Awareness of lung cancer risk factors and symptoms in Syria: an online cross-sectional study

Hidar Alibrahim; Haidara Bohsas; Sarya Swed; Yasmeen Abouainain; Mohammad Badr Almoshantaf; Mohamad Nour Nasif; Lazaward Kazan; Rawan Farid Alnadaf; Nadim Schkeif; Raghad Al Ali; Bisher Sawaf; Enas Swed; Sherihan fathey; Gowhar Rashid; Wael Hafez

doi:10.12688/f1000research.144432.1

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Research Article

Awareness of lung cancer risk factors and symptoms in Syria: an online cross-sectional study

[version 1; peer review: 1 approved, 1 not approved]

Hidar Alibrahim¹, Haidara Bohsas¹, Sarya Swed¹, [...] Yasmeen Abouainain², Mohammad Badr Almoshantaf ³, Mohamad Nour Nasif¹, Lazaward Kazan⁴, Rawan Farid Alnadaf⁵, Nadim Schkeif⁵, Raghad Al Ali⁵, Bisher Sawaf⁶, Enas Swed⁷, Sherihan fathey⁸, Gowhar Rashid⁹, Wael Hafez^10,11

Hidar Alibrahim¹, Haidara Bohsas¹, [...] Sarya Swed¹, Yasmeen Abouainain², Mohammad Badr Almoshantaf ³, Mohamad Nour Nasif¹, Lazaward Kazan⁴, Rawan Farid Alnadaf⁵, Nadim Schkeif⁵, Raghad Al Ali⁵, Bisher Sawaf⁶, Enas Swed⁷, Sherihan fathey⁸, Gowhar Rashid⁹, Wael Hafez^10,11

PUBLISHED 11 Mar 2024

Author details Author details

¹ Faculty of Medicine, Aleppo University, Aleppo, Syria
² University of Jordan, Amman, Faculty of Medicine, University of Jordan,, Amman, Jordan
³ Neurosurgery, Ibn Al-walid Hospital, Homs, Homs, Syria
⁴ Altınbaş university, ISTANBUL, Turkey
⁵ Faculty of Medicine, Damascus University, Damascus, Damascus Governorate, Syria
⁶ Hamad Bin Khalifa University, Doha, Doha, Qatar
⁷ Faculty of Pharmacy, Damascus University, Damascus, Damascus Governorate, Syria
⁸ Health, Giza university, Giza, Egypt
⁹ Amity Medical School, Amity University, Haryana, India
¹⁰ NMC Royal Hospital, Abu Dhabi, United Arab Emirates
¹¹ Internal Medicine, The National Research Centre, Cairo, Egypt

Hidar Alibrahim
Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing

Haidara Bohsas
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Sarya Swed
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Yasmeen Abouainain
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Mohammad Badr Almoshantaf
Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing

Mohamad Nour Nasif
Roles: Writing – Original Draft Preparation

Lazaward Kazan
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Rawan Farid Alnadaf
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Nadim Schkeif
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Raghad Al Ali
Roles: Writing – Original Draft Preparation

Bisher Sawaf
Roles: Writing – Original Draft Preparation

Enas Swed
Roles: Writing – Original Draft Preparation

Sherihan fathey
Roles: Writing – Original Draft Preparation

Gowhar Rashid
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Wael Hafez
Roles: Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Globally, lung cancer is the leading cause of cancer fatalities and the second most frequent cancer. Population knowledge of the features of lung cancer is a crucial strategy for early diagnosis and decreasing the mortality rate of lung cancer patients. In this study, we aim to assess the Syrian population’s knowledge of lung cancer and its risk factors and to measure awareness of symptoms related to lung cancer.

Methods

This national cross-sectional study was conducted between October 12 to November 21, 2022, in Syria. We included Syrian people above 18 years from all Syrian governorates. The questionnaire consisted of three categories of questions: sociodemographic information, awareness of lung cancer symptoms, and awareness of lung cancer risk factors.

Results

Overall, 2251 participants were involved in this research; almost half of them (47.3%) were aged between 21-30 years, and 30.9% indicated they are smoking cigarettes. The overall mean score of knowledge regarding closed questions about risk factors of lung cancer was 4.29; however, the mean score of knowledge regarding open questions about symptoms of lung cancer was 1.52. About half of the study sample (51.3%) indicated that unexplained weight loss is a possible symptom of lung cancer. Our findings showed that cigarette smokers have a lower probability of having adequate knowledge toward lung cancer risk factors than a non-smoker (AOR=0.73, COR=0.68, P-value<0.05). We also defined that females have higher statistically significant odds (AOR=1.3, COR=1.38, P-value<0.05) for being knowledgeable about the symptoms of lung cancer compared to the male sample study.

Conclusion

According to our findings, there is inadequate knowledge toward lung cancer risk factors and moderate knowledge of lung cancer symptoms. Along with educational programs to raise public knowledge of the dangers of smoking and other LC risk factors, effective tobacco control policy execution is crucial.

Keywords

Lung Cancer, Risk factors, Symptoms, Syria

Corresponding author: Mohammad Badr Almoshantaf

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Alibrahim H et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Alibrahim H, Bohsas H, Swed S et al. Awareness of lung cancer risk factors and symptoms in Syria: an online cross-sectional study [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2024, 13:172 (https://doi.org/10.12688/f1000research.144432.1) First published: 11 Mar 2024, 13:172 (https://doi.org/10.12688/f1000research.144432.1) Latest published: 11 Mar 2024, 13:172 (https://doi.org/10.12688/f1000research.144432.1)

1. Background

Lung cancer is the most common cause of cancer-related deaths and the second most prevalent cancer worldwide (WHO, 2020). It is estimated that the incidence of lung cancer is 2.2 million globally. Also, there are 1.7 million death cases every year from lung cancer.¹^,² It is classified histologically into two types: Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC is more common, accounting for 85% of lung cancers, and includes three major subgroups: adenocarcinoma, large cell carcinoma, and squamous cell carcinoma.³ In 2018, the number of new lung cancer cases was evaluated as 79887 in the Middle East and North Africa region, and 2144 were from Syria. Although diagnosis and treatment of lung cancer have been improved, the 5-year survival rate in those regions remains at 8%. Among all countries in the region, Morocco and Tunisia had the highest number of lung cancer-related deaths.⁴ The most significant contributing risk factor to lung cancer is cigarette smoking. It is believed that there is a 5 to 10-fold increase in lung cancer risk among smokers. Also, the risk increases by 20% for nonsmokers exposed to passive smoking.⁵ Although more than 85% of the cases are caused by avoidable tobacco exposure, lung cancer remains the leading cause of cancer deaths worldwide.⁴^,⁶ Other risk factors include family history, genetic tendency, occupational exposure (radon, ionizing radiation, diesel, and asbestos), chronic lung diseases and infections, lifestyle factors, and bad diet habits.⁶^,⁷ Since lung cancer symptoms are non-specific, most patients are diagnosed at advanced stages, particularly stage IV.⁸ The most presenting symptoms are persistent cough, hemoptysis, chest pain, and dyspnea. Other metastatic symptoms can also occur, such as weight loss, fatigue, fever, and bone pain.⁸^,⁹ It is confirmed that many genetic and epigenetic modifications are triggered by cigarette smoking.¹⁰ The knowledge of lung cancer-associated epigenetics helps us assess the risk, understand the process of carcinogenesis, diagnose the subtypes of cancer and predict the aggressiveness of the cancerous cells, response to treatment, prognosis, and metastasis. Therefore, we can make effective screening and treatment plans targeting those epigenetic alterations.¹⁰^–¹² An early lung cancer diagnosis is critical to decreasing mortality and enhancing prognosis. Screening people at high risk using low-dose computed tomography (LDCT) results in a 20% reduction in mortality rate, as proved by The National Lung Screening Trial (NLST). Annual screening of high-risk groups starting from age 50 is recommended in many current guidelines.¹³^–¹⁵ It is recognized that late lung cancer diagnosis is due to the lack of understanding of the disease’s common symptoms. Therefore, raising public knowledge and awareness of lung cancer is crucial for early detection and treatment.¹⁶ It is believed that low-income countries and high tobacco consumption have less knowledge of symptoms and contributing factors of lung cancer, resulting in less effective treatment and a low survival rate.¹^,⁴ Therefore, our aim in this study is to assess the knowledge of lung cancer and its risk factors and to measure the awareness of lung cancer-related symptoms among the Syrian population.

