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Article

Validation of “Trust/Mistrust in God Scale” for Spanish Cancer Patients

by
David Almaraz
1,
Jesús Saiz
1,
Iván Sánchez-Iglesias
2,* and
David H. Rosmarin
3
1
Department of Social, Work and Differential Psychology, Complutense University of Madrid, 28040 Madrid, Spain
2
Psychobiology & Behavioral Sciences Methods, Complutense University of Madrid, 28040 Madrid, Spain
3
McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA
*
Author to whom correspondence should be addressed.
Religions 2021, 12(12), 1077; https://doi.org/10.3390/rel12121077
Submission received: 4 November 2021 / Revised: 30 November 2021 / Accepted: 1 December 2021 / Published: 5 December 2021
(This article belongs to the Special Issue Religion, Spirituality and Psychosocial Well-Being)
Review Reports Versions Notes

Abstract

:
Trust/Mistrust in God have turned out to be two constructs that have great relevance in the study of the relationship between religion, spirituality, and health. In Spain, there are no instruments adapted to measure trust/mistrust in God, which limits the work of researchers interested in these aspects. Therefore, the aim of this study was to validate the Brief Trust/Mistrust in God Scale (BTMGS) in Spanish. The scale translated into Spanish was applied in a sample of 178 oncologic patients together with the Positive and Negative Affect Schedule (PANAS) and the significant others subscale of the Multidimensional Scale of Perceived Social Support, due to the existing evidence of relationships between the variables evaluated by these measures. Internal consistency, structural validity, convergent and discriminant validity were evaluated. The Spanish adaptation of the BTMGS obtained high internal consistency, both for trust subscale (α = 0.95) and for the mistrust subscale (α = 0.86). Furthermore, the correlations found between the BTMGS and the measures of positive and negative emotions and social add evidence of convergent and discriminant validity. These results suggest that the Spanish version of the BTMGS is a valid and reliable measure to be used in research on religion, spirituality and health in Spanish-speaking contexts.

1. Introduction

1.1. Psychology, Health and Cancer: A Brief Conceptualization

Cancer continues to constitute one of the world’s leading causes of morbi-mortality, with approximately 18.1 million new cases in 2018 and estimates of 19.3 new cases diagnosed in 2020 (SSMO 2021). Long-term forecasts are not encouraging, as global estimates indicate that the number of new cases will increase over the next two decades to 30.2 million per year (SSMO 2021).
In fact, according to SSMO (2021) data, approximately 9.9 million cancer-related deaths occurred worldwide in 2020, with mortality estimated at more than 16 million by 2040.
In Spain the figures are not encouraging either, since the number of cancers diagnosed in 2021 is expected to be 276,239 cases. And in terms of mortality, it is estimated that cancer mortality will increase from 113,000 cases in 2020 to more than 160,000 in 2040 (SSMO 2021).
As Ortiz et al. (2014) stated, the medical treatment of cancer depends largely on the location and degree of progression of the disease, with different forms of treatment, such as surgery, chemotherapy or radiotherapy.
However, every disease, including cancer, involves a series of psychological and social aspects that are present throughout the disease process and that play a relevant role in the process. Thus, psychology has shown a broad interest not only in cancer, but also in the area of health in general.

