1 Introduction. Patients with chronic diseases often report unmet needs during their struggle with illness. The needs of cancer

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1 Research Article Psychosocial and spiritual needs of patients with chronic diseases: validation of the Chinese version of the Spiritual Needs Questionnaire Arndt Büssing 1, Xiao-feng Zhai 2, Wen-bo Peng 2, Chang-quan Ling 2 1. Center for Integrative Medicine, Faculty of Medicine, University Witten/Herdecke, Herdecke, Germany 2. Changhai Hospital of Traditional Chinese Medicine, Second Military Medical University, Shanghai , China OBJECTIVE: Even in secular societies, a small portion of patients find their spirituality to help cope with illness. But for the majority of patients, psychosocial and spiritual needs are neither addressed nor even considered a relevant factor by health care professionals. To measure such specific needs, the Spiritual Needs Questionnaire (SpNQ) was developed. The aim of this study was to validate the Chinese version of the SpNQ (SpNQ-Ch) and thus to measure psychosocial and spiritual needs of Chinese patients. METHODS: This was a cross-sectional study among 168 patients with chronic diseases who were recruited in the Changhai Hospital of Traditional Chinese Medicine, Shanghai, China using standardized questionnaires. We performed reliability and factor analyses, as well as analyses of variance, first order correlations and regression analyses. RESULTS: The 17-item SpNQ-Ch had a similar factorial structure as the original version with two main and three minor factors which accounted for 64% of variance, and internal consistency estimates (Cronbach s α) ranging from 0.51 to Included were the 4-item scale Inner Peace Needs, the 5-item scale Giving/Generativity Needs, the 5-item scale Religious Needs (with 2 sub-constructs, Praying and Sources), and a 3-item scale Reflection/Release Needs. In Chinese patients with cancer (63%), pain affections (10%), or other chronic conditions (23%), the needs for Giving/Generativity (which refer to categories of Connectedness and Meaning) and Inner Peace Needs scored highest, while Religious Needs and the Reflection/Release Needs scored lower. CONCLUSION: The SpNQ-Ch is congruent with its primary version, and can be used in future studies with the mostly nonreligious patients from China. First findings indicate specific psychosocial and spiritual needs which should be addressed by health care professionals to support patients in their struggle with chronic illness in terms of psycho-emotional stabilization, finding hope and meaning, and thus achieving peaceful states of mind despite chronic illness. KEYWORDS: spirituality; chronic disease; psychology; adaptation, psychological; questionnaires DOI: /jintegrmed Büssing A, Zhai XF, Peng WB, Ling CQ. Psychosocial and spiritual needs of patients with chronic diseases: validation of the Chinese version of the Spiritual Needs Questionnaire. J Integr Med. 2013; 11(2): Received November 22, 2012; accepted December 26, Open-access article copyright 2013 Arndt Büssing et al. Correspondence: Arndt Büssing, MD, Professor; Arndt.Buessing@uni-wh.de. 1 Introduction Patients with chronic diseases often report unmet needs during their struggle with illness. The needs of cancer patients can be treatment-related physical problems (i.e., physical impairment, fatigue, sleep disturbance, side effects of treatment), psychological and social needs (i.e., emotional distress, depression, loss of sense of control, altered body image, impaired social function and March 2013, Vol.11, No Journal of Integrative Medicine

2 relationships), and informational and support needs (i.e., management of illness, prognosis, treatment options and side effects, support groups, complementary therapies) [1]. A recent study among patients with advanced cancer indicated the majority (72%) reported that their spiritual needs were supported minimally or not at all by the medical system, and 47% felt supported minimally or not at all by a religious community [2]. Studies have also shown that spiritual support from the medical team and pastoral care visits was significantly and positively associated with cancer patients quality of life [2,3], and those who lacked this support experienced more depressive symptoms, less meaningful lives, and less peace [4]. The combined findings of the above studies indicate that a large fraction of patients with specific spiritual needs are not being served by the health care system, even