Amharic Trust in Oncologist Scale Validated Among Ethiopian Cervical Cancer Patients

Trust sits at the heart of every successful doctor-patient relationship, but in oncology it becomes something close to a lifeline. Cancer is complex, treatments are uncertain, and patients depend on their oncologists not only for medical expertise but also for guidance, reassurance, and help with life-altering decisions. Now, a research team in Ethiopia has taken a major step toward measuring that trust in one of the world’s most underserved cancer populations, translating and validating the Trust in Oncologist Scale into Amharic and developing a streamlined five-item version for women with cervical cancer.

The study, published in Cancer Reports, recruited 197 women with confirmed cervical cancer at Tikur Anbessa Specialized Hospital in Addis Ababa, one of the country’s largest tertiary teaching hospitals and a pioneer in radiation therapy. Between February and April 2025, the team administered the full 18-item Amharic version of the Trust in Oncologist Scale, known as the AM-TiOS, along with validated Amharic versions of a shared decision-making questionnaire and a health literacy instrument. The result is the first psychometric validation of this oncology-specific trust measure in Ethiopia’s most widely spoken national language.

The Trust in Oncologist Scale, originally developed in Dutch and later validated in English, is the only instrument specifically designed to measure cancer patients’ trust in their oncologists. It captures four theoretical dimensions of trust: competence, honesty, fidelity, and caring, plus two global items. The Amharic adaptation followed a rigorous multistep process guided by international test-translation guidelines. Two independent bilingual experts conducted forward translations, clinical oncologists reviewed the drafts for conceptual equivalence, and a blinded translator performed a back-translation into English. An expert panel then resolved every discrepancy through systematic discussion, with decisions documented to preserve the tool’s core constructs.

Participants were recruited with unusual care to protect the integrity of the data. An oncology nurse from a different hospital, with no treatment responsibilities at the study site and no clinical relationship with the women, identified eligible patients and introduced the study. Only women who voluntarily expressed interest were contacted by the research team. Inclusion criteria required at least one consultation with an oncologist, one round of chemotherapy, no clinically diagnosed mental disorders, and fluency in Amharic. Interviews took place in a private consultation room, and participants were explicitly assured that their responses would never be shared with their oncologists, minimizing social desirability bias.

The sample reflected the heavy burden of advanced disease. The mean age was 54.44 years, and most women had never attended formal education, were unemployed, and lived on modest incomes. Nearly half were diagnosed with Stage III cervical cancer, and over half reported an Eastern Cooperative Oncology Group performance status of II, meaning they were symptomatic but able to carry out light activity. On average, participants had more than 16 consultations with oncologists, and the mean time since diagnosis was 34 months. These characteristics matter, because low literacy and advanced disease can shape how patients respond to Likert-scale items and how they interpret negatively worded questions.

Statistically, the study delivered a surprise. Confirmatory factor analysis, conducted in STATA-17 with maximum likelihood estimation and Satorra-Bentler corrections for skewed items, showed that neither the original four-factor structure nor a one-factor model of the full 18-item scale fit the data adequately. The four-factor model produced a root mean square error of approximation of 0.128 and a comparative fit index of 0.82, both well below acceptable thresholds, while the one-factor model fared no better. Internal consistency, however, was excellent, with a Cronbach’s alpha of 0.92 and item-scale correlations ranging from 0.30 to 0.82. The researchers attribute the poor structural fit to the sample’s low literacy, the extreme response style common in collectivist cultures, and the strong overlap between the constructs of competence, honesty, caring, and fidelity in this context.

From the full scale, the team developed a short form using pre-specified statistical criteria. Items had to show factor loadings of at least 0.40, item-scale correlations of at least 0.50, inter-item correlations between 0.30 and 0.70, and standard deviations above 0.50. Two five-item solutions emerged, and the researchers selected the combination of items 1, 3, 14, 15, and 18 to preserve content validity, ensuring one item from each construct. This version asks whether the doctor is careful and precise, gives honest information about prospects, listens with care and concern, will do whatever it takes to secure needed care, and whether the patient has complete trust overall. The fit was outstanding: a nonsignificant chi-square, a root mean square error of approximation of 0.066, a comparative fit index of 0.992, and a Cronbach’s alpha of 0.88.

The choice of items also tells a cross-cultural story. Validations in Italy and the Netherlands selected nearly identical item combinations, while the Japanese version prioritized different items. The Ethiopian selection closely parallels the European versions but substitutes item 1, emphasizing precision, over item 2, which focuses on honesty about treatment options. The researchers suggest this reflects contextual variations in how patients construct trust, shaped by sociocultural norms and differing expectations of truth-telling versus technical accuracy, a distinction recently highlighted by a bioethics consortium report on oncology care in low- and middle-income countries.

Convergent validity added further depth. The short-form trust score correlated positively with time since diagnosis and with perceived shared decision-making, consistent with the idea that trust deepens as patients navigate prolonged treatment and that shared decision-making fosters trust by honoring patients’ values. More intriguingly, the trust score correlated negatively with health literacy. The researchers interpret this as evidence of a complex dynamic: patients with limited literacy may rely more heavily on their oncologists, placing greater trust as a coping mechanism when they cannot evaluate medical information themselves, while patients with higher literacy may question clinical decisions, which can temper their trust. This sensitivity to vulnerability and empowerment underscores the scale’s clinical value.

The implications reach beyond measurement. Cervical cancer is a leading cause of cancer-related death among Ethiopian women, and validated trust instruments enable oncologists to quickly identify communication gaps, guide patient-centered interventions, and strengthen shared decision-making in gynecologic oncology services. The short form could serve as a quality indicator for cancer centers and inform training programs aimed at enhancing oncologists’ communication skills. The study does carry limitations: recruitment was limited to a single center, and test-retest reliability could not be established because repeated measurements proved impractical. Still, the findings align with validations across four countries and provide cross-cultural evidence that the Trust in Oncologist Scale is a robust, adaptable tool, now ready to serve Ethiopia’s cervical cancer patients in their own language.

Subject of Research: Validation of the Amharic full and short form of the Trust in Oncologist Scale among cervical cancer patients in Ethiopia.

Article Title: Validation of the Amharic Version of the Full and Short Form of the Trust in Oncologist Scale Among Cervical Cancer Patient

Article References: Tilahun, S. W., Nega, A., Wagaw, L., Hillen, M. A., & Addissie, A. (2026). Validation of the Amharic Version of the Full and Short Form of the Trust in Oncologist Scale Among Cervical Cancer Patient. Cancer Reports, 9(10), Article e70718. https://doi.org/10.1002/cnr2.70718

Image Credits: AI Generated

DOI: 10.1002/cnr2.70718

Keywords: Trust in Oncologist Scale, TiOS, Amharic validation, cervical cancer, Ethiopia, psychometrics, confirmatory factor analysis, oncology, shared decision-making, health literacy, scale adaptation, Tikur Anbessa Specialized Hospital