Awareness of ovarian cancer risk and protective factors: A national cross-sectional study from Palestine

Ovarian cancer (OC) is the second most deadly gynecological cancer worldwide with an estimated number of 207,252 deaths in 2020 [ 1 ]. After corpus uterine cancers, OC is the second most frequent gynecological cancer in Palestine [ 2 ]. The number of Palestinian women diagnosed with OC in 2020 was 74 women, of whom 53 (71.6%) died [ 2 ]. Low-resource settings, such as Palestine, necessitate finding efficient, cost-effective approaches to mitigate the high mortality of OC. Risk factors of OC can be divided into modifiable and non-modifiable factors. Non-modifiable risk factors include family history of OC, older age, history of endometriosis or ovarian cysts, having no children, and early menarche [ 3 – 8 ]. Modifiable risk factors include smoking, obesity, having in vitro fertilization (IVF) treatment, and long-term use of hormonal replacement therapy [ 6 , 9 , 10 ]. On the other hand, protective factors of OC include breast feeding, using oral contraceptive pills and bilateral salpingo-oophorectomy [ 4 , 5 , 11 , 12 ]. Promoting the awareness of OC risk and protective factors may lead to behavioral changes that could lower women’s risk to develop OC. These include smoking cessation, encouraging breastfeeding, having a lower body mass index, and decreasing or stopping the use of hormonal replacement therapy if not needed [ 4 , 6 , 13 ]. Raising the awareness of OC risk and protective factors could contribute to enhancing early diagnosis of OC [ 14 ]. This is especially critical for countries with under-funded healthcare systems, such as Palestine. This national study aimed to: (i) assess Palestinian women’s awareness level of OC risk and protective factors, (ii) compare awareness levels between women living in the Gaza Strip vs. those living in the West Bank and Jerusalem (WBJ), and (iii) identify the factors associated with good awareness.

Of 6095 participants approached, 5618 agreed and completed the questionnaire (response rate = 92.1%). A total of 5411 questionnaires were included in the final analysis (158 had missing data and 49 were ineligible): 3133 from the WBJ and 2278 from the Gaza Strip. The median age [IQR] for all study participants was 32.0 years [24.0, 44.0] ( Table 1 ). Participants living in the Gaza Strip were more likely to be younger, have lower education and monthly income, and suffer from less chronic diseases than participants living in the WBJ. n = number of participants, IQR = interquartile range, WBJ = West Bank and Jerusalem. The most identified modifiable risk factor was ‘being a smoker’ (n = 4024, 74.4%), whereas the least identified was ‘having IVF treatment’ (n = 1652, 30.5%) ( Table 2 ). The most identified non-modifiable risk factor was ‘having ovarian cysts’ (n = 3136, 58.0%), whereas the least identified was ‘having endometriosis’ (n = 1880, 34.7%). On the other hand, the most identified protective factor was ‘breastfeeding’ (n = 4770, 88.2%), whereas the least identified factor was ‘using the pill for a long time’ (n = 930, 17.2%). n = number of participants. WBJ = West Bank and Jerusalem, IVF = in vitro fertilization. Only 820 participants (15.2%) displayed good awareness of OC risk and protective factors ( Table 3 ). Participants from the Gaza Strip were slightly more likely than participants from the WBJ to have a good level of awareness (16.4% vs. 14.2%). On the multivariable analysis, living in the WBJ and visiting primary healthcare centers were both associated with a decrease in the likelihood of having a good awareness level of OC risk and protective factors ( Table 4 ). On the other hand, post-secondary education, high monthly income (≥1450 NIS), being married, and knowing someone with cancer were all associated with an increase in the likelihood of displaying a good awareness level. n = number of participants, WBJ = West Bank and Jerusalem. COR = crude odds ratio, AOR = adjusted odds ratio, CI = confidence interval, WBJ = West Bank and Jerusalem. * Adjusted for age-group, menarche, educational level, occupation, monthly income, marital status, residency, having a chronic disease, knowing someone with cancer, and site of data collection. On the multivariable analysis, participants form the WBJ were less likely than the participants from the Gaza Strip to identify all modifiable risk factors except ‘using talcum powder in the genital area’, where no difference was noticed (S1 Table in S1 File ). On the contrary, married women were more likely than single women to identify all modifiable risk factors except ‘having IVF treatment’ for which no difference was noticed. The multivariable analysis showed that women living in the WBJ were less likely than women living in the Gaza Strip to recognize all non-modifiable risk factors except ‘having a close relative with OC’ for which the opposite was noticed (S2 Table in S1 File ). In addition, visitors to primary healthcare centers were less likely than visitors to public spaces to identify all non-modifiable risk factors except ‘having a close relative with OC’, where no difference was found. Conversely, participants who knew someone with cancer had a higher likelihood than those who did not to identify all non-modifiable risk factors. Women who knew someone with cancer were more likely to identify ‘breastfeeding’ and ‘undergoing prophylactic bilateral oophorectomy’ as OC protective factors (S3 Table in S1 File ). On the other hand, women who were employed or recruited from primary healthcare centers were less likely to identify ‘breastfeeding’ and ‘undergoing prophylactic bilateral oophorectomy’ as protective factors.

The awareness level of OC risk and protective factors among women included in this study was low with only 15.2% demonstrating good awareness. Women from the Gaza Strip were slightly more likely to demonstrate higher awareness than women from the WBJ. Higher education and monthly income, being married, and knowing someone with cancer were all associated with higher likelihood of having good awareness. The most commonly identified modifiable OC risk factor was ’being a smoker’ while the least identified was ‘having IVF treatment’. The most commonly identified non-modifiable OC risk factor was ‘having ovarian cysts’ while the least identified was ‘having endometriosis’. Finally, the most frequently identified OC protective factor was ‘breastfeeding’ while the least frequently identified protective factor was ‘using the pill for a long time’. The findings of this study open new opportunities for targeted educational interventions to facilitate prevention and early detection of OC.

