Asia-Pacific Journal of Oncology Nursing

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 6  |  Issue : 2  |  Page : 145--150

Spiritual Experiences of Women with Breast Cancer in Singapore: a Qualitative Study


M Kamala Devi, Karis Cheng Kin Fong 
 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, Singapore

Correspondence Address:
M Kamala Devi
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine
Singapore

Abstract

Objective: Although there has been increasing emphasis on the importance of spirituality in patients with cancer, few studies have examined the spiritual experiences of an ethnically diverse sample of Asian women with breast cancer. The objective of this study was to examine the spiritual experiences of Singaporean women with breast cancer in the first year of diagnosis. Methods: A qualitative exploratory study design was used and data were gathered using individual semi-structured interviews. Purposive sampling selected the participants and data saturation sample size was reached after interviews with 28 participants. Data were analyzed using Braun and Clarke's thematic approach. Results: The participants were aged between 28 and 64 years and included women from the three major ethnic groups. The three themes that emerged from the data included transcendental experiences, meaning and purpose, and changing perspectives. Conclusions: This study informs that while spiritual needs are common, Singaporean women in their first year of the breast cancer diagnosis express spirituality in culturally specific ways. The clinical implications of the study emphasize the importance of addressing women's spiritual concerns, with attention to cultural differences so as to render holistic patient-centered care.



How to cite this article:
Devi M K, Fong KC. Spiritual Experiences of Women with Breast Cancer in Singapore: a Qualitative Study.Asia Pac J Oncol Nurs 2019;6:145-150


How to cite this URL:
Devi M K, Fong KC. Spiritual Experiences of Women with Breast Cancer in Singapore: a Qualitative Study. Asia Pac J Oncol Nurs [serial online] 2019 [cited 2019 Jul 17 ];6:145-150
Available from: http://www.apjon.org/text.asp?2019/6/2/145/251297


Full Text



 Introduction



A breast cancer diagnosis is often perceived as a tragic event and can be a life-altering experience. One of the reported life changes is spiritual change.[1] Women struggle to find meaning and purpose of life following the cancer diagnosis, question previously held beliefs of life and raise concerns related to spirituality, both existential and religious, raised.[2] According to the World Health Organization,[3] spiritual and religious dimensions of a patient's life should be considered as integral components of total patient care.

Spirituality is defined as the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.[4] There is a growing interest in the role of spirituality as a component of quality of life of cancer survivors.[5] The body of evidence suggests that spirituality can play a vital role in healing and well-being, as spirituality confers inner strength, peace, comfort, and wholeness and serves as a means of coping with cancer.[6],[7]

Essentially, everyone has a personal interpretation of the concept of spirituality. A person's age, gender, race, culture, and personal experience may affect the expression of spirituality.[6],[7] While the importance of the essentiality of spirituality in patients with cancer has been well acknowledged, there is a paucity of studies that have examined the spiritual experiences of women with breast cancer in Southeast Asia. Most studies exploring spirituality were conducted on breast cancer survivors from America and the Islamic countries,[8],[9],[10] where the patient population is relatively homogeneous in regard to ethnicity and religious beliefs. Given the difference in sociocultural characteristics, it makes it difficult to generalize the findings of the aforementioned studies to women with breast cancer in Southeast Asia.

Women of Southeast Asian diaspora often regard religion, family, and culture as key markers in shaping personal and community values.[11] Singapore is a multiethnic society where people have access to a wide range of beliefs systems, religious, and cultural practices. Therefore, Singaporean women's interpretation of spirituality and spiritual needs may not necessarily be similar to women of other cultures. Recognizing and understanding spirituality in the cultural texture of a society is crucial, so that culturally competent care can be provided. Furthermore, it has been noted that how women perceive their cancer experience during the first year of diagnosis has implications for long-term mental health and coping.[12] This study aimed to explore the spiritual experiences of women in the first year of their breast cancer diagnosis. The research question for the present study was during the first year following the breast cancer diagnosis, how do women in Singapore explain their spiritual experiences?

 Methods



Study and sampling

A qualitative approach was adopted to understand the spiritual experience of women in their first year of the breast cancer diagnosis. The participants of the study were recruited from two ambulatory cancer treatment centers in Singapore.

A purposive sample of women who met the following criteria was invited to participate: (i) in their first year of breast cancer, (ii) having Stage 0–3 breast cancer, (iii) aged ≥21 years, and (iv) able to speak in English. In an effort to capture ethnic variability in spiritual experiences, women from the three ethnic groups, Chinese, Malay, and Indian, were approached. The sample size for the study was determined by data saturation, which occurred after conducting 28 interviews.

Ethical approval

The Institutional Review Board of the participating study sites approved the conduct of the study and permission to conduct the study was sought and approved by the Heads of the Department of both the study sites. The study was conducted in accordance with the Declaration of Helsinki.[13] Participants were provided detailed explanation on the purpose of the study, risks, benefits, and procedures. They were informed that participation was strictly voluntary and that confidentiality and anonymity would be assured. Written consent was obtained from all 28 participants who agreed to participate in the study.