2. Methods

2.1 Study design and setting

An online survey cross-sectional study was conducted between October 12 to November 21, 2022 in Syria. The inclusion criteria of study participants were adults (≥18 years old), Syrian nationals from all Syrian governorates. Participants who were non-Syrians, students or workers in healthcare facilities were excluded from the study. This survey was created in the light of a previous research that used modified, approved scales.¹⁷^,¹⁸ Then, the questionnaire was translated into Arabic by healthcare professionals in order to be easily understood and answered for the participants, which the utilized questionnaire was uploaded as extended data (see data availability statement). Specific collaborators from many medical Syrian colleges (Data Collection Group) were responsible to collect the data by disrupting the online survey, which was generate at google form website, on social media platforms such as WhatsApp, Telegram, and Facebook. Regarding, the sample size calculation, it was estimated using Calculator.net tool (Population Size (The number of the individuals of the Syrian community in 2021 according to the world bank organization¹⁹ (PS) = 18,275,704. The proportion of the population who are aware toward the lung cancer (PP) = 50%, Confidence level (CL) = 95%, and the margin error (ME) = 5%, which the recommended sample size to represent overall findings at level of the Syrian population was 385.

2.2 Measures

A modified version of the Lung Cancer Awareness Measure (LCAM) was utilized as an assessment tool. LCAM is a face-to-face questionnaire that was developed and approved by University College London and Cancer Research UK to measure the awareness of lung cancer.²⁰ The questionnaire had three parts: The first one contained sociodemographic data of the participants. The second part focused on measuring the awareness of the — symptoms of lung cancer, and the last part analyzed the level of the knowledge toward the lung cancer risk factors. Although the awareness level was assessed in the original LCAM questions by using yes/no/unknown responses scale, in modified Arabic LCAM we used a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) to reduce the possibilities of random answers. Then, the resultant responses were converted into correct/incorrect responses as was done in the previous researches.²¹^–²⁵

2.2.1 Sociodemographic variables

In this section, the sociodemographic data of the respondents were included. There were 10 questions covering the needed details about: 1) age. 2) Gender. 3) Marital status explained as single, married, divorced, or widowed. 4) Educational level as below secondary or post-secondary. 5) Occupational status as unemployed, student, employed, or retired. 6) Monthly income. 7) Suffering from a chronic disease. 8) Living place. 9) Knowing someone diagnosed with cancer. 10) History of cigarette/water pipe smoking expressed as never smoked, former, or current smoker.

2.2.2 Awareness of lung cancer symptoms

This section was contained 14 questions with answers using 3- Likert scale (Yes, No, I don’t know) evaluating participants’ awareness level of symptoms lung cancer. Included symptoms were 1) unexplained weight loss. 2) Persistent chest infection ≥ 3 weeks. 3) Persistent cough for ≥ 2/3 weeks. 4) Persistent shortness of breath. 5) Persistent tiredness. 6) Persistent chest pain. 7) Persistent shoulder pain. 8) Coughing up blood. 9) Pain while breathing. 10) Loss of appetite. 11) Painful cough. 12) Changes in the shape of fingers and nails. 13) Developing an unexplained loud, high-pitched sound when breathing. 14) Worsening or change in an existing cough.

2.2.3 Awareness of lung cancer risk factors

This part involved 9 questions with answers using 5 - Likert scale (1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree) evaluating participants’ awareness level of risk factors lung cancer. Included risk factors were 1) Exposure to radon gas. 2) Exposure to near smoker. 3) Having a previous treatment of cancer. 4) Having a relative with lung cancer patient. 5) Exposure to chemicals such as asbestos. 6) Having a previous diagnosis of any cancer. 7) Air pollution. 8) Smoking. 9) Having a previous diagnosis with lung disease such as interstitial lung disease.

2.3 Pilot study

To ensure clarity and readability for respondents, we distributed the online survey among various Syrian individuals and incorporated their feedback to enhance the questionnaire. Although the initial questionnaire was adapted from a study conducted in an Arabic country (Palestine),²¹ we rigorously assessed its reliability and validity. Specifically, we computed Cronbach’s alpha for each scale, including knowledge of risk factors and symptoms of lung cancer, confirming consistency with previously published work.

2.4 Ethical consideration

The study was ethically reviewed and approved by Syrian Ethical Society for Scientific Research in Aleppo University (IRB: SA19/01). In compliance with ethical standards, a comprehensive statement about informed consent was provided to all participants on the first page of the online survey. At the first page of the online survey, all participants were informed about the study goal, research group’s identity, their right to pull out from the research, collected data privacy and protection, and the fact that only totally submitted information would be analyzed. Completing the whole survey takes from 5 to 10 minutes. For clarity, consent from participants was obtained, and this process was approved by the ethical review committee. Participants were presented with the necessary information to make an informed decision, and their consent was obtained written.

2.5 Statistical analysis

The IBM SPSS V. 28.0 package application was used to analyses the data (IBM Corporation, Armonk, NY, USA). a proprietary research instruments. It is confirmed that a valid copyright license for the use of SPSS v. 28.0 has been obtained. A P-value of 0.05 or less indicated statistical significance. A mean and standard deviation were provided for the quantitative data. In contrast, the categorical data was presented as frequency and percentage after the Shapiro-Wilk test confirmed that the distribution of the data was non-parametric. Kruskal–Wallis one-way analysis of variance and One-way analysis of variance tests were performed to determine the difference in the level of knowledge toward the risk factors and symptoms of the lung cancer between the subgroups. In order to determine the expected values of “Odds ratios” between the dependent variable (knowledge the risk factors and symptoms of the lung cancer) and independent factors (sociodemographic variables), we utilized a binary logistic regression, which we relied on the cut off points from the Palestinian research.¹⁷^,¹⁸

3. Results

3.1 Sociodemographic characteristics and health-related factors of study participants

We define that 2303 participants were invited to participate in this study, and 52 participants refused to complete the received online survey, so the final sample size of the study participants was 2251. Almost half of the respondents (n = 1041, 47.3%) aged between 21-30 years, and about two-thirds were females and were lived in the city (n = 1430, 63.5%), (n = 1475, 65.5%). Regarding the educational level, 72.6% of participants had a university (Bachelor’s\Master) degree, and 35.1% (n = 791) of respondents were married. However, 1234 of the study participants (54.8%) reported moderate monthly income. The majority of participants (92.7%) were with no chronic disease. Finally, 30.9% of study participants indicated they were smokers (Table 1).

Table 1. Baseline characteristics of the inquired participants in the study sample.

