Quality-of-life and spirituality

Abstract

Spirituality has been identified as an important dimension of quality-of-life. The objective of this study was to review the literature on quality-of-life and spirituality, their association, and assessment tools. A search was conducted of the keyterms ‘quality-of-life’ and ‘spirituality’ in abstract or title in the databases PsycINFO and PubMed/Medline between 1979–2005, complemented by a new search at PUBMED from 2006–2016. Quality-of-life is a new concept, which encompasses and transcends the concept of health, being composed of multiple domains: physical, psychological, environmental, among others. The missing measure in health has been defined as the individual’s perception of their position in life in the context of culture and value system in which they live and in relation to their goals, expectations, standards, and concerns. There is consistent evidence of an association between quality-of-life and religiosity/spirituality (R/S), through studies with reasonable methodological rigour, using several variables to assess R/S (e.g. religious affiliation, religious coping, and prayer/spirituality). There are also several valid and reliable instruments to evaluate quality-of-life and spirituality. Further studies are needed, however, especially in Brazil. Such studies will provide empirical data to be used in planning health interventions based on spirituality, seeking a better quality-of-life. In the last 10 years, research is consistently growing about quality-of-life and spirituality in many countries, and also in many areas of health research.

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Quality-of-life and spirituality
Raquel Gehrke Panzini, Bruno Paz Mosqueiro, Rogério R. Zimpel, Denise
Ruschel Bandeira, Neusa S. Rocha & Marcelo P. Fleck
To cite this article: Raquel Gehrke Panzini, Bruno Paz Mosqueiro, Rogério R. Zimpel, Denise
Ruschel Bandeira, Neusa S. Rocha & Marcelo P. Fleck (2017) Quality-of-life and spirituality,
International Review of Psychiatry, 29:3, 263-282, DOI: 10.1080/09540261.2017.1285553
To link to this article: http://dx.doi.org/10.1080/09540261.2017.1285553
Published online: 07 Jun 2017.
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Quality-of-life and spirituality
Raquel Gehrke Panzini
a
, Bruno Paz Mosqueiro
a
, Rog
erio R. Zimpel
a
, Denise Ruschel Bandeira
b
,
Neusa S. Rocha
a
and Marcelo P. Fleck
a
a
Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre-RS, Brazil;
b
Department of Psychology,
Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre-RS, Brazil
ABSTRACT
Spirituality has been identified as an important dimension of quality-of-life. The objective of this
study was to review the literature on quality-of-life and spirituality, their association, and assess-
ment tools. A search was conducted of the keyterms ‘quality-of-life’and ‘spirituality’in abstract
or title in the databases PsycINFO and PubMed/Medline between 1979–2005, complemented by
a new search at PUBMED from 2006–2016. Quality-of-life is a new concept, which encompasses
and transcends the concept of health, being composed of multiple domains: physical, psycho-
logical, environmental, among others. The missing measure in health has been defined as the
individual’s perception of their position in life in the context of culture and value system in
which they live and in relation to their goals, expectations, standards, and concerns. There is
consistent evidence of an association between quality-of-life and religiosity/spirituality (R/S),
through studies with reasonable methodological rigour, using several variables to assess R/S (e.g.
religious affiliation, religious coping, and prayer/spirituality). There are also several valid and reli-
able instruments to evaluate quality-of-life and spirituality. Further studies are needed, however,
especially in Brazil. Such studies will provide empirical data to be used in planning health inter-
ventions based on spirituality, seeking a better quality-of-life. In the last 10 years, research is con-
sistently growing about quality-of-life and spirituality in many countries, and also in many areas
of health research.
KEYWORDS
Quality-of-life; spirituality;
religiosity; evaluation;
instruments
Introduction
There is plenty of data on the impact of spirituality
and religion in people’s lifes (Levin & Vanderpool,
1991). In Eastern medicine there is a tendency to inte-
grate the religiosity/spirituality dimension to the bino-
mial health-disease (Fabrega, 2000). Nevertheless,
until recently in Western Medicine and especially in
Psychiatry, there are two main positions in relation to
the theme: neglect by considering such matters unim-
portant or outside the main area of interest, or oppos-
ition, to characterize the religious experiences of
patients as evidence of several psychopathological
states (Sims, 1994). Historically ignored by many psy-
chologists, religion has been called by Larson and
Larson a ‘forgotten factor in physical and mental
health’(Pargament, Olsen, Reilly, & Falgout, 1992). In
recent decades, however, this picture has changed
because of what Saad, Masiero, and Battistella (2001)
named ‘spirituality based on evidence’. There are now
hundreds of scientific papers showing an association
between Spirituality/Religiosity and health that is
statistically valid and possibly causal (Levin, 1994).
Thus, health professionals have scientific based evi-
dence of the benefit of spirituality in treatment plan-
ning of virtually any disease. The wall between
medicine and spirituality is collapsing, doctors and
other health professionals have discovered the import-
ance of prayer, of spirituality, and religious participa-
tion in the improvement of physical and mental
health, as well as to respond to stressful situations of
life (Epperly, 2000).
More recently, there is a concern for establishing
broad parameters for assessing health not only
through morbidity and mortality. In this context,
interest in measuring constructs such as ‘well-being’
and ‘quality-of -life’has grown remarkably (Fleck,
2008).
The main objective of this article is to review the
relationships between religiosity, spirituality, and
quality-of-life, and its implications for clinical practice.
This article is based on its first version that eval-
uated scientific literature regarding spirituality and
quality-of-life, published in 2007, including a
CONTACT Raquel Gehrke Panzini ragepa@yahoo.com.br Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
This is an updated English version of the paper: Panzini, R.G., et al. Qualidade de vida e espiritualidade quality of life and spirituality. Rev Psiq Cl

ın
2007;34(suppl 1):105–15.
ß2017 Institute of Psychiatry and Johns Hopkins University
INTERNATIONAL REVIEW OF PSYCHIATRY, 2017
VOL. 29, NO. 3, 263–282
http://dx.doi.org/10.1080/09540261.2017.1285553
ARTICLE

