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October 2015 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Canada, A. L., Murphy, P. E., Fitchett, G. and Stein, K. "Re-examining the contributions of faith, meaning, and peace to quality of life: a report from the American Cancer Society’s Studies of Cancer Survivors-II (SCS-II)." Annals of Behavioral Medicine 50, no. 1 (February 2016): 79-86. [This article was originally featured ahead-of-print.]


COMMENT and SUMMARY: Over the past 20 years, one of the most popular measures in Spirituality & Health research has been the FACIT-Sp (the Spirituality subscale of the Functional Assessment of Chronic Illness Therapy), and it has been at the heart of various studies previously featured by our Network, including the one just last month. Its twelve items were first proposed and validated according to a two-factor structure: 1) Meaning and Peace and 2) Faith. Later, a three-factor structure was validated, with Meaning, Peace, and Faith all being separately measured dimensions of Spirituality [--see Items of Related Interest, §I, below]. It is noteworthy that this instrument highlights the term faith, which is relatively little used in the overall research literature that continues to struggle with basic terminology in the field. Not even a 2011 nursing concept analysis of faith [see Items of Related Interest, §II, below] was able to distinguish it sharply enough from spirituality or religion to gain traction in the literature. Findings from the 2002 article that introduced the FACIT-Sp, "suggest[ed] that the Faith subscale may measure a dimension of spirituality that overlaps with, or is enhanced by, religion" [p. 56 of Peterman, et al. --see Items of Related Interest, §I, below]. Perhaps, for our purposes, faith is most practically understood by the four items of the FACIT-Sp that purport to measure it:

  • I find comfort in my faith or spiritual beliefs
  • I find strength in my faith or spiritual beliefs
  • My illness has strengthened my faith or spiritual beliefs
  • I know that whatever happens with my illness, things will be okay
          [--The full questionnaire may be obtained from]

It is faith, as measured by the FACIT-Sp, that is the emphasis of our article this month. The authors, one of whom was a co-author of the original 2002 introductory article and all of whom have published on the FACIT-Sp, hold that numerous studies using the instrument may have underestimated the role of faith as a dimension of spirituality/religion on Quality of Life (QoL) by not taking into account both its direct and indirect effects in relation to the Meaning and Peace domain(s). They challenge the tendency of researchers to find Faith as generally a lesser influence on QoL than Meaning/Peace, proposing that "faith plays a more central role in [cancer] survivors' QoL via indirect effects through meaning and peace" [p. 80]. This is a model of a mediated relationship, whereby Faith not only exerts a direct effect on QoL but also -- and importantly -- an indirect effect through the dimensions of Meaning and Peace. In other words, "meaning and peace are mediators of the way that faith influences cancer survivors' QoL" [p. 80, emphasis added]. (The authors are preferring here the three-factor model of the FACIT-Sp that separates out Meaning and Peace to the two-factor model that combines them, and the study actually works from the same data set used previously to examine the three-factor model [--see Peterman, et al., in Items of Related Interest, §I, below].)

The researchers analyzed data from 8405 participants in a national, cross-sectional study from the American Cancer Society examining psychosocial functioning and QoL in cancer survivors who were two, five and ten years post-diagnosis [--see Items of Related Interest, §III, below].) FACIT-Sp scores were evaluated in relation to both the mental and physical functioning scales from the SF-36.

Findings are presented in statistical detail, narratively and in tables and in diagrams depicting the direct and indirect (mediated) pathways of influence, which provide elegant summaries.

