Nama : ERIK KURNIAWAN

NMP : 08210100222
Kelas : Ekstensi 2C
UAS Metodologi Penelitian

Tugas UAS dari Mata Kuliah

Metodologi Penelitian II
ERIK KURNIAWAN
NPM 08210100222
Dosen Pengampu : “Ns.Agus Purnama,S.Kep,MKM”

Program Studi S1 Keperawatan Ekstensi

Universitas Indonesia Maju Jakarta
2022

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UAS METODOLOGI
Tugasnya adalah Cari 3 buah artikel berbahasa Inggris yang berkaitan dg judul skripsi
masing2 mahasiswa

Pertanyaan nya :

1. Cari urgensi dari ke 3 artikel tersebut

2. Apa tujuan peneliti dari ke 3 artikel tsb

3. Desain apa yg ada di artikel tsb ( populasi , sampling , alat ukur instrumen dan memakai
uji apa )

4. Apa kesimpulan dari artikel tsb

5. Apa kebaruan kita ttg penelitian itu ( alasan kita mengambil judul skripsi tsb apa ? Dan
menggunakan metode apa ...ini mah ttg skripsi yg kita ambil )

Dikumpulkan Sabtu depan dan sertakan kartu ujian nya di kumpulkan ke sipen 🙏

Jawaban :
1. Urgensi dari 3 artikel :
artikel 1:

Hipertensi dapat menyebabkan kematian diantara semua usia. Hipertensi ini biasanya

terjadi karena resiko kebiasaan yang dapat dirubah seperti diet tidak sehat, tidak ada

aktivitas fisik, konsumsi alcohol dan rokok, serta faktor yang tidak dapat dirubah

seperti gen, usia, dan gender. Para peneliti telah menetapkan peran keturunan dan gaya

hidup dalam terjadinya hipertensi ,tetapi peran potensial factor psikososial,terutama

religiusitas yang kurang dipahami.

Artikel 2:
Prevalensi hipertensi berdasarkan usia dan jenis kelamin meningkat secara

signifikan dari 60,1% menjadi 65,2% dari survei 2001 hingga 2010. Di antara

peserta dengan hipertensi, kesadaran, pengobatan dan pengendalian hipertensi

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 semuanya meningkat secara signifikan dari 69,8% menjadi 74,5%, 50,3% menjadi

63,7%, dan 15,3% menjadi 30,3%, masing-masing, dari tahun 2001 hingga 2010.

Regresi logistik menunjukkan bahwa a tingkat pendidikan yang lebih tinggi, BMI

yang lebih tinggi, riwayat keluarga hipertensi dan penyakit kardiovaskular yang

didiagnosis dokter secara signifikan terkait dengan kesadaran dan pengobatan

hipertensi.

Artikel 3 :
Pentingnya spiritualitas dan kepedulian eksistensial dalam pengaturan perawatan

kesehatan . mengukur beberapa aspek spiritualitas dalam penelitian klinis, dan

mereka mengusulkan sistem klasifikasi yang membedakan antara ukuran spiritualitas

umum, kesejahteraan spiritual, kebutuhan spiritual, dan koping spiritual.

2. Tujuan Penelitian
Artikel 1 :
menganalisis hubungan antara beberapa dimensi religiusitas dan tekanan darah

sistolik, tekanan darah diastolik, dan hipertensi

Artikel 2 :
Prevalensi hipertensi meningkat pesat antara tahun-tahun yang disurvei.

Pengendalian hipertensi meningkat secara signifikan, Perhatian lebih harus

diberikan kepada orang tua karena populasi menua di seluruh dunia, dan tindakan

segera, pendekatan pengobatan yang optimal dan strategi kesehatan masyarakat

yang tepat harus diambil untuk mencegah dan mengelola hipertensi.

Artikel 3 :
WHOQOL-SRPB dikelompokkan bersama sebagai faktor koping spiritual dan

aspek lainnya membentuk faktor kualitas hidup spiritual. Sementara membuang

aspek keterhubungan, kekuatan, dan keyakinan tanpa penelitian tambahan akan

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 terlalu dini, pengguna skala perlu menyadari struktur dua faktor alternatif ini, dan

mungkin ingin menganalisis skor menggunakan struktur ini.

3. Desain artikel (populasi, sampling, alat ukur instrument, uji

Artikel 1:

Menggunakan data yang diambil dari Chicago Community Adult Health Study,

sampel probabilitas orang dewasa (N=3105) berusia 18 tahun ke atas yang

tinggal di kota. dari Chicago, AS. Dari variabel religiusitas utama yang diperiksa

di sini, kehadiran dan partisipasi publik tidak berhubungan secara signifik an

dengan hasil. Doa dikaitkan dengan peningkatan kemungkinan hipertensi, dan

spiritualitas dikaitkan dengan peningkatan tekanan darah diastolik. Penambahan

beberapa variabel religiusitas lain ke dalam model tampaknya tidak

mempengaruhi temuan ini. Namun, variabel untuk makna dan pengampunan

dikaitkan dengan tekanan darah diastolik yang lebih rendah dan kemungkinan

penurunan hasil hipertensi.

Artikel 2 :

Metode

Kami melakukan dua survei cross-sectional orang dewasa Cina berusia 60 tahun

pada tahun 2001 dan 2010. Sebanyak 2.272 (943 laki-laki, 1.329 perempuan) dan

2.074 (839 laki-laki, 1.235 perempuan) peserta dimasukkan dalam dua survei,

masing-masing.

Hasil

Prevalensi hipertensi berdasarkan usia dan jenis kelamin meningkat secara

signifikan dari 60,1% menjadi 65,2% dari survei 2001 hingga 2010. Di antara

peserta dengan hipertensi, kesadaran, pengobatan dan pengendalian hipertensi

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 semuanya meningkat secara signifikan dari 69,8% menjadi 74,5%, 50,3% menjadi

63,7%, dan 15,3% menjadi 30,3%, masing-masing, dari tahun 2001 hingga 2010.

Regresi logistik menunjukkan bahwa a tingkat pendidikan yang lebih tinggi, BMI

yang lebih tinggi, riwayat keluarga hipertensi dan penyakit kardiovaskular yang

didiagnosis dokter secara signifikan terkait dengan kesadaran dan pengobatan

hipertensi.

Metode

Desain studi

Seperti yang dijelaskan dalam penelitian kami sebelumnya [20], metode

pengambilan sampel bertingkat dua dilakukan untuk merekrut peserta berusia 60

tahun ke atas di Komunitas Wanshoulu di Distrik Haidian, wilayah metropolitan

yang mewakili karakteristik geografis dan ekonomi Beijing. pada tahun 2001.

Pertama, kami menggunakan metode randomized cluster sampling untuk memilih

secara acak 9 dari 94 komunitas di Komunitas Wanshoulu. Kedua, semua rumah

tangga dengan penduduk lanjut usia dipilih dari 9 komunitas, dan satu penduduk

lanjut usia dari setiap rumah tangga dipilih. Sebanyak 2.680 orang lanjut usia

dipilih dan diundang untuk berpartisipasi dalam survei kami. Sebanyak 2.334

peserta menyelesaikan survei (tingkat respons adalah 87,1%). Setelah

mengecualikan 62 orang dengan data yang tidak lengkap, total 2.272 peserta (943

laki-laki dan 1.329 perempuan) dimasukkan dalam survei kami pada tahun 2001.

Pada tahun 2010, kami melakukan survei potong lintang kedua di kabupaten yang

sama dengan menggunakan metode yang sama dengan survei tahun 2001. Pada

survei kedua, 2.162 dari 2.510 peserta lanjut usia menyelesaikan survei (tingkat

respons adalah 86,1%). Setelah mengecualikan 88 orang dengan data yang tidak

lengkap, total 2.074 peserta (839 laki-laki dan 1.235 perempuan) dimasukkan dalam

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 survei 2010 kami. Setelah dua survei selesai, kami menemukan bahwa total 731

peserta (33%) dimasukkan dalam kedua survei.

Penelitian ini telah disetujui oleh Komite Etika Independen Rumah Sakit Umum

Tentara Pembebasan Rakyat Tiongkok; menandatangani informed consent

diperoleh dari semua peserta.

