October 2007 - Volume 1, Issue 5

EFFECT OF PRAYER ON THE SPIRITUAL WELL-BEING IN IRANIAN PATIENTS WITH CANCER

Naiemeh. Seyedfatemi (1), Mahbobeh Rezaie (2) Aazam Givari (3), Fatemeh Hoseini (4) Correspondence author: Senior lecturer, PH.D in nursing, school of nursing and midwifery. Iran university of medical sciences, Tehran, Iran Address: Faculty of Nursing and Midwifery, Iran Medical Sciences University, Yasemi street, Valiasr avenue. Tehran, Iran e-mail:nseyedfatemi@yahoo.com M.Sc N Kashan medical sciences university, Iran email: Mahbobeh_4@yahoo.com Senior lecturer, M.Sc, Faculty of nursing and midwifery. Iran university of medical sciences, Tehran, Iran e-mail: nseyedfatemi@yahoo.com Senior lecturer ,School of management and medical information . Iran university of medical sciences, email: fatemeh_h@yahoo.com

ABSTRACT Background: Spiritual well-being is a unique power that can harmonize several dimensions of a human's life and thus can be essential for coping with illness. Cancer causes crises in physical, psychological, and spiritual dimensions. Prayer can be a strong resource to resist these crises especially, in spiritual domain. Objective: This correlational study was carried out to examine the impact of prayer on the spiritual well-being of 360 cancer patients undergoing chemotherapy who were referrals to Oncology ward of Cancer Centers of Iran and Tehran Medical Sciences Universities. Methods: The spiritual well-being was assessed using the questionnaire developed by Paloutzian & Ellison (1982). Prayer was measured by Adapted Prayer Scale which was developed by Poloma, Endelton (1991) and Meraviglia (2002). Results: The findings revealed that the total mean score for spiritual well-being of patients was estimated to be about (98.35±14.36) and the spiritual well-being of the patients stands at the medium level. Given to the study findings, it was observed that the patients' religious well-being is more than that of their existential dimension. The findings showed that the total mean score for prayer activity in these patients was 94.5±12.98, the previous experience of prayer in 57.2% of the patients was favorable. The attitude toward prayer in 52.2% of the patients was positive with the mean score 38.2±4.84. Significant relationships existed between spiritual well being with prayer practice, prayer experience and attitude toward prayer respectively, (r=0.61, p=0.00), (r=0.70, p=0.00) and (r=0.59, p=0.00). The findings demonstrated a direct and significant association between the Total score of prayer and the spiritual well-being of the patients(r=0.74, p=0.00). Conclusion: The findings support healthcare providers encouraging patients diagnosed with cancer to utilize prayer as an effective resource for dealing with cancer.

