Defining Spiritual Wellbeing in Survivors of Stroke: A Convergent Parallel Mixed Methods Study

Abstract

Background

Stroke recovery involves adapting to physical impairments, emotional distress, and uncertainty about the future. Survivors of stroke may rely on spirituality and spiritual wellbeing practices to cope with illness. However, how survivors of stroke experience spiritual wellbeing remains unexplored. This study aimed to explore spiritual wellbeing in survivors of stroke and identify associated practices.

Methods

A convergent parallel mixed methods study using virtual focus groups with survivors of stroke and caregivers and survey data on spirituality using the All of Us research database was completed from October 2023 to February 2025. The framework method was used for qualitative data analysis and a 7‐item spirituality survey completed by survivors of stroke was analyzed from the All of Us research database using descriptive statistics. Data sets were integrated through joint displays to assess coherence.

Results

A total of 41 participants completed 6 focus groups. In this context, spirituality was defined as trust in a higher power and maintaining emotional balance. Focus groups identified spiritual wellbeing practices, including mindfulness, prayer, and spending time in nature. These findings converged with survey data (n=5428), with 70% of respondents endorsing connection with god/higher power. Spiritual practices extended beyond religious services, as 51.7% of respondents reported they did not attend religious services as a practice. Spending time in nature was a common practice, with 90.4% of respondents feeling spiritually touched by nature at least occasionally.

Conclusions

Spiritual wellbeing and its practices are important to survivors of stroke and can serve as a foundation for targeted interventions in poststroke care. Future research should investigate spiritual wellbeing in diverse populations to develop tailored interventions for survivors of stroke.

Nonstandard Abbreviation and Acronym

SDOH

social determinants of health

Clinical Perspective.

What Is New?

• This study explores spiritual wellbeing in survivors of stroke using a mixed‐methods design by integrating data from a national database with qualitative focus groups.

• This study identifies definitions of spiritual wellbeing and spiritual wellbeing practices that extend beyond traditional religious practices, including maintaining connection with others through acts of service and connection with nature.

What Are the Clinical Implications?

• By identifying definitions of spiritual wellbeing and spiritual wellbeing practices in survivors of stroke, this study offers clinicians a roadmap to integrate spiritual wellbeing and its practices into the care of survivors' recovery.

The impact of spirituality on health is increasingly evident in recent years, particularly in the field of palliative medicine and chronic disease management. ¹ , ² , ³ Prior studies show that patients want providers to discuss spiritual needs, and many consider it a priority for medical decision‐making. ⁴ , ⁵ , ⁶ This preference could be due to the positive influence of spirituality on stress, coping skills, and overall quality of life among chronically ill patients. ⁷ , ⁸ Thus, understanding the role spirituality plays in patients' lived experience can enable health care professionals to provide care that more closely align with patients' values and preferences.

Prior studies have aimed to define spirituality in populations without stroke. First, a prior systematic review of 166 articles reported a common definition of spirituality as “connection,” a connection that can occur in relation to the divine/gods/higher power, or in relation to other people, through self‐connection, or through nature. ⁹ Similarly, prior frameworks suggest that spirituality incorporates 2 interconnected dimensions of transcendence: a transpersonal dimension described as “connectedness” with god/gods/ higher power and intrapersonal, describing “connectedness” with self, other, and the natural world. ¹⁰ , ¹¹ These definitions are consistent with the International Consensus definition of spirituality that regard spirituality as a dynamic and intrinsic aspect of humanity that includes both religious (gods/divine/higher power) and areligious (self, community, nature) aspects of connection. ¹²

Correspondingly, spiritual wellbeing is a subjective state of expression based on how these spiritual needs are met. The 4 domains model of spiritual health and wellbeing suggests that spiritual wellbeing encompasses a state of perceived alignment of an individual's relationship with personal, communal, environmental, and transcendental elements. ¹³ Scales examining spiritual wellbeing have focused on the extent to which needs across these domains are met. ¹⁴ , ¹⁵ In chronic diseases, spiritual wellbeing serves as a protective factor by affecting coping and thereby improves quality of life. ¹⁶ , ¹⁷ , ¹⁸ In contrast, when spiritual needs are not met, individuals experience lower spiritual wellbeing, which can lead to poorer health related outcomes. ¹⁹ , ²⁰ Without understanding spiritual wellbeing, health care professionals may overlook factors that affect coping and medical decision‐making. Spirituality and spiritual wellbeing reflect distinct but related concepts. Whereas spirituality is an intrinsic human orientation reflecting an individual's predisposition to establish a connection, ¹² spiritual wellbeing refers to how individuals experience alignment with and engage in practices that support fulfillment of spiritual needs. ¹³

