International Review of Psychiatry

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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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INTERNATIONAL REVIEW OF PSYCHIATRY, 2017
VOL. 29, NO. 3, 263–282
http://dx.doi.org/10.1080/09540261.2017.1285553

ARTICLE

Quality-of-life and spirituality

Raquel Gehrke Panzinia, Bruno Paz Mosqueiroa, Rog
erio R. Zimpela, Denise Ruschel Bandeirab,
Neusa S. Rochaa and Marcelo P. Flecka
a
Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre-RS, Brazil; bDepartment of Psychology,
Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre-RS, Brazil

ABSTRACT KEYWORDS
Spirituality has been identified as an important dimension of quality-of-life. The objective of this Quality-of-life; spirituality;
study was to review the literature on quality-of-life and spirituality, their association, and assess- religiosity; evaluation;
ment tools. A search was conducted of the keyterms ‘quality-of-life’ and ‘spirituality’ in abstract instruments
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.

Introduction statistically valid and possibly causal (Levin, 1994).

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
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.
ß 2017 Institute of Psychiatry and Johns Hopkins University
264 R. G. PANZINI ET AL.
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,

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;
INTERNATIONAL REVIEW OF PSYCHIATRY 265
(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 (l ¼ 54.6 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 (n ¼ 40, 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 (l ¼ 37 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
266 R. G. PANZINI ET AL.
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

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 (n ¼ 5087) [Argentina (n ¼ 221),
Brazil (Porto Alegre, n ¼ 253, Santa Maria, n ¼ 253),
Uruguay (n ¼ 251), Italy (n ¼ 376), Spain
(n ¼ 240), Lithuania (n ¼ 482), Turkey (n ¼ 240), UK
(n ¼ 283), Egypt (n ¼ 240), Kenya (n ¼ 480), Israel
(n ¼ 270), India (Bangalore, n ¼ 240, Pondicherry,
n ¼ 364), China (n ¼ 259), Japan (n ¼ 226), Thailand
(n ¼ 118), and Malaysia (n ¼ 240)]. 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
INTERNATIONAL REVIEW OF PSYCHIATRY 267
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
268 R. G. PANZINI ET AL.
and 119 healthy controls in the community. Each par-
ticipant (n ¼ 241) 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 ¼ 0.17), social
(beta ¼ 0.12), environment (beta ¼ 0.11), SRBP
(beta ¼ 0.72), and overall QoL (beta ¼ 0.10)
(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

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,
INTERNATIONAL REVIEW OF PSYCHIATRY 269
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’.
Table 1. Original studies.
270

Religiosity/
Title Main author QoL measure spirituality measures Country Year Journal
1 Religion involvement and quality-of-life in patients Caqueo-Ur
ızar A S-QoL 18 Religion involvement (RI) Chile, Peru, Bol
ıvia 2015 Soc Psychiatry Psychiatr
with schizophrenia in Latin America Epidemiol
2 Quality-of-life in persons living with HIV in Bakiono F WHOQOL HIV-BREF WHOQOL SRPB items Burkina Faso 2015 BMC Public Health
Burkina Faso: a follow-up over 12 months
3 Relationship between spiritual health and quality- Mohebbifar R European Organization for Spiritual Health Iran 2015 Asian Pac J Cancer Prev
of-life in patients with cancer Research and Treatment Questionnaire
of Cancer Quality of Life
R. G. PANZINI ET AL.

Questionnaire (EORTC-
QLQ)
4 Re-examining the contributions of faith, meaning, Canada AL SF-36 FACIT-Sp USA 2016 Ann Behav Med
and peace to quality-of-life: a report from the
American Cancer Society’s Studies of Cancer
Survivors-II (SCS-II)
5 Health-related quality-of-life and the predictive Rohani C European Organization for Spiritual Perspective Iran 2015 Health Qual Life
role of sense of coherence, spirituality, and reli- Research and Treatment Scale and the Brief Outcomes
gious coping in a sample of Iranian women of Cancer QLQ-C30 Religious Coping Scale
with breast cancer: a prospective study with
comparative design
6 The relationship between spiritual well-being and Ali J SF-36 Ellison & Palutzian Iran 2015 Holist Nurs Pract
quality-of-life among elderly people Spiritual Well-Being
Index
7 Religiosity and spirituality during cardiac rehabili- Trevino KM Heart disease–specific QOL Spiritual and Religious USA 2015 J Cardiopulm Rehabil
tation: a longitudinal evaluation of patient- questionnaire Concerns Prev
reported outcomes and exercise capacity Questionnaire (SRCQ),
Religiosity Measure
(RM) and Religious
Coping Activities Scale
8 Caregiving motivation predicts long-term spiritual- Kim Y Medical Outcomes Study FACIT-Sp USA 2015 Ann Behav Med
ity and quality-of-life of the caregivers 12-Item Short Form (MOS
SF-12)
9 Spirituality and the recovery of quality-of-life fol- Leeson LA Functional Assessment of FACIT-Sp USA 2014 Health Psychol
lowing hematopoietic stem cell transplantation Chronic Illness Therapy
(FACIT)
10 Quality-of-life of Nigerians living with human Pan Afr Med J. WHOQOL-HIV BREF Nigeria 2014 Pan Afr Med J
immunodeficiency virus
11 Religion, spirituality, social support, and quality- Hamren K CASP-12(v2) Brief Multidimensional Ethiopia 2015 Aging Ment Health
of-life: measurement and predictors CASP- Measures of
12(v2) amongst older Ethiopians living in Addis Religiousness/
Ababa Spirituality (BMMRS)
12 Quality-of-life in a large cohort of adult Brazilian Cassia Amaral R WHOQoL-BREF Brazil 2015 Clin Endocrinol (Oxf)
patients with 46,XX and 46,XY disorders of sex
development from a single tertiary centre
13 The relationship between quality-of-life and spir- Kr€ageloh CU WHOQoL-BREF WHOQoL-SRPB New Zealand 2015 Acad Psychiatry
ituality, religiousness, and personal beliefs of
medical students
14 Religious wellbeing as a predictor for quality-of- Taheri Kharame Z SF-36 Spiritual wellbeing Scale Iran 2014 Glob J Health Sci
life in Iranian hemodialysis patients
15 Exploring the relationship between spiritual well- Bai M Functional Assessment of FACIT-Sp-12 USA 2015 Palliat Support Care
being and quality-of-life among patients newly Cancer Therapy-General
diagnosed with advanced cancer (FACT-G)
(continued)
Table 1. Continued
Religiosity/
Title Main author QoL measure spirituality measures Country Year Journal
16 Religiosity and religious coping in patients with Trevino KM Quality-of-Life after Acute Religious Coping USA 2014 J Relig Health
cardiovascular disease: change over time and Myocardial Infarction Activities Scale,
associations with illness adjustment (QLMI) Questionnaire Religiosity Measure
17 Spiritual well-being as predictor of quality-of-life Finocchiaro DN QoL Scale Ellison’s SWB Scale USA 2014 Rehabil Nurs
for adults with paraplegia
18 A quantitative study of factors influencing quality- Holtz C HAT-QoL Instrument Coping scale, spirituality Mexico 2014 J Assoc Nurses AIDS Care
of-life in rural Mexican women diagnosed with sub-scale
HIV
19 The effect of service satisfaction and spiritual Lanfredi M WHOQoL-Bref Spiritual Well-being scale Italy 2014 Psychiatry Res
well-being on the quality-of-life of patients
with schizophrenia
20 Positive and negative religious coping, depressive Lee M HAT-QoL Religious Coping Scale USA 2014 J Behav Med
symptoms, and quality-of-life in people with (RCOPE)
HIV
21 Psychosocial factors as predictors of quality-of-life Vilhena E SF-36 Spirituality of the Portugal 2014 Health Qual Life
in chronic Portuguese patients Portuguese population Outcomes
22 Predictors of change in quality-of-life of family Leow MQ CQOLC Spiritual Perspective Singapore 2014 Cancer Nurs
caregivers of patients near the end of life with Scale
advanced cancer
23 The relationship between spiritual well-being and Anye ET Centers for Disease Control Spiritual Well-Being Scale USA 2013 J Am Coll Health
health-related quality-of-life in college students and Prevention's scale for
HRQL
24 Religious affiliation, quality-of-life, and academic Henning MA WHOQoL-BREF WHOQoL-SRPB, religious New Zealand 2015 J Relig Health
performance: New Zealand medical students affiliation
25 Spiritual/religious coping in patients with epilepsy: Tedrus GM Quality-of-Life in Epilepsy Spiritual/Religious Brazil 2013 Epilepsy Behav
relationship with sociodemographic and clinical Inventory-31 (QOLIE-31) Coping (SRCOPE)
aspects and quality-of-life Scale
26 Association between religiosity/spirituality and Moon YS Geriatric Quality-of-Life— Duke Religion Index South Korea 2013 Asia Pac Psychiatry
quality-of-life or depression among living-alone Dementia (GQ-L-D) (DUREL)
elderly in a South Korean city
27 Nursing home care: exploring the role of reli- Lucchetti G SF-36 Duke Religion Index Brazil 2014 J Psychiatr Ment Health
giousness in the mental health, quality-of-life (DUREL) Nurs
and stress of formal caregivers
28 Religiosity, mood symptoms, and quality-of-life in Stroppa A WHOQ0L-BREF Duke Religion Index Brazil 2013 Bipolar Disord
bipolar disorder (DUREL)
29 Personal spiritual values and quality-of-life: evi- Zhang KC WHOQ0L-BREF 57-item Schwartz’ Value China 2014 J Relig Health
dence from Chinese college students Survey, spiritual values
item
30 Spiritual coping, religiosity, and quality-of-life: a Saffari M EuroQol Group EQ-5D-3L Spiritual coping strat- Iran 2013 Nephrology (Carlton)
study on Muslim patients undergoing egies, Duke University
haemodialysis Religion Index
31 Two years after cancer diagnosis, what is the rela- Pr
eau M SF36 Degree the importance France 2013 Psychol Health Med
tionship between health-related quality-of-life, of religion in their
coping strategies and spirituality? lives
32 Spiritual well-being and quality-of-life in Iranian Jafari N European Organization for Spiritual Well-Being Scale Iran 2013 Support Care Cancer
women with breast cancer undergoing radi- Research and Treatment (FACIT-Sp12)
ation therapy of Cancer Quality of Life
INTERNATIONAL REVIEW OF PSYCHIATRY