Pengumpulan dan pengukuran data

Setiap peserta menyelesaikan wawancara tatap muka dan kuesioner standar pada

karakteristik demografi seperti usia, jenis kelamin, status perkawinan, riwayat

kesehatan, riwayat keluarga penyakit kronis dan karakteristik gaya hidup. Pengamat

terlatih mengukur tinggi badan, berat badan, lingkar pinggang, dan tekanan darah

setiap peserta sesuai dengan protokol standar. Tinggi badan diukur dalam meter

(tanpa sepatu), dan berat badan diukur dalam kilogram (pakaian berat dilepas, dan

satu kilogram dikurangi untuk pakaian yang tersisa). Lingkar pinggang diukur di

tengah antara batas rusuk bawah dan krista iliaka saat peserta dalam posisi berdiri

[21]. Merokok sigaret didefinisikan sebagai telah merokok setidaknya satu batang

rokok per hari selama lebih dari satu tahun [22]. Konsumsi alkohol didefinisikan

sebagai minum alkohol setidaknya 12 kali selama setahun terakhir [23]. Indeks

massa tubuh (BMI) dihitung sebagai berat badan dalam kilogram dibagi tinggi badan

dalam meter kuadrat [21]. Para peserta dikelompokkan ke dalam empat kelompok

usia berikut: 60-64, 65-69, 70-74 dan 75 tahun. Spesimen darah puasa semalam

diperoleh untuk pengukuran lipid serum dan glukosa, dan sampel dikirim ke

laboratorium bersertifikat pusat Rumah Sakit Umum PLA China dalam waktu 30

menit.

Artikel 3 :

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 Metode

Peserta

Penelitian ini menyelidiki sifat psikometrik dari WHOQOL-SRPB menggunakan

dataset yang sebelumnya telah diterbitkan sebagai artikel tentang hubungan antara

QOL, koping, dan spiritualitas, religiusitas, dan keyakinan pribadi [20]. Dataset ini

berasal dari sampel 679 mahasiswa di Selandia Baru dan cocok untuk tujuan ini

karena berisi ukuran dari WHOQOL-SRPB [14], kuesioner Brief COPE [21], PSS

[22], dan New Versi Selandia dari WHOQOL-BREF [23], juga divalidasi untuk

digunakan dengan siswa [24]. Informasi demografis rinci tentang sampel dilaporkan

oleh Chai et al. [20]. Karena data diperoleh dari mahasiswa, rata-rata usia peserta

relatif rendah (M = 22.83, SD = 6.88). Sekitar 73% siswa adalah siswa perempuan,

dan sekitar setengah dari peserta melaporkan berafiliasi dengan keyakinan agama.

WHOQOL-SRPB

Modul WHOQOL-SRPB 32 item [14] berisi delapan aspek spiritualitas, religiusitas,

dan keyakinan pribadi (keterhubungan dengan makhluk atau kekuatan spiritual,

makna hidup, kekaguman, keutuhan dan integrasi, kekuatan spiritual,

kedamaian/ketenangan/harmoni batin). , harapan dan optimisme, dan keyakinan)

yang diucapkan dengan cara yang dianggap dapat diterima oleh peserta dari berbagai

keyakinan agama dan non-agama [2].

COPE singkat

Kuesioner 28 item ini mengukur 14 strategi koping disposisional adaptif dan

maladaptif yang berbeda, yang diekspresikan oleh masing-masing dua item [21]. Ini

termasuk koping aktif, perencanaan, pembingkaian ulang positif, penerimaan, humor,

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 agama, menggunakan dukungan emosional, menggunakan dukungan instrumental,

gangguan diri, penolakan, melampiaskan, penggunaan zat, pelepasan perilaku, dan

menyalahkan diri sendiri. Delapan strategi koping pertama umumnya dianggap

adaptif, dan enam sisanya dianggap maladaptif. Namun, struktur faktor kuesioner

tidak stabil, dan berbagai macam struktur faktor tingkat tinggi telah diusulkan [25].

Penelitian ini menganalisis skor strategi individu dengan menjumlahkan skor dua

item dari setiap strategi, tanpa mengusulkan struktur tingkat tinggi. Sementara COPE

Singkat biasanya diberikan menggunakan skala Likert empat poin, Chai et al. [20]

menggunakan skala lima poin sebagai gantinya. Data yang hilang tidak

diperhitungkan untuk COPE Singkat, yang berarti bahwa tidak ada skor sub-skala

yang dihitung ketika setidaknya satu item pada sub-skala itu hilang.

PSS

Kuesioner 14 item ini menanyakan tentang tingkat stres yang dirasakan oleh

responden selama sebulan terakhir [22]. Skor ringkasan dihitung menghasilkan

tingkat keseluruhan stres yang dirasakan.

4. Kebaharuan penelitian (alasan pengambilan judul skripsi dan

metode penelitian)

Judul : Hubungan Kesehatan Spiritual Dengan Hipertensi Pada

Lansia

1. Alasan pengambilan judul skripsi

Hipertensi dapat menyebabkan kematian diantara semua usia. Hipertensi ini biasanya

terjadi karena resiko kebiasaan yang dapat dirubah seperti diet tidak sehat, tidak ada

aktivitas fisik, konsumsi alcohol dan rokok, serta faktor yang tidak dapat dirubah

[Ketik di sini]
 seperti gen, usia, dan gender. Para peneliti telah menetapkan peran keturunan dan

gaya hidup dalam terjadinya hipertensi ,tetapi peran potensial factor

psikososial,terutama religiusitas yang kurang dipahami.

Prevalensi hipertensi berdasarkan usia dan jenis kelamin meningkat secara

signifikan dari 60,1% menjadi 65,2% dari survei 2001 hingga 2010. Di antara

peserta dengan hipertensi, kesadaran, pengobatan dan pengendalian hipertensi

semuanya meningkat secara signifikan dari 69,8% menjadi 74,5%, 50,3% menjadi

63,7%, dan 15,3% menjadi 30,3%, masing-masing, dari tahun 2001 hingga 2010.

Regresi logistik menunjukkan bahwa a tingkat pendidikan yang lebih tinggi, BMI

yang lebih tinggi, riwayat keluarga hipertensi dan penyakit kardiovaskular yang

didiagnosis dokter secara signifikan terkait dengan kesadaran dan pengobatan

hipertensi.

Pentingnya spiritualitas dan kepedulian eksistensial dalam pengaturan perawatan

kesehatan . mengukur beberapa aspek spiritualitas dalam penelitian klinis, dan

mereka mengusulkan sistem klasifikasi yang membedakan antara ukuran

spiritualitas umum, kesejahteraan spiritual, kebutuhan spiritual, dan koping

spiritual.

2. Metode Penelitian

Menggunakan data yang diambil dari Chicago Community Adult Health Study,

sampel probabilitas orang dewasa (N=3105) berusia 18 tahun ke atas yang

tinggal di kota. dari Chicago, AS.

Melakukan dua survei cross-sectional orang dewasa Cina berusia 60 tahun

pada tahun 2001 dan 2010

Seperti yang dijelaskan dalam penelitian kami sebelumnya [20], metode

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 pengambilan sampel bertingkat dua dilakukan untuk merekrut peserta berusia 60

tahun ke atas di Komunitas Wanshoulu di Distrik Haidian, wilayah metropolitan

yang mewakili karakteristik geografis dan ekonomi Beijing.

Wawancara tatap muka dan kuesioner standar pada

karakteristik demografi seperti usia, jenis kelamin, status perkawinan, riwayat

kesehatan, riwayat keluarga penyakit kronis dan karakteristik gaya hidup.

Penelitian ini menyelidiki sifat psikometrik dari WHOQOL-SRPB menggunakan

dataset yang sebelumnya telah diterbitkan sebagai artikel tentang hubungan antara

QOL, koping, dan spiritualitas, religiusitas, dan keyakinan pribadi

WHOQOL-SRPB

Modul WHOQOL-SRPB 32 item [14] berisi delapan aspek spiritualitas,

religiusitas, dan keyakinan pribadi (keterhubungan dengan makhluk atau kekuatan

spiritual, makna hidup, kekaguman, keutuhan dan integrasi, kekuatan spiritual

kedamaian/ketenangan/harmoni batin). , harapan dan optimisme, dan keyakinan)

PSS

Kuesioner 14 item ini menanyakan tentang tingkat stres yang dirasakan oleh

responden selama sebulan terakhir [22]. Skor ringkasan dihitung menghasilkan

tingkat keseluruhan stres yang dirasakan.

DAFTAR PUSTAKA

Buck, A., Williams, D. R., Musick, M. A., Sternthal, M. J. (2009). An Examination of the
Relationship between Multiple Dimensions of Religiosity, Blood Pressure, and Hypertension.
Soc Sci Med, 68(2), 314-322. doi:10.1016/j.socscimed.2008.10.010.

Wu, L., He, Y., Jiang, B., Sun, D., Wang, J., Liu, M., Yang, S., Wang, Y. (2015). Trends in
Prevalance, Awareness, Treatment and Control of Hypertension during 2001-2010 in an Urban
Elderly Population of China. Plos One, 2. doi:10.1371/journal. pone.0132814.

