Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: http://www.tandfonline.com/loi/udst20

Association of sense of coherence and

supernatural beliefs with death anxiety and death
depression among Romanian cancer patients

Roxana Postolică, Violeta Enea, Ion Dafinoiu, Iuliana Petrov & Doina Azoicăi

To cite this article: Roxana Postolică, Violeta Enea, Ion Dafinoiu, Iuliana Petrov & Doina
Azoicăi (2018): Association of sense of coherence and supernatural beliefs with death
anxiety and death depression among Romanian cancer patients, Death Studies, DOI:
10.1080/07481187.2018.1430083

To link to this article: https://doi.org/10.1080/07481187.2018.1430083

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DEATH STUDIES
https://doi.org/10.1080/07481187.2018.1430083

none defined

Association of sense of coherence and supernatural beliefs with death

anxiety and death depression among Romanian cancer patients
Roxana Postolicăa,b, Violeta Eneac , Ion Dafinoiuc, Iuliana Petrovc, and Doina Azoicăib
a
Regional Institute of Oncology, Iasi, Romania; bFaculty of Medicine, Department of Oncogenetics, “Grigore T. Popa” University of Medicine
and Pharmacy of Iasi, Iasi, Romania; cFaculty of Psychology and Education Sciences, Department of Psychology, “Alexandru Ioan Cuza”
University of Iasi, Iasi, Romania

ABSTRACT
The aim of this cross-sectional study was to examine the association of supernatural beliefs and
sense of coherence with death anxiety and death depression in a Romanian sample of cancer
patients. We found support for the terror management theory worldview defence hypothesis
postulating the presence of a curvilinear relation between death anxiety and supernatural beliefs
among cancer patients. Results conformed to an inverted U-shape quadratic regression, indicating
that cancer patients who scored moderately on supernatural beliefs were afraid of death the most,
while death anxiety was lowest for the extreme atheists and extreme believers in supernatural
entities.

Introduction beliefs and SOC might be important resources of

In 2013 Global Burden of Cancer estimated that there
were 14.9 million new cases of cancer in the world
and were around 8.2 million of deaths caused by cancer
(Fitzmaurice et al., 2015). According to the survey, one
in three men and one in five women will have cancer
during their lifetime. For many people, the diagnosis
of “cancer” means a death sentence because of the
uncontrolled cell multiplication that destroys the body,
leading to a slow and painful death (Moorey, Greer, &
Greer, 2002), although the cancer is a curable disease
at an early stage. Different cultures relate differently to
the notion of death (Neimeyer, 1997), but the conscious
awareness of our own mortality generates death anxiety
(Solomon, Greenberg, & Pyszczynski, 2000) and
depression (Rodgers, Martin, Morse, Kendell, & Verrill,
2005), regardless of cultural background or religious
beliefs. Death anxiety is a basic fear, which appears to
be a significant theoretically and clinically issue, under-
lying many mental disorders (Iveracy & Menzies, 2014).
Nonetheless, research on death anxiety and death
depression in advanced cancer has been scarce and
inconclusive in comparison to depression, despite the
potential for death anxiety to be more common (Krause,
Rydall, Hales, Rodin, & Lo, 2015). A recent study found
a significant negative association between religious
beliefs and sense of coherence (SOC) with depressive
symptoms (Anyfantakis et al., 2015), therefore religious
resilience. The objective of this research was to advance
a better understanding of the relationship between
supernatural beliefs and SOC with death anxiety and
death depression by studying a Romanian sample of
cancer patients.
Supernatural beliefs and religiosity in cancer
patients
Supernatural phenomena, such as superstitions and
belief in life after death or belief in angels and demons
are included in the paranormal beliefs domain (Irwin,
1993), which is one of the four domains of religiosity.
According to Irwin (1993), religiosity is defined as
the role and importance of religion in one’s life
and encompasses spirituality, intrinsic religiosity,
religious fundamentalism, and paranormal beliefs.
Klonoff and Landrine (1994) examined the common-
sense beliefs about the causes of six illnesses and
found that women were more likely than men to view
illness caused by sins, especially sex, as a form of
punishment. Cancer patients with low social support
perceived the consequences of their illness in a severe
manner and believed in supernatural control of their
illness compared with patients with high social sup-
port, which believed in self and doctors (Awasthi &
Mishra, 2010).

