The effects of spiritual wellbeing on life satisfaction in hematologic cancer patients aged 65 and older in Turkey: mediating role of hope.

INTRODUCTION

In today's conditions, the ratio of individuals over the age of 65 to the whole population is gradually increasing with longer average life expectancy in developed and developing countries. 1 , 2 Longer life expectancy leads to higher incidence of cancer, which is a global problem, and cancer‐related mortality rates. 1 , 3 Among individuals aged 65 and older, cancer was reported to be the leading cause of death by World Health Organization (WHO) 2019 data, 4 while GLOBOCAN 2022 ( Estimated Cancer Incidence, Mortality and Prevalence Worldwide ) data reported that cancer incidence increased with age in individuals aged 65 and older. 5 One of the cancers causing significant morbidity and mortality in older adults is haematologic cancers. Half of the hematologic cancers classified as Hodgkin lymphoma, non‐Hodgkin lymphoma, multiple myeloma and leukaemia occur in the population aged 65 and older and 70% of cancer‐related deaths occur in this population. 6 It is also predicted that there will be an increase in the incidence of haematologic cancers in parallel with the increase in the population aged 65 and older until 2030. 7

Old age is a period in which individuals experience physical, social and economic problems. In addition, situations such as losses in the family and a closed environment, decrease in social participation and role changes cause individuals to experience a large number of mental problems. 8 Chronic diseases such as cancer also cause individuals' lives to be negatively affected. Therefore, spirituality comes to the fore while patients try to deal with these diseases. 9 , 10

The word of spirituality is derived from the Latin ‘spiritus’, which can be translated as to breathe and to feel life. 11 While there are different definitions of spirituality, in general it is a personal search for the divine or transcendent, and also a search for a purpose and meaning in life, a sense of commitment, hope, and inner peace. 12 It can guide individuals to find meaning in life with more power than one has. 9 , 10 Especially in old age, having a strong spirituality is necessary to cope with chronic health problems, to participate actively in social life and to increase life satisfaction. 13 , 14 From a different perspective, having strong hopes in addition to strong spirituality can help cancer patients increase their life satisfaction with strength and courage against this difficult process brought by the disease. 15 , 16

Hope can be expressed as a dynamic force that helps individuals to adjust to the future, to show interest in the future and to make life meaningful. 17 Especially in cancer patients, hope is very important since it helps in adjusting to the treatment process, increasing wellbeing and getting healthy. 15 , 18 It is also very important in helping individuals to effectively deal with the loss, uncertainty and pain of cancer. In addition to being the ability to dream and wish for something to happen, it is also the ability to make sure difficulties can be dealt with and reality can be managed. It is also important for a peaceful death. 17 While an increased level of hope increases good thoughts about life in cancer patients, it may also improve spirituality that helps individuals to find meaning from life 19 , 20 The main source of hope is spirituality, and studies have stated that spirituality positively affects hope. 21 , 22 In addition, a strong spirituality and hope can increase satisfaction with life and wellbeing in cancer patients by decreasing pain and suffering and causing calmness and wellbeing. 19 , 23

It is expected that older populations will increase in the following years, and therefore there will be wider experience of complex treatment and care processes due to problems that ageing may bring, and cancer, which is frequent in this population. 24 In addition, the long duration of this disease, the uncertainty and risk of relapse can cause patients to have pessimistic feelings about life and significantly reduce life satisfaction. 25 For this reason, nurses can help to increase life satisfaction of patients through the assessment of spiritual wellbeing and hope levels of geriatric haematology patients and by conducting relevant practices. 19 , 26

Not many studies were found in the literature examining spiritual wellbeing, satisfaction with life and hope in cancer patients all together. 19 The relationship between hope, life satisfaction and spiritual wellbeing in older individuals was investigated in one study. 27 The present study examined the mediating role of hope in the effect of spiritual wellbeing on life satisfaction in haematologic cancer patients aged 65 and over.

