
==== Front
Cureus
Cureus
2168-8184
Cureus
2168-8184
Cureus Palo Alto (CA)

10.7759/cureus.66111
Gastroenterology
Palliative Care
Oncology
The Effect of Educational Intervention on Knowledge, Attitude, and Practices Regarding Colorectal Cancer Screening Practices Among Nursing Students in Jordan
Muacevic Alexander
Adler John R
Alzoubi Majdi M 1
Al-Ghabeesh Suhair 1
Qutami Batool 2
1 Department of Clinical Nursing, Al-Zaytoonah University, Amman, JOR
2 Department of Emergency Medicine, Specialty Hospital, Amman, JOR
Suhair Al-Ghabeesh suhair_alghabeesh@yahoo.com
4 8 2024
8 2024
16 8 e661114 8 2024
Copyright © 2024, Alzoubi et al.
2024
Alzoubi et al.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article is available from https://www.cureus.com/articles/275825-the-effect-of-educational-intervention-on-knowledge-attitude-and-practices-regarding-colorectal-cancer-screening-practices-among-nursing-students-in-jordan
Background: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. This study aimed to examine the impact of an educational intervention on nurses' knowledge, attitude, and practice regarding CRC screening in Jordan.

Methodology: The study was an experimental design conducted before and after the educational intervention. Participants attended four 30-minute sessions held weekly over one month. A paired t-test was used to determine the mean difference in participants' knowledge, attitude, and practice regarding CRC screening before and after the intervention. Statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY).

Results: A total of 43 participants took part in the study, of whom 29 (67.4%) were female and 14 (32.6%) were male. The majority (30, 69.8%) were aged between 20 and 30 years. The results showed a significant mean increase in knowledge (mean difference [MD] = 3.09, P < 0.001), attitude (MD = 4.16, P < 0.001), and practice (MD = 2.67, P < 0.001) regarding CRC screening following the intervention.

Conclusions: The implementation of health education about CRC screening for the study participants was successful based on the results. This strategy could provide a solid basis for organizing, implementing, and supervising CRC screening initiatives.

practices
attitude
knowledge
screening
health education
colorectal cancer
==== Body
pmcIntroduction

Over the years, colorectal cancer (CRC) has become the third most commonly diagnosed cancer and the second leading cause of cancer-related mortality worldwide [1,2]. Several studies indicate that advanced screening tools are now available for detecting and reducing the occurrence of CRC [2,3]. Despite this, the incidence of CRC cases is rising, with estimates predicting 2.2 million cases and approximately 1.1 million deaths globally by 2030 [1]. The incidence of CRC is particularly increasing among individuals under 50 in developed countries, including the United States, Canada, the United Kingdom, France, Australia, New Zealand, and Japan [4-8]. This rise in incidence among younger individuals may be attributed to lifestyle factors such as diet and obesity [9].

CRC is the second most common type of cancer in both men and women in Jordan, making up 11.3% of all new cases [10]. The overall age-standardized rate was 16.3 per 100,000, with males and females at 15.9 and 16.6 per 100,000, respectively, among the Jordanian population [10]. The causes of Jordan's high incidence of CRC are not yet fully understood. Recently, however, the Jordanian Ministry of Health has begun to focus more on CRC as a health issue that has to be resolved by informing the populace about the disease's prevention, screening, and early identification.

According to the World Health Organization (WHO), 40% of cancers are preventable, and 40% are curable if detected early [11]. Jordan has less population knowledge than is necessary to promote the growth of screening behavior of CRC [12]. Fecal immunochemical testing (FIT), flexible sigmoidoscopy every 10 years with an FIT test every year, or a colonoscopy every 10 years are the best screening methods for CRC [13]. These methods will gradually extend the number of years that these CRC patients can live with a high quality of life, but they will also necessitate more colonoscopies to be conducted in the community [13,14].

Understanding the state of a population in terms of their present knowledge levels, practices, and attitudes toward cancer prevention is a crucial aspect in determining cancer control initiatives. The overall five-year and 10-year survival rates for CRC in Jordan were 58.2% and 51.8%, respectively. Low survival rates were associated with older age, poor differentiation, advanced cancer stage, and right-sided tumors [10]. However, CRC is one of the cancers that can be largely prevented through early detection. Given this, the knowledge gap among nursing students must therefore be understood for teachers to improve their teaching methods and student learning outcomes [15]. The inclusion of cancer prevention in students’ curricula has been proposed by medical educators to improve long-term retention of knowledge, positive self-reported attitudes and beliefs, and an intent to apply prevention in future practice [16]. Hence, this study aimed to determine whether an educational intervention for nursing students would increase their knowledge, attitudes, and practice, as well as increase patients’ participation in CRC screening.

