Developing a definition of spiritual health for Canadian young people: a qualitative study

ABSTRACT

While the spiritual dimensions of health are often tangentially recognized in the health sciences, minimal direction is given as to what spiritual health is, or to what it means to policy or practice. In Canada, this lack of understanding is problematic because despite strong evidence suggesting that spiritual health can operate as a protective health asset in the lives of young people, it is difficult to create effective health promotion strategies for supporting spiritual health without clear definitional agreement. Guided by interpretive description as a methodological orientation, I conducted a qualitative study (n=74) with the goal of developing a definition of spiritual health that would have practical value for Canadian young people and could be used to support the optimization of their health. Data were generated through focus groups and interviews. Results yielded a child-informed definition that provides a clear starting place for operationalizing spiritual health in health-related contexts.

KEYWORDS:

• Child
• spiritual health
• interpretive description
• definition
• qualitative

Introdution

Spiritual health is sometimes recognised as a protective health asset in the lives of young people (Scales et al. 2014; Brooks et al. 2018). Globally, researchers have argued that the World Health Organisation should include spirituality as a domain of health (Chirico 2016). And in Canada, the Public Health Agency of Canada includes having a ‘positive sense of emotional and spiritual well-being’ in its definition of positive mental health (Public Health Agency of Canada 2016). While these examples suggest modest interest in the spiritual dimensions of health, each of these references to spirituality is notably underdeveloped. This is equally true in relation to the tangential ways that the word spiritual and its cognates are included in many international documents related to health promotion (World Health Organization 1997, 2000, 2009). Very little direction is given in any of these examples as to what is actually meant by spiritual, or of what it means to health policy, interventions or practice. In scholarly journals in the health sciences, the word spiritual is used to describe complementary or alternative approaches to medicine, health and healing and is also found in more clinical journals such as the Lancet (Rosmarin, Pargament, and Koenig 2020) and the British Medical Journal (Murray et al. 2010). What is spiritual health? Probably one of the most realistic answers is: that depends on whom you ask.

One reason that this lack of definitional clarity is problematic is that in the health sciences, interventions and health promotion strategies are all dependent on research evidence. Before spiritual health can be studied in ways that have the potential to make a meaningful contribution to the field, we have to be able to measure it accurately and reliably. This is simply not possible to do unless there is some level of consensus as to what we are talking about. While a large body of research related to child spirituality exists in disciplines such as education (see, e.g., Watson 2003; Eaude 2008; De Souza and Halafoff 2018), child and adolescent development (Benson et al. 2012; Lerner, Lerner, and Benson 2011) and religious studies and theology (Yust, Johnson, and Sasso 2006), focussed attention on child and adolescent spiritual health is still scant in the applied health sciences. This is short-sighted, because a great deal of emerging scholarship (e.g., Scales et al. 2014; Brooks et al. 2018) suggests that if the spiritual dimensions of health were taken seriously and well-supported in an evidence-based manner, they could be utilised as important protective health resources for children.

This study arose out of reflection on the perceived value of a clear definitional framework that could be used in our Canadian context, which could be used as a starting place for empirical research and the development of health interventions and health promotion initiatives to support the health of children. To address this observed gap in knowledge, I conducted a national qualitative study (n = 74) with the purpose of conceptualising and defining spiritual health in a way that was meaningful to Canadian young people and also rooted in theory and research evidence.

Background

A great deal of existing scholarship addresses the challenges of defining spirituality. Some scholars such as Nye argue that we ‘delude ourselves’ if we think we can capture something as complex and fluid as spirituality in a ‘tidy box or neat categories’ (Nye 1999, 58). Other leaders in the field (i.e., Benson, Roehlkepartain, and Rude 2003; Roehlkepartain et al. 2006) propose working definitions, yet remain hesitant to endorse any one definition as definitive or comprehensive (Roehlkepartain et al. 2008). In the health sciences, King and Koenig (2009) have proposed a useful definition of spirituality that is specifically catered to medical research and health service provision. Primarily developed through a survey of literature related to spirituality in adult populations, it involves combinations of a variety of factors related to domains of belief, practice, awareness, and experience. Yet here too, King and Koenig are cautious, and maintain that rather than consider their definition to be a definitive and final product, it is best used to encourage continued dialogue and debate.

