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Original Research (Original Article) 


Waleed E. Almalki et al, 2020;4(2):352–357.

International Journal of Medicine in Developing Countries

The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study

Waleed E. Almalki1*, Hazim A. Alzhoufui1, Moath A. Altwaijry1, Abdulrahman M. Dad1, Owais K. Khoshhal1

Correspondence to: Waleed E. Almalki

*Taibah University, College of Medicine, Madinah, Saudi Arabia.

Email: wm1416 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 04 December 2019 | Accepted: 21 December 2019


ABSTRACT

Background:

Colorectal Cancer (CRC) is the third most common malignancy in males and the second most common malignancy in females worldwide. This study aims at planning targeted educational programs to raise the awareness of CRC and its risk factors, through assessing the knowledge about CRC and its risk factors in the population of Madinah, Saudi Arabia.


Methodology:

A cross-sectional study was carried out in Madinah, Saudi Arabia involving study subjects approached by a 25 multiple-choice question-survey about CRC. The results were analyzed according to demographic data to determine the different levels of knowledge and associated risk factors.


Results:

Among the total of 385 study participants, more than half of them were males, 18–29 years old subjects constituted 44.2% and undergraduates constituted 54%. Regarding the knowledge score, the highest score by the participants was 8, and 53.4% of them were with a score of 2–3. At least 64.3% of the participant had two or three risk factors for CRC. The most common risk factor found was eating red meat with 61.5%.


Conclusion:

Overall, the knowledge about CRC in Madinah was found poor. The higher the education level and income, the higher was the knowledge regarding CRC among the study subjects. With the increase in financial income and education level, there was a decrease in the number of CRC risk factors, the opposite was found in relation to age.


Keywords:

Colorectal cancer, awareness, risk factors, Madinah.


Introduction

Colorectal Cancer (CRC) is the third most common malignancy in males and the second most common malignancy in females worldwide [1]. In Saudi Arabia, CRC is the second most common malignancy, which is considered as the most common type of cancer in males 10.6% of the Saudi population, and the third in females by 8.9% [2]. CRC is associated with several risk factors such as age above 40, family history of CRC or colorectal polyps, physical inactivity, smoking, and alcohol consumption [3]. A previous study about risk factors of CRC in Saudi Arabia showed that a positive family history of CRC and physical inactivity were the most common risk factors associated with CRC [4]. There are no previous studies that have investigated the awareness and the risk factors of CRC in the population of Madinah. This study aims to assess the CRC awareness, prevalence of risk factors in the population of Madinah. The results of this study will help in creating more targeted educational programs to raise the awareness of CRC and its risk factors which will be reflected by a decrease in the incidence of CRC in Madinah.


Subjects and Methods

A cross-sectional study was conducted in Madinah, Saudi Arabia during the period from November 2017 to August 2018. Madinah has a population of 2,080,436 (the year 2016), of which 15.5% are above the age of 50 years [5]. The calculated sample of this study was 384 participants following the parameters of the 95% confidence level, 50% expected frequency, and design effect 1.0. The study subjects were interviewed in various Primary Health Care centers in Madinah. The inclusion criteria for this study included subjects aged above 18 and living in Madinah. The individuals who have been diagnosed with CRC living outside of Madinah were excluded from the study. The collection of the sample was done using a multi-stage sampling technique. Data collected through interview questionnaires consisting of 25 multiple-choice questions written in the Arabic language in a standard format. Of these, four questions were obtained from a survey of Zubaidi et al. [6]. All questions were validated according to the Cancer Awareness Measure. Statistical analysis performed using Statistical Package for the Social Sciences (SPSS) version 24, data were presented as numbers, percentages, tables, and figures. Informed consent was obtained from every participant. Data were considered confidential, ethical approval has been obtained from the Ethical Committee at Taibah University and General Directorate of Health Affairs in Madinah.

Table 1. Demographic characteristics of the respondents.

