Spirituality as intrinsic motivational factor and health related quality of life among hospitalized male patients practicing Hinduism in India.

Introduction: Intrinsic motivation denotes doing an activity for itself and deriving pleasure and satisfaction from involvement. Intrinsic spirituality as the most important motive or driving factor in a person's life has a significant influence on the perception of one's own physical and psychological health, social relationships, and environmental health. Aim: The study aims to investigate the influence of intrinsic spirituality as a motivational factor on the dimensions of health-related quality of life (HRQoL) among hospitalized patients. Materials and
Methods: Three hundred and sixty-seven patients admitted to a tertiary hospital were selected by stratified random sampling from different medical and surgical wards. Patients comprised Hindu male patients, mean age 36 (standard deviation = 13.2) years suffering from either medical or surgical disorders of minor-to-moderate intensity. Measures of Intrinsic Spirituality Scale and WHOQOL-BREF were administered to assess their intrinsic spirituality and the four dimensions of HRQoL, namely physical and psychological health, social relationships, and environmental quality of life. Data of 325 patients (42 participants eliminated in data cleaning process) were analyzed using SPSS version 25 for Pearson's correlation, and regression analysis.
Results: Higher scores on intrinsic spirituality were found to be positively impact overall quality of life and general health (r = 0.169, P = 0.002; ß =0.180, P = 0.001), psychological health (r = 0.149, P = 0.007; ß =0.151, P = 0.006), social relationships (r = 0.123, P = 0.026; ß =0.133, P = 0.016), and environmental health perception (r = 0.211, P = 0.000; ß =0.22, P = 0.000) and were not significantly correlated with physical health perception (r = 0.091, P = 0.10; ß =0.093, P = 0.094).
Conclusion: Spiritual motivation significantly predicts better psychological, social, and environmental health perception among hospitalized male Hindu patients. Realistic perception with respect to physical health is also reflected in this study. Copyright:

Motivation is a driving force that gives purpose or direction to behavior and it operates at both conscious and unconscious levels among humans.[1] Self-determination theory describes motivation on a continuum, ranging from amotivation (nonmotivation) to intrinsic motivation based on different reasons or goals that give rise to action.[2] Intrinsic motivation involves the performance of any action for inherent satisfaction rather than for some separable consequence.[2] Satisfaction of the need for competence (self-efficacy), autonomy (perceived locus of causality), and relatedness are known to enhance the intrinsic motivation and persistence of the goal-directed behavior.[2] Spirituality has been defined as “an intrinsic phenomenon, a personal, experiential connectedness with transcendence or ultimate reality that is expressed in ones beliefs and behaviors.”[3] Intrinsic religion has been shown to clearly manifest some type of connectedness with transcendence as the central theme and provided the master motive for life directing one's thoughts and actions.[4] Intrinsic religion could be tapped as an internalized spiritual commitment of individuals from the six-item Intrinsic Spirituality Scale (ISS) (Hodge, 2003) which can assess the degree to which spirituality functions as a master motive for both theistic and nontheistic populations within and outside religious framework.[4] A recent study that investigated intrinsic spirituality as a context for motivation revealed that intrinsic spirituality in the workplace significantly functions as a person's master motive.[5] In another study on patients suffering from lung and large bowel cancer (mean age of 60 years), it was reported that those with higher levels of intrinsic spirituality had more effective coping mechanisms with stressful situations by developing their own capacities and potentialities (intrapsychic processes) as compared to those with lower levels of intrinsic spirituality.[6] Intrinsic spirituality was observed to reduce psychological distress in the face of stressful situations by promoting adaptive coping behaviors and reducing avoidance coping among culturally and religiously diverse undergraduate students.[7] In yet another study on orthodox and nonorthodox Jewish community, it was reported that intrinsic religiosity had a protective or moderating effect to ameliorate the influence of poor physical health on depression symptoms significantly; it had an ameliorating effect also on clinical levels of depression even after controlling for social support.[8] It was also reported that intrinsic religiousness, spiritual maturity, and self-transcendence were significantly predictive of better mental health and positive psychological functioning even among adolescents and young adults.[9] In one study involving a sample of religious students, it was found that 98.6% of the sample was intrinsically oriented. Intrinsic religiousness was found to be positively correlated with self-control and better personality functioning and negatively correlated with anxiety; there was no correlation with irrational beliefs or depression.[10]

