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December 2012 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Salsman, J. M., Garcia, S.F., Lai, J. S. and Cella, D. "Have a little faith: measuring the impact of illness on positive and negative aspects of faith." Psycho-Oncology 21, no. 12 (December 2012): 1357-1361.


SUMMARY and COMMENT: Over the past decade, one instrument has become most associated with the idea of measuring positive and negative aspects of the interplay between religion/spirituality and health: the Brief RCOPE, which has proved enormously useful in many studies and now practically defines positive and negative religious coping during illness. Some researchers have offered variations for different purposes [--see Items of Related Interest §IV (below)], but the authors of this month's featured article present a new instrument utilizing the positive-negative framework and focusing on the "impact of illness on issues of faith" [p. 1360]. Chaplain researchers should benefit in their own thinking about the dynamics of positive-negative assessment by considering the Impact of Illness upon Faith (II-Faith) measure along side of the Brief RCOPE and bearing it in mind as an alternative for certain investigations.

The II-Faith grew out of a larger study and project to develop a bank of items on the psychosocial impact of illness for the National Institutes of Health-funded Patient Reported Outcome Measurement Information System (PROMIS, The initial focus of the authors was on the scope of the psychosocial impact of cancer, in terms of Stress/Coping, Self-Esteem, Social Impact, and Meaning/Spirituality [--see p. 1357 and Items of Related Interest §I (below)]. After a test of the conceptual model on 754 cancer patients and survivors, a further validation test with 509 such participants led to the data analyzed in the current article.

Given the importance of religion and spirituality for individuals with chronic illnesses such as cancer and the relative lack of brief assessments incorporating both negative and positive aspects of religious faith, we sought to (1) identify items from the Meaning/Spirituality item set of the Psychosocial Illness Impact measure [re: the larger study and project] useful for assessing positive and negative aspects of religious faith in a Faith short-form and (2) explore the psychometric properties of the resulting Faith short-form. [p. 1358]
Statistical analysis of Meaning & Spirituality items from the parent instrument indicated that nine were separable as "'faith' items" --five "positive" and four "negative," to which one conceptually and statistically appropriate "negative" item was added ("I feel punished by God") to create the final ten-item, two-domain measure.

It is important to reiterate that the II-Faith is intended as a measure of the "impact of illness on issues of faith" [p. 1360], and so its emphasis is perhaps related to but not exactly the same as that of the Brief RCOPE. Indeed, the authors propose that future studies might examine how the II-Faith relates to "positive and negative religious coping" [1360]. Chaplain researchers might be in a good position to undertake further exploration on this score, but contemplating the differences and similarities between the II-Faith and the Brief RCOPE may be instructive generally. See:

Brief RCOPE -- POSITIVE Items II-Faith -- POSITIVE Items
  - Looked for a stronger connection with God   - I feel close to God
  - Sought Godís love and care   - I find strength in prayer
  - Sought help from God in letting go of my anger   - I find comfort in my faith or spiritual beliefs
  - Tried to put my plans into action together with God   - I find strength in my faith or spiritual beliefs
  - Asked forgiveness of my sins   - I have a strong faith
  - Focused on religion to stop worrying about my problems
  - Tried to see how God might be trying to strengthen me in this situation
Brief RCOPE -- NEGATIVE Items II-Faith -- NEGATIVE Items
  - Wondered what I did for God to punish me   - I feel punished by God
  - Felt punished by God for my lack of devotion   - Difficult times weaken my spiritual beliefs
  - Wondered whether God had abandoned me   - I am losing my faith
  - Wondered whether my church had abandoned me   - Difficult times weaken my faith
  - Questioned Godís love for me   - I find it hard to pray
  - Questioned the power of God
  - Decided the devil made this happen

One distinction of this new instrument from the Brief-RCOPE is that the II-Faith repeats each item with the qualifiers, "before your illness" and "since your illness." [--see p. 1358]. This before-and-after strategy potentially makes for more of a state measure than a trait measure. [The corresponding author has communicated to the Network that another article is forthcoming that addresses the before-and-after strategy for questioning.]

