Introduction
According to the World Health Organization, cancer is one of the leading causes of morbidity and mortality in the world, which only continues to grow. Since 2012, the number of cancer patients has been increasingly growing, with over 14 million new cases appearing every year (WHO, 2017). At the same time, the number of cancer-related death exceeded that of 8.8 million since 2015 (WHO, 2017). The disease has been regarded as a worldwide healthcare problem for several decades now. As it stands, there is no effective cure for cancer in its later stages, and early cancer response and prevention remains the only response to the disease that has any chance of succeeding. However, the views on cancer and cancer prevention differ greatly across the countries. Even in the more medically and technologically advanced countries in Europe and the USA, there is a certain stigma associated with cancer.
Chemotherapy is viewed as a very dangerous and ineffective procedure that significantly shortens the overall lifespan and leads to numerous health complications in the future (Hilal et al., 2015). The situation is even worse in the Middle East, where religious views often interact with medicine and influence public opinion on cancer, cancer patients, and cancer prevention practices. This issue affects even the developed countries of the Arabian Peninsula, such as the UAE and the Emirates. Education, the understanding of mechanisms of the disease, possible influencing factors, and stereotyping all play an important role in affecting the populace’s perception of cancer. Understanding the views of the population and the underlying issues behind cancer are paramount to developing a coherent and effective strategy to promote health and improve early prevention.
Statement of the Problem
The purpose of this research is to analyze the state of early response and prevention measures to cancer, as well as the population’s perception towards cancer in the state of Oman, which is one of the prominent and economically prosperous countries of the Arabian Peninsula. The country possessed an all-encompassing and developed healthcare industry, which covers the majority of the population. At the same time, according to the Programme of Action for Cancer Therapy, Oman faces an almost two-fold increase in cancer incidence in the period between 2008 and 2020 (IAEA, 2013). Understanding the reasons behind such a drastic increase and improving the chances of early detection and response to cancer is thus paramount for the promotion of health in the Sultanate of Oman.
Methodology
The research will be conducted in the form of meta-analysis, which suggests a complex synthesis of all accredited and available sources of information pertaining to the subject. The information used in this study will be extracted from accredited scientific journals, official statistics, and official sites of major healthcare organizations such as WHO, PACT, and others. In addition, the research will feature the limited use of Omani national press releases, in the context of understanding and perceiving the views of the population towards cancer, cancer prevention, rehabilitation, and survival. The reasoning for using meta-analysis as the primary form of research, in this case, is formulated by the inability to travel to Oman and perform quantitative research and include the population of Oman in the research directly.
Hypothesis
The research hypothesis that the following study will be seeking to either prove or disprove states the following:
- Sultanate of Oman is facing a major cancer increase due to a multitude of factors, such as a change of lifestyle, as well as outdated views of the population on cancer prevention and cancer treatments, which are motivated by the local traditions as well as historical tendencies and religious views.
The null hypothesis, in this case, would be the complete opposite of the research hypothesis. As such, it would state that:
- The major cancer crisis currently faced by the Sultanate of Oman is not influenced by the change of lifestyle as well as outdated views of the population on cancer prevention and cancer treatments, which are motivated by the local traditions as well as historical tendencies and religious views. The growing incidence of cancer is motivated by other factors.
Scope and Limitations
The following meta-analysis is aimed to reflect on the situation with cancer prevention, early detection, treatment, and population perceptions of the disease in the Sultanate of Oman. While the results of this research can be extrapolated, to a degree, on other countries of the Arabian Peninsula, the research limits itself largely to the situation in Oman. Another limitation of this research comes from the format of the study. As this is qualitative literature research, it is limited in the use of sources. All information used in this research has been provided by someone else and did not come as a result of a direct quantitative study and research performed on the population of the Sultanate of Oman.
Another limitation of the study is that it reflects the attitudes and opinions of the population, as well as the overall situation in Oman in a yearly diapason between 2012-2017. As the situation may change in the following years due to the implementation of specific policies as well as the overall political situation in the country and region, the information provided in the following research may become outdated. After a certain period of time, it would require being reaffirmed and revalidated.
The recommendations were based on the information available for public use and possess a general connotation, not attached to any specific location within Oman. The emphasis on specific points mentioned in this analysis may change depending on the situation within particular communities.
