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March 2004 Articles of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Presbyterian, Philadelphia PA.


Beery, T. A., Baas, L. S., Fowler, C. and Allen, G. "Spirituality in persons with heart failure." Journal of Holistic Nursing 20, no. 1 (March 2002): 5-25 [--Quiz on pp. 26-27, and continuing education information on pp. 28-30].

Tuck, I., McCain, N. and Elswick, R. K. "Spirituality and psychosocial factors in persons living with HIV." Journal of Advanced Nursing 33, no. 6 (March 2001): 776-783.

Cooper-Effa, M., Blount, W., Kaslow, N., Rothenberg, R. and Eckman, J. "Role of spirituality in patients with Sickle Cell disease." Journal of the American Board of Family Practice 14, no. 2 (March-April 2001): 116-122.


SUMMARIES AND COMMENTS This month's article selection continues the theme of measures of spiritual well-being by looking at studies that employ Paloutzian and Ellison's Spiritual Well-Being Scale (SWBS), as promised in the February Articles-of-the-Month page. Since its introduction in 1982, the SWBS has been used in more than 300 studies [see below under Items of Related Interest, the article by Hammermeister, J., et al., p. 591], but the three here have been selected because they address differences in the measure's subscales for Existential Well-Being and for Religious Well-Being, and because they illustrate a bit of the measure's range of applicability with varied populations: those living with heart failure, HIV, and Sickle Cell disease.

Detailed information on the SWBS is provided in Paloutzian, R. F. and Ellison, C. W., Manual for the Spiritual Well-Being Scale (Nyack, NY: Life Advance, Inc., 1991) or by visiting The scale may also be found in Hill, P. C. and Hood, R. W., eds., Measures of Religiosity (Birmingham: Religious Education Press, 1999) on pp. 382-385. In brief, the measure has 20 items, consisting of two interlaced 10-item subscales: the Existential Well-Being subscale, which focuses on a general sense of direction and purpose and satisfaction, and the Religious Well-Being subscale, which is distinguished by references to "God." (Note: More recent measures of spirituality, like the FACIT-Sp, which was the subject of the February Articles-of-the-Month page, have moved away from such "God"-language.)

The article by Beery, et al. begins with an overview not only of heart disease but of possible relations of spirituality to health in general, of the use of the term spirituality (instead of religion), and of spirituality as a dimension in quality-of-life research. As the last phase of a three-year longitudinal study of persons with heart failure, 58 subjects competed the Spiritual Well Being Scale as part of a battery that also included the Index of Well Being, the Medical Outcome Study Short Form 36, the Living with Heart Failure Questionnaire, and the Relative Importance Scale. Analysis was structured according to five research questions:

Question 1: Is there a difference in religious or existential well-being between those with heart failure who are treated medically and those who have undergone heart transplant? The data showed that persons who had undergone transplant had slightly higher scores of religious well-being and existential well-being than did persons who were treated medically, but the difference was not statistically significant. Question 2: Is there a gender difference in religious well-being or existential well-being? Women had slightly higher scores of religious well-being and existential well-being than did men, but the difference was not statistically significant. Question 3: What is the relative importance of spirituality in these patients' lives? Respondents indicated that participating in religious activities was "moderately important" to the overall quality of their lives, but that fulfilling spiritual needs was slightly more important, "nearer the 'quite important' rating" [p. 16]. Question 4: Is the relative importance of spirituality related to religious or existential well-being? The importance of fulfilling spiritual needs was significantly correlated with both the Religious Well-Being and the Existential Well-Being subscales of the SWBS, but the need to participate in religious activities was not significantly correlated with the Existential Well-Being subscale. Question 5: What are the relationships between religious well-being and existential well-being and global, heath-related, and disease-specific measures of quality of life in persons with heart failure treated medically or with transplant? "Existential well-being had a slightly stronger relationship with global quality of life than did religious well-being The combined spirituality score predicted 24% of the variance in quality of life" [p. 17].

The authors note that there do seem to be differences between what is measured by the two subscales of the SWBS, and that this suggests that existential well-being and religious well-being are distinct constructs. On this point, they make reference to the findings of our second article, by Tuck, McCain, and Elswick.

