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This is the reference for this article:
Johnson, E. T., Kaseroff, A., Flowers, S., Sung, C., Iwanaga,
K., Chan, F., . . . Catalano, D. (2017). Psychosocial mechanisms
explaining the association between spirituality and happiness in
individuals with spinal cord injuries. The Journal of
Rehabilitation, 83(4), 34-42.
Abstract
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The main objective of this study was to examine health status,
perceived stress, social support, self-esteem and psychological
well-being as mediator variables for the relationship between
spirituality and happiness. Quantitative descriptive research
design using multiple regression and correlation techniques was
used. Participants were 274 individuals with spinal cord injuries
(SCI) recruited from the Alberta, Manitoba, Nova Scotia,
Ontario, and Saskatchewan chapters of the Canadian Paraplegic
Association. All of the five mediators were significantly
associated with happiness. The five-mediator model accounted
for 68% of the variance in happiness. The findings confirm
spirituality is associated with happiness indirectly through its
association with perceived stress, health status, social support,
self-esteem, and psychological well-being, each of which is
uniquely associated with happiness. Rehabilitation counselors
should consider integrating spiritual interventions with health
promotion interventions in vocational rehabilitation services for
individuals with SCI to improve outcomes in life satisfaction.
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Headnote
The main objective of this study was to examine health status,
perceived stress, social support, self-esteem and psychological
well-being as mediator variables for the relationship between
spirituality and happiness. Quantitative descriptive research
design using multiple regression and correlation techniques was
used. Participants were 274 individuals with spinal cord injuries
(SCI) recruited from the Alberta, Manitoba, Nova Scotia,
Ontario, and Saskatchewan chapters of the Canadian Paraplegic
Association. All of the five mediators were significantly
associated with happiness. The five-mediator model accounted
for 68% of the variance in happiness. The findings confirm
self-esteem, and psychological well-being, each of which is
uniquely associated with happiness. Rehabilitation counselors
should consider integrating spiritual interventions with health
promotion interventions in vocational rehabilitation services for
individuals with SCI to improve outcomes in life satisfaction.
At the onset of a traumatic disability, such as a spinal cord
injury (SCI), a person's spiritual beliefs may provide a
mechanism for healing and coping with stress (Marini &
Glover-Graf, 2011). The physical and psychological effects of
sustaining a SCI may require individuals to reevaluate their
worldview in order to successfully adjust to a newly acquired
disability identity. A person's worldview is molded by spiritual
influences including his or her thoughts and beliefs concerning
life, death, and suffering (Littooij et al., 2016). As such,
spirituality impacts how a person adapts to an acquired
disability.
In the fields of health and rehabilitation, an extensive body of
literature addresses the relationship between spirituality and
health outcomes. However, the majority of research has focused

on individuals with terminal health conditions (e.g., end stage
cancer), who may use spiritual and religious coping as a way to
make peace with their illness, resolve lingering issues, and
prepare for death. As medical and technological advances
extend longevity, improve health and function, and facilitate
independent living, the influence of spirituality for a person
living with a disability, such as SCI may be different. Spiritual
and religious beliefs may facilitate positive adjustment by
helping individuals with disabilities maintain health status,
manage the daily stress of coping with a disability, find new
meaning and purpose, and establish new life goals (Johnstone et
al., 2007; Johnstone, Franklin, Yoon, Burris & Shigaki, 2008).
Despite empirical evidence linking spirituality and health
outcomes, the relationship between spirituality and positive
psychosocial adjustment to disability has not been adequately
investigated. A recent scoping review of 26 studies addressing
spirituality and psychosocial adjustment for persons with SCI
does provide some evidence that spirituality plays a
contributing role in adjustment post-SCI (Jones, Simpson,
Briggs, and Dorsett, 2016). However, the mechanisms via which
spirituality influences psychosocial adjustment remains unclear,
resulting in a gap in knowledge. Considering depression and
rates of suicide for persons with SCI are higher than people
without disabilities, (Marini & Glover-Graf, 2011), it is
important to further investigate psychosocial mechanisms, such
as spirituality, that may improve mental health and quality of
life for persons with SCI to mitigate potential negative
outcomes.
Spirituality and Happiness
Spirituality has long been associated with better health, a longer
life span, and greater levels of happiness and life satisfaction
(Udermann, 2000). Martinez and Scott (2014) identify
spirituality as a strong psychosocial predictor of happiness
implying spirituality influences engagement in meaningful daily
activities which then influences happiness. For persons with
disabilities, one study shows spirituality is a strong predictor

