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Religiosity as a Cultural Resource for Arab-Palestinian Women’s Coping with Cancer:

Religiosity as a Cultural Resource for Arab-Palestinian Women’s Coping with Cancer: Drawing on the discourse analysis of 36 in-depth interviews, this qualitative study explores how Arab-Palestinian women cope with breast cancer and ascribe meaning to their illness within the local religious and traditional cultural context. In particular, the study shows that religious beliefs and practices help Arab-Palestinian women to handle emotional and psychological difficulties while perpetuating traditional cultural norms of concealment. Two main functions of religiosity as a coping resource are analyzed by (a) managing distress and identity crisis and (b) changing the meaning of the illness experience. In this sociocultural context, the practice of religious rituals provides cancer patients with an effective and culturally situated instrument for coping with a deep existential crisis. Practical implications of the study are discussed in the conclusions. Keywords breast cancer, religiosity, religion, coping resources, occupied Palestinian territories, Arab-Palestinian women face the disease (Alby, 2018, 2019; Alby, Fatigante, et al., Introduction 2017; Alby & Zucchermaglio, 2019; Alby, Zucchermaglio, Studies have analyzed the cancer patients’ coping resources et al., 2017). The literature has shown also how cultural rep- which mainly focuses on individualistic strategies such as ertoires are in evolution including debates on the meanings positivity, fighting spirit, or personality traits, such as “sense of stigma, shame, and confidentiality, as well as repertoires of coherence” (Antonovsky, 1979; Sarenmalm et al., 2013; that enhance both determination and willingness to survive Silva et al., 2012). (Ahmadi, Hussin, et al., 2018; Ahmadi, Khodayarifard, et al., Coping is found to be the major determinant in a process 2018; Alby et al., 2015; Alby, Fatigante, et al., 2017; Fosket that starts with stressful events and then to adaptation out- et al., 2000; Klawiter, 1999; Patterson, 1987; Sontag, 1978; comes, such as psychological symptoms and somatic illness. Zucchermaglio & Alby, 2016; Zucchermaglio et al., 2016). For example, coping strategies can influence treatment out- This work focuses on the sociocultural context of the occu- comes and survival rates of women who have breast cancer pied Palestinian territories (OPT). The Palestinian society is (Lazarus, 1993; Mehrabi et al., 2016). crossed by strong conservation trends of values and traditional Also, coping with cancer is affected by the kind of lifestyles. This tendency is strengthened by the long Israeli– resources that members of a culture use to interpret life Palestinian conflict which promotes an appreciation of identi- events. Religiosity has been explored as a potential adaptive ties that are distinctive of a cultural tradition. It is traditionally resource for cancer patients and survivors in several cultural a collectivist society that gives priority to the needs of the fam- contexts (Gesselman et al., 2016; Thuné-Boyle et al., 2006, ily compared with individual needs, in which women play a 2011). Drawing on Lazarus and Folkman’s Transactional central role in preserving cultural norms and values through Model of Stress and Coping, Mukwato et al. (2010) found child care (Surbone, 2008). The increased levels of education that the “reliance to God” was one of the four predominant coping strategies by patients and family caregivers (together Department of Social and Developmental Psychology, Sapienza University with social support, positive attitude and acquisition of infor- of Rome, Italy mation and education). Fatalism as well as elements of the Corresponding Author: popular culture (e.g., the notion of adverse events as strength- Francesca Alby, Department of Social and Developmental Psychology, ening and the uselessness of despairing) can be powerful Sapienza University of Rome, via dei Marsi, 78, 00185 Rome, Italy. resources to give meaning to a recent cancer diagnosis and to Email: Francesca.Alby@uniroma1.it Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open and the entry into labor market have led to changes for Trust in religion as a resort and a coping strategy can also Palestinian women, who nevertheless coexist with strong con- be explained by the difficulties experienced by patients in servative tendencies sustained by the adherence to family val- accessing cancer care in the OPT. Treatments available are ues, customs, and by widespread religious beliefs (Azaiza, limited (in particular there are restrictions on radiation ther- 2013). More than three quarters of the Palestinian population apy due to security reasons; treatment plans can be delayed claim to be religious (Goldblatt et al., 2012). due to lack of medications); moreover, patients face many Some studies have documented the cultural resources challenges in accessing the health system due to the military used by Arab women in Israel to interpret and cope with a occupation and the restrictions to mobility (Giacaman, 2018; disruptive life event such as a diagnosis of breast cancer. Hammoudeh et al., 2017). Goldblatt et al. (2012) described how the coping strategies of In the OPT, breast cancer is the most common type of Arab women in Israel are affected by local cultural norms, cancer among women and the leading cause of cancer-related beliefs, and perceptions. Findings stress a duality in partici- mortality (Husseini et al., 2009). pants’ cancer coping experience: they comply with the tradi- tional cultural norms of concealment, while encountering Objectives more open Western attitudes through interactions with health care providers and Jewish women receiving treatment along- To date, very few studies have focused on and gave a voice side them. A recent study, conducted by Goldblatt et al. to Arab-Palestinian women diagnosed with breast cancer. We (2016) on Arab women in Israel, indicated, among the strate- aim to study how they ascribe meaning to their illness and to gies mostly used to cope with the disease; praying, talking to examine their coping strategies within this religious and tra- God, reading the Quran or the New Testament, accepting the ditional cultural context. We focus on the particular role disease as “meant to be” and believing on God’s healing played by religiosity, broadly defined as a personal devotion powers. Research participants stated that their belief in God and participation in religious practices. had increased their personal strength to confront the disease. Several other studies involving breast cancer patients (includ- Method ing Muslim and Christian Palestinian women) found that deeply rooted religious beliefs assisted patients in making This article focuses on a subset of data gathered in a study decisions related to their health; even though most patients conducted in the OPT. Data were collected through in-depth attributed their disease to the will of God, they were actively interviews with breast cancer patients of two medical cen- engaged in fighting it and strictly adhered to medical treat- ters: (a) the Oncology Department at Beit Jala Government ments (Doumit et al., 2010; Hammoudeh et al., 2017; Hospital in Bethlehem Governorate, which is the first hospi- Harandy et al., 2009; Taleghani et al., 2006). Somewhat dif- tal distinguished for providing