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2.  Instruments Measuring Spirituality in Clinical Research: A Systematic Review 
Journal of General Internal Medicine  2011;26(11):1345-1357.
ABSTRACT
INTRODUCTION
Numerous instruments have been developed to assess spirituality and measure its association with health outcomes. This study’s aims were to identify instruments used in clinical research that measure spirituality; to propose a classification of these instruments; and to identify those instruments that could provide information on the need for spiritual intervention.
METHODS
A systematic literature search in MEDLINE, CINHAL, PsycINFO, ATLA, and EMBASE databases, using the terms “spirituality" and “adult$," and limited to journal articles was performed to identify clinical studies that used a spiritual assessment instrument. For each instrument identified, measured constructs, intended goals, and data on psychometric properties were retrieved. A conceptual and a functional classification of instruments were developed.
RESULTS
Thirty-five instruments were retrieved and classified into measures of general spirituality (N = 22), spiritual well-being (N = 5), spiritual coping (N = 4), and spiritual needs (N = 4) according to the conceptual classification. Instruments most frequently used in clinical research were the FACIT-Sp and the Spiritual Well-Being Scale. Data on psychometric properties were mostly limited to content validity and inter-item reliability. According to the functional classification, 16 instruments were identified that included at least one item measuring a current spiritual state, but only three of those appeared suitable to address the need for spiritual intervention.
CONCLUSIONS
Instruments identified in this systematic review assess multiple dimensions of spirituality, and the proposed classifications should help clinical researchers interested in investigating the complex relationship between spirituality and health. Findings underscore the scarcity of instruments specifically designed to measure a patient’s current spiritual state. Moreover, the relatively limited data available on psychometric properties of these instruments highlight the need for additional research to determine whether they are suitable in identifying the need for spiritual interventions.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1769-7) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1769-7
PMCID: PMC3208480  PMID: 21725695
spirituality; spiritual assessment; spiritual intervention; spiritual well-being; spiritual needs
3.  Validation of the spiritual distress assessment tool in older hospitalized patients 
BMC Geriatrics  2012;12:13.
Background
The Spiritual Distress Assessment Tool (SDAT) is a 5-item instrument developed to assess unmet spiritual needs in hospitalized elderly patients and to determine the presence of spiritual distress. The objective of this study was to investigate the SDAT psychometric properties.
Methods
This cross-sectional study was performed in a Geriatric Rehabilitation Unit. Patients (N = 203), aged 65 years and over with Mini Mental State Exam score ≥ 20, were consecutively enrolled over a 6-month period. Data on health, functional, cognitive, affective and spiritual status were collected upon admission. Interviews using the SDAT (score from 0 to 15, higher scores indicating higher distress) were conducted by a trained chaplain. Factor analysis, measures of internal consistency (inter-item and item-to-total correlations, Cronbach α), and reliability (intra-rater and inter-rater) were performed. Criterion-related validity was assessed using the Functional Assessment of Chronic Illness Therapy-Spiritual well-being (FACIT-Sp) and the question "Are you at peace?" as criterion-standard. Concurrent and predictive validity were assessed using the Geriatric Depression Scale (GDS), occurrence of a family meeting, hospital length of stay (LOS) and destination at discharge.
Results
SDAT scores ranged from 1 to 11 (mean 5.6 ± 2.4). Overall, 65.0% (132/203) of the patients reported some spiritual distress on SDAT total score and 22.2% (45/203) reported at least one severe unmet spiritual need. A two-factor solution explained 60% of the variance. Inter-item correlations ranged from 0.11 to 0.41 (eight out of ten with P < 0.05). Item-to-total correlations ranged from 0.57 to 0.66 (all P < 0.001). Cronbach α was acceptable (0.60). Intra-rater and inter-rater reliabilities were high (Intraclass Correlation Coefficients ranging from 0.87 to 0.96). SDAT correlated significantly with the FACIT-Sp, "Are you at peace?", GDS (Rho -0.45, -0.33, and 0.43, respectively, all P < .001), and LOS (Rho 0.15, P = .03). Compared with patients showing no severely unmet spiritual need, patients with at least one severe unmet spiritual need had higher odds of occurrence of a family meeting (adjOR 4.7, 95%CI 1.4-16.3, P = .02) and were more often discharged to a nursing home (13.3% vs 3.8%; P = .027).
Conclusions
SDAT has acceptable psychometrics properties and appears to be a valid and reliable instrument to assess spiritual distress in elderly hospitalized patients.
doi:10.1186/1471-2318-12-13
PMCID: PMC3368768  PMID: 22455520
5.  The spiritual distress assessment tool: an instrument to assess spiritual distress in hospitalised elderly persons 
BMC Geriatrics  2010;10:88.
Background
Although spirituality is usually considered a positive resource for coping with illness, spiritual distress may have a negative influence on health outcomes. Tools are needed to identify spiritual distress in clinical practice and subsequently address identified needs. This study describes the first steps in the development of a clinically acceptable instrument to assess spiritual distress in hospitalized elderly patients.
Methods
A three-step process was used to develop the Spiritual Distress Assessment Tool (SDAT): 1) Conceptualisation by a multidisciplinary group of a model (Spiritual Needs Model) to define the different dimensions characterizing a patient's spirituality and their corresponding needs; 2) Operationalisation of the Spiritual Needs Model within geriatric hospital care leading to a set of questions (SDAT) investigating needs related to each of the defined dimensions; 3) Qualitative assessment of the instrument's acceptability and face validity in hospital chaplains.
