Knowledge toward ovarian cancer symptoms among women in Syria: Cross-sectional study.

JOUDY KARH DAMOUR (Faculty of medicine Aleppo University, Aleppo, Syria; [email protected] ). Danya Mourad (Al-HAWASH PRIVATE UNIVERSITY, Syria; [email protected] ).

Haidara Bohsas: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper. Hidar Alibrahim; Sarya Swed: Conceived and designed the experiments; Performed the experiments; Wrote the paper. Amro A. El-Sakka: Performed the experiments; Analyzed and interpreted the data; Wrote the paper. Mohammad Alyosef; Mhd Baraa Habib; Sherihan fathey; Gowhar Rashid: Analyzed and interpreted the data; Wrote the paper. Haia Haitham Sarraj: Performed the experiments; Wrote the paper. Bisher Sawaf: conceived and designed the experiments; wrote the paper. Ahmed Thabet Daraghmi; Angham Thabet Daraghmi; Wael Hafez: conceived and designed the experiments; analyzed and interpreted the data; wrote the paper.

An online cross-sectional study was conducted in Syria between July 29 and August 17, 2022. The inclusion criteria of study participants were females aged 18 or older with Syrian nationality from all Syrian governorates. Exclusion criteria were non-Syrian nationality females under 18 years of age, females working in health sector, and females (or their first degree relatives) diagnosed with ovarian cancer. An informed consent was taken from all participants at the first page of the questionnaire. All participants were informed about the ability to withdraw their response at any section during answering the questionnaire at the description of the survey. This questionnaire was developed based on prior research that included a comprehensive, validated scale [ 8 , 9 ]. Then, medical researchers translated the questionnaire into Arabic so that participants could read and answer the questions easily; the final version of the questionnaire was included in the study's supplemental material ( S1 Table 1 ). A Data Collection Group collected data made up of volunteers from several Syrian medical universities; they used the social media platforms such as WhatsApp, Telegram, and Facebook to publicize a Google Form( https://www.google.com/forms/ ). This study's sample size was determined using the sample size calculator at " https://www.calculator.net/sample-size-calculator.html ." The minimal sample size was computed by interrupting the formula [n = [(Za/2)2. P (1-P)]/d2], [Confidence level = 95%, Z a/2 = 1.96, Margin of error = 5%, P = the proportion of females who were aware of OC risk factors and symptoms (17.4%) [ 8 ] and the requested sample size was 221. The evaluation was conducted using a modified ovarian cancer awareness measure (OCAM) [ 10 ]. The questionnaire had 41 questions separated into three parts. The first segment included sociodemographic information. The second segment examined individuals' Confidence in their capacity to identify ovarian cancer symptoms. The last part tested women's Awareness of the manifestations of ovarian cancer. Participants' Confidence in their capability to identify ovarian cancer manifestation was assessed using a four-point measurement (1 = not at all confident, 4 = extremely confident). On the other hand, a five-point Likert scale (1 = strongly disagree, 5 = strongly agree) was employed to assess participants' Awareness of 11 ovarian cancer manifestations. The questions that originally had yes/no/unknown answers were changed to a five-point Likert scale (1 = strongly disagree, 5 = strongly agree) to decrease the probability that people would answer randomly. Similar to earlier research, the participant answers were transformed into correct or incorrect replies [ 11 , 12 ]. This section contains eight questions about the participants' sociodemographic variables, which include (age, residency, educational level, whether the participants are not educated or finished school or college, economic status, social status, whether the participant is in a relationship or married or single, occupational status, if the participants are suffering from chronic diseases such as diabetes or hypertension, and if the participant is a smoker or not). This section contains 11 questions about participants' Confidence in identifying ovarian cancer symptoms, which include the participants mentioning all the symptoms they know about ovarian cancer if the participants noticed any symptoms of ovarian cancer when they visited the doctor to investigate, what are the reasons that the participants think to increase a woman's chances of developing ovarian cancer, how confident are participants in recognizing ovarian cancer manifestations (not at all confident, not confident, confident, very confident), do the participants think there are programs for early detection of breast cancer(if yes, at what age do women receive their first call for early detection of breast cancer), and the same questions for colorectal and ovarian cancer. This section contains ten questions evaluating participants' knowledge of ovarian cancer symptoms, including if the respondent considers (abdominal pain, pelvic discomfort, bloated abdomen, sense of fullness, urinary symptoms, weariness, and other symptoms stated in the survey) as ovarian cancer symptoms. We sent the online survey to 47 Syrian individuals to check that the questionnaire was clear and comprehensible for responders, and based on their responses, we adjusted the questionnaire. Although we obtained the questionnaire from previously published research done in an Arabic nation (Palestine), we re-verified its reliability and validity by calculating Cronbach's alpha (above 0.71) for each scale (Knowledge of symptoms of ovarian cancer). The language has been adapted from informal to formal, and a simplified explanation has been provided for each question to ensure comprehension among all participants in the community. A concise clarification was incorporated below the symptoms of the disease, pelvic pain and how to distinguish it from abdominal pain in order for the participants to provide clear answers. Similarly, for (change in bowel habit) sign, which we added an explanation for it (diarrhea or constipation etc.), because it was incomprehensible to some participants. The Aleppo University Syrian Ethical Society for Scientific Research conducted an ethical assessment and authorized the research (IRB: RE 22/03). On the first page of the online survey, all participants were informed of the study's purpose, the research group's name, their ability to withdraw from the study, the privacy and protection of gathered data, and the fact that only fully submitted data would be examined. The whole survey may be completed in 5–7 min. We conducted the analysis by employing SPSS V.28 (Statistical Package for the Social Sciences), considering the values of P-value under 0.05 statistically significant. We present the categorical data as frequency and percentage and the continuous data as mean and standard deviation. We ensured that the data was non-parametric after performing the Shapiro–Wilk test, then we performed a Kruskal–Wallis one-way analysis of variance and variance of variance (ANOVA) to determine the difference between the subgroups toward the knowledge of ovarian cancer symptoms. We also performed binary logistic regression to define the predictor factors (Independent variables: Sociodemographic variables) of having an adequate level of knowledge of the symptoms of ovarian cancer based on the cut-off points presented in the survey's published article [ 8 , 9 ].

