Psychosocial-spiritual interventions among Muslims undergoing treatment for cancer: an integrative review

Background Cancer is a global disease that affects all populations, including Muslims. Psychological and spiritual care of Muslim patients with cancer includes psychosocial and spiritual techniques that help to improve their mental health and spiritual well-being. Although these techniques are available to cancer patients worldwide, they are poorly studied among Muslim patients. This review aims to integrate the literature on the psychosocial-spiritual outcomes and perspectives of Muslim patients with cancer who have undergone psychotherapy. Method We used the Whittemore and Knafl five-step methodology. We conducted a comprehensive search of PubMed, CINAHL, and PsycINFO using relevant keywords. Studies that focused on adult patients with cancer and on published evidence of using psychosocial and spiritual interventions among Muslim patients were included. Each study was reviewed, evaluated, and integrated. Results A systematic search produced 18 studies that were thematically analyzed. Results showed different psychosocial and spiritual approaches currently used to care for Muslim patients with cancer that target mainly patients’ mental health, quality of life, and spiritual well-being. Four major themes emerged: (1) Treating Psychological Distress Without Psychopharmacologic Agents, (2) Improving Knowledge of Cancer for Improving QOL, (3) Depending on Faith for Spiritual Well-being, and (4) Relying on Religious and Spiritual Sources: Letting Go, Letting God. Conclusions The rigor of psychosocial and spiritual studies that target psychosocial-spiritual outcomes of Muslim cancer patients needs to be improved to reach conclusive evidence about their efficacy in this population.

culturally and spiritually diverse groups [8]. Culturally and spiritually sensitive psycho-oncologic care embraces patients' self-reported stories, beliefs, values, and practices shaped by historical and geopolitical contexts and religious and spiritual beliefs and practices [9]. However, few cancer-care specific psycho-oncologic interventions are specific to Muslim patients [10].
Islam is the second largest and fastest growing religion in the world. By 2050, Muslims will comprise almost 30% of the world's population; it will be the world's largest religious population [11]. In 2019, the global Muslim population was estimated at 1.9 billion. The ongoing growth of the Muslim population, and the increasing cancer prevalence among Muslims worldwide, warrant the need to gain insights into psycho-oncologic care, particularly psychosocial and spiritual approaches, used in the treatment of Muslims. The outcomes of psycho-oncologic approaches in patients with cancer have been widely studied and reviewed. Yet, these reviews have not examined such approaches as provided to Muslims. Given the predominance and ongoing growth of Islam, it is necessary to understand Muslims' experiences with, and perceptions of, psycho-oncologic approaches, particularly with regard to their psychosocial-spiritual care. Thus, in addition to describing the effect of psychosocial and spiritual interventions on mental health, spiritual, and quality of life outcomes, a review is needed that integrates the literature on Muslim cancer patients' experiences of these interventions.
The purpose of this review was to integrate the literature on the mental health, spiritual well-being, and quality of life outcomes with the perspectives of Muslims who have been treated with psychosocial and spiritual techniques to treat the psychosocial-spiritual distress associated with cancer or its treatment. We used the biopsychosocial-spiritual model as a framework for this review [12]. According to this model, illness can disrupt biological relationships that in turn disrupt the patients' psychological, social, and spiritual relational aspects. Following the model, culturally and spiritually sensitive cancer care must address the totality of the patient's relational existence-physical, psychological, social, and spiritual. In the model, spirituality is construed to have four domains: religiosity, religious coping and support, spiritual well-being, and spiritual need [12].

Design
This integrative literature review used Whittemore and Knafl's [13] methodology and the PRISMA criteria of quality for reporting reviews [14]. We used the narrative synthesis approach as it allows for the inclusion of studies with different research designs, including qualitative studies, thus providing a better understanding of the potential positive outcomes of using psycho-oncologic interventions from multiple lenses [13]. This synthesis provides extensive literature coverage and has the flexibility to deal with emerging knowledge and concepts. Table 1 presents the search terms and Boolean operators that were used to build the search strategy. This strategy was developed in consultation with a medical librarian. The search was conducted from September to November 2019 and updated in July 2020.

