Int
ern
at
i
onal
Journ
al of
P
u
bli
c Hea
lt
h S
c
ie
nce (IJPH
S)
Vo
l.
8
, No
.
4,
Dec
2019
, p
p.
4
3
8
~
4
5
1
IS
S
N: 22
52
-
8806,
DOI: 10
.11
591/ij
phs.
v8
i
4.203
11
438
Journ
al
home
page
: htt
ps://
ww
w.i
aesco
re
.c
om
/j
our
nals/
ind
ex.
php/IJP
H
S
S
piritu
al we
llb
eing in br
ea
st a
nd
ce
rv
i
cal ca
ncer su
rvivo
rs:
differenc
es
in
each
stage of sur
vivorshi
p
Ni Pu
tu
Wula
n Pu
rn
am
a Sa
ri
Depa
rte
m
ent of P
al
li
a
ti
ve
Nurs
in
g,
W
id
y
a
Manda
la
C
at
hol
ic Univ
ersity
Surab
a
y
a
,
Indone
sia
Art
ic
le
In
f
o
ABSTR
A
CT
Art
ic
le
history:
Re
cei
ved
J
uly
11
, 201
9
Re
vised
Oct
1
0
, 2
01
9
Accepte
d
Nov 30,
2019
Spirit
ual
n
ee
ds
in
ca
n
ce
r
sur
vivors
are
und
era
ppre
ciate
d
c
om
par
ed
to
ph
y
sic
al
and
psy
cho
logical
n
eeds
.
Thi
s
stud
y
ai
m
ed
to
:
1)
co
m
par
e
and
ana
l
y
z
e
th
e
diff
ere
nc
es
in
spiritual
wel
lbe
ing
(
SW
B)
bet
wee
n
bre
ast
a
n
d
c
erv
i
ca
l
ca
nc
er
survivors
(BCS
and
CCS
)
gene
ral
l
y
,
and
bet
we
e
n
stage
s
of
survivorship
spec
ifica
l
l
y
,
and
2)
det
ermine
th
e
be
st
pre
dic
tor
of
SW
B
in
bo
th
ca
ses.
Thi
s
cro
ss
-
sec
ti
ona
l
stud
y
invol
v
ed
58
BCS
and
47
C
CS
(n=
105)
.
Questionna
ir
e
of
QO
L
-
CS
p
art
IV
was
used
in
data
col
lect
ion.
Vari
ous
stat
ist
ical
t
ests
were
u
sed
in
da
ta
anal
y
sis
(
α<
0
.
05).
S
WB
was
signifi
c
ant
l
y
d
if
fer
ent
b
et
we
en
BCS
and
CCS
(p=
0.
0
02),
which
infl
uen
ce
d
b
y
significan
t
di
ffe
ren
c
es
in
rel
i
gious
ac
ti
v
ity
,
s
piri
tual
activit
y
,
unce
rt
ai
n
t
y
,
positi
ve
li
fe
ch
a
nges,
life
go
al
s,
and
hope
(
all
p
<α
).
In
BCS
,
ov
era
l
l
SW
B
was
not
signifi
ca
nt
l
y
diff
ere
n
t
bet
wee
n
survivorship
stage
s
(p=
0.
179)
;
but
rel
ig
ious
ac
ti
vi
t
y
,
l
ife
go
al
s,
and
hope
were
signifi
c
antl
y
diff
ere
n
t
(p=
0.
043,
p=0
.
0
22,
and
p=0.
036
respe
ct
iv
ely
)
which
indi
c
ate
that
the
se
three
aspe
ct
s
ch
ange
over
ti
m
e
a
long
with
the
survivo
rship
stage
s.
W
hil
e
in
CCS
,
SW
B
and
al
l
of
it
s
aspe
ct
s
were
n
ot
signi
fic
an
tly
differe
nt
bet
wee
n
survivorship
stage
s
(
al
l
p>
α
)
which
indicate
th
at
SW
B
is
stabl
e/
stagn
an
t
ac
ross
the
survi
val
l
ife
span
in
CCS
.
Spirit
ua
l
li
fe
cha
ng
es
a
nd
rel
ig
ious
ac
t
ivi
t
y
ar
e
the
best
pre
dic
to
rs
of
SW
B
in
both
ca
ses
and
were
ac
c
ounte
d
fo
r
70.
3%
(R
2
=0.
70
3)
and
69.
7%
(R
2
=0.
697)
var
i
a
nce
of
SW
B
in
BCS
and
CCS
respe
ctively
.
Ke
yw
or
d
s
:
Breast
cance
r
Ca
ncer
survi
vor
Ce
rv
ic
al
ca
nce
r
Sp
irit
ual
well
be
ing
Well
bein
g
Copyright
©
201
9
Instit
ut
e
o
f Ad
vanc
ed
Engi
n
ee
r
ing
and
S
cienc
e
.
Al
l
rights
reserv
ed
.
Corres
pond
in
g
Aut
h
or
:
Ni P
utu
Wu
la
n Pu
rnam
a Sari,
Dep
a
rt
m
ent o
f Pal
li
at
ive N
urs
ing
,
W
i
dya Ma
nd
al
a Cat
ho
li
c
Un
i
ver
sit
y S
ur
a
ba
ya
,
Jl. Ray
a K
al
isa
ri Selat
an 1,
Pa
kuw
on Ci
ty
, Sur
a
baya
60112, I
ndonesi
a.
Em
a
il
: wu
la
npurnam
a@u
kw
m
s.ac.id
1.
INTROD
U
CTION
Ca
ncer
sta
rts
wh
e
n
cel
ls
gro
w
ou
t
of
c
on
t
r
ol
an
d
c
r
owd
out
no
rm
al
cells
[
1].
Ca
nce
r
is
the
gr
ow
t
h
of
new
cel
ls
that
fo
rm
abn
orm
al
ti
ssu
e
and
char
act
e
rized
by
un
c
ontr
olled
f
un
ct
io
n
.
Ca
ncer
is
not
j
ust
one
disease,
it
can
sta
rts
in
var
io
us
pa
rts
of
ou
r
body.
In
wom
en,
m
os
tl
y
c
ancer
sta
rts
in
the
br
east
or
cerv
i
x.
A
stud
y
in
18
7
countries
fro
m
19
80
unti
l
20
10
was
c
ondu
ct
ed
to
analy
ze
the
epidem
ic
of
cer
vical
and
br
east
cancer
inci
dence
an
d
m
or
ta
li
ty
world
wide
[
2].
Re
s
ults
s
howed
that
g
lo
ba
l
br
ea
st
canc
er
incide
nce
i
ncrea
se
d
from
64
1,0
00
(
95%
un
certai
nty
intervals
610,0
00
–
750,0
00)
cases
in
1980
to
1,643,0
00
(1,42
1,000
–
1,7
82,00
0)
cases
in
20
10,
a
n
a
nnual
rate
of
i
nc
rease
of
3.1%
.
Gl
ob
al
ce
r
vical
cancer
incid
enc
e
increase
d
from
378,0
00
(2
56,
000
–
48
9,000
)
cases
pe
r
ye
a
r
in
19
80
to
45
4,0
00
(
318,0
00
–
62
0,000
)
case
s
pe
r
ye
ar
in
2010
—
a
0.6%
an
nual
rate
of
inc
rease.
Nati
onal
ly
,
the
inciden
ce
of
breast
cancer
occupie
d
the
first
po
sit
io
n
f
ollo
wed
by
cerv
i
cal
cancer
in
2
nd
po
sit
io
n
in
Indonesia
n
canc
e
r
sta
ti
sti
cs
of
2014
[
3].
No
t
hing ch
a
ng
ed
m
uch
thr
ee
ye
ars
after,
i
n
2017
breast
ca
ncer
sti
ll
reach
ed
the
1
st
posit
ion
as t
he
hi
gh
e
st new
cases an
d deat
hs
fo
ll
owe
d by cer
vical
cance
r
in
2
nd
posit
ion
in
In
donesia
n
ca
ncer st
at
ist
ic
s [
4]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Sp
iri
tu
al wel
lb
ei
ng
i
n bre
as
t
and
ce
rvi
cal c
an
ce
r s
ur
vi
vor
s:d
if
fe
rence
s
in
… (
Ni
Pu
tu W
ul
an
Purn
ama S
ar
i
)
439
The
li
fe
ex
pect
an
cy
o
f
pe
ople
li
ving w
it
h
ca
ncer
inc
reases steadil
y,
due
t
o
ad
va
nces
i
n
diagnosis
a
nd
thera
py,
m
aki
ng
ca
ncer
on
e
of
the
non
-
c
omm
un
ic
able
diseases
(
NCD)
with
lo
ng
te
r
m
bu
rd
e
n
need
e
d
long
-
te
rm
su
pport
ive
a
nd
pa
ll
ia
ti
ve
care.
The
sta
ge
of
survi
vors
hip
in
canc
e
r
ca
te
gorizes
into
three
,
nam
ely:
acute
(<1
ye
ar),
short
te
rm
(1
-
5
ye
ars
),
an
d
lo
ng
te
rm
su
rv
iv
ors
hip
(>5
ye
ar
s)
[
5].
Locall
y,
a
pr
i
or
st
ud
y
to
wa
rd
s
279
wo
m
en
li
ving
with
cancer
i
n
Sur
abaya’s
c
ommun
it
ie
s
sho
we
d
that
nowa
days
m
os
t
wo
m
en
li
vin
g
with
breas
t
cancer
wer
e
a
ge
d
m
idd
le
-
up
ad
ul
tho
od
wh
il
e
ol
der
a
ge
we
re
f
ound
in
th
os
e
with
c
erv
ic
al
ca
ncer
;
the
m
ajo
rity
ha
s
bee
n
diag
nosed
with
ca
nce
r
f
or
le
ss
tha
n
five
ye
ar
s,
bu
t
ther
e
was
a
te
nd
e
nc
y
that
the
lon
ge
r
li
fe
exp
ect
a
ncy
was
f
ound
in
tho
se
with
cerv
ic
al
cance
r
;
m
or
e
wo
m
en
with
adv
a
nce
d
sta
ge
cer
vical
cance
r
w
ere
f
ound to
b
e l
ong
-
te
rm
su
r
vivor
s [6].
Most
ind
i
vidua
ls
con
si
der
s
pi
ritual
it
y
and
re
li
gio
sit
y
to
be
central
an
d
s
o
fun
dam
ental
to
the
hum
an
exp
e
rience
tha
t
they
re
pr
ese
nt
an
in
de
pende
nt
dim
ension
of
pe
rsonali
ty
[7
]
.
Sp
irit
ualit
y
and
reli
gi
os
it
y
are
rooted
in
cult
ur
e
,
and
c
ultu
re
is
ro
ote
d
in
sp
irit
ualit
y
and
reli
gio
sit
y
[8
]
.
Eve
n
th
ough
reli
gio
sit
y
and
sp
irit
ualit
y
are
relat
ed,
t
hey
are
not
syn
onym
ou
s
and
m
ay
differ
with
re
gards
t
o
predic
ti
on
of
va
ri
ous
healt
h
ou
tc
om
es
[9
]
.
Sp
irit
ualit
y
is
t
he
relat
io
ns
hi
p
people
ha
ve
w
it
h
a
force
or
powe
r
bey
ond
t
hem
sel
ves
that
helps
them
feel
con
nected
a
nd
en
rich
their
li
ves
,
w
hile
r
el
igio
n
is
a
sp
eci
fic
set
of
belie
fs
or
pr
act
ic
es
usual
ly
connecte
d
t
o
an
orga
nize
d
group
[
10]
.
Ju
st
as
reli
gio
sit
y
and
s
pirituali
ty
are
relat
ed
ye
t
diff
e
r
in
predi
ct
ive
abili
ti
es,
nonthe
ist
ic
and
t
heis
ti
c
sp
irit
ualit
y
m
ay
be
sim
il
ar
with
re
gards
t
o
c
or
e
co
ntent,
but
they
m
ay
diff
e
r
with
re
gards
t
o
pre
dicti
on
of
healt
h
outc
om
es
.
No
t
on
ly
do
patie
nts
wan
t
thei
r
hea
lt
hcar
e
pro
vi
de
rs
to
ackno
wled
ge
sp
irit
ualit
y
as
par
t
of
t
heir
identit
y,
e
m
pirical
literat
ure
su
pp
or
ts
the
relat
ion
s
hip
betwee
n
sp
irit
ualit
y/
relig
iosit
y an
d var
iou
s
m
ental
h
eal
th and
ph
ysi
c
al
h
eal
th
outc
om
es [
11]
.
