Introduction
Childhood cancer is one of the most difficult challenges that an individual, particularly a mother, can experience during a lifetime (Fotokian, Reference Fotokian2004). Most mothers of children with cancer say this experience is the worst experience of their lives, and these individuals need specific support and care to cope with this difficult situation (Fletcher, Reference Fletcher2011; Samie Sibani, Anushe, & Alhani, Reference Samie Sibani, Anushe and Alhani2012). Nurses are familiar members of the caregiver team and should seek out mothers dealing with these difficult situations (Ahmadifaraz et al., Reference Ahmadifaraz, Reisi-Dehkordi and Mosavizadeh2015; Alligood & Tomey, Reference Alligood and Tomey2010). Most studies conducted on the families of children with cancer have focused on the family's response, particularly that of a mother (Samie Sibani et al., Reference Samie Sibani, Anushe and Alhani2012). Results indicate that empowering the caregivers, particularly a mother, can lead to a better prognosis and superior treatment outcomes (Fotokian, Reference Fotokian2004). Because the caregivers of patients are considered “silent patients,” different methods are necessary to help them (Balboni et al., Reference Balboni, Vanderwerker and Block2007).
One such method is spirituality. Spirituality increases self-esteem, lending a sense of purpose and meaning to life (Rezaie et al., Reference Rezaie, Seyed Fatemi and Hoseyni2010). The power of religious beliefs as a kind of spiritual care can have an important role in the health and well-being of individuals (Akbarri et al., Reference Akbarri, Motlagh and Sheibani2009). Spiritual interventions can enhance the quality of life of patients and their families by reducing the effects of cancer on the mind and soul (Yesilbakan, Ozkutuk, & Ardahan, Reference Yesilbakan, Ozkutuk and Ardahan2010). Religious beliefs and practices create a positive mental state in patients, helping them feel better and enabling them to get through any circumstances (Hoseyni Vajari, Reference Hoseyni Vajari2012; Woodgate, Reference Woodgate2003). In religious societies, spiritual nursing interventions are received better, and families expect their spiritual needs to be addressed like their other needs (Javedanpour et al., Reference Javedanpour, Sadat Hosseini and Cheraghi2017; sadat Hoseini, Alhani, & Khosro-panah, Reference sadat Hoseini, Alhani and Khosro-panah2011).
Among the various spiritual interventions, prayer is the main method used to communicate with one's Creator or God (Shariati, Reference Shariati1970; Tatsumura et al., Reference Tatsumura, Maskarinec and Shumay2003). Through prayer, people develop a relationship with the source of life. Some consider prayer a core human instinct that is not limited to a specific time, location, or religion (Rezaei et al., Reference Rezaei, Seyed Fatemi and Givari2008; Watson et al., Reference Watson, Craig and Robinson2004; Young & Koopsen, Reference Young and Koopsen2005). Patients develop a close relationship with God through prayer. They ask others to pray for them and gain a sense of strength as a result. Many studies have shown spiritual care, such as prayer, reduces anxiety and creates positive feelings in patients and families (Ahmadifaraz et al., Reference Ahmadifaraz, Reisi-Dehkordi and Mosavizadeh2015; Dossey, Keegan, & Guzzetta, Reference Dossey, Keegan and Guzzetta2003; Edwards et al., Reference Edwards, Pang and Shiu2010; Lin & Bauer-Wu, Reference Lin and Bauer-Wu2003; Walton & Sullivan, Reference Walton and Sullivan2004). For example, Meireles et al. (Reference Meireles, Maia and Linhares2015) showed that spirituality helps sick children and their families acquire positive feelings, even in the middle of the cancer experience.
