See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/256448845 Religious Affiliation, Quality of Life and Academic Performance: New Zealand Medical Students Article in Journal of Religion and Health · September 2013 DOI: 10.1007/s10943-013-9769-z · Source: PubMed CITATION READS 1 1,080 6 authors, including: Marcus A Henning Chris Krägeloh University of Auckland Auckland University of Technology 80 PUBLICATIONS 516 CITATIONS 79 PUBLICATIONS 559 CITATIONS SEE PROFILE SEE PROFILE Iain Doherty Susan Hawken The University of Hong Kong University of Auckland 42 PUBLICATIONS 217 CITATIONS 41 PUBLICATIONS 350 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: Academic Mentoring View project The Impact of Progress Testing on Medical Students' Learning and Stress View project All content following this page was uploaded by Chris Krägeloh on 22 March 2017. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document and are linked to publications on ResearchGate, letting you access and read them immediately. J Relig Health DOI 10.1007/s10943-013-9769-z ORIGINAL PAPER Religious Affiliation, Quality of Life and Academic Performance: New Zealand Medical Students Marcus A. Henning • Christian Krägeloh • Andrea Thompson Richard Sisley • Iain Doherty • Susan J. Hawken • Springer Science+Business Media New York 2013 Abstract The present study investigated the connections between religious affiliation, quality of life (QOL) and measures of academic performance. Participants (n = 275) were recruited from the School of Medicine within a New Zealand university. Religious affiliation was classified according to three subcategories: Christian (n = 104), Eastern religion (n = 34) and non-religious (n = 117). The participants completed the World Health Organisation quality of life questionnaire (WHOQOL-BREF) and the World Health Organisation Spiritual, Religiousness, and Personal Beliefs questionnaire immediately before their lecture time. The main findings of the study indicated that participants from different religious affiliations expressed different spiritual QOL perceptions. However, these different expressions did not translate into their perceptions related to hours of study and academic achievement. In addition, the QOL measures did not relate to academic achievement estimation but did predict hours of study. Greater hours of study were related to greater physical health but lower psychological health and poorer engagement in developing social relationships. Data from a small focus group (n = 4) revealed that these students believed that having a belief system assisted them when coping with the academic M. A. Henning (&) A. Thompson Centre for Medical and Health Sciences Education, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand e-mail: m.henning@auckland.ac.nz C. Krägeloh Department of Psychology, AUT University, Private Bag 92006, Auckland 1142, New Zealand R. Sisley School of Business, AUT University, Private Bag 92006, Auckland 1142, New Zealand I. Doherty ELearning Pedagogical Support Unit, Centre for the Enhancement of Teaching and Learning, University of Hong Kong, Hong Kong, China S. J. Hawken Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand 123 J Relig Health learning environment, although little difference could be found between external religious orientations and internal belief systems. Keywords Medical students Quality of life Religiosity Spirituality Personal beliefs Academic achievement Introduction There is an established interest in the literature connecting the ideas of religiosity, spirituality and quality of life (QOL) in relation to tertiary students (Ferriss 2002; Zullig et al. 2006). There is also some literature linking religiosity with education and academic achievement (Schieman 2011; Sutantoputri and Watt 2012). There is, however, a dearth of research linking these concepts within the medical education literature. The main objective of this paper was to focus on the medical learning environment and to examine the links between students’ sense of religiosity, and their perceptions of QOL and academic performance. Zullig et al. (2006) defined religion as an ‘organized belief system with set of rituals and practices, which are acquired in places of worship’ (p. 255). Religiosity is a complex term that has numerous meanings dependent upon the frame of reference (Glock and Stark 1965; Holdcroft 2006). According to Holdcroft, several authors have described religiosity as a term that encompasses several dimensions, including the experiential, ritualistic, ideological, intellectual and consequential. Religiosity is a multidimensional concept involving the exclusive religious life and more expansive views that could incorporate utilitarian aspects of belief, such as ameliorating the stress of examinations (Spilka et al. 1985). Spirituality has been described as a way of being that determines the way people respond to life experiences (Zullig et al. 2006). It has also been suggested that spirituality is an existential or experiential concept or practice that