though such needs seem to be of significant importance to patients. To fully understand patient need in this area, one must critically assess whether the needs are truly spiritual, because they can also be categorized as existential or psychosocial, depending on the patient s own attitudes, views and convictions. Specific needs can be regarded as spiritual by patients with a religious background, while nonreligious individuals would interpret the same needs as existential and/or humanistic. In secular German patients for example, religious needs were strongly interrelated with existential needs, but only moderately so with needs for inner peace [5]. Moreover, one could identify secular spiritual needs which are of relevance for atheists/agnostics, and specific religious needs which are only of relevance for patients with a specific cultural and/or religious background. Recently, a conceptual framework for further research and clinical practice was suggested. It categorized four (interconnected) core dimensions of spiritual needs which can be attributed to the underlying categories of social, emotional, existential, and religious [6], or respectively, peace (inner peace, hope, balance, forgiveness, distress, fear of relapse, etc.), connection (love, belonging, alienation, partner communication, etc.), transcendence (spiritual resources, relationship with God/Sacred, praying, etc.), and meaning/purpose (meaning in life, self-actualization, role function, etc). Relying on this model, spiritual needs go beyond a strict religious context, and are also relevant for those who are atheist/agnostic. To investigate and understand such needs, research using either interviews (spiritual history-taking and formal spiritual assessment [7] ) or standardized questionnaires/checklists [8] can be appropriate, depending on the objective and clinical context. One instrument to measure such needs is the Spiritual Needs Questionnaire (SpNQ) [5,9] which differentiates four main factors: religious needs, inner peace needs, existential needs (reflection/meaning), and needs for giving/generativity [5,9]. The SpNQ is currently available in German, English, French, and Polish, avoids exclusive religious terminology, and can be suitable in both secular and religious societies. The aim of this study was to validate the Chinese version of the SpNQ (SpNQ-Ch) in a population of mainly secular or nonreligious Chinese patients with chronic diseases. 2 Methods 2.1 Participants All individuals were informed of the purpose of the study, the confidentiality policy, and signed an informed consent for their participation. The patients willing to respond to the questionnaires were recruited consecutively in the Changhai Hospital of Traditional Chinese Medicine, Shanghai, China. We have no data about those who refused to participate. Probable differences exist between patients from urban cities like Shanghai and the rural areas in the inner part of China, and thus these data are not expected to be representative for all Chinese patients. The study did not provide financial incentives to patients who completed the questionnaires. 2.2 Measures The respective questionnaires did not ask for names, initials, addresses, or clinical details (with the exception of a diagnosis). All questionnaires used Chinese language adopted from the respective English and/or German versions Spiritual needs To measure patients psychosocial and spiritual needs, we used the SpNQ [5,9] in its Chinese version. The original items were translated by a team of medical doctors in Shanghai; this first version was then checked for consistency by a bilingual colleague living in Germany, particularly with respect to the primary German language version and the English translation. All unclear phrasings were presented to and passed an edit with the primary author of the instrument. The instrument differentiates four main factors [5] : (1) Religious Needs (Cronbach s α = 0.92), i.e., praying for and with others, and by themselves, participating at a religious ceremony, reading spiritual/religious books, turning to a higher presence; (2) Existential Needs (Reflection/Meaning) (α = 0.82), i.e., reflecting on previous life events, talking with someone about the meaning of life/suffering, dissolving open aspects in life, talking about the possibility of a life after death, etc.; (3) Need for Inner Peace (α = 0.82), i.e., wishing to dwell at quiet and peaceful places, immersing in the beauty of nature, finding inner peace, talking with others about one s fears and worries, having substantial emotional support; (4) Need for Active Giving/Generativity (α = 0.74), i.e., actively providing others with support, comforting others, sharing one s own life experiences with others, and knowing that one s life is meaningful and of value. All items were scored according to self-ascribed importance, Journal of Integrative Medicine 107 March 2013, Vol.11, No.2