Key words: Spiritual well-being, Prayer, Cancer patients

INTRODUCTION

Cancer is described to be one the widespread, chronic non-communicable diseases(1). Various kinds of cancers are the causes of 9% of death throughout the world. After cardiovascular disease, cancer is considered to be the second leading cause of death in the developed and industrialized countries, and the 4th main cause in the developing countries,which are estimated to be about 19% and 6% of death in those societies respectively. Based on the statistics, 5 out of 50 million deaths are attributed to have a cancer cause (2). Treatment of cancer is often done by invasive modalities such as surgery, and chemotherapy which can lead to numerous side effects (3). Diagnosis of cancer influences spiritual needs due to the threatening nature of the illness(4). A diagnosis of cancer often provokes a crisis regarding the meaning of life, and shakes religious faith and burdens relationships with an uncertain future (5). Spiritual well-being is an important dimension of human well-being which is described as the affirmation of life in a relationship with a higher being or God, self, community and environment, which nurtures the development of wholeness (6-7). Spiritual well-being involves a religious vertical component, which refers to a sense of well-being in relation to God, and a socio-psychological, horizontal or existential component which refers to a sense of life purpose and life satisfaction (5). Patients who strengthen their spiritual well-being can cope effectively with their illness (8). Human religious and spiritual resources are estimated as important adaptation forces during the illness process (9). Various studies indicate that there are positive associations between physical health, spiritual well-being, meaning in life and prayer (10). Prayer is defined as an activity and expression of the human spirit reflecting connectedness with God (11). Prayer is described as being a spiritual and for some people a religious behavior. In the encyclopedia of religion, prayer is defined as any form of communication and divine intercourse with God, the supreme and divine being (12). Keegan, Guzzetta and Deusy (2000) define prayer as the deepest part of human nature that lifts up human beings from their isolation to a conscious communion with life(14). Deusy (1993) emphasizes that prayer does not pertain to a particular religion and is not confined by time and place (14). It becomes our souls' dialogues with God and is a spontaneous utterance that comes from the deepest nature of mankind, which is an innate and divine action by nature yet not a learned behavior. There is a strong eagerness for people to find a way of communication with the origin of the world (15). Prayer is associated with meaning in life and spiritual well-being. Prayer is regarded as an effective coping strategy for ill persons (10). There are numerous kinds of prayers, as to the number of the persons themselves who pray. It may be public or private. It is described as any form of divine communication with God as a supreme being, including verbal talking (sometimes silence), singing, listening, waiting and groaning. Some people utilize other techniques, complementary to their prayers, such as tranquility, comforting, meditation, imagination, contemplation and observation (15). Prayer is characterized as a practice of worship, praising, confession and intercession to God, mediation, supplication and thanksgiving (16). It is a practice performed in many cultural and religious customs. Bringing the meaning of the prayer to mind and the ways wherein one can experience the presence of God and the communion with Him, provides the patients with a very strong and profound spiritual resource. When a person faces an illness and needs to be hospitalized, his imagination power paves the way for him/her to fly to another place that may be curative and comforting, and this may cause him/her to turn to practices of praying and religious commitment (15). Some people have found that their prayer, provides a resource to withstand the physical and psychologic crises brought on by the diagnosis and subsequent treatment of cancer (11). Prayer lets cancer patients have a heart to heart relationship with God. His/her personal prayers and the prayers of others are inspiring for them. These patients ask others to pray for them too (17).

It is concluded that there is a reciprocal association between the innate belief and spiritual well-being on one hand and hope and positive moods on the other which helps patients to cope more comfortably with their diseases (18). A number of studies reported that survivors of breast cancer emphasized the positive benefits of the spiritual resources of prayer and a relationship with God. In addition, long-term cancer survivors reported prayer and putting trust in God as important coping strategies during their cancer experiences (19).

MATERIALS AND METHODS

In this study 2 data gathering tools were used: - Paloutzian & Ellison's (1982) Spiritual well-being Scale (SWBS) was used to examine the spiritual well-being of cancer patients. The SWBS has been used extensively in research and has been tested with samples including college students, patients and caregivers(7). This questionnaire comprising 20 items was divided into 2 parts: the first part included 10 items referring to the respondent's relationship with God and thus assesses a vertical religious dimension of spirituality-religious well-being. The other 10 items assessed a horizontal or existential dimension of spiritual well-being. Each item is related on a six-point, Likert-scale from "strongly agree" to "strongly disagree", with higher scores indicating a greater degree of spiritual well-being. About half of the items are worded negatively to minimize response bias. The related score of the spiritual well-being was computed by summing the scores of these two subcategories which ranged from 20-120 finally; the spiritual well-being is divided into 3 levels of low (20-40), middle (41-99) and high (100-120).
-
Poloma and Pendleton's Prayer Scale (PS) was the most acceptable tool which was developed to assess types of prayer activities and prayer experiences. Poloma reported a Cronbach's alpha reliability coefficient of .85 for the instrument. Because the original instrument by Poloma and Pendleton was not sensitive enough to tap cancer illness, the scale was adapted by Meraviglia (2002) for use with people with cancer. The adapted and revised PS was used in this study. The scale had 32 items, which included 17 items on prayer activities, 9 items on prayer experiences, 6 items on attitudes toward prayer. The 3 subscales had 7 Likert-type response categories ranging from 7 = strongly agree to 1 = strongly disagree. Total scores were computed for each subscale by adding the item scores. High scores reflected a high degree of prayer activity, prayer experience, or positive attitude toward prayer. Subscale scores could range from 17-119 for prayer activities, 9-63 for prayer experiences, and 6-42 for attitudes toward prayer (20). The variables such as having chronic cardiovascular, hepatic, renal, respiratory and psychiatric diseases and those who abuse the psychedelic drugs are not recorded and considered in the study. The prayer and spiritual well-being were determined by measuring the quantity reliability. The reliability of the questionnaire was determined by using alpha co-efficient recommended by Cronbach. The related results were r=0.79 and r=0.82 for prayer and spiritual well-being questionnaire respectively. These tools were used after translation and evaluated by content reviewers. Content reviewers critiqued the items for accuracy and clarity of the content of the instruments.