Characteristic No. (N = 385) Percent
Age
18–29 170 44.2%
39–30 124 32.2%
40–49 62 16.1%
>50 29 7.5%
Sex
Male 214 55.6%
Female 171 44.4%
Marital status
Single 109 28.3%
Married 259 67.3%
Divorced / Widowed 17 4.4%
Education
Elementary 18 4.7%
Intermediate 19 4.9%
High school 140 36.4%
Undergraduate and above 208 54.0%
Financial situation
<5,000 SR 150 39.0%
5,000–10,000 SR 151 39.2%
10,000–20,000 SR 71 18.4%
>20,000 SR 13 3.4%

Results

The sample of the study comprised of 385 participants, out of 420 invited to participate, giving a response rate of 91.7%. Among them, 35 were excluded as they were not living in Madinah (n = 16) or didn’t complete the questionnaire (n = 19). The general characteristics of the respondents are shown in Table 1. They were 56% (n = 214) males and 44% (n = 171) females. Most of the respondents were 18–29 years old—44.2%, undergraduate or above—54%, and married—67.3%. The knowledge was assessed by 9 questions containing 28 items that covered certain aspects of CRC, including awareness, risk factors, signs, and symptoms; 22 of these items were true, the others were either wrong answers or “I Don’t Know” (Table 2). The maximum score to get was 22 and the lowest was zero. The highest score by the participants was 8, while the lowest was 1. Over half of the participants (53.4%) got a score of 2 or 3 (Table 3). According to the participants perception of their knowledge about CRC and risk factors, the results showed that 44.4% (n = 171) poor, 35.6% (n = 137) low, 19.2% (n = 74) good, and 0.8% (n = 3) excellent. Among participants with “undergraduate or above” level of education, 84.1% (n = 175) had heard about CRC compared to 70.7% (n = 99) among those with high school education (p = 0.002). According to the financial income, people whose income was > 20,000 SR 100% (n = 13) heard about CRC while those with an income < 5,000 SR 74.0% (n = 111) did not hear of it (p = 0.036). The majority of participants (78.5%) didn’t know that CRC is the second most common cancer in Saudi Arabia. The undergraduate or above participants (75%) (n = 156) didn’t answer correctly, the same was observed for the subjects with an elementary level of education (94.5%) (n = 17). Regarding the financial income, 53.9% (n = 7) of whom their income > 20,000 SR didn’t get the right answer was 84.7% (n = 127) of whom their income < 5,000 SR didn’t get the right answer (p = 0.014). Most of the sample 71% (n = 276) didn’t know that CRC is more common in males. The majority of males and females didn’t know that CRC is more common in males 80.4% (n = 172), 60.8% (n = 104), respectively (p = 0.000). People whose income was > 20,000 SR knew that CRC was found more in males 61.5% (n = 8) was 18.7% (n = 28) of whom their income < 5,000 SR didn’t get the right answer (p = 0.001). The risk factors were assessed by eight questions (Table 4), we considered sex as a risk factor. The maximum score the participant can get is eight. The highest score was 5. 64.3% (n = 248) of the participants has at least two or three risk factors for CRC. The risk factors score and its items are listed in Tables 4 and 5. In people who are aged 50 years or more, 55.2% (n = 16) have three or more risk factors compared to who are aged from 18 to 29 years 44.1% (n = 75), the same for male 50.7% (n = 108) compared to female 38% (n = 65) (p = 0.000). According to the education level, 41.5% (n = 86) of participants who were undergraduates or above had three or more risk factors, compared to 55.6% (n = 10) of those with elementary education. Also, the same regarding the financial income, people who had an income of > 20,000 SR 30.8% (n = 4) compared to who had income <5,000 SR 51.3% (n = 77). The most common risk factors found in the sample was eating red meat daily 61.5% (n = 237), not doing regular physical activity 50.6% (n = 195), not eating fruit and vegetable regularly 49.3% (n = 190). Concerning physical activity, 45.3% (n = 77) of participants aged from 18 to 29 didn’t practice regular physical activity, also there is 72.4% (n = 21) at the age of 50 years or more didn’t practice regular physical activity (p = 0.021). The same difference was presented regarding the education level, people with an educational level of undergraduate or above and didn’t practice physical activity were 42.8% (n = 89), were 84.2% (n = 16) of intermediate level of education didn’t practice physical activity (p = 0.000). People aged 50 years or more and eating red meat daily were 69% (n = 20). The majority of the participants who eat red meat daily were male (70.1%; n = 150, p = 0.002).