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Krageloh, C. U., Billington, D. R., Chai, P. P. M. (2015). Spiritual quality oflife and spiritual
Coping: evidence for a two-factor structure of the WHOQOL spirituality, religiousness, and
personal beliefs module. Health and Quality of Life Outcomes, 13(26), 1-2. doi:10.1186/s12955-
015-0212-x.

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Artikel 1:
An examination of the relationship
between multiple dimensions of
religiosity, blood pressure, and
hypertension
Anna C Buck 1, David R Williams, Marc A Musick, Michelle J Sternthal

Researchers have established the role of heredity and lifestyle in the occurrence of
hypertension, but the potential role of psychosocial factors, especially religiosity, is less
understood. This paper analyzes the relationship between multiple dimensions of religiosity
and systolic blood pressure, diastolic blood pressure, and hypertension using data taken from
the Chicago Community Adult Health Study, a probability sample of adults (N=3105) aged
18 and over living in the city of Chicago, USA. Of the primary religiosity variables examined
here, attendance and public participation were not significantly related to the outcomes.
Prayer was associated with an increased likelihood of hypertension, and spirituality was
associated with increased diastolic blood pressure. The addition of several other religiosity
variables to the models did not appear to affect these findings. However, variables for
meaning and forgiveness were associated with lower diastolic blood pressure and a decreased
likelihood of hypertension outcomes. These findings emphasize the importance of analyzing
religiosity as a multidimensional phenomenon. This study should be regarded as a first step
toward systematically analyzing a complex relationship.

Artikel 2:

Trends in Prevalence, Awareness, Treatment

and Control of Hypertension during 2001-2010
in an Urban Elderly Population of China
• Lei Wu,
• Yao He ,
• Bin Jiang,
• Dongling Sun,
• Jianhua Wang,
• Miao Liu,

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 • Shanshan Yang,
• Yiyan Wan

Objective

As the most important risk factors of cardiovascular disease, pre-hypertension and hypertension are
important public health challenges. Few studies have focused on the trends of pre-hypertension and
hypertension specifically for the aging population in China. Given the anticipated growth of the elderly
population in China, there is an urgent need to document the conditions of pre-hypertension and
hypertension in this aging population.

Methods

We conducted two cross-sectional surveys of Chinese adults aged ≥60 years in 2001 and 2010. A total of
2,272 (943 males, 1,329 females) and 2,074 (839 males, 1,235 females) participants were included in the
two surveys, respectively.

Results

The age- and sex-standardized prevalence of hypertension significantly increased from 60.1% to 65.2%
from the 2001 to the 2010 survey. Among the participants with hypertension, the awareness, treatment
and control of hypertension all significantly increased from 69.8% to 74.5%, 50.3% to 63.7%, and 15.3%
to 30.3%, respectively, from 2001 to 2010. A logistic regression showed that a higher education level, a
higher BMI, a family history of hypertension and doctor-diagnosed cardiovascular disease were
significantly associated with hypertension awareness and treatment.

Conclusion

Hypertension prevalence increased rapidly between the years surveyed. Although the awareness,
treatment and control of hypertension improved significantly, the values of these variables remained low.
More attention should be given to the elderly because the population is aging worldwide, and urgent
action, optimal treatment approaches and proper public health strategies must be taken to prevent and
manage hypertension.

Figures

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Citation: Wu L, He Y, Jiang B, Sun D, Wang J, Liu M, et al. (2015) Trends in Prevalence, Awareness,
Treatment and Control of Hypertension during 2001-2010 in an Urban Elderly Population of China. PLoS
ONE 10(8): e0132814. https://doi.org/10.1371/journal.pone.0132814
Editor: Yan Li, Shanghai Institute of Hypertension, CHINA
Received: March 4, 2015; Accepted: June 18, 2015; Published: August 4, 2015
Copyright: © 2015 Wu et al. This is an open access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This study was supported by research grants from the National Natural Science Foundation of
China, 81373080; Ministry of Science and Technology of China, 2013CB530800; Research Foundation by
the Ministry of Health of PLA China, 13CXZ029 and the Beijing Municipal Science and Technology
Commission, D121100004912003.
Competing interests: The authors have declared that no competing interests exist.
Introduction

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According to a WHO report, cardiovascular disease (CVD) is estimated to become the leading cause of
morbidity and mortality worldwide by 2020 [1]. As the risk factors of CVD, pre-hypertension and
hypertension are important public health challenges worldwide [2, 3]. Therefore, an effective strategy for
preventing CVD requires increased prevention of hypertension along with timely diagnosis and
appropriate treatment of hypertension [4].

A large number of studies have been conducted to evaluate the prevalence, awareness, treatment and
control of hypertension among the Chinese [5–12], but data on recent trends of pre-hypertension and
hypertension prevalence are rare in China [13–16]. In developed countries such as the US, studies have
reported trends of hypertension prevalence, particularly for older US adults [17, 18]. However, few
studies have focused on the trends of pre-hypertension and hypertension specifically for the aging
population in urban areas of China. The aging population presents a serious challenge for China;
individuals aged ≥60 and ≥80 years will constitute 29.7% and 7.6% of the total Chinese population by
2050, respectively [19]. Given the anticipated growth of the elderly population in China, there is an urgent
need to document the conditions of pre-hypertension and hypertension in this population.

As the capital of China, Beijing is highly developed and urbanized. To explore the situation of pre-
hypertension and hypertension among the aging population during the past decade of rapid development
and change, the current study reported the prevalence of pre-hypertension and the prevalence,
awareness, treatment and control of hypertension in participants aged ≥60 years in two cross-sectional
surveys that were conducted in 2001 and 2010 in Beijing, China.

Methods
Study design

As described in our previous study [20], a two-stage stratified sampling method was conducted to recruit
participants aged 60 years and older in the Wanshoulu Community within the Haidian District, a
metropolitan area that was representative of the geographic and economic characteristics of Beijing in
2001. First, we used the randomized cluster sampling method to randomly select 9 of the 94 communities
in the Wanshoulu Community. Second, all of the households with elderly residents were selected from the
9 communities, and one elderly resident from each household was selected. A total of 2,680 elderly
individuals were selected and invited to participate in our survey. A total of 2,334 participants completed
the survey (the response rate was 87.1%). After excluding 62 people with incomplete data, a total of
2,272 participants (943 males and 1,329 females) were included in our survey in 2001.

In 2010, we conducted a second cross-sectional survey in the same district using the same method as
with the 2001 survey. In the second survey, 2,162 of 2,510 elderly participants completed the survey (the
response rate was 86.1%). After excluding 88 people with incomplete data, a total of 2,074 participants
(839 males and 1,235 females) were included in our 2010 survey. After the two surveys were completed,
we found that a total of 731 participants (33%) were included in both surveys.

This study was approved by the Independent Ethics Committee of the Chinese People's Liberation Army
General Hospital; signed informed consent was obtained from all the participants.

Data collection and measurement

Each participant completed a face-to-face interview and a standardized questionnaire on demographic

characteristics such as age, gender, marital status, medical history, family history of chronic disease and
lifestyle characteristics. Trained observers measured each participant’s height, weight, waist
circumference and blood pressure according to the standardized protocol. Height was measured in

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meters (without shoes), and weight was measured in kilograms (heavy clothing was removed, and one
kilogram was deducted for remaining garments). Waist circumference was measured midway between
the lower rib margin and iliac crest while participants were in the standing position [21]. Cigarette
smoking was defined as having smoked at least one cigarette per day for more than one year [22]. Alcohol
consumption was defined as drinking alcohol at least 12 times during the past year [23]. Body mass index
(BMI) was calculated as weight in kilograms divided by height in meters squared [21]. The participants
were stratified into the following four age groups: 60 to 64, 65 to 69, 70 to 74 and ≥75 years. Overnight
fasting blood specimens were obtained for the measurement of serum lipids and glucose, and the samples
were sent to the central certified laboratory of the Chinese PLA General Hospital within 30 minutes.

BP measurement and definitions

The participants were advised to avoid alcohol, cigarette smoking, coffee or tea and exercise prior to
blood pressure measurement. Two measurements were obtained from the right arm using standardized
mercury sphygmomanometers while participants were in a sitting position [24]. Systolic blood pressure
(SBP) and diastolic blood pressure (DBP) were defined as the averages from the two readings. If the two
measurements differed by over 10 mmHg, the observers measured the blood pressure a third time and
calculated the average of the three measurements as the final measurement.

