Spiritual Needs as Expressed by People Living with HIV: A Systematic Review

Round 1

Reviewer 1 Report

All my concerns were corrected. I accept the article in this form.

Author Response

Dear reviewer 1

Thank you for you time!

The manuscript was revised by a native speaker, a teacher at our University.

Sincerely

Author Response File: Author Response.pdf

Reviewer 2 Report

The authors reviewed the manuscript. Many aspects are good, other aspects could be improved.

Good:

- The reviewer asked why publications from 2019-2020 were not included. The authors have now included also publications from 2019-2020. That is a good contribution to the paper!

- The reviewer suggested some limitations of the study, which are now included in the limitation section.

 

Questions:

- The reviewer suggest that the Brazilian interest of the authors should be formulated from the beginning. Now it seems that they did not do that? Why not?

- The discussion is very limited. Especially when including these new papers, the discussion remains very small. Are these the only insights that the authors conclude based on all these articles?

- English language is better now, but is this revised by an English native speaker?

* A new question about the table part on "How spiritual needs are defined and expressed by the participants". The answers given for each publication are answers about religious support, spirituality... but not about 'what are the spiritual needs'. I have the concern that they mix concepts spiritualty, spiritual needs, spiritual support... Maybe they have a good explanation for this, but now it seems that they do not know what their main concept is they want to research in Table 1.

- Also in Table 1 they formulate the study designs as quantitative or qualitative, but more information on the study designs should be provided (cross-sectional, longitudinal, experiment? )

 

 

Author Response

Dear reviewer 2

Thank you for your comments!

Please see the attachment.

Sincerely

Author Response File: Author Response.pdf

Reviewer 3 Report

R/S (line 23...) lumps religion and spirituality together, which they cannot be. You go on to discuss these separately, but you should be clear if what you mean here is Religion and Spirituality, the two things, and you are speaking of them both. R/S lumps them together, and they are different. 

Para. 3 (line 30)- You have definitions of religion and spirituality confused. Religion is collective, social, cultural, historical, doctrinal. Spirituality is individual, personal, internal, and as internal it influences outer behavior. Puchalski is one source among thousands in the field. To take this one source is wrong, and must be corrected. 

You go on to say, "spirituality is related to personal dimensions", which you must clarify. The world's religions define spirituality is the relationship of the individual to the Divine, the Transcendent, which is not only a relationship but determines the ontology of the person and of the Divine. Religion addresses this collectively, historically, etc., and spirituality addresses this individually. The individual experiences religion collectively and externally, but experiences spirituality internally, as intrinsic, personally, privately. 

You go on, for example, to characterize 4 types of "spiritual needs" - which cannot be social because they are internal and individual. Emotional needs are emotional needs, not spiritual. If someone emotionally is depressed, it may have nothing to do with their spirituality. Existential needs may or may not be spiritual needs. Someone may be perfectly spiritually fulfilled but question why they exist. And religious needs are not spiritual needs. Religious needs are the need for community, socialization, doctrinal commonality, and may or may not be spiritual.

The subject of this study and paper - the spiritual and religions needs of people living with HIV - can not be a more important topic, and it is absolutely under explored and needs as much attention as it can get. Your paper is headed in the right direction. But you must identify and clarify - define and delimit - religion and spirituality, in order to know what you are researching. The spiritual practice of a person with HIV - or anyone - is substantially different from religious practice. An atheist who feels they have a personal spiritual experience is not in any way connecting with religion. They are experiencing their own personal, internal, spiritual selves. 

You must first clear this up, and only then can you go on with your study. Studying these two things are very different things and are studied very differently. You must set this forth first, because it is foundational to what follows. You have to have this foundation, because what you are trying to build on it is confused and unsteady without it. This is so important - in all respects, and you are to be congratulated for identifying it and saluted for tackling it, and it appears to be a very important study. But you cannot build it firmly without the foundation of religion as religion and spirituality as spirituality.

