Post-traumatic growth in cancer patients: a correlational study in Turkey

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ORIGINAL PAPER

Post‑traumatic Growth in Cancer Patients: A Correlational Study in Turkey

Nur Elçin Boyacıoğlu¹ · Münire Temel² · Sibel Çaynak³

Accepted: 20 April 2022 / Published online: 14 May 2022

Abstract

This study aims to evaluate the factors that influence post-traumatic growth (PTG), including religious coping and resilience. This descriptive and correlational study involved 111 cancer patients, followed up at a hematology inpatient clinic of a university hospital in Turkey. Religious coping scale, resilience scale, and PTG inventory were used for data collection. PTG was positively associated with negative religious coping and was negatively associated with age. PTG scores were higher for patients without children, who were recently diagnosed, had higher knowledge about the disease, and used negative religious coping.

Keywords Adaptation · Adult · Post-traumatic growth · Resilience · Religious coping · Turkey

Introduction

A cancer experience may fundamentally change the lives of patients (Greup et al., 2018). A cancer diagnosis and the treatment processes may result in various problems, including stress, depression, anxiety, sleep disorders, and fatigue (Borges et al., 2017; Zebrack, 2015). On the other hand, the concept of post-traumatic growth (PTG), which refers to the contribution of harsh experiences to psychological development, has attracted attention in the recent years (Greup et al., 2018). PTG indicates a positive cognitive, emotional, and behavioral development that occurs after a major crisis affecting life (Boyle et al., 2017; Jansen et al., 2011). PTG involves mentally reprocessing

* Nur Elçin Boyacıoğlu

[email protected]; [email protected]

1 Department of Gerontology, Faculty of Health Sciences, İstanbul Üniversitesi-Cerrahpaşa Büyükçekmece Yerleşkesi, Alkent 2000 Mah. Yiğittürk Cad. No: 5/9/1, 34500 Büyükçekmece/

Istanbul, Turkey

2 School of Health, Nursing Department, Tekirdağ Namık Kemal University, Tekirdağ, Turkey

3 Vocational School of Health Services, Antalya Bilim University, Antalya, Turkey

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traumatic events, converting the meaning attributed to an event into a more functional one, and reconstructing the cognitive scheme. This outcome, however, depends on sociocultural characteristics, personal traits, stress management, the ability to express feelings, resilience, and religious coping (Dursun & Söylemez, 2020).

Diagnosis and treatment of cancer is a traumatic process for most people. Reli- gious and spiritual resources help individuals cope with the problems associated with the diagnosis and treatment of cancer (Borges, 2017). The concept of religious coping has been gaining importance in the literature on psychiatry in the recent years (Rezaei et al., 2017; Thombre et al., 2010). Cancer for most people refers to suffering and death and raises existential questions. Religion and spirituality as a collectivist way to cope with these problems help people to interpret the negative feelings and opinions that occur after diagnosis in a more positive way (Merath et al., 2020). Religious beliefs may result in positive religious coping, which may be displayed in the form of feeling that God will help when the patient prays for help. Alternatively, it can also lead to negative religious coping, in which the patient believes that God has punished them and that there is no hope for mercy, which in turn, may result in a feeling of anger against God (Ekşi & Sayın, 2016; Exline et al., 2011).

Another concept that pertains to the capacity to cope with negative experiences is resilience (Hu et al., 2018; Ristevska-Dimitrovska et al., 2015). Resilience is an important feature, which causes an individual to recover quickly from stressful life events. It is related to not only general life satisfaction (Zhang et al., 2018) but also the mental well-being of the patients as a protective factor against psychological distress (Greup et al., 2018). Therefore, adherence to cancer treatment is believed to be closely related to religious coping, resilience, and PTG.

We have not found any studies that analyzed the relationship between these three parameters for cancer patients in Turkey. A study that analyzes this relationship may contribute to the treatment and recovery of cancer patients and bridge the gap in the literature.

Aim

This study aims to discern the factors that influence PTG, including religious coping and resilience, in cancer patients. Within this context, it aims to answer the following questions:

What are the PTG, religious coping, and resilience levels of cancer patients?

Is there a relationship between sociodemographic and clinical features and PTG levels?Is there a relationship between PTG, religious coping, and resilience levels?

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Methods Design

This study had a descriptive and correlational design.

