Psychometric and Factor Analysis of the Greek Version of the SpREUK Questionnaire ()
1. Introduction
In the context of healthcare, the significance of spirituality and religiosity becomes evident as they contribute to the holistic well-being of patients ( Büssing et al., 2007 ; Kharroubi & Elbarazi, 2023 ; Zimmer et al., 2016 ). Spirituality encompasses an individual’s sense of meaning, purpose, and connection with the transcendent ( Vaughan, 2002 ), while religiosity involves adherence to specific religious beliefs, practices, and rituals ( Astrow et al., 2001 ). Spirituality and religiosity provide a framework for patients to find solace, hope, and meaning in times of illness or distress ( Ardelt et al., 2008 ; Evans et al., 2018 ; Zimmer et al., 2016 ). Engaging with these dimensions can positively influence mental and emotional well-being, coping mechanisms, and resilience ( Manning et al., 2019 ; Pargament et al., 2000 ; Ryff, 2021 ; Thuné-Boyle et al., 2006 ).
Studies have shown that spirituality and religiosity are associated with improved health outcomes and can play a fundamental role in the lives of individuals facing chronic, severe, or fatal illnesses ( Elhag et al., 2022 ; Koenig et al., 2012 ; Zimmer et al., 2016 ). These conditions often lead to mental and emotional changes, such as anxiety and depression, that can negatively impact the patient’s overall quality of life ( Büssing, 2010 ; Büssing et al., 2005a ; Lima et al., 2020 ) and health prognosis ( Dragioti et al., 2023 ). Faith and belief systems often serve as sources of strength, offering patients a sense of comfort, peace, and purpose amidst challenging healthcare journeys ( Büssing, 2010 ; Bożek et al., 2020 ; Klimasiński et al., 2022 ). Recognizing the importance of spiritual reinforcement, many patients turn to prayers, vows, and other religious or spiritual practices as sources of comfort and hope during their recovery journey ( Büssing, 2010 ). By addressing patients’ spiritual needs, healthcare professionals can create a supportive and inclusive environment that promotes healing on multiple levels ( Koenig et al., 2012 ).
To effectively address spirituality and religiosity in healthcare, appropriate measurement tools are crucial. The SpREUK questionnaire (SpREUK is an acronym of the German translation of “Spiritual and Religious Attitudes in Dealing with Illness”) assesses patients’ attitudes and convictions regarding religious and spiritual matters ( Büssing, 2010 ; Büssing et al., 2005a , 2008 ). It appears to be a reliable scale for assessing a patient’s interest in spiritual concerns that is not biased for or against a particular religious commitment ( Büssing, 2010 ; Büssing et al., 2005a , 2008 ). As the field continues to expand, the psychometric properties of the SpREUK questionnaire are being evaluated in different cultural contexts ( Büssing et al., 2005b , 2007 , 2016 ; Ostermann et al., 2004 ; Pasalar et al., 2022 ), including this first application in Greece. Therefore, this study aimed to assess the psychometric properties and factor structure of the Greek version of the SpREUK questionnaire in a sample of the general population.
2. Methods
Participants
A total of 429 individuals residing in 15 distinct regions of Greece participated in the study, where the Greek translation of the SpREUK was utilized. Our rule of thumb was to enroll more than 300 participants based on recommendations for scale development studies (≥300 considered as good, including Monte Carlo simulations) ( Kyriazos, 2018 ). The inclusion criteria for the sample required participants to be Greek-born and proficient in the Greek language. The primary source of participants was the public university in each region, although additional individuals from the general population were randomly selected to expand the sample. To ensure consistency, participants had to meet specific criteria: they had to be at least 18 years old, possess at least a Primary school education, and not have any current medical diagnosis or a history of psychiatric or other medication-dependent mental disorders. Prior to their involvement, all participants were properly informed that their responses would remain confidential, and their participation in the study was entirely voluntary. Detailed information regarding the demographics of the sample is provided in the results section.
