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Table of Contents
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 194-202

Development and psychometric evaluation of the Spiritual Health Questionnaire among Iranian Muslim adults

1 Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
2 Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
3 Research Center of Quran, Hadith and Medicine, Spiritual Health Group, Tehran University of Medical Sciences, Tehran, Iran
4 Behavioral Sciences Research Center, Life style institute, Baqiyatallah University of Medical Sciences, Tehran, Iran

Date of Submission25-Apr-2020
Date of Decision20-May-2020
Date of Acceptance06-Jan-2021
Date of Web Publication23-Jul-2021

Correspondence Address:
Marzieh Momennasab
Zand Street, Namazee Sq, Shiraz.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nms.nms_35_20

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Background: Spiritual health (SH) has received great attention from nurses and other health-care providers in recent years. The existing instruments for SH measurement measure either some aspects of SH or SH-related concepts, and there is no specific SH measurement instrument, particularly for Muslim adults in Iran. Objective: This study aimed at the development and psychometric evaluation of the Spiritual Health Questionnaire (SHQ). Methods: This exploratory sequential mixed methods study was conducted in a qualitative and a quantitative phase in 2014–2016. In the qualitative phase, a concept analysis was conducted using the hybrid model and its results were used to develop the primary SHQ. In the quantitative phase, the face, content, and construct validity and reliability of SHQ were assessed. Exploratory factor analysis and concurrent validity assessment were performed for construct validity assessment. Test–retest stability and internal consistency were also assessed for reliability assessment. Results: The qualitative phase of the study showed that the concept of SH had six main components. In the quantitative phase, the number of primary SHQ items was reduced from 88 to 59 after face and content validity assessments. In construct validity assessment, 12 more items were excluded and the remaining 47 items were loaded on six factors which explained 45.2% of the total variance. The Cronbach’s alpha values of the questionnaire and its six dimensions were 0.778 and 0.752–0.788, respectively. Convergent validity assessment showed that the mean scores of SHQ and the Spiritual Well-Being Index had a significant correlation with each other (r = 0.35; P = 0.032). Conclusion: The 47-item SHQ is a specific instrument for SH assessment with acceptable validity and reliability.

Keywords: Adults, Methodological study, Reliability, Spirituality, Validity

How to cite this article:
Jaberi A, Momennasab M, Cheraghi MA, Yektatalab S, Ebadi A. Development and psychometric evaluation of the Spiritual Health Questionnaire among Iranian Muslim adults. Nurs Midwifery Stud 2021;10:194-202

How to cite this URL:
Jaberi A, Momennasab M, Cheraghi MA, Yektatalab S, Ebadi A. Development and psychometric evaluation of the Spiritual Health Questionnaire among Iranian Muslim adults. Nurs Midwifery Stud [serial online] 2021 [cited 2022 Jan 26];10:194-202. Available from: https://www.nmsjournal.com/text.asp?2021/10/3/194/322224

  Introduction Top

Health is one of the meta-paradigms of nursing with many different aspects, including spiritual health (SH).[1],[2] Therefore, one of the main responsibilities of nurses is to promote their clients’ SH.[3] SH has received great attention in recent years and has been addressed in many studies.[4],[5],[6] Nonetheless, many ambiguities still surround the concept.[7],[8] Without clarifying the concept and providing a clear conceptual definition for it, effective strategies for SH assessment and promotion cannot be developed and used.

There are many different instruments for SH measurement such as the Spiritual Well-Being Scale,[9] the SH and Life-Orientation Measure,[10] the Spirituality Index of Well-Being,[11] and the World Health Organization Quality of Life Survey.[12] However, most of these instruments were developed in Western countries, reflect Judeo-Christian and Western philosophical and cultural worldview, and hence may not be appropriate for SH measurement in Islamic cultures.[13] A study highlighted that the items of SH-related instruments should originate from the immediate culture.[14] Moreover, most existing instruments assess concepts similar to SH such as spiritual well-being, and some of them have not been developed through systematic psychometric evaluation.[15] On the other hand, spirituality-related instruments developed in the Islamic culture of Iran measure concepts other than SH such as spiritual well-being,[16] spiritual experience,[17] spiritual care perception,[18] or competency in spiritual care[19] or their items were developed based on the existing literature.[20] Using culturally inappropriate instruments or instruments which measure SH-related concepts provides no reliable data about SH. Consequently, despite the large population of Muslims in the world and in Iran, there is still no Muslim-specific SH measurement instrument. Therefore, the present study was conducted to fill this gap.