1.2. Religion, Spirituality and Health

Within the aforementioned relevance that health has for psychology, numerous authors (Koenig et al. 1988; Poloma and Pendleton 1990; Hawks et al. 1995; Patel et al. 2002; Contrada et al. 2004; Bento Gastaud et al. 2006; Koenig et al. 2012; Saiz et al. 2020) have added the variables of religion and spirituality to their attempt to improve the understanding of the various aspects that make up the subject of health and illness from a psychological point of view.
Since the mid-twentieth century, religious beliefs have come to be considered as a topic of interest for study in terms of health maintenance and recovery (González 2004), and there are numerous investigations that include various aspects ranging from the positive evaluation of symptoms and behaviors to health interventions (Bergin 1991; Koenig et al. 1993, 2012; Steffen et al. 2001; Saiz et al. 2021b).
More specifically, the concept of spirituality has gained special relevance in recent years, being increasingly examined as a construct related to physical and mental health. The term spirituality has been defined in multiple ways. If we define religion as an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (Koenig et al. 2012), spirituality would be the substratum of religion, that which nourishes it and gives it meaning (Salgado 2014). In the words of Koenig et al. (2012), spirituality is the search for answers to different questions about life in order to understand its meaning, the search for and finding of the transcendent, as well as the relationship with the sacred or transcendent. Thus, spirituality has traditionally been considered a characteristic of deeply religious people that separates them from those who are only superficially religious (Koenig et al. 2012). However, this term has been broadened to also describe the superficially religious person, the religious seeker, the seeker of well-being and happiness, and the completely secular person (Koenig 2008). In this study, we will opt for the more traditional conception of spirituality.
Thus, in the context of research conducted in this field, various positive effects that religion and spirituality can have on health have been found. For example, with regard to mental health, religion and spirituality have been found to be associated with lower levels of depression, anxiety and other clinical associated symptoms (Koenig et al. 1993; Smith et al. 2003; Saiz et al. 2020), as well as a higher rate of recovery in people with severe mental illnesses (Saiz et al. 2021a). However, despite the many positive effects of religion and spirituality on mental health, it is equally necessary to understand that negative religious coping (e.g., through reading religious scriptures) can sometimes occur in the face of psychosocial stress, which can worsen e.g., depressive symptoms (DeAngelis et al. 2019). In addition, focusing on cancer patients, numerous studies have found a positive impact of religion and spirituality on the health of this people, represented by higher levels of well-being or quality of life and lower levels of despair, social isolation, anxiety or depression (McCoubrie and Davies 2006; Krupski et al. 2006; Tarakeshwar et al. 2006; Janiszewska et al. 2008; Yanez et al. 2009; Kim et al. 2011), and even lower mortality rates (McCullough et al. 2000; Koenig et al. 2012).
With regard to physical health, a great example is found in the review by Koenig et al. (2012), who summarized research examining the relationships between religion, spirituality, and health, finding that people who are more religious and spiritual are less prone to coronary artery disease, hypertension, cerebrovascular disease, or cancer. Likewise, research shows direct relationships between religion and spirituality and improved immune and endocrine functions (Koenig et al. 2012).
Thus, given the need to better understand the relationship between religious variables and health, it is essential to have reliable and valid measurement instruments that contribute to a better performance of this task (Austin et al. 2018).

1.3. Strategies for Assessing Religion and Spirituality

Establishing measures on variables such as religiosity or spirituality is not a simple task. One of the main difficulties arises from the very definition of these concepts, such as, for example, the different ways of understanding spirituality mentioned above. Another reason may be their complex and varied structure (Głaz 2021). In this case, as Koenig (2008) argued, the expansion and current meaning of this concept is reflected in the instruments, so that they are contaminated with questions that assess positive traits of character or mental health: optimism, forgiveness, gratitude, meaning and purpose in life, tranquility, harmony and general well-being. For this reason, Zwingmann et al. (2011) argued that given the growing number of people who define themselves as “spiritual, but not religious”, the distinction between religiosity and spirituality is important, especially in those countries with a more secular background, in order to better adapt the instruments to what is to be measured, and to avoid their contamination. In this sense, De Jager Meezenbroek et al. (2012) expounded the need to understand spirituality as universal, so that the instruments transcend specific beliefs in order to quantify the importance of spirituality among people who adhere to one religion or none.
Another difficulty in measuring these variables is the lack of a single approach that serves as a standard, as well as the risk of overgeneralizing the findings, since most measures are limited to quantifying religiosity “in general”, ignoring the specific context of each religious tradition (Hall et al. 2008). With regard to context, Zwingmann et al. (2011) attached particular importance to the wording of the items, especially when deciding between instruments that use specific religious terminology and instruments that refer to a wider variety of worldviews. Thus, instruments with a very particular religious perspective and traditional religious terminology are less suitable for people with an atheistic or agnostic background, who may nevertheless appreciate plural forms of spirituality, so it is crucial to ensure that respondents understand the items (Zwingmann et al. 2011).
Moreover, as far as this paper is concerned, it should be noted that typically, religion and spirituality have been measured by global indices (e.g., frequency of church attendance, self-rated religiousness and spirituality) that do not specify how or why religion and spirituality affect health (Hill and Pargament 2003).
However, different authors have identified numerous measures that assess factors related to spirituality and religiosity in clinical and health care settings (Cutting and Walsh 2008; Zwingmann et al. 2011; De Jager Meezenbroek et al. 2012; Austin et al. 2018; Motiño et al. 2021). Among the most common are: the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-SP) (Peterman et al. 2002), that measures spiritual well-being in cancer patients; the Daily Spiritual Experiences Scale (DES) (Underwood and Teresi 2002), used for the measurement of spiritual experiences in physical and mental health studies; the Spiritual Well-Being (SWB) Scale (Paloutzian and Ellison 1982), that assesses individual and congregational spiritual well-being; the Duke University Religion Index (Koenig et al. 1997), through which different dimensions of religiosity are evaluated; or the Brief RCOPE (Pargament et al. 1998), focused on religious coping assessment.
Hill and Pargament (2003), however, proposed that it is through measures more conceptually related to physical and mental health (e.g., closeness to God, religious orientation and motivation, trust and mistrust in God or religious support) that psychologists can discover more about the contributions of religion and spirituality to physical and mental health.
For example, closeness to God has been associated with different aspects of health, such as less depression, anxiety and stress (Proeschold-Bell et al. 2014), better adjustment to medical illness (Koenig et al. 1998), higher levels of life purpose, personal mastery and life satisfaction (Culver 2020), and better self-rated health and emotional functioning (Kent et al. 2020). Other variables, such as religious support, is also closely related to health, as it is associated with higher health-related quality of life (Mirghafourvand et al. 2018), lower level of depressive symptoms (Holt et al. 2018), higher well-being in oncology patients (Flores et al. 2021), and better mental health in general (Johnstone et al. 2009). It also appears to be a protective factor against depression (Nugraheni and Hastings 2020), and even turns out to be a predictor of health behaviors (Debnam et al. 2012).
Be that as it may, it is important to understand that these aforementioned variables are closely related to religion and spirituality, and even form part of them. If we attend to the definitions of religion and spirituality by Koenig et al. (2012), we observe how implicit in them is the search for meaning of the transcendent, the finding of the transcendent and the relationship with it. In this way, it is understood how the concepts of, for example, trust in God or closeness to God can enter into the meaning of spirituality, since they imply a relationship with the transcendent. In fact, focusing on trust in God, Rahnama et al. (2012) show how trust in God is a term broadly included within the meaning of spirituality.
For this reason, understanding trust in God as a part of spirituality can help researchers better understand the relationships between the spiritual and physical and mental health. In the following, we focus on research about this area and try to expose the influences of trust/mistrust in God on physical and mental health.

