for most symptoms.

Association between awareness and socio demographic variables:

There is significant association between awareness on cancer warning signs with age (38-57). (x² (1) =10.407, p=0.034.), highest education group (x² (1) =15.843, p=0.003), participants with no history of smoking (x² (1) =6.698 (p=0.035) and alcoholism (x² (1) =14.526, p=0.001). There is no significant association between awareness on cancer warning signs and other demographic variables.

DISCUSSION:

Recall (open question) was good for the classic tumor symptom of lump/swelling (33.5%), but very poor for all other symptoms (e.g.4% for a sore that does not heal). Recognition (closed items) gave a considerably higher score than recall. Unexplained pain (95%) and lump/swelling (80.5%) were the most recognized (both 94%), and even the least recognized sign (a sore that does not heal) was acknowledged by over 29% of participants.

K Robb (2009) in their study which recruited 2216 participants from Britain found that Cancer warning signs using an open question was relatively poor (<30%) for all symptoms except ‘lump/swelling’ which was mentioned by 68% of respondents. Recognition of cancer warning signs with a closed question was much higher, with ‘mole’ and ‘lump/swelling’ being identified by over 90% of participants.

Recognition scores would be greater than recall scores (Waller et al, 2004), but it is difficult to determine which better captures the concept of cancer awareness. Recall underestimates awareness because it is limited by memory, while recognition overestimates awareness because participants find it easy to guess. A study in Iran conducted by Awat F found that a small (18.8%) proportion of the respondents had high level of knowledge, and 54.5% had moderate awareness, and 26.7% had low level of awareness regarding cancer warning signs. Most effective predictors for awareness were educational attainment, sex, and marital status.

None of the respondents knew all the warning signs of cancer. The similar result was found in the study conducted in Chandigarh by S Puri. In India the common cancer in females is Cancer of breast. In the present study, it was interesting that almost 55 % and 60% of respondents could correctly name the commonest cancer to be the breast cancer in females and lung cancer in males, similar findings were evident in study done in Britain. ⁹

The majority of respondents indicated that they would seek medical help in < 2week for most symptoms. K Robb identified that the majority of respondents indicated that they would seek

Medical help in <2 weeks for most symptoms. The relationship between anticipated delay and age was examined by looking at the total number of symptoms for which respondents would wait 2 weeks or more before seeking help. The youngest age group and the oldest group reported the lowest anticipated delay (16–24 years: 3.90±2.71 and 65 years: 3.77±2.67).

Being worried about what the doctor might find was the most commonly endorsed emotional barrier to prompt help seeking, which is in line with previous work citing fear and fatalism as barriers to cancer-protective behaviors (Powe, 1995; Aro et al, 2001; Lostao et al, 2001; Subramanian et al, 2004). But it was also notable that almost 62% of people concerned about ‘economy’ 56.5% worried about ‘what doctors might find’ could make them delay presentation.

REFERENCES:

1. K Park. Text book of Preventive and Social Medicine, 21^st edition, Banassidus Publishers, 2010.Pp :561-570.

2. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F (2013). GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer. Available from http://globocan.iarc.fr

3. National Centre for Disease informatics and Research. National Cancer Registry Programme. Consolidated Report of Hospital based cancer Registries: 2007 – 2011.NCDIR- NCRP (Indian Council of Medical Research). Bangalore, India. Sep 2013.

4. K Robb, S Stubbings, A Ramirez, U Macleod, J Austoker, J Waller, S Hiom and J Wardle. Public awareness of cancer in Britain: a population-based survey of adults. British Journal of Cancer (2009) 101, Pp18 – 23.

5. S Puri, C Mangat, V Bhatia, A Kaur, D Kohli. Knowledge of cancer and its risk factors in Chandigarh, India. The Internet Journal of Epidemiology. 2009 Volume 8 Number 1.

6. Sherin R, Lam K.P, Nair KS, Tiwari VK, Harneet K, Bacchu S. Assess the level of awareness and knowledge about cancer and associated risk factors among households in selected states of India. Asian pacific journal of cancer prevention ,13, Pp: 4057-62.

7. Awat Feizi, Anoshirvan Kazemnejad, Mohsen Hosseini, Zohreh Parsa-yekta, and Jamshid Jamali. Assessing Awareness Level about Warning Signs of Cancer and its Determinants in an Iranian General Population. J Health Popul Nutr. Dec 2011; 29(6): 656–659.

8. Aswathy Sreedevi, Mariya Amin Quereshi, Beteena Kurian, Leelamoni Kamalamma. Screening for breast cancer in a low middle income country: predictors in a rural area of kerala, India. Asian Pac J Cancer Prev, 15 (5), 1919-1924.

9. J Wardle, J Walker, N. Brunswick, Awareness of risk factors for cancer among British adults. Public Health. 2001; 115:173-74

Received on 05.06.2015 Modified on 28.06.2015

Int. J. Adv. Nur. Management 3(3): July- Sept. 2015; Page 253-258

DOI: 10.5958/2454-2652.2015.00012.8

Assessment of Public Awareness of Cancer Warning Signs among

Rural Population, Kochi. Kerala.

7. Awat Feizi, Anoshirvan Kazemnejad, Mohsen Hosseini, Zohreh Parsa-yekta, and Jamshid Jamali. Assessing Awareness Level about Warning Signs of Cancer and its Determinants in an Iranian General Population. J Health Popul Nutr. Dec 2011; 29(6): 656–659.