Nevertheless, the terms spirituality and religiousness have been used in different ways by different authors, sometimes interchangeably because of the elusiveness of both concepts. Narayanasamy argues that the lack of any authoritative definition of these two terms has resulted in a multiple definition and hence in the confusion surrounding these concepts [20]. Furthermore, Mokuau et al. aptly state: "...the difficulties in developing standardized definitions and measures relate to varying interpretations of religiousness and spirituality..." and they stress that the potential for providing quality care that integrates religiousness and spirituality to a large extent depends upon the development of measures that are at least psychometrically sound [21].

Studies on religiousness, spirituality and spiritual care are rare in Greece [17,22] and this may be the reason for the present lack of a valid instrument. Sapountzi et al. mention that "...the lack of valid instruments is a widespread phenomenon, concerning not only Greece but rather all non-English speaking countries, owing to the fact that in this day and age, English is the language of science, just as Greek was in biblical times..." [23].

In 1995 King et al. developed a scale, "The Royal Free Interview for Religious and Spiritual Beliefs", in order to evaluate religious and spiritual beliefs in a variety of populations. Some years later, this scale was modified in order to make it more functional [24,25]. The Royal Free Interview for Religious and Spiritual Beliefs is a valid and reliable scale; in the English version [24], it is short and simple and can be easily completed by most people. Moreover, it focuses on the strength and the consequences of faith, rather than on the specific nature of each belief and as King et al. stress, the "...interview was designed specifically to avoid a focus on any one religious system or type of spiritual belief and thus comparisons were impossible to make..." [24].

At the time that The Royal Free Interview for Religious and Spiritual Beliefs was published, the researchers of the present paper were looking for an instrument capable of measuring spirituality and religiousness in the Greek population [24]. Following careful consideration, they decided to translate an already valid instrument instead of developing a new one, choosing a European rather than an American one, because they believe that although cultural differences exist among European populations, they also share many common cultural issues. In addition, taking into account that the vast majority of the population living in Greece belongs to the Greek Orthodox Church, it was desirable to find a scale designed specifically to avoid a focus on any one religious system or type of spiritual belief. The Royal Free Interview for Religious and Spiritual Beliefs fulfilled most of the criteria set, and therefore the researchers approached Professor King, asking for his permission to translate the scale into the Greek language and validate it. After obtaining written permission, the Royal Free Interview for Religious and Spiritual Beliefs was translated into Greek in 2003 [23]. In a second stage, the research team continued evaluating the psychometric properties of the scale. Let us point out that as a result of extensive discussions among the research team and with other researchers, we decided to revise the question "How would you describe yourself? (tick one or more)". More precisely, the modified question in the Greek version asked participants to tick a specific part of Greece as their place of origin. Given that over the past twenty years, Greece has been faced with immigration from the Balkan countries and the former USSR, the question was adapted to include these newcomers' origin as well. The question was thus revised, and instead of asking respondents to indicate specific parts of Greece as their place of origin, they are now requested to indicate their origin from an international perspective. The modification was made in order to make the question suitable for people from a variety of ethnic backgrounds living in contemporary Greece.

The translation and the cultural adaptation of the Royal Free Interview for Spiritual and Religious Beliefs was carried out at an early stage [23]. A panel of experts who were also bilinguals was requested to translate the English version of the Royal Free questionnaire. Furthermore, in order to assess the linguistic accuracy of the translated instrument, a pilot study using bilingual persons was carried out. Details related to the translation and adaptation of the Royal Free questionnaire for spiritual and religious beliefs are mentioned elsewhere [23].

A total of 18 out of 207 participants of the test group (8.7%) stated that they had no religious or spiritual understanding of their life; 44 (21.1%) reported a religious belief; 18 (8.7%) told of a spiritual belief and the vast majority of participants (61.4%) reported both a religious and a spiritual belief. In group B, responses were similar. Those with a spiritual or religious understanding of their life explained that they believed in God, the Saints, the Holy Trinity, a superior creature, or the Bible.

Spiritual belief differed in a statistically significant manner between the two genders of the test population (x² = 25.808, df = 3, p < .001) as shown in table ​table2.2. The vast majority of women (66.8%), rather than men (41.4%), reported religious and spirituals beliefs and only 2.1% of the women and 12.6% of the men had neither religious nor spiritual beliefs. Logistic regression analysis indicated that women (OR 2.3, 95%CI 1.1–4.6) were significantly more likely to hold a religious and spiritual view of life. Table ​Table22 presents the gender-specific difference of mean scores of spiritual scale.

Four persons (1.5%) answered that they underwent an intense experience at a time when they almost died, but were eventually revived. Four other persons were uncertain as to whether or not they had had such an experience. For these four persons, the mean effect of this experience on their lives was moderate (4.69 ± 2.9). The majority of persons participating in our study answered that they prayed by themselves (N = 215, 77.3%) or with others (N = 24, 8.6%). Only 57 persons (20.5%) stated that religious ceremonies play a central role in their faith; 43.2% said the same of meditation, 60.8% of reading and study, 36.3% of contact to religious leaders and 7.2% none of the above.

After we tallied the scores of participants for questions 3, 7 to 11, which make up the spiritual scale, we found that during the test phase the t-test was significant (t = -3.562, df = 256, p < .001) and showed that the mean scores of the participants on the spiritual scale differed significantly between women (mean = 36.10 ± 10.54) and men (mean = 31.80 ± 11.25), as shown in table ​table2.2. The retest did not lead to the same result, as the t-test showed no statistical difference between the two genders (p = .563). There was a gender-specific difference (Fisher's exact test p = .001), though, between those who believed that prayer plays an important role in their faith: the majority of women (75.6%) like to pray alone, instead of men (60.9%) who prefer to pray with others.

