Given that spirituality is expressed within the wider cultural context of an individual, it would make more sense to compare studies on this topic within similar ethnic or cultural groups. However, in Cyprus, there is no other study that has previously empirically explored patients’ spiritual well-being and its associations with quality of life. Thus, the evaluation of our findings will be explored in relation to those from studies in other countries.
Two other studies employed the newly developed EORTC-SWB32 tool and reported on levels of spiritual well-being in patients with advanced cancer and its associations with QOL(27)(28). The perceived Global SWB score was high in all three samples (Table 7). Additionally, the 104 patients from Cyprus scored higher in the “Existential” scale as well as in the “Relationship with Others” and “Relationship with Something Greater” scale compared to that reported by Rhode (2019), from 451 patients (14 countries), and those reported by Chen (2021), from 705 Chinese patients with gynaecological cancer(27)(28). However, Cypriot patients scored lower compared to patients from the other countries in the “Relationship with Self” scale as well as in the Global SWB score.
Similarly, the mean score for the “Relationship with God” scale (74.9, SD=29.7), reported for the Cypriot population, is high and probably compatible with the fairly homogenous spiritual orientation of the island’s population which is mostly Greek Orthodox(18). Given the absence of reports from the other two studies on the scale, “Relationship with God”, mean scores on the “Relationship with Someone or Something Greater” scale from the other two studies are used to compare results from all three studies. The reported values in Rhode (2019) and Chen (2021) (between 50 and 60)(27)(28) are considered in the middle range and are lower compared to those reported by our patients (64.6).
The EORTC-SWB32 measure was developed to facilitate measurement of spiritual well-being in multi-cultural environments and it is certainly useful to have different studies reporting on the same measure. Notwithstanding, the findings need to still be translated with caution. It is hard to make meaningful comparisons between the patients of these studies. Spirituality is part of the culture of each population, whichever way defined. As such, it requires a deep understanding of traditions and social connections to interpret findings accurately. Cyprus and China are certainly different. As noted by Chen (2021), even their study from one centre in China might not be representative of different regions of the same country. In the same way there are probably differences among the 14 countries in the study by Rhode (2019)(27)(28).
Quality of Life
The EORTC-QLQ-C30 is a valid and extensive tool for the exploration of the various dimensions of the perceived quality of life of patients. Shorter measures have been developed, particularly for the palliative care setting (i.e., the EORTC-QLQ-C15-PAL)(29). However, we opted for the former because this report is part of a larger study that aims to validate the Greek version of the EORTC-SWB32 which is itself extensive (30 questions). Thus, an extensive measure of quality of life was chosen to test whether any associations between the two may exist. Furthermore, two recent studies, from non-US or northern Europe origin were selected to compare our findings on quality of life with(30)(31). The aforementioned studies were selected because participants from the Middle East and Africa might share some cultural influences that makes it interesting to compare with our sample from eastern Europe. Most studies on the topic have been performed in the US and Northern Europe(32). Additionally, the similarities in the demographic and clinical characteristics between the samples of all three studies allowed for further elaboration.
Our participants’ Global health status/QOL scale (GL) mean score was 45.2 (SD = 24). Compared to that reported by Davda (2021) (53, SD=27) and by Chaar (2018) (65.81, SD=16.48) the Global health status/QOL scale score in our sample was lower (Table 8)(30)(31). This is an interesting finding since in the three studies, patients were similar in terms of stage of disease and mean age. Compared to those in the other two studies, the participants in our study had the lowest stated score in the “Physical functioning” scale despite exhibiting a better profile in several symptoms (i.e., fatigue, pain, dyspnea, insomnia and diarrhea) (Table 8). Interestingly, “Role functioning (63.1, SD=34.3), and “Social functioning” (47.4, SD=34.6) in our sample was equally low. It would be interesting to explore in future studies the contribution of each scale (i.e., “Role, Social functioning”) in the prediction of the Global health score/QOL.
Correlations between the SWB32 and QLQ-C30 questionnaires
Although the sample size in our study was small, several associations were observed between the scales of the SWB32 and QLQ-C30 (Table 6). The scale “Relationship with Self” demonstrated significant correlations with all items of the QOL-C30. Similarly, the scale “Relationship with Others” demonstrated significant, mostly negative correlations, in ten out of twelve scales of the QOL-C30 (in “Emotional, Cognitive, Social functioning”). “Existential” questions had positive associations with six out the 12 scales of the EORTC-QOL-C30 [“Global health status/Quality of life” (r = 0.27, p <0.01), “Physical functioning” (r = 0.24, p <0.05), “Social functioning” (r=0.20, p<0.05), “Emotional functioning” (r = 0.50, p <0.01), “Cognitive functioning” (r = 0.36, p <0.01)], and a negative correlation with “Financial difficulties” (r = -0.26, p <0.01).
Given that the items of the “Existential” scale in the SWB32 encompass positive statements (“I have felt able to deal, at peace, my life fulfilling” etc) positive associations with the above aspects of quality of life are reasonable. Accordingly, they associate negatively with the question “Financial difficulties) (-0.26, p<0.01) (Table 6). Furthermore, in 16 studies that examined the Meaning/Peace factor (which could be thought to correspond broadly to the “Existential” scale of the SWB32) of various spiritual well-being tools, positive associations with overall QOL were reported (ranges from 0.49 to 0.70) and for physical (ranges from 0.25 to 0.28) and mental health (ranges from 0.55 to 0.73) and remained significant after controlling for demographic and clinical variables(32). Remarkably, the score of the scale “Relationship with someone or something bigger” only had positive correlations with the scales “Emotional functioning” (r = 0.35, p <0.01), “Cognitive functioning” (r=0.25, p<0.01) and a negative association with the scale “Role functioning” (r=-0.23, p<0.05) whereas “Relationship with God” did not have any statistically significant correlations with any of the scales of the QLQ-C30.
Interestingly, in our study the “Global Health Status/Quality of Life” was not correlated with SWB total score probably due to the small sample size that did not allow for extensive calculations. Whereas, in the study by Chen (2021), with 705 participants, a positive association was observed between the “Global Health Status/Quality of Life” and the SWB total score (0.468, P<0.01). Even in the study by Rhode (2019), where another measure for quality of life was used (the EORTC-QLQ-C15-PAL)(29), a positive association (0.276, p<0.01) was observed between “Global Quality of Life” in the QOL-C15-PAL and SWB global score in the SWB32(28). This would be consistent with early studies supporting that the two dimensions are related(8)(10,33)(34) both at the scale and factor level(32). The Global SWB score in our study was associated with the scales “Emotional functioning” and “Cognitive functioning” of the EORTC-QOL-C30 (0.42 and 0.40 respectively, p<0.01). Similar associations were observed by Chen (2021) (0.158, 0.339, p<0.01) pointing to the potential contribution of emotional and cognitive aspects of quality of life in the experience of spiritual well-being(27).
Strengths and limitations
The strength of the current study is its selection of measures for spiritual well-being and quality of life developed by the same organization (EORTC). It is hoped that the comparisons between the two might lead to more meaningful conclusions for the care of patients with cancer receiving palliative care. Its limitation is its small sample which only depicts trends in the responses and cannot test statistically significant comparisons or perform multivariate analysis between independent and dependent variables. Also, the cross-sectional design of this study cannot test causal associations between the variables. However, this pilot study is part of a larger validation study of the EORTC-SW32 in Greek which has been extended due to restrictions imposed by the pandemic. Hopefully, upon its completion, more comparisons will be applicable between the spiritual well-being and quality of life of patients before and after the pandemic.