Introduction

Cancer is considered as one of the commonest diseases in the world. The reports of the Health International Organization show that cancer will increase in the upcoming decades(1). Leukemia is the cancer of blood producer textures and the commonest cancer during the childhood that has caused 41 % all the malignancy in children less than 15 years old.  In 2000 approximately 3600 children suffering from Leukemia equal with the annual emergence of one fourth of new cases out of 100000 children less than 15 years old were recognized and in boys after one year of age more than girls and the peak of its emergence is 2-6 years of age(2). The study done By MAHAK( the Institute of Protecting the Cancerous Children) about the rate of cancer outbreak in Iran demonstrate during different years, the number of children suffering from cancer in the country is 9 out of 100000 children annually. This statistical information rose to 15 children in 2008(3). Increasing children's health indices is one of the most significant signs of health conditions and the most obvious signs of the quality of providing health services in a society(4). Children suffering from Leukemia experience a severe decrease in their quality of life during all the phases of the treatment. Cancer leaves outstanding effects on corporal, social, psychological and spiritual aspects of the people suffering from cancer and their caregivers and puts them to a challenge from the very early stages of diagnosis, therefore leaves a very destructive effect on the quality of their life(5).

Spirituality and religion sometimes interpreted as spiritual health and religious acts overlap in a way that both present frameworks by which a person is able to understand meaning, objective and supreme values of his or her life(6). Some believe that spirituality goes beyond religion and encompass other concepts such as spiritual health, tranquility and comfort caused by faith and spiritual conformity(7). Findings show that spirituality and religious acts are effective in promoting mental health, in fact praying, generosity and daily spiritual experiences can predict the status of mental health(8). The people enjoying spiritual health are considered strong and mighty and possess authority and social protection(9). Spirituality bestows hope and the value of life to the family caregivers of the patients with acute disease, giving them a sense of balance in their lives, helping them how to cope with the disease of the person suffering from it(10). Spirituality is not separate from corporal or mental aspects of the people and provides an integrating power. Spiritualty affects moods, motivations and behaviors. These findings signify that it provides the people suffering from cancer with an effective defense mechanism as a bumper especially when people face a chronic disease or become responsible for looking after a patient suffering from a chronic disease(11). Meanwhile in some studies different results have been obtained which shows the necessity of the current study for instance  thestudy done by Velan et al. showed no meaningful relationship between hope and doing religious acts like saying prayers(10). Also in an investigation conducted by Beery et al. on 250 patients in England showed patients who had better and stronger spiritual beliefs, during nine months of consecutive pursuance, had forewarning and far worse condition compared to other patients(12).

Looking after a person suffering from a chronic disease can cause a lot of stress for a caregiver and the patient's family. Caregivers are susceptible especially to stress, since biological, social and mental needs of the patient precede their own needs(13). Diagnosing cancer causes profound emotional and sentimental problems such as stress, anxiety and depression in patient and his family. Studying parents' stress is important since children with respect to their development degree can receive stress and anxiety from their parents(14). Investigations demonstrate that disruption in the parents' emotions affect development of emotions in children(15). When parents especially mothers can feel self-sufficiency and mightiness in stressful conditions, they 'll be able to protect their own sick child and  make possible his treatment. Findings of several studies demonstrate a meaningful statistical relationship between higher levels of spiritual health and mental health variables such as depression, disappointment, request of death sooner than its time and suicidal beliefs(16). Since caregivers of the patients suffering from cancer play a basic role in caring, supervising and managing the symptoms experienced in such patients(17), supporting and following the treatments of such patients, securing their mental health is essential for the continuation of treatments of these patients.  Four corporal, mental, emotional and social needs have been recognized and executed but the ambit of spiritual care is frequently disregarded. Paying attention to spiritual care is an indispensable part of the holistic treatment in nursing(18).  Because of the attention given to spirituality in health and treatment and especially spiritual care, as one of the essential duties of the nurses, in recent years  because of our religion and our religious beliefs and lack of sufficient investigative evidences, the investigator decided to study the effects of spiritual support of the family on the stress of caregivers of children suffering from Leukemia. Thus the main motivation to conduct this study is helping patients suffering from Leukemia and their families especially the main caregiver of the child to have better compatibility with Leukemia and decrease of the stress of the caregivers of these patients. We hope that this study be a basis to provide better services and further investigations.