systematic review of relevant papers indexed in
PsycINFO and PubMed/Medline from 1979–2005.
Articles were selected according to their scientific rele-
vance and purpose to provide a comprehensive over-
view of quality-of-life and spirituality in terms of
concepts, research, and tools. As a complement to this
first version, a general overview of literature regarding
these topics has been performed, including an update
with scientific publications from 2006–2016.
Spirituality and religiosity concepts
Religiosity and spirituality are not consensual con-
cepts. The Oxford Dictionary (Simpson & Weiner,
1993) defines spirit as part of the immaterial, intellec-
tual, or moral man. The term spirituality involves
questions about the meaning of life and meaning to
live, not limited to types of beliefs or practices.
Religion is the ‘belief in the existence of a supernat-
ural power, the creator and controller of the universe,
who gave the man a spiritual nature which continues
to exist after the death of his body’(Simpson &
Weiner, 1993, p. 656). Religiosity is the extent to
which an individual believes, follows, and practices a
religion. Although there is overlap between spirituality
and religiosity, the latter differs by the suggestion of a
clear system of worship or a specific doctrine shared
with a group. Beliefs can be defined as any personal
beliefs or values held by an individual that character-
ize their lifestyle and behaviour. There may be an
overlap with spirituality, although personal beliefs are
not necessarily non-material, such as atheism.
Additionally, Koenig, Larson, and Larson (2001)
define religion as an organized system of beliefs, prac-
tices, rituals, and symbols designed to facilitate close-
ness to the sacred and the transcendent (God, Higher
Power, or Truth) and spirituality as a personal quest
for understandable answers to existential questions
about life, its meaning, and the relationship to the
sacred or transcendent which may (or may not) lead
to development of religious rituals and the formation
of a community.
Concept of quality-of-life
The introduction of the concept of quality-of-life
(QoL) as an outcome measure in healthcare emerged
in the 1970s, in the context of medical progress. This
progress brought an increment in life expectancy,
since acute diseases previously lethal (e.g. infections)
became curable, and chronic diseases (e.g. diabetes)
could also be controlled by efficient treatments.
Consequently, it became of great importance to
measure how people live these ‘additional years’.In
fact, Fallowfield (1990) defined QoL as ‘the missing
measure in health’.
QoL has intersections with biological and func-
tional concepts, such as health status, functional
status, and disability; social and psychological con-
cepts such as well-being, satisfaction, and happiness;
and based on economic theory of ‘preference’(utility).
Six major trends have converged to the develop-
ment of the concept of QoL: (1) basic epidemio-
logical studies on happiness and well-being; (2) the
search for social indicators; (3) the insufficiency of
objective health outcome measures; (4) ‘customer sat-
isfaction’; (5) the movement of humanization of
medicine, and (6) positive psychology. The latter is
part of the current trend towards the development of
research of the positive aspects of human experience
(Seligman & Csikszentmihalyi, 2000). Backed by the
broad concept of the World Health Organization
(1946, p. 1) that health is ‘a state of complete phys-
ical, mental and social and not merely the absence
of disease or infirmity’, the exclusive focus on the
disease, which always dominated research in the area
of health, is giving way to the study of adaptive
traits such as resilience, hope, wisdom, creativity,
courage, and spirituality.
There is still no definitive consensus in the litera-
ture on the concept of quality-of-life. However, it is
important to distinguish between the concepts of
standard of living and QoL (Skevington, 2002). The
first includes objective socioeconomic, demographic,
and basic healthcare indicators. The second is based
on parameters that refer to the subjective perception
of the important aspects of a person’s life, which may
or may not coincide with the objective indicators of
standard of living. The World Health Organization
Quality-of-Life Group (WHOQoL Group) proposed
that these perceptions originate in the culture to
which one belongs. Therefore, the cultural issue is
fundamental in QoL, as different cultures tend to
emphasize different aspects as fundamental in QoL
determination. The WHOQoL Group was the first to
include the cultural component as central to Qol def-
inition. This group is a collaboration between
researchers, clinicians, and scientists who have worked
together for over 12 years based on international con-
sensus protocols developed in agreement at each stage
of project development (Skevington, 2002). From a
cultural perspective, this group defined quality-of-life
as ‘an individual’s perception of their position in life
in the context of culture and value system in which
they live and in relation to their goals, expectations,
264 R. G. PANZINI ET AL.

standards and concerns’(WHOQOL GROUP, 1994,
p. 43).
Groups of researchers in QoL
Besides the WHOQoL Group, independent research-
ers and other research groups have also studied QoL
throughout the world, as the IQOLA (International
Society for Quality of Life Assessment) and the group
of researchers who built the SEIQoL (The Schedule
for the Evaluation of Individual Quality of Life)
(Beaton, Bombardier, Guillemin, & Ferraz, 2000;
Skevington, 2002). These groups have different per-
spectives that can be summarized in two positions:
universalistic or relativistic view of the concept
of QoL.
The universalistic view was supported by data col-
lected by the IQOLA Group, based on the high degree
of similarity found between the profiles of the SF-36
from four European countries, and also by data col-
lected around the world by the WHOQoL Group,
through the WHOQoL-100 and WHOQoL-bref.
The relativistic view employs an idiographic
approach that understands the individual as a unique
being, considering individual differences among peo-
ple more important than their similarities.
Instruments such as SEIQoL and SEIQoL-DW
(Browne, O’Boyle, McGee, & McDonald, 1997;
McGee, O’Boyle, & Hickey, 1991) access QoL indi-
vidually by semi-structured, with groups of individuals
suffering from the same disease (Waldron, O’Boyle,
Kearney, Moriarty, & Carney, 1999). Although they
demonstrated good acceptability and reliability, they
are inappropriate for some populations such as elderly
or severely ill patients because it requires a complex
abstract information processing.
Studies associating QoL and spirituality/
religiousness
Several studies have focused on the relationship
between QoL and spirituality and religiousness.
Ferriss (2002) examined the relationship between reli-
giouness and QoL by means of objective and subject-
ive indicators of QoL. He found that happiness was
associated with the frequency and presence at reli-
gious services, proselytizing or doctrinal preferences,
as well as the belief that the world is good or bad, but
not the belief in immortality. The author concluded
that: (1) religious organizations contribute to commu-
nity integration, thereby increasing QoL; (2) as the
frequency or presence at religious services was not
associated with QoL, other factors should be acting;
(3) the American conception of ‘good life’relies heav-
ily on Judeo-Christian ideals; (4) religion could attract
people prone to happiness; and (5) religion can lead
to a purpose in life that promotes well-being.
Evidence of a significant positive association between
QoL and spiritual well-being were found in different
populations: in multi-ethnic sample of 1617 partici-
pants (l¼54.6 years old), during the development
and validation of the instrument FACIT-Sp (The
Functional Assessment of Chronic Illness Therapy-
Spiritual Well-Being Scale) (Peterman, Fitchett, &
Brady, 2002) and in a sample of cancer patients,
regardless of the type of cancer (Brady, Peterman,
Fitchett, Mo, & Cella, 1999). Still, patients with vari-
ous types of gynecological cancers showed a positive
relationship between QoL and spiritual, existential,
and religious well-being (Gioiella, Berkman, &
Robinson, 1998).
Another study confirmed that quality-of-life in
HIV-positive individuals (n¼40, 80%men, 25–54
years) was directly related to religious faith, religious
affiliation, and health, which, with socioeconomic sta-
tus, contributing positively, and significantly to QoL
scores of participants in the Quality-of-Life Index
(QLI). Independent variables such as age, ethnicity,
and gender did not contribute to the regression model
(Flannelly & Inouye, 2001). In a survey of 44 widows
of fire victims (l¼37 years old), most of those
described as more religious reported QoL as more sta-
ble over the past 5 years after the death of their hus-
bands. Frequency of religious participation in social
events and a member of any religious institution were
also associated to greater stability in QoL (Bahr &
Harvey, 1979). In a study of 560 people randomly
interviewed by telephone, the qualitative aspects of
prayer and how to pray were the variables that had
greatest effect on QoL (Poloma & Pendleton, 1989).
A variable that is associated to QoL is Religious/
Spiritual Coping (RSC): the use of religion, spiritual-
ity, or faith to cope with stress and problems of life.
Using a global index of QoL (Spitzer et al., 1981),
Pargament, Smith, Koenig, and Perez (1998) found
that, in a sample which included 551 critically ill hos-
pitalized elderly patients, 256 victims of the bomb
attack in Oklahoma and 540 students who had experi-
enced stressful life events, greater use of positive RSC
did not correlate with depression or QoL. However,
greater use of negative RSC moderately correlated
with worse QoL levels and higher depression. The
authors concluded that Religiosity/Spirituality could
be a source of relief or discomfort, troubleshooting, or
cause of stress, depending on how the person relates
INTERNATIONAL REVIEW OF PSYCHIATRY 265

