J Relig Health (2016) 55:67–84

DOI 10.1007/s10943-014-9967-3

ORIGINAL PAPER

Spiritual and Religious Attitudes in Dealing with Illness

in Polish Patients with Chronic Diseases: Validation
of the Polish Version of the SpREUK Questionnaire

Arndt Büssing • Kazimierz Franczak • Janusz Surzykiewicz

Published online: 26 October 2014

 Springer Science+Business Media New York 2014

Abstract Although providing religious/spiritual (SpR) support to sick has received in

Poland growing attention in the scientific literature, little has been written about how to
measure whether patients are in search for SpR or may already have trust in such a resource
helpful to cope with disease. The Polish version of the SpREUK questionnaire was vali-
dated in a sample of 275 patients with chronic diseases. Both explorative and confirmatory
factor analysis confirmed the already established three subscales, i.e., Search, Trust, and
Reflection, with good internal consistency coefficients (Cronbach’s a between .74 and .91).
The instrument appears to be a good choice to be used in both secular and religious
societies.

Keywords Spirituality
Religiosity
Questionnaire
Validation
Chronic diseases

Patients
Catholic
Poland

Background

In recognition of the fact that religion and spirituality play an important role in many
people’s lives, over the past 30 years, there has been significant increase in social sciences

Arndt Büssing and Janusz Surzykiewicz would like to dedicate this manuscript to the memory of Kazimierz
Franczak who started this study with us, but passed away during the process of data evaluation.

A. Büssing (&)
Faculty of Medicine, Institute for Integrative Medicine, University Witten/Herdecke,
Gerhard-Kienle-Weg 4, 58313 Herdecke, Germany
e-mail: arndt.buessing@uni-wh.de

K. Franczak
J. Surzykiewicz
Faculty of Paedagogy, Cardinal Wyszynski University, Warsaw, Poland

J. Surzykiewicz
Faculty for Religious Education, Catholic University Eichstätt-Ingolstadt, Eichstätt, Germany

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and especially in psychological and medical research about religion and spirituality (Pa-
loutzian and Park 2005; Koenig et al. 2012).

Spirituality/Religiosity and Health

Chronic illness, especially life-threatening diseases, confronts patients with the question of
meaning and purpose of life. In such times of need, several patients rely on additional
(external) sources of help, among them spirituality/religiosity (SpR). SpR has been iden-
tified as a relevant resource to cope with chronic illness, even in secular societies (Büssing
et al. 2005a, b, 2007b, 2009b; Zwingmann et al. 2006, 2008). Studies on the influence of
religiousness and spirituality on physical health were mainly performed on cancer patients
and show that SpR is important for the vast majority of patients (Balboni et al. 2007). In
fact, SpR can be used to relieve stress, retain a sense of control, and maintain hope and
sense of meaning and purpose in life (Thuné-Boyle et al. 2006).
There is mounting research that specific aspects of SpR can be associated with better
health outcomes (reviewed by Koenig et al. 2001, 2012). Moreover, a recent study by
Chida et al. (2009) found an association between SpR and reduced mortality in healthy
individuals which can be attributed to organizational activities, while neither non-orga-
nizational activities nor intrinsic aspects (i.e., cognitive belief in God, spiritual well-being,
spiritual experience or orientation) were associated with better survival (Chida et al. 2009).
This means that engagement in religious issues may be of importance. However, it is
unclear whether secular forms of spirituality could also be associated wwith health
benefits.
In order to address such questions and to compare samples from different cultural
contexts and societies, one needs instruments equally suitable for atheists, secular
‘‘searchers’’, and religious individuals.

Definitions of Spirituality/Religiosity

Currently there are many definitions of spirituality on the one hand and religiosity on the
other, depending on the world view and on underlying professions. Worldwide research
shows that defining religiosity and spirituality can be difficult because some see both
constructs as similar, while others see them as separate or even opposite entities (Hill et al.
2000; Heszen-Niejodek 2003; Pargament 2011; Pargament et al. 2013; Skrzypińska 2012;
Pawlikowski 2013). Koenig (2008) raised concerns about measuring spirituality in research
and argued that spirituality was traditionally ‘‘a subset of deeply religious people’’, while
today it is ‘‘including religion but expanding beyond it’’. However, for research, it is useful
to distinguish between spirituality as an individual experience and religiosity as a ritualized
form (Büssing 2012). In general, spirituality can be globally defined as humans’ search for
meaning in life, while religion involves an organized entity with rituals and practices about
a higher power or God (Tanyi 2002). In the same venue, Pargament described spirituality
as the search for the sacred (1997), while Doyle (1992) referred to it as the search for
existential meaning.
Some authors interpret spirituality as a kind of attitude with cognitive, emotional, and
behavioral components (Saucier 2000; Socha 2000, 2009; Chlewiński 1980; Popielski
1994), while others regard it as a specific and unique dimension of personality (Piedmont
2005; MacDonald 2000). Finally, spirituality may be the search for meaning in life, a kind
of self-realization in terms of the true meaning and ultimate goal in life. In that way,

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spirituality may pervade the whole life of man and is therefore that the basis of spiritual
needs either explicit or implicit (Dobroczyński 2009; Pawlikowski 2013).

