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  • Review Article

    A Psychometric Evaluation of Measuresof Spirituality Validated in Culturally DiversePalliative Care Populations

    inclusion criteria. Twenty-four tools demonstrated good content validity and 12

    Kingdom. E-mail:

    6, 2011.

    604 Journal of Pain and Symptom Management Vol. 42 No. 4 October 2011 2011 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

    0885-3924/$ - see front matterdoi:10.1016/j.jpainsymman.2011.01.015adequate construct validity, usually because specific hypotheses were not statedand tested. Seven tools demonstrated adequate test-retest reliability; two toolsshowed adequate responsiveness, and two met the interpretability criterion. Dataon the religious faith of the population of validation were available for 11 tools; ofthese, eight were tested in multifaith populations.

    Conclusion. Results suggest that, at present, the McGill Quality of LifeQuestionnaire, the Measuring the Quality of Life of Seriously Ill Patients

    Address correspondence to: Lucy Selman, BA, MPhil,PG Cert Pall Care, Department of Palliative Care,Policy and Rehabilitation, Kings College London,Cicely Saunders Institute, Bessemer Road, Denmark

    Hill, London SE5 9PJ, Unitedlucy.selman@kcl.ac.uk

    Accepted for publication: January 2demonstrated adequate internal consistency. Only eight tools demonstratedResults. A total of 191 articles were identified, yielding 85 tools. Twenty-six tools(representing four families of measures and five individual tools) met theinterpretability), multifaith appropriateness, anLucy Selman, BA, MPhil, PG Cert Pall Care,Richard Siegert, BSc, MSocSci, DipPsych (Clin), PhD,Richard Harding, BSc, MSc, PhD, DipSW, Marjolein Gysels, BA, MA, PhD,Peter Speck, BSc, MA, and Irene J. Higginson, BMedSci, BMBS, PhD, FFPHM, FRCPDepartment of Palliative Care, Policy and Rehabilitation (L.S., R.S., R.H., P.S., I.J.H.), Cicely

    Saunders Institute, Kings College London, London, United Kingdom; and Barcelona Centre for

    International Health Research (CRESIB) (M.G.), University of Barcelona, Barcelona, Spain

    AbstractContext. Despite the need to accurately measure spiritual outcomes in diverse

    palliative care populations, little attention has been paid to the properties of thetools currently in use.

    Objectives. This systematic review aimed to appraise the psychometricproperties, multifaith appropriateness, and completion time of spiritual outcomemeasures validated in multicultural advanced cancer, HIV, or palliative carepopulations.

    Methods. Eight databases were searched to identify relevant validation andresearch studies. A comprehensive search strategy included search terms in threecategories: palliative care, spirituality, and outcome measurement. Inclusioncriteria were: validated in advanced cancer, HIV, or palliative care populations andin an ethnically diverse context. Included tools were evaluated with respect topsychometric properties (validity, reproducibility, responsiveness, and

    d time to complete.

  • le are tl itemsese meopriate622. ved.


    in the Brief Reli-ntory (sins, devil,res on the SWBS

    among mainline denominations and Catho-tional bias.d religious biases,ve been identifiede measures.26 Forhich exist where

    ative skew and/or

    Vol. 42 No. 4 October 2011 605Systematic Review and Psychometric Evaluation of Spirituality Measuresand religious bias of spiritual outcome mea-sures is related to inadequate sample represen-tativeness in the validation studies of themeasures. Most tools have been developedand tested in ethnically and religiously homoge-neous samples in the United States, primarilyCaucasian24e27 and Protestant.30e32 Bias results

    lics45 also suggest denominaIn addition to cultural an

    psychometric limitations hain existing spiritual outcomexample, ceiling effects, wthere is considerable negequal amounts of a trait have different probabil-ities of scoring high on that trait.29 The cultural

    among evangelical Christian groups than44In psychometric terms, biased tests are thosein which persons from different groups with

    noted with respect to termsgious Coping (RCOPE) inveand church).43 Higher scobias25e27 and psychometric limitations.26,28not religious.42 Similar concerns have beenQuestionnaire, and the Palliative Outcome Scamultidimensional measures containing spirituapalliative care populations. However, none of thpsychometric criteria, and their multifaith apprtesting. J Pain Symptom Manage 2011;42:604eCommittee. Published by Elsevier Inc. All rights reser

