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An exploration of public knowledge of warning signs for cancer
European Journal of Oncology Nursing 15 (2011) 31e37
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European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
An exploration of public knowledge of warning signs for cancer Sinead Keeney a, *, Hugh McKenna b, Paul Fleming b, Sonja McIlfatrick a a b
Institute of Nursing Research, School of Nursing, University of Ulster, Shore Road, Newtownabbey, Co. Antrim, BT37 0QB, UK Faculty of Life and Health Sciences, University of Ulster, UK
a b s t r a c t Keywords: Cancer Prevention Warning signs Knowledge
Background: Warning signs of cancer have long been used as an effective way to summarise and communicate early indications of cancer to the public. Given the increasing global burden of cancer, the communication of these warning signs to the public is more important than ever before. Aim: This paper presents part of a larger study which explored the attitudes, knowledge and behaviours of people in mid-life towards cancer prevention. The focus of this paper is on the assessment of the knowledge of members of the public aged between 35 and 54 years of age. Method: A questionnaire was administered to a representative sample of the population listing 17 warning signs of cancer. These included the correct warning signs and distracter signs. Respondents were asked to correctly identify the seven warning signs. Results: Findings show that respondents could identify 4.8 cancer warning signs correctly. Analysis by demographics shows that being female, being older, having a higher level of educational attainment and being in a higher socio-economic group are predictors of better level of knowledge of cancer warning signs. Recommendations: Recommendations are proffered with regard to better targeting, clarification and communication of cancer warning signs. Ó 2010 Elsevier Ltd. All rights reserved.
Introduction The high prevalence of cancer is demonstrated by the fact that more than 11 million people worldwide are diagnosed with cancer each year. It is estimated that by the year 2030 cancer will account for 12 million deaths annually (WHO, 2009). It is acknowledged that survival from many types of cancer is significantly improved if treatment is started at an early stage and early detection depends partly on people having the knowledge to recognise the warning signs (DH, 2000; Cancer Research UK, 2004, 2006). The warning signs of cancer have been considered an effective way to summarise early signs of cancer into a usable and memorable communication to the public (Cancer Research UK, 2006; DH, 2000). However, there has been no universal agreement on what should be included in this list of early warning signs. The implications have not been explored but it is apparent that this could be confusing for the public considering even the experts cannot agree on what should be included! The original seven warning signs of cancer adopted by the National Cancer Institute is the list that researchers in the UK have used to explore people’s knowledge of
* Corresponding author. Tel.: þ44 28 90368463; fax: þ44 28 90368202. E-mail address: [email protected] (S. Keeney). 1462-3889/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2010.05.007
cancer warning signs (Wardle et al., 2001; Brunswick et al., 2001; Waller et al., 2004). These signs are outlined in Fig. 1. Background It is clear from the existing literature that many international research studies have explored the public’s general knowledge of the signs and symptoms of cancer. However, only one previous study has been undertaken in the UK. Most studies exploring knowledge of cancer warning signs and symptoms focused on a specific type of cancer and do not facilitate comparisons between studies or across types of cancers. General knowledge about cancer warning signs The majority of studies exploring public knowledge of cancer in general have highlighted the low level of cancer knowledge. Over the last decade, US studies reflect this trend (Bostick et al., 1993; Katz et al., 1995; Nichols et al., 1996; Breslow et al., 1997). Other international studies showed a similar pattern (Hancock et al., 1996; Fitch et al., 1997; Paul et al., 2003). The single UK study focusing on cancer knowledge of the general public reflected the findings of the US studies. It notes the low and worrying level of cancer knowledge among the general public (Wardle et al., 2001).
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Fig. 1. Original seven warning signs of cancer.
Only one study carried out in Spain (Rebello-Palencia et al., 1996) uncovered findings at variance with those of other studies in the field. The researchers posited no reasons for the contrasting findings. Bostick et al.’s (1993) US study with 4915 randomly selected members of the public determined that while four fifths of the participants believed that cancer was preventable, their knowledge of cancer warning signs and symptoms was low. Thirteen percent could not identify even one of the seven warning signs of cancer. Findings also indicated that women were able to list more warning signs than men. Brunswick et al. (2001) carried out a UK interviewbased study with 3693 randomly selected members of the public. They supported Bostick et al.’s findings showing that women were more likely than men to identify five or more warning signs correctly. In both studies the most commonly recognised symptom of cancer was ‘a thickening or a lump’. It is interesting and perhaps alarming to note that these two studies were carried out eight years apart in different countries yet the levels of knowledge had not improved. Brusnwick et al. showed that only 1.6% (n ¼ 58) of the sample identified all seven warning signs. On average, participants could identify four of the seven signs. Several years after Bostick et al.’s (1993) work, Nichols et al. (1996) undertook a small pilot study with 172 members of the public in the US. They aimed to evaluate knowledge of cancer prevention. Again, participants were asked to identify the seven warning signs. The average number of correctly identified warning signs was three but 19% (n ¼ 33) of the sample could not identify any. Nichols et al. (1996) asserted that the level of knowledge among this small, well educated and moderate to high-income sample was “appalling” (p. 103). However, it is important to note that this was a small pilot study and that the findings may not be representative. This is acknowledged by the authors who indicate the need for a replication with a larger, culturally diverse, representative sample. In Australia, Paul et al. (2003) undertook a cross-sectional telephone survey to assess the public’s awareness and knowledge of cancer. This study part-replicated a previous Australian study (Clover et al., 1989). The intention was to compare the results of both studies to assess any shift in knowledge in the intervening 11 years. The sample was made up of 685 residents living in New South Wales. Knowledge of risk factors for colorectal and cervical cancer was poor. When compared with the results of Clover et al.’s study, there appeared to be some improvements in knowledge and awareness of cancer risks: in particular, knowledge of mammograms as a screening test for breast cancer had improved. Nonetheless, for other cancers, any gain in knowledge or awareness appeared minimal. Paul et al. asserted that while improvements in
knowledge have been made in some areas (breast cancer), major challenges exist for other cancers. There is an obvious debate about the way that knowledge and awareness has been measured (Waller et al., 2004). It appears from these Australian studies that regardless of whether a list of signs or risk factors was used as opposed to unprompted recall, levels of knowledge and awareness remain low. While there are few European or Asian research studies published in English that assessed the level of knowledge and awareness of cancer, the findings of these are interesting. Cetingoz et al. (2002) carried out a study in Turkey to assess the public’s knowledge and attitudes to cancer prevention and treatment. A questionnaire consisting of 24 questions was administered to a sample of 630 respondents to determine their knowledge and attitudes to cancer. Results showed that 78% (n ¼ 491) of the respondents had little knowledge of cancer. This is consistent with the findings from Wardle et al. (2001) UK study. Ninety-eight percent (n ¼ 617) of the respondents in Cetingoz et al’s study wanted to improve their knowledge of cancer and 74% (n ¼ 466) thought that this should be done through “television programs or public seminars” (p.56). Rebello-Palencia et al. (1996) undertook a study in Spain to assess the knowledge and attitudes that patients at a health centre had of cancer risks and cancer prevention. A questionnaire was administered to a non-probability sample of 400 people aged between 14 and 75. Findings showed that respondents had a good understanding of cancer risk factors and prevention. Overall Rebello-Palencia et al’s findings contrast with those of other international studies. The researchers provide no explanation for these atypical findings. Perhaps one possible explanation is that the sample was obtained from people attending a health centre. This could suggest that they are more interested, informed or pro-active about their health than those who would not attend health centres. Another reason could be that the local health authority may have recently launched a cancer prevention campaign. Knowledge of risk factors Knowledge of risk factors for cancer has been explored by a number of researchers internationally. Level of knowledge and awareness of the public was found to be low in studies that explored specific cancer risk factors such as diet (Breslow et al., 1997), multiple sexual partners (Breslow et al., 1997) and family history (Wardle et al., 2001). While age is a risk factor for a number of cancers (NCI, 2004), this is not widely known by the general public (Fitch et al., 1997; Breslow et al., 1997; Wardle et al., 2001). Fitch et al.’s (1997) Canadian study examined the knowledge level of adults in an urban community. They used a convenience sample of 513 adults over the age of 55. A self-report questionnaire was
