May 2009 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Kremer, H., Ironson, G. and Kaplan, L. "The fork in the road: HIV as a potential positive turning point and the role of spirituality." AIDS Care 21, no. 3 (Mar 2009): 368-377.
SUMMARY and COMMENT: The article begins with a quote from a study participant: "HIV made me ask the question: What I am going to do in my life?" [p. 368] --illustrating a basis for how some patients may come to experience HIV as a turning point --a "dramatic transformation occur[ing] in an individual's attitudes, behaviors, beliefs (including spiritual beliefs), or self-views" [p. 368]. The authors address three questions:
- Do people with HIV perceive their disease as the key positive/negative turning point in their lives?
- Are spiritual, demographic, or medical characteristics associated with this perception?
- What are the perceived antecedents and consequences of viewing HIV as the key positive/negative turning point? [p. 369]
This research analyzed interviews from 147 individuals in two groups: one from a longitudinal study of people with chronic HIV disease, and one from a "purposeful sample of people with HIV who considered themselves as spiritual or who had a spiritual experience" [p. 369] Interviews lasting 1-2 hours (with one lasting 3 hours) were audiotaped.
…[W]e interviewed the participants asking whether they ever had an experience that profoundly changed or impacted their lives. If so, we asked what changed (consequences) and what initiated the change (antecedents). If HIV and/or spirituality were not mentioned spontaneously, follow-up questions determined how HIV changed their life, and how their spirituality changed after HIV diagnosis and whether spirituality was involved in the key turning point. Additional interview questions addressed amongst others whether the participants ever had a spiritual experience, believed in a reason on a larger spectrum for getting (apart from the immediate risk factors), and whether they had ever felt close to death (probing if this experience qualified as a near-death experience).
Among the results:
Surprisingly, our study found that 26% (chronic disease sample 20%, spiritual sample 31%) perceived that HIV triggered the most powerful and positive turning point in their lives. This was often accompanied by changes in priorities, and by enhancing altruism, relationships, self-perceptions, and a healthy lifestyle. Perceiving HIV as the key positive turning point was associated with an enhanced spirituality after the HIV diagnosis and the belief of being chosen by a Higher Power to have HIV….
…Participants who perceived themselves as hitting rock bottom with drugs and alcohol often viewed HIV as a "wake-up call" from God/Higher Power that helped them to positively transform their lives….
…Interestingly, we observed that only 11% (chronic disease sample 15%, spiritual sample 7%) viewed their HIV diagnosis as the worst turning point in their lives. Negative life changes encompassed mainly depression, hopelessness, irritability, hostility, negative self-view, issues in relationships, and turning to substance use. Participants viewing HIV as the most traumatic life event mostly described a disengagement from their spirituality. … Our study adds to the literature by demonstrating that viewing HIV as the most traumatic life event is associated with a decrease in spirituality after diagnosis. …Notably, we observed that dramatic negative changes attributed to HIV were sometimes temporary, and that experiencing a life-threatening situation or hitting rock bottom due to HIV, in turn, triggered a secondary positive transformation many years later. [p. 374]
…37% (55/147) had an increase, 53% (78/147) no change, and 10% (14/147) a decrease in spirituality after their HIV diagnosis. The direction of the change in spirituality was significantly associated with the direction of the turning point (e.g., a positive turning point was significantly associated with an increase, no turning point with no change, and a negative turning point with a decrease in spirituality after diagnosis). …In addition, participants who perceived HIV as the key negative turning point vs. those who did not, were significantly less likely to pray daily….
And one particular set of findings about Near Death Experiences:
…Perceiving HIV as the key turning point (positive/negative/not) was not associated with reporting spiritual experiences…(although 69% (102/147) reported one or more spiritual experiences) or with any demographic or medical characteristic. [p. 371].
Overall, 20% (29/147) reported an AIDS-related near-death experience. All seven participants with an AIDS-related near-death experience and HIV as the key negative turning point, perceived their diagnosis as negative, but not their near-death experience. Moreover, 40% (6/15) of those perceiving HIV as positive, despite feeling close to death due to their disease, reported that their near-death experience was their most positive life change.
While a total of 37% of participants identified HIV as either a positive or negative turning point, it seems significant that 63% indicated that they did not experience a key turning point that was HIV-related. The authors speculate that this latter finding regarding the majority of participants might be the result of "a normalization of HIV in the era of effective HIV treatments" [p. 374], observing that the development of effective treatments in 1996 "transformed an HIV diagnosis from a virtual death sentence into living with a chronic disease" [p. 368].
