Online prayer benefits breast cancer patients?

Online prayer benefits breast cancer patients?

At least that's what they were saying a couple of days ago on the Internets:

NEW YORK (Reuters Health) - Praying online in a support group may help women with breast cancer cope with the disease more effectively, a new study shows.

Dr. Bret Shaw of the University of Wisconsin-Madison and colleagues found that breast cancer patients who used a higher percentage of religion-related words in their communications with an Internet support group had lower levels of negative emotions, better functional well-being, and more confidence in their ability to deal with their illness.

"Breast cancer patients who want to pray can use online support groups as a place to cope with their illness with other people going through similar situations," Shaw told Reuters Health. "Our data suggest that this might make you feel better."

Shaw decided to launch the study after observing how common it was for people to use prayer in online support groups. "We noticed a lot of people were exchanging prayers on line, praying for themselves and other group participants," he said.

However, he added that "some women were so kind of turned off by the overly religious tone of the groups that they did not want to participate."

To investigate the health, social and emotional effects of online prayer for women with breast cancer, Shaw and his team loaned a group of women computers linked to the Web. They also provided training on computer and Internet use. The women were surveyed at the study's outset and again after four months of support group participation.

Among the 97 women who posted more than twice to the group, those who used a higher percentage of religion-related words (such as bless, faith, heaven and pray) showed lower levels of negative emotions, better functional well-being, and greater health-related self-efficacy, meaning they had more confidence in their ability to cope with their illness.

Hoo boy. I have little doubt that online religious support may make some women feel better, particularly religious women, but does this study really show that much of a benefit, or any benefit at all? You know how they say "let's go to the tape" on sports shows. Well, let's go to the abstract, and, thanks to Razib, I have a PDF of the full study (curse my university, which lacks online subscriptions to a lot of journals):

Effects of prayer and religious expression within computer support groups on women with breast cancer. Psychooncology. 2006 Nov 27; [Epub ahead of print]

Shaw B, Han JY, Kim E, Gustafson D, Hawkins R, Cleary J, McTavish F, Pingree S, Eliason P, Lumpkins C. The Centre of Excellence in Cancer Communication Research, University of Wisconsin-Madison, USA.

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 first 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-efficacy and functional well-being, after controlling for patients' levels of religious beliefs. Given the proposed mechanisms for how these benefits occurred and a review of the support group transcripts, it appeared that several different 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, finding blessings in their lives and appraising their cancer experience in a more constructive religious light.

What? That's it? They analyzed the number of "religious words" used and then correlated them to measurements of negative emotions, health self-sufficiency, and functional well-being? And this is supposed to demonstrate that online prayer is helpful? That's pretty thin gruel to base much in the way of conclusions on. Not unexpectedly, there are a number of problems with this study, the very first of which is that the authors seem to assume a priori that religious views and prayer will be a good thing. Here's just a sample:

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 effectiveness of their coping with cancer [19]. Spirituality has been found to be significantly 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 well being [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 effect 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 first 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 effects 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}affects psychosocial health outcomes. Our purpose is to offer scientific insights about how the phenomena of religious expression within computer support groups may positively influence quality of life for breast cancer patients. It is not our intent to extrapolate these findings to more metaphysical domains such as the existence of God or the power of prayer outside of 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.

There's a lot more of that in the paper, with references to God, the support religion can presumably bring to breast cancer patients, and how religion brings feelings of peace and makes these patients better able to cope with their disease. In other words, the introduction comes off as highly biased, at least to me. The authors are, as far as I know, correct in stating that online religious support hasn't really been studied for its ability to be of help to breast cancer patients. However, leaving the online support group angle aside, the literature looking at the effect of religiosity on how cancer patients deal with their disease (at least what I'm aware of) is conflicting; it isn't nearly the slam dunk that the authors seem think it is that religious expression is an unalloyed good when it comes to helping women cope with breast cancer. For example, what about the possibility that religion decreases the feeling of well-being? It's called negative religious coping, and there's no doubt that this is true, at least for some patients. I've encountered patients who ask God why He inflicted cancer on them or who thought that they had brought cancer upon themselves by not living adequately upstanding lives. Religious people who have these sorts of thoughts can torture themselves with guilt as they try to endure the treatment for their disease.