Methods

This study is a clinical trial whose population included caregivers of children aged 8 to 12 with acute lymphoblastic leukemia hospitalized in oncology ward of Dr. Sheikh  hospital in Mashhad. The number of samples was 60 people selected by convenience sampling method. 25 (83/3%) of caregivers in the intervention group and 22 (73/3%) in the control group were mothers and the rest were fathers or other members of family. Allocation of subjects under study to two groups of intervention and control groups was performed randomly (based on random numbers table).According to a guide study and comparison means formula and regarding the power of 80% and confidence intervals of 95%, the sample size was determined. Inclusion criteria included the following: Having written informed consents, Iranian citizenship, Mashhad and the surrounding residents, having ability to read and write, no substance abuse and psychotropic drugs, lack of known mental illness, acute Lymphoblastic Leukemia diagnosis was confirmed by a doctor, children aged 8 to 12. Exclusion criteria: The unwillingness of the individual to participate in the study, occurrence of an emergency situation and interference in the continuation of the project, the absence of 2 sessions or more, receiving another educational program during the intervention. Assessment tools include: 1. the researcher made demographic questionnaire with 18 questions. 2. spiritual health questionnaire: in this study spiritual health assessed with Palouutzain & Ellison and Ellison questionnaire containing 20 questions, 10 questions of which existential health and 10 other questions assess person's religious health. Spiritual health score is the sum of these two sub-groups which range between 20-120. The answers to these questions are classified Likert with 6 options from strongly disagree to strongly agree. 3. Depression, anxiety, stress questionnaire (DASS): Each subscale consists of 7 questions. Each question is scored from 0 to 3, then the final score for each of subscales should be doubled. severe depression is 28, anxiety is 20 and stress is 33. The validity of assessment tools of research was confirmed through content validity and seven faculty members of Nursing and Midwifery faculty of Mashhad. For determining the reliability of spiritual health questionnaire, Cronbach's alpha was used and alpha coefficients were calculated for each of existential health and religious health sub-scales respectively, 0.80 and 0.86 and for whole of spiritual health scale was 0.87. Also for DASS questionnaire, reliability was calculated by using Cronbach's alpha for depression, anxiety, stress respectively, 0.70, 0.75, 0.85 for the total scale was obtained 0.90.

After obtaining permission from the ethics committee of Mashhad University of Medical Science, for collecting data, researcher attended in the ward. After explaining the purpose of study to head nurse, at first course selection chart of the study that included exclusion and inclusion criteria was completed by the researcher through interview with caregivers, and caregivers meet the inclusion and exclusion criteria were selected. Then the necessary explanations about the purpose of the study was presented to each selected person by researcher, face-to-face about 10 to 15 minutes. Every one wish to participate in the study, written informed consent was obtained and demographic information form was completed with interview. It should be noted that,before collecting data, researcher trained by religious expertabout spiritual support.Spiritual support meetings for caregivers was held by researcher and under supervising of religious experts.

Before starting the sessions, DASS and spiritual health questionnaires were completed by caregivers of intervention and control groups in the room is intended in the ward and the time that researcher was given.

Since this study was performed in two groups-intervention and control-, the intervention was done only for intervention groupandcontrol group received no intervention. Before the session's beginning, the interventional group's caregivers using randomized method are divided to 6 to 8 groupsand remained the same until the end of sessions. Then intervention groupwas put under 5 sessions based on spiritual intervention on the pattern of Richards and Bergin focusing on the rituals of Islam and includes psycho-spiritual components: prayer, trust and appeal, patience, gratitude and forgiveness, each day was 60 minutes.

In the first session, participants will be asked to put forward their supportive needs in terms of personal experience.

 During the second session caregivers will be familiar with the role of trust and appeal in getting along with psychological stress caused by child disease and will be trained to know the theoretical bases of trust and appeal, trust as a contrastive strategy to deal with stress, ways to achieve the trust and appeal and how one can use trust and appeal as effective contrastive strategy to convert inappropriate negative excitements to negative excitements.

