Cancer is highlighted as a growing public health concern globally, as it negatively affects low- and middle-income countries (LMICs) disproportionately.¹ South Africa, as a middle-income country, experiences a high burden of cancer, as well as high cancer mortality.² The World Health Organization (WHO) developed a cancer strategy that encouraged countries to develop comprehensive cancer strategies to address the cancer burden and needs of patients.³ In line with this recommendation, the National Department of Health in South Africa developed the National Cancer Strategic Framework, which recommends palliative care throughout the cancer continuum of care.⁴ The National Policy Framework and Strategy for Palliative Care (Palliative Care Framework) recognises the need for holistic care, covering physical, social, emotional and spiritual care.⁵ In line with WHO recommendations, South Africa approved the Traditional Health Practitioners Act 22 of 2007, which has not yet been fully incorporated as part of the public health system.⁶ Evidence on the physical, social, emotional and spiritual aspects of cancer care is scarce in South Africa.

A diagnosis of a life-threatening illness causes distress, which can include spiritual distress.^7,8 While there are many definitions for spirituality, spirituality in this study aligns with the consensus definition by Puchalski et al.⁹ According to Puchalski et al., spirituality is a human need and the way people seek meaning, purpose, transcendence and connections, expressed through beliefs, values and practices.⁹ While spirituality is different from religion, people can express their spirituality through religion.⁹ Spirituality is unique for each individual, and spiritual care provides a means of identifying these unique needs and developing a care plan that is specific to patients.¹⁰ Spiritual care is the process of assessing and addressing the spiritual needs of patients and families¹¹ and is an important component of palliative cancer care, recommended by the South African national palliative care policy and other guidelines globally.^5,9,12,13 According to these recommendations, health professionals can identify patients who have spiritual needs and who would benefit from spiritual care.

Most patients living with cancer in sub-Saharan Africa (SSA) use traditional, complementary and alternative medicine (TCAM).^14,15 Patients living with a cancer diagnosis consult traditional healers for different reasons, such as not being covered by biomedical medicine, using traditional medicine, practising faith healing and praying.^16,17,18 While research among patients living with cancer is increasing in SSA, such research is still limited in South Africa.¹⁵

Providing spiritual care and support for patients living with cancer is associated with better treatment outcomes, quality of life, improved coping, a source of hope and strength, pain and decision making,^19,20,21,22 whereas a lack of spiritual care support is associated with poor quality of life and existential suffering, which negatively impacts treatment outcomes.^23,24 Hence, the recommendation is that spiritual care should be incorporated as part of holistic person-centred care for people with cancer.^13,25 Compared with high-income countries (HICs), research on the spiritual needs and practices of patients living with a cancer diagnosis in South Africa is limited and has not been incorporated as part of comprehensive cancer care, despite policy recommendations.^5,13,26

This study aims to describe the spiritual and religious needs and practices of people living with cancer referred to palliative care units at two public tertiary hospitals in Johannesburg. The study specifically describes spiritual and religious needs and identifies common spiritual and religious practices among people living with cancer. The study further assesses the association between spirituality, having ancestral beliefs, consulting with the THP, socio-demographic and clinical characteristics. Lastly, the association between spiritual interventions and spiritual characteristics will be explored.

Of the 3908 records for patients living with a cancer diagnosis who were retrieved, only 2465 records with complete information on spiritual characteristics were included in the analysis (Figure 1).

