Beliefs and attitudes about cancer are closely associated with the ways that persons behave when confronted with cancer and related issues.1 Individuals who have negative attitudes towards cancer or believe that a cancer diagnosis is predetermined and invariably fatal are less likely to engage in preventive health behaviors,23 present with cancer-related symptoms in early stage of the disease,45 participate in cancer screenings,67 and receive treatment58 than those with positive attitudes.

More importantly, various demographic and socioeconomic factors can modify or interact with beliefs and influence health-related behaviors. Evidence from multiple studies suggests that positive and negative attitudes toward cancer vary by age, gender, education, income level, and ethnicity or cultural group.3910 In particular, fatalistic or negative attitudes about cancer have been found to be more prevalent in low socioeconomic and ethnic minority groups.451011 The combination of unemployment, less education, and social frustration were more likely to reinforce the fatalistic belief that certain life events are beyond one's control. Research findings also suggest that the negative attitudes among these groups might have led to avoidable delays in being diagnosed with cancer, and ultimately, worsened their survival outcomes.101213 Poor knowledge, perceived barriers to treatment, and low self-efficacy are presumed to mediate these associations.

Korea has experienced rapid industrialization and economic growth in recent decades. The country's fast-paced development has triggered advancements in medical technology and caused widespread changes in lifestyles and patterns of disease occurrence in a short period. However, it simultaneously has brought about a widening socioeconomic gap at the national level. Studies have reported that income inequality in Korea is linked to disparities in cancer-related behavioral risk factors, stage of the disease at diagnosis, and screening and mortality rates.141516 Likewise, in Korea, general attitudes towards cancer may vary by socioeconomic status (SES), although there are few reports on this issue.17

An individual's attitudes towards health risks usually reflect the psychological and cultural aspects of the community that he/she belongs to, as well as factors at the individual level.18 To acquire a better understanding of cancer-related health behaviors in the general population and to guide the development and implementation of public education programs, it is critical to know how people across different socioeconomic groups and demographic characteristics perceive cancer. This exploratory study examined differences in general beliefs and attitudes towards cancer among Koreans who did not have a firsthand experience of cancer and compared the implications of the study's findings to those of western populations.

The ways in which people respond to cancer or a cancer diagnosis is highly dependent on their socioeconomic, cultural, and demographic backgrounds. In particular, how and in which direction those variables modify beliefs and attitudes in a rapidly industrialized country may be distinctive. The present study's results reflect a complicated context of cancer beliefs in Korea that are unlike the findings of studies conducted in Western populations.

Some results of the present study are consistent with those of a UK study that used the same questionnaire.12 The rates of agreement with all positive cancer beliefs were 84.8%–88.5%, which were similar or slightly lower than 88.0%–97.6% in the UK study with older adults. Considering the optimistic attitudes towards cancer, the rates of agreement with negative cancer beliefs were as high as 40.5%–79.9% overall (Table 1); the highest rate of agreement was with the statement that cancer treatment is worse than the cancer itself. Across all the age groups, 35.6%–87.7% agreed with negative beliefs (Table 2), which was roughly 30% higher than the results of the study with the UK adults (8.3%–52.9%).12 The relatively high prevalence of negative attitudes among the Koreans is consistent with the results of another study, which found that 58.4% of Koreans believed that cancer is an untreatable disease, regardless of the recent developments in the medical sciences and the improved survival rates.17 The Western studies conducted with ethnic minorities also found that Asians had more fatalistic and negative beliefs than the other ethnic groups210; however, they used education level as an index for representing SES instead of income level.

The high percentage of both positive and negative attitudes towards cancer can be explained by the dual nature of information processing by humans. That is, the individual's response to cancer is a dual system consisting of an intuitive and immediate sense of death that is linked to negative attitudes, and a subsequent, deliberative, and rational perception that is linked to positive attitudes.2122 The items from the ABC used in the present study might have included these dual aspects of cancer-related information. The items such as “These days, many people with cancer can expect to continue with normal activities and responsibilities,” “Cancer can often be cured,” and “Going to the doctor as quickly as possible after noticing a symptom of cancer could increase the chances of surviving” are related to the beliefs that can be influenced by messages from newspapers, TV, books, magazines, or word of mouth based on statistical facts. On the other hand, the items such as “Most cancer treatment is worse than the cancer itself,” “I would NOT want to know if I have cancer,” and “A cancer diagnosis is a death sentence” would be related to the beliefs formed by direct observation of neighborhoods and can spread by storytelling of cancer survivors or caregivers. Therefore, such negative beliefs can be regarded as natural phenomena induced by anxiety due to negative emotion such as fear.

In Asian populations, these conflicting attitudes can be further attributed to the unique cultural factors. Some qualitative studies using ethnographic interviews have described a more complex belief system and fatalistic view in the Asian culture.9 In a recent study of Chinese patients with cancer, the researchers observed contradictory behavioral and cognitive aspects among the participants. The participants actively engaged in self-care management, but were simultaneously fatalistic, which the researchers depicted as “fatalistic voluntarism”.23 This finding might be related to the preference of Confucian cultures for moderate states of balance between positive and negative events rather than extreme states of balance.24 A dual negative and positive attitude in the present study can be seen in a similar vein.

Nevertheless, the specific finding of a positive association between higher income level and more negative beliefs remains unresolved. Unlike educational level and participation in economic activity, higher income levels were linked to the negative statements that expressed fear of a cancer diagnosis and undergoing cancer treatment. Oddly, this finding contradicts the accumulated results of studies with Western samples which reported that groups with lower SES were more likely to hold fatalistic beliefs or negative attitudes.45 One possible explanation is that higher income groups in Korea perceive health risks differently from those in western communities, where the phenomena were deeply influenced by the country's social and cultural environments. The higher income groups in Korea might have preferred the negative statements because they were more acutely aware of the risks of cancer, acknowledging it as the leading cause of death in Korea. Studies on risk perception in various contexts in Korea have found that the optimism of higher income groups was more realistic, and their risk perception was less distorted and more acute.2526 The finding that the Koreans who lived in the Metropolitan cities had more negative attitudes than those who lived in the provinces can be understood by taking the same perspective, which is also inconsistent with the results of western studies.1727

The present study has some limitations; first, we used the ABC questionnaire for Korean adults aged 20–79 years; however, it was originally developed and demonstrated for older populations at least 50 years of age and its reliability was tested under such conditions. Second, it was not clearly interpreted why the educational level was not significantly associated with the attitudes to cancer in contrast to the income level. In line with our result, Cho et al.17 did not observe any relation between education and the cancer belief. Nevertheless, higher education level was related to lower agreement rates in the negative statements as in the case of income level, although those were not statistically significant. The different effect between educational or income level in the risk perception of cancer would be carefully monitored in the future study.

In summary, the present results imply a complicated context of cancer beliefs in Korea, unlike those shown in the studies of Western populations. The contradictory attitudes toward cancer found in this study can be understood as being related to the dual nature of information processing; however, the negative attitudes of the higher income groups might have been influenced by their struggles to respond to various types of risk, rather than their unrealistic pessimism or fatalism. Likewise, the association between SES, attitudes toward cancer, and health behaviors may not have a single or straightforward direction but it can vary depending on the diversity of the contexts.