may have links with religious or other belief systems (Sawatzky et al. 2009). The common element between religiosity and spirituality is the transcendental quality of assumed reality and/or acceptance of a higher power (Casaset et al. 2009). There are strong arguments and evidence to support the hypothesis that religiosity, spirituality and personal beliefs positively affect QOL (Dezutter et al. 2006; Ferriss 2002; Sawatzky et al. 2009, 2005; Siegel et al. 2001). Several studies (Calestani 2009; Ferriss 2002; Sawatzky et al. 2009) have stated that engagement in spiritual or religious activities translates into higher levels of QOL, such as promoting more optimal mental health or longevity. There are also indications in the literature that religious belief systems are used as coping mechanisms especially in the presence of stressful situations. These coping mechanisms may vary from individual to individual, with adaptive formulations represented by emotional and instrumental support as opposed to the more maladaptive forms of self-distraction, denial and behavioural disengagement (Krägeloh et al. 2012; Siegel et al. 2001). There is a growing literature attempting to explain QOL issues pertaining to university students and their learning environments (Chow 2010; Dyrbye et al. 2006a, b, c; Henning et al. 2011, 2010; Hojat et al. 2003; Stewart et al. 2009). Further to this discussion are the multifaceted associative factors within student populations, such as gender, enrolment status, ethnicity and so forth (Chai et al. 2011; Henning et al. 2012; Hsu et al. 2009). There 123 J Relig Health is considerable evidence to indicate that medical students are working within a stressful learning environment, which may adversely influence their sense of QOL (Aktekin et al. 2001; Bramness et al. 2007; Dyrbye et al. 2006a, b, c; Hojat et al. 2003; McManus et al. 2004; Moffat et al. 2004; Radcliffe and Lester 2003; Ross et al. 2006). It is, therefore, reasonable to propose that religion may be a powerful resource for dealing with this stressinducing environment of university study (Siegel et al. 2001; Sutantoputri and Watt 2012). Using a ‘karma’ frame of reference, one study suggested a link between a strong religious belief and expected academic achievement (Sutantoputri and Watt 2012). However, there is no known research examining the links between religious affiliation, QOL and academic achievement within the medical learning environment. The present authors were interested in whether religious affiliation could explain perceptions of QOL and academic performance. The research questions driving the project were: (1) Do students with defined religious affiliations have higher QOL self-perceptions than those students with non-religious affiliations? And (2) does religious affiliation translate into higher self-perceived engagement in hours spent on study and own selfpredictions of future grade predictions? Methods Participants Survey This study examined the responses from 275 medical students (156 females, 118 males and 1 missing datum) at the University of Auckland, New Zealand, who voluntarily participated. More detailed demographic information and response rates are shown in Table 1. Table 1 Demographic details of participants (n = 275) Response rate 78 % Age Years (SD) Gender Male Female 156 Study year Year 4 127 Year 5 148 Ethnicity Asian European Māori Pacific island Other Religious affiliation 7 10 54 117 Christian 104 Other Enrolment status 89 113 No religion Eastern religion (Buddhist and Hindu) Some respondents did not provide all details resulting in missing values for some variables 22.86 (2.65) 118 Domestic International 34 34 243 32 123 J Relig Health Focus Group From this sample of 275 students, four students volunteered to attend a focus group. Participants were described as follows: P1 (female, European and non-religious); P2 [male, Māori and Rātana (for more details see Henderson 1972)]; P3 (male, Asian and agnostic); and P4 (female, European and fundamental Christian). No other information is provided to avoid identification. Students were extensively canvassed and encouraged to participate in these focus groups; however, their heavy study load and commitment to clinical placement may have discouraged most students from participation. Procedure Ethics approval was obtained from the University of Auckland Human Participants Committee. Data collection for this study began in June 2011. Two phases of data collection were conducted. Survey Data After permission from senior faculty was obtained, the researchers introduced the purpose and nature of the study to fourth- and fifth-year medical students immediately before lecture time and invited students to fill in the questionnaires. Three of the authors collected participants’ completed questionnaires, which took approximately 10–15 min to complete. Focus Groups After students had completed the paper-and-pencil questionnaires, they were invited to attend a focus group to discuss issues of religion, and its impact on QOL and academic