for happiness, controlling for inflammation, pain and stiffness,
physical functioning, age, and mood in those diagnosed with
rheumatoid arthritis (Bartlett, Piedmont, Bilderback,
Matsumoto, & Bathon, 2003). In another study, a spiritualty-
based intervention led to increased hope, happiness, and life
satisfaction in breast cancer survivors (Fallah, Golzari, Dastin,
& Akbari, 2011). These studies elucidate the need to further
investigate of the impact of spirituality and mental health
outcomes including happiness and well-being.
Psychosocial Mechanisms
Due to an emerging conceptual framework highlighting
spirituality as an important positive coping strategy for
psychosocial adaptation to chronic illness and disability, the
need for further research forms the basis for the current study.
Specifically, we examine the underlying psychosocial
mechanisms by which health status, perceived stress, social
support, self-esteem, and psychological well-being influence the
relationship between spirituality and happiness based on the
following summative review of the literature.
Health status. The relationship between spirituality and health
status has been well-documented in the literature. Research
indicates spirituality and regular engagement in spiritual
practices, such as prayer and service attendance, are strong
predictors of general health status independent of age, level of
education, and socioeconomic status (Krause, Emmons, &
Ironson, 2015; Ferraro & Albrecht-Johnson, 1991). Spirituality
also plays a role in recovery and healing. For example, in a
study of heart-transplant recipients, those persons who reported
strong spiritual beliefs and regular spiritual service attendance
adhered more closely to their rehabilitation plan, had higher
physical functioning levels, and better indexes of emotional
wellbeing (Harris et al., 1995). Hudson (1996) states the
beneficial effects of spirituality are not just limited to
individuals with strong spiritual beliefs prior to the onset of
illness. In Hudson's study, those who increased their level of
spiritual commitment while in treatment reported their health as

better than the health of those who did not. In Cheadle and
Schnetter's (2017) summative review of the spirituality and
health status literature, they indicate four underlying
mechanisms linking the two variables including (1) social
mechanisms (e.g., social interactions and support), (2)
behavioral mechanisms (e.g., religious/spiritual practices such
as medication and prayer which may reduce anxiety), (3)
psychological mechanisms (e.g., finding purpose and meaning
in life) and (4) biological mechanisms (e.g., reduction in stress
and inflammatory biomarkers). Based on these findings, the
potential influence of spirituality on the health status of persons
with SCI cannot be ignored.
Perceived stress. People with chronic illness have to cope with
high levels of stress that pose a barrier to their happiness and
well-being, particularly those who have acquired a severe injury
such as SCI (Livneh & Wilson, 2003). For instance, individuals
with SCI have indicated bowel or bladder accidents, secondary
injuries, and public embarrassment are disability-related sources
of stress (DeGraff & Schaffer, 2008). Research indicates that a
reduction of stress is associated with greater levels of life
satisfaction in older adults (Lee, Besthom, Bolin, & Jun, 2012),
individuals with psychiatric and physical disabilities (Livneh &
Wilson, 2003), and individuals with SCI (DeGraff & Schaffer,
2008). Specifically, for persons with SCI, spiritually-based
interventions did arise as a valuable coping resource for dealing
with stress (DeGraff & Schaffer, 2008). The use of spirituality
as a coping mechanism to reduce stress is clear, and suggests
further exploration of stress as a mediator of the relationship
between spirituality and happiness is necessary.
Social support. Spirituality can positively affect subjective
appraisal of social support by increasing (a) individuals'
perception of closeness and connection to others and (b) the
frequency and quality of social contacts. McColl et al. (2000)
explored changes in spiritual beliefs in eight people with either
traumatic brain injury or SCI less than two years post-injury.
Post-injury, McColl and colleagues found respondents

