Introduction

The Latino/a population is the largest minority population in the USA and is the fastest growing demographic group (U.S. Census Bureau 2011). With a growth rate that is four times that of the general population, Latinos now comprise approximately 16 % of the total US population, 50.5 million people (U.S. Census Bureau 2011; Siegel et al. 2012). Latinos hail from diverse regions: The Mexican-origin population represents the fastest growing Latino group, at 31.8 million, followed by the Puerto Rican population, which grew by 36 %, increasing to 4.6 million in 2010, followed in size by Cubans, who increased by 44 % to 1.8 million in 2010.

The American Cancer Society estimates that there will be about 112,800 new cancer cases among the Latino population over the next ten years and 29,935 deaths (ACS 2012). Eighteen percent of the expected deaths in Latino men will be from lung cancer, followed by colorectal cancer at 11 %; 15 % of the expected deaths in Latina women will be from breast cancer, followed by 13 % from lung cancer (Howe et al. 2006). Cancer impacts multiple aspects of a person’s life and health, including psychological, functional, emotional, spiritual, economic, and social (Aziz and Rowland 2003). During the initial response to a cancer diagnosis, emotional feelings of shock, disbelief, despair, anger, fear, sorrow, and uncertainty may prevail, and a person can experience serious distress that can be detrimental to his/her overall health and well-being.

Going through adverse life events can help a person learn how to cope with life’s challenges, overcome them, learn from the adverse experiences, grow, and be positively transformed by them (Grotberg 1995). Some people with cancer manifest resilience in the face of the adversity and challenge (Londoño 2009). Human resilience has broadly been defined as the ability of humans to cope and adapt when faced with tragedy, trauma, adversity, hardship, and life stressors while maintaining normal psychological and physical functioning (Wu et al. 2013; Newman 2005); it is the ability to adapt or “bounce back” after adversity and challenge (Wagnild and Collins 2009). According to Londoño (2009), the attachment to life (desire to live and the family as a reason for living) and the development of a positive mindset, either as a personality trait or developed during the cancer disease process, are essential for successful adaptation to the disease.

Factors that promote resilience include a person’s beliefs, spirituality, religious assets, good relations with others, confidence, and self-esteem, among others. Spirituality has been shown to be a key in promoting resilience among older adults (Manning 2012; 2013; Vahia et al. 2011; Moberg 2005; Koeing et al. 2004; Abraido-Lanza et al. 2004). Research has focused on understanding the association between spirituality and resilience as a variable associated with successful aging, rather than as part of a pathway to resilience in cancer patients and cancer survivors. In fact, remarkably little research has examined the role of spirituality in cancer-related resilience, particularly in the Latino/a population.

In this paper, we will discuss spirituality as an integral part of the conceptual bridge between coping and resilience. We will explore the literature that has intended to establish a connection between resilience and spirituality among the Latino population, and its implication for well-being in Latino cancer patients and cancer survivors. Understanding how to facilitate resilience in the face of potentially negative life events, such as cancer, can not only help Latino cancer patients in active treatment, but can also impact effectiveness of managing and coping with the consequences of cancer during survivorship.

Process of Human Resilience

The vast majority of studies on the processes that encompasses human resilience have focused on understanding why some people are able to overcome adversity and stressful life events while others succumb to adversity. This has propelled interest in understanding aspects of human development that facilitate the overcoming of adversity or stress, and in finding ways to deal with disruptive events or challenging situations (Earvolino-Ramirez 2007). The study of resilience has not only focused on facilitative internal factors (related to personality and genetic factors) but also on external factors found in the social context and social experiences as important contributors to resilient responses toward trauma and stress (Wu et al. 2013; Luthar et al. 2000).

The scope of research in this area has provided knowledge of a multidimensional concept that envelops several characteristics identified as resilience. These include hardiness, coping, self-efficacy, optimism, patience, tolerance, faith, adaptability, self-esteem, sense of humor, having and maintaining good relations with others, having an optimistic world view, keeping things in perspective, setting goals and working toward them, and possessing confidence (Grafton et al. 2010; Luthar et al. 2000). Building resilience is an individualized process that relies greatly on each individual’s strength, skills, and experience (Newman 2005).

