WHOQOL Spirituality, Religiousness and Personal Beliefs (SRPB)

Abstract

The World Health Organization Quality of Life Spirituality, Religiousness and Personal Beliefs (WHOQOL-SRPB) instrument represents a milestone in the cross-cultural operationalization of existential and spiritual dimensions within health-related quality of life (HRQoL). Conceived and developed by the World Health Organization (WHO) Quality of Life Group across 18 international field centers, the WHOQOL-SRPB was engineered to address a pervasive limitation in standard biopsychosocial assessment: the marginalization or oversimplification of spiritual and existential coping mechanisms. The comprehensive SRPB module consists of 32 standardized items partitioned into eight specific facets: Spiritual Connection, Meaning & Purpose in Life, Experiences of Awe & Wonder, Wholeness & Integration, Spiritual Strength, Inner Peace, Hope & Optimism, and Faith. In addition, when deployed within the parent WHOQOL-100 or alongside the 26-item WHOQOL-BREF, it integrates seamlessly into a holistic, multidimensional evaluation covering physical, psychological, independence, social, and environmental health domains.

Each item is evaluated on a standardized 5-point Likert-type scale across distinct response anchors measuring intensity, capacity, frequency, or satisfaction. Extensive international psychometric validations comprising over 5,000 respondents globally have demonstrated excellent internal consistency, with facet-level Cronbach's alpha coefficients ranging from 0.77 to 0.95 and an overall module reliability consistently exceeding 0.90. Confirmatory factor analyses (CFA) support both an eight-factor correlated structure and a hierarchical second-order model where a global spiritual quality-of-life dimension accounts for the shared variance among the eight facets. The instrument exhibits robust convergent validity with established measures of subjective well-being, life satisfaction, and coping, as well as divergent validity against severe psychopathology. Moreover, the WHOQOL-SRPB has shown remarkable sensitivity in discriminating between healthy populations and individuals with acute, chronic, or palliative medical conditions, positioning it as an indispensable assessment tool in behavioral medicine, health psychology, psychiatry, palliative care, and cross-cultural epidemiological research.

Keywords

WHOQOL-SRPB, World Health Organization, Quality of Life, Spirituality, Religiousness, Personal Beliefs, Psychometrics, Health-Related Quality of Life, Cross-Cultural Assessment, Palliative Care

Authors

The WHOQOL-SRPB was developed under the auspices of the World Health Organization Quality of Life (WHOQOL) Group, an international collaborative consortium established by the WHO Division of Mental Health and Prevention of Substance Abuse in Geneva, Switzerland. Initial foundational coordination was led by prominent figures in international psychiatric epidemiology and psychometrics, notably:

• Dr. Willem Kuyken – Department of Psychology, University of Exeter, United Kingdom (subsequently Professor of Mindfulness and Psychological Science, University of Oxford).
• Dr. John Orley – Former Head of the Mental Health Division, World Health Organization, Geneva, Switzerland.
• Dr. Mick Power – Department of Psychiatry, University of Edinburgh, United Kingdom (subsequently Professor of Clinical Psychology, National University of Singapore).
• Dr. Shekhar Saxena – Former Director of the Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.
• The International WHOQOL-SRPB Group – A collaborative research network comprising principal investigators across 18 centers worldwide, including institutions in Melbourne (Australia), Porto Alegre (Brazil), Bangalore (India), Tokyo (Japan), Kaunas (Lithuania), Madras (India), Beersheba (Israel), Bangkok (Thailand), Istanbul (Turkey), Bath and Edinburgh (United Kingdom), and Seattle (United States).