1.4. Trust and Mistrust in God

Trust in God is a cognitive and affective state in which a person feels that God is taking care of their best interests (Rosmarin et al. 2009b). Thus, according to Rosmarin et al. (2011), a worldview based on trust in God can mitigate negative appraisals of adversity, in addition to contributing to positive religious coping and serving as a spiritual resource in the face of stressful life events. Indeed, other authors have also shown how trust in God can be a powerful religious and spiritual coping strategy (Burns 2004; Büssing et al. 2021; Ladak et al. 2020). In contrast, mistrust in God seems to measure the notion that God is willfully ignorant and malevolent, and is related to divine spiritual struggles, which reflect the tension between the individual and God (Rosmarin et al. 2009b).
In relation to mental health, trust in God has been found to be associated with lower levels of depression, anxiety, and stress, while mistrust in God is associated with higher levels of symptoms in these affective disorders (Krumrei et al. 2013; Pirutinsky et al. 2020; Rosmarin et al. 2009a, 2010; Serfaty et al. 2020). Trust in God has also been related to drug use, although contrary to expectations, no significant effect of the former on the latter has been found (Bartkowski and Xu 2007). In addition, by promoting doubts and conflicts with divinity, mistrust in God can increase the level of stress and worry (Pirutinsky et al. 2020; Rosmarin et al. 2010).
Here it is necessary to expose the idea of authors such as Koenig et al. (2012), who consider positive and negative emotions and social support as very important variables in the relationship between religion, spirituality, and mental (and also physical) health. Indeed, positive emotions (Harpøth et al. 2020; Park et al. 2014; Yoo et al. 2017) and social support (Casale 2021; Wang et al. 2018) are known to have positive impact on health and well-being, the opposite being true for negative emotions (Miyamoto et al. 2013; Piqueras et al. 2010). In any case, the relationship of these variables with trust/mistrust in God has been studied. For example, Fadardi and Azadi (2017) have found positive associations between trust in God and positive emotions, as well as negative associations between the former variable and negative emotions. Likewise, Maselko et al. (2011) have observed direct relationships between trust in God and social support within the study of social determinants of health.
On the other hand, part of the research has tried to explain the relationship between trust/mistrust in God and physical health. Referring to the above idea of trust in God as a coping strategy, some authors have observed a wide use of such a strategy against different diseases, such as heart failure (Shahrbabaki et al. 2017), COVID-19 (Javed and Parveen 2021) or cancer (Shaw et al. 2007). In the particular case of cancer, there are some studies, although given the relevance of this disease, much more study is needed. However, existing studies clearly show how trust in God facilitates better adaptation to cancer and coping with this disease (Haghighi 2013; Rassouli et al. 2015; Shaw et al. 2007), as well as being a determinant of hope in cancer patients (Proserpio et al. 2015).
In this sense, Krumrei et al. (2013), in an attempt to understand the relationships between these variables, proposed that trust/mistrust in God may simply be a pathway by which religious coping is initiated, and religious coping may explain the links between trust/mistrust in God and mental/physical health outcomes. In this study, significant positive correlations were observed between physical health and trust in God, as well as significant negative correlations between physical health and mistrust in God (Krumrei et al. 2013). On the other hand, regression analyses by Krumrei et al. (2013) showed that trust in God did not predict physical health, although it was observed that higher levels of intrinsic religiosity increased the magnitude of the relationships between both variables. With this, although significant relationships were found between trust/mistrust in God and physical health, more research on the subject is needed.
In any case, a better understanding of these relationships requires the use of appropriate instruments to measure these variables. The main instrument for this work is the Brief Trust/Mistrust in God Scale by Rosmarin et al. (2011), which validly and reliably assesses these aspects of religious beliefs.
In the specific context of Spain, Galiana et al. (2014) make a systematic review of the existing literature, examining the various instruments for measuring spirituality, their psychometric properties, their general characteristics and their use in the Spanish population. In this review it is observed that in Spain there are language adaptations of the main instruments used in the area of oncology to measure religious and/or spiritual aspects, such as the FACIT-Sp (Peterman et al. 2002), the WHOQOL-SRPB (The WHOQOL Group 1998), the Spiritual Well-Being Scale (Paloutzian and Ellison 1982) or the SpREUK (Büssing et al. 2005). Despite this, there are no instruments translated and validated in Spanish to measure people’s trust and mistrust in God, which in turn makes it difficult to study the relationship between these two variables and health, more specifically cancer. For this reason, in the present study we adapted the Brief Trust/Mistrust in God Scale to the Spanish context in a sample of oncology patients.