Among the 586 respondents contacted, 557 filled out the survey, while 29 declined to participate. Participants' median ages (IQR) were 23 years (22–28), and participants living in the city were (82.9%); however, participants with a university education level were compressed (84.9%). More than half the participants were students (58.7%). Less than a quarter of respondents (24.6%) were married, and approximately half of the participants (51.3%) had a moderate economic status. Only 20.5% of participants showed good knowledge (prompt recognition of more than 8 out of 11 OC symptoms) ( Table 1 ). Table 1 Sociodemographic characteristic of the participants. Table 1 Variable Categories N(%) Age, median [IOR] 23 (22–28) Age group 18–29 431 (77.4) 30 or older 126 (22.6) Level of education Primary school 10 (1.8) Middle school 28 (5) secondary school 46 (8.3) University (Bachelor's or Master's) 473 (84.9) Occupation Student 327 (58.7) House wife 81 (14.5) Public sector 85 (15.3) Private sector 66 (9.9) Idle 9 (1.6) living location City 462 (82.9) Countryside 95 (17.1) marital status Single 4.3 (72.4) Married 137 (24.6) Widowed 9 (1.6) Divorced 8 (1.4) Monthly income High 40 (7.2) Good 200 (35.9) Middle 286 (51.3) Low 31 (5.6) Do you suffer from chronic diseases? Yes 70 (12.6) No 487 (87.4) Smoking Yes 64 (11.5) No 493 (88.5) Sociodemographic characteristic of the participants. Regarding the pain-related symptoms of ovarian cancer, participants reported abdominal pain and pelvic pain (36.8%) and (63.9%), respectively, as symptoms of ovarian cancer. Concerning other symptoms associated with ovarian cancer, the most frequently identified symptoms were “extreme generalized fatigue” (66.1%), “passing more urine than usual” (50.1%), and “increased abdominal size on most days” (39%) ( Table 2 ). Only 20.5% of participants showed good knowledge (prompt recognition of more than 8 out of 11 OC symptoms), whereas participants with poor knowledge were 24.6%. ( Table 3 ). Table 2 Confidence and recognition of OC symptoms. Table 2 Variable Categories n (%) Symptoms with pain Persistent pain in the abdomen Yes 205 (36.8) No 352 (63.2) Persistent pain in the pelvis Yes 356 (63.9) No 201 (36.1) Persistent low back pain Yes 346 (62.1) No 211 (37.9) Other symptoms Increased abdominal size on most days Yes 217 (39) No 340 (61) Feeling full persistently Yes 190 (34.1) No 367 (65.9) Difficulty eating on most days Yes 124 (22.3) No 433 (77.7) Passing more urine than usual Yes 279 (50.1) No 278 (49.9) Changes in bowel habit Yes 245 (44) No 312 (56) Extreme generalized fatigue Yes 368 (66.1) No 189 (33.9) Persistent bloating Yes 22.8 (40.9) No 329 (59.1) Table 3 Knowledge level of ovarian cancer symptoms among study participants. Table 3 Statement n (%) Good 114 (20.5) Fair 306 (54.9) Poor 137 (24.6) Confidence and recognition of OC symptoms. Knowledge level of ovarian cancer symptoms among study participants. Table 4 showed that there is a statistically significant