Cancer is a severe health conditions and poses great risk of spiritual distress. O’Conner-Von12 stated that adolescence is a period of transition from dependent child to independent adult and if adolescence able to adapt with their illness, they will be independent and will use healthy coping strategies.

Reynolds et al13 stated that positive spiritual coping strategies correlate with fewer problems in adolescents with chronic illness. Someone with a negative spiritual coping strategy could be detrimental, such as when believing that what happened was a punishment from God14.

In this study, adolescents had both negative and positive spiritual coping strategies. Negative spiritual coping strategies were shown when participants were first diagnosed with cancer. After a therapy program, these patients began to sincerely accept their condition. Positive spiritual coping strategies were mostly demonstrated by participants who had been diagnosed with cancer for more than a year and were entering the maintenance treatment phase. As matter of fact, some of them were undergoing chemotherapy again due to relapse.

Taylor et al15 claimed that adolescents who were diagnosed with cancer and had the possibility of facing sudden death often have more focused attention on their spirituality regardless whether the disease is in remission, relapsing, or even cannot be cured. This result was also congruent with Engvall et al study16, which claimed that the psychosocial function of adolescents with cancer improves over time. It even becomes exemplary as their health improves, and they are often less anxious and depressed compared to the noncancer group of adolescents the same age.

Believing that the illness they suffered was God’s will indicates that adolescents believe that everything that happens in life is part of God’s plan. Adolescents with illnesses rely more on spiritual beliefs to overcome their problems17.

Someone who is facing difficulties usually reverts to the Almighty as “something” greater than themselves18. In this study, some participants said that the disease they suffered occurred because God granted it to them, while other participants said that when God makes you ill, then He will provide the relief as well.

Some participants in this study claimed that the disease they are currently experiencing comes from God, so God will give the cure as well. Participants understood that something going on in their life was a destiny from God. Religious belief about the possibility of recovery by a miracle and God’s will is also included among religious sources that give them high life expectancy19.

Fowler’s spiritual development theory described that at this stage of life, an adolescent is capable of understanding abstract things and believing and accepting that God has supreme power. One of the participants gave a statement on this theme: “God gave us this disease, definitely along with its cure.” The finding of adolescents’ beliefs that the illness they suffered is the will of God is an indication that adolescents accept their condition. This result corresponds with Ragsdale et al study20, which stated that God has His own reason to choose them to experience the illnesses, and they believe that they are chosen by God.

Adolescents use different coping strategies and beliefs as one of the main techniques to provide comfort. Spiritual practice is a religious practice that is often identified by the patient as a prayer to cope with the disease21. In this study, all participants said that they improved their overall spiritual activity even more after experiencing the disease, as the disease increased their trust in God and their expectations of healing. Spiritual activities were performed in accordance with their religious beliefs.

Spurr et al8 stated that adolescents whose spirituality represented a good relationship with God are associated with the belief in accordance with their beliefs. Another study conducted by Revuelta-Iniesta et al22 revealed that respondents admitted that they used spiritual treatment. Praying is most popular for children, followed by the children praying for themselves. Prayer or religion is also often used to manage the symptoms suffered by children with sickle cell anemia23.

A phenomenology study conducted by Al Omari et al24 on the coping strategies of adolescents with cancer stated that adolescents improved their prayers to overcome their suffering. Rahnama et al19 said that a relationship with Allah through praying, cultivating an inner relationship with Allah, and talking to Allah are recognized as spiritual practices.

Prayer or other rituals related to spirituality or religion have the ability to produce a calming effect, love, or a sense of belonging for one’s self, and this kind of practice is considered to provide health benefits25. The adolescents in this study showed closeness to God through prayer, participation in religious activities, and through reading the holy book. They said prayers made their lives better.

Empathy is a response by someone to understand others. The theme of empathy in this study demonstrated that adolescents felt their situation was a burden to their parents. Santrock26 stated that autonomy is important in adolescence as autonomy makes them want to reduce childhood dependence on their parents, develop emotional autonomy, and reduce the ideal image of parents and dependence of emotional support from their parents.

Participants in this study felt sad because their parents had to wait for them during therapy, and because their parents had to afford a great amount of finance to pay for the treatment. This coincides with the study conducted by Clayton-Jones et al27, which stated that adolescents who participate in a collaborative relationship with God believe they must do their part and should not trouble others.

Cancer experienced by adolescents changes their relationships with peers and family. Parents generally perceive themselves as protectors, and this has been proven by children responding to their parents as protectors. On the one hand, adolescents were happy to show a cheerful attitude because they were protected by parents and family members. On the other hand, the children actually wanted to avoid making their parents feel sad or disappointed about what had happened to them28.

Cancer causes some changes in adolescent relationships with parents, family, and peers. A study conducted by Pehler and Craft-Rosenberg29 explained that the experience of living spiritually is interpreted by teenagers as a desire to change their lives by improving their spiritual relationships, which is shown by relationship with oneself, others, and beyond self.

Hendricks-Ferguson said that adolescents with cancer have diverse spiritual resources. The authors also suggested that when physical limitations due to treatment and side effects begin to subside, adolescents are more dependent on peer support and less on spiritual support. This is also in line with the study30 by Al Omari et al24 that friendship is another contributing factor in helping adolescents to cope with their disease.

Adolescents in this study motivated themselves by doing their own hobbies. Cancer treatment requires a long period of time, which made them feel exhausted and bored. Participants in this study attempted to overcome their boredom by doing beneficial activities, such as playing games, singing, sports, and following the activities held by the Cancer Foundation.

Souza et al30 explained that adolescents living with cancer often experience fear, anxiety, restlessness, unreliability, despair, and helplessness. Adolescents try to find comfort, as well as cope with the stress of the illness they experience, through spirituality, belief, and faith. They keep thinking positively, which can give them strength, calmness, and confidence, as well as increase self-care to improve their health, spiritual coping strategies and emotions—giving meaning to life by being around friends and family. Activities performed by the participants to get rid of their boredom are positive activities.