a large part of diagnostic and ferent findings were found by Azaiza and Cohen (2008) fol- therapeutic services for oncology patients in the OPT; (b) lowing which Arab women in Israel defer to God, or Dunya Women’s Cancer Center in Ramallah Governorate, predestination, the responsibility for their body and health, which is the first and only non-profit center that provides an adopting a passive attitude toward self-care. early diagnostic service for breast cancer and gynecological The importance of “Tawakkul” (reliance on the power of cases in the Palestinian Territories. God) was found among both Palestinian caregivers and can- The study was approved by the Palestinian Ministry of cer patients (Hammoudeh et al., 2017). These findings show Health. Research participants were requested to sign an how religion and spirituality incorporate internal and exter- informed consent form. Data were collected by a researcher nal beliefs and values, and how these interwoven beliefs are who was an Arab-Palestinian woman, which probably facili- deeply rooted in the Palestinian sociocultural system (see tated adherence to the research (there was no refusal to par- also Albarghouthi & Klempe, 2019). ticipate). Participants were also fully ensured about the Several studies showed that in the Arab and Palestinian anonymity and confidentiality of any information collected society, a powerful social stigma is still attached to cancer for the purpose of the study. The data collection ran from (Hammoudeh et al., 2017 see also Hwang, 2013; Lamyian January 2015 to April 2015. et al., 2007). Some studies showed that Arab breast cancer The participants recruited for the study are 36 women patients try to hide their illness to neighbors, friends, and col- selected according to the following inclusion criteria: (a) liv- leagues refraining from socializing and attending gatherings ing in the OPT; (b) been diagnosed with breast cancer and celebrations (Azaiza & Cohen, 2008; and see also Azaiza between 1 month to 3 years prior to the interview; (c) having et al., 2011; Goldblatt et al., 2012). no previous history of mental disorders or other forms of Moreover, in Israel, Arab women rely more on cultural cancer; (d) accepting to be interviewed without the presence resources such as religiosity in the absence of any social sup- of a third person to ensure the participant’s freedom to port or in case of marriage problems, in their attempt to get express their feelings; (e) signing an informed consent form. through the tribulations of a challenging experience such as The interview guide had three sections. The first section breast cancer (Azaiza et al., 2011). explored how the illness was discovered, the second section Almuhtaseb et al. 3 focused on the communication with doctors and the treat- ranged from no formal schooling (i.e., illiteracy) to second ment decision-making process, and the third section explored university degree (i.e., graduate studies). Only one partici- changes and adjustments in life after the illness. This last pant did not have any school education at all; two partici- section examined religiosity as a resource for coping by ask- pants had completed 6 years of school. Six participants had ing what changed in the interviewee’s life after the diagnosis; completed 9 years of school, and two participants had com- if the interviewee defined herself religious, with which pleted 12 years. Eight participants had obtained a postschool degree of observance; and if (and how) religion was a source diploma (i.e., community college). Eleven participants had of support in facing the illness. This article focuses on the completed high school, whereas five participants had com- answers given to questions within the third section. pleted their first degree university education. Finally, only The interview also covered sociodemographic character- one participant had a Master’s degree. As for their social sta- istics (religion, degree of religiosity, age, place of residence, tus and number of children, the majority of the participants education, marital status, employment status, how many (N = 31) were married and two thirds (N = 24) were house- children) and medical information (date of diagnosis, stage, wives. Thirty had children and the number of children per type of treatment). participant ranged from one to nine. Seventeen participants The interviews were carried out in a private room at the reported that they did not know at which stage of the disease hospital or in the cancer center by one of the authors they were at when they were first diagnosed; five partici- (M.I.A.A.) who presented herself as a researcher in social pants reported that they were diagnosed with breast cancer at psychology. The participants were informed about the study’s Stage 1, nine participants at Stage 2, and three participants at objectives both orally and in writing. All the interviews were Stage 3. Three participants stated that they were diagnosed conducted in Arabic (Palestinian dialect) through audio with advanced breast cancer (Stage 4). Regarding the treat- recording, transcribed into standard Arabic and then finally ments, 22 participants were still receiving their treatment translated into English. The actual names of the participants (i.e., chemotherapy), whereas 14 participants reported that have been replaced for confidentiality. The time period of they had completed it, but still had to undergo follow-up tests participants’ interviews ranged from 1 to 2 hr. and diagnostic images regularly according to posttreatment Analytical procedures involved a discourse analysis of follow-up guidelines. the interviews’ transcripts (Alby & Fatigante, 2014; Edwards & Potter, 1992; Wilkinson & Kitzinger, 2000). In the dis- Life Following the Cancer Illness: The Role course analysis, we considered the accounts produced in the of Religiosity interviews as modes through which interviewees reconstruct and make comprehensible their actions and their own selves When asked about changes in life following their illness, while they narrate them (Edwards, 1998). most of the interviewees report negative effects on their We coded as “negative” the instances in which the inter- mood, behaviors, and relationships; higher levels of distress; viewees, when asked about changes in life following the ill- and tendency to isolation. We found 23 instances of this kind ness, report of fear, distress, embarrassment. We coded as across 36 data extracts. We will briefly outline some of these. “non-negative” the instances that report either a positive In the following extract, Maria is talking about her reactions effect or assert a non significant effect (e.g., “life continued to being told she has cancer: as before”). We decided to focus on the analysis of these lat- ter instances because they offered a good opportunity to My mood has become bad, my behavior at home has changed, explore the features of religion as a coping resource. We then and my view of life has also changed. Sometimes I prefer to sit developed an analytic focus on the specific functions that alone and to be isolated from others, and I don’t like to get out of my home. My relationship with my husband was completely religiosity plays in the interviewees’ perceptions of the ill- affected. He treats me well but I can’t deal with him after I had ness experience. A quantitative analysis was performed to cancer, as I still can’t accept that I have cancer