ORI GIN AL PA PER

Validation of the Portuguese Version of the FunctionalAssessment of Chronic Illness Therapy–SpiritualWell-Being Scale (FACIT-Sp 12) Among BrazilianPsychiatric Inpatients

Giancarlo Lucchetti • Alessandra Lamas Granero Lucchetti •

Juliane Piasseschi de Bernardin Goncalves • Homero P. Vallada

Published online: 24 October 2013� Springer Science+Business Media New York 2013

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

(FACIT-Sp 12) is one of the most used and most validated instruments for assessing

spiritual well-being in the world. Some Brazilian studies have used this instrument without,

however, assessing its psychometric properties. The present study aims to validate the

Portuguese version of the FACIT-Sp 12 among Brazilian psychiatric inpatients. A self-

administered questionnaire, covering spiritual well-being (FACIT-Sp 12), depression,

anxiety, religiosity, quality of life, and optimism, was administered. Of those who met the

inclusion criteria, 579 patients were invited to participate and 493 (85.1 %) were able to fill

out the FACIT-Sp 12 twice (test and retest). Subsequently, the validation analysis was

carried out. Estimation of test–retest reliability, discriminant, and convergent validity was

determined by the Spearman’s correlation test, and the internal consistency was examined

by the Cronbach’s alpha. The sample was predominantly male (63.9 %) with a mean age of

35.9 years, and the most common psychiatric condition was bipolar disorder (25.7 %)

followed by schizophrenia (20.4 %), drug use (20.0 %), and depression (17.6 %)

according to ICD-10. The total FACIT-Sp 12 scale as well as the subscales demonstrated

high internal consistency (coefficient alphas ranging from 0.893 for the total scale to 0.655

for the Meaning subscale), good convergent and divergent validity, and satisfactory test–

retest reliability (rho = 0.699). The Portuguese version of FACIT-Sp 12 is a valid and

reliable measure to use in Brazilian psychiatric inpatients. The availability of a brief and

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

A. L. G. Lucchetti � J. P. de Bernardin GoncalvesJoao Evangelista Hospital, Sao Paulo, Brazil

A. L. G. Lucchetti � J. P. de Bernardin Goncalves � H. P. ValladaUniversity of Sao Paulo, Sao Paulo, Brazil

A. L. G. Lucchetti � J. P. de Bernardin GoncalvesSao Paulo Medical Spiritist Association, Sao Paulo, Brazil

123

J Relig Health (2015) 54:112–121DOI 10.1007/s10943-013-9785-z

broad measure of spiritual well-being can help the study of spirituality and its influence on

health by researchers from countries that speak the Portuguese language.

Keywords FACIT-Sp 12 � Spirituality � Psychometrics � Religion and

medicine � Spiritual well-being

Introduction

Several studies have shown the influence of spirituality and religiosity on physical and

mental health (Bonelli and Koenig 2013; Koenig 2012; Lucchetti et al. 2011; Powell et al.

2003). Although some studies use these terms interchangeably, evidence has shown dif-

ferent health outcomes when assessing spiritual and religious aspects.

Recently, Maselko et al. (2009) found that existential spiritual well-being was protective

for depression and that religious well-being was associated with increased odds of

depression. On the other hand, King et al. (2013) found that people who have a spiritual

understanding of life in the absence of a religious framework are more vulnerable to mental

disorder.

In general, most studies assessing spirituality have shown beneficial results. Spirituality

is considered a critical resource for many patients in coping with illness and is an important

component of quality of life and mental health (Monod et al. 2011).

In some secular areas of the world where religion has become less popular, the term

spirituality has emerged as an important aspect of life, and therefore, this concept is

increasingly used in research (Koenig 2008).

However, measuring spirituality in clinical research is a cumbersome process because of

the complexity of the elements and definitions involved (Lucchetti et al. 2013b). Thus,

numerous instruments have been developed to assess spirituality and measure its associ-

ation with health outcomes (Lucchetti et al. 2013b; Monod et al. 2011).

