Psycho-Oncology Psycho-Oncology 16: 676687 (2007) Published online 27 November 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.

1129

Effects of prayer and religious expression within computer support groups on Women with Breast Cancer
Bret Shaw1*, Jeong Yeob Han2, Eunkyung Kim2, David Gustafson3, Robert Hawkins2, James Cleary4, Fiona McTavish1, Suzanne Pingree5, Patricia Eliason5 and Crystal Lumpkins6
1 2

The Centre of Excellence in Cancer Communication Research, University of Wisconsin-Madison, USA School of Journalism and Mass Communication, University of Wisconsin-Madison, USA 3 Department of Industrial Engineering, University of Wisconsin-Madison, USA 4 Department of Medicine, University of Wisconsin-Madison, USA 5 Department of Life Science Communication, University of Wisconsin-Madison, USA 6 School of Journalism, University of Missouri-Columbia, USA * Correspondence to: The Centre of Excellence in Cancer Communication Research, University of WisconsinMadison, USA. E-mail: bretshaw@chsra.wisc.edu

Abstract
Research indicates that two common ways breast cancer patients or women with breast cancer cope with their diagnosis and subsequent treatments are participating in computer support groups and turning to religion. This study is the rst we are aware of to examine how prayer and religious expression within computer support groups can contribute to improved psychosocial outcomes for this population. Surveys were administered before group access and then 4 months later. Message transcripts were analyzed using a word counting program that noted the percentage of words related to religious expression. Finally, messages were qualitatively reviewed to better understand results generated from the word counting program. As hypothesized, writing a higher percentage of religion words was associated with lower levels of negative emotions and higher levels of health self-ecacy and functional well-being, after controlling for patients levels of religious beliefs. Given the proposed mechanisms for how these benets occurred and a review of the support group transcripts, it appeared that several dierent religious coping methods were used such as putting trust in God about the course of their illness, believing in an afterlife and therefore being less afraid of death, nding blessings in their lives and appraising their cancer experience in a more constructive religious light. Copyright # 2006 John Wiley & Sons, Ltd.
Keywords: cancer; oncology; online support group; internet; religion/prayer

Received: 8 February 2006 Revised: 11 October 2006 Accepted: 11 October 2006

Introduction
Breast cancer is the most commonly diagnosed cancer in the US, and the second leading cause of cancer death in women. About 211 240 women in the US will be diagnosed with invasive breast cancer this year, and there are more than two million women living in the US who have been treated for breast cancer [1]. Not surprisingly, research has found that a breast cancer diagnosis and subsequent treatments are a traumatic set of events and that patients face a variety of psychosocial concerns such as isolation and loneliness [2] as well as psychological diculties such as distress, depression, and anxiety [3]. Research also indicates that distress associated with breast cancer can persist in survivors for 5 years and longer following the initial breast cancer diagnosis [4]. Given the high prevalence of breast cancer and suering associated with the diagnosis, it is

important to identify and understand how various coping mechanisms may succeed in reducing suering and improving the quality of life for this patient population. One increasingly common method that women with breast cancer are using to cope with their health crisis is participation in online support groups. The number of people participating in these groups currently counts in the millions and has been rising steadily the past few years [5]. In the past decade, a number of studies on how women with breast cancer use these groups have been published. There have been a number of descriptive accounts [68] related to whether people will use such groups, the extent to which they will do so, and the general nature of the support exchanged within such groups. Other research oers a more qualitative, phenomenological account of the discourse exchanged within computer support groups for women with breast cancer [9,10]. Recent research also illustrates some

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of the dierent ways that women with breast cancer from dierent demographic backgrounds participate in these groups [11] and also what user characteristics predict participation in these groups [12]. More recent research has begun to demonstrate that participation in these groups can positively aect various educational and psychosocial outcomes [1315] and oered some explanations for how these eects may occur. For example, Shaw and colleagues [14,15] found that insightful disclosure within computer support groups}using the groups as a forum in which to communicate about and understand and make sense of their breast cancer experience}was associated with improved mental health outcomes. Another of the most common ways that patients react to a breast cancer diagnosis is the use of religion [16,17]. Both religiosity and spirituality have been reported to serve as coping mechanisms to help face threatening health situations and the accompanying emotional distress [18]. More importantly, researchers have found a strong relationship between patients reliance on religious belief and practice and the eectiveness of their coping with cancer [19]. Spirituality has been found to be signicantly correlated with meaning in life among breast cancer patients and psychological and spiritual variables have also been found to be highly correlated [20]. Research also indicates that seeking comfort in or actively relying on religion can serve to increase patients psychological wellbeing [21]. Some recent research even indicates that prayer is the most commonly used coping strategy among cancer patients [22]. There is growing support for the notion that religiosity appears to positively eect coping among cancer patients but not as much is known about the processes and contexts that explain the connection between religion and more positive coping styles [23]. Previous research has documented the presence of prayer within online support groups for cancer patients [24,25] yet this current study is the rst that we are aware of to examine how prayer and religious expression communicated within computer support groups can contribute to improved psychosocial outcomes for breast cancer patients. As distinguished from the eects of insightful disclosure within computer support groups referred to above, this paper focuses on how religious expression within computer support groups }prayer and public communication about spirituality from a formal religious perspective as it relates to coping with illness}aects psychosocial health outcomes. Our purpose is to oer scientic insights about how the phenomena of religious expression within computer support groups may positively inuence quality of life for breast cancer patients. It is not our intent to extrapolate these ndings to more metaphysical domains such as the existence of God or the power of prayer outside of
Copyright # 2006 John Wiley & Sons, Ltd.

