University students throughout the world can experience low levels of Quality of Life (QoL). For example, Swedish university students have been shown to have lower levels of QoL than their working counterparts (Vaez et al. 2006). Similar findings have been found among Brazilian medical students (Lins et al. 2015). Other studies have found levels of QoL comparable to community norms, with notable exceptions in specific domains. For example, American university students studying pharmacy have shown a lower QoL in the domain of mental health (Marshall et al. 2008), which is consistent with medical and dental students in Saudi Arabia (Aboalshamat et al. 2014) and Germany (Burger et al. 2016) having high levels of depression, anxiety and stress. In contrast, Serbian university students (Pekmezovic et al. 2011) and Canadian university students (Raj et al. 2000) report lower perceptions of general health on measures of QoL than population norms. While university students’ QoL tends to be lower than community norms, the evidence suggests specific deficits in QoL are likely to be culturally defined. To the best of our knowledge, so far, no studies to date have examined the factors associated with multiple domains of QoL in Indian university students.

One important cultural factor that has been shown to be associated with QoL is spirituality (Sawatzky et al. 2005). The association between spirituality and QoL has also been investigated in university students. Using one of the World Health Organization ‘s (WHO) measures of QoL (the WHOQOL-BREF), religiosity/spirituality has been shown to be associated with psychological quality of life in adolescents (Mirghafourvand et al. 2016) and both domestic and international university students (Deb et al. 2016; Hsien-Chuan Hsu et al. 2009), and with social quality of life in international students (Hsien-Chuan Hsu et al. 2009). Spirituality is a complex, multidimensional construct (Pesut et al. 2008). An important consideration when examining spirituality is the overlapping construct of religiosity (Krägeloh et al. 2015; Pargament 1999). Individuals can be spiritual without being religious; therefore assessing both religiosity and spirituality is vital for mapping the full spirituality/religiosity (S/R) domain in the present study. While it is common that spirituality is a stronger predictor of QoL or wellbeing, it is common to measure both due to cultural differences. For example, Lau et al. (2015) found that spirituality rather than religion was a predictor of QoL in Chinese university students over a 3 year period. Similarly spirituality, but not necessarily religiosity, is associated with adolescents’ well-being in Zambia (Holder et al. 2016). However religiosity has also been found to be associated with university student QOL in American college students (Anye et al. 2013) and New Zealand medical students (Henning et al. 2015). Given that religiosity and spirituality are both multidimensional and specific relationships between these constructs and QoL vary across cultures, it is common practice to include measures of both in studies examining QoL in young people. As such measures of both religiosity and spirituality will be include in this study.

In an attempt to conceptualise spirituality using a scientific methodology, Gijsberts and colleagues, conducted a systematic review of questionnaires of spirituality, identifying a number of key constructs (Gijsberts et al. 2011). Their model proposed the domains of spirituality of Spiritual Well-Being (e.g., peace), Spiritual Cognitive Behavioral Context (spiritual beliefs, spiritual activities, and spiritual relationships), as well as Spiritual Coping. Recognising that spirituality is a multi-domain construct, these domains were incorporated into the present study, in addition to the separate construct of religiosity. A component of spiritual well-being called existential well-being has been associated with psychological well-being (as measured by depressive symptoms and self-esteem) in American college students across different faiths (Genia 2001). Negative religious coping is a construct that measures a tenuous relationship with God during stressful event (i.e. a spiritual belief that God has abandoned you or will punish you). In contrast, positive religious coping is a construct that measures a secure relationship with God during stressful events. There is evidence that negative religious coping is associated with poorer mental health and life satisfaction, while there may be no association between positive religious coping and wellbeing (Hebert et al. 2009). However another study found that negative religious coping was related to QoL in domestic Muslim university students, while positive religious coping was associated with QoL in international Muslim university students (Gardner et al. 2014). Given the more consistent findings for negative religious coping, this construct was included in the current study along with religiosity, existential wellbeing and QoL.

