The Multiple Mediating Effects of Perceived Social Support and Spiritual Well-being on the Relationship Between Spiritual Needs and Quality of Life Among Patients With Advanced Cancer

Aims: The purpose of this study was to test the associations between spiritual needs, perceived social support, spiritual well-being, and quality of life (QoL) and examine the multiple mediating effects of perceived social support and spiritual well-being on the relationship between spiritual needs and QoL among patients with advanced cancer. Methods: Spiritual needs, perceived social support, spiritual well-being and QoL were assessed using self-report questionnaires among 286 cancer patients in a tertiary oncology hospital. The mediation model was analysed using the SPSS PROCESS procedure, and indirect effects were evaluated with bootstrapping. Results: QoL was positively correlated with spiritual needs (r=0.315, p<0.01), perceived social support (r=0.451, p<0.01) and spiritual well-being (r=0.636, p<0.01). The relationship between spiritual needs and QoL was mediated by perceived social support (indirect effect: 0.063, condence interval (CI) (0.018, 0.118)) and spiritual well-being (indirect effect: 0.068, CI (0.001, 0.155)) and serially mediated by spiritual needs and QoL (indirect effect: 0.072, CI (0.041, 0.113)). Conclusions: The results emphasize the importance of spiritual well-being and social support for cancer patients, especially those with more spiritual needs. They suggest that healthcare providers should develop strategies to enhance perceived social support and spiritual well-being when caring for cancer patients to improve patients’ QoL.