The degree to which people are aware of CRC and screening procedures, as well as their opinions on these topics, affect CRC screening. Student nurse practitioners may have a significant impact on raising screening rates in the community's asymptomatic high-risk populations through education, particularly for those who operate in primary care offices and community clinics [17]. The likelihood of screening and early detection of CRC cases in Jordan may rise as a result of the knowledge gained through research examining whether group education interventions influence awareness and attitudes towards CRC. This knowledge is important since nurses are crucial to preventative healthcare initiatives in primary care settings. Additionally, there were no previous studies conducted to determine the effect of a health education intervention on knowledge, attitude, and perceived barriers regarding CRC risk factors and screening techniques among nursing students in Jordan.

Materials and methods

Study design

An experimental study was conducted to determine the effect of educational intervention on the participant’s knowledge, attitude, and practices toward CRC screening. The target population of this study was nursing students in Jordan. The participant received four 30-minute sessions held weekly over one month. The participants completed the study questionnaires before and after the educational intervention.

Sample size

The sample size was estimated using the G Power program (version 3.0.10, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany) for this study. The parameters used were 80% power, medium effect size of 0.50, and a significance level of α = 0.05 (two-tailed). The estimated sample size was 34 participants. Because of the expected attrition rate, a 20% dropout rate was added, making the adjusted sample size to be 43. The study adopted a nonprobability convenience sampling method to recruit nursing students who met the inclusion criteria for the study.

Ethical consolidation

This study was approved by the Institutional Review Board of Al-Zaytoonah University (reference no. 2022-2023/17/29), written informed consent was obtained, and the purpose of the study was explained to all participants. Patients' confidentiality was protected. All data were available only to the authors.

Intervention

The relevant studies in the evidence-based literature were used to create the health education intervention's content [18-21]. The educational intervention is divided into four sections according to the participants, who are Jordanians at average risk for CRC. Basic information about CRC is included in the first section, including its definition, pathogenesis, symptoms, and incidence in Jordan. The purpose of this section was to improve participants' understanding and perceptions of their susceptibility to CRC. To raise participants' perceptions of their vulnerability to CRC and the severity of the disease, the risk factors for CRC are presented in the second section. The final section offers potential CRC screening choices to raise participants' perceptions of the benefits of screening and lower their perceptions of its limitations. In the fourth section, CRC treatment options are discussed, along with survival information for both early and late detection. The effectiveness of the content intended for the study participants was evaluated by experts from community health nursing and oncology who reviewed the educational intervention.

Instrument

The instrument used was the Colorectal Cancer Knowledge, Perceptions, and Screening Survey (CRCKPSS) [22]. The CRCKPSS is composed of three main sections. The first section, titled The CRC Knowledge Test, assesses participants' knowledge in three key areas, including CRC incidence and risk, warning signs and symptoms, myths, and truths, and performing screening tests, with an internal consistency of 0.8. In the second section, labeled Health Perceptions, participants' perceptions of their susceptibility to CRC, the seriousness of CRC, the advantages of screening, and the obstacles to screening are assessed, with an internal consistency of 0.85. The last section assesses the participants' CRC screening behaviors using nine questions with a yes/no response option [22]. Additionally, the questionnaire consisted of demographic characteristics of the participants, including age, gender, residence, year of study, and marital status.

Statistical analysis

Initially, the preliminary data analysis was performed for data cleaning to investigate missing values and wrong data entry. The statistical analyses employed in the study were descriptive statistics and paired t-tests. The descriptive analysis presents the frequencies, mean, and standard deviation of the study variables. The paired t-test was performed to determine the mean difference in the participants’ knowledge, attitude, and practice regarding CRC screening before and after intervention. The statistical analyses were performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY).

Results

Table 1 summarizes the general characteristics of the study participants. Among the 43 individuals who took part, 29 (67.4%) were female and 14 (32.6%) were male. The majority of participants (30, 69.8%) were aged between 20 and 30 years. The highest educational level achieved by most participants was a bachelor's degree (16, 37.2%). Additionally, 30 (69.8%) participants were single, 18 (41.9%) were employed full-time, 24 (55.8%) were self-supported, and 34 (79.1%) had no family history of CRC.

Table 1 General characteristics of the study participants (n = 43).

