Soc Indic Res (2017) 132:291–312

DOI 10.1007/s11205-016-1308-3

Cross Cultural Application of the WHOQOL-SRPB

in the Chinese Community with Diverse Spiritual
Affiliations

Kitty Chan1 · Bas Verplanken2 · Suzanne Skevington3

Accepted: 18 March 2016 / Published online: 28 March 2016

© Springer Science+Business Media Dordrecht 2016

Abstract The aim was to determine the cross-cultural applicability, reliability, construct
and convergent validity of the WHOQOL-SRPB in the Chinese community, and to
compare the quality of life of contrasting spiritual groups. The WHOQOL-SRPB and
Importance measures were administered to community participants (n = 445) in Hong
Kong. The spiritual well-being scale (SWBS) was administered to examine the convergent
validity of the SRPB domain. Quotas for three age bands (18–44, 45–64, ≥65) were
targeted, within two broad religious groupings: Chinese spiritual (CSG) and Christian
(CG). Test–retest reliability over two weeks was assessed in a second sample (n = 68).
Confirmatory factor analysis (CFA) and other psychometric tests were performed. Alphas
for the original WHOQOL domains were acceptable, ranging from 0.72 to 0.84, and
excellent for the SRPB domain (α = .92). Test–retest reliability (ICC) of the SRPB domain
(α = .95) and its facets (range .80– .94) was excellent. A confirmatory factor analysis on
the SRPB-expanded model suggested a reasonable fit (Chi square/df = 4.78), in spite of a
relatively low Comparative Fit Index (0.80). The SRPB domain showed a similar structure
to SWBS religious and existential subscales. The nine SRPB facets and their Importance
scores discriminate well between CSG and CG. The WHOQOL-SRPB is reliable, valid and
applicable for Chinese people with Christian and traditional Chinese Spiritual beliefs to
use. SRPB is a distinctive dimension that is conceptually consistent with religious and
existential beliefs.

& Kitty Chan

kitty.yy.chan@polyu.edu.hk
Bas Verplanken
b.verplanken@bath.ac.uk
Suzanne Skevington
suzanne.skevington@manchester.ac.uk
1
School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong Sar
2
Department of Psychology, University of Bath, 2 South 1.14, Claverton Down, Bath BA27 AY, UK
3
Manchester Centre for Health Psychology and International Hub for Quality of Life Research,
University of Manchester, Coupland 1 Building, Manchester M13 9PL, UK

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Keywords Quality of life · Spiritual · Valid · Culture · WHOQOL-SRPB

Abbreviations
QoL Quality of life
SRPB Spiritual, religious and personal beliefs
WHOQOL World health organization quality of life assessment

1 Introduction

The framework of quality of life (QoL) has been expanded to include the spiritual
dimension recently to better understand the concept in more general populations and
specific communities (Hilbers and Lewis 2013; O’Connell and Skevington 2007, 2010;
Skevington et al. 2013). Spiritual QoL in health is not just applicable to end of life and
palliative care (Gijsberts et al. 2011; Vermandere et al. 2013; Williams et al. 2011) but
extends to psychotherapies (Lomax et al. 2011; Pargament and Cummings 2010; Peter
et al. 2012; Rentala et al. 2015), complementary therapies (Hilbers and Lewis 2013; Hunter
et al. 2013), and to building resilience (Celinski and Gow 2011; Neenan 2009; Smith et al.
2010; Stewart and Yuen 2011). Additionally, spiritual peace predicted mortality in patients
(Park et al. 2016), and existential well-being was deemed to be a vital component in the
spirituality dimension, and one that provides an important predictor of QoL (Peirano and
Franz 2012; Selman et al. 2011).
Reciprocal influences of culture and spiritual concept exist whereby the spiritual
characteristics of a culture shape the values of the moral system (袁 2011) and play a key
role in driving both economic development and collective and social action (杨 and 蒙
2010). Where this has been studied, former work has tended to focus on religious beliefs to
the exclusion of spiritual life, and personal beliefs that provide a guiding philosophy of life
(Collicutt 2011; Marler and Hadaway 2002). In offering spiritual, religious and personal
beliefs (SRPB) for endorsement, researchers can achieve better coverage of the entire
population, irrespective of whether that community is atheist or agnostic (e.g. UK), reli-
gious (e.g. Iran), or irreligious (e.g. China). Not all researchers agree that spiritual QoL is a
distinctive dimension. Some indicate that it is integral to mental health, and should be
evaluated within a psychological domain, rather than independently (Burkhardt 1989; Hall
et al. 2008; Hill et al. 2000; Hunter et al. 2013; Koenig 2004, 2008; Koenig and Larson
2001). Other researchers have shown that a spiritual domain is an integral part of a holistic
concept of QoL (O’Connell and Skevington 2005, 2007, 2010; WHOQOL SRPB Group
2006). New measurement methods may help to clarify this debate.
Systematic reviews on measures assessing spirituality are available (de Jager
Meezenbroek et al. 2012; Monod et al. 2011; Sessanna et al. 2011), and meta-analysis
(Sawatzky et al. 2005) shows that this dimension is a unique, yet related facet to the
concept of QoL. However some of these assessments were developed for specific popu-
lations e.g. older adults (Dunn 2008), or disease groups (Kaasa and Loge 2003; Koenig
1997), or to evaluate program-specific needs (Lillis et al. 2008). Other studies are
monotheistic (Reitsma et al. 2007), designed to detect the sense of closeness to with the
sacred (Davis et al. 2015), spiritual awakening or development (Hall and Edwards 2002;
Kass et al. 1991). While the generic WHOQOL-SRPB fills the gap by developing the
SRPB domain into a holistic concept from simultaneous international contributions

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(O’Connell and Skevington 2005, 2007, 2010), less evidence is available on the differences
in the spiritual QoL of Chinese and Western spiritual believers.
The main purpose of the present study was to determine whether the WHOQOL-SRPB
is a valid tool to explore spiritual QoL in a traditional spiritual Chinese community.
Another objective was to inspect whether the expanded SRPB domain adequately covered
the existential and religious perspectives, while retaining is independence from the other
QoL dimensions. There are many differences between Chinese and Western cultures in
terms of the value of a ‘good life’ and their associated philosophical teachings (Ip 2011;
Lavy and Littman-Ovadia 2011; Sundararajan 2005; van Dierendonck and Mohan 2006).
The four major religious groups in HK are Confucianism, Taoism, Buddhism and Chris-
tianity (Chen 2002; Kwong 2002). Strictly speaking, Confucianism is a philosophical
teaching rather than religious tradition as it forms the basis of meaning in life. Unlike
Confucian scholars and religious leaders, the majority of HK Chinese merge Confucian-
ism, Taoism, and Buddhism into their belief system, to promote a good life (Lu 2001), and
few believers practice Confucianism as a formal religion. The local Chinese religion is also
a mix of folk practices, such as ancestral worship. In contrast, Christianity is a theist
religion that centres on transcendental experiences such as the relationship with God.
Conducting the present study in the HK cultural context therefore allows spiritual group
comparisons to be made.

2 Methods

A cross-sectional survey design was adopted to test the psychometric properties of the
WHOQOL-SRPB scale.

2.1 Samples

Prior to the main survey, questionnaires were distributed to nursing students in the Hong
Kong Polytechnic University, and acquaintances of alumni volunteers twice over two
weeks, to examine test–retest reliability of the measure. It is important to establish the
reliability before examining the validity when testing the psychometric properties of the
scale (Streiner and Norman 2008). The university offers Masters, Bachelors and sub-
degree nursing programs to over 2000 nursing students. These participants were excluded
from the main study. It was carried out on the pilot sample and these participants were
excluded in the main study.
In the main study, we applied the rule of 10 or more observations per predictor to
identify model fit used in maximum likelihood (ML) for confirmatory factor analysis
(CFA) (Nunnally and Bernstein 1978, 1994), where a sample size of 320 is required. To
minimise bias and yield a sample that maximizes diversified backgrounds, a more con-
trolled selection procedure to stratify participants was planned. At least 10 participants
were targeted (equal proportions of genders) in each of the four religious communities and
three age bands (young adult 18–44; middle age 45–64; older adults ≥65). As few believers
practice Confucianism as a formal religion, a proportional recruitment of Confucian
believers was not implemented in the stratified sampling procedure.
For the inclusion criteria, community-dwelling Chinese adults aged (18+ years) were
recruited if they had lived in Hong Kong for two or more years, indicating adaptation and
connection to this society. Immigrants to HK have contributed to population growth over

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the past decade (Mo et al. 2006). Participants were required to have lived in HK for at least
two years, so that they were relatively adapted to HK culture (Mo et al. 2006). To assess
whether respondents were cognitively eligible to complete the questionnaire, the inter-
viewer ensured that participants were oriented to time, place and persons. Those currently
living in institutions or hospitalised were excluded from the study.
Participants were recruited from four main sources: (1) acquaintances of university
nursing students and alumni volunteers in the Hong Kong Polytechnic University. (Only
one family member or acquaintance was recruited from each student); (2) institutional,
recreational and interest groups; (3) centres for the elderly; (4) Buddhist, Taoist, Roman
Catholic and Protestant religious communities. Various organisations declined participa-
tion either due to the length of the questionnaire or lack of interest in this research.

2.2 Instruments

2.2.1 The World Health Organization Quality of Life instrument; Version Designed
to Assess Spiritual, Religious and Personal Beliefs in Quality of Life
(WHOQOL-SRPB)

The WHOQOL-SRPB assessment (132-items) (WHOQOL SRPB Group 2006) is com-

prised of 32 facets of QoL scored in six domains, with an additional overarching facet on
General QoL and Health (G-QoL). Built from the parent instrument—the WHOQOL-100
(The WHOQOL Group 1995; WHOQOL Group 1993)—the measure is scored in six
quality of life domains: (1) Physical (3 facets), (2) Psychological (5 facets), (3) Level of
Independence (4 facets), (4) Social relationships (3 facets), (5) Environment (8 facets), and
(6) Spiritual, Religious and Personal Beliefs (SRPB, 1 facet). However, the original SRPB
domain in the WHOQOL-100 consists of only one facet (meaning in life), that was
insufficient to measure this complex, multi-dimensional domain. As such, the SRPB
module of spiritual items was expanded from one facet in the WHOQOL-100 to nine facets
in the WHOQOL SRPB, namely (1) meaning in life (original facet), (2) spiritual con-
nection, (3) purpose in life, (4) awe, (5) wholeness, (6) spiritual strength, (7) inner peace,
(8) hope and optimism, and (9) faith.
The WHOQOL-SRPB fills the gap in diverse ethnic backgrounds and cultural identity,
since items of the expanded Spiritual-religious-personal beliefs (SRPB) module were
generated from 18 countries and included the relevant national religious belief systems
(O’Connell and Skevington 2007). Content and construct validity were achieved, where
items were first generated by users, followed by expert panel focus groups from a repre-
sentative sample, including religious, agnostic and atheist believers. Christianity, Judaism,
Islam, Buddhism and Hinduism were the represented religious denominations. The psy-
chometric properties of the internationally designed WHOQOL SRPB, and the SRPB
domain alone, are excellent (α = .91), with the alphas of these standard facets ranging from
.77 (meaning in life) to .95 (faith) (Fleck and Skevington 2007; WHOQOL SRPB Group
2006). Exploratory factor analysis on the selected items has shown that an eight-factor
solution was obtained, with each item loading onto its predicted facet (each of the factors
explaining equal proportions of the variance), and has explained a total of 72.2 % of
variance.
Four additional questions separately examine the intensity of spiritual, religious and
personal beliefs, and level of attachment to any specific religious community. As in the

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development of other WHOQOL measures (Skevington et al. 2013), Importance items

were rated on 5-point Likert interval scales to register the importance of each spiritual facet
of QoL. Importance measures are particularly useful to determine the relevance of items to
the culture in multi-cultural instruments. Importance item contents were compatible with
the facet topics of the WHOQOL-SRPB.
The Chinese version of the WHOQOL-SRPB is available (Chan et al. 2010), following
cultural adaptation and reflexive translation processes developed by the WHOQOL Group
(Sartorius and Kuyken 1994). In brief, an agreed iterative protocol was used to verify the
feasibility of employing this scale among HK Chinese. To achieve conceptual, semantic
and technical equivalence of WHOQOL-SPRB in the Chinese cultural context, the scale
was subjected to forward- and backward-translation by bilingual experts and linguistic
panels, monolingual English speakers, and lay persons from the target population.

2.2.2 Spirituality Well-Being Scale (SWBS)

The SWBS (Paloutzian and Ellison 1982) provides a general indicator of overall perceived
spiritual well-being (SWB) by summing responses from 20 items. Two subscale indices of
ten items separately measure religious well-being (RWB) and existential well-being
(EWB). Higher scores indicate better well-being (Ellison 1983). The Chinese version of
the SWBS demonstrates good internal reliability: overall alpha for SWB was .93; RWB
was 0.91 and EWB was 0.89. This measure has been validated for Chinese cancer patients
(唐 2008).

2.3 Procedures

Ethical approval for both stages of the study was obtained from the ethics committee of
The Hong Kong Polytechnic University. Consenting participants were invited to complete
the questionnaires unaided. In cases where self-completion was not possible, a trained
interviewer assisted participants, without explaining the items. Each respondent was
offered a $HK20 food coupon upon receipt of the completed questionnaire.
The WHOQOL-SRPB was administered simultaneously with the SWBS, with the aim
of examining the convergent validity of the SRPB domain with the SWBS. Half of the
participants were requested to complete the WHOQOL-SRPB importance questions to find
out how important each SRPB facet was to their QoL. The data was collected between
February and May 2009. A two-hour briefing was held to ensure reliability in asking the
questions and to maintain a neutral, non-biased relationship with the respondents. Item-by-
item explanation of the questionnaire was provided for these interviewers. The data col-
lection protocol and a frequently asked questions (FAQ) guide were provided for the
helpers so that there would be consistent and unbiased responses to the participants when
issues related to the study were raised. Interviewer quality was monitored by the researcher
during the three rounds of questionnaire administration. After training research assistants,
questionnaires were distributed to targeted participants.

2.4 Analysis Plan

Analysis was conducted using SPSS v. 12.0, with significance set at p \ .05. AMOS v. 7.0
was employed for CFA. Missing values, outliers and normality were evaluated. Mean facet
and domain scores were calculated after negatively framed items were reversed, so that
higher scores mean better QoL. Domain scores were transformed using an SPSS syntax file

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described in the WHOQOL-SRPB manual (WHOQOL SRPB Group 2002). Recoded

SWBS items were summed to yield overall SWB scores, and subscale scores for RWB and
EWB, as described in the manual (Paloutzian and Ellison 1991). Means, standard devia-
tions (SD) and frequencies were examined to determine the appropriate use of parametric
tests (Hair et al. 2010; Langdridge and Hager-Johnson 2009). Ceiling and floor effects were
identified if 20–25 % of respondents scored at the highest or lowest level (Holmes and
Shea 1997; Jang et al. 2004; McHorney et al. 1994). To minimize data loss in the com-
putation, pairwise deletion was used, so the number of participants reported in the Results
section varies from analysis to analysis.
Test–retest reliability was performed on the pilot dataset using Intraclass Correlation
Coefficient (ICC—two way random model) (Keszei et al. 2010; Portney and Watkins
2009) (criterion α ≥ 0.70 good reliability; 0.50 acceptable) (Fayers and Machin 2007). In
the main study, internal consistency was measured by Cronbach’s α (criterion [ .70)
(Keszei et al. 2010). Pearson product-moment correlation examined item-facet and
domain-facet correlations of the WHQOQOL-SRPB, as it is not affected by the scale
length (criterion r [ .40). This was done after subtracting the corresponding facet values
in the domain scores, so that items in the facet, or facet within the domain, would not be
inflated (Streiner and Norman 2008).
Following WHOQOL-SRPB statistical computation (O’Connell and Skevington 2010;
WHOQOL SRPB Group 2006), confirmatory factor analysis (CFA) was used to inspect
model fit of the SRPB structure (O’Connell and Skevington 2010). Structures for both 6
domains and 5 domains (spiritual items subsumed in the psychological domain) were
calculated. To indicate good model fit, the Chi square/df should not exceeding 5 (Rigdon
1996), the comparative fit index (CFI) should approach 1.0 (Bentler 1990; Tabachnick and
Fidell 2013) and the root mean square error of approximation (RMSEA) ≤ .08 (Brown
2006). Standardised beta coefficients (β \ 0.60) reflect how well variables are captured by
the corresponding domain.
Convergent validity was investigated using Pearson’s correlations (Bowling 2005;
Cronbach and Meehl 1955; Fayers and Machin 2007). Associations of the corresponding
domain and facets scores were processed with the SWBS total and subscale scores. Sig-
nificant correlations was expected between the WHOQOL-SRPB spiritual domain and the
SWBS (criterion [ .40) (Keszei et al. 2010), but it should not correlate with dissimilar
constructs.
One-way ANOVA analysis compared differences between groupings, using subsample
scores: traditional Chinese spiritual group (CSG) comprised of Buddhism, Taoism and folk
religions; and Christian group (CG) that included the Roman Catholic and Protestants.
Assumption of Homogeneity of Variance was assessed by Levene’s test (criterion
p [ .05). Replies to questions on the intensity of being a religious person and part of a
religious community, and intensity of spiritual and personal beliefs, were conducted using
independent t-tests to observe whether there were significant differences (p \ .05)
between both spiritual groupings.
Three stepwise multiple regressions (Portney and Watkins 2009; Tabachnick and Fidell
2013) were conducted to examine contributions of various WHOQOL-SRPB items to the
prediction of the overall QoL. First, the six WHOQOL-SRPB domains were entered into
the regression as independent variables. The regression was repeated twice, using the nine
SRPB facets to observe the predictors of G-QoL in Chinese and Christian spiritual
groupings respectively. Beta regression coefficients (β) explain the unique contribution of
each dependent variable on general QoL. Adjusted R2 estimated the variance of all

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dependent variables. This together with the standard error of estimate and F ratio, were
reported in the hypothesised model.

2.5 Results

2.5.1 Test–Retest Reliability

In the pilot study, 80 questionnaires were distributed and 68 were returned as valid (re-
sponse rate 85 %). Older persons were more reluctant to complete a lengthy questionnaire
twice, so the sample obtained was predominantly middle aged, ranging from ages 20 to 59
(mean = 30 years, SD = 10.8). More participants were female (n = 43, 63.2 %) and
university educated (n = 53, 77.9 %). Marital status showed 70.6 % were single, 28 %
married and 1.5 % separated. Over half (50.1 %) reported having a religious affiliation:
Catholic (4.4 %), Protestant (33.8 %), Buddhist (8.8 %) and Taoist (2.9 %). Missing values
in WHOQOL-SRPB items were low (missing 1 or 2 per variable). No major outliers were
recorded.
Five WHOQOL-SRPB domains showed good ICC results (Table 1): Physical (.85),
Psychological (.87), Social relationships (.89), Environment (.90) and SRPB (.95), and
Level of independence was acceptable (.66). All the facets showed good test–retest reli-
ability, ranging from .94 (spiritual connection) to .70 (working capacity). Three facets were
exceptions; values for two were acceptable: dependence on medication and treatment (.60),
physical safety and security (.62) but mobility (.50) was unacceptable. All the nine facets
in the SRPB domain were excellent; highest was spiritual connection (.94), and lowest
inner peace (.80). All SRPB Importance measures showed good ICC, ranging from .76
(inner peace) to .90 (purpose in life).
The pilot showed that including ‘spiritual or higher being’ in the Chinese version was
appropriate for Chinese and Christian religious believers and non-believers although items
that included the term ‘spiritual or heavenly being’ were irrelevant to three respondents out
of 68 participants. Some atheists also regarded this term as irrelevant, as the existence of a
deity was denied. To prevent discounting the relevance of the religious dimension to
spiritual well-being, or losing major information from the religious community, the term
‘higher being’ was retained. Interpreting low scores in the main study findings was cau-
tious, as these could be due to spiritual struggles, or to being an atheist.

2.5.2 WHOQOL-SRPB Validity Analysis

In the main study, a total of 520 sets of questionnaires were distributed and 445 returned
completed; response rate 85.6 %. Commensurate with previous WHOQOL studies, the sex-
life facet had most missing values (7.8 %). The SRPB domain facets had negligible values
missing, most were for spiritual connection (1.1 %). No floor or ceiling effects were found
for SRPB domain variables, except for one floor effect for spiritual connection shown by
26.2 % scoring at the lowest level.

2.5.3 Sample Characteristics

The mean age of the main study sample was 51.6 years (SD = 20.5) (range 18 to 90);
45.8 % were male (see Table 2). Education was distributed fairly evenly: 26.3 % com-
pleted primary school, 33.6 % secondary, and 32 % post-secondary institutions or

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Table 1 Test-retest reliability of

Domain Facets ICC
pilot study participants on
WHOQOL-SRPB core items
(N = 68) D1 Physical 0.85
(F1) Pain 0.74
(F2) Energy 0.78
(F3) Sleep 0.84
D2 Psychological 0.87
(F4) Positive feelings 0.75
(F5) Concentration 0.86
(F6) Self-esteem 0.75
(F7) Body image 0.87
(F8) Negative feelings 0.72
D3 Level of Independence 0.66
(F9) Mobility 0.50
(F10) Activities of daily living 0.82
(F11) Treatment 0.60
(F12) Work 0.70
D4 Social relationships 0.89
(F13) Personal relationships 0.83
(F14) Social support 0.84
(F15) Sex life 0.84
D5 Environmental 0.90
(F16) Physical safety 0.62
(F17) Home environment 0.92
(F18) Financial resources 0.91
(F19) Access to health services 0.76
(F20) Information 0.79
(F21) Leisure 0.78
(F22) Physical environment 0.72
(F23) Transport 0.80
D6 SRPB 0.97
(F24) Meaning in life 0.89
(SP1) Spiritual connection 0.94
(SP2) Purpose in life 0.87
(SP3) Awe 0.89
(SP4) Wholeness 0.90
(SP5) Spiritual strength 0.92
(SP6) Inner peace 0.80
(SP7) Hope and optimism 0.84
(SP8) Faith 0.91
Bold indicates p \ .01

university. Eight percentage reported no formal education; they were unable to read
Chinese, needing interviewer-assisted administration. Of these, 42.7 % reported a specific
illness (e.g. high blood pressure, diabetes), and 57.3 % no current health problem.
Over half (62.3 %) of the participants indicated that they belonged to a specific religious
community. Among the Chinese religions there were Buddhists (23.1 %), Taoists (5.2 %)

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Table 2 Sample characteristics

Variable Sample (total) Young Middle-aged Older adults
adults adults (≥65)
(18–40) (41–64)

(n = 445) (n = 139) (n = 163) (n = 143)

Age (Mean and SD) 51.6 (20.47) 26.3 (6.30) 52.5 (6.21) 75.2 (6.24)
Minimum 18 18 41 65
Maximum 90 40 64 90
Gender (%)
Male 204 (45.8) 69 (49.6) 75 (46.0) 60 (42.0)
Female 241 (54.2) 70 (50.4) 88 (54.0) 83 (58.0)
Marital status (%)
Single 125 (28.1) 106 (76.3) 10 (6.2) 9 (6.3)
Married 257 (57.8) 31 (22.3) 136 (84.5) 90 (62.90)
Living as married 4 (0.9) 0.0 (0.0) 2 (1.2) 2 (1.4)
Separated 4 (0.9) 0.0 (0.0) 2 (1.2) 2 (1.4)
Divorced 9 (2.0) 0.0 (0.0) 5 (3.1) 4 (2.8)
Widowed 43 (9.7) 2.0 (1.4) 6 (3.7) 35 (24.5)
Education (%)
Unable to read Chinese 36 (8.2) 2 (1.4) 3 (1.9) 31 (21.7)
Primary 116 (26.3) 0.0 (0.0) 53 (32.7) 63 (44.1)
Secondary 148 (33.6) 46 (33.3) 69 (42.6) 33 (23.1)
Tertiary 141 (32.0) 90 (65.2) 37 (22.8) 14 (9.8)
Religious groups (%)
Roman Catholic 37 (8.3) 9 (12.3) 17 (14.8) 11 (7.7)
Protestant 107 (24.0) 47 (64.4) 41 (35.7) 19 (13.3)
Buddhism 103 (23.1) 14 (19.2) 43 (37.4) 46 (32.2)
Taoism 23 (5.2) 2 (2.7) 13 (11.3) 8 (5.6)
Others 8 (1.7) 1 (1.4) 1 (0.9) 6 (4.2)
Ancestral worship 1 (0.2) 1 (1.4) 0 (0.0) 1 (0.7)
Folk Religions 6 (1.3) 1 (0.7) 1 (0.9) 4 (2.8)
Muslim 1 (0.2) 0 (0.0) 0 (0.0) 1 (0.7)
Do not belong to a religious community 167 (37.5) 66.0 (47.5) 48 (29.4) 53 (37.1)

SD standard deviation

and folk religions and/or ancestral worship (1.5 %) who were grouped into the Chinese
spiritual group (CSG) (n = 126, male = 59, 46.8 %). Other religious affiliations included
Protestants (24 %) and Roman Catholics (8.3 %), who formed the Christianity Group (CG)
(n = 144, male = 50, 34.7 %). More young adults were Christian (64.4 %) compared with
13.3 % in those [65 years. In contrast, 19.2 % of young adults were Buddhist, 37.4 %
middle-aged and 32.2 % older adults.

2.5.4 Internal Consistency

Alphas for the original WHOQOL domains were acceptable, ranging from 0.72 to 0.84,
and excellent for the SRPB domain (α = .92) (Table 3). Correlations between General QoL

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Table 3 Domain reliability analyses for the WHOQOL-SRPB and correlation of facets means with G-QoL
Domain Facets Domain-Facet Correlations (r) Cronbach alpha (α)
(n = 445)

D1 Physical 0.76
Pain 0.64**
Energy 0.74**
Sleep 0.61**
D2 Psychological 0.84
Positive feelings 0.56**
Thinking 0.61**
Self-esteem 0.70**
Body image 0.51**
Negative feelings 0.47**
D3 Independence 0.77
Mobility 0.59**
Activities of daily living 0.62**
Treatment 0.49**
Work capacity 0.56**
D4 Social Relationships 0.72
Relationships 0.79**
Support 0.48**
Sex 0.48**
D5 Environment 0.84
Safety 0.50**
Home environment 0.42**
Finance 0.35**
Health & social care 0.52**
Information 0.55**
Leisure 0.45**
Physical environment 0.27**
Transport 0.31**
D6 SRPB 0.92
Meaning in life 0.65**
Spiritual connection 0.57**
Purpose in life 0.75**
Awe 0.67**
Wholeness 0.82**
Spiritual strength 0.82**
Inner peace 0.57**
Hope & optimism 0.72**
Faith 0.74**
Bold indicates p \ .01
**p \ .01

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Fig. 1 Schematic illustration of a 6-domain structure with 9-faceted SRPB domain in the WHOQOL-SRPB
and corresponding regression coefficients

and Health (G-QOL) and domain scores were highest for the Environment domain
(r = .78, p \ .01) and lowest for Level of independence (r = .46). Domain-facet corre-
lations were moderate to good, ranging from 0.42 to 0.79 (p \ .01), except for three facets;
finance (.35), physical environment (.27) and transport (.31). The SRPB domain-facet

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correlations were .57 to .82. The SRPB facet-item associations were excellent for spiritual
connection (.86–.97) and faith (.83–.92, p \ .01). For other domains these correlations
were good to excellent (purpose in life (.55) to meaning in life (.86)).
Analysis by age-band (young adults (α = .92), middle age (α = .96), older persons
(α = .94)) and spiritual groupings (CSG (α = .95), and CG (α = .94)) showed consistently
high alphas across subsamples. All other domains displayed consistently high alphas (.62
to .95). Particularly notable are the excellent alphas in the SRPB domain for CG (α = .91)
and CSG (α = .85) groupings.

2.5.5 Confirmatory Factor Analysis

The SRPB module of items was examined under the two hypothesised 6-domain models, as the
1-facet structure in the conventional WHOQOL-100 (The WHOQOL Group 1998), and as the
expanded SRPB 9-facet structure in WHOQOL-SRPB. The results of the former are CFI = .79,
RMSEA = .10, χ2 = 1328.46 (df = 248), p \ .001 and the expanded 9-facet model has
CFI = .80, RMSEA = .09, χ2 = 2190.07 (df = 458), p \ .001 (see Fig. 1). A confirmatory
factor analysis on the SRPB-expanded model suggested a good fit (Chi square/df = 4.78), in
spite of a relatively low Comparative fit index (.80). Furthermore, improvement was shown in
the expanded SRPB model. In addition, when combining SRPB facets with psychological
domain facets, the RMSEA was unacceptable (1.0). The standardised regression weights of all
nine spiritual facets had met the criterion of .60, or above. The results ranged from moderate (.61
in spiritual connection) to high loadings (.90 in wholeness and spiritual strength). All were
positive and significant with reference to the critical ratio (CR), p \ 0.001. This indicates that
the variables measured were strongly related to the hypothesised expanded SRPB domain.

2.5.6 Convergent Validity

As predicted by the six domain model, SRPB showed strongest correlations with SWB overall
(.76) and its subscale scores, but only moderate correlations were observed between SWB and
all other domains (from .27 Physical to .47 Psychological and Social (all p \ .01) (Table 4).
The association of SRPB domain with EWB (r = .71, p = .01) was stronger than for RWB
(r = .62, p = .01). Investigating the SRPB domain at a facet level, SWB correlations ranged
from .52 (awe, inner peace) to .70 (spiritual connection) (p = .01). Correlations between
RWB and EWB with SRPB facets ranged from .33 to .75, and .42 to .68 respectively. It was
noted that the original SRPB facet meaning in life, had similar association levels with RWB
(.51) and EWB (.58). Not all facets had similar coefficients; spiritual connection and faith
most strongly correlated with RWB, but those with EWB were ranked low (spiritual con-
nection = .42; faith = .54) (p = .01). In contrast, hope and optimism and inner peace had the
lowest correlation with RWB (.33), but hope and optimism showed the strongest correlation
(r = .68), while inner peace correlated moderately (.61), (p = .01) with EWB.

2.5.7 Differences Between Spiritual Groupings

There was no significant difference between the two groupings in terms of considering
themselves as a religious person and part of a religious community (CSG (2.96, SD = 1.30;
2.88, SD = 1.17); CG (3.10, SD = 1.12; 3.21, SD = 1.13). However, significant differences
in the intensity of spiritual and personal beliefs respectively, were shown in CSG
(2.80 ± 1.71 and 3.12 ± 1.05) and CG (3.58 ± 1.16; 3.68 ± .89) (p \ .0001). Although

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the G-QoL was similar in both groupings, CG scored higher on Psychological QoL
(p \ .001), SRPB QoL (p \ .0001), and all SRPB facets (p \ .0001) except inner peace
(p \ .01), and hope and optimism (p \ .001) (see Table 5).
About half the participants completed Importance questions (n = 270). Inner peace
(3.44) was ranked as most important, while meaning of life and hope and optimism were
equally important (3.32). Faith and awe were moderately important (3.0 and 2.97
respectively). Higher mean importance was found for all SRPB items in CG, when
compared to CSG (p \ .001) (see Table 6). Inner peace was consistently most important to
both subsamples. Faith and awe were less important for men, for younger people, and in
old age, and for the CSG (all less than 3.0).
When all six domains were entered into a stepwise regression, only four were retained
in the final model, explaining 67.4 % of the total variance (F = 229.13, p \ .0001).
Environment made the biggest contribution (β = .49), then Psychological (β = .17), Social
(β = .14) and Physical (β = .11). However the SRPB domain was not entered into the final
regression model. When the 32 WHOQOL-SRPB facets were entered into a second
regression analysis (adjusted R2 = .71), the spiritual facet of hope and optimism (β = .13)
was entered into the final model with seven facets from other domains: home environment
(β = .31), leisure (β = .18), personal relationships (β = .16), finance (β = .16), sleep
(β = .12), pain (β = .09) and activities of daily living (β = .08).
The analysis was repeated entering nine SRPB facets to observe the predictors to
G-QoL in each of the two spiritual groups. The results showed that both inner peace (CG:
β = .31; CSG: β = .39, p \ .0001) and hope and optimism (CG: β = .22; CSG: β = .34,
p \ .0001) predicted G-QoL in CG (Adjusted R2 = .499) and CSG (Adjusted R2 = .409),
but wholeness (β = .27, p \ .0001) was only retained in CG.

Table 4 Pearson correlations

WHOQOL-SRPB SWB SWBS subscales
between the WHOQOL-SPRB
domains, the nine SRPB facets Domains and facets RWB EWB
and the SWBS subscales
G-QoL .43** .26** .52**
Physical .27** .11* .40**
Psychological .47** .26** .59**
Independence .31** .15** .43**
Social relationships .47** .28** .57**
Environment .45** .28** .54**
SRPB .76** .62** .71**
Meaning in life .62** .51** .58**
Connection .70** .75** .42**
Purpose in life .62** .46** .63**
Awe and wonder .52** .40** .52**
Wholeness .63** .47** .64**
Strength .61** .47** .61**
* Correlation is significant at the Peace .52** .33** .61**
0.05 level (2-tailed) Hope and optimism .56** .33** .68**
** Correlation is significant at the Faith .69** .65** .54**
0.01 level (2-tailed)

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3 Discussion

The present study shows that the WHOQOL-SRPB is a reliable and robust tool for use in
the Chinese population, and has several strengths. We were able to explore and confirm the
feasibility of applying the WHOQOL-SRPB instrument in both Chinese and Christian
belief groups, and more importantly found that SRPB domain scores successfully dis-
criminated between these two spiritual groupings. By administering SWBS with the
WHOQOL SRPB we discovered that the WHOQOL-SRPB has an internal structure of
existential and religious aspects within the SRPB dimension. Religious, spiritual and
personal beliefs formed a holistic, comprehensive and distinctive concept. Furthermore, it
was confirmed that SRPB contributed significantly to overall QoL and health (The
WHOQOL-SRPB Group 2006), in the Chinese culture.
Consistent with the international findings reported by the WHOQOL-SRPB Group
(2006), the SRPB domain was found to be independent from other domains. The SRPB
module showed very high internal consistency reliability. The confirmatory factor analysis
on the SRPB-expanded model suggested a reasonable fit (Chi square/df = 4.78), despite a
relatively low CFI (0.80), which is more appropriate to exploratory models (Rigdon 1996).
It is noteworthy that when combining SRPB facets with those from the psychological

Table 5 Means and standard deviations for the WHOQOL-SRPB scores and the comparison of differences
between groupings using subsample scores: traditional Chinese spiritual group (CSG) and Christian group
(CG)
Spiritual groupings

CSG CG

(n = 126) (n = 144) ANOVA

Mean SD Mean SD F

WHOQOL-SRPB domain
G-QoL 3.5 (0.66) 3.6 (0.65) 0.60
Physical 13.9 (2.84) 14.4 (2.85) 2.79
Psychological 14.1 (2.24) 14.6 (2.26) 3.02**
Independence 15.3 (2.89) 16.4 (2.29) 11.38
Social Relationships 14.1 (2.17) 14.6 (1.96) 2.68
Environment 14.0 (2.10) 14.4 (2.04) 1.85
SRPB 12.6 (2.56) 14.6 (2.67) 41.81***
SRPB facets
Meaning in life 3.4 (0.82) 3.8 (0.80) 21.61***
Spiritual connection 2.8 (1.05) 3.6 (1.04) 43.43***
Purpose in life 3.3 (0.76) 3.8 (0.74) 31.24***
Awe 3.1 (0.84) 3.6 (0.81) 28.03***
Wholeness 3.1 (0.79) 3.5 (0.78) 16.26***
Spiritual strength 3.2 (0.83) 3.6 (0.78) 21.23***
Hope and optimism 3.3 (0.77) 3.6 (0.77) 10.80**
Faith 2.9 (0.95) 3.7 (0.92) 49.39***
Inner peace 3.5 (0.75) 3.7 (0.75) 6.67*

* Significant \ 0.01, ** significant \ 0.001, *** significant \ 0.001 level (One way ANOVA)

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domain, the RMSEA was unacceptable, so contradicting the position put forward by
(Koenig 2008; Moreira-Almeida and Koenig 2006), that personal and religious beliefs
should be integrated as spiritual indicators. As the fit of the international instrument was
determined through statistical and conceptual consensus of 17 cultures, this lower fit level
is not surprising for one single culture. Recent research from New Zealand (Krägeloh et al.
2015) suggests a two-factor structure within the SRPB domain, consisting of spiritual
coping (connected, strength and faith) and spiritual QoL (remaining facets). If confirmed
by other cultures, this might explain the lower fit we report here.
Results from the present study, showed that SRPB was ranked top among the six
domains in its correlation with the overall SWBS score, as expected. It also revealed the
possible internal features of the SRPB domain. Spiritual connection and faith appear to
reflect RWB, concurring with French findings which show that both load onto the same
factor (Mandhouj et al. 2012). In contrast, hope and optimism and inner peace had strong
correlations with EWB, in line with another study (Peirano and Franz 2012) where EWB
rather than RWB was found to predict QoL. This points to the significance of including
existential features in the SRPB dimension when measuring QoL. The findings of the
present study serve to increase the usefulness of the WHOQOL-SRPB to both populations
of Western and Chinese spiritual believers.
There are several published studies on spiritual QoL (O’Connell and Skevington 2007,
2010; Skevington et al. 2013; WHOQOL SRPB Group 2006), but many of these inves-
tigated the differences between religious and non-religious believers (Panzini et al. 2011),
or diverse patient groups (Shah et al. 2011; Torskenæs and Kalfoss 2013). Some included
Buddhist participants (Mandhouj et al. 2012). However no comparison of traditional
Chinese religions and Christians were investigated, and this is an original feature of the
present work that merits a more thorough understanding of their QoL in future inquiry
(Johnstone et al. 2012; Reitsma et al. 2007). Dissimilarities between the sub-cultures of the
Chinese community (Yao and Wu 2009) and new research across different Chinese
societies will maximize knowledge about the applicability and acceptability of the

Table 6 Means and standard deviations for the importance questions in the WHOQOL-SRPB and the
comparison of differences between groupings using subsample scores: traditional Chinese spiritual group
(CSG) and Christian group (CG)
Importance score All Spiritual groupings

CSG CG

(n = 270) (n = 126) (n = 144) ANOVA

Mean SD Mean SD Mean SD (Welch)

Meaning in life 3.32 (1.07) 3.20 (1.06) 3.94 (0.80) 21.24***

Spiritual connection 3.27 (1.11) 3.19 (1.08) 3.87 (0.89) 16.50***
Purpose in life 3.25 (1.03) 3.16 (0.98) 3.89 (0.72) 24.89***
Awe 2.97 (1.03) 2.95 (1.04) 3.57 (0.89) 14.29***
Wholeness 3.16 (1.04) 2.95 (1.04) 3.84 (0.72) 34.76***
Spiritual strength 3.29 (1.07) 3.11 (1.03) 3.89 (0.79) 25.33***
Hope and optimism 3.32 (1.08) 3.16 (1.07) 3.97 (0.72) 27.38***
Faith 3.00 (1.26) 2.89 (1.11) 4.00 (0.98) 38.10***
Inner peace 3.44 (1.07) 3.38 (1.12) 4.06 (0.82) 17.00***

*** Significant \ 0.001 level (One way ANOVA)

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306 K. Chan et al.

