Cancer is a worldwide health problem; it is estimated that the global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020 (Sung et al, 2021). Having a cancer diagnosis is often perceived as equal to imminent death (Lheureux et al, 2004). This attitude is believed to negatively affect people's decisions regarding participation in early detection programmes, treatment, and follow up, and therefore results in poor quality of life (Cho et al, 2013; Khalife et al, 2019). Receiving a diagnosis of cancer may then result in anxiety, depression and hopelessness (Mansour et al, 2017). It has been proposed that personal attitudes and perspectives are affected by the amount of information patients receive. This will affect human behaviours and perceptions of their health status (Smith and Liehr, 2018). Therefore, exploring public information needs and attitudes towards cancer and cancer patients might be the first step in developing an intervention that encourages public engagement in early detection of cancer and cancer prevention programmes. Disclosing a cancer diagnosis is the first step in information provision about the disease.
Disclosure of diagnosis and information needs
Studies have shown that patients with cancer deserve and wish to be given information about their disease, diagnostic tests, and the available treatment (Al Qadire, 2014; Tariman et al, 2014; Al Qadire, 2018a). Patients may perceive having cancer as leading to an unavoidable death, with no possible complete cure. This makes telling patients the truth of their diagnosis complicated, burdensome and emotionally difficult for both patients and healthcare providers (Al Qadire, 2014; Tariman et al, 2014; Al Qadire, 2018a). Healthcare providers face this challenge in their practice on a daily basis, and may do so without the benefit of official guidelines. Nevertheless, informing patients of their diagnosis may improve management of symptoms, most importantly pain, and enhance patients' co-operation and compliance with their treatment (Holmes-Rovner et al, 2015; Miyashita et al, 2015).
Some patients may not wish to be informed about their diagnosis. This might be perceived as their right, but it can also be an issue known as cancer information avoidance that needs to be followed up and resolved (Chae, 2016). However, generally, treating patients with cancer without telling them the truth is unacceptable ethically; it may lead to uncertainty, stress, hinder cancer treatment and, most importantly, it may well be an act against a patient's wishes. The literature shows that the majority of the public are willing to be informed about a cancer diagnosis, and their demands for information are relatively high (Tariman et al, 2014; Al Qadire 2018b). Patients prioritise information on life expectancy (prognosis), the possibility of a cure, the stage of the cancer and treatments available (Tariman et al, 2014; Al Qadire, 2018b). Limited research has been conducted involving the public rather than patients within an Eastern culture where the attitude ‘not to disclose’ prevails (Mansour et al, 2017; Al Qadire, 2018b). Therefore, public opinions on the disclosure of a cancer diagnosis and information needs should be further explored within the Middle East region, as it may affect attitudes towards cancer of the general public, cancer patients and healthcare staff.
Attitudes towards cancer
Previous studies among the public, which are limited and out of date, indicated a negative public attitude and poor knowledge of cancer in terms of signs and symptoms, risk factors and possible causes (Berrenberg, 1991; Schernhammer et al, 2010; Al Qadire, 2018a). Such attitudes would affect a person's willingness to engage in screening and early detection programmes, and even cancer treatment.
A recent study exploring Jordanian public attitudes towards cancer and cancer patients (Al Qadire et al, 2020) indicated positive attitudes to towards cancer. Having a family member with cancer, and willingness to participate in early detection programmes and to be informed of cancer diagnosis, were predictive factors of positive attitudes (Al Qadire et al, 2020). However, other studies reported negative attitudes, including one conducted in Iran to explore public attitudes towards cancer and cancer patients (Badihian et al, 2017). A survey of 953 participants living in one large city, using a 12-item questionnaire, indicated that most of the participants had a negative attitude towards cancer. For example, 19.5% were sure that cancer is untreatable, 33.9% believed that patients with cancer would not be cured after treatment, and 17.4% felt uncomfortable when dealing with cancer patients. There was also fear and hesitancy with regard to disclosing a cancer diagnosis to a friend, a neighbour or a co-worker (Badihian et al, 2017).
