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1.  French-language version of the World Health Organization quality of life spirituality, religiousness and personal beliefs instrument 
A valid assessment of spirituality and religiousness is necessary for clinical and research purposes. We developed and assessed the validity of a French-language version of the World Health Organization Quality of Life Spirituality, Religiousness and Personal Beliefs Instrument (WHOQOL-SRPB).
The SRPB was translated into French according to the methods recommended by the WHOQOL group. An Internet survey was conducted in 561 people in 2010, with follow-up 2 weeks later (n = 231, 41%), to assess reliability, factor structure, social desirability bias and construct validity of this scale. Tests were performed based on item-response theory.
A modal score of 1 (all answers=”not at all”) was observed for Faith (in 34% of participants), Connectedness (27%), and Spiritual Strength (14%). All scales had test-retest reliability coefficients ≥0.7. Cronbach’s alpha coefficients were high for all subscales (0.74 to 0.98) and very high (>0.9) for three subscales (Connectedness, Spiritual Strength and Faith). Scores of Faith, Connectedness, Spiritual Strength and Meaning of Life were higher for respondents with religious practice than for those who had no religious practice. No association was found between SRPB and age or sex. The Awe subscale had a low information function for all levels of the Awe latent trait and may benefit from inclusion of an additional item.
The French language version of the SRPB retained many properties of the original version. However, the SRPB could be improved by trimming redundant items. The strength of SRPB relies on its multinational development and validation, allowing for cross-cultural comparisons.
PMCID: PMC3462699  PMID: 22515747
Spirituality; Religiousness; Quality of life; Internet surveys; Validity
2.  Validation of Hindi Translation of SRPB Facets of WHOQOL-SRPB Scale 
World Health Organization's Quality of Life – Spirituality, Religiousness and Personal Beliefs Scale (WHOQOL SRPB) is a valuable instrument for assessing spirituality and religiousness. The absence of this self-administered instrument in Hindi, which is a major language in India, is an important limitation in using this scale.
To translate the English version of the SRPB facets of WHOQOL-SRPB scale to Hindi and evaluate its psychometric properties.
Materials and Methods:
The SRPB facets were translated into Hindi using the World Health Organisation's translation methodology. The translated Hindi version was evaluated for cross-language equivalence, test-retest reliability, internal consistency, and split half reliability.
Hindi version was found to have good cross-language equivalence and test-retest reliability at the level of facets. Twenty-six of the 32 items and 30 of the 32 items had a significant correlation (ρ<0.001) in cross language concordance and test-retest reliability data, respectively. The Cronbach's alpha was 0.93, and the Spearman-Brown Sphericity value was 0.91 for the Hindi version of SRPB.
The present study shows that cross-language equivalence, internal consistency, split-half reliability, and test-retest reliability of the Hindi version of SRPB (of WHOQOL-SRPB) are excellent. Thus, the Hindi version of WHOQOL-SRPB as translated in this study is a valid instrument.
PMCID: PMC3868086  PMID: 24379495
Hindi translation; religiousness; spirituality; WHOQOL-SRPB
3.  An international measure of awareness and beliefs about cancer: development and testing of the ABC 
BMJ Open  2012;2(6):e001758.
To develop an internationally validated measure of cancer awareness and beliefs; the awareness and beliefs about cancer (ABC) measure.
Design and setting
Items modified from existing measures were assessed by a working group in six countries (Australia, Canada, Denmark, Norway, Sweden and the UK). Validation studies were completed in the UK, and cross-sectional surveys of the general population were carried out in the six participating countries.
Testing in UK English included cognitive interviewing for face validity (N=10), calculation of content validity indexes (six assessors), and assessment of test–retest reliability (N=97). Conceptual and cultural equivalence of modified (Canadian and Australian) and translated (Danish, Norwegian, Swedish and Canadian French) ABC versions were tested quantitatively for equivalence of meaning (≥4 assessors per country) and in bilingual cognitive interviews (three interviews per translation). Response patterns were assessed in surveys of adults aged 50+ years (N≥2000) in each country.
Main outcomes
Psychometric properties were evaluated through tests of validity and reliability, conceptual and cultural equivalence and systematic item analysis. Test–retest reliability used weighted-κ and intraclass correlations. Construction and validation of aggregate scores was by factor analysis for (1) beliefs about cancer outcomes, (2) beliefs about barriers to symptomatic presentation, and item summation for (3) awareness of cancer symptoms and (4) awareness of cancer risk factors.