Resilience in Cancer

Cancer survivors may show a great deal of resilience in the face of illness (Rowland and Baker 2005). Positive and negative emotions are both experienced when going through severe adverse experiences such as cancer (Aspinwall and MacNamara 2005; Tugade et al. 2004). Aspinwall and Macnamara (2005) discuss that positive beliefs (e.g., optimism) help people gain coping skills, knowledge, and resources when dealing with illness and other stressors even when it entails dealing with negative information. Aspinwall and Macnamara (2005) further suggest that many people benefit from the cancer experience by showing enhanced quality of life, better interpersonal relationships, and changes in their values and priorities. Seemingly in contrast, Costanzo et al. (2009) found that cancer survivors exhibit poorer psychological functioning in various areas such as environmental mastery, relations with others, and self-acceptance compared to those who have never been diagnosed with cancer. However, their results also demonstrate that after the experience of cancer, people show resilient functioning through social well-being, spirituality, and personal growth. Wenzel et al. (2002) found that long-term survivors seem to experience good QOL through satisfaction with life, supportive relationships, and existential well-being such as hopefulness, purpose in life, and positive changes in spirituality related to cancer. The cancer experience can serve as an opportunity to build on resilience and to implement different ways to respond to life’s stressors to cope and adapt successfully.

Although studies have demonstrated how people manifest resilient functioning after such an adverse experience, there is a great gap in knowledge concerning the factors that promote and influence resilience and well-being among ethnically diverse populations, particularly among Latinos facing chronic and/or terminal illness. Little attention has been given to specific coping strategies, such as spirituality, that may provide ways of enhancing mental and physical well-being in this population. Understanding spirituality can be a crucial factor in promoting psychosocial adjustment and well-being among Latinos facing a chronic illness such as cancer, through its impact on building resilience.

Spirituality and Religiosity in Cancer Coping

In a general sense, spirituality can be defined as experiences or expressions in a unique and dynamic process that reflect faith either in a supreme being, or in connection to self, others, or nature (Meraviglia 1999). Activities such as communing with nature, art, community, meditation, contemplation, and religious services can resonate with one’s spirituality, which is an important aspect of making meaning in one’s life (Manning 2012). Spirituality is a resource that supports adaptation and resilience to improve quality of life in patients with cancer or other chronic illnesses (Harris et al. 2010). Dyer (2011) suggests that the diagnosis of cancer can precipitate spiritual reflection when faced with the possibility of death. The initial reaction to a cancer diagnosis may evolve and the person, as a survivor, can find meaning in his/her illness, which can then lead to a deep sense of spirituality (Vachon 2008). Other studies have also found that people experience greater spirituality following a cancer diagnosis (Costanzo et al. 2009).

Religion or religiosity is a concept which often overlaps with the concept of spirituality. Spirituality may, but does not necessarily, have a connection with a specific religious belief, whereas religiosity is the behavioral expression of spirituality through different activities and practices which are intertwined with a particular religious denomination (Campesino and Schwartz 2006). Religion is linked to a formal or collective context, while spirituality involves self and the inner state of being (George et al. 2000). Religion can provide social support, coping resources, and a sense of self-esteem or self-worth. Religious traditions and rituals offer metaphors to understand and face the possibility of death, (Dyer 2011) and these metaphors can help people find balance during the cancer experience.

Both religious and spiritual practices (e.g., meditation, prayer, and worship) have been found to prompt positive emotions such as love, hope, faith, and forgiveness that, in turn, lead to stress reduction (Mueller et al. 2001). Meraviglia (2006) conducted a study to examine the influence of spirituality, particularly the sense or meaning of life and the use of prayer, on the well-being of women who have been diagnosed with breast cancer. Seventy-one percentage of women with breast cancer believed they had a close relationship with God, and 51 % reported praying three to four times a day. Those women who reported high levels of psychological well-being also reported being diagnosed at an earlier stage, had higher-functioning, and had closer relationships with God. Women who reported having more meaning in life were older, reported close relationships with God, and had greater satisfaction with their economic income. Women who practice prayer on a consistent basis reported a close relationship with God, had lower educational attainment, and lower income to meet their needs, but higher psychological well-being (Meraviglia 2006).

