REVIEW ARTICLE
DOI: 10.11606/issn.1806-6976.v13i1p45-51

 

Religious/Spiritual Coping by People with Cancer Undergoing Chemotherapy: Integrative Literature Review

 

Enfrentamiento religioso/espiritual en personas con cáncer en quimioterapia: revisión integrativa de la literatura

 

 

Fernanda Fernandes de Paiva Ribeiro Dantas Sousa^I; Susy Maria Feitosa de Melo Freitas^II; Ana Gesselena da Silva Farias^III; Maria da Conceição dos Santos Oliveira Cunha^III; Márcio Flávio Moura de Araújo^IV; Vívian Saraiva Veras^IV

^IRN, Instituto do Câncer do Ceará, Fortaleza, CE, Brazil
^IIMaster’s student, Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Redenção,CE, Brazil. RN, Secretaria da Saúde de Caucaia, Caucaia, CE, Brazil
^IIIMaster’s student, Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Redenção,CE, Brazil
^IVPhD, Adjunct Professor, Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Redenção,CE, Brazil

 

 

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ABSTRACT

The objective of this study was to identify the scientific evidence available regarding the religious/spiritual coping approach used by people with cancer undergoing chemotherapy. It is an integrative review of the literature. The descriptors "chemotherapy" and "spirituality" were used. The databases were: LILACS, PUBMED, ScienceDirect, EMBASE, CINAHL, and BDENF. The studies recognize religion/spirituality as a positive approach strategy, since it contributes to adherence to treatment and stress reduction. The negative effect was associated with the incidence of collateral effects, psychological suffering, anxiety, and depression. We concluded that the recognition of spirituality as a coping strategy and the identification of spiritual needs provide nursing professionals with a better scope of information for care planning and more comprehensive assistance.

Descriptors: Drug Therapy; Spirituality; Religion; Adaptation, Psychological; Oncology Nursing.

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RESUMEN

Se objetivó identificar las evidencias científicas disponibles acerca del enfrentamiento religioso/espiritual utilizado por personas con cáncer, en quimioterapia. Se trata de revisión integrativa de la literatura. Se utilizó los descriptores Quimioterapia y Espiritualidad. Las bases de datos fueron: LILACS, PUBMED, ScienceDirect, EMBASE, CINAHL y BDENF. Los estudios reconocen la religión/espiritualidad como estrategia de enfrentamiento positivo, con el hecho de contribuir para la adhesión al tratamiento y reducción del estrés. El enfrentamiento negativo fue asociado a la incidencia de efectos colaterales, sufrimiento psicológico, ansiedad y depresión. Se concluye que el reconocimiento de la espiritualidad como estrategia de enfrentamiento y la identificación de las carencias espirituales suministran a los profesionales de enfermería un mejor objetivo de informaciones para el plan de atenciones y para una asistencia más integral.

Descriptores: Quimioterapia; Espiritualidad; Religión; Adaptación Psicológica; Enfermería Oncológica.

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Introduction

Cancer is a serious public health problem, especially in developing countries. The World Health Organization (WHO) estimates an incidence of 20 million cases worldwide by the year 2025. It is the second highest cause of death by chronic disease in Brazil (16.3%), where, according to the estimate for the year 2016, 596 thousand new cases of the disease will be registered.⁽¹⁾

Chemotherapy is the most common treatment in oncology, and during this mode of therapy people may present important physical and emotional changes such as pain, fatigue, apathy, weight loss, and alopecia, among others. In addition to prolonged hospitalizations, all of these factors cause discomfort, stress, and suffering, leading to feelings of sadness, indignation, distress, and fear of death.^(2-3)

Coping with the abovementioned changes demands greater resilience from people with cancer and their respective families. In this regard, it is common for people to seek a meaning for this experience in spirituality, which can help those with chronic diseases through the action of neurotransmitters that promote feelings of well-being, attenuation of heart and breathing frequency, as well as anxiety and cortisol levels, in addition to improving the immune system.^(2,4)

Management of a chronic disease such as cancer requires individualized care, as this moment can mean different things for each person. Thus, supporting care with spirituality can be indispensable, since it occupies an important place in the lives of most individuals. Its significance should be evaluated regardless of its use as a therapeutic tool, since Religious/Spiritual Coping (RSC) can play both a positive and a negative role in handling the disease.⁽⁵⁾

Religious people present a higher capacity for dealing with adverse life circumstances through the use of RSC. Coping refers to a group of behavioural and cognitive strategies used with the objective of dealing with stressful situations. When positive, it includes strategies that have a beneficial effect on the individual, such as seeking the love/protection of God or a greater connection with transcendental forces. Negative RSC involves strategies that generate harmful consequences, such as, for example, redefining the stressor as divine punishment.⁽⁵⁾