until now! Maria calculate the frequency of the interviewees’ answers to yes\ (38 years old) no questions. Next to answers that report of fear, regret, and embarrass- Results ment regarding the illness, some interviewees’ answers depict a quite different experience, which suggest a better Participant Characteristics adjustment to the situation. These answers were less expected The participants of this study consisted of 34 Muslim and (given the meanings and beliefs associated with the disease two Christian women from the OPT. When asked about the and the disruptive impact on the patients’ lives) and seem to degree of religiosity, 23 participants stated that they were offer an opportunity to deepen the possibilities of coping moderately religious, whereas 13 stated that they were offered by religion. We therefore chose to focus in particular extremely religious. The participants’ age ranged between 22 on these instances. Specifically, nine instances reported that and 67 years. As for the participants’ educational level, it life following the illness continued as before and that there 4 SAGE Open was neither positive nor negative significant effect, and four In Lama’s words, we can possibly retrace the need of instances indicated that the illness had a positive effect on some of these women to conceal their distress and not to be a their life since this experience made them stronger by bring- burden to relatives. In this sense, faith can be seen as a wom- ing them closer to God. The salience of religious customs in en’s way for self-help, while respecting the wider cultural coping with the illness for Arab-Palestinian women is out- prescriptions. In this cultural context, the use of religiosity as lined in the words of Tamara: a solitary coping strategy is in line with sociocultural expec- tations that favor traditional customs such as concealing the Yes, illness alerts us to certain things such as how to be closer to disease and opposing the sharing of negative emotions. God, this helps to deal with people in a better way. Tamara (42 Dima became closer to God after being diagnosed with years old) cancer. In the next extract, she said that her faith helped to manage anxiety by focusing on religious matters and by reas- Tamara frames the disease as a learning experience which suring herself through the belief in God’s reward to sick allows her to review the order of priority of her life by put- people for withstanding all the suffering and pain: ting the religious experience first, a change of perspective that also helps to better manage relationships. If I wasn’t close to God, I would be wandering about like a crazy Participants reported that religion was a source of support woman. In the beginning, when I found out I had breast cancer, for them in coping with the disease, particularly by perform- I couldn’t sleep, and I would stand in front of the mirror and cry. Now, I sometimes I get up at night and read on the Internet about ing certain religious acts, worship, or rituals. religious matters and God’s reward. Dima (36 years old) Our analysis revealed that religiosity has two main func- tions: (a) managing distress and the identity crisis involved Cancer is here described as something that makes the inter- in such a life-threatening situation; (b) changing the meaning viewee cry while alone with herself in front of a mirror, as of the illness experience into something else: a test, a learn- something that challenges her body image and her identity, ing path, the mean to a reward. a disruptive event that could make her lose her mind. Faith The features of the two main functions are further ana- mitigates the identity crisis, saves the interviewee from lyzed in the following sections. being split between mind and body (becoming a crazy woman), and calms her down by pulling her attention on a) Managing distress and identity crisis. The following something else (she reads during the sleepless nights quotes well illustrate the psychological and emotional sup- instead of crying). There is a “beginning,” the moment of port coming from faith. Some women became religious after the initial diagnosis, in which Dima locates her identity cri- the diagnosis and clearly acknowledge the faith in God as a sis, and there is a “now” in which she presents herself as way of dealing with the disease, as Safa says, less hopeless, a self that has been shaped by her religious practices. Feeling weak is not simple; I needed the support of some power. Honestly, I have never been religious but I am now trying to be religious . . . Believing in a (supreme) divine power helps a lot. b) Changing the meaning of the illness experience. In think- Safa (56 years old) ing of a divine reward for her sufferings, Dima comforts herself and finds hope by framing this event within a more Safa represents herself as a nonreligious person before the general class of events that God assesses and rewards or pun- illness and as a religious person after the illness. According ishes. The disease is perceived as a God’s test, which may to Safa, faith provided her major help and emotional eventually grant good things in life (a renewed health) or in encouragement and the sense of a “borrowed” power of the afterlife. Such an existential shift relieves the interviewee control throughout the illness. It is interesting to note that from the emotional burden of an uncertain, life-threatening she makes it a psychological rather than a spiritual matter, outcome. which is linked to her ability to manage and overcome a For Tamara, the very meaning of the illness changes when difficult situation. Lama too considered God the only seen as a faith experience: source of support: One should thank God in sickness and in health; sickness is God’s test to the extent of our endurance and patience. Tamara My faith in God is what made me endure the situation. When I (42 years old) felt pain I used to say “God: be with me!” instead of calling on my father, mother or siblings for help or support. Lama (41 years old) The illness is seen as a path through which one can develop competences such as patience and endurance, and learn a dif- According to Lama, her faith strengthened and helped her to ferent attitude toward difficulties in life. cope. She started to perform daily prayers and read the Quran Also, Rana represents the illness as a learning experience as a strategy for her distress. that will lead to value life differently: Almuhtaseb et al. 5 When I read verses from the Holy Quran or Sayings (Hadith) by invites to its concealment, and promotes adherence to tradi- Prophet Mohammed or stories that give hope of God’s reward tional customs, of which religion is an important component. after all the suffering and pain, and the idea that after all this This cultural background sheds light on the results of our something pleasant would come my way, I don’t believe that study that seems to outline religiosity as a relevant coping cancer is miserable but I hope that after my experience with it I resource among the interviewees. In several instances, par- can truly appreciate happiness, and can learn patience. Rana (22 ticipants asserted that religion was one of the most important years old) sources which helped them to adjust to the disease and boosted their determination to resist the disease. Rana also explained the benefits received by her commit- Our study shows that the interviewees rely on the avail- ment to certain