Study Population
The study population is part of an ongoing cross-sectional study on distress, coping, and hope among patients aged ≥ 65 years diagnosed with cancer and their informal caregivers [20,2,21]. The current study included a Muslim group and a Jewish group. The inclusion criterion for both groups was patients diagnosed with cancer, aged>=65 years, who had concluded a course of treatment within six months of the date of enrollment. Patients with non-metastatic cancer who were >2 years following diagnosis were considered survivors and not included in the study.
Muslim Group
The Muslim patients were recruited from the outpatient oncology clinic in the Makassed Hospital in East Jerusalem which provides tertiary care to the Palestinian population of East Jerusalem, the West Bank, and the Gaza Strip. A total of 153 eligible patients were identified and all gave their consent to participate in the study. Three of the caregivers refused to sign the formal informed consent document, and one patient was excluded after failing to meet the active disease criterion. The final sample thus included 149 patients.
Jewish Group
The Jewish patients were recruited from the outpatient clinics of three major cancer centers in Israel. The Jewish patients sample included 350 patients with a substantially larger group of oldest old (aged>85 years) patients. In order to ensure a similar age and sex distribution within the two samples, the Jewish participants were randomly selected according to sex, age, cancer stage (metastatic vs. non-metastatic), and time from diagnosis matching (age tolerance for matching was ±4 years and time from diagnosis tolerance for matching was ±6 months). The final sample of Jewish participants included 122 participants randomly selected to match 122 Muslim participants. It was difficult to find a matching Jewish participant for every Muslim participant since the latter were generally younger with a shorter time from diagnosis; therefore, 27 Muslim participants could not be matched with a corresponding Jewish participant.
Patients’ Characteristics
Table 1 presents the patients’ sociodemographic and medical data by study group. The mean age was 73 for Muslims and 74 for Jews, with 55% of the Muslim sample and 45% of the Jewish sample being men. 78% of the Patients in the Jewish sample have completed more than 12 years of schooling in comparison to 22% of the patients in the Muslim sample (p<0.0001). All the Muslim participants except four defined themselves as religious or traditional in comparison to only 46% of the Jewish participants. Common cancer types in both samples included lung, colorectal, prostate, and breast. Functional levels were similar between the two samples (63.5% of the Muslim participants and 64% of the Jewish participants had no symptoms or low levels of symptoms). 32% patients in each grouphad metastatic cancer. Muslim patients had more comorbidities than Jewish patients (mean of 1.19 vs. 0.8 respectively, p<0.01). Mean time from diagnosis was 5.06 months among Muslim patients and 5.5 months among Jewish patients.
Ethical Approval and Procedure
The study protocol was approved by the Medical Ethics Review Committees of Hadassah-Hebrew University Medical Center, Sheba Medical Center, Assuta Ashdod University Hospital and the Medical Ethics Review Committee of Makassed Hospital. After obtaining the permission of the attending physicians, patients were approached during routine medical visits to the outpatient clinics or during chemotherapy sessions. Each participant signed an informed consent form. Data were collected between May 2013 and June 2020 (Jewish participants) and December 2019 and June 2020 (Muslim participants).
Measures
Background Data
Sociodemographic data were collected directly from the patients. Data regarding the patients’ diagnosis, treatment, cancer stage, Eastern Cooperative Oncology Group (ECOG) performance status [22], and Charlson Comorbidity Index (CCI) [23] were obtained from the medical records.
Depression
Depression was measured using the five-item version of the Geriatric Depression Scale (5-item GDS). This is a shorter version of the 15-item Geriatric Depression Scale, which has proven to be as effective as the longer validated version (Weeks et al., 2003). The scale consists of five binary items (i.e., “Are you basically satisfied with your life?,” ) with each individual item scoring 0–1 and the five items thus scoring in a range of 0–5. The English and Hebrew versions were reported as valis and reliable [24, 25] as has the longer Arabic version [26]. For the current study, we used the five relevant items from the longer validated Hebrew version and a professional translation of the English version into Arabic (as required by the Helsinki Committee). The recommended cutoff score ≥ 2 is the clinical cutoff for susceptibility to depression [27].