Measurements
Spiritual and Religious Attitudes in Dealing with Illness (SpREUK)
All participants in the study completed the Greek version of the SpREUK questionnaire. The SpREUK questionnaire was specifically developed to explore how individuals with chronic illnesses, residing in secular societies, perceive the role of spirituality in their approach to dealing with their health conditions, particularly in terms of reactive coping ( Büssing, 2010 ). The SpREUK questionnaire consists of 15 items and demonstrates strong internal consistency (with reliability estimates ranging from 0.86 to 0.91). It provides a total score as well as three subscale scores that assess a) Search for Support/Access, b) Trust in Higher Guidance/Source, and c) Reflection involving a positive interpretation of the disease. This instrument has been validated and proven to be reliable, making it suitable for use with patients in both secular and religious societies ( Büssing, 2010 ).
The Family Crisis-Oriented Personal Evaluation Scales (F-COPES)
The study sample was also administered the Greek version of the F-COPES ( Gouva et al., 2016 ; Mccubbin et al., 1985 ). A five-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree) is used to rate the respondents at each item. The F-COPES produces a total score and five subscale scores referring to: 1) Acquiring Social Support, 2) Reframing, 3) Seeking Spiritual Support), 4) Mobilizing Family to Acquire and Accept Help and 5) Passive Appraisal. The total, as well as subscale scores, were calculated by sum of all individual items’ responses. It has been weighed and used in the Greek population and provided satisfactory psychometric properties ( Gouva et al., 2016 ). For the purposes of this study, i.e. to evaluate the convergent validity of the SpREUK questionnaire, only the subscale of Seeking Spiritual Support was used in the analysis.
The Family Environment Scale (FES)
The Greek version of the Family Environment Scale (FES) ( Gouva et al., 2009 ; Moos, 1990 ) was additionally selected to evaluate the convergent validity of the SpREUK questionnaire. The FES measures the family atmosphere, exploring three dimensions of family environment in all types of families ( Loveland-Cherry et al., 1989 ). It consists of 90 items that measure 3 sectors, each of which includes 3, 5 and 2 respectively subscales (that is: A. Relationship Dimensions (Cohesion-Expressiveness-Conflict,) B. Personal Growth Dimensions (Independence-Achievement Orientation-Intellectual & Cultural Orientation-Active Recreational Orientation-Moral Religious Emphasis) and C. System Maintenance Dimensions (Organization-Control) ( Lanz & Maino, 2014 ). It has been used in the Greek population and provided satisfactory psychometric properties ( Gouva et al., 2009 ). For this study, also we used the subscale of Moral Religious Emphasis in the convergent validity analysis.
Demographics
Each participant in the study completed a questionnaire that collected information on their socioeconomic characteristics, including age, gender, region of residence, educational qualifications, and marital status.
Translation Procedure
The Greek translation of the SpREUK scale was performed by three authors who were part of the present study. Following previous guidelines ( Van de Vijver & Hambleton, 1996 ), two additional independent bilingual psychologists conducted a back-translation of the scale from Greek to English. It is worth noting that these psychologists were unaware of the original version of the scale, ensuring a blind and unbiased evaluation. The translated questionnaire was slightly modified considering the presence of a chronic condition to be useful for people with and without a current condition and was subjected to a thorough comparison with the original version and only a few minor adjustments were made. The modified version was then administered to the study sample. To assess the test-retest reliability of the scale, a subset of 100 individuals (70 women and 30 men) was randomly selected from the original sample two months later.
Statistical Analysis
All analyses were performed using Jamovi (Jamovi project: Version 2.3.28; lavaan package) ( Rosseel, 2012 ) and SPSS (IBM Corp) statistical software packages. Descriptive analysis was performed for all variables. For the psychometric analysis, we used analytical approaches that are widely accepted in such studies ( Dragioti et al., 2011 ; Kyriazos, 2018 ). Data with missing values were excluded from the analysis. The Content Validity Index (CVI) was applied to content validity of the scale ( Polit et al., 2007 ; Zamanzadeh et al., 2015 ) while the scale’s internal consistency was examined with Cronbach’s α coefficient ( Cronbach, 1951 ). To test the suitability of the data for factor analysis, we used the Kaiser-Meyer-Olkin Measure of Sampling Adequacy and Bartlett’s Test of Sphericity ( Dziuban & Shirkey, 1974 ). Exploratory Factor Analysis (EFA) was first performed, using maximum likelihood extraction and parallel analysis ( Lim & Jahng, 2019 ) with principal axis factoring in combination with a “promax” rotation ( Dragioti et al., 2011 ). Confirmatory Factor Analysis (CFA) was then performed using maximum likelihood estimation ( Gatignon, 2014 ). To examine the models’ goodness of fit, we used the absolute and incremental (relative) fit indices ( Kline, 2011 ): Overall chi-square [χ2] test ( Hooper et al., 2007 ), Root Mean Square Error of Approximation (RMSEA) ( Hooper et al., 2007 ; Steiger, 1990 ), the Standardized Root Mean Square Residual (SRMR) ( Hooper et al., 2007 ), Tucker-Lewis Index (TLI), and the Comparative Fit Index (CFI) ( Bentler, 1990 ). CFI values of >0.95 indicate good model fit and values of >0.90 acceptable model fit. RMSEA values of <0.08 are indicative of acceptable fit ( Gatignon, 2014 ). The correlation coefficients (Pearson r) were calculated, following a two-month interval to examine the test-retest stability of the questionnaire. Regression analysis was used to assess possible effects of age, gender and education on the three factors and the SpREUK total score.
3. Results
Characteristics of the Sample
The study encompassed a sample size of 429 individuals, with a mean age of 37.7 years (SD = ±15.1). Women constituted a larger proportion (65.5%) compared to men (34.5%). The majority of participants had either high school degrees or were college students and the majority were also married (59.9%). The characteristics of the total sample are shown in Table 1.
Cultural Adaptation, Linguistic Equivalence, and Content Validity
The entire team of the study members approved the cultural adaptation, linguistic equivalence, and content validity of the Greek version of the SpREUK questionnaire. The CVI for all items exceeded 79% ( Polit et al., 2007 ; Zamanzadeh et al., 2015 ).
Item Reliability Statistics
The reliability of the total questionnaire was satisfactory (Cronbach’s α = 0.89), and the item reliability statistics ranged between 0.87 and 0.89 (Supplementary Table S1). The item-rest correlation ranged between 0.38 and 0.71 (Figure 1).
Construct Validity
We divided the dataset into two subsamples of n1 = 159 and n2 = 270 to conduct an exploratory and a confirmatory factor analysis respectively, using the generated random sample function in Jamovi (Version 2.3.28) to ensure the representative of the entire sample. Subsample 1 included 66.4% women (mean age = 36.60, SD = 15.10) and Subsample 2 included 66.0% women (mean age = 38.70, SD = 15.20). There were no statistically significant differences between the two subsamples (p > 0.05).
Exploratory Factor Analysis
The findings from the EFA in a random subsample (n1) of 159 participants, revealed that the three-factor solution accounted for 69.8% of the variance,
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Table 1. Characteristics of the sample (N = 429).
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Figure 1. Item-rest correlation of the Greek version of the SpREUK questionnaire.
demonstrating a lack of factor complexity and salient loadings (>0.20) on factors other than the proposed ones. The loadings ranged between 0.506 and 0.900 (Table 2). The Kaiser-Meyer-Olkin Measure of Sampling Adequacy yielded a value of 0.894, indicating that the sample size was sufficient, and Bartlett’s Test of Sphericity yielded a significant p-value of less than 0.001. A Scree plot (Figure 2) supported the presence of the three-factor structure. The chi-square test statistic for this model was 67.2 (with 51 degrees of freedom [d.f.]). To further explore the latent structure of the questionnaire, a confirmatory factor analysis was subsequently conducted as follows.
