Articles & Thesis

RETAINING THE MEANING OF THE WORDS RELIGIOUNESS AND SPIRITUALITY:

A commentary on the WHOQOL SRPB group’s "A cross-cultural study of spirituality,

religion and personal beliefs as components of quality of life" (62: 6, 2005, 1486-1497)

Alexander Moreira de Almeida MD, PhD  a), b) *

Harold G. Koenig MD,  MHSc a)

a) Duke University Medical Center, Durham, NC, USA
b) University of Sao Paulo, Hospital Joao Evangelista, Sao Paulo, SP, Brazil

Abstract
Recent years have seen increasing recognition paid to the relation of religiousness/spirituality (R/S) to health care andresearch. This has led to the development of more inclusive and trans-culturally validated measurements of R/S. This papercomments on the WHOQOL SRPB Group’s ‘‘A cross-cultural study of spirituality, religion, and personal beliefs ascomponents of quality of life’’ (62: 6, 2005, 1486–1497), a recently published paper in Social Science & Medicine, and illustrates a possible problem in the measurement of R/S, especially as related to the study of mental health outcomes.
Some scales have included questions about psychological well-being, satisfaction, connectedness with others, hopefulness, meaning and purpose in life, or altruistic values as part of their measure of R/S. These questions are really tapping indicators of mental health, and should not be included in the definition of R/S itself. Otherwise, tautology is the result, and it should not be surprising that such measures of R/S (defined by questions tapping mental health) are related to mental health outcomes.

2006 Published by Elsevier Ltd.

Keywords

Definition; Well-being; Quality of life; Health

Publisher in Social Science & Medicine 63 (2006) 843–845

* Corresponding author. Tel.: 1 919 309 1405.
E-mail addresses: alexma@usp.br (A. Moreira-Almeida),
koenig@geri.duke.edu (H.G. Koenig).
 

The importance of people’s religiousness and spirituality for their well-being and health status has been widely acclaimed and is based on hundreds of published studies (Koenig, McCullough, & Larson, 2001). Recently, this journal published a crosscultural
study involving 18 countries (n ¼ 5087) that used the World Health Organization’s Quality of Life Measure (WHOQOL) for assessment of spirituality, religion and personal beliefs (SRPB) (WHOQOL SRPB Group, in press). We think it is a very welcome advance, since it highlights the importance of religiousness and spirituality to quality of life in many different cultures. Because almost all studies and scales in this field were developed in the United States, there is an urgent need for more transculturally validated scales and replication of studies in different countries.
We would like to utilize this study to discuss the pitfall that exists when one tries to create an inclusive and worldwide-acceptable measure of spirituality and religiousness: the risk of being too broad and losing the core meaning of these words.
We think this is the case with a number of scales in common use today, such as the Spiritual Well-Being Scale (SWBS) (Paloutzian & Ellison, 1982), Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) (Brady, Peterman, Fitchett, Mo, & Cella, 1999) and the WHOQOL SRPB. These instruments include questions that tap psychological well-being, mental health, meaning and purpose in life and altruistic values that confound any findings where mental health is the outcome. Is it not surprising that psychological health is correlated with psychological health? Constructs such as well-being, meaning in life, and altruistic activities are usually, but not necessarily, related to spirituality—but should they be included in the definition itself?
Undoubtedly, the definitions of religiousness and spirituality have a long history of controversy.
However, there is general agreement that these constructs are related to the search for the sacred or transcendent, which includes concepts of God, a higher power, the divine, and/or ultimate reality.
The sacred represents the most vital destination sought by the religious/spiritual person (Hill & Pargament, 2003). In the Merriam-Webster’s Dictionary spirituality is defined as ‘‘sensitivity or attachment to religious values’’ or ‘‘the quality or state of being spiritual’’ (spiritual is defined as ‘‘of or relating to sacred matters’’ or ‘‘of, relating to, consisting of, or affecting the spirit : incorporeal’’).
In our work, we have used the following definitions (Koenig et al., 2001):

Religion: is an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality).

Spirituality: is the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship with the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community.