You also must determine clearly what you are studying - you name spiritual needs of HIV folks, spirituality and health, cultural competency for the sake of public policy, and many other subjects of study. What is the one thing you are looking at and for? If it has multiple aspects to it, fine, but you must determine what it is you are studying, and study it. It is not clear in your article, and you must make it clear and make it the core of how you do your  study and then you results based on it. 

I hope you will rethink, clarify, and rewrite, and I wish you the very best of luck with it! 

Author Response

Dear Reviewer 3

Thank you for your comments.

Please, see the attachment.

Sincerely

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

You have made some worthwhile revisions, but the basic issue of not understanding, and conflating, religion and spirituality remains.

At this point I suggest that there are two ways for you to go. First, succeed in distinguishing religion and spirituality, and then be clear about how you studied each of them, so that you have a result for religiosity and a result for spirituality. For example, you continue to say that religious experience is  one of the four characteristics of spiritual experience. This is confused and must be clarified. There is literature and are specific survey instruments to measure each for what it is. I reiterate that religion is social, collective, external, historic, doctrinal, and has specific public practice. Spirituality is individual, personal, internal experience unique to, and understood by, the individual alone who is having the inner experience.

The second way you could go may be more practical and expedient. Do not distinguish them at all, but put them together in one category and contrast them with other experiences, such as emotional and psychological, showing that "R/S" have impact that is different from other impacts. 

R and S both deal with the transcendent, and in some way with the Divine - the Supreme Spiritual Deity, or if Pagan or Pantheist, deities, whether in a religious person, spiritual person, or atheist. That is what distinguishes R + S, or, R/S, from other aspects of experience which are worldly- they deal with ultimate concerns, not worldly concerns. This is precisely what you need to show that is having an impact on folks with HIV, which is what makes your study so very important. You must either separate them, define them, and study them as the separate and distinct experiences and practices that they are- as in suggestion #1, or you should lump them together as you study subjects' relationship to the transcendent as this option #2. An atheist may consider themselves to be "spiritual" as they walk in the woods alone and transcend their worldly existence, but they would vehemently deny their participation in religion. They cannot be conflated. But, for the sake of getting your study - which is extremely important - to get published, you can combine them as "R+S" if you define them together as having the common characteristic of dealing with the person and the transcendent, which both R + S do. And you could put this over by contrasting R+S transcendent experiences of both kinds of transcendence, with experiences which are transformative - like emotional, or cognitive - but not transcendent. If you say R/S you are conflating them as being the same. If you say R+S you are taking them together as two distinct things which have a common characteristic which distinguishes them from everything else in human experience. 

Until you are clear on this, the study you layer on top of it is unclear and has tentative results. It should be clear and you should assert your results as important vs. results of other realms of human experience.  That is what your study really is doing. You need to get the foundation right, and everything else will fall into place. Please do! This is so important!

 

Author Response

Dear Reviewer 3

Thank you for your comments

See attached the answers.

Sincerely

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

1. The title of the article is consistent with its content.
2. The abstract is well prepared. It is worth adding that the classification of the social, emotional, existential and religious needs viewed as the dimensions of spiritual needs is based on Bussing and Koenig model.
3. The introduction is short and concise but it contains key information concerning the content analysed in the article.
4. The text contains small punctuation mistakes (e.g. line 96 –  the sentence ends with a comma instead of a stop). 
5. Materials and methods are clearly and sufficiently described.
6. The results of systematic review are clear and orderly – they are presented in a readable way.
7. Conclusions are correct but quite general. I would suggest completing them with more detailed deductions from the analyses conducted.
8. I highly appreciate both the substantive content of the article as well as the way the content is presented.

Reviewer 2 Report

This paper offers a systematic review of 2008-2018 publications regarding spiritual needs and religious needs expressed by people affected by HIV. Findings indicate that the relationship between spirituality and health in the field has been under-investigated, although the results of this study show a trend toward expressing such needs. The main contribution of this paper might lie in the suggestion of a need for investigation of the variations among cultures and the multifaceted aspect of spirituality/spiritual needs, although such aspects are not well defined in the study. Overall, the paper needs extensive editing and re-writing so that it is delivered in the format and the language of a scientific paper. The abstract is sufficiently well written. As it stands, the study has several major methodological flaws and lacks scientific rigour in its execution. 

