Introduction

The rapid increase in cancer incidence is receiving global attention as a major public health threat and an increasing socioeconomic burden of the 21^st century. In 2022, the World Health Organization (WHO) reported an estimated 20 million new cancer cases and 9.7 million cancer-related deaths [1,2]. In many low- and middle-income countries (LMICs), cancer is not only increasing rapidly but is also imposing a double burden on already fragile healthcare systems [3,4]. Although cancer incidence is lower in LMICs than in high-income countries (HICs), these regions experience a disproportionately high mortality rate compared to HICs [5]. This is due largely to late diagnosis, limited access to diagnostic and treatment services, and fragile health system capacity [1,4].

In the African Region, more than 900 000 new cancer cases and over 580 000 deaths were recorded in 2022, demonstrating the growing public health impact of the disease [5]. Ethiopia is also experiencing a rapid increase in cancer cases and mortality [5–7].‌‌ The WHO report showed that in 2022, an estimated 80,334 new cancer cases and 54,698 deaths occurred [8]. The national healthcare system is weak in effectively responding to this rapidly growing burden due to limited infrastructure, a shortage of trained personnel, and limited access to essential cancer services [9,10]. In addition, insufficient public awareness, sociocultural interpretations of illness, and unfavorable socioeconomic conditions influence care-seeking pathways [9,11,12].

From the onset of symptoms and throughout illness trajectories, patients and caregivers frequently seek to understand how cancer entered their lives. These questions often reflect existential concerns that cannot be fully answered or addressed within biomedical frameworks [13,14]. People attempt to make sense of the ultimate cause of the illness and the suffering it brings to the entire family. These reflections often manifest in deeply personal and existential questions such as, “Why me?”, “Why us?”, or “Why now?” [14]. In response, many draw on non-biomedical explanatory models, such as sociocultural and spiritual frameworks, to interpret illness, address these existential questions, and cope with uncertainty [14–16].

Previous studies have indicated that sociocultural beliefs and explanatory models play a central role in shaping how individuals and families interpret illness, seek care, and engage with treatment [15,17,18]. Religion, in particular, plays a crucial role in individuals’ daily lives and in all cultures and societies [15,19,20]. Research suggests that religious beliefs and practices are an important source of values, meanings, and images for people seeking answers to existential questions concerning human vulnerability and destiny, especially in the context of serious illness [21,22]. In health crises such as cancer, religious frameworks may influence perceptions of disease causation, treatment options and coping strategies [20–22].

In low-resource settings, the strong influence of religious and spiritual practices is often linked to limited access to modern biomedical services, high medical costs, and geographical barriers [19,23]. Studies have shown that even individuals with access to modern healthcare may turn to religious practices as a primary or complementary source of support [20,24]. In Ethiopia, religion and cultural beliefs are crucial parts of social life, shaping values, daily practices, beliefs, and approaches to health and illness [18–20]. Religious interpretations often inform understandings of suffering, guide treatment decisions, and guide coping strategies [18,19]. Importantly, engagement with religious practices does not necessarily reflect the rejection of biomedical services or as an option for limited healthcare services; rather, it expresses deeply rooted cultural identities and social relationships [23,25].

Despite the growing recognition of the importance of sociocultural and religious factors in health, biomedical systems have often given limited attention to patients’ and caregivers’ spiritual worldviews [20,26]. While some studies portray religious beliefs as barriers that delay biomedical care [27,28], others highlight their positive functions, including emotional support, resilience, and meaning-making [29]. Recognizing the significant influence of local belief systems in shaping illness interpretations and care-seeking behaviors, recent studies have proposed their incorporation into healthcare systems as a pathway toward more culturally responsive and patient-centered cancer care [29,30].

In Ethiopia, cancer research has examined epidemiology, focusing on prevalence and clinical outcomes, as well as limitations in healthcare infrastructure and service delivery [7,31–34]. These studies were usually based on biomedical perspectives and methodologies, paying less attention to the lived experiences of patients and family caregivers and the sociocultural and spiritual dimensions of illness interpretations, which can significantly influence illness experiences and cancer-care trajectories. In a context like Ethiopia, what patients and caregivers think and believe about the origin of illness, which is usually embedded in their sociocultural and religious or spiritual frameworks, is crucial as it significantly affects cancer trajectories. However, there is still limited understandings of how patients and caregivers make sense of cancer, negotiate diverse illness explanatory frameworks, including biomedical and religious frameworks, and orient their perspectives on cancer care practices.

