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9 Health, Spirituality and Medical Ethics - Vol.7, No.1, Mar 2020
Spiritual Problems of Women with Breast Cancer in Iran: A Qualitative Study
Received 31 Aug 2019; Accepted 14 Dec 2019
http://dx.doi.org/10.29252/jhsme.7.1.9
Zeinab Ghaempanah1, Parvin Rafieinia1* , Parviz Sabahi1, Shahrokh Makvand Hosseini1
, Nadereh Memaryan2
1 Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran.
2 Spiritual Health Research Center, Mental Health Department, School of Behavioral Sciences and Mental Health (Tehran Institute of
Psychiatry), Iran University of Medical Sciences, Tehran, Iran.
Introduction
breast cancer diagnosis is often
realized as a traumatic and life-
changing event and a stressful
experience (1). Questioning one's
religious/spiritual beliefs and spiritual struggle
is one of the life challenges people face (2).
Being diagnosed with cancer, women feel
severe distress, encounter religious conflicts,
and cannot use meaning-making coping
strategies (3,4). Kamala Devi, M and Karis
Cheng Kin Fong (5) studied the spiritual
experiences of Singaporean women with breast
cancer in the first year of diagnosis. They
reported that spiritual needs are common and
Harrison et al. (6) documented patients
indicated through survey responses that they
had unmet spiritual needs. The spectrum of
spirituality encompassed spiritual despair
(alienation, loss of self, and dissonance),
spiritual practice (forgiveness, self-
exploration, search for balance), and spiritual
well-being (connection, self-actualization,
consonance). According to the World Health
Organization and the US National Quality
Forum, spiritual and religious dimensions of a
patient’s life should be considered in holistic,
multidimensional care (7,8). Based on the
structure of spirituality in Iran, it is defined as
A
Abstract
Background and Objectives: A developing body of evidence has demonstrated the detrimental effects of spirituality and
religion on the well-being of patients with cancer. This necessitates the need to explore the content of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-V (code 62.89). The present study aimed to identify the spiritual problems of Iranian patients
with breast cancer concerning their religious beliefs and cultures.
Methods: A qualitative content analysis with an abductive approach was used and data were gathered using individual semi-
structured interviews. The participants were selected by purposive sampling which continued until data saturation after 12
interviews. Data were analyzed using the Graneheim and Lundman thematic approach.
Results: The themes extracted from the data were “Questioning spiritual values” and “loss or questioning of faith”. The three
categories in the first theme included “Find spiritual cause of illness”, “Question God's justice”, and “Deal with God”. Moreover,
“Lack of intimacy with God”, “Giving up rituals” and “Losing religious faith” were the categories of the second theme.
Conclusion: As evidenced by the obtained results, awareness of religious/spiritual problems of the patients with breast cancer
may be of great help to healthcare professionals to manage the patients who need a referral, further assessment, and appropriate
intervention. In addition, the assessment of spiritual/ religious problems is of paramount importance in designing cultural and
spiritual care and interventions.
Keywords: Spirituality, Religion, DSM-V, Breast cancer.
Original Article Health, Spirituality and Medical Ethics. 2020;7(1):9-15
Please Cite This Article As: Ghaempanah Z, Rafieinia P, Sabahi P, Makvand Hosseini Sh, Memaryan N. Spiritual
Problems of Women with Breast Cancer in Iran: A Qualitative Study. Health Spiritual Med Ethics. 2020;7(1):9-15.
This is an open-access article distributed under the
terms of the Creative Commons Attribution-Non
Commercial 4.0 International License
*Correspondence: Should be addressed to Ms. Parvin
Rafieinia. Email: p_rafieinia@semnan.ac.ir
Ghaempanah Z, et al
Health, Spirituality and Medical Ethics - Vol.7, No.1, Mar 2020 10
“the noble dimension of human existence
which all humans have been endowed to
follow the path of transcendence that is
proximity to God” (9). There is an increasing
interest in the role of spirituality as a part of
well-being and supportive care of patients with
cancer (10-12). A growing body of evidence
documented that spirituality can play a leading
role in healing and quality of life (4,13) since
spirituality confers inner power, tranquility,
welfare, and wholeness and influence the way
people cope with cancer (13-15). Although
race, culture, and personal experience may
affect the expression of spirituality, everyone
has their unique interpretation of spirituality
(16).
