Spirituality Index of Well-Being (SIWB)

1. Abstract

The Spirituality Index of Well-Being (SIWB) is an empirically validated, 12-item psychometric instrument developed to assess an individual’s perception of their spiritual quality of life and subjective spiritual health. Conceived by Bruce B. Frey, Timothy P. Daaleman, and Vichki Peyton, the instrument addresses a longstanding methodological challenge in health-related quality of life (HRQoL) research: measuring spirituality without conflating it with formal religious practices, sectarian dogmas, or institutional affiliations. Grounded in a conceptual framework that defines spirituality as a sense of meaning, purpose, and personal efficacy derived from an internal or transcendent source, the SIWB captures the functional manifestations of spiritual well-being in everyday coping and existential understanding.

The instrument is divided into two distinct, six-item subscales: the Self-Efficacy subscale and the Life-Scheme subscale. Items are scored on a five-point Likert scale ranging from 1 (“Strongly Agree”) to 5 (“Strongly Disagree”). All items are worded in a reverse-valenced direction, assessing existential distress, perceived helplessness, or a lack of purpose; when reverse-scored, higher composite values reflect higher levels of spiritual well-being. Psychometric evaluations across diverse adult, geriatric, and clinical populations have demonstrated exceptional reliability, with total scale Cronbach’s alpha coefficients ranging from 0.87 to 0.91, Self-Efficacy alpha coefficients ranging from 0.83 to 0.86, and Life-Scheme alpha coefficients ranging from 0.80 to 0.89. The SIWB exhibits robust construct, convergent, and discriminant validity, demonstrating positive associations with psychological well-being, life satisfaction, and subjective health, alongside inverse relationships with depressive symptomatology and hopelessness. It serves as a vital clinical and research tool across primary care, palliative medicine, psycho-oncology, and gerontological health research.

2. Keywords

Spirituality Index of Well-Being, SIWB, spiritual well-being, existential health, self-efficacy, life-scheme, health-related quality of life, psychometrics, palliative care assessment, meaning in life

3. Authors

The Spirituality Index of Well-Being was conceived, developed, and psychometrically validated through collaborative interdisciplinary investigations led by researchers in educational psychology, psychometrics, and family medicine:

• Timothy P. Daaleman, DO, MSPH: Professor of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine. Dr. Daaleman is an internationally recognized physician-investigator whose research centers on palliative care, chronic illness trajectories, and the integration of religion, spirituality, and culture into patient-centered clinical care.
• Bruce B. Frey, PhD: Professor of Educational Psychology and Research Methodology at the University of Kansas. Dr. Frey specializes in classroom assessment, scale development, structural equation modeling, and health measurement design.
• Vichki Peyton, PhD: Methodologist and psychometrician associated with the University of Kansas, contributing extensive expertise in psychometric factor modeling, item response evaluation, and construct validation.
• Additional Developmental Collaborators: Dennis Wallace, PhD, and Stephanie A. Studenski, MD, MPH, who participated in initial pilot studies and clinical validation trials within geriatric outpatient environments at the University of Kansas Medical Center.

4. Purpose

The primary objective of the Spirituality Index of Well-Being (SIWB) is to provide clinicians, behavioral scientists, and healthcare researchers with a concise, non-sectarian, and functionally oriented metric of spiritual quality of life. Historically, empirical investigations into spirituality and health have been hindered by instruments that heavily conflate spirituality with institutional religion—relying on proxy items such as church attendance, frequency of prayer, or doctrinal adherence. Such operationalizations introduce profound demographic and conceptual bias, rendering scales inadequate for secular, agnostic, non-affiliated, or religiously unorthodox individuals, while obscuring whether positive outcomes stem from spiritual peace or social support networks.

To overcome these limitations, the authors developed the SIWB specifically to capture how a person’s underlying spiritual foundation facilitates daily adaptive functioning, problem-solving, and existential coherence. Rather than surveying religious behaviors or abstract metaphysical beliefs, the SIWB examines the operational consequences of an individual’s existential framework. It investigates whether respondents feel equipped to navigate profound life disruptions (Self-Efficacy) and whether they experience their personal existence as grounded in overarching purpose, direction, and significance (Life-Scheme).

