Spirituality as a Resource to Rely on in Chronic Illness: the Spreuk Questionnaire

The SpREUK questionnaire (SpREUK is an acronym of the German translation of "Spiritual and Religious Attitudes in Dealing with Illness") was developed to investigate how patients with chronic diseases living in secular societies view the impact of spirituality in their dealing with illness (in terms of reactive coping). The aim was to operationalize and quantify patients' search for a transcendent source of support; their reliance on such a source of help; and whether they regard their illness as a chance for reflection and subsequent change of life and behavior. The contextual 15-item SpREUK has very good internal consistency estimates (ranging from 0.86 to 0.91), and differentiates three factors, i.e., Search (for Support/Access), Trust (in Higher Guidance/Source), and Reflection (Positive Interpretation of Disease). It avoids exclusive religious terminology and appears to be a good choice for assessing patients' interest in spiritual/religious concerns, which is not biased for or against a particular religious commitment. This reliable and valid instrument is suited for patients in secular and also in religious societies. 1. Background One can not ignore the trend to individualization and secularization in Western societies with subsequent rejection of ecclesiastic approaches and development of new forms of`secular spiritualityór even`religious patchworksínstead. In times of existential need, several patients with chronic or fatal diseases rely on powerful external sources of help [1], i.e., medical health professionals, information and alternative help, or even transcendent sources. Even in secular societies we have large OPEN ACCESS

One can not ignore the trend to individualization and secularization in Western societies with subsequent rejection of ecclesiastic approaches and development of new forms of `secular spirituality´ or even `religious patchworks´ instead.In times of existential need, several patients with chronic or fatal diseases rely on powerful external sources of help [1], i.e., medical health professionals, information and alternative help, or even transcendent sources.Even in secular societies we have large

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fractions of patients with a vital interest in spirituality/religiosity; those who are not interested in institutional religiosity but in individual ways of spirituality; and those who do not care about spirituality/religiosity at all.For example, despite the predominance of a Christian denomination (82%; 5% had other religious affiliations, 14% had none) in German patients with chronic pain diseases, 50% would not regard themselves as religious; at least 32% reported themselves as religious but not spiritual (R+S−), and 18% as both religious and spiritual (R+S+), while 8% regarded themselves as not religious but spiritual (R−S+), and 42% as neither religious nor spiritual (R−S−) [2].Thus, instruments with a very particular religious perspective and traditional religious terminology are less suited for individuals with an atheistic or agnostic background, albeit one may assume that they do appreciate pluralistic forms of spirituality, particularly secular humanism.One can not ignore a need for measures of spirituality valid and specific also for patients living in secular societies.
For this purpose, one should differentiate behavioral aspects of spirituality/religiosity (i.e., frequency of engagement in specific forms of spirituality) and cognitive and emotional aspects (i.e., specific attitudes and convictions).To address the behavioral aspects, we have developed a practice manual, the SpREUK-P(ractices), and a disease-related instrument, the SpREUK (SpREUK is an acronym of the German translation of "Spiritual and Religious Attitudes in Dealing with Illness"), which refers to patients' attitudes and convictions.
The SpREUK questionnaire was developed to examine how patients with chronic diseases view the impact of spirituality/religiosity on their health and how they cope with illness [3][4][5][6].The intention was to have a specific instrument which operationalizes whether patients with chronic diseases are in search of a transcendent source of support; whether they still do rely on such an external source of help (i.e., they trust such a higher source); and whether they can view their illness as a chance for reflection and subsequent change of life and behavior.The SpREUK relies on these essential motifs found in counseling interviews with chronic disease patients (i.e., having trust/faith; search for a transcendent source to rely on; stimulus to change life/`message of disease) [7].The instrument was qualitatively upgraded in several steps and avoids exclusive religious terminology.Moreover, it appears to be a good choice for assessing patients´ interest in spiritual/religious concerns which is not biased for or against a particular religious commitment.

