Journal of Religion and Health
https://doi.org/10.1007/s10943-020-01117-1
ORIGINAL PAPER

Investigation of the Spiritual Care Effects on Anxiety,
Depression, Psychological Distress and Spiritual Levels
of Turkish Muslim Radiotherapy Patients
Turgay Şirin1

· Fatih Göksel2

Accepted: 16 October 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
The aim of this study is to examine the spiritual care support given to Muslim cancer patients undergoing radiotherapy with an experimental study on the spirituality,
anxiety, depression and distress levels of these patients. In this study, experimental research design with experimental control group was used. Personal information form designed by researchers, HAD scale, DT scale and Spirituality Scale was
used for personal information. In conclusion, it was determined that the support
for Islamic spiritual care had positive effects on hospitalized radiotherapy patients.
According to the results obtained, it is recommended to examine in larger sample
groups in different treatment programs in order to reveal the effect of spiritual care
support.
Keywords Cancer · Radiotheraphy · Islamic spiritual care · Muslims · Psychology
of religion

Introduction
Cancer is a serious health problem that requires long-term struggle financially and
spiritually in all societies. Despite the improvement in survival rates over the past
two decades due to diagnostic and therapeutic advances, cancer remains the second
leading cause of death worldwide (Fitzmaurice et al. 2017). It is predicted that in
2018, 18.1 million people worldwide were diagnosed with cancer and 9.6 million
* Turgay Şirin
turgay.sirin@izu.edu.tr; turgaysirin@gmail.com
Fatih Göksel
fatihgoksel73@gmail.com
1

Islamic Sciences Faculty, Department of Psychology of Religion, Istanbul Sabahattin Zaim
University, Halkalı Street, No: 281 Halkalı, Küçükcekmece, Istanbul 34303, Turkey

2

Department of Radiation Oncology, SBÜ Dr. Abdurrahman Yurtaslan Oncology Training
and Research Hospital, Mehmet Akif Ersoy Street, Yenimahalle, 06200 Ankara, Turkey

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Journal of Religion and Health

patients died due to cancer. The projected global burden will double by approximately 29–37 million new cancer cases by 2040, and more than two-thirds of this
increase is expected to be in countries with low- or middle-income levels. Out of
15 million deaths (early death) between the ages of 30 and 69 in 2018, 4.5 million
developed due to cancer (World Health Organization 2020). Due to life expectancy
and epidemiological and demographic transitions, it is predicted that the number
of new cases and deaths will continue to increase in the coming years. If the cancer continues similarly, 22 million new cases are expected to emerge in 2030. As
can be seen from these data, cancer will continue to be the main health problem
in the twenty-first century we are in. The World Health Organization recommends
gradual establishment of effective cancer management systems, even in low-income
countries, with appropriate planning and implementation in the prevention of cancer
deaths (Ferlay et al. 2015). As can be seen from these data, cancer will continue to
be the main health problem in the twenty-first century we are in.
Cancer is a major health problem in Turkey and also all over the world. According to the mortality statistics in Turkey, cancer accounts for about 20% of all deaths.
With the decrease in the population growth rate, the average age of the population in
Turkey increased. While people aged 45 and over constitute 20% of the population
in 2000, it is expected to constitute 27.2% of the population in 2012 and 33.4% in
2023 (Göksel 2019). Cancer incidence, as in the world, has been increasing in Turkey over the years.
Today, there has been an increasing interest in the role that religion and spirituality might play in patients’ responses to cancer (Thuné-Boyle et al. 2006; Lin and
Bauer-Wu 2003). One of the strategies that can be applied against the stress caused
by cancer is the use of religious and spiritual resources to support the treatment.
The American Clinical Oncology Association and other related organizations recommend meeting spiritual needs in clinics (Gaston-Johansson et al. 2013; Astrow
et al. 2007).
Spiritual Care (in German: Geistige Pflege; Seelsorgerische Pflege; Seelsorge) is
an important part of areas such as palliative care, medical treatment, medical and
social work, medical and psychosocial rehabilitation services. These are social and
human-oriented care services that aim to support the spirituality of people in need
of care, increase their loyalty to life, to be at peace with their inner worlds, to eliminate spiritual deviations and fears (Şirin 2018a). Spiritual care is an interdisciplinary field located at the intersection of fields such as medicine, religion, psychology, social work, education and consultancy. It has been applied in a modern way
for more than a hundred years in Europe and the United States (Ferlay et al. 2015).
But spiritual care profession is an emerging concept in Turkey. Therefore there is
a need to study on spiritual care in Turkey. Turkey is also observed an increase in
the work done on this issue in recent times. For example, in his study, Dedeli et al.
(2015) Assessing the Spiritual Needs and Practices of Oncology Patients in Turkey,
his researches investigated the spiritual needs of cancer patients and their research
was to “address problems before death and death” (100%), “feeling of peace and
satisfaction” (94.8%) and “accompaniment” (93.5%). These findings can help nurses
and healthcare professionals start the process of providing spiritual care to cancer
patients (Dedeli et al. 2015).