The clinical and research applications of the SIWB are extensive:

• Primary and Palliative Care: Identifies existential suffering, demoralization, and spiritual crisis among patients coping with life-limiting illnesses, terminal diagnoses, or debilitating chronic conditions.
• Geriatric Medicine: Assesses spiritual reserves and resilience in aging populations facing cumulative functional decline, bereavement, cognitive transitions, and role loss.
• Psycho-Oncology: Evaluates interventions (such as meaning-centered psychotherapy or dignity therapy) designed to restore personal meaning and agency in patients undergoing cancer treatment.
• Cross-Sectional and Longitudinal Health Research: Enables epidemiologists and health psychologists to model spiritual well-being as a mediator or moderator of physical health outcomes, treatment adherence, health-related quality of life, and mortality without confounding spirituality with sociodemographic religious indicators.

5. Psychological Construct

The Spirituality Index of Well-Being defines spirituality as a personal dimension of human experience characterized by a sense of meaning or purpose derived from a transcendent perspective—whether that transcendence is understood in relation to God, the cosmos, nature, humanity, or a deeply held philosophical truth. The instrument conceptualizes spiritual quality of life through two distinct, yet intimately interrelated psychological constructs: Self-Efficacy and Life-Scheme.

Self-Efficacy Subscale (Items 1–6)

The Self-Efficacy subscale operationalizes spirituality as an existential resource that equips the individual with agency and personal empowerment when confronting adversity, psychological trauma, or severe illness. Within the SIWB framework, spiritual self-efficacy does not refer merely to generic self-confidence; rather, it reflects an internal conviction that one possesses the personal and transcendent resources needed to understand, confront, and work through life’s most challenging circumstances.

Items in this subscale capture the negative spectrum of efficacy—specifically, feelings of helplessness, paralysis in problem-solving, and cognitive or emotional overwhelm when facing distress. For instance, Item 1 (“There is not much I can do to help myself”) and Item 4 (“I am overwhelmed when I have personal difficulties and problems”) assess whether an individual’s spiritual perspective serves as an internal buffer against perceived helplessness. An individual with high spiritual self-efficacy maintains a sense of mastery and navigational competence even when external outcomes cannot be controlled, perceiving adversity not as an insurmountable catastrophe, but as a condition within which personal choice, growth, and coping remain possible.

Life-Scheme Subscale (Items 7–12)

The Life-Scheme subscale captures the overarching structural meaning, identity, and purposeful coherence that an individual attributes to their trajectory in the world. Derived conceptually from existential philosophy and cognitive appraisal theories, a “life-scheme” represents an internal cognitive-affective map that answers fundamental existential questions: Who am I? What is my purpose? Where do I belong in the broader cosmos?

Items within this subscale assess existential alienation, purposelessness, and internal emptiness. Item 8 (“I don’t know who I am, where I came from, or where I am going”) evaluates foundational identity and ontological continuity, while Item 12 (“There is a great void in my life at this time”) measures subjective existential emptiness or demoralization. Conversely, an integrated life-scheme provides respondents with an anchor of belonging and intentionality (Item 10: “In this world, I don’t know where I fit in”). Individuals with an intact, robust life-scheme experience their lives as directed toward meaningful goals, perceive themselves as belonging to a larger whole, and derive continuity across their past, present, and future.

6. Theoretical Framework

The development and validation of the SIWB integrate foundational tenets from the Biopsychosocial-Spiritual Model of health, Albert Bandura‘s Social Cognitive Theory of Self-Efficacy, Viktor Frankl‘s Logotherapy and Existential Analysis, and Aaron Antonovsky‘s Salutogenic Model of Health.

The Biopsychosocial-Spiritual Model

Broadening George Engel’s classic biopsychosocial framework, scholars such as Sulmasy (2002) and Daaleman et al. (2001) emphasized that human health and disease cannot be comprehensively comprehended without addressing the spiritual dimension. Spirituality is viewed as an intrinsic component of human wholeness that interacts dynamically with neurobiological processes, affective states, and social support systems. The SIWB was designed precisely to serve as the operationalized spiritual pillar within this integrated paradigm, enabling medical research to evaluate spiritual wellness on par with biological and psychosocial markers.