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administered focusing on their knowledge about cancer, language group and the length of time they had lived in the country. The main finding indicated that 66% (n ¼ 339) of the sample did not consider age to be a risk factor for cancer. Results also showed that even though the questionnaire was administered in each participant’s native language, non-English speakers were less knowledgeable about cancer. It should be noted that 68% (n ¼ 349) of the sample came from countries other than Canada and as such this sample had a large proportion of people who may not have been exposed to Canadian cancer prevention strategies for any significant length of time. In the US, Breslow et al. (1997) undertook a large study to examine the public’s knowledge of cancer risks and survival. Data were used from 12,035 respondents who had completed the 1992 National Health Interview Cancer Control Supplement. This survey included questions about cancer risk factors and most respondents could not identify them. Two-thirds did not recognise that age was a risk factor for breast and colon cancer, that diet was a risk factor for colon cancer or that multiple sexual partners was a risk factor for cervical cancer. In the UK, Wardle et al. (2001) asked participants to identify risk factors for breast, cervical, prostate, colorectal and lung cancer from a list of 14 factors which included “established causes” such as older age, low fibre diet, smoking and being overweight and “mythic causes” such as food additives, pollution and stress (p. 173). Older age was not widely recognised as being a risk factor and neither was family history. Overall, the average number of risk factors identified correctly was five out of 15. The authors also reported that “endorsement of mythic causes was comparatively low, less than 5%, but were higher in men and those with less education” (p. 173). In this case mythic causes were food additives, overhead power cables, pollution and stress. Ethnic minorities knowledge of cancer warning signs There have been many studies undertaken in the US and Canada exploring the cancer knowledge and attitudes of different minority ethnic groups (Breslow et al., 1997; Shankar and Figueroa-Valles, 1999; Mishra et al., 2000; Coronado and Thompson, 2000; Ratnasinghe et al., 1999; Ma and Fleisher, 2003). With the exception of one more recent study (Paisley et al., 2002), all others concluded that the level of knowledge and awareness of cancer of the specific ethnic group studied was poor (Breslow et al., 1997; Coronado and Thompson, 2000; Ratnasinghe et al., 1999). Findings showed that minority ethnic groups often had misconceptions about cancer risk and prevention (Shankar and Figueroa-Valles, 1999; Mishra et al., 2000), a fatalistic attitude to cancer (Coronado and Thompson, 2000), inadequate knowledge about cancer warning signs (Shankar and Figueroa-Valles, 1999; Ratnasinghe et al., 1999) and a low level of awareness of cancer prevention (Ma and Fleisher, 2003). These findings highlight the different cultural aspects of cancer awareness and knowledge that should be taken into account when targeting cancer prevention education and information to minority ethnic groups. Summary With the exception of the one study alluded to above (RebelloPalencia et al., 1996), the conclusions from the main body of research have remained the same. Researchers all concluded that it is important to provide up-to-date, appropriate and culturally sensitive information on cancer to specific social or ethnic groups (Shankar and Figueroa-Valles, 1999; Mishra et al., 2000;
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Ratnasinghe et al., 1999; Ma and Fleisher, 2003). In relation to Hispanics specifically, Breslow et al. (1997) concluded that the current health provision was insufficient and that this remained a challenge to the public health services. In Turkey, researchers concluded that the basic level of cancer knowledge must be improved and that more appropriate information must be targeted to the general public (Cetingoz et al., 2002). These assertions have been echoed in Australia (Hancock et al., 1996; Paul et al., 2003) and the US (Bostick et al., 1993; Nichols et al., 1996; Breslow et al, 1997). The Study Why this age group? Evidence shows that more than three-quarters of deaths from cancer occur in people aged 65 years or over (Cancer Research UK, 2006). In the younger age groups, although there are fewer deaths from cancer, proportionally cancer is even more important as a cause of death. In adults under the age of 65, more than 1 in 3 deaths (37%) are attributable to cancer (Cancer Research UK, 2006). When the statistics are broken down by gender, the proportion rises even higher for women with almost 1 in every 2 deaths (47%) caused by cancer in adult women under 65. In the year 2002, 38,273 people between the ages of 35 to 54 were diagnosed with cancer in the UK. This accounted for 13% of all cancer diagnoses in that year. The latest figures for Northern Ireland show that the incidence of cancer was 11,419 cases for people aged 35e54 over the period 1993e2001 (NICR, 2006). Methodology For the part of the study being described in this paper, a questionnaire was administered to a representative sample of the population listing 17 warning signs of cancer. These included the correct warning signs and misleading distracter signs. Respondents were asked to correctly identify the seven warning signs of cancer. Sampling The inclusion criteria for the study dictated that participants should be aged between 35 and 54 years of age at the time of the study. The exclusion criteria stated that participants must not have had a past diagnosis or a current diagnosis of cancer. The rationale for excluding people with a past or present diagnosis of cancer centered on the belief that they would have an elevated knowledge of cancer. Furthermore, it was felt that their attitudes and behaviours would differ from a member of the public who did not have or previously had a cancer diagnosis. Despite much exploration, there was no possible way to gain access to the ages of members of the public in order to target the age group for the study. Therefore it was decided that all age groups would be targeted and that those within the age group for the present study would be used. Funding has subsequently been gained to analyse the data from the returned questionnaires from other age groups. The Edited Electoral Register for Northern Ireland was used to sample the population. The edited version of the electoral register is available for purchase in Northern Ireland to use for research purposes (see http://www.eoni.org.uk/index/electoral-register.htm for further information). One rural and one urban district were selected from each of the four Health and Social Services Board area within Northern Ireland. Each district was then split into wards using the Electoral Register. The numbers of people in each ward was expressed as a percentage of the total population of voters in that district. This was to ensure a representative spread. Equal numbers of men and women were selected within each ward.
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In total 5000 questionnaires were posted to members of the public. It was anticipated that the response rate would be lower than 50% as is common in postal questionnaires to the public. A total of 2350 usable questionnaires were returned representing a response rate of 47% which is considered above average for unsolicited questionnaires mailed to the public. In total, 1067 of the returned questionnaire where within the age group 35e54 years and were used for this study. Two rounds of follow up postcards were sent to participants to enhance the response rate. This comprises a representative sample at a confidence level of 95% and a confidence interval of 3. The questionnaire From a list of 17 possible warning signs, respondents were asked to identify the seven warning signs of cancer (See Fig. 2). Pilot study A pilot study was undertaken to test the questionnaire during which 150 questionnaires were distributed to a random selection of people chosen from the edited electoral register. In total, 70 questionnaires were returned, giving a response rate of 47%. Minor wording changes were made before questionnaire administration to the main study sample.
Administration of the survey A cover letter was designed to accompany the questionnaire explaining the purpose of the study and how the person’s name and address had been accessed. The researchers’ names and contact details were also put on the letter for respondents to contact if they felt that they required more information. A section was included in the letter asking respondents not to complete the questionnaire if they had cancer or had ever had a cancer diagnosis. The reason for this was because people with a past or present diagnosis of cancer may a higher level of knowledge and awareness than those people who have never been diagnosed with cancer. The questionnaires were posted over a ten-day period. Follow up reminder postcards were distributed one week before the return date and one week after the return date. Data analysis The data from the questionnaires were entered into SPSS. Descriptive statistics were used to analyse demographics and socioeconomic information. Non-parametric statistics (ManneWhitney U and Kruskal Wallis) were used to explore the relationship between each demographic and knowledge of warning signs. Logistic regression was used to explore the influence of demographics on knowledge of cancer warning signs. For the purposes of this procedure, the ‘knowledge of warning signs’ variable was dicotomised using a median split into high (five or more warning signs identified correctly) and low (less than five signs identified correctly). Ethical approval Ethical approval was granted for this study by the University of Ulster Research Ethics Committee for research being undertaken with healthy volunteers. Anonymity and confidentiality were assured and the return of the completed questionnaire was taken to indicate consent.
Results
Fig. 2. List of warning signs and distracter signs included in the questionnaire.