Despite the importance of spirituality in
patients with cancer (17) as a coping strategy
(Whether positive or negative) (18), there is a
paucity of studies on negative spiritual
experiences of women with breast cancer.
Furthermore, women's perception of
spirituality and their cancer experience has
implications for long-term mental health and
coping (19). The majority of studies have
explored cancer patients' spiritual needs or
distress (5, 20), While the content of them is
underestimated. According to the American
Psychiatric Association and Diagnostic and
Statistical Manual of Mental Disorders (DSM–
5), recognizing and understanding spirituality
in the cultural texture of society is pivotal to
the provision of culturally appropriate care
(21). To this end, it is of utmost importance to
identify the spiritual problems of patients
according to their religious beliefs and culture
(22). Furthermore, the present study was
targeted at exploring the spiritual problems of
women with breast cancer.
Methods
Qualitative content analysis with an
abductive (combined) approach was used to
identify the spiritual problems of women with
breast cancer (23) under the ethical code:
IR.IUMS.REC.1398.489). Consolidated
criteria for reporting qualitative research
(COREQ): a 32-item checklist was applied to
describe the research methodology (24).
Purposeful Random Sampling was used in
the current study. The inclusion criteria
entailed: 1) taking chemotherapy therapy for at
least 6 months, 2) breast cancer stages of 0-3,
3) age range of 30-65, and 4) ability to speak
and communicate in Persian. On the other
hand, the exclusion criteria included: 1)
psychotic or bipolar disorders, 2) intrusive
suicidal thoughts, and 3) current drug abuse.
Patients were recruited from the Hematology
and Oncology Department of Rasoul-e-Akram
Hospital in Tehran. Audio-recorded interviews
were conducted from August 2018 until
February 2019. Table 1 demonstrates the
demographic characteristics of the participants.
All interviews were conducted by the first
author who was trained in conducting
qualitative studies (items 1-5 in COREQ
checklist). The patients were provided with
research subject, objectives, and identity of the
researchers. Subsequently, the researcher fully
explained the study procedure to all those who
agreed to participate and informed consent was
obtained from all of them (6-8 in COREQ
checklist).
Data were collected by individual semi-
structured with the stance of friendship
interviews. The interview guide was designed
for the study. It was based on reviewing texts
and consulting three spiritual care experts.
Open-ended questions were crafted to gather
the patients’ problems about spirituality and
challenges they face concerning
religious/spiritual values, as well as coping
Table 1. Demographic characteristics of patients
Patient
code
Age
Educational
level
Religion
Employment
status
Marital
status
1
53
Secondary
Islam
Housewife
Married
2
30
Bachelor
Islam
disabled
Single
3
45
Associate
degree
Islam
disabled
Married
4
32
Diploma
Islam
Housewife
Married
5
40
Secondary
Islam
Housewife
Married
6
56
Associate
degree
Islam
Employee
Married
7
51
Diploma
Islam
Housewife
Married
8
39
Associate
degree
Islam
Housewife
Married
9
48
Primary
Islam
Housewife
Married
10
56
Secondary
Islam
Housewife
Married
11
65
Primary
Islam
Hairdresser
Married
12
57
Diploma
Islam
Teacher
Divorced
Spiritual Problems of Women with Breast
11 Health, Spirituality and Medical Ethics - Vol.7, No.1, Mar 2020
with cancer. Some general questions were
proposed to start the interview process, and the
interview was based on self-response. Sample
questions entailed: “Have you experienced any
change in spiritual/religious issues after being
diagnosed with cancer?” “How do you
evaluate yourself on religion/spirituality now?”
“What are the effects of this illness on your
religious/spiritual beliefs?” “Is the cause of
your illness related to spiritual/religious
issues?” “Do you perform religious or spiritual
practices? Are they affected by the illness?”
To ensure that the questions were clear for
patients and study purpose is fulfilled, the
guide was reviewed after the first several
interviews. In this regard, some questions were
added, for instance: “What effect do you think
this disease has on your meaning in life?” “Did
you complain to God during your illness?”