Another study (Cho et al, 2013) investigated public attitudes towards cancer in South Korea. The researchers developed a 12-item questionnaire that comprised three sub-scales: impossibility of cancer cure, cancer stereotypes and discrimination. The respondents were asked to select their response to each item, measured on a Likert-type scale. The sample consisted of 1011 participants who were randomly selected from all regions of South Korea. The results showed that negative attitudes were prevalent; 58.5% of the participants did not agree that cancer could be treated. A large percentage (71.8%) indicated that cancer patients represent a burden on the community, and that they do not contribute to society. Again, one-third to half of the participants would opt not to tell their friends, neighbours and co-workers of their cancer diagnosis (Cho et al, 2013).
A study conducted in Austria on knowledge and attitudes regarding cancer collected data in 1995 and again in 2005 (Schernhammer et al, 2010), with the results showing a change to more positive attitudes towards cancer over this period. However, participants with a low level of education thought that cancer could not be treated. Furthermore, knowledge of cancer seemed to be correlated with participants' willingness to take part in an early detection and screening campaign (Schernhammer et al, 2010).
Few studies have explored public information needs and attitudes regarding cancer in the Middle East region; thus, this study aims to explore public information needs and attitudes towards cancer in Oman.
The study aimed to answer the following questions:
- What is the preference of the Omani public regarding disclosure of a cancer diagnosis?
- What information does the Omani public need about cancer?
- What are the attitudes of the Omani public towards cancer and cancer patients?
- Are there differences in the Omani public's information needs with regard to demographic variables?
- Is there a relationship between attitudes to cancer and information needs?
- What are the predictors of the Omani public's information needs about cancer?
A cross-sectional survey was used.
Sample, sampling, and settings
This study included Omanis who were 18 years and older, who could read and understand Arabic, and were willing to take part. The sample included people who do not have cancer and have never been treated for cancer. Healthcare providers, such as physicians, nurses, social workers and students in medicine, nursing and applied medical science were excluded. A convenience sample of participants was recruited from public places such as malls and public parks within the Muscat governorate of Oman.
The sample size was calculated to be adequate for the multiple linear regression analysis. The authors expected to include a maximum of 15 independent variables (m) in the regression module. Therefore, for medium-sized relationships between the independent variables and the outcome variable, 5% significance and 80% power, the sample size n should satisfy the following: n≥50+8m (Peduzzi et al, 1996). Hence, the sample size should be equal or larger than 50+8×25=250; adding 20% as attrition rate, any sample size ≥300 would be adequate. Data were collected from 569 respondents to improve the generalisability of the results.
Three data collection tools were used: a demographic data sheet (DDS), the Public Attitudes toward Cancer Questionnaire (PACQ) (devised by Cho et al, 2013) and the Arabic–Cancer Patients Information Needs Questionnaire (Al Qadire, 2014; 2018b).
Demographic data sheet
The DDS includes questions constructed to collect data about participants' demographic characteristics such as age, sex, marital status, education and monthly family income.
Public Attitudes toward Cancer Questionnaire
The PACQ was developed to measure public attitudes towards cancer and cancer patients (Cho et al, 2013). It comprises 12 items categorised into three domains: impossibility of recovery, stereotypes of cancer patients, and discrimination against cancer patients. For each item, the participant is asked to select their response on a 4-point Likert-type scale (1=strongly disagree, 2=disagree, 3=agree, and 4=strongly agree). This tool was originally developed and validated in South Korea and then used in an Iranian study in a Persian version (Badihian et al, 2017). An Arabic version has been validated (Al Qadire et al, 2020).
Arabic–Cancer Patients Information Needs Questionnaire
This tool was developed originally to measure cancer patients' information needs (Al Qadire, 2014). In this study, the authors used a modified form appropriate for use with the public (Al Qadire, 2018b). The first two questions asked whether the participants would wish to be informed if they developed cancer; and whether they would require information about cancer. The remaining 18 items required them to respond to options on a 5-point scale, where 0 meant no information needed and 5 meant information strongly needed (Al Qadire, 2014; 2018b). There are four subdomains: information about disease, information about medical tests, information about treatment, and information about the support available. The total score is calculated by adding all items together; the higher the total, the greater is the need for information.
Data collection procedure
First, the research team obtained approval from the university and the appropriate authorities. The research assistant then visited public places and malls in Muscat, Oman, where people come for shopping and recreation. The study's purpose, procedure and requirements were explained to potential participants; once they agreed, they were sent the link to the online questionnaire and asked to complete it in their own time.