performance. Measures Survey Measures There has been extensive debate about the objective and subjective measurement of QOL with the subjective measure being most often applied to educational and psychological research designs (Billington et al. 2010; Camfield and Skevington 2008; Henning et al. 2013). The abbreviated version of the World Health Organisation quality of life questionnaire (WHOQOL-BREF) has 26 items; this includes two global items about health-related QOL and 24 items relating to four domains (physical, psychological, social and environmental QOL). The respondents rate the items using a 5-point Likert scale; except for three negatively worded items, a low rating towards 1 suggests a negative evaluation, and a high rating towards 5 indicates a more positive perception of QOL. The WHOQOL-BREF measure has been psychometrically validated in reference to medical students (Krägeloh et al. 2011) and has since also been validated for use in the general population in New Zealand (Krägeloh et al. 2013). The WHOQOL-Spirituality, Religiousness and Personal Beliefs (SRPB) questionnaire was used to measure aspects of QOL and health that are connected with faith structures (personal and defined; O’Connell and Skevington 2010; WHOQOL SRPB Group 2006). 123 J Relig Health SRPB has 32 items each with a 5-point Likert scale response option of ‘not at all [1]’ to ‘an extreme amount [5]’. In addition, students’ estimated academic achievement measures were obtained in relation to end-of-year grade for clinical and written examinations. The estimated grade options were distinction, clear pass, pass (borderline) or fail. These estimated grading criteria were developed by a senior faculty staff member who had familiarity with clinical and written grading systems. Students were further asked, ‘How many hours would you study over and above your contact time per week?’ Other relevant measures were also obtained (Table 1). Focus Group Measures Two questions were initially asked: (1) QOL in a general sense has been linked to physical symptoms, psychological wellness, social activities and access to environmental assets (such as housing and transport). Do you think it is related to a person’s religious, spiritual or personal beliefs? Can you give any examples that link these ideas? (2) Do you think a person’s religious, spiritual or personal beliefs can assist them in coping with the medical school environment? Please explain and give examples. In the first instance, students wrote down their responses to these questions that were then collected by the researchers. Then a discussion ensued so that their ideas could be refined and notes from this discussion were taken by two researchers present at the meeting. Data Analysis Survey Analysis The initial religious affiliation information (Table 1) was categorised to enable multivariate statistical examination. The ‘other’ category was not included in the analysis as the participants in the category would likely be too heterogeneous. The dependent variables consisted of the WHOQOL-BREF and the WHOQOL-SRPB measures. Age and gender were included in the model as potential confounders. A multivariate analysis of covariance was used to analyse the data and Bonferroni post hoc analysis to further investigate any differences across the three levels of the independent variable. An analysis of variance procedure was used to investigate the effect of number of study hours with respect to the religious affiliation, and a regression analysis was conducted to consider links between study hours and QOL measures. A chi-square test of independence was performed to examine the relation between religious affiliations and participant estimates of clinical and written academic grades. Focus Group Data were analysed and interpreted based on the students’ open-ended written commentaries in response to the two questions asked. In addition, notes were taken by two researchers in relation to the subsequent discussion. A qualitative content analysis was conducted to consider the focus group data (Graneheim and Lundman 2004). Meaningful units were discerned in relation to religious affiliation and impact on QOL and academic study. The meaningful units were condensed and interpreted to ascertain manifest and latent meaning of the content. Thematic interpretations were proposed to consider the impact of the information in relation to the study’s research questions. 