The English ABC had acceptable test–retest reliability and content validity. International assessments of equivalence identified a small number of items where wording needed adjustment. Survey response patterns showed that items performed well in terms of difficulty and discrimination across countries except for awareness of cancer outcomes in Australia. Aggregate scores had consistent factor structures across countries.
The ABC is a reliable and valid international measure of cancer awareness and beliefs. The methods used to validate and harmonise the ABC may serve as a methodological guide in international survey research.
PMCID: PMC3547316  PMID: 23253874
early detection of cancer; cancer early diagnosis; validation studies; cross-cultural comparison; reliability and validity
4.  Psychometric Evaluation of the Spanish and English Versions of the Spiritual Coping Strategies Scale 
Journal of nursing measurement  2011;19(1):46-54.
The Spiritual Coping Strategies (SCS) Scale measures how frequently religious and nonreligious (spiritual) coping strategies are used to cope with a stressful experience. This study’s purpose is to evaluate the psychometric properties of the newly translated Spanish version of the SCS. A total of 51 bilingual adults completed the SCS in Spanish and English, with 25 completing them again 2–3 weeks later. Internal consistency reliability for the Spanish (r = 0.83) and English (r = 0.82) versions of the SCS in the total sample were good. Test–retest reliability was .84 for the Spanish and .80 for the English version. Spanish and English responses to the SCS items and the resulting score for the subscales and the total scale were not significantly different. Scores on the English and Spanish versions were correlated as expected with time since the stressful event and happiness with family and with spouse or partner, supporting the validity of the Spanish SCS. Study findings support the reliability and validity of the newly translated Spanish SCS.
PMCID: PMC3124707  PMID: 21560900
spirituality; Spanish; stressful events; coping strategies
5.  Psychometric properties of the Greek version of the NEI-VFQ 25 
BMC Ophthalmology  2008;8:4.
To evaluate the reliability and construct validity of a Greek version of the NEI-VFQ-25 in patients with chronic ophthalmic diseases.
We developed the Greek version of the instrument using forward and backward translation. One hundred-eighty-six patients responded to the questionnaire. To examine reliability, Cronbach's alpha for each subscale was used as an index of internal consistency. Test-retest reliability was evaluated with intraclass correlation coefficients. Regarding construct validity, both convergent and discriminant validities were calculated by means of multi-trait analysis. Rasch analysis was used to estimate the visual ability required by each item for a particular response, and each patient's visual ability. Correspondingly, instrument validity was evaluated by estimating the distribution of residuals for item and subject measures.
Four patient groups were studied, each including participants with a single cause of visual impairment. Group 1 consisted of 84 glaucoma subjects. Group 2 included 30 subjects with age-related macular degeneration (ARMD); group 3 included 25 subjects with dry-eye syndrome, whereas group 4 included 18 cataract patients. Twenty-nine healthy individuals comprised the control group. NEI-VFQ scores (mean ± SD) for the glaucoma, ARMD, dry-eye, cataract and control groups were: 76.9 ± 20.2, 70.9 ± 20.2, 81.6 ± 16.5, 73.5 ± 24.0 and 93.7 ± 8.9 respectively. Item analysis revealed no significant data skewing. Cronbach's alpha ranged from 0.678 to 0.926, with most subscales having high internal consistency. Intraclass correlation coefficient ranged from 0.717 to 0.910 for all subscales. All items passed the convergent and discriminant validity tests. Strong correlations were detected between visual acuity and "general vision", "distant activities" and "near activities" subscales. Significant correlations were also detected between visual field deficits and the "peripheral vision" and "general vision" subscales. Rasch analysis revealed potential weaknesses of the instrument that are associated with the assumptions of the model itself. Specifically, low precision of the "agreement" items was detected in the estimation of visual ability. Twenty-three percent of the subjects had fit statistics that fell outside the tolerance box.
Although traditional validation methods indicated that the Greek version of the NEI-VFQ-25 is a valid and reliable instrument for VS-QoL assessment, Rasch analysis detected significant misfits to the model, especially of the "agreement" items. This means that results of the corresponding subscales should be interpreted with extreme caution.
