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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 251-255

Knowledge, perception, and attitude of the general population toward cancer and cancer care: A cross-sectional study

1 Division of Clinical Research and Biostatistics, Malabar Cancer Centre, Kannur, Kerala, India
2 Department of Surgical Oncology, Malabar Cancer Centre, Kannur, Kerala, India
3 Former Medical Social Worker, Malabar Cancer Centre, Kannur, Kerala, India

Date of Submission05-Feb-2021
Date of Decision23-Apr-2021
Date of Acceptance04-May-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Satheesan Balasubramanian
Department of Surgical Oncology, Malabar Cancer Centre, Kannur, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_31_21

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Background: Despite the advances in the field of oncology, the diagnosis of cancer is often considered a death sentence, owing to the misconceptions and myths about cancer treatment. Moreover, improvements in health literacy and awareness about cancer have also not been able to change the attitude of people toward cancer-related health behaviors.
Objective: In this study, we aimed to evaluate the knowledge, perception, and attitude of the general population toward cancer and cancer care.
Materials and Methods: This cross-sectional study was conducted at Malabar Cancer Center, a tertiary cancer center in Kerala, India, between June 2017 and February 2018. A survey was conducted in the general population in the northern part of Kerala in the districts of Kannur, Kasargod, and Wayanad during a medical camp. People who were aged above 18 years and could read the Malayalam language were included in the study. The participants were administered a questionnaire comprising 26 questions, and the knowledge, perception, and attitude of the general population toward cancer and cancer care were evaluated.
Results: A total of 487 people responded to the survey. Of these, 354 (72.7%) were women and 133 (27.3%) were men. The mean age of the cohort was 43.7 years. About 74% of the participants disagreed that all cancers can be treated using the same treatment modalities. A total of 84% of the participants agreed that cancer can be detected early with screening. Almost 95% of the participants were aware of the importance of cancer screening and strongly recommended establishing cancer screening clinics in government setups.
Conclusion: There is a positive attitude among the general public toward cancer. Almost all the people surveyed were interested in attending cancer awareness programs, believed in the role of screening and felt that establishing cancer screening programs would be useful. This may help provide a road map for cancer policy-makers.

Keywords: Attitude, cancer, knowledge, perception, myth, misconception

How to cite this article:
Padmanabhan M, Balasubramanian S, Muhammed Sha E K, Malodan R. Knowledge, perception, and attitude of the general population toward cancer and cancer care: A cross-sectional study. Cancer Res Stat Treat 2021;4:251-5

How to cite this URL:
Padmanabhan M, Balasubramanian S, Muhammed Sha E K, Malodan R. Knowledge, perception, and attitude of the general population toward cancer and cancer care: A cross-sectional study. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Oct 23];4:251-5. Available from: https://www.crstonline.com/text.asp?2021/4/2/251/320143

  Introduction Top

Cancer is one of the leading causes of death worldwide and has a considerable disease burden.[1] Despite the progress made in cancer diagnostics and therapeutics over the past three decades, about 50% of the patients in the developed countries die of this disease. It is because, in most cases, the diagnosis of cancer is established at an advanced stage of the disease.[2] The incidence of cancer is on the rise in the developing countries. However, improvements in the rate of diagnosis and treatment strategies for cancer have also improved the 5-year survival rates.[3]

Cancer is considered one of the most feared non-communicable diseases in the general population because of its serious and life-threatening nature.[4],[5] A major problem associated with the diagnosis of cancer is the stigma which can lead to the isolation of the patients and their caregivers.[6] Patients with cancer often face several challenges, both in their personal and professional lives. As a result, people usually worry about the consequences of cancer diagnosis and associate it with unpleasantness, pain, and death.[7]

Health literacy plays an important role in defining the perception and attitude of people toward cancer. Poor health literacy has been consistently correlated with poor health outcomes. With health literacy, it becomes easy to access and appraise the health information as well as convey and communicate it to the general public. It also makes it easy to implement various health-related policies and measures for the general public, thus improving the overall health outcomes of the population.[8] The level of health literacy is an important factor that influences the attitudes of individuals toward cancer and their chances of taking an appropriate and timely health-care action.[9] The fear of cancer may lead to a negative attitude toward early cancer detection among individuals and prevent them from participating in screening programs.[10] Some studies have reported that people with a higher perceived risk of cancer are more likely to participate in screening than those with higher health literacy.[11] Hence, it is necessary to understand the attitude of the general public toward cancer and patients with cancer in order to improve the formulation and implementation of cancer treatment policies. This knowledge will help to tailor these policies according to the specific needs of the community and stakeholders.

Despite improvements in the survival rates, negative beliefs and myths about cancer still abound. Therefore, in this study, we aimed to evaluate the knowledge, perception, and attitude of the general population toward cancer and cancer care.

  Materials and Methods Top

General study details

This cross-sectional study was conducted at Malabar Cancer Center, a tertiary care center in Kerala, India, between June 2017 and February 2018. As a part of the study, a survey was conducted in the general population in the northern part of Kerala in the districts of Kannur, Kasargod, and Wayanad. The study was approved by the Institutional Ethics Committee (IEC) [IEC approval Ref. No: 1617/IRB-IEC/13/MCC/30-06-17/2 dated July 4, 2017 – Supplementary Appendix 1], and written informed consent was obtained from all the participants. The study was conducted according to the ethical guidelines outlined in the Declaration of Helsinki, Good Clinical Practice guidelines, and the Indian Council of Medical Research guidelines. No funding was obtained for this study. As this study was a cross-sectional survey, it was not registered in a public clinical trials registry, like the Clinical Trials Registry of India.


Our cancer center organizes medical camps in different parts of the districts of Kannur, Kasargod, and Wayanad. This cross-sectional survey was conducted during one such medical camp. People aged more than 18 years who could read the Malayalam language were eligible to participate in the survey.


The knowledge, perception, and attitude of the study participants toward cancer and cancer care were evaluated based on their responses to the questionnaire.

Study methodology

After obtaining a written informed consent, the participants were administered a questionnaire and were given adequate time to provide their responses. The questionnaire comprised 35 questions related to the knowledge and general attitude of the people toward cancer. There were three possible responses to all the items in the questionnaire, namely “agree,” “no opinion,” and “disagree.” The contents of the questionnaire were validated, and nine questions were excluded as they were not relevant to the current study. Thus, the final questionnaire comprised a total of 26 questions [Supplementary Appendix 2]. The questionnaire was administered in the Malayalam language. The filled questionnaires were collected, and the participants' responses were scrutinized and entered in the case record format in Microsoft Excel. Data cleaning was performed prior to statistical analysis.


A formal sample size calculation was not performed for this study. All participants fulfilling the eligibility criteria and who were willing to participate in the study were included in the analysis. Data were analyzed using descriptive statistics. Continuous variables were expressed as mean with standard deviation (SD), and categorical variables were expressed as proportions and percentages. P < 0.05 was considered statistically significant. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) (IBM Corp. IBM SPSS Statistics for Windows, version 23.0. Armonk, NY, USA: IBM Corp.). For questions that were left unanswered by the participants, a fourth response category called “not answered” was included for the ease of data analysis.

  Results Top

Between June 2017 and February 2018, 487 people voluntarily participated and completed the cross-sectional survey. Over 70% of the participants were women. The mean age ± SD of the cohort was 43.7 ± 13.0 years. The sociodemographic details of the study participants are described in [Table 1].
Table 1: Sociodemographic details of the study participants (n=487)

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With regard to the myth that naturopathy can cure cancer, about 11% of the participants agreed that naturopathy is a better treatment for cancer; 59% disagreed with this statement, 28% did not have any opinion on this; and the remaining did not answer this question. The participants had adequate knowledge about the different treatment modalities for cancer (including surgery, radiation, and chemotherapy). About 74% of the participants were aware that all cancers do not have the same treatment modalities. Approximately 54% of the participants disagreed that visiting a cancer hospital was dangerous, while 32% of them believed otherwise. Over 80% of the participants strongly agreed that many cancers could be detected early with the help of screening. Thus, they were aware about the importance of cancer screening and strongly recommended establishing cancer screening clinics in the government setups [Table 2].
Table 2: Participants' responses to the questionnaire (n=487)

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  Discussion Top

We evaluated the knowledge, perception, and attitude of the general population toward cancer and cancer care and observed a positive attitude toward the disease. The majority of the participants believed that cancer could be detected early with screening and were aware of the importance of cancer screening programs.

Most studies have reported that the diagnosis of cancer is associated with the fear of suffering and death.[11] Population-based studies have consistently shown that many people (5%–10%) worry to some extent about getting cancer.[12],[13],[14] Studies have shown that some people distance themselves from the person diagnosed with cancer because of the fear of death. It is also commonly reported that patients with cancer avoid social interactions and are often not interested in making public appearances because they feel awkward.[15] They also tend to limit their interactions with friends and family owing to the associated stigma and the related social constraints.[16]

In our study, we observed that 24.2% of the participants had a misconception that only the rich can afford cancer treatment. The participants in our cohort belonged to the lower socioeconomic strata. A total of 73.5% of the participants disagreed that avoiding screening is better than being diagnosed with cancer. Moreover, 75.2% of the participants also disagreed that the detection of any abnormality during screening is considered as cancer. Studies have shown that the stigma faced by patients with cancer and the negative attitude of the general population toward cancer is associated with lower socioeconomic status.[17] In our study, however, the participants had adequate health literacy; 84% of the participants strongly believed that cancer is a common disease nowadays, and hence, frequent cancer screening is essential.

Studies have also shown that the fear about cancer treatment may be a barrier to screening.[18] In our study, 64.1% of the participants believed that cancer treatment is painful, which showed their lack of adequate knowledge and awareness about the treatment procedures for cancer. Studies from The Netherlands[19] have reported that belief in God and the attitude toward death are directly or indirectly associated with the quality of life, depression, and hopelessness in patients with advanced cancers. Similar findings have also been reported by studies on the African-American population.[20] It was observed that religiosity and health were closely linked, with illness and healing being associated with God and faith. Moreover, many people believed that there is a reason for their suffering that cannot be explained or understood. In our study, we observed that only 1.8% of the people believed that disease is a blessing from God, and that prayers play a key role in their cure. About 90.1% of the participants disagreed that prayers play a key role in curing a disease and that it is better to avoid treatment.

The findings from the present study have to be interpreted in the context of a number of limitations. This survey was performed in the state with the highest literacy rate in the country, so the results may not be representative of the knowledge, attitude, and perception of the Indian population in general. Moreover, the study was conducted among the participants of a medical camp, and hence, it likely that they had some prior knowledge about cancer or the life of patients with cancer. A control group should therefore have been included.

In future, studies should be conducted to assess the attitude of the general public toward patients with cancer, survivorship, and how the society accepts their return to normal life after the disease has been cured. Moreover, in order to improve the knowledge about cancer and the attitude toward patients with cancer, awareness programs and related subjects should be included in the curriculum right from the school level.

  Conclusion Top

Our study reports an overall positive attitude of the general population toward cancer and emphasizes the importance of cancer screening as well as awareness about the disease and survivorship. The government must therefore set up cancer screening clinics at the primary level.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Supplementary Appendixes Top

Supplementary Appendix 1: Study protocol

Research Protocol

A cross-sectional study on attitudes toward cancer and cancer patients in northern Kerala population

  Introduction Top

Attitude is predisposition or a tendency to respond positively or negatively toward a certain idea, object, person, or situation. Attitude influences an individual's choice of action and responses to challenges, incentives, and rewards; simply defined, attitudes are generally positive or negative views of a person (including oneself) place, thing, or event (the attitude object). Attitudes are favorable or unfavorable evaluations of people, objects, or events – or just about anything in our environment.

Components of attitude (ABCs of attitude)

Favorable or unfavorable evaluations toward something that define a person's attitude can exhibit in beliefs, feelings, or inclinations to act. This is known as the multidimensional or tricomponent view of attitudes (e.g., Breckler, 1984, and Katz and Stotland, 1959). These three components represent the basic building blocks of attitudes. These dimensions are known as the ABCs of attitudes: Affect (feelings), behavior (tendency to act), and cognition (thoughts).


Affect refers to feelings or emotions that are evoked by a particular person, item, or event – the attitude object, or the focus of our attitude, for example, fear, sympathy, hate, like, and pleasure. Obviously, such feelings can vary in intensity. Such feelings form from our experiences (or observing experiences) and serve to guide our future behavior.


Attitudes have a behavioral component – a tendency or a predisposition to act in a certain manner. It may seem logical to assume that if we have a negative attitude for a particular object – your boss in the above example – it is likely to be translated into a particular type of behavior. Behaviors are typically defined as overt actions of an individual. It is more reasonable to assume that one's behavioral intention, the verbal indication or typical behavioral tendency of an individual, rather than actual behavior is more likely to be in tune with his affective and cognitive components.


The term cognition literally means “to know,” “to conceptualize,” or “to recognize.” Hence, the cognitive component of attitude is the storage component where we organize information about an attitude object. It comprises our thoughts, beliefs, opinions, and ideas about the attitudinal object. The congruence between affective and cognitive components may influence the intention to behave.

Review of literature

A survey instrument named cervical cancer awareness measure (cervical CAM) was developed by the University College London Health Behaviour Research Centre, in collaboration with the Department of Health Cancer Team and The Eve Appeal, with funding from The Eve Appeal. It forms part of the Cervical Cancer Awareness and Symptoms Initiative. Psychometric evaluation of the cervical CAM (paper in preparation) indicates that it has satisfactory internal reliability with Cronbach's alpha above 0.7 for all components. Test–retest reliability over a 1-week interval was found to be good, with all correlations above 0.7-item difficulties.

The BCSBQ, first developed in English, is a 13-item instrument designed to investigate behaviors in terms of three subscales as follows: (1) Attitudes toward general health checkups, with a subscale of four items designed to determine the participants' attitudes to undergoing such checks in the absence of signs and symptoms of disease; (2) Knowledge and perceptions about breast cancer, with a subscale of four items designed to elicit information on the participants' cultural beliefs regarding breast cancer; (3) Barriers to mammographic screening practices, with a subscale of five items covering what participants perceive as psychological and practical barriers that prevent or at least discourage them from participating in mammographic screening.

McCance, Mooney, Smith, and Field (1990) developed the Breast Cancer Knowledge Test (BCKT) originally based on Stillman's (1977) Knowledge Questionnaire. The BCKT is a 19-item instrument that measures subjects' knowledge of breast cancer detection and screening practices. It consists of 18 items that focus on general information about breast cancer (early signs and symptoms, for example) as well as breast health practices (such as when and how breast self-examinations [BSEs] should be performed).

Champion, 1999, developed the Barriers Scale for Mammography Screening for assessing women's beliefs about breast cancer screening. The RSBBSMS contains 58 items and utilizes a five-point Likert scale ranging from one “strongly disagree” to five “strongly agree.” This instrument is comprised of eight subscales: 5 items related to susceptibility, 7 related to seriousness, 6 related to benefits of BSE, 6 related to barriers to BSE, 11 related to confidence, 7 related to health motivation, 5 related to benefits of mammography, and 11related to barriers to mammography.

Caryn Lerman et al. (1991) constructed the Breast Cancer Worry Scale to study the degree to which women have anxiety or worry related to breast cancer. This concise scale consists of three items: One that measures the frequency of worrying about “getting breast cancer someday” and two items measuring the impact worry has on mood and the performance of daily activities.

Most of the literature exploring cancer screening attitude scales has developed for assessing only attitude of a specific group and toward cancer in a specific site such as cervical cancer. To our knowledge, at the time of starting this work, no scales were available for assessing attitude of public toward cancer screening. The aim of the present study is to develop a cancer screening attitude scale for use in general population of Kerala.

Need and significance of the scale

An attitude is defined as an enduring system of the cognitive component, the feeling component, and the action tendency component, all of which center round an object, person, event, etc. The degree of a person's attitude may vary from favorable through neutral to unfavorable.

Basic assumptions of measurement of attitudes

  1. An individual's behavior with respect to the object of attitude will be consistent from one situation to another. In all situations, if consistency is not exhibited, it is difficult to assess the individual's attitude
  2. Attitude cannot be observed directly. It is, therefore, assumed that it must be inferred from the statements and actions of a person. The statements and actions toward the object of the attitude reveal the degree of favorableness or unfavorable, which together constitute the valence of attitude.

Cancer is a leading cause of mortality worldwide. In 2008, this disease was responsible for 7.6 million deaths, which account for 13% of all global fatalities.[1] It estimated that, in that same year, almost 170 million years of disability-free life were lost to cancer.[2] According to the World Health Organization, over 30% of cancer fatalities could be avoided by modifying or avoiding the leading behavioral, dietary, and environmental risk factors associated with the disease.[1] In addition, cancer mortality may be greatly reduced through early detection and prompt treatment.[3] Thus, as healthy lifestyle promotion and cancer screening are the fundamental pillars of the fight against the disease, effective delivery of health communication plays a key role in cancer prevention efforts.