3 on a 4-point scale from disagreement to agreement (0: not at all; 1: somewhat; 2: very; 3: extremely). The higher the scores were, the stronger the respective needs were Life satisfaction Life satisfaction was measured using the Brief Multidimensional Life Satisfaction Scale (BMLSS) [10]. The items of the BMLSS address intrinsic (myself, life in general), social (friendships, family life), external (work situation, where I live) and prospective dimensions (financial situation, future prospects) of life satisfaction as a multifaceted construct. The internal consistency of the instrument was found to be high in the validation study (Cronbach s α = 0.87) [10]. In this study the 10-item version was employed that includes satisfaction with the health situation and abilities to deal with daily life concerns (BMLSS-10). Internal consistency of the Chinese version was very high (α = 0.931). The items were introduced by the phrase I would describe my level of satisfaction as, and scored on a 7-point scale ranging from dissatisfaction to satisfaction (0: terrible; 1: unhappy; 2: mostly dissatisfied; 3: mixed (about equally satisfied and dissatisfied); 4: mostly satisfied; 5: pleased; 6: delighted). The BMLSS-10 sum scores referred to a 100% level ( delighted ). Scores >50% indicated higher life satisfaction, while scores <50% indicated dissatisfaction Reflection: positive interpretation of illness To measure patients interpretation of illness in terms of a reflection process, we used the respective subscale of the SpREUK questionnaire (SpREUK is the German language acronym of Spiritual and Religious Attitudes in Dealing with Illness ), i.e., the Reflection: Positive Interpretation of Illness scale [11-13]. This Reflection scale (α = 0.86) deals with patients cognitive reappraisal of negative life experiences and subsequent attempts to improve upon them (i.e., reflecting on what is essential in life, to change certain aspects of life, better understanding of oneself). Internal consistency of the Chinese version was high (α = 0.803). Moreover, we added two additional fatalistic items which were derived from the primary version of the SpREUK, i.e., I have no influence on my life, it is fixed by fate (item f2.1) and I accept my illness and bear it calmly (f2.2). The instrument scored items on a 5-point scale from disagreement to agreement (0: does not apply at all; 1: does not truly apply; 2: don t know (neither yes nor no); 3: applies quite a bit; 4: applies very much). The scores were referred to a 100% level (transformed scale score). Scores >50% indicated higher agreement (positive attitude), while scores <50% indicated disagreement (negative attitude) Escape from Illness scale The 3-item scale for Escape from Illness is an indicator of an (resigning) escape-avoidance strategy to deal with illness (i.e., fear what illness will bring, would like to run away from illness, when I wake up, I don t know how to face the day ) [14]. Internal consistency of the Chinese version was weak (α = 0.532). The items were scored on a 5-point scale from disagreement to agreement (0: does not apply at all; 1: does not truly apply; 2: don t know (neither yes nor no); 3: applies quite a bit; 4: applies very much). Scores >50% indicated an escapist attitude Self-perceived health affection Patients self-perceived health affections were measured with a visual analogue scale. We asked how strongly they regarded their current disease-related symptoms, ranging from 0 (none) to 100 (unbearable). 2.3 Statistical analyses Descriptive statistics, internal consistency (Cronbach s coefficient α) and factor analyses (principal component analysis using Varimax rotation with Kaiser s normalization), as well as analyses of variance, first order correlations and regression analyses were computed with SPSS Given the exploratory character of this study, significance level was set at P < With respect to classifying the strength of the observed correlations, we regarded r > 0.5 as a strong correlation, an r between 0.3 and 0.5 as a moderate correlation, an r between 0.2 and 0.3 as a weak correlation, and r < 0.2 as no or negligible correlation. 