Data collection and analysis

Data were collected using individual semi-structured interviews. Women who met the inclusion criteria were approached and detailed explanation of the study including purpose, risks, benefits, and the data collection process was provided. The interviews were conducted in English, audio-recorded with the permission of the participants, and conducted in either the participants' residence or in a private room at the treatment centers.

During the interviews, the participants were asked to describe how they understood their spirituality in the context of the breast cancer diagnosis. The question included: Can you describe what spirituality means to you and share experiences that have shaped your spirituality? The questions were developed based on the review of the literature on spirituality among cancer patients.[14] A demographic form was used to collect data on age, marital status, educational level, income, employment, and stage of disease. Questions were posed according to the information shared by the participants to clarify matters where necessary. The length of the individual face-to-face interviews lasted between 45 and 60 min. All the interviews were recorded and transcribed verbatim.

In this study, Braun and Clarke's[15] thematic data analysis approach was adopted, to explain the women's spiritual experience. The analytical steps include familiarization, generating initial codes, searching for themes, reviewing themes, defining, and naming themes. The first step of familiarization began with reading and re-reading the transcripts to gather understanding of the meaning and content of the interviews. Next, the entire data set was organized in a systematic and meaningful manner, and initial codes were generated. Codes were assigned to segments of data that were relevant to the research question. Coding was performed manually, with the principal investigator working through hard copies of the transcripts using highlighters. The search for themes included codes being examined, and all similar codes grouped and fitted into subthemes and themes. The principal investigator first independently verified the reliability of the codes, subthemes, and themes. Thereafter, the principal and coinvestigator met to discuss and review all identified codes, subthemes, and themes until consensus was reached. The subthemes and themes were predominantly descriptive as they described the meaning of the women's spiritual experiences. Subsequently, the association between the identified themes and supporting data was reviewed and the names of the themes were finalized.

Lincoln and Guba[16] criteria for trustworthiness were used for rigor. It comprised credibility, transferability, dependability, and conformability. Credibility was realized through prolonged engagement and member checking to correct any error in the interpretation. To ensure transferability and dependability, detailed description of the research details was documented to allow for readers to decide how the findings may be transferred. Conformability was assured by discussing the codes, subthemes, and themes with the research team and participants of the study to obtain consensus.

 Results



A total of 28 women were interviewed. The mean age of the participants was 46.6 years (range: 28–64 years). The majority of the participants was married, completed secondary education, gainfully employed, had a monthly household income above S$ 2000, and diagnosed at Stage II and IIIA. All 28 participants had religious affiliation [Table 1].{Table 1}

The analysis of the data resulted in the emergence of six subthemes and three themes.

Theme 1: Transcendental experiences

The majority of the women in the study spoke of how their relationship with God changed following the breast cancer diagnosis.

Closer to God

Several participants spoke of turning to God, to give them hope and to heal.

“I am constantly praying to God … prayers give me hope, God will help me … will heal me” (Malay patient).

“I go to church more often... I light a candle, attend mass … the cancer has brought me close to God”. (Chinese patient).

Communication with God

Participants discussed several means for communicating with God, which included praying, visiting places of worship, meditation, and reading scriptures such as the Quran, Bible, or Bhagavad Gita. One participant shared that speaking directly to God affirmed her trust in him:

“When I speak to him, I can feel him, like he is near me … hearing me. It gives me hope and the strength to move on” (Indian patient).

Theme 2: Meaning and purpose

Other participants shared how answers to existential questions helped them to see their lives in a more meaningful and coherent manner.

Acceptance of the diagnosis

Several of the participants volunteered an acceptance of the diagnosis within the context of their faith in God.

“Since my cancer, my belief in Him gave me strength … to accept my diagnosis and to move forward” (Malay patient).

I have faith in God … this illness, it is God's will. I am leaving everything in his hands” (Malay patient).

Reason for the cancer diagnosis

Some of the participants shared perspectives about how their spiritual and religious beliefs helped explain why they developed cancer. For the majority of the Malay participants, the cancer diagnosis was considered a divine test. In this respect, they shared:

“I asked myself, why me? Is it because if God gives me something, he is testing me?”.

“I think it is God's test for me”.

The Indian women discussed their condition as a manifestation of Karma, the law of causality. They believed that they were destined to have cancer as a consequence of the bad deeds they had committed in their previous births. They explained:

“Whatever has happened was meant to happen. I think it is written somewhere (looks up). I must have done something bad in my previous birth … as they say; you reap what you sow”.

“Karma … I must have been a bad person in my previous birth … must have sinned” “Karma is what I am experiencing now … sinned … in my earlier life”.

Theme 3: Changing perspectives

For other women, spirituality helped them to view their life from a new perspective.

Learning to let go

After the cancer diagnosis, several participants said that they learned to “let go” and not be affected by trivialities of life. They talked about moving out into a different space and learning to look at life from another perspective.

“I used to be so petty … everything must be perfect. My children used to leave things all over the place. I used to get so angry. But now … I am changing” (Chinese patient).