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In conclusion, the literature review shows that spirituality is an important component of the health and social status of cancer patients and spiritual distress has
a negative effect on the quality of life of cancer patients. It made it necessary to
implement spiritual-based interventions to support patients with cancer spiritually
(Puchalski et al. 2019).
In literature, supported by the spiritual content of alternative methods of treatment of cancer patients in Turkey or spiritual needs of cancer patients were found
to be a limited number of studies to assess. In addition, it is understood that there
is not a sufficient number of experimental studies involving a spiritual care practice that includes religious interventions in the direct Islamic framework for radiotherapy patients (Özdoğan 2020; Çınar and Şirin 2019; Dedeli et al. 2015; Üstündağ
and Zencirci Demir 2015; Kurt and Özdoğan 2005). This is the originality of our
research. In this study, the effects of Islamic spiritual care practices on anxiety,
depression and spiritual level that can develop in cancer patients undergoing radiotherapy were investigated. It was also aimed to investigate the effects of different
religious beliefs and cultures in clinical settings in order to better understand how
spiritual care can be applied in the treatment of cancer patients and to integrate spiritual care into oncology.
Within the scope of the main purpose of the research, the following hypotheses
were tested:
1. Hypothesis: Spiritual counseling and guidance support significantly reduce anxiety of radiotherapy patients.
2. Hypothesis: Spiritual counseling and guidance support significantly reduce the
depression of radiotherapy patients.
3. Hypothesis: Spiritual counseling and guidance support significantly reduce psychological distress levels of radiotherapy patients.
4. Hypothesis: Spiritual counseling and guidance support significantly increase the
level of spirituality of radiotherapy patients.

Materials and Methods
Research Model
The study was designed as a controlled experimental study with a pretest/posttest with an experiment and control group. This research conducted to determine
the effect of spiritual care practices on the levels of spirituality, distress, hospital
anxiety and depression of radiotherapy patients. According to the purpose of the
study, the patients were randomly assigned into experimental and control groups.
In both groups, measurements were made using the same scales before and after the
experiment. While “islamic spiritual care (IHSAN Model)” support was given to the
experimental group, no experimental intervention was made to the control group.
Independent variable in the research design is “islamic spiritual care practices”. Our
dependent variable is the hospital anxiety and depression, distress symptoms and

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the level of spirituality which are measured by scales with validity and reliability
studies.
Participants
This experimental research was conducted in Ankara, capital of Turkey, “Dr. Abdurrahman Yurtaslan Ankara Oncology Hospital Radiation Oncology Clinic” between
September 2019 and February 2020. The study group consisted of 70 radiotherapy
patients who received inpatient treatment here. Thirty five of the study group were
determined as the experimental group and 35 of them as the control group. Of the
35-person experimental group, 24 (68.6%) were male and 11 (31.4%) were female;
of the 35-person control group, 18 (51.4%) were male and 17 (48.6%) were female.
While the age range of the experimental group was between 34 and 78, the average age was 57.54 ± 10.90, the age range of the patients in the control group is
between 25 and 80 and the average age is 58.06 ± 13.36. The total of the experiment and total group consists of 42 males (60%) and 28 females (40%) in total 70
people. The average age of the whole experimental and control groups was found
to be 57.84 ± 12.09. In the experimental group five patients were head and neck
tumors (14.3%), ten patients were lung cancer (28.6%), six patients were brain cancer (17.1%), three patients were gastrointestinal cancer (8.6%), four patients were
breast cancer (11.4%), three patients were multiple myeloma (8.6%), one patient was
gynecological cancer (2.9%), one patient was soft tissue cancer (2.9%), one patient
was malign melenoma (2.9%), one patient was non-hodgkin lymphoma (2.9%).
In the control group seven patients were head and neck cancer (20%), six patients
were lung cancer (17.1%), one patient was brain cancer (2.9%), seven patients were
gastrointestinal cancer (20%), five patients were breast cancer (14.3%), one patient
was multiple myeloma (2.9%), three patients were gynecological cancer (8.6%), one
patient was soft tissue cancer (2.9%), three patients were malign melenoma (8.6%),
one patient was non-hodgkin lymphoma (2.9%). When examined in terms of education level, 8 people in the experimental group are literate (22.9%); 16 people stated
that they received education at the level of primary school (45.7%), 4 people in secondary school (11.4%), 4 people in high school (11.4%) and 3 people in university
(8.6%). In the control group, 12 people are literate (34.3%); 15 people stated that
they received education in primary school (42.9%), 4 people in secondary school
(11.4%), 2 people in high school (5.7%) and 1 person in university (2.9%).
Experimental Process
This study was carried out by including patients who were over 18 years old, who
received inpatient radiotherapy, who did not have a level of cognitive dysfunction
that would interfere with psychiatric interviewing or testing, and who voluntarily
participated in the study.
Before the experimental applications, the participants were assigned to the experimental and control groups by drawing lots. Then, the characteristics of the dependent variables were measured in both groups, and this way it was tested whether the

