Introduction
Cancer poses a significant health challenge globally, characterized by its chronic nature and the potential to affect every aspect of an individual’s life (Hausman Reference Hausman2019). It is one of the leading causes of death worldwide. In 2022, there were nearly 20 million new cases and 9.7 million cancer-related deaths worldwide. By 2050, the number of new cases is projected to rise to 33 million annually, with cancer-related deaths reaching 18.2 million. Generally, cancer incidence is highest in countries with higher life expectancy, education levels, and standard of living. However, for certain cancer types, such as cervical cancer, it is reversed, with the highest incidence rate observed in countries where populations rank low on these socioeconomic measures (Institute Reference Institute2025). Iran faces a considerable health challenge due to cancer, experiencing higher incidence and mortality rates. According to the latest data from the International Agency for Research on Cancer for 2020, there were an estimated 131,191 new cancer cases in Iran, leading to 79,136 deaths. Projections suggest that these figures will continue to increase in the future (Creswell Reference Creswell2017). Developing countries, including Iran, bear a disproportionate burden, accounting for over 50% of cases and 70% of related deaths globally (Zahedi et al. Reference Zahedi, Rafiemanesh and Enayatrad2015; Rafiemanesh et al. Reference Rafiemanesh, Rajaei-behbahani and Khani2016). In Iran, cancer ranks as the third leading cause of death, with an annual incidence of 98–110 cases per 100,000 individuals (Danaei et al. Reference Danaei, Haghdoost and Momeni2019). Beyond its physical toll, cancer imposes profound emotional and social burdens on patients and their families, disrupting their quality of life and overall well-being (Taets et al. Reference Taets, Fernandes and Torres2020).
In recent years, research has increasingly focused on psychosocial factors that facilitate better adjustment to illness and reduce illness-related distress. Among these, mindfulness has garnered significant attention due to its potential to enhance emotional regulation and psychological well-being. Mindfulness, defined as the conscious, purposeful, and non-judgmental attention to present-moment experiences (including thoughts, feelings, and bodily sensations) (Baydoun et al. Reference Baydoun, Moran and McLennan2021), plays a crucial role in reducing psychological symptoms in cancer patients. Studies indicate that mindfulness-based interventions are associated with reductions in stress, anxiety, depression, emotional distress, and treatment-related symptoms, while simultaneously improving psychological adjustment and quality of life (Xunlin et al. Reference Xunlin, Lau and Klainin-yobas2020; Pedro et al. Reference Pedro, Monteiro-reis and Carvalho-maia2021). Mindfulness, a practice that emphasizes being present and accepting reality without judgment, has emerged as a complementary approach to enhancing self-care. It is associated with improved emotional regulation, reduced stress, and enhanced psychological well-being (Williams and Penman Reference Williams and Penman2011; Ghanbaritalab et al. Reference Ghanbaritalab, Javanmard and Rezaei2019). Mindfulness helps individuals address negative thoughts triggered by the challenges of adhering to medical recommendations by fostering adaptive coping mechanisms (Bogusch and O’Brien Reference Bogusch and O’Brien2019).
Furthermore, it enhances patients’ ability to cope with uncertainty, regulate emotional responses, and maintain engagement in meaningful daily activities despite illness-related challenges (Haller et al. Reference Haller, Winkler and Klose2020). Various dimensions of mindfulness, including emotional awareness, focused attention, relaxation, and conscious action, contribute distinctly to the psychological functioning and overall well-being of cancer patients (Haller et al. Reference Haller, Winkler and Klose2020; Kvillemo and Bränström Reference Kvillemo and Bränström2021).
Alongside mindfulness, spirituality and spiritual self-care have also been identified as key factors in improving the quality of life for cancer patients. Evidence suggests that patients with higher spiritual well-being often report better quality-of-life outcomes (Taghlili et al. Reference Taghlili, Khankeh and Norouzi Tabrizi2023). Spiritual care, by reducing stress, depression, anxiety, distress, and anger, leads to improvements in health status, sleep quality, behaviors, and positive cognitive and emotional states in chronic patients, including those with cancer (Valipour eskandarkolaii et al. Reference Valipour Eskandarkolaii, Hekmatipour and Hojjati2023; Najmadini et al. Reference Najmadini, Malakoutikhah and Tian2024).
The connection between mindfulness and spiritual self-care holds significant potential for the holistic improvement of health outcomes in cancer patients. By strengthening self-awareness and emotional regulation, mindfulness provides a foundation for a deeper understanding of spiritual beliefs and for finding meaning in one’s experiences. This self-awareness facilitates a stronger connection with faith, enabling individuals to accept events, experience reduced stress and anxiety, and maintain a more hopeful outlook for the future (Taghlili et al. Reference Taghlili, Khankeh and Norouzi Tabrizi2023).
Research indicates a significant correlation between mindfulness and self-care behaviors. Individuals who incorporate mindfulness skills – such as acceptance – into their daily lives are more likely to engage in behaviors associated with increased self-care (Fallah et al. Reference Fallah, Barkhordari-sharifabad and Nasiriani2022).
