Knowledge, Attitudes, and Practices of Lung Cancer Risk Factors in West Bandung Society.

BACKGROUND: Lung cancer is one of the leading causes of morbidity and mortality worldwide, so prevention of lung cancer is necessary. The aim of this study was to measure level of knowledge, attitude, and actions concerning risk factors of lung cancer in West Bandung.
MATERIALS AND METHODS: The research was conducted by quantitative study design with a quasi-experimental approach. Measurement of respondents' knowledge, attitudes, and actions was carried out by giving questionnaires of knowledge, attitudes, and actions. Questionnaires were given to respondents before and after providing education about risk factors of lung cancer. Respondents were from 42 societies in Bandung. The data obtained were tested by using comparison and correlation test.
RESULTS: The results showed a significant difference between knowledge and attitudes (P = 0.001). Meanwhile, the action did not change significantly (P > 0.05). Correlation test showed that knowledge and attitude had a correlation of P = 0.001 in the pretest and P = 0.23 (P < 0.05) in the posttest.
CONCLUSION: This research concludes that the level of knowledge and attitudes toward risk factors of lung cancer has increased. Copyright:

Introduction

Lung cancer is a type of cancer with the highest incidence in men. On the contrary, breast cancer is the most common type of cancer in women worldwide. In total, 25% of deaths in cancer cases are caused by lung cancer. Even in developed countries such as America, lung cancer is a cause of death in both men and women.[12] The worldwide death caused by lung cancer increased from 14 million in 2012 to 22 million in the next two decades. Lung cancer has been ranked first in the world among other cancers with the highest incidence rate, noted at 13% in 2012 and increased by around 18% in 2015. According to World Health Organization, in 2014 the prevalence of lung cancer was the largest type of cancer in Indonesia in men and ranked fifth in women.[345] West Bandung is a potential area for lung cancer, because it comprises mostly industrial areas and is close to mining areas that produce high air pollution. Air pollution is one of the risk factors for lung cancer.

The major risk factor of lung cancer is 80% from cigarette, both as active smokers and passive smokers. Smokers have a risk of getting lung cancer 20–40 times greater than those who do not smoke.[6] A research in China revealed that escalation of cigarette consumption increased the number of lung cancer cases and led to the death of 1.2 million people yearly. Male smokers have prevalence of lung cancer 70% higher than nonsmokers. Same thing happens with passive smokers accidentally inhaling cigarette smoke which contains 69 types of carcinogens, including the most abundant substances, such as polycyclic aromatic hydrocarbons, arsenic, benzene, and nitrosamines. Therefore, the policy of “no smoking area” and health education for reducing of lung cancer cases are really suggested.[7] Other risk factors of lung cancer include air pollution, unhealthy food (containing polycyclic aromatic hydrocarbons, such as satay and junk food), chemicals (radon, asbestos, chemical waste, paint materials), jobs with risk of getting carcinogen exposure (construction workers, painters, drivers), family history of cancer, lack of physical activity, alcohol (>30g/day), and a history of pulmonary disease (asthma, tuberculosis).[58] Some researches reported that consumption of high fat, exposure of incense smoke, and frying fumes can increase the risk of lung cancer.[9] Urban community has a higher risk of getting lung cancer than rural community. This is related to high level of air pollution and unhealthy lifestyle.[10]

Fruits and vegetables that are rich in sources of antioxidant vitamins and other micronutrients, especially carotenoids, are considered beneficial for health by reducing the risk of lung and other cancers. Dietary supplements and vitamins increase the survival of small cell lung cancer (SCLC) and nonsmall cell lung cancer (NSCLC) patients by reducing the mortality rate of 26% NSCLC and 37% SCLC.[11]

More than 75% of patients with lung cancer are diagnosed after they are getting into the advanced or metastatic stage. Developing countries such as India and neighboring countries in the Asia Pacific region showed that the survival of lung cancer for 5 years is only 9%.[6] Therefore, early detection is needed to reduce morbidity of lung cancer. The common symptoms of lung cancer suffered by patients include fatigue, pain, choking condition, coughing, and anorexia.[121314]

Various methods are conducted to prevent lung cancer in Indonesia, such as providing policy of “no smoking area,” health promotion for smoking cessation, counseling about the danger of cigarette, and the campaign/advertisement of the dangers of smoking. However, counseling or training concerning about risk factors of lung cancer has never been conducted. Therefore, providing information about lung cancer risk factors to improve knowledge, attitudes, and actions to prevent lung cancer is necessary. This study aimed to measure the level of knowledge, attitudes, and actions by providing education to the community.