In the third session the role of prayer in solving their problems and the impact of prayer on the process of problem solving is discussed. Also some instructions will be given about the value and importance of prayer, its philosophy, familiarity with the correct practical way of praying, And familiarity with the effects of prayer on the relationship of the individual with God, oneself and others.

 In the fourth session they will be familiar with the concept of thanksgiving and its effect on reducing negative excitements and effective beliefs will be taught about thanksgiving´s effect to decrease caregivers´negative excitements and in the last session they will be familiar with the steps of patience and they will be taught about the value of patience, kinds of patience, steps of patience and patience as a strategy to deal with the pressures caused by the child´s illness.

Education was conducted through lectures, ask and answer, group discussion and distribution of print papers with information that presented in each session. Intervention and control groups were matched in terms of the number of caregivers.

Immediately after finishing the sessions, DASS and spiritual health questionnaires were completed by caregivers of intervention and control groups in the room dedicated to the same notion in a ward and in time determined by theresearcher .After completion of data collection in terms of compliance of ethical issues in research, all of educational interventions and executive protocol of the spiritual support was delivered to the control group. Thenthe collected data were analyzed bySPSS16software and were processed by using Kolmogorov-Smirnov and Shapiro wilk tests, paired t-test, analysis of variance and linear regression modelwith 95% confident interval(percent significant level) and power test of 80%.

Results:

The average age of caregivers in the control group was 40.0±6.9 and in the intervention group was 35.7±6.2. The average number of family members in the control group was 4.6±1.0 and the intervention group was 4.9± 1.8. According to independent t-test, two groups regarding these two variables and the variables of the rank of child with leukemia, height, age and body mass index were similar and the difference were not significant. The results of linear regression model to examine the effect of confounding variables on the difference of stress scores before and after interventionshow thatjustthe effect of group on the difference of stress was significant(P<0.001)and the control group shows 8.72 score of stress more than intervention group(table 1).Alsothe effect of age of child on the difference of DASS score was meaningful(P= 0.032) so that by increasing the age of children- one year- the difference of DASS scorebecome as low as 0.95.In other words, for children with older age, reducing the effectiveness of the intervention was more on the DASS(table 2); This means that caregivers with older children had suffered from more stress(Stress caused by not studying the lessons, lack of ability to communicate with peers, child abuse in school because of changes in appearance). Intervention reduces their stress score more than caregivers with younger children.

The results of stress tests showed that before the intervention, the difference of stress between two groups was not significant(P<0.655). After the intervention, stress in intervention group was significantly lower than control group(P<0.04). Comparing the difference of stress between two groups before and after intervention with analysis of covariance showed intervention group was significantly lower stress scores than control group(P<0.001)(table3).

Results of the DASS variable test showed that before the intervention, the difference of DASS between two groups was not significant(P<0.882).After the intervention, DASS score in intervention group was significantly lower than the control group(P<0.032).Comparing difference of DASS score before and after intervention between two groups showed decreasing DASS in the intervention group was more meaningful(P<0.001)(table4).

Discussion

In the present study, sessions of spiritual support has been able to reduce the stress of caregivers of children with leukemia. Before the intervention, the difference of stress between two groups was not significant. After the intervention, stress in intervention group was significantly lower than control group. Comparing the difference of stress between two groups before and after intervention showed intervention group was significantly lower stress scores than control group(P<0.001).

After doing a lot of searches in domestic and foreign articles, we examine the articles that were closer to results of the present study.

