Adres do korespondencji:
Karvan Bekmaz
Department of Nursing Orumieh Branch Islamic Azad University, Orumieh, Iran.
e-mail: K.bekmaz@iaurmia.ac.ir
Leila Mamashli
1, Hadiseh Okhli
2, Maryam Fattahi
3, Azam Hajibeglo
4, Karvan Bekmaz
51Department of Nursing, Gonbad Kavoos Branch, Islamic Azad University, Gonbad Kavoos, Iran
2Department of Nursing, Ali Abad Katoul Branch, Islamic Azad University, Ali Abad Katoul, Iran
3MS Nursing, School of Nursing and Midwifery, Shahed University of Medical Sciences, Tehran, Iran
4MS Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
5Department of Nursing, Orumieh Branch, Islamic Azad University, Orumieh, Iran
The effect of group logotherapy on the life expectancy of cancer patients in the north of Iran: a quasi-experimental study
Abstract
Introduction: Cancer as a formidable diagnosis causes the loss of life expectancy in patients. This study was conducted to determine the effectiveness of logotherapy on the life expectancy of cancer patients in the 5th Azar Hospital of Gorgan, Iran.
Material and methods: This quasi-experimental study with two groups (intervention group and control group) was conducted on 40 cancer patients referred to Gorgan’s 5 Azar hospital in Golestan province in the north of Iran from 1 March 2019 to 1 December 2019. The samples were selected by simple random sampling method. The Snyder’s Hope Scale (AHS) was used for data collection. In the logotherapy group, eight 60–90 minute-long sessions were performed in 4 groups included 5 participants. The data were analyzed by SPSS-16 statistical software using descriptive statistics (mean table and standard deviation) and inferential statistics (paired t-test and ANOVA test).
Results: The result of the paired t-test showed no significant difference before and after the intervention in the control group (p = 0.67), but this test showed a significant difference in the intervention group before and after the intervention (p = 0.01). The ANOVA test also showed a significant difference between the two groups (p < 0.01).
Conclusion: Considering the effectiveness of logotherapy on increasing the life expectancy of cancer people, it is recommended that relevant authorities should try to use this low-cost method to address the problems related to the meaning of life and life expectancy in cancer patients, and change the attitude of patients towards life expectancy.
Psychiatry 2021; 18: 30–35
Key words: group logotherapy, life expectancy, cancer
Introduction
Cancer, like other chronic diseases, is considered a health care issue and a major health problem that affects public health [1, 2]. It currently accounts for 12% of all deaths. It is estimated that cancer deaths will increase by between
10 and 6 million a year for the next 20 years [3]. All humans have the potential to develop cancer, and it is the second and fourth leading cause of death in devel- oped and developing countries, respectively [4]. Cancer has a significant impact on the lives of people and their families so that its diagnosis and treatment can change the course of life, daily activities, work, communication, and family role of the affected person, and all these are accompanied by severe stress [2]. Although cancer affects people’s mental health, the biggest problem for the patient at this time seems to be a sense of hopeless-
ness and despair. According to some studies, cancer has the greatest effect on hope compared to other chronic diseases [4]. Therefore, most hope-related studies have been conducted on cancer patients, as this disease is considered a threatening factor for hope. The results of studies show that people with higher levels of hope show more resistance in long-term treatment, pain, and side effects of chemotherapy and radiotherapy [5]. Cancer and hopeful thinking are interrelated. Firstly, hopeful people are more focused on the problem and are more active in solving it. They are also more likely to perform cancer screening behaviors. Secondly, hopeful people are less distressed and more adaptive to the diagnosis and treatment of cancer [1]. However, this requires learning new skills and training or using new methods that are beyond the patient’s control, and therefore, they require the support of others, including psychotherapists [6, 7].
Moreover, supportive care with different counseling methods is an integral part of patient treatment [8]. One of the most common treatment strategies to reduce frus- tration in the lives of patients with incurable diseases is the therapeutic approach [6]. The meaning therapy helps patients not to focus on the grief and despair caused by the disease, but also to seek meaning [9]. Teaching the meaning therapy, followed by the search for meaning, which is a combative task, increases one’s inner tension and forces the person to strive for what is to be achieved.