to it, that is, using positive or negative RSC strategies.
In 2 years of following-up a sample of 268 elderly
inpatients, the RSC was a predictor of change in the
spiritual scores and mental and physical health scores.
Positive RSC was associated with improvements in
health and negative RSC was a predictor of health
decline. The authors concluded that patients continu-
ally struggling with religious issues may be particu-
larly at risk for health problems (Pargament, Koenig,
Tarakeshwar, & Hahn, 2001), since they tend to use
negative RSC.
Koenig, Pargament, and Nielsen (1998) studied a
sample of 577 patients of more than 55 years old.
They use a measure of QoL (Spitzer et al., 1981), a
Brief-RCOPE scale of 63 items and a shortened form
of 22 items from the COPE scale (Carver & Scheier,
1989) to evaluate non-religious coping. Greater use of
coping, religious or not, was associated with worse
physical health. This association was stronger for
negative RSC than positive. Acceptance was the only
non-religious coping associated with better physical
health. Frequency of religion was also consistently
associated with better physical health. In relation to
mental health, five positive RSC strategies were associ-
ated with less depression and greater QoL. Negative
coping strategies were associated with greater depres-
sion and poorer QoL. All 12 RSC positive strategies,
frequency of religion practice, importance of religion,
and private religious activities were robustly associated
with growth associated with stress, cooperativeness,
and spiritual growth.
Longitudinal study with the use of QoL instru-
ments to predict hospitalization and mortality in
patients with obstructive pulmonary disease found
that low QoL would be a powerful predictor of hospi-
talization and all-cause mortality, indicating that brief
and self-administered instruments could identify
patients who could benefit to preventive interventions
(Curtis, Tu, & McDonell, 2002). If these instruments
were used within a cultural perspective, they could
also facilitate comparisons between different social
groups, cultures, or different contexts of healthcare.
QoL instruments that assess spirituality and
religiousness
Several studies have shown the importance of
Religiosity/Spirituality in quality-of-life. For example,
patients with tuberculosis, rather than their physi-
cians, have indicated that their disease and/or treat-
ment increased their spirituality, and this could result
in an improvement in Qol (Hansel, Wu, Chang, &
Diette, 2004). These findings led to some QoL
generic instruments (Peterman et al., 2002) and some
disease-specific (Zebrack & Chesler, 2001) to include
a spiritual dimension among their domains.
Ross (1995) considered that the spiritual dimension
depends on three components: (a) the need to find
meaning and fulfillment in life; (b) the need to hope
and to have will to live, and (c) the need to have faith
in himself, in others, or in God. For Pargament
(2001), to find meaning in life is one of the key objec-
tives of religion, avoiding feelings of emptiness and
despair (Ross, 1995). Unidentified spiritual suffering is
often associated with an unsuccessful treatment plan
for the rehabilitation of physical disabilities (Davis,
1994). In a study of 10 women with cancer and five
men with acquired immunodeficiency syndrome,
those who have found a meaning for their disease
also had a better QoL (Fryback & Reinert, 1999).
The importance of the spirituality and religiousness
in QoL was highlighted by Robbins, Simmons,
Bremer, and Walsh (2001). In a longitudinal study of
60 patients with amyotrophic lateral sclerosis (ALS),
the authors examined the relationship between phys-
ical function, QoL, and spirituality and religiousness,
and their variation in time (baseline, 3, and 6 months).
Despite the progressive decline in physical function,
overall QoL scores and religiosity have changed little.
In contrast, the specific HRQoL score for ALS
decreased in parallel with the decline in physical func-
tion scores. The authors concluded that QoL in ALS
patients appear to be independent of physical func-
tion. QoL instruments that include the assessment of
spirituality, religiousness, and psychological dimen-
sions produce different results compared to those
obtained using only measures of physical functioning.
The same conclusion about the importance of
Religiousness/Spirituality dimension in QoL was
found by the WHOQoL Group using focus groups
around the world in 1991 during the development of
the WHOQoL-100 instrument (Skevington, 2002).
Four questions about spirituality, religiousness, and
personal beliefs (SRBP) were included in the instru-
ment consisting in a SRPB domain that was added to
the five existing other domains (physical, psycho-
logical, personal relationships, environment, and level
of independence). Nevertheless, in the field tests con-
ducted in several centres, the domain SRBP has been
proved insufficient to cover such a broad and complex
domain (Skevington, 2002). To cover this gap, the
WHOQoL Group cross-culturally developed a specific
module to evaluate SRPB: the WHOQoL Spirituality,
Religiousness, and Personal Beliefs (WHOQoL-SRBP),
an expansion of SRBP domain of WHOQoL-100 (da
266 R. G. PANZINI ET AL.

Almeida Fleck & Borges, 2003; Panzini, Maganha,
Rocha, Bandeira, & Fleck, 2011; WHOQOL-SRPB,
2006). This instrument has been developed collabora-
tively in selected countries with different levels of
industrialization and availability of health services,
through a series of steps. Initially, an international
group of experts suggested facets and items related to
SRBP, which were reviewed by 92 focus groups con-
ducted in 15 countries on four continents: Argentina,
Brazil, Uruguay, Italy, Spain, Lithuania, Turkey, UK,
Egypt, Israel, India, China, Japan, Thailand, and
Malaysia. These focus groups aimed to review the ori-
ginal facets proposed by the experts and suggest items
and/or facets to be included in the questionnaire.
They were composed by health professionals (regard-
less of their beliefs), patients with acute, chronic and
terminal diseases, patients who have recovered from
diseases, atheists, and members of either dominant
religion in each centre or minority religious groups.
Based on the qualitative and quantitative levels of
importance, a total of 15 facets represented by 105
items was confirmed as relevant by the WHOQoL-
SRBP Group panel and released to be pilot tested
in 18 centres (n¼5087) [Argentina (n¼221),
Brazil (Porto Alegre, n¼253, Santa Maria, n¼253),
Uruguay (n¼251), Italy (n¼376), Spain
(n¼240), Lithuania (n¼482), Turkey (n¼240), UK
(n¼283), Egypt (n¼240), Kenya (n¼480), Israel
(n¼270), India (Bangalore, n¼240, Pondicherry,
n¼364), China (n¼259), Japan (n¼226), Thailand
(n¼118), and Malaysia (n¼240)]. After psychometric
analysis, a total of eight facets were selected (Spiritual
connection, Meaning and purpose in life, Experiences
of awe and wonder, Wholeness and integration,
Spiritual strength, Inner peace, Hope and optimism,
Faith), represented by 32 items, with Likert-scale
response in five points (Rocha, Panzini, Fleck, &
Fleck, 2008). The field test to validate the WHOQoL-
SRBP was conducted in six countries: Uruguay, Spain,
England, Israel, China, and Brazil (Panzini, 2005).
Moreira-Almeida and Koenig (2006) pointed to the
fact that five of the eight factors of the WHOQoL-
SRBP (Meaning and purpose in life, Experiences of
awe and wonder, Wholeness and integration, Inner
peace, Hope and optimism) are not measuring reli-
gion or spirituality themselves, but results or conse-
quences of religion. They also considered that the
three remaining facets (Spiritual connection, Spiritual
connection, and Faith) could not reflect any kind of
spirituality, since, based on the instructions of the
questionnaire, one could respond in a personal system
of beliefs that were not religious or spiritual. Replying
to this comment, Fleck and Skevington (2007) justi-
fied that: (1) WHOQoL-SRPB is not an instrument
developed to evaluate SRPB, but the Quality-of-Life
construct; (2) personal beliefs may function as a strat-
egy to cope with life problems, since they give mean-
ing to human behaviour and hypothetically influence
quality-of-life; (3) SRPB is a coherent construct and
may be considered an independent construct specially
concerning psychological well-being; and (4) the con-
cepts included in the WHOQoL project were consid-
ered genuine cross-cultural concepts through
international consensus, and this is one of its major
strengths.
Besides the WHOQoL-100 and WHOQoL-SRBP,
there are other QoL instruments that include spiritu-
ality and religiousness dimension. The Quality-of-Life
Cancer Survivors (QoL-CS) has a spiritual well-being
sub-scale, beyond physical, psychological, and social
sub-scales. Its psychometric properties were explored
in a sample of 177 childhood cancer survivors of
16–29 years old (Zebrack & Chesler, 2001). The scale
demonstrated good internal consistency, concurrent,
and discriminant validity. The authors concluded that
the instrument measures relevant and distinct
domains of QoL for children surviving cancer, but
they suggested that certain changes would improve
the measure for this population. The Self-Perception
and Relationships Tool (S-PRT), a subjective measure
of HRQoL validated in a clinical sample (psychiatric
patients, cardiology, nephrology, oncology, sleep dis-
orders, or chronic pelvic pain), has 36 items arranged
in five domains: Intrapersonal Well-being (physical,
mental and emotional), Interpersonal Receptivity,
Interpersonal Contribution, Transpersonal Receptivity,
and Transpersonal Orientation. The last two scales are
spiritual dimensions concerning characteristics or
beliefs and feelings towards the universal principles or
divine presence (Atkinson, Wishart, & Wasil, 2004).
Brazilian research involving quality-of-life,
spirituality, and religious/spiritual coping
Although religion is an important cultural element in
Brazilian culture, there are relatively few studies that
focused on its impact on quality-of-life and health.
Below we wil describe two studies investigating the
relationship between QoL and Religiosity/Spirituality
held in south Brazil.
In 2002, there was a controlled cross-sectional
study (Rocha, 2002) in order to verify the association
between quality-of-life, health status, and levels of
spirituality, religiousness, and personal beliefs (SRBP).
The sample was composed of 122 hospitalized patients
INTERNATIONAL REVIEW OF PSYCHIATRY 267