Below are the major areas of improvement that this paper should undergo before moving toward publication.

• the manuscript should undergo extensive English revision.
• Citation style: the paper often uses incorrect citation style and one that is inconsistent with the reference list. For example, line 67: why using capital letters for the author? Also, in case of multiple authors, “XX and cols…” should be edited into “XX et al.”
• Key concepts used for the systematic review should be better defined. If the author(s) focus on religion/spirituality as coping strategies for chronic patients and how needs for such coping strategies are articulated, then the paper should offer e better definition of “religious/spiritual coping strategy”: what are the components? What does it entail? What does the extant literature say about it?
• Line 21: “chronicity character”. This is primarily what affects people affected by HIV and relates with the topic of the study, therefore this ‘chronicity’ and its relation to life quality of PLWHIV and spiritual needs should be better discussed.
• 25: WHOQOL- HIV (World Health Organization, 2003): what are the indicators offered by WHO? Why do the author(s) think that such indicators have not been sufficient to improve life quality in HIV patients?
• In relation to the above, although the author(s) clarifies in ll. 102-106 that they are not interested in looking at “quality of life” but on “spiritual needs”, which precedes the analysis of the impact of R/S on the quality of life, a better definition of ‘quality of life’ and a better discussion for excluding such component from the analysis should be added. Moreover, author(s) should clarify how they distinguished between ‘spiritual needs’ from ‘quality of life’ in their exclusion criteria, since spiritual needs might be discussed papers dealing with quality of life.
• Definition of religion and spirituality. The key definitions of religion and spirituality as expressed in the two paragraphs (ll.29-42) are not very accurate and make inconsistent use of some terminology. A very simple definition of religion cannot only include “beliefs” (l.29). I believe Koenig defined religion as “beliefs, practices, and rituals related to the transcendent” or an equivalent definition. A religious community is also a component of religion, along with collective and individual rituals. Most importantly for this study, religion entails specific beliefs about life after death and rules about conduct within a social group. As such, religion holds a multidimensional construct that includes beliefs, behaviors, rituals, and ceremonies that may be held or practiced in private or with others. Elements of social capital, trust and social cohesion come into play when people practice religion. I think that all these components should be offered in the definition of religion in the paper, along with a discussion of the impact that religion holds on people with health condition. Similarly, spirituality should be better defined. It may be or may not related to organized religion, as the author’s) suggest in lines 31-32, but the definition that is offered in ll. 32-44 is not well articulated. There is abundant literature on the relation between religion, spirituality and health that might help formulate a suitable definition of religion and spirituality. I recommend that the author(s) offer references to the latest development and trends in research output in such regard. A few good sources are Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York: Oxford University Press; 2001; Lucchetti G, Lucchetti AL. Spirituality, religion, and health: over the last 15 years of field research (1999-2013). Int J Psychiatry Med. 2014;48(3):199-215; Lucchetti, Giancarlo, Prieto Peres, Mario Fernando, Damiano, Rodolfo Furlan (Eds.) 2019. Spirituality, Religiousness and Health
• Lines 29-30. Related to this, what is meant by “transcendental practice”? Does it indicate “meditation practice”? If so, the correct terminology should be used and an explanation should be given of it.
• 33-36: “the way by 33 which individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.“ If this is a quotation from Puchalski et al 2014, quotation marks should be used an page number added.
• Line 47: why is there a footnote reference “13”? Where is the footnote?
• Lines 49-51. Paragraph transition should be better structured. This paragraph deals with Engel’s (1978) biopsychological model, however, the transition from the previous paragraph which deals with the definition of spirituality is not clear. Also, a short description of Engel’s (1978) biopsychological model is needed to understand its relationship with the topic of the study.
• Line 53: here the author(s) introduce the concept of chronic disease care. The notion of “spiritual care” in the medical/clinical setting should be addressed since it closely related with the growing inclusion of such care in treatment of patients mental and emotional health.
• Line 63: “This questionnaire avoids the (a) of religious terminology”. What does (a) stands for? This sentence is not clear.
• Lines 71-72: “Despite that the spiritual needs (SN) can be a source of support and resilience.” Language use. Moreover, this sentence is not clear. How can spiritual needs be source of support and resilience given that the status of “need” is a pre-satisfied condition?
• Related to the above, since “spiritual needs” is the core topic of this study, a better definition of what the author(s) will include in such “spiritual needs” is needed. Koenig and Bussing’s definition is a good start, but the author(s) should clearly lay out what key terms they identified that guided their review.
• Lines 76-77: “to see if they fit to classify the results”: here we have a methodological problem. The meaning of this sentence is that Koenig and Bussing’s classification is tested, however, the author(s) assert above that the same Koenig and Bussing’s classification is used to review literature. The author should clarify if they are testing Koenig and Bussing’s classification and the rationale for that, or whether their findings will be then tested against Koenig and Bussing’s classification.
