Spiritual health locus of control and life satisfaction among African American breast cancer survivors

Abstract

Purpose:

To examine the relationships between spiritual health locus of control (SHLOC) and satisfaction with life in African American (AA) breast cancer survivors (BCS).

Methods:

A total of 118 AABCS completed a mailed survey. Logistic regression models were used to examine relationships among variables of interest.

Results:

Annual income and SHLOC were significantly associated with life satisfaction. In unadjusted analyses, high overall SHLOC increased the odds (odds ratio [OR] = 2.8) of being satisfied with life. The adjusted relationships between SHLOC and life satisfaction differed by income level. Among survivors with lower incomes, high spiritual life/faith and God’s grace subscale scores increased the odds of life satisfaction, when compared to those with higher incomes.

Conclusions:

Our data indicated that high overall SHLOC was significantly related to higher odds of life satisfaction. Further, SHLOC may serve as a resource to bolster life satisfaction, especially in low-income AA BCS.

Background

Among the 3.5 million female breast cancer survivors (BCS) in the US, over 300,000 are African American (AA).¹ Following a cancer diagnosis, survivors cope with treatment-related side effects that may persist for years after treatment completion. Common treatment-related side effects include lymphedema, fatigue, muscle stiffness and weakness, sleep disturbances, sexual dysfunction, hot flashes, and deficits in both emotional and cognitive functioning.² AA BCS have poor survival outcomes and experience the highest prevalence of treatment-related side effects when compared to women of other racial and ethnic groups.^2,3 Regarding psychological symptoms, during the first two years of survivorship, an estimated 30–45% of BCS experience symptoms such as anxiety and depression.⁴ Impaired psychological and emotional adaptation can have lasting negative physiological consequences and higher risk of death.^5,6 Studies have shown mixed results for racial differences in subjective well-being (i.e. psychological and emotional well-being), with some suggesting that racial differences are mediated by socioeconomic status.⁷ Due to the persistent nature of long-term cancer-related symptoms and poor overall health and well-being of AA BCS,² examining the subjective well-being of BCS is paramount. Thus, it is critical to understand the mechanisms that diminish or enhance health in AA BCS.

Subjective well-being has two facets: a cognitive judgment of life satisfaction and an emotional aspect consisting of independent positive and negative affect components.^8,9 Life satisfaction has been identified as an independent factor of subjective well-being that should be measured and studied separately.⁹ Life satisfaction represents a conscious cognitive evaluation of one’s level of enjoyment and contentment with their life led so far, and level of fulfillment of personal needs and desires.⁹ Individuals report high levels of life satisfaction if their perceived life circumstances are in line with their self-imposed life standards. Life satisfaction, measured by the satisfaction with life scale,⁹ has been used in hundreds of health-related studies and shown to be an effective outcome measure for intervention research.¹⁰ Understanding determinants of life satisfaction in AA BCS is essential to improving subjective well-being and potentially understanding the factors that may help to minimize racial disparities in health outcomes.

Spirituality may play a role in one’s life satisfaction and health outcomes. Studies have indicated that AAs have higher rates of spirituality than whites, and that spirituality often affects the lifestyle behaviors and treatment decisions of AAs.^2,11 The relationship between spirituality and health outcomes is overwhelmingly positive;¹² spirituality is associated with enhanced physical and mental functioning.^2,12 Spirituality may work as a coping mechanism to help promote resilience and positive psychosocial outcomes after a cancer diagnosis.^13,14 However, certain spiritual beliefs can lead to negative consequences.¹² For example, while the belief that God works through doctors to cure breast cancer is associated with mammography utilization,,¹⁵ cancer diagnosis is sometimes associated with a sense of fatalism and choosing less aggressive cancer treatments from the belief that a cancer diagnosis is “a mandate from God that cannot be managed by the healthcare system.”¹⁶ The clarity of relationships and various ways that spirituality may influence health outcomes are poorly understood.¹⁷ Moreover, there are over 100 standardized measures of spirituality and religiosity that contribute to limited knowledge in understanding mechanisms targetable by intervention.¹⁸

Locus of control is one factor that may help explain the incongruence between spirituality and health outcomes. Locus of control (i.e. the internal and external factors and beliefs that influence outcomes) stems from Rotter’s social learning theory and represents the concept of generalized expectancies for prediction of behavior.¹⁹ In other words, a combination of an individual’s personality and life experience builds up a certain set of beliefs which therefore causes certain behavior. Rotter believed that “personality, and therefore behavior, is always changeable.” He conceived that if you change the way a person thinks or the environment a person is responding to, then behavior will change. In other words, life experiences afford a person’s set of beliefs which thereby requires interventions to affect change. Rotter developed the first internal-external locus of control scale.²⁰ The underlying concept is that individuals vary in the degree to which they believe they have control over their own health. Derivations of locus of control (i.e. health locus of control²¹ and the multidimensional health locus of control²²) were spawned in effort to increase predictive power in the relationship between locus of control and health outcomes. Among cancer patients and survivors, internal versus external loci of control are associated with physical and mental well-being.²³ Cancer patients with higher external health locus of control may have poorer coping skills and experience higher rates of depression, anxiety, and worse physical well-being.^23,24 For some, external locus of control may allow cancer patients to separate themselves from their illness and relinquish control and worry to “powerful others” such as their doctor or a higher power., leading to lower levels of distress.^22,25 However, external locus of control can differ greatly in definition from chance, fate, doctors/healthcare providers, government, or a higher power (i.e. God).^22,26

Qualitative work with AA women revealed that spirituality was a significant dimension of health locus of control beliefs that was not specifically addressed by existing health locus of control instruments. AA women often perceive a strong influence of God in shaping their actions and behaviors. Thus, the spiritual health locus of control was developed.²⁶ The spiritual health locus of control (SHLOC) scale is a more precise measure in understanding the complex relationships between spirituality and health.²⁶ The SHLOC was developed to link personal spiritual beliefs to how health outcomes are controlled. Individuals with an internal locus of control believe they have control, versus individuals with an external locus of control believe in a stronger role of God in their health. SHLOC also consists of active and passive factors that are distinct from the internal and external dimensions of control.²⁶ The active spirituality factor describes the belief that God empowers individuals to take care of their health. It is a collaborative approach in which the individual shares responsibility with God for one’s health. The passive spirituality factor describes the belief that God entirely determines one’s health which largely minimizes individual responsibilities, making it unnecessary to engage in health-promoting behaviors.

Spiritual health locus of control has been associated with various behaviors and health outcomes. Active SHLOC has been positively associated with fruit consumption and negatively associated with alcohol consumption.²⁷ Passive SHLOC has been associated with lower vegetable consumption, higher alcohol consumption and depressive symptoms.^27,28 In AA women at high risk for breast cancer, the belief that God controls health has been associated with lower adherence to clinical recommendations for breast examinations and mammograms.²⁹ The relationship between SHLOC and quality of life or life satisfaction has not been investigated in AA cancer survivors.

The purpose of this exploratory study was to determine whether SHLOC was related to life satisfaction. Limitations of previous work include the broad categorization of external locus of control (i.e. fate, luck, chance, doctors/healthcare providers, a higher power) and not measuring the effect of SHLOC on life satisfaction. Further, SHLOC and potential interactions between sociodemographic factors (i.e. education and income) that may have the greatest impact on well-being in AAs have not yet been determined.¹⁷ Previous studies have reported higher spirituality among BCS with lower education and lower income, and that perceptions of life satisfaction may be buffered by higher income levels.¹⁷ Locus of control beliefs and health outcomes may be moderated by socioeconomic status.³⁰ Therefore, in this study we explore potential interactions by education and income. Providing insight on the specificity of these relationships may help to enhance life satisfaction via support-based interventions for AA BCS.

Methods

Study population

Survivors were identified between February 2014 and February 2015 via cases ascertained from tumor registries in a southwestern state, existing relationships with community-based organizations, and snowball sampling. Mailed surveys were sent to approximately 850 survivors from tumor registries, however 273 (32%) were returned due to incorrect addresses (i.e. patients no longer reside at the address recorded during their cancer diagnosis or treatment). Of those not returned due to incorrect address, 96 (17%) were completed and returned. Eligibility criteria included (a) AA (b) a previous diagnosis of breast cancer, (c) being at least 18 years old at study enrollment, (d) having completed treatment (except adjuvant hormone therapy) at least six months before study enrollment, and (e) receptivity to participating in a mailed survey. Survivors with missing data (n = 32) were ineligible. Ethical approval to conduct the study was established before enrolling survivors.

Measures

Demographics

Age, annual family income, education, and marital status were self-reported using a standardized questionnaire.

Medical information

Age of cancer diagnoses, type of cancer treatment (i.e. surgery, chemo, radiation, and hormone therapy), and cancer recurrence were self-reported using a standardized questionnaire.

Spiritual health locus of control

This scale was developed by Holt and colleagues to link spiritual beliefs to how health outcomes are controlled.²⁶ The scale includes 13 statements categorized in 4 subscales: spiritual life/faith, God’s grace, active spirituality, and passive spirituality. Each item was measured in a 5-point Likert-type scale ranging from strongly disagree to strongly agree. The statements by domain are shown in Table 1. The scale was validated among a community-based sample of urban AA women.²⁶ In this study, the Cronbach’s α coefficient of the overall scale was 0.82, indicating good internal consistency. To further examine the reliability of each of the four subscales, Cronbach’s α is reported for each subscale. For spiritual life/faith α = 0.77, God’s grace α = 0.81, active spirituality α = 0.72, and passive spirituality α = 0.51. Cronbach’s α ≥ 0.70 are generally acceptable, however when considering subscales with three to four items, α = 0.51 is satisfactory.³¹ For the purposes of identifying high-risk groups that might benefit from intervention and due to skewness of responses, we categorized SHLOC domains into tertiles (i.e. high, medium, and low levels).³²

Table 1.

Spiritual health locus of control items.

Domains	Statements
Spiritual life/faith	Through my faith in God, I can stay healthy If I lead a good spiritual life, I will stay healthy If I stay healthy, it’s because I am right with God
God’s grace	I rely on God to keep me in good health God works through doctors to heal us Prayer is the most important thing I do to stay healthy If I stay well, it is because of the grace of the good Lord
Active spirituality	Living the way the Lord says I’m supposed to live means I have to take care of myself Even though I trust God will take care of me, I still need to take care of myself God gives me the strength to take care of myself
Passive spirituality	It’s ok not to seek medical attention because I feel that God will heal me There is no point in taking care of myself when it’s all up to God anyway God and I share responsibility.

Satisfaction with life

Life satisfaction was used as a measure of subjective well-being. The scale consists of 5-items, each measured in a 5-point Likert-type scale. Items are summed to create a total score ranging 5–25 that can be categorized into various levels of satisfaction (i.e. extremely satisfied, satisfied, neutral, dissatisfied, and extremely dissatisfied).⁹ In this study, the Cronbach’s α coefficient of the scale was 0.77, indicating good internal consistency. For our analyses, we categorized satisfaction with life into two levels: satisfied (slightly satisfied to extremely satisfied) or not satisfied (extremely dissatisfied to neutral). Similar approaches have been applied when characterizing life satisfaction in large samples,³³ and provide guidance for categorizing BCS who may differ in their subjective outlook on their lives.

Analysis

Descriptive analyses were conducted to assess demographic and clinical characteristics and the distribution of the SHLOC and life satisfaction scales among participants. Five logistic models were used to examine the unadjusted relationships of the overall SHLOC scale and for each of the four SHLOC subscales in association with life satisfaction. Thus, our five models include the following exposure variables (1) overall SHLOC scale (2) spiritual life/faith (3) God’s grace (4) active spirituality (5) passive spirituality. We then approached our model building strategy with consideration of potential confounders using purposeful selection of variables proposed by Hosmer and Lemeshow:³⁴ age, education, annual income, marital status, time since diagnosis, treatment (i.e. surgery, chemo, radiation, and hormone therapy), and cancer recurrence. Purposeful selection is an iterative process that begins with an unadjusted analysis of each potential confounder with the outcome variable. Any variable that has a significant p-value with cutoff point of α = 0.25 is selected as a candidate for the multivariate model. Then all the significant variables are entered into a multivariate model. One by one, variables that do not contribute to the model (if α > 0.05) are removed and the smaller model is compared to the full model using a partial likelihood ratio test to determine the most parsimonious model. If a change of coefficient in the main exposure is >20%, then the deleted variable is added back in. The process of removing, adding, and model refitting continues the most parsimonious model is determined. Lastly, we investigated a potential interaction by income in our final model. STATA 14.2 (College Station, TX) was used to perform data analyses. To assess goodness of fit of our final models, we performed likelihood ratio tests. We also reported area under the receiver operating characteristic curve (AUC) as an effect size indicator of our final models.

Results

Descriptive characteristics

A total of 118 women participated in the study. The average age of participants was 56 years (ranged 31–81 years). Almost half, 45%, indicated scores of being satisfied with life and there were overall high levels of SHLOC (average score 50 out of 65). Many (52%) had at least a college degree and 65% were at least five-year out from diagnosis (Table 2). Table 3 shows correlational relationships between SHLOC, life satisfaction, and covariates. Pearson correlations indicated significant correlations (p = 0.01) between life satisfaction and overall SHLOC as well as two subscales: spiritual life/faith and God’s grace.

Table 2.

Characteristics of African American breast cancer survivors (N= 118).

Variables	%
Age (mean ± SD)	56 ± 10.9
Time since diagnosis
≤5 years	35%
5–10 years	23%
>10 years	42%
Cancer treatment
Surgery	91%
Chemo	80%
Radiation	68%
Hormone therapy	25%
Cancer recurrence
Yes	24%
No	76%
Marital status
Single	17%
Divorced	35%
Married	38%
Other	10%
Annual income
<25,000	12%
$25–35k	11%
$35–50k	20%
$50–75k	23%
≥$75k	34%
Education
High school	6%
Associates degree	13%
Some college, no degree	29%
College degree or higher	52%
Overall Spiritual Health Locus of Control Score (possible range 13–65)	50.23 (7.00)
Active (possible range 3–15)	13.91 (1.47)
Passive(possible range 3–15)	7.84 (2.33)
Spiritual life/faith(possible range 3–15)	11.81 (2.94)
God’s grace(possible range 4–20)	16.67 (3.08)
Satisfaction with life
Dissatisfied	55%
Satisfied	45%

Table 3.

Pearson correlations of spiritual health locus of control, life satisfaction, and covariates.

	Life satisfaction	SHLOC overall	Spiritual life/faith	God’s grace	Active	Passive
Age	0.08	−0.02	−0.04	−0.07	−0.08	0.19
Education	0.11	0.10	0.03	0.19	0.12	0.00
Income	0.25*	−0.22*	−0.15	−0.19	−0.15	−0.03
Marital status	0.04	0.10	0.13	−0.01	0.04	0.15
Time since diagnosis	0.08	−0.02	0.002	−0.17	0.01	0.07
Cancer treatment type	−0.03	0.01	0.07	−0.12	−0.03	0.04
Cancer recurrence	−0.08	0.31*	0.34*	0.17	0.12	0.10
Life satisfaction	1	0.22*	0.22*	0.20*	0.14	0.07

Note.

^*=significant at p=0.01.

Unadjusted models

High overall SHLOC increased the odds (odds ratio [OR] = 2.79, 95% Confidence Interval [CI] = 1.17, 6.63) of higher levels of satisfaction with life compared to low level of SHLOC. Subscales of SHLOC were generally not significant, except for high levels of spiritual life/faith increasing the odds (OR = 3.14, 95% CI = 1.19, 8.39) of life satisfaction compared to low levels of spiritual life/faith. Unadjusted models are presented in Table 4.

Table 4.

Unadjusted models: spirituality in association with satisfaction with life.

p Value	O.R. (95% CI)	Variable	Overall LR test
Overall SHLOC			0.051
Low	1
Medium	1.58 (0.62, 4.03)	0.34
High	2.79 (1.17, 6.63)	0.02
Spiritual life/faith			0.044
Low	1
Medium	2.21 (0.93, 5.26)	0.07
High	3.14 (1.19, 8.39)	0.02
God’s grace			0.031
Low	1
Medium	0.40 (0.16, 1.00)	0.05
High	1.44 (0.59, 3.54)	0.43
Active			0.12
Low	1
High	1.78 (0.35, 1.03)	0.125
Passive			0.60
Low	1
Medium	1.67 (0.51, 5.49)	0.40
High	1.35 (0.60, 3.03)	0.46

Note.

^†Overall, passive, spiritual life/faith, and God’s grace scales are divided by tertiles. Active spirituality was split by the median due to highly skewed data.

Adjusted models

The purposeful selection of variables process resulted in annual income as the only significant variable influencing the association between SHLOC and life satisfaction. The interaction between overall SHLOC and annual income was significant, therefore we present stratified results in Table 5. Likelihood ratio tests of our final models showed that overall SHLOC, spiritual life/faith, and God’s grace had good model fit (p < 0.003), but active and passive SHLOC did not (p > 0.10). For significant models (i.e. overall SHLOC, spiritual life/faith, and God’s grace), the AUC was between 0.70 and 0.75 which indicate a fair effect size³⁴ (Table 5).

Table 5.

Adjusted models: effect of spiritual health locus of control on satisfaction with life by income level.

	High income		Low income		Fit statistics
	O.R. (95% CI)	p-value	O.R. (95% CI)	p-value	Overall LR test p-value	AUC
Overall SHLOC	1.55 (0.85, 2.80)	0.15	3.42 (1.38, 8.52)	0.0080	<0.0020	0.703
Spiritual life/faith	1.75 (0.88, 3.45)	0.11	2.82 (1.20, 6.63)	0.018	<0.0030	0.71
God’s grace	0.82 (0.60, 5.66)	0.50	3.00 (1.21, 7.43)	0.018	<0.002	0.75
Active	2.02 (0.76, 5.33)	0.16	3.09 (0.73, 13.03)	0.13	0.11	0.67
Passive	1.11 (0.65, 1.90)	0.69	1.20 (0.62, 2.35)	0.59	0.43	0.65

Note.

^†Overall, passive, spiritual life/faith, and God’s grace scales are divided by tertiles. Active spirituality was split by the median due to highly skewed data.

The effect of SHLOC on life satisfaction differed by income level. Low income corresponded to the lowest quartile (≤$50,000/yr) and high income corresponded to the highest 75th percentile (≥$50,000/yr). Lower income survivors reporting higher levels of overall SHLOC were more than three times more likely (OR = 3.42; 95% CI = 1.38, 8.52) to have higher levels of life satisfaction, however overall SHLOC was not significantly associated with life satisfaction among higher income survivors (OR = 1.55, 95% CI = 0.85, 2.80). Similar trends were observed for the spiritual life/faith and God’s grace subscales. Lower income survivors reporting higher levels of spiritual life/faith were almost three times more likely (OR = 2.82; 95% CI = 1.20, 6.63) to have higher levels of life satisfaction; however this was not observed among higher income survivors (OR = 1.75, 95% CI = 0.88, 3.45). Lower income survivors reporting higher levels of God’s grace were three times more likely (OR = 3.99; 95% CI = 1.21, 7.43) to have higher levels of life satisfaction; however this was not observed among higher income survivors (OR = 0.82, 95% CI = 0.60, 5.66). Active and passive spirituality were not associated with life satisfaction and income was not a factor in these relationships (p > 0.10).

Discussion

The current cross-sectional study found that SHLOC was associated with increased odds of life satisfaction among lower income AA BCS. SHLOC was not associated with life satisfaction among higher income survivors. We found that spiritual life/faith and God’s grace beliefs were associated with better life satisfaction, however active versus passive locus of control beliefs did not distinguish life satisfaction. These findings suggest that SHLOC may be a relevant factor for life satisfaction exclusively among lower income BCS, which may help bolster subjective well-being among this disadvantaged group.

Our findings contribute to previous work that help to identify the impact that spiritual life/faith and God’s grace beliefs may have on subjective well-being. Some studies have indicated that faith beliefs mediate the relationship between religious functioning and subjective well-being in non-cancer populations. Similar to our spiritual life/faith and God’s grace domains, studies using the Spiritual Assessment Inventory identifies awareness of God to describe the intensity of one’s faith- how strongly a person feels the presence of a God in daily life.³⁵ Individuals with greater awareness of God often have higher external as well as internal locus of control because they believe their relationship with God will protect and guide them and therefore are more optimistic and confident.^12,17,25 This mixed translation of faith beliefs to both increased internal and external control may explain why internal vs external control was not significant in our sample of highly spiritual BCS. Aligning oneself with a higher power can create a perception of that one shares in the higher power’s external control, allowing for a greater sense of personal control, which helps them maintain higher levels of life satisfaction compared to those who are less spiritual.³⁶ This may spare some individuals from the hopelessness and discouragement that often occurs with circumstances that seem uncontrollable, such as in the context of cancer survivorship and fear of cancer recurrence. Furthermore, in line with our findings that spiritual life/faith and God’s grace is associated with better life satisfaction among lower income AA BCS, Vahia et al.¹⁴ found that spirituality may promote resilience to stressors to a greater degree among women with lower income or education level.

In the present study, we did not find significant associations between active or passive locus of control domains and life satisfaction. Our sample had highly skewed responses towards high active SHLOC beliefs, with very few having low levels of active SHLOC beliefs, and the majority of this sample had mid-range levels of passive SHLOC beliefs which may explain our lack of associations with life satisfaction. It may also be possible that active and passive SHLOC beliefs are more important for influencing health behaviors than impacting life satisfaction. Passive SHLOC is characterized by the belief that God determines one’s health therefore minimizing personal responsibility to engage in health-promoting behaviors,³⁷ while active SHLOC describes the belief that God empowers individuals to take care of their health. In a longitudinal study of AAs, active SHLOC was not related to changes in any physical or mental health outcomes.²⁸ However, passive SHLOC was found to be associated with greater depressive symptoms but not with overall emotional functioning.²⁸ It may be that passive and active SHLOC beliefs do not have a large impact on physical or emotional functioning that would translate to life satisfaction. Nevertheless, active and passive SHLOC beliefs are shown to be associated with health behaviors. In a study of AA women at high-risk for BC, passive control beliefs were associated with lower likelihood of following recommendations for clinical breast examinations and mammograms.²⁹ In AA adults, active SHLOC has been associated with higher fruit consumption.²⁷ Among AA women, active SHLOC has been associated with less alcohol use.³⁷ Among AA adults, passive SHLOC has been associated with less vegetable intake, and higher alcohol use among men.²⁸ Neither passive nor active SHLOC has been significantly associated with tobacco use or physical activity.²⁸ Further studies such as these need to be conducted to better understand mechanisms of SHLOC affecting health behavior change in order to develop relevant interventions.

Our study should be interpreted with caution in light of its limitations. This study used cross-sectional data rather than longitudinal therefore we must consider the possibility of reverse causality. It is possible that lower income and worse life satisfaction leads AA BCS to become more spiritual and relinquish their sense of control over to God, or vice versa.³⁸ However, the directionality of these relationships is supported by previous longitudinal work showing that spirituality and locus of control do impact psychological functioning.¹⁷ Our participants were self-selected, the majority were highly-educated (most having some college or beyond), and our sample size was modest which limits our generalizability to other AA BCS. The analyses were also exploratory and power analyses were not computed prior to our data collection. Despite these limitations, there are several strengths of our study. We used validated measures for spirituality (i.e. SHLOC scale²⁶) and life satisfaction (i.e. satisfaction with life scale⁹). These measures can be used in future studies to attain consistency across results and confirm findings from our study and others. Further, our intent to illuminate possible associations between SHLOC and life satisfaction adds valuable perspective that needs to be confirmed in further studies.

Implications

Spiritual health locus of control may be one of the underlying mechanisms linking spirituality to life satisfaction in low income AA BCS.^25,28,38 Future research is needed to confirm our findings that SHLOC is positively associated with life satisfaction in low-income AA BCS. SHLOC is one factor that can be potentially targeted by intervention with the goal of facilitating empowerment and increasing life satisfaction.³⁹ Other factors may also play a role in the relationship between spirituality and subjective well-being such as social support, self-esteem and self-efficacy, religious coping styles, stressful life events, or health status. It is critical that researchers continue to investigate the mechanisms through which spirituality may have on health outcomes for BCS. Regarding SHLOC, work is warranted to investigate the impact that SHLOC may have on life satisfaction and health outcomes, and ways that SHLOC can be targeted with interventions. Additionally, relevant supportive interventions will need to be developed and tested specifically tailored to low-income minority groups. In other populations, such as women with postpartum depression, interventions have shown to modify internal and external loci of control beliefs and translate into improving psychological health.⁴⁰ Studies such as these have not yet been applied to BCS. Park et al.⁴¹ recommend collaboration between the behavioral medicine community and spiritual leaders to develop spiritually-sensitive interventions to improve patients’ well-being. Work in this field can help to minimize racial disparities in health outcomes and well-being among BCS.

Spiritual care is not well-integrated into the clinical care of cancer treatment and survivorship, despite evidence of the importance that spirituality plays for AA survivors.⁴² The National Comprehensive Cancer Network recommends that patients who report spiritual concerns be referred to chaplaincy services for spiritual assessment and support.⁴³ Although healthcare providers are not spiritual leaders, they should be aware of cultural influences to care (e.g. spirituality) as they play important roles in patient lives and may affect their well-being during cancer diagnosis and treatment.^27,42 Resources are available to help clinicians sensitively assess spiritual concerns among patients and appropriate inquiries are well-received by patients.⁴⁴ One example is given by Nolan et al.’s⁴⁴ five-step approach to managing spirituality: (1) respect of patient beliefs, (2) acknowledge concerns, (3) maintain integrity, (4) empower survivors, and (5) mobilize resources. Thus, a first practical step for clinicians to incorporate a patient’s spirituality into medical care is for providers to implement and document a comprehensive cultural assessment (which includes a spiritual assessment) as part of medical encounters.⁴⁴ Then, support resources such as chaplains or faith-based counselors can provide follow-up care with special emphasis on components of loci of control that have shown to be modifiable and beneficial for better subjective well-being. Overlooking patient spirituality is a missed opportunity for providing support to AAs or other low-income groups who may lean on spirituality as resource for coping after cancer diagnoses.