CONTACT Violeta Enea violeta.enea@uaic.ro Faculty of Psychology and Education Sciences, Department of Psychology, “Alexandru Ioan Cuza”
University of Iasi, 3 Toma Cozma Street, Iasi, România.
© 2018 Taylor & Francis
2 R. POSTOLICĂ ET AL.
Despite the fact religious beliefs has been shown to be
an important resource for people to find meaning in life
(Pevey, Jones, & Yarber, 2008–2009), the research
studying Christian samples on the relationship of
religious variables with death anxiety and death
depression reported inconsistent data. Some studies
indicated that in healthy individuals lower death
depression and death anxiety scores were associated
with belief in God and greater belief in afterlife
(Alvarado, Templer, Bresler, & Thomas‐Dobson, 1995;
Cohen et al., 2005; Harding, Flannelly, Weaver, and
Costa, 2005), while others reported a positive associ-
ation between death anxiety and literal interpretations
of Christian faith (Dezutter, Luyckx, & Hutsebaut,
2009). In cancer patients, death anxiety was correlated
with beliefs in afterlife due to the unknown nature of life
after death which brings uncertainty and insecurity
(Gonen et al., 2012). Although women generally are
more religious than men (Levin & Taylor, 1993),
changes in religiosity are not influenced by gender in
cancer patients (McFarland, Pudrovska, Schieman,
Ellison, & Bierman, 2013). With reference to the coping
strategies used by cancer patients, Zaza, Sellick, and
Hillier (2005) argued that of all the coping strategies
assessed, prayer was the most used strategy. In the same
direction, Bowie, Sydnor, Granot, & Pargament (2004)
explored the influence of religion and spirituality on
coping among patients that suffered from prostate can-
cer. Results indicated that a majority of participants
reported a high degree of religiosity, measured by
denominational affiliation and church attendance.
According to Weaver and Flannelly (2004), cancer
patients who rely on spiritual and religious beliefs to
cope with their illness were more likely to use an active
coping style in which they accept their illness and try to
deal with it in a positive and meaningful way.
In the present study, we used The Supernatural Belief
Scale (Jong, Bluemke, & Halberstadt, 2013), which was
designed to measure respondents ‘tendencies to believe
in existentially significant supernatural entities and
events, like God, Devil, angels, demons, heaven, hell,
miracles and prophecy. Jong et al. (2013), using this
scale, examined the relation between death anxiety
and religious belief and they found a positive association
for atheist and agnostic participants and a negative one
for religious participants.
Death anxiety, religiosity, and terror
management theory
The greatest challenge for cancer patients is the fear of
death and dying (Adelbratt & Strang, 2000). The terms
fear and anxiety overlap, but also differ, according to
DSM-5 (APA, 2013): fear is the emotional response to
real or perceived imminent threat associated with the
autonomic arousal necessary for fight or flight, while
anxiety is anticipation of future threat. “Fear of death”
refers to the concrete belief that death is frightening
(Lehto & Stein, 2009), while the concept of “death anxi-
ety” is so complex that there is currently no consensus
in the scientific literature on the definition of it
(Nyatanga & de Vocht, 2006). Thus, death anxiety refers
to negative emotional reactions provoked by the antici-
pation of a state in which the self does not exist (Tomer
& Eliason, 1996) and describes an emotional state of
death awareness that deals with the fear of the end of life
and with the fear of the unknown afterlife (Cicirelli,
2006). Death anxiety is a multidimensional concept
and, according to Conte, Weiner, & Plutchik, 1982, it
yielded four factors: fear of the unknown, fear of suffer-
ing, fear of loneliness, and fear of personal extinction.
Although a considerable amount of literature has been
published on death anxiety in healthy individuals, little
attention has been paid to death anxiety and death
depression in cancer patients. Death depression is asso-
ciated with the death of significant others, depression
about impending death, experiencing distress, and death
in general (Templer et al., 2001), while death anxiety is
related to somatic distress, general anxiety, global
psychological distress, and depression (Cella & Tross,
1987; Sherman, Norman, & McSherry, 2010). According
to Templer et al. (2001) death depression comprises
four dimensions: death sadness, anergia, existential
vacuum (a sense of meaninglessness of life), and
anhedonia.
The link between death anxiety and cancer or other
chronic diseases was investigated but the existing
empirical findings are contradictory. While Robinson
and Wood (1983) found no association between death
anxiety and chronic diseases such as cancer or diabetes
mellitus, Strömberg and Jaarsma (2008) argued that
patients with chronic diseases have more death anxiety
than healthy controls. Death anxiety is considered to
have an important role in the development, mainte-
nance and course of many psychological disorders
(Furer, Walker, & Stein, 2007). The assessment of death
anxiety among cancer patients may help to individualize
the support programs for these patients because the
level of death anxiety may be different based on varying
patient population (Sherman et al., 2010). In a cross-
sectional study, Neel, Lo, Rydall, Hales, and Rodin
(2015) found that thirty-two per cent of the 60
Canadian outpatients with different types of metastatic
cancer reported death anxiety of at least moderate sever-
ity. They found that death anxiety in advanced cancer
patients is positively associated with physical symptom