Inclusion and exclusion criteria
Thus, studies were included if they used psychosocialspiritual interventions, including those that appealed to religiosity and religious coping, as the primary intervention in cancer care; included Muslim participants with a diagnosis of any cancer; and were published in peerreviewed journals between 2010 and 2020, in English. This timeframe reflects the last decade of international growth of psychosocial-spiritual interventions for Muslims living with cancer, all of which are the result of a systematic search process. We defined psychosocialspiritual interventions as addressing mental health problems through systematic, time-limited activities, including those that involved complementary therapies, including those that appealed to religiosity and religious coping; that involved contacts between a cancer patient and a trained healthcare provider who sought to ameliorate cancer-related distress by producing changes in individuals' feelings, thoughts, attitudes, and behavior; and that included a psychotherapeutic component, such as psychoeducation, therapeutic alliance, counseling, and structured, manualized interventions [15]. Studies were excluded if they were case reports or used observational methods, did not describe the applied psychosocial and spiritual technique/approach/intervention in the methods, and/or included psychopharmacologic agents as part of the intervention.

Procedures
Two authors (AA and ML) independently screened titles and abstracts using the Covidence systematic review software (https://www.covidence.org), to identify studies for full-text screening. These two authors then independently screened full-text studies to identify studies that fit inclusion criteria. At all stages, disagreements were resolved. The reference lists of the included studies were scanned for further studies.

Data evaluation
The included studies' quality was assessed using two criteria, methodological or theoretical rigor and data relevance, on a 2-point scale (high = 1, low = 2).
Methodological rigor was assessed according to whether the study's methodology was explained in such detail that it could be replicated. Data relevance was assessed according to whether the data presented addressed the study's stated aims. No studies were excluded on the basis of quality; however, more weight was given in analysis to studies with rigor and data relevance rates of 1.

Data extraction, analysis, and synthesis
Narrative synthesis accounted for differences in intervention approaches, study design, and methodological quality among the reviewed studies. Studies reporting similar outcomes were clustered and discussed together to draw meaningful interpretations of the data.
Interpretations regarding clinical relevance were made regardless of whether studies were statistically powered; however, we only described the intervention as useful for studies that used a 2-arm design. We only described the intervention as useful if the outcome measure between the study arms was reported as significantly different (p ≤ 0.05).
Extracted data were compared word-by-word in a data extraction table in Excel. We (AA and ML) created a list of keywords for each study. These keywords were reviewed to decide what concepts the data reflected. We used these concepts as codes. Each code was compared to all other codes. Comparisons for similarities, differences, and general patterns were made. Similar and reciprocal codes were categorized and grouped. These coded categories were compared and contrasted. The initial subgroup classification relied on psychosocialspiritual outcomes, which were analyzed by evaluating all interventions and qualitative designs. We (AA and ML) organized these subgroups by themes based on commonality, relationships, and patterns and refined these themes to encompass as much of the data as possible. Presentations of primary source data were employed to simplify the distinctions between patterns, themes, and associations. We assembled the analogous variables next to one another to assess for any associations between them. The final stage involved a shift from interpretive efforts to descriptive ones that sought to determine patterns and relationships to understand higher abstraction levels.

Search outcomes
The final sample included 18 articles for review (see Fig. 1).