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groups were equal before the experimental manipulation. In the research, 3 scales
were applied to the participants in the experimental and control groups, namely
Personal Information Form, Spirituality Scale, Hospital Anxiety Depression Scale
(HAD) and stress thermometer. Then, spiritual counseling support was provided to
the participants in the experimental group individually. For this support, the spiritual
counseling approach “IHSAN Model” developed by Şirin (2018a, b) was followed.
At least once a week during inpatient treatment with patients; At least 8, at most 14
on average, 10 individual interviews were held. During this period, no process was
applied to the control group, which was formed as a “Waiting List”.
Applied Spiritual Care Model: IHSAN
IHSAN Model is the first spiritual counseling model has been developed in Islamic
religious framework in Turkey (Şirin 2018b). The pioneering work of IHSAN
Model was first made by Şirin (2013) as a doctorate study. Later, it took its final
shape with the improvements and was published in 2014 under the name of İHSAN
Model (Şirin 2014). This model is basically an Islamic religious/spiritual counseling model developed by integrating with the Cognitive-Behavioral Psychotherapy
approach. The spiritual counseling model developed was basically based on the elements that should be included in a model. These elements are; The religious-spiritual ground on which the model in question is based on is the operational consultancy approach of the model and the methods used. The religious basis of the model
developed in this sense is the belief principles of the religion of Islam. The counseling approach is the cognitive-behavioral psychotherapy approach. The applied
techniques consist of cognitive-behavioral psychotherapy techniques and religious
techniques and practices in accordance with the additionally created religion. Ihsan
Model has been developed in a structure that can be used in compliance with other
consultancy approaches. The religious-spiritual counseling model developed in this
sense is defined as follows: “to provide the solution of the problems that the person
associates with religion and spirituality and causes dysfunction in the person, fed
by the processes applied in cognitive-behavioral psychotherapy and using modern
counseling techniques and religious-spiritual methods and techniques. It is a spiritual counseling approach, which is made according to clinical definitions to provide
mentally and mentally healthy people with the aim of ensuring behavioral adjustment and behavioral change regarding their problem” (Şirin 2018b).
IHSAN Model is designed as a 5-stage model. The name of the model consists of
the initials of these stages. These stages and steps have been established in accordance with general psychotherapy and counseling principles. The word “ihsan”,
which constitutes the name of the Ihsan Model, has been defined as an acrostic name
consisting of the initials of the consultancy stages. These stages are as follows (Şirin
2018b).
(I): İnstallation and initation phase: the stage where the first communication is
established and the consulting process is structured. At this stage, consulting needs
are determined and the system is structured (H): Hadaf phase: hadaf is an arabic
word and means target or goal. This stage is the determination of the expected and

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desired situation in the consultancy, that is, the goal setting stage. (S): Strategy
phase: this stage is the consulting strategic planning phase. At this stage, strategies
regarding how to reach the previously determined consultancy targets are determined with the client. (A): Applying and administering phase: the process of managing the process and applying it step by step. (N): Natija phase: the word “natija”
is an arabic word and it means conclusion. This is the stage where the process is
completed. At this stage, the last measurements were made; It is the stage where the
client prepares for the end of the process in order not to lose the gains made.
The word ihsan also has a special meaning in Islam. Ihsan (Arabic: ‫ إحسان‬ʾiḥsān,
also romanized ehsan), is an Arabic term meaning “beautification, perfection, favor,
help, aid, charity, philanthropy, kindness, beneficence, alodium, benevolence or
excellence” (arab. husn, meaning: beauty). It is a matter of taking one’s inner faith
(iman) and showing it in both deed and action, a sense of social responsibility borne
from religious convictions. In Islam, ihsan is the Muslim responsibility to obtain
perfection, or excellence, in worship, such that Muslims try to worship God as if
they see Him, and although they cannot see him, they undoubtedly believe that He is
constantly watching over them. That definition comes from the Hadith of Gabriel in
which Muhammad states, “[Ihsan is] to worship God as though you see Him, and if
you cannot see Him, then indeed He sees you” (Buhârî 1990, pp. Kitabu’l-Iman,
38).
Within the scope of religious techniques used in the IHSAN Model, the reading
of the Qur’an, repentance, dhikr, contemplation, the integration of faith, accounting
of the nafs, religious communique and suggestions, discussion of negative religious
beliefs and attitudes; There are also techniques suitable for Islamic religion such
as strengthening positive religious coping, religious storytelling, prayer, worship,
group (congregation) studies (Şirin 2018b).
Data Collection Tools
Demographic Information Form
It is an information form for age, gender, education level, marital status, occupation,
family type, socioeconomic level, social security, place of residence, habits, history
of psychiatric history and family history.
Hospital Anxiety and Depression Scale (HAD)
It is a self-assessment scale developed to determine the risk in terms of anxiety and
depression and to measure the level and severity change in patients with physical illness and those who apply to primary health care (Zigmond and Snaith 1983). Hospital Anxiety and Depression Scale (HAD) was developed by Zigmond and Snaith
(1983), and validity and reliability were performed by Aydemir et al. (1997). The
scale consists of 14 questions. Seven of the scale questions measure anxiety and
the other seven measure depression. In the scale, odd numbers measure anxiety and
even numbers measure depression. The lowest score that patients can get from both

