Associations among Patient Characteristics,Health-Related Quality of Life,and Spiritual Well-Being among Arab Muslim Cancer Patients

Abstract

Background:

Despite Islam being the world's second largest religion and despite the fact that there are 22 Arabic-speaking nations representing North Africa and the Middle East, little is known about the relationship between spiritual well-being and health-related quality of life (HrQoL) for Arabic-speaking Muslims in treatment for cancer.

Aim:

The study's aim was to determine whether spiritual well-being is correlated with HrQoL and whether participants' age, sex, marital status, site of cancer, and stage of disease are related to spiritual well-being.

Design:

Using a cross-sectional design, a total of 159 Arabic-speaking, study-eligible cancer patients who were in treatment at the King Hussein Cancer Center (KHCC), Amman, Jordan, completed three questionnaires: a demographic questionnaire; the Functional Assessment in Cancer Therapy–General (FACT-G), which assesses the physical, social, functional, and emotional domains of HrQoL; and the Functional Assessment in Chronic Illness Therapy–Spiritual Well-being (FACIT-Sp).

Results:

Physical well-being was negatively correlated with the FACIT-Sp for men, divorced, and stage IV disease. Social Well-being was positively correlated with the FACIT-Sp for ages 18–34 and 35–49 years; both sexes; married, never married, and divorced; breast, bone/sarcoma, and gastrointestinal cancers; and stages II–IV. Emotional Well-being was negatively correlated with the FACIT-Sp for ages 35–49; males; never married; and stages III and IV. Functional Well-being was positively correlated with the FACIT-Sp for ages 35–49 and 50–64; both sexes; married or never married; and stages II and III. Age and cancer site showed a positive relationship with spiritual well-being.

Conclusions:

The FACIT-Sp distinguishes between domains of HrQoL and patient characteristics. Further study on the unique contribution of the FACIT-Sp's Peace and Meaning subscales to HrQoL is needed.

Background

The world's second largest religion, Islam, has 1.6 billion followers (23% of the world's population) and is the predominant religion in 50 countries, including 22 Arabic-speaking nations representing North Africa and the Middle East.^1,2 Yet little is known about the role of Islamic spirituality in the health-related quality of life (HrQoL) of patients in treatment for cancer. What few studies exist have found that Muslims in treatment for cancer find their Islamic practices important; for instance, nonpracticing Muslims at the time of diagnosis taking up religious practices thereafter.^3,4 To determine whether the Functional Assessment of Chronic Illness Therapy–Spiritual Well-being (FACIT-Sp) scale provides information about the relationship of spirituality well-being to HrQoL in an Arab, predominantly Muslim cancer population, we translated the FACIT-Sp into Arabic and validated it in a study undertaken at the King Hussein Cancer Center (KHCC), Amman, Jordan.⁵ We chose the FACIT-Sp because the Functional Assessment of Cancer Therapy–General (FACT-G) questionnaire, which serves as the cancer-specific core measure of HrQoL for the FACIT-Sp, had already been translated into Arabic and validated (www.facit.org). We found that the FACIT-Sp is a psychometrically sound instrument for detailed assessment of the spiritual well-being of Arabic-speaking cancer patients with three distinct factors that allow for discrimination among other factors highly associated with different aspects of HrQoL.⁵ Other studies have found that cancer site is a factor related to spiritual well-being and HrQoL.^6–9

Aim

In this study we investigated (1) whether spiritual well-being, as measured by the FACIT-Sp, is associated with different aspects of HrQoL as measured by the FACT-G according to participants' age, sex, marital status, site of cancer, and stage of disease; and (2) whether participants' age, sex, marital status, and site and stage of disease are related to spiritual well-being among Arab Muslims in treatment for cancer.

Methods

Setting

The setting was KHCC, Amman, Jordan, which is a regional cancer center accredited in oncology by the Joint Commission International. It is a 65-beded stand-alone cancer hospital, with 14 full-time medical oncologists, three stem cell transplant specialists, two pulmonologists, three intensivists, and three palliative care physicians, among other supportive services, such as psychiatry and psychology, social work, and spiritual care.