The qualitative data is well summarized, but three case vignettes [--see pp. 373 and 375] illustrate in personal terms the stories of the participants. Quantitative data is presented clearly in the text and in six particularly helpful tables. There is a great deal of information here to be mined for future research, but the authors have an eye for clinical application. They encourage clinicians to think of how an HIV diagnosis could be viewed by some patients as a "chance for change" [p. 376] and a positive as well as a negative turning point. Chaplains/clergy are not mentioned explicitly, but the authors' suggestion that their findings should help in counseling patients has obvious pertinence. The theme of turning points is often key in patients' stories of a spiritual journey, when specific events and/or decisions are recalled sometimes as starkly as the proverbial fork in the road. This research helps to contextualize the place of turning points for patients following an HIV diagnosis, to highlight the potential role of spirituality, and to hold out the prospect that even "negative" turning points can give way to "positive" ones.
Suggestions for the Use of the Article for Discussion in CPE:
Since the most obvious theme here is that of "turning points" or "forks in the road" for patients, students may wish to address this broadly and personally: How do students identify with such concepts in terms of their own life story (regardless of whether their own "turning points" involved a health crisis)? Do they find utility in identifying key points along the many twists and turns of one's life. Perhaps one exercise that could accompany the discussion would be to complete a Lifemap using the model of David Hodge [--see Hodge, D. R., "Spiritual Lifemaps: a client-centered pictorial instrument for spiritual assessment, planning, and intervention," Social Work 50, no. 1 (January 2005): 77-87]. Another approach would be to consider the value of potential patterns or trajectories of patients' experiences affecting spiritual needs [--see Related Items of Interest, below]. How might a chaplain's knowledge of typical patterns in the illness-experience of patients be illuminating or prejudicial for the provision of pastoral care? A third way to address this material would be to focus on the experience of the HIV+ patient in particular. Spirituality is a strong theme in the HIV+ and AIDS literature [--see Related Items of Interest, below]. A nurse or physician could be invited to participate in the article discussion and to comment on their observations of the role of spirituality in addition to turning points in patients' lives after diagnosis.
Related Items of Interest:
I. The concept of "turning points" is not far removed from that of "illness trajectories." Regarding the latter, see the November 2007 Article of the Month page. The articles there focus on end-of-life care rather than the experience of patients with a largely manageable disease like HIV, but they raise questions about tracing common patterns in patients experiences and needs.
II. For more on Near Death Experiences, see the May 2006 Article of the Month page.
III. For more on "turning points" per se, see the following (in addition to those cited in the bibliography of this month's article):
Agrimson, L. B. and Taft, L. B."Spiritual crisis: a concept analysis." Journal of Advanced Nursing 65, no. 2 (Feb 2009): 454-461. [(Abstract:) AIM: This paper is a report of an analysis of the concept of spiritual crisis. BACKGROUND: The term spiritual crisis has been used ambiguously in the literature, resulting in lack of clarity. A holistic approach includes spirituality in nursing care of the whole person. DATA SOURCES: Papers available online between 1998 and 2007 in the CINAHL, Medline and PsycInfo databases were retrieved for analysis. The search engine Google was also used to examine additional references to 'spiritual crisis'. REVIEW METHODS: Spiritual crisis, spiritual emergency and life crisis were the terms initially used to search each database. The search was expanded to include spirituality to draw more literature into the review. FINDINGS: Using Walker and Avant's method of concept analysis, a definition of spiritual crisis was identified. Spiritual crisis can be described as a unique form of grieving or loss, marked by a profound questioning of or lack of meaning in life, in which an individual or community reaches a turning point, leading to a significant alteration in the way life is viewed. Possible antecedents include sudden acute illness and loss of important relationships. Potential consequences may include physical and emotional responses. CONCLUSION: People with terminal illness, depression, and those who are grieving losses may be at special risk of spiritual crisis. The literature suggests an interdisciplinary approach, nurses' self-exploration of spirituality, and refraining from defining spirituality by religious affiliation as part of improving practice.]
Fiori, K. L., Hays, J. C. and Meador, K. G.