Introduction
A progressive cancer diagnosis and the subsequent treatments such as surgery, chemotherapy, and radiation therapy treatment often create a crisis for patients [1][2][3][4], as they are confronted with deteriorating physical conditions, impaired functional ability, emotional anguish, psychological distress, and the threat of death [1-4, 5, 6]. All these adverse effects lead to a serious decline in the quality of life (QoL) of patients, which is a serious burden for individuals, families, and society [7]. As cancer generates increasing attention worldwide, effective interventions to help patients maintain good QoL become very necessary. QoL is a multidimensional concept, and measures of QoL usually include well-being, which re ects a person's positive or negative perceptions of physical, functional, emotional, psychological, social, and spiritual well-being [8][9][10]. Particularly for cancer patients, QoL is commonly considered a health indicator that assists in evaluating the impacts of diseases and the effects of treatments on an individual's well-being [8,9]. Whereas many cancer patients suffer from various stressors that could impair their QoL, meeting patients' spiritual needs has been found to be signi cantly associated with self-perceived good health [11,12].
Spiritual needs are common in cancer patients [13] and have been demonstrated to be correlated with cancer patients' QoL [14,15]. Unmet spiritual needs increase the physical and psychological symptoms of patients and reduce the effect of treatment and rehabilitation, leading to adverse prognoses such as depressive symptoms [15]. In addition, failure to meet spiritual needs is associated with impaired physical, emotional, psychological, social, and spiritual well-being in cancer patients [14]. A literature review suggested that the spiritual needs of cancer patients increase as a disease progresses [16] and that most patients report less spiritual care provided by health care providers than desired or even an unavailability of spiritual care [14,15,17]. Therefore, providing spiritual care to meet spiritual needs in this population is crucial. To meet spiritual needs and improve QoL, it is important to identify the mechanism of the relationship between these two variables and the variables that can be improved in cancer patients.
Cognitive appraisal theory (CAT), developed by Lazarus and Folkman [18][19][20][21], provides a framework for understanding and interpreting the role of individual cognitive behaviours in the relationship between stress and health outcomes. CAT underscores the importance of cognitive appraisal in the process of stress response and suggests that the process of action, that is, the role of cognition in the individual's stress response, nally determines the process of the stress response through many intermediary factors [18,20]. Folkman et al.[18,19] noted that in a certain situation, the result of stress events is the decision based on the individual's cognitive appraisal process and coping process. According to the model, people generate cognitive appraisals based on their experiences of illness and treatment and the special needs during the disease period that they respond to, including factors such as perceived social support from family members, friends, and important others; social role or family role changes; and spirituality. Numerous studies have demonstrated the positive effects of cognitive behavioural therapy on improving the QoL of cancer patients [22][23][24]. As a cognitive appraisal factor, perceived social support directly in uences health outcomes (e.g., depression symptoms, fatigue, sleep behaviour, QoL) [25][26][27][28][29], but it may also affect patients' spiritual well-being [30]. In the present study, spiritual needs were operationalized as a stress response of individuals threatened by cancer and QoL was operationalized as a health outcome to test the multiple mediating role of perceived social support and spiritual well-being in the relationship between spiritual needs and QoL. Figure 1 shows the proposed mediation model.
Cognitive appraisal is fundamental to CAT[18,19], which proposes that "stressful events are personenvironment transactions that are appraised by the person as relevant to well-being" [19]. The outcome of a stress event depends to a certain extent on the individual's cognitive appraisal factors because the individual will use the appraisal as an avoidance mechanism or as a motivation to engage in healthy behaviour. Perceived social support has three components: support from family, friends, and important others [31,32]. Studies have shown that perceived social support plays an important role in illness outcomes [33,34] (e.g., QoL) among cancer patients. For example, patients who perceived more support from family, friends, and important others reported higher levels of QoL [35]. Perceived social support may be one pathway through which spiritual needs affect QoL. Thus, patients' perceived social support should be addressed as a modi able component in the development of interventions for QoL among cancer patients.
Spiritual well-being is a complex, subjective, individualized, and latent construct [36,37]. Although spiritual well-being lacks a uni ed de nition across cultures, most people acknowledge that spiritual well-being is often assessed to evaluate one's spiritual experiences and outcomes [38]. Spiritual well-being can be conceptually de ned in the context of disease-related health as a patient's perceptions, experiences, and feelings of well-being and health resulting from seeking intrinsic congruence; connections to nature, the sacred, and other individuals; presence in the moment; and meaning and purpose in life [39][40][41], as well as gaining the self-con dence to overcome existential challenges [42] and achieve the life goals of life that he or she truly wants to achieve. This operational de nition has the potential to allow oncology nurses and doctors, psychologists, and healthcare managers to promote cancer patients' spiritual well-being with cognitive or/and behavioural changes via effective spiritual care interventions or educational programmes [43]. Peterman et al. [44] described two components of spiritual well-being in illness: (1) a sense of meaning and peace and (2) faith. An increasing number of studies have indicated that spiritual well-being is a signi cant predictor or indicator of one's perceived QoL [45][46][47]. Studies have reported associations between spiritual well-being and QoL among various cancer patient populations, such as breast, lung, or prostate cancer patients [38]. Empirical and theoretical work has also supported the potential of individuals to restore, maintain, and enhance their QoL after a diagnosis with life-threatening cancer, as well as the notion that spiritual well-being is one of the determinants of patient QoL [45][46][47].
The literature has shown a relationship between the degree of satisfaction of spiritual needs and QoL, and studies have found that spiritual well-being may function as a coping mechanism in addressing stress responses to illness. The links of perceived social support and spiritual well-being with QoL have been tested in the cancer patient population. According to CAT, perceived social support and spiritual wellbeing may be intermediate variables and may sequentially mediate the relationship between spiritual needs and QoL. However, literature on the mechanisms by which perceived social support and spiritual well-being play a serial mediating role in the relationship between spiritual needs and QoL in cancer patients is absent. To improve QoL among patients with cancer, especially among patients with greater spiritual needs, it is necessary to understand the modi able elements that may mediate the relations for health carers, the patients themselves and their family caregivers. Therefore, this study proposes the following hypothesis: (a) perceived social support mediates the relationship between spiritual needs and QoL; (b) spiritual well-being mediates the relationship between spiritual needs and QoL; (c) perceived social support and spiritual well-being sequentially mediate the relationship between spiritual needs and QoL in patients with cancer. If these hypotheses are con rmed, they can potentially be used to meet spiritual needs and improve QoL among cancer patients.

Design and sample
This study was a cross-sectional study. Participants were recruited from July 2020 to October 2019 from an oncology university hospital in China using a convenience sampling method and were asked to provide written informed consent. The present study was reviewed and approved by the Institutional Review Board of the Henan Province Medical Science and Technology Research Plan (Joint Construction) Project (#LHGJ20190654). Participants completed the questionnaires, and nurses collected them on the spot. The inclusion criteria were as follows: (a) age ≥18 years old, (b) a con rmed diagnosis of cancer by a physician, and (c) stage II-IV cancer according to the American Joint Committee on Cancer (AJCC) eighth edition cancer staging manual. The exclusion criteria were as follows: patients who were extremely frail, had a mental illness, had visual or hearing impairments, or who were illiterate.
We found a moderate f 2 effect size of 0.15, an α of 0.05 and a power of 0.90 (using G*Power Version 3.1, written by Franz Faul). We calculated a patient sample size of 206 and assumed a dropout rate of 20%; thus, two hundred eighty-six participants were su cient for the study.