Bandura’s Self-Efficacy Theory

Bandura defined self-efficacy as an individual’s belief in their capability to execute behaviors necessary to produce specific performance attainments. In the context of existential psychology and health coping, spiritual self-efficacy represents the application of efficacy beliefs to existential threats, suffering, and mortality. When individuals experience profound physical pain or life-altering medical prognoses, biomedical interventions may offer limited relief. In such states, an internal spiritual foundation provides an ultimate coping mechanism, reinforcing the belief that the self can remain dignified, composed, and purposeful despite external vulnerability.

Frankl’s Logotherapy and Antonovsky’s Sense of Coherence

The Life-Scheme dimension draws heavily from Viktor Frankl’s premise that the “will to meaning” is the primary motivational drive in human beings. Frankl observed that individuals can endure extreme suffering provided they perceive a meaning, task, or purpose within that experience. When meaning breaks down, an individual falls into what Frankl termed the “existential vacuum”—a state characterized by profound void, apathy, and alienation. Items 7 through 12 of the SIWB operationalize this existential continuum, capturing the difference between an integrated, purposeful existence and the presence of an existential void.

This perspective closely mirrors Aaron Antonovsky’s concept of the Sense of Coherence (SOC) within salutogenic theory. Antonovsky posited that individuals stay healthy and adaptively manage severe stressors when they perceive the world as comprehensible (structured, predictable, explicable), manageable (having sufficient resources to meet demands), and meaningful (viewing demands as challenges worthy of investment). The SIWB’s Self-Efficacy subscale aligns directly with manageability, while the Life-Scheme subscale mirrors comprehensibility and meaningfulness.

7. Validity

Extensive psychometric investigations have established the construct, convergent, discriminant, and predictive validity of the Spirituality Index of Well-Being across both community-dwelling and clinical populations (Daaleman & Frey, 2004; Frey, Daaleman, & Peyton, 2005).

Content and Face Validity

The initial generation of items was grounded in extensive qualitative research conducted by Daaleman, Cobb, and Frey (2001), who conducted in-depth interviews with diverse patient cohorts regarding their lived experiences of spirituality and health. Themes extracted from these qualitative narratives directly informed the conceptualization of the original item pool. Expert review panels consisting of physicians, psychometricians, chaplains, and behavioral scientists refined the items to ensure semantic clarity, non-sectarian language, and functional relevance to clinical populations.

Convergent Validity

Convergent validity has been repeatedly demonstrated through statistically significant, theoretically consistent correlations with established psychological and spiritual measures:

• Life Satisfaction: Demonstrates strong positive correlations with the Satisfaction with Life Scale (SWLS) ($r = 0.55$ to $0.68, p < 0.001$), confirming that spiritual well-being is an integral contributor to global subjective well-being.
• Health-Related Quality of Life: Displays significant positive associations with the Mental Health Composite Scale (MCS) of the Medical Outcomes Study 36-Item Short Form Survey (SF-36) ($r = 0.42$ to $0.58, p < 0.001$).
• Established Spiritual Inventories: Exhibits moderate-to-high correlations with other validated spiritual assessment tools, including the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being (FACIT-Sp) ($r = 0.65$ to $0.74$) and the Spiritual Well-Being Scale (SWBS) of Paloutzian and Ellison ($r = 0.60$ to $0.72$).

Discriminant Validity

Crucially, the SIWB exhibits robust discriminant validity when contrasted with measures of formal religiosity and sociodemographic variables:

• Religious Participation and Attendance: Shows weak correlations ($r < 0.20$, frequently non-significant) with frequency of church attendance, religious affiliation, or frequency of private devotional acts. This empirical independence confirms that the SIWB measures spiritual quality of life rather than religious observance.
• Social Desirability: Correlations with the Marlowe-Crowne Social Desirability Scale are negligible to low ($r < 0.15$), confirming that scores are not driven by impression management.
• Physical Functioning: Displays only weak correlations with physical health subscales (e.g., SF-36 Physical Functioning, $r = 0.12$ to $0.22$), illustrating that spiritual well-being remains psychometrically distinct from physiological impairment.

Predictive and Criterion Validity

The SIWB has demonstrated exceptional predictive utility regarding psychological distress and patient adjustment. In outpatient geriatric and oncology samples, lower SIWB composite scores prospectively predicted elevated scores on the Geriatric Depression Scale (GDS) and the Center for Epidemiologic Studies Depression Scale (CES-D), as well as increased risk of demoralization syndrome and suicidal ideation, even after controlling for age, medical comorbidity burden, and cognitive status.

