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


Idler, E. L., Musick, M. A., Ellison, C. G., George, L. K., Krause, N., Ory, M. G., Pargament, K. I., Powell, L. H., Underwood, L. G. and Williams, D. R. "Measuring multiple dimensions of religion and spirituality for health research." Research on Aging 25, no. 4 (July 2003): 327-365.


COMMENT AND SUMMARY: In 1999 the Fetzer Institute published A Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research. This report--and the instrument it set forth--was the result of a two-year formal collaboration between the Fetzer Institute and the National Institute on Aging Working Group (part of the National Institutes of Health)--the idea having been generated from a March 1995 conference at the NIH--as a response to both growing interest in research into connections between religiousness/spirituality and health and growing recognition that religious/spiritual variables seemed to call for a multidimensional measure. According to the Fetzer Institute, as of November 2003 there have been 1,800 requests for the instrument, and it has been cited in over 40 articles, with the incidence of its citation presently increasing. The current article by Idler, et al. describes much of the conceptual and methodological background to this instrument as well as the validity and reliability testing of most of its items. [For more on Fetzer's 1999 instrument itself, see Related Items of Interest, below.]

The article begins with a brief overview of the growth of interest in research into spirituality and health [pp. 328-330] and notes the need for a multidimensional measure: "The view of the working group was that religious or spiritual variables could not be simply combined into a single scale and the effects of religiosity examined; rather, the various dimensions of religiousness and spirituality had to be examined separately for their potential effects on health" [p. 331]. Moreover, in order to be practical, an instrument would need to be both brief and incorporate inclusive language [see pp. 330-331]. Ultimately, 33 items--representing 10 principal domains plus a domain of Overall Self-Ranking--were tested through the 1998 General Social Survey (a nationally representative household survey, N=1,445) of the University of Chicago National Opinion Research Center. The method of testing and the results form the core of the article [pp. 347-356] with statistically detailed tables. The authors conclude:

Findings from the 1998 GSS showed that all of the indicators of religious and/or spiritual experience were endorsed by substantial numbers of respondents, that the items formed reliable indices within domains, that the indices were moderately but most not highly correlated with each other, and that they had the expected relationships with other measures of the concepts. Overall, the instrument has the appropriate characteristics of reliability and validity to be used in further research. [p. 356]

The authors enumerate four pathways by which religiousness/spirituality may be connected to health outcomes: reduction of behavioral risks, expansion of social support, enhancement of coping skills, and psychological mechanisms [see pp. 331-334], before discussing the various domains individually (1-3 paragraphs each). The 10 domains initially identified are (according to the narrative headings on pp. 335, 340-347): Religious Affiliation, Public Religious Practices, Private Religious Practices, Social Support, Religious Coping, Beliefs and Values, Commitment, Forgiveness, and Daily Spiritual Experience. However, to these is added an eleventh area of measurement: Overall Self-Ranking, which at other points the authors call Religious Intensity. Herein lies an example of a significant problem in the presentation of the article: there is inconsistency in references to the domain names, between the narrative sections and the tables and between the several tables. This may cause confusion in reading. And what is more, the domain names, as well as their constituent questionnaire items, do not exactly match the final instrument published by Fetzer, though this fact is not explicated (--for more on this, see below, under Related Items of Interest).

The authors comment that the instrument may be especially applicable in gerontological research [see p. 359], though more because of the characteristics of that field and its population than because of the qualities of the instrument. They also appropriately address potential limitations of the instrument and their analysis, including "the relatively small number of items for each domain" [p. 356] and the fact that in the GSS there are "insufficient numbers of the small but important groups of non-Judeo-Christians in the United States for whom the instrument may be less relevant" [p. 358]. They further comment on the instrument that "some of the scales overlap more than some investigators would like," but in at least one case this could "offer investigators the opportunity to select among those measures that are most appropriate for the population under study" [pp. 356 and 358]. The illustration given is that the Daily Spiritual Experience scale shows high pairwise correlations to the scales for Positive Religious Coping, Private Religious Practices, and Religious Intensity; but whereas the Daily Spiritual Experience scale focuses on "nontraditional, noninstitutionalized spiritual feelings," the other three use "more traditional religious language" [p. 358].

This reader found the article to be, frankly, a bit hard to follow at points, especially with regard to its relation to the actual instrument published by Fetzer in 1999, but it is nevertheless a valuable contribution to the literature. The working group collaborating on this instrument has indeed furthered research by the careful proposition of domains, if not also by the particular formulation of questionnaire items indicative of those domains. There seems to be a perennial struggle in this field of research between a desire to capture the multidimensional richness of the religious/spiritual experience that may be pertinent to health and a desire for a brief and handy instrument. This article gives some glimpse of a learned working group's attempt at a practical compromise and their success, at least to a degree. In their conclusion, the authors write: "This presentation of the conceptual basis and descriptive characteristics of the instrument is only a small, early step toward understanding the complex religion-health relationship, with its probable multiple pathways and differences by population subgroup" [p. 358]. This is a grand project undertaken with admirable care. The Fetzer instrument shows good promise as it is increasingly employed in research, and any researcher interested in using it should be familiar with this background article.