a psychological context, which is simply outside the scope of our purview. This line of research inquiry is theoretically valuable as it increases understanding of how computer support groups may produce positive outcomes by identifying another possible mechanism for how they may do so. Furthermore, empirical support for the idea that prayer within computer support groups can construe positive outcomes for patients drawn toward religious coping methods may encourage clinicians, health educators, pastors and others to refer people to these systems and enhance their quality of life during this traumatic time in their lives. While we believe it is likely that the hypothesized eects in this study would hold across diverse religious faiths and cultures, it is important to put the particular computer support group that is examined in this study into context. The support group examined in this study is part of a particular Interactive Cancer Communication System (ICCS) called the Comprehensive Health Enhancement Support System (CHESS) Living with Breast Cancer program, which is a computer-based system that provides patients and their families with a range of conceptually distinct services [6,1012,14,2635]. The sample of breast cancer patients examined in this particular study was rural Caucasians from Wisconsin and urban African Americans from Detroit, Michigan. There are a variety of reasons why religious coping may be related to improved emotional, psychological, social and attitudinal outcomes among breast cancer patients. From an emotional standpoint, recent research has indicated that surrendering control to God may be associated with less depression and less anxiety among breast cancer patients [36]. One way that people in health crises nd comfort in religion is by believing that God will see them through the illness whatever the outcome [21]. With the Christian perspective about a heavenly afterlife for the faithful, fears about mortality that may be associated with a cancer diagnosis are reduced as death is less likely to be considered the worst possible outcome. Furthermore, research indicates that trust in God implies believers will be provided the means to get through their illness to either restoration of health or death and a greater willingness to accept the outcome of their illness based on Gods will for their life. Another way that religion may improve cancer patients attitudes and help them cope with their illness is through nding strength in their spiritual beliefs. Research has found religious patients facing life threatening illnesses nd strength in biblical verses, prayers and scripture readings and that some patients feel that they could not have coped with their life-threatening illness without the strength of God and their spiritual lives [37]. Researchers have identied a number of other
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religious coping mechanisms that may explain how religious expression could improve psychosocial outcomes. For example, some spiritual people have been found to appraise dicult situations in a more constructive religious light (e.g. as the will of a purposeful God, as an opportunity to share in the pain of Jesus Christ, or as a challenge to grow purposefully) [38]. Research has also found that religious coping in the face of life threatening illness can bestow a feeling of being blessed despite or through the illness, which is likely to help patients appraise their lives more favorably [37]. Other religious coping methods have also been found to contribute to greater perceptions of condence and strength in the face of adversity. For example, Pargament et al. [39] found that selfdirecting religious coping assumes that God gives the individual the skills and resources they need to solve their problems so adherents of such methods will likely feel more capable to face whatever challenges come before them. Another method of religious coping that was identied in this same study was collaborative. This coping method rests on the assumption of a partnership with God in problem solving, and both the individual and God share responsibility for the persons active engagement in stressful situations. The presumption here is that the person will feel more condent with God playing a continuously supportive role in the individuals life [40]. Signicantly, both the self-directing and the collaborative approaches of religious coping were found to be associated with higher levels of competence. Research has also found that religious faith can provide breast cancer patients a sense of comfort through the feeling that they are never alone and that God is always by their side [18]. Across numerous studies, collaborative religious coping has shown the most consistent pattern of ndings for helping people with a health crisis [41].

H1: Writing a higher percentage of religion words will be associated with fewer breast cancer-related concerns. H2: Writing a higher percentage of religion words will be associated with lower levels of negative emotions. H3: Writing a higher percentage of religion words will be associated with higher levels of emotional well-being.

As referred to earlier, past research also suggests that self-directing religious coping as well as collaborative religious coping can increase patients perceptions that they have the resources they need to confront the breast cancer experience, which leads to the next hypothesis.
H4: Writing a higher percentage of religion words will be associated with higher levels of health self-ecacy.