This level of inner tension not only does not interfere with the course of treatment but also it is necessary for one’s escape from the existential vacuum. The stress caused by inner tension turns the person’s despair into a feel- ing of success and hope [10]. Thus, meaning therapy is effective in cancer patients [11]. In this regard, the study of Breitbart et al. [12] entitled: “Psychotherapy with a focus on group logotherapy in the promotion of mental health in patients with advanced cancer”, showed a reduction in depression, frustration and significant improvement in patients’ mental health and quality of life. Also, a study conducted by Ebrahimi et al. [6] on the effectiveness of meaning therapy on increasing hope in patients with leukemia showed that logotherapy training can increase hope in patients with leukemia. Therefore, teaching the logotherapy intervention seems necessary for these patients, because various studies have reported the effectiveness of meaning therapy in these patients [13]. Also since cognitive, behavioral, and social factors can influence cancer adaptation and treatment, many researchers have assessed the effects of psychological interventions on psychological adjustment during treat- ment [14]. However, most of the treatment team mem- bers pay more attention to the physical problems of cancer patients and less attention to their psychological
problems. Therefore, considering the sensitivity of cancer issues and its psychological and physical effects on the patient and the need for intervention in this area, the researcher decided to study the effect of logotherapy on the life expectancy of cancer patients.
Material and methods
This quasi-experimental study was conducted on 40 cancer patients referred to a teaching hospital (to 5th Azar Hospital) in the north of Iran from 1 March 2019 to 1 December 2019. Participants were selected using a simple random sampling method. From all of the cancer patients, 40 participants were selected by the available sampling method and randomly divided into two groups: intervention (logotherapy) group (20 people) and control group (20 people). The sample size of this study was calculated to be 40 people (20 in each group) with an effect size of 1.28, the significance level of p = 0.05, and the test power of 95%. Inclusion criteria were: having a medical record related to the definitive diagnosis of cancer, being at the age range of 30–60 years, undergoing chemotherapy, willing to participate in research, having no experience of participating in the logotherapy training in the past, and having no psycho- logical problems. The exclusion criteria were: unwilling to participate in the study, experiencing psychological problems during the study, and death of the patient.
In this study, two questionnaires of demographic charac- teristics (gender, level of education, marital status, place of residence, occupation), and Snyder’s Hope Scale (AHS) were used. The hope questionnaire was developed in 1991 by Snyder et al. [15], to measure life expectancy in adults (over 15 years of age). This questionnaire consists of 12 questions and its purpose is to examine the level of life expectancy in people using self-assessment. The questionnaire includes 4 items for measuring factor thinking, 4 items for measuring strategic thinking, and 4 deviant items, and its scoring method is based on a five-option Likert’s scale from completely disagree (score 1) to completely agree (score 5). The subscale of factor thinking includes four questions (2, 9, 12, 10), the subscale of strategic thinking has four questions (1, 4, 7, 8) and the other 4 questions (3, 5, 6, 11) are considered deviant questions [16]. Snyder et al. [15] determined the internal consistency of the whole scale be between 0.74 and 0.84 through Cronbach’s alpha. Grewal et al. [17] found the internal consistency of 0.71–0.76 for the subscale of factor thinking and Alexander [18]
calculated the internal consistency of 0.63–0.80 for the subscale of strategic thinking. Also, by the test-retest method, they found the internal consistency of 0.85 after 3 weeks, 0.73 after 8 weeks, and 0.82 after 10 weeks.
Kermani et al. [16] calculated the Cronbach’s alpha of 0.86 for the whole scale, 0.77 for the subscale of factor thinking, and 0.79 for the subscale of strategic thinking.