Spirituality and Religiosity in Latinos

For Latinos, spirituality is an important core cultural value. Spiritual beliefs are seen in Latinos mainly through religious practices such as attending church and prayer (Ashing-Giwa et al. 2006). Faith experiences are interconnected with family life and the community of which they are a part (Campesino et al. 2009). Spirituality provides a particular path for coping with health and illness in Latina women (Jurkowski et al. 2010; Mickley and Soeken 1993). It promotes faith that the person will be able to get better, putting trust in God as He will provide guidance. As such, there may be acceptance of the illness (Zea et al. 1994). Overall, cultural values may influence a person’s experience with illness and decisions regarding that illness. As such, it is crucial to pay close attention to how cultural values play a role in health-related concerns when caring for Latino cancer patients, and to how spirituality, being an important aspect of Latino culture, influences how Latinos adjust and cope with cancer.

Religion and spirituality have a significant role through the cancer experience as they are embedded in Latino health beliefs and are important in cancer coping responses (Jurkowski et al. 2010; Erwin et al. 2007; Culver et al. 2002). Religious beliefs provide a different perspective of the cancer experience and of the future (Aquino 2007). Juarez and collaborators (1998) found in a study with Latino cancer patients that their perceptions of quality of life were based on acceptance of God’s will and religious beliefs, among other factors. Prayer and reading the bible were identified as sources of spiritual well-being that provided strength and comfort. The illness was acknowledged to have a positive impact by enhancing faith and spiritual beliefs. In Kellison’s (2002) work with Latina breast cancer patients, spirituality was found to be the coping strategy used primarily at the time of diagnosis, along with other associated factors such as faith, religion, church, God, and/or prayer. Moreover, spirituality served as an explanation for the illness; the cancer was viewed as an event that brought strength as a result of spirituality. Similarly, in a study with Latina breast cancer survivors, Ashing-Giwa et al. (2006) found that although the illness made them feel vulnerable, it also strengthened their spirituality. Overall, spirituality helped them endure the cancer experience and provided them personal insight and comfort (Ashing-Giwa et al. 2006). Religious practices, such as attending church and prayer, are coping resources that provide strength during the recovery process of cancer treatment and help alleviate suffering (Ashing-Giwa et al. 2006; Ashing-Giwa et al. 2004; Juarez et al. 1998).

The influence of faith and spirituality is predominant in the recovery process as they provide support, a positive outlook (Coreil et al. 2012; Ashing-Giwa et al. 2006), and security and comfort to manage the challenges arising from illness (Ashing-Giwa et al. 2004). Furthermore, in studies, Latinos have expressed gratitude toward God as a source of strength in coping with diagnosis and treatment, and in helping patients to understand the meaning of the cancer experience which, ultimately, has enhanced their faith (Fatone et al. 2007; Juarez et al. 1998).

Building Resilience Through Spirituality in Latinos

Resilience can be promoted through many means, including through spirituality in those for whom this is concordant with their values. Tapping into spirituality can enhance coping mechanisms in negative life events (Vahia et al. 2011) and can promote recovery by providing faith and hope in being able to surpass the experience of chronic illness and regain health. Fatone and collaborators (2007) found that after a breast cancer diagnosis, Latina women viewed faith as an important aspect of coping with their illness.

However, there are important gaps in the spirituality and coping literature vis-a-vis Latinos and cancer. The majority of spirituality studies focus on non-Latino Whites (Vahia et al. 2011; Costanzo et al. 2009). There is some evidence that spirituality and religious coping are crucial among Latinos/as facing a chronic illness (e.g., Abraido-Lanza et al. 1996; Puchalski et al. 2004; Simoni and Ortiz 2003) but there have only been two published papers on spirituality and religion as forms of coping and psychosocial adaptation, and as a pathway to resilience, among Latinos cancer patients and survivors.

Maliski et al. (2012) conducted a study with underserved Spanish-speaking Latino men with prostate cancer. They found that spirituality was manifested through faith and trust, and that coping with treatment-related side effects was manageable through an alliance of support based on God, the doctors, and self, which gave the men strength to manage the effects of the disease and treatment and maintain hope for the future. This alliance emphasized faith and God controlling their time of death. A study examining coping resources and health status of Latina breast cancer survivors within one to 5 years of diagnosis found that spirituality served as an intrapersonal factor associated with adaptation and was a coping resource (Napoles et al. 2011). Furthermore, this study found that spirituality was associated with better quality of life and provided cancer survivors with a sense of worth.