difference between the material status and occupational subgroups toward the score of the knowledge of ovarian cancer symptoms, in which the divorced (7.13 ± 3.314) and widowed women (6.56 ± 3.678) have the highest score compared to single and married women (P-value = 0.028). As well, the students (6.37 ± 3.061) and the women who are workers in the public sector (6.38 ± 2.507) have the highest score in the knowledge of ovarian cancer symptoms compared to other occupational subgroups (P-value = 0.027) ( Table 4 ). Table 4 Differences between the subgroups and the knowledge of the ovarian cancer symptoms score. Table 4 Variable Categories Mean (SD) 95%CI (lower-upper) P-value Age groups 0.115 18 to 29 6.27 (3.002) 5.99–6.56 30 or older 5.87 (2.951) 5.34–6.39 Marital status 0.028 Single 6.38 (2.924) 6.09–6.44 Married 5.52 (3.061) 5–6.04 Widowed 6.56 (3.678) 3.73–9.38 Divorced 7.13 (3.314) 4.35–9.9 Living location 0.92 City 6.08 (3.004) 5.8–6.35 Countryside 6.68 (2.9) 6.09–7.27 Occupation 0.027 Student 6.37 (3.061) 6.04–6.7 House wife 5.35 (2.971) 4.69–6 Public sector 6.38 (2.507) 5.84–6.92 Private sector 6.18 (2.963) 5.38–6.98 Idle 5 (4.093) 1.85–8.15 Level of education 0.42 Primary school 5.4 (2.757) 3.43–7.37 Middle school 5.75 (3.051) 4.57–6.93 secondary school 5.96 (2.503) 5.21–6.7 University (Bachelor's or Master's) 6.25 (3.041) 5.97–6.52 Monthly income 0.153 High 6.75 (2.753) 5.87–7.63 Good 5.81 (3.252) 5.36–6.26 Middle 6.28 (2.86) 5.94–6.61 Low 6.97 (2.496) 6.05–7.88 Do you suffer from chronic diseases? 0.391 Yes 5.93 (3.316) 5.14–6.72 No 6.22 (2.946) 5.96–6.48 Smoking 0.202 Yes 5.75 (3.441) 4.89–6.61 No 6.24 (2.929) 5.98–6.5 Differences between the subgroups and the knowledge of the ovarian cancer symptoms score. Logistic regression in Table 5 has shown no association between the sociodemographic variables and predicting an adequate knowledge of ovarian cancer (P value > 0.05). ( Table 5 ). Table 5 Predictors related to good knowledge of ovarian cancer symptoms and participant characteristics. Table 5 Variable Categories OR (95%CI) p -value Age group 18–29 Ref 30 or older 1.617 (0.51–5.1) 0.412 Level of education Primary school Ref Middle school 3.14 (0.26–37.23) 0.365 secondary school 2.99 (0.54–16.69) 0.212 University (Bachelor's or Master's) 2.21 (0.71–6.9) 0.172 Occupation Student Ref House wife 0.97 (0.18–5.41) 0.976 Public sector 1.67 (0.21–13.39) 0.632 Private sector 1.71 (0.28–10.51) 0.565 Idle 1.13 (0.16–7.99 0.904 living location City Ref Countryside 1.641 (0.92–2.93) 0.094 marital status Single Ref Married 4.10 (0.61–27.65) 0.147 Widowed 5.06 (0.8–31.91) 0.085 Divorced 1.42 (0.15–13.53) 0.761 Monthly income High Ref Good 0.88 0.22–2.48) 0.853 Middle 0.76 (0.23–2.48) 0.648 Low 0.92 (0.29–2.94) 0.889 Do you suffer from chronic diseases? Yes Ref No 1.13 (0.16–2.24) 0.756 Smoking Yes Ref No 1.03 (0.52–2.06) 0.934 Predictors related to good knowledge of ovarian cancer symptoms and participant characteristics.