Settings and Participants

The study was conducted on cancer patients who were followed up at a hematology inpatient clinic of a university hospital in Istanbul, Turkey, between 15.02.2019 and 15.02.2020. Using the sampling method whose universe is known, sample size was 156 patients with a 95% confidence interval and the 260 patients that stayed at the hematology clinic in the previous year. Hematologic cancer patients above the age of 18, who had no communication problems and agreed to participate, were included in the study. Since the number of patients in the clinic decreased during the period of data collection, the study was finalized with 111 cancer patients.

Data Collection Tools

Information form, religious coping scale (RCS), resilience scale for adults (RSA), and PTG inventory were used for data collection.

Personal Information Form

The personal information form was prepared by the researchers by using the rel- evant literature. It included 12 questions on the sociodemographic characteristics of the patients and their history of diseases.

Religious Coping Scale

RCS measures the extent to which the factors of religious coping are used to cope with the main stressors of life, developed by Pargament et al. (1998). The reliability and validity of the Turkish version of the scale has been evaluated by Ekşi and Sayın (2016), who used a four-point Likert scale with 2 subscales and 10 items. The first seven items belonged to the positive religious coping subscale, whereas the remaining items belonged to the negative religious coping subscale.

Scores of the two subscales were separately calculated and possible scores of the positive and negative religious coping subscales ranged between 7 and 28 and 3 and 12, respectively. Lower scores from the subscales indicated lower religious coping. Cronbach’s alpha for the positive and negative religious coping subscales was 0.91 and 0.86, respectively (Ekşi & Sayın, 2016). In our study, Cronbach’s alpha for the positive and negative religious coping subscales was 0.92 and 0.88, respectively.

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Resilience Scale for Adults

RSA was developed by Friborg et al. (2005). The reliability and validity of the Turkish version of the RSA was evaluated by Basım and Çetin (2011). RSA comprised 33 items that were scored on a five-point Likert scale. Items 1, 3–4, 8, 11–16, 23–25, 27, 31, and 33 were reverse scored. The total scores obtained ranged between 33 and 165, with higher scores indicating a higher level of resilience. Cronbach’s alpha of the original scale and our study was both 0.86.

Post‑traumatic Growth Inventory

Post-traumatic growth inventory (PTGI) was developed by Tedeshi and Colhoun (1996) to evaluate the changes perceived as a result of coping with trauma or ill- ness. The reliability and validity of the Turkish version of the PTGI were evaluated by Dirik and Karancı (2008). PTGI consisted of 21 items, which were grouped into three subscales, namely changes in relationship with others (items 6, 8, 9, 15, 16, 20, and 21), changes in philosophy of life (items 3, 7, 11, 14, and 17), and changes in self-perception (items 1, 2, 4, 5, 10, 12, 13, 18, and 19). Ratings were marked on a five-point scale and the possible scores ranged between 0 and 105, with higher scores indicating higher changes. Cronbach’s alpha of the original scale and our study was 0.90 and 0.95, respectively.

Procedures

We conducted a pilot study with five female and five male participants to evaluate the comprehensibility of the questions. Following the corrections, we asked two hematologists, one social service expert, one psychiatric nurse, and one psychiatric expert to evaluate our questions; we then finalized the surveys. The surveys were completed by the participants in about 15–20 min.

After obtaining necessary permissions, we informed the participants about the aim and the scope of the research. Data were collected by a psychiatric nurse (NEB), who had professional experience in the hematology clinic, by using a face-to-face interview method in a special room. Due to the researcher’s experience working with hematology patients, only hematology patients were included in the sample group.

Ethical Considerations

We obtained permission from the clinical research ethics board of the institution that the study was conducted at (No 63; dated 18.01.2018). The study was conducted in line with the principles of the Declaration of Helsinki, and verbal and written informed consent of the participants was obtained. Names of the participants were not identified in the forms, and the information provided by the participants was exclusively used for research.

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Data Analysis

Descriptive analysis was used for sociodemographic characteristics and disease history of the patients. Independent t-test, ANOVA, and Tukey’s test were used for data analysis. The correlation between the scales was analyzed with Pearson’s correlation analysis, whereas multiple regression analysis was used to analyze the variables that influenced PTG.

Results

The findings were presented under four headings, namely sociodemographic and disease-related characteristics, mean scale scores and correlations, comparison between sociodemographic and patient characteristics and PTGI scores, and regression analysis.