Spiritual self-care training has been shown to reduce stress, depression, anxiety, and distress, thereby improving quality of life, sleep, and overall well-being in chronically ill patients, including those with cancer (Valipour eskandarkolaii et al. Reference Valipour Eskandarkolaii, Hekmatipour and Hojjati2023). This complementary therapeutic approach, especially in palliative care, increases life expectancy in chronically ill patients (Zhang et al. Reference Zhang, Pang and Sharma2019) and helps reduce unpleasant feelings associated with loneliness, mortality, and the fear of death (Ochoa Arnedo et al. Reference Ochoa Arnedo, Sánchez and Sumalla2019). By addressing existential needs, such as understanding the meaning of life and resolving challenges related to concepts such as divine justice, spiritual self-care fosters resilience, leading to better illness adjustment and improved sleep quality (Ochoa et al. Reference Ochoa, Casellas-grau and Vives2017; Taghlili et al. Reference Taghlili, Khankeh and Norouzi Tabrizi2023). Even regular participation in religious centers and self-care practices has been associated with a 24% reduction in stress and anxiety (Bekmaz et al. Reference Bekmaz, Rasooli and Shamsi2022). These findings underscore the importance of culturally tailored spiritual self-care interventions, especially in Islamic societies, where spiritual health is closely linked to religious practices (Heidari et al. Reference Heidari, Raisi and Ahmari-tehran2013; Rahnama et al. Reference Rahnama, Javidan and Saberi2015; Vasigh et al. Reference Vasigh, Tarjoman and Borji2020). For instance, Goudarzian et al. (Reference Goudarzian, Boyle and Beik2019) demonstrated that promoting religious attachments, a key component of spiritual self-care, positively impacts self-care behaviors in cancer patients (Goudarzian et al. Reference Goudarzian, Boyle and Beik2019). Similarly, a study by Dehghan et al. (Reference Dehghan, Jazinizade and Malakoutikhah2020) found a direct relationship between mindfulness and quality of life, noting that mindfulness can indirectly reduce stress (Dehghan et al. Reference Dehghan, Jazinizade and Malakoutikhah2020). These findings indicate that mindfulness serves as a powerful tool to facilitate and strengthen the dimensions of spiritual self-care.
The increasing prevalence of cancer among younger populations underscores the importance of focusing on adults (individuals over 18 years old) in this study. This demographic group bears significant social and professional responsibilities, making them particularly vulnerable to the challenges of cancer treatment. Cancer treatment often leads to decreased work productivity, increased absenteeism, and even job abandonment in this group, which places significant economic and psychological pressure on both patients and their families. Furthermore, caregivers, who are often from the same age group, face similar challenges in balancing work and caregiving duties. There is a greater need for supportive programs and self-care interventions for this population (Kamal et al. Reference Kamal, Covvey and Dashputre2017). Cancer deeply impacts all areas of life, making self-care essential for those living with the disease. Among various self-care dimensions, spiritual self-care, influenced by cultural beliefs, plays a vital role. Nurses are crucial in providing culturally sensitive self-care education. However, existing research has predominantly focused on intervention-based studies, failing to provide a comprehensive understanding of the prevalence and correlates of spiritual self-care within this vulnerable population. Furthermore, despite recent advancements in the field of mindfulness and its potential to enhance well-being, its direct relationship with spiritual self-care, as well as its potential role as a moderator, remains incompletely elucidated. In Iran, research on spiritual self-care remains limited, with most studies being intervention-based. This study aimed to address these gaps by examining the relationship between mindfulness, spiritual self-care, and psychological distress in cancer patients, offering insights into how integrated self-care approaches can enhance the quality of life for this population.
Materials and methods
Study design, setting, and participants
This cross-sectional descriptive correlational study employed a convenience sampling method. The study was conducted on a sample of 600 cancer patients referred to Afzalipour Hospital and Javad Al-Aemeh Clinic affiliated with Kerman University of Medical Sciences. The sample size was calculated using the formula for estimating correlations in cross-sectional studies and a previous similar study (Garcia et al. Reference Garcia, Junior and Sarto2021). The calculation accounted for a 95% confidence level, 90% test power, and an expected correlation coefficient of 0.2. Initially, 325 samples were estimated to ensure sufficient power for detecting significant relationships between spiritual self-care practices and mindfulness dimensions. However, the sample size was adjusted to account for potential non-responses or incomplete questionnaires. Consequently, 600 participants were included in the study. Inclusion criteria consisted of individuals aged 18 years and above, with adequate literacy (reading and writing skills) to understand the study questions, a confirmed cancer diagnosis, and no history of psychosis and suicidal ideation (Dehghan et al. Reference Dehghan, Jazinizade and Malakoutikhah2020). Exclusion criteria included incomplete completion of more than 10% of the questionnaire items. In cases of data loss and incomplete responses, the respective samples were excluded and replaced with new participants. Of the 600 participants, 12 participants were excluded due to incomplete responses and the analysis was conducted on 588 questionnaires, resulting in an effective response rate of 98%.