Purpose

The fundamental purpose of the WHOQOL-SRPB is to provide a globally valid, culturally sensitive, and psychometrically rigorous instrument capable of quantifying the impact of spirituality, religiousness, and personal beliefs on an individual's subjective perception of their position in life. Prior to its inception, the operationalization of spirituality in health research suffered from significant ethnocentric and theological biases. Existing measures were predominantly developed within Western, Judeo-Christian frameworks, frequently conflating institutional religiosity (such as church attendance, frequency of formal prayer, or doctrinal orthodoxy) with existential well-being. Consequently, such instruments were systematically ill-suited for secular individuals, adherents of Eastern philosophical traditions (e.g., Buddhism, Hinduism, Daoism), polytheistic traditions, or individuals identifying as spiritual but not religious.

The WHOQOL Group recognized that human health, as codified in the 1946 WHO constitution, is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Over successive decades of empirical inquiry, an expanding body of medical and psychological literature demonstrated that existential meaning, spiritual connectedness, and transcendent beliefs exert profound influences on morbidity, mortality, pain threshold, resilience, and treatment adherence. The original WHOQOL-100 assessment incorporated only a single four-item facet dedicated to spirituality (Facet 24: Spirituality/Religion/Personal Beliefs). International consensus panels and patient advocacy groups concluded that a single facet was insufficient to capture the breadth and nuances of existential health, especially among individuals confronting catastrophic illness, chronic disability, or end-of-life trajectories.

In response, the WHOQOL-SRPB module was developed to achieve three primary objectives:

1. Comprehensive Domain Disaggregation: Deconstruct the broad construct of existential well-being into clinically distinct and theoretically grounded dimensions, enabling researchers and clinicians to ascertain precisely which facets of spiritual or personal belief systems serve as protective buffers or sources of distress.
2. Cross-Cultural and Pluralistic Applicability: Establish a universal lexical and conceptual framework that functions equitably across deeply religious communities, diverse faith traditions, agnostic or atheistic individuals, and secular existentialists through an emphasis on personal experience rather than institutional dogmas.
3. Clinical and Public Health Integration: Provide an adjunct module that can be utilized alongside generic quality-of-life instruments (WHOQOL-BREF or WHOQOL-100) to inform holistic clinical interventions, palliative care planning, psycho-oncology protocols, and health policy formulations.

Psychological Construct

The psychological construct underlying the WHOQOL-SRPB is rooted in a subjective, phenomenological definition of quality of life. The WHO defines quality of life as “an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” When extended to spirituality, religiousness, and personal beliefs, the construct encompasses the ways in which transcendent connections, overarching frameworks of meaning, existential coherence, and moral or spiritual values shape human cognitive appraisals and emotional states. The 32 items of the specialized module delineate eight discrete psychological dimensions:

1. Spiritual Connection

This facet evaluates the extent to which an individual experiences an experiential or relational bond with a higher power, spiritual being, divine entity, or transcendent reality. Crucially, items are framed using inclusive nomenclature (“spiritual being” or transcendent entity) rather than denominational titles, capturing how this perceived relationship delivers comfort, stress tolerance, coping capabilities, and interpersonal empathy during adversity.

2. Meaning & Purpose in Life

Drawing heavily from existential psychology and Viktor Frankl's logotherapy, this dimension assesses whether an individual experiences their existence as having significance, teleological orientation, and underlying coherence. It gauges whether life events are interpreted as purposeful and investigates the extent to which altruistic behaviors, such as caring for others, furnish vitalizing existential significance.

3. Experiences of Awe & Wonder

This subscale investigates an individual's capacity for aesthetic and transcendent receptivity. It measures affective responses to nature, art, music, and the broader cosmos, quantifying feelings of inspiration, elevation, wonder, and deep gratitude for the natural world. In psychometrics, this facet bridges contemplative spirituality with modern empirical studies on positive emotions and self-transcendent states.

4. Wholeness & Integration

Reflecting holistic health paradigms, this facet appraises the subjective harmony and coherence among mind, body, and soul. It evaluates the concordance between an individual's internal ethical or spiritual beliefs and their manifest daily behaviors, assessing whether personal philosophy fosters psychological integration rather than cognitive dissonance or somatic alienation.