Variables	F = frequency (%)	
Age (Years)	 	
20-30	30 (69.8) 	
31-40	8 (18.6)	
41-50	5 (11.6)	
Gender	 	
Female	29 (67.4)	
Male	14 (32.6)	
Education	 	
Diploma	15 (34.9)	
Bachelor	16 (37.2)	
Masters	12 (27.9)	
Marital status	 	
Single	30 (69.8)	
Married	13 (30.2)	
Employment	 	
Unemployed	13 (30.2)	
Self-employed	3 (7.0)	
Part time	6 (14.0)	
Full time	18 (41.9)	
Retired	3 (7.0)	
Financial support	 	
Self-supported	24 (55.8)	
Supported by family	16 (37.2)	
Supported by government	2 (4.7)	
Others	1 (2.3)	
Family history	 	
No	34 (79.1)	
Yes	7 (16.3)	
I don’t know	2 (4.7)	

Table 2 displays the mean differences in knowledge scores for CRC screening before and after intervention. The results reveal a significant mean increase in knowledge score after intervention (MD = 3.09, P < 0.001).

Table 2 Mean difference of knowledge toward colorectal cancer screening before and after intervention.

SD, standard deviation; CI, confidence interval; DF, degree of freedom

Knowledge	Mean (SD)	MD (95% CI)	t-stat (DF)	P	
Pre-intervention	12.67 (3.54)	3.09 (1.79-4.390)	4.79 (42)	< 0.001	
Post-intervention	15.77 (2.07)	 	 	 	

Table 3 displays the mean differences in attitude scores for CRC screening before and after intervention. The results reveal a significant mean increase in attitude score after intervention (MD = 4.16, P < 0.001).

Table 3 Mean difference of attitudes toward colorectal cancer screening before and after intervention.

SD, standard deviation; CI, confidence interval; DF, degree of freedom

Attitude	Mean (SD)	MD (95% CI)	t-stat (DF)	P	
Pre-intervention	34.07 (4.73)	4.16 (2.41-5.92)	4.78 (42)	<0.001	
Post-intervention	38.23 (2.32)	 	 	 	

Table 4 displays the mean differences in practice scores for CRC screening before and after intervention. The results reveal a significant mean increase in practice score after intervention (MD = 2.67, P < 0.001).

Table 4 Mean difference of practices toward colorectal cancer screening before and after intervention.

SD, standard deviation; CI, confidence interval; DF, degree of freedom

Practice	Mean (SD)	MD (95% CI)	t-stat (DF)	P	
Pre-intervention	2.35 (1.72)	2.67 (1.98-3.37)	7.74 (42)	<0.001	
Post-intervention	5.02 (1.52)	 	 	 	

Discussion

The purpose of this study was to determine how health education on CRC screening can improve nursing students' knowledge, attitudes, and practices regarding CRC screening in Jordan. Given the alarming incidence rate of CRC and the critical role of screening in survival rates, ensuring that people seek medical attention for suspicious symptoms and utilize screening programs is an essential strategy to reduce cancer mortality [8,23]. The lack of educational resources and facilities for participating in CRC screening programs may be the primary reason for people's poor knowledge and participation in these screenings [21,23-25]. Nurses are pivotal in enhancing the effectiveness of CRC screening programs, improving patient outcomes, and contributing to early detection and prevention [26]. Therefore, understanding nurses' knowledge, attitudes, and practices regarding CRC is vital, particularly when providing emotional support and counseling to patients who may be anxious or fearful about screening and potential results.

The present study's findings showed a significant increase in knowledge score after intervention, with a mean increase of 3.09. The findings of a recent study by Rakhshani et al. reveal a significant increase in the experimental group's mean knowledge scores following the intervention, highlighting the importance of education in enhancing participant knowledge [23]. This highlights the essential of doctors, healthcare professionals, and media outlets to advise and encourage individuals to undergo screening tests and participate in training sessions to prevent CRC [27]. Retraining programs for medical staff and community-based interventions can also significantly contribute to reducing the incidence of this disease [28]. Poor knowledge about CRC significantly lowers screening rates [28,29]. Consequently, adequate knowledge is a key factor in promoting the adoption of preventive measures within the study population [28].

The participants' attitudes regarding CRC screening mean scores significantly increased after the intervention, with a mean increase of 4.16. While no prior study specifically examined the impact of educational interventions on participants' attitudes toward CRC screening, a recent study by Rakhshani et al. reported a substantial improvement in CRC screening behavior following a health education intervention [28]. Health professionals assert that understanding the benefits of a habit can facilitate behavior modification [30]. One could argue that individuals with gastrointestinal malignancies are more likely to modify their behavior if they comprehend the personal benefits of doing so [27]. As a result, education promotes positive attitudes about the importance of CRC screening, motivating nurses to actively support screening initiatives.

