Journal of Cancer Research and Therapeutics

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 15  |  Issue : 5  |  Page : 1124--1130

Association between spiritual intelligence and stress, anxiety, and depression coping styles in patients with cancer receiving chemotherapy in university hospitals of Tehran University of medical science


Mahboobeh Safavi1, Seyyed Taha Yahyavi2, Hamideh Fatehi Narab3, Seyyed Hossein Yahyavi4,  
1 Department of Management and Health Services, Islamic Azad University of Tehran Medical Sciences, Tehran, Iran
2 Department of Psychiatry, Tehran University of Medical Sciences and Health Services, Tehran, Iran
3 Department of Nursing, Islamic Azad University of Tehran Medical Sciences, Tehran, Iran
4 Department of Anesthesia, Islamic Azad University of Tehran Medical Sciences, Tehran, Iran

Correspondence Address:
Hamideh Fatehi Narab
Department of Nursing, Islamic Azad University of Tehran Medical Sciences, P. O. Box: 6651432, Tehran
Iran

Abstract

Background: Holistic care addresses the physical, psychological, social, and spiritual dimensions of the patient in which spiritual dimension plays a pivotal role in patient care. Objective: The objective of this study is to investigate the association between spiritual intelligence with stress, anxiety, and depression coping styles in patients with cancer. Methods: This analytic descriptive study was carried out on 276 patients with cancer receiving chemotherapy in university hospitals of Tehran University of Medical Sciences during 2013–2014. The participants were selected using cluster sampling. Data collection tools included patients' medical history, demographic questionnaire developed by researcher, spiritual intelligence self-report inventory questionnaire, ways of coping questionnaire, and depression, anxiety, and stress scales-42. Pearson correlation and multiple regression analyses were conducted to analyze the data using SPSS 20. Differences were considered significant at the P < 0.05 level. Results: There was inverse significant relationship between spiritual intelligence and stress (r = −0.268 and P < 0.001) and between spiritual intelligence and anxiety (r = −0.200 and P = 0.001) and between spiritual intelligence and depression (r = −0.317 and P = 0.000). There was a significant relationship between spiritual intelligence and coping styles (P < 0.01). The highest association was observed between spiritual intelligence and problem-focused strategy or positive reevaluation strategy (P = 0.000 and r = 0.668 and P = 0.000 and r = 0.667, respectively). Conclusions: Spirituality and religion are an important source of strength for adjusting of patients to cancer and help patients to achieve the sense of meaning and purpose in the course of disease. Implications for Practice: Establishment of settings in hospitals focusing on using spiritual intelligence to improve treatment outcomes in patients with cancer.



How to cite this article:
Safavi M, Yahyavi ST, Narab HF, Yahyavi SH. Association between spiritual intelligence and stress, anxiety, and depression coping styles in patients with cancer receiving chemotherapy in university hospitals of Tehran University of medical science.J Can Res Ther 2019;15:1124-1130


How to cite this URL:
Safavi M, Yahyavi ST, Narab HF, Yahyavi SH. Association between spiritual intelligence and stress, anxiety, and depression coping styles in patients with cancer receiving chemotherapy in university hospitals of Tehran University of medical science. J Can Res Ther [serial online] 2019 [cited 2019 Nov 22 ];15:1124-1130
Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1124/231451


Full Text



 Introduction



Cancer is the leading cause of death worldwide. It is the second leading cause of death in developing countries following cardiovascular diseases and the third leading cause of death in developing countries. Cancers account for approximately 12% of all deaths each year worldwide. Number of global cancer deaths is projected to increase 45% from 2007 to 2030 (from 7.9 to 12 million deaths). Each year, more than 11 million people are diagnosed with cancer and 7 million cancer-related deaths and approximately 22 million cancer survivors worldwide. Studies show that of new cancer cases, 45% occurred in Asia, 26% in Europe, 15% in North America, 7% in Central/South America, 6% in Africa, and 1% in Oceania.[1],[2],[3] Lung cancer is the most common cancer and leading cause of cancer death among both men and women in the world followed by breast cancer (women only) which is the second most common cancer worldwide. However, breast cancer ranked the fifth, after lung, stomach, liver, and colorectal cancers. It is estimated that there are nine risk factors accounting for 1/3 of all cancers in the world including smoking, sedentary lifestyle, obesity, low consumption of fruits and vegetables, unsafe sexual behaviors, environmental pollutions, indoor air pollution, and unsafe health-care injections.[4]