(EORTC QLQ-C30) and

breast cancer question-
naire (QLQ-BR23)
271

(continued)
Table 1. Continued
272

Religiosity/
Title Main author QoL measure spirituality measures Country Year Journal
33 Religious coping and quality-of-life among individ- Nolan JA WHOQoL-BREF 14-item RCOPE USA 2012 Psychiatr Serv
uals living with schizophrenia
34 Associations among patient characteristics, health- Lazenby M FACT-G FACIT-Sp Jordan 2012 J Palliat Med
related quality-of-life, and spiritual well-being
among Arab Muslim cancer patients
35 The relationship between spirituality, psychosocial Davison SN Kidney Dialysis Quality-of- Spiritual Well-Being Scale Canada 2013 J Pain Symptom Manage
adjustment to illness, and health-related qual- Life Short Form
R. G. PANZINI ET AL.

ity-of-life in patients with advanced chronic

kidney disease
36 Role of spiritual beliefs on disability and health- Maggi L SF-36 Royal Free Interview for Italy 2012 Eur J Phys Rehabil Med
related quality-of-life in acute inpatient Spiritual and Religious
rehabilitation unit Beliefs (RFI)
37 Correlates of quality-of-life among African Cancer Nurs SF36 FACIT-SP USA 2012 Cancer Nurs
American and white cancer survivors
38 The factors associated with the quality-of-life of Son KY Korean version of the FACIT-Sp South Korea 2012 J Palliat Med
the spouse caregivers of patients with cancer: Caregiver Quality-of-Life
a cross-sectional study Index-Cancer (CQoLC)
39 Religiousness, mental health, and quality-of-life in Lucchetti G WHOQoL-BREF Private and Social Brazil 2012 Hemodial Int
Brazilian dialysis patients Religious Practice
Scale
40 Changes in spirituality and quality-of-life in Samuelson BT FACT-G FASCIT Sp-12 USA 2012 Am J Hosp Palliat Care
patients undergoing radiation therapy
41 The role of spirituality and religious coping in the Vallurupalli M McGill QoL Questionnaire Fetzer Multidimensional USA 2012 J Support Oncol
quality-of-ife of patients with advanced cancer Measure of
receiving palliative radiation therapy Religiousness/
Spirituality
42 Contribution of spirituality to quality-of-life in Shah R WHOQoL-100 WHOQoL-SRPB India 2011 Psychiatry Res
patients with residual schizophrenia
43 The relationship of spiritual concerns to the qual- Winkelman WD McGill QoL Questionnaire Fetzer Multidimensional USA 2011 J Palliat Med
ity-of-life of advanced cancer patients: prelim- Measure of
inary findings Religiousness/
Spirituality and
Spiritual concerns
questions
44 Lower sense of coherence, negative religious cop- Khanjari S Caregiver Quality-of-Life Spirituality Perspective Iran/Sweden 2012 Cancer Nurs
ing, and disease severity as indicators of a IndexYCancer (CQoLC), Scale (SPS), e Brief
decrease in quality-of-life in Iranian family care- Religious Coping
givers of relatives with breast cancer during (RCOPE) Scale
the first 6 months after diagnosis
45 Religiosity and social support: implications for the Thomas CJ SF-36v2 Measure of Religious USA 2012 J Relig Health
health-related quality-of-life of African Involvement
American hemodialysis patients
46 Quality-of-life among patients receiving palliative Selman LE Missoula Vitas Quality-of- Spiritual domain MVQoLI South Africa, 2011 Health Qual Life
care in South Africa and Uganda: a multi-cen- Life Index (MVQoLI) Uganda Outcomes
tred study
47 The multidimensionality of spiritual wellbeing: Whitford HS FACT-G FACIT-Sp Australia 2012 Psychooncology
peace, meaning, and faith and their association
with quality-of-life and coping in oncology
(continued)
Table 1. Continued
Religiosity/
Title Main author QoL measure spirituality measures Country Year Journal
48 Religiousness is positively associated with quality- Calvo A McGill Quality-of-Life Idler Index of Religiosity Italy 2011 Amyotroph Lateral Scler
of-life of ALS caregivers Questionnaire (MQoL),
49 Religiousness affects mental health, pain, and Lucchetti G WHOQoL-Bref Private and Social Brazil 2011 J Rehabil Med
quality-of- life in older people in an outpatient Religious Practice
rehabilitation setting Scale
50 Influence of religiosity on the quality-of-life and Basin

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

Cancer Sub-scale
(continued)
273
Table 1. Continued
274

Religiosity/
Title Main author QoL measure spirituality measures Country Year Journal
60 A prospective descriptive study exploring hope, Pipe TB USA 2008 Medsurg Nurs
spiritual well-being, and quality-of-life in hospi-
talized patients
61 Significance of health-related quality-of-life and Gerbershagen K SF-12 Structure of religiosity Germany 2008 Schmerz
religiosity for the acceptance of chronic pain test
62 The impact of spirituality on health-related qual- Wang CW Vision Related Chinese Spirituality Scale China 2008 Aging Ment Health
ity-of-life among Chinese older adults with Quality-of-Life Scale and (CSS)
R. G. PANZINI ET AL.