Factorial Structure of the SpREUK-15
During the process of optimization, there was an 18-item version (SpREUK 1.2) which was tested in German patients [8], and a 16-item version (SpREUK 1.2b) which was tested in Arabic Muslims and German patients [5].Here, the structure of the final 15-item version (SpREUK-15) which is particularly suited for patients in secular societies will be reviewed.All items were scored on a 5-point scale from disagreement to agreement (0 -does not apply at all; 1 -does not truly apply; 2 -don't know; 3 -applies quite a bit; 4 -applies very much).The respective scores were conveyed to a 100% level (transformed scale score).
The Search scale (Search for Support/Access to Spirituality/Religiosity) consists of two cognitive, two emotional and one behavioral item.It operationalizes patients' intention to find or have access to a spiritual/religious resource which may be beneficial to cope with illness, and interest in spiritual/religious issues (insight and renewed interest).Moreover, the patients' self categorization as a spiritual individual is part of this scale, too.As shown in Table 2, the Search scale is strongly related with frequency of spiritual practices (i.e., meditation, rituals, etc.) and also frequency of religious practices (i.e., praying, church attendance, etc.), as measured with the SpREUK-P (practices).The Trust scale (Trust in Higher Guidance/Source) consists of four emotional items and one cognitive item, and is a measure of intrinsic religiosity which identifies religion as an end in itself.This scale deals with the motifs of connection with a higher source which carries the patient through.The conviction that death is not an end (which implies either resurrection or rebirth, and persistence of the soul itself) is part of this scale.The scale correlates strongly with conventional religious practices, and also with spiritual practices and Gratitude/Reverence (Table 2), which underlines construct validity.Moreover, the Trust scale correlated strongly (r = 0.78) with the adaptive coping strategy Trust in Higher Source, which is a measure of intrinsic religiosity, too [2].Although Search and Trust were strongly inter-correlated, and, from a conceptual point of view, the differentiation between spiritual Search and religious Trust is sound, one has to recognize that, particularly for Arabic Muslims [5] or Orthodox Jews [10], this distinction `spiritual´ or `religious´ might be less relevant in their daily life.In fact, the factorial structure of the 15-item Arab version of the SpREUK (alpha = 0.923) differentiates the same three factors, but patients' perception of being a spiritual individual (item 1.1) and the cognitive statement that finding access to a spiritual source can have a positive influence on illness (item 1.5) would add to the Trust scale rather than the Search scale.Moreover, most Arabic Muslims would regard themselves as both a spiritual and religious individual (80% R+S+), just 5% as religious but not spiritual (R+S−), 2% as spiritual but not religious (R−S+) and 14% as neither spiritual nor religious (R−S−) [5].This is in sharp contrast to findings among German patients [5].In a sample of 888 patients (see Table 3) with chronic diseases, 48% would regard themselves as R−S−, 6% as R−S+, 29% as R+S− and 17% as R+S+, despite a predominance of a Christian denomination (74%, 3% other, 23% none).
The third scale, Reflection (Positive Interpretation of Disease) refers to a cognitive appraisal attitude, and operationalizes the possibility to interpret illness as an opportunity, a `hint´ to change life, or to reflect upon what is essential in life.Even patients without an explicit interest in spirituality/religiosity (either agnostics or atheists) can interpret illness in such a way.Nevertheless, Reflection was strongly associated with both Search and Trust, indicating its spiritual connotation, and moderately with existential practices (i.e., personal insight and development, orientation to nature, etc.) and with spiritual and religious practices (Table 2).In fact, several patients argued that they regard their illness as a hint´ (i.e., by God) to change their life, to behave differently, etc. [2,11,12].A similar interpretation can be found in the Quran (i.e., illness as given by Allah to remember and redirect) or in the Bible (i.e., healing connected with the imperative to change one's life, to behave differently).Interestingly, this scale was found to be moderately associated with patients´ happiness, weakly with positive God images, and negatively with pain severity in patients with chronic pain diseases [13].Positive interpretation of disease (Reflection) was found to be a mediator of the impact of a positive God image on patients' happiness [13].The Reflection scale was closely correlated with the scale Reflection: Illness as a Chance (r = 0.62), which is a reappraisal strategy in terms of adaptive coping [2], indicating convergent validity.Moreover, it correlated moderately (r between 0.44 and 0.45) with positive disease interpretations (challenge, value) [2].