Re
su
lt
s
of
a
li
te
ratur
e
re
view
showe
d
tha
t
reli
gio
sit
y
a
nd
s
pirituali
ty
sign
ific
antly
con
t
rib
ute
to
ps
yc
hos
ocial
a
dju
stm
ent
to
c
ancer
an
d
it
s
t
reatm
ents.
Re
l
igion
offe
rs
ho
pe
to
th
os
e
suffe
rin
g
f
r
om
c
ancer
,
and
it
h
a
s b
ee
n fou
nd
t
o
ha
ve a
p
osi
ti
ve
eff
ec
t on
the
qual
i
ty
o
f
li
fe
of
ca
nc
er p
at
ie
nts
. Nu
m
ero
us
stu
dies h
av
e
fou
nd
t
hat
reli
gion
a
nd
s
pirit
ualit
y
al
so
pro
vid
e
e
ff
ect
ive
cop
i
ng
m
echan
ism
s
fo
r
ca
nc
er
patie
nts
a
s
well
as
fam
i
ly
caregiv
ers.
Re
searc
h
ind
ic
at
es
that
c
ancer
patie
nts
who
rely
on
spi
ritual
and
reli
gious
belie
fs
t
o
co
pe
with their ill
ne
ss ar
e m
or
e li
ke
ly
to
us
e an a
ct
ive copin
g
sty
le
in
wh
ic
h
th
ey
accept thei
r i
ll
ness
and try t
o
deal
with
it
in
a
posit
ive
and
pur
po
s
ef
ul
way.
Fait
h
-
based
co
m
m
un
it
ie
s
al
s
o
off
er
a
n
ess
entia
l
so
urce
of
so
ci
a
l
su
pp
or
t
to
ca
nc
e
r
patie
nts,
a
nd
reli
gi
ou
s
org
anizat
ion
s
ca
n
play
a
direct
a
nd
vital
ro
le
in
cancer
pr
e
ve
nt
ion
by
pro
vid
in
g
sc
re
enin
g,
c
ounse
li
ng, a
nd educat
i
on
al
pro
gr
am
s,
especial
ly
in m
ino
rity
co
m
m
un
it
ie
s
[
12
]
.
W
el
lbein
g
has
been
ass
ociat
e
d
with
ph
ysi
cal
healt
h
an
d
lo
n
gev
it
y,
so
ci
al
pros
pe
rity
and
s
at
isfact
ion
,
as
well
as
occ
up
at
io
nal
s
ucc
ess
[
13
-
15
]
.
A
ccordin
g
t
o
s
oc
ia
l
determ
inatio
n
t
heory
,
wel
lbeing
is
pr
e
dicte
d
on
the
basis
of
en
vir
on
m
ental
con
diti
ons
in
w
hi
ch
an
in
div
id
ua
l
is
nested,
by
sat
isfyi
ng
the
basic
ps
yc
hol
ogic
al
needs
for
aut
onom
y,
co
m
petence,
an
d
relat
edn
e
ss
[
16
]
.
Q
ualit
y
of
li
fe
i
n
cance
r
survi
vors
is
form
ed
by
four
dim
ension
s
of
well
bei
ng,
nam
ely:
ph
ysi
cal
,
ps
yc
holo
gical
,
so
ci
al
,
and
s
piri
tual
well
bein
g
[
17
]
.
Unfortu
natel
y,
the
qu
al
it
y
of
li
fe
m
ov
em
ent
h
as
virt
ually
un
de
ra
ppreciat
ed
the
sp
irit
ual
dim
ension
of
li
fe
an
d
the p
a
rt that
suc
h beli
efs
a
nd
pr
act
ic
es
i
n
rel
igiosit
y
play
in
w
el
lbein
g.
The
ta
xono
m
y
of
reli
gi
os
it
y/
sp
irit
ualit
y
in
cente
red
on
t
he
assum
ption
that
m
os
t
reli
gio
sit
y/
sp
iri
tuali
ty
con
str
uc
ts
c
ou
l
d
be
unde
rst
ood
an
d
cat
e
gori
zed
within
one
of
th
ree
pr
im
ary
dim
ension
s
,
nam
el
y:
aff
ect
ive
(e.
g.
r
el
igiou
s
st
rug
gle,
gu
il
t,
sp
irit
ual
well
bein
g,
e
xistenti
al
well
bein
g
)
,
beh
a
vioral
(e.
g.
reli
gious
pr
act
ic
es
an
d
organ
iz
at
io
na
l
reli
gio
usne
ss,
reli
gi
ou
s/
s
piritual
in
vo
l
vem
ent
)
,
and
c
ogniti
ve
reli
gio
sit
y/
sp
iri
tuali
ty
(e.g
.
m
eanin
g,
co
gnit
ive
or
ie
ntati
on
towards
s
pirituali
ty
,
par
an
orm
a
l
belie
fs
)
[18].
It
is
cl
ear
no
w
t
hat
sp
irit
ual
w
el
lbeing
in
ca
nc
er
survi
vors
is
belo
ng
to
th
e
aff
ect
ive
dom
ai
n
of
reli
gio
si
ty
/spiri
tuali
ty
.
A
f
undam
ental
stud
y
ab
out
sp
irit
ual
well
being
i
n
1983
f
ound
that
sel
f
-
est
eem
and
s
piritual
well
bein
g
were
posit
ively
relat
ed
,
w
hile
sp
i
ritual
well
bein
g
an
d
i
nd
i
vidu
al
is
m
,
su
ccess,
and
pe
rs
on
al
f
reedom
wer
e
ne
gativel
y
relat
ed;
t
her
e
was
a
con
sist
e
nt
relat
ion
s
hip
betwee
n
sp
irit
ual
well
bein
g
and
ty
pe
of
rel
igious
com
m
itm
ent
wh
ic
h
s
howe
d
that
ind
ivi
dual
s
with
a
m
or
e
inter
naliz
ed
an
d
intim
at
e
rela
ti
on
s
hip
with
God
not
on
ly
ha
d
highe
r
reli
gious
wel
lbeing
bu
t
al
so
hig
he
r
over
al
l
sp
irit
ual
well
bei
ng
[
19
]
.
T
he
recent
stu
dy
about
reli
gion
a
nd
s
pirituali
ty
in
c
ancer
patie
nts
in
20
19
f
ound
that
cance
r
pa
ti
ents
pr
ay
e
d
m
or
e
and
ha
d
m
or
e
po
sit
ive
reli
gious att
it
ud
e tha
n non
-
ca
nce
r
in
div
id
uals
who visi
te
d
the tom
bs
, c
onsu
lt
ed
t
he
reli
gi
ou
s
off
ic
ia
ls,
and
m
or
e,
i
n
wh
ic
h
reli
gi
ous
wo
m
en
we
re
m
or
e
posit
ive
than
reli
gious
m
en
wh
ic
h
i
nf
l
uen
ce
d
by
lowe
r
edu
cat
io
n
le
vel
;
fo
r
giv
e
ness
,
s
piritual
val
ues,
and
belie
fs
w
ere
stron
ger
i
n
cancer
patie
nt
s
than
in
non
-
c
ancer
ind
ivi
du
al
s
[20
]
.
Although
w
om
en
wer
e
f
ound
to
be
m
or
e
reli
gious
tha
n
m
en,
bu
t
thi
s
recent
stu
dy
did
no
t
on
ly
s
pecified
the
m
easur
em
ent
on
f
e
m
al
e
cancer,
bu
t
al
s
o
di
d
not
m
easur
e
the
c
hang
es
in
reli
gio
sit
y/
sp
iri
tuali
ty
happen
e
d ov
e
rtim
e b
ased
on the c
onc
ept of ca
nce
r
s
urviv
orshi
p.
In
Ind
on
e
sia
,
sp
irit
ual
it
y
is
highly
relat
ed
to
reli
giosi
ty
du
e
t
o
c
ultur
al
con
te
xt.
E
very
ci
ti
zen
in
Ind
on
esi
a
has
a
reli
gion
in
wh
ic
h
they
tr
ul
y
belie
ve
an
d
this
dete
rm
in
e
their
daily
r
el
igiou
s
an
d
s
piritual
act
ivit
y,
wh
ic
h
in
flue
nce
th
ei
r
sp
irit
ualit
y
to
s
om
e
extend.
Life
eve
nt
of
seri
ou
s
il
lness,
su
c
h
as
cancer
,
m
ay
be
per
cei
ved
i
nto
var
i
ous
per
ce
ption
by
ind
i
viduals.
It
co
uld
be
pe
rceive
d
as
a
punis
hm
ent,
a
tria
l,
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci.
Vo
l
.
8
, N
o.
4
,
Dece
m
ber
201
9
:
4
3
8
–
4
5
1
440
or
a
wa
rn
i
ng
from
Go
d,
an
d
this
per
c
epti
on
m
ay
chan
ge
overti
m
e
as
influ
e
nce
d
by
var
io
us
fact
or
s
in
the
proces
s.
A
stud
y
to
wards
254
Mu
slim
wo
m
en
with
c
erv
ic
al
cance
r
sh
owe
d
that
th
os
e
w
ho
pe
rce
ive
d
the
disease
as
a
punish
m
ent
from
Go
d
w
ere
pro
ve
d
to
had
l
ow
e
r
od
ds
of
hav
i
ng
ha
d
Pa
p
te
sti
ng
after
con
t
ro
ll
in
g
f
or
so
ci
o
-
dem
og
raphic
facto
rs
[21]
.
Si
m
il
ar
stud
y
in
Musli
m
wo
m
en
with
br
east
cancer
is n
ot foun
d
ye
t.
Sp
irit
ual
well
be
ing
is
reall
y
im
po
rtant
to
be
stud
ie
d
beca
use
this
is
on
e
of
the
dom
ai
ns
determ
ining
qu
al
it
y
of
li
fe
in
cance
r
s
urvivors.
This
st
udy
aim
ed
to
:
1)
com
par
e
an
d
analy
ze
the
di
f
fer
e
nces
in
sp
i
ritual
well
bein
g
bet
ween
BC
S
a
nd
CC
S
ge
ner
al
ly
,
and
bet
wee
n
sta
ges
of
s
urviv
or
s
hip
in
both
cases
s
pec
ific
al
ly,
and
2)
determ
ine
the
best
predict
or
of
s
piritual
well
bein
g
in
bot
h
case
s.
By
know
i
ng
this
stu
dy
r
esults,
it
will
be
be
ne
fici
a
l
for
de
ve
lop
in
g
a
de
quat
e
s
piritual
s
uppo
rt
m
ulti
dis
ci
plinary
,
dete
rm
ining
w
hich
gro
up
who
m
or
e
in
need
,
w
he
n
is
t
he
best
tim
e
to
pr
ovide
s
piritual
su
pp
or
t
f
or
cancer
survi
vors
,
an
d
wh
ic
h
aspect
of
sp
i
ritual
well
being
that
re
quires
sp
eci
al
at
te
ntion
f
ro
m
h
eal
th
care
pro
f
essionals
.
It
is
i
m
po
rtant
t
o
a
ddress
the
s
piritual
ne
eds
of
cance
r
s
urviv
ors
a
ppropr
ia
te
ly
to
ass
ur
e
opti
m
u
m
qu
al
it
y
of
li
fe
.
Each
ca
nce
r
s
urvi
vor
m
ay
h
ave
diffe
ren
t s
piritual
ne
eds, de
pe
nd
i
ng
on cu
lt
ural
a
nd r
el
igi
ou
s
tra
diti
on
s
.
2.
RESEA
R
C
H
METHO
D
This
C
r
os
s
-
se
ct
ion
al
stu
dy
involve
d
58
BC
S
and
47
CC
S
in
the
di
stric
t
of
Ra
ngka
h,
Ga
ding,
and
Paca
r
kelin
g,
S
ur
a
baya,
I
ndonesi
a
.
The
r
e
wer
e
27,
45,
and
33
ac
ute,
s
hort
-
te
rm
,
and
long
-
te
rm
su
rvi
vors
par
ti
ci
pated
i
n
this
stud
y
res
pe
ct
ively
.
CC
S
was
47,
a
nd
BC
S
was
58.
Sa
m
ple
s
iz
e
was
105.
In
cl
us
io
n
crit
eria
w
ere
bein
g
an
ad
ult
(>
18
ye
ars
old),
wi
th
cancer
diagnosis
that
ha
s
been
c
onfi
rm
ed,
and
re
gu
la
rly
ho
m
e
-
visit
ed
(
on
ce
a
wee
k)
by
a
palli
at
ive
volu
nteer
unde
r
the
s
up
e
rv
isi
on
of
Ra
ng
kah
P
ub
li
c
Heal
th
C
ente
r
(P
HC
)
,
S
ur
a
ba
ya
.