    Key WordsSystematic review, spirituality, outcome measurement,

    IntroductionSpirituality, understood to include existen-

    tial questions relating to meaning and pur-pose, as well as religious belief and practice,often underpins the experience of advancedillness.1e8 Spirituality has been identified asan important concern for patients with incur-able progressive disease, and studies suggestthat many people wish to discuss their beliefswith their physicians.9e11 Within palliativecare, the need to take into account the roleof spirituality is reflected in global policy guid-ance, which stipulates spiritual care provisionand assessment as integral components of themultidimensional care of persons affected byprogressive life-limiting disease.12e17

    The measurement of spiritual outcomes isessential in screening for spiritual distress, iden-tifying spiritual health and providing appropri-ate spiritual support,18e21 service evaluationand quality improvement,22 and for researchpurposes, for example, testing spiritual inter-ventions and investigating the relationship be-tween spiritual variables and other healthoutcomes. With the growth in research in spiri-tuality within health care in recent years,23 thenumber of outcome measurement tools hasproliferated.24 However, existing measureshave been criticized for cultural and religioushe most appropriatefor use in multiculturalasures score perfectly on allness requires further2011 U.S. Cancer Pain Relief

    metrics, culture

    from a lack of fit between the worldview em-bedded in the measure and that of the respon-dent population,28 often because of theuncritical transfer of concepts between culturesor belief systems,33 or the emphasis of irrelevantissues or de-emphasis of issues of impor-tance.27,32 There is evidence from the UnitedStates of differences in how spirituality isconceptualized in Caucasian, Latino, andAfrican-American populations34e36 and thatthis has implications for the validity and appro-priateness of outcome measures in diversepopulations.25,37e39 For example, differencesin the factor structure of the Spiritual Well-Being Scale (SWBS)40,41 in Caucasian andAfrican-American populations suggest culturaldifferences in the concept of spirituality andthe interpretation of scale results37,38 anddraw into question the construct validity of thetool in African-American populations.39 Thelanguage of the SWBS also assumes that reli-gious well-being consists of a close relationshipwith God and that spiritual well-being can bemeasured as a composite score of religiousand existential well-being. Arguably, the SWBSdefines spirituality toonarrowly anddoes not re-flect the spirituality of people of a non-Christianbackground, including atheists, agnostics, andthose who define themselves as spiritual but

  • DSR, ACP Journal Club, DARE, CCTR, CMR,

    606 Vol. 42 No. 4 October 2011Selman et al.most individuals score within one or two stan-dard deviations of the maximum score, havebeen reported for the SWBS among evangelicalpopulations.46 Concerns also have been raisedregarding the construct validity of a number oftools, including the SWBS,44,46 the Quest scale(a measure of religious orientation),47 and thePurpose in Life Test.48

    From a palliative care perspective, an addi-tional problem is that only a limited numberof existing tools have been developed andtested in palliative care populations. Given thespecific spiritual needs and experiences of pa-tients with progressive incurable disease,3 it isessential that the measures used in palliativecare practice and research have been validatedin relevant populations. However, evidence sug-gests this is not the case at present. We recentlypublished results from a comprehensive andsystematic review of tools used to measure spiri-tuality in palliative care, advanced cancer, andHIV populations.49 We found that of 50 differ-ent tools used to measure spiritual outcomesin those populations, only 30 had been psycho-metrically validated in those groups.In our previous publication, we sought to

    guide tool selection by palliative care cliniciansand researchers by focusing on the clinical andcultural characteristics of the populations inwhich tools had been tested. We identifiedand categorized those spiritual outcome mea-surement tools that had been validated in ad-vanced cancer, HIV infection, or palliative carepopulations, and went on to identify those toolsthat had been validated cross-culturally. How-ever, it was beyond the remit of that article to in-vestigate the psychometric properties of theidentified tools, their multifaith appropriate-ness and the burden of completion time theyplace on patients (i.e., additional factors thatare crucial in the selection of measures in palli-ative care populations). Although previous re-views have identified some of the spiritualmeasures used in palliative care research,50,51

    none have evaluated the psychometric proper-ties of the tools in a systematic way.In this article, we present a psychometric eval-

    uationof the cross-culturally validatedmeasuresidentified in our previous publication, also as-sessing time to complete and the religious diver-sity of the populations in which the tools werevalidated. In doing so, we aim to guide thechoice of outcomemeasurement tools in fut