Participants

Study participants included inpatients and outpatients older than 18 years of age who were Muslim, aware of their illness, without mental disorder or dementia, and in treatment for cancer at KHCC. All who consented to participate were considered eligible for our study. Patients were approached by a member of the psychosocial oncology team between November 2009 and June 2010. The Institutional Review Board of KHCC reviewed and approved the study.

Data collection

Eligible patients were asked to complete three questionnaires: the FACIT-Sp Version 4 and FACT-G questionnaires (www.facit.org), and a questionnaire that asked participants' age, sex, marital status, and site of cancer. Stage of disease was taken from the medical record.

The 12-item FACIT-Sp assesses spiritual well-being along three aspects—Peace, Meaning, and Faith.¹⁰ The 33-item FACT-G assesses HrQoL across four aspects: Physical, Functional, Social/family, and Emotional.¹¹ Coefficients of reliability and validity are uniformly high for both scales. Both the FACIT-Sp and FACT-G ask patients to respond on a 5-point scale ranging from “not at all” (0) to “very much” (4), in reference to activities attempted, attitudes, and feelings experienced in the past week. A total of 159 participants completed the FACT-G, FACIT-Sp, and demographic questionnaires. We did not collect data on numbers of patients approached or on reasons for refusal to participate; we did not repeat the measures. Eleven participants' questionnaires had one item missing on one of the subscales; the missing data were imputed by summing the other items of the same subscale and using the mean, which in a scale that uses multiple items to measure constructs yields good parameter estimates.¹² We reversed the scoring of items 4 (4r) and 8 (8r), which are negatively worded.

Statistical analysis

We assumed the null hypothesis with an alpha 0.05.

Question 1

We used Spearman's correlation to test whether there is any association between the 12-item FACIT-Sp and each subscale of the FACT-G by age placed into four groups (18–34, 35–49, 50–64, ≥65 years), sex, marital status (married, never married, widowed, divorced), cancer site, and stage of disease. When type of cancer fell to ≤5 in number (≤3%), we grouped them into the “Other” category; these included participants with different liquid tumors, brain tumors, and genitourinary tumors).

Question 2

To test the relationship of participant characteristics on the 12-item FACIT-Sp, the dependent variable, we used linear regression with age (18–34, 35–49, 50–64, ≥65 years), sex, marital status (married, never married, widowed, divorced), and site and stage of disease as independent variables. We did not use separate models for each category of participant characteristics, given that subsetting the data into individual categories and assessing each one separately would reduce the amount of statistical power. Without such subsetting, there were five independent variables for linear regression; thus, the recommended size for adequate power is at least 100 subjects (20 subjects per independent variable).¹³ All analyses were conducted using the Statistical Packages for the Social Sciences version 17 software (SPSS, Somers, NY), with a two-sided alpha of 0.05 being considered as statistically significant.

Results

One-hundred fifty-nine adult Muslim patients in treatment for cancer at KHCC in Amman, Jordan, completed the questionnaires. The average age was 46.22 (13.8) years, with a range of 19 to 77 years. Table 1 displays patient characteristics, results of the Spearman correlations, and mean scores for both the 12-item FACIT-Sp and each of its three factors. When statistically significant, correlations between the FACIT-Sp and the four aspects of HrQoL generally fell in the same direction and with similar magnitudes across the different patient characteristics and categories within those characteristics: Physical Well-being was negatively correlated with the FACIT-Sp for participants who were men, divorced, and had stage IV disease. Social Well-being was positively correlated with the FACIT-Sp for participants who were ages 18–34 and 35–49 years; both sexes; married, never married, and divorced; breast, bone/sarcoma, gastrointestinal, and the category of other sites of cancer; and disease stages II–IV. Emotional Well-being was negatively correlated with the FACIT-Sp for participants aged 35–49 years; male; never married; cancers in the other category; and disease stages III and IV. Functional Well-being was positively correlated with the FACIT-Sp for participants aged 35–49 and 50–64 years; both sexes; married or never married; cancer sites that fell into the other category; and disease stages II and III. The regression analysis revealed that age and site of cancer have a positive relationship with the 12-item FACIT-Sp (beta coefficients and 95% confidence interval are in footnotes a and b, respectively, to Table 1, with p<0.000).

