O R I G I N A L

R E S E A R C H

Measuring Spiritual Quality of

Life in Patients With Cancer
Mary E. Johnson, MA, Katherine M. Piderman, PhD, Jeff A. Sloan, PhD, Mashele Huschka, BSN,
Pamela J. Atherton, MS, Jean M. Hanson, Paul D. Brown, MD, Teresa A. Rummans, MD,
Matthew M. Clark, PhD, and Marlene H. Frost, PhD, RN

uality of life (QOL) and its related physiologic and psychologic domains are often included in cancer research, but the spiritual
domain is less often addressed.1 In part, this
is because spiritual well-being (SWB) is a term that
is subjective in interpretation. Even among researchers, there is no common denition of SWB,24 and
there is a growing awareness of the complexity of this
construct.5,6 However, progress has been made in the
development of instruments to measure several aspects of SWB, including 1) reliance on spiritual beliefs and practices and 2) spiritual qualities such as
hopefulness, peacefulness, and meaning.2,7,8
Preliminary research indicates that SWB is
a signicant independent predictor of physical,
emotional, and social well-being.2 Because of this
unique contribution to other domains of QOL,
further investigation of SWB seems warranted.
In our investigation, we were mindful that as one
struggles with the challenges of a cancer diagnosis, previous approaches to coping may no longer
be sufcient, resulting in a spiritual quest for the
patient.9 Thus, we approached SWB as a dynamic
From the Department of Chaplain Services, the Department
of Psychiatry and Psychology, Department of Health Sciences
Research, the Cancer Center, the Department of Radiation
Oncology, and the Womens Cancer Program, Mayo Clinic,
Rochester, Minnesota.
Manuscript submitted February 28, 2007; accepted July 23, 2007.
This study was supported by grants from the Saint Marys Hospital Sponsorship Board, Inc., the Mayo Clinic Cancer Center
Support Grant, and the Linse Bock Foundation.
This article is dedicated to the patients who participated in
this study. We thank them for their commitment to learning
for the sake of others.
Correspondence to: Mary E. Johnson, MA, Department of
Chaplain Services, Mayo Clinic, Rochester, MN 55905; telephone: (507) 284-2511; fax: (507) 266-7882; e-mail: johnson.
mary3@mayo.edu
J Support Oncol 2007;5:437442

VOLUME 5, NUMBER 9

2007 Elsevier Inc. All rights reserved.

OCTOBER 2007

Abstract There is no one established approach to the measurement of

spiritual quality of life (QOL). Available instruments are based on various theoretical components. We used a multi-instrument approach to
measure the spiritual domain of QOL that adds to our understanding
of a participant self-denition of spiritual QOL. In total, 103 participants
with advanced cancer receiving radiation therapy were enrolled in this
study. Most were Caucasian, male, and had advanced lung, head and
neck, or gastrointestinal cancer. Two instruments, the Spiritual Well-Being
Linear Analogue Self Assessment (SWB LASA) and the 12-item Functional
Assessment of Chronic Illness TherapySpiritual (FACITSp-12), were used
to measure spiritual QOL at enrollment and 4, 8, and 27 weeks after enrollment. Analyses included descriptive statistics, Spearman correlations,
stepwise multiple regression, and repeated measures analysis of variance.
There was a strong association between SWB LASA and FACITSp-12 total
scores. However, FACITSp-12 items dening SWB LASA scores varied over
time. Two to three of the FACITSp-12 items explained approximately two
thirds of the variance in the SWB LASA scores at each time point with
the exception of 4 weeks after enrollment. SWB scores were strongly associated with all QOL domains. In research and clinical care, SWB must be
treated as a complex concept that has the potential to change over time.
Although a single-item measure of SWB provides valuable information
and is strongly associated with the multiple item FACITSp-12, our more
detailed inquiry using the FACITSp-12 provides additional guidance for
the design and timing of spiritual support interventions.

concept that may change over time.

