CHAPTER ONE
INTRODUCTION

1.1 Background of the Study

Leukaemia is generally differentiated into acute and chronic forms depending on the rate of progression, and then further into lymphoid or myeloid variants depending on the cell line affected, as discussed by Malard and Mohty (2020). These pathological changes affect oxygen transport, immune competence and haemostatic balance and often result in systemic complications. Scientific literature consistently proves that the development of leukaemia is affected by a combination of biological, genetic, environmental and lifestyle related factors. Chromosomal abnormalities, inherited susceptibility, immune dysfunction and viral exposures have been widely documented and environmental agents such as ionising radiation and benzene have been central issues in occupational and residential settings (Li et al., 2020; Furci et al., 2023; Wu et al., 2025). These determinants are further interacted with by lifestyle behaviours such as exposure to tobacco which highlights the multifactorial nature of leukaemia risk.

At the global level, leukaemia is a major cancer burden, with great variation in the incidence, prevalence and mortality of this disease between regions. Epidemiological studies suggest that improvements in both capacities to diagnose and treat the disease have led to improved survival in high income countries, while disparities still exist in the low- and middle-income regions (Erdmann et al., 2020; Gupta et al., 2023). Across Africa, incidence rates are relatively low when compared with that of Europe and North America, yet mortality is relatively high due to a late diagnosis and restricted access to specialised care, as seen by Andres-Jensen et al. (2021). According to Wang et al. (2024), childhood leukaemias occupy a significant percentage of all paediatric cancers in the world, whereas most adults have chronic forms of the disease. Such international and continental trends illustrate that demographic change, environmental exposure, and health system capacity have a role to play in determining the outcomes of leukaemia, which contributes to the importance of the contextual awareness in diverse populations.

In Nigeria, leukaemia is also a significant part of haematological malignancies, despite the fact that national statistics are still disjointed because of a small cancer registry area. It has been reported in the extant literature that the number of detections is rising in the past few decades, and that regional variation is related to population density and access to diagnosis (Onyije et al., 2022; Kakaje et al., 2020). Southeastern Nigeria has been prominent in the hospital-based records and this shows a steady contribution to national estimates of cases. In this regional setting, Enugu Metropolis offers unique environmental and socioeconomic features that may determine exposure to leukaemia risk factors. The metropolis is a mixture of urban residential areas with commercial and informal industrial activities and the extensive use of chemical products and variable waste management practices. Occupational exposures, healthcare related radiation and peri urban agricultural chemical use have been described in similar Nigerian settings as well (Jensen et al., 2025; Cicconi et al., 2024), thus, putting Enugu in the wider context of environmental health issues.

Against this background, there has been a growing focus on community awareness of the risk factors for cancer as a key foundation of effective public health action. Studies have been carried out in similar low resource settings that suggest that knowledge about haematological malignancies is often lower than awareness of more visible solid tumours despite the clinical importance of the former (Peppas et al., 2023). Awareness has been found to influence preventive behaviours and the recognition of initial symptoms as well as the decision to seek health, as underlined by Jimenez-Vicente et al. (2024). Enlightened societies are in a better position to utilize health educative programs and promote early diagnosis programs, which will help in the minimal disease burden. Within southeastern Nigeria, emerging work highlights both the importance of context specific awareness research in directing specific intervention (Hasaart et al., 2021; Zhang et al., 2025a). Consequently, the motivation for this study is to produce some empirical evidence on community awareness of leukaemia risk factors in Enugu Metropolis to aid informed public health planning and prevention.

1.2 Statement of the Problem

Leukaemia and other cancers are taking on an ever-rising share of the burden of non-communicable diseases in many parts of the world with low and middle-income populations, including Nigeria. Regardless of this increasing load, the publicity of leukaemia is still disproportionately lower than that of more widely spoken cancers. Knowledge of its causes, risk factors, and signs of early warning is often lacking in communities and also makes the disease less visible in public discourse. This low level of awareness continues despite rising exposure to potential risk factors through urbanisation, industrial activities and changes in lifestyle, and thus a critical gap exists between the level of disease burden and the level of population level understanding.

In many communities in urban and semi urban areas of Nigeria, people are regularly exposed to risk factors of leukaemia which are preventable or modifiable without adequate knowledge of the health implications of these risk factors. Environmental pollutants from waste disposal practices, vehicular emission and informal industrial activities, as well as occupational exposure to chemicals and radiation, are not well understood on a community level. This situation is further compounded by lifestyle related factors such as tobacco exposure and unsafe handling of chemicals. Without adequate awareness, people may not realise these exposures as harmful and this results in poorer personal and collective efforts at risk reduction and prevention.

Poor awareness about risk factors for leukaemia has important implications for health seeking behaviour. Limited knowledge of the disease can lead to a delay in realizing the presence of early and nonspecific signs and symptoms, which are frequently mistaken as symptoms of common infections or spiritual or cultural conditions. Such misattribution may promote self-medication, dependence on traditional services or delayed seeking conventional healthcare services. Consequently, the individuals may only present to health facilities once symptoms have become severe and thereby reducing the effectiveness of the available diagnostic and therapeutic interventions.