The first part of the questionnaire comprised questions related to the personal information and status of illness which, were acquired through interview or gathering information from their profiles. The questionnaires were completed in a self-monitoring way by patients. The patients signed the letter of satisfaction initially.

PARTICIPANTS

Participants were recruited from 2 Oncology Centers affiliated to Iran and Tehran medical Sciences University in Tehran City. Any cancer patient who was referred to Oncology Centers for chemotherapy, aged more than 20 years, able to read and write, and aware of their illness, were included in this study. Three hundred and sixty cancer patients who meet study criteria participated in this study. After participants agreed to participate in the study and signed an informed consent form, they completed questionnaires.

Statistical analysis of the data was conducted using SPSS 11.0. Descriptive statistics (e.g., frequency, mean, standard deviation) summarized the data from the study variables.

RESULTS

Findings:
A total of 360 patients (171 women (47.5%), 189 men (52.5%)) participated in the study, ranging in age from 20 to 78 years, with a mean age of 42.5. The majority of participants (46.1%) were under 40 years (n=166). Concerning participants' educational status, 89.4% were at high school level and 10.6% were university graduated.

Considering the patients marital status, the majority of subjects (73.1%) were married. Participants had a variety of cancers, which included oessophageal cancer (28.6%), blood and lymphatic cancer (24.7%), breast cancer (18.6%), bone cancer (10.8%), renal cancer (8.2%), lung cancer (3 %), nervous system cancer (1.6%) and 3.6% had other types of cancers. About half of the sample (45.8%) reported that they were within the first 6 months of being diagnosed with cancer, and only 3% reported more than 36 months of being diagnosed with cancer. The average period for being diagnosed with the illness was 13.7 months

In terms of spiritual well-being findings revealed that the Mean score of total spiritual wellbeing is 98.35. In general the spiritual well-being of patients with cancer is at the medium level. Due to the fact that the religious and existential well-being are the two main aspects of each individual's spiritual wellbeing, results showed that the patients mean score for religious well-being is higher than existential well-being (54.6 Vs 43.6) which may be due to the fact that the Iranians are described to be religious and at the time of facing crisis put trust in God and resort to religious affairs as a means of coping with the new critical situation. (Table 1)

Among items of well-being scale, the majority of respondents acquired high scores in the items "I believe that God likes me and cares for me" and "My relationship with God helps me not to feel alone" with mean score 5.59 and item "I believe that there is a philosophy behind my existence" with mean score 5.37.

Total scores on the 3 subscales varied. Prayer activity scores ranged from 55 to 119, with a mean of 94.5. The scores of the prayer experience subscale ranged from 23 to 63, with a mean of 51.2, whereas attitudes toward prayer scores ranged from 6 to 42, with a mean of 38.2. Scale total scores ranged from 94 to 221, with a mean of 1841.05 (Table 2).

The findings indicated that the previous experience of prayer in 59.2% of patients was favorable and to be unfavorable in 40.8%. Range of Attitude toward prayer in cancer patients undergoing chemotherapy was estimated between 6-42 and the total mean score was about 38.2 ±4.84.

Table 3 was drawn for showing the effect of prayer on the spiritual well-being of cancer patients undergoing chemotherapy. There is a direct and significant relationship between the prayer and spiritual well-being. (p=0.00, r=0.74). Patients who resorted more to the prayer gained a favorable experience from their previous prayer and so have a positive attitude toward it and have higher spiritual well-being.

DISCUSSION

Prayer activity scores ranged from 55 to 119, with a mean of 94.5. This range was reported by Meraviglia (2002) as about 58-108 with mean of 87 which showed to be less than the scores of the present study (20). This is due to the difference between cultural and religious beliefs among people. Sodestrom and Martinson reported that people with cancer described both praying personally and asking others to pray for them as spiritual coping strategies. (11)
The findings indicated that the previous experience of prayer in 59.2% of patients was favorable and to be unfavorable in 40.8%. The considered area for the attitudes of cancer patients undergoing chemotherapy toward prayer was estimated to be between 6-42 and the total mean score was about 38.2 ±4.84, which showed itself to be similar to the outcomes obtained from Meraviglia's (2002) survey. (20)

