Refusal of Hospital-Based Oral Cancer Treatment Driven by Health Beliefs in Pakistan: A Qualitative Study

OBJECTIVES: Hospital-based treatment refusal among oral cancer (OC) patients remains poorly understood. No qualitative studies have examined this phenomenon specifically in OC. This study aimed to explore the beliefs and attitudes underlying treatment refusal among OC patients in Pakistan. METHODS: We conducted a theory-informed qualitative case study guided by the Health Belief Model (HBM) using purposive criterion sampling. Semistructured interviews were conducted with eight OC patients who refused hospital-based treatment, eight family members involved in decision-making, and three oral surgeons. Interviews were audio-recorded, transcribed verbatim, translated into English, and analysed using inductive thematic analysis. Emergent themes were subsequently interpreted in relation to HBM constructs using abductive, theory-informed pattern matching. Methodological rigour was enhanced through data source triangulation and member checking. RESULTS: From the 19 in-depth interviews, we identified seven interconnected themes underlying treatment refusal: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, cues to action, and religious beliefs. Treatment refusal was shaped by fatalistic perceptions of cancer incurability, intense fears of treatment-related harm, and substantial financial, access, and role-related constraints. Strong family influence and trust in traditional and complementary medicine further reinforced these decisions. Religious interpretations functioned bidirectionally, reinforcing acceptance of divine destiny and legitimizing nonbiomedical healing pathways, while in some cases also supporting treatment-seeking through religious doctrine. CONCLUSION: Refusal of hospital-based OC treatment reflects a culturally embedded decision-making process shaped by interacting sociocultural, religious, and structural factors. The findings support the applicability of the HBM in this context and inform the development of culturally responsive, communication-focused interventions in oral oncology. CLINICAL RELEVANCE: Recognition of belief-driven treatment refusal can help clinicians tailor communication, address fears of treatment harm, and engage family and religious influences to improve acceptance of hospital-based OC care.