Salsman and his colleagues conclude that "the II-Faith provides promise as a brief, valid, and reliable measure of the impact of illness on issues of faith" and stress the value of "[i]ndependent assessment of positive and negative faith dimensions" [p. 1360]. While the context of the present report is that of cancer patients, a related article on the larger project regarding assessment of psychosocial impact states that questionnaire items were created with an eye toward a broader scope of patients: "Given that psychosocial impact is experienced by people with various chronic diseases, items were worded in a general way to permit future adaptation to other illnesses" [p. 196 of Lai, J. S., Garcia, S. F., Salsman, J. M., Rosenbloom, S. and Cella, D., "The psychosocial impact of cancer: evidence in support of independent general positive and negative components," Quality of Life Research 21, no. 2 (March 2012): 195-207; and see Items of Related Interest §I (below)]

A final comment from this reader's perspective as a chaplain: This article makes a significant contribution to the research literature on spirituality & health, especially with regard to exploring the "positive"-"negative" assessment framework. The authors have chosen to use the language of faith here, and that term itself has been largely ignored in the health care literature (which favors religion and spirituality), but they do not specifically define the conceptual boundaries and qualities of faith vis-ŗ-vis religion, spirituality, or other terms like beliefs. Their assertions that "[f]aith is a concept related to Meaning and Spirituality, but psychometrically distinct" [p. 1359] and that a "faith" component of questionnaires "may be distinct from more existential counterparts" [p 1357] refer back to other articles that do not really define the concept either. Our authors use the phrase "religious faith" [p. 1358], and so that would seem to imply some essential connection being made between those two concepts, but faith appears to need greater explication. [See, however, Related Items of Interest §II (below)].


Suggestions for the Use of the Article for Discussion in CPE: 

This month's article is admittedly suited more to researchers than CPE students, but it should be engaging to students at a conceptual level regarding the positive and negative impact of illness. The table on p. 1359, listing the tested "faith" items could suggest aspects of illness impact that chaplains should be especially sensitive to and prepared to address. How have students encountered these themes in their patient visitation? Does the present study's identification of ten items that may be particularly relevant to the experience of with illness invite students to think of new areas for pastoral concern? Does it seem feasible that the impact of illness could have both positive and negative effects on a single person (i.e., the effects are not exclusive of one another)? The article also raises a good question about generalizing results: participants are said to have been from a "predominantly White convenience sample" [1360]. How might this present difficulties in generalizing to other groups?


Related Items of Interest:

I. A report from the larger study and project to develop a bank of items on the psychosocial impact of cancer, using a positive-negative instrument framework, may be found in the following article. Note the listing of 43 positive illness impact items and 45 negative illness impact items on pp. 204 and 205, grouped according to the domains of Stress/Coping, Self-Esteem, Social Impact, and Meaning/Spirituality.

Lai, J. S., Garcia, S. F., Salsman, J. M., Rosenbloom, S. and Cella, D. "The psychosocial impact of cancer: evidence in support of independent general positive and negative components." Quality of Life Research 21, no. 2 (March 2012): 195-207. [(Abstract:) PURPOSE: Considerable research has demonstrated the negative psychosocial impact of cancer. Recent work has highlighted positive psychosocial outcomes. Research is now needed to evaluate the relationship between negative and positive impacts. This paper reports the development and validation of a measurement model capturing positive and negative psychosocial illness impacts. METHODS: The sample included 754 cancer patients on- or post-treatment. Item development was informed by literature review, expert input patient interviews and the results of a pilot study of 205 cancer patients, resulting in 43 positive and 46 negative items. Factor analyses were used to evaluate the dimensionality of the item pools. Analysis of variance (ANOVA) was used to examine relationships between psychosocial illness impact and other variables. RESULTS: Unidimensionality was demonstrated within but not across negative and positive impact items. ANOVA results showed differential relationships between negative and positive impacts, respectively, and patient sociodemographic and clinical variables. CONCLUSION: Positive and negative psychosocial illness impacts are best conceptualized and measured as two independent factors. Computerized adaptive tests and short-form measures developed from this comprehensive psychosocial illness impact item bank may benefit future research and clinical applications.]


II. Faith has recently been the subject of a concept analysis in the nursing literature. While it may be limited, it does give a sense of the concept as pertinent to the spirituality & health literature.

Dyess, S. M. "Faith: a concept analysis." Journal of Advanced Nursing 67, no. 12 (December 2011): 2723-2731. [(Abstract:) AIM: This paper reports a concept analysis of faith. BACKGROUND: There are numerous scholars who consider spirituality and religiosity as they relate to health and nursing. Faith is often implied as linked to these concepts but deserves distinct exploration. In addition, as nursing practice conducted within communities of faith continues to emerge, concept clarification of faith is warranted. METHOD: Qualitative analysis deliberately considered the concept of faith within the lens of Margaret Newman's health as expanding consciousness. Data sources used included a secondary analysis of stories collected within a study conducted in 2008, two specific reconstructed stories, the identification of attributes noted within these various stories and selected philosophical literature from 1950 to 2009. FINDINGS: A definition was identified from the analysis; faith is an evolving pattern of believing, that grounds and guides authentic living and gives meaning in the present moment of inter-relating. Four key attributes of faith were also identified as focusing on beliefs, foundational meaning for life, living authentically in accordance with beliefs, and interrelating with self, others and/or Divine. CONCLUSION: Although a seemingly universal concept, faith was defined individually. Faith appeared to be broader than spiritual practices and religious ritual and became the very foundation that enabled human beings to make sense of their world and circumstances. More work is needed to understand how faith community nursing can expand the traditional understanding of denominationally defined faith community practices and how nurses can support faith for individuals with whom they encounter within all nursing practice.]