When haematological cancers are compared with other cancer types, it is a type of cancer that needs to be focused more on by health professionals due to both the parameters used in the diagnosis and comorbidity and the high mortality rate. 28 Therefore, it is inevitable that the psychological wellbeing of patients who experience these problems and the problems brought by old age will be negatively affected. It may be inevitable for elderly cancer patients to fall into despair as a result of experiencing these negative situations, and their mental wellbeing and life satisfaction may decrease. However, increasing wellbeing and life satisfaction by holding on to hope in these individuals has an important place in the development of the ability to adapt to stressors related to conditions that threaten their life processes. 19 Therefore, these three parameters are thought to be important indicators of the ability of elderly individuals to cope effectively with the losses experienced due to illness. When all this is considered, examining the mediating role of hope in the effect of spiritual wellbeing on life satisfaction may help to decrease physical and psychosocial symptoms of haematologic cancer patients aged 65 and over and make their psychological adjustment to the disease easier. Therefore, the present study aimed to research the mediating role of hope in the effects of spiritual wellbeing on life satisfaction in haematological cancer patients aged 65 and over in Turkey. Another aim of the study is to guide health professionals in providing psychological wellbeing in elderly haematological cancer patients.

Research questions

What are the spiritual wellbeing, life satisfaction and hope levels of haematological cancer patients aged 65 and over in Turkey?

What are the variables that affect spiritual wellbeing, life satisfaction and hope in haematological cancer patients aged 65 and over in Turkey?

Is there a relationship between spiritual wellbeing, life satisfaction and hope levels in haematological cancer patients aged 65 and over in Turkey?

Does hope have a mediating role in the effect of spiritual wellbeing on life satisfaction in haematological cancer patients aged 65 and over in Turkey?

METHODS

Research type

The study was conducted by using a cross‐sectional correlational design.

Population and sample

Patients aged 65 and over with haematological cancer admitted to the Haematology Clinic and Outpatient Clinic of Fırat University Hospital between April 2022–February 2023 constituted the population of the study. One hundred and seventy patients were reached between these dates. Patients meeting the inclusion criteria (≥65 years of age, having a haematologic cancer diagnosis for at least 6 months, absence of psychiatric problems, volunteering to be included as a participant) between these dates were included in the sample. Since 17 patients refused to participate in the study and three were not meeting the research criteria, the study was completed with 150 patients (88% participation). Post hoc power analysis with G‐Power 3.1.9.4 program found the effect size was 0.176, 0.05 significance level and the power of the study was 99% (the values used in this study; R 2 (0.152) value in regression analysis findings for prediction of spiritual wellbeing scale). The sample size can be said to be at the desired level with these values. 29

Data collection tools

Descriptive Information Form, Dispositional Hope Scale (DHS), Spiritual Well‐being Scale (FACIT‐Sp‐12) and Satisfaction with Life Scale (SWLS) are the tools used in the study to collect data.

Descriptive Information Form

There are eight questions in this form related to participants' socio‐demographic (age, gender, working status, educational status, income status) and disease (diagnosis status, duration of diagnosis, status of having another chronic disease) characteristics, was prepared by the researchers.

DHS

Snyder et al . developed this scale to find out the dispositional hope levels in individuals aged ≥15 years. 30 The scale was adapted to Turkish culture by Tarhan and Bacanlı. DHS has 12 items and two dimensions. 31 The scale is an eight point Likert type measurement instrument. The two dimensions Alternative Ways Thinking and Actuating Thinking have four items each, one of which includes an expression about the past, two items include expressions about the present and the last item includes an expression about the future. The remaining four items consist of fillers not related with hope. While scoring the scale, filler items are not scored; the scores from Alternative Ways Thinking and Actuating Thinking dimensions are added and DHS total score is found. Possible scores are between eight and 64. Higher scores indicate higher hope levels. The original study 31 had a Cronbach's alpha internal consistency coefficient of 0.86, while this value was 0.85 in the present study.

FACIT‐Sp‐12

Peterman et al . developed FACIT‐Sp‐12 to analyze the levels of spiritual wellbeing in patients with chronic diseases and cancer. 32 Aktürk et al . studied Turkish validity and reliability. 33 The 12‐item, five point Likert type scale is scored between zero and 48, with higher scores showing higher spiritual wellbeing. Three subscales are called Meaning (items 2, 3, 5, 8), Peace (items 1, 4, 6, 7) and Faith (items 9, 10, 11, 12). The Turkish validity and reliability study had a Cronbach alpha value of 0.87, 33 while the present study had a Cronbach alpha value of 0.81.

