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Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: http://www.tandfonline.com/loi/udst20

Association of sense of coherence and


supernatural beliefs with death anxiety and death
depression among Romanian cancer patients

Roxana Postolică, Violeta Enea, Ion Dafinoiu, Iuliana Petrov & Doina Azoicăi

To cite this article: Roxana Postolică, Violeta Enea, Ion Dafinoiu, Iuliana Petrov & Doina
Azoicăi (2018): Association of sense of coherence and supernatural beliefs with death
anxiety and death depression among Romanian cancer patients, Death Studies, DOI:
10.1080/07481187.2018.1430083

To link to this article: https://doi.org/10.1080/07481187.2018.1430083

Accepted author version posted online: 02


Feb 2018.
Published online: 27 Mar 2018.

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DEATH STUDIES
https://doi.org/10.1080/07481187.2018.1430083

none defined

Association of sense of coherence and supernatural beliefs with death


anxiety and death depression among Romanian cancer patients
Roxana Postolicăa,b, Violeta Eneac , Ion Dafinoiuc, Iuliana Petrovc, and Doina Azoicăib
a
Regional Institute of Oncology, Iasi, Romania; bFaculty of Medicine, Department of Oncogenetics, “Grigore T. Popa” University of Medicine
and Pharmacy of Iasi, Iasi, Romania; cFaculty of Psychology and Education Sciences, Department of Psychology, “Alexandru Ioan Cuza”
University of Iasi, Iasi, Romania

ABSTRACT
The aim of this cross-sectional study was to examine the association of supernatural beliefs and
sense of coherence with death anxiety and death depression in a Romanian sample of cancer
patients. We found support for the terror management theory worldview defence hypothesis
postulating the presence of a curvilinear relation between death anxiety and supernatural beliefs
among cancer patients. Results conformed to an inverted U-shape quadratic regression, indicating
that cancer patients who scored moderately on supernatural beliefs were afraid of death the most,
while death anxiety was lowest for the extreme atheists and extreme believers in supernatural
entities.

Introduction beliefs and SOC might be important resources of


resilience. The objective of this research was to advance
In 2013 Global Burden of Cancer estimated that there
a better understanding of the relationship between
were 14.9 million new cases of cancer in the world
supernatural beliefs and SOC with death anxiety and
and were around 8.2 million of deaths caused by cancer
death depression by studying a Romanian sample of
(Fitzmaurice et al., 2015). According to the survey, one
cancer patients.
in three men and one in five women will have cancer
during their lifetime. For many people, the diagnosis
of “cancer” means a death sentence because of the
Supernatural beliefs and religiosity in cancer
uncontrolled cell multiplication that destroys the body,
patients
leading to a slow and painful death (Moorey, Greer, &
Greer, 2002), although the cancer is a curable disease Supernatural phenomena, such as superstitions and
at an early stage. Different cultures relate differently to belief in life after death or belief in angels and demons
the notion of death (Neimeyer, 1997), but the conscious are included in the paranormal beliefs domain (Irwin,
awareness of our own mortality generates death anxiety 1993), which is one of the four domains of religiosity.
(Solomon, Greenberg, & Pyszczynski, 2000) and According to Irwin (1993), religiosity is defined as
depression (Rodgers, Martin, Morse, Kendell, & Verrill, the role and importance of religion in one’s life
2005), regardless of cultural background or religious and encompasses spirituality, intrinsic religiosity,
beliefs. Death anxiety is a basic fear, which appears to religious fundamentalism, and paranormal beliefs.
be a significant theoretically and clinically issue, under- Klonoff and Landrine (1994) examined the common-
lying many mental disorders (Iveracy & Menzies, 2014). sense beliefs about the causes of six illnesses and
Nonetheless, research on death anxiety and death found that women were more likely than men to view
depression in advanced cancer has been scarce and illness caused by sins, especially sex, as a form of
inconclusive in comparison to depression, despite the punishment. Cancer patients with low social support
potential for death anxiety to be more common (Krause, perceived the consequences of their illness in a severe
Rydall, Hales, Rodin, & Lo, 2015). A recent study found manner and believed in supernatural control of their
a significant negative association between religious illness compared with patients with high social sup-
beliefs and sense of coherence (SOC) with depressive port, which believed in self and doctors (Awasthi &
symptoms (Anyfantakis et al., 2015), therefore religious Mishra, 2010).

CONTACT Violeta Enea violeta.enea@uaic.ro Faculty of Psychology and Education Sciences, Department of Psychology, “Alexandru Ioan Cuza”
University of Iasi, 3 Toma Cozma Street, Iasi, România.
© 2018 Taylor & Francis
2 R. POSTOLICĂ ET AL.

