The Predictive Power of Religious Coping on Care Burden, Depression, Stress, and Anxiety of Parents of Pediatric Oncology Patients in Turkey

Childhood cancers are a global health problem affecting children and their families worldwide (American Childhood Cancer Organization, 2022). When considering the impact of childhood cancer, it is essential to recognize the devastating nature of a cancer diagnosis, regardless of the treatment and resources available. This is particularly evident in resource-limited countries, where the relevant statistics are concerning. In addition, inequalities in children's access to health services exacerbate these concerns, which are prevalent in high-income and low-income countries (Johnston et al., 2021; Kebudi & Cakir, 2016; WHO, 2021a). According to the World Health Organization (WHO), the global burden of childhood cancer is indeed substantial, with approximately 400,000 children (aged 0–19 years) being diagnosed with cancer each year. Furthermore, the WHO estimates that there will be an expected 13.7 million new childhood cancer cases worldwide between 2020 and 2050 (WHO, 2021b; Atun et al., 2020).

Advances in childhood cancer treatment have significantly increased five-year survival rates, reaching 85% in developed countries (Kebudi & Alkaya, 2021). This rate indicates a significant improvement compared to the survival rate of 58% reported in the 1970s. The five-year survival rate for children and adolescents diagnosed with cancer in Turkey is 70.8% (Kutluk & Yeşilipek, 2019). However, despite these advances, cancer remains the second leading cause of death after accidents among children aged 1–14 years (American Cancer Society, 2021). In Turkey, between 4,000 and 4,500 new cases of pediatric cancer (in children aged 0–14 years) are diagnosed each year (Gheorghe et al., 2020). Unfortunately, these rates are predicted to continue to rise in Turkey and globally in the future.

Current treatments for childhood cancers have significantly increased survival rates, but these treatments often lead to negative physical, cognitive, and psychological side effects that affect the quality of life of both the child and their family. Although the diagnosis of cancer seems to impact children more, it also has a devastating negative impact on their families (Kong & Guan, 2019). The diagnosis comes as a shock to the parents, as they cannot believe that their child is facing a life-threatening illness such as cancer. In a state of shock, parents are burdened with many responsibilities related to their child's treatment, and these tasks place a significant burden of care on the family (Vitorino et al., 2018). In addition to the care burden, parents often have to deal with psychological problems such as guilt, frustration, sadness, grief, despair, hopelessness, anxiety, depression, and loneliness (Chong et al., 2019; Mowla et al., 2020). Consequently, there is an urgent need for strategies to improve caregivers' well-being. Given the burden of care and psychological challenges faced by caregivers as the prevalence of childhood cancer cases increases, it is crucial to take measures to support and improve caregivers' mental health (Kong & Guan, 2019).

The literature indicates that there is a relationship between religious or spiritual practices and human well-being (Mowla et al., 2020). Religious and spiritual practices are reported to play an important role in supporting cancer patients to manage psychological distress (Malhotra & Thapa, 2015; Mosher et al., 2015). This positive impact may extend to caregivers of pediatric oncology patients. Several studies show that religious coping practices are crucial in supporting parents to manage the struggles associated with caring for their children diagnosed with cancer (Abu-Raiya & Sulleiman, 2021; Khanjari et al., 2018; Mowla et al., 2020). In a study with parents of children with cancer in Iran, religious coping practices were found to help reduce the burden on the caregiver and reduce psychological distress (Hassankhani et al., 2019). Similarly, another study found that religious coping practices increased parents' ability to adapt to their children's cancer treatment and reduced their stress levels (Vitorino et al., 2018).

Considering this information, caring for a child diagnosed with cancer poses significant challenges for parents. The literature highlights that religious coping practices can reduce parents' caregiving burden. In this regard, this study aimed to determine the predictive power of religious coping in terms of caregiving burden, depression, stress, and anxiety among parents of pediatric oncology patients in Turkey.

The descriptive characteristics of the parents are presented in Table 1. The mean age of the parents was 36.38 ± 7.56 years, 50.6% of the parents were fathers, 38.4% of them had primary school education, 53% of them did not work, 77.4% of them had a nucleus family structure, 53.4% of had income less than expenditure, 15.2% of them had chronic diseases, and 4.9% of them had another child with a chronic illness (Table 1).

