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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
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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: [email protected]
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
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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
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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
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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).
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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.
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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.
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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
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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):
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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).
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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.
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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
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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
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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.
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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). There is more scope for further research for investigating students’ actual
grade attainment, ways of coping with stress in the learning environment and levels of
religious orientation and attitude.
Acknowledgments The authors wish to express sincere appreciation to Mandy Tan, Kritan Chand and
Avinesh Pillai, and fourth- and fifth-year medical students for their valuable input and support. We also
found the erudite comments made by Associate-Professor Papaarangi Reid in the planning stage very
valuable and constructive.
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