expressed increased feelings of connection and greater
closeness with others, the world, or God. Preliminarily, there is
some evidence to indicate social support may be a mediator for
spirituality and happiness. In an exploratory study examining
the impact of spiritual and religious beliefs and practices on life
satisfaction for people living with SCI, Marini and Glover-Graf
(2011) found, while half of the study participants reported
feeling closer to God, and nearly twothirds felt closer to others,
10% of respondents reported lasting anger at God. This same
10% indicated feeling abandoned and punished by God, and that
the disability made them a worse person. These beliefs have
important implications for rehabilitation professionals, as anger,
hostility, resentment, and contempt for others may cause
persons to alienate loved ones and withdraw from social
interaction with others. This withdrawal and alienation can
potentially damage main sources of social support, and
negatively influence life satisfaction for persons with SCI. As
such, further investigation of the mediating influence of social
support on the relationship between spirituality and happiness is
warranted.
Self-esteem. In a narrative review of psychosocial concerns for
persons with SCI, Post and van Leeuwen (2012) show hope,
having a sense of purpose in life, and a sense selfworth and
self-esteem, significantly affect subjective well-being post-SCI.
Individuals with SCI indicated post- injury, they felt a great
sense of purpose, or their purpose had become more urgent
(McColl et al, 2000). Marini and Glover-Graf (2011) indicate
faith and spirituality contribute to higher levels of physical and
mental health well-being by increasing levels of hope and
positive expectation for persons with SCI. Based on the
emerging literature, investigating self-esteem as a mediating
variable in the relationship between spirituality and happiness is
conceptually and empirically sound.
Psychological well-being. Spirituality has shown to have both
mediating and moderating effects on aspects of psychological
well-being. As a moderator, spirituality reduced the depressive

effects of chronic illness on psychological well-being (Ballew,
Hannum, Gaines, Marx, & Parrish, 2012). As a mediator,
Meraviglia (2006) found the spirituality factor of "meaning in
life," in conjunction with physical functioning, explained 43%
of the variance in the psychological well-being in a sample
breast cancer survivors. The results of these studies clearly
indicate a connection from spirituality to psychological well-
being, suggesting positive well-being as a viable mediator
between spirituality and happiness. This connection will be
further explored in the current study.
Purpose of the Study
Clearly, there is strong support in the psychosocial literature for
the mediating effects of the aforementioned variables, the
purpose of this study is to evaluate the extent health status,
perceived stress, social support, self-esteem, and psychological
well-being serve as underlying psychosocial mechanisms to
explain the association between spirituality and happiness.
Research Hypothesis
1. The relationship between spirituality and happiness is
mediated by health status, perceived stress, social support, self-
esteem, and psychological well-being.
Methods
Sample
Two hundred and seventy-four individuals with SCI were
recruited from the Alberta, Manitoba, Nova Scotia, Ontario, and
Saskatchewan chapters of the Canadian Paraplegic Association
(CPA). Research packets were mailed directly by these CPA
chapters to members to ensure confidentiality and anonymity.
The inclusion criteria for this study were as follows: (a) have an
acquired SCI, (b) be at least 18 years of age, and (c) be able to
read and understand English.
Participants ranged in age from 18 to 82 years (M = 46.82, SD =
13.46). More than half of the participants were men (68%) and
the majority described themselves as White (84%). Participants
in this study were relatively well educated with 77% having
some level of postsecondary education and training. More than