3 Results 3.1 Participants As shown in Table 1, patients mean age was (51.0 ± 16.4) years; 61% were male, and 39% were female. Most were married (86%) or living with a partner (2%), while 7% were living alone (divorced, widowed, or single); 5% did not provide information on their living status; 10% had a basic educational level (primary school), 29% a medium level (secondary school equivalent), 24% a highschool level, 30% other, and 2% none; 5% did not provide information on their educational level. Most had no religious affiliation (68%), 13% were Buddhist, 5% were Christians, and 2% other, and 11% did not provide information. Patients had either cancer (63%), pain affections (10%), or other chronic conditions, i.e. hypertension, diabetes, liver diseases (total 23%); 5% did not provide information. 3.2 Reliability and exploratory factor analysis For this analysis we used only those items which were confirmed in previous analyses [5,9]. However, we did not include item N21 ( participate at a religious ceremony ), but retained item N5 ( dissolve open aspects of life ) from the primary version (SpNQ 1.0). Among these 20 items, 3 were later eliminated due to a weak factor loading (< 0.5), i.e., N2 ( talk about fears and worries ), N11 ( talk about the meaning in life ) and N14 ( give away something from yourself ). The item difficulty of the remaining 17 items was 0.63; while most values were in the acceptable March 2013, Vol.11, No Journal of Integrative Medicine

4 Table 1 Characteristics of 168 individuals Gender (%) Men Women Variable Mean / % * Age (years, mean ± standard deviation) 51.0 ± 16.4 Living status (%) Living with a partner (married, or not married) Living alone (single, divorced, widowed) Educational level (%) Low (primary school)/none Medium (secondary school equivalent) High (high school) Other Religious orientation (%) None Religious denominations Underlying disease (%) Cancer Other chronic diseases Health-associated variables (mean ± standard deviation, range) Life Satisfaction (BMLSS-10) Escape from Illness (Escape) Symptom score (VAS) ** * Percentage of individuals providing the respective information. ** Several patients did not mark the symptoms on the VAS (n=67). BMLSS: Brief Multidimensional Life Satisfaction Scale; VAS: visual analogue scale ± 14.8 (0-100) 53.2 ± 20.6 (0-100) 36.9 ± 22.7 (12-100) range from 0.2 to 0.8. Four religious items had very low scores indicating bottom effects, which is not surprising in a predominantly nonreligious population. Factor analysis of the 17-item version revealed a Kaiser- Mayer-Olkin value of 0.80, which as a measure for the degree of common variance, indicates that the item-pool is suitable for a factorial validation. Exploratory factor analysis pointed to 5 factors that accounted for 64% of variance (Table 2). The 4-item scale Inner Peace Needs (eigenvalue 5.0; α = 0.76) addresses external and internal facilitators of inner peace states (i.e., nature and finding meaning in illness/suffering). In contrast to the original scale of the SpNQ, item N10 was primarily an existentialistic item, but can be regarded in this context as an internal facilitator of inner peace, too. The 5-item scale Giving/Generativity Needs (eigenvalue 2.1; α = 0.78) combines in its Chinese version items of the versions SpNQ 1.0 and SpNQ 2.1, and is thus more appropriate than the current 3-item version of the original SpNQ version 2.1. While the original SpNQ measures Religious Needs with 6 items, the respective items of the Chinese version are split into 2 sub-constructs, i.e., Religious Needs: Praying (eigenvalue 1.4; α = 0.81) and Religious Needs: Sources (eigenvalue 1.2; α = 0.72). The latter scale has only two items addressing turning to a higher presence and reading religious/spiritual books, while the former scale addresses praying with someone, for oneself, and patients need that someone would pray for them. From the primary scale Existential Needs, item N11 was eliminated due to a weak factor loading, while item N10 correlated much better with the Internal Peace scale and item N16 with Giving/ Generativity; the remaining three existentialistic items would make up the new scale termed Reflection/Release Needs (eigenvalue 1.1; α = 0.51), addressing patients intention to reflect on previous life experiences to dissolve open aspects of life, and then to talk with someone about death/and the possibility of life after death. However, the internal consistency of this scale was less satisfactory. 3.3 Correlation analysis Correlation analyses (Table 3) revealed moderate to strong interconnections between the respective needs. In particular, Giving/Generativity was strongly associated with Inner Peace Needs, while both Religious Needs scales were not or only weakly associated with the other needs. Escape from Illness, as a passive depressive-avoidance strategy, was not correlated with the respective needs, while patients s symptom score (which unfortunately had just 60% response return) correlated weakly only with Reflection/Release Journal of Integrative Medicine 109 March 2013, Vol.11, No.2

