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


Daaleman, T. P., Perera, S. and Studenski, S. A. "Religion, spirituality, and health status in geriatric outpatients." Annals of Family Medicine 2, no. 1 (January-February 2004): 49-53.


NOTICE OF ON-LINE AVAILABILITY OF THE ARTICLE, WITH DISCUSSION: This month's article is available on-line through the Annals of Family Medicine web site, at (for Full Text, with a link for a PDF). The Spirituality Index of Well-Being (SIWB), used in the study, is additionally available at Comments from the journal's on-line discussion may be viewed at

COMMENT AND SUMMARY: This month's article revisits the subject of measures of spiritual well-being, previously considered in the February and March 2004 Article-of-the-Month pages, which highlighted the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) and the Spiritual Well-Being Scale (SWB), respectively. It presents a new scale--the Spirituality Index of Well-Being (SIWB)--which, in addition to being potentially useful itself, implicitly raises some questions about measurement strategies. The study reported here also suggests that differences in measures of the concepts of spirituality and religion may be clinically significant.

One of the trends in the measurement of spiritual well-being over the past 20+ years (as can be seen by comparing the older SWB scale with the more recent FACIT-Sp), has been the move away from explicitly religious language (e.g., "prayer" and "God") that may have limited applicability in a spiritually diverse population. The FACIT-Sp emphasizes qualities like one's "sense of purpose" and "peace of mind" that may be markers of spiritual well-being but still employs the phrase, "faith or spiritual beliefs." However, the Spirituality Index of Well-Being (SIWB), used in this month's article, goes so far as to avoid religious language altogether. This twelve-item instrument uses the language of problem-solving and of purposefulness, based in themes of life scheme and of positive intentionality, without any explicit reference to spirituality apart from the use of the word in its title.

The theoretical foundation for the SIWB is said to be: "In brief, a congruent, meaningful life scheme and a high degree of positive intentionality, or self-efficacy beliefs, promote personal agency that is an intermediary between spirituality and well-being" [p. 51]. The instrument emerged out of earlier qualitative research by Daaleman, et al. [--see Daaleman, Cobb and Frey, in the "Related Items of Interest" section, below] that explored elements of patient-reported, health-related spirituality. The strategy of avoiding explicitly spiritual language in the instrument's items in favor of language that some research has associated with a type of well-being is, however, worth some scrutiny. The authors are clearly sensitive overall to the ambiguity of the concept of spirituality, but their measure here of "intermediary" concepts between spirituality and well-being appears, at least to this reader, to risk too closely associating those "intermediary" concepts with spirituality or spiritual well-being in toto. In other words--and in broad perspective--how far afield from overtly spiritual language can we presently venture in instrument items and still be confident that what we are measuring is essentially spiritual in nature? Of course, validity and reliability testing attempts to address such concerns, but the overarching issue remains how to work with the concept of spirituality, which has various popular meanings and which furthermore is employed in health research as a largely academic construct created over against the more traditional and colloquial construct of religion in order to avoid the latter's perceived limits (especially sectarian). For chaplains, in particular, the question is whether an instrument like the SIWB--so unmoored from traditional ways of speaking about spirituality or spiritual well-being--seems practical for pastoral research.

This having been said, the study of 277 geriatric outpatients in the Kansas City area found that "spirituality (P < .01), but not religiosity (P = .12), was associated with self-reported health status..." [pp. 51-52]. In their discussion of the results, the authors speculate that the association between spirituality and self-reported good health status may be found in health optimism.

Health optimism, or the reporting of good health despite objective physical evidence to the contrary, is one possible explanation for the interaction between spirituality and health appraisal. Elders with a greater degree of spirituality might share characteristics with health optimists, who tend to use a health-transcendent approach to appraise their health and attribute their symptoms, and to incorporate a broader, more inclusive view of health. [p. 52]
They go on to propose that "social comparison theory--the way people compare themselves to others to learn about themselves" [p. 52] may play into the interaction between spirituality and health status.

The authors conclude that "spirituality, as determined by the SIWB, may be best situated in studies of chronic illness, aging, and end-of-life care as an explanatory factor or predictor of subjective health status or quality of life" [p. 53]. The results are critically discussed on-line by several researchers, including David O. Moberg, who is a pioneer in studies of spiritual well-being [--for more about Moberg, see the opening paragraphs of the February 2004 Article-of-the-Month page].

One note of caution about the text: the Internet address for the SIWB printed on p. 51 is incorrect. (The link listed at the beginning of this Article-of-the-Month page shows the correct address.)


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

This study has been featured primarily for its potential interest to experienced researchers engaged in issues of current measures of spirituality, but the article has some application to discussion in CPE. First, its brevity (only four pages) makes it a good choice for newer students who may become bogged down in longer reports or who are not yet familiar with distinctions between the use of spirituality and religion in the health care literature. As such an introductory piece, it might be paired with an overview article like: George, L. K., Larson, D. B., Keonig, H. G. and McCullough, M. E., "Spirituality and health: what we know, and what we need to know," Journal of Social and Clinical Psychology 19, no. 1 (Spring 2000): 102-16. Second, it would be a good entree to the subject of spiritual assessment: namely, how do chaplains appraise a patient's spiritual well-being, and do chaplains' criteria relate to any of the items on the SIWB? Third, students could discuss the quality of health optimism and the way that they may see patients compare themselves to others. Discussion could explore how patients may say that they are aware of others who are "worse off" than they are, and how they themselves "are grateful" or "should be grateful" because of their relatively easier plight. Moreover, is this typically a matter simple social comparison, or does this take place in a religious/theological context of meaning?


Related Items of Interest: 

Daaleman, T. P., Cobb, A. K. and Frey, B. B. "Spirituality and well-being: an exploratory study of the patient perspective." Social Science and Medicine 53, no. 11 (December 2001): 1503-1511. [This study used focus groups comprised of a total of 35 women (17 with type 2 diabetes mellitus and 18 with no self-identified illness) to explore how patients describe spirituality and view its impact on their health and well-being. Transcripts were coded into the following conceptual categories: 1) change in functional status, 2) core beliefs, 3) medical/disease state information gathering and processing, 4) interpretation and understanding, 5) life scheme, 6) positive intentionality, 7) agency, and 8) subjective well-being. The authors conclude: "Patient-reported spirituality is predominantly a cognitive construct incorporating the domains of life scheme and positive intentionality" (--see p. 1503, abstract).]

Daaleman. T. P., Frey, B. B., Wallace, D. and Studenski, S. A. "Spirituality Index of Well-Being scale: development and testing of a new measure." Journal of Family Practice 51, no. 11 (November 2002): 952. [This is a brief abstract reporting validity/reliability testing of the instrument, apparently with the same population of 277 geriatric outpatients in the Kansas City area used in the study reported in this month's featured article.]

Kirby, S. E., Coleman, P. G. and Daley, D. "Spirituality and well-being in frail and nonfrail older adults." Journals of Gerontology Series B-Psychological Sciences and Social Sciences 59, no. 3 (May 2004): P123-P129. [This British study of 233 retirement housing residents found that spirituality was a predictor of psychological well-being (PWB) and that it moderated the negative effects of frailty on PWB, thus suggesting that "spirituality is a resource in maintaining PWB, and that the use of this resource is more significant for individuals with greater levels of frailty" (--see p. P123, abstract).]


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