Effectiveness of Spiritual Intervention toward Coping and Spiritual Well-being on Patients with Gynecological Cancer.

OBJECTIVE: Coping and spiritual well-being are two important things in improving quality of life of patients with gynecological cancer. However, both of them are still neglected. Spiritual interventions are one of the alternatives in improving coping and spiritual well-being of patients with gynecological cancer. Right now, this intervention is not developed yet in Indonesia, especially about the effect on coping and spiritual well-being. This study aims at determining the effectiveness of spiritual intervention toward coping and spiritual well-being on patients with gynecological cancer.
METHODS: This was a quantitative research with quasi-experimental method and used a pre- and posttest with control design. The number of respondents in this study was 108 patients (54 patients in each group) and used consecutive sampling. The intervention group received spiritual intervention and the control group received usual care. Spiritual intervention was provided by certified oncology nurses of spiritual training. The instrument used for measuring coping is Brief COPE Scale and Functional Assessment of Chronic Illness Therapy-Spiritual Therapy (FACIT-Sp-12) for measuring spiritual well-being.
RESULTS: There was a positive change in the average scores of coping (P = 0.001) and spiritual well-being in the intervention group after receiving spiritual intervention (P = 0.006). The result of this research also shows that there was a significant difference in the average score of coping (P = 0.004) and spiritual well-being (P = 0.001) after spiritual intervention between intervention and control groups.
CONCLUSIONS: This study shows that coping and spiritual well-being in the intervention group increased significantly after receiving spiritual intervention. Copyright:

Introduction

Gynecological cancer is one of the causes of morbidity and mortality among women in developing countries.[1] This cancer includes cancer of cervix, ovary, uterus, fallopian tube, vagina, and vulva. There were 528,000 new cases and 266,000 women who died of cervical cancer in the world. Moreover, cervical cancer as one kind of gynecological cancer is a cancer with the highest prevalence in Indonesia. Based on the data from Basic Health Research in 2013, there were 330,000 cases of gynecological cancer in Indonesia.[2]

Patients with gynecological cancer experience various physical and psychological impacts as part of the disease process.[3456] Physical symptom includes pain, fatigue, or other physical changes, and psychological impact is related to maladaptive coping and disruption to spiritual well-being.[789] Individual coping can be conceptualized as an individual ability to accept and deal with situation and/or event that causes emotional distress.[10] This is a dynamic process.[11] Whereas, spiritual well-being is an individual perception related to quality of life.[12131415] Spiritual well-being will affect the acceptance of current illness, motivation in undergoing treatment, decision-making, and quality of life. One of the interventions in overcoming maladaptive coping and disruption to spiritual well-being is spiritual intervention.[8916]

Coping in gynecologic cancer survivors is related to emotional reactions toward stressful situations, such as anxiety, depression, feelings of uncertainty, and fear of disease recurrence.[17] Adaptive coping affects treatment outcomes, whereas maladaptive coping is associated with high patient mortality, anxiety, depressive feeling, and increase of the recurrence risk.[1718] Coping dysfunctional strategies can result in increased distress and dysfunction neurohormonal and immune system; consequently, it can increase cancer growth.[1819]

Furthermore, several studies show that cancer patients with high spiritual well-being enjoy life and have a high value of life (meaning) and peace (peace) even though they feel cancer symptoms such as pain and fatigue.[1520] Other studies also show that spiritual well-being in cancer patients can reduce symptoms of depression and increase life expectation and positive attitudes in their experiences.[1221] Spiritual well-being is related to physical, psychological, and social well-being.[2223] Spiritual well-being also affects the reduction of disease symptoms and the recovery from physical and psychological illness. Biologically, spirituality is related to the optimal function of cardiovascular, neuroendocrine, and immune system. Particularly, spiritual well-being is one source of individual strength in dealing with difficult situations, uncertainties, and serious events.[2123]

Another study has shown that spiritual intervention can improve coping and improve the quality of life of cancer patients.[1624] It is a therapy based on strengthening individual coping through encouragement on aspects of spirituality. Effective coping as the goal of this therapy is expected to reduce anxiety and sadness and even trauma.[25] Spiritual intervention helps patients to use their spirituality strategies; foster good relationship with themselves, family, and friend; improve self-care practice; practice religion; improve positive aspect; listen actively; and foster patients confidence.[2526] This intervention focuses on spiritual well-being to achieve individual satisfaction with their life, acceptance, love, and even forgiveness.[27] Research related to spiritual intervention has not been widely carried out in Indonesia, especially on coping and spiritual well-being of patients with gynecological cancer. Therefore, this study aims at determining the effectiveness of spiritual intervention toward coping and spiritual well-being on patients with gynecological cancer.