Excl
us
io
n
crit
eria
we
re
r
ejecti
on
on
fil
li
ng
out
the
c
on
s
ent
f
or
m
,
ver
y
poor
c
on
diti
on
,
and
c
on
sci
ousn
ess
loss
or
diso
rie
ntati
on
.
“Ve
ry
poor
co
ndit
ion
”
was
m
easure
d
qual
it
at
ively
by
the
researc
he
r.
The
cl
inica
l
sign
s
wer
e:
unable
to
wake
up
f
r
om
the
bed
(
be
d
re
st),
av
oid
i
ng
gu
e
st,
extrem
el
y
fati
g
ue;
so
that
the
researc
her
can
no
t
m
eet
the
in
div
id
ual.
Total
sam
pling
was
app
li
ed
an
d
sa
m
ple
siz
e
of
105
was
obta
ined
.
The
re
searc
he
r
go
t
th
e
pat
ie
nts’
data
fro
m
Ra
ng
kah
P
HC
via
the
head
of
the
palli
at
ive
vo
l
un
te
e
r
gro
up.
T
he
resea
rc
her
the
n
did
“
door
to
do
or
”
data
colle
ct
ion
by
com
pan
i
on
of
the p
al
li
at
ive
volu
nteer
beca
use
the
researc
he
r was
unfam
iliar for
the
patie
nts.
Qu
est
i
onnaire
of
Q
ua
li
ty
of
Life
-
Ca
ncer
Su
r
vi
vors
(QO
L
-
CS)
pa
rt
I
V
wh
ic
h
dev
el
oped
by
Fer
rel,
et
al
.
(1
99
5)
was
use
d
in
data
colle
ct
ion
[17]
.
It
co
nsi
sts
of
seve
n
it
e
m
s
assessi
ng
reli
gious
ac
ti
vity
,
sp
irit
ual
act
ivit
y,
sp
irit
ual
li
fe
changes
,
unce
rtai
nty,
posit
iv
e
li
fe
cha
nges,
li
fe
go
al
s,
a
nd
hope
as
t
he
as
pects
of
s
piritual
we
ll
being
.
S
piritual
well
bei
ng
was
a
sses
sed
by
the
ti
m
e
of
data
colle
ct
io
n
(act
ual
co
nd
it
ion
)
.
Likert
scal
e
of
0
to
10
re
pres
enting
ne
gativ
e
to
posit
ive
at
ti
tud
e
was
us
e
d
to
disti
ng
uis
h
in
div
id
ual
re
sp
onse
reg
a
rd
i
ng
to
wh
ic
h
e
xten
d
changes
ha
pp
e
n
in
eac
h
it
em
:
1)
none=
0,
2)
m
i
ni
m
u
m
=1
-
3,
3)
m
od
e
rate=
4
-
6,
and
4)
m
axi
m
um
=
7
-
10
.
Tota
l
scor
e
then
ca
te
gorized
into
three
cat
eg
or
ie
s,
nam
el
y:
1)
op
ti
m
u
m
wellb
ei
ng
(47
-
70)
,
2)
suf
fici
ent
well
be
ing
(
24
-
46),
an
d
3)
lo
w
well
bein
g
(1
-
23
);
bu
t
t
his
cat
e
gory
was
m
ade
to
eas
e
the
data
prese
nt
at
ion
only
in
r
esult
sect
ion,
a
nd
not
for
sta
ti
sti
cal
analy
sis
pur
po
ses
.
Af
te
r
inst
ru
m
ent
te
sti
ng
proce
dure,
t
his
instr
um
ent
was
pro
ved
to
be
valid
a
nd
hi
gh
ly
reli
able
(
r=0.5
22
-
0.75
1;
Ch
r
onbach’
s
Alpha=0
.71
0).
Data
we
re
c
ollec
t
ed
since
Februa
ry
unt
il
Ma
rch
,
2018.
Et
hical
cl
earance
was
is
su
e
d
by
Faculty
of
Nur
sing, Uni
ver
sit
as A
irla
ngga, S
ur
a
baya,
Ind
onesi
a, w
it
h ce
rti
ficat
e num
ber
of
681
-
KEPK.
Descr
i
ptive
sta
ti
sti
c,
ind
epe
nd
e
nt
sam
pl
e
T
te
st
,
M
ann
-
Wh
it
ney
U
te
st,
on
e
way
ANO
VA
te
s
t
,
Krus
kal
-
Wall
is
H
te
st,
and
sim
ple
li
near
regressio
n
te
st
wer
e
us
e
d
in
data
analy
sis
(α<0.
05).
Data
of
rel
igious
act
ivit
y,
sp
irit
ua
l
act
ivit
y,
sp
ir
it
ual
li
fe
cha
nges,
unce
rtai
nty,
posit
ive
li
fe
c
hanges
,
li
f
e
goal
s,
an
d
hope
wer
e
no
t
norm
al
ly
distribu
te
d
(
al
l
p
<0
.05
)
,
there
f
or
e
Ma
nn
-
Whi
tney
U
te
st
and
Kr
uskal
-
Wall
is
H
te
st
wer
e
use
d
to
analy
zed
the
da
ta
.
In
the
othe
r
ha
nd,
data
of
overall
sp
i
ritual
well
bein
g
was
no
rm
ally
distrib
uted
(p
=
0.384
),
therefo
re inde
p
end
e
nt sam
ple T test
and
one
way A
N
OVA
t
est
w
ere
used
to
a
naly
zed t
he data
.
3.
RESU
LT
S
A
ND
DI
SCUS
S
ION
Ther
e
wer
e
105
res
ponde
nt
s
w
ho
par
ti
ci
pa
te
d
in
this
stud
y
res
pecti
ve
ly
.
All
stu
dy
respo
nd
e
nts
expresse
d
the
ir
agr
eem
ent
to
par
ti
ci
pat
e
in
this
stu
dy,
an
d
they
had
si
gn
e
d
the
co
ns
ent
form
.
Most
respo
nd
e
nts
are
Java
ne
se,
Islam
,
m
arr
ie
d,
ho
us
e
wif
e,
with
Gross
Do
m
est
ic
Pr
oduct
(GDP
)
le
ss
than
m
ini
m
u
m
wag
e
of
Sura
baya
in
20
18
(ID
R
3,300,0
00.00).
E
du
cat
io
na
l
backgro
und,
occ
up
at
io
nal
sta
tus
,
and
GDP
wer
e
bette
r
in
the
gr
ou
p
of
br
east
cancer
.
CC
S
wer
e
m
os
tly
old
er
than
BC
S.
T
hese
res
ults
ind
ic
at
e
that
the
m
ajo
ri
ty
of
fem
al
e
c
ancer
s
uffer
e
d
by
la
te
adu
lt
wo
m
en
with
lowe
r
-
m
idd
le
so
ci
oec
onom
ic
sta
tus
.
More
si
ng
le
wo
m
en
we
re
fou
nd
t
o
hav
e
br
ea
st
cance
r
in
this
st
ud
y
.
Table
1
s
ho
ws
the
dem
ograph
ic
char
act
e
risti
c of stu
dy
respo
ndents
in deta
il
s.
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Sp
iri
tu
al wel
lb
ei
ng
i
n bre
as
t
and
ce
rvi
cal c
an
ce
r s
ur
vi
vor
s:d
if
fe
rence
s
in
… (
Ni
Pu
tu W
ul
an
Purn
ama S
ar
i
)
441
Table
1
.
Dem
og
ra
phic
ch
a
ract
erist
ic
Ch
arac
teristic
Cerv
ical ca
n
ce
r
(n
=4
7
)
Breast cance
r
(n=5
8
)
Fr
eq
u
en
cy
%
Fr
eq
u
en
cy
%
1.
Ag
e (
y
ears old
)
a.
<
21
0
0
1
1
.72
b.
21
-
30
0
0
5
8
.62
c.
31
-
40
d.
41
-
50
e.
51
-
60
f.
61
-
70
g.
>
70
5
11
17
13
1
1
0
.64
2
3
.40
3
6
.17
2
7
.66
2
.13
10
15
15
8
4
1
7
.24
2
5
.86
2
5
.86
1
3
.79
6
.90
2
.
Relig
io
n
a.
Cath
o
lic
b
.
Ch
ristian
c.
Isla
m
0
7
40
0
1
4
.89
8
5
.11
1
11
46
1
.72
1
8
.97
7
9
.31
3
.
Ethn
ic
a.
Ja
v
an
ese
b
.
Madu
ra
n
ese
c.
Ch
in
ese
40
6
1
8
5
.11
1
2
.76
2
.13
57
0
1
9
8
.28
0
1
.72
4
.
Edu
catio
n
al back
g
rou
n
d
a.
Pri
m
a
r
y
sch
o
o
l
15
3
1
.91
11
1
8
.97
b.
S
econ
d
ary
sch
o
o
l
c.
Hig
h
sch
o
o
l
d.
Dip
lo
m
a/
Bach
elo
r
d
eg
ree
e.
Un
ed
u
cated
14
13
2
3
2
9
.79
2
7
.66
4
.25
6
.38
5
26
15
1
8
.62
4
4
.83
2
5
.86
1
.72
5
.
Mar
i
tal
statu
s
a.
Sin
g
le
b
.
M
ar
ried
c.
W
id
o
w
d
.
Div
o
rce
3
39
4
1
6
.38
8
2
.98
8
.51
2
.13
8
36
14
0
1
3
.79
6
2
.07
2
4
.14
0
6
.
Livin
g
at
h
o
m
e
with
a.
Sp
o
u
se
b
.
Ch
ild
ren
c.
Alo
n
e
d
.
Parents
e.
Sib
lin
g
7
.
Occup
atio
n
al statu
s
a.
Full
-
t
im
er
b
.
Par
t
-
time
r
c.
Retir
ed
d
.
Ho
u
sewif
e
e.
S
eeki
n
g
f
o
r
a jo
b
f
.
Un
e
m
p
lo
y
ed
39
17
3
0
0
2
3
0
40
0
2
8
2
.98
3
6
.17
6
.38
0
0
4
.25
6
.38
0
8
5
.11
0
4
.25
30
35
2
11
2
11
2
4
37
1
3
5
1
.72
6
0
.34
3
.45
1
8
.97
3
.45
1
8
.97
3
.45
6
.90
6
3
.79
1
.72
5
.17
8
.
GDP pe
r
m
o
n
th
a.
Less
than
m
in
i
m
u
m
wage
b
.
Mini
m
u
m
w
ag
e
-
IDR
5
m
illio
n
c.
Mor
e than
I
DR
5
m
illio
n
d
.
No
inco
m
e
34
8
3
2
7
2
.34
1
7
.02
6
.38
4
.25
34
14
6
3
5
8
.62
2
4
.14
1
0
.34
5
.17
The
m
ajo
rity
of
res
pondents
i
n
both
groups
wer
e
diag
nose
d
be
fore
20
14
(m
or
e
than
fi
ve
ye
ars
ago),
ind
ic
at
in
g
they
wer
e
lo
ng
te
r
m
su
rv
i
vors.
T
his
fin
ding
in
di
cat
es
that
the
su
r
viv
al
rate
of
breast
an
d
cerv
ic
al
cancer
is
par
ti
cularly
long,
wh
ic
h
m
akes
bo
t
h
t
ypes
of
cancer
a
c
hro
nic
disease
ne
eded
l
ong
te
r
m
care.
Most
respo
nd
e
nts
with
breas
t
cancer
unde
r
took
surge
ry
on
ly
,
both
f
or
cur
at
ive
an
d
palli
at
ive
pu
r
poses.
In
t
he
oth
er
ha
nd,
m
os
t
responde
nts
with
c
erv
ic
al
ca
ncer
unde
rto
ok
a
m
or
e
c
om
plex
r
egim
ent,
wh
i
c
h
wa
s
a
m
od
ific
at
ion
of
s
urger
y
a
nd
c
hem
o
-
rad
i
ot
her
a
py.
T
he
s
urpr
isi
ng
fact
was
1.9%
of
total
res
ponden
ts
pr
e
fe
r
no
t
t
o
unde
rgo
a
ny
the
rap
y
,
they
possi
bly
us
e
al
te
rn
at
iv
e
thera
py
.
Re
gardless
of
m
i
nim
u
m
info
rm
at
ion,
la
ck
of
kn
ow
l
edg
e
,
fina
ncial
pr
oble
m
s,
or
per
s
onal
belie
f
s/pre
fer
e
nce
s
,
these
1.9%
res
pondents
ex
pr
essed
the
ir
go
od
physi
cal
conditi
on
desp
it
e
of
not
getti
ng
any
thera
py.
Table
2
e
xpla
ins
the
prim
ary
data in
detai
ls.