8. Reliability

The reliability of the Spirituality Index of Well-Being has been rigorously evaluated across multiple validation trials and independent replication cohorts, demonstrating excellent internal consistency and temporal stability.

Internal Consistency

Internal consistency estimates across key validation studies (Daaleman et al., 2002; Daaleman & Frey, 2004; Frey et al., 2005) reveal high homogeneity among scale items while preserving distinct subscale variance:

• Total SIWB Scale (12 items): Cronbach’s alpha ($lpha$) coefficients have consistently yielded values between 0.87 and 0.91 across diverse clinical and non-clinical cohorts (e.g., initial development study $lpha = 0.91$; geriatric outpatient sample $lpha = 0.91$; community validation sample $lpha = 0.87$).
• Self-Efficacy Subscale (Items 1–6): Cronbach’s alpha coefficients range from 0.83 to 0.86 ($lpha = 0.84$ in development sample; $lpha = 0.86$ in geriatric sample; $lpha = 0.83$ in validation sample).
• Life-Scheme Subscale (Items 7–12): Cronbach’s alpha coefficients range from 0.80 to 0.89 ($lpha = 0.86$ in development sample; $lpha = 0.89$ in geriatric sample; $lpha = 0.80$ in validation sample).

Composite reliability coefficients (McDonald’s $\omega$) derived from confirmatory factor analyses similarly exceed 0.85 for both dimensions, indicating that measurement error is minimal and that the items effectively tap their targeted latent constructs.

Test-Retest Reliability

Evaluations of temporal stability over a two- to four-week interval among stable outpatient populations demonstrated an intra-class correlation coefficient (ICC) of 0.79 to 0.85 for the overall SIWB, indicating that the instrument reliably captures an enduring existential orientation while remaining sensitive to genuine psychological or existential shifts resulting from clinical interventions or acute life crises.

9. Factor Analysis

The structural dimensionality of the SIWB was established through an iterative process of Exploratory Factor Analysis (EFA) followed by Confirmatory Factor Analysis (CFA) across independent participant samples.

Exploratory Factor Analysis (EFA)

During scale development, an initial pool of candidate items administered to adult outpatients was subjected to principal axis factoring with both orthogonal (varimax) and oblique (promax) rotations. Scree plot inspection, parallel analysis, and eigenvalues greater than 1.0 unequivocally supported a two-factor latent structure accounting for over 56% to 62% of the total variance across validation cohorts:

• Factor 1 (Self-Efficacy): Items 1 through 6 exhibited strong, primary factor loadings ranging from 0.58 to 0.81, with minimal cross-loadings (< 0.25) on the second factor. These items exclusively tapped perceptions of individual mastery, problem-solving, and resilience against existential overwhelm.
• Factor 2 (Life-Scheme): Items 7 through 12 loaded robustly on this second dimension, with factor loadings ranging from 0.54 to 0.85, capturing overarching purpose, cosmic identity, and the presence or absence of an existential void.

Confirmatory Factor Analysis (CFA)

In subsequent validation cohorts (Frey et al., 2005), CFA was utilized to compare competing models: a unidimensional (single-factor) model, an orthogonal two-factor model, and a correlated two-factor model. The correlated two-factor model demonstrated superior fit to the empirical data across all conventional goodness-of-fit benchmarks:

• Comparative Fit Index (CFI): Values ranged between 0.95 and 0.98, exceeding the standard threshold of 0.95 for excellent model fit.
• Tucker-Lewis Index (TLI): Consistently reported between 0.94 and 0.97.
• Root Mean Square Error of Approximation (RMSEA): Values ranged from 0.045 to 0.062 (with 90% confidence intervals bounded below 0.08), demonstrating minimal residual error.
• Standardized Root Mean Square Residual (SRMR): Reported between 0.038 and 0.051.
• Chi-Square to Degrees of Freedom Ratio ($\chi^2 / df$): Values fell comfortably below the conservative benchmark of 2.5 ($p > 0.05$ or non-significant relative discrepancy).

The latent correlation between the Self-Efficacy and Life-Scheme factors was moderate-to-strong ($r pprox 0.58$ to $0.65$), confirming that while the two dimensions represent related facets of global spiritual well-being, they are psychometrically distinct constructs that warrant separate reporting alongside the composite score.

