Abstract
Objective
Patients with gynecological cancer commonly use complementary and alternative medicine (CAM) methods to cope with the disease. However, despite the existence of treatment strategies, the effect of fear and anxiety caused by coronavirus disease 2019 (COVID-19) pandemic on attitudes about CAM use is unclear. This study was carried out to investigate the effect of fear and anxiety experienced by patients with gynecological cancer during the COVID-19 pandemic on their attitudes towards the use of CAM.
Methods
This is a cross-sectional and descriptive study that included 177 women with gynecological cancer; participants were recruited from a social networking site for cancer patients in Turkey between June and December 2021. Data were collected using an online survey that included the Personal Information Form, the Fear of COVID-19 Scale, the Coronavirus Anxiety Scale, and the Attitude Towards Holistic Complementary and Alternative Medicine Scale. Descriptive statistics, t-test, Pearson’s correlation test, and simple linear and multiple regression analyses were performed to analyze the data.
Results
During the pandemic, 55.4% of the participants reported using CAM methods, but only 22.6% were using CAM before the pandemic. The participants who used CAM during the pandemic also scored higher on the fear of COVID-19 and coronavirus anxiety scales (20.69 ± 5.37 and 13.09 ± 6.29, respectively) compared to the participants who did not use CAM (9.29 ± 2.72 and 6.35 ± 2.06, respectively). Fear of COVID-19 accounted for 52% of the CAM attitude score, while coronavirus anxiety accounted for 15% of the CAM attitude score. Fear of COVID-19 and coronavirus anxiety together accounted for 53% of CAM attitude.
Conclusion
Gynecological cancer patients with high levels of COVID-19-related anxiety and fear during the pandemic used CAM more. Given that the psychological effects of the pandemic will continue in the coming years, CAM use should be evaluated as a coping strategy, especially due to the COVID-19-related anxiety and fear experienced by patients with gynecological cancer. While the rational and effective CAM methods should be supported, strategies should be developed to prevent misuse of CAM and its interference in prescribed medical treatments.
Keywords: Complementary and alternative medicine, Anxiety, COVID-19, Fear, Gynecological cancer
1. Introduction
The coronavirus disease 2019 (COVID-19) pandemic has deeply affected health systems around the world [1], [2], [3], [4]. As of November 2022, more than 633 million cases of COVID-19-related infections and more than 6.5 million deaths have been reported globally [5]. The presence of comorbid conditions has been identified as the main factor influencing the outcome of COVID-19 [3]. Cancer patients experience more comorbid conditions than the general population. However, the immune system of cancer patients can be suppressed due to the cancer and its treatment (e.g., chemotherapy) [1], [2], [3], [4]. For these reasons, cancer patients are defined as a population at high-risk of poor COVID-19 outcomes [1], [3], [6], [7].
COVID-19 is thought to be especially stressful for cancer patients [6], [8], [9], [10]. The literature shows that cancer patients have a higher risk of death due to COVID-19; the level of admission to intensive care units is high; and they need more invasive ventilation, compared to non-cancer patients [3], [11]. During the pandemic, cancer patients cancelled or postponed elective and non-emergency cancer surgeries and medical tests due to concerns over these negative health outcomes, and changes in treatment protocols were made (e.g., longer intervals between chemotherapy cycles) [1], [2], [11]. These delays and changes in cancer care have increased the fear and anxiety levels of cancer patients who have difficulty reaching healthcare personnel [2], [4], [6], [10], [12], [13] and have adversely affected patients’ quality of life and access to healthcare services [4], [10], [12], [13]. In order to cope with these feelings of fear and anxiety during the pandemic, patients turned to complementary and alternative medicine (CAM) [4], [14].
CAM is defined as a diverse group of medical and healthcare systems, practices and products that are not considered part of conventional medicine [15]. Cancer patients may prefer to use CAM to strengthen their ability to fight the disease, maintain psychosocial well-being, and reduce the side effects of treatment [16], [17], [18], [19], [20]. However, inappropriate use of CAM may interact with the drugs used in the treatment process, resulting in side effects or a decrease in the effectiveness of the treatment [17], [18], [20].
