Religious and Spiritual Factors Help Adolescents and Young Adults With Cancer In Their Subjective Outcomes of Anxiety, Depressive Symptoms, Fatigue, and Pain Interference

Association of Religious and Spiritual Factors With Patient-Reported Outcomes of Anxiety, Depressive Symptoms, Fatigue, and Pain Interference Among Adolescents and Young Adults With Cancer. Daniel H. Grossoehme et al. JAMA Netw Open. 2020;3(6):e206696, Jun 16 2020. doi:10.1001/jamanetworkopen.2020.6696

Key Points
Question  Among adolescents and young adults with cancer, is there an association between spirituality and patient-reported outcomes, and are these outcomes associated with a sense of meaning, peace, and comfort provided by faith?

Findings  In this cross-sectional study of 126 adolescents and young adults with cancer, structural equation modeling revealed that meaning and peace were associated with aspects of spirituality and religiousness as well as anxiety, depressive, and fatigue symptoms.

Meaning  In this study, participants’ sense of meaning and peace was associated with religiousness and with anxiety and depression, possibly representing an underappreciated intervention target.

Abstract
Importance  The associations of spiritual and religious factors with patient-reported outcomes among adolescents with cancer are unknown.

Objective  To model the association of spiritual and religious constructs with patient-reported outcomes of anxiety, depressive symptoms, fatigue, and pain interference.

Design, Setting, and Participants  This cross-sectional study used baseline data, collected from 2016 to 2019, from an ongoing 5-year randomized clinical trial being conducted at 4 tertiary-referral pediatric medical centers in the US. A total of 366 adolescents were eligible for the clinical trial, and 126 were randomized; participants had to be aged 14 to 21 years at enrollment and be diagnosed with any form of cancer. Exclusion criteria included developmental delay, scoring greater than 26 on the Beck Depression Inventory II, non-English speaking, or unaware of cancer diagnosis.

Exposures  Spiritual experiences, values, and beliefs; religious practices; and overall self-ranking of spirituality’s importance.

Main Outcomes and Measures  Variables were taken from the Brief Multidimensional Measurement of Religiousness/Spirituality (ie, feeling God’s presence, daily prayer, religious service attendance, being very religious, and being very spiritual) and the spiritual well-being subscales of the Functional Assessment of Chronic Illness Therapy (meaning/peace and faith). Predefined outcome variables were anxiety, depressive symptoms, fatigue, and pain interference from Patient-Reported Outcomes Measurement Information System pediatric measures.

Results  A total of 126 individuals participated (72 [57.1%] female participants; 100 [79.4%] white participants; mean [SD] age, 16.9 [1.9] years). Structural equation modeling showed that meaning and peace were inversely associated with anxiety (β = –7.94; 95% CI, –12.88 to –4.12), depressive symptoms (β = –10.49; 95% CI, –15.92 to –6.50), and fatigue (β = –8.90; 95% CI, –15.34 to –3.61). Feeling God’s presence daily was indirectly associated with anxiety (β = –3.37; 95% CI, –6.82 to –0.95), depressive symptoms (β = –4.50; 95% CI, –8.51 to –1.40), and fatigue (β = –3.73; 95% CI, –8.03 to –0.90) through meaning and peace. Considering oneself very religious was indirectly associated with anxiety (β = –2.81; 95% CI, –6.06 to –0.45), depressive symptoms (β = −3.787; 95% CI, –7.68 to –0.61), and fatigue (β = –3.11, 95% CI, –7.31 to –0.40) through meaning and peace. Considering oneself very spiritual was indirectly associated with anxiety (β = 2.11; 95% CI, 0.05 to 4.95) and depression (β = 2.8, 95% CI, 0.07 to 6.29) through meaning and peace. No associations were found between spiritual scales and pain interference.

Conclusions and Relevance  In this study, multiple facets of spirituality and religiousness were associated with anxiety, depression, and fatigue, all of which were indirectly associated with the participant’s sense of meaning and peace, which is a modifiable process. Although these results do not establish a causal direction, they do suggest palliative interventions addressing meaning-making, possibly including a spiritual or religious dimension, as a novel focus for intervention development.

Discussion

To our knowledge, this is the first study to document an indirect association of meaning and peace with religiousness and spirituality as well as the likelihood of anxiety, depressive symptoms, and fatigue in AYAs with cancer. Specifically, this study went beyond a bivariate approach, demonstrating that feeling God’s presence and identifying as a very religious person were associated with the extent of anxiety, depressive symptoms, and fatigue. The model proposes an indirect association through a sense of meaning and peace. Although the causal direction of these associations cannot be established from our study, these results suggest that a novel and potentially efficacious intervention target may be a sense of meaning and peace when considering ways to improve anxiety, depression, and fatigue among AYAs with cancer.

Findings from the present study are also consistent with previously published theoretical models and empirical data. Park’s work on meaning, including religious and spiritual meaning,^32,47,48 posits that religious and spiritual beliefs and practices inform constructed meaning, which is related to health outcomes. Meaning-making coping mediates the association of religiosity with psychological adjustment.³³ Religion and spirituality are not important to all AYAs; Salsman and colleagues⁴⁹ recommend identifying subgroups for whom dimensions of religion and spirituality are important to their health-related quality of life and offering them interventions that include religion and/or spirituality.⁴⁹

The meaning of a cancer diagnosis is an important factor for AYAs and the adults living with them.^47,48,50,51 Clinical attention to constructing meaning of the cancer experience is an important element in improving outcomes.⁵² Barakat and colleagues⁵² reported that although distress continued because of having had cancer, finding positive meaning contributed to posttraumatic growth in a sample of 150 AYA cancer survivors and their parents. This is also consistent with findings from a metasynthesis by Kim and colleagues of 51 qualitative studies,⁵³ which revealed that constructed meaning fosters resilience and inner growth and that the benefits persist well into survivorship. They noted the different meanings of an adolescent’s cancer experience from their parents’ and suggested that care be individualized for patients and for patient-parent dyads to maximize outcomes. Rosenberg and colleagues reported^54,55 positive outcomes (ie, resilience, cancer-related quality of life, distress) with skills-based intervention for AYAs with cancer that included meaning as a component. Moskowitz and colleagues⁵⁶ reported improved outcomes in positive affect, antidepressant use, and intrusive or avoidant thoughts using an intervention that included constructed meaning.

