Health, Spirituality and Medical Ethics

Introduction

Diagnosing a child with cancer causes several physical, mental, and social problems for the patient and their family [1, 2]. Due to their traditional role in care provision, mothers accept more responsibilities regarding their sick children. On the other hand, the children are in contact with their mothers more than any other family member [3]. Therefore, mothers are at a higher risk of mental health problems and stress. The presence of a sick child as a stressor in the family has profound effects on the parents’ depression [3]. The fear of losing the child or other disease-related problems, such as treatment costs, disease duration, and recurrence, are among the reasons leading to parents’ depression. As a result of depression, parents may feel incompetent and unable, which increases their stress and reduces their self-confidence. These psychological tensions affect their ability to provide effective care. The mother-child relationship is so close and interwoven that any change in one affects the other. Hence, a mother’s depression and anxiety can affect her relationship with her child and change the child’s behavior [3].

In addition to solutions to address psychological wellbeing issues, positive psychology and improving psychological status are crucial approaches to reducing psychological tension. Therefore, besides considering methods to reduce the psychological consequences of diseases, such as depression, attention should be paid to improving happiness as a positive approach to managing stressful life events [4].

Various methods can be employed to reduce the psychological consequences experienced by parents of children diagnosed with cancer and to enhance their hope and happiness. One such method is the provision of spiritual care. Spiritual care is a nursing intervention that addresses three key dimensions of the human experience when facing illness: Existential, transcendental, and emotional [5]. Among the various forms of spiritual care, logotherapy has been specifically applied to mothers [6]. Abdi Hamlabad et al. Posits in their article Logotherapy, is based on the premise that every individual seeks meaning in life. The discovery of an individual’s unique meaning serves as the central mechanism for change in psychotherapy [7]. There are different approaches to logotherapy, one of which incorporates a religious perspective. Religion plays a significant role in alleviating psychological tension and addressing challenges [8, 9]. It acts as a protective and defensive system, enabling

The presence of a sense of meaning in life is an effective strategy for coping with challenging life circumstances that teaches people to show appropriate reactions to unpleasant conditions [10]. Logotherapy awakens people to the fact that life is sometimes intertwined with unchangeable conditions; however, in these conditions, people are free to choose their attitude to life. People’s attitudes to their suffering stem from their choices; therefore, responsibility training can enhance their ability to go on with their lives [11].

When individuals are diagnosed with cancer, they feel empty and void and doubt the meaning of life. Logotherapy, as a positive psychology approach, is helpful for individuals who have experienced existential failure or are unable to find meaning in life [12]. Logotherapy helps people understand life and its conditions better, continue their path more hopefully, and persevere in the face of problems [13].

Many researchers have found that the presence of meaning in life is crucial to mental-emotional well-being and is compatible and consistent with different aspects of personality, mental and physical health, coping with tensions, and religion [14]. However, research findings in this regard, despite their importance, are insufficient, warranting further research to assess more variables with a focus on cultural components to provide better services, especially to the families of children with cancer [15]. Since the cultural and theological context of the Iranian people originates from and is intertwined with Islam, it seems appropriate to use Quranic teachings for logotherapy. Therefore, depression is a consequence of parents’ exposure to their children’s affliction with cancer, and happiness is a feeling that gives meaning and hope to life [16, 17]. These two concepts are not necessarily complementary or contradictory; however, considering the different aspects of psychological issues and positive psychology, they can act synergistically to open new horizons in the provision of healthcare services. There are different methods for reducing parents’ psychological consequences or increasing their hope and happiness while their children are diagnosed with cancer, including providing spiritual care for mothers [17, 18]. Logotherapy is a type of spiritual care [12]. Therefore, this study aimed to determine the effect of logotherapy with an Islamic approach on improving depression and happiness in mothers of children diagnosed with cancer.

Methods

A quasi-experimental (before-and-after) study was conducted in 2022-23 in Tehran City, Iran, involving 60 mothers of children with cancer. Participants were selected using convenience sampling and were randomly assigned to the intervention or control group.

The inclusion criteria were a lack of somatic diseases and psychological disorders related to the depressive disorder spectrum (according to the children’s medical records) and being a Muslim. The exclusion criterion was missing more than two educational sessions. To conduct this study, the mothers in the intervention group participated in eight 90-minute sessions on Islamic logotherapy every other day in groups of 3-5. Due to the COVID-19 pandemic during the study, half of the sessions were held in the department classroom every other day, while the other half were held online via social media video calls. All sessions included discussions, and questions, and answers between the mothers and the treating nurse (Table 1) [10, . The content of the logotherapy sessions was developed in collaboration with two experts in Islamic studies: One holding a master’s degree in Quranic Sciences and Hadith, and the other with a level 4 qualification in islamic seminary studies. to ensure validity, the material was subsequently reviewed by three psychologists with additional level 2 seminary qualifications, all of whom confirmed its appropriateness and accuracy. The Islamic texts utilized in this study were derived from articles that introduced and developed Islamic logotherapy. Specific examples and Quranic verses were directly selected from the Quran in consultation with experts on the research team.

