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Cancer Nursing:
doi: 10.1097/NCC.0b013e31826f3bc4
Articles

Hopelessness and Complementary Therapy Use in Patients With Ovarian Cancer

Gross, Anne H. PhD, RN; Cromwell, Jerry PhD; Fonteyn, Marsha PhD, RN; Matulonis, Ursula A. MD; Hayman, Laura L. PhD, RN, FAAN

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Author Information

Author Affiliations: Department of Nursing and Patient Care Services (Drs Gross and Fonteyn) and Medical Gynecologic Oncology (Dr Matulonis), Dana-Farber Cancer Institute; Harvard Medical School, Boston, Massachusetts; and College of Nursing and Health Sciences, University of Massachusetts, Boston (Drs Cromwell and Hayman).

The authors have no funding or conflicts of interest to disclose.

Correspondence: Anne H. Gross, PhD, RN, Department of Nursing and Patient Care Services, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 ( anne_gross@dfci.harvard.edu).

Accepted for publication August 12, 2012.

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Abstract

Background:

Hopelessness negatively affects ovarian cancer patients’ quality of life (QOL). Research validating the effects of complementary and alternative medicine (CAM) use on QOL and hope is scarce, even though QOL and hope are reasons that patients cite for using CAM therapy. Clinicians need effective, evidence-based interventions to improve QOL and reduce hopelessness.

Objective:

The objectives of this study were to examine factors influencing hopelessness in patients with newly diagnosed disease, long-term survivors, and patients experiencing ovarian cancer recurrence and to examine the effects of CAM on hopelessness in the same population.

Methods:

Surveys of ovarian cancer patients (N = 219) undergoing treatment at a comprehensive cancer center in the United States were analyzed. Descriptive, correlation, and multivariate analyses described variables and demonstrated the effects of sociodemographics, disease state, psychological distress, QOL, CAM use, and faith on hopelessness.

Results:

Patients ages 65 years or older (−0.95, P = .03), with strong faith (−0.28, P = .00), and good QOL (0.11, P = .00) directly reduced hopelessness scores (mean, 3.37). Massage therapy substantially reduced hopelessness scores (−1.07, P = .02); holding age constant, employed patients were twice as likely to use massage (odds ratio, 2.09; P = .04). Patients who had newly diagnosed and recurrent ovarian cancer were more hopeless because of greater distress from symptoms and adverse effects of treatment.

Conclusion:

Patients who used massage therapy were significantly less hopeless, as were those with strong faith and well-controlled disease symptoms and treatment for adverse effects.

Implications for Practice:

Support of spiritual needs and symptom management are important interventions to prevent and/or reduce hopelessness, especially for patients with newly diagnosed and recurrent ovarian cancer. Further research testing the positive effect of massage interventions on hopelessness is needed.

Ovarian cancer is the fifth most frequent cause of cancer-related death in American women. Patients are most often diagnosed in late stages (International Federation of Gynecology and Obstetrics [FIGO] stages III and IV),1 where disease recurrence is common and 5-year survival rates remain as low as 20% to 25%.2 Because of the trends in diagnosis, treatment outcomes, and prognosis, the quality of life (QOL) for a patient with ovarian cancer can be threatened, and feelings of hopelessness, fear, anxiety, and depression during and after treatment are common.3–7 Additionally, disease symptoms and adverse effects of treatment are often physically and emotionally debilitating.

Hopelessness, sometimes viewed as the opposite of hope, is distinct from yet inextricably linked to hope.4,8–10 It is a predictor, for mental health issues such as depression and suicidal ideation,11–13 which inhibit patients’ ability to participate in effective medical decision making14 and interfere with physical, psychological, and cognitive QOL.15 Feelings of hopelessness can prevail and fluctuate even in patients with early-stage ovarian cancer whose outcomes are often better than those of patients with advanced cancer.16–18 However, factors that influence hopelessness and interventions to reduce it in ovarian cancer patients are not well documented. We found no studies comparing hopelessness in ovarian cancer patients across disease states and 1 study comparing QOL in ovarian cancer patients across disease states. In that study, Ferrell et al7 reported significant concerns among ovarian cancer patients relative to QOL, fear of recurrence, and death, which varied across disease states.

