Journal of Preventive Medicine

Cancer is one of the chronic and non-communicable diseases that includes a wide group of diseases. Breast cancer is one of the most common cancers among women. Each year, 6 thousand women in Iran get this disease. Since cancer causes many problems for them, it can leave a deep impact on their body image. The changes such as hair loss, body deformity or limb amputation may cause women feel uncomfortable. One of the psychological treatment methods to control this anxiety is cognitive hypnotherapy (CH). It is one of the oldest methods that is effective in managing poor body image. Spiritual therapy (ST) is another method of treatment. Spirituality is an important resource for adapting to stressful events in life. The purpose of this study is to compare the effects of CH and ST on the body image concern of women with breast cancer.

Methods
This is a quasi-experimental study with a pre-test/post-test design. The study population consists of all women with breast cancer referred to Mirdamad clinic in Gorgan, Iran (n=800). Of these, 30 were selected using a convenience sampling method and then were divided into two intervention groups (CH and ST each with 20 people) and one control group with 10 people. The control group did not receive any intervention but put on the waiting list. The inclusion criteria were the consent to participate, reading and writing literacy, having the cancer for at least 6-7 months, not reaching the fourth level and the need for surgery, chemotherapy and radiotherapy. The exclusion criteria were mental disorders, taking psychiatric drugs, and absence from more than two sessions of intervention. The data collection tool was the Body Image Concern Inventory (BICI) developed by Littleton et al. (2005). 
It has 19 items rated on a five-point Likert scale from 1 (never) to 5 (always) and two subscales of dissatisfaction with appearance (Items 1,3,5,8,9,14,15,16,17,18,19) and social dysfunction due to concern about appearance (items 2,4,6,7,10,11,12,13). Basaknejhad and Ghaffari [18] reported the acceptable internal consistency of the Persian version of BICI (Cronbach's alpha=0.96 and 0.89, respectively). The ST group received spiritual intervention based on the ST protocol at eight 150-minute group sessions, one session per week. The CH group received 8 group sessions of CH, each for 150 minutes

Results
The results of ANCOVA showed that both CH and ST had a significant positive effect on reducing body image concern, and there was no significant difference between the two methods.

Conclusion
Since breast cancer targets the female body, it has negative psychological effects on the woman and her family, including body image concern which has important effects on their well-being. This study revealed that both CH and ST had a significant positive effect on reducing body image concern of women with breast cancer in Iran. Our results related to the effectiveness of CH are consistent with the results of Janbaz Fereydoni et al. [17] and Ahmadifard et al. [21] Our results related to the effectiveness of SH are consistent with the results of Mohammadizadeh et al. [22] and Abbarin et al. [16]. The effect of ST can be due to changing a person's knowledge and perception towards illness and life. The cognitive change has an effect on the cognitive evaluations of a person and helps her manage stressful life situations consciously and rationally. Spirituality, along with religious rituals and ceremonies such as praying, plays an important role in accepting the disease. In fact, spirituality is a part of a person's being that develops humanity in her and has specific effects that help her deal with the disease.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of the Islamic Azad University of Bojnord Branch (Code: IR.IAU.BOJNOURD.REC1400.016) and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20211109053024N1).

Funding
This article was extracted from the doctoral thesis of Azam Solaymani registered by Faculty of Humanities, Islamic Azad University of Bojnord Branch. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions 
The authors contributed equally to preparing this paper.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank Dr. Shariatnia, Dr. Sabouri and other personnel of Mirdamad Clinic in Gorgan City and all participants for their cooperation in this study.

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