Empirical Articles

The Spiritual Beliefs of Cancer Survivors: A Thematic Analysis

As Crenças Espirituais dos Sobreviventes de Câncer: Uma Análise Temática

Devaki Nandan Sharmaa, Gyanesh Kumar Tiwari*a, Pramod Kumar Raia

Abstract

Aim: This study explored the nature of spiritual beliefs and their role in regulating various life outcomes of cancer survivors.

Method: A heterogeneous sample of thirty diagnosed cancer patients with age ranging from 18 to 75 years participated in the study. The study employed a qualitative research design which involved semi-structured interviews and the thematic analysis of the audiotaped contents of these interviews.

Results: The analyses led to five themes regarding the spiritual beliefs of the participants. The identified themes were: “optimistic change towards life”, “fighting spirit towards life”, “enhanced trust in family and friends”, “improved realistic self-perception”, and “positive thinking with future orientations”.

Conclusions: The findings of the study showed that spiritual beliefs represented a complex phenomenon comprising cognitive, affective and behavioural components. Spiritual beliefs also carried many positive outcomes to regain and maintain psychological balance, well-being, quality of life and health. It also facilitated the patients to have strong desires to compensate their losses due to ill health by setting and achieving higher spiritual, social and interpersonal goals by carrying out social services, sacrifice and altruistic deeds.

Keywords: spiritual belief, thematic analysis, health outcome, cancer, cancer survivors

Resumo

Objetivo: Este estudo explora a natureza das crenças espirituais e o seu papel na regulação de vários resultados de vida de sobreviventes de cancro.

Método: A amostra do estudo foi composta por trinta pacientes diagnosticados com cancro, com idades compreendidas entre 18 e 75 anos. Este estudo de natureza qualitativa utilizou entrevistas semiestruturadas analisadas através de análise temática.

Resultados: Através da análise temática obtiveram-se cinco temas relativamente às crenças espirituais dos participantes. Os temas foram “mudanças otimísticas em relação à vida”, “espírito lutador em relação à vida”, “aumento de confiança nos familiares e amigos”, “melhoria de autoperceção realística”, e “pensamento positivo com orientações futuras”.

Conclusões: Os resultados indicam que as crenças espirituais dos participantes representam um fenómeno complexo que compreende componentes cognitivos, afetivos e comportamentais. As crenças espirituais contribuiram para resultados positivos na recuperação e manutenção do equilíbrio psicológico, bem-estar, qualidade de vida e saúde. Observou-se que os participantes exibiram fortes desejos de compensar as suas perdas, resultantes da falta de saúde, definindo e procurando atingir objetivos espirituais, sociais e interpessoais mais elevados, ao desempenharem ações sociais, de sacrifício e altruísticas.

Palavras-Chave: crença spiritual, análise temática, consequências de saúde, cancro, sobreviventes de cancro

Psychology, Community & Health, 2020, Vol. 8(1), https://doi.org/10.5964/pch.v8i1.290

Received: 2018-04-06. Accepted: 2019-02-15. Published (VoR): 2020-04-03.

Handling Editor: Sara Monteiro, Universidade de Aveiro, Departamento de Educação e Psicologia, Aveiro, Portugal; CINTESIS - Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Porto, Portugal

*Corresponding author at: Department of Psychology, School of Humanities & Social Sciences, Doctor Harisingh Gour Vishwavidyalaya, Sagar, 470003, Madhya Pradesh, India. Phone: +91-8819031611. E-mail: gyaneshpsychology@gmail.com

This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The diagnosis of cancer may badly affect the value system and the assumptive world of the sufferers (Murray Parkes, 1971) and may lead them to face many physiological and psychological ill consequences. Moreover, it may also cause the sufferers to undergo depression and extreme anxiety creating a barrier in the way of their well-being (Cordova, 2008; Luoma & Hakamies-Blomqvist, 2004). Along with these negative changes accompanying physiological and psychological disturbances after the diagnosis, a set of uplifting mechanism also emerges which act as the catalysts for many positive changes in the personality of the sufferers. The researchers have suggested that the Head and Neck cancer patients show increased appreciation of life, self-confidence, sense of self-control and self-awareness, improved interpersonal relationships and spirituality, development of new interests and healthier diets (Thambyrajah, Herold, Altman, & Llewellyn, 2010). The similar positive changes have also been observed in individuals diagnosed with prostate and breast cancers as a result of spirituality (Gotay, Holup, & Muraoka, 2002; Milne, Shaw, & Bull, 2008). The researchers have argued that spirituality may underlie as one of the major forces behind these positive changes in the personality of the persons suffering from cancer (Gotay et al., 2002; Milne et al., 2008; Thambyrajah et al., 2010).

According to the National Cancer Institute (2011), an individual is considered a cancer survivor from the time of diagnosis through the rest of his or her life. The family members, friends and caregivers are part of survivorship as they are influenced strongly by it. Wronski (2015) has elucidated it by suggesting that the cancer survivor and cancer survivorship describe who, what, and when of cancer, and includes the origin, experiences, time, and other impacted people. Thus, the cancer survivorship includes the period after primary treatment, the involvement of family, friends, caregivers, and treatment providers with a focus on the diagnosed individual. In other words, the cancer survivorship is a multifaceted term that includes all aspects of diagnosis, treatment, caregivers and specialists focused to underscore health, symptoms, lifestyle, and well-being of the afflicted person (Wronski, 2015). Based on the understanding of these descriptions, a cancer survivor was operationally defined as a person who has been diagnosed with cancer in any part of his/her body and has been undergoing regular treatment for the last 6 months or more.