In the United States, patients spend billions of dollars annually on complementary and alternative medicine (CAM) therapies. Patients usually bear the full costs of using CAM because these therapies are seldom covered by insurance.19 The most common reasons patients cite for using CAM are improved QOL, perceived beneficial response, strong belief in a therapeutic effect, improved sense of control, as a last resort, and increased feelings of hope.3,20–24

Complementary and alternative medicine therapy use is becoming an increasingly important factor in cancer care.14,25 Estimates show that 31.4% to 91% of all cancer patients use CAM therapies for some periods, often in conjunction with standard medical treatment. The range most likely relates to a lack of consistency in definitions of CAM and patients’ underreporting use to their providers.19,20,26,27 Despite wide use, evidence demonstrating specific, beneficial outcomes of many individual CAM therapies remains scarce, and some have been shown to interact with standard medicines and be harmful or toxic to patients.28

The primary aim of this exploratory study was to examine factors that influence hopelessness in ovarian cancer patients at various stages of illness. A secondary aim was to establish whether the use of CAM therapies had any effect on ovarian cancer patients’ hopelessness and, in particular, whether there were specific CAM therapies that had a greater or lesser effect. Based on the current evidence describing various patient perceptions and factors associated with reducing hopelessness, we developed a model to test the direct effects of psychological distress, CAM use (general use and individual CAM therapies used), faith, and QOL on ovarian cancer patients’ self-reported hopelessness while controlling for the potentially confounding variables of disease state, age, education, employment, and living situation. The effects of these same variables on CAM use were also examined as well as the indirect effects of the disease state and sociodemographic variables on hopelessness and CAM.

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Conceptual Model

The framework guiding this study was adapted from Russell and Fawcett’s29 Conceptual Model of Nursing and Health Policy. The model guides nurse researchers to specific nursing interventions and outcomes at the individual, organizational, and/or community levels, articulating the unique contribution of the discipline to health policy formation, implementation, and evaluation.

Two policy sources drove the study aims. The first is the Oncology Nursing Society Research Priorities document (2009–2013), which outlines priorities for nursing research with emphasis toward intervention research.30 We analyzed the effect of multiple variables on hopelessness, which will guide future research testing interventions to prevent or reduce it. The second policy is Public Law 105–277, whereby the National Center for Complementary and Alternative Medicine was established in fiscal year 1999 as a separate agency within the National Institutes of Health with a mandate to conduct research to increase the knowledge and evidence base in areas of efficacy and effectiveness of CAM therapy.31 We examined the effect of CAM therapy use in general and individual CAM therapies on patients’ hopelessness. We also examined factors influencing the use of CAM therapies.

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Methods

Data Sources and Participants

A data set (N = 219) for this study joined data from 3 QOL studies of patients with ovarian cancer receiving gynecologic oncology treatment at hospitals within a National Cancer Institute comprehensive cancer center in the United States. Patients in the original studies included English-speaking women without major psychiatric diagnoses, who agreed to participate and met the following age and disease state criteria:

  1. 18 years or older, at least 3 years from ovarian cancer diagnosis (FIGO stages I–IV), without recurrence (long-term survivors);
  2. 65 years or less or younger than 55 years with ovarian, primary peritoneal, or fallopian tube cancer, who had experienced 2 or more recurrences of their cancer (recurrent patients); and
  3. 18 years or older, with newly diagnosed advanced ovarian cancer (FIGO III–IV) (patients with newly diagnosed disease).

In each of the 3 original studies, clinical research coordinators collected survey data in patient interviews by telephone or in person, after eligibility screening and obtaining consent for voluntary participation. At that same time, sociodemographic and disease state data were manually extracted from medical records.

The data set for this study had the following inclusion criteria: patients with newly diagnosed disease, long-term survivors, and patients experiencing a disease recurrence as described above, for whom there was complete information relative to selected variables that have been hypothesized and/or previously shown to influence hopelessness and CAM use in cancer patients in general and/or in ovarian cancer patients in particular. The selected variables were QOL, psychological distress, CAM use, faith, education, employment (as a proxy for functionality), and living situation (as a proxy for social support). Although previous studies have examined some of these variables’ effects on hopelessness, there are no published studies, to our knowledge, that compare the effects of these specific variables on hopelessness and CAM use among patients with ovarian cancer in all 3 disease states. Sensitivity testing was conducted testing variable construction and various groupings within variables, establishing the most highly significant coefficients supporting particular cutoff points.