Variable		Frequency	Percentage %
Age	18-20	470	21.3%
	21-30	1041	47.3%
	31-40	332	15.1%
	41-50	214	9.7%
	51-60	111	5.0%
	61-70	31	1.4%
	70<	4	0.2%
Gender	Male	821	36.5%
Gender	Female	1430	63.5%
Residency	Village	776	34.5%
Residency	City	1475	65.5%
Educational level	Primary	46	2.0%
	Secondary (1-3)	133	5.9%
	Secondary (4-6)	415	18.4%
	University (Bachelor’s\Master)	1634	72.6%
	Ph.D.	23	1.0%
Marital status	Married	791	35.1%
	Single	1399	62.2%
	Widowed	30	1.3%
	Divorced	31	1.4%
Occupation	Unemployed	351	15.6%
	Student	940	41.8%
	Employed	960	42.6%
Monthly income	Bad	179	8.0%
	Moderate	1234	54.8%
	Good	766	34.0%
	Excellent	72	3.2%
Chronic disease	No	2087	92.7%
Chronic disease	Yes	164	7.3%
Have you ever smoked cigarettes?	No	1556	69.1%
Have you ever smoked cigarettes?	Yes	695	30.9%

3.2 Summary of participants’ knowledge scores on lung cancer risk factors and symptoms

The mean score and standard deviation of knowledge regarding closed questions of risk factors of lung cancer (mean = 4.29, SD = 2.32); however, the mean score and stander deviation regarding the open questions were 8.63 and 3.07, respectively. Concerning the knowledge of lung cancer symptoms, the closed questions scored mean = 8.63, SD = 3.07, while open questions scored (mean = 1.52, SD = 1.25) (Table 2).

Table 2. The observational findings of the utilized sub-scales.

Items	Mean	Std. Deviation	Minimum	Maximum
Knowledge of risk factors (Closed)	4.29	2.42	.00	9.00
knowledge of lung cancer symptoms (Closed)	8.63	3.07	.00	14.00
Knowledge of risk factors (open)	1.29	0.83	.00	7.00
knowledge of lung cancer symptoms (open)	1.52	1.25	.00	7.00

3.2.1 Participants’ Awareness of Lung Cancer Symptoms

Concerning the knowledge toward lung cancer symptoms, about half of the study respondents (1155, 51.3%) indicated that unexplained weight loss is a possible symptom. On the other hand, about 80% of participants believed that persistent (3 weeks or longer) chest infection might be a lung cancer symptom. Regarding the persistent shortness of breath (1904, 84.6%) of participants revealed it as one of the lung cancer symptoms. Nearly a quarter of participants didn’t identify loss of appetite as a possible symptom of lung cancer (543, 24.1%). Also, about a third of respondents didn’t recognize that lung cancer symptom include changes in the shape of fingers or nails. Finally, (n=518, 23.0%) didn’t know if worsening or change in an existing cough is one of the lung cancer symptoms (Table 3).

Table 3. The description of the inquired items within the knowledge of lung cancer symptoms scale.

Statement		Frequency	Percentage %
1. Unexplained weight loss	No	501	22.3%
	Don’t Know	595	26.4%
	Yes	1155	51.3%
2. Persistent (3 weeks or longer) chest infection	No	221	9.8%
	Don’t Know	232	10.3%
	Yes	1798	79.9%
3. A cough that does not go away for two or three weeks	No	227	10.1%
	Don’t Know	227	10.1%
	Yes	1797	79.8%
4. Persistent shortness of breath	No	170	7.6%
	Don’t Know	177	7.9%
	Yes	1904	84.6%
5. Persistent tiredness or lack of energy	No	377	16.7%
	Don’t Know	620	27.5%
	Yes	1254	55.7%
6. Persistent chest pain	No	210	9.3%
	Don’t Know	240	10.7%
	Yes	1801	80.0%
7. Persistent shoulder pain	No	724	32.2%
	Don’t Know	933	41.4%
	Yes	594	26.4%
8. Coughing up blood	No	324	14.4%
	Don’t Know	318	14.1%
	Yes	1609	71.5%
9. An ache or pain when breathing	No	262	11.6%
	Don’t Know	398	17.7%
	Yes	1591	70.7%
10. Loss of appetite	No	543	24.1%
	Don’t Know	726	32.3%
	Yes	982	43.6%
11. Painful cough	No	211	9.4%
	Don’t Know	325	14.4%
	Yes	1715	76.2%
12. Changes in the shape of your fingers or nails	No	769	34.2%
	Don’t Know	1026	45.6%
	Yes	456	20.3%
13. Developing an unexplained loud, high-pitched sound when breathing	No	348	15.5%
	Don’t Know	641	28.5%
	Yes	1262	56.1%
14. Worsening or change in an existing cough	No	218	9.7%
	Don’t Know	518	23.0%
	Yes	1515	67.3%

3.3 Participants’ perceptions of lung cancer risk factors: Responses to specific statements

Regarding the knowledge of lung cancer risk factors, 45.7% of study participants were unsure whether exposure to radon gas is one of the risk factors. As well, concerning cigarette smoke exposure, about half of the participants (n = 1065, 47.3%) agreed it is a lung cancer risk factor. Almost a quarter of respondents (546, 24.3%) didn’t agree that lung cancer risk factors included the presence of a close relative with lung cancer. In addition, 8.3% of participants strongly disagreed that exposure to chemicals, for example asbestos is one of the lung cancer risk factors, and just half of the study respondents indicated that smoking is a risk factor for developing lung cancer (Table 4).

Table 4. The description of the inquired items within the knowledge of lung cancer risk factors scale.

Statement		Frequency	Percentage %
Exposure to radon gas	Strongly Disagree	165	7.3%
	Disagree	144	6.4%
	Not Sure	1028	45.7%
	Agree	712	31.6%
	Strongly agree	202	9.0%
Cigarette smoke exposure	Strongly Disagree	181	8.0%
	Disagree	348	15.5%
	Not Sure	377	16.7%
	Agree	1065	47.3%
	Strongly Agree	280	12.4%
Past cancer treatment	Strongly Disagree	163	7.2%
	Disagree	504	22.4%
	Not Sure	942	41.8%
	Agree	549	24.4%
	Strongly Agree	93	4.1%
Close relative with lung cancer	Strongly Disagree	374	16.6%
	Disagree	546	24.3%
	Not Sure	573	25.5%
	Agree	649	28.8%
	Strongly Agree	109	4.8%
Exposure to chemicals for example asbestos	Strongly Disagree	186	8.3%
	Disagree	151	6.7%
	Not Sure	653	29.0%
	Agree	1006	44.7%
	Strongly Agree	255	11.3%
Past history of cancer, for example head and neck	Strongly Disagree	218	9.7%
	Disagree	444	19.7%
	Not Sure	869	38.6%
	Agree	639	28.4%
	Strongly Agree	81	3.6%
Air pollution	Strongly Disagree	199	8.8%
	Disagree	282	12.5%
	Not Sure	470	20.9%
	Agree	1082	48.1%
	Strongly Agree	218	9.7%
Being a smoker	Strongly Disagree	216	9.6%
	Disagree	119	5.3%
	Not Sure	189	8.4%
	Agree	1134	50.4%
	Strongly Agree	593	26.3%
History of lung disease, for example Chronic obstructive pulmonary disease	Strongly Disagree	204	9.1%
	Disagree	283	12.6%
	Not Sure	770	34.2%
	Agree	809	35.9%
	Strongly Agree	185	8.2%

3.4 Knowledge of lung cancer symptoms and risk factors by demographic characteristics

As shown in Table 5, we noticed the mean score of knowledge (8.78, 4.38) toward symptoms and risk factors of lung cancer were higher in females than males. Regarding the education status, participants with University (Bachelor’s\Master) and with a Ph.D. degree were more knowledgeable (mean = 8.77, 4.65) about lung cancer symptoms and risk factors, respectively. However, single participants had more knowledge (mean = 4.44) of risk factors of lung cancer than other marital status subgroups. Students had more averages of knowledge about symptoms and risk factors of lung cancer compared to other occupation status subgroups. Respondents who were smokers were less knowledgeable about identifying lung cancer symptoms and risk factors (mean = 8.36, 3.99). The participants said that persons aged 70 years old had a higher understanding regarding the symptoms and risk factors of lung cancer (Table 5).