In survivors of stroke, prior research has suggested that spirituality is associated with lower anxiety and depression. ²¹ , ²² , ²³ Additionally, one study with survivors of stroke and care‐partner dyads revealed higher levels of spirituality were associated with better psychological quality of life. ²² Although these studies and established frameworks offer a strong foundation, how survivors of stroke conceptualize spiritual wellbeing remains largely unknown. Because spirituality and spiritual wellbeing are strongly influenced by personal, cultural, and geographical variations, ²⁴ an inductive approach to explore spiritual wellbeing in survivors of stroke allows for novel concepts specific to this population to emerge. Given that survivors of stroke report high rates of adverse mental health outcomes, developing a context‐specific definition could help to address distinct care gaps that improve spiritual wellbeing for survivors of stroke. ²⁵

Little is known about how survivors of stroke conceptualize spiritual wellbeing and which spiritual practices they engage in during recovery. The objective of this mixed methods study is to employ an inductive approach to explore spiritual wellbeing and its associated practices in survivors of stroke using their lived experiences in during recovery.

Methods

Study Setting and Design

A mixed‐method, convergent parallel study (Figure 1) was conducted from October 2023 until February 2025. Qualitative data were collected at 2 quaternary‐care, academic medical centers that are certified comprehensive stroke centers. ²⁶ Six focus groups, each comprising 5 to 8 participants, were conducted over secure, Health Insurance Portability and Accountability Act‐protected online Zoom conferences. ²⁷ Quantitative data were collected from the national All of Us research database from survivors of stroke who completed a 7‐item survey on spirituality. ²⁸ The deidentified transcripts that support the findings of this study are available upon reasonable request from the corresponding author.

Figure 1. Convergent parallel mixed methods design.

Participant Recruitment for Focus Groups

Study participants were recruited across the United States through online platforms and hospital‐based methods were used to recruit participants within the United States from October 2023 to July 2024. Most participants were recruited through web‐based research platforms using online fliers. Other recruitment methods included advertisements on social media platforms and through community‐based organizations, including an online stroke survivorship group. Purposive sampling was employed to prospectively to ensure diverse representation across participants.

The inclusion criteria were (1) aged 18 years or older, (2) personal history of ischemic or hemorrhagic stroke or serve as the primary caregiver for a person with history of stroke, (3) ability to read and speak English; and (4) functional internet access.

Qualitative Data Collection and Analysis

Prior literature suggests that 90% of data saturation is reached after 6 focus groups and 7 to 12 interviews, with basic themes being formed by the sixth interview. ²⁹ , ³⁰ Based on this prior literature, a total of 6 focus groups comprising 41 nationally recruited samples of survivors of stroke and caregivers were completed across 2 sites: 3 at site 1 and 3 at site 2. The focus groups were conducted in English and investigated spiritual wellbeing in stroke recovery. Participants were informed that the goal of the study was to explore stroke recovery by understanding wellbeing. At site 1, all focus groups were conducted by N.Y. (MD, MSc), a female neurointensivist with clinical expertise in stroke management. At site 2, focus groups were conducted by R.F. (MD), a female vascular neurologist; G.F. (MD, ScD, MPH), a male neurointensivist; and S.C. (BS), a female postgraduate clinical research associate. The interviewers across both sites had a shared interest in understanding the nonclinical determinants of stroke recovery. The interviewers provided clinical care to some participants, although majority of the participants had no prior relationship with the interviewers. Each session lasted approximately 60 minutes and was recorded on a Health Insurance Portability and Accountability Act‐secure Zoom. Across both sites, the interviewers were accompanied by the research team members who attended the sessions. The interviewers were aware of the potential bias being introduced due to their clinical roles, and the entire research team practiced reflexivity through iterative discussions to minimize bias.

A common semistructured interview guide was constructed with expertise from N.Y., R.F., G.F., and E.E. The interview guide was used at both sites to facilitate focus group discussions, ensuring consistency in data collection across the 2 centers (Table 1).

Table 1.

Interview Guide

Session opening questions

What does emotional wellbeing mean to you? And how did it change after a stroke?

Grand tour questions

How does spirituality impact health and recovery?

How does your social community impact your health and recovery?

Clarification questions—emotional wellbeing

How does emotional wellbeing change after a stroke?

Did you notice a change in your emotions after stroke?

Did anyone talk to you about emotional wellbeing after your stroke? A doctor? Therapist?

How did your social network or community impact your emotional wellbeing?

What were the parts of your community/social network that helped wellbeing?

What were the parts of your community/social network that made wellbeing more difficult to achieve?

How did your neighborhood environment change after a stroke? – physical environment that you live in

Did you feel like the environment you lived in had an impact on your emotional wellbeing?

What parts of your neighborhood helped wellbeing?

What parts of your neighborhood made achieving wellbeing more difficult?

Did you wish you had other resources in your environment?

A lot of you have mentioned counseling, how did that impact your emotional wellbeing?

Clarification questions—spiritual wellbeing

How does spirituality impact health?

How does spirituality impact wellbeing?

How does spiritual wellbeing change after a stroke?

What does spiritual wellbeing mean? And how did it change after a stroke

Did you notice a change in your spirituality after stroke?

Did you ever meet with a faith‐leader in the hospital or afterwards to talk about your stroke?

How did your social network or community impact your spiritual wellbeing?

What were the parts of your community/social network that helped wellbeing?

What were the parts of your community/social network that made wellbeing more difficult to achieve?

How did your neighborhood environment change after a stroke? – physical environment that you live in

Did you feel like the environment you lived in had an impact on your spiritual wellbeing?

Were you able to return to your place of worship after your stroke?

What parts of your neighborhood helped wellbeing?

What parts of your neighborhood made achieving wellbeing more difficult?

Social community

When you refer to your social community, are you thinking primarily of family, friends, or a broader network?

Could you specify the kinds of support or influence you find most significant within your social community?

Data analysis was conducted using the framework method comprising the following steps: (1) transcription, (2) familiarization with interviews, (3) coding, (4) developing an analytical framework, (5) applying an analytical framework, (6) charting the data into a matrix, and (7) interpreting the data. ³¹ Audiovisual recordings of each focus group interview were transcribed using NVivo 14 software in addition to detailed field notes during each session. To facilitate data sharing across sites, the finalized transcripts were deidentified and stored on a secure cloud platform. Three independent coders at site 1 (D.C., A.M., N.Y.) and site 2 (S.C., R.K., E.E.) reviewed the transcripts and conducted open coding to develop a preliminary site‐specific codebook. Researchers across both sites held regular meetings to triangulate the codes and develop a unified codebook, enhancing the credibility of analysis. ³² Transcripts were recoded using unified codebooks to ensure validity and consistency of the data. The codes were organized into parent and child codes. For instance, “spirituality and wellbeing” represented a parent code encompassing child codes related to subthemes such as belief in God or emotional regulation. Similarly, codes such as “physical environment” or “gratitude” were grouped under broader conceptual categories of how spiritual wellbeing was practiced by survivors of stroke. This coding structure was then applied to all the transcripts to identify overarching themes. All participants were invited to attend the last session, and themes were presented to the participants for feedback to ensure validity of the findings. Transcripts were not returned to the participants for corrections and no repeat interviews were carried out. Having multiple coders, achieving triangulation through unified codebooks, and strengthening validity and credibility through participant feedback allowed researchers improve the trustworthiness and qualitative rigor. ³³ Consolidated Criteria for Reporting Qualitative Research guidelines were followed to ensure transparent reporting of the methodology (Table S1).

Statistical Analysis

Publicly available, deidentified survey data were used from the All of Us research database (release version 7, May 1, 2018, to July 1, 2022). ²⁸ , ³⁴ The protocol for the All of Us research program is previously published. ³⁵

The cohort was constructed using the All of Us cohort builder (Figure 2). Respondents were selected based on age at consent, sex at birth, ethnicity, race, education, and income level. Only respondents who completed the social determinants of health (SDOH) survey items on religious and spiritual practices were included. Additionally, to assess the physical health status, respondents who rated their overall physical health status in the Overall Health survey were included. All surveys under the All of Us research program were available to participants in English and Spanish.

Figure 2. Flow diagram.

ICD indicates International Classification of Diseases; SDOH, social determinants of health; and TIA, transient ischemic attack.

To identify survivors of stroke, respondents with a combination of International Classification of Diseases (ICD) codes for either stroke (I60‐62) or transient ischemic attack (G45.9), or those who responded “Self” to the survey questions, “Including yourself, who in your family has had a stroke?” or “Including yourself, who in your family has had a transient ischemic attack?” were included.

SDOH survey responses were combined, and the total count and percentage was reported for those categories (Table 2).

Table 2.

Quantitative Survey Results (n=5428)

Survey question	No., %
How often do you feel God's (or a higher power's) love for you, directly or through others?*
Every d, many times a day, or most days	2646 48.7
Some d, once in a while	1156 21.3
Never or almost never, I do not believe in God (or a higher power)	1466 27.0
How often do you feel God's (or a higher power's) presence?†
Every d, many times a d, or most d	1695 31.2
Some d, once in a while	1085 20.0
Never or almost never, I do not believe in God (or a higher power)	1389 25.6
How often do you go to religious meetings or services?‡
Once a wk, more than once a wk	1119 20.6
Less than once per mo, 1–3 times a mo	769 14.2
Never or almost never, I am not religious	2806 51.7
How often do you desire to be closer to or in union with God (or a higher power)?§
Every d, many times a d, or most d	2619 48.2
Some d, once in a while	1219 22.5
Never or almost never, I do not believe in God (or a higher power)	1483 27.3
How often do you find strength and comfort in your religion?||
Every d, many times a d, most d	2643 48.1
Some d, once in a while	984 18.1
Never or almost never, I am not religious	1683 31.0
How often do you feel that you are spiritually touched by the beauty of creation?¶
Every d, many times a day, most d	3758 69.2
Some d, once in a while	1149 21.2
Never or almost never	402 7.4
How often do you feel deep inner peace or harmony?#
Every d, many times a d, most d	3170 58.4
Some d, once in a while	1778 32.8
Never or almost never	362 6.7

^*Percentage of missing observations=2.9.