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subscales is 0 and the highest score is 21 (Aydemir and Köroğlu 2000). As a result
of their validity and reliability study, Aydemir et al. (1997) determined the cutoff
score as 10 for anxiety subscale (HAD-A) and 7 for depression subscale (HAD-D).
Accordingly, areas above these points are considered to be at risk. In this study, the
internal consistency α 80 for HAD-A in the experimental group measurements as of
the pretest results, the internal consistency α 78 for (HAD-D); In the control group
pretest measurements, the internal consistency was α 79 for HAD-A, and the internal consistency was α 60 for (HAD-D). In the posttest measurements, the HAD-A
internal consistency α 75 for the experimental group, the internal consistency α 78
for (HAD-D); In the posttest measurements, the internal consistency was found to
be 83 for HAD-A, and the internal consistency was α 72 for (HAD-D).
Spirituality Scale (SS)
The Spirituality Scale is a 5-point Likert-type scale developed by Şirin (2018a)
and consists of 3 negative 24 positive 27 items. The scale items were prepared in
a 5-point Likert style as “(1) Not Suitable For Me, (2) Some Parts Not Suitable For
Me, (3) Some Parts Good For Me, (4) Good For Me, (5) Totally For Me” Negative
items that are taken are reversed before being evaluated. When the scale is evaluated in terms of total score, the highest score to be obtained from the scale is 135
and the lowest score is 27. The spirituality scale consists of 7 factors whose total
explained variance is 49.68% and the eigen value is greater than 1. These sub-factors named as a “Spiritual Coping,” “transcendence,” “Spiritual Life,” “The Seeking
of Meaning,” “Spiritual Satisfaction,” “Connection” and “Harmony with Nature.”
The high score obtained from each subdimension of the scale shows that the individual has the feature evaluated by the relevant subdimension. When the reliability
coefficients of the subdimensions of the scale are examined; the lowest Cronbach
Alpha Coefficient (0.49), the lowest Guttman value (0.63). The scale also gives a
total spiritual score. Total reliability values of the scale were reported as total Cronbach Alpha value 0.90, total Guttman value 0.91 and total Spearman Brown value
0.89 (Şirin 2018a). During the development of the spirituality scale, the recommended modifications values for the model are given by looking at the covariance
between the latent variables observed in the confirmatory factor analysis (CFA) fit
indices (MI). This model fit values [(χ2 (833.651, sd = 303, p = 0.000); χ2/Sd = 2.75;
RMSEA = 0.05; SRMR = 0.04; GFI = 0.90; AGFI = 0.88; CFI = 0.91; IFI = 0.91;
NFI = 0.90, RFI = 0.85]. The high score obtained from the scale shows that the level
of spirituality in the person is high (Şirin 2018a). In this study, Cronbach Alpha
Coefficient α 0.83 as a result of the pretest results of the spirituality scale; the last
test α value was determined as 0.91.
Distress Thermometer Scale (DT)
The Distress Thermometer, developed by Roth et al., is a screening tool for psychological distress in patients with cancer (Roth et al. 1998). A thermometer with numbers from 0 to 10 on the scale takes place. It is a visual analog scale consisting of
only one question, in which individuals can apply the scale to themselves. Distress

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level is rated between 0 and 10. In this question, zero points show that the individual
has never had distress, and 10 points show that he has a distress at the highest limit.
The Turkish validity and reliability study of the scale was conducted by Özalp, Cankurtaran, Soygür, Geyik and Jacobsen in 2006. The cutoff score of the scale is 4.
Scores of four and above indicate that the level of distress of the cancer patient has
increased. In the study, the sensitivity of the scale was 0.73 and the specificity was
0.49. To scan for psychosocial distress is the first car that was approved in the Turkish language, the use of DT, for optimal treatment of cancer to the psychosocial difficulties that interfere with specific needs constitute the first step for quick browsing
in Turkey. In our study, the problem list section of the distress thermometer was not
used, since the evaluations for the comparison of spiritual support practice in groups
were discussed in detail.
Ethical Considerations
Ethical permissions and other necessary permissions were obtained at the beginning
of the study. This experimental study was approved by the Medical Specialty Training Board of Dr.Abdurrahman Yurtaslan Ankara Oncology Training and Research
Hospital (Approval ID:2019-06/333).
Data Analysis
IBM SPSS-25 package program was used for statistical analysis. In order to decide
the statistical analyses of the scales applied to the experimental and control groups,
the normality analysis of the scales was made first and descriptive statistics were
examined. In addition, normality tests of the scales were performed and Kolmogorov–Simirnov (K–S) significance (p) values were examined. As a result of the
operations carried out, the spiritual scale pretest score average of the experimental
group that participated in the research was 117.17 (Sd = 12.64; K–S = 0.04 < 0.05);
average posttest score 122.83 (Sd = 12.04; K–S = 0.03 < 0.05); HAD-A pretest
scale mean 7.77 (Sd = 5.17; K–S = 0.20 > 0.05); HAD-A posttest scale mean 5.11
(Sd = 3.35, K–S = 0.20 > 0.05); HAD-D pretest 8.23 (Sd = 5.46, K–S = 0.20 > 0.05);
HAD-D posttest scale mean 7.14 (Sd = 4.66, K–S = 0.20 > 0.05); Distress Thermometer Scale pretest mean score 6.37 (Sd = 3.16, K–S = 0.10 > 0.05); Distress Thermometer Scale posttest mean score was found to be 2.34 (Sd = 2.72,
K–S = 0.08 > 0.05). In the control group, the mean spiritual scale pretest score was
117.13 (Sd = 11.74; K–S = 0.06 > 0.05); average posttest score 109.83 (Sd = 16.12;
K–S = 0.00 < 0.05); HAD-A pretest scale mean 8.86 (Sd = 4.45; K–S = 0.20 > 0.05);
HAD-A last test scale mean 11.60 (Sd = 4.64, K–S = 0.20 > 0.05); HAD-D pretest
8.11 (Sd = 3.30, K–S = 0.10 > 0.05); HAD-D posttest scale mean 10.54 (Sd = 3.95,
K–S = 0.14 > 0.05); Distress Thermometer Scale pretest mean score 2.34 (Sd = 2.72,
K–S = 0.05 > 0.05); Distress Thermometer Scale posttest mean score was found as
5.69 (Sd = 3.03, K–S = 0.06 > 0.05).
When the Kolmogorov–Smirnov values were analyzed as a result of the descriptive statistics on the scales, it was found that the pretest and posttest scores showed