In their study of 52 men with HIV, Tuck, et al. found that "spirituality as measured by the Existential Well-Being (EWB) subscale of the Spiritual Well-Being Scale [SWBS] was positively related to quality of life, social support, effective coping strategies and negatively related to perceived stress, uncertainty, psychological distress and emotional-focused coping" [p. 776, abstract]. The battery of measures used, in addition to the SWBS, were the Spiritual Perspective Scale and the Spiritual Health Inventory. Significantly, the Existential Well-Being subscale of the SWBS was found to be the scale that best captured the relationships between spirituality and health. Thus, the authors especially recommend the use of the Existential Well-Being subscale for future research into spirituality and health.

This study sought to connect findings from three spirituality scales to five psychosocial scales (i.e., the Mishel Uncertainty in Illness Scale, the Dealing with Illness Scale, the Social Provisions Scale, the Impact of Events Scale, and the Function Assessment of HIV Infection Scale), and so the analysis is statistically complex. The authors offer two very informative tables concerning descriptions of the instruments themselves [p. 779] and the correlation of spirituality measures to psychosocial variables in the study [p. 781], but their elaborate figure of relationships between psychosocial and spiritual variables [p. 781] is rather bewildering even if it is rich in information. For this reason, the article may be interest to experienced researchers but not very attractive to many students. Its principal importance may be that it highlights the research value of the SWBS's Existential Well-Being subscale--the particular subscale that approaches spirituality in terms of one's sense of meaning and purpose, emphasizing spiritual qualities that have increasingly become the focus of measures of spirituality developed after the SWBS (like that FACIT-Sp that was the topic of the last Articles-of-the-Month page).

Cooper-Effa, et al. also found in their study of 71 adult (mean age 35.9 years) patients with Sickle Cell disease that, while these subjects seemed to have a high degree of both religious well-being and existential well-being, "the existential component appeared to play a greater role than did the religious component" [p. 119]. The study indicated that spiritual well-being can be quite important for patients coping with the pain of Sickle Cell disease. Interestingly, however, while spiritual well-being was correlated with perceived life control, it was not correlated with perceived pain severity or life interference, as measured by the West Haven-Yale Multidimensional Pain Inventory. Patients with strong SWBS scores--and especially Existential Well-Being subscale scores--appeared to show enhanced capacity to cope with Sickle Cell pain, but they indicated that these patients continued to experience fully the pain itself.

What this reader found intriguing was that, if patients' experience of pain was not lessened by strong spiritual well-being, there was not a greater divergence in the scores between the Religious Well-Being subscale (that uses "God"-language) and the Existential Well-Being subscale (that focuses broadly on meaning and purpose), since the "God" items of the Religious Well-Being subscale would seem to be essentially more vulnerable to religious struggle, such as disappointment that pain was unrelieved or perplexity over how and why God continued to cause or allow such suffering. Though the article by Cooper-Effa, et al. provides several very good tables summarizing the statistical relationships of the variables measured, this reader was left curious to know about the responses to several specific items on the Religious Well-Being subscale: e.g., "I believe that God loves me and cares about me," "I believe that God is concerned about my problems," and "I believe that God is impersonal and not interested in my daily situations."

All three of the articles featured here suggest that the SWBS could be useful in research on religious coping and quality of life, and that the Existential Well-Being subscale could have special utility. The one proviso may be that the language of the items in the Religious Well-Being subscale should be assessed as appropriate for any proposed study population, since it seems to be most in tune with the theological perspective of Christianity.

Suggestions for the Use of the Articles for Discussion in CPE: 

The article by Beery, et al. is a good choice for students, briefly covering basic concepts in the field of spirituality and health and presenting its findings clearly according to specific research questions. Students should be encouraged to think in terms of precise research questions, and this article is more articulate than most in addressing its organizing questions. The interplay between the results of the various measures may be challenging for students new to research, but the relationships of scores are explained well for the careful reader. The inclusion of a 10-item quiz on pp. 26-27 may also be handy for supervisors. The study by Tuck, et al. is, as already noted, geared more for experienced researchers than students, but the study by Cooper-Effa, et al., is quite readable and may provide a number of "jumping off points" for discussion not only about research but about how patients experience and cope with pain in ways that are related to religion/spirituality. [On this latter point, see also the last citation in the Items of Related Interest section below: the article by McNeill, J. A., et al. It is not a study of spiritual well-being, but it produced a fascinating finding on pain management and religion/spirituality.]