According to a systematic review carried out by Monod et al. (2011), when comparing

all spirituality instruments, the FACIT-Sp 12 and the Spirituality Index of Well-being were

considered the best tools to assess the current spiritual state of patients.

In fact, FACIT-Sp 12 is one of the most used and most validated instruments for

assessing spiritual well-being in the world (Lucchetti et al. 2013b; Monod et al. 2011). It

was first created in the 1990s as a measure of spiritual well-being and is not limited to any

one religious or spiritual tradition (Bredle et al. 2011). It was developed with the input of

cancer patients, psychotherapists, and religious/spiritual experts who were asked to

describe the aspects of spirituality and/or faith that contributed to quality of life (QOL).

Basically, it evaluates harmony, peacefulness, sense of strength, faith, and meaning (Pe-

terman et al. 2002).

This instrument has been used in numerous published papers worldwide (Lucchetti et al.

2013b) and, therefore, is one of the most used instruments for assessing spirituality in

scientific studies (Bredle et al. 2011). However, few studies have used this instrument in

Portuguese.

FACIT-Sp12 was first translated into Portuguese by the Functional Assessment of

Chronic Illness Therapy (FACIT) (Bredle et al. 2011). Since then, some Brazilian studies

have used this instrument without assessing its psychometric properties (Batista and

Mendonca 2012; Fonseca-Guedes 2009; Furia 2006; Teixeira 2009).

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To our knowledge, the only study which evaluated the psychometric properties of the

Portuguese, FACIT-Sp 12 was conducted by Pereira et al. (Pereira and Santos 2011) in

end-of-life oncologic patients in Portugal. They found good internal consistency (Cron-

bach’s alpha 0.92), construct validity, and test–retest reliability (r of 0.99).

The present study aims to validate the Portuguese version of the Functional Assessment

of Chronic Illness Therapy–Spiritual Well-Being scale (FACIT-Sp 12) among Brazilian

psychiatric inpatients.

Methods

Sample

This study was conducted in psychiatric inpatients from a mental health hospital in Sao

Paulo, Brazil, the ‘Joao Evangelista Hospital’ (HoJE), during a 12-month period from July

2011 to June 2012.

HoJE is a 100-bed psychiatric hospital located in the northern part of the city of Sao

Paulo, Brazil, which cares for patients with mental health conditions such as substance

dependence, bipolar disorder, depression, schizophrenia, including others. The hospital has

60 % of its psychiatric beds for the general public subsidized by the government and is,

therefore, considered a philanthropic institution by the Brazilian law (Lucchetti et al.

2013a).

Patients included in the study were 18 years or older, hospitalized for treating an acute

psychiatric condition, willing to participate, and had a condition not so severe that they

could not complete the questionnaire (psychosis or confusion). The patients stayed in the

hospital for at least 15 days, and they had no severe cognitive impairment.

Of those who met the inclusion criteria, 579 patients were invited to participate. From

these, 493 (85.1 %) were able to fill the FACIT-Sp 12 twice (test and retest).

The study was approved by the Human Subjects Review Committee at University of

Sao Paulo (Sao Paulo, Brazil).

Procedures and instruments

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

interviews and through medical charts. All patients have filled out the questionnaire twice

with approximately a 1-month interval. It covered the following aspects:

• Socio-demographic characteristics: sex, age, race, marital status, education;

• Depression, evaluated using the Beck Depression Inventory, validated in Portuguese

(Gorenstein et al. 1998);

• Anxiety, assessed using the Beck Anxiety Inventory, validated in Portuguese

(Marcolino et al. 2007);

• Optimism, evaluated using the Life Orientation Test-Revised, validated in Portuguese

(Bandeira et al. 2002);

• Quality of life, assessed using the SF-12 Health Survey, validated in Portuguese

(Andrade et al. 2007);

• Religiousness, evaluated using the Duke Religion Index, validated in Portuguese

(Lucchetti et al. 2012) and asking the religious affiliation;

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• Spiritual well-being, assessed using the FACIT-Sp12 (Peterman et al. 2002) which was

translated into Portuguese by the Functional Assessment of Chronic Illness Therapy

(FACIT) (Bredle et al. 2011).

