J Relig Health (2015) 54:112–121

DOI 10.1007/s10943-013-9785-z

ORIGINAL PAPER

Validation of the Portuguese Version of the Functional

Assessment of Chronic Illness Therapy–Spiritual
Well-Being Scale (FACIT-Sp 12) Among Brazilian
Psychiatric Inpatients

Giancarlo Lucchetti • Alessandra Lamas Granero Lucchetti •

Juliane Piasseschi de Bernardin Gonçalves • Homero P. Vallada

Published online: 24 October 2013

 Springer Science+Business Media New York 2013

Abstract Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being scale

(FACIT-Sp 12) is one of the most used and most validated instruments for assessing
spiritual well-being in the world. Some Brazilian studies have used this instrument without,
however, assessing its psychometric properties. The present study aims to validate the
Portuguese version of the FACIT-Sp 12 among Brazilian psychiatric inpatients. A self-
administered questionnaire, covering spiritual well-being (FACIT-Sp 12), depression,
anxiety, religiosity, quality of life, and optimism, was administered. Of those who met the
inclusion criteria, 579 patients were invited to participate and 493 (85.1 %) were able to fill
out the FACIT-Sp 12 twice (test and retest). Subsequently, the validation analysis was
carried out. Estimation of test–retest reliability, discriminant, and convergent validity was
determined by the Spearman’s correlation test, and the internal consistency was examined
by the Cronbach’s alpha. The sample was predominantly male (63.9 %) with a mean age of
35.9 years, and the most common psychiatric condition was bipolar disorder (25.7 %)
followed by schizophrenia (20.4 %), drug use (20.0 %), and depression (17.6 %)
according to ICD-10. The total FACIT-Sp 12 scale as well as the subscales demonstrated
high internal consistency (coefficient alphas ranging from 0.893 for the total scale to 0.655
for the Meaning subscale), good convergent and divergent validity, and satisfactory test–
retest reliability (rho = 0.699). The Portuguese version of FACIT-Sp 12 is a valid and
reliable measure to use in Brazilian psychiatric inpatients. The availability of a brief and

G. Lucchetti (&)
Federal University of Juiz de Fora, Av. Eugênio do Nascimento s/n8 - Dom Bosco, Juiz de Fora,
MG CEP 36038-330, Brazil
e-mail: g.lucchetti@yahoo.com.br

A. L. G. Lucchetti
J. P. de Bernardin Gonçalves

João Evangelista Hospital, São Paulo, Brazil

A. L. G. Lucchetti
J. P. de Bernardin Gonçalves
H. P. Vallada

University of São Paulo, São Paulo, Brazil

A. L. G. Lucchetti
J. P. de Bernardin Gonçalves

São Paulo Medical Spiritist Association, São Paulo, Brazil

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broad measure of spiritual well-being can help the study of spirituality and its influence on
health by researchers from countries that speak the Portuguese language.