RSC is the most adaptive response to stress and includes resources such as problem solving, planning, and procurement of emotional support. Avoidance or non-adaptive coping, on the other hand, refers mainly to the methods through which individuals try to face problems mentally and/or physically by distancing themselves from the stressor, including strategies such as denial and use of alcohol/drugs.^(5-6)

There are studies on the relationship of religiosity/spirituality in the prevention of drug use⁽⁶⁾, quality of life^(7-8), hormonal therapy⁽⁹⁾, and radiotherapy⁽¹⁰⁾. From our knowledge, no publications were found analysing the role of RSC in people during chemotherapy treatment. Thus, the purpose of this revision was to synthesize the knowledge generated based on the results of other studies, and, based on these results, develop generalizations regarding the impact of religiosity/spirituality on the coping mechanisms of people with cancer undergoing chemotherapy.

 

Method

This is an integrative literature review, performed during May and June 2016.

The guiding question of this study was: what evidence is there in the literature regarding religious/spiritual coping used by people with cancer undergoing chemotherapy?

The following databases were used: LILACS, EMBASE, PUBMED, CINAHL, Science Direct, and BDENF. The controlled descriptors used were Chemotherapy (Quimoterapia/Quimioterapia) and Spirituality (Espiritualidade/Espiritualidad), with the boolean operator AND between the terms.

The following criteria were used for inclusion of the articles: original articles with complete abstracts and texts available for analysis, published in English, Portuguese, or Spanish between 2005 and 2016. The searches were performed by three reviewers, following the same procedure, with the goal of validating the results found.

We excluded review studies, theses, and dissertations, informal case reports, chapters of books, news articles, and non-scientific editorials and texts, as well as articles that did not reference the objective of the study.

By reading the titles and abstracts of all the publications found, and according to the inclusion and exclusion criteria defined, we obtained a pre-selection of the articles that composed the sample for this study. The final sample included 11 articles.

Figure 1 displays the number of primary studies identified in each database (N). The articles that met the inclusion criteria composed the number of pre-selected articles (n). Thus, the articles selected for the study, excluding those repeated in the databases, composed the "Final N".

The articles were then read, analysed, and categorized based on the following characteristics: authors, objectives, population, and sample size, as shown in Figure 2.

 

Results

Eleven articles met the established inclusion criteria. The publications predominated in the PUBMED database (6), followed by LILACS (3) and CINHAL and BDENF (one in each). The ScienceDirect and EMBASE databases did not have any articles selected in the final N.

As for the methodological design, the studies had varied approaches, namely: mixed (4), quantitative (4), and qualitative (3). The main publication language was English (6), followed by Portuguese (5).

The studies were developed in Brazil (4) and the United States (3), followed by Iran, Italy, Portugal, and Turkey, with one study each.

Most of the studies were published in the last five years, namely: 2013 (3), 2014 (2), 2012 (2), and the rest in 2011, 2008, 2007, and 2006, each with one publication.

It was noted that the articles found in the search were mostly (5) developed by a multi-professional team, followed by four studies undertaken by nurses and two by doctors.

 When evaluating religious/spiritual coping in chemotherapy sessions, it was found that most (7) of the articles used validated instruments such as the Spiritual Health Scale (SHS), Religious/Spiritual Coping Scale (RCOPE), Brief RCOPE, Spiritual Well-Being Questionnaire (SWBQ), Functional Assessment of Cancer Therapy General (Fact-G), and Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being Scale (Facit-Sp 12). In addition, the instruments were found to be repeated in some studies.

The aid of religion/spirituality in coping with cancer during chemotherapy treatment was a consensus among the scientific articles included in this integrative review. It was noted that this theme is of the interest of various professionals in the health area, thus highlighting the importance of studies regarding people with cancer and religious/spiritual coping.

 

Discussion

In the last decade, greater attention has been paid to the study of spirituality/religiosity as a coping strategy used by people with cancer, given its protective role against psychological morbidity. Each individual relates spirituality with the hope of surviving cancer.⁽⁵⁾

After reading the articles, extracting and analysing the information pertinent to answering the guiding question, the data were organized into three categories: use of positive or negative RSC by patients in chemotherapy; relationship between RSC and the religious practice; and RSC associated with the quality of life and spiritual well-being of the patient in chemotherapy.