On a related note, since previous research indicates that many patients employ collaborative religious coping methods in which they view God as an active partner in facing lifes stressors and traumatic events, we also posit that religious expression will be related to greater perceptions of social support in confronting the breast cancer experience.
H5: Writing a higher percentage of religion words will be associated with higher levels of perceived social support.

Additionally, religious coping contributes to patients seeing their lives as a blessing from God, which is accompanied by a greater appreciation for what they have going well in their lives rather than focusing on what is not going well, which leads to the next hypothesis.
H6: Writing a higher percentage of religion words will be associated with higher levels of functional well-being.

Along similar lines, because religious expression may inuence group participants to appraise their cancer experience in a more constructive religious light, we propose the nal hypothesis in this study:
H7: Writing a higher percentage of religion words will be associated with higher levels of positive reframing.

Summary and hypotheses

This study examines the eects of prayer and religious expression within computer support groups. The basic hypotheses are that prayer and religious expression in a computer-mediated environment will improve psychosocial outcomes for breast cancer patients. Specic hypotheses and explanations for the proposed eects of religious expression are below. Some common religious coping methods among people facing health crises relate to accepting in Gods will for their life accompanied by lower levels of worrying about death as a result of believing in an afterlife. Because of these basic tenets of the Christian faith, the rst several hypotheses relate to how we expect prayer and religious expression will contribute to reduced distress and improved emotional outcomes.
Copyright # 2006 John Wiley & Sons, Ltd.

Methods Participants
The data analyzed in this study were collected as a part of a larger Digital Divide Pilot Project (DDPP) where underserved breast cancer women in rural Wisconsin and Detroit, Michigan were given access to CHESS for 4 months. Both pre-test and a 4-month post-test surveys were conducted with a sample of 231 patients (81% return rate from 286 subjects). Subjects were paid $15 for each completed pre- and post-test. Wisconsin recruitment began in May 2001 and ended in April 2003 and Detroit recruitment began in June 2001 and ended in April 2003. Participants had a mean age of 51 years and had a diverse educational background, with 42.5%
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having a high school education or less, 29.9% having attended some college, 24.2% were college graduates and 3.5% attended graduate school. In terms of stage of cancer, 70.1% were classied as early stage (02) and 29.9% classied as late stage (34). The ethnic/racial characteristics of the sample were 62.3% Caucasian women, 35.9% African American, and 1.7% other minorities. In addition, 27.3% lived alone and 34.2% of women had private insurance. Study participants were identied through a variety of sources, including the Cancer Information Service, hospitals and clinics, public health departments, and the Medicaid program. Patients were eligible if they were at or below 250% of the Federal poverty level, within 1 year of diagnosis or had metastatic breast cancer, not homeless, and able to read and understand an informed consent letter. All study participants were loaned a computer and given Internet access for 4 months and received personal training to learn how to use the computer and the Internet. However, the majority of time was spent on learning how to use CHESS. They also had ongoing technical support available to them if they needed it.

Criterion for inclusion in analysis

To be considered an active participant in the computer-mediated support groups, a woman had to write at least three messages over the course of the study. This criterion was selected based on

several observations that emerged from both a qualitative and quantitative analysis of the messages that occurred following data collection. As part of the training process, women were encouraged to write a message introducing themselves to the rest of the group, which provided the participant the opportunity to show during the in-house training that she could use the communication function that allowed her to participate in the computer support group. The rst two messages tended to be short, containing simple background information about diagnosis, marriage, children or where they lived. Limiting this analysis to women who wrote three or more messages assured that all training and introductory messages were excluded from the analysis. Furthermore, the median number of messages written by study participants was two, though some women wrote a lot of messages, so the criterion amounts to a median split. Finally, since the study addressed religious disclosure in the computer support groups, writing fewer than three messages (and earlier messages tended to be short) was deemed insucient to achieve eects from religious expression. Based on the criterion, 97 active participants were included in future analyses. The initial two messages are excluded in the subsequent analyses. Table 1 presents demographic characteristics of study participants, active and inactive discussion group participants. When comparing women classied as active participants in the discussion groups with the inactive group, statistical tests indicated

Table 1. Demographic characteristics

Study participants (N 231) Age Mean (SD) Ethnicity Caucasian African American Other minorities Live alone Yes Education Some junior high Some high school High school degree Some college Associate or technical degree Bachelors degree Graduate degree Private insurance Yes Stage of cancer Early stage (stage 0,1,2) 51.58 (11.81) Active participants (N 97) 48.21 (11.26) Inactive participants (N 134) 54.01 (11.64)

144 (62.3%) 83 (35.9%) 4 (1.7%)

76 (78.4%) 21 (21.6%) 0 (0%)

68 (50.7%) 62 (46.3%) 4 (2.9%)

63 (27.3%)

32 (33.0%)

31 (23.1%)

2 24 72 69 28 28 8

(0.9%) (10.4%) (31.2%) (29.9%) (12.1%) (12.1%) (3.5%)

0 9 29 31 15 10 3

(0%) (9.3%) (29.9%) (32.0%) (15.5%) (10.3%) (3.1%)

2 15 43 38 13 18 5

(1.5%) (11.2%) (32.1%) (28.4%) (9.7%) (13.4%) (3.7%)

79 (34.2%)

40 (41.2%)

39 (29.1%)

162 (70.1%)

64 (66%)

98 (73.1%)

Copyright # 2006 John Wiley & Sons, Ltd.

