Introduction

Prostate cancer (PC) is considered the second most prevalent cancer worldwide after lung cancer, with more than 1,414,259 new cases diagnosed in 20201. Over the years, Lebanon was considered one of the countries with higher-than-average rates of PC, with the highest age-standardized rate of 41.3 cases per 100,000 Lebanese men in 20122. Hence, the importance of increasing public awareness and screening to control and prevent PC.

To ensure early detection, the most commonly used screening test is the PSA test3. In fact, the number of deaths started decreasing after the PSA test was FDA-approved in 19864. Similarly, the decreased use of PSA in Sweden resulted in 2.5 times more deaths in men due to PC compared to the United States3.

Thus, the Knowledge, Attitudes, and Practices (KAP) of men about PC are of high interest, as they affect the detection, treatment, and quality of life. For instance, a study performed in Chile showed that 81% had limited knowledge about PC5. Another KAP study in Italy concluded that 72.7% of the respondents have heard about PSA from their doctors6. A study in Saudi Arabia recorded 81% had poor knowledge about screening methods7. Despite being the most prevalent cancer in Lebanese men, only one KAP PC was published in Lebanon by Boustany J. et al. in 2021, who found that KAP PC significantly increased with educational level, higher monthly income, and younger age8.

Therefore, the aim of this study was to assess KAP regarding PC in Lebanese men and to identify predictors affecting their awareness and their behaviors to undergo screening tests.

Methods

Ethical considerations

The study was approved by the ethical committee of Al Zahraa hospital (reference number: 9/2021), in accordance with Good Clinical Practice ICH Section three, and the principles laid down by the 18th World Medical Assembly (Helsinki, 1964) and all applicable amendments. At the beginning of the questionnaire, an electronic consent form was included and encompassed a description of the topic, study objectives, the time needed to fill the survey, the confidentiality of the data, voluntary nature of subjects’ participation.

Study design and population

This was a cross sectional online survey-based study, aiming to assess the KAP of the Lebanese men on the PC. Eligible participants were Lebanese men ≥ 18 years old and recruited between April and December 2021. The sample size was calculated based on Slovin’s formula (n = N/(1 + N e2) to have a representative sample of the Lebanese population. We assumed the Lebanese population (N) accounts for 5,261,372 in 2021 based on the Index Mundi registry, and we considered 5% as the margin of error (e). Accordingly, at least 400 patients must complete the survey to be representative of the general population in Lebanon. We employed a multi-stage sampling technique to choose participants, ensuring that all Lebanese governorates were included in proportion to their respective population densities. Subsequently, data collection was conducted through the convenience sampling method.

Tools and procedure of data collection

The study questionnaire was designed by the researchers and KAP questions were based on previous publications6,9,10. Data collection was ensured by the researcher or designated staff and was recorded on an electronic data collection form using the Google Form. Data Collection included the Socio-demographic characteristics of the participants, habits, source of information, and family history about PC, Knowledge was tested by asking participants to answer questions about risk factors, general information and tests of PC, Attitude about willingness to perform a screening. (please refer to the Questionnaire in the supplementary material).

Data management

For Knowledge (K) & Attitude (A) assessments, the widely adopted Bloom’s cutoff points are the following: 80–100% (good KA), 60–79% (moderate KA), and less than 60% (poor KA)11,12. In this study, we used the Median of the scores and a modified Bloom’s cutoff values with the subcategories of ‘’Poor’’ and ‘’ Fair’’ scores grouped under the category “limited KA” about PC and subcategories of ‘’Good’’ and ‘’ Excellent’’ scores grouped under the category of “adequate KA” about PC. These cutoff values were also based on previously published KAP studies13,14 (Supplementary table 1).