2. Method

2.1. Participants

The sample consisted of 178 subjects with a diagnosis of cancer, inhabitants of the city of Salamanca, Spain (the distribution according to cancer types is shown in Table 1). 89 women (50%) and 89 men (50%), ranging in age from 17 to 81 years (M = 45.5; SD = 16.5), participated. Almost half of the participants placed themselves within a medium socioeconomic level (48.5%), with the other half split between the lower-middle (24.7%) and upper-middle (25.3%) levels. In addition, most of the participants had university studies, both undergraduate (39.3%) and master’s or doctoral degrees (22.5%).

2.2. Procedure

For the adaptation of the instrument, two different translations of the items were made, one more literal than the other, in order to compare them and observe which of the two was better understood in Spanish. These two translations were back-translated into English by an independent native English speaker and bilingual in Spanish, who had no prior knowledge of the original text, to ensure that the items retained their original meaning. Thus, we decided on the most literal translation of these items, since when comparing the accuracy and equivalence between the two versions, it was observed that there were no differences between the Spanish translation and the original version of the scale. The items in Spanish can be found in Appendix A.
After this, an online administration questionnaire was prepared using the Google Forms application.
Given the difficulty of contacting cancer patients, a non-probabilistic snowball sampling was carried out, through close cases of people with cancer, which helped to find more people affected by this disease. In this way, a wide sample of cancer patients was reached, since the questionnaire was sent not only to individuals, but also to workers of hospitals, associations, residences or day care centers, who were able to disseminate it among a larger number of subjects.
Once they received the questionnaire, the subjects had access on the first page to an explanation of what the questionnaire consisted of, as well as the option to give their consent to the confidential treatment of their data for research purposes. Once the conditions were accepted, the subjects had access to the second page of the questionnaire, where they had to complete the socio-demographic data requested. After this, the subjects were able to answer the different items that included the questionnaire.
Finally, given that the questionnaire was sent to healthy persons or persons affected by other types of diseases, and despite the fact that it was described in the introduction that it was focused on persons affected by cancer, we proceeded to eliminate those data of healthy persons or persons non affected by cancer. In this way, a total of 27 non-relevant cases were eliminated from an initial sample of 205 subjects.
The ethics committee of the Complutense University of Madrid audited the ethical issues for this study.

2.3. Measures

2.3.1. Sociodemographic Characteristics

An ad hoc survey was administered in which participants were asked about their age, sex, educational level, employment status, socioeconomic status, and health problems.

2.3.2. Brief Trust/Mistrust in God Scale

The Brief Trust/Mistrust in God Scale (Rosmarin et al. 2011) consists of six items divided in both factors, three of which assess trust in God (e.g., “God loves me immensely”) and three of which assess mistrust in God (e.g., “God hates me”). This is a Likert scale with five response alternatives (from “not at all” to “very much”) were participants indicated their degree of belief. Thus, the higher the score, the greater the degree of trust or mistrust in God, depending on the subscale. The Cronbach’s alpha coefficient is 0.94 for the Trust factor and 0.88 for the Mistrust factor.

