Promoting Resilience among Family Caregiver of Cancer through Islamic Religious Coping among family of

. The burden placed on family caregivers in providing care to cancer patients can reduce resilience. This study aimed to increase the resilience of cancer caregivers’ families through Islamic religious coping. In practice, Islamic religious coping consisted of cognitive, emotional, behavioral, and spiritual aspects. This study involved eight family caregivers for cancer patients. The participants were divided into intervention group (n = 4) and control group (n = 4). The pre-test post-test control group design was used as the research design, and it was assessed at three points (pre-intervention, post-intervention, and 2-week follow-up). To assess any changes in resilience, the participants completed the Connor-Davidson Resilience Scale (CD-RISC). An intervention module was developed based upon Pargament, Smith, Koenig, and Perez (1998) and modified using Islamic coping strategies based on the positive religious coping concept. The results showed that participants in the intervention group reported a significant increase in resilience than those in the control group. Participants also reported positive changes in their perceptions of their role as family caregivers. This study discussed the implications and limitations of the finding.


INTRODUCTION
Cancer is one of the chronic diseases that has been on the rise in recent years. According to the World Health Organization (WHO) in 2013, the number of cancer patients increased from 12.7 million in 2008 to 14.1 million in 2012. As informed by the Basic Health Research (locally abbreviated as Riset Kesehatan Dasar) in 2013, the prevalence of cancer disease in a population of all ages in Indonesia was 1,4% or approximately 347.792 people. The Special Region of Yogyakarta has the highest prevalence of cancer disease (4,1%). Furthermore, the result of RISKESDAS revealed that the majority of cancer diseases in Indonesia is 1,4 per 1.000 people. It has made cancer the seventh leading cause of death in Indonesia, accounting for 5,7% of all death causes (Kementrian Kesehatan Republik Indonesia, 2015).
Cancer patients require the assistance of others in their daily activities, such as family or well-known as a family caregiver. The family caregiver is responsible for providing physical, emotional, and financial support to the family members who are unable to care for themselves due to disease, wounds, and limitations (World Federation of Mental Health, 2010). The psychological burden of family caregivers increases in time, energy, and emotion as cancer patients' condition worsens. Even the family caregiver's psychological burden may be greater than the patient's (Berry e-ISSN: 2541-450X p-ISSN: 0854-2880 Indigenous: Jurnal Ilmiah Psikologi 2021, 6(2), 54-65 et al., 2017). Female caregivers of cancer patients report a higher level of fatigue, sleep disturbance, perceived stress, anxiety, and social strain than male caregivers (Johansen et al., 2018;Ketcher et al., 2020). Cancer is categorized as a prolonged chronic disease that affects several life aspects of the family caregiver, including physiological, psychological, and behavioral problems (Bevans & Sternberg, 2012), such as experiencing depression in the first six months of cancer diagnosis symptoms (García-Torres et al., 2020;Stajduhar, 2013), worry, anxiety (Din et al., 2017), and anger (Given et al., 2012). In addition, family caregivers are prone to exhibit aggressive behavior, a decline in cognitive function, social isolation, family conflict, economic issues, and job loss (Brémault-Phillips et al., 2016;Liu et al., 2020). The heavier burden felt by family caregivers, the lower their resilience (Li et al., 2018;Vagharseyyedin & Molazem, 2013). The complexity of the arising problems will affect the resilience of cancer caregivers' families.
Resilience is the quality of an individual's ability to deal positively with difficult situations or adversity (Connor & Davidson, 2003;Nashori & Saputro, 2021). Resilience can also be defined as a dynamic and adaptive process that assists people in maintaining their psychological health during stressful situations (Rutten et al., 2013). Yu and Zhang (2007) conducted a psychometric evaluation of aspects developed by Connor and Davidson (2003) and found three elements of resilience. First, tenacity refers to mental calmness, preparedness, perseverance, and self-control when confronted with difficult or challenging situations. Second, strength is defined as an individual's ability to recover and become stronger after experiencing any past setbacks and experiences. Third, optimism reflects an individual's proclivity to see the positive side of things, to trust themselves, and to believe in other people. Thus, resilience is required to help family caregivers deal with stressors, followed by strengthening and increasing the intrapersonal and interpersonal quality while taking care of their family members.