The demographic profile of the sample is outlined in Table 1. The average number of warning signs identified correctly for this sample was 4.8. On average, female respondents identified 5 signs correctly and male respondents 4.4 signs correctly. The average number of warning signs correct for the younger age band (35e44) was 4.7 and for the older age band (45e54) was 4.9. Findings show that the number of correctly identified warning signs increases from the younger age band of 35e44 to the older age band of 45e54 (p < 0.01). This suggests that the older age group has a higher awareness of cancer warning signs. In relation to gender, women can identify correctly more warning signs than men (p < 0.01). Furthermore, respondents with a higher level of education were able to correctly identify more warning signs (p < 0.01). When housewives/househusbands were excluded from the analysis, respondents with a higher income can identify more cancer warning signs correctly (p < 0.01). Higher socio-economic status is also associated significantly with better knowledge of cancer warning signs (p < 0.05). The socio-economic status variable was organised into five categories e professional, employers/ managers, intermediate/junior non-manual, skilled manual, unskilled. Unskilled includes housewives and househusbands. Excluding them from the sample increases the significance of the association (p < 0.01). This suggests that housewives/househusbands knowledge of cancer warning signs is higher than that of other unskilled respondents.
S. Keeney et al. / European Journal of Oncology Nursing 15 (2011) 31e37 Table 1 Sample demographics. Demographic groups
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Table 2 Signs identified as warning signs (by %). Number of respondents
Percentage of sample
Age 35-44 45-54
600 467
56.2 43.8
Gender Male Female
415 652
38.9 61.1
Level of education attained Primary school GCSE/O’level A-level Degree Masters/PhD
70 476 161 276 83
6.6 44.6 15.1 25.9 7.7
Annual personal gross income 0e£10,000 £10,000e£20,000 £20,001e£30,000 £30,001e£40,000 £40,001e£50,000 £50,001 þ
305 299 239 152 32 39
28.6 28 22.4 14.2 3 3.7
Socio-economic status Professional Employers/managers Intermediate/junior low manual Skilled manual Semi-skilled Unskilled
314 163 217
29.4 15.3 20.3
162 16 172
15.2 1.5% 16.1
Country of birth Northern Ireland Outside Northern Ireland
951 116
89.1 10.9
Marital status Single Married/living together Divorced/separated/widowed
132 844 91
12.4 79.1 8.5
Housing tenure Rented/other persons home Owner occupied
117 950
11 89
Residential environment Urban Rural
559 508
52.4 47.6
Table 2 shows percentages of warning signs identified correctly and distracter signs identified incorrectly by the sample and by gender. It is clear from Table 2 that the most recognised sign was a change in a wart or mole, closely followed by a thickening or lump on the body, unexplained weight loss and a change in bowel or bladder habits. All these signs were recognised by over 90% of respondents but by more women than men. A sore that does not heal was recognised by just over half of the sample (51%) but the most poorly recognised warning sign was indigestion or difficulty swallowing which was recognised by only 30% of the sample. Interestingly, this was the only warning sign identified more by men than by women. Women were more likely than men to identify warning signs such as unusual bleeding or discharge (p < 0.01), a change in bowel or bladder habits (p < 0.01), a change in a wart or mole (p < 0.01) and a nagging cough or hoarseness (p < 0.01). Older respondents (aged 45e54) were more likely to identify warning signs such as indigestion or difficulty swallowing (p < 0.01), nagging cough or hoarseness (p < 0.01) and a sore that does not heal (p < 0.01). Those respondents with a higher level of educational attainment were more likely to identify warning signs such as unusual bleeding or discharge (p < 0.01), a change in a wart or mole (p < 0.01) and unexplained weight loss (p < 0.05).
All (%)
Women (%)
Men (%)
Warning signs Unusual bleeding or discharge Indigestion or difficulty swallowing A change in bowel or bladder habits A change in a wart or mole Nagging cough or hoarseness Thickening or lump on body A sore that does not heal Unexplained weight loss
86 30 90 95 35 94 51 91
77 33 84 87 24 94 48 91
92 28 95 99 42 94 53 91
Distracter signs Tiredness Poor appetite Bleeding gums Numbness in parts of your body Nausea or upset stomach Feeling weak in parts of your body Headaches Sore muscles Pain in your heart or chest
29 25 15 11 10 10 8 3 2
33 27 12 17 14 17 7 7 4
28 23 16 8 7 8 8 1 1
Younger respondents (aged 35e44) were more likely to identify incorrectly warning signs such as tiredness (p < 0.01), numbness in parts of your body (p < 0.01), feeling weak in parts of your body (p < 0.05), headaches (0 < 0.01) and unexplained weight loss (p < 0.01). Men were more likely than women to identify incorrectly warning signs such as numbness in parts of your body (p < 0.01), nausea or upset stomach (p < 0.01), feeling weak in parts of your body (p < 0.01), sore muscles (p < 0.01) or pain in your heart or chest (p < 0.05). Those with a lower level of educational attainment were more likely to identify incorrectly warning signs such as poor appetite, nausea or upset stomach and feeling weak in parts of your body (p < 0.01). Logistic regression was used to assess the association of the demographic variables with knowledge of cancer warning signs. The dependant variable was dicotomised into high and low level of knowledge of cancer warning signs with high being correctly identifying five or more signs from the cancer warning signs list within the questionnaire (Table 3). From the table above it is clear that knowledge of cancer warning signs has a significant relationship with age, gender, level of educational attainment, socio-economic status, income, marital status and type of accommodation. Discussion This study aimed to assess the level of knowledge of cancer warning signs among members of the public aged between 35 and 54 years (mid-life). The cancer warning signs can be seen at Fig. 2 with the addition of an eighth sign ‘unexplained weight loss’ which has been included in various different lists of warning signs over recent years. There is clear evidence from this study that there is a low level of knowledge of cancer warning signs among people in mid-life. This reflects the UK findings of Brunswick et al.’s (2001) study. Theirs was the first study to be undertaken in Europe in this area. It used a sample of 3693 men and women aged 18 years and above. Their findings, broken down into different age bands, show that there is a higher level of knowledge among people in mid-life. However, from the present study it is clear that the level of knowledge for this age grouping is also low. This is a major cause of concern in relation to cancer prevention and the recognition of warning signs. These findings are reflective of many published international and national research studies in this area (Bostick et al., 1993; Katz et al., 1995;
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Table 3 Logistic regression of knowledge of warning signs with demographics. Demographic Groups
N
Odds ratio
95% CI
Gender Male Female
415 652
1.0 2.2
1.7e2.8
Age 35e44 years 45e54 years
600 467
1.0 1.7
1.4e2.3
Marital status Married Single Living with partner Divorced/separated Widowed
801 132 43 81 10
1.0 0.42 0.32 0.43 0.73
0.1e1.6 0.1e1.2 0.1e1.6 0.2e3.9
Socio-economic group Professional Employers/managers
314 163
2.7 2.9
0.6e4.9 1.0e8.3
Intermediate/junior Low-manual Skilled manual Unskilled
217 162 23
2.0 1.9 1.0
0.7e5.6 0.7e5.3 0.5e4.2
Income Low Moderate High
305 538 224
1.0 1.2 1.3
0.8e1.7 0.9e1.8
Educational attainment Primary school Secondary school Third level
70 637 360
1.0 1.2 5.5
0.9e1.6 3.2e9.6
Tenure Rented accommodation Owner occupier
84 950
1.0 2.0
1.3e3.1
Location Rural Urban
508 559
1.0 1.0
0.7e1.3
Country of birth Outside NI NI
115 952
1.0 1.2
0.8e1.9