We conducted a multidisciplinary intervention
study in which SWB was among the QOL outcomes explored. A secondary analysis from this
study was conducted to examine both the subjective nature of SWB and the aspects that individuals
consider when assessing their SWB. To undertake
this objective, we focused on the following research
questions: 1) What is the association between participants self-report of their SWB as indicated by
the single-item SWB Linear Analogue Self Assessment (SWB LASA) and the total score of the
12-item Functional Assessment of Chronic Illness

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Measuring Spiritual Quality of Life in Patients With Cancer

Table 1

Demographics (n = 103)
CHARACTERISTIC

n (%)

Gender
Female
Male
Race
Caucasian
Unknown
Marital status
Married
Divorced
Widowed
Single
Education
Less than high school
High school graduate/GED
Some college/vocational
Four-year degree
Graduate degree
Other
Religious afliation
Protestant
Roman Catholic
None
Other
Employment
Yes
No
Currently receiving chemotherapy
Yes
No
Prior surgery
Yes
No
Tumor types
Gastrointestinal
Head and neck
Other
Lung
Brain
Ovarian

37 (36)
66 (64)
98 (95)
5 (5)
86 (83)
6 (6)
6 (6)
5 (5)
4 (4)
21 (20)
33 (32)
16 (16)
18 (17)
11 (11)
65 (63)
27 (26)
6 (6)
5 (5)
57 (55)
46 (45)
63 (61)
40 (39)
102 (99)
1 (1)
39 (38)
18 (17)
18 (17)
15 (15)
12 (12)
1 (1)

TherapySpiritual (FACITSp-12)? 2) What is the association

between participants self-report of SWB as measured by the
single-item SWB LASA and their responses to instrumentidentied components of SWB as measured by the FACITSp12? 3) What specic components of SWB change over time? 4)
How is SWB related to other domains of QOL?

Methods
STUDY POPULATION

Study participants were at least 18 years of age, diagnosed

with advanced stage cancer, and receiving radiation therapy at

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Mayo Clinic, Rochester, Minnesota. All participants had been

diagnosed with cancer within the past 12 months and had a
life expectancy between 6 months and 5 years. Exclusion criteria included impaired cognitive function, active substance
abuse or dependence (except nicotine), an active thought
disorder, suicide risk, and participation in other psychosocial
research trials. Half of the participants were randomized to
an intervention group and successfully completed at least six
of eight multidisciplinary sessions focusing on all domains of
QOL. The sessions began with physical therapy exercises; followed by behavioral, spiritual, and coping content; and ended
with relaxation exercises.10
APPROACH

Informed consent was obtained. Participants completed

a demographic form at enrollment. The FACITSp-12 and
single-item SWB LASA, along with other parent study assessments, were completed at enrollment and 4, 8, and 27 weeks
after enrollment.10
INSTRUMENTS

The instruments chosen to measure SWB were the FACITSP-12 and the SWB LASA. The FACITSP-12, composed
of 12 items, was developed as an overall index of SWB. It captures such important aspects of spirituality as a sense of meaning in ones life, inner harmony, peacefulness, and a sense of
comfort and strength in ones spiritual beliefs. The instrument
has demonstrated reliability and validity.2,11,12 Items are rated
on a ve point Likert-like scale of 0 (not at all) to 4 (very
much). The FACITSp-12 was chosen because of its inclusive
approach to SWB assessment and its previous use in persons
with cancer.2
LASA items have been used as general measures of global
QOL in a number of populations.2,1317 The single-item SWB
LASA question was How would you describe your overall
spiritual well-being? This instrument elicited a response
based on participant self-assessment and interpretation of
SWB, rated from 0 (as bad as it can be) to 10 (as good as
it can be). Other LASA items assessed physical, mental, and
emotional well-being, as well as social activity.18
STATISTICAL APPROACH

Descriptive statistics, including means, standard deviations,

ranges, and percentages, were used to describe the data. Spearman correlation procedures were used to examine the association of the SWB LASA with the total score of the FACITSp-12
as well as the SWB LASA total score and individual FACIT
Sp-12 item scores. For this study, a correlation of 0.0 to 0.3 was
considered a weak relationship; between 0.3 to 0.5, a moderate
relationship; and above 0.5, a strong relationship.19 Collinearity
diagnostics were performed to identify if multicollinearity between FACITSp-12 items was a factor when examining their
associations with the SWB LASA. Forward stepwise multiple
regression was used to identify the extent to which SWB was
explained by individual FACITSp-12 items.

