Religious / Spiritual Coping by People with Cancer Undergoing Chemotherapy : Integrative Literature Review

The objective of this study was to identify the scientific evidence available regarding the religious/spiritual coping approach used by people with cancer undergoing chemotherapy. It is an integrative review of the literature. The descriptors “chemotherapy” and “spirituality” were used. The databases were: LILACS, PUBMED, ScienceDirect, EMBASE, CINAHL, and BDENF. The studies recognize religion/spirituality as a positive approach strategy, since it contributes to adherence to treatment and stress reduction. The negative effect was associated with the incidence of collateral effects, psychological suffering, anxiety, and depression. We concluded that the recognition of spirituality as a coping strategy and the identification of spiritual needs provide nursing professionals with a better scope of information for care planning and more comprehensive assistance.


Introduction
Cancer is a serious public health problem, especially in developing countries.The World Health Organization (WHO) estimates an incidence of 20 million cases worldwide by the year 2025.It is the second highest cause of death by chronic disease in Brazil (16.3%), where, according to the estimate for Sousa FFPRD, Freitas SMFM, Farias AGS, Cunha MCSO, Araújo MFM, Veras VS.
the year 2016, 596 thousand new cases of the disease will be registered. (1)emotherapy is the most common treatment in oncology, and during this mode of therapy people may present important physical and emotional changes such as pain, fatigue, apathy, weight loss, and alopecia, among others.oping with the abovementioned changes demands greater resilience from people with cancer and their respective families.In this regard, it is common for people to seek a meaning for this experience in spirituality, which can help those with chronic diseases through the action of neurotransmitters that promote feelings of well-being, attenuation of heart and breathing frequency, as well as anxiety and cortisol levels, in addition to improving the immune system. (2,4)nagement of a chronic disease such as cancer requires individualized care, as this moment can mean different things for each person.Thus, supporting care with spirituality can be indispensable, since it occupies an important place in the lives of most individuals.Its significance should be evaluated regardless of its use as a therapeutic tool, since Religious/Spiritual Coping (RSC) can play both a positive and a negative role in handling the disease. (5)ligious people present a higher capacity for dealing with adverse life circumstances through the use of RSC.Coping refers to a group of behavioural and cognitive strategies used with the objective of dealing with stressful situations.When positive, it includes strategies that have a beneficial effect on the individual, such as seeking the love/protection of God or a greater connection with transcendental forces.
Negative RSC involves strategies that generate harmful consequences, such as, for example, redefining the stressor as divine punishment. (5)C is the most adaptive response to stress and includes resources such as problem solving, planning, and procurement of emotional support.here are studies on the relationship of religiosity/ spirituality in the prevention of drug use (6) , quality of life (7)(8) , hormonal therapy (9) , and radiotherapy (10) .From our knowledge, no publications were found analysing the role of RSC in people during chemotherapy treatment.Thus, the purpose of this revision was to synthesize the knowledge generated based on the results of other studies, and, based on these results, develop generalizations regarding the impact of religiosity/spirituality on the coping mechanisms of people with cancer undergoing chemotherapy.

Method
This is an integrative literature review, performed during May and June 2016.
The guiding question of this study was: what evidence is there in the literature regarding religious/ spiritual coping used by people with cancer undergoing chemotherapy?
The following databases were used: LILACS, EMBASE, PUBMED, CINAHL, Science Direct, and BDENF.The controlled descriptors used were Chemotherapy (Quimoterapia/Quimioterapia) and Spirituality (Espiritualidade/Espiritualidad), with the boolean operator AND between the terms.
The following criteria were used for inclusion of the articles: original articles with complete abstracts and texts available for analysis, published in English, Portuguese, or Spanish between 2005 and 2016.The searches were performed by three reviewers, following the same procedure, with the goal of validating the results found.
We excluded review studies, theses, and dissertations, informal case reports, chapters of books, news articles, and non-scientific editorials and texts, as well as articles that did not reference the objective of the study.
By reading the titles and abstracts of all the publications found, and according to the inclusion and exclusion criteria defined, we obtained a pre-selection of the articles that composed the sample for this study.
The final sample included 11 articles.Analyze the levels of spirituality in oncology patients in chemotherapy.
92 cancer patients in chemotherapy.

Guerrero et al.
Understand the relationship between spirituality and coping with cancer from the perspective of oncology patients.
14 cancer patients in chemotherapy.

Balboni et al.
Examine religiosity and spiritual support in patients with advanced cancer and their association with quality of life.
230 patients with chemotherapy failure.

Gaston-Johansson et al.
Examine coping, psychological affliction, spiritual well-being, and coping strategies in Afro-American women.
17 Afro-American women with breast cancer.
Canada et al.
Investigate the role of religion/spirituality and coping in the quality of life of women in chemotherapy.
129 women with ovarian cancer in chemotherapy.
(the Figure 2 continue in the next page...)

