We have confirmed the structure and consistency of the previously described SpREUK-P manual [26
], which is an integral part of the SpREUK construct [24
], and improved the quality of the current construct by adding several new items. Apart from conventional religious and unconventional spiritual practices, three other distinct forms of engagement were of relevance to the patients with life-threatening diseases, i.e. existentialistic practice, humanistic practice, and nature/environment-oriented practice. The latter three topics are obviously more philosophical forms of SpR.
When confronted with a life-threatening disease, more existentialistic or self-centered issues become relevant to the patients. Existentialistic philosophers (such as Søren Kierkegaard and Jean-Paul Sartre) emphasized the universal struggle to find meaning in life, to live by moral standards, and to come to an understanding of suffering and death [31
]. To them, life might be without inherent meaning (existential atheists) or it might be without a meaning we can understand (existential theists). Consequently, since man is ultimately alone, one is free to pick and choose one's own values, and to create one's own suitable religious patchwork. In accordance with these views we found strong correlations between ExP and the SpREUK scales "Search for meaningful support" and "Positive interpretation of disease". Moreover, the ExP engagement score was much higher compared to the more formalized practices, i.e. CRP and USP. The highest engagement scores were found for HuP and NoP. One could speculate that these forms reflect a higher level of "insight", but it is also true that less effort is needed to turn to others (HuP) and nature (NoP) than to reflect on yourself (ExP); and their social desirability is much higher. One the other hand, within recent decades, ecological issues and people's appreciation of nature ("earth connection") have gained much attention, and thus higher agreement levels are not surprising. Engagement in an ExP is significantly dependent on the SpR attitude (low engagement level were found for R-S- individuals and those without any religious affiliation); gender and marital status are also relevant variables. One may speculate that divorced individuals, who have the highest ExP engagement level, reflect more on themselves because of the process of divorce ("liberation", "self-realization").
A more self-centered attitude is also measured in a scale of Holland's Spiritual Beliefs Inventory (SBI-15R-D) [19
]: The underlying attitude of a social support through a religious faith community can be described as "What will others do for me?" In our HuP and NoP scales, the question is "What can I do for others, for nature and environment?" These contrasting views are highly affected by the state of "insight" an individual has developed.
The items of the scale HuP are related to the views of Secular Humanism [34
] and the Philosophical resp. Christian Humanism [36
]. Secular Humanism is an atheistic and naturalistic philosophy promoting humanity as the measure of all things, and roots in the rationalism of the 18th Century and the free-thought movement of the 19th Century. Secular Humanists reject the concept of a personal creator God, and regard man as fully responsible for the future of the world, its political systems, its ecology, etc. [34
]. Thus, it is not surprising that the scale HuP neither correlates to CRP nor to the SpREUK scale "Trust in External Guidance". In fact, it correlates somewhat better with ExP and the SpREUK scale "Search for meaningful support". Consequently, the lowest HuP engagement levels were found for individuals lacking a spiritual attitude (R+S- and R-S-). Low engagement levels were also found with respect to higher age, and in patients with cancer and MS. The impact of disease and its duration on HuP remains to be explained in further studies.
To our surprise, one of the most accepted topics defining conventional religious practice, "going to church" resp. "service attendance", had a low engagement score among the German individuals tested. The same is true for the participation in religious events, while praying seems to be much more attractive. The items from the USP scale had low engagement scores too, even meditation, which is highly valued in several other questionnaires.
The presumption that both scales do not measure what they are intended to do can be rejected both from a statistical but also from a contextual point of view, because individuals with a Christian affiliation had significantly higher engagement scores for CRP than those with other religious affiliations or none, while individuals with non-Christian affiliations had the highest scores for USP. Moreover, a religious attitude (R+S+ and R+S-) was associated with significantly higher mean levels for CRP than subjects with a spiritual attitude (R-S+ and R-S+), while in contrast a spiritual attitude (R+S+ and R-S+) was associated with higher levels for USP. In this context it is worth mentioning that an R-S- attitude was associated with the lowest engagement scores for all five forms of a SpR practice. Variance analyses confirmed that SpR attitude and religious affiliation are the main relevant covariate for CRP, while for USP, the SpR attitude and the educational level are of significance, but not religious affiliation.
The level of engagement in CRP also depends on the professional background of the tested subjects. We found that the engagement score was very high in attendants of a Christian Caritas meeting (mainly priests, chaplains, Christian social workers etc.) and in composers of Contemporary Christian Songs (mean values 79.9 ± 20.3 resp. 77.0 ± 13.1); high scores were found also in attendants of a meeting on "Spirituality and Health" (56.9 ± 33.3), while the lowest CRP score was found in hospital staff (32.7 ± 20.0). The engagement score of catholic nurses caring for out-patients (45.7 ± 25.6) was similar to the overall mean level (47.1 ± 28.8). Details of this investigation will be presented elsewhere.
Using the German version of Holland's Spiritual Beliefs Inventory (SBI-15R-D), Albani et al
. found that higher religiosity is observed for women, older people, people with lower education, former West Germans vs. former East Germans, and people stating a religious affiliation [33
]. These findings are only in part congruent with ours: The higher CRP engagement score in women was not statistically significant, while lower age and lower educational level were associated with significantly lower CRP engagement scores. However, we can confirm higher scores for patients with a Christian affiliation and a religious attitude (R+S+ and R+S-). Using the SpREUK 1.1 inventory, we have found that women with cancer have significantly higher scores for "Search for meaningful support", "Interpretation of disease" and "Support in relations with the external life through SpR", but not for "Trust in external Guidance"[24
] Similar, cancer patients with a lower educational level had significantly lower scores for "Search for meaningful support" and "Interpretation of disease", though again not for "Trust in external Guidance" [24
]. Thus, it is obvious that the condensed 10-item scale of the shortened SB-15-R [19
], which measures mainly religious beliefs and convictions dealing with the support through God and faith, represents only a distinct aspect of religiosity.
In fact, "religiosity" is already multidimensional construct. Batson et al. described a three-dimensional model of religiosity: Means or external, End or internal, and Quest [14, 37]. Intrinsic religiosity identifies religion as an end in itself. Strong personal convictions, beliefs and values are what matter, while the social aspects of religion are not that important. In contrast, the motifs of extrinsic religiosity are based on social or external values and beliefs; religion is used to gain social standing and endorsement. The Quest orientation is founded on a willingness to question complex ideas. The persons are open to the exploration of existential questions and they are open for new information and doubts. Thus, as we have to assume a complex interconnection of various existing views, attitudes and concepts, an oversimplification ("two scales are enough") of SpR concerns in QoL research is not appropriate.