A Meta-analysis of A Meta-analysis of Spirituality and Spirituality and Quality of LifeQuality of Life

Presented by Rick Sawatzky, Presented by Rick Sawatzky, MSN, RNMSN, RN

Co-Investigators: Dr. P. Ratner, Co-Investigators: Dr. P. Ratner, PhD, RNPhD, RN

Dr. L. Chiu, PhD, Dr. L. Chiu, PhD, RNRN

Background:Background:Spirituality in the context Spirituality in the context

of healthof healthConceptual themes of spiritualityConceptual themes of spirituality

ExistentialExistential ExperientialExperiential Meaning and purposeMeaning and purpose

TranscendentTranscendent Connectedness / RelationshipConnectedness / Relationship Power/Force/EnergyPower/Force/Energy

Chiu, L., Emblen, J., VanHofwegen, L., Sawatzky, R., & Meyerhof, H. (2004). An integrative review of spirituality in the health sciences. Western Journal of Nursing Research, 26(4), 405-428.

Spirituality and HealthSpirituality and Health

Spirituality Health

Traditional research focus on external indicators

Religious behaviorsReligious affiliationReligious involvement

Morbidity and mortality rates based on medical diagnoses

Current research focus on “Subjective” indicators

Spiritual experiencesSpiritual beliefsSpiritual quest

Quality of LifeWell-beingLife-satisfaction

An increase in a person’s An increase in a person’s spirituality, however experienced, spirituality, however experienced, is accompanied by an increase in is accompanied by an increase in health.health.

Trends in Spirituality Trends in Spirituality ResearchResearch

Spirituality is defined as a subjective Spirituality is defined as a subjective experienceexperience

Distinction between spirituality and Distinction between spirituality and religionreligion

Spirituality has implications for health-Spirituality has implications for health-related outcomesrelated outcomes Previous emphasis on external indicatorsPrevious emphasis on external indicators Current emphasis on “subjective” indicatorsCurrent emphasis on “subjective” indicators

Current Study:Current Study:A Meta-analysis of the A Meta-analysis of the Relationship between Relationship between

Spirituality and Quality of LifeSpirituality and Quality of LifeIs there a significant relationship Is there a significant relationship between spirituality and quality of between spirituality and quality of

life? life?

ObjectivesObjectives To synthesize results from completed studies to To synthesize results from completed studies to

determine whether there is empirical support for determine whether there is empirical support for a relationship between spirituality and quality of a relationship between spirituality and quality of life.life.

To provide an estimate of the strength of this To provide an estimate of the strength of this relationship.relationship.

To hypothesize and examine the existence of any To hypothesize and examine the existence of any potential related variables affecting this potential related variables affecting this relationship.relationship.

Study Design: A Meta-Study Design: A Meta-analysisanalysis

Specifying the domain of inquirySpecifying the domain of inquiry

Defining studies characteristics Defining studies characteristics

Searching and retrieving Searching and retrieving studiesstudies

Coding study variablesCoding study variables

Analyzing across studiesAnalyzing across studies

A proposed A proposed conceptualization of conceptualization of

spiritualityspirituality““The feelings, thoughts, experiences, The feelings, thoughts, experiences, and behaviors that arise from a and behaviors that arise from a search for the sacred. The term search for the sacred. The term “search” refers to attempts to “search” refers to attempts to identify, articulate, maintain, or identify, articulate, maintain, or transform. The term “sacred” refers transform. The term “sacred” refers to a divine being or Ultimate Reality to a divine being or Ultimate Reality or Ultimate Truth as perceived by or Ultimate Truth as perceived by the individual”the individual”

Larson, D. B., Sawyers, J. P., & McCullough, M. E. (1998). Scientific research on spirituality and health: A report based on the Scientific Progress in Spirituality Conferences. New York: John M. Templeton Foundation.

Spirituality & ReligionSpirituality & Religion

Religion may or may not encompass Religion may or may not encompass “a search for non-sacred goals (such “a search for non-sacred goals (such as identify, belongingness, meaning, as identify, belongingness, meaning, health, or wellness) in a context that health, or wellness) in a context that has as its primary goal the has as its primary goal the facilitation of [the previous facilitation of [the previous definition]” definition]”

Religion refers to “the means and Religion refers to “the means and methods (i.e., rituals or prescribed methods (i.e., rituals or prescribed behaviors) of the search that receive behaviors) of the search that receive validation and support from within validation and support from within an identifiable group of people” an identifiable group of people”

Attributes of SpiritualityAttributes of SpiritualityEssential Attributes of Essential Attributes of SpiritualitySpirituality

Spirituality is Spirituality is existential in existential in naturenatureIt is often described as It is often described as something that something that involves a search for involves a search for meaning and purpose meaning and purpose or as something that or as something that provides meaning and provides meaning and purpose.purpose.