Sociodemographic and Disease‑Related Characteristics

The mean age of the participants was 50.4 ± 16.0 years and 55.9% were male. Of the total participants, 54.0% were diagnosed with cancer 1–6 months ago, 66.7% did not have any other chronic diseases, and 73.9% did not have metastasis. Table 1 presents the characteristics, including education, marital status, and income status.

Mean Scale Scores and Correlations

The mean PTGI score of the participants was 47.9 ± 29.4. The mean scores obtained from the changes in the relationship with others, changes in the philosophy of life, and changes in self-perception subscales of PTGI were 15.9 ± 11.4, 8.2 ± 7.3, and 23.8 ± 12.9, respectively. The mean scores obtained from the positive and negative subscales of the RCS were 24.5 ± 5.6 and 4.9 ± 2.9, respectively. Finally, the mean RSA score was 121.3 ± 21.4. There was a positive and weak relationship between the PTGI and the negative RCS scores (r: 0.333; p ≤ 0,01). We also found a negative and weak relationship between the age of the participants and the PTGI scores (r:

−0.194; p = 0.041).

Comparison between Sociodemographic and Disease‑Related Characteristics and PTGI Scores

Tables 2 and 3 show the findings from the comparison between sociodemographic and disease-related characteristics and PTGI scores. We found a statistically sig- nificant difference between time after diagnosis (F = 11.231; p < 0.001), level of knowledge about the disease (F = 9.109; p < 0.001), and PTGI scores. There was no significant difference between gender, marital status, education, occupation, working status, social security, income status, family type, stage of disease, metastases, chronic diseases, and PTGI scores (p > 0.05).

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Table 1 Sociodemographic and

Disease-Related Characteristics n % Mean ± SD (Min.–Max.)

Sociodemographic characteristics

Age 50.45 ± 16.03 (18–78)

Gender

Female 49 44.1

Male 62 55.9

Marital status

Married 80 72.1

Single 23 20.7

Divorced 8 7.2

Having child

Yes 84 75.7

No 27 24.3

Education

Illiterate 6 5.4

Primary school 44 39.6

Secondary school 24 21.6

High School 19 17.1

University and above 18 16.2 Occupation

Student 5 4.5

Housewife 30 27.0

Public officer 11 9.9

Self-employment 37 33.3

Retired 28 25.2

Working status

Has a regular job 14 12.6

Does not work 97 87.4

Social security

Yes 105 94.6

No 6 5.4

Income status (self-perceived) Income < Expense 16 14.4

Income = Expense 87 78.4

Income > Expense 8 7.2 Family type

Core 79 71.2

Broad 17 15.3

Alone 15 13.5

Disease-related characteristics Time after Diagnosis

1–6 months 60 54.0

7–12 months 25 22.5

13 months and above 26 23.5

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Regression Analysis

Table 4 presents the multiple regression analysis on the impact of age, having children, time after diagnosis, knowledge level about the disease, and negative religious coping on PTGI scores. An evaluation of the regression table shows a statistically meaningful model (F: 9.850 and p < 0.001). Accordingly, having a child (β = −0.219, p = 0.022), time after diagnosis (β = −0.357, p < 0.001), knowledge level about the disease (β = 0.242, p = 0.008), and negative religious coping (β = 0.230, p = 0.007) were predictors of PTGI scores. A combination of these factors predicted 29% of PTGI scores.

Discussion

Cancer is a community health problem that has become widespread around the world. Due to this reason, psychosocial problems associated with cancer should be revealed and necessary measures should be taken to cope with the problem (Rezaei et al., 2017; Thombre et al., 2010). Within this context, this study aimed to discern the level of and the factors affecting PTG among cancer patients. This study found that PTGI scores were higher for cancer patients without children, who were diagnosed with the disease in recent times, had higher level knowledge about the disease, and used negative religious coping.

The level of PTG may vary according to individual interpersonal relationships, life philosophies, self-perceptions, and the way they perceive trauma.

In our study, the PTGI scores (47.9 ± 29.4) of the participants were at medium levels. Other studies on cancer patients found that the PTGI scores were either

Table 1 (continued) n % Mean ± SD (Min.–Max.)