Based on the measured blood pressure, the participants were classified into the following three groups:
optimal blood pressure, pre-hypertension, and hypertension. Optimal blood pressure was defined as a
mean SBP <120 mmHg and DBP <80 mmHg. Pre-hypertension was defined as SBP ≥120 mmHg and <140
mmHg or DBP ≥80 mmHg and <90 mmHg. Hypertension was defined as SBP ≥140 mmHg and/or DBP ≥90
mmHg and/or the self-reported use of antihypertensive medication in the previous two weeks [25–27].
Among the participants who were defined as hypertensive in the review, awareness of hypertension was
defined as any prior diagnosis of hypertension by a health care professional, treatment of hypertension
was defined as use of prescribed antihypertensive medication within the previous two weeks, and control
of hypertension was defined as an average SBP <140 mmHg and an average DBP <90 mmHg and was
associated with pharmacological treatment of hypertension [28]. The Eighth Joint National Committee
(JNC-8) proposed the treatment blood pressure goal of less than 150/90 mmHg among individuals aged
60 years or older [29]. We defined the control of hypertension as SBP <150 mmHg and/or DBP <90
mmHg in a subsequent sensitivity analysis.

Statistical analysis

The data were entered (double entry) using Epidata (3.1) and analyzed using SPSS (Inc., Chicago, IL, USA)
for Windows (19.0). A two-sided P-value of <0.05 was considered statistically significant.

The prevalence of pre-hypertension and the prevalence, awareness, treatment and control of
hypertension were standardized by age and sex. We weighted the survey data, and age- and sex-
standardizations (both treated as the dichotomous variables) were performed based on the urban
population distributions in Beijing in 2001 and 2010 [30]. The baseline characteristics were described
using descriptive statistics, and t-tests and chi-square tests were used to examine differences in the
continuous and categorical variables, respectively. Prevalence in the two surveys from 2001 and 2010
was compared using a chi-square test. A logistic regression was used to calculate the factors associated
with the awareness, treatment and control of hypertension in the 2001 and 2010 surveys.

We conducted sensitivity analyses of subject characteristics and the prevalence, awareness, treatment
and control of hypertension during 2001–2010 after excluding those individuals who were included in
both surveys (n = 731).

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Results
As shown in Table 1, a total of 2,272 (943 males and 1329 females) and 2,074 (839 males and 1235
females) participants completed the surveys in 2001 and 2010, respectively. The mean age of the
participants was 67.92±5.76 years in 2001 and significantly increased to 71.69±6.56 years in 2010. The
proportion of participants aged 75 and older had increased rapidly over the decade, which indicated the
aging of the population. SBP and DBP also significantly increased from 137.14±21.27 mmHg to
138.93±19.78 mmHg and 77.03±10.52 mmHg to 77.30±9.93 mmHg, respectively, from 2001 to 2010.

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Table 1. Characteristics of the subjects who completed the surveys in 2001 and 2010.
https://doi.org/10.1371/journal.pone.0132814.t001
Prevalence of pre-hypertension and hypertension

Table 2 shows the crude age- and sex-standardized prevalence of optimal blood pressure; pre-
hypertension; hypertension; and the awareness, treatment and control of hypertension among females
and males in the two surveys from 2001 and 2010.

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Table 2. Prevalence of pre-hypertension and the prevalence, awareness, treatment and control
of hypertension among females and males who completed the surveys in 2001 and 2010.
https://doi.org/10.1371/journal.pone.0132814.t002
From 2001 to 2010, the proportion of the population with optimal blood pressure decreased significantly,
and the age- and sex-standardized prevalence of pre-hypertension decreased from 27.2% to 25.5%,
particularly in females (26.7% to 22.7%, P = 0.021). Additionally, the prevalence of hypertension
significantly increased from 60.1% to 65.2% (P = 0.001), particularly in females (60.6% to 68.3%,
P<0.001). Males had a higher prevalence of pre-hypertension (29.6% for males vs. 22.7% for females in
2010, P<0.001), and females had a higher prevalence of hypertension (60.5% for males vs. 68.3% for
females in 2010, P<0.001), particularly in 2010. There were no significant sex differences in pre-
hypertension and hypertension prevalence in 2001, but the trend was similar to that in 2010.

After stratifying the participants into four age groups, the results indicated that the prevalence of pre-
hypertension decreased with age and that hypertension markedly increased with age. The greatest
decline and increment were in the subgroup of those aged 65–69 years in both sexes (Fig 1A and 1B). As
shown in Fig 1B, the age-specific prevalence of hypertension increased in all age groups from the 2001 to
the 2010 survey, except for those aged 65–69 years. From 2001 to 2010, the prevalence of hypertension
was highest among the subgroup of participants aged ≥70 years in both sexes.

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Fig 1. Age-specific prevalence of pre-hypertension and the prevalence, awareness, treatment

and control of hypertension.
Fig 1 shows the age-specific prevalence of (A). prehypertension (B). prevalence (C). awareness (D).
treatment and (E). control of hypertension.
https://doi.org/10.1371/journal.pone.0132814.g001

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Awareness, treatment and control of hypertension

Among the participants who had hypertension, 69.8% were aware of their condition in 2001, and this
rate significantly increased to 74.5% in 2010 (P = 0.007), particularly in females (from 70.6% to 76.0%, P
= 0.013).

From 2001 to 2010, there was a significant increase in hypertensive patients receiving treatment both in
males (50.3% to 63.7%, P<0.001) and females (50.7% to 68.0%, P<0.001).

In 2001, only 15.3% of patients with hypertension had controlled their blood pressure to reach the
optimal range, but in 2010, this proportion approximately doubled to 30.3% (31.1% for males and 29.3%
for females, both P<0.001).

The age-specific subgroups in both sexes indicated that the participants aged 60–64 years and ≥75 years
had both the lowest hypertension awareness and treatment rates in both surveys (Fig 1C and 1D). In
2010, the participants aged 60–64 years had the highest hypertension control rate (Fig 1E).

Factors associated with awareness, treatment and control of hypertension

The logistic regression model analysis results of factors associated with hypertension awareness,
treatment and control in 2001 and 2010 are shown in Table 3. A higher education level, a higher BMI, a
family history of hypertension and doctor-diagnosed CVD were all significantly associated with
hypertension awareness and treatment in both 2001 and 2010. A lower age, a higher education level and
doctor-diagnosed CVD were significantly associated with hypertension control in 2001. We also found
that a lower BMI and a family history of hypertension were significantly associated with hypertension
control in 2010.

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 original image

Table 3. Factors associated with the awareness, treatment and control of hypertension in two
surveys, 2001 and 2010.
https://doi.org/10.1371/journal.pone.0132814.t003
Sensitivity analysis

After excluding the data of the 731 participants who were included in both surveys, we assessed the
subject characteristics and the prevalence, awareness, treatment and control of hypertension in 2001 and
2010 (S1 and S2 Tables), and the results were similar to those reported above. According to the new
treatment blood pressure goal (JNC-8) of the elderly participants [29], the control rate of hypertension
significantly increased from 25.3% in 2001 to 36.9% in 2010 (S3 Table).

Discussion
To our knowledge, the present study is the first to report the trends of pre-hypertension prevalence and
hypertension prevalence, awareness, treatment and control in the past decade in an elderly population in
Beijing, China. Two cross-sectional surveys were conducted with participants aged ≥60 years in the same
district and using the same methods in both 2001 and 2010. The results showed that the age- and sex-
standardized prevalence of pre-hypertension decreased and that the prevalence, awareness, treatment
and control of hypertension all increased significantly from 2001 to 2010.

The upward trends in age- and sex-standardized prevalence of hypertension (from 60.1% in 2001 to
65.2% in 2010) found in the current study are consistent with the results of previous studies in China.
Among participants aged ≥60 years, Xi et al. reported that the prevalence of hypertension increased from
48.4% in 1991 to 53% in 2009 in nine provinces in China [16]. Zhao et al. reported that the prevalence of
hypertension increased from 42.2% in 1999 to 70.8% in 2007 in Shandong Province [13], and the
prevalence of hypertension in a northern Chinese population increased from 68.6% in 1991 to 71.2% in
2011 [14]. However, the prevalence of hypertension in US elderly individuals has been relatively stable
over the past decade [31, 32], and the prevalences of hypertension in the present study of participants
aged ≥75 years (75.4%) and ≥60 years (65.2%) in 2010 are similar to those reported in the US. Bromfield
et al. reported that 76.5% of US adults ≥80 years had hypertension in 2005–2010 [17], and Guo et al.
reported that the prevalence of hypertension was 66.7% among US adults ≥60 years in 2009 and 2010
[31].