Despite the fact religious beliefs has been shown to be DSM-5 (APA, 2013): fear is the emotional response to
an important resource for people to find meaning in life real or perceived imminent threat associated with the
(Pevey, Jones, & Yarber, 2008–2009), the research autonomic arousal necessary for fight or flight, while
studying Christian samples on the relationship of anxiety is anticipation of future threat. “Fear of death”
religious variables with death anxiety and death refers to the concrete belief that death is frightening
depression reported inconsistent data. Some studies (Lehto & Stein, 2009), while the concept of “death anxi-
indicated that in healthy individuals lower death ety” is so complex that there is currently no consensus
depression and death anxiety scores were associated in the scientific literature on the definition of it
with belief in God and greater belief in afterlife (Nyatanga & de Vocht, 2006). Thus, death anxiety refers
(Alvarado, Templer, Bresler, & Thomas‐Dobson, 1995; to negative emotional reactions provoked by the antici-
Cohen et al., 2005; Harding, Flannelly, Weaver, and pation of a state in which the self does not exist (Tomer
Costa, 2005), while others reported a positive associ- & Eliason, 1996) and describes an emotional state of
ation between death anxiety and literal interpretations death awareness that deals with the fear of the end of life
of Christian faith (Dezutter, Luyckx, & Hutsebaut, and with the fear of the unknown afterlife (Cicirelli,
2009). In cancer patients, death anxiety was correlated 2006). Death anxiety is a multidimensional concept
with beliefs in afterlife due to the unknown nature of life and, according to Conte, Weiner, & Plutchik, 1982, it
after death which brings uncertainty and insecurity yielded four factors: fear of the unknown, fear of suffer-
(Gonen et al., 2012). Although women generally are ing, fear of loneliness, and fear of personal extinction.
more religious than men (Levin & Taylor, 1993), Although a considerable amount of literature has been
changes in religiosity are not influenced by gender in published on death anxiety in healthy individuals, little
cancer patients (McFarland, Pudrovska, Schieman, attention has been paid to death anxiety and death
Ellison, & Bierman, 2013). With reference to the coping depression in cancer patients. Death depression is asso-
strategies used by cancer patients, Zaza, Sellick, and ciated with the death of significant others, depression
Hillier (2005) argued that of all the coping strategies about impending death, experiencing distress, and death
assessed, prayer was the most used strategy. In the same in general (Templer et al., 2001), while death anxiety is
direction, Bowie, Sydnor, Granot, & Pargament (2004) related to somatic distress, general anxiety, global
explored the influence of religion and spirituality on psychological distress, and depression (Cella & Tross,
coping among patients that suffered from prostate can- 1987; Sherman, Norman, & McSherry, 2010). According
cer. Results indicated that a majority of participants to Templer et al. (2001) death depression comprises
reported a high degree of religiosity, measured by four dimensions: death sadness, anergia, existential
denominational affiliation and church attendance. vacuum (a sense of meaninglessness of life), and
According to Weaver and Flannelly (2004), cancer anhedonia.
patients who rely on spiritual and religious beliefs to The link between death anxiety and cancer or other
cope with their illness were more likely to use an active chronic diseases was investigated but the existing
coping style in which they accept their illness and try to empirical findings are contradictory. While Robinson
deal with it in a positive and meaningful way. and Wood (1983) found no association between death
In the present study, we used The Supernatural Belief anxiety and chronic diseases such as cancer or diabetes
Scale (Jong, Bluemke, & Halberstadt, 2013), which was mellitus, Strömberg and Jaarsma (2008) argued that
designed to measure respondents ‘tendencies to believe patients with chronic diseases have more death anxiety
in existentially significant supernatural entities and than healthy controls. Death anxiety is considered to
events, like God, Devil, angels, demons, heaven, hell, have an important role in the development, mainte-
miracles and prophecy. Jong et al. (2013), using this nance and course of many psychological disorders
scale, examined the relation between death anxiety (Furer, Walker, & Stein, 2007). The assessment of death
and religious belief and they found a positive association anxiety among cancer patients may help to individualize
for atheist and agnostic participants and a negative one the support programs for these patients because the
for religious participants. level of death anxiety may be different based on varying
patient population (Sherman et al., 2010). In a cross-
sectional study, Neel, Lo, Rydall, Hales, and Rodin
Death anxiety, religiosity, and terror
(2015) found that thirty-two per cent of the 60
management theory
Canadian outpatients with different types of metastatic
The greatest challenge for cancer patients is the fear of cancer reported death anxiety of at least moderate sever-
death and dying (Adelbratt & Strang, 2000). The terms ity. They found that death anxiety in advanced cancer
fear and anxiety overlap, but also differ, according to patients is positively associated with physical symptom
DEATH STUDIES 3