The present study assessed religiosity and spirituality using a battery of published questionnaires collated in the Spiritual Attitudes Inventory. The questionnaires measure constructs such as beliefs about the importance of religion using the Duke University Religion Index (Koenig and Büssing 2010); spiritual coping using the Negative Religious Coping (Pargament et al. 1998); a sense of spiritual purpose and connection using the Existential Well-Being Scale (EWBS) (Paloutzian and Ellison 1982); and sense of hope and control as measured using the Multiple Health Locus of Control Scale (Wallston et al. 1978).

Multiple demographic factors have also been found to be associated with university students’ QoL, including gender, family income, smoking status, discipline studying at university, whether living at home or alone, and level of physical activity (Pekmezovic et al. 2011). In addition, there is evidence of associations between social support and spirituality (Salsman et al. 2005). Therefore this study also included a range of demographics and social support as possible covariates for the association between spirituality and QoL.

While religion and ethnic/national cultures may often be inseparable, culture can have a moderating impact upon the expression of religious/spiritual beliefs upon various psychological and health outcomes (Saroglou and Cohen 2013). As such it is important that the associations between measures of spirituality and QoL in university students be examined cross-culturally. Given that there is a paucity of research exploring these associations in Indian populations, the aim of this study was to investigate the association between multiple measures of spirituality and QoL in a sample of Indian university students after controlling for a range of demographic variables and levels of social support. It was hypothesised that higher levels of spirituality, as measured by all questionnaires included in the Spiritual Attitudes Inventory, would be associated with all measures of QoL after controlling for a range of demographics and social support.

Methods

Participants

Six hundred post-graduate students from different educational streams at Pondicherry University were approached for this research. The students were either in their 4th and 5th year of an integrated program (i.e. undergraduate and postgraduate coursed integrated into the one course) or were master’s degree students who had completed an undergraduate degree. Out of 600 approached, 534 students (i.e., 89%) agreed to participate in the study. After eliminating cases due to missing data, data analysis was conducted with the remaining 475 participants (241 males and 234 females). There were no differences on demographics between those with and without missing data. The age ranged from ranged from 20 to 27 with a mean of 22.13 years (SD = 1.47 years). The majority of the participants considered themselves Hindu (78.1%), while the remaining sample described themselves as Christian (11.6%), Muslim (7.4%) or other (2.9%). See Table 1 for details on the demographics of this sample.

Table 1 Description of the sample
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Measures

Demographics

The participants were asked to provide demographic data on age, gender, education, discipline studying at university, religion, place of origin of birth in India, marital status, family income per month, family type (living with family of origin or also with extended family), and whether or not they had experienced a severe crisis in the past (such as death of family member or close friend, financial crisis and breakup of intimate relationships). The options for responses to these questions are shown in Table 1 below.

Social Support

The participants were asked to complete study specific questions on their perceived level of support from their family environment (i.e. perceived support from entire family), university environment, parents, teachers and classmates. Participants rated these areas of social support on a three point scale: highly supportive, moderately supportive and not so supportive.

Spirituality Attitude Inventory

The Spiritual Attitude Inventory (SAI) is a battery of existing questionnaires collated by the US Army’s Centre for Health Promotion and Preventive Medicine (USACHPPM). The 28-item SAI was compiled by combining four currently validated measures of religion and spirituality to address the following areas:

  • Duke University Religion Index (DUREL) developed by Koenig et al. (1998) is a 5-item measure of religiosity and the importance of religion in one’s life. Two items are rated on a 5 point scale and three items are rated on a 6 point scale. Higher scores indicate higher levels of religiosity or spiritual practice. It is a widely used measure of religiosity (Koenig and Büssing 2010) and has been shown to have good test-retest reliability (Storch et al. 2004b), and good convergent validity with other established measures of religiosity as well as a stable factor structure (Koenig and Büssing 2010; Storch et al. 2004a) The Cronbach alpha for this study was .79.