Like many scholars who work in this area (King and Koenig 2009; Watson 2003; Swinton and Pattison 2010), my own views on defining spirituality have been shaped by Wittgenstein’s critique that language is not to be abstracted from its usage and meaning. Rather, meaning is rooted in the everyday application and usage of words (Wittgenstein 1961, 2001). In her work on spirituality in school contexts, Watson too draws on Wittgenstein’s thinking, and makes a compelling argument that if ‘words derive meaning from their use – it should be possible, at least in principle, to derive the meaning of the word “spirituality” from its use’ (Watson 2003, 10). This logic forms the rational for this Canadian study: to root an understanding of spirituality in the experiences and words of everyday speakers. My goal was also very similar to that articulated by King and Koenig: ‘to present an accessible, reasoned background for health researchers and for health professionals who encounter patients’ [in my case, children’s] … spiritual concerns in their [everyday lives]’ (King and Koenig 2009, 6).

My intention is that this definition is to be used primarily by the adults whose duty is to shape the best possible health experiences for young people. Even so, the voices of children are critical to its development, because any definition of spiritual health that would have practical value for usage in relation to Canadian young people needs to be emergent from and responsive to their experiences, ideas and everyday usage and understanding of the word.

Theoretical and methodological orientation

This study is one element of an ongoing mixed-methods study on spiritual health as a protective health asset in Canadian children (see Michaelson et al. 2016, 2019). This larger study, funded by the Canadian Institutes of Health Research, is grounded in a well-established conceptual framework that was developed by Fisher (2011) and Hay and Nye (1998) as a way of understanding child spirituality. It involves conceptualising child spirituality as related to the strengths of one’s connections in four relational domains (connections to one’s self, to others, to nature and to the transcendent).

The methodological orientation for the qualitative strand of this study is interpretive description (ID) (Thorne, Kirkham, and MacDonald‐Emes 1997; Thorne 2016). Originally rooted in applied nursing research, ID was developed out of the recognition that the methodological boundaries posed by more traditional approaches (such as grounded theory, ethnography and phenomenology) sometimes constrained the complex, experiential questions that applied health researchers were asking. While ID is strongly influenced by aspects of these well-established approaches in terms of study design, sampling strategies, data collection and analysis, it also provides a logical structure to design decisions that depart from – or even blend – aspects of these more traditional approaches. The practical and versatile nature of this method enables health researchers the ‘opportunity to work outside of the disciplinary confines of the more traditional methodological approaches’ (Thorne, Kirkham, and O’Flynn-Magee 2004, 18) with the purpose of informing real-world, applied practice. Data generated in this way provide a rich foundation for informing a definition that has real-life value and practical applicability.

Sample

Using snowball sampling techniques, I studied 74 participants who were purposely recruited to represent a variety of demographic factors (Table 1). Written informed consent (from parents) and assent (from youth participants) was obtained at the beginning of each interview or focus group.

Table 1. Characteristics of study participants

Characteristics		# of participants
Total		74
Gender
	Male	26
	Female	48
Age
	10–11	6
	12–13	20
	14–15	43
	16–18	5
Religious self-identification
	Christian	19
	Muslim	13
	No details provided as to religious beliefs	41
	Self-identified as atheist	1
Geographic location
	British Columbia	20
	Alberta	2
	Ontario	39
	Quebec	1
	Nova Scotia	2
	Prince Edward Island	3
	Nunavut	7

Data collection and analysis

Data were generated through 9 focus groups and 21 semi-structured interviews with participants from across Canada between 2016 and 2019. Focus groups were used to gain understanding of discussion and interaction between participants and interviews were used to explore in-depth and more personal aspects of the individuals’ experiences. In both, I used open-ended questions to explore the ways that participants understand spirituality overall and specifically in relation to health. I also asked participants to complete focussed tasks that were used to facilitate discussion (see Table 2). Participants were invited to direct the flow of the discussion and no conversational points were discouraged or diminished. While the study was designed around a well-established theoretical framework for understanding child spirituality in relation to one’s connections to self, others, nature and the transcendent, I allowed room for the children to push the boundaries of this framework and adapt it (including by adding, adapting or rejecting one or all of the domains) as they reflected on their own experiences and ideas about spiritual health.