vision impairment SF-12

63 Relationships among communicative acts, social Prince-Paul M FACT-G and single-item QoL JAREL Spiritual Well- USA 2008 J Palliat Med
well-being, and spiritual well-being on the indicator of the QUAL-E Being tool
quality-of-life at the end of life in patients with
cancer enrolled in hospice
64 Spirituality as a core domain in the assessment of Whitford HS Mental Adjustment to FACIT-Sp Australia 2008 Psychooncology
quality-of-life in oncology Cancer (MAC) scale
65 Symptom distress, spirituality, and quality-of-life Leak A Quality-of-Life Index-Cancer Spiritual Perspective USA 2008 Cancer Nurs
in African American breast cancer survivors Version Scale
66 Coping strategies, emotional outcomes, and spirit- Desbiens JF FACIT-sp FACIT-sp and COPE scale Canada 2007 Int J Palliat Nurs
ual quality-of-life in palliative care nurses
67 Sense of coherence, spirituality, stress, and qual- Delgado C Quality of Life Index – Spiritual Transcendence USA 2007 J Nurs Scholarsh
ity-of-life in chronic illness Pulmonary Version III Scale (STS)
(QLI-PV)
68 Religious beliefs and quality-of-life in an American Ko B KDQoL Royal Free Score USA 2007 Nephrol Dial Transplant
inner-city haemodialysis population
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- Colgrove LA MOS Short Form-36 Functional Assessment of USA 2007 Ann Behav Med
ity-of-life of spousal caregivers of cancer Chronic Illness
survivors Therapy-Spirituality
71 Religiousness and spiritual support among Balboni TA McGill Quality-of-Life Religiousness and spirit- USA 2007 J Clin Oncol
advanced cancer patients and associations with questionnaire ual support, Brief
end-of-life treatment preferences and quality- RCOPE
of-life
72 Religious coping is associated with the quality-of- Tarakeshwar N McGill QoL questionnaire RCOPE, Multidimensional USA 2006 J Palliat Med
life of patients with advanced cancer Measure of Religion/
Spirituality
73 The contribution of spirituality to quality-of-life in Giovagnoli AR WHOQoL 100 WHOQoL-SRPB Italy 2006 Epilepsy Behav
focal epilepsy
74 Spirituality influences health-related quality-of-life Krupski TL SF-12, UCLA Prostate Cancer FACIT-Sp USA 2006 Psychooncology
in men with prostate cancer Index short form (PCISF)
 INTERNATIONAL REVIEW OF PSYCHIATRY 275

Table 2. Validation studies.

Title Main author QoL measure Country Year
1 Spiritual quality-of-life and spiritual coping: evidence for a two-factor Kr€ageloh CU WHOQoL-SRPB New Zealand 2015
structure of the WHOQoL spirituality, religiousness, and personal
beliefs module
2 Translation and focus group testing of the WHOQoL spirituality, reli- Berg Torskenæs K WHOQoL-SRPB Norway 2013
giousness, and personal beliefs module in Norway
3 Translation and validation of the Persian version of the functional Jafari N FACIT-Sp Iran 2013
assessment of chronic illness therapy-Spiritual well-being scale
(FACIT-Sp) among Muslim Iranians in treatment for cancer
4 Introducing the WHOQoL-SRPB BREF: developing a short-form instru- Skevington SM WHOQoL-SRPB UK 2013
ment for assessing spiritual, religious, and personal beliefs within
quality-of-life
5 The Spiritual Needs Assessment for Patients (SNAP): development Sharma RK SNAP USA 2012
and validation of a comprehensive instrument to assess unmet
spiritual needs
6 French-language version of the World Health Organization quality-of- Mandhouj O WHOQoL-SRPB France 2012
life spirituality, religiousness, and personal beliefs instrument
7 Psychometric properties of the Functional Assessment of Chronic Lazenby M FACIT-Sp USA 2013
Illness Therapy–Spiritual Well-being (FACIT-Sp) in an Arabic-speak-
ing, predominantly Muslim population
8 Brazilian validation of the Quality-of-Life Instrument/spirituality, reli- Panzini RG WHOQoL-SRPB Brazil 2011
gion, and personal beliefs

Table 3. Intervention studies.

Religiosity/spirituality
Title Main author QoL measure measures Country Year
1 Meaning-centred group psychotherapy: an effective Breitbart W MQoL Spiritual well-being USA 2015
intervention for improving psychological well-
being in patients with advanced cancer
2 Contemplative self healing in women breast cancer Charlson ME Functional FACIT-Spirituality USA 2014
survivors: a pilot study in under-served minority Assessment of
women shows improvement in quality-of-life and Cancer Therapy
reduced stress Scale (FACT-G)
3 The beneficial role of spiritual counselling in heart Tadwalkar R QIDS-SR16 FACIT-Sp-Ex USA 2014
failure patients
4 A longitudinal, randomized, controlled trial of Lyon ME Pediatric Quality-of- Spiritual Well-Being USA 2014
advance care planning for teens with cancer: anx- Life Scale
iety, depression, quality-of-life, advance directives,
spirituality
5 The influence of a spirituality-based intervention on Delaney C QoL Spirituality Scale USA 2011
quality-of-life, depression, and anxiety in commu- Index–Cardiac
nity-dwelling adults with cardiovascular disease: a Version
pilot study

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
276 R. G. PANZINI ET AL.
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.
References
Abdel-Khalek, A.M. (2010). Quality of life, subjective well-
being, and religiosity in Muslim college students. Quality
of Life Research: An International Journal of Quality of
Life Aspects of Treatment, Care and Rehabilitation, 19,
1133–1143. Retrieved from http://doi.org/10.1007/
s11136-010-9676-7
Akinboro, A.O., Akinyemi, S.O., Olaitan, P.B., Raji, A.A.,
Popoola, A.A., Awoyemi, O.R., & Ayodele, O.E. (2014).
Quality of life of Nigerians living with human immuno-
deficiency virus. The Pan African Medical Journal, 18,
234. Retrieved from http://doi.org/10.11604/pamj.2014.18.
234.2816
Ali, J., Marhemat, F., Sara, J., & Hamid, H. (2015). The
relationship between spiritual well-being and quality of
life among elderly people. Holistic Nursing Practice, 29,
128–135. Retrieved from http://doi.org/10.1097/HNP.
0000000000000081
Anye, E.T., Gallien, T.L., Bian, H., & Moulton, M. (2013).
The relationship between spiritual well-being and health-
related quality of life in college students. Journal of
American College Health:ACH, 61, 414–421. Retrieved
from http://doi.org/10.1080/07448481.2013.824454
Atkinson, M.J., Wishart, P.M., Wasil, B.I. (2004). The Self-
Perception and Relationships Tool (S-PRT): A novel
approach to the measurement of subjective health-related
quality of life. Health and Quality of Life Outcomes, 2, 36.
Retrieved from http://doi.org/10.1186/1477-7525-2-36
Bahr, H.M., & Harvey, C.D. (1979). Widowhood and per-
ceptions of change in quality of life: Evidence from the
Sunshine Mine Widows. Journal of Comparative Family
Studies, 10, 411–428.
Bai, M., Lazenby, M., Jeon, S., Dixon, J., & McCorkle, R.
(2015). Exploring the relationship between spiritual well-
being and quality of life among patients newly diagnosed
with advanced cancer. Palliative & Supportive Care, 13,
927–935. Retrieved from http://doi.org/10.1017/
S1478951514000820
Bakiono, F., Guiguimd
e, P.W.L., Sanou, M., Ou
edraogo, L.,
& Robert, A. (2015). Quality of life in persons living with
HIV in Burkina Faso: A follow-up over 12 months. BMC
Public Health, 15, 1119. Retrieved from http://doi.org/10.
1186/s12889-015-2444-4
Balboni, T.A., Vanderwerker, L.C., Block, S.D., Paulk, M.E.,
Lathan, C.S., Peteet, J.R., & Prigerson, H.G. (2007).
Religiousness and spiritual support among advanced can-
cer patients and associations with end-of-life treatment
preferences and quality of life. Journal of Clinical
Oncology: Official Journal of the American Society of
Clinical Oncology, 25, 555–560. Retrieved from http://
doi.org/10.1200/JCO.2006.07.9046
Basi

nski, A., Stefaniak, T., Stadnyk, M., Sheikh, A., &
Vingerhoets, A.J.J.M. (2013). Influence of religiosity on
the quality of life and on pain intensity in chronic
pancreatitis patients after neurolytic celiac plexus block:
Case-controlled study. Journal of Religion and Health, 52,
276–284. Retrieved from http://doi.org/10.1007/s10943-
011-9454-z
Beaton, D.E., Bombardier, C., Guillemin, F., & Ferraz, M.B.
(2000). Guidelines for the process of cross-cultural adap-
tation of self-report measures. Spine, 25, 3186–3191.
Retrieved from http://doi.org/10.1097/00007632-
200012150-00014
Berg Torskenæs, K., & Kalfoss, M.H. (2013). Translation
and focus group testing of the WHOQOL spirituality,
religiousness, and personal beliefs module in Norway.
Journal of Holistic Nursing: Official Journal of the
American Holistic Nurses' Association, 31, 25–34.
Retrieved from http://doi.org/10.1177/0898010112461976
Braam, A.W., Beekman, A., Deeg, D. (1997). Religiosity as a
protective or prognostic factor of depression in later life;