Findings showed a direct and significant relationship between prayer and spiritual well-being. In other words, patients who resorted more to prayer gained a favorable experience from their previous prayer and so have a positive attitude toward it and have a higher spiritual well-being. It seems that the most effective factor on the spiritual well-being of patients is regarded to be the previous experience of prayer. In fact the previous experience of prayer is described to have a more crucial effect on improving the spiritual well-beings of patients rather than the frequency of prayer and the attitude toward it. As Norum and his colleagues (2000) found in a survey conducted on 20 cancer patients in Norway, that believing in God and prayer play important roles in improving patients' spiritual well-being (8). Taleghani (1384) conducted a study which demonstrated that the important factor to be taken into consideration is the influence of spirituality on well-being for females who have been diagnosed with breast cancer and resort to prayer and seeking aids from the prophets, oblation, pilgrimage and other things. This issue is of a great importance in psychological comforting and decreasing the fear of disease (21). Maly & Feher (1999) in a study on breast cancer patients showed that the religious belief is perceived as a great spiritual support for patients and they believe that relying more on God will bring human beings, better psychological well-being This gives them enough inspiration to cope with the disease(21). Byrd (1988) found that prayer had a positive effect on the physical responses of critically ill patients, and Turner and Clancy (1986) found that prayer positively affected people experiencing chronic low back pain (20). Regarding the first hypothesis of the study which states that "the prayer activity has an important impact on the spiritual well-being of cancer patients undergoing chemotherapy", findings indicated that the spiritual well-being of patients significantly associated with prayer activity using linear regression test (p=0.00, r=0.61). It means that as the frequency of prayer increases, the more better the spiritual well-being of these patients. Therefore the hypothesis 1 is proved.

Considering hypothesis 2 which states that "the previous experience of prayer influences the spiritual well-being of cancer patients undergoing chemotherapy greatly and directly using linear regression test. (p=0.00, r=0.70). The outcome from linear regression (Table 2) shows that there is a direct and significant association between the patients' previous experience of prayer and spiritual well-being. In other words the more the score of the previous experience of prayer increases, the more would be the score for the spiritual well-being .It is concluded that the hypothesis is proved.

The third hypothesis states that "attitude toward prayer is described to have great impact on the spiritual well-being of cancer patients undergoing chemotherapy". The outcomes indicated that there is a direct and significant association between attitude to prayer and spiritual well-being of cancer patients using linear regression test (p=0.00, r=0.59) which revealed that the more the related mean score of attitude toward prayer increases, the more improvement we have in spiritual well-being of cancer patients, so this hypothesis is proved too. Religion is an important resource and is regarded as an effective factor in improving spiritual well-being when people resort to it. At the time of confronting problems, prayer proves to be a psychological comforter for cancer patients (21).

By the way of using Kruscalvalis test there is found to be meaningful association between the frequency of prayer and cancer patients' ages. (p=0.00) which showed that the higher the age of cancer patients undergoing chemotherapy increase, the higher the mean score for frequency of prayer, in such a way that the mean score in the age-group of more than 70 years is more than that of other age-groups. Algier et al (2005) proved that cancer patients of the age-group of 40 to 59 years of use more complementary and alternative therapies compared with other age-groups (22).

Based on T-test, there is a significant association between the frequency of prayer and sex of the cancer patients undergoing chemotherapy. (p=0.01). It is shown that the mean score for frequency of prayer in females suffering from cancer and undergoing chemotherapy is more than that of males, which is consistent with the following research outcome:

Mulasiotis et al (2005) indicated that females suffering from hematological malignancy are more reluctant to use complementary and alternative therapies especially prayer (23).

Tas et al(2001) and Guzom(201) in their studies on cancer outpatients found out that the females suffering from cancer use more complementary and alternative therapies like prayer. Algir and his colleagues (2005) also reported similar findings(22).

Honda and Jacobson (2005) in their study demonstrated females use prayer more than males (24).

Based on the Kruscavalis test, the present study shows that there is a significant association between the frequency of prayer and cancer patients' educational status (p=0.00), and the mean score for the frequency of prayer in patients with lower level of education was reported to be higher. This mean score for patients at primary level was observed to be thehighest. Meraviglia (2002) in his survey on cancer patients proved that the mentioned mean score for patients with lower level of education is also more. The study outcomes are shown to be contradictory (20). Ceylan et al (1998) and Gazoom (2001) in their study on outpatients suffering from cancer and with lower level of education found out that the patients with lower level of education utilize more complementary and alternative therapies like prayer compared with people with higher level of education. This is while Samoor and his colleagues (1999) in their studies on outpatients observed that the patients with higher level of education use more complementary and alternative therapies (22). Likewise, Mulasiotis et al (2005) showed that patients with malignant hematonosis and higher level of education resort more to prayer (23).