The current study’s findings support the inclusion of constructed meaning as part of AYA oncology care.⁵⁵ This approach has also been recognized by the government of the Netherlands, which recently adopted a person-centered definition of health, including attention to meaning and meaninglessness.⁵⁷ Furthermore, that country’s health budget provides for care at home by a recognized spiritual caregiver to address issues of illness-related meaning, focusing on persons older than 50 years and palliative care patients (including children) and their families.⁵⁸ Demonstration of the effects of these outcomes is in progress.

We anticipated finding an association between spiritual constructs and PROs and did not find one. It is possible that no such association exists in this population. It may also be because of the way faith was operationalized. The FACIT faith subscale quantifies the degree of comfort and strength faith provides rather than the magnitude of its importance. Although comfort and strength of faith were not associated with the PROs measured, the actual importance of faith may be motivational, prohealthy behaviors that may relate to PROs. The current study also assessed how pain interferes with life and found no relationship with spiritual or religious variables. Wachholtz and colleagues⁵⁹ reviewed the religious and spiritual literature related to pain, noting that the mixed results between religion, spirituality, and pain may be the result of focusing on a single aspect of the multidimensional experience of pain. Pain interference may not be an aspect of pain associated with the religious and spiritual constructs quantified by the measures used in this study. It is also possible that the model used by Wachholtz and colleagues⁵⁹ is not fully applicable for AYAs.

This study has important clinical implications. All pediatricians and adolescent medicine specialists should practice primary palliative care to minimize AYAs’ suffering in any form. Primary palliative care comprises basic evaluation and management of symptoms and facilitated conversations about goals of care and advance care planning.⁶⁰ Although many pediatric providers may be reluctant to address these issues, AYAs want providers to address their concerns, including spiritual concerns, and their desire for these to be addressed increases with their disease acuity.^61-63 Steinhauser and colleagues have demonstrated the efficacy of a 1-question intervention among adults, asking, “Are you at peace?”⁶⁴ Such simple, nonthreatening interventions may be a feasible way to explore the topic of peace with AYAs. Their sense of peace and their expressed needs for dealing with death and dying may provide opportunities for the broader use of interdisciplinary palliative care teams.

Specialty care addressing meaning and peace to improve outcomes may take several forms. Referrals to psychologists, who routinely deal with issues of spirituality, meaning, and health, may be appropriate.^32,51 Individual and group interventions addressing meaning for people with cancer have shown efficacy for increasing spiritual well-being and for decreasing anxiety, depression, and pain.^65-68 Referrals for specialty spiritual care from clinically trained chaplains may also be beneficial.⁶⁹ Chaplains are trained to work with existential questions of meaning within the framework of the patient’s beliefs.^70,71

Meaningful conclusions can be drawn from this study, moving the state of the science of spirituality forward.⁷² Meaning-making is a complex⁷³ but modifiable process. Clinical application of these findings could facilitate further integration of religious considerations and meaning-making into pediatric palliative care,⁷⁴ as has been demonstrated with adults.⁷⁵

Limitations

This study has several limitations. Cross-sectional data do not permit examination of causality, and longitudinal data were not available. There are no universally accepted definitions of spirituality and religion among researchers.^76,77 Participants self-defined these terms when completing the questionnaires; the results may be confounded through the use of multiple definitions, although there is evidence that AYAs define these terms similarly to some reseachers.^76,78 Several factors limit generalizability. First, it is not possible to generalize beyond the participating population, ie, English-speaking individuals aged 14 to 21 years with cancer in the United States. Second, the sample size dictated a parsimonious model that could not include potential confounders or predicting variables. Finally, the religious and spiritual affiliations of participants did not reflect the US demographic characteristics for this age group. There was a risk of participants providing socially desirable responses by having questions read aloud, although responses were entered by a research assistant who was trained to ask the questions in a way that would minimize bias. If adolescents preferred to enter their own responses, they were permitted; this rarely occurred. Furthermore, this was an analysis of baseline data informing an advance care planning trial. Male patients were more likely to decline participation in the primary study; thus, selection bias may affect the generalizability of these results. Nevertheless, strengths of this study include the application of rigorous scientific methods. First, 39% of those approached agreed to participate. While this is lower than participation rates in psychosocial intervention trials and represents a limitation,⁷⁹ it is better than the 20% or lower participation rates of individuals aged 15 to 19 years in clinical trials, an enrollment problem identified by the US Centers for Disease Control and Prevention.^80-82 Second, use of validated and reliable questionnaires increased replicability and transparency. Third, 99.5% of the data were complete. Fourth, the use of structural equation modeling to identify indirect associations between meaning and peace and/or faith on physical and emotional symptoms addresses weaknesses in the rigor of previous research.

Identification of aggressive driving from naturalistic data in car-following situations

Identification of aggressive driving from naturalistic data in car-following situations. Jordanka Kovaceva, Irene Isaksson-Hellman, Nikolce Murgovski. Journal of Safety Research, Volume 73, June 2020, Pages 225-234. https://doi.org/10.1016/j.jsr.2020.03.003

Highlights
• Aggressive driving in car-following situations is identified by jerk metrics.
• We use naturalistic data and self-reported questionnaires.
• Aggressive drivers who are tailgating tend to drive with rapid brake pedal usage.
• Differences in the jerk behavior are observed between countries.