Perceived Social Support
Caregivers’ support was assessed using the Cancer Perceived Agents of Social Support [17], which is a 12-item questionnaire (i.e., “To what extent do you feel you receive helpful information from your spouse?”), with each item scoring in a range of 1–5. The scale combines two theoretical content facets of social support: agent of support and type of support. The current research uses the aggregated score of the agents (spouse, family, friends, beliefs), each based on the mean of three items (instrumental, cognitive, and emotional support). The Hebrew version of the scale was previously proven to be valid and reliable for Jewish patients and their spouses in Israel [17]. For the Muslim sample we used a professional translation of the Hebrew version into Arabic. Internal reliabilities (Cronbach’s alpha values) were as follows: Muslim group, Cronbach’s alpha = 0.78, 0.77, 0.62, and 0.845 (spouse, family, friends, beliefs, respectively); Jewish group, Cronbach’s alpha = 0.75, 0.845, 0.89, and 0.97 (spouse, family, friends, beliefs, respectively).
Hope
Hope was assessed by the Adult Hope Scale (AHS) [18] and by six single items targeting specific hope content. The AHS is a 12-item measure (4-point Likert-type scale) comprising two components: agency (goal-directed determination) and pathways (routes to achieving goals). The AHS contains eight hope items and four fillers. For the Jewish sample we used a translation of the English version into Hebrew [28]; for the Muslim sample we used a professional translation of the English version into Arabic. Cronbach’s alphas for the aggregate measure of the eight hope items were 0.85 for Muslim patients and 0.895 Jewish patients. We also included six single items targeting specific hope content and measuring the extent to which the patients hope to: 1. stay alive; 2. have no pain; 3. be with their family; 4. be more active and less tired; 5. die without pain; and 6. be cured. Each item was rated on a Likert-type scale of 1–5.
Statistical Analysis
Matching
The two samples were matched for sex, age, cancer stage, and time from diagnosis. Nevertheless, based on the basic characteristics of the samples (Muslims vs. Jews), the samples were treated as independent (non-paired).
Missing Value Analysis
All variables (study variables and background variables) were screened for missing values. None of the missing values exceeded 2% except ECOG (3.7%) and treatment (7.4%). The data were found to match a “missing completely at random” (MCAR) pattern (Little’s MCAR test Chi2 (83)=93.78, P=0.196 N.S), hence no further steps were taken to complete the missing data.
Validity and Reliability of Hope Items
Prior to the analyses, validity and reliability of the single hope items was assessed (separately for each sample) In the Muslim sample, Pearson correlations between the aggregate measure of the AHS and the single hope items were all significant; correlations ranged between r=0.20, p<0.012 (hope to be cured) and r=0.55, p<0.0001 (hope to feel no pain). In the Jewish sample, all single items except the item “I hope to feel no pain when I die” were significantly correlated to the aggregate measure of the AHS; correlations ranged from r=0.46, p<0.0001 (hope to feel no pain) to r =0.76, p<0.001 (hope to stay alive). Internal correlations between the single hope items were all significant in the Muslim sample and ranged from r=0.30, p<0.01 (between hope to stay alive and hope to be cured) to r=0.68, 0.01 (between hope to stay alive and hope to feel no pain). Pearson correlations between the items in the Jewish sample were all significant except correlations to the item “hope to feel no pain when I die” and ranged from r=0.45, p<0.0001 (between hope to stay alive and hope to feel no pain) to r=0.74, p<0.0001 (between hope to stay alive and hope to be less tired). The internal reliability (Cronbach’s alpha) was 0.84 in the Muslim sample and 0.79 in the Jewish sample (or 0.83 not including the item “hope to feel no pain when I die”).
Comparisons Between Study Groups
A two-way MANOVA (ethnicity by gender) was used to compare reported levels of depression, levels of hope, and perceived social support between the study groups. These comparisons were conducted while controlled for (using as covariates) all background variables except cancer type since there were too many types with low frequencies that were included in the “other” category. Religiosity was also not included as a covariate since almost all the Muslims declared themselves religious or traditional.
Predicting Depression
A separate regression model was calculated for each of the study groups. The predicted variable was depression and the predictors were perceived social support, hope (AHS), and all the background variables. In order to examine the role of the single hope items in predicting depression, we calculated a separate regression model for each of the study groups including the single hope items as predictors of depression. The data were analyzed using IBM SPSS Statistics (Version 25) predictive and analytic software.