They also stated that the Snyder’s hope scale has good validity and reliability for the Iranian population, can be used in psychological assessments in Iran, and it is an appropriate tool in clinical and educational settings for people assessment and planning treatment and preven- tion programs [19]. Therefore, the validity and reliability of this tool were extracted from the above article. The reverse scoring method was used for questions 3-7–11 and its items were as follows: 1) I completely disagree, 2) I disagree, 3) I have no opinion, 4) I agree, 5) I com- pletely agree.
After approving the project in the Research Council of the Faculty, obtaining the code of ethics from the Islamic Azad University of Chalous Branch (IR.IAU.
AK.REC.1397.005), and receiving permission from the hospital officials, the researcher attended the relevant hospital for data collection. Cancer patients who were admitted to the oncology ward of the selected hospital for chemotherapy were invited to participate in the study. Then, by observing the ethical considerations, after providing explanations about the objectives, the process, and the importance of the study, written and informed consent was taken from all patients. They were also ensured that their information would be kept
confidential and they can withdraw from the study at any time for any reason, even during the data collection.
Before the implementation of the educational interven- tion, a life expectancy questionnaire was distributed between the control and intervention groups. It should be noted that 6 patients were illiterate to fill out the questionnaire, so the researcher filled out the question- naire by interviewing them. Also, all questionnaires were completed and none of the patients left the study.
Then, a logotherapy intervention was implemented.
For the intervention process, the logotherapy training was conducted according to the article of Ahmarian et al. [20] in 8 sessions of 60–90 minutes in 4 groups of 5 people (Table 1). In the control group, patients did not receive any intervention except routine care. In the control group, all ethical issues were observed according to national protocols.
Results
Patient demographic characteristics showed that men made up the highest percentage of samples (85% in the intervention group and 75% in the control group). In terms of education, the largest subgroup in the interven- tion group were the illiterate (30%), while in the control group – people with primary and secondary education (30% each). Also, 95% of the subjects in the interven- tion group and 80% in the control group were married, Table 1. The process of logotherapy sessions
Session process Logotherapy sessions
Content of training
Session 1 Determine the objectives and rules of the groups with the help of each other and counseling Session 2 Address the problem of group members and the commitment of members to participate in
group sessions
Session 3 Strengthen members’ social relationships with each other Session 4 Receive the main concept of feeling hopeless and hopeful for life Session 5 Discuss freedom and the right to choose the lifestyle
Session 6 Overcome despair, and increase life expectancy
Session 7 Discuss one’s responsibility towards oneself, others, and living in each period of life, and fin- ding the meaning of life expectancy
Session 8
Review of the topic of the meaning of life and life expectancy, working on the attitudes of group members, continuing the discussion of the previous session, conclusion, and end of group counseling sessions
Logotherapy sessions were conducted by a psychiatrist and clinical psychologist. No interven- tion was implemented for the control group. Then, after completing the group meaning thera- py training, the life expectancy questionnaires were completed again by both groups. The data were collected and analyzed by descriptive statistics (descriptive, mean, and standard deviation) and inferential statistics (paired t-test and ANOVA test).
70% of them in the intervention group, and 60% in the control group were residents of the city and the highest percentage (40%) of them were self-employed. In the intervention group, 30% were housewives (Table 2).
The paired t-test did not show a significant difference before and after the intervention in the control group (p = 0.41), but in intervention group, it showed a signi- ficant difference (p < 0.01). In other words, the finding showed that meaning therapy has increased life expec- tancy in cancer patients (Table 3).
Results of the ANOVA test also showed that by elimi- nating the effect of the pretest, there was a significant difference between the intervention and control groups, and probably 32% of the post-test changes have been caused by the intervention (Table 4).