burden and having children under 18 years of age. In a generates a sense of threat to life, with a variety of
Chinese sample of cancer patients, Ho and Shiu (1995) related existential challenges (Kissane, Lethborg, &
showed that significantly more patients had either Kelly, 2012). Moreover, death anxiety, difficulties of
very high or very low death anxiety levels as compared coping with uncertainty, loss of meaning and purpose,
to the control group. Tang, Chiou, Lin, Wang, and loss of control, a heightened sense of loneliness and fear
Liand (2011) examined the factors that influenced the of uncertainty of the future can appear among these
degree of death anxiety among Taiwanese cancer patients (Kissane et al., 2006, 2012). Resilience in diffi-
patients. Results showed that when level of fear of dis- cult situations depends on the individual’s SOC, which
ease relapse, sense of purpose in life, and gender were is a global orientation to life based on self-confidence
significant predictors of level of death anxiety among regarding challenges, confidence in personals skills
cancer patients. Other predictors of death anxiety and resources in order to cope with difficult events,
included general health, experiences of death and dying, and the belief that negative events may have a meaning
religious aspects, unresolved psychological and physical or a sense in the person’s life (Alivia, Guadagni, &
distress, psychopathology and family circumstances di Sarsina, 2011; Antonovsky, 1987). Although Anto-
(Daradkeh & Moselhy, 2011; Gonen et al., 2012; novsky had not developed the salutogenic model by
Neel et al., 2015). studying patients with cancer, the recent research indi-
The relationship between death anxiety and religion cated a strong negative association between stress and
has been intensely investigated in many empirical SOC, especially between SOC, depression and anxiety
studies trying to answer the question whether religious in these patients (Coyne, Tennen, & Ranchor, 2010;
people fear death more or less than those who are Flensborg-Madsen, Ventegodt, & Merrick, 2005;
nonreligious. This was studied in healthy individuals Olsson, Gassne, & Hansson, 2009).
but it was not explored in cancer patients. Terror Previous studies which focused on patients with
management theory (TMT; Greenberg, Pyszczynski, & cancer and chronic diseases demonstrated that SOC
Solomon, 1986) is the most influential theoretical did not depend on sex, race, or education (Bruscia
approach about how people psychologically deal with et al., 2008; Pudrovska, 2010). Further, it was a
death. This theory asserts that the awareness of death mediator of health-related quality of life dimensions
coupled with the motivation to stay alive engender (Rohani et al., 2015) and a low SOC was independently
paralyzing fear of death which may be buffered by the a predictor for depression and quality of life in the case
cultural worldviews and self-esteem (Hayes, Schimel, of patients diagnosed with colorectal cancer (Hyphan-
Arndt, & Faucher, 2010). Believing in an afterlife may tis et al., 2011). A qualitative study conducted on
suppress death anxiety by providing a sense of meaning, women who were at risk for hereditary cancer of breast
permanence and order through the connection of the or ovarian cancer concluded that understanding their
individual to mainstream cultural standards and values stories of life, especially the “mother’s death” due to
(Greenberg, 2012). According to Jong et al. (2017), ovarian cancer and the finding of coherence contribu-
TMT predicts a curvilinear (an inverted-U curve) ted to the adoption of salutogenetic behaviors in order
relationship between death anxiety and religious belief to prevent cancer in their future families (Mæland,
in healthy individuals: very religious and non-religious Eriksen, & Synnes, 2014). Recently, Rohani et al.
individuals experience reduced levels of anxiety and (2015) found that spirituality and religious coping
individuals who are moderately religious fear death are less important as a predictor for health-related
the most. A recent meta-analysis found support for an quality of life changes in breast cancer patients than
inverted-U pattern in 10 of the 11 studies that directly the degree of SOC.
tested for a curvilinear relationship between death anxi-
ety and religiosity (Jong et al., 2017).
Overview of this study
The concept of death anxiety has received increasing
Sense of coherence in cancer patients
attention in the scientific literature in healthy indivi-
The model of salutogenesis (Antonovsky, 1987), in con- duals from different cultures (Darban et al., 2016;
trast to the pathogenic model, has the goal of drawing MacLeod, Crandall, Wilson, & Austin, 2016; Ron,
people’s attention on the sources of health and healing 2016). This subject has been studied only in Romanian
individuals. It explores the reasons why some people inmates with nonsuicidal self-injury behavior (Enea,
remain healthy when facing stressful situations, while Dafinoiu, Bogdan, & Matei, 2017). The health care
others confronting with the same difficulties, get sick system is underfinanced in Romania and cancer patients
(Lindström & Eriksson, 2006). The cancer diagnosis do not receive the best available standard treatments for
4 R. POSTOLICĂ ET AL.