One hundred and sixty-five participants (62%) answered that they do not communicate with a spiritual power at all, i.e. by way of prayer or contact via a medium. Eleven persons (4.1%) were uncertain. Women communicate more often by praying than do men (Chi-Square test 7,595 df = 2 p = .022). Twenty-five percent of the men, as against 45% of the women communicate with a spiritual power in some other way.

The percentage of those who believe that we continue to exist in some form after death (37.5%) was similar to those who were uncertain (39.3%). Thirty-two participants (23.9%) had had an intense experience through which they sensed some deep new meaning in life that lasted for a few moments, hours or even days. Eleven of them felt it once (44%) and ten of them had had eleven to fourteen such intense experiences (40%). This experience lasted for 7.96 ± 8.53 days. For some, it lasted 4.88 ± 0.61 hours, for others 5.02 ± 0.65 minutes and for a few individuals it lasted for 5 seconds.

When asked to describe this experience, they answered that the incident was a prophetic dream, the recovery from an accident or an illness, the presence of an invisible force, the birth of their child, a detachment of the material body, a strong feeling of happiness, of feeling protected from harm. Further analysis of this open question (describe the intense experience) put to those participants who had had an intense experience rendered a description of a dreamy journey to an unknown place, filling them with a strong euphoric feeling of happiness, wellness and inner peace. The main characteristic of this experience was the lack of any sense of control over the circumstances. They felt no fear, although it was an unusual experience – perhaps precisely because it was a perceived spiritual experience, providing an opportunity to become closer to God or clarifying the grace of God. It was an isolated moment of physical and bodily sensation, or a sharing emotion. For others it was a unique and private emotional experience, or simply a prophetic reassurance of future recovery from a difficult situation. Some of the respondents were not able to describe it, even though their experience had been very intense.

Between those 90 participants (67.2%) who had never felt an intense experience, two persons mentioned that they had undergone an intense experience at a time when they almost died but were eventually revived. It was an incident that changed their lives.

Fourteen (88.9%) of the 18 participants with a spiritual belief communicate in some way with a spiritual power, compared to 26 (59.1%) of the 44 persons with a religious faith and 67 (52.8%) of the 127 persons with both a religious and a spiritual belief (Chi Squared 18.20, df = 6, p = .006). Respondents who reported having intensely experienced a power were more likely to believe in a spiritual power that influences the universe (5.52 ± 3.30) than those who had never had such an experience (4.25 ± 2.54). Belief in the existence of some form of life after death was more common among Muslims and those who do not belong to a specific religion. The majority of Orthodox Christians did not believe in life after death (73.6%). Forty-nine (38.9%) of the 126 persons who spoke of both a religious and spiritual faith believed in life after death, as against forty-five (35.7%) persons who were uncertain.

There was a major difference in mean scores on the spiritual scale between persons who expressed a religious/spiritual view of life on the Royal Free Questionnaire and those who did not [37.2 (sd 10.2) cf 23.1 (sd 18.3), mean diff 14.0, CI 6.6 to 21.5, df (equal variance) 131, p < 0.0001]. Those who communicate with a spiritual power obtained higher mean scores on the spiritual scale than those who do not [42.4 (sd 8.9) cf 31.1 (sd 9.7), mean diff 11.3, CI 8.5 to 14.1, df (unequal variance) 156.55, p < 0.0001]. Women expressed a higher spirituality than did men [37 (sd 12) cf 31 (sd 10.7), mean diff -5.97, CI -9.4 to -2.5, df (unequal variance) 125,64, p < 0.0001].

The intra-class correlation coefficient for continuous variables ranged from 0.73 to 0.86, and for total spiritual scale score it was 0.86. Coefficient kappa ranged from 0.70 to 0.74. In King et al., intra-class research correlation ranged from 0.72 to 0.89 and 0.94 for the total spiritual scale score. Coefficient kappa ranged from 0.76 to 0.79. These findings are evidence of cross-cultural test-retest agreement of scale items.

The majority of respondents replied that they believe in God and go to Church. Furthermore, the vast majority of participants (58.9%) reported both a religious and a spiritual belief. This is a constant finding of other research studies in the U.S.A. [37-39], with a percentage varying from 59% to 74%. It would seem that Greek respondents dissociate themselves from both spirituality and religion, and that they have a more traditional attitude toward religion. A similar attitude is mentioned by Streib in a research study on spirituality and religious orientation in adolescents in Germany [40]. However, we might interpret this evidence in the context of Christianity and with a view to the age structure of the respondents, who were very young. The low mean age of the sample may explain the distinction between spirituality and religiousness, as young people perceive the spiritual meaning of religiousness and distinguish it from church-related spirituality. In our sample, women were significantly more likely to hold a religious and/or spiritual view of life [24] and expressed a greater spirituality than men did.

The term "spirituality" is multidimensional, allowing for various interpretations with its many connotations and vague structure. Parker Palmer mentions that spiritual questions always revolve around angels or ethers or include the word God: Spiritual questions are the kind that we and our patients ask every day of our lives, as we yearn to connect with the largeness of life: "Does my life have a meaning and a purpose?" "How do I deal with suffering?" "What is the real meaning of my life?" [41] The last question accounts for the core meaning of the term spirituality for Greeks, as it includes all features that give meaning and purpose to life. All these approaches challenge the perceptual and conceptual framework of any instrument assessing spirituality and religiousness. The Greek version of the Royal Free Interview for Religious and Spiritual Beliefs captures all dimensions of this construct. Further evaluation of the scale might include a wider population, encompassing ethnic minorities and persons representing a greater variety of religions.