Hancock et al., 1996; Nichols et al., 1996; Mishra et al., 2000; Fitch et al., 1997; Paul et al., 2003). There was only one study undertaken in Spain which uncovered findings that were at variance to other research studies in the field (Rebello-Palencia et al., 1996). Evidence from this study also shows that the level of knowledge is lower within specific population sub-groups such as those with a lower level of educational attainment, a lower socio-economic status, men and those who are not married/single. This evidence supports findings from previous studies in which demographics have been demonstrated to have an effect on knowledge of cancer and cancer warning signs including level of education (Wardle et al., 2001; Cetingoz et al., 2002; Huisman et al., 2005; Wetter et al., 2005) and gender (Wardle et al., 2001; Kiekbusch et al., 2000; Wetter et al., 2005; Katz et al., 1995). Findings from the present study also shows that age also affects knowledge as the lower age group displayed a lower level of knowledge than the higher band. When housewives/househusbands were excluded from the analysis those with a higher socio-economic status (SES) showed that their knowledge is better than their counterparts in the unskilled SES category. Further evidence shows that a higher level of knowledge is also associated with owing your own home, which is in keeping with the findings regarding the effect of SES. These SES findings echo those of other international studies (Weinrich et al., 1992; Price and Everett, 1994; Brunswick et al., 2001). Findings demonstrate that there are differences in the identification of warning signs of cancer between genders, age bands, level
of educational attainment and SES. The most identified warning sign was ‘a change in a wart or mole’, followed closely by ‘thickening or lump on body’, ‘unexplained weight loss’ and ‘a change in bowel or bladder habits’. A ‘thickening or lump on the body’ has been well recognised by the public for some years and has been attributed to high profile and ongoing media campaigns for testicular and breast cancer (Bostick et al., 1993; Nichols et al., 1996; Paul et al., 2003). The identification by a high percentage of the sample of ‘unexplained weight loss’ as a cancer warning sign is worthy of note. The inclusion or exclusion of this warning sign from various lists does not appear to have had much effect on its identification as a warning sign by the public. It was the second most recognised sign in Brunswick et al’s (2001) study five years ago and is the third most recognised sign among the present study. Brunswick et al. suggested that the recognition of this sign is possibly less to do with its publication in various lists of warning signs and more to do with the public’s perception of cancer as a “wasting disease” (p. 36). The danger with unexplained weight loss being recognised as a cancer warning sign is that people could overlook another sign of cancer because it was not accompanied by weight loss. Perhaps further education on the importance of unexplained weight loss needs to be communicated. Poorly recognised signs included ‘indigestion or difficulty swallowing’, ‘a nagging cough or hoarseness’ and ‘a sore that does not heal’. Misconceptions about cancer warning signs emerged as ‘tiredness’, ‘poor appetite’ and ‘bleeding gums’. Brunswick et al’s (2001) study also showed that ‘indigestion or difficulty swallowing’ was poorly recognised. The level of recognition of this sign does not appear to have increased in the five intervening years between these studies. Further exploration of the reasons for this may be required. The present study highlights the low level of knowledge and negative attitudes held by men and especially single men/not married. Men who are single/not married have the lowest level of knowledge and awareness of cancer warning signs in this sample. These findings suggest that information and education needs to be targeted at single men. Brunswick et al. (2001) also suggested that single men should be a priority area for cancer prevention. The findings of the present study show that the knowledge of single, unmarried men has not improved in the intervening years. It should be stressed that if members of the public were aware of all the cancer warning signs, this does not mean that their prevention behaviours will change dramatically. For instance, most of the population is aware that smoking causes cancer but a significant proportion continues to smoke. The researchers are aware of this but note Cancer Research UK’s assertion that being aware of cancer warning signs can help early detection. Limitations The use of the Edited Electoral Register for Northern Ireland was the result of a long and protracted search for an effective method of access to the home contact details of members of the public. This is a notoriously difficult task, as individuals must have given their consent for their home address to be used for research purposes. This is implied when individuals over the age of 18 in Northern Ireland allow their name and home address to be placed on the edited register. The limitation associated with the edited register is that it only holds the names and address of 60% of the Northern Ireland population and the ages of these people. However, as there are no significant trends identified in the type of person who allows their name and address to be used therefore this was considered the most appropriate method of access available. Considering also that at the outset the study was intending to focus on a specific age group (35e54 years), it became apparent
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quickly that identifying a specific age group of members of the public was going to be difficult. Having discussed this at length with the funder, it was agreed that all age groups would be targeted and further funding agreed for the analysis and write up of all age groups. The issue of collecting data from age groups outside the main study age group was detailed in the ethical application. It was made explicit that this data would be analysed and written up for the funder and public consumption. Support information was also provided to every participant about cancer and cancer prevention including the free helpline number of a large cancer charity in Northern Ireland in case of distress caused by participation in the study. This data is of utmost importance in the targeting of cancer prevention information to the different age groups. In retrospect, perhaps a more effective way of targeting a specific age group would be to use telephone interviews. This can be an expensive method of recruitment and funding needs to be obtained appropriately. Additionally, the use of surveys in social science research will always incur several limitations. Self-report surveys rely on people completing the questionnaire themselves and truthfully. Furthermore, it must be acknowledged that the responses are the opinions of a sample of individuals at any one given time. However, the fact that the findings of the study concur, on the whole, with other studies conducted in the area gives credence to the method and findings of the study.
Conclusions This paper has focused on the knowledge of people in this age group of cancer warning signs. Priority groups have been identified as single men and those people in a low socio-economic group due to the low levels of knowledge that they exhibit. These groups are in need of targeted information and education to help them with the early detection and prevention of cancer. In conclusion, the outcomes from this study should be used to inform policy and identify strategies to enhance the cancer prevention knowledge and actions in this population. In turn, it is anticipated that this will have an impact on cancer deaths and diagnoses in the future.
Recommendations There are several recommendations arising from this part of the study. A strategy should be developed to raise this population’s knowledge of cancer warning signs to promote recognition of early signs of cancer. Further exploratory research should be undertaken into the reasons why housewives and househusbands have an elevated level of knowledge of cancer warning signs. Consideration should be given to targeting sub-groups with information on cancer warning signs in different ways and formats based on the data available from this study. The level of importance of the cancer warning sign ‘unexplained weight loss’ should be clarified and communicated to the public. Single, unmarried men in this age group should be a priority for the targeting of information and education on the warning signs of cancer. A clear, concise message of the warning signs of cancer should be communicated to all men in this age group with the immediate priority being single men.
37