SWLS

The scale was developed by Diener et al . to find out life satisfaction of individuals. Dağlı and Naysal carried out the Turkish validity and reliability study. 34 , 35 The five‐item Likert type scale is scored between one and seven as ‘totally disagree’ and ‘totally agree’. The score participants can achieve from the scale varies between five and 35. Increased scores from the scale mean high satisfaction with life. Cronbach alpha was found as 0.88 35 and as 0.81 in the present study.

Data collection

The data were collected by the researcher between the specified dates using the Descriptive Information Form, DHS, FACIT‐Sp‐12, and SWLS through face‐to‐face interviews after the patients completed their outpatient appointments. The researcher read the questions on the forms to the participants and recorded their answers. It took approximately 15–20 min for each elderly person to answer the questions on the forms.

Data assessment

Data were analyzed with SPSS version 25.0. Descriptive statistics are shown as percentage, mean and standard deviation. Spearman's correlation analysis and multiple linear regression analysis were used to analyze the correlation between independent and dependent variables.

The effects of spiritual wellbeing on life satisfaction were examined with PROCESS macro regression analysis. Significance level was P < 0.05.

Ethical considerations

The study was initiated with permission from the ethics committee of a university (28.01.2022 dated and 2022/01 numbered) and from the institution where the study was conducted. Aims and methods of the study were explained to the participants and their written informed consents were obtained. The Declaration of Helsinki and its ethical standards were followed. Individuals who volunteered to participate were recruited and personal identity information was kept confidential.

RESULTS

It was found that 44.7% of the patients were between 65 and 74 years of age, 40.7% were female, 50% were not working, 36% were illiterate, 50% had income less than expense, 42.7% ( n = 64) were diagnosed with lymphoma, 65.3% had a different chronic disease, and mean diagnosis duration was found as 1.94 ± 2.42 years (Table 1 ).

Mean DHS score of the patients was found as 40.42 ± 8.29, while their Alternative Ways Thinking mean score was found as 19.99 ± 4.88 and their Actuating Thinking mean score was found as 20.43 ± 3.94. Mean FACIT‐Sp‐12 score of the patients was found as 37.25 ± 7.29, while their Meaning mean score was found as 12.07 ± 2.71, Peace mean score as 12.25 ± 2.56, and Belief mean score as 12.92 ± 3.06. SWLS mean score was found as 16.24 ± 8.79 (Table 2 ).

The effect of educational status on DHS was examined with simple linear regression analysis, and it was found to be statistically significant ( F = 6.907, P < 0.01). The variable of educational status in the model explains 0.44% of DHS variance ( P < 0.01). Regression coefficient shows that the state of being illiterate (β = −0.211, P < 0.01) affected DHS negatively and significantly (Table 3 ).

The effects of independent variables on FACIT‐Sp‐12 were examined with multiple linear regression analysis, and they were found to be statistically significant ( F = 3.668, P < 0.001). There was 15.2% of FACIT‐Sp‐12 total variance which was explained by the independent variables in the model ( P < 0.01). The state of having an additional chronic disease (β = −0.177, P < 0.01) was found to have a negative and significant effect on FACIT‐Sp‐12 (Table 4 ).

The effects of independent variables on SWLS were examined with multiple linear regression analysis and the results were found to be statistically significant ( F = 5.217, P < 0.001). Independent variables in the model explain 15.3% of satisfaction with life total variance ( P < 0.01). Having an educational status of university and higher was found to have a positive and significant effect on SWLS (β = 0.209, P < 0.01) (Table 5 ).

SPSS PROCESS macro 4 Model was used to show the effects of spiritual wellbeing on satisfaction with life and the mediating role of dispositional hope in this effect. (Fig. 1 ) and (Table 6 ) show the details of analysis results.

According to analysis results, both spiritual wellbeing (β = 0.668) and dispositional hope (β = 0.226) positively affect satisfaction with life. According to another result, DHS has a mediating role in the effect of spiritual wellbeing on satisfaction with life (β =0.103) and spiritual wellbeing strengthens its positive effect on satisfaction with life (β = 0.771). These two variables were found to have a predictive effect of 44.7% in explaining satisfaction with life.

