Journal of Genetic Counseling, Vol. 15, No.

6, December 2006 (

c 2006)
DOI: 10.1007/s10897-006-9037-4

Professional Issues

Spiritual Coping, Family History, and Perceived Risk

for Breast CancerCan We Make Sense of it?

John M. Quillin,1,4,5 Donna K. McClish,2,4 Resa M. Jones,3,4

Karen Burruss,4 and Joann N. Bodurtha1,4

Published Online: 30 September 2006

Differences in spiritual beliefs and practices could influence perceptions of the role of ge-
netic risk factors on personal cancer risk. We explored spiritual coping and breast cancer risk
perceptions among women with and without a reported family history of breast cancer. Anal-
yses were conducted on data from 899 women in primary care clinics who did not have breast
cancer. Structural equation modeling (SEM), linear, and logistic modeling tested an interac-
tion of family history of breast cancer on the relationship between spiritual coping and risk
perceptions. Overall analyses demonstrated an inverse relationship between spiritual coping
and breast cancer risk perceptions and a modifying effect of family history. More frequent
spiritual coping was associated with lower risk perceptions for women with positive family
histories, but not for those with negative family histories. Results support further research in
this area that could influence communication of risk information to cancer genetic counseling
patients.
KEY WORDS: risk; spirituality; coping; genetic predisposition to disease; breast neoplasms.

INTRODUCTION abuse, depression, and chronic illness (Koenig, 1997;

Genetic counselors strive to counsel patients in
a manner that is culturally-congruent, which includes
patients religious and spiritual beliefs and practices
(Beckendorf et al., 1992; Weil, 2001). Patients re-
liance on religious and spiritual resources has been
associated with positive health outcomes in a vari-
ety of disciplines including mental health, substance
1
Department of Human Genetics, Virginia Commonwealth Uni-
versity, Richmond, Virginia.
2
Department of Biostatistics, Virginia Commonwealth Univer-
sity, Richmond Virginia.
3
Department of Epidemiology & Community Health, Virginia
Commonwealth University, Richmond Virginia.
4
Massey Cancer Center, Virginia Commonwealth University,
Richmond Virginia.
5
Correspondence should be directed to John M. Quillin, Depart-
ment of Human Genetics, Virginia Commonwealth University,
1101 E. Marshall Street, Richmond, Virginia 23298-0033; e-mail:
jmquilli@vcu.edu.
Larson and Larson, 2003; Sloan and Bagiella, 2002)
and has been considered to be a positive, active
coping mechanism associated with lowered distress
(Carver, 1997). Religion/spirituality may also play
a role in womens perceived risk for breast cancer
(Duncan et al., 2001).
Risk communication and improvement of per-
ceived risk are considered to be important goals of
cancer genetic counseling (Trepanier et al., 2004).
Although there are widespread inaccuracies (usually
overestimates) of numerical risk perceptions for can-
cer (Fischoff et al., 2004; Haas et al., 2005; Quillin
et al., 2004), there is also evidence for optimistic bias
(i.e., belief that one has lower than average risks)
(Fontaine and Smith, 1995; Katapodi et al., 2004;
Quillin et al., 2004). Accurate risk perceptions are im-
portant because they are consistently associated with
adherence to cancer screening guidelines and uptake
of genetic susceptibility testing (Audrain-McGovern