PMCID: PMC2287166  PMID: 18325083
6.  Predictors of spirituality at the end of life 
Canadian Family Physician  2008;54(12):1720-1721.e5.
To assess the relationship between spirituality and hopelessness, desire for hastened death, and clinical and disease-related characteristics among patients with advanced cancer, and to investigate predictors of spirituality. Spiritual well-being is thought to have a beneficial effect on patients’ response to illness.
Patients were asked to complete 4 questionnaires: the Greek version of the Spiritual Involvement and Beliefs Scale, the Greek version of the Schedule of Attitudes toward Hastened Death, the Beck Hopelessness Scale, and a questionnaire on demographics.
A palliative care unit in Athens, Greece.
A total of 91 patients with advanced cancer.
Associations between scores on the Spiritual Involvement and Beliefs scale and scores on the Schedule of Attitudes toward Hastened Death scale and the Beck Hopelessness scale, and demographic characteristics.
Statistically significant associations were found between spirituality and sex of patients (P = .001) and spirituality and stronger hopelessness (r = 0.252, P = .016). In multivariate analyses, stronger hopelessness, male sex, younger age, and receiving chemotherapy were found to be the strongest predictors of being spiritual.
Demographic and clinical characteristics and stronger hopelessness appeared to have statistically significant relationships with spirituality. Interventions to improve patients’ spiritual well-being should take these relationships into account.
PMCID: PMC2602627  PMID: 19074719
7.  Role of religious involvement and spirituality in functioning among African Americans with cancer: testing a mediational model 
Journal of behavioral medicine  2011;34(6):437-448.
The present study tested a mediational model of the role of religious involvement, spirituality, and physical/emotional functioning in a sample of African American men and women with cancer. Several mediators were proposed based on theory and previous research, including sense of meaning, positive and negative affect, and positive and negative religious coping. One hundred patients were recruited through oncologist offices, key community leaders and community organizations, and interviewed by telephone. Participants completed an established measure of religious involvement, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-SP-12 version 4), the Positive and Negative Affect Schedule (PANAS), the Meaning in Life Scale, the Brief RCOPE, and the SF-12, which assesses physical and emotional functioning. Positive affect completely mediated the relationship between religious behaviors and emotional functioning. Though several other constructs showed relationships with study variables, evidence of mediation was not supported. Mediational models were not significant for the physical functioning outcome, nor were there significant main effects of religious involvement or spirituality for this outcome. Implications for cancer survivorship interventions are discussed.
PMCID: PMC3653301  PMID: 21222026
Religion; Spirituality; Cancer coping; Mechanisms; Mediation; African Americans
This discussion article contributes to ethics reform by introducing the contribution of religious, spiritual, and traditional beliefs and practices to both subject vulnerability and patient improvement. A growing body of evidence suggests that religious, spiritual, and traditional beliefs and practices may provide positive benefits, although in some cases mixed or negative consequences to mental and physical health. These beliefs and practices add a new level of complexity to ethical deliberations, in terms of what ignoring them may mean for both distributive justice and respect for persons. International ethical guidelines need to be created that are expansive enough to cover an array of social groups and circumstances. It is proposed that these guidelines incorporate the religious, spiritual, and/or traditional principles that characterize a local population. Providing effective mental healthcare requires respecting and understanding how differences, including ones that express a population's religious, spiritual, or traditional belief systems, play into the complex deliberations and negotiations that must be undertaken if researchers are to adhere to ethical imperatives in research and treatment.
PMCID: PMC3747831  PMID: 22439296
religion; spirituality; mental health; ethics
9.  Spiritual and Religious Beliefs and Practices, and Social Support's Relationship to Diabetes Self-Care Activities in African Americans 
The Diabetes educator  2013;39(2):10.1177/0145721713475843.
The purpose of this study is to investigate the relationship among spiritual and religious beliefs and practices, social support, and diabetes self-care activities in African Americans with type 2 diabetes, hypothesizing that there would be a positive association.
This cohort study used a cross-sectional design that focused on baseline data from a larger randomized control trial. Diabetes self-care activities (Summary of Diabetes Self-Care Activities; SDSCA) and sociodemographic characteristics were assessed, in addition to spiritual and religious beliefs and practices and social support using the Systems of Belief Inventory (SBI) subscale I (beliefs and practices) and subscale II (social support).
