Introduction
Cancer remains a threat among the Malaysian society nowadays. According to the Malaysian National Cancer Registry Report (MNCR) (
2007–2011), there were 103,507 new cancer cases reported from 2007 to 2011. Females made up 46,794 cases (54.8%) of these reported cases, while males 56,713 cases (45.2%).
It has been reported that, in Malaysia, cancer patients find it difficult to cope with their stress after the diagnosis and choose to commit suicide at the hospitals where they reside (Satibi
2015). Satibi also reported that, from 2008 to 2013, there were 50 cases of patients who jumped from high floors in public hospitals in Malaysia and that 31 cases resulted in death. The National Suicide Registry of Malaysia (
2009) reported that 11.4% of the total suicide cases in 2009 were victims with a history of cancer diagnosis.
A few studies have reported on the relationship between level of religiosity and its effect on suicide (e.g., Dervic et al.
2004; Wu et al.
2015). Given that Malaysia is a highly religious society (Gallup International
2012), it might be supposed that religion plays an important role in alleviating the experience of being a cancer patient, but the statistics compiled above raise the question of why these suicidal cases still occur (Inglehart et al.
2010).
Confronting a life-threatening disease such as cancer can be very stressful. In order to cope with the experience, cancer patients may search for meaning in relation to why they got cancer. Assigning meaning in life is vital, as it seems to impact psychological well-being and may help to moderate negative feelings, especially after being diagnosed with cancer (Tomich and Helgeson
2002). Some researchers have maintained that religiosity and spirituality are the main factors facilitating meaning-making coping. However, more recent studies by Ahmadi (
2006,
2015) have shown that, apart from religiosity and spirituality, cancer patients were able to use other meaning-making resources, such as nature, to help them to find some meaning in their illnesses.
Searching for coping methods to find meaning has been described as having the potential to bring positivity into individuals’ lives, especially after a cancer diagnosis (Schroevers et al.
2011). In addition, the ability to find meaning after the diagnosis helps cancer patients create new goals in life. In this way, cancer patients are able to make the necessary adaptation to their illnesses, while still preserving hope about the future.
However, other studies have associated the search for meaning after the diagnosis with poorer adjustment (Roberts et al.’s
2005). This study revealed that the process of searching for meaning could be also associated with intrusive thoughts that make it difficult to adjust to the situation cancer brings about. In addition, cancer survivors or patients who are unable to successfully integrate their beliefs into the process of searching for meaning may also reflect on their cancer experience without achieving any resolution (Holland and Reznik
2005).
Theoretical Background
Being diagnosed with cancer may affect various domains in the patient’s life: physical, psychological, interpersonal, vocational and spiritual (Aziz
2007; Hewitt et al.
2003). A cancer diagnosis may also affect the patient’s daily functioning, for example, by limiting her/his ability to work. Young cancer patients seem to be at a higher risk of experiencing psychological problems, which may extend over time (Arndt et al.
2004; Costanzo et al.
2009; Hewitt et al.
2003). These psychological problems may include young cancer patients being unable to lead healthy lifestyles, which may prevent them from achieving positive quality of life in the long term.
After diagnosis, patients may employ various methods to cope with their experience of being cancer patients and to maintain positivity. One of the coping styles that have received a great deal of interest among researchers involves searching for meaning (e.g., Lee et al.
2004; Martino and Freda
2016; Tomich and Helgeson
2002). A searching for meaning coping style is referred to as accommodative coping, which involves cognitive restructuring. According to Folkman and Moskowitz (
2000), there are two forms of meaning making: situational and global. Situational meaning refers to appraisals of stress that help determine the degree of personal significance of the tragedy in relation to a person’s beliefs, goals or values. Global meaning, on the other hand, is more concerned with the abstract, generalized meaning that is related to people’s existential assumptions or “assumptive worlds” (Janoff-Bulman,
1992).