^† Percentage of missing observations=23.2.

^‡ Percentage of missing observations=13.5.

^§ Percentage of missing observations=2.0.

^|| Percentage of missing observations=2.2.

^¶ Percentage of missing observations=2.2.

^# Percentage of missing observations=2.2.

To assess spirituality in the All of Us research database, we analyzed 7 items on religiosity/spirituality from the SDOH survey that were originally taken from the Daily Spiritual Experience Scale and the Nurses Health Study. ⁹ , ³⁶ , ³⁷ Six items were from the Daily Spiritual Experience Scale, a 16‐item self‐reported scale comprising items that identify theistic practices and beliefs as well as nontheistic perspectives on spirituality. ⁹ These items measure connection with the transcendent, compassionate love, and sense of inner peace. This 6‐item short scale was developed for the General Social Survey ³⁶ and has been previously validated in a French population. ³⁸ The last survey item from the SDOH survey regarding religious service attendance was from the Nurses Health Study. ³⁷

To characterize the cohort, we also descriptively analyzed participant demographic data and a validated item regarding overall physical health status from the Patient‐Reported Outcomes Measurement Information System Global Health Scale. ³⁹ , ⁴⁰ SDOH survey responses were combined, and the total count and percentage was reported for those categories (Table 2). All the analysis was performed within the All of Us researcher workbench using R studio (version 2024.4.0.735).

Mixed Methods Analysis

Using established mixed‐methods integration approaches, qualitative and quantitative data were merged using joint displays to assess the “fit” of data integration. ⁴¹ Findings from qualitative and quantitative data sets were said to be convergent if both types of data confirmed the results of the other. The term expansion was used if findings from one data set supplemented the findings from the other data set, and findings were considered discordant if they conflict or contradict each other. ⁴¹ , ⁴²

Ethical Considerations

The study was approved by the Massachusetts General Hospital (Protocol Number: 2023P002123) and Yale School of Medicine (Institutional Review Board Registration Number: HIC 2000036890) Institutional Review Board. All participants provided voluntary informed consent electronically. To maintain confidentiality, focus group transcripts were deidentified to replace participant names with speaker labels.

Results

Qualitative Results

Focus Group Demographics

A total of 41 individuals participated in focus groups. The cohort comprised 30 survivors of stroke and 11 caregivers; with a majority of the participants between 45 and 64 years of age, identifying as White and non‐Hispanic or Latino, and having an annual income of >$100 000. The sample included a range of self‐reported modified Rankin Scale scores, ranging from no significant disability (0–1) to severe disability (4, 5), with 72.5% of the participants reporting no to slight disability and 27.5% reporting moderate to severe disability. Additional demographics are outlined in Table 2.

Our focus group data identified 2 context‐specific definitions of spiritual wellbeing based on lived experiences, the first demonstrating connection with god/gods/higher power, and the second aligned with one's connection with self. Similarly, findings from our focus group indicate that survivors of stroke engaged in the following spiritual wellbeing practices: prayer and participation in organized religion, regulating emotions through mindfulness and meditation, practicing gratitude through acts of service, and being connected to nature.

Definitions of Spiritual Wellbeing

Trust in a Higher Power

Participants who endorsed belief in a higher power or god/gods described spiritual wellbeing as having faith in divine presence. This belief that god/gods was taking care of them supported their recovery by helping them trust the recovery process and providing a positive outlook despite challenges. Trust in god/gods fostered a sense of hope, motivation, and resilience.

I strongly believe I can slowly get back into that path of having confidence in higher power taking control. I think it is better because you're more calm, more relaxed, believing that god's going to get you out of these things and all that. [Speaker 13, Site 1]

With the stroke, it drew me closer to god. And every day I'm learning that he's not just good, but he loves me. And that love, knowing that he loves me is doing something to my body. It's doing something to my mind, it's doing something to my psyche. [Speaker 17, Site 2]

Maintaining Emotional Balance

For other participants, spirituality included regulating emotions and maintaining balance. These participants often noted that meditation and practicing mindfulness allowed them to feel at peace and remain calm, which was integral to their spiritual wellbeing.