Table 1.

Participant Characteristics, Spearman Correlation Coeffecients between Subscales of the FACT-G and FACIT-Sp, and Mean Scores of the FACIT-Sp and Its Three Aspects (Peace, Meaning, Faith) (n=159)

		Spearman correlation coefficients for association between 12-item FACIT-Sp and each subscale of the FACT-G				Mean scores (SD)
Participant characteristics	N (%)	Physical well-being	Social/family Well-Being	Emotional well-being	Functional well-being	FACIT-Sp (all 12 items; 0–48 range)	Peace (0–16 range)	Meaning (0–16 range)	Faith (0–16 range)
Age (years)^a
18–34	33 (20.8%)	−0.126	0.593^*	−0.251	0.337	32.7 (5.1)	9.5 (1.9)	9.3 (2.6)	14.0 (5.1)
35–49	60 (37.7%)	−0.134	0.413^*	−0.278^**	0.477^*	34.2 (5.9)	9.7 (2.5)	10.3 (2.5)	14.2 (2.2)
50–64	50 (31.4%)	−0.185	0.524^*	−0.035	0.637^*	34.9 (5.3)	10.0 (2.6)	10.4 (2.1)	14.5 (1.9)
≥65	16 (10.1%)	0.063	0.220	−0.339	0.260	36.2 (3.3)	10.6 (1.9)	10.6 (2.1)	15.0 (1.4)
Sex
Male	53 (33.3%)	−273^*	0.458^*	−0.500^*	0.487^*	35.7 (4.4)	10.4 (2.2)	10.5 (2.3)	14.8 (1.6)
Female	106 (66.6%)	−0.008	0.468^*	−0.032	0.472^*	33.8 (5.8)	9.6 (2.4)	10.1 (2.4)	14.2 (2.2)
Marital status
Married	128 (80.5%)	−0.076	0.436^*	−0.114	0.445^*	34.8 (5.5)	9.9 (2.5)	10.4 (2.4)	14.5 (1.9)
Never married	16 (10.1%)	−0.139	0.720^*	−0.712^*	0.579^**	34.1 (4.3)	10.3 (1.8)	9.5 (2.3)	14.4 (1.9)
Widowed	12 (7.5%)	0.037	0.084	−0.055	0.716^**	32.7 (5.6)	9.5 (2.0)	9.4 (1.9)	13.8 (2.9)
Divorced	3 (1.9%)	−1.0^*	1.0^*	−0.50	0.866	32.0 (7.0)	8.7 (2.1)	9.7 (3.5)	13.7 (1.5)
Cancer site^b
Breast	59 (37.1%)	−0.148	0.494^*	−0.145	0.633^*	32.9 (6.6)	9.1 (2.7)	9.8 (2.7)	13.8 (6.5)
Bone/Sarcoma	11 (6.9%)	0.043	0.659^**	−0.158	0.613	35.7 (3.6)	10.5 (1.6)	9.9 (1.9)	15.4 (0.8)
Gastrointestinal	34 (21.4%)	−0.112	0.376^**	−0.130	0.303	35.1 (4.5)	10.1 (2.1)	10.3 (2.1)	14.7 (1.9)
Gynecologic	9 (5.7%)	0.077	0.127	−0.030	0.485	34.1 (4.5)	9.7 (2.1)	10.1 (1.8)	14.3 (1.7)
Lung	11 (6.9%)	−0.219	0.324	−0.274	0.478	38.3 (4.0)	10.8 (2.6)	12.5 (1.5)	14.9 (1.3)
Other	35 (22%)	−0.227	0.562^*	−0.273^**	0.488^*	34.5 (4.7)	10.0 (2.2)	10.4 (2.1)	14.1 (2.3)
Stage of disease
Stage I	14 (8.8%)	−0.126	0.498	−0.204	−0.092	35.6 (5.7)	10.0 (2.7)	11 (2.4)	14.6 (1.5)
Stage II	40 (25.2%)	0.046	0.612^*	0.327	0.435^**	34.6 (6.2)	10.0 (2.1)	10.2 (2.8)	14.3 (2.2)
Stage III	53 (33.3%)	−0.170	0.520^*	−0.453^*	0.624^*	34.0 (5.9)	9.9 (2.7)	10.0 (2.3)	14.0 (2.6)
Stage IV	52 (32.7%)	−0.371^*	0.539^*	−0.503^*	0.570^*	34.8 (5.5)	9.9 (2.7)	10.3 (2.7)	14.6 (1.8)

p<0.000

p<0.05

Estimate=1.13 (.313, 1.952)