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normal distribution in all scales except the Spirituality Scale in the experimental and
control groups (p > 0.05). In addition, Skewness and Kurtosis values were observed
to be in the range of − 1.5 to + 1.5 in all scales except the spiritual scale (Tabachnick and Fidell 2013). In addition, in order to decide whether the data show normal
distribution, the homogeneity tests (levene) of the experimental and control groups
were carried out, and it was found that the variances of the tests other than the spirituality scale showed a homogeneous distribution (p > 0.05). On top of that, it was
decided that scales other than the spirituality scale had normal distribution.
The group t-test independent of the parametric tests was used to examine the difference between the groups for the normally distributed data, and the paired samples
t-test was performed to determine the intra-group pretest posttest changes. For nonnormality data, Mann–Whitney U and Wilcoxon Marked Ranks Test tests, which are
nonparametric analyzes, were used.

Results
As seen in table, the Depression subscale mean scores of the HAD scale (t = 0.11;
p > 0.05); No significant difference was observed between the experiment and control groups in terms of the HAD Scale anxiety subdimension (t = −0.94; p > 0.05)
(p > 0.05). In terms of Distress Thermometer (t = 5.71; p < 0.05), a significant difference was observed between the pretest scores between the experimental and control
groups (p < 0.05). It was determined that the stress score of the experimental group
was significantly higher than the control group (p < 0.05) (Table 1).
When Table 2 is examined, it is seen that the mean scores and subdimensions of
the spiritual scale in terms of pretest scores did not make a significant difference in
the experimental and control groups (p > 05).
As seen in the Table 3, the HAD-D subscale scores (t = −6.70; p < 0.05); HAD-A
subscale scores differed significantly between groups in favor of the experimental
group in terms of anxiety (t = −3.29; p < 0.05) and Distress Thermometer Scores
(t = −4.86; p < 0.05).
When Table 4 is examined, it was found that the total scores of the spirituality
scale and subscale scores differed significantly in favor of the experimental group in
terms of the experimental and control groups (p < 0.05).
Table 1  Independent group t test results to determine whether HAD and DT pretest scale scores of
experimental and control groups differ
Scales

Group

N

Mean

Std. deviation

Std. error mean

t

df

p

HAD-A

Experiment

35

7.77

5.17

0.87

− 0.94

68

0.35

Control

35

8.86

4.45

0.75

Experiment

35

8.23

5.46

0.92

0.11

55.87

0.92

Control

35

8.11

3.3

0.56

Experiment

35

6.37

3.16

0.53

5.71

68

0.00

Control

35

2.34

2.72

0.46

HAD-D
Distres (DT)

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Table 2  Non-parametric Mann Whitney-U test results to determine whether the pretest scores of the spirituality scale of the experimental and control groups differ
Scales

Group

N

Mean rank

Sum of ranks

Mann–Whit. U

z

p

Spirituality (total)

Experiment

35

35.90

1256.50

598.50

− 0.16

0.87

Control

35

35.10

1228.50

Experiment

35

38.83

1359.00

496.00

− 1.43

0.15

Control

35

32.17

1126.00

Experiment

35

37.77

1322.00

533.00

− 1.16

0.25

Control

35

33.23

1163.00

Experiment

35

40.07

1402.50

452.50

− 1.94

0.05

Control

35

30.93

1082.50

Experiment

35

37.37

1308.00

547.00

− 0.83

0.41

Control

35

33.63

1177.00

Experiment

35

32.71

1145.00

515.00

− 1.15

0.25

Control

35

38.29

1340.00

Experiment

35

34.69

1214.00

584.00

− 0.41

0.68

Control

35

36.31

1271.00

Experiment

35

33.43

1170.00

540.00

− 0.88

0.38

Control

35

37.57

1315.00

Spiritual coping
Transcendence
Spiritual life
Seeking meaning
Spiritual satisfaction
Connection
Harmony with nature

Table 3  Independent group t test results to determine whether HAD and DT scale posttest scores of
experimental and control groups differ
Scales
HAD-A
HAD-D
Distres (DT)

