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A Meta-analysis of Spirituality
and Quality of Life
Presented by Rick Sawatzky, MSN, RN
Co-Investigators: Dr. P. Ratner, PhD, RN
Dr. L. Chiu, PhD, RN
Background:
Spirituality in the context of health
Conceptual themes of spirituality
Existential
Experiential
Meaning and purpose
Transcendent
Connectedness / Relationship
Power/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 Health
An increase in a person’s spirituality, however
experienced, is accompanied by an increase
in health. Spirituality Health
Traditional Religious behaviors Morbidity and
research focus Religious affiliation mortality rates based
on medical diagnoses
on external Religious
indicators involvement
Current Spiritual experiences Quality of Life
research focus Spiritual beliefs Well-being
on “Subjective” Spiritual quest Life-satisfaction
indicators
Trends in Spirituality Research
Spirituality is defined as a subjective experience
Distinction between spirituality and religion
Spirituality has implications for health-related
outcomes
Previous emphasis on external indicators
Current emphasis on “subjective” indicators
Current Study:
A Meta-analysis of the Relationship
between Spirituality and Quality of Life
Is there a significant relationship between
spirituality and quality of life?
Objectives
To synthesize results from completed studies to
determine whether there is empirical support for a
relationship between spirituality and quality of life.
To provide an estimate of the strength of this
relationship.
To hypothesize and examine the existence of any
potential related variables affecting this relationship.
Study Design: A Meta-analysis
Specifying thedomain of inquiry
Defining studies characteristics
Searching and retrieving studies
Coding study variables
Analyzing across studies
A proposed conceptualization of
spirituality
“The feelings, thoughts, experiences, and
behaviors that arise from a search for the sacred.
The term “search” refers to attempts to identify,
articulate, maintain, or transform. The term
“sacred” refers to a divine being or Ultimate
Reality or Ultimate Truth as perceived by 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 & Religion
Religion may or may not encompass “a search
for non-sacred goals (such as identify,
belongingness, meaning, health, or wellness) in a
context that has as its primary goal the
facilitation of [the previous definition]”
Religion refers to “the means and methods (i.e.,
rituals or prescribed behaviors) of the search
that receive validation and support from within
an identifiable group of people”
Essential Attributes of Spirituality
Attributes of Spirituality
Spirituality is Spirituality is
existential in nature relational in nature
It is often described as The object of the relationship
something that involves a is something that lies beyond
search for meaning and physiological, psychological or
purpose or as something that social domains of life. This
provides meaning and object is defined as being
purpose. transcendent in nature or, as a
life-force or energy.
Conceptualizing Quality of Life
Quality of life was conceptualized as a as a
person’s perception of his/her quality of life
however it is defined by the individual.
Emphasis on the subjective perspective of QOL
Largely synonymous concepts:
Subjective wellbeing
Life-satisfaction
Operationalization of QOL
The measurement of quality of life is based on
(a) “[persons’] perspective[s] of their overall quality
of life and
(b) their assessment of specific components of
quality of life (i.e., physical, psychological and 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 of life
As analogous concepts
QOL
Spirituality Wellbeing
Life-Satisfaction
Spirituality and Quality of Life
As a multidimensional framework
Quality of Life
Physical Social Psychological Spiritual
Spirituality and Quality of Life
A Proposed Framework
Quality of Life
Spirituality Life Perceived Subjective
Satisfaction Quality of Life Well-Being
Dimensions of Life
Social Physical Psychological
Selection Criteria for Instruments
Measuring Spirituality
Instruments based on subjective ratings (i.e.,
self-reported ratings on a Likert-type scale) of
spiritual experiences, beliefs or behavior
associated with:
an existential search for meaning and
a relationship with a transcendent reality (e.g., God
or divine being, Ultimate Reality, or Ultimate
Truth).
Selection Criteria for Quality of Life
Instruments
Quality of life is measured by:
using subjective ratings of a person’s self-reported
quality of life, satisfaction with life or subjective
well-being, or
using instruments that measure quality of life by
statistically combining subjective ratings of
multiple dimensions of life (e.g., physical, social,
psychological and emotional dimensions). This
refers primarily to broad multi-dimensional
measures of quality of life or wellbeing.