Spirituality is Spirituality is relational in relational in naturenatureThe object of the The object of the relationship is relationship is something that lies something that lies beyond physiological, beyond physiological, psychological or social psychological or social domains of life. This domains of life. This object is defined as object is defined as being transcendent in being transcendent in nature or, as a life-nature or, as a life-force or energy.force or energy.

Conceptualizing Quality Conceptualizing Quality of Lifeof Life

Quality of life was conceptualized as a Quality of life was conceptualized as a as a person’s perception of his/her as a person’s perception of his/her quality of life however it is defined by quality of life however it is defined by the individual. the individual.

Emphasis on the subjective perspective of Emphasis on the subjective perspective of QOLQOL

Largely synonymous concepts:Largely synonymous concepts: Subjective wellbeingSubjective wellbeing Life-satisfactionLife-satisfaction

Operationalization of Operationalization of QOLQOL

The measurement of quality of life is The measurement of quality of life is based onbased on (a) “[persons’] perspective[s] of their overall (a) “[persons’] perspective[s] of their overall

quality of life andquality of life and (b) their assessment of specific components of (b) their assessment of specific components of

quality of life (i.e., physical, psychological and quality of life (i.e., physical, psychological and social well-being)”social well-being)”

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

Spirituality and Quality Spirituality and Quality of lifeof life

QOLQOLWellbeingWellbeing

Life-SatisfactionLife-SatisfactionSpiritualitySpirituality

As analogous conceptsAs analogous concepts

Spirituality and Quality Spirituality and Quality of Lifeof Life

As a multidimensional frameworkAs a multidimensional framework

Quality of Life

Physical Social Psychological Spiritual

Spirituality and Quality of Spirituality and Quality of LifeLife

A Proposed FrameworkA Proposed Framework

Dimensions of Life

Social Physical Psychological

Spirituality Life

Satisfaction Perceived Quality of Life

Subjective Well-Being

Quality of Life

Selection Criteria for Selection Criteria for Instruments Measuring Instruments Measuring

SpiritualitySpirituality Instruments based on subjective Instruments based on subjective

ratings (i.e., self-reported ratings ratings (i.e., self-reported ratings on a Likert-type scale) of spiritual on a Likert-type scale) of spiritual experiences, beliefs or behavior experiences, beliefs or behavior associated with:associated with:

an existential search for meaning an existential search for meaning andand a relationship with a transcendent a relationship with a transcendent

reality (e.g., God or divine being, reality (e.g., God or divine being, Ultimate Reality, or Ultimate Truth).Ultimate Reality, or Ultimate Truth).

Selection Criteria for Selection Criteria for Quality of Life InstrumentsQuality of Life Instruments

Quality of life is measured by:Quality of life is measured by: using subjective ratings of a person’s using subjective ratings of a person’s

self-reported quality of life, satisfaction self-reported quality of life, satisfaction with life or subjective well-being, with life or subjective well-being, oror

using instruments that measure quality using instruments that measure quality of life by statistically combining of life by statistically combining subjective ratings of multiple dimensions subjective ratings of multiple dimensions of life (e.g., physical, social, of life (e.g., physical, social, psychological and emotional dimensions). psychological and emotional dimensions). This refers primarily to broad multi-This refers primarily to broad multi-dimensional measures of quality of life or dimensional measures of quality of life or wellbeing.wellbeing.

Design: Literature Design: Literature SearchSearch

Search methodsSearch methods Electronic database searches: CINAHL; Electronic database searches: CINAHL;

PubMED; EMBASE; HEALTHSTAR; PubMED; EMBASE; HEALTHSTAR; PsychINFO; SOCIAL SCIENCES CITATION PsychINFO; SOCIAL SCIENCES CITATION INDEX; SCIENCE CITATION INDEX INDEX; SCIENCE CITATION INDEX EXPANDED and the ARTS AND HUMANITIES EXPANDED and the ARTS AND HUMANITIES INDEX INDEX

Forward and backward citation searchesForward and backward citation searches BrowsingBrowsing

KeywordsKeywords Spiritual(ity), Religion / Religiosity / Spiritual(ity), Religion / Religiosity /

Religiousness, Transcendent / Transcendence, Religiousness, Transcendent / Transcendence, Existential, Transpersonal and Sacred(ness)Existential, Transpersonal and Sacred(ness)

Quality of Life, Well(-)Being, Life-SatisfactionQuality of Life, Well(-)Being, Life-Satisfaction

