The spiritual beliefs of cancer survivors: A thematic analysis


 Aim
 This study explored the nature of spiritual beliefs and their role in regulating various life outcomes of cancer survivors.
 
 
 Method
 A heterogeneous sample of thirty diagnosed cancer patients with age ranging from 18 to 75 years participated in the study. The study employed a qualitative research design which involved semi-structured interviews and the thematic analysis of the audiotaped contents of these interviews.
 
 
 Results
 The analyses led to five themes regarding the spiritual beliefs of the participants. The identified themes were: “optimistic change towards life”, “fighting spirit towards life”, “enhanced trust in family and friends”, “improved realistic self-perception”, and “positive thinking with future orientations”.
 
 
 Conclusions
 The findings of the study showed that spiritual beliefs represented a complex phenomenon comprising cognitive, affective and behavioural components. Spiritual beliefs also carried many positive outcomes to regain and maintain psychological balance, well-being, quality of life and health. It also facilitated the patients to have strong desires to compensate their losses due to ill health by setting and achieving higher spiritual, social and interpersonal goals by carrying out social services, sacrifice and altruistic deeds.


to Roof (2001), spirituality represents four basic themes namely, a source of values and meaning or purpose beyond the self, understanding, inner awareness, and personal integration. Moreover, inner awareness and personal integration are the basic ingredients of spirituality.
The basic mechanisms through which spirituality has been argued to impact health and other life outcomes involve positive coping styles, locus of control, social support and social networks, physiological mechanisms, and an enhanced relationship with architecture and built environment (Cobb et al., 2012;Koenig, 2012). It has been argued that spirituality helps to achieve optimistic attribution styles by perceiving negative events as externally caused and positive events as internally caused, which, in turn, may facilitate to attain better mental health outcomes and to position the individuals to reframe or reinterpret events that are seen as uncontrollable (Cobb et al., 2012;Koenig, 2012).
The individuals obtain social support from many sources as a result of spiritual arrangements which may act as the mediators between their existing cognitions and mental health (Hill & Pargament, 2003). These social supports are believed to be valuable sources of self-esteem, information and companionship that enable people to successfully cope with their stress and negative life events or exert its own main effects (Cohen & Wills, 1985). According to Loewenthal (1995), these supports may include protecting people from social isolation, providing and strengthening family and social networks, a sense of belonging and self-esteem, and offering spiritual support in times of adversity. Hill and Pargament (2003) argued that members of other social networks may be fluid or transitory, whereas support gathered from a spiritual network can accompany an individual from birth to death.
It is to be argued that religion and religiosity are intertwined with the spiritual system that is multi-dimensional and intricate. Religion is a set of beliefs, practices and rituals, whereas religiosity is the practice of these beliefs and rituals in real life. Practices are associated with festivals and special occasions also which act as a buffer to adversity and failures of life of the Indians. The religion, religiosity and spirituality for the Indians are well-known and are expressed in their behaviours, feelings and perceptions of the realities of life including ill-health conditions. It has been argued that spirituality refers to the way individuals seek and express meaning and purpose in life, experience their connectedness to the moment, self, others and nature (Puchalski, 2006). Spiritual beliefs have been reported to be closely linked with meaningfulness, harmony with nature, positive emotions, peace, contentment, gratitude and acceptance, a positive state of mind, internal wisdom, creativity, awareness of self, with others and this world, love with life, self-esteem, hope and joy, optimism, values, belief, forgiveness, coping, support and commitment (Beauregard & O'Leary, 2008;Clinebell, 1992;Murray & Zentner, 1979).
Likewise, other researchers have identified six dimensions of spirituality namely, an appreciation of nature, creativity, personal development, religious beliefs, social and political, and relationship with people (O'Connor & Chamberlain, 1996). These attributes of spiritual beliefs empower individuals to be a strong regulator of mental and physical health as well as other positive outcomes of life (Thoresen & Harris, 2002;Toussaint, Williams, Musick, & Everson, 2001).
The review of the previous works showed that the study of spiritual beliefs is important for understanding many life outcomes of people including health outcomes. It was observed that previous studies on spiritual belief have been mostly quantitative in nature and based on American and Western samples. Moreover, these studies have reported spiritual beliefs to work well as these involve social support and other benefits that may Sharma, Tiwari, & Rai lead to positive changes in the cancer survivors (Tsuchiya, Horn, & Ingham, 2013). Thus, these findings serve a limited purpose in understanding about the nature, mechanisms and dynamics of the spiritual beliefs of cancer survivors belonging to the Indian socio-cultural milieu, characterized by ancient heritage, having a dissimilar ontology, and with a multitude of spiritual systems. It has been suggested that qualitative research design is suitable to develop a deeper understanding of the nature and attributes of complex constructs like spirituality and spiritual beliefs (Mudgal & Tiwari, 2015Sharma, Tiwari, & Rai, 2017).
Thus, it is explicit that spiritual belief may be conceived as the source of origin of many psychological mechanisms that may involve the development of social support, development of positive cognitions and attributions, understanding of relationships with other people, society and nature, understanding of the adaptive demands of life, life goals and positive self. These psychological mechanisms arising out of spiritual beliefs may be assumed to be closely linked with many perceived positive life outcomes. These perceived life outcomes act both as means and end in themselves. For example, having good relationships, positive cognitions and social support are useful to face the other demands of life. In this sense, they signify end in themselves. Moreover, this positivity arising out of the development of spiritual gains may also affect biological and psychological processes that, in turn, may facilitate to understand nature, causes and consequences of chronic diseases like cancer. This discussion makes it apparent that spiritual beliefs may have significant curative, preventive and promotive values for physical and mental health problems. In the backdrop of these arguments and facts, the present study attempted to develop a primary and in-depth understanding of spiritual beliefs of a heterogeneous sample of cancer survivors employing a qualitative research design for collecting, processing and analyzing data collected from semi-structured interviews.