Abstract
Introduction: Aggressive driving has been associated as one of the causes for crashes, sometimes with very serious consequences. The objective of this study is to investigate the possibility of identifying aggressive driving in car-following situations on motorways by simple jerk metrics derived from naturalistic data.
Method: We investigate two jerk metrics, one for large positive jerk and the other for large negative jerk, when drivers are operating the gas and brake pedal, respectively.
Results: The results obtained from naturalistic data from five countries in Europe show that the drivers from different countries have a significantly different number of large positive and large negative jerks. Male drivers operate the vehicle with significantly larger number of negative jerks compared to female drivers. The validation of the jerk metrics in identifying aggressive driving is performed by tailgating (following a leading vehicle in a close proximity) and by a violator/non-violator categorization derived from self-reported questionnaires. Our study shows that the identification of aggressive driving could be reinforced by the number of large negative jerks, given that the drivers are tailgating, or by the number of large positive jerks, given that the drivers are categorized as violators.
Practical applications: The possibility of understanding, classifying, and quantifying aggressive driving behavior and driving styles with higher risk for accidents can be used for the development of driver support and coaching programs that promote driver safety and are enabled by the vast collection of driving data from modern in-vehicle monitoring and smartphone technology.

Keywords: Aggressive drivingJerk metricsNaturalistic drivingCar-followingSelf-reported questionnaires

Consumers Believe That Products Work Better for Others

Polman, Evan, Ignazio Ziano, Kaiyang Wu, and Anneleen Van Kerckhove. 2020. “Consumers Believe That Products Work Better for Others.” PsyArXiv. June 17. doi:10.31234/osf.io/p3jz7

Abstract: Hundreds of studies have shown that consumers tend to see themselves in the best
possible light, yet we present evidence that consumers have a surprisingly glum perspective on receiving a product’s claimed effects. In 10 studies (N = 3,825; including 8 pre-registered), we found that consumers believe that product efficacy is higher for others than it is for themselves. For example, consumers believe that consuming products like an adult coloring book (to inspire creativity), or a granola bar (to satisfy hunger), or moisturizer (to hydrate skin), or an online class (to learn something new) will have a greater effect on others than on themselves. We show that this bias holds across many kinds of products and populations, and inversely correlates with self-selecting product usership. We evidence that this bias stems from the fact that consumers believe they are more unique than others, and less malleable; and we show that this bias in perceived product efficacy alters the choices that consumers make for others. We conclude by discussing implications for research on gift-giving, advice-giving, and for interpersonal social-, health-, and financial-choices.

Nocebo & lessebo effects: Defined as the expectation of harm in the form of adverse events in a placebo arm & the reduction of therapeutic benefit due to the uncertainty of being allocated to placebo

Chapter Six - Nocebo and lessebo effects. Tiago A. Mestre. In Part of volume:
Placebo Effects in Neurologic Disease. Edited by Natalie P. Witek, Christopher G. Goetz, Glenn T. Stebbins. International Review of Neurobiology, Volume 153, 2020, Pages 121-146. https://doi.org/10.1016/bs.irn.2020.04.005

Abstract: The power of placebos is commonly associated with the placebo effect. In contrast, detrimental effects related to the use of a placebo are little studied and less well recognized. This chapter covers the nocebo and lessebo effects defined, respectively, as expectation of harm in the form of adverse events in a placebo arm and reduction of therapeutic benefit due to the uncertainty of being allocated to placebo. The lessebo effect is a more recent concept and has been described only in depression, schizophrenia and Parkinson's disease. The nocebo response was evaluated in many neurological diseases, including epilepsy, multiple sclerosis, Parkinson's disease, Alzheimer's disease, restless leg syndrome, among others. Meta-analyses of randomized controlled trials in these conditions reveal a significant variability of the magnitude of the nocebo response and that factors related to study design, study participants or neurological disease can be associated with a nocebo response, although with the opposing findings across conditions. The knowledge about neurobiological mechanisms of the nocebo effect is poor for neurological diseases, and most of the information has been generated in pain. Functional neuroimaging suggests the existence of a distinct network for the anticipation and the experience of a hyperalgesia nocebo response. Different types of neurotransmitters have been involved, including cholecystokinin, dopamine and opioids. Recognizing the potential impact of nocebo and lessebo effects, mitigating strategies are in development with application to clinical research and clinical practice, such as a contextualized informed consent process, alternative study designs and enhancement of patient-physician communication.

Keywords: PlaceboNoceboLesseboExpectationParkinson's diseaseAlzheimer's diseasePainHeadacheEpilepsy

Heterosexual men pornography use (in terms of both overall level of pornography use and use of violent and humiliating pornography) was not predictive of old-fashioned and modern sexism

Pornography use and sexism among heterosexual men. Dan J. Miller, Garry Kidd, Peter T. F. Raggatt, Kerry Anne McBain & Wendy Li. Communication Research Reports , Jun 16 2020. https://doi.org/10.1080/08824096.2020.1777396

ABSTRACT: The idea that pornography promotes sexism is a commonly purported one. This study employed an online sample of heterosexual men (N = 323) to investigate the relationship between pornography use (in terms of both overall level of pornography use and use of violent and/or humiliating pornography) and old-fashioned and modern sexism. The moderating effects of agreeableness and perceived realism of pornography were also assessed. Level of general pornography use and use of violent and/or humiliating pornography was not predictive of either sexism measure. Agreeableness was negatively predictive of both sexism measures, whereas perceived realism was positively predictive of sexism. Agreeableness and perceived realism did not moderate the relationship between level of pornography use and any of the outcome measures.

KEYWORDS: Attitudes, men, pornography, sexism

Do We Know What We Enjoy? Accuracy of Forecasted Eating Happiness

Do We Know What We Enjoy? Accuracy of Forecasted Eating Happiness. Karoline Villinger et al. Front. Psychol., June 17 2020. https://doi.org/10.3389/fpsyg.2020.01187

Abstract: Forecasting how we will react in the future is important in every area of our lives. However, people often demonstrate an “impact bias” which leads them to inaccurately forecast their affective reactions to distinct and outstanding future events. The present study examined forecasting accuracy for a day-to-day repetitive experience for which people have a wealth of past experiences (eating happiness), along with dispositional expectations toward eating (“foodiness”). Seventy-three participants (67.12% women, M age = 41.85 years) used a smartphone-based ecological momentary assessment to assess their food intake and eating happiness over 14 days. Eating happiness experienced in-the-moment showed considerable inter-and intra-individual variation, ICC = 0.47. Comparing forecasted and in-the-moment eating happiness revealed a significant discrepancy whose magnitude was affected by dispositional expectations and the variability of the experience. The results demonstrate that biased forecasts are a general phenomenon prevalent both in outstanding and well-known experiences, while also emphasizing the importance of inter-individual differences for a detailed understanding of affective forecasting.