Syrian women appear to have low levels of awareness about OC symptoms. Educational programs are urgently needed to raise awareness about the disease's symptoms, risk factors, and when to seek medical care. Establishing an organized national screening program for OC is also of paramount importance to allow for diagnosing the disease at its early stages, offer prompt treatment, and consequently provide a better quality of life for Syrian women.

OC is one of the most common cancers globally, accounting for hundreds of thousands of cases worldwide and tens of thousands of deaths annually [ 13 ]. In Syria, the situation is no different. Thousands of cases emerge every year with relatively high rates of mortality [ 14 ]. Women with good knowledge of OC symptoms have a greater ability to perform informative discussions with their physicians about the disease, which is crucial for achieving earlier diagnoses and improving survival rates [ 15 ]. Therefore, it is paramount to tackle the disease early in its course before it reaches a stage beyond any realistic hope of a cure. This study investigated Syrian women's awareness of OC symptoms. Our results showed that only about one-fifth (20.5%) of the participants had good knowledge of OC symptoms, in which they recognized at least 8 out of 11 OC symptoms. Previous studies in Palestine, Jordan, and Nigeria showed similar results [ 8 , 16 , 17 ]. This is quite alarming as only a minority of women have adequate knowledge about the symptoms of the disease. The most recognized symptoms were “extreme generalized fatigue’ (66.1%), “persistent pain in the pelvis' (63.9%), and “persistent low back pain’ (62.1%), mirroring the results from previous studies [ 8 , 16 , 18 ]. The least commonly recognized symptoms were “difficulty eating on most days' (22.3%), followed by “feeling persistently full’ (34.1%), and “persistent pain in the abdomen’ (36.8%). Similar results were found in previous studies [ 8 , 16 ], while, unsimilar to our results, a UK and an Omani study found that 85.0% and 60.3% of women, respectively, recognized “persistent pain in the abdomen’ as a symptom of OC [ 18 , 19 ]. These symptoms being less known among women might be their overlap with other benign conditions. Indeed, women might mistake these symptoms for gastrointestinal upset, as the suspicion of malignancy would not be the first thing that comes to the mind of a less knowledgeable individual. However, the fact that Goff and colleagues found that these symptoms were significantly associated with OC should catalyze starting awareness campaigns as soon as possible [ 20 ]. Among the most knowledgeable women about OC symptoms were the divorced, women who work in the public sector, and students. This might be due to their higher education level than their counterparts. Educated women are more empowered to recognize health-related issues and are more aware of disease symptoms and risk factors. [ 21 ] Nonetheless, further research is needed to evaluate the relationship between educational level and cancer awareness. Spreading knowledge about OC among Syrian women should be undertaken by all means at our disposal. Social media platforms can provide rapid and widespread access to many recipients. Awareness campaigns should be deployed at schools, universities, and primary healthcare units. Many of the elderly population, who are at higher risk for OC and other malignancies, do not have access to social media and are staying at home, so neither online nor physical campaigns can reach them. Thus, national television and radio broadcasts should target this population and host programs to draw their attention to such issues. Syria currently has no national screening program for OC, which is one of the significant barriers to early diagnosis nationally. In the past few years, the Syrian government established successful polio vaccination and smoking cessation campaigns that produced fruitful results. [ [21] , [22] ] A similar campaign is needed to raise awareness about OC among the general public and healthcare professionals and provide the necessary tools for appropriate screening and diagnosis. Awareness campaigns should focus on OC symptoms, risk factors, and when to seek medical care. Also, the current economic difficulties should not deter the efforts of those facing such an issue. Because despite the financial burden that these campaigns might pose, early diagnosis and improved quality of life will prove cost-effective in the long run. OC is a grim reality that faces women worldwide and particularly in Syria. As shown in our results, awareness among Syrian women is inadequate, and with the prevalence of OC in the country, the condition becomes unsettling. Significant steps should be taken, and collaborative efforts from policymakers and healthcare professionals should be exerted to enhance the effectiveness and quality of the healthcare provided. This is the first cross-sectional study conducted in Syria about this topic which reflects the knowledge level about ovarian cancer, and we collected data from all Syrian governorates. A professional investigator was investigating the data collection process and deleting duplicated or illogical responses in order to minimize the bias. This study has some limitations. Firstly, the young age of the participants. Most participants were university students; thus, older age groups at the most risk of OC needed to be better represented in the study. Secondly, the questionnaire assessed OC symptom recognition instead of a recall, which might lead to guessing the symptoms. Therefore, our study is cross-sectional, accessible, and does not need much time to conduct; however, it might not present the actual causal relationship and the generality of the findings. This is an online cross-sectional study based on Google form survey which may contain bias data; thus, areas with bad intirnit and electricity services could not participate in the study, and elderly people who cannot deal with smart phone could not participate in the study. Participants aged under 30 were more than participants aged above 30 which makes an important limitation of our study.