This study explored religious narratives and interpretations of illness etiology among individuals diagnosed with cancer and their family caregivers in Ethiopia. Using an interpretive phenomenological approach, this study draws on in-depth interviews with patients, caregivers, and religious figures. It examines how participants understand the causes of cancer, construct meaning around illness, and incorporate spiritual beliefs into their healthcare decisions and coping strategies. By foregrounding lived experiences, this study contributes to a more context-sensitive understanding of cancer and provides evidence to inform culturally responsive healthcare practices and policies in Ethiopia and in similar contexts.

In this study, we employed multiple but complementary theoretical frameworks to assist in data analysis. First, we drew on Kleinman’s explanatory model framework [35], which emphasizes how individuals and families interpret illness causation, symptoms, and treatment within cultural contexts. Second, it is guided by Berger and Luckmann’s social constructionist perspective, which views the meanings of illness and suffering as socially produced through shared religious and cultural narratives. Third, in this study, we adopted Foster [36]’s personalistic etiology, recognizing that participants attributed cancer to spiritual or moral causes. Finally, we employed spiritual coping frameworks to examine how religion contributes as a coping resource for managing distress, uncertainty, and suffering, contributing to positive coping. Together, these perspectives provide an integrated conceptual framework for understanding how lived experiences of cancer are interpreted through religious meaning-making processes that shape treatment options, health care seeking decisions and coping strategies.

Materials and methods

Participants and recruitment

In this study, individuals diagnosed with cancer and their family caregivers were recruited using a purposive sampling technique based on their direct experience as patients undergoing biomedical treatment or as caregivers accompanying the patient in a hospital setting. Although the initial aim was to recruit a comparable number of patients and caregivers, the study included fewer patients due to illness severity, as most presented at advanced stages, treatment schedules, and fatigue during treatment, particularly during and after chemotherapy. In contrast, caregivers were more accessible, interested, and actively involved in care decisions and spiritual practices. Although some caregivers were responsible for children with cancer, only adult caregivers were interviewed in this study. Information regarding the pediatric patients was provided by their caregivers. Given the study’s focus on relational meaning-making within families, caregivers were retained as key participants. In addition, although the number of patient interviews was limited, an in-depth case-by-case analysis revealed strong convergence in core meaning-making patterns across participants. The final sample composition reflects both ethical considerations and fieldwork realities in the study setting.

Initial contact with the study participants was facilitated by an oncology nurse from TASH who had direct professional contact with patients and their caregivers during routine clinical visits. The corresponding author approached potential participants individually, informed about the purpose of the study, and invited to participate. Interested individuals were referred to the corresponding author for further information and consent procedures. Participants from the two NGOs were contacted through TASH’s networks.

In this study, a total of 41 participants: 33 family caregivers, six individuals diagnosed with cancer aged between 19 and 64 years participated (see Table 1 for demographic characteristics of the study participants), and two religious fathers. Purposive sampling was used to recruit participants based on three inclusion criteria: 1) individuals diagnosed with cancer who were receiving cancer care at TASH during the data collection period; 2) family caregivers who accompanied individuals diagnosed with cancer during their hospital appointments; and 3) at least one month since cancer diagnosis. Individuals who met the criteria and expressed interest in the study were contacted in person and interviewed. In addition, the study included two religious fathers from the Ethiopian Orthodox Christian and Protestant Christian denominations.

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Table 1. Demographic characteristics of study participants, N = 41, 6 patients, 33 caregivers, 2 religious leaders.

https://doi.org/10.1371/journal.pone.0349510.t001

Results

Discussions

This study unveiled how individuals diagnosed with cancer and their family caregivers interpreted illness etiology in Addis Ababa, Ethiopia, and indicated diverse religious interpretations of illness etiology. Participants conceptualized cancer as spiritually mediated, rather than merely biologically determined. They indicated a dynamic interplay between religious worldviews, illness, and interpretation across cancer trajectories. The spiritual framing of illness or cancer offered strategies in meaning-making pathways of participants’ experiences, enabling them to negotiate uncertain experiences or existential concerns, assume moral responsibility, and hope in the context of cancer. The study revealed multiple religious-oriented illness narratives rather than a single coherent illness interpretation. In addition, illness narratives were not fixed; rather, they evolved throughout illness trajectories owing to interactions between personal experiences and interpretations, sociocultural contexts, and exposure to diverse religious meanings. In this respect, the findings extend previous studies [11,19,20,23,41,42] by illustrating the centrality of religion in illness interpretation and the fluid and contested nature of these explanatory models. Similarly, studies have demonstrated the influence of sociocultural contexts in shaping the interpretations of illness etiology [38].