Materials and Methods

Subjects

The inclusion criteria of the research were respondents willing to sign an informed consent, with age more than 18 years old, living in an area with high air pollution exposure (mine employees, stone craftsmen, or those living near factory waste). On the contrary, the exclusion criteria of the research were patients who did not join the research until it was finished. The number of samples taken was 42 respondents. The number of samples was based on magnitude of minimum sample by using number in pairs comprising 12 respondents (95% of confidence level, 5% of type 1 error, and 20% of type 2 error, X1 = 45.46; n1 = 43; s1 = 6.66, X2 = 51.20; n2 = 40; s2 = 7.6). The research was conducted after obtaining ethical permission from Padjadjaran University with reference number of 981/UN6.C.10/PN/2017.

Validity and reliability questionnaires

The questionnaire was made by researchers. The preparation of questionnaires was motivated by the results of interviews with patients with lung cancer. Validation and reliability tests were conducted in Garut City community. The number of respondents (n = 30) was based on the minimum number of samples. The questionnaire comprised 18 questions about knowledge, 15 questions about attitude, and 18 questions about actions. The validation used in this study was construct validation. The reliability test on the knowledge domain was performed with the KR 20 method, the attitude, and the action domains with the Cronbach’s α method. The questionnaire is valid if the results of r count > r table and reliable if the results of questionnaire reliability > critical point (0.7). The questionnaires were tested for validity by comparing the correlation value of r counted with r table (df = 28 which is 0.361). The results showed that the questionnaires were valid (coefficient of validity >0.361). The reliability test results in the first test were 0.918 for knowledge, 0.891 for attitudes, and 0.749 for actions domains. In the second test, the results were 0.906 for knowledge, 0.870 for attitudes, and 0.728 for actions (the reliability value exceeded the critical point of 0.7) domains. From the consistency test of the first and second tests of the knowledge, attitudes, and actions domains by Wilcoxon method, it was obtained values of 0.243, 0.373, and 0.792 (P > 0.05). It can be concluded that the questionnaire is valid, reliable, and consistent.

Study design and procedures

The design of this research used quantitative design with quasi-experimental pre–post test approach. The data were taken twice, that is, at the pretest and at the posttest. At the time of the pretest, the respondents were given questionnaire about knowledge, attitudes, and actions regarding risk factors of lung cancer. Then they were provided education, such as counseling and training with a module aid (containing information concerning risk factors of cancer). Counseling and training were conducted twice, that is, in the first and second weeks. Then the measurement of pretest was carried out by giving the same questionnaire to the respondents. The used questionnaire was a valid and reliable questionnaire comprising 18 items of knowledge, 15 items of attitude, and 18 items of actions regarding risk factors of lung cancer.

The obtained data were scored comprising knowledge (know = 1, do not know = 0); attitude (disagree = 1, neutral = 2, disagree = 3, strongly disagree = 4); action (never = 1, very rarely = 2, rarely = 3, often = 4). Score measurements were carried out at the level of knowledge, attitudes, and actions at the time of the pretest and posttest. Education via modules is successful if there is an increase in the level of knowledge from the pretest score to the posttest score and significant statistically.

Statistical analysis

The data were analyzed statistically by using the Wilcoxon signed rank test and Spearman’s correlation test. Statistics tabulation used the Statistical Package for the Social Sciences software, version 16.0. The increase in the level and correlation of knowledge, attitudes, and actions at the pretest and posttest can be seen at P > 0.05 (95% confidence level).

Results

Subject characteristics

The results of research based on the characteristics of patients with lung cancer were dominated by patients with age >40 years old of about 72.5%; education level of elementary school of about 66.7%; married status of about 95.2%; women of about 64.3%; and distance to health facilities (>5 km) of about 69%. On the contrary, the economic status of the respondents was about 88.1% dominated by monthly income below the Regional Minimum Wage (UMR) of West Java in 2016, which was Rp. 2,250,000. [Table 1] shows no significant relationship between confounding variables (demographic data) and the alteration in knowledge, attitudes, and action of respondents in both the pretest and the posttest (P > 0.05).

