The Role of the Spiritual Meaning System in Coping with Cancer

Round 1

Reviewer 1 Report

See attached file.

Comments for author File: Comments.pdf

Author Response

Please see the attached file for our replies.

Author Response File: Author Response.pdf

Reviewer 2 Report

This is a very good article but I would like to raise a couple of questions and comments. 

I would suggest that a figure is included that visualises the meaning-making theory of Park (see her own graph in the 2005 publication the authors refer to; a helpful adaptation of this figure can be found in Park and Folkman's article "Meaning in the Context of Stress and Coping" in Review of General Psychology 1 (1997) 2, 115-144). This figure can then be expanded (possibly in a second figure) with the meaning systems the authors have identified. Visualisation of the typology and the meaning-making system will assist the reader in understanding the various types that are key to this article.  Can the authors 'unpack' their observation about difficulties in finding 'adurable answer', lines 220-222.  line 227-229. Is this observation necessarily and only related to an Enclosed Spirituality?  Section 3.1. Limitations raises two questions. First, line 415ff. Only the limitations of interviews are pointed out. However, surely interviews reveal as much as they conceal. The authors must have had good reasons to use interviews, so a more positive approach can be taken, or at least the reasons for interviewing should be stated just as their limitations. Second, line 430. The construction of knowledge through the interviews is framed as a limitation. That is quite questionable and depends on one's epistemology. In qualitative research it is commonplace to view all knowledge as constructed (see for example Kenneth Gergen, An Invitation to Social Construction (Sage, 2011). Therefore, this can hardly be said to be a limitation. Moreover, the authors relate this to storytelling as a coping strategy. That same strategy patients will have applied when telling their story to and with family members and friends. Again, seeing this as a limitation is a limited view on narrative research.  A question provoked by 440-447 but relevant to the whole article. Does the fourfold typology as used and identified by the authors sufficiently take into account that perhaps all patients struggle to give meaning to their cancer, regardless of their spiritual meaning system? Furthermore, whilst typologies can be helpful to get a grip on something, they are often - if not always - a reduction of the complexities, richness and nuances of life. I don't find that acknowledged in the article.  Related to the previous point, the authors show no interview abstracts or code book. This leaves the reader without the option to hear from the participants themselves or follow how the authors came to their categories or saw their typologies confirmed in the interviews. In other words, the readers see only the conclusions and results after analysis, but don't see how the authors arrived at these.  The word 'narrative' is used for the interviews. The interviews themselves (cf. section 4.3.) don't sound like they were narrative in nature. They could have been thematic interviews or something else just as well. Unless the authors can state clearer how the interviews themselves (specifically the questions asked) were narrative, this is a weakness in the research design. Narrative analysis presumes narrative data and therefore a narrative data collection method.  With regard to data analysis, line 602ff. raises the question whether the typology could be seen to emerge from the interview data or was rather imposed on the interviews (probably using the quantitative data obtained earlier). In the latter case, it again raises the question whether such a deductive imposition of categories (or typology) can do justice to the richness and nuances in the interview data itself. 

My critical notes notwithstanding, in my opinion this is overall a very good article and a solid piece of research. 

Author Response

Please see the attached file for our response.

Author Response File: Author Response.pdf

Reviewer 3 Report

Introduction. I have the feeling that there are some references missing (lines 26-31). Or provide one single definition, such as the one from EAPC SC Task Force.

Line 32 What are spiritual practices? Please provide a definition.

Page 2 Line 57-78 could you find some European studies? The spirituality and spiritual coping that has been described in European studies is rather different from North-American ones (look at Feresteh Ahmadi, Elisabeth Assing-Hvidt, Suvi Saarelainen, etc).

Page 2, line 90 what do you mean by symbolic language? Metaphors, poems, pictures – provide examples? How people express themselves  linguistically is an interesting aspect often overseen in qualitative Analysis.

Methods chapter is missing? Reference to the previous study is confusing. Please carefully restructure the entire paper. Describe your method of analysis so that it becomes a coherent paper.

Suddenly you have some quantitative data included. Why? Consider it for publishing somewhere else.

Provide examples from your data that support your argumentation.

The literature used in this paper is not up to date.

Embed the entire paper into European context. It has been established as different from North-American.

Author Response

Please see the attached file for our response.

Author Response File: Author Response.pdf

Reviewer 4 Report

This is a very interesting study on spirituality in the context of meaning making among people with cancer. The study presents some novel findings regarding the impact of a person’s meaning system on their adjustment and coping with cancer. It was very interesting to see that some participants regarded the cancer experience as something they wanted to forget about as soon as possible, while others considered it a valuable learning experience and others again were quite apathetic towards the experience. The study findings are important for healthcare professionals working with people with cancer. The paper is generally well-written. However, some sections could be sharper and more concise. The following suggestions should help the authors revise the manuscript.  