Confirmatory Factor Analysis
After conducting EFA and determining a suggested three-factor solution, a CFA was subsequently performed on a random subsample (n2) of 270 participants. Both unstandardized and standardized coefficients were utilized, employing maximum likelihood model estimation ( Table 3). Upon estimating the model, various goodness-of-fit statistics as described above were computed. The findings revealed that the three-factor model (Figure 3) demonstrated a particularly good fit to the data, as indicated by the incremental fit indices (CFI = 0.908; TLI = 0.889), and an adequate fit in terms of absolute fit indices (RMSEA = 0.057 and SRMR = 0.084). Specifically, the RMSEA ranged from 0.047 to 0.066. The chi-square test yielded a non-significant result (χ2 = 209; d.f. = 87: p > 0 .05), indicating that the observed data did not significantly deviate from the model’s expected values. However, for comparison, we also examined the fit of a single-factor model, which showed principally poor fit (Supplementary Table S2).
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Table 2. Exploratory factor analysis.
Note: “Principal axis factoring” extraction method was used in combination with a “promax” rotation.
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Figure 2. Sree plot of the explonatory factor analysis of the Greek version of the SpREUK questionnaire.
The factor covariance of Search for Support (Factor 1) was 0.844 with Trust in Higher Guidance (Factor 2) and 0.523 with Reflection (Factor 3) (Supplementary Table S3).
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Table 3. Thee-factor model unstandardized and standardized coefficients and associated data.
Convergent Validity
The subsequent analysis involved examining the correlations between the SpREUK scores and the scores on two different subscales: the Moral-Religious Emphasis subscale of the FES ( Moos & Moos, 1986 ), and the Seeking Spiritual Support subscale of the F-COPES ( Gouva et al., 2016 ; Mccubbin et al., 1985 ). The results indicated that all three factors of the SpREUK questionnaire exhibited statistically significant positive correlations with both subscales (Supplementary Table S4).
Internal Consistency and Temporal Stability
The Cronbach coefficients for the three subscales ranged between 0.66 and 0.87 (Supplementary Table S5). Two months later the SpREUK was readministered to a randomly chosen subset of the original sample (N = 100), to assess the test-retest reliability. At the retest period for this subset Cronbach’s α, was 0.81. The test-retest reliability was r = 0.86 (p < 0.001) for the total SpREUK score. On a subscale level the correlation was: Search for Support r = 0.81, Trust in Higher r = 0.81, Reflection r = 0.95.
Age, Sex, and Education Effect
The linear regression analysis showed that only sex significantly affected the three subscales, namely, Search for Support (b = 1.11, p = 0.039), Trust in
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Figure 3. Path diagram of the factor structure of the Greek version of the SpREUK questionnaire. Note: SfS = Search for Support; TiHG = Trust in Higher Guidance; Rfl = Reflection.
Higher (1.09, p = 0.024), Reflection (b = 1.22, p = 0.013) as well as total score of SpREUK (b = 3.78, p = 0.003). Sex variations are shown in Supplementary Table S5.
4. Discussion
The present study aimed to investigate the psychometric properties and the factor structure of the Greek version of the SpREUK questionnaire in the general population. The SpREUK is designed to assess peoples’ perspectives on spirituality and its role in their approach to illness and well-being ( Büssing, 2010 ; Büssing et al., 2005a , 2008 ). One notable strength of the SpREUK questionnaire is its ability to capture spiritual aspects without relying on exclusive religious terminology ( Büssing, 2010 ; Büssing et al., 2005a , 2007 , 2008 , 2016 ). Given the potential of spirituality to offer individuals a sense of purpose, meaning, and coherence in their lives ( Villani et al., 2019 ), which can enhance the management of life stress ( Park, 2005 ), our objective was also to adapt the questionnaire to facilitate broader usage beyond people with chronic illnesses.