Cancer is also the third most common cause of death in Iran. Each year, an estimated 3000 Iranians die of cancer. It is expected that cancer incidence will increase twice over the next two decades in Iran due to increase in average life expectancy and older people, new technologies, unhealthy life style, and in industrial carcinogens. According to the WHO projections, there will be 86,553 cancer cases and 62,897 cancer deaths in Iran by 2020.[5] Therefore, adopting scientific and correct cancer prevention measures is important to control and reduce the cancer incidence rates in Iran.

Despite treatment with several methods, cancer is considered to be an incurable and lethal disease by many patients. In addition, one out of three patients with cancer appears to experience anxiety and depression. It has also been shown that disease severity and prognosis and treatment method had not significant effect on patient adjustment to cancer. However, those patients who feel what has happened to them and who are capable to overcome their condition can adjust to cancer.[5] The studies show that cancer has a great negative impact on quality of life in patients including reduced quality of life, depression, anxiety, stress, hopeless, anger, and aggression, among them depression and anxiety are the most common consequences of cancer development in patients. These problems result in reduced sense of well-being and lowered efficiency in patients leading to reduced patients' contribution to their treatment. Therefore, their capability to accommodate with such stressful event (cancer) will be attenuated because it overloads beyond their capacity.[6] Cancer diagnosis which is followed by treatments such as chemotherapy and radiotherapy causes feeling of apprehension and anxiety in patients resulting in inability of patients to control cancer pain and making them hesitated and undecided. These problems, in turn, lead to reduction or loss of hope for patients.[7] Until recently, there was little information on the emotional reactions impact on patient resistance against diseases. Recent studies show that there is biochemical connection between mood status and immunity such that certain emotions may suppress immune system.[8] Detected cancer is a worrying experience for the patient. Awareness of cancer patient from his/her life-threatening condition may change his/her perception of life, according to which, it is important to help the patient to adjust his/her condition.[9]

In recent years, spirituality has been increasingly regarded as a basis for human existence and healing. Holistic care addresses the physical, psychological, social, and spiritual dimensions of the patient in which spiritual dimension plays a pivotal role in patient care.[10]

Spiritual forces as source of peace and happiness for patients have been prominent in many nursing theories over past decade.[11] In this respect, a construct influencing mental health called spiritual intelligence has attracted the world's attention and interest.[12] A study in West Canada on situated clinical encounters in the negotiation of the religious and spiritual plurality by Barbara (2010) showed that religious and spiritual beliefs have key role in health care decisions and are effective in treating the patient.[13] Coping is action directed at the resolution or mitigation of a problematic situation including number of strategies. These strategies include adaptive (effective) and maladaptive (ineffective) strategies used by patients to cope with a threat and to create mental equilibrium.[14] There are two types of coping strategies including emotion-focused and problem-focused strategies. Usually, people use both of these strategies to cope with their tensions. Coping strategies are also known as mediators between stress and disease.[15]

Since the results obtained by the previous studies on relationship between spiritual intelligence and stress, anxiety, and depression coping styles are conflicting and there are limited studies in Iran in this area, the present study was carried out to determine the association between spiritual intelligence and stress, anxiety, and depression coping styles in patients with cancer-receiving chemotherapy in university hospitals of Tehran University of Medical Science.

 Methods



This analytic descriptive study was carried out on 276 patients with cancer receiving chemotherapy in university hospitals of Tehran University of Medical Sciences during 2013–2014.