Excluded studiesExcluded studies

1.1. Case studiesCase studies2.2. Qualitative studiesQualitative studies3.3. Studies that measured quality of life Studies that measured quality of life

based on external indicators or a based on external indicators or a single dimensionsingle dimension

4.4. Studies that measured spirituality Studies that measured spirituality based on the frequency of religious or based on the frequency of religious or spiritual practices or behavior spiritual practices or behavior

5.5. Studies prior to 1991Studies prior to 19916.6. Studies not reported in EnglishStudies not reported in English

Search ResultsSearch Results Total search database: Total search database: 3,0403,040 citations citations After initial screening of citation After initial screening of citation 371371 study study

reports of potential interest were identified and reports of potential interest were identified and retrievedretrieved 59 studies were excluded because the study was a 59 studies were excluded because the study was a

case study, a qualitative study or was not reported in case study, a qualitative study or was not reported in English.English.

200 studies were excluded because methodological 200 studies were excluded because methodological inclusion criteria pertaining to the measurement of inclusion criteria pertaining to the measurement of spirituality or quality of life were not met. spirituality or quality of life were not met.

60 studies were excluded the criteria for calculating 60 studies were excluded the criteria for calculating an effect size were not met.an effect size were not met.

1 study was excluded because it reported findings on 1 study was excluded because it reported findings on the same sample as another study.the same sample as another study.

Final sample size: Final sample size: 6262 primary ES’s from primary ES’s from 5151 studiesstudies

Design: CodingDesign: Coding

Study Study characteristicscharacteristics SettingSetting Research designResearch design Sampling methodSampling method

Sample Sample characteristicscharacteristics Age & genderAge & gender Religious affiliationReligious affiliation Cultural backgroundCultural background

Characteristics of the Characteristics of the instrumentsinstruments Classification of Classification of

instrumentsinstruments Type of scales, # of itemsType of scales, # of items Psychometric informationPsychometric information

Effect size dataEffect size data Statistics to calculate the Statistics to calculate the

effect sizeeffect size

Design: Statistical Design: Statistical AnalysisAnalysis

1.1. Convert primary findings to a common Convert primary findings to a common metricmetric

2.2. Weigh primary ES’s by inverse variancesWeigh primary ES’s by inverse variances

3.3. Weigh primary ES’s by instrument Weigh primary ES’s by instrument reliability coefficientsreliability coefficients

4.4. Analyze the distribution forAnalyze the distribution for1.1. NormalityNormality

2.2. HomogeneityHomogeneity

5.5. Examine for moderating variablesExamine for moderating variables1.1. Fixed, random or mixed multivariate Fixed, random or mixed multivariate

analysesanalyses

Sample DescriptionSample Description

Ethnic backgroundEthnic background (reported for (reported for 55%)55%) Caucasian / “white”: 67.6%Caucasian / “white”: 67.6% African American / “black”: African American / “black”:

23.7%23.7% South American: 5.8%South American: 5.8% Asian: 0.8%Asian: 0.8% Hispanic: 0.4%Hispanic: 0.4% Other: 1.8%Other: 1.8%

5959 ES’s derived from ES’s derived from 4848 studies studies Total participant pool: Total participant pool: 22,55422,554

Sample DescriptionSample Description

Religious affiliationReligious affiliation (reported for (reported for 19.7%)19.7%) Protestant: 34.7%Protestant: 34.7% Catholic: 35.2%Catholic: 35.2% Jewish: 4.1%Jewish: 4.1% Hindu: 0.1%Hindu: 0.1% Islam: 0.1%Islam: 0.1% No religious affiliation: 9%No religious affiliation: 9% Other: 14.9 %Other: 14.9 % Unkown: 1.9%Unkown: 1.9%

Operational Definitions of Operational Definitions of SpiritualitySpirituality

Existential & Existential & RelationalRelational

20 ES’s 20 ES’s

13 instruments13 instruments

Primarily Primarily RelationalRelational

14 ES’s 14 ES’s

6 instruments6 instruments

Primarily Primarily ExistentialExistential

12 ES’s 12 ES’s

5 instruments5 instruments

AmbiguousAmbiguous13 ES’s13 ES’s

10 instruments10 instruments

Results: Distribution of Results: Distribution of ES’sES’s

Results: Final Results: Final DistributionDistribution

Mean Effect Size Adjusted for Instrument Reliability (N=59)

Model Pearson’s r - 95% CI + 95% CI P

Fixed .3097 .2942 .3250 .0000

Random .3413 .2824 .3977 .0000

Mean Effect Size Not Adjusted for Instrument Reliability (N=59)

