Correlation between spiritual well-being with satisfaction with life and death anxiety among elderlies suffering from cancer

Introduction: Spirituality is one of human capabilities providing problem solving and coping strategies; in addition, it creates a sense of meaning, against disaster and confusion, as a social support resource. Spiritual well-being is a state of health expressing emotions, behaviors, and positive cognitions of self-, others, nature, and a super entity communication. Elderly is an undeniable evolutionary period of human being. Getting older, elderlies would undergo several physical and mental problems including cancer. Knowledge of cancer may influence several life aspects among elderlies, the most important of which may include death anxiety and life satisfaction. Life satisfaction indicates the individual positive attitude to the world where he lives. It is inclusively related to the individual needs. With the knowledge of cancer, there would be an inconsistency between the individual’s needs and natural tendencies leading to life dissatisfaction among the patients suffering from cancer. Purpose: The present research is conducted to study the correlation between spiritual well-being with life satisfaction and death anxiety among patients enduring cancer at major hospitals in Tehran. Given the increased population of elderlies, high prevalence of cancer and its malicious effect, and regarding cancer incidence in recent decades influencing different life aspects including life satisfaction and death anxiety; and otherwise, the effect of life satisfaction and death anxiety on cancer progression, the present research is significant considered as national research priorities. Research methodology: This is a descriptive-correlation study. Research statistical population included Iranian elderlies enduring cancer at major hospitals in Tehran in 2016. 185 research samples were selected based on inclusion criteria through convenience sampling method using a demographic questionnaire, spiritual well-being scale (Ferry and Dollman), satisfaction with life scale (SWLS; Diener), and death anxiety scale (Templler). Research data were analyzed through SPSS 20 using multiple linear regression analysis, independent t-test, and analysis of variance (ANOVA). Further, the correlation between the two variables was tested by Pearson correlation coefficient at significance level 0.05. Findings: The research showed that there is a positive significant relationship between spiritual well-being and life satisfaction (at 0.05). In other word, spiritual well-being can predict satisfaction with life in understudied elderlies. In addition, there was seen a significant inverse relationship between death anxiety and spiritual well-being. As a result, the individuals with higher spiritual well-being would experience less death anxiety. Conclusion: Spiritual well-being is of effective factors of death anxiety and satisfaction with life among elderlies suffering from cancer. Spirituality and meeting spiritual needs are considered as nursing care priorities for elderlies. Paying attention to the elderlies’ spirituality by nurses may shield against individual difficulties; furthermore, it also reduces mental disorders and improves mental health and satisfaction with life in elderlies.