Measures
Demographic and clinical characteristics. The demographic characteristics included gender, age, marital status, working status, educational level, and monthly income. The clinical characteristics included diagnosis, chemotherapy/radiotherapy, somatic pain score, and cancer duration, as obtained from patient self-reports or medical records.
Spiritual needs. The original 26-item Korean version of the Spiritual Needs Scale (SNS) developed by Yong[48] measures the spiritual needs of patients with cancer. It consists of ve factors with Cronbach's alpha values ranging from 0.74 to 0.91. Spiritual needs were measured in this study using the 23-item Chinese version of the SNS which was translated, cross-culturally adapted, and evaluated by Cheng [49]. It has ve different components with good psychometric properties: relationship with God (divine, sacred; Cronbach's alpha=0.65); meaning and purpose (Cronbach's alpha=0.81); acceptance of dying (Cronbach's alpha=0.79); hope and peace (Cronbach's alpha=0.74); and love and connection (Cronbach's alpha=0.79).
The Chinese version of the SNS uses a ve-point Likert response scale ranging from one (not at all) to ve (a great deal). Higher scores on the scale indicate more spiritual needs.
Perceived social support. The 12-item self-report Multidimensional Scale of Perceived Social Support (MSPSS) developed by Zimet et al. [50][51][52] assesses persons' perceived social support from family, friends, and signi cant others. The Chinese version of the Scale of Perceived Social Support (SPSS) includes two subscales (perceived social support from within the family and outside the family) and was translated and evaluated by Huang et al [53]. experienced cancer for less than 12 months. Nearly half of the participants (47.9%) had more than four points of somatic pain measured using a pain thermometer. In addition, 61.5% of the patients had less than a high school education, 66.8% were on duty, and 42.3% earned less than 1000 per month. Table 1 shows more details of the sample characteristics.
3.2 Mean scores and correlation coe cients of the study variables As shown in Table 2, the mean scores for spiritual needs, perceived social support, spiritual well-being,

Multivariable linear regression analysis of quality of life
The results of this study revealed that all variance tolerances were higher than 0.5, and all variance in ation factors were lower than 2, suggesting that there was no multicollinearity. The number of children, pain rating, spiritual needs, perceived social support and spiritual well-being were associated with QoL, accounting for 45.7% of the variance in QoL (Table 3).

Multiple mediating effects of perceived social support and spiritual well-being
The indirect effects of spiritual needs on QoL via both perceived social support and spiritual well-being were examined using serial mediation mode 6 with a 95% CI based on 5000 bootstrapping samples [59]. All the mediated indirect effects of each speci c path are shown in Figure 2 and

Discussion
To date, the interplay between spiritual needs, perceived social support, spiritual well-being, and QoL has not been evaluated via a mediation model. Several studies have found an association between spiritual needs and QoL; however, few studies have explored the possible mechanism for this relationship. The results of this study revealed that cancer patients with more spiritual needs perceived more social support and tended to use spiritual well-being as a coping strategy, which led to higher levels of QoL. This nding is consistent with CAT[18]. Spiritual needs had no signi cant direct effect on QoL. However, they had an indirect effect on QoL serially mediated by perceived social support and spiritual well-being.
The average QoL score (total scale score range: 0-to 108 points) of the cancer patients was in the low-tomoderate level (M=69.86 (SD=16.65)), which was congruent with previous studies [59,60] with cancer patients that employed the Quality of Life Questionnaire-Core 30 (QLQ -C30) in China. However, cancer patients showed higher levels of spiritual needs, with an average score of 82.59 (SD= 19.10) (total scale scores range: 23 to 115), which was congruent with a previous study [13]  This current study revealed that spiritual well-being mediated the relationship between spiritual needs and QoL. Thus, hypothesis 2 was supported. Additionally, spiritual well-being may be a mechanism of the relationship of disease responses and coping behaviour with healthy outcomes, consistent with Scheffold [42] and Li's[64] research. Studies have found that people turn to spirituality and desire spiritual well-being in times of crisis [13,38]. Individuals with cancer who used spiritual well-being to cope with their illness had higher levels of QoL, which was supported by previous studies [48]. Maintaining cancer treatment and living with disease was challenging, so patients who adopted spiritual coping strategies were likely to mitigate the negative emotions of their illness responses and experience positive effects of disease. Patients with spiritual coping strategies had more feelings hope, peace, meaning, and con dence, which contributed to higher levels of QoL [48]. Thus, health care providers should assess patients' spiritual well-being to promote bene cial coping strategies and thus improve QoL in patients with cancer.
We discovered a serial mediating effect of perceived social support and spiritual well-being on the relationship between spiritual needs and QoL, which supported hypothesis 3. That is, the indirect effect of spiritual needs on QoL through perceived social support and spiritual well-being was signi cant even though no signi cant direct effect of spiritual needs on QoL was observed. According to CAT, individuals created cognitive appraisals based on their experiences and responses to illness, which helped them seek and appreciate the importance of support from inside and outside the family and guided them to use spiritual well-being to manage their diseases. Previous studies [28][29][30] reported direct effects of perceived social support on psychological well-being and indirect effects mediated by coping. When cancer patients feel that their lives are threatened, they may have strong desires for social support [65]. In addition, perceived social support was shaped directly in response to patients' illnesses and thus in uenced the use of spiritual well-being to address the condition. Spiritual well-being as an adaptive coping strategy tended to encourage individuals to meet their spiritual needs and form positive cognitive appraisals about their diseases, resulting in their ability to achieve peace, meaning, life goals, self-transcendence, and rehabilitation from cancer. Therefore, healthcare professionals should evaluate cancer patients' spiritual needs, improve their perceived social support and help them develop appropriate spiritual wellbeing to improve and maintain QoL.