Data analysis

Data were presented as mean ± SD for continuous variables and proportions or percentages for categorical variables. Two scores were generated: A knowledge score (over 27) was computed by adding the scores of the related items (the correct answer will be coded by “1” and the wrong answer will be coded by “0”. The Attitude score (over 150) was computed using the 5-point Likert scale from ‘’strongly disagree’’ to “strongly agree”. To validate each score, we recurred to Cronbach’s alpha test for reliability analysis with internal consistency when Cronbach’s alpha above than 0.7. The Cronbach alpha coefficients K = 0.861, A = 0.657, respectively. There was no Cronbach alpha value for practice as no score was calculated since P was represented by two variables (PSA testing and prostate exam performance). We examined the graphical representation to determine if the KA scores follow a normal distribution. We initially performed a bivariate analysis using Pearson’s Chi-square test, Student t-test, and ANOVA test to determine the relationship between KAP levels and sociodemographic characteristics (age, gender, educational level, residence, socioeconomic level, employment, smoking habit, dietary habit, and alcohol intake) clinical parameters (family history of PC, willingness to know more about PC, physician advices related to PC, and source of information on PC), and KAP questions (please refer to the Questionnaire in the supplementary material). A statistically significant correlation was set at 5% and all statistical tests were two-sided. Then, we conducted a linear and binary regression analysis to predict the factors independently affecting the “KA” scores and “P”, respectively. We included all above-mentioned factors associated to the dependent variable with a p < 0.1 in the bivariate setting. All statistical analysis was performed using IBM SPSS version 25.

Results

Demographic characteristics of PC

We had a response rate of 83.32%. A total of 844 Lebanese males responded to our survey, with a mean age of 42 ± 19.3 years, 36.4% had less than university level, 76.3% were workers, and 21.4% were healthcare professionals. Only 10.3% of them experienced a prostate problem, with the majority after their fifties (Table 1).

Table 1 Demographic characteristics and history of PC in the study population and in relatives.
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PC related knowledge

The mean knowledge score about PC reached 18.10 ± 2.23 over 27 (67.03 ± 8.25%) in our population. The overall knowledge score was normally distributed as assessed via the histogram and the Q-Q plot. Only 4.6% of our participants demonstrated an “Adequate” Knowledge level about PC. Almost 95% of our participants, regrouping 55.4% Poor and 40% Fair knowledge scores, reported a “Limited” Knowledge level about PC (Fig. 1A). For instance, 7.3% of men in this study never heard about PC, and only 56.3% knew that digital rectal examination (DRE) is a type of examination for the detection of PC, and the most common source of information of PC was doctors, friends, and TV (Supplementary table 2).

Figure 1
figure 1

Percentage (%) of participants with (A) knowledge (K) and (B) attitude (A) scores about prostate cancer represented in categories (limited/adequate) and sub-categories (poor/fair/good/excellent) (C) Summary of the study findings.

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The Knowledge about PC is positively increased in subjects with higher educational level (p < 0.001), higher monthly income (p = 0.002), being healthcare professionals (p < 0.001), and living in the capital Beirut (p < 0.001), however, it is negatively correlated in patients who never heard about PC (Supplementary table 3).

Linear regression analysis showed that Lebanese men knew more about PC when they had a higher educational level (p < 0.001) and when they had previously heard about PC (p = 0.002) (Table 2).

Table 2 Multivariate analysis with linear regression analysis of knowledge, attitude, prostate exam, and PSA test.
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PC related attitude

The studied population scored 24.54 ± 3.24 over 30 (81.80 ± 10.80%) on attitude questions regarding PC. Only one-third of our participants demonstrated an “Adequate” Attitude about PC (Fig. 1B), with only 30.6% correctly believing that the PSA test is useful to detect PC before symptoms appear.

Attitude score is positively linked in participants with higher educational levels (p < 0.001), being married (p < 0.045), lived in north Lebanon (p < 0.001), currently employed (p < 0.001), higher monthly income (p < 0.001), having history of prostate problem (p = 0.013), previously heard about PC (p = 0.005), having a relative with prostate problem (p < 0.001), being advised by their physician, especially urologist, to get screened for PC (p < 0.001) (Supplementary table 3).

Linear regression analysis demonstrated that an adequate attitude towards PC was achieved when participants had a higher educational level (p < 0.001), were informed by a physician and/or urologist about the PSA test (p < 0.001), previously heard about PC (p = 0.001), were advised to be screened for PC by their physician (p = 0.006) and were employed (p = 0.007) (Table 2).