Table 2. Participants knowledge on CRC.

Questions Sex p Value
Male Female
Number Percent Number Percent
Have you ever heard about CRC? No 48 22.4% 32 18.7% 0.373
Yes 166 77.6% 139 81.3%
How widespread is CRC in Saudi Arabia? The most widespread 17 7.9% 12 7.0% 0.298
The second most widespread 47 22.0% 35 20.5%
The third most widespread 35 16.4% 18 10.5%
I don’t know 115 53.7% 106 62.0%
CRC is more in: Men 42 19.6% 67 39.2% 0.000
Women 27 12.6% 8 4.7%
Equal in Men and Women 58 27.1% 31 18.1%
I don’t know 87 40.7% 65 38.0%
CRC considered to be: Inherited 14 6.5% 15 8.8% 0.230
Acquired 56 26.2% 54 31.6%
Inherited and Acquired 72 33.6% 42 24.6%
I don’t know 72 33.6% 60 35.1%
CRC signs and symptoms
Bleeding from Rectum Chose 103 48.1% 61 35.7% 0.014
Blood in Stool Chose 110 51.4% 67 39.2% 0.017
Change in Bowel Habits Chose 88 41.1% 46 26.9% 0.004
Continuous Abdominal Pain Chose 112 52.3% 90 52.6% 0.954
Unreasonable Weight Loss Chose 77 36.0% 50 29.2% 0.162
Feeling Bloated Chose 72 33.6% 41 24.0% 0.038
Feeling of Incomplete Defecation Chose 39 18.2% 16 9.4% 0.013
Has No Symptoms Chose 0 0.0% 3 1.8% 0.052
I Don’t Know
CRC Risk Factors
Older Age Chose 40 18.7% 43 25.1% 0.126
Personal or Family History of CRC Chose 84 39.3% 51 29.8% 0.054
IBD Chose 95 44.4% 60 35.1% 0.064
Obesity Chose 45 21.0% 26 15.2% 0.143
Smoking Chose 87 40.7% 64 37.4% 0.519
Eating Red Meat Chose 38 17.8% 20 11.7% 0.099
Low Physical Activity Chose 50 23.4% 40 23.4% 0.995
I Do Not Know any CRC Risk Factors Chose 52 24.3% 58 33.9% 0.038
Have you ever heard of CRC screening? No 149 69.6% 117 68.4% 0.799
Yes 65 30.4% 54 31.6%
At what age is CRC screening performed? At the age of 30 years 34 15.9% 19 11.1% 0.344
At the age of 40 years 27 12.6% 21 12.3%
At the age of 50 years 14 6.5% 20 11.7%
At the presence of symptoms 38 17.8% 29 17.0%
I don’t know 101 47.2% 82 48.0%
CRC screening
FOBT Chose 41 19.2% 36 21.1% 0.644
X-Ray Chose 15 7.0% 9 5.3% 0.481
CT-Scan Chose 29 13.6% 9 5.3% 0.007
Colonoscopy Chose 89 41.6% 89 52.0% 0.041
I Do Not Know Chose 98 45.8% 70 40.9% 0.340

Table 3. Knowledge score.

Knowledge score
Score Number Percent
1 49 12.7%
2 103 26.7%
3 103 26.7%
4 68 17.6%
5 41 10.6%
6 13 3.5%
7 5 1.4%
8 3 .9%

Table 4. Participants risk factors.

