A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life

Abstract

This paper reports on an international study in 18 countries ($n=5087$) to observe how spirituality, religion and personal beliefs (SRPB) relate to quality of life (QoL). SRPB is assessed using the World Health Organization's QoL Instrument (the WHOQOL), where eight additional facets were included to more fully address these issues as they pertain to QoL, along with physical, social, psychological and environmental domains. The facets address issues such as inner peace, faith, hope and optimism, and spiritual connection. The results showed that SRPB was highly correlated with all of the WHOQOL domains ($p<0.01$), although the strongest correlations were found with psychological and social domains and overall QoL. When all of the domain scores were entered into a stepwise hierarchal regression analysis, all of the domains contributed to overall quality of life ($N=3636$), explaining 65% of the variance. When this was repeated for those people who reported poor health ($N=588$), it was found that only four domains explain 52% of the variance. The first was the level of independence, followed by environment, SRPB and physical. Gender comparisons showed that despite showing lower scores for facets in the psychological domain, such as negative feelings and poorer cognitions, women still reported greater feelings of spiritual connection and faith than men. Those with less education reported greater faith but were less hopeful. It is suggested that SRPB should be more routinely addressed in assessment of QoL, as it can make a substantial difference in QoL particularly for those who report very poor health or are at the end of their life.

Introduction

Traditionally, generic assessments of quality of life (QoL) have not routinely addressed aspects related to religion, spirituality or existential well-being. Measures that have included such issues have been specific to cancer patients (e.g. the Quality of Life in Cancer Survivors, Ferrell, et al., 1990, Functional Assessment of Cancer Therapy (FACT), Cella, Tulkky, Gray, Sarafian, Linn, Bonomi et al., 1993), the FACT-SP (Peterman, Fitchett, Brady, Hernandez, Cella, 2002, Brady, Peterman, Fitchett, Cella, 1999), HIV/AIDS (the WHOQOL HIV/AIDS Instrument, WHOQOL HIV Group (2003a), WHOQOL HIV Group (2003b), WHOQOL HIV Group (2003c)) or those at end of life (e.g. the Hospice Index, McMillan & Mahon, 1994). These measures are therefore not applicable to people who may be free from illness, or suffering from other diseases. Other instruments that have addressed religion or spirituality have subsumed such items into the psychological or social domains (e.g. McMaster Health Questionnaire, Chambers, MacDonald, Tugwell, 1982; Chambers, 1996), making it impossible to investigate the contribution of spirituality to QoL. Likewise, with the Hospice Index mentioned previously, scores are summarised to form a total score, and therefore the impact of spirituality alone cannot be assessed. It is also acknowledged that many of the current measures have been developed in Western countries, which may be less likely to consider the role of spirituality as important in generic assessment of QoL. Those that have addressed QoL cross culturally have at times included such components (e.g. the WHOQOL, WHOQOL Group, 1998).

While the literature has largely focused on health outcomes, research does suggest that some domains of QoL, other than health-related dimensions, will be affected by spiritual or religious experience. This has largely centred around social and psychological aspects, showing positive relationships between a number of variables, such as positive feelings, social support and self-esteem, depression, anxiety and hopelessness, personal growth, mastery, control, happiness and satisfaction (as reviewed in Pargament, Smith, Koenig, & Perez, 1998, Koenig, McCullough & Larson, 2001). There is increasing evidence that peoples’ spiritual or religious experiences may be important contributors to QoL. Studies have shown that spiritual or religious variables are important for coping with illness (O’Connor, Wicker, & Germino, 1990, Johnston & Spilka, 1991) and that experiences change following diagnosis (Ferrell et al., 1992). Of the 101 studies reviewed by Koenig (2001) that observed the relationship between religion, depression and negative feelings, 65% reported a significant positive relationship between a measure of religious involvement and lower rates of depression or depressive symptoms. Other studies using the Functional FACT-Sp found that the spirituality module was related to all domains of QoL and to overall global QoL assessment (Ferrell, Hassey & Grant, 1995). Cohen and Mount (2000) conducted qualitative work with cancer patients ($n=100$) and found that when people were asked to indicate the most important influences on their QoL during the preceding 2 days, many were spiritual, such as being alive, existential calm/peace, freedom, hope and faith.

Though current research has largely been conducted in Western contexts, the importance of spirituality may be particularly high for certain cultural and ethnic groups. For example, Lo et al., (2001) found that among palliative care patients in Hong Kong, existential well being made the strongest contribution to overall QoL of four domains assessed in their measure.

Related to this, the world is currently 80% non-western, with growing numbers of immigrants and refugees moving from non-western to western regions. In addition, a large portion of the world's population relies, at least partially, on non-allopathic systems of medicine and many traditional healers that operate within such systems view patient's complaints as having spiritual aetiologies. Furthermore, anthropological studies of health and healing in diverse cultures show that health is often a cultural ideal and varies widely over time and across culture (McGuire, 1993).

Addressing religious or spiritual experiences from a cross-cultural perspective will help to elaborate and understand these concepts as they relate to QoL. As such, any development of a domain to assess spiritual and religious experiences might benefit from the input of different cultures and religions. Generic QoL instruments may also benefit from more routinely including assessments of existential or spiritual aspects, as they may hold more value for some people than items which enquire, for example, about one's sex life, sleep or work capacity. This paper reports on the World Health Organization's Quality of Life Measure (WHOQOL) for assessment of Spirituality, Religion and Personal Beliefs (SRPB) in a cross-cultural sample representing 18 countries. The aim of this work is to report on preliminary psychometric properties, determine how SRPB relate to other domains of QoL and to identify differences in terms of gender, age, education and health status.