Table 2. Tasks used for generating data

Task	Description
1. Describe a person.	Participants were asked to describe a person whom they would consider to have positive spiritual health.
2. Choose a picture. (Focus groups only.)	Twenty letter-size picture cards were prepared in consultation with our project youth advisory group. They reflected a wide variety of elements of spirituality that are found in the literature. Participants were invited to choose one card that said something to them about what spiritual health is or is not and then to explain their choice.
3. Card sort.	Participants were each given a deck of eight cards. Each card depicted one of the four domains (2 cards per domain). Participants were asked to sort the cards into order of the connections that were most to least important to supporting their daily challenges and then to explain their choices.
4. Tell a story. (Interviews only.)	Participants were asked to consider how they coped when things were tough in their lives, and then to reflect on whether or not anything we had discussed in relation to spiritual health had helped them to cope.
5. Engage with a definition.	Beginning with a definition that was rooted in the four domains framework (Michaelson et al. 2016), participants were invited to engage with the definition individually, circling anything they thought was important; crossing out anything that shouldn’t be there; putting a question mark beside anything they didn’t understand; and adding anything they thought was missing. We then discussed their insights together (during the focus group or interview), and afterwards I updated the definition to include these insights. The exercise was repeated iteratively with different individual children or groups of children throughout the study.

Focus groups lasted two hours and took place in locations such as community centres. Interviews took place in participants’ homes and ranged from 45 minutes to 60 minutes in length. Both focus groups and interviews were audio recorded and then transcribed. Participants names were removed and were replaced with a unique code number, and all other identifying information was altered to protect privacy.

Coding and analysis

In keeping with Interpretive Description, data collection and analysis proceeded concurrently. I worked with two undergraduate (FM and AH) and two graduate students (SL, EL) (see acknowledgements) over two years to code and analyse data as they were generated. Interviews and focus groups were transcribed and analysed quickly following their conduct so that insights that were developed early on could be incorporated into the ongoing data collection, in particular in relation to the definition that was informed and reshaped iteratively after each focus group or interview. This approach also allowed us to invite new participants to reflect and elaborate on the themes that we were observing in the data as they were identified. I also asked new participants to provide insights into surprising and contradictory findings that we observed as we analysed the data.

We began with a holistic, line-by-line reading of each transcript with the goal of identifying broad themes and developing initial conceptual codes in order to organise the data in a manageable way. We then examined these broader themes for patterns, adjusting the themes as new data clarified their relevance to the research question. We looked for relationships, including contradictory ones, between segments of data within the themes by using a comparative analysis. We also extracted data related to each of the five tasks and examined these extracted data in order to gain a focused understanding of what could be learned from each task.

Because one of our goals was to create a definition, we invited participants to provide input into our emergent definition of spiritual health (Task 5). At the end of each interview or focus group, we asked participants to consider whether anything that had been talked about during the entire course of their interview or focus group should be incorporated into the emerging definition. Their comments were incorporated, and the revised definition was then passed to the next participant(s).

To claim saturation for this study would be naïve to the complexity of Canadian young people and to the diverse experiences, contexts and relationships that shape their lives. Further, a tidy and unproblematic definition would be in contradiction with the complex and fluid nature of spirituality itself (Nye 1999). My goal was simply to obtain sufficient depth and richness of understanding of the participants’ ideas and experiences that we could create a definition that would be meaningful, accessible, and have practical value to Canadian young people when it was used by adult health decision makers, educators and leaders. As I felt we were nearing an appropriate stopping point for data collection, I presented a draft of the definition to two focus groups. Participating young people confirmed that they could ‘see themselves in the definition’ and that it reflected their own experiences. The rationale for this step was not to confirm that we had achieved one perfect definition of spiritual health, but rather, to clarify that the nuances and logic of the final definition was understandable and accessible to the young people who were participating. Methodological rigour was also established by maintaining a clear audit trail, being transparent about methodological decisions and analytical strategies, rigorous discussions, and presenting rich data.