The educational material was prepared using books, articles, and the results of research activities in logotherapy and Islamic logotherapy. After preparing the educational material, its content validity was confirmed by 10 professors in medical sciences, Islamic sciences, and clinical nursing (Table 2). The study variables were evaluated using the Oxford happiness inventory (OHI) and the Beck’s depression inventory (BDI). The data collected from the intervention and control groups were analyzed using the SPSS software, version 16. Statistical tests, including the chi-square test, Fisher’s exact test, and independent and paired t-tests, were used.

Argyle and Lu developed the OHI in 1990 [22] by reversing the BDI items. The OHI comprises 29 items scored on a 4-point likert scale ranging from 1 to 4. The total score of the OHI ranges between 29 and 116, with a higher score indicating a higher level of happiness. The validity of the OHI has been confirmed in several studies, including one by Alipoor and Noorbala [23]. The reliability coefficient of the OHI in this study was 0.763 using the split-half method. The validity of the questionnaire was evaluated using the face validity method, involving a panel of ten expert professors. The questionnaire was distributed to the professors, and after two weeks, the completed evaluations were collected. The professors’ feedback and suggested revisions were carefully reviewed and implemented to enhance the questionnaire’s quality.

The BDI-II is a 21-item self-report measure. The items are scored on a 4-point Likert scale from 0 to 3. A 14-19, 20-28, and 29-63 score indicates mild, moderate, and severe depression, respectively. The validity of the BDI has been measured in several studies, including a study by Rajabi and Karju Kasmai et al. [24]. The reliability coefficient of the BDI in this study was 0.910 using the split-half method. The validity of this instrument was assessed using the same method as that of the previous instrument.

Results

Regarding the mothers’ demographic variables, 50% were in the 31-40 age group, 46.7% held a bachelor’s degree or higher, and 76.7% were housewives. Most mothers in the control (76.7%) and intervention (80%) groups lived in cities. The income of 43.3% of the mothers in the control group and 50% of the mothers in the intervention group was between IRR 2-5 million per month. The results showed no significant differences in demographic variables between the two groups (P>0.05) (Table 3).

Regarding the children’s demographic variables, most children in the intervention (43.3%) and control (33.3%) groups were under 5 years old. Most children in the intervention (53.3%) and control (60.0%) groups were boys. The cancer type was acute lymphocytic leukemia-acute myeloid leukemia (ALL-AML) in 56.7% of the participants in both groups, and the time from diagnosis to initiation of treatment was less than 6 months in most of the children in the control (43.3%) and intervention (40%) groups. The general condition of most children in the intervention (90%) and control (96.7%) groups was good. The number of household members was 3-4 persons in 70.0% of the controls and 86.7% of the cases. Most children in both groups had social security insurance and were supported by the Mahak society for the support of children with cancer. The results showed no significant differences in demographic variables between the two groups of children (P>0.05) (Table 3).

The results of an independent t-test showed that the depression score was significantly reduced in the intervention group (5.63±5.27) compared to the control group (0.73±2.88) (P<0.001). The scores for the affective and cognitive domains reduced significantly more in the intervention group compared to the control group (P<0.001). However, no significant difference was observed in the score changes of the somatic domain between the two groups (P=0.065) (Tables 4 and 5).

The results of independent t-test showed that after the intervention, the happiness score was significantly higher in the intervention group (38.53±6.19) compared to the control group (34.23±8.60) (P<0.001). The increase in the score was significantly higher in the intervention group versus the control group in all domains of happiness (P<0.05), except for the control (P=0.110) (Tables 6 and 7).

Discussion

No significant difference was found in depression and its domains between the two groups before the intervention, and the participants in both groups suffered moderate depression. According to several studies, a cancer diagnosis causes several physical, mental, and social problems for patients and their families, especially mothers [1, . Mothers are more prone to mental problems and stress due to their traditional role of care provision, having a close relationship with children, and accompanying their children in different stages of diagnosis and treatment, since caring for the child, financial-social issues, and family problems contribute to a reduction in their quality of life and consequent psychological problems. Therefore, depression is a probable consequence for mothers whose children are diagnosed with cancer. Ljungman et al. found that parents experience a subset of mental health problems and stress, like depression and anxiety, even years after a diagnosis . Moreover, the score of the affective domain of depression reduced significantly after the intervention compared to baseline in the intervention group.

