Impact of Islam-Based Caring Intervention on Spiritual Well-Being in Muslim Women with Breast Cancer Undergoing Chemotherapy

: This research emphasizes the nurse’s role in incorporating Islamic teaching through the care practices provided in order to promote spiritual well-being in Muslim women with breast cancer undergoing chemotherapy. In addition, religion and spirituality have been recognized as the primary resources for coping. The aim of the study, therefore, was to explore the impact of an Islam-based caring intervention on the spiritual well-being of Muslim women with cancer. Furthermore, data were collected using a questionnaire and, also, the Functional Assessment of Chronic Illness Therapy-Spiritual well-being (FACIT-Sp) on baseline (Time 1), days 3 (Time 2), 23 (Time 3), and 44 (Time 4). The results showed the signiﬁcant impact of an Islam-based caring intervention on the participants’ level of spiritual well-being. In addition, the mean scores varied between the intervention and control group over time. Based on the reﬂection, participants stipulated feeling peace of mind, closer to God, spirit for further life, and healthier.


Introduction
The most frequent origin of deaths related to cancer in women worldwide is breast cancer (DeSantis et al. 2015), and many patients are late to seek treatment. This is because hospital visitations are made at advanced stages of the disease or after a fatal metastasis condition. Furthermore, breast cancer is also regarded as the most common cause of death in women from developing countries (Aranda et al. 2006), and the incidence of advanced stages in Indonesia continues to increase, especially in urban areas, including the West Java Province (Oemiati et al. 2011).
Individuals with advanced-stage breast cancer commonly suffer spiritual distress caused by the disease, diagnosis, treatments, and their complications. Spiritual distress occurs when a person experiences severe physical and emotional pain, leading them to question their beliefs (crossroadshospice.com 2020). The treatment at this stage is stressful and requires various physical, psychological, behavioral, social, and spiritual concerns (Thasaneesuwan et al. 2018). The recent advancements in treatments have resulted in longer life for patients with cancer, although this is not always good, as a number of sufferers endure the disease chronicity with a low quality of life (Sibeoni et al. 2018). The suffering experienced from diagnosis through treatment, survival, recurrence, and dying often results in issues, including spiritual distress (Caldeira et al. 2017;Loh 2004;Martins and Caldeira 2018;Villagomeza 2005). Furthermore, the affected patients express concern about the meaning of life, death, and suffering and, also, attribute the illness to a form of punishment (Caldeira et al. 2017;Martins et al. 2019). This is sometimes accompanied with the feeling of anger, sadness, withdrawal, 6.4 weeks with a mean of 46.3 min in each. The findings confirmed the significant impact of spiritual interventions on spiritual well-being and life-meaning (Pok-Ja Oh and Kim 2014).
Furthermore, spiritual therapy based on the Islamic approach was assumed to be capable of promoting the spiritual well-being of breast cancer patients. Jafari et al. (2013) investigated affected Iranian women using a randomized, control-trial design, and the therapy consisted of six sessions, where each had a theme. This involved combining a specific spirituality domain and is terminated with a 20 to 30-min guided relaxation and meditation exercise. The program was conducted over a six-week duration, and each session is performed in two to three hours. The results showed a positive outcome, which was similar with the report by Zamaniyan et al. (2016) from a quasi-experimental project. This investigation was carried out with 12 participants, including Iranian women with breast cancer, expected to comply with group spiritual therapy. The therapy spanned 12 sessions, and each lasted for 120 min over a period of one week. Furthermore, the treatment focused on self-consciousness, communication with oneself, self-concept, the word of God, altruism, relationship with holy sites, forgiveness, death and fear, faith and trust in God, gratefulness and blessings, and a final session. The program was, therefore, concluded to have potential application in improving spiritual well-being of breast cancer patients (Zamaniyan et al. 2016). Furthermore, one of the studies was affiliated with the spiritual intervention rooted in Buddhism to significantly enhance spiritual well-being (Chimluang et al. 2017).
It is evident that there has been extensive research on spirituality and management for survivors. However, existing literature has certain limitations, attributed to sample size restrictions (Chimluang et al. 2017;Jafari et al. 2013;Zamaniyan et al. 2016). Hence, the effectiveness of the aforementioned interventions remains questionable. Evidence from existing reports encourages nurses to provide spiritual care to individuals at the advanced stage of breast cancer, although issues of spiritual health gains minimal attention from the real clinical practice of nurses. This is possibly due to the impractical nature of existing spiritual care programs, and the poor nurse knowledge in this aspect, mostly related to the culture and beliefs of patients. This current study, therefore, aims to develop a practical and feasible spiritual program, characterized by the ease of implementation in the clinical setting. Furthermore, Islamic religious activities, including prayers and 1 dhikr meditation (as part of Muslim's daily life routine) were selected and incorporated into the nurses' caring practice. Despite the compulsorily practice of these religious activities, not all Muslims gain the expected benefits, and this is due to the incorrect application without insightful awareness.
In addition, prayer and dhikr meditation are found to greatly affect spiritual well-being, when performed appropriately with 2 khushu (Imamoglu and Dilek 2016;Rosmani et al. 2015). This is referred to as the state of mind of an individual during prayers, characterized by the complete direction of minds and hearts to God (Sayeed and Prakash 2013). Furthermore, those reported to regularly offer prayer with mindfulness (khushu) tended to have better mental health, compared to others (Ijaz et al. 2017). Therefore, it is vital to develop a correct, feasible, practical, and easily practiced Islam-based caring intervention. This is necessary to enhance the attractiveness and, also, to motivate the nurses and patients towards the practice.