Establishing professional credibility

As an additional step in the analytic process, I presented different iterations of the definition at three separate international conferences between 2018 and 2019 (The American Academy of Religion Conference, Boston, 2018; The International Association of Children’s Spirituality Conference in Laval, 2018; and The Qualitative Public Health Conference, Vancouver, 2019). Again, my rationale here was not to confirm the subjective experiences of the participants, but rather, to clarify whether or not the overall study would have credibility with audiences that included researchers in this area and also spiritual care and health care professionals.

The audiences at the 2018 conferences included global experts on child spirituality. While feedback was encouraging, I was challenged to generate additional data in order to explore the relationship between struggle and child spiritual health, which I then did. At this conference, most of the feedback and questions related to the theoretical framework of the study and to interpretation of the results. The disciplinary home of participants at the 2019 conference was in the applied health sciences. Here, discussion primarily related to the research methods that had been used, and to practical application of the findings. Many of these professionals also commented that while they were enthusiastic about the research, spirituality was difficult to address in secular public health contexts because of the common association that is often made between spirituality and religion, which can be considered inappropriate in public health contexts. I received encouragement from this professional group to publish this definition in the scholarly literature. The hope was that it could then be used as a basis for developing interventions and health promotion initiatives that were rooted in theory and evidence, and to do so in a way that was respectful of Canada’s diversity and did not prioritise any one religious or non-religious orientation over any other.

Ethical issues

Ethical approval was attained from Queen’s University in 2016 and from Brock University in 2019.

Results

Data generated from this study were used to gain insight into how young Canadians understand spiritual health broadly, and to understand how their various perspectives and experiences intersect with and diverge from key perspectives in the academic literature. I observed four overarching themes in the data. First, even knowing that I hoped to generate a consensus definition, the young people were clear that any definition we produced would mean different things to different young people because spiritual health is fundamentally and necessarily different for every person. Second, participants resonated with the four domains framework, yet adapted the framework to match their own experiences and ideas. Third, participants reported that spiritual health is protective to health and well-being. Finally, participants described a mysterious aspect of spiritual health that they suggested is at the core of what it is to be human. Figure 1 depicts these themes visually.

Figure 1. Perceptions of spiritual health identified as important by Canadian young people

In this next section, I provide details and illustrative quotes related to each of the main themes and describe how they were used to formulate the final definition of spiritual health that I propose.

Spiritual health is different for each person

While participants were enthusiastic about creating a definition of spiritual health, they were clear that the definition will still ‘mean a lot of different things for different people.’ One participant gave this example, telling me that an important part of spiritual health is having a balance and centre, but ‘everyone has their own centre and what they consider their perfect balance … Maybe their centre is being calm and at peace but maybe my centre is being happy and feeling really outgoing.’ She reiterated that even if we develop a definition, there will still be a wide range of interpretation as to what the definition means: ‘I think it is good to know about your spiritual health but still be aware that for other people … everyone has a different importance of spiritual health. And it is good to be accepting of other people’s spiritual health whatever that might be.’ This theme was reinforced throughout data collection. One participant shared that spiritual health is ‘about perceiving things in your own way and being your own person.’ Another said that ‘individuality’ is a big part of spiritual health ‘because when you know … that every individual is different, then you can accept yourself.’ As this next participant stated, ‘your spiritual health … it might be different for every person because it makes you who you are.’

While the theoretical framework of the four domains resonated with Canadian young people, the participants added their own interpretive nuance to the framework

Overall framework

Most study participants found the initial theoretical framework (developed by Hay and Nye 1998 and Fisher 2011) of the four domains of connections to be a valuable way of thinking about the spiritual dimensions of health. One participant described the domains as ‘the core’ of spiritual health. Yet, in contrast to much of the literature around this framework (Fisher 2011), the four domains were not considered equal in importance to these participants. Indeed, there was strong consensus that the domain ‘connection to self’ was more important than the other three domains (others, nature and the transcendent). One of the participants described it like this:

Well I think that before you think of others you need to think of yourself. You need to make sure that you have something … you need to make sure you are happy when you are by yourself. Others are not always going to be there to make you happy. So if you have a connection with yourself first then you can have healthy relationships that make you even more happy. But it is all based on your connections to yourself.