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B. Shaw et al.

that the active group was more likely to be younger (t 3.856, p50.001) and Caucasian (w2 19.67, p50.001).

Measures
Criterion variables

Besides basic demographic information, participants reported seven primary dependent measures: breast cancer-related concerns, negative emotions, emotional well-being, functional well-being, health self-ecacy, social support, and positive reframing. Means and standard deviations for the hypothesized variables at each time point (pre-test and 4 months) from the active members are displayed in Table 2. Breast cancer-related concerns: Breast cancerrelated concerns (pre-test M 1.27, SD 0.72; post-test M 1.34, SD 0.66) assessed a breast cancer patients emotional, physical, and body image concerns related to treatments and side eects and this scale had been validated in previous research [43] and used in other CHESS studies (e.g., [12,29]. Breast cancer-related concerns was operationalized as an additive index (pre-test a 0.73; post-test a 0.72) of eight items that asked, on a ve-point scale ranging from 0 not at all to 4 extremely, if (1) they were short of breath, (2) they were self-conscious about the way they dress, (3) they were bothered by swollen or tender arms, (4) they worried about the eect of stress on their illness, (5) they were fatigued, (6) their change in weight bothered them, (7) their hair loss bothered them, and (8) their skin bothered them as a result of radiation treatment. Negative emotions: A 10-item negative emotions scale (pre-test M 2.69, SD 0.81; post-test M 2.35, SD 0.73) used in previous CHESS studies [31,29] asked, on a ve-point scale ranging from 1 never to 5 always, how often patients had felt each of the following during the past month; (1) helpless, (2) tense, (3) loved/cared for (reversed), (4) angry, (5) hopeless, (6) worried, (7) supported (reversed), (8) frustrated, (9) sad, and (10) anxious (pre-test a 0.91, post-test a 0.90).

Table 2. Means and standard deviations of dependent variables (n 97)

Dependent variables Pre-test M Breast cancer concerns Negative emotions Emotional well-being Functional well-being Health self-efficacy Social support Positive reframing 1.27 2.69 2.36 2.31 2.82 2.86 2.92 SD 0.72 0.81 0.96 0.97 0.77 0.82 0.93 Four-month M 1.34 2.35 2.68 2.48 3.07 3.05 3.02 SD 0.66 0.73 0.89 0.95 0.62 0.79 0.88

Emotional well-being: Six ve-point items (pretest M 2.36, SD 0.96; post-test M 2.68, SD 0.89) asked, on a ve-point scale ranging from 0 not at all to 4 very much, how often participants had felt each of the following: (1) sad, (2) feel like my life is a failure, (3) nervous, (4) worried about dying, (5) feel like everything is an eort, and (6) worried that my illness will get worse. These items were reversed before computing an emotional well-being scale (pre-test a 0.86, post-test a 0.85) and they were extensively tested in other studies in terms of reliability, validity, and responsiveness to clinical change [43,44]. Functional well-being: A ve-item functional well-being scale (pre-test M 2.31, SD 0.97; post-test M 2.48, SD 0.95) was also used and validated extensively in other studies [43,44]. Respondents are asked, on a ve-point scale ranging from 0 not at all to 4 very much, if (1) they are able to work (including working in home), (2) they are able to enjoy life in the moment, (3) they are sleeping well, (4) they are enjoying their usual leisure pursuits, and (5) their work (including work in home) is fullling (pre-test a 0.84, post-test a 0.85). Health self-ecacy: Health self-ecacy (pretest M 2.82, SD 0.77; post-test M 3.07, SD 0.62) is a three-item scale assessing breast cancer patients perceptions of self-ecacy specic to health-related situations [29]. It was operationalized as an additive index (pre-test a 0.76; posttest a 0.80) of items that asked, on a ve-point scale ranging from 0 disagree very much to 4 agree very much, if (1) they are condent they can have a positive eect on their health, (2) they have set some denite goals to improve their health, and (3) they are actively working to improve their health. Social support: Social support (pre-test M 2.86, SD 0.82; post-test M 3.05, SD 0.79) was created using six items (pre-test a 0.87, post-test a 0.86) that asked respondents, on a ve-point scale ranging from 0 not at all to 4 very much, if (1) there are people they could count on for emotional support, (2) there are people who will help them understand things they are nding out about their illness, (3) there are people they could rely on when they need help doing something, (4) there are people who can help them nd out the answers to their questions, (5) there are people who will ll in for them if they are unable to do something, and (6) they are pretty much all alone (reversed) [31]. Positive reframing: Positive reframing (pretest M 2.92, SD 0.93; post-test M 3.02, SD 0.88) was created using two items (pre-test a 0.70, post-test a 0.74) that asked respondents, on a four-point scale ranging from 1 I havent been doing this at all to 4 I ve been doing this a lot, if (1) they have been trying to see breast
Psycho-Oncology 16: 676687 (2007) DOI: 10.1002/pon

