Environmental factors and awareness of colorectal cancer in people at familial risk

Objective to identify the association between environmental risk factors and awareness of colorectal cancer in people at familial risk. Method cross-sectional correlational study, with a sample consisted of people who met at least one of the Revised Bethesda criteria, and 80 participants were included in this study. A sociodemographic data record, the AUDIT Test for alcohol use, the Fagerström Test for tobacco smoking, the Estimation and Frequency of Food Intake scale, and the Cancer Awareness Measure questionnaire to assess the colorectal cancer awareness were used. Body mass index was calculated, and descriptive statistics and the Pearson’s Correlation Coefficient were used to estimate the association. Results female sex predominated, with an average age of 37.8 years, almost half of the participants were overweight, 45% showed symptoms of alcohol dependence, half of the sample showed an association between hereditary factors and the development of colorectal cancer, and less than half of them were aware of cancer prevention programs. Conclusion there is little information on the main environmental risk factors, signs and symptoms of colorectal cancer, and no significant association was found between these and colorectal cancer awareness.


Introduction
Colorectal cancer (CRC) is one of the most common types of cancer, the third most incident cancer and the fourth leading cause of deaths from malignant tumors, accounting for approximately 774,000 deaths in 2015 worldwide (1) . In the Americas region, CRC is the fourth most common type of cancer, with 240,000 new cases each year, accounting for approximately 112,000 deaths, and it is predicted that by 2030 its incidence rate will increase by 60% (2) .
There are multiple environmental factors associated with CRC diagnosis and different studies indicate that obesity, alcohol use, tobacco smoking, intake of red and processed meat are related to CRC, while factors such as physical activity and maintaining an appropriate weight can reduce the risk of developing it (3)(4)(5)(6)(7) . It has been identified that CRC is also associated with hereditary factors, since having at least one first-degree relative diagnosed with CRC increases the risk of developing the disease (8) . Moreover, it has been found that people over 50 years are more likely to develop CRC (8)(9)(10) .
It is important to emphasize that most cases of CRC due to sporadic causes or environmental factors.
However, 10-30% of cases of CRC occur when there is a relative with the same diagnosis (11) . Lynch syndrome (LS) is the most frequent cause of hereditary CRC and is attributed to up to 5% of cases (11)(12)(13)(14)(15) . In addition, alcohol use, tobacco smoking, intake of red and processed meat, as well as obesity, are associated with an early CRC diagnosis in people at risk for LS (15)(16)(17)(18) .
There are several methods to diagnose LS, however, strategies such as prevention and awareness of the risk of developing the disease are equally effective and have lower costs. CRC risk awareness refers to knowledge on the warning signs, risk factors, delay in seeking medical help in case of having signs or symptoms, high-risk age, risk of developing CRC throughout life, knowledge on timely detection programs and confidence in detecting symptoms (19) .
Several researches have aimed to study CRC awareness worldwide and they agree that there is little knowledge about the risk factors, signs and symptoms of this disease (20)(21)(22) . There is a need to implement strategies to raise CRC awareness and identify possible cases of LS to prevent the development of the disease at an early age, since cancer can develop before the age of 30 in the case of having this health condition.