their illness. Therefore, the ratios between cancer supernatural beliefs among Romanian cancer patients.
incidence and mortality rates are higher in Romania Specifically, we hypothesized that: (1) the level of death
than those in EU, and even worldwide (Straja, Panait, anxiety among cancer patients will be above the average
Busca, & Cinca, 2015). In addition, Pickel (2009) ana- score for healthy individuals, (2) the participants will
lyzed data from several waves of the World Values indicate confident belief in supernatural entities, (3)
Survey and found that Romania is one of the most SOC will be negatively related to death anxiety and
religious nations in Europe. The average Romanian death depression. (4) according to thanatocentric the-
adult attends Christian church 17 times a year, 93% of ories of religion there will be a curvilinear relationship
the participants characterized as religious persons and between supernatural beliefs and death anxiety/death
97% declared that they believe in God. The experience depression. Death anxiety will be highest among cancer
of death anxiety might be influenced by the cultural patients who are moderately believers in supernatural
religious orientations and the death terror could be entities, while atheists and extreme believers in super-
modified by cultural beliefs and values, as it was natural entities will have lower level of it.
examined by the TMT (Pyszczynski et al., 2004).
In this study, we had two major aims. Our first aim
was to examine the association of supernatural beliefs Method
and SOC with death anxiety and death depression Participants
among cancer patients. We tested whether the saluto-
genic model, TMT and religious beliefs might be The current research was conducted in the Regional
embedded in the domain of oncology because the Institute of Oncology and the participants were inpati-
cancer diagnosis is life-changing and can easily trigger ents at this hospital. The exclusion criteria were:
mortality salience, also known as the awareness of one’s (1) being younger than age 18 or older than 70;
eventual death. Studies conducted on the impact of (2) having significant intellectual disability; (3) having
mortality salience found that it constitutes a unique any disease that significantly impairs cognition such as
psychological threat with a great impact on anxious delirium, dementia, or a neurological illness. Of the
responding and behavior (Hayes et al., 2010). According 123 patients with a cancer diagnosis eligible for partici-
to the dual process model of TMT, when death-related pation, 10 women and 17 men declined to take part in
thoughts come into conscious awareness, proximal the study. Participants (n ¼ 96) ranged in age from 26 to
defenses are triggered in order to maintain optimum 70 years (M ¼ 52.70); 50% men; the majority of patients
physical health for self (Pyszczynski et al., 1999). In were married (82.2%) and 87.5% had children. Of the
alignment with spiritual beliefs, SOC was considered sample, 66.7% were under treatment and 31.3% had
one of the generalized resistance forces that neutralize received combinations of chemotherapy and radiation
stressors (Antonovsky, 1987; Anyfantakis et al., 2015; therapy as treatments post-surgery. In addition, 63.5%
Siglen et al., 2007). Recently, Anyfantakis et al. (2015) of the patients had no history of familial cancer. In
examined the effect of SOC and religiosity/spirituality terms of religion, 91.7% were Christian, and 8.3% were
on depression within a rural population in Greece. other religion. The complete socio demographic data,
Results indicated a significant negative association clinical features, and religious characteristics of the
between SOC and religious beliefs with depressive study sample are presented in Table 1.
symptoms, enhancing the presupposition that these
two variables may buffer the negative effects of stress
Procedure
on human health. Some empirical research examining
relationship between death anxiety and religiosity found The study protocol received the Ethics Committee of
support for the curvilinearity hypothesis (Downey, the Faculty of Psychology and Education Sciences and
1984; Jong et al., 2013; Wink & Scott, 2005), while Regional Institute of Oncology approval before
others found a negative correlation, a positive associ- initiation. Participants signed informed consent forms
ation or no significant relationship, depending on the after they were explained the objectives of the study
aspect of religiosity being assessed (Ellis & Wahab, and were instructed that they can choose to withdraw
2012). The present study is the first to examine the from the study at any time. Questionnaires were admi-
relations between death anxiety/death depression, nistered by the psychologist of the hospital and took
supernatural beliefs and SOC in cancer patients. approximately 30 min to complete. Following the com-
Second, given the Romanian cultural peculiarities on pletion of the study materials, participants were fully
religiosity and the situation of the health care system, we debriefed in order to eliminate any negative feelings
aimed to explore the level of death anxiety and triggered by remembering death.
DEATH STUDIES 5