449
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C 2006 National Society of Genetic Counselors, Inc.
450
et al., 2003; Fischoff et al., 2004; Katapodi et al., 2004;
Kinney et al., 2001).
The development of a perceived risk is com-
plex and can include beliefs about disease etiol-
ogy, personal and social experience with disease,
perceived seriousness of disease, and health lo-
cus of control (Cameron, 2003; Fischoff et al.,
2004; Glanz et al., 1997; Robb et al., 2004; Wind-
schitl, 2003). Recent studies suggest most people
are aware of the relevance of family history for
their own health (although most people do not ac-
tively collect family health histories) (Patenaude,
2005; Yoon et al., 2004). Despite this finding, a sig-
nificant number of individuals with positive family
histories of cancer maintain an optimistic bias, and
this might be particularly true for persons of mi-
nority races (Audrain-McGovern et al., 2003). This
is concerning because individuals with positive fam-
ily histories in particular could benefit from ad-
hering to screening and prevention guidelines (of-
ten motivated by perceived risk) and genetic risk
assessment.
Despite the large literature assessing psychoso-
cial factors that contribute to risk perceptions, rel-
atively little is known about the role of spiritual or
religious beliefs in development of risk perceptions.
While religious involvement is generally associated
with positive healthcare choices (Dessio et al., 2004;
Felix Aaron et al., 2003; Koenig, 1997), the role of
religion in healthcare decisions and perceived risk
among persons at increased genetic risk has not been
thoroughly explored.
A few studies have found mixed results re-
garding religious beliefs and intentions to have ge-
netic testing. One group found that spiritual faith
was inversely associated with pursuing genetic test-
ing for breast and ovarian cancer risk (OR = 0.2),
and interest in genetic testing was lowest for women
with low spirituality and low perceived breast can-
cer risk (Schwartz et al., 2000). Another study found
no association between spirituality and intentions to
learn genetic test results for hereditary colon cancer
(Vernon et al., 1999). A third study found that iden-
tifying God as a locus of health control did not pre-
dict intentions to have genetic testing (Kinney et al.,
2001). In addition to mixed results, these previous
studies have several limitations that hinder clear con-
clusions. These limitations include use of different
measures of religion/spirituality, an exclusive focus
on high-risk families who were being offered genetic
testing (often through self-referral), and sample lim-
itations.
Quillin, McClish, Jones, Burruss, and Bodurtha
Persons with strong religious convictions may
discount the effect of genetic factors (which are more
or less randomly distributed and uncontrollable) and
focus more on the impact of human or divine ac-
tions, both of which might be viewed as modifiable
(through free will and prayer, respectively), and in
any case are unlikely to be perceived as random
(Parrott et al., 2004). Similarly, there appears to be a
relationship between spirituality and fatalisma be-
lief that some health issues are beyond human con-
trol on the basis of certain views about luck, fate,
predestination, and destiny (Powe, 1997; Powe and
Finnie, 2003). In turn, fatalism may influence pa-
tients conceptions about how disease occurs, and if
they believe they are at risk for disease based on fam-
ily history (Walter et al., 2004). If this is true, then ge-
netic counselors and others interested in applying ge-
nomic advances to preventing disease must dialogue
with the religious public as they craft their health
messages and communicate with patients.
In light of these insights stemming from the liter-
ature, the purpose of our analyses was to explore the
relationship between spiritual coping mechanisms
and risk perceptions for women with and without
a family history of breast cancer. We hypothesized
that women who used spiritual coping mechanisms
frequently would have lower risk perceptions than
those who used spiritual coping less often. Further-
more, because this relationship may be driven by dif-
ferences in beliefs of genetic versus supernatural ill-
ness attributions, the relationship between spiritual
coping practices and risk perceptions may be more
apparent among those with a family history of breast
cancer. Value-congruent risk communication is an in-
tegral role of cancer genetic counselors; findings from
this investigation could provide insight necessary to
fulfill this role.
METHODS
Study Sample
This investigation involved analyses of baseline
data collected from the Women Improving Screening
through Education and Risk assessment (WISER)
study, an ongoing randomized controlled trial that
recruited 899 women. Participants were enrolled to
the study in the waiting rooms of four primary care
clinics at Virginia Commonwealth University Health
System (VCUHS). Women eligible for the study
were at least 40 years old, not currently pregnant, and
Spiritual Coping, Family History, and Breast Cancer Risk Perceptions
had no personal history of breast cancer or breast
carcinoma in situ. No women were excluded based
on family history of cancer. This study was approved
by the VCU institutional review board.
Administrative records show the clinics include
a large proportion (about half) of minority patients,
and about half of patients are at least 40 years old.
These clinics are located in an urban downtown set-
ting, and patients tend to reside in the surrounding
greater metropolitan Richmond area, which has over
1.5 million people and includes a wide range of set-
tings, from rural to urban. Census data show that
most (57%) city residents are African American, and
the median age is 35 years old.
Measures
All participants were asked to complete a sur-
vey at the time of recruitment. Responses to the
surveys provided information on the variables rele-
vant for this studyperceived risk of breast cancer,
spiritual/religious coping, and family history of can-
cer. Additional items included each participants self-