In cancer patients, the use of CAM varies according to socioeconomic status, location, religious and spiritual background, and the type of cancer [7], [17], [20], [21]. A study conducted with 956 cancer patients from 14 European countries revealed that the prevalence of CAM use varies significantly among patients with different types of cancer: pancreatic cancer (56.3%), breast cancer (44.7%), gynecological cancer (40.3%), lung cancer (23.6%), and head and neck cancer (22.7%) [22]. In addition, the prevalence of CAM use in cancer patients is 26%–50% in Western countries [15], [16], [19], [20], [22], and it is estimated to be between 30% and 81.1% in Eastern countries [21], [23]. The results of the pre-pandemic reports have indicated that herbal products, prayer, yoga, meditation, relaxation techniques, massage and diets are the most commonly used CAM methods among patients with cancer [17], [18], [20], [24]. In Turkey, cancer patients have an increasing interest in CAM use, and its prevalence is reported to be between 46.4% and 61.2% [24], [25]. In recent years, with the increasing interest in CAM practices in Turkey, the Ministry of Health has issued and implemented the “Regulation on Traditional and Complementary Medicine Practices” [26]. In addition, Traditional, Complementary and Functional Medicine Practices Department was established [27]. These regulations encourage the integration of evidence-based traditional and complementary practices and therapies with conventional medicine in the treatment and care of cancer patients [25].
Gynecological cancers are the most common cancers in women after breast cancer. It is reported that globally 40% of cancer in women is classified as gynecological, while in Turkey this proportion is 30% [28]. Patients with gynecological cancers are known to use CAM for multiple reasons, including the severity of the disease, its life-threatening nature, and the numerous complex medical, psychosocial and emotional problems that they experience [15], [24], [29]. It is predicted that the pandemic may cause additional fear and anxiety in these patients, which, in turn, may affect their attitude towards the use of CAM. During the pandemic, the use of CAM by cancer patients has been investigated in limited studies [14], [30], [31]. However, these studies were conducted with participants with various types of cancer. To the best of our knowledge, there are no studies investigating the effect of the fear and anxiety experienced by patients with gynecological cancers on their attitudes towards CAM during the pandemic. Understanding the CAM modalities selected by these patients, their reasons for selection and the factors affecting their use of CAM is vital for both health personnel and patients. Therefore, this study will contribute to the literature by filling this information gap. It is thought that the psychological effects of the COVID-19 pandemic, which have been reported every day since the first case, will continue in the coming years. For this reason, this study was conducted to investigate the effect of fear and anxiety experienced by patients with gynecological cancer on their attitudes towards CAM during the pandemic. Considering the importance of mental health in coping with gynecological cancers in the pandemic, this research seeks to answer the following questions: (i) What is the level of COVID-19-related fear and anxiety experienced by patients with gynecological cancer and what are their attitudes towards CAM during the COVID-19 pandemic? (ii) Are there patterns in the use of CAM and the levels of COVID-19-related fear and anxiety among patients with gynecological cancer? (iii) Does the degree of fear and anxiety experienced by a gynecological cancer patient affect their attitude towards CAM?
2. Materials and methods
2.1. Study design
This descriptive and cross-sectional study investigate the effect of fear and anxiety experienced by patients with gynecological cancers on their attitudes towards CAM during the pandemic.
2.2. Participants
The target population of the study consisted of patients with gynecological cancer. The purposive sampling method was used for sample selection. This study was carried out by using the online platforms (Facebook, WhatsApp, etc.) of the Dance with Cancer Association, a patient association in Turkey that focuses on early cancer detection and prevention, which was founded and managed by cancer patients and their relatives. The Dance with Cancer Association actively carries out projects and studies to improve the health of cancer patients and their relatives. The inclusion criteria for the study were: being older than 18 years of age, having been diagnosed with the disease at least six months prior to study enrollment, being in the curative-palliative treatment process, being able to use computer or smart mobile phone, having the ability to understand and read Turkish, and agreeing to participate in the research. Exclusion criteria from the study were: diagnosis with a neurological or psychiatric disorder and not agreeing to participate in the study.