I have been dabbling with the mindfulness and meditation space primarily. I think that does it goes back to what we talked about in the beginning for the emotional wellbeing, just having balance. And for me, I think that helps toward that goal. [Speaker 17, Site 1]

I think tapping into that [spirituality] is about finding what brings each individual person peace. For me, it's been that meditation that brings peace in there. That's really what it comes down to, finding that peace in your life which for me brings that balance into that wellbeing. [Speaker 16, Site 1]

Spiritual Wellbeing Practices

Maintaining Connection With a Higher Power Through Prayer and Religious Services

For participants who described the supportive influence of god/gods, spiritual wellbeing practices included praying and attending services through organized religious institutions.

I pray and talk to god during the day, several times at particularly with stuff that's been going on lately. And I find comfort in that. [Speaker 4, Site 1]

And [I] gradually started going back to church again. And I love the Episcopal Church. Their programs and services and stuff like that. [Speaker 4, Site 1]

Maintaining Connection With Self Through Meditation and Mindfulness

For participants who associated spiritual wellbeing with emotional balance, mindfulness activities through meditation groups were key practices.

But in terms of community, the one thing that stands out most of all is there is a meditation group that gathers outside my place of work. It is very peaceful and allows me to process my emotions. I cannot do when I'm writing emails at work because usually that's when I can't channel my anxiety that well. [Speaker 15, Site 1]

Maintaining Connection With Others Through Acts of Service

Participants also noted that practicing gratitude through acts of service was an important component of spiritual wellbeing. These included participation in peer support programs and assisting those in need. This practice was described by both participants who identified with an organized religion as well as participants who did not explicitly identify with a particular religion, demonstrating its relevance beyond traditional frameworks.

For me, in terms of spirituality and faith my brand of Christianity focuses on helping others. And so, for me and my faith, just knowing I can still help, even when I've lost pretty much everything else, I'm okay. [Speaker 23, Site 1]

I went back to Spalding and [I] see stroke survivors who had a stroke only 1 or 2 weeks ago. And I would help the stroke survivors and the family of my stroke survivors. [Speaker 26, Site 1]

Maintaining Connection With Nature

Spending time in or access to nature was another commonly reported practice. Spending time in nature included both physical excursions in outer spaces or simulated realities portraying nature.

I find myself comfortable and at peace in nature, and exploring the environment and the outdoors and breathing and doing things that help give me comfort. [Speaker 14, Site 1]

I ride a recumbent bike. And 90% of the time I'm by myself and I will get on and off depending on where I am. I'll ride up the coastline, or I'll ride through the woods, not through the woods, but in a forest area and it's just me. I guess that's mindfulness because there's nobody else to talk to and it's just me and whatever is going on around me which I find relaxing. [Speaker 3, Site 2]

Quantitative Results

Demographics

Of 410 361 eligible participants in the All of Us database, 117 023 (29%) completed the spirituality survey, and 5428 (1%) of these respondents had an ICD diagnosis of stroke or transient ischemic attack and were included in the final cohort. Most of the respondents were aged 65 or older, predominantly White, identified as non‐Hispanic or Latino, and most respondents were female based on sex assigned at birth (Table 3). Most respondents were college graduates or held an advanced degree and had an annual income of ≤$50 000. The overall physical health status was rated good (34.6%) by most survey respondents, followed by fair (26.3), and very good (26%).

Table 3.

Demographic Characteristics

Participant characteristics	Qualitative focus groups	All of Us database
	No., %	N, %
Total participants (N)	41	5428
Sex at birth*
Male	18 (43.9)	2244 (41.3)
Female	23 (56.1)	3025 (55.7)
Age, (y)
18–44	8 (19.5)	243 (4)
45–64	18 (43.9)	1295 (24)
>65	15 (36.6)	3890 (72)
Race†
White	28 (68.3)	4281 (78.9)
Black	7 (17.1)	541 (10)
Asian	3 (7.3)	54 (1)
Some other race/another single population/>1 race	3 (7.3)	65 (1.2)
Ethnicity‡
Hispanic or Latino	4 (9.8)	285 (5.3)
Non‐Hispanic or Latino	36 (87.8)	4870 (89.7)
Income§
<$50 000	9 (21.9)	1943 (35.8)
$50–100 000	8 (19.5)	1370 (25.2)
>$100 000	16 (41.5)	1406 (25.9)
Education||
Less than high school	1 (2.4)	136 (2.5)
High school graduate	1 (2.4)	620 (11.4)
Some college/technical school	3 (7.3)	1571 (28.9)
College graduate or higher degree	29 (70.7)	2946 (54.3)

^*Percentage of participants from the All of Us database identifying as not man only, not woman only, prefer not to answer, or skipped=3.

^† Percentage of survey respondents from the All of Us database responding I prefer not to answer, none of these, none indicated, skip=8.9.

^‡ Percentage of missing observations from qualitative focus groups =2.4; Percentage of survey respondents answering skip, prefer not to answer, none of these=5.

