ORIGINAL RESEARCH

 

Spiritual needs, practices and associated factors among patients with cancer at two teaching hospitals

 

 

Mpho Ratshikana^{I, II}; Daynia Ballot^III; Hellen Myezwa^IV; Mary-Lou Galantino^{IV, V, VI}; Sonti Pilusa^IV

^IWits Centre for Palliative Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IIDepartment of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
^IIIDepartment of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IVDepartment of Physiotherapy, School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VDepartment of Integrative Health, School of Health Sciences, Stockton University, Galloway, United States
^VIDepartment of Physiotherapy, Centre for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia,United States

Correspondence

 

 

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ABSTRACT

BACKGROUND: Patients diagnosed with cancer require holistic care that covers the physical, psychosocial and spiritual aspects of wellbeing.
AIM: To describe the spiritual needs, practices, association between spirituality, using Traditional Health Practitioners (THPs), ancestral belief, with socio-demographic and clinical characteristics, and examine the association between spiritual interventions and spiritual characteristics.
SETTING: Palliative Care units at two tertiary hospitals in Johannesburg.
METHODS: An observational retrospective study used routinely collected data of patients older than 18 years, diagnosed with cancer, having complete records on spiritual questions, and enrolled between January 2021 and December 2023. Data were analysed using STATA V18.
RESULTS: Most participants (n = 2465) were female (70.5%), with a mean age of 53.6 (s.d.: 22.7). Half were unemployed, 40.1% married/partnered, and 54.4% living with HIV. Many participants were religious (94.1%) and spiritual (96.3%), Christian (84.3%), 11.3% consulted a TPHs, and 20.0% had ancestral beliefs. Most (94.7%) relied on their faith for comfort, their faith grew stronger (84.9%,) and 79.7% needed forgiveness. Receiving spiritual interventions was associated with the need for forgiveness, relying on faith for comfort and receiving support from the faith community.
CONCLUSION: The study confirms that patients with cancer are spiritual and religious; some have ancestral beliefs, need forgiveness, and rely on their faith and faith communities to cope. The study further highlights the need for culturally relevant tools and interventions to address these needs.
CONTRIBUTION: The article highlights the unique spiritual beliefs and practices among patients with cancer that may influence planning for palliative care and cancer programmes.

Keywords: spiritual needs; practices; spiritual care; cancer; palliative care; traditional health practitioners; ancestors.

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Introduction

Cancer is highlighted as a growing public health concern globally, as it negatively affects low- and middle-income countries (LMICs) disproportionately.¹ South Africa, as a middle-income country, experiences a high burden of cancer, as well as high cancer mortality.² The World Health Organization (WHO) developed a cancer strategy that encouraged countries to develop comprehensive cancer strategies to address the cancer burden and needs of patients.³ In line with this recommendation, the National Department of Health in South Africa developed the National Cancer Strategic Framework, which recommends palliative care throughout the cancer continuum of care.⁴ The National Policy Framework and Strategy for Palliative Care (Palliative Care Framework) recognises the need for holistic care, covering physical, social, emotional and spiritual care.⁵ In line with WHO recommendations, South Africa approved the Traditional Health Practitioners Act 22 of 2007, which has not yet been fully incorporated as part of the public health system.⁶ Evidence on the physical, social, emotional and spiritual aspects of cancer care is scarce in South Africa.

A diagnosis of a life-threatening illness causes distress, which can include spiritual distress.^7,8 While there are many definitions for spirituality, spirituality in this study aligns with the consensus definition by Puchalski et al.⁹ According to Puchalski et al., spirituality is a human need and the way people seek meaning, purpose, transcendence and connections, expressed through beliefs, values and practices.⁹ While spirituality is different from religion, people can express their spirituality through religion.⁹ Spirituality is unique for each individual, and spiritual care provides a means of identifying these unique needs and developing a care plan that is specific to patients.¹⁰ Spiritual care is the process of assessing and addressing the spiritual needs of patients and families¹¹ and is an important component of palliative cancer care, recommended by the South African national palliative care policy and other guidelines globally.^5,9,12,13 According to these recommendations, health professionals can identify patients who have spiritual needs and who would benefit from spiritual care.