• Line 81: citation style: Moher and cols, 2009
• Lines 83-92: a more detailed explanation of descriptors should be given here. Beyond the general descriptors, what specific search words or expressions where used for the search? Moreover, since there was no clear explanation of what is meant by “spiritual needs” in the introduction, it is still unclear what vocabularies/concepts the search included/excluded.
• Line 96: regarding databases searched, the author(s) include Google Scholar for the systematic review. Although Google Scholar may be used as an initial tool helping to quantify the number of studies that might meet the search criteria, it should not be included in the investigation. Pubmed, Web of Science and others included by the authors are human-curated databases, meaning that journals and articles are selected for inclusion by humans based on scholarly and quality criteria by literature review committees. In contrast, Google Scholar is not a human-curated database but a search engine of the whole internet, thus it narrows the results to "scholarly " ones based on machine-automated criteria. For this reason, for scientific rigour the entire investigation should be reframed upon clear search words and performed on human-curated databases. If the author(s) do include Google Scholar in the systematic review, they should offer clear rationale behind that, supporting their decision so that it meets rigour academic/scientific standards.  
• Lines 107-108: “The outcome measure of interest was any definitions of spiritual needs expressed by the participants of the studies”. This sentence is not clear. What is the measure of interest set upon?
• Line 116: “clients included”: who are the clients included?
• Line 117: “e) how the spiritual needs were 117 defined and expressed by individuals included in the studies”: this is a key point inn the methodology. Author(s) should give a breakdown of what search words they sued and the rationale for the selection of search words, also drawing upon the extant literature dealing with spirituality/religion/spiritual needs.
• Line 120: “This study was conducted between August 2018 and March 2019.” Repetition: this was already mentioned in the methodology section.
• Line 121: “1,399 studies”. This data is inconsistent with the data in Table 1, which indicates 1429 entries (line 215). Line 122 “363 article” is also inconsistent with the data on Table 1, which states “393” on line 224.
• Line 126 “37 articles were included in this review”. Inconsistency with Table 1, Line 246, which states “Articles included in the review: 38”
• Line 131: “Google Scholar originated the most of included references”. As mentioned above, Google Scholar
• Lines 141-142: “the research about the theme was present only 140 in public health, medicine, and psychology journals”. This finding needs more discussion in the discussion section since it clearly shows a trend of inclusion of spiritual practices in clinical settings.
• Lines 145-203. This is a good summary of findings and one that, at last, lists what search words were used by the author(s). As mentioned above, these search criteria should be included in the explanation of the methodology. The author(s) have already categorized findings according to major thematic areas (praying, individual vs collective religious practices, spiritual practices…). These categorizations are not supported by an explanation/discussion in the research methodology. Author(s) should clarify what criteria they used for classifying findings. If classification is based upon Koenig and Bussing’s classification, then a better explanation of what each category includes/excludes should be offered in the methodology section. Please see my comments in 16).
• Line 141: “and on”?: grammar
• Table 2: while the table offers a detailed summary of the systematic review, in the paper author(S) should offer a summary of findings, outlining the research characteristics. Also, a better layout for both Table 1 and 2 is recommended.  
• citation style. Inconsistencies: “XX et al.” vs “XX and cols)
• Table 2: “Impaired religiosity and spiritual distress”: what does “impaired religiosity” mean?
• Discussion: I recommend that author(s) include a table summarizing the thematic areas identified in the systematic review. Each major theme identified through the review should be discussed. The content of this Discussion section is too similar to the content of the Introduction section, and it lacks in-depth discussion of findings.
• 259-262. The author(s) mention again here of a “multidimensional comprehension” of spiritual needs. More explanation on what is meant should be included in the introduction and here author(s) should discuss whether such multidimensionality is supported by their findings. Also, to be included in the discussion is the impact/relevance of the SpNQ: how many of the reviewed articles used the Spiritual Needs Questionnaire (SpNQ) formlated by Koenig and Bussing? To what extent is this questionnaire used/not used? Why?
• Line 264: “expressing their needs in diverse ways and cultures”. It is still unclear how they “expressed” their spiritual needs since there is a lack of definition of spiritual needs and how it was searched and detected in the extant literature author(s) have reviewed.
• Lines 270-271: this paragraph is misplaced. This should be part of the research background/literature review. I recommend the author(s) they reorganize the paper so that each section comply with the requirements of academic papers.
• 289-296: these two paragraphs should be part of the discussion, and author(s) should articulate more in-depth the results of such findings, also in reference to the extant literature in the field.
• Line 293 “calls” is misspelt