SPSS version 21 was used to analyse the data. Descriptive statistics, such as means, standard deviation, frequency, and percentages were calculated to summarise participants' characteristics and their responses. In addition, an independent t-test and Pearson correlation test were conducted. Multiple linear regression analysis was used to identify the predictors of the Omani public's information needs.
Ethical approval to conduct the study was obtained. All participants were assured that their participation was voluntary. No personal or identifying information was recorded and only aggregate data are published. Participants were informed that completing and submitting the questionnaire would be considered as implicit consent. They were given permission to edit or delete responses after submitting the online form
Of the 569 participants, 369 (64.9%) of them were female; the mean age was 30.9 (SD=9.5) years. Most of the participants (77.5%) have at least a bachelor's degree; 59.9% reported a monthly income of US$3116 or less, 58.2% were currently working and 59.9% were married. Table 1 details participants' characteristics.
Table 1. Demographical characteristics of participants (n=569)
|Attitudes toward cancer||Information needs about cancer|
|Variable||Frequency (%)||Mean (SD)||95% CI||P value*||Mean (SD)||95% CI||P value*|
|Male||200 (35.1)||39.9 (4.8)||-0.39 to 1.21||0.320||83.5 (11.4)||-0.16 to 3.40||0.750|
|Female||369 (64.9)||40.3 (4.5)||85.2 (9.8)|
|High (≥bachelor's degree)||441 (77.5)||40.3 (4.5)||-1.10 to 0.73||0.689||84.8 (11.5)||-2.97 to 1.15||0.388|
|Low (≤diploma)||128 (22.5)||40.1 (5.1)||83.5 (10.1)|
|Married||318 (55.9)||39.9 (4.8)||-0.11 to 1.42||0.095||85.5 (8.9)||-3.6 to -0.22||0.027**|
|Not married||251 (44.1)||40.6 (4.4)||83.5 (12.0)|
|Family monthly income|
|Low (≤US$3116)||341 (59.9)||40.0 (4.6)||-1.27 to 0.28||0.215||84.3 (11.3)||-2.55 to 0.96||0.375|
|High (≥US$3117)||228 (40.1)||40.5 (4.7)||85.1 (9.0)|
|Yes||331 (58.2)||40.3 (4.6)||-0.91 to 0.64||0.731||85.7 (8.4)||-4.23 to -0.82||0.004**|
|No||238 (41.8)||40.1 (4.8)||83.1 (12.6)|
|Has anyone in your family or among your friends had cancer?|
|Yes||364 (64.0)||40.3 (4.6)||-0.94 to 0.65||0.722||84.6 (10.1)||-1.92 to 1.67||0.691|
|No||205 (36.0)||40.1 (4.7)||84.5 (11.0)|
|Have you provided care for a person with cancer?|
|Yes||190 (33.4)||40.3 (4.7)||0.91 to 0.71||0.810||84.9 (9.7)||-2.24 to 1.41||0.652|
|No||379 (66.6)||40.2 (4.6)||84.5 (10.9)|
|Would you like to be informed about your cancer diagnosis?|
|Yes||537 (94.4)||40.3 (4.6)||-3.60 to -0.64||0.022**||85.9 (7.3)||-27.20 to -20.84||≤0.001**|
|No||32 (5.6)||38.4 (5.1)||61.9 (22.8)|
|I would like to participate in early detection programmes|
|Yes||500 (87.9)||40.3 (4.6)||-2.02 to 0.32||0.156||84.8 (10.9)||-3.86 to 1.41||0.363|
|No||69 (87.9)||39.5 (4.7)||83.5 (10.6)|
The results indicated that 94.4% of participants (n=537) wanted to be informed if they were found to have cancer in the future. The total mean score of information need was 84.6 (SD=10.5) out of 90. The participants mainly needed information about available supportive services (item 14, mean=4.6, SD=0.8), medical tests (item 5, mean=4.7, SD=0.6), and the availability and details of the treatment (item 8, mean=4.8, SD=0.7); the least information needed was about the spread of the disease itself (item 2, mean=4.6, SD=0.9) (Table 2).