Results
Four dimensions of spirituality (Meaning, Transcendence, Values, and Psychosocial Identity) and their corresponding needs were defined. A formalised assessment procedure to both identify and subsequently score unmet spiritual needs and spiritual distress was developed. Face validity and acceptability in clinical practice were confirmed by chaplains involved in the focus groups.
Conclusions
The SDAT appears to be a clinically acceptable instrument to assess spiritual distress in elderly hospitalised persons. Studies are ongoing to investigate the psychometric properties of the instrument and to assess its potential to serve as a basis for integrating the spiritual dimension in the patient's plan of care.
doi:10.1186/1471-2318-10-88
PMCID: PMC3017043  PMID: 21144024
6.  Orally Co-Infected Aedes albopictus from La Reunion Island, Indian Ocean, Can Deliver Both Dengue and Chikungunya Infectious Viral Particles in Their Saliva 
Background
First described in humans in 1964, reports of co-infections with dengue (DENV) and chikungunya (CHIKV) viruses are increasing, particularly after the emergence of chikungunya (CHIK) in the Indian Ocean in 2005–2006 due to a new variant highly transmitted by Aedes albopictus. In this geographic area, a dengue (DEN) outbreak transmitted by Ae. albopictus took place shortly before the emergence of CHIK and co-infections were reported in patients. A co-infection in humans can occur following the bite of two mosquitoes infected with one virus or to the bite of a mosquito infected with two viruses. Co-infections in mosquitoes have never been demonstrated in the field or in the laboratory. Thus, we question about the ability of a mosquito to deliver infectious particles of two different viruses through the female saliva.
Methodology/Principal Findings
We orally exposed Ae. albopictus from La Reunion Island with DENV-1 and CHIKV isolated respectively during the 2004–2005 and the 2005–2006 outbreaks on this same island. We were able to show that Ae. albopictus could disseminate both viruses and deliver both infectious viral particles concomitantly in its saliva. We also succeeded in inducing a secondary infection with CHIKV in mosquitoes previously inoculated with DENV-1.
Conclusions/Significance
In this study, we underline the ability of Ae. albopictus to be orally co-infected with two different arboviruses and furthermore, its capacity to deliver concomitantly infectious particles of CHIKV and DENV in saliva. This finding is of particular concern as Ae. albopictus is still expanding its geographical range in the tropical as well as in the temperate regions. Further studies are needed to try to elucidate the molecular/cellular basis of this phenomenon.
Author Summary
Dengue (DEN) and chikungunya (CHIK) are two mosquito borne infections transmitted by Aedes mosquitoes in the tropical world. Ae. albopictus has been shown to efficiently transmit the new variant of CHIK virus (CHIKV) that emerged in the Indian Ocean region in 2005. At the same time, this vector is able to sustain outbreaks due to DEN virus (DENV). Since this CHIK emergence, co-infections DENV-CHIKV in humans have been regularly reported. This phenomenon, known for a long time, may be due to two consecutive bites from two mosquitoes infected by one virus or by the bite of a mosquito infected by both viruses. We used two viral strains isolated in La Reunion Island, DENV-1 in 2004 and CHIKV in 2005, and co-infected an autochthonous strain of Ae. albopictus, testing experimentally one of the possible ways to get co-infections in humans. We were able to show the ability of Ae. albopictus to replicate simultaneously both arboviruses and, furthermore, to deliver both infectious viral particles concomitantly in their saliva. This finding is of particular interest since Ae. albopictus is now widely distributed all around the world and still expanding its geographical range.
doi:10.1371/journal.pntd.0000706
PMCID: PMC2882319  PMID: 20544013
7.  Differential responses of the mosquito Aedes albopictus from the Indian Ocean region to two chikungunya isolates 
BMC Ecology  2010;10:8.
Background
Aedes aegypti and Aedes albopictus are both vectors of chikungunya virus (CHIKV). The two Aedes species co-exist in the Indian Ocean region and were involved in the 2005-2006 CHIKV outbreaks. In the Reunion Island, a single mutation in the viral envelope has been selected that leads to high levels of replication in Ae. albopictus, and a short extrinsic incubation period as the virus could be found in saliva as early as two days after infection. An important question is whether this variant is associated with adverse effects impacting some mosquito life-history traits such as survival and reproduction.
Results
We performed experimental infections using three mosquito strains of Ae. aegypti Mayotte and Ae. albopictus (Mayotte and Reunion), and two CHIKV strains (E1-226A and E1-226V). Ae. aegypti Mayotte were similarly susceptible to both viral strains, whereas Ae. albopictus Mayotte and Ae. albopictus Reunion were more susceptible to CHIKV E1-226V than to E1-226A. In terms of life-history traits measured by examining mosquito survival and reproduction, we found that: (1) differences were observed between responses of mosquito species to the two viruses, (2) CHIKV infection only affected significantly some life-history traits of Ae. albopictus Reunion and not of the other two mosquito strains, and (3) CHIKV reduced the lifespan of Ae. albopictus Reunion and shortened the time before egg laying.
Conclusion
We demonstrated that CHIKV only reduces the survival of Ae. albopictus from the Reunion Island. By laying eggs just before death, reproduction of Ae. albopictus from the Reunion Island is not reduced since other parameters characterizing oviposition and hatching were not affected.
doi:10.1186/1472-6785-10-8
PMCID: PMC2847964  PMID: 20226023

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