Table 1. Sociodemographic, clinical and religious characteristics Respondents indicate their agreement or disagreement
of the study sample. with each proposition on a 9-point Likert scale,
Characteristics (N ¼ 96) % anchored at −4 (Strongly Disagree) and 4 (Strongly
Age
Mean 52.70
Agree). For this study the Cronbach’s α ¼ .83.
Range 26–71
SD 11.28 Sense of coherence-13
Gender
Male 48 50 (Antonovsky, 1987) is a 13-item short version that
Female 48 50 reflects the ability to cope with stress. It consists of
Marital status
Single 6 6.3 four meaningfulness items (e.g., “How often do you
Married 79 82.2 have the feeling that there’s little meaning in the
Separate/divorced 6 6.3
Widowed 5 5.2 things you do in your daily life”), five comprehensi-
Children bility items (e.g., “Do you have the feeling that you
Yes 84 87.5
No 12 12.5
are in an unfamiliar situation and don’t know what
Education to do?”), and four manageability items (e.g., “How
Primary school 17 17.7 often do you have feelings that you’re not sure you
Middle School 35 36.4
Secondary school 21 21.9 can keep under control?”). Meaningfulness describes
Degree 23 24 the ability to give emotional meaning to the situation,
Religion affiliation
Catholic 14 14.6 comprehensibility describes the ability to give a
Orthodox 74 77.1 cognitive meaning to stimulus, and manageability
Another 8 8.3
Stage of illness means how capable people are and what resources
Complete Remission 15 15.6 they have to cope with a difficult situation. All items
Under treatment 64 66.7
Monitorization after treatment 17 17.7
were answered on a 7-point Likert scale, in which the
Type of treatment response options range from, (1) very seldom or never
SU 2 2.1 to (7) very often. The total score is from 13 to 91. The
CHT 11 11.5
RT 5 5.2 scale test–retest reliability ranges .69 to .72 (Eriksson
SU þ CHT 24 25 & Lindstrom, 2005). For this study the Cronbach’s
CHT þ RT 19 19.8
SU þ CHT þ RT 30 31.3 α ¼ .82.
SU þ CHT þ HT 1 1
SU þ CHT þ RT þ HT 1 1
History of familial cancer Death anxiety questionnaire
Yes 35 36.5 (DAQ, Conte et al., 1982) is a 15-item scale, with four
No 61 63.5
Psychiatric treatment
independent dimensions of death anxiety: fear of the
Anxiolytics 38 39.5 unknown (“Are you worried about not knowing what
Anxiolytics and antidepressants 11 11.5 to expect after death?”) (α ¼ .84); fear of suffering
Without treatment 47 49
Cancer type (“Do you worry that dying may be very painful?”)
Gynaecological 21 21.9 (α ¼ .45); fear of loneliness (“Do you worry that you
Breast 15 15.6
Colon 20 20.8 may be alone when you are dying?”) (α ¼ .87) and fear
Head and neck 13 13.5 of personal extinction (“Do you worry that those you
Other 31 28.2
care about may not remember you after your death?”)
CHT, chemotherapy; HT, hormone therapy; RT, radiation therapy; SU,
surgery. (α ¼ .44). The response set for each question contains
three options; not at all, somewhat, or very much (scored
0, 1, or 2). Internal consistency of the DAQ was .83 and
test-retest reliability was .87 (Conte et al., 1982). For this
Measures
study, the Cronbach’s α ¼ .75.
Supernatural belief scale
(SBS, Jong et al., 2013) is an essentially unidimensional Death depression scale-revised
measure designed and validated to measure individuals’ (DDS-R; Templer et al., 2001) is a self-report question-
tendencies to believe in supernatural agents, entities, naire with a 21-item scale designed to measure
and events. 10 commonly recurring types of supernatu- depression about impending death or death in general.
ral concepts were selected, from which 10 statements Items are scored from 1 (strongly disagree) to 5
were composed, each affirming belief in their actual (strongly agree). It has four factors: death sadness
existence or occurrence (“There exists an all- powerful, (“Thinking about death makes me tearful.”) (α ¼ 0.77),
all-knowing, loving God.”, “There exists an evil personal anergia (“The thought of death saps my energy.”)
spiritual being, whom we might call the Devil”). (α ¼ 0.83), existential vacuum (α ¼ 0.63) (“Death makes
6 R. POSTOLICĂ ET AL.

