Religious Rituals Performed by Muslim Palliative Caregivers in Turkey During the Grieving Process: An Exploratory Study.

This study identifies the religious and cultural mourning rituals used by family members who provided care for palliative care patients. The study was conducted between January and February 2021. The research population was composed of family and community caregivers for patients in a palliative care unit at a hospital. The sample size was 245 people. An examination of the food rituals of caregivers during the mourning period showed that 47.3% thought it was appropriate to cook at the deceased patient's residence for 7 days during the mourning period, 59.6% read Mawleed (prayer ritual) on the 3rd day after death and 56.3% offered halwa (food ritual) on the 3rd day. An examination of the religious rituals of the caregivers during the mourning period revealed that 97.6% prayed on the first day, 59.6% recited prayers for the lost one on the first 'Eid after a death, and 83.3% read the Qur'an on the anniversary of the death. The study revealed that the majority of caregivers carried out religious and cultural rituals.

Introduction

Providing care to patients in palliative care can be a long and challenging experience for family and community members. Studies have shown that caregivers have an increased incidence of infectious diseases, depression, anxiety, and burnout syndromes (Zarıt, 2004; Martinson, 2002). In addition, caregivers reported health problems such as long-term fatigue, changes in body mass, deterioration in sleep quality, fibromyalgia, and focusing problems are also experienced (Kasuya et al., 2000; İnci & Erdem, 2006).

Some changes occur in the lives of the relatives of the deceased person in cases of death-related losses and uncertain losses. In the case of death, there is a formal verification of the certainty of the loss, whereas in the case of an indefinite loss, no official verification of the certainty of the loss can be made. For this reason, it is more difficult for those who have experienced indefinite loss to accept the change in their lives than for those who have experienced loss due to death (Boss & Yeats, 2014). Palliative patients may experience addiction to medication, memory loss, and chronic mental or physical disorders that impair consciousness and emotional expression. In such disorders, the patient can change so much to become inaccessible emotionally to family that there is an ambiguity for them between existence and non-existence. This uncertainty creates a unique type of loss, ambiguous loss, that has both psychological and physical qualities.

This grief can cause emotional confusion or feelings such as guilt and loneliness. It can be quite difficult to realize the loss, and the mourning experienced becomes constant (Boss & Yeats, 2014).

Expectation of the approaching death yet the presence of the family member prevents the full understanding of the loss, as well as coping with the process after the loss, and imprisons people in a frozen mourning process (Boss, 2018). Losses experienced during the caregiving process cause caregivers to grieve and mourn. This grief can negatively affect the mood, health, and social life of the caregiver.

In many cultures, grieving is an accepted process, but mourners are expected to overcome bereavement and resume normal life. However, this is difficult for uncertain losses because in an uncertain loss, the loss cannot be officially accepted. This makes it difficult to accept the loss and the changes in family roles due to the loss (Boss, 2004).

Mourning the loss of a patient for the caregiver begins when the patient is physically present. The mourning process of caregivers can last longer than that of other palliative caregivers. For this reason, it is thought that applying religious rituals during a long mourning process will improve the physiological and spiritual well-being of caregivers. In light of this information, it is thought that the religious rituals performed by palliative patient caregivers will have an important place in the determination of the religious rituals applied during their mourning process, in the creation of the content and scope of the care to be given to these caregivers by the health personnel. For this reason, determining the religious rituals that Muslim palliative patient caregivers practice will shed light on the care to be applied by health personnel.

Aim

This study attempts to identify the religious and cultural rituals of caregivers for palliative care patients in the mourning period.

Method

Research Type

This research was conducted within the descriptive tradition.

Research Time and Setting

This study was conducted in a hospital in a city center between January and February 2021.

Research Population and Sample

The research population of the study consisted of those who gave home care to the patients in a Palliative care center of a Training and Research Hospital for at least 6 months. The sample comprised the family members who provided care for patients hospitalized in the palliative care center. The sample size was 245 people; this number was determined by convenience sampling with an unknown population method and power analysis at the error level of 0.05 and at the influence level of 0.25, and the representativeness was at 0.95 of the universe. The sample group was chosen from the population with the convenience sampling method.