"Spiritual turning points and perceived control over the life course." International Journal of Aging and Human Development 59, no. 4 (2004): 391-420. [(Abstract:) Recent evidence indicates that spirituality and religion are associated with both physical and psychological health. Because a belief that rewards are largely determined by external forces tends to be detrimental to mental health, the idea that God can be equated with such an external force seems contradictory to the proven benefits of religion and spirituality. The purpose of this article is to examine changes in perceived control in the context of spiritual turning points as uncovered in the narrative histories of 30 elderly people. We propose that for many people who derive benefits from religion or spirituality, God may act as a mediator, in the sense that trusting in God provides personal control. In addition to creating a model of God-mediated control, the study's findings suggest a relationship between recall for type of control during a spiritual turning point and the interpretation of that turning point in late life.]
IV. One of the article's authors, Gail Ironson, is also the co-creator of the Ironson-Woods Spirituality/Religiousness Index. For more on this measure, see the February 2003 Article of the Month page.
V. The health care literature on spirituality and HIV/AIDS -- as a general topic -- is quite extensive. The following is a small sample of recent research articles.
Bormann, J. E., Aschbacher, K., Wetherell, J. L., Roesch, S. and Redwine, L. [Veterans Affairs San Diego Healthcare System, San Diego, CA]. "Effects of faith/assurance on cortisol levels are enhanced by a spiritual mantram intervention in adults with HIV: a randomized trial." Journal of Psychosomatic Research 66, no. 2 (Feb 2009): 161-71. [(Abstract:) OBJECTIVES: Previous research among HIV-infected individuals suggests that spiritual well-being is inversely related to psychological distress and rates of disease progression. Use of a mantram, a spiritual word or phrase repeated frequently and silently throughout the day, has been associated with decreased psychological distress and increased spiritual well-being. This study compared the effects of 2 interventions --a spiritually-based mantram intervention versus an attention-matched control group-on faith/assurance and average salivary cortisol levels among HIV-infected individuals. METHODS: Using a randomized design, HIV-infected adults were assigned to the intervention (n = 36) or control condition (n = 35). Faith scores and saliva (collected at 7 a.m., 11 a.m., 4 p.m., and 9 p.m.) were assessed at preintervention, postintervention, and 5-week follow-up. Path analyses tested competing models that specify both concurrent and sequential relationships between faith and average daily cortisol levels while comparing groups. RESULTS: Faith levels increased among mantram participants from pre- to postintervention. Greater faith at preintervention was significantly associated with lower average cortisol at postintervention in the mantram group but not in the controls. The associations between faith at postintervention and cortisol levels at 5-week follow-up were significant among both groups but weaker than the pre- to postintervention association identified in the mantram group. CONCLUSIONS: These results suggest the presence of lagged or antecedent consequent relationships between faith and cortisol, which may be enhanced by mantram use. Decreased cortisol could potentially benefit immune functioning among HIV-infected individuals.]
Cotton, S., Puchalski, C. M., Sherman, S. N., Mrus, J. M., Peterman, A. H., Feinberg, J., Pargament, K. I., Justice, A. C., Leonard, A. C. and Tsevat, J. [Health Services Research & Development, VA Medical Center, Cincinnati, OH]. "Spirituality and religion in patients with HIV/AIDS." Journal of General Internal Medicine 21, Suppl 5 (Dec 2006): S5-S13. [(Abstract:) BACKGROUND: Spirituality and religion are often central issues for patients dealing with chronic illness. The purpose of this study is to characterize spirituality/religion in a large and diverse sample of patients with HIV/AIDS by using several measures of spirituality/religion, to examine associations between spirituality/religion and a number of demographic, clinical, and psychosocial variables, and to assess changes in levels of spirituality over 12 to 18 months. METHODS: We interviewed 450 patients from 4 clinical sites. Spirituality/religion was assessed by using 8 measures: the Functional Assessment of Chronic Illness Therapy-Spirituality-Expanded scale (meaning/peace, faith, and overall spirituality); the Duke Religion Index (organized and nonorganized religious activities, and intrinsic religiosity); and the Brief RCOPE scale (positive and negative religious coping). Covariates included demographics and clinical characteristics, HIV symptoms, health status, social support, self-esteem, optimism, and depressive symptoms. RESULTS: The patients' mean (SD) age was 43.3 (8.4) years; 387 (86%) were male; 246 (55%) were minorities; and 358 (80%) indicated a specific religious preference. Ninety-five (23%) participants attended religious services weekly, and 143 (32%) engaged in prayer or meditation at least daily. Three hundred thirty-nine (75%) patients said that their illness had strengthened their faith at least a little, and patients used positive religious coping strategies (e.g., sought God's love and care) more often than negative ones (e.g., wondered whether God has abandoned me; P<.0001). In 8 multivariable models, factors associated with most facets of spirituality/religion included ethnic and racial minority status, greater optimism, less alcohol use, having a religion, greater self-esteem, greater life satisfaction, and lower overall functioning (R(2)=.16 to .74). Mean levels of spirituality did not change significantly over 12 to 18 months. CONCLUSIONS: Most patients with HIV/AIDS belonged to an organized religion and use their religion to cope with their illness. Patients with greater optimism, greater self-esteem, greater life satisfaction, minorities, and patients who drink less alcohol tend to be both more spiritual and religious. Spirituality levels remain stable over 12 to 18 months. (This article is part of the journal's special theme issue on spirituality and HIV/AIDS.)]