Folkman and Moskowitz (
2000) found positive effects of searching for meaning among people who suffer from chronic diseases. Searching for meaning cultivates positive emotions and improves well-being. Positive emotions gained from the process of making meaning help broaden an individual’s thought and action, thereby building his/her enduring personal resources and counteracting negative emotions (Fredrickson et al.
2000). Studies found that religious belief and spirituality may also facilitate the process of searching for meaning among cancer patients, helping them make sense of their illnesses (e.g., Jenkins and Pargament
1995; Johnson and Spilka
1991). Having a high level of religiosity and spirituality causes cancer patients to believe in a higher power and to see the situation as being “part of a bigger plan” or as a sign of God’s love. However, Ahmadi (
2006) revealed that there are also other resources for meaning making that help cancer patients who do not believe in God make sense of their situation (Ahmadi
2006). Ahmadi’s study of 2355 Swedish cancer patients showed that nature provided strength and tranquility for them to deal with their illnesses. This finding suggested a new method of coping, which was defined as “new spiritually oriented coping methods dissimilar to religious coping.” In this article, we focus, however, only on religious coping methods, not these new ones.
Meaning-Making Coping
Coping is often considered a multilayered contextual phenomenon (Lazarus and Folkman
1984: 148; Pargament
1997: 89)—a process individuals undertake to try to understand and manage important demands in their lives (Ganzevoort
1998: 260), or a quest to find or create meaning in life during periods of stress (Pargament
1997: 90). Furthermore, coping has been suggested to be a process that develops and changes over time (Pargament
1997: 89).
Earlier studies have used the terms “religious” and “spiritual” to refer to coping methods that are principally based on existential issues (Ahmadi
2006,
2015). Findings from previous studies (Ahmadi
2006, 2015; Ahmadi and Ahmadi
2015), carried out among people who lived in predominantly non-religious contexts and had been struck by cancer, indicate that other coping strategies are frequently employed in these contexts—strategies that can hardly be considered religious or spiritual. Among these strategies are Spiritual Connection with Oneself, Spiritual Sanctification of Nature, Positive Solitude, Empathy/Altruism, Search for Meaning, Visualization, Healing Therapy, Spiritual Music and Meditation. An analysis of these methods clearly showed that they had much more to do with
connectedness to nature, to self and to others than to something transcendent (God or any spiritual power) (Ahmadi
2006).
Although the term “existential coping methods” may still be used, given that these methods concern people’s efforts to find a source—in nature, in themselves or in others—that could help them cope with their problems, we wish to avoid restricting ourselves to either the religious or secular nature of these methods and will hereafter use the term “meaning-making coping.” Meaning-making coping is thus used in the present study to address the whole spectrum of religious, spiritual and existential coping methods.
Background of the Ethnic Malay Community
Malaysia is a multiracial and multi-religious country in South-East Asia. The Malaysian citizens comprise the Malay (68.6%), Chinese (23.4%), Indians (7%) and other (1%) ethnic groups (Department of Statistics Malaysia
2016). In terms of religions, Islam, the official religion of the country, is the most widely professed religion in Malaysia, followed by Buddhism (19.8%) and Hinduism (6.3%). However, all of the religions are free to be practiced in peace and harmony, as stated in the Federal Constitution of Malaysia (Mohd Sani & Abdul Hamed Shah
2011). However, Malaysia does not tolerate any denominations of Islam other than Sunni Islam. Any teaching that deviates from the official Sunni code is illegal, and no other forms of Islam are allowed (International Religious Freedom Report
2016).
Islam has a great influence on various aspects of the lives of the Malay people (Oka et al.
2017). Compared to other Muslim populations in the world, the Malay Muslims have “unique” characteristics. In understanding an illness medically, besides the scientific explanation, Malay people also believe in supernatural and mystical aspects of illnesses. This is due to the influence of animistic belief, which preceded Islam (Haque,
2005). Some Malay people believe that any illness they have is caused by unexpressed
angin (wind) that gets stuck in the body and induce pathology (Haque
2005; Ng et al.
2003).