Table 5. Knowledge of lung cancer symptoms and risk factors score for each sub-groups in the inquired sample.

Statement	Age
Statement	Age groups	Mean	Std. Deviation	P-value
Knowledge of symptoms of lung cancer	20>	8.4702	2.97218	0.420760
	21-30	8.7185	2.92544
	31-40	8.4849	3.30198
	41-50	8.6168	3.30356
	51-60	9.0000	3.46935
	61-70	8.7097	3.33860
	70<	6.7500	3.50000
	Total	8.6310	3.06818
Knowledge of risk factors of lung cancer	20>	4.2213	2.28977	0.089128
	21-30	4.4419	2.38399
	31-40	4.2500	2.44100
	41-50	4.2103	2.48520
	51-60	3.8288	2.93838
	61-70	4.2581	2.35185
	70<	2.5000	1.73205
	Total	4.3064	2.41534
Gender
Knowledge of symptoms of lung cancer	Male	8.3630	3.21919	0.001594
	Female	8.7881	2.98384
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	Male	4.1352	2.36437	0.020010
	Female	4.3818	2.45056
	Total	4.2919	2.42187
Residency
Knowledge of symptoms of lung cancer	Village	8.6933	3.09485	0.500681
	City	8.6014	3.06948
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	Village	4.2255	2.43298	0.345868
	City	4.3268	2.41609
	Total	4.2919	2.42187
Education’s status
Knowledge of symptoms of lung cancer	Primary	7.2826	3.82775	0.000005
	Secondary (1-3)	7.6015	3.83749
	Secondary (4-6)	8.5928	3.27270
	University (Bachelor’s\Master)	8.7785	2.89580
	Ph.D.	7.6957	3.71036
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	Primary	2.7391	2.39847	0.000
	Secondary (1-3)	3.2932	2.68210
	Secondary (4-6)	4.0337	2.53551
	University (Bachelor’s\Master)	4.4774	2.33397
	Ph.D.	4.6522	2.14495
	Total	4.2919	2.42187
Monthly income
Knowledge of symptoms of lung cancer	Bad	8.3966	3.53541	0.104242
	Moderate	8.5600	2.98062
	Good	8.8394	3.08003
	Excellent	8.2778	3.39935
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	Bad	4.0726	2.67537	0.554220
	Moderate	4.2804	2.34304
	Good	4.3525	2.46036
	Excellent	4.3889	2.68305
	Total	4.2919	2.42187
Marital status
Knowledge of symptoms of lung cancer	Married	8.6321	3.30668	0.882820
	Single	8.6219	2.93625
	Widowed	8.7333	3.61923
	Divorced	9.0645	2.81585
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	Married	4.0632	2.57073	0.001376
	Single	4.4417	2.31636
	Widowed	3.5333	2.59620
	Divorced	4.0968	2.50805
	Total	4.2919	2.42187
Occupation
Knowledge of symptoms of lung cancer	Unemployed	8.7379	3.33975	0.014080
	Student	8.8160	2.88862
	Employed	8.4156	3.14660
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	Unemployed	4.0627	2.55042	0.001754
	Student	4.5021	2.33120
	Employed	4.1698	2.44722
	Total	4.2919	2.42187
Chronic disease
Knowledge of symptoms of lung cancer	No	8.6593	3.02584	0.148658
	Yes	8.2988	3.67078
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	No	4.3076	2.40191	0.271187
	Yes	4.0915	2.66266
	Total	4.2919	2.42187
Have you ever smoked cigarettes?
Knowledge of symptoms of lung cancer	No	8.7532	2.99273	0.005555
	Yes	8.3640	3.24657
	Total	8.6331	3.07787
Knowledge of risk factors of lung cancer	No	4.4248	2.40474	0.000095
	Yes	3.9942	2.43532
	Total	4.2919	2.42187
Taking an appointment from a doctor
Knowledge of symptoms of lung cancer	I don’t have symptoms	8.5204	3.60924	0.000163
	I don’t know	7.2874	4.17609
	I will wait for a week or more	8.8362	2.92962
	Immediately (within 3 days)	8.7329	2.87410
	Total	8.6635	3.05239
Knowledge of risk factors of lung cancer	I don’t have symptoms	4.1338	2.49565	0.000007
	I don’t know	3.1034	2.66779
	I will wait for a week or more	4.2560	2.43392
	Immediately (within 3 days)	4.4200	2.35949
	Total	4.3111	2.41217
Who is most at risk of developing lung cancer in the next year?
The Knowledge of symptoms of lung cancer	Not related to age	8.4490	3.09703	0.000047
	30 years old person	8.3506	3.41346
	50 years old person	9.1184	2.91826
	70 years old person	9.1692	2.96163
	Total	8.6331	3.07787
The Knowledge of risk factors of lung cancer	Not related to age	4.1937	2.35402	0.000007
	30 years old person	3.6623	2.52675
	50 years old person	4.4324	2.53097
	70 years old person	5.0050	2.52685
	Total	4.2919	2.42187

3.5 Association between knowledge of lung cancer risk factors and demographic characteristics

In overall, good knowledge toward the risk factors of lung cancer was shown in females (34.8%, P-value < 0.05) more than in males (17.8%), and for the educational level, more knowledgeable persons were found in participants with university (Bachelor’s\Master) degree group (40.4%, P-value < 0.01) compared to other educational sub-groups. Participants who were smokers and had an inadequate level of awareness regarding risk factors formed just 14.2%, and the participants who reported lung cancer not related to age and had good knowledge of risk factors of lung cancer were (34.8%) (Table 6).

Table 6. Knowledge of Risk factors based on baseline characteristics of the study sample.

Statement		Knowledge of Risk factors of lung cancer				P-value
		Poor knowledge		Good knowledge
		Frequency	Percentage %	Frequency	Percentage %
Age	20>	229	10.4%	241	10.9%	0.125848
	21-30	470	21.3%	571	25.9%
	31-40	164	7.4%	168	7.6%
	41-50	105	4.8%	109	4.9%
	51-60	58	2.6%	53	2.4%
	61-70	12	0.5%	19	0.9%
	70<	4	0.2%	0	0.0%
Gender	Male	421	18.7%	400	17.8%	0.006468
Gender	Female	646	28.7%	784	34.8%	0.006468
Residency	Village	387	17.2%	389	17.3%	0.279274
Residency	City	680	30.2%	795	35.3%	0.279274
Educational level	Primary	34	1.5%	12	0.5%	0.000
	Secondary (1-3)	88	3.9%	45	2.0%
	Secondary (4-6)	211	9.4%	204	9.1%
	University (Bachelor’s\Master)	725	32.2%	909	40.4%
	Ph.D.	9	0.4%	14	0.6%
Marital status	Married	399	17.7%	392	17.4%	0.007510
	Single	635	28.2%	764	33.9%
	Widowed	16	0.7%	14	0.6%
	Divorced	17	0.8%	14	0.6%
Occupation	Unemployed	179	8.0%	172	7.6%	0.003189
	Student	413	18.3%	527	23.4%
	Employed	475	21.1%	485	21.5%
Monthly income	Bad	99	4.4%	80	3.6%	0.447395
	Moderate	580	25.8%	654	29.1%
	Good	357	15.9%	409	18.2%
	Excellent	31	1.4%	41	1.8%
Chronic disease	No	987	43.8%	1100	48.9%	0.296619
Chronic disease	Yes	80	3.6%	84	3.7%	0.296619
Have you ever smoked cigarettes?	No	692	30.7%	864	38.4%	0.000065
Have you ever smoked cigarettes?	Yes	375	16.7%	320	14.2%	0.000065
Taking an appointment from a doctor	I don’t have symptoms	129	5.9%	140	6.4%	0.000251
	I don’t know	52	2.4%	35	1.6%
	I will wait for a week or more	140	6.4%	153	7.0%
	Immediately (within 3 days)	714	32.5%	836	38.0%
Who is most at risk of developing lung cancer in the next year?	Not related to age	775	34.4%	784	34.8%	0.000002
	30 years old person	44	2.0%	33	1.5%
	50 years old person	175	7.8%	239	10.6%
	70 years old person	73	3.2%	128	5.7%
Knowledge of lung cancer symptoms	Poor Knowledge	582	25.9%	399	17.7%	0.000
Knowledge of lung cancer symptoms	Good Knowledge	485	21.5%	785	34.9%	0.000