Spiritual beliefs represent the cognitive structures centred around the basic comprehension and practice of spirituality having its genesis in cultural roots and practical relevance to the life of individuals. It is also corroborated with pertinent affective and behavioural components. Some researchers have argued that spiritual beliefs reflect divine power and relevant to understand existence, realities of life and the nature of reality (Holland et al., 1998). A spiritual belief represents the values and meanings of an individual that are reflected in his/her behaviours. The term spirituality refers to a process of reformation with the goal to recover the original shape of a man and the image of God (Waaijman, 2002). It represents the subjective experiences, the deepest values and meanings which, in turn, promote personal growth or transformation, usually in a context separate from organized religious institutions (Griffin, 1988; Sheldrake, 2007). Researchers have reported spirituality to be closely associated with mental health, substance abuse, marital functioning, parenting, and coping as well as with a host of indices of human functioning and performance (Cobb, Puchalski, & Rumbold, 2012; Koenig, 2012). In essence, spirituality is closely linked to the physical, mental, emotional, and social aspects of human existence and plays an important role in understanding intrapersonal and interpersonal relations (Snyder & Lopez, 2007). Spiritual beliefs also strengthen interpersonal and social relationships and help to understand the relationship of individuals to nature and environment, help to move towards the best, and prepare them to face the realities of their life (Snyder & Lopez, 2007). Some researchers have also posited that spirituality goes beyond religious affiliations and denotes universal and unique experiences juxtaposed with innate and dynamic energy carrying multiple positive emotional outcomes for the individuals (Snyder & Lopez, 2007). According to Roof (2001), spirituality represents four basic themes namely, a source of values and meaning or purpose beyond the self, understanding, inner awareness, and personal integration. Moreover, inner awareness and personal integration are the basic ingredients of spirituality.

The basic mechanisms through which spirituality has been argued to impact health and other life outcomes involve positive coping styles, locus of control, social support and social networks, physiological mechanisms, and an enhanced relationship with architecture and built environment (Cobb et al., 2012; Koenig, 2012). It has been argued that spirituality helps to achieve optimistic attribution styles by perceiving negative events as externally caused and positive events as internally caused, which, in turn, may facilitate to attain better mental health outcomes and to position the individuals to reframe or reinterpret events that are seen as uncontrollable (Cobb et al., 2012; Koenig, 2012).

The individuals obtain social support from many sources as a result of spiritual arrangements which may act as the mediators between their existing cognitions and mental health (Hill & Pargament, 2003). These social supports are believed to be valuable sources of self-esteem, information and companionship that enable people to successfully cope with their stress and negative life events or exert its own main effects (Cohen & Wills, 1985). According to Loewenthal (1995), these supports may include protecting people from social isolation, providing and strengthening family and social networks, a sense of belonging and self-esteem, and offering spiritual support in times of adversity. Hill and Pargament (2003) argued that members of other social networks may be fluid or transitory, whereas support gathered from a spiritual network can accompany an individual from birth to death.

It is to be argued that religion and religiosity are intertwined with the spiritual system that is multi-dimensional and intricate. Religion is a set of beliefs, practices and rituals, whereas religiosity is the practice of these beliefs and rituals in real life. Practices are associated with festivals and special occasions also which act as a buffer to adversity and failures of life of the Indians. The religion, religiosity and spirituality for the Indians are well-known and are expressed in their behaviours, feelings and perceptions of the realities of life including ill-health conditions.

It has been argued that spirituality refers to the way individuals seek and express meaning and purpose in life, experience their connectedness to the moment, self, others and nature (Puchalski, 2006). Spiritual beliefs have been reported to be closely linked with meaningfulness, harmony with nature, positive emotions, peace, contentment, gratitude and acceptance, a positive state of mind, internal wisdom, creativity, awareness of self, with others and this world, love with life, self-esteem, hope and joy, optimism, values, belief, forgiveness, coping, support and commitment (Beauregard & O’Leary, 2008; Clinebell, 1992; Murray & Zentner, 1979). Likewise, other researchers have identified six dimensions of spirituality namely, an appreciation of nature, creativity, personal development, religious beliefs, social and political, and relationship with people (O’Connor & Chamberlain, 1996). These attributes of spiritual beliefs empower individuals to be a strong regulator of mental and physical health as well as other positive outcomes of life (Thoresen & Harris, 2002; Toussaint, Williams, Musick, & Everson, 2001).

The review of the previous works showed that the study of spiritual beliefs is important for understanding many life outcomes of people including health outcomes. It was observed that previous studies on spiritual belief have been mostly quantitative in nature and based on American and Western samples. Moreover, these studies have reported spiritual beliefs to work well as these involve social support and other benefits that may lead to positive changes in the cancer survivors (Tsuchiya, Horn, & Ingham, 2013). Thus, these findings serve a limited purpose in understanding about the nature, mechanisms and dynamics of the spiritual beliefs of cancer survivors belonging to the Indian socio-cultural milieu, characterized by ancient heritage, having a dissimilar ontology, and with a multitude of spiritual systems. It has been suggested that qualitative research design is suitable to develop a deeper understanding of the nature and attributes of complex constructs like spirituality and spiritual beliefs (Mudgal & Tiwari, 2015, 2017; Sharma, Tiwari, & Rai, 2017).