Lastly, since this is a qualitative study, the conclusions and evaluations of the provided information may be subject to bias and misinterpretation.
Significance of the Study
This study has two purposes. The first purpose of this study is to develop practical recommendations that could be implemented by the Sultanate of Oman in order to reduce the incidence of cancer and promote early response and detection of the disease. This makes the research significant for any parties interested in the promotion of the health agenda within the country. In addition, the results of the research could be interesting to other countries in the Arabic Peninsula, as they share many similarities with Oman, including religion, healthcare practices, traditions, and mutual history.
Other than that, the results of the study could be invaluable to any researchers aiming to perform a quantitative study pertaining to the perception, attitudes and practice towards cancer early detection, prevention and survivorship in Oman. The research could provide a suitable theoretical and informational framework to be used as a starting point for the formulation and development of said study. The accumulation of relevant sources may enable future researchers to locate and use them in their own endeavors, thus promoting interconnectivity within the medical, scientific community.
Lastly, the research helps create a scientific and historical continuity to the subject of managing and treating cancer in Oman, as it reflects on the progression of the public perception and methods of prevention and treatment of the disease in 2012-2017. In the future, this information would allow tracing said progression in the scope of a wider, all-encompassing review.
Literature Review
The dynamics of cancer incidence in the Middle East differ from those in Europe, the USA, or the Far East, due to a unique combination of factors affecting the situation in these countries. The study performed by Hilal et al. (2015) is dedicated to prostate cancer, yet the results of this study could be extrapolated on the entirety of the region concerning other types of cancers as well. The study found that the factors affecting cancer rates in Arab countries, such as Oman, include the relatively young age structure, lower androgen and antigen levels in Arab men, the metabolic syndrome paradox, and the effect of the Mediterranean diet patterns, which are prevalent in the region. The study suggests that a variety of regional and country-specific factors could be causing or preventing the spread of cancer in Oman, at least, as far as prostate cancer is concerned. It highlights the positive effect of the Mediterranean diet that includes many vegetables, grain, and low amounts of fat, as one of the positive factors that prevent the apparition of cancer in Arabs. At the same time, it provides important information on genetic predisposition of the population towards particular kinds of cancer.
Breast cancer is considered to be among the most common types of cancers associated with women. A study published by Miri Cohen in 2013 reflects on the cultural perceptions of breast cancer among Arab women in Israel. According to Cohen (2013), Arab women in Israel have a low early screening attendance rate when compared to other groups of patients. Non-attendance is largely associated with personal religious views and beliefs in regards to healthcare, in particular, the “health belief” model, which states that perception of a disease will inevitably lead to one, thus provoking a reaction of not attending cancer screenings out of fear that it may provoke a disease. The research also showed a disparity of views towards cancer as a healthcare problem, ranging widely from traditional towards modern and integrated medical views on the subject, the latter being motivated by education and family background. The major supporting factors contributing towards survival and the desire to live among Arab breast cancer patients were concluded to be familial support, which is common due to the collective and clustered nature of Arab families, as well as religious guidance. This study is important in the scope of our research due to the fact that it reflects on Arab women in highly developed hospital settings, which are compatible to those in the Sultanate of Oman. At the same time, any information related specifically to Israeli healthcare was not used in the following discussion due to apparent differences between the two countries, the state religion, and the approach towards healthcare.
Oman is not the only state among the countries of the Arabian Peninsula that had experienced a gradual increase in cancer incidence. Other developed countries in the region, such as Qatar, have also experienced the same problem, which was largely motivated by the changes in lifestyle and the increasing westernization of the youth, as well as dietary changes and climatic alterations perceivable across the world. Donnely et al. (2013) find that the main factors for women not attending cancer screenings were a lack of doctor’s recommendation, fear, and embarrassment. All of these are culturally-motivated factors, stemming from the highly personal nature of cancer and the fear of being looked upon as “diseased” among Arab women. The results of this study correlate with the findings presented by Cohen (2013) pertaining the attitudes of Arab women towards cancer screenings in Israel, thus showing a cultural pattern of the issue being viewed as taboo. Unlike Israel, however, Qatar bears more similarities to Oman in terms of quality and national identity of healthcare, due to both being Arab nations. The results of this research show that the cultural views on cancer screenings in women remain similar across several countries in the Middle East and are largely motivated by cultural and religious homogeneity.