5 Table 2 Reliability and factor analysis of the Chinese version of SpNQ Factor and item Mean value Standard deviation Difficulty index (0.32) Corrected item-total correlation Alpha if item deleted (a = 0.847) Factors I II III IV V SpNQ factor Need for Inner Peace (eigenvalue 5.0; a = 0.76) N7 Dwell at quiet and IP peaceful places N8 Find inner peace IP N6 Immerse in the beauty of nature IP N10 Find meaning in illness and/or suffering EN Giving/Generativity (eigenvalue 2.1; a = 0.78) N15 Comfort others GG N16 Forgive someone from EN past events N13 Have a loving attitude GG/IP toward others N27 Know that your life was meaningful and of value GG N26 Pass own life experiences to others GG Religious Needs: Praying (eigenvalue 1.4; a = 0.81) N19 Someone prays for you RN N20 Pray for yourself RN N18 Praying with someone RN Religious Needs: Sources (eigenvalue 1.2; a = 0.72) N23 Turn to a higher presence RN (i.e., God, Angels) N22 Read religious/spiritual books RN Reflection/Release Needs (eigenvalue 1.1; a = 0.51) N5 Dissolve open aspects of your life EN N12 Talk about the possibility of life after death EN N4 Reflect on previous events in life EN Eliminated items and marker item N25 N2 Talk about fears and IP worries N11 Talk about the meaning EN in life N14 Give away something GG from yourself N25 Feel connected with family Principal Component Analysis; Varimax Rotation with Kaiser Normalization; the respective 5 factors would explain 64% of variance. SpNQ: Spiritual Needs Questionnaire; IP: Inner Peace; EN: Existential Needs; GG: Giving/Generativity; RN: Religious Needs. March 2013, Vol.11, No Journal of Integrative Medicine

6 Table 3 Correlations between Chinese version of SpNQ subscales and external measures Correlating variable Inner Peace Needs Giving/ Generativity Religious Needs: Praying Religious Needs: Sources Reflection/ Release Needs Psychosocial and Spiritual Needs Inner Peace Needs 0.51 ** 0.23 ** 0.19 * 0.39 ** Giving/Generativity 0.39 ** 0.28 ** 0.37 ** Religious Needs: Praying 0.47 ** 0.24 ** Religious Needs: Sources 0.15 Life Satisfaction (BMLSS-10) * Escape from Illness (Escape) Symptom score (VAS) * Interpretation of Illness Reflection: Positive Interpretation of Illness (SpREUK) 0.18 * Life is fixed by fate (f2.1) Accept illness and bear it calmly (f2.2) * * P< 0.05, ** P < 0.01, by Pearson s χ 2 test. SpNQ: Spiritual Needs Questionnaire; BMLSS: Brief Multidimensional Life Satisfaction Scale; VAS: visual analogue scale; SpREUK: Spiritual and Religious Attitudes in Dealing with Illness. Needs; similarly, patients Life Satisfaction was marginally (negatively) associated with patients Reflection/Release Needs. Positive Interpretation of Illness (SpREUK s Reflection scale) was marginally associated with Inner Peace Needs, while the statement that one has no influence on life because it is fixed by fate was not significantly associated with the respective needs (Table 3). However, the statement that one has to accept illness and bear it calmly showed a weak (negative) association with Reflection / Release Needs. This indicates that no matter the degree of life satisfaction or severity of patients symptoms, the respective needs are present as independent dimensions which are only minorly influenced by either positive interpretations of illness or fatalistic attitudes of acceptance (i.e., resignation). 