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Measures and Survey Instruments
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COMPLEMENTARY AND ALTERNATIVE MEDICINE

The survey of Richardson et al22 measures use/no use of CAM and the specific CAM therapies used, without measurement of dose, frequency, or time. In this study, we explained CAM therapy by examining patients’ responses to the yes/no question: “Have you used this therapy?” and their report of the total number and type of CAM therapies they had used. The effects of specific CAM therapies and CAM use in general on patients’ hopelessness are not well documented in the literature despite the large number of patients who use CAM. To address this gap, we evaluated the CAM variable in sensitivity testing and examined use/no use and the total quantity of CAM therapies used. We also examined use of each specific CAM therapy to ascertain whether any one in particular had a greater effect on hopelessness.

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HOPELESSNESS

Beck’s Hopelessness Scale (Beck and Weissman13) is a 20-item true/false survey based on the definition of hopelessness as “a system of negative expectancies concerning a patient and his/her future life.” It yields a score ranging from 0 to 20, scored as 0 to 3, normal; 4 to 8, mild hopelessness; 9 to 14, moderate hopelessness; and 15 or greater, severe hopelessness. The tool was designed to quantify hopelessness and was administered to several diverse samples of patients to test psychometric properties: high degree of internal consistency (P < .01) with Cronbach α = .93; concurrent validity was determined comparing scores from 2 samples, both correlations significant at 0.74 (P < .001) and 0.62 (P < .001).13 Patients’ total scores were used to explain hopelessness in the study; the higher the score, the greater the hopelessness.

From a theoretical perspective, the construct put forth by Farran et al9 regarding the interrelatedness, shared roots of development, and situational determinants of hope and hopelessness guided our study. The patient experience of hope and hopelessness along a continuum has been previously reported in the literature.18,32 However, we focused our examination on factors that influence hopelessness as defined by Beck, so as to guide future research toward interventions to prevent or reduce it, which, under this construct, could result in a more hopeful state for the patient.

In the latter part of the 20th century, the nursing literature focused largely on concept and construct analysis of hope rather than hopelessness and the articulation of patients’ experience of hope through qualitative analyses of patient interviews. Guided by the priorities set by the Oncology Nursing Society in recent years, hope and hopelessness research in oncology nursing is now more focused on examining factors that affect these variables so as to move the field toward interventional research.30

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FAITH

A subscale of the Functional Assessment of Chronic Illness Therapy–Spiritual Well-being (FACIT-Sp) scale, faith and spirituality, measured faith. The 12-question scale examines meaning, peace, and faith. Items are rated on a 5-point scale from “not at all” to “very much.” The reliability of the FACIT-Sp scale and subscales (faith and spirituality) was found to have a high degree of internal consistency with Cronbach α range of .81 to .88. The faith subscale measures strength and comfort derived from faith and the extent to which patients’ faith is strengthened by their illness. The spirituality subscale measures meaning and peace. Some questions in the spirituality subscale are similar to those on Beck’s Hopelessness Scale. To distinguish the faith variable from the hopelessness variable in our study, the FACIT-Sp faith subscale score was used to measure faith. The faith subscale has a Cronbach α = .88; the higher the score, the stronger the faith.33

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PSYCHOLOGICAL DISTRESS

Psychological distress was measured using a 17-item Mental Health Inventory,34 which has an excellent internal consistency (Cronbach α = .96). In addition to a total score, the 17-item Mental Health Inventory yields 2 global scores of psychological distress and psychological well-being. The total score was used in this study as a measure of patients’ psychological distress; the higher the score, the greater the psychological distress.

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QUALITY OF LIFE

The 28-item Ovarian Cancer Module developed by the European Organization for Research and Treatment of Cancer is a subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30–general scale. It measures the QOL of ovarian cancer patients. The 28 items assess: abdominal/gastrointestinal symptoms, peripheral neuropathy, other chemotherapy adverse effects specific to ovarian cancer treatments, hormonal symptoms, body image, sexuality, and attitudes concerning the disease and its treatment.35,36 Intended to be used in its entirety, the raw scores from the module were linearly transformed to a 0- to 100-point scale in which a higher score reflected poorer QOL. Participants’ total scores on this module were used solely as a directional measure of patients’ QOL.

