Table 2.

Description of Studies Included in the Mixed Methods Systematic Review

First author (year)	Country	Primary focus	Study design	Data collection method	Findings related spirituality	MMAT scoring
Wong (2010)	USA	After patients HSCT, predictors of QOL concerns	Prospective longitudinal study	COH-QOL-HCT	Sp-WB improved after HSCT. Sp-WB remained unchanged at other postallogeneic HCT time points. Chronic GVHD was the only factor significantly associated with concurrently worse spiritual well-being after allogeneic HCT. Spiritual QOL in patients who underwent allogeneic HCT without chronic GVHD was significantly better than among patients who underwent autologous HCT.	☆☆☆☆
Sherman (2004)	USA	How supportive care needs are addressed across different pediatric centers	Prospective longitudinal study	Item construction was informed in part by previous supportive care surveys	Spiritual concerns were screened less frequently.	☆☆☆☆☆
Byar (2005)	USA	Evaluate the QOL of individuals at least 5 years post-AHSCT and to determine instrument preference	Cross-sectional study	MOS-SF-36 COH-BMT FACT-BMT	MOS-SF-36 did not address spiritual life, changes in perspective. COH-BMT is easy to answer because it is very spiritual. Spiritual questions, very powerful healing tool.	☆☆☆☆☆
King (2013)	USA	Used of a screening protocol that identified patients who may have been experiencing R/S struggle and examined the prevalence and correlates of possible R/S struggle	Cross-sectional study	The ESRA-C; the Rush Protocol; RTCQOLQ-C30; PHQ-9; a standard pain intensity numerical scale of 0–10	Gender, race, and time since diagnosis were significantly associated with positive screening for R/S struggle. There were no associations between potential R/S struggle and QOL or pain.	☆☆☆☆
King (2017)	USA	Describes the prevalence of R/S struggle in long-term survivors after HSCT, demographic and medical correlates of R/S struggle, and its associations with depression and quality of life	Cross-sectional study	NRC; SFHS; McGill QOL; PHQ-8; current GVHD	Younger age and describing oneself as either spiritual but not religious or religious but not spiritual were associated with a higher risk of any R/S struggle. R/S struggle was not associated with gender, religious affiliation, diagnosis, years since diagnosis, or years since transplant. R/S struggle was not significantly associated with medical variables. Participants who described themselves as spiritual but not religious or religious but not spiritual were more likely to have R/S struggle than those who were both spiritual and religious.	☆☆☆☆☆
Harris (2010)	USA	The relationship between Sp-WB and QOL in patients with cGVHD	Cross-sectional study	FACIT-Sp; FACT-G	The level of current QOL is significantly associated in a positive manner to level of Sp-WB. Patients with a higher Sp-WB also experienced a better QOL overall.	☆☆☆☆
Prince (2015)	USA	Compares Sp-WB and QOL of Hispanic and non-Hispanic survivors	Cross-sectional study	FACIT-SpWB; FACT-G; SAS	Complication/ethnicity/education/culture affects Sp-WB. Sp-WB improved after HSCT.	☆☆☆☆☆
Sinclair (2016)	Canada	Examine the relationships between spiritual, religious, and sociodemographic factors and post-traumatic growth, QOL, and Sp-WB in outpatients undergoing BMSCT	Cross-sectional study	FACT-BMT; PTGI; FACIT-Sp	Statistically significant differences were revealed in different incomes for the FACIT-Sp meaning subscale and the FACT-BMT spiritual well-being subscale. Significant differences not religious at all versus having at least some religiosity in spiritual change. Significant differences not spiritual at all versus having at least some spirituality on spiritual change. A religious affiliation was at least somewhat likely to recommend that a new patient seek the support of the clinic’s spiritual care professional.	☆☆☆☆☆
Sirilla (2013)	USA	Evaluate the effect of QOL, Sp-WB, and supportive care resources post-HSCT	Prospective longitudinal study	FACT—BMT; FACIT—Sp; The Resource Questionnaire	Sp-WB mean baseline score (37.4) to day 180 (37.0) did not change. Faith, prayer, and spiritual healing were the most used resources at 63% of the participants. Moderate correlations between QOL and sp-WB were found in autologous patients. Spirituality scores increased as time increased from transplant.	☆☆☆☆☆
Wingard (2010)	Center for International Blood and Marrow Transplant Research (CIBMTR)	We evaluated demographic and clinical factors before and after HCT and selected psychosocial factors after HCT, exploring their association with self-reported physical and mental health	Cross-sectional study	PCS and MCS score of SF-36; QOL; Duke-UNC FSSQ; FACIT-Sp; LOT	Psychosocial factors associated with mental health included greater spiritual well-being.	☆☆☆☆☆
Cigrang (2003)	USA	Compare the frequency of spontaneous reports of religious coping across three groups of patients who were experiencing different types of chronic physical illness	Cross-sectional study	A written, open-ended question asking how they were coping with the challenges involved in their medical condition	Religious coping was highest in participants preparing for a BMT.	☆☆☆☆