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Johnson, Piderman, Sloan, et al

Table 2

Correlations (r) Between Spiritual Well-Being LASA and FACITSP-12 Items and Total Score (n = 81)
SPIRITUAL WELL-BEING LASA
FACIT ITEM

1. Peaceful
2. Reason for living
3. Life has been productive
4. Trouble feeling peace of mind
5. Sense of purpose in life
6. Comfort within
7. Inner harmony
8. Life lacking meaning/purpose
9. Comfort in spiritual beliefs
10. Strength in spiritual beliefs
11. Illness strengthens beliefs
12. Things will be OK
Total score

ENROLLMENT

4 WEEKS

8 WEEKS

0.61
0.20
0.27
0.38
0.40
0.62
0.67
0.34
0.58
0.59
0.47
0.68
0.82

0.54
0.13
0.18
0.34
0.26
0.41
0.51
0.22
0.50
0.40
0.46
0.54
0.57

0.49
0.33
0.43
0.50
0.41
0.30
0.49
0.33
0.70
0.69
0.48
0.51
0.70

27 WEEKS

0.70
0.34
0.43
0.64
0.52
0.58
0.65
0.51
0.69
0.70
0.53
0.58
0.81

Only patients who completed questionnaires at all four measurement times were included. High scores reect favorable response to item/scale. Correlations > 0.50 are in bold.
Abbreviations: LASA = Linear Analogue Self Assessment; FACITSP-12 = 12-item Functional Assessment of Chronic Illness TherapySpiritual

Results
In total, 115 participants were enrolled in this study. Three
withdrew before completing the initial assessment and 9 participants did not complete one of the subsequent assessments.
The remaining 103 participants were considered evaluable.
The majority of participants were male (64%), Protestant
(63%), Caucasian (95%), married (83%), employed (55%),
and had some education beyond high school (65%). The
average age of participants was 59.6, with a range of 3185
years of age. A number of tumor types were represented,
with gastrointestinal tumors comprising the largest group
(38%; Table 1).
RELATIONSHIP BETWEEN THE SWB LASA
AND FACITSP-12 TOTAL SCORES

SWB LASA and FACITSp-12 total scores revealed a

strong association across time points. The strength of that
association, however, was diminished at week 4, which corresponded to the end of the intervention and near the end of
radiation treatment (enrollment, r = 0.82; week 4, r = 0.57;
week 8, r = 0.70; week 27, r = 0.81). In an attempt to better
understand this change, we explored the relationship between
the SWB LASA and each of the FACITSp-12 items at all of
the measurement time points.
RELATIONSHIP BETWEEN THE SWB LASA
AND THE FACITSP-12 ITEMS

Our examination of the associations between the SWB

LASA and the FACITSp-12 items yielded several ndings.
(FACITSp-12 items appear in italics.) At enrollment, participants favorable SWB LASA scores were strongly associated with six FACITSp-12 items: peaceful (r = 0.61); comfort
within (r = 0.62); inner harmony (r = 0.67); comfort in spiritual
beliefs (r = 0.58); strength in spiritual beliefs (r = 0.59), and

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OCTOBER 2007

things will be okay (r = 0.68). The association between these

FACITSp-12 items and the SWB LASA remained moderate
to strong across time (Table 2).
Other associations were less stable over time. The association between lower SWB LASA scores and increased
trouble feeling peace of mind as measured by the FACITSp-12
strengthened at weeks 8 and 27 (enrollment, r = 0.38; week
4, r = 0.34; week 8, r = 0.50; week 27, r = 0.64). The correlation between lower SWB and life lacking meaning/ purpose
was even less stable over time. Its moderate association at enrollment (r = 0.34) weakened at week 4 (r = 0.22), became
slightly stronger at week 8 (r = 0.33), and was strongly associated at week 27 (r = 0.51). Interestingly, at week 27 the SWB
LASA was strongly associated with 10 of the 12 FACITSp12 items. The exceptions were reasons for living (r = 0.34) and
life has been productive (r = 0.43). These items demonstrated
only moderate correlations (Table 2).
FACITSP-12 ITEMS MOST STRONGLY
ASSOCIATED WITH SWB

Collinearity diagnostics were done to identify whether differences between the SWB LASA and the FACITSp-12 over
time were due to multicollinearity.20 No complex collinearity
was found. However, strong collinearity was found between
the FACITSp-12 items: 1) comfort within and inner harmony
and 2) comfort in spiritual beliefs and strength in spiritual beliefs.
This collinearity was supported by simple correlations (r =
0.80 and r = 0.94, respectively, at enrollment). As a result,
the items comfort within and comfort in spiritual beliefs were removed from multiple regression analysis.
A forward stepwise regression model was constructed using
the remaining FACITSp-12 items as potential predictors of
the SWB LASA score. With 10 items and 103 observations,
we have a modest but reasonable observation-to-variable ra-

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Measuring Spiritual Quality of Life in Patients With Cancer