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

This is obviously an article written for dedicated researchers interested in instrument development and familiar with strategies of statistical analysis to that end. However, it is not without potential for application to general discussion in CPE. The section on pathways [pp. 331-335] is a good, brief treatment of the idea of pathways per se, with four prominent illustrations. Students could discuss pathways as a research concept and offer their own thoughts on how they might "connect the dots" between religion/spirituality and health. [More resources about pathways may be found on the May 2003 Articles-of-the-Month page of this web site.] Also quite readable--for students who are relatively new to the research--are the narrative descriptions of the 10 (or 11) domains of religiousness/spirituality [pp. 335, 340-347]. Again, students could be asked to muse about how it may be possible to "break down" such a complex concept as religiousness/spirituality: What might be the constituent elements? Students could be asked to write down their ideas prior to reading this section of the article, and then compare and contrast their list with that of the Working Group. Students could even attempt to construct questions for one or more domains, as an exercise introducing them to the difficulties of instrument development, and discuss the questionnaire items proposed in the article in Table 1 on pp. 336-338. If the article's 39 pages seem daunting to students, such an extensive presentation should drive home the point that instrument development in this field is a very serious and complicated enterprise. Finally--and by the way--students may be intrigued by the brief summary of studies on the importance of religion/spirituality for Americans in general [p. 330].


Other Items of Interest: 

For the Fetzer instrument itself, see A Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research: A Report of the Fetzer Institute/National Institute on Aging Working Group (1999). [Note that this document includes in the front matter the blanket permission (in bold type) that the document "may be used and reprinted without special permission."] The instrument is formally titled the "Brief Multidimensional Measurement of Religiousness/Spirituality: 1999" and is found on pp. 85-88 of the report. The web site also offers a list of articles that cite the report and a new Preface added in October 2003.

As noted above, the domain names and specific questionnaire items in the article by Idler, et al. do not match exactly the final published form of the measure. Note the differences in domain names:

Domains in the Idler, et al. Article:Domains in the Fetzer Instrument:
- Religious Affiliation- Religious Preference (item 36)
- Personal Religious/Spiritual History- Religious/Spiritual History (items 28-30)
- Public Religious Practices/Activity- Organizational Religiousness (items 34-35)
- Private Religious Practices/Activity- Private Religious Practices (items 12-16)
- Social/Congregation Support- Religious Support (items 24-27)
- Religious Coping- Religious and Spiritual Coping (items 17-23)
- Beliefs and Values- Values/Beliefs (items 7-8)
- Commitment- Commitment (items 31-33)
- Forgiveness- Forgiveness (items 9-11)
- Daily Spiritual Experience- Daily Spiritual Experiences (items 1-6)
- Overall Self-Ranking/Religious Intensity- Overall Self-Ranking (items 37-38)

Six items in the Fetzer instrument were apparently not tested in the study by Idler, et al.: two items in the Private Religious Practices domain (i.e., "How often do you watch or listen to religious programs on TV or Radio?" and "How often are prayers or grace said before or after meals in your home?"--items 14 and 16, respectively), one item in the Religious and Spiritual Coping domain (i.e., "To what extent is your religion involved in understanding or dealing with stressful situations in any way?"--item 23), two items in the Religious/Spiritual History domain (i.e., "Have you ever had a significant gain in your faith?" and "Have you ever had a significant loss in your faith?"--items 29 and 30, respectively), and one item in the Commitment domain (i.e., "In an average week, how many hours do you spend in activities on behalf of your church or activities that you do for religious or spiritual reasons?"--item 33). Also, an additional domain of Meaning is noted in an appendix to the Fetzer instrument but is not formally included in the measure "at this time."

[In Fetzer's 1999 published report, their instrument is preceded by very informative chapters that address various potential domains and include a variety of measures, but these chapters do not match exactly the domains of the final instrument, and neither do their included measures translate directly into items for the final instrument.]

The item in the Fetzer instrument on "carry[ing]...religious beliefs into all...other dealings in life" is listed as part of the Commitment domain (as item 31), but in the Idler, et al. article it is part of the Beliefs and Values domain.

Two items apparently tested in the Idler, et al. article do not appear in the Fetzer instrument: a Values and Beliefs domain item about belief in an afterlife and a Commitment domain item about one's "giving ratio" [though this latter item is listed in the article in Table 2 but not in Table 1].

Finally, note that the domain of Religious Preference in the Fetzer instrument, is included in the article by Idler, et al. (as Religious Affiliation), but it is listed only in the article's Table 1, not in Table 2.


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