Inequalities in the spiritual health of young Canadians: a national, cross-sectional study

Adolescence is a key stage of life that requires ongoing focus as children learn, grow and develop. Society pays great attention to almost all aspects of the health of young people during adolescence, with physical, mental, and social health the subject of a wide range of well-intended preventive interventions [28, 29]. However, although recognized by the WHO and many Indigenous cultures as a fourth domain of health [1], and by UNICEF as a fundamental human right [6], the spiritual health of young people in Canada has not been a significant focus for research and intervention development and even more rarely has it been quantified empirically. This lack of attention represents an important gap in the biomedical and social science literatures.

The most important findings of this national study were as follows. First, we adapted a series of measures in an attempt to describe and quantify the perceived importance of spiritual health to adolescents. This series of items was brief and at an appropriate level of literacy for children as young as 11 years of age. The content of this module was informed by theory [2, 3, 8] and the analyses presented with these items are unique to the Canadian adolescent health literature. The overall scale, while exploratory, shows promise as a composite measure of some key components of adolescents’ rating of the importance spiritual health, as opposed to their lived reality of spiritual health experiences. Further refinement of this scale is also indicated. Second, we applied these items, both as a composite scale and then by each of the four spiritual sub-domains, to the study of inequalities in spiritual health in young Canadians. In doing so, we demonstrated inequalities by age, gender, relative material wealth, immigration status, and geography. This profile is unique to a literature that is dominated by theoretical discussions and qualitative enquiry [30] and provides new evidence that is helpful to our Canadian context.

Our methodological exploration in this field of research is important. While recognized as a concept that is best measured in composite [2, 3, 8], assessment of spiritual health as a multi-dimensional construct is uncommon [25] with less psychometric research and very few credible quantitative studies in early adolescence [20] particularly in our own country of Canada. Our findings show the possibilities of adapting a brief, factor-analytically derived scale to early adolescence that is theoretically sound and considers the four sub-domains of spiritual health multi-dimensionally. While further refinement to this scale is desirable, findings from our principal components analyses were promising, meeting all conventional criteria for scale development [31]. We also found that this measure had very reasonable confirmatory psychometrics, although it performed best as a 4-factor solution rather than a composite scale, and these findings resonate with those of a substantial body of qualitative work with children that provided the theoretical basis for its development [17]. The number of items included (eight) was also the maximum permitted by the national research collaboration involved in the Canadian HBSC survey. Moving forward, scale refinements might involve reverting to the larger number of items present in Fisher’s original scale [25], and consideration too of lived experiences of spiritual health (i.e., whether or not young people experience this themselves) to compliment our existing ratings of its perceived importance.

We were able to demonstrate strong and consistent inequalities in self-reported importance of spiritual health, both overall and by sub-domain, in association with all versions of the scale derived in our analysis. Such inequalities have not been quantified previously nor examined in terms of how they influence wellbeing, development, and other aspects of adolescent health. The highly gendered patterns that were observed, for example, may reflect the ways that boys and girls are differentially socialized in Canadian society. Because boys and girls may relate to the four established sub-domains of spiritual health differently, gender-specific approaches to the promotion of healthy connections, relationships, and other aspects of spiritual health are warranted.

The reported declines in perceptions of importance of spiritual health related to age may reflect normative changes in cognition, reason, abstract thought, and independent thinking that come naturally with adolescent growth and development [32]. More challenging, such declines may relate to the deeper emotional needs that emerge during adolescence, and thus also relate to the mental health of young people. Our developmental findings point to a persistent demand to promote and foster healthy relationships in adolescent lives. Relationships lie at the heart of what it is to be a human being [33]. Healthy connections, whether they are within adolescents themselves, with others in their lives, or with the world that surrounds them, relate strongly to their health and their ability to flourish [34]. We believe that the quality of these connections lies at the heart of the concept of adolescent spiritual health, and that this is some of what is being reflected through this measure.

Our analysis also identified inequalities in reported perceptions of the importance of spiritual health in association with indicators of the social environments that surround young Canadians. We demonstrated these inequalities for a measure of relative material wealth (which showed that young people who perceived themselves to be less well off attached less importance to spiritual health), immigration status (those born in Canada provided lower ratings for its importance vs. recent immigrants), and geographic status (wide variations existed across the provinces and territories).