The ability to recognize symptoms of cancer is considered paramount to the efforts of early prevention of cancer, especially in countries such as Oman. At the same time, despite the overall level of healthcare being relatively high, especially when compared to the low-income and middle-income countries of the region, Oman has a surprisingly low level of public awareness of warning signs and symptoms of cancer. This could be a potential factor to contribute to the growing cancer incidence and mortality rates in Oman. A survey performed by Al-Azri et al. (2015) showed a surprising rate of ignorance in regards to the subject among Omani men and women aged 18 and older. According to the survey, total awareness of the participants who took the CAM (Cancer Awareness Measure) questionnaire amounted to 40.6%, which is very low. The survey managed to identify the major cultural, practical, and emotional barriers among the respondents. The most widespread barriers included the fear of the doctor actually finding any symptoms of cancer (65.6%), and the inability to talk the doctor about cancer (46.1%). The most common practical barrier to screening tests involved the inability to make the time for an appointment due to work and general business (75.1%). The study also showed that women were more likely to avoid medical help due to fear, shame, and embarrassment. This study highlights a major barrier for the Omani healthcare – as even the most efficient medical systems are powerless against cancer if it is reported too late. The research by Al-Azri et al. (2015) states an urgent need for the Sultanate of Oman to improve the public awareness and knowledge of cancer if the incidence and mortality rates for cancer are ever to go down. The results of this research resonate with other survey findings done in other countries, highlighting the fact that public healthcare in countries of the Arabian Peninsula has advanced faster than the public knowledge and perception of it.
Another study performed by Mohammed Al-Azri in 2016, titled “Delay in cancer diagnosis: Causes and possible solutions” addresses the necessity of early detection in cancer treatment. According to the researcher, cancer has a reasonably high treatment rate if addressed at the early stages of development. However, the more the disease progresses, the more likely it is for treatments to fail. Al-Azri reflects on the results of the CAM survey performed by him and his team in 2015 and states that one of the main reasons for delays in cancer diagnosis is related to the educational system of Oman. Although the standard school curriculum features extensive information about cancer, it never addresses any practical means of self-diagnosis and description of the symptoms, which is especially true for breast cancer. This conclusion resonates with the findings of the other researches mentioned in this list. However, Al-Azri highlights another problem that is more relevant to Omani healthcare system as a whole. The hospital system in the countries of the Arabian Peninsula is surprisingly uniform and consists of a network of local health centers and hospitals. Primary healthcare centers are supposed to identify possible symptoms of cancer and direct the patients for a more in-detail screening to a better-equipped facility. This creates a delay, which has the potential for further complications. In addition, the early diagnosing system is far from perfect, as the patient is often required to travel in order to get a second opinion, sometimes even abroad. This creates a loop in the continuity of care, which, in turn, causes delays and complications, reducing the probability of successful treatment.
Faith has a major influence on the people of Oman, and on Arabs in general, as Islam is the dominant religion in the region. According to the study conducted by Albar (1994), Islam as a religion strives to protect its tenants against cancer by prohibiting certain products and activities associated with cancer. For instance, Islam prohibits the use of tobacco, whether in smoking or chewing. Tobacco is known to be a major cancerogenic substance, responsible for the majority of lung cancer incidents around the world. At the same time, Islam prohibits excess in food consumption, as well as the consumption of certain fat-saturated meats, such as pork. Thus, it contributes to the overall healthiness of Arabs and acts as a preemptive measure against cancer. While this effect of the faith can be considered as positive, Islam may have a negative effect on early response and treatment to the disease.
This is due to the fact that the Qur’an sends several controversial messages in regards to diseases, which may have different effects and interpretations. For instance, Islam teaches not to fear death because our time on this plane of existence is short and that the soul is immortal, while the body is not. At the same time, Qur’an states that Allah sends troubles and misfortunes upon his servants to test their faith, and rewards those who patiently persevere. Lastly, according to Albar (1994), faithful Muslims who die of disease are considered martyrs in the eyes of Allah. These three factors, in combination, may lead the population to a conclusion that in order to ascend to a different plane of existence, they must not prolong their time in this world, and not seek treatment for cancer even at the stages when they could still be saved. While it is their personal decision, it does not help decreasing the incidence or morbidity of the disease.