There were 132 participants: most were female, middle-aged, obese, single, high school-educated, and not employed. Using Pearson correlation matrices, there were significant relationships between spiritual and religious beliefs and practices and general diet. Additional significant relationships were found for social support with general diet, specific diet, and foot care. Using multiple linear regression, social support was a significant predictor for general diet, specific diet, and foot care. Gender was a significant predictor for specific diet, and income was a significant predictor for blood glucose testing.
The findings of this study highlight the importance of spiritual and religious beliefs and practices and social support in diabetes self-care activities. Future research should focus on determining how providers integrate patients' beliefs and practices and social support into clinical practice and include those in behavior change interventions.
PMCID: PMC3859187  PMID: 23411653
10.  Daily Spiritual Experiences, Systolic Blood Pressure, and Hypertension among Midlife Women in SWAN 
There is reasonable evidence that religious beliefs and activities are associated with lower blood pressure and less hypertension. It is not known if daily spiritual experiences have similar effects.
We examined the relationship between an eight-item version of the Daily Spiritual Experiences Scale (DSES) and systolic blood pressure (SBP) and hypertension.
With data from 1,060 Caucasian and 598 African-American midlife women participating in Study of Women’s Health Across the Nation, in race-stratified models, we used regression equations, logistic regression, and mixed effects regression to estimate the relationship between DSES group and SBP and hypertensive status.
We found little difference across DSES groups in adjusted mean SBP for either Caucasian or African-American women. Nor did DSES protect against 3-year increases in SBP, hypertensive status, or incident hypertension.
Daily spiritual experiences do not appear protective for SBP or hypertension in midlife women. Further research should examine factors that condition the religion–BP relationship.
PMCID: PMC2867660  PMID: 19662465
Blood pressure; Hypertension; Religion; Spirituality; Spiritual experiences
11.  Baseline Predictors of Ninety Percent or Higher Antiretroviral Therapy Adherence in a Diverse Urban Sample: The Role of Patient Autonomy and Fatalistic Religious Beliefs 
AIDS Patient Care and STDs  2011;25(2):103-111.
The role of patient autonomy and influence of religious/spiritual beliefs on antiretroviral therapy (ART) adherence is to date not fully understood. This study assessed baseline predictors of high ART adherence (≥90%) measured by electronic drug monitors (EDM) at 12 and 24 weeks after enrollment in a randomized controlled trial testing behavioral interventions to improve ART adherence. Baseline data were collected with audio computer-assisted self interviews (ACASI) surveys among a diverse urban sample of HIV-infected participants (n = 204) recruited from community clinics in a large midwestern city. Baseline variables included a range of established ART adherence predictors as well as several less frequently studied variables related to patient autonomy and religious/spiritual beliefs. Statistically significant (p < 0.05) variables identified in univariate analyses were included in subsequent multivariate analyses predicting higher than 90% adherence at 12 and 24 weeks. Several baseline predictors retained statistical significance in multivariate analysis at 24 weeks. Baseline levels of autonomous support from friends and family, motivation to adhere, and having an active coping style were all positively associated with adherence, while the belief that God is in control of one's health was negatively associated with adherence. Results indicate that effective interventions should include a focus on promoting patients' autonomous regulation and religious/spiritual beliefs regarding ART adherence.
PMCID: PMC3049424  PMID: 21235403
12.  A focus-group study on spirituality and substance-abuse treatment 
Substance use & misuse  2010;45(1-2):134-153.
Individuals recovering from addictions frequently cite spirituality as a helpful influence. However, little is known about whether or how spirituality could be incorporated into formal treatment in a manner that is sensitive to individual differences. In the present study, focus groups were conducted with 25 methadone-maintained outpatients (primarily high-school educated, African-American males) to examine beliefs about the role of spirituality in recovery and its appropriateness in formal treatment. Groups also discussed the relationship between spirituality and behavior during active addiction. Thematic analyses suggested that spirituality and religious practices suffered in complex ways during active addiction, but went “hand in hand” with recovery. Nearly all participants agreed that integration of a voluntary spiritual discussion group into formal treatment would be preferable to currently available alternatives. One limitation was that all participants identified as strongly spiritual. Studies of more diverse samples will help guide the development and evaluation of spiritually based interventions in formal treatment settings.