me feel discouraged about the future.”), and anhedonia linear correlated with death anxiety/death depression
(“The thought of death makes it difficult to experience variables (ps > .05).
pleasure.”) (α ¼ 0.75). For this study, the Cronbach’s
α ¼ .86.
Demographic relationships
A Demographic questionnaire covered age, gender,
education, family status, having children and religious Correlational analyses of the demographic variables
affiliation. Age was categorised into two groups revealed that patient age was significantly related
(0: 26–50 years and 1: 51–71 years), also gender to DAQ scores (r ¼ −.31, p < .002), DDS-R scores
(0: male, 1: female), family status (0: not married, (r ¼ −.28, p < .006) and SOC scores (r ¼ .31, p < .002).
widowed, divorced; 1: married), religion (0: Christian, The younger cancer patients had higher death anxiety
1: other religion), and having children variable (0: yes; and death depression, but lesser internal resources. In
1: no). Education was categorized into four levels addition, gender was significantly associated with DDS-R
ranging from primary school to postgraduate degree. scores (r ¼ .28, p < .005), female respondents showed
The following information covering the cancer more death depression. The cancer type was correlated
variables was collected from participants’ medical with SOC scores (r ¼ .23, p < .02) and DDS-R scores
charts: cancer type, stage of illness, type of treatment, (r ¼ −.23, p < .02), and also there was a significant nega-
psychiatric treatment, and history of familial cancer tive correlation between history of familial cancer and
(Table 1). SOC scores (r ¼ −.22, p < .02), indicating that patients
without a history of familial cancer had a higher level
of SOC. Cancer patients who have children reported
Results stronger supernatural beliefs (r ¼ .25, p < .013).
Descriptive statistics and intercorrelations
Curvilinear relationship
The Shapiro–Wilk test was used to determine whether
the variables had normal distributions. As the distri- To investigate the curvilinear relationship between
bution for DAQ and SOC scores did not meet the stan- supernatural beliefs and death anxiety/death depression
dard for normality (p > .05), they were transformed in cancer patients, we applied curve estimations to the
using a two-step approach: (1) they were transformed data. If the correlation would conform to an inverted
into a percentile rank and (2) submitted to an inverse U-shape quadratic regression line rather than a linear
normal transformation using the mean and the standard regression line, moderately religious cancer patients will
deviation (see Templeton, 2011). The descriptive stat- be more fearful than either those who are atheists or
istics for the DAQ scale, with a scoring range of 0–30, very confident believers in supernatural entities. First,
showed a minimum score of 2 and a maximum score we analyzed the relationship between supernatural
of 25 with a mean of 15.95. The average score of beliefs and death anxiety and found that the F- score
DAQ scale for most people, regardless of age, is 8.5, for the quadratic equation R2 ¼ .11, F (2,92) ¼ 5.71,
according to Conte et al. (1982). Of the 96 participants, β1 ¼ 1.27, β2 ¼ −.41, p < .005 was significantly and
89.6% scored above 8.5 and 10.4% scored lower than 8.5 considerably greater and than was the F- score for the
in this sample. As we expected, a great proportion of the linear equation R2 ¼ .01, F (1, 93) ¼ 1.83, β1 ¼ .42,
participants (72. 9%) indicated confident and moder- p ¼ .17. The β2 value was negative, indicating that the
ately belief in supranatural entities, only 19.8% reported shape of the quadratic curve conformed to an inverted
agnosticism and 7.3% reported extreme disbelief or U- shape. The graph shows that death anxiety is lowest
atheism. for the extreme atheists and extreme believers in super-
No correlations for the relations among the variables natural entities, while agnostic and cancer patients who
exceeded .80, satisfying the assumptions of multicolli- scored moderately on supernatural beliefs were afraid of
nearity (Field, 2013). The correlations support our death the most (Figure 1).
hypothesis concerning the relation of SOC variable with Second, we analyzed the relationship between
death anxiety and death depression outcomes partially. supernatural beliefs and death depression and found a
Specifically, SOC scores were negatively related to similar tendency with negative β2 value indicating that
DDS-R scores (r ¼ −.27, p < .007), indicating that can- the shape of the quadratic curve conformed to an
cer patients who reported higher levels of SOC also inverted U- shape pattern. The F- score for the quad-
reported lower levels of death depression. Contrary to ratic equations R2 ¼ .08, F (2,93) ¼ 4.37, β1 ¼ 1.17,
expectations, there was no relationship between SOC β2 ¼ −.86, p < .015 was significantly and considerably
and death anxiety. Also, supernatural beliefs was not greater than was the F- score for the linear equation
DEATH STUDIES 7

Figure 1. Predicted values of death anxiety by supernatural beliefs among cancer patients. A strong agreement (þ4) indicates
confident belief, the midpoint indicates agnosticism and a strong disagreement (−4) implies atheism.