Implications for Clinical Practice

With the growing interest among mental health professionals in spirituality, what are its implications in the clinical context and why should it be acknowledged? As the research reviewed above indicates, both spirituality and religion serve as important coping resources and help some patients adapt to cancer treatment. As a coping resource, spirituality should be a matter of consideration for clinical practice as it can be beneficial for building resilience and can, ultimately, lead to enhanced QOL. Resilience can be fostered through different mechanisms, such as spirituality, to help promote better adjustment to treatment and positive psychosocial outcomes (Molina et al. 2014). Therefore, it is crucial that clinicians at the very least acknowledge patient’s spirituality as it impacts a person’s coping and adjustment to illness. Aspects of spirituality, as well as religiosity, may especially have significance among Latinos in coping and overcoming illness adversity while providing faith and hope.

Integrating the patient’s spiritual and religious beliefs and needs into clinical practice should be explored during the initial encounter to develop an understanding of how particular beliefs play a role in how the person adapts to the illness, treatment, and life after diagnoses. Implementing a spiritual history or spiritual/religious assessment (formal or informal) can be beneficial as it can identify the importance of spiritual matters to the patient, help address concerns that the person may have regarding spiritual issues, can guide targeted interventions, an can uncover other sources of support (e.g., congregations) (Mueller et al. 2001; Post and Wade 2009). Understanding patients’ spirituality may provide a bridge between the clinician and patient that can help focus interventions on aspects pertaining to patients’ spiritual issues or concerns (Aten 2009). Establishing guidelines at cancer centers for specific questions regarding this matter may lead to a more thorough understanding of patients’ spiritual and religious beliefs. Josephson and Peteet (2007) provide a guide on ways to explore spirituality and a person’s worldview by inquiring in several areas, such as exploring if the person belongs to a religious or spiritual community that can be identified as a source of support; theological beliefs that the person relies on in order to make sense of the world and the implications of those beliefs in their daily lives; and belief in the existence of God; rituals and spiritual practices and the function they serve in their life; and spiritual experiences. To explore and inquire about a patient’s spiritual beliefs, we present several questions we have developed in order to initiate the conversation such as: “Do you have any spiritual or religious beliefs? Was your spirituality or religiosity an important aspect for you before cancer? Are they important parts of your current experience with illness? Are they a current source of coping for your cancer experience? How important is it to have these aspects be integrated into your health care?”

The physician or healthcare professional may provide the space for patients to discuss their spiritual beliefs through open-ended questions that help broaden the discussion and welcome any responses of how they and their families find meaning and purpose in life. This also allows the physician or healthcare professional to connect in a deep and caring way and to establish an open relationship that may help increase their well-being (Puchalski et al. 2004).

Puchalski et al. (2004) suggests that it is important to listen to patients’ fears, hopes, pain, and dreams while obtaining a spiritual history and to include chaplains as part of the interdisciplinary healthcare team. Collaborations between clinicians and clergy can help lead to holistic care that addresses both psychological and spiritual aspects of religious or spiritual experiences (Aten and Worthington 2009).

There is a lack of research on spirituality as a coping mechanism and pathway to resilience among the Latino/a population. Many of the studies in this area have been conducted with non-Latino Whites. These studies have provided essential information as to the importance of spirituality and religious beliefs as pathways to resilience, but with little focus on the Latinos/as. Despite the central role that religion has in the lives of many Latinos, research should focus on factors that contribute to resilience in this population, taking into consideration particular cultural aspects that help promote well-being.

Research findings can help establish programs and approaches that help foster and promote well-being and resilience in the Latino/a population. Such data could determine targets for interventions focused on promoting optimal psychological well-being in Latinos with cancer. An application of methods for increasing resilience could help improve quality of life and prevent poor life adjustment among this population. Future studies could examine possible interventions that incorporate aspects of spirituality as a bridge to resilience and help improve health among Latinos/as. Establishing programs that are specifically designed to increase resilience can help move patients toward positive life adaptations in the face of their illness.