Thus, it is explicit that spiritual belief may be conceived as the source of origin of many psychological mechanisms that may involve the development of social support, development of positive cognitions and attributions, understanding of relationships with other people, society and nature, understanding of the adaptive demands of life, life goals and positive self. These psychological mechanisms arising out of spiritual beliefs may be assumed to be closely linked with many perceived positive life outcomes. These perceived life outcomes act both as means and end in themselves. For example, having good relationships, positive cognitions and social support are useful to face the other demands of life. In this sense, they signify end in themselves. Moreover, this positivity arising out of the development of spiritual gains may also affect biological and psychological processes that, in turn, may facilitate to understand nature, causes and consequences of chronic diseases like cancer. This discussion makes it apparent that spiritual beliefs may have significant curative, preventive and promotive values for physical and mental health problems. In the backdrop of these arguments and facts, the present study attempted to develop a primary and in-depth understanding of spiritual beliefs of a heterogeneous sample of cancer survivors employing a qualitative research design for collecting, processing and analyzing data collected from semi-structured interviews.

Objectives [TOP]

The following were the major objectives of the present study:

1. To further explore the role of spiritual beliefs on the perceived life outcomes among a heterogeneous sample of cancer survivors, and

2. To develop an understanding of the mechanisms inherent in spiritual beliefs impacting the life of a heterogeneous sample of cancer survivors.

Method [TOP]

The present study followed a qualitative research design which employed semi-structured interviews for data collection. Before the actual data collection, a pilot study was conducted to ascertain the procedural details and to gain first-hand experience.

Participants [TOP]

Thirty cancer patients who have been visiting Bundelkhand Medical College Hospital, Sagar, Madhya Pradesh, India for routine testing and treatments, were selected using purposive sampling. From these, 19 were male cancer survivors with age between 18 to 75 years (M = 51.21, SD = 13.87) and 11 were female survivors with age between 35 to 71 years (M = 47.36, SD = 10.75). Most of the participants belonged to lower-middle-class Hindu families. A set of inclusion and exclusion criteria were employed to recruit the participants in the study. A male or female who had attained the age of 18 years or older and had been diagnosed with cancer in any part of his/her body for the last 6 months or more and had been undergoing regular active treatment, were included in the study. The participants who were suffering from other diseases were excluded from the study. The biographic details of the male and female participants are displayed in Table 1 and Table 2, respectively.

Table 1

The Biographic Details and Clinical Features of the Male (N = 19) Cancer Survivors

S. No. Education Domicile Marital Status Occupation Age Cancer Type Affected body part/s Approx. Duration (months) Codes
1. Graduate Urban Unmarried Part-Time Private Job 28 Lung cancer Lungs 12 P01_28_M
2. Illiterate Rural Married Agriculture 65 Prostate cancer Urethra 36 P02_65_M
3. Graduate Urban Married Government 40 Lung cancer Lung 10 P03_40_M
4. 12th Standard Rural Married Private Job 55 Pharynx cancer Nose /mouth 18 P04_55_M
5. Graduate Urban Married Retired 60 Prostate cancer Urethra 15 P05_60_M
6. Graduate Urban Married Government 50 Pharynx cancer Nose /mouth 10 P06_50_M
7. 8th Standard Rural Married Business 56 Kidney cancer Bladder parts of the kidney 8 P07_56_M
8. Graduate Urban Married Unemployed 33 Lung cancer Lung 12 P08_33_M
9. Illiterate Rural Married Private Job 62 Stomach cancer Oesophagus 18 P09_62_M
10. Graduate Rural Married Agriculture 53 Pharynx cancer Nose /mouth 24 P10_53_M
11. 12th Standard Urban Married Business 68 Stomach cancer Small intestine 28 P11_68_M
12. Postgraduate Urban Unmarried Private Job 48 Lung cancer Lungs 12 P12_48_M
13. Graduate Urban Married Government 52 Bladder cancer Urine 10 P13_52_M
14. Graduate Rural Married Government 49 Mouth cancer Tongue 12 P14_49_M
15. Graduate Urban Married Private Job 37 Mouth cancer Cheeks and tongue 12 P15_37_M
16. Postgraduate Rural Married Business 54 Prostate cancer Urethra 20 P16_54_M
17. Illiterate Rural Married Unemployed 63 Prostate cancer Urethra 24 P17_63_M
18. 8th Standard Urban Married Unemployed 68 Kidney cancer Bladder parts of the kidney 12 P18_68_M
19. 12th Standard Rural Married Agriculture 35 Lung cancer Lungs 15 P19_35_M

Note. The details of cancer survivors belong to those who came under the inclusion criteria. These details were recorded with the help of the caretaking medical practitioners. The age reported by illiterate patients are approximate and based on their informal knowledge.

Table 2

The Biographic Details and Clinical Features of the Female (N = 11) Cancer Survivors

S. No. Education Domicile Marital Status Occupation Age Cancer Type Affected body part/s Approx. Duration (months) Codes
1. Graduate Urban Married Part-Time Private Job 35 Breast cancer Tissues /nodes under the arm 24 P01_35_F
2. Illiterate Rural Married Agriculture 71 Ovarian cancer Ovary 14 P02_71_F
3. Graduate Urban Married Government 55 Ovarian cancer Ovary 18 P03_55_F
4. 12th Standard Rural Married Part-Time Private Job 49 Pharynx cancer Vocal cords 20 P04_49_F
5. Graduate Urban Married Retired 46 Breast cancer Tissues /Lymph nodes 16 P05_46_F
6. Graduate Urban Married Government 38 Breast cancer Tissues /Lymph nodes 18 P06_38_F
7. 8th Standard Rural Married Business 36 Lung cancer Lungs 24 P07_36_F
8. Graduate Urban Married Unemployed 51 Ovarian cancer Ovary 15 P08_51_F
9. 5th Standard Rural Married Private 56 Stomach cancer Small intestine 9 P09_56_F
10. Illiterate Rural Married Agriculture 39 Breast cancer Tissues /Lymph nodes 16 P10_39_F
11. 12th Standard Urban Married Business 45 Breast cancer Tissues /Lymph nodes 18 P11_45_F

Note. The details of cancer survivors belong to those who came under the inclusion criteria. These details were recorded with the help of the caretaking medical practitioners. The age reported by illiterate patients are approximate and based on their informal knowledge.