Among the eight facets of the WHOQOL SRPB scale, five are not measuring religion or spirituality (Meaning of life, Awe, Wholeness & integration, Inner peace/ serenity/harmony, Hope & optimism).
These constructs have been associated with religious involvement and can be a consequence of a religious/spiritual life (Moreira-Almeida, Lotufo Neto, & Koenig, 2006). So, they can be outcomes of religiousness, but we argue that they are not, themselves, religiousness or spirituality. For example, the acceptance of the Marxist historical materialism can give someone a strong sense of meaning in life and optimism (believing in the future development of society towards a communist society) so much so that many people have given their lives voluntarily to this ideology. However, they would probably take offense at being called spiritual or religious.
Even the three facets that have some more direct connection with spirituality (connectedness to a spiritual being or force, spiritual strength, and faith) may not actually reflect any sort of spirituality, as stated in the preamble of the SRPB questionnaire:
‘‘While some of these questions will use words such as spirituality, please answer them in terms of your own personal belief system, whether it be religious, spiritual or personal.’’ (WHOQOL, p. 3)
One piece of evidence that these three facets are tapping something different from the other facets is given by the results comparing the scores of people with different health status. From all the eight facets, the only three facets that scored higher among currently ill comparing to currently well people were exactly connectedness to a spiritual being or force, spiritual strength, and faith (only faith was statistically significant). This usually reflects the turning to religion by sick people to cope with the illness.
Some of the problems we address here were raised in the Brazilian focus groups during the development process of the WHOQOL SRPB. Groups of patients suggested that questions without a clear relation to religiousness should be eliminated exactly because they were not related to religiousness.
In contrast, health professionals and atheists criticized the questions that carried a religious connotation (Fleck, Chachamovich, & Trentini, 2003).
We strongly agree with the importance of including hope, meaning of life, optimism, forgiveness and sense of awe and wonder in a well-being or quality of life instrument. However, we think that calling these constructs ‘‘spirituality’’ only adds confusion. Qualities such as meaning of life, hope, optimism, wholeness, serenity, and awe already
have names that describe these constructs; there is little reason to include them under a new category, spirituality (a term that involves relationship to the sacred or the transcendent). The major reason for concern with these scales is that in using them, spirituality will always be related to mental health, because they, tautologically, define spirituality by positive human traits (Koenig et al., 2001). Despite these concerns, we would like to emphasize that the WHOQOL SRPB module is a pioneering initiative in the trans-cultural and global assessment of a dimension of human life that has heretofore been excluded. The module provides an important template for future cross-cultural and cross-national research in the field of the epidemiology of religion and quality of life measurements.
Discussion of results from studies that use this scale, however, should not fail to address the concerns mentioned above.

Acknowledgment
Alexander Moreira-Almeida was supported by grant from the Hospital Joao Evangelista, Brazil.
 

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REFERENCES
Brady, M. J., Peterman, A. H., Fitchett, G., Mo, M., & Cella, D. (1999). A case for including spirituality in quality of life measurement in oncology. Psychooncology, 8(5), 417–428.
Fleck, M. P., Chachamovich, E., & Trentini, C. M. (2003). WHOQOL-OLD Project: Method and focus group results in Brazil. Rev Saude Publica, 37(6), 793–799.
Hill, P. C., & Pargament, K. I. (2003). Advances in the conceptualization and measurement of religion and spirituality. Implications for physical and mental health research. American Psychologist, 58(1), 64–74.
Koenig, H. G., McCullough, M., & Larson, D. B. (2001). Handbook of religion and health: A century of research reviewed. New York: Oxford University Press.
Moreira-Almeida, A., Lotufo Neto, F., & Koenig, H. G. (2006). Religiousness and Mental Health: A review. Revista Brasileira de Psiquiatria, 28, in press.
Paloutzian, R. F., & Ellison, C. W. (1982). Loneliness, spiritual well-being and quality of life. In L. A. Peplau, & D. Perlman (Eds.), Loneliess: A sourcebook of current theory, research and therapy (pp. 224–237). New York: Wiley.

Retaining the meaning of the words religiousness and spirituality: A commentary on the WHOQOL SRPB group’s "A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life." Social Science & Medicine, 62(6), 1486–1497, in press.