The descriptive characteristics of the pediatric oncology patients are presented in Table 2. The mean age of the children was 7.92 ± 8.96 years, and the diagnosis duration was 6.28 ± 4.60 months. More of the children were male (64%), 34.8% of them diagnosed with leukemia. Most of the children received chemotherapy (97%), 26.4% received radiotherapy, and 32.9% received surgery (Table 2).

Figure 1 illustrates the religious practices of parents participating in the study. It shows that while an even higher percentage, 99.4% (163 out of 164), perform praying rituals, 98.8% of the parents (162 out of 164) believe in a religion, indicating a high level of religious affiliation among participants. Additionally, a significant portion of parents, 82.9% (136 out of 164), participate in helping others, and 80.5% of the parents (132 out of 164) engage in regular prayer. Reading the Qur'an is practiced by 66.5% of the parents (109 out of 164), and 62.6% (102 out of 164) attend the mosque. Furthermore, 33.5% (55 out of 164) visit places of worship, such as shrines. These findings indicate a strong engagement in various religious and spiritual activities among the parents in the study (Fig. 1).

The correlation between Religious Coping Scale, Caregiver Burden Scale, and Depression, Anxiety, and Stress Scale was presented in Table 3. There was a positive correlation between Positive Religious Coping and Negative Religious Coping (r = 0.279). There was a negative correlation between the Caregiver Burden Scale and Positive Religious Coping (r = − 0.157) and between the Caregiver Burden Scale score and Negative Religious Coping (r = − 0.167). There was a positive correlation between the Depression score and the Caregiver Burden Scale score (r = 0.467). There was a positive correlation between Anxiety and the Caregiver Burden Scale score (r = 0.432). There was a positive correlation between Anxiety and the Depression score (r = 0.666). There was a positive correlation between Stress and Caregiver Burden Scale score (r = 0.491). There was a positive correlation between Stress and Depression (r = 0.681) and between Stress and Anxiety scores (r = 0.734) (Table 3).

Based on the relationship between variables in multiple regression analysis, the impact of sub-dimensions of the Religious Coping Scale scores for parents of children with cancer on various outcomes was assessed. For positive religious coping, the analysis revealed several important findings. The caregiver burden scale had a negative but not statistically significant effect on positive religious coping (B = − 0.044, p = 0.064). Similarly, the depression (B = − 0.131, p = 0.061), anxiety (B = − 0.126, p = 0.068), and stress (B = − 0.099, p = 0.159) sub-dimensions of DASS-21 did not significantly predict positive religious coping. However, proximity to the child (mother) was a significant predictor, with a negative relationship (B = − 1.807, p = 0.004). Education level (illiterate) also showed a significant negative effect on positive religious coping (B = -1.477, p < 0.001), while employment status (not working) (B = 1.803, p = 0.004), family structure (extended) (B = 1.770, p = 0.013), and family income (income less than expenditure) (B = − 1.529, p = 0.015) were significant predictors. Age at diagnosis also significantly predicted positive religious coping with a negative relationship (B = − 0.165, p = 0.002) (Table 4).

For negative religious coping, the caregiver burden scale was a significant predictor with a negative relationship (B = − 0.040, p = 0.032). Depression (B = 0.067, p = 0.260), anxiety (B = 0.005, p = 0.935), and stress (B = − 0.023, p = 0.695) sub-dimensions of DASS-21 were not significant predictors of negative religious coping. Education level (illiterate) was a significant negative predictor (B = − 1.241, p < 0.001), while family structure (extended) (B = 2.170, p < 0.001) and family income (income less than expenditure) (B = − 1.098, p = 0.009) were also significant predictors of negative religious coping. These findings highlight the complex interplay between various factors and religious coping strategies among parents of children with cancer (Table 4).

This study aims to determine the predictive power of religious coping in terms of caregiving burden, depression, stress, and anxiety among Turkish parents of pediatric oncology patients. The study determined that most parents (98.8%) believed in a religion, 80.5% prayed, 99.4% prayed, and 66.5% read the Qur'an. 82.9% of the respondents stated that they helped others, and 33.5% visited places of worship (Fig. 1). People struggle with problems such as death, divorce, and illness throughout their lives and try to cope with them. Thus, they aim to regain control of life and gain a sense of meaning in life. One of the most essential strategies people use to cope with these stressful situations is religion. Religion helps people to overcome problems by giving them courage and meaning. It helps to maintain psychological well-being by providing patience and acceptance in a situation that cannot be coped with (Abanoz, 2020).