reported age, race, and highest level of education.
Table I provides each of the measurement items re-
lated to perceived risk and spiritual coping.
Participants were asked to respond to four mea-
sures of breast cancer risk perception. Two measures
were adapted from a previous study conducted by the
researchers (Quillin et al., 2004). One item (descrip-
tive) asked participants to choose which descriptive
word corresponds most closely to their own risk for
breast cancerusual, moderate, or strong. A 1997). Participants said how often, You try to find
second item (percent) asked participants to estimate
their lifetime risks as less than 15%, 15 to 30% You pray or meditate, during stressful times (each
or more than 30%. These responses reflected the
risk feedback some participants would receive later
as part of the ongoing randomized trial, and they
are consistent with breast cancer risk categories used
elsewhere (e.g., Kriege et al., 2004). Another mea-
sure (quantity) asked participants to estimate how
many women out of 100 like them would develop
breast cancer over a lifetime. Finally, a fourth mea-
sure (compare) asked women to compare their breast
cancer risks to the average womans risk.
In addition to risk perceptions, participants re-
ported their use of spiritual or religious resources
as a coping mechanism in times of stress through
two items. These items are from the Brief COPE
which assesses 14 dimensions of coping. The reli-
gious coping subscale has been used extensively in
451
Table I. Measurement Items and Related Constructs
Short item name Text
Risk perception
Quantity Of 100 women with your same
breast cancer risk, how many
will get breast cancer by the
time they are 90 years old?
Percent What do you think the chances
are that you will have breast
cancer someday? (less than
15, 15% to 30%, more than
30%)
Compare Compared to most women,
what do you think your
chances are that you will get
breast cancer? Would you
say that your chances are . . .
(a lot lower than average . . . a
lot higher than average)
Descriptive How would you rate your risk
of developing breast cancer
in your lifetime? (usual,
moderate, strong)
Spiritual coping
Comfort You try to find comfort in your
religion or spiritual beliefs.
(you usually dont do this at
all . . . you do this a lot)
Pray You pray or meditate. (you
usually dont do this at
all. . .you do this a lot)
studies to assess coping among cancer patients
(Ben-Zur et al., 2001; Carver et al., 1993, 2002; Sher-
liker and Steptoe, 2000; Sherman et al., 2000; Stanton
et al., 2002), and has been shown to have good inter-
nal consistency (Cronbachs alpha = 0.82) (Carver,
comfort in your religion or spiritual beliefs, and
item had four response options ranging from you
usually dont do this at all to you do this a lot,
which were coded from 1 to 4).
To assess family history, participants were asked
to indicate which of their blood relatives had can-
cer, the type of cancer s/he had, age at diagnosis,
and whether or not she died from cancer. For the
primary analyses, women were considered to have a
positive family history if they reported any blood rel-
ative with breast cancer. To investigate the effect of
various family history structures further, additional
exploratory analyses assessed family history in terms
of the biological closeness of relatives (those with
first-degree affected relatives versus only distant rel-
atives) and whether or not a relative had died of
breast cancer.
452
Statistical Analyses
Both regression modeling and structural equa-
tion modeling (SEM) were used to test the hypothe-
sis that differences in spiritual/religious coping were
associated with risk perceptions. For regression mod-
eling, separate analyses (logistic and linear, as appro-
priate) were conducted to assess the relationship be-
tween each measure of risk perception and the two
spiritual coping items, which were summed to create
a single scale of spiritual coping. Family history of
breast cancer, education, race, and three of the risk
perception variables (descriptive, percent, and com-
pare) were treated as categorical variables in ordinal
logistic regression analyses, while age, quantity, and
spiritual coping were treated as continuous measures.
Since most participants reported African Amer-
ican or Caucasian race, and because previous studies
suggest that the use of spirituality/religion as a coping
mechanism is more prevalent among African Amer-
icans than Caucasians (Culver et al., 2002; Dessio
et al., 2004; Johnson et al., 2005), for analyses, race
was modeled as a binary variable (African Amer-
ican or other race). Spiritual/religious coping has
also been associated with age (Aukst-Margetic et al.,
2005; Moberg, 2005) and education (Aukst-Margetic
et al., 2005). These demographic covariates were
tested in bivariate analyses with spiritual coping, and,
if there was suggestion of an association (P < 0.10),
they were entered into regression and SEM models
to control for potential confounding.
To look for a differential effect of family his-
tory of breast cancer, an interaction term for family
history and spiritual coping was entered into the re-
gression models. When the interaction term was sig-
nificant, the main effects of spiritual coping on risk
perception were stratified and assessed separately for
participants with and without a positive family his-
tory of breast cancer. Regression modeling and as-
sociation studies were performed using SAS 9.1 for
Microsoft Windows (SAS Institute, 1997).
After assessing effects for each risk perception
variable and identifying covariates, the analyses were
examined and confirmed using SEM. SEM has sev-
eral advantages over solving individual regression
models (Kline, 2005). For example, individual mea-
surement items can be modeled as imperfect mani-
festations of underlying latent constructs, and error
terms for each item in the model can be estimated.
The need for modeling spiritual coping, in particu-
lar, as a latent variable has been suggested in the
literature (Berry, 2005). Furthermore, rather than
Quillin, McClish, Jones, Burruss, and Bodurtha
conducting separate tests, as was done with regres-
