This document discusses definitions, measurement issues, and commonly used measures related to assessing religion and spirituality in health outcomes research. It provides definitions for spirituality, religiosity, and the distinction between the two. Measurement issues discussed include the multidimensional nature of religion and spirituality as well as the lack of gold standard measures. Commonly assessed domains include religious attendance, religious coping, spirituality/meaning, and spiritual well-being. Several validated multidimensional measures are described that assess constructs such as daily spiritual experiences, meaning, and forgiveness.

1. Definitions and Measurement of
Religion/Spirituality in
Health Outcomes Research
Devon Berry, RN, PhD
Sian Cotton, PhD

2. Objectives
1. Basic Definitions and Measurement
Issues
2. Models of Religion-Health
3. Measures

3. Historical Perspectives
• Historically, opposition to relevance of patients'
spirituality or religious beliefs in clinical setting
• James, Leuba, Starbuck,….Allport (Harvard, 60’s)
• Renewed interest in faith and healing (e.g.,
academic journals, pop culture, federal funding
for faith-based programs)

4. Definitions Commonly Used
• Spirituality is rooted in an awareness which is part of the
biological make up of the human species. Spirituality is
present in all individuals and it may manifest as inner peace
and strength derived from perceived relationship with a
transcendent God or an ultimate reality or whatever an
individual values as supreme (Narayanasamy, 1999)
• Spirituality is the essence and core of our being… (McSherry
& Draper, 1998)
• Spirituality is implied as being a person’s view of the purpose
of their existence. It is also more explicitly stated that a
person’s spirituality is a function or expression of their genes
and environment (Yawar, 2001)

5. Definitions Commonly Used (cont.)
• …the defining attribute of spirituality [is] a
relationship with the transcendent, which is the
experience or disposition that conveys a sense of
belonging to something greater than oneself
(Balducci & Meyer, 2001)
• Spirituality is the personal quest for understanding
answers to ultimate questions about life, about
meaning, and about relationship to the sacred or
transcendent, which may (or may not) lead to or
arise from the development of religious rituals and
the formation of community (Koenig et al., 2001)

6. Measurement Issues: Anatomy of R/S
• The problem of presumption
• Latency
• Multidimensionality

7. Measurement Issues: Definitions
Problems & Solutions
• Substantive vs. Functional
• Universalism vs. Particularism
• Theocentric vs. Non-theocentric
Moberg, D. O. (2002). Assessing and measuring spirituality: Confronting dilemmas of
universal and particular evaluative criteria. Journal of Adult Development, 9(1), 47–60.

8. Measurement Issues: (con’t)
• Spirituality vs. Religiosity
• Global measures (denom affil, church attend) with
limited reliability
• Theoretical and Functional Linkage to Health
– Dimensions: Closeness to God, orienting motivating forces,
religious support, religious and spiritual struggle
• Contextually-sensitive measures, alternatives to self-
report, measures of r/s outcomes, measures of r/s
change and transformation
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.

9. Proposed Mechanisms of Action
1. Health Behaviors
2. Social Support
3. Meaning/Purpose
4. Psychosocial Resources (e.g.,
optimism, self-esteem)
5. Physiological

10. Koenig’s Religion-Health Model
Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. Oxford;
New York: Oxford University Press.

11. Pargament’s Distal-Proximal Model
Health Status
• HRQOL
• Depressive symptoms
• HIV/AIDS symptoms
• etc.
Sense that Life Has Improved
Healthier Lifestyle
Social Support
Self-Perception
Healthy Beliefs
Spirituality/Religion
Distal Variables Proximal Variables
• Service attendance
• Frequency of prayer/
meditation
• Self-rated religiousness
• Etc.
• Meaning and peace
• Positive or negative
Religious coping
• Positive and negative
Church support
• Etc.
Adapted by Tsevat et al., 2001

12. Definitions/ Areas Most Often Assessed
1. Religious Attendance; Affiliation
2. Religious Coping
3. General Spirituality (Meaning/Purpose)
4. Spiritual “Well-Being”
5. Multiple R/S Domains
• Meaning
• Daily Spiritual Experiences
• Forgiveness

13. Brief RCOPE
 14-items
– How frequently one uses a particular way of coping with stressor
(e.g., illness)
 7 positive religious coping strategies
– Spiritual connection, seeking spiritual support, religious
forgiveness, collaborative religious coping, benevolent religious
reappraisals, religious purification, and religious focus
 7 negative religious coping strategies
– Spiritual discontent, punishing God reappraisals, interpersonal
religious discontent, demonic reappraisals, and reappraisals of
God's powers
 Internal consistencies range (0.61-0.94)
Pargament KI, Koenig HG, Perez LM. The many methods of religious coping: development and initial
validation of the RCOPE. J Clin Psychol 2000;56(4):519-43

14. FACIT-Sp
 23-and 12-item versions
– Faith and Assurance
 4 items (Cronbach's =0.88)
– Meaning and Peace
 8 items (Cronbach's =0.81)
– 11 additional items (e.g., connectedness,
appreciation, gratitude, hope, and forgiveness)
 Good psychometric properties
Peterman AH, Fitchett G, Brady MJ, Hernandez L, Cella D. Measuring spiritual well-being in people
with cancer: the functional assessment of chronic illness therapy--Spiritual Well-being Scale (FACIT-
Sp). Ann Behav Med 2002;24(1):49-58

15. SWB Scale
• Most widely used measure
• 20-item global perception of one’s spiritual well-being
• Religious well-being
– 10-items assessing how one perceives their spiritual well being in
relation to God
– “I believe that a Higher Power loves me and cares about me”
• Existential well-being
– 10-items assessing how someone relates to their community and is
satisfied with their life from a spiritual perspective
– “I believe there is some real purpose for my life”
• Cronbach’s  = 0.78 to 0.94
Ellison, CW. Spiritual well-being: Conceptualization and measurement. J Psych
Theol 1983;11:330-340

16. Multidimensional Measure (Fetzer/NIA)
• Developed by experts (NIA and Fetzer)
• Multiple Dimensions
– Meaning
– Daily Spiritual Experiences
– Commitment
– Forgiveness
• Brief form (40-items); (BMMRS; 1999)
http://www.fetzer.org/Resources/resources_multidimens.htm
Fetzer Institute. (1999, October). Multidimensional measurement of religiousness/spirituality for use in
health research: A report of the Fetzer Institute/National Institute on Aging Working Group with
additional psychometric data. Kalamazoo, MI: Author.

17. Summary Points
• On the near side of complexity is simplistic. On the
far side of complexity is simplicity.
• Absence of a gold standard…
• Multidimensional
– Meaning (Purpose in Life)
– Beliefs (measures of “orthodoxy”)
– Behaviors (non-organizational, organizational religious
activity)
– Valuing (intrinsic religiosity)
– Transcendence
• Anatomy of R/S, models explaining mechanisms of
effect on physical & mental health