Objectives
The following were the major objectives of the present study: 1. To further explore the role of spiritual beliefs on the perceived life outcomes among a heterogeneous sample of cancer survivors, and 2. To develop an understanding of the mechanisms inherent in spiritual beliefs impacting the life of a heterogeneous sample of cancer survivors.

Method
The present study followed a qualitative research design which employed semi-structured interviews for data collection. Before the actual data collection, a pilot study was conducted to ascertain the procedural details and to gain first-hand experience.

Participants
Thirty cancer patients who have been visiting Bundelkhand Medical College Hospital, Sagar, Madhya Pradesh, India for routine testing and treatments, were selected using purposive sampling. From these, 19 were male cancer survivors with age between 18 to 75 years (M = 51.21, SD = 13.87) and 11 were female survivors with age between 35 to 71 years (M = 47.36, SD = 10.75). Most of the participants belonged to lower-middle-class Hindu families. A set of inclusion and exclusion criteria were employed to recruit the participants in the study. Spiritual Beliefs, Cancer, Chronic Disease, Thematic Analysis A male or female who had attained the age of 18 years or older and had been diagnosed with cancer in any part of his/her body for the last 6 months or more and had been undergoing regular active treatment, were included in the study. The participants who were suffering from other diseases were excluded from the study.
The biographic details of the male and female participants are displayed in Table 1 and Table 2, respectively. Note. The details of cancer survivors belong to those who came under the inclusion criteria. These details were recorded with the help of the caretaking medical practitioners. The age reported by illiterate patients are approximate and based on their informal knowledge.

Semi-Structured Interview
A protocol of a semi-structured interview comprising 12 questions was prepared based on the spiritual experiences, thoughts, and needs of the patients of a pilot study.
These questions were open-ended and were selected following the criteria of relevance and significance to the field of spiritual beliefs, and based on the conclusions of some important studies in the field of spirituality (Cobb et al., 2012;Koenig, 2012;Sheldrake, 2007;Snyder & Lopez, 2007). In addition, the researchers were free to add some additional items in interview protocol based on their insights during the process of data collection, their regular touch with the upcoming literature and discussions with the experts of the field. The verbatim contents of the interviews of the participants were audio-recorded.