Most patients living with cancer in sub-Saharan Africa (SSA) use traditional, complementary and alternative medicine (TCAM).^14,15 Patients living with a cancer diagnosis consult traditional healers for different reasons, such as not being covered by biomedical medicine, using traditional medicine, practising faith healing and praying.^16,17,18 While research among patients living with cancer is increasing in SSA, such research is still limited in South Africa.¹⁵

Providing spiritual care and support for patients living with cancer is associated with better treatment outcomes, quality of life, improved coping, a source of hope and strength, pain and decision making,^19,20,21,22 whereas a lack of spiritual care support is associated with poor quality of life and existential suffering, which negatively impacts treatment outcomes.^23,24 Hence, the recommendation is that spiritual care should be incorporated as part of holistic person-centred care for people with cancer.^13,25 Compared with high-income countries (HICs), research on the spiritual needs and practices of patients living with a cancer diagnosis in South Africa is limited and has not been incorporated as part of comprehensive cancer care, despite policy recommendations.^5,13,26

This study aims to describe the spiritual and religious needs and practices of people living with cancer referred to palliative care units at two public tertiary hospitals in Johannesburg. The study specifically describes spiritual and religious needs and identifies common spiritual and religious practices among people living with cancer. The study further assesses the association between spirituality, having ancestral beliefs, consulting with the THP, socio-demographic and clinical characteristics. Lastly, the association between spiritual interventions and spiritual characteristics will be explored.

 

Research methods and design

Setting

The study was conducted at two academic hospitals in Johannesburg. Both hospitals provide cancer care, diagnosis, surgery and chemotherapy for adult patients living with cancer. The two hospitals jointly have a bed capacity of 4000 and have palliative care units that address the physical, social, emotional and spiritual aspects of patients living with cancer.

Design

This was an observational retrospective study in which data were routinely collected at both hospitals. Patients living with a cancer diagnosis who are referred to palliative care are assessed by teams of doctors, nurses, social workers and spiritual counsellors and chaplains for physical, social, emotional and spiritual needs, followed by tailor-made interventions by the relevant team members. Spiritual counsellors/chaplains are volunteers who are trained in spirituality and chaplaincy in palliative care short course through the University of the Witwatersrand. Spiritual care interventions included spiritual counselling, facilitating reconciliations, family meetings and referral to spiritual leaders as appropriate and prayers.^21,27 All the data were captured in the REDCap^28,29 electronic database maintained at the Wits Centre for Palliative Care. Records of patients enrolled between January 2021 and December 2023 were extracted for patients who were older than 18 years, were diagnosed with cancer, and were able to respond to questions from the team. Records of patients who were recorded as unconscious and unable to be assessed and those with incomplete spiritual questions were excluded.

Study data collection tools

Data were collected by teams of doctors, nurses, social workers, social auxiliary workers and spiritual counsellors via an electronic tool and captured via REDCap.^28,29 The routine information collected included socio-demographic characteristics (age, sex, race, nationality, ethnic group, marital status, employment, level of education); clinical characteristics (diagnosis, staging, comorbidities); palliative outcome measures, which were determined using the Integrated Palliative Outcome Scale, a validated tool globally^30,31; and, to determine spiritual needs, some questions from the Brief RCOPE³² and FICA,³³ validated tools used internationally, were extracted. To address face validity, palliative care staff were consulted on the adapted questions that address ancestral and traditional beliefs, common practices and interventions, some of which are described by Puchalski et al. and Zuma et al.^27,34 (Online Appendix 1: Supplement A).