Study characteristics and quality of the reviewed studies
The included studies in this review were published between 2013 and 2019. The 18 studies included a total of 2996 participants. Female participants outnumber male participants, and all participants' ages were ≥ 18 years old. Fewer than 50% of the studies used two or more self-reported outcome measures. Table 2 describes the country where the study was conducted and the study's design and analytic approach. Table 3 shows the characteristics and findings of psychosocial-spiritual interventions by treatment approach. The cancer types and stages in the included studies were heterogeneous and ranged between the early and late cancer stages. However, several studies did not specify the site or stages of cancer of the participants. The most prevalent cancer type in the review sample is breast cancer. These studies were conducted in different cancer care settings, such as hospitals, cancer research centers, and oncology and radiotherapy departments.
The psychosocial-spiritual interventions' duration ranged from 3 to 12 weeks. The contents of the interventions and duration and length of sessions varied, but two had relatively similar content and protocol [18,19]. A trained facilitator performed the interventions in some of the included studies (n = 5, 28%). Two studies [20,21] used complementary therapy such as laughter yoga and aromatherapy. Three studies implemented psychoeducation, including , and the Rosenberg Self-Esteem Scale (RSES). The quality scores and comments on reviewed studies are presented in Table 3.

Treating mental health without psychopharmacologic agents
Among the 18 studies, eight studies showed improvement in mental health outcomes [10, 20-22, 24, 27, 29, 34]. Specifically, psychoeducation [22] and CBT [27] improved depression and anxiety symptoms and stress. Mindfulness-based cognitive therapy had a significant long-term effect (p = 0.014) on self-management, posttraumatic growth, and functional disability [29]. Aromatherapy [21] contributed to stress relief and improved sleep quality. Complementary therapy (laughter yoga) [20] and psychoeducation [22,24] enhanced a sense of optimism and hopefulness. Improving knowledge of Cancer for improving QOL This theme was represented by seven studies that addressed the role of CBT [25,26,28,30], spiritual therapy [34], and psychoeducation [23,24] on enhancing quality of life in Muslim patients with cancer. Spiritual group therapy helped patients listen to their inner voice, let go of resentment, and forgive, which led to improvements in quality of life [18,34]. Education about the psychological aspects of cancer and mindfulness-based stress reduction [30] assisted patients in enhancing cognitive, emotional, and social function [24]. Other participants showed improvement in overall quality of life and emotional well-being among psychoeducation groups [23]. Men with prostate cancer also indicated that CBT enhances their quality of life [26]. Finally, a combination of CBT and a spiritual-religious intervention was found to promote breast cancer survivors' quality of life and coping responses [25].

Depending on faith for spiritual well-being
Five studies employed a spiritual therapeutic technique [18,19,[32][33][34], all of which reported improved spiritual well-being. Patients who received spiritual psychoeducation and counseling, such as educational materials about Islam, relaxation exercises, and meditation, reported improved spiritual well-being scores [33]. Women with breast cancer, through spiritual therapy, discussed spiritual and religious beliefs (regarding death and fear of death, faith, and trust in God) and the effect of these beliefs on life [34]. In Jafari and colleagues' [18] study, women with breast cancer explored negative and positive thoughts in a spiritually based therapy, which resulted in improved senses of meaning and peace.
Relying on religious and spiritual sources: letting go, letting god Muslim patients with cancer relied on spiritual and religious sources while applying psychosocial-spiritual therapy to provide comfort, coping, and meaning in their experience, as described in three studies (spiritual counseling [19] & spiritual-religious interventions [23. 30]). Patients living with cancer considered their belief in God as a central source of their power [32]. This source supported their inner-strength, which was necessary to fight death anxiety. Patients adopted a strategy of accepting divine providence, which leads to improvements in the faith element of spiritual well-being. In the 2017 study by Ghahari and colleagues [25], breast cancer survivors used spiritual/religious resources to solve personal and interpersonal problems that enhanced their coping responses. Both were practicing prayer and religious advice, such as reciting verses from the Qur'an, which played a paramount role in alleviating patients' suffering and promoting a sense of contentment and selfconfidence [20].