Discussion
This study aimed to investigate the effect of logotherapy on the life expectancy of cancer patients in Gorgan 5th Azar Hospital. The results of the present study showed Table 2. Frequency distribution of the samples in the intervention and control group based on demographic characteristics
Demographic characte- ristics of the groups
Intervention Control Total
Percentage Frequency Percentage Frequency Percentage Frequency
Gender Female 3 15 5 25 8 20
Male 17 85 15 75 32 80
Education
Illiterate 6 30 3 15 9 22.5
Primary 3 15 6 30 9 22.5
Secondary 5 25 6 30 11 27.5
Diploma 4 20 4 20 8 20
University 3 15 1 5 3 7.5
Marital status
Single 1 5 4 20 5 12.5
Married 19 95 16 80 35 87.5
Place of residence
City 14 70 12 60 26 65
Village 6 30 8 40 14 35
Occupa- tion
Farmer 4 20 3 15 7 17.5
Housewife 3 15 6 30 9 22.5
Office worker 1 5 – – 1 2.5
Self-employed 8 40 6 30 14 35
Shopkeeper 1 5 1 5 2 5
Unemployed 3 15 4 20 7 17.5
Table 3. Comparison of life expectancy of cancer patients in the intervention and control group before and after the intervention according to paired t-test
Group Demographic
Before intervention Test results After intervention Test results
Intervention Control Intervention Control
Life expectancy 47.45 ± 4.8 44.15 ± 4.67 p = 0.41 51.95 ± 4.12 15.15 ± 5.45 p < 0.0 ± 01
Table 4. Comparison of life expectancy of cancer patients in the intervention and control group according to the ANOVA test
Group Before intervention After intervention Total
Intervention 47.45 ± 4.8 51.95 ± 4.12 p < 0.001
Control 44.15 ± 4.67 45.15 ± 5.45 Eta = 0.32
that teaching logotherapy increased the life expectancy of cancer patients. This finding is consistent with the results of a study by Mohabbat-Bahar et al. [10] that sho- wed group logotherapy training is effective in improving the life expectancy of patients with gastric cancer. Also, the results of the present study are in line with the study of Ebrahimi et al. [6] and Abolghasemi et al. [21], which showed meaning therapy significantly increased life expectancy in cancer patients. The study of Mehangiz [22]
showed that logotherapy training reduced frustration in women with breast cancer. Also, the findings of this stu- dy are consistent with the studies of Jaarsma et al. [23], and Breitbart et al. [12] that indicated the usefulness of logotherapy intervention in reducing frustration and mental disorders. HajiAzizi et al. [24] in their study wit- nessed the effect of meaning therapy on increasing life expectancy in the elderly, which is consistent with the finding of the present study, with the difference that the type of samples is different in these two studies. Kang et al. [25] showed that meaning therapy has affected the lives of cancer patients and increased their morale. The meaning of life is a structure that comes from hope, and hope can be considered as an element of a meaningful life, so hope can be a predictor of physical and mental health [26]. Thus, life expectancy is an important issue that should be considered in these patients, because hope is an important mechanism in chronic diseases such as cancer, and can potentially improve patient’s status and help them adapt to their new situation [27].
Hope is a factor that has a therapeutic value in dealing with chronic pain or life-threatening events. Having hope in a face of chronic disease is an endless process and has a positive effect on people’s health, because it enables people to cope with the crisis, increases the quality of life, and leads to satisfaction in achieving health goals and health promotion [28]. Logotherapy can improve mental health in patients with breast cancer who have serious problems with their meaning of life.
Such psychological therapies can improve the mental pain of cancer patients, which is usually a concern re- lated to feelings of hopelessness and loss of meaning of life [29].
One of the limitations of the present study was the individual differences in honesty and psychological and mental conditions of the research units in answering the questions, the control of which was beyond the control of the researcher. Participants were also selected from different types of cancer and no specific type of cancer was considered. Also, in this study, assessment of meaning therapy was not carried out in a long period; for example, over several months. The advantages of the study were the use of a quasi-experimental method to improve the quality
of the study. The use of standard tools to measure hope among patients as well as the use of the control group to better compare the results of the study.
Conclusion
Based on the findings of the present study, it can be concluded that meaning therapy as a psychological intervention changes the lives of people with cancer.