results from a community survey in The Netherlands.
Acta Psychiatrica Scandinavica, 96, 199–205. Retrieved
from http://doi.org/10.1111/j.1600-0447.1997.tb10152.x
Brady, M.J., Peterman, A.H., Fitchett, G., Mo, M., & Cella,
D. (1999). A case for including spirituality in quality of
life measurement in oncology. Psycho-Oncology, 8,
417–428. Retrieved from http://doi.org/10.1002/(SICI)
1099-1611(199909/10)8:53.0.CO;2-4
Breitbart, W., Rosenfeld, B., Pessin, H., Applebaum, A.,
Kulikowski, J., & Lichtenthal, W.G. (2015). Meaning-cen-
tered group psychotherapy: An effective intervention for
improving psychological well-being in patients with
advanced cancer. Journal of Clinical Oncology: Official
Journal of the American Society of Clinical Oncology, 33,
749–754. Retrieved from http://doi.org/10.1200/JCO.
2014.57.2198
Browne, J.P., O'boyle, C.A., McGee, H.M., McDonald, N.J.
(1997). Development of a direct weighting procedure for
quality of life domains. Quality of Life, 6, 301–309.
Retrieved from http://doi.org/10.1023/A:1018423124390
Calvo, A., Moglia, C., Ilardi, A., Cammarosano, S., Gallo, S.,
Canosa, A., … Chi o, A. (2011). Religiousness is positively
associated with quality of life of ALS caregivers.
Amyotrophic Lateral Sclerosis: Official Publication of the
World Federation of Neurology Research Group on Motor
Neuron Diseases, 12, 168–171. Retrieved from http://doi.
org/10.3109/17482968.2011.560947
Canada, A.L., Murphy, P.E., Fitchett, G., & Stein, K. (2016).
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).
Annals of Behavioral Medicine: A Publication of the
Society of Behavioral Medicine, 50, 79–86. Retrieved
from http://doi.org/10.1007/s12160-015-9735-y
Caqueo-Ur
ızar, A., Alessandrini, M., Zendjidjian, X., Urz
ua,
A., Boyer, L., & Williams, D.R. (2016). Religion involve-
ment and quality of life in caregivers of patients with
schizophrenia in Latin-America. Psychiatry Research, 246,
769–775. Retrieved from http://doi.org/10.1016/j.psy-
chres.2016.07.063
Carver, C.S., Scheier, M.F. (1989). Assessing coping strat-
egies: A theoretically based approach. Journal of
Personality and Social Psychology, 56, 267–283. Retrieved
from http://doi.org/10.1037//0022-3514.56.2.267
Cassia Amaral, R., Inacio, M., Brito, V.N., Bachega, T.A.,
Oliveira, A.A., Domenice, S., Gomes, L. (2015). 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. Clinical Endocrinology, 82, 274–279.
Retrieved from http://doi.org/10.1111/cen.12572
Charlson, M.E., Loizzo, J., Moadel, A., Neale, M.,
Newman, C., Olivo, E., Wolf, E., Peterson, J.C. (2014).
Contemplative self healing in women breast cancer
survivors: A pilot study in underserved minority
women shows improvement in quality of life and
reduced stress. BMC Complementary and Alternative
Medicine, 14, 349. Retrieved from http://doi.org/10.1186/
1472-6882-14-349
Colgrove, L.A., Kim, Y., & Thompson, N. (2007). The effect
of spirituality and gender on the quality of life of spousal
caregivers of cancer survivors. Annals of Behavioral
INTERNATIONAL REVIEW OF PSYCHIATRY 277
Medicine, 33, 90–98. Retrieved from http://doi.org/10.
1207/s15324796abm3301_10
Curtis, J.R., Tu, S.P., McDonell, M.B. (2002). Using quality
of life to predict hospitalization and mortality in patients
with obstructive lung diseases. Chest, 122, 429–436.
Retrieved from http://doi.org/10.1378/chest.122.2.429
da Almeida Fleck, M.P., Borges, Z.N. (2003).
Desenvolvimento do WHOQOL, m
odulo espiritualidade,
religiosidade e crenças pessoais. Revista De Sa
ude
P
ublica, 37, 446–455.
Davis, M.C. (1994). The rehabilitation nurse's role in spirit-
ual care. Rehabilitation Nursing, 19, 298–301. Retrieved
from http://doi.org/10.1002/j.2048-7940.1994.tb00826.x
Davison, S.N., & Jhangri, G.S. (2010). Existential and reli-
gious dimensions of spirituality and their relationship
with health-related quality of life in chronic kidney dis-
ease. Clinical Journal of the American Society of
Nephrology, 5, 1969–1976. doi:10.2215/CJN.01890310
Davison, S.N., & Jhangri, G.S. (2013). The relationship
between spirituality, psychosocial adjustment to illness,
and health-related quality of life in patients with
advanced chronic kidney disease. Journal of Pain and
Symptom Management, 45, 170–178. Retrieved from
http://doi.org/10.1016/j.jpainsymman.2012.02.019
Delaney, C., Barrere, C., Helming, M. (2010). The influence
of a spirituality-based intervention on quality of life,
depression, and anxiety in community-dwelling adults
with cardiovascular disease: A pilot study. Journal of
Holistic Nursing, 29, 21–32. Retrieved from http://doi.
org/10.1177/0898010110378356
Delgado, C. (2007). Sense of coherence, spirituality, stress
and quality of life in chronic illness. Journal of Nursing
Scholarship: An Official Publication of Sigma Theta Tau
International Honor Society of Nursing/Sigma Theta Tau,
39, 229–234. Retrieved from http://doi.org/10.1111/j.
1547-5069.2007.00173.x
Desbiens, J.F., & Fillion, L. (2007). Coping strategies, emo-
tional outcomes and spiritual quality of life in palliative
care nurses. International Journal of Palliative Nursing,
13, 291–300. Retrieved from http://doi.org/10.12968/ijpn.
2007.13.6.23746
Elerhorst-Ryan, J.M., Spilker, B. (1996). Instruments to
measure spiritual status. In B. Spilker (Eds.), Quality of
life and pharmacoeconomics in clinical trials. New York:
Lippincott Williams & Wilkins.
Epperly, B.G. (2000). Prayer, process, and the future of
medicine. Journal of Religion and Health, 39(1), 23–37.
doi: 10.1023/A:1004686624118
Fabrega, H.J. (2000). Culture, spirituality and psychiatry.
Current Opinion in Psychiatry, 13, 525. doi: 10.1097/
00001504-200011000-00001
Fallowfield, L. (1990). The quality of life: The missing meas-
urement in health care. London, England: Souvenir Press.
Ferriss, A.L. (2002). Religion and the quality of life. Journal
of Happiness Studies, 3, 199–215. doi: 10.1023/A:1020684
404438
Finocchiaro, D.N., Roth, P.A., & Connelly, C.D. (2014).
Spiritual well-being as predictor of quality of life for
adults with paraplegia. Rehabilitation Nursing: The
Official Journal of the Association of Rehabilitation
Nurses, 39, 285–293. Retrieved from http://doi.org/10.
1002/rnj.161
278 R. G. PANZINI ET AL.
Flannelly, L.T., & Inouye, J. (2001). Relationships of reli-