Knowledge level about the disease

No 20 18.0

Partial 44 39.6

Adequate 47 42.3

Chronic disease

Yes 37 33.3

No 74 66.7

Metastases

Yes 29 26.1

No 82 73.9

Stage of disease

1. stage 9 8.1

2. stage 6 5.4

3. stage 8 7.2

4. stage 7 6.3

Not Known 81 73.0

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Table 2 Comparison of sociodemographic features with Post-Traumatı̇c Growth score FeaturesPTGI (Mean ± SD)Test/pCRO (Mean ± SD)Test/pCPL (Mean ± SD)Test/pCSP (Mean ± SD)Test/p GenderFemale53.91 ± 29.83t = 1.909 p = 0.05917.75 ± 11.48t = 1.531 p = 0.1299.20 ± 8.20t = 1.212 p = 0.22826.95 ± 12.75t = 2.318 p = 0.022Male43.29 ± 28.3514.43 ± 11.227.51 ± 6.4721.33 ± 12.63 Marital StatusMarried*43.81 ± 29.78F = 3.064 p = 0.05114.73 ± 11.77F = 1.524 p = 0.2228.91 ± 7.04F = 5.884 p = 0.004

*–** p = 0.042

*–*** p = 0.020

22.16 ± 12.96F = 2.432 p = 0.093Single**57.43 ± 27.5418.65 ± 10.6310.95 ± 7.0627.82 ± 12.95 Divorced***62.50 ± 22.8619.62 ± 8.3614.00 ± 6.1828.87 ± 9.64 Having ChildYes44.15 ± 29.60t = −2.468 p = 0.01515.15 ± 11.86t = 1.218 p = 0.2267.08 ± 6.96t = 3.114 p = 0.00221.91 ± 12.88t = 2.819 p = 0.006No59.88 ± 26.1218.22 ± 9.7011.92 ± 7.2329.74 ± 11.39 EducationIlliterate33.66 ± 27.71F = 1.571 p = 0.18711.16 ± 10.14F = 1.230 p = 0.3035.16 ± 6.36F = 2.398 p = 0.05517.33 ± 11.72F = 1.734 p = 0.148Primary school49.22 ± 29.8417.06 ± 12.327.06 ± 7.0425.09 ± 12.41 Secondary school38.70 ± 27.6612.25 ± 9.866.87 ± 6.9119.58 ± 12.79 High School52.31 ± 27.8218.10 ± 11.4710.26 ± 6.6723.94 ± 12.95 University & above57.50 ± 31.1917.16 ± 10.9311.94 ± 8.1723.38 ± 13.66 OccupationStudent*62.40 ± 17.37F = 2.116 p = 0.08414.40 ± 7.66F = 1.896 p = 0.11615.40 ± 5.85F = 3.957 p = 0.005

*–***** p = 0.035

****–***** p = 0.029

32.60 ± 9.39F = 1.664 p = 0.164Housewife**46.00 ± 28.5615.43 ± 10.607.03 ± 7.7423.53 ± 12.22 Public officer***43.72 ± 24.5416.45 ± 12.506.63 ± 4.4320.63 ± 9.56 Self-employment****56.64 ± 30.7819.43 ± 11.5210.78 ± 7.0726.43 ± 14.26 Retired*****37.75 ± 29.5011.78 ± 11.425.60 ± 6.7420.35 ± 12.74 Working statusHas a regular job53.57 ± 24.84t = 0.758 p = 0.45015.28 ± 9.41t = −0.215 p = 0.83011.00 ± 6.77t = 1.510 p = 0.13427.28 ± 10.45t = 1.073 p = 0.286Does not work47.17 ± 30.1115.98 ± 11.717.86 ± 7.3223.31 ± 13.22 Social SecurityYes47.04 ± 29.05t = 1.403 p = 0.16315.67 ± 11.40t = 0.867 p = 0.3887.98 ± 7.08t = 1.707 p = 0.09123.39 ± 12.84t = 1.471 p = 0.144No64.33 ± 34.9419.83 ± 11.8713.16 ± 9.9031.33 ± 13.33