Methods

This study was a quantitative research with quasi-experimental method and used a pre- and posttest with control group for research design. This study was conducted to measure coping and spiritual well-being of patients with gynecological cancer before and after providing spiritual intervention. The study was conducted after passing the ethical test and obtaining a research permit from the Faculty of Nursing of University of Indonesia and Dr. Hasan Sadikin Central General Hospital, Bandung.

The population in this study were all gynecological cancer patients with inpatient services at RSUP Dr. Hasan Sadikin Bandung (Hasan Sadikin Hospital). The number of samples was obtained using the average difference test between the two groups, namely intervention and control groups. The test result suggested that this study needed 54 respondents in each group. The samples were chosen using consecutive sampling technique by taking all research patients who met the criteria as many as the number of samples needed.

There are five inclusion criteria in this sample as follows: (1) patients are in a compos mentis state; (2) they are over 18 years old; (3) they are inpatients in the gynecological cancer treatment unit at RSUP Dr. Hasan Sadikin Bandung; (4) they have cancer Stages I, II, III, and IV including gynecological cancer patients with cancer recurrence; and (5) they are not diagnosed with mental disorders. Whereas, there are three exclusion criteria as follows: (1) patients with speech disorders; (2) patients with unstable clinical conditions; and (3) patients with psychiatric disorders diagnosed more than 3 years.

Respondents on the ward were administrated as intervention and control groups. The intervention group received a spiritual intervention given by oncology nurses with the spiritual guidance certification of Hasan Sadikin Hospital, whereas the control group received common treatment (care as usual). The control group also receive a leaflet related to spiritual intervention after the posttest. Spiritual intervention was carried out within four intervention sessions for 2 weeks, and then, posttest data collection was carried out after the following 2 weeks. Intervention session includes introduction and relaxation, control, identity and relationship, and prayer therapy. Each session took 60–90 min. Introduction and relaxation session is a discussion session with patients about conflicts within themselves and their current feelings related to their illness. This session also facilitates positive feelings and thoughts related to their cancer experiences. In this session, patients are taught relaxation techniques and advised to repeat them every day. The relaxation techniques consist of breathing deeply and listening to verses from the scripture.

The control session focuses on discussion with patients regarding two focus controls, namely, things within self-control and those outside of self-control (cannot be controlled by humans such as God's decrees). This session also focuses on the role of God in conflict resolution of life. Then, in the identity session, the patients expressed their grieving experienced related to their cancer condition. The relationship and prayer therapy session focuses on discussing three types of relationships: the relationship between the respondents and themselves, the relationship between the respondent and other people (various parties in various environments), and the relationship between the respondent and God. The patients were also asked to discuss their closeness with God through religious practices in this session.

The instrument used for measuring coping is Brief COPE and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) for measuring spiritual well-being. Validity and reliability tests have also been conducted for the Brief COPE questionnaire by Rosyani (2012) with a validity value of 0.593–0.807 and a Cronbach's alpha value of 0.843. Validity and reliability tests for FACIT-Sp-12 questionnaire in Indonesian language (Bahasa) have been conducted with a validity value of r = 0.503–0.876 and a reliability value of 0.768.

Results

The characteristics of respondents in this study are presented in Table 1. Table 1 shows that the average age of respondents in the control group was lower than in the intervention group. Besides, the average length of time diagnosed with cancer in the control group had difference of 3 months compared to the intervention group. Majority of the respondents in the control group had high school diploma education level (74%), whereas most of the respondents in the intervention group had primary education level (44.4%). Furthermore, most of the respondents in the control group worked as a private employee (42.6%), whereas most of the respondents in the intervention group worked as a laborer (72.2%). In addition, highest cancer stage of respondents in the control group was Stage I (37.0%), whereas the highest cancer stage of respondents in the intervention group was Stage III (44.4%).