Writing is a scientific approach for expressing negative feelings, emotions, and stress. Writing can be effective in reducing anxiety and stress (Esterling et al., Reference Esterling, L'Abate and Murray1999; Meireles et al., Reference Meireles, Maia and Linhares2015). In the process of writing, the writer demonstrates increased ability to control his or her emotions and is better able to cope with aversive experiences (Burton & King, Reference Burton and King2008; Ramezani et al., Reference Ramezani, Abdul Javad and Moussaoui2010; Saraie et al., Reference Saraie, Talebi and Pezeshki2010). Writing strengthens the immune and autonomic nervous systems and promotes physical and mental health. Some studies have shown that writing about feelings or anything else reduces anxiety (Burton & King, Reference Burton and King2008; Kadivar et al., Reference Kadivar, Seyedfatemi and Akbari2015). Nurses seek to reduce the anxiety of patients and their families; however, there are few nonpharmacological interventions that have been empirically validated (Ahmadifaraz et al., Reference Ahmadifaraz, Reisi-Dehkordi and Mosavizadeh2015; Burton & King, Reference Burton and King2008; Kadivar et al., Reference Kadivar, Seyedfatemi and Akbari2015). Hence, as previous studies have shown, mothers of children with cancer require spiritual cares, and it is the responsibility of nurses to provide appropriate care to reduce their anxiety (Javedanpour et al., Reference Javedanpour, Sadat Hosseini and Cheraghi2017; sadat Hoseini et al., Reference sadat Hoseini, Alhani and Khosro-panah2011). Given that Iran has a predominantly religious culture and, as such, spiritual care interventions such as prayers are commonplace and consistent with Iranian culture (LotfiKashani, Mofid, & SarafrazMehr, Reference LotfiKashani, Mofid and SarafrazMehr2013; Sadat-Hoseini & Khosropanah, Reference Sadat-Hoseini and Khosropanah2017), the present study was designed in accordance with the dominant culture of these mothers to meet their spiritual needs and reduce their anxiety.
This study combined prayer (as a type of spiritual care) and writing (as a type of psychological care) to measure the effect of written prayer technique on the anxiety of mothers of children with cancer.
Methods
This experimental study was a clinical trial conducted on 90 mothers of children with cancer admitted to the Medical Centre of Tehran. Data was collected from spring (April 1) to summer (September 22) 2017.
Sampling
Sample size was calculated as a means comparison based on the study of Dehghani et al. (Reference Dehghani, Rahimabadi and Pourmovahed2012). Sample size was determined 40.6 (41 individuals) at 95% confidence interval and 80% power, considering at least 7 points difference in mean anxiety (based on Spielberger's questionnaire), which was increased to 45 individuals per group (a total of 90 individuals), taking into account withdrawal of 10% (Appendix 1).
We calculated the number of samples as 41 mothers for each group. Convenience sampling was used, and the samples were randomly divided into two groups: control (n = 46) and intervention (n = 47) (Fig. 1). The inclusion criteria were: mothers of hospitalized children with cancer who were able to read and write and had no anxiety disorders. Children were hospitalized during the study period and their mothers were constantly present in the ward. The exclusion criteria were : intervention performed for less than three days, child discharged before three days, or mother physically or mentally unable to continue the study. Four of the participants withdrew from the study and were replaced. Two participants withdrew because of a lack of patience and two others stated that writing prayers was too upsetting. Data collection was performed using the Spielberger's anxiety scale and a demographic questionnaire. The anxiety of mothers was measured before the intervention, immediately after the three-day intervention, and five weeks after the intervention. At the five-week follow-up, the questionnaire was completed over the phone.
Fig. 1. Consolidated Standards Of Reporting Trials table
The demographic questionnaire sampled information including age, sex, birth order, mother's education level, mother's age, type of illness, and number of hospitalizations. The Spielberger's anxiety scale included self-report Likert-like scales for measuring anxiety. Both questionnaires were previously proven to be reliable and valid. The demographic questionnaire had adequate face and content validity and test-retest reliability. The Spielberger's anxiety scale demonstrated reliability with a Cronbach's alpha of 0.87.
Intervention
A writing technique was used in both the groups for 20 minutes per day over three consecutive days. Writing interventions took place in a silent and calm setting without distractions. The researcher briefed mothers in the intervention group on their freedom to participate and that they should feel free to write down their prayer when they felt closer to God, such as during the time of “azan” (Muslims’ call for prayer), or any time they wished. The participants in the intervention group were asked to spend 20 minutes praying to God over three consecutive days and to ask Him whatever they wanted in writing, with the intention that they would write down their sincere desires and wishes without any worry and stress about communicating these desires and wishes to God. They were told not to worry about grammar or spelling errors while writing their prayer. Similar advice was given to the control group, which spent 20 minutes each day anytime they wished writing their normal daily schedules such as feeding their children or changing their children's clothes without worrying about grammar or spelling errors.