Study Design
This is a quasi-experimental study with pre-and post-test control groups. The research was approved by the Institutional Review Board, with document number 2017 NSt-Qn 054, on the approved date: 15 January 2018. Furthermore, before the program was implemented, informed consent was 1 Dhikr refers to divine remembrance, methodical repetitions of the divine name with prayer beads, and the repetition of devotional poems and Quranic formulas.
2 Khushu refers to performing prayers quietly, focusing one's mind only on God.
Religions 2020, 11, 361 4 of 13 asked from the participants, as well as giving them information about the research objectives, data collection procedures, duration, expected benefits, and confidentiality during and following the study. Furthermore, the participants possessed the right to withdraw from the investigation at any time, after submitting a signed consent form.

Participants and Setting
The recruitment process was performed at the outpatient Chemotherapy Unit of a Teaching Hospital, Bandung, West Java Province, Indonesia, between February and July 2018. Therefore, a total of 120 patients met the inclusion criteria of: (1) being Muslim women; (2) being aged >18 years old to ensure the ability to legally give consent; (3) having a new or recurrent diagnosis of stage III breast cancer by a physician; (4) being able to accomplish basic routine activities using the measure of Eastern Cooperative Oncology Group (ECOG), and possessing a Performance Score between 0-2; (5) having intact reasoning capacity with no documented diagnosis of mental illness by a psychiatrist; (6) having competency in speaking and understanding Bahasa Indonesia; (7) having access to a telephone; and, (8) receiving chemotherapy every 21 days at any cycle ≤ 4 cycles, encompassing the current period. Furthermore, the exclusion criteria included patients regularly on complementary alternative medicine and those without the capacity to complete the Islam-based caring protocol. The study sample size was determined considering the large effect size from a similar study (d = 0.61) (Lengacher et al. 2009), with a power of 0.80 and alpha level probability (0.05). The estimated sample size is expected to consist of at least 44 subjects per group, and a total of 120 patients were recruited to achieve more reliable results. Therefore, 53 and 59 participants were drafted in the experimental and control groups, respectively.