Results
Eleven articles met the established inclusion criteria.The publications predominated in the PUBMED database (6), followed by LILACS (3) and CINHAL and BDENF (one in each).The ScienceDirect and EMBASE databases did not have any articles selected in the final N.
The studies were developed in Brazil (4) and the United States (3), followed by Iran, Italy, Portugal, and Turkey, with one study each.
Most of the studies were published in the last five years It was noted that the articles found in the search were mostly (5) developed by a multi-professional team, followed by four studies undertaken by nurses and two by doctors.
When evaluating religious/spiritual coping in chemotherapy sessions, it was found that most (7)  of the articles used validated instruments such as the Spiritual Health Scale (SHS), Religious/Spiritual Coping Scale (RCOPE), Brief RCOPE, Spiritual Well-Being Questionnaire (SWBQ), Functional Assessment of Cancer Therapy General (Fact-G), and Functional Assessment of Chronic Illness Therapy -Spiritual Well-Being Scale (Facit-Sp 12).In addition, the instruments were found to be repeated in some studies.
The aid of religion/spirituality in coping with cancer during chemotherapy treatment was a consensus among the scientific articles included in this integrative review.It was noted that this theme is of the interest of various professionals in the health area, thus highlighting the importance of studies regarding people with cancer and religious/spiritual coping.

Discussion
In the last decade, greater attention has been paid to the study of spirituality/religiosity as a coping strategy used by people with cancer, given its protective role against psychological morbidity.Each individual relates spirituality with the hope of surviving cancer. (5)fter reading the articles, extracting and analysing the information pertinent to answering the guiding question, the data were organized into three categories: use of positive or negative RSC by patients in chemotherapy; relationship between RSC and the religious practice; and RSC associated with the quality of life and spiritual well-being of the patient in chemotherapy.

Use of Positive or Negative RSC by Patients in Chemotherapy
)(13)(14) The role of religion, in this case, can be related to matters such as resilience, hope, and spiritual well-being.In addition, religion cooperates in coping with the idea of cancer as a disease caused by the divine. (4,11,14)here is evidence that people with some type of spirituality tend to present lower incidence of disease, greater longevity, faster recuperation, and fewer complications during treatment.However, religion/spirituality can be a source of discomfort and stress, depending on how the person relates to itin other words, if they use positive or negative RSC strategies. (15)t is known that negative RSC is correlated to a higher incidence of collateral effects, greater psychological suffering as a consequence of weakened mental health, anxiety, lower use of positive self-affirmation, and depression, as well as  lower quality of life levels and worse total spiritual well-being.

Relationship between RSC and Religious Practice
Among the reasons for a positive association between religion and health is the fact that religious beliefs and practices can evoke positive emotions.Thus, considering religion/spirituality as something important in life also evidences that the individuals who profess some sort of faith, and who have a declared religion, present a negligible level of negative RSC. (12) A notable particularity is the support of religion/ spirituality in the field of psychoendocrinology.Some authors have ascertained good responses to chemotherapy on lymphocyte and cortisol levels and in tumor size in people with good scores on spirituality tests. (17)This support mechanism can be higher in elderly people, for they are greater believers and/or have a less materialistic and more transcendental view on life.This is also important because elderly people with cancer suffer more greatly from spiritual distress. (16)C Related to Quality of Life and Spiritual Well-Being in People Undergoing Chemotherapy RSC and the support of spiritual needs contribute positively to improving quality of life of patients in chemotherapy by increasing psychological, emotional, functional, and affective well-being of the patients.(5,12,(15)(16)18) Perhaps because of this, authors have ascertained the desire of patients to receive some type of spiritual care during chemotherapy.However, most people complain that their spiritual needs are not considered during treatment.(5,18) Countless obstacles impede nurses from contributing to the provision of spiritual support simultaneously to biological care.The lack of professional training and, in a way, a theoretical deficit for spiritual care are a pretext for which it is often not offered.
However, the Nursing Interventions Classification (NIC), which is a consolidated reference regarding nursing interventions, contains two interventions specifically related to spirituality: spiritual support and facilitation of spiritual growth.By implementing these interventions, nurses meet the spiritual needs of the patient, establishing an interface between spirituality and the body of knowledge of the profession. (2)t is known that, in the view of some oncology patients, the nurse is the professional with the best ability to deal with people undergoing spiritual suffering, because they have more availability to listen and demonstrate greater affection during care. (14)

Final considerations
The results obtained demonstrate that oncology patients should be viewed in their totality, and that their religious/spiritual aspects should be understood, valued, and considered for individualized, singular care.These findings allow us to reflect on the importance of spirituality in the lives of people undergoing chemotherapeutic treatment, which is fundamental in handling the disease.
It is important to highlight that RSC can be an element that contributes to adherence to treatment and reduction of situational stress and anxiety.Respecting the beliefs of the individual and considering them also contribute to better interpersonal relationships between the professional team and the person they are treating.
Thus, the study offers relevant contributions to nursing, as nurses are the professionals that have the most proximity to patients in chemotherapeutic treatment during their routines, making them a reference for establishing a bond of trust, and thereby facilitating the provision of spiritual support to these people, who may be spiritually weakened.
One of the limitations presented in this review is with regard to the quantity of controlled descriptors, which are lower in number than those usually employed in integrative reviews.Only two standardized descriptors were selected in all of the databases.Adding more descriptors in some specific databases might have increased the number of results found.
Based on this study, expectations and possibilities also arise for the development of new studies indicating the need for professionals in the healthcare area to be trained to deal with topics such as religion/spirituality, related to the care provided to oncology patients.

Figure 1
Figure1displays the number of primary studies identified in each database (N).The articles that met the inclusion criteria composed the number of preselected articles (n).Thus, the articles selected for the study, excluding those repeated in the databases, composed the "Final N".