The SpREUK Questionnaire as a Measure of Spirituality/Religiosity in Secular

and Religious Societies

Although Christianity has shaped Western culture and society, the impact of institutional
religiosity has changed and decreased, particularly in Europe. Due to the fact that in
Western societies, the trend to individualization and secularization is still ongoing, often
with subsequent rejection of ecclesiastic approaches, up to 50 % of German patients with
chronic disease would not regard themselves as religious (Büssing et al. 2009b). Thus, if
one intends to analyze the effects of specific aspects of spirituality (either cognitive beliefs
and convictions or engagement in concrete practices) in more secular societies, measures
with a very particular religious perspective and traditional religious terminology are less
suited for individuals with an atheistic or agnostic background.
For that purpose, we have designed the SpREUK (Büssing et al. 2005a; Büssing 2010).
This instrument was developed to examine how patients with chronic diseases view the
impact of SpR on their health and how this source relates to their coping with illness. The
intention was to have a specific instrument to address whether patients are in search of a
transcendent source of support, which implies an individual search for meaning; whether
they still do rely on such an external source of help (i.e., they trust such a higher source),
which refers to the concept of intrinsic religiosity; 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 (Büssing 2006). 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.
The instrument was tested not only in the more secular German patients (Büssing et al.
2005b, 2007b, 2009b), but also in Arabic Muslims (Büssing et al. 2007a) and Orthodox
Jews (Zini et al. 2010). Now, we intended to test the SpREUK in a society with a still vital
Christian tradition, i.e., Poland, which is predominantly Catholic.

Spirituality/Religiosity in Catholic Poland

Studies have shown that up to 97 % of the population of 38 million inhabitants identify

themselves as Roman Catholic (Boguszewski 2012; CBOS 2009; Zarzycka 2008). Nev-
ertheless, beginning in the 1990’s the situation in Poland started to change, i.e., the reli-
gious and spiritual movements became more divergent and polarized, with an increasing
devotion and reverence for nature and environment, calling for the creation of eco-spiri-
tuality, because that which is ecological and that which is spiritual may become the same
(Skolimowski 1996).
One has to keep in mind that Poland is situated in an area of cultural and religious
borderland, in the sphere of Latin and Greek-Slavonic influence but with different influ-
ences from communist ideology and recently from a lasting, stronger impact of seculari-
zation processes. Currently, one can note an exchange of values between the Christian
Churches and civil society. Polish society is faced with different degrees of sacral tension,
spirituality, and mysticism; different dogmatic attitudes; different theologies and ecclesi-
ologies; and ideologies. Originally, Polish religiosity displayed an extremely ‘‘Church-

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oriented’’ structure. The low level of religious knowledge has never prevented people from
having a strong identification with the Roman Catholic Church. ‘‘To be Polish means to be
Roman Catholic’’, the famous stereotype formed during the partition of Poland in the
eighteenth century remained, lively until recently. Religious affiliation was a very
important indicator of national identity (Grabowska 2001).
Particularly for the Polish population, one can see a double dimension of religiousness,
subjective on the one hand and objective on the other hand (Grotowska 1999). This
subjective dimension is more connected with inner freedom, an individual search of
meaning, a reorientation of identity, finding purpose of everyday life, and meaning in life
in general. This form of religiosity is a more personal, individual choice of peoples’
lifestyles and their strategies to cope with challenges. On the other hand, Grotowska (1999)
regards objective religiousness as the ultimate sacred and centered on personal growth in
light of this sacred.
There is a marked motivational switch from religiosity based on tradition to religiosity
based on the individual’s own choice and own religious experience, which is quite often
rooted in Eastern tradition (Wandrasz 1998).