Copyright # 2006 John Wiley & Sons, Ltd.

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cancer in a dierent light, to make it seem more positive, and (2) they have been looking for something good in what is happening. Positive reframing is one of coping strategies that were measured with the Brief Cope [45], a shorter version of the original 60 item COPE scale developed by Carver et al. [46] and has strong evidence of its validity and reliability [45].
Religious expression

Table 3. Descriptive statistics for word usage of the active participants (n 97)
M Word count Percentage of religion words Number of messages Mdn SD Min. Max. 212 584 5.79 1123

11 572 1740 0.82 0.40 87 14

30 711 76 1.07 0 218 3

Note: The statistics shown in the table represent values per participant over the entire 4 months.

Religious expression serves as our independent variable. In order to assess the degree to which each breast cancer patient expressed religious words within online support groups, this study analyzed the entire body of each subjects text messages within the CHESS computer-mediated support groups for women with breast cancer using the LIWC (Linguistic Inquiry and Word Count) computerized text analysis program [47,48]. LIWC counted the percentage of religion-related words for each subject and the religion dimension captures words suggestive of religious belief and practice (e.g. pray, worship, faith, holy, Christ). For a complete listing of words that constitute the religion linguistic dimension, see Appendix A. Furthermore, percentage of religion words are used rather than frequency because people vary in how much they write but the important thing is how much of their writing is religion-related. In addition, LIWC developers created the linguistic dimensions and those dimensions were validated by comparing judges ratings of linguistic dimensions with those calculated by the program (see [4749] for psychometric information). Two selected excerpts are included below as examples of religious disclosure from the computer-mediated support groups, with religion-related words underlined to demonstrate the coding procedure. The rst is coded as having 14.8% religious words.
May God watch over each of you and bless you with healing and comfort. God bless and love all of the sisters, send healing love to us.

religion words per person) with a low of 0% and a high of 5.8%. Table 3 presents the descriptive statistics for word usage including religion-related words tested in this study. Subsequent analyses used the logarithm of this measure because of the positively skewed distribution of the variable.
Control variables

The second sample excerpt is coded as having 2.6% religion words.

Give yourself a big hug, and tell yourself that you are beautiful and this cancer has no place in your life, and do what you have to do. God put us all here for the divine purpose of love. And CHESS members love each other even if we havent been in person. Keep your head high, my friend. You are going to make it. And be able to tell someone else about how you got over.

In the 4-month intervention, 58% of the sample (n 134) wrote two or fewer messages and therefore did not meet the selection criterion for active participants. The mean percentage of religion words written for the 97 active group members was 0.82 (translating to an average of 95
Copyright # 2006 John Wiley & Sons, Ltd.

Since one might assume that more religious people would express more religious expression and get more benets from it, prior level of religious belief was controlled. In the pre-test survey, a two-item religious beliefs scale (M 3.17, SD 0.85) asked respondents, on a ve-point scale ranging from 1 I havent been doing this at all to 4 Ive been doing this a lot, how often patients had done each of the following during the past month; (1) Ive been trying to nd comfort in my religion or spiritual beliefs, and (2) Ive been praying or meditating (pre-test a 0.84). Since other research suggests that African American breast cancer women rely on religion as a coping resource to a greater extent than Caucasian women [50], we additionally controlled patients ethnicity (Caucasian coded 1). As shown in Table 4, zero-order correlations between religious expression and baseline variables (including demographics, a diseaserelated variable, and religious belief) revealed that religious beliefs and ethnicity turned out to be signicantly related to religious expression. Thus, we include these two measures in the nal analyses as controls to reduce confounding eects. Additionally, we tried to identify other variables that might be needed as control variables in the regression analyses. The procedure of identifying appropriate control variables is a necessary step to test the relationship between predictor and criterion variables when the sample size is relatively small and when it is dicult to decide which control variables to use and which to exclude [51]. To do this, a group of potential control variables including four demographic variables (i.e. age, education, insurance status, and living status) and a disease-related variable (i.e. stage of cancer) were selected from the survey along with pre-test level of each dependent variable. Then, forward, backward, and stepwise methods were preformed repeatedly to identify any signicant controls for
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Table 4. Baseline correlations

Religious expression Demographics & Religious belief Age Ethnicity (Caucasian 1) Education Private insurance (yes 1) Religious beliefs Live alone (yes 1) Cancer stage Pre-test level of outcome variables Breast cancer-related concerns Negative emotions Emotional well-being Functional well-being Health self-efficacy Social support Positive reframing
**p50.01.