Angin is believed to be a whirl of wind that gets stuck in some parts of the body and that causes discomfort. Some also believe in supernatural causes, such as the possession of
Jinn (Genie) or the result of
Santau (black magic), typically sent by enemies (Haque
2005).
Such belief opens up another possibility for Malay people to get treatment. They may choose either a conventional medical doctor or a traditional healer, called a pawang or bomoh, to get rid of any spiritual possession that may cause their physical and psychological illnesses.
Among the three major races in Malaysia, namely the Malay, Chinese and Indian, evidences found that Malay cancer patients were prominent to be diagnosed at a later stage and to have poorest prognosis (Taib et al.
2008; Xin et al.
2017). A qualitative study on female Malay with advanced breast cancer reported that the patients were most likely to discontinue their treatment and cope with their illnesses by turning to spiritual belief to fight with their cancer (Ahmad et al.
2011). Nevertheless, our knowledge of how Malay people cope with their illnesses is still limited. Previous researchers in other countries had discovered new coping mechanisms—such as Sanctification of Nature, Spiritual Connection with Oneself, Positive Solitude, Altruism, Spiritual Music (Ahmadi
2006,
2015)—which may or may not be prevalent among Malay cancer patients. According to Ahmadi (
2015), these coping mechanisms are described as a part of meaning-making coping which may not related to religion only but also influenced by everyone’s cultural belief. A study among Korean cancer patients in Korea, for example, reported that their belief on nature as a healer has helped the Korean cancer patients to cope with their cancer better (Ahmadi et al.
2016). Therefore, the present study aims at deepening our understanding of how Malay cancer patients use the elements of religiosity and spirituality to cope with their illness. The study also aims to integrating the role of culture in choosing different meaning-making coping methods.
Methodology
Approximately 35% of the Malaysian population (37.1 million) was reported to use Facebook in 2013 (Mahadi
2013). Based on this, and to further enhance the voluntary nature of participation, the researchers used Facebook as a medium to recruit respondents from various locations and age groups in Malaysia. Twenty-nine participants were recruited to the present study by posting a participant recruitment advertisement in a closed Facebook group where cancer patients/survivors could post a comment indicating their intention to voluntarily participate in the study. In the first steps, only Muslim informants were chosen.
The participants were contacted using the contact information left on the Facebook advertisement. Although Facebook users in this closed group have been monitored by several administrators, the researchers also applied a strict verification process before the interview, where potential participants were asked to verify their status by sharing documents related to their medical and treatment histories. The documents were then verified by an appointed oncologist. After verification, the researchers contacted the potential participants by phone to make an appointment for the interview.
Interview questions for the study were primarily based on results from the Swedish study (Ahmadi
2015). The original interview guide was translated from English to the Malay language by two Malaya researchers involved in the project. The questions were modified to better suit the Malay culture.
Procedure
Prior to the interview, the researcher obtained the participant’s informed consent. In the present study, all respondents’ names were kept anonymous. The location and time of the interviews were chosen according to the participants’ preference. Each interview lasted from around 45 min to one and half hours. Bahasa Malaysia was spoken during the interviews.
The data were obtained from 29 Malay cancer patients between 29 and 60 years of age. Their respective cancer survival longevity ranged from one to 25 years. Their level of education varied from high school to Doctor of Philosophy (PhD). Participants’ stage of cancer varied from earliest, palliative care and survivors. The participants’ backgrounds varied from housewife, retirees, businessman, working in private or government sectors and educators. All of the participants are Sunni Muslims. The socio-demographic background of the respondents is summarized in Table
1.