All written prayers were collected by the researcher. Manuscripts were collected only to ensure the accuracy of the intervention; no qualitative analysis was performed on them. All stationery was given to the mothers by the researcher.
Statistical analysis
Data were analyzed by independent t, paired t, Mann-Whitney U, and chi-square tests; repeated measures analysis was undertaken using SPSS software, version 16. The manuscripts presented in the Results section contain experiences of mothers who wished to express them; no content analysis was performed on these manuscripts.
Ethical considerations
The researcher obtained permission from the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.REC.139402193). This ethical code was carried out in accordance with principles embodied in the Declaration of Helsinki (Code of Ethics of the World Medical Association). The study objectives were explained to the mothers and they were told they could participate in this study if they wished to do so. They were assured that participating in the study would not affect their child's treatment or harm their child in any way. They were assured of anonymity and confidentiality for all the information provided, and each participant provided written informed consent for participation. The study objectives concerning reducing anxiety of mothers were explained to all participating mothers according to ethical guidelines of Tehran University of Medical Sciences, and, with regard to the type of intervention, they were asked to write an essay based on researcher's explanations. Thus, mothers were fully informed of the study objectives when giving their consent to take part in the study, but had no knowledge about their groups. During sampling, all eligible mothers consented to take part in the study. Statistical analysis of data was performed by a person who was blinded to the classification. This study was registered in the Iranian Clinical Trials Database (IRCT201501205163N3).
Results
Table 1 shows the demographic variables of mothers and their children. No statistically significant differences were observed between the two groups regarding demographic variables including child's age, mother's age, duration of illness and number of hospitalizations.
Table 1. Demographic characteristics of mothers and their children
*All demographic variables using the Kolmogorov-Smirnov z test were evaluated for the normal distribution curve. The t test was used for variables with normal curve (p > 0.05); nonparametric Mann-Whitney tests were used in cases in which the curve was not normal.
After the three-day intervention, the mean level of anxiety of mothers was 34.9 ± 9.9 in the intervention group and 47.9 ± 16.2 in the control group. The anxiety level reduced by −44.7 in the intervention group compared with the prestudy baseline while that in the control group reduced by −17.7.
The anxiety level of mothers at 5 weeks after the intervention was 34.7 ± 9.6 in the intervention group and 48.5 ± 16.4 in the control group. The reduction in the intervention group was −44.3 and that in the control group was −16.7. The results showed that the mean anxiety level in the intervention group reduced sharply, and, once reduced, it remained low until at least five weeks after the intervention. In contrast, the mean anxiety level in the control group started to increase beginning at day 3 until the fifth week (Table 2). Pairwise comparisons of the anxiety before the intervention, after three days of intervention, and five weeks after the intervention showed in Table 3.
Table 2. Comparison of the M and SD level of anxiety before the intervention, after three days of intervention, and five weeks after the intervention
Table 3. Pairwise comparisons of the mean difference in anxiety before the intervention, after three days of intervention, and five weeks after the intervention
In this study, the researcher asked the mothers to express their views on the effects of written prayer and their statements are presented as follows.
Mom B: “It feels so alone. I am surrounded by people but I am still alone. I keep saying to myself that, you people are angels sent by God to help me. Written prayer helped me a lot and I say to myself, God cares about me.”
Mom L: “After writing a letter to God, I felt so comfortable and happy. I suddenly felt a heavy weight on my shoulder has been lifted. My life is very difficult. I love my life, and I like to write my life events and problems to you.”
A's mother: “I felt really good after writing my prayer. I returned to normal life and I feel I can get through this period. It will end. When I was writing, I had a feeling like; God wants to read my letter. I was writing without thinking about anything; I was just writing. I believe it is a good method.”
Mom A: “Writing reveals the gaps in your life. It improved my spirit. I feel much better now and I feel, I have someone to talk to. Someone that I can tell him about my pain and someone who wants to help me. I am glad that I learned about this method.”
Mom P: “God is a patient listener; he does not tell you what kind of language you are using, and what are you talking about? He listens to me. When I started writing to him, a lot of things became clear for me. I felt the presence of God next to me in difficult circumstances.”
These statements reflect the effectiveness of this intervention.