Variables with an Impact on the SpREUK Scores
In a sample of patients with chronic diseases, Search was of lowest relevance, while Trust was of moderate relevance, and Reflection of highest relevance (Table 3).In Arab Muslims, the mean scores were much higher (Search: 74.5 ± 13.6; Trust: 82.2 ± 13.0; Reflection: 79.0 ± 14.0) as compared to German individuals (Table 3).Although there were significant differences with respect to gender and age, most differences can be explained by patients' religious denomination.In fact, patients without a religious denomination had the lowest scores for Search, Trust and also Reflection.One cannot ignore the fact that patients with a higher educational level have significantly higher scores for Search (F = 9.1; p < 0.0001) and Reflection (F = 2.7; p = 0.044), while Trust did not differ (F = 1.3; p = 0.286).Moreover, the Reflection scores showed strong variances also for women and men (Table 3).Univariate analyses indicate that denomination rather than gender, age and education had the strongest impact on patients´ Search (F = 5.2; p = 0.002) and Reflection (F = 6.7; p < 0.0001), while for Trust both denomination (F = 14.5; p < 0.0001) and age (F = 3.8; p = 0.005) were of outstanding relevance; disease itself had not relevant impact on the SpREUK scores.Because both spirituality and coping strategies are highly individual, depending on several co-influencing variables, the respective mean values should not be used as expected `norms´ for the SpREUK but as reference values which may significantly differ between countries and communities.Table 3. Mean values of German patients with chronic diseases.
Data refer to 888 German patients (see Table 1).
Thus, there are distinct characteristics which may identify patients either in search of a spiritual source which might be beneficial in their struggle with disease, or those who already have found such a source of support.Regression analyses indicated that patients´ engagement in spiritual practices (and also age and other forms of practice) may predict their Search for Support/Access to Spirituality/Religiosity, while their Trust in Higher Guidance/Source can be predicted by engagement in religious practices (and also engagement in other forms of practice); their ability or desire to reflect on their life (Positive Interpretation of Disease) can be predicted best by their engagement in existential practices (also age had a negative impact) (Table 4).These predictors underline construct validity of the scales.

Conclusions
Apart from the inevitable differentiation of search for a beneficial source on the one hand (Search), and patients' conviction to have access to such a transcendent source of help (Trust), the SpREUK uniquely addresses patients' ability to view illness as a chance for reflection and re-orientation in life (Reflection).Both Search and Trust are strongly associated with this cognitive behavioral (meaning--focused) coping strategy.This means, although Reflection was found to be of relevance also in individuals without a religious denomination, it nevertheless has a spiritual connotation.Further findings with the SpREUK showed that particularly Search and Reflection were moderately associated with positive interpretations of illness (i.e., value, challenge), but not with negative interpretations [2].Spirituality thus can have an impact on how patients deal with their life concerns, and probably also on treatment decisions.None of the SpREUK scales correlated with life satisfaction [2] indicating that these dimensions are independent.
The SpREUK appears to be a reliable, valid, and useful measure of spirituality in the context of how a patient deals with chronic illness.The 15-item version of the SpREUK has important strengths: (1) it avoids exclusive religious terminology and thus is suited both in secular and also in religious societies; (2) it operationalizes aspects of spirituality relevant for patients facing chronic illness; and (3) the scales are not contaminated with positive character traits or indicators of mental health.In contrast to the 10-item short version, the SpREUK-15 has the advantage of two additional items relevant for patients´ spiritual/religious self-categorization, and holds a more precise Reflection scale.In fact, the mean values of the Search and Trust scales of the SpREUK-15 and SpREUK-SF10 are similar, while the Reflection scale of the short version has higher mean values.The SpREUK-SF10 is particularly suited to address "spiritual attitudes" of agnostics and atheists, too, and thus the data can be compared with those of other denominations.
The SpREUK is currently available in English, German, Arabic, Hebrew, and Spanish.

Table 1 .
Factorial structure of the SpREUK-15 and mean values of respective items.
Emotion(1.1)In my opinion, I am a spiritual individual 1.38 ± 1.36 0.78 Emotion (1.9)It urges me on to spiritual or religious insight, whether it diminishes my difficulties in life or not 1.21 ± 1.33 0.70 0.41 Cognition (1.4) My illness has brought me a renewed interest in spiritual or religious questions 1.25 ± 1.32 0.70 Trust in Higher Guidance/Source (alpha = 0.91; Eigenvalue 1.5; 10% explained variance) Emotion (2.5) Whatever happens, I trust in a higher power which carries me through 1.99 ± 1.47 0.31 0.81 Emotion (2.6)In my opinion, I am a religious individual 2.03 ± 1.44 0.77 Emotion (37) I have faith in the spiritual guidance in my life 1.77 ± 1.40 0.34 0.76 0.31 Cognition (39) I am convinced that death is not an end 2.05 ± 1.42 0.75 Emotion (38) In my mind I am connected with a "higher source".1.50 ± 1.43 0.40 0.73 Reflection: Positive Interpretation of Disease (alpha = 0.86; Eigenvalue 1.1; 8% explained variance)
[9]a refer to 888 German patients (see Table1). * Only the strongest prediction model is presented (gender, disease categories, and spiritual/religious self categorization were excluded from the respective models); ** Frequency of spiritual practices was measured with the SpREUK-P[9].Engagement categories were never, seldom, often, regularly.