Indeed, it isn't until well into the discussion near the end of the paper that the authors acknowledge:

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 efforts 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.

Nice that they mentioned it near the end. At least they state that the positive and negative effects of religious activity among breast cancer patients should be studied. Furthermore, the description above makes the CHESS forum sound as though there was a lot of God talk and religious discussion going on, given that it was enough to turn off a significant number of study participants.

Another problem is that they state six hypotheses (which, unbelievably, they number H1-H6, something I've never seen done before, although I can't say that I've read enough of the psychosocial literature to know if this is a common practice or not). Not surprisingly, all of them state that using a higher percentage of religious words in online forums is predicted to be associated with good outcomes, including fewer breast cancer-related concerns, lower levels of negative emotions, higher levels of emotional well being, higher levels of health self-sufficiency, and higher levels of perceived social support. I don't know about psychology, but in surgery and cancer biology, it's hard enough to demonstrate one hypothesis in a paper, maybe two at most. Trying to examine six hypotheses in a paper usually leads to a mess, and this paper comes close to that. On the other hand, one could boil down their hypothesis to "prayer and online religious expression will improve psychosocial outcomes for breast cancer patients," with the six hypotheses in reality being simply six proposed measures of that outcome. Be that as it may, all the investigators could find was a correlation between the percentage of religious words written and functional well-being and perceived health self efficacy (whatever that means), while no correlation was found with breast cancer-weighted concerns, emotional well-being, social support, or positive reframing (whatever that is, too). Of course, this runs up against the problem of multiple correlations (the more correlations you look for, the more likely you are to find spurious correlations by random chance alone). It's not clear to me that they adequately controlled for that, although they do represent their final results as a multiple regression analysis; so perhaps they did. It's just that the statistical methods were not well-described.

Overall, it's not particularly impressive.

But perhaps the biggest problem with this study is that the group examined is a highly self-selected group. Quite correctly, the investigators limited their analysis to only patients who had posted more than two messages to the online CHESS forum, in order to exclude the required introductory posts, which usually included information about who the patient was and a little background information. There's just one problem. Only 97 of the 231 study subjects met that criterion, and there were a number of differences in the ones who dropped out (deemed "inactive") compared with the ones who posted more than two messages (active). Inactive participants tended to be older (six years on average), minorities, and uninsured. They also tended to have earlier stage cancer.

Basically, this study is yet another example of correlation not necessarily equaling causation. (To be fair, the investigators do recognize that this is merely an observed correlation, but again not until near the end of the discussion, even after they have proposed that perhaps online chaplains to help women in support groups would be a good idea.) Certainly one possibility is that women with breast cancer who don't feel good don't bother to read all the messages and respond to them in the online forums. Or what about this possibility? Perhaps religious women with breast cancer who feel well will tend to attribute their well-being to God, post more often, and use more religious language while doing so. Perhaps women with breast cancer who blame God for their predicament won't feel comfortable discussing it in an online forum where there is clearly a lot of religious discussion going on, fearing that their feelings might not be well received, a not unreasonable fear if the impression that I get of the CHESS forum (a lot of religious discussion) is accurate. Finally, this study only looked at Christian women. Would similar results be obtained if the patients were Muslims, Hindus, Jews, or other religions?

Overall, this is another of a number of studies that try to claim that religious activity is good for one's health in which broad generalizations are made on scanty data and dubious experimental design. It's quite possible that online religious support may help certain religious women feel better and cope with their breast cancer more effectively. This study just isn't particularly strong evidence that this is the case.