Data Collection Tools

Questionnaire Form

The study utilized a questionnaire that included 17 questions about the socio-demographic characteristics of the caregivers and patients and 13 questions about both their religious and cultural rituals during the mourning period. Questions regarding the rituals were generated from the literature (Okan, 2019; Ahluwalia & Mohabir, 2017; Düzgün et al., 2016; Ahaddour et al., 2020; Kuijt, 2020; Özel & Özkan, 2020) and a Google Scholar search using “religious and cultural practices in the mourning period in Turkey.”

Data Collection

A questionnaire form prepared by the author was used to collect the data. The data were collected through the answers received by the authors during in-person interviews with the caregivers. Completing the questionnaire took an average of 10–15 min.

Data Analysis

The SPSS program was used to analyze the data. Percentages, standard deviations, and averages were used in the data analysis.

Ethical Principles

Ethical approval was obtained from Inonu University Health Sciences Non-Interventional Clinical Research Ethics Committee for the study (Approval No: 2021-1784), and legal permission to conduct the study was obtained from the institutions. Before the study, the purpose of the study was explained to the individuals, and verbal consent was obtained from the participants.

Results

This section presents the study findings on the religious and cultural practices of caregivers for palliative care patients during the mourning period.

Overall, 92.7% participants considered first day after death an important day; 62% said this for the 3rd day, 44.9% for the 7th day, 42.4% for the 40th, 6.1% for the 52nd day, 40.8% for the first ‘Eid after the death, and 39.2% for the anniversary of the death (Table 1).

Table 1

Descriptive characteristics of caregivers (n = 245)

Descriptive characteristics	n	%
Gender
Female	154	62.9
Male	91	37.1
Marital status
Married	183	74.7
Single	49	20.0
Divorced	13	5.3
The caregiver's presence of the child
Yes	189	77.1
No	56	22.9
Education level
Illiterate	19	7.8
Literate	15	6.1
Primary education	87	35.5
High school	92	37.6
University	32	13.1
Employment status of the caregiver
Working	79	32.2
Not working	166	67.8
Perceived income level of the caregiver
Good	30	12.2
Middle	182	74.3
Bad	33	13.5
The degree of kinship with the patient being cared for
Daughter	65	26.5
Partner	36	14.7
Son	35	14.3
Brother	26	10.6
Caregiver	20	8.2
His grandson	15	6.1
Mother	10	4.1
Other	38	15.2
Descriptive characteristics of the patient
The sex of the patient
Woman	128	52.2
Male	117	47.8
Education level of the patient
Illiterate	85	34.7
Literate	31	12.7
Primary education	78	31.8
High school	38	15.5
University	13	5.3
The patient's diagnosis
Cancer	59	22.5
Alzheimer's	47	19.2
Traffic accident	33	13.5
Stroke	26	10.6
Cerebral hemorrhage	12	4.9
Nutritional disorder	12	4.9
Other	56	24.4
X±SD
Age of the caregiver	45.51±13.76
The number of dependents who are	1.90±1.65
Number of people in the family	3.93±1.53
Care time (days)	13.90±9.65
Age of the patient	63.73±19.37
Number of children of the caregiver	3.07±1.85

When asked about the activities of family caregivers after the death of a palliative patient, 38.4% said that they were talking about their lost relative, 69.4% visited the cemetery, and 26.1% cooked the deceased person’s favorite food or sang their favorite song and 26.1% stated that they had sung a lament for the dead.

A total of 21.6% of the caregivers stated that they visited the grave of their lost loved ones for 7 days following the death, 5.7% indicated that the practices during the mourning period differed according to the gender of the deceased, and 42.4% noted that the age of the lost one influenced the process (Table 2).

Table 2

Distribution of caregivers by their perception of the important days in the mourning period (n = 245)

Important days perception status	N	%
First day
Yes	227	92.7
No	18	7.3
3. days
Yes	152	62.0
No	93	38.0
7. days
Yes	110	44.9
No	135	55.1
40 days
Yes	104	42.4
No	141	57.6
52 days
Yes	15	6.1
No	230	93.9
First feast
Yes	100	40.8
No	145	59.2
1st Anniversary
Yes	96	39.2
No	149	60.8

The food rituals practiced by caregivers during the mourning period showed that 47.3% thought it was appropriate to cook at the deceased person’s residence for 7 days during the mourning period and 59.6% supported reading Mawleed on the 3rd day. Participants stated that on the third, seventh, fortieth, and fiftieth days after the death, and on the anniversary of the death they served tea or bitter coffee instead of sweets such as halwa and sugar for the first ‘Eid after the burial (56.3%, 44.9%, 44.9%, 25.3%, 42.9%, and 25.7%, respectively). In addition, as a religious ritual, family caregivers said that on the fortieth day and anniversary of the funeral (26.1% and 67.8%, respectively), the person organizing the funeral should cook and distribute it to the poor and needy.