Data collection
The code of ethics was obtained from the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1401.377). Additionally, permission was obtained from the authorities at Afzalipour Hospital and Javad Al-Aemeh Clinic, along with a letter of introduction from the Nursing Faculty. All participants in the study volunteered to take part and were aware of their right to withdraw from the study at any time. The researcher introduced the study objectives to the patients and emphasized the strict confidentiality of the collected information.
Data collection spanned nine months, from March 20, 2023, to December 30, 2023, at Afzalipour Hospital and Javad Al-Aemeh Clinic. Patients who met the inclusion criteria were approached during their hospital visits. After obtaining informed consent, the researcher distributed the questionnaires and provided detailed instructions for completion. Participants were assured of the confidentiality of their responses and were informed that participation was voluntary.
To accommodate patients experiencing illness or treatment side effects, the researcher visited the clinics in different shifts to ensure optimal data collection. Questionnaires with less than 90% completion were excluded from the analysis. The collected data were checked for completeness and accuracy before being entered into SPSS for statistical analysis.
To reduce potential bias due to time-related variation in patient characteristics, the researcher ensured balanced distribution across different months and shifts. Moreover, key demographic and clinical factors (e.g., age, sex, disease stage, duration, comorbidities) were statistically adjusted in the regression models. This approach aimed to account for sample heterogeneity and enhance the internal validity of the findings.
Measurements
Three questionnaires were used in this study: a demographic and background information questionnaire, the Spiritual Self-Care Practice Scale (SSCPS), and the Relaxation, Meditation, and Mindfulness Experiences Questionnaire Trait Month Tracker 3.1 (RMMtm 3.1).
1. Demographic and background information questionnaire
This tool collected data on sex, age, marital status, occupation, income, education level, and clinical characteristics such as type of cancer, duration of diagnosis, stage of illness, type of treatment, history of comorbidities, and history of hospitalization.
2. Spiritual Self-Care Practice Scale
The scale was originally developed by White and Schim (Reference White and Schim2013) to examine the mediating role of spiritual self-care practices between quality of life and depression (White Reference White2016). The 35-item questionnaire consists of four domains: personal self-care practices, spiritual practices, physical spiritual practices, and interpersonal spiritual practices. It utilizes a 5-point Likert scale ranging from 1 (never) to 5 (always). The minimum score is 5, while the maximum score is 180, with higher scores indicating greater spiritual self-care practice. White and Schim (Reference White and Schim2013) established the validity and reliability of the questionnaire, reporting a Cronbach’s alpha of 0.92. The content and structural validities of the questionnaire were appropriate, and its reliability was found to be 0.92 based on Cronbach’s alpha coefficient, indicating good internal consistency(White and Schim Reference White and Schim2013; White Reference White2016).
The Persian version demonstrated excellent face validity, with a content validity index of 0.948. Exploratory factor analysis retained 23 items, accounting for 61.25% of the total variance. The Kaiser–Meyer–Olkin measure was 0.865, indicating the factorability of the correlation matrix of the SSCPS. A five-factor solution with an eigenvalue >1 was derived. These factors were labeled: (1) Personal and Interpersonal Spiritual Practices, (2) Shaping and Strengthening Relationship Practices, (3) Religious Practices, (4) Physical Spiritual Practices, and (5) Reshaping Relationship Practices. Confirmatory factor analysis confirmed the model’s fit indices. The Cronbach’s alpha coefficient for the entire questionnaire was 0.89, while the coefficients for the domains ranged from 0.596 to 0.882 (Najmadini et al. Reference Najmadini, Malakoutikhah and Tian2024). In the present study, the Cronbach’s alpha coefficient for the entire questionnaire was 0.88, while the coefficients for the domains ranged from 0.585 to 0.872.
3. Relaxation, Meditation, and Mindfulness Experiences Questionnaire trait month Tracker 3.1 (RMMtm 3.1)
The RMMtm 3.1 aims to assess individuals’ mindfulness experiences, with a focus on events occurring within the past two months, including infrequent occurrences. The questionnaire consists of 32 questions organized into six dimensions: mindful relaxation, mindful quiet, mindful focus/awareness, mindful action, mindful emotion, and mindful transcendence.
Participants are required to rate their experiences on a 7-point scale ranging from 0 (never or I do not understand the question) to 6 (several times a day). Scoring is performed dimension-wise: the sum of item scores in each dimension is divided by the number of items in that dimension. A total score is not calculated. Higher scores indicate higher levels of mindfulness (Smith Reference Smith, Lehrer and Woolfolk2021).
The Persian version of the questionnaire demonstrated good face validity with a content validity index of 0.965, explaining 72.387% of the total variance. Confirmatory factor analysis confirmed fit indices for the 24-item questionnaire. The Cronbach’s alpha coefficient for the dimensions ranged from 0.802 to 0.89 (Najmadini et al. Reference Najmadini, Malakoutikhah and Tian2024). In the present study, the Cronbach’s alpha coefficient for the dimensions ranged from 0.78 to 0.88.
Data analysis
IBM SPSS Statistics 26 was utilized for data analysis. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were calculated to describe the background characteristics and the main study variables. Pearson’s correlation coefficient was used to examine the relationship between spiritual self-care practice and mindfulness. Independent t-test and analysis of variance were conducted to investigate the relationship between spiritual self-care practice and background characteristics.
