Introduction

The term “quality of life” (QoL) is a common term in many scientific literatures, and it reflects the high level of well-being of individuals and the society (Psatha et al., 2011). The quality of life includes two main aspects: the objective aspect, which means income, work conditions, and the size of social support. These are measurable dimensions which have been largely covered by the literature. The second is the subjective aspect, which is concerned with personal well-being, satisfaction with life and personal happiness.

Through the material and objective aspects, the integrative quality-of-life (IQOL) theory was developed. It is noticeable that the objective part represents a limited gap in the interpretation of the quality of life, and there is a correlation between the objective part and the subjective part (Michalos, 1991).

This notwithstanding, economic indicators surpass all other criteria for assessing the quality of life in cities (Psatha et al., 2011). The World Health Organization (WHO) has tended to address the concept of quality of life from the aspect of the individual's perception of happiness in life in line with his culture, value and concern for his mental health, social relations and his relationship with the environment (WHO, 1997). From the forgoing, it can be said that determination of quality of life completely depends on subjective factors such as culture and traditions. Simultaneously, it can be said that there is a correlation between quality of life and psychological comfort dimension. In this regard, Ryff & Singer (2005) presented a model which dealt with the quality of life through different opinions and concepts in the field of personality, and they divided the factors determining the quality of life into purposeful life, self-acceptance, personal development, environmental empowerment, independence, and positive relationships with others).

It is noteworthy that Ryff's view tends to have subjective social and psychological dimensions, health-related behavior, multiple aspects and measurement of satisfaction, as well as the psychological and social security of individuals. Therefore, Ryff’s model is based on the concept of Psychological Happiness to sense happiness and consequently the quality of life. In contrast, the model described by Schalock et al. (2011) was found to focus more on the subjective dimensions considering them as more important than objective dimensions in determining the degree of a person’s feeling of the quality of life. This scale analyzes the quality of life through eight areas: emotional happiness, interpersonal relationships, physical health, social integration, legal rights, self-development, material factor, and human and legal rights, and each of these previous areas consists of three indicators .Boluarte Carbajal (2019) dealt with the determining factors for the quality of life of the mentally disabled, and an integrated measure of quality of life was used, consisting of two axes (the goal axis - the personal axis), and this scale aims to link demographic factors and quality of life for the mentally disabled.

In order to study the quality of life in cities, the belief that the average satisfaction of a group of individuals living in a city can be considered the average satisfaction in that city must be discarded; this is only an indicator of the quality of life in that city. It must also be considered that there are specific factors for the quality of life on a personal level that cannot be relied on or taken as a reference when judging the quality of life in cities, for example, the state of health of the individual. The determinants that affect the quality of life in the city may not affect the person's quality of life, such as environmental factors related to time and climate (Psatha et al., 2011). There are numerous studies that deal with quality of life in cities. Vo et al. (2019) measured and identified the factors of quality of life for elderly people in Ho Chi Minh, Vietnam, and showed that improving working health conditions and standard of living can enhance the quality of life of the elderly people in Ho Chi Minh, Vietnam. Milivojević et al. (2017) also developed a model for assessing the quality of life in modern cities, regardless of their size or structure, while at the same time comparing images of future cities such as megacities, smart cities, eco-cities and cities under the dome. To compare the quality of life in urban cities, Węziak-Białowolska (2016) used a set of standard factors to examine the quality of urban life in European cities. In the same context, Psatha et al. (2011) dealt with the quality of life in urban cities, outlined the quality of the factors that determine them, and explained that quality of life at the social level is affected by the capabilities and opportunities available for community members to obtain a good quality of personal life.

The main objective of this study is to show the impact of religious and spiritual factors on the quality of life of the residents of Islamic cities. The study is based on the Arabic version of WHOQoL-SRPB scale and uses the confirmatory factor analysis to show the extent of the impact of these factors on the quality of life of the residents of Medina.

Quality of life related to spiritual and personal beliefs

There are several determinants related to the quality of life of societies, and the spiritual and religious domain is considered important for analyzing it. Villani et al. (2019) has found that spirituality and religiosity play a role in the quality of life and well-being of individuals of different religious status. Again, Ferriss (2002) found that happiness is associated with frequenting and attendance of religious services, and that religion can lead to a goal in life that promotes well-being. Moreover, he found that there is a significant correlation between quality of life and spiritual well-being in a sample of cancer patients. The study of Poloma and Pendleton (1989) showed that quality and manner of prayer has a great impact on the quality of life. In fact, many literature shave concluded that religiosity/spirituality can be a source of comfort or discomfort, discovering mistakes and troubleshooting them, or a cause of stress, depending on how the person is associated with it (Panzini et al., 2017). In the same context, patients who constantly struggle with religious issues may be at risk of health problems (Pargament et al., 2001).