PC related practice

Among the 844 men, 19.9% were advised by a physician to be screened for PC, 78.8% have never undergone a PSA test, 25.2% performed a prostate examination (of whom 54.5% were screened for prevention, and 39% were tested for presented symptoms) (Supplementary Table 2).

Prostate exam and associated factors

Performance of the prostate exam and the PSA test was dependent on being older than 50 years in men older than 50 years (p < 0.001), being married (p < 0.001), being a healthcare professional (p < 0.001), having a higher monthly income (p = 0.001), having a previous history of prostate problems (p < 0.001), and those who had ever been advised by a physician to be screened for PC (p < 0.001). Although performing the prostate exam was not statistically associated with men’s knowledge about PC (p˃0.05), it was significantly associated with men’s attitude towards PC (p < 0.001) (Table 2).

Discussion

Assessing KAP levels related to PC is crucial, particularly given the high prevalence and earlier onset of the disease in Lebanon2. Our study revealed a concerning trend in awareness regarding PC, compared to the national survey conducted in 2020 by Boustany et al.8. It highlighted that Lebanese men exhibited limited awareness of PC, as evidenced by their low knowledge and attitude scores, coupled with suboptimal practices. This underscores the need for targeted public health interventions to address and improve the situation.

Approximately 95% of our survey respondents indicated a limited level of knowledge regarding PC, aligning with findings from prior studies in the Middle East region and Arabic communities, where knowledge was often characterized as poor or inadequate15,16. A recent study, conducted on Lebanese urologists, oncologists, and radiation oncologists, revealed that a lack of knowledge among Lebanese males emerged as a significant barrier to active surveillance for PC17. In contrast, studies conducted in Italy and Jamaica revealed that most men possessed a satisfactory knowledge level, with percentages of 82.1% and 96% for PC knowledge, respectively6,9. Despite limited knowledge, 69.2% our participants were aware that PSA is the primary screening method, replicating Boustany et al.’s results (70.2%)8, and surpassing findings in Saudi Arabia (20.3%)18. Additionally, a significant majority of our participants were aware that both men with and without urinary symptoms should undergo screening. This exceeds the findings of another study in Saudi Arabia, where a lower percentage of participants were informed about symptoms such as low back pain (32%), nocturia (36%), and weak and intermittent urination (43%) as indicators of prostate cancer15. Furthermore, our study revealed that a significant proportion of participants expressed a desire for more information, with 82.2% expressing the need for more insights into PC and 77.5% seeking additional details about the PSA test. This inclination toward seeking more information implies a lower level of existing knowledge. A noteworthy observation from our results is the strong correlation between knowledge levels and educational attainment. Participants with higher educational backgrounds exhibited a greater understanding of PC and the PSA test. This emphasizes the pivotal role of education in shaping awareness. In fact, Molazem et al. demonstrated a remarkable increase in both knowledge about PC and participation in PSA testing among men aged 50 and above after an educational program focusing in PC prevention19. This program's success in empowering individuals to make informed decisions about their health and take proactive measures for early detection and prevention of PC, highlights the importance of educational campaigns in addressing knowledge gap. Consistent with other research findings, the majority of male participants relied on friends, social media, and the internet to obtain information about PC7,16. However, in the multicentric study conducted in the Arab community, physicians emerged as the primary source of information, diverging from the trend observed in other studies15. Despite being conducted in the same geographic region, this difference between studies could be attributed to the growing prevalence of internet usage as a source of information in the present years compared to 201120. Hence, continued vigilance may be essential to adapt the sources of information, as information from the internet is often inconsistent with expert opinion and causes misinformation, which leaves patients in the confusing and uncomfortable position to decide.