Most
res
ponde
nts
in
bo
t
h
cas
es
ag
ree
d
that
r
el
igiou
s
an
d
spi
ritual
act
ivit
i
es
are
ve
ry
m
uch
im
po
rtan
t
for
thei
r
li
fe,
t
he
y felt
m
axi
m
u
m
ch
ang
es i
n
their s
piritual l
i
fe a
nd
li
fe
as a
whole
po
sit
ivel
y, an
d
they
sti
ll
h
a
d
no
t
on
ly
m
any
li
fe
go
al
s
but
al
so
high
hope
.
Di
ff
e
ren
c
es
betwee
n
ca
ses
co
uld
be
s
een
in
t
he
as
pe
ct
of
un
ce
rtai
nt
y
with
bette
r
outc
om
e
in
BC
S,
in
wh
ic
h
they
m
os
tl
y
felt
m
ini
m
u
m
un
c
ertai
nty
com
p
ared
t
o
m
od
erate
un
c
ertai
nty
in
CC
S.
O
ver
al
l,
op
ti
m
u
m
sp
irit
ual
well
bein
g
was
f
ound
in
BC
S
an
d
CC
S.
Table
3
e
xp
la
i
ns
t
he
c
om
par
ison o
f
s
piritual
w
el
lbein
g bet
ween case
s i
n det
ai
ls.
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci.
Vo
l
.
8
, N
o.
4
,
Dece
m
ber
201
9
:
4
3
8
–
4
5
1
442
Table
2.
Year
of 1
st
diag
nose
d wit
h
ca
ncer,
and the ty
pe
of r
ecei
ve
d
t
her
a
py
Ch
arac
teristic
Cerv
ical ca
n
ce
r
(n
=4
7
)
Breast cance
r
(n=5
8
)
Fre
q
u
en
cy
%
Fre
q
u
en
cy
%
1
.
Firstl
y
diag
n
o
sed
a.
2018
b
.
2017
c.
2016
d
.
2015
e.
2014
f
.
<
2014
0
7
12
5
5
18
0
1
4
.89
2
5
.53
8
.62
8
.62
3
8
.30
4
16
7
10
3
18
6
.90
2
7
.59
1
2
.07
1
7
.24
5
.17
3
1
.03
2
.
Ty
p
e
of
therapy
a.
Su
rger
y
b
.
Ch
e
m
o
th
erapy
c.
Su
rger
y
+
ch
e
m
o
t
h
erapy
d
.
Su
rgery
+
radi
o
th
erapy
e.
Ch
e
m
o
th
erap
y
+
rad
io
th
erapy
f
.
Su
rgery
+
ch
e
m
o
t
h
erapy
+
r
ad
i
o
th
erapy
g
.
Su
rgery
+
ch
e
m
o
t
h
erapy
+
r
ad
i
o
th
erapy
+
an
alg
esic
h
.
Su
rgery
+
ch
e
m
o
t
h
erapy
+
r
ad
i
o
th
erapy
+
m
ed
icin
e
i.
Su
rger
y
+ch
e
m
o
t
h
erapy+
o
ral
m
ed
ic
in
e
j.
Or
al
m
ed
icin
e (
v
ariou
s ty
p
es)
k
.
Un
treated
5
13
2
0
7
17
1
1
0
0
1
8
.62
2
7
.66
4
.25
0
1
4
.89
3
6
.17
2
.13
2
.13
0
0
2
.13
26
8
11
1
1
5
0
0
1
4
1
4
4
.83
1
3
.79
1
8
.97
1
.72
1
.72
8
.62
0
0
1
.72
6
.90
1
.72
Table
3.
C
om
par
iso
n of
s
pi
ritual
w
el
lbei
ng
betwee
n
c
ases
Ch
arac
teristic*
Cerv
ical ca
n
ce
r
(n
=4
7
)
Breast cance
r
(n=5
8
)
Fr
eq
u
en
cy
%
Fr
eq
u
en
cy
%
1
.
Relig
io
u
s activ
ity
a.
Much
i
m
p
o
rtant
b
.
Relativ
ely
i
m
p
o
rtant
c.
No
t i
m
p
o
rtant
43
2
2
9
1
.49
4
.26
4
.26
58
0
0
100
0
0
2
.
Sp
iritual activ
it
y
a.
Much
i
m
p
o
rtant
b
.
Relativ
ely
i
m
p
o
rtant
c.
No
t i
m
p
o
rtant
39
5
3
8
2
.98
1
0
.64
6
.38
51
4
3
8
7
.93
6
.90
5
.17
3
.
Sp
iritual lif
e cha
n
g
es
a.
M
ax
i
m
u
m
b
.
Mod
erate
c.
Mini
m
u
m
36
8
3
7
6
.60
1
7
.02
6
.38
35
15
8
6
0
.34
2
5
.86
1
3
.79
4
.
Un
certa
in
t
y
a.
M
ax
i
m
u
m
b
.
Mod
erate
c.
Mini
m
u
m
7
25
15
14
89
3
1
.91
9
14
35
1
5
.52
2
4
.14
6
0
.34
5
.
Po
sitiv
e lif
e chan
g
es
a.
M
ax
i
m
u
m
b
.
Mod
erate
c.
Mini
m
u
m
38
9
0
8
0
.85
1
9
.15
0
43
13
2
7
4
.14
2
2
.41
3
.45
6
.
Lif
e go
als
a.
M
ax
i
m
u
m
b
.
Mod
erate
c.
Mini
m
u
m
43
4
0
9
1
.49
8
.51
0
57
1
0
9
8
.28
1
.72
0
7
.
Ho
p
e
a.
Hig
h
b
.
Su
f
f
icien
t
c.
Low
43
3
1
9
1
.49
6
.38
2
.13
58
0
0
100
0
0
8
.
Ov
erall
sp
iri
tu
al wellbein
g
a.
Op
ti
m
u
m
b
.
Su
f
f
icien
t
c.
Low
39
8
0
8
2
.98
1
7
.02
0
55
3
0
9
4
.83
5
.17
0
*
Categ
o
ry
was
m
a
d
e to ease the d
ata
p
resentatio
n
on
ly
,
an
d
no
t f
o
r
statis
ti
cal
an
aly
sis
pu
rpo
ses
Descr
i
ptive
sta
ti
sti
c
resu
lt
s
showe
d
that
Me
a
n
an
d
sta
nda
rd
dev
ia
ti
on
(
SD)
of
sp
i
ritual
w
el
lbeing
in
the
case
of
ce
rv
ic
al
cance
r
was
51.34
a
nd
7.57
res
pecti
vely
,
w
hile
for
breast
cance
r
was
55.
71
a
nd
6.
45
resp
ect
ively
.
T
his
ind
ic
at
es
th
at
aver
agely
optim
u
m
sp
irit
ual
well
being
w
as
found
in
bo
t
h
cases,
bu
t
th
e
data
of
s
piritual
we
ll
being
in
B
CS
was
m
or
e
ho
m
og
enous
c
om
par
ed
to
C
CS
beca
us
e
of
l
ow
e
r
S
D
,
a
nd
BC
S
had
sli
gh
tl
y
bette
r
sp
irit
ual
well
bein
g
tha
n
C
CS
due
to
hi
gh
e
r
Me
a
n
.
R
el
igiou
s
act
ivit
y,
sp
irit
ual
a
ct
ivit
y,
un
ce
rtai
nty,
po
sit
ive
li
fe
changes
,
li
fe
goal
s,
a
nd
ho
pe
we
r
e
sign
ific
a
ntly
diff
e
ren
t
betwee
n
cases
(p
=
0.
00
0,
p=0.00
2,
p=
0.002,
p=
0.0
07,
p=
0.0
00,
and
p=
0.000
resp
ect
ively
)
,
i
m
pacti
ng
sig
nificant
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Sp
iri
tu
al wel
lb
ei
ng
i
n bre
as
t
and
ce
rvi
cal c
an
ce
r s
ur
vi
vor
s:d
if
fe
rence
s
in
… (
Ni
Pu
tu W
ul
an
Purn
ama S
ar
i
)
443
diff
e
re
nces
on
sp
irit
ual
well
bein
g
bet
ween
cases
(p
=
0.0
02
).
Sp
i
ritual
li
fe
cha
ng
e
s
wa
s
the
only
asp
ect
of
sp
irit
ual
well
be
ing
w
hich
w
as
no
t
sig
nifi
cantl
y
diff
ere
nt
betwee
n
c
ases
(
p=
0.2
90
).
Table
4
ex
plains
the sig
nifica
nt
diff
e
re
nces in s
pir
it
ual
well
being b
et
ween cas
es.
Table
4.
Sig
nif
ic
ant
d
if
fer
e
nc
es in
s
piritual
w
el
lbein
g betw
een
c
ases
Facto
rs
Cerv
ical Can
cer
(
n
=
47)
Breast Can
cer
(
n
=
5
8
)
Mean d
if
(
CI=9
5
%
)
t
-
statis
tic
p
-
v
alu
e
Mean
SD
Mean
SD
Relig
io
u
s activ
ity
8
.23
1
.62
9
.43
0
.88
-
-
0
.00
0
Sp
iritual activ
ity
7
.62
1
.88
8
.45
2
.06
-
-
0
.00
2
Un
certa
in
ty
4
.53
2
.42
2
.94
2
.94
-
-
0
.00
2
Po
sitiv
e lif
e chan
g
es
7
.62
1
.44
8
.36
1
.71
-
-
0
.00
7
Lif
e go
als
7
.98
1
.34
9
.51
0
.94
-
-
0
.00
0
Ho
p
e
8
.00
1
.68
9
.64
0
.69
-
-
0
.00
0
Ov
erall
sp
iritual
w
ellb
ein
g
5
1
.34
7
.57
5
5
.71
6
.45
4
.37
3
.19
0
.00
2
Most
res
ponde
nts
we
re
s
hort
te
rm
su
rv
iv
or
s
(
42.86%
i
n
t
otal)
wit
h
opti
m
u
m
sp
irit
ual
well
bein
g
(70.4
8%
in
tot
al
).
More
ac
ute
to
sh
ort
te
rm
s
urviv
ors
wer
e
f
ound
in
the
cas
e
of
breast
can
cer
(n
=
20
an
d
n=22
resp
ect
ively
)
c
om
par
ed
to
m
or
e
s
hort
to
lon
g
te
rm
su
rv
iv
or
s
in
the
case
of
cerv
ic
al
cancer
(
n=
23
an
d
n=
17
resp
ect
ively
)
.
Op
ti
m
u
m
sp
irit
u
al
well
bein
g
was
f
ound
in
the
m
ajo
rity
of
al
l
sta
ges
of
su
r
vivo
rsh
i
p
in
BC
S
and
CC
S
,
bu
t
t
he
f
ul
le
st
was
f
ound
i
n
acu
te
su
r
vivor
shi
p
f
or
both
cases
(
100%).
CC
S,
especial
ly
the
ind
ivid
ua
l
in
sh
or
t
an
d
long
te
rm
su
rv
ivors
hip
seem
e
d
to
be
m
or
e
diff
ic
ult
in
a
chievi
ng
op
ti
m
u
m
sp
irit
ual
well
bei
ng
than
BC
S
in
th
e
sam
e
sta
ge.
Table
5
e
xp
la
i
ns
th
e
s
piritual
well
bein
g
le
ve
l
in
al
l
sta
ges of ca
nce
r
s
urviv
or
s
hi
p for
bo
t
h
cases
in deta
il
s.
Table
5
.
C
om
par
iso
n of
sp
i
ritual
w
el
lbei
ng
i
n
a
ll
s
ta
ges
of
s
urviv
orshi
p
be
tween ca
ses
Cas
e
Su
rviv
o
rsh
ip
Stage
Sp
iritual W
ellb
ein
g
Level*
Frequ
en
cy
%
Cerv
ical
cancer
(n=4
7
)
Acu
te
(n=7
)
Op
ti
m
u
m
7
100
Su
f
f
icien
t
0
0
Low
0
0
Sh
o
rt
ter
m
(n=2
3
)
Op
ti
m
u
m
18
7
8
.26
Su
f
f
icien
t
5
2
1
.74
Low
0
0
Lon
g
ter
m
(n=1
7
)
Op
ti
m
u
m
14
8
2
.35
Su
f
f
icien
t
3
1
7
.65
Low
0
0
Breast
cancer
(n=5
8
)
Acu
te
(n=2
0
)
Op
ti
m
u
m
20
100
Su
f
f
icien
t
0
0
Low
0
0
Sh
o
rt
ter
m
(n=2
2
)
Op
ti
m
u
m
21
9
5
.45
Su
f
f
icien
t
1
4
.55
Low
0
0
Lon
g
ter
m
(n=1
6
)
Op
ti
m
u
m
14
8
7
.50
Su
f
f
icien
t
2
1
2
.50
Low
0
0
*
Categ
o
ry
w
as
m
ad
e to ease the d
at
a presen
tatio
n
,
an
d
no
t f
o
r
statis
tical a
n
aly
sis
p
u
rpo
ses
In
BC
S
,
reli
gi
ou
s
act
ivit
y,
lif
e
goal
s,
a
nd
hope
wer
e
si
gnific
antly
dif
fe
ren
t
betwee
n
s
urviv
orshi
p
sta
ges
(
p=0.