Table 3

Stepwise Regression of FACITSP-12 Variables Most Strongly Associated With the Spiritual QOL LASA (n = 81)
VARIABLE ENTERED

Enrollment
Things will be okay
Inner harmony
Strength in spiritual belief
Week 4
Peaceful
Illness strengthens spiritual beliefs
Week 8
Strength in spiritual beliefs
Trouble feeling peace of mind
Purpose in life
Week 27
Strength in spiritual beliefs
Trouble feeling peace of mind
Peaceful

PARTIAL R-SQUARE

MODEL R-SQUARE

F VALUE

PARTIAL R-SQUARE >

F VALUE

0.46
0.14
0.06

0.46
0.60
0.66

64.19
26.31
13.09

< 0.0001
0.0005
<0.0001

0.28
0.08

0.28
0.36

29.81
9.74

< 0.0001
0.0026

0.49
0.08
0.03

0.49
0.56
0.59

71.97
13.39
4.85

< 0.0001
0.0005
0.0307

0.49
0.14
0.04

0.49
0.63
0.67

72.78
27.20
9.81

< 0.0001
< 0.0001
0.0025

Only patients who completed questionnaires at all four measurement times were included. High scores reect favorable response to item/scale.
Abbreviations: FACITSP-12 = 12-item Functional Assessment of Chronic Illness TherapySpiritual; QOL = quality of life; LASA = Linear Analogue Self Assessment

tio.21 A backward elimination model was used to validate the

forward regression model ndings. Findings were consistent
using both forward and backward models.
We discovered that a relatively small number of FACIT
Sp-12 items that varied across time explained much of the
variance in the SWB LASA. With the exception of strength
in spiritual beliefs, which entered three of the four regression
models, other items entering the model at any given time
point varied. Items entering into the enrollment model were
strength in spiritual beliefs, things will be okay, and inner harmony.
This combination of items explained 66% out of a possible
100% of the variance in the SWB LASA. When week-4 item
scores were compared with enrollment scores, all of the original variables fell out of the regression model, and peaceful and
illness strengthens spiritual beliefs entered into the model. However, at week 4, only 36% of the variance could be explained.
At week 8, strength in spiritual beliefs, trouble feeling peace of
mind, and purpose in life were the items that were most strongly
associated with the SWB LASA. These three items explained
59% of the variance in the SWB LASA. At week 27, peaceful replaced purpose in life in the model. Thus, at week 27,
67% of the variance in the SWB LASA was explained by the
items strength in spiritual beliefs, trouble feeling peace of mind,
and peaceful (Table 3).
RELATIONSHIPS BETWEEN SWB AND
OTHER DOMAINS OF QOL

The SWB LASA was strongly associated with the other

domains of QOL at all time points: overall QOL (r = 0.59
0.70); mental well-being (r = 0.630.75); physical well-being
(r = 0.500.64); emotional well-being (r = 0.640.76); and
social well-being (r = 0.630.75; Table 4).

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Discussion
We found strong associations between the SWB LASA
and FACITSp-12 total scores at all time points. However,
items dening the SWB LASA scores varied over time. Two
to three items dening participant self-assessment of SWB as
measured by the SWB LASA explained approximately two
thirds of variance at all time points except four weeks after enrollment. We propose areas that may dene the unexplained
variance. Finally, we found that SWB is strongly associated
with all other domains of QOL.
The FACITSp-12 and SWB LASA scores were strongly
associated over time. The association diminished slightly at
week 4. The FACITSp-12 items that remained strongly associated with the SWB LASA across time included peaceful,
inner harmony, strength in spiritual beliefs, things will be okay,
comfort within, and comfort in spiritual beliefs.
At enrollment and weeks 8 and 27, two thirds of the variance in the SWB LASA could be explained by FACITSp-12
items and reects the ability of the FACITSp-12 to capture
participant denitions of SWB at various time points. It should
be noted that, at these time points, only two to three FACIT
Sp-12 items explain the majority of participant SWB LASA
scores. The only item that consistently entered the model at
three of the four time points was strength in spiritual beliefs.
The other items entering the model intermittently focused on
peace, inner harmony, having a purpose in life, and believing that
things will be okay, suggesting that participant assessment of
SWB changes over time and can be explained, in large part,
by a few FACITSp-12 items. This information implies some
aspects commonly included in the self-denition of SWB in
this population (Table 3).
Our ndings suggest that supporting people in their spiri-

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Johnson, Piderman, Sloan, et al

Table 4

Spearman Correlations (r) Between Spiritual LASA and Other Aspects of QOL (n = 81)
SPIRITUAL WELL-BEING LASA
QOL LASA