Late diagnosis of leukaemia is strongly linked to poor treatment outcomes, more morbidity and mortality. Advanced stages of the disease often necessitate more complex and expensive treatment regimens, which can put a lot of financial and emotional strain on those affected by the disease, the family, and the healthcare system. In the environment with a low coverage rate of health insurance, late presentation also promotes inequities in care accessibility and survival. These consequences illustrate the important role of early detection, which has a strong relationship with awareness and seeking health behaviour in a timely manner.

Within Enugu Metropolis there is still limited empirical evidence specifically investigating community level awareness of leukaemia risk factors. While wider studies on cancer awareness are available, they often do not disaggregate them for haematological malignancies or have location specific insights. This lack of context specific data is a constraint when trying to effectively plan for public health and to create targeted educational interventions. Addressing this evidence gap is important for informing strategies targeting improvement of awareness for early detection, and ultimately reduction of the burden of leukaemia in the metropolis.

1.3 Objective of the Study

The broad aim of this study is to assess community awareness of the risk factors of leukaemia. the specific objectives are as follows;

1. To assess the level of community awareness of leukaemia in Enugu Metropolis, Enugu State.

2. To evaluate community knowledge of environmental, and occupational risk factors associated with leukaemia in Enugu Metropolis.

3. To examine residents’ perception of susceptibility to identified risk factors of leukaemia in Enugu Metropolis.

4. To assess preventive practices adopted by community members in reducing exposure to potential leukaemia risk factors in Enugu.

1.4 Research Questions

1. What is the level of community awareness of leukaemia in Enugu Metropolis, Enugu State?

2. What is the community’s knowledge of environmental, and occupational risk factors associated with leukaemia in Enugu Metropolis?

3. What is the residents’ perception of susceptibility to identified risk factors of leukaemia in Enugu Metropolis?

4. What are the preventive practices adopted by community members in reducing exposure to potential leukaemia risk factors in Enugu?

1.5 Significance of the Study

The results of this study will be of immediate value to the people living in Enugu Metropolis as it will contribute to better knowledge of leukaemia and its risk factors in the community setting. Improved awareness can contribute to informed personal health choices, promote risk reducing behaviour and increase recognition of early warning signs. Increased knowledge on the community level also leads to proactive involvement in the health information and the development of a culture of preventative health consciousness.

Healthcare professionals working in Enugu Metropolis and its environs will benefit from the study via access to evidence-based knowledge about community knowledge gaps associated with leukaemia risk factors. Such information can help to guide the design of specific health education, counselling strategies and outreach programmes in the community. Enhanced knowledge about levels of awareness will also help clinicians and public health practitioners to develop communication strategies that are culturally appropriate and relevant to the context.

Public health authorities and policymakers at the local and state level will find the study useful for planning and implementation of cancer prevention and control efforts. The evidence generated can inform policy formulation, prioritization of health education campaigns and allocation of resources towards non communicable diseases prevention. Data specific to leukaemia awareness can also go along with the existing cancer control frameworks and reinforce surveillance and health promotion strategies in Enugu State.

Academics and researchers from the areas of public health, epidemiology and health education will find the study useful as it adds to the scanty body of literature on community awareness of haematological malignancies in south east Nigeria. The findings may be used as a reference for comparative studies, further research and theory development relating to health awareness and behaviour. In addition, non-governmental organisations and advocacy groups concerned with cancer awareness can use the results of the study to develop evidence informed interventions that can reduce the burden of leukaemia in Nigeria.

1.6 Scope of the Study

This study is empirically scoped to determine the community awareness of leukaemia and its risk factors among the people of Enugu Metropolis. In terms of content, the study has four interrelated dimensions: the level of general awareness of leukaemia, knowledge on environmental and occupational risk factors, resident's perception of personal and community susceptibility to these risks, and preventive practices adopted to reduce exposure to potential leukaemia related hazards. The empirical scope is limited to data that is generated directly from the community members which captures their knowledge, perceptions and self-reported behaviours as they relate to leukaemia risk. Geographically, the study is limited to the urban area of Enugu Metropolis including its major residential and commercial districts. This defined geographical boundary makes it possible to conduct a context specific analysis while ensuring that the findings will be relevant to urban populations in the context of southeastern Nigeria and similar metropolitan areas.

1.7 Definition of Terms

Leukaemia: A group of malignant disorders in which there is abnormal growth of white blood cells which are derived from the bone marrow and other blood forming tissues.

Risk Factors: Biological, environmental, genetic, occupational or lifestyle related conditions or exposures that cause or increase the likelihood of developing leukaemia.

Community Awareness: The level of knowledge, understanding and perception among members of Enugu Metropolis of leukaemia and risk factors.

Early Detection: The detection of leukaemia at an early stage in the development of the disease by recognition of symptoms and early medical evaluation.

Health Seeking Behavior: Behavior exhibited by people to identify their health needs and seek appropriate medical attention from the healthcare facilities.

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