The total and mediated effect of faith on mental functioning ("using only meaning as a mediator of the impact of faith on the mental component summary of the SF-36, to avoid inflation of results from similar items in the measurement of peace and mental functioning" [p. 80]):

The total and mediated effect of faith on physical functioning:

To put these results in plain words:

The findings support our hypothesis that faith makes significant and meaningful contributions to cancer survivors' functional QoL, both directly and indirectly through meaning and peace. …The results described here are consistent with a religious meaning system and stand in contrast to the reports of other studies…that have asserted it is primarily meaning, not faith, that accounts for the association between spiritual well-being and QoL in survivors of cancer. Our finding that faith has a larger effect on mental functioning than physical functioning is consistent with other reports…. [p. 84]
The authors further make the quite strong statement that their results "suggest that investigators…who imply that the role of faith in QoL is minimal or non-existent have misinterpreted their findings" [p. 84]. They do address limitations to the research, but maintain that "[i]f these findings are replicated in longitudinal designs, investigators will need to reconsider the role of faith in studies of QoL with oncology populations" [p. 84].

Returning to the very concept of faith, however, this reader appreciated the following comments in conclusion:

In light of its widespread use, several concerns about the FACIT-Sp must be considered, including what it measures. Critics of the FACIT-Sp suggest the items simply measure emotional well-being or quality of life…. This debate about the FACIT-Sp reflects the ongoing debate about definitions of religion and spirituality…. Investigators should become familiar with the literature about definitions and measurement of R/S [i.e., religion/spirituality] before assuming that, because of its widespread use, the FACIT-Sp is the best measure for a given project. Future research will benefit from a move beyond broad measures of generic R/S or spiritual well-being, such as the FACIT-Sp, to examine the role of more specific dimensions of R/S in coping with cancer. Once this goal is accomplished, the models described here will need to be retested. [p. 84]
This article would seem to highlight for chaplains the caution necessary in using even well-established measures in Spirituality & Health research.


Suggestions for the Use of the Article for Student Discussion: 

This month's article would be a good follow-up to the September Article-of-the-Month, which used the FACIT-Sp and found, among other things, that the Meaning and Peace subscale (taken together) affected better adjustment and functioning among hematopoietic stem cell transplantation recipients, but not the Faith subscale. A suggestion for discussing the September article was for students to consider the differences in findings for Meaning and Peace vis-à-vis Faith, and if a CPE group did explore that then they should be on track to delve further into the subject this month. The present article may demand a particular interest in quantitative methodology and an ability to read through statistical material, but it is clearly written and should be accessible to any CPE group, though some students may need to use a strategy of reading the Introduction and Discussions sections first before the Results section. For those students less interested in statistics, they may be invited to consider the conceptualizations of the FACIT-Sp itself, especially that of the Faith subscale. What do students make of the quote from Harold Koenig: "One would expect stronger relationships between R/S and mental health since R/S involvement consists of psychological, social, and behavioral aspects that are more 'proximally' related to mental health than to physical health" [p. 84]? Of course, the present study would be an excellent entrée to a discussion of indirect or mediated effects. While the basic idea of mediation may seem clear, there is always a risk of confusion when articles are discussed, so it may be helpful to draw on a whiteboard the following:

Here, an independent variable affects a mediator variable (relationship A) which then affects a dependent variable (relationship B). The mechanism of mediation differs from one by which an independent variable would directly affect a dependent variable (relationship C).


Related Items of Interest:

I. The key articles about the twelve-item FACIT-Sp are:

Canada, A. L., Murphy, P. E., Fitchett, G., Peterman, A. H. and Schover, L. R. "A 3-factor model for the FACIT-Sp." Psycho-Oncology 17, no. 9 (September 2008): 908-916. [(Abstract:) OBJECTIVE: The 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp) is a popular measure of the religious/spiritual (R/S) components of quality of life (QoL) in patients with cancer. The original factor analyses of the FACIT-Sp supported two factors: Meaning/Peace and Faith. Because Meaning suggests a cognitive aspect of R/S and Peace an affective component, we hypothesized a 3-factor solution: Meaning, Peace, and Faith. METHODS: Participants were 240 long-term female survivors of cancer who completed the FACIT-Sp, the SF-12, and the BSI 18. We used confirmatory factor analysis to compare the 2- and 3-factor models of the FACIT-Sp and subsequently assessed associations between the resulting solutions and QoL domains. RESULTS: Survivors averaged 44 years of age and 10 years post-diagnosis. A 3-factor solution of the FACIT-Sp significantly improved the fit of the model to the data over the original 2-factor structure (Delta chi(2)=72.36, df=2, p<0.001). Further adjustments to the 3-factor model resulted in a final solution with even better goodness-of-fit indices (chi(2)=59.11, df=1, p=0.13, CFI=1.00, SMRM=0.05).The original Meaning/Peace factor controlling for Faith was associated with mental (r=0.63, p<0.000) and physical (r=0.22, p<0.01) health on the SF-12, and the original Faith factor controlling for Meaning/Peace was negatively associated with mental health (r=-0.15, p<0.05). The 3-factor model was more informative. Specifically, using partial correlations, the Peace factor was only related to mental health (r=0.53, p<0.001); Meaning was related to both physical (r=0.18, p<0.01) and mental (r=0.17, p<0.01) health; and Faith was negatively associated with mental health (r=-0.17, p<0.05). CONCLUSION: The results of this study support a 3-factor solution of the FACIT-Sp. The new solution not only represents a psychometric improvement over the original, but also enables a more detailed examination of the contribution of different dimensions of R/S to QoL.]

Murphy, P. E., Canada, A. L., Fitchett, G., Stein, K., Portier, K., Crammer, C. and Peterman, A. H. "An examination of the 3-factor model and structural invariance across racial/ethnic groups for the FACIT-Sp: a report from the American Cancer Society's Study of Cancer Survivors-II (SCS-II)." Psycho-Oncology 19, no. 3 (March 2010): 264-272. [(Abstract:) OBJECTIVES: Recent confirmatory factor analysis (CFA) of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) Scale in a sample of predominantly white women demonstrated that three factors, Meaning, Peace, and Faith, represented a psychometric improvement over the original 2-factor model. The present study tested these findings in a more diverse sample, assessed the stability of the model across racial/ethnic groups, and tested the contribution of a new item. METHODS: In a study by the American Cancer Society, 8805 cancer survivors provided responses on the FACIT-Sp, which we tested using CFA. RESULTS: A 3-factor model provided a better fit to the data than the 2-factor model in the sample as a whole and in the racial/ethnic subgroups (Deltachi(2), p<0.001, for all comparisons), but was not invariant across the groups. The model with equal parameters for racial/ethnic groups was a poorer fit to the data than a model that allowed these parameters to vary (Deltachi(2)(81)=2440.54, p<0.001), suggesting that items and their associated constructs might be understood differently across racial/ethnic groups. The new item improved the model fit and loaded on the Faith factor. CONCLUSIONS: The 3-factor model is likely to provide more specific information for studies in the field. In the construction of scales for use with diverse samples, researchers need to pay greater attention to racial/ethnic differences in interpretation of items.]

Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L. and Cella, D. "Measuring spiritual well-being in people with cancer: the Functional Assessment of Chronic Illness Therapy--Spiritual Well-Being Scale (FACIT-Sp)." Annals of Behavioral Medicine 24, no. 1 (January 2002): 49-58. [(Abstract:) A significant relation between religion and better health has been demonstrated in a variety of healthy and patient populations. In the past several years, there has been a focus on the role of spirituality, as distinctfrom religion, in health promotion and coping with illness. Despite the growing interest, there remains a dearth of well-validated, psychometrically sound instruments to measure aspects of spirituality. In this article we report on the development and testing of a measure of spiritual well-being, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACI T-Sp), within two samples of cancer patients. The instrument comprises two subscales--one measuring a sense of meaning and peace and the other assessing the role of faith in illness. A total score for spiritual well-being is also produced. Study 1 demonstrates good internal consistency reliability and a significant relation with quality of life in a large, multiethnic sample. Study 2 examines convergent validity with 5 other measures of religion and spirituality in a sample of individuals with mixed early stage and metastatic cancer diagnoses. Results of the two studies demonstrate that the FACIT-Sp is a psychometrically sound measure of spiritual well-being for people with cancer and other chronic illnesses.]


