Encouragement and Health-Related Quality-of-Life (HRQoL) Among American Muslims

Background: Health-related quality-of-life (HRQoL) is an important outcome variable, as it provides a comprehensive picture of wellness that incorporates physical, mental, and emotional dimensions of functioning. One variable that may be related to HRQoL is encouragement, which can be defined as verbal expressions of support designed to instill confidence, hope, or perseverance in the face of challenging circumstances.

Muslims have faced challenging circumstances in the United States (US) since at least 9/11, yet, little research has examined the relationship between encouragement and HRQoL, despite the growing size of the Islamic community in the US. This study addressed this gap in the literature by examining the relationship between encouragement and HRQoL among a sample of American Muslims. Drawing from Adlerian theory, a theoretically based model was tested using structural equation modeling (SEM). Based upon prior research, it was hypothesized that higher levels of encouragement would predict higher levels of HRQoL, and that depression and spirituality would mediate the relationship between encouragement and HRQoL.

Methods: To obtain a national sample of Muslims for this cross-sectional study, a snowball sampling strategy was used to identify Islamic organizations in the US (N=22). After pilot testing, surveys were administered online to organizational members who agreed to participate in the study. The mean age of the resulting sample (N=284) was approximately 38 years (SD=11.70), and a majority were: female (68%), married (57%), born outside the US (52%), and a plurality self-identified as Middle Eastern (38%).

In addition to demographic items, the self-report survey included measures of HRQoL [Cronbach's alpha=0.80] (Farhat et al., 2015); depression, measured with the short form of the Center for Epidemiological Studies Depression (CESD) scale [alpha=0.87] (Melchior, et al., 1993); and spirituality [alpha=0.70] (Jana-Masri & Priester, 2007). SEM was conducted with AMOS using full information maximum likelihood (FIML) estimation. FIML makes use of all the available data to calculate parameter estimates and standard errors without deletion or imputing missing values.

Results: After validating the measurement model, the fit of the structural model was assessed with three widely recommended fit indices: normed Chi-square, CFI, and RMSEA. The values for the fit indices indicated a good fit between the data and the proposed model [χ²=174.959 (df=94, p<0.001), normed χ²=1.842, CFI=0.951, RMSEA=0.055 (90% CI, 0.042-0.067)].

Partial support was found the for study hypotheses. Encouragement had a direct effect on HRQoL. However, neither depression nor spirituality mediated the relationship between encouragement and HRQoL. Rather, both depression and spirituality exhibited an independent effect on HRQoL, apart from the effect of encouragement. In addition, spirituality also impacted HRQoL indirectly through lower levels of depression.

Implications: The results have significant implications, especially given that hate crimes directed towards Muslims have increased dramatically during the past two years. The results underscore the importance of communicating expressions of support to Muslims, as such encouragement can be instrumental in fostering wellness. The direct, protective effects of spirituality on depression and HRQoL highlight the importance of incorporating Muslims’ spiritual strengths into clinical work by, for example, adapting CBT to incorporate clients’ spiritual beliefs.