Panzini et al. (2017) also found that there is a correlation between religiosity and higher levels of quality of life according to a set of variables such as (religious affiliation, religious adaptation, and prayer/spirituality). They also discovered that quality of life does not only include the concept of health, but it goes beyond that and consists of multiple physical, psychological, environmental and other areas. From the above, it can be said that the general feeling of happiness, peace and psychological reassurance is an appropriate measure of the quality of life, and this feeling can be achieved through availability of the spiritual, emotional and religious aspects of the city in which the individual lives. There are yet studies that focused on the effect of religion on the quality of a healthy life. Panzini et al. (2011) studied the correlation between quality of life, health, levels of spirituality, religiosity and personal beliefs in southern Brazil.

The study showed that there is a positive correlation between positive spiritual and religious coping and quality of life and a negative relationship between the quality of life and religious adjustment and negative quality of life. Paragoli (2020) considers that spirituality is linked to physical and mental health. Along the same lines, Chen et al. (2020) indicated that there is a positive impact of religious and spiritual factors on the quality of life of cancer patients, in conditions of the reproductive system in women, as a combination of spiritual care and psychological counseling is needed to help them, especially those who suffer from low quality of life, severe symptoms, or anxiety.

Visser (2018) considers that spirituality plays a key role in the control of dementia and anxiety related to cancer or depression. Carranza Esteban et al. (2021) and Koenig (2004) believe that there is a positive impact of spiritual and psychological factors on the quality of life in general, that the understanding of these factors can help doctors formulate adequate preventive and therapeutic measures for Corona patients.

Gallardo-Peralta (2017) further concluded that there is a relationship between religiosity/spirituality and the quality of life among Chilean elderly people, so the study recommended the need to include religiosity and spirituality in social work interventions. Moon and Kim (2013) explained that there is a relationship between religiosity and spirituality, quality of life and depression for elderly people in Chuncheon city, South Korea. This is based on the Short Geriatric Depression Scale-Korean version (SGDS-K) and the Geriatric Quality of Life-Dementia scale.

Measuring the quality of life

To measure quality of life, Fleck and Skevington (2007) designed a large number of indicators, most focused on the quality of life of patients with chronic diseases such as Functional Assessment of Cancer Therapy –General (FACT-G), Kidney Disease Quality of Life Instrument (KDQOL), Schizophrenia Quality of Life Questionnaire Short Form - Clinical Practice (S-QOL 18), European Organization for-Research and Treatment of Cancer Quality of Life Questionnaire (EORTCQLQ) - SF Health Surveys - Functional Assessment of Cancer Therapy (FACT-G) - General.

The World Health Organization (WHO) has developed a set of scales to measure quality of life under the name of WHOQoL, a scale to measure spirituality, religion and personal beliefs. The scale (WHOQoL-SRPB) is considered a version of the index (WHOQoL-100) to measure quality of life.

The terms of this index have been proposed by a group of experts and have been reviewed by a wide range of groups spread over four continents in a large number of countries, so that they may include different professional and ideological groups and religious minorities. A total of 132 elements were identified, including 100 elements from (WHOQoL- 100) and 32 related to QoL (SRPB) that were recorded in eight areas (spiritual connection, meaning and purpose in life, awe, wholeness, spiritual strength, inner peace, hope and optimism, and faith). The WHOQoL-SRPB scale is considered one of the most important scales that can be used to measure the impact of religious, spiritual and personal aspects (SRPB) on the quality of life of individuals (QoL).

Chan et al. (2017) believe that this scale is conceptually consistent with religious and existential beliefs. Fleck & Skevington (2007) also believe that WHOQOL-SRPB should be viewed as an important contribution to the study of the relationship between quality of life, spirituality, religiosity and personal beliefs. Besides, the scale was used by Chan et al. (2017) to demonstrate the effect of religious beliefs on the quality of life of different religious groups in the Chinese society. In view of the importance of this scale, it has been translated into 20 languages including the Arabic version of (WHO | World Health Statistics, 2020), which was translated by WHO office in Amman – Jordan (Younis et al., 2012).

Method

The current study used the Arabic version of WHOQOL-SRPB to cover the quality of life related to the spiritual and religious aspects and personal beliefs of the residents of Medina. This city is one of the most important Islamic cities in the world, and it has the peculiar honor of hosting the tomb of Prophet Muhammad (may the peace and blessings of Allah be upon him). This version was translated by WHO office in Amman in 2016, and the five-point Likert scale was adopted, which ranges between an extreme amount/very satisfied and very dissatisfied/not at all. The questionnaire was distributed so that all age and social groups are studied, based on their voluntary consent. As for groups that cannot read proficiently, paragraphs of the questionnaire were read for them by the support team without interfering with the responses or directing them to specific answers, and the identity of the respondents was concealed throughout the study period to reduce the percentage of partiality.