III. This month's featured article notes briefly the use of a measure regarding benefit-finding and gives a reference for the Benefit-Finding Scale as Helgeson, V. S. and Tomich, P. L., "Surviving cancer: a comparison of 5-year disease-free breast cancer survivors with healthy women," Psycho-Oncology 14, no. 4 (April 2005): 307-317. However, for students interested in exploring the concept or the scale, that reference may not be the most useful. Other good sources would be:

Helgeson, V. S., Reynolds, K. A. and Tomich, P. L. "A meta-analytic review of benefit finding and growth." Journal of Consulting & Clinical Psychology 74, no. 5 (October 2006): 797-816. [This is a rather technical but very thorough article from key scholars of the concept.]

Tomich, P. L. and Helgeson, V. S. "Is finding something good in the bad always good? Benefit finding among women with breast cancer." Health Psychology 23, no. 1 (January 2004): 16-23. [See the Benefit-finding Scale items in the table on p. 19.]

See also the work of Kenneth I. Pakenham on benefit-finding in the context of multiple sclerosis, in our January 2008 Article-of-the-Month, especially §I of that page's Items of Related Interest.


IV. The Brief RCOPE has been a point of departure for several variations, in light of cultural differences. For example:

Aflakseir, A. and Coleman, P. G. "Initial development of the Iranian Religious Coping Scale." Journal of Muslim Mental Health 4, no. 1 (2011). [This study aimed to develop a religious coping measure for Iranians comparable to Pargamentís RCOPE scale. A group of university students (N = 185) completed the research measures. The findings of this study demonstrated that the religious coping scale developed for use with Iranians had five factors comprising religious practice, benevolent reappraisal, negative feelings towards God, passive and active religious coping. The study also showed that the different scales of religious coping had good internal consistency and test-retest reliability and construct validity. The results indicated that Iranian students used positive religious cop- ing methods more frequently than negative strategies. The present research also indicated a significant association between the dimensions of positive religious coping, such as religious practice and psychological well-being. The results suggest that this scale may be useful to the researchers interested in religious coping within Islamic context.]

Rosmarin, D. H., Pargament, K. I., Krumrei, E. J. and Flannelly, K. J. "Religious coping among Jews: development and initial validation of the JCOPE." Journal of Clinical Psychology 65, no. 7 (July 2009): 670-683. [See our July 2009 Article-of-the-Month.]

Zwingmann, C., Wirtz, M., Muller, C., Korber, J. and Murken, S. "Positive and negative religious coping in German breast cancer patients." Journal of Behavioral Medicine 29, no. 6 (December 2006): 533-547. [(Abstract:) A growing interest has been focusing on the relationship between religious coping and psychosocial adjustment among cancer patients. However, previous research mostly has not differentiated between positive and negative components of religious coping. The current cross-sectional study investigated the role of both positive religious coping, i.e., a confident and constructive turning to religion, and negative religious coping, i.e., religious struggle and doubt, in a sample of 156 German breast cancer patients. Participants were assessed upon admission to an inpatient rehabilitation program. In addition to religious coping, two basic nonreligious coping styles (depressive coping and active problem-focused coping) and psychosocial adjustment (anxiety and depression) were measured. Major research questions concerning the mediating role of nonreligious coping and the relative predictive power of positive and negative religious coping were primarily addressed using structural equation modeling. Results indicated that the relationship between religious coping and psychosocial outcomes was completely mediated by nonreligious coping, whereby only depressive coping and not active problem-focused coping proved to be a mediating variable. Positive and negative religious coping were somewhat positively related to each other; their (indirect) predictive power on psychosocial adjustment was identical though in an opposite direction. All in all, the results correspond to previous Anglo-American research. There are, however, some discrepancies which may be due to the specific religious-cultural background in Germany.]

[NOTE: For more on the Brief RCOPE measure itself, see the April 2009 Article-of-the-Month, specifically the Items of Related Interest on that page.]


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