Design: Literature Search
Search methods
Electronic database searches: CINAHL; PubMED;
EMBASE; HEALTHSTAR; PsychINFO; SOCIAL
SCIENCES CITATION INDEX; SCIENCE CITATION
INDEX EXPANDED and the ARTS AND HUMANITIES
INDEX
Forward and backward citation searches
Browsing
Keywords
Spiritual(ity), Religion / Religiosity / Religiousness,
Transcendent / Transcendence, Existential, Transpersonal
and Sacred(ness)
Quality of Life, Well(-)Being, Life-Satisfaction
Excluded studies
1. Case studies
2. Qualitative studies
3. Studies that measured quality of life based on
external indicators or a single dimension
4. Studies that measured spirituality based on the
frequency of religious or spiritual practices or
behavior
5. Studies prior to 1991
6. Studies not reported in English
Search Results
Total search database: 3,040 citations
After initial screening of citation 371 study reports of
potential interest were identified and retrieved
59 studies were excluded because the study was a case study, a
qualitative study or was not reported in English.
200 studies were excluded because methodological inclusion
criteria pertaining to the measurement of spirituality or quality of
life were not met.
60 studies were excluded the criteria for calculating an effect size
were not met.
1 study was excluded because it reported findings on the same
sample as another study.
Final sample size: 62 primary ES’s from 51 studies
Design: Coding
Study characteristics Characteristics of the
Setting instruments
Research design Classification of instruments
Sampling method Type of scales, # of items
Psychometric information
Sample characteristics
Age & gender Effect size data
Religious affiliation Statistics to calculate the
Cultural background effect size
Design: Statistical Analysis
1. Convert primary findings to a common metric
2. Weigh primary ES’s by inverse variances
3. Weigh primary ES’s by instrument reliability
coefficients
4. Analyze the distribution for
1. Normality
2. Homogeneity
5. Examine for moderating variables
1. Fixed, random or mixed multivariate analyses
Sample Description
59 ES’s derived from 48 studies
Total participant pool: 22,554
Ethnic background (reported for 55%)
Caucasian / “white”: 67.6%
African American / “black”: 23.7%
South American: 5.8%
Asian: 0.8%
Hispanic: 0.4%
Other: 1.8%
Sample Description
Religious affiliation (reported for 19.7%)
Protestant: 34.7%
Catholic: 35.2%
Jewish: 4.1%
Hindu: 0.1%
Islam: 0.1%
No religious affiliation: 9%
Other: 14.9 %
Unkown: 1.9%
Operational Definitions of
Spirituality
Existential & Relational Primarily Relational
20 ES’s 14 ES’s
13 instruments 6 instruments
Primarily Existential Ambiguous
12 ES’s 13 ES’s
5 instruments 10 instruments
Results: Distribution of ES’s
Results: Final Distribution
Mean Effect Sizes
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
147-1
656-9
142-1
145-1
616-1
351-1
124-1
569-1
675-1
52-1
73-2
138-1
394-1
462-1
554-1
359-1
521-1
217-1
124-2
255-1
240-1
61-1
169-8
665-2
218-1
169-6
169-4
89-3
Effect Size ID
196-1
521-2
515-1
761-1
54-1
439-1
69-1
527-1
169-2
169-7
491-1
665-1
320-1
460-1
37-1
406-2
169-3
63-1
522-1
223-1
703-1
555-2
169-5
794-1
770-1
317-1
292-1
529-1
263-1
316-1
724-1
739-1
169-1 Mean correlation with
240-2 95% confidence
interval
-0.6 -0.4 -0.2 0.0 0.2 0.4 0.6 0.8 1.0 1.2 Distribution Mean
Mean
Correlation Coefficient
Mixed effect model
Mean ES - Fisher’s
Z(r) R-Square N
.3555 .3242 59
- 95% + 95%
Variable b SE CI 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
Trimmed Mixed Effects Model
Mean ES -
Fisher’s Z(r) R-Square N
.3562 .2719 59
- 95% + 95%
Variable b SE CI 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
Exist
(n = 12)
r .50
Ambiguous
(n = 12)
r .39
MEAN ES
(n = 59)
r .34
Exist & Rel
(n = 20)
r .30
Rel
(n = 15)
r .23
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Mean
Pearson Correlation
95% CI Associated with Each Categorical Group of QOL
Instruments as Revealed by the ANOVA Analysis.
Disease Specific Multi-dimensional
n9 r .45
Overall QOL - Wellbeing - Lifesat.
n 44 r .37
General Multi-dimensional
n6 r .11
-0.2 0.0 0.2 0.4 0.6 0.8
Implications
Theoretical
Confidence in a moderate effect size (as defined by Cohen,
1988)
Failsafe N: 151 studies with r = 0.00 would be needed to
reduce the mean effect size to .10.
Spirituality as a unique concept in relation to quality of life
Implications
Operational
The measurement of spirituality and quality of life
explains a significant proportion of the variance
Mean ES varies between .23 and .50 for spirituality
instruments (R2 = 12%)
Mean ES varies between .11 and .45 for quality of life
instruments (R2 = 12%)
Implications for selection of instruments
Implication for power considerations
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