Reviewer 3 Report

This is a very interesting and important research. Well written and well organised. There are, however, a few shortcomings.

Quotation marks are missing when the authors refer to the definition of Puchalski (p 1, l 33)

“Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred”.

See:  

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038982/

is the aspect of humanity that refers to the way by which individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.

 

This is a literal quote (on p 1) without quotation marks. In my university, this counts as clear plagiarism with severe punishments.

 

The classification of Koenig -Büssinig is used, without much further theoretical reflection on this measure.

 

Publications included are already old: until December 2018

Why not take into account 2019 and 2020?

 

Inclusion criteria:

Only articles available free of charge on the internet. This might be a limitation. Further reflections on limitations are encouraged.

 

On p 3 l 134 it suddenly becomes apparent that the authors are from Brazil/have a particular interest in Brazil. This should probably be clear from the beginning, otherwise it is a bit weird to have this sudden stress on Brazil on p 3

P 3:

Regarding the definition of spiritual needs in the selected studies, the results showed

a predominance of aspects related to religiosity. The individual prays were the most mentioned (Arrey et al., 2016; Caixeta et al., 2012; Dalmida et al., 2012; Emlet et al., 2018; Espirito Santo et al., 2013; Grodensky et al., 2015; Hodge & Roby, 2010; Hussen et al., 2014; 148Ironson et al., 2016; Kremer & Ironson 2009; Lee et al., 2014; Löckenhoff et al., 2009; 149Lowther et al., 2018; Metaweh et al., 2016; Molzahn et al., 2012; Perez-Giraldo et al., 2012; 150Peterson et al., 2011; Pinho et al., 2017; Ridge et al.,

 

It is unclear what it means ‘regarding the definition’ and then ‘predominance’. Does this mean that there are more studies about religiosity or does it mean that religious needs are dominant (in reality). This is a difference, and should be explained more.

 

The English might need a profound revision – I recognize sentences that are clearly not written by native speakers, and I think the general English can be improved.

 

It might be good to add some reflection on the relationship between spiritual needs (in the scale of Bussing) and the definition of spirituality by Puchalski

 

“The present study through a systematic review aimed to summarize how the spiritual needs are defined by PLWHIV.” P 18

This is not correct. The study uses a definition of spiritual needs and checks whether these aspects are found in the studies, but it does not ask how patients themselves define spiritual needs.

 

Conclusions are limited. Suggestions for further research/practice could be added.