INTRODUCTION
Spirituality is one of human capabilities providing problem-solving strategies and coping.In addition, as a source of social support, it creates a sense of meaningfulness to deal with confusion and disasters, and gives a sense of indirect control over occurrences, which finally leads to decreased isolation and loneliness in individuals (1).Spiritual well-being is a state of health reflecting emotions, behaviors, and positive recognitions of a relationship between self, others, nature, and a superior entity (2).Spirituality has always constituted a major part of human life.Human beings have manifested the spirituality in relation to god going beyond borders and giving meaning to life.This aspect is intrinsically inherent, which evolves as a result of religious practices regarding human growth and development (3).Scholars have demonstrated that spirituality is of critical treatment aspects of illness compatibility, which helps in improved quality of life, making decision in end-of-life care, and in reducing pain (4).
Elderliness is an undeniable evolutionary path the human being must travel.In most countries, elderliness begins at 65 years old; however, the evolution and lack of power in human body largely depends upon the life style.Elderly process is strongly influenced by geographic, health, social, and economic structures.Although, population aging phenomenon is considered as positive development results; it would be followed with many negative consequences and complications if we are not prepared to face it in a developed world.At senility and disability, elderlies majorly experience several difficulties including loneliness, economic problems, as well as chronic diseases and disabilities.Cancer may be known as the most prevalent chronic disease of the present world, which deteriorates by aging (5).Despite remarkable advances in medicine, cancer still continues to be known as one of the most critical diseases of the current century and the second leading cause of death following cardiovascular disease (6).Being aware of cancer influences several life aspects in elderlies, the most important of which are undoubtedly death anxiety and satisfaction with life (7).Near end-life patients may strive for finding life meaning and purpose; and spirituality establishes the foundation to overcome frustration and despair (8,9).The patients suffering from cancer and their families' spiritual needs are recognized as care major dimension (10).Diagnosis of a terminal illness like cancer results in an existentialism deep crisis in daily life and seriously threatens the patients and the families (11).Nurses play a critical role in maintaining optimal health and quality of life in elderlies and their families during cancer (12).Studies conducted on spiritual care, especially among patients suffering from cancer, showed that nurses must use the effect of spirituality and religious on forming life and death meaning and discovering ways to deal with physical and spiritual stress.Spiritual care like other care aspects must follow nursing procedure.Recognition of the patient spiritual needs in addition to the possible contributions of the extant illness in its spiritual experiences is critically necessary in the care process.It is significant to respect the patient spiritual faith within the care process (13,14).
Death anxiety consists of thoughts, fears, and emotions associated to the end of life (15).This typical anxiety is a multidimensional notion.According to Halter and Halter, it embraces eight dimensions as follows: 1. necrophobia, 2. early death phobia, 3. fear of death of beloved ones, 4. death phobia, 5. Downfall phobia, 6. dead body phobia, 7. fear of unknown death, and 8. fear of the dead (16).In recent years, death anxiety has been largely investigated.Recent bio, mental, social and theological studies have declared several factors influencing death anxiety in elderlies.Self-integrity, mental and physical difficulties, age, sex, ethnicity, life order, as well as religious prejudices, for instance, are correlated to death anxiety (17,18).Spirituality and religious orientation are considered as one way of diminishing death anxiety and phobia; further, it has been demonstrated that negative religious orientations may increase death anxiety (19).According to scholars, there is a significant relationship between intrinsic and extrinsic religious orientations with death anxiety, satisfaction with life and afterlife belief (20).Spiritual attitudes of how to deal with death determines the individuals' death perception.Spiritual recovery may present some hope for imminent death individuals (21).Death anxiety of individuals enduring cancer may influence different dimensions of life satisfaction and drop the quality of life (22).
Life satisfaction an obvious sign of consistency in different dimensions of an elderly life reflects the individual intentions and extant well-being; moreover, it is of significant individual well-being factors, which is critical in health care systems as it is closely tied to mental and physical health (5, 23, and 24).Indeed, life satisfaction assessment for elderlies evaluates effectiveness of health care service providing (25).Life satisfaction implies the individual positive attitude to the world where it lives and is inclusively correlated to the individual needs.Once the person is informed of cancer, there would create an inconsistency between the individual's needs and tendencies, which leads to life dissatisfaction (7).By aging, life satisfaction slowly decreases caused by descending physical and mental health in elderlies (23).
Increased elderly population (26), high prevalence of cancer and its malicious effect, as well as cancer outbreak in recent decades (27), in addition to the cancer contribution in different aspects of an individual's life including life satisfaction and death anxiety, and regarding the effect of life satisfaction and death anxiety on cancer progression, the present research is considered as national research priorities.Regarding the importance of considering spiritual requirements in elderlies with cancer and inconsistent results of prior literature, it is necessary to study the issue.It appears that spiritual recovery factor may positively influence life satisfaction and death anxiety among elderlies with cancer (28).In general, as death anxiety is of important challenges elderlies face, and regarding that this variable significantly contributes in mental health maintenance and adults anxiety level, it is substantially prominent that predictors, correlated variables, and effective factors of death anxiety are identified, measured and controlled in elderlies so that death anxiety is reduced and satisfaction with life is enhanced.Therefore, according to the gaps of studies conducted on the simultaneous role of spiritual well-being factors in death anxiety and life satisfaction among elderlies enduring cancer, and regarding that no similar studies have been so far carried out in Iran, scholars have intended to light shed on this issue.Moreover, given the significant role of nursing in caring cancer patients, different spirituality attitudes, and cultural differences with other nations, and regarding the significance of this issue in improving satisfaction with life of elderlies, enhanced nursing care quality for patients with cancer and reducing the death anxiety, this research has been carried out to study the correlation between spiritual well-being with death anxiety and life satisfaction among elderlies suffering from cancer at selected hospitals of Shahid Beheshti University in 2016.