3.4 Expression of psychosocial and spiritual needs among Chinese patients To analyse which needs were of relevance, we measured the responses of respective needs among the patients. Inner Peace Needs scored high (mean score 1.16 ± 0.69), with 7% yielding scores of 0, indicating absolutely no needs for Inner Peace; while 17% had scores 2, indicating strong needs. The 50% percentile was 1.25, and the 75% quartile was Needs for Giving/Generativity were the highest among the Chinese patients (mean score 1.30 ± 0.64), with 5% yielding scores of 0, indicating absolutely no needs for Giving/Generativity, while 20% had scores 2, indicating strong needs. The 50% percentile was 1.20, and the 75% quartile was Religious Needs: Praying scored low (mean score 0.69 ± 0.74), with 41% yielding scores of 0, indicating absolutely none of the respective needs, while 10% had scores 2, indicating strong needs. The 50% percentile was 0.50, and the 75% quartile was Religious Needs: Sources were found to be very low (mean score 0.32 ± 0.56), with 67% yielding scores of 0, indicating absolutely none of the respective needs, while 4% had scores 2, indicating strong needs and the 75% quartile was Reflection/Release Needs were stronger (mean score 0.86 ± 0.61), with 17% yielding scores of 0, indicating absolutely no Reflection/Release Needs, while 8% had scores 2, indicating strong needs. The 50% percentile was 0.67, and the 75% quartile was With respect to specific sociodemographic data, the living status (i.e., living alone or with partner) had no significant influence (data not shown). Patients with a lower educational levels had the lowest needs for Inner Peace and Giving/ Generativity (Table 4), while those with higher educational levels had somewhat higher religious needs. Age and gender also significantly influenced Religious Needs: Praying (Table 4). In general, Religious Needs were the highest in patients with clear religious denominations (Buddhist, Christians, or other), while the other needs did not significantly differ between those with or without a religious denomination (Table 4). Patients with cancer had significantly lower Reflection/ Release Needs. This effect cannot be simply explained by differences in gender, age or educational levels. Univariate analyses revealed that the variance can be explained best by categorized diseases (F=9.7, P<0.002), while gender and educational levels (F=3.1, P=0.031) and also age and disease (F=2.9, P=0.037) had an effect only in trend (Levene s test was significant and thus the level of significance should be 0.01). Journal of Integrative Medicine 111 March 2013, Vol.11, No.2

7 Table 4 Mean values of Chinese version of SpNQ subscales and sociodemographic data All individuals (n=168) Gender Variable Mean SD Inner Peace Needs Giving/ Generativity Religious Needs: Praying Religious Needs: Sources Reflection/ Release Needs Women (39%) Mean SD Men (61%) Mean SD F value P value n.s. n.s n.s. n.s. Age < 41 years (22%) Mean SD years (18%) Mean SD years (32%) Mean SD > 61 years (27%) Mean SD F value P value n.s. n.s n.s. n.s. Disease Cancer (66%) Other chronic diseases (34%) Mean SD Mean SD F value P value n.s. n.s. n.s Religious orientation None (77%) Mean SD Religious (23%) Mean SD F value P value n.s. n.s < n.s. Educational level Low/none (13%) Mean SD Intermediate (30%) Mean SD High (26%) Mean SD Other (31%) Mean SD F value P value n.s SpNQ: Spiritual Needs Questionnaire; SD: standard deviation; n.s.: not siginificant. March 2013, Vol.11, No Journal of Integrative Medicine

8 4 Discussion This study intended to analyse psychosocial and spiritual needs in patients from Shanghai, who as a whole tend to be nonreligious. For this purpose we adapted the SpNQ to be used in a Chinese population. Among the 20 tested items, 17 had a good internal consistency (α = 0.85) and good loading on 5 factors (> 0.5) which accounted for 64% of variance. Similar to the primary version of the instrument [5,9], the instrument used in this study on Chinese patients differentiates needs for Inner Peace, Giving/Generativity, Religious Needs (divided into two sub-categories, i.e., Praying and Sources), and Reflection/ Release needs (referred to in the former scale as Existential Needs). Interestingly, the existential items showed the strongest changes compared to the original version of the instrument: item N11 ( talk about the meaning in life ) was eliminated due to a weak factor loading, while item N10 ( find meaning in illness and/or suffering ) fit much better to the Internal Peace scale for this population. N16 ( forgive someone from a distinct period of your life ) showed better load to Giving/Generativity and only weakly to the intended existential scale. The remaining items formed the new scale termed Reflection/Release needs which is nevertheless an existential scale; however, the internal quality of this scale is less than satisfactory. These specific Reflection/Release needs address patients intention to reflect on previous life events to dissolve open aspects of life and, much more weakly, to talk about the possibility of life after death. The last item may be so weakly correlated because of it low relevance in a generally nonreligious society, but it was highly relevant particularly for the Buddhists, Hindus and Christians among the patients (i.e., belief in rebirth, resurrection). These needs were significantly lower in patients with cancer; one could speculate that the psychoemotional support is much better in this group of patients. Although these needs showed some significant changes with respect to educational levels, there were no clear attributions to either lower or higher educational levels. Of highest relevance for the patients in this study were Inner Peace Needs and Giving/Generativity. This was similar to German patients with chronic diseases [5], where secular forms of spirituality were also of higher relevance. One can understand how needs for inner peace are of such relevance for patients struggling with chronic diseases; patients expressed their intention to dwell at quiet and peaceful places, to immerse in the beauty of nature, and to find inner peace and meaning in illness and suffering. Thus they addressed external and internal facilitators of peaceful states of mind to let go of pain and suffering for a while. These specific needs were significantly higher in individuals with a higher educational level. Of highest relevance for the investigated sample of patients were needs for Giving/Generativity. This scale addresses the knowledge that life was meaningful and of value and pass life experiences to others on the one hand (this ability to care for others and guide the next generation and to prove that one s life was of value to others refers to Erikson s psychosocial developmental stage generativity [15] ), and on the other hand to have a loving attitude toward others, to forgive someone from past events and to comfort others. These needs refer to the categories Connectedness and Meaning. Given that three-quarters of the patients in this study had no religious affiliation, it is not surprising that Religious Needs were of minor relevance. Nevertheless, the Praying subscale revealed significantly higher scores in women than in men, and this scale evidently had significantly higher scores in religious individuals. While several of these specific needs are moderately interconnected, only the Reflection/Release needs are marginally (negatively) associated with patients life satisfaction, and weakly with their symptom score. None of the needs scales correlated with an escape-avoidance strategy (resignation) to deal with illness (Escape). Moreover, patients positive interpretation of illness (SpREUK s Reflection scale) was just marginally associated with Inner Peace needs, while Reflection/Release needs were just weakly (negatively) associated with a passive acceptance of illness. Thus, it is not primarily the impact of the underlying disease on the patients lives that result in the expression of the specific needs, but other, yet undefined attitudes. Compared to findings from German patients with chronic pain and cancer [5,9], the scores of the respective findings did not differ strongly on a more general level. As with this study, German patients (most nominally with a Christian background) needs for Inner Peace and Giving/Generativity also had the strongest relevance, while Religious and Existential Needs showed much lower relevance [5,9]. In German patients, living status, and combinations of age and educational level, age and religious affiliation, etc. had an influence on the respective needs [5]. In Korean patients with cancer, using the Korean language Spiritual Needs Scale, Yong et al [16] differentiated five categories of spiritual needs, i.e., Love and Connection, Hope and Peace, Meaning and Purpose, Relationship with the Divine/Sacred/God, and Acceptance of Dying. Interestingly, all needs were expressed relatively high in the Korean patients, particularly Hope and Peace, and Meaning and Purpose, with Relationship with the Divine/Sacred garnering the lowest scores [16]. In Taiwanese patients with advanced cancer, four main themes of spiritual needs were identified [17] : hope for survival and peaceful mindset, meanings of life and dignity, reciprocal Journal of Integrative Medicine 113 March 2013, Vol.11, No.2