From 2001 to 2010, the prevalence of pre-hypertension decreased, whereas the prevalence of
hypertension increased with increasing age, which is consistent with other studies [13, 15 33, 34]. Males
had a higher prevalence of pre-hypertension but a lower prevalence of hypertension, particularly in 2010,
demonstrating a trend similar to that reported for the subgroup aged 65–74 by Gu et al. [28]. These
results indicate that females in the aging population might have an increased chance of developing
hypertension if they are pre-hypertensive. Whether gender influences the progression of pre-
hypertension to hypertension among elderly people might be an interesting topic to explore with a larger
sample size in the future.

Among the participants with hypertension, the awareness, treatment and control of hypertension all
significantly increased from 69.8% to 74.5%, 50.3% to 63.7%, and 15.3% to 30.3%, respectively, from
2001 to 2010. These rates are higher than those of Xi et al [16], who reported increases of 38.7% to
54.3% for awareness, 30.5% to 49.0% for treatment, and 6.1% to 12.0% to control from 2000 to 2009
among participants aged ≥60 years. The rates found in the present study are also higher than those of
Zhao et al [15], who reported increases of 39.1% to 49.2% for awareness, 28.1% to 43.4% for treatment,
and 4.4% to 7.1% for control from 1999 to 2007 among all age groups. Furthermore, the rates of the

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present study are higher than those of a 2007 southeast Asian study of 19,848 participants aged ≥65
years [35]. Both the increase in the education level of our population in the past decade (from 57.7% to
72.1%) and preventive measures from the government and health professionals during this time might
have contributed to the increases in awareness, treatment and control of hypertension. However, the
prevalence remained lower than in the US elderly population (73.4% to 84.0% for awareness, 72.4% to
85.3% for treatment, and 34.1% to 54.9% for control from 2001 to 2010) [31] and in participants aged
≥65 years in Macau, China (79%, 75% and 35% for awareness, treatment and control, respectively, in
2012) [11]. Given the rapid social and economic changes occurring in China, public health strategies
should be developed to meet the need of the aging population in China, particularly by providing more
effective pharmacologic interventions aimed at elderly hypertensive patients.

Previous studies have found that older age and a higher BMI are associated with greater hypertension
awareness and treatment but poorer hypertension control, which is in accordance with the current report
[8, 9, 36–39]. A family history of hypertension is also significantly associated with greater hypertension
awareness, treatment and control [8, 9, 40]. Participants who know their high risk of hypertension pay
special attention to their blood pressure. Other studies have reported that being female, being retired,
being married and cigarette smoking are all related to hypertension awareness, treatment and control,
[8, 10, 39], although these variables did not reach statistical significance in the present study. We found
that more females than males were both aware of their hypertension condition and received treatment,
but the percentage of controlled hypertension was slightly lower among females than among males. The
associations between education level and hypertension awareness, treatment and control are
inconsistent among previous studies. A multi-ethnic Asian population study [39] and Wang et al. [9]
reported that high education levels were associated with poor hypertension awareness and treatment,
but Tian et al. [33] reported that increased awareness and treatment were found among those with high
education levels, which is consistent with the findings of the present study. The differences among
populations might be partially attributed to differences in education level; thus, a larger sample size is
required to detect more factors associated with hypertension in future research. We also found that
diagnosed CVD was significantly associated with hypertension awareness, treatment and control,
indicating that the control of hypertension is a key treatment for patients who are diagnosed with CVD
and that lowering blood pressure can significantly reduce the risk of cardiovascular events [41].

The age of the urban elderly population increased significantly over the decade evaluated in the current
study. We previously found the same result in other areas of China [13–15], which suggests the aging of
the population. The percentage of individuals more than 60 years old has dramatically increased during
this time, and China has entered into an aging society [42, 43]. With the increased aging of the population,
China is facing many challenges in adequately meeting the medical demand for chronic disease treatment
[44]. The prevalence of multiple chronic conditions (MCC) among individuals increases with age: the
older the population, the greater the prevalence of MCC [45]. In the present study, we found that elderly
people aged 60–64 years had fewer coexisting diseases than did those greater than 65 years old (data not
shown), the latter of which increases the difficulty of treatment and control of hypertension. This may
explain the higher control rate of hypertension in the relatively younger elderly population.

The present study has some limitations. First, because of the characteristics of cross-sectional studies, we
could only observe the prevalence of hypertension at the two survey times and, thus, cannot infer
causation. Second, we did not collect detailed information on diet, such as the amount of salt consumed.
Therefore, we were unable to detect relationships between diet conditions and hypertension prevalence
rates. Third, we measured blood pressure during a single visit, which might overestimate or
underestimate the true prevalence of hypertension [15]. Fourth, we found that the mean age of
participants in 2010 was significantly higher than that in 2001 and that the prevalence of hypertension
significantly increased with age. Although the age-specific prevalence of hypertension approximately
increased in all age groups, age might also be a confounding factor in the present study. Although we

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adjusted several potential confounding variables in the current analysis, differences between surveys in
age and other unmeasured covariates might have affected the results of the present study. As Beijing is
the capital of China, residents of this city might be more educated and wealthy than those in rural areas,
and they might pay more attention to their health. These characteristics could explain the higher
hypertension awareness, treatment and control rates in Beijing compared with other areas. Prospective
studies with larger sample sizes are required to examine the causes of the trends of pre-hypertension and
hypertension prevalence, awareness, treatment and control in the elderly population in the future.

In conclusion, according to two cross-sectional surveys, hypertension prevalence increased rapidly over
the past decade among urban elderly residents in Beijing, northern China. Although the awareness,
treatment and control of hypertension improved significantly, they remain low. We should pay greater
attention to the elderly, as population aging is occurring worldwide. Thus, urgent action, optimal
treatment approaches and proper public health strategies are needed for the prevention and
management of hypertension, with the ultimate goal of lowering the incidence of hypertension-related
chronic diseases.

Supporting Information
Trends in Prevalence, Awareness, Treatment and Control of
Hypertension during 2001-2010 in an Urban Elderly Population of
China
Showing 1/4: S1_Dataset.xls
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A B C D E F G H I J K L M N O P Q R S T U V

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0 6 . 6 9 8 . . . . .
8 9 2 1 2 0 1 1 0 1 2 3
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1 0 1 7 . 4 6 9 6 . . .
2 1 5 2 2 1 0 2 1 . .
1 0 2 2 5 8 5 3 0 4 6 7
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2 1 5 4 2 1
1 1 1
1 0 1 7 . 7 9 8 . . . .
1 2 2 1 2 2 1 0 1 6 .
2 0 3 6 6 8 6 0 7 3 8 7
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2 2 2 0 2 2 1 0 1
4 0 5 5 6 5 6 0 8 2 7 3 8 5
2
1 6 7 1 2 8 3

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2 5 5 1 3 1
1 1
1 0 1 7 6 8 9 6 . . . . .
1 1 2 . 1 2 0 0 2 1
5 0 6 0 2 3 6 0 6 3 4 8 8
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1 1
1 0 1 7 . 5 7 9 9 . . . .
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6 0 7 0 5 7 6 7 0 0 9 6 9
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8 0 9 0 5 5 3 0 4 5 4 6
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9 0 0 9 7 0 3 0 5 6 9 0 4
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2 1 2 . 0 1 2 0 1 2 3
1 0 2 1 2 5 4 6 8 2 5 0
7 0 0
1 8 8 7 2 6

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2 1 5 5 1 3 1
1 1 1
2 0 2 6 . 7 8 . . . . .
1 2 2 0 0 3 2 0 1 2 3
2 0 3 9 6 6 0 7 5 2 8 5
7 1 0
1 9 7 6 6 3 9

2 1 5 5 1 3 0
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1 1 2 1 2 0 0 1 2
5 0 6 9 6 0 2 7 0 5 3 1 4 0
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2 1 8 6 0 1 9
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2 0 2 6 . 5 8 9 6 . . . . .
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6 0 7 8 5 5 0 6 8 1 2 9 3 5
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2 0 2 6 . 6 8 8 . . . .
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8 0 9 8 5 8 5 0 5 3 5 3
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1 8 6 6 6 7

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2 1 5 7 1 6 1
1 1
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2 2 2 1 2 2 0 1 2 3
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2 0
1 3 2 7 2 9 3

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2 1 6 4 1 2 1
1 1
3 0 3 7 . 7 9 8 . . . . .
1 2 2 0 1 2 1 0 1 3
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7 0 8 4 6 0 1 4 1 2 5
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2 1 6 5 1 3 1
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1 2 2 0 1 2 0 1 1 3
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2 1 5 5 1 1
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2 3 2 2 2 0 0 2 5 .
1 0 2 2 5 9 3 7 4 5 6 7 6
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2 0 3 0 6 0 5 0 1 9 2 8 0
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2 1 5 6 1 3
1 1 1
4 0 4 7 . 7 9 7 . . . .
2 1 2 0 1 2 0 0 1 4 .
3 0 4 0 6 0 0 6 9 1 7 9
3 0 4
1 1 6 8 1 7