Table 1

Characteristics of respondents

Variable	Mean
	Intervention group	Control group
Age (years)	47.17	44.35
Length of time diagnosed	13.94	17.02
Number of children	2.13	2.48
Education, n (%)
Primary	9 (16.7)	24 (44.4)
High school diploma	40 (74.1)	21 (38.9)
College	5 (9.3)	9 (16.7)
Occupation, n (%)
Housewife	0 (0.0)	1 (1.9)
Laborer	17 (31.5)	39 (72.2)
Private employee	23 (42.6)	2 (3.7)
Entrepreneurial employee	1 (1.9)	6 (11.1)
Government employees	7 (13.0)	5 (9.3)
Others	6 (11.1)	1 (1.9)
Cancer stage, n (%)
Stage I	20 (37.0)	12 (22.2)
Stage II	12 (22.2)	16 (29.6)
Stage III	18 (33.3)	24 (44.4)
Stage IV	4 (7.4)	2 (3.7)
Total, n (%)	54 (100.0)	54 (100.0)

The results of this study identified change of score in coping and spiritual well-being after receiving spiritual intervention and difference of score between intervention and control groups. Table 2 shows that there was a decrease of 0.39 points for coping aspect including subscale of problem-focused coping, and there was a significant difference in posttest (P < 0.05). The subscale of emotion-focused coping also decreased by 0.74 points and there was a significant difference between pretest and posttest. For aspect of spiritual well-being, there was an increase in the average score of 0.42 points for subscale of meaning, 1.52 points for subscale of faith, and 0.83 points for subscale of peace. The three subscales showed that there was a significant difference between pretest and posttest.

Table 2

Score of coping and spiritual well-being in the control and intervention groups (n=54)

Variable	n	Mean	SD	P
Control group
Coping
Problem-focused coping
Pretest	54	25.55	3.85	0.397
Posttest	54	24.92	3.72
Emotion-focused coping
Pretest	54	43.92	3.03	0.283
Posttest	54	42.62	3.37
Spiritual well-being
Meaning
Pretest	54	7.09	1.23	0.351
Posttest	54	7.17	1.24
Faith
Pretest	54	6.59	1.35	0.301
Posttest	54	6.68	1.27
Peace
Pretest	54	7.24	2.75	0.244
Posttest	54	6.96	2.57
Intervention group
Coping
Problem-focused coping
Pretest	54	26.96	4.65	0.013
Posttest	54	27.35	4.25
Emotion-focused coping
Pretest	54	43.46	6.31	0.001*
Posttest	54	44.20	5.44
Spiritual well-being
Meaning
Pretest	54	10.00	2.08	0.031*
Posttest	54	10.42	1.85
Faith
Pretest	54	8.46	2.92	0.036*
Posttest	54	9.98	4.38
Peace
Pretest	54	13.26	3.44	0.006*
Posttest	54	14.09	2.74

SD: Standard deviation. * Statistically significant (P<0.05)

The results of statistical analysis presented in Table 3 showed that a difference in coping score between control and intervention groups was 6.57 after receiving spiritual intervention. It is believed that 95% of difference in coping score between two groups ranged from 1.57 to 8.14. It means that there was a significant difference in coping score in both the groups (P < 0.05). Whereas, different scores of spiritual well-being in the control and intervention groups was 4.71. It is believed that 95% of difference in spiritual well-being score between the two groups ranged from 11.80 to 15.57. It also means that there was a significant difference in spiritual well-being score in both the groups (P < 0.05).

Table 3

Coping and spiritual well-being score in the intervention and control groups after receiving spiritual intervention (n=108)

Variable	Mean	SD	P	95%CI
Coping
Control	72.61	7.02	0.004*	1.57-8.14
Intervention	77.46	9.94
Problem-focused coping
Control	70.21	6.92	0.012*
Intervention	78.46	7.77
Emotion-focused coping
Control	63.35	7.01	0.033*
Intervention	77.31	9.92
Spiritual well-being
Control	20.81	3.87	0.001*	11.80-15.57
Intervention	34.50	5.79
Meaning
Control	7.17	1.24	0.001*
Intervention	10.42	1.85
Faith
Control	6.68	1.27	0.001*
Intervention	9.98	4.38
Peace
Control	6.96	2.57	0.001*
Intervention	14.09	2.74