3.6 Association between knowledge of lung cancer symptoms and demographic characteristics

There was a statistically significant difference between specific subgroups regarding the knowledge of symptoms of lung cancer, of which 37.7% and 25.8% of females have shown good and inadequate knowledge of risk factors of lung cancer, respectively. In addition, we define that there was a statistical difference between the educational subgroups regarding the level of knowledge of lung cancer risk factors, which the participants in the university educational category and those who had adequate knowledge (42.3%) were more than those who hadn’t (30.3%). In addition, less recognition toward lung cancer symptoms has been found among 29.1% of smokers, and 39.7% of respondents reported they taking an immediate appointment with a doctor with adequate knowledge toward lung cancer symptoms (Table 7).

Table 7. Knowledge of symptoms based on sociodemographic variables of the study sample.

Variable		Knowledge of lung cancer symptoms				P-value
		Poor knowledge		Good knowledge
		Count	Layer N %	Count	Layer N %
Age	20>	202	9.2%	268	12.2%	0.320125
	21-30	446	20.2%	595	27.0%
	31-40	152	6.9%	180	8.2%
	41-50	97	4.4%	117	5.3%
	51-60	44	2.0%	67	3.0%
	61-70	14	0.6%	17	0.8%
	70<	3	0.1%	1	0.0%
Gender	Male	400	17.8%	421	18.7%	0.001027
Gender	Female	581	25.8%	849	37.7%	0.001027
Residency	Village	331	14.7%	445	19.8%	0.369899
Residency	City	650	28.9%	825	36.7%	0.369899
Educational level	Primary	30	1.3%	16	0.7%	0.000388
	Secondary (1-3)	72	3.2%	61	2.7%
	Secondary (4-6)	185	8.2%	230	10.2%
	University (Bachelor’s\Master)	681	30.3%	953	42.3%
	Ph.D.	13	0.6%	10	0.4%
Marital status	Married	346	15.4%	445	19.8%	0.721687
	Single	610	27.1%	789	35.1%
	Widowed	11	0.5%	19	0.8%
	Divorced	14	0.6%	17	0.8%
Occupation	Unemployed	141	6.3%	210	9.3%	0.005210
	Student	384	17.1%	556	24.7%
	Employed	456	20.3%	504	22.4%
Monthly income	Bad	82	3.6%	97	4.3%	0.117684
	Moderate	559	24.8%	675	30.0%
	Good	305	13.5%	461	20.5%
	Excellent	35	1.6%	37	1.6%
Chronic disease	No	900	40.0%	1187	52.7%	0.380556
Chronic disease	Yes	81	3.6%	83	3.7%	0.380556
Have you ever smoked cigarettes?	No	655	29.1%	901	40.0%	0.010937
Have you ever smoked cigarettes?	Yes	326	14.5%	369	16.4%	0.010937
Taking an appointment from a doctor	I don't have symptoms	102	4.6%	167	7.6%	0.022422
	I don't know	49	2.2%	38	1.7%
	I will wait for a week or more	123	5.6%	170	7.7%
	Immediately (within 3 days)	678	30.8%	872	39.7%
Who is most at risk of developing lung cancer in the next year?	Not related to age	715	31.8%	844	37.5%	0.000199
	30 years old person	38	1.7%	39	1.7%
	50 years old person	157	7.0%	257	11.4%
	70 years old person	71	3.2%	130	5.8%
Knowledge of Risk factors	Poor Knowledge	582	25.9%	485	21.5%	0.000
Knowledge of Risk factors	Good Knowledge	399	17.7%	785	34.9%	0.000

3.7 Predictors of adequate knowledge toward lung cancer risk factors

Seven out of twelve predictor factors were significantly linked with a good knowledge of lung cancer risk factors (P-value < 0.05). The university participants (Bachelor’s\Master) educational category were more likelihood to recognize the lung cancer risk factors than other participants with primary degree (OR = 2.620, P-value < 0.05), and the respondents who were smokers were less likely to identify the adequate degree of the knowledge toward risk factors of lung cancer than who weren’t a smoker (OR = 0.773, P-value < 0.05). In addition, we showed that persons aged 70 years under the most risk of developing lung cancer in the next year had higher odds of understanding the risk factors 1.579 times than those who reported that lung cancer was not related to age (Table 8).

Table 8. Binary logistic regression of the predictors variables to having adequate level of knowledge toward lung cancer risk factors.

Predictor Item for having adequate knowledge toward lung cancer risk factors		P-value	Adjusted odds ratio	Upper	Lower	P-value	Non-adjusted odds ratio	Upper	Lower
Age	20>	Ref
	21-30	.088	1.261	.966	1.645	.197	1.154	.928	1.436
	31-40	.178	1.313	.884	1.952	.851	.973	.735	1.289
	41-50	.102	1.456	.928	2.286	.934	.986	.714	1.363
	51-60	.615	1.152	.664	1.997	.504	.868	.574	1.314
	61-70	.081	2.158	.909	5.119	.283	1.504	.714	3.169
	70<	.999	.000	.000	.	.999	.000	.000	.
Gender	Male	Ref
Gender	Female	.137	1.165	.952	1.425	.005	1.277	1.076	1.517
Residency	Village	Ref
Residency	City	.354	1.094	.904	1.325	.089	1.163	.977	1.384
Educational level	Primary	Ref
	Secondary (1-3)	.590	1.253	.552	2.847	.332	1.449	.685	3.066
	Secondary (4-6)	.037	2.257	1.050	4.854	.004	2.739	1.380	5.438
	University (Bachlor’s\Master)	.013	2.620	1.230	5.581	.000	3.552	1.826	6.910
	Phd	.022	3.967	1.220	12.901	.006	4.407	1.519	12.786
Marital status	Married	Ref
	Single	.174	1.210	.919	1.592	.023	1.225	1.028	1.458
	Widowed	.878	1.067	.464	2.456	.756	.891	.429	1.849
	Divorced	.614	1.228	.553	2.729	.631	.838	.408	1.724
Occupation	Unemployed	Ref
	Student	.625	1.089	.775	1.529	.024	1.328	1.039	1.698
	Employed	.956	.992	.742	1.326	.626	1.063	.832	1.357
Monthly income	Bad	Ref
	Moderate	.421	1.152	.816	1.627	.038	1.395	1.018	1.912
	Good	.859	1.033	.718	1.488	.036	1.418	1.022	1.966
	Excellent	.405	1.293	.707	2.365	.080	1.637	.943	2.842
Chronic disease	No	Ref
Chronic disease	Yes	.202	1.286	.873	1.895	.713	.942	.685	1.295
Have you ever smoked cigarettes?	No	Ref
Have you ever smoked cigarettes?	Yes	.014	.773	.628	.950	.000	.683	.571	.818
Taking an appointment from a doctor	I don’t have symptoms	Ref
	I don’t know	.344	.779	.465	1.306	.056	.620	.380	1.013
	I will wait for a week or more	.734	1.062	.749	1.508	.967	1.007	.723	1.403
	Immediately (within 3 days)	.388	1.128	.858	1.483	.566	1.079	.833	1.398
Who is most at risk of developing lung cancer in the next year?	Not related to age	Ref
	30 years old person	.456	.827	.501	1.363	.204	.741	.467	1.177
	50 years old person	.056	1.257	.994	1.589	.007	1.350	1.085	1.680
	70 years old person	.006	1.579	1.141	2.185	.000	1.733	1.279	2.349
Knowledge of lung cancer symptoms	Poor Knowledge	Ref
Knowledge of lung cancer symptoms	Good Knowledge	.000	2.258	1.887	2.703	.000	2.361	1.991	2.800

