Association of Cancer Prevention Awareness with Liver Cancer Screening Participation Rates Among a High-Risk Population: Results from Rural Anhui Province
Liver cancer (LC) remains a critical global health challenge, ranking as the third leading cause of cancer-related mortality worldwide. In 2020 alone, approximately 905,677 new cases and 830,180 deaths were attributed to LC, emphasizing the urgent need for effective prevention and early detection strategies. Despite advancements in oncology, the 5-year survival rate for LC in China remains alarmingly low, ranging from 10.1% to 12.1% between 2003 and 2015. This poor prognosis is largely due to late-stage diagnoses, which underscores the importance of early detection through population-based screening initiatives.
In 2007, China launched a nationwide LC screening program targeting high-risk populations in rural areas, utilizing a combination of B-scan ultrasound and serum alpha-fetoprotein (AFP) testing. While studies in regions like Shanghai demonstrated the program’s potential to reduce LC mortality, participation rates (PRs) across the country have been suboptimal. A key factor hypothesized to influence screening engagement is cancer prevention awareness. Prior research on other cancers, such as cervical and breast cancer, has established a positive correlation between health knowledge and screening adherence. However, no such evidence existed for LC screening in China, particularly among high-risk rural populations. This study, conducted in Anhui Province from 2015 to 2019, sought to fill this gap by examining how cancer prevention knowledge impacts LC screening PRs.
Study Design and Population
The cross-sectional analysis focused on residents of rural Anhui Province, a region with elevated LC incidence and mortality. Eligible participants included men aged 35–64 and women aged 45–64. Exclusion criteria involved individuals with a prior LC diagnosis, other cancers, severe comorbidities, or limited self-care capacity. A total of 180,756 individuals completed an initial health factor questionnaire (HFQ), designed to identify high-risk LC candidates based on factors such as hepatitis B virus (HBV) infection, family history of gastrointestinal cancers, poor dietary habits, and symptoms of upper gastrointestinal disorders. From this cohort, 46,425 were classified as high-risk, and 4,204 provided complete data on a supplementary health knowledge questionnaire (HKQ), forming the final study cohort.
Data Collection and Measurement
The health knowledge questionnaire (HKQ) assessed general cancer knowledge and prevention strategies through 11 items (7 single-choice and 4 multiple-choice questions). Knowledge scores ranged from 0 to 22, with one point awarded per correct answer. The HKQ demonstrated high reliability, with a Cronbach’s alpha of 0.833. The health factor questionnaire (HFQ) collected demographic data (marital status, education, income), lifestyle factors (smoking, alcohol use), medical history (digestive diseases, cancer family history), and HBV status via HBsAg testing.
Screening Participation and Statistical Analysis
Screening participation was defined as undergoing AFP testing, B-scan ultrasound, or both. PRs were calculated as the proportion of high-risk individuals completing at least one screening test. Participants were stratified by tertiles of cancer prevention knowledge scores: T1 (1–10), T2 (11–15), and T3 (≥16). Chi-square tests compared PRs across demographic and behavioral subgroups. Logistic regression models adjusted for confounders such as age, sex, education, income, smoking, alcohol use, family history, and HBV status to isolate the relationship between knowledge scores and screening participation.
Key Findings
The study cohort comprised 2,796 men (66.5%) and 1,408 women (33.5%), with a mean age of 52.3 years. Overall, 45.2% (1,899/4,204) of high-risk individuals participated in LC screening. Knowledge scores averaged 13.78 (±4.30), with no significant sex-based differences. However, PRs varied markedly across subgroups:
- Sex: Women exhibited higher PRs (59.2%) than men (38.1%).
- Age: Participants aged 61–64 had the highest PR (52.1%) compared to younger age groups.
- Education: Illiterate individuals showed higher PRs (48.8%) than those with primary or secondary education.
- Lifestyle: Non-smokers (58.7%) and non-drinkers (50.0%) were more likely to participate.
- Medical History: Individuals with a family history of cancer had a PR of 57.9%, nearly double that of those without (29.7%).
In unadjusted models, higher knowledge scores correlated with increased PRs: T2 (OR=1.29, 95% CI:1.11–1.50) and T3 (OR=1.24, 95% CI:1.05–1.45) participants were significantly more likely to screen than T1. After adjusting for covariates, the association remained robust for T2 (aOR=1.31, 95% CI:1.10–1.55) and T3 (aOR=1.20, 95% CI:1.00–1.43).
Subgroup Variations
Stratified analyses revealed nuanced patterns:
- Sex: Knowledge significantly predicted PRs in women (T3 vs. T1: aOR=1.35) but not men.
- Age: Adults ≥50 years showed stronger knowledge-PR associations (T3 vs. T1: aOR=1.26) than younger groups.
- Education: Illiterate individuals in T3 had 70% higher odds of screening (aOR=1.70) compared to T1, a trend absent in educated subgroups.
- HBV Status: Despite being high-risk, HBV-positive individuals with higher knowledge scores paradoxically had lower PRs, suggesting alternative healthcare-seeking behaviors (e.g., preferential use of hospital-based services).
Implications and Limitations
This study provides the first empirical evidence linking cancer prevention awareness to LC screening participation in rural China. The findings advocate for targeted educational campaigns, particularly for men, younger adults, and HBV-positive populations, to address knowledge gaps and cultural barriers. However, the study’s cross-sectional design limits causal inference, and the modest sample size (4,204 of 46,425 high-risk individuals) may introduce selection bias, as excluded participants were younger, less educated, and less likely to screen.
Conclusion
Improving cancer prevention literacy is a viable strategy to enhance LC screening uptake in high-risk rural populations. Tailored interventions for demographic subgroups, combined with systemic efforts to reduce financial and logistical barriers, could optimize the effectiveness of China’s national screening program. Future research should explore longitudinal impacts of education campaigns and the role of healthcare access in moderating knowledge-behavior relationships.
doi.org/10.1097/CM9.0000000000001735
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