Data analysis

Descriptive statistics were used to summarise the characteristics of the study sample, and the results were presented via different summary statistics for continuous and categorical variables. For categorical variables, frequencies (n) and percentages (%) were used to describe the data. The means and standard deviations (s.d.s) were used for normally distributed data, whereas the medians and interquartile ranges were used for skewed data. For bivariate analysis, Chi-square tests were conducted to assess associations, and independent t tests were used to compare age. The level of significance was set at 5%.

Ethical considerations

The study was approved by the University of the Witwatersrand Health Research Committee M240205; MED24-01-375, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) (No. GP_202403_059) and Chris Hani Baragwanath Academic Hospital (NHRD number: GP_202403_059). Ethical standards of the two institutional public tertiary hospitals were adhered to. Approval for the use of the deidentified dataset was obtained from management at both hospitals. Consent from participants was not required because the study was part of routine clinical care and retrospective, and the data were deidentified, which the ethics committee waived.

 

Results

Of the 3908 records for patients living with a cancer diagnosis who were retrieved, only 2465 records with complete information on spiritual characteristics were included in the analysis (Figure 1).

 

 

Socio-demographic characteristics of patients living with a cancer diagnosis at the two academic hospitals in Johannesburg

Most of the patients were black (81.8%), women (70.5%), with a mean age of 53.6 years. Half (51.9%) of the patients were unemployed, 78.2% had high school, technical high school and tertiary education, while 40.1% and 40.5% were married or partnered and single, respectively. Table 1 outlines the patients' demographic profiles.

 

 

Clinical characteristics of patients living with a cancer diagnosis at the two academic hospitals in Johannesburg

The most common cancers among the patients were breast (26.9%), cervix (22.2%) and gastro-intestinal, including hepatobiliary (20.2%) cancer. Lung and prostate cancer accounted for 6.9% and 5.7%, respectively. Almost half (54.4%) of the patients were living with HIV, 28.8% had hypertension and 8.4% had a diagnosis of diabetes. Common symptoms included pain, weakness/fatigue and poor mobility (see Figure 2). Most patients (78.0%) were worried about their disease, 86.4% reported family worry, while 69.9% felt at peace despite their diagnosis. Table 2 shows the clinical characteristics of the participants.

 

 

Spiritual and religious needs and characteristics of patients living with a cancer diagnosis at the two academic hospitals in Johannesburg

Almost all the participants agreed and strongly agreed that they were religious (94.1%), 96.3% were spiritual and 93.1% purportedly both spiritual and religious. Among the 494 with ancestral beliefs, 432 (87.4%) also reported having a Christian religion. Only 269 (11.3%) of the participants reported consulting a traditional healer/alternative medical practitioner (THP). Concerning the other spiritual and religious needs, 74.6% agreed and strongly agreed that they were looking for a stronger connection with God or Allah or Yahweh or ancestors, and 89.9% of the 494 who had ancestral beliefs were looking for a stronger connection with their ancestors. Most (94.7%) participants agreed and strongly agreed that their faith offered them comfort, whereas 84.9% indicated that their faith grew stronger after they became sick.

Only 279 (11.9%) participants consulted THPs, while 198 practised rituals. Of those who consulted THPs, half (53.5%) consulted THPs for prophecy, 19.0% because THPs understand the cause of the disease and 10.4% because THPs use herbs. The most common spiritual interventions provided by the spiritual counsellors were spiritual counselling (52.5%) and family meetings (25.6%).

Associations between spirituality, consulting with the traditional healer practitioner, having ancestral beliefs and socio-demographic and clinical characteristics among patients living with a cancer

Being spiritual was associated with being female, unemployed, having a high school education, diagnosed with breast and cervical cancer, living with HIV and having a diabetes diagnosis. (see Table 3 and Table 4). Being religious was associated with being female, being black, and having female cancers. Consulting the THP was associated with younger age (< 50 years), being black, female, unemployed, single, having a high school education and having a cervical cancer diagnosis. Ancestral belief was associated with being black and living with HIV (see Table 3 and Table 4).