gion, health status, and socioeconomic status to the qual-
ity of life of individuals who are HIV positive. Issues in
Mental Health Nursing, 22, 253–272. Retrieved from
http://doi.org/10.1080/01612840152053093
Fleck, M.P. de A., (2008). A Avaliaç~ao de Qualidade de
Vida. 1st ed. Porto Alegre: Artmed Editora SA.
Fleck, M.P., & Skevington, S.M. (2007). Explaining the
meaning of the WHOQOL-SRPB. Revista de Psiquiatria
Cl
ınica, 34(1), 67–69.
Fryback, P.B., & Reinert, B.R. (1999). Spirituality and people
with Poetentially fatal diagnoses. Nursing Forum, 34(1),
13–22. Retrieved from http://doi.org/10.1111/j.1744-
6198.1999.tb00231.x
Gerbershagen, K., Trojan, M., Kuhn, J., Limmroth, V., &
Bewermeyer, H. (2008). [Significance of health-related
quality of life and religiosity for the acceptance of
chronic pain]. Schmerz (Berlin, Germany), 22, 586–593.
Retrieved from http://doi.org/10.1007/s00482-008-0656-6
Gioiella, M.E., Berkman, B., & Robinson, M. (1998).
Spirituality and quality of life in gynecologic oncology
patients. Cancer Practice, 6, 333–338. Retrieved from
http://doi.org/10.1046/j.1523-5394.1998.006006333.x
Giovagnoli, A.R., Meneses, R.F., & da Silva, A.M. (2006).
The contribution of spirituality to quality of life in focal
epilepsy. Epilepsy & Behavior, 9(1), 133–139. Retrieved
from http://doi.org/10.1016/j.yebeh.2006.04.002
Hamren, K., Chungkham, H.S., & Hyde, M. (2015).
Religion, spirituality, social support and quality of life:
measurement and predictors CASP-12(v2) amongst older
Ethiopians living in Addis Ababa. Aging & Mental
Health, 19, 610–621. Retrieved from http://doi.org/10.
1080/13607863.2014.952709
Hansel, N.N., Wu, A.W., Chang, B., & Diette, G.B. (2004).
Quality of life in tuberculosis: Patient and provider per-
spectives. Quality of Life Research, 13, 639–652.
Retrieved from http://doi.org/10.1023/B:QURE.
0000021317.12945.f0
Henning, M.A., Kr€ageloh, C., Thompson, A., Sisley, R.,
Doherty, I., & Hawken, S.J. (2015). Religious affiliation,
quality of life and academic performance: New Zealand
medical students. Journal of Religion and Health, 54,
3–19. Retrieved from http://doi.org/10.1007/s10943-013-
9769-z
Holtz, C., Sowell, R., VanBrackle, L., Velasquez, G., &
Hernandez-Alonso, V. (2014). A quantitative study of
factors influencing quality of life in rural Mexican
women diagnosed with HIV. The Journal of the
Association of Nurses in AIDS Care: JANAC, 25, 555–567.
Retrieved from http://doi.org/10.1016/j.jana.2014.03.002
Jafari, N., Farajzadegan, Z., Zamani, A., Bahrami, F.,
Emami, H., & Loghmani, A. (2013). Spiritual well-being
and quality of life in Iranian women with breast cancer
undergoing radiation therapy. Supportive Care in Cancer:
Official Journal of the Multinational Association of
Supportive Care in Cancer, 21, 1219–1225. Retrieved
from http://doi.org/10.1007/s00520-012-1650-1
Jafari, N., Zamani, A., Lazenby, M., Farajzadegan, Z.,
Emami, H., & Loghmani, A. (2013). Translation and val-
idation of the Persian version of the functional assess-
ment of chronic illness therapy-spiritual well-being scale
(FACIT-Sp) among Muslim Iranians in treatment for
cancer. Palliative & Supportive Care, 11, 29–35.
Retrieved from http://doi.org/10.1017/S1478951512000727
Kandasamy, A., Chaturvedi, S.K., & Desai, G. (2011).
Spirituality, distress, depression, anxiety, and quality of
life in patients with advanced cancer. Indian Journal of
Cancer, 48, 55–59. Retrieved from http://doi.org/10.
4103/0019-509X.75828
Khanjari, S., Oskouie, F., Langius-Ekl€ of, A. (2012). Lower
sense of coherence, negative religious coping, and disease
severity as indicators of a decrease in quality of life in
Iranian family caregivers of relatives with breast cancer
during first 6 months after diagnosis. Cancer Nursing, 35,
148–156.
Kim, Y., Carver, C.S., & Cannady, R.S. (2015). Caregiving
motivation predicts long-term spirituality and quality of
life of the caregivers. Annals of Behavioral Medicine: A
Publication of the Society of Behavioral Medicine, 49,
500–509. Retrieved from http://doi.org/10.1007/s12160-
014-9674-z
Ko, B., Khurana, A., Spencer, J., Scott, B., Hahn, M., &
Hammes, M. (2007). Religious beliefs and quality of life
in an American inner-city haemodialysis population.
Nephrology, Dialysis, Transplantation: Official Publication
of the European Dialysis and Transplant Association -
European Renal Association, 22, 2985–2990. Retrieved
from http://doi.org/10.1093/ndt/gfm341
Koenig, H.G., Larson, D.B., Larson, S.S. (2001). Religion
and coping with serious medical illness. The Annals of
Pharmacotherapy, 35, 352–359. Retrieved from http://
doi.org/10.1345/1542-6270(2001)0352.0.CO;2
Koenig, H.G., Pargament, K.I., Nielsen, J. (1998). Religious
coping and health status in medically ill hospitalized
older adults. The Journal of Nervous and Mental Disease,
186, 513–521. Retrieved from http://doi.org/10.1097/
00005053-199809000-00001
Kr€ageloh, C.U., Billington, D.R., Henning, M.A., & Chai,
P.P.M. (2015). Spiritual quality of life and spiritual cop-
ing: Evidence for a two-factor structure of the WHOQOL
spirituality, religiousness, and personal beliefs module.
Health and Quality of Life Outcomes, 13, 26. Retrieved
from http://doi.org/10.1186/s12955-015-0212-x
Kr€ageloh, C.U., Henning, M.A., Billington, R., & Hawken,
S.J. (2015). The relationship between quality of life and
spirituality, religiousness, and personal beliefs of medical
students. Academic Psychiatry: The Journal of the
American Association of Directors of Psychiatric Residency
Training and the Association for Academic Psychiatry, 39,
85–89. Retrieved from http://doi.org/10.1007/s40596-
014-0158-z
Krupski, T.L., Kwan, L., Fink, A., Sonn, G.A., Maliski, S., &
Litwin, M.S. (2006). Spirituality influences health related
quality of life in men with prostate cancer. Psycho-
Oncology, 15, 121–131. Retrieved from http://doi.org/10.
1002/pon.929
Landis, B.J. (1996). Uncertainty, spiritual well-being, and
psychosocial adjustment to chronic illness. Issues in
Mental Health Nursing, 17, 217–231. Retrieved from
http://doi.org/10.3109/01612849609049916
Lanfredi, M., Candini, V., Buizza, C., Ferrari, C., Boero,
M.E., Giobbio, G.M., … . De Girolamo, G. (2014). The
effect of service satisfaction and spiritual well-being on
the quality of life of patients with schizophrenia.