The study aimed at the development and psychometric evaluation of the Spiritual Health Questionnaire (SHQ).

  Methods Top


This exploratory sequential mixed methods study was conducted in a qualitative and a quantitative phase in 2014–2016 in Shiraz, Iran.

In the qualitative step, a concept analysis was performed through the hybrid model. The three phases of the model were the theoretical phase, the fieldwork phase, and the analytic phase. In the theoretical phase, the method proposed by Walker and Avant (1995) was used to clarify the concept of SH. The results of the theoretical phase were categorized into the main categories of the attributes, antecedents, and consequences of the concept of SH and published elsewhere.[21]

In the fieldwork phase of the hybrid concept analysis, semi-structured interviews were held with 14 adult participants who were purposively selected with maximum variation regarding their sociodemographic characteristics. Inclusion criteria were age 18–60 years, ability to share detailed data about SH-related experiences, no affliction by incurable illnesses, ability to speak and understand Persian, and being Muslim. Study setting was two large shopping centers, banks, retirement centers, and Shiraz University of Medical Sciences all in Shiraz, Iran. Data collection lasted 9 months. The OneNote 2007 software was used for data management.

In the final analytic phase, the results of the theoretical and the fieldwork phases were merged, SH was defined, and its dimensions and subscales were determined. The final results of the hybrid concept analysis were used to generate the item pool for SHQ.

In the quantitative step, the psychometric properties of SHQ, namely its face, content, and construct validity and reliability, were assessed.

Face validity assessment

The face validity of SHQ was assessed both quantitatively and qualitatively. In qualitative face validity assessment, interviews were held with eight faculty members and participants in order to evaluate the rationality, appropriateness, attractiveness, allocation, and comprehensiveness of the SHQ items. The questionnaire was revised based on their comments. In quantitative face validity assessment, we asked nine experts to rate the importance of each item on a five-point scale, and then, their rating scores were used to calculate the item impact score using the following formula, “Item impact score = Importance × Frequency.” In this formula, “frequency” was the number of experts who rated the intended item 4 or 5 and “importance” was the mean score of the item importance on the Likert scale.

Content validity assessment

The content validity of SHQ was also assessed both quantitatively and qualitatively. In qualitative content validity assessment, 15 clergies and experts in nursing, literature, statistics, and psychiatrics were asked to comment on the grammar and wording of the SHQ items, and then, the questionnaire was revised based on their comments. In quantitative content validity assessment, content validity ratio (CVR), item-level content validity index (CVI), and scale-level CVI were calculated.[22] For CVR calculation, at least five experts are needed.[23] Accordingly, 15 experts in spirituality and instrument development were asked to rate item essentiality on a three-point scale as “Essential,” “Useful but not essential,” or “Unessential.” Then, CVR was calculated through the “CVR=(NE-(N⁄2))/(N⁄2)” formula, where N was the total number of the experts and NE was the total number of the experts who rated the intended item “Essential.” The results were compared with the minimum critical values in Lawshe’s table.[23] If the CVR of an item was greater than the minimum critical value in the table, that item was considered appropriate.

For CVI calculation, the same experts were asked to rate the relevance of each item on a four-point scale. If the CVI of an item was >75%, it was considered relevant. The modified kappa was also calculated as a measure of agreement among content validity assessors. Average S-CVI (S-CVI/Ave) was also calculated through averaging item CVI values. An S-CVI/Ave value >0.9 was considered acceptable.