In this study, religious interpretations such as “punishment,” “test of faith,” “divine plan,” and “attack of evil spirits” are understood within established explanatory frameworks of illness meaning-making. It draws on from Kleinman’s [35] explanatory model framework, which views illness interpretations as culturally shaped accounts through which individuals explain illness causation and suffering. It also employed a social constructionist perspective, which reflects that illness narratives are shared religious understandings produced and sustained within communities. These interpretations also correspond to Foster’s [36] personalistic etiologies, which attribute illness to spiritual, moral, or divine agents rather than to solely biological processes. Furthermore, within spiritual coping frameworks, religious interpretations that frame illness as a test or divine purpose are often associated with positive coping, whereas interpretations emphasizing punishment may reflect spiritual distress. These conceptual distinctions guided the analysis of the participants’ narratives in this study.

In line with previous studies in low-resource settings [15,19,30], this study indicates the centrality of religion in shaping health-related meaning making. This also aligns with VanderWeele’s [43] argument that religion functions as a powerful social determinant of health, shaping both meaning-making processes and health-seeking behaviors. According to this study’s participants, understandings illness was based on broader religious interpretations that guided how illness was understood and managed. Religiously grounded interpretive frameworks offered moral, emotional, and spiritual structures through which patients and caregivers made sense of cancer and navigated uncertainty throughout illness trajectories.

The findings revealed that spiritual interpretations were the most dominant frameworks and unveiled participants’ diverse religious explanations for illness as having a spiritual origin, either as divine punishment for sin, a test of faith, a manifestation of God’s sovereign will, or an affliction brought about by evil spirits or the devil. This interpretation aligns with the studies by Vecchiato [44] and Østebø et al. [18], which emphasized the role of supernatural agents in the etiology of illness in Ethiopia. Similar perceptions have been widely documented in low-and middle-income countries (LMICs), particularly in Africa, where illness is often attributed to supernatural beings [15,19,23,45]. Liddell et al. [45] similarly observed that relationships with supernatural beings are often embedded in everyday life and are central to family wellbeing. These interpretations align with Foster’s [36] concept of personalistic etiology, in which illness is understood as resulting from the intentional actions of the divine (e.g., God), spiritual (e.g., evil spirits), or human (e.g., enemies).

The findings further demonstrated another form of personalistic etiology, which links illness to socio-culturally rooted beliefs, particularly the concept of the Evil Eye or Buda. This view attributes physical illness to interpersonal relationships and community dynamics. Rather than being viewed as a divine act, random, or a biological condition, illness was interpreted by embedding it within moral and social relationships in which envy and spiritual vulnerability played crucial roles. In the Ethiopian context, Boylston reflected that Buda attacks might be intentional or inadvertent [46]. While buda are often described as animal spirits, their actions can be traced back to humans, some of whom are believed to be permanently associated with them. Research conducted in Pakistan has indicated parallel belief systems, where envy, particularly toward children, is thought to manifest as the evil eye and cause harm [47]. This perspective thus intersects illness etiology not only to an attack of spiritual agents, but also to social relationships, particularly feelings of envy and resentment within the community.

The study also highlights the social authority of religion in shaping knowledge, beliefs, meanings, and explanations of illness. In this regard, religious teachings emerged as major sources of interpretive frameworks, serving not only theological functions but also collective meaning-making roles that enable patients and caregivers confront existential threats such as cancer [15,19,23,48]. Although access to biomedical services is increasing, spiritually based illness interpretations remain highly influential in Ethiopia [48], indicating how religious epistemologies persist alongside modern medical systems.

The study also demonstrated that religious interpretations varied both between and within Christian and Islamic traditions. Although personal reflections shaped illness interpretations across both faiths, Islamic traditions mostly framed illness as a test of faith rather than as punishment. This finding is line with previous research showing that within Islam, illness is often regarded as a sign of divine love and spiritual refainment [15,42,49,50]. These variations highlight the interaction between formal religious doctrine and individual meaning-making processes.