Results Quantitative analysis

Table 5 summarizes how percentage of religion words was associated with sets of psychosocial health outcomes (i.e. breast cancer concerns, negative emotions, emotional well-being, functional well-being, health self-ecacy, social support, and positive reframing), which were obtained from seven regression analyses, respectively. For control variables, religious belief assessed in the pre-test survey was not signicantly related to any of dependent variables and only ethnicity was found to be signicantly related to functional wellbeing (b 0.212, p50.05). As expected, pre-test scores of outcome measures were strong predictors of corresponding 4 month outcomes. As expected, the hypothesis that a higher percentage of religion words would predict lower levels of negative emotions received strong support (b 0.292, p50.01). The percentage of religion words also predicted improved functional well-being (b 0.310, p50.001) and perceived health selfecacy (b 0.251, p50.05). As shown in Table 5, however, the percentage of religion words written was not signicantly associated with breast cancerrelated concerns (b 0.128, p 0.221), emotional well-being (b 0.173, p 0.111), social support (b 0.154, p 0.167), or positive reframing (b 0.145, p 0.175).

0.048 0.332** 0.010 0.006 0.301** 0.065 0.074 0.213 0.212 0.168 0.051 0.120 0.028 0.110

each of seven dependent variables. To test the possibility those variables may inuence our theorized outcomes, a series of model reduction procedures were conducted. These tests revealed that potential control variables excluding pre-test level of each dependent measure were not signicant predictors for our dependent variables. One of the reasons that the inuence of demographic variables did not appear to be strong may be due to the homogeneous nature of the sample (i.e. underserved). Therefore, those potential variables were dropped from future analyses and only religious belief, ethnicity, and pre-test score of each dependent measure were included as the nal control variables.

Qualitative analysis
A qualitative review of the support groups was also conducted to shed some insights on what types of religious coping methods women appeared to be using. Given our proposed mechanisms for how benets from prayer within computer support groups may occur, this review provided evidence that several dierent methods of religious coping were being used. It seems that some of the reduced emotional distress and worrying may have related to placing trust in God about the course of their illness and subsequent treatments as several participants alluded to in their writing. For example, one woman wrote Sometimes I get depressed, but God truly lifts me up. I try to think very much on Gods goodness. Another woman alluded to the benets of trusting in Gods plan in the message excerpt below:
I am praying for you to have a good outcome and no additional cancer. Its wasted energy to worry, due to the fact all the worry in this old world wont change anything. . . Utilize the energy in prayer instead. . . Easier said than done I know, however, prayer is the more positive approach.

Analytic framework
To examine how religious disclosure within the computer support groups was associated with various psychosocial health outcomes, the hierarchical ordinary least squares (OLS) regression models were employed to test the eects of religious expression on each of the criterion variables separately. For each of the regression models, religious beliefs, ethnicity, and pre-test scores of each dependent measure were entered rst, followed by the main eects of religious expression. Additionally, message transcripts from the computer support groups were also analyzed to better understand the results generated from the LIWC. While the aims of this study were primarily quantitative in nature, selected quotes from group participants are also presented to help illustrate some of the phenomena related to prayer and religious expression that appeared to have occurred within this study.
Copyright # 2006 John Wiley & Sons, Ltd.

There was also support for the idea that religious expression may have been associated with reduced negative emotions and worry as a result of
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Table 5. Multiple regression analyses predicting influence of religion-related words on hypothesized outcome variablesa
Criterion variables Breast cancer concerns Negative emotions Emotional well-being

Block 1: Demographics and pre-test measures Ethnicity (Caucasian 1) 0.025 Religious beliefs 0.021 Breast cancer concerns 0.572*** Negative emotions } Emotional well-being } Incremental R2 0.364*** Block 2: Main effect Religious expression Incremental R2 Total R2 Criterion variables

0.144 0.057 } 0.526*** } 0.339***

0.141 0.019 } } 0.506*** 0.299***

0.128 0.013 0.377 Functional well-being

0.292** 0.069** 0.408 Health self-efficacy 0.089 0.007 } 0.411*** } } 0.232***

0.173 0.024 0.323 Social support 0.028 0.174 } } 0.499*** } 0.241*** Positive reframing 0.096 0.197 } } } 0.427*** 0.301***