Fitzpatrick, A. L., Standish, L. J., Berger, J., Kim, J. G., Calabrese, C. and Polissar, N. [Department of Epidemiology, University of Washington, Seattle]. "Survival in HIV-1-positve adults practicing psychological or spiritual activities for one year." Alternative Therapies in Health & Medicine 13, no. 5 (Sep-Oct 2007): 18-20, 22-24. [(From the abstract:) …Nine hundred one HIV+ adults living in the United States using at least 1 form of complementary and alternative medicine (CAM) completed a questionnaire 3 times between 1995 and 1998. Information on specific mind-body therapies included psychotherapy (group therapy, support groups, individual therapy) and spiritual therapies (self-defined "spiritual" activities, prayer, meditation, affirmations, psychic healing, visualizations). Subsequent death was ascertained from the National Death Index (NDI). …RESULTS: Use of any psychological therapy reported in both the 6- month and 12-month follow-up questionnaires (1 year continuous use) was associated with a reduced risk of death…adjusted for income, clinical acquired immune deficiency syndrome, CD4 count, smoking, alcohol use, and use of antiretroviral therapy or highly active antiretroviral therapy (HAART). The relationship between spiritual activities and survival was modified by use of HAART, which may reflect severity of illness. Individuals not currently using HAART and who participated in spiritual activities over the previous year were found to be at a reduced risk of death...compared to those not practicing spirituality. CONCLUSIONS: Participation in spiritual and psychological therapies may be related to beneficial clinical outcomes in HIV+ individuals, including improved survival….]
Ironson, G., Stuetzle, R., Fletcher, M. A. [Dept. of Psychology, University of Miami, FL]. "An increase in religiousness/spirituality occurs after HIV diagnosis and predicts slower disease progression over 4 years in people with HIV." Journal of General Internal Medicine 21, Suppl 5 (Dec 2006): S62-68. [(Abstract:) BACKGROUND: Most studies on religion/spirituality predicting health outcomes have been limited to church attendance as a predictor and have focused on healthy people. However, confronting a major medical crisis may be a time when people turn to the sacred. OBJECTIVE: The purpose of this study was to determine the extent to which changes in spirituality/religiousness occur after HIV diagnosis and whether changes predict disease progression. DESIGN/PARTICIPANTS: This longitudinal study examined the relationship between changes in spirituality/religiousness from before with after the diagnosis of HIV, and disease progression (CD4 and viral load [VL] every 6 months) over 4 years in 100 people with HIV. Measures included change in religiousness/spirituality after diagnosis of HIV, religiousness/spirituality at various times in one's life, church attendance, depression, hopelessness, optimism, coping (avoidant, proactive), social support, CD4/VL, and health behaviors. RESULTS: Forty-five percent of the sample showed an increase in religiousness/spirituality after the diagnosis of HIV, 42% remained the same, and 13% decreased. People reporting an increase in spirituality/religiousness after the diagnosis had significantly greater preservation of CD4 cells over the 4-year period, as well as significantly better control of VL. Results were independent of (i.e., held even after controlling for) church attendance and initial disease status (CD4/VL), medication at every time point, age, gender, race, education, health behaviors (adherence, risky sex, alcohol, cocaine), depression, hopelessness, optimism, coping (avoidant, proactive), and social support. CONCLUSIONS: There is an increase in spirituality/religiousness after HIV diagnosis, and this increase predicts slower disease progression; medical personnel should be aware of its potential importance. (This article is part of the journal's special theme issue on spirituality and HIