SPIRITUAL PERSPECTIVES OF ________ IN A SOUTHERN STATE

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

SPIRITUAL PERSPECTIVES AND HEALTH:

A RANDOM SURVEY IN A SOUTHERN STATE

Jeri Dunkin, PhD, RN
1

Linda L. Dunn, DSN, RN, CNL
2

1
Saxon Chair and Professor; Capstone College of Nursing, University of Alabama, jdunkin@bama.ua.edu

2
Professor, Capstone College of Nursing, University of Alabama, ldunn@bama.ua.edu*

* Contact author

Key words: Spirituality, Health, Rural

ABSTRACT

While multiple studies have shown that there is a relationship between Religion/Spirituality and self

reported health, as well as health and spiritual well-being, no studies could be found that correlated

spiritual perspectives with Self Reported Health. This study was a part of a random-digit-dialing

telephone poll of 452 adult respondents 18 years of age or older in the State of Alabama. The 10-item

Spiritual Perspectives Scale (SPS) was used to measure participants’ perceptions of the extent to which

they hold certain spiritual views and engage in spiritually-related interactions. Respondents were also

asked to rate their health on a four point Likert type scale from poor (1) to excellent (4) (SRH).

Significant differences were found for the SPS on age, marital status and rurality. There was a positive

correlation between SPS and SRH. Rurality did not show a significant correlation with SRH. Three

variables were significantly different on gender: SPS, age and current marital status. However, only three

variables were significantly different between men and women: SPS, age, and current marital status. This

study adds support to the literature that spirituality is positively related to one’s health and brings to focus

the need to pursue the study of the spiritual experience and health connection.

INTRODUCTION

Nursing has historically viewed humans as holistic: body, mind, and spirit. As the United

States of America (USA) becomes more diverse in culture, lifestyles, religions, and worldviews,

nurses are challenged more than ever before in providing holistic care to patients (Fawcett &

Noble, 2004). Religion and spirituality are two important aspects of one’s culture that permeates

this holistic view, particularly in the healthcare arena where RS beliefs may determine the

patient’s choices for treatment or end-of-life decisions, as well as affect the way one copes with

illness or finds sustaining comfort and support in illness (Johnson, Elbert-Avila, & Tulsky,

2005). Additionally, during physician-patient encounters, patients want physicians to respect

their spiritual beliefs (Hebert el al., 2001). The spiritual dimension of humans is universal and

relative to one’s state of health (Miller & Thoresen, 2003). Health has been defined as a state of

holistic well-being, not just the absence of disease or infirmity (Venes, 2005). Even though self-

rated health (SRH) is a subjective assessment of one’s health, it has been shown to be a strong

predictor of morbidity, mortality, and health care utilization (Daaleman, Perera, & Studenski,

2004; Erikson, Unden, & Elofsson, 2001).

Reed (1992) defined spirituality as the tendency to make meaning through one’s

intrapersonal, interpersonal and transpersonal relationships that empower one to transcend. She

further clarified that spiritual perspectives are “the extent to which spirituality permeates their

lives and they engage in spiritually-related interactions” (Reed, 1987, 337). Thus, it is spiritual

perspectives that guide choices, provide comfort, formulate personal values/morals, and assist

with coping during illness, suffering, grief and loss.

BACKGROUND

Koenig, McCullough, & Larson (2001) reviewed more than 1,200 studies and found that

religious beliefs/practices were consistently associated with better health. Space within this

article prohibits specific discussion of the studies they reviewed. However, empirical studies

continue to demonstrate a positive relationship between religion, spirituality, and health, albeit

most research has focused more on religion than spirituality (Ameling & Povilonis, 2001;

Koenig, 2002; Mauk & Schmidt, 2004). There have been reports that some religious

beliefs/practices are harmful and irrelevant to health, such as refusing medical treatment, failure

to seek medical care, maladaptive coping practices, and involvement in cults (Flannelly, Ellison,

& Strock, 2004; George, Larson, Koenig, & McCullough, 2000; Koenig, McCoullough, &

Larson, 2001).

http://nursing.ua.edu/
mailto:jdunkin@bama.ua.edu
http://nursing.ua.edu/
mailto:ldunn@bama.ua.edu

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

Daaleman, Perera, & Studenski., (2004) examined the relationship between religion,

spirituality and self-reported health (SRH). They brought to light that geriatric outpatients who

reported greater measure of spirituality, but not greater religiosity, were more likely to rate their

health as good. Koenig, George, & Titus (2004) concluded that patients who considered

themselves to be both spiritual and religious were more likely to have more social support and

better psychosocial and physical health outcomes than patients who did not consider themselves

spiritual and religious. Interestingly, one group of investigators found spirituality to be

associated with one’s subjective perception of health status (Boero et al., 2005). Yi, et al.,

(2007) ascertained that the self-rated health of young, resident physicians was not only lower

than expected, but was also positively correlated with current resident placement in internal

medicine, higher level of depressive symptoms, and lower level of spiritual well-being. While

numerous populations have been investigated, limited spiritual research has been conducted with

rural dwellers (Craig et al., 2006).

Several studies have investigated the spiritual perspectives within various populations,

such as hospitalized adults, healthy and chronically ill older adults, bereaved adults, homeless

substance abusers, chronic mentally-ill, and healthcare providers. For example, Reed (1987)

reported significantly higher spiritual perspective scores among hospitalized, terminally ill, older

adults than for hospitalized, non-terminally ill as well as healthy older adults. Martin (1996)

confirmed a high level of spiritual perspectives in African American women with arthritis.

Brush & McGee (2000) identified spiritual perspectives to be important in the lives of homeless

men in substance abuse recovery. Walsh et al., (2002) concluded that people who profess

stronger spiritual beliefs could more rapidly and completely resolve their grief after the loss of a

loved one. Johnson, Elbert-Avila, & Tulsky (2005) demonstrated through an extensive literature

review that spiritual beliefs strongly direct decisions by African Americans on both treatment

decisions and end-of-life choices.

Despite these findings, there continues to be much controversy in how spirituality and

religion are defined. The authors of this study distinguish between religion and spirituality as

follows: Spirituality is more abstract than religion and can be described as that which gives life

meaning and purpose and enables one to transcend. Religion is an organized system that

designates beliefs, values, rituals, practices, behaviors, and symbols that enhance a relationship

with God/higher power. We believe that just as each patient has physical needs (air, water,

shelter, food), each patient also has spiritual needs: trust, love, hope, peace, forgiveness,

connectedness, and meaning/purpose in life. While all humans are born spiritual, religious

affiliation is an individual choice.

Many studies have shown a relationship between spirituality, religion, and self-reported

health (SRH) as well as health and spiritual well-being (Boero, et al., 2005; Daaleman, Perera, &

Studenski, 2004; Koenig, George, & Titus, 2004; Reed, 1987; Yi, et al., 2007); however, no

studies could be found that correlated spiritual perspectives with SRH. Also, much of the

published research on spirituality, religion, and health has focused on older adults, women, end-

of-life issues, as well as cross-sectional designs (Becker et al., 2007; Flannelly, Ellison, & Stock,

2004; George, Ellison, & Larson, 2002). Therefore, the purpose of this study was to investigate

the relationship of spiritual perspectives to SRH in a sample of adults 18 years and older living in

the state of Alabama.

METHODOLOGY

The purpose of this article is to report the findings related to spirituality from the

Omnibus Poll, an annual statewide telephone survey conducted by the Capstone Poll of the

University of Alabama. The Omnibus Poll, comprised of sets of questions submitted by

University of Alabama faculty members and other organizations, covers a wide range of topics

and differs somewhat from year to year. Permission was obtained to include Reed’s (1986)

Spiritual Perspective Scale (SPS) as one set of questions.

Once IRB approval was obtained from the University of Alabama, this 1999 Omnibus

Survey was conducted between March 22, 1999 and April 21, 1999 and was based upon a

random-digit-dialing (RDD) telephone poll of 452 adult respondents 18 years of age or older in

the State of Alabama. The survey had a margin error of plus or minus five percentage points for

the total sample. The sample of households was drawn by using the three area codes and all of

the three-digit telephone exchanges in Alabama. Random telephone numbers were generated

beginning with the specified area codes and exchanges. These numbers were then used to

establish house hold contacts. For each house hold contact, a respondent was randomly selected

by asking for the adult whose birthday had occurred most recently. If that person was available,

the interview was conducted. If the appropriate person was not available, a call back was

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

arranged. Telephone interviews were conducted by employees of the Capstone Poll who were

trained and experienced in telephone interview techniques. They received additional training

specific to the questionnaire for this project. An experienced supervisor was present at all times

during the interview process. Data for this study were analyzed using the SPSS.

The 10-item Spiritual Perspective Scale (SPS) (Reed, 1986) was designed to measure

participants’ perceptions of the extent to which they hold certain spiritual views and engage in

spiritually-related interactions. The SPS has been used successfully in a wide variety of adult

populations: healthy, terminally ill, chronic mental illness, Appalachian pregnant women,

substance addiction, and African-Americans (Brush & McGee, 2000; Conner & Eller, 2004;

Jesse & Reed, 2004; Reed, 1987). The psychometric properties of the SPS are good. Criterion-

related validity and discriminant validity have been demonstrated (Reed, 1986, 1987). Using

the Cronbach’s alpha, reliability has consistently rated above .90 with very little redundancy

among the items. Average inter-item correlations range from .54 to .60 across the adult groups.

All item-scale correlations have been above .60. Women and lower socioeconomic groups tend

to score higher on the SPS, as they have on similar instruments, and participants who identify no

religious affiliation score significantly lower on the SPS than participants who identify a

religious affiliation. The SPS is scored by calculating the arithmetic mean across all items for a

total score that ranges from 1.0 to 6.0. Each of the 10 items use a 6-point Likert-type scale that

is anchored with descriptive words (i.e. 1.0=Not at all or Strongly Disagree) (Reed, 1986). The

Chronbach’s Alpha for this study (N=452) which included both men and women was .864 which

is very close to what Reed (1987) reported.

Self reported health (SRH) has most frequently been reported in the literature by asking

only one question. This question simply asks patients/participants to rate their overall health on

a scale from poor to excellent (Fayers & Sprangers, 2002).

FINDINGS

The sample for this study included adults who answered a random digit dial survey at

their home telephone number. Four hundred fifty-two subjects completed the telephone survey.

Sixty three percent (n=295) of the respondents were female and 67% (n=301) were married. The

age of the respondents ranged from 18 years (n=2) to 95 years (n=1), with the mean age being

48.58 years.

Thirty three percent had completed high school (n=148) and another 29% had some

college education (n=131), while 17.5% (n=79) completed college. Twenty six percent chose the

“don’t know/not applicable” response to the question.

Interestingly, 46% of the respondents were employed full time and another 41% were not

employed. There were approximately 11% who were employed part-time and most surprising

was the 26 % who responded that they didn’t know or felt that it was not applicable to them.

This is the same percentage that did not provide data in response to the family income question.

Fully, two-thirds of the sample reported being married (66.6%) with nearly equal distribution of

the rest across widowed, divorced/separated, and single. The family income category most

frequently chosen was $30-40,000 (14.6%); however, it is interesting to note that the income

categories surrounding that were very close with approximately 12% in the three surrounding

categories. Twenty-six percent of the subjects did not respond to the family income question.

See table 1A for all the respondent demographics.

Chi-Square Goodness of Fit

In analyzing the data for this study, we compared age, race, and education to the 2000

Alabama Census data. As expected with a telephone survey, there was an over representation of

Caucasian and an under representation of African Americans. There was an over representation

of higher levels of education in the study sample compared to the 2000 Alabama Census. There

was no significant difference on age. See table 1B.

Rate Your Health

Respondents were asked to rate their health on a Likert scale from 1 to 5 with 1 being

poor to 5 being excellent. There was also a selection of “Don’t Know/Not Applicable”. Two

respondents chose that response. The mean for Rate Your Health was 3.39 (N=452), with the

median and mode both being 3 (good). The standard deviation was 1.135. The details of the

responses can be found in table 2.

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

Table 1A

Respondent Demographics

Item Frequency Percent Item Frequency Percent

Gender Family Income

Male 166 36.7 <10,000 33 7.3

Female 286 63.3 10 – 20,000 41 9.1

Marital Status 20 – 30,000 55 12.2

Married 301 66.6 30 – 40,000 66 14.6

Widowed 41 9.1 40 – 50,000 56 12.4

Divorced – Separated 49 10.8 50 – 70,000 53 11.7

Single 59 13.1 70 – 90,000 11 2.4

DKNA 2 .4 >90,000 18 4.0

DKNA 9 2.0

Race Education

White 360 79.6 0-8 Grade 15 3.3

African American 80 17.7 9-11 Grade 44 9.7

Other 10 2.2 High School – GED 148 32.7

DKNA 2 .4 Some College 131 29.0

Religion Complete College 79 17.5

Protestant 356 78.8 Graduate / Professional 30 6.6

Catholic 36 8.0 DKNA 5 1.1

Jewish 9 2.0 Employment

Christian 6 1.3 Full-Time 206 45.6

Non-Denominational 9 2.0 Part-Time 49 10.8

Other 8 1.8 Not Employed 187 41.4

None 20 4.4 DKNA 10 2.2

DKNA 9 2.0

TABLE 1B

Comparison of Survey Sample and State Demograhpics

VARIABLE STUDY 2000 ALABAMA
CENSUS

Chi-Square

Race White = 79.6%
Black = 17.7%
Other = 2.2%

White = 71.1%
Black = 26.0%
Other = 2.9%

17.74, df=2,p<.001

Education 0-8 = 3.3%
9-11 = 9.7%
HS = 32.7%
Some = 29.0%
Coll. = 17.5%
Grad = 6.6%

0-8 = 8.3%
9-11 = 12.3%
HS = 34.5%
Some = 25.9%
Coll. = 12.2%
Grad = 6.8%

28.69, df=5,p<.001

Age 20-29 = 19.1
30-39 = 20.1
40-49 = 20.7
50-59 = 16.0
60-69 = 11.2
70-79 = 8.4
80+ = 4.5

20-29 = 14.4
30-39 = 17.7
40-49 = 21.0
50-59 = 21.2
60-69 = 10.9
70-79 = 9.9
80+ = 4.9

1.16, df=6,p=.98

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

Table 2

Rate Your Health

Table 3A

Spiritual perspectives Scale: Beliefs (N=452)

Spiritual Perspective Scale

The Spiritual Perspective Scale (PSP) consisted of two sections. The first section

addressed the frequency of spiritual activities and the second section focused on the role of

spirituality in the person’s life. All items were on a 6 item response scale. See tables 3A and 3B

for detailed descriptions of the responses to each item. All items were scored with the highest

number (6) being the desired response. The mean for the SPS was 42.75 (SD= 5.47) (N=452)

Correlations

Significant correlations were found between the Spiritual Perspective Scale, Rate Your

Health, and each of the three definitions of rurality, employment, religion, race, family income,

respondent sex, current marital status, education, and age. This information is displayed on table

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

Table 3B

Spiritual Perspectives Scale: Behaviors (N=452)

Table 4

Correlations

Item

Scale

Rate
Your

Health

Urban/

Rural

U/R Level

U/R
North
South

Religion

Family

Income

Employment

Education

Age

Race

Gend

Marital
Status

SP
Scale

Rate
Your

Health

-.007 –
.887

Urban/
Rural

.048

.306
-0.24 -

.611
1

U/R
Level

.044

.306
-.027 -

.562
.915**

.000
1

U/R North
/South

059
.213

-.015 -
0.751

.857**
.000

.842**
.000

Religion -.031
.517

.098 - .038 -.094*
.046

-.116*
.013

-.104*
.026

Family
Income

.120*
.011

0.112 -
0.017

-.068
.148

-.060
.203

-.081
.086

.020

.676
1

Employment .091
.052
-262*– 0.000 -.070

.136
-.052
.273

-.025
.593

.027

.570
.068
.146

Education .116*
.013
.286** - .000 -.106*

.024
-.124**

.008
-.121*

.010
.060
.203

.196**
.000

-.146**
.002

Age .139*
.003

-0.272***-
0.000

.048

.309
.044
.347

.097*
.039

-.091
.052

.104*
.027

.405**
.000

-.076
.109

Race .019
.694

0.001 – 0.983 -.136**
.004

-.119*
.011

-.095
.044

.091

.054
-.026
.582

-.015
.757

-.041
.387

-.186** 1

Gender -.114*
.015

0.010 – 0.839 .043
.363

.054

.253
.024
.609

-.015
.748

.053

.264
.208**

.000
-.018
.710

.100*
.033

-.083
.077

Current
Marital
Status

-.124*
.015

0.020 – 0.674 -.114*
.016

-.119*
.011

-.084
.075

.014

.762
-.193**

.000
-.014
.774

.081

.084
-.163**

.000
.174**

.000
-.098*

.037
1

*p=.05 **p=.01 ***p=.001

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

MANOVA on Gender

Since much of the research on spirituality, religion, and health has been conducted

frequently with samples that were mostly women, older adults, and end-of-life issues (Becker et

al., 2007; Flannelly, Ellison, & Stock, 2004; George, Ellison, & Larson, 2002), we purposely

designed the inclusive sample to be open to all men and women who were 18 years of age or

older. To determine whether there were significant differences in the variables of interest in this

study, a multiple analysis of variance (MANOVA) was performed between men and women.