II. For more on the concept of faith, in relation to the present concern of its nature for the field of spirituality/religion and health, see the following article by Susan MacLeod Dyess. It has to date been cited at least seven times (according to the Science Citation index), though in no articles focused on the conceptualization issue.

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.]

Editor's note about the literature on the concept of faith:
The broader philosophical/theological literature on the concept of faith does not tend to address the sort of practical issues of terminology germane to present-day Spirituality & Health research. Still, it may be of interest to chaplains. For instance, Nathan Rotenstreich’s On Faith (ed. by Mendes-Flohr, P., University of Chicago Press, 1998) approaches the concept of faith as an attitude distinct from cognition and religion, though he acknowledges the affinity between faith and religion and uses religious concepts in exploring the phenomenon of faith. Rotenstreich also sees faith in relation to belief and feeling, among other concepts. A similarly broad but quite different approach is taken by William Lad Sessions in The Concept of Faith: A Philosophical Investigation (Cornell University Press, 1994), in which he outlines seven major conceptions of faith (i.e., Thomistic Christian, Calvinist Christian, Lutheran Christian, Contemporary Reconstructive, Tripartite Hindu, Shin Buddhist, and Son Buddhist) that may be seen in light of six models (i.e., Personal Relationship, Belief, Attitude, Confidence, Devotion, and Hope). In the end, Sessions argues not for a simple definition of faith but for a unified quality in the phenomenon that allows for its application across diverse contexts. Works such as these by Rotenstreich and Sessions are richly thought-provoking in their own right, but they offer philosophical/theological groundwork that may be informative to the continued development of research concepts and measures.


III. The following article gives background information on the American Cancer Society’s studies of Cancer Survivors, data from which was used in our present study:

Smith, T., Stein, K. D., Mehta, C. C., Kaw, C., Kepner, J. L., Buskirk, T., Stafford, J. and Baker, F. "The rationale, design, and implementation of the American Cancer Society's studies of cancer survivors." Cancer 109, no. 1 (January 1, 2007): 1-12. [(Abstract:) The American Cancer Society (ACS) defines cancer survivorship as beginning at diagnosis with cancer and continuing for the balance of life and views quality of life (QOL) as a key outcome. In this article, the authors describe the rationale, methodology, and sample characteristics of the 2 ACS Studies of Cancer Survivors (SCS): 1) a longitudinal study identifying and surveying survivors approximately 1 year postdiagnosis that includes plans to resurvey the panel at 2 years, 7 years, and 12 years postdiagnosis to identify predictors of QOL; and 2) a cross-sectional study of QOL among 3 separate cohorts of survivors who were approximately 3 years, 6 years, and 11 years postdiagnosis at the time of data collection. Survivors of prostate, breast, lung, colorectal, bladder, skin, kidney, ovarian, and uterine cancers and of non-Hodgkin lymphoma were sampled from 25 different central cancer registries, with African-American and Hispanic survivors over sampled. Survivors completed either mail or telephone surveys that described their physical, psychological, social, and spiritual functioning. The overall recruitment rate was 34.0%; 15411 participants completed surveys, of whom 40.1% had a high school education or less and 19.4% were racial/ethnic minorities. The SCS surveys provide a large diagnostically, geographically, and demographically diverse database on cancer survivorship that was designed to overcome some of the limitations of past research. Future reports will compare QOL of survivors at different well-defined times postdiagnosis, investigate the issues of understudied populations and diagnostic groups, and describe survivor QOL at state levels. Insights valuable to those considering registry-based studies are offered on issues of ascertainment, sampling, and recruitment.]



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