Table 2. Descriptive statistics of the responses to the information need questionnaire items (n=569)
|1. I want to know my precise diagnosis||4.7||0.8|
|2. I want information about spread of my disease||4.6||0.9|
|3. I want information about possible cause of my disease||4.6||0.9|
|4. I want to know if my disease is under control||4.7||0.7|
|5. I want to know the purpose of all medical tests I will undergo||4.7||0.6|
|6. I want to know which medical tests will be conducted||4.7||0.6|
|7. I want to know the results of my medical tests||4.7||0.7|
|8. I want information about my treatment||4.8||0.7|
|9. I want to know the possible benefits of my treatment||4.7||0.6|
|10. I want to know the side effects of the treatment||4.6||0.8|
|11. I want to know the expected effects of the treatment on disease symptoms||4.7||0.7|
|12. I want to know the effects of the treatment on my social and family life||4.6||0.8|
|13. I want to know the effects of the treatment on my sexual life||4.4||1.0|
|14. I want to know if there is additional help outside the hospital||4.6||0.8|
|15. I want to know if there is a rehabilitation service||4.7||0.6|
|16. I want to know how to deal with illness at home||4.8||0.6|
|17. I want to know if there is any psychological support||4.7||0.7|
|18. I want to know if there are things that would cure the disease or improve my health||4.9||0.5|
Table 2 shows the descriptive statistics for participants' responses for each item in the questionnaire. All the items of the information needs questionnaire had a mean score of at least 4.4 (out of 5). The least information needed was about the impact on sexual life (item 13) (mean=4.4, SD=1.0), whereas the highest rated item was number 18, about things that might cure the disease (mean=4.9, SD=0.5). Overall, participants reacted strongly to the need for information about all aspects of cancer and its treatment.
The independent t-test was conducted to examine the differences in the mean total score of information need when compared with participants' demographics (Table 1). The results show that married participants (mean=85.5, SD=8.9) needed significantly more information than unmarried participants (mean=83.5, SD=12.0) (t=-2.17, df=567, P=0.027). Working participants (mean=85.7, SD=8.4) reported a significantly higher need for information than those who were not working (mean=83.2, SD=12.6) (t=-2.89, df=567, P=0.004). Participants who wanted to be informed of their cancer diagnosis (mean=85.9, SD=7.3) were found to have a significantly higher need for information than those who did not want to be informed (mean=61.9, SD=22.8) (t=-14.84, df=567, P≤0.001). Furthermore, there were no significant differences in the mean score of the total information need regarding other variables (P>0.05) (see Table 2). Finally, the Pearson correlation test showed no significant correlation between age of participants and their information needs (r=-0.06, P=0.185).
Attitudes towards cancer and cancer patients
The mean total attitudes score was 40.2 (SD=4.7) out of a maximum of 48. As shown in Table 3, 96.3% of participants strongly disagreed or disagreed that cancer patients are not able to contribute to society; 96.2% would not avoid working with cancer patients and 94.4% would not avoid interacting with their neighbour if their neighbour was a cancer patient. However, 40.2% of the participants agreed or strongly agreed that cancer patients would have problems in their sexual life. In addition, 33.7% agreed or strongly agreed that cancer patients can be easily recognised based on their appearance. Finally, 26% agreed or strongly agreed that cancer patients cannot regain full health after their diagnosis.
