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 finding is consistent with CAT. Spiritual needs had no significant 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-to-moderate 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 with cancer patients that employed the 26-item English version of the SNS. Höcker’s survey showed that more than 94% of patients reported at least one spiritual need, and no significant associations for medical characteristics were observed. The results emphasized the relevance of QoL and spiritual needs for cancer patients. The call for spiritual care programmes to meet spiritual needs and enhance QoL in cancer patients is strengthened.
This study demonstrated that perceived social support mediated the relationship between spiritual needs and QoL in cancer patients. Experiences of a life-threatening illness led to the patients’ stress responses and triggered their internal needs and cognitive appraisals, which promoted their emotional well-being and healthy behaviour and, eventually, positive illness outcomes[18, 33, 34]. Due to the risk of cancer recurrence, the pain of treatment, and the natural threat to patients’ survival, patients experienced increased spiritual needs and social support. Insufficient patient social support leads to poor perceived social support, serious psychological distress and decreased QoL[25, 28, 29]. Perceived social support has also been viewed as a significant factor in coping with physical symptoms, contributing to spiritual well-being, decreasing loneliness and mental health problems. Thus, interventions should focus on the role of social support in improving QoL and the development of strategies to promote support from family and non-family members for patients with cancer.
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 and Li's 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. 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 confidence, which contributed to higher levels of QoL. Thus, health care providers should assess patients’ spiritual well-being to promote beneficial 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 significant even though no significant 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[28-30] 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. In addition, perceived social support was shaped directly in response to patients’ illnesses and thus influenced 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 well-being to improve and maintain QoL.
4.1 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 findings 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. 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, structured psycho-oncological care model from healthcare staff, 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.
4.2 Strengths and limitations
This is the first study to simultaneously investigate spiritual needs, perceived social support, spiritual well-being, and QoL among cancer patients. It is also provides the first 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 sufficient 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.