SD: Standard deviation, CI: Confidence interval. *Statistically significant (P<0.05)

Discussion

This study shows that the average score of intervention group was higher than the control group with a difference of 1.48 points before receiving intervention. After taking intervention, the average score of intervention group increased. This finding is in line with Ghahari et al., which showed that there was an increase in the average score for coping in the intervention group.[7] A research by Torabi et al. also showed that there was an increase in the average score of coping after receiving spiritual intervention.[28]

The results of this study indicate that there was no significant change between pretest and posttest scores for both subscales of problem-focused coping and emotion-focused coping in the control group. Whereas, there was a significant change between pretest and posttest scores for both subscales of problem-focused coping and emotion-focused coping in the intervention group. Problem-focused coping is self-coping which includes cognitive and behavioral abilities as an effort to deal with stressor, whereas emotion-focused coping is self-coping which includes cognitive and behavioral abilities as an effort to reduce and control emotional stress experienced.[28]

This finding is also in accordance with a research by Torabi et al., which showed that there was a significant difference between pretest and posttest scores for both subscales of problem-focused coping and emotion-focused coping after receiving spiritual intervention.[28] Furthermore, this study also shows that there was no significant difference in coping score between intervention and control groups before receiving spiritual intervention. After receiving intervention, there was a significant difference in coping score for both subscales of problem-focused coping and emotion-focused coping between intervention and control groups. This finding is in line with a study by Torabi et al., which stated that there was a significant difference in coping score for intervention group after receiving spiritual intervention. However, this finding is not in accordance with Ghahari et al., which stated that there was a difference between intervention and control groups, but it is not significant. Spiritual intervention in their study increased the frequency of religious rituals, such as increasing frequency of reading scripture, remembering God, and practicing other religious rituals.[729]

This study showed an increase in the average score of coping in the intervention group after receiving intervention. This finding is supported by a review study, showing that spiritual intervention as part of care for cancer patients can improve patients' mental condition and it affects the improvement of their physical condition.[30] A treatment for cancer patients with spiritual intervention approach is not only during the period of palliative care but also it can be applied in the beginning of their diagnosis to prevent maladaptive coping. It is to achieve the goal of treatment process optimally.[3031] A meta-analysis of 10 randomized controlled trial studies with 1239 patients showed that spiritual intervention can reduce feeling of despair and improve coping for cancer patients.[24] Coping includes aspect of improving overall quality of life of patients after receiving spiritual intervention.

Intervention of introduction and relaxation interventions in this study facilitate patients in expressing conflicts or problems that they feel, feelings related to illness and their opinion about spirituality in their life. It aims to help patients strengthen emotion-focused coping which will help them regulate emotional reaction from stressors that they experience.[723282932] Likewise, in the third session, identity, patients are asked to express their feelings of grief and positive thinking that they have at this time to help improve their emotion-focused coping.[232832]

Intervention of control in this study facilitates the patients in expressing problems that they currently can control, revealing efforts that they have been made and expressing things that they cannot control. It aims to improve problem-focused coping which helps them in solving problems. Next session is relationship and prayer therapy, in which patients are facilitated to improve their relationship with God and their families and other individuals around them to increase their problem-focused coping and emotional-focused coping.[7232428]

Furthermore, this study also showed that in the intervention group, the average change in coping scores on the problem-focused coping subscale was higher than the average emotion-focused coping subscale score. This is in accordance with the research of Torabi et al., which showed that there was an increase in the average problem-focused coping score in cancer patients after receiving spiritual intervention. Spiritual intervention sessions mostly aim at strengthening coping to resolve conflicts and problems in patients such as intervention sessions in the form of controls, relationship intervention sessions, and prayer therapy intervention sessions.[2328] Therefore, there is a higher change in the mean score of the subscale of problem-focused coping in patients after receiving spiritual intervention.