sion models, the effect of spiritual coping on all four
risk perception outcomes can be analyzed simultane-
ously with risk perception modeled as a latent con-
struct. The moderation effect of family history can
be tested through multi-sample SEM whereby the
model is tested simultaneously among two groups
in this case, those with and those without a positive
family history of breast cancer. One can determine if
a moderation effect exists by allowing the parameter
estimates to vary between populations and then con-
straining them to be equal. A significant difference
in model fit with these analyses would suggest an
interaction.
SEM was conducted using LISREL 8.7 soft-
ware (Scientific Software International, Inc., 2004).
A model was tested simultaneously for two groups of
participantsthose with and those without a family
history of breast cancer, while including the demo-
graphic covariates for race and education. There is
strong evidence for a relationship between race and
spiritual coping (Culver et al., 2002; Felix Aaron et al.,
2003; Johnson et al., 2005; Powe, 1997). The relation-
ships between race, education, and risk perceptions
have been less clear, although there is some sugges-
tion that differences in risk perception by race might
be mediated by differences in knowledge (Dono-
van and Tucker, 2000; Hughes et al., 1997; Katapodi
et al., 2004). Initial modeling, then, including race as
a direct influence on spiritual coping, and education
was modeled as a mediator between race and per-
ceived risk. Model fit was assessed by examining the
model 2 and the Root Mean Square Error of Ap-
proximation (RMSEA). Good model fit is supported
by a non-significant 2 and RMSEA less than 0.05
(Kline, 2005). As opposed to linear modeling in the
regression analyses, SEM modeling assumes multi-
variate normality. SEM parameters were estimated
using full information maximum likelihood which has
been shown to be robust against various missing data
patterns and violations of multivariate normality
(Enders, 2001; Lei and Lomax, 2005; Schafer and
Graham, 2002). The relationships between latent
variables are assessed through standardized path co-
efficients. Standardized path coefficients less than
0.10 generally indicate weak relationships, values
around 0.30 suggest a moderate association, and val-
ues of at least 0.50 reflect a strong relationship be-
tween constructs (Kline, 2005).
Initially all parameters were constrained to be
equal across the two groups except for the structural
relationship between spiritual coping and risk
Spiritual Coping, Family History, and Breast Cancer Risk Perceptions
perception. To test for a moderation effect, in a
second run the structural relationship between spir-
itual coping and risk perception was also con-
strained to be equal across groups. A moderation ef-
fect by family history was tested by examining the
change in model fit (2 and RMSEA) with this con-
straint (Kline, 2005). P-values less than 0.05 were
considered statistically significant. Since these anal-
yses were exploratory, we conducted SEM analyses
initially on a subset of half of the data that was ran-
domly selected using simple random sampling in SAS
9.1 (PROC SURVEY SELECT). The path coeffi-
cients were examined, and non-significant paths were
deleted and tested in a second confirmatory analytic
run on the remaining subset of the data. Subsequent
exploratory analyses of the effect of different fam-
ily structures (biological closeness of relatives and
whether or not a relative had died of breast can-
cer) utilized the final SEM model with the full data
set. For biological closeness, differences in the rela-
tionship between spiritual coping and perceived risk
were investigated for three groups: (a) women with
negative family histories, (b) women with only dis-
tant (not first-degree) relatives with breast cancer,
and (c) women with at least one first-degree rela-
tive with breast cancer. Similar analyses looked for
a modification effect of having a relative who died
from breast cancer. Again, family history was strati-
fied into three groups: (a) women with negative fam-
ily histories, (b) women with positive family histories,
but no relative who died from breast cancer, and (c)
women who had at least one relative die from breast
cancer. As with the previous SEM analyses, the fit of
a model in which the relationship between spiritual
coping and perceived risk was free to vary was com-
pared to the fit of a model in which this relationship
was constrained to be equal between family history
groups.
RESULTS
Of the 899 participants, mean age was
50.1 years (SD 8.25). A total of 404 (45%) par-
ticipants reported African American race, and most
(50%) other women were Caucasian. There was
diversity in educational background with 124 (14%)
having less than a high school education and 524
(59%) reporting education beyond high school.
Overall, 305 (34%) women in the study reported
that at least one blood relative had breast cancer.
Among all participants most women (55%) felt they
453
had usual risk, while 6% reported strong risk (de-
scriptive). Similarly, 54% felt their lifetime risk was
less than 15%, and 10% thought it was more than
30% (percent). In contrast, women reported a mean
of 31 (SD 21.7) out of 100 women like you would
get breast cancer by the time they are 90 years old
(quantity). The most common (38%) perceived risk
compared to other women of the same age was av-
erage; 21% of women felt their risk was a lot lower
than average, and only 4% felt their risk was a
lot higher than average (compare). Because so few
women perceived their risk to be a lot higher than
average, for regression analyses the 5-point scale
was collapsed into a 3-point scale (lower, average,
and higher risk).
Most women reported frequent use of spiritual
coping mechanisms. Approximately half of women
said they try to find comfort in your religion or spiri-
tual beliefs a lot during times of stress (comfort) and
a similar proportion (51%) said they pray or medi-
tate a lot during these times (pray). For each item,
only about 10% said they did not pray or seek com-