3.8 Predictors of adequate knowledge toward lung cancer symptoms

Five out of twelve predictor variables were significantly associated with having an acceptable level of knowledge of the symptoms of lung cancer (P-value < 0.05), which females more likelihood to be knowledgeable about the lung cancer symptoms than males (OR = 1.301, P-value < 0.05), and the participants with a university (Bachelor’s\Master) educational stage were more likely to recognize the lung cancer symptoms than other participants with primary degree (OR = 2.030, P-value). The participants who indicated that persons aged 50 years under the most risk of developing lung cancer in the next year had higher odds of understanding the symptoms of lung cancer 1.328 times than those who reported that the lung cancer was not related to age. However, respondents who didn’t know about taking an appointment with a doctor were less likely to identify an acceptable level of knowledge about lung cancer symptoms than those who reported they didn’t have symptoms (OR = .528, P-value < 0.05) (Table 9).

Table 9. Binary logistic regression of the predictors variables to having adequate level of knowledge toward lung cancer Symptoms.

Predictor Item for having adequate knowledge toward lung cancer symptoms		P-value	Adjusted odds ratio	Upper	Lower	P-value	Non-adjusted odds ratio	Upper	Lower
Age	20>	Ref
	21-30	.988	.998	.763	1.305	.961	1.006	.807	1.253
	31-40	.851	.962	.646	1.433	.431	.893	.673	1.184
	41-50	.907	1.027	.654	1.614	.566	.909	.657	1.259
	51-60	.172	1.469	.845	2.554	.522	1.148	.753	1.750
	61-70	.943	1.031	.444	2.396	.812	.915	.441	1.900
	70<	.872	.815	.067	9.853	.233	.251	.026	2.433
Gender	Male	Ref
Gender	Female	.010	1.301	1.064	1.591	.000	1.388	1.168	1.650
Residency	Village	Ref
Residency	City	.149	.868	.716	1.052	.520	.944	.792	1.125
Educational level	Primary	Ref
	Secondary (1-3)	.400	1.390	.646	2.988	.192	1.589	.792	3.186
	Secondary (4-6)	.102	1.816	.889	3.710	.009	2.331	1.233	4.407
	University (Bachlor’s\Master)	.049	2.030	1.003	4.111	.002	2.624	1.419	4.852
	Phd	.915	1.065	.339	3.344	.483	1.442	.518	4.014
Marital status	Married	.454				.892
	Single	.243	.849	.644	1.118	.950	1.006	.844	1.199
	Widowed	.304	1.572	.663	3.725	.444	1.343	.631	2.859
	Divorced	.766	.887	.403	1.952	.876	.944	.459	1.942
Occupation	Unemployed	Ref
	Student	.967	1.007	.715	1.420	.825	.972	.757	1.248
	Employed	.080	.770	.575	1.032	.018	.742	.579	.951
Monthly income	Bad	Ref
	Moderate	.576	.906	.642	1.279	.898	1.021	.745	1.398
	Good	.691	1.077	.748	1.551	.143	1.278	.921	1.773
	Excellent	.186	.668	.367	1.215	.687	.894	.517	1.545
Chronic disease	No	Ref
Chronic disease	Yes	.123	.741	.506	1.085	.120	.777	.565	1.068
Have you ever smoked cigarettes?	No	Ref
Have you ever smoked cigarettes?	Yes	.942	.992	.806	1.221	.034	.823	.687	.985
Taking an appointment from a doctor	I don’t have symptoms	.061				.025
	I don’t know	.015	.528	.316	.881	.003	.474	.290	.773
	I will wait for a week or more	.260	.814	.570	1.164	.326	.844	.602	1.184
	Immediately (within 3 days)	.037	.742	.561	.982	.075	.786	.602	1.025
Who is most at risk of developing lung cancer in the next year?	Not related to age	Ref
	30 years old person	.670	.898	.546	1.475	.549	.869	.550	1.374
	50 years old person	.019	1.328	1.048	1.683	.004	1.387	1.111	1.732
	70 years old person	.021	1.468	1.058	2.036	.005	1.551	1.142	2.106
Knowledge of Risk Factors	Poor Knowledge	Ref
Knowledge of Risk Factors	Good Knowledge	.000	2.261	1.889	2.706	.000	2.361	1.991	2.800

4. Discussion

Lung cancer (LC) is the main cause of cancer-related fatalities and the second most diagnosed malignancy worldwide.²⁶^,²⁷ Due to a lack of education about the disease and its symptoms, lung cancer is frequently identified late in low and middle-income countries (LMICs). If more people knew about lung cancer, it would be diagnosed and treated faster. Evidence shows that providing palliative care early on might increase a patient’s quality of life and possibly extend their lifespan.¹⁶ This research aims to assess how well-informed the Syrian public is about lung cancer and its avoidable risk factors, as well as how well-known the disease’s symptoms are. As per the results, participants’ knowledge levels were categorized as satisfactory and insufficient using two revised Bloom’s cutoff thresholds: 70% and 80% of the overall score. This classification was determined by the number of correct answers, with 24 and 27 correct responses out of a total of 34 questions, respectively. While the knowledge was higher among females, non-smokers, and people with a university degree or a doctorate, the knowledge was still rather low overall.

The most widely acknowledged respiratory symptom of lung cancer was identified as ’persistent shortness of breath,’ while the most recognized non-respiratory symptom was ‘unexplained weight loss.’ On the other hand, the least recognized respiratory symptom for lung cancer was ‘developing an unexplained loud, high-pitched sound when breathing,’ and the least acknowledged non-respiratory symptom was ‘changes in the shape of fingers/nails.’

