A Pilot Study of a Gratitude Journaling Intervention to Enhance Spiritual Well-Being and Exercise Self-Efficacy in Black Breast Cancer Survivors

doi:10.21203/rs.3.rs-4903270/v1

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Research Article

A Pilot Study of a Gratitude Journaling Intervention to Enhance Spiritual Well-Being and Exercise Self-Efficacy in Black Breast Cancer Survivors

https://doi.org/10.21203/rs.3.rs-4903270/v1

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Background

Breast cancer (BC) survivorship presents significant health disparities, particularly affecting Black women, who experience a 40% higher BC death rate compared to White women. These disparities are exacerbated by comorbidities, which contribute to poorer overall health outcomes. Additionally, Black BC survivors often face psychosocial challenges, including increased stress and lower well-being, which can lead to adverse physical health effects. This pilot study aims to assess the feasibility and efficacy of a culturally sensitive gratitude journaling intervention designed to enhance spiritual well-being, exercise self-efficacy, and reduce inflammation among Black BC survivors.

Methods

This pilot study employed a two-group, parallel random-assignment experimental design to compare a gratitude journaling intervention with a general memory journaling control group. Twenty-six Black women aged 40 to 70 years with a history of BC were randomly assigned to either the gratitude journaling intervention group (n = 13) or the control group (n = 13). The gratitude intervention group engaged in gratitude journaling twice weekly for eight weeks, while the control group documented daily memories. Outcomes measured included dispositional gratitude, spiritual well-being, perceived stress, exercise self-efficacy, and inflammatory biomarkers. Statistical analyses included the Wilcoxon rank sum test and Fisher's exact test.

Results

Twenty-six participants were enrolled, with 73% completing baseline and post-intervention assessments. The intervention group showed a significant improvement in spiritual well-being (p = 0.014) with a large effect size (ES = 0.57). Marginal improvements in exercise self-efficacy were also observed (ES = 0.39). Although there were no significant differences in dispositional gratitude and perceived stress between groups, the intervention group exhibited trends toward increased gratitude and reduced stress. Inflammatory biomarker analysis indicated non-significant changes, though IL-6 levels increased in the intervention group.

Conclusion

This study demonstrates the feasibility and acceptability of a gratitude journaling intervention among Black BC survivors. The intervention significantly enhanced spiritual well-being and showed promise in improving exercise self-efficacy, suggesting its potential for promoting holistic wellness in this population. These findings provide a foundation for future larger-scale randomized controlled trials to further evaluate the efficacy of gratitude-based interventions for Black BC survivors.

Trial registration:

This study was registered prospectively at ClinicalTrials.gov (NCT05473026) on 07-01-2022.

breast cancer survivors

health disparities

spiritual well-being

positive psychology

randomized control trial

Breast cancer (BC) survivorship care remains a significant health concern after treatment. Survivors often face adverse psychosocial and physical effects, including elevated stress levels, chronic inflammation, and poor lifestyle behaviors, all of which negatively impact their well-being and health-related quality of life (1–3). According to the American Cancer Society (4), Black women still have a 4% lower incidence rate of breast cancer than White women but a 40% higher BC death rate. Moreover, a significant proportion of BC survivors face challenges related to comorbidities, which exacerbate their overall physical health outcomes (5, 6). Among these comorbidities, metabolic syndrome—a cluster of conditions that increase the risk for cardiovascular disease and Type 2 diabetes—is particularly prevalent among Black women with BC (7, 8). Metabolic syndrome not only amplifies the risk of developing BC but also contributes to poorer prognosis and outcomes, thus exacerbating existing health disparities among racial groups.

The intersection of race, age, and a cancer diagnosis creates unique challenges for Black women with breast cancer. Cultural constructs, such as the Superwoman Schema, which is deeply rooted in Black culture, further complicate the health landscape. This schema involves cognitive, affective, and behavioral responses emphasizing strength, emotional suppression, resistance to vulnerability, success despite adversity, and prioritizing others' needs over one's own. While these traits may foster resilience, they can also lead to heightened stress levels and increased vulnerability to metabolic syndrome and related health complications (9).

Promoting spiritual well-being among breast cancer survivors, particularly Black women, is critical not only for emotional resilience but also for reducing physiological risk factors associated with metabolic syndrome. Existing literature indicates a significant association between spiritual well-being and positive psychological constructs, such as gratitude, which serve as protective factors against metabolic syndrome (10–12). Spiritual practices, including gratitude, meditation, and journaling, have been linked to improved metabolic parameters, such as blood pressure, blood glucose levels, and lipid profiles (13–16).

Cultivating dispositional gratitude—a trait linked to enhanced spiritual well-being, reduced psychological distress, and improved self-efficacy—offers a promising avenue for addressing these challenges (17–19). According to Fredrickson's Broaden-and-Build theory (20), gratitude broadens an individual’s cognitive and emotional resources, strengthening self-efficacy and resilience. Research by Konopack and McAuley (21) suggests that spirituality and physical activity are partially mediated by self-efficacy perceptions, which influence adults' quality of life. However, many of these studies are outdated, and there is a notable lack of research addressing both the physical and psychological aspects of positive psychological interventions, especially in racially diverse populations. Mind-body techniques, such as gratitude journaling, offer strategies for mitigating stress, promoting positive health behaviors, and potentially improving inflammatory biomarkers among Black BC survivors (15, 19, 22). Despite evidence supporting the effectiveness of gratitude interventions in other populations, there remains a critical gap in research concerning their applicability and efficacy, specifically among Black women with breast cancer.

In this pilot study, we sought to address the multifaceted health needs of Black women with breast cancer by integrating culturally sensitive approaches into our intervention framework, guided by Giscombe's Superwoman Schema and Fredrickson's Broaden-and-Build theory (20, 23). By examining the associations of gratitude and perceived stress with spiritual well-being, exercise self-efficacy, and inflammatory biomarkers, our study aims to provide valuable insights into the potential mechanisms underlying the observed benefits of gratitude interventions in this population. We hypothesized that culturally tailored interventions would significantly enhance spiritual well-being among Black breast cancer survivors, laying the groundwork for future randomized controlled trials to further evaluate the efficacy of gratitude-based interventions in this underserved population.

Aim and Design

This pilot study aimed to assess the feasibility and acceptability of a gratitude journaling intervention and to evaluate its preliminary efficacy on dispositional gratitude, spiritual well-being, perceived stress, dimensions of the Superwoman Schema, exercise self-efficacy, and inflammatory biomarkers among Black women with breast cancer. We employed a two-group, parallel random-assignment experimental design to compare a gratitude journaling intervention with a general memory journaling (attention control) group. The study followed a pre-post design, with outcomes measured at baseline and after eight weeks of intervention.

Setting

Participants' surveys and biospecimen collection were performed at the University of Florida (UF) Clinical and Translational Science Institute's Clinical Research Center (CRC). The CRC offers comprehensive services for research studies encompassing a wide range of diseases and age groups and provides essential resources and support for data management and execution. The CRC includes a team of experienced research professionals, including registered nurses, research coordinators, dietitians, investigational pharmacists, and administrative personnel.

Participants

The participants for the study were screened for eligibility via telephone. Eligible participants were English-speaking, self-reported African American or Black women with a history of breast cancer (Stage I–IV). Women on hormonal therapies and anti-human epithelial receptor 2 (HER-2) therapy were included. Exclusion criteria included self-reported regular meditation or gratitude practices (more than once a week for at least a month) or meeting the Centers for Disease Control and Prevention's physical activity guidelines. Participants were compensated $100 within two time points for their participation.

Sample Size

Following Julious' (24) recommendation to have 12 participants per group for a pilot study, 26 Black female participants were recruited to account for attrition.

Approval and consent

The pilot study (Protocol ID: 202201483) was approved by the Institutional Review Board (IRB) at the University of Florida. IRB approval was obtained before participant recruitment. Potential participants underwent a brief phone screening to assess their suitability for the study. During this screening process, they were provided with a concise overview of the study procedures, which included information regarding the nature of the questionnaires, blood-draw collection, and any associated risks. Upon signifying their understanding of the study procedures and risks, participants provided informed consent before enrollment.

Recruitment

Participants were recruited using organic social media recruitment, flyers, and multiple specialized strategies from various resources, including the OAIC Pepper Center Clinical Research Core - Claude D. Pepper Center Participant Registry (IRB201601352), UF Health Cancer Center Community-Partnered Cancer Disparities Research Collaborative, UF Health Cancer Center Community Outreach and Engagement, UF Healthstreet, Integrated Data Repository, and UF Consent2Share Registries. Potential participants were screened for eligibility via telephone.

Gratitude journaling intervention group

The proposed study was built on the McCullough, Emmons (17) original gratitude journaling intervention to reduce the burden of journaling for breast cancer survivors. Participants received a gratitude journal and were instructed to journal at least twice weekly over an eight-week period. They were instructed to complete the following journaling prompt at least twice a week for 10–15 minutes: "There are many things in our lives, both large and small, that we might be grateful about. Think back over the day and write down on the line below all that you are grateful for today" (maximum six reasons). The educational goal-setting component was drawn from the American Cancer Society's Diet and Physical Activity Guideline. Participants were allowed to choose the order in which they completed the goal-setting modules.

General memory journaling control group

For the attention control arm, the participants engaged in general memory journaling and documented their daily activities and reflections to be a neutral comparison against the intervention group. Participants received the following general journaling prompt at least twice a week for no more than 15 minutes: "What are some memorable events that happened to you today, big or small (maximum six memories)? Write a brief statement about it." At the end of the intervention, at week 8, both groups collected the journals for treatment fidelity.

Data and Biomarker Collection

After screening for eligibility and obtaining verbal consent, participants were scheduled for an in-person appointment to collect baseline and post-intervention survey data, including collecting a blood sample over two-time points. Participants completed demographic and cancer history questionnaires and self-report instruments at each appointment. Informed written consent was obtained during the baseline appointment. Before the appointment, participants were randomized to either the gratitude journaling intervention or attention control group in a 1:1 ratio, with a permuted block randomization method. The participants received concealed bags that informed them of their group assignment and intervention details. The research assistant and biostatistician were unaware of group allocation throughout the study to maintain blinding.

Inflammatory Biomarker Collection

The collected blood samples were processed and stored in collaboration with the OAIC Metabolism and Translational Science Core at the UF Clinical Research Center. After blood sample collection, the plasma was separated, aliquoted, and stored at − 80°C for later assay. A custom multiplex immunoassay panel for TNF-α, IL-6, and GDF15 (R&D Systems, Minneapolis, MN) was analyzed using a MILLIPLEX® Analyzer 4.3 xPONENT System (Luminex Corp, Austin, TX). CRP levels were measured via ELISA (R&D Systems) utilizing BioTek Instruments (Winooski, VT) Synergy™ HTX Multi-Mode Microplate Reader and analyzed via Gen5 Microplate Reader Software (Bio-Tek Instruments). Analyses demonstrated a minimal interassay coefficient of variation < 14%.

Assessment of feasibility and acceptability

The research assistant inputted various metrics using spreadsheet software to assess the feasibility and acceptability of the intervention, including recruitment and retention rates, participant adherence, and satisfaction measures. Recruitment and retention rates were tracked by monitoring the number of potential participants screened and enrolled in the study. The enrollment rate was calculated as the number enrolled relative to the total number of individuals screened to indicate the effectiveness of the recruitment process.

Participant adherence to the intervention was evaluated by analyzing journal logs to determine the frequency and consistency of engagement with the assigned journaling tasks. Adherence rates were calculated based on the number of completed journal entries relative to the expected frequency, indicating participants' compliance with the intervention protocol. The proportions of women meeting the inclusion criteria relative to the number approached was calculated, with feasibility defined as > 75% of women approaching meeting the criteria. Additionally, the percentage of participants completing baseline assessment measures was computed, with feasibility defined as > 80% of participants completing these measures. Furthermore, the percentage of participants completing both baseline and post-intervention assessments was determined, with feasibility defined as > 80% of those completing baseline assessments completing post-intervention assessments.

Feasibility and acceptability were further assessed through exit interviews and the Client Satisfaction Questionnaire (CSQ) administered at the end of the study. The CSQ is a standard measure widely used in healthcare delivery settings to evaluate the acceptability of interventions (25). The CSQ provided additional insights into the gratitude exercises. The exit interview comprised structured and open-ended questions to explore participants' perceptions of the intervention's content, value, structure, and potential burden.

Demographic, Psychosocial, and Inflammatory Biomarker Measures

Demographic, psychosocial variables, and inflammatory biomarkers were measured at baseline (T1) and postintervention at eight weeks (T2).

Demographics (T1)

Demographic information, including age, sex, education, marital status, and body mass index was collected from participants at baseline (T1). Additional variables related to cancer and its treatment were recorded, such as time since diagnosis, cancer stage, grade, hormonal and HER2 + status, surgical type, chemotherapy, radiotherapy, and other relevant treatment modalities.

Psychosocial Variables (T1, T2)

Dispositional gratitude. Dispositional gratitude was assessed using the Gratitude Questionnaire-6 (GQ-6) at baseline (T1) and follow-up (T2). The GQ-6 is a well-validated, self-administered 6-item scale that measures four facets of dispositional gratitude, including intensity, frequency, span, and density. Participants rated each item on a 7-point Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree) (17). Scores range from 6 to 42, with higher scores implying a greater level of dispositional gratitude and lower scores indicating a decreased disposition in gratitude.

Spiritual well-being. Spiritual well-being was evaluated using the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being 12 Item Scale (FACITsp12) at both baseline (T1) and follow-up (T2). The FACITsp12 consists of 12 items rated on a Likert-type scale ranging from 0 (not at all) to 4 (very much), that assesses spiritual well-being over the past seven days among individuals with chronic illness (26). Higher scores indicate enhanced spiritual well-being.

Perceived stress. Perceived stress levels were measured using the Perceived Stress Scale (PSS) at baseline (T1) and follow-up (T2). The PSS comprises ten items rated on a 5-point Likert scale ranging from 0 (never) to 4 (very often), reflecting perceived stress experienced during the last month (27). Higher scores indicate more perceived stress during the last month.

Superwoman Schema. The Giscombe Superwoman Schema Questionnaire (G-SWS-Q) was utilized to assess the superwoman schema, including racial and gender identity, at both baseline (T1) and follow-up (T2). The G-SWS-Q consists of 35 statements rated from 0 (not true) to 4 (true all the time) across five subscales: (1) obligation to present an image of strength, (2) obligation to suppress emotions, (3) resistance to being vulnerable, (4) intense motivation to succeed, and (5) obligation to help others (23). Higher scores indicate higher agreement with the identity.

Exercise self-efficacy. Exercise self-efficacy was assessed using the Stage of Motivational Readiness for Physical Activity questionnaire at baseline (T1) and follow-up (T2). This highly reliable instrument comprises five items and classifies individuals into the pre-contemplation, contemplation, preparation, action, or maintenance stage of exercise behavior change based on the selection by the participant (28).

Inflammatory Biomarkers (T1, T2)

Levels of tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), growth/differentiation Factor-15 (GDF15), and C-reactive Protein (CRP) were measured at baseline (T1) and follow-up (T2) using a Luminex panel for TNF-α, IL-6, and GDF15, and an enzyme-linked immunosorbent assay (ELISA) kit for CRP.

Data analysis

The statistical analysis was conducted using R software (Version 4.3.2). Results were reported as mean (standard deviation, SD) for continuous variables and as frequencies and percentages for categorical variables. Demographic characteristics were examined by groups at baseline. Participant satisfaction was assessed using mean CSQ scores post-intervention.

The Wilcoxon rank sum test and Fisher's exact test were used to calculate p-values and estimate effect sizes (ES) for group comparisons on changes between the baseline and post-test for the secondary psychosocial and inflammatory biomarker measures. Cohen's (29) guidelines were used to interpret ES as follows: small (ES = .10), medium (ES = .24), and large (ES = .37).

Participant Flow

This study follows the CONSORT 2010 guidelines for reporting randomized trials (30). The flow of participants through the study is illustrated in the CONSORT diagram (Fig. 1). Out of 40 individuals approached for participation, 26 met the inclusion criteria and were enrolled in the study. These participants were randomly assigned to either the gratitude journaling intervention group (n = 13) or the general memory journaling control group (n = 13). Eight participants completed the intervention in the gratitude journaling group, while five were lost to follow-up due to various reasons, including transportation and scheduling conflicts. In the control group, 11 participants completed the study, with two participants lost to follow-up. Overall, 73% of the participants (n = 19) completed both baseline and post-intervention assessments.

Feasibility and Acceptability

The feasibility analysis revealed that 65% of individuals approached met the inclusion criteria, and 26 participants completed baseline assessment measures with a completion rate of 100%. Seventy-three percent of the participants (N = 19) completed baseline and post-intervention assessments. This slightly lower rate was attributable to transportation and work scheduling conflicts that some participants reported. Participants engaged in journaling activities regularly and, on average, three times per week, meeting the goal of at least twice a week. Regarding acceptability, participants reported high satisfaction with the intervention, as evidenced by a mean score of 29 on the CSQ-8.

Analyses of Demographic, Psychosocial, and Inflammatory Biomarker Outcomes

Demographics

Baseline demographics for the overall population (N = 26) and intervention groups are summarized in Table 1. At baseline, 26 participants were included in the study, with 13 assigned to either the control or intervention groups. The demographic characteristics and descriptive statistics in Table 2 showed no significant differences between the two groups. The mean age among participants was 65.0 years; gender and race distribution were equal across both groups, with all participants identifying as female Black breast cancer survivors (100.0%). Educational levels, employment status, and general area of residence also showed no significant differences between the groups.

Table 1

Demographics by Groups at Baseline (N = 26)
Characteristic	N	Overall (N = 26)	Control (N = 13)	Intervention (N = 13)	p-value
Age	26				0.396
Mean (SD)		65.0 (7.9)	66.7 (9.1)	63.4 (6.5)
Median (25–75%)		64.0 (59.3 to 71.0)	67.0 (62.0 to 71.0)	63.0 (59.0 to 69.0)
Range		51.0 to 83.0	51.0 o 83.0	52.0 to 72.0
Gender	26
Female		26 (100%)	13 (100%)	13 (100%)
Race	26
African American		26 (100%)	13 (100%)	13 (100%)
Hispanic	26
No		26 (100%)	13 (100%)	13 (100%)
Education	26				> 0.999
Graduate degree		2 (7.7%)	1 (7.7%)	1 (7.7%)
Some graduate school		2 (7.7%)	1 (7.7%)	1 (7.7%)
College graduate		2 (7.7%)	1 (7.7%)	1 (7.7%)
College 1–3 years		12 (46.2%)	6 (46.2%)	6 (46.2%)
Grade 12 or GED		5 (19.2%)	2 (15.4%)	3 (23.1%)
Some high school		3 (11.5%)	2 (15.4%)	1 (7.7%)
Employment	26				> 0.999
Full-time		9 (34.6%)	4 (30.8%)	5 (38.5%)
Part-time		3 (11.5%)	2 (15.4%)	2 (15.4%)
Not working		14 (53.8%)	7 (53.8%)	7 (53.8%)
Income	26				0.174
Less than $25,000		7 (26.9%)	6 (46.2%)	1 (7.7%)
$25,000 to $49,999		9 (34.6%)	4 (30.8%)	5 (38.5%)
$50,000 to $74,999		3 (11.5%)	2 (15.4%)	1 (7.7%)
$75,000 or more		2 (7.7%)	0 (0.0%)	2 (15.4%)
Prefer not to say		4 (15.4%)	1(7.7%)	3 (23.1%)
Relationship Status	26				0.827
Single		16 (61.5%)	9 (69.2%)	7 (53.8%)
Dating		2 (7.7%)	1 (7.7%)	1 (7.7%)
Married		7 (26.9%)	3 (23.1%)	4 (30.8%)
Prefer not to say		1 (3.8%)	0 (0.0%)	1 (7.7%)
Religion	26				0.480
Christian		22 (84.6%)	11 (84.6%)	11 (84.6%)
Not Religious		1 (3.8%)	0 (0.0%)	1 (7.7%)
Other		2 (7.7%)	2 (15.4%)	0 (0.0%)
Prefer not to say		1 (3.8%)	0 (0.0%)	1 (7.7%)
Weight	26				0.137
Mean (SD)		201.8 (59.3)	181.1 (39.8)	222.5 (69.3)
Median (25–75%)		186.5 (157.0 to 231.5)	180.0 (153.0 to 212.0)	205.0 (168.0 to 271.0)
Range		120.0 to 352.0	120.0 to 250.0	136.0 to 352.0
Body Mass Index	26				0.589
Mean (SD)		33.9 (8.7)	31.7 (5.7)	36.1 (10.7)
Median (25%to 75%)		31.0 (28.0 to 39.3)	31.0 (28.0 to 36.0)	31.0 (27.0 to 44.0)
Range		20.0 to 54.0	20.0 to 40.0	24.0 to 54.0
* p-value were calculated using Wilcoxon rank sum test; Fisher’s exact test

Table 2

Change in Psychological Outcomes Pre and Post Intervention by Groups
Characteristic	Control (N = 11) Mean (SD)	Intervention (N = 8) Mean (SD)	p-value	Effect Size
Gratitude	-0.3 (1.0)	0.5 (1.3)	0.4	0.183
Spiritual Well-being	-1.8 (3.1)	3.6 (8.0)	0.014*	0.572
Perceived Stress	-1.3 (4.5)	-2.1 (4.9)	> 0.9	0.029
Superwoman Schema Subscale (Image of Strength)	-0.4 (3.9)	-0.4 (1.9)	> 0.9	0.010
Superwoman Schema Subscale (Suppress Emotions)	0.5 (5.2)	-0.8 (4.2)	0.3	0.239
Superwoman Schema Subscale (Resistance to Vulnerability)	-0.3 (7.6)	-2.1 (4.2)	0.4	0.190
Superwoman Schema Subscale (Motivation to succeed)	-1.0 (4.4)	-1.3 (3.2)	0.8	0.074
Superwoman Schema Subscale (Obligation to Help Others)	1.3 (6.8)	0.1 (5.5)	0.7	0.105
Superwoman Schema Total Score	1.1 (23.9)	-4.4 (11.4)	0.9	0.052
Exercise Self-Efficacy	-0.2 (0.6)	0.8 (1.5)	0.10	0.391
p-value were calculated using Wilcoxon rank sum test
The Wilcoxon effect size r is calculated as Z statistic divided by square root of the sample size (N): Z/√N\
* p < 0.05

Change in Psychosocial Outcomes Pre and Post-Intervention

The study results indicate notable changes in psychosocial outcomes baseline and post-intervention among the control (N = 11) and intervention groups (N = 8) (see Table 2). There were no significant differences between groups (p = 0.4) for dispositional gratitude, although a small ES of 0.18 was observed. The intervention group exhibited a higher mean change in score (M = 0.5, SD = 1.3) than the control group (M = -0.3, SD = 1.0). Similarly, no significant difference was observed in perceived stress between the groups (p > 0.9), with an ES of 0.03. For spiritual well-being, a statistically significant difference was noted (p = 0.014), with a large ES of 0.57.

Regarding the five dimensions of the G-SWS-Q instrument, for the obligation to present an image of strength, there was no significant change between baseline and post-intervention assessments (p > 0.9), with a negligible ES of 0.01. Similarly, the obligation to help others and intense motivation to succeed also did not show significant changes post-intervention (p > 0.7), with small and insignificant ES (0.11 and 0.07, respectively). However, the intervention did lead to a notable change in participants' tendencies to suppress their emotions (medium ES of 0.24, p-value of 0.3) and a slight shift in participants' willingness to expose vulnerability (small ES of 0.190, p-value of 0.4). Overall, the total score of the G-SWS-Q did not exhibit a significant change post-intervention (ES = 0.052; p = 0.9). However, exercise self-efficacy displayed a marginally significant improvement post-intervention (p = 0.10) with a medium ES (0.391), suggesting that the intervention may have positively influenced participants' beliefs in their ability to engage in physical exercise, offering hope for their future well-being.

Change in Inflammatory Biomarker Outcomes Pre and Post-Intervention

Examining inflammatory biomarker outcomes before and after the intervention in both the control (n = 11) and intervention groups (n = 8) yielded diverse findings, as presented in Table 3. In the control group, there was a mean increase from baseline to post-intervention in CRP levels of 0.6 mg/L (SD = 2.6), while the intervention group showed an increase of 3.1 mg/L (SD = 6.0). The Wilcoxon rank sum test resulted in a non-significant p-value of 0.4 and a small ES of 0.22.

Table 3

Changes in Biomarker Outcomes Pre and Post Intervention by Groups
Characteristic	Control (N = 11) Mean (SD)	Intervention (N = 7) Mean (SD)	p-value	Effect Size
C-Reactive Protein (mg/L)	0.6 (2.6)	3.1 (6.0)	0.4	0.224
Tumor Necrosis Factor Alpha (pg/mL)	-0.2 (1.1)	-2.4 (5.1)	0.5	0.182
Interleukin-6 (pg/mL)	0.0 (15.3)	3.0 (4.1)	> 0.9	0.011
Growth/Differentiation Factor 15 (pg/mL)	15.2 (696.4)	17.4 (89.4)	0.7	0.117
p-value were calculated using Wilcoxon rank sum test
The Wilcoxon effect size r is calculated as Z statistic divided by square root of the sample size (N): Z/√N
* p < 0.05

Conversely, for TNF-α, the mean change (decrease) was − 0.2 pg/mL (SD = 1.1) in the control group and − 2.4 pg/mL (SD = 5.1) in the intervention group. On the contrary, IL-6 demonstrated a significant contrast between the groups, with no mean change of 0.0 pg/mL (SD = 15.3) in the control group and 3.0 pg/mL (SD = 4.1) increase in the intervention group. The p-value exceeded 0.9, signifying a non-significant ES of 0.01.

Additionally, growth differentiation GDF-15 demonstrated a mean change (increase) of 15.2 pg/mL (SD = 696.4) in the control group and 17.4 pg/mL (SD = 89.4) in the intervention group. These findings suggest that while some biomarkers showed changes in response to the intervention, particularly IL-6, the overall impact was not statistically significant across all biomarkers examined.

Breast cancer survivors, especially Black women, have been reported to encounter multifaceted challenges post-treatment, impacting their psychosocial and physical well-being (31). Our study addressed this issue by investigating the efficacy of a gratitude journaling intervention tailored to Black women with BC while considering the intersectionality of race, gender, and cultural norms such as the Superwoman Schema. The significant improvement in spiritual well-being post-intervention suggests the intervention's effectiveness in fostering holistic wellness among Black BC survivors. While no significant difference was found in dispositional gratitude between the intervention and control groups, the intervention group exhibited a trend towards increased gratitude, indicating a positive impact.

Historically, Black BC survivors have used spirituality to deal with hardships. Spiritual well-being is a primary coping mechanism during all phases of treatment and survivorship (32, 33). In a psychometric study of the construct gratitude of 298 Blacks at risk for cardiovascular disease, Cousin, Redwine (34) found that dispositional gratitude correlates with spiritual well-being and positive affect. Moreover, gratitude and spiritual well-being are related to improved mood, higher rates of self-efficacy, and lower levels of inflammatory biomarkers in other clinical populations (18). Similar research findings from gratitude studies among cancer survivors show that gratitude is associated with lower levels of psychological distress (19, 35, 36). Yet, there is little evidence to support the impact of dispositional gratitude on perceived stress among Black women.

The Superwoman Schema dimensions reflect culturally ingrained behaviors among Black women that influence their health behaviors and outcomes (9). In a study of Black women (n = 208) that examined whether the Superwoman Schema modified the relationship between racial discrimination and allostatic load (a marker of cumulative stress), researchers reported that two of the subscales, “maintaining unwavering strength” and “suppressing emotions,” were each protective factors, while “placing the need of others before themselves” exacerbated the health risk associated with experiencing racial discrimination (37). In our study, while changes in Superwoman Schema dimensions were observed, they were not consistently significant across all domains, suggesting potential variability in participants' responses to the intervention. However, our intervention appeared to influence participants' tendencies related to emotional suppression and vulnerability, indicating a potential shift in coping strategies and self-perception. A lack of significant changes in other dimensions suggests a complex relationship between cultural norms and health behaviors. Future interventions may benefit from further exploration of these dimensions to better understand their implications for health outcomes among Black women with BC.

Most gratitude interventions utilized across the cancer continuum only focused on their impact on psychological outcomes and cognitive measures of their work, while few have examined inflammatory biomarkers. Higher inflammatory biomarkers and their reactivity to stress may predict worsening outcomes among Black BC survivors. For example, Black BC survivors have higher serum IL-6 than White women, suggesting an additional risk of BC complications and poor prognosis (38). Although more evidence is needed, gratitude, positive affect, self-efficacy, and spiritual well-being have been linked to improved inflammatory biomarkers (15, 18, 39). While some inflammatory biomarkers exhibited changes indicative of potential improvements in inflammation levels, the overall impact did not reach statistical significance across all biomarkers examined. These findings suggest that while the intervention may have influenced certain aspects of participants' health, further research is needed to elucidate its full effects on inflammatory processes.

Exercise self-efficacy, a crucial determinant of physical activity engagement, displayed marginal improvement post-intervention, indicating the intervention's potential to enhance participants' confidence in adopting healthier lifestyle behaviors. Given the importance of physical activity in mitigating BC-related complications, this finding underscores the holistic approach of gratitude interventions in promoting overall well-being. Individuals with BC and high exercise self-efficacy are more likely to initiate and maintain physical activity, overcome barriers, and persevere through challenges. Conversely, low exercise self-efficacy may hinder engagement in exercise programs, leading to decreased adherence and limited health benefits (40, 41). By addressing exercise self-efficacy, healthcare professionals, support groups, and community organizations can empower BC survivors to embrace physical activity as an integral part of their post-treatment journey. Lastly, the intervention's high feasibility and acceptability underscore its relevance and suitability for the target population. Despite logistical challenges affecting post-intervention assessment completion, participants demonstrated strong adherence to journaling activities, indicating a high level of engagement and commitment.

Limitations and Future Directions

Several limitations warrant consideration, including the small sample size, short intervention duration, and potential confounding variables. Future research should address these limitations by conducting larger randomized controlled trials with longer follow-up periods to assess the sustained effects of gratitude interventions on health outcomes among Black women with BC. Additionally, exploring the mechanisms underlying the observed changes in psychosocial and inflammatory outcomes will be crucial for informing the development of more targeted and effective interventions in the future.

Gratitude journaling intervention for Black women breast cancer survivors has yielded significant findings regarding both feasibility and the intervention's impact. Findings from this study demonstrated the applicability and high acceptability of within this population. Participants reported high satisfaction levels with the intervention, underscoring its usability in addressing the psychosocial needs of Black women breast cancer survivors.

Significant findings emerged from the study, shedding light on the potential efficacy of gratitude journaling in enhancing spiritual well-being and exercise self-efficacy among participants. While no significant differences were observed in dispositional gratitude between the intervention and control groups, the intervention demonstrated a notable improvement in spiritual well-being post-intervention, indicating its effectiveness in fostering holistic wellness among survivors. Promising trends in exercise self-efficacy were observed, suggesting that gratitude journaling may empower survivors to adopt and maintain healthy lifestyle behaviors. Future research should focus on scaling up interventions with a larger sample size tailored to meet BC survivors' diverse needs. Gratitude journaling is a valuable tool in empowering and uplifting BC survivors to promote resilience and enhance overall well-being during their survivorship journey.

Acknowledgments

We are grateful to the participants who were willing to journal and complete the measures and to the nurses and staff at the University of Florida Clinical and Translational Science Institute Clinical Research Center.

Disclosure statement

The authors reported no potential conflict of interest.

Data Availability Statement

The data supporting this study's findings are available from the corresponding author, [LC], upon reasonable request.

Funding

This work was supported by the University of Florida Claude D. Pepper Older Americans Independence Center [grant number P30AG028740].

Vandendorpe B, Drouet Y, Ramiandrisoa F, Guilbert P, Costa B, Servagi-Vernat S. Psychological and physical impact in women treated for breast cancer: Need for multidisciplinary surveillance and care provision. Cancer Radiother. 2021;25(4):330-9.
Yeganeh L, Willey S, Wan CS, Bahri Khomami M, Chehrazi M, Cook O, et al. The effects of lifestyle and behavioural interventions on cancer recurrence, overall survival and quality of life in breast cancer survivors: A systematic review and network meta-analysis. Maturitas. 2024;185:107977.
Manigault AW, Kuhlman KR, Irwin MR, Cole SW, Ganz PA, Crespi CM, et al. Psychosocial Resilience to Inflammation-Associated Depression: A Prospective Study of Breast-Cancer Survivors. Psychol Sci. 2022;33(8):1328-39.
American Cancer Society. American Cancer Society. Breast Cancer Facts & Figures 2022-20242022. Available from: https://www.cancer.org/research/cancer-facts-statistics/breast-cancer-facts-figures.html.
Edwards MJ, Campbell ID, Lawrenson RA, Kuper-Hommel MJ. Influence of comorbidity on chemotherapy use for early breast cancer: systematic review and meta-analysis. Breast Cancer Res Treat. 2017;165(1):17-39.
Minicozzi P, Van Eycken L, Molinie F, Innos K, Guevara M, Marcos-Gragera R, et al. Comorbidities, age and period of diagnosis influence treatment and outcomes in early breast cancer. Int J Cancer. 2019;144(9):2118-27.
Gallagher EJ, Greco G, Lin S, Yagnik R, Feldman SM, Port E, et al. Insulin resistance and racial disparities in breast cancer prognosis: a multi-center cohort study. Endocr Relat Cancer. 2022;29(12):693-701.
Gallagher EJ, Fei K, Feldman SM, Port E, Friedman NB, Boolbol SK, et al. Insulin resistance contributes to racial disparities in breast cancer prognosis in US women. Breast Cancer Res. 2020;22(1):40.
Woods-Giscombé CL. Superwoman schema: African American women's views on stress, strength, and health. Qual Health Res. 2010;20(5):668-83.
Brintz CE, Birnbaum-Weitzman O, Llabre MM, Castañeda SF, Daviglus ML, Gallo LC, et al. Spiritual well-being, religious activity, and the metabolic syndrome: results from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study. J Behav Med. 2017;40(6):902-12.
Movahed AH, Sabouhi F, Mohammadpourhodki R, Mahdavi S, Goudarzian S, Amerian M, et al. Investigating the effect of transcendental meditation on spiritual wellbeing of Type-2 diabetic amputees: A clinical trial study. Heliyon. 2020;6(11):e05567.
Carrillo A, Feig EH, Harnedy LE, Huffman JC, Park ER, Thorndike AN, et al. The role of positive psychological constructs in diet and eating behavior among people with metabolic syndrome: A qualitative study. Health Psychol Open. 2022;9(1):20551029211055264.
Leavy B, O'Connell BH, O'Shea D. Heart rate reactivity mediates the relationship between trait gratitude and acute myocardial infarction. Biol Psychol. 2023;183:108663.
Leavy B, O'Connell BH, O'Shea D. Gratitude, affect balance, and stress buffering: A growth curve examination of cardiovascular responses to a laboratory stress task. Int J Psychophysiol. 2023;183:103-16.
Redwine LS, Henry BL, Pung MA, Wilson K, Chinh K, Knight B, et al. Pilot Randomized Study of a Gratitude Journaling Intervention on Heart Rate Variability and Inflammatory Biomarkers in Patients With Stage B Heart Failure. Psychosom Med. 2016;78(6):667-76.
Lord D, Deem A, Pitchford P, Bray-Richardson E, Drennon M. A 6-Week Worksite Positivity Program Leads to Greater Life Satisfaction, Decreased Inflammation, and a Greater Number of Employees With A1C Levels in Range. J Occup Environ Med. 2019;61(5):357-72.
McCullough ME, Emmons RA, Tsang JA. The grateful disposition: a conceptual and empirical topography. J Pers Soc Psychol. 2002;82(1):112-27.
Mills PJ, Redwine L, Wilson K, Pung MA, Chinh K, Greenberg BH, et al. The Role of Gratitude in Spiritual Well-being in Asymptomatic Heart Failure Patients. Spiritual Clin Pract (Wash D C ). 2015;2(1):5-17.
Tan TT, Tan MP, Lam CL, Loh EC, Capelle DP, Zainuddin SI, et al. Mindful gratitude journaling: psychological distress, quality of life and suffering in advanced cancer: a randomised controlled trial. BMJ Support Palliat Care. 2023;13(e2):e389-e96.
Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol. 2001;56(3):218-26.
Konopack JF, McAuley E. Efficacy-mediated effects of spirituality and physical activity on quality of life: a path analysis. Health Qual Life Outcomes. 2012;10:57.
Williams F, Jeanetta SC. Lived experiences of breast cancer survivors after diagnosis, treatment and beyond: qualitative study. Health Expect. 2016;19(3):631-42.
Woods-Giscombe CL, Allen AM, Black AR, Steed TC, Li Y, Lackey C. The Giscombe Superwoman Schema Questionnaire: Psychometric Properties and Associations with Mental Health and Health Behaviors in African American Women. Issues Ment Health Nurs. 2019;40(8):672-81.
Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharmaceutical Statistics: The Journal of Applied Statistics in the Pharmaceutical Industry. 2005;4(4):287-91.
Attkisson CC, Greenfield TK. Client Satisfaction Questionnaire-8 and Service Satisfaction Scale-30. 1994.
Peterman AH, Fitchett G, Brady MJ, Hernandez L, Cella D. Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy--Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med. 2002;24(1):49-58.
Cohen S, Kamarck T, Mermelstein R. Perceived stress scale. Measuring stress: A guide for health and social scientists. 1994;10(2):1-2.
Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport. 1992;63(1):60-6.
Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Academic press; 1988.
Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. J Pharmacol Pharmacother. 2010;1(2):100-7.
Ko NY, Fikre TG, Buck AK, Restrepo E, Warner ET. Breast cancer survivorship experiences among Black women. Cancer. 2023;129(S19):3087-101.
Sheppard VB, Walker R, Phillips W, Hudson V, Xu H, Cabling ML, et al. Spirituality in African-American Breast Cancer Patients: Implications for Clinical and Psychosocial Care. J Relig Health. 2018;57(5):1918-30.
Mkuu RS, Harvey IS, Brown E, Spears EC, Jira MG, Johnson KL, et al. "I Struggle with Breast Cancer and I Struggle with God": Insights from African American Breast Cancer Survivors. J Racial Ethn Health Disparities. 2022;9(2):566-75.
Cousin L, Redwine L, Bricker C, Kip K, Buck H. Psychometrics of the Gratitude Questionnaire-6 in African-Americans at Risk for Cardiovascular Disease. West J Nurs Res. 2020;42(12):1148-54.
Amonoo HL, Daskalakis E, Deary EC, Guo M, Boardman AC, Keane EP, et al. Gratitude, optimism, and satisfaction with life and patient-reported outcomes in patients undergoing hematopoietic stem cell transplantation. Psychooncology. 2024;33(2):e6307.
Sztachańska J, Krejtz I, Nezlek JB. Using a Gratitude Intervention to Improve the Lives of Women With Breast Cancer: A Daily Diary Study. Front Psychol. 2019;10:1365.
Allen AM, Wang Y, Chae DH, Price MM, Powell W, Steed TC, et al. Racial discrimination, the superwoman schema, and allostatic load: exploring an integrative stress-coping model among African American women. Ann N Y Acad Sci. 2019;1457(1):104-27.
Griffith KA, Ryan AS. IL-6 and Soluble Receptors in Overweight and Obese African American Women With and Without Breast Cancer. Biol Res Nurs. 2021;23(2):218-22.
Cousin L, Redwine L, Bricker C, Kip K, Buck H. Effect of gratitude on cardiovascular health outcomes: a state-of-the-science review. The Journal of Positive Psychology. 2021;16(3):348-55.
Loprinzi PD, Cardinal BJ. Self-efficacy mediates the relationship between behavioral processes of change and physical activity in older breast cancer survivors. Breast Cancer. 2013;20(1):47-52.
Awick EA, Phillips SM, Lloyd GR, McAuley E. Physical activity, self-efficacy and self-esteem in breast cancer survivors: a panel model. Psychooncology. 2017;26(10):1625-31.

No competing interests reported.

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A Pilot Study of a Gratitude Journaling Intervention to Enhance Spiritual Well-Being and Exercise Self-Efficacy in Black Breast Cancer Survivors

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Abstract

Background

Methods

Results

Conclusion

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Background

Methods

Aim and Design

Setting

Participants

Sample Size

Approval and consent

Recruitment

Gratitude journaling intervention group

General memory journaling control group

Data and Biomarker Collection

Inflammatory Biomarker Collection

Assessment of feasibility and acceptability

Demographic, Psychosocial, and Inflammatory Biomarker Measures

Demographics (T1)

Psychosocial Variables (T1, T2)

Inflammatory Biomarkers (T1, T2)

Data analysis

Results

Participant Flow

Feasibility and Acceptability

Analyses of Demographic, Psychosocial, and Inflammatory Biomarker Outcomes

Demographics

Change in Psychosocial Outcomes Pre and Post-Intervention

Change in Inflammatory Biomarker Outcomes Pre and Post-Intervention

Discussion

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Conclusion

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Acknowledgments

Disclosure statement

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