fort in religion at all. Scores from the summed spir-
itual coping scale ranged from 2 (low frequency of
spiritual coping) to 8 (high frequency of spiritual cop-
ing). Mean spiritual coping was 6 (SD 2.0). The inter-
nal consistency of the two spiritual coping measures
was fairly high (Cronbachs alpha = 0.85).
We looked for associations between the
demographic variables and spiritual coping to
identify potential confounders. Race was signifi-
cantly associated with frequency of spiritual coping
(P < 0.001) with African Americans having a mean
score of 6.8, and women of other races having a
mean of 5.8. There also was a borderline significant
association with education (P = 0.063) such that
those with higher education reported more frequent
spiritual coping. Age was not significantly associ-
ated with score on the summed spiritual coping
scale (P = 0.142), so it was not included in further
analyses.
We next examined the relationships between
spiritual coping and each measure of risk perception
in unadjusted and adjusted (for education and race)
analyses. Spiritual coping was not associated with
the quantity variable of perceived risk in any of the
regression analyses, and there was no moderation
effect of family history. For the ordinal perceived
risk variables, spirituality was inversely associated
with risk perception for those with a family history
of breast cancer, but there were no significant rela-
tionships among participants with negative family
454
Table II. Different Effects of Spiritual Coping on Risk Perceptions by Family History of Breast Cancer
Risk perception Family history of breast cancer
Percentb Positive
Negative
Comparec Positive
Negative
Descriptived Positive
Negative
Note. Statistically significant (P < 0.05) findings are in bold font.
a Adjusted for educational background and reported race.
b What do you think the chances are that you will have breast cancer someday? (less than 15, 15 to 30%, more than 30%).
c Compared to most women, what do you think your chances are that you will get breast cancer? Would you say that your chances are. . .
(lower than average, average, higher than average).
d How would you rate your risk of developing breast cancer in your lifetime? (usual, moderate, strong).
histories (Table II). In all analyses the interaction
effect of family history with spiritual coping was sta-
tistically significant, except for the percent variable
when adjusting for race and education (P = 0.076).
Next, the relationship between spiritual coping
and risk perception was assessed using SEM on a sub-
set of half (n = 449) of the data. Within this subset,
two models were compared. The structure of these
models is presented in Fig. 1. All variables were en-
tered into the models using their original metric ex-
cept for quantity (perceived risk on a scale from 1 to
100) which was divided by 20 so that the variances of
the risk perception variables were of similar magni-
tude (Kline, 2005). To test for an interaction effect
of family history of breast cancer, the model was ap-
plied to data from participants with positive and neg-
ative family histories, treated as separate groups in
the same analysis (i.e., multi-group SEM analysis).
In one analytic run, the structural relationship be-
tween spiritual coping and risk perception was
allowed to differ between groups. Standardized pa-
rameter estimates are presented in Fig. 1. For the
model presented in Fig. 1, model 2 was 122.42 with
53 degrees of freedom (P < 0.001). RMSEA was
0.076 suggesting reasonable model fit. In a second an-
alytic run the structural relationship between spir-
itual coping and risk perception was constrained
to be equal across groups (family history positive and
family history negative). The model 2 in this analy-
sis was 125.44 with 54 degrees of freedom suggesting
a worse fit, although the change in model fit did not
reach statistical significance (2 = 3.02, P = 0.082),
and the RMSEA was essentially unchanged (0.077).
Quillin, McClish, Jones, Burruss, and Bodurtha
P-value for interaction
Effect of spiritual coping on perceived risk (Spiritual coping by family
[Odds ratio (95% C.I.)] history)
Unadjusted Adjusteda Unadjusted Adjusteda
0.82 (0.73, 0.93) 0.86 (0.76, 0.98) 0.043 0.076
0.95 (0.87, 1.03) 0.98 (0.90, 1.07)
0.83 (0.74, 0.94) 0.86 (0.76, 0.98) 0.020 0.040
0.97 (0.90, 1.05) 1.00 (0.92, 1.09)
0.88 (0.77, 0.99) 0.86 (0.76, 0.99) 0.021 0.010
1.04 (0.96, 1.14) 1.04 (0.95, 1.14)
All parameter estimates for the observed
variables, including their path coefficients from the
latent variables, were statistically significant except
for the error variance for pray (P = 0.327), and
the path between education and risk perception
(P = 0.128). For participants with no family history
of breast cancer, the structural relationship between
spiritual coping and risk perception was not
significant (P = 0.164). In contrast, there was a
significant (P = 0.003) negative relationship between
spiritual coping and risk perception among
those with a positive family history of breast cancer
that was of moderate magnitude (standardized
estimate = 0.32). For this group, more frequent
use of spiritual coping was associated with lower
perceived risk for breast cancer.
To refine the model, the analyses were repli-
cated for data from the remaining 450 participants,
and this time the education variable was removed
from the model since its path was not found to
contribute significantly. Results are presented in
Fig. 2. Results similar to the initial model were found
with the second analysis. There was a significant
path from race to risk perception (P = 0.008). Also
similar to the initial model, there was a significant
(P = 0.026) inverse relationship between spiritual
coping and risk perception for participants with a
positive family history of breast cancer, but not for
those with negative family histories (P = 0.337). In
this final model, there was a significant moderation
effect of family history on the relationship between
spiritual coping and risk perception (2 = 5.73,
P = 0.017). The best-fitting model had a 2 of 72.17
Spiritual Coping, Family History, and Breast Cancer Risk Perceptions 455