religious duties and rituals, such as reading able cultural resources to handle emotional and psychologi- the Holy Quran (other religious practices included fasting, cal difficulties while respecting and perpetuating cultural praying, talking to God). Ruba also states in the next extract norms that invite to hide the disease from the social that she resorts to the recitation of the Quran when she feels environment. troubled: This study also shows that religious beliefs and practices help the participants to change their outlook on the disease. When I feel restless, I read the Quran and rise over everything; They re-interpreted the disease as part of God’s will and as a death is in God’s hands, and—when He wills—the day will test of their endurance. In addition, their belief in God’s heal- come and I will die. I’m certain that I will be cured from this ing power and in predestination (whether they have cancer or illness. Ruba (56 years old) not) orient them to frame their current uncertain situation within a broader unpredictability in life shared by human- The belief that “death rests in God’s hands” turns death into kind while helping them to maintain hope for the future. By something that is not caused by cancer but something that is making a shift from a medical to a spiritual perspective, reli- controlled by God, and therefore something that can only be gious practice (together with medical treatments) is seen as dealt with within a religious framework. life-saving devices. In this perspective, healing is provided by medical treat- The religious coping operates through a radical work of ment, but through praying and appealing to God (cf. also re-signification of the whole experience of illness. The Hussein, 1998). The spiritual inspiration which one feels by accounts refer of an existential shift, marked by a “conver- firmly believing that God will heal her is considered to be a sion,” a reading of the events in a religious key, which type of treatment in itself, which can provide spiritual, if not changed the way the interviewees feel and deal with the ill- a physical healing, as stated by Asma: ness. After taking such a perspective, the sense of the disease is discursively transformed into a formative and spiritual I used to read the Quran and based on my knowledge (of Islam), I was quite certain that I would be treated by the Quran. Asma experience and we encounter another version of the inter- (37 years old) viewees, better able to manage anxiety and disruptive events. In terms of practical implication, this study is an initial Following religious prescriptions of behavior not only miti- step for a culturally situated practice that tailors psychoso- gates the deep identity crisis of the interviewees but com- cial interventions to patients’ unique cultural background. In pletely reformulates the meaning of the disease that is particular, the present results support the previous literature described as a spiritual experience, by moving it from the on the efficacy of encouraging the practice of religious ritu- domain of medicine into the sacred or divine dimension. It als for breast cancer patients in Arab communities (Doumit is therefore an experience that can find a resolution only in et al., 2010; Goldblatt et al., 2012, 2016; Taleghani et al., that area: in this realm, the Quran is discursively represented 2006). Our findings show that, at the stage of cancer diagno- as a more effective and suitable resource than medical sis and treatment, religious practices and beliefs seem to be treatments. a useful resource for coping with the disease rather than an obstacle to seeking medical services, as found in other stud- ies (cf. “Introduction”). In our data, there is no evidence of Discussion a passive attitude, but rather the respondents use the faith as a culturally situated instrument for self-help, a way to find This research is one of the few studies that analyzes the rela- comfort and construct meanings during a deep identity and tion between Arab-Palestinian women’s cancer coping and existential crisis. the religious sociocultural context of the OPT. The study also Further analyses on the data will be performed to better outlines the specific functions played by religious beliefs and understand the relationship between the stage of the illness practices as available cultural coping resources. In the OPT, and religious practices and beliefs. Given the nature of quali- Arab women with breast cancer experience a double diffi- tative research, we do not aim to generalize results, but to culty: on one hand, they live an existential crisis because of contribute to the situated understanding of coping within the the oncological illness, on the other hand, they find them- local context of the OPT. selves in a sociocultural context that stigmatizes cancer, 6 SAGE Open Acknowledgments Azaiza, F. (2013). Processes of conservation and change in Arab society in Israel: Implications for the health and welfare of The authors, hereby, thank all of the patients who participated in the Arab population. International Journal of Social Welfare, this study and shared their experiences with us. 22(1), 15–24. Azaiza, F., & Cohen, M. (2008). Between traditional and modern Declaration of Conflicting Interests perceptions of breast and cervical cancer screenings: A qualita- The author(s) declared no potential conflicts of interest with respect tive study of Arab women in Israel. Psycho-Oncology, 17(1), to the research, authorship, and/or publication of this article. 34–41. Azaiza, F., Cohen, M., Daoud, F., & Awad, M. (2011). Traditional- Westernizing continuum of change in screening behaviors: Funding Comparison between Arab women in Israel and the West Bank. The author(s) received no financial support for the research, author- Breast Cancer Research and Treatment, 128(1), 219–227. ship, and/or publication of this article. Doumit, M. A., El Saghir, N., Huijer, H. A. S., Kelley, J. H., & Nassar, N. (2010). Living with breast cancer, a Lebanese expe- ORCID iD rience. European Journal of Oncology Nursing, 14(1), 42–48. Francesca Alby https://orcid.org/0000-0001-5126-5293 Edwards, D. (1998). 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O., Fall-Dickson, J., & Mona I. A. Almuhtaseb holds a PhD in social psychology from Gaston-Johansson, F. (2013). Relationship of sense of coher- Sapienza University of Rome (Italy). Her research focuses on com- ence to stressful events, coping strategies, health status, and munication in medical settings and patients’ coping strategies. quality of life in women with breast cancer. Psycho-Oncology, Francesca Alby is an associate professor of social psychology at 22(1), 20–27. Sapienza University of Rome (Italy). Her research focuses on social Silva, S. M., Crespo, C., & Canavarro, M. C. (2012). Pathways for interaction and action in workplaces, notably oncology units and IT psychological adjustment in breast cancer: A longitudinal study start-up companies. on coping strategies and posttraumatic growth. Psychology & Health, 27(11), 1323–1341. Cristina Zucchermaglio is professor of social psychology at Sontag, S. (1978). Illness as metaphor. Farrar, Straus and Giroux. 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A systematic review of the course analytic methods. literature. Social Science & Medicine, 63(1), 151–164. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

Religiosity as a Cultural Resource for Arab-Palestinian Women’s Coping with Cancer:

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Abstract

Drawing on the discourse analysis of 36 in-depth interviews, this qualitative study explores how Arab-Palestinian women cope with breast cancer and ascribe meaning to their illness within the local religious and traditional cultural context. In particular, the study shows that religious beliefs and practices help Arab-Palestinian women to handle emotional and psychological difficulties while perpetuating traditional cultural norms of concealment. Two main functions of religiosity as a coping resource are analyzed by (a) managing distress and identity crisis and (b) changing the meaning of the illness experience. In this sociocultural context, the practice of religious rituals provides cancer patients with an effective and culturally situated instrument for coping with a deep existential crisis. Practical implications of the study are discussed in the conclusions. Keywords breast cancer, religiosity, religion, coping resources, occupied Palestinian territories, Arab-Palestinian women face the disease (Alby, 2018, 2019; Alby, Fatigante, et al., Introduction 2017; Alby & Zucchermaglio, 2019; Alby, Zucchermaglio, Studies have analyzed the cancer patients’ coping resources et al., 2017). The literature has shown also how cultural rep- which mainly focuses on individualistic strategies such as ertoires are in evolution including debates on the meanings positivity, fighting spirit, or personality traits, such as “sense of stigma, shame, and confidentiality, as well as repertoires of coherence” (Antonovsky, 1979; Sarenmalm et al., 2013; that enhance both determination and willingness to survive Silva et al., 2012). (Ahmadi, Hussin, et al., 2018; Ahmadi, Khodayarifard, et al., Coping is found to be the major determinant in a process 2018; Alby et al., 2015; Alby, Fatigante, et al., 2017; Fosket that starts with stressful events and then to adaptation out- et al., 2000; Klawiter, 1999; Patterson, 1987; Sontag, 1978; comes, such as psychological symptoms and somatic illness. Zucchermaglio & Alby, 2016; Zucchermaglio et al., 2016). For example, coping strategies can influence treatment out- This work focuses on the sociocultural context of the occu- comes and survival rates of women who have breast cancer pied Palestinian territories (OPT). The Palestinian society is (Lazarus, 1993; Mehrabi et al., 2016). crossed by strong conservation trends of values and traditional Also, coping with cancer is affected by the kind of lifestyles. This tendency is strengthened by the long Israeli– resources that members of a culture use to interpret life Palestinian conflict which promotes an appreciation of identi- events. Religiosity has been explored as a potential adaptive ties that are distinctive of a cultural tradition. It is traditionally resource for cancer patients and survivors in several cultural a collectivist society that gives priority to the needs of the fam- contexts (Gesselman et al., 2016; Thuné-Boyle et al., 2006, ily compared with individual needs, in which women play a 2011). Drawing on Lazarus and Folkman’s Transactional central role in preserving cultural norms and values through Model of Stress and Coping, Mukwato et al. (2010) found child care (Surbone, 2008). The increased levels of education that the “reliance to God” was one of the four predominant coping strategies by patients and family caregivers (together Department of Social and Developmental Psychology, Sapienza University with social support, positive attitude and acquisition of infor- of Rome, Italy mation and education). Fatalism as well as elements of the Corresponding Author: popular culture (e.g., the notion of adverse events as strength- Francesca Alby, Department of Social and Developmental Psychology, ening and the uselessness of despairing) can be powerful Sapienza University of Rome, via dei Marsi, 78, 00185 Rome, Italy. resources to give meaning to a recent cancer diagnosis and to Email: Francesca.Alby@uniroma1.it Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open and the entry into labor market have led to changes for Trust in religion as a resort and a coping strategy can also Palestinian women, who nevertheless coexist with strong con- be explained by the difficulties experienced by patients in servative tendencies sustained by the adherence to family val- accessing cancer care in the OPT. Treatments available are ues, customs, and by widespread religious beliefs (Azaiza, limited (in particular there are restrictions on radiation ther- 2013). More than three quarters of the Palestinian population apy due to security reasons; treatment plans can be delayed claim to be religious (Goldblatt et al., 2012). due to lack of medications); moreover, patients face many Some studies have documented the cultural resources challenges in accessing the health system due to the military used by Arab women in Israel to interpret and cope with a occupation and the restrictions to mobility (Giacaman, 2018; disruptive life event such as a diagnosis of breast cancer. Hammoudeh et al., 2017). Goldblatt et al. (2012) described how the coping strategies of In the OPT, breast cancer is the most common type of Arab women in Israel are affected by local cultural norms, cancer among women and the leading cause of cancer-related beliefs, and perceptions. Findings stress a duality in partici- mortality (Husseini et al., 2009). pants’ cancer coping experience: they comply with the tradi- tional cultural norms of concealment, while encountering Objectives more open Western attitudes through interactions with health care providers and Jewish women receiving treatment along- To date, very few studies have focused on and gave a voice side them. A recent study, conducted by Goldblatt et al. to Arab-Palestinian women diagnosed with breast cancer. We (2016) on Arab women in Israel, indicated, among the strate- aim to study how they ascribe meaning to their illness and to gies mostly used to cope with the disease; praying, talking to examine their coping strategies within this religious and tra- God, reading the Quran or the New Testament, accepting the ditional cultural context. We focus on the particular role disease as “meant to be” and believing on God’s healing played by religiosity, broadly defined as a personal devotion powers. Research participants stated that their belief in God and participation in religious practices. had increased their personal strength to confront the disease. Several other studies involving breast cancer patients (includ- Method ing Muslim and Christian Palestinian women) found that deeply rooted religious beliefs assisted patients in making This article focuses on a subset of data gathered in a study decisions related to their health; even though most patients conducted in the OPT. Data were collected through in-depth attributed their disease to the will of God, they were actively interviews with breast cancer patients of two medical cen- engaged in fighting it and strictly adhered to medical treat- ters: (a) the Oncology Department at Beit Jala Government ments (Doumit et al., 2010; Hammoudeh et al., 2017; Hospital in Bethlehem Governorate, which is the first hospi- Harandy et al., 2009; Taleghani et al., 2006). Somewhat dif- tal distinguished for providing a large part of diagnostic and ferent findings were found by Azaiza and Cohen (2008) fol- therapeutic services for oncology