Spiritual Coping Strategies (SCS) Scale Research

Background of the Study

The study of religion and spirituality has been gaining much attention to researchers nowadays. Research studies on these two areas and their relationship to health are expanding rapidly. (Koenig & Büssing, 2010) The relationship of religion and health has been existing in all groups of population even in the past. (Koenig, King, & Carson, 2012 as cited by Koenig, 2012) Koenig (2012) comprehensive systematic review of existing research about the relationship of religion and spirituality to health revealed positive influence of religion and spirituality to patients’ health and longevity, specifically to psychological, social and health behavior. Religion offers resources for coping with stress and increases the positive emotions rather than the likelihood of the negative effects of stress. On the part of the healthcare providers, religious beliefs found to be influential in making medical decisions. Furthermore, it may generate beliefs that conflict with medical care, induce spiritual struggles that create stress and impair health outcomes and it may interfere with disease detection and treatment compliance (Koenig, 2004). While Christian dominated countries in the west have been serious in this area, there is a much lesser studies that has been done in the Muslim – dominated Middle East countries that examines the relationship of these variables to health. (Koenig &Alshohaib, 2014) This holds true in Saudi Arabia where Islam was born and is considered as one of the most religious place in the world. Little is known about religiosity and spirituality and their relationship to health as perceived by Saudi Muslims. (Al Zaben, et al., 2014)

For the last three decades, there has been a marked rise in the prevalence of End Stage Renal Disease (ESRD) in Saudi Arabia. (Al-Sayyari & Shaheen, 2011) Alsuwaida et. al (2010) reported in their study that the prevalence of ESRD in the young Saudi population is around 5.7%. Furthermore, a systematic review conducted by Hassanien, et. al (2012) reported yearly mortality rate in three different regions in Saudi Arabia. The data showed that between 2001 and 2003, there were no significant changes in the mortality rates of these regions. However, at present, the annual cases of ESRD in the country continue to grow. It was anticipated that the Saudi population will rise up to 3.5 folds over the next 20 years. Probably this will also cause a rise in new cases. In 2008, 2976 new patients were added to the hemodialysis program pool. This represents 29.2 % of the total 10,203 patient. (Al-Sayyari & Shaheen, 2011)

Patients undergoing dialysis experience serious challenges to their physical and mental health. These challenges are brought by stresses, fears, family problems, and physical discomforts. (Al Zaben, et al., 2014) In addition, the complexity of their treatment regimen as well as the unknown complications which are associated with such disease contributes to the suffering of these patients. (Lingerfelt & Thornton, 2011; Barnett, Yoong, Pinikahana, & Si-Yen, 2007). These patients also perceive uncertainty of life on dialysis because of the struggles and hard times that they experience in life as related to their mode of treatment. (Polascheck, 2003) Likewise, psychiatric disorders such as major depression, dementia and delirium are relatively high in these patients. Furthermore, coping problems are very common to these patients which if not addressed can lead to more serious problems such as higher mortality. (Kimmel et al. 1998; Drayer et al. 2006; Chilcot et al. 2011; Mapes et al. 2003; Al Zaben, 2014)

The involvement of religion and other spiritual activities are widely used by patients to cope with physical and mental challenges that they face throughout the course of their disease. (Saad & de Medeiros, 2012; Wachholtz & Sambamoorthi, 2011; Amjad & Bokharey, 2014) Patients from Saudi Arabia have shown similar use of these variables as ways of coping. Interventions with religious background are widely used which indicates the strong influence of religion to their lives most especially when they are in life-threatening situations such as in chronic illnesses. (Jazieh et al. 2012) Religious and spiritual coping are widely studied in relation with hemodialysis patients both in Christian and non – Christian patients. (Valcanti, Chaves, Mesquita, Nogueira & Carvalho, 2012; Saffari, Pakpour, Naderi, Koenig, Baldacchino & Piper, 2013; Spinale et al. 2008; Asayesh, Zamanian, & Mirgheisari, 2013; Patel, Shah, Peterson & Kimmel, 2002; Berman et al. 2004) Studies have reported that spiritual coping affects the over-all health of patients with ESRD. It also assists in the patients’ adaptation as well as in their health – related quality of life. (Patel, Shah, Peterson & Kimmel, 2002; Valcanti, Chaves, Mesquita, Nogueira & Carvalho, 2012; Ramirez et al. 2012) Thus, religiosity is potentially influential to the overall health of dialysis patients, including their commitment and compliance to dialysis treatment. (Pruchno, Lemay, Field & Levinsky, 2006)