043,
p=0.02
2,
a
nd
p=
0.0
36
res
pecti
vely
)
,
bu
t
ov
e
rall
sp
irit
ua
l
well
being
was
not
sig
nif
ic
antly
diff
e
re
nt
betw
een
survi
vors
hi
p
sta
ges
(p
=
0.1
79)
.
I
n
CC
S,
ov
erall
sp
irit
ua
l
well
being
a
nd
al
l
of
it
s
aspects
w
ere
not
si
gn
i
ficantl
y
dif
fer
e
nt
bet
wee
n
s
urvi
vors
hip
sta
ge
s
(all
p
>α
)
.
Table
6
revea
ls
the
com
par
is
on
of
sp
irit
ual
well
be
ing
betwee
n s
urviv
orshi
p
sta
ges
i
n
BC
S a
nd CC
S i
n detai
ls.
It
is
known
t
hat
sp
irit
ua
l
well
bein
g
in
cancer
s
urvi
vors
is
i
nf
lue
nc
ed
by
reli
gio
us
act
ivit
y,
sp
irit
ual
act
ivi
ty
,
sp
irit
ual
li
fe
c
hanges,
uncertai
nty,
po
sit
ive
li
fe
cha
ng
e
s
,
li
fe
goa
ls,
an
d
hope
[17].
We tried
to
determ
ine w
hich
on
e
of
all
these
asp
ect
s b
ei
ng
the b
est
predict
or
or
m
ajo
r
det
erm
inant o
f
sp
i
ritual
well
bein
g
in
B
CS
and
C
CS
.
Si
m
ple
li
nea
r
regressio
n
te
st
resu
lt
s
sh
owed
that
sp
i
ritual
li
fe
chang
es
an
d
reli
gious
act
ivi
ty
was
the
best
pr
e
dicto
r
of
s
pi
ritual
well
bein
g
in
BC
S
an
d
CC
S
res
pecti
ve
ly
.
Un
ce
rtai
nt
y
was
the
on
ly
aspec
t
that
did
no
t
influ
e
nce
s
piritual
well
bein
g
in
CC
S,
in
wh
ic
h
m
os
t
of
the
m
felt
m
o
der
at
e
un
ce
rtai
nty
acc
ordin
g
t
o
Ta
ble
3
(53.1
9%). Tab
le
6
sh
ows
the
in
flue
nce of
eac
h
determ
i
nan
t
t
ow
a
r
ds
s
piritual
well
bein
g
i
n
B
CS an
d
CC
S
in
d
et
ai
ls.
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci.
Vo
l
.
8
, N
o.
4
,
Dece
m
ber
201
9
:
4
3
8
–
4
5
1
444
Table
6.
C
om
par
iso
n of
s
pi
ritual
w
el
lbei
ng
betwee
n
s
urviv
or
s
hip
s
ta
ges
in
b
ot
h
c
ases
A.
Bre
ast
c
an
ce
r
(
n
=5
8
)
Facto
rs
Acu
te
(n=2
0
)
Sh
o
rt
Ter
m
(n=2
2
)
Lon
g
T
er
m
(n=1
6)
Mean Sq
u
are
(CI
9
5
%)
F or X
2
(df
)
p
Value
Mean (S
D)
Mean (S
D)
Mean (S
D)
Relig
io
u
s activ
ity
9
.80
(0.6
2
)
9
.27
(0.8
8
)
9
.19
(1.0
5
)
-
6
.30
0
.04
3
Sp
iritual activ
ity
8
.30
(2.5
6
)
8
.50
(1.6
0
)
8
.56
(2.0
6
)
-
0
.63
0
.73
1
Sp
iritual lif
e chan
g
es
8
.45
(2.1
6
)
6
.50
(3.1
6
)
7
.19
(3.3
5
)
-
3
.08
0
.21
5
Un
certa
in
ty
2
.75
(3.3
1
)
3
.50
(2.7
2
)
2
.44
(2.8
0
)
-
1
.97
0
.37
3
Po
sitiv
e lif
e chan
g
es
8
.85
(1.6
9
)
7
.91
(1.5
1
)
8
.38
(1.9
3
)
-
5
.06
0
.07
9
Lif
e go
als
9
.80
(0.8
9
)
9
.23
(1.0
2
)
9
.56
(0.8
1
)
-
7
.62
0
.02
2
Ho
p
e
9
.90
(0.4
5
)
9
.41
(0.8
0
)
9
.63
(0.7
2
)
-
6
.67
0
.03
6
Ov
erall
sp
iritual
wellb
ein
g
5
7
.85
(5.1
9
)
5
4
.32
(7.2
5
)
5
4
.94
(6.3
9
)
7
1
.88
1
.77
0
.17
9
B. Cervical
c
an
cer
(n=4
7
)
Facto
rs
Acu
te
(n=7
)
Sh
o
rt
Ter
m
(n=2
3
)
Lon
g
T
er
m
(n=1
7
)
Mean
Sq
u
are
(CI
9
5
%)
F or X
2
(df
)
p
Value
Mean (S
D)
Mean (S
D)
Mean (S
D)
Relig
io
u
s activ
ity
8
.57
(0.9
8
)
7
.91
(1.6
2
)
8
.53
(1.8
1
)
-
3
.49
0
.17
5
Sp
iritual activ
ity
7
.71
(1.5
0
)
7
.43
(2.0
6
)
7
.82
(1.8
5
)
-
0
.45
0
.80
0
Sp
iritual lif
e chan
g
es
8
.00
(0.5
8
)
7
.26
(2.0
5
)
7
.23
(2.3
1
)
-
0
.68
0
.71
2
Un
certa
in
ty
5
.86
(2.0
4
)
4
.78
(2.3
7
)
3
.65
(2.4
2
)
-
4
.65
0
.09
8
Po
sitiv
e lif
e chan
g
es
8
.00
(0.0
0
)
7
.43
(1.3
4
)
7
.71
(1.8
3
)
-
2
.02
0
.36
5
Lif
e go
als
8
.29
(0.7
6
)
7
.83
(1.3
0
)
8
.06
(1.6
0
)
-
0
.86
0
.65
2
Ho
p
e
8
.00
(0.0
0
)
7
.61
(1.9
7
)
8
.53
(1.5
0
)
-
4
.37
0
.11
2
Ov
erall
sp
iritual
w
ellb
ein
g
5
4
.43
(2.7
0
)
5
0
.26
(7.7
4
)
5
1
.53
(8.9
0
)
4
7
.08
0
.81
6
0
.44
9
Table
6.
Pr
e
dic
tors o
f
s
piritual
w
el
lbein
g
i
n
b
oth
c
a
ses
A.
Pr
ed
icto
rs of
s
p
iritual
w
ellb
ein
g
in
BCS
N
o.
D
eter
m
in
an
t
R
S
q
u
are
% o
f
I
n
f
lu
en
ce
p
Va
lu
e
1
Relig
io
u
s activ
ity
0
.32
7
3
2
.7
0
.00
0
2
Sp
iritual activ
ity
0
.17
2
1
7
.2
0
.00
1
3
Sp
iritual lif
e
ch
an
g
es
0
.70
3
7
0
.3
0
.00
0
4
Un
certa
in
ty
0
.09
4
9
.4
0
.01
9
5
Po
sitiv
e lif
e
c
h
an
g
es
0
.15
6
1
5
.6
0
.00
2
6
Lif
e go
als
0
.33
0
3
3
.0
0
.00
0
7
Ho
p
e
0
.47
0
4
7
.0
0
.00
0
B
.
Predicto
rs
of
spir
itu
al wellbein
g
in
CCS
N
o.
D
eter
m
in
an
t
R
S
q
u
are
% o
f
I
n
f
lu
en
ce
p
Va
lu
e
1
Relig
io
u
s activ
ity
0
.69
7
6
9
.7
0
.00
0
2
Sp
iritual activ
ity
0
.35
1
3
5
.1
0
.00
0
3
Sp
iritual lif
e chan
g
es
0
.42
3
4
2
.3
0
.00
0
4
Un
certa
in
ty
0
.03
7
-
0
.19
4
5
Po
sitiv
e lif
e
c
h
an
g
es
0
.69
1
6
9
.1
0
.00
0
6
Lif
e go
als
0
.65
5
6
5
.5
0
.00
0
7
Ho
p
e
0
.39
5
3
9
.5
0
.00
0
Re
su
lt
s
sh
owe
d
that
optim
um
sp
irit
ual
well
being
w
as
f
ound
in
m
os
t
B
CS
and
CC
S
,
especial
ly
in
the
ac
ute
sta
ge
of
s
urviv
orshi
p
.
This
stu
dy
al
so
f
ound
that
BC
S
ha
d
sli
ghtl
y
bette
r
s
pir
it
ual
well
bein
g
than
CC
S.
This
stu
dy
res
ults
were
su
pp
or
te
d
by
a
stud
y
to
wards
24
0
patie
nts
with
ad
va
nce
d
cance
r
in
T
ha
il
an
d
wh
ic
h
sho
wed
that
m
os
t
resp
on
den
ts
had
m
od
erate
to
hi
gh
le
vel
of
spi
ritual
well
being,
in
wh
ic
h
it
wa
s
correla
te
d
with
sym
pto
m
se
ver
it
y
[
22
]
,
w
hich
c
onfirm
ed
the
res
ults
of
previ
ous
st
ud
y
by
r
esults
BC
S
repor
te
d
m
or
e
op
ti
m
al
ph
ysi
cal
well
bein
g
c
om
par
ed
to
CC
S
[23].
T
his
happe
ned
pote
ntial
ly
becau
se
m
or
e
op
ti
m
al
ph
ysi
cal
well
bein
g
in
BC
S
was
in
flue
nced
by
th
e
sli
gh
tl
y
better
sp
irit
ual
well
bein
g
fou
nd
in
BC
S
al
so
in
this
stud
y.
T
his
i
s
co
ns
is
te
nt
with
the
resul
ts
of
a
m
e
ta
-
analy
sis
study
wh
ic
h
f
ound
that
reli
gio
sit
y/
sp
iri
tuali
ty
was
associat
ed
with
physi
cal
well
being,
f
un
ct
io
nal
well
bein
g,
a
nd
ph
ysi
cal
sy
m
pto
m
s
;
gr
eat
er
r
el
igi
osi
ty
/spirit
ualit
y
is associat
ed
wi
th b
et
te
r pati
ent
-
re
porte
d phy
sic
al
h
eal
th
[
24]
.
Re
su
lt
s
sho
we
d
that
overall
sp
irit
ual
well
be
ing
was
sig
ni
ficantl
y
dif
fer
e
nt
bet
wee
n
B
CS
an
d
CC
S
wh
ic
h
was
i
nfl
ue
nced
by
s
ign
ific
a
nt
di
fferences
on
re
li
gio
us
act
ivit
y,
sp
irit
ua
l
a
ct
ivit
y,
un
ce
rtai
nty,
po
sit
ive
li
fe
c
ha
ng
e
s,
li
fe
go
a
ls,
an
d
ho
pe.
S
pecifica
ll
y
in
BC
S,
reli
gious
act
ivit
y,
li
fe
go
al
s,
a
nd
hope
were
sign
ific
a
ntly
diff
ere
nt
betwe
en
survi
vors
hip
sta
ges
,
bu
t
ov
e
rall
sp
irit
ua
l
well
being
was
not
sign
i
f
ic
antly
diff
e
re
nt.
T
his
ind
ic
at
es
th
at
reli
gio
us
a
ct
ivit
y,
li
fe
go
al
s,
a
nd
ho
pe
cha
nge
overti
m
e
al
on
g
with
the
s
urviv
or
s
hi
p
sta
ges
i
n
BC
S
.
