Introduction

Stigma is a social phenomenon in which an individual’s condition renders them unaccepted or rejected by the community [1]. Weiss and Ramakrishna [2] defined stigma as a social process or personal experience involving exclusion, rejection, blame, or devaluation. It arises from the actual experience or the rational anticipation of negative social judgment directed at an individual or a collective entity.

Health-related stigmatization is the negative evaluation of a person due to a disease or condition [3]. Individuals facing stigma may encounter different types, including social and self-stigma [4]. Social stigma occurs when community members discredit individuals with specific attributes [4,5]. Self-stigma involves an internalized sense of devaluation that can result in shame, guilt, discrimination, and social unacceptability [6], along with adverse consequences such as psychosomatic issues [3]. Adverse outcomes include limited access to healthcare services and treatment, healthcare provider acceptance, resilience, and treatment adherence [7].

Most previous stigma studies have centered on patients with diverse conditions, including mental illness, HIV, AIDS, and, recently, cancer [4]. Studies about patients with cancer provide evidence of stigmatization within this population. In the report from the U.S. National Cancer Institute titled “Global Cancer Stigma Research Workshop,” it is highlighted that patients with cancer frequently experience fears of being blamed for their illness, held accountable for their cancer diagnosis, and facing potential abandonment by their social circles [8]. Many patients with lung cancer reported avoiding treatment to conceal their diagnosis [9,10]. Previous studies indicated that the public and healthcare providers held negative perceptions of patients diagnosed with lung cancer [11,12]. Furthermore, Else-Quest et al. [13] found that the specific type of cancer does not influence the experience of stigmatization.

Cultural norms and practices substantially influence a community’s lifestyle, beliefs, and values, affecting its overall well-being and ability to adapt and thrive [14]. The cultural belief system enables individuals to comprehend, interpret, explain, and label their experiences [15]. Furthermore, it shapes individuals’ responses to challenging and unforeseen circumstances [16]. People who share the same culture have certain values, beliefs, and practices that distinguish them from other cultures [17].

Oman is an Arab country with a predominantly Muslim population, situated in the Gulf region. In Oman, government healthcare facilities provide accessible medical services, either free of charge or at affordable rates, to both Omani citizens and expatriates working in the public sector. Due to the differences in social, economic, and religious beliefs between Arab and Western cultures, research findings from the West may not be directly applicable to individuals in Arab Muslim countries. For example, a study conducted in an Arabic Muslim country found that some cancer survivors preferred to isolate themselves to conceal their needs and the shame associated with being diagnosed with cancer [18]. Patients in Jordan associated cancer with death and hopelessness [19], and certain misconceptions about cancer were found to be associated with gender, education level, and income in this population [19]. Additionally, in Arabic communities, both healthcare providers and family members may view cancer as an evil or wicked disease [20]. Conversely, cancer survivors may experience self-stigmatization and emotional distress stemming from a perceived responsibility for their disease, with some blaming their lifestyle for their illness (5). Furthermore, it is common for healthcare providers and family members in Arab countries not to disclose a cancer diagnosis to patients [21]. The primary goal of this study was to explore the perceived stigmatization experienced by patients with cancer within the framework of Arabic and Islamic culture.

Theoretical framework: The Health Stigma and Discrimination Framework served as the foundational basis for this study, which elucidates how social judgment and attribution of blame can adversely affect health-related stigma experienced by Muslim patients diagnosed with cancer.

Methods

Results

Sociodemographic and medical characteristics

Out of 194 patients invited to participate in the study, 190 consented to take part, resulting in a response rate of 97%. This high level of participation enhances the reliability of the study’s findings. The average age of the participants was 46.52 years (SD = 13.9). Approximately 72% of the participants were female, and 73.6% were married. Nearly 40% of the participants held college or university degrees. Around 54.4% of the participants had a low income. Most participants (59.5%) were diagnosed with breast and colon cancers, were still undergoing cancer treatment (82.4%), and did not have other chronic diseases (67.9%). The average duration of cancer was 24.2 months (SD = 30.5), and the average treatment duration was 21.0 months (SD = 28.9) (Table 1).

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Table 1. Socio-demographic and medical characteristics (N = 190).

https://doi.org/10.1371/journal.pone.0333185.t001

The level of stigma

Table 2 presents the findings of a study on stigma. The average total stigma level was 82.36, which is considered high. The dimensions, ranked from highest to lowest, are as follows: social rejection (M = 3.69), financial security (M = 3.35), isolation (M = 3.34), and internalized shame (M = 3.16). The means for each subscale are detailed in Table 2. Furthermore, Table 3 illustrates the number of participants who responded to each item on the stigma scale, categorized by dimension.

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Table 2. Descriptive statistics of the level of stigma (N = 190).

https://doi.org/10.1371/journal.pone.0333185.t002

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Table 3. Frequency of stigmatization items among muslim Arab patients with cancer in Oman (N = 190).

https://doi.org/10.1371/journal.pone.0333185.t003

Discussion

The study findings indicate that Muslim Arab patients with cancer experience significant stigmatization. Among the identified dimensions, the highest stigmatization was observed in social rejection, while the lowest was noted in internalized shame. However, all dimensions demonstrated notably high levels of stigmatization.

This study demonstrates that patients with cancer experience significant social rejection from their social circles and immediate environments. In contrast, a study conducted in Germany found that individuals with various types of cancer reported low to medium levels of social rejection [24]. Additionally, research in China indicated that patients with leukemia encounter a medium level of social rejection [25]. Meanwhile, a study in the United States by Wood et al. [4] found that patients with prostate cancer reported lower levels of social rejection compared to those observed in our findings. The high level of social rejection experienced by Arab Muslim patients with cancer may be attributed to prevailing misconceptions surrounding cancer. In this study, patients reported high levels of social discrimination from some family members, friends, and the broader community due to their cancer. They felt less competent and respected. In Arabic communities, there is a tendency among some healthcare providers and some family members to perceive cancer through a lens of negativity, often considering it as an evil or wicked disease [20]. In Arab communities, cancer is often viewed as a punishment or a test from God. Moreover, it is frequently seen as an incurable disease that is closely linked to death [26]. These community views can negatively influence the experience of Muslim Arab patients with cancer [27]. Healthcare providers should thoroughly assess patients’ perceptions of community attitudes towards cancer. Additionally, they should make concerted efforts to enhance public awareness of cancer and its treatment options within these communities.

The level of stigmatization associated with internalized shame was significant; however, it ranked as the lowest among the different dimensions of stigma. Interestingly, the higher level of stigmatization related to social rejection did not exhibit the same negative internal consequences. Our findings are consistent with previous studies, which indicated that the levels of internalized shame among patients in Germany and China were relatively comparable to those observed in the participants from this study [24,25]. However, contrary to our findings, Wood et al. indicated that patients with prostate cancer in the United States reported lower levels of internalized shame. In Muslim patients with cancer, the lower levels of internalized shame, as compared to other dimensions of stigma, may be influenced by several factors. These factors include their belief in and connection to God, the social support received from family members, and a tendency to conceal their cancer diagnosis [28,29]. A qualitative study conducted by Alaloul et al. [28] found that Arab Muslim patients with cancer often choose to hide their diagnosis from the public to avoid negative comments and reactions from specific community members. In the current study, only one-third of the patients reported feeling comfortable disclosing their diagnosis and being open with others. These findings highlight the social stigma surrounding cancer and its impact on individuals’ willingness to share their health status. This perception can significantly influence various aspects of cancer care, including awareness, prevention, and treatment-seeking behaviors [30].

This study indicates that Muslim Arab patients diagnosed with cancer frequently experience profound feelings of isolation and loneliness stemming from stigma. These individuals often perceive themselves as distinct from those who are healthy, leading to a sense of inequality in their social relationships. Consequently, their illness contributes to feelings of worthlessness and inadequacy. In contrast to our findings, previous studies have indicated that patients with cancer in Germany, China, and the United States reported low to moderate levels of isolation attributed to stigma [4,24,25]. A literature review study found that women diagnosed with breast cancer in Arab countries employed isolation and prayer as strategies to mitigate the impact of the cultural stigma associated with cancer [27]. Healthcare providers are responsible for actively addressing the stigma associated with social isolation and its adverse effects on patients. Researchers need to identify targeted, culturally sensitive interventions that can enhance the well-being and health outcomes of individuals diagnosed with cancer.

Conclusion

This study underscores the substantial issue of stigma faced by Arab Muslim patients diagnosed with cancer. The emotional and psychological challenges stemming from this stigma highlight the necessity for targeted support and interventions that address the unique needs of this population. Stigma is frequently intertwined with cultural factors that shape how cancer is perceived and discussed within different communities. Thus, culture plays a vital role in influencing perceptions and experiences of cancer, leading to varying levels of stigma associated with the disease across diverse cultural backgrounds.

Acknowledgments

The authors thank the patients for participating in the study and acknowledge the Directorate General of Health Services in Muscat and the staff at data collection sites for their assistance and support.