9 human love, and facing death peacefully. Findings among U.S. patients with cancer indicated that they wanted help with overcoming fears, finding hope, meaning in life, and spiritual resources, or identifying someone to talk to about finding peace of mind, meaning of life, and dying and death [18]. Thus, with respect to the main domains (Peace, Hope, Meaning, Relation) all these data are consistent with the findings among Chinese patients with cancer investigated herein. The proposed model of spiritual needs from which this study is modeled [6] shows that the main categories of Peace and Connection address more general needs which are not significantly influenced by cultural or religious differences, while the categories Meaning/Purpose and Transcendence can be influenced by these variables. This was particularly true for the subset of patients with specific religious beliefs and attitudes. Is the topic of spirituality in healthcare really new in China? At least within the last two years, the possibility of spirituality s relevance in health care has been increasingly recognized. There are three papers dealing with nurses experiences in spirituality and spiritual care in Hong Kong [19-21], and a further study from a school of nursing examining the spiritual concerns of stroke survivors during hospitalization as well as their transition back to the home [22]. A recent study tested the efficacy of a group intervention to improve the psychosocial and spiritual well-being of women from Hong Kong undergoing in vitro fertilization [23]. As stated above, Hsiao et al [17] investigated spiritual needs of Taiwanese patients with advanced cancer. There is also a study using the Chinese version of Underwood s Daily Spiritual Experience Scale [24]. This study did have some limitations. We did not follow the conventional procedures to translate an instrument from one language to another. Rather than the usual protocol of a back translation from Chinese to English or German language, the translated version for cultural and language consistency was checked by a Chinese colleague with respect to the primary German language version, and the English translation received input from the primary author of the instrument. Additionally, we have no analyses on how many patients did not fill out the instrument forms, and thus the sample should be regarded as a convenience sample. Taken together, the SpNQ-Ch is congruent with its primary version and the respective scales have satisfying to good internal consistency. First findings among patients with cancer and other chronic diseases from Shanghai indicate specific spiritual needs should be addressed by medical doctors, nurses and psychologists to support patients in their struggle with the burden of chronic illness. Doing so can improve patients psychoemotional stabilization, degrees of hope and meaning, and thus peaceful states of mind despite their chronic illness. We are aware of potential differences between patients from urban cities and the rural zones of China, and thus we suggest further studies enrolling different cohorts of patients from different areas of China. Overall, there is a general need for adequate education and training for health care professionals to uncover and respond to these needs. Regardless of their own belief systems, medical doctors should be open to the possibility that specific spiritual beliefs may play an important role for their patients. The 2009 Consensus Conference in Pasadena, California provided practical recommendations to be implemented in palliative, hospice, hospital, long-term and other settings [7]. Supporting these needs remains a challenging task for a modern health care system. With respect to findings among terminally ill patients from Hong Kong, Mok et al [21] stated clearly that if healthcare professionals can provide a compassionate and loving environment that facilitates acceptance and hope, the spiritual life of patients is enhanced. While the above quote refers to terminally ill patients, we encourage further studies to also analyze the relevance of Spiritual Needs in patients with other, primary non-fatal chronic diseases. 5 Acknowledgements We are highly grateful to Jingdong Li for all advises and comments to check the Chinese version of the instrument. 6 Competing interests The authors declare that they have no competing interests. REFERENCES 1 Schmid-Büchi S, Halfens RJ, Dassen T, van den Borne B. A review of psychosocial needs of breast-cancer patients and their relatives. J Clin Nurs. 2008; 17(21): Balboni TA, Vanderwerker LC, Block SD, Paulk ME, Lathan CS, Peteet JR, Prigerson HG. 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