Participants

The participants were selected using cluster sampling method, by which we divided the population into separate groups (clusters); then, a simple random sample of clusters is selected from the population. The inclusion criteria were diagnosis of cancer inpatient, age over 18 years, able to write and read, patient awareness of his/her illness, and consent to participate in the study. Patients with mental illness were excluded from study to reduce selection bias.

Instruments

Data collection tools included demographic questionnaire developed by researchers, spiritual intelligence self-report inventory (SISRI) questionnaire, ways of coping questionnaire (WOCQ), and depression, anxiety, and stress scales (DASS-42). Demographic questionnaire included quantitative variables (age, gender, number of chemotherapy sessions, and period after cancer diagnosis) and qualitative variables (type of cancer, type of treatment, marital status, level of education, occupation). SISRI Scale was used to assess the spiritual intelligence by King in 2008 and included four subscales – critical existential thinking (CET, 7 items), personal meaning production (PMP, 5 items), transcendental awareness (TA, 7 items), and conscious state expansion (CSE, 5 items). The final 24-item pool displayed an alpha of 0.92, which represents a more appropriate level of internal reliability. Individual subscales of CET, PMP, TA, and CSE also displayed adequate alpha coefficients of 0.78, 0.78, 0.87, and 0.91, respectively. The average interitem correlation was 0.34, with split-half reliability at the 0.91 level.[16] Participants were required to respond to the measuring a five-point Likert scale (0 = “not at all true of me,” “1 = not very true of me,” 2 = “somewhat true of me,” 3 = “very true of me,” and 4 = “completely true of me”). After calculating the total score for patients, the scores 0–24, 24–48, 48–72, and 72–96 were considered as low, lower than moderate, moderate, and higher than moderate spiritual intelligence, respectively. Validity of the test also was confirmed using face content validity and reliability of the test was ascertained using Cronbach's alpha. The total alpha coefficient was 0.92 and alpha coefficients were 0.96, 0.94, 0.90, and 0.92 for CET, PMP, TA, and CSE, respectively, indicating high reliability of the test.

Coping styles were evaluated using standard questionnaire and the WOCQ (Folkman and Lazarus, 1980). This self-report questionnaire comprises 66 items covering a wide range of thoughts and acts that people use to deal with the internal or external demands of specific stressful encounters.[17]

Coping strategies are summarized on problem- and emotion-focused subscales. Problem-focused subscales include (1) seeking social support, (2) Accepting responsibility, (3) positive reappraisal and (7) planful problem-solving. Emotion-focused subscales include (1) confrontive coping, 2) distancing, (3) self-controlling, and (4) escape-avoidance. Participants were required to respond to the questions measuring 66 items and a four-point Likert scale (0 = “Not at all,” “1 = Sometimes,” 2 = “Often,” 3 = “Very often” was used for each item. Validity of the test was confirmed using face content validity, and reliability of the test was ascertained using Cronbach's alpha. The alpha coefficients were 0.88, 0.93, 0.89, 0.90, 0.89, 0.88, 0.92, and 0.91 for seeking social support, accepting responsibility, positive reappraisal, planful problem-solving, confrontive coping, distancing, self-controlling, and escape-avoidance.

Pearson correlation and multiple regression analyses were conducted to analyze the data using SPSS Version 20 (IBM Corp, Armonk, NY: USA). Differences were considered significant at the P < 0.05 level.

To evaluate stress, anxiety, and depression in patients, DASS-42 (Lovibond and Lovibond, 1995) was used. The DASS is a 42-item questionnaire which includes three self-report scales (the sum of the relevant 14 items for each scale) designed to measure the negative emotional states of depression, anxiety, and stress. The reliability scores of the scales regarding Cronbach's alpha scores rate the depression scale at 0.91, the anxiety scale at 0.84, and the stress scale at 0.90 in the normative sample. The depression and stress scales meet the standard threshold requirement of 0.9 for research; however, the anxiety scale still meets the 0.7 threshold for clinical applications and is still close to the 0.9 required for research.[18] After calculating the scores of questions of stress subscale, the scores 0–14, 15–18, 19–25, 26–33, and ≥34 were considered as normal, mild, moderate, severe, and extremely severe levels of stress, respectively. For questions of anxiety subscale, the scores 0–7, 8–9, 10–14, 15–19, and 20 were considered as normal, mild, moderate, severe, and extremely severe levels of anxiety, respectively. For questions of depression subscale, the scores 0–9, 10–13, 14–20, 21–27, and ≥28 were considered as normal, mild, moderate, severe, and extremely severe levels of depression, respectively. Validity of the test was confirmed using the face content validity, and reliability of the test was ascertained using Cronbach's alpha. The alpha coefficients were 0.94, 0.95, and 0.97 for stress, anxiety, and depression, respectively.