PMCID: PMC2943841  PMID: 20025443
spirituality; religion; addiction; focus groups; treatment
13.  Iranian nurses’ perception of spirituality and spiritual care: a qualitative content analysis study 
The purpose of the present study was to explore nurses’ perception about spirituality and spiritual care. A qualitative content analysis approach was conducted on 20 registered nurses interviewed using unstructured strategy in 2009. Three themes emerged from the data analysis: 1) “meaning and purpose of work and life” including ‘spiritualistic view to profession’, ‘commitment and professional responsibility’, and ‘positive attitude’; 2) “religious attitude” including ‘God approval’, ‘spiritual reward’, ‘taking advice’, ‘inner belief in the Supreme Being’, ‘faith-based interactions and altruism’; 3) “transcendence-seeking” including ‘need for respect’ and ‘personal–professional transcendence’. Therefore, the spirituality produces maintenance, harmony and balance in nurses in relation to God. Spiritual care focuses on respecting patients, friendly and sympathetic interactions, sharing in rituals and strengthening patients and nurses’ inner energy.
This type of spirituality gives a positive perspective to life and profession, peaceful interactions, a harmonious state of mind, and acts as a motivator among nurses to promote nursing care and spirituality.
PMCID: PMC3713882  PMID: 23908741
Evaluation; Content analysis; Nurses’ spirituality; Spiritual care; Nurses’ lifestyle
14.  Measuring meaning in life following cancer 
Meaning in life is a multi-faceted construct that has been conceptualized in diverse ways. It refers broadly to the value and purpose of life, important life goals, and for some, spirituality. We developed a measure of meaning in life derived from this conceptualization and designed to be a synthesis of relevant theoretical and empirical traditions. Two samples, all cancer patients, provided data for scale development and psychometric study. From exploratory and confirmatory factor analyses the Meaning in Life Scale (MiLS) emerged, and includes four aspects: Harmony and Peace, Life Perspective, Purpose and Goals, Confusion and Lessened Meaning, and Benefits of Spirituality. Supporting data for reliability (internal consistency, test–retest) and construct validity (convergent, discriminant, individual differences) are provided. The MiLS offers a theoretically based and psychometrically sound assessment of meaning in life suitable for use with cancer patients.
PMCID: PMC2168592  PMID: 16838197
Cancer; Meaning; Quality of life; Spirituality; Survivor
15.  Self evolution: 1st domain of spiritual health 
Ayu  2012;33(2):174-177.
While measuring physical, mental, and social health as defined by the World Health Organization (WHO), the basis of measurement is in terms of Determinants. Recently with the advent of health promotion activities, the emphasis is on enabling individuals, groups, and societies to have control on these Determinants. To measure the spiritual health, the 4th Dimension, a Spiritual Health Scale consisting of 3 Domains, 6 Constructs, and 27 Determinants of spiritual health were identified through a scientific process. A statistically reliable and valid Spiritual Health Scale (SHS 2011) containing 114 items has been developed. Construct validity and test-retest reliability has been established. The 3 Domains are: Self-Evolution, Self-Actualization, and Transcendence. In this article, the process of self evolution in terms of “Wider Perspective” and “Nurturance-Art” have been captured through the Determinants like Commitment, Introspection, Honesty, Creativity, Contemplation, Prayer, Philanthropy, Extending Self, Empathy, Yoga and Exercise, Questioning Injustice, Aesthetics, Value for Time, and Being Away From Comparisons.
PMCID: PMC3611654  PMID: 23559785
Determinants; domains; self-evolution; spirituality
16.  Religious Factors and Hippocampal Atrophy in Late Life 
PLoS ONE  2011;6(3):e17006.
Despite a growing interest in the ways spiritual beliefs and practices are reflected in brain activity, there have been relatively few studies using neuroimaging data to assess potential relationships between religious factors and structural neuroanatomy. This study examined prospective relationships between religious factors and hippocampal volume change using high-resolution MRI data of a sample of 268 older adults. Religious factors assessed included life-changing religious experiences, spiritual practices, and religious group membership. Hippocampal volumes were analyzed using the GRID program, which is based on a manual point-counting method and allows for semi-automated determination of region of interest volumes. Significantly greater hippocampal atrophy was observed for participants reporting a life-changing religious experience. Significantly greater hippocampal atrophy was also observed from baseline to final assessment among born-again Protestants, Catholics, and those with no religious affiliation, compared with Protestants not identifying as born-again. These associations were not explained by psychosocial or demographic factors, or baseline cerebral volume. Hippocampal volume has been linked to clinical outcomes, such as depression, dementia, and Alzheimer's Disease. The findings of this study indicate that hippocampal atrophy in late life may be uniquely influenced by certain types of religious factors.
