Not a Cure but a Comfort: The Role of Spiritual Coping in Responding to Anxiety among Women Living with Human Immunodeficiency Virus

INTRODUCTION

Human immunodeficiency virus (HIV)/Acquired immuno-deficiency syndrome (AIDS) continues to be a meaningful global health issue, especially one that affects women.^[1] Every week, 4200 women aged 15–24 are infected with HIV and they are twice as likely to be infected as males.^[1,2] Women living with HIV (WLHIV) face substantial psychological challenges, including anxiety. Anxiety is a phenomenon that is often found among WLHIV. Research reveals that 37% of WLHIV of reproductive age in Canada experience high levels of anxiety,^[3] and data in Ethiopia 28.9% of WLHIV experienced anxiety.^[4]

Stigma and discrimination from health workers, along with perceived shame, are major factors contributing to anxiety among WLHIV.^[5,6] In Indonesia, approximately 570,000 people are living with HIV, with an adult prevalence (aged 15–49 years) of about 0.4% and women aged ≥15 years representing 31.6% of this population.^[1] Although national data on anxiety among Indonesian WLHIV are limited, mental health problems are common among PLHIV in Indonesia. A recent study reported that 23.3% of HIV-infected adults in Indonesia experienced lifetime suicidal ideation, often linked to underlying anxiety and depression.^[7] One strategy that has the potential to help in managing anxiety is the use of spiritual coping skills. Through this approach, individuals rely on the strength of faith, prayer, remembrance, and surrender to God to face stress. Some studies suggest that spirituality may contribute to reducing symptoms of depression, anxiety, and hopelessness among WLHIV.^[8] Women often find calmness, strength, and development through spiritual practice.^[9] The use of prayer, in particular, has been identified as a highly effective self-care strategy.^[10]

Information about the impact of spiritual coping on anxiety is still minimal. The majority of the studies have placed more emphasis on the effect of spiritual handling on symptoms of depression, stress, and mental health in general, rather than specifically on anxiety.^[11-13] Although there have been several studies involving women, none have specifically explored the effects of spiritual coping on anxiety among WLHIV.^[9,12-14] Research on anxiety in individuals with HIV/AIDS has generally focused on pharmacological approaches and conventional psychological therapies. Psychological interventions, particularly cognitive behavioural therapy and cognitive behavioural stress management, have generally demonstrated greater effectiveness than pharmacological approaches in alleviating anxiety among people living with HIV.^[15,16] However, definitive evidence identifying the most beneficial non-pharmacological intervention remains limited.^[17] Meta-analyses of psychosocial interventions have reported small-to-moderate effects in reducing anxiety, with standardised mean differences ranging from –0.12 to –0.22.^[18] The limitations in research representation from developing countries, as well as among specific population groups, such as women, are noteworthy. The majority of research is focused on North America, while data from other regions are still limited.^[19] The necessary interventions should be tailored to the cultural context and take into account the specific challenges faced by WLHIV in different regions.^[19,20] This indicates a need for more focused research on anxiety with varied outcomes.

This research contributes to the comprehension of the function of spiritual coping in supporting WLHIV to anxiety stability. An in-depth comprehension of the function of spiritual coping in anxiety management is anticipated to underpin the creation of psychosocial interventions for WLHIV. The methodology employed in this research is based on the theory of spiritual coping.^[21] The selection of this theory was based on its clear emphasis on how people construct their spiritual coping mechanisms by interpreting stressful events through a spiritual framework. This theoretical framework aims to facilitate the development of effective interventions based on spirituality and to investigate the role of spiritual coping in helping WLHIV manage anxiety.

MATERIALS AND METHODS

RESULTS

The following is a description of demographic variables, spiritual coping, and anxiety of WLHIV.

Table 1 can be concluded that most of the respondents were 36–49 years old (56.7%), had a high school education (58.3%), were married (61.6%) and were diagnosed with HIV for more than 2 years (63.3%). Most of the respondents had spiritual coping in the high category (55.0%) and most of the respondents were in the non-anxiety category (58.3%), while others experienced anxiety to varying degrees.

Next, the researcher continued to examine the connection between dependent variables and independent variables using Spearman’s Rank analysis to determine the relationship and direction between age, marital status, length of diagnosis, spiritual coping and WLHIV anxiety.

As shown in Table 2, indicated a noteworthy correlation between age and anxiety (ρ = +0.346; P < 0.001), as well as between the length of diagnosis and anxiety (ρ = −0.356; P < 0.001). Both associations showed a negative pattern, indicating that as the age and duration of the HIV diagnosis increased, WLHIV anxiety levels tended to decrease. A significant positive correlation was found between spiritual coping and anxiety (ρ = +0.364; P < 0.001). This finding suggests that while individuals with higher levels of spiritual coping tend to engage more deeply in religious or spiritual practices, such engagement may occur as a response to psychological distress or anxiety rather than its absence. This analysis also showed that marital status had no meaningful relationship with WLHIV anxiety levels (ρ = −0.115; P = 0.211). This lack of association suggests that marital status may not capture the quality of social relationships or perceived social support factors that are typically more closely linked to psychological distress. Hence, meaningful differences in anxiety levels by marital category were observed in this sample.

Table 3 presents the results of the ordinal regression analysis examining factors influencing anxiety levels among WLHIV. The findings indicate that age significantly affects anxiety levels, particularly among participants aged 20–25 years (B = 1.553; P = 0.041; Odds ratio [OR] = 4.73; 95% Confidence interval [CI] = 1.07–20.92). This suggests that WLHIV in 20–25 years of age group is approximately 4.7 times more likely to experience anxiety compared to those aged 36–49 years.