5. Spiritual Strength

This facet assesses the pragmatic utilization of spiritual resources as internal psychological capital. It captures the degree to which personal or spiritual convictions supply resilience, fortify determination, and provide an inner reserve of courage when confronting severe adversity, existential dread, debilitating illness, or bereavement.

6. Inner Peace

Inner peace captures psychological tranquility, affective serenity, and equanimity. It measures the individual's ability to sustain or retrieve emotional balance in the presence of external turmoil, life stressors, or physical suffering, representing the antithesis of internal existential angst and psychological turmoil.

7. Hope & Optimism

This dimension operationalizes future-oriented positive cognitive appraisals. Moving beyond generalized dispositional optimism, it assesses how spiritual grounding or deeply rooted personal philosophies nurture enduring hopefulness, maintain constructive perspectives during radical uncertainty, and elevate subjective quality of life despite objective constraints.

8. Faith

The faith facet assesses the degree to which religious or non-religious faith operates as an active, daily resource. It measures the extent to which firm belief systems instill reassurance, well-being, strength, and joy, acting as an anchor that stabilizes life experiences across both tranquil and tumultuous periods.

Theoretical Framework

The theoretical architecture of the WHOQOL-SRPB rests upon three interlocking paradigms within psychology, sociology, and psychosomatic medicine: the Biopsychosocial-Spiritual Model, Existential Meaning-Making Theory, and the Cognitive-Relational Theory of Stress and Coping.

The Biopsychosocial-Spiritual Paradigm

Historically, Engel's (1977) biopsychosocial model revolutionized clinical practice by asserting that biological processes must be conceptualized within psychological and social matrices. However, contemporary scholars in health psychology, such as Sulmasy (2002), argued that the model remained incomplete without explicitly incorporating the existential and spiritual dimensions of the human condition. In this expanded framework, humans are intrinsically relational beings whose psychological integrity depends on relationships with self, others, the environment, and the transcendent. Disease and suffering disrupt these systemic relationships; hence, assessing quality of life requires evaluating how spiritual and existential frameworks restore homeostasis and systemic coherence.

Existential Meaning-Making and Logotherapy

The instrument incorporates the central tenets of logotherapy formulated by Viktor Frankl, alongside Park's (2010) integrative meaning-making model. Frankl posited that the “will to meaning” is the primary motivational force in human existence. When confronted with unavoidable suffering (the tragic triad of pain, guilt, and death), individuals who possess an overarching framework of meaning are capable of transmuting tragedy into triumph. The WHOQOL-SRPB operationalizes these existential constructs by assessing how internal schemas allow individuals to integrate stressful events into a coherent global belief system, preventing demoralization and despair.

Cognitive-Relational Coping Theory

The scale is further grounded in Richard Lazarus and Susan Folkman's transactional model of stress and coping, augmented by Kenneth Pargament's theory of spiritual coping. According to this perspective, spirituality and personal beliefs operate as fundamental components of an individual's orienting system. In primary appraisal, spiritual beliefs influence whether an adversity is viewed as a threat, a loss, or an opportunity for spiritual maturation. In secondary appraisal, spiritual resources (such as inner peace, transcendent connection, and faith) serve as coping mechanisms that modulate affective reactivity and facilitate cognitive restructuring.

Validity

The psychometric validation of the WHOQOL-SRPB is among the most comprehensive cross-cultural measurement endeavors ever undertaken in behavioral health. Psychometric evaluations were conducted across 18 international field centers spanning every major habitable continent, encompassing highly diverse populations, religious traditions (Christianity, Islam, Buddhism, Hinduism, Judaism, secularism), and clinical categories.

Construct and Structural Validity

Construct validity was initially established through a rigorous simultaneous international development methodology. Items were not simply translated from an Anglo-American prototype; rather, local focus groups conducted across global centers generated items simultaneously, ensuring ecological validity. Subsequent confirmatory factor analyses verified that the 32 items converged into their eight designated facets with high standardized factor loadings (typically ranging from 0.65 to 0.88). The multi-center investigations revealed that an overarching second-order construct – global spiritual quality of life – demonstrated excellent goodness-of-fit across cultural contexts, supporting the structural integrity of the instrument.

Convergent and Discriminant Validity

Convergent validity has been repeatedly corroborated against established psychological and well-being inventories. The WHOQOL-SRPB facets exhibit statistically significant positive correlations with:

• The Purpose in Life Test (Crumbaugh & Maholick) and the Meaning in Life Questionnaire (MLQ) (r values typically ranging between 0.58 and 0.74).
• Measures of subjective well-being, such as the Satisfaction with Life Scale (SWLS) (r = 0.52 to 0.68).
• Constructive spiritual coping inventories, including Pargament's R-COPE (positive coping subscales correlating at r = 0.60 to 0.75 with Spiritual Connection and Faith).

Discriminant validity is evidenced by moderate-to-low correlations with purely somatic or functional subscales of quality of life, such as physical mobility or sensory acuity (r < 0.30), demonstrating that the SRPB module captures distinct subjective variance that is not redundant with physical health. Furthermore, the instrument successfully diverges from measures of social desirability, verifying that high scores reflect genuine existential well-being rather than impression management.

Known-Groups and Predictive Validity

Known-groups validity was demonstrated by testing the scale's capacity to differentiate between distinct clinical cohorts. Across global validation trials, the WHOQOL-SRPB demonstrated significant discriminant power between healthy community participants and patients suffering from chronic medical conditions (e.g., terminal cancer, end-stage renal disease, HIV/AIDS, and major depressive disorder). Notably, in longitudinal palliative cohorts, higher baseline scores on the Inner Peace and Meaning & Purpose facets prospectively predicted lower incidence of existential distress, decreased desire for hastened death, and sustained subjective well-being despite deteriorating physiological performance.

Reliability

The WHOQOL-SRPB demonstrates exceptional reliability across diverse languages, cultural strata, and clinical populations. Extensive empirical studies published by the WHOQOL Group and independent international researchers provide consistent statistical benchmarks:

Internal Consistency

Internal consistency, measured via Cronbach's alpha (α), consistently exceeds the accepted psychometric threshold of 0.70 for exploratory research and 0.80 for clinical application. In the definitive 18-center global validation study (N = 5,087), the reliability coefficients for the individual four-item facets were documented as follows:

• Spiritual Connection: α = 0.91 – 0.95
• Meaning & Purpose in Life: α = 0.84 – 0.88
• Experiences of Awe & Wonder: α = 0.78 – 0.85
• Wholeness & Integration: α = 0.81 – 0.87
• Spiritual Strength: α = 0.87 – 0.92
• Inner Peace: α = 0.82 – 0.89
• Hope & Optimism: α = 0.83 – 0.88
• Faith: α = 0.90 – 0.94

The full 32-item module routinely yields an aggregate Cronbach's alpha between 0.93 and 0.97, reflecting high internal consistency without redundant item overlap. McDonald's omega (ω) estimates have similarly affirmed high composite reliability across multiple cultural adaptations.

Test-Retest Stability

Temporal stability was evaluated across clinical and non-clinical sub-samples retested at intervals ranging from two to four weeks under stable health conditions. Intraclass correlation coefficients (ICC) and Pearson test-retest coefficients (r) ranged from 0.72 to 0.91 across the eight facets, confirming that the instrument captures stable existential traits and long-term coping mechanisms while remaining sufficiently sensitive to genuine therapeutic, palliative, or spiritual transformations.

Factor Analysis

The factorial structure of the WHOQOL-SRPB was delineated using iterative Exploratory Factor Analysis (EFA) and confirmed through robust Multigroup Confirmatory Factor Analysis (MGCFA) across global datasets.