Statistical Analyses Path

Descriptive statistical methods were used to explore the characteristics of the sample. To verify the reliability of the index, return, an Intra-class correlation coefficient (ICC) was used, while the internal reliability and validity were confirmed using the Alpha Cronbach parameter. A confirmatory factor analysis of Eight-Factor-First-Order model was also used.

As in Figure 1, eight factors of the WHOQoL-SRBP index, was used to verify the validity of the theoretical assumptions about the specified factor for the proposed index, and the models were estimated based on the maximum likelihood method. In addition, a set of indicators RMR, RMSEA associated with Goodness of fit, were also used and were acceptable at (.80 ˃) and GFI, CFI were acceptable at (.90 ˃) χ./df and at values less than 5. At that point, appropriate adjustments were made to achieve the best model. In order to perform these statistical analysis, we used the IBM SPSS V.20 statistical package and AMOS V.25 software.

Samples

In order to test the psychometric properties of the scale, an exploratory sample consisting of 50 individuals was drawn, and the reliability of the index return was verified, which is necessary before examining the other psychometric properties of the index. It was considered that the members of the exploratory sample must not be included in the main sample. In order to conduct the applied study, 800 questionnaires were distributed over a wide range of Medina residents, covering all different age and social strata. 682 individuals responded to the survey, with a response rate of 85.25 %. Eleven uncompleted surveys were found and were excluded. Therefore, the final number of respondents reached 671 individuals, all of them Muslim.

The respondents were selected through an intentional sample, and the focus was only on the Medina community. The sample items were chosen to represent all sectors of the population according to their educational levels, age, gender, social and health status, and commitment to praying in the mosque.

The results of analyses

Results of the descriptive analysis of the respondents of WHOQoL-SRPB sample showed that the ages of the respondents ranged between (18-76 years) with a mean age of 51.6 and a standard deviation of 11.85. The minimum and maximum confidence interval of 95 % for the variable of ages ranged between 52.49-50.7. Men formed 78.5 % while the women formed 21.4 %. The percentage of those with a university degree is 69.6 %, those with qualifications below a university degree is 14.7 % while those without any academic qualification is 11.1 %. The percentage of married people is 61.8 %, and that of the bachelors is 32.2 %, that of males is 78.5 % while females is 21.5 %. Table 1 summarizes the characteristics of the sample respondents to the WHOQoL-SRPB tool .

Results

Internal consistency

In the current study, tests of internal consistency and convergent validity of the WHOQoL-SRPB were performed. The alpha coefficient of the WHOQoL-SRPB instrument reached .81, which is significant at p < .001. It ranged between .75-.89 for its factors, which are significant at p < .001, except for the Totality factor, which is significant at p < .01, and its value ranged between .86-.91. The elements of the Spiritual Connection factor, between .73-.85, while the elements of the Meaning in Life factor, between .76-.89; the elements of the awe factor, between .70-.88 and the elements of the Totality factor, between .80-.88. The elements of the Spiritual Strength factor, between .76-.86 for the Inner Peace factor, between .73-.89 for the Hope and Optimism factors; between .84-.89 for the Faith factors. The number 32 was significant in p < .001 and two significant elements in p < .01. All these values are high, which indicates that all the factors and associated elements on the scale have internal consistency.

Test-retest reliability

The results of the ICC test also showed that all WHOQoL-SRPB factors are acceptable. The ICC value ranged between (.82-.93), and all were significant at p < .001. Its value ranged between .86-.90 for elements of the “Spiritual connection” factor; between .90-.92 for the elements of “Meaning in life” factor; between .79-.91 for elements of “Awe” factor; between .79-.95 for “Wholeness” factor; between .88-.95 for elements of “Spiritual strength factor”, between .89-.94 for elements of “Inner peace” factor, between .86- .92 for “Hope and optimism” factor, and between .88-.94 for “Faith” factors. The 31 elements were significant at p < .001 while only one element was significant at p < .01.