PMCID: PMC3068149  PMID: 21479219
17.  Psychometric properties of the Chinese craving beliefs questionnaire for heroin abusers in methadone treatment 
BMC Psychiatry  2011;11:39.
This paper reports the psychometric properties of the Chinese version of Craving Beliefs Questionnaire (CCBQ), an easy-to-administer assessment instrument of measurement of craving beliefs for heroin abusers.
Participants were 445 heroin abusers from four methadone clinics in Northern Taiwan. Fifty-one of the participants were tested twice within a two-week period at a different hospital to examine test-retest reliability.
Three-factor solution using principal component analysis was identified in the CCBQ: will power, compulsive behavior, and negative coping, accounting for 54.6% of the variance. Internal consistency analysis indicated that the three factors have strong reliability, with Cronbach alphas ranging from .81 to .92. The test-retest ICC coefficient is .80. The test-retest coefficients for the subscales will power, compulsive behavior, and negative coping are .76, .51, and .64, respectively. Overall, the data show that the CCBQ has acceptable reliability and validity, demonstrating that it can be a research instrument for assessing heroin craving beliefs.
The psychometric properties of the CCBQ seem promising for both research and clinical purposes, and the scale thus deserves further refinement and validation with heroin abusers.
PMCID: PMC3065399  PMID: 21388523
18.  Spirituality and Quality of Life in Limb Amputees 
Limb amputation is a life-changing event that signifies long-term physical, social, psychological, and environmental change. Spiritual well-being in patients plays a significant role in coping and may affect outcomes of patients with limb loss. The objective of this study was to describe the role of spirituality in individuals with limb amputation and to determine whether spirituality is related to the quality of life (QOL) in this sample. Study participants were recruited through prosthetists, physicians, amputee support groups, the Amputee Coalition of America, and amputee listserv discussion groups in the United States and Canada. Participants completed questionnaires containing measures of satisfaction with life, general health, mobility, and social integration. A quantitative descriptive research design was used to examine the relationships between existential spirituality (belief that one's life is meaningful or has purpose) and religious spirituality and QOL among individuals with limb amputation. A prospective study of 108 patients with a history of limb amputation was performed. The study population consisted of 66.3% males and 33.7% females. Most patients were Caucasian (96.2%). Of the 108 participants, 86 (79.6%) were 41 years of age or older with a mean of 18 years since amputation. The most frequent cause of amputation was trauma (55.6%) and the most common location of amputation was below-the-knee (49.1%). Existential spirituality, female gender, and age above 50 years related to higher QOL in patients with a history of limb amputation. The findings of this research confirmed that amputees use spirituality to cope with limb amputation. Existential spirituality was a significant predictor of satisfaction with life, general health, and social integration.
PMCID: PMC3444036  PMID: 23449135
quality of life; spirituality; well-being; coping; spirituality; limb amputation
19.  Spirituality in Recovery: A Lagged Mediational Analysis of Alcoholics Anonymous’ Principal Theoretical Mechanism of Behavior Change 
Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through “spiritual” practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes.
Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects.
Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day).
Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals’ spiritual practices and provides support for AA’s own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.
PMCID: PMC3117904  PMID: 21158876
Alcoholics Anonymous; Spirituality; self help groups; alcoholism; alcohol dependence
20.  Psychometric properties of the Iranian interview-administered version of the World Health Organization's Quality of Life Questionnaire (WHOQOL-BREF): A population-based study 
The objective of the current study was to translate and validate the Iranian version of the WHOQOL-BREF.
A forward-backward translation procedure was followed to develop the Iranian version of the questionnaire. A stratified random sample of individuals aged 18 and over completed the questionnaire in Tehran, Iran. Psychometric properties of the instrument including reliability (internal consistency, and test-retest analysis), validity (known groups' comparison and convergent validity), and items' correlation with their hypothesized domains were assessed.