“How is your relationship with God?” More
detailed questions about their feelings and
thoughts along with exploratory ones were also
asked (e.g., "Can you explain more about
this?"). It is worthy to note that given the
stance of friendship interviews, the researchers
expressed empathy for the feelings of patients.
In this respect, if the patient became disturbed
or sad while expressing her experiences, the
interview process ended with positive notes.
For instance, the patient was asked to describe
the advantages of this illness, summarize the
experience of her illness that can be instructive
for others, and describe her plans for recovery
and discharge.
The patients were interviewed in the time and
place convenient to them. The interviews
lasted within 35-70 min, with 50 min being the
average. The sampling continued until data
saturation was achieved when no new data
were emerging. After the conduction of 12
interviews, no new code was developed for
creating categories and themes; however, two
additional interviews were administered (17-22
in COREQ checklist).
All transcribed interviews were reviewed,
coded, and immediately analyzed. A
conventional content analysis, followed by
Graneheim and Lundman's method, was used
for data analysis (23). Firstly, each interview
was thoroughly read to get a sense of the
overall content and an accurate perception of
the statements. Meaning units were extracted
from the interview texts and condensed into a
description of their manifest and literal content
and an interpretation of their latent content.
Subsequently, the meaning units were
condensed and initial codes were generated.
The categories were abstracted based on the
content similarities of codes available in the
descriptions and interpretations.
The researchers of the present study reflected
on the categories and revised them before the
whole text was analyzed. The fifth author read
one-third of the interview texts and checked
the codes and categories. Through a process of
reflection and discussion, the authors agreed
upon a set of themes. On a final note, the
categories were reflected on and seemed
related to DSM-5 which includes a new V
code entitled "Religious or Spiritual Problem":
Given that V code focuses on religious or
spiritual problems, it was considered relevant
headings would unify the categories to themes.
The initial content of interviews and analysis
was not reviewed by the patients; however, the
researcher took her notes and comments into
account after each interview. All processes
were performed by one person who spent an
extensive amount of time on data collection
and analysis. Manual data management was
used and no software was used for data
analysis. Direct quotations of interviews are
provided in the results section to clarify codes,
categories, and themes (items 23–32 in the
COREQ checklist).
Lincoln & Guba's trustworthiness criteria
were used to evaluate the credibility,
dependability, conformability, and
transferability of the obtained data (25).
Credibility was realized through sufficient
cooperation and interaction with the patients,
prolonged involvement, and immersion in the
subjects. Transferability and dependability
were insured by correcting any error made by
the external supervisors and arriving at a
consensus. The researchers were provided with
the research details to decide on the
application of the findings. Triangulation of
data resources was performed to review the
opinion of experts (psycho-oncologist,
Ghaempanah Z, et al
Health, Spirituality and Medical Ethics - Vol.7, No.1, Mar 2020 12
chaplain, and oncologist) through interviews.
In addition, opposed evidence for a
comprehensive description of subjects was
confirmed by purposeful sampling on
individuals with positive spiritual coping
strategies.
Result
The analysis of data revealed that women
with breast cancer lose or question their faith
and spiritual values. The themes are presented
below, and illustrative codes for each can be
found in Table 2.
Theme 1: Questioning spiritual values
Most of the women in the present study
pointed to how spiritual values have been
questioned following the breast cancer
diagnosis. They seek spiritual causes for their
illness and question God's justice.
Patients explain the cause of their cancer
concerning God and seek a spiritual reason,
and check their religious practices to find some
spiritual lapses that led to this illness. Women
asked the question “why me?” and declared
that God’s will or God’s punishment was
effective. They believed that God was testing
their faith or saw their suffering as retribution
for the sins of their past life. In this regard,
participant#1 said: “I used to think that sinners
get cancer; however, I was diagnosed with this
illness and it was a blow to me. I did not hurt a
soul. Why did I get this disease? I am still
wondering why God did this to me”. Not only
did they expect their good deeds to protect
them from illness, but also they were waiting
for rewards, the lack of which has been
challenging to them. They had gone through
hard times in the past and being diagnosed
with breast cancer seemed a miscarriage of
God’s justice. Patient #6 explained: “I
shouldered the responsibility of the whole
family. I cried out to God why he gave this
terminal disease to me and complained to
him”. When their illness-centered prayers are
not answered, they lose their trust in God.