Associations between spiritual interventions and spiritual characteristics among patients living with cancer

The associations between receiving spiritual interventions and spiritual characteristics are shown in Table 5. Receiving spiritual intervention is not influenced by the type of religion, whether the individual is spiritual or religious, belief in ancestors or consulting the THP. Only participants who felt that their faith offered them comfort, those who felt supported by their faith communities, those who were asking for forgiveness and those who practised rituals were more likely to receive spiritual counselling. The participants who felt abandoned by their God or Allah or Yahweh or ancestors were less likely to receive spiritual counselling.

 

Discussion

This study revealed that most patients living with cancer have spiritual needs. Similar to previous studies, patients living with cancer desire forgiveness and closer connections. These are both spiritual and religiously oriented, and patients use their faith to navigate the cancer disease journey.^19,22,35 In a systematic review, Balboni et al. highlighted that patients diagnosed with serious illnesses, including cancer, have spiritual needs that must be addressed as part of their holistic care.³⁶

Transcendence and connections with self and others are important dimensions of spirituality among patients living with cancer, as reported elsewhere.^8,9,19,37 In this study, most patients expressed the need for closer connections with higher power, God and ancestors. In addition, the patients embraced support from their faith communities.^19,34 Masola explained that for African patients diagnosed with chronic illnesses, restoring relationships with the supernatural may be part of the healing process for some patients.³⁸

Like in previous studies, some patients in this study not only relied on their faith in coping with their illness but also consulted THPs.^19,22,35,39 The use of THPs in this research is, however, lower than what was previously reported.^21,39,40 Low reporting rates for THP use have been associated with easy access to health facilities.³⁹ However, on the other hand, patients do not disclose the use of THP for fear of being discriminated against by health professionals, or they do not feel the need to share the information.^35,36,37 In a study conducted in Langa, Cape Town, Hughes (2015) reported that participants cited accessibility and affordability as reasons for using THPs.⁴¹

Of note is that most of the research conducted on THP use among patients living with cancer has been conducted mainly in Nigeria, Ethiopia and Ghana.¹⁴ This study fills this knowledge gap.

Previous research highlighted that patients living with cancer combine biomedical medicine and use THPs for different reasons. Patients with cancer use THPs because they believe that the disease has both physical and spiritual causes, that THPs give them hope, that they can connect them to ancestors, and that they can prophesy and have supernatural powers for faith healing.^42,43,44,45 Efforts to integrate traditional health and biomedical medicine have been unsuccessful, despite recommendations globally and by the South African Traditional Health Practitioners Act.⁶

According to some African scholars, there seems to be a link between belief in God, or the higher being, ancestors (who protect, bless and can curse descendants) and the use of THPs, who believe in witchcraft and the practice of rituals.^42,46,47,48 This might explain why some patients in this study reported having both ancestral and Christian beliefs. Research on the role of ancestors as part of religious and spiritual care in palliative and cancer care is limited. The need for forgiveness from ancestors among study participants may be a way of expressing the need to appease ancestors to avoid misfortunes, which can manifest as illness.^42,46

The spiritual care interventions used in this study included spiritual counselling, facilitating reconciliations, family meetings and referral to spiritual leaders as appropriate and prayers.^21,27 Receiving spiritual counselling was not influenced by the type of religion, being spiritual or religious, having a belief in ancestors or consulting the THPs in this study, confirming that providing spiritual care can address diverse palliative care patients, irrespective of their belief system, in line with previous recommendations.⁴⁸ Receiving spiritual interventions was associated with having a spiritual need and relying on faith for support and coping, highlighting the importance of spiritual assessment to identify needs that guide spiritual care interventions relevant to patients' needs. Patients who felt abandoned were less likely to receive spiritual support. This might be because they experience hidden loneliness and suffering that is not visible to others, as explained elsewhere.⁴⁹ This highlights the need for trained spiritual care counsellors and chaplains who can build trust and rapport to engage patients at a deeper level, because abandonment, being part of a religious struggle, has been associated with poor treatment outcomes.⁵⁰