Research and Instruments Used on Spirituality/Religiosity in Catholic Poland

Even if Poland is a religiously very active country, the constructs of religiosity and spir-
ituality at this time were not investigated as unique dimensions, particularly in the case of
chronic illness or life-threatening events. In Polish studies previous to today, religiosity
and spirituality had been covered only rarely. If religious issues were assessed, they
appeared with sociological variables or in psychological studies only as a secondary
variable, which were in several cases not adequately interpreted.
Despite the growing interest, there is a lack of well-validated, psychometrically sound
instruments to measure issues of SpR not only with respect to denomination, but also with
respect to the impact of this resource to cope with illness, and patients’ search for meaning
in life (which is an important aspect of an ‘‘individual spirituality’’).
Some of the already established measures of spirituality and religiosity in Polish
research were used in primarily healthy samples, i.e., the scale of religiousness from
Pre˛z_ yna (1968), scale of spirituality from Heszen-Niejodek and Gruszczyńska (2004), and
Jaworski (2004) scale of personal religiousness. Krok (2008, 2012) found that healthy
students’ spirituality (as measured with Heszen-Niejodek’s Self-description Questionnaire
of Spirituality with its subscales Religious attitudes, Ethical sensitivity, and Harmony) was
an important buffer against stressful events. However, this scale was developed as a
generic instrument and was not validated in patients. A further Polish instrument is Ja-
worski’s Scale of Personal Religiousness (SPR) which differentiates personal and a-per-
sonal religiousness. Personal religiousness means to have faith in God that is expressed
through religious practices, spiritual development and being an active member of a church
community, while a-personal religiousness means the opposite of the previous attitude, i.e.,
it reduces faith to tradition, ceremonies, and superficial forms of piety. This SPR scale was
used by Janiszewska et al. (2008) in women with breast cancer. Further, the Wagle Health-
Specific Religiousness (WHSR) scale was used to measure religious beliefs and the
influence of those beliefs on mammography, yet the data were not adequately described.
Among the few data regarding oncology patients from Poland are the studies of Pis-
kozub (2010) and Wnuk et al. (2010). Piskozub (2010) used the Coping Inventory for
Stressful Situations (CISS), Maholick’s Purpose of Life Test, and Jaworski’s Personal

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Religiosity Scale and assumed that spirituality, as expressed by personal religiosity and the
sense of meaning of life, correlated with preferences of coping strategies with stress.
Similarly, Wnuk et al. (2010) intended to analyze the connection between religious/
spiritual variables and meaning of life and strength of hope, using US American instru-
ments such as the Santa Clara Strength of Religious Faith (SCSORF) and the Daily
Spiritual Experiences Scale (DSES), and single items to measure the frequency of prayer
and church attendance on the one hand, and the Purpose Inventory of Life (PIL) and Herth
Hope Index (HHI) on the other hand. They showed that, among cancer patients, motiva-
tional and behavioral aspects of religiosity are precisely connected to the source of hope
and meaning of life (Wnuk et al. 2010).

Aim of this Study

SpR in a person’s life includes significant cultural experiences and inherent beliefs and
therefore might influence a person’s health behavior. The fact that there is a relative lack of
appropriate measures in Polish language which address specific SpR attitudes and con-
victions, engagement in spiritual practices, and specific spiritual needs in this field is a
major limitation to investigate the impact on health-associated variables. Development of
culturally appropriate measures of SpR is suggested to strengthen the quality of research in
this area.
Here, we report on the validation of the Polish version of the SpREUK questionnaire as
applied among patients with chronic diseases on the one hand, and on the other hand its
correlation with the subscales of the Self-description Questionnaire of Spirituality (SQS)
developed by Heszen-Niejodek et al. (2003), which was used as an external measure
sensitive to spiritual activities of Polish individuals. This evaluation study is part of a larger
study on the impact of spirituality in Polish patients; its first part on patients’ spiritual
needs is already published in this journal (Büssing et al. 2014b).

Methods

Participants

All individuals were informed of the purpose of the study, were assured of confidentiality,
and gave informed consent to participate. The patients were recruited consecutively by a
psychologist and educators in the Oncology Hospital in Wieliszew and in the Department
of Social Welfare in the province of Warsaw. Because this sample might not be repre-
sentative for all patients in Poland, one should regard it rather as a convenience sample.
Demographic information of these patients is presented in Table 1.
Individuals provided informed consent to participate by returning a completed ques-
tionnaire which did not ask for names, initials, addresses, or clinical details (with the
exception of a diagnosis). For this analysis, we intended to enroll patients with a wide
spectrum of chronic diseases with varying impact on life and life expectancy (i.e., cancer,
pain, and diabetes mellitus). The internal review boards in the persons of the Directorate
Institutions and psychologists working in these institutions approved the survey. The study
did not provide financial incentives to patients. All completed the questionnaires by
themselves.

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Table 1 Characteristics of 275 patients

Variables Mean (%)

Gender (%)
Women 74
Men 26
Age, years (mean, standard deviation) 56 ± 16
Family status (%)
Married 54
Divorced 26
Widowed 20
Educational level (%)
Basic 12
Professional 20
Medium 42
Higher 25
Denomination (%)
Christian 100
Spiritual/religious self-categorization (%)
R?S? 78
R?S- 7
R-S? 2
R-S- 13
Underlying diseases (%)
Cancer 35
Chronic pain diseases 10
Diabetes mellitus 16
Other chronic conditions (including asthma bronchiale, multiple sclerosis) 40

Measures

All items of the respective instruments were translated by a bilingual scientist and critically
discussed with a committee of Polish psychologists, theologists and medical doctors, and
the primary author of the SpREUK. Because cultural equivalence is not guaranteed, the
team decided to avoid the back-translation procedure. Instead, to ensure linguistic
equivalence, unclear phrases were discussed and adjusted (with respect to cultural specifics
and with reference to the intended construct) with the input of the developing author to
achieve the best-fitting translation suited for the Polish context. After the start of the
validation process, positive feedback of the patients suggests acceptance of the
instruments.