Estimate=1.273 (.163, 2.383)

Discussion

In this study we asked whether spiritual well-being as measured by the FACIT-Sp is associated with the four aspects of HrQoL by participant characteristics. The negative correlation between emotional and spiritual well-being for participants with stage I disease, though weak, may be due to an existential crisis from recent diagnosis.¹⁴ Moderate to strong negative associations between emotional and spiritual well-being of participants with stage III and IV cancer highlight the importance of assessing mood disturbance and the spiritual well-being of patients with progressive cancer.

Our second question was whether participant characteristics were related to spiritual well-being. Being a participant aged 18–34 years predicted poorer spiritual well-being, as did being a participant with stage III disease. Lung cancer as site of disease is related to better spiritual well-being.

Age

Age is positively related to spiritual well-being. And yet age, for all categories except ≥65, is positively correlated with the Social/Family subscale of the FACT-G and the overall FACIT-Sp. However, the age categories 18–34 and 35–44 had the lowest means on the Peace factor of the FACIT-Sp, and the 18–34 category had the lowest means on the Meaning factor of the FACIT-Sp. This highlights the importance of spiritual well-being as a multidimensional concept that includes that which contributes to, or detracts from, patients' abilities to find peace and meaning amid the cancer experience, even when they appear to be socially supported. Interestingly, the means on all three factors of the FACIT-Sp rose by increasing age category, with the ≥65 category having the highest means on all factors of the FACIT-Sp.

Site

Cancer site is positively related to spiritual well-being scores. Participants with lung cancer reported the highest means for the Peace and Meaning factors of the FACIT-Sp of all cancer sites, despite the lowest physical and functional well-being scores of all cancer sites. A sense of peace and being able to find meaning in the cancer experience, in this small sample of 11 patients with lung cancer, may be more important than the physical and functional aspects of HrQoL as measured by the FACT-G.⁹ A common feature of Muslims' attitudes toward illness is the belief that suffering is a form of test or trial to confirm a believer's spiritual station.¹⁵ It may be that enduring unmanaged symptoms is viewed as part of that trial. This may be why participants with lung cancer in our study report poor physical and functional well-being but reported high spiritual well-being.

Ours was a cross-sectional study; this limits it. Religious culture may differ across the Arabic-speaking Middle East and North Africa, and adherence to Islamic practices may differ among Arabic-speaking patients with cancer in the diaspora; this limits the generalizability of our findings. Our focus is indeed narrow; but this is warranted, given the dearth of literature on the population we studied.

Another limitation of our study is that our participants may not have been used to the Likert scale, which the FACT-G and FACIT-Sp use. And the FACIT-Sp has two reversely worded questions that are not usual in the style of questioning in the culture. These too present limitations, which we have raised previously.⁵

These limits notwithstanding, the Arabic translation of the FACIT-Sp is sensitive to patient characteristics and domains of HrQoL. Our findings illustrate the importance of the Peace and Meaning subscales. For younger patients and for patients with advanced disease, senses of peace and meaning appear to be important, as for patients with lung cancer. Our findings illustrate the need to assess patients' senses of peace and meaning, regardless of age, site, stage of cancer, or apparent social well-being. Further study on the unique contribution of the Peace and Meaning subscales of the FACIT-Sp to HrQoL is needed, including whether HrQoL should include them as a fifth domain. This research needs to occur across religions, ethnicities, and geography.

Footnotes

Acknowledgments

The authors thank Drs. Hasan Abbas, Basam Kamal, and Amina Al-Tamimi, and Ms. Feda’ Al-Khair and Ms. Majdoleen Neamatt.

For this work, Mark Lazenby was supported by a Fulbright Research Scholarship in the Medical Sciences.

Author Disclosure Statement

No competing financial interests exist.

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