Therefore, considering the effect of meaning therapy on increasing life expectancy of cancer patients, it is recom- mended that the relevant authorities should try to use this low-cost method and pay attention to the problems related to the lack of meaning of life and life expectancy to change the patients’ view of life expectancy.
Acknowledgment
This article is part of a research project at the Student Research Committee of the Faculty of Nursing, Islamic Azad University of Aliabad Kotoul Branch in Iran, with the code of ethics: IR.IAU.AK.REC.1397.005 and the clinical trial code: IRCT20181214041959N1. The authors would like to thank the staff of Gorgan 5th Azar Hospital and all the patients who helped us in this research.
References:
1. Wei Di, Liu XY, Chen YY, et al. Effectiveness of Physical, Psychological, Social, and Spiritual Intervention in Breast Cancer Survivors: An Integrative Review. Asia Pac J Oncol Nurs. 2016; 3(3): 226–232, doi:
10.4103/2347-5625.189813, indexed in Pubmed: 27981165.
2. Shahsavari H, Matory P, Zare Z, et al. Effect of self-care education on the quality of life in patients with breast cancer. J Educ Health Promot. 2015; 4: 70, doi: 10.4103/2277-9531.171782, indexed in Pubmed: 27462612.
3. Nia HS, Lehto RH, Ebadi A, et al. Death anxiety among nurses and health care professionals: a review article. Int J Community Based Nurs Midwifery. 2016; 4(1): 2–10, indexed in Pubmed: 26793726.
4. Alizadeh S, Khanahmadi S, Vedadhir A, et al. The relationship between resilience with self- compassion, social support and sense of belonging in women with breast cancer. Asian Pac J Cancer Prev.
2018; 19(9): 2469–2474, doi: 10.22034/APJCP.2018.19.9.2469, indexed in Pubmed: 30255701.
5. Khattab M, Elkababri M, Cherkaoui S, Benmiloud S, ElHoudzi J, Hessissen L, et al. 46 Congress of The International Society of Paediatric Oncology (SIOP) 2014 Toronto, Canada, 22-25 October, 2014 SIOP Abstracts. Pediatr Blood Cancer. 2014; 61 Suppl 2:
S105-S433 https://doi.org/10.1002/pbc.25314.
6. Ebrahimi N, Bahari F, Zare-Bahramabadi M. The effectiveness of group logo therapy on the hope among the leukemic patients. Iran J Cancer Prev. 2014; 7(1): 9–16, indexed in Pubmed: 25250142.
7. Bekmaz K, Hojjati H, Akhoundzadeh G. Relationship between mothers’ concerns and nursing support of children admitted to Baqiyatallah Al-Azam Hospital of Ali Abad Katoul, Golestan Province, Iran, in 2018. Modern Care Journal. 2019; 16(4), doi: 10.5812/
modernc.92471.
8. Delavari H, Nasirian M, Baezegar Bafrooei K. Logo therapy effect on anxiety and depression in mothers of children with cancer. Iran J Ped Hematol Oncol. 2014; 4(2): 42–48, indexed in Pubmed: 25002923.
9. Morgan J. Geriatric Logotherapy: Exploring the Psychotherapeutics of Memory in Treating the Elderly. Psychological Thought. 2012;
5(2), doi: 10.5964/psyct.v5i2.39.
10. Mohabbat-Bahar S, Golzari M, Moradi-Joo M, et al. Efficacy of group logotherapy on decreasing anxiety in women with breast cancer. Iran J Cancer Prev. 2014; 7(3): 165–170, indexed in Pubmed: 25250168.
11. Mohabbat-Bahar S, Golzari M, Moradi-Joo M, et al. Efficacy of group logotherapy on decreasing anxiety in women with breast cancer. Iran J Cancer Prev. 2014; 7(3): 165–170, indexed in Pubmed: 25250168.
12. Breitbart W, Rosenfeld B, Pessin H, et al. Meaning-centered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer. J Clin Oncol. 2015;
33(7): 749–754, doi: 10.1200/JCO.2014.57.2198, indexed in Pubmed: 25646186.