2 1 5 3 0 2 1
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4 0 4 7 . 7 8 7 . . . . .
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4 0 5 0 6 2 8 0 7 9 8 2 3
2 0
1 8 7 3 8 8 3

2 1 9 4 1 2 1
1
4 0 4 6 . 5 8 9 8 . . . . .
2 1 2 1 2 0 1 1 3
5 0 6 8 5 7 0 6 0 3 8 7 9 4
2
1 5 1 8 3 3 6

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1 1 2 0 2 1 1 0 2 2 . .
6 0 7 9 7 4 1 0 9 6 6
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2 1 6 6 1 4 1
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4 0 4 5 . 7 9 6 . . . . .
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2 1 6 7 1 5 1
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4 0 4 7 . 6 9 7 . . . . .
2 1 5 0 1 2 0 0 1 3
8 0 9 2 5 8 0 0 6 2 6 3 6
3 0
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2 1 5 4 1 2 0
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4 0 5 7 . 7 7 9 6 . . . . .
1 2 2 2 2 0 1 2 3
9 0 0 5 7 0 9 7 8 9 5 9 4 9
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2 1 5 5 1 3 1
1 1
5 0 5 6 . 6 8 8 . . . . .
2 3 2 0 1 2 0 0 2 7
0 0 1 8 5 3 1 2 6 0 4 3 0
1 0
1 9 4 9 1 7 5
Sheet1Sheet2Sheet3
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Download

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It contains the raw data of 4,346 participants (2,272 participants in 2001 and 2,074 participants in
2010) with 22 variables. Including investigation year (2001, 2010), code, gender (male, female), age,
education years (0–6, 7–9, 10–12, 13–16, ≥17 years), marriage status (married, single, divorce,
widowed), height (m), weight (kg), waist (cm), hip (cm), SBP (mmHg), DBP (mmHg), TC (mmol/l), TG
(mmol/l), HDL-C (mmol/l), LDL-C (mmol/l), FPG (mmol/l), physical exercise (< 1 h/d, ≥1 h/d), smoking
status, drinking status, family history of hypertension and doctor-diagnosed CVD.
S1 Dataset. The dataset of the participants in two surveys.
It contains the raw data of 4,346 participants (2,272 participants in 2001 and 2,074 participants in 2010)
with 22 variables. Including investigation year (2001, 2010), code, gender (male, female), age, education
years (0–6, 7–9, 10–12, 13–16, ≥17 years), marriage status (married, single, divorce, widowed), height
(m), weight (kg), waist (cm), hip (cm), SBP (mmHg), DBP (mmHg), TC (mmol/l), TG (mmol/l), HDL-C
(mmol/l), LDL-C (mmol/l), FPG (mmol/l), physical exercise (< 1 h/d, ≥1 h/d), smoking status, drinking
status, family history of hypertension and doctor-diagnosed CVD.
https://doi.org/10.1371/journal.pone.0132814.s001
(XLS)
S1 Table. Characteristics of the subjects who completed the surveys in 2001 and 2010 (excluding the
data of 731 participants that completed both surveys).
S1 Table shows the subject characteristics in 2001 and 2010, after excluding the data of the 731
participants who were included in both surveys.
https://doi.org/10.1371/journal.pone.0132814.s002
(DOC)
S2 Table. Prevalence of pre-hypertension and the prevalence, awareness, treatment and control of
hypertension among females and males who completed the surveys in 2001 and 2010 (excluding the
data of 731 participants that completed both surveys) S2 Table shows the prevalence, awareness,
treatment and control of hypertension in 2001 and 2010, after excluding the data of the 731
participants who were included in both surveys.
https://doi.org/10.1371/journal.pone.0132814.s003
(DOC)
S3 Table. Hypertension control rate of the all participants who completed the surveys in 2001 and
2010 (excluding the data of 731 participants who completed both surveys) (JNC-8).
S3 Table shows the control rate of hypertension, according to the new treatment blood pressure goal
(JNC-8) of the elderly participants.
https://doi.org/10.1371/journal.pone.0132814.s004
(DOC)
Acknowledgments
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We thank Drs. Y Jiang, Q Chang, K Feng and WY Kang for research assistance with field work.

Author Contributions
Conceived and designed the experiments: YH LW. Performed the experiments: LW DLS JHW. Analyzed the
data: YH LW. Contributed reagents/materials/analysis tools: YH LW BJ DLS JHW ML SSY YYW. Wrote the
paper: YH LW.

Artikel 3:
Spiritual quality of life and spiritual
coping: evidence for a two-factor
structure of the WHOQOL spirituality,
religiousness, and personal beliefs
module
• Christian U Krägeloh,
• D Rex Billington,
• Marcus A Henning &
• Penny Pei Minn Chai

Background
The WHOQOL-SRPB has been a useful module to measure aspects of QOL related to
spirituality, religiousness, and personal beliefs, but recent research has pointed to potential
problems with its proposed factor structure. Three of the eight facets of the WHOQOL-SRPB
have been identified as potentially different from the others, and to date only a limited
number of factor analyses of the instrument have been published.

Methods
Analyses were conducted using data from a sample of 679 university students who had
completed the WHOQOL-BREF quality of life questionnaire, the WHOQOL-SRPB module,
the Perceived Stress scale, and the Brief COPE coping strategies questionnaire. Informed by
these analyses, confirmatory factor analyses suitable for ordinal-level data explored the
potential for a two-factor solution as opposed to the originally proposed one-factor solution.

Results
The facets WHOQOL-SRPB facets connected, strength, and faith were highly correlated with
each other as well as with the religious coping sub-scale of the Brief COPE. Combining these

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three facets to one factor in a two-factor solution for the WHOQOL-SRPB yielded superior
goodness-of-fit indices compared to the original one-factor solution.

Conclusions
A two-factor solution for the WHOQOL-SRPB is more tenable, in which three of the eight
WHOQOL-SRPB facets group together as a spiritual coping factor and the remaining facets
form a factor of spiritual quality of life. While discarding the facets connectedness, strength,
and faith without additional research would be premature, users of the scale need to be aware
of this alternative two-factor structure, and may wish to analyze scores using this structure.
Introduction
The importance of spirituality and existential concerns in health care settings has been firmly
established within the biopsychosociospiritual model [1], and is now increasingly recognized
beyond its initially limited applications with terminally ill and older patients [2]. A number of
questionnaires are available that measure various aspects of spirituality or spiritual wellbeing
[3], including the Spiritual Well-being Scale (SWBS) [4], the Functional Assessment of
Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp) [5], or the SpREUK (German
acronym for Spiritual and Religious Attitudes in Dealing with Illness) [6]. In their systematic
review, Monod et al. [7] identified 35 instruments that measure some aspects of spirituality in
clinical research, and they proposed a classification system that distinguishes between
measures of general spirituality, spiritual wellbeing, spiritual needs, and spiritual coping.

Spirituality, religiousness, and existential concerns have also become a major component of
health-related quality of life (HRQOL) [8] and thus part of so-called patient-reported
outcome measures [9,10]. The World Health Organization Quality of Life (WHOQOL) tools
provide a particularly attractive suite of HRQOL instruments due to its original development
as part of international collaborations spanning across 15 centers in 14 countries and its
ability to claim strong cross-cultural validity [11]. During the development of its HRQOL
instruments, the WHOQOL Group recognized the importance of spirituality to HRQOL [12],
which was subsequently included in the WHOQOL-100 questionnaire as a domain
alongside physical, psychological, levels of independence, social relationships,
and environmentalQOL [11]. In the 26-item abbreviated version of the questionnaire, the
WHOQOL-BREF, spirituality is no longer a stand-alone domain, but one item about
existential considerations (meaningful life) was carried over into the psychological domain
[13]. To enable more detailed investigations of spirituality and QOL, the WHOQOL-SRPB
was later developed using the same international collaborative methodology of the original
WHOQOL [14]. This questionnaire module contains eight facets of spirituality, religiousness,
and personal beliefs (connectedness to a spiritual being or force, meaning of
life, awe, wholeness and integration, spiritual strength, inner peace/serenity/harmony, hope
and optimism, and faith) expressed by four items each. Items are worded in ways that do not
make any particular assumptions and are thus applicable to individuals with a range of
different spiritual, religious, and personal beliefs.