2.3.3. Positive and Negative Affect Schedule (PANAS)

The Positive and Negative Affect Schedule (PANAS) (Watson et al. 1988), adapted to Spanish by López-Gómez et al. (2015), has been widely used to measure affect and emotions. The PANAS includes two subscales, one for positive affect and the other for negative affect, with ten items each (e.g., “Satisfied with oneself” and “Distressed”, respectively), for a total of twenty items. It is a five-point Likert scale where the participants must indicate whether he/she has felt each of the affects, from 1 (“not at all or very slightly”) to 5 (“very much”). In each subscale, a total score ranging from 10 to 50 is obtained, where a higher score indicates a greater presence of that type of affect. In this version, Cronbach’s alpha coefficient is 0.92 for the Positive Affect subscale and 0.88 for the Negative Affect subscale. In the case of our sample, the results were also satisfactory, both for the positive affect subscale (α = 0.88) and the negative affect subscale (α = 0.86). This scale has already been used to analyze the relationship between trust in God and positive and negative emotions, with satisfactory results (Fadardi and Azadi 2017).

2.3.4. Multidimensional Scale of Perceived Social Support

This scale developed by Zimet et al. (1988), and adapted to Spanish by Landeta and Calvete (2002) and Ruiz et al. (2017), consists of twelve items that evaluate the level of social support perceived by individuals, and has three different dimensions (family, friends, and significant others). The scale is presented in Likert format with seven response alternatives, with a value of 1 “Strongly disagree” and 7 “Strongly agree”. However, for the present study only the items of the significant others dimension were used, as they represent an even more abbreviated version to assess perceived social support without focusing on any specific source of support (e.g., “There is a person who is around when I am in a difficult situation”). This subscale also yields very positive reliability data (α = 0.94). For the present sample, although the reliability is lower, it is equally adequate (α = 0.80). With the use of this scale we expect to find significant positive associations between trust in God and social support, as in the study by Maselko et al. (2011) mentioned in the introduction.

2.4. Data Analysis

First, descriptive statistics for the items were calculated. Then, reliability of the scale was analyzed through an internal consistency analysis using Cronbach’s alpha statistic. In addition, an exploratory factor analysis (EFA) was performed to provide evidence on the structural validity of the translated instrument: First, we assessed the adequacy of the data, via KMO estimate and Bartlett’s sphericity test. Before selecting the extraction method, we tested for Mardia’s multivariate coefficients (Mardia 1970). The criterion for deciding how many factors to retain was a parallel analysis, comparing the empirical eigenvalues with the mean eigenvalues of 500 random correlation matrices. To facilitate interpretation, we allowed correlation between the factors, using a Promax oblique rotation.
Convergent and discriminant validity was evaluated through a correlation analysis using Pearson’s r coefficient. In the original version Rosmarin et al. (2011) correlated the subscales of trust and mistrust in God with measures of depression, anxiety and distress. In this case, the correlation of both subscales was performed with the positive emotions and negative emotions subscales of the PANAS scale, as well as with the “significant others” dimension of the Multidimensional Scale of Perceived Social Support. Positive, significant correlations were considered evidence of convergent validity, and no correlation were considered evidence of discriminant validity. Level of significance, α, was set at 0.05. Some statistical analyses were carried out using base R and two packages: for Mardia’s multivariate normality analysis (MVN, Korkmaz et al. 2014); and for Bartlett’s sphericity test, KMO estimator, and parallel analysis (psych, Revelle 2018). We ran the rest of analyses using SPSS 25.

3. Results

As mentioned above, half of the participants were men and half were women, with an average age of 45.5 years old (SD = 16.535). Mean scores were 7.34 (SD = 4.39) for the trust in God subscale and 7.15 (SD = 3.97) for the mistrust in God subscale, representing similar levels overall on both variables. Descriptive statistics for each item of the scale are presented in Table 2.

3.1. Internal Consistency

The internal consistency of each of the translated subscales was evaluated using Cronbach’s alpha statistic (Table 3).