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SOCIODEMOGRAPHIC VARIABLES

Education, employment, living situation, and disease state data were collected in interviews and/or abstracted from medical records in the original studies.

  1. Living situation: This variable was a proxy for “social support” with some limitations. It was dichotomized representing those living with and/or married to another and those living alone not married, single, separated, divorced, and/or widowed.
  2. Education: Education data reflected the highest grade completed in school at time of enrollment in the original studies. Sensitivity testing identified optimum cutoff points. It was dichotomized as less than a baccalaureate degree and greater than or equal to a baccalaureate degree and also examined as a continuous variable.
  3. Employment: Employment status was documented at the time of enrollment in the original studies. Employment was perceived as a measure of functionality and a proxy for “maintaining a normal routine” with some limitations. The variable was dichotomized as employed or unemployed (including those who were retired).
  4. Age: Patients’ age was documented at the time of enrollment in the original studies. We used sensitivity testing to establish cutoff points based on statistical significance. Age was dichotomized as younger than 65 years and 65 years or older, which is just over the mean age (60 years) and median (63 years) of women with a diagnosis of ovarian cancer.
  5. Disease state: Patients were differentiated by disease state when enrolled in the original studies, and these differentiators were maintained in this study: patients with newly diagnosed disease, long-term survivors, and patients experiencing a disease recurrence.
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Analysis Plan

Descriptive statistics illustrated the study population demographics, disease states, living situation, and the distributions of scores on surveys measuring hopelessness, CAM use, psychological distress, faith, and physical QOL. We examined the relationships among these variables using correlation analyses and χ2 tests. Multiple regression analyses were then conducted to describe the effects of the continuous, explanatory variables on hopelessness and complementary therapy use in general and each specific CAM utilized by participants. Two logistic regressions explained the dichotomized employment and massage variables. The significant findings in the study are depicted in a final model (Figure). Arrows in the model identify variables having statistically significant, direct effects on hopelessness and those having statistically significant, indirect effects on hopelessness, working through other variables. Coefficients in the model explain the effects of age, faith, QOL, and massage variables on hopelessness in the study population. The odds ratios (ORs) represent the strength of the age and QOL effects on employment and strength of the employment effect on massage therapy use.

Figure
Figure
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Results

Summary Statistics

Patients’ sociodemographics, disease state, CAM use, and other attitudinal measurements are outlined in Tables 1–3. Overall, patients (N = 219) were white (97%), highly educated (46% completed college or higher), middle-aged (median age, 58 years) population with ovarian cancer, who were either long-term survivors, those with newly diagnosed disease, or those experiencing a disease recurrence. The majority was employed (52%) and resided with someone at home (66%). Most patients had strong faith (mean, 14.93 out of 20), and good QOL (mean, 43.85 out of 100), though this differed by disease state. They also had very low hopelessness scores (mean, 3.37 out of 20), despite high levels of psychological distress (mean, 66.47 out of 102). The majority (89%) of patients used CAM therapies (Table 2).

Table 1
Table 1
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Table 2
Table 2
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Table 3
Table 3
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Hopelessness and CAM Use

There was no significant association between hopelessness and CAM use, although the 17 most hopeless patients used CAM therapies, and the 23 least hopeless patients did not use CAM. When examining the individual CAMs used by patients, there was a significant correlation (−0.1329, P < .047) between massage therapy and less hopelessness. In χ2 tests of association, age was significantly associated with CAM use (χ2 = 9.3378, P < .002), indicating that younger patients (<65 years old) used CAM the most.

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Hopelessness and Faith, QOL, Psychological Distress

Table 4 describes the associations between hopelessness and faith, QOL, and psychological distress. Strong faith (> mean, 14.93) was reported by the majority of least hopeless patients, whereas only 24% of the most hopeless patients reported strong faith. The associations were significant (χ2 = 9.5, P < .002), indicating that having stronger faith was associated with being less hopeless. Well-controlled disease symptoms and adverse effects of treatment (QOL mean, 43.85) were reported by 53% of the least hopeless patients, whereas only 18% of the most hopeless patients reported well-controlled disease symptoms and adverse effects. The associations were significant (χ2 = 8.0, P < .005), indicating that better controlled symptoms and adverse effects were associated with being less hopeless. Most patients scored above the mean (66.47) for psychological distress, yet there were no significant associations between psychological distress and hopelessness in any group.