To identify the most parsimonious set of predictors for spiritual self-care practice, a stepwise multivariate regression analysis was conducted. This method was chosen for the exploratory nature of the study, as no prior empirical study has definitively established predictors of spiritual self-care specifically among cancer patients. This approach allowed the data to guide variable selection while controlling for shared variance among predictors. The regression model included spiritual self-care practice as the dependent variable and the following independent variables: mindfulness (total scores for each dimension), sex, marital status, education level, income, duration of cancer, disease stage, and history of comorbidities (yes/no). Prior to the main analysis, regression assumptions were systematically tested. Multivariate outliers were detected using Mahalanobis distance (d2) with a conservative critical χ2 threshold (df = number of predictors; p < 0.001). Six outliers were identified and excluded from the analysis. Univariate normality of the main variables was assessed using skewness and kurtosis indices. Multivariate normality was confirmed using Mardia’s normalized multivariate kurtosis value (1.40), which falls within the acceptable range of ±3.0. Variance Inflation Factor (VIF <10) and Tolerance (>0.1) were examined for all predictors. No multicollinearity was detected (VIF range: 1.018–2.583; Tolerance range: 0.387–0.983). The Durbin-Watson statistic was 1.95, within the acceptable range of 1.5–2.5, indicating no significant autocorrelation in the residuals. Scatterplots of standardized residuals against standardized predicted values were visually inspected, showing random dispersion around zero without funnel pattern. Additionally, the Breusch-Pagan test (p = 0.31) confirmed homoscedasticity. A significance level of α < 0.05 was considered statistically significant for all tests.
Results
The mean age of cancer patients was 47.31 ± 12.85 years, with a mean cancer duration of 16.31 ± 22.54 months. The majority of patients were female and married. Most of the patients had an academic education, were employed, and reported a monthly income of over 10 million tomans. The most prevalent types of cancer were gastrointestinal and breast cancers. More than half of the patients were in the early stages of the disease, and the majority were undergoing combination therapy. A significant number of patients had a history of underlying diseases and previous hospitalizations (Table 1).
The relationship between cancer patients’ background characteristics and spiritual self-care practice
Table 1 Long description
Background characteristics are listed with frequency and percent, plus spiritual self care practice reported as mean and standard deviation, alongside a statistical test and p value. Age groups ranged from under 30 years at 40 people, 6.7 percent, mean 3.25, SD 0.83, to over 50 years at 229 people, 38.2 percent, mean 3.26, SD 0.79, with p value 0.43. Sex showed female 314, 52.3 percent, mean 3.36, SD 0.81, and male 286, 47.7 percent, mean 3.23, SD 0.76, with p value 0.047. Marital status showed single 148, 24.7 percent, mean 3.43, SD 0.76, and married 452, 75.3 percent, mean 3.25, SD 0.79, with p value 0.02. Education level ranged from lower or upper secondary 117, 19.6 percent, mean 3.18, SD 0.52, to masters or PhD 95, 15.8 percent, mean 3.51, SD 0.86, with p value 0.004. Income level ranged from under 3 at 126, 21.0 percent, mean 3.20, SD 0.78, to over 10 million tomans at 264, 44.0 percent, mean 3.36, SD 0.81, with p value 0.02. Disease duration ranged from 1 to 6 months at 276, 46.0 percent, mean 3.31, SD 0.78, to 25 months or more at 98, 16.3 percent, mean 3.02, SD 0.81, with p value below 0.001. Cancer type categories included cervical at 38, 6.3 percent, mean 3.56, SD 0.82, and prostate at 25, 4.2 percent, mean 3.07, SD 0.81, with p value 0.23. Treatment type included chemotherapy 217, 36.2 percent, mean 3.29, SD 0.83, others 22, 3.7 percent, mean 3.47, SD 0.58, and combination therapy 361, 60.1 percent, mean 3.29, SD 0.77, with p value 0.57. History of comorbidities showed yes 308, 51.3 percent, mean 3.20, SD 0.82, and no 292, 48.7 percent, mean 3.40, SD 0.74, with p value 0.001, while history of hospitalization showed yes 477, 79.5 percent, mean 3.29, SD 0.78, and no 123, 20.5 percent, mean 3.32, SD 0.80, with p value 0.77.
T = independent t-test; F = analysis of variance test.
The highest mean scores for spiritual self-care practice were observed for the following items: “I ask questions about medical orders,” “I spend time with my family,” I maintain friendships,” and “I maintain positive relationships.” Conversely, the lowest mean score was reported for “I practice yoga or tai-chi,” which involves spiritual meditation through a series of exercises (Table 2).