^§ Percentage of missing observations from qualitative focus groups=13.1; Percentage missing or skipped observations from quantitative survey=13.

^|| Percentage of missing observations from qualitative focus groups=17.1; Percentage missing or skipped observations from quantitative survey=2.9.

Most of the participants had an ICD diagnosis of cerebral infarction (31.2%), followed by transient ischemic attack diagnosis (24.5%), other nontraumatic hemorrhage (4.1%), intracerebral hemorrhage (3.9%), and subarachnoid hemorrhage (3.3%).

Additionally standardized mean difference (SMD) was calculated between respondents and nonrespondents, and significant differences were observed between spirituality survey responders and nonresponders across race, ethnicity, education, income, and physical health status (Table S2). Responders were more likely to be White (SMD=0.5), non‐Hispanic (SMD=0.4), and had higher education (SMD=0.6) and income levels (SMD=0.5), indicating disparities between individuals who completed the survey and those who did not.

Survey Results

As shown in Table 2, survey responses demonstrated a varying degree of spirituality across the 7 items. Connection with god/gods (or higher power) was a frequently reported finding. Almost half of the respondents (48.7%) reported feeling god's (or higher power) love either every day, many times a day, or on most days. Similarly, 48.2% of the respondents expressed a desire to be closer to god/gods (or higher power). In contrast, 27.3% of respondents reported never expressing a desire to be closer to god/gods (or higher power) or did not believe in god/gods. Experiencing inner peace or harmony was another commonly reported finding, with 58.4% of respondents stating that they experienced it daily, many times a day, or on most days and an additional 32.8% experiencing it some days or once in a while.

Notably, connection with god/gods was reported by respondents regardless of religious service attendance. Among respondents who expressed a connection with god/gods, a majority (51.7%) indicated they did not engage in religious meetings/services. Although 66.2% of respondents endorsed religion as a source of strength, 20.6% of the total respondents engaged in religious meetings or services at least once a week. Furthermore, 90.2% of respondents reported feeling touched by the beauty of creation at least once in a while, highlighting the frequent role nature plays in spiritual wellbeing.

Mixed‐Method Analysis

Cohort Comparison

Demographics are shown in Table 3, highlighting that both cohorts had a similar composition of race/ethnicity and sex, with most identifying as White, non‐Hispanic or Latino, and female. Most focus group participants were between 45 and 65 years of age, whereas most survey respondents were aged 65 years or older. The distribution of annual income differed between the cohorts, with 41.5% of focus group participants reporting an annual income of ≥$100 000 and most survey respondents had an annual income of <$50 000. Education was also different between populations, with 70.7% of the focus group sample having a college degree or greater as compared with 54.3% of the All of Us population.

Data Integration

Integration of qualitative and quantitative data revealed complementary findings, and no conflicting evidence was observed.

Spiritual wellbeing in survivors of stroke was confirmed in qualitative and quantitative results as either a connection with god/gods or higher power (feeling god's love or presence) or connection with self through emotional regulation (experiencing inner peace). A joint display of integrated results is presented in Table 4.

Table 4.

Joint Display of Quantitative and Qualitative Data

Dimension	Quantitative data	Qualitative quotes*	Comparison
Defining spiritual wellbeing	48.7% of respondents reported feeling God's (or higher power's) love for themselves directly or through others every d, many times a d, or on most d	With the stroke, it drew me closer to God. And every day I'm learning. That he's not just good, but he loves me. And that love, knowing that he loves me is doing something to my body. It's doing something to my mind, it's doing something to my psyche. [Speaker 17, Site 2]	Convergence
	31.2% of the respondents reported feeling God's or higher powers presence every d, many times a d. Or on most d	I was able to recuperate. Every milestone, whether it's a small one or a large one, it's a victory. And I'm always thankful for God. You [God] got me this where I was able to gain this back. [Speaker 21, Site 1]
	48.2% of respondents desired to be closer or in union with God (or higher power)	I've always been spiritual before, and now I'm just more attached to spirituality because I know that keeps me sane. [Speaker 21, Site 1]
	58.4% of the respondents reported feeling deep inner peace or harmony every d, many times a d, or on most d	I'm just going to add that I think the meditation piece just helps you calm yourself and get your thoughts just focused on peace and more than like a religious peace, just a peace in your own body and mind and I think it's been very resourceful. [Speaker 10, Site 2] I think mindfulness and yoga have been important in kind of regulating my nervous system as it relates to my emotional and mental health. One of the programs I was in at rehab was the mindful chair yoga. We just did mindfulness meditation and, you know, simple yoga poses that were adapted for those who had suffered a stroke. [Speaker 9, Site 2]
Spiritual wellbeing practices	51.7% of the respondents reported never going to religious services or meetings or did not consider themselves religious	I think for me it was self‐inquiry because mine was a personal journey. It wasn't really like I didn't start going to church or anything. It was just kind of like a personal thing. [Speaker 9, Site 2]	Expansion
	48.1% of respondents stated they find strength and comfort in their religion every d, on many d, or in most d	I kind of reconnected with it [spirituality] after having abandoned it for like the better part of a decade. Something about my experience, kind of reawakened it for me, it's now like a like an anecdote to me. I've taken a lot of personal comfort and meaning from that reconnection with the spirituality. [ Speaker 9, Site 2]
	69.2% of the respondents reported feeling touched by the beauty of creation every d, many times a d, or on most d	I live in a very natural place. I have no problem seeing the presence or the work of God around me, and I live in the midst of that. So it's very spiritual. [Speaker 23, Site 1] Part of my running is just being out with nature and trying to just listen. And I find that the noise in my brain disappears when I'm running because I'm concerned and thinking about my breathing. [Speaker 3, Site 2]