Like in previous studies, spiritual and religious beliefs can be associated with some socio-demographic and clinical characteristics. Being female, unemployed, black and having low socio-economic status is associated with spiritual and religious beliefs and the use of THPs,^43,51,52 whereas breast cancer and cervical cancer are associated with being spiritual, religious and consulting THPs. More research to determine the associations between socio-demographic and clinical characteristics and spiritual, religious, ancestral and traditional beliefs is recommended.

Strengths and limitations

Limitations of the study include its retrospective nature, which may have introduced bias. The study participants are predominantly black people in urban settings and are mostly Christian, with missing values for some of the variables, particularly in response to 'Do you believe in ancestors' and 'Do you practice rituals?' The strengths of this study include its large sample size and use of validated tools.

Implications and recommendations

More research is needed to understand spiritual needs and develop relevant tools and interventions for the current setting. Policymakers and clinicians should consider integrating spiritual care as a component of cancer care across the continuum of care. Research to understand the use of THPs among patients living with cancer in the current setting is recommended. Culturally sensitive spiritual care tools that embrace the use of THPs and incorporate ancestral beliefs and interventions that capture rituals specific to the current population should be prioritised. Research investigating the reasons for less acceptance of spiritual counselling by patients who express abandonment by God or Allah or ancestors is recommended.

 

Conclusion

This study highlights that patients living with cancer are spiritual and religious. Patients have ancestral beliefs, need forgiveness and connections with God, higher beings and ancestors, rely on their faith and faith communities to cope, and some use THPs for distinct reasons. Receiving spiritual interventions was positively associated with being ritualistic and providing comfort, whereas spiritual care ignites feelings of abandonment and the need for forgiveness. Research should explore specifically what patients are seeking forgiveness for in the context of their lived experience and determine rituals practised and THPs used among this population.

 

Acknowledgements

The authors would like to thank Ms Peedi Mathobela for supporting them with the analysis of the data. They would also like to thank the palliative care teams at Chris Hani Baragwanath and Charlotte Maxeke Johannesburg Academic Hospitals for their assistance during the study.

This article is partially based on the author's thesis entitled 'Development of a model for spiritual care for cancer patients in Gauteng Province, South Africa' towards the degree of PhD in the Department of Internal Medicine, University of the Witwatersrand, South Africa, with supervisors Hellen Myezwa, Daynia Ballot, Mary-Lou Galantino, Sonti Pilusa.

Competing interests

The authors reported that they received funding from the Bristol Myers Squibb Foundation grant and the Female Academic Leaders Fellowship grant, which may be affected by the research reported in the enclosed publication. The authors have disclosed those interests fully and have implemented an approved plan for managing any potential conflicts arising from their involvement. The terms of these funding arrangements have been reviewed and approved by the affiliated university in accordance with its policy on objectivity in research.

Authors' contributions

M.R. is a PhD student who conceptualised the ideas of the manuscript, analysed and wrote the manuscript and sourced the funding. D.B., H.M., M.-L.G. and S.P. assisted as supervisors and supported M.R. during the conceptualisation and protocol development, analysis, review of the protocol and manuscript.

Funding information

The authors reported that they received funding from the Bristol Myers Squibb Foundation grant (grant number 95181377) and the Female Academic Leaders Fellowship grant (Award Cohort #2023).

Data availability

The data that support the findings of this study are available from the corresponding author M.R., upon reasonable request.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or the publisher. The authors are responsible for this article's results, findings and content.

 

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Correspondence:
Mpho Ratshikana
mpho.ratshikana-moloko@wits.ac.za

Received: 18 Apr. 2025
Accepted: 15 July 2025
Published: 30 Sept. 2025