The article reporting on the development of the 32-item WHOQOL-SRPB module [14] only
reported preliminary results of the factor structure of the instrument. Using an exploratory
factor analysis, an eight-factor solution for the module was proposed, with each facet being a
separate factor. When testing their French translation of the WHOQOL-SRPB, Mandhouj et
al. [15] were not able to replicate this factor structure, with the largest deviation being
that connectedness to a spiritual being or force and faith loaded together as one factor. At
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that stage, concerns with the instrument’s conceptual clarity had already been raised:
Moreira-Almeida and Koenig [16] argued that the three facets faith, connectedness to a
spiritual being or force, and spiritual strength are different from the other facets in that they
appear to reflect coping strategies rather than spiritual wellbeing. As with Mandhouj et al.
[15], Krägeloh et al. [17] found that faith, connectedness to a spiritual being or force,
and spiritual strength were highly correlated, and this high collinearity
prevented faith and connectedness to a spiritual being or force from being entered as
predictors in a multiple linear regression. Unlike the other facets that were positive predictors
of WHOQOL-BREF domains in this regression analysis, spiritual strength produced
significant negative associations, further highlighting that this facet may be conceptually
different from the others [17].

The only study so far [18] reporting on results from a confirmatory factor analysis conducted
with the WHOQOL-SRPB [14] module also reported some potential deviations from its
original structure. When testing a six-factor model by adding items of the WHOQOL-SRPB
module to the spirituality domain of the WHOQOL-100, excellent fit indices were obtained.
However, based on a preceding exploratory factor analysis, the facets hope and inner
peacewere not included. While the authors [18] concluded that spiritual QOL made a
significant independent contribution to overall QOL, they also raised the possibility of
multidimensionality of spiritual QOL.

Very recently, an abbreviated version of the WHOQOL-SRPB (so-called WHOQOL-SRPB

BREF) has been developed [19]. The WHOQOL-SRPB was shortened by selecting the most
suitable item from each of the eight SRPB facets and the one spirituality item (meaning in
life) located in the psychological domain of the WHOQOL-BREF. An exploratory factor
analysis of these nine items revealed two factors, with faith, connectedness to a spiritual
being or force, spiritual strength, and wholeness and integration loading together. When
conducting an exploratory factor analysis of the nine SRPB items together with the
WHOQOL-BREF, the authors observed some deviations from the established factor structure
of the WHOQOL-BREF, but concluded that a five-factor solution was tenable in which the
nine SRPB items form a fifth domain alongside the four WHOQOL-BREF domains
of physical, psychological, social, and environmental QOL.

Clearly, more detailed investigations of the factor structure of the WHOQOL-SRPB are
needed, particularly using confirmatory factor analysis. The purpose of the present study was
to provide such an investigation, particularly of the suggestion that this measure of spiritual
QOL may be multidimensional [18] and may contain one factor that could be more accurately
described as spiritual coping [17]. The dataset by Chai et al. [20] was suitable for this purpose
since participants had completed the WHOQOL-BREF, WHOQOL-SRPB, as well as the
Brief COPE as a measure of coping strategies [21] and the Perceived Stress Scale (PSS) [22].
Using this sample of 679 university students, we used confirmatory factor analysis
appropriate for ordinal-level data to explore the potential for an alternative two-factor
solution for the WHOQOL-SRPB module.
Methods
Participants
The present study investigated the psychometric properties of the WHOQOL-SRPB using a
dataset that had previously been published as an article on the relationships between QOL,
coping, and spirituality, religiousness, and personal beliefs [20]. This dataset was from a
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sample of 679 university students in New Zealand and was suitable for the present purposes
as it contained measures from the WHOQOL-SRPB [14], the Brief COPE questionnaire [21],
the PSS [22], and the New Zealand version of the WHOQOL-BREF [23], also validated for
use with students [24]. Detailed demographic information about the sample was reported by
Chai et al. [20]. As the data were obtained from university students, the average age of the
participants was relatively low (M = 22.83, SD = 6.88). Around 73% of the students were
female students, and approximately half of the participants reported being affiliated with a
religious faith.

Instruments
WHOQOL-BREF
The 26-item WHOQOL-BREF questionnaire is available as a validated New Zealand version
[23] and has also been validated for use in medical students [24]. All items are scored on a
five-point Likert scale, and missing items were imputed by the rounded average of the other
items of the same domain, but only if less than half of the items in that domain were missing.
Two items measure global QOL and health, and the remaining 24 items are part of one of the
following four domains: physical QOL (seven items), psychological QOL (six items), social
relationships (three items), and environmental QOL (eight items). The psychological domain
of the WHOQOL-BREF contains one item from the spiritual QOL domain of the WHOQOL-
100 [13]. For the present purposes of comparing previously proposed WHOQOL-BREF
factor structures with alternatives, this item was assigned to the spiritual QOL domain,
consistent with previous approaches [19]. The number of items in the psychological domain
therefore decreased to five.

WHOQOL-SRPB
The 32-item WHOQOL-SRPB module [14] contains eight facets of spirituality, religiousness,
and personal beliefs (connectedness to a spiritual being or force, meaning of
life, awe, wholeness and integration, spiritual strength, inner peace/serenity/harmony, hope
and optimism, and faith) that are worded in ways that are considered acceptable to
participants of a wide range of religious and nonreligious beliefs [2].

Brief COPE
This 28-item questionnaire measures 14 different adaptive and maladaptive dispositional
coping strategies, expressed by two items each [21]. These include active
coping, planning, positive reframing, acceptance, humor, religion, using emotional
support, using instrumental support, self-distraction, denial, venting, substance
use, behavioral disengagement, and self-blame. The first eight coping strategies are generally
considered as adaptive, and the remaining six as maladaptive. However, the factor structure
of the questionnaire is unstable, and a wide variety of higher-order factor structures have
been proposed [25]. The present study analyzed scores of the individual strategies by
summing the score of the two items of each strategy, without proposing any higher-order
structure. While the Brief COPE is typically administered using a four-point Likert scale,
Chai et al. [20] used a five-point scale instead. Missing data were not imputed for the Brief
COPE, which means that no sub-scales scores were calculated when at least one item on that
sub-scale was missing.

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PSS
This 14-item questionnaire inquires about the stress level perceived by the respondent during
the past month [22]. A summary score was calculated yielding an overall level of perceived
stress.

Data analysis
Confirmatory factor analyses were conducted using LISREL v. 8.80, and all remaining data
analyses with IBM SPSS v. 22.0. Two types of confirmatory factor analyses were conducted.
Firstly, the factor structure of the 32-item WHOQOL-SRPB module was evaluated by
comparing the simplest factor solution (with all facets being a separate factor which in turn
load onto a higher-order spiritual QOL factor) versus an alternative model that was informed
by the analyses of the Chai et al. [20] dataset outlined below. These analyses explored
whether postulating a second higher-order factor (spiritual coping) may be a tenable
alternative to be tested by confirmatory factor analysis. Secondly, the five-factor solution of
the WHOQOL-BREF (with spiritual QOL as a fifth domain) proposed by Skevington et al.
[19] was compared to alternative models that were also based on the analyses conducted on
the Chai et al. [20] dataset.

As the data were ordinal in nature, confirmatory factor analyses used an asymptotically
distribution free (ADF) method with polychoric correlations and asymptotic co-variance
matrices [26,27]. For small to moderate sample sizes, the method of diagonally weighted
least squares is recommended as a suitable ADF method [27], and was therefore also selected
for the present study. Error variances were not allowed to be correlated. Since chi-square
values tend to become inflated with increases in sample size [28], model fits were evaluated
using a set of goodness-of-fit indices: root mean square error of approximation (RMSEA),
comparative fit index (CFI) and standardized root mean square residual (SRMR). Following
the frequently quoted guidelines by Hu and Bentler [29], model fits were considered
acceptable if RMSEA < 0.06, CFI > 0.90, and SRMR < 0.08.
Results
Table 1 shows the correlations of the eight WHOQOL-SRPB facets with each other and the
global QOL item. All SRPB facet scores were significantly correlated with each other,
typically with values of rho around .50 or .60. The three facets connectedness, strength,
and faith were highly correlated with each other, with correlation coefficients exceeding .80.
None of these three facets were correlated with the global QOL item. The remaining items
were significantly correlated with global QOL, and correlation coefficients ranged from .16
to .30.

Table 1 Spearman’s rho correlation coefficients for the overall QOL item from the
WHOQOL-BREF and the eight facet scores of the WHOQOL-SRPB

Full size table

The following analysis explored the contribution of each facet to overall QOL, while also
controlling for perceived stress. Using a hierarchical linear regression, the demographic
variables age and gender were entered in the first block, followed by the facet scores and
perceived stress in the second block. Due to issues of collinearity, the
facets connectednessand faith were not entered. Meaning of life, wholeness, and inner

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peace did not significantly predict overall QOL (Table 2). Awe, inner peace, and hope were
positive predictors of overall QOL, but strength and perceived stress presented with a
negative associations.