Questions Overall Sex p value
Male Female
Number Percent Number Percent Number Percent
Are you currently smoking? No 314 81.77% 149 69.6% 165 96.5% 0.000
Yes 71 18.49% 65 30.4% 6 3.5%
Do you practice regular physical activity 30 min / 5 days a week? No 195 50.78% 107 50.0% 88 51.5% 0.776
Yes 190 49.48% 107 50.0% 83 48.5%
Does your daily diet contain red meat? No 148 38.54% 97 45.3% 51 29.8% 0.002
Yes 237 61.72% 117 54.7% 120 70.2%
How many times do you ear fruit or vegetables per week? Daily 79 20.57% 46 21.5% 33 19.3% 0.283
3-5 times / week 116 30.21% 69 32.2% 47 27.5%
1-2 times / week 108 28.13% 61 28.5% 47 27.5%
I rarely eat it weekly 82 21.35% 38 17.8% 44 25.7%
Are you currently have inflammatory bowel disease or you have history of it? No 364 94.79% 201 93.9% 163 95.3% 0.549
Yes 21 5.47% 13 6.1% 8 4.7%
Are you currently have CRC or you have history of it? No 385 100.26% 214 100.0% 171 100.0%
Yes 0 0% 0 0% 0 0%
Is your father/mother, brothers/sisters, children has/have history of CRC? No 378 98.44% 208 97.2% 170 99.4% 0.105
Yes 7 1.82% 6 2.8% 1 .6%

Discussion

According to the Saudi Cancer Registry in 2014, the number of cases of CRC was 1,347, which was considered as 11.5% of all newly diagnosed cases among the Saudi population. Madinah was the sixth-highest region in the number of CRC cases in Saudi Arabia. The Age-Standardized Incidence Rate among Saudi males (per 100,000) was 10.0 / 100,000 and among Saudi females was 6.6 / 100,000[7]. As the highest knowledge score by the participants was 8 / 22, only half of the participants got 2 or 3, which means that there is a significant defect of knowledge about CRC which can be explained by the responses on their perception of knowledge about it. For instance, limited knowledge and awareness of CRC was found in Ireland [8], Croatia [9]and between ethnic minority in the UK [10]. According to this, in 2007 Croatia created a national screening program to fill the gap of knowledge and screening awareness [9]. The majority of the participants didn’t know that CRC is the second most common malignancy in Saudi Arabia. Depending on the education level and its effect on the level of knowledge, there was a significant difference that people with a high level of education have a better knowledge of CRC as they had heard about CRC and knew that it is the second most common malignancy in Saudi Arabia. Overall, participants with more education had a better knowledge of CRC. The same relation in the previous points appeared regarding the financial status as people with high incomes have better knowledge than those with low incomes. As the majority of people found not knowing that CRC is more common in males, there was a significant difference between males and females as females were more knowledgeable that CRC is more common in males. Moreover, females were more knowledgeable about CRC which is not uncommon from the global perspective [7]. Regarding the knowledge about signs and symptoms, less than half of the participants knew other CRC signs and symptoms other than continuous abdominal pain (Figure 1). In another study, females were more knowledgeable about CRC symptoms [7]. As the main risk factors for CRC include smoking, physical inactivity and eating processed meat [12], most of the sample thought that Inflammatory Bowel Disease (IBD) is considered a risk factor of CRC. People aged 50 years or more showed the same association [7], while most of them didn’t think that eating red meat is one of them (Figure 2), which correlates with the fact that daily eating red meat is the most common risk factor among Madinah population. More than half of the people aged 50 years or more are at this risk. On the same relation with financial income, those with high incomes are consuming red meat more than with a lower income. Other studies showed that older participants aged 50 years and more knew that CRC family history considered a risk factor of CRC [7]. On the other hand, a family or relative history of CRC was the lowest risk factor found in the sample. Regarding consuming a sufficient amount of fruits and vegetables, we found that there was a significant relationship between increasing age and having this healthy habit. In our study, we chose eight items of CRC risk factors to be measured. More than half of the participants had two or three risk factors. A few of them got the highest number of risk factors which was 5. That means that there is a different distribution of risk factors in the Madinah population. We found that there is an increase in the number of risk factors with the increasing age. People with high incomes have fewer risk factors compared to those with less income. The same relation appeared in the education level, participants with a high educational level have fewer risk factors compared to those with a lower educational level. In the meta-analysis of 21 studies, there was a significant reduction of CRC risk with regular physical activity [11]. In addition, there was an obvious relation between decreasing regular physical activity and increasing age. On the other hand, people who had a high education level are practicing regular physical activity.

Table 5. Number of risk factors.