RESEARCH METHODOLOGY
This is a correlation-descriptive study.Research population included elderly patients with cancer visiting selected hospitals affiliated to Shahid Beheshti University of Medical Sciences in 2016.Research sample included male and female cancer inpatients of oncology wards of selected hospitals qualifying inclusion criteria in 2016.Based on the research inclusion criteria, 185 individuals were selected using Pearson correlation coefficient through convenience sampling method as research sample.Research inclusion criteria were 1. 60 years old and more, 2. cancer diagnosed patients, 3. the cancer has been diagnosed at least 6-8 months earlier, 4. the elderly is able to recognize the researcher questions (speaks Persian).Research exclusion criteria were mental retardation, dementia, or schizophrenia.
Research data were collected through a researcher-made demographic questionnaire of 11 items.The questionnaire gathered data of sex, education level, employment status and income level, marital status, cancer type, cancer stage, residence, medication history, cancer duration, and number of hospital admissions per year.
Spiritual well-being scale: Ferry and Dollman designed the questionnaire in 2005 (29).It consists of 12 items covering two self-efficacy and life plan sub-scales.Scale items are scored on a 5-point Likert scale as follows: 1. Absolutely agree, 2. Agree, 3. Neutral (neither agree nor disagree), 4. Disagree, 5. Absolutely disagree.The maximum score is 60 and the minimum is 12.The maximum number indicates that the individual enjoys high spiritual well-being; whereas, less score reveals high levels of mental well-being (29).
Satisfaction with life scale (SWLS): Diener et al introduced satisfaction with life sacle (SWLS) in 1985 (30).It is composed of five 7-point Likert scale items as follows (31): absolutely disagree: 1 point, disagree: 2 points, to some extent disagree: 3 points, neutral: 4 points, to some extent agree: 5 points, agree: 6 points, absolutely agree: 7 points.Finally, the individual may score within the range of 7-35, the higher score represents larger satisfaction with life (30).
Death anxiety scale: Templler provided death anxiety scale in 1970.It is a self-administered questionnaire (SAQ) containing 15 true-false items.

DATA COLLECTION
Once the permission has been obtained from Shahid Beheshti University of Medical Sciences, the researcher visited understudied hospitals and selected the patients qualifying inclusion criteria according to the medical records.The patients were given a questionnaire once an informed written and verbal consent form was obtained.

DATA ANALYSIS
Research data were analyzed using SPSS 20 through multiple linear regression analysis, independent t-test, and ANOVA.The correlation between variables was investigated using Pearson correlation coefficient at significance level 0.05.