“I used to be so goal oriented … doing what I had to do during a given time. Now it all over … I am now taking it light … taking it day by day” (Chinese patient).

Understanding of self

Another participant, a teacher, mentioned that since her illness, she has changed her thoughts of people's behavior during an illness phase. Initially, she believed that behavior could be controlled by one's thoughts and perception, but when she became a patient, it made her understand the “being sick feeling” better. She shared “mentally, I was quite arrogant. When somebody was ill, and when they are groaning and moaning, I will ask why the fuss? It is mind over matter. Inside my head, I will say if it were me, I would get over it. Now I know that is not the way. After I became sick, I realised that everyone is vulnerable, to being sick, being in pain. When it happens to you, then you realise. So I am now correcting myself (Indian patient).

Another woman added that she now sees new meaning in her relationships with others. She began to appreciate people that she had taken for granted earlier “I am also learning to be more humble, and appreciate the things people do for me, my husband, family, friends. Be gentle and kind to everyone around us. Don't take your loved ones for granted” (Chinese patient).

 Discussion



This study enunciates the spiritual experiences of women with breast cancer. The uniqueness of this study lies in its focus on an unstudied population, women with breast cancer from a multiethnic population in Singapore. While the women from all three ethnic groups did not use the term spirituality explicitly, the words used and experiences shared following the cancer diagnosis, reflected key characteristics of spirituality.

For several women in the study, spirituality was the transcendental experience where they saw a change in their relationship with God. Women drew hope and strength from their connection and communication with God. Researchers have emphasized the importance of the relationship with God as aspects of spirituality that may provide hope, optimism, and inner strength when adapting to stressful situations.[17]

In this study, engagement with the spiritual realm comprised both religious and spiritual-related activities. They used a variety of activities including attendance at places of worship, increasing the frequency of worship, engaging in prayers and meditation, and reading scriptures. In most parts, the women did not need the mediation of a religious leader or priest and described their relationship with God as personal and accessible. It becomes important to note that these activities are cultural strategies adopted by Singaporean women with breast cancer from all three ethnic groups.

Thomas and Retsas[18] eluded that a cancer diagnosis can be a stimulus for spiritual exploration, a search for meaning. Women from all three ethnic groups in this study drew on religious and spiritual practices to make sense of their cancer diagnosis and come on terms of acceptance. Spirituality provided the vehicle from moving their emotional concerns to finding meaning and purpose in life.

A salient finding in this study is the philosophical doctrine that emphasizes that life events are beyond individuals' locus of control and involves predestination, happening as a will of God. The frequent reference by the Malay women in the study that the disease is a divine test is congruent to findings of previous studies conducted on women with Islamic faith.[19],[20] Dominant Islamic teachings emphasize that birth, life, and death are in the hands of God. This could explain why the majority of the Malay women in the present study presented at Stage 3a despite the country's rigorous breast cancer screening efforts. Knowledge of spiritual beliefs of Muslim women can help health-care professionals provide appropriate advice to this group of women. Muslim women could be reminded that the Islamic doctrine also espouses that individuals should respect and care for their bodies.

Similar to the women in Gurm et al.'s study,[21] all the Indian women attributed breast cancer as a manifestation of bad Karma. In Hinduism, Karma denotes the cycle of cause and effect where right actions produce good results and wrong actions produce bad outcomes. Karma is central to the Hindu religious consciousness and provides a context to understand the way Indian women made sense of their lives and how they adapted to the changed reality.[21],[22]

Women in this study shared how spirituality helped them find meaning and purpose and view life with a new lens. The breast cancer diagnosis made them see life differently and not to hold onto trivialities. These findings are congruent with Coward and Kahn's[23] argument that people faced with adversity such as breast cancer tend to reach within and without to find renewed purpose and meaning in their lives. The results of the present study suggest that breast cancer may have provided an opportunity for internal growth and transformation.

Limitations

The study was conducted at one-time point and therefore may not be adequate to provide a thorough understanding of the spiritual experience of the women in the study. Furthermore, all the interviews were conducted in English. Including women who are non-English speaking may have added another dimension to the findings of the present study.

 Conclusion



This study shows evidence that the concept of spirituality has relevance for women with breast cancer in Singapore. Transcendental experiences, efforts to construe meaning and purpose as well as changing perspective are attributed related to spirituality. The findings of the study inform that women in their first year of breast cancer express spirituality in culturally specific ways. The voice of the women demonstrates that care provision must be therapeutically focused as the findings feature spiritual practices that women adopt to cope and adjust to their changing lives. The findings offer insight to the spiritual experiences of women and may be used as fundamental knowledge to guiding clinicians on the importance of integrating spiritual assessment and spiritual intervention in the care delivery.

Acknowledgments

The research team would like to extend their thanks all the women who have participated in the present study.

Financial support and sponsorship

This study was partially funded by a grant from the the National University Cancer Institute, Singapore (NCIS) Endowment Fund and NHU Cancer Fund.

Conflicts of interest

There are no conflicts of interest.

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