Table 1

Sociodemographic characteristics

Demography	N (42)	Knowledge		P value	Attitude		P value	Practice		P value
		Median	Range		Median	Range		Median	Range
Age
>40	29	40	–12.5 to 400	0.164	20	–12.5 to 400	0.31	0	–88.9 to 64.7	0.632
<40	13	80	12.5 to 220		22.2	–9.4 to 73.7		0	–19.2 to 54.5
Education
Primary	28	52.3	0 to 1700	0.277	21.1	–9.3 to 400	0.211	0	–88.9 to 64.7	0.308
Intermediate	11	40	–22.2 to 125		17.3	–9.4 to 73.7		0	–32.1 to 25
College	3	200	0 to 1500		10.7	4.4 to 37.0		–7.1	–16.7 to 4
Occupation
Risk of causing lung cancer	2	881.8	63.6 to 1700	0.123	223.2	46.4 to 400	0.227	15.1	9.09 to 21.1	0.518
Not at risk of causing lung cancer
	40	45.8	–22.2 to 1500		19.1	–12.5 to 181.3		0	–88.9 to 64.7
Marital status
Married	40	59.1	–22.2 to 1700	0.243	20.3	–12.5 to 400	0.706	0	–88.9 to 64.7	0.111
Not married	2	40	40 to 40		35.2	–3.3 to 400		–11.4	–34.6 to 11.7
Gender
Men	15	41.7	0 to 1700	0.203	33.3	–12.5 to 400	0.227	4	–42.8 to 50	0.371
Women	27	54.5	22.2 to 800		17.2	–10.0 to 37		–4	–88.9 to 64.7
Wage
<RMW	37	54.5	0 to 1700	0.06	20.7	–12.5 to 400	0.227	0	–88.9 to 64.7	0.241
>RMW	5	41.7	–22.2 to 1500		10.7	–10.0 to 37		4	–16.7 to 50
Distance to health facilities
<5 km	13	63.6	6.25 to 800	0.164	18.2	–6.9 to 68	0.31	0	–32.42 to 50	0.398
>5 km	29	40	–22.2 to 1700		21.4	–12.5 to 400		4	–88.9 to 64.7

Chi Square Test, except for age with the t test, is significant if (P < 0.05)

Pretest and posttest analysis

The results of the pretest and posttest measurements showed a significant improvement/uplift in knowledge (48.7 [30.5] to 95.4 [7.6]) and attitudes (61.7 [14.6] to 77.1 [14.1]) at P = 0.001 (P < 0.05). On the contrary, the results of the pretest and posttest measurement concerning the action showed no uplift (46.9 [9.8] to 46.1 [11.0]) at P = 0.872 (P > 0.05) [Table 2].

Table 2

Level of knowledge, attitudes, and actions

Variable	Pretest mean (SD)	Posttest mean (SD)	P value
Knowledge	48.7 (30.5)	95.4 (7.6)	0.001*
Attitudes	61.7 (14.6)	77.1 (14.1)	0.001*
Actions	46.9 (9.8)	46.1 (11.0)	0.872

*Wilcoxon test (significance correlation [asymp sig < 0. 05])

On the basis of the correlation test, it could be seen that when the pretest was conducted, the knowledge and attitudes had positive and significant correlation of P = 0.001 (P < 0.05), but knowledge did not correlate significantly with action, and attitudes with actions did not have a significant correlation (P > 0.05) as well. When the posttest was conducted, the knowledge and attitudes also had a positive and significant correlation of P = 0.023 (P < 0.05), and attitudes and actions had a positive and significant correlation of P = 0.022 (P < 0.05) as well. Meanwhile, knowledge with action did not have a significant correlation (P > 0.05) [Table 3].