Resilience is influenced by several factors, such as personality (Fourmani et al., 2015), religiosity (Javanmard, 2013), social support (Sabouripour & Roslan, 2015), self-regulation (Artuch-Garde et al., 2017), self-efficacy, optimism, gratitude, and coping stress (Nashori & Saputro, 2021). According to Rosenberg, Baker, Syrjala, Back, and Wolfe (2013), coping stress strategies are factors that can increase caregivers' resilience. Coping strategies refer to the process of attempting to neutralize or reduce stress (Sarafino, 2006). The psychological burden of family caregivers of cancer disease must be addressed in order to obtain psychological interventions through a religious approach with religious coping. Religious coping, such as faith in Allah, is vital in improving the quality of life among family caregivers and finding the meaning of their roles as caregivers (Kusi et al., 2020). Pargament, Smith, Koenig, and Perez (1998) define religious coping as a variety of things related to spirituality and religiosity in cognitive, behavioral, and interpersonal responses in dealing with the stressors. Then, Pargament, Smith, Koenig, and Perez (1998) classified religious coping into two types, namely positive religious coping and negative religious coping. Positive religious coping consists of four stages: (1) believing that life has a meaning or wisdom that can be discovered, (2) expressing a spiritual feeling possessed, (3) having a good relationship with Allah, and (4) spiritually having a feeling connected with others. In Islamic perspectives, Achour, Bensaid, and Nor (2015) identify six religious coping strategies: trust in Allah, prayer performance, remembrance of Allah (dhikr), patience, forbearance, and forgiveness, positive thinking, and community support.
Islamic coping strategies, methods, and techniques are deeply rooted in Islamic spirituality and are inextricably linked to various forms of worship and moral discipline. These coping strategies are supported by a large number of verses in the Qur'an and hadiths of Prophet Muhammad and coherently designed to nurture, fulfill, and sustain Muslim devotion to Allah while continually cultivating a deep sense of service to others. Islam teaches and encourages people to quickly rise from problems by solving them and immediately return to the spirit of living life as usual. Allah presents the problem that an individual can still solve, and He will reward the good things that are appropriate for the person who is resistant (resilient) to the problem that God gives. Individual characteristics of the Quran perspective (QS. Al-Baqarah: 155-156, 214 & 286) are individuals with patience and fortitude, who are optimistic, and have a great spirit (Wahidah, 2018). Positive religious coping correlates positively with life quality and negatively with PTSD and depressive symptoms (Henslee et al., 2015). However, when a person engages in negative religious coping, it correlates positively with the level of psychological distress (Chan & Rhodes, 2013).
McIntire and Duncan (2013) discovered that individuals who use positive religious coping have a better level of resilience than those who use negative religious coping. In terms of religious coping, Islam has several strategies. Abdullah, Razali, Taha, and Kechil (2016) found that psychological management based on Qur'an and Sunnah can help other people cope with stress by involving the inner spiritual aspect. Kristanti, Effendy, Utarini, Vernooji-Dassen, and Engels (2019) conducted a study to explore a model experience of family caregivers of patients with cancer in Indonesia in performing caregiving tasks. The findings revealed that the greatest strength in providing care was the combination of spiritual, religious, value, and motivation to care.
Based on the explanation above, researchers identified that religion plays an essential role in assisting individuals in dealing with and recovering from life's stressors. Islam teaches its followers to establish a good relationship with Allah (hablum minallah) and human beings (hablum minannas) as protective factors in life. Furthermore, Islam per se is a protective factor that increases resilience in caring for cancer-stricken family members. Thus, the researchers conducted Islamic religious coping training using religious coping strategies to increase the resilience level among the family caregiver of cancer disease.

METHOD
The study involved eight female family caregivers of cancer disease in Yogyakarta, Indonesia. They were Muslim women between 23-48 years old, who were actively involved in caregiving to their family members. The participants were divided into two groups: the intervention group (n = 4) and the control group (n = 4). Participants in the intervention group lived in dormitories under a cancer foundation, while the control groups lived in a different foundation. Participants in the intervention group and control group did not know each other because they lived in different places. This study used an experimental method with a pretest-posttest control group design. The measurements were taken three times in pre-test, post-test, and follow-up. Besides, the intervention was given to experimental groups only. Follow-up data collection was carried out two weeks after the intervention.
The measurement was done using two scales: Connor-Davidson Resilience Scale and the Islamic Positive Religious Coping subscale-short form. Researchers tested these two measuring instruments on 49 families of chronic disease caregivers before using them in this study. The Connor-Davidson Resilience Scale (CD-RISC) was used to measure family caregiver resilience, which refers to the resilience aspects developed by Yu and Zhang (2007) consisting of 24 items with the Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) (Cronbach's alpha = 0.895). Researchers also employed Islamic Positive Religious Coping subscale-short form (IPRC) to assess Islamic religious coping, which is based on the concept developed by Abu Raiya (2008) and consists of 7 items with a Likert scale ranging from 1 (never) to 4 (often) (Cronbach's alpha = 0.824). In addition, during the intervention process, researchers were committed to conducting interviews to complement quantitative data.