In a study, it was determined that 80% of relatives of cancer patients had positive contributions from using religious coping strategies. It was determined that prayer and patience were the most used religious coping strategies, followed by fate, gratitude, and surrendering to trial (Akbulut-Şahin, 2019). The high number of those who believe in a religion, pray, and prayer among the participants in the current study may be related to the characteristics of the population in which the study was conducted. People's most valuable assets in life are their children. The fact that their children are struggling with a complex disease such as cancer may have led parents to fulfill religious responsibilities more. Another reason for this result may be that religious people are more willing to participate in this research.

The study's results indicate a positive relationship between Positive Religious Coping and Negative Religious Coping scores, with both types of coping increasing or decreasing in parallel, suggesting an intriguing dynamic in the context of religious coping strategies. This phenomenon may be attributed to the specific characteristics of the scale utilized in the study, particularly the absence of items related to distancing from religion within the negative religious coping items (Ekşi and Sayın (2016). Instead, the negative religious coping items focused on attributing problems to sins committed by individuals and the potential for punishment by God for perceived shortcomings in faithfulness (Ano & Vasconcelles, 2005). In Islamic beliefs, the world is viewed as a testing ground where individuals face trials and tribulations as a means of assessing their patience, prompting reflection on their actions, and potentially serving as a form of retribution for sins committed in this life rather than the afterlife, as outlined in the Qur'an (Nikfarid et al., 2018; Saari et al., 2022). Therefore, individuals who adhere to Islamic beliefs may resonate with positive and negative religious coping strategies, as both are considered valid within the framework of their faith (Mazhari et al., 2021).

The positive relationship observed between Positive Religious Coping and Negative Religious Coping in the study may reflect the multifaceted nature of religious coping within an Islamic context. While Positive Religious Coping may involve seeking solace, guidance, and strength from religious beliefs and practices, Negative Religious Coping could encompass guilt, fear of divine retribution, or a sense of accountability for one's actions based on religious teachings (Dolcos et al., 2021). The co-occurrence of these coping strategies suggests a complex interplay between seeking comfort and confronting challenges within the religious worldview of Islam (Ano & Vasconcelles, 2005). Future research could delve deeper into the nuances of religious coping among individuals of different faith traditions, exploring how specific religious beliefs and doctrines shape coping mechanisms in response to life stressors. By examining the interplay between positive and negative religious coping strategies within diverse religious contexts, researchers can better understand how individuals draw upon their faith to navigate adversity and find meaning in challenging circumstances.

This study found a negative correlation between the Caregiver Burden Scale and Positive and Negative Religious Coping (Table 3). Positive religious coping is associated with lower levels of psychological distress. In comparison, negative religious coping is reported to be associated with higher levels of distress among parents of children with cancer (Dolan et al., 2021). This suggests that the way parents use religious coping mechanisms may significantly affect their psychological well-being when caring for a child with cancer. Research has shown that caregivers who use coping approaches emphasizing problem-focused techniques tend to reduce caregiver burden and better adapt to the situation (Deribe et al., 2023; Dolan et al., 2021; Liu et al., 2007). Caregivers who employ problem-focused coping techniques, which involve actively addressing and managing stressors, tend to experience lower burden levels and demonstrate better adaptation to their caregiving roles. The findings from these studies underscore the significance of religious coping mechanisms and coping strategies in influencing the psychological well-being and caregiver burden experienced by parents of children with cancer. Healthcare professionals working with this population should consider the role of religious coping and encourage the use of positive coping strategies to support caregivers in managing their stress and promoting better psychological outcomes.

The positive correlation observed between the Depression, Anxiety, Stress score and the Caregiver Burden Scale score among parents of children with cancer suggests that there is a significant relationship between parents' psychological well-being and the burden they experience while caring for their sick children (Table 4). This finding is consistent with recent literature investigating the impact of parental mental health on caregiving in the context of childhood cancer. Studies such as Salem et al. (2019) have highlighted high levels of psychological distress, anxiety, and depression in parents of children with cancer, particularly in the early years following diagnosis. This suggests that parents' emotional well-being is intricately linked to their challenges when caring for their sick children. Link and Fortier (2016) demonstrated that parental anxiety significantly predicted various aspects of the child's quality of life, suggesting that parental mental health and child well-being are interconnected. Luo et al. (2022) discussed the role of resilience in parents of children with cancer. They showed that resilience can positively affect parents' mental health and is negatively associated with depressive symptoms and post-traumatic stress disorder.

