A Meta-analysis of Spirituality and Quality of Life

1. 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

2. 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.

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

4. 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

5. 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.

6. Study Design: A Meta-analysis Specifying the domain of inquiry Defining studies characteristics Searching and retrieving studies Coding study variables Analyzing across studies

7. 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.

8. 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”

9. Attributes of Spirituality

10. 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

11. 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.

12. Spirituality and Quality of life As analogous concepts Spirituality QOL Wellbeing Life-Satisfaction

13. Spirituality and Quality of Life As a multidimensional framework Quality of Life Physical Social Psychological Spiritual

14. Spirituality and Quality of LifeA Proposed Framework

15. 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).

16. 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.

17. 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

18. Excluded studies • Case studies • Qualitative studies • Studies that measured quality of life based on external indicators or a single dimension • Studies that measured spirituality based on the frequency of religious or spiritual practices or behavior • Studies prior to 1991 • Studies not reported in English

19. 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

20. Study characteristics Setting Research design Sampling method Sample characteristics Age & gender Religious affiliation Cultural background Characteristics of the instruments Classification of instruments Type of scales, # of items Psychometric information Effect size data Statistics to calculate the effect size Design: Coding

21. Design: Statistical Analysis • Convert primary findings to a common metric • Weigh primary ES’s by inverse variances • Weigh primary ES’s by instrument reliability coefficients • Analyze the distribution for • Normality • Homogeneity • Examine for moderating variables • Fixed, random or mixed multivariate analyses

22. 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% 59 ES’s derived from 48 studies Total participant pool: 22,554 Sample Description

23. 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%

24. Operational Definitions of Spirituality

25. Results: Distribution of ES’s

26. Results: Final Distribution

27. Mean Effect Sizes

29. Mixed effect model

30. Trimmed Mixed Effects Model

32. 95% CI Associated with Each Categorical Group of QOL Instruments as Revealed by the ANOVA Analysis.

33. 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

34. 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