burden and having children under 18 years of age. In a
Chinese sample of cancer patients, Ho and Shiu (1995)
showed that significantly more patients had either
very high or very low death anxiety levels as compared
to the control group. Tang, Chiou, Lin, Wang, and
Liand (2011) examined the factors that influenced the
degree of death anxiety among Taiwanese cancer
patients. Results showed that when level of fear of dis-
ease relapse, sense of purpose in life, and gender were
significant predictors of level of death anxiety among
cancer patients. Other predictors of death anxiety
included general health, experiences of death and dying,
religious aspects, unresolved psychological and physical
distress, psychopathology and family circumstances
(Daradkeh & Moselhy, 2011; Gonen et al., 2012;
Neel et al., 2015).
The relationship between death anxiety and religion
has been intensely investigated in many empirical
studies trying to answer the question whether religious
people fear death more or less than those who are
nonreligious. This was studied in healthy individuals
but it was not explored in cancer patients. Terror
management theory (TMT; Greenberg, Pyszczynski, &
Solomon, 1986) is the most influential theoretical
approach about how people psychologically deal with
death. This theory asserts that the awareness of death
coupled with the motivation to stay alive engender
paralyzing fear of death which may be buffered by the
cultural worldviews and self-esteem (Hayes, Schimel,
Arndt, & Faucher, 2010). Believing in an afterlife may
suppress death anxiety by providing a sense of meaning,
permanence and order through the connection of the
individual to mainstream cultural standards and values
(Greenberg, 2012). According to Jong et al. (2017),
TMT predicts a curvilinear (an inverted-U curve)
relationship between death anxiety and religious belief
in healthy individuals: very religious and non-religious
individuals experience reduced levels of anxiety and
individuals who are moderately religious fear death
the most. A recent meta-analysis found support for an
inverted-U pattern in 10 of the 11 studies that directly
tested for a curvilinear relationship between death anxi-
ety and religiosity (Jong et al., 2017).
Sense of coherence in cancer patients
The model of salutogenesis (Antonovsky, 1987), in con-
trast to the pathogenic model, has the goal of drawing
people’s attention on the sources of health and healing
individuals. It explores the reasons why some people
remain healthy when facing stressful situations, while
others confronting with the same difficulties, get sick
(Lindström & Eriksson, 2006). The cancer diagnosis
DEATH STUDIES 3
generates a sense of threat to life, with a variety of
related existential challenges (Kissane, Lethborg, &
Kelly, 2012). Moreover, death anxiety, difficulties of
coping with uncertainty, loss of meaning and purpose,
loss of control, a heightened sense of loneliness and fear
of uncertainty of the future can appear among these
patients (Kissane et al., 2006, 2012). Resilience in diffi-
cult situations depends on the individual’s SOC, which
is a global orientation to life based on self-confidence
regarding challenges, confidence in personals skills
and resources in order to cope with difficult events,
and the belief that negative events may have a meaning
or a sense in the person’s life (Alivia, Guadagni, &
di Sarsina, 2011; Antonovsky, 1987). Although Anto-
novsky had not developed the salutogenic model by
studying patients with cancer, the recent research indi-
cated a strong negative association between stress and
SOC, especially between SOC, depression and anxiety
in these patients (Coyne, Tennen, & Ranchor, 2010;
Flensborg-Madsen, Ventegodt, & Merrick, 2005;
Olsson, Gassne, & Hansson, 2009).
Previous studies which focused on patients with
cancer and chronic diseases demonstrated that SOC
did not depend on sex, race, or education (Bruscia
et al., 2008; Pudrovska, 2010). Further, it was a
mediator of health-related quality of life dimensions
(Rohani et al., 2015) and a low SOC was independently
a predictor for depression and quality of life in the case
of patients diagnosed with colorectal cancer (Hyphan-
tis et al., 2011). A qualitative study conducted on
women who were at risk for hereditary cancer of breast
or ovarian cancer concluded that understanding their
stories of life, especially the “mother’s death” due to
ovarian cancer and the finding of coherence contribu-
ted to the adoption of salutogenetic behaviors in order
to prevent cancer in their future families (Mæland,
Eriksen, & Synnes, 2014). Recently, Rohani et al.
(2015) found that spirituality and religious coping
are less important as a predictor for health-related
quality of life changes in breast cancer patients than
the degree of SOC.
Overview of this study
The concept of death anxiety has received increasing
attention in the scientific literature in healthy indivi-
duals from different cultures (Darban et al., 2016;
MacLeod, Crandall, Wilson, & Austin, 2016; Ron,
2016). This subject has been studied only in Romanian
inmates with nonsuicidal self-injury behavior (Enea,
Dafinoiu, Bogdan, & Matei, 2017). The health care
system is underfinanced in Romania and cancer patients
do not receive the best available standard treatments for
4 R. POSTOLICĂ ET AL.
their illness. Therefore, the ratios between cancer
incidence and mortality rates are higher in Romania
than those in EU, and even worldwide (Straja, Panait,
Busca, & Cinca, 2015). In addition, Pickel (2009) ana-
lyzed data from several waves of the World Values
Survey and found that Romania is one of the most
religious nations in Europe. The average Romanian
adult attends Christian church 17 times a year, 93% of
the participants characterized as religious persons and
97% declared that they believe in God. The experience
of death anxiety might be influenced by the cultural
religious orientations and the death terror could be
modified by cultural beliefs and values, as it was
examined by the TMT (Pyszczynski et al., 2004).
In this study, we had two major aims. Our first aim
was to examine the association of supernatural beliefs
and SOC with death anxiety and death depression
among cancer patients. We tested whether the saluto-
genic model, TMT and religious beliefs might be
embedded in the domain of oncology because the
cancer diagnosis is life-changing and can easily trigger
mortality salience, also known as the awareness of one’s
eventual death. Studies conducted on the impact of
mortality salience found that it constitutes a unique
psychological threat with a great impact on anxious
responding and behavior (Hayes et al., 2010). According
to the dual process model of TMT, when death-related
thoughts come into conscious awareness, proximal
defenses are triggered in order to maintain optimum
physical health for self (Pyszczynski et al., 1999). In
alignment with spiritual beliefs, SOC was considered
one of the generalized resistance forces that neutralize
stressors (Antonovsky, 1987; Anyfantakis et al., 2015;
Siglen et al., 2007). Recently, Anyfantakis et al. (2015)
examined the effect of SOC and religiosity/spirituality
on depression within a rural population in Greece.
Results indicated a significant negative association
between SOC and religious beliefs with depressive
symptoms, enhancing the presupposition that these
two variables may buffer the negative effects of stress
on human health. Some empirical research examining
relationship between death anxiety and religiosity found
support for the curvilinearity hypothesis (Downey,
1984; Jong et al., 2013; Wink & Scott, 2005), while
others found a negative correlation, a positive associ-
ation or no significant relationship, depending on the
aspect of religiosity being assessed (Ellis & Wahab,
2012). The present study is the first to examine the
relations between death anxiety/death depression,
supernatural beliefs and SOC in cancer patients.
Second, given the Romanian cultural peculiarities on
religiosity and the situation of the health care system, we
aimed to explore the level of death anxiety and
supernatural beliefs among Romanian cancer patients.
Specifically, we hypothesized that: (1) the level of death
anxiety among cancer patients will be above the average
score for healthy individuals, (2) the participants will
indicate confident belief in supernatural entities, (3)
SOC will be negatively related to death anxiety and
death depression. (4) according to thanatocentric the-
ories of religion there will be a curvilinear relationship
between supernatural beliefs and death anxiety/death
depression. Death anxiety will be highest among cancer
patients who are moderately believers in supernatural
entities, while atheists and extreme believers in super-
natural entities will have lower level of it.
Method
Participants
The current research was conducted in the Regional
Institute of Oncology and the participants were inpati-
ents at this hospital. The exclusion criteria were:
(1) being younger than age 18 or older than 70;
(2) having significant intellectual disability; (3) having
any disease that significantly impairs cognition such as
delirium, dementia, or a neurological illness. Of the
123 patients with a cancer diagnosis eligible for partici-
pation, 10 women and 17 men declined to take part in
the study. Participants (n ¼ 96) ranged in age from 26 to
70 years (M ¼ 52.70); 50% men; the majority of patients
were married (82.2%) and 87.5% had children. Of the
sample, 66.7% were under treatment and 31.3% had
received combinations of chemotherapy and radiation
therapy as treatments post-surgery. In addition, 63.5%
of the patients had no history of familial cancer. In
terms of religion, 91.7% were Christian, and 8.3% were
other religion. The complete socio demographic data,
clinical features, and religious characteristics of the
study sample are presented in Table 1.
Procedure
The study protocol received the Ethics Committee of
the Faculty of Psychology and Education Sciences and
Regional Institute of Oncology approval before
initiation. Participants signed informed consent forms
after they were explained the objectives of the study
and were instructed that they can choose to withdraw
from the study at any time. Questionnaires were admi-
nistered by the psychologist of the hospital and took
approximately 30 min to complete. Following the com-
pletion of the study materials, participants were fully
debriefed in order to eliminate any negative feelings
triggered by remembering death.
 DEATH STUDIES 5

Table 1. Sociodemographic, clinical and religious characteristics Respondents indicate their agreement or disagreement
of the study sample. with each proposition on a 9-point Likert scale,
Characteristics (N ¼ 96) % anchored at −4 (Strongly Disagree) and 4 (Strongly
Age
Mean 52.70
Agree). For this study the Cronbach’s α ¼ .83.
Range 26–71
SD 11.28 Sense of coherence-13
Gender
Male 48 50 (Antonovsky, 1987) is a 13-item short version that
Female 48 50 reflects the ability to cope with stress. It consists of
Marital status
Single 6 6.3 four meaningfulness items (e.g., “How often do you
Married 79 82.2 have the feeling that there’s little meaning in the
Separate/divorced 6 6.3
Widowed 5 5.2 things you do in your daily life”), five comprehensi-
Children bility items (e.g., “Do you have the feeling that you
Yes 84 87.5
No 12 12.5
are in an unfamiliar situation and don’t know what
Education to do?”), and four manageability items (e.g., “How
Primary school 17 17.7 often do you have feelings that you’re not sure you
Middle School 35 36.4
Secondary school 21 21.9 can keep under control?”). Meaningfulness describes
Degree 23 24 the ability to give emotional meaning to the situation,
Religion affiliation
Catholic 14 14.6 comprehensibility describes the ability to give a
Orthodox 74 77.1 cognitive meaning to stimulus, and manageability
Another 8 8.3
Stage of illness means how capable people are and what resources
Complete Remission 15 15.6 they have to cope with a difficult situation. All items
Under treatment 64 66.7
Monitorization after treatment 17 17.7
were answered on a 7-point Likert scale, in which the
Type of treatment response options range from, (1) very seldom or never
SU 2 2.1 to (7) very often. The total score is from 13 to 91. The
CHT 11 11.5
RT 5 5.2 scale test–retest reliability ranges .69 to .72 (Eriksson
SU þ CHT 24 25 & Lindstrom, 2005). For this study the Cronbach’s
CHT þ RT 19 19.8
SU þ CHT þ RT 30 31.3 α ¼ .82.
SU þ CHT þ HT 1 1
SU þ CHT þ RT þ HT 1 1
History of familial cancer Death anxiety questionnaire
Yes 35 36.5 (DAQ, Conte et al., 1982) is a 15-item scale, with four
No 61 63.5
Psychiatric treatment
independent dimensions of death anxiety: fear of the
Anxiolytics 38 39.5 unknown (“Are you worried about not knowing what
Anxiolytics and antidepressants 11 11.5 to expect after death?”) (α ¼ .84); fear of suffering
Without treatment 47 49
Cancer type (“Do you worry that dying may be very painful?”)
Gynaecological 21 21.9 (α ¼ .45); fear of loneliness (“Do you worry that you
Breast 15 15.6
Colon 20 20.8 may be alone when you are dying?”) (α ¼ .87) and fear
Head and neck 13 13.5 of personal extinction (“Do you worry that those you
Other 31 28.2
care about may not remember you after your death?”)
CHT, chemotherapy; HT, hormone therapy; RT, radiation therapy; SU,
surgery. (α ¼ .44). The response set for each question contains
three options; not at all, somewhat, or very much (scored
0, 1, or 2). Internal consistency of the DAQ was .83 and
test-retest reliability was .87 (Conte et al., 1982). For this
Measures
study, the Cronbach’s α ¼ .75.
Supernatural belief scale
(SBS, Jong et al., 2013) is an essentially unidimensional Death depression scale-revised
measure designed and validated to measure individuals’ (DDS-R; Templer et al., 2001) is a self-report question-
tendencies to believe in supernatural agents, entities, naire with a 21-item scale designed to measure
and events. 10 commonly recurring types of supernatu- depression about impending death or death in general.
ral concepts were selected, from which 10 statements Items are scored from 1 (strongly disagree) to 5
were composed, each affirming belief in their actual (strongly agree). It has four factors: death sadness
existence or occurrence (“There exists an all- powerful, (“Thinking about death makes me tearful.”) (α ¼ 0.77),
all-knowing, loving God.”, “There exists an evil personal anergia (“The thought of death saps my energy.”)
spiritual being, whom we might call the Devil”). (α ¼ 0.83), existential vacuum (α ¼ 0.63) (“Death makes
6 R. POSTOLICĂ ET AL.
me feel discouraged about the future.”), and anhedonia
(“The thought of death makes it difficult to experience
pleasure.”) (α ¼ 0.75). For this study, the Cronbach’s
α ¼ .86.
A Demographic questionnaire covered age, gender,
education, family status, having children and religious
affiliation. Age was categorised into two groups
(0: 26–50 years and 1: 51–71 years), also gender
(0: male, 1: female), family status (0: not married,
widowed, divorced; 1: married), religion (0: Christian,
1: other religion), and having children variable (0: yes;
1: no). Education was categorized into four levels
ranging from primary school to postgraduate degree.
The following information covering the cancer
variables was collected from participants’ medical
charts: cancer type, stage of illness, type of treatment,
psychiatric treatment, and history of familial cancer
(Table 1).
Results
Descriptive statistics and intercorrelations
The Shapiro–Wilk test was used to determine whether
the variables had normal distributions. As the distri-
bution for DAQ and SOC scores did not meet the stan-
dard for normality (p > .05), they were transformed
using a two-step approach: (1) they were transformed
into a percentile rank and (2) submitted to an inverse
normal transformation using the mean and the standard
deviation (see Templeton, 2011). The descriptive stat-
istics for the DAQ scale, with a scoring range of 0–30,
showed a minimum score of 2 and a maximum score
of 25 with a mean of 15.95. The average score of
DAQ scale for most people, regardless of age, is 8.5,
according to Conte et al. (1982). Of the 96 participants,
89.6% scored above 8.5 and 10.4% scored lower than 8.5
in this sample. As we expected, a great proportion of the
participants (72. 9%) indicated confident and moder-
ately belief in supranatural entities, only 19.8% reported
agnosticism and 7.3% reported extreme disbelief or
atheism.
No correlations for the relations among the variables
exceeded .80, satisfying the assumptions of multicolli-
nearity (Field, 2013). The correlations support our
hypothesis concerning the relation of SOC variable with
death anxiety and death depression outcomes partially.
Specifically, SOC scores were negatively related to
DDS-R scores (r ¼ −.27, p < .007), indicating that can-
cer patients who reported higher levels of SOC also
reported lower levels of death depression. Contrary to
expectations, there was no relationship between SOC
and death anxiety. Also, supernatural beliefs was not
linear correlated with death anxiety/death depression
variables (ps > .05).
Demographic relationships
Correlational analyses of the demographic variables
revealed that patient age was significantly related
to DAQ scores (r ¼ −.31, p < .002), DDS-R scores
(r ¼ −.28, p < .006) and SOC scores (r ¼ .31, p < .002).
The younger cancer patients had higher death anxiety
and death depression, but lesser internal resources. In
addition, gender was significantly associated with DDS-R
scores (r ¼ .28, p < .005), female respondents showed
more death depression. The cancer type was correlated
with SOC scores (r ¼ .23, p < .02) and DDS-R scores
(r ¼ −.23, p < .02), and also there was a significant nega-
tive correlation between history of familial cancer and
SOC scores (r ¼ −.22, p < .02), indicating that patients
without a history of familial cancer had a higher level
of SOC. Cancer patients who have children reported
stronger supernatural beliefs (r ¼ .25, p < .013).
Curvilinear relationship
To investigate the curvilinear relationship between
supernatural beliefs and death anxiety/death depression
in cancer patients, we applied curve estimations to the
data. If the correlation would conform to an inverted
U-shape quadratic regression line rather than a linear
regression line, moderately religious cancer patients will
be more fearful than either those who are atheists or
very confident believers in supernatural entities. First,
we analyzed the relationship between supernatural
beliefs and death anxiety and found that the F- score
for the quadratic equation R2 ¼ .11, F (2,92) ¼ 5.71,
β1 ¼ 1.27, β2 ¼ −.41, p < .005 was significantly and
considerably greater and than was the F- score for the
linear equation R2 ¼ .01, F (1, 93) ¼ 1.83, β1 ¼ .42,
p ¼ .17. The β2 value was negative, indicating that the
shape of the quadratic curve conformed to an inverted
U- shape. The graph shows that death anxiety is lowest
for the extreme atheists and extreme believers in super-
natural entities, while agnostic and cancer patients who
scored moderately on supernatural beliefs were afraid of
death the most (Figure 1).
Second, we analyzed the relationship between
supernatural beliefs and death depression and found a
similar tendency with negative β2 value indicating that
the shape of the quadratic curve conformed to an
inverted U- shape pattern. The F- score for the quad-
ratic equations R2 ¼ .08, F (2,93) ¼ 4.37, β1 ¼ 1.17,
β2 ¼ −.86, p < .015 was significantly and considerably
greater than was the F- score for the linear equation
 DEATH STUDIES 7

Figure 1. Predicted values of death anxiety by supernatural beliefs among cancer patients. A strong agreement (þ4) indicates
confident belief, the midpoint indicates agnosticism and a strong disagreement (−4) implies atheism.

R2 ¼ .008, F (1, 94) ¼ .77, β1 ¼ −.63, p ¼ .38. The graph moderately supernatural believers had greater death
shows that while death depression is lowest for cancer depression than very confident believers in supernatural
patients who are atheists, agnostic cancer patients and entities (Figure 2).

Figure 2. Predicted values of death depression by supernatural beliefs among cancer patients. A strong agreement (þ4) indicates
confident belief, the midpoint indicates agnosticism and a strong disagreement (−4) implies atheism.
8 R. POSTOLICĂ ET AL.

Discussion confident and moderately belief in supranatural entities,

only 19.8% reported agnosticism and 7.3% reported
This cross-sectional study had two aims: (a) to examine
extreme disbelief or atheism. Because no other study
the association of supernatural beliefs and SOC with
explored the relationship between SBS and death
death anxiety and death depression among cancer
anxiety in cancer patients, we cannot compare our
patients and (b) to explore the level of death anxiety
results with other empirical findings. More research is
and supernatural beliefs among Romanian cancer
needed to better understand how cancer diagnosis
patients. An important main finding of this study is that
changes the relation of people with God and their
we found support for the TMT worldview defence
religious belief.
hypothesis postulating the presence of a curvilinear
The results showed that younger cancer patients
relation between death anxiety and supernatural beliefs.
reported higher death anxiety and death depression
These results are in line with Jong et al. (2013) and Jong
than older cancer patients. These findings contradicted
et al. (2017), who found that death anxiety is lowest
the recent data which showed a positive association of
among atheists and very religious healthy individuals,
age with death anxiety in advanced cancer patients from
and highest among moderately religious healthy indivi-
Canada (Neel et al., 2015), but they were in accordance
duals. The present findings extend these previous results
with other previous studies (e.g., Feroz & Beg, 1987;
from the healthy individuals’ belief in supernatural con-
Thorson & Powell, 2000). The ages of the participants
cepts to cancer patients. Previous studies found that
in the current study ranged from 26 years to 71 years
SOC variable was negatively related with depressive
and they were broken down into two equal groups to
symptoms (Anyfantakis et al., 2015) and we made a
enable a comparison to be made. The first group
similar hypothesis for the relationship between SOC
consists of participants who are in young adulthood
and death anxiety/death depression. Our results showed
(from 26 years old to 50 years old) while the second
that SOC was negatively associated to death depression,
group of participants includes individuals who are in
but contrary to our hypothesis, it was not correlated
mid-adulthood and above (from 51 years old to 71 years
with death anxiety. This finding may be due to the
old) (Corr, Nabe, & Corr, 2003). Studies have generally
stronger association between SOC and depression than
found mixed results regarding the relationship between
between SOC and anxiety (Siglen et al., 2007). Previous
age and death anxiety. Some of them showed that age
research has demonstrated that a higher SOC is associa-
was not linked to death anxiety (Chuin & Choo, 2010;
ted with a lower stress and less depressive symptoms in
Feifel & Nagy, 1981) while others found that older part-
cancer patients (Coyne et al., 2010; Greimel, Lahousen,
icipants (55–70 years old) had greater rates of death
Dorfer, Lambauer, & Lang, 2011; Poppius, Virkkunen,