Keywords FACIT-Sp 12
Spirituality
Psychometrics
Religion and

medicine
Spiritual well-being

Introduction

Several studies have shown the influence of spirituality and religiosity on physical and
mental health (Bonelli and Koenig 2013; Koenig 2012; Lucchetti et al. 2011; Powell et al.
2003). Although some studies use these terms interchangeably, evidence has shown dif-
ferent health outcomes when assessing spiritual and religious aspects.
Recently, Maselko et al. (2009) found that existential spiritual well-being was protective
for depression and that religious well-being was associated with increased odds of
depression. On the other hand, King et al. (2013) found that people who have a spiritual
understanding of life in the absence of a religious framework are more vulnerable to mental
disorder.
In general, most studies assessing spirituality have shown beneficial results. Spirituality
is considered a critical resource for many patients in coping with illness and is an important
component of quality of life and mental health (Monod et al. 2011).
In some secular areas of the world where religion has become less popular, the term
spirituality has emerged as an important aspect of life, and therefore, this concept is
increasingly used in research (Koenig 2008).
However, measuring spirituality in clinical research is a cumbersome process because of
the complexity of the elements and definitions involved (Lucchetti et al. 2013b). Thus,
numerous instruments have been developed to assess spirituality and measure its associ-
ation with health outcomes (Lucchetti et al. 2013b; Monod et al. 2011).
According to a systematic review carried out by Monod et al. (2011), when comparing
all spirituality instruments, the FACIT-Sp 12 and the Spirituality Index of Well-being were
considered the best tools to assess the current spiritual state of patients.
In fact, FACIT-Sp 12 is one of the most used and most validated instruments for
assessing spiritual well-being in the world (Lucchetti et al. 2013b; Monod et al. 2011). It
was first created in the 1990s as a measure of spiritual well-being and is not limited to any
one religious or spiritual tradition (Bredle et al. 2011). It was developed with the input of
cancer patients, psychotherapists, and religious/spiritual experts who were asked to
describe the aspects of spirituality and/or faith that contributed to quality of life (QOL).
Basically, it evaluates harmony, peacefulness, sense of strength, faith, and meaning (Pe-
terman et al. 2002).
This instrument has been used in numerous published papers worldwide (Lucchetti et al.
2013b) and, therefore, is one of the most used instruments for assessing spirituality in
scientific studies (Bredle et al. 2011). However, few studies have used this instrument in
Portuguese.
FACIT-Sp12 was first translated into Portuguese by the Functional Assessment of
Chronic Illness Therapy (FACIT) (Bredle et al. 2011). Since then, some Brazilian studies
have used this instrument without assessing its psychometric properties (Batista and
Mendonça 2012; Fonseca-Guedes 2009; Furia 2006; Teixeira 2009).

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To our knowledge, the only study which evaluated the psychometric properties of the
Portuguese, FACIT-Sp 12 was conducted by Pereira et al. (Pereira and Santos 2011) in
end-of-life oncologic patients in Portugal. They found good internal consistency (Cron-
bach’s alpha 0.92), construct validity, and test–retest reliability (r of 0.99).
The present study aims to validate the Portuguese version of the Functional Assessment
of Chronic Illness Therapy–Spiritual Well-Being scale (FACIT-Sp 12) among Brazilian
psychiatric inpatients.

Methods

Sample

This study was conducted in psychiatric inpatients from a mental health hospital in São
Paulo, Brazil, the ‘João Evangelista Hospital’ (HoJE), during a 12-month period from July
2011 to June 2012.
HoJE is a 100-bed psychiatric hospital located in the northern part of the city of São
Paulo, Brazil, which cares for patients with mental health conditions such as substance
dependence, bipolar disorder, depression, schizophrenia, including others. The hospital has
60 % of its psychiatric beds for the general public subsidized by the government and is,
therefore, considered a philanthropic institution by the Brazilian law (Lucchetti et al.
2013a).
Patients included in the study were 18 years or older, hospitalized for treating an acute
psychiatric condition, willing to participate, and had a condition not so severe that they
could not complete the questionnaire (psychosis or confusion). The patients stayed in the
hospital for at least 15 days, and they had no severe cognitive impairment.
Of those who met the inclusion criteria, 579 patients were invited to participate. From
these, 493 (85.1 %) were able to fill the FACIT-Sp 12 twice (test and retest).
The study was approved by the Human Subjects Review Committee at University of
São Paulo (São Paulo, Brazil).

Procedures and instruments

The questionnaire was self-administered, and socio-demographic data were retrieved by

interviews and through medical charts. All patients have filled out the questionnaire twice
with approximately a 1-month interval. It covered the following aspects:
• Socio-demographic characteristics: sex, age, race, marital status, education;
• Depression, evaluated using the Beck Depression Inventory, validated in Portuguese
(Gorenstein et al. 1998);
• Anxiety, assessed using the Beck Anxiety Inventory, validated in Portuguese
(Marcolino et al. 2007);
• Optimism, evaluated using the Life Orientation Test-Revised, validated in Portuguese
(Bandeira et al. 2002);
• Quality of life, assessed using the SF-12 Health Survey, validated in Portuguese
(Andrade et al. 2007);
• Religiousness, evaluated using the Duke Religion Index, validated in Portuguese
(Lucchetti et al. 2012) and asking the religious affiliation;

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• Spiritual well-being, assessed using the FACIT-Sp12 (Peterman et al. 2002) which was
translated into Portuguese by the Functional Assessment of Chronic Illness Therapy
(FACIT) (Bredle et al. 2011).