Conflict of interest The authors confirm that there are no conflicts of interest with regard to this paper. Funding The study was funded by Ulster Cancer Foundation. References Bostick, R.M., Sprafka, J.M., Virnig, B.A., Potter, J.D., 1993. Knowledge, attitudes and personal practices regarding prevention and early detection of cancer. Preventive Medicine 22, 65e85. Breslow, R.A., Sorkin, J.D., Frey, C.M., Kessler, L.G., 1997. Americans’ knowledge of cancer risk and survival. Preventive Medicine 26, 170e171. Brunswick, N., Wardle, J., Jarvis, M.J., 2001. Public awareness of warning signs for cancer in Britain. Cancer: Causes and Control 12 (1), 33e37. Cancer Research UK, 2004. Incidence e UK (February 2004). http://www. cancerresearchuk.co.uk. Cancer Research UK, 2006. Cancer Statistics. http://www.cancerresearchuk.org/ aboutcancer/statistics/. Cetingoz, R., Kentli, S., Uruk, O., Demirtas, E., Eyiler, F., Kinay, M., 2002. Turkish people’s knowledge of cancer and attitudes toward prevention and treatment Journal of Cancer Education Spring 17 (1), 55e58. Clover, K., Redman, S., Boyle, K., Wiggers, J., Sanson-Fisher, R., 1989. Community knowledge of cancer. Health Promotion International 6, 193e201. Coronado, G., Thompson, B., 2000. Rural Mexican American men’s attitudes and beliefs about cancer screening. Journal of Cancer Education 15, 41e45. Department of Health, 2000. The NHS Cancer Plan: a Plan for Investment, a Plan for Reform. Department of Health, London. Fitch, M.I., Greenberg, M., Levstein, L., Muir, M., Plante, S., King, E., 1997. Health promotion and early detection of cancer in older adults: assessing knowledge about cancer. Oncology Nursing Forum 24, 1743e1748. Hancock, L., Sanson-Fisher, R., Redman, S., Reid, A., Tripodi, T., 1996. Knowledge of cancer risk reduction practices in rural towns of New South Wales. Australian and New Zealand Journal of Public Health 20 (5), 529e538. Huisman, M., Kunst, A.E., Macenbach, J.P., 2005. Inequalities in the prevalence of smoking in the European Union: comparing education and income. Preventive Medicine 40, 756e764. Katz, R.C., Meyers, K., Walls, J., August 1995. Cancer awareness and self examination practices in young men and women. Journal of Behavioural Medicine 18 (4), 377e384. Kiekbusch, S., Hannich, H.J., Isacsson, A., Johnannisson, A., Lindholm, L.H.J., Sager, E., Slaug, B., Moller, T.R., 2000. Impact of a cancer education multimedia device on public knowledge, attitudes and behaviours: a controlled intervention study in southern Sweden. Journal of Cancer Education 15 (4), 232e236. Ma, G.X., Fleisher, L., 2003. Awareness of cancer information among Asian Americans. Journal of Community Health 28 (2), 115e130. Mishra, S.I., Aoelus, P.L., Hubbell, F.A., 2000. Knowledge of and attitudes about cancer among American Samoans. Cancer Detection and Prevention 24 (2), 186e195. National Cancer Institute (US), 2004. Cancer Prevention Information. http://www. nci.nih.gov/cancerinfo/pdq/prevention. Nichols, B.S., Misra, R., Alexy, B., 1996. Cancer detection: how effective is public education? Cancer Nursing 19, 98e103. Northern Ireland Cancer Registry (NICR), 2006. Cancer Statistics. NICR. http://www. qub.ac.uk/nicr. Paisley, J.A., Haines, J., Greenberg, M., Makarchuk, M.J., Volgelzang, S., Lewicki, K., 2002. An examination of cancer risk beliefs among adults from Toronto’s Somali, Chinese, Russian and Spanish speaking communities. Canadian Journal of Public Health 33 (2), 138e141. Paul, C., Tzelepis, F., Walsh, R.A., Girgis, A., King, L., McKenzie, J., 2003. Has the investment in public cancer education delivered observable changes in knowledge over the last ten years? Cancer 97 (12), 2931e2939. Price, J.H., Everett, S.A., 1994. Perceptions of lung cancer and smoking in an economically disadvantaged population. Journal of Community Health 19 (5), 361e375. Ratnasinghe, D., Weed, D.L., Shankar, S., 1999. Cancer knowledge and misconceptions among immigrant Salvadorean men in the Washington D.C. area. Journal of Immigrant Health 1 (4), 207e213. Rebello-Palencia, M.R., Berlanga-Gonzalez, M.A., Casado-Alonsa, Y., et al., 1996. Knowledge and attitudes related with cancer prevention in a population served at a health centre. Aten Primara 18, 417e424. Shankar, S., Figueroa-Valles, N., 1999. Cancer knowledge and misconceptions: a survey of immigrant Salvadorean women. Ethnic Discourse 9, 201e211. Waller, J., McCaffery, K., Wardle, J., 2004. Measuring cancer knowledge: Comparing prompted and unprompted recall. British Journal of Psychology 95, 219e234. Wardle, J., Waller, J., Brunswick, N., Jarvis, M.J., 2001. Awareness of risk factors for cancer among British adults. Public Health 115 (3), 173e174. Weinrich, S., Weinrich, M., Boyd, M., Johnson, E., Frank-Stromborg, M.,1992. Knowledge of colorectal cancer among older people. Cancer Nursing 15 (5), 322e330. Wetter, D.W., Cofta-Gunn, L., Irvin, J.E., Fouladi, R.T., Wright, K., Daza, P., Mazas, C., Cincirpini, P.M., Gritz, E.R., 2005. What accounts for the association of education and smoking cessation? Preventive Medicine 40, 452e460. World Health Organisation (WHO), 2009. Cancer. WHO. http://www.who.int/ mediacentre/factsheets/fs297/en/index.html (accessed 26.08.09).
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
An exploration of public knowledge of warning signs for cancer Sinead Keeney a, *, Hugh McKenna b, Paul Fleming b, Sonja McIlfatrick a a b
Institute of Nursing Research, School of Nursing, University of Ulster, Shore Road, Newtownabbey, Co. Antrim, BT37 0QB, UK Faculty of Life and Health Sciences, University of Ulster, UK
a b s t r a c t Keywords: Cancer Prevention Warning signs Knowledge
Background: Warning signs of cancer have long been used as an effective way to summarise and communicate early indications of cancer to the public. Given the increasing global burden of cancer, the communication of these warning signs to the public is more important than ever before. Aim: This paper presents part of a larger study which explored the attitudes, knowledge and behaviours of people in mid-life towards cancer prevention. The focus of this paper is on the assessment of the knowledge of members of the public aged between 35 and 54 years of age. Method: A questionnaire was administered to a representative sample of the population listing 17 warning signs of cancer. These included the correct warning signs and distracter signs. Respondents were asked to correctly identify the seven warning signs. Results: Findings show that respondents could identify 4.8 cancer warning signs correctly. Analysis by demographics shows that being female, being older, having a higher level of educational attainment and being in a higher socio-economic group are predictors of better level of knowledge of cancer warning signs. Recommendations: Recommendations are proffered with regard to better targeting, clarification and communication of cancer warning signs. Ó 2010 Elsevier Ltd. All rights reserved.
Introduction The high prevalence of cancer is demonstrated by the fact that more than 11 million people worldwide are diagnosed with cancer each year. It is estimated that by the year 2030 cancer will account for 12 million deaths annually (WHO, 2009). It is acknowledged that survival from many types of cancer is significantly improved if treatment is started at an early stage and early detection depends partly on people having the knowledge to recognise the warning signs (DH, 2000; Cancer Research UK, 2004, 2006). The warning signs of cancer have been considered an effective way to summarise early signs of cancer into a usable and memorable communication to the public (Cancer Research UK, 2006; DH, 2000). However, there has been no universal agreement on what should be included in this list of early warning signs. The implications have not been explored but it is apparent that this could be confusing for the public considering even the experts cannot agree on what should be included! The original seven warning signs of cancer adopted by the National Cancer Institute is the list that researchers in the UK have used to explore people’s knowledge of
* Corresponding author. Tel.: þ44 28 90368463; fax: þ44 28 90368202. E-mail address: [email protected] (S. Keeney). 1462-3889/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2010.05.007
cancer warning signs (Wardle et al., 2001; Brunswick et al., 2001; Waller et al., 2004). These signs are outlined in Fig. 1. Background It is clear from the existing literature that many international research studies have explored the public’s general knowledge of the signs and symptoms of cancer. However, only one previous study has been undertaken in the UK. Most studies exploring knowledge of cancer warning signs and symptoms focused on a specific type of cancer and do not facilitate comparisons between studies or across types of cancers. General knowledge about cancer warning signs The majority of studies exploring public knowledge of cancer in general have highlighted the low level of cancer knowledge. Over the last decade, US studies reflect this trend (Bostick et al., 1993; Katz et al., 1995; Nichols et al., 1996; Breslow et al., 1997). Other international studies showed a similar pattern (Hancock et al., 1996; Fitch et al., 1997; Paul et al., 2003). The single UK study focusing on cancer knowledge of the general public reflected the findings of the US studies. It notes the low and worrying level of cancer knowledge among the general public (Wardle et al., 2001).
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Fig. 1. Original seven warning signs of cancer.
