The EORTC QLQ-SWB32 questionnaire has been used in many countries around the world and shows a positive effect in evaluating SWB in cancer patients. Interestingly, our study was conducted in Vietnam where the participants differed in terms of culture, education, religion, and traditional values. According to Feng et al., understanding the role of spirituality and SWB for both curative and palliative patients is essential in developing and delivering holistic and culturally appropriate patient-oriented care [24].
This study evaluated the reliability and validity of the Vietnamese version of the EORTC QLQ-SWB32 questionnaire on cancer patients in Vietnam. After conducting the survey on 214 cancer patients, lung cancer accounted for 71.0% of all participants, and the rest had cancers of the digestive system (17.8%), urinary cancer (2.3%), head and neck cancer (2.3%), and breast and gynecological cancer (3.3%). Having stage 4 cancer accounted for 59.8% of the participants. The proportion of men (72.9%) was higher than that of women. The disease was also seen mainly in people over 55 years of age (77.1%).
The results of the reliability analysis showed that Cronbach’s alpha coefficients of the scales were all higher than the threshold of acceptance, ranging from 0.60 to 0.74. This result was quite similar to other language versions of Dabo et al. [25], however, it was lower when compared with the reliability value in the international study [16] and the study on Chinese women with gynecological cancer [26]. We found that this measurement was easy to understand and accepted by patients, being used to quantify SWB widely in Vietnam. The results were similar to other studies around the world [16, 25].
The construct validity result indicated that most of the questions were arranged in the RO, RS, RSG, and EX groups, like the original questionnaire. However, there was a change in the factor loading for six sentences in the scales (items 8, 9, 17, 18, 27, 31). Since the research participants had differing characteristics, our results were different compared to other studies [16, 27]. In comparison with the recommendation from Hair et al. [28], the standardized estimate (factor loading) of some items was lower than the accepted value of .50 for 214 participants.
Specifically, item 9 could be classified in the EX or RO group, however, the load multiplier was the strongest in RO (0.455); thus, I9 was classified in the RO group, similar to the results of previous studies. Meanwhile, sentence I8, “I feel able to share thoughts about life with people close to me,” had the strongest loading in EX (0.371), and the factor loading in the RO group was less strong (0.323). Our research results contrasted with those of previous studies, showing the strongest factor loading of I8 in the RO group and being less strong in the EX group [16, 25]. The emotional state of cancer patients during this time could be observed. According to their own emotion, they looking forward to share their feelings, thoughts, and love with close ones, which was important to them as they contemplated their existence [18].
Similarly, item 17 regarding worries and/or concerns for the future had a higher multiplier load factor in the EX group compared to the RS group (0.329 and 0.307, respectively). Item 27, “the words and actions will live forever in people’s minds,” also had the highest factor loading in the EX group (0.323), and a lower one in the RSG group (0.290). These results also strengthened the hypothesis that the Vietnamese people’s discomfort with the concept of death may be more sensitive than others [9]. As for “wanting the best for their children [18]”, the cancer patients tried to maintain their health status, being optimistic or having happy smiles in front of their relatives in order to preserve a good memory for all.
Question 31, “I have spiritual well-being,” had a load factor of -0.305 in the RS group. This result can be explained by the fact that the target content of item 31 was reversed to the content of other parts of the scale. This point also highlighted the opposite direction of this item in the RS scale, shown in Table 6.
Table 6
Scale/items | RO | RS | RSG | EX | RG | GSW |
Relationship with Others (RO) | | | | | | |
Relationship with Self (RS) | 0.093 | | | | | |
Relationship with Someone or Something Greater (RSG) | 0.397*** | 0.221** | | | | |
Existential (EX) [5] | 0.475*** | 0.065 | 0.322*** | | | |
Relationship with Buddha (God, Allah) (RG) | 0.106 | -0.130 | 0.373** | 0.017 | | |
Global SWB (GSW) | 0.052 | -0.201** | 0.183** | 0.009 | 0.199 | |
*p < 0.05, **p < 0.01, ***p < 0.001 |
The result of CFA testing with Chi-Square/df = 2.283, GFI = 0.846, CFI = .742, and RMSEA = .078 confirmed the construct validity of our instrument that evaluated the well-being of culturally different Vietnamese people. Although it was not an excellent fit, the model was considered a good instrument for SWB for cancer patients.
Age
For age, we did not find a statistically significant difference between age and the RO, RS, or EX scales. Interestingly, the finding was same as that of Dabo et al. [25], in which the RSG scale score was the lowest for the oldest participants (p < 0.05). For older people with cancer, it seems that their beliefs in things like meditating, being attentive about having someone pray for them, and believing in life in the afterlife are no longer important.