SpREUK-15

The contextual SpREUK-15 questionnaire measures SpR attitudes and convictions of

patients’ dealing with chronic diseases (Büssing et al. 2005b; Büssing 2010). The SpREUK
questionnaire relies on essential motifs found in counseling interviews with chronic disease

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patients, i.e., having trust/faith in a higher source (i.e., God); being in search for a tran-
scendent source to rely on; reflect life due to illness, change priorities, and ability to change
of life and behavior).
The instrument avoids exclusive terms such as God, Jesus, or church, and is thus also
applicable in individuals who do not believe in God, but who may be in search for
individual, secular approaches of search for meaning and support when dealing with
illness.
It differentiates three factors (Büssing 2010):
1. Search scale, or search (for support/access to SpR), deals with the intention of patients
to find or have access to a spiritual or religious resource, which may be beneficial for
coping with illness, and with their interest in spiritual or religious issues (insight and
renewed interest).
2. Trust scale, or trust (in higher guidance/source), is a measure of intrinsic religiosity;
the factor deals with the conviction of patients that they want to be connected with a
higher source, and with their desire to be sheltered and guided by that source, whatever
may happen to them.
3. Reflection scale, or reflection (positive interpretation of disease), deals with a patient’s
cognitive reappraisal of his or her life because of illness and subsequent attempts to
change (i.e., reflecting on what is essential in life, changing aspects of life or behavior,
looking for opportunities for development, believing that the illness has meaning).
The SpREUK-15 scores items on a 5-point scale from disagreement to agreement
(0—does not apply at all; 1—does not truly apply; 2—do not know [neither yes nor no];
3—applies quite a bit; 4—applies very much). The scores were referred to a 100 % level
(transformed scale score). Scores [50 % indicate higher agreement (positive attitude),
while scores \50 % indicate disagreement (negative attitude).
To analyze external validity of the SpREUK, the following instruments were used:

SQS

The Self-description Questionnaire of Spirituality (SQS) is an instrument tested in Polish

individuals (Heszen-Niejodek et al. 2003) and was used as an external measure sensitive to
spiritual activities of Polish individuals. The scale uses originally 20 items and differen-
tiates three factors, i.e., Religious attitudes (i.e., faith allows me to survive difficult periods
in my life’’. ‘‘while making decisions, I rely on my religious beliefs’’), Ethical sensitivity
(i.e., ‘‘react when someone is being hurt’’, ‘‘care about other people’s situations’’), and
Harmony (i.e., ‘‘I am part of the world’’, ‘‘while thinking about my life I experience peace
and happiness’’).
However, when testing this scale in our sample, explorative factor analysis indicated
four main factors and four items which loaded weakly on the respective factors (\0.5).
These items were thus eliminated. The resulting 17-item version of the instrument (SQS-
17) with its two main scales Religious attitudes and Ethical sensitivity, and the third scale
Peace/Harmony with two sub-constructs, has a very good reliability coefficient (Cron-
bach’s a = 0.90) and explains 68 % of variance. For this analysis, we used the SQS-17
version.
The SQS scores on a 5-point Likert scale range from ‘‘not at all’’ to ‘‘very much’’. The
sum of the subscales indicates overall spirituality.

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SpREUK-P

The items of the newly validated Polish version of the SpREUK-P were taken from the
original SpREUK-P 1.1 (Büssing et al. 2005a) and additional items from the SpREUK-P
SF17 (Büssing et al. 2012). Administered to Polish patients, this 17-item construct had
very good quality (Cronbach’s a = 0.90) (Büssing et al. 2014a). Factor analysis pointed to
a 4-factor solution (all with initial eigenvalues [ 1) which explains 67 % of variance and
is congruent with the primary version, i.e., a 6-item sub-scale Religious practices
(a = 0.90), a 4-item scale Humanistic practices (a = 0.87), a 4-item scale Existentialistic
practices (a = 0.80), and a 3-item scale Gratitude/Reverence (a = 0.80).
All items were scored on a 4-point scale (0—never; 1—seldom; 2—often; 3—regu-
larly). The sum scores were referred to a 100 % level (3 ‘‘regularly’’ = 100 %; trans-
formed scale score), which reflects the degree of engagement in the respective forms of
practice (‘‘engagement scores’’).

