TY - JOUR T1 - Stress Levels of the Cancer Patients During the COVID-19 Pandemic: The Roles of Self-Efficacy and Spiritual Exercises AU - Güvenç Erdoğan, İrem Berna AU - Kezik, İrem AU - Toy, Ayşe Yağmur AU - Bozo, Özlem PY - 2025 DA - October Y2 - 2025 DO - 10.37898/spiritualpc.1618949 JF - Spiritual Psychology and Counseling PB - Halil EKŞİ WT - DergiPark SN - 2458-9675 SP - 367 EP - 383 VL - 10 IS - 3 LA - en AB - During the COVID-19 pandemic, cancer patients, a vulnerable group, faced heightened stress along with the stress they experienced due to their ongoing condition. Previous research emphasized the importance of engaging in spiritual exercises in stress management. Furthermore, self-efficacy is recognized as a crucial variable in coping with stress. The current study aims to examine whether self-efficacy predicted stress levels in cancer patients during the COVID-19 pandemic and explored whether performing spiritual exercises moderated this relation. Ninety-one cancer patients were recruited through the oncology departments of hospitals and social media channels of cancer-related solidarity associations. The results of the hierarchical regression analysis indicated that higher self-efficacy was associated with lower stress levels. However, engaging in spiritual exercises neither directly affected stress levels of the cancer patients nor moderated the relation between self-efficacy and stress. The association between stress levels and self-efficacy during periods of heightened health threats, such as the COVID-19 pandemic, holds significant implications for health psychologists and clinical psychologists who work with cancer patients. Understanding this relationship can inform targeted interventions and therapeutic strategies aimed at enhancing self-efficacy, which may, in turn, mitigate stress and improve overall psychological well-being in this vulnerable population. Future research is recommended to consider the significance attributed to spiritual practices and the duration of individuals’ engagement with these practices to yield more precise findings. KW - COVID-19 pandemic KW - stress KW - cancer KW - self-efficacy KW - spiritual exercises CR - Abdel-Khalek, A. M., & Lester, D. (2017). The association between religiosity, generalized self-efficacy, mental health, and happiness in Arab college students. Personality and Individual Differences, 109, 12–16. https://doi.org/10.1016/j.paid.2016.12.010 CR - Adegbola, M. (2011). Spirituality, self-efficacy, and quality of life among adults with sickle cell disease. Southern Online Journal of Nursing Research, 11(1), 1–16. CR - Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. SAGE. CR - Akıncı, İ., Akyüz-Yılmaz, C., & Bozo, Ö. (2021). Dispositional optimism and well-being in cancer patients: The role of cancer-related self-efficacy. Mediterranean Journal of Clinical Psychology, 9(3), 1–20. https://doi.org/10.13129/2282-1619/mjcp-3229 CR - Alagizy, H. A., Soltan, M. R., Soliman, S. S., Hegazy, N. N., & Gohar, S. F. (2020). Anxiety, depression and perceived stress among breast cancer patients: Single institute experience. Middle East Current Psychiatry, 27(1), 1–10. https://doi.org/10.1186/s43045-020-00036-x CR - Bandura, A. (Ed.). (1995). Self-efficacy in changing societies. Cambridge University Press. https://doi.org/10.1017/CBO9780511527692 CR - Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. https://doi.org/10.1037/0022-3514.51.6.1173 CR - Beckham, J. C., Burker, E. J., Lytle, B. L., Feldman, M. E., & Costakis, M. J. (1997). Self-efficacy and adjustment in cancer patients: A preliminary report. Behavioral Medicine, 23, 138–142. https://doi.org/10.1080/08964289709596370 CR - Bisaz, R., Conboy, L., & Sandi, C. (2009). Learning under stress: A role for the neural cell adhesion molecule NCAM. Neurobiology of Learning and Memory, 91, 333–342. https://doi.org/10.1016/j.nlm.2008.11.003 CR - Bozo, Ö., Akıncı, İ., & Akyüz, C. (2019). The psychometric properties of Cancer Behavior Inventory as a predictor of quality of life in Turkish cancer patients. Current Psychology, 38, 229–238. https://doi.org/10.1007/s12144-017-9609-5 CR - Chemers, M. M., Hu, L.-t., & Garcia, B. F. (2001). Academic self-efficacy and first year college student performance and adjustment. Journal of Educational Psychology, 93(1), 55–64. https://doi.org/10.1037/0022-0663.93.1.55 CR - Chen, G., Wu, Q., Jiang, H., Zhang, H., Peng, J., Hu, J., Min, C., Zhong, Y., & Xie, C. (2020). Fear of disease progression and psychological stress in cancer patients under the outbreak of COVID-19. Psycho-Oncology, 29, 1395–1398. https://doi.org/10.1002/pon.5451 CR - Chrousos, G. P. (1998). Stressors, stress, and neuroendocrine integration of the adaptive response: The 1997 Hans Selye Memorial Lecture. Annals of the New York Academy of Sciences, 851, 311–335. https://doi.org/10.1111/j.1749-6632.1998.tb09006.x CR - Çorapçıoğlu, A., Yargıç, I., Geyran, P., & Kocabaşoğlu, N. (2006). Validity and reliability of Turkish version of “Impact of Event Scale-Revised” (IES-R). New Symposium Journal, 44(1), 14–22. CR - Cui, Q., Cai, Z., Li, J., Liu, Z., Sun, S., Chen, C., & Wang, G. (2020). The psychological pressures of breast cancer patients during the COVID-19 outbreak in China: A comparison with frontline female nurses. Frontiers in Psychiatry, 11, 559701. https://doi.org/10.3389/fpsyt.2020.559701 CR - Dai, M., Liu, D., Liu, M., Zhou, F., Li, G., Chen, Z., Zhang, Z., You, H., Wu, M., Zheng, Q., Xiong, Y., Xiong, H., Wang, C., Chen, C., Xiong, F., Zhang, Y., Peng, Y., Ge, S., Zhen, B., Yu, T., Wang, L., Wang, H., Liu, Y., Chen, Y., Mei, J., Gao, X., Li, Z., Gan, L., He, C., Li, Z., Shi, Y., Qi, Y., Yang, J., Tenen, D. G., Chai, L., Mucci, L. A., Santillana, M., & Cai, H. (2020). Patients with cancer appear more vulnerable to SARS-CoV-2: A multicenter study during the COVID-19 outbreak. Cancer Discovery, 10, 783–791. https://doi.org/10.1158/2159-8290.CD-20-0422 CR - Delaney, C. (2005). The Spirituality Scale: Development and psychometric testing of a holistic instrument to assess the human spiritual dimension. Journal of Holistic Nursing, 23(1), 145–171. https://doi.org/10.1177/0898010105276180 CR - Dhar, N., Chaturvedi, S. K., & Nandan, D. (2013). Spiritual health, the fourth dimension: A public health perspective. WHO South-East Asia Journal of Public Health, 2(1), 3–5. https://doi.org/10.4103/2224-3151.115826 CR - Doster, J. A., Harvey, M. B., Riley, C. A., Goven, A. J., & Moorefield, R. (2002). Spirituality and cardiovascular risk. Journal of Religion and Health, 41(1), 69–79. https://doi.org/10.1023/A:1015110206578 CR - Edwards, R., Telfair, J., Cecil, H., & Lenoci, J. (2000). Reliability and validity of a self-efficacy instrument specific to sickle cell disease. Behaviour Research and Therapy, 38(9), 951–963. https://doi.org/10.1016/S0005-7967(99)00140-0 CR - Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535–544. https://doi.org/10.1176/ajp.137.5.535 CR - Fehring, R. J., Miller, J. F., & Shaw, C. (1997). Spiritual well-being, religiosity, hope, depression, and other mood states in elderly people coping with cancer. Oncology Nursing Forum, 24(4), 663–671. CR - Fisher, J. W. (2015b). A critique of quantitative measures for assessing spirituality and spiritual wellbeing. In E. C. Roberts (Ed.), Spirituality, global practices, societal attitudes and effects on health (pp. 91–131). Nova Science Publishers Inc. CR - Fu, F., Liang, Y., An, Y., & Zhao, F. (2018). Self-efficacy and psychological well-being of nursing home residents in China: The mediating role of social engagement. Asia Pacific Journal of Social Work and Development, 28(2), 128–140. https://doi.org/10.1080/02185385.2018.1464942 CR - Gong, J., Hu, C., Chen, M., Cao, Q., & Li, Q. (2021). Interventions to improve self‐efficacy in colorectal cancer patients and/or caregivers: A systematic review and meta‐analysis. Journal of Oncology, 2021(1), 4553613. https://doi.org/10.1155/2021/4553613 CR - Gülerce, H., & Maraj, H. A. (2021). Resilience and hopelessness in Turkish society: Exploring the role of spirituality in the COVID-19 pandemic. Journal of Economy Culture and Society, 63, 1–15. https://doi.org/10.26650/JECS2020-0075 CR - Haas, B. K. (2011). Fatigue, self-efficacy, physical activity, and quality of life in women with breast cancer. Cancer Nursing, 34(4), 322–334. https://doi.org/10.1097/NCC.0b013e3181f9a300 CR - Hassed, C. S. (2000). Depression: Dispirited or spiritually deprived? The Medical Journal of Australia, 173(10), 545–547. https://doi.org/10.5694/j.1326-5377.2000.tb139326.x CR - Johnson, M. E., Piderman, K. M., Sloan, J. A., Huschka, M., Atherton, P. J., Hanson, J. M., Brown, P. D., Rummans, T. A., Clark, M. M., & Frost, M. H. (2007). Measuring spiritual quality of life in cancer patients. The Journal of Supportive Oncology, 5(9), 437–442. CR - Kasapoğlu, F. (2022). The relationship among spirituality, self-efficacy, COVID-19 anxiety, and hopelessness during the COVID-19 process in Turkey: A path analysis. Journal of Religion and Health, 61(1), 767–785. https://doi.org/10.1007/s10943-021-01472-7 CR - Laubmeier, K. K., Zakowski, S. G., & Bair, J. P. (2004). The role of spirituality in the psychological adjustment to cancer: A test of the transactional model of stress and coping. International Journal of Behavioral Medicine, 11(1), 48–55. https://doi.org/10.1207/s15327558ijbm1101_6 CR - Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company. CR - Lenoci, J. M., Telfair, J., Cecil, H., & Edwards, R. F. (2002). Self-care in adults with sickle cell disease. Western Journal of Nursing Research, 24(3), 228–245. https://doi.org/10.1177/01939450222045879 CR - Lopez, J., Romero-Moreno, R., Marquez-Gonzalez, M., & Losada, A. (2012). Spirituality and self-efficacy in dementia family caregiving: Trust in God and in yourself. International Psychogeriatrics, 24(12), 1943–1952. https://doi.org/10.1017/S1041610212001287 CR - Martos-Méndez, M. J. (2015). Self-efficacy and adherence to treatment: The mediating effects of social support. Journal of Behavior, Health & Social Issues (México), 7(2), 19–29. https://doi.org/10.5460/jbhsi.v7.2.52889 CR - McCoubrie, R., & Davies, A. (2006). Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer? Support Care Cancer, 14(4), 379–385. https://doi.org/10.1007/s00520-005-0892-6 CR - McSherry, W. (2000). Education issues surrounding the teaching of spirituality. Nursing Standard, 14(42), 40–43. https://doi.org/10.7748/ns2000.07.14.42.40.c2875 CR - Memon, M. A., Ting, H., Hwa, C., Ramayah, T., Chuah, F., & Cham, T. H. (2020). Sample size for survey research: Review and recommendations. Journal of Applied Structural Equation Modeling, 4(2), 1–20. http://doi.org/10.47263/JASEM.4(2)01 CR - Merluzzi, T. V., Nairn, R. C., Hegde, K., Martinez Sanchez, M. A., & Dunn, L. (2001). Self-efficacy for coping with cancer: Revision of the cancer behavior inventory (version 2.0). Psycho‐oncology, 10(3), 206–217. https://doi.org/10.1002/pon.511 CR - Merluzzi, T. V., Pustejovsky, J. E., Philip, E. J., Sohl, S. J., Berendsen, M., & Salsman, J. M. (2019). Interventions to enhance self‐efficacy in cancer patients: A meta‐analysis of randomized controlled trials. Psycho‐oncology, 28(9), 1781–1790. https://doi.org/10.1002/pon.5148 CR - Miaskowski, C., Paul, S. M., Snowberg, K., Abbott, M., Borno, H., Chang, S., Chen, L. M., Cohen, B., Hammer, M. J., Kenfield, S. A., Kober, K. M., Levine, J. D., Pozzar, R., Rhoads, K. F., Van Blarigan, E. L., & Van Loon, K. (2020). Stress and symptom burden in oncology patients during the COVID-19 pandemic. Journal of Pain and Symptom Management, 60(5), e25–e34. https://doi.org/10.1016/j.jpainsymman.2020.08.037 CR - Miller, W. R., & Thoresen, C. E. (1999). Spirituality and health. In W. R. Miller (Ed.), Integrating spirituality into treatment: Resources for practitioners (pp. 3–18). American Psychological Association. https://doi.org/10.1037/10327-001 CR - Monod, S., Brennan, M., Rochat, E., Martin, E., Rochat, S., & Büla, C. J. (2011). Instruments measuring spirituality in clinical research: A systematic review. Journal of General Internal Medicine, 26(11), 1345–1357. https://doi.org/10.1007/s11606-011-1769-7 CR - Moreno-Smith, M., Lutgendorf, S. K., & Sood, A. K. (2010). Impact of stress on cancer metastasis. Future Oncology, 6(12), 1863–1881. https://doi.org/10.2217/fon.10.142 CR - Park, Y., Suh, S. Y., Kim, S. H., Park, J., Yoon, S. J., Kim, Y. J., Kang, B., Kwon, J. H., Park, K., Hui, D., Kim, H. J., Lee, S., & Ahn, H. Y. (2021). Development of a one-item screening question to assess spiritual well-being for advanced cancer inpatients in Korea. Journal of Pain and Symptom Management, 62(5), 910–917. https://doi.org/10.1016/j.jpainsymman.2021.05.005 CR - Pitman, A., Suleman, S., Hyde, N., & Hodgkiss, A. (2018). Depression and anxiety in patients with cancer. BMJ, 361, k1415. https://doi.org/10.1136/bmj.k1415 CR - Porter, L. S., Keefe, F. J., Garst, J., McBride, C. M., & Baucom, D. (2008). Self-efficacy for managing pain, symptoms, and function in patients with lung cancer and their informal caregivers: Associations with symptoms & distress. Pain, 132(2), 306–315. https://doi.org/10.1016/j.pain.2007.09.010 CR - Rias, Y. A., Rosyad, Y. S., Chipojola, R., Wiratama, B. S., Safitri, C. I., Weng, S. F., Yang, C. Y., & Tsai, H. T. (2020). Effects of spirituality, knowledge, attitudes, and practices toward anxiety regarding COVID-19 among the general population in Indonesia: A cross-sectional study. Journal of Clinical Medicine, 9, 3798. https://doi.org/10.3390/jcm9123798 CR - Rottmann, N., Dalton, S. O., Christensen, J., Frederiksen, K., & Johansen, C. (2010). Self-efficacy, adjustment style and well-being in breast cancer patients: A longitudinal study. Quality of Life Research, 19(6), 