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PTGI post-traumatic growth inventory; CRO changes in relationships with others; CPL changes in the philosophy of life; CSP changes in self-perception Tukey post hoc test was used Table 2 (continued) FeaturesPTGI (Mean ± SD)Test/pCRO (Mean ± SD)Test/pCPL (Mean ± SD)Test/pCSP (Mean ± SD)Test/p Income StatusIncome < Expense50.62 ± 30.07F = 0.121 p = 0.88617.68 ± 12.08F = 0.303 p = 0.7398.18 ± 7.85F = 0.023 p = 0.97724.75 ± 12.30F = 0.160 p = 0.853 Income = Expense47.25 ± 24.6215.45 ± 11.238.32 ± 7.4223.47 ± 13.15 Income > Expense50.62 ± 30.3117.12 ± 13.067.75 ± 5.2325.75 ± 13.10 Family TypeCore45.48 ± 29.67F = 1.151 p = 0.32014.72 ± 11.07F = 1.723 p = 0.1837.62 ± 7.40F = 1.059 p = 0.35023.13 ± 13.17F = 0.638 p = 0.530Broad56.94 ± 35.0220.11 ± 14.479.76 ± 7.9527.05 ± 14.77 Alone51.00 ± 19.3617.33 ± 8.309.93 ± 5.7223.73 ± 9.12

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Table 3 Comparison of disease-related features with Post-Traumatı̇c Growth score PTGI post-traumatic growth inventory; CRO changes in relationships with others; CPL changes in the philosophy of life; CSP changes in self-perception Tukey post hoc test was used

FeaturesPTGI (Mean ± SD)Test/pCRO (Mean ± SD)Test/p

CPL (Mean

± SD)Test/p

CSP (Mean

± SD)Test/p Time after Diagnosis1–6 months*59.20 ± 28.73F = 11.231 p < 0.001 *–** p < 0.001 *–*** p < 0.001

20.86 ± 11.21F = 15.883 p < 0.001 *–** p < 0.001 *–*** p < 0.001

10.06 ± 7.02F = 4.585 P = 0.012

*–*** p = 0.015

28.26 ± 12.76F = 9.019 p < 0.001 *–** p = 0.001 *–*** p = 0.0087–12 months**35.44 ± 28.2010.92 ± 9.976.96 ± 7.8117.56 ± 12.10 13 months & above***34.15 ± 21.279.23 ± 7.125.34 ± 6.3919.57 ± 10.26 Knowledge Level About The Disease

No*31.50 ± 26.22F =

9.109 p < 0.001 *–*** p < 0.001 **–*** p:0.007

10.60 ± 10.03F = 7.339 p = 0.001 *–*** p = 0.003 **–*** p = 0.010

2.70 ± 5.62F = 11.617 p < 0.001

*–** p = 0.019

*–*** p < 0.001

**–*** p = 0.035

18.20 ± 12.18F = 6.762 p = 0.002 *–*** p = 0.005 **–*** p = 0.012

Partial**42.43 ± 28.2113.59 ± 11.017.65 ± 6.1821.18 ± 12.52 Adequate***60.19 ± 27.3720.31 ± 10.9111.19 ± 7.4928.68 ± 12.14 Chronic Dis- easeYes54.35 ± 30.37t = − 1.622 p = 0.10819.05 ± 12.31t = − 2.089 p = 0.0399.27 ± 7.36t = − 1.030 p = 0.30526.02 ± 12.61t = − 1.275 p = 0.205No44.79 ± 28.6914.32 ± 10.677.75 ± 7.2622.71 ± 13.03 MetastasesYes56.68 ± 25.18t = 1.872 p = 0.06418.79 ± 10.90t = − 1.599 p = 0.1139.96 ± 7.16t = − 1.470 p = 0.14427.93 ± 10.08t = − 2.019 p = 0.046No44.90 ± 30.3914.87 ± 11.477.65 ± 7.2922.36 ± 13.56 Stage of Dis- ease1. stage61.88 ± 20.31F = 1.555 p = 0.19220.88 ± 9.91F = 1.104 p = 0.3599.33 ± 4.52F = 1.666 p = 0.16331.66 ± 8.01F = 2.044 p = 0.0942. stage48.83 ± 30.4412.16 ± 12.4611.66 ± 7.5525.00 ± 13.63 3. stage60.25 ± 16.4718.62 ± 8.9512.12 ± 1.9529.50 ± 8.71 4. stage60.57 ± 22.7820.28 ± 11.3811.42 ± 7.4128.85 ± 9.70 Not known43.97 ± 31.2714.92 ± 11.717.26 ± 7.7121.78 ± 13.55

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high (Rezaei et al., 2017; Zebrack, 2015) or low (Cormio et al., 2017). In studies using the scale used in data collection, the mean PTG score was found to be 51.8 ± 25.9 (moderate) in patients with rheumatoid arthritis, and 60.5 ± 24.7 (high-level) in patients diagnosed with lymphoma (Dirik & Karancı, 2008; Smith et al., 2014). Different findings may be explained with reference to the type of cancer, methodology, and cultural characteristics of the population.