123 J Relig Health Results Participant Details The demographic details (Table 1) show that the majority of students are within the age range of 20–26 years. In addition, more female than male students responded to the survey, and more Year-5 students responded than those from Year 4. The ethnicity statistics revealed that the highest proportion of students were European and Asian. Most students were domestic (88 %), and 12 % were international. Some students did not respond to all items; hence, some differences in cell counts were found. In the religion statistics, most students aligned themselves to ‘no religion’ and then ‘Christian’, with other religious categories showing substantially lower frequency counts. It was noted that the dispersion of religious affiliation amongst medical students was very different to that found amongst the New Zealand general population census. In the general population, there was a greater proportion of Christians (54 %) and less non-religious (27.5 %) and fewer classified as Eastern religion (2.1 %; Human Rights Commission 2012). Religious Affiliation and Domains of Quality of Life Religious affiliation was modelled against the WHOQOL-BREF domain scores and the WHOQOL-SRPB total scores, with age and gender included as potential confounders. Prior testing showed that year of study was not a likely confounder given that it did not yield significant results when compared with QOL or religious affiliations. The total WHOQOL-SRPB scores were also found to be significantly correlated with all WHOQOLBREF domain scores (range of r-values from .23 to .45, p \ .05). The multivariate test statistic showed significant main effects for religious affiliation (Wilks’ lambda = .62, F(10, 482) = 13.19, p \ .001) and gender (Wilks’ lambda = .93, F(5, 241) = 3.53, p \ .01). No other significant multivariate results were noted. It was also noted that the Box’s M-test of the equality of covariance matrices was not significant (M = 101.03, p [ .05). The tests of between-subject effects (Table 2) showed significant results for: 1. Religious affiliation with respect to SRPB (F(2, 245) = 63.31, p \ .001), 2. Gender with respect to psychological health (F(1, 245) = 13.88, p \ .001) and environmental QOL (F(1, 245) = 4.86, p \ .05) and 3. Age with respect to environmental QOL (F(1, 245) = 5.74, p \ .05). A post hoc analysis for religious affiliation (Bonferroni, p \ .05) showed that each of the three religious classification groups differed from the others with respect to SRPB (Table 3). Christian students generated higher response scores than those classified as Eastern religion who in turn responded higher than non-religious students. It was also noted that the association between religious affiliation and psychological health was close to significance (F(2, 245) = 2.44, p = .06). A post hoc test of the facets within the psychological domains showed a significant difference between the Christian and nonreligious student groups (F(2, 248) = 5.36, p = .005) for facet 6 of the psychological domain of the WHOQOL-BREF: To what extent do you feel your life to be meaningful? Table 3 shows the mean scores and standard deviations for the WHOQOL-BREF and WHOQOL-SRPB questionnaires scores in terms of religious affiliation. 123 J Relig Health Table 2 Tests of between-subject effects for religious affiliation with respect to the WHOQOL-BREF and the WHOQOL-SRPB measures; age and gender were included as potential confounders Variables Religious affiliation Dependent variable Physical .11 2 245 2 245 Social 1.46 2 245 .26 2 245 63.31 2 245 2.80 1 245 13.88 1 245 Physical Psychological Social 2.13 1 245 Environment 4.86* 1 245 245 SRPB Covariate (age) .69 1 Physical 1.37 2 245 Psychological 2.48 2 245 Social 2.20 2 245 Environment 1.22 2 245 SRPB 1.62 2 245 Physical 2.74 1 245 .31 1 245 Psychological Social Environment * p \ .05, ** p \ .01, p \ .001 df2 2.44 SRPB Religious affiliation* Gender df1 Psychological Environment Gender F SRPB .95 1 245 5.74* 1 245 .90 1 245 Table 3 Means (and standard deviations) for religious affiliation against WHOQOL-BREF and WHOQOL-SRPB domains WHOQOL subscales Christian (n = 104) Eastern religion (n = 34) Non-religious (n = 117) Physical 4.07 (.50) 4.08 (.41) 4.07 (.56) Psychological 3.73 (.55) 3.62 (.57) 3.55 (.61) Social 3.89 (.63) 3.69 (.65) 3.70 (.79) Environment 3.85 (.61) 3.76 (.57) 3.81 (.49) SRPB 3.71 (.66) 3.35 (.59) 2.72 (.63) * p \ .05, ** p \ .01, p \ .001 Religious Affiliation and Facets of SRPB The eight facet scores of the WHOQOL-SRPB were analysed to unpack the detailed effects of religious affiliation on QOL measures involving spirituality, religion and personal beliefs. The multivariate test statistic showed significant main effects for religious affiliation (Wilks’ lambda = .40, F(16, 472) = 17.07, p \ .001) and gender (Wilks’ lambda = .92, F(8, 236) = 2.52, p \ .05). No other multivariate results were noted. Table 4 shows the between-subject effects for religious affiliation in terms of the eight SRPB facet scores, and Table 5 shows the mean (and standard deviation) differences. Only one interaction effect between gender and religious affiliation was noted for ‘meaning of life’, indicating that ‘non-religious’ male students rate ‘meaning of life’ lower compared 123 J Relig Health Table 4 Tests of between-subject effects for religious affiliation with respect to the facets of the WHOQOL-SRPB measures; gender was included as a potential confounder Variables Religious affiliation Dependent variable F df1 df2 Connectedness 102.57 2 243 22.00 2 243 Meaning Awe Gender 6.81** 19.44 2 243 Strength 88.15 2 243 Peace 7.16** 2 243 Hope 2.69 2 243 Faith 151.50 2 243 Meaning Awe 1.97 1 243 .11 1 243 243 .28 1 4.81* 1 243 .02 1 243 Peace 9.70** 1 243 Hope 4.83* 1 243 Faith .00 1 243 Connectedness 1.68 2 243 Meaning 3.36* 2 243 Awe 2.28 2 243 Wholeness 2.22 2 243 Strength 1.91 2 243 Peace 1.82 2 243 Hope .52 2 243 Faith 1.82 2 243 Wholeness Strength * p \ .05, ** p \ .01, p \ .001 243 Wholeness Connectedness Religious affiliation* Gender 2 Table 5 Means (and standard deviations) for religious affiliation against WHOQOL-SRPB facets WHOQOL-SRPB facets Christian (n = 104) Eastern religion (n = 34) Non-religious (n = 117) Mean SD Mean Mean SD SD Connectedness to a spiritual force*,à, 3.67 1.07 2.99 1.09 1.68 .92 Meaning of life*,à 4.08 .66 3.77 .81 3.36 .88 Awe* 3.73 .69 3.42 .58 3.35 .80 Wholeness and integration*,à 3.54 .71 3.39 .74 2.90 .84 Spiritual strength*,à, 3.66 .90 3.19 .88 1.99 .96 Inner peace, serenity and harmony* 3.50 .77 3.35 .66 3.12 .82 Hope and optimism 3.78 .70 3.47 .64 3.61 .79 Faith*,à 3.73 1.01 3.31 .91 1.56 .85 Differences (Bonferroni, p \ .05) between Christian and non-religious *, Eastern religion and non-religious à, and Christian and Eastern religion with their female peers, but ‘Christian’ and ‘Eastern religion’ male students rate ‘meaning of life’ significantly higher. The results revealed the following significant main effects (Table 5): 123 J Relig Health 1. Each of the three religious classification groups differed on ‘connectedness to a spiritual force’ and ‘spiritual strength’, with Christian students having higher response scores than those classified as Eastern religion, who in turn responded higher than nonreligious students. 2. Both Eastern and Christian religious groups reported higher scores for ‘meaning of life’, ‘wholeness and integration’ and ‘faith’ than the non-religious group, but no difference is noted between the religion groups. 3. The Christian religious group reported higher scores than the non-religious group for ‘inner peace, serenity and harmony’ and ‘awe’, but no other differences were noted. 4. No differences were noted for ‘hope and optimism’. Religious Affiliation and Estimated Academic Performance Religious affiliation was considered in terms of estimated clinical and written academic performance. 1. Hours of study. No difference was found (F(2, 245) = 1.58, p [ .05) between the three religious affiliations with respect to ‘How many hours would they study over and above their contact time per week?’. 2. Estimated clinical grade. A chi-square test of independence was performed to examine the relation between religious affiliation and self-estimated clinical grade. The relation between these variables was non-significant (v2 (3, N = 272) = 3.50, p [ .05). 3. Estimated written grade. A chi-square test of independence was performed to examine the relation between religious affiliation and self-estimated written grade. The relation between these variables was non-significant (v2 (3, N = 272) = .25, p [ .05). Quality of Life Measures and Estimated Academic Performance 1. Hours of study. A multiple-regression analysis was used to test whether QOL measures significantly predicted participants’ ratings of ‘hours of study’. The results of the regression indicated that the five predictors explained 7 % of the variance (R2 = .07, F(5,261) = 3.66, p \ .01). It was found that physical health (b = .19, p \ .05), psychological health (b = -.22, p \ .05) and social relationships (b = -.15, p \ .05) significantly predicted participants’ ratings of ‘hours of study’. However, no significance was noted for environment (b = -.08, p [ .05) and total SRPB (b = .10, p [ .05) values. These values indicate that higher levels of participation in study over and above contact time were related to higher levels of physical health, but lower levels of psychological health and engagement in social relationships. 2. Estimated clinical and written grade. To consider the effect of estimated academic achievement on the QOL measures (WHOQOL-BREF and WHOQOL-SRPB), we analysed the four WHOQOL-BREF domain scores and the WHOQOL-SRPB total score as dependent variables in terms of the clinical and written grade estimations. The multivariate test statistic showed no significant main effects for either clinical grade (Wilks’ lambda = .98, F(5, 263) = 1.09, p [ .05) or written grade (Wilks’ lambda = .98, F(5, 263) = 1.27, p [ .05). Nor was there any interaction effect between the two grade options (Wilks’ lambda = .97, F(5, 263) = 1.72, p [ .05). 123 J Relig Health Religious Affiliation, QOL, Academic Achievement: Focus Group Comments Three themes emerged from students’ commentaries in relation to their religious affiliation, QOL and academic achievement. 