3.2. Structural Validity: EFA

As for structural validity, we found data adequate for EFA, KMO test, 0.89, as well as Bartlett’s test of sphericity, χ2(15) = 1127.49, p < 0.001. The estimates of Mardia’s multivariate kurtosis (371.79) and skewness (10.02) coefficients were significant (p < 0.001), so we rejected the hypothesis of multivariate normality. Therefore, we selected an unweighted least squares (ULS) extraction method. Considering the results of the parallel analysis, we retained two factors. This two-factor model accounted for 80.1% of the test’s variance. The correlation between the two factors was r = −0.81. The items assigned to each factor are the same of the original instrument, and therefore we named them as Trust (Factor 1) and Mistrust (Factor 2). Table 4 shows the factor loadings of the rotated structure matrix.

3.3. Convergent and Discriminant Validity

On the other hand, the convergent and discriminant validity of both subscales was estimated. The correlations can be seen in Table 5.
Regarding convergent validity, significant positive correlations were found between the total scores of Trust in God and positive emotions (r = 0.61, p < 0.001). Significant positive correlations were also found between total Mistrust in God scores and negative emotions scores (r = 0.67, p < 0.001). A significant positive correlation was also observed between Trust in God and social support (r = 0.44, p < 0.001).
Also in terms of convergent validity, significant negative correlations were found between Mistrust in God scores and total positive emotions scores (r = −0.701, p < 0.001). Significant negative correlations were also observed between Trust in God total scores and negative emotions total scores (r = −0.620, p < 0.001). On the other hand, the correlation between Mistrust in God and social support was negative and significant (r = −0.476, p < 0.001).

4. Discussion

Validity is concerned with establishing evidence for the use of an instrument in a particular setting and with a particular population (Morgan et al. 2001). This study evaluated the psychometric properties of the Brief Trust/Mistrust in God Scale for its use in the Spanish context, in order to validate the scale.
Good reliability results (as internal consistency) were obtained for both the trust (α = 0.95) and mistrust (α = 0.86) subscales, data quite similar to those of the original scale (α = 0.90 and α = 0.85, respectively) from Rosmarin et al. (2011). The data showed a strong internal consistency in accordance with the published literature on the subject (Henson 2001; Campo-Arias and Oviedo 2008).
The significant positive correlations observed between the scores of the trust in God subscale and those of positive emotions and social support, and those of the mistrust in God subscale and negative emotions, provide evidence of convergent validity of this measure. More evidence in this sense are the negative correlations between the scores of the subscale of mistrust in God and positive emotions and social support, as well as those of the subscale of trust in God and negative emotions. In other words, we can conclude that trust in God is associated with higher levels of positive emotions and social support, and lower levels of negative emotions, with the opposite happening in the case of mistrust in God, results that are similar to those found by Rosmarin et al. (2011). Similarly, other research has found the same type of relationships between trust/mistrust in God and social support (Maselko et al. 2011), as well as positive and negative emotions, including affective disorders such as depression, anxiety, stress (Rosmarin et al. 2009a, 2009b, 2010; Krumrei et al. 2013; Fadardi and Azadi 2017).
These findings have several implications in the area of health care. First, in the face of a threatening life event such as a cancer diagnosis, the ability to make sense of the event by having trust in God can help preserve a person’s positive emotional state (Fadardi and Azadi 2017). This, given the positive association between positive emotions and mental and physical health, might lead one to think that promoting trust in God within medical practice in those patients with religious and/or spiritual needs could be beneficial. However, we must be cautious with these conclusions because both our research and previous literature establish relationships between trust in God and positive emotions, but no causal ones. Therefore, more research is needed to find out if there is any other variable that mediates this relationship.
Similarly, the association between trust in God and greater social support invites us to think that given the relationship between the latter variable and health, the implications for medical practice may be important. Nevertheless, this relationship needs to be studied further, since other studies show the possibility that trust in God makes people less likely to rely on material or social resources to cope with their problems (Fadardi and Azadi 2017).
In short, we believe that inquiring into the models of Koenig et al. (2012) can help to improve the understanding of the relationship between religious or spiritual variables, such as trust/mistrust in God, and emotions or social support, in order to understand how this whole web of connections can affect health.
Regarding to structural validity of this Spanish version, a two-factor model emerged from the item correlations in an EFA. This model replicates the structure of the original scale by Rosmarin et al. (2011). This coincidence with the model originally proposed suggests the robustness of the theoretical model.
The limitations of the study are largely due to the difficulty in achieving a representative sample. Although we believe that we have worked with a good number of participants, it is true that data protection laws make it difficult for associations and organizations working with cancer patients to collaborate with this type of studies. Therefore, this should be considered in order to find alternative ways of accessing large samples of oncology patients in the future. In addition, our results can only be applied to patients with cancer, so studies with other populations would be necessary to assure the generalization of the use of this instrument.
On the other hand, we should mention that in this study no significant differences were found in terms of the gender of the participants. However, authors such as Cetrez (2011) found that women present a greater number of religious behaviors than men, being more involved in their faith. In other words, the existence of differences in religiosity and spirituality between men and women have been documented, so we believe that on future occasions this variable should be taken into account.
Moreover, in relation to data analysis, we could have used a confirmatory factor analysis (CFA) to analyze the data, given that this is a new application of an existent measurement tool. However, we decided to use EFA instead. The reason was two-fold: Firstly, the two-factor model of Trust and Mistrust in God is not anchored in a broader measurement theory (i.e., a theoretical model), and thus EFA would be preferred (Hair et al. 2015 p. 603). Secondly, Rosmarin et al. (2011) explored the subjacent structure of the original six items scale in two distinct samples recruited from USA and Canada, comprised of Christian (mostly Protestants) and Jewish participants respectively. Then, they confirmed the two-factor model in a third sample of Jewish participants from the USA. The same authors discussed that the measure could be appropriate for other monotheistic religious backgrounds with a personal God concept, but this concept “may vary considerably both across and within traditions”. (p. 258). As we used a Spanish adaptation of the scale, and applied it to a sample of oncologic patients from a Catholic Christian background in Spain, we considered appropriate to explore the scale as if it was a brand new measure. Further studies could confirm the two-factor structure in similar settings in Spain, adding construct validity, and allowing the development of a theoretical model throughout countries, cultures, and religions.
Likewise, on future occasions it would be appropriate and necessary to study the psychometric properties of the scale in other Spanish-speaking religious contexts, given that Spain is a country with a deep-rooted Christian tradition and other religious traditions may have been overlooked. This idea is consistent with that proposed by Hall et al. (2008) regarding the need to take the context into consideration in this type of research. In addition, following this line, the appropriate wording of the items is particularly important so that they are adapted to the context in which the instrument is to be applied, as proposed by Zwingmann et al. (2011).
Finally, the Spanish adaptation of the Brief Trust/Mistrust in God Scale has proved to be a valid and reliable instrument for the measurement of the constructs trust and mistrust in God in the Spanish oncology population. Thus, we believe that this version of the scale represents an advance in the study of the relationships between religion, spirituality and health, by providing a measure for a construct closely linked to a better understanding of these relationships.