Kerala state has a high literacy rate (93.7) and health-conscious population. The basic attitude of the population has always been for sickness management rather than health maintenance. Regular or periodical health checkup is rarely practiced. Even educated people maintain undesirable attitude toward cancer, its prevention, and screening. Fake health practitioners, some religious beliefs, consumerism all have major role in creating these negative attitudes. Disseminating accurate information is not enough; it is essential that health messages inspire in the recipient a positive attitude toward both prevention and early diagnosis of the attitude. Despite this evidence illustrating the importance of a positive (or negative) attitude toward cancer information on an individual's preventive behaviors,[9] empirical research on the specific factors determining such attitudes is scarce. Moreover, we are currently unaware of the Kerala population's attitude toward cancer information seeking and/or scanning and the factors contributing to such attitudes. Therefore, the aim of this work is to develop a cancer screening attitude scale for use in general population of Kerala.

  Methodology Top


The aim of the present study is to develop a cancer screening attitude scale for use in general population of Kerala.

Tentative selection of items

The topic on which the scale to be developed is attitude toward cancer screening. It will be done following a long discussion. The factors influencing attitude toward cancer and cancer screening will be collected from reference books, periodicals, journals, and personal experiences. The components of attitude are the cognitive component, the feeling component, and the action tendency component. Based on these components, many questions will be prepared and will be submitted to experts and possible changes will be made based on suggestions given.


The sample consists of individuals above 18 years old. The samples will be selected from community camps conducted by Malabar Cancer Center. The sample size will be determined according to the statistical norms.


The samples will be seated comfortably and rapport will be established with them. The clinical research assistant will explain the aims and objectives of the test and prior written consent will be collected. The samples will be instructed as follows. This sheet contains some statements. Read them carefully. There are three options corresponding to each of statements – “agree,” “no opinion,” and “disagree.” If you agree to a statement, put a tick mark in corresponding column, and if you do not agree with any statement, put a tick mark in corresponding column, and if you do not hold any opinion about a statement, put a tick mark in corresponding “no opinion” column.


Being the proposed cancer screening attitude scale is Thurstone type of scale, there are three options to express the attitude of the participants – “agree,” “no opinion,” and “disagree.” There are positive and negative items in the scale. For positive items, if the participant has put a tick mark against “agree,” three points will be given, and if the participant has put a tick mark against “no opinion,” two marks will be given. If his tick mark is against “disagree” option, his score is one mark.

For negative items, if the participant has put a tick mark against “agree,” one point will be given, and if the participant has put a tick mark against “no opinion,” two marks will be given. If his tick mark is against “disagree” option, his score is three marks.

Item analysis

The effectiveness and usefulness of the scale depend upon the quality of items that are included in it. In the process of test construction, the item analysis is quite necessary for the selection of items for the final test form, which will be according to the objective, and subject matter of the test. Items can analyze qualitatively and quantitatively.

After the administration of the scale in samples, scoring will be doing. After that, arrange the inventory in increasing order of scores, count the total number of inventories, and take 27% of the total from the top and 27% from the bottom. The middle 46% will be used to mark off the two end groups. The number of top group, which passes each item on the test, and number of bottom, which passes each item, would be tallied. These numbers are converted into proportions. After item analysis, based on discriminative index, items for final scale will be selected.

  References Top

  1. Becker MH, editor. The Health Belief Model and Personal Health Behavior. Vol. 2. Health Education Monographs; 1974. p. 324-473.
  2. Champion VL. Instrument development for health belief model constructs. Adv Nurs Sci 1984;6:73-87.
  3. Champion VL. Revised susceptibility, benefits, and barriers scale for mammography screening. Res Nurs Health 1999;22:341-8.
  4. Janz NK, Becker MH. The health belief model: A decade later. Health Educ Behav 1984;11:1-47.
  5. Janz NK, Champion VL, Strecher VJ. The health belief model. In: Glanz K, Rimer BK, Lewis FM, editors. Health Behavior and Health Education: Theory, Research, and Practice. 3rd ed. San Francisco, CA: Jossey-Bass; 2002. p. 45-66.
  6. Marin G, Sabogal F, Marin V. Development of a short acculturation scale for Hispanics. Hisp J Behav Sci 1987;9:183-205.
  7. McCance KL, Mooney KH, Smith KR, Field R. Validity and reliability of a breast cancer knowledge test. Am J Prev Med 1990;6:93-8.

Pro forma

Supplementary Appendix 2

  References Top

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  [Table 1], [Table 2]


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