Mean (SD) scores of spiritual self-care practice in cancer patients
Table 2 Long description
Spiritual self care practice items are listed with a Mean and SD for each item. Mean values range from 1.92 to 4.30, and SD values range from 1.27 to 2.40. Item 1, I make time for myself, has mean 3.16 and SD 1.27; item 2, I eat healthy foods, 3.44 and 1.35; item 3, I feel at peace or in harmony, 3.06 and 1.47; item 4, I rest to regain health and energy, 3.23 and 1.34. Item 5, I maintain a sense of hope for the future, has mean 3.73 and SD 1.38; item 6, I maintain friendships, 3.87 and 1.86; item 7, I spend time with my family, 3.96 and 1.32; item 8, I have meaningful and deep conversations with others, 3.52 and 1.42; item 9, Others love me, 3.88 and 1.38; item 10, I spend time with my friends, 3.66 and 1.50; item 11, I maintain positive relationships, 3.87 and 1.37. Item 12, I ask questions about medical orders, has mean 4.30 and SD 2.40; item 13, I forgive others, 3.70 and 1.38; item 14, I help others, 3.73 and 1.31. Item 15, I attend religious services, has mean 3.03 and SD 1.45; item 16, I contribute to a religious group, 2.87 and 1.45; item 17, I consult a spiritual advisor, 2.78 and 1.50; item 18, I walk and climb mountains, 2.58 and 1.52; item 19, I practice yoga or tai chi, 1.92 and 1.36; item 20, I follow a special diet for example vegetarian, 2.16 and 1.45; item 21, I mend my broken relationships, 3.12 and 1.33; item 22, I resolve conflicts, 3.12 and 1.36; item 23, I give alms to the poor or do other acts of charity, 3.27 and 1.45.
The mean total score for spiritual self-care practice in cancer patients was 3.17, which was higher than the questionnaire midpoint (3). Among the different domains of SSCPS, religious practices received the highest mean score, followed by practices related to maintaining and enhancing connections. The lowest mean score was assigned to the dimension of practices related to restoring connections (Table 3).
Total mean (SD) score of spiritual self-care practice and scores of its domains in cancer patients
Table 3 Long description
Spiritual self-care practice domains are summarized with columns for Mean, SD, Minimum, and Maximum. Personal and interpersonal practices had a mean of 3.30 with SD 0.80, minimum 1.20, and maximum 5. Practices related to maintaining and enhancing connections had a mean of 3.55 with SD 1.0, minimum 1, and maximum 5. Religious practices had a mean of 3.90 with SD 1.13, minimum 1, and maximum 5. Spiritual physical practices had a mean of 2.89 with SD 1.24, minimum 1, and maximum 5. Practices related to restoring connections had a mean of 2.22 with SD 1.18, minimum 1, and maximum 5. The total row reported a mean of 3.17 with SD 1.15, minimum 1.30, and maximum 4.91.
Mindful emotion had the highest mean score, followed by mindful focus/awareness and mindful relaxation dimensions. Mindful transcendence had a lower mean score. Overall, scores across all dimensions ranged from 2.25 to 3.78. The mean scores for mindful emotion, mindful focus, and mindful relaxation were higher than the questionnaire midpoint, while the mean score for mindful quiet was equal to the questionnaire midpoint. In contrast, the mean scores for mindful transcendence and mindful action were lower than the questionnaire’s midpoint (Table 4).
Mean (SD) mindfulness score in cancer patients
Table 4 Long description
Mindfulness subscales are listed with columns for mean, standard deviation, minimum, and maximum scores. Mindful transcendence has a mean of 2.25 with a standard deviation of 1.30, minimum 0, and maximum 6. Mindful relaxation has a mean of 3.14 with a standard deviation of 1.65, minimum 0, and maximum 6. Mindful emotion has a mean of 3.78 with a standard deviation of 1.67, minimum 0, and maximum 6. Mindful focus has a mean of 3.20 with a standard deviation of 1.57, minimum 0, and maximum 6. Mindful quiet has a mean of 3.0 with a standard deviation of 1.73, minimum 0, and maximum 6. Mindful action has a mean of 2.79 with a standard deviation of 1.54, minimum 0, and maximum 6.
A significant and positive correlation was observed between the total scores of the SSCPS and the RMMtm 3.1 dimensions, as well as between their respective dimensions. However, the strength of these correlations was weak to moderate (Table 5).
The relationship between spiritual self-care practice and mindfulness in cancer patients
Table 5 Long description
Correlations are listed between spiritual self care practice categories and mindfulness domains, Transcendence, Relaxation, Emotion, Focus, Quiet, and Action. Personal and interpersonal practices correlate 0.625 with Transcendence, 0.626 with Relaxation, 0.640 with Emotion, 0.625 with Focus, 0.595 with Quiet, and 0.625 with Action. Practices related to maintaining and enhancing connections correlate 0.342 with Transcendence, 0.414 with Relaxation, 0.501 with Emotion, 0.382 with Focus, 0.351 with Quiet, and 0.377 with Action. Religious practices correlate 0.280 with Transcendence, 0.244 with Relaxation, 0.349 with Emotion, 0.163 with Focus, 0.189 with Quiet, and 0.269 with Action. Spiritual physical practices correlate 0.382 with Transcendence, 0.460 with Relaxation, 0.184 with Emotion, 0.242 with Focus, 0.427 with Quiet, and 0.434 with Action. Practices related to restoring connections correlate 0.403 with Transcendence, 0.387 with Relaxation, 0.420 with Emotion, 0.399 with Focus, 0.432 with Quiet, and 0.393 with Action. Total correlations are 0.628 for Transcendence, 0.650 for Relaxation, 0.650 for Emotion, 0.585 for Focus, 0.609 for Quiet, and 0.642 for Action.
p < 0.001.