Around two third of our respondents exhibited inadequate attitude toward PC and its screening tools, aligning with previous research in the Middle East and West Africa15,16,21. In contrast, a survey conducted in Italy revealed a predominantly positive attitude. This divergence in attitudes could be due to variation in infrastructures including better healthcare support and public health initiatives. Contrary to our findings, Arafa et al. reported that 58% of Saudi men believed that PSA is an effective tool for early PC detection and Musali et al. demonstrated that majority of Saudi men showed a positive attitude toward regular prostate examination18,22. Aligning with our results, men with good educational and socio-economic levels, previous knowledge about PC, a positive personal of family history of PC, and guidance by their physicians on PC screening tools exhibited a favorable attitude15,18,23. This highlights the interconnected influences that education, socio-economic status, family history and healthcare engagement can have on attitudes. As demonstrated in a Danish national survey, elevated health literacy and improved access to information in people with high educational attainment and high socio-economic status contribute to a positive proactive preventative measure24. In addition, effective physician–patient communication, and a clear understanding of the patient’s background and culture enhance men’s willingness to undergo screenings25. Furthermore, personal experiences or family histories with PC further shape their attitudes out anticipatory anxiety or fear of having the disease. Based on what has been advanced, educational initiatives should be introduced with the aim of fostering a positive attitude. This positive mindset, in turn, would manifest in improved practices. Indeed, real-world experience with educational programs has shown successful outcomes in terms of raising awareness about PC and improving screening practices19,26.

Among our participants, 10.3% experienced issues related to the prostate, and within that subgroup, 18.4% specifically had PC. Furthermore, 34.4% of individuals were aware of a family member experiencing prostate issues, predominantly identifying their fathers as the affected relatives. It is essential to highlight that existing literature suggests a twofold increase in the risk of lethal prostate cancer for men with a family history, specifically if a brother or father has succumbed to prostate cancer27. Therefore, there is a significant importance in being vigilante of PC screening in patients with positive family history. Similarly to our results, men from the Middle East and west Africa demonstrated poor practice15,16,18,28. Our findings revealed that the likelihood of undergoing PSA testing increased 4 times in the presence of prostate problems, nearly 8 times with age, and 13 times when individuals were informed by a physician about the advantages of the PSA test. Hence, physicians play a pivotal role in dispelling misunderstandings among their patients regarding screening tests25. Increased efforts in patient education during medical PC screening, along with a focus on emphasizing its potential benefits, would contribute significantly to proactive and correct PC practices.

Study’s weaknesses and strengths

There were some potential limitations encountered in this study. First, this was a self-reported questionnaire, and the ability to reach illiterate and underprivileged population was not feasible. So collected data is prone to misreporting and recall bias. To overcome these biases, 87% of surveys were filled via face-to-face interviews or phone calls. Second, a bias could also be present in the Likert scale used in evaluating PC-related attitude. In general, people tend to avoid selecting extreme values like “strongly agree” or “strongly disagree” in questionnaires and opt for neutral answers. Third, this study discusses correlations between PC KAP and studied factors without providing exact causation. On the other hand, our research represents the second large national study in Lebanon to assess the level of awareness related to PC and to delve into the actual practices related to PC screening. This provides valuable insights into the real-world impact of the participants' KAP.

Study perspectives and recommendations

Based on our findings, good attitude favored good practices and participants demographics were important factors that influenced level of KAP (Fig. 1C). We, hence, recommend implementing public health strategies, particularly focus on groups with limited awareness identified in this study. Our study also could inspire physicians to better encourage their male patients to perform PC screening. Educational programs initiative, through interpersonal communication, videos, brochures, web-based models, or educational mobile applications, can improve Lebanese men's knowledge of PC, which has been shown to be a barrier to undergo screening. In addition, it can enhance shared decision-making related PC prevention and management. The content of the educational programs may draw inspiration from the KAP gaps found in our study. Future studies should check PC KAP specifically in patients with PC as this will be beneficial in allocating gaps in knowledge and practices to alleviate their disease progression.

Conclusion

In conclusion, Lebanese men showed limited level of awareness regarding PC as revealed by low KAP levels. Predictors of adequate KAP identified in this study were age, educational level, occupation, marital status, monthly income, and subjects whose physicians advised to screen for PC. These findings emphasize on the need of tailored awareness campaigns that target Lebanese men gaps in knowledge, misconception, poor attitude, and flawed practices. In addition, our study supports the necessity of health promotion programs that focus on ways to educate men about benefits of early detection of PC.