Instruments [TOP]

Semi-Structured Interview [TOP]

A protocol of a semi-structured interview comprising 12 questions was prepared based on the spiritual experiences, thoughts, and needs of the patients of a pilot study. These questions were open-ended and were selected following the criteria of relevance and significance to the field of spiritual beliefs, and based on the conclusions of some important studies in the field of spirituality (Cobb et al., 2012; Koenig, 2012; Sheldrake, 2007; Snyder & Lopez, 2007). In addition, the researchers were free to add some additional items in interview protocol based on their insights during the process of data collection, their regular touch with the upcoming literature and discussions with the experts of the field. The verbatim contents of the interviews of the participants were audio-recorded.

Data Collection Procedure [TOP]

Pilot Study [TOP]

The proposal was submitted to the competent authority of the Medical College to seek written permission to conduct the study. In the first phase, a pilot study was carried out to finalize the efficacy and functionality of the interview protocol and to ascertain other procedural details of the study. The efficacy of the interviews was ascertained applying the criteria of the relevancy of the contents, the wording of the questions to be asked, styles of putting the questions in a manner to motivate the participants to come up with detailed information about their experiences without negative emotional swing and use of comprehensive native language in the interview as per the requirement of the questions. Initially, 21 questions were prepared on the basis of previous findings on spiritual beliefs of clinical and non-clinical samples and the same were put before the three researchers with the request to express their comments and suggestions. They recommended for removal of five questions from the protocol. Next, a pilot study was conducted with 4 cancer patients, 2 males and 2 females, with age between 25 to 47 years, whose data were not included in the final analysis. After assessing the suitability of the questions in the pilot study, 4 more questions were removed from the interview protocol. A list of initial and final items has been given in Table 3. Considering the suggestions of the experts and the insights of the pilot study, the following questions were finally included in the interview protocol of the study:

Table 3

Initial and Final Items of the Interview

S. No. Initial Items Final Items
1. What types of problems you have faced after the disease was diagnosed? What types of problems you have faced after the disease was diagnosed?
2. Do you believe that having faith in God can relieve you from disease? --
3. What were your experiences of life after the disease was diagnosed? What were your experiences of life after the disease was diagnosed?
4. From where did you learn spiritual beliefs? --
5. How spirituality is related to your life? How spirituality is related to your life?
6. What is the role of your family in the acquisition of your spiritual beliefs? --
7. How does spirituality help to bear sufferings of life? How does spirituality help to bear sufferings of life?
8. Do you believe that your spiritual beliefs will help you in all respect? --
9. Why does a spiritual person feel sorrow? Why does a spiritual person feel sorrow?
10. What were you thinking about when you were diagnosed with the disease? --
11. How could you get out of anxiety or stress after the disease was diagnosed? How could you get out of anxiety or stress after the disease was diagnosed?
12. Do you forgive other people for their wrongdoings? Do you forgive other people for their wrongdoings?
13. How do you enhance your spiritual beliefs? --
14. Does spirituality play a role in understanding the meaning in your life and help you compensate for the losses of the disease? Does spirituality play a role in understanding the meaning in your life and help you compensate for the losses of the disease?
15. To what extent spiritual beliefs are helpful in understanding one’s value of life? --
16. How does spirituality connect you with other people? How does spirituality connect you with other people?
17. What did you do when you face problems in your life before the diagnosis of this disease? --
18. How do you practice spirituality? How do you practice spirituality?
19. Do you get empowered through your spiritual beliefs? --
20. Do you experience pleasure in art and nature? Do you experience pleasure in art and nature?
21. Do you feel positive in your life? Do you feel positive in your life?

Current Study [TOP]

After the interview protocol was finalized, the proposal was put before the Ethical Committee of the Department of Psychology, School of Humanities & Social Sciences, Doctor Harisingh Gour Vishwavidyalaya, Sagar, M. P. for its approval to conduct the study. After the approval of the proposal, the researcher (the first author) visited the hospital and obtained the informed consent from the participants. Their basic biographic details along with nature, history, course and treatment of the disease were recorded. The participants who fulfilled the criteria of inclusion were debriefed about the basic objectives and requested to take part in the study. The interview was carried out by the first author in a separate room of the hospital provided for the purpose by adopting a one-on-one interview style. To ensure the confidentiality and privacy of the participants, the interviews were conducted in a secure place and codes were assigned to the data of all the participants. After setting up a rapport with each participant, the process of the interview was started. Initially, the interview was started with the general questions like “When did you come to know about the disease?” and “What were your initial experiences?” During the interview, some queries like "Can you explain something else?", “Can you tell me a bit more clearly” and “What does this mean for you?” were also asked. Following this procedure, the questions were put before each participant and the contents of their answers were recorded.

Qualitative Data Analysis Procedures [TOP]

The verbatim transcriptions of the recorded interviews were prepared with comments, if any, to smooth the process of carrying out the coding for the contents of the interviews with the thematic analysis by the researchers who have experiences of teaching and research on qualitative methods for more than five years. The data of all the participants were supplied to the three researchers with the request to generate codes that described cognitive, affective, behavioural, interpersonal, social and other experiences occurring in the significant amount and have meaning to understand the causes and consequences of disease as well as life experiences. The codes refer to a unit of meaning reflected in words, phrases, sentences or a paragraph. The codes were labelled as the spiritual experiences that indicated positive life changes, positive efforts with no fear of consequences, positive faith in others and society, realistic and non-emotional understanding of life events and positive future orientations with common humanity. When the codes were generated from the data, the themes were identified by the researchers by adopting the Thematic Analysis Method (Braun & Clarke, 2006). The Thematic Analysis is the method of identifying, analysing and reporting repeated patterns (themes) of meaning within data. The Thematic Analysis Method comprises six steps, namely, familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report sample (Braun & Clarke, 2006). Thus, a data-driven analysis was made that involved generation of codes, identification of patterns and themes with the help of the researchers independently followed by a conference to establish consistency in their themes with concomitant descriptions. This was done to enhance objectivity and consistency in analysis.