The score of spiritual self-care practice demonstrated a significant relationship with various factors including sex, marital status, education level, income, disease duration, disease stage, and underlying disease history (Table 1). The multivariate linear regression analysis revealed that 63.9% of the variance in spiritual self-care practice could be explained by the variables of mindful emotion, mindful quiet, mindful transcendence, mindful action, mindful relaxation, income level, history of comorbidities, and disease stage.
Specifically, higher scores in all mindfulness dimensions were associated with higher spiritual self-care practice scores. Additionally, an income level between 3 and 5 million tomans was associated with lower spiritual self-care practice scores. Patients with no history of comorbidities and those in the early stages of the disease exhibited higher spiritual self-care practice scores. Other variables included in the model did not show a significant relationship with spiritual self-care practice (Table 6).
Regression coefficients of factors predicting spiritual self-care practice in cancer patients
Table 6 Long description
Regression coefficients are reported for independent variables predicting spiritual self care practice, with columns for b, S. E, beta, T, p value, and 95 percent confidence interval. Mindful quiet has b 0.097, S. E 0.016, beta 0.213, T 6.04, p value less than 0.001, and confidence interval from 0.065 to 0.128. Mindful transcendence has b 0.099, S. E 0.021, beta 0.163, T 4.73, p value less than 0.001, and confidence interval from 0.058 to 0.139. Mindful action has b 0.083, S. E 0.019, beta 0.161, T 4.37, p value less than 0.001, and confidence interval from 0.046 to 0.120. Mindful relaxation has b 0.056, S. E 0.019, beta 0.117, T 2.96, p value 0.003, and confidence interval from 0.019 to 0.092. Income between 3 to 5 million compared to less than 3 million tomans has b negative 0.179, S. E 0.080, beta negative 0.056, T negative 2.23, p value 0.026, and confidence interval from negative 0.022 to negative 0.337. History of comorbidities, coded 0 yes and 1 no, has b 0.084, S. E 0.039, beta 0.053, T 2.13, p value 0.034, and confidence interval from 0.007 to 0.160. Disease stage, coded 0 late and 1 early, has b 0.082, S. E 0.040, beta 0.052, T 2.03, p value 0.043, and confidence interval from 0.161 to 0.934.
Adjusted R 2 = 0.639 F = 130.68 (p < 0.001).
Discussion
The aim of this study was to investigate the relationship between spiritual self-care practice and mindfulness in cancer patients referred to medical centers affiliated with Kerman University of Medical Sciences. Cancer is a debilitating disease that affects all aspects of a person’s well-being. The results showed that the mean score of the spiritual self-care practice among the studied cancer patients was higher than the midpoint of the questionnaire. Spiritual self-care uses non-pharmacological approaches to address spiritual needs. In Iran, as an Islamic country, adherence to spiritual and religious principles necessitates the use of non-drug treatments such as spiritual therapy to reduce anxiety and stress (Najmadini et al. Reference Najmadini, Malakoutikhah and Tian2024). Spiritual self-care guidelines are based on cultivating a connection with a higher power, improving interpersonal relationships, and developing self-awareness, self-control, and self-efficacy (Asadzandi et al. Reference Asadzandi, Eskandari and Khademolhosseini2018). In addition, spiritual self-care includes self-love, physical and mental health, strengthening overall well-being, and empowering individuals to provide more effective care (Akbari et al. Reference Akbari, Dehghan and Tirgari2023).
Researchers emphasize the importance of spiritual self-care, which includes physical, mental, and emotional dimensions. This includes the connection between a person’s mind, soul, and body, as well as the influence of moral and religious beliefs and lived experiences rooted in faith, emotions, and feelings. Spiritual self-care enhances positive emotions, optimizes nervous system functioning, strengthens psychological capacities, and promotes mindfulness (White Reference White2016; Harbi et al. Reference Harbi, Oraki and Alipour2020; Bekmaz et al. Reference Bekmaz, Rasooli and Shamsi2022).
The findings showed that cancer patients had higher-than-average levels of spiritual self-care. Although no specific study on this issue was found in cancer patients, White (Reference White2011) reported a moderate level of spiritual self-care in patients with heart failure (White Reference White2011). Additionally, receiving a cancer diagnosis creates a threat to a person’s sense of security and deeply affects their feelings and emotions. In addition to the physical effects of the disease and its treatment, cancer patients face long-term health disorders leading to disability, fatigue, and pain. Consequently, emotional and mental pressures manifest in various aspects of daily life (Lewandowska et al. Reference Lewandowska, Rudzki and Lewandowski2021).
This difference can be related to the greater diagnostic difficulty, tougher prognosis, and more intense emotional and existential pressures associated with cancer compared to other chronic diseases. Cancer patients may rely more heavily on spiritual practices and self-care to cope with the fear of death and psychological distress. Therefore, this comparison shows that spiritual support in oncology care should be tailored to the specific needs and challenges of patients.