According to the World Health Organization, there will be 15,526 new cases of ovarian cancer (OC) for every 100,000 Arab women in 2022, with 10,499 deaths for every 100,000 women. In Syria, there are 473 ovarian cancer cases for every 100,000 women [ 1 , 2 ]. OC is the second most common cancer in women over 40. In addition, 1 in 75 women will get OC at some point in their lifetimes. In most cases, OC symptoms do not manifest until the late stages, resulting in a 5-year survival rate of 29%. If the cancer is diagnosed early, 92% of OC patients will still be alive after five years [ 3 ]. Several factors increase the development of ovarian cancer, including BRCA1, BRCA2, and MMR gene mutations, endometriosis, hormone replacement therapy (HRT), being overweight, and smoking [ 4 ]. As mentioned above, ovarian cancer manifests at late stages; thus, there is a high risk of developing metastases. Ovarian cancer may induce various symptoms, including abdominal pain, edema, back pain, diarrhea, tiredness, nausea, and urinary disorders. However, precocious puberty, menstrual irregularity, and hirsutism may also be present [ 5 ]. A careful pelvic and abdominal examination, as well as a clear medical history of gynecologic cancers, must be performed as part of the diagnosis protocol of OC. Transvaginal ultrasonography is one of the most important diagnostic tools as it gives a true image of the structure and blood supply of the ovaries and differentiates between cystic and solid masses [ 6 ]. Women's knowledge of ovarian cancer and its symptoms has been shown to play a significant role in halting the disease's progression and lowering the burden of treatment costs on the healthcare system, which could encourage women to make positive changes to their lifestyle and their exposure to potential risk factors [ 7 ]. This study examines the Awareness of ovarian cancer symptoms among Syrian women and identifies the factors associated with adequate knowledge.

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Hidar Alibrahim reports was provided by University of Aleppo. Hidar Alibrahim reports a relationship with University of Aleppo that includes: non-financial support. Hidar Alibrahim has patent pending to NA. None.

Data will be made available on request.