Results [TOP]

The qualitative data were analysed as per the guidelines of Thematic Analysis Method which led to insightful and interesting facts about the spiritual beliefs of the participants. The qualitative analysis of the data showed that the majority of the cancer survivors expressed that spirituality is a set of transcendental experiences (e.g. God is helping me. People are good and they are caring for me and I should also remain honest towards them.), self-cognition and self-perception which is full of higher values and humanity (I am good. I know the causes of disease.). It is widely known that cognitive distancing from pain increases the threshold of pain perception (Peláez, Martínez-Iñigo, Barjola, Cardoso, & Mercado, 2016). It was explicit that the beliefs in the theory of karma, rebirth, and incessant presence of divine powers were the major attributes of spiritual beliefs of the cancer survivors. The majority of the participants believed that spirituality involves doing something for all organisms. The survivors believed in the theory of karma (deed) which was promulgated by Bhagwat Gita, a sacred Hindu religious text. The theory of karma posits that everything is determined by one’s deeds. The individuals should only care for their deeds and the consequences are well-determined and regulated by the nature of their deeds. Moreover, the present state of an individual is determined by his/her karma of his past and present. It leads to the fact that one has to take further birth to enjoy, good or bad, of the karma phal (consequences of one’s deeds) of the deeds of one’s past life.

The majority of the survivors expressed their firm belief about the omnipresence of God (With the grace of God, the doctor has given me medicines that are working well. People are helping me as God is willing to help me.), the indestructibility of the soul (This world is very fragile. I will take another birth.) and mortality of their bodies (One day, each one of us has to die. In his incarnation, God has to leave his body.). It is explicit in the expressions of the survivors that the Atman (soul) remains intact and alive forever.

The Cancer Survivors Demonstrated an Optimistic Change Towards Life [TOP]

This theme denoted that most of the survivors accepted that their disease gradually facilitated to induce optimistic thinking towards intrapersonal, interpersonal and other realities of life. Optimism, hope and joy are important ingredients of spiritual beliefs (Beauregard & O’Leary, 2008). They also showed enhanced positivity towards the cancer treatments and their outcomes. They developed a better attitude towards self, other people and the things happening around them. They occasionally reported transcendental experiences to their life happenings. The significant positive changes reported by the survivors were perceived treatment outcomes, support of others, and an enhanced self-understanding. Their positive thinking made them live their lives in a meaningful way. One male patient (P04_55_M) expressed himself “When the doctor told me about the positive reports of pathological examination of cancer, I was shocked. I was mentally unstable for many days. One of my relatives encouraged me and said that everyone has to die one day. Do not get afraid of death. Try to remain happy. I tried to save myself from negative thoughts which helped me to regain mental balance. Today, I feel healthy”. A female (P07_36_F) reported “Initially I was very depressed after hearing about the development of cancer. I did not expect any help from close relatives. Gradually, my beliefs regarding others changed and I observed that many of my close relatives are helping me and encouraging me to face this unusual situation”. Similar expressions were also done by other male patients (P02_65_M, P03_40_M).

A good number of cancer survivors exhibited enhanced positive perceptions, optimism and positive attribution style. For example, one female survivor (P08_51) replied “After I was diagnosed with cancer, I realized that people around me are not as bad as I used to think. They are caring for me and I will surely get out of the pain of this disease. I am also noticing that the doctor who is supervising my treatment is also very empathetic and supportive”. Other female participants expressed similar views (F, P09_56_F_, P10_39_F, and P11_45_F).

The Cancer Survivors Evidenced a Fighting Spirit Towards Life [TOP]

The chronic health conditions instilled the fighting spirit in the cancer survivors. Initially, the diagnosis of the disease led them to face family and financial problems and gave birth to suicidal ideation and many types of psychological problems. Occasionally, they also had positive thoughts and took the condition as challenging. Later on, this negative state of affairs led to emerging a fighting attitude with the adversities in the majority of the patients. One male cancer survivor (P01_28_M) expressed “I was feeling very bad due to my ill health and financial conditions of my family. I used to think that either I should become healthy or die as soon as possible. The physician motivated me and said that you have nothing to lose. If you will fight, you will win. It changed me and from that day I decided to fight with the disease”. Similar expressions were also done by other male patients (P02_65_M, P03_40_M, P04_55_M). A female respondent (P01_35_F) verbalized “As soon as I was diagnosed with cancer, I lost all my courage and vitality of life. I decided that there is no other way but to fight this situation. I extended my faith to the doctors and God”. Similarly, other female patients verbalized also (P02_71_F, P03_55_F, P04_49_F). It was due to the fact that spiritual beliefs represent an array of strengthening and promotive strengths that gave birth to the fighting spirit in the majority of the patients. For instances, the researchers have posited that spiritual beliefs carry gratitude and acceptance, internal wisdom, creativity, awareness of self, self-esteem, hope, optimism, coping, support and commitment that can be easily associated with one’s fighting spirit (Beauregard & O’Leary, 2008; Clinebell, 1992; Murray & Zentner, 1979).