2.3. Procedure for data collection
The data collection tools were prepared through Google Forms. The Dance with Cancer Association distributed the survey via email by making announcements on its online social media platforms. Brief notes on the purpose, procedure, anonymity, and confidentiality of the research were added to the introduction of the online survey of the study. The participants were required to answer a “yes or no” question regarding providing informed consent to participate in the study. They were directed to complete the self-report questionnaire after confirming their volunteer participation. The participants were allowed to save and print a copy of the consent form. The first item of the questionnaire established the eligibility of the participants. To prevent duplicate responses, the program was set up so that each IP address could send only one response. The researchers tracked the submitted responses and terminated the data collection process when there were enough participants. The estimated time required to complete the survey was approximately 20 min, and the program was designed to minimize missing data. The online survey remained active from June to December 2021.
2.4. Measurement
2.4.1. Demographic and clinical information form
The demographic characteristics (age, marital status, education level, perceived income level, etc.), the clinical characteristics (diagnosis, disease stage, treatment options, duration of diagnosis, etc.), and the CAM use characteristics of the participants were investigated using the Demographic and Clinical Information Form, which included 15 questions and was prepared by the researchers after reviewing the literature.
2.4.2. The fear of COVID-19 scale
The scale was developed by Ahorsu et al. [32] to measure the fear associated with COVID-19 experienced by individuals. The Turkish validity and reliability study of the scale was conducted by Satici et al. [33]. The scale is a five-point Likert-type scale and consists of seven items. A minimum of 7 and a maximum of 35 points can be obtained from the scale. Higher scores indicate higher levels of COVID-19 fear [32], [33]. The Cronbach’s α of the original scale is 0.82. The Cronbach’s α of the scale was found to be 0.88 in this study.
2.4.3. The coronavirus anxiety scale
The scale was developed by Lee [34] to measure the coronavirus-induced anxiety levels of individuals. The Turkish validity and reliability study of the scale was conducted by Evren et al. [35]. The scale includes five items rated on a five-point Likert-type scale. A minimum of 5 and a maximum of 25 points can be obtained from the scale. Higher scores indicate higher levels of anxiety associated with the coronavirus [34], [35]. The Cronbach’s α of the original scale is 0.80. The Cronbach’s α of the scale in this study is 0.84.
2.4.4. The attitude towards holistic complementary and alternative medicine scale
The scale developed by Hyland et al. [36] was used to reveal the attitudes of individuals towards the holistic CAM. The Turkish validity and reliability study of the scale was conducted by Erci [37]. The scale contains 11 items rated on a six-point Likert-type scale. A minimum of 11 and a maximum of 66 points can be obtained from the scale. Lower scores on this scale indicate more positive attitudes towards CAM [36], [37]. The Cronbach’s α of the original scale is 0.72. The Cronbach’s α of the scale in this study is 0.88.
2.5. Data analysis
The data was analyzed using SPSS version 20.0 (Chicago, IL, USA). The conformity of continuous variables to a normal distribution was evaluated with the Kolmogorov-Smirnov test. Descriptive statistics were used to explore the study population and scores obtained from the scales. The independent sample t-test was used to compare scores among cancer patients who were using or not using CAM. Pearson’s correlation coefficients were used to examine the correlations among participants’ attitudes towards CAM, fear of COVID-19, and anxiety about COVID-19. Based on correlations, simple linear regression analysis was used to examine the relationship between attitude towards CAM and the fear of COVID-19 and anxiety about COVID-19. Multiple linear regression analyses (enter method) were used to examine the relationship between the fear of COVID-19 and the attitude towards CAM score and to evaluate the interaction of the level of the fear of COVID-19 and anxiety about COVID-19. The autocorrelation of the independent variables was examined using the Durbin-Watson test. Tolerance and variance inflation factor (VIF) values were used to assess the multicollinearity of the regression models. The threshold for significance was set at P < 0.05.