Materials
Patients were invited to answer some questionnaires, including: ECOG Performance Status was used to evaluate patient functionality, specifically for the purposes of making oncological decisions. This tool incorporated the ambulatory status elements and the demand for care. Furthermore, the instrument encompassed five performance levels, which were rated from 0 (normal performance and function) to 5 (dead). Furthermore, participation was allowed after attaining a score of 0-2.
Demographic and clinical features of all participants were collected, including age, education, marital status, occupation, number of children, family income, stage of breast cancer, number of chemotherapy cycles, and types of chemotherapy.
A scale was used to measure the level of khushu prayer, including the Khushu Prayer Questionnaire, developed by Nawansih and Purwanto (2012). This consisted of 30 items based on the indicators of concentration to God during prayer, efforts of the heart towards understanding the meaning of contents read during prayers, exaltation and honor, the fear of God, and ability to embody the message of prayer in everyday life. Furthermore, a Likert scale was used with the categories of strongly agree, agree, disagree, and strongly disagree. The higher acceptable score level is 75-120, while 30-74 is regarded as low.
A self-report form documenting prayer and meditation practice at home. This record consisted of the date, practice duration in minutes, feelings, thoughts, and any problems or difficulties encountered during the process.
The Functional Assessment of Chronic Illness Therapy (Spiritual) (FACIT-Sp) developed by Cella et al. (1993) was used to assess the level of spiritual well-being. In addition, it contains a 12-item scale in 2 subscales, encompassing 8 items for meaning/peace, and 4 for faith (items 9, 10, 11, 12). This involved Likert-type scales (absolutely not = 0, very much = 4), and a higher score indicated a better level of spiritual well-being. Furthermore, reliability was reported for the total FACIT-Sp and subscales, and the internal consistency ranged from 0.81 to 0.88. Moreover, the possible scores for FACIT-Sp ranged from 0-48, and, by comparison, the Indonesian version showed a value of 0.88 for the reliability test (Aisyah 2017). Questions related to the reflection sessions: This guideline was used to encourage reflection in participants, with respect to personal feelings, and the spiritual problem faced during the program. Some of the questions included: "How do you feel during the khushu prayer or dhikr meditation?", and "What changes do you perceive after the process?"

Procedures
The intervention program was conducted by the researcher and three trained research assistants as the Muslim care team. All the research assistants were Muslim and held a bachelor's degree in Nursing. They were trained by the researcher to implement the intervention program and to assist in data collection for both the intervention and the control groups.
All participants were assessed using a Performance Scale (ECOG). Therefore, the questionnaire and the FACIT-Sp were applied to the intervention and control groups at the first meeting, and the questionnaires were repeated on days 3, 23, and 44. This timeline was designed because the highest level of physical suffering often develops 3 days after receiving chemotherapy (Battaglini et al. 2008). Furthermore, participants in the intervention group were charged to follow the program by the provision of training and practice evaluation using the Khushu Prayer Questionnaire. In addition, they were requested to self-evaluate the khushu prayer, the regularity, and the intervention program experience during home practice. Furthermore, a Daily Self-Report at Home was required, for a duration of 6 weeks, as determined in a previous study conducted by Jafari et al. (2013). This parameter was used to establish the effectiveness of using 6 weeks of Islamic spiritual therapy.
An Islam-based caring program was performed with the intervention group. This involved the provision of Islamic prayer and dhikr meditation through nurses' caring actions and was divided into 3 sessions according to the chemotherapy cycle received (3 cycles). During the first meeting, the participants were briefed with knowledge about the disease, possible complications, and side effects of chemotherapy. The caring approach to be adopted was crucial in strengthening the relationship, including greeting, demonstration of respect, and disseminating blessing through an Islamic approach, praying for healing together. Furthermore, patients and relatives are also encouraged to exercise patience with the illness and consider death risks, by praying for help and, also, accepting cancer as an atonement for sins, with death attributed as a vital aspect of the way to encounter Allah. This present study involved an individual face-to-face approach, and the intervention was practiced together with both patients and respective family members during hospital visits every 3 weeks, for the next chemotherapy cycle. In addition, the first, second, and third meetings lasted for 73, 43, and 43 min respectively, with each featuring reflections after practice. The researcher assigned the participants of the intervention group to individually practice prayer and dhikr meditation at home after being discharged.

Data Analysis
This was achieved using descriptive statistics (mean, SD, range), independent t-test, chi-square test, and one-way repeated measures analysis of variance (one-way RM-ANOVA). All statistical analysis was performed using SPSS software (version 16), and p values were considered significant below 0.05. Meanwhile, content analysis was performed on qualitative data.

