Interventions to improve spiritual well-being in adult patients with cancer: A rapid review

The diagnosis of cancer causes significant suffering and anxiety to the patient and threatens the meaning of the patient's life leading to the appearance of a sense of disintegration, so the fulfillment of the spiritual needs of the cancer patient is necessary. Addressing the spiritual needs of cancer patients plays a role in accelerating recovery and achieving spiritual well-being. The purpose of this study was to find out recommendations for interventions in improving the spiritual well-being of adult patients with cancer. This research is a rapid review study with article searches using EBSCOhost, PubMed, and Google Scholar databases. The criteria for listing articles taken include research articles from the last 10 years during 2012-2022, randomized controlled trials or quasi-experiments, English, and full text. As a result of searching the literature, 8 articles from all three databases met the criteria. Based on these results, it was found that there are several interventions that can be done, including spiritual therapy, spiritual group therapy, mindfulness, spiritual counseling and Islamic-based caring. Of the several interventions obtained, it is recommended that Islam based caring because it is suitable to be applied in Indonesia, also features the practice of do'a and dhikr meditation that can be practiced daily and is proven to improve the spiritual well-being of adult patients


INTRODUCTION
Cancer is a disease caused by the growth of abnormal cells that go beyond the limit. According to the WHO report cancer is a major problem causing death in the world, with 10 million deaths in 2020 (Jayani & Ruffaida, 2020). A cancer diagnosis causes suffering and anxiety for cancer patients. Cancer threatens the meaning of the patient's life which sometimes leads to the appearance of a sense of disintegration. This indicates the need for the fulfillment of spiritual needs (Sajadi et al., 2018).
Cancer is the second leading cause of death in the United States based on a report from the Centers for Disease Control and Prevention (Boyd et al., 2017). In 2018 in the USA there are expected to be 1,735,350 new cancer cases with an estimated death toll of 609,640. Every day the estimated incidence of new cancers is 4,750 cases and deaths from cancer every day are estimated at 1,670, and this figure has increased every year (CDC, 2021). Based on 2013 data in Indonesia, the prevalence of cancer at all ages is estimated to be around 347,792 people. From 2011 to 2013 the prevalence of people with cancer increased (Kemenkes, 2019).
Patients diagnosed with cancer experience a variety of existential needs that include emotional, psychological, and spiritual areas (Kienle et al., 2018). Cancer diagnosis can cause a spiritual crisis and affect different aspects of life (Hatamipour et al., 2015). Patients with cancer have a high risk of developing psychiatric disorders classified as depression and increased anxiety (Tsaras et al., 2018), lower quality of life (İzci et al., 2018) and increasing the need for spiritual care from healthcare professionals (Pearce et al., 2012). Some studies report that 25-30% of patients with nonhematological malignancies suffer from depressive disorders (Moeini et al., 2014).
The spiritual is a unique holistic component of care. When handled properly will affect the patient's positive response during the course of cancer (Richards & Richardson, 2012). Spirituality and religion in forms such as: meditation, yoga, music, belief in existential, prayer, or religious traditions all of which can bring peace, meaning and hope to individuals facing the reality of death from cancer (Friebert et al., 2011). Nurses play an important role in patient care care because they are able to spend more time with patients and their families than other health professionals (Lin et al., 2019) and must actively participate in implementing spiritual care into the nursing care plan of every cancer patient (Richards & Richardson, 2012). However, nurses are inconsistent in providing spiritual care to patients due to lack of information about the types of spiritual care practices that include spiritual care interventions (Chirila et al., 2019).
Spirituality is an important resource for many individuals when faced with a cancer diagnosis that can help overcome difficult times and serve to reduce distress (Connolly & Timmins, 2021). Spirituality is a personal aspect that refers to the way individuals seek and express the meaning and purpose of life in the present moment, oneself, others, nature, and God (Sarfati et al., 2016). Many cancer patients seek comfort and help in spiritual beliefs, which are associated with positive psychological outcomes (Su et al., 2018).
Conceptually, spiritual is defined as a person's view or feeling of a close relationship with other aspects of a dynamic life (Ramezani et al., 2014). Spiritual for patients is a word that describes their relationship with God S.W.T and makes them carry out worship activities with a more regular intensity (Sari & Wijayanti, 2014). Spiritual needs may not be expressed in detail in all phases of the disease (Surbone et al., 2010), however, the spiritual needs of cancer patients must be recognized, realized and considered as long as the patient receives treatment by the medical team (Hatamipour et al., 2015). Since it is believed that spiritual care can successfully lower the rate of depression in patients with cancer, nurses are required to apply a holistic care approach with an emphasis on spiritual care (Moeini et al., 2014) also used as an individual's strength and coping that can provide moral support or zest for life in the face of the reality of his illness (Penman et al., 2013).
Addressing the spiritual needs of cancer patients plays a role in accelerating recovery and achieving spiritual wellbeing (Moeini et al., 2014). Cancer patients are faced with existential questions, and many find that spiritual well-being gives meaning and purpose to life and can reduce psychological and even physical problems (Bauereiß et al., 2018). Some research suggests that spiritual and religious interventions show positive effects such as; lower depression and more life expectancy (Afrasiabifar et al., 2021;Creswell et al., 2012).
The purpose of this study was to find out the recommendations of interventions to improve spiritual wellbeing in adult patients with cancer. This research is expected to benefit researchers, nurses, and other professions in adding insight so that they can develop interventions in meeting the spiritual needs of cancer patients.