Participant # 7 said in this regard: “I prayed so
much, went on pilgrimage, and pledged for a
negative pathology. However, God liked me
this way”.
Theme 2: loss or questioning of faith
Participants pointed to isolation and
disconnection as the primary result of a
spiritual problem. Lack of intimacy with God,
giving up rituals, and losing religious faith was
reported to be an unmet experience for these
patients.
Having experienced cancer, patients reported
a troubled spiritual relationship and detached
themselves from God. Some were even
annoyed at God, avoided him and even lost
their friendly and intimate spiritual
relationship. Patient #11 asserted: “I had a
close and friendly relationship with God and
constantly remembered him. Nonetheless, this
disease took its toll leading to the breakdown
of our relationship”. Breast cancer sufferers
expressed religious uncertainty and doubt,
challenged their past beliefs and religious
values, and even discontinue the religious
rituals since they were not meaningful to them
Table 2. Themes, categories, and codes
Themes
Categories
codes
Questioning spiritual values
Find the
spiritual
cause of
illness
Question God's purpose of illness
Why me?
Challenge God’s retribution
Non-sinful cause of illness
Test of Faith with cancer
Compensation for sins with illness
Question the
justice of
God
Lack of eligibility for illness
Review the past difficulties in life
Lack of God 's fairness
Being oppressed
Blamed God for the disease
Deal with
God
Safety expected of disease
Pray for health
Waiting for rewards
Health in exchange for prayer
Recovery for worship
loss or questioning of faith
lack of
intimacy with
God
Abandonment by God
Anger at God
Negative image of God
Blaming God for experiencing cancer
Relinquishing
rituals
Leaving religious communities
Regarding religious practices and
worship as ineffective
Reluctance to perform usual religious
practices
Giving up prayer
Failure to observe religious practices
Separation from religious gatherings
Loss of
religious faith
Verbalized inner conflicts about
religious beliefs
Conflicts between religious beliefs
Doubt about religious values
Shaken faith
Question religious values
Nonreligious beliefs
Spiritual Problems of Women with Breast
13 Health, Spirituality and Medical Ethics - Vol.7, No.1, Mar 2020
anymore. Some even left the religious
community or maintained distance from
religious gatherings they attended before.
Their faith is sometimes shaken to the point
that they give up prayers. Patients #8 reported:
“After this disease, I gave up prayer since I
lost my trust in God”. Participant # 9 claimed
that “There exist no God, Prophet, and Imams
in the world. If they even existed, I would not
believe them.
Discussion
As illustrated by the results of the current
study, questioning spiritual values and losing
or questioning faith are the most
spiritual/religious problems posed to breast
cancer patients. To make matters worse, these
problems get intertwined while being
simultaneously in contact with each other.
These results were in accordance with spiritual
problems in DSM 5 (V code 62.89). The first
theme consisted of three categories, including
the search for a spiritual cause of disease,
questioning divine justice, and dealing with
God. Since breast cancer sufferers held God
responsible for their sufferings, they blame
God by asking why me? Why now? Although
these ‘why’ questions have been addressed in
previous studies (26-28), the content of God-
oriented questions was illustrated in this
research. God's plan for testing patients' faith
or punish them is the sensible answer to most
of these questions. Nonetheless, cancer
sufferers consider this contrary to God's
righteousness and promises. In this regard,
affliction with this disease seemed unfair to
several women with hard times in life. This
problem and such a spiritual perception of the
disease leads to spiritual crisis and discontent
(29) which can be explained by passive
spiritual resources reported by Holt et al. (30).
They indicated that patients consider God's
will as a cause of illness and recovery. They do
not have a specific role, and through this,
attribution adapts to stressful situations.
Another result related to this theme is
contrary to the expected outcomes of religious
practices. Patients expected protection from
daily prayers, reading scriptures, and
attendance at religious services. They used a
variety of religious and spiritual practices in
order to prevent diseases or promote healing;
nonetheless, the desired outcomes were not
bestowed on them by God (31). Taylor et al.
suggested that patients performed religious
rituals with specific purposes, such as health,
and questioned the existence of God after
being diagnosed with cancer (32). In the same
vein, in the study conducted by Jors et al.,
disease-centered prayer was the most common
after the diagnosis of cancer (14). Gall et al.
regarded these challenges as the coping
strategies to find meaning in disease which
ultimately leads to spiritual growth (33).