Table 1List of demographic characteristics of the participants
Gender | Female | 21 |
| Male | 8 |
Age | 25–30 | 2 |
| 31–40 | 15 |
| 41–50 | 9 |
| 51–60 | 3 |
Education | High school | 7 |
| Undergraduates | 17 |
| Postgraduates | 5 |
Employment status | Housewife | 6 |
| Businessman | 3 |
| Private sector | 5 |
| Government sector | 5 |
| Retirees | 2 |
| Educators | 8 |
Survival longevity | 0–5 years | 23 |
| 6–10 years | 2 |
| 11–20 years | 3 |
| 21–25 years | 1 |
The interviews were fully transcribed and translated into English. A professional translator was used to ensure the accuracy of the translation. Coding, identification of the themes that emerged and identification of the relationship for each theme were done during the analysis process. Codes were grouped into categories. The research team identified, discussed and finalized the categories and themes that emerged from the interviews. An expert on cultural backgrounds has also been consulted to ensure the validity of the analysis.
Achieving an acceptable degree of the trustworthiness, which guaranties the credibility of qualitative research, is an important issue in qualitative research (Morrow
2005). There are four general types of trustworthiness in qualitative research: credibility, transferability, dependability and confirmability (Lincoln and Guba
1985). To achieve credibility, the researcher developed a rapport with the participants. They were also told to answer the questions honestly without thinking about searching for the “correct” answers. To achieve credibility, the researcher explained the rationale of the study and shared stories about self-experience to promote a comfortable and trustful relationship between the participants and the researcher. To ensure validity, each answer given by the participants was paraphrased by the researcher, and the participants were asked to listen and validate the statement. To establish transferability, the interviews were conducted with care to ensure that every item in the interview guide was covered. To establish dependability, the researcher carefully discussed the procedure, process and analysis to establish inter-subjectivity. Finally, to establish confirmability, the researcher applied bracketing, which entails excluding one’s own perceptions and experience throughout the research activity.
Discussion
As the present results indicate, some of the RCOPE methods seem to be highly relevant for the interviewees in Malaysia. As for our interviewees in Turkey (Ahmadi et al.
2016), for those in Malaysia, religion is a “larger part of [their] orientation system” (Ahmadi,
2006:28). Religion is, indeed, constantly available in people’s sociocultural context. Given this, it is understandable that, when facing a life-threatening illness like cancer, people turn to religion rather than to other resources. The present study shows, however, that for some interviewees, the role of culture in coping may be even stronger than that of fundamental religious axioms. Phenomena such as applying the coping method
Demonic Reappraisal, believing in black magic and getting help from shamans/bomohs for alternative treatment reveal the strong role of cultural beliefs, even when they are in opposition to religious axioms. We discuss this point below.
Spiritual beliefs among Malay people are influenced by animism, Hinduism and Buddhism, all of which preceded the Islamization of Malaysia (Osman
1988). Concerning the Malay people’s indigenous knowledge about illness, some believe in witchcraft, black magic or
santau, which originate from ancient mystical rituals. These ancient mystical rituals are believed to involve jinn and demons. They are used to destroy friendly relations among family members, to end spousal relationships, to bring about insanity and illness and, in the worst case, to cause the death of their victims (Mahyuddin
2014). Santau, which is a popular term among Malay people, is described as a poison that is sent using black magic or physically by the sender (Daud
2010). The motivation for sending
santau is usually feelings of hatred and jealousy. It is believed that the illnesses caused by santau and black magic cannot be curing using conventional medical treatments (Sahad and Abdullah
2013); what is needed is religious treatment.
Ruqyah, which refers to prayer therapy, is a common treatment among Malay people.
In the Malay world, shamans include pawang (specific kind of black or white magicians) or dukun and bomoh (spiritual counselors, traditional healers or medicine men). The bomoh’s original role was that of a healer. Before European colonization, bomoh is described as the most important person to integrate the complex beliefs and practices among traditional and rural communities (Osman
1989). These beliefs and practices were influenced by a combination of indigenous, Hindu and Islam that interacted and integrated to function in a whole. The bomoh’s craft remained largely unchanged even after Islam became dominant until the Islamic revival in the 1970s and 1980s. Bomohs were then seen as deviant from the Muslim faith because of their invocation of spirits and the potentially harmful black magic they were accused of practicing. This period saw a drastic decline in traditional herbalism, and many fraudulent practitioners filled the void (Sahad and Abdullah
2013). As a result, bomohs are today regarded with suspicion even though they are still commonly consulted by some Muslims.