In Saudi Arabia, researchers are beginning to focus on this area in Hemodialysis patients. Al-Jahdali et al. (2009) surveyed 100 HD patients at King Fahd National Guard Hospital in Riyadh and King Abdulaziz University Hospital in Jeddah about predictors of advanced care planning preferences. They reported that majority (70%) of the patients scored high in a single question religiosity scale. However, they found out that religiosity is not identified as a predictor of advanced care planning preferences. A more recent study was conducted by Al Zaben et al. (2014) to examine the relationships between religious involvement and the mental and physical health of HD patients in Jeddah region. They have found out that involvement in religious activities is associated with better overall psychological functioning, better social support, improved physical and mental functioning, better health behavior and better commitment to dialysis treatment.

Because of the increasing interest of researchers in Saudi Arabia in this area, it is essential to have an instrument that can accurately measure the spiritual coping of patients. Majority of the available instruments in this area were structured for Christian patients. (Baldacchino & Buhagiar, 2003; Koenig & Büssing, 2010; Hawthorne, Youngblut & Brooten, 2011; Charzynska, 2012) To my knowledge, there is no available valid instrument that measures the spiritual coping strategies of Saudi Muslim HD patients. It is for this reason that this study was conducted. The aim of this study was to evaluate the validity and reliability of the Arabic version of the Spiritual Coping Strategies Scale (SCS) among Saudi HD patients.



This is a cross-sectional study that evaluated the validity and reliability of the Saudi Muslim version of the Spiritual Coping Strategies Scale (SCS) among hemodialysis patients.


The participants of the study included _______ patients enrolled and undergoing hemodialysis in the HD unit of a general hospital located in Riyadh Province, Saudi Arabia. Convenience sampling technique was employed for sample identification. The study participants’ number was adequate for a factorial analysis. Inclusion criteria were: (1) being a Saudi, (2) self-identified Muslim, (3) being HD patient with CRF or ESRD, (4) enrolled in the HD unit of the general hospital, (5) 20 years old and above, (6) male and female, and (7) conscious, coherent and oriented.


Demographic Characteristics

Patient’s information in the patient’s chart was examined to collect the data for their demographic characteristics. These included: (1) age, (2) gender, (3) religion, (4) civil status, (5) employment, and (6) duration of undergoing HD.

Spiritual Coping Strategies Scale

The Spiritual Coping Strategy Scale (SCS), developed by Baldacchino and Buhagiar (2003), is a self – administered questionnaire that determines the spiritual coping of the respondents. It has a Judeo-Christian orientation and was based on the nursing, psychological, sociological, philosophical and theological literature. The SCS scale was developed in English and then translated into the Maltese language. It is a scale that measures both religious and spiritual (nonreligious) coping strategy which constituted its two subscales. It measured the respondents’ attitude towards religion and belief in God. The SCS is a 20-item, 4 – point response scale from “never used” or 0 to “often used” or 3. The responses indicated how often they use the various coping strategies presented. The Religious Coping subscale was comprised of 9 items which were meant to assess the respondents’ attitude towards their religious practices and their relationship to God. On the other hand, the Spiritual Coping subscale has 11 items which relates to coping strategies that involve relationship to self, others and nature. The scores of all items is ranging from 0 to 60. A higher subscale and total scale score indicated more frequent use of the religious or spiritual coping strategies. The internal consistency reliability of the religious and spiritual coping factors was 0.82 and 0.74, respectively. A test – retest reliability of r=0.47 and r=0.81 for the subscales and total scale, respectively, was also reported. (Baldacchino & Buhagiar, 2003) The SCS was earlier translated to Italian (Burrai, Scalorbi, Sebastiani, Cenerelli & Cocchi, 2009), Spanish (Hawthorne, Youngblut & Brooten, 2011) and Farsi (Saffari, Koenig, Ghanizadeh, Pakpour & Baldacchino, 2014) languages. Validity and reliability of these versions were established accordingly.

Muslim Religiosity Scale

This is a 13 – items scale that measures the religiosity of Muslim population. It has two subscales. The first subscale is a 10 – item religious practices scale while the second subscale is a 3 – items intrinsic religious beliefs scale. Validity and reliability of the scale was earlier established with a Cronbach’s alpha of 0.68, 0.64 and 0.93 for the full scale, religious practices scale and intrinsic beliefs scale, respectively. (Koenig, Al Zaben, Khalifa & Al Shohaib, 2014; Al Zaben et al. 2014) The Arabic version of the scale was utilized in this study.