half of the participants were married or in a significant long-
term relationship (56%). With regard to employment, 45%
worked either full-time or part-time, 46%% were retired or not
seeking employment, 9% were seeking employment. The mean
duration since injury onset was 17.33 years (SD = 11.94). The
proportion of participants who reported having
quadriplegia/tetraplegia was 44% (19% with a complete lesion,
25% with an incomplete lesion).
Measures
Participants completed seven empirically validated instruments
with strong psychometric properties assessing the predictor and
outcome variables described in the following sections.
Spiritual Health Inventory (SHI). The SHI was developed by
Veach and Chappel (1992) to assess perceptions of spirituality.
It is composed of 18 items and three subscales: (a) Spiritual
Experience, (b) Spiritual Locus of Control, and (c) Spiritual
Well-Being. Only the 9-item Spiritual Well-Being subscale was
used for the purpose of this study (e.g., "I have an internal
experience of being accepted for who I am," "Life has a
purpose," and "1 believe my life has meaning"). Each item is
rated on a 5-point Likert-type rating scale ranging from 1
(strongly disagree) to 5 (strongly agree) with higher scores
reflecting a greater perception of spiritual well-being. The
internal consistency reliability estimates (Cronbach's alpha) for
the Spiritual Well-Being subscale was reported to be .72 (Veach
& Chappel, 1992). Support for the validity of the SHI is based
on positive correlations with measures of physical and
psychological health (Veach & Chappel, 1992). Cronbach's
alpha coefficient for the Spiritual Well-Being subscale in the
present study was computed to be .89.
Rand Short-Form 36-General Health Scale. The SF36 is a
generic health-related quality of life measure with 36 items and
eight subscales: (a) Physical Function-10 items, (b) Role
Limitations due to Physical Health-4 items, (c) Role Limitations
due to Emotional Problems-3 items, (d) Energy/ Fatigue-4
items, (e) Emotional Well-being-5 items, (f) Social

Functioning-2 items, (g) Pain-2 items, and (h) General Health-5
items. The two summary measures of the SF-36 are referred to
as Physical Component Summary and Mental Component
Summary. In this study, only the general health subscale
comprised of five items was used to assess the general health
status of the participants (i.e., "In general, would you say your
health is...," "I seem to get sick a little easier than other
people," "I am as healthy as anybody I know," "I expect my
health to get worse," and "My health is excellent"). Each item is
rated on a 5-point Likert-type scale and then rescaled to a 0-100
point scale with higher average score reflecting higher level of
general health. The internal consistency reliability estimates
(Cronbach's alpha) was reported to be .78 (Ware & Sherbourne,
1992). Cronbach's alpha coefficient in the present study was
computed to be .81.
Perceived Stress Questionnaire (PSQ). The PSQ was developed
by Levenstein et al. (1993) to assess subjective experience of
stressful situations in the last month and stress reactions on
cognitive and emotional levels. It is composed of 30 items and
seven subscales: (a) Harassment, with four items (e.g., "You are
under pressure from other people"); (b) Overload, with four
items (e.g., "You have too many things to do"); (c) Irritability,
with two items (e.g., "You are irritable or grouchy"); (d) Lack
of joy, with seven items (e.g., "You enjoy yourself'); (e)
Fatigue, with four items (e.g., "You feel rested"); (f) Worries,
with five items (e.g., "You are afraid for the future"); and (g)
Tension, with four items (e.g., "You have trouble relaxing").
Each item is rated on 4-point Likert-type rating scale ranging
from 1 (almost never) to 4 {usually). In this study, the total
scale was used to assess stress levels of the participants, with
higher scores reflecting greater perceived stress. The PSQ was
validated among English-speaking and Italian-speaking samples
including gastroenterological inpatients, outpatients, and
hospital employees, and was found to have high internal
consistency and test-retest reliability (Fliege et al., 2005;
Kocalevent et al., 2007; Levenstein et al., 1993). Cronbach's

alpha for the PSQ in the current study was .93.
Multidimensional Scale of Perceived Social Support (MSPSS).
The MSPSS was developed by Zimet, Dahime, Zimet, and
Farley (1988) to assess perceived social support from multiple
sources. The instrument is composed of 12 items and three
subscales: (a) Family, with four items (e.g., "I can talk about
my problems with my family"), (b) Friends, with four items
(e.g., "I can count on my friends when things go wrong"), and
(c) Significant Others, with four items (e.g., "There is a special
person who is around when I am in need"). Each item is rated
on a 7-point Likert-type ranging scale ranging from 1 {very
strongly disagree) to 7 {very strongly agree). Scores for each
subscale are represented by the mean of the raw scores for items
in the subscale and a total score is represented by the mean of
the scores obtained on the three subscales. In this study, the
total scale was used to assess social support level of the
participants, with higher scores reflecting greater perceived
social support. Reported evidence supporting the psychometric
properties of the MSPSS include its inverse relationship to the
depression and anxiety subscales of the Hopkins Symptom
Checklist and reported high test-retest reliability coefficients of
.85 for the total scale and .97, .85, and .91 for the Family,
Friends, and Significant Others subscales, respectively (Zimet
et al., 1988). Cronbach's alpha coefficients for the Family,
Friends, and Significant Others subscales and the total scale in
the current study were computed to be .93, .93, 96, and .81
respectively.
Rosenberg Self-Esteem Scale (RSES). The RSES was developed
by Rosenberg (1965) to evaluate global self-worth by measuring
both positive and negative feelings about the self. It is
composed of five positively worded (e.g., "I feel that I have a
number of good qualities") and five negatively worded (e.g.,
"At times I think I am no good at all") items. Each item is rated
on a four-point Likert-type rating scale ranging from 1
{strongly disagree) to 4 {strongly agree), with higher scores
indicate higher self-esteem. Studies using the RSES report test-