1. Social affiliations and connectedness (mainly derived from P1 and P3 commentaries) • Responses to participants’ questions about the relationship of QOL with their religious, spiritual and personal beliefs suggest that their beliefs influence the relationships and connections they form with others, which in turn enhance their QOL. All participants also highlighted that beliefs enable a sense of community and shared culture, and sense of belongingness. • P1 explains: ‘I think for myself and other people, religion, spirituality, or personal beliefs have been strongly linked to the ability to affect one’s QOL, through the social roles these play in one’s life’. P1 also gave an interesting description of her journey as a student as she became more connected with her course of study. She talked about why she first enrolled in this medical school, and she started out because she was an academically successful (grade-focused) student at school and then found medical science an interesting topic (degree-focussed). After that, she found medical school a thrilling passion and also felt she was helping humanity (patient-focussed). P1 conveyed greater connectedness by developing a cognitive and affective interest in her study, which differed from her original purely cognitive interest. 2. Wholeness, grounding and meaning of life (mainly derived from P2, P3 and P4 commentaries) • The significance of beliefs was important for both the non-religious and agnostic participants and those who had a religious affiliation. P3, who was identified as agnostic, has provided his view: I believe people with a solid belief system of any kind will be more likely to have a better QOL than those who do not have such a solid foundation. Having a belief system that helps people to make sense of the world in whatever way will help them to deal with the stressors because they have a reference point or something to ground themselves. • Rātana and the centrality of family provided a sense of grounding and strength for the Māori participant (P2): We have our own idea of Christianity (Rātana), and it gives you the idea of gratefulness; for everything I have a sense of grounding. My family is also my source of strength. • The participant who was identified as a fundamental Christian (P4) emphasised the significance of the support religion provides when confronted with challenges: Even if I have confidence in my own strength, there is a higher power to help me, and spiritual beliefs can also help with family conflicts. 123 J Relig Health 3. Coping with tensions in the learning environment (emerged from all four commentaries) • Although students’ beliefs provided them some support in the medical school environment, tensions were also apparent. The four students agreed that religious belief systems do enable students ‘to support study and life and [it] influences QoL, as they are tools that can be used’. • The students in this group found resolution to tension in external and internal frames of reference. For example, in the second person P3 stated, If your personal beliefs allow you to see medical school in a context/in perspective then they would be useful. Some personal beliefs can be challenged at medical school—such as evolution vs. Creation, right to life vs. Abortion. This could be stressful if you did not have a system for reconciling the issues. A lot of people find peace/solace in their personal beliefs e.g. prayer/meditation which would be helpful in the context of medical school. Discussion The present investigation explored potential connections between religious affiliation, QOL and academic performance. The study had two propositions: firstly, it was conceived that students with defined religious affiliations would likely have different QOL selfperceptions to non-religious students and secondly that this would translate into different self-perceived grade predictions and estimates of hours of study. The findings evidenced differences in the first part of the proposition with regard to QOL perceptions, but the second part of the proposition related to perceived academic achievement was not supported, although hours of study (academic behaviours) was shown to be related to QOL. Consistent with the literature and attribution theory (Sutantoputri and Watt 2012; Weiner 2010), it was expected that students would likely attribute levels of success or failure to defined causal areas (such as religion and QOL), and it was further postulated that there would be a relationship between sense of religious belief and self-estimated academic performance. Religious coping also has been linked to lowered levels of depression, suggesting that mental health issues amongst students may have an adverse effect on academic achievement (Dyrbye et al. 2006a, b, c; Hojat et al. 2003; Siegel et al. 2001; Stewart et al. 1999). Religious Affiliation and Quality of Life QOL Domains The present study found no significant association between religious affiliation and the WHOQOL-BREF domains of physical health, psychological health, social relation relationships and environment. One potential way forward to explaining these non-significant findings is to consider the ideas posed by Dezutter et al. (2006), who showed that religious attitude and orientations were more potent predictors of mental health than religious involvement per se. The total WHOQOL-SRPB scores were significantly correlated with all WHOQOL-BREF