This was a cross-sectional study conducted between July 2019 and March 2020 in the two main areas of Palestine: the Gaza Strip and the WBJ. Palestinian women aged 18 or over were the study population. Female visitors to Palestinian government hospitals, primary healthcare centers, and public spaces, such as malls, markets, gardens, restaurants, churches, mosques, and transportation stations, were recruited. Women with non-Palestinian citizenship, women working or studying in a health-related field, and those visiting oncology departments or clinics at the time of data collection were all excluded from the study. Eligible women were recruited using a convenience sampling method from governmental hospitals, primary healthcare centers and public spaces in 11 governorates across Palestine. This was intended to make the study cohort resemble the Palestinian community by recruiting participants from different places and with varying sociodemographics [ 15 – 17 ]. A modified version of the OC Awareness Measure (OCAM) was utilized for data collection. The OCAM is a validated tool that was created to assess public awareness of OC [ 6 ]. Two bilingual experts first translated the original OCAM from English into Arabic, and then another two bilingual experts back-translated it into English. Five experts in the fields of gynecologic oncology, public health, and survey design reviewed the Arabic version of the OCAM for content validity and accuracy of translation. A pilot study (n = 128) was then conducted to test the clarity of the Arabic version of the OCAM. Participants included in the pilot study were excluded from the final analysis. Internal consistency of the Arabic OCAM was evaluated using Cronbach’s Alpha, which reached an acceptable value of 0.734. For the purposes of this study, the same 12 OC risk factors mentioned in the original OCAM were used in the questionnaire. However, three OC protective factors that were not part of the original OCAM were added. Those included breastfeeding, the use of oral contraceptive pills, and undergoing bilateral salpingo-oophorectomy. Exploring the awareness of those factors in Palestine was deemed important due to common misconceptions about them [ 18 ], therefore, they were added. The final questionnaire consisted of three sections. The first section described the sociodemographics of study participants. The second section assessed the participant’s awareness of 12 OC risk factors. The third section assessed the participant’s awareness of three OC protective factors. The awareness of OC risk and protective factors was evaluated using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The electronic tool ‘Kobo Toolbox’ was utilized to collect data [ 19 ]. Kobo Toolbox is a secure tool that can be used both offline and online on mobile devices. Participants were invited to fill out the questionnaire in a face-to-face interview. Female data collectors with medical backgrounds were trained on how to use Kobo Toolbox, how to approach the study participants, and how to facilitate their completion of the questionnaire. Ethical approval was obtained from the Palestinian Ministry of Health to collect data from hospitals and primary healthcare centers. The study was also approved by the Ethics Committee at the Islamic University of Gaza and the Helsinki Committee for Research Ethics in the Gaza Strip. The purpose of the study was explained to study participants and a written informed consent was taken before enrollment into the study. Data were collected anonymously, and confidentiality was kept throughout the study. Characteristics of participants were summarized utilizing descriptive statistics. The median and interquartile range (IQR) were used to describe continuous non-normally distributed variables. Frequencies (n) and percentages (%) were utilized to describe categorical variables. In order to reflect the age-related risk of OC, age was categorized into two groups: 18 to 44 years and 45 years or older (at-risk group) [ 6 ]. The onset of menstruation (menarche) was categorized into three categories; early (≤ 10 years), normal (11–15 years), and late (≥ 16 years) [ 20 ]. The cutoff of 1450 NIS (about $450) was selected to categorize the monthly income into two categories since it was the minimum wage in Palestine [ 21 ]. A baseline comparison between characteristics of participants living in the Gaza Strip and of those living in the WBJ was performed using the Kruskal-Wallis test if the variable was continuous or the Pearson’s Chi-square test if it was categorical. Answers to questions about OC risk and protective factors with ‘strongly agree’ or ‘agree’ were considered correct, whereas answers with ‘strongly disagree’, ‘disagree’, or ‘not sure’ were considered incorrect. OC risk factors were categorized into two categories: modifiable and non-modifiable. Identifying each of the OC risk/protective factors was described utilizing frequencies and percentages with comparisons performed utilizing Pearson’s Chi-Square test. This was followed by running bivariable and multivariable logistic regression. The model of the multivariable analysis included age-group, menarche, educational level, occupation, monthly income, residency, having a chronic disease, knowing someone with cancer, marital status, and site of data collection. This model was determined a priori based on previous studies [ 14 , 16 , 22 – 25 ]. Results of bivariable analyses are provided in the supplementary materials. To evaluate the participant’s awareness level about OC risk and protective factors, a scoring system was utilized. Similar scoring systems were used in previous studies [ 15 – 17 , 26 , 27 ]. The total score (ranging from 0 to 15) was calculated and categorized into three categories: poor (0 to 5), fair (6 to 10) and good awareness (11 to 15). Pearson’s Chi-Square test was used to compare the awareness level between the participants from the Gaza Strip vs. the WBJ. The association between participant characteristics and having good awareness level was tested using bivariable and multivariable logistic regression analyses. Missing data were hypothesized to be missed completely at random. Therefore, complete case analysis was used to handle missing data, where questionnaires with at least one variable missing were excluded from the analysis. Data were analyzed using Stata software version 16.0 (StataCorp, College Station, Texas, United States).

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