^*At MGH the speaker labels were created irrespective of the roles, while at Yale School of Medicine speaker labels were further classified into survivors of stroke and caregivers.

MGH indicates Massachusetts General Hospital.

Qualitative and quantitative analysis identified diverse spiritual wellbeing practices that included activities beyond organized religion. In the quantitative data strand, a significant proportion of respondents reported feeling god's/gods' love or presence. However, among the 2806 participants who reported not attending religious services or being religious, many still reported experiencing inner peace every day, many times a day, or on most days, suggesting that spiritual wellbeing practices extended beyond traditional religious services. Our qualitative focus groups expanded upon the specific spiritual practices that could lead to this inner peace and promote spiritual wellbeing, which included meditation, prayer, mindfulness activities, experiences of nature, and expressing gratitude. Specifically, both qualitative and quantitative analysis revealed that proximity and access to nature was central to spiritual wellbeing practices, as indicated by the survey responses showing 90.4% of participants at least occasionally being spiritually touched by the beauty of creation.

Discussion

Spirituality remains largely understudied in survivors of stroke. This study leveraged a mixed methods approach to explore spiritual wellbeing and to identify spiritual wellbeing practices in survivors of stroke. Consistent with prior conceptual framework defining spirituality as experiences, beliefs, and practices promoting connection with the divine, others, self, or nature, ¹⁰ , ⁴³ results show that survivors of stroke also experience spiritual wellbeing as (1) trust in god/gods/ higher power, reflecting beliefs promoting connection with the divine and (2) ability to maintain emotional balance, reflecting experiences that advance connection with self. Notably, most survey respondents reported experiencing peace or a connection with god/gods or a higher power despite infrequently attending religious services. The finding that spiritual wellbeing was expressed as connection with god/gods or a higher power reinstates the idea that faith‐based coping is one of the many components within a broader construct of spirituality. The spiritual wellbeing practices described by survivors of stroke praying, practicing gratitude, meditation, and being connected with nature, aligned with the framework of identifying spirituality as connection with the divine, others, self, or nature. ¹⁰ Participation in religious communities has declined over the past decades, ⁴⁴ and in addition, those with chronic health issues often have diminished ability to participate in communities built around spirituality. ⁴⁵ These findings highlight the need for spiritual care that attends to spiritual practices, and, where desired, facilitates connections and environments conducive to ongoing spiritual support. Exploring the role of spirituality within illness can be facilitated by a brief spiritual history, such as the Faith, Importance and Influence, Community, and Address spiritual history model. ⁴⁶ Other models probe spiritual needs or distress such as the 1‐item assessment, “Are you at peace?” ⁴⁷ or an inquiry integrated into a larger symptom assessment tool, such as the modified Edmonton Symptom Assessment System, which includes a rating of “spiritual pain.” ⁴⁸

This study identified spiritual wellbeing practices that were varied and largely personal, but important for promoting spiritual wellbeing, including prayer, meditation, and activities in nature that can address nonclinical determinants of health that promote reconstruction of identity, emotional regulation, and resilience. Prior research has shown that spirituality mediates the relationship between engagement with nature and psychological wellbeing, ⁴⁹ aligning with stroke survivors' experiences regarding proximity to nature and spiritual wellbeing. Moreover, many participants endorsed mindfulness, prayer, and meditation‐based exercise as important to spiritual wellbeing during their recovery. Although meditation and mindfulness practices focused on cultivating inner balance and self‐awareness, practices such as praying and attending religious services improved spiritual wellbeing by reinforcing a sense of trust in higher power/gods. These distinct practices highlight how spiritual wellbeing can be expressed as both self‐regulatory (areligious) practices as well as faith‐based (religious) practices. Although limited, prior intervention studies point to the potential utility of mindfulness interventions in improving emotional wellbeing outcomes among survivors of stroke. ⁵⁰ The findings from this study suggest that spiritual practices for fostering spiritual wellbeing, such as mindfulness or other spiritual practice interventions, require further exploration as targeted components for future interventions that could be integrated into stroke care settings to better provide comprehensive care.