Data analysis

Pearson correlation and multiple regression analyses were conducted to analyze the data using SPSS 20. Differences were considered significant at the P < 0.05 level.

This study was approved by the local ethics committee.

 Results



A total of 267 (126 females and 151 males) cancer patients on chemotherapy with mean age of 52 (age range 18–84) years old participated in the study. Number of chemotherapy sessions was 1–51. The least period after cancer diagnosis was 6 months. The majority of patients (34.1%) had education level of under high school diploma.

About 3 (1.1%), 129 (46.7%), 107 (38.8%), 2 (0.7%), and 35 (12.7%) of patients had history of surgery, chemotherapy, surgery and “chemotherapy + radiotherapy” and “surgery + chemotherapy + radiotherapy,” respectively. Colon cancer was the most common cancer (17.8%) among patients and also the most common cancer (9.4%) among female patients. Stomach cancer was the most commonly diagnosed (9.4%) among male patients. Metastasis has been identified in 89 (32.2%) of patients.

Colon cancer, bone cancer, and non-Hodgkin's lymphoma has recurred once in 30, twice in four, and thrice in 3 patients, respectively. Colon cancer (with recurrence of 3 times in 3 patients) and Hodgkin's lymphoma (with recurrence of 4 times in 1 patient) had the highest reoccurrence rate.

Mean spiritual intelligence score was 70.18 ± 16.59 (moderate level). Of 4 spiritual intelligence subscales, TA (20.53 ± 5.31) and CSE (14.54 ± 3.93) had the lowest and highest score, respectively.

Of coping styles, accepting responsibility (10/95 ± 2/31), confrontive, coping (14/33 ± 3/09) had low scores and positive reappraisal (20/21 ± 4/56), escape-avoidance (19/97 ± 4/14), self-controlling (19/26 ± 4/23), seeking social support (18/36 ± 4/16), and planful problem-solving (16/24 ± 3/93) had the higher scores.

About 90 (32.6%), 33 (12%), 52 (18.8%), 54 (19.6%), and 47 (17%) of patients had mean stress scores of ≤14, 15–18, 19–25, 26–33, and ≥34, respectively; according to which, mean scores ≤14 were observed in higher proportion and scores 15–18 were observed in lower proportion of patients.

About 57 (20.7%), 22 (8%), 47 (17%), 45 (16.3%), and 105 (38%) of patients had mean anxiety scores of 0–7, 8–9, 10–14, 15–19, and ≥20, respectively; according to which, mean scores ≥20 were observed in higher proportion and mean scores 8–9 were observed in lower proportion of patients.

About 99 (35.9%), 28 (10.1%), 44 (15.9%), 49 (17.8%), and 56 (20.3%) of patients had mean depression scores of 0–9, 10–13, 14–20, 21–27, and ≥28, respectively; according to which, mean scores 0–9 were observed in higher proportion and mean scores 10–13 were observed in lower proportion of patients.

In our study, mean total scores for DASS were 39.16 ± 71.11, 30.16 ± 42.90, and 66.20 ± 57.11, respectively. According to DASS-42, norms from individuals in a nonclinical sample for DASS are 6.3 ± 6.97, 4.70 ± 4.91, and 10.11 ± 7.91, respectively, and in a clinical sample for DASS are 10.65 ± 9.30, 10.90 ± 8.12 and 21.10 ± 11.15, respectively. According to statistical analysis, our findings, therefore, indicated that mean scores for depression, anxiety, and stress were significantly higher in patients with cancer compared to normative data.