Furthermore, the participants' practices regarding CRC screening mean scores significantly increased after the intervention, with a mean increase of 2.67. Educational interventions are essential for enhancing nursing practices related to CRC screening [26,28]. By increasing knowledge, improving communication skills, fostering positive attitudes, and boosting self-efficacy, these interventions empower nurses to deliver higher-quality care [28]. Consequently, this leads to better patient outcomes, more effective screening programs, and a reduction in the incidence and mortality of CRC. Similarly, Rakhshani et al. discovered that cues to action regarding CRC screening in their experimental group nearly doubled following the intervention [28].

The study does have some limitations. First, it relies on interview questionnaires, which were inevitably collected through self-reporting and are associated with a response bias. Second, because the data was gathered from a single hospital, it may not be generalizable to the entire community. Therefore, it is recommended to conduct additional research with control and experimental groups, including follow-up periods, to determine the long-term effects of education on CRC screening behaviors in both groups. Additionally, similar research should be conducted in other cities and regions to create a suitable screening environment for the general public.

Conclusions

The study's overall findings reveal a significant increase in mean knowledge, attitude, and practice toward CRC screening after completing the educational program. This indicates that the implemented training program had a positive impact. Consequently, it can be concluded that the participants greatly benefited from the educational intervention in this study. Therefore, enhancing these factors, such as providing basic information about CRC, including its definition, pathogenesis, symptoms, and incidence, can promote CRC screening behaviors.

Continuing education for this group of patients should be encouraged to prevent subsequent complications and to improve their quality of life. This is the responsibility of all healthcare providers working with those patients.

Disclosures

Author Contributions

Human subjects: Consent was obtained or waived by all participants in this study. The Institutional Review Board (IRB) in Al-Zaytoonah University issued approval 2022-2023/17/29. Informed consent was obtained from all participants.

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Concept and design:  Suhair Al-Ghabeesh, Batool Qutami, Majdi M. Alzoubi

Acquisition, analysis, or interpretation of data:  Suhair Al-Ghabeesh, Batool Qutami, Majdi M. Alzoubi

Drafting of the manuscript:  Suhair Al-Ghabeesh, Batool Qutami, Majdi M. Alzoubi

Critical review of the manuscript for important intellectual content:  Suhair Al-Ghabeesh, Batool Qutami, Majdi M. Alzoubi