Data Collection Procedure Pilot Study
The proposal was submitted to the competent authority of the Medical College to seek written permission to conduct the study. In the first phase, a pilot study was carried out to finalize the efficacy and functionality of the interview protocol and to ascertain other procedural details of the study. The efficacy of the interviews was ascertained applying the criteria of the relevancy of the contents, the wording of the questions to be asked, styles of putting the questions in a manner to motivate the participants to come up with detailed information about their experiences without negative emotional swing and use of comprehensive native language in the interview as per the requirement of the questions. Initially, 21 questions were prepared on the basis of previous findings on spiritual beliefs of clinical and non-clinical samples and the same were put before the three researchers with the request to express their comments and suggestions. They recommended for removal of five questions from the protocol. Next, a pilot study was conducted with 4 cancer patients, 2 males and 2 females, with age between 25 to 47 years, whose data were not included in the final analysis. After assessing the suitability of the questions in the pilot study, 4 more questions were removed from the interview protocol. A list of initial and final Spiritual Beliefs, Cancer, Chronic Disease, Thematic Analysis items has been given in Table 3. Considering the suggestions of the experts and the insights of the pilot study, the following questions were finally included in the interview protocol of the study:

Current Study
After the interview protocol was finalized, the proposal was put before the Ethical Committee of the Department of Psychology, School of Humanities & Social Sciences, Doctor Harisingh Gour Vishwavidyalaya, Sagar, M. P.
for its approval to conduct the study. After the approval of the proposal, the researcher (the first author) visited the hospital and obtained the informed consent from the participants. Their basic biographic details along with nature, history, course and treatment of the disease were recorded. The participants who fulfilled the criteria of inclusion were debriefed about the basic objectives and requested to take part in the study. The interview was carried out by the first author in a separate room of the hospital provided for the purpose by adopting a one-on-one interview style. To ensure the confidentiality and privacy of the participants, the interviews were conducted in a secure place and codes were assigned to the data of all the participants. After setting up a rapport with each participant, the process of the interview was started. Initially, the interview was started with the general questions like "When did you come to know about the disease?" and "What were your initial experiences?" During the interview, some queries like "Can you explain something else?", "Can you tell me a bit more clearly" and "What does this mean for you?" were also asked. Following this procedure, the questions were put before each participant and the contents of their answers were recorded.

Qualitative Data Analysis Procedures
The verbatim transcriptions of the recorded interviews were prepared with comments, if any, to smooth the process of carrying out the coding for the contents of the interviews with the thematic analysis by the researchers who have experiences of teaching and research on qualitative methods for more than five years.
The data of all the participants were supplied to the three researchers with the request to generate codes that described cognitive, affective, behavioural, interpersonal, social and other experiences occurring in the significant amount and have meaning to understand the causes and consequences of disease as well as life experiences. The codes refer to a unit of meaning reflected in words, phrases, sentences or a paragraph.
The codes were labelled as the spiritual experiences that indicated positive life changes, positive efforts with no fear of consequences, positive faith in others and society, realistic and non-emotional understanding of life events and positive future orientations with common humanity. When the codes were generated from the data, the themes were identified by the researchers by adopting the Thematic Analysis Method (Braun & Clarke, 2006). The Thematic Analysis is the method of identifying, analysing and reporting repeated patterns (themes) of meaning within data. The Thematic Analysis Method comprises six steps, namely, familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report sample (Braun & Clarke, 2006). Thus, a data-driven analysis was made that involved generation of codes, identification of patterns and themes with the help of the researchers independently followed by a conference to establish consistency in their themes with concomitant descriptions. This was done to enhance objectivity and consistency in analysis.

Results
The qualitative data were analysed as per the guidelines of Thematic Analysis Method which led to insightful and interesting facts about the spiritual beliefs of the participants. The qualitative analysis of the data showed that the majority of the cancer survivors expressed that spirituality is a set of transcendental experiences (e.g. God is helping me. People are good and they are caring for me and I should also remain honest towards Spiritual Beliefs, Cancer, Chronic Disease, Thematic Analysis them.), self-cognition and self-perception which is full of higher values and humanity (I am good. I know the causes of disease.). It is widely known that cognitive distancing from pain increases the threshold of pain perception (Peláez, Martínez-Iñigo, Barjola, Cardoso, & Mercado, 2016). It was explicit that the beliefs in the theory of karma, rebirth, and incessant presence of divine powers were the major attributes of spiritual beliefs of the cancer survivors. The majority of the participants believed that spirituality involves doing something for all organisms. The survivors believed in the theory of karma (deed) which was promulgated by Bhagwat Gita, a sacred Hindu religious text. The theory of karma posits that everything is determined by one's deeds. The individuals should only care for their deeds and the consequences are well-determined and regulated by the nature of their deeds. Moreover, the present state of an individual is determined by his/her karma of his past and present. It leads to the fact that one has to take further birth to enjoy, good or bad, of the karma phal (consequences of one's deeds) of the deeds of one's past life.
The majority of the survivors expressed their firm belief about the omnipresence of God (With the grace of God, the doctor has given me medicines that are working well. People are helping me as God is willing to help me.), the indestructibility of the soul (This world is very fragile. I will take another birth.) and mortality of their bodies (One day, each one of us has to die. In his incarnation, God has to leave his body.). It is explicit in the expressions of the survivors that the Atman (soul) remains intact and alive forever.