Wh
il
e
i
n
C
CS,
s
piritual
w
el
lbeing
an
d
al
l
of
it
s
asp
ect
s
wer
e
not
si
gn
if
ic
antly
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Sp
iri
tu
al wel
lb
ei
ng
i
n bre
as
t
and
ce
rvi
cal c
an
ce
r s
ur
vi
vor
s:d
if
fe
rence
s
in
… (
Ni
Pu
tu W
ul
an
Purn
ama S
ar
i
)
445
diff
e
re
nt
betw
een
s
urviv
orsh
ip
sta
ges
,
w
hic
h
in
dicat
e
that
sp
irit
ual
well
be
ing
is
relat
ive
ly
sta
ble
or
sta
gn
a
nt
acro
s
s
the
sur
vi
val li
fe s
pa
n i
n
CC
S.
A
sim
i
la
r
stu
dy
to
wards
c
ancer
survi
vor
s
showe
d
t
ha
t
a
m
on
g
t
he
qu
al
it
y
of
li
f
e
dom
ai
ns
,
sp
irit
ual
do
m
ai
n
was
ra
nk
e
d
highest;
canc
er
-
s
pecific
worr
y
em
erg
ed
a
s
a
sig
nificant
pr
e
dicto
r
f
or
ov
e
rall
qu
al
it
y
of
li
fe;
survi
vors
ra
te
d
high
on
po
si
ti
ve
li
fe
c
hang
es
an
d
sense
of
purpose
but
t
his
was
te
m
per
ed
by
worr
ie
s
a
nd
un
certai
nty
[2
5].
An
a
utobio
gr
a
ph
ic
al
stu
dy
towards
16
ad
ults
with
cancer
s
howe
d
that
reli
giou
s
m
eaning
was
fou
nd
w
hen
the
disease
wa
s
di
sc
ov
e
re
d
as
a
cal
li
ng
f
ro
m
God,
sp
i
ritual
m
eaning
was
disco
ver
e
d
wi
thin
a
buff
e
re
d
ide
ntit
y
and
i
m
po
rtant
relat
ion
s
hip
s,
an
d
sec
ular
m
ea
ning
wa
s
f
ou
nd
i
n
the cou
rag
e
to m
ake a
caree
r
change
[
26
]
.
R
el
igiou
s
act
iv
it
y
is
def
ined
a
s
any
act
ivit
y
t
hat
pr
im
aril
y
pr
om
otes
or
m
a
nifests
a
par
ti
c
ular
belie
f
in
or
a
bout
a
de
it
y
or
an
ulti
m
at
e
reali
ty
ac
cordin
g
to
l
aw
an
d
le
gal
def
i
niti
on
[27]
.
M
os
t
res
ponde
nts
wer
e
Muslim
in
thi
s
stu
dy
(t
otall
y
81.9%).
Mu
slim
s
eng
age
in
a
var
ie
ty
of
devotio
nal
r
el
igiou
s
pract
ic
es
to
increase
thei
r
God
-
co
ns
ci
o
usness
a
nd
t
o
di
sci
pline
their
at
ti
tud
es
towa
rd
s
oth
e
rs.
S
unni
Musli
m
s
hav
e
identifie
d
five
pill
ars
of
I
slam
as
a
fo
cus
fo
r
t
heir
ritu
al
pr
act
ic
es
w
hich
ba
sed
on
Quran
a
nd
S
unna
h,
nam
ely:
1)
th
e
sh
ah
adah
(t
he
te
stim
on
y
of
t
he
unit
y
of
God
a
nd
t
he
pr
opheth
oo
d
of
Mu
ham
m
ad)
,
2)
s
ala
t
(ca
nonical
pr
ay
e
r)
,
3)
z
ak
at
(alm
s
),
4)
s
aw
m
(t
he
fast
of
Ra
m
adan),
a
nd
5)
ha
jj
(
pilg
rim
a
ge
to
Me
cca)
[
28
]
.
These
five
pi
ll
ars
are
obli
gato
ry
act
s
of
w
or
s
hip,
a
nd
f
ollow
i
ng
Isl
a
m
ic
la
w
(
s
haria
),
wh
ic
h
to
uc
hes on vi
rtuall
y
ev
ery aspect
of li
fe a
nd so
ci
et
y
of Musli
m
s.
Re
su
lt
s sho
we
d
that
reli
gious
acti
vity
w
as sign
i
ficantl
y dif
f
eren
t
betwee
n B
CS an
d
CC
S
.
T
his as
pect
was
sig
nifican
tl
y
diff
eren
t
be
tween
s
urviv
or
s
hip
sta
ges
in
BC
S
especia
ll
y
,
and
bein
g
the
best
predic
tor
of
sp
i
ritual
well
be
ing
in
CC
S.
Most
res
ponde
nts
in
both
cas
es
agr
ee
d
that
r
el
igiou
s
act
ivit
y
is
ver
y
i
m
po
r
ta
nt
for
their
li
fe.
A
lo
ng
it
udinal
stu
dy
towards
45
com
m
un
it
y
-
dwel
li
ng
cancer
s
urviv
ors
in
f
our
ye
ars
per
i
od
after
diag
nosis
sho
wed
t
hat
ne
wly
diagnose
d
pa
rtic
ipants
we
re
m
or
e
li
kely
to
decr
ease
c
hur
ch
at
te
nd
a
nce
bu
t
the
y
had
a
n
increas
e
in
non
-
orga
ni
zat
ion
al
reli
gio
sit
y
beh
a
vio
r
s
and
intri
ns
ic
reli
gio
sit
y;
baseli
ne
reli
gio
sit
y
was
the
stronge
st
pr
e
dictor
of
r
el
igiosit
y
at
4
8
m
on
ths
after
cancer
diag
no
sis
(
s
hort
t
erm
su
rv
iv
or
s
)
[
29
]
.
Ther
e
is
a
high
po
s
sibil
it
y
that
this
stu
dy
re
su
lt
s
w
hich
f
ound
t
hat
reli
gi
ou
s
act
ivit
y
ch
ang
e
s
ov
e
rti
m
e
al
on
g
with
the
s
urvi
vors
hip
sta
ges
i
n
BC
S
is
caus
e
d
by
the
increa
se
in
no
n
-
orga
nizat
ion
al
reli
gi
os
it
y
beh
a
vior
s
an
d
intrins
ic
reli
gio
sit
y.
The
bas
e
li
ne
of
reli
gi
osi
ty
at
the
tim
e
first
ti
m
e
of
cancer
dia
gnos
is
was
no
t
m
easu
red
i
n
this stu
dy and
bein
g on
e
of st
ud
y l
im
i
ta
ti
on
s.
Rosm
arin
had
exp
la
ine
d
th
at
even
th
ough
reli
gi
os
it
y
and
s
pirituali
ty
are
relat
ed,
t
hey
are
no
t
synony
m
ou
s
[9
]
.
Ferrel
who
dev
el
ope
d
the
instru
m
ent
us
ed
in
this
study
gav
e
exam
ple
of
sp
irit
ual
act
ivit
y,
su
c
h
as
m
editation
an
d
yo
ga
[
17
]
.
S
piritual
a
ct
ivit
y
is
no
t
relegate
d
to
wh
a
t
we
do
w
hen
we
at
rend
a
w
or
s
hi
p
serv
ic
e
or
s
pir
it
ualit
y
se
m
inar;
it
pe
rm
eat
es
our
ordi
nar
y
existe
nce
on
a
co
ns
ci
ous
an
d
subc
on
sci
ous
le
vel
,
and
i
t
is
intens
el
y
per
sonal
ye
t
bin
ds
us
t
o
our
c
omm
un
it
y
[30]
.
Ca
r
do
s
o
d
efi
ned
a
ny
pr
act
ic
e
as
m
editation
i
f
it
(1)
util
iz
es
a
sp
eci
fic
an
d
cl
early
de
fine
d
te
c
hn
i
qu
e
,
(
2)
in
vo
l
ves
m
us
cl
e
relax
at
io
n
s
om
ewh
ere
durin
g
the
process,
(
3)
in
volves
lo
gic
relaxati
on
[
31]
.
At
the
phys
ic
al
le
vel,
Y
og
a
is
de
fine
d
as
a
ph
ysi
cal
harm
on
y
&
healt
h
a
nd
m
ental
balance
&
peace
[
32
]
.
Othe
r
tha
n
m
edita
t
ion
or
m
edita
ti
ve
br
eat
hing
an
d
Yoga,
Nati
on
al
C
ompre
he
ns
ive
Ca
ncer
Net
work
giv
es
an
oth
e
r
exam
ple
of
s
pi
ritual
act
ivit
y
that
m
ay
help
cancer
patie
nts
co
pe
with
the
disease
and
it
s
treatm
ents,
su
c
h
as:
pr
ay
ing
al
one
or
with
so
m
eon
e
el
se
,
hav
i
ng
so
m
eon
e
el
se
pray
for
th
e
patie
nt,
read
i
ng
sc
ri
pture
or
ot
her
ho
ly
works
,
say
ing
on
e
pas
sage
f
r
om
par
ti
cular
reli
gi
ou
s
tradit
ion
over
and
over
a
gai
n
li
ke
a
m
antra,
us
in
g
the
la
ng
uag
e
of
ce
rtai
n
r
el
igion
,
li
ste
ning
to
cl
a
ssica
l
or
s
pi
ritual
m
us
ic
,
an
d
ta
lkin
g
a
bout
s
piritual
m
at
te
rs
with
oth
ers
[
10]
.
Re
su
lt
s
sho
w
ed
that
sp
i
r
it
ual
act
ivit
y
was
si
gn
i
ficantl
y
dif
fer
e
nt
betwee
n
BC
S
an
d
CC
S
.
Most
respo
nd
e
nts
in
bo
t
h
cas
es
agr
ee
d
that
sp
irit
ual
act
ivit
y
is
ver
y
i
m
po
rtant
for
their
li
fe.
Sp
irit
ual
a
ct
ivit
y
was
no
t
si
gn
i
f
ic
antly
diff
e
re
nt
bet
ween
sur
vivorship
sta
ge
s
in
BC
S
a
nd
CC
S.
T
his
in
dicat
es
that
s
pi
ritual
act
ivit
y
is
stab
le
/st
agn
a
nt
overti
m
e
a
lon
g
with
the
su
r
vi
val
li
fesp
an
in
both
cases.
A
com
par
at
ive
stud
y
towa
rd
s
202
w
om
en
new
ly
diagnose
d
with
br
east
ca
ncer
a
nd
110
he
al
thy
wo
m
en
sh
owe
d
that
there
we
re
no
sign
ific
a
nt
di
fferen
ces
in
reli
gi
ou
s/s
piritual
be
li
efs
an
d
pr
act
ic
es
betwee
n
gro
ups,
but
canc
er
patie
nts
re
porte
d
that
their
beli
ef
in
G
od,
str
eng
t
h
of
fait
h
and
pr
i
vate
r
el
igiou
s/s
piritu
al
pr
act
ic
es
sign
i
ficantl
y
increase
d
sh
ort
ly
after
surge
ry
com
par
e
d
to
a
ye
ar
pr
i
or
to
su
rg
e
ry
[
33
]
.
Sim
il
ar
st
ud
y
in
w
om
en
new
ly
dia
gnose
d
with
cerv
ic
al
ca
ncer i
s not fo
und
y
et
.
Ma
ny
patie
nts
with
cance
r
rel
y
on
s
piritual
or
reli
gious
belie
fs
an
d
pr
act
ic
es
to
help
t
he
m
cop
e
with
their
disease
;
t
his
is
cal
le
d
s
piritual
co
ping
[34].
A
qual
it
at
ive
stud
y
to
wards
10
pa
rtic
ipants
with
c
ance
r
sh
owe
d
that
they
m
entio
ne
d
ab
out
e
m
otion
-
fo
c
use
d
r
oles
of
sp
irit
ualit
y:
f
eel
ing
sup
ported
by
a
transcende
ntal
con
fi
dan
t,
th
e
expressio
n
of
negat
ive
em
o
ti
on
s
(in
pr
ay
e
r)
,
acce
ptance
,
al
lowin
g
feeli
ng
s
of
m
ise
ry
,
and
vi
ewin
g
pro
blem
s
fr
om
a
distance
[35].
Sp
irit
ua
li
ty
is
i
m
po
rtant
in
regulat
in
g
their
em
otion
s
an
d
consi
der
e
d
as
help
fu
l
in
ad
justm
ent
after
cancer
.
A
noth
er
stu
dy
to
wards
94
w
om
en
with
m
ast
ecto
m
iz
ed
br
east
ca
ncer
s
howe
d
that
al
l
respo
nd
e
nts
us
ed
sp
i
ritual
/rel
igio
us
co
ping
(
SRC
),
m
os
tl
y
at
hig
h
a
nd
very
hig
h
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci.
Vo
l
.
8
, N
o.