DISCUSSION

The results found in this study, which is the first to examine the mediating role of hope in the effects of spiritual wellbeing on satisfaction with life, were discussed in the light of the literature.

The patients aged 65 and older in this study were found to have high levels of spiritual wellbeing. In studies conducted with cancer patients of different types and stages, similar to our results, high spiritual wellbeing levels were found in cancer patients. 9 , 36 , 37 , 38 Unlike our study, moderate levels of spiritual wellbeing were reported in some studies conducted with cancer patients. 39 , 40 , 41 In addition, spiritual wellbeing was found to be high in studies conducted with individuals aged 65 and over. 27 , 41 Results in the literature mostly support the results of our study. Patients with serious diseases such as cancer are influenced by the disease process and in order to fight with and deal with the negative situations they face, they turn to spirituality more. Psychological and physiological problems experienced by cancer patients may be reduced by spiritual wellbeing. 9 , 37 , 40 Studies in the literature show that economic, health and social problems of individuals increase in old age; stress levels of older individuals increase with situations including death of a spouse or a close friend, retirement, and role changes, leading to mental problems such as depression and anxiety. In old age, coping with these problems is easier with religious and spiritual orientations. 8 Spirituality in older individuals can also affect successful ageing, the skills to cope with serious diseases and injuries and the outcome of the disease. 14

The state of having an additional chronic disease affected spiritual wellbeing negatively in our study. In this context, it can be said that having a chronic disease decreases spiritual wellbeing. In one study, it was observed that the presence of more than one chronic disease in elderly individuals negatively affected their spiritual wellbeing. 42 Kavak et al . conducted a study on gastrointestinal cancer patients and concluded that having an additional chronic disease negatively affected spiritual wellbeing. 9 Our results were found to be in line with the literature. Although religious beliefs are usually a source of support for individuals who have a serious disease, some researchers have reported a relationship between religious beliefs and negative health consequences. For example, negative religious coping (that is, feeling left or punished by God, spiritual discontent) has been found to be correlated with increased anxiety, depression and risk of low quality of life. 37 The results indicate that increase in additional chronic diseases as a result of ageing creates spiritual distress in individuals.

It was found that haematologic cancer patients aged 65 and older in our study had moderate levels of life satisfaction. Fonseca et al . found that patients with breast cancer had high life satisfaction. In this sense, it was stated that patients had good life conditions in general and they considered their lives were close to ideal. 43 Similarly, Hamdan‐Mansour et al . found that cancer patients had high satisfaction with life and older patients had higher satisfaction with life. 25 In studies conducted with elderly individuals in the literature, it was observed that the majority of individuals were satisfied with their lives. 44 , 45 , 46 In other studies, it was found that elderly individuals were moderately satisfied with their lives. 47 , 48 Our results were in parallel with the literature and it was found that cancer patients did not have low levels of satisfaction with life. However, the reason why satisfaction with life was lower than other studies conducted can be both cultural differences and the fact that increased psychological needs of patients were not sufficiently met and the high (50%) number of patients with low level of income.

The present study found that having an educational level of university and higher positively affected satisfaction with life. Similarly, a study conducted showed that high educational level had a positive contribution to quality of life in cancer patients. 49 On the other hand, it was found in another study that education did not affect life satisfaction. 37 In other studies conducted on the elderly, it has been observed that individuals with higher levels of education report higher levels of life satisfaction, 50 and that higher levels of education contribute to healthy ageing. 51 We have both similar and different results from the literature. The reason for this can be the differences in sample groups.

It was found that haematologic cancer patients aged 65 and older in our study had moderate levels of hope. In the studies conducted in the literature, the hope level of the elderly was found to be moderate. 52 Similarly, level of hope was moderate in some of the studies conducted with cancer patients 53 , 54 In a large number of studies on cancer patients, patients were found to have stable and relatively high hope levels during the course of the disease 17 , 55 , 56 , 57 , 58 Hope is a positive psychological source that helps patients in adjusting to cancer, maintaining and improving their wellbeing and life quality. 15 Hope was found to increase the feeling of wellbeing, promote positive thoughts about the diagnosis and give a reason to live in patients with cancer. 59 Our study results were found to be consistent with some of the studies conducted and it was found that cancer patients did not have low levels of hope in general. As can be seen, cancer can affect hope levels of individuals in various ways whatever their culture, belief or country. Based on these results, the fact that our sample consisted of individuals aged 65 and older and most of these had another chronic disease, may have caused them to have moderate levels of hope.