retest reliabilities ranging from .72 to .90 (Robins, Heiden, &
Trzesniewski, 2001) and Cronbach's alpha between .77 and .88
(Blascovich & Tomaka, 1993). Cronbach's alpha for the RSES
in the current study was .88.
Sense of Well-Being Inventory (SWBI). The SWBI was
developed by Rubin, Chan, Bishop, and Miller (2003) to
operationalize the construct of quality of life for vocational
rehabilitation clients. The original SWBI has 36 items and five
subscales. Recently, Catalano et al. (2010) has validated an
abbreviated version of the SWBI. The abbreviated SWBI is
composed of 20 items and four subscales: (a) Financial Well-
being, with five items (e.g., "I feel good about my financial
future"); (b) Family and Social Well-being, with five items
(e.g., "I have friends who care about me" and "I receive
emotional support from my family"); (c) Psychological Well-
being with six items (e.g., "I frequently feel down," "I
frequently feel nervous," and "I feel good about myself'); and
(d) Physical Well-being with four items ("I feel good about my
physical stamina and energy level"). Each item is rated on a
four-point Likert-type rating scale ranging from 1 {strongly
disagree) to 4 {strongly agree). Only the psychological well-
being subscale was used for the purpose of this study. The
reported internal consistency estimate for the instrument was
found to range from.81 to .85, with the Cronbach's alpha
reported to be .82 for the Psychological Well-being subscale
(Catalano et al., 2010). Cronbach's alpha for the psychological
well-being in the current study was .81.
Subjective Happiness Scale (SHS). The SHS was developed by
Lyubomirsky and Lepper (1999) as a global measure of
subjective happiness. The instrument comprises only four items.
An example of items included in this instrument is "Some
people are generally very happy. They enjoy life regardless of
what is going on, getting the most out of everything. To what
extent does this characterization describe you?" Each item is
rated on a 7-point Likert-type scale ranging from 1 ("not a very
happy person ", or "not at all") to 7 ("a very happy person ", or

"a great deal"). A total score of happiness is obtained by
computing the mean of the scores with higher means reflecting a
higher level of happiness. The reported internal consistency
estimate for the instrument was found to range from .79 to .94.
Test-retest reliability coefficients were found to range from .55
to .90. Convergent validity was supported based on correlations
with related constructs, such as self-esteem, optimism, positive
emotionality and negative emotionality, extraversión and
neuroticism, and dysphasia (Lyubomirsky & Lepper, 1999).
Cronbach's alpha for the SHS in the current study was .87.
Data Analysis
The primary analysis was conducted using multiple regression
analysis to test the hypothesis that the association between
spirituality and happiness is mediated by reduction in stress
level, improved health status, stronger social support, improved
self-esteem, and better psychological well-being. In addition,
the bootstrap test for multiple mediators developed by Preacher
and Hayes (2008) was used to test the significance of the
indirect effects of the independent variable (IV; spirituality) on
the dependent variable (DV; happiness) through the mediators
(perceived stress, general health status, social support, self-
esteem, and psychological well-being).
Results
Prior to analysis, perceived stress, general health status, social
support, self-esteem, psychological well-being, and happiness
were examined for accuracy of data entry, missing values, and
fit between distribution of variables and the assumption of
multiple regression analysis. All measures in this study have
less than 5% missing values. A simple imputation method
available in SPSS using regression analysis was used to
compute missing value estimates. This method is preferred over
case deletion since it will not decrease the sample size (i.e.,
statistical power loss) or affect the sample representativeness.
Using Mahalanobis distance with p < .01, six cases (2%) were
identified as multivariate outliers and eliminated from the
study.