The participants noted the religious rituals used was reading the Qur'an and pray on the first day of the mourning process and on the seventh, fortieth, fifty-second days after the death as well as the anniversary of the death (97.6%, 80%, 85.3%, 64.5%, 83.3%, respectively). In addition, 59.6% of caregivers also stated that they read the Qur’an on the first holiday after burial (Table 3).

Table 3

Rituals performed for a while after a caregiver’s relative dies (n = 245)

Features	n	%
Talking about the lost relative
Yes	94	38.4
No	151	61.6
Cemetery visits
Yes	170	69.4
No	75	30.6
Doing the things that the deceased liked (cooking, singing, etc.)
Yes	64	26.1
No	181	73.9
Lament the dead
Yes	82	26.1
No	163	73.9
Going to the grave before sunrise for 7 days and ending the mourning period in funeral-residence after 7 days
Yes	53	21.6
No	192	78.4
The practices in the mourning period differ according to the gender of the deceased
Yes	14	5.7
No	231	94.3
The practices in the mourning period differ according to the age of the deceased
Yes	104	42.4
No	141	57.6

The motivations for caregivers’ activities were: 70.6% stated that they would be uncomfortable if they did no, 38.4% asserted that the people around them would be upset/angry, 33.5% attributed participation to feeling social pressure, 68.6% indicated that their religion dictated it, and 85.7% noted the importance of honoring their lost loved ones (Table 4).

Table 4

Religious and cultural rituals during the mourning period (n = 245)

Features	n	%
Food rituals in the mourning period
7 days of cooking in the funeral-residence during the mourning period
Yes	116	47.3
No	129	52.7
Reading the Mawleed on the third day of the mourning period
Yes	146	59.6
No	99	40.4
Offering halwa to guests on the third day of the mourning period
Yes	138	56.3
No	107	43.7
Offering dessert (halwa, biscuit, candy) on the seventh day after the burial
Yes	110	44.9
No	135	55.1
Offering halwa on the 40th day after the burial
Yes	110	44.9
No	135	55.1
The funeral-residence owner cooks and offers food on the 40th day after the burial
Yes	154	26.1
No	91	73.9
Offering halwa on fifty-second days after the burial
Yes	62	25.3
No	183	74.7
Serving tea or bitter coffee instead of sweets and sugar for the first ‘Eid after the burial
Yes	63	25.7
No	182	74.3
Offering halwa on the anniversary of the burial
Yes	105	42.9
No	140	57.1
The funeral-residence owner cooks and offers food on the burial day anniversary
Yes	166	67.8
No	79	32.2
Religious rituals in the mourning period
Praying on the first day of the mourning period
Yes	239	97.6
No	6	2.4
Reciting the Qur’an on the 7th day of the mourning period
Yes	196	80.0
No	49	20.0
Reciting the Qur’an on the 40th day of the mourning period
Yes	209	85.3
No	36	14.7
Reciting the Qur’an on the 52nd day of the mourning period
Yes	158	64.5
No	87	35.5
Praying on the first ‘Eid after the burial
Yes	146	59.6
No	99	40.4
Reading the Qur’an on the death anniversary
Yes	204	83.3
No	41	16.7

Discussion

Important Days in the Grieving Process

Overall, 92.7% of the caregivers in the study considered the first day of the mourning period to be an important day; 62% stated that this was true for the 3rd day, 44.9% for the 7th day, 42.4% for the 40th, and 6.1% for 52nd day. Also, 40.8% said this about the first ‘Eid after the death, and 39.2% said this about the anniversary of the death (Table 2).

The religion of Islam orders that the mourning period should not be more than 3 days. The reason for this is related to the fact that death is a command of Allah. According to the religion of Islam, the practices or rituals that will be beneficial to shorten the mourning process are praying and providing charity for the deceased relative of the person in the mourning process (Presidency of Religious Affairs, 2021).

Cultural Rituals in the Grieving Process

The study identified the activities that caregivers want to do after their loved ones died included that talking about the deceased person, visiting his grave, making the food that the deceased loved, singing, lamenting to the deceased. It was evident that the practices in the grieving process vary according to the gender and age of the deceased person (Table 3). In a study conducted in Turkey; cemetery attendance on the anniversaries of the death and on ‘Eid, was especially important for those who die at a young age (Dikmen, 2015). Another study conducted in Turkey discovered that the age and social status of the deceased individuals influenced the mourning period. If the deceased was a young person or someone with high social status, the mourning period may be longer than for an older person or a person with lower social standing (Keskin, 2003).

For Muslims, doing something for the deceased identified in the study including reading the Qur'an, distributing food, giving alms, visiting the grave, will make the mourning process easier and more comfortable by transferring the mourning feelings to other feelings and thoughts (Sayar, 2011).

The religious literature identifies “Condolence houses” being set up for the condolences which last for 3 days. In addition, it is seen that halva or food is distributed to the deceased's relatives for the benefit of the deceased, and Surah Yasin is recited. These behaviors contribute to both fulfilling the responsibility of burial to the deceased and the caregiver's acceptance of death, shortening the mourning process and making it lighter (Kara, 2017).

Ahaddour et al. (2020) examined the mourning and remembrance practices of Muslim women, and almost all participants stated that meals were usually provided during the mourning visits and that it was important to offer condolences to the mourning family within the first 3 days. The overwhelming majority of the participants also stated that prayers and merciful blessings for those grieving and for the deceased were important remembrance practices (Ahaddour et al., 2020)

Since all these rituals are accepted as a necessity in Islam, the caregiver will give the peace of fulfilling his last duty toward the deceased. Thus, caregivers will have a more peaceful mourning period.

Meal Rituals During the Grieving Process

The food-oriented rituals of the participants in this study revealed that they cook food at the residence of the deceased for 7 days after the burial and perform rituals such as reciting the Mawleed, offering halwa and sweet foods, and cooking and offering food on the third, ninth, and fortieth days after the death and on the anniversary of the death (Table 4).

The funeral feast is a tradition inherited from the ancient Turks. It is a practice focused on moderating suffering and is meant to help mourners cope with the absence of the deceased person in a social sense, including through religious practices. The funeral feast comprises the food that the relatives of the deceased person offer to neighbors and relatives after the funeral, on the fortieth day after the death, or on another agreed-upon day; it is prepared by the funeral organizers in some places and cooked by neighbors and relatives and brought to the funeral home in others (Sağır, 2012). Several studies conducted in Turkey revealed that people did not cook for the first 3 or 7 days in the home of the deceased, and the family’s friends, relatives, and neighbors brought food. Other studies showed that this activity was performed on the 40th, 50th, and 52nd days after the death (Albayrak, 2006; Çelik, 2010; Öncül, 2010; Nas, 2015).

The tradition of offering halwa for the dead involves cooking, offering, and eating halwa to do charity on behalf of the deceased on the first day of the funeral as well as on the seventh, fortieth, and fifty-second days after death. Halwa is made by roasting flour or semolina in oil and sweetening it with sugar. Peanuts, walnuts, and rose water are added and served to visitors and sent to the homes of those who cannot come. The halwa tradition for the dead involves the joint participation of the deceased’s relatives, neighbors, and acquaintances. Thus, these kin and acquaintances fulfill their last duty to the deceased while sharing the pain of the loss (TR Ministry of Culture and Tourism, 2021).

Religious Rituals in the Grieving Process

The religious rituals of the caregivers in our study after the loss are usually performed on the first, third, fortieth, and fifty-second days after the death and on the anniversary of the death; they involve praying, visiting the grave, and reading the Qur’an (Table 4). In Okan et al. (2019), 75.9% of the participants read the Qur’an as a ritual on the first ‘Eid after a death. Lamentation can involve many things, including folk songs sung during ceremonies after a death and reminiscing about one’s memories with the deceased (Artun, 2009: 153). Folk songs with regular or irregular words and melodies that express suffering, sorrow and grief following the loss of a loved one are often referred to as laments in Western Turkey (Uzunoğlu, 2019). There is no doubt that lamentations for the dead are a universal phenomenon. Turks regard lamentation as the starting point of the burial ritual (Şeker, 2019).