Number of Risk Factors
Number of risk factors No. %
0 9 2.3%
1 71 18.4%
2 132 34.2%
3 116 30.1%
4 54 14.0%
5 3 .8%

Figure 1. Knowledge of CRC signs and symptoms.

Figure 2. Participants knowledge of CRC risk factors.


Conclusion

There was a significant defect of knowledge regarding CRC among the population of Madinah. Most of the population of Madinah had at least two or three risk factors for CRC. The most common risk factor for CRC in Madinah was eating red meat, and the lowest was a family or relative history of CRC. As there is an increase in education level and financial income, there is a decrease in the number of CRC risk factors and the opposite is true in regards to age. We recommend creating an educational program for CRC that targets all the population and demographics in Madinah.


Acknowledgment

The authors would like to express our appreciation to our supervisor Dr. Abdulmohsen Al-Zalabani for his professional guidance and development of this research project. The authors also like to thank our colleagues; Rahaf Alsayed, Imtinan Alhejaili, Salha Sorour, Waad Albalawi, and Rawan Alharbi for their participation in data collection.


List of Abbreviations

CRC Colorectal Cancer
IBD Inflammatory Bowel Disease

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval has been obtained from the Ethical Committee at Taibah University and the General Directorate of Health Affairs in Madinah.


Author details

Waleed E. Almalki1, Hazim A. Alzhoufui1, Moath A. Altwaijry1, Abdulrahman M. Dad1, Owais K. Khoshhal1

  1. Taibah University, College of Medicine, Madinah, Saudi Arabia

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How to Cite this Article
Pubmed Style

Almalki WE, Alzhoufui HA, Altwaijry MA, Dad AM, Khoshhal OK. The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. IJMDC. 2020; 4(2): 352-357. doi:10.24911/IJMDC.51-1575486671


Web Style

Almalki WE, Alzhoufui HA, Altwaijry MA, Dad AM, Khoshhal OK. The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. https://www.ijmdc.com/?mno=76637 [Access: January 28, 2022]. doi:10.24911/IJMDC.51-1575486671


AMA (American Medical Association) Style

Almalki WE, Alzhoufui HA, Altwaijry MA, Dad AM, Khoshhal OK. The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. IJMDC. 2020; 4(2): 352-357. doi:10.24911/IJMDC.51-1575486671



Vancouver/ICMJE Style

Almalki WE, Alzhoufui HA, Altwaijry MA, Dad AM, Khoshhal OK. The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. IJMDC. (2020), [cited January 28, 2022]; 4(2): 352-357. doi:10.24911/IJMDC.51-1575486671



Harvard Style

Almalki, W. E., Alzhoufui, . H. A., Altwaijry, . M. A., Dad, . A. M. & Khoshhal, . O. K. (2020) The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. IJMDC, 4 (2), 352-357. doi:10.24911/IJMDC.51-1575486671



Turabian Style

Almalki, Waleed E., Hazim A. Alzhoufui, Moath A. Altwaijry, Abdulrahman M. Dad, and Owais K. Khoshhal. 2020. The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. International Journal of Medicine in Developing Countries, 4 (2), 352-357. doi:10.24911/IJMDC.51-1575486671



Chicago Style

Almalki, Waleed E., Hazim A. Alzhoufui, Moath A. Altwaijry, Abdulrahman M. Dad, and Owais K. Khoshhal. "The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study." International Journal of Medicine in Developing Countries 4 (2020), 352-357. doi:10.24911/IJMDC.51-1575486671



MLA (The Modern Language Association) Style

Almalki, Waleed E., Hazim A. Alzhoufui, Moath A. Altwaijry, Abdulrahman M. Dad, and Owais K. Khoshhal. "The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study." International Journal of Medicine in Developing Countries 4.2 (2020), 352-357. Print. doi:10.24911/IJMDC.51-1575486671



APA (American Psychological Association) Style

Almalki, W. E., Alzhoufui, . H. A., Altwaijry, . M. A., Dad, . A. M. & Khoshhal, . O. K. (2020) The Awareness of colorectal cancer and its risk factors in Madinah, Saudi Arabia: a cross-sectional study. International Journal of Medicine in Developing Countries, 4 (2), 352-357. doi:10.24911/IJMDC.51-1575486671