It was found that having a strong knowledge of the symptoms of LC was connected with a shorter amount of time before seeking medical treatment, which can help with the early diagnosis of LC.²⁸^–³¹ As a result, determining the degree to which the general public is aware of the symptoms of LC is essential if one is to locate the knowledge gap that has to be filled by educational interventions. According to the findings of this research, there is potential for advancement in the level of public awareness of the symptoms of LC in Syria. It was discovered that Australia, Nigeria, and the United Kingdom all had less than desirable levels of understanding of LC symptoms.²⁰^,³²^,³³ This may emphasize the vital need for standardized educational programs to enhance public awareness of LC symptoms by world health authorities. This is particularly important, considering LC substantially contributes to the global burden of cancer-related morbidity and mortality.²⁷ The high rate of smoking prevalence in Syria, particularly among men, may contribute to increased awareness of the symptoms of LC.³⁴ The general population is probably well aware that smoking is a risk factor for lung cancer; hence, there could be more curiosity among the general public to read more about lung cancer than other malignancies. This study showed that women had a better understanding of LC symptoms than men did, which is an interesting finding. Women, particularly those who do not smoke, have a greater risk of developing lung cancer than men.³⁵ Syrian women may be aware of this fact, which may motivate them to increase their health literacy regarding LC. Additional research is required to evaluate people’s awareness of the risk factors associated with LC, as well as to investigate the disparities in awareness that exist between smokers and non-smokers, as well as between men and women. This study found that LC’s least recognized respiratory symptom was ‘developing an unexplained loud, high-pitched sound when breathing.’ The findings of another study carried out in the United Kingdom found that the least recognized respiratory symptom of LC was a ‘cough that does not go away for two or three weeks.³² It’s possible that people attributed their continuous coughing to something other than LC. This could have been due to participants mistaking the symptoms of LC for those of a less serious lung illness (like COPD) or to their own habits (like smoking).³⁶^,³⁷ Conversely, ‘persistent shortness of In contrast to studies conducted in Australia, Nigeria, and Canada, where ‘coughing up blood’ was identified as one of the most recognized respiratory symptoms of lung cancer, the present findings highlight ‘persistent shortness of breath’ as a prominent respiratory symptom. Similarly, aligning with a study from the United Kingdom,³² the two least recognized non-respiratory symptoms in this study were ‘persistent shoulder pain’ and ‘changes in the shape of fingers or nails’ associated with lung cancer. In the future, educational activities should stress the fact that LC symptoms are not always respiratory.³⁷ Consistent with previous research in Nigeria and the United Kingdom,³²^,³³ we found that higher levels of education were related to a higher likelihood of demonstrating good awareness of LC. Participants with a greater level of education may be more likely to interact with others who share their expertise in health-related fields. Also consistent with previous research is the finding that having personal experience with cancer increases one’s awareness of LC symptoms.³⁸^,³⁹ Female participants were more likely to show a high awareness of LC symptoms, a finding consistent with an Australian study.²⁰ Assuming that the moderately high levels of awareness found in this study represent the population as a whole, it may be possible to achieve greater social justice by implementing standard educational interventions in Syria to increase public awareness of the symptoms of LC. Previous research has shown that educating the public about cancer symptoms increases consultations with medical professionals and leads to better early identification of LC.²⁹^,³⁰ While cancer mortality in high-income nations is stable or decreasing, it is steadily rising in low- and middle-income countries like Syria and is expected to account for 75% of global cancer fatalities by 2030.³⁹ Anti-smoking programs, better early detection, and more effective treatment are all factors in this drop.⁴⁰ Since effective treatment modalities are often in short supply in low- and middle-income nations, early identification of cancer is crucial for better cancer management in these regions.¹⁶ Unfortunately, there is a lack of data on LC awareness or efforts to raise that awareness in poor and middle-income countries.¹⁶ Syrian health policymakers should prioritize identifying LC risk factors, developing educational programs, and implementing effective tobacco control laws to raise risk awareness, alter consumer behavior, and promote early diagnosis and presentation. Smokers aware of the higher risk of developing LC may quit early should they encounter any of the disease’s symptoms. Campaigns like this may also help dispel the misconception that smokers with respiratory difficulties have nothing else to worry about but their habits.²⁰^,⁴¹

In order to efficiently disseminate information through widely accessed channels targeting various demographic groups such as younger males or older age cohorts, it is imperative to conduct additional research on the information sources preferred by the general public. Understanding the sources from which different segments of the population obtain information can guide tailored communication strategies, ensuring that messages are effectively conveyed to specific audiences is required in Syria and the wider region. This research needs to focus on both Syria and the wider region. In addition, obstacles to health-seeking behavior need to be investigated to find solutions to these problems and enable early presentation at healthcare facilities.²⁸^,³⁰ In addition, increasing investments in cancer prevention and control in low- and middle-income nations like Syria, where the disease is prevalent, but resources are limited, is essential but is sometimes neglected to owe to the expenses involved.⁴⁰ Yet, programs that focus on LC awareness and prevention, such as anti-smoking campaigns and tobacco control regulations, are potentially low-cost and high-effect interventions that might have a favorable influence on the modification of risk factors and the early presentation of the disease.

4.1 Strengths and limitations

This study has several strengths, the most notable of which are its high response rate and its recruitment of participants from various locations throughout Palestine. Using a cross-sectional questionnaire that was administered during an in-person interview helped reduce the likelihood that respondents relied on information obtained from other sources when responding to survey questions. There are a few limitations to this study. The use of convenience sampling does not assure that a representative sample will be generated and restricts the extent to which the findings may be generalized. On the other hand, this might have been somewhat compensated for by the high response rate and the fact that they were recruited from various geographical locations. For instance, females constituted 63.5% of the participants in this study, despite the fact that they account for around 50% of the population in Syria.⁴² Another potential restriction is that most of the people who participated in the research were young (less than 30 years old), and as a result, they were at a lesser risk of getting LC than older people. The fact that younger people make up the majority of Syria’s population.⁴³ may explain why many younger people are participating in the demonstrations. Nevertheless, increasing awareness among young people may be an efficient technique for building a culture of early detection of LC symptoms and rapid medical care for any probable LC symptoms. This would be a civilization where early recognition of LC symptoms is a cultural norm.

5. Conclusion

The knowledge of Syrian medical professionals on LC symptoms and risk factors was limited. Factors related to heightened awareness were female gender, postsecondary education, and nonsmoking status. The most recognized respiratory LC symptom was ‘persistent shortness of breath’, whereas the most recognized non-respiratory LC symptom was ‘unexplained weight loss. This research emphasizes the need for education and awareness efforts, especially in low and middle-income countries like Syria, where the prevalence of LC is significant yet often misdiagnosed due to a lack of knowledge about the disease.

Data availability

Underlying data

Zenodo: Awareness of Lung Cancer Risk Factors and Symptoms in Syria: An Online Cross-Sectional Study, https://doi.org/10.5281/zenodo.10148451.⁴⁴

This project contains the following underlying data:

• lung cancer.xlsx

Extended data

Zenodo: Awareness of Lung Cancer Risk Factors and Symptoms in Syria: An Online Cross-Sectional Study, https://doi.org/10.5281/zenodo.10148451.⁴⁴

This project contains the following extended data:

• S1 Table.docx

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

1. Elshami M, Abukmail H, Aqel W, et al.: Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study. BMC Pulm. Med. 2022; 22(1): 135. PubMed Abstract | Publisher Full Text | Free Full Text
2. WHO: Cancer. Reference Source Reference Source
3. Duffy MJ, O’Byrne K: Tissue and Blood Biomarkers in Lung Cancer: A Review. Adv. Clin. Chem. 2018; 86: 1–21. Publisher Full Text
4. Jazieh AR, Algwaiz G, Errihani H, et al.: Lung Cancer in the Middle East and North Africa Region. J. Thorac. Oncol. 2019; 14(11): 1884–1891. PubMed Abstract | Publisher Full Text
5. Schwartz AG, Cote ML: Epidemiology of Lung Cancer. Adv. Exp. Med. Biol. 2016; 893: 21–41. Publisher Full Text
6. Bade BC, Dela Cruz CS: Lung Cancer 2020: Epidemiology, Etiology, and Prevention. Clin. Chest Med. 2020; 41(1): 1–24. Publisher Full Text
7. Malhotra J, Malvezzi M, Negri E, et al.: Risk factors for lung cancer worldwide. Eur. Respir. J. 2016; 48(3): 889–902. Publisher Full Text
8. Ruano-Raviña A, Provencio M, Calvo de Juan V, et al.: Lung cancer symptoms at diagnosis: results of a nationwide registry study. ESMO Open. 2020; 5(6): e001021. PubMed Abstract | Publisher Full Text | Free Full Text
9. Lung Cancer: May 5, 2022. Reference Source
10. Langevin SM, Kratzke RA, Kelsey KT: Epigenetics of lung cancer. Transl. Res. 2015; 165(1): 74–90. PubMed Abstract | Publisher Full Text | Free Full Text
11. Duruisseaux M, Esteller M: Lung cancer epigenetics: From knowledge to applications. Semin. Cancer Biol. 2018; 51: 116–128. PubMed Abstract | Publisher Full Text
12. Ansari J, Shackelford RE, El-Osta H: Epigenetics in non-small cell lung cancer: from basics to therapeutics. Transl. Lung Cancer Res. 2016; 5(2): 155–171. PubMed Abstract | Publisher Full Text | Free Full Text
13. Toumazis I, Bastani M, Han SS, et al.: Risk-Based lung cancer screening: A systematic review. Lung Cancer. 2020; 147: 154–186. PubMed Abstract | Publisher Full Text
14. Nooreldeen R, Bach H: Current and Future Development in Lung Cancer Diagnosis. Int. J. Mol. Sci. 2021; 22(16). PubMed Abstract | Publisher Full Text | Free Full Text
15. Jones GS, Baldwin DR: Recent advances in the management of lung cancer. Clin. Med. (Lond.). 2018; 18(Suppl 2): s41–s46. Publisher Full Text
16. Nwagbara UI, Ginindza TG, Hlongwana KW: Lung cancer awareness and palliative care interventions implemented in low-and middle-income countries: a scoping review. BMC Public Health. 2020; 20(1): 1466. PubMed Abstract | Publisher Full Text | Free Full Text
17. Elshami M, Abukmail H, Aqel W, et al.: Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study. BMC Pulm. Med. 2022; 22(1): 135. PubMed Abstract | Publisher Full Text | Free Full Text
18. Mansour AA, Elshami M, Al-Ser M, et al.: P2.11-01 Awareness of Lung Cancer Risk Factors in Palestine: Current Situation and Future Directions. J. Thorac. Oncol. 2022; 17(9, Supplement): S148. Publisher Full Text
19. Population, total - Syrian Arab Republic. Reference Source
20. Crane M, Scott N, O’Hara BJ, et al.: Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study. BMC Public Health. 2016; 16: 508. PubMed Abstract | Publisher Full Text | Free Full Text
21. Elshami M, Al-Slaibi I, Abukmail H, et al.: Knowledge of Palestinian women about cervical cancer warning signs: a national cross- sectional study. BMC Public Health. 2021; 21(1): 1779. PubMed Abstract | Publisher Full Text | Free Full Text
22. Elshami M, Thalji M, Abukmail H, et al.: Knowledge of cervical cancer risk factors among Palestinian women: a national cross-sectional study. BMC Womens Health. 2021; 21(1): 385. PubMed Abstract | Publisher Full Text | Free Full Text
23. Elshami M, Yaseen A, Alser M, et al.: Knowledge of ovarian cancer symptoms among women in Palestine: a national cross-sectional study. BMC Public Health. 2021; 21(1): 1992. PubMed Abstract | Publisher Full Text | Free Full Text
24. Elshami M, Elshami A, Alshorbassi N, et al.: Knowledge level of cancer symptoms and risk factors in the Gaza Strip: a cross-sectional study. BMC Public Health. 2020; 20(1): 414. PubMed Abstract | Publisher Full Text | Free Full Text
25. Elshami M, Bottcher B, Alkhatib M, et al.: Perceived barriers to seeking cancer care in the Gaza Strip: a cross-sectional study. BMC Health Serv. Res. 2021; 21(1): 28. PubMed Abstract | Publisher Full Text | Free Full Text
26. International Agency for Research on Cancer: Lung Cancer Fact Sheet.2020. Accessed 1 November 2022. Reference Source
27. Sung H, Ferlay J, Siegel RL, et al.: Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J. Clin. 2021; 71(3): 209–249. PubMed Abstract | Publisher Full Text
28. Moffat J, Bentley A, Ironmonger L, et al.: The impact of national cancer awareness campaigns for bowel and lung cancer symptoms on sociodemographic inequalities in immediate key symptom awareness and GP attendances. Br. J. Cancer. 2015; 112 Suppl 1(Suppl 1): S14–S21. PubMed Abstract | Publisher Full Text
29. Ironmonger L, Ohuma E, Ormiston-Smith N, et al.: An evaluation of the impact of large-scale interventions to raise public awareness of a lung cancer symptom. Br. J. Cancer. 2015; 112(1): 207–216. PubMed Abstract | Publisher Full Text | Free Full Text
30. Power E, Wardle J: Change in public awareness of symptoms and perceived barriers to seeing a doctor following Be Clear on Cancer campaigns in England. Br. J. Cancer. 2015; 112(1): S22–S26. PubMed Abstract | Publisher Full Text | Free Full Text
31. Saab MM, Noonan B, Kilty C, et al.: Awareness and help-seeking for early signs and symptoms of lung cancer: A qualitative study with high-risk individuals. Eur. J. Oncol. Nurs. 2021; 50: 101880. PubMed Abstract | Publisher Full Text
32. Simon AE, Juszczyk D, Smyth N, et al.: Knowledge of lung cancer symptoms and risk factors in the U.K.: development of a measure and results from a population-based survey. Thorax. 2012; 67(5): 426–432. PubMed Abstract | Publisher Full Text
33. Desalu OO, Fawibe AE, Sanya EO, et al.: Lung cancer awareness and anticipated delay before seeking medical help in the middle-belt population of Nigeria. Int. J. Tuberc. Lung Dis. 2016; 20(4): 560–566. PubMed Abstract | Publisher Full Text
34. Ward KD, Eissenberg T, Rastam S, et al.: The tobacco epidemic in Syria. Tob. Control. 2006; 15 Suppl 1(Suppl 1): i24–i29. PubMed Abstract | Publisher Full Text
35. Rivera MP, Stover DE: Gender and lung cancer. Clin. Chest Med. 2004; 25(2): 391–400. Publisher Full Text
36. Cunningham Y, Wyke S, Blyth KG, et al.: Lung cancer symptom appraisal among people with chronic obstructive pulmonary disease: A qualitative interview study. Psychooncology. 2019; 28(4): 718–725. PubMed Abstract | Publisher Full Text | Free Full Text
37. Walter FM, Rubin G, Bankhead C, et al.: Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study. Br. J. Cancer. 2015; 112 Suppl 1(Suppl 1): S6–S13. PubMed Abstract | Publisher Full Text
38. Lubuzo B, Ginindza T, Hlongwana K: The barriers to initiating lung cancer care in low-and middle-income countries. Pan Afr. Med. J. 2020; 35: 38. Publisher Full Text
39. Friedemann Smith C, Whitaker KL, Winstanley K, et al.: Smokers are less likely than non-smokers to seek help for a lung cancer ‘alarm’ symptom. Thorax. 2016; 71(7): 659–661. PubMed Abstract | Publisher Full Text | Free Full Text
40. Shah SC, Kayamba V, Peek RM Jr, et al.: Cancer Control in Low- and Middle-Income Countries: Is It Time to Consider Screening? J. Glob. Oncol. 2019; 5: 1–8. PubMed Abstract | Publisher Full Text
41. Haastrup PF, Jarbøl DE, Balasubramaniam K, et al.: Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study. NPJ Prim. Care Respir. Med. 2020; 30(1): 15. PubMed Abstract | Publisher Full Text | Free Full Text
42. Syria Population: Syria Population clock (live).Reference Source
43. World Population Dashboard Syrian Arab Republic: Syrian Arab Republic - Overview.Reference Source
44. Almoshantaf MB: Awareness of Lung Cancer Risk Factors and Symptoms in Syria: An Online Cross-Sectional Study. [Data set]. Zenodo. 2023. Publisher Full Text

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