Discussion

The present study investigated forecasting accuracy for a familiar day-to-day experience, comparing forecasted eating happiness with eating happiness experienced in-the-moment using an event-based ecological momentary assessment. A significant difference between forecasted and in-the-moment eating happiness was observed. This shows that people’s forecasted emotional reactions for both distinct, outstanding events and familiar day-to-day experiences are inaccurate. Furthermore, the magnitude of the discrepancy was affected by both dispositional expectations (“foodiness”) and the variability of the in-the-moment experience, demonstrating that both stable inter-individual differences and experience-specific aspects influence forecasting accuracy.

Interestingly, while the relative difference score between forecasted and in-the-moment experience did not reveal an impact bias in the present study, the analysis of the absolute difference demonstrated a large effect for the divergence between forecasted and in-the-moment experience across participants (d = 1.81). The tendency to mispredict the intensity and/or duration of an emotional event has usually been described as an overestimation of the emotional impact, such as overestimating the pleasure of a vacation or the disappointment of a romantic breakup (see e.g., Gilbert et al., 1998; Wirtz et al., 2003). However, data from the present study revealed a substantial number of both overestimations and underestimations of in-the-moment eating happiness, explaining why the relative difference score did not reveal an impact bias across participants. One reason for this mixed forecasting pattern in this study might be the nature of the forecasted event. While distinct and outstanding events such as vacations or romantic breakups typically have uniformly positive or negative connotations across individuals, eating happiness is characterized by a greater inter- and intra-individual variance, meaning that eating experiences can vary both in their valence and in their intensity across as well as within individuals. General mechanisms such as focusing on central aspects (Wilson et al., 2000) or underestimating adaption over time (Gilbert et al., 1998) can provide an explanation for the absolute error, but the absolute error can be both to the positive and negative. The present study revealed an effect which is substantially higher than previously reported, for example, by Wirtz et al. (2003) with d > 0.61 from examining students’ real-life vacation experiences. However, the observed effect size is comparable to effect sizes in studies which also analyzed the absolute value of the discrepancy. For example, Hoerger et al. (2012a) found a significant discrepancy with an effect of d = 2.84 when comparing forecasted and in-the-moment experiences related to emotion-evoking pictures. This suggests that, examining an experience with no uniform connotation across individuals, the relative difference might reveal no impact bias across individuals not because people are able to provide accurate forecasts, but due to the prevalence of both overestimations and underestimations in forecasted reactions.

Further, day-to-day experiences are characterized by high familiarity and repetition, both possibly impacting the magnitude of the impact bias. The present data suggest that familiarity of the experience such as having previous experiences of an event or an emotional reaction does not necessarily improve forecasting accuracy. To learn from their emotional experiences, people must actively refer to and integrate relevant previous experiences into the process of forecasting (Wilson et al., 2001, 2003; Kermer et al., 2006; Ayton et al., 2007), which in turn necessitates an accurate recall of past emotional reactions. However, as the emotion itself is not stored in memory in a form that can be directly retrieved later (Robinson and Clore, 2002), past experiences are also subject to biases and people tend to overestimate their past emotional reactions (e.g., Redelmeier and Kahneman, 1996; Fredrickson, 2000). Furthermore, Robinson and Clore (2002) argue that the ability to learn from past experiences is impaired as details of our affective reactions become faded and less accessible over time, which in turn makes people rely more on general knowledge and beliefs when forecasting future affective reactions (see also Schwarz and Xu, 2011; Schwarz, 2012). In addition, the intensity of the impact bias might be so pronounced that it remains even after partial adjustment according to previous experiences, leading to biased forecasts (Wilson et al., 2001). The results of the present study, together with previous research, show that biases in forecasts are a general and robust phenomenon, prevalent for both outstanding and familiar events, with previous experience possibly moderating the magnitude of the bias, but not preventing it.

To further understand the impact bias, we analyzed the variability of the experience both between eating occasions within individuals and in relation to participants’ dispositional expectation toward eating (“foodiness”). One consequence of repeatedly eating throughout the day is a high number of distinct events that can vary both in valence and intensity. Forecasting an experience that involves a high fluctuation may be more difficult than a stable or consistent experience as people need to incorporate the variation of the experience across individual occasions. Focusing on the aspect of repetition within the experience shows that, as hypothesized, a greater variability of in-the-moment eating happiness resulted in lower forecasting accuracy across participants. Besides variations in the experience associated with food intake itself, people may also differ in their experience while eating, with some people enjoying and being happy with almost every food or meal and other people differentiating more between individual eating experiences.

To analyze this difference in experience while eating, we divided the sample into three groups based on the general expectation of eating (“foodiness”). The results showed that variability of in-the-moment eating happiness differed between foodiness groups with people in the low foodiness group displaying the greatest amount of variation between individual eating occasions. Expectations about an experience have been shown to affect the actual in-the-moment experience (Wilson et al., 1989; Klaaren et al., 1994; Totterdell et al., 1997; Wilson and Gilbert, 2003) and might therefore explain the difference in variability between foodiness groups. Specifically, differences in the variability might be explained by the affective expectation model (Wilson et al., 1989), according to which an affective reaction is formed by a comparison between expected and actual experience.