domain scores, indicating that, within each of the religious affiliation 123 J Relig Health groups, there was a substantial range of the extent to which participants were spiritual, had personal beliefs or were intrinsically or extrinsically religious. Additionally, the lack of an effect by religious affiliation may have resulted from the fact that the beneficial effects of religion are sometimes only detectable at high stress levels—the so-called stress-buffering effect (Cohen and Wills 1985). The mental health effects of religion and spirituality are complex and are often investigated in terms of religious coping strategies. Participant response burden was a potential factor but not considered in the design of the present study. Future studies could investigate religious coping in medical students in more detail. SRPB Facets In relation to religious affiliation, differences were noted on seven of the eight WHOQOLSRPB facets, with the greatest difference between Christian and non-religious participants. Given the orientation of the Christian religion towards a higher-power figure, it is not surprising that there would be differences on the facets of connectedness to a spiritual force, spiritual strength and faith. However, Christians and those aligned with Eastern religions felt a greater sense of ‘meaning of life’, ‘wholeness and integration’ and ‘inner peace, serenity and harmony’ when compared with the non-religious group. The notions of ‘awe’ and ‘wholeness and integration’ were other facets that were different for Christians versus the non-religious group. In all cases, Christian students outscored Eastern religious students who in turn outscored non-religious students on all facets except for hope and optimism. These results suggested that Christian students are more focussed on issues related to religiosity, spirituality and personal beliefs than the other two groups and in turn students with an Eastern religious affiliation are more focused on these aspects of faith than non-religious students. According to the SRPB findings, the direction of spiritual importance suggests that Christian medical students have a more defined religious and spiritual code of understanding than Eastern religious students who appear to have a more defined understanding than non-religious students. The difference could be explained by the way they frame religious and spiritual concepts and how these apply to personal experiences and understandings (O’Connell and Skevington 2005). In their study and using the WHOQOLSRPB, O’Connell and Skevington found similarities across religious affiliations for inner peace, hope and optimism and spiritual strength, but revealed that Christians (in comparison with non-religious and other religious groupings) attached more importance to aspects concerned with meaning and purpose in life, spiritual strength, wholeness and integration. These findings, as with the present study, clearly differentiated perceptions around important issues such as meaning and purpose in life, and this is informative for educationalists and counsellors attempting to design stress reduction courses such as mindfulness training (Hassed et al. 2009), which may have technical mechanisms but also spiritual connotations. Religious Affiliation, Quality of Life and Estimated Academic Performance Even though there is some evidence in the literature supporting the connection between belief systems and academic performance (Dyrbye et al. 2006a, b, c; Hojat et al. 2003), this connection was not found in this study. The present findings indicated that students’ religious affiliation or their sense of spirituality and religiousness did not directly translate into expectancies around grade accomplishment in either written or clinical work or hours of study. It is reasonable to assume that religious students do not specifically equate 123 J Relig Health religious affiliation as a coping mechanism that ameliorates academic stressors any more than a non-religious student would use self-will or social networking (Krägeloh et al. 2012; Park 2005; Siegel et al. 2001). There is, however, evidence of a conflicting pattern between the QOL measures (WHOQOL-BREF and WHOQOL-SRPB domain values) in terms of ‘hours of study’ (an effort component). The physical health variable was higher for more engagement in extra study above contact time, but lower for psychological health and social relationships. This inconsistency may suggest a mind–body disconnection (Huang and Galinsky 2011), implying that medical students engaging in high levels of study feel physically well but that there is some negative impact on their psychological well-being and engagement in social activities. Therefore, it seems likely enough that more hours spent studying means less hours free to socialise, and reduced social contact could in turn reduce psychological well-being. Further research could investigate this feeling of physical wellness and may need to determine whether perceptions around physical wellness are in fact the same as