FACIT-Sp12

In this instrument, participants are instructed to indicate how true an item had been for

them during the past 7 days, using a 5-item response format ranging from not at all (0) to

very much (4), except that two items are negatively stated and must be reverse-coded

(Murphy et al. 2009). It consists of 12 items and three sub-domains of spiritual well-being

(peace, meaning, and faith) (Bredle et al. 2011).

FACIT-Sp 12 consists of 12 statements to which agreement is rated and includes the

following items: ‘‘I feel peaceful,’’ ‘‘I have a reason for living,’’ ‘‘My life has been

productive,’’ ‘‘I have trouble feeling peace of mind,’’ ‘‘I feel a sense of purpose in my life,’’

‘‘I am able to reach down deep in myself for comfort,’’ ‘‘I feel a sense of harmony within

myself,’’ ‘‘My life lacks meaning and purpose,’’ ‘‘I find comfort in my faith or spiritual

beliefs,’’ ‘‘I find strength in my faith or spiritual beliefs,’’ ‘‘My illness has strengthened my

faith or spiritual believe,’’ and ‘‘I know that whatever happens with my illness, things will

be okay’’ (Bredle et al. 2011). Higher scores indicate higher levels of spiritual well-being

(Murphy et al. 2009).

Analyses

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

measure the same characteristic (e.g., spiritual well-being) (Lucchetti et al. 2012).

The construct validity of a questionnaire refers to how accurately it measures the aspect

it was designed to measure. Construct validity is established in part through convergent and

discriminant validity. An instrument that correlates well with other measures of the same

construct demonstrates convergent validity. Discriminant validity indicates that a ques-

tionnaire does not measure characteristics other than the one it was developed to measure

(Lucchetti et al. 2012).

The stability of an instrument can be determined using a test–retest procedure, which

involves multiple administration of an instrument to the same people (Hendrickson et al.

1993).

Estimation of test–retest reliability, discriminant, and convergent validity was determined

by the Spearman’s correlation test, and the internal consistency was examined by the

Cronbach’s alpha. We also presented the scale means and variance, and the sample demo-

graphic, religious, and disease characteristics. All statistical procedures were carried out

using SPSS version 17.0 software. A p value of 0.01 is used to define statistical significance.

The present study was approved by the ‘‘University of Sao Paulo’’ ethics committee.

Results

Demographics

The patients’ demographics and religious characteristics are summarized in Table 1. The

sample was predominantly male (63.9 %) with a mean age of 35.9 years. Sixty-nine

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Table 1 Sample demographic,religious, and diseasecharacteristics

Characteristic

Sex (n, %)

Male 313 (63.9)

Female 177 (36.1)

Age (mean, SD) 35.96 (11.04)

Marital status

Married 128 (26.3)

Single 203 (41.8)

Divorced 35 (7.2)

Widow 7 (1.4)

Living together 113 (23.3)

Education

0–4 years 71 (15.8)

4–8 years 68 (15.2)

More than 8 years 309 (69.0)

Diagnosis

Alcohol dependence 42 (8.5)

Drug use 98 (20.0)

Schizophrenia 100 (20.4)

Bipolar disorder 126 (25.7)

Depression 86 (17.6)

Personality disorder 19 (3.9)

Others 19 (3.9)

Religion

Catholic 132 (34.4)

Protestant/Evangelical 145 (37.8)

Spiritist 78 (20.3)

Others 29 (4.4)

No religion 12 (3.1)

Religious attendance

Never 91 (18.5)

Once a year or less 121 (24.5)

A few times a year 65 (13.2)

A few times a month 115 (23.3)

Once a week 36 (7.3)

More than once/week 65 (13.2)

Non-organizational religiosity (prayer, meditation, or Bible study)

Rarely or never 80 (16.2)

A few times a month 175 (35.5)

Once a week 55 (11.2)

Two or more times/week 43 (8.7)

Daily 54 (11.0)

More than once a day 86 (17.4)

Intrinsic religiosity (Mean, SD) 11.77 (3.18)

FACIT-Sp 12 total score (Mean, SD) 27.97 (11.35)

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percent of the studied population had more than 8 years of education, and 41.8 % of the

patients were single.