Author Contributions

Conceptualization, D.A. and J.S.; methodology, D.A. and I.S.-I.; software, D.A. and I.S.-I.; validation, D.A., J.S. and D.H.R.; formal analysis, D.A. and I.S.-I.; investigation, D.A.; resources, D.A. and D.H.R.; data curation, D.A. and I.S.-I.; writing—original draft preparation, D.A.; writing—review and editing, D.A., J.S. and D.H.R.; visualization, D.A.; supervision, J.S.; project administration, D.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the ethics committee of the Complutense University of Madrid (2020/21_020).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

Appendix A

Original Scale ItemsResponse Options of the Original ScaleSpanish Version ItemsResponse Options for the Spanish Version
1. God loves me immensely1. Not at all1. Dios me ama inmensamente1. No, en absoluto
2. A little2. Un poco
3. Somewhat3. Ligeramente
4. A lot4. Bastante
5. Very much5. Totalmente
2. God ignores me1. Not at all2. Dios me ignora1. No, en absoluto
2. A little2. Un poco
3. Somewhat3. Ligeramente
4. A lot4. Bastante
5. Very much5. Totalmente
3. God cares about my deepest concerns1. Not at all3. A Dios le importan mis preocupaciones más profundas1. No, en absoluto
2. A little2. Un poco
3. Somewhat3. Ligeramente
4. A lot4. Bastante
5. Very much5. Totalmente
4. God hates me1. Not at all4. Dios me odia1. No, en absoluto
2. A little2. Un poco
3. Somewhat3. Ligeramente
4. A lot4. Bastante
5. Very much5. Totalmente
5. No matter how bad things may seem, God’s kindness to me never ceases1. Not at all5. No importa lo mal que parezcan las cosas, la bondad de Dios hacia mí nunca cesa1. No, en absoluto
2. A little2. Un poco
3. Somewhat3. Ligeramente
4. A lot4. Bastante
5. Very much5. Totalmente
6. God doesn’t care about me1. Not at all6. Dios no se preocupa por mí1. No, en absoluto
2. A little2. Un poco
3. Somewhat3. Ligeramente
4. A lot4. Bastante
5. Very much5. Totalmente