Another important spiritual wellbeing practice was acts of service, specifically through peer mentoring and volunteering that offered survivors of stroke a sense of identity, purpose, and connection, all of which are particularly important as changes in social roles often leads to disrupted sense of identity post stroke. ⁵¹ , ⁵² Although participation in religious communities has declined in the recent years, ⁴⁴ engaging in acts of service both within and outside of religious communities was considered as an important form of spiritual expression. Prior research has shown that religious involvement is associated with increased social support, ⁵³ which plays a protective role against stress‐related outcomes. Religious service attendance has also been associated with increased social integration and satisfaction with life. ⁵³ , ⁵⁴ Similarly, volunteering has shown to improve subjective wellbeing by strengthening social connections and providing a sense of purpose. ⁵⁵ , ⁵⁶ Religious institutions also provide a structured setting for volunteering; church attendance has been linked to increased volunteering, ⁵⁷ and informal support received in religious settings has been linked to improved health. ⁵⁸ This study builds on this finding by demonstrating that areligious activities, including peer mentor programs and similar volunteering opportunities can also serve as similar platforms to engage in spiritual wellbeing practices and develop meaningful relationships with others. Additionally, given that proximity to nature supported spiritual wellbeing, this finding highlights how stroke care settings could consider incorporating elements of nature. Lastly, for stroke clinicians, these findings are relevant to promote discussions regarding spirituality in an inclusive manner that recognizes the diversity of spiritual expressions and practices, including nonreligious, nontraditional forms. These findings also highlight the potential utility of integrating spiritual care professionals, such as chaplains, as part of the holistic care of patients with stroke. ²

The strengths of this study include a mixed methods approach that allowed us to contextualize and expand upon quantitative survey results by integrating the lived experiences of survivors of stroke and the inclusion of caregivers for those survivors of stroke living with aphasia. Limitations of this study include the selection bias in both databases of our study. First, focus group participants may be more willing to engage in research, limiting the generalizability of our findings. Furthermore, the focus group participants tended to be younger, more educated, and more affluent than the All of Us survey respondents. Second, only 29% of the survey participants completed the All of Us spirituality survey, potentially leading to nonresponse bias that could influence our findings. Individuals who declined the survey were more likely to self‐report Black race, report education less than high school, and have an annual income of <$50 000, limiting the generalizability of our findings. Next, this study comprised primarily White/Non‐Hispanic cohorts, limiting the understanding of spirituality in racially diverse populations. Third, this study did not account for differences in time since stroke onset; understanding how time since stroke influences spiritual practices could improve the effectiveness of spiritual care interventions. Fourth, given the samples were drawn from US populations where Christianity is the major religion represented, this study provides a limited religio‐cultural perspective on spirituality. Fifth, although virtual focus group allowed participants to overcome geographic barriers, it is possible that individuals with limited digital literacy were excluded from the study. Additionally, the focus groups were conducted in English and relied on interview guides that may require higher literacy levels, and future studies are required to understand how individuals from more diverse racial, socioeconomic, and of different faiths define spirituality and practice spiritual wellbeing in poststroke recovery. Lastly, although this study explored spiritual wellbeing through lived experiences, spirituality remains underdefined in survivors of stroke, limiting its utility in clinical practice. Given these limitations and the exploratory nature of this study, future studies are required to refine workable frameworks and evaluate the clinical implications of the specific components of spiritual wellbeing.

Conclusions

This mixed‐methods study explores and identifies practices important to spiritual wellbeing in survivors of stroke. Survivors of stroke described spiritual wellbeing as either trust in god/gods or a higher power or the ability to maintain emotional balance and identified key spiritual wellbeing practices including prayer and religious service attendance, meditation, engaging in acts of service, and accessing nature. Importantly, it highlights definitions and practices for both religious and areligious participants, highlighting potential targets for intervention development. Future studies should conduct similar assessments defining and identifying practices important for spiritual wellbeing in survivors of stroke of more diverse populations.

Sources of Funding

This work was funded by the Bugher Collaborative Project (principal investigator, Dr Falcone; No. 23BFHSCP1178409; Dr Rosand; No. 23BFHSCP1176239).

Disclosures

D. Choksi is supported by the Lavine Brain Health Innovation Fund; G. J. Falcone is supported by the AHA (817 874, 24GWTGSIC1341098, 23BFHSCP1178409) and the National Institutes of Health (P30AG021342, U01NS106513, RF1NS139183); J. Rosand has a leadership or fiduciary role at Columbia University, Lancet Neurology, and European Stroke Journal.

Supporting information

Table S1–S2