Block 1: Demographics and pre-test measures Ethnicity (Caucasian 1) 0.212* Religious beliefs 0.142 Functional well-being 0.678*** Health self-efficacy } Social support } Positive reframing } Incremental R2 0.438*** Block 2: Main effect Religious expression Incremental R2 Total R2
a

0.310*** 0.080*** 0.518

0.251* 0.052* 0.284

0.154 0.020 0.261

0.145 0.018 0.319

*p50.05; **p50.01; ***p50.001; n 97. Cell entries are final standardized regression coefficients.

communicating about the belief in an afterlife, which made their confrontation with mortality less frightening. This reduced fear is illustrated by one participant in the following excerpt: We are in a win/win situation as the Bible says: To live is Christ, to die is gain}to be here is to be away from the Lord and to be with Him is to be Home. I want to go home. . .as soon as the purpose and plan for me is accomplished. It also appeared that religious expression related to participants nding blessings in their lives and appraising their cancer experience in a more constructive religious light as is potently illustrated by the following excerpt God is so good!! I can still move around, I can still play with my grandbabies. . .I can still praise my God!!!! Another participant expressed the value of collaborative coping related to breast cancer when she writes Isnt it nice to know we have a God who is up 24/7 when we need him! I wouldnt have gotten thru this without him, his guidance, his Word, his grace, and loving kindness. Another woman shared her belief that God is participating actively in her cancer experience when she wrote about her hair loss resulting from her chemotherapy God is a very personal and intimate God
Copyright # 2006 John Wiley & Sons, Ltd.

knowing every little hair that is falling out of my head! Ever wonder what he thinks or says [about] each hair, which falls to the ground?? As earlier literature has suggested, it also appeared that many participants found some strength and comfort in biblical verses and scripture readings as much of the religious expression appeared to be quoted directly from the Bible rather than expressed in their own original words.

Discussion
This study provides some support for the hypotheses that religious expression within computer support groups can be a benecial form of coping when facing a life threatening diagnosis such as breast cancer. Most notably, a higher percentage of religion words were associated with lower levels of negative emotions and higher levels of perceived health self-ecacy and functional well-being. The prayer and religious expression in these groups occurred spontaneously without any prompting from an online chaplain or spiritual guidance counselor. Future research on this subject area should examine whether there are any
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enhanced benets of adding such a gure to these groups in order to guide religious patients toward religious coping methods that are most likely to bring them comfort and nd the strength they need to navigate the breast cancer experience. This study has taken the novel approach of examining how religious expression within computer support groups is related to improved psychosocial outcomes. However, we have also pointed out that there are numerous methods of religious coping (e.g. self-directing, collaborative, trust in Gods plan, reduced fear of death) that are subsumed within this larger construct of religious expression. While it is beyond the scope of this study, future research should examine what specic methods of religious coping are most associated with improved outcomes [38] as this will provide more granular insights about the phenomena examined in this paper. Similarly, this study looked at intercessory prayer and prayers made for personal help together while some previous research has examined these two issues separately. Future research should examine the dierent eects of intercessory prayer as compared to prayers made for personal help [52]. Previous research has also distinguished between less religious existential forms of spiritual coping versus more religious spiritual coping (e.g. [53]) and this study focused squarely on the latter. Future research should examine how religious spiritual coping compares with the more existential forms of spirituality and whether these distinctive forms of spiritual coping have dierential eects on individuals with varying needs and belief systems. Largely due to the demographics of the group, the prayer and religious expression within these groups was almost exclusively Christian in composition (an isolated few Native American and Hindu religious quotes were also identied). This was not by design of the researchers but rather a function of the study participants themselves, which is a limitation of the sample. In terms of understanding the phenomena identied in this study relative to what might be found in women from other religious backgrounds, it may be that Christians are more likely to publicly express their faith given the evangelical emphasis of many denominations within this tradition. Whatever the case, it is worth noting the Christian background of the participants as it seems likely that the particular doctrine and faith-based assumptions of this religion may help explain some of the psychosocial benets identied in this study. Future research should examine whether there are similar benets among people from other religious faiths as the authors speculate they might. It should also be noted that this study looked exclusively at the benets of writing prayer and religious expression within computer support groups but did not address whether exposure to
Copyright # 2006 John Wiley & Sons, Ltd.