actual physical wellness (Carlson et al. 2008). Religious Affiliation, QOL, Academic Achievement: Focus Group Comments The four focus group members were aligned with four disparate affiliations: non-religious, Rātana, agnostic and fundamental Christianity. From this sample of four students and their focus group commentaries, we identified three emerging themes: (1) social affiliation and connectedness, (2) wholeness, grounding and meaning of life and (3) coping with tensions in the learning environment. Each student had their own sense of self, adaptation and coping mechanisms. Social affiliation and connectedness was a theme that mainly came from P1 (non-religious student) and P3 (agnostic student) who conveyed a sense of social responsibility and was strongly aware of their role as emerging doctors. The next theme, wholeness, grounding and meaning of life, was articulated in different ways by P2, P3 and P4. P2 was strongly aware of the role of his family as it was embedded within his Christian faith and found that meaning came from a religious or belief system as it provided clear guidelines for action, whilst P3 asserted the benefits of an unspecified ‘belief system’ and P4 was more aligned to notion of ‘higher power’. The third theme, coping with tensions in the learning environment, identified the power of belief systems in coping with tensions associated with the medical learning environment. These focus group students suggested that resilience and academic performance could be attributed to their own particular belief affiliations, which likely has an attitudinal focus rather than an involvement one (Dezutter et al. 2006). The two Christian students clearly saw the value of their defined faith with P2 also adding family as a crucial element. P1 found resilience through a sense of responsibility and insight into the value of her profession, whilst P3 was more outcome-oriented and his sense of family was connected to the notion of familial commitment, which may have an ethnicity component (Henning et al. 2011). The four students articulated that to survive the medical school experience and the stress entrenched within that system, unique coping strategies are developed. It is clear that uniform strategies such as mindfulness training may work for some students (Dyrbye et al. 2006a, b, c; Hassed et al. 2009; Shapiro et al. 1998), but each of the four students in this study had their own particular frame of reference driving their own coping strategy which was linked to the way they made meaning out of their lives. It is, therefore, likely that strategies that connect students with their own resources around wellness issues (Lee and Graham 2001) may have a more generic appeal and may in turn be more effective. 123 J Relig Health Limitations of the Study Several limitations associated with this study are acknowledged. First, the focus group size was small and unlikely to have reached a reasonable level of saturation. Second, the students were sampled according to a convenience framework, although the reasonable response rate would likely negate any criticism-related non-representative survey data. Lastly, the sample size was not large enough to fully investigate some potentially confounding factors such as ethnicity. As a further cautionary note, the current results did not show that religious affiliation groups were different in actual academic accomplishments and were unable to report a significant expectancy gain. It is further acknowledged that the analysis in this study only considered the notion of academic self-concept in terms of students’ estimated academic achievement (Marsh 1992), which may not clearly differentiate between the notions of task difficulty, ability, effort or luck. Conclusion The research questions driving this research project were answered by the present findings. The main findings of the study indicated that participants from different religious affiliations expressed different spiritual QOL perceptions. However, these different expressions did not directly translate into their perceptions related to hours of study and academic achievement. In addition, the QOL measures did not relate to academic achievement estimation but did predict hours of study, and this finding may imply a subtle mind–body disconnection. Nonetheless, no evidence was found to link QOL perceptions and selfestimates of academic achievement. The implication of these findings therefore infers that each student has their own unique spiritual and religious mechanisms for developing meaning about life and for potentially coping with life issues, but these religious beliefs do not directly translate into self-estimations for academic performance. However, it is likely that high levels of academic effort over and above normal contact time may have an adverse impact on psychological and social aspects of QOL, and further research could incorporate actual measures of physical health such as heart rate variability (Chandola et al. 2010). 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