Spirituality is an important domain in palliative care provision with a holistic approach. Patients utilize religious beliefs and understanding to endure the agony of their illness.[22, 23] Those with higher levels of optimism, self-esteem, and life satisfaction show higher levels of spiritual orientation. [24] A prospective cohort study that looked into parental decision-making in paediatric palliative care shows that some parents highlight questioning their faith with temperaments of anger and blame toward God. Most have felt that spirituality was instrumental in helping them to face difficulties.[25]
Our study shows that the S-SNAP has a high Cronbach’s alpha value demonstrating satisfactory internal consistency with adequate reliability. The item-total correlations confirm the positive contribution made by the individual items to the performance of the questionnaire. The questionnaire showed inverse correlations with age, comorbidity and activities of daily living while a positive correlation was seen between the questionnaire and Karnofsky performance scale. These correlations were all significant (p < 0.05), suggesting criterion-related validity of the questionnaire.
The Cronbach alpha of 0.94 we observed is concordant with previous validations of the SNAP questionnaire. Cronbach alpha values of 0.95, 0.90, and 0.89 were observed during the validation of English, Brazilian Portuguese and Mandarin translations, respectively.[17, 18, 26] The average scores of psychological, spiritual and religious needs, however, varied somewhat between translations and this could, partly, be due to the diversity of social, cultural and religious beliefs of different populations or ethnicities. (Table 4)
Table 4
Comparison of average scores of various domains and the internal consistency of SNAP in validated translations
| English | Mandarin | Brazilian | Sinhala |
Psychological Needs | 12.1 | 13.7 | 16.3 | 13.1 |
Spiritual Needs | 30.1 | 28.5 | 40.57 | 35.6 |
Religious Needs | 9.5 | 8.3 | 15.53 | 10.2 |
Internal Consistency (Cronbach alpha coefficient) | 0.95 | 0.85 | 0.90 | 0.94 |
Addressing the religious aspect in a palliative care plan is a well-accepted practice that reflects and projects success in coping with physical illnesses. A higher level of intrinsic religiousness predicts more rapid remission of depression, an association that is particularly strong in patients whose physical function is not improving.[27, 28]
According to Monod et al., most of the instruments for spirituality assessment measure general spirituality and spiritual coping and only a few address spiritual needs and spiritual well-being. [6] The SNAP questionnaire, however, addresses the domains of psychological, spiritual and religious needs robustly. Moreover, this tool assesses the current state of spirituality, which is more relevant in designing a care plan and spiritual interventions.
The study demonstrates that the validated S-SNAP is suitable for screening the spiritual needs of patients with malignancies in Sri Lanka. Such needs are currently not assessed or included in the care plan, mostly due to the unawareness of this crucial domain in palliative care. Furthermore, the lack of a valid and reliable questionnaire adds to this care gap. Busy clinics with overcrowding and time constraints may limit the utilization of this questionnaire in real clinical settings We, however, found that the S-SNAP requires only 4.5 minutes for the full completion and we believe that this questionnaire has the potential to be incorporated into the palliative care plan of those with malignancies in Sri Lanka.
The SNAP questionnaire has originated from Western society which uses English as the first language and has social, cultural and religious beliefs and needs different from those in Sri Lanka, Although we consider this to be a limitation, we assessed the content validity and face validity of the questionnaire with a panel of local experts in a focus group discussion. This involved the removal and consolidation of recurring themes as items which do not apply to our setting. As an example visitation of clergy and hospital chaplain were found to be similar. This questionnaire was piloted three times to ensure face validity, content validity and semantic equivalence.