Introduction

World Health Organization has indicated that spiritual well-being (SWB) is listed as an important element of health [1]. For cancer patients, it plays an ever-increasing role for patients before diagnosis and within 10 years after diagnosis [2]. As one element for the health of individuals, spirituality can be seen as a universal trait by which individuals look for hope and meaning in their life [3]. Spirituality has been conceptualized as a framework which can be divided into various components: meaning, peace, and faith [4]. Meaning and peace are mainly used to measure the cognitive and affective dimensions of spirituality. Faith is used to measure the relationship of illness with one’s belief and spiritual belief [4]. Three dimensions have different roles during the course of treatment of cancer patients [5].

After being diagnosed with cancer, the cancer patients often show physical, psychological, social, and spiritual changes that may be related to anxiety, depression, and meaningless, and they even have suicide attempts [6]. Existing studies have confirmed that spirituality is an important strength and coping resource for cancer patients with adjustment to their disease [5, 7, 8]. The patients who are religious usually pray to God to find a connection with the Supreme Soul, so as to get comfort and strengthen the willing of actively seeking treatment [9]. For non-religious patients, it’s equally important to seek evidence that spirituality in general is related to secular concepts such as humanism and existentialism [10, 11]. It has been reported that cancer patients with higher SWB level have greater satisfaction with their decision-making and less decisional conflict [12] and experience less decisional regret [13]. Additionally, better SWB is related to lower levels of anxiety and depression [7, 14, 15]. It also serves a protective role against feeling isolated, resulting in better psychological well-being [16, 17]. Further, SWB is an important factor that may influence different aspects of health-related quality of life (QOL) in patients. A study has proved that spirituality is positively associated with the functional dimension of QOL [18]. Better emotional and cognitive functions are also reported in patients with better SWB [14]. Another study also reports that meaning and peace are positively related with overall QOL and physical and mental health [19]. Based on these results, it’s important to assess the spiritual dimension of cancer patients.

However, addressing spiritual issues has not been a priority among nurses who carry out cancer treatment [20], which may be due to their confusion related to spirituality and religiosity. While the majority of studies have been conducted in medical institutions in a religious society [16, 21], the present study was conducted in the context where formal religion is not developed.

Given shifting trends of medical model in China, SWB has attracted more and more attention from health care providers and researchers. There is an increasing recognition among oncology providers to improve the SWB of cancer patients. A better understanding of the effect of patients’ SWB on health-related QOL may help tailor the use of spiritual interventions, but little is known about SWB among patients who are spiritual but not religious. The present study was conducted to explore the effect of SWB in cancer patients and analyze the relationship between SWB and QOL.

Methods

Design

This study was a cross-sectional investigation of SWB of cancer patients receiving inpatient care in a culture where religion is not a priority.

Participants and setting

Participants were recruited from all types of cancer patients who were admitted to a tertiary cancer hospital for treatments (surgery and/or chemotherapy and/or radiotherapy and/or hormonotherapy and/or Chinese traditional treatment, etc.) through convenience sampling. The tertiary cancer hospital is a provincial cancer center that treats cancer patients from all over the province, including both rural and urban areas. Data were collected between March and April 2017. Cancer patients who met the following criteria were asked to participate in the study: (1) age ≥ 18 years with competent language communication ability, (2) mentally stable, (3) informed of his/her disease.

Measures

General information questionnaire

Information such as participants’ demographics (year of schooling, self-perceived religiosity, marital status, residence area, and household monthly income) and clinical characteristics (disease stage, time since confirmed diagnosis, hospitalization frequency, whether having comorbidities) was collected.

Functional Assessment of Cancer Therapy-General

Functional Assessment of Cancer Therapy-General (FACT-G) is a self-reported scale used to measure QOL of participants. It has four subscales which can measure one’s physical well-being, emotional well-being, social/family well-being, and functional well-being. All items were scored on a 5-point scale from 0 (not at all) to 4 (very much). The range of the total score was 0–108. Higher scores indicated better well-being. The FACT-G demonstrated good internal consistency in Chinese population (α = .884, .867, .821, and .835 for each subscale) [22].

Functional Assessment of Chronic Illness Therapy-Spiritual Well-being

Spiritual well-being was assessed by Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp), which is a 12-item scale widely used in cancer patients. The scale was developed to measure important aspects of spirituality, such as a sense of meaning in one’s life, harmony, peacefulness, and a sense of strength and comfort from one’s faith. It is divided into three dimensions such as faith, meaning, and peace. All items have the following response options: “not at all,” “a little bit,” “somewhat,” “quite a bit,” and “very much.” The score ranges from 0 to 4. The total score is the sum of scores of subscales, which ranges from 0 to 48, with a higher score signifying greater SWB [4, 23]. The Chinese version of scale has showed sound psychometric properties (α = .831 for total scale and .711~.920 for each dimension) [24].