The number of participants was calculated using the G*Power 3.1.9.2 program (Franz Faul, Universität Kiel, Germany). The minimum number of patients with gynecological cancer required for the independent t test with a 2-sided significance level of 0.05, 90% power, and a medium effect size (0.25) [38] was 171. The study was completed with 177 patients with gynecological cancer.
2.6. Ethical considerations
The research was conducted in accordance with the Declaration of Helsinki. The research protocols were accepted by the University of Health Sciences Gülhane Scientific Research Ethics Committee, and ethical approval (Date: 03 June 2021; Decision Number: 46418926) was obtained to conduct the research. In addition, approval was obtained from the Ministry of Health (No. 2021‐05‐26T00‐11‐17) to conduct the study. Written permission was obtained from the Dance with Cancer Association director so that the research could be carried out on the Association’s social platforms. Online informed consent was obtained from all participants in line with the principle of voluntary participation. After the study’s data collection process was completed, the data were downloaded from Google Forms to a password-protected file on a computer accessible only to the researchers.
3. Results
The mean age of the participants was (53.74 ± 10.12) years (minimum of 34; maximum of 81), with 38.4% of the participants between 50 and 60 years old. The majority of the participants were primary school graduates (50.8%), did not work (67.2%), perceived their income as medium (48.6%), were married (62.7%), and had no chronic disease (51.4%). Of the types of gynecologic cancer, the most common were ovarian (44.1%), endometrial (26.0%), cervical (24.3%), and 5.6% had vulvar cancer. The majority of the participants were at stage III of the disease (46.3%), received surgery and chemotherapy treatment (57.6%), and had received their cancer diagnoses between 13 and 24 months (38.4%) prior to the study. Of the participants, 55.4% used CAM during the pandemic, and 22.6% used CAM before the pandemic (Table 1 ).
Table 1.
Demographic and clinical characteristics of the participants (n = 177).
| Variable | n | Percentage (%) |
|---|---|---|
| Age | ||
| <50 years | 59 | 33.3 |
| 50–60 years | 68 | 38.4 |
| >60 years | 50 | 28.3 |
| Education level | ||
| Primary School | 90 | 50.8 |
| High School | 56 | 31.6 |
| University | 31 | 17.6 |
| Employment status | ||
| Unemployed/retired | 119 | 67.2 |
| Employed | 58 | 32.8 |
| Perceived economic status | ||
| Low incomes | 69 | 39.0 |
| Average incomes | 86 | 48.6 |
| High incomes | 22 | 12.4 |
| Marital status | ||
| Married | 111 | 62.7 |
| Single | 66 | 37.3 |
| Chronic illness status | ||
| No | 91 | 51.4 |
| Yes | 86 | 48.6 |
| Cancer type | ||
| Ovarian cancer | 78 | 44.1 |
| Endometrial cancer | 46 | 26.0 |
| Cervical cancer | 43 | 24.3 |
| Vulvar cancer | 10 | 5.6 |
| Stage of disease | ||
| I | 21 | 11.9 |
| II | 45 | 25.4 |
| III | 82 | 46.3 |
| IV | 8 | 4.5 |
| Unknown | 21 | 11.9 |
| Time since diagnosis | ||
| 6–12 months | 43 | 24.3 |
| 13–24 months | 68 | 38.4 |
| Over 24 months | 66 | 37.3 |
| Type of treatment | ||
| Surgery | 28 | 15.8 |
| Chemotherapy | 19 | 10.7 |
| Surgery and chemotherapy | 102 | 57.6 |
| Surgery, chemotherapy and radiotherapy | 21 | 11.9 |
| Surgery and radiotherapy | 7 | 4.0 |
| CAM usage during COVID-19 | ||
| Yes | 98 | 55.4 |
| No | 79 | 44.6 |
| CAM usage prior to COVID-19 | ||
| Yes | 40 | 22.6 |
| No | 137 | 77.4 |
CAM: complementary and alternative medicine; COVID-19: coronavirus disease 2019.