Several empirical studies conducted in the past integrating spirituality and health in conditions of chronic illnesses such as diabetes, hypertension, coronary heart disease, kidney diseases, joint disorders, spinal and other neurological disorders, autoimmune diseases, HIV infections, cancers, debilitating illnesses, psychological stress disorders, and anxiety disorders revealed that the quality of life led by these patients irrespective of the health outcome was significantly and positively influenced by their spirituality.[11] They reported a subjective feeling of well-being, a meaning and purpose in life, and healthy acceptance of the prevailing condition.[11] Quality of life is “the conscious cognitive judgment of satisfaction with one's life and individual perception of the position in the context of the culture and value system in which they live and their relation to their goals, expectations, standards and concerns.”[12] Previous research has demonstrated intrinsic spirituality to have a positive influence on a better health-related quality of life (HRQoL) in both physical and psychological health domains. The present study was intended to specifically investigate the role of spirituality as a master motive, i.e. intrinsic motivational factor and its influence on the various domains of HRQoL among hospitalized male patients following Hinduism.

MATERIALS AND METHODS

The sample consisted of 367 participants who were patients with minor-to-moderate illness admitted to a tertiary hospital selected through stratified random sampling from the medical, surgical, skin, and other wards of the hospital (data of 325 participants were analyzed as 42 were eliminated in the data cleaning process).

Inclusion and exclusion criteria

Stable male patients above the age of 16 years with minor-to-moderate illnesses, education 10th standard belonging to Hindu religious faith, or those with Vedic belief were included in the study. Critically ill patients, age <16 years, and those without belief in Vedic philosophy were excluded. The purpose was to control the influence of confounding factors such as gender, religious faith, and severity of illness. Incidentally, Hindus formed the majority of the sample and hence non-Hindus were excluded from the study. The possibility of gender differences in spirituality, mental health, and quality of life is eliminated by having only male patients in the sample. Critically ill patients are both physically and mentally unstable and their responses are not reliable and cannot be stable over time.

Tools

(a) Demographic questionnaire to gather information about participant details such as name, age, gender, education, family type, ethnicity (region of India), comorbidity, and medication. (b) ISS (David R Hodge, 2003): It is a six-item scale for assessing the salience of spirituality as a motivational construct. ISS assesses the degree to which spirituality plays a vital role as an individual's master motive in his life. The scale has good reliability coefficients (Cronbach's alpha of 0.96) and also has reasonably good construct validity (RMSEA value of 0.062 suggesting good fit) and a high concurrent validity with original scale of intrinsic religion (r = 0.911, P < 0.001). ISS (translated to Hindi) was administered in the present study and it had significantly high correlation with standardized Spiritual Beliefs Scale (SBS-NHD) developed by Neelam Deshmukh and Hemanth Deshmukh for Indian population (r = 0.632, P = 0.01) and Beliefs and Values Scale by King et al., 2006 (r = 0.654, P = 0.01). The potential respondents were oriented to the phrase completion method with a brief introductory paragraph. Spirituality was defined in a manner that included both theistic and nontheistic expressions of connectedness with ultimate transcendence. An incomplete sentence fragment is provided, followed directly below by two phrases that are linked to a scale ranging from 0 to 10. The phrases, which complete the sentence fragment, anchor each end of the scale. The 0–10 range provided the participant with a continuum on which to reply, with 0 corresponding to absence or zero amount of the attribute, while 10 corresponding to the maximum amount of the attribute. The total score divided by six gives the mean score of ISS where spirituality acts as a motivating factor in a person's life (range of zero to ten).[4]

Example: In terms of the questions I have about life, my spirituality answers.

No questions 0 1 2 3 4 5 6 7 8 9 10 absolutely all my questions.

The other items include the following statements: Growing spiritually is more important than anything else in life... of no importance to me; when I am faced with an important decision, my spirituality plays absolutely no role....is always the overriding consideration; spirituality is the master motive of my life directing every other aspect of my life....not part of my life; When I think of the things that help me to grow and mature as a person, my spirituality has no effect on my personal growth….is absolutely the most important factor in my personal growth; My spiritual beliefs affect absolutely every aspect of my life…No aspect of my life.[4]

(c) WHOQOL-BREF[13] has 4 domains and 26 items. The four major domains are physical, psychological, social relationships and environment. In addition, it contains one item each for the overall quality of life and general health. It had shown good discriminant validity, content validity, and test–retest reliability in the past. It has a wide application in medical practice, research, audit, and also health policymaking. The tool helps in evaluation of medical treatment and the changes in quality of life over the course of treatment, patients’ perception of the quality, and availability of health care, how disease impairs or impacts the subjective well-being of a person across a whole range of areas. It is either self-administered if respondents have sufficient ability or interviewer-assisted or interview-administered forms are also available.

