Awareness of Lung Cancer and Associated Factors among Public Health Students at Kabul University of Medical Sciences, Afghanistan: A Cross-Sectional Study

*Bashir Ahmad Qudrati ¹, Rohullah Sakhi ², Zarif Haidari ¹, Naweedullah Noori ¹

Introduction

Cancer represents a significant global health issue, standing as the second leading cause of mortality across the world. Based on estimates, the year 2020 witnessed approximately 9.6 million deaths attributed to cancer, alongside 18.1 million newly reported cases of the disease on a global scale (1-3). Lung cancer ranks as the most frequently diagnosed form of cancer and holds the grim distinction of being the leading cause of cancer-related mortality worldwide. In 2020, approximately 2.21 million new cases and 1.8 million deaths were reported (1). According to the WHO, nearly one in five cancer-related deaths (18.4%) that year was attributed to lung cancer (1). By 2020, lung cancer maintained its position as the deadliest cancer, causing 1.8 million deaths, while it also became the second most commonly diagnosed cancer globally, surpassed only by breast cancer, with 2.21 million new cases that year (2).

Lung cancer is observed more frequently in low- and middle-income countries, where the rate of cancer-related deaths continues to climb. This increase can be attributed to aging populations and the prevalence of common risk factors such as tobacco use, alcohol consumption, unhealthy dietary habits, and physical inactivity. In 2012, these nations were responsible for 65% of all cancer-related fatalities worldwide, and projections suggest this share could rise to 75% by 2030 (4, 5). Afghanistan, like other low-income nations, faces similar challenges. In 2012, WHO reported that cancer claimed the lives of 15,000 Afghans, including 8,100 men and 7,400 women, with lung cancer listed as one of the primary contributors to cancer-related mortality (3).

Globally, smoking remains the most significant risk factor for lung cancer, responsible for nearly 70% of related deaths. Smokers are approximately 20 times more likely to die from this disease compared to those who do not smoke (6, 7). Lung cancer poses a significant public health challenge due to its high mortality rate and the limited likelihood of survival. This issue is particularly severe in developing nations, where survival rates are less than one-third of those observed in more developed countries, highlighting a stark disparity in outcomes (1).

The occurrence of lung cancer is heavily shaped by various factors, such as an aging population, increased life expectancy, and the prevalence of high-risk habits, particularly tobacco use (8, 9). Smoking alone contributes to over 30% of all cancer-related deaths, with lung cancer accounting for 80% of these fatalities (10, 11). Although lung cancer affects both genders, it is more frequently diagnosed in men than in women (12). Persistent symptoms, such as a chronic cough, often serve as critical indicators of the disease and play an essential role in determining its prognosis (13-15).

Lung cancer plays a significant role in Afghanistan's cancer-related mortality, reflecting patterns observed worldwide. According to the latest WHO data published in 2020, lung cancer deaths in Afghanistan reached 1,076, accounting for 0.46% of total deaths. The age-adjusted mortality rate for lung, tracheal, and bronchial cancers is 6.90 per 100,000 of the population, ranking Afghanistan 122nd globally. These statistics are consistent with the general patterns of cancer mortality observed worldwide, where lung cancer remains a leading cause of cancer-related death (16).

Although limited studies have assessed lung cancer awareness and associated factors in various populations, no research to date has specifically examined awareness of lung cancer and its associated factors among public health students at Kabul University of Medical Sciences, Afghanistan. This study fills a significant gap in the existing literature, as public health students represent future healthcare professionals who will play a critical role in health education, disease prevention, and community awareness. This gap is particularly important because the level of awareness in this group can have a substantial impact on early detection and preventive efforts related to lung cancer in Afghanistan. The present study is the first of its kind in Afghanistan, providing baseline data on lung cancer awareness among public health students, and lays the foundation for future research in this field.