4
,
Dece
m
ber
201
9
:
4
3
8
–
4
5
1
446
le
vel;
SRC
pr
oved
to
be
an
im
po
rtant
cop
i
ng
strat
egy
in
stress
sit
uations
exp
e
rience
d
by
wo
m
en
with
breast
cancer
an
d
hel
pful
in
c
opin
g
with
the
diseas
e
an
d
the
co
nse
qu
e
nces
of
th
e
treat
m
ents
[36]
.
Sim
il
ar
stud
y
in
wo
m
en
with
c
erv
ic
al
cance
r
i
s
no
t
fou
nd
ye
t.
A
stu
dy
in
di
ff
e
ren
t
c
onte
xt
to
wards
901
a
du
lt
s
with
H
I
V
sh
owe
d
that
do
ing
regular
sp
i
ritual
act
ivit
ie
s
for
one
ye
ar
was
ass
ociat
ed
with
reduce
d
r
isk
of
death
,
in
oth
e
r
words
it
im
pr
ov
e
d
survi
val
[37]
.
Sim
il
ar
stud
y
i
n
the
c
on
te
xt
of
fem
al
e
cancer
nee
ds
t
o
be
c
onduct
ed
in the f
utu
re
.
Sp
irit
ual
need
s
in
healt
h
care
m
ay
be
disti
nct
fr
om
reli
gio
us
on
e
s
an
d
are
integral
to
palli
at
ive
care
,
and
it
c
hanges
with
ti
m
e
and
ci
rcu
m
sta
nces
[38]
,
es
pecial
ly
in
the
case
of
cance
r.
A
st
udy
towa
r
ds
18
ca
ncer
patie
nts
s
how
ed
t
hat
s
piritual
need
s
s
hould
be
rec
og
nized,
reali
ze
d,
a
nd
c
onsid
ered
in
patie
nt
care;
wh
ic
h
inclu
des
f
our
ki
nd
s
of
needs, su
c
h
as connecti
on, p
e
ace,
m
eaning
a
nd
purpose
, and
transce
ndenc
e [3
9]
.
Sp
irit
ual
li
fe
c
hanges
was
t
he
on
ly
as
pec
t
wh
ic
h
di
ff
e
red
insig
nificantl
y
betwee
n
cas
es
,
but
it
was
bein
g
the
be
st
predi
ct
or
of
s
piritu
al
well
bein
g
i
n
BC
S
.
T
his
ind
ic
at
es
t
hat
s
piritual
li
fe
c
ha
ng
e
s
wer
e
ha
pp
e
ne
d
si
m
il
arl
y
gr
eat
in
BC
S
a
nd
CC
S.
Table
3
co
nf
irm
s
this
res
ult
in
w
hi
ch
m
os
t
respo
nd
e
nts
in
both
cases
exp
e
rience
d
m
axim
u
m
chan
ge
s
in
their
sp
i
ritual
li
fe
after
cancer
diag
nosis.
A
st
ud
y
towa
rd
s
614
c
ancer
su
r
vivo
rs
sho
wed
that
ha
vi
ng
ca
ncer
ha
d
po
sit
ively
affe
ct
ed
their
sp
i
ritual
well
bein
g;
in
wh
ic
h
40.
3%
respo
nd
e
nts
e
xp
e
rience
d
hi
gh
ly
po
sit
ive
sp
irit
ual
c
ha
nges
a
nd
75.9%
res
ponde
nts
re
ported
bei
ng
ve
ry
hope
fu
l;
wh
il
e
the
rest
w
ho
ex
per
ie
nce
d
neg
at
ive
s
piritual
c
hanges
(
36.1%)
re
port
ed
t
hat
s
om
e
of
them
exp
e
rience
d hi
gh level
of unc
ertai
nty (27.
2%
) [40]
.
Un
ce
rtai
nty
is
sim
ply
def
ined
as
t
he
sta
te
of
uncertai
n.
S
it
uationally
,
uncertai
nty
is
a
sit
uation
i
n
wh
ic
h
so
m
et
hin
g
is
no
t
kn
own
;
w
hile
em
otion
al
ly
,
unce
rtai
nty
is
the
feeli
ng
of
no
t
be
ing
s
ur
e
wh
a
t
will
happe
n
in
the
fu
t
ur
e
[
41]
.
A
li
te
ratur
e
rev
ie
w
ab
ou
t
unce
r
ta
inty
in
cancer
patie
nts
sho
wed
that
unce
r
ta
inty
was
f
ound
to
com
pr
ise
three
m
ai
n
the
m
es,
nam
ely:
1)
un
c
ertai
nty
becau
s
e
of
lim
i
te
d
or
la
ck
of
inf
or
m
at
ion
,
2)
uncertai
nty
con
ce
r
ning
the
course
a
nd
tr
eatm
ent
cho
ic
e
s
relat
ed
to
ca
ncer,
an
d
3)
uncertai
nty
relat
ed
to
ever
y
day
li
fe
and
c
opin
g
wit
h
cancer
[
42
]
.
U
ncer
ta
inty
m
ay
represe
nt
a
ke
y
m
echan
ism
d
ur
i
ng
t
he
tra
ns
it
ion
from
cancer
pa
ti
ent to sur
vivo
r
.
Re
su
lt
s
showe
d
that
uncerta
inty
was
sign
i
ficantl
y
diff
e
r
ent
betwee
n
BC
S
and
CC
S,
an
d
CC
S
exp
e
rience
d
m
or
e
un
ce
rtai
nt
y
than
BC
S.
Un
ce
rtai
nty
w
as
no
t
sig
nific
antly
diff
ere
nt
betwee
n
survi
vors
hip
sta
ges
in
BC
S
and
CC
S
.
T
his
ind
ic
at
es
tha
t
un
ce
rtai
nty
is
sta
ble/st
agn
a
nt
overti
m
e
alo
ng
with
the
s
urviva
l
li
fesp
an
in
bo
th
cases.
A
qual
it
at
ive
study
towards
35
cancer
sur
vio
rs
an
d
25
pa
rtners
s
howe
d
that
p
arti
ci
pa
nts
de
scribe
d
m
edic
al
(e.g
.
cal
s
ources
of
uncer
ta
inty
included
)
,
pe
rs
on
al
(e.
g.
am
big
uous
valu
e
d
identit
ie
s
an
d
career
-
relat
ed
qu
e
sti
ons
)
,
a
nd
so
ci
al
s
our
ces
of
unce
rtai
nty
(e.g.
un
cl
ear
com
m
un
ic
at
ive,
relat
ion
al
a
nd
f
a
m
ilial
con
se
quen
ce
s
of
il
lne
ss
)
[
43]
.
Anothe
r
stu
dy
to
wards
313
breast
c
ancer
sur
vivor
s
w
ho
wer
e
a
ge
d
24
to
50
ye
ars
an
d
we
re
2
to
4
ye
ars
post
-
trea
t
m
ent
sh
owed
that
cance
r
-
relat
ed
uncertai
nty
wa
s
sign
ific
a
ntly
associat
ed
with
m
or
e
sel
f
-
repor
te
d
fati
gue
,
inso
m
nia
,
neg
a
ti
v
e
aff
ect
,
an
d
le
ss
posit
ive
aff
ect
;
u
nce
rtai
nty
ab
ou
t
c
ance
r
-
relat
ed
sym
pto
m
s,
treat
m
ent,
and
disease
co
urse
has
bee
n
relat
ed
to
poor
e
r
m
ental
and
ph
ysi
cal
he
al
th
[4
4]
.
Sim
il
ar
stud
y
in
wo
m
en
with
cerv
ic
al
ca
ncer
is
no
t
fou
nd
ye
t.
Schap
ira
s
ugge
ste
d
few
ways
to
m
anag
e
unc
ertai
nty
in
ca
ncer
patie
nts
,
su
c
h
a
s:
1)
healt
h
pro
fe
ssion
al
can
le
ver
a
ge
the knowled
ge a
nd
c
om
passion to help steer
the p
at
ie
nts to
wards treatm
ent d
eci
sion
s
, and
2) offe
rin
g
a
ste
ady
pr
ese
nce a
nd a
prom
ise
to
sta
y wit
h
t
h
em
all
t
he way
[
45]
.
Po
sit
ive
li
fe
changes
or
post
-
traum
at
ic
gr
owth
in
ap
preci
at
ing
li
fe
was
the
m
os
t
sal
i
ent
area
f
or
cancer
s
urvi
vors
,
incl
ud
i
ng
c
om
passion
f
or
oth
e
rs
an
d
healt
h
-
relat
e
d
li
fe
changes
[46]
.
P
os
t
-
tra
um
at
ic
g
rowt
h
(P
T
G)
ca
n
be
def
in
ed
as
po
sit
ive
li
fe
ch
ang
e
s
that
res
ult
from
m
ajor
li
fe
c
rises
or
stressf
ul
eve
nt
s
[47].
Lit
eratur
e
re
view
s
howe
d
t
ha
t
PTG
is
a
n
i
m
po
rtant
phe
nom
eno
n
in
t
he
ad
justm
ent
to
cance
r
a
nd
it
can
be
m
od
ifie
d
thr
ough
ps
yc
holo
gi
cal
and
ph
a
r
m
acolog
ic
al
in
te
rv
e
ntion
s
[
47]
.
A
qual
it
at
i
ve
stu
dy
to
wa
rd
s
10
cancer
patie
nts
f
ound
t
hat
par
ti
ci
pa
nts
e
xperie
nced
eve
r
yday
li
fe
c
hanges,
w
hich
co
ns
ist
of
norm
al
li
fe
changes
, peo
pl
e cha
ng
i
ng b
e
ha
vior, a
nd c
hanges
hurtin
g
si
gnific
ant
oth
e
rs [48]
.
Steph
a
n
e
xp
la
ins
how
li
fe
changes
a
fter
hav
i
ng
breas
t
cancer,
w
hich
re
flect
ed
on
em
otion
al
adjustm
ents
and
sta
ges,
c
hanges
in
ap
pear
a
nce,
physi
cal
chall
enges,
ef
f
ect
s
on
fe
rtil
ity,
changin
g
r
ol
es
in
relat
ion
s
hip
s
,
changes
in
se
xu
al
it
y
and
in
tim
ac
y,
chan
ge
s
in
wo
r
k
li
fe
and
fina
nces
[49]
.
A
nothe
r
stud
y
towa
rd
s
35
ce
rv
ic
al
cance
r
su
r
vivo
rs
sho
wed
t
hat
the
disease
im
pact
ed
their
p
hysi
cal
and
psy
ch
ologica
l
seq
uelae,
fam
i
ly
distress,
fin
ancial
burd
e
n,
and
disruptio
ns
to
their
so
ci
a
l
fu
nctio
ning
a
nd
se
xual
li
fe
;
there
wer
e
posit
ive
gains
incl
uding
c
han
ges
in
their
outl
ook
on
li
fe,
treasur
i
ng
their
li
fe,
a
nd
bette
r
fam
i
ly
r
el
at
ion
sh
ips
[
50
]
.
Re
su
lt
s
sho
we
d
that
posit
ive
li
fe
cha
nges
was
si
gn
i
ficantl
y
diff
e
re
nt
betwee
n
BC
S
an
d
CC
S,
howe
ver
m
os
t
BC
S
and
C
CS
repor
te
d
m
axi
m
u
m
po
s
it
ive
li
fe
changes
.
P
os
it
iv
e
l
ife
cha
ng
es
w
ere
not
sign
ific
a
ntly
di
ff
e
ren
t
betwee
n
s
urviv
orshi
p
sta
ges
in
BC
S
and
CC
S.
This
ind
ic
at
es
t
hat
po
sit
ive
li
fe
c
ha
ng
e
s
is
sta
ble/st
agnant
overti
m
e
a
long
with
t
he
s
urvival
li
fes
pa
n
in
bo
t
h
cases
.
A
qu
al
it
at
ive
stud
y
to
wards
so
m
e
br
east
ca
nce
r
long
te
rm
su
r
vi
vors
s
howe
d
t
ha
t
li
fe
patte
rns
after
fi
ve
ye
ars
or
m
or
e
of
bre
ast
cancer
dia
gnos
is
cl
us
te
red
a
rou
nd
posit
ive,
ex
pansi
ve
interac
ti
on
s,
a
nd
tra
nsfo
rm
ing
them
es
ind
ic
at
ing
t
hey
ha
d
gro
w
n
fr
om
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Sp
iri
tu
al wel
lb
ei
ng
i
n bre
as
t
and
ce
rvi
cal c
an
ce
r s
ur
vi
vor
s:d
if
fe
rence
s
in
… (
Ni
Pu
tu W
ul
an
Purn
ama S
ar
i
)
447
the
exp
e
rience
wh
ic
h
c
on
sist
ent
with
cha
ra
ct
erist
ic
s
of
young’s
sta
ge
of
centerin
g
[
51
]
.