patients in the OPT; (b) lowing which Arab women in Israel defer to God, or Dunya Women’s Cancer Center in Ramallah Governorate, predestination, the responsibility for their body and health, which is the first and only non-profit center that provides an adopting a passive attitude toward self-care. early diagnostic service for breast cancer and gynecological The importance of “Tawakkul” (reliance on the power of cases in the Palestinian Territories. God) was found among both Palestinian caregivers and can- The study was approved by the Palestinian Ministry of cer patients (Hammoudeh et al., 2017). These findings show Health. Research participants were requested to sign an how religion and spirituality incorporate internal and exter- informed consent form. Data were collected by a researcher nal beliefs and values, and how these interwoven beliefs are who was an Arab-Palestinian woman, which probably facili- deeply rooted in the Palestinian sociocultural system (see tated adherence to the research (there was no refusal to par- also Albarghouthi & Klempe, 2019). ticipate). Participants were also fully ensured about the Several studies showed that in the Arab and Palestinian anonymity and confidentiality of any information collected society, a powerful social stigma is still attached to cancer for the purpose of the study. The data collection ran from (Hammoudeh et al., 2017 see also Hwang, 2013; Lamyian January 2015 to April 2015. et al., 2007). Some studies showed that Arab breast cancer The participants recruited for the study are 36 women patients try to hide their illness to neighbors, friends, and col- selected according to the following inclusion criteria: (a) liv- leagues refraining from socializing and attending gatherings ing in the OPT; (b) been diagnosed with breast cancer and celebrations (Azaiza & Cohen, 2008; and see also Azaiza between 1 month to 3 years prior to the interview; (c) having et al., 2011; Goldblatt et al., 2012). no previous history of mental disorders or other forms of Moreover, in Israel, Arab women rely more on cultural cancer; (d) accepting to be interviewed without the presence resources such as religiosity in the absence of any social sup- of a third person to ensure the participant’s freedom to port or in case of marriage problems, in their attempt to get express their feelings; (e) signing an informed consent form. through the tribulations of a challenging experience such as The interview guide had three sections. The first section breast cancer (Azaiza et al., 2011). explored how the illness was discovered, the second section Almuhtaseb et al. 3 focused on the communication with doctors and the treat- ranged from no formal schooling (i.e., illiteracy) to second ment decision-making process, and the third section explored university degree (i.e., graduate studies). Only one partici- changes and adjustments in life after the illness. This last pant did not have any school education at all; two partici- section examined religiosity as a resource for coping by ask- pants had completed 6 years of school. Six participants had ing what changed in the interviewee’s life after the diagnosis; completed 9 years of school, and two participants had com- if the interviewee defined herself religious, with which pleted 12 years. Eight participants had obtained a postschool degree of observance; and if (and how) religion was a source diploma (i.e., community college). Eleven participants had of support in facing the illness. This article focuses on the completed high school, whereas five participants had com- answers given to questions within the third section. pleted their first degree university education. Finally, only The interview also covered sociodemographic character- one participant had a Master’s degree. As for their social sta- istics (religion, degree of religiosity, age, place of residence, tus and number of children, the majority of the participants education, marital status, employment status, how many (N = 31) were married and two thirds (N = 24) were house- children) and medical information (date of diagnosis, stage, wives. Thirty had children and the number of children per type of treatment). participant ranged from one to nine. Seventeen participants The interviews were carried out in a private room at the reported that they did not know at which stage of the disease hospital or in the cancer center by one of the authors they were at when they were first diagnosed; five partici- (M.I.A.A.) who presented herself as a researcher in social pants reported that they were diagnosed with breast cancer at psychology. The participants were informed about the study’s Stage 1, nine participants at Stage 2, and three participants at objectives both orally and in writing. All the interviews were Stage 3. Three participants stated that they were diagnosed conducted in Arabic (Palestinian dialect) through audio with advanced breast cancer (Stage 4). Regarding the treat- recording, transcribed into standard Arabic and then finally ments, 22 participants were still receiving their treatment translated into English. The actual names of the participants (i.e., chemotherapy), whereas 14 participants reported that have been replaced for confidentiality. The time period of they had completed it, but still had to undergo follow-up tests participants’ interviews ranged from 1 to 2 hr. and diagnostic images regularly according to posttreatment Analytical procedures involved a discourse analysis of follow-up guidelines. the interviews’ transcripts (Alby & Fatigante, 2014; Edwards & Potter, 1992; Wilkinson & Kitzinger, 2000). In the dis- Life Following the Cancer Illness: The Role course analysis, we considered the accounts produced in the of Religiosity interviews as modes through which interviewees reconstruct and make comprehensible their actions and their own selves When asked about changes in life following their illness, while they narrate them (Edwards, 1998). most of the interviewees report negative effects on their We coded as “negative” the instances in which the inter- mood, behaviors, and relationships; higher levels of distress; viewees, when asked about changes in life following the ill- and tendency to isolation. We found 23 instances of this kind ness, report of fear, distress, embarrassment. We coded as across 36 data extracts. We will briefly outline some of these. “non-negative” the instances that report either a positive In the following extract, Maria is talking about her reactions effect or assert a non significant effect (e.g., “life continued to being told she has cancer: as before”). We decided to focus on the analysis of these lat- ter instances because they offered a good opportunity to My mood has become bad, my behavior at home has changed, explore the features of religion as a coping resource. We then and my view of life has also changed. Sometimes I prefer to sit developed an analytic focus on the specific functions that alone and to be isolated from others, and I don’t like to get out of my home. My relationship with my husband was completely religiosity plays in the interviewees’ perceptions of the ill- affected. He treats me well but I can’t deal with him after I had ness experience. A quantitative analysis was performed to cancer, as I still can’t accept that I have cancer until now! Maria calculate the frequency of the interviewees’ answers to yes\ (38 years old) no questions. Next to answers that