The Cancer Survivors Showed Enhanced Trust in Family and Friends [TOP]

The diagnosis of cancer was reported to facilitate and improve trust in family and social relationships. It has been argued that spiritual beliefs catalyze multiple aspects of human existence (i.e., physical, mental, emotional, and social) and play an important role in strengthening intrapersonal and interpersonal relations (Snyder & Lopez, 2007). In this manner, enhanced family and social relations reflected the increased spiritual beliefs. One of the male cancer survivors (P05_60_M) expressed himself “At the start, I was very depressed after the first diagnosis of cancer. I did not believe any concrete help from my family and society. With the passage of time, my perceptions regarding the support from family members and friends got modified and I observed that they are investing their best efforts to get me cured”. Other males expressed the same (P11_68_M, P12_48_M, P13_52_M). A female cancer survivor (P05_46_F) verbalized “The diagnosis of cancer has broken me from all angles. I did not expect any genuine help from my family and friends. I lost every hope of my further survival. Gradually, I noticed that even those family members were doing everything for me to whom I did not expect. They visited the hospital with me and prayed to God to help me to come out form this poor condition. It increased my faith towards relationships of both family and society”. Other female expressed similarly (P08_51_F, P09_56_F).

The theme denoted that chronic health conditions initially lowered the trust in close relationships. With the passage of time and realization of the facts of life, the survivors developed their trust and faith in their relationships. Another female cancer survivor (P09_56_F) verbalized “I felt loneliness in spite of many people present around me in the hospital and used to think that no one is able to understand me. One close friend and my brother always took regular care of me. They were always careful about my needs. They tried to know whether I am thinking negative and sad. If I expressed my pain, they always consulted the physicians and caring staff. It led me to believe that I can be cured. It also compelled me to become even more positive towards them even than in earlier days”. Other female patients also expressed the same (P08_51_F, P10_39_F, P11_45_F).

In fact, the initial reactions to fatal illness are alike universally. But at deeper levels, they are clear expressions of religiosity in Vedic religion (mostly prevalent here). Anybody who stands in time of crisis is ‘bandhav’ or brother. Thus, these caregivers come forward for extending social support in the form of extending spiritual meaning who are not necessarily kith or kin but members of the community and work as a traditional shock absorber and practice some kind of religious cognitive restructuring needed at the time. These were some cultural expressions of spiritual experiences unique to Indian society. It emphasizes universal brotherhood, seeking and giving social support as spiritual duties and social expectations.

Chronic Health Conditions Help Improved Realistic Self-Perception [TOP]

The analysis of the data exhibited that chronic health conditions like cancer affect the self-perception of individuals. It leads to poor self-perception at the beginning followed by improved self-perception. Spiritual beliefs have been attributed with enhanced meaning and purpose in life, connectedness, and a positive state of mind, internal wisdom, awareness and adaptive attribution styles (Beauregard & O’Leary, 2008; Clinebell, 1992; Murray & Zentner, 1979). These attributes might have enhanced the clarity of perceptions of the patients. A close examination of the data revealed that such people deeply look into the realities of life and relationships which help them to take a shift from negative to the positive direction in their self-concept. One male participant (P17_63_M) reported “After a positive report of cancer, I initially lost all of my hope. Then, I gradually found sufficient time to examine the realities of life and my role to live a better life. As per the advice of the physicians, I took regular diet, practised yoga and meditation, and observed other beneficial health practices. These observations impacted my self-concept positively. Now, I have more positive self-concept than before. I have been converted into a person of hope. I realized the meaningfulness and importance of positive efforts. It lessened my grief and negative self-perception also”. Similarly, other male patients expressed in their interviews (P15_37_M, P16_54_M, P18_68_M, and P19_35_M). A female participant expressed herself “During my healthy times; I was careless about any change in my body. With the diagnosis of cancer, I became more alert and careful about such bodily changes. I have developed a new self-confidence in my abilities to initiate positive change. These changes in my self-perceptions were well noticed by my caregivers and the physicians as well as nursing staff. The changes enhanced my happiness to some extent”. These resulted in the consolidation of the internal harmony in their personality functioning of the patients.

Chronic Health Conditions Help Facilitate Positive Thinking of Future Orientations [TOP]

Chronic health conditions like cancer bring about change in the thinking styles of the people. People reported to become more concerned about the future and admitted that if they get well, they will compensate for previous life achievements by doing even more valuable jobs. It has been argued that spiritual beliefs are characterized by enhanced awareness of self, others and the world, positive emotions, hope, optimism, coping and support (Beauregard & O’Leary, 2008; Clinebell, 1992; Murray & Zentner, 1979). These psychological mechanisms may naturally lead one to think positively with prospective orientations. One male participant (P08_33_M) admitted “I am hopeful about my recovery. After recovery, I have to perform those tasks in my life to which I have been remaining careless, idle and non-effective. In future, I will set a new standard of achievements in my life. I will devote much of these efforts adding to the welfare of humanity”. Similar expressions were also shown by the majority the male participants (P03_40_M, P04_55_M, P05_60_M, P06_50_M, P07_56_M, P09_62_M, P10_53_M, P11_68_M, P12_48_M and P13_52_M). A female participant (P04_49_F) verbalized “The poor health condition has opened my eyes. Up to now, I have been ignorant about the meaningfulness of life and its true meaning. After recovery, I will certainly do something good for the betterment of others. I have to perform many big tasks in my next phase of life”. Similar expressions were also done by the majority of the female participants P02_71_F, P03_55_ F, P05_46_ F, P06_38_ F, P07_36_ and F_P08_51_F).

