2.4.1.

Symptom Distress Scale

The Symptoms Distress Scale (SDS) was used to measure patients’ symptom distress. It
contains 11 symptoms including nausea, appetite, insomnia, pain, fatigue, bowel pattern,
concentration, appearance, outlook, breathing and cough and 2 questions about frequency of
nausea and pain. Each symptom is rated by 5-point Likert scale from 1-5 (1 referring to normal
or no distress, 5 referring to extensive distress, 2-4 referring to intermediate levels of distress).
The two questions about frequency of nausea and pain are also with 5 point-scale where one
represents almost never experience the symptom and five means experience the symptom almost
constantly. The total scores more than equal 25 indicate moderate distress and scores of 33 or
more represent severe distress (McCorkle, Cooley & Shea, 1995). Cronbach alphas showed
range 0.7 – 0.85 (McCorkle, Cooley & Shea, 1995; Stapleton et al., 2016).
2.4.2. Hospital Anxiety and Depression Scale
Patients’ anxiety and depression were assessed by the Hospital Anxiety and Depression Scale
(HADS). The HADS consists of 2 subscales; anxiety (7 items) and depression (7 items). Each
item is rated on a 4-point Likert scale of 0-3. The scores were classified into 4 categories; 0-7
represent normal, 8-10 indicate mild cases of anxiety or depression, while the scores of 11-15
represent moderate cases of anxiety or depression and 16-21 score means severe cases of anxiety
or depression (Rudy, Widyadharma & Oka, 2015). The HADS has been translated in Indonesian
language. This tool had been used in stroke patients in Indonesia with good reliability (Kappa
coefficient of anxiety subscale 0.71; depression subscale is 0.68) (Rudy, Widyadharma & Oka,
2015).
2.4.3. The Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp-12)
The FACIT –Sp 12 was used to assess spiritual aspect which comprises of three factors with
12 items; meaning (four items), peace (four items) and faith (four items). A five-point Likert
scale is applied, ranging from 0 (not at all) to 4 (very much). Two items are negative statements
and need to be reversed for the score. Patient’s responses are summed for each subscale and for
the whole FACIT Sp-12. The higher scores of FACIT-Sp indicate the better spiritual state. High
spiritual well-being state was interpreted a total score of Facit-Sp 12 ≥ 36 (McClain, C. S.,
Rosenfeld, B., & Breitbart, W., 2003). This questionnaire was translated in previous study and
was reviewed by cancer specialist with the Cronbach alpha coefficients 0.84 (Widyaningsih,
Petpichetchian, & Kitrungrote, 2014).