In Malaysia, shamanism and cosmology are formed by a mixture of various elements of belief and religion, such as animism, Hinduism–Buddhism. Some shamans have tried to adapt their practice in the context of modern Islam, such as reciting verses of the Qur’an or invoking the name of Allah, but this practice is viewed as shallow by conservative shamans. The objection was also heard from Muslim leaders. The practice of bombo, as mentioned before, is regarded by Muslim scholars as shirk (idolatry, deification of figures other than Allah). Shirk is a major sin in Islam.
It is believed that the Malay originally believed in animism. This belief is still present in modern times among certain ethnic groups, such as the Senoi, Semang, Negrito, Kenak, Dayak. As Daud (
2010: 183) maintains:
Their mystical views are replete with a variety of spirits connected with the forest, mountains, the sea, large trees, and hillocks and such things like. These spirits are an integral aspect of their lives and form a channel to realize their existence and their lives. Before the arrival of Islam approximately in the fourteenth century, peninsula Malays are said to have adhered to Hindu-Sivaism and subsequently to Hinayana Buddhism. The belief in the cosmos and the gods in these religions share with animism that they also believe that natural objects such as stones, hills, and the sun are endowed with power and spirit. This is an important aspect in Malay shamanism and mysticism. The Malay way of life and what they believed went through another change with the arrival of Islam, which brought the belief in the One and Only God (Allah), and with the Qur’an and hadith as guidelines in life. Slowly but surely, Hinduism and animism were set aside and were replaced by a belief system based on Islam. However, because animistic and Hindu elements were so firmly implanted in the Malay souls, Islam did not succeed in obliterating them completely. This is the reason these three elements form an integral part of Malay mysticism and shamanism. They colour their beliefs, values, and norms through fairytales that connect the real with the supernatural world and humans with the gods (Mohamed Ghouse Nasuruddin
2006: 10).
The interesting point here is, as mentioned above, the impact of the culture on health beliefs, which can even be stronger than fundamental religious axioms. According to Ahmadi (
2015), culture is a basic element in construction of the belief system. The myths, symbols and rituals tied to religion can be seen as a way to try to understand the world. Cultural systems of heath explain what causes illness, how it can be cured or treated and who should be involved in the process. Applying
Demonic Reappraisal as a coping method presumably requires belief in a Devil who can determine the course of individuals’ lives—a Devil who has the power to change a person’s “destiny.”
Indeed, in Islam, the devil is considered a creation of God and never becomes “evil as such”; he always remains a necessary instrument in God’s hand, because, in Islam, there is hardly any decisive dualism between good and evil or between God and Satan. The Qur’an does not portray Satan as an enemy of God, as God is greatest and supreme over all creation, Satan being just one of his creations. Satan’s only enemy is humanity.
Thus, a Muslim who strongly believes in an omnipotent God and does not regard Satan as possessing the power to change the course of events, in contrast to God’s will, can hardly redefine her/his stressor as an act of an evil power; everything is in the hands of God, not Satan. Therefore, shamanism was condemned often by religious leaders as shirk (idolatry) by referring to Qur’an, which directly condemns magicians and shamanists:
1… and the magician will never be successful, no matter what amount (of skill) he may attain (Taa Haa 20:69)
Despite this antipathy toward shamanism, the idea of black power seems to be quite strong in Malay culture (and generally among East Asian people), but it is more a superstition than a theological belief in the power of Evil. So here, we are witnessing the strength of old pre-Islamic cultural beliefs, which have survived even after Islam became predominant.
Summing up, the present study indicates that informants used several RCOPE methods, both passive and active. It also showed that shamanism—although it is in opposition to the religion of our informants (all Muslims)—plays a role in how they cope with cancer. The study highlights the important role of culture in the choice of coping methods. Following the present study, we are planning to conduct a quantitative survey study among cancer patients in Malaysia to examine the qualitative interview findings obtained here.