Table 2 Results from a hierarchical multiple-linear regression (unstandardized

coefficient B and standardized coefficient β) with the overall QOL item from the WHOQOL-
BREF as the outcome variable and with age and gender as predictor variables in the first
block, followed by the WHOQOL-SRPB facets and the PSS summary score as predictors in
the second block

Full size table

Table 3 presents correlations of all WHOQOL-SRPB facets with the coping strategies scores
of the Brief COPE. With the exception of humor, adaptive coping strategies were generally
significantly correlated with the SRPB facet scores. Most of these correlations were relatively
small, only occasionally exceeding .30. The coping strategy religion, in contrast, showed
high correlations with connectedness, strength, and faith (>.70), moderate correlations
with meaning of life and wholeness (>.40), and small to moderate correlations
with awe, inner peace, and hope (>.20). The relationship between SRPB facets and
maladaptive coping strategies was less clear, with generally small and negative correlations.

Table 3 Spearman’s rho correlation coefficients for the Brief COPE sub-scale scores and the
eight facet scores of the WHOQOL-SRPB

Full size table

The first confirmatory factor analyses tested the factor structure of the WHOQOL-SRPB
module alone, in which all facets were part of one higher-order spiritual QOL factor (Model
1). Informed by the preceding analyses that correlated SRPB items with coping measures, an
alternative factor solution (Model 2) was tested which subsumed the three
facets connectedness, strength, and faith under one higher-order factor (spiritual coping) and
the remaining ones under another one (spiritual QOL). Table 4 shows a summary of the
good-of-fit indices for the two alternative models. The improvement of the nested model with
two higher-order factors compared to the model with one higher-order factor was significant
(χ2(1) = 1005.51, p < .01). Values of RMSEA, CFI, and SRMR also indicated strongly that the
solution with two higher-order factors was superior. The results of fitting the data to Models
1 and 2 are also shown in Figures 1 and 2, respectively.

Table 4 Goodness-of-fit indicators of alternative models: Satorra-Bentler scaled χ2 ,

RMSEA, CFI, and SRMR

Full size table

Figure 1

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Results from fitting the data to Model 1.

Full size image

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Figure 2

Results from fitting the data to Model 2.

Full size image

The second confirmatory factor analyses tested the five-factor structure of the WHOQOL-
BREF (Model A) with one item from the psychological domain and one item from each of

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the eight facets of WHOQOL-SRPB module (meaning of life, awe, wholeness and
integration, inner peace/serenity/harmony, and hope and optimism) forming a fifth domain
alongside physical QOL, psychological QOL, social relationships, and environmental QOL
of the WHOQOL-BREF. This structure was proposed by Skevington et al. [19] for the
WHOQOL-SRPB BREF, the abbreviated version of the WHOQOL-SRPB. Fits were
compared to Model B that had the same five-factor structure but that did not contain the three
SRPB facets connectedness, strength, and faith. These facet items were not included in
Model B as they appeared to be items that were more related to coping. In the six-factor
structure of Model C, these three facet items were included but were grouped into an
additional separate spiritual coping factor (connectedness, strength, and faith) alongside the
five factors of Model B. Both Model B and Model C exhibited clearly improved fit indices
compared to Model A (Table 4), and the nested Model C provided a significantly better fit
than Model A (χ2(1)=1249.59, p<.01). The results of fitting the data to Models A, B and C are
also shown in Figures 3, 4, and 5, respectively. Note the low factor loadings for the
WHOQOL-BREF items 3 (being free of pain) and 4 (free of dependence on medicine and
treatment) exhibited low factor loadings.

Figure 3

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Results from fitting the data to Model A.

Full size image

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Figure 4

Results from fitting the data to Model B.

Full size image

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Figure 5

Results from fitting the data to Model C.

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 Full size image

Discussion
The present study adds important new empirical evidence to the limited formal investigations
that have been conducted so far on the factor structure of the WHOQOL-SRPB. The article
on the original development of the instrument reported results from a preliminary exploratory
factor analysis where the four items from each facet loaded together as separate factors [14].
As these analyses were conducted on a global dataset of more than 5,000 participants in 18
countries around the world and collected using standard WHOQOL procedures, isolated
reports [15] from individual countries about deviations from this factor structure may be of
relatively limited concern. However, the fact that deviations from the factor structure had
emerged repeatedly and were generally driven by similar facets [15,19] highlighted the need
for further investigation. The present study confirmed previous hypotheses [16,17] that the
facets connectedness, strength, and faith are more accurately described as spiritual
coping than spiritual QOL. Unlike the other WHOQOL-BREF facets, these three facets were
particularly highly correlated with the religious coping sub-scale of the Brief COPE [21].
Grouping these three facets together as a separate factor also resulted in more tenable
solutions in the confirmatory factor analyses.

Considerable debate has centered around the distinctions between various aspects of
spirituality and measures purporting to assess the role of spirituality in health care settings
[30]. If the WHOQOL-SRPB is used as a measure of spirituality, correlations with wellbeing
will be tautological, as items refer to positive affect and positive human traits such as
altruistic values and activities [16,30]. However, the WHOQOL-SRPB was never intended to
be a measure of spirituality. The original authors of the scale [14] described it as spirituality,
religiousness, and personal beliefs as they relate to HRQOL, and Skevington et al. [19]
explicitly used the expression spiritual QOL to capture the aspects of the items in that
module. In the classification system proposed by Monod et al. [7], the WHOQOL-SRPB is
recognized as a measure of spiritual wellbeing. Results from factor analyses clearly place the
SRPB items as a separate domain of HRQOL [18,19], and the present study confirms these
findings.

In a measure of spiritual QOL, then, do facets of spiritual coping (connectedness, strength,

and faith) have a role to play or does their inclusion diminish the conceptual clarity of the
WHOQOL-SRPB? In other words, are these facets best to be dropped from the WHOQOL-
SRPB such as in Model B or should they to be retained as a separate factor such as in Model
C? The principles of parsimony and simplicity favor Model B that excludes the
facets connectedness, strength, and faith as they are more related to coping rather than QOL.
The results from the confirmatory factor analyses indicate that the precision of the instrument
is also improved that way. However, arguments can also be made for retaining these facets.
First of all, extensive and thoroughly conducted focus group work around the world
repeatedly highlighted these facets as important to spiritual QOL for participants with a wide
range of spiritual, religious, and personal beliefs [2,14,19]. Connectedness, in particular, is
considered a core element of spirituality [30], and the issues with this facet thus appear to be
related more to the way it is worded. One avenue for future research may thus be attempting
to re-word the items from the connectedness, strength, and faith facets so that they express
more clearly aspects of spiritual wellbeing rather than coping. On the other hand, items
inquiring about spiritual coping may be a means to capture spiritual distress—an aspect

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typically not covered in measures of spiritual wellbeing [7]. This may increase the precision
of the instrument [7] and acknowledge the fact that spirituality and spiritual QOL may not be
associated exclusively with adaptive aspects of coping but equally with unsuccessful and
maladaptive coping strategies [31].

A limitation of the present study is that analyses were conducted on a dataset from a sample
of university students. Certain model misfits such as the low factor loadings for the
WHOQOL-BREF items 3 (being free of pain) and 4 (free of dependence on medicine and
treatment) obtained here and similar problems with these items reported elsewhere [24,32]
appear to be related to the collection of this type of information from samples with
predominantly young people. Future work will need to confirm these findings with
participants of a wider age range and with both healthy and ill participants, as is typically the
case in WHOQOL work [12,14]. Furthermore, the present study inquired about participants’
dispositional coping strategies. Rather than assessing coping strategies in response to acute
stress, assessment of dispositional coping relies on participants reflecting back on how they
generally cope with stress, which is likely to be affected by retrospective bias.

To conclude, the present study adds to the limited number of studies that have formally
investigated the factor structure of the WHOQOL-SRPB. Analyses confirmed previous
hypotheses that the three facets connectedness, strength, and faith tap into a slightly different
concept than the remaining five facets of the WHOQOL-SRPB. Patterns of correlations with
measures of coping strategies and subsequent confirmatory factor analyses revealed that these
three facets may be better described as facets of spiritual coping. However, discarding the
facets connectedness, strength, and faith without additional research would be premature. The
extensive focus group work during the development of the WHOQOL-SRPB noted the
importance of these facets to QOL [14], and future research may thus attempt to re-word
these facets so that they are expressed as spiritual QOL rather than spiritual coping. In the
mean time, users of the scale need to be aware of its alternative two-factor structure, and may
even wish to analyze scores in this manner, depending on circumstances of application.
While inclusion of connectedness, strength, and faith has advantages in terms of content
validity, precision of the instrument is improved if they are removed or analyzed as a separate
domain.

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