This study suggests that cancer patients engage in higher levels of spiritual self-care compared to those with other chronic illnesses, possibly due to the emotional and psychological impact of a life-threatening diagnosis. The fear of death, uncertainty, and existential distress associated with cancer often lead patients to seek meaning and peace through spiritual practices. Unlike many chronic diseases, cancer increases awareness of life fragility, and increases the need for spiritual coping strategies. Cultural and religious beliefs also affect how patients approach spiritual self-care. Understanding these unique factors can help design interventions that target the specific emotional and spiritual needs of cancer patients (Caldeira Reference Caldeira2018).
Research indicates that spiritual care and religious teachings foster positive emotions, optimize nervous system functioning, strengthen psychological well-being, and cultivate mindfulness. Mindfulness has a wide impact on various aspects of well-being; it enhances concentration, relieves stress, and promotes overall mental and physical health. Studies have shown that mindfulness can reduce chronic pain, boost the immune system, and relieve stressful conditions such as fibromyalgia, breast cancer, and psoriasis. This exercise also improves mental and psychological health by reducing symptoms of depression, anxiety, and addiction-related problems, while increasing positive mood, self-efficacy, and empathy (Creswell Reference Creswell2017; McConville et al. Reference McConville, McAleer and Hahne2017; Bamber and Morpeth Reference Bamber and Morpeth2019). White (Reference White2011) suggests that practicing spiritual self-care can effectively calm the mind and soothe inner turmoil because mindfulness emphasizes focused awareness (White Reference White2011). Therefore, the findings of the present study confirmed a correlation between spiritual self-care practice and mindfulness in cancer patients referred to medical centers affiliated with Kerman University of Medical Sciences. Regarding mindfulness, the dimension of mindful emotion obtained the highest mean score. Spiritual self-care includes activities rooted in spirituality or religion, aimed at deepening knowledge, nurturing the soul, and achieving inner peace. This concept includes using spiritual beliefs and teachings as a source for controlling behavior and protecting well-being (Najmadini et al. Reference Najmadini, Malakoutikhah and Tian2024). Additionally, the results showed a direct and significant relationship between different aspects of mindfulness and spiritual self-care practice. As the level of spiritual self-care increased, the average scores for different dimensions of mindfulness also increased. Although no similar study was found specifically in the cancer patient population, research on self-care and mindfulness has been conducted in other contexts.
Mikolasek et al. (Reference Mikolasek, Witt and Barth2021) showed that a mindfulness and relaxation software for cancer patients can serve as a practical and effective self-care intervention, especially for highly anxious patients (Mikolasek et al. Reference Mikolasek, Witt and Barth2021). Badpar et al. (Reference Badpar, Bakhtiarpur and Haiderai2020) investigated the structural model of self-care in patients with diabetes in Tehran, focusing on the mediating role of healthy lifestyle in the relationship between mindfulness and self-care behaviors. Their findings indicated a correlation between mindfulness, self-care behaviors, and a healthy lifestyle (Badpar et al. Reference Badpar, Bakhtiarpur and Haiderai2020). Another study by Harbi et al. (Reference Harbi, Oraki and Alipour2020) investigated the effect of a mindfulness-based stress reduction program on self-care in women with type 2 diabetes. The results showed that stress reduction based on mindfulness had a positive effect on self-care (Harbi et al. Reference Harbi, Oraki and Alipour2020). Similarly, Slonim et al. (Reference Slonim, Kienhuis and Di Benedetto2015) examined the relationship between self-care, trait mindfulness, and psychological distress among male medical students at Monash University, Australia. Their findings indicated that mindfulness plays a moderating role in the relationship between self-care and psychological distress and has overlapping characteristics that help reduce psychological distress (Slonim et al. Reference Slonim, Kienhuis and Di Benedetto2015).
One possible explanation for these findings is that spiritual self-care, as a subset of general self-care, can positively affect thought processes and mindfulness by addressing both physical and mental dimensions. The strong relationship between spiritual self-care and mindfulness can be attributed to the similarities in their core components. Overall, the findings of this study support the growing evidence emphasizing the role of mindfulness and spirituality in comprehensive cancer care. Recent studies have increasingly highlighted the importance of integrating psychosocial and spiritual interventions into oncology services to improve patient outcomes (Najmadini et al. Reference Najmadini, Malakoutikhah and Tian2024).
Findings regarding demographic and background variables showed an inverse relationship between education level (diploma compared to lower/secondary education) and spiritual self-care practice; as education increased, the self-care practice decreased. In conditions such as diabetes, hypertension, multiple sclerosis, and heart failure, individuals with lower education levels typically demonstrate less self-care, which is against the results of the present study (Lynning et al. Reference Lynning, Hanehøj and Karnøe Knudsen2017; Santesmases-Masana et al. Reference Santesmases-Masana, González-de Paz and Hernández-martínez-esparza2019; Kurnia et al. Reference Kurnia, Hariyati and Melizza2023; Montazeri et al. Reference Montazeri, Bakhshi and Malekzadeh2023).