Factor analyses

The preliminary results of the evaluation of the Eight-Factor-Second-Order model showed that there are five factors that achieved a good result, namely Spiritual connection; Meaning in life; Inner peace; Hope and optimism; Faith, where its load was greater than 30, as can be seen in Table 2. The model also showed acceptable fit for some indicators: χ. = 2 412.843, DF = 496, χ./DF = 4.865; p < .001 GFI = .90, RMSEA = .048; RMR = .02, noting that there are some that did not achieve good fit as CFI = -.84. Moreover, the measurement errors matrix indicates the possibility of improving the model by linking the errors that have shown high values to each other in this matrix

The value between the two elements SP1.1-SP1.3 in the error matrix was -2.359, between SP2.3-SP2.4 was 2.214, and between SP8.4-SP8.1 was 3.178. The model was modified to convert it into a Five-Factor Second-Order model, consisting of 20 items. Taking into account the correlation between measurement errors as in Figure 2, the result of the estimation of the model was the saturation of the elements SP1.2-SP1.3-SP1.4 for the Meaning in life factor, and SP2.1-SP2.2-SP2.3 for the Connection factor, SP6.1-SP6.4 for the Peace factor and SP8.3-SP8.2-SP8.1 for the Faith factor. All the elements were saturated for the Hope factor where the load of these elements was greater than 0.30. Regarding the good fit results: 2 = 812.354, DF = 190, χ2/DF= 4.275; p < .001, GFI = .959, RMSEA = .042, CFI = .96, RMR = .01, which are results that achieve good fit and surpass the Eight-Factor-Second-Order model in all results. Under this proposed model, the five factors achieved standard weights ranging between .46 and .85, and the highest weight was in favour of two factors: “Hope and Optimism” and “Faith”, and the lowest weight was for the “Meaning in Life” factor.

Discussion

Religiosity and spirituality are important elements in understanding the quality of life for members of the society, and in view of this, the World Health Organization has codified the WHOQoL-SRPB scale in English to indicate the effect of religiosity and spirituality on quality of life. Therefore, multiple studies have used the scale by applying it to different religious environments and cultures, as well as to compare the impact of religiosity and spirituality on the quality of life in societies with multiple religions. In the same vein, a group of studies have codified the WHOQoL-SRPB scale in different languages: the study Mandhouj et al. (2012) has codified the French version of this scale. Yonas (2003) also applied the amended spiritual and religious quality of life scale in Arabic (WHOQOL-SRPB) to show the effect of religious and spiritual beliefs on the quality of life of university students in Jordan. There are studies that used other measures of spiritual well-being factors and their impact on quality of life. Chen et al. (2020) used the scale EORTC QLQ-SWB32 and EORTC QLQ-C30 and the simple and multiple regression method for this purpose, and the study was applied to patients with gynecological cancer. Chen et al. (2020) differs than the current study in terms of purpose and application, as it focuses on the community of patients with cancer of the reproductive system, and it relies on measures of depression and does not address other spiritual and religious factors.

There are other studies that focused on the impact of spiritual and religious factors on the quality of life in light of the Corona disease. Cherblanc et al. (2021) used a short version of the WHOQoL-SRPB scale to analyze the relationship between spiritual and religious factors and quality of life in light of the Corona pandemic. This study shows that positive mental health, religion and age are the main factors affecting the quality of life. Some spiritual factors affect the quality of life more than others.

As these studies did not measure the quality of life through religious and spiritual factors in Islamic societies, the current study dealt with the effect of religious and spiritual factor on the quality of life in these societies. The study was applied to Medina community which is considered one of the holiest cities among Muslims, and all members of the study population were Muslims. In this direction, the modified Arabic version of the WHOQoL-SRPB scale was codified, and the results of retesting and internal consistency were satisfactory. Thus, it was discovered that spiritual and religious factors that determine the quality of life have effect on Medina community. It became clear that there are main factors around which the quality of life is centered. They are Spiritual connection; Meaning in life; Inner peace; Hope and optimism; Faith. There are also three factors that do not have significant effect on the quality of life, namely: awe, wholeness, spiritual strength, and this corresponds to the nature of Islamic religious beliefs. The current study did not address the impact of spiritual and religious factors according to the demographic aspect on the quality of life, and the data can be processed using the statistical method ANOVA. In this case, the relationship between spiritual and religious factors and the characteristics of the case according to each demographic aspect can be addressed.

On the other hand, the current study can be developed by studying the influence of spiritual and religious factors on the quality of healthy life for residents of Islamic cities, and thus the study community can be changed to include those with chronic disease.

In accordance with the results of the study, the WHOQoL-SRPB scale can be codified in Arabic language to be used in other Islamic societies or for comparison of quality of life in other Islamic societies with multiple sects.

Conclusion

There is a set of scales that can be used to measure the quality of life, and the modified Arabic version of the WHOQoL-SRPB scale is considered suitable for assessing the quality of life from the spiritual and religious point of view. This is what the results of retesting and internal consistency of the current study have displayed. This indicates that the current version maintains the same reliability characteristics and internal consistency of the original version. So, the current study concluded that this scale can be improved by reducing it to a component of five factors in which 20 elements are saturated. When exploring the factors affecting the quality of life in Medina community, we found that two factors, which are “Hope and Optimism and “Faith” have greater effect, while the factor “Meaning in Life” has the least effect.

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