Fig. 1. Path diagram of initially modeled relationship (standardized estimates) between spiritual coping and breast
cancer risk perceptions on a random sample of 449 participants. Note. NS: Unstandardized estimates were not
significant (P > 0.05); ( ) The unstandardized values for these paths were fixed to 1 to identify the model. ( ) In
LISREL, the exogenous observed variables (education and race) were modeled as single indicator latent constructs
with no measurement error and path coefficients fixed to 1.

with 39 degrees of freedom, and the RMSEA was
0.061.
The modifying effects of various subgroups of
family histories were next examined. Of the 899 par-
ticipants, 594 reported no family history of breast
cancer, 189 reported a positive family history includ-
ing only distant (not first-degree) relatives, and 116
indicated at least one first-degree relative had breast
cancer. This SEM analysis suggested a moderate in-
verse relationship between spiritual coping and risk
perception among women with only distant affected
relatives (standardized path = 0.33, P = 0.006), a
low-moderate inverse relationship for women with at
least one first-degree relative that approached signif-
icance (standardized path = 0.22, P = 0.072), and
no significant relationship between these constructs
for women with negative family histories (standard-
ized path = 0.02, P = 0.764).
In the multi-sample SEM analysis assessing po-
tential effect modification of having a relative who
died with breast cancer, family history was stratified
to include the 594 women with negative family histo-
ries, 161 women with relatives who had breast can-
cer and did not die of disease, and 144 women with
at least one relative who died from breast cancer.
Women with positive family histories who had a rel-
ative die with breast cancer had a moderate inverse
relationship between spiritual coping and perceived
risk (standardized path = 0.30, P = 0.004), whereas
the relationship was low-moderate for women whose
relatives had breast cancer but did not die from it
(standardized path = 0.25, P = 0.018). No signifi-
cant relationship between spiritual coping and per-
ceived risk was identified for women with negative
family histories.
DISCUSSION
In recent years there has been growing inter-
est in assessing and integrating patients spiritual be-
liefs as part of culturally competent genetics care
and patient empowerment (Leonard and Plotnikoff,
2000; Reynolds et al., 2005; Trepanier et al., 2004;
Wang, 2001; Weil, 2001). Typically, the purpose
of this assessment has been to help patients make
clinical decisions that are congruent with their cul-
tural, religious, or spiritual beliefs. This emphasis on
456 Quillin, McClish, Jones, Burruss, and Bodurtha

Fig. 2. Path diagram of final modeled relationship (standardized estimates) between spiritual coping and breast
cancer risk perceptions on the remaining sample of 40 participants. Note. NS: Unstandardized estimates were not
significant (P > 0.05). ( ) The unstandardized values for these paths were fixed to 1 to identify the model. ( ) In
LISREL, the exogenous observed variable race was modeled as a single indicator latent construct with no measure-
ment error and path coefficient fixed to 1.

cultural competency is particularly important when
the right decisions are unclear, or are at least
not universally agreed-upon (e.g., pregnancy termi-
nation, or decisions about cancer prevention through
screening versus surgery). In contrast, it is fairly well-
accepted that improving risk perceptions (i.e., bring-
ing perceived risk in line with scientifically calcu-
lated objective risk) is a goal of genetic counseling
(Trepanier et al., 2004). The exploratory findings pre-
sented here suggest that, in the context of a positive
family history of breast cancer, use of spiritual coping
mechanisms influences this perceived breast cancer
risk.
It is interesting to note specifically that spiritual
coping is negatively associated with perceived risk
for breast cancer. In other words, at least for women
with a positive family history of breast cancer, those
who reported they frequently turn to their religion
or spiritual beliefs to cope with stress had lower risk
perceptions. How can one account for this inverse
association? What are its implications for genetic
counseling?
Frequent spiritual coping may be a manifesta-
tion of ones spiritual locus of control, the belief that
God empowers the faithful to prevent disease, or
God can be consulted to actively interfere with a dis-
ease process, in this case genetic susceptibility for
cancer (Holt et al., 2003). The relevance of this coping
mechanism might be heightened in light of a family
history of breast cancer. In related work, use of spir-
itual coping mechanisms has been shown to increase
at disease onset, when one senses lack of control over
ones life (Baldacchino and Draper, 2001). Because
health concerns with controllable risks are perceived
to be less likely to occur (Osei et al., 1997; Weinstein,
1982), belief in supernatural assistance (and, conse-
quently, some level of control) may lower perceived
risk of breast cancer. The idea of controllability is
closely tied to fatalism. Given the prevalence of fa-
talistic attitudes among African Americans in partic-
ular (Powe and Finnie, 2003), the inclusion of race
in our model of spiritual coping and risk perceptions
is both theoretically and statistically justified. This
finding, combined with research suggesting a high
spiritual locus of control among African Americans
(Johnson et al., 2005), could explain a piece of racial
disparities among those served by genetic counseling
(Armstrong et al., 2005).
Spiritual Coping, Family History, and Breast Cancer Risk Perceptions
It is intriguing that a link between spiritual cop-
ing and risk perceptions was noted for those with,
but not those without, a family history of breast
cancer. Previous studies suggest persons who report
more spiritual beliefs may be less likely to pursue ge-
netic counseling and testing (Furr and Seger, 1998;
Schneider, 2002; Schwartz et al., 2000), and they may
be less likely to attribute disease to hereditary causes
(Pargament et al., 1990; Walter et al., 2004). These
studies and our findings suggest women with high
spirituality, in general, could be underrepresented
among genetic counseling patients and/or those who
pursue genetic testing.
This study has important limitations and areas
for further investigation that should be noted. Our
analyses were exploratory, and data were not col-
lected with the primary intent of investigating the
relationship between spiritual coping and risk per-
ceptions. Thus, the findings could be spurious, and
it will be important for future studies to attempt to
replicate this association. Also, the findings come
from a single study sample, and the generalizability
of findings are likewise limited; for example, most
women (95%) were either African American or Cau-
casian, and all women were at least 40 years old
and from a womens health clinic population. Stud-
ies with younger women, women of different cultures
and ethnicities, and women from different clinic pop-
ulations (or non-clinical populations) may have dif-
ferent results. Further exploration is particularly war-
ranted given the relationship between reported race
and spiritual practices. Only about 5% (n = 44) of
participants in this study reported races other than
African American or Caucasian, and analyses ex-
cluding these participants did not alter conclusions.
We also note that our assessment of spiri-
tual and religious coping combined these two con- ways to operationalize familial risk, particularly as
cepts, and several studies suggest these constructs,
though related, are likely distinct (Berry, 2005;
Kilpatrick et al., 2005; Salsman et al., 2005; Stefanek
et al., 2005; Thompson, 2002). Furthermore, there
are a number of available instruments that mea-
sure these constructs (Kilpatrick et al., 2005), and
our findings are limited to only two items. We did
find that, in SEM analyses, the factor loadings for
the spiritual coping latent construct manifested by
these two items were high (standardized path coef-
ficients were 0.83 for comfort and 0.90 for pray in
the final model). These high factor loadings suggest
that, although the measures might not distinguish
spirituality from religion, they do seem to be tap-
ping into a common factor. Finally, we note that the
457
items from the Brief COPE measure spiritual cop-
ing, rather than spirituality. Though related, these
constructs could have differences that are important
in assessing relationships with risk perceptions and
health behaviors. While use of spiritual and religious
resources may be a manifestation of spirituality,
several other constructs (e.g., intrinsic/extrinsic reli-
giosity, spiritual well-being, transcendence, fatalism,
and hope/despair) could be important (Berry, 2005;
Kilpatrick et al., 2005). Future studies investigat-
ing spiritual/religious constructs and risk perceptions
might benefit from use of measures that address
other constructs likely to be related to risk percep-
tions.
The factor loadings for three (percent, compare,
and descriptive) of the four risk perception measures
seemed reasonable (standardized path coefficients
of at least 0.60). Notably the quantity risk percep-
tion measure had a relatively low standardized factor
loading (0.39) in the final SEM model suggesting it
contributes weakly to the common risk perception
construct. This finding is consistent with the regres-
sion analyses that found neither a main effect of spir-
itual coping nor an interaction effect on the outcome
of quantity. It is possible that this measure of risk per-
ception acts differently than the other measures and
could reflect the documented unreliability of asking
about probabilistic perceived risk (Katapodi et al.,
2004).
For primary analyses, family history was con-
sidered positive if any blood relative was reported
to have breast cancer. This broad measurement of
familial risk allowed sufficient sample size for pre-
cise parameter estimates in multi-sample SEM, was
positively associated with risk perceptions, and was
appropriate for exploratory analysis. Several other
it might affect perceived risk, are possible. These
ways include establishing a minimum estimate of
increased breast cancer risk [e.g., using the Claus
model (Claus et al., 1994) or chance of inherited can-
cer susceptibility]; or, intensity of risk could have
been defined through criteria involving the number
of close relatives with breast cancer, or whether or
not a close relative had died from breast cancer.
Each of these family history conceptualizations is re-
lated to perceived personal risk (Patenaude, 2005),
although it is unknown how various family history
structures might modify the relationship between
spiritual coping and perceived risk. While the ex-
ploratory post-hoc analyses showed similar modifi-
cation effects regardless of family history structure,
458
there was some suggestion that having more distant
relatives with breast cancer inversely affected the
relationship between spiritual coping and perceived
risk to a greater extent. Future theoretical and em-
pirical studies will be needed to explore the impact of
different family history characteristics. Additionally,
although we are not aware of members of the same
family being enrolled in this study, we did not ask
participants if other relatives were also enrolled in
the study; thus, it is possible that responses about the
family history variable (and potentially other vari-
ables) are not independent among participants.
We are also aware that our statistical model-
ing assumed directionality, specifically that spiritual
coping influences risk perceptions (and not the other
way around). Although this direction of causation
is based on theoretical insight from the literature
and was our a priori hypothesis, analyses were cross-
sectional and temporality could not be tested. We ran
all statistical models reversing the direction of these
variables. In no case was there evidence for better
model fit, and, in most cases, model fit worsened.
The above-mentioned limitations notwithstand-
ing, there are a number of strengths of this study in-
cluding a large sample size, data from women not
selected for high-risk status or from a genetic coun-
seling clinic, fairly consistent findings from analyses
including different measures of risk perception, use
of both multiple regression and multivariate analytic
techniques, and confirmation of the SEM model us-
ing separate random subsets of the available data.
This study of the relationship between spiritual
coping and breast cancer risk perceptions enters aca-
demic territory about which there is general inter-
est, but little knowledge. Given the goals of increas-
ing cultural competence, patient empowerment, and
improving access to genetic counseling services, our
findings justify more research in this area. In general
medical practice, there is increasing support for the
incorporation of spirituality assessments in patient
care (Koenig, 2004) and the integration of spiritual
therapies in cancer care (Taylor, 2005). The bene-
fit of spiritual therapy in cancer genetic counseling
is unknown. Given the emphasis on risk communi-
cation, the findings from this study support genetic
counselors asking patients about their use of spir-
itual coping mechanisms, just as counselors would
want to know about other personal experiences that
could influence perceived risk. Raising patients con-
sciousness of the influence of their spiritual/religious
practices could help to empower patient autonomy in
making health care decisions based on presented risk
Quillin, McClish, Jones, Burruss, and Bodurtha
information and would promote mutual understand-
ing about patients and counselors stories of disease
etiology. Outside of the clinic, these study findings
could suggest persons with more frequent use of spir-
itual/religious coping may be less likely to come for
genetic counseling, assuming perceived familial risk
influences attendance in genetic counseling clinics.
CONCLUSIONS
In a sample of 899 womens health clinic pa-
tients, these analyses explored a relationship be-
tween use of spiritual coping mechanisms and per-
ceived risk for breast cancer. While no association
was found for women with negative family histories,
for women with positive family histories of breast
cancer more frequent use of spiritual coping was as-
sociated with lower perceived risk for breast cancer.
Because risk perception is related to important out-
comes ranging from preventive health practices to at-
tending genetic counseling clinics, these findings are
relevant for genetic counseling researchers and oth-
ers who are interested in reducing the disease burden
of hereditary cancer.
ACKNOWLEDGMENTS
The authors would like to acknowledge the con-
tribution of Dr. Elizabeth Fries, a dear friend, expert
psychologist, and co-Principal Investigator on the
project through which data were collected. Dr. Fries
died before the manuscript was developed, but the
work would not have been possible without her con-
tribution. Data collected for these analyses was sup-
ported by a grant from the National Cancer Institute
of the National Institutes of Health (R01 CA94213).
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