Table 4
Table 4
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The analysis of hopelessness and disease state revealed that 7% of patients with recurrent disease and 6% of long-term survivors were moderately to severely hopeless. By contrast, 13% of patients with newly diagnosed disease were moderately to severely hopeless. However, the associations between disease states and hopelessness were not significant.

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Multivariate Analysis: Hopelessness and CAM Use

Results of multivariate analyses are shown on the causal arrows in the Figure. Coefficients explaining dichotomous variables are shown as ORs. Replacement of the CAM variable with the massage therapy (use/no use) variable strengthened the model of hopelessness. The most robust model (R2 = 0.2852) included the dichotomized age variable (<65, ≥65), disease states, faith, QOL, and massage (Table 5).

Table 5
Table 5
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Age had a significant effect on hopelessness (−0.95, P < .03), indicating that as patients 65 years or older continued to age, they were significantly less hopeless (by almost an entire point on the hopelessness scale, with a mean = 3.4) than were patients who were younger than 65 years, when controlling for disease state, QOL, faith, and massage use.

The 3 disease states did not have a direct, significant effect on hopelessness once other variables were controlled for in the regression model. However, they did have a significant indirect effect on hopelessness working through the faith and QOL variables. Patients with newly diagnosed disease and those with recurrent disease had significantly poorer QOL than did the long-term survivors. In addition, patients with newly diagnosed disease had much stronger faith scores than did patients in the other disease states.

Quality of life (0.11, P < .00) and faith (−0.28, P < .00) were highly significant in explaining hopelessness. One-SD (10.0) difference in QOL scores led to a 1.10 change (+0.11 [10.0], one-third of the mean) in the hopelessness scores, indicating that as distress from disease symptoms and adverse effects of treatment increased, so did hopelessness in the study population. One-SD (4.5) difference in the faith score led to a 1.22-point change (−0.28 [4.5], 37%) in hopelessness scores, indicating that the stronger the patients’ faith, the lower their hopelessness scores. Holding other variables constant, patients with well-managed disease symptoms and/or treatment adverse effects (low QOL scores) were less hopeless. Similarly, patients with greater faith were less hopeless, even controlling for age differences.

Employed patients were no more hopeless than were unemployed patients. The odds of patients 65 years or older being employed were only 14.5% of those who were younger than 65 years, and those with poor QOL (1 SD above the mean) were one-third less likely (exp[−0.067 {10.0}]) to be employed as those with average physical QOL.

Psychological distress, a measure of anxiety, was high particularly among survivors and those with recurrent disease; however, it had no significant effect on hopelessness.

The number of CAM therapies used did not have a significant effect on hopelessness. The CAM variable was replaced in the final regression model by the massage variable, which had been found to be significantly correlated with less hopelessness. Massage had a significant effect (−1.07, P < .02) on hopelessness, indicating that patients who reported use of massage had a full-point lower hopelessness scores than did those who did not use massage. Additionally, those who used massage were twice as likely (OR, 2.09) to be employed.

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Discussion

Our primary aim was to identify factors that influence hopelessness in ovarian cancer patients in 3 disease states: new diagnosis, recurrent disease, and survivorship. The secondary aim was to establish whether the use of CAM therapies had any effect on ovarian cancer patients’ hopelessness and, in particular, whether specific CAM therapies had a greater or lesser effect. The findings validate the current literature and provide new information about the patient experience across disease states. This new information can guide the study of specific interventions to reduce hopelessness in patients with ovarian cancer.

Patients with newly diagnosed disease reported the strongest faith. Patients with newly diagnosed disease and those with disease recurrence also had the poorest QOL scores. However, those with strong faith and better QOL across all disease states were significantly less hopeless. Spirituality and QOL have been associated with better psychological functioning and hope.9,17,37–40 Mystakidou et al17 examined the effect of sociodemographic variables and clinical characteristics on spirituality in Greek patients with cancers at various stages. They concluded that addressing spiritual needs in palliative care could be a crucial aspect of psychological functioning, particularly in dying patients. Gustavsson-Lillius et al40 found strong associations between low hopelessness scores and improved health-related QOL in a study of 155 male and female patients with cancer. Our findings highlight the importance of effective symptom management and spiritual needs assessment and intervention in preventing and reducing hopelessness across all disease states.