Only one study carried out in Spain (Rebello-Palencia et al., 1996) uncovered findings at variance with those of other studies in the field. The researchers posited no reasons for the contrasting findings. Bostick et al.’s (1993) US study with 4915 randomly selected members of the public determined that while four fifths of the participants believed that cancer was preventable, their knowledge of cancer warning signs and symptoms was low. Thirteen percent could not identify even one of the seven warning signs of cancer. Findings also indicated that women were able to list more warning signs than men. Brunswick et al. (2001) carried out a UK interviewbased study with 3693 randomly selected members of the public. They supported Bostick et al.’s findings showing that women were more likely than men to identify five or more warning signs correctly. In both studies the most commonly recognised symptom of cancer was ‘a thickening or a lump’. It is interesting and perhaps alarming to note that these two studies were carried out eight years apart in different countries yet the levels of knowledge had not improved. Brusnwick et al. showed that only 1.6% (n ¼ 58) of the sample identified all seven warning signs. On average, participants could identify four of the seven signs. Several years after Bostick et al.’s (1993) work, Nichols et al. (1996) undertook a small pilot study with 172 members of the public in the US. They aimed to evaluate knowledge of cancer prevention. Again, participants were asked to identify the seven warning signs. The average number of correctly identified warning signs was three but 19% (n ¼ 33) of the sample could not identify any. Nichols et al. (1996) asserted that the level of knowledge among this small, well educated and moderate to high-income sample was “appalling” (p. 103). However, it is important to note that this was a small pilot study and that the findings may not be representative. This is acknowledged by the authors who indicate the need for a replication with a larger, culturally diverse, representative sample. In Australia, Paul et al. (2003) undertook a cross-sectional telephone survey to assess the public’s awareness and knowledge of cancer. This study part-replicated a previous Australian study (Clover et al., 1989). The intention was to compare the results of both studies to assess any shift in knowledge in the intervening 11 years. The sample was made up of 685 residents living in New South Wales. Knowledge of risk factors for colorectal and cervical cancer was poor. When compared with the results of Clover et al.’s study, there appeared to be some improvements in knowledge and awareness of cancer risks: in particular, knowledge of mammograms as a screening test for breast cancer had improved. Nonetheless, for other cancers, any gain in knowledge or awareness appeared minimal. Paul et al. asserted that while improvements in
knowledge have been made in some areas (breast cancer), major challenges exist for other cancers. There is an obvious debate about the way that knowledge and awareness has been measured (Waller et al., 2004). It appears from these Australian studies that regardless of whether a list of signs or risk factors was used as opposed to unprompted recall, levels of knowledge and awareness remain low. While there are few European or Asian research studies published in English that assessed the level of knowledge and awareness of cancer, the findings of these are interesting. Cetingoz et al. (2002) carried out a study in Turkey to assess the public’s knowledge and attitudes to cancer prevention and treatment. A questionnaire consisting of 24 questions was administered to a sample of 630 respondents to determine their knowledge and attitudes to cancer. Results showed that 78% (n ¼ 491) of the respondents had little knowledge of cancer. This is consistent with the findings from Wardle et al. (2001) UK study. Ninety-eight percent (n ¼ 617) of the respondents in Cetingoz et al’s study wanted to improve their knowledge of cancer and 74% (n ¼ 466) thought that this should be done through “television programs or public seminars” (p.56). Rebello-Palencia et al. (1996) undertook a study in Spain to assess the knowledge and attitudes that patients at a health centre had of cancer risks and cancer prevention. A questionnaire was administered to a non-probability sample of 400 people aged between 14 and 75. Findings showed that respondents had a good understanding of cancer risk factors and prevention. Overall Rebello-Palencia et al’s findings contrast with those of other international studies. The researchers provide no explanation for these atypical findings. Perhaps one possible explanation is that the sample was obtained from people attending a health centre. This could suggest that they are more interested, informed or pro-active about their health than those who would not attend health centres. Another reason could be that the local health authority may have recently launched a cancer prevention campaign. Knowledge of risk factors Knowledge of risk factors for cancer has been explored by a number of researchers internationally. Level of knowledge and awareness of the public was found to be low in studies that explored specific cancer risk factors such as diet (Breslow et al., 1997), multiple sexual partners (Breslow et al., 1997) and family history (Wardle et al., 2001). While age is a risk factor for a number of cancers (NCI, 2004), this is not widely known by the general public (Fitch et al., 1997; Breslow et al., 1997; Wardle et al., 2001). Fitch et al.’s (1997) Canadian study examined the knowledge level of adults in an urban community. They used a convenience sample of 513 adults over the age of 55. A self-report questionnaire was
S. Keeney et al. / European Journal of Oncology Nursing 15 (2011) 31e37
administered focusing on their knowledge about cancer, language group and the length of time they had lived in the country. The main finding indicated that 66% (n ¼ 339) of the sample did not consider age to be a risk factor for cancer. Results also showed that even though the questionnaire was administered in each participant’s native language, non-English speakers were less knowledgeable about cancer. It should be noted that 68% (n ¼ 349) of the sample came from countries other than Canada and as such this sample had a large proportion of people who may not have been exposed to Canadian cancer prevention strategies for any significant length of time. In the US, Breslow et al. (1997) undertook a large study to examine the public’s knowledge of cancer risks and survival. Data were used from 12,035 respondents who had completed the 1992 National Health Interview Cancer Control Supplement. This survey included questions about cancer risk factors and most respondents could not identify them. Two-thirds did not recognise that age was a risk factor for breast and colon cancer, that diet was a risk factor for colon cancer or that multiple sexual partners was a risk factor for cervical cancer. In the UK, Wardle et al. (2001) asked participants to identify risk factors for breast, cervical, prostate, colorectal and lung cancer from a list of 14 factors which included “established causes” such as older age, low fibre diet, smoking and being overweight and “mythic causes” such as food additives, pollution and stress (p. 173). Older age was not widely recognised as being a risk factor and neither was family history. Overall, the average number of risk factors identified correctly was five out of 15. The authors also reported that “endorsement of mythic causes was comparatively low, less than 5%, but were higher in men and those with less education” (p. 173). In this case mythic causes were food additives, overhead power cables, pollution and stress. Ethnic minorities knowledge of cancer warning signs There have been many studies undertaken in the US and Canada exploring the cancer knowledge and attitudes of different minority ethnic groups (Breslow et al., 1997; Shankar and Figueroa-Valles, 1999; Mishra et al., 2000; Coronado and Thompson, 2000; Ratnasinghe et al., 1999; Ma and Fleisher, 2003). With the exception of one more recent study (Paisley et al., 2002), all others concluded that the level of knowledge and awareness of cancer of the specific ethnic group studied was poor (Breslow et al., 1997; Coronado and Thompson, 2000; Ratnasinghe et al., 1999). Findings showed that minority ethnic groups often had misconceptions about cancer risk and prevention (Shankar and Figueroa-Valles, 1999; Mishra et al., 2000), a fatalistic attitude to cancer (Coronado and Thompson, 2000), inadequate knowledge about cancer warning signs (Shankar and Figueroa-Valles, 1999; Ratnasinghe et al., 1999) and a low level of awareness of cancer prevention (Ma and Fleisher, 2003). These findings highlight the different cultural aspects of cancer awareness and knowledge that should be taken into account when targeting cancer prevention education and information to minority ethnic groups. Summary With the exception of the one study alluded to above (RebelloPalencia et al., 1996), the conclusions from the main body of research have remained the same. Researchers all concluded that it is important to provide up-to-date, appropriate and culturally sensitive information on cancer to specific social or ethnic groups (Shankar and Figueroa-Valles, 1999; Mishra et al., 2000;
33
Ratnasinghe et al., 1999; Ma and Fleisher, 2003). In relation to Hispanics specifically, Breslow et al. (1997) concluded that the current health provision was insufficient and that this remained a challenge to the public health services. In Turkey, researchers concluded that the basic level of cancer knowledge must be improved and that more appropriate information must be targeted to the general public (Cetingoz et al., 2002). These assertions have been echoed in Australia (Hancock et al., 1996; Paul et al., 2003) and the US (Bostick et al., 1993; Nichols et al., 1996; Breslow et al, 1997). The Study Why this age group? Evidence shows that more than three-quarters of deaths from cancer occur in people aged 65 years or over (Cancer Research UK, 2006). In the younger age groups, although there are fewer deaths from cancer, proportionally cancer is even more important as a cause of death. In adults under the age of 65, more than 1 in 3 deaths (37%) are attributable to cancer (Cancer Research UK, 2006). When the statistics are broken down by gender, the proportion rises even higher for women with almost 1 in every 2 deaths (47%) caused by cancer in adult women under 65. In the year 2002, 38,273 people between the ages of 35 to 54 were diagnosed with cancer in the UK. This accounted for 13% of all cancer diagnoses in that year. The latest figures for Northern Ireland show that the incidence of cancer was 11,419 cases for people aged 35e54 over the period 1993e2001 (NICR, 2006). Methodology For the part of the study being described in this paper, a questionnaire was administered to a representative sample of the population listing 17 warning signs of cancer. These included the correct warning signs and misleading distracter signs. Respondents were asked to correctly identify the seven warning signs of cancer. Sampling The inclusion criteria for the study dictated that participants should be aged between 35 and 54 years of age at the time of the study. The exclusion criteria stated that participants must not have had a past diagnosis or a current diagnosis of cancer. The rationale for excluding people with a past or present diagnosis of cancer centered on the belief that they would have an elevated knowledge of cancer. Furthermore, it was felt that their attitudes and behaviours would differ from a member of the public who did not have or previously had a cancer diagnosis. Despite much exploration, there was no possible way to gain access to the ages of members of the public in order to target the age group for the study. Therefore it was decided that all age groups would be targeted and that those within the age group for the present study would be used. Funding has subsequently been gained to analyse the data from the returned questionnaires from other age groups. The Edited Electoral Register for Northern Ireland was used to sample the population. The edited version of the electoral register is available for purchase in Northern Ireland to use for research purposes (see http://www.eoni.org.uk/index/electoral-register.htm for further information). One rural and one urban district were selected from each of the four Health and Social Services Board area within Northern Ireland. Each district was then split into wards using the Electoral Register. The numbers of people in each ward was expressed as a percentage of the total population of voters in that district. This was to ensure a representative spread. Equal numbers of men and women were selected within each ward.