Positive Emotions (Associated with God)

To measure positive or negative emotions associated with God (EtG scale), we used a
12-item scale which was not yet validated for the Polish population. The instrument
addresses positive emotions with six items (i.e., Happiness/Joy, Love, Affection, Security,
Shelter, and Confidence/Trust), negative emotions with 5 items (i.e., Guilt, Punishment,
Failure, Fear, and Anger/Rage), and one item addressing a person’s disinterest in God.
Within this sample, the sub-scale measuring positive emotions had a very good internal
reliability (a = 0.95), and the sub-scale measuring negative perceptions had a good
internal reliability (a = 0.85).
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—do not know [neither yes nor no]; 3—applies quite
a bit; 4—applies very much). The score was referred to a 100 % level (transformed scale
score).

Life Satisfaction

Life satisfaction was measured using the Brief Multidimensional Life Satisfaction Scale
(BMLSS) (Büssing et al. 2009a, b) which refers to Huebner’s ‘‘Brief Multidimensional
Students’ Life Satisfaction Scale’’. The items of the BMLSS address intrinsic dimen-
sions (Myself, Life in general), social (Friendships, Family life), external (Work situ-
ation, Where I live), and prospective dimensions (Financial situation, Future prospects).
The internal consistency of the instrument was good (Cronbach’s a = 0.87) (Büssing
et al. 2009a, b). Here, we included two further items addressing the health situation of
patients and their abilities to deal with daily life concerns. Each item was introduced
by the phrase ‘‘I would describe my level of satisfaction as …’’, and scored on a
7-point scale from dissatisfaction to satisfaction (0—terrible; 1—unhappy; 2—mostly
dissatisfied; 3—mixed (about equally satisfied and dissatisfied); 4—mostly satisfied;
5—pleased; 6—delighted). The BMLSS-10 sum score refers to a 100 % level
(‘‘delighted’’). Scores [50 % indicate higher life satisfaction, while scores \50 %
indicate dissatisfaction.

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Escape from Illness

The 3-item scale Escape from illness is an indicator of an escape-avoidance strategy to deal
with illness (i.e., ‘‘fear what illness will bring’’, ‘‘would like to run away from illness’’,
‘‘when I wake up, I don’t know how to face the day’’) (Büssing et al. 2006). The items were
scored on a 5-point scale from disagreement to agreement (0—does not apply at all;
1—does not truly apply; 2—do not know [neither yes nor no]; 3—applies quite a bit;
4—applies very much). Scores [50 % indicate an escape attitude.

Statistical Analyses

The research team performed reliability (Cronbach’s coefficient a) and confirmatory factor
analyses (AMOS), and analyses of variance, correlation, and regression analyses with SPSS
21.0. The team judged p \ .05 as significant. With respect to the correlation analyses, we
regarded r [ .5 as a strong correlation, an r between .3 and .5 as a moderate correlation, an r
between .2 and .3 as a weak correlation, and r \ .2 as no or a negligible correlation.

Results

Participants

As shown in Table 1, patients’ mean age was 56 ± 16; 74 % were women and 26 % men.
Most were married and had a medium educational level. All patients had chronic diseases,
predominantly cancer (35 %), diabetes mellitus (16 %), chronic pain diseases (10 %), and
other chronic conditions. Polish patients were 100 % Catholics; 78 % regarded themselves
as religious and spiritual (R?S?), 7 % as religious but not spiritual (R?S-), 2 % as not
religious but spiritual (R-S?), and 13 % as neither religious nor spiritual (R-S-).

Reliability Analysis

Because there was less variance in the Polish sample which consists of 100 % Catholics
and 85 % which regarded themselves as religious (either R?S? or R?S2), we tested the
items of the SpREUK questionnaire on a single-factor level. According to the standard
procedures, all items with a poor corrected item-scale correlation were intended to be
removed.

Search Scale

All 5 items of the Search scale were retained in their original form (Table 2). The scale had
a very good quality (Cronbach’s a = 0.91). The frequency distribution of the items and
their item difficulty (2.64 [mean value]/4 = 0.66) is given in Table 2. All values were in
the acceptable range from 0.2 to 0.8; this means there are no bottom or ceiling effects in the
responses.

Trust Scale

The items of the Trust scale were retained in their original form (Table 3). The items had a
good quality (a = 0.75). The frequency distribution of the items and their item difficulty

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Table 2 Mean values and reliability analysis of the Search scale

Item phrasing and identifying Mean ± standard Item Corrected a if item
item number deviation (0–4) Difficulty item, scale deleted
Index correlation (a = 0.907)
(=0.66)

1.9 urged to spiritual/religious 2.59 ± 1.15 0.65 0.82 0.88 –

insight
1.6 searching for an access to 2.55 ± 1.21 0.64 0.81 0.88 SF10
SpR
1.5 finding access to a spiritual 2.48 ± 1.17 0.62 0.78 0.88 SF10
source can have a positive
influence on illness
1.4 illness has brought renewed 2.39 ± 1.19 0.60 0.73 0.89 SF10
interest in SpR questions
1.1 regard myself as a spiritual 3.20 ± 0.96 0.80 0.71 0.90 –
person

(2.77 [mean value]/4 = 0.69) is given in Table 3. With the exception of item 2.6, all
values were in the acceptable range from 0.2 to 0.8; this means that the statement (‘‘regard
myself as a religious person’’) has a ceiling effect in the predominantly Catholic Polish
population.