R2 ¼ .008, F (1, 94) ¼ .77, β1 ¼ −.63, p ¼ .38. The graph moderately supernatural believers had greater death
shows that while death depression is lowest for cancer depression than very confident believers in supernatural
patients who are atheists, agnostic cancer patients and entities (Figure 2).

Figure 2. Predicted values of death depression by supernatural beliefs among cancer patients. A strong agreement (þ4) indicates
confident belief, the midpoint indicates agnosticism and a strong disagreement (−4) implies atheism.
8 R. POSTOLICĂ ET AL.

Discussion confident and moderately belief in supranatural entities,


only 19.8% reported agnosticism and 7.3% reported
This cross-sectional study had two aims: (a) to examine
extreme disbelief or atheism. Because no other study
the association of supernatural beliefs and SOC with
explored the relationship between SBS and death
death anxiety and death depression among cancer
anxiety in cancer patients, we cannot compare our
patients and (b) to explore the level of death anxiety
results with other empirical findings. More research is
and supernatural beliefs among Romanian cancer
needed to better understand how cancer diagnosis
patients. An important main finding of this study is that
changes the relation of people with God and their
we found support for the TMT worldview defence
religious belief.
hypothesis postulating the presence of a curvilinear
The results showed that younger cancer patients
relation between death anxiety and supernatural beliefs.
reported higher death anxiety and death depression
These results are in line with Jong et al. (2013) and Jong
than older cancer patients. These findings contradicted
et al. (2017), who found that death anxiety is lowest
the recent data which showed a positive association of
among atheists and very religious healthy individuals,
age with death anxiety in advanced cancer patients from
and highest among moderately religious healthy indivi-
Canada (Neel et al., 2015), but they were in accordance
duals. The present findings extend these previous results
with other previous studies (e.g., Feroz & Beg, 1987;
from the healthy individuals’ belief in supernatural con-
Thorson & Powell, 2000). The ages of the participants
cepts to cancer patients. Previous studies found that
in the current study ranged from 26 years to 71 years
SOC variable was negatively related with depressive
and they were broken down into two equal groups to
symptoms (Anyfantakis et al., 2015) and we made a
enable a comparison to be made. The first group
similar hypothesis for the relationship between SOC
consists of participants who are in young adulthood
and death anxiety/death depression. Our results showed
(from 26 years old to 50 years old) while the second
that SOC was negatively associated to death depression,
group of participants includes individuals who are in
but contrary to our hypothesis, it was not correlated
mid-adulthood and above (from 51 years old to 71 years
with death anxiety. This finding may be due to the
old) (Corr, Nabe, & Corr, 2003). Studies have generally
stronger association between SOC and depression than
found mixed results regarding the relationship between
between SOC and anxiety (Siglen et al., 2007). Previous
age and death anxiety. Some of them showed that age
research has demonstrated that a higher SOC is associa-
was not linked to death anxiety (Chuin & Choo, 2010;
ted with a lower stress and less depressive symptoms in
Feifel & Nagy, 1981) while others found that older part-
cancer patients (Coyne et al., 2010; Greimel, Lahousen,
icipants (55–70 years old) had greater rates of death
Dorfer, Lambauer, & Lang, 2011; Poppius, Virkkunen,
anxiety because they might think about their mortality
Hakama, & Tenkanen, 2006). Our results confirmed
more often being nearer to death (Suhail & Akram,
these findings and cancer patients who reported higher
2002). Conversely, this explanation might be a reason
levels of SOC, also reported lower levels of death
for lower death anxiety in older cancer patients from
depression. Moreover, the younger cancer patients have
our study because there are differences between young
higher death anxiety and death depression, but lesser
and old cancer patients in death acceptance (Pinquart,
internal resources. One possible explanation is that the
Frohlich, Silbereisen, & Wedding, 2006). Therefore,
SOC forms at the age of about 30 years and under the
older patients already used to think about death because
impact of strong emotional trials the level of SOC can
they have lived most of their lives, but younger patients
change (Antonovsky, 1987). Younger cancer patients
were unprepared to confront death and the unexpected
have a lower level of SOC, indicating that they are not
diagnosis of cancer increased their death anxiety and
able to take care of themselves and reflecting the inad-
death depression. Future research needs to examine
equacy of their coping mechanisms with the disease,
the differences between young and old cancer patients
which was found to be the most consistently related
regarding their perspective on death in more detail.
variable with death anxieties (Sigal et al., 2007). These
The results highlight the importance of other demo-
results suggest that the younger cancer patients are the
graphic and cancer variables (gender, having children,
most vulnerable category for which dealing with death
cancer type) which was also found to be associated with
anxiety and death depression should be one of the
death anxiety in another recent study (Neel et al., 2015).
clinicians’ priorities.
The findings of the current study must be interpreted
As expected, we found that the level of death anxiety
in the context of its limitations. One limitation consists
in Romanian cancer patients was higher than the aver-
of our cross-sectional design that precludes any causal
age score for most people (15.95 > 8.5) and that a great
explanations of the results. It is well-known that the
proportion of the participants (72.9%) indicated
DEATH STUDIES 9