The mass media play an important role in the promotion of health and education, as well as in forming the public opinion towards cancer prevention, cancer screenings, and cancer survivorship. Cancer survivorship, in particular, is being viewed as an example of fortitude, bravery, and dedication to life. A good example of this trend is a news article featured in Times of Oman, which tells the story of Doaa Elseoud, who was named the most inspiring cancer survivor in Oman (Afifi, 2017). In the interview regarding her survivorship, Doaa covers very important aspects of fighting cancer on an individual level – the importance of the support of friends and family, the importance of self-examination and early prevention, the value of discipline in enduring prolonged cancer treatments, as well as the positive influence of the Faith in her recovery (Afifi, 2017). She also touches the issue of cancer survivorship in Oman and other Arab countries, stated that there is an issue of perceived shaming of cancer survivorship. This causes many women to hide the signs of being treated, such as covering their heads when undergoing chemotherapy and not disclosing the issue with anyone, even close friends and family, thus denying themselves an important source of emotional support (Afifi, 2017).
Prospects for Oman to improve its cancer incense and survival rates are positive, however. The country is making an effort into solving the problems associated with cancer through higher quality of healthcare and the all-encompassing program of disease prevention. According to Times of Oman, since 2015, Oman has become the cancer-prevention body hub – an initiative that stretches beyond the borders of one single country, instead aiming to encompass the entire region. Other countries to partake in this effort are Kuwait, Bahrain, Saudi Arabia, Ethiopia, Kenya Tanzania, Egypt, Zambia and Tunisia (Blesson, 2015). This initiative involves cooperation between different healthcare systems in order to establish a united patient database, which would allow for faster sharing of data and result in the improved rates of cancer detection and prevention. The countries acknowledge the need for better disease prevention at the early stages due to the fact that chances of survival during the 3rd and 4th stages of cancer are extremely low (Blesson, 2015). The most common types of cancer for Arabic countries are stated to be breast cancer for women and prostate cancer for men. Cancers associated with the cardiovascular system are also becoming more common due to changes in lifestyle and diet (Blesson, 2015).
Discussion
After thoroughly reviewing the data assembled in the course of this research, it is possible to construct a cohesive picture of the situation in regards to perception, attitudes, and practice towards cancer early detection, prevention, and survivorship in Arab countries and Oman. This discussion will mostly focus on the identified problems found in the healthcare system and the public perception of the problem.
Although the country is stated to possess a highly developed healthcare system that is competent and well-equipped for handling cancer patients at all stages of development, the current system lacks the optimization required for a quick diagnosis of the disease. This is supported by Al-Azri (2016), who states that cancer incidence rates largely depend on how quickly they are diagnosed. The current system does not offer any effective ways of getting a second opinion on the diagnosis, which causes delays in the treatment and hurts the continuity of care.
The most common types of cancer encountered in Oman, and other countries of the Arabian Peninsula are breast cancer, prostate cancer, and cardiovascular cancers. This statement is supported by Hilal et al. (2015), Cohen (2013), and Donnely et al. (2013), who state that the Arabs are vulnerable to this particular type of cancer due to genetics, choices of food, changes from one lifestyle to another, pollution, and cultural barriers. Breast cancer is prevalent in women, while prostate cancer – in men.
The main mechanism of cancer detection and prevention, which is public awareness and education, is very poorly developed in Oman and other Arab countries. This data is supported by Al-Azri and his CAM survey conducted in 2015, as well as by other sources, to various degrees. The Omani system of healthcare education fails on all levels, from government programs to individual efforts performed by doctors and nurses. Cohen (2013) and Al-Azri (2016) both indicate that in many cases the doctors fail to convey any information about cancer to the patients. The school curriculums in Oman, while dedicating some attention to explaining the mechanisms of cancer, do not pay enough attention to describing the major symptoms and methods of self-diagnosis, which contributes to the lack of early diagnosis and prevention efforts.