Other aspects in this study show that the average score of intervention group for spiritual well-being was higher than the control group with a difference of 10.79 points before intervention. After intervention, the intervention group experienced an increase in spiritual well-being score of up to 13.69 points. This is in line with Musarezaie et al.'s study, which stated that there was an increase in the average score of spiritual well-being in the intervention group and there was no increase in the average score of spiritual well-being in the control group.[33] Sajadi et al. also stated that there was an increase in spiritual well-being score in the intervention group after receiving spiritual intervention.[9] This study is also in accordance with a study by Zamaniyan et al. and Jafari et al., which showed that there was an increase in the average score of spiritual well-being in the intervention group.[3234]

The result of this study indicates that there was no significant change between pretest and posttest scores in the control group for subscales of meaning, faith, and peace. Whereas, there was a significant change between pretest and posttest scores in the intervention group for subscales of meaning, faith, and peace. This result is in line with a research by Musarezaie et al., which showed that there was a significant change between pretest and posttest scores in the intervention group.[93233] However, this finding differs from Zamaniyan et al., which showed that there was a change between pretest and posttest scores, but it is not significant.[34]

The results of this study showed that there was a significant difference between intervention and control groups before and after spiritual intervention. This is in line with a study by Sajadi et al., which showed that there was a significant difference in spiritual well-being score between intervention and control groups after receiving spiritual intervention.[932] Besides, this study is also in accordance with a research by Musarezaie et al., which stated that there was a significant difference in spiritual well-being score in the intervention group compared to the control group.[33]

When viewed from spiritual intervention session conducted, this study is in accordance with Jafari et al.'s research, whereas in Sajadi et al.'s study, the intervention session included the same session as this research, but it was added with book therapy and strengthening patience sessions. Book therapy session is a session, in which patients are devoted to reading scripture verses and stories in scriptures that increase their hope and meaning of life. Whereas, strengthening patience session is a session to enhance patients' patience and tolerance by appreciating patience that they have now.[9]

The finding of this study is in accordance with many researches. It shows that the whole sessions can improve spiritual well-being including subscales of meaning and faith (including subscale element of spiritual well-being) and subscales of peace (including subscale element of emotional well-being).[93235] Spiritual intervention in this study can increase subscales of meaning and faith by facilitating patients to reevaluate their life goals, priorities, and sources of life for themselves. In addition, spiritual intervention can improve peace by facilitating patients to be able to express their fears and things they think; facilitate their feelings and emotions; and strengthen their patience, tolerance, and peace. This result is supported by the findings of previous research.[92332]

This study shows that the intervention group increased the average spiritual well-being score on the faith subscale higher than the mean score on the subscale of meaning and peace. This is different from the study by Sajadi et al., namely, an increase in the average score of spiritual well-being in the intervention group, especially in the peace subscale when compared to the other two subscales.[9] Sajadi et al. emphasized the strengthening patience intervention session, so that the peace subscale increased higher than the other two subscales. In this study, there were no special intervention sessions on strengthening patience; this probably led to an increase in the mean score, especially in the faith subscale.[9]

Conclusion

This study found the coping in intervention group increased after receiving spiritual intervention. Intervention of introduction and relaxation and identity can improve emotion-focused coping. Intervention of control and relationship and prayer therapy can increase problem-focused coping. Furthermore, for aspects of spiritual well-being, intervention group showed an increase in all aspects of spiritual well-being. The whole spiritual intervention including introduction and relaxation, identity, control, and relationship and prayer therapy enhances spiritual well-being in both subscales of meaning and faith (including subscale of spiritual well-being) and subscale of peace (emotional well-being). The result of this study proves that spiritual intervention is effective in increasing coping and spiritual well-being in patients with gynecological cancer.

This study did not use self-report because most respondents are elderly and have difficulty to write self-reports. The existence of a self-report that contains a record of the frequency of spiritual interventions carried out independently by the respondent as well as a record of the feelings of respondents after independently carrying out spiritual interventions can be a source of data to explore deeper information. Furthermore, the number of samples in this study was 108 patients who were treated in a referral hospital in Bandung and all respondents were Muslim. If viewed from this, the sample variation and location of the study is still limited, so that the generalization aspect is not optimal.

Further research can include field notes or self-reports from each respondent in the intervention group in order to get more adding data. Besides, research with qualitative designs can be developed related to this topic to get more accurate result. In addition, further research can also add the number of samples in the term of study sites and characteristics of respondents.

Financial support and sponsorship

This work is supported by HIBAH PITTA 2019 funded by DRPM Universitas Indonesia (Grant No. NKB-0504/UN2.R3.1/HKP.05.00/2019).

Conflicts of interest

There are no conflicts of interest.