Discussion
The purpose of this integrative review was to synthesize the research on the psychosocial-spiritual outcomes of psychosocial-spiritual interventions in Muslim patients undergoing treatment for cancer. We used a narrative approach to research synthesis and sought to generate new insights and recommendations by going beyond the summary of findings from different studies [14]. The individual studies used various outcome measures, cancer types and stages, and intervention modalities in our review. This heterogeneity renders it challenging to conduct a systematic review due to clinical diversity (population, intervention, & outcomes), inconsistency in effect size and direction, and lack of data to calculate standardized effect sizes, hence the narrative design. Psychosocial-spiritual interventions are nonpharmacological strategies that address psychosocial-spiritual distress associated with cancer [5]. Throughout this review, we noted a myriad of psychosocial-spiritual interventions studied in Muslim patients with cancer that target various psychosocial-spiritual outcomes, including promoting patients' mental health, quality of life, and spiritual well-being [24,25], which were the most common outcomes in the studies included for review. Reviewed studies have shown that CBT-based interventions are promising strategies to improve psychosocial-spiritual              [10,18,19,[31][32][33][34]. The reviewed studies are also informative in building a base for the effectiveness of psychosocialspiritual interventions in Muslim patients' psychooncologic treatment. This review confirms the positive outcomes of various psychosocial-spiritual interventions on improving mental health, such as improving symptoms of depression, anxiety, and stress [10,20,21,24,27,29,32,34]. Consulting sessions [23,25] provide patients with practical and educational information and resources related to emotions such as depression, anxiety, and fear associated with cancer. Mindfulness-based cognitive therapy [27,29] increases patients' awareness of their feelings; throughout this therapy, patients acquire cognitive skills that promote metacognitive awareness, acceptance of negative thoughts, and an ability to effectively cope with psychological distress. Aromatherapy [21] entails using volatile essential oils of plants to enhance mental health. These oils stimulate the olfactory nerves, which connect to long-term memories that involve long-forgotten memories and their emotional links to one's life. These emotions can enhance sleep quality and relieve stress. Laughter yoga [20] includes various techniques, such as clapping and chanting, and deep breathing, which prepare the mind for happiness and improve a sense of optimism and hopefulness.
This review also suggests that different psychosocialspiritual interventions can enhance Muslim cancer patients' quality of life. A diagnosis of cancer and its associated treatment leads to emotional distress because of deteriorating health and impending death, which can result in reduced quality of life. The hopelessness [18] that is associated with poor quality of life can also be a predictor of depressive symptoms among patients with cancer. Seven of the studies included in this review suggest that psychosocial-spiritual strategies can improve patients' quality of life [23-26, 28, 30, 34].
Mindfulness-based cognitive therapy [28] helps patients by incorporating cognitive therapy and meditative practices to attract attention to thoughts and feelings without prejudging consciously. This can help patients to improve mood and combat depressive symptoms such as hopelessness, and in turn, enhance quality of life. While yoga sessions [30] and psychoeducation [23] may stimulate brain pleasure centers, spiritual therapy [31] works on promoting illness perception through patients' cultural beliefs and psychological needs. Zamaniyan and colleagues [34] indicate how spiritual therapy that includes education about the psychological aspects of patients undergoing chemotherapy contributes to improving symptoms of depression and anxiety, ultimately enhancing patients' quality of life. Some authors discussed the role of spiritual counseling and therapy [18,19,[32][33][34] in improving spiritual wellbeing. These approaches help patients to increase selfawareness and broaden inner strengths and resources through addressing their spiritual questions, reciting Qur'an, and practicing relaxation exercises and meditation. Rassouli and colleagues [32] used these approaches to support patients coping with cancer and its related problems. Patients' religious beliefs and some practices may conflict with therapists' interpretations of patients' experiences. Therefore, these spiritual counseling approaches may help patients with cancer to find meaning in the cancer experience and resolve these conflicts [19,33]. Finally, Jafari and colleagues [18] demonstrate how a spiritual therapy intervention can help patients identify and shift negative thoughts and validate positive ones.
In three studies [19,25,32], the participants believed that God has the power to control their lives and circumstances and that God alone can cure the disease. These participants attributed their cancer to the will of God and admitted that they could not alter their own fates. These beliefs may help observant Muslims cope with negative feelings and experiences that may be associated with cancer. Patients acknowledged the significance of their absolute belief in God's forgiveness and mercy as religious practices and spiritual resources and, while applying psycho-spiritual therapy, support the process of changing feelings of powerlessness into feelings of power.
There may be belief-hurdles for some Muslims. For example, they may feel that God has preordained all that happens in life, even cancer. Others may feel that, sometimes, suffering redeems for past sins. These beliefhurdles should be addressed in future studies, including how prevalent they are among Muslims, as they may be more culturally rather than theologically bounded.