and 119 healthy controls in the community. Each par-
ticipant (n¼241) responded to the following instru-
ments: Beck Depression Inventory (BDI), Beck
Hopelessness Inventory (BHS), WHOQoL-100, and
WHOQOL-SRBPi (Scale of importance given to the
facets of WHOQoL-SRBP, used test pilot). The sample
was matched by sex, age, and religion. Student t-test
for independent samples showed that the mean BDI
scores were higher for patients (10.55 ± 8.46) com-
pared to controls (5.54 ± 5.68, p0.0001). The same
happened to the average scores of BHS: 3.68 ± 3.16
and 2.76 ± 2.65 (p0.007), respectively. In the
WHOQoL-100, patients showed worse QoL scores
than the healthy subjects, with a significant difference
in all areas, except in the SRBP domain, in which
patients had higher not statistically significant scores.
The data are consistent with literature that shows
greater use of Religiousness/Spirituality to cope with
disease (Pargament & Hahn, 1986; Siegel, Anderman,
& Schrimshaw, 2001; Tix & Frazier, 1998). Thus, the
presence of a disease may be associated with worsen-
ing in most areas of QoL, except in the field of SRBP.
The WHOQoL-SRBPi score for patients (96.9) was
higher compared to the average score of healthy con-
trols (92.9, p0.03). After multiple regression, includ-
ing socioeconomic status (SES) as an independent
variable, this difference was no longer significant,
indicating that, despite patients giving more import-
ance to the R/S, the importance of this dimension for
healthy individuals is also high considering that the
score maximum for importance was 100. The differ-
ence between patients and healthy controls could be
under-estimated in this study, as healthy individuals
were not selected in the community but were active
members of religion communities and, therefore,
tended to have higher scores of religiousness and spir-
ituality than the general population. The difference,
therefore, could be explained by the greater need of
support associated with illness (Koenig et al., 2001;
Landis, 1996; Pargament & Brant, 1998), the search
for a meaning or explanation for the illness (Ross,
1995), or even the attempt of healing through faith
(Rabelo, 1993).
Also in a multiple regression model, the
WHOQoL-SRBPi appeared to be positively associated
with psychological health (beta ¼0.17), social
(beta ¼0.12), environment (beta ¼0.11), SRBP
(beta ¼0.72), and overall QoL (beta ¼0.10)
(0.10 p0.0001) when adjusted for age, SES,
depressive symptoms (BDI), and health status. This
demonstrated the importance given to spirituality/reli-
giousness/personal beliefs is positively associated with
most domains of QoL. This finding supports the lit-
erature that shows a positive relationship between
religiosity and social relationships (Levin, 1998; Levin
& Chatters, 1998; Levin & Vanderpool, 1987).
Regarding the psychological domain, it is known that
religiousness may be associated with lower levels of
depression (Braam, Beekman, & Deeg, 1997; Koenig
et al., 1998) and higher levels of hope and well-being
(Elerhorst-Ryan & Spilker, 1996), which may also
explain the positive correlation with overall QoL.
The authors concluded that (1) although the
increase in the WHOQoL-SRBPi (scores of import-
ance of the facets of SRBP) is influenced by other fac-
tors, especially NSE, spirituality/religiousness/personal
beliefs had a positive association with some domains
of QoL; and (2) although it is a cross-sectional study
and it is not possible to establish a cause–effect rela-
tionship, the data presented suggest that the R/S
should be considered as an important factor associ-
ated with both the disease and the process of coping
with the disease.
In 2004, a cross-sectional survey that validated the
Scale of Religious-Spiritual Coping scale (SRCOPE
scale) (Panzini & Bandeira, 2005) investigated the
expected relationship between quality-of-life, religious-
ness, and spiritual coping and health. The 616 partici-
pants belonged to different religions and beliefs:
40.4%Catholics; 31.5%spiritualists; 8.3%Spiritualists
without religion; 7.5%Evangelics; 4.2%two or more
religions simultaneously; 3,9 Umbanda; 2.2%other
religions, and 2%atheists/agnostics.
The results showed a positive association between
overall QoL and SRCOPE. SRCOPE total scores,
which consider the mean scores of positive and nega-
tive SRCOPE, were positively correlated with all QoL
domains of WHOQoL-bref. The negative SRCOPE
score was correlated (negatively) with QoL at higher
levels than the SRCOPE positive score was correlated
(positively) with QoL, indicating a significant adverse
effect of the negative SRCOPE on QoL. It was also
shown that those with higher scores of quality-of-life
have higher scores in positive coping and lower in
negative coping.
Further analysis showed that participants who used
more spiritual and religious coping had higher levels
of QoL in all domains of WHOQoL-BREF, higher
levels of objective health, religious and spiritual
growth, compared to participants who used less. Since
it is cross-sectional study, however, it could not be
established as a causal relationship (the direction of
the association between QoL and SRC).
Panzini’s(2005) study confirmed previous
international data (Koenig et al., 1998; Pargament
268 R. G. PANZINI ET AL.