DISCUSSION
According to the results, research samples were at age range 60-85 with mean age of 65.8 ± 6.9.58.4% (108 individuals) were females and 41.6% (77 individuals) were males.Most research samples were married (73.5%) with elementary education level (62.7%), housewife (63.7%), and an income level of less than 130$ per month (67.5%); and 48.6% of research participants lived with their spouse and children.High age range of understudied individuals, and consequently (38) the probability of retirement and overtime inability caused by illness may justify less income levels in the individuals.
According to the mean age range 65.8±6.9, the majority of elementary education level seems natural as education level was not as much considered about 6 decades ago.In addition, it may also express that intermediate and academic education level individuals pay more attention to health promotion behaviors; and hence, are less exposed to cancer.Given the mean age range of 65.14 ± 5.71 in which almost all are married and have children; therefore, the majority married participants is natural.Most understudied elderlies live with spouses and children.This finding demonstrates the family significance in Iranian culture respecting to elderlies.
In this study, gastrointestinal (29.2%) and breast cancers (19.5%) were most prevalent in understudied elderlies.20% of the participants were at stage 4 and 21.6% were at the first stage of cancer.Also, 35.1% of the attendees endured diabetes and blood pressure in addition to the cancer.Cancer duration was obtained within 6 months to 14 years and the mean was 1.21 years with a standard deviation of 1.69.
According to the Table 2, it is observed that there is a positive significant relationship between spiritual well-being and life satisfaction in elderlies.In other word, spiritual well-being may predict satisfaction with life among understudied elderlies.This finding is consistent with Hajloo et al (2014) (32).Thus, spiritual well-being is taken into account as effective factors of satisfaction with life.Spirituality and meeting spiritual needs at elderliness are of nursing care priorities.Nursing care for spirituality in elderlies may protect the individuals from difficulties and discomforts; further, it also reduces mental disorders and enhances mental health and life satisfaction in elderlies.As a result, spiritual well-being may effectively contribute in increased life satisfaction of elderlies enduring cancer (33).Moreover, the research also exhibited a negative significant relationship between spiritual well-being and death anxiety, which is consistent with Salajeghe et al (2012).The study presented that spiritual and cognitive treatment group influences reduced death anxiety in patients suffering from cancer.Spiritual well-being is related to physical well-being of chronic patients.Spirituality and correction of cognitive distortions, especially in facing death, play a remarkable role in the mental and physical well-being (34).The results are consistent with Ghorbanalipour and Ismaeili (2012) (35).Indeed, it can be concluded that spiritual well-being is able to influence individuals' death anxiety, especially elderlies suffering from cancer.Thus, individuals with higher spiritual well-being may experience less death anxiety, which emanates from believing in a superior power i.e. god and in another world that may make death encounter easy.In this regard, a study, conducted by Dollman on elderlies suffering from chronic disease, revealed that elderlies enjoying higher level of spirituality and religiosity who have found the life meaning and objective, showed significant less necrophobia and were more ready for death (36).The findings were consistent with the present research results in which individuals with higher spiritual well-being reported less death anxiety.
As seen in Table 3, descriptive studying of spiritual well-being scale reported minimum and maximum scores of 12 and 56, respectively at mean 36.32.According to Table 4, spiritual well-being mean score in female elderlies suffering from cancer was obtained 36.83 at standard deviation 36.83 and 35.62 at standard deviation of 8.96 for males with cancer.In satisfaction with life scale, the minimum and maximum scores were also reported 5 and 35, respectively with mean 22.69 indicating that research samples enjoy an intermediate spiritual well-being and satisfaction with life.
In addition, it was also demonstrated that in descriptive studying of Templler death anxiety scale, minimum 2 and maximum 12 scores have been obtained at standard deviation of 2.99 with mean 6.69 implying that understudied elderlies experience an intermediate death anxiety.
As observed in Table 5, 36.5% of understudied individuals were satisfied with life, 32.4% showed little life satisfaction, and only 5.9% of the individuals were seriously dissatisfied; in average, research participants showed intermediate satisfaction with life.Sonerim et al (2012), in a study on elderlies of 6 welfare centers in South Korea, declared that satisfaction with life was 22.50 among elderlies, which is at an intermediate level in consistent with the present research findings.Probably, financial problems, loneliness, absence of health insurance, and illness are of some causes influencing and decreasing satisfaction with life in elderlies (37).

CONCLUSION
According to the obtained results, nurses may provide increased life satisfaction through improving spiritual life dimensions of elderlies with cancer and significantly contribute in cancer coping with mechanism and improvement.Spirituality leads to positive results like life satisfaction through lessening negative emotions including depression,    anxiety and anger against improving positive emotions such as hope, love and happiness.In fact, a strong metaphysically relationship (attachment) may remove anxiety, stress, and negative emotions, gives a fresh meaning to the life, and makes the feeling of dependence on an infinite power keeping him safe from all difficulties lasting.It seems that strong concepts like thanksgiving, trust, forgiveness and patience may compensate for weakness and disability and empower the individuals.According to Diener theory, such emotions would result in individuals' empowerment in coping with hard situations and in increased satisfaction.In fact, spirituality fills the gap between what the human being holds and what he aspires for, and helps him in achieving new opportunities and increased life satisfaction through decreasing the distance between reality and ideality.Indeed, it is concluded that spiritual well-being may influence death anxiety, especially in elderlies suffering from cancer.Spiritual attitudes of how individuals deal with death determine their death orientation and perception.Spiritual well-being may offer hope to those waiting for imminent death.
Given that providing mental health professional services is necessary for presenting effective medical strategies to deal with death anxiety challenges, studies on this area can be a starting point.Also, considering that accepting death reality and active involvement in a meaningful life cane be accounted as the best coping strategies of death anxiety, the present research may guide individuals, particularly medical education faculty, in service delivering to the patients, especially elderlies suffering from incurable diseases.

Table 1 :
Demographic characteristics of elderlies

Table 2 :
Correlation between spiritual well-being and life satisfaction among elderlies

Table 3 :
Spiritual well-being sub-scales of elderlies

Table 4 :
Spiritual well-being mean score base on gender in elderlies

Table 5 :
Levels of life satisfaction in elderly