Supervision:  Majdi M. Alzoubi
==== Refs
References

1 Global patterns and trends in colorectal cancer incidence and mortality Gut Arnold M Sierra MS Laversanne M Soerjomataram I Jemal A Bray F 683 691 66 2017 26818619
2 Association of body mass index with risk of early-onset colorectal cancer: Systematic review and meta-analysis Am J Gastroenterol Li H Boakye D Chen X Hoffmeister M Brenner H 2173 2183 116 2021 34309586
3 Stage-specific sensitivity of fecal immunochemical tests for detecting colorectal cancer: systematic review and meta-analysis Am J Gastroenterol Niedermaier T Balavarca Y Brenner H 56 69 115 2020 31850933
4 Changes in colorectal cancer incidence in seven high-income countries: a population-based study Lancet Gastroenterol Hepatol Araghi M Soerjomataram I Bardot A 511 518 1016 2019
5 Increasing colorectal cancer incidence trends among younger adults in Canada Prev Med Brenner DR Ruan Y Shaw E De P Heitman SJ Hilsden RJ 345 349 105 2017 28987338
6 Increasing incidence of colorectal cancer in adolescents and young adults aged 15-39 years in Western Australia 1982-2007: examination of colonoscopy history Front Public Health Troeung L Sodhi-Berry N Martini A 179 5 2017 28791283
7 Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years Gut Vuik FE Nieuwenburg SA Bardou M 1820 1826 68 2019 31097539
8 Incidence and characteristics of young-onset colorectal cancer in the United States: an analysis of SEER data collected from 1988 to 2013 Clin Res Hepatol Gastroenterol Wang W Chen W Lin J Shen Q Zhou X Lin C 208 215 43 2019 30686691
9 Trends in colorectal cancer incidence and related lifestyle risk factors in 15-49-year-olds in Canada, 1969-2010 Cancer Epidemiol Patel P De P 90 100 42 2016 27060626
10 Colorectal cancer in Jordan: survival rate and its related factors J Oncol Sharkas GF Arqoub KH Khader YS Tarawneh MR Nimri OF Al-Zaghal MJ Subih HS 3180762 2017 2017 28458690
11 Assessment of country implementation of the WHO global health sector strategy on sexually transmitted infections (2016-2021) PLoS One Taylor MM Wi T Gerbase A 0 17 2022
12 An interventional study to improve colorectal cancer screening knowledge and health perceptions among Jordanians' average risk population Open Nurs J 12] Abuadas FH Abuadas MH 13 2019
13 The impact of stress associated with caring for patients with COVID-19 on career decisions, resilience, and perceived self-efficacy in newly hired nurses in Jordan: a cross-sectional study Health Sci Rep Al Hadid LA Al Barmawi MA Alnjadat R Farajat LA 0 5 2022
14 Colorectal cancer screening: the time to act is now BMC Med Brenner H Stock C Hoffmeister M 262 13 2015 26459270
15 What do we know about education in colorectal cancer prevention?-survey among 1130 medical students J Cancer Educ Pietrzyk Ł Torres A Denisow-Pietrzyk M Torres K 406 412 32 2017 26706466
16 Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools J Cancer Educ Boehler M Advani V Schwind CJ 147 152 26 2011 20848257
17 Stee nocturnal air temperature traverses across the city of Jakarta, Indonesia Global J Adv Pure Appl Sci Maru R Ahmad S 19 23 2 2014 http://www.world-education-center.org/index.php/paas
18 Factors associated with initial participation in a population-based screening for colorectal cancer in Catalonia, Spain: a mixed-methods study Prev Med García M Borràs JM Milà N 265 267 52 2011 21295061
19 Public awareness of colorectal cancer and screening in a Spanish population Public Health Gimeno-García AZ Quintero E Nicolás-Pérez D Jiménez-Sosa A 609 615 125 2011 21794885
20 Public awareness of colorectal cancer screening: knowledge, attitudes, and interventions for increasing screening uptake ISRN Oncol Gimeno Garcia AZ Hernandez Alvarez Buylla N Nicolas-Perez D Quintero E 425787 2014 2014 24729896
21 Health literacy and cancer screening behaviors among community-dwelling female adults in Taiwan Women Health Huang CH Lo YJ Kuo KM 408 419 61 2021 33902386
22 Colorectal cancer knowledge, perceptions, and behaviors in African Americans Cancer Nurs Green PM Kelly BA 206 215 27 2004 15238806
23 The effect of educational intervention based on health belief model on colorectal cancer screening behaviors BMC Public Health Rakhshani T Razeghi E Kashfi SM Kamyab A Khani Jeihooni A 1640 24 2024 38898503
24 The association between health literacy and colorectal cancer screening uptake in a publicly funded screening program in Denmark: cross-sectional study Prev Med Rep Horshauge PM Gabel P Larsen MB Kirkegaard P Edwards A Andersen B 101132 19 2020 32551215
25 Does health literacy affect colorectal cancer screening rates? J Commun Health Nurs Yalçın Gürsoy M Bulut Ayaz C 147 156 40 2023
26 Improving colorectal cancer screening in primary care practice: innovative strategies and future directions J Gen Intern Med Klabunde CN Lanier D Breslau ES Zapka JG Fletcher RH Ransohoff DF Winawer SJ 1195 1205 22 2007 17534688
27 Predictive factors based on the health belief model on cancer screening behaviour in first degree relatives of patients with Lynch syndrome-associated colorectal cancer Int J Nurs Sci Gu J Jia S Chao H Chen T Wu X 251 257 10 2023 37128484
28 Effect of education based on health belief model on the behavior of breast cancer screening in women Asia Pac J Oncol Nurs Masoudiyekta L Rezaei-Bayatiyani H Dashtbozorgi B Gheibizadeh M Malehi AS Moradi M 114 120 5 2018 29379843
29 Likelihood of a fecal occult blood test uptake among older adults: comparisons between health professionals and healthcare volunteers based on the health belief model BMC Geriatr Lin TY Chuang ST Huang SF Hsu HP Lu LT Guo JL 51 19 2019 30791892
30 The effect of a blended educational program (BEP) on cervical cancer screening behavior among housekeeper women in West Eslamabad in 2016: an application of health belief model J Ilam Univ Med Sci Ezzati E Shariat F Moradi F babazadeh T 110 120 25 2017