Discussion
The results of this study showed that the written prayer technique had a positive effect on the anxiety of mothers of children with cancer, reducing their anxiety levels for up to five weeks after the intervention. Kadivar et al. (Reference Kadivar, Seyedfatemi and Akbari2015) conducted a study on 70 mothers of premature infants hospitalized in neonatal intensive care units. Their results showed that writing could reduce the mothers’ stress levels (Kadivar et al., Reference Kadivar, Seyedfatemi and Akbari2015). Their results showed that maternal stress levels significantly decreased, indicating the effectiveness of writing on stress levels. The results of that study were similar to those in this study. Mothers in the intervention group stated that writing made them feel lighter and that they felt better after writing. LotfiKashani et al. (Reference LotfiKashani, Mofid and SarafrazMehr2013) conducted a study focusing 12 mothers of children with cancer. After conducting six sessions of spiritual intervention, which included the concepts of reliance on God, prayer, redemption, being thankful, patience, forgiveness and its outcomes and their effects on emotion, they concluded that spiritual interventions had a positive effect on the mothers of children with cancer (LotfiKashani et al., Reference LotfiKashani, Mofid and SarafrazMehr2013). Spiritual interventions can provide a social support network for patients with cancer and their caregivers who are experiencing severe distress. It appears that spiritual and religious obligations protect people against uncontrollable life events such as death and serious diseases that can lead to severe distress and anxiety (Salarifar et al., Reference Salarifar, Shojaie and Mousavi Asl2008). Monazamitabar et al. (Reference Monazamitabar, Ahmadi Tahoor Soltani and Bagherian Sararoodi2015) showed that writing significantly reduced depression, anxiety, and stress in veterans (Monazamitabar et al., Reference Monazamitabar, Ahmadi Tahoor Soltani and Bagherian Sararoodi2015). The results of one study explored the quality of life in patients with cancer (Tang, Reference Tang2006). In this study, caregivers revealed that an increase in religious and spiritual beliefs and practices effectively reduced distress in the caregivers of patients with cancer. In their study, Kim, Spillers, and Hall (Reference Kim, Spillers and Hall2012) showed that religious beliefs reduced psychological distress in mothers of children with cancer by reducing the sense of guilt, anxiety, frustration, and hopelessness while increasing the sense of internal peace and hope (Kim et al., Reference Kim, Spillers and Hall2012).
The spiritual intervention study by Hayley Harriet (Reference Hayley Harriet2008) showed that religious and spiritual commitments protected people against uncontrollable life events such as death and serious diseases that can lead to severe distress, anxiety, and depression (Hayley Harriet, Reference Hayley Harriet2008). According to another study, spiritual interventions can provide a social support network for patients with cancer and their caregivers who are experiencing severe distress (Weaver & Flannelly, Reference Weaver and Flannelly2004).
Another study conducted by Kloss and Lisman (Reference Kloss and Lisman2002) concluded that expressing emotions through writing is an effective strategy for reducing anxiety. In this study, writing prayer and connecting with the Creator decreased the mothers’ anxiety levels. All of these findings were consistent with the results of this study.
In the present study, mothers in the intervention group were satisfied with the written prayer technique and subsequently stated that they would certainly recommend this method to others. Because of cultural compatibility and consistency with mothers' needs (Javedanpour et al., Reference Javedanpour, Sadat Hosseini and Cheraghi2017), the intervention appears to have satisfied their psychological as well as spiritual needs.
The results of this study showed that 20 minutes of written prayer once per day over three consecutive days had a positive effect on reducing the anxiety of mothers of children with cancer. This technique reduced the average maternal anxiety level. The cultural compatibility of the intervention rendered it acceptable and satisfying for mothers.
According to the results obtained, care providers and nurses working in pediatric oncology department can recommend writing as a stress-reducing technique to mothers with sick children. The results are also useful for nurses and care providers in religious societies inclined to hold religious ceremonies, especially prayers, so that by recommending prayer writing to mothers, they can help further reduce their stress about writing alone. Hence, nurses and care providers are recommended to use prayer writing by mothers as a cost-efficient, simple, and effective technique for reducing stress of mother with sick children.
Acknowledgments
The authors thank all the mothers who participated in this study and all those who assisted in study completion. This article serves as the dissertation for the master of pediatric nursing at Tehran University of Medical Sciences, which was the supporting institution of this research (registration number, 95-02-189-31582).