The results showed that this modified questionnaire exhibited good construct validity, as evidenced by Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), which supported the proposed three-factor structure ( Büssing, 2010 ). Therefore, in addition to the total score of the scale, the Greek version of the SpREUK supported the three key dimensions, namely, Search, Trust, and Reflection. The search factor examines the extent to which individuals seek a transcendent source of support or access to spirituality in dealing with their health challenges. The trust dimension evaluates individuals’ reliance on higher guidance or a spiritual source of assistance during times of illness. The reflection dimension explores individuals’ perception of their illness as an opportunity for personal growth, reflection, and subsequently positive changes in their lives and behaviors ( Büssing, 2010 ; Büssing et al., 2005a , 2007 , 2008 , 2016 ).
The results also demonstrated favorable outcomes in terms of cultural adaptation, linguistic equivalence, content validity, internal consistency, and convergent validity. Of particular note, the CVI was satisfactory indicating that the items adequately represented the construct measured and were relevant to the target population ( Polit et al., 2007 ; Zamanzadeh et al., 2015 ). Reliability analyses indicated satisfactory results for the internal consistency of the total questionnaire as well as for the three subscales. However, only the reflection dimension was minimally acceptable ( Cortina, 1993 ). Despite the above, our study showed that the SpREUK questionnaire is not only a reliable and valid tool, but also demonstrates temporal stability over time. The test-retest reliability coefficient indicated that the questionnaire provides consistent results when administered at different time points, allowing for reliable longitudinal assessments. Furthermore, the SpREUK questionnaire demonstrated convergent validity, as it showed significant positive correlations with relevant subscales of other measures, such as the Moral-Religious Emphasis subscale of the FES and the Seeking Spiritual Support subscale of the F-COPES.
In terms of limitations, it should be noted that the participants in the current study had a relatively younger age and higher education, which was a result of the sample selection method employed. This may limit the generalizability of the findings, as previous research has indicated that individuals may hold onto their faith or experience an increase in religious practices and beliefs as their age ( Bengtson et al., 2015 ; Koenig, 2006 ). The relationship between education and spirituality is still under consideration ( Van der Walt et al., 2008 ). Another limitation of the study is that the scale was administered to a sample of the general population with some modifications in the items about the presence of a chronic illness. This differs from previous studies that included individuals with specific chronic illnesses ( Büssing et al., 2016 ; Büssing et al., 2005b , 2007 ; Ostermann et al., 2004 ; Pasalar et al., 2022 ). Consequently, the findings may be influenced by these sample differences, as they are specific to the particular samples used and may not be universal properties of the scale. To address these limitations, future research should focus on investigating the dimensional nature of the SpREUK in clinical samples, including those with chronic illness as well as an aging population. This would provide a more comprehensive understanding of the questionnaire’s applicability and validity in different populations.
Overall, the findings of this study provide strong evidence for the validity and reliability of the Greek version of the SpREUK questionnaire. It appears to be a valuable and well-validated instrument for assessing spirituality-related coping strategies in individuals with or without chronic illnesses. Its inclusive approach and good psychometric properties make it suitable for use in both secular and religious societies, providing valuable insights into the role of spirituality in individuals’ well-being and coping processes. Researchers and clinicians can confidently utilize this instrument to assess peoples’ spirituality-related coping strategies, irrespective of their religious commitments, in both secular and religious societies. This is of great importance if one considered that spirituality and health are intertwined dimensions of human existence that significantly impact well-being ( Manning et al., 2019 ; Pargament et al., 2000 ; Ryff, 2021 ; Thuné-Boyle et al., 2006 ). Understanding and nurturing spirituality can promote physical, psychological, and social health, offering individuals a sense of meaning, purpose, and support in their lives.
Data Availability Statement
The detailed datasets used for analysis during the current study are available by the reasoned request.
Supplementary Material
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Table S1. Item reliability statistics total sample (N = 429).
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Table S2. Goodness-of-fit statistics for the two examined models.
Note: CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; RMSEA = Root Mean Square Error of Approximation; SRMR = Standardized Root Mean Square Residual.
Note: ᵃFixed parameter.
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Table S4. Correlation matrix total sample (N = 429).
Note: *p < 0.05, **p < 0.01, ***p < 0.001.
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Table S5. Means, standard deviations, and correlations.
Note: *p < 0.05, **p < 0.01, ***p < 0.001.