Exploratory Factor Analysis (EFA)

During the pilot phases, principal axis factoring and maximum likelihood extractions with oblique rotations (promax and oblimin) revealed an eight-factor solution corresponding directly to the conceptual facets formulated by the international expert panels. Eigenvalues for these eight factors exceeded 1.0 (Kaiser criterion), collectively explaining between 62% and 71% of the total variance across different national cohorts. Item cross-loadings were low, with target items exhibiting primary factor loadings exceeding 0.60 on their designated construct.

Confirmatory Factor Analysis (CFA)

Structural equation modeling has tested both first-order and hierarchical models across diverse international cohorts:

• First-Order Correlated Model: The eight-factor correlated model demonstrated acceptable goodness-of-fit across global validation centers: RMSEA ≤ 0.052 (90% CI [0.049, 0.055]), CFI ≥ 0.945, TLI ≥ 0.938, and Standardized Root Mean Square Residual (SRMR) ≤ 0.041.
• Second-Order Hierarchical Model: A higher-order model incorporating a global “SRPB Quality of Life” latent construct driving the eight primary factors yielded comparable fit statistics: RMSEA ≈ 0.056, CFI ≈ 0.938, TLI ≈ 0.932. Factor loadings of the eight first-order factors onto the second-order latent variable ranged from 0.61 (Experiences of Awe & Wonder) to 0.92 (Spiritual Strength).
• Cross-Cultural Measurement Invariance: Multigroup CFA established metric and scalar invariance across diverse national samples, confirming that comparisons of factor scores across Western, Middle Eastern, Latin American, and Asian populations reflect valid construct differences rather than psychometric measurement artifacts.

Instrument / Measurement Tool

The WHOQOL-SRPB can be administered as an independent specialized module or embedded within the comprehensive 100-item WHOQOL-100 or the shortened 26-item WHOQOL-BREF assessments. Below are the operational measurement specifications:

• Test Type: Patient-Reported Outcome Measure (PROM); psychometric self-report questionnaire (interviewer-administered formats are validated for visually impaired or low-literacy populations).
• Target Population: Adults (ages 18 and older) across both general community cohorts and specialized medical, psychiatric, or palliative care populations.
• Administration Time: Approximately 8 to 12 minutes for the standalone 32-item SRPB module; approximately 25 to 35 minutes when administered alongside the full WHOQOL-100 profile.
• Item Composition: 32 specialized SRPB items systematically organized into eight 4-item facets (Items 1–32). When combined with the baseline assessment profile, it includes general health evaluation and standard WHOQOL domains (Physical Health, Psychological, Level of Independence, Social Relations, Environment, and Spirituality).
• Response Format: Standardized 5-point Likert scales utilizing specific anchoring systems depending on item phrasing:
• Scale A (Intensity/Extent): 1 = Not at all; 2 = A little; 3 = A moderate amount; 4 = Very much; 5 = An extreme amount
• Scale B (Capacity/Degree): 1 = Not at all; 2 = Slightly; 3 = Moderately; 4 = Very; 5 = Extremely
• Scale C (Evaluation): 1 = Not at all; 2 = Slightly; 3 = Moderately; 4 = Very well; 5 = Extremely
• Scale D (Completeness/Amount): 1 = Not at all; 2 = A little; 3 = Moderately; 4 = Mostly; 5 = Completely
• Scale E (Satisfaction): 1 = Very dissatisfied; 2 = Dissatisfied; 3 = Neither satisfied nor dissatisfied; 4 = Satisfied; 5 = Very satisfied
• Scale F (Happiness): 1 = Very unhappy; 2 = Unhappy; 3 = Neither happy nor unhappy; 4 = Happy; 5 = Very happy
• Scale G (Evaluation/Quality): 1 = Very poor; 2 = Poor; 3 = Neither poor nor good; 4 = Good; 5 = Very good
• Scale H (Frequency): 1 = Never; 2 = Seldom; 3 = Quite often; 4 = Very often; 5 = Always
• Scoring and Transformation Rules:
• Each of the eight SRPB facets is computed by summing the raw item scores (ranging from 4 to 20 for each 4-item facet). Negatively keyed items, if present, are reverse-coded prior to summation.
• Raw facet scores are subsequently transformed into a normalized linear scale ranging from 4 to 20, or converted to a 0 to 100 percentage scale in accordance with standard WHOQOL manualized algorithms: Transformed Score = ((Raw Score - 4) / 16) * 100.
• Higher scores systematically reflect superior subjective existential well-being and more robust spiritual quality of life.