In the study that PahlevanZade et al. had done(1388)to investigate the effect of psychological education of family on depression, anxiety and stress of 100 of caregivers(older than 15 years old)of psychiatric patients hospitalized in Noor hospital in Isfahan, training reduced depression, anxiety and stress of these people and was semantically close to present study(19).Najiesfahani et al. (1391)in a study investigated the Relationship between Spiritual Wellbeing and Stress, Anxiety, and Depression in Patients with Breast Cancer, and got the same results(20). In the study of Bolhari et al. (2012) had done with the aim of examining the effectiveness of spiritual care on reduction of stress and depression in women with breast cancer, spiritual intervention reduced stress, tension and depression in the people, which is close to present study(21).The results of these three studies were consistent with present study, the reason can be the effect of intervention on depression, anxiety and stress of these people in stressful situations. These studies are somehow the same as present study in type of intervention. In this regard Sanaei et al. (2011)believe that spiritual and religious content having numerous consequences cause positive attitude towards oneself, environment and future; as a result, people did not consider themselves vulnerable and feel comfortable in the environment(22).Also spirituality, by targeting individual beliefs help to evaluate negative events in a better manner and have a stronger sense of control of existing conditions(23). Also the sense of control strengthen people in coping with living conditions and after that promoting the mental health and stress reduction(24). Also Fallah et al. (2011)did a study to evaluate the effect of spiritual intervention on the mental health of 60 women with breast cancer,its result shows that spiritual intervention can reduce tension and anxiety in people and increase their public health(25).This study can be consistent with the present study in terms of similarity in the instruction of spiritual self-caring program and the sameness of the culture of two societies which has caused spiritual care be presented as an effective defense mechanism and as a bumper so as to promote dominance in them.

It seems that religious and spiritual obligations protect the individual against stress caused by life’s uncontrollable incidents such as death and severe diseases that can produce anxiety, nervousness and depression(26).

Having studied the other papers extensively, in addition to the consistent results, some studies were obtained whose results were different from the results in the present study.

Tuck(2012) in a study named examining spiritual interferences reached different results about interference and spiritual care which demonstrate this interference causes augmentation of the improvement in life quality and decrease of the response to the stress, tension and depression. But in general, the results obtained from his study show limited effects of the spiritual care and its interferences on the people(27). Likewise, the results of Hart etal. (2012) on 1362 patients suffering from cancer demonstrate limited effects of the spiritual interferences on the symptoms and warning of the cancer in the people suffering from it(28) and the incongruity of the results of this study with the present study can be caused by the inconsistence of the circumstances of the participants of the mentioned study- individuals suffering from various types of cancer participating in Hart study versus caregivers of the children aged 8-12 suffering from acute leukemia lymphoblastic in the present study- can be different society being examined so that the individuals in both of the studies were culturally and socially different. Also in the study carried out by Qahari et al. (2012) which examined the effect of spiritual interference on 45 women suffering from cancer, this interference did not have any meaningful effect on the tension, anxiety and depression of the these people and did not have any consistence with the results of the present study(29). The reason of this difference may be related to the limited size of the sample or difference in the people's disease, background problems, not having any emotional supporter or difference in the society being examined. The number of educational sessions in the mentioned study is more than the present study; furthermore, these studied did not employ similar means.

In this study, there were limitations including caregivers' spiritual beliefs and these beliefs were different in every caregiver and out of the researcher's control so that they could be effective factors on the stress of the caregivers of the children suffering from leukemia.

In spite of the fact that caregivers did not have behavioral- cognitive disruptions, some of the caregivers did not have high focus while others were able to focus their attention on their child and themselves, something that can affect the results of the study. Consequently in order to remove this problem, it was better if the caregiver could be instructed in an appropriate time in a day having good conditions for listening and receiving the information. Likewise the existence of caregivers with stronger beliefs in two groups of control and interference was monitored.

So it can be concluded that spiritual support sessions had been able to reduce the stress of caregivers of children with leukemia.Regarding to this point that spiritual support can reduce the stress of diagnosis or long period of treatment for caregivers of children with leukemia and the results showed that the intervention group had significantly less stress than the control group, so it is recommended that such interventions be done for caregivers of children with leukemia due to the low cost, safety and effectiveness.

Acknowledgment

This paper was the result of a master thesis of nursing, baby and infant field ratified by investigation assistance in Mashhad Medical University having code number 941111. We appreciate sincere cooperation Vice Chancellor for research of Mashhad University of Medical Sciences, respected professors of nursing and midwifery faculty, management of doctor Sheikh Hospital and all staff in oncology ward.