Descriptive Statistics
Means, standard deviations, and the correlation matrix for
variables in the hypothesized mediational model are shown in
Table 1.
The average spirituality rating of 3.65 (SD = 0.81; range 1 to 5)
indicated relatively high spirituality scores for participants in
this study. The mean perceived stress score was 2.04 (SD =
0.50; range 1 to 4). The general health scale had a range of 0 to
100 and the average score for this sample was 56.58 (SD =
21.40), indicating participants rated their health status as "fair"
or average. The average rating for social support was 5.38 (SD
= 1.33; range 1 to 7). The mean score for self-esteem was 3.13
(SD = 0.55; range 2 to 4). The psychological well-being scale
had a mean of 2.87 (SD = 0.57; range 1 to 4). The mean
happiness score was 5.08 (SD = 1.31; rangel to 7).
As presented in Table 1, Pearson product-moment correlation
coefficients generally ranged from medium to large among the
dependent variable and the predictor variables in the
correlational matrix, with all correlations significant at p <
.001. Perceived stress was inversely related to spirituality (r = -
.35), happiness (r = -.65), health status (r = -.43), social support
(r = -.38), self-esteem (r = -.62), psychological well-being (r = -
.67).
Testing the Mediational Hypothesis
The Baron and Kenny (1986) procedure was used to test the
mediational hypothesis of the relation between spirituality and
happiness. This procedure involves three steps:
1. Regress the mediator (M) onto the independent variable (X)
to show the two variables are causally linked.
2. Regress the dependent variable (Y) onto the X to show a
causal relation between the variables are plausible.
3. Regress the dependent variable (Y) simultaneously onto the
IV and the mediator to show the mediator is significantly
related to the DV, even when the IVs is statistically controlled.
If the regression coefficients for steps 1 and 2 are significant,
and the partial regression coefficient for predicting the DV from

the mediator is significant in step 3, a mediator hypothesis is
supported (Baron & Kenny, 1986). In this study, it was
hypothesized that the association between spirituality and
happiness is mediated by perceived stress, health status, social
support, self-esteem, and psychological well-being. This model
is graphically depicted in Figure 1 and was tested using seven
separate regression equations.
As expected, the association between spirituality (IV) and
happiness (DV) (step 2) was significant: ß (95% confidence
interval [Cl]) = .58 (.48, .68). (Note: When the 95% Cl excludes
0, the effect size differs significantly from zero, p < .001.)
Next, the association between the IV (spirituality) and each of
the mediators (step 1) was assessed. Spirituality was
significantly related to perceived stress, health status, social
support, self-esteem, and psychological well-being: ßs (95%
Cis) = -.35 (-.46, -.24), .28 (.17, .40), .49 (.39, .60), .52 (.42,
.63), and .55 (.44, .65) respectively. Finally, each of the
presumed mediators was significantly related to the DV (hap-
piness), while statistically controlling for the IV (step 3). The
relevant analysis was a simultaneous regression of happiness
(DV) onto spirituality (IV), perceived stress, health status,
social support, self-esteem, and psychological well-being. The
reason for including all five mediators and the IV in the
regression equation is related to the path model in Figure 1,
which implies that each mediator is uniquely related to
happiness (DV), controlling for the other mediators and
spirituality (IV). The model accounted for 68% of the variance
in happiness, R = .83, R^sup 2^ = .68, F{6, 261) = 93.89, p <
.001, and is considered a large effect size (Cohen, 1988). All of
the five mediators were significantly associated with happiness,
ßs (95% Cis) = -.18 (-.28, -.08), .14 (.06, .22), .10 (.02, .18),
.18 (.07, .30), .30 (.17, .42) for perceived stress, health status,
social support, self-esteem and psychological well-being,
respectively. In summary, all three steps were significant as
predicted, yielding support for the proposed mediation model.
The findings conform to the predictions of a model in which