Construct validity assessment

Exploratory factor analysis was performed for construct validity assessment. For sampling, the total frequencies of different age and gender groups in Iran were determined, and then, a proportionate sample was selected from each age and gender group through quota sampling. According to the National Statistics Center of Iran, around 23% of Iranians age 20–30 years, 17% age 30–40, 12% age 40–50, and 8% age 50–60. Moreover, 49% of Iranians are male and 51% are female.[24] Sample size was determined based on the respondent-to-item ratio guidelines which recommend that 5–30 participants per item are needed. Another guideline suggests that a total sample of <100 participants is very small, a sample of 200 participants is fairly small, a sample of 300 participants is good, a sample of 500 participants is very good, and a sample of 1000 participants is excellent.[25] In the present study, six participants per item were selected. The Kaiser–Meyer–Olkin statistic and the Bartlett’s test were used to test the appropriateness of the factor analysis model. Moreover, before factor analysis, a pilot study on fifty participants was conducted to assess the appropriateness of the items and identify poor items. Based on the results of that study, if the coefficient of the correlation between the score of an item and the total score of the questionnaire was <0.3, that item was removed.[26]

The convergent validity of SHQ was also assessed through assessing the correlation between the total score of SHQ and the total score of the Spiritual Well-Being Index.[9] This index measures spiritual well-being in the two dimensions of religious and existential well-being. It includes forty items scored on a Likert scale from 1 (“Strongly disagree”) to 6 (“Strongly agree”), resulting in a total dimensional score of 10–60 and a total score of 20–120. Higher scores reflect greater sense of well-being. Reliability assessment using the data obtained from 100 students in a former study showed that the test–retest correlation coefficients of the index and its religious and existential well-being dimensions were, respectively, 0.93, 0.96, and 0.86, which confirm the acceptable reliability of the index.[27] The Cronbach’s alpha of the index was 0.90 in a former study on university students in Iran[28] and 0.742 in the present study. Thirty-eight participants completed both SHQ and Spiritual Well-Being Index, and then, the correlation between the scores of these two instruments was assessed.

Reliability assessment

The internal consistency and the stability assessment methods were employed for assessing the reliability of SHQ. Accordingly, Cronbach’s alpha was calculated at two time points, namely after face and content validity assessments using the data obtained from 42 participants and after factor analysis using the data obtained from 322 participants.

Stability was assessed through the test–retest method, in which 54 participants twice completed the questionnaire with a 2-week interval. Then, intraclass correlation coefficient was calculated and values >0.80 were interpreted as acceptable stability.[29] It is noteworthy that a sample of thirty participants is adequate for stability assessment.[26]

Ceiling and floor effects were also assessed for SHQ. These effects exist when more than 20% of participants, respectively, obtain the highest and the lowest possible scores of the intended instrument.[30]

Quantitative data analysis was performed using the SPSS software (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.), and the level of significance was set at <0.05.

Ethical considerations

The Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran, approved this study (Ethical approval code: IR.SUMS.REC.1393.S7216, Grant number: 93.7216). Participants were primarily informed about the aim and the methods of the study, confidential management of the study data, and their freedom to withdraw from the study. Then, written informed consent was obtained from all of them.

  Results Top

The results of the qualitative step

In the theoretical phase of the hybrid concept analysis, 436 documents were reviewed. The experiences of 14 participants of the fieldwork phase showed that SH is a complex and multidimensional concept. The results of this phase also showed that the major components of SH were harmonious reciprocal connectedness, moderation, spiritual striving, transcendence, purpose seeking and wisdom thinking, and faith.[31] The novel findings of this phase of the study were moderation in life and communications, spiritual striving, spiritual thinking, and deep contemplation into the inner self. Based on the results of this phase, SH was defined from the perspectives of Iranian Muslim adults. In the analytic phase of the hybrid concept analysis, the results of the first and the second phases were combined. Finally, the concept of SH was defined as “a dynamic, developmental, conscious, multidimensional, and universal process that stimulates transcendence through spiritual awareness, personal capacity, and potentials, has the characteristics of integrating force for existential aspects, transcendence and moderation, harmonious connectedness, wisdom thinking, purpose seeking, and faith, and results in physical, psychosocial, and spiritual well-being and moral development.” [Table 1] presents the results of this step. Based on this definition, a pool with 88 items was generated for the primary SHQ.
Table 1: The themes and subthemes of the qualitative step of the study

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The results of the quantitative step

In this step, 387 Iranian adults with a mean age of 35.00 ± 11.55 were studied. Most of them were female (58.1%), married (63%), and employed (71.3%), and 42.9% of them had high school diploma [Table 2].
Table 2: Demographic characteristics of participants in the quantitative phase of the study (n = 387)

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Face and content validity assessments