Method
Study with a cross-sectional descriptive design, developed in two public health institutions in the city of Chihuahua, Mexico, whose data collection was carried out between August and September 2016. The study population consisted of people at familial risk, of which 167 were patients diagnosed with CRC who were under treatment and diagnosed before the age of 50. Once the list of patients diagnosed with CRC was available, these people were contacted by telephone so that they could provide the data of a relative who wished to participate, since the study was composed of people at risk of developing CRC. Each patient provided information about a family member who was contacted by telephone and to whom the purpose of the study was explained.
The sample was calculated using the nQuery Advisor ® program for multiple regression, with a significance level of 0.05, bilateral alternative hypothesis, effect size of 0.7 and a power of 80%. The final sample size was composed of 68 individuals, considering rejection and abandonment rates of 16%, according to a similar study (23) , from a total of 80 participants, and a simple random sampling was performed using the random function of the Microsoft Excel program ® .
People at familial risk, aged between 18 and 60 years and who met at least one of the Revised Bethesda www.eerp.usp.br/rlae 3 Pacheco-Pérez LA, Ruíz-González KJ, de-la-Torre-Gómez AC, Guevara-Valtier MC, Rodríguez-Puente LA, Gutiérrez-Valverde JM criteria (14) were included, and those participants who were under any treatment to stop using alcohol, tobacco smoking or lose weight during the study period were excluded to reduce bias.
A sociodemographic data record and four instruments were used and anthropometric measures of weight and height were performed to calculate the BMI. Tobacco smoking. The Fagerström Test that has been validated to Spanish was used to assess nicotine dependence (25) . The questionnaire consists of six items, During this study, no CAM validated to Spanish was found, but the process of implementing this instrument is described in another similar study conducted with a population from Mexico (29) .
BMI. Anthropometric measurements of body weight and height were performed (30) . A Teraillon ® portable digital scale was used, and whose accuracy was previously checked by comparing the weights of five different objects estimated using other scales. A Zaude ® wall-mounted stadiometer with 1mm precision was used to measure height, and two measurements were performed, whose values were averaged,

Results
In the study, female sex predominated (55%), the majority of participants were married (62.5%), the average age was 36.8 years (SD = 10.72); the alcohol use index showed an average of 18 (Table 3).   The contingency coefficient test was performed to determine the CRC risk awareness by sex, and no statistically significant association was found between the variables (p = 0.483). Similarly, the marital status was considered and no statistically significant association was found (p = 0.274).

Discussion
The results of this study confirm that changes in  It is necessary to increase the level of knowledge and strengthen the information in terms of prevention so that the population recognizes the risk factors, with emphasis on those that can be modified. This type of intervention is cost effective in public health, as well as a permanent campaign for the timely diagnosis of the disease, because even in screening programs there is a lack of CRC awareness, which makes the participation of the population in diagnostic studies to be around 70.3% (34) .
Alcohol use has been identified as one of the main risk factors for CRC, and almost half of the population in this study showed symptoms of alcohol dependence.
A study conducted in Spain reports that primary care professionals, including nurses, find it difficult to identify patterns of alcohol use among the population, but it is necessary to overcome this obstacle to get to know the use of licit and illicit substances when family risk factors for CRC are present (35) . It is necessary to design and implement more effective and lasting strategies to increase knowledge about risk factors and CRC awareness. By this, prevention programs with a nationwide scope are designed and hence, the costs of medical care, complications, hospitalizations and associated death are reduced.
The objective of this study was to identify the association between environmental risk factors and CRC awareness, although the results found were not statistically significant. In addition, a low knowledge about the risk factors, signs and symptoms of CRC was observed, with these results being similar to those reported in another study (19) . Because it is a population at familial risk, there is a higher probability of developing the disease at an early age. Given that the nursing professional actively participates in health education, it is necessary that they can identify people at risk for LS and inform them about environmental factors with the aim of modifying unhealthy lifestyles.
The nursing professionals, due to their training in the biological and behavioral areas, are the best people to carry out studies to identify the population at risk of getting sick. Moreover, during their work in the clinical field, they can recognize the familial and hereditary risks, such as the LS, in people, which can reduce the exposure to factors associated to unhealthy lifestyles.
One of the limitations in this study was the small sample used, because several of the records in the www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2019;27:e3195.
institutions were incomplete and did not meet the initial selection criteria for LS. It was difficult to locate people at first, but after making the invitation and informing them about the benefits of the study, they agreed to participate.

Conclusion
There is scientific evidence on the environmental and family risks for developing CRC. In this study, overweight and alcohol use are two of the most prevalent modifiable factors, and the low level of knowledge about the CRC risk factors, signs and symptoms results in a lack of CRC awareness and, therefore, an increased incidence of CRC is likely. No association between risk factors and CRC awareness was found in this study, but it is suggested to replicate it with a larger sample.
It is important that the nursing staff contribute to the education on CRC by informing people of the environmental and hereditary risk factors to prevent or early diagnose the disease.