WHOQOL-SRPB. More work is required to test the tool’s feasibility, sensitivity and
responsiveness to change, to add weight to its application to different individuals expe-
riencing diverse life events, and to evaluate clinical and spiritual interventions.
Collecting importance information linked to the WHOQOL-SRPB and ranking
importance serves to provide valuable information for a full assessment of the spiritual
QoL of specific populations. In the present study, core QoL and importance ratings in the
SRPB domain and all its facets, successfully distinguished between the two relatively
diverse groupings of spiritual beliefs: Chinese and Christian. The stability of importance
questions for each SRPB facet was found to be good, and this is an original finding. Gender
differences in the importance of SRPB were endorsed by our results (The WHOQOL
SRPB Group 2006), with women reporting that faith and awe are more important to them
than men. Higher ratings of importance for all nine spiritual facets were displayed by
Christians. While Chinese religious believers believed that most facets were at least
moderately important, awe, wholeness and faith were deemed to be less important overall,
so six out of nine spiritual facets were valued by both religious groups.
Conceptual differences might have contributed to the observed pattern in the perceived
importance of these items. The amalgamation of mythology, astrology and cosmology has
also been noted in Chinese religious practice that blends with Buddhism and Confucian
teachings as a united whole (Dillon 2009; Lafleur 2010). The spiritual figures and founders
of the traditional Chinese religions were considered to be sacred or divine beings. In
contrast, faith and awe are heavily emphasized in Judeo-Christian beliefs, where God is
love, and a source of caring and comfort (Polkinghorne 2006). As such, the Importance
scores revealed the salience of spiritual items in spiritual and cultural contexts. In turn,
these and other contextual factors, may therefore significantly influence how SRPB affects
general QoL.
Unlike the international findings on the six domains (WHOQOL SRPB Group 2006),
SRPB did not predict general QoL in this Hong Kong sample. One possible reason is the
population profile. The present study targeted equal proportion of spiritual groups, whereas
the former study investigated health status groups in diverse religious communities. Hope
and optimism contributed to general QoL and health in the regression of 32 facets, sig-
nifying its paramount importance in the context of the present study. Compared with UK
findings (O’Connell and Skevington 2010), where hope and optimism, and inner peace did
not enter into the hypothesised model, the HK results show that hope and peace gained
high beta values in the spiritual dimension. In addition, the present regression findings
report that peace and hope are the best predictors of overall QoL in both religious
groupings. It is suggested that these two appeared to be the common spiritual facets of both
Christian and Chinese religious groups, despite the spiritual disparities among them.
Hope and peace are compatible with the Chinese cultural and spiritual concept. The
pursuit of inner peace and remaining hopeful are seen both in Chinese folk happiness
concepts (Ip 2011), and Taoist and Buddhist teachings (van Dierendonck and Mohan
2006). Similarly, these two aspects are much emphasised in the Christian faith, particularly
during life challenges (Luk 2007). This demonstrates the pertinence of this broadened
dimension of WHOQOL-SRPB to both traditional Chinese religious and Christian par-
ticipants. Hope has been of considerable interest in the positive psychology field (Weis and
Speridakos 2011), and recently it has been used in multiple enhancement strategies
(Fredrickson 2011; Massey et al. 2011; Shorey et al. 2007; Tong et al. 2010; Werner 2012),
including various therapies in the Chinese community (Mok et al. 2010a, b; Yeung et al.
2011). The present findings further strengthened its appropriateness when designing and
evaluation hope-based interventions. On the other hand, inner peace seems to be a less

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prominent component in interventions, although it has been well researched in palliative

care settings (Keall et al. 2013; Whitford and Olver 2012). Consequently, its value in
improving QoL should be further explored.
However, wholeness only predicted general QoL only in Christians. Such an observa-
tion could be both a spiritual and a cultural issue. As reflected in Mok et al.’s findings
(2010c), the boundaries between mind, body and soul are obscure in the Chinese culture,
and they are deemed as an integrative whole instead of distinctive features. Christians
adopt distinctive entities of mind, body and soul in their teachings and this may have
affected the perceived significance of the wholeness facet. Chinese religious believers had
lower scores in all the spiritual items, which were significantly different from the Chris-
tians, but they had higher spiritual scores than the non-religious subsamples in only four
spiritual facets, meaning in life, strength, connection and faith. This again echoes the
literature, which documents the philosophical nature of their spiritual belief in Buddhism
and Taoism. The expanded SRPB dimensions therefore served to interpret the QoL of
diverse spiritual groups in a meaningful way.
In summary, the present study field tested the WHOQOL-SRPB Chinese version,
showing excellent test–retest reliability, promising construct validity, and good applica-
bility to the Chinese community, irrespective of their spiritual background. No major
conceptual or linguistic problems were reported by those who were surveyed, however,
rarely will an international instrument be changed on the basis of evidence from one single
study in one culture. The WHOQOL-100 has satisfactory psychometric properties in a
wide range of published studies, including those conducted in HK (Leung et al. 1996; The
WHOQOL Group 1998). Since SRPB is the newly enlarged domain for investigation, and
attained excellent results across a wide range of tests in the present study, we consider that
this expanded module representing the spiritual dimension to be robust. Recently, a short
form WHOQOL-SRPB-BREF instrument has received preliminary psychometric testing
(Skevington et al. 2013), and awaits cross-cultural validation. Examining the psychometric
properties of this Chinese short version will be the next step to enhancing its pragmatic use.
The present survey had several limitations. Some variables were slightly skewed, which
might have affected sensitive goodness-of-fit indices (Marsh and Hocevar 1985). The scale
used to test convergent validity could have been counterbalance for order, due to different
lengths. Recruitment of Confucian believers would in the future, would provide a more
comprehensive picture of the traditional Chinese spiritual perspective and been a valuable
methodological addition to the study.
In conclusion, the WHOQOL-SRPB is found to be a robust cross-cultural instrument
that is applicable to the Chinese ethnic and spiritual community. Religious and existential
perspectives are covered by the expanded SRPB domain, providing greater comparability
among religious and non-religious beliefs. The degree of acceptability may vary with the
different religious groups. It is vital to interpret spiritual QoL scores against the importance
scores of the corresponding items to evaluate whether the respondents’ expectations were
attained. It is premature to propose any systematic theorization on the western and Chinese
spiritual QoL, but the initial findings suggest the existence of two patterns in the traditional
Chinese spiritual group and the Christianity group. While fine tuning of the WHOQOL-
SRPB instrument may be necessary to accommodate cultural variations of spiritual QoL,
preserving the universality of core items is crucial to allow comparisons of spiritual QoL
across cultural contexts (Saroglou 2011; Skevington et al. 2004).

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