Psychiatry Research, 216, 185–191. Retrieved from http://
doi.org/10.1016/j.psychres.2014.01.045
Lazenby, M., & Khatib, J. (2012). Associations among
patient characteristics, health-related quality of life, and
spiritual well-being among Arab Muslim cancer patients.
Journal of Palliative Medicine, 15, 1321–1324. Retrieved
from http://doi.org/10.1089/jpm.2012.0208
Lazenby, M., Khatib, J., Al-Khair, F., & Neamat, M. (2013).
Psychometric properties of the Functional Assessment of
Chronic Illness Therapy–Spiritual Well-being (FACIT-
Sp) in an Arabic-speaking, predominantly Muslim popu-
lation. Psycho-Oncology, 22, 220–227. Retrieved from
http://doi.org/10.1002/pon.2062
Leak, A., Hu, J., & King, C.R. (2008). Symptom distress,
spirituality, and quality of life in African American breast
cancer survivors. Cancer Nursing, 31, E15–E21.
Retrieved from http://doi.org/10.1097/01.NCC.000030
5681.06143.70
Lee, M., Nezu, A.M., & Nezu, C.M. (2014). Positive and
negative religious coping, depressive symptoms, and qual-
ity of life in people with HIV. Journal of Behavioral
Medicine, 37, 921–930. Retrieved from http://doi.org/10.
1007/s10865-014-9552-y
Leeson, L.A., Nelson, A.M., Rathouz, P.J., Juckett, M.B.,
Coe, C.L., Caes, E.W., & Costanzo, E.S. (2015).
Spirituality and the recovery of quality of life following
hematopoietic stem cell transplantation. Health
Psychology, 34, 920–928. Retrieved from http://doi.org/
10.1037/hea0000196
Leow, M.Q.H., Chan, M.F., & Chan, S.W.C. (2014).
Predictors of change in quality of life of family caregivers
of patients near the end of life with advanced cancer.
Cancer Nursing, 37, 391–400. Retrieved from http://doi.
org/10.1097/NCC.0000000000000101
Levin, J.S., & Chatters, L. (1994). Religion and health: Is
there an association, is it valid, and is it causal? Social
Science & Medicine, 38, 1475–1482. Retrieved from
http://doi.org/10.1016/0277-9536(94)90109-0
Levin, J.S. (1998). Research on religion and mental health:
an overview of empirical findings and theoretical issues.
In H.G. Koenig (Eds.), Handbook of religion and mental
health. New York: Academic Press.
Levin, J.S., & Chatters, L.M. (1998). Religion, health, and
psychological well-being in older adults findings from
three national surveys. Journal of Aging and Health, 10,
504–531. Retrieved from http://doi.org/10.1177/
089826439801000406
Levin, J.S., & Vanderpool, H.Y. (1987). Is frequent religious
attendance really conducive to better health?: Toward an
epidemiology of religion. Social Science & Medicine, 24,
589–600.
Levin, J.S., & Vanderpool, H.Y. (1991). Religious factors in
physical health and the prevention of illness. Prevention
in Human Services, 9, 41–64. Retrieved from http://doi.
org/10.1300/J293v09n02_03
Lim, J.W., & Yi, J. (2009). The effects of religiosity, spiritu-
ality, and social support on quality of life: A comparison
between Korean American and Korean breast and gyne-
cologic cancer survivors. Oncology Nursing Forum, 36,
699–708. Retrieved from http://doi.org/10.1188/09.ONF.
699-708
INTERNATIONAL REVIEW OF PSYCHIATRY 279
Lucchetti, G., de Almeida, L.G.C., & Lucchetti, A.L.G.
(2012). Religiousness, mental health, and quality of life in
Brazilian dialysis patients. Hemodialysis International.
International Symposium on Home Hemodialysis, 16,
89–94. Retrieved from http://doi.org/10.1111/j.1542-
4758.2011.00623.x
Lucchetti, G., Lucchetti, A.G., Badan-Neto, A.M., Peres,
P.T., Peres, M.F.P., Moreira-Almeida, A., Gomes, C.,
Koenig, H.G. (2011). Religiousness affects mental health,
pain and quality of life in older people in an outpatient
rehabilitation setting. Journal of Rehabilitation Medicine,
43, 316–322. Retrieved from http://doi.org/10.2340/
16501977-0784
Lucchetti, G., Lucchetti, A.L.G., Oliveira, G.R., Crispim, D.,
Pires, S.L., Gorzoni, M.L., … , Koenig, H.G. (2014).
Nursing home care: exploring the role of religiousness in
the mental health, quality of life and stress of formal
caregivers. Journal of Psychiatric and Mental Health
Nursing, 21, 403–413. Retrieved from http://doi.org/10.
1111/jpm.12092
Lyon, M.E., Jacobs, S., Briggs, L., Cheng, Y.I. (2014). A lon-
gitudinal, randomized, controlled trial of advance care
planning for teens with cancer: Anxiety, depression, qual-
ity of life, advance directives, spirituality. Journal of
Adolescent Health, 53, 710–717. Retrieved from http://
doi.org/10.1016/j.jadohealth.2013.10.206
Maggi, L., Ferrara, P.E., Aprile, I., Ronconi, G., Specchia,
A., Nigito, C., … . Bertolini, C. (2012). Role of spiritual
beliefs on disability and health-related quality of life in
acute inpatient rehabilitation unit. European Journal of
Physical and Rehabilitation Medicine, 48, 467–473.
Mandhouj, O., Etter, J.F., Courvoisier, D., & Aubin, H.J.
(2012). French-language version of the World Health
Organization quality of life spirituality, religiousness and
personal beliefs instrument. Health and Quality of Life
Outcomes, 10, 39. Retrieved from http://doi.org/10.1186/
1477-7525-10-39
Matthews, A.K., Tejeda, S., Johnson, T.P., Berbaum, M.L., &
Manfredi, C. (2012). Correlates of quality of life among
African American and white cancer survivors. Cancer
Nursing, 35, 355–364. Retrieved from http://doi.org/10.
1097/NCC.0b013e31824131d9
McGee, H.M., O'boyle, C.A., Hickey, A. (1991). Assessing
the quality of life of the individual: the SEIQoL with a
healthy and a gastroenterology unit population.
Psychological Medicine, 21, 749–759. Retrieved from
http://doi.org/10.1017/S0033291700022388
Mohebbifar, R., Pakpour, A.H., Nahvijou, A., & Sadeghi, A.
(2015). Relationship between spiritual health and quality
of life in patients with cancer. Asian Pacific Journal of
Cancer Prevention, 16, 7321–7326. Retrieved from http://
doi.org/10.7314/APJCP.2015.16.16.7321
Mohr, S., Borras, L., Rieben, I., Betrisey, C., Gillieron, C.,
Brandt, P.Y., Perroud, N., Huguelet, P. (2010). Evolution
of spirituality and religiousness in chronic schizophrenia
or schizo-affective disorders: a 3-years follow-up study.
Social Psychiatry and Psychiatric Epidemiology, 45,
1095–1103. Retrieved from http://doi.org/10.1007/
s00127-009-0151-0
Mohr, S., Perroud, N., Gillieron, C., Brandt, P.Y., Rieben, I.,
Borras, L., & Huguelet, P. (2011). Spirituality and reli-
giousness as predictive factors of outcome in
280 R. G. PANZINI ET AL.
schizophrenia and schizo-affective disorders. Psychiatry
Research, 186, 177–182. Retrieved from http://doi.org/10.
1016/j.psychres.2010.08.012
Molzahn, A.E. (2007). Spirituality in later life: effect on
quality of life. Journal of Gerontological Nursing, 33,
32–39.
Moon, Y.S., & Kim, D.H. (2013). Association between
religiosity/spirituality and quality of life or depression
among living-alone elderly in a South Korean city. Asia-
Pacific Psychiatry: Official Journal of the Pacific Rim
College of Psychiatrists, 5, 293–300. Retrieved from
http://doi.org/10.1111/appy.12025
Moreira-Almeida, A., & Koenig, H.G. (2006). 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 Science & Medicine, 63, 843–845.
Retrieved from http://doi.org/10.1016/j.socscimed.2006.
03.001
Nolan, J.A., McEvoy, J.P., Koenig, H.G., Hooten, E.G.,
Whetten, K., & Pieper, C.F. (2012). Religious coping and
quality of life among individuals living with schizophre-
nia. Psychiatric Services (Washington, D.C.), 63,
1051–1054. Retrieved from http://doi.org/10.1176/appi.
ps.201000208
Panzini, R.G. (2005). Aplicaç~ao da vers~ao em portugu^es do
WHOQOL–M
odulo espiritualidade, religiosidade e cren-
oes entre … .
ças pessoais (SRPB) e investigaç~ao das relaç~
Aplicaç~ao da vers~ao em portugu^es do WHOQOL: … .
Panzini, R.G., & Bandeira, D.R. (2005). Escala de coping
religioso-espiritual (Escala CRE): elaboraç~ao e validaç~ao
de construto. Psicologia Em Estudo, 10, 507–516.
Retrieved from https://dx.doi.org/10.1590/S1413-
73722005000300019
Panzini, R.G., Maganha, C., Rocha, N.S.D., Bandeira, D.R.,
& Fleck, M.P. (2011). Brazilian validation of the Quality
of Life Instrument/spirituality, religion and personal
beliefs. Rev Saude Publica, 45, 153–165. Retrieved from
http://doi.org/10.1590/S0034-89102011000100018
Pargament, K.I. (2001). The psychology of religion and cop-
ing: Theory, research, practice. New York: The Guilford
Press.
Pargament, K.I., & Brant, C.R. (1998). Religion and coping.
In H. Koenig, (Ed.), Handbook of religion and mental
health. San Diego: Academic Press.
Pargament, K.I., & Hahn, J. (1986). God and the just world:
Causal and coping attributions to God in health situa-
tions. Journal for the Scientific Study of Religion, 25,
193–207. doi: 10.2307/1385476
Pargament, K.I., Koenig, H.G., Tarakeshwar, N., & Hahn, J.
(2001). Religious struggle as a predictor of mortality
among medically ill elderly patients: A 2-year longitu-
dinal study. Archives of Internal Medicine, 161,
1881–1885. Retrieved from http://doi.org/10.1001/
archinte.161.15.1881
Pargament, K.I., Olsen, H., Reilly, B., Falgout, K. (1992).
God help me (II): The relationship of religious orienta-
tions to religious coping with negative life events. Journal
for the Scientific Study of Religion, 31, 504–513.
Retrieved from http://doi.org/10.2307/1386859
Pargament, K.I., Smith, B.W., Koenig, H.G., Perez, L.
(1998). Patterns of positive and negative religious coping
with major life stressors. Journal for the Scientific Study
of Religion, 37, 710–724. Retrieved from http://doi.org/
10.2307/1388152
Peterman, A.H., Fitchett, G., Brady, M.J. (2002). Measuring
spiritual well-being in people with cancer: the functional
assessment of chronic illness therapy—Spiritual Well-
being Scale (FACIT-Sp). Annals of Behavioral Medicine,
24(1), 49–58.
Pipe, T.B., Kelly, A., LeBrun, G., Schmidt, D., Atherton, P.,
& Robinson, C. (2008). A prospective descriptive study
exploring hope, spiritual well-being, and quality of life in
hospitalized patients. Medsurg Nursing: Official Journal of
the Academy of Medical-Surgical Nurses, 17, 247–253.
Poloma, M.M., & Pendleton, B.F. (1989). Exploring types of
prayer and quality of life: A research note. Review of
Religious Research, 31(1), 46–53. Retrieved from http://
doi.org/10.2307/3511023
Pr
eau, M., Bouhnik, A.D., & Le Coroller Soriano, A.G. ALD
Cancer Study Group. (2013). Two years after cancer diag-
nosis, what is the relationship between health-related
quality of life, coping strategies and spirituality?
Psychology, Health & Medicine, 18, 375–386. Retrieved
from http://doi.org/10.1080/13548506.2012.736622
Prince-Paul, M. (2008). Relationships among communica-
tive acts, social well-being, and spiritual well-being on
the quality of life at the end of life in patients with can-
cer enrolled in hospice. Journal of Palliative Medicine, 11,
20–25. Retrieved from http://doi.org/10.1089/jpm.2007.
0119
Rabelo, M.C. (1993). Religi~ao e cura: algumas reflex~ oes
sobre a experi^encia religiosa das classes populares
urbanas. Cadernos de Sa
ude P