report of fear, regret, and embarrass- Results ment regarding the illness, some interviewees’ answers depict a quite different experience, which suggest a better Participant Characteristics adjustment to the situation. These answers were less expected The participants of this study consisted of 34 Muslim and (given the meanings and beliefs associated with the disease two Christian women from the OPT. When asked about the and the disruptive impact on the patients’ lives) and seem to degree of religiosity, 23 participants stated that they were offer an opportunity to deepen the possibilities of coping moderately religious, whereas 13 stated that they were offered by religion. We therefore chose to focus in particular extremely religious. The participants’ age ranged between 22 on these instances. Specifically, nine instances reported that and 67 years. As for the participants’ educational level, it life following the illness continued as before and that there 4 SAGE Open was neither positive nor negative significant effect, and four In Lama’s words, we can possibly retrace the need of instances indicated that the illness had a positive effect on some of these women to conceal their distress and not to be a their life since this experience made them stronger by bring- burden to relatives. In this sense, faith can be seen as a wom- ing them closer to God. The salience of religious customs in en’s way for self-help, while respecting the wider cultural coping with the illness for Arab-Palestinian women is out- prescriptions. In this cultural context, the use of religiosity as lined in the words of Tamara: a solitary coping strategy is in line with sociocultural expec- tations that favor traditional customs such as concealing the Yes, illness alerts us to certain things such as how to be closer to disease and opposing the sharing of negative emotions. God, this helps to deal with people in a better way. Tamara (42 Dima became closer to God after being diagnosed with years old) cancer. In the next extract, she said that her faith helped to manage anxiety by focusing on religious matters and by reas- Tamara frames the disease as a learning experience which suring herself through the belief in God’s reward to sick allows her to review the order of priority of her life by put- people for withstanding all the suffering and pain: ting the religious experience first, a change of perspective that also helps to better manage relationships. If I wasn’t close to God, I would be wandering about like a crazy Participants reported that religion was a source of support woman. In the beginning, when I found out I had breast cancer, for them in coping with the disease, particularly by perform- I couldn’t sleep, and I would stand in front of the mirror and cry. Now, I sometimes I get up at night and read on the Internet about ing certain religious acts, worship, or rituals. religious matters and God’s reward. Dima (36 years old) Our analysis revealed that religiosity has two main func- tions: (a) managing distress and the identity crisis involved Cancer is here described as something that makes the inter- in such a life-threatening situation; (b) changing the meaning viewee cry while alone with herself in front of a mirror, as of the illness experience into something else: a test, a learn- something that challenges her body image and her identity, ing path, the mean to a reward. a disruptive event that could make her lose her mind. Faith The features of the two main functions are further ana- mitigates the identity crisis, saves the interviewee from lyzed in the following sections. being split between mind and body (becoming a crazy woman), and calms her down by pulling her attention on a) Managing distress and identity crisis. The following something else (she reads during the sleepless nights quotes well illustrate the psychological and emotional sup- instead of crying). There is a “beginning,” the moment of port coming from faith. Some women became religious after the initial diagnosis, in which Dima locates her identity cri- the diagnosis and clearly acknowledge the faith in God as a sis, and there is a “now” in which she presents herself as way of dealing with the disease, as Safa says, less hopeless, a self that has been shaped by her religious practices. Feeling weak is not simple; I needed the support of some power. Honestly, I have never been religious but I am now trying to be religious . . . Believing in a (supreme) divine power helps a lot. b) Changing the meaning of the illness experience. In think- Safa (56 years old) ing of a divine reward for her sufferings, Dima comforts herself and finds hope by framing this event within a more Safa represents herself as a nonreligious person before the general class of events that God assesses and rewards or pun- illness and as a religious person after the illness. According ishes. The disease is perceived as a God’s test, which may to Safa, faith provided her major help and emotional eventually grant good things in life (a renewed health) or in encouragement and the sense of a “borrowed” power of the afterlife. Such an existential shift relieves the interviewee control throughout the illness. It is interesting to note that from the emotional burden of an uncertain, life-threatening she makes it a psychological rather than a spiritual matter, outcome. which is linked to her ability to manage and overcome a For Tamara, the very meaning of the illness changes when difficult situation. Lama too considered God the only seen as a faith experience: source of support: One should thank God in sickness and in health; sickness is God’s test to the extent of our endurance and patience. Tamara My faith in God is what made me endure the situation. When I (42 years old) felt pain I used to say “God: be with me!” instead of calling on my father, mother or siblings for help or support. Lama (41 years old) The illness is seen as a path through which one can develop competences such as patience and endurance, and learn a dif- According to Lama, her faith strengthened and helped her to ferent attitude toward difficulties in life. cope. She started to perform daily prayers and read the Quran Also, Rana represents the illness as a learning experience as a strategy for her distress. that will lead to value life differently: Almuhtaseb et al. 5 When I read verses from the Holy Quran or Sayings (Hadith) by invites to its concealment, and promotes adherence to tradi- Prophet Mohammed or stories that give hope of God’s reward tional customs, of which religion is an important component. after all the suffering and pain, and the idea that after all this This cultural background sheds light on the results of our something pleasant would come my way, I don’t believe that study that seems to outline religiosity as a relevant coping cancer is miserable but I hope that after my experience with it I resource among the interviewees. In several instances, par- can truly appreciate happiness, and can learn patience. Rana (22 ticipants asserted that religion was one of the most important years old) sources which helped them to adjust to the disease and boosted their determination to resist the disease. Rana also explained the benefits received by her commit- Our study shows that the interviewees rely on the avail- ment to certain religious duties and rituals, such as reading able cultural resources to handle emotional and psychologi- the Holy Quran (other