title: The measurement of spirituality in palliative care and the content of tools validated cross-culturally: a systematic review.
abstract: BACKGROUND
  Despite the need to assess spiritual outcomes in palliative care, little is known about the properties of the tools currently used to do so. In addition, measures of spirituality have been criticized in the literature for cultural bias, and it is unclear which tools have been validated cross-culturally.
  
  
  OBJECTIVE
  This systematic review aimed to identify and categorize spiritual outcome measures validated in advanced cancer, human immunodeficiency virus (HIV), or palliative care populations; to assess the tools' cross-cultural applicability; and for those measures validated cross-culturally, to determine and categorize the concepts used to measure spirituality.
  
  
  METHODS
  Eight databases were searched to identify relevant validation and research studies. An extensive search strategy included search terms in three categories: palliative care, spirituality, and outcome measurement. Tools were evaluated according to two criteria: 1) validation in advanced cancer, HIV, or palliative care and 2) validation in an ethnically diverse context. Tools that met Criterion 1 were categorized by type; tools that also met Criterion 2 were subjected to content analysis to identify and categorize the spiritual concepts they use.
  
  
  RESULTS
  One hundred ninety-one articles were identified, yielding 85 tools. Fifty different tools had been reported in research studies; however, 30 of these had not been validated in palliative care populations. Thirty-eight tools met Criterion 1: general multidimensional measures (n=21), functional measures (n=11), and substantive measures (n=6). Nine measures met Criterion 2; these used spiritual concepts relating to six themes: Beliefs, practices, and experiences; Relationships; Spiritual resources; Outlook on life/self; Outlook on death/dying; and Indicators of spiritual well-being. A conceptual model of spirituality is presented on the basis of the content analysis. Recommendations include consideration of both the clinical and cultural population in which spiritual instruments have been validated when selecting an appropriate measure for research purposes. Areas in need of further research are identified.
  
  
  CONCLUSIONS
  The nine tools identified in this review are those that have currently been validated in cross-cultural palliative care populations and, subject to appraisal of their psychometric properties, may be suitable for cross-cultural research.
authors.affiliation: Department of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom. lucy.selman@kcl.ac.uk
authors.forename: Lucy
authors.initials: L
authors.lastname: Selman
authors.forename: Richard
authors.initials: R
authors.lastname: Harding
authors.forename: Marjolein
authors.initials: M
authors.lastname: Gysels
authors.forename: Peter
authors.initials: P
authors.lastname: Speck
authors.forename: Irene J
authors.initials: IJ
authors.lastname: Higginson
mesh_terms: D003431:Cross-Cultural Comparison; D003469:Culture; D015658:HIV Infections / Q000523:psychology / Q000628:therapy; D006801:Humans; D009369:Neoplasms / Q000523:psychology / Q000628:therapy; D010166:Palliative Care / Q000379:methods*; D011594:Psychometrics; D029181:Spirituality; D016896:Treatment Outcome