The results of Pearson's correlation showed that there was significant inverse correlation between spiritual intelligence and stress (P = 0.000, r = −0.286), and between spiritual intelligence and anxiety (P = 0.001, r = −0.200), and also between spiritual intelligence and depression (P = 0.000, r = −0.317) in patients with cancer [Table 1].{Table 1}

There was positive relationship between coping styles and spiritual intelligence subscales (P < 0.01). The results of Pearson's correlation showed that there was stronger relationship between spiritual intelligence and planful problem-solving (P = 0.000, r = 0.668) and between spiritual intelligence and positive reappraisal (P = 0.001, r = 0.667) [Table 2].{Table 2}

The results of multiple regression analysis showed that adjusted R2 = 0.538 and Δ = 220.681 (α < 0.001), and there was also 54% of the variance in spiritual intelligence in multiple regression model. Planful problem-solving strategy indicates 44.4% of the variance for spiritual intelligence. Standardized and unstandardized regression coefficients showed that four variables (positive reappraisal, self-controlling, seeking social support, and planful problem-solving) had significant impact on prediction of spiritual intelligence in patients, which among these variables, planful problem-solving strategy had the strongest impact on spiritual intelligence followed by positive reappraisal, self-controlling, seeking social support, respectively. The other variables including depression, anxiety, stress, confrontive coping, distancing, accepting responsibility, and escape-avoidance were not able to predict spiritual intelligence in patients [Table 3], [Table 4], [Table 5].{Table 3}{Table 4}{Table 5}

 Discussion



The results of our study showed that total mean score for spiritual intelligence was moderate in patients with cancer receiving chemotherapy. This finding is similar to other reports in this area. It has been demonstrated that there is a significant correlation between spirituality and anxiety and depression in patients with advanced cancer.[19] There has also been relationship between spiritual intelligence and quality of life in patients with cancer.[20],[21],[22],[23],[24] It has also been shown that among patients with migraine, fibromyalgia, chronic pain, lumbar pain, or chronic fatigue those who had higher score for spiritual and religious dimension experienced significant lower pain.[25] The findings show that spirituality and in particular spiritual intelligence is an effective coping strategy to solve problems of everyday life.[26] The findings also indicate that spiritual values are important to patients coping with cancer such that the patients with higher level of spirituality value could cope effectively to their problem.[27]

Spiritual intelligence integrates inner life of mind and spirit with the outer life of work. The factors that may influence the development of spiritual intelligence are linked to person's environment construct.[13] In the term spiritual intelligence, spirituality refers to seeking of human for sacrifice, awareness, and meaning, and intelligence refers to using of these resources to promote the human adjustment and welfare.[3],[4],[6] In contrast to some researchers that believe in spiritual intelligence only for solving human existential and ethical problems, Emmons defines spiritual intelligence as “the adaptive use of spiritual information to facilitate everyday problem-solving and goal attainment and yet he believes that in the eyes of a spiritual person, all aspects of life are spiritual.[23]

According to King, when people need assistance to deal with life pressures, the spiritual intelligence can help them find meaning in stressful situations and through that, they can more easily cope with the circumstances. Development of spiritual intelligence gives people a new insight into themselves and improves their self-confidence. It also helps people to achieve self-consistency and reduce their worries and anxiety and to create strong relationship with others.[16]

In our study, patients with cancer have used positive reappraisal, escape-avoidance, self-controlling, seeking social support, and planful problem-solving coping styles more than other styles; that is, they have used adaptive (problem-solving focused) coping styles more than maladaptive (emotion focused) coping styles. In line with this finding, there are other studies reporting that patients with cancer use adaptive coping styles in the course of cancer treatment to achieve treatment goals.;[28],[29] however, in contrast to this finding, a study on women with cancer showed that the patients score in extroversion was low and experienced significantly higher negative emotions (anger, anxiety, and depression) than control group; i.e., they used emotion-focused coping styles more than problem-solving focused coping styles.[30] The results of an investigation on coping styles of hemodialysis patients also showed that most of the hemodialysis patients used emotion-focused coping styles.[31]