such writings may also be associated with benets from participation in these groups as well, which would be another interesting line of inquiry for future studies. While the mental health benets identied in this study are worthwhile outcome variables in their own right as they relate to reducing cancer patients suering and distress, it would also be interesting to examine more objective, clinical outcome variables as there is currently very limited support for the hypotheses that religion or spirituality impact cancer progression or mortality [54]. Future research should track over longer periods of time whether prayer and religious expression contributes to increased survival, reduced medical costs and other relevant clinical outcome measures. It should be noted that this study admittedly only looked at the positive side of prayer and religious expression within computer support groups, and previous research has not found that all forms of religious coping contribute toward improved outcomes. For example, one recent study found that negative religious coping (i.e. statements regarding punishment or abandonment by God) was positively associated with distress, confusion, depression, and negatively associated with physical and emotional well-being, as well as quality of life [55]. Additionally, Pargament and his colleagues [39] found that one method}deferring religious coping}places the responsibility for problem solving on God and since solutions are said to emerge through the active eorts of God alone, individuals who cope in this way tend to take a passive coping stance. Not surprisingly, the deferring approach is associated with lower psychosocial competence. While we did not identify a single message expressing these types of thoughts, it is certainly possible that such thoughts were running through these patients heads as they were coping with their breast cancer. Furthermore, we have heard anecdotes from some study participants that they have turned away from the support groups within CHESS as a result of what they perceive to be the overly religious composition of the messages exchanged. It would be worth examining whether prayer and religious expression within computer support groups inhibits some women from participating and obtaining benets they otherwise would have received such as informational support or other more secular forms of emotional support. Future research should look at both the positive and negative sides of religious coping to provide as comprehensive a picture as possible about the eects of such phenomena on individuals facing life-threatening illnesses. While this article takes an important step forward in contributing to understanding how religious expression within computer support groups may contribute to improved mental health outcomes, the correlational analysis is only
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suggestive and an experimental design would provide stronger evidence of the suggested eects. However, prayer and religious expression may be one context in which an experimental design could raise some issues of face validity. It is questionable whether researchers could use random assignment to prevent prayer among control subjects facing life-threatening illness or to inuence non-believers to pray in any type of sincere or heart-felt way. That said, there are likely ways that researchers could encourage prayer and religious expression using an experimental design, and this would be a valuable mode of inquiry for future studies. Related to this, it should be noted that our results need to be interpreted with caution. Our ndings cannot denitively determine whether religious expression causes the changes in hypothesized outcomes or is merely reecting such changes. For instance, it is also possible that as patients feel more ecacious in dealing with their symptoms, they engage in more religious expression to place belief and trust in God. On this note, however, we found no signicant relationships between religious expression and baseline scores (excluding two control variables), which suggest that our ndings were not confounding eects from potential dierences in baseline scores. One limitation of this study is that the sample is comprised solely of underserved breast cancer patients. While this is a worthy population to identify ecacious interventions for, it is not a nationally representative sample. Future research should employ a more diverse sample to determine whether these same phenomena appear to produce positive eects in cancer patients from other backgrounds. Finally, while prayer and religious expression is a dicult process to quantify, another limitation of this paper is that the LIWC only counts and classies words, which some may legitimately criticize as reducing the full richness of the religious expression occurring in these groups [52]. Additionally, it should also be noted that simply counting words is an admittedly crude way to understand what people are saying about any issue}not just religious expression}as most computer programs do a poor job of acknowledging context ([56], in press). However, even with this in mind, the fact that a relatively low percentage of words related to religious expression was associated with improved outcomes for cancer patients suggests that this is clearly a phenomena worth further study.

thoughtful insights about the role of prayer in coping with health crises. The authors would also like to thank Felicia Hudson for her assistance with the literature review. The study was funded by grants from the National Cancer Institute and John and Mary Markle Foundation (RFP No. NO2-CO-01040-75).

Appendix A
*Religion-related words as included in the Linguistic Inquiry Word Count (LIWC) Program Dictionary

angel jewish angels jews bible* lord bless* meditat* catholic* mercy chaplain* methodis* christ minister christian* moral* church* pastor commandment* pope* communion pray* confess* preach* devil* presbyterian* divine* priest* easter protestant* etern* religio* faith* Sacred fundamentalis* saint* god satan* god* sin gods sins gospel* soul heaven* souls hell spirit* holy temple* immortal* testament* jesus theolog* jew worship* Note: In the dictionary, use of an asterisk (*) at the end of the word signals the computer to ignore all subsequent letters. For example, the LIWC Dictionary includes the stem pray* which allows for any target word that matches the first four letters to be counted as an prayrelated word (this would include pray, praying, prayed). The asterisk, then, denotes the acceptance of all letters, hyphens, or numbers following its appearance.

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Acknowledgements
The authors would also like to thank Helene McDowell and Gina Landucci for their central role in conducting this study. Additionally, gratitude is extended to Haile Berhe for his work in setting up the CHESS use data collection system. The authors would also like to thank Donald Gatzke for his
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Psycho-Oncology 16: 676687 (2007) DOI: 10.1002/pon