Equally, for most of the participants, the transcendent domain was much less important than the other three domains. In part, this was because while we had tried hard to frame this domain as being larger than any kind of organised religion, the young people were still inclined to interpret it this way. As one said, ‘I think that you do not have to believe in God. It is your choice and you can believe in what you want and you don’t even have to believe in anything. So that is why I put feel a connection to a higher spiritual power last.’

While some definitions in the scholarly literature place more priority on experiences of the transcendent (for example, Miller 2016, who is based in the United States, describes child spirituality as ‘an inner sense of relationship to a higher power that is loving and guiding,’ 25) for the most part, the Canadian children did not interpret the transcendent domain (even when it is interpreted as being outside formal religious experiences) to be as important as the other three domains. There were notable exceptions to this pattern, which I describe below.

Connection to self

In keeping with our complementary quantitative work (Michaelson et al. 2016) I initially presented connections to self as involving a sense of meaning and purpose in life and experiencing joy in life. While participants thought these ideas were important, they wanted to enlarge this way of thinking about connections to self. Participants told me that people with strong spiritual health would also be able to feel ‘balanced’ and would be ‘true to themselves.’ They would ‘have a clear mind,’ ‘feel calm and in control,’ and have ‘perspective on life.’ Understanding one’s own identity, and ‘taking time and really worrying about you and to connect with yourself and figure yourself out’ was also of core importance to having strong connections to oneself. In keeping with this logic, one participant told me that when young people are struggling, it’s ‘because they sort of lost their identity of who they are.’

Connection to others

Initially I presented the domain connections to others as related to being kind and forgiving to others. While there was consensus that kindness was an important component of spiritual health, the word forgiving received mixed reviews. Illustratively, one participant said that ‘if you don’t forgive someone then you feel bad or you could lose a friend that you like. Or in general you could feel not as happy and that would make it harder to live the best possible life that you can.’ Others valued forgiveness differently. One participant said: ‘I am not one of those people who puts forgiving high up on my list.’ Another explained that ‘Just because you forgive someone doesn’t mean that you have a great connection or relationship with them.’ There was debate between many of the focus group participants as to whether or not forgiveness belonged in the final definition. Ultimately, it was left in because many participants argued that even if it didn’t mean something to them it might be meaningful to others. Respect for other people was repeatedly suggested as being an important component of what characterises being connected to others, and this too was incorporated into the final definition.

All of the participants agreed that spiritual health is about seeing past your own needs, and making the world better for others, not just yourself. This theme came through with particular clarity during Task 1, when we asked participants to describe someone who has strong spiritual health. This person would ‘help people,’ and ‘teach me to treat people better.’ One participant described a person whom he felt had positive spiritual health like this:

Okay so I know this person … She always tries to help kids who are in need. She is always out there to communicate with them and to help them achieve their goals. To help them live a better life … There is a centre there where they feed them food and they play sports and do a lot of stuff. I feel like that person is really connected with these people to make a better world.

Connection to nature or the land

While most participants saw some value in having a connection to nature, enthusiasm as to the way that nature related to their own experiences of spiritual health was mixed. For instance, as this participant told me that ‘The forest is beautiful and it is calming but in general I don’t like.’ Another said ‘for me nature doesn’t have an effect on my spiritual health. I can appreciate it but it doesn’t affect me personally. So I don’t really have much … it is there but it is not really a part of me.’ Yet, when the young people did experience a connection to nature as important, the connection was profound. One participant out it like this:

Sometimes when you go outside it gives you a sense of peace. And so that is why when people feel sad or are upset they go outside to calm themselves down. It gives you a chance to admire the world and how it is outside. And then it kind of takes you away from the buzz of the world now because there are so many things happening. And when you are outside it is calm and it is like time stops.

Another of the young people described how when you are not connecting to nature, ‘you are kind of missing the joy.’