Use of Positive or Negative RSC by Patients in Chemotherapy

The suffering caused by the disease results in a greater connection with religion and spirituality, which favors the high rate of positive RSC.^(2,11-14) The role of religion, in this case, can be related to matters such as resilience, hope, and spiritual well-being. In addition, religion cooperates in coping with the idea of cancer as a disease caused by the divine.^(4,11,14)

There is evidence that people with some type of spirituality tend to present lower incidence of disease, greater longevity, faster recuperation, and fewer complications during treatment. However, religion/spirituality can be a source of discomfort and stress, depending on how the person relates to it – in other words, if they use positive or negative RSC strategies.⁽¹⁵⁾

It is known that negative RSC is correlated to a higher incidence of collateral effects, greater psychological suffering as a consequence of weakened mental health, anxiety, lower use of positive self-affirmation, and depression, as well as lower quality of life levels and worse total spiritual well-being. Negative RSC is more characteristic of younger individuals, without religion and who disregard spiritual support.^(5,11,15-16)

Relationship between RSC and Religious Practice

People with some organized religion and regular religious practice present higher levels of spirituality, resulting in a more positive use of RSC.^{(2,5,11,13-14)}

Among the reasons for a positive association between religion and health is the fact that religious beliefs and practices can evoke positive emotions. Thus, considering religion/spirituality as something important in life also evidences that the individuals who profess some sort of faith, and who have a declared religion, present a negligible level of negative RSC.⁽¹²⁾

A notable particularity is the support of religion/spirituality in the field of psychoendocrinology. Some authors have ascertained good responses to chemotherapy on lymphocyte and cortisol levels and in tumor size in people with good scores on spirituality tests.⁽¹⁷⁾ This support mechanism can be higher in elderly people, for they are greater believers and/or have a less materialistic and more transcendental view on life. This is also important because elderly people with cancer suffer more greatly from spiritual distress.⁽¹⁶⁾

RSC Related to Quality of Life and Spiritual Well-Being in People Undergoing Chemotherapy

RSC and the support of spiritual needs contribute positively to improving quality of life of patients in chemotherapy by increasing psychological, emotional, functional, and affective well-being of the patients.^{(5,12,15-16,18)}

Perhaps because of this, authors have ascertained the desire of patients to receive some type of spiritual care during chemotherapy. However, most people complain that their spiritual needs are not considered during treatment.^(5,18)

Countless obstacles impede nurses from contributing to the provision of spiritual support simultaneously to biological care. The lack of professional training and, in a way, a theoretical deficit for spiritual care are a pretext for which it is often not offered.

 However, the Nursing Interventions Classification (NIC), which is a consolidated reference regarding nursing interventions, contains two interventions specifically related to spirituality: spiritual support and facilitation of spiritual growth. By implementing these interventions, nurses meet the spiritual needs of the patient, establishing an interface between spirituality and the body of knowledge of the profession.⁽²⁾

It is known that, in the view of some oncology patients, the nurse is the professional with the best ability to deal with people undergoing spiritual suffering, because they have more availability to listen and demonstrate greater affection during care.⁽¹⁴⁾

 

Final considerations

The results obtained demonstrate that oncology patients should be viewed in their totality, and that their religious/spiritual aspects should be understood, valued, and considered for individualized, singular care. These findings allow us to reflect on the importance of spirituality in the lives of people undergoing chemotherapeutic treatment, which is fundamental in handling the disease.

It is important to highlight that RSC can be an element that contributes to adherence to treatment and reduction of situational stress and anxiety. Respecting the beliefs of the individual and considering them also contribute to better interpersonal relationships between the professional team and the person they are treating.

Thus, the study offers relevant contributions to nursing, as nurses are the professionals that have the most proximity to patients in chemotherapeutic treatment during their routines, making them a reference for establishing a bond of trust, and thereby facilitating the provision of spiritual support to these people, who may be spiritually weakened.

One of the limitations presented in this review is with regard to the quantity of controlled descriptors, which are lower in number than those usually employed in integrative reviews. Only two standardized descriptors were selected in all of the databases. Adding more descriptors in some specific databases might have increased the number of results found.

Based on this study, expectations and possibilities also arise for the development of new studies indicating the need for professionals in the healthcare area to be trained to deal with topics such as religion/spirituality, related to the care provided to oncology patients.