Implications for research
The psychosocial-spiritual approaches in the included studies were not all described with the specificity necessary for replication. Psychosocial-spiritual approaches already established as efficacious in cancer patients need to be adapted to be culturally and spiritually sensitive to Muslims undergoing treatment for cancer and then tested to determine these adaptations' benefits in this understudied population. And rigorous research designs, such as sufficiently powered randomized control trials with wellstructured control groups, are necessary. Measuring the effects of extant efficacious psychosocial-spiritual interventions using a common set of standardized mental health, quality of life, and spiritual well-being outcome measures will facilitate comparing and synthesizing results of different studies across populations.
Our findings stress the need to conduct further randomized control trial (RCT) research with larger sample sizes of participants to determine the benefits and efficacy of culturally and spiritually sensitive psychooncologic interventions. RCT research would help to draw more definite conclusions about the efficiency of psycho-oncologic interventions. This will require standardized protocols for culturally and spiritually sensitive psycho-oncologic interventions, such as cancer type and stage included, uniform durations, and topics covered across the population. Cohort studies are also needed to evaluate the level of stability of these therapies' longterm effects and improve the science of psychooncologic interventions. In conducting these studies, researchers should consider the representation of cancer patients from different socio-economic, cultural, and religious backgrounds to develop more sensitive adaptations of psychosocial-spiritual approaches to the care of Muslims living with cancer.
In addition, further qualitative studies are needed to explore the psychosocial-spiritual needs of cancer patients of different ages, cancer stages, and ethnicities. As well, none of the included studies reported cost or examine cost-effectiveness analysis, which is a crucial matter that should be considered in developing countries.
There is a paucity of studies conducted in the Middle East, the sub-continent of Asia, and the Asia-Pacific region, where most Muslims live. This lack may be due to conditions specific to, or a need to invest resources for rigorous RCT research in, these regions. While there are no religious restrictions on psychosocial-spiritual interventions (and indeed, in our experience the more devout a patient is the more inclined the patient is to accept psychosocial-spiritual interventions), clinicians and some patients may opt for a medical approach, due to quick onset of psychotropic medications' effects, and that such medications are less costly than psychosocial-spiritual interventions. As well, there is pervasive doubt in the effectiveness of psychosocial-spiritual interventions. Testing interventions in rigorous RCTs may help to change this perception. There is also a paucity of studies conducted among Muslim cancer patients who live in Canada, Europe, the United Kingdom, and the United States. As Muslim populations grow in these areas, psychosocial-spiritual intervention studies in Muslims undergoing cancer treatment will be necessary for these regions.