  • Negative Religious Coping (NRCOPE) developed by Pargament et al. (1998) is a 7-item measure of spiritual belief. These items are scored on a 6 point Likert scale. Higher scores indicate lower levels of negative religious coping or beliefs about a tenuous relationship with God. This measure has shown good construct validity, predictive validity, and incremental validity, in particular, is a robust predictor of health-related outcomes (Pargament et al. 2011). The Cronbach Alpha for this study was .76.

  • Existential Well-Being Scale (EWBS) [a subscale of the Spiritual Well Being Scale (SWBS)] developed by Paloutzian and Ellison (1982) is a 10-item measure of ‘sense of purpose/connection’. Test-retest reliability ranges from r = 0.73 to 0.99. These items are scored on a 4 point Likert scale. Higher scores indicate greater existential well-being. The EWBS has been shown to have a stable factor structure with good internal consistency in university students with different religious affiliations (Genia 2001). The Cronbach alpha for this study was .83.

  • Internal/external subscale of the Multidimensional Health Locus of Control Scale (MHLC) developed by Wallston et al. (1978) is a 6-item measure of ‘sense of hope/control’. Test retests stability coefficients range from 0.60 to 0.70. These items are scored on a 6 point Likert scale. Higher levels indicate greater internal locus of control/hope regarding one’s health. Whist there is ample evidence for the reliability and validity of the MHLC in western populations (Wallston 2005), there is also some evidence of a stable factor structure and good concurrent validity in non-western countries (Moshki and Ashtarian 2010). The Cronbach alpha in this study was .82.

WHO Quality of Life-BREF (WHOQOL-BREF)

The WHOQOL-BREF questionnaire comprises 26 items, which measure the following broad domains: physical health, psychological health, social relationships, and environment WHOQoL Group (1998). Item four was taken out from the subscale of Physical Health QoL as it was negatively correlated with other items in the same scale in this sample. The Physical Health QoL subscale comprised of six items and had a Cronbach alpha of .70 in this study. The Psychological QoL subscale was composed of six items and had an internal reliability of .75 in this study. The Social QoL subscale involved three items and had a Cronbach alpha of .63 in this study. The low Cronbach alpha represents the fact that only two items were included in this subscale. The Environment QoL subscale was made up of eight items and had a Cronbach alpha of .79 in this study. Finally the Total QoL scale involved 24 items and had an internal consistency of .91 in this study. The scale’s single item ratings of overall perceived QoL and overall perceived health were not included in the analyses of this study. The WHOQOL-BREF has been shown to have good internal consistency reliability, discriminant validity, criterion-related validity and construct validity in Asian university students (Li et al. 2009).

Procedure

Ethical approval was granted by the Institutional Ethics Committee of the Pondicherry University. The university departments that were involved in the study were selected to achieve equal representation from the Faculties of Science and Arts. Departments were approached for permission to collect data. Postgraduate students from the selected departments were invited to learn more about the study either individually or in groups, and were then briefed on the purpose of the study. The participants completed hard copy versions of the questionnaires and then returned these to the research assistant either individually or in group format outside lecture periods. Participants were informed that participation was voluntary and that they could withdraw from the study at any time without penalty or comment. The de-identified data was entered into a database by a research assistant who was blind to the identity of the participants.

Statistical Analyses

Because of the multiple comparisons included in this study, alpha was set at .01 in order to minimise the chance of Type 1 errors. To facilitate inclusion in the bivariate correlations, the following dichotomous variables were dummy coded: gender, education, family type, and crisis. Only covariates with significant bivariate correlations with the different domains of QoL were included in the relevant hierarchical regressions. Similarly only the measures of spirituality that had significant bivariate correlations with the different domains of QoL were included in the relevant hierarchical regressions. The hierarchical regressions included the covariates as step 1 and then included the measures of spirituality as step 2 with measures of QoL as the dependent variables.