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Table
Table 1. Types of cancer present in the sample.
Table 1. Types of cancer present in the sample.
Type of Cancern%
Breast cancer3620.2
Leukemias 12916.2
Colon cancer179.6
Lymphomas 2179.6
Lung cancer158.4
Unspecified cancer 395.1
Cervical cancer73.9
Liver cancer52.8
Throat cancer42.2
Ovarian cancer42.2
Pancreatic cancer42.2
Prostate cancer42.2
Stomach cancer42.2
Metastatic cancers 442.2
Skin cancer31.7
Kidney cancer21.1
Testicular cancer21.1
Bladder cancer21.1
Cholangiocarcinoma10.6
Multiple myeloma10.6
GIST10.6
Polycythemia vera10.6
Pleural mesothelioma10.6
Osteosarcoma10.6
Ocular melanoma10.6
Pancoast Syndrome10.6
Brain cancer10.6
Rectal cancer10.6
1 Leukemias include lymphoblastic leukemia, myeloblastic leukemia and unspecified leukemias. 2 Lymphomas include Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. 3 Subjects did not specify what type of cancer they had. 4 People affected by various cancers due to metastasis.
Table
Table 2. Items of the Brief Trust/Mistrust in God Scale. Descriptive statistics.
Table 2. Items of the Brief Trust/Mistrust in God Scale. Descriptive statistics.
Response OptionsMSDRItem-total
1. Not at All2. A Little3. Somewhat4. A Lot5. Very Much
1. God loves me immensely75 (42.1%)16 (9.0%)38 (21.3%)27 (15.2%)22 (12.4%)2.471.470.93
2. God ignores me70 (39.3%)26 (14.6%)21 (11.8%)26 (14.6%)35 (19.7%)3.391.580.91
3. God cares about my deepest concerns83 (46.6%)21 (11.8%)21 (11.8%)33 (18.5%)20 (11.2%)2.361.490.91
4. God hates me118 (66.3%)25 (14.0%)19 (10.7%)9 (5.1%)7 (3.9%)4.341.100.71
5. No matter how bad things may seem, Gods kindness to me never ceases83 (46.6%)12 (6.7%)24 (13.5%)25 (14.0%)34 (19.1%)2.521.620.93
6. God doesn’t care about me66 (37.1%)19 (10.7%)17 (9.6%)22 (12.4%)54 (30.3%)3.121.710.91
Note. Trust in God items: 1, 3, 5; Mistrust in God items: 2, 4, 6.
Table
Table 3. Cronbach’s alpha of the subscales of trust and mistrust in God.
Table 3. Cronbach’s alpha of the subscales of trust and mistrust in God.
SubscaleCronbach’s Alpha
Trust in God0.958
Mistrust in God0.868
Table
Table 4. Exploratory factor analysis. Factor loadings of the items of the Trust/Mistrust in God scale. Structure matrix.
Table 4. Exploratory factor analysis. Factor loadings of the items of the Trust/Mistrust in God scale. Structure matrix.
Factor
ItemTrustMistrust
Item 50.950−0.777
Item 10.946−0.809
Item 30.928−0.761
Item 2−0.8060.919
Item 6−0.8170.876
Item 4−0.5650.719
Note. Extraction method: Unweighted Least Squares. Rotation method: Promax. N = 178.
Table
Table 5. Pearson’s r coefficients between the subscales of trust and mistrust in God, the two dimensions of the PANAS scale and social support.
Table 5. Pearson’s r coefficients between the subscales of trust and mistrust in God, the two dimensions of the PANAS scale and social support.
Variables12345
1. Trust in God −0.8280.611−0.6200.441
2. Mistrust in God−0.828 −0.7010.667−0.476
3. Positive emotions0.611−0.701 −0.6860.473
4. Negative emotions−0.6200.667−0.686 −0.419
5. Social support0.441−0.4760.473−0.419
Note. All correlations are significant at the 0.001 level.
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Almaraz, D.; Saiz, J.; Sánchez-Iglesias, I.; Rosmarin, D.H. Validation of “Trust/Mistrust in God Scale” for Spanish Cancer Patients. Religions 2021, 12, 1077. https://doi.org/10.3390/rel12121077

AMA Style

Almaraz D, Saiz J, Sánchez-Iglesias I, Rosmarin DH. Validation of “Trust/Mistrust in God Scale” for Spanish Cancer Patients. Religions. 2021; 12(12):1077. https://doi.org/10.3390/rel12121077

Chicago/Turabian Style

Almaraz, David, Jesús Saiz, Iván Sánchez-Iglesias, and David H. Rosmarin. 2021. "Validation of “Trust/Mistrust in God Scale” for Spanish Cancer Patients" Religions 12, no. 12: 1077. https://doi.org/10.3390/rel12121077

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