Fixed .2338 .2214 .2463 .0000

Random .2561 .2135 .2976 .0000

Mean Effect Size Prior to Removal of Outliers[3]

Fixed .2361 .2237 .2390 .0000

Random .2615 .2177 .3043 .0000

Mean Effect SizesMean Effect Sizes

Correlation Coefficient

-0.6 -0.4 -0.2 0.0 0.2 0.4 0.6 0.8 1.0 1.2

Eff

ect

Siz

e I

D

240-2169-1739-1724-1316-1263-1529-1292-1317-1770-1794-1169-5555-2703-1223-1522-1

63-1169-3406-2

37-1460-1320-1665-1491-1169-7169-2527-1

69-1439-1

54-1761-1515-1521-2196-1

89-3169-4169-6218-1665-2169-8

61-1240-1255-1124-2217-1521-1359-1554-1462-1394-1138-1

73-252-1

675-1569-1124-1351-1616-1145-1142-1656-9147-1

Mean

Mean correlation with95% confidenceintervalDistribution Mean

Mean ES - Fisher’s Z(r) R-Square N

.3555 .3242 59

Variable b SE- 95%

CI+ 95%

CI p Beta

Constant .0778 .0896 -.0978 .2534 .3852 .0000

Spirit. – Existential [2] .1801 .1043 -.0243 .3845 .0841 .2231

Spirit - Relational -.2586 .1022 -.4589 -.0583 .0114 -.3413

Spirit - Ambiguous -.0309 .1078 -.2422 .1805 .7747 -.0388

QOL – Disease Specific[3] .3011 .1435 .0199 .5823 .0358 .2933

QOL - General QOL .3976 .1012 .1992 .5960 .0001 .5467

Sampling Method[4] -.0536 .1086 -.2666 .1593 .6215 -.0585

Age Group[5] -.0445 .1029 -.2462 .1571 .6652 -.0494

Ethnic Black[6] .1371 .1391 -.1356 .4098 .3244 .1211

Ethnic White[7] -.2290 .1595 -.5417 .0837 .1511 -.1650

Mixed effect modelMixed effect model

Trimmed Mixed Effects Trimmed Mixed Effects ModelModel

Mean ES - Fisher’s Z(r) R-Square N

.3562 .2719 59

Variable b SE- 95% CI

+ 95% CI p Beta

Constant .0656 .0912 -.1132 .2443 .4723 .0000

Spirit. Dummy Var.1[1] .1975 .1062 -.0106 .4057 .0629 .2438

Spirit Dummy Var. 2 -.2227 .0975 -.4139 -.0315 .0224 -.2931

Spirit Dummy Var. 3 .0080 .0985 -.1851 .2012 .9350 .0101

QOL Dummy Var. 1[2] .2793 .1476 -.0100 .5687 .0585 .2706

QOL Dummy Var. 2 .3705 .1032 .1683 .5727 .0003 .5074

ANOVA Spirituality Categories

Pearson Correlation

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

Rel

Exist & Rel

MEAN ES

Ambiguous

Exist

Mean

(n = 12)

(n = 12)

(n = 59)

(n = 20)

(n = 15)

30.r

23.r

39.r

50.r

34.r

Pearson's Correlation

-0.2 0.0 0.2 0.4 0.6 0.8

General Multi-dimensional

Overall QOL - Wellbeing - Lifesat.

Disease Specific Multi-dimensional

37.r

11.r

45.r9n

6n

44n

95% CI Associated with Each Categorical Group of QOL Instruments as Revealed by the ANOVA Analysis.

ImplicationsImplications TheoreticalTheoretical

Confidence in a moderate effect size (as defined by Confidence in a moderate effect size (as defined by Cohen, 1988)Cohen, 1988)

Failsafe N: 151 studies with Failsafe N: 151 studies with r r = 0.00 would be = 0.00 would be needed to reduce the mean effect size to .10. needed to reduce the mean effect size to .10.

Spirituality as a unique concept in relation to quality Spirituality as a unique concept in relation to quality of lifeof life

ImplicationsImplications

OperationalOperational The measurement of spirituality and The measurement of spirituality and

quality of life explains a significant quality of life explains a significant proportion of the varianceproportion of the variance

Mean ES varies between .23 and .50 for Mean ES varies between .23 and .50 for spirituality instruments (Rspirituality instruments (R22 = 12%) = 12%)

Mean ES varies between .11 and .45 for Mean ES varies between .11 and .45 for quality of life instruments (Rquality of life instruments (R22 = 12%) = 12%)

Implications for selection of instrumentsImplications for selection of instruments Implication for power considerationsImplication for power considerations