Quality of Life Index Dialysis Version III

The Ferrans and Powers Quality of Life Index Dialysis (QLI) Version-III measures the HRQoL of the HD patients. This scale has four subscales which includes health and functioning subscale, social and economic subscale, psychological/spiritual subscale, and family subscale. The QLI has two parts. The first part measures the satisfaction of the respondents and the second part measures the importance of the various aspects of life. The ratings in the second part are used to weight the satisfaction responses. Items that are rated with higher importance have a greater effect on scores than those of lesser importance. Overall quality of life as well as scores in the four domains is calculated. A score of 19 and lower means poorer quality of life. Validity and reliability of the QLI Dialysis Version was reported somewhere else with a Cronbach’s alpha of 0.93. Likewise, the four subscales exhibited acceptable validity and reliability. Content validity was good as it was based from extensive literature reviews on HRQoL and with patients’ report. (Ferrans, 1996; Ferrans & Powers, 1985; Ferrans & Powers, 1992) The Arabic version of the Quality of Life Index Dialysis (QLI) Version-III was used in this study.

Translation and Cross – Cultural Adaptation of the SCS

The translation and cross – cultural adaptation of the SCS followed the cross-cultural adaptation of self-report measures guidelines for translation. (Beaton, Bombardier, Guillemin & Ferraz, 2000) The guideline suggests five stages: (1) translation, (2) synthesis, (3) back translation, (4) expert committee review, and (5) pretesting. In this study, the cultural and religious context of Saudi Arabic language was considered in the translation process.

The first step of the adaptation is the forward translation. Two independent forward translations were made from English to Arabic by two bilingual Saudi nationals. One of them is a nurse educator who specializes in mental health nursing. The other Saudi is a lecturer with specialization in English language. After the translations have been done, the two translators together with an observer met to synthesize the result of the translation. A consensus from the two translators signified the completion of the Saudi Arabic version of the SCS. The Arabic version was then presented to two non-medically inclined translators who translated it back to English. These two translators were unaware of the concept as well as the purpose of the scale. The Arabic version was then presented to a panel which comprised of a: (1) Muslim religious leader; (2) Islam scholar, (3) nurse clinician, (4) nurse researcher, and (5) translator. The committee decided for the cultural and religious equivalence of each items in the scale. After reaching a consensus, the pre-final Arabic version of the SCS was formed. The pre-final Arabic version was then subjected for pilot testing for validity and reliability.

……… (Add modifications done here)

Data Collection

Data gathering was performed from May to June 2015. The SCS Arabic version, the Muslim Religiosity Scale Arabic version and the Ferrans and Powers Quality of Life Index Dialysis (QLI) Version-III Arabic version was distributed to the respondents by the researchers with the assistance of the nurses on duty. The nurses where properly informed about the purpose and procedure of the study. The respondents were given 20 to 25 minutes to respond to the scales. Three weeks after the initial data collection, the same questionnaires were redistributed to a subsample of 25 respondents. (Hawthorne, Youngblut & Brooten, 2011)

Ethical Consideration

Ethical approval was granted by the Ethical Review Board of Shaqra University. Permission to conduct the study was sought from the administration of the general hospital. Modification and translation of the original version of the SCS to Arabic language was permitted by the original authors. The respondents were asked prior to participation to sign the informed consent signifying their understanding of their voluntary participation to the study. No incentives were offered to the respondents for their participation.

Statistical Analysis

All statistical analyses were done using the SPSS version 21.0. Internal consistency reliability of the Arabic version was assessed with coefficient alpha and item–total correlation (ITC). An alpha higher than 0.70 was considered acceptable internal consistency reliability while an ITC between 0.30 and 0.50 is considered moderate and ITC higher than 0.50 means good.

Exploratory factor analysis was conducted to assess the factor structure of the SCS Arabic version. Kaiser – Meyer – Olkin (KMO) index was computed to check for sampling adequacy. KMO value equal to or higher than 0.6 indicate sampling adequacy. Further, to determine whether the correlations among variables were appropriate for the factor model, the Barlett’s test of sphericity was used. A Barlett’s test of sphericity with p< 0.05 indicates that the variables are uncorellated in the population and the data are factorable. (Saffari, Zeidi, Pakpour, & Koenig, 2013)

The stability reliability for the test–retest subsample of the translated scale was assessed with Pearson product moment correlations.

Convergent validity was established by examining the association between spiritual coping and religiosity. Divergent validity was established by the relationship between spiritual coping and health-related quality of life. Both were tested using Pearson product moment correlations. Differences between demographic profiles on the spiritual coping strategies using the SCS Arabic version were also examined using t-test and One-way ANOVA. A p-value less than 0.05 was considered significant.