Reflection Scale: Meaning/Chance

The items had a good internal consistency coefficient (a = 0.75). The frequency distri-
bution of the items and the item difficulty (2.45 [mean value]/4 = 0.61) are given in
Table 4. All values were in the acceptable range from 0.2 to 0.8; this means there are no
bottom or ceiling effects in the responses.

Confirmatory Factor Analysis

Using confirmatory factor analysis (performed in the AMOS 21.0 using the method ADF),
we obtained a model which fits the data well (v2(32) = 42.95, p = .094, CMIN/
DF = 1.34, CFI = 0.96, RMSEA = 0.035) and specifies the relationship between the
three factors: F1—Search, F2—Trust, and F3—Reflection.
As shown in Fig. 1, three items (F1.6 searching for an access to SpR, F1.9 urged to
spiritual/religious insight, and F1.4 illness has brought renewed interest in SpR questions)
would enter the Search factor, four items (F 2.5 trust in a higher power, f 37 I have faith in
the spiritual guidance in my life, f 38 connected with a ‘‘higher source’’, and f 39 death is
not an end) the Trust factor, and three the Reflection factor (F 3.4 illness has meaning, F3.5
illness as a chance for development, and F3.2 illness as a hint to change life). Items with
too low values of factor loadings were not included in the respective factors. In addition, all
the factors are correlated with each other strongly (p \ 0.001).
Because we intended to compare the data of the Polish sample with other patient
sample, we will use the respective scales with all items verified by exploratory factor
analysis. The scales referring to the ten items verified by confirmatory factor analysis will
be indicated as shortened versions (SV).

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Table 3 Mean values and reliability analysis of the Trust scale

Item phrasing and Mean ± standard Item Corrected item, a if item
identifying item number deviation (0–4) Difficulty scale deleted
Index (=0.69) correlation (a = 0.754)

2.5 trust in a higher 2.97 ± 1.13 0.74 0.60 0.66 SF10

power
2.6 regard myself as a 3.33 ± 0.96 0.83 0.57 0.68 –
religious person
39 death is not an end 2.07 ± 1.18 0.52 0.52 0.70 SF10
38 connected with a 2.68 ± 1.06 0.67 0.51 0.70 SF10
‘‘higher source’’
37 I have faith in the 2.78 ± 1.15 0.69 0.37 0.75 SF10
spiritual guidance in
my life

Validity

In the Catholic Polish sample, all SpREUK scales were strongly intercorrelated (r [ .50)
(Table 5). Both the long form and also the corresponding shortened form of the respective
scales were very strong connected (r [ .90). With respect to the external measures, the
SpREUK scales (both long and short versions) correlated strongly with respect to SQS’s
Religious attitudes, Positive Emotions toward God, and engagement in Religious practices.
With respect to Ethical sensitivity and Harmony and also engagement in Humanistic
practices, the correlations were moderate. Experience of Gratitude/Awe correlated strongly
with the Reflection scale, and moderately to strongly with Trust and Search.
However, life satisfaction correlated weakly with Trust and Reflection, but not with
Search; similarly, escape from illness correlated weakly (negative) with Trust and
Reflection, but not with Search (Table 5). Negative emotions associated with God were
weakly (negative) associated with the SpREUK scales.

Influencing Socio-demographic Variables

Due to the fact that some items of the 15-item version of the SpREUK were not included in
the shortened Polish version confirmed by CFA, the mean scores of the shortened scales
were lower than the long version scores (Table 6).
As shown in Table 6, the mean scores of the SpREUK subscales differed significantly
with respect to gender and SpR self-categorization (Table 6), while there were no sig-
nificant differences for diseases (cancer versus other), partner status (living with or without
a partner), or education (data not shown),

Predictor Analyses

Because we empirically investigated several variables that could have influenced patients’
spiritual attitudes and convictions in terms of their coping with illness, we performed
stepwise regression analyses to identify the most significant predictors (Table 7). The
variables which were recognized to have a significant impact on the scales included
gender, self-described Spirituality (SQS) scales, positive emotions toward God, and
engagement in spiritual/religious practices (SpREUK-P SV).