Implication for practice
Patients and healthcare providers should work together to evaluate the psychosocial-spiritual distress associated with cancer and provide culturally and spiritually sensitive psycho-oncologic care. Since non-Muslim healthcare providers are not fully aware of how to offer culturally and spiritually sensitive cancer care to Muslims, this may result in misunderstandings of their religious beliefs and practices [17,35]. Thus, culturally and spiritually sensitive psycho-oncologic interventions are likely to improve Muslim patients' psychosocial-spiritual outcomes. Cultural and spiritual diversity is a variant that needs to be considered when teaching non-Muslim providers [16,36]. Since psychosocial-spiritual approaches differ in their contents, durations, and goals, manuals of interventions adapted for, and tested in, Muslims would enable non-Muslim providers to deliver culturally and spiritually sensitive psycho-oncologic care.
Seeking medical help or disclosing psychosocialspiritual distress because of mental illness stigma may be a matter of great concern among patients [35]. This stigma is not based on religious beliefs and practices, but rather on the stigma that a cancer diagnosis carries [37]. This stigma may interfere with seeking psycho-oncologic help to improve their mental health, quality of life, and spiritual well-being [38]. Culturally and spiritually sensitive interventions may help to reduce this stigma.
Overall, Muslims consider Islam a comprehensive way of life, and their faith plays a vital role in coping with adverse life events. Spirituality has a positive role in coping with loss and disease. As a consequence, non-Muslim cancer care providers need to be educated about culturally and spiritually sensitive psycho-oncologic interventions. Such providers need to learn about patients' cultural backgrounds, religious beliefs and values (e.g., sincerity and selflessness), social norms (e.g., hospitality and generosity), and hierarchies, such as respect for the seniors, and gender differences. Future psycho-oncologic and palliative care practices require greater clarification regarding spiritual care competencies in an increasingly globalized world.

Limitations and strengths
Our findings should be considered in the context of their methodological shortcomings and potential limitations in generalizability. The scientific rigor of the studies included varies. The majority of reviewed studies recruited relatively small sample sizes, which resulted in being underpowered to detect the effects of these psychosocial and spiritual interventions. The experimental studies included in this review did not indicate whether intervention fidelity was applied in their protocol, and some lacked randomization, blindness techniques, and control groups. Most reviewed studies did not examine long-term effects, but rather focused on effects 3-12 weeks post-intervention. Only one study examined intervention effects at 10 weeks [31], and two studies at 12 weeks [26,34]. The included studies used various controls, outcome measures, and intervention modalities, which rendered synthesis across studies challenging. This diversity makes it difficult to draw conclusions about any specific modality for a particular cancer stage or type. Our review highlights the importance of future studies sufficiently powered and with long-termfollowup. We used the procedure of both authors coming consensus regarding disagreements in code development and data analysis [39]; however, code development and data analysis could have been strengthened by using a third researcher to settle disagreements.
Several studies included participants with a range of cancer types and stages simultaneously, instead of focusing on a specific type, stage, or treatment phase. This is a challenge in conducting cancer studies, except at major academic cancer centers where it is possible to conduct studies in patients of only a specific cancer type, stage, or treatment phase. Some studies included in this review did not specify the cancer stage or treatment phase, nor did they specify what the control group participants received. These limitations can act as threats to these studies' validity or mask the real effect of the interventions implemented. Thus, in addition to well-powered studies with long-termfollow-up, future studies in homogenous populations are needed.

Conclusion
The reviewed studies provide an overview of the current state of research on psychosocial-spiritual interventions used to address psychosocial-spiritual distress associated with cancer in Muslim cancer patients. It complements previous reviews that did not include Muslims, which are soon to be nearly 30% of the world's population [12]. Our results indicate the need for increased capacity to address Muslim patients' psychosocial-spiritual needs living with cancer. Considering the rigor of the studies involved, in addition to their limitations, the evidence discussed here supports future studies to build an evidence base for clinical practice. Incorporating psychosocial-spiritual counseling and therapy into routine cancer care can promote the mental health, quality of life, and spiritual well-being of Muslims undergoing treatment for cancer. Researchers need to further examine the psychosocial-spiritual outcomes of established psycho-oncologic treatment modalities adapted to Muslims. Manualized interventions can help non-Muslim providers deliver culturally and spiritually sensitive cultural psycho-oncologic cancer care to Muslim patients.