METHODS
The appropriate literature review methodology for use in this literature study is rapid review based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) research protocol guidelines. Because the purpose of this literature study is to find out recommendations for interventions to improve spiritual well-being in adult patients with cancer.
Rapid reviews are a form of evidence synthesis that may provide more timely information for decision making compared with standard systematic reviews." (Kelly, S. E., Moher, D., & Clifford, T. J. (2016). The methods of conducting rapid reviews varies widely, and are typically done in less than 5 weeks. Often policy makers require a short deadline and a systematic review for synthesizing the evidence is not practical. A rapid review speeds up the systematic review process by omitting stages of the systematic review making it less rigorous (Polisena et al., 2015).
Rapid Reviews are best designed for: New or emerging research topics, updates of previous reviews, critical topics, to assess what is already known about a policy or practice using some systematic review methods. (MacDonald, 2014).
Literature review using the rapid review method based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) guidelines. Article search using electronic databases namely PubMed, EBSCOhost, and Google Schoolar. Based on this technique in the search for British literature, the author uses keywords using an electronic database. with keywords including: "cancer" OR "cancer patient" AND " intervention" OR "program" AND "Spiritual Well Being.

RESULTS AND DISCUSSION
The articles obtained are carried out in order to get articles according to the topic of literature studies carried out. Article submission is carried out by adjusting to the established inclusion and exclusion criteria.
The inclusion criteria set are patients diagnosed with cancer aged ≥ 18 years, quasi-experimental or randomized controlled trial, fulltext, English-speaking, in the range of 2012-2022, and in the form of interventions to improve spiritual well-being in cancer patients. The exclusion criteria in this literature study are articles that do not list the volume, number, and publisher of the article.
The next stage is critical appraisal in articles using Joanna Briggs Institute (JBI) instruments. The results of the critical appraisal obtained articles that were worthy or not used in this study. While articles that have been on the topic of literature study and have been judged worthy of use in this literature study are reviewed and read as a whole to be able to know the intervention methods of intervention to improve spiritual well-being in cancer patients described in the article. The following is a flowchart of sorting articles obtained according to the topic of the literature study conducted: Google Scholar : 53, PubMed: 26, EBSCOhost: 9, (n= 88)

Chart 1. Article Selection Process Flowchart
Presentation of the results of the study of each literature used, the information will be presented in the form of tabulations. The tabulations created will contain interventions to improve spiritual well-being in cancer patients that have been obtained from previous literature searches, article titles, article authors along with the year of publication of the article, types of research, research methods and research results.
To obtain the most effective interventions to improve spiritual well-being in cancer patients. Based on the results of journal searches, 8 journals with various interventions were obtained that showed positive results as follows.  (Nasution et al., 2020) 88.8% (8/9) Good Quality (Park et al., 2020) 100% (13/13) Good Quality (Zernicke et al., 2014) 76,9% (10/13) Good Quality (Hosseini Rafsanjani et al., 2017) 88,8% (8/9) Good Quality (Zamaniyan et al., 2016) 77,7% (7/9) Good Quality The results of a literature search show interventions that can improve spiritual well-being in cancer patients, including spiritual therapy, spiritual group therapy, mindfulness, spiritual counseling, and Islam-based caring. Intervention in the spiritual aspect is carried out because it is known to have a good effect on physical and psychic health (Zamaniyan et al., 2016). Here is a breakdown of each intervention.