Results
The total of 56 and 64 participants were allocated into the intervention and control groups, respectively. In addition, eight people out of those that initially agreed to participate dropped out for a variety reasons (e.g., changed setting, extended treatment, death). Hence, 53 and 59 women, respectively, completed the program in the intervention and control groups.
The demographic information obtained from women with breast cancer, and the individual variables include age, education, occupation, marital status, number of children, family income, stage of breast cancer, surgical action, chemotherapy treatment, and cycle (Table 1). Furthermore, most participants were married, unemployed, with a minimum of primary education. Moreover, there was a high prevalence of adequate family income. There was also no significant statistical difference in terms of individual characteristics.  Table 2 showed no statistically significant difference in the mean score of spiritual well-being at the baseline (Time 1) between groups (p = 0.918). However, the intervention group was significantly higher on Time 2, Time 3, and Time 4 at (p = 0.042), (p = 0.015), (p = 0.000), respectively.
A one-way RM-ANOVA was used to test the variations in variables over time within groups, and the results were significant for intervention (p = 0.027) and control group (p = 0.005). Based on a post hoc test, the spiritual well-being score indicated an increased significant difference from Time 1 to Time 4 (p < 0.05).  Table 3 shows the level of improvement, especially for meaning/peace subscale (items no 1-8), and the mean score of items gradually increased based on reports from assessment on Time 2, Time 3, and Time 4. For instance: "I feel peaceful," "I have a reason for living," "my life has been productive," "I have trouble feeling peace of mind," "I feel a sense of harmony within myself," and "my life lacks meaning and purpose." Note: * p < 0.05, ** p < 0.001; In = intervention group, Ct = control group; SWB = Spiritual well-being; Gr = Groups.
Religions 2020, 11, 361 8 of 13 As shown in Figure 1, the intervention program was continuously implemented over Time 2, Time 3, and Time 4, and the spiritual well-being score significantly increased among the study population. However, the value for the control group gradually regressed from the baseline. Note: * p < 0.05, ** p < 0.001; In = intervention group, Ct = control group; SWB = Spiritual well-being; Gr = Groups.
As shown in Figure 1, the intervention program was continuously implemented over Time 2, Time 3, and Time 4, and the spiritual well-being score significantly increased among the study population. However, the value for the control group gradually regressed from the baseline. Furthermore, all participants demonstrated a high level of khushu, categorized as borderline-high (52.83%), moderate-high (28.30%), and very high (18.87%) (Figure 2). This indicates the correct prayer practice by people in the intervention group and is supported by the verbatims as follows.
'This program is very useful for us, because it ensures the proper practice of religious performances. Moreover, there is better enlightenment on how to correctly perform prayers and dhikr meditation. This facilitates the expected health benefits, and there is need for these types of programs in hospitals. ……as it helps reduce stress and promotes relaxation.' 'This is very useful, and I've also heard that meditation is good for cancer patients, but personally don't know how it is practiced? I feel lucky to have been provided with the chance to join this program.' 'Now, I'm confident in my ability to correctly practice these prayers. Also, my mind is focused better and longer than before during a connection with God.' 'Before practicing the khushu prayer, I always felt restless, and now my feeling is much better and peaceful, and my body is healthier as well. ' 'Alhamdulillah (Praise be to God), the khushu prayer indeed improves interpersonal devotedness, and Allah seems very close to hear my prayers. This practice is meaningful and important in life.' Furthermore, all participants demonstrated a high level of khushu, categorized as borderline-high (52.83%), moderate-high (28.30%), and very high (18.87%) (Figure 2). This indicates the correct prayer practice by people in the intervention group and is supported by the verbatims as follows.