The findings further demonstrate that illness was understood not only as a physical condition but also as a spiritual experience. In this regard, Kraus and Desmond [51] study shows that individuals facing serious illness actively engage in “lived religion,” whereby spiritual meaning is constructed through everyday practices, personal reflection, and relational experiences rather than through formal doctrine alone. This perspective highlights how illness becomes an embodied and existential condition through which individuals reinterpret their relationship with the divine, reconstruct identity, and navigate uncertainty. From an intersectional framework, religious identity interacted with other social, cultural, and familial contexts to shape illness interpretations [52]. In line with earlier studies [15,53], participants commonly conceptualized cancer as having spiritual origins, reinforcing the central role of faith in illness narratives. From a social constructivist perspective, religious beliefs, teachings, and leaders play a crucial role in shaping how illness is understood and experienced [54]. These actors contribute to the production and circulation of dominant narratives that influence patients’ and caregivers’ perceptions, decisions, and coping strategies.

Religious interpretations shaped not only causal explanations but also emotional and behavioral responses to illness. Participants frequently reported raising existential questions such as “Why me?” and “Why us?” as they sought meaning in suffering and divine justice. Similar patterns have been documented among individuals with chronic illness who use religious frameworks to negotiate uncertainty and distress [21]. These existential struggles were more commonly expressed among Christians, whereas Muslim participants more often framed illness as an accepted test of faith [54].

The findings further demonstrated that symptoms onset often led patients and caregivers into existential questions, usually resulting in emotional problems, such as confusion, anxiety, and frustration. In response, participants frequently engaged in spiritual practices, such as prayer, visiting sacred places to bathe in or drink holy water, consulting with religious leaders, and participating in communal rituals. Previous studies similarly indicated that religious participation serves as a key coping strategy during serious illness such as cancer [11,34,36].

On the other hand, religious interpretations of illness etiology, particularly a test of faith narrative, helped patients and caregivers to accept their suffering as divine’s goodwill and emotional resilience. This form of experience was particularly evident among Muslim participants, for whom illness was commonly understood as a test of faith, which was an expression of divine will. Such illness interpretations usually contributed for positive coping through fostering patience throughout illness pathways and spiritual commitment, enabling individuals to tolerate uncertainty and suffering with a sense of divine purpose [49,50]. As noted by Ashy [49], religious faith provides both patients and caregivers with psychological strength and social support during periods of hardship. This interpretation frequently contributed to positive coping.

Nevertheless, religious grounded illness interpretations and meanings are not fixed. Instead, they change during illness pathways through personal reflection, social relationships, and exposure to multiple knowledge systems. This finding is also aligns with Kraus’s [55] study that showed religious and spiritual beliefs are dynamic, often shifting over time as individuals reinterpret suffering, renegotiate their relationship with the divine, and integrate new forms of knowledge. This perspective resonates with the present findings, where although religious meanings remained central, patients and caregivers frequently combined them with biomedical explanations, reflecting a fluid and negotiated process of meaning-making. While Kraus’s work is situated in a Western context, the present study similarly demonstrates that in Ethiopia, religious meaning-making is dynamic and relational, shaped through ongoing interactions with family, community, and religious institutions, rather than being a static set of beliefs. This finding aligns with recent studies documenting the gradual integration of biomedical explanations into traditionally spiritual illness narratives in Ethiopia [35,51,55]. For example, communities increasingly acknowledge factors such as heredity and environmental exposure while maintaining spiritual interpretations.

Implications of the study

This study has some implications for oncology practices, public health policy frames, and future research in Ethiopia and similar contexts. First, the study illuminated how spiritual frameworks are central in illness interpretations of cancer etiology, making it crucial to integrate religious support in cancer care pathways. Therefore, it is important to work with religious leaders, and use their religious social settings and networks to enhance public health knowledge regarding cancer and provide spiritual counseling. Besides, it is important to have a curriculum on health and religion in training healthcare professionals, as it helps them to understand the co-existence of multiple perspectives on illness etiology and enhance the provision of holistic and patient-centered care. This can enhance trust between patients, caregivers and providers in the cancer care pathways.

Second, the study highlighted how spiritual interpretation of illness etiology is dominant among patients’ and caregivers’ interpretations of illness. This might require acknowledging the contextual influence in cancer prevention efforts and early detection programs. Therefore, it is important to recognize local belief systems and design public health interventions accordingly. Moreover, improving the active community participation and using religious social networks enable to increase cancer awareness, reduce delayed diagnosis, and promote timely medical care.

