i An update to this article is included at the end

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Discussion

Retaining the meaning of the words religiousness and

spirituality: A commentary on the WHOQOL SRPB group’s
‘‘A cross-cultural study of spirituality, religion, and personal
beliefs as components of quality of life’’ (62: 6, 2005, 1486–1497)
Alexander Moreira-Almeidaa,b,, Harold G. Koeniga
a
Duke University Medical Center, Durham, NC, USA
b
University of Sao Paulo, Hospital Joao Evangelista, Sao Paulo, SP, Brazil
Available online 2 May 2006

Abstract

Recent years have seen increasing recognition paid to the relation of religiousness/spirituality (R/S) to health care and
research. This has led to the development of more inclusive and trans-culturally validated measurements of R/S. This paper
comments on the WHOQOL SRPB Group’s ‘‘A cross-cultural study of spirituality, religion, and personal beliefs as
components of quality of life’’ (62: 6, 2005, 1486–1497), a recently published paper in Social Science & Medicine, and
illustrates a possible problem in the measurement of R/S, especially as related to the study of mental health outcomes.
Some scales have included questions about psychological well-being, satisfaction, connectedness with others, hopefulness,
meaning and purpose in life, or altruistic values as part of their measure of R/S. These questions are really tapping
indicators of mental health, and should not be included in the definition of R/S itself. Otherwise, tautology is the result,
and it should not be surprising that such measures of R/S (defined by questions tapping mental health) are related to
mental health outcomes.
r 2006 Published by Elsevier Ltd.

Keywords: Definition; Well-being; Quality of life; Health

The importance of people’s religiousness and tuality, religion and personal beliefs (SRPB) (WHO-
spirituality for their well-being and health status has QOL SRPB Group, in press). We think it is a very
been widely acclaimed and is based on hundreds of welcome advance, since it highlights the importance
published studies (Koenig, McCullough, & Larson, of religiousness and spirituality to quality of life in
2001). Recently, this journal published a cross- many different cultures. Because almost all studies
cultural study involving 18 countries (n ¼ 5087) that and scales in this field were developed in the United
used the World Health Organization’s Quality of States, there is an urgent need for more trans-
Life Measure (WHOQOL) for assessment of spiri- culturally validated scales and replication of studies
in different countries.
Corresponding author. Tel.: 1 919 309 1405. We would like to utilize this study to discuss the
E-mail addresses: [email protected] (A. Moreira-Almeida), pitfall that exists when one tries to create an
[email protected] (H.G. Koenig). inclusive and worldwide-acceptable measure of

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 ARTICLE IN PRESS
844 A. Moreira-Almeida, H.G. Koenig / Social Science & Medicine 63 (2006) 843–845

spirituality and religiousness: the risk of being too religious/spiritual life (Moreira-Almeida, Lotufo
broad and losing the core meaning of these words. Neto, & Koenig, 2006). So, they can be outcomes
We think this is the case with a number of scales in of religiousness, but we argue that they are not,
common use today, such as the Spiritual Well-Being themselves, religiousness or spirituality. For exam-
Scale (SWBS) (Paloutzian & Ellison, 1982), Func- ple, the acceptance of the Marxist historical
tional Assessment of Chronic Illness Therapy- materialism can give someone a strong sense of
Spiritual Well-Being (FACIT-Sp) (Brady, Peter- meaning in life and optimism (believing in the future
man, Fitchett, Mo, & Cella, 1999) and the development of society towards a communist
WHOQOL SRPB. These instruments include ques- society) so much so that many people have given
tions that tap psychological well-being, mental their lives voluntarily to this ideology. However,
health, meaning and purpose in life and altruistic they would probably take offense at being called
values that confound any findings where mental spiritual or religious.
health is the outcome. Is it not surprising that Even the three facets that have some more direct
psychological health is correlated with psychologi- connection with spirituality (connectedness to a
cal health? Constructs such as well-being, meaning spiritual being or force, spiritual strength, and faith)
in life, and altruistic activities are usually, but not may not actually reflect any sort of spirituality, as
necessarily, related to spirituality—but should they stated in the preamble of the SRPB questionnaire:
be included in the definition itself? ‘‘While some of these questions will use words such as
Undoubtedly, the definitions of religiousness and spirituality, please answer them in terms of your own
spirituality have a long history of controversy. personal belief system, whether it be religious,
However, there is general agreement that these spiritual or personal.’’ (WHOQOL, p. 3)
constructs are related to the search for the sacred or One piece of evidence that these three facets are
transcendent, which includes concepts of God, a tapping something different from the other facets is
higher power, the divine, and/or ultimate reality. given by the results comparing the scores of people
The sacred represents the most vital destination with different health status. From all the eight
sought by the religious/spiritual person (Hill & facets, the only three facets that scored higher
Pargament, 2003). In the Merriam-Webster’s Dic- among currently ill comparing to currently well
tionary spirituality is defined as ‘‘sensitivity or people were exactly connectedness to a spiritual
attachment to religious values’’ or ‘‘the quality or being or force, spiritual strength, and faith (only
state of being spiritual’’ (spiritual is defined as ‘‘of or faith was statistically significant). This usually
relating to sacred matters’’ or ‘‘of, relating to, reflects the turning to religion by sick people to
consisting of, or affecting the spirit : incorporeal’’). cope with the illness.
In our work, we have used the following Some of the problems we address here were raised
definitions (Koenig et al., 2001): in the Brazilian focus groups during the develop-
ment process of the WHOQOL SRPB. Groups of

