Surveying barriers to Colorectal Cancer screening in Jordan Open Access

Abstract

Colorectal cancer (CRC) is the most common cancer for men in Jordan, and the second most common for women (Globocan, 2020). There is a need to better understand the underlying factors that have resulted in very low screening rates, with studies indicating a 12.6% referral rate and a 9.1% uptake rate (Ahmad, 2015). Patients are hesitant to receive CRC screenings because of poor public awareness of the risk factors and screening options(Abuadas et al., 2018; Omran et al., 2015), while also experiencing practical obstacles to meeting routinely with providers (Hammad et al., 2022). Similarly, reduced supportive resources for providers and workloads create barriers to higher CRC screening advocacy to patients(Abuadas & Abuadas, 2019; Ahmad et al., 2015). The intention of this work was to better understand the motivators and barriers to CRC screening as perceived by healthcare providers in Jordan.

We conducted a cross sectional survey of 153 primary healthcare providers in two Jordanian health governates that applied social implementation principals to assess factors that influence their decision to discuss CRC screening with their patients. The Theoretical Domain Framework (TDF) is a social-behavioral implementation framework used to understand the mechanics of specific behaviors with 12 of the 14 main domains representing various personal, social, and psychological factors, which were used in this survey to evaluate the context of practice for Jordanian providers. Attested knowledge varied between different types of Jordanian providers, while confidence in the reliability and availability of all screening options remained high. Responses also strongly indicated that providers were aware of social and personal concerns around CRC screenings but felt unsure of their ability to relieve these concerns. Respondents included 46% male providers and 54% female providers, with the majority of those being physicians (69%). Practice distribution among respondents was 45% urban, 42% rural, and 11% indicating practice in other areas. Concerns with resources capacities, knowledge levels between provider types, and logistical issues for patients strongly indicated that additional public health education and clinical support measures are needed to improve the uptake of CRC screenings in Jordan.

Table of Contents

Chapter 1: Introduction 1

Problem Statement 1

Purpose Statement and Aims 2

Significance Statement 3

Chapter 2: Literature Review 4

Burden of colorectal cancer 4

Colorectal cancer types and biology 7

Etiology and primary prevention 8

Screening and Early detection 9

Barriers to Screening CRC 11

References 54

Chapter 3: Manuscript 16

Abstract 16

Background 16

Purpose 17

Methods 17

Results 17

Conclusion 18

Background 18

Methods 19

Study Design 19

Study population and sample 20

Survey tool and data collection 20

Underpinning theory for survey: 20

Survey development: 21

Knowledge 21

Skills 22

Optimism 23

Motivation and Goals 23

Reinforcement and Memory, Attention, or Decision-making Processes 24

Professional Role 25

Emotions 25

Social Influence 25

Environmental Context and Resources 25

Divisions between provider groups 26

Non-TDF variables 27

Practice Setting 27

Profession 27

Recent screening referrals 27

Data Collection: 28

Data Management and Statistical Analysis 28

Results 29

Participants’ characteristics 29

Barriers to colorectal cancer screening as perceived by healthcare providers 29

Knowledge 29

Skills 30

Beliefs in Capabilities 30

Motivation and goals 31

Reinforcement 31

Memory, Attention, or Decision-making processes 32

Behavioral Regulation 33

Professional role 33

Emotions 33

Environmental Context and Resources 34

Discussion 34

Recommendations 37

Conclusions 38

Table 1 – Characteristics of the study population (N%) 40

Table 2 – Percentage of provider agreement to questions within domains of the Theoretical Domains Framework (TDF) 41

Chapter 4: Discussion 46

Discussion 46

Strengths & Limitations 50

Recommendations 51

Conclusions 52

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Oncology
Keyword	cancer Theoretical Domains Framework Jordan Colorectal cancer
Committee Chair / Thesis Advisor	Ghada N. Farhat, Emory University
Committee Members	Yousef Khader, Jordan University of Science and Technology

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