Procedure

Data were collected in small groups of 10–15 participants in each group. It was collected in a hospital setting. Ethical clearance and administrative permission were obtained from the authorities to carry out the study. Data were collected at the same time, i.e., 1000 h to 1200 h on all days for all the groups. Data were collected from different wards randomly. A rapport was built with the group. The purpose of the study was conveyed and informed consent was taken from the group. All of them had a basic qualification of 10th standard. The answer sheets were distributed to all the participants. Demographic data sheet was filled by them. The translated Hindi version of each statement was read out to the group, and they gave their responses in the answer sheets. Both the instruments were administered same time ISS followed by WHOQOL-BREF. It took around 30 min to complete the entire procedure.

Statistical analysis

IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp, a predictive analytics software was used for Pearson's product-moment correlation, multiple linear regression analysis, and post hoc (Tukey's HSD) test of the data.

RESULTS

All were male patients belonging to Hindu religion. The mean age was 36.0 (standard deviation = 13.2) years; 75% of them had basic education up to XII grade and 25% had higher education of graduation and above. Family environment in general was religious and spiritually oriented (96.7%). Only 3.3% confessed to be belonging to nonreligious families. 72.2% of the participants were married, 26.7% were unmarried, and the rest were separated/widowed. The participants belonged to different parts of India including Delhi (9.8%), North India (56.7%), South India (18.5%), North East India (8.2%), and western India (6.8%). 77.1% of them were employed in a government job. The distribution of patients from various wards of the hospital comorbidity wise includes diabetes (3.8%), hypertension (5.3%), heart problems (7.9%), respiratory illness (3.9%), skin ailments (10.2%), gastrointestinal problems (11.7%), arthritis or joint pains (11.7%), neck and back pain (4.5%), neurological problems (17.2%), obesity (1.3%), sleep problems (3%), anxiety (3%), depression (1.4%), other psychiatric problems (0.8%), surgeries (7.5%), and other minor illnesses (13.9%). Of these patients, 54.2% were on regular continuous medication.

Table 1 shows that the group with higher levels of intrinsic spirituality total scores also scored higher in the domains of WHOQOL, namely overall QoL, physical health, psychological health, social relationships, and environmental QoL.

Table 1

The descriptive statistics of WHOQOL domains based on the levels of Intrinsic Spirituality Scale

ISS_Total score (level)	Mean	SD	n
OQL_amp_GH
Low	7.12	1.689	84
Moderate	7.42	1.637	175
High	8.32	1.816	66
Total	7.52	1.735	325
Physical_Health
Low	24.17	3.158	84
Moderate	24.46	3.729	175
High	25.06	3.926	66
Total	24.51	3.634	325
Psychological
Low	20.99	3.685	84
Moderate	21.89	3.407	175
High	22.70	4.121	66
Total	21.82	3.668	325
Social
Low	11.45	2.690	84
Moderate	12.06	2.103	175
High	12.48	2.910	66
Total	11.99	2.461	325
Environment
Low	27.42	6.237	84
Moderate	29.01	5.453	175
High	32.27	7.651	66
Total	29.26	6.359	325

SD: Standard deviation, ISS: Intrinsic Spirituality Scale, OQL_GH: Overall quality of life and general health

Correlation between the domains of intrinsic spirituality (independent variable) with health-related quality of life (dependent variables)

From Table 2, it can be observed that the scores of intrinsic spirituality are significantly and positively correlated with overall quality of life and general health, psychological health, social relationships, and environmental health perception but not with physical health domain.