827–836. https://doi.org/10.1007/s11136-010-9653-1 CR - Sheeran, P., Maki, A., Montanaro, E., Avishai-Yitshak, A., Bryan, A., Klein, W. M. P., Miles, E., & Rothman, A. J. (2016). The impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: A meta-analysis. Health Psychology, 35(11), 1178–1188. https://doi.org/10.1037/hea0000387 CR - Simandan, D. (2010). On how much one can take: Relocating exploitation and exclusion within the broader framework of allostatic load theory. Health & Place, 16, 1291–1293. https://doi.org/10.1016/j.healthplace.2010.08.009 CR - Sinha, S., & Kundu, C. N. (2021). Cancer and COVID-19: Why are cancer patients more susceptible to COVID-19? Medical Oncology, 38(9), 101. https://doi.org/10.1007/s12032-021-01553-3 CR - Slimano, F., Baudouin, A., Zerbit, J., Toulemonde-Deldicque, A., Thomas-Schoemann, A., Chevrier, R., Daouphars. M., Madelaine, I., Pourroy, B., Tournamille, J. F., Astier, A., Ranchon, F., Cazin, J. L., Bardin, C., & Rioufol, C. (2020). Cancer, immune suppression and Coronavirus Disease-19 (COVID-19): Need to manage drug safety (French Society for Oncology Pharmacy [SFPO] guidelines). Cancer Treatment Reviews, 88, 102063. https://doi.org/10.1016/j.ctrv.2020.102063 CR - Sohrabi, C., Alsafi, Z., O’Neill, N., Khan, M., Kerwan, A., Al-Jabir, A., Iosifidis, C., & Agha, R. (2020). World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery, 76, 71–76. https://doi.org/10.1016/j.ijsu.2020.02.034 CR - Stoll, R. (1989). The essence of spirituality. In V. B. Carson (Ed.), Spiritual dimensions of nursing practice (pp. 4–23). Saunders. CR - Swinton, J., & Pattison, S. (2001). Spirituality. Come all ye faithful. The Health Service Journal, 111(5786), 24–25. CR - Şirin, T. (2018). Maneviyat Ölçeği’nin geliştirilmesi: Geçerlik ve güvenirlik çalışması [Spirituality scale: Development, validity and reliability]. Turkish Studies, 13(18), 1283–1309. CR - Tsaras, K., Papathanasiou, I. V., Mitsi, D., Veneti, A., Kelesi, M., Zyga, S., & Fradelos, E. C. (2018). Assessment of depression and anxiety in breast cancer patients: Prevalence and associated factors. Asian Pacific Journal of Cancer Prevention, 19, 1661–1669. https://doi.org/10.22034/APJCP.2018.19.6.1661 CR - Turke, K. C., Canonaco, J. S., Artioli, T., Lima, M. S. S., Batlle, A. R., Oliveira, F. C. P., Cubero, D. I. G., Sette, C. V. M., & Giglio, A. D. (2020). Depression, anxiety and spirituality in oncology patients. Revista da Associacao Medica Brasileira (1992), 66, 960–965. https://doi.org/10.1590/1806-9282.66.7.960 CR - Vachon, M. L. (2008). Meaning, spirituality, and wellness in cancer survivors. Seminars in Oncology Nursing, 24(3), 218–225. https://doi.org/10.1016/j.soncn.2008.05.010 CR - Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., McIntyre, R. S., Choo, F. N., Tran, B., Ho, R., Sharma, V. K., & Ho, C. (2020). A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain, Behavior, and Immunity, 87, 40–48. https://doi.org/10.1016/j.bbi.2020.04.028 CR - Weaver, A. J., & Flannelly, K. J. (2004). The role of religion/spirituality for cancer patients and their caregivers. Southern Medical Journal, 97(12), 1210–1214. https://doi.org/10.1097/01.SMJ.0000146492.27650.1C CR - Weiss, D., & Marmar, C. (1997). The Impact of Event Scale - Revised. In J. P. Wilson, & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399–411). Guilford. UR - https://doi.org/10.37898/spiritualpc.1618949 L1 - https://dergipark.org.tr/en/download/article-file/4516982 ER -