Table 3

Correlation of the level of knowledge, attitudes, and actions

Variable	Rs	P value
Pretest
Knowledge vs. attitudes	0.574	0.000*
Knowledge vs. actions	–0.101	0.523
Attitudes vs. actions	–0.049	0.760
Posttest
Knowledge vs. attitudes	0.350	0.023*
Knowledge vs. actions	0.035	0.825
Attitudes vs. actions	0.352	0.022*

*Spearman test (significance correlation [asymp sig < 0. 05])

Discussion

On the basis of the results of the research above, it showed that there was an improvement/uplift in knowledge and attitude from the pretest to the posttest. This also showed that providing education was very effective. There is relevance in providing information/education on cancer risk factors to increase knowledge in the prevention of cancer.[15] Education plays a main role in reducing the prevalence of lung cancer. Faith and attitudes have a major impact in preventing and early detection to access the medical treatment, rehabilitation treatment, palliative care, and life sustainability.[16] The high prevalence of lung cancer in India can be a background of the survey conducted concerning information of lung cancer risk factors and symptoms of lung cancer in urban and rural areas in India. The results showed that knowledge and awareness were very low; thus, education program and campaign concerning lung cancer risk factors were suggested to be conducted.[17]

Research conducted by Xiu et al.[7] showed that providing education was needed to do to improve the knowledge and awareness through various policies, such as cooperation between the Ministry of Health and the Ministry of Education related to the prohibition of smoking in schools, the construction of no smoking areas in the surroundings and nonsmoking public spaces, advertisement of dangers of smoking in mass media, and construction of “smoke free health care system.” The method was applied in China based on the survey of the level of knowledge and awareness of smokers in China that was so low; therefore, it had impact on exposure of cigarette smoke in various public spaces that could lead to cause lung cancer in the future. Similar research in Cameroon showed low level of knowledge regarding the risk factors and symptoms of lung cancer, so that the research suggested for health campaigns held by health institutions and mass media.[18]

A research conducted by Xianglong et al.[19] by using a cross-sectional study showed that “Respondents who were highly educated had good knowledge and good attitude towards the danger of smoking, even though it did not affect them from smoking cessation.” Knowledge and smoking cessation action did not have a significant positive correlation in Pearson’s correlation test. It showed that high level of knowledge and awareness had no potential to stop them from smoking, even though they knew the dangers of smoking are lung cancer, cancer of the mouth, stroke, heart disease, and impotence. A research in India by Shankar et al.[6] was conducted by measuring knowledge, awareness, and action by giving questionnaires at the pretest and then giving a campaign about risk factors and symptoms of lung cancer. The same questionnaire was given at the posttest, which was 6 months and 1 year later. The research showed that Knowledge and attitudes increased significantly (P < 0.05), but it was not followed by lung cancer screening examination with reasons of not concerning about it, not having much time, and lazy to do the examination. Another research in India showed that high levels of knowledge and awareness about the dangers of cigarettes that can lead to lung cancer were not followed by action to stop smoking, therefore suggesting the government to take action by conducting counseling program of health education. That research affirms this research in which there is no correlation between high levels of knowledge and attitudes/awareness toward action. It is caused by the habits that are not easy to be changed and need adjustments to be spared from risk factors of lung cancer, such as smoking, pollution, and unhealthy food.

However, based on a Bogota Research conducted by the Meneses-Echávez et al.,[20] it was found that “Educational intervention significantly increased awareness regarding risk factors and symptoms of lung cancer, it was also followed by positive actions, i.e decline of smoking rates, uplift in fruit and vegetable consumption.” This research succeeded because of such interventions, such as videos, presentations, and discussions fitted with the guidance of national education regarding cancer in Colombia. It had been followed up in every 6 months; thus, the awareness was paid off with the actions. A research in Malaysia showed that high level of knowledge about lung cancer caused a perception to do a screening as an attempt of lung cancer prevention by doing early detection.[21] The danger of smoking as a major risk factor of lung cancer was being an awareness by about 91% of respondents, but it was not proportional with their actions to stop smoking.[22] This research aims to prevent lung cancer by providing education. It is expected that there is improvement of knowledge and awareness and it can also be followed by positive actions to avoid modified risk factors or can even be an encouragement to do an early examination. The limitation of this study is that there is no follow-up routine, so that routine follow-ups are needed to improve respondents’ habits to avoid risk factors for lung cancer.

Conclusion

This research concludes that the level of knowledge and attitudes toward risk factors of lung cancer has increased. Counseling and training of lung cancer risk factors are necessary to do routinely with high frequency to increase the decline of cancer prevalence in all regions of Indonesia.

Financial support and sponsorship

This work was supported by 2018 postgraduate grant from the Ministry of Research Technology and Higher Education, Indonesia [grant number 391b / UN6.O / LT / 2018].

Conflicts of interest

There are no conflicts of interest.