Implications for clinical practice
Although it is widely acknowledged that people have more spiritual needs in times of threatening illness, interest in exploring the spiritual needs and spiritual well-being of cancer patients and corresponding spiritual care is just beginning to grow in China. The study ndings have key implications for meeting patients' spiritual needs and improving their QoL. Spiritual needs were found to be a common demand among cancer patients that could not be neglected [13]. Consequently, hospitals should create conditions that allow and encourage patients' families, relatives, colleagues, friends to visit and accompany them.
Healthcare providers should assess patients' spiritual needs when evaluating their health statuses and organize various forms of health education activities that promote their spiritual well-being to improve their perceived social support (e.g., patient group activities, patient-caregiver dyadic intervention programmes, or various social/cultural activities) and spiritual well-being (e.g., spiritual care, expression of emotions, life review, life and death education), thereby improving their QoL.
Rehabilitation therapists, community nurses, physicians and staff, together with the family caregivers of cancer patients, should provide more social support ( e.g., information provision and communication[66], structured psycho-oncological care model from healthcare staff[67], and encourage individuals to participate in various social activities tailored to patients' competencies and interests. Staff should take social support and spiritual well-being into account when developing health plans for cancer patients. Levels of perceived social support and spiritual well-being should be indicators for hospital quality evaluation.

Strengths and limitations
This is the rst study to simultaneously investigate spiritual needs, perceived social support, spiritual well-being, and QoL among cancer patients. It is also provides the rst evidence of the mechanism by which perceived social support and spiritual well-being exert their mediating role in the relationship between spiritual needs and QoL. This study helped explain the impact of spiritual needs on cancer patients' QoL.
Despite the above strength, some limitations must be acknowledged. First, the sample of this study was from a large oncology hospital in China recruited using a convenient sampling method. This group may not be su cient to represent all cancer patients in China. Second, spiritual needs, spiritual well-being, and QoL are situational factors that may vary during the illness trajectory. Thus, future studies should conduct longitudinal studies. Third, this survey relied on self-report methods, which may have led to bias. Moreover, the FACT-G is a multidimensional scale that includes physical, emotion, family/social, and functional domains, and the Chinese version of the MSPSS consists of two subscales, as do the SNS and FACIT-Sp. However, this study used the total scale scores of the various scales for the evaluations and did not separately assess the relationships between the various dimensions. A future study may investigate the relationship between the various components.

Conclusion
These ndings revealed the theoretical relationships between spiritual needs, perceived social support, spiritual well-being and health outcomes and expanded CAT to the cancer research area. Spiritual needs, together with perceived social support and spiritual well-being, had an indirect effect on QoL. Additionally, perceived social support and spiritual well-being played a serial mediating role in the relationship between spiritual needs and QoL. Therefore, effective programmes that can improve patients' perceived social support and/or spiritual well-being may be bene cial in helping cancer patients, especially those who have more spiritual needs, improve their QoL. Future research to develop culturally based spiritual care interventions for cancer patients is suggested. Availability of data and material

Abbreviations
The datasets generated and/or analyzed in the current study are available upon request from the coauthor Yanli Hu in the format of SPSS les.

Competing interests
The authors declare that they have no competing interests.

Funding
This work was supported by grants from the Henan Province Medical Science and Technology Research Plan (Joint Construction) Project (#LHGJ20190654) . The funding agencies did not have any role in the design of the study, the collection, analysis, and interpretation of the data, or the writing of the manuscript.

Authors' contributions
Wen and Jiao wrote the article, Wang made the gure and table of the article, Hu wrote and revised the article.
WQY JMR,WHL and HYL made substantial contributions to the conception, design, acquisition of the data, or analysis and interpretation of the data; WQY and JMR were involved in drafting or critically revising the manuscript for important intellectual content; WQY, JMR,WHL and HYL gave nal approval of the version to be published. Each author participated su ciently in the work to take public responsibility for the appropriate portions of the content; WQY and HYL agree to be accountable for all aspects of the work by ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ind3: spiritual needs → spiritual well-being→ quality of life SE: standard error; LLCI: lower limit con dence interval; ULCL: upper limit con dence limit interval.