Data collection

All paper questionnaires were delivered by two trained investigators. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and 1964 Helsinki Declaration and its later amendments or comparable ethical standards. A total of 200 participants were recruited in this study after informed consent, and it took 15–20 min for them to complete the questionnaires without interruption from the other, so as to ensure the accuracy of the information.

Data analysis

All data were inputted to the computer and analyzed in SPSS Statistics software Version 19.0. The sociodemographic and medical characteristics of cancer patients were described as frequencies and percentages. Their SWB and QOL scores were also computed. Multiple linear regression analysis was performed to determine the relationships between three different types (meaning, peace, and faith) of SWB and QOL (physical well-being, emotional well-being, social/family well-being, functional well-being) in the regression model. Different dimensions of QOL were set as dependent variables; meanwhile, the demographic and clinical characteristics and different dimensions of spirituality were set as independent variables. A p value of < .05 was considered statistically significant.

Results

Sociodemographic and medical characteristics

A total of 200 cancer patients were recruited into the investigation, of whom 185 filled out the questionnaires. Sociodemographic and medical characteristics are presented in Table 1. As demonstrated in Table 1, there are more female patients than male patients. The average age of patients was 48.94 years. Most of the patients (69.7%) had less than 9 years of schooling. The majority of the patients were non-religious. Other details are shown in Table 1.

Table 1 Sociodemographic and medical characteristics
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Spiritual well-being and quality of life in the participants

The mean scores of SWB and QOL are presented in Table 2.

Table 2 Mean scores of spiritual well-being and quality of life
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Associated factors of spiritual well-being of cancer patients

Multiple linear regressions were analyzed to explore the associated factors of SWB. Hospitalization frequency (B (95%CI) = 1.791 (.503–3.080), β = .199, p = .007) was the only variable related to SWB, which explained 3.9% of the total variation. The result of F-test (F = 7.522, df = 1, p = .007) indicated that the multiple linear regression equation fitted the data well.

The relationship between spiritual well-being and quality of life

Multiple linear regressions were performed with the total score and the each dimension (physical well-being, emotional well-being, social/family well-being, functional well-being) of QOL as dependent variables. Five stepwise linear regression equations were computed, all of which fitted the data well. Table 3 demonstrated the results of multiple linear regression analysis. The results demonstrated that meaning and peace were significantly related to QOL as a whole. Meaning was positively related to social/family, emotional, and functional well-being. Faith was negatively related to physical and emotional well-being, but it was positively related to functional well-being. Peace was positively related to physical, social/family, and functional well-being.

Table 3 Results of multiple linear regression analysis of associated factors of QOL for patients with cancer (n = 185)
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Discussion

It was demonstrated that the total score of SWB in the participants in this study was lower than that in another study which also explored spirituality in patients with all types and stages of cancer during various treatments [14], which indicated that due attention should be paid to SWB in cancer patients. The possible reasons may be that SWB does not evoke much attention in such a secular society and it is more likely to be neglected by health care providers. Secondly, spiritual care has not been implemented to cancer patients due to various reasons, although spiritual care has been recommended as essential elements of care. This may also be related to a lower SWB level. Thirdly, the existing study has implied that the SWB level may be lower among populations who are not highly religious [25]. All these above reasons contribute to a lower SWB level in this sample.

In China, the majority of people do not adhere to any religion, and they are also different from patients who are not religious in other counties, because the Chinese population is influenced by Chinese traditional culture such as Confucianism, Taoism, and Buddhism, which advocate establishing good moral character, acting morally, and getting rid of all greed, anger, and delusion. In this culture, Chinese people attempt to discover the true meaning of life, find self-worth in the world, and even explore the essence of being human. The highest level of spirituality is expressed as “Man being an integral part of nature,” which means that only when man can find his own proper position in the universe, he can form a harmonious relationship with nature. The current study contributes to a deep understanding of spirituality in cancer patients in the unique background, and it also provides a new perspective on spirituality in addition to religiosity.

In the present study, a higher hospitalization frequency was related to a higher SWB level. This could be due to the fact that patients with a lower hospitalization frequency, especially those who were admitted into hospital for the first time, suffered from more anxiety, depression, or distress. Moreover, after being admitted into the hospital, the patients received regular psychological interventions and thus they could easily get professional help from oncology providers, who made the patients felt less anxiety or depression. In addition, the family caregivers of patients could get help easily especially when they had difficulty in providing physical or emotional supports for patients; thus, the burdens of the family caregivers would be decreased, which was proved to be related to a better emotional state in the patients [26]. Lower levels of anxiety and depression of patients were often related to a lower SWB level [14, 15]. The present result was totally contradictory to those in other studies. Different characteristics and cultural backgrounds of the participants may lead to different results. A study conducted in Portugal reported that the time of illness is the only factor related to SWB and spiritual distress in elderly cancer patients [27]. The results of another study involving advanced cancer patients in an Italian home palliative care setting showed that better SWB level was found in patients with less impaired Karnofsky performance status and fully participating in religious rituals [25]. In the present study, there was only one associated factor identified, and other variables which were proved to be relevant in other studies were not observed. As the regression equation only explained 3.9% of the variation in SWB, there may exist other potential associated factors that were not detected in the present study. In present study, we mainly explored the relationships of sociodemographic and medical characteristics with SWB, and the psychological or social factors were not included. Therefore, further researches were needed to explore the effect of psychological or social factors.