Spiritual Therapy
Spiritual therapy is a form of psychotherapy based on religious/spiritual techniques to empower patients to achieve a nonmaterial understanding of themselves, the universe, events and phenomena, as well as health and growth (Zamaniyan, 2016). On research Jafari et al. (2013) The intervention was carried out on 34 patients in the intervention group, carried out in 6 sessions for 6 weeks. The therapy session addresses spiritual topics and then closes with relaxation and meditation. Results showed the spiritual well-being score changed from 29.76 to 37.24 (p<0,001). While in the study Nasution et al. (2020) The intervention is carried out in 4 sessions for 2 weeks. During the therapy sessions, topics related to spirituality and prayer are discussed. The results of the study there was a significant difference in coping scores (p=0,001) and spiritual wellbeing (p=0.006) in the intervention group. Spiritual therapy is proven to improve spiritual well-being, coping ability, quality of life to reduce anxiety, and social isolation in cancer patients (Jafari et al., 2013;Nasution et al., 2020). This is in line with that stated by Naveen, Rao, & Kadam (2014) Breast cancer patients gain comfort in spiritual activities, significantly associated with the provision of spiritual interventions and positive outcomes. Likewise, in systematic studies conducted by Xing et al. (2018)  Comparing the mean scores of hope, mental health, and spiritual health before and after the intervention showed a significant difference (P < 0.001) in the test group. In the control group, no significant difference was found before and after the study. This indicates the benefits of the spiritual group therapy in cancer patients The study results show that spiritual group therapy has a significant positive impact on the mental and spiritual health of patients with colorectal cancer, and that it also gives them hope. Thus, the use of spiritual therapy is suggested as a good way to improve the spiritual and mental health and hope in patients with colorectal cancer There were no significant differences on SWBS and its two subscales scores (RWB and EWB) between intervention and control groups at baseline (p > .05). After intervention, there was a significant mean difference in SWB (p = .001), RWB (p = .013) and EWB (p = .001) in two groups.
Spiritual counseling is associated with significant improvements in SWB in Iranian women with cancer. Interventions that acknowledge the spiritual needs of these patients should be incorporated into conventional treatments. There was a positive change in the average scores of coping (P = 0.001) and spiritual well-being in the intervention group after receiving spiritual intervention (P = 0.006). The result of this research also shows that there was a significant difference in the average score of coping (P = 0.004) and spiritual well-being (P = 0.001) after spiritual intervention between intervention and control groups.
This study shows that coping and spiritual well-being in the intervention group increased significantly after receiving spiritual intervention After six spiritual therapy sessions, the mean spiritual well-being score from 29.76 (SD= 6.63) to 37.24 (SD= 3.52) in the intervention group (P < 0.001). There was a significant difference between arms of study (F= 22.91, P < 0.001). A significant positive correlation was detected between meaning and peace with all subscales of functional subscales on European Organization for Research and Treatment of Cancer quality of Life (EORTC QLQ-C30) (P < 0.05). Hierarchical regression analyses of participants indicated that the study arm, pain, and financial impact were significant predictors of spiritual wellbeing and overall QOL. Social functioning was another significant predictor of spiritual well-being The results of this randomized controlled trial study suggest that participation in spiritual therapy program is associated with improvements in spiritual well-being and QOL. Targeted interventions to acknowledge and incorporate spiritual needs into conventional treatment should be considered in caring of Iranian patients with breast cancer

Spiritual Group Therapy
On research Zamaniyan et al. (2016) Using the intervention of Spiritual Group Therapy, it was performed on 12 breast cancer patients in each control and intervention group. The intervention was carried out in 12 sessions. Treatment sessions address spiritual topics such as building a relationship with God or praying, letting go of feelings of hate, and increasing faith. The results showed an improvement in the quality of life and well-being of spirituality in the intervention group. While spiritual group therapy in research Rafsanjani et al. (2017) conducted in 8 8week sessions. The therapy sessions contain topics with an Islamic approach, namely altruism, patience, and trust. The results obtained on the average score of expectations, mental health and spiritual well-being before and after the intervention showed significant differences (p<0.001) in the intervention group. In both studies, it was found that spiritual group therapy is effective for improving the spritual well-being of patients with cancer.
Spiritual group therapy can change the attitude of cancer patients to be more positive in living life and facing their illnesses (Zamaniyan et al., 2016). Cancer patients tend to stay away from their social environment and routines which makes them tend to determine life goals and life values in the short term, therefore group therapy is needed for cancer patients to help them determine life goals and values in the long term (Sadeghi et al., 2018). Bellver-Pérez et al. (2019) Bringing up other benefits of group therapy can help improve the patient's ability to communicate and adapt to others and be a source of support for individuals because they are joined by others who have similar problems.