The majority of the CAM users adopted CAM to fight their cancers (89.8%), to increase their body’s ability to prevent COVID-19 (70.4%), and to boost hope and positive thinking (70.4%). Of the participants, 89.9% obtained information about the CAM methods they used from family members (Table 2 ). The CAM methods most frequently used by the participants included taking multi-vitamin (n = 90, 91.8%); consuming ginger (n = 85, 86.7%) or green vegetables and fruits (n = 80, 81.6%); praying (n = 73, 74.5%); consuming garlic (n = 71, 72.4%) and engaging in worship (n = 70, 71.4%) (Fig. 1 ).
Table 2.
CAM therapy-related characteristics of the CAM users during COVID-19 (n = 98).
| Variable | n | Percentage (%) |
|---|---|---|
| Reason for CAM use* | ||
| To fight their cancers | 88 | 89.8 |
| To increase body's resistance to protect against COVID-19 | 69 | 70.4 |
| To boost hope and positive thinking | 69 | 70.4 |
| To reduce stress and relax physically | 48 | 49.0 |
| To reduce the undesirable effects of medical treatment | 22 | 22.4 |
| Not to feel pain | 1 | 1.0 |
| Information sources of CAM* | ||
| Family members | 88 | 89.8 |
| Other patients | 71 | 72.4 |
| Media or internet | 63 | 64.3 |
| Healthcare providers | 23 | 23.5 |
CAM: complementary and alternative medicine; COVID-19: coronavirus disease 2019.
Respondents may report more than one answer.
Fig. 1.
The prevalence of cams used by the patients. CAM: complementary and alternative medicine. *Respondents may report more than one answer.
As seen in Table 3 , there is a significant difference between participants using and not using CAM and their scores of COVID-19 fear, coronavirus anxiety and CAM attitude. The CAM users showed significantly higher COVID-19 fear score (P = 0.001) and coronavirus anxiety score (P = 0.001) compared to non-CAM users. The CAM users were found to have more COVID-19 fear and coronavirus anxiety. The CAM users had a significantly lower CAM attitude score compared to non-CAM users (P = 0.001). The CAM users were found to have a more positive attitude towards CAM (Table 3).
Table 3.
Comparison of fear of COVID-19, coronavirus anxiety and attitudes about CAM between participants using and not using CAM.
| Variable | All patients (n = 177) | CAM nonusers (n = 79) | CAM users (n = 98) | t | p |
|---|---|---|---|---|---|
| Fear of COVID-19 | 17.30 ± 6.91 | 13.09 ± 6.29 | 20.69 ± 5.37 | –8.681 | 0.001 |
| Coronavirus anxiety | 7.98 ± 2.85 | 6.35 ± 2.06 | 9.29 ± 2.72 | –7.914 | 0.001 |
| Attitude towards CAM | 27.27 ± 9.73 | 32.95 ± 10.40 | 22.69 ± 6.12 | 8.169 | 0.001 |
Data are expressed as mean ± standard deviation. CAM: complementary and alternative medicine; COVID-19: coronavirus disease 2019; t: independent sample t test.
A high negative correlation was found between the participants’ CAM attitude and their level of COVID-19 fear (r: –0.722; P < 0.05). A moderate negative correlation was found between CAM attitude and coronavirus anxiety (r: –0.381; P < 0.05). As the COVID-19 fear and coronavirus anxiety scores of the participants increased, the CAM attitude score decreased; thus, patients with greater fear and anxiety about COVID-19 and coronavirus also had more positive attitudes towards CAM.