By addressing this gap, the study aimed to explore lung cancer awareness and associated factors among public health students at Kabul University of Medical Sciences. It provides the first empirical evidence in this specific population in Afghanistan, contributing to the development of targeted educational interventions and public health strategies aimed at improving awareness, early detection, and prevention of lung cancer. Filling this gap is significant as it will help strengthen educational programs, enhance the capacity of public health students for community education, and ultimately contribute to reducing the burden of non-communicable diseases like lung cancer in Afghanistan.

Materials and Methods

Study design and setting

This study is a descriptive cross-sectional study based on a questionnaire conducted to assess lung cancer awareness and associated factors among public health students at Kabul University of Medical Sciences (one of the largest and oldest medical universities in Afghanistan). The study was carried out between Oct and Dec 2024.

Sample Size and Sampling Method

In 2024, the Public Health Faculty included a total of 272 undergraduate students (from first to fourth year). To determine the sample size, a 95% confidence level and a 5% margin of error were considered. Using Cochran's formula and Epi Info software version 7.2.6, the initial sample size was calculated to be 159 students. To account for a potential 5% non-response rate, the final sample size was increased to 167 students.

In this study, a two-step stratified random sampling method was applied to ensure proper representation across academic years. First, the students were grouped into strata according to their academic year (class). Then, within each stratum, participants were selected using simple random sampling, with the sample size proportional to the number of students in each academic year. This stratification ensured that each academic year was proportionately represented in the final sample.

Data Source and Measurement

The standardized questionnaire, adapted from previous research (17, 18), was modified to suit the context of this study. Specifically, certain items were reworded to ensure clarity and relevance to the study population. The questionnaire was divided into three sections: the first section (7 questions) collected demographic data, the second section (5 questions) assessed awareness of lung cancer risk factors, and the third section (9 questions) measured general awareness about lung cancer. Each correct response was awarded 2 points, incorrect answers were given 0 points, and “don’t know” responses were assigned 1 point. The total possible score was 28 points, with participants scoring above 14 classifieds as having good awareness and those scoring below 14 classifieds as having poor awareness. The questionnaire was translated into the local language to ensure clarity and ease of understanding for participants. To ensure reliability and validity, a pilot study was conducted with 20 students who were excluded from the main sample. The questionnaire was designed in closed-ended, multiple-choice questions to facilitate ease of completion in less than ten minutes and to minimize recall bias.

Ethics Approval

This study was approved by the Institutional Review Board (IRB) of the Public Health Faculty at Kabul University of Medical Sciences issued approval 109/2024. Participation was entirely voluntary, and each participant provided written informed consent before participation. All information was collected and stored anonymously, with no identifying details recorded. The study adhered to the institutional guidelines, national ethical standards, and respected Afghan cultural norms and traditions. Measures were taken to protect participants from any physical or psychological harm, ensuring their rights, safety, and well-being throughout the study.

Statistical Analysis

To conduct the statistical analysis, the collected data were entered into SPSS ver. 27 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including mean, standard deviation, frequency, and percentage, were first employed to summarize the data. To describe categorical variables and the demographics of the participants, frequency distributions and percentages were used. To determine the relationship between awareness levels and demographic variables based on participants' characteristics, cross-tabulation and Chi-square tests were applied to investigate the relationships and associations between categorical variables. A P-value of <0.05 was considered statistically significant.

Results

Students’ Sociodemographic Characteristics

Out of 167 questionnaires, 164 were fully completed and collected (response rate 98.2%). Demographic characteristics are detailed in (Table 1). The participants' ages were divided into two age groups: 18–20 yr and 21–24 yr. The majority of participants, 102 (62.2%), belonged to the 21–24 age group. The mean age of the participants was 20.9, with a standard deviation of 1.41. Only 5.5% reported a family history of lung cancer, and 19.5% of the participants had a history of smoking. As illustrated in (Figure 1), students reported diverse sources of information about lung cancer. The most commonly cited sources were books or articles 54 (33.01%), followed by the Internet 42 (25.73%).

Table 1: Demographic characteristics of the participants

Notes: Data are presented as Number (N) and percentage (%). No statistical analysis was applied.