ublica, 9, 316–325.
Rohani, C., Abedi, H., Omranipour, R., & Langius- Ekl€ of,
A. (2015). Health-related quality of life and the predictive
role of sense of coherence, spirituality and religious cop-
ing in a sample of Iranian women with breast cancer: A
prospective study with comparative design. Health and
Quality of Life Outcomes, 13, 40. doi:10.1186/s12955-015-
0229-1
Robbins, R.A., Simmons, Z., Bremer, B.A., & Walsh, S.M.
(2001). Quality of life in ALS is maintained as physical
function declines. Neurology, 56, 442–444. Retrieved
from http://doi.org/10.1212/WNL.56.4.442
Rocha, N.S. (2002). Association between health status, spir-
ituality/religiosity/personal beliefs and quality of life
(Master Degree Thesis). Porto Alegre. UFRGS. Retrieved
from https://www.lume.ufrgs.br/bitstream/handle/10183/
3365/000386777.pdf?sequence ¼1
Rocha, N.S., Panzini, R.G., Fleck, M.P. (2008).
Desenvolvimento do modulo para avaliar espiritualidade,
religiosidade e crencas pessoais do WHOQOL
(WHOQOL-SRPB). In M.P. Fleck (Ed.), A Avaliac~ ao de
Qualidade de Vida: guia para profissionais de sa
ude.
Porto Alegre. ARTMED.
Ross, L. (1995). The spiritual dimension: Its importance to
patients' health, well-being and quality of life and its
implications for nursing practice. International Journal of
Nursing Studies, 32, 457–468.
Saad, M., Masiero, D., & Battistella, L.R. (2001).
Espiritualidade baseada em evid^encias. Acta Fisi
atrica, 8,