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Table 4 Mean values and reliability analysis of the Reflection scale

Item phrasing and Mean ± standard Item Corrected a if item
identifying item number deviation (0–4) Difficulty item, scale deleted
Index (=0.63) correlation (a = 0.754)

3.4 illness has meaning 2.06 ± 1.16 0.51 0.67 0.65 –

3.5 illness as a chance for 1.89 ± 1.19 0.47 0.71 0.64 –
development
3.2 illness as a hint to 2.75 ± 1.22 0.69 0.47 0.73 SF10
change life
3.7 reflect on what is 2.84 ± 1.03 0.71 0.46 0.73 SF10
essential in life because of
the illness
3.3 illness encourages me to 2.69 ± 1.05 0.67 0.32 0.77 SF10
get to know myself better

Fig. 1 Graphical representation of the structural model of the SpREUK-Polish. In the upper right corner of
the variable contains information about the percentage of explained variance of the variable. Other values
are standardized estimates of the relationship

Search can be predicted best (R2 = .63) by Religious attitudes (SQS), with fur-
ther influences of engagement in various spiritual practices and reduced life
satisfaction.

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Table 5 Correlation analyses

Search Search— Trust Trust— Reflection Reflection—
SV SV SV

SpR attitudes and convictions (SpREUK)

Search 1 .972** .741** .675** .702** .728**
Search—SV 1 .690** .632** .673** .700**
Trust 1 .980** .833** .799**
Trust—SV 1 .809** .772**
Reflection: meaning/ 1 .932**
chance
Reflection—SV 1
Emotions associated with God
Negative .007 -.006 -.013 -.001 .030 .039
Positive .577** .550** .647** .585** .595** .595**
Self-description of spirituality (SQS)
Religious attitudes .798** .762** .722** .631** .692** .734**
Ethical sensitivity .452** .417** .497** .489** .420** .390**
Harmony .384** .385** .401** .418** .370** .417**
Engagement in specific practices (SpREUK-P SF17 Polish)
Religious practices .718** .680** .658** .569** .654** .681**
Humanistic practices .334** .320** .344** .346** .364** .341**
Existentialistic practices .274** .269** .272** .314** .274** .265**
Gratitude/awe .493** .499** .466** .455** .504** .527**
Life satisfaction/escape
Life satisfaction .065 .045 .224** .228** .201** .202**
Escape from illness -.021 -.010 -.172** -.173** -.186** -.201**

** p \ 0.01 (Pearson)

Trust can be described best (R2 = .52) by patients’ Religious attitudes (SQS), and
further influences of engagement in Existentialistic practices, positive emotions toward
God, and Ethical Sensitivity (SQS).
Reflection can be predicted best (R2 = .61) by Religious attitudes (SQS), followed by
engagement in various spiritual practices and positive emotions toward God.
Gender was not a significant predictor in any of the regression models.
Since the regression coefficients may be compromised by collinearity, we checked the
Variance Inflation Factor (VIF) as an indicator for collinearity. A VIF higher than 10 is
indicative of high collinearity. Results suggest that a VIF was not present in the respective
models.

Discussion

The SpREUK was primarily designed to be used in secular societies with both religious/
spiritual and secular patients. However, the Polish sample consists of 100 % Catholics, and
thus, there was less variance among the different patients who would regard themselves as
religious (85 %) rather than spiritual but not religious (2 %) or neither religious nor

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Table 6 Mean values and standard deviation of SpREUK scores

Search Search—SV Trust Trust—SV Reflection Reflection—SV

All patients
Mean 66.20 62.79 68.97 65.42 66.39 61.24
SD 24.24 26.37 19.69 20.66 20.54 24.31
Gender
Women
Mean 69.47 65.80 72.06 68.43 68.99 64.53
SD 22.33 25.06 18.42 19.91 19.46 23.24
Men
Mean 56.98 54.28 60.26 56.92 59.05 51.97
SD 27.04 28.25 20.64 20.52 21.84 25.04
F value 14.8 10.5 20.5 17.5 13.0 14.9
P value \.0001 .001 \.0001 \.0001 \.0001 \.0001
SpR self-categorization
Religious
Mean 72.05 68.56 73.71 69.22 70.65 66.24
SD 20.13 23.10 16.09 18.67 18.27 21.78
Non-religious
Mean 32.44 29.47 41.31 42.94 41.83 32.72
SD 17.18 18.08 14.63 16.45 15.03 17.81
F value 140.6 105.9 145.0 71.5 91.1 86.7
p value \.0001 \.0001 \.0001 \.0001 \.0001 \.0001