During face validity assessment, two items were merged with each other and nine items were deleted due to importance scores <1.5. In content validity assessment, 11 items had low CVR scores [Table 3] and 8 had low CVI and modified Kappa values [Table 4]. After removing these items, the S-CVI/Ave of the 59-item SHQ was calculated to be 0.93.
Table 3: Items with low content validity ratio values

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Table 4: Spiritual Health Questionnaire items with low content validity index and modified Kappa values

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Construct validity assessment

The correlation coefficients of the mean scores of ten items (i.e., items 5, 10, 15, 23, 26, 36, 39, 43, 53, and 59) with the total score of SHQ were <0.3, and hence, these ten items were excluded. The Kaiser–Meyer–Olkin statistic for sampling adequacy assessment was 0.903, and the result of the Bartlett’s test for assessing the sphericity of the item matrix was statistically significant (P < 0.001). During exploratory factor analysis using the maximum likelihood method and varimax orthogonal rotation, two items were deleted and the remaining 47 items were loaded on six factors with Eigenvalues >1 and factor loading values >0.4. Scree plot also confirmed the six-factor structure of the SHQ [Figure 1]. The extracted six factors of SHQ explained 45.2% of the total variance. Items which were loaded on two factors were allocated to the factor with greater factor loading. Another criterion for the allocation of such items was congruence between their content and the content of the loaded factors. Accordingly, the items “I feel satisfied with individual prayer” and “My extra attention to one aspect of life causes me to neglect other aspects” were transferred from Factor 5 to Factor 4. Finally, factors were labeled according to their items as follows: transcendental connectedness, harmonious reciprocal relationships, transcendence, moderation, faith, and purposefulness and meaningfulness [Table 5]. Convergent validity assessment showed that the coefficient of the correlation between the total mean scores of SHQ and the Spiritual Well-Being Index was 0.35 (P = 0.032).
Figure 1: Scree plot based on factor loading values equal to 0.4

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Table 5: The results of varimax rotation (factor analysis) and factor loadings of each items

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Reliability assessment

The Cronbach’s alpha of SHQ before factor analysis was 0.749. After factor analysis, the Cronbach’s alpha values of the final SHQ and its transcendental connectedness, harmonious reciprocal relationships, transcendence, moderation, faith, and purposefulness and meaningfulness dimensions were 0.778, 0.783, 0.774, 0.752, 0.766, 0.766, and 0.778, respectively [Table 6]. Stability assessment also showed no significant difference between the mean scores of SH at the two measurements (P = 0.182) and revealed that the test–retest intraclass correlation coefficient of SHQ was 0.959 with a 95% confidence interval of 0.931–0.976 (P < 0.001), confirming the acceptable reliability of the questionnaire.{Table 6}

The relative frequency of participants which obtained the highest and the lowest possible scores of SHQ was 30.7% (102 participants) and 0.3% (one participant), respectively.

  Discussion Top

In this study, SHQ was developed and its psychometric properties were assessed. Findings showed that the questionnaire has six main dimensions, namely transcendental connectedness, harmonious reciprocal relationships, transcendence, moderation, faith, and purposefulness and meaningfulness. While transcendental connectedness was a subcategory of the harmonious reciprocal connectedness in the hybrid concept analysis in the present study, construct validity assessment through exploratory factor analysis revealed it as a main dimension of SHQ, indicating the importance of transcendental connectedness in the Islamic culture of Iran.

Internal consistency assessment revealed that the Cronbach’s alpha values of SHQ and its dimensions were more than 0.75, confirming the acceptable reliability of SHQ. Previous studies also reported great Cronbach’s alpha values for other SH-related instruments.[9],[20],[32] The test–retest stability assessment in the present study also showed that the test–retest intraclass correlation coefficients of SHQ and its dimensions were >0.7, confirming the acceptable stability of the questionnaire over time.