 

References

1.Instituto Nacional de Câncer José Alencar Gomes da Silva. Estimativa 2016: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2015.         [ Links ]

2. Guerrero GP, Zago MMF, Sawada NO, Pinto MH. Relação entre espiritualidade e câncer: perspectiva do paciente. Rev Bras Enferm. 2011;64(1):53-9.         [ Links ]

3. Brateibach V, Domenico EBL, Berlezi EM, Loro MM, Rosanelli CLSP, Gomes JS, et al. Sintomas de pacientes em tratamento oncológico. Rev Ci Saúde. 2013 mai-ago;6(2):102-9.         [ Links ]

4. Pinto S, Caldeira S, Martins JC. A espiritualidade em pacientes com câncer em quimioterapia. CuidArte Enferm. 2012;6(1):8-14.         [ Links ]

5. Mesquita AC, Chaves ECL, Avelino CCV, Nogueira DA, Panzini RG, Carvalho EC. The use of religious/spiritual coping among patients with cancer undergoing chemotherapy treatment. Rev. Latino-Am. Enfermagem. 2013;21(2). doi: http://dx.doi.org/10.1590/S0104-11692013000200010.         [ Links ]

6. Felipe AOB, Carvalho AMP, Andrade CUB. Spirituality and religion as protectors for adolescent drug use. SMAD, Rev. Eletrôn Saúde Mental Álcool Drog. 2015;11(1):49-58. doi: http://dx.doi.org/10.11606/issn.1806-6976.v11i1p49-58.         [ Links ]

7. Brown AJ, Sun CC, Urbauer D, Zhukovsky DS, Levenback C, Frumovitz M, et al. Targeting those with decreased meaning and peace: a supportive care opportunity. http://link.springer.com/journal/520.2015;23(7):2025-32.         [ Links ]

8.Fornazari SA, Ferreira RER. Religiosidade/Espiritualidade em Pacientes Oncológicos: Qualidade de Vida e Saúde. Psicologia: Teoria e Pesquisa. 2010;26(2):265-72.         [ Links ]

9. Barlow F, Walker J, Lewith G. Effects of Spiritual Healing for Women Undergoing Long-Term Hormone Therapy for Breast Cancer: A Qualitative Investigation. J Alternative Compl Med. 2013;19(3):211-6.         [ Links ]

10. Paula W Jr, Zanini DS. Pacientes em radioterapia: um estudo de coping.  Psicol Saúde Doenças. 2012;13(2):480-93.

11. Gaston-Johansson F, Haisfield-Wolfe ME, Reddick B, Goldstein N, Lawal TA. The Relationships Among Coping Strategies, Religious Coping, and Spirituality in African American WomenWith Breast Cancer Receiving Chemotherapy. Oncol Nurs Forum. 2013;40(2):120-31.         [ Links ]

12. Canada AL, Parker PA, de Moor JS, Basen-Engquist K, Ramondetta LM, Cohen L. Active coping mediates the association between religion/spirituality and quality of life in ovarian cancer. Gynecol Oncol. 2006;101:102-7.         [ Links ]

13. Fouladi N, Ali-Mohammadi H, Pourfarzi1 F,Homaunfar N.Exploratory Study of Factors Affecting Continuity of Cancer Care: Iranian Women’s Perceptions. Asian Pac J Cancer Prev. 2014;15(1):133-7.

14. Günüşen NP, İnan FS, Üstün B. Experiences of Turkish Women with Breast Cancer During the Treatment Process and Facilitating Coping Factors. Asian Pacific J Cancer Prev. 2013;14(5):3143-9.         [ Links ]

15. Batista S, Mendonça ARA. Espiritualidade e qualidade de vida nos pacientes oncológicos em tratamento quimioterápico. Rev Bioética. 2012;20(1):175-88.         [ Links ]

16. Caldeira S, de Carvalho EC, Vieira M. Between spiritual wellbeing and spiritual distress: possible related factors in elderly patients with cancer. Rev. Latino-Am. Enfermagem. 2014;22(1):28-34.         [ Links ]

17. Lissoni P, Messina G, Balestra A, Colciago M, Brivio F, Fumagalli L, et al. Efficacy of Cancer Chemotherapy in Relation to Synchronization of Cortisol Rhythm, Immune Status and Psychospiritual Profile in Metastatic Non-small Cell Lung Cancer. In Vivo. 2008;22:257-2.         [ Links ]

18. Balboni TA, Vanderwerker LC, Block SD, Paulk ME, Lathan CS,Peteet JR, et al. Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations With End-of-Life Treatment Preferences and Quality of Life. J Clin Oncol. 2007;25(5):555-60.         [ Links ]

 

 

Received: July 6^th 2016
Accepted: Oct 10^th 2016

Corresponding Author:
Fernanda Fernandes de Paiva Ribeiro Dantas Sousa
Instituto do Câncer do Ceará
Rua Papi Júnior, 1222
Bairro: Rodolfo Teófilo
CEP: 60430-235, Fortaleza, CE, Brasil
E-mail: fernandafernandes_@hotmail.com