The data analysis method used in this study was a non-parametric test with Mann-Whitney U-Test analysis to compare participants' resilience rate before and after intervention in the form of Islamic religious coping compared to the control group. Data analysis was done using the statistical program for Social Science (SPSS) 22.0 for Windows.
The Islamic religious coping module was arranged in accordance with the stages of religious coping proposed by Pargament, Smith, Koenig and Perez (1998). The stages were having the faith that there is meaning or wisdom that can be found in life, expressing spiritual feelings, having a strong relationship with Allah, and connecting spiritually with others. The module was also designed to allow the participants to reflect on their role as family caregivers. The module referred to the positive aspects of religious coping put forward by Pargament, Smith, Koenig and Perez (1998). Achour, Bensaid, and Nor (2015) composed the module's materials on Islamic religious coping strategies (see figure 1). The module was implemented over three meetings, with a total of 17 sessions lasting approximately 120 minutes each.  Based on the descriptive statistics, the resilience score of the intervention group increased after the interventions in post-test and follow-up measurements. The intervention group also experienced an increase in religious coping scores after interventions in post-test and follow-up measurements (see Table 1).

RESULTS AND DISCUSSION
Due to the small number of participants in the study, hypothesis testing was carried out using the non-parametric test method. The hypothesis presented in this study was that there would be a significant difference in resilience scores between the intervention group and the control group after the intervention of Islamic religious coping. The results of hypothesis testing showed a significant difference in resilience score in family caregiver cancer after the intervention compared to the control group (p < 0,05). In other words, the hypothesis was accepted. Furthermore, significant differences in resilience scores were also found in follow-up conditions two weeks after the intervention (p < 0,05). There was no significant difference in religious coping scores between the intervention group and the control group (p > 0,05). However, there were significant differences in religious coping scores between the groups in follow-up measurements (p< 0,05) (see Table 2). Based on the interviews with four participants, they felt some changes in themselves after the intervention, such as how to look at the condition of her role as a family caregiver. According to the participants, their perception of the reality of cancer suffered by their children has gradually changed from negative to positive as they recognize Allah's presence in it. It happened because the participants found wisdom or positive changes that occur when becoming a family caregiver. Trying to maintain a positive attitude toward Allah made the participants feel confident or optimistic to pass the role of the family caregiver as a form of worship in facing the test in life. According to the participants, one of the benefits of being a family caregiver is having more time to interact with and be close to family members.
The participants said they began to express dhikr while caring for their family, such as rest, feeding, or medication. The feeling of anxiety started to diminish, and they felt calmer when they were caring while meditating through dhikr. The participants' usual dhikr was to read istighfar while caring for her family. Although it was not done regularly, some participants also took the time to pray in the congregation. Furthermore, participants realized how important it was to keep other people's feelings from being offended and provoked by their emotions due to excessive speech or jokes. Previous experiences made them more empathetic when they were not treated well by others. Participants were also encouraged to help each other with daily activities while living in the dormitory.
This study aimed to increase the resilience of family caregivers of cancer through Islamic religious coping. The proposed hypothesis was accepted if there was a significant difference in resilience scores in family caregivers of cancer after the intervention when compared to the control group. The findings of this study are supported by Mosqueiro, Rocha, and Fleck (2015), who found that religiosity and spirituality are predictors and sources of resilience in people facing difficulties or living in stressful situations. Lamoshi (2015) added that Islam is a source of resilience for individuals in the face of life's problems. The findings are also consistent with Rahmati, Khaledi, Salari, Bazrafshan, and Ananhita (2017), who discovered that intervention with religious and spiritual approaches can increase resilience in Muslim families with family members undergoing medical treatment. Therefore, religion's process is to help individuals or family caregivers of cancer disease become more resilient.
The presence of positive or optimistic thoughts on the role of family caregivers influenced the participants' resilience. Yucel (2014) found that husnudzan (positive thinking to Allah) encourages people to focus on the positive rather than the negative. It also gives participants hope and confidence that there will be ease after difficulties. The individual who has husnudzan will recall the good things that happened to her in the past can feel more relieved with her current condition. According to Siddik and Uyun (2017), there is a significant positive correlation between husnudzan and psychological well-being. The participants expressed gratitude for having more time with their family members due to their role as family caregivers. The participants' resilience was influenced by their gratitude. Previous studies have found a significant positive correlation between gratitude and resilience (Kumar & Dixit, 2014;Listiyandini, 2018;Shabrina et al., 2020). Then, through gratitude, individuals reduce the negative emotions, such as envy, anger, hatred, and disappointment (Snyder & Lopez, 2002). Joint activities, such as the invitation to pray in the congregation, also influenced the change in resilience. Ashy (Uyun & Rumiani, 2012) found that prayer can reduce psychological pressure while also maintaining regularity and discipline. Although it has not been done regularly, participants who take the time to pray in the congregation help reduce the psychological burden of a family caregiver. Prayer can also cause a relaxation response that affects physiological and psychological conditions in the future (Syed, 2003).