107–112. Retrieved from http://doi.org/10.5935/0104-
7795.20010003
Saffari, M., Pakpour, A.H., Naderi, M.K., Koenig, H.G.,
Baldacchino, D.R., & Piper, C.N. (2013). Spiritual coping,
religiosity and quality of life: a study on Muslim patients
undergoing haemodialysis. Nephrology (Carlton, Vic.), 18,
269–275. Retrieved from http://doi.org/10.1111/nep.
12041
Salsman, J.M., Yost, K.J., West, D.W., & Cella, D. (2011).
Spiritual well-being and health-related quality of life in
colorectal cancer: A multi-site examination of the role of
personal meaning. Supportive Care in Cancer: Official
Journal of the Multinational Association of Supportive
Care in Cancer, 19, 757–764. Retrieved from http://doi.
org/10.1007/s00520-010-0871-4
Samuelson, B.T., Fromme, E.K., & Thomas, C.R. (2012).
Changes in spirituality and quality of life in patients
undergoing radiation therapy. The American Journal of
Hospice & Palliative Care, 29, 449–454. Retrieved from
http://doi.org/10.1177/1049909111428607
Seligman, M.E., & Csikszentmihalyi, M. (2000). Positive
psychology. An introduction. Am Psychol, 55, 5–14.
Retrieved from http://doi.org/10.1037//0003-066X.55.1.5
Selman, L.E., Higginson, I.J., Agupio, G., Dinat, N.,
Downing, J., Gwyther, L., … . Harding, R. (2011).
Quality of life among patients receiving palliative care in
South Africa and Uganda: a multi-centred study. Health
and Quality of Life Outcomes, 9, 21. Retrieved from
http://doi.org/10.1186/1477-7525-9-21
Shah, R., Kulhara, P., Grover, S., Kumar, S., Malhotra, R., &
Tyagi, S. (2011). Contribution of spirituality to quality of
life in patients with residual schizophrenia. Psychiatry
Research, 190, 200–205. Retrieved from http://doi.org/10.
1016/j.psychres.2011.07.034
Sharma, R.K., Astrow, A.B., Texeira, K., & Sulmasy, D.P.
(2012). The Spiritual Needs Assessment for Patients
(SNAP): development and validation of a comprehensive
instrument to assess unmet spiritual needs. Journal of
Pain and Symptom Management, 44, 44–51. Retrieved
from http://doi.org/10.1016/j.jpainsymman.2011.07.008
Siegel, K., Anderman, S.J., & Schrimshaw, E.W. (2001).
Religion and coping with health-related stress. Psychology
& Health, 16, 631–653. doi: 10.1080/08870440108405864
Simpson, J.A., & Weiner, E.S.C. (1993). Oxford English
Dictionary. Oxford: Oxford University Press.
Sims, A. (1994). “Psyche”: Spirit as well as mind? The
British Journal of Psychiatry, 165, 441–446.
Skevington, S.M. (2002). Advancing cross-cultural research
on quality of life: observations drawn from the
WHOQOL development. Quality of Life Research, 11,
135–144. Retrieved from http://doi.org/10.1023/
A:1015013312456
Skevington, S.M., Gunson, K.S., & O'connell, K.A. (2013).
Introducing the WHOQOL-SRPB BREF: developing a
short-form instrument for assessing spiritual, religious
and personal beliefs within quality of life. Quality of Life
Research: An International Journal of Quality of Life
Aspects of Treatment, Care and Rehabilitation, 22,
1073–1083. Retrieved from http://doi.org/10.1007/
s11136-012-0237-0
Son, K.Y., Lee, C.H., Park, S.M., Lee, C.H., Oh, S.I., Oh, B.,
… . Lee, S.H. (2012). The factors associated with the
INTERNATIONAL REVIEW OF PSYCHIATRY 281
quality of life of the spouse caregivers of patients with
cancer: a cross-sectional study. Journal of Palliative
Medicine, 15, 216–224. Retrieved from http://doi.org/10.
1089/jpm.2011.0305
Spitzer, W.O., Dobson, A.J., Hall, J., Chesterman, E.,
Levi, J., Shepherd, R., … . Catchlove, B.R. (1981).
Measuring the quality of life of cancer patients: a concise
QL-index for use by physicians. Journal of Chronic
Diseases, 34, 585–597.
Stroppa, A., & Moreira-Almeida, A. (2013). Religiosity,
mood symptoms, and quality of life in bipolar disorder.
Bipolar Disorders, 15, 385–393. Retrieved from http://
doi.org/10.1111/bdi.12069
Tadwalkar, R., Udeoji, D.U., Weiner, R.J., Avestruz, F.L.,
LaChance, D., Phan, A., … . Schwarz, E.R. (2014).
The beneficial role of spiritual counseling in heart
failure patients. Journal of Religion and Health, 53,
1575–1585. Retrieved from http://doi.org/10.1007/
s10943-014-9853-z
Taheri Kharame, Z., Zamanian, H., Foroozanfar, S., &
Afsahi, S. (2014). Religious wellbeing as a predictor for
quality of life in Iranian hemodialysis patients. Global
Journal of Health Science, 6, 261–269. Retrieved from
http://doi.org/10.5539/gjhs.v6n4p261
Tarakeshwar, N., Vanderwerker, L., Paulk, E., Pearce, M.,
Kasl, S., & Prigerson, H. (2006). Religious coping is asso-
ciated with the quality of life of patients with advanced
cancer. Journal of Palliative Medicine, 9, 646–657.
doi:10.1089/jpm.2006.9.646
Tedrus, G.M.A.S., Fonseca, L.C., De Pietro Magri, F., &
Mendes, P.H.M. (2013). Spiritual/religious coping in
patients with epilepsy: Relationship with sociodemo-
graphic and clinical aspects and quality of life. Epilepsy &
Behavior: E&B, 28, 386–390. Retrieved from http://doi.
org/10.1016/j.yebeh.2013.05.011
Thomas, C.J., & Washington, T.A. (2012). Religiosity and
social support: implications for the health-related quality
of life of African American hemodialysis patients. Journal
of Religion and Health, 51, 1375–1385. Retrieved from
http://doi.org/10.1007/s10943-011-9483-7
Tix, A.P., & Frazier, P.A. (1998). The use of religious cop-
ing during stressful life events: main effects, moderation,
and mediation. Journal of Consulting and Clinical
Psychology, 66, 411–422. Retrieved from http://doi.org/
10.1037//0022-006X.66.2.411
Trevino, K.M., & McConnell, T.R. (2014). Religiosity
and religious coping in patients with cardiovascular dis-
ease: change over time and associations with illness
adjustment. Journal of Religion and Health, 53,
1907–1917. Retrieved from http://doi.org/10.1007/
s10943-014-9897-0
Trevino, K.M., & McConnell, T.R. (2015). Religiosity and
Spirituality During Cardiac Rehabilitation: A longitudinal
evaluation of patient-reported outcomes and exercise cap-
acity. Journal of Cardiopulmonary Rehabilitation and
Prevention, 35, 246–254. Retrieved from http://doi.org/
10.1097/HCR.0000000000000110
Vallurupalli, M., Lauderdale, K., Balboni, M.J., Phelps, A.C.,
Block, S.D., Ng, A.K., … , Balboni, T.A. (2012). The role
of spirituality and religious coping in the quality of life
of patients with advanced cancer receiving palliative radi-
ation therapy. The Journal of Supportive Oncology, 10,
282 R. G. PANZINI ET AL.
81–87. Retrieved from http://doi.org/10.1016/j.suponc.
2011.09.003
Verlag, H. (1994). WHOQOL group: The development of
the World Health Organization quality of life assessment
instrument (the WHOQOL). In Quality of life assessment:
International perspectives. New York: Springer.
Vilhena, E., Pais-Ribeiro, J., Silva, I., Pedro, L., Meneses,
R.F., Cardoso, H., da Silva, A.M., Mendonça, D. (2014).
Psychosocial factors as predictors of quality of life in
chronic Portuguese patients. Health and Quality of Life
Outcomes, 12, 3. Retrieved from http://doi.org/10.1186/
1477-7525-12-3
Waldron, D., O'boyle, C.A., Kearney, M., Moriarty, M., &
Carney, D. (1999). Quality-of-life measurement in
advanced cancer: assessing the individual. Journal of
Clinical Oncology: Official Journal of the American Society
of Clinical Oncology, 17, 3603–3611. Retrieved from
http://doi.org/10.1200/jco.1999.17.11.3603
Wang, C.W., Chan, C.L.W., Ng, S.M., & Ho, A.H.Y. (2008).
The impact of spirituality on health-related quality of life
among Chinese older adults with vision impairment.
Aging Ment Health, 12, 267–275. Retrieved from http://
doi.org/10.1080/13607860801951903
Whitford, H.S., & Olver, I.N. (2012). The multidimensional-
ity of spiritual wellbeing: peace, meaning, and faith and
their association with quality of life and coping in oncol-
ogy. Psycho-Oncology, 21, 602–610. Retrieved from
http://doi.org/10.1002/pon.1937
Whitford, H.S., Olver, I.N., & Peterson, M.J. (2008).
Spirituality as a core domain in the assessment of quality
of life in oncology. Psycho-Oncology, 17, 1121–1128.
Retrieved from http://doi.org/10.1002/pon.1322
Whoqol-Srpb, G. (2006). A cross-cultural study of spiritual-
ity, religion, and personal beliefs as components of
quality of life. Social Science & Medicine, 62, 1486–1497.
Retrieved from http://doi.org/10.1016/j.socscimed.2005.
08.001
Wildes, K.A., Miller, A.R., de Majors, S.S.M., & Ramirez,
A.G. (2009). The religiosity/spirituality of Latina breast
cancer survivors and influence on health-related quality
of life. Psycho-Oncology, 18, 831–840. Retrieved from
http://doi.org/10.1002/pon.1475
Winkelman, W.D., Lauderdale, K., Balboni, M.J.,
Phelps, A.C., Peteet, J.R., Block, S.D., … , Balboni,
T.A. (2011). The relationship of spiritual concerns to
the quality of life of advanced cancer patients:
Preliminary findings. Journal of Palliative Medicine,
14, 1022–1028. Retrieved from http://doi.org/10.1089/
jpm.2010.0536
World Health Organization, (1946). Constitution of the
World Health Organization. American Journal of Public
Health and the Nations Health, 36, 1315–1323.
Zavala, M.W., Maliski, S.L., Kwan, L., Fink, A., & Litwin,
M.S. (2009). Spirituality and quality of life in low-income
men with metastatic prostate cancer. Psycho-Oncology,
18, 753–761. Retrieved from http://doi.org/10.1002/pon.
1460
Zebrack, B.J., & Chesler, M.A. (2001). A psychometric ana-
lysis of the Quality of Life-Cancer Survivors (QOL-CS) in
survivors of childhood cancer. Quality of Life Research,
10, 319–329. Retrieved from http://doi.org/10.1023/
A:1012228823115
Zhang, K., Hui, C.H., Lam, J., Lau, E.Y., Cheung, S.F., &
Mok, D.S. (2014). Personal spiritual values and quality of
life: evidence from Chinese college students. Journal of
Religion and Health, 53, 986–1002. Retrieved from
http://doi.org/10.1007/s10943-013-9686-1