The most common psychiatric condition was bipolar disorder (25.7 %) followed by

schizophrenia (20.4 %), drug use (20.0 %), and depression (17.6 %).

Concerning religious aspects, the majority of participants had some religious affiliation

(37.8 % were evangelical Protestants, followed by 34.4 % Catholics and 20.3 % Spiritists),

and the following results were obtained in relation to organizational, non-organizational,

intrinsic religiosity, and spiritual well-being: Most of them attended a church service less

than once a week; only about 28 % practiced a private religiosity (praying, religious

reading, TV programs, meditation) daily; and most of them obtained high scores on the

intrinsic religious scale and on the FACIT-Sp 12 total score.

Reliability

Means, standard deviations, and reliability coefficients of the FACIT-Sp 12 scales are

displayed in Table 2. The total FACIT-Sp 12 scale as well as the subscales Meaning,

Peace, and Faith demonstrated high internal consistency in this setting (coefficient alphas

ranging from 0.893 for the total scale to 0.655 for the Meaning subscale).

Construct Validity (Discriminant and Convergent Validity)

Correlations among the FACIT-Sp 12 scale, subscales, and different religious measures were

also examined for evidence of discriminant and convergent validity (Table 3). Correlation

coefficients of[0.7 between scales indicate a strong relationship (Aaronson et al. 1993).

In this study, all correlation coefficients between FACIT-Sp 12 scale and subscales were

strong (rho = 0.867–0.890), indicating convergence. However, the correlation coefficients

between FACIT-SP 12 subscales (except Meaning and Peace correlation) were \0.7,

which indicated that each subscale was distinct.

Table 2 FACIT-SP 12 descrip-tive statistics

FACIT-Sp 12 Mean SD Possible range Cronbach’salpha

Total 27.97 11.35 0–48 0.893

Meaning 9.95 4.14 0–16 0.655

Peace 8.00 3.87 0–16 0.742

Faith 10.02 4.79 0–16 0.861

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

Measure Meaning Faith Peace FACIT-Sp12 total

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

Non-organizational religiosity 0.272** 0.389** 0.249** 0.351**

Intrinsic religiosity 0.465** 0.607** 0.433** 0.569**

Meaning – 0.646** 0.728** 0.890**

Faith 0.646** – 0.646** 0.867**

Peace 0.728** 0.646** – 0.887**

** p \ 0.01

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In addition, there were weak correlations between organizational religiosity and non-

organizational religiosity with FACIT-Sp scale and subscales, pointing to a difference

between spirituality and religiosity (supporting the divergent validity). Only intrinsic

religiosity, which is considered closer to spirituality, presented a moderate correlation to

FACIT-Sp 12 (supporting the convergent validity).

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

of Life

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

being and mental health problems (depression and anxiety) (Bekelman et al. 2007; Pe-

terman et al. 2002). Further, there is an association between spirituality, optimism, and

better quality of life (Bredle et al. 2011). Therefore, a measure of spiritual well-being must

be able to correlate with these measures.

We found strong correlations between the total and all subscales scores from FACIT-Sp

12 and mental health quality-of-life scores, as measured by SF 12. Further, FACIT-Sp 12

and its subscales were also strongly negative correlated with depression (Beck Depression

Index) and anxiety (Beck Anxiety Inventory) and positive correlated with optimism (Life

Orientation Test-Revised) (Table 4).

Test–Retest Reliability

Four hundred and ninety three participants (85.1 %) were able to fill the FACIT-Sp 12

twice. (Mean interval of answering both questionnaires was 27.11—IC95 % 24.98–29.24.)

Although there is no agreement upon the level for test–retest reliability coefficients, a

minimum reliability of 0.7 has been recommended when the test is used for research

(Nunnally et al. 1967; Ruggeri et al. 2000). In the present study, we found a test–retest

reliability of 0.699, p \ 0.01 which is satisfactory after 1 month of interval.