Honda and Jacobson (2005) also perceived that those who are university graduated resort most to prayer (24). A significant association between the previous experience of prayer and cancer patients ages undergoing chemotherapy has been observed in Kruskalvalis test(p=0.00). The older the cancer patients undergoing chemotherapy are, the more the related mean score for the previous experience of prayer would increase, in such a way that the mean score in the age-group of more than 70 years is reported to be more than the related score in other age-groups. Various studies demonstrated that 90% of Americans in their old age, resort to religion and spirituality in order to cope with stress. They believe that religion brings peace, comfort and tranquility. Stressful elements during the old age period may result in losing one's health, friends, and family members. If these people live in societies where in the values of people are evaluated according to the productivity and young appearance of people, they will become more disturbed and anxious; therefore, they seeks aids from religion to cope with stressful elements (25).

The mean score for the previous experience of prayer for cancer patients undergoing chemotherapy in females is reported to be more than males although the T-test showed no significant difference. (p=0.09). Based on Kruscalvalis test, there is found to be a significant association between the levels of education and the previous experience of prayer in cancer patients undergoing chemotherapy (p=0.00). The related mean score for the previous experience of prayer in cancer patients undergoing chemotherapy at primary level is reported to be more, in contrast with those with other levels of education. Meravglia (2002) also recommended that the previous experience of prayer in cancer patients has an opposite relationship with level of education (20). According to the study conducted by the researchers of Harvard University, spirituality not only roots in a person's own beliefs but also in their own experiences. Believing in something with out experiencing it will cause persons to lose the physical and psychological benefits of spirituality. Some people may be exposed by spiritual experiences but may not know it.. Spirituality has indexes such as prayer, which needs to be experienced (25). Kruskalvalis test indicates that there is a significant association between cancer patients' attitudes toward prayer and their related ages (p=0.00) and the mean score for attitude toward prayer will increase along with the increase of their ages, in such a way that the related mean score in the age-group of more than 70 years is found to be more than other age-groups. Findings indicated that the mean score for attitude toward prayer in females is a little higher than that of males, but the related outcomes of T-test showed no significant difference in the mean score for attitude toward prayer between males and females(p=0.28).

A significant relationship is observed between the attitude toward prayer and cancer patients levels of education(p-0.00). Its related mean score for those at primary level is described to be more than other levels. Meraviglia (2002) demonstrated that the attitude toward prayer in cancer patients has an opposite relationship with their levels of education. Frequency of prayer in cancer patients undergoing chemotherapy ranges from 55-119 and the mean score for frequency of prayer in the patients is 94.5±12.98 while in the Mervaglia's study (2002) performed in Texas, the score limit for frequency of prayer in cancer patients was 55-108 with the mean score of 87, which reported to be fewer in contrast with the present study score. This may be due to the cultural and religious beliefs discrepancies. The score limit for the frequency of prayer in cancer patients undergoing chemotherapy is estimated to be 23-63 with the mean score of 51.2±7.49. Meraviglia (2002) reported the score limit for the previous experience of prayer in cancer patients to be 18-52 with the mean score of 38.8, which is shown to be less than its counterpart outcome in the present study. Also the score limit for attitude toward prayer in cancer patients undergoing chemotherapy ranges from 6-42 with the mean score of 38.2±4.84 which is similar to the outcomes obtained from Meraviglia's research (2002). Given the findings of the study it is considered as essential for patients suffering from threatening illnesses such as cancer to pay more and greater attention to the important role that spiritual well-being and alternatives such as prayer play in maintaining a healthy life and finding the coping techniques (20).

Back to text

Back to text

Prayer experience                                              =0.49
Prayer activity and prayer experience               =0.55
Prayer activity, prayer experience and attitude    =0.58

Back to text

Prayer activity

Back to text

Previous experience of prayer

Back to text

Attitude toward prayer

Back to text

ACKNOWLEDGEMENTS

The authors deem it necessary to gratefully acknowledge the personnel of Rasul-E- Akram teaching center (Oncology Unit) affiliated to Iran Medical Sciences University and Imam Khomeini cancer institute affiliated to Tehran Medical Sciences University as well the cancer patients for their cooperation. The authors also acknowledge and appreciate the research Vice-chancellor of Medical Sciences University of Iran for his financial support.