anxiety because they might think about their mortality
Hakama, & Tenkanen, 2006). Our results confirmed
more often being nearer to death (Suhail & Akram,
these findings and cancer patients who reported higher
2002). Conversely, this explanation might be a reason
levels of SOC, also reported lower levels of death
for lower death anxiety in older cancer patients from
depression. Moreover, the younger cancer patients have
our study because there are differences between young
higher death anxiety and death depression, but lesser
and old cancer patients in death acceptance (Pinquart,
internal resources. One possible explanation is that the
Frohlich, Silbereisen, & Wedding, 2006). Therefore,
SOC forms at the age of about 30 years and under the
older patients already used to think about death because
impact of strong emotional trials the level of SOC can
they have lived most of their lives, but younger patients
change (Antonovsky, 1987). Younger cancer patients
were unprepared to confront death and the unexpected
have a lower level of SOC, indicating that they are not
diagnosis of cancer increased their death anxiety and
able to take care of themselves and reflecting the inad-
death depression. Future research needs to examine
equacy of their coping mechanisms with the disease,
the differences between young and old cancer patients
which was found to be the most consistently related
regarding their perspective on death in more detail.
variable with death anxieties (Sigal et al., 2007). These
The results highlight the importance of other demo-
results suggest that the younger cancer patients are the
graphic and cancer variables (gender, having children,
most vulnerable category for which dealing with death
cancer type) which was also found to be associated with
anxiety and death depression should be one of the
death anxiety in another recent study (Neel et al., 2015).
clinicians’ priorities.
The findings of the current study must be interpreted
As expected, we found that the level of death anxiety
in the context of its limitations. One limitation consists
in Romanian cancer patients was higher than the aver-
of our cross-sectional design that precludes any causal
age score for most people (15.95 > 8.5) and that a great
explanations of the results. It is well-known that the
proportion of the participants (72.9%) indicated

trajectory of religious beliefs can change over time for
cancer patients (McFarland et al., 2013) and future
longitudinal studies might be worthwhile to further
elucidate the extent to which the diagnosis of cancer
influences the relation of people with God and their
religious beliefs. Another limitation of this study was
that it relied on the self-report of cancer patients and
this could influence their ratings. Our findings need
further testing with other larger samples restricting
participants to one cancer type and with various lengths
of previous treatments. Further, in our study parti-
cipants were not divided into religious and non-
religious groups and this can be explored in future
studies.
There are some clinical implications of the findings
from the current study. Death anxiety and death
depression findings are extremely useful in improving
the cancer patient’s quality of life and health care ser-
vices. For example, hospitals could establish support
groups for these individuals in order to express their
fears and concerns as well as find healthy and effective
coping strategies. Understanding death anxiety,
depression and related factors may help us to offer these
patients satisfactory therapy strategies during their diffi-
cult times. Moreover, this current investigation offers
some insights into the relation among supernatural
beliefs, SOC, death anxiety and death depression in
cancer patients.
ORCID
Violeta Enea http://orcid.org/0000-0003-3789-2017
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