In all 1164 individuals entered into the study. The mean age of the participants was 36.6 (SD = 13.2) years, and the mean years of their formal education was 10.7 (SD = 4.4). In general the questionnaire received well and all domains met the minimum reliability standards (Cronbach's alpha and intra-class correlation > 0.7), except for social relationships (alpha = 0.55). Performing known groups' comparison analysis, the results indicated that the questionnaire discriminated well between subgroups of the study samples differing in their health status. Since the WHOQOL-BREF demonstrated statistically significant correlation with the Iranian version of the SF-36 as expected, the convergent validity of the questionnaire was found to be desirable. Correlation matrix also showed satisfactory results in all domains except for social relationships.
This study has provided some preliminary evidence of the reliability and validity of the WHOQOL-BREF to be used in Iran, though further research is required to challenge the problems of reliability in one of the dimensions and the instrument's factor structure.
PMCID: PMC2287168  PMID: 18366715
21.  End-of-life practices in Danish ICUs: development and validation of a questionnaire 
BMC Anesthesiology  2012;12:16.
Practices for withholding or withdrawing therapy vary according to professional, cultural and religious differences. No Danish-validated questionnaire examining withholding and withdrawing practices exists, thus the aim of this study was to develop and validate a questionnaire for surveying the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the ICU.
A questionnaire was developed on the basis of literature, focus group interviews with intensive care nurses and intensivists, and individual interviews with primary physicians. The questionnaire was validated in the following 3 phases: a qualitative test with 17 participants; a quantitative pilot test with 60 participants; and a survey with 776 participants. The validation process included tests for face and content validity (by interviewing participants in the qualitative part of the pilot study), reliability (by assessing the distribution of responses within the individual response categories), agreement (by conducting a test-retest, evaluated by paired analyses), known groups’ validity (as a surrogate test for responsiveness, by comparing two ICUs with a known difference in end-of-life practices), floor and ceiling effect, and missing data.
Face and content validity were assessed as good by the participants in the qualitative pilot test; all considered the questions relevant and none of the participants found areas lacking. Almost all response categories were used by the participants, thus demonstrating the questionnaires ability to distinguish between different respondents, agreement was fair (the average test-retest agreement for the Likert scale responses was 0.54 (weighted kappa; range, 0.25-0.73), and known groups’ validity was proved by finding significant differences in level of satisfaction with interdisciplinary collaboration and in experiences of withdrawal decisions being unnecessarily postponed. Floor and ceiling effect was in accordance with other questionnaires, and missing data was limited to a range of 0-7% for all questions.
The validation showed good and fair areas of validity of the questionnaire. The questionnaire is considered a useful tool to assess the perceptions of collaboration and other aspects of withholding and withdrawing therapy practices in Danish ICUs amongst nurses, intensivists, and primary physicians.
PMCID: PMC3519525  PMID: 22853051
22.  Changes in Religiousness and Spirituality Attributed to HIV/AIDS: Are There Sex and Race Differences? 
Journal of General Internal Medicine  2006;21(Suppl 5):S14-S20.
Having a serious illness such as HIV/AIDS raises existential issues, which are potentially manifested as changes in religiousness and spirituality. The objective of this study was (1) to describe changes in religiousness and spirituality of people with HIV/AIDS, and (2) to determine if these changes differed by sex and race.
Three-hundred and forty-seven adults with HIV/AIDS from 4 sites were asked demographic, clinical, and religious/spiritual questions. Six religious/spiritual questions assessed personal and social domains of religiousness and spirituality.
Eighty-eight participants (25%) reported being “more religious” and 142 (41%) reported being “more spiritual” since being diagnosed with HIV/AIDS. Approximately 1 in 4 participants also reported that they felt more alienated by a religious group since their HIV/AIDS diagnosis and approximately 1 in 10 reported changing their place of religious worship because of HIV/AIDS. A total of 174 participants (50%) believed that their religiousness/spirituality helped them live longer. Fewer Caucasians than African Americans reported becoming more spiritual since their HIV/AIDS diagnosis (37% vs 52%, respectively; P<.015), more Caucasians than African Americans felt alienated from religious communities (44% vs 21%, respectively; P<.001), and fewer Caucasians than African Americans believed that their religiousness/spirituality helped them live longer (41% vs 68% respectively; P<.001). There were no significantly different reported changes in religious and spiritual experiences by sex.
Many participants report having become more spiritual or religious since contracting HIV/AIDS, though many have felt alienated by a religious group—some to the point of changing their place of worship. Clinicians conducting spiritual assessments should be aware that changes in religious and spiritual experiences attributed to HIV/AIDS might differ between Caucasian and African Americans.