Our study showed that being illiterate negatively affected hope levels. In this context, it can be said that levels of hope increased as participants' educational status increased. In some of the studies conducted, it was found that levels of hope increased as educational status increased, in parallel with our results. 18 , 60 , 61 In addition, in a study conducted with elderly individuals, it was reported that the level of hope increased as the level of education increased. 62 On the other hand, it was found in some studies that level of education was not correlated with hope. 17 , 26 , 53 , 63 In another study conducted, level of hope was found to decrease as educational status increased. In a study conducted with elderly individuals, it was found that the perceptions of hopelessness among illiterates and university graduates were higher than those of primary school graduates. 45 We have results both similar to and different from the literature. Based on this result, it can be said that having a high level of education, learning about coping behaviours and reading studies and articles about the disease may have helped individuals with high levels of education to get rid of the feeling of hopelessness.

In our study, spiritual wellbeing positively affected life satisfaction and the mediating role of hope strengthened this positive effect. Similarly, studies in the literature have found that spiritual wellbeing positively affects life quality. 19 , 37 , 38 , 64 Schultz et al . found that spirituality encouraged calmness and general wellbeing and made pain and suffering easier. 23 Delgado‐Guay et al . found that spirituality and religiousness were helpful in coping with cancer and they were a source of strength and comfort in almost all of their participants (99%) and these patients stated that spiritual religious coping positively affected their lives. 65 Özdemir et al . reported there was a positive correlation between hope, spiritual wellbeing, and life satisfaction in elderly individuals. They also suggested that supporting individuals in terms of these three parameters could contribute to quality ageing. 27 The results of the same study showed that spiritual pain negatively affected physical emotional symptoms of patients and could result in higher depression, anxiety, anorexia and sleeping state. 65 Hope consists of thoughts (for example, ‘I can do this!’) that provide motivation to pursue goals even when obstacles are encountered. Hope is very important in coping with cancer. 66 A positive association between hope and quality of life and spiritual wellbeing was reported in a review of 33 studies conducted on patients receiving cancer treatment. 67 Hope means a feeling of assurance and belief that things will develop in a positive way and it is usually associated with optimistic perspectives. 68 Hope is fuelled by spirituality, and can promote compliance for cancer patients in terms of survival, considering its role in promoting positive perceptions. 69 Women with breast cancer who reported higher spirituality were found to be more hopeful and have a higher perceived quality of life in one study. 70 In preventing quality of life from deteriorating, hope plays an important role as a psychological and spiritual resource useful in fighting cancer. Psychological wellbeing, physical wellbeing and quality of life are positively influenced by hope. 71 Studies conducted with cancer patients reported spirituality as a positive predictor of life quality and this effect was found to increase through hope, similar to the results of our study. 19 The results showed that spiritual wellbeing and hope were effective factors in compliance with cancer and life satisfaction in our study. In addition, spirituality may make individuals more optimistic and increase their life quality.

LIMITATIONS

The study has two limitations. First, the results cannot be generalised, and they only apply to the patients in the study. Second, data reliability is limited by the accuracy of the patients' answers.

CONCLUSION

It was found that haematologic cancer patients aged 65 and older in our study had high levels of spiritual wellbeing and moderate levels of life satisfaction and hope. In our study, it was found that being illiterate negatively affected the level of hope, while the state of having another chronic disease negatively affected spiritual wellbeing and having a university degree or a higher degree positively affected life satisfaction. Life satisfaction was found to be positively affected by spiritual wellbeing, and the positive effect was found to increase with the mediating role of hope. In nursing care, it is recommended to regularly evaluate spiritual wellbeing, hope and life satisfaction in older individuals, to organise nursing interventions to increase hope and life satisfaction and to conduct the study with different sample groups.

DISCLOSURE

The authors have no conflict of interest to disclose.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

ACKNOWLEDGMENTS

The authors are grateful to all the study participants for their cooperation in this study.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.