Other Items of Interest: 

I. A few other recent studies incorporating the SWBS:

[Added 11/6/05:] Bormann, J. E., Smith, T. L., Becker, S., Gershwin, M., Pada, L., Grudzinski, A. H. and Nurmi, E. A. "Efficacy of frequent mantram repetition on stress, quality of life, and spiritual well-being in veterans: a pilot study." Journal of Holistic Nursing 23, no. 4 (December 2005): 395-414. [This is featured as the November 2005 Article-of-the-Month.]

Hammermeister, J., Flint, M., Havens, J, and Peterson, M. "Psychosocial and health-related characteristics of religious well-being." Psychological Reports 89, no. 3 (December 2001): 589-594. [Among the findings of this study of 462 college students, persons with higher spiritual well-being scores scored lower in measures of loneliness and hopelessness and higher on self-esteem.]

[Added 9/5/05:] Popkess-Vawter, S., Yoder, E. and Gajewski, B. "The role of spirituality in holistic weight management." Clinical Nursing Research 14, no. 2 (May 2005): 158-174. [This is featured as the September 2005 Article-of-the-Month.]

Ramaniaih, N. V., Rielage, J. K. and Sharpe, J. P. "Spiritual well-being and personality." Psychological Reports 89, no. 3 (December 2001): 659-662. [This study of 319 psychology undergraduates found that persons with high and low SWBS scores had significantly different personality profiles. Also, persons with high SWBS scores scored lower in a measure of neuroticism and higher in measures of extraversion, agreeableness and conscientiousness than did persons with low SWBS scores.]

[ADDED 9/13/07]: Tsuang, M. T., Simpson, J. C., Koenen, K. C., Kremen, W. S. and Lyons, M. J. [Department of Psychiatry, University of California, San Diego CA, and Massachusetts General Hospital, Boston, MA]. "Spiritual well-being and health." Journal of Nervous and Mental Disease. 195, no. 8 (August 2007): 673-680. [(Abstract:) Data on empirical associations between religious variables and health outcomes are needed to clarify the complex interplay between religion and mental health. The aim of this study was to determine whether associations with health variables are primarily attributable to explicitly religious aspects of spiritual well-being (SWB) or to "existential" aspects that primarily reflect a sense of satisfaction or purpose in life. Three hundred forty-five pairs of twins from the Vietnam Era Twin Registry completed a diagnostic interview and questionnaires containing the 2-factor SWB Scale and general health items. Observed associations between SWB and health outcomes were uniquely explained by the SWB subscale of existential well-being, with much less of a unique explanatory contribution from religious well-being or "spiritual involvement." We concluded that studies of SWB and health should continue to distinguish between explicitly religious variables and others that more closely approximate the psychological construct of personal well-being. ]

Tsuang, M. T., Williams, W. M., Simpson, J. C. and Lyons, M. J. "Pilot study of spirituality and mental health in twins." American Journal of Psychiatry 159, no. 3 (March 2002): 486-488. [The study of 100 pairs of male twins looks at spiritual well-being in relation to dimensions of personality, with clusters of personality disorder symptoms, and with alcohol abuse and dependence.]

II. For a literature review that illustrates how the SWBS may figure into an array of measures pertinent to health-related quality-of-life research, see:

Mytko, J. J. and Knight, S. J. "Body, mind, and spirit: towards the integration of religiosity and spirituality in cancer quality of life research." Psycho-Oncology 8 (1999): 439-450.

III. As an aside, on the subject of the use of religion/spirituality and pain management (though not part of research into spiritual well-being), the following study included an interesting finding:

McNeill, J. A., Sherwood, G. D., Starck, P. L. and Thompson, C. J. "Assessing clinical outcomes: satisfaction with pain management." Journal of Pain and Symptom Management 16, no. 1 (1998): 29-40. [One-hundred-fifty-seven inpatients were asked about "pain control methods" that they had used during their hospitalization, and 62% stated that they had used "prayer." Only "pain pills" ranked higher at 67%. "Prayer" had a higher ranking than "pain medication in IV" (54%), "pain injections" (51%), "relaxation" (27%), "distraction" (24%) or eleven other methods. The article, however, does not focus on the use or prayer and only mentions it briefly in its discussion section.]


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