Discussion
This current study confirms the impact of spiritual therapy implemented through the caring approach, aimed at increasing spiritual well-being of patients with breast cancer. The program was implemented for 6 weeks, and the intervention variables were evaluated over a time period (4 times measured). Furthermore, the spiritual well-being outcome was appraised from Time 2 after chemotherapy treatment, followed by Time 3, and Time 4. The mean scores gradually increased over time, especially on Time 3 and 4, thus revealing the positive impact of regular Islam-based caring practice, and, also, in terms of strengthening the individuals' spiritual well-being.
Spiritual well-being involves meaning/peace and faith subscale of FACIT-Sp12. Overall, spiritual well-being among the patients with breast cancer showed a gradual increase for the intervention group. On Time 2, Time 3 and Time 4, post intervention reports were provided with respect to spiritual well-being domain modifications, and the treatment group was statistically different from the control. The results show statistically significant elevations in the mean scores of spiritual well-being in the intervention group, from pre to post-interventions. This finding is in line 'This program is very useful for us, because it ensures the proper practice of religious performances. Moreover, there is better enlightenment on how to correctly perform prayers and dhikr meditation. This facilitates the expected health benefits, and there is need for these types of programs in hospitals. . . . . . . as it helps reduce stress and promotes relaxation.' 'This is very useful, and I've also heard that meditation is good for cancer patients, but personally don't know how it is practiced? I feel lucky to have been provided with the chance to join this program.' 'Now, I'm confident in my ability to correctly practice these prayers. Also, my mind is focused better and longer than before during a connection with God.' 'Before practicing the khushu prayer, I always felt restless, and now my feeling is much better and peaceful, and my body is healthier as well.' 'Alhamdulillah (Praise be to God), the khushu prayer indeed improves interpersonal devotedness, and Allah seems very close to hear my prayers. This practice is meaningful and important in life.'