Although less psychological distress did not reduce hopelessness, high levels of psychological distress have been shown to impair optimum QOL. Our finding is consistent with prior research,5,16,41,42 reinforcing the need to evaluate distress regularly in this population throughout treatment and into survivorship.

Use of CAM therapies in general did not significantly influence hopelessness scores. However, when each therapy was analyzed separately, massage therapy was found to significantly reduce hopelessness, controlling for other factors. Massage has been reported to be an effective intervention for managing cancer pain and the perception of pain.43,44 However, 2 recent systematic reviews, 1 of 14 randomized clinical trials and the other of 15 massage intervention studies, found that the majority of the studies lacked methodological rigor, which jeopardized any definitive conclusions.45,46 Massage was not examined in terms of its potential effect on hopelessness in any of those studies. The explicit relationship between massage and hopelessness has not been documented and is an important finding in our study. It is not known if patients had insurance coverage for massage, if they paid for the service, or if it was provided free of charge. These unknowns raise the question of whether the cost of massage limited access to it because less than one-half of the patients reported use of massage therapy, and those employed were twice as likely to use massage as those unemployed.

Our findings emphasize the importance of key interventions to reduce the risk of hopelessness in patients with ovarian cancer: (1) the management of disease symptoms and treatment adverse effects to improve and/or maintain QOL and hope, (2) the support of patients’ spiritual needs, and (3) the use of massage therapy.

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Limitations

As described, extensive efforts went into variable construction to decrease the potential for tautological associations and overlaps among the attitudinal variables. Despite these efforts, there were certain limitations. The CAM therapy variable was a limitation because the survey of Richardson et al22 assumed all types of CAM would have the same effect. This was shown to be an invalid assumption with the massage finding. As in any study of this kind, using data captured at a single moment in time, it is impossible to know for certain whether the direction of the significant variables’ effects changes over time. With respect to massage therapy in particular, the doses, frequency of use, settings, and types of massage patients received were unknown, limiting our understanding of the overall effect. However, despite these limitations, the strong positive massage effect in reducing hopelessness highlights an area for future research.

The variables of living situation and employment status were proxies for the key, latent variables of social support and functionality. Possible errors in variables limited our ability to find statistically reliable relationships between these key variables and hopelessness, even though lack of social support, measured by living situation, has been previously associated with greater hopelessness.47 Employment status is only 1 of many indicators of functionality and therefore a limitation; however, it was important in understanding massage therapy usage.

The fact that the study data were collected at a single moment in time limited our ability to predict the variables’ ongoing effects on hopelessness. The number of patients in the sample (N = 219), although adequate to run the regression models, limited our statistical power. Results were vulnerable to type II errors because of sample size and the level of significance we held constant in the analysis. And finally, the homogeneity of the sample limited the generalizability of the findings.

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Conclusion

Patients’ feelings of hope and hopelessness change over time with the realities and phases of their illnesses.10,32,48–50 Women with ovarian cancer are at risk for hopelessness and have reported feeling traumatized and overwhelmed with fear of recurrence and death at various points in the illness trajectory.50 Frequent assessment of hopelessness and QOL can guide clinicians in providing the appropriate supports and interventions as patients move through each phase of illness, survivorship, and/or end of life. In the clinical environment, special attention should be given to ensuring the availability of resources for spiritual support and symptom management for patients. Complementary and alternative medicine use, where appropriate, may be effective in supporting more optimum QOL and hope in patients with ovarian cancer.

An expansion of this study to patients beyond those seen in a comprehensive cancer center would add diversity to what was a relatively homogeneous sample. A multisite prospective study examining the role of education, socioeconomic status, QOL, faith, and CAM use over time in explaining hopelessness would guide the development of new nursing interventions. Inclusion of patients with other types of cancers and patients of diverse cultures and ethnicities would increase the sample size and the potential generalizability of any findings. However, given how significantly massage therapy reduced hopelessness in this study and the paucity of evidence surrounding the efficacy of this therapy, a well-designed, randomized clinical trial testing the effect of a massage intervention on patients’ hopelessness is the most logical next step.

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Keywords:

CAM; Hope; Hopelessness; Massage; Ovarian cancer; Quality of life; Spirituality

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