A study conducted with university students in Turkey showed that thinking that the deceased is at peace after a close loss, remembering him constantly, visiting his grave and talking about the deceased with love indicates coping with the loss in a positive way (Kara, 2017).

In the study on the death of family members who care for terminally ill individuals at home or in the palliative care unit; caregivers; have been found to have many different images, all of which are related to death. Families whose patients receive palliative care; it has been observed that patients now think that their death is approaching and therefore they enter the mourning process before their death (Lessard et al., 2016). The importance of what was done after the deceased for his relatives; it is the feeling that they have done something instead of feeling deeply sorry for the deceased. According to the religion of Islam, the bereaved family is visited for 3 days after death to console them, to advise them to be patient, to pray for the deceased and to meet the other needs of the survivors. Many of the cultural practices of mourning are still ongoing rituals from pre-Islamic Turkish beliefs and traditions of different ethnic origins. According to Islamic belief, death is not the end, but rather the beginning of a new and eternal life. It is believed to live after death. Therefore, the mourning period is not extended. In the Islamic belief, it is emphasized not to overdo it during the mourning process (Presidency of Religious Affairs, 2021).

The Motivations for Caregivers’ Activities

The motivations for caregivers’ activities were: they would be uncomfortable if they did no asserted that the people around them would be upset/angry, attributed participation to feeling social pressure, indicated that their religion dictated it, and noted the importance of honoring their lost loved ones (Table 4).

Boss stated that to deal with uncertain loss, it is necessary to work with a tolerance for uncertainty. The awareness that survivors gain about how they make sense of uncertain situations can help them make the necessary decisions for daily life and manage the grieving process (Boss, 2004).

On the one hand, palliative caregivers get tired of the negative consequences of their struggle with multiple stressors (despair, hopelessness, anxiety, depression, burden of care, family conflict, etc.) that they experience during caregiving. On the other hand, they are faced with emotional (shock, denial, anger, etc.), physical and behavioral reactions during the grieving process. Despite all this, caregivers have responsibilities to fulfill the mourning rituals according to the traditions and expectations of the society, religion, culture. In this direction, it is necessary to prepare the caregivers for the process with open, consistent and safe communication between the health personnel and their family members and to reduce the severity of the grief of the caregivers. Nurses should try to clarify ambiguous emotions and roles, and to raise awareness about how uncertainty is interpreted in their interviews with caregivers. In addition, it should help caregivers to relax by performing their religious and spiritual rituals during the grieving process, to provide social support, to develop coping methods such as anger control, anxiety, and stress.

Limitations

This study had some limitations. This study involved surveying caregivers in a hospital in Malatya. Individuals living in other parts of the country may have given different answers. Asking the caregivers of palliative patients about the bereavement period also presents emotionally draining challenges.

Data were collected from 245 people due to the COVID-19 Pandemic. Caregivers were randomly selected from volunteers for fear of COVID-19. Therefore, this situation should be taken into account in the evaluation and interpretation of the results. In this study, no data about COVID-19 were collected.

Conclusion

The participants in this study indicated that they used both religious and cultural practices in their mourning rituals. Of the participating caregivers, 92.7% identified the first day of the bereavement period as important. Following the death of their relative, the activities that the caregivers wanted to participate in were to visit the grave and talk about the deceased.

The cultural rituals that the participants identified were cooking in the deceased’s home and offering halva and dessert to neighbors. They also recited mawlids. In addition to the cultural practices, religious rituals were observed by the caregivers on the first, third, fortieth, and fifty-second days after the death and on the anniversary of death. The rituals identified by the participants were praying, visiting graves, and reading the Qur'an.

A number of these rituals can be rigorous, and it is thought that participation in these have an emotional, physical, and spiritual cost to the caregivers. Healthcare personnel can support caregivers to reduce the level of attrition during these intense rituals by informing and training caregivers about the need to practice self-care and be mindful of their own health when performing rituals and of the emotional and spiritual cost of anticipating grieving while their relative is receiving palliative care.