Results

Descriptive Statistics

The means and standard deviations for the measures of QoL are shown in Table 2 below. Each subscale was moderately correlated with each other and strongly correlated with the overall total score of the WHOQOL-BREF.

Table 2 Means, standard deviations and correlation coefficients of the WHOQOL-BREF
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The means and standard deviations for the measures of spirituality are shown in Table 3 below. Spiritual practice (DUREL) was positively correlated with Spiritual belief (NRCOPE) but has no relationship with sense of purpose or connection (EWBS) or sense of hope or control (MHLC). NRCOPE, EWBS and MHLC scores were all positively correlated, however the size of the correlations were all small indicating that the four measures of spirituality used in this study tend to measure quite distinct aspects of spirituality in this population.

Table 3 Means scores (SDs) and inter-scale correlations of spirituality measures
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There were no significant differences between the categories of discipline studied with levels of QoL-Physical, QoL-Psychological, QoL-Social, QoL-Environment and QoL-Total (F(2, 472) = 0.55, 0.48, 1.46, 0.76 and 0.33 respectively). Similarly, there were no significant differences between the categories of place of origin born with levels of QoL-Physical, QoL-Psychological, QoL-Social, QoL-Environment and QoL-Total (F(4, 470) = 0.95, 1.92, 2.56, 2.08 and 2.26 respectively). Note that while the difference in QoL-Soc for Place of Origin was less than p < .05, due to correction for the large number of comparisons, it was not considered statistically significant as p was not less than 0.01. In addition, there were no significant differences between the categories of marital status with levels of QoL-Physical, QoL-Psychological, QoL-Social, QoL-Environment and QoL-Total (F(2, 472) = 1.62, 1.36, 1.43 and 1.45 respectively). Finally, there were no significant differences between the categories of religion with levels of QoL-Physical, QoL-Psychological, QoL-Social, QoL-Environment and QoL-Total (F(3, 471) = 1.69, 2.93, 1.06, 2.10 and 2.62 respectively). Again, while the difference in QoL-Psychological for Relig-on was less than p < .05, due to correction for the large number of comparisons, it was not considered statistically significant as p was not less than 0.01.

Covariates

The bivariate correlations between the possible covariates and the QoL measures are shown in Table 4 below. There were no significant associations between any of the QoL measures and Gender, Education, Family Type, Crisis and Age (with the exception of an association between Age and Qol-Social). Family Support, University Support, Parental Support and Classroom Support were included as covariates for all of the hierarchical regressions using the quality of life measures as dependent variables. In addition, Family Income was included as a covariate for the hierarchical regression using QoL-Environment as a dependent variable.

Table 4 Bivariate correlations between demographics, social support and QoL
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Spirituality and Quality of Life

The correlation coefficients between spirituality scores and QoL scores are presented in Table 5. Among scores of four spirituality domains (i.e., religiosity (DUREL), negative religious coping (NRCOPE), sense of purpose or connection (EWBS) and sense of hope or control (MHLC), the score of NRCOPE domain showed the strongest correlations with QoL scores. Given that all of the measures of spirituality were correlated with all of the QoL scores, all of the spirituality measures were included in the hierarchical regression analyses.

Table 5 Correlation coefficients between QoL and spirituality scores
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The relationships between spirituality and QoL were further examined in hierarchical regression analyses (see Table 6). After controlling for the relevant covariates, negative religious coping, existential well-being and health locus of control were all independently associated with physical health QoL, environmental QoL and the total score on the QoL measure. Of the significant independent variables, negative religious coping had the strongest association. Religiosity was independently unrelated to any of the measures of QoL. With regards to psychological quality of life, after adjusting for covariates, only negative religious coping and existential well-being were related. Religiosity and health locus of control were not significantly associated with psychological QoL. After controlling for the relevant covariates, only negative religious coping and health locus of control were independently associated with social QoL with again negative religious coping having the strongest relationship.