FACIT-Sp12

In this instrument, participants are instructed to indicate how true an item had been for
them during the past 7 days, using a 5-item response format ranging from not at all (0) to
very much (4), except that two items are negatively stated and must be reverse-coded
(Murphy et al. 2009). It consists of 12 items and three sub-domains of spiritual well-being
(peace, meaning, and faith) (Bredle et al. 2011).
FACIT-Sp 12 consists of 12 statements to which agreement is rated and includes the
following items: ‘‘I feel peaceful,’’ ‘‘I have a reason for living,’’ ‘‘My life has been
productive,’’ ‘‘I have trouble feeling peace of mind,’’ ‘‘I feel a sense of purpose in my life,’’
‘‘I am able to reach down deep in myself for comfort,’’ ‘‘I feel a sense of harmony within
myself,’’ ‘‘My life lacks meaning and purpose,’’ ‘‘I find comfort in my faith or spiritual
beliefs,’’ ‘‘I find strength in my faith or spiritual beliefs,’’ ‘‘My illness has strengthened my
faith or spiritual believe,’’ and ‘‘I know that whatever happens with my illness, things will
be okay’’ (Bredle et al. 2011). Higher scores indicate higher levels of spiritual well-being
(Murphy et al. 2009).

Analyses

Internal consistency involves the extent to which different items on a questionnaire

measure the same characteristic (e.g., spiritual well-being) (Lucchetti et al. 2012).
The construct validity of a questionnaire refers to how accurately it measures the aspect
it was designed to measure. Construct validity is established in part through convergent and
discriminant validity. An instrument that correlates well with other measures of the same
construct demonstrates convergent validity. Discriminant validity indicates that a ques-
tionnaire does not measure characteristics other than the one it was developed to measure
(Lucchetti et al. 2012).
The stability of an instrument can be determined using a test–retest procedure, which
involves multiple administration of an instrument to the same people (Hendrickson et al.
1993).
Estimation of test–retest reliability, discriminant, and convergent validity was determined
by the Spearman’s correlation test, and the internal consistency was examined by the
Cronbach’s alpha. We also presented the scale means and variance, and the sample demo-
graphic, religious, and disease characteristics. All statistical procedures were carried out
using SPSS version 17.0 software. A p value of 0.01 is used to define statistical significance.
The present study was approved by the ‘‘University of São Paulo’’ ethics committee.

Results

Demographics

The patients’ demographics and religious characteristics are summarized in Table 1. The
sample was predominantly male (63.9 %) with a mean age of 35.9 years. Sixty-nine

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Table 1 Sample demographic,

Characteristic
religious, and disease
characteristics
Sex (n, %)
Male 313 (63.9)
Female 177 (36.1)
Age (mean, SD) 35.96 (11.04)
Marital status
Married 128 (26.3)
Single 203 (41.8)
Divorced 35 (7.2)
Widow 7 (1.4)
Living together 113 (23.3)
Education
0–4 years 71 (15.8)
4–8 years 68 (15.2)
More than 8 years 309 (69.0)
Diagnosis
Alcohol dependence 42 (8.5)
Drug use 98 (20.0)
Schizophrenia 100 (20.4)
Bipolar disorder 126 (25.7)
Depression 86 (17.6)
Personality disorder 19 (3.9)
Others 19 (3.9)
Religion
Catholic 132 (34.4)
Protestant/Evangelical 145 (37.8)
Spiritist 78 (20.3)
Others 29 (4.4)
No religion 12 (3.1)
Religious attendance
Never 91 (18.5)
Once a year or less 121 (24.5)
A few times a year 65 (13.2)
A few times a month 115 (23.3)
Once a week 36 (7.3)
More than once/week 65 (13.2)
Non-organizational religiosity (prayer, meditation, or Bible study)
Rarely or never 80 (16.2)
A few times a month 175 (35.5)
Once a week 55 (11.2)
Two or more times/week 43 (8.7)
Daily 54 (11.0)
More than once a day 86 (17.4)
Intrinsic religiosity (Mean, SD) 11.77 (3.18)
FACIT-Sp 12 total score (Mean, SD) 27.97 (11.35)