Connection to the transcendent

Regardless of whether or not the individual child self-identified as religious him or herself, honouring religious commitment as a potentially valuable part of spiritual health was seen as important by all participants. In Task 1, many of the descriptions of people who have strong spiritual health that participants gave included people who had a high level of formal religious commitment. They were ‘devoted to God or Buddha,’ they would ‘teach me the Koran,’ ‘pray a lot,’ ‘gain meaning from their higher power,’ ‘teach others religion or Koran,’ and have ‘a strong sense of their beliefs or culture.’ Beyond describing other people’s spiritual health, the transcendent domain was also important to many of the participants in their own lives. Illustratively, one said: ‘Without these things like meditating or praying or feeling connected to … without these I feel like you would be kind of lost in the world.’

However, the young people were clear that this domain needs to be interpreted more broadly than having an affiliation with religion. One participant described a First Nations Elder as someone who would have positive spiritual health. Another said ‘When I hear spiritual health I think of people and kind of hippies. Not like smoking weed hippies. People that love to meditate and connect with nature and they purposely go and take off work to do stuff like that.’ As they observed, you can have a connection to the transcendent without being religious:

Well I know that a lot of people … don’t feel connected to some sort of God or something or someone. But even if you don’t believe in God that feeling, a sense of belonging to something bigger than yourself, even if you don’t believe in God that you can feel sort of connected and the whole universe and world is connected in some way.

Spiritual health is protective in terms of health and overall well-being

Having positive spiritual health does not mean that life is free of challenges. In the experiences that were described, I heard that spiritual health can involve ‘a little bit of sadness,’ and that sometimes our struggles lead to greater spiritual health. During Task 4, one participant shared the experience of having been in a major accident, and how it had ‘opened [her] eyes to ‘everyone and everything around [her]’ and showed her what was most meaningful in life. Another told a story about the hard things she has overcome in her own life, and how she is glad for them because of what she has learned in terms of ‘finding out what is important to [her] in her life.’ ‘I have gone through hardships,’ she said, ‘and it showed me who was there and who was not there and what was important and what is not so important.’

All participants agreed that while life is full of stress and struggles, aspects of spiritual health are helpful in coping, ‘overcoming challenges,’ and even growing when things go wrong. Task 3 was particularly useful in eliciting details about what this looks like in the lives of young people. Here, participants ranked each of the domains of connections (to self, others, nature and transcendent) in relation to how it helps them to cope with life when things are tough.

Overwhelmingly, participants told me that it was the domain ‘connections to self,’ followed by ‘connections to others’ (particularly among females) that were most important to dealing with difficult challenges in life. Experiencing meaning and purpose was especially noted as important for supporting mental health. As one person described,

people who think their life has no meaning are usually more depressed. And if someone thinks their life has meaning then they will try to get that and when they do achieve it then they will be happy. And if you have something to achieve it makes you keep going. And every morning you will wake up and try to get that goal. But if you don’t have a goal then you might think, oh I could just sleep in later. I don’t have to really get up.

For those who did not self-identify as religious, the transcendent domain was ranked last in terms of supporting well-being. Yet, for the much smaller group who self-identified as ‘very religious,’ the transcendent domain was unanimously their most important resource for coping with life’s struggles. As one participant said: ‘There are lots of things that can help you cope with things through your day,’ but the most important thing is ‘when you are talking to God you kind of feel like it is just you and Him.’

Regardless of what it looked like specifically, participants were clear: whatever has happened in our lives that we have to deal with, our connections are one of the main ways that we handle things. When our connections are strong, they contribute to the ways that we cope. Spiritual health has a lot to offer because

without connections like these here you would be completely isolated. So going back to the four basics … so connection with yourself, others, the natural world, and then to a higher spiritual power … if it was just yourself it would be that base to build on instead of the four to help you. And they are there if you need them too in a way. I mean definitely the way you interact with them affects how much they are there for you. But still they will be if you need them. At least for me.

Spiritual health is central to our humanity

Throughout the focus groups and interviews, I heard many words and phrases that were difficult to categorise and that alluded to a mystical dimension of health. One participant described spiritual health like this: ‘[it] is kind of like the basis for life. It helps you with all aspects of life …. It can help you deal with situations better because you know what to do. It can help you become a better person and like yourself more.’ It was also described by different participants as your ‘life string,’ ‘mysterious,’ and ‘the centre of your whole being.’ As one of the young people shared some of the challenges she had had with mental health, she offered this image: ‘Mental health is a closed box and spiritual health is an open box with flowers in it.’ All of these ideas were important, yet difficult to integrate into the final definition in a concise way.