Table 6 Multivariable models for quality of life scores on spirituality scores and background variables
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Discussion

The present study aimed to assess the QoL of Indian post-graduate university students and its association with their spirituality after adjusting for a range of demographic and perceived social support variables. The results of the study indicate that spirituality is independently associated with QoL in this population. The measure of spirituality that had the strongest association with QoL was negative religious coping. This aspect of spirituality was associated with all measures of QoL and consistently had the strongest associations out of any of the independent variables. Existential well-being and hope/health locus of control had similar strengths of association with QoL although slightly different patterns of association. Existential well-being was independently associated with all of the measures of QoL with the exception of social QoL, while health locus of control was independently associated with all measures of QoL with the exception of psychological QoL.

The results of this study are consistent with other similar studies. The finding that negative religious coping is associated with QoL is consistent with studies using other populations (Gardner et al. 2014; Tarakeshwar et al. 2006) and findings from a meta-analysis (Ano and Vasconcelles 2005). The finding that existential well-being was associated with QoL, including psychological QoL, corresponds with the results from Jafari and colleagues (Jafari et al. 2013), who also found a significant relationship between existential well-being and mental health in university students. While our study appears to be the first to examine the link between a sense of hope/health locus of control and QoL in university students, others have found associations between hope and QoL in other populations (Hasson-Ohayon et al. 2009; Krägeloh et al. 2015) and more specifically associations between the MHLC and QoL in other populations (Kostka and Jachimowicz 2010). While previous studies have shown an association between spirituality and QoL in university students, there is evidence that the relationship between subjective perceptions of well-being and spirituality may be culturally bound (Lun and Bond 2013).

The finding that lower family income was related to lower QoL scores in several domains and in overall total score of QoL was consistent with the findings of previous studies (Dolan et al. 2008; Ma and McGhee 2013; Ng et al. 2010). The finding of no relationship between gender and QoL has also been demonstrated in previous studies (Mercier et al. 1998; Lau et al. 2015). The strong associations between various areas of social support and different measures of QoL is consistent with what has been found in a number of other studies (Chen et al. 2013; Gabriel and Bowling 2004; Ibrahim et al. 2013).

However there are also some differences in findings in this study compared with other studies. For instance, religiosity was not independently associated with QoL in Indian university students in this study. However, religiosity has previously been associated with QoL in Muslim undergraduate students living in Kuwait (Abdel-Khalek 2010). Given that approximately 78% of this sample reported being of the Hindu faith and only approximately 7% reported being of the Muslim faith, it is possible that this difference may represent a difference in the religion of the two samples and requires further investigation in future studies. The finding that having experienced a crisis was not associated with QoL is different from other studies that have shown that past trauma and recent severe stressful events are associated with worse health related QOL (Leserman et al. 2005). It is possible that this is attributable to differences in the measurement of this construct.

Limitations

This study has a number of limitations that need to be considered when interpreting the findings. First the cross-sectional design precludes considerations of causality. Second the participants in this study were in their fourth and fifth year of university studies. It is possible that different results may have been obtained in undergraduate students in their first, second or third year of study. Similarly, the participants tended to be young, unmarried and Hindu. It is therefore possible that different results may be found in a different Indian university population. These findings therefore need to be replicated using a longitudinal design that includes Indian university students with a broader range of demographics.

Another limitation relates to the inclusion of the measure of health locus of control. While Koenig (2009) included this as part of his battery in the Spiritual Attitudes Inventory as a measure of sense of hope/control, and health locus of control has been associated with religiosity (Ai et al. 2005), the constructs of hope and locus of control are not interchangeable (Carifio and Rhodes 2002). Moreover, Koenig (2008) cautions against equating measures of positive psychology with measures of spirituality. As such caution is needed when interpreting the findings of health locus of control in terms of a measure of spirituality.