This finding was consistent with the results of a study by Wakhid et al. who found a significant difference in the depression of cancer patients in Ken Sras Hospital, Indonesia, before and after the intervention [27]. Heshmati et al. reported the significant effect of group logotherapy on the depression and anxiety of cancer patients. They concluded that group logotherapy could be considered an effective intervention for improving the emotions of patients with cancer [28]. In a study by Rezaei et al. the mean depression was not significantly different between intervention and control groups before the intervention, while a significant difference was observed after the intervention, indicating the effect of logotherapy on improving depression in cancer patients [29]. Breitbart et al. indicated a significant improvement in spiritual well-being and quality of life and a marked reduction in depression, hopelessness, desire for death, and somatic symptoms of tension in cancer patients after meaning-centered group psychotherapy [30]. Moreover, Hamid et al. found that group logotherapy reduced depression and anxiety and increased the quality of life in cancer patients [1]. The results of a study by Bahar et al. also showed that logotherapy reduced depression in diabetic patients with depression, indicating the effectiveness of this method in chronic diseases [31]. Therefore, logotherapy, by emphasizing the presence of an aim in pain, suffering, and disease, helps people not to concentrate on losses despite hopelessness and instead search for meaning. The presence of meaning in life is a crucial factor in emotional-mental well-being. This is consistent with different aspects of personality, mental and physical health, coping with tension, and religion. The results confirmed the effect of logotherapy on depression improvement in mothers of children with cancer.

Happiness and its domains did not differ significantly between the intervention and control groups before the intervention, and the happiness level was rather low in both groups [32]. According to the results, the happiness score increased significantly in the intervention group compared to the control group after the intervention. However, no significant difference was observed in the happiness score in the control group after the intervention compared to baseline. The total score of happiness and the scores of its domains, including life satisfaction, joy, self-esteem, calm, control, and efficacy, increased significantly after the intervention compared to baseline in the intervention group. The effectiveness of positive psychology in increasing happiness was shown in a study by Khodadadi et al. [6] on the mothers of children with special needs and a study by Pourfaraj and Rezazadeh [33] on cancer patients. In the above studies, the target groups were people exposed to high levels of physical and mental tensions due to occurrences, such as their disease, the disease or disability of their children, or old age, which are considered life crises and can cause a great deal of tension, resulting in the disruption of their lives as well as the lives of family members and relatives. Hence, it is necessary to pay close attention to the quality of life of these individuals and improve their psychological state. The results of the present study indicate the effect of logotherapy on increasing the happiness of mothers of children with cancer.

Conclusion

The results suggest that logotherapy with an Islamic approach can improve depression and increase the happiness of mothers of children with cancer. Psychological tensions resulting from a disease and related problems and issues affect parents’ ability to provide effective care for their children. Moreover, parents’ feeling of being incapable of solving problems leads to the formation of an unstable and powerless coping, resulting in poor outcomes for children. The mother-child relationship is so close and interwoven that any change in one affects the other. Hence, the mother’s depression and anxiety will certainly affect her relationship with her child and change the child’s behavior. The anxiety and depression of mothers affect the children’s treatment process and their cooperation in diagnostic-therapeutic interventions. Therefore, it is vital to pay close attention to care methods to reduce tensions, solve psychological issues, and improve happiness as a positive approach to enhance psychological well-being. According to the results, depression reduced significantly, and happiness significantly increased in the intervention group compared to the control group after the intervention. However, more studies are required to evaluate the effects of logotherapy with an Islamic approach on the psychological state of the mothers of children with cancer.

Limitations

The present study was conducted during the COVID-19 pandemic, which caused disorders in holding face-to-face sessions. Therefore, half of the sessions were conducted online. Moreover, the COVID-19 pandemic had a great impact on the study variables like depression and happiness; however, since both groups were affected by the pandemic, the probability of its effects on the results was minimized.

Ethical Considerations

Compliance with ethical guidelines

This study was approved by the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (Code: IR.TUMS.FNM.REC.1399.048). All participants provided written informed consent, and their information was accessible only to the research team.

Funding

This paper was extracted from an master thesis of Sayed Maryam Fatemi Sade, approved by Tehran University of Medical Sciences, Tehran, Iran (Code: 99-2-100-48618).

Authors' contributions

Supervision, investigation, writing and original draft, review and editing: Akram Sadat Sadat Hoseini; Conceptualization, methodology and data analysis: All authors.

Conflict of interest

The authors declared no conflicts of interest.

Acknowledgments

The authors appreciate the support of the Tehran University of Medical Sciences.