While any self-reported adolescent health survey will be limited by its reliance on the subjective perceptions of adolescents with respect to socio-demographic factors (e.g., our measure of relative material wealth) as well as our indicators of spiritual health, our findings still have merit. They were, however, different than evidence presented in some past studies. Lower socio-economic status has been shown to correlate directly with known risks for health, and self-perceptions have also been shown to be more consistent determinants of health than measures of lived experience [35‐37]. Lower levels of perceived socio-economic status also have been found to correlate strongly with higher levels of religiosity in both children and adults [38], consistent with the “deprivation theory,” which posits that poor individuals are more likely to be religious than those who are materially wealthy [39]. This past evidence, however, only focuses on the correlation between religious attitudes and expression, and lower socioeconomic status, and does not account for the broader protective qualities of spirituality that lie outside of religious involvement. When one views the broader adolescent literature on spirituality, different findings emerge. For example, “poor teenagers are less likely than non-poor teenagers to report meaningful experiences of spiritual worship” [40], while youth who report low socio-economic status also report low levels of existential well-being [41]. With respect to the transcendental domain, ours, and past findings, indicate a need for scholars to distinguish between the concepts of spirituality and religiosity, as their social patterns may in fact be quite different for adolescents.

Our findings do reinforce the idea that the origins of spiritual health are in part cultural, and perhaps reflect the values and tenets of the social environment. The geographic findings may indicate that jurisdictions with educational policies and programs that bring spiritual practices (e.g., mindfulness inspired activities, relationship-building programs and outdoor education initiatives) into the school setting are potentially facilitating the development of positive spiritual health. Past findings [17‐19, 42] have also demonstrated that measures such as ours describing spiritual health are strongly associated with the health status of young people, whether that is measured in composite or via specific indicators of mental and emotional health. More in-depth investigation of the mechanisms by which spiritual health is promoted and optimized in specific social contexts is warranted, as higher levels of spiritual health coincide with healthier relationships and associated positive health outcomes that help young people to thrive.

Canada, like many other countries, is experiencing an epidemic of mental health problems in its young people. There is not one comprehensive explanation for the failure of our children and adolescents to thrive. The cultural contexts in which such health inequalities have arisen have been the subject of debate and scrutiny [43]. Extensive work by Louv and others suggests that health inequalities may be attributed to what we are presenting as the third sub-domain of spiritual health, a disconnection from the natural world due to a lack of intentional exposures to such environments [15]. Other cultural explanations include the intense pace and expectations of modern life for children [44] and consumerism [45]. In turn, there has been a recent surge in interest around adolescent spiritual health and its application to these modern day challenges, both clinically and in terms of primary prevention [12‐14]. Optimization of spiritual health has been related to positive health outcomes including happiness among children [30], as well as resilience [46]. Spiritual health may indeed be an under-appreciated positive health asset to the health of young people.

Canadian political scientists have argued that Canada is best defined in terms of its regional variations, with some authors emphasizing provincial/territorial distinctions by legal boundaries [47, 48] and others downplaying these boundaries [49]. These variations have come about through migration patterns from different cultures and the balance between urban/rural populations, among other factors. The provincial/territorial cultures are expressed in voting patterns and political views. The analyses in this paper indicate the possibility that the variations extend to views on aspects of spiritual health. Speculatively, this may be congruent with the greater individualism in some regions and the greater collectivism in other regions.

Strengths and limitations of this study warrant comment. Our analysis is novel and addresses some fundamental gaps in the adolescent health and spiritual health research literatures. The analysis was large and national in scope. Our efforts to adapt and test a quantitative, composite measure of the perceived importance of spiritual health advances attempts to foster research in this field, while our demonstration of potential health inequalities points to avenues for health promotion and clinical intervention. Limitations include our recognized need for further refinement of the adolescent spiritual health scale, measurement error inherent to self-report surveys, and limits on causal inference attributable to the cross-sectional nature of our study opportunity. The potential for reverse causality for our focal relationships of interest is clearly possible.