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percent of the studied population had more than 8 years of education, and 41.8 % of the
patients were single.
The most common psychiatric condition was bipolar disorder (25.7 %) followed by
schizophrenia (20.4 %), drug use (20.0 %), and depression (17.6 %).
Concerning religious aspects, the majority of participants had some religious affiliation
(37.8 % were evangelical Protestants, followed by 34.4 % Catholics and 20.3 % Spiritists),
and the following results were obtained in relation to organizational, non-organizational,
intrinsic religiosity, and spiritual well-being: Most of them attended a church service less
than once a week; only about 28 % practiced a private religiosity (praying, religious
reading, TV programs, meditation) daily; and most of them obtained high scores on the
intrinsic religious scale and on the FACIT-Sp 12 total score.

Reliability

Means, standard deviations, and reliability coefficients of the FACIT-Sp 12 scales are
displayed in Table 2. The total FACIT-Sp 12 scale as well as the subscales Meaning,
Peace, and Faith demonstrated high internal consistency in this setting (coefficient alphas
ranging from 0.893 for the total scale to 0.655 for the Meaning subscale).

Construct Validity (Discriminant and Convergent Validity)

Correlations among the FACIT-Sp 12 scale, subscales, and different religious measures were
also examined for evidence of discriminant and convergent validity (Table 3). Correlation
coefficients of[0.7 between scales indicate a strong relationship (Aaronson et al. 1993).
In this study, all correlation coefficients between FACIT-Sp 12 scale and subscales were
strong (rho = 0.867–0.890), indicating convergence. However, the correlation coefficients
between FACIT-SP 12 subscales (except Meaning and Peace correlation) were \0.7,
which indicated that each subscale was distinct.

Table 2 FACIT-SP 12 descrip-

FACIT-Sp 12 Mean SD Possible range Cronbach’s
tive statistics
alpha

Total 27.97 11.35 0–48 0.893

Meaning 9.95 4.14 0–16 0.655
Peace 8.00 3.87 0–16 0.742
Faith 10.02 4.79 0–16 0.861

Table 3 Spearman’s correlations between FACIT-Sp 12 and other measures of religiosity

Measure Meaning Faith Peace FACIT-Sp12 total

Organizational religiosity 0.266** 0.400** 0.253** 0.357**

Non-organizational religiosity 0.272** 0.389** 0.249** 0.351**
Intrinsic religiosity 0.465** 0.607** 0.433** 0.569**
Meaning – 0.646** 0.728** 0.890**
Faith 0.646** – 0.646** 0.867**
Peace 0.728** 0.646** – 0.887**

** p \ 0.01

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In addition, there were weak correlations between organizational religiosity and non-
organizational religiosity with FACIT-Sp scale and subscales, pointing to a difference
between spirituality and religiosity (supporting the divergent validity). Only intrinsic
religiosity, which is considered closer to spirituality, presented a moderate correlation to
FACIT-Sp 12 (supporting the convergent validity).

Relation Between Spiritual Well-Being, Depression, Anxiety, Optimism, and Quality

of Life

Previous researches have established an inverse relation between spirituality/spiritual well-

being and mental health problems (depression and anxiety) (Bekelman et al. 2007; Pe-
terman et al. 2002). Further, there is an association between spirituality, optimism, and
better quality of life (Bredle et al. 2011). Therefore, a measure of spiritual well-being must
be able to correlate with these measures.
We found strong correlations between the total and all subscales scores from FACIT-Sp
12 and mental health quality-of-life scores, as measured by SF 12. Further, FACIT-Sp 12
and its subscales were also strongly negative correlated with depression (Beck Depression
Index) and anxiety (Beck Anxiety Inventory) and positive correlated with optimism (Life
Orientation Test-Revised) (Table 4).

Test–Retest Reliability

Four hundred and ninety three participants (85.1 %) were able to fill the FACIT-Sp 12
twice. (Mean interval of answering both questionnaires was 27.11—IC95 % 24.98–29.24.)
Although there is no agreement upon the level for test–retest reliability coefficients, a
minimum reliability of 0.7 has been recommended when the test is used for research
(Nunnally et al. 1967; Ruggeri et al. 2000). In the present study, we found a test–retest
reliability of 0.699, p \ 0.01 which is satisfactory after 1 month of interval.