Many different instruments are used for the measurement of SH. However, most these instruments measure concepts similar to SH such as spiritual well-being, daily spiritual experience, and spirituality,[33],[34] and hence, they do not help nurses differentiate SH from its similar concepts. Moreover, SH-related instruments developed in Iran are mainly based on the existing literature rather than contextual data and hence are not perfectly appropriate for the Iranian context.[20],[32] For example, the Sayemiri et al.’s instrument for SH measurement includes the following two items, “Healthy thinking depends on discovering a supreme being who guarantees the rules and the traditions of the existence” and “Compared with secular lifestyle, worshiping or religious lifestyle is an abstract and unattainable system.” These items are not perfectly appropriate for the religious context of Iran. On the other hand, most existing SH-related instruments have been developed in Western cultures and under the influence of Judeo-Christian worldview.[35] Instruments, particularly instruments related to religious beliefs, should be developed based on the characteristics and values of the immediate context; otherwise, they may produce unreliable results when used in different contexts. In addition, the existing SH-related instruments contain items on the antecedents and consequences of SH such as belief system and mortality, while they do not cover some aspects of SH such as moderation and the existence of an integrating force in the universe. Contrarily, the SHQ developed in the present study exclusively includes items on the attributes of SH which were generated based on the findings of the qualitative step and covers moderation and the existence of an integrating force in the universe.

Before construct validity assessment, ten items were excluded because the coefficients of the correlation between their mean scores and the total mean score of SHQ were <0.3. The content of some of these items had been addressed in other items. Examples of these items were as follows: “My beliefs play an important role in my life,” “The pleasure I get from worshiping separates me from my everyday problems,” and “Spirituality promotes my soul.” Moreover, some of the excluded items were too abstract and difficult to understand for participants. Examples of these items were as follows: “I know my shortcomings and abilities to achieve my goals,” “When I face problems, I feel doubtful about God’s wisdom,” “I don’t get tired in moving towards perfection,” and “Barriers in life don’t stop me in my way towards perfection.” Excluding these items enhanced participants’ understanding of the questionnaire.

One of the strengths of SHQ is its very low floor effect which means that the questionnaire can discriminate participants with low levels of SH. Another strength of the questionnaire is its development based on the Islamic context of Iran. Individuals’ worldviews and beliefs significantly affect their perceptions of SH. Therefore, instruments for SH measurement should be developed based on the worldviews of the target population. Most existing SH-related instruments have been developed based on the Judeo-Christian worldview about spirituality which was formed after the Second World War. Despite similarities among Islam, Christianity, and Judaism, these religions widely differ from each other regarding the manifestations of spirituality. For example, unlike other studies, our study revealed moderation, spiritual striving, and deep inward contemplation as the components of SH. The primary item pool of SHQ also included 88 items, and hence, it was strong enough. Considering the probability of item exclusion during psychometric analysis, the primary item pool of an instrument should include large number of well-developed items. The inclusion of negatively worded items was another strength of SHQ. Psychometric specialists believe that negatively worded items can better reflect respondents’ views. Moreover, the mixed methods design of the study and the triangulation of the study data helped collect and present more in-depth data, ensure credibility, and develop a more reliable instrument. Study participants were also selected with maximum variation in order to include a wide range of ideas and experiences in the study.

One of the main limitations of the present study was the similarity of the concept of SH with some other concepts such as spirituality and spiritual well-being which might have caused problems for participants in understanding the concept. Moreover, study participants were selected just from urban areas. Therefore, despite sampling with maximum variation, study findings may not easily be generalizable to people in rural areas. Further studies are recommended to assess the psychometric properties of SHQ in different urban and rural populations.

  Conclusion Top

This study concludes that the 47-item SHQ has acceptable validity and reliability for SH measurement among Iranian Muslim adults. SHQ is not only a culturally appropriate instrument for SH measurement in Iran but also has good psychometric properties compared with other SH-related instruments in the country. This questionnaire is specific for SH rather than SH-related concepts such as spirituality, spiritual well-being, and SH outcomes. SH measurement using SHQ can provide valuable information for nurses and other health-care providers and enable them to develop strategies for SH improvement. As psychometric evaluation of an instrument is an endless process, further studies are needed to provide more conclusive results about the psychometric properties of SHQ.


This article was derived from a PhD dissertion of Azita Jaberi with project number 93-7216, Shiraz University of Medical Sciences, Shiraz, Iran. The authors would like to acknowledge the research deputy at Shiraz University of medical sciences for their support. We also are thankful of all patients who participated in this study

Financial support and sponsorship

Shiraz University of Medical Sciences (Ethics code: IR.SUMS.REC.1393.S7216). This article was derived from a thesis research project.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 5]


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