Pereira (2010)	USA	The relationship between spiritual absence and 1-year all-cause mortality in AHSCT recipients	Cross-sectional study	MBMD; patient survival time and status were abstracted from medical records	Spiritual absence was not associated with 1-year mortality secondary to disease progression or new/secondary malignancy.	☆☆☆☆☆
Lounsberry (2010)	Canada	Feasibility and efficacy of a telehealth delivered psychoeducational support group for AHSCT survivors	Intervention study	FACT-BMT; FACIT–Sp-WB; PTGI	Spirituality was not significant change after mindfulness exercise with six weekly, 1.5 h.	☆☆☆☆
Lynchkelly (2016)	USA	Explore associations among lifestyle behaviors, perceived stress, and inflammation of individuals with cGVHD	Secondary analysis of prospective observational study	The data of individual factors and disease factors; HPLP-II; PSS; blood	There was a significant negative association between spiritual growth and total perceived stress.	☆☆☆☆☆
Andrykowski (2004)	40 transplantation centers worldwide	Examine HRQOL and growth, and Sp-WB in adult survivors of HSCT for a malignant disease	Quantitative descriptive	SF-36-GH; PHQ; STAI-Trait; SF-36-MH; CES-D; SF-36-PF; SF-36-Pain; FACT-PWB; FACIT-Fatigue; MOS-Sex and MOS-Sleep; SIP-AB; SF-36-SF; MOS-Family; Duke-UNC; UCLA; PTGI; FACIT-Sp	The survivor group reporting poorer sp-WB	☆☆☆☆☆
Fitchett (2017)	USA	Examining the validity of the Rush Protocol to screen for R/S struggle	Cross-sectional study	Neg RCOPE subscale of the Brief RCOPE; two versions of the Rush Protocol	Patients did not like about MOS-SF-36, because it did not address spiritual life, changes in perspective. The scale with spiritual evaluation is more popular with patients.	☆☆☆☆☆
Lesson (2015)	USA	Investigated changes in spirituality in hematologic cancer patients recovering from HSCT and relationships between spirituality and dimensions of quality of life following HSCT	Prospective longitudinal study	FACIT-Sp; IDAS; FSI; BPI; FACIT-PWB and FWB	The meaning/peace dimension changed significantly over time. Religious faith also changed significantly over time…	☆☆☆☆☆
Tallman (2010)	USA	Explore posttraumatic growth and psychological and physical well-being among 25 cancer survivors (12 men, 13 women) 9 years after receiving a HSCT from an unrelated donor	Prospective longitudinal study	LOT-Revised; MOS-SS; FACT-G; PTGI	Spiritual growth, with older participants reporting more spiritual growth than younger participants	☆☆☆☆
Saleh (2001)	USA	Understand the concept of hope in patients with cancer hospitalized for BMT	Hermeneutic phenomenology	One-time semistructured interview using open-ended questions	Feeling connected with god; affirming relationships; anticipating survival; fostering ongoing accomplishment	☆☆☆☆☆
Alaloul (2015)	USA	Understand the role of spirituality in the cancer experience among Arab Muslim HSCT survivors	Qualitative descriptive	Responded to 2 open-ended, self-report questions	Genuine belief in God is the best cure for disease and sickness; faith in destiny; sickness is not seen as misfortune; patience; supplication; reading from the Holy Book and listening to its recitation; strengthening of faith in God and greater reliance on R/S activities	☆☆☆☆☆
Berger (2001)	USA	Find common themes in the spiritual journeys of BMT/HSCT survivors	A story	Story and literature	Commonalities among the spiritual journeys of BMT/HSCT survivors; chaplain interventions are beneficial.	☆☆☆☆☆
Faris (2010)	Iran	Explored the coping strategies acute leukemia patients who were undergoing this form of treatment in transplantation units	Qualitative	Semistructured interviews	Connection with divine purpose (acceptance of fate; reliance on faith); patience and resignation	☆☆☆☆☆
Fairs (2012)	Iran	Elicit the coping process of adults experiencing acute leukemia who underwent HSCT therapy	Grounded theory	A series of pretransplant and posttransplant interviews	Perceived threat (disregarding disease signs and symptoms; limited time); suspension between fear and hope; finding meaning; coping strategies	☆☆☆☆☆
Fairs (2015)	Iran	Explain how the meaning of disease and spiritual responses to threatening stressors influence the final experiential outcomes of adults with leukemia undergoing HSCT	Grounded theory	A series of pretransplant and posttransplant interviews	Experiencing the meaning of cancer; divine test; god interest; atonement/punishment for sins	☆☆☆☆☆
King (2012)	USA	A chaplain’s faithful companioning a cancer patient	Case study	Telling stories	Courage; meaning; courage and growth in facing S/R struggle; rituals; R/S struggle; religious care; family emotional pain and struggles	☆☆☆☆
Lawson (2012)	USA	Explored BMT patients’ perceptions of an art-making experience during BMT treatment	Qualitative	Patients receiving semistructured, in-depth interviews	Spirituality guided their individual treatment process.	☆☆☆☆☆