Group

N

Experiment

35

Control

35

Mean
5.11
11.6

Std. dev

Std. error mean

t

df

p

3.35

0.57

− 6.70

68

0.00

4.64

0.78
− 3.29

68

0.00

− 4.86

68

0.00

Experiment

35

7.14

4.66

0.79

Control

35

10.54

3.95

0.67

Experiment

35

2.34

2.72

0.46

Control

35

5.69

3.03

0.51

As can be seen in the Table 5, when the pretest and posttest scores of the
experimental group are examined, it is seen that there is a significant difference
in the anxiety subdimension (HAD-A) of the HAD scale in terms of scale scores
(t = 4.74, p < 0.01). When the difference in question is examined, it is understood
that the HAD-A scale decreased in the experimental group as a result of spiritual
care practices. However, when the pretest–posttest scores of the HAD scale in the
depression subdimension (HAD-D) are examined, it is understood that this difference is not statistically significant according to the paired samples t test results
(t = 1.49; p > 0, 05). It was observed that the DT scores applied to the experimental group (t = 6.59; p < 0.01) decreased significantly after the experimental process and the said differentiation was statistically significant (p < 0.01).

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Table 4  Non-parametric Mann Whitney-U test results to determine whether the posttest scores of the
spirituality scale of the experimental and control groups differ
Scale
Spirituality (total)

Group

Spiritual life

917.00

Experiment 35 42.61

1491.50

35 28.39

Experiment 35 40.50

1417.50

35 30.50

1067.50

Experiment 35 43.40

1519.00

35 27.60

966.00

Experiment 35 42.61

1491.50

Control

35 28.39

993.50

Spiritual satisfaction

Experiment 35 44.13

1544.50

35 26.87

940.50

Connection

Experiment 35 41.74

1461.00

Control

1024.00

Control

35 29.26

Harmony with nature Experiment 35 40.64
Control

p

287.00

− 3.83 0.00

363.50

− 3.07 0.00

437.50

− 2.35 0.02

336.00

− 3.33 0.00

363.50

− 3.22 0.00

310.50

− 3.56 0.00

394.00

− 2.96 0.00

432.50

− 2.14 0.03

993.50

Control
Control
Seeking meaning

1568.00

35 26.20

Control
Transcendence

Mean rank Sum of ranks Mann–Whitney U z

Experiment 35 44.80
Control

Spiritual coping

N

1422.50

35 30.36

1062.50

Table 5  Paired group t test results to determine whether there is a significant difference between the pretest and posttest averages of HAD and DT scales within the groups
Group
Experiment group

Control group

Scale

N

Mean

Std. dev

Std. Er. mean

HAD-A (pretest)

35

7.77

5.17

0.87

HAD-A (posttest)

35

5.11

3.35

0.57

HAD-D (pretest)

35

8.23

5.46

0.92

HAD-D (posttest)

35

7.14

4.66

0.79

DT (pretest)

35

6.37

3.16

0.53

DT (posttest)

35

2.34

2.72

0.46

HAD-A (pretest)

35

HAD-A (posttest)

35

8.86
11.6

4.45

0.75

4.64

0.78

HAD-D (pretest)

35

8.11

3.3

0.56

HAD-D (posttest)

35

10.54

3.95

0.67

DT (pretest)

35

2.34

2.72

0.46

DT (posttest)

35

5.69

3.03

0.51

t

df

p

4.74

34

0.00

1.49

34

0.15

6.59

34

0.00

− 3.94

34

0.00

− 4.66

34

0.00

− 4.62

34

0.00

When Table 5 is examined, in the HAD-A subscale of the control group scores,
which are not done and constructed as waiting lists (t = −3.94; p < 0.01); There
was an increase in the posttest measurement scores in the HAD-D subscale
(t = −4.66; p < 0.01) and the Distress Thermometer scale (t = −4.62; p < 0.01); It
is understood that the difference between the pretest and the posttest points differed significantly.

13

Journal of Religion and Health

The results of the nonparametric Wilcoxon marked rank test results we have
made regarding the question which “Do the pretest and posttest spirituality scores of
groups differ significantly?” are given in Table 6.
As can be seen in Table 6, the difference between the pretest and posttest scores
of NonParametric Wilcoxon Marked Ranks Test in terms of the spiritual scale total
score of the patients constituting the experimental group was statistically significant (z = −3.252; p = 0.00 < 0.01). The difference occurred in favor of the posttest.
In other words, the spirituality scores of the patients constituting the experimental
group increased significantly after the group applications. However, when the subdimensions of the spirituality scale are analyzed, there is a significant difference in the
subdimension of “seeking meaning” (z = −2.128; p = 0.03) and in the subdimensions
of “spiritual satisfaction” (z = −3.649; p = 0.00). It is understood that the number
of people who increase the spiritual score among the patients in the experimental
group in these subdimensions is high (p < 0.05). In the transcendence dimension, the
scale scores of 28 people from 35 experimental groups did not change (z = −0.351;
p = 0.73); 20 people in spiritual life dimension (z = −1.032; p = 0,30), 25 people in connection dimension (z = −1.040; p = 0.30) and in harmony with nature
(z = −2.480; p = 0.50) It was observed that the subscale scores of 20 people did not
change in the subdimension of 19 and finally spiritual coping (z = −1.543; p = 0.12),
and therefore, there was no significant difference between the pretest–posttest scores
(p > 0.05).
When the findings of the control group are analyzed, it is understood that there is
a significant difference between the pretest and posttest scores in favor of the pretest
in terms of the total score of the spiritual scale (z = −2.48; p = 0.01 < 0.05). When
the data are examined, it is understood that the posttest scores decreased in 22 people according to the pretest scores. Likewise, in the “Transcendence” subdimension
(z = −2.28; p = 0.02 < 0.05), in the “search for meaning” subdimension (z = −2.06;
p = 0.04 < 0.05), in the connection subdimension (z = −3.13; p = 0.00 < 0.01) and
there is a significant difference in favor of pretest in terms of compliance with
nature (p < 0.05). It is understood that there is a decrease in posttest scores in these
scales. However, spiritual coping (z = −1.13; p = 0.26); No significant difference was
observed in the dimensions of spiritual life (z = −1.06; p = 0.29) and spiritual satisfaction (z = −1.33; p = 0.18 > 0.05).