Midway through the interviews, one of our participants told me this: ‘I feel like these connections are part of what being human is.’ As per our protocol, I iteratively adapted the next round of the definition to include his phrase about how the connections that are core to spiritual health are ‘part of what being human is’ into the emergent definition to see how the later participants would respond. Unexpectedly, his phrase resonated deeply with all future participants. Perhaps the fact that none of the later participants wanted to provide any explanation as to what they liked about the phrase – they just liked it – was appropriate to the elusive nature of spirituality itself. Because of this, I used this phrase in the final definition in order to capture some of the more ineffable aspects of spiritual health in a way that the young people endorsed.

A living definition

Throughout the entire collection of data, I was synthesising what I was learning, putting it together in a definition, and then testing the next iteration of the definition with different individuals and groups. Here is the final, overall proposed definition of spiritual health that was developed in collaboration with 74 young people from across Canada.

Spiritual health is different for everyone.

It can involve a sense of purpose to life, and the experiences of feeling calm, joyful, balanced and being connected and true to one-self.

It is also about how we connect with people. It is about being kind, respectful and forgiving, and helps you see past your own needs. It is about making the world better for others, not just yourself.

It is about connecting with nature or the land. For some people, being religious might be an important part of it. It can impact your worldview and guide your moral choices.

Life is full of stress and struggles. Having these strong spiritual connections can help us overcome challenges, cope, and grow, even when things go wrong. These connections are part of what makes us human.

These findings illustrate that from the perspective of these Canadian young people, spiritual health is a robust, multi-faceted concept that is of deep relevance to their lives. Across the country, the young people who participated in this qualitative study were highly capable informants, and enthusiastic to share. One participant didn’t want her interview to end and asked if she could come back the next day. ‘We never get to talk about this stuff,’ she complained. Even after two hours in a focus group, the maximum my ethics agreement allowed, another of the young people sighed, saying ‘I feel like I have so much more to say!’

These findings convincingly demonstrate that young people are highly articulate in talking about the spiritual dimensions of health, and of their lives. Further, they demonstrate that it is also highly possible to conceptualise, and even define spiritual health, in a way that is meaningful and accessible to young people, and that is rooted in their everyday usage of the word spiritual.

Practical applications

Spirituality is often considered to belong in the personal domain, where it relates to personal transformation, beliefs and private values. Yet, when it is only considered as appropriate to the personal domain, a potentially important health asset remains underutilised in professional contexts in the applied health sciences. The definition I have presented provides a clear, theoretically-based and child-informed starting place for operationalising spiritual health in the public sphere, including in health -related contexts. Next steps would include the development of evidence-based practices, supported by high levels of evaluation, that relate to spiritual health as a whole construct and also to the four domains individually. This definition and associated research evidence could then be used as a basis for the creation of effective interventions and health promotion strategies for supporting the spiritual dimensions of health in the lives of young people. Adults and caregivers have responsibility for shaping the environments of young people to be positive for their development. If adults are able to support opportunities to develop a healthy spirituality in everyday contexts, research evidence suggests that young people will benefit (Scales et al. 2014; Brooks et al. 2018; Michaelson et al. 2019). This definition offers a starting place for this work.

Strengths and limitations

While rooted in an established theoretical framework (Fisher 2011; Hay and Nye 1998), an important strength of this study lies in how it was used to enlarge this already established way of thinking about spirituality for a new temporal, geographical and cultural context. Its credibility is enhanced by the contributions from, and eventual endorsement by, many Canadian young people and also by the groups of adult professionals who also offered their insights and acceptance of this definition.

A limitation relates to our sample. While I used intentional strategies to recruit participants whom I anticipated would hold a wide range of perspectives on spirituality, it is still likely that those who are disinterested in the spiritual dimensions of life are under-represented in this study. Further, a higher number of Christian and Muslim young people participated than is representative of the general population. Because a relationship between spirituality and religion is often assumed, participating in a study on spirituality may have been more appealing for this group than others who did not have a religious affiliation. Because of this, it may be that our results about the importance of religion to spiritual health, while already modest, should be interpreted with even greater caution when spiritual health is considered in relation to the broader Canadian population. This sampling reality, combined with the inability to generalise qualitative findings at a population level, means that this proposed definition may not resonate with – or may even be resisted by – some young people.