However, the anger at God and the
simultaneous mobilization of the spiritual and
religious powers for healing leads to internal
conflicts in the patient, which creates more
frustration and spiritual challenges (33).
The second theme of this study is loss or
questioning of faith with three categories,
including lack of intimacy with God,
relinquishment of religious rituals, and losing
religious faith. Being diagnosed with breast
cancer, women in this study lost their inner,
sincere, and friendly relationship with God,
and started blaming him. They were reluctant
to talk to God and lost their hope and trust in
God which was consistent with the argument
of Penson et al. They suggested that the pain of
the disease may take its toll on the patients and
distort the spiritual relationship (26).
Therefore, the patients avoid God since they
regard him as the source of all their sufferings
(34). Having lost their love of God, they feel
isolated and lonely (31,35). In the present
study, the patients stated that they did not
adhere to their past religious beliefs, doubted
the existence of God, and were confronted
with spiritual questions, especially in painful
situations. These findings confirmed the results
of previous studies concerning spiritual
struggles (4,34-36). This change in patients'
attitudes is accompanied by the abandonment
of previous religious and ritual practices.
Cancer poses challenging questions about the
benefits of religious practices which can exert
adverse effects on spiritual beliefs.
Researchers reported that religious struggles
affect rituals and the discontinuity of religious
Ghaempanah Z, et al
Health, Spirituality and Medical Ethics - Vol.7, No.1, Mar 2020 14
practices might make it more likely (11,37).
The findings of this category were in line with
the research carried out by Salsman et al. In
the mentioned study, the spiritual and religious
dimensions of cancer patients were categorized
as emotional, behavioral, and beliefs which
affect each other (12). Pargament noted that
stressful events in life, such as cancer, could
challenge people's spiritual beliefs and lead to
spiritual disruption (2). Therefore, the negative
attitude to God and spiritual challenges are
considered red flags for these patients and
threaten the quality of life of affected women
(38). It is noteworthy that negative religious
coping is associated with lower life
satisfaction, distress, and depression among
patients with cancer and predicted suicide (37).
Limitations of the study
Every study has some limitations that should
be addressed in the paper. One of the
limitations of this study was the purposeful
sampling method. Therefore, the
generalization of the findings should be carried
out with caution. Since the statistical
population of the present study included
women with breast cancer in Tehran (22), the
generalizations of the research may be affected
by cultural differences among different ethnic
groups in Iran. Despite these limitations, the
results of the present study provide some
promising areas for future research.
Most importantly, longitudinal studies are
required to investigate how various aspects of
spiritual problems affect short- and long-term
quality of life in different stages of breast
cancer among women. Longitudinal research
will be also of great help to determine the
adaptive and maladaptive aspects of these
problems. Finally, based on these results,
health care providers should assess and attend
to the spiritual problems of patients, especially
in a stressful situation, since such factors may
have implications for adjustment.
Conclusion
The findings of the present study highlighted
the spiritual problems posed to women in the
face of breast cancer. They hold God
responsible for their cancer and seek the
spiritual cause of the disease. The tone of their
voice demonstrated that cancer is unfair and
opposed to fairness of God which conflicts
with their religious beliefs. They questioned
their religious values and relinquished
religious practices which were previously
important to them. Researchers and therapists
need to turn their close attention to these
problems from the beginning of the process of
cancer diagnosis and treatment since these
problems may lead to a lower quality of life
and poorer health outcomes. These patients
need emotional support and care from
clinicians and nurses along with their treatment
process and spiritual care providers should
attend to patients’ spiritual problems.
Conflict of interest
The authors declare that they have no conflict
of interest regarding authorship, and/or
publication of the current article.
Acknowledgements
Our deepest appreciation goes to all the
women who kindly participated in the present
study, as well as Spiritual health research
center of Iran University of medical sciences
for supporting this project. In addition, we
extend our gratitude to Shareda Hosein,
Octavio Areas, Peery Brent, and Chenene
Layne for their invaluable scientific support.
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