Af
te
r
sur
viv
in
g
thei
r
cancer
,
pa
rtic
ipants
c
onsci
ou
sn
ess
s
hifte
d
f
ro
m
the
bindin
g
sta
ge
t
o
that
of
ce
nterin
g,
so
m
e
even
evi
den
ce
d
the
c
har
act
eris
ti
cs
of
the
ch
oi
ce
sta
ge.
T
hes
e
cha
nges
i
n
li
fe
patte
rn
s
re
fl
ect
the
e
xp
a
ns
i
on
of
c
onsci
ou
sn
ess
exp
e
rience
d
by
this
group
of
wo
m
en
survi
vors
of
breast
cancer
.
Sim
i
la
r
stud
y
to
wards
acute
an
d
s
hor
t
te
r
m
br
east
ca
nce
r
s
urviv
ors, a
nd c
erv
ic
al
ca
ncer
su
r
vivo
rs
is
no
t fou
nd yet
.
A
cance
r
diag
no
sis
a
ff
ect
s
pa
ti
ents'
qu
al
it
y
of
li
fe
a
s
well
as
their
pursu
i
t
of
li
fe
go
al
s
.
Life
pur
po
s
e
and
goal
is
one
of
the
as
pe
ct
s
of
m
eaning
i
n
li
fe,
to
ge
ther
with
h
a
r
m
on
y
and
p
ea
ce,
l
ife
p
er
sp
e
ct
ive,
c
onf
us
io
n
an
d
l
essened
m
eaning
,
a
nd
b
ene
f
it
s
of
sp
irit
ualit
y
[5
2]
.
A
stu
dy
towards
60
wo
m
en
with
br
eas
t
cancer
s
howe
d
that
the
le
vel
of
m
eaning
of
li
fe
a
m
on
g
r
esp
onde
nts
is
low
,
in
wh
ic
h
m
arit
al
sta
tus
and
edu
cat
io
n
we
r
e
fo
un
d
to
be
sign
ific
a
ntly
a
sso
ci
at
ed
with
the
m
eaning
in
li
fe
and
li
fe
s
at
isfact
ion
;
there
wa
s
sign
i
fica
nt
relat
ion
s
hip
betw
e
en
m
eaning
of
li
fe
and
li
fe
sat
isfact
ion
,
a
nd
t
he
low
se
ns
e
of
identit
y
as
a
whole
le
ads
res
ponde
nts
to
be
diss
at
isfie
d
with
their
li
ves
[
53
]
.
Sim
i
la
r
sudy
in
w
om
en
wi
th
cer
vical
ca
ncer
is
no
t
f
ound yet
.
Re
su
lt
s
of
a
s
yst
e
m
atic
r
eview
sho
wed
th
at
cancer
im
p
act
s
patie
nt’s
li
fe
go
al
cha
ra
ct
erist
ic
and
processes
,
an
d
li
fe
go
al
distu
rb
a
nce
is
relat
ed
to
poorer
psy
cho
l
og
ic
al
outc
om
es;
there
wer
e
se
ve
n
li
f
e
go
al
char
act
e
risti
cs
and
processes
[54]
.
T
he
r
ole
of
goal
adjus
t
m
ent
or
go
al
ree
nga
gem
ent
(i.e.
dise
ng
a
ge
m
ent
from
un
at
ta
inable
goal
s
an
d
reenga
gem
ent
in
al
te
rn
at
ive
go
al
s
)
an
d
c
ogniti
ve
em
otion
‐r
e
gu
la
ti
on
str
at
egies
(i.e.
r
um
inati
on
,
cat
ast
r
ophiz
ing
,
posit
ive
r
efo
c
us
in
g)
afte
r
cance
r
is
i
m
portant
f
or
i
nc
reasin
g
ps
yc
holog
ic
al
well
bein
g
[55]
.
A
com
par
at
iv
e
stu
dy
bet
wee
n
159
ca
nce
r
pa
ti
ents
an
d
160
healt
hy
c
on
t
ro
ls
w
hich
f
ollow
e
d
up
at
ni
ne
a
nd
18
m
on
ths
la
te
r
s
howe
d
that
cancer
patie
nts
repo
rted:
1)
fe
wer
ac
hie
vem
e
nt
-
relat
e
d
goal
s
an
d
le
isure
go
al
s
,
a
nd
2)
m
or
e
he
al
th
-
relat
ed
ba
r
riers
t
o
go
al
purs
uit,
a
nd
ha
d
a
sho
rter
ti
m
e
pe
rsp
ect
ive
f
or
their
go
al
s
[
56
]
.
T
her
e
fore
ca
nce
r
in
flue
nces
l
os
s
-
base
d
goal
sel
ect
ion
a
fter
tim
e
of
first
diag
nosis
a
nd
that
the ch
a
nge
goa
l per
s
pecti
ve
is w
idely
m
ai
ntained f
or
1.5 ye
ars
a
head.
Life
goal
was
sig
n
ific
antly
diff
e
re
nt
bet
w
een
BC
S
an
d
CC
S,
a
nd
thi
s
aspect
was
sign
ific
a
ntly
diff
e
re
nt
betwe
en
s
urviv
or
s
hi
p
sta
ges
in
BC
S
especial
ly
.
H
ow
e
ve
r,
BC
S
ha
d
the
s
am
e
maxim
u
m
l
ife
goal
s
as
CCS
.
A
com
par
at
ive
stu
dy
to
wards
159
can
cer
patie
nts
a
nd
160
healt
hy
con
t
ro
l
s
sho
we
d
that
ca
nce
r
pa
ti
ents
repor
te
d
fe
we
r
achievem
ent
-
r
el
at
ed
an
d
le
isure
goal
s,
a
nd
had
a
s
horter
t
im
e
per
s
pecti
ve
for
thei
r
goal
s
;
this
happe
ned
due to the
existe
nce
o
f heal
th
-
relat
ed
ba
rr
ie
r
s to
goal
pur
s
uit, the
refor
e ca
ncer
i
nf
l
uen
ces l
os
s
-
base
d
go
al
sel
ect
ion
especial
ly
in
the
first
days
after
diag
nosis
[5
6].
A
lo
ngit
ud
inal
stu
dy
towa
r
ds
153
c
ancer
patie
nts
w
ho
got
chem
oth
era
py
and
fo
ll
ow
ed
up
ni
ne
m
o
nth
s
la
te
r
sho
wed
that
highe
r
pur
pose
in
li
fe
was
relat
ed
with
h
i
gh
im
po
rta
nce
of
s
ocial
,
psy
cho
l
og
ic
al
,
a
nd
healt
h
-
relat
e
d
goal
s
;
ha
ving
hi
gh
le
vels
of
so
ci
al
go
al
s
pr
e
dicte
d
an
inc
rease
i
n
pur
pose
of
li
fe
over
ti
m
e
;
hig
he
r
i
m
po
rta
nc
e
of
m
at
erial
go
al
s
was
ass
oc
ia
te
d
with
lowe
r
pur
po
s
e
in
li
fe
and
with
a
decli
ne
of
pur
po
se
in
li
fe
ov
er
ti
m
e
[5
7
]
.
A
no
t
her
lo
ngit
ud
i
na
l
stud
y
towa
rd
s
86 can
cer p
at
ie
nts
whic
h
f
ollow
e
d u
p
20 m
on
ths la
te
r
showe
d
that
t
he
overall
att
ai
nm
ent o
f
l
ife
go
al
s
was
ass
ociat
ed
with
qual
it
y
of
li
fe,
ov
e
r
a
pe
rio
d
of
20
m
on
ths
,
pe
rceive
d
qu
al
it
y
of
li
fe
and
goal
at
ta
inm
ent
rem
ai
ned
sta
ble,
wh
e
reas
im
po
rta
nce
of
li
fe
go
al
s
decr
ease
d
;
l
esser
i
m
po
r
ta
nce
an
d
i
m
prov
e
d
goal
at
ta
inm
ent
wer
e
predict
or
s
of
inc
reases
i
n
qu
al
it
y
of
li
f
e
[58]
.
A
s
peci
fic
stu
dy
in
w
om
en
with
br
e
a
st
or
cer
vical
cancer
is n
ot foun
d
ye
t.
H
ope
i
s
an
in
ner
powe
r
th
a
t
facil
it
ates
th
e
tran
sce
nden
ce
of
the
pr
es
ent
sit
ua
ti
on
and
e
nables
a
realit
y
-
base
d
expect
atio
n
of
a
br
ig
hter
t
omor
ro
w
f
or
se
lf
and/o
r
ot
he
rs
[
59
]
.
H
ope
is
a
posit
ive
fu
t
ur
e
or
ie
ntati
on
,
refe
rs
to
hope
as
lookin
g
f
orwa
rd
t
o
a
go
od
f
uture
[
60
]
,
s
om
e
exp
erts
li
nk
ho
pe
to
go
al
s
[61]
,
oth
e
rs
li
nk
hope
to
li
fe
pur
pose
[62],
"t
i
m
e
ref
oc
us
i
ng,"
"spiritual
belie
fs,
"
"u
pl
ifti
ng
energy
"
[5
9]
,
and
a
se
ns
e
of
"i
nn
er
stre
ngth"
[
63
]
.
O
we
n
sta
te
d
that
there
wer
e
si
x
subthem
es
of
ho
pe
in
cance
r
pa
ti
ents,
nam
ely
:
go
al
set
ti
ng
,
pos
it
ive
per
sonal
at
tribu
te
s,
f
uture
red
e
fini
ti
on
,
m
eaning
in
li
fe,
pe
ace,
and
e
nergy
w
hi
ch
e
m
erg
ed
as
a
strand
run
ning
thr
ough
e
ach
of
the
se
six
subthem
es
and
se
rv
e
d
as
a
fo
cal
po
i
nt
in
the
de
scriptio
n
an
d
m
od
el
of
ho
pe
[62].
Eac
h
of
the
subt
he
m
es
descr
i
bed
a
c
om
po
nen
t
of
the
proces
s
wh
e
re
by
ene
r
gy
was
exc
ha
ng
e
d,
tra
ns
f
orm
ed,
or
m
ov
e
d,
res
ulti
ng
i
n
the
pr
ese
rv
at
ion
or
loss
of
hope
.
A
decad
e
afte
r,
Be
nzein
&
Savem
an
ar
gued
that
t
her
e
wer
e
five
subt
hem
es
of
hope
in
ca
ncer
pa
ti
ents,
nam
ely
:
inn
e
r
stren
gth
a
nd
e
nergy,
sig
nific
ant
eve
nts,
s
up
port
f
ro
m
relat
ives
an
d/or
a
f
a
m
iliar
env
i
ronm
ent,
confide
nce
in
treatm
ent,
an
d
nursing
act
io
ns
a
nd
t
reatm
ent
[
63
]
.
Re
s
ul
ts
of
a
c
om
pr
ehensi
ve
syst
e
m
at
i
c
rev
ie
w
s
howe
d
that
t
he
biopsyc
hos
ocial
f
act
or
s
t
hat
we
re
m
os
t
consi
ste
ntly
associa
te
d
with
ho
pe
an
d
hopeless
ness
include
d
so
ci
od
em
ographic
va
riables
(e
du
cat
io
n,
em
plo
ym
ent
and
eco
no
m
ic
sta
tus);
cl
inica
l
factors
(can
ce
r
sta
ge
,
ph
ysi
cal
co
nd
it
io
n
an
d
s
ym
pto
m
s);
and
ps
yc
ho
s
ocia
l
factor
s
(em
otion
al
distress,
s
oc
ia
l
su
ppor
t
and
co
nnect
ions,
qu
al
it
y
of
li
fe,
co
ntr
ol
or
sel
f
-
e
ff
ic
acy
,
adjustm
ent an
d resil
ie
nce)
[
64
]
.
Re
su
lt
s
sh
owe
d
that
hope
w
as
sign
ific
a
ntly
diff
ere
nt
bet
ween
BC
S
an
d
CC
S,
an
d
th
is
aspect
was
sign
ific
a
ntly
di
ff
ere
nt
bet
we
en
s
urviv
or
s
hi
p
sta
ge
s
in
B
C
S
especial
ly
.
This
se
ns
e
of
‘s
hiftin
g
hope’
is
recog
ni
z
ed
by
Hag
e
rty
,
who
co
nclu
ded
t
hat
per
ce
ptio
ns
of
ho
pe
ch
ang
e
al
on
g
th
e
disease
traj
ect
or
y
,
relat
ives
an
d
caregive
rs
ha
ve
a
sig
nifi
cant
ro
le
to
play
in
influe
ncin
g
ho
pe
for
the
patie
nt
[65].
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