PMCID: PMC1924779  PMID: 17083495
HIV/AIDS; religion; spirituality; coping; chronic illness
23.  Tanzanian Nurses Understanding and Practice of Spiritual Care 
ISRN Nursing  2011;2011:534803.
Spirituality, as a basic characteristic of humans and a contributor to human health, is regarded as part of nursing practice. The purpose of this study was to examine how Tanzanian nurses understand spirituality and spiritual care. Using the qualitative method of interpretive description, fifteen registered nurses engaged in clinical practice in a Tanzanian hospital were recruited to participate in this study. In-depth interviews using open-ended questions were carried out, tape-recorded, and transcribed verbatim. Data collection and inductive analysis occurred concurrently. In this paper, key findings are grouped under the following headings: meaning of spiritual care, recognition of spiritual needs, and interventions to respond to spiritual needs. Although there were some differences, overall participants' understanding of spirituality and spiritual care was similar to what is found in the literature about nurses in other countries. The provision of spiritual care also included some unique elements that may reflect the African context.
PMCID: PMC3169833  PMID: 22007322
24.  Religious/Spiritual Coping in Adolescents with Sickle Cell Disease 
Religious/spiritual (R/S) coping has been associated with health outcomes in chronically ill adults; however, little is known about how adolescents use R/S to cope with a chronic illness such as sickle cell disease (SCD). Using a mixed method approach (quantitative surveys and qualitative interviews), we examined R/S coping, spirituality, and health-related quality of life in 48 adolescents with SCD and 42 parents of adolescents with SCD. Adolescents reported high rates of religious attendance and belief in God, prayed often, and had high levels of spirituality (e.g., finding meaning/peace in their lives and deriving comfort from faith). Thirty-five percent of adolescents reported praying once or more a day for symptom management. The most common positive R/S coping strategies used by adolescents were: “Asked forgiveness for my sins” (73% of surveys) and “Sought God’s love and care” (73% of surveys). Most parents used R/S coping strategies to cope with their child’s illness. R/S coping was not significantly associated with HRQOL (p = NS). R/S coping, particularly prayer, was relevant for adolescents with SCD and their parents. Future studies should assess adolescents’ preferences for discussing R/S in the medical setting and whether R/S coping is related to HRQOL in larger samples.
PMCID: PMC2749498  PMID: 19415008
religiosity; coping; sickle cell disease; health-related quality of life
25.  Religious and Spiritual Beliefs of Gynecologic Oncologists May Influence Medical Decision Making 
Religious and spiritual (R/S) beliefs often affect patients' health care decisions, particularly with regards care at the end of life (EOL). Furthermore, patients desire more R/S involvement by the medical community however; physicians typically do not incorporate R/S assessment into medical interviews with patients. The effects of physicians' R/S beliefs on willingness to participate in controversial clinical practices such as medical abortions and physician assisted suicide has been evaluated, but how a physicians' R/S beliefs may affect other medical decision-making is unclear.
Using SurveyMonkey, an online survey tool, we surveyed 1972 members of the International Gynecologic Oncologists Society and the Society of Gynecologic Oncologists to determine the R/S characteristics of gynecologic oncologists and whether their R/S beliefs affected their clinical practice. Demographics, religiosity and spirituality data were collected. Physicians were also asked to evaluate 5 complex case scenarios.
Two hundred seventy-three (14%) physicians responded. Sixty percent “agreed” or “somewhat agreed” that their R/S beliefs were a source of personal comfort. Forty-five percent reported that their R/S beliefs (“sometimes,” “frequently,” or “always”) play a role in the medical options they offered patients, but only 34% “frequently” or “always” take a R/S history from patients. Interestingly, 90% reported that they consider patients' R/S beliefs when discussing EOL issues. Responses to case scenarios largely differed by years of experience although age and R/S beliefs also had influence.
Our results suggest that gynecologic oncologists' R/S beliefs may affect patient care but that the majority of physicians fail to take a R/S history from their patients. More work needs to be done in order to evaluate possible barriers that prevent physicians from taking a spiritual history and engaging in discussions over these matters with patients.
PMCID: PMC3127444  PMID: 21436706
Religion; spirituality; gynecologic oncology; mentorship; spiritual history; medical decision-making

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