Geers and Lassiter (2002) further demonstrated that mental orientations toward experiences (optimism-pessimism) play an important role in the formation of in-the-moment experiences. People with a generally more positive outlook about their future (optimists) tend to assimilate their in-the-moment experiences toward their expectations, independent of whether their in-the-moment experience stands in line with or in contrast to their expectations. In contrast, people with a generally more negative outlook about their future (pessimists) have been shown to be more sensitive to contradicting information (Spirrison and Gordy, 1993). As a consequence, they only assimilate to their prior expectation when the experience is consistent with their expectation, while their affective reaction diverges from their expectation if they realize inconsistency (Wilson et al., 1989; Geers and Lassiter, 2002). Therefore, people with a low tendency toward foodiness might only have shown assimilation in congruent cases, while people with a high tendency toward foodiness might have assimilated toward their forecasted eating happiness regardless of whether or not their experience in-the-moment was consistent with their forecasts, leading to a more homogenous experience pattern and less variability.

However, even though variability of in-the-moment eating happiness differed between foodiness groups, the impact of variability on forecasting accuracy remained the same. Independent of dispositional expectations, experiencing more variability in-the-moment is more difficult to forecast, resulting in a lower forecasting accuracy. This indicates that forecasting accuracy is influenced by both stable differences between individuals, such as dispositions, but also by experience-specific differences such as the variability/stability of the experience. To summarize, dispositional expectation might influence the displayed variability of the in-the-moment experience, but the impact of the variability on forecasting accuracy is independent of dispositional expectations.

Findings of inter-individual differences also have implications on theories of affective forecasting. Most studies aim at examining and displaying errors at the general level across participants (see Wilson and Gilbert, 2003 for a review), focusing on mechanisms such as attention focus (Wilson et al., 2000) and rationalization processes (Gilbert et al., 1998). However, even though forecasts are prone to general mechanisms creating a systematic bias, a growing body of research provides evidence that people differ in their ability to provide accurate forecasts (Dunn et al., 2007; Wenze et al., 2012; Hoerger et al., 2012b; Christophe and Hansenne, 2016). Hoerger et al. (2016) suggest that dispositional differences such as personality contribute to forecasting accuracy because they affect underlying processes such as the ability to visualize the future, the awareness of the experience, and people’s tendency to forecast and experience more positive or negative emotions.

We add to this stream of research by assessing the impact of dispositional expectations as one facet of people’s personalities. The present results reveal that both in-the-moment experience and the magnitude of the bias are affected by people’s dispositional expectations toward eating (“foodiness”). Even though some people are better at forecasting their future affective responses, the pattern and variability of the actual experience play a crucial role in forecasting accurately. Consequently, summing up the independent effect for group membership and variability explains the greater divergence between forecasted and in-the-moment eating happiness in the low foodiness group. Hence, both dispositional differences and experience-specific aspects must be considered to enable meaningful conclusions for forecasting accuracy to be drawn.

From a broader perspective, it is interesting to relate the present findings to previous research on eating behaviors using ecological momentary assessment. Several studies focused on the relationship between affective reactions and eating behaviors (e.g., Liao et al., 2018; Strahler and Nater, 2018; Jeffers et al., 2019; Schultchen et al., 2019). However, their focus was primarily on the impact of stress and negative affect on food choice rather than the phenomenon of affective forecasting and how forecasted eating happiness relates to in-the-moment experienced happiness. However, integrating these lines of research appears promising and future research may specifically assess the degree to which variability of eating happiness can be attributed to situational context variables such as daily stress or emotional states (see Loewenstein, 1996; Loewenstein and Schkade, 1999; Gilbert et al., 2002; Loewenstein et al., 2003). In a related vein, the present study did not collect data on participant’s familiarity with the consumed foods. It seems possible that a diet composed of a rather limited and stable number of food items is easier to forecast than forecasting experiences with a greater variety and new and unknown foods and cuisines. Thus, future research should consider actual food intake to assess the effects of diet composition on the variability of in-the-moment eating happiness. It needs also to be considered that our results are based on a generally healthy sample that was interested in exploring their eating behavior. Furthermore, even though the sample size is comparable to or even larger than in other EMA studies assessing eating behaviors (Stein and Corte, 2003; Zepeda and Deal, 2008; Schüz et al., 2015a, 2015b), the sample might be considered as rather small in order to detect between-person effects (Gignac and Szodorai, 2016). Thus, the study findings should be replicated using larger and representative samples to acknowledge that eating is a complex behavior that is impacted by various factors and aspects on the personal, situational, and societal level (Renner et al., 2012; Stok et al., 2017). In addition, the finding that forecasted and actual experience often diverges may have potential implications for eating behaviors. For instance, while people adhere to the general belief that unhealthy foods lead to high pleasure (Raghunathan et al., 2006), in-the-moment eating happiness assessments revealed that fruits and vegetables evoked comparable high eating happiness as stereotypical unhealthy foods such as cake or candy (see Wahl et al., 2017a). Thus, one future direction of this line of research could build upon differences between forecasted and in-the-moment experiences to promote healthy eating.

In conclusion, the results of the present study contribute to the generalizability of research on affective forecasting, demonstrating that biased forecasts are a general phenomenon, present not only for outstanding events but also for familiar day-to-day experiences. Furthermore, dispositional differences between people such as dispositional expectations (“foodiness”) and experience-specific aspects such as variability/stability of the in-the-moment experience are both shown to be of great importance, with both impacting forecasting accuracy. Overall, while biased forecasts appear as a stable phenomenon in affective forecasts, inter-individual differences, and experience-specific aspects have a substantial impact in the manifestation and magnitude, and differentiated analyzes are therefore needed in research about affective forecasting.