In Table 4 , the first model examined the effect of fear of COVID-19 on the CAM attitude score. In the test for autocorrelation errors, to ensure that the conditions for regression analysis were met, the Durbin-Watson statistic was 1.618–1.93. The test for multicollinearity tolerance resulted in a range of 0.823–1.000, which was higher than 0.1, and the variance inflation factor was 1.000–1.215, which was lower than the reference level 10. Thus, these regression diagnostics indicate that the analysis met the required statistical assumptions, i.e., there was no autocorrelation or multicollinearity. In the first model, participants' fear of COVID-19 accounted for 52% of the CAM attitude score. The increase in fear of COVID-19 caused a 1.017-fold decrease in CAM attitude score, indicating a more positive attitude towards CAM. The second model examined the impact of coronavirus anxiety on the CAM attitude score. In this model, the anxiety of the participants about coronavirus accounted for 15% of the CAM attitude score. The increase in COVID-19 anxiety reduced the CAM attitude score 1.301-fold, indicating a more positive attitude towards CAM. The third model examined the impact of COVID-19 fear and coronavirus anxiety on attitudes towards CAM. The third model resulted in β = –0.953 for fear of COVID-19 and β = –0.405 for coronavirus anxiety, while the R 2 was 0.53 and F statistic was 99.663. The participants' fear of COVID-19 and coronavirus anxiety together accounted for 53% of the CAM attitude score. The attitude towards CAM was modestly influenced by fear of COVID-19 with a 0.953-fold factor and more intensively by coronavirus anxiety with a 0.405-fold factor. The fourth model examined the interaction effect of COVID-19 fear and coronavirus anxiety on CAM attitude. This model resulted in β = –0.879 for fear of COVID-19, β = –0.639 for coronavirus anxiety, and β = 0.184 for the interaction between fear of COVID-19 and coronavirus anxiety, with an R2 of 0.65 and F statistic of 109.351. This interaction term accounts for 65% of the CAM attitude score.
Table 4.
Effect of fear of COVID-19 and coronavirus anxiety on attitudes of CAM.
| Variable | Unstandardized coefficient |
t value | R2 | r | F | Durbin-Watson | Collinearity statistics |
||
|---|---|---|---|---|---|---|---|---|---|
| β | Standard error | Tolerance | Variance inflation factor | ||||||
| Model 1 | |||||||||
| Constant | 44.870 | 1.370 | 32.745a | 0.52 | –0.722a | 191.111a | 1.722 | / | / |
| Fear of COVID-19 | –1.017 | 0.074 | –13.824a | 1.000 | 1.000 | ||||
| Model 2 | |||||||||
| Constant | 37.649 | 2.023 | 18.606a | 0.15 | –0.381a | 29.633a | 1.618 | / | / |
| Coronavirus anxiety | –1.301 | 0.239 | –5.444a | 1.000 | 1.000 | ||||
| Model 3 | |||||||||
| Constant | 46.981 | 1.686 | 27.86a | 0.53 | –0.731a | 99.663a | 1.758 | / | / |
| Fear of COVID-19 | –0.953 | 0.079 | –12.053a | 0.850 | 1.177 | ||||
| Coronavirus anxiety | –0.405 | 0.192 | –2.109b | 0.850 | 1.177 | ||||
| Model 4 | |||||||||
| Constant | 25.877 | 0.469 | 25.877a | 0.65 | 0.81 | 109.351a | 1.93 | / | / |
| Fear of COVID-19 | –0.879 | 0.069 | –0.879a | 0.834 | 1.200 | ||||
| Coronavirus anxiety | –0.639 | 0.168 | –0.639a | 0.823 | 1.215 | ||||
| Fear of COVID-19 × coronavirus anxiety | 0.184 | 0.024 | 0.184a | 0.963 | 1.039 | ||||
CAM: complementary and alternative medicine; COVID-19: coronavirus disease 2019.
P < 0.05.
P < 0.01.