Third, this study demonstrates the value of an interpretive phenomenological approach in eliciting deeply held narratives that shape illness interpretation and care-seeking behaviors. By foregrounding patients’ and caregivers’ lived experiences, the study provides a nuanced understanding of how meaning is constructed around cancer within a specific sociocultural context.

Building on these insights, future research could extend this work in several directions. First, longitudinal studies exploring illness narratives across different stages of the cancer trajectory would provide deeper insight into how meanings evolve over time and in response to changing illness experiences. Such work could inform the development of more culturally responsive and context-sensitive healthcare services. Second, further research is needed to examine the influence of religious narratives on care-seeking behaviors within broader sociocultural and economic contexts. A more detailed understanding of these dynamics would support the integration of patient and caregiver perspectives into the design of equitable and effective cancer care systems.

Finally, comparative research across diverse sociocultural and healthcare settings would help assess the transferability of these findings. Studies conducted in contexts with similar characteristics,such as strong religious influences and pluralistic healthcare systems as well as in more secular or highly biomedicalized environments, could clarify which aspects of illness meaning-making are context-specific and which may extend across settings. Such work would contribute to a more comprehensive understanding of how explanatory models of illness are negotiated in different contexts.

Limitations of the study

This study has limitations. The findings of this study are grounded in the specific sociocultural and religious context in which participants live, where religious traditions play a central role in shaping understandings of illness, care-seeking practices, and moral interpretations of suffering. While this contextual depth is strength, it may limit the transferability of the findings to settings with different sociocultural environments, religious orientations, or healthcare structures. In particular, the explanatory models identified here may be less applicable in contexts where secular biomedical frameworks predominate or where patterns of healthcare access, literacy, and institutional trust differ substantially. As such, the illness narratives should be understood as contextually situated rather than broadly generalizable.

Second, this study is based on participants’ self-reported accounts. This is sometimes subject to recall bias and social desirability bias. It illustrates how certain illness etiologies, particularly religious ones, are dominant in participants’ narratives. This is due to the strong influence of spiritual illness narratives in shaping meanings attached to illness experiences. Similarly, participants might not pay attention to biomedical perspectives if they perceive them as secondary to religious care.

Third, this study was conducted with cross-sectional research design, which captured participants’ perspectives at a certain point in time. This limits to understand how explanatory models may change during illness trajectory. Therefore, although it has been difficult to follow patients for longer periods, as cancer is a deadly disease, a longitudinal research could offer a better understanding on how illness etiologies shift over time or during illness trajectories. Besides, exploring the perspectives of religious father could offer further understanding on how religious teachings shape illness narratives.

Conclusion

This study unveiled the crucial role religion played in participants’ interpretations of illness and overall experiences in cancer trajectories. Religion offered spiritual frameworks in the meaning-making of illness etiology. The study demonstrated that interpretations of illness etiology were not only seen as a biological condition but also as spiritually interceded. Furthermore, illness interpretations usually shift during illness trajectories, from the perspective of divine punishment to a trial or divine purpose narratives. In this regard, the role of religious teachings, sociocultural contexts of patients and caregivers, and personal reflection were important shaping participants’ interpretations of illness etiology.

Besides, the study indicated how interpretations of illness etiology shaped participants’ emotions, strategies they employed to cope with it, and care-seeking behaviors. On one hand, these religious and spiritual worldviews impacted some to experience emotional turmoil, such as anxiety, confusion, and stress, raising existential questions and struggling to accept their situations, contributing to negative coping. On the other hand, these interpretations shaped others to accept it as meant to the goodness of their fate, fostering patience and spiritual commitment and enabling individuals to tolerate uncertainty and suffering with a sense of divine purpose, contributing to positive coping.

Supporting information

Acknowledgments

The authors would like to thank all study participants for their time, willingness, and openness in sharing their experiences, which were essential for this study. We are also deeply grateful to the religious leaders, healthcare professionals, and individuals who facilitated access and provided guidance during the research process. We acknowledge the support of Tikur Anbessa Specialized Hospital for enabling and facilitating the study. Finally, we extend our appreciation to supervisors and colleagues for their constructive guidance throughout the development of this work. We are also grateful to the reviewers for their insightful comments, which significantly improved the quality of the manuscript.