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S. Keeney et al. / European Journal of Oncology Nursing 15 (2011) 31e37
In total 5000 questionnaires were posted to members of the public. It was anticipated that the response rate would be lower than 50% as is common in postal questionnaires to the public. A total of 2350 usable questionnaires were returned representing a response rate of 47% which is considered above average for unsolicited questionnaires mailed to the public. In total, 1067 of the returned questionnaire where within the age group 35e54 years and were used for this study. Two rounds of follow up postcards were sent to participants to enhance the response rate. This comprises a representative sample at a confidence level of 95% and a confidence interval of 3. The questionnaire From a list of 17 possible warning signs, respondents were asked to identify the seven warning signs of cancer (See Fig. 2). Pilot study A pilot study was undertaken to test the questionnaire during which 150 questionnaires were distributed to a random selection of people chosen from the edited electoral register. In total, 70 questionnaires were returned, giving a response rate of 47%. Minor wording changes were made before questionnaire administration to the main study sample.
Administration of the survey A cover letter was designed to accompany the questionnaire explaining the purpose of the study and how the person’s name and address had been accessed. The researchers’ names and contact details were also put on the letter for respondents to contact if they felt that they required more information. A section was included in the letter asking respondents not to complete the questionnaire if they had cancer or had ever had a cancer diagnosis. The reason for this was because people with a past or present diagnosis of cancer may a higher level of knowledge and awareness than those people who have never been diagnosed with cancer. The questionnaires were posted over a ten-day period. Follow up reminder postcards were distributed one week before the return date and one week after the return date. Data analysis The data from the questionnaires were entered into SPSS. Descriptive statistics were used to analyse demographics and socioeconomic information. Non-parametric statistics (ManneWhitney U and Kruskal Wallis) were used to explore the relationship between each demographic and knowledge of warning signs. Logistic regression was used to explore the influence of demographics on knowledge of cancer warning signs. For the purposes of this procedure, the ‘knowledge of warning signs’ variable was dicotomised using a median split into high (five or more warning signs identified correctly) and low (less than five signs identified correctly). Ethical approval Ethical approval was granted for this study by the University of Ulster Research Ethics Committee for research being undertaken with healthy volunteers. Anonymity and confidentiality were assured and the return of the completed questionnaire was taken to indicate consent.
Results
Fig. 2. List of warning signs and distracter signs included in the questionnaire.
The demographic profile of the sample is outlined in Table 1. The average number of warning signs identified correctly for this sample was 4.8. On average, female respondents identified 5 signs correctly and male respondents 4.4 signs correctly. The average number of warning signs correct for the younger age band (35e44) was 4.7 and for the older age band (45e54) was 4.9. Findings show that the number of correctly identified warning signs increases from the younger age band of 35e44 to the older age band of 45e54 (p < 0.01). This suggests that the older age group has a higher awareness of cancer warning signs. In relation to gender, women can identify correctly more warning signs than men (p < 0.01). Furthermore, respondents with a higher level of education were able to correctly identify more warning signs (p < 0.01). When housewives/househusbands were excluded from the analysis, respondents with a higher income can identify more cancer warning signs correctly (p < 0.01). Higher socio-economic status is also associated significantly with better knowledge of cancer warning signs (p < 0.05). The socio-economic status variable was organised into five categories e professional, employers/ managers, intermediate/junior non-manual, skilled manual, unskilled. Unskilled includes housewives and househusbands. Excluding them from the sample increases the significance of the association (p < 0.01). This suggests that housewives/househusbands knowledge of cancer warning signs is higher than that of other unskilled respondents.
S. Keeney et al. / European Journal of Oncology Nursing 15 (2011) 31e37 Table 1 Sample demographics. Demographic groups
35
Table 2 Signs identified as warning signs (by %). Number of respondents
Percentage of sample
Age 35-44 45-54
600 467
56.2 43.8
Gender Male Female
415 652
38.9 61.1
Level of education attained Primary school GCSE/O’level A-level Degree Masters/PhD
70 476 161 276 83
6.6 44.6 15.1 25.9 7.7
Annual personal gross income 0e£10,000 £10,000e£20,000 £20,001e£30,000 £30,001e£40,000 £40,001e£50,000 £50,001 þ
305 299 239 152 32 39
28.6 28 22.4 14.2 3 3.7
Socio-economic status Professional Employers/managers Intermediate/junior low manual Skilled manual Semi-skilled Unskilled
314 163 217
29.4 15.3 20.3
162 16 172
15.2 1.5% 16.1
Country of birth Northern Ireland Outside Northern Ireland
951 116
89.1 10.9
Marital status Single Married/living together Divorced/separated/widowed
132 844 91
12.4 79.1 8.5
Housing tenure Rented/other persons home Owner occupied
117 950
11 89
Residential environment Urban Rural
559 508
52.4 47.6
Table 2 shows percentages of warning signs identified correctly and distracter signs identified incorrectly by the sample and by gender. It is clear from Table 2 that the most recognised sign was a change in a wart or mole, closely followed by a thickening or lump on the body, unexplained weight loss and a change in bowel or bladder habits. All these signs were recognised by over 90% of respondents but by more women than men. A sore that does not heal was recognised by just over half of the sample (51%) but the most poorly recognised warning sign was indigestion or difficulty swallowing which was recognised by only 30% of the sample. Interestingly, this was the only warning sign identified more by men than by women. Women were more likely than men to identify warning signs such as unusual bleeding or discharge (p < 0.01), a change in bowel or bladder habits (p < 0.01), a change in a wart or mole (p < 0.01) and a nagging cough or hoarseness (p < 0.01). Older respondents (aged 45e54) were more likely to identify warning signs such as indigestion or difficulty swallowing (p < 0.01), nagging cough or hoarseness (p < 0.01) and a sore that does not heal (p < 0.01). Those respondents with a higher level of educational attainment were more likely to identify warning signs such as unusual bleeding or discharge (p < 0.01), a change in a wart or mole (p < 0.01) and unexplained weight loss (p < 0.05).