Discussion [TOP]

It is explicit that spiritual beliefs refer to the cognitive structures that unfold understanding of inner and outer realities of all sorts of life and have been suggested to be rooted in familial and cultural upbringings of individuals. These beliefs are more responsive to the situations that need reflection and integration to derive the meaning of significant events of life and have practical relevance to the life of individuals. It closely shapes affective, behavioural and relational aspects of individuals (Holland et al., 1998). The findings of the study evinced that the spiritual beliefs catalysed some meaningful positive force to the life of the people suffering from cancer. It helped them to be aware of the forgotten realities of their being. It acted as the precursor to initiate a chain of self-enhancement and diversification of their spiritual understanding in meaningful and productive ways. The findings showed that many universal correlates of spiritual beliefs were observed in the verbalizations of the cancer survivors. Common humanity, social support, positive cognitions, meaningfulness, connectedness, hope and optimism were reflected in the expressions of the patients. Some behavioural, outcomes such as adherence to medical treatments, recommended diets and positive health practices, were also evident in the replies of the survivors. Moreover, positive attribution style in thinking, reframing and reinterpretation of the realities of life and transcendental experiences were also reported.

These arguments provided a strong base to explain the experiences of the survivors caused by cancer. The deeper spiritual explorations by the cancer survivors led them to believe that cancer can do some harm to their body which is taken care of by medical regimen. It cannot make any harm to them as they are not the body but blissful Atman (soul) beyond pleasure and pain. It is widely believed that the ill-conditions created by the disease are the results of the karma of the past or present life and will dissipate away as soon as the survivors will face the proportionate consequences of their ill-karma.

There were some unique spiritual experiences of the survivors which may be said to be peculiar to the Indian people only. It represented the beliefs in the theory of karma, rebirth and incessant presence of divine powers. In addition, many associated attributes were shown to be present in the expressions of the survivors. For example, chanting of mantras (hymns), explaining the life realities in terms of the theory of karma (deeds), karma phal (consequences of deeds), Moksha (salvation), rebirth, the immorality of Atman (soul), social comparisons and the concept of narak (hell) were among them which guided the spiritual understanding of the cancer survivors. It is to be argued here that Indian health practices are well-tuned with the spiritual beliefs of the people. For example, cancer is fatal that led to thinking patients that the disease was the consequences of prarabdh (fate). The experiences of cancer disease facilitated the survivors in rendering services to humanity. These convictions were done to compensate the poor-utilizations the resources of healthy life by the patients. These experiences were also a kind of optimism and desire to live. Here in India, people think that by promising good things in future to God or society may help relieve their current problems. Indian people assume medical practitioners as God and have a firm belief that they do everything for their good health. People generally do not complain to consumer courts for failed treatments or lapses on the part of practitioners due to this assumption. People also assume that disease may affect and kill their body which is only a physical aspect of their existence. It may not kill the self which remains away from the disease.

The self-perceptions and cognitions reflected in the spirituality of the survivors may have given birth to their self-motivation which, in turn, may have maintained their compliance with the medical advice. Anger in some themes shows a positive sign in the sense that puts challenges to face the ill situations created by disease and its symptoms as well as the perception of the overall state of the facts related to the disease. For Indians, the biggest goal of their life is to know thyself (atmanvid). The Moksha (salvation) is the basic and ultimate goal of life to achieve for each Indian. The findings observed in the present study are somewhat in consonance with the Western findings of the area. However, they reflected the Indian spiritual system prevalent in the survivors.

It was obvious in the very first theme that ill-health conditions initially weaken the survivors within and breed negativity in them. With the time elapsed and increased awareness of new realities of life, positivity is engrained in the survivors in the form of spirituality which, in turn, facilitates espousal of optimistic views. These adaptive attribution styles result in fresh psychological coping with new meaning to the events of life that act as the precursor to foster positive cognitive reinterpretation and growth. Positive attribution style also helps to reassess the previous beliefs and experiences, interpersonal and social relationships in the light of newly acquired frame of mind. The emerged optimism leads to situate one in one’s reality that is basically social, meaningful and pleasant. It also enhances one‘s perceptions in the direction of coherency and ubiquity that, in turn, make them remain in touch with the realities of life. Spirituality as a source of optimism has been well documented in the conceptualizations of researchers who have posited that optimistic attribution styles lay in the very core of spirituality that helps to perceive negative outcomes caused by external forces and positive outcomes by internal forces (Cobb et al., 2012; Koenig, 2012).

The findings of the study also demonstrated that chronic health conditions induce a kind of spirit that supplies incessant positive energy to face the odds of life and converts adversities into opportunities. It has been argued that spirituality carries innate and dynamic energy that cultivate the active and positive role of the individuals in facing the challenges of life as these are studded with positive emotional outcomes (Snyder & Lopez, 2007). A good number of participants have expressed in their verbalizations that accepting the challenges of life in the face of adversity or pain improved their courage and vitality in life and increased positive faith in those around them. According to Roof (2001), spirituality represents four basic themes namely, a source of values and meaning or purpose beyond the self, understanding, inner awareness, and personal integration. It is the inner awareness and personal integration that may be assumed to needle the individuals to accept the challenges of life.

The findings of the present research have evinced that the cancer survivors exhibited enhanced trust in their family and friends. It can be argued that spirituality spontaneously fetches social supports which consolidated the hope of further survival and positive efforts carried out by others and relationships of both family and society. It is noteworthy that social supports are valuable sources of self-esteem, information and companionship that help cope with stress and negative life events (Cohen & Wills, 1985). It is also believed that social supports originating through spirituality are well engrained and long-lasting (Hill & Pargament, 2003).