Religion: is an organized system of beliefs, patients suggested that questions without a clear
practices, rituals, and symbols designed to facil- relation to religiousness should be eliminated
itate closeness to the sacred or transcendent exactly because they were not related to religious-
(God, higher power, or ultimate truth/reality). ness. In contrast, health professionals and atheists

Spirituality: is the personal quest for under- criticized the questions that carried a religious
standing answers to ultimate questions about life, connotation (Fleck, Chachamovich, & Trentini,
about meaning, and about relationship with the 2003).
sacred or transcendent, which may (or may not) We strongly agree with the importance of
lead to or arise from the development of religious including hope, meaning of life, optimism, forgive-
rituals and the formation of community. ness and sense of awe and wonder in a well-being or
quality of life instrument. However, we think that
Among the eight facets of the WHOQOL SRPB calling these constructs ‘‘spirituality’’ only adds
scale, five are not measuring religion or spirituality confusion. Qualities such as meaning of life, hope,
(Meaning of life, Awe, Wholeness & integration, optimism, wholeness, serenity, and awe already
Inner peace/ serenity/harmony, Hope & optimism). have names that describe these constructs; there is
These constructs have been associated with religious little reason to include them under a new category,
involvement and can be a consequence of a spirituality (a term that involves relationship to the
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A. Moreira-Almeida, H.G. Koenig / Social Science & Medicine 63 (2006) 843–845 845

sacred or the transcendent). The major reason for References

concern with these scales is that in using them,
spirituality will always be related to mental health, Brady, M. J., Peterman, A. H., Fitchett, G., Mo, M., & Cella, D.
because they, tautologically, define spirituality by (1999). A case for including spirituality in quality of life
measurement in oncology. Psychooncology, 8(5), 417–428.
positive human traits (Koenig et al., 2001). Fleck, M. P., Chachamovich, E., & Trentini, C. M. (2003).
Despite these concerns, we would like to empha- WHOQOL-OLD Project: Method and focus group results in
size that the WHOQOL SRPB module is a Brazil. Rev Saude Publica, 37(6), 793–799.
pioneering initiative in the trans-cultural and global Hill, P. C., & Pargament, K. I. (2003). Advances in the
conceptualization and measurement of religion and spiritual-
assessment of a dimension of human life that has
ity. Implications for physical and mental health research.
heretofore been excluded. The module provides an American Psychologist, 58(1), 64–74.
important template for future cross-cultural and Koenig, H. G., McCullough, M., & Larson, D. B. (2001).
cross-national research in the field of the epidemiol- Handbook of religion and health: A century of research
ogy of religion and quality of life measurements. reviewed. New York: Oxford University Press.
Discussion of results from studies that use this scale, Moreira-Almeida, A., Lotufo Neto, F., & Koenig, H. G. (2006).
Religiousness and Mental Health: A review. Revista Brasileira
however, should not fail to address the concerns de Psiquiatria, 28, in press.
mentioned above. Paloutzian, R. F., & Ellison, C. W. (1982). Loneliness, spiritual
well-being and quality of life. In L. A. Peplau, & D. Perlman
(Eds.), Loneliess: A sourcebook of current theory, research and
Acknowledgment therapy (pp. 224–237). New York: Wiley.
WHOQOL SRPB Group. (in press). A cross-cultural study of
spirituality, religion, and personal beliefs as components
Alexander Moreira-Almeida was supported by of quality of life. Social Science & Medicine, 62(6), 1486–1497,
grant from the Hospital João Evangelista, Brazil. in press.
 Update
Social Science & Medicine
Volume 63, Issue 10, November 2006, Page 2753

DOI: https://doi.org/10.1016/j.socscimed.2006.08.001
 ARTICLE IN PRESS

Social Science & Medicine 63 (2006) 2753

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Corrigendum

Corrigendum to: ‘‘Retaining the meaning of the words

religiousness and spirituality: A commentary on the WHOQOL
SRPB group’s ‘‘A cross-cultural study of spirituality, religion,
and personal beliefs as components of quality of life’’ (62(6),
2005, 1486–1497)’’
[Social Sci. Med. 63 (2006) 843–845]
Alexander Moreira-Almeidaa,b,, Harold G. Koeniga
a
Duke University Medical Center, Durham, NC, USA
b
Hospital Joao Evangelista, University of Sao Paulo, Sao Paulo, SP, Brazil
Available online 18 September 2006

It has come to the authors’ attention that an incorrect reference was listed in this paper. The authors
apologize for this error and the correct reference is given below.
Fleck, M. P., Borges, Z. N., Bolognesi, G., & da Rocha, N. S. (2003). Development of WHOQOL
spirituality, religiousness and personal beliefs module. Revista de Saude Publica, 37(4), 446–455.

DOI of original article: 10.1016/j.socscimed.2006.03.001

Corresponding author. Federal University of Juiz de Fora, MG, Brazil. Tel.:+55 32 3212 2444.
E-mail addresses: [email protected] (A. Moreira-Almeida), [email protected] (H.G. Koenig).

0277-9536/$ - see front matter r 2006 Published by Elsevier Ltd.

doi:10.1016/j.socscimed.2006.08.001