Impact of Protestant Evangelism On Economic Outcomes: This church-based program may represent a method of increasing noncognitive skills & reducing poverty among adults in developing countries

Randomizing Religion: The Impact of Protestant Evangelism On Economic Outcomes. Gharad Bryan, James J. Choi, and Dean Karlan. Jun 2020. https://economics.harvard.edu/files/economics/files/ms29321.pdf

Abstract: We study the causal impact of religiosity through a randomized evaluation of an evangelical Protestant Christian values and theology education program delivered to thousands of ultra-poor Filipino households. Six months after the program ended, treated households have higher religiosity and income; no statistically significant differences in total labor supply, consumption, food security, or life satisfaction; and lower perceived relative economic status. Exploratory analysis suggests that the income treatment effect may operate through increasing grit. Thirty months after the program ended, significant differences in the intensity of religiosity disappear, but those in the treatment group are less likely to be Catholic and more likely to be Protestant, and there is some mixed evidence that their consumption and perceived relative economic status are higher. We conclude that this church-based program may represent a method of increasing noncognitive skills and reducing poverty among adults in developing countries.


I. INTRODUCTION
A literature dating back at least to Adam Smith and Max Weber has argued that religiosity is associated with a set of characteristics that promote economic success, including diligence, thriftiness, trust, and cooperation (Iannaccone 1998; Iyer 2016). More recent research has linked religiosity to positive outcomes in domains such as physical health (Ellison 1991), crime rates (Freeman 1986), drug and alcohol use (Gruber and Hungerman 2008), income (Gruber 2005), and educational attainment (Freeman 1986; Gruber 2005). Other studies have argued for negative economic effects of some aspects of religiosity due to a focus on otherworldliness (Weber [1905] 1958 in his discussion of Catholicism) and substitution toward church attendance away from production (Barro and McCleary 2003). Despite extensive research, claims that religion causes outcomes remain controversial, in part because people choose their religion. Naturally occurring religious affiliation is likely to be correlated with unobserved personal characteristics, which may be the true drivers of the observed correlations. Iannaccone (1998) writes that “nothing short of a (probably unattainable) ‘genuine experiment’ will suffice to demonstrate religion’s causal impact.” To study the causal impact of religiosity, we partnered with International Care Ministries (ICM), an evangelical Protestant anti-poverty organization that operates in the Philippines, to conduct an evaluation that randomly assigned invitations to attend Christian theology and values training. There are 285 million evangelical Christians in the world, comprising 13% of Christians and 36% of Protestants (Hackett and Grim 2011). 1 ICM is representative of an important sector that attempts to generate religiosity while alleviating poverty. ICM’s program, called Transform, normally consists of three components—Protestant Christian theology, values, and character virtues (“V”), health behaviors (“H”), and livelihood (i.e., self-employment) skills (“L”)—taught over 15 weekly meetings (plus a 16th meeting for a graduation ceremony). Each meeting lasts 90 minutes, spending 30 minutes per component. ICM’s leadership believes that the Values curriculum lies firmly in the mainstream of evangelical belief. Between 2009 and 2017, 194,000 people participated in Transform. The basic structure of the program, using a set series of classes outside of a Sunday worship service to evangelize, is a common model. For example, over 24 million people in 169 countries have taken the evangelistic Alpha course since 1977 (Bell 2013), and Samaritan’s Purse has enrolled 11 million children in about 100 countries in its evangelistic Greatest Journey course since 2010 (Samaritan’s Purse 2017). Like Transform, these are courses of approximately a dozen sessions. We randomly assigned 320 communities (from which we selected 7,999 households) to receive the full Transform curriculum (VHL), to receive only the Health and Livelihood components of the curriculum (HL), to receive only the Christian values component of the curriculum (V), or to be a no-curriculum control (C). We identify the effect of religiosity by comparing invited households in VHL communities to invited households in HL communities, and invited households in V communities to households in C communities that would have been invited had that community been assigned to be treated. We measure outcomes approximately six months and 30 months after the training sessions ended and analyze them in accordance with a pre-analysis plan. At six months, we find that those who were invited to receive the V curriculum have significantly higher religiosity than those who did not receive the V curriculum, demonstrating that the treatment had its intended first-stage effect. Examining downstream economic outcomes while correcting for multiple hypothesis tests by controlling the false discovery rate (FDR), we find that the V curriculum increased household income by 9.2%, but had no statistically significant effect on total labor supply, assets, consumption of a subset of goods, food security, or life satisfaction, and it decreased perceptions of relative economic status within one’s community by 0.11 points on a 10 point scale. 2 Post-hoc analysis shows that the income effect is strongly concentrated on the Transform invitee and is not significant for other household members’ labor income, providing further support that the estimated income effect is not a Type I error. Exploratory regressions suggest that the religiosity treatment effect operates by increasing grit (Duckworth et al. 2007)—specifically, the portion of grit associated with perseverance of effort (and in particular, agreement with the statements “I am a very hard worker,” “I finish whatever I begin,” and “Setbacks don’t discourage me.”). This mechanism accords with Weber’s conception of the Protestant work ethic. We find no consistent movement in the other potential mechanisms that we measured: social capital, locus of control (other than the belief that God is in control, which increases), optimism, and self-control. Furthermore, post-hoc analysis finds that the HL treatment had no statistically significant effects on income or perceived relative economic status at six months. 3 Because the HL treatment includes many of the non-religious aspects of the V intervention (e.g., meeting in a group over a number of weeks), this null finding suggests that the six-month V curriculum treatment effect primarily captures the impact of altered religiosity. By 30 months, there is no longer a statistically significant difference in the intensity of religiosity between the experimental groups. However, individuals who received the V curriculum are 3.6 percentage points less likely to identify as Catholic and 2.3 percentage points more likely to identify as Protestant. To put these changes in context, the control group at 30 months is 70% Catholic and 21% Protestant. There is mixed evidence on the effects on downstream economic outcomes. Relative to the no-curriculum control, those who received only the V curriculum have a significantly higher perceived relative economic status (0.34 points on a 10-point scale) and marginally significantly higher consumption (7.5% of the control group mean, FDR q-value = 0.062). Exploration of the mechanisms responsible for these positive effects finds that V curriculum recipients are more optimistic, even though they do not have higher grit. On the other hand, we find no statistically significant effects on primary economic outcomes when combining the VHL versus HL and V versus control comparisons. This difference in findings is driven by the fact that the HL group appears better off than the VHL group at 30 months. Relative to the no-curriculum control, the HL group has significantly higher income and perceived relative economic status (in tests that do not adjust for multiple comparisons). Interpreting these results requires an understanding of the context and details of the intervention. ICM operates in a setting where most people claim to be religious. In the six-month survey, only 2.4% of those who did not receive the V curriculum and 2.3% of those who did receive the V curriculum indicate that they are “not religious at all.” Our experiment should therefore be understood as measuring the effects of strengthening pre-existing religiosity or changing the emphasis of pre-existing religious beliefs, rather than the effects of causing the completely irreligious to become religious. Arguably, these intensive margin effects are the most relevant ones, since 84% of the world’s population is religious (Pew Research Center 2015). It is also important to note that ICM targets the ultra-poor within communities, and the communities in our study (including those in the no-curriculum control) are chosen by pastors who presumably believe that they would be able to run a successful program there. Most expansions by religious organizations into a community are probably based on a belief that the community would be receptive, so these are an externally relevant type of community. It is possible that the ultra-poor are more receptive to religious outreach than less impoverished individuals (Chen 2010), so ICM’s outreach may be more effective than comparable outreach to higher-income populations. In addition, religiosity is not a singular concept, and its causal impact will likely depend on many factors. Johnson, Tompkin, and Webb (2008) differentiate between “organic” exposure to religion over a prolonged period of time (e.g., through one’s upbringing at home) and “intentional” exposure through participation in a specific program targeting a specific set of individuals. Both are important channels of religious propagation, and the type of religiosity produced may depend on the channel. Our study is about intentionally generated religiosity of a specific kind (evangelical Protestant Christian), and a significant aim of our study is to establish, in the context of a randomized controlled trial, that intentional exposure to a religious program can generate the critical first stage: an exogenous change in religiosity.