This study revealed that most patients living with cancer have spiritual needs. Similar to previous studies, patients living with cancer desire forgiveness and closer connections. These are both spiritual and religiously oriented, and patients use their faith to navigate the cancer disease journey.^19,22,35 In a systematic review, Balboni et al. highlighted that patients diagnosed with serious illnesses, including cancer, have spiritual needs that must be addressed as part of their holistic care.³⁶

Transcendence and connections with self and others are important dimensions of spirituality among patients living with cancer, as reported elsewhere.^8,9,19,37 In this study, most patients expressed the need for closer connections with higher power, God and ancestors. In addition, the patients embraced support from their faith communities.^19,34 Masola explained that for African patients diagnosed with chronic illnesses, restoring relationships with the supernatural may be part of the healing process for some patients.³⁸

Like in previous studies, some patients in this study not only relied on their faith in coping with their illness but also consulted THPs.^19,22,35,39 The use of THPs in this research is, however, lower than what was previously reported.^21,39,40 Low reporting rates for THP use have been associated with easy access to health facilities.³⁹ However, on the other hand, patients do not disclose the use of THP for fear of being discriminated against by health professionals, or they do not feel the need to share the information.^35,36,37 In a study conducted in Langa, Cape Town, Hughes (2015) reported that participants cited accessibility and affordability as reasons for using THPs.⁴¹

Of note is that most of the research conducted on THP use among patients living with cancer has been conducted mainly in Nigeria, Ethiopia and Ghana.¹⁴ This study fills this knowledge gap.

Previous research highlighted that patients living with cancer combine biomedical medicine and use THPs for different reasons. Patients with cancer use THPs because they believe that the disease has both physical and spiritual causes, that THPs give them hope, that they can connect them to ancestors, and that they can prophesy and have supernatural powers for faith healing.^42,43,44,45 Efforts to integrate traditional health and biomedical medicine have been unsuccessful, despite recommendations globally and by the South African Traditional Health Practitioners Act.⁶

According to some African scholars, there seems to be a link between belief in God, or the higher being, ancestors (who protect, bless and can curse descendants) and the use of THPs, who believe in witchcraft and the practice of rituals.^42,46,47,48 This might explain why some patients in this study reported having both ancestral and Christian beliefs. Research on the role of ancestors as part of religious and spiritual care in palliative and cancer care is limited. The need for forgiveness from ancestors among study participants may be a way of expressing the need to appease ancestors to avoid misfortunes, which can manifest as illness.^42,46

The spiritual care interventions used in this study included spiritual counselling, facilitating reconciliations, family meetings and referral to spiritual leaders as appropriate and prayers.^21,27 Receiving spiritual counselling was not influenced by the type of religion, being spiritual or religious, having a belief in ancestors or consulting the THPs in this study, confirming that providing spiritual care can address diverse palliative care patients, irrespective of their belief system, in line with previous recommendations.⁴⁸ Receiving spiritual interventions was associated with having a spiritual need and relying on faith for support and coping, highlighting the importance of spiritual assessment to identify needs that guide spiritual care interventions relevant to patients’ needs. Patients who felt abandoned were less likely to receive spiritual support. This might be because they experience hidden loneliness and suffering that is not visible to others, as explained elsewhere.⁴⁹ This highlights the need for trained spiritual care counsellors and chaplains who can build trust and rapport to engage patients at a deeper level, because abandonment, being part of a religious struggle, has been associated with poor treatment outcomes.⁵⁰

Like in previous studies, spiritual and religious beliefs can be associated with some socio-demographic and clinical characteristics. Being female, unemployed, black and having low socio-economic status is associated with spiritual and religious beliefs and the use of THPs,^43,51,52 whereas breast cancer and cervical cancer are associated with being spiritual, religious and consulting THPs. More research to determine the associations between socio-demographic and clinical characteristics and spiritual, religious, ancestral and traditional beliefs is recommended.

This study highlights that patients living with cancer are spiritual and religious. Patients have ancestral beliefs, need forgiveness and connections with God, higher beings and ancestors, rely on their faith and faith communities to cope, and some use THPs for distinct reasons. Receiving spiritual interventions was positively associated with being ritualistic and providing comfort, whereas spiritual care ignites feelings of abandonment and the need for forgiveness. Research should explore specifically what patients are seeking forgiveness for in the context of their lived experience and determine rituals practised and THPs used among this population.