Discussion

We found good psychometric properties in the Portuguese version of FACIT-Sp 12, such

as good internal consistency, adequate construct validity, and satisfactory test–retest

reliability.

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

FACIT-Sp 12 total Peace Faith Meaning

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

Beck anxiety inventory -0.499** -0.493** -0.464** -0.464**

Optimism (Life Orientation Test-Revised) 0.630** 0.564** 0.617** 0.617**

SF 12—physical health 0.325** 0.312** 0.349** 0.349**

SF 12—mental health 0.688** 0.689** 0.591** 0.591**

** p \ 0.01

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These results are in line with a previous study conducted by Pereira et al. (Pereira and

Santos 2011) in Portugal. However, due to considerable differences between countries,

cultures, and even language style, a Brazilian validation is recommended and needed.

In regard to the reliability, the Portuguese FACIT-Sp 12 (total scale) presented a high

internal consistency (Cronbach’s alpha = 0.89) which is in accordance with other vali-

dation studies such as the Persian version (Jafari et al. 2013) (Cronbach’s alpha = 0.90),

the European Portuguese version (Pereira and Santos 2011) (Cronbach’s alpha = 0.92), the

Japanese version (Noguchi et al. 2004) (Cronbach’s alpha = 0.91), and the original

English version (Cronbach’s alpha = 0.87).

FACIT-Sp 12 has also proved to have construct validity. The scale was able to assess

spiritual well-being and to discriminate this concept from other religious aspects such as

organizational religiosity and non-organizational religiosity (weak correlation coeffi-

cients). Interestingly, intrinsic religiosity, considered closer to spirituality by some authors

(Nelson et al. 2009), presented moderate correlation to FACIT-Sp12 scale and subscales.

The subscales were correlated, as expected, but seemed to evaluate different dimensions

of spiritual well-being (Peace, Faith, and Meaning). The strong correlation between

Meaning and Peace opens the discussion on whether FACIT-Sp 12 evaluates 2 factors

(Meaning/Peace and Faith) or 3 factors (Meaning, Peace, and Faith). There are some

articles proposing a 2-factor FACIT-Sp12 (Bredle et al. 2011; Noguchi et al. 2004), and

recently, others articles are showing that the 3-factor model is likely to provide more

specific information for studies (Murphy et al. 2008, 2009). The original authors of FACIT

have recommended to considering 3 factors instead of 2 factors in a recent review (Bredle

et al. 2011).

We have also found an inverse relation between FACIT-Sp 12 scores and depressive/

anxiety symptoms, and a direct relation between FACIT-Sp 12 scores and quality of life,

which is in accordance with the recent studies (Murphy et al. 2009; Noguchi et al. 2004;

Peterman et al. 2002).

Finally, the Portuguese version of FACIT-Sp 12 had a test–retest reliability of 0.69

(minimum recommended = 0.70). This result is different from the study conducted in

Portugal (Pereira and Santos 2011) which found a test–retest reliability of 0.99. However,

we considered our result satisfactory in view of our setting (psychiatric inpatients) and our

interval (1-month).

An interesting aspect of the present study is the possibility of using FACIT-Sp 12 in

psychiatric inpatients. Although first designed to assess spiritual well-being in cancer

patients, this scale is very versatile and it has been used in many contexts such as end-of-

life patients, psychiatric outpatients, cardiovascular patients, and general population,

among others (Bean et al. 2009; Bredle et al. 2011).

Our study has some limitations that should be considered when analyzing our results.

We have evaluated a single mental health hospital in Brazil, and the generalization of these

findings is uncertain. Therefore, studies in other settings are needed to confirm the psy-

chometric properties. However, if we consider the good results in these patients, we could

assume even better results in the general population.

Conclusion

The Portuguese version of FACIT-Sp 12 is a valid and reliable measure to use in Brazilian

psychiatric inpatients. The availability of a brief and broad measure of spiritual well-being

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can help the study of spirituality and its influence in health by researchers from countries

that speak the Portuguese language.

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