Overall QOL
Mental well-being
Physical well-being
Emotional well-being
Social well-being

ENROLLMENT

4 WEEKS

8 WEEKS

27 WEEKS

0.70
0.73
0.60
0.76
0.75

0.64
0.63
0.50
0.68
0.63

0.61
0.75
0.64
0.74
0.65

0.59
0.69
0.57
0.64
0.64

Only patients who completed questionnaires at all four measurement times were included. High scores reect favorable response to item/scale. All correlations are > 0.50.
Abbreviations: LASA = Linear Analogue Self Assessment; QOL = quality of life

tual beliefs may be potentially useful. Since spiritual beliefs

can be challenged by a health crisis, such as the diagnosis
of advanced cancer, a discussion of spiritual beliefs in a supportive, non-judgmental environment may facilitate reliance
on those beliefs. This idea is consistent with the ndings of
Norum and colleagues,22 in which patients in a palliative
care setting indicated that the sharing of spiritual beliefs with
another was benecial. Approaches that promote the use of
spiritual beliefs might include life review, the identication of
potential contributors to SWB, antidotes to spiritual distress,
and preparation for the end of life.
The fact that different FACITSp-12 items explained SWB
LASA scores over time reveals the complexity of SWB and
suggests that spiritual assessments at a single time point may
be inadequate. These ndings are supported by several coping
theories. Park and Folkman23 note that meaning making is
critical in the coping process. Once meaning is established, it
often leads to the mobilization of a variety of resources seen
as helpful in dealing with a challenging situation. Also, the
dynamic nature of these associations is reminiscent of the
non-linear process of adjustment described by Pargament.9
This theory promotes coping with difculty as a process with
several phases, beginning with reliance on the familiar and
re-evaluation and establishment of a new set of reorienting
responses. Kindlen24 suggests that adaptation to loss occurs
by confronting issues associated with loss in an attempt to live
through the process of integration. Our ndings and related
theories suggest the importance of including an oncology or
palliative care provider, preferably a spiritual care professional,
in the clinical setting who is trained to assist with the process
of spiritual coping and integration associated with a diagnosis
of advanced cancer.
Finally, SWB was highly correlated with all other domains
of QOL. These strong associations have been well documented.12,25,26 The strong associations between SWB and other domains of QOL suggest that changes in any dimension of QOL
may affect overall QOL and vice versa. Lin and Bauer-Wu12
note the importance of building interventions that support
SWB due to the association between psychospiritual well-being, enhanced coping, and the ability to discover meaning in
experience. More research is needed to prospectively investigate the nature and sequence of change among the various

VOLUME 5, NUMBER 9

OCTOBER 2007

domains of QOL in an effort to clarify the mediating effect of

SWB. For example, in a crisis situation, does emotional distress occur rst, followed by spiritual distress or does spiritual
distress occur rst, followed by emotional distress? These variables may be functionally discreet or they may coexist. This
information could inuence the content and timing of future
spiritual and QOL interventions.
LIMITATIONS

This study was limited by its size and its single-study population: persons with advanced cancer receiving radiation
therapy. In addition, the social homogeneity of the study was
a limitation. Study participants were mostly male, Caucasian,
married, educated, Protestant, employed, and from the midwestern United States. The applicability of study results for
persons from a wider variety of racial, cultural, and religious
backgrounds is limited. Participants in this study had just begun receiving treatment for advanced-stage cancer. If measurement was applied for a longer period during which physical decline would be expected, the results of the assessment
of spiritual QOL may have been quite different. In addition,
this study was limited by its utilization of only two approaches
to the measurement of SWB. Additional approaches certainly
merit exploration.

Conclusion
This study was initiated to increase our understanding of
participant self-denition of spiritual QOL. Our ndings led
us to conclude that, in both research and clinical care, SWB
must be treated as complex with the potential to change
over time. The SWB LASA yields important results about
overall SWB, so it seems essential that it be used at various
time points across the episode of care to provide information about important changes in the patients SWB. This
may be pertinent for the integration of ndings into clinical
practice. Because the SWB LASA and the FACITSp-12
have been used primarily in research settings, more inquiry
is needed into their usefulness as screening tools in the clinical setting. We have highlighted a need to identify a more
complete understanding of SWB as well as consideration of
its complex and dynamic nature in both the scientic and
clinical arenas.

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Measuring Spiritual Quality of Life in Patients With Cancer

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