religious practices included fasting, cal difficulties while respecting and perpetuating cultural praying, talking to God). Ruba also states in the next extract norms that invite to hide the disease from the social that she resorts to the recitation of the Quran when she feels environment. troubled: This study also shows that religious beliefs and practices help the participants to change their outlook on the disease. When I feel restless, I read the Quran and rise over everything; They re-interpreted the disease as part of God’s will and as a death is in God’s hands, and—when He wills—the day will test of their endurance. In addition, their belief in God’s heal- come and I will die. I’m certain that I will be cured from this ing power and in predestination (whether they have cancer or illness. Ruba (56 years old) not) orient them to frame their current uncertain situation within a broader unpredictability in life shared by human- The belief that “death rests in God’s hands” turns death into kind while helping them to maintain hope for the future. By something that is not caused by cancer but something that is making a shift from a medical to a spiritual perspective, reli- controlled by God, and therefore something that can only be gious practice (together with medical treatments) is seen as dealt with within a religious framework. life-saving devices. In this perspective, healing is provided by medical treat- The religious coping operates through a radical work of ment, but through praying and appealing to God (cf. also re-signification of the whole experience of illness. The Hussein, 1998). The spiritual inspiration which one feels by accounts refer of an existential shift, marked by a “conver- firmly believing that God will heal her is considered to be a sion,” a reading of the events in a religious key, which type of treatment in itself, which can provide spiritual, if not changed the way the interviewees feel and deal with the ill- a physical healing, as stated by Asma: ness. After taking such a perspective, the sense of the disease is discursively transformed into a formative and spiritual I used to read the Quran and based on my knowledge (of Islam), I was quite certain that I would be treated by the Quran. Asma experience and we encounter another version of the inter- (37 years old) viewees, better able to manage anxiety and disruptive events. In terms of practical implication, this study is an initial Following religious prescriptions of behavior not only miti- step for a culturally situated practice that tailors psychoso- gates the deep identity crisis of the interviewees but com- cial interventions to patients’ unique cultural background. In pletely reformulates the meaning of the disease that is particular, the present results support the previous literature described as a spiritual experience, by moving it from the on the efficacy of encouraging the practice of religious ritu- domain of medicine into the sacred or divine dimension. It als for breast cancer patients in Arab communities (Doumit is therefore an experience that can find a resolution only in et al., 2010; Goldblatt et al., 2012, 2016; Taleghani et al., that area: in this realm, the Quran is discursively represented 2006). Our findings show that, at the stage of cancer diagno- as a more effective and suitable resource than medical sis and treatment, religious practices and beliefs seem to be treatments. a useful resource for coping with the disease rather than an obstacle to seeking medical services, as found in other stud- ies (cf. “Introduction”). In our data, there is no evidence of Discussion a passive attitude, but rather the respondents use the faith as a culturally situated instrument for self-help, a way to find This research is one of the few studies that analyzes the rela- comfort and construct meanings during a deep identity and tion between Arab-Palestinian women’s cancer coping and existential crisis. the religious sociocultural context of the OPT. The study also Further analyses on the data will be performed to better outlines the specific functions played by religious beliefs and understand the relationship between the stage of the illness practices as available cultural coping resources. In the OPT, and religious practices and beliefs. Given the nature of quali- Arab women with breast cancer experience a double diffi- tative research, we do not aim to generalize results, but to culty: on one hand, they live an existential crisis because of contribute to the situated understanding of coping within the the oncological illness, on the other hand, they find them- local context of the OPT. selves in a sociocultural context that stigmatizes cancer, 6 SAGE Open Acknowledgments Azaiza, F. (2013). Processes of conservation and change in Arab society in Israel: Implications for the health and welfare of The authors, hereby, thank all of the patients who participated in the Arab population. International Journal of Social Welfare, this study and shared their experiences with us. 22(1), 15–24. Azaiza, F., & Cohen, M. (2008). 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O., Fall-Dickson, J., & Mona I. A. Almuhtaseb holds a PhD in social psychology from Gaston-Johansson, F. (2013). Relationship of sense of coher- Sapienza University of Rome (Italy). Her research focuses on com- ence to stressful events, coping strategies, health status, and munication in medical settings and patients’ coping strategies. quality of life in women with breast cancer. Psycho-Oncology, Francesca Alby is an associate professor of social psychology at 22(1), 20–27. Sapienza University of Rome (Italy). Her research focuses on social Silva, S. M., Crespo, C., & Canavarro, M. C. (2012). Pathways for interaction and action in workplaces, notably oncology units and IT psychological adjustment in breast cancer: A longitudinal study start-up companies. on coping strategies and posttraumatic growth. Psychology & Health, 27(11), 1323–1341. Cristina Zucchermaglio is professor of social psychology at Sontag, S. (1978). Illness as metaphor. Farrar, Straus and Giroux. Sapienza University of Rome (Italy), where she is also director of Surbone, A. (2008). Cultural aspects of communication in cancer the Interaction & Culture Laboratory (LInC). She specializes in care. Supportive Care in Cancer, 16(3), 235–240. ethnographic studies of social interaction in various settings, such Taleghani, F., Yekta, Z. P., & Nasrabadi, A. N. (2006). Coping with as schools, homes, high-tech companies, hospitals, and sport teams. breast cancer in newly diagnosed Iranian women. Journal of Marilena Fatigante is an assistant professor of social psychology Advanced Nursing, 54(3), 265–272. at Sapienza University of Rome (Italy). Her research focuses on Thuné-Boyle, I. C., Stygall, J. A., Keshtgar, M. R., & Newman, S. social interaction in natural settings (e.g., doctor-patient, family, P. (2006). Do religious/spiritual coping strategies affect illness classroom), which she investigates through ethnographic and dis- adjustment in patients with cancer? A systematic review of the course analytic methods. literature. Social Science & Medicine, 63(1), 151–164.

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SAGE OpenSAGE

Published: Jan 2, 2020

Keywords: breast cancer; religiosity; religion; coping resources; occupied Palestinian territories; Arab-Palestinian women

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