Discussion

We found good psychometric properties in the Portuguese version of FACIT-Sp 12, such
as good internal consistency, adequate construct validity, and satisfactory test–retest
reliability.

Table 4 Correlations of FACIT total score, Meaning, Faith, and Peace with SF-12 physical (PCS) and
mental (MCS) components, Beck Anxiety and Depression Inventories, and optimism
FACIT-Sp 12 total Peace Faith Meaning

Beck depression inventory -0.714** -0.689** -0.694** -0.694**

Beck anxiety inventory -0.499** -0.493** -0.464** -0.464**
Optimism (Life Orientation Test-Revised) 0.630** 0.564** 0.617** 0.617**
SF 12—physical health 0.325** 0.312** 0.349** 0.349**
SF 12—mental health 0.688** 0.689** 0.591** 0.591**

** p \ 0.01

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These results are in line with a previous study conducted by Pereira et al. (Pereira and
Santos 2011) in Portugal. However, due to considerable differences between countries,
cultures, and even language style, a Brazilian validation is recommended and needed.
In regard to the reliability, the Portuguese FACIT-Sp 12 (total scale) presented a high
internal consistency (Cronbach’s alpha = 0.89) which is in accordance with other vali-
dation studies such as the Persian version (Jafari et al. 2013) (Cronbach’s alpha = 0.90),
the European Portuguese version (Pereira and Santos 2011) (Cronbach’s alpha = 0.92), the
Japanese version (Noguchi et al. 2004) (Cronbach’s alpha = 0.91), and the original
English version (Cronbach’s alpha = 0.87).
FACIT-Sp 12 has also proved to have construct validity. The scale was able to assess
spiritual well-being and to discriminate this concept from other religious aspects such as
organizational religiosity and non-organizational religiosity (weak correlation coeffi-
cients). Interestingly, intrinsic religiosity, considered closer to spirituality by some authors
(Nelson et al. 2009), presented moderate correlation to FACIT-Sp12 scale and subscales.
The subscales were correlated, as expected, but seemed to evaluate different dimensions
of spiritual well-being (Peace, Faith, and Meaning). The strong correlation between
Meaning and Peace opens the discussion on whether FACIT-Sp 12 evaluates 2 factors
(Meaning/Peace and Faith) or 3 factors (Meaning, Peace, and Faith). There are some
articles proposing a 2-factor FACIT-Sp12 (Bredle et al. 2011; Noguchi et al. 2004), and
recently, others articles are showing that the 3-factor model is likely to provide more
specific information for studies (Murphy et al. 2008, 2009). The original authors of FACIT
have recommended to considering 3 factors instead of 2 factors in a recent review (Bredle
et al. 2011).
We have also found an inverse relation between FACIT-Sp 12 scores and depressive/
anxiety symptoms, and a direct relation between FACIT-Sp 12 scores and quality of life,
which is in accordance with the recent studies (Murphy et al. 2009; Noguchi et al. 2004;
Peterman et al. 2002).
Finally, the Portuguese version of FACIT-Sp 12 had a test–retest reliability of 0.69
(minimum recommended = 0.70). This result is different from the study conducted in
Portugal (Pereira and Santos 2011) which found a test–retest reliability of 0.99. However,
we considered our result satisfactory in view of our setting (psychiatric inpatients) and our
interval (1-month).
An interesting aspect of the present study is the possibility of using FACIT-Sp 12 in
psychiatric inpatients. Although first designed to assess spiritual well-being in cancer
patients, this scale is very versatile and it has been used in many contexts such as end-of-
life patients, psychiatric outpatients, cardiovascular patients, and general population,
among others (Bean et al. 2009; Bredle et al. 2011).
Our study has some limitations that should be considered when analyzing our results.
We have evaluated a single mental health hospital in Brazil, and the generalization of these
findings is uncertain. Therefore, studies in other settings are needed to confirm the psy-
chometric properties. However, if we consider the good results in these patients, we could
assume even better results in the general population.

Conclusion

The Portuguese version of FACIT-Sp 12 is a valid and reliable measure to use in Brazilian
psychiatric inpatients. The availability of a brief and broad measure of spiritual well-being

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can help the study of spirituality and its influence in health by researchers from countries
that speak the Portuguese language.

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