Gender
There was a difference in the proportions of men and women; however, there was no distinction among women and men in any scales, which was inconsistent with previous studies. Most other studies showed that women scored higher than men in relationships with others, with themselves, and with belief in someone or something greater [16, 24, 25, 29, 30]. This inconsistency among the Vietnamese and other cultural areas can be explained by the fact that in general, there are similarities in prevalence and determinants of mental health indicators between women and men, especially for older people [18, 31].
Religion
The majority of participants (144) answered no for items 22 and 23, concerning religion. The remaining 70 (214 − 144) participants will be considered as having religious beliefs. In considering beliefs toward religion, the study results indicated a statistically significant difference for RSG, with the median score on this scale being lower for those who confirmed having no religion. This result differed from a Croatian study in that the difference in relationships with someone or something greater than oneself between religious groups occurred only in the group identified as having religion. Concerning all people with cancer, including people of different religions, beliefs, and even people with no religion, the SWB32 questionnaire is designed to be universal and suitable for all [16, 27]. Remarkably, people with no religion have a greater need for spiritual care than those who follow a certain religion [27]. Therefore, in clinical practice, it is very necessary to pay attention to spiritual care for patients who do not follow any religion.
In terms of religion, there was a notable difference among participants compared to previous studies. According to reports, Vietnam currently has 4.8% and 6.1% of the population following Buddhism and Catholicism, respectively. In this study, the percentages of people following Buddhism and Christianity were 5.1% and 2.8%, respectively. Thus, up to 90.7% of the study participants identified as having no religion. In the 194 participants who mentioned belonging to no religion, they had belief in someone or something greater than themselves, similar to the group of participants in the research of Ku et al. [9]. Although Vietnamese people may not be Buddhists or Christians, they sometimes visit pagodas in the middle of or at the end of the month to pray or find their peace of mind. They are not truly believers, but they can engage in some religious activities. In addition, in every Vietnamese family (except for Catholics), there is an altar for grandparents and ancestors, which comprises a custom for Vietnamese people to worship ancestors [32].
Regarding the Edmonton Symptom Rating Scale, there was a statistically significant difference in the RS scores between groups with severe conditions of pain, fatigue, nausea, drowsiness, difficulty breathing, loss of appetite, inability to sleep, and emotional problems such as depression, anxiety, and a general feeling of well-being. These results were similar to those in the studies of Asgeirsdottir et al. and Vivat et al. [16, 27]. Both physical and emotional symptoms were statistically significantly associated with sadness, anxiety about the future, and about what could be done for the cancer patient at this stage. Psychological stress may increase the risk of insomnia, poor sleep, nocturia, decreased appetite, fatigue, and nausea [33]. At the same time, these symptoms themselves may increase the patient’s anxiety, depression, and overthinking [34]. For Vietnamese people in their traditional culture, the family lives together for three to four generations, and parents and children express their responsibility and obligation to take care of each other. However, when the elderly get sick, they easily fear becoming a burden to the younger generation [18]. Therefore, they hide their symptoms until they worsen, post which they and their family members become very stressed, trying to cope with the disease.
Thus, when patients experience caring behaviors and improved symptoms, the reduction in stress may improve their depressed mood and anxiety, leading to an improvement in RS—their relationship with themselves—while strengthening their religion, beliefs about great power, and their attitudes about SWB (Table 6). These results have implications for the improvement of thoughts and views on existence, with people being more accepting and feeling at peace with their reality. For the group of participants who are cancer patients, general SWB attitudes are related to relationships with themselves and with beliefs about someone or something bigger than them. The correlation between items in the questionnaire confirmed its construct validity.
Study strengths and limitations
This study was conducted on a homogeneous group of participants, incorporating the common characteristics of Vietnamese people with research locations in many territories. The instrument was translated and adjusted closely to the context of Vietnamese people, being easy to understand and answer. The reliability of the questionnaire was assessed at a quite high level, being equivalent to other versions in the world. It could be applied to assess SWB in Vietnam, as well as other neighboring countries with similar cultural characteristics and education levels.
However, this study had a limitation in terms of its low sample size. The research participants were mainly lung cancer patients, requiring future study samples to be more open to other groups of cancer patients. In addition, because the assessment of the participants involved inpatient treatment at the hospitals, the disease stage was mainly set at levels 3 and 4, that is, the severe level. Since SWB mainly occurs at a low level, it is necessary to expand research on these diseases for patients at stages 1 and 2. However, without any mandatory regulation and awareness of periodic health check-ups, most of the patients who are diagnosed with cancer in Vietnam are already at an advanced stage, making it difficult to conduct studies on stage 1 and 2 patient groups.