et al., 2001), showing in a Brazilian population that
there is a positive association between positive spirit-
ual and religious coping and quality-of-life and a
negative association between Quality-of-life and nega-
tive spiritual and religious coping. One proposition of
the authors is to use a rate between negative and posi-
tive coping as a more valid measure. The rate may
partly explain the conflicting results reported by dif-
ferent studies.
An overview of recent research
The first version of this paper was published in 2007,
including articles from 1975–2005. In order to evaluate
the development of this research field in the years since
then, we performed a brief review of recent advances
in the field of quality-of-life and spirituality research.
Relevant original quantitative articles indexed in
PubMed from 2006–2016 were evaluated with the key-
terms ‘quality of life AND spirituality’. From 860
papers that match the search terms, 87 were included
in the analysis (Abdel-Khalek, 2010; Akinboro et al.,
2014; Ali, Marhemat, Sara, & Hamid, 2015; Anye,
Gallien, Bian, & Moulton, 2013; Bai, Lazenby, Jeon,
Dixon, & McCorkle, 2015; Bakiono, Guiguimd
e,
Sanou, Ou
edraogo, & Robert, 2015; Balboni et al.,
2007; Basi
nski, Stefaniak, Stadnyk, Sheikh, &
Vingerhoets, 2013; Berg Torskenæs & Kalfoss, 2013;
Breitbart et al., 2015; Calvo et al., 2011; Canada,
Murphy, Fitchett, & Stein, 2016; Caqueo-Ur
ızar,
Alessandrini, Zendjidjian, Urz
ua, Boyer, & Williams,
2016; Cassia Amaral et al., 2015; Charlson et al., 2014;
Colgrove, Kim, & Thompson, 2007; Davison &
Jhangri, 2010,2013; Delaney, Barrere, & Helming,
2010; Delgado, 2007; Desbiens & Fillion, 2007;
Finocchiaro, Roth, & Connelly, 2014; Gerbershagen,
Trojan, Kuhn, Limmroth, & Bewermeyer, 2008;
Giovagnoli, Meneses, & da Silva, 2006; Hamren,
Chungkham, & Hyde, 2015; Henning, Kr€
ageloh,
Thompson, Sisley, Doherty, & Hawken, 2015; Holtz,
Sowell, VanBrackle, Velasquez, & Hernandez-Alonso,
2014; Jafari, Farajzadegan, et al., 2013; Jafari, Zamani,
et al., 2013; Kandasamy, Chaturvedi, & Desai, 2011;
Khanjari, Oskouie, & Langius-Ekl€
of, 2012; Kim,
Carver, & Cannady, 2015; Ko, Khurana, Spencer, Scott,
Hahn, & Hammes, 2007;Kr
€
ageloh, Billington,
Henning, & Chai, 2015;Kr
€
ageloh, Henning, Billington,
& Hawken, 2015; Krupski, Kwan, Fink, Sonn, Maliski,
& Litwin, 2006; Lanfredi et al., 2014; Lazenby &
Khatib, 2012; Lazenby, Khatib, Al-Khair, & Neamat,
2013; Leak, Hu, & King, 2008; Lee, Nezu, & Nezu,
2014; Leeson, et al., 2015; Leow, Chan, & Chan, 2014;
Lim & Yi, 2009; Lucchetti, de Almeida, & Lucchetti,
2012; Lucchetti, et al., 2011; Lucchetti, et al., 2014;
Maggi, et al., 2012; M. E. L. P. D, D, N, S, & D, 2014;
Matthews, Tejeda, Johnson, Berbaum, & Manfredi,
2012; Mandhouj, Etter, Courvoisier, & Aubin, 2012;
Mohebbifar, Pakpour, Nahvijou, & Sadeghi, 2015;
Mohr, et al., 2010; Mohr, et al., 2011; Molzahn, 2007;
Moon & Kim, 2013; Nolan et al., 2012; Panzini et al.,
2011; Pipe et al., 2008;Pr

eau, Bouhnik, & Le Coroller
Soriano, 2013; Prince-Paul, 2008; Rohani, Abedi,
Omranipour, & Langius-Ekl€
of, 2015; Saffari et al.,
2013; Salsman, Yost, West, & Cella, 2011; Samuelson,
Fromme, & Thomas, 2012; Selman et al., 2011;
Sharma, Astrow, Texeira, & Sulmasy, 2012; Skevington,
Gunson, & O’Connell, 2013; Shah, Kulhara, Grover,
Kumar, Malhotra, & Tyagi, 2011; Son et al., 2012;
Stroppa & Moreira-Almeida, 2013; Taheri Kharame,
Zamanian, Foroozanfar, & Afsahi, 2014; Tadwalkar et
al., 2014; Tarakeshwar et al., 2006; Tedrus, Fonseca, De
Pietro Magri, & Mendes, 2013; Thomas & Washington,
2012; Trevino & McConnell, 2014,2015; Vallurupalli
et al., 2012; Vilhena et al., 2014; Wang, Chan, Ng, &
Ho, 2008; Whitford & Olver, 2012; Whitford, Olver, &
Peterson, 2008; Wildes, Miller, de Majors, & Ramirez,
2009; Winkelman et al., 2011; Zavala, Maliski, Kwan,
Fink, & Litwin, 2009; Zhang 2014).
The research showed a relative growing interest in
the research of spirituality and its relationships with
quality-of-life (Figure 1). A wide distribution of
regions around the world and cultures evaluating
these topics extend the relevance and validity of find-
ings. This study has identified publications about R/S
and quality-of-life in 29 different countries. The coun-
tries with more publications were the US (32 articles),
Iran (seven articles), Brazil (six articles), Italy (four),
India (three), Canada (three), and New Zealand
(three). To evaluate each specific article, see the
Supplementary material.
Figure 1. Number of articles published by year with the
PubMed search terms ‘quality of life’and ‘spirituality’.
INTERNATIONAL REVIEW OF PSYCHIATRY 269

Table 1. Original studies.
Title Main author QoL measure
Religiosity/
spirituality measures Country Year Journal
1 Religion involvement and quality-of-life in patients
with schizophrenia in Latin America
Caqueo-Ur

ızar A S-QoL 18 Religion involvement (RI) Chile, Peru, Bol

ıvia 2015 Soc Psychiatry Psychiatr
Epidemiol
2 Quality-of-life in persons living with HIV in
Burkina Faso: a follow-up over 12 months
Bakiono F WHOQOL HIV-BREF WHOQOL SRPB items Burkina Faso 2015 BMC Public Health
3 Relationship between spiritual health and quality-
of-life in patients with cancer
Mohebbifar R European Organization for
Research and Treatment
of Cancer Quality of Life
Questionnaire (EORTC-
QLQ)
Spiritual Health
Questionnaire
Iran 2015 Asian Pac J Cancer Prev
4 Re-examining the contributions of faith, meaning,
and peace to quality-of-life: a report from the
American Cancer Society’s Studies of Cancer
Survivors-II (SCS-II)
Canada AL SF-36 FACIT-Sp USA 2016 Ann Behav Med
5 Health-related quality-of-life and the predictive
role of sense of coherence, spirituality, and reli-
gious coping in a sample of Iranian women
with breast cancer: a prospective study with
comparative design
Rohani C European Organization for
Research and Treatment
of Cancer QLQ-C30
Spiritual Perspective
Scale and the Brief
Religious Coping Scale
Iran 2015 Health Qual Life
Outcomes
6 The relationship between spiritual well-being and
quality-of-life among elderly people
Ali J SF-36 Ellison & Palutzian
Spiritual Well-Being
Index
Iran 2015 Holist Nurs Pract
7 Religiosity and spirituality during cardiac rehabili-
tation: a longitudinal evaluation of patient-
reported outcomes and exercise capacity
Trevino KM Heart disease–specific QOL
questionnaire
Spiritual and Religious
Concerns
Questionnaire (SRCQ),
Religiosity Measure
(RM) and Religious
Coping Activities Scale
USA 2015 J Cardiopulm Rehabil
Prev
8 Caregiving motivation predicts long-term spiritual-
ity and quality-of-life of the caregivers
Kim Y Medical Outcomes Study
12-Item Short Form (MOS
SF-12)
FACIT-Sp USA 2015 Ann Behav Med
9 Spirituality and the recovery of quality-of-life fol-
lowing hematopoietic stem cell transplantation
Leeson LA Functional Assessment of
Chronic Illness Therapy
(FACIT)
FACIT-Sp USA 2014 Health Psychol
10 Quality-of-life of Nigerians living with human
immunodeficiency virus
Pan Afr Med J. WHOQOL-HIV BREF Nigeria 2014 Pan Afr Med J
11 Religion, spirituality, social support, and quality-
of-life: measurement and predictors CASP-
12(v2) amongst older Ethiopians living in Addis
Ababa
Hamren K CASP-12(v2) Brief Multidimensional
Measures of
Religiousness/
Spirituality (BMMRS)
Ethiopia 2015 Aging Ment Health
12 Quality-of-life in a large cohort of adult Brazilian
patients with 46,XX and 46,XY disorders of sex
development from a single tertiary centre
Cassia Amaral R WHOQoL-BREF Brazil 2015 Clin Endocrinol (Oxf)
13 The relationship between quality-of-life and spir-
ituality, religiousness, and personal beliefs of
medical students
Kr€
ageloh CU WHOQoL-BREF WHOQoL-SRPB New Zealand 2015 Acad Psychiatry
14 Religious wellbeing as a predictor for quality-of-
life in Iranian hemodialysis patients
Taheri Kharame Z SF-36 Spiritual wellbeing Scale Iran 2014 Glob J Health Sci
15 Exploring the relationship between spiritual well-
being and quality-of-life among patients newly
diagnosed with advanced cancer
Bai M Functional Assessment of
Cancer Therapy-General
(FACT-G)
FACIT-Sp-12 USA 2015 Palliat Support Care
(continued)
270 R. G. PANZINI ET AL.