All (%)
Women (%)
Men (%)
Warning signs Unusual bleeding or discharge Indigestion or difficulty swallowing A change in bowel or bladder habits A change in a wart or mole Nagging cough or hoarseness Thickening or lump on body A sore that does not heal Unexplained weight loss
86 30 90 95 35 94 51 91
77 33 84 87 24 94 48 91
92 28 95 99 42 94 53 91
Distracter signs Tiredness Poor appetite Bleeding gums Numbness in parts of your body Nausea or upset stomach Feeling weak in parts of your body Headaches Sore muscles Pain in your heart or chest
29 25 15 11 10 10 8 3 2
33 27 12 17 14 17 7 7 4
28 23 16 8 7 8 8 1 1
Younger respondents (aged 35e44) were more likely to identify incorrectly warning signs such as tiredness (p < 0.01), numbness in parts of your body (p < 0.01), feeling weak in parts of your body (p < 0.05), headaches (0 < 0.01) and unexplained weight loss (p < 0.01). Men were more likely than women to identify incorrectly warning signs such as numbness in parts of your body (p < 0.01), nausea or upset stomach (p < 0.01), feeling weak in parts of your body (p < 0.01), sore muscles (p < 0.01) or pain in your heart or chest (p < 0.05). Those with a lower level of educational attainment were more likely to identify incorrectly warning signs such as poor appetite, nausea or upset stomach and feeling weak in parts of your body (p < 0.01). Logistic regression was used to assess the association of the demographic variables with knowledge of cancer warning signs. The dependant variable was dicotomised into high and low level of knowledge of cancer warning signs with high being correctly identifying five or more signs from the cancer warning signs list within the questionnaire (Table 3). From the table above it is clear that knowledge of cancer warning signs has a significant relationship with age, gender, level of educational attainment, socio-economic status, income, marital status and type of accommodation. Discussion This study aimed to assess the level of knowledge of cancer warning signs among members of the public aged between 35 and 54 years (mid-life). The cancer warning signs can be seen at Fig. 2 with the addition of an eighth sign ‘unexplained weight loss’ which has been included in various different lists of warning signs over recent years. There is clear evidence from this study that there is a low level of knowledge of cancer warning signs among people in mid-life. This reflects the UK findings of Brunswick et al.’s (2001) study. Theirs was the first study to be undertaken in Europe in this area. It used a sample of 3693 men and women aged 18 years and above. Their findings, broken down into different age bands, show that there is a higher level of knowledge among people in mid-life. However, from the present study it is clear that the level of knowledge for this age grouping is also low. This is a major cause of concern in relation to cancer prevention and the recognition of warning signs. These findings are reflective of many published international and national research studies in this area (Bostick et al., 1993; Katz et al., 1995;
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Table 3 Logistic regression of knowledge of warning signs with demographics. Demographic Groups
N
Odds ratio
95% CI
Gender Male Female
415 652
1.0 2.2
1.7e2.8
Age 35e44 years 45e54 years
600 467
1.0 1.7
1.4e2.3
Marital status Married Single Living with partner Divorced/separated Widowed
801 132 43 81 10
1.0 0.42 0.32 0.43 0.73
0.1e1.6 0.1e1.2 0.1e1.6 0.2e3.9
Socio-economic group Professional Employers/managers
314 163
2.7 2.9
0.6e4.9 1.0e8.3
Intermediate/junior Low-manual Skilled manual Unskilled
217 162 23
2.0 1.9 1.0
0.7e5.6 0.7e5.3 0.5e4.2
Income Low Moderate High
305 538 224
1.0 1.2 1.3
0.8e1.7 0.9e1.8
Educational attainment Primary school Secondary school Third level
70 637 360
1.0 1.2 5.5
0.9e1.6 3.2e9.6
Tenure Rented accommodation Owner occupier
84 950
1.0 2.0
1.3e3.1
Location Rural Urban
508 559
1.0 1.0
0.7e1.3
Country of birth Outside NI NI
115 952
1.0 1.2
0.8e1.9
Hancock et al., 1996; Nichols et al., 1996; Mishra et al., 2000; Fitch et al., 1997; Paul et al., 2003). There was only one study undertaken in Spain which uncovered findings that were at variance to other research studies in the field (Rebello-Palencia et al., 1996). Evidence from this study also shows that the level of knowledge is lower within specific population sub-groups such as those with a lower level of educational attainment, a lower socio-economic status, men and those who are not married/single. This evidence supports findings from previous studies in which demographics have been demonstrated to have an effect on knowledge of cancer and cancer warning signs including level of education (Wardle et al., 2001; Cetingoz et al., 2002; Huisman et al., 2005; Wetter et al., 2005) and gender (Wardle et al., 2001; Kiekbusch et al., 2000; Wetter et al., 2005; Katz et al., 1995). Findings from the present study also shows that age also affects knowledge as the lower age group displayed a lower level of knowledge than the higher band. When housewives/househusbands were excluded from the analysis those with a higher socio-economic status (SES) showed that their knowledge is better than their counterparts in the unskilled SES category. Further evidence shows that a higher level of knowledge is also associated with owing your own home, which is in keeping with the findings regarding the effect of SES. These SES findings echo those of other international studies (Weinrich et al., 1992; Price and Everett, 1994; Brunswick et al., 2001). Findings demonstrate that there are differences in the identification of warning signs of cancer between genders, age bands, level
of educational attainment and SES. The most identified warning sign was ‘a change in a wart or mole’, followed closely by ‘thickening or lump on body’, ‘unexplained weight loss’ and ‘a change in bowel or bladder habits’. A ‘thickening or lump on the body’ has been well recognised by the public for some years and has been attributed to high profile and ongoing media campaigns for testicular and breast cancer (Bostick et al., 1993; Nichols et al., 1996; Paul et al., 2003). The identification by a high percentage of the sample of ‘unexplained weight loss’ as a cancer warning sign is worthy of note. The inclusion or exclusion of this warning sign from various lists does not appear to have had much effect on its identification as a warning sign by the public. It was the second most recognised sign in Brunswick et al’s (2001) study five years ago and is the third most recognised sign among the present study. Brunswick et al. suggested that the recognition of this sign is possibly less to do with its publication in various lists of warning signs and more to do with the public’s perception of cancer as a “wasting disease” (p. 36). The danger with unexplained weight loss being recognised as a cancer warning sign is that people could overlook another sign of cancer because it was not accompanied by weight loss. Perhaps further education on the importance of unexplained weight loss needs to be communicated. Poorly recognised signs included ‘indigestion or difficulty swallowing’, ‘a nagging cough or hoarseness’ and ‘a sore that does not heal’. Misconceptions about cancer warning signs emerged as ‘tiredness’, ‘poor appetite’ and ‘bleeding gums’. Brunswick et al’s (2001) study also showed that ‘indigestion or difficulty swallowing’ was poorly recognised. The level of recognition of this sign does not appear to have increased in the five intervening years between these studies. Further exploration of the reasons for this may be required. The present study highlights the low level of knowledge and negative attitudes held by men and especially single men/not married. Men who are single/not married have the lowest level of knowledge and awareness of cancer warning signs in this sample. These findings suggest that information and education needs to be targeted at single men. Brunswick et al. (2001) also suggested that single men should be a priority area for cancer prevention. The findings of the present study show that the knowledge of single, unmarried men has not improved in the intervening years. It should be stressed that if members of the public were aware of all the cancer warning signs, this does not mean that their prevention behaviours will change dramatically. For instance, most of the population is aware that smoking causes cancer but a significant proportion continues to smoke. The researchers are aware of this but note Cancer Research UK’s assertion that being aware of cancer warning signs can help early detection. Limitations The use of the Edited Electoral Register for Northern Ireland was the result of a long and protracted search for an effective method of access to the home contact details of members of the public. This is a notoriously difficult task, as individuals must have given their consent for their home address to be used for research purposes. This is implied when individuals over the age of 18 in Northern Ireland allow their name and home address to be placed on the edited register. The limitation associated with the edited register is that it only holds the names and address of 60% of the Northern Ireland population and the ages of these people. However, as there are no significant trends identified in the type of person who allows their name and address to be used therefore this was considered the most appropriate method of access available. Considering also that at the outset the study was intending to focus on a specific age group (35e54 years), it became apparent
S. Keeney et al. / European Journal of Oncology Nursing 15 (2011) 31e37
quickly that identifying a specific age group of members of the public was going to be difficult. Having discussed this at length with the funder, it was agreed that all age groups would be targeted and further funding agreed for the analysis and write up of all age groups. The issue of collecting data from age groups outside the main study age group was detailed in the ethical application. It was made explicit that this data would be analysed and written up for the funder and public consumption. Support information was also provided to every participant about cancer and cancer prevention including the free helpline number of a large cancer charity in Northern Ireland in case of distress caused by participation in the study. This data is of utmost importance in the targeting of cancer prevention information to the different age groups. In retrospect, perhaps a more effective way of targeting a specific age group would be to use telephone interviews. This can be an expensive method of recruitment and funding needs to be obtained appropriately. Additionally, the use of surveys in social science research will always incur several limitations. Self-report surveys rely on people completing the questionnaire themselves and truthfully. Furthermore, it must be acknowledged that the responses are the opinions of a sample of individuals at any one given time. However, the fact that the findings of the study concur, on the whole, with other studies conducted in the area gives credence to the method and findings of the study.
Conclusions This paper has focused on the knowledge of people in this age group of cancer warning signs. Priority groups have been identified as single men and those people in a low socio-economic group due to the low levels of knowledge that they exhibit. These groups are in need of targeted information and education to help them with the early detection and prevention of cancer. In conclusion, the outcomes from this study should be used to inform policy and identify strategies to enhance the cancer prevention knowledge and actions in this population. In turn, it is anticipated that this will have an impact on cancer deaths and diagnoses in the future.
Recommendations There are several recommendations arising from this part of the study. A strategy should be developed to raise this population’s knowledge of cancer warning signs to promote recognition of early signs of cancer. Further exploratory research should be undertaken into the reasons why housewives and househusbands have an elevated level of knowledge of cancer warning signs. Consideration should be given to targeting sub-groups with information on cancer warning signs in different ways and formats based on the data available from this study. The level of importance of the cancer warning sign ‘unexplained weight loss’ should be clarified and communicated to the public. Single, unmarried men in this age group should be a priority for the targeting of information and education on the warning signs of cancer. A clear, concise message of the warning signs of cancer should be communicated to all men in this age group with the immediate priority being single men.
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