The mean scores obtained from the positive and negative subscales of the RCS were 24.5 ± 5.6 and 4.9 ± 2.9, respectively. Although the participants of our study used both positive and negative religious coping methods, positive religious coping methods were relatively higher. This made us realize that individuals benefit from the healing functions of religion by using religious coping methods such as prayer, worship, patience, gratitude, tawakkul, and consent. A study on breast cancer patients found that the participants mostly used positive religious coping methods (Borges et al., 2017). Other studies on religious coping methods among cancer patients reported that cancer patients with higher levels of religious coping had lower anxiety and better psychological mood (Borges et al., 2017). Besides, these patients had better self-care (Goudarzian, 2019). In a study in which the scale used in the research was carried out with healthcare professionals, it was found that the average of positive coping scores in women and negative coping scores in men was higher (Angın, 2021). In a different study conducted with a sample without a specific target group, the positive religious coping score was found to be quite high, while the negative religious coping score was found to be close to the average (Korkmaz, 2021). This showed that religious perception could differ in different sample groups.

The cancer patients in our study had high resilience levels. There are no clear data on psychological resilience in studies conducted with cancer patients. In a study conducted with lung patients (Hu et al., 2018), while high resilience was reported, moderate resilience was reported in a study conducted with colorectal cancer patients (Zhang et al., 2019). In another study comparing treated and palliative cancer patients, it was reported that the mean psychological resilience was higher in the treated group (Somasundaram & Yavaşani, 2016). Existing studies reported that cancer patients with higher resilience could better deal with

Table 4 Multiple regression analysis of variables predicting post-traumatic growth

Parameters B Std. Error Βeta t p 95% CI

Constant 30.598 13.730 2.228 0.028 3.373 57.822

Age 0.340 0.196 0.185 1.740 0.085 − 0.048 0.728

Having Child − 14.983 6.463 − 0.219 − 2.318 0.022 − 27.797 − 2.169 Time after Diagnosis − 12.691 3.256 − 0.357 − 3.898 p < 0.001 − 19.147 − 6.235 Knowledge Level About The

Disease 9.638 3.556 0.242 2.711 0.008 2.588 16.688

Negative Religious Coping 2.298 0.838 0.230 2.740 0.007 0.636 3.960 R = 0.565 Adjusted R² = 0.287 F = 9.850 p < 0.001

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intensive emotional stress (Min et al., 2013), had lower anxiety and depression symptoms (Hu et al., 2018), easily manage the disease, and suffered less from the side effects of treatment (Ristevska-Dimitrovska et al., 2015). These findings indicate the importance of resilience for cancer patients.

Different variables on PTG have been discussed in the literature. We did note a relationship between gender, marital status, and PTG in our study, which is in line with the literature (Cormio et al., 2017; Love et al., 2011; Zebrack, 2015). Although some studies have not found a relationship between age and PTG (Love et al., 2011;

Zebrack, 2015), others reported that PTG was higher for younger participants (Boyle et al., 2017). Similarly, our study found that age was negatively associated with PTG levels. Education level (Cormio et al., 2017; Rezaei et al., 2017) and working status (Cormio et al., 2017) have been reported to influence PTG levels. However, we did not find any relationship between education level, working status, and PTGI scores.

Cormio et al. (2017) reported that PTG was lower for cancer patients who had other health problems. However, we did not find any significant relationship between chronic diseases and PTGI scores. Jansen et al. (2011) reported that the level of PTG differed according to the level of cancer, whereas we did not find any relationship between the PTGI scores and the stage of disease. This made us conclude that some sociodemographic and disease-related characteristics of individuals may have an effect on PTG.

Our study found no relationship between PTG and resilience. A number of studies reported a positive relationship between PTG and resilience (Li et al., 2015; Yu et al., 2014). However, the same traumatic event may not cause the same effects on everyone. If the individual is psychologically more resistant or capable of inter- preting the basic schemes, they may live without experiencing PTG or a personal change (Dursun & Söylemez, 2020).