13. Antoni MH. Psychosocial intervention effects on adaptation, disease course and biobehavioral processes in cancer. Brain Behav Immun.
2013; 30 Suppl: S88–S98, doi: 10.1016/j.bbi.2012.05.009, indexed in Pubmed: 22627072.
14. Girmenia E, Andrissi L, Tambone V. [On the clinical applications of logotherapy: a review of Victor Emil Frankl inheritance]. Clin Ter.
2014; 165(4): e330–e335, doi: 10.7417/CT.2014.1751, indexed in Pubmed: 25203351.
15. Snyder CR, Harris C, Anderson J, et al. The will and the ways:
Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology. 1991; 60(4):
570–585, doi: 10.1037/0022-3514.60.4.570.
16. Kermani Z, Khodapanahi MK, Heydari M. Psychometric features of the Snyder Hope Scale. Applied Psychology. 2011;5:-.
17. Grewal PK, Porter JE. Hope theory: a framework for understan- ding suicidal action. Death Stud. 2007; 31(2): 131–154, doi:
10.1080/07481180601100491, indexed in Pubmed: 17410693.
18. Alexander E, Onwuegbuzie A. Academic procrastination and the role of hope as a coping strategy. Personality and Individual Differences.
2007; 42(7): 1301–1310, doi: 10.1016/j.paid.2006.10.008.
19. Adhiya-Shah K. Book Review: The will to meaning: foundations and applications of logotherapy. Front Psychol. 2017; 8, doi: 10.3389/
fpsyg.2017.02106.
20. Ahmarian SF, Kolaei KJ. The effectiveness of meaningful therapy on life expectancy and sleep quality in the elderly living in boarding schools. Research in Religion and Health. 2015; 3: 12–18.
21. Abolghasami S, Saeadi S, Morri Najafi N. The effect of guided imagery and logo therapy on depression, anxiety and hopefulness in women with cancer in Ahwaz. Woman and Culture. 2010; 2:
31–47. 2010.
22. Mehangiz SK, Masoumeh S. The study of effective logo therapy trai- ning on reduction hopelessness in breast cancer Women’s in Tehran city. Iranian Quarterly Journal of Breast Diseases. 2010; 3: 40–48.
23. Jaarsma TA, Pool G, Ranchor AV, et al. The concept and measure- ment of meaning in life in Dutch cancer patients. Psychooncology.
2007; 16(3): 241–248, doi: 10.1002/pon.1056, indexed in Pubmed: 16850389.
24. Hajiazizi A, Bahmani B, Mahdi N, et al. Effectiveness of group lo- gotherapy on death anxiety and life expectancy of the elderly living in boarding houses in Kerman. Salmand. 2017; 12(2): 220–231, doi: 10.21859/sija-1202220.
25. Kang KA, Im JI, Kim HS, et al. The effect of logotherapy on the suffering, finding meaning, and spiritual well-being of adolescents with terminal cancer. Journal of Korean Academy of Child Health Nursing. 2009; 15(2): 136, doi: 10.4094/
jkachn.2009.15.2.136.
26. Owen DC. Nurses’ perspectives on the meaning of hope in patients with cancer: a qualitative study. Oncol Nurs Forum. 1989; 16(1):
75–79, indexed in Pubmed: 2911530.
27. Herth KA. The relationship between level of hope and level of coping response and other variables in patients with cancer. Oncol Nurs Forum. 1989; 16(1): 67–72, indexed in Pubmed: 2911529.
28. Mamashli L, Baziar N, Fard NG, Leila Jouybari AS, Rezapour Esfahani M. Evaluation of hopefulness in patients undergoing hemodialysis in Golestan University of Medical Sciences. nursing development in health. 2019; 9: 55–64.
29. Hasannezhad Re, Mirzaian B, Hosseini SH. Effect of acceptance and commitment-based training on difficulty in emotion regulation and health in women with breast cancer: A clinical trial study. J Gorgan University of Medical Sciences. 2020; 21: 22–28.