Introduction Section

Page 2, Line 57-78: I would recommend that the studies are presented in chronological order beginning with the oldest. This would better show the evolution of knowledge on the topic over time. Furthermore, I would encourage the authors to search for more up-to-date literature as 2 of the 3 studies mentioned are over 15 years old.  

Materials and Methods Section

I would recommend moving the Materials and Methods section to before the Results section. Otherwise, it is quite confusing for the reader. 

I note that the authors referred to a prior paper for further details of the methods. Considering this, perhaps the materials and methods section could be shorter and more concise in this paper.

Please include a statement in the statistical analysis paragraph verifying that this analysis was done only for the 20 interview participants.

Regarding ethical considerations, the authors should include a statement confirming that the original participant consent did not prohibit the use of the data almost 10 years after collection.

Results Section

Section 2.1 discusses roles and outcomes addressing research question 1 and 2. The opening paragraph clearly differentiates between the roles and outcomes; however, this is not reflected in the presentation or numbering of the subheadings thereafter. Please consider restructuring this section to clearly differentiate between the three roles and the two outcomes. It might just be a matter of renumbering the subheadings.

Lines 190-192: paragraph is unclear. Please emphasize where you are referring to a study theme i.e. ‘discrepancies’.

Discussion Section

This section is very detailed. However, it could be more concise and less repetitive of results.

Inclusion of a figure or diagrammatical overview of the main themes and sub-themes would complement the results and discussion section. Furthermore, it would help the reader to clearly understand the findings that emerged.  

Minor text/grammar amendments:

Page 1, Line 25: Replace the word ‘here’ with ‘In this study’.

Page 2, Line 85: change to ‘However, in the Netherlands, only 12% of the population reported regularly visiting a religious service in 2015’.

Page 3, Line 127: ‘In the interviews people talked about how being diagnosed with cancer…’ (Remove ‘the event of’).

Page 3, Line 139: ‘…the participants used expressions such as…’

Page 5, Line 231: ‘…of the illness. Participants described…’ (Remove ‘The’).

Page 5, Line 241: ‘…is underpinning this process…’

Page 7, Line 332-333: similar to lines 190-192, paragraph is unclear here. Please emphasize where you are referring to a study theme i.e. ‘discrepancies’.

Page 10, Line 485: Please use past tense i.e. The present study involved.

Page 10, Line 486: ‘…as part of an overarching longitudinal project investigating the relationship…’

Page 11, Line 490: ‘…participants were recruited for the project…’ (remove 'overarching')

Page 11, Line 520: ‘…highest or lowest…’

Page 11, Line 523: ‘Eligible participants were telephoned by the interviewer to verify permission…’

Page 11, Line 527: ‘…selection of new participants ceased’.

Page 13, Line 592: Referencing error noted here.

Tables

Demographics table on page 11 appears to have been placed awkwardly among the main text (probably in error). This upsets the reading flow of the text. Also, there seems to be no reference to this table in the text. Furthermore, some of the details in the table were missing i.e. only information on gender and mean age was observed on page 11 with more details on page 12.

The quantitative analysis table (table 1) is also disjointed within the text. Perhaps, these should be presented separately to the main document or on a new page within the main document.

The table numbering needs to correspond with when the tables appear in the text so this will need to be updated when the Materials and Methods section is moved up.

Author Response

Please see the attached file for our response.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Dear authors,

Thank you for your kind efforts in revising your paper. I still have three major concerns that in my opinion would improve the article overall:

Please consider dropping the quantitative part, albeit interesting the sample is clearly too small for any statistical analysis. The qualitative part is plenty and as such interesting for readers. 

In the discussion you mention just one reference. Please, DISCUSS how the findings are similar to the findings presented in the introduction. You call the European view the novel part of this paper. Elaborate on this to make it more vivid based on available literature.

Please revise the abstract so that it includes the methods of data collection and analysis.

Thank you!

Author Response

We are grateful to the reviewer for their recommendations to further improve our paper. Please find our responses below.

 

Please consider dropping the quantitative part. 
Because the reviewer insists on this point, we have now removed the quantitative part. However, because we do think it is important to verify alternative explanations for the qualitative findings when possible, we have retained a small paragraph on this in the limitations section.

 

Please, DISCUSS how the findings are similar to the findings presented in the introduction.

We have now done so.

 

You call the European view the novel part of this paper. Elaborate on this to make it more vivid based on available literature.

We have now done so.

 

Please revise the abstract so that it includes the methods of data collection and analysis.

The methods of data collection were already included, but we have now also included a description of the analysis. Because of word-count this has led to a rephrasing of the results.