Discussion
This current study confirms the impact of spiritual therapy implemented through the caring approach, aimed at increasing spiritual well-being of patients with breast cancer. The program was implemented for 6 weeks, and the intervention variables were evaluated over a time period (4 times measured). Furthermore, the spiritual well-being outcome was appraised from Time 2 after chemotherapy treatment, followed by Time 3, and Time 4. The mean scores gradually increased over time, especially on Time 3 and 4, thus revealing the positive impact of regular Islam-based caring practice, and, also, in terms of strengthening the individuals' spiritual well-being.
Spiritual well-being involves meaning/peace and faith subscale of FACIT-Sp12. Overall, spiritual well-being among the patients with breast cancer showed a gradual increase for the intervention group. On Time 2, Time 3 and Time 4, post intervention reports were provided with respect to spiritual well-being domain modifications, and the treatment group was statistically different from the control. The results show statistically significant elevations in the mean scores of spiritual well-being in the intervention group, from pre to post-interventions. This finding is in line with several previous reports, where various types of spiritual therapies with different program-duration range are used. These include the successful outcome of spiritual group therapy conducted for 6-12 weeks (Jafari et al. 2013;Zamaniyan et al. 2016), spiritual intervention for 8 weeks (Fallah et al. 2011), and spiritual intervention backed by the Quran and Islamic standards for 10 weeks ).
In the present study, since spiritual well-being is characterized by two main components, including meaning/peace and faith, all the mean scores of the spiritual well-being of the subcomponents of meaning and peace-i.e., feeling a sense of purpose in life, feeling peaceful, and a feeling of harmony-were higher than those of the baselines and the control groups. While the component of faith-i.e., strength in faith or spiritual beliefs and hopeful thought ("whatever happens with my illness, things will be okay")-scores were slightly decreasing along with the four-time point of both intervention and control groups. This indicated that subcomponents of meaning and peace had more impact on spiritual well-being than the subcomponent of faith, which is congruent with several previous studies. Jafari et al. (2013) reported on the strong association between the existential meaning and peace components with psychological adjustments, as against the faith concept. This outcome is congruent with the report from Australian research conducted on 449 patients, which featured significantly improved health-related quality of life domains, characterized by a close association with the meaning/peace component than faith. Furthermore, the subscale "meaning" was a relatively better predictor of cravings for accelerated death, as well as improved quality of life, as reported by Wang and Lin (2016) from research performed in Taiwan with 85 critically ill cancer patients.
This investigation provides support on Islam-based caring intervention effectiveness in an Indonesian context, with respect to meaning and peace, as subscales of spiritual well-being. However, the finding is a little unexpected as faith in the religion and God has been emphasized and strengthen by the practice of Muslim people in daily life. Since a study that attempts to investigate the subcomponents of a religion-based program has still been neglected, further research in this area is required to confirm findings.
This positive outcome is possibly due to the program structure and specification being specially composed of Islamic principles. Furthermore, the caring approach also impacted on the health consequences in this study, as nurses incorporated the Islamic culture to establish a nurse-patient-family relationship and to heal the patients. These developments were based on religious teachings, with the main path focused on the Five Pillars and the True Faith, as an effective physical-spiritual care.
According to the results, all participants (100%) were able to follow the program with khushu prayer, after receiving an explanation on the appropriate practice technique. However, only 88.68% followed up accordingly during the first session (first three weeks after baseline), and this was lower than expected. The probable reason was that almost half of the participants (41.5%) in the intervention group received the first cycle of chemotherapy, which was reported to be more severely affected by the treatment side effects, e.g., nausea, fatigue, vomiting, and difficulty in sleeping (Werdani 2018). Meanwhile, all patients in the current study reported on the feeling of peace, a spirit of life experienced while praying solemnly, followed by dhikr meditation. It is in line with the data from Table 3 that the participants have an increase in the subscale of meaning and peace (items no. 1-8) after receiving the intervention program for six-week. According to Lewis et al. (2014) and Pok-Ja Oh and Kim (2014), breast cancer patients derive comfort in spiritual activities, significantly associated with the provision of spiritual intervention and the positive outcomes.
This finding was also supported by the narrative accounts of a peaceful mind, as well as improved meaning of life as a result of the intervention program. The qualitative data showed the feeling of restlessness, worry about the disease, and uncertainty of the future before practicing the khushu prayer, despite the regular performance of prayers and dhikr. This prompts the need to develop an Islam-based caring program with emphasis on correct practices, featuring the allotment of adequate time for each session. Furthermore, the entire duration is considered to ensure the achievement of all expected health outcomes. The results from narrative accounts after receiving the intervention program confirm the programs' ability to provide more benefits, including an increased feeling of peace, closeness to God, spirit for further life, meaning of life, and better health. It was expected that the strength derived from spiritual health can further reduce the side effects of chemotherapy as reported by Chimluang et al. (2017), while the positive impact of high level spiritual well-being on the existential meaning of life also provides an individual with greater sense of inner strength and positive energy reported by Al-Natour et al. (2017).
Furthermore, Islamic caring is known to convey good health consequences, by providing patients education in relation to the disease and treatment and also confers suitable effects in terms of healing. The interaction between nurses and patients through the delivery of care, love, empathy, and compassion integrated with Islamic teaching helps boost the therapeutic effects (Ismail and Hatthakit 2018). This study also involved family members as caregivers providing support and care to the patients.
A limitation of the study was discovered. First, the researcher could not directly observe the practices of the program in the participants' homes, such as properly engaging in the prayer and dhikr meditation. However, phone calls were used to discuss the program and ensure participants in the intervention group followed the program accordingly, adding to the individual training in prayer and dhikr meditation provided at the first meeting. Furthermore, the participants were asked to self-report their daily practice at home to ensure the adequacy of the practice. Second, the study's findings could not generalize, as it was limited only to Muslim women with breast cancer in Indonesia. Therefore, further research in Muslim women in other countries is still needed.

Conclusions
Based on the results and discussion, the Islam-based caring intervention posed a challenge to nurses in terms of managing and supporting the spiritual well-being of women with breast cancer, currently receiving chemotherapy treatment. This is, therefore, recommended as suitable for sufferers in Indonesia, featuring the consistent practice of prayer and dhikr meditation as a part of daily life.

Funding:
The authors make known the receipt of financial reinforcement provided, alongside article authorship and publication: The project was supported by the Graduate School, Prince of Songkla University, through the Thailand Education Hub for ASEAN Countries (TEH-AC) Scholarships, and Universitas Padjadjaran, Indonesia, for funding this study and providing the scholarship.