The Cancer Survivors Evidenced a Fighting Spirit Towards Life
The chronic health conditions instilled the fighting spirit in the cancer survivors. Initially, the diagnosis of the disease led them to face family and financial problems and gave birth to suicidal ideation and many types of psychological problems. Occasionally, they also had positive thoughts and took the condition as challenging.  (Beauregard & O'Leary, 2008;Clinebell, 1992;Murray & Zentner, 1979).

The Cancer Survivors Showed Enhanced Trust in Family and Friends
The diagnosis of cancer was reported to facilitate and improve trust in family and social relationships. It has been argued that spiritual beliefs catalyze multiple aspects of human existence (i.e., physical, mental, emotional, and social) and play an important role in strengthening intrapersonal and interpersonal relations (Snyder & Lopez, 2007). In this manner, enhanced family and social relations reflected the increased spiritual beliefs. In fact, the initial reactions to fatal illness are alike universally. But at deeper levels, they are clear expressions of religiosity in Vedic religion (mostly prevalent here). Anybody who stands in time of crisis is 'bandhav' or brother. Thus, these caregivers come forward for extending social support in the form of extending spiritual meaning who are not necessarily kith or kin but members of the community and work as a traditional shock absorber and practice some kind of religious cognitive restructuring needed at the time. These were some cultural expressions of spiritual experiences unique to Indian society. It emphasizes universal brotherhood, seeking and giving social support as spiritual duties and social expectations.

Chronic Health Conditions Help Improved Realistic Self-Perception
The analysis of the data exhibited that chronic health conditions like cancer affect the self-perception of individuals. It leads to poor self-perception at the beginning followed by improved self-perception. Spiritual beliefs have been attributed with enhanced meaning and purpose in life, connectedness, and a positive state of mind, internal wisdom, awareness and adaptive attribution styles (Beauregard & O'Leary, 2008;Clinebell, 1992;Murray & Zentner, 1979).

Chronic Health Conditions Help Facilitate Positive Thinking of Future Orientations
Chronic health conditions like cancer bring about change in the thinking styles of the people. People reported to become more concerned about the future and admitted that if they get well, they will compensate for previous life achievements by doing even more valuable jobs. It has been argued that spiritual beliefs are characterized by enhanced awareness of self, others and the world, positive emotions, hope, optimism, coping and support (Beauregard & O'Leary, 2008;Clinebell, 1992;Murray & Zentner, 1979). These psychological mechanisms may