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Our work also relates to a growing number of papers that use instrumental variables or natural experiments to study the causal effect of religion on economic outcomes.4 Clingingsmith, Khwaja, and Kremer (2009) find that winning a lottery for hajj visas changes beliefs, values, and religious practices. Barro and McCleary (2003) conduct a cross-country analysis of economic growth using the existence of a state religion, state regulation of religion, adherence shares for the major religions, and a religious pluralism index as instruments. They find that religious beliefs (“believing”) increase economic growth, whereas religious service attendance (“belonging”) decreases growth. Because our study does not induce independent exogenous variation in beliefs versus behaviors, we cannot add further evidence on this “believing versus belonging” hypothesis. Gruber (2005) uses local ancestral mix as an instrument and finds that religious participation in the U.S. (which is almost entirely Christian) increases education, income, and marriage rates and decreases disability and divorce rates. Gruber and Hungerman (2008) exploit the repeal of U.S. state laws prohibiting retail activity on Sundays and find that Christian religious participation decreases drinking and drug use. Bottan and Perez-Truglia (2015) study the decline in Catholic religious participation caused by clergy scandals and find evidence that religious participation increases charitable giving

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We report an association between the increased frequency of cannabis use and increased male sexual function; although selection bias in this survey may limit the generalizability of these findings

Bhambhvani HP, Kasman AM, Wilson-King G, et al. A Survey Exploring the Relationship Between Cannabis Use Characteristics and Sexual Function in Men. J Sex Med 2020;XX:XXX–XXX. https://doi.org/10.1016/j.esxm.2020.06.002

Abstract
Introduction: Cannabis is the most commonly used drug in the United States; however, the effects of cannabis use on male sexual function are poorly understood.

Aim: To characterize the contemporary landscape of cannabis use and to assess the associations between male sexual function and the frequency of use, the primary method of consumption, or cannabis chemovar (tetrahydrocannabinol or cannabidiol) among current users.

Methods: We surveyed adults who visited a single cannabis dispensary for baseline demographic information, medical history, cannabis use habits, and sexual function as assessed by the International Index of Erectile Function (IIEF). An IIEF-5 < 21 was considered erectile dysfunction.

Main Outcome Measures: The main outcome measure of the study was male sexual function via the IIEF domain scores.

Results: A total of 325 men completed the survey with a mean age of 46.7 years. 71.1% of the men were Caucasian and 52.6% were married. 13 men (4%) were never users; 29 men (8.9%) used 1–2 times/week; 51 men (15.7%) used 3–5 times/week, and 232 men (71.4%) used 6+ times/week. The average IIEF-5 score was 22.3 with 19.4% of the men having erectile dysfunction. In univariate analysis, men using cannabis more frequently had a higher overall IIEF (65.36 vs 60.52, P = .001), erectile domain (27.32 vs 25.74, P = .03), orgasm domain (9.08 vs 8.12, P < .001), intercourse satisfaction domain (12.42 vs 11.31, P = .006), and overall satisfaction domain (8.11 vs 7.05, P = .002). In multivariable analysis, compared to men who used cannabis 0 times/week, those who used 6 times/week had an increased overall IIEF (69.08 vs 64.64, P-value adjusted = 0.02), intercourse satisfaction domain (P-value adjusted = 0.04), and overall satisfaction domain (P-value adjusted = 0.02). The primary method of consumption (eg, smoking, edibles, etc.) and cannabinoid composition (eg, cannabidiol vs tetrahydrocannabinol dominant) were not associated with sexual function.

Conclusion: We report an association between the increased frequency of cannabis use and increased male sexual function. However, while the increased frequency of use was statistically significant with regard to the IIEF scores, the clinical significance of this is likely low, and selection bias may limit the generalizability of these findings. The method of consumption and cannabis chemovar were not associated with sexual function.

Key Words: CannabisOrgasmErectile dysfunctionSHIM

Discussion

In this study of over 300 men, we report, for the first time, evidence of a frequency-response relationship between cannabis use and sexual function, with increasing use associated with an increased overall IIEF score, intercourse satisfaction domain, and overall satisfaction domain. Similarly, more frequent cannabis use is associated with lower odds of ED. Importantly, the primary method of consumption, cannabis chemovar, and indication for use are not associated with sexual function.