self-esteem, and psychological well-being each of which is
uniquely associated with happiness.
In addition, the association between spirituality and happiness
in the final (six-predictor) regression equation was examined.
This was also statistically significant, ß (95% Cl) = .17 (.08,
.26). The ß for spirituality was reduced from .58 to .17, after
controlling for the effect of the mediators. Thus, while the
intervening variables (perceived stress, health status, social
support, self-esteem, and psychological well-being) help to
explain the link between spirituality and happiness, they do not
completely explain the relationship. The finding of significant
indirect effects through one or more mediators accompanied by
significant direct effects, is common and was characterized by
Baron and Kenny (1986) as a case of partial mediation.
Finally, we conducted a bootstrap test to determine the
significance of the indirect effect of the IV on the DV through
the mediators. The indirect effect for the mediation model was
tested using a SPSS macro for conducting bootstrap tests of
multiple-mediator models downloaded from Kristopher
Preacher's website (www.people.ku.edu/preacher/). For the
mediation model, the unstandardized indirect effects (with 95%
CIs derived from bias-corrected and accelerated bootstrap
procedures) were products (ab) = .06 (.03, .11) for the indirect
path through perceived stress and happiness; .04 (.02, .07) for
the indirect path through health status and happiness; .05 (.01, .
10) for the indirect path through social support and happiness;
.09 (.03, .16) for the indirect path through self-esteem and
happiness; and .16 (.09, .25) for the indirect path through
psychological well-being and happiness. Given that the
individual paths a and b were significant for each mediator, the
95% CIs do not include zero indicating that the indirect effect is
significant (p < .05) in each case.
Discussion
The researchers in this study recruited 274 individuals with SCI

from five chapters of the Canadian Paraplegic Association and
administered seven measurement instruments addressing health,
spirituality, social support, self-esteem, stress, well-being and
happiness through multiple regression and a bootstrap test for
multiple mediators to show the relationship between happiness
and spirituality is mediated by the above seven factors. Findings
confirmed the link between happiness and spirituality, as well
as the mediating effect of the other factors.
Seligman's (2008) positive psychological movement, with its
focus on strengths and virtues, has permeated the field of health
and rehabilitation research and practice, a movement he entitles
"positive health" (p.3). This strengths-based framework
highlights the hallmark of the fields of rehabilitation counseling
and psychology-enhancing the quality of life of persons with
chronic illness and disability as elucidated in the early seminal
writings of Beatrice Wright (1983). This study examined
positive psychological constructs in a population of persons
with SCI. The purpose of this study was to explore how health
status, perceived stress, social support, self-esteem, and
psychological well-being mediate the relationship between
spirituality and happiness. First, the relationship between
spirituality and happiness was examined and this relationship
was found to be significant. This finding adds additional
support to recent findings by Martinez and Scott (2014)
indicating spirituality is an important contributing factor to
happiness, specifically engaging in meaningful activities
enables a person to feel connected to something outside of
himself, searching for significance in life, and positively
adapting to events that challenge a person's sense of meaning
(e.g., onset of a traumatic disability such as SCI).
Next, we tested a mediational model to determine the extent to
which health status, perceived stress, social support, self-
esteem, and psychological well-being explained the relationship
between spirituality and happiness. This hypothesized
mediational model explained 68% of the variance in happiness,
a large effect size. Thus, these five variables explain the