The participants said that they were getting used to practicing dhikr while caring for their family members. Research conducted by Perwataningrum, Prabandari, and Sulistyarini (2016) found that meditating by reading istighfar sentences can reduce negative emotions, such as anxiety. The repetition of dhikr sentence can train an individual to build fighting power and seriousness in obtaining pleasure from Allah (Adz-Dzakiey, 2008). Dhikr was an effort by participants to control and calm themselves, and becoming accustomed to remembering Allah can affect the resilience level. Dhikr was also a way for participants to draw closer to Allah. Ahmadi, Bonab, Sarabandi, Sheikh, Khaligi, and Karimian (2014) said that closeness to Allah (secure attachment to God) is the factor that can improve resilience and mental health in people who undergo chronic life problems. One example is caring for family members who are suffering from chronic diseases such as cancer. Dhikr was also an effort by participants to regulate their emotions. Dhikr assists participants in becoming calmer by allowing them to focus on the present moment rather than overthinking about bad things that are not necessarily happening. Participants' ability to regulate emotions through dhikr can make them more resilient (Kay, 2016).
Other's prosocial behavior had a direct impact on participants living in dormitories. Prosocial behaviors that become social support for participants affected their resilience level. The participants were supported by professional caregivers who understand cancer to help the participants carry out the role of a family caregiver. According to Manzini, Brigola, Pavarini, and Vale (2016), a caregiver's resilience is influenced by others, experts, or professionals' social support. Sabouripour and Roslan (2015) pinpointed that social support and optimism are predictors of resilience. Resilient family caregivers positively correlate with the quality of life and positive adaptation, and a negative correlation with caregiver burden, depression, and anxiety (Toledano-Toledano et al., 2021;Üzar-Özçetin & Dursun, 2020). Qualitative research conducted by Fajriyati and Asyanti (2017) found that the coping stress strategies used by family caregivers of chronic diseases are emotion-focused coping, problemfocused coping, and religious coping. Hawken, Turner-Cobb, and Barnett (2018) conducted a meta-analysis study on caregivers' coping strategies and found a gap between commonly used coping stress strategies. Their study informed that problem-focused coping, emotion-focused coping, and cognitive strategies are all complimentary coping strategies that cannot be separated. Therefore, a holistic coping stress strategy is required to assist caregivers in overcoming burdens. The holistic coping stress strategy is characterized by fulfillment of cognitive, emotional, behavioral, social, and spiritual aspects. Based on the process and results of this study, it is obvious that religion plays an essential role in understanding an individual's resilience from many aspects. Through Islamic religious coping, individuals are facilitated to reflect on their responsibilities in the world as religious people, their relationships with themselves, and their role.
The process of Islamic religious coping can be a spiritual journey for individuals to solve problems in life. Realizing the presence of Allah makes people more positive in their interpretation and acceptance of their lives. Islamic religious coping encourages individuals to have positive behavior toward themselves and others, which increases resilience. Annalakshmi and Abeer (2011) found that resilience in the Islamic perspective is seen in religious practice and manifestations in behavior toward families, fellow human beings, and other creatures. The understanding and knowledge of religion are insufficient to explain resilience until it manifests in behavior. There are some limitations of this study. Because of the relatively small number of participants in the intervention and control groups, the results of this study have a weak external validity. The characteristics of participants in both groups of female gender also restricted the results of this study if they wanted to compare it with male caregivers.

CONCLUSION
Based on the results of this study, Islamic religious coping effectively increases resilience in family caregivers of cancer. In other words, after the intervention of Islamic religious coping, there is a substantial difference in resilience score between family caregivers of cancer in the intervention group and the control group. Participants in the intervention group noticed positive changes in their psychological, religious, and social lives. The increase in resilience scores was accompanied by an increase in religious coping scores among intervention group participants. Islamic religious coping helps the family caregiver reflect on her role from an Islamic point of view. The process of Islamic religious coping becomes a spiritual journey and holistic coping strategy for family caregivers to connect with Allah, themselves, and fellow human beings, which would be a novelty of this study.
The presence of psychological problems, which the family also feels, will impede the treatment of cancer patients if they do not receive appropriate psychological services. Psychological services or joint activities with psychologists on a regular basis may alleviate the family's burden. Islamic religious coping interventions can be provided to family caregivers in groups to support each other and gain a positive understanding from an Islamic point of view. Group or family support is considered necessary in undergoing the role of caregiver for chronic diseases because it takes a long time to provide care