It has also been observed in the verbalizations of the cancer survivors that their chronic health conditions reshape their self-perceptions in tune with the realities of life. Previous research portrays that inner awareness and personal integration are the basic ingredients of spirituality (Roof, 2001). Such changes have been observed in the form of increased positive health practices such as yoga and meditation in the sample studied. It has also been observed to increase alertness, self-confidence, and body care. These findings mirror the findings of the previous research that has suggested spirituality to facilitate the understanding of various dimensions of life such as health, illness, diagnosis, recovery, and loss (D’Souza, 2007).

Last but not the least, the findings of the study have exhibited that ill-health conditions also facilitate positive future orientations to compensate with their present infirmity. It resulted in the setting of people-oriented life goals to benefit humanity. This may be seen in many verbalizations where patients have expressed hope, optimism and positive behaviours. In this way, their thinking may be said to be future-oriented. Many earlier researchers have reported that spirituality represents positive values and meanings and is an ingredient of transformation that shape positive functioning and performance to consolidate human existence (Cobb et al., 2012; Koenig, 2012; Sheldrake, 2007; Snyder & Lopez, 2007). Previous researchers have also posited that spirituality fosters other similar outcomes like resilience, resources, sense of support (Eckersley, 2007), decision-making, self-care (Rumbold, 2007), expectations, relationships (Koslander & Arvidsson, 2007), health practices (Larson & Larson, 2003), and overall health outcomes (Koenig, 2007).

The findings of the present study borrow their support from the previous studies which have argued that certain expressions or elements of spirituality may positively affect various physiological mechanisms involved in health (Seybold & Hill, 2001). The positive emotions encouraged in many spiritual traditions, including hope, contentment, love and forgiveness, serve the individual by affecting the neural pathways connecting to endocrine and immune systems (Seybold & Hill, 2001). The negative emotions that are actively discouraged in many religions like anger or fear trigger the release of the neurotransmitter norepinephrine and the endocrine hormone cortisol which inhibit the immune system, increase the risk of infection, elevate blood pressure and increase the risk of stroke and cardiovascular disease. This malfunctioning at biological and psychological levels may have motivated the patients to carry out and instate their beliefs in positive behaviours. Moreover, the ill-conditions may have helped them with the enhanced social and medical support that benefitted them with increased spiritual beliefs in their real life. The sense of connectedness to other people and to oneself may be an important factor that underpins many expressions and outcomes of spirituality (Meis, 1991). In essence, the findings of the study indicated that spirituality and spiritual beliefs represent complex phenomena which carry benefits of both psychological and physiological nature. The spiritual beliefs benefitted the cancer survivors in many respects and helped them cope with negative feelings towards the self, others, and society, and enhanced their perceived efficacy of treatments and well-being. In other words, the spiritual beliefs helped the patients to face the anomalous situations caused by cancer, affecting their health and well-being in a positive manner. It also consolidated internal harmony in their personality functioning. This harmony may be observed in their enhanced understanding, hope, optimism, and positive changes in behaviours at all levels. In the light of the above arguments and findings of the previous studies, it can be concluded that spirituality has a synergic effect in facing the pain and adversities of life caused by cancer that may be observed in their positive changes at cognitive, affective and behavioural levels.

Conclusions [TOP]

The findings of the study revealed that spiritual belief is an important phenomenon comprising cognitive, affective and behavioural components and carry many positive outcomes to regain and maintain psychological balance, well-being and quality of life, as well physical and mental health. The findings revealed five major themes regarding the spiritual beliefs of the cancer survivors. The themes denoted a set of changes at all levels in the behaviours and personality of the survivors. Explicitly, the cancer survivors demonstrated optimistic change towards life, fighting spirit towards life, enhanced trust in family and friends, improved realistic self-perception and positive thinking of future orientations.

Directions for Future Research [TOP]

The scientific studies of spiritual beliefs are still in its infancy. There is ample scope for the future researchers to contribute to uncovering the basic nature, genesis, dynamics, relevant antecedents and correlates of spiritual beliefs of clinical and non-clinical populations. The spiritual belief represents a multifaceted construct and it is advised that future researchers may integrate other relevant variables such as perceived health (Sharma et al., 2017; Sharma, Tiwari, Rai, & Gour, 2018), self-forgiveness (Mudgal & Tiwari, 2015, 2017), positive body image (Jain & Tiwari, 2016a, 2016b; Tiwari, 2014; Tiwari & Kumar, 2015), self-concept (Gujare & Tiwari, 2016a, 2016b), emotional intelligence, (Tiwari, 2016a), yogic practices (Tiwari, 2016b), emotion regulation (Tiwari, 2015), self-compassion (Verma & Tiwari, 2017a, 2017b) and, metacognition and locus of control (Jain, Tiwari, & Awasthi, 2017, 2018a, 2018b) to develop better understanding of the dynamics of spiritual beliefs and their outcomes. Many avenues for applying new methods of data collection and analyses to understand the construct are also open for future researchers. The applications of qualitative methods, mixed methods and meditational analysis will help improve the understanding of spiritual beliefs. Cross-cultural verification of these findings also constitutes another scope for future researchers. Future researchers may come up with intervention plans involving spirituality.

Funding [TOP]

The submitted research work belongs to the doctoral research of the first author with no external funding except UGC NON-NET scholarship awarded by Doctor Harisingh Gour Vishwavidyalaya, Sagar, 470003, Madhya Pradesh, India.

Competing Interests [TOP]

The authors have declared that no competing interests exist.

Acknowledgments [TOP]

The authors acknowledge the cooperation and support extended by Dr Sushil Gour, Associate Professor, Department of Radio Therapy, Bundelkhand Medical College, Sagar, 470003, Madhya Pradesh, India in conducting interviews and collecting data for the study. We also appreciate the participants without whose consent and support the study would not have been completed.

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