It is likely that interpersonal, cultural, and religious differences among patients play a significant role. In Iran, an Islamic country, spiritual self-care is strongly influenced by cultural and religious values. Islamic teachings emphasize patience (sabr), trust in God (tawakkul), and spiritual practices such as prayer and Quran recitation, which serve as key coping strategies for many cancer patients. These beliefs shape how patients perceive their disease and engage in spiritual self-care. Understanding this cultural-religious context is vital for oncology nurses to provide culturally sensitive and spiritually supportive care. However, further research is necessary to validate these findings and achieve a more comprehensive understanding. Given that spiritual self-care is a relatively new and mid-range theory that has emerged in the past decade, more studies are needed to increase our understanding of this concept and its associated factors. This study highlighted the importance of mindfulness as a vital component of spiritual self-care for cancer patients who are seeking peace in their lives. Future research should examine how specific Islamic practices promote mindfulness and well-being in cancer care (Hosseini et al. Reference Hosseini, Kashani and Akbari2016). Mid-range theories are designed to build a knowledge base that supports clinical decision-making, enabling nurses to predict outcomes and make informed decisions in practice.
Limitations
This study offers valuable insights into spiritual self-care practices among cancer patients; however, several limitations warrant consideration when interpreting the findings. First, the sample size and the specific population studied may limit the generalizability of the results to broader patient groups. Moreover, the use of a convenience sampling method may have introduced selection bias, potentially limiting the representativeness of the sample. The study’s cross-sectional design also restricts the ability to draw conclusions about causal relationships between mindfulness and spiritual self-care, as it captures only a snapshot in time. Additionally, reliance on self-reported data may introduce bias, as participants might overestimate or underestimate their spiritual practices. Further clarity is needed to differentiate between spirituality, spiritual self-care, and mindfulness, and a more robust conceptual framework explaining the link between mindfulness and spiritual self-care would strengthen future research. The specific research gap and the study’s novelty require clearer articulation, and the regression analyses, particularly the stepwise approach, would benefit from more detailed justification of variable selection and clearer presentation of diagnostic checks and assumption testing. Finally, potential redundancies in the discussion section and inconsistencies in reference formatting should be addressed. Future research could address these limitations by exploring the long-term effects of spiritual self-care, examining how these practices evolve over time and impact emotional well-being and overall quality of life. Furthermore, investigating the role of different spiritual practices – such as meditation, prayer, or gratitude – could provide deeper insights into how specific spiritual activities influence mindfulness and self-care behaviors. Addressing these gaps will enhance the understanding of spiritual self-care and facilitate its integration into oncology nursing practice.
Conclusion
This study reveals that cancer patients engage in spiritual self-care practices at levels above the midpoint, with mindfulness, particularly the mindful emotion, playing a significant role in shaping these practices. The results indicate that dimensions of mindfulness such as mindful emotion, quiet, transcendence, and relaxation, alongside demographic factors like income, disease history, and stage, account for a substantial portion of the variance in spiritual self-care practices. For oncology nursing practice, these findings underscore the importance of incorporating mindfulness-based approaches into patient care routines. Nurses can integrate strategies that promote mindful emotion, mindful relaxation, and overall mindfulness to enhance spiritual well-being in cancer patients. Additionally, tailoring interventions based on a patient’s disease stage and personal circumstances may further optimize the effectiveness of spiritual self-care practices. By incorporating these insights into daily care, oncology nurses can provide more holistic and individualized support, addressing both the emotional and spiritual needs of patients in their cancer journey.
Theoretical implications
This study enhances the theoretical understanding of spiritual self-care by demonstrating the role of mindfulness in cancer patients’ self-care practices. It aligns with the Integrative Model of Spirituality and Health, which highlights how spiritual practices promote well-being. The findings suggest that mindfulness dimensions, especially mindful emotion and relaxation, are key to spiritual self-care. This study broadens current theories by showing how both internal (mindfulness) and external (e.g., income, disease stage) factors influence spiritual self-care.
Data availability statement
The data used to support the findings of this study are available from the corresponding author upon request.
Acknowledgments
We would like to thank all the participants who participated in the study, as well as the support and collaboration of the Kerman of Medical Sciences, Kerman, Iran (Project No: 401000406).
Authors contributions
A.N., M.A.F., and M.D. designed the study. A.N. conducted the search and data collection. M.D. analyzed data collection. A.N. and M.A.F. drafted the manuscript. S.D., W.A.A.H., J.F.E.C., and M.D. revised the manuscript. All the authors read and approved the final manuscript.
Funding
No funding or research grant was received during the study.
Competing interests
The authors declare that they have no conflict of interest. They have no relevant financial or non-financial interests to disclose.
Ethical approval
This study is based on the Declaration of Helsinki. The project received approval from the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1401.377).
Ethics and consents
Participants were presented with a consent form. The researcher explained the research objectives, assured confidentiality, emphasized the non-influence of participation in the treatment process, and then provided questionnaires to patients. The consent form detailed the study’s purpose, objectives, data confidentiality, participant anonymity, and the option to withdraw at any time. Participants formally signed informed consent forms. All methods were carried out in accordance with relevant guidelines and regulations. The data-collecting author ensured that participants were informed about when and how they could access psychological support if needed.
Open access