The population in Oman and in other Arab countries expresses a wide range of opinions in regards to cancer detection and prevention. These range from traditionalist to modern biomedical perceptions and highly dependent on the personal background of a particular patient (Cohen, 2013). Despite this, the majority of the population in Oman have a skewered perception of cancer prevention, detection, and survivorship, which is demonstrated in feelings of fear and shame in patients, who are reluctant to undergo screenings (Donnely et al. 2013). This fear is associated with incomplete knowledge of what cancer is and how it is treated. The common stereotype is that cancer is largely incurable and that chemotherapy is a long and unhealthy procedure that makes a person suffer more in the long term. These beliefs are connected to the issue of cancer education, which was already mentioned in the previous section, and the absence of knowledge is thus replaced with rumors and stereotypes. In the Arab society, which is largely dominated by males, women feel particularly conscious about their health and appearance, and to them, cancer is associated with being diminished in value as a woman and a person, which leads to avoidance of cancer screenings and treatments (Donnely et al., 2013).
At the same time, the Arab society views cancer survivorship as something that a person should be hiding and ashamed of. Many cancer survivors are stated to hide the fact that they underwent chemotherapy, masking the signs of treatment underneath the clothes or under blankets overhead. Baldness, associated with patients that underwent chemotherapy, is shunned, particularly by women, who are expected to have long hair. This tendency, however, is a subject to changing, as more progressive views come into Oman and other Arab countries. The story of Doaa Elseoud showcases this trend, as cancer survivors are being turned from a shunned topic into becoming the symbols of bravery, endurance, and determination to live (Afifi, 2017).
The Islamic faith is stated to have an immense influence on Omani population, as well as on the populations of other Arab countries. However, this influence is controversial, as Islamic texts tend to have contradictory connotations, some of which have a positive meaning, while the others are detrimental to the acceptance of cancer treatment and all the necessary screenings. According to Albar (1994), Islamic faith tends to have a positive connotation in the prevention of cancer and promotion of a healthy way of life, while at the same time a negative connotation in regards to the acceptance of the disease and willingness to depart to another world, rather than clinging for life. The difference between undergoing necessary treatments and “clinging to life” is not explained clearly enough (Albar, 1994).
These are the major issues with the public opinion and the general state of Omani healthcare industry in regards to cancer prevention, detection, and survivorship. The following recommendations would address the issues identified in the discussion section, and describe the ways of how these issues could be overcome.
Conclusions and Recommendations
The following recommendations are to address the problem of early cancer prevention and detection by making improvements in the key areas and involve key stockholders that represent the healthcare industry, the government, and the Faith. Together, these stockholders are to adopt a complex and all-encompassing approach in order to improve cancer incidence and morbidity rates.
The first step that needs to be taken involves the promotion of healthcare education on all levels, ranging from schools to individuals. The curriculum must be revised in order to include the basics of self-examination and the major symptoms of cancer. In addition, all healthcare providers, from primary healthcare providers to major hospitals, to enroll in periodic information campaigns to inform the population about the dangers of cancer, major cancerogenic factors, self-care and self-diagnosis techniques, as well as major symptoms. The promotion of screening tests is encouraged. Screening tests should be subsidized by the Omani government in order to encourage the population to undergo them. These measures, when combined, would help shift the viewpoint of the Arabic population from traditional (which contains many harmful stereotypes) towards biomedical, which should improve the screening attendance rates and the overall attitude towards medical procedures.
Members of the Faith communities will play a paramount role in promoting a more positive attitude towards cancer detection, prevention, and survivorship. The leaders of Muslim religious communities must explain to their members in no uncertain terms that there is nothing shameful or wrong with screening tests and that not fighting for survival and doing everything in their power to live is against the will of Allah. One of the ignored tenets of Islam faith states that it is a sin against God to take one’s own life or to perform actions that would, in the end, lead to the termination of life. Inaction against cancer could be considered just that – a termination of life.
Social services, medical personnel, and faith communities are to work together in order to change the public opinion towards cancer detection, prevention, and survivorship in Oman. Working through mass-media and other available channels, it would be possible to improve the attendance to screenings and reduce the social stigma that follows cancer patients and cancer patients alike. Education is the answer. If the situation remains as it is, it is bound to get worse and lead to increased mortality and morbidity rates among the population.
References
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