1. Farzanpie R. Recognize of Cancer: Prevention and fighting. 1994, Tehran: Mad Co. p20
   
2. shojaee Tehrani H. prevention community Medicine Textbook: Common non-communicable chronic diseases. Volt 4.2003. Gilan Medical Sciences University. pp3-5, 43-49
   
3. Corner J, Baily C. Cancer nursing care in context. Black well publishing: UK, 2001.P.3-5.
4. O'Brien ME. Spirituality in nursing: standing on holy ground. Massachussett: Jones and Bartlett publishing; 1998.P.182, 183,176.
   
5. Highfield MF. Spiritual health of oncology patients: nurse and patient perspectives. Cancer nursing 1992; 15(1):1-8.
   
6. Craven RF, Hirnle CJ. Fundamental of nursing: human health and function.4thed. Philadelphia: Lippincott Williams and Wilkins , 2003.P.1383-1392.
   
7. Fernsler JI, Klemm P, Miller MA. Spiritual well-being and demands of illness in people with colorectal cancer. Cancer nursing 1999; 22(2):134-140.
   
8. Lin HR, Bauer-Wu SM. Psycho-spiritual well-being in patients with advanced cancer: an integrative review of the literature. Journal of advanced nursing 2003; 44(1):69-80
9. Tatsumura Y, Maskarinec G, Shumay DM, Kakai H. Religious and spiritual resources. Alternative therapies in health and medicine 2003; 9(3):64-71.
10. Meraviglia MG. Critical analysis of spirituality and its empirical indicators: prayer and meaning in life. Journal of holistic nursing 1999; 17(1):18-33.
    
11. Salmenpera L. The use of complementary therapies among breast and prostate cancer patients in Finland. European Journal of Cancer Care 2002 11, 44-50.
    
12. Taylor EJ, Hopkins Outlaw F. Use of prayer among persons with cancer. Holistic nursing practice 2002; 16(3):46-60.
    
13. Gomez R, Fisher JW. Item response theory analysis of the spiritual well-being questionnaire. Personality and individual differences 2005; 38:1107-1121.
    
14. Young C, Koopsen C. Spirituality, health and healing. California: Slack incorporated; 2005.P.3-15, 45-48,232,233
    
15. Dossey BM, Keegan L, Guzzetta CE. Holistic nursing: a hand book for practice. 3rded. Massachusset: Jones & Bartlett publishing; 2003.P.5, 6, 9-14, 92-94,134.
    
16. Shariati A. philosophy of Worship . Tehran:Author, 1988.p 54.
    
17. Watson J, Craig C, Robinson B, Weinert C. I am not alone: spirituality of chronically ill rural dwellers. Rehabilitation Nursing 2004; 29(5):164-168.
    
18. Fehring RJ, Miller JF, Shaw C. Spiritual well-being, religiousity, hope, depression, and other mood states in elderly people coping with cancer. Oncology nursing forum 1997;24(4):663-671.
    
19. Halstead MT, Fernsler JL. Coping strategies of long-term cancer survivors. Cancer Nursing 1994; 17: 94-100.
    
20. Meraviglia MG. Prayer in people with cancer. Cancer nursing 2002;25(4):326-331.
    
21. Taleghani F. Coping process with breast cancer in newly diagnosed Iranian women. Dissertation for Phd. Faculty of nursing and midwifery.Tehran medical Sciences University, 2005, pp 75-138
22. Algier LA, Hanoglu Z, Kara F. The use of complementary and alternative ( non-conventional ) medicine in cancer patients in Turkey. European journal of oncology nursing 2005;9:138-146.
    
23. Molassiotis A, Margulies A, Fernandez P. Pud D, Panteli V, Bruyns I, etal. Complementary and alternative medicine use in patients with hematological malignancies in Europe. Complementary therapies in clinical practice 2005;11:105-110.
    
24. Honda K, Jacobson JS. Use of complementary and alternative medicine among United-States adults: the influences of personality, coping strategies, and social support. Journal of adolescence 2005; 12(1):16-26.
    
25. Karren KJ, Hafen BQ, Smith NL, Frandsen KJ. Mind-body health: the effects of attitudes, emotions, and relationship. 3thed. 2006;P.23,56,57,343,344,417-430,444.