4. Discussion
The negative effects of COVID-19 on cancer patients, which are thought to continue for many years, are important. The use of effective coping mechanisms can reduce this psychological burden imposed on cancer patients [7], [14], [17], [31]. CAM use is one of the coping methods commonly used by cancer patients. However, there is concern that uncareful use of CAM during cancer treatment may interact with treatment drugs, reducing their effectiveness or resulting in toxicity [17], [20], [24]. Understanding the factors that affect a patient’s attitude towards CAM in the COVID-19 pandemic is essential for preventing the potential negative effects of CAM interactions with their cancer treatment regime. This research was conducted to investigate how the COVID-19- and coronavirus-related fear and anxiety that was experienced by patients with gynecological cancer affected their attitudes towards CAM during the COVID-19 pandemic.
The study revealed that while before the pandemic 22.6% of participants had been using CAM, during the pandemic the proportion of CAM users rose to 55.4%. Studies conducted before the COVID-19 pandemic showed that the frequency of CAM use varied between 26% and 85% for cancer patients [20], [21], [23], [39]. In the literature, there are a limited number of studies that have examined the use of CAM methods by cancer patients during the pandemic [7], [14], [30], and these studies highlighted that the majority of cancer patients used a CAM method during the pandemic. Dehghan et al. [7] found that 85.7% of cancer patients used at least one type of CAM in the previous year. Similarly, another study examining the use of CAM methods by the general population during the COVID-19 pandemic reported that approximately 85% of the participants used a CAM method [31]. It is thought that these differences between the studies are due to characteristics of the sample population and cultural differences.
The participants in our study stated that before the pandemic, they used CAM at a lower level than the rates in the published literature [20], [40]; however, it was found that this rate increased more than two-hundred percent during COVID-19 pandemic. Most participants who used CAM stated that they used CAM to fight their cancers, increase their body’s ability to resist COVID-19 infection, and boost hope and positive thinking. Similarly, it has been reported in the literature that cancer patients prefer CAM practices to derive psychological and emotional support, to increase the effectiveness of treatment, and because they think these practices are beneficial [15], [20], [23], [29]. Our research revealed the importance of informing the health professionals responsible for treating and caring for women with gynecological cancer about the use of CAM.
The majority of the participants in our study received information about the CAM methods they used from family members and other patients. Previous studies of cancer patients also reported that the most common sources of information about CAM were media [19], family and friends [15], [19], [21], and other patients [15], [20], [40]. In this study, patients with gynecological cancer were not asked how reliable the information sources were. However, in line with the findings obtained from the study and the literature, it has been revealed that patients need accurate and reliable information sources about CAM practices [7], [16], [17]. Still, they cannot access the literature that documents the safe use of CAM. It is thought that informing patients about the use of CAM is important for their careful and rational addition into a treatment plan. Given the potential risks of some of the CAM methods used, it is recommended that healthcare professionals responsible for treating and caring for women with gynecological cancers routinely ask about a patient’s use of CAM and provide appropriate counseling.
The most common CAM methods used by the participants in our study included using multi-vitamin supplements, consuming ginger, garlic, green vegetables and fruits, praying, and worshipping. Given Turkey's religious tradition as an Islamic country, that prayer is in one of the top five CAMs in the current study was unsurprising. Similar to our results, Dehghan et al. [7] stated that the most common CAM methods used by cancer patients in Iran were prayer, medicinal herbs, massage and nutritional supplements. A study of ovarian cancer patients during the pandemic by Bahall et al. [15] reported that women tried to find comfort in religion and spiritual beliefs as a coping strategy. Literature studies that investigated the use of CAM in patients with different types of cancer found that spiritual practices and medicinal herbs were frequently used by patients [15], [40]. The results of our study revealed the importance of asking women with gynecological cancer what CAM methods they are including as a part of their treatment and care process and the significance of reporting CAM use to health professionals.