Positive reappraisal style has been found to reduce distress in the face of a number of medical conditions, including breast cancer. Positive reappraisal is a critical component of meaning-based coping that enables individuals to adapt successfully to stressful life events. However, when the individuals attend to negative past events, it may also cause more stress due to individuals' concern about reoccurring the same negative effects in their life.[11]

Patients using escape-avoidance strategy show high levels of stress due to their aggressive behaviors with their relatives and decreased creativity and low self-confidence and their inability in concentration on their daily tasks and in decision-making. They also experience exhaustion, unhappiness, and intolerance which results in stress, anxiety, and depression.

The self-controlling strategy requires ability to wait, which makes patients provoked resulting in anxiety in patients during long time.[32]

In our study, total scores for DASS was considerably high in patients with cancer, among which, total score for stress had highest score. In line with this finding, there are other reports indicating that stress, anxiety, and depression are prevalent in cancer patients.[33] The results of a study on anxiety, depression, and quality of life among Chinese breast cancer patients during adjuvant therapy show that the percentage of participants with anxiety or depression was higher in the chemotherapy group compared to patients receiving radiation therapy. More participants in the chemotherapy group also had both anxiety and depression than those in the radiotherapy group possibly because of severe side effects from chemotherapy and poorer self-esteem through side-effects involving changes in physical appearance. Uncertainty about the recurrence of cancer in patients undergoing chemotherapy may also cause higher levels of anxiety and depression.[34]

Research on recognizing depression in patients with cancer shows that diagnosis of cancer often precipitates intense emotions such as fear, sadness, and anger. Individuals who may never have given much thought to their own death are confronted with the very real possibility of a shortened life and future suffering and also financial worries which in turn lead to stress, depression, and anxiety.[35] Nowadays positive psychology has particular attention to mental health which arises from physical, mental, and social well-being.[36]

Regression analysis of data showed that spiritual intelligence was influenced primarily by planful problem-solving strategy followed by positive reappraisal, self-controlling, and seeking social support strategies. Other variables including depression, anxiety and stress, and confrontive coping, distancing, accepting responsibility, and escape-avoidance strategies were not able to predict spiritual intelligence scores in patients.

The results of present study show that chronic diseases including cancer have serious negative impact on many aspects of human health. The feeling of belonging in God, trusting God in tough times and having social and spiritual supports are the ways which can be relied on to reduce the negative effects of adverse events.

Analysis of data also showed that planful problem-solving strategy as predicting variable accounted for 44.4% of the total variance for spiritual intelligence followed by positive reappraisal, self-controlling, and seeking social support strategies. However, variables including depression, anxiety and stress, and confrontive coping, distancing, accepting responsibility, and escape-avoidance strategies were not able to predict variance for spiritual intelligence in patients.

There was positive relationship between spiritual intelligence components and copying style components. Most of the patients also have used problem-focused rather than emotional-focused coping styles indicating that importance of pressurizing factor is determined by cognitive evaluation which is influenced by individual beliefs and values such as self-control and existential and spiritual beliefs.

 Conclusions



We have demonstrated that spirituality and religious beliefs had central and pivotal role in adjusting of patients to cancer and help patients to achieve the sense of meaning and purpose in the course of disease. Religion and spirituality are important source of strength for adjusting to cancer in patients with cancer. Promoting the spiritual intelligence in Iranian people who have deep believe in religious and spiritual beliefs also can help to guarantee success of medical and psychological interventions in this area. Since such interventions can be easily learned and performed by nurses, it is recommended that nursing programs to cover interventions by which the spiritual intelligence can be promoted. Considering the fact that this study included different cancers and that patterns of different cancers vary, the results might bias by this fact. Further research is also required to demonstrate the significant role played by spiritual intelligence in patients with cancer to improve their disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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