10. Instrument / Measurement Tool

The structured operational details of the Spirituality Index of Well-Being are summarized below:

• Instrument Name: Spirituality Index of Well-Being (SIWB)
• Instrument Type: Self-report psychometric rating scale / health-related quality of life assessment
• Administration Format: Paper-and-pencil questionnaire, digital/online survey, or verbally administered clinical interview
• Target Population: Adults (18 years of age and older), older adults/geriatric outpatients, patients with chronic or life-limiting illnesses, palliative care patients
• Estimated Completion Time: 3 to 5 minutes
• Total Number of Items: 12 items
• Subscale Structure:
  • Self-Efficacy Subscale: Items 1, 2, 3, 4, 5, and 6
  • Life-Scheme Subscale: Items 7, 8, 9, 10, 11, and 12
• Response Scale: 5-point Likert scale with options:
  • 1 = Strongly Agree
  • 2 = Agree
  • 3 = Neither Agree nor Disagree
  • 4 = Disagree
  • 5 = Strongly Disagree
• Scoring Instructions:
  • All 12 items are phrased in a negative or deficit-oriented direction (e.g., expressing helplessness, identity confusion, or lack of purpose).
  • Under the standard scoring convention utilized in the primary literature, responses are either analyzed as scored directly where 5 (“Strongly Disagree”) indicates the absence of distress / presence of spiritual well-being, or values are interpreted continuously such that higher numbers denote greater spiritual well-being.
  • Subscale Scores: Computed by summing the raw response values of the designated items:
    • Self-Efficacy Score: Sum of Items 1 through 6 (Theoretical range: 6 to 30).
    • Life-Scheme Score: Sum of Items 7 through 12 (Theoretical range: 6 to 30).
  • Total SIWB Score: Sum of all 12 items (Theoretical range: 12 to 60), with higher composite values reflecting superior spiritual well-being and existential resilience. Alternatively, mean item scores (range: 1 to 5) may be calculated for both subscales and the global score to facilitate interpretability across measures.

11. Permissions & Fee and Test Year

The Spirituality Index of Well-Being was developed and formally published between 2002 and 2005, with foundational psychometric validation studies appearing in the Journal of Family Practice (2002), the Annals of Family Medicine (2004), and Research on Aging (2005).

Licensing and Accessibility: The SIWB is in the public domain for non-commercial academic, research, and clinical assessment purposes. No licensing fees or royalty payments are required to administer the scale in clinical practice or scholarly investigations. The instrument was developed under institutional support and peer-reviewed academic grants. When utilizing the SIWB, researchers and clinicians are expected to provide formal attribution and citation to the original authors (Daaleman & Frey, 2004; Frey, Daaleman, & Peyton, 2005). Modification of item wording or response anchors is discouraged to preserve psychometric comparability across published literature.

12. References

• Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. Jossey-Bass.
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Daaleman, T. P., Cobb, A. K., & Frey, B. B. (2001). Spirituality and well-being: An exploratory study of the patient perspective. Social Science & Medicine, 53(1), 119–127. https://doi.org/10.1016/S0277-9536(00)00320-3
• Daaleman, T. P., & Frey, B. B. (2004). The Spirituality Index of Well-Being: A new instrument for health-related quality of life research. Annals of Family Medicine, 2(5), 499–503. https://doi.org/10.1370/afm.89
• Daaleman, T. P., Frey, B. B., Wallace, D., & Studenski, S. A. (2002). The Spirituality Index of Well-Being: Development and testing of a new measure. Journal of Family Practice, 51(11), 952.
• Daaleman, T. P., Perera, S., & Studenski, S. A. (2004). Religion, spirituality, and health status in geriatric outpatients. Annals of Family Medicine, 2(1), 49–53. https://doi.org/10.1370/afm.20
• Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460
• Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy (3rd ed.). Simon & Schuster.
• Frey, B. B., Daaleman, T. P., & Peyton, V. (2005). Measuring a dimension of spirituality for health research: Validity of the Spirituality Index of Well-Being. Research on Aging, 27(5), 556–577. https://doi.org/10.1177/0164027505277843
• Hill, P. C., & Pargament, K. I. (2003). Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. American Psychologist, 58(1), 64–74. https://doi.org/10.1037/0003-066X.58.1.64
• Sulmasy, D. P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, 42(Special Issue 3), 24–33. https://doi.org/10.1093/geront/42.suppl_3.24

13. Items of the Scale (Questionnaire)