While others have examined the association between male sexual function and cannabis use, most studies have not used validated measures of erectile function. Despite this, our findings of increased intercourse satisfaction domain and overall satisfaction domain with increased cannabis use are consistent with subjective reports of increased sexual satisfaction, sensitivity, and orgasm strength among most cannabis users reported by some studies.9,15 The largest survey of sexual health among male cannabis users was conducted by Smith et al in Australia and included over 4,000 men.7 Although the authors did not use a validated measure of erectile function, they found that subjectively there was no association between the frequency of cannabis use and self-reported trouble keeping an erection. The current report also found no change in erectile function; however, we did identify improvements in other domains of sexual function and a lower prevalence of ED with more cannabis use. Smith et al also found that daily cannabis use in men was associated with difficulty to achieve orgasm as desired. Although the authors did not discuss any potential mechanisms underpinning this association, it is possible that an altered cognitive state induced by cannabis consumption may contribute to difficulty in attaining orgasm. A recent qualitative survey of both men and women reported that some participants were unable to orgasm as desired on cannabis because of a lack of focus or altered mindset.16

To our knowledge, only one study, by Kumsar et al, has investigated male sexual health associations with cannabis using the complete IIEF survey.17 Here, the authors surveyed men with substance use disorder presenting to a dedicated substance abuse treatment center in Turkey. They found no differences in the overall IIEF score or any domain scores between cannabis users and nonusers. However, this study of 20 cannabis users had limited power to identify differences between the control population and was not able to identify the frequency of cannabis use.

A few studies have used the SHIM as an outcome measure, allowing for proper comparison with our results. In a survey of 2,507 Swiss men aged between 18 and 25 years, Mialon et al found that there was no association between cannabis use and ED in a bivariate analysis.18 However, the age of the population may limit the prevalence of sexual dysfunction. In contrast, Elbendary et al found that adult drug use, which mostly consisted of cannabis use in their cohort, was associated with increased odds of ED in multivariable analysis.19 However, the lack of granularity with regard to the type or frequency of use may have confounded the association between cannabis use and ED. Thus, the literature suggests that the effects of cannabis on sexual function can be either positive or negative and may vary by the dose and frequency of use.

Although we found statistically significant associations between the increasing frequency of cannabis use and increases in the overall IIEF, intercourse satisfaction domain, and overall satisfaction domain scores, the clinical significance of these results is unclear. The minimal clinically important difference for the erectile domain of the IIEF is widely considered to be an increase by 4 points.20 To our knowledge, however, no other studies have assessed what constitutes a minimal clinically important difference for the overall IIEF or other domain scores. Given the point increases conferred by the increasing frequency of cannabis by 6 additional uses per week ranged from a 4.44-point increase for the overall IIEF to a 0.68-point increase for overall satisfaction, it is likely that these modest increases in the IIEF scores are not clinically significant. At a minimum, these results suggest that the increasing frequency of cannabis consumption does not impair sexual function. Furthermore, our results must not be interpreted as implying a causal relationship between the increased frequency of cannabis use and improved sexual function; rather, the results of the present study simply identify a correlation.

Taken together, our findings suggest that there exists a relationship between the increasing frequency of cannabis use and slight sexual benefit to men in the realms of intercourse satisfaction and overall satisfaction, while the primary method of consumption and chemical composition are not associated with sexual function. The mechanisms underlying sexual enhancement from cannabis use are as yet poorly understood. It is postulated that the aphrodisiac-like properties of cannabis, including increased sensitivity, sexual satisfaction, and orgasm strength, involve altered perception of the sexual encounter and activation of cannabinoid receptors in the central nervous system.21 Indeed, a study of noncopulating male rats demonstrated that pharmacologic activation of the central nervous system's endocannabinoid network resulted in sexual behavior in 50% of the population.22 In humans, a study using functional magnetic resonance imaging revealed that cannabis intoxication modulates the response of the right nucleus accumbens to visual erotic stimuli.23 The nucleus accumbens is involved in the processing of the rewarding effects of sexual behavior, and activation of dopamine receptors in this brain region is shown to increase sexual motivation even among sexually satiated rodents.24,25 The cannabinoid composition of consumed cannabis may modulate the effect on sexual behavior, as well. In one study of male mice, chronic CBD exposure resulted in a decreased sexual behavior, as demonstrated by a reduced number of mounts and ejaculations, whereas THC exposure has been linked to a heightened sexual behavior in female mice.26,27 Ultimately, the effect of cannabis chemovar on sexuality is not well defined and should be further explored. Finally, cannabis use can induce an altered perception of time, potentially leading to artificially prolonged feelings of sexual pleasure and excitement.28

This study should be considered in the context of its limitations. First, our cohort is a population of men who made a purchase at a dispensary and represents a select population of cannabis users, which excludes individuals receiving cannabis through other means and therefore may not be generalizable. Indeed, the erectile function scores of men in the present study are higher than what would be expected of a typical cohort of men, roughly half of whom are at least 50 years old. Furthermore, the rates of use in the present study are high, with most men using 6+ times per week. Reassuringly, however, the population is geographically diverse and does not apply to a single region in the US, as can be seen from the home region data in Table 1. Second, there is inherent volunteer bias among men who chose to complete the surgery. Third, although we used a validated questionnaire for erectile function, the responses are still subjective and self-reported, as opposed to objectively measured. Fourth, it is possible that some of the self-reported responses, in particular cannabis chemovar, were inaccurate as the accuracy of self-reporting of chemovar is unknown. Fifth, while the frequency was assessed, the dose of the cannabis chemovar was not assessed in the survey; therefore, it is possible that less-frequent users may have been consuming higher doses. Sixth, the lack of a large, widely representative control group prevents robust comparison between heavy users and nonusers. Finally, although users were asked about their experiences in the last 4 weeks, we did not discriminate between new and chronic users.