A final limitation relates to the generalisability of the findings from this study. A comparison across 114 countries found that religiosity declined with economic and social development (Deb et al. 2016), income security, and health security (Barber 2013). Indeed there is even some evidence that the strength of religious/spiritual beliefs varies within subcultures in India with those living in Bangalore having slightly stronger religious beliefs than those living in Pondicherry (WHOQoL SRPB Group 2006). As such there are strong cultural factors influencing the intensity of religious/spiritual beliefs. Given that the degree to which a culture values religiosity influences the psychological benefits of religious/spiritual beliefs (Gebauer et al. 2012), it is uncertain as to the degree to which the associations found in this study may generalise to other countries and cultures with differing material security and cultural beliefs. Further research is therefore required to replicate these findings in other cultures, including examining whether the same associations with QoL are found in Indian postgraduate university students studying abroad.

Implications

The results of this study support negative religious coping, existential well-being and health locus of control as targets for screening and intervention in order to improve the QoL in Indian university students. In particular, reducing students’ negative religious coping (i.e. beliefs of being abandoned or punished by God) is likely to have the biggest effect in improving QoL in Indian university students compared with targeting any other variable measured in this study. The associations need to be confirmed in prospective and interventional studies.

Based upon the findings with Psychology –QoL, student counselling services and mental health providers should explore negative religious coping or beliefs about a tenuous relationship with God, as well as existential wellbeing when counselling with Indian post-graduate university students for psychological problems. This is consistent with emerging evidence that incorporating discussions about religion/spirituality in cognitive behaviour therapy for anxiety and depression can enhance its effect upon those who are religious (Paukert et al. 2009) as well as evidence of a moderate effect size for spiritually oriented psychotherapies (Smith et al. 2007).

However the findings from this study indicate that spirituality has a broader effect upon Indian post-graduate university students’ QoL than just psychological QoL. As such the findings from this study indicate that improving the spirituality of post-graduate Indian university students may have an impact upon a range of different dimensions of QoL. This should provide encouragement to Indian university administrators, or administrators of international universities with high populations of Indian students, to consider embedding programs to provide training in spirituality within curriculum or university based activities. While currently such programs are likely to be rare in most universities, there are some isolated examples of universities embedding training in spirituality in to curriculum (Brawer et al. 2002; Schmidt-Wilk et al. 2000). As evidence builds in linking spirituality to QoL in university student populations, there may be stronger arguments for more universities to consider such options.

Given that negative religious coping proved to be the strongest independent variable in this study, there is a need to further investigate interventions that can reduce this variable in this population. There is some evidence in other populations that Christian pastoral care can significantly reduce negative religious coping (Bay et al. 2008). Given that the majority of participants in this study were Hindu, with a smaller percentage being Christian and Muslim, future studies should explore the efficacy of Hindu and Muslim pastoral care upon negative religious coping and QoL.

Finally, while the results of this study suggest the value of developing interventions for enhancing spirituality in university students in order to improve their quality of life, there are also clear ethical implications that accompany such implications with regards to respecting personal values and choice in engaging in such interventions. As such an important next step may involve conducting exploratory studies about the needs and preferences of Indian university students, as well as investigating the current efforts/activities/preferences of key stakeholders at Indian Universities. Findings from such studies would help guide the development of implementable and sustainable interventions for improving the spirituality and therefore QoL of Indian post-graduate university students.

Conclusion

Cultural factors have a strong bearing upon the experience of QoL upon all individuals including university students. Given that religion/spirituality is such an integral aspect of Indian culture, this study examined the relationship between measures of spirituality and QoL in Indian post-graduate students. The findings of this study indicate that while religiosity did not seem to be associated with QoL, even after adjusting for a range of demographics and social support, measures of spirituality such as negative religious coping, existential well-being and health locus of control were associated with QoL in Indian post-graduate university students. Of the measures of spirituality used in this study, negative religious coping appeared to have the strongest association with QoL in this population.