Discussion
As a result of the analyses the Spirituality, HAD and DIT Scales used in the research
showed a significant difference between the experimental and control groups in favor
of the experimental group, after the experimental process. These results show us that
the research hypotheses we identified at the beginning of the study are confirmed.
When the literature is examined, some studies supporting our research results. In
this regard, there are studies showing that spiritual well-being has a positive effect
on cancer patients (Puchalski et al. 2019; Çınar and Şirin 2019; Ahmad and Abdullah 2011; Azhar and Varma 1995a). An example of such research is the study of
Eilami et al. (2019). According to the results of the study conducted by Eilami et al.

13

6

10

19

35

8.10

9.17

Harmony with nature (pretest)

N

35

Harmony with nature (posttest)

25

8.75

8

4.69

2

Connection (pretest)

N

35

Connection (posttest)

6

9.80

24

16.08

5

Spiritual satisfaction (pretest)

N

35

Spiritual satisfaction (posttest)

20

5.75

11
8.82

4

Seeking meaning (pretest)

N

35

Seeking meaning (posttest)

20

8.40

10
7.80

5

35

Spiritual life (pretest)

N

28

Spiritual life (posttest)

3
5.33

4

Transcendence (pretest)

3.00

N

15.36

Transcendence (posttest)

35

35

8.70

20

1

Mean rank

Spiritual coping (pretest)

10

27

Total

6.60

5

7

Ties
18.06

N

Po. ranks

Spirituality (total) (pretest)

Spirituality (total) (posttest)

Experiment group

Neg. ranks

Spiritual coping (posttest)

Scales

Group

81

55

37.50

17.50

386

49

97

23

78

42

16

12

87

33

487.50

107.50

Sum of ranks

− 0.67

− 1.04

− 3.64

− 2.12

− 1.03

− 0.35

− 1.54

− 3.25

z

0.50

0.30

0.00

0.03

0.30

0.73

0.12

0.00

p

Table 6  Nonparametric Wilcoxon marked ranks test results to determine whether there is a significant difference between the spirituality scale pretest and posttest averages
of the groups

Journal of Religion and Health

13

13

Harmony with nature (pretest)

17

3

15

35

8.83

10.79

N

35

harmony with nature (posttest)

16

5.83

3

Connection (pretest)

16

10.78

N

35

Connection (posttest)

8

14.38

10

13.35

17

Spiritual satisfaction (pretest)

N

35

Spiritual satisfaction (posttest)

16
7.33

6

Seeking meaning (pretest)

13

11.23

N

35

Seeking meaning (posttest)

12
14.71

7

Spiritual life (pretest)

16

10.81

N

35

Spiritual life (posttest)

15
8.90

5

Transcendence (pretest)

15

11.03

N

35

18.02

Transcendence (posttest)

11

35
13.54

10

3

Mean rank

11.05

14

10

Total

Spiritual coping (pretest)

N

22

Ties

Spiritual coping (posttest)

N

Po. ranks

13.15

Spirituality (total) (posttest)

Control group

Neg. ranks

Spirituality (Total) (pretest)

Scales

Group

Table 6  (continued)