The group was almost 2 to 1 female (286 to 166). Those variables that demonstrated significant

correlations were included in the MANOVA. It is interesting to note only three variables were

significantly different between men and women: SPS, age, and current marital status. Table 5

displays the details of this analysis.

Table 5

MANOVA on Gender

Variable
Sum of
Squares

Mean
Square.

Sig

SPScale Between Groups
Within Groups

Total

175.486
13330.255
13505.741

1
450
451

175.486
29.623

5.94 .016*

AGE Between Groups
Within Groups

Total

1345.668
132504.140
133849.810

1
450
451

1345.668
294.454

4.570 .033*

Current Marital Between Groups
Status Within Groups

Total

5.488
562.264
567.752

1
450
451

5.488
1.249

4.392 .037*

EDUCATION Between Groups
Within Groups

Total

.205
667.111
667.316

1
450
451

.205
1.482

.138 .710

RACE Between Groups
Within Groups

Total

.783
112.358
113.142

1
450
451

.783

.250
3.137 .077

FAMILY Between Groups
INCOME Within Groups

Total

9.092
3269.926
3279.018

1
450
451

9.092
7.267

1.251 .264

RATE YOUR Between Groups
HEALTH Within Groups

Total

.054
581.849
581.903

1
450
451

.054
1.293

.041 .839

COMPARE Between Groups
YR AGO RATE Within Groups
YOUR HEALTH Total

.023
338.533
338.555

1
450
451

.023

.752
.030 .862

LEVEL OF Between Groups
RURALITY Within Groups

Total

.978
336.270
337.248

1
450
451

.978

.747
1.308 .253

URBAN/ Between Groups
RURAL Within Groups

Total

.206
111.909
112.115

1
450
451

.206

.249
.830 .363

RURAL Between Groups
NORTH/ Within Groups
SOUTH Total

.158
271.689
271.847

1
450
451

.158

.604
.262 .609

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

Spiritual Perspective Scale Patterns of Response by Gender

Because there was a significant difference found on the Spiritual Perspective Scale and

Gender we examined the Spiritual Perspective Sub-Scales (Beliefs and Behaviors) by Gender.

Figure 1 illustrates the significance that was found on the Beliefs subscale. No significant

differences were found on the Behaviors Sub-scale. Remember that the Beliefs subscales

measures the role spirituality plays in a person’s life and the Behaviors is the activities associated

with one’s spirituality.

Figure 1: Beliefs and Behaviors by Gender

LIMITATIONS

Since this study utilized a random digit dialed survey methodology, people without home

telephones or those persons with unlisted numbers were excluded from possible inclusion in the

study. Those surveyed were primarily female (63%); however, the methodology was random

selection and could not control for gender. The findings from this study cannot be generalized to

people in other geographic locations.

DISCUSSION AND CONCLUSIONS

To our knowledge, this was the first study to report on the correlations between spiritual

perspectives and self-reported health. Significant differences were found for the Spiritual

Perspective Scale (SPS) on age, marital status and rurality. Additionally, there was a positive

correlation between SPS and Self Reported Health (SRH). Rurality, however, did not show a

Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, Fall 2009

significant correlation with SRH. SPS, age and current marital status were significantly different

on gender.

While this study offers additional support to the literature that spirituality is positively

related to one's health, it again brings to focus the need to pursue the study of the “epidemiology

of spiritual experience” (George, et al., 2000, 113) since the spiritual experience is perhaps the

area in religious and spiritual research that is the least explored. Furthermore, this study lends

support to the findings of Brush & McGee (2000) who concluded that health care providers

should encourage patients to share their spiritual perspectives and spiritual experiences.

We believe the findings from this study have major implications for healthcare providers.

Every patient should receive a spiritual assessment. For the participants in this study, more than

half reported that they talk about spiritual matters and read spiritual materials daily while 77%

pray daily (see table 3A: Beliefs) Knowing what is important spiritually to the patient should be

incorporated into the treatment plan, particularly in relation to coping with or transcending the

illness experience. In addition, each of the Spiritual Perspectives behaviors (see table 3B) were

either scored “agree” or “strongly agree” by 92-97% of the participants. The findings from this

study demonstrated that for this Alabama sample, spiritual perspectives are valued and correlated

with self-reported health.

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