PTGI scores were correlated with having a child, time after diagnosis, knowledge level about the disease, and negative religious coping. In our study, time after diagnosis had a negative impact on PTG, which contradicted the results of some studies in the literature. Some studies found that PTG was higher when the time after diagnosis was low (Gianinazzi et al., 2016; Gunst et al., 2016; Yi & Kim, 2014;

Zhang et al., 2019), whereas others found that the length of time after diagnosis was positively associated with PTG (Aflakseir et al., 2016; Danhauer et al., 2013; Jansen et al., 2011). These conflicting findings may be related with the duration of disease, difficulties that patients experience, treatment/prognosis period, and other factors.

Cancer patients without any children obtained higher PTGI scores and having a child had a negative impact on PTGI. No study had evaluated the impact of having a child on PTG. It is possible to suggest that Turkish adults are more likely to sacri- fice themselves to provide a better living condition for their children. Therefore, the lower PTGI scores obtained by the Turkish participants with children may indicate their belief that a significant change in their lives may end up with a negative impact on their children.

PTGI scores were higher for the participants with higher knowledge about the disease, which had a positive impact on the PTGI scores. Positive impacts of positive cognitive processing on PTG in cancer patients has been reported by Caspari et al.

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(2017). This situation may be related to the decrease in fear, despair, and obscurity after learning more realistic information on prognosis and treatment processes.

Religious coping has been reported to influence PTG (Dursun & Söylemez, 2020) and various studies have considered the impact of positive religious coping on PTG (Gall et al., 2011; Leung & Chan, 2010; Paredes & Pereira, 2018). A study on cancer patients reported an increase in PTG levels parallel to an increase in religios- ity (Rezaei et al., 2017). However, religious coping methods may take other forms.

For example, some studies argue that eastern-culture-based spiritual practices may help cancer patients to cope with their diseases by using their internal power (Leung

& Chan, 2010). On the other hand, positive religious coping has been reported to contribute to PTG (Gall et al., 2011). In our study, we found a positive impact of negative religious coping on PTGI scores. This finding implies that the relationship between PTG, religion, and spirituality may be affected by various factors and may change among different cultures. Besides, we may argue that explanations about one’s life may be influenced by religious beliefs.

Conclusions and Suggestions

Individuals may experience various traumatic events or may witness the experiences of people around. These traumatic experiences may result in either positive or negative feelings, including not just post-traumatic stress disorder or depression but also PTG. This study found that PTGI scores were higher for the cancer patients without children, who were diagnosed with the disease in recent times, had higher knowledge about the disease, and used negative religious coping. Further prospective studies on different types of cancer with a more inclusive sample and from different centers may be conducted.

Strengths and Limitations

To our knowledge, no study has dealt with these parameters thus far. However, the findings of our study are limited to our sample; therefore, they cannot be generalized to the whole population of cancer patients. Other limitations of this study are that it was conducted at a single center, the targeted sample size was not obtained, and the design of the study was cross-sectional.

Clinical Implications

The increasing prevalence of cancer in Turkey and abroad has resulted in increased curiosity regarding the positive impacts of cancer experience. PTG is mostly used to define the positive psychological developments that occur after the diagnosis of cancer (Casellas‐Grau et al., 2017). Revealing the positive changes in cancer patients may help us to decrease the impact of negative experiences and develop efficient methods to deal with these experiences (Rezaei et al., 2017).

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Our study confirmed the relationship between PTG and religious coping. Reli- gious beliefs are important sources that help people to cope with difficulties. There- fore, health professionals that study cancer patients should be more sensitive to the religious and spiritual concerns of the patients and consider them while providing healthcare. In recent years, researchers have been attempting to develop novel tech- niques to provide spiritual care, find a meaning to existentialist problems, or increase PTG (Thombre et al., 2010). While including psychosocial interventions, patients and their readiness for interventions should be taken into consideration.

This study found that the PTGI scores were higher for participants who were recently diagnosed and had a higher knowledge level about the disease. Based on these findings, we suggest that patients in the early stages of cancer be informed about their diseases.

Acknowledgements No external funding was available for this study. We appreciate all participants who allowed us to collect data.

Author Contributions N.E.B., M.T, and S.Ç. were responsible for concept, design, supervision, resources, materials, data collection and/or processing, analysis and/or interpretation, literature search, writing the manuscript, and critical review.

Funding The authors have not disclosed any funding.

Data Availability Data have been deposited (Kanserspss2).sav) and will be available following a reason- able request.

Declarations

Conflict of interest The authors declare no conflict of interest.

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