trajectory of religious beliefs can change over time for within a rural population in Greece: The Spili III Project.
cancer patients (McFarland et al., 2013) and future BMC Psychiatry, 15, 173. doi:10.1186/s12888-015-0561-3
longitudinal studies might be worthwhile to further Awasthi, P., & Mishra, R. C. (2010). Illness beliefs of women
cancer patients and their relationships with social support.
elucidate the extent to which the diagnosis of cancer Indian Academy of Applied Psychology mourns the sad
influences the relation of people with God and their demise of Prof. S. Sultan Akhtar, 36(2), 317–327.
religious beliefs. Another limitation of this study was Bowie, J. V., Sydnor, K. D., Granot, M., & Pargament, K. I.
that it relied on the self-report of cancer patients and (2004). Spirituality and coping among survivors of prostate
this could influence their ratings. Our findings need cancer. Journal of Psychosocial Oncology, 22(2), 41–56.
doi:10.1300/j077v22n02_03
further testing with other larger samples restricting
Bruscia, K., Shultis, C., Dennery, K., & Dileo, C. (2008). The
participants to one cancer type and with various lengths sense of coherence in hospitalized cardiac and cancer
of previous treatments. Further, in our study parti- patients. Journal of Holistic Nursing, 26(4), 286–294.
cipants were not divided into religious and non- doi:10.1177/0898010108317400
religious groups and this can be explored in future Cella, D. F., & Tross, S. (1987). Death anxiety in cancer
studies. survival: A preliminary cross-validation study. Journal of
Personality Assessment, 51(3), 451–461. doi:10.1207/
There are some clinical implications of the findings s15327752jpa5103_12
from the current study. Death anxiety and death Cicirelli, V. G. (2006). Fear of death in mid-old age. The
depression findings are extremely useful in improving Journals of Gerontology Series B: Psychological Sciences
the cancer patient’s quality of life and health care ser- and Social Sciences, 61, 75–81. doi:10.1093/geronb/61.2.P75
vices. For example, hospitals could establish support Chuin, C. L., & Choo, Y. C. (2010). Age, gender, and religi-
osity as related to death anxiety. Sunway Acad J, 6, 1–15.
groups for these individuals in order to express their
Cohen, A. B., Pierce, J. D., Chambers, J., Meade, R., Gorvine,
fears and concerns as well as find healthy and effective B. J.,& Koenig, H. G. (2005). Intrinsic and extrinsic
coping strategies. Understanding death anxiety, religiosity, belief in the afterlife, death anxiety, and life sat-
depression and related factors may help us to offer these isfaction in young Catholics and Protestants. Journal of
patients satisfactory therapy strategies during their diffi- Research in Personality, 39, 307–324. doi:10.1016/j.
cult times. Moreover, this current investigation offers jrp.2004.02.005
Conte, H. R., Weiner, M. B., & Plutchik, R. (1982). Measuring
some insights into the relation among supernatural death anxiety: Conceptual, psychometric, and factor-ana-
beliefs, SOC, death anxiety and death depression in lytic aspects. Journal of Personality and Social Psychology,
cancer patients. 43(4), 775. doi:10.1037//0022-3514.43.4.775
Corr, C. A., Nabe, C. M., & Corr, D. M. (2003). Death and
dying, life and living (4th ed.). Belmont, CA: Wadsworth/
ORCID Thomson Learning.
Violeta Enea http://orcid.org/0000-0003-3789-2017 Coyne, J. C., Tennen, H., & Ranchor, A. V. (2010). Positive
psychology in cancer care: A story line resistant to evi-
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