Table 3. Attitudes towards cancer and cancer patients (n=569)
|Item||n (%)||Mean score (SD)|
|Strongly disagree||Disagree||Agree||Strongly agree|
|Impossibility of recovery||3.3 (0.5)|
|It is impossible to treat cancer regardless of highly developed medical science||276 (48.5)||178 (31.3)||97 (17.0)||18 (3.2)||3.0 (0.7)|
|It is very difficult to be healthy again once a person is diagnosed with cancer||169 (34.4)||225 (39.5)||107 (18.8)||41 (7.2)||2.8 (0.8)|
|Cancer patients would not be socially active once diagnosed with cancer||402 (70.7)||117 (20.6)||39 (6.9)||11(1.9)||3.3 (0.7)|
|The ability of cancer patients to perform tasks at the workplace may decrease even after successful cancer treatment||222 (39.9)||222 (39.9)||100 (17.6)||25 (4.4)||2.9 (0.7)|
|Cancer patients would not be able to make contributions to society||455 (80.0)||93 (16.3)||16 (2.8)||5 (0.9)||3.5 (0.5)|
|Stereotypes of cancer patients||3.0 (0.5)|
|Cancer patients are easily recognised through their looks||136 (23.9)||241 (42.4)||152 (26.7)||40 (7.0)||2.7 (0.7)|
|Cancer patients would have a difficult time having sexual intimacy||99 (17.4)||241 (42.4)||189 (33.2)||40 (7.0)||2.5 (0.6)|
|Cancer patients deserve to be protected in society||17 (3.0)||46 (8.1)||109 (19.2)||397 (69.8)||3.6 (0.6)|
|Discrimination against cancer patients||3.6 (0.5)|
|I feel uncomfortable when I am with cancer patients||422 (74.2)||97 (17.0)||28 (4.9)||22 (3.9)||3.4 (0.7)|
|I tend to avoid interacting with neighbours who have cancer||471 (82.8)||66 (11.6)||21 (3.7)||11 (1.9)||3.6(0.6)|
|I would avoid marrying people whose family members have cancer||299 (52.5)||154 (27.1)||81 (14.2)||35 (6.2)||3.3 (0.8)|
|I would avoid working with people who have cancer||475 (83.5)||72 (12.7)||12 (2.1)||10 (1.8)||3.7(0.5)|
To examine the difference in mean total attitudes scores, the independent t-test was conducted (results shown in Table 1). There were no significant differences (P>0.05) in the mean total attitude score except for participants' willingness to be informed of a cancer diagnosis. Participants who wanted to be informed (mean=40.3, SD=4.6) reported more positive attitudes than those who did not want to be informed (mean=38.4, SD=5.1) (t=-2.30, df=567, P=0.022). However, the Pearson correlation test showed no significant correlation between age of participants and their attitudes towards cancer and cancer patients (r=-0.05, P=0.223).
The relationship between attitudes towards cancer and cancer patients and information needs
The Pearson correlation test indicated a significant positive relationship between the mean total attitude score and the mean score of information need (r=0.1, P=0.04).
Predictors of public information needs about cancer
All variables that were significant in the bivariate analysis were included in the multiple-linear regression model to identify which would predict the information needs of the Omani public. These variables are: marital status, work, preference for disclosure of cancer diagnosis, and the mean of total attitudes score. The results show that being employed, preferring to be informed about cancer diagnosis and having positive attitudes towards cancer and cancer patients predicted higher information needs (Table 4).
Table 4. Multiple linear regression analysis of variables that predict participants' information needs
|Unstandardised beta (B)||Standard error||Beta||P-value||95% confidence interval for B|
|Disclosure of cancer diagnosis||23.6||1.62||0.52||<0.001*||20.4||26.79|
|Total Attitudes Score||0.79||0.08||0.03||0.003*||0.79||2.36|
This study demonstrated that the Omani public would prefer to be informed if they had cancer. This in line with internationally and locally published literature (Noguera et al, 2014; Eggert, 2016; Rao et al, 2016; Al Qadire, 2018b; Alzahrani et al, 2018). However, clinical practice may differ. Many studies have shown that, despite disclosure of a cancer diagnosis being accepted practice, the amount of information given varies considerably from one place to another; approaches to telling the truth are not of the same quality, and families still control the amount and timing of information flow to the patient (Khalil, 2013; Holmes-Rovner et al, 2015). In Middle Eastern countries it is common to conceal the truth from patients, and it is a fact that some patients die without knowing they had cancer (Khalil, 2013). For example, one study showed that only 69% of physicians in Lebanon were willing to disclose a cancer diagnosis to patients (Naji et al, 2015), although this percentage may reach 90% or more in Western counties (Oliveira et al, 2015).
The type of information about cancer that the Omani public wanted is consistent with previous studies. They wanted information about prognosis, treatment and all aspects related to their healthcare, with priority given to the possibility of cure (Al Qadire, 2014; Tariman et al, 2014; Mansour et al, 2017; Al Qadire, 2018b; Alzahrani et al, 2018). This should be taken into consideration in clinical practice. In addition, healthcare providers may need training in breaking bad news, especially those working regularly with cancer patients, with guidelines that set out what is to be told and when, in terms of content, in order to reduce variations in practice. What is disclosed to patients needs to be standardised, especially within the Middle East region, and this needs legislation and polices for healthcare settings.