spiritual (13 %). Testing the primary SpREUK scales as independent item pools with an
exploratory factor analysis approach indicated that the respective scales were retained.
Nevertheless, confirmatory factor analysis indicated that 5 items had to be removed from
the item pool. Thus, the SpREUK questionnaire in its Polish version (SpREUK-Polish)
uses three items for Search scale, four items for the Trust scale, and three items for the
Reflection scale.
These scales could be used to differentiate specific attitudes and convictions (albeit in
the Polish population); in contrast to more secular patients from Germany (Büssing et al.
2005a, 2009a, b; Büssing 2010), these attitudes were strongly intercorrelated.
To compare the SpREUK with an instrument which was developed for validation with
Polish individuals, we used the Self-description Questionnaire of Spirituality (SQS)
(Heszen-Niejodek et al. 2003). Its main scale, Religious attitudes, involves items such as
‘‘faith allows me to survive difficult periods in my life’’ and ‘‘while making decisions, I
rely on my religious beliefs’’. Regression analyses revealed that the scale Religious atti-
tudes was the best predictor of all SpREUK scales. This indicates that not only patients’
Search and Trust, but also their ability to reflect about life (in terms of a cognitive
reappraisal of life because of illness and subsequent attempts to change), has a strong
religious connotation in Polish patients.
With respect to patients’ engagement in various religious and non-religious spiritual
activities, the SpREUK scales correlated strongly with Religious practices, while both the
Search scale and the Reflection scale correlated weakly to moderately with patients’

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Table 7 Regression analyses with the SpREUK scales as dependent variables (stepwise method)
b T p Collinearity statisticsa

Tolerance VIF

Dependent variable: Search-SV (R2 = .63)

Model 5
(Constant) -1.626 .105
SQS’s religious attitudes .592 9.396 .000 .345 2.895
Existentialistic practices .120 2.973 .003 .844 1.185
Gratitude/awe .128 2.727 .007 .619 1.615
Life satisfaction -.102 -2.657 .008 .924 1.082
Religious practices .132 2.087 .038 .341 2.931
Dependent variable: Trust-SV (R2 = .52)
Model 4
(Constant) -2.459 .015
SQS’s religious attitudes .323 5.176 .000 .464 2.156
Existentialistic practices .194 4.368 .000 .914 1.095
Positive emotions toward god .293 4.947 .000 .515 1.942
SQS’s ethical sensitivity .160 3.194 .002 .716 1.397
Dependent variable: Reflection-SV (R2 = .61)
Model 5
(Constant) -2.677 .008
SQS’s religious attitudes .400 5.480 .000 .275 3.632
Gratitude/awe .140 2.904 .004 .631 1.585
Religious practices .186 2.843 .005 .341 2.934
Positive emotions toward god .146 2.719 .007 .506 1.977
Existentialistic practices .102 2.449 .015 .840 1.190
a
Because the regression coefficients may be compromised by collinearity, we checked the variance
inflation factor (VIF) as an indicator for collinearity. VIF [ 10 is indicative of high collinearity

engagement in Existentialistic and Humanistic practices; patients’ ability to experience

Gratitude/Awe was strongly related particularly to the Reflection scale.
While the scale Religious attitudes was the best predictor of Polish patients’ Search for
support, religious Trust in higher guidance, and Reflection, also the patients’ engagement in
Existentialistic practices, Religious practices, and Gratitude/Awe, (but not Humanistic
practices) had a significant influence on the SpREUK scales. Albeit desired behaviors in
Christianity, it seems that helping others, considering the needs of others, being with the
thoughts with those in need, and doing good are not among the predictors of Search, Trust,
and Reflection. However, this engagement in Humanistic practices was only moderately
correlated with the SpREUK scales.
In line with this, positive emotions toward God were among the best predictors of both
religious Trust and the ability to Reflect on one’s own life concerns. However, not only
patients’ life satisfaction but also depressive intentions to escape from illness were either
not at all or only weakly associated with the SpREUK scales indicating independent
dimensions.

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Although Polish religiosity had been extremely ‘‘Church-oriented’’, in the past decade it
has changed. According to research, up to 97 % identify themselves as Roman Catholics
(Boguszewski 2012; CBOS 2009; Zarzycka 2008). Polish individuals identified as the most
important aspects of religiosity in their life a belief in the existence of God, personal
prayer, public practice of their religion, a belief in eternal life and living in accordance with
religious commandments. This is supported by the current data using the SpREUK scales.
Today, Polish people stay religious, yet many become engaged in more private and
more intrinsic ways of religiosity. In several cases, people’s religiousness does not include
the Church as an indispensable element (CBOS 2009; Zarzycka 2008).
Taken together, the factorial structure of SpREUK in its Polish version was approved by
confirmatory factor analysis. The respective Search, Trust, and Reflection scales correlated
strongly with external measures used in some other studies enrolling Polish individuals,
such as Religious attitudes (SQS), positive emotions associated with God, and engagement
in various spiritual practices, which would indicate validity of the construct. To assess
important aspects of spirituality/religiosity relevant for patients with chronic diseases both
in secular and religious societies, the SpREUK questionnaire appears to be a good choice.
The instrument is currently available in English, German, Arabic, Hebrew, Spanish, and
now also in Polish language. It may be obtained for epidemiological/clinical studies in
Polish individuals by the authors of this paper.

Acknowledgments We are grateful to Iwona Pilchowska who performed the confirmatory factor analysis.

Conflict of interest The authors disclose any direct conflict of interest. The work was not funded by any
religious, governmental, or non-governmental organization.

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