Marital status and duration of HIV diagnosis did not show statistically significant associations with anxiety levels (P > 0.05), indicating that these factors may not independently influence psychological distress in this population.

In contrast, spiritual coping demonstrated a significant relationship with anxiety. Participants categorised as having moderate spiritual coping were about 4.6 times more likely to experience anxiety compared to those with highlevels of spirituality (B = 1.520; P = 0.013; OR = 4.57; 95% CI = 1.38–15.20). This suggests that moderate spiritual coping engagement may represent an active coping response to psychological distress rather than an absence of anxiety it-self. To enhance the interpretability of these findings, a heat map [Figure 1] was added to visually illustrate the strength and direction of the relationships between variables and anxiety levels among WLHIV. The colour gradient reflects the regression coefficients (B), with darker red shades indicating stronger positive associations with anxiety, and blue shades indicating weaker or negative associations. The visualisation reinforces the regression findings by highlighting that younger age (20–25 years) and moderate spiritual coping are the most significant predictors of increased anxiety among WLHIV.

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Figure 1:

Heat map of ordinal regression coefficients (B) for predictors of anxiety among women living with human immunodeficiency virus. The colour gradient represents the direction and strength of associations, with red indicating stronger positive relationships and blue indicating negative ones. Asterisk (*) indicates statistically significant variables (P < 0.05)*.

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The overall model fit test [Table 4] determined that the regression model was meaningful (Chi-Square = 95.276; df = 42; p < 0.001), indicating that the independent variables meaningfully contributed to the model. The goodness of fit test showed a deviance value of 122,959 (df = 267; P = 1,000), which indicates that there is a model fit (fit) with the data. Nagelkerke’s Pseudo R-Square value of 0.631 showed that the model was able to explain 63.1% of the variation in anxiety in WLHIV.

DISCUSSION

This study examined factors influencing anxiety among WLHIV through bivariate (Spearman Rank) and multivariate (ordinal regression) analyses. The findings highlight that younger age and spiritual coping are the most important predictors of anxiety, showing the interplay between psychological and spiritual factors in shaping emotional well-being.

Younger WLHIV (aged 20–25 years) reported higher anxiety compared to older participants. This finding aligns with prior studies showing that younger women tend to experience greater psychological distress due to stigma, fear of rejection and life disruption following diagnosis.^[29-31] The Spearman Rank correlation also confirmed that younger age was significantly associated with higher anxiety levels. The vulnerability of younger women may reflect the transitional nature of early adulthood, where social and emotional stability is still developing, and illness-related uncertainty increases anxiety.

The analysis also found a negative correlation between duration of HIV diagnosis and anxiety, indicating that newly diagnosed WLHIV experience higher anxiety levels. This supports earlier evidence that the initial post-diagnosis phase is a psychologically fragile period marked by fear and denial.^[32,33] However, this relationship became non-significant in the regression model, suggesting that when multiple variables were analysed simultaneously, factors such as age and spiritual coping had a stronger impact on anxiety.

The most striking finding concerns the relationship between spiritual coping and anxiety. Ordinal regression revealed that participants with moderate levels of spiritual coping experienced significantly higher anxiety than those with high spirituality. This positive association suggests that spirituality may become more salient as a response to distress rather than its absence. According to Pargament’s Spiritual Appraisal Theory,^[34-36] individuals interpret stressful situations through a spiritual lens, viewing illness as a divine test, punishment, or opportunity for growth. This process – known as spiritual appraisal – bridges stress (anxiety) and coping, explaining why WLHIV experiencing anxiety might increase their spiritual engagement to find meaning, comfort and endurance.

Nevertheless, alternative explanations should be acknowledged. Some individuals may engage in negative religious coping, such as feelings of guilt, fear of divine punishment, or abandonment by God, which may exacerbate rather than alleviate anxiety.^[35,36] It is also possible that the direction of the relationship is reversed, where higher anxiety motivates individuals to increase their spiritual practices to seek comfort and control. These interpretations suggest a bidirectional relationship between spirituality and anxiety– spirituality may both reflect and regulate emotional struggle. This finding is consistent with Andersson,^[37] who found that greater distress was associated with increased prayer and reflection, and with Visser et al. (2018) and Margetić et al. (2022), who emphasised that spirituality can serve as either a buffer or an indicator of emotional distress depending on the nature of one’s appraisal.^[38,39] Hence, spiritual coping among WLHIV should be viewed as a dynamic and context-dependent process.

From a nursing perspective, these findings underscore the importance of spiritual assessment in holistic care. Nurses should recognise that increased spiritual activity may signal unresolved distress rather than resilience. Integrating faith-based counselling, reflective dialogue and mindfulness rooted in spirituality into HIV care can help patients transform anxiety-driven spirituality into adaptive coping, reducing distress and improving quality of life.

In conclusion, spirituality among WLHIV represents a complex, reciprocal process. Understanding how women interpret anxiety through a spiritual lens can guide culturally sensitive nursing interventions that address psychological and spiritual needs simultaneously

CONCLUSION

WLHIV who experience high levels of anxiety are more likely to use spiritual coping, suggesting that this strategy works in response to emotional stress, rather than as a protective factor that directly reduces anxiety. The influence of age and meaningful spiritual handling on anxiety levels reinforces the understanding that internal factors, such as emotional maturity and spirituality, play a role in affective regulation. Conversely, the duration of the diagnosis suggests that the length of life with HIV is not the main factor determining the level of anxiety. These findings emphasise that the protective role of spirituality is complex and context-dependent. Therefore, nursing interventions should be culturally grounded and psychospiritual in nature, focusing not only on the presence of spirituality but also on the form and quality of spiritual coping used by WLHIV.