Table 1. Continued
Title Main author QoL measure
Religiosity/
spirituality measures Country Year Journal
16 Religiosity and religious coping in patients with
cardiovascular disease: change over time and
associations with illness adjustment
Trevino KM Quality-of-Life after Acute
Myocardial Infarction
(QLMI) Questionnaire
Religious Coping
Activities Scale,
Religiosity Measure
USA 2014 J Relig Health
17 Spiritual well-being as predictor of quality-of-life
for adults with paraplegia
Finocchiaro DN QoL Scale Ellison’s SWB Scale USA 2014 Rehabil Nurs
18 A quantitative study of factors influencing quality-
of-life in rural Mexican women diagnosed with
HIV
Holtz C HAT-QoL Instrument Coping scale, spirituality
sub-scale
Mexico 2014 J Assoc Nurses AIDS Care
19 The effect of service satisfaction and spiritual
well-being on the quality-of-life of patients
with schizophrenia
Lanfredi M WHOQoL-Bref Spiritual Well-being scale Italy 2014 Psychiatry Res
20 Positive and negative religious coping, depressive
symptoms, and quality-of-life in people with
HIV
Lee M HAT-QoL Religious Coping Scale
(RCOPE)
USA 2014 J Behav Med
21 Psychosocial factors as predictors of quality-of-life
in chronic Portuguese patients
Vilhena E SF-36 Spirituality of the
Portuguese population
Portugal 2014 Health Qual Life
Outcomes
22 Predictors of change in quality-of-life of family
caregivers of patients near the end of life with
advanced cancer
Leow MQ CQOLC Spiritual Perspective
Scale
Singapore 2014 Cancer Nurs
23 The relationship between spiritual well-being and
health-related quality-of-life in college students
Anye ET Centers for Disease Control
and Prevention's scale for
HRQL
Spiritual Well-Being Scale USA 2013 J Am Coll Health
24 Religious affiliation, quality-of-life, and academic
performance: New Zealand medical students
Henning MA WHOQoL-BREF WHOQoL-SRPB, religious
affiliation
New Zealand 2015 J Relig Health
25 Spiritual/religious coping in patients with epilepsy:
relationship with sociodemographic and clinical
aspects and quality-of-life
Tedrus GM Quality-of-Life in Epilepsy
Inventory-31 (QOLIE-31)
Spiritual/Religious
Coping (SRCOPE)
Scale
Brazil 2013 Epilepsy Behav
26 Association between religiosity/spirituality and
quality-of-life or depression among living-alone
elderly in a South Korean city
Moon YS Geriatric Quality-of-Life—
Dementia (GQ-L-D)
Duke Religion Index
(DUREL)
South Korea 2013 Asia Pac Psychiatry
27 Nursing home care: exploring the role of reli-
giousness in the mental health, quality-of-life
and stress of formal caregivers
Lucchetti G SF-36 Duke Religion Index
(DUREL)
Brazil 2014 J Psychiatr Ment Health
Nurs
28 Religiosity, mood symptoms, and quality-of-life in
bipolar disorder
Stroppa A WHOQ0L-BREF Duke Religion Index
(DUREL)
Brazil 2013 Bipolar Disord
29 Personal spiritual values and quality-of-life: evi-
dence from Chinese college students
Zhang KC WHOQ0L-BREF 57-item Schwartz’Value
Survey, spiritual values
item
China 2014 J Relig Health
30 Spiritual coping, religiosity, and quality-of-life: a
study on Muslim patients undergoing
haemodialysis
Saffari M EuroQol Group EQ-5D-3L Spiritual coping strat-
egies, Duke University
Religion Index
Iran 2013 Nephrology (Carlton)
31 Two years after cancer diagnosis, what is the rela-
tionship between health-related quality-of-life,
coping strategies and spirituality?
Pr
eau M SF36 Degree the importance
of religion in their
lives
France 2013 Psychol Health Med
32 Spiritual well-being and quality-of-life in Iranian
women with breast cancer undergoing radi-
ation therapy
Jafari N European Organization for
Research and Treatment
of Cancer Quality of Life
(EORTC QLQ-C30) and
breast cancer question-
naire (QLQ-BR23)
Spiritual Well-Being Scale
(FACIT-Sp12)
Iran 2013 Support Care Cancer
(continued)
INTERNATIONAL REVIEW OF PSYCHIATRY 271