Another limitation of this study relates to its potential for transferability. While I would be delighted if this definition held value for young people beyond Canada, I suspect that it would be more useful as a starting point for discussion and debate rather than as a definition that is transferable across contexts. This is in keeping with Swinton and Pattison's (2010) claim that any one understanding of what spirituality means will almost certainly be ‘contested’ in another context because understandings of spirituality are inevitably shaped by the contexts out of which they emerge. Future research could replicate this study in other countries in order to understand any potential for transferability more fully.

Conclusions

When there is no consensus as to what spiritual health means, it is left up to individuals, including educators and others who support the health of young people, to choose from any number of anecdotal, personal, religious, and other frameworks to create opportunities for supporting spiritual health. Inevitably, this results in approaches to supporting the spiritual health of young people that are dictated by adult agendas and concerns rather than by the needs and experiences of children. Another result of the current ambiguity around what is meant by the spiritual dimensions of health means that they are overlooked and underutilised as supports for the health of young people, or that they are dismissed altogether as inappropriate for the public sphere. This is regrettable, because an increasingly robust body of research evidence demonstrates how important spiritual health can be to optimising the health and well-being of young people (Scales et al. 2014; Brooks et al. 2018; Michaelson et al. 2019). This study contributes to that literature base by providing a practical, accessible, and child-informed definition of spiritual health that can be used in contexts such as education, health promotion, research, policy and practice related to supporting the health of children.

The definition that I have proposed depicts a multi-dimensional, rich and yet also elusive concept. In keeping with the conclusions of many scholars (Watson 2003; Swinton and Pattison 2010; King and Koenig 2009; Roehlkepartain et al. 2006) I remain resistant to any final or comprehensive definition, and I do not intend for this it to be the final word on spiritual health and children in Canada. As more actors become engaged in this topic, and also as society changes, if it is to remain relevant and practically useful, the definition that I have proposed will inevitably need to evolve. In the meantime, this definition is well-positioned to provide a foundation for health research, to facilitate clear communication about spiritual health as a protective health asset for Canadian young people, and to inform interventions, policy, and health promotion initiatives.

Ethical approval

Ethical approval was attained from Queen’s university (ROMEO/TRAQ #6017552) in 2016. It was later also attained from Brock University (File 19-087) in 2019 when the lead qualitative researcher (VM) changed institutions.

Acknowledgments

I would like to acknowledge two undergraduate students (Francis McVicar and Amy Heatherington) and two graduate students (Sabreena Lawal and Emma Lockhart) from Queen’s University, who assisted with various elements of analyses between 2017–2018. I presented the definition at three separate international conferences between 2017 and 2019 (The American Academy of Religion conference in Boston, 2018, The International Association of Children’s Spirituality Conference in Laval, Quebec in 2018 and The Qualitative Public Health Conference in Vancouver, BC in October, 2019). Colleagues at each of these conferences provided invaluable insights and encouragement, for which I am most grateful. I am indebted to each of them as I have developed this work. I would also like to thank two anonymous reviewers, whose comments greatly improved this manuscript.

Disclosure statement

None declared by any author. This study is double-blinded for peer review.

Additional information

Funding

Support for this study came from an operating grant from the Canadian Institutes of Health Research [CIHR Grant MOP 341188]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Notes on contributors

Valerie Michaelson

Valerie Michaelson is an Assistant Professor in the Department of Health Sciences at Brock University. Her research is concerned with the health and well-being of children and adolescents, and the social determinants that shape their health trajectories. In particular, she focuses on social, cultural and religious norms that rationalise or normalise harmful health behaviours or attitudes, and that lead to deleterious health outcomes. Her current projects focus on violence, spirituality, mental health, and decolonisation and reconciliation in Canadian contexts. She is a qualitative researcher who typically works in mixed methods paradigms. Most of her projects have participatory strands, in which young people are positioned as co-researchers, and she recognises children as competent and insightful agents in interpreting their own worlds.