Permissions & Fee and Test Year

The WHOQOL-SRPB was officially finalized and published by the World Health Organization Quality of Life Group between 2002 and 2006, following foundational developmental work initiated in the mid-1990s. As an instrument generated by the World Health Organization, the WHOQOL-SRPB is protected by international copyright law (World Health Organization). However, it is maintained as an open-access public health and research instrument.

Licensing and Usage Terms:

• Non-Commercial Academic & Clinical Research: The WHOQOL-SRPB is available free of charge for non-commercial research, academic inquiry, epidemiological surveys, and standard clinical diagnostics. Users are required to submit a user agreement registration or adhere to the terms established by the WHO Department of Mental Health and Substance Abuse or regional WHOQOL national coordinating centers.
• Commercial and Funded Trials: For-profit entities, pharmaceutical clinical trials, or commercial digital health applications must request formal licensing and written permission from WHO Health Information Management and Dissemination (Geneva, Switzerland).
• Modifications: Users are strictly prohibited from altering item text, removing facets, or changing response anchors without prior formal authorization, as structural alterations invalidate standardized population norms and cross-cultural comparability.

References

Bonomi, A. E., Patrick, D. L., Bushnell, D. M., & Martin, M. (2000). Validation of the United States' version of the World Health Organization Quality of Life (WHOQOL) instrument. Journal of Clinical Epidemiology, 53(1), 1–12. https://doi.org/10.1016/S0895-4356(99)00123-7

Kuyken, W., Orley, J., Hudelson, P., & Sartorius, N. (1994). Quality of life assessment across cultures. International Journal of Mental Health, 23(2), 5–27. https://doi.org/10.1080/00207411.1994.11449280

McDowell, I. (2006). Measuring health: A guide to rating scales and questionnaires (3rd ed.). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195165678.001.0001

O'Connell, K. A., & Skevington, S. M. (2005). The relevance of spirituality, religion and personal beliefs to health-related quality of life: Scoping the field. British Journal of Health Psychology, 10(3), 379–399. https://doi.org/10.1348/135910705X25492

O'Connell, K. A., & Skevington, S. M. (2010). To measure or not to measure? Reviewing the assessment of spirituality and religion in health-related quality of life. Chronic Illness, 6(3), 209–225. https://doi.org/10.1177/1742395310375936

Skevington, S. M., Sartorius, N., Amir, M., & The WHOQOL-SRPB Group. (2004). Developing methods for assessing quality of life in different cultural settings: The history of the WHOQOL instruments. Social Psychiatry and Psychiatric Epidemiology, 39(1), 1–10. https://doi.org/10.1007/s00127-004-0700-5

WHOQOL Group. (1993). Study protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL). Quality of Life Research, 2(2), 153–159. https://doi.org/10.1007/BF00435734

WHOQOL Group. (1994). The development of the World Health Organization quality of life assessment instrument (the WHOQOL). In J. Orley & W. Kuyken (Eds.), Quality of life assessment: International perspectives (pp. 41–57). Springer-Verlag. https://doi.org/10.1007/978-3-642-79123-9_4

WHOQOL Group. (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine, 28(3), 551–558. https://doi.org/10.1017/S0033291798006667

WHOQOL-SRPB Group. (2006). A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life (WHOQOL-SRPB). Social Science & Medicine, 62(6), 1486–1497. https://doi.org/10.1016/j.socscimed.2005.08.001

Items of the Scale