The current study showed that women with gynecological cancer had moderate fear of COVID-19 (17.30; minimum of 7 and maximum of 35), a low level of coronavirus anxiety (8; minimum of 5 and maximum of 25), and positive attitudes towards CAM (27.27; minimum of 11 and maximum of 66). Similarly, one study which examined the fear of COVID-19 in patients with ovarian cancer reported that participants experienced moderate fear [12]. Another study examining pandemic-related impacts was conducted with low-income patients with gynecological cancer in New York City and reported that patients experienced high levels of anxiety and fear [13]. Most studies have emphasized that COVID-19 has increased the cancer patients' anxiety and fear [6], [8], [10], [12], [13], [31], [41]. Contrary to the literature, our study found that women with gynecological cancer had lower coronavirus anxiety levels. This study was conducted approximately 1.5 years after COVID-19 was declared a pandemic. It is thought that the decrease in uncertainties about COVID-19 and the start of vaccination in this period affected the participants' anxiety levels.
COVID-19 fear and coronavirus anxiety may be associated with preventive behaviors against COVID-19 [7], [42], [43]. In the studies conducted by Lam et al. [43] and Bystritsky et al. [39], the high levels of anxiety and fear in individuals during the pandemic resulted in higher use of CAM. Another study showed that most individuals (50%–66%) used CAM to prevent the transmission of COVID-19 or reduce the anxiety caused by the pandemic [7]. The current study further revealed that the participants using CAM had higher levels of COVID-19 fear and anxiety. In parallel to this finding, the participants of the present study had a more positive attitude towards CAM as their COVID-19 fear and coronavirus anxiety scores increased. Thus, it is thought that women with high levels of COVID-19 fear and anxiety resort to CAM methods more frequently. It can be argued that women with high levels of anxiety and fear need more supportive health care. Women who experience fear and anxiety about COVID-19 infection use CAM methods to fight the disease and increase immunity and hope. It is thought that reduction in hospital visits and interruption of treatment, due to the pandemic [1], [6], [11], caused patients with gynecological cancer to opt for CAM methods to help control their conditions. In the literature, no similar studies on this subject have been found. The results of our study indicate that women with gynecological cancer use CAM as a coping method for the fear and anxiety they experience during the pandemic.
5. Limitations
This study has both limitations and strengths. The results obtained from the study are based on the self-reports of patients with gynecological cancer. The study did not evaluate how reliable the women with gynecological cancer believed their sources of information about CAM to be. The participants' use of CAM methods before COVID-19 was questioned retrospectively. The strength of the study is that, to the best of our knowledge, it is the first to examine the use of CAM practices among women with gynecological cancer in the context of the fear and anxiety triggered by the COVID-19 pandemic.
6. Conclusions
In our study population, one out of every two women with gynecological cancer resorted to CAM practices. These women mostly obtained information about CAM methods from their family members and friends. Therefore, women need reliable sources of information about CAM practices that might be beneficial to their conditions. The study showed that fear of COVID-19 and anxiety about coronavirus were correlated with increased positivity towards CAM practiced among the participants. Women who experience high levels of anxiety and fear about COVID-19 were more likely to use CAM. Given that the pandemic continues, patients with gynecological cancer will need to manage their medical treatment in the context of fears and anxieties caused by COVID-19 for the foreseeable future. The use of CAM as a strategy to cope with pandemic-related fear and anxiety among women with gynecological cancer should be investigated, and strategies should be developed to prevent wrong practices while supporting the rational and effective use of CAM methods. There is a need for further large-scale studies to investigate the use of CAM methods by patients with gynecological cancer.
Funding
There was no funding for this study.
Authors’ contributions
FUS, IY, GK and GG designed the study. FUS and GG performed the study and their analyses. All authors were responsible for data collection. FUS performed data analyses. All authors participated in data interpretation, and manuscript review and writing. FUS and GK were responsible for the preparation of the tables and figures. All authors contributed to the scientific discussion of the data and of the manuscript.
Acknowledgements
The authors would like to thank the Dance with Cancer Association and all participants for their cooperation.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Please cite this article as: Uslu-Sahan F, Yesilcınar I, Kurt G, Hancer E, Guvenc G. Effects of COVID-19 fear and anxiety on attitudes towards complementary and alternative medicine use in women with gynecological cancer during the COVID-19 pandemic. J Integr Med. 2023; Epub ahead of print.
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