Ragsdale (2014)	USA	Explore the use of R/S in AYA HSCT recipients and to assess changes in belief during the transplantation experience	Grounded theory	Two semistructured interviews	Believing God has a reason; using faith practices; and benefitting from spiritual support people; believing God chose me; affirming that my life has a purpose; receiving spiritual encouragement; and experiencing strengthened faith.	☆☆☆☆☆
Alnasser (2018)	Saudi Arabia	To explore the lived experience of the patients post-HSCT and specifically after engraftment and before discharge	Descriptive phenomenology	In-depth semistructured interviews	Self-purification; spirituality and stress relief	☆☆☆☆☆
Cook (2012)	USA	Understand discharge needs of allogeneic transplantation recipients	Content analysis	Most of the patient-initiated topics, which were psychosocial in nature	Fear of future, uncertainty, life, death; more appreciate in life, “do not sweat the small stuff”	☆☆☆☆☆
Gabriel (2001)	USA	The benefit of art therapy	Art therapy intervention	Image-making with the art therapist	Existential/spiritual issues	☆☆☆☆☆
Lawson (2016)	USA	Understand patients’ perceptions in relation to their experience with illness through the art-making process	Thematic analysis	Participants are encouraged to paint freely during their time in the BMT outpatient clinic	Faith; hope; positive attitude; social support	☆☆☆☆☆
Ragsdale (2018)	USA	Describe how Arabic-speaking Muslim families from the Middle East use Islam in the process of their child receiving BMT in the USA	Grounded theory	The open-ended interview	Muslim families used religious practices in the hospital; hospital supported Muslim practices.	☆☆☆☆☆
Rivera (1997)	USA	Share a story about being the wife of a cancer survivor who had a BMT	Case study	Personal experience and published articles related to the impact of cancer on the family	Find out what the family members’ usual coping strategies are and encourage them to use those strategies; identify spiritual resources and encourage the patient and family to use these resources.	☆☆☆☆☆
Mattson (2013)	USA	Examine QOL among young adult survivors in relation to middle-aged and older adults, identify common areas of concern, and explore the association of individual characteristics with levels of QOL	Convergent design	A 1-time telephone interview utilizing the COH-QOL and 3 open-ended questions	The greatest difference was in the spiritual domain, with nonwhites reporting higher levels of spiritual well-being. There was a need for religious/spiritual services. Disease relapse was their biggest worry; returning to “normal life” was a worry; the long-term adverse effects secondary to their treatment are their difficulty. Well prepared for life after treatment; support or counseling groups; more treatment and information/education on adverse effect may be beneficial.	☆☆☆☆

HSCT, hematopoietic stem cell transplantation; HCT, hematopoietic cell transplantation; AHSCT, allogeneic hematopoietic stem cell transplant; BMT, blood and marrow transplantation; COH-BMT, City of Hope-Quality of Life-Bone Marrow Transplant; FACT-BMT, Functional Assessment of Cancer Therapy-Bone Marrow Transplant; FACIT-Sp, Functional Assessment of Chronic Illness Therapy–Spiritual well-being; Sp-WB, spiritual well-being; FACT-PWB, Physical Well-Being subscale of the Functional Assessment of Cancer Therapy scale; FACT-G, Functional Assessment of Cancer Therapy-General; QOL, quality of life; COH-QOL-HCT, The City of Hope Quality of Life; GVHD, graft-versus-host disease; R/S, religious/spiritual; ESRA-C, Electronic Self-Report Assessment—Cancer; RTCQOLQ-C30, Research and Treatment of Cancer Quality of Life Questionnaire-C30; PHQ, Perceived Health Questionnaire; NRC, Negative Religious Coping; SFHS, Short Form Health Survey; SBI, Spiritual Beliefs Inventory; SAS, The Short Acculturation Scale; PTGI, Post-Traumatic Growth Inventory; PCS, Physical Component Summary; MCS, Mental Component Summary; Duke-UNC, Duke-University of North Carolina Social Support Questionnaire; LOT, Life Orientation Test; MBMD, Stress Moderator Scale of the Millon Behavioral Medicine Diagnostic; HPLP-II, Health-Promoting Lifestyle Profile II; PSS, Perceived Stress Scale; MOS, Medical Outcomes Study; MOS-SS, The Medical Outcomes Study Social Support Survey; MOS-SF-36, Medical Outcomes Study-Short Form; SF-36-GH, general health perception subscale of the Medical Outcomes Study 36-Item Short Form Health Survey; SF-36-PF, Physical Functioning of the SF-36; SF-36-MH, Mental Health Subscale of the SF-36; SF-36-SF, Social Functioning subscale of the SF-36; STAI-Trait, Trait Anxiety subscale of the Spielberger State-Trait Anxiety Inventory; CES-D, Center for Epidemiologic Studies Depression Scale; SIP-AB, Alertness Behavior subscale of the Sickness Impact Profile; UCLA, University of California, Los Angeles Loneliness scale; Neg RCOPE subscale of the Brief RCOPE, 7-item negative religious coping subscale of the Brief RCOPE; IDAS, Inventory of Depression and Anxiety Symptoms; FSI, Fatigue Symptom Inventory; BPI, Brief Pain Inventory; FACIT-PWB and FWB, physical well-being and functioning well-being of FACIT