Counseling Spiritual
Another intervention is in the form of spiritual counseling conducted by Sajadi et al. (2018). Spiritual counseling is an intervention that helps explore the spiritual aspects of the patient that can improve health, and his coping strategies that include meditation, self-disclosure and emotions, keeping a journal, praying, studying scriptures, and reading inspiring reading resources. (Sajadi et al., 2018). The intervention was carried out on each of the 21 intervention and control participants, carried out 8 8-week sessions, including question and answer sessions, sharing, reflection, relaxation, and meditation. The results showed that spiritual well-being, existential well-being, and religious well-being increased after being given intervention. Spiritual counseling facilitates the patient to be able to reevaluate the purpose of life, and the source of the meaning of life, which has a positive impact on his spiritual well-being (Sajadi et al., 2018).

Mindfulness
Mindfulness-based cognitive intervention (MBCT) is carried out by Park et al. (2018) consisting of 38 MBCT people and a control group of 36 people, using the MBCT method for 8 months. The program is based on the original MBCT program with modifications (adding psychoeducation). The program consists of formal meditation exercises, cognitive therapy-based psychoeducation, as well as discussions and interactions between participants to facilitate learning. Patients are given a Compact Disc (CD) containing a meditation guide. Results in the MBCT group experienced a significant improvement in psychological and spiritual well-being outcomes compared to the control group.
Another Mindfulness intervention is Mindfulness Based Cancer Recovery (MBCR). On research Zernicke et al. (2014) MCBR is used online because these interventions make it easier for many people due to barriers such as geographical distance, transportation problems, disease, and mobility limitations. The intervention consists of weekly sessions for 8 weeks. Meditation recordings and videos are given to support exercise at home, hatha yoga, and mindfulness meditation every day.
The results of the intervention showed a decrease in mood disorders, symptoms of stress, fatigue, anger, and a simultaneous improvement in the spiritual aspects of well-being, and quality of life (Zernicke et al., 2014). After the intervention there was a significant improvement in the online MBCR group, a total score of mood disorders (p=0.049), stress symptoms (p=0.021), spirituality (p=0.040), and caring action with awareness (p=0.026). Something similar was found. Wahyuningsih, Achsan, Sofro, & Dwidiyanti (2019) that Mindfulness has a significant effect on awareness and also improves the spiritual well-being of breast cancer patients. Mindfullness therapy is very beneficial for patients by practicing focus to be aware of the problem at hand, improving self-acceptance, so that negative judgments about the disease can be reduced (Wahyuningsih et al., 2019).

Islam-based Caring
Research based on Islamic caring conducted by Komariah et al. (2020) which was done on Muslim women with breast cancer and undergoing chemotherapy. There were 53 intervention groups and 59 participants in the control group. Islamic-based caring program interventions include The results showed spiritual well-being scores improved gradually and significant outcomes for the intervention group (p=0.027). Participants also experienced an increase in the subscale of meaning and peace after receiving the itervensi. These findings are in line with the study Hosseini et al. (2016) spiritual intervention supported by the Qur'an and islamic standards for 10 weeks. Not only that, but one study related to spiritual interventions rooted in religion significantly improved the spiritual well-being of end-stage cancer patients (Chimluang, Thanasilp, & Akkayagorn, 2017). In addition to spiritual well-being, quality of life is also the outcome of faith-based therapies such as research conducted by Romadloni & Mukarromah (2015) obtaining results that Islamic psycho-spiritual interventions significantly improve the quality of life in people with cervical cancer.

CONCLUSIONS AND SUGGESTIONS
Based on the results of this rapid review, it was found that spiritual well-being was significantly improved by the provision of spiritual therapy interventions, spiritual group therapy, spiritual counselling, mindfulness and Islamic-based caring. Islam-based caring is a recommended intervention in Indonesia because the majority of religions in Indonesia are Islam and feature do'a practices and dhikr meditations that are biased to be practiced daily, and have positive benefits by improving spiritual well-being in adult patients with cancer.
Suggestions for future research on recommendations for interventions to improve homecare-based spiritual wellbeing, which are suitable for application in the current era of the COVID-19 pandemic