Discussion
It is explicit that spiritual beliefs refer to the cognitive structures that unfold understanding of inner and outer realities of all sorts of life and have been suggested to be rooted in familial and cultural upbringings of individuals.
These beliefs are more responsive to the situations that need reflection and integration to derive the meaning of significant events of life and have practical relevance to the life of individuals. It closely shapes affective, behavioural and relational aspects of individuals (Holland et al., 1998). The findings of the study evinced that the spiritual beliefs catalysed some meaningful positive force to the life of the people suffering from cancer. It helped them to be aware of the forgotten realities of their being. It acted as the precursor to initiate a chain of self-enhancement and diversification of their spiritual understanding in meaningful and productive ways.
The findings showed that many universal correlates of spiritual beliefs were observed in the verbalizations of the cancer survivors. Common humanity, social support, positive cognitions, meaningfulness, connectedness, hope and optimism were reflected in the expressions of the patients. Some behavioural, outcomes such as adherence to medical treatments, recommended diets and positive health practices, were also evident in the replies of the survivors. Moreover, positive attribution style in thinking, reframing and reinterpretation of the realities of life and transcendental experiences were also reported.
These arguments provided a strong base to explain the experiences of the survivors caused by cancer. The deeper spiritual explorations by the cancer survivors led them to believe that cancer can do some harm to their body which is taken care of by medical regimen. It cannot make any harm to them as they are not the body but blissful Atman (soul) beyond pleasure and pain. It is widely believed that the ill-conditions created by the disease are the results of the karma of the past or present life and will dissipate away as soon as the survivors will face the proportionate consequences of their ill-karma.
There were some unique spiritual experiences of the survivors which may be said to be peculiar to the Indian people only. It represented the beliefs in the theory of karma, rebirth and incessant presence of divine powers. In addition, many associated attributes were shown to be present in the expressions of the survivors. For example, chanting of mantras (hymns), explaining the life realities in terms of the theory of karma (deeds), karma phal (consequences of deeds), Moksha (salvation), rebirth, the immorality of Atman (soul), social comparisons and the concept of narak (hell) were among them which guided the spiritual understanding of the cancer survivors. It is to be argued here that Indian health practices are well-tuned with the spiritual beliefs of the people. For example, cancer is fatal that led to thinking patients that the disease was the consequences of prarabdh (fate). The experiences of cancer disease facilitated the survivors in rendering services to humanity.
These convictions were done to compensate the poor-utilizations the resources of healthy life by the patients.
These experiences were also a kind of optimism and desire to live. Here in India, people think that by promising good things in future to God or society may help relieve their current problems. Indian people assume medical practitioners as God and have a firm belief that they do everything for their good health. People generally do not complain to consumer courts for failed treatments or lapses on the part of practitioners due to this Spiritual Beliefs, Cancer, Chronic Disease, Thematic Analysis assumption. People also assume that disease may affect and kill their body which is only a physical aspect of their existence. It may not kill the self which remains away from the disease.
The self-perceptions and cognitions reflected in the spirituality of the survivors may have given birth to their self-motivation which, in turn, may have maintained their compliance with the medical advice. Anger in some themes shows a positive sign in the sense that puts challenges to face the ill situations created by disease and its symptoms as well as the perception of the overall state of the facts related to the disease. For Indians, the biggest goal of their life is to know thyself (atmanvid). The Moksha ( the very core of spirituality that helps to perceive negative outcomes caused by external forces and positive outcomes by internal forces (Cobb et al., 2012;Koenig, 2012).
The findings of the study also demonstrated that chronic health conditions induce a kind of spirit that supplies incessant positive energy to face the odds of life and converts adversities into opportunities. It has been argued that spirituality carries innate and dynamic energy that cultivate the active and positive role of the individuals in facing the challenges of life as these are studded with positive emotional outcomes (Snyder & Lopez, 2007). A good number of participants have expressed in their verbalizations that accepting the challenges of life in the face of adversity or pain improved their courage and vitality in life and increased positive faith in those around them. According to Roof (2001), spirituality represents four basic themes namely, a source of values and meaning or purpose beyond the self, understanding, inner awareness, and personal integration. It is the inner awareness and personal integration that may be assumed to needle the individuals to accept the challenges of life.
The findings of the present research have evinced that the cancer survivors exhibited enhanced trust in their family and friends. It can be argued that spirituality spontaneously fetches social supports which consolidated the hope of further survival and positive efforts carried out by others and relationships of both family and society. It is noteworthy that social supports are valuable sources of self-esteem, information and companionship that help cope with stress and negative life events (Cohen & Wills, 1985). It is also believed that social supports originating through spirituality are well engrained and long-lasting (Hill & Pargament, 2003).
It has also been observed in the verbalizations of the cancer survivors that their chronic health conditions reshape their self-perceptions in tune with the realities of life. Previous research portrays that inner awareness and personal integration are the basic ingredients of spirituality (Roof, 2001). Such changes have been ob-Sharma, Tiwari, & Rai served in the form of increased positive health practices such as yoga and meditation in the sample studied.
It has also been observed to increase alertness, self-confidence, and body care. These findings mirror the findings of the previous research that has suggested spirituality to facilitate the understanding of various dimensions of life such as health, illness, diagnosis, recovery, and loss (D'Souza, 2007).
Last but not the least, the findings of the study have exhibited that ill-health conditions also facilitate positive future orientations to compensate with their present infirmity. It resulted in the setting of people-oriented life goals to benefit humanity. This may be seen in many verbalizations where patients have expressed hope, optimism and positive behaviours. In this way, their thinking may be said to be future-oriented. Many earlier researchers have reported that spirituality represents positive values and meanings and is an ingredient of transformation that shape positive functioning and performance to consolidate human existence (Cobb et al., 2012;Koenig, 2012;Sheldrake, 2007;Snyder & Lopez, 2007). Previous researchers have also posited that spirituality fosters other similar outcomes like resilience, resources, sense of support (Eckersley, 2007), decision-making, self-care (Rumbold, 2007), expectations, relationships (Koslander & Arvidsson, 2007), health practices (Larson & Larson, 2003), and overall health outcomes (Koenig, 2007).
The findings of the present study borrow their support from the previous studies which have argued that certain expressions or elements of spirituality may positively affect various physiological mechanisms involved in health (Seybold & Hill, 2001). The positive emotions encouraged in many spiritual traditions, including hope, contentment, love and forgiveness, serve the individual by affecting the neural pathways connecting to endocrine and immune systems (Seybold & Hill, 2001). The negative emotions that are actively discouraged in many religions like anger or fear trigger the release of the neurotransmitter norepinephrine and the endocrine hormone cortisol which inhibit the immune system, increase the risk of infection, elevate blood pressure and increase the risk of stroke and cardiovascular disease. This malfunctioning at biological and psychological levels may have motivated the patients to carry out and instate their beliefs in positive behaviours. Moreover, the ill-conditions may have helped them with the enhanced social and medical support that benefitted them with increased spiritual beliefs in their real life. The sense of connectedness to other people and to oneself may be an important factor that underpins many expressions and outcomes of spirituality (Meis, 1991). In essence, the findings of the study indicated that spirituality and spiritual beliefs represent complex phenomena which carry benefits of both psychological and physiological nature. The spiritual beliefs benefitted the cancer survivors in many respects and helped them cope with negative feelings towards the self, others, and society, and enhanced their perceived efficacy of treatments and well-being. In other words, the spiritual beliefs helped the patients to face the anomalous situations caused by cancer, affecting their health and well-being in a positive manner. It also consolidated internal harmony in their personality functioning. This harmony may be observed in their enhanced understanding, hope, optimism, and positive changes in behaviours at all levels. In the light of the above arguments and findings of the previous studies, it can be concluded that spirituality has a synergic effect in facing the pain and adversities of life caused by cancer that may be observed in their positive changes at cognitive, affective and behavioural levels.

Conclusions
The findings of the study revealed that spiritual belief is an important phenomenon comprising cognitive, affective and behavioural components and carry many positive outcomes to regain and maintain psychological balance, well-being and quality of life, as well physical and mental health. The findings revealed five major Spiritual Beliefs, Cancer, Chronic Disease, Thematic Analysis themes regarding the spiritual beliefs of the cancer survivors. The themes denoted a set of changes at all levels in the behaviours and personality of the survivors. Explicitly, the cancer survivors demonstrated optimistic change towards life, fighting spirit towards life, enhanced trust in family and friends, improved realistic self-perception and positive thinking of future orientations.

Directions for Future Research
The scientific studies of spiritual beliefs are still in its infancy. There is ample scope for the future researchers to contribute to uncovering the basic nature, genesis, dynamics, relevant antecedents and correlates of spiritual beliefs of clinical and non-clinical populations. The spiritual belief represents a multifaceted construct and it is advised that future researchers may integrate other relevant variables such as perceived health (Sharma et al., 2017;Sharma, Tiwari, Rai, & Gour, 2018), self-forgiveness (Mudgal & Tiwari, 2015, positive body image (Jain & Tiwari, 2016a, 2016bTiwari, 2014;Tiwari & Kumar, 2015), self-concept (Gujare & Tiwari, 2016a, 2016b, emotional intelligence, (Tiwari, 2016a), yogic practices (Tiwari, 2016b), emotion regulation (Tiwari, 2015), self-compassion (Verma & Tiwari, 2017a, 2017b and, metacognition and locus of control (Jain, Tiwari, & Awasthi, 2017, 2018a, 2018b to develop better understanding of the dynamics of spiritual beliefs and their outcomes. Many avenues for applying new methods of data collection and analyses to understand the construct are also open for future researchers. The applications of qualitative methods, mixed methods and meditational analysis will help improve the understanding of spiritual beliefs. Cross-cultural verification of these findings also constitutes another scope for future researchers. Future researchers may come up with intervention plans involving spirituality.

Funding
The submitted research work belongs to the doctoral research of the first author with no external funding except UGC NON-NET scholarship awarded by Doctor Harisingh Gour Vishwavidyalaya, Sagar, 470003, Madhya Pradesh, India.