This study showed that the Omani public had a positive attitude towards cancer and cancer patients; the mean was higher than previously reported (Mansour et al, 2017; Al Qadire et al, 2020). The positive attitude may indicate that people are more receptive to information about cancer, encouraging more engagement with early detection and screening programmes (Al Qadire et al, 2020). This positive attitude may also lead to greater social and psychological support for cancer patients during their treatment.
This study found that the higher the mean attitude scores, the greater the information needs. The results also indicate that participants who would opt for a disclosure of cancer diagnosis had more positive attitudes than those who would not. No previous studies have tested both issues, which limits the possibility for comparison. However, the results of this study are of importance for clinical practice and for policy makers, to prioritise actions to improve attitudes towards cancer and to satisfy the need for information. One study found that women who survived breast cancer with unmet information needs had a poorer quality of life that those who were satisfied with the information received (Miyashita et al, 2015). Further, having positive attitudes may ease disclosure of a cancer diagnosis to patients, resulting in a more trusting relationship between patients and healthcare providers and facilitating communication (Holmes-Rovner et al, 2015; Miyashita et al, 2015). The results indicated that being in employment, having positive attitudes towards cancer and preferring to be informed of a cancer diagnosis are predictive of higher information need. These factors need to be taken into consideration when treating and providing information for cancer patients. Disclosing the diagnosis is the first step of an ongoing process of information provision. It is the patients' preference to be involved in their own care and decision making, and not to be solely dependent on the physician or family.
Recommendations for clinical practice
This study highlights the need for a change in the way healthcare staff communicate with cancer patients in the Middle East region—moving away from the traditional paternalistic practices to a more open culturally sensitive communication approach. This approach will depend on a prior assessment of the patient's attitude towards cancer and their informational needs. Based on that assessment, the amount, type, and method of information delivery can be determined. This applies to practices in Oman and any institution with patients from different cultural backgrounds. Although the results indicated that most patients prefer more open communication, an individualised approach to communication with each patient is highly recommended. Further, if the traditional paternalistic practices are to be changed to a culture of open communication, then education of the public as well as health professionals needs to be prioritised
This study was conducted in one city in Oman; people living in other cities may have different opinions. However, many Omanis from other cities often move to Muscat for work, education and other reasons. In addition, most participants were young, female and well educated. This to some extent matches the young, well-educated Omani population, except for sex. More responses were received from females than males in the study. The opinions of males and older people may differ and therefore prospective studies would be advised to use a sampling approach that guarantees the recruitment of a more representative sample. Further, this study used a survey design where non-participants may have had a different perspective on disclosure, information needs and attitudes towards cancer. Furthermore, when answering a self-reporting questionnaire, people tend to give what they understand as ‘ideal’ answers. Thus, replicating this study with a larger sample size, and including participants from other cites, may be advisable.
This study demonstrated that the Omani people who responded to this survey wanted to be informed about cancer diagnosis, demanded information about all aspects of cancer care, and had positive attitudes towards cancer and cancer patients. This indicates that more respect for patients' autonomy and their right to be informed of a cancer diagnosis is needed. This requires training for healthcare providers in breaking bad news, combined with a policy that emphasises patients' right to be told the truth. The current paternalistic approach seems to be no longer appropriate for cancer patients, and there is a need for a more open communication approach and active patient involvement in decision-making.
- Telling patients with cancer the truth of their diagnosis is complicated, burdensome, and emotionally difficult for both patients and healthcare providers
- In Middle Eastern countries it is common to conceal the truth from patients, and some patients die without knowing they had cancer
- This study demonstrated that the participants would prefer to be informed if they have cancer and they wanted information about prognosis, treatment and all aspects related to their health care, with priority given to the possibility of a cure
- Participants had a positive attitude toward cancer; this positive atmosphere may offer a kind of social and psychological support for cancer patients throughout their treatment
CPD reflective questions
- How do patients' and their relatives' attitudes towards cancer affect your clinical practice?
- What type of information do patients with cancer in your area receive about their disease? How do you judge what level of information is provided and at what stage?
- What do you think could be done in your setting to improve truth-telling practices and breaking bad news to patients?