This underlines the importance of resilience in mitigating the adverse effects of caregiving stress on parental mental health. Rismawati and Paramastri (2020) investigated the role of religious coping as a moderator of the relationship between psychological burden and quality of life among caregivers of individuals with cancer. Although the study did not find that religious coping significantly moderated this relationship, it highlights the complex interaction between coping mechanisms, psychological burden, and quality of life in caregivers. Norberg et al. (2008) found that anxiety, depression, and post-traumatic stress symptoms of parents in childhood cancers were higher than healthy parents. Wang et al. (2017) concluded that the burden of care was high in parents of children with newly diagnosed acute lymphoblastic leukemia and that parents' anxiety decreased as the burden of care decreased. All these results are important in terms of showing how valuable each intervention to reduce the burden of caregiving in families with sick or disabled children is. In this way, the rates of anxiety, stress and depression in parents can be reduced. In conclusion, the positive correlation between indicators of parental mental health and caregiver burden in the context of childhood cancer underlines the need for comprehensive support systems that address the psychological well-being of parents caring for sick children. The literature suggests that interventions focussing on resilience, coping strategies, and mental health support can play an essential role in improving the overall well-being of parents facing the challenges of caring for children with cancer.

The results of the study indicate that parents' depression, anxiety, stress, and caregiver burden scores did not significantly affect the ‘Positive Religious Coping’ score. However, an increase in caregiver burden scores significantly predicted the ‘Negative Religious Coping’ score, accounting for 2.8% of its variation. These findings align with previous research showing an association between caregiver burden and negative religious coping (Cheang, 2023). Negative religious coping is linked to anxiety and depression, whereas positive religious coping has a lesser impact on mental health (Francis et al., 2019). Studies have also reported that negative coping practices are related to anxiety disorders and an increased risk of major depression  (Asano et al., 2021).  Conversely, religious coping has been associated with reduced anxiety and depression scores (Dolcos et al., 2021).

The study further highlights those factors such as proximity to the child, education level, employment status, family structure, and family income significantly influence religious coping strategies. These findings underscore the importance of considering these variables when developing interventions to support caregivers. The severity and duration of the stressor also play crucial roles in the effectiveness of coping strategies (Maier et al., 2022). The study aligns with previous findings that religiosity during the stress of illness can be associated with either positive or negative religious coping among caregivers (Asano et al., 2021; Dolcos et al., 2021; Maier et al., 2022). Promoting positive coping mechanisms is essential for enhancing caregivers' well-being, as these strategies can mitigate the adverse effects of caregiver burden.

Despite the valuable insights this study provides, some limitations must be acknowledged. The cross-sectional design limits the ability to establish causality between religious coping and psychological outcomes. Longitudinal studies are needed to elucidate the temporal dynamics of these relationships. The study sample was drawn from a single cultural and geographical context, which may limit the generalisability of the findings to other settings or populations. Cultural factors play an essential role in religious coping strategies, and future research should consider a more diverse sample to increase the external validity of the findings.

This study contributes to the understanding of the interaction between religious coping mechanisms and the psychological health of parents caring for children with cancer. Our findings reveal that while positive religious coping does not significantly affect levels of depression, anxiety, stress, and caregiver burden, an increase in caregiver burden is a predictor of negative religious coping. This suggests that religious coping strategies play a nuanced role in caregivers' psychological resilience or vulnerability, highlighting the complex nature of spirituality in pediatric oncology care. The association between caregiver burden and negative religious coping underscores the importance of supporting caregivers on their spiritual journey, recognizing that negative religious coping may indicate increased psychological distress.

The findings from this study underline the need for a holistic approach in clinical settings, particularly in paediatric oncology, where the spiritual well-being of caregivers significantly influences overall mental health. Clinicians should conduct routine assessments of both the emotional and spiritual health of caregivers and identify the nature of their religious coping mechanisms. There is a critical need to develop support programmes that promote positive religious coping strategies. These programmes could include spiritual counselling and support groups facilitated by chaplains or spiritual leaders, designed to promote constructive spiritual practices. In addition, healthcare providers should receive targeted training to better understand the role of spirituality in mental health, enabling them to effectively integrate this aspect into their therapeutic approach. Finally, there is a call for the design of specific interventions aimed at reducing negative religious coping and associated psychological distress, which may include directly addressing underlying spiritual crises and conflicts. By implementing these strategies, health professionals can better support caregivers, reduce their burden and increase their overall psychological resilience.