Table 2

The correlation of Intrinsic Spirituality Scale total score with the dependent variables overall quality of life and general health, physical health, psychological health, social relationships, and environmental health perception

ISS_Total	OQL_GH	Physical	Psychological	Social	Environment
Pearson correlation	0.169	0.091	0.149	0.123	0.211
Significant (two-tailed)	0.002	0.101	0.007	0.026	0.000
n	325	325	325	325	325

ISS: Intrinsic Spirituality Scale, OQL_GH: Overall quality of life and general health

Linear regression of intrinsic spirituality scores (independent variable) with health-related quality of life domains (dependent variables)

Table 3 confirms that ISS has a significant positive impact on the overall QoL and general health, psychological health, social relationships, and environmental QoL but not the physical health. On further post hoc analysis (Tukey's HSD test), the group with high levels of ISS total scores had significantly higher levels of overall QoL and general health, psychological health, social relationships, and environmental QoL, as shown in Table 4.

Table 3

The impact of Intrinsic Spirituality Scale total score on the dependent variables overall quality of life and general health, physical health, psychological health, social relationships, and environmental health perception

ISS_Total	OQL_GH	Physical	Psychological	Social	Environment
Beta-coefficient (SD)	0.180	0.093	0.151	0.133	0.22
Significant	0.001	0.094	0.006	0.016	0.000
n	325	325	325	325	325

SD: Standard deviation, ISS: Intrinsic Spirituality Scale, OQL_GH: Overall quality of life and general health

Table 4

Post hoc (Tukey’s HSD test) analysis of WHOQOL domains based on the levels of Intrinsic Spirituality Scale total scores

Dependent variable	Comparison groups	Mean difference (SE)	Significance
OQL_GH	1.0 and 3.0	−1.20 (0.28)	0.000
	2.0 and 3.0	−0.90 (0.24)	0.001
Psychological health	1 and 3	−1.71 (0.60)	0.013
Social relationship	1 and 3	−1.03 (0.40)	0.029
Environmental QoL	1 and 3	−4.86 (1.01)	0.000
	2 and 3	−3.27 (0.89)	0.001

1.0: Low level of ISS total scores, 2.0: Moderate level of ISS total scores, 3.0: High level of ISS total scores, ISS: Intrinsic Spirituality Scale, SE: Standard error, OQL_GH: Overall quality of life and general health, HSD: Honest significant difference

From Tables 3 and 4 results, it has been observed that the scores of intrinsic spirituality are significant predictors of overall quality of life and general health, psychological health, social relationships, and environmental health perception. However, ISS did not predict the physical health of the study sample.

DISCUSSION

The influence of intrinsic spirituality on one's own perception of general well-being among individuals afflicted with various comorbid conditions was already established in the previous studies.[11] The present study was conceived to investigate what would be the perception about one's own health when intrinsic spirituality became a master motive or the sole motivating factor in each and every event or aspect of life. The findings of the study brought out that intrinsic spirituality as a motivating factor in life was a significant predictor and had a positive impact on the domains of psychological health, social relationships, environmental health, and the overall quality of life including the general health similar to the findings of the previous studies.[11] However, the relationship between physical health and spiritual motivation was not significant which indicates that the individuals were fully aware of their illness and suggests acceptance of their prevailing health condition.[11] Perception of psychological well-being, social relationships, and satisfaction with the available facilities or environmental quality of life suggests that spirituality as an intrinsic motivational factor probably enhances the intrapsychic processes (capabilities and potentialities) to adopt better coping mechanisms in overcoming challenging situations and this needs further investigation in future studies.[6789] It also indicates the possible moderating influence of spirituality as an intrinsic motivational factor in promoting the HRQoL in poor physical health conditions.[8] Spirituality is such an intrinsic phenomenon and does promote the cultivation of the traits such as self-efficacy, autonomy, and relatedness, thus serving as an intrinsic motivational factor in life.[234]

CONCLUSION

The findings of the study corroborated with those of previous studies that intrinsic spirituality improves the HRQoL. Spirituality as an intrinsic motivational factor is found to influence the HRQoL positively in the domains of psychological health, social relationships, and environmental health. However, it is not significantly related to the domain of physical health, suggesting realistic acceptance of the prevailing health condition. Spirituality as a master motive of life plays a vital role in healthy and better psychosocial functioning in faces of unexpected challenging experiences, adverse physical health conditions, or losses in life along with simultaneous realistic acceptance of the prevailing condition. Promotion of spirituality as an intrinsic motivational factor in life can be adopted as part of person-centered counseling for individuals requiring overcoming challenging situations.

Limitations of the study

The study involved a homogenous sample of male patients and only Hindus. Further studies need to be carried out with a large-scale sample involving different cohorts both male and female groups, different age groups, different religious and nonreligious faiths, different chronic health conditions, and also acute illnesses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.