In terms of the relationship between SWB and QOL, previous studies had demonstrated that SWB was significantly related to QOL [18, 25]. In our study, we explored the effects of different dimensions of SWB on various components of QOL. The results showed that higher levels of meaning and peace were related to better QOL, which is in accordance with the results in other studies [14, 19]. A previous study indicated that meaning and peace have a greater association with QOL [28], which was also validated in our study. Additionally, the faith was proved to be not associated with QOL, and this result was consistent with the findings in a study [19], but it was totally inconsistent with the findings in another study, in which it was found that the faith emerged as the only component of spirituality that was related to QOL in cancer patients who were close to death [29]. The different relationship may be due to the fact that these patients had different characteristics that might affect their spirituality and QOL. We also found that the faith had different effects on each dimension of QOL. It had significant negative associations with physical well-being and emotional well-being, but had a positive association with functional well-being. However, this result was not consistent with that in another study in which it was found that the faith was positively associated with emotional well-being and social/family well-being [30].

Strengths and limitations

There are several limitations of this study. The current study is a cross-sectional descriptive study which only investigates the spirituality and explores the association of spirituality with clinical factors and QOL at a certain point in time. A longitudinal study is needed to observe the variation of SWB among cancer patients during the treatment and post-treatment and explore its relationships with outcomes (mortality), re-admissions due to complications, risk of complications, and other clinical factors. Additionally, the representativeness of the sample was limited. A multi-center investigation is needed to explore the SWB in patients with a larger sample size to help us understand the effect of spirituality in Chinese cancer patients comprehensively and objectively. In spite of these limitations, the present study has some notable advantages. Although many studies focus on spirituality of cancer patients, fewer studies are conducted to explore the spirituality in the context where formal religion is not developed. This study contributes to a comprehensive understanding of spirituality from a non-religious perspective.

Clinical implications: integration of spiritual care into cancer care

A better understanding of SWB and its effect on health-related QOL may help tailor the use of spiritual interventions. Spiritual care, which is usually given in a one-to-one relationship, is completely person centered and makes no assumptions about personal conviction or life orientation, which is not necessarily religious [31]. It can be concluded from this study that spiritual care is an essential element of care for cancer patients. However, there are still many issues to be settled, for example, how and when is the spiritual care delivered to non-religious cancer patients? Who will be the main intervener and what is the role of medical staff?

The evidence proved that spiritual therapy interventions such as relaxation, meditation, control, identity, and prayer therapy are effective in improving spiritual well-being and quality of life [32]. What’s more, reminiscence, life story, creative activities, meaningful rituals, presence, and listening [33] are beneficial to “meaning making” and “life review,” which are important in spiritual process [34]. Further studies are needed to verify the effects of these measurements among non-religious cancer patients. However, one thing is for certain: we should accept the patients while remaining true to ourselves and make it clear how non-religious patients develop their spirituality before delivering spiritual care [3].

Apart from the spiritual interventions, the person who delivers the interventions is also important. Although the role of all health care professionals in spirituality is acknowledged, it’s not clear what their duties are yet. In China, we still do not know who is the most appropriate people to be engaged in the management of spirituality such as assessment, screening, and intervention, and the best time for delivering spiritual care is also uncertain. In religious context, spiritual care was provided by chaplains. However, most of patients with seriously illness would like to discuss their religious/spiritual beliefs with chaplains, while the minority of patients would like to discuss their religious/spiritual beliefs with medical staff [35]. Therefore, before spiritual care is delivered, researchers need to investigate what kind of spiritual care is preferred by non-religious patients and whom the patients want to discuss their religious/spiritual beliefs with.

It’s necessary for us to learn how to enable the medical staff to be competent in spiritual care. Training should be carried out to enhance the ability of health care professionals to deliver spiritual care consistent with their knowledge, skills and actions, and the ability [36]. To our best knowledge, there is not any training curriculum available for oncology providers to be competent for spiritual care in China. In other countries and regions of the world, there is a lack of researches in this area.

Conclusions

In conclusion, the hospitalization frequency is the only influencing factor related to SWB. Strong associations exist between different aspects of SWB and QOL (physical well-being, emotional well-being, social/family well-being, functional well-being). Further studies should be carried out to identify whether the interventions targeting on SWB, especially meaning and peace, is effective in improving QOL in cancer patients.