Table 1. Continued
Title Main author QoL measure
Religiosity/
spirituality measures Country Year Journal
33 Religious coping and quality-of-life among individ-
uals living with schizophrenia
Nolan JA WHOQoL-BREF 14-item RCOPE USA 2012 Psychiatr Serv
34 Associations among patient characteristics, health-
related quality-of-life, and spiritual well-being
among Arab Muslim cancer patients
Lazenby M FACT-G FACIT-Sp Jordan 2012 J Palliat Med
35 The relationship between spirituality, psychosocial
adjustment to illness, and health-related qual-
ity-of-life in patients with advanced chronic
kidney disease
Davison SN Kidney Dialysis Quality-of-
Life Short Form
Spiritual Well-Being Scale Canada 2013 J Pain Symptom Manage
36 Role of spiritual beliefs on disability and health-
related quality-of-life in acute inpatient
rehabilitation unit
Maggi L SF-36 Royal Free Interview for
Spiritual and Religious
Beliefs (RFI)
Italy 2012 Eur J Phys Rehabil Med
37 Correlates of quality-of-life among African
American and white cancer survivors
Cancer Nurs SF36 FACIT-SP USA 2012 Cancer Nurs
38 The factors associated with the quality-of-life of
the spouse caregivers of patients with cancer:
a cross-sectional study
Son KY Korean version of the
Caregiver Quality-of-Life
Index-Cancer (CQoLC)
FACIT-Sp South Korea 2012 J Palliat Med
39 Religiousness, mental health, and quality-of-life in
Brazilian dialysis patients
Lucchetti G WHOQoL-BREF Private and Social
Religious Practice
Scale
Brazil 2012 Hemodial Int
40 Changes in spirituality and quality-of-life in
patients undergoing radiation therapy
Samuelson BT FACT-G FASCIT Sp-12 USA 2012 Am J Hosp Palliat Care
41 The role of spirituality and religious coping in the
quality-of-ife of patients with advanced cancer
receiving palliative radiation therapy
Vallurupalli M McGill QoL Questionnaire Fetzer Multidimensional
Measure of
Religiousness/
Spirituality
USA 2012 J Support Oncol
42 Contribution of spirituality to quality-of-life in
patients with residual schizophrenia
Shah R WHOQoL-100 WHOQoL-SRPB India 2011 Psychiatry Res
43 The relationship of spiritual concerns to the qual-
ity-of-life of advanced cancer patients: prelim-
inary findings
Winkelman WD McGill QoL Questionnaire Fetzer Multidimensional
Measure of
Religiousness/
Spirituality and
Spiritual concerns
questions
USA 2011 J Palliat Med
44 Lower sense of coherence, negative religious cop-
ing, and disease severity as indicators of a
decrease in quality-of-life in Iranian family care-
givers of relatives with breast cancer during
the first 6 months after diagnosis
Khanjari S Caregiver Quality-of-Life
IndexYCancer (CQoLC),
Spirituality Perspective
Scale (SPS), e Brief
Religious Coping
(RCOPE) Scale
Iran/Sweden 2012 Cancer Nurs
45 Religiosity and social support: implications for the
health-related quality-of-life of African
American hemodialysis patients
Thomas CJ SF-36v2 Measure of Religious
Involvement
USA 2012 J Relig Health
46 Quality-of-life among patients receiving palliative
care in South Africa and Uganda: a multi-cen-
tred study
Selman LE Missoula Vitas Quality-of-
Life Index (MVQoLI)
Spiritual domain MVQoLI South Africa,
Uganda
2011 Health Qual Life
Outcomes
47 The multidimensionality of spiritual wellbeing:
peace, meaning, and faith and their association
with quality-of-life and coping in oncology
Whitford HS FACT-G FACIT-Sp Australia 2012 Psychooncology
(continued)
272 R. G. PANZINI ET AL.

Table 1. Continued
Title Main author QoL measure
Religiosity/
spirituality measures Country Year Journal
48 Religiousness is positively associated with quality-
of-life of ALS caregivers
Calvo A McGill Quality-of-Life
Questionnaire (MQoL),
Idler Index of Religiosity Italy 2011 Amyotroph Lateral Scler
49 Religiousness affects mental health, pain, and
quality-of- life in older people in an outpatient
rehabilitation setting
Lucchetti G WHOQoL-Bref Private and Social
Religious Practice
Scale
Brazil 2011 J Rehabil Med
50 Influence of religiosity on the quality-of-life and
on pain intensity in chronic pancreatitis
patients after neurolytic celiac plexus block:
case-controlled study
Basi
nski A EORTC QLQ C-30 Open questions, religious
faith, and institucional
attendance
Poland 2013 J Relig Health
51 Spirituality, distress, depression, anxiety, and qual-
ity-of-life in patients with advanced cancer
Kandasamy A Functional assessment of
cancer therapy-Palliative
Care (FACT-pal)
FACIT-sp India 2011 Indian J Cancer
52 Spirituality and religiousness as predictive factors
of outcome in schizophrenia and schizo-affect-
ive disorders
Mohr S Visual Analogue Scale Semistructured interview
and Visual Analogue
Scale
Switzerland 2011 Psychiatry Res
53 Existential and religious dimensions of spirituality
and their relationship with health-related qual-
ity-of-life in chronic kidney disease
Davison SN Kidney Dialysis Quality-of-
Life Short Form
ESRD Spiritual Beliefs
Scale, Spiritual
Perspective Scale, and
the Spiritual Well-
Being Scale
Canada 2010 Clin J Am Soc Nephrol
54 Quality-of-life, subjective well-being, and religios-
ity in Muslim college students
Abdel-Khalek AM Arabic version of WHOQoL-
Bref
Open questions: What is
your level of religios-
ity in general?
What is the strength
of your religious belief
when compared to
others?
Kuwait 2010 Qual Life Res
55 Spiritual well-being and health-related quality-of-
life in colorectal cancer: a multi-site examin-
ation of the role of personal meaning
Salsman JM FACT-Colorectal (FACT-C) FACIT-Sp
Spiritual well-being
(SpWB)
USA 2011 Support Care Cancer
56 The effects of religiosity, spirituality, and social
support on quality-of-life: a comparison
between Korean American and Korean breast
and gynecologic cancer survivors
Lim JW SF-36 Spiritual well-being sub-
scale of the Quality-
of-Life–Cancer
Survivor (QOL-CS)
measure
USA 2009 Oncol Nurs Forum
57 Evolution of spirituality and religiousness in
chronic schizophrenia or schizo-affective disor-
ders: a 3-years follow-up study
Mohr S WHOQoL-BREF Semi-structured interview Switzerland 2010 Soc Psychiatry Psychiatr
Epidemiol
58 Spirituality and quality-of-life in low-income men
with metastatic prostate cancer
Zavala MW UCLA
Prostate Cancer Index
(PCI) short form and
RAND
SF-12
FACIT-Sp USA 2009 Psychooncology
59 The religiosity/spirituality of Latina breast cancer
survivors and influence on health-related qual-
ity-of-life
Wildes KA Functional Assessment of
Cancer Therapy -
General, Version 2 (FACT-
G), and FACT Breast
Cancer Sub-scale
Systems of Belief
Inventory –15
USA 2009 Psychooncology
(continued)
INTERNATIONAL REVIEW OF PSYCHIATRY 273

Table 1. Continued
Title Main author QoL measure
Religiosity/
spirituality measures Country Year Journal
60 A prospective descriptive study exploring hope,
spiritual well-being, and quality-of-life in hospi-
talized patients
Pipe TB USA 2008 Medsurg Nurs
61 Significance of health-related quality-of-life and
religiosity for the acceptance of chronic pain
Gerbershagen K SF-12 Structure of religiosity
test
Germany 2008 Schmerz
62 The impact of spirituality on health-related qual-
ity-of-life among Chinese older adults with
vision impairment
Wang CW Vision Related
Quality-of-Life Scale and
SF-12
Chinese Spirituality Scale
(CSS)
China 2008 Aging Ment Health
63 Relationships among communicative acts, social
well-being, and spiritual well-being on the
quality-of-life at the end of life in patients with
cancer enrolled in hospice
Prince-Paul M FACT-G and single-item QoL
indicator of the QUAL-E
JAREL Spiritual Well-
Being tool
USA 2008 J Palliat Med
64 Spirituality as a core domain in the assessment of
quality-of-life in oncology
Whitford HS Mental Adjustment to
Cancer (MAC) scale
FACIT-Sp Australia 2008 Psychooncology
65 Symptom distress, spirituality, and quality-of-life
in African American breast cancer survivors
Leak A Quality-of-Life Index-Cancer
Version
Spiritual Perspective
Scale
USA 2008 Cancer Nurs
66 Coping strategies, emotional outcomes, and spirit-
ual quality-of-life in palliative care nurses
Desbiens JF FACIT-sp FACIT-sp and COPE scale Canada 2007 Int J Palliat Nurs
67 Sense of coherence, spirituality, stress, and qual-
ity-of-life in chronic illness
Delgado C Quality of Life Index –
Pulmonary Version III
(QLI-PV)
Spiritual Transcendence
Scale (STS)
USA 2007 J Nurs Scholarsh
68 Religious beliefs and quality-of-life in an American
inner-city haemodialysis population
Ko B KDQoL Royal Free Score USA 2007 Nephrol Dial Transplant
69 Spirituality in later life: effect on quality-of-life Molzahn AE WHOQoL-100 Canada 2007 J Gerontol Nurs
70 The effect of spirituality and gender on the qual-
ity-of-life of spousal caregivers of cancer
survivors
Colgrove LA MOS Short Form-36 Functional Assessment of
Chronic Illness
Therapy-Spirituality
USA 2007 Ann Behav Med
71 Religiousness and spiritual support among
advanced cancer patients and associations with
end-of-life treatment preferences and quality-
of-life
Balboni TA McGill Quality-of-Life
questionnaire
Religiousness and spirit-
ual support, Brief
RCOPE
USA 2007 J Clin Oncol
72 Religious coping is associated with the quality-of-
life of patients with advanced cancer
Tarakeshwar N McGill QoL questionnaire RCOPE, Multidimensional
Measure of Religion/
Spirituality
USA 2006 J Palliat Med
73 The contribution of spirituality to quality-of-life in
focal epilepsy
Giovagnoli AR WHOQoL 100 WHOQoL-SRPB Italy 2006 Epilepsy Behav
74 Spirituality influences health-related quality-of-life
in men with prostate cancer
Krupski TL SF-12, UCLA Prostate Cancer
Index short form (PCISF)
FACIT-Sp USA 2006 Psychooncology
274 R. G. PANZINI ET AL.