mechanism through which spirituality influences happiness.
Results of this study have important clinical rehabilitation
counseling implications. Rehabilitation counselors and
psychologists working with persons with SCI can adapt spiritual
interventions that focus on health promotion, stress reduction,
increasing social support networks, building the person's self-
esteem and psychological well-being. Using a spiritual
framework as a basis for intervention, would have a positive
effect on the psychological well-being and happiness of persons
with SCI. For example, Honarparvaran, Ghaderi, Bayat, and
Cheraghi (2014) show group counseling with an existential
framework focusing on self-determination, values, choice, and
meaning can facilitate spiritual growth in persons with SCI.
This spiritual growth may lead to a greater sense of self, inner
peace, acceptance, and happiness because "positive values,
attitudes, beliefs and strength that one acquires through
spiritual practices contribute to health and happiness" (Sinha,
2014, p. 396).
Individually, each predictor variable significantly influenced
happiness, thereby adding to the body of literature in this area.
As in this study, Graham (2008) found self-reported health
status was a strong predictor of happiness worldwide. For
persons with chronic illness and disability, Graham states
initially the illness or disability may have a negative impact on
happiness. Over time, persons with chronic illness and
disability return to their initial level of happiness once
expectations for health status shift in relation to their condition.
This shift portrays how the locus of evaluation for health status
shifts from the general population to those persons with similar
conditions. In alignment with the findings this study, Schiffrin
and Nelson (2010) found support for the intuitive inverse
relation between perceived stress and happiness. Siedlecki,
Salthouse, Oishi, and Jeswani (2014) found family
embeddedness (i.e., frequency of contact) and provided support
(i.e., emotional, tangible, or informational help) predicted
positive affect, a proxy for happiness in their study. This study

provides additional supporting evidence for the relationship
between those two variables. In spiritually focused
interventions aimed at increasing happiness for persons with
SCI, self-esteem should be addressed. As Nosek, Hughes,
Swedlund, Taylor, and Swank (2003) report, for women with
disabilities, self-esteem is significantly associated with
engaging in health promoting behaviors and employment, key
factors influencing overall quality of life for this population.
Addressing psychological well-being for persons with SCI is
essential as previous literature suggests. Perceived loss of
physical functioning is associated with psychological well-
being; however, global meaning making mediates the
relationship between perceived loss of physical functioning and
psychological well-being (deRoon-Cassini, de St. Aubin,
Valvano, Hastings, & Horn, 2009).
Thus, psychological interventions are indeed necessary to
improve the quality of life of persons with SCI. The prevalence
of depression, anxiety, and post-traumatic stress disorders is
higher for persons with SCI compared to the general population
(Post & van Leeuwen, 2012). In a review the literature, Post and
van Leeuwen show life satisfaction, a proxy for happiness, is
lower initially following SCI and life satisfaction improves over
time. This trend is important as interventions aimed at
increasing self-esteem, finding ways to cope with newfound
stressors, and finding a strong support network as early as
possible after medical rehabilitation may help to improve
psychosocial outcomes for persons with SCI. This potential for
effective intervention is supported by previous research
showing positive psychological constructs greatly influence
subjective well-being in persons with SCI post- acute
rehabilitation (Kortee, Gilbbert, Gorman, & Wegener, 2010).
Although the results of this study provide support for the
mediational model, the five predictor variables did not
completely explain the mechanism by which spirituality
influences happiness in persons with SCI. Future studies should
examine other potential positive psychological constructs as

predictors such as optimism, hope, and resiliency to determine
if the addition of variables such as those completely explain the
link between spirituality and happiness.
Concluding Statements
In this article, we explored the relationship of spirituality and
happiness, specifically spirituality and happiness for individuals
with SCI and the mediating factors of health status, perceived
stress, social support, self-esteem and psychological well-being.
Each of these variables taken alone have an individual effect on
happiness and spirituality both. This study found a significant
association between spirituality and happiness for people with
SCI; while each of the variables could explain this association,
the explanation was not complete. Future studies would do well
to continue research to find a more complete link between
spirituality and happiness. An individual's spirituality brings
with it several positive effects on life happiness; a person with
a SCI can likewise benefit from these positive effects. We know
individuals with SCI experience many encroachments to life
satisfaction, but happiness and life satisfaction can
fundamentally return. Rehabilitation counselors and
psychologists can facilitate quality of life improvements for
people with SCI through interventions that include the
individual's spirituality and all correlating factors therein. As
spirituality is linked to better health and life satisfaction, and is
seen as a positive coping strategy, further investigations will
only further aid people with SCI in healing, coping and positive
psychosocial adaptation.
Sidebar
Ebonee Traneice Johnson, Ph.D., CRC, Assistant Professor, The
University of Iowa College of Education-Rehabilitation and
Counselor Education, N364 North Lindquist Center, Iowa City,
IA 52242
Email: [email protected]
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