26.50

183.50

17.50

172.50

133.50

244.50

44

146.00

103.00

173.00

44.50

165.50

110.50

189.50

131.50

396.50

Sum of ranks

− 2.95

− 3.13

− 1.33

− 2.06

− 1.06

− 2.28

− 1.13

− 2.48

z

0.00

0.00

0.18

0.04

0.29

0.02

0.26

0.01

p

Journal of Religion and Health

Journal of Religion and Health

(2019) with cancer patients, the application of supportive spiritual intervention
caused an increase in the life expectancy of the patients in the experimental group
(Eilami et al. 2019).
There are some studies in the literature that have found effective results for spiritual counseling studies used in the treatment of anxiety, depression and mourning for
Muslim patients (Tirgari et al. 2013; Lazenby and Khatib 2012; Ahmad and Abdullah 2011; Carter and Rashidi 2004; Razali et al. 2002; Rashidi and Rajaram 2001;
Rhazali et al. 1998; Azhar and Varma 1995a, b; Azhar et al. 1994). In these studies,
participants in the psychotherapy group using religious techniques were reported
to respond rapidly to treatment at a significant level compared to those in the traditional treatment group. The most important reason for this may be that religious
psychotherapies are compatible with the patient’s religious and cultural faith system
(Eilami et al. 2019; Khaki and Habibabad 2020).
The research conducted by Çınar and Şirin, whose sample was composed of 111
cancer patients who were hospitalized in the palliative unit of two public hospitals
in the European side of Istanbul between January and August 2018, support our
results. In this study, it was found that spiritual well-being had a positive effect on
the healing process of individuals with impaired health (Çınar and Şirin 2019). Spiritual well-being helps individuals overcome difficulties in life-threatening diseases
such as cancer. In this case, spiritual well-being of the individual can be increased
by making spiritual care interventions a part of the healing process by healthcare
professionals.
The vast majority of cancer patients experience anxiety throughout the treatment
process from the moment of diagnosis. However, when looking at the causes of anxiety in cancer patients; diagnosis-related uncertainty, side effects of chemotherapy
and radiotherapy, personal and social uncontrolled, increased physical worsening,
thoughts about death are common (Zabalegui et al. 2005). Researches conducted
show that the treatments applied in cancer patients, side effects of treatment, thinking that death will be very soon, uncertainties about life and treatment are the main
sources of stress (Marrs 2006). Thereby, cancer is a disease in which there is a high
probability of psychiatric disorders as well as its potential to affect all physiological systems (Ferlay et al. 2015). In this regard, side effects of radiotherapy applied
due to cancer diagnosis are often accompanied by psychological disorders. Anxiety
and distress come first among them. The incidence of anxiety in cancer patients is
above 50% and approximately 30% of cancer patients experience chronic anxiety
(Marrs 2006). Especially before radiotherapy, approximately 50% of patients experience increased anxiety and distress (Halkett et al. 2012; Mitchell and Lozano 2012;
Holmes and Williamson 2008). Bultz and Carlson (2006) stated that stress levels in
cancer patients can be up to 70% (Bultz and Carlson 2006). In a study conducted in
Australia, DT (Distress Thermometer) and clinical interviews were used as a screening tool. In this study, 40% of 68 participants reported high stress (Musiello et al.
2017). In the problem list in DT, all patients reported experiencing physical problems, and 72% of patients reported emotional problems (Musiello et al. 2017). In
a study conducted by Özalp et al (2006) in Turkey, regardless of the type of cancer
59.3′n% of patients were reported to experience stress. Clinically significant psychological distress is reported in 22–35% of radiotherapy outpatient patients (Söllner

13

Journal of Religion and Health

et al. 2001; Dinkel et al. 2010; Kirchheiner et al. 2013; Mackenzie et al. 2013). The
psychological factors accompanying the disease negatively affect the person’s compliance to treatment and quality of life (Seven et al. 2013). In patients not adequately
prepared for radiotherapy and anxiety, treatment compliance may take longer
because compliance to treatment may decrease (Clover et al. 2011). Accordingly,
both treatment costs and infection risks increase due to long-term hospitalization.
Besides, in cancer patients, anxiety and depression harm the patient mentally and
negatively affect the prognosis of the disease (Giraldi et al. 2007; Çalışkan et al.
2017). Nevertheless, when the psychosocial needs of cancer patients are not adequately met, it has been shown that diagnosis and treatment for psychological morbidity cannot be done adequately (Sanson-Fisher et al. 2000; Newell et al. 2002).
For this reason, in addition to medical treatment, patient’s psychological and social
support is important for treatment (Yee et al. 2017; Verdonck-de Leeuw et al. 2009).
Recognizing the physical severity of the disease and the effect of the mental state on
treatment, increases the person’s compliance to treatment and quality of life. One of
the most important of this support is spiritual care.

Conclusion and Recommendations
According to the results of the study, IHSAN Model which is applied as an
Islamic spiritual care practice, significantly reduces the hospital anxiety, depression and distress levels of the patients in the study group and increases the spirituality levels significantly. On the other hand, control group patients who did
not receive spiritual care support and continued normal radiotherapy treatment,
were found to have significantly increased hospital anxiety, hospital depression
and distress levels and a decrease in spirituality levels.
Given the increased cancer rates in the World and Turkey, in patients belonging to different cultures and religions, to better understand the impact of spirituality, and to make a positive impact on the healing process of patients, hospitals
promotion of spiritual care practices during the routine service and more research
on this issue is recommended.
It is suggested to increase the number of such studies in Muslim societies and
to investigate the effect of spiritual care services on more patients.

Limitations
The limitation of this research is to include only patients hospitalized in Dr.
Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital Radiation Oncology Clinic. Therefore, by planning the research in a different sample,
the anxiety, depression and stress levels of the patients should be studied with different measurement tools and compared with the results of this research.

13

Journal of Religion and Health
Acknowledgements The authors did not receive financial support for the research and would like to
thank all patients who participated in the research. We would also like to thank Ahmet Erdoğan who
assisted in spiritual care practices.
Author Contributions T.Ş.: Methodology, investigation, data preparation, statistics, supervision, writing
and editing. F.G.: Data preparation, investigation, writing, supervision, reviewing and editing.

Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflicts of interest.
Ethical Approval This experimental study was approved by the Medical Specialty Training Board of Dr.
Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital (Approval ID:2019-06/333).
Informed Consent Informed consent was taken from the participants. The patients were randomly assigned
in the spiritual care group and control group. Patients received no payment and could leave the study at any
time during the study period.

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