Concerning the characteristics of the studies, 87%
were original studies (Table 1), 8%validation of
instruments (Table 2) (Berg Torskenæs & Kalfoss,
2013; Jafari, Zamani, et al., 2013;Kr
€
ageloh, Billington,
et al., 2015; Lazenby et al., 2013; Mandhouj et al.,
2012; Panzini et al., 2011; Sharma et al., 2012;
Skevington et al., 2013), and 5%intervention articles
(Table 3) (Breitbart, et al., 2015; Charlson et al., 2014;
Delaney et al., 2010; Lyon, Jacobs, Briggs, & Cheng,
2014; Tadwalkar et al., 2014).
The studies showed a great variety of spirituality
and QoL measures during the mentioned period. The
most used spirituality scales were Functional
Assessment of Chronic Illness Therapy-Spiritual Well-
Being Scale (FACIT-Sp) (21%), WHOQoL-SRPB
[10%], Spiritual Well-Being Scale (SWB) [10%],
Religious Coping Scale (RCOPE), and its brief
measure (Brief RCOPE Scale) (7%), Spiritual
Perspective Scale (SPS) [5%], Duke Religion Index
[4%], Fetzer Multidimensional Measures of
Religiousness/Spirituality (MMRS), and Brief Fetzer
MMRS (BMMRS) [4%], totalizing 61%.
The most used Quality-of-Life Scales were MOS SF
(36 or 12 items) [21.25%], WHOQoL (100, Bref or
HIV-Bref) [18.75%], FACT (FACT-G, FACT-G V2,
and Specific Diseases FACT-Palliative Care/Coloretal/
Breast Cancer) [13.50%]; medium used QoL Scales
was EORTC (EORTC-QLQ, EORTC QLQ-C30), and
McGill QoL [6.25%each one]; and lower used QoL
Scales was KDQoL and CQoLC [3.75%each one],
UCLA PCI-SF, HAT-QoL, and FACIT [2.50%each
one], totalizing 80%.
The most recent studies continue to indicate a
positive association between spirituality and QoL. The
Table 2. Validation studies.
Title Main author QoL measure Country Year
1 Spiritual quality-of-life and spiritual coping: evidence for a two-factor
structure of the WHOQoL spirituality, religiousness, and personal
beliefs module
Kr€
ageloh CU WHOQoL-SRPB New Zealand 2015
2 Translation and focus group testing of the WHOQoL spirituality, reli-
giousness, and personal beliefs module in Norway
Berg Torskenæs K WHOQoL-SRPB Norway 2013
3 Translation and validation of the Persian version of the functional
assessment of chronic illness therapy-Spiritual well-being scale
(FACIT-Sp) among Muslim Iranians in treatment for cancer
Jafari N FACIT-Sp Iran 2013
4 Introducing the WHOQoL-SRPB BREF: developing a short-form instru-
ment for assessing spiritual, religious, and personal beliefs within
quality-of-life
Skevington SM WHOQoL-SRPB UK 2013
5 The Spiritual Needs Assessment for Patients (SNAP): development
and validation of a comprehensive instrument to assess unmet
spiritual needs
Sharma RK SNAP USA 2012
6 French-language version of the World Health Organization quality-of-
life spirituality, religiousness, and personal beliefs instrument
Mandhouj O WHOQoL-SRPB France 2012
7 Psychometric properties of the Functional Assessment of Chronic
Illness Therapy–Spiritual Well-being (FACIT-Sp) in an Arabic-speak-
ing, predominantly Muslim population
Lazenby M FACIT-Sp USA 2013
8 Brazilian validation of the Quality-of-Life Instrument/spirituality, reli-
gion, and personal beliefs
Panzini RG WHOQoL-SRPB Brazil 2011
Table 3. Intervention studies.
Title Main author QoL measure
Religiosity/spirituality
measures Country Year
1 Meaning-centred group psychotherapy: an effective
intervention for improving psychological well-
being in patients with advanced cancer
Breitbart W MQoL Spiritual well-being USA 2015
2 Contemplative self healing in women breast cancer
survivors: a pilot study in under-served minority
women shows improvement in quality-of-life and
reduced stress
Charlson ME Functional
Assessment of
Cancer Therapy
Scale (FACT-G)
FACIT-Spirituality USA 2014
3 The beneficial role of spiritual counselling in heart
failure patients
Tadwalkar R QIDS-SR16 FACIT-Sp-Ex USA 2014
4 A longitudinal, randomized, controlled trial of
advance care planning for teens with cancer: anx-
iety, depression, quality-of-life, advance directives,
spirituality
Lyon ME Pediatric Quality-of-
Life
Spiritual Well-Being
Scale
USA 2014
5 The influence of a spirituality-based intervention on
quality-of-life, depression, and anxiety in commu-
nity-dwelling adults with cardiovascular disease: a
pilot study
Delaney C QoL
Index–Cardiac
Version
Spirituality Scale USA 2011
INTERNATIONAL REVIEW OF PSYCHIATRY 275

most studied patients are oncological (26%), with
chronic diseases (e.g., renal failure, HIV/AIDS) (17%)
and mental illnesses (8%). In the general population,
the most studied groups are caregivers, elderly, and
students. Interventional studies in spirituality are still
in the minority (5%), using mainly spiritual counsel-
ling or contemplative meditation.
Conclusions
There is consistent literature supporting the existence
of a positive relationship between spirituality and
quality-of-life. There are an increasing number of
researchers engaged in this topic in different countries
and in different areas. There are also valid and reliable
tools to access it and many studies with reasonable
methodological rigour.
In the development of QoL studies, the importance
of spiritual issues were recognized early and incorpo-
rated in some important generic instruments like
WHOQoL, for example. The quality-of-life field seems
to be a candidate to become a mediator between the
field of health and the one of religiosity/spirituality.
Since Quality-of-life is a more recent construct in
health, it is probably easier to incorporate new dimen-
sions in its scope. Also, since quality-of-life is a broad
and multidimensional construct, it is expected that it
could incorporate dimensions that show empirical
effects on its measurement.
An outline of the articles published since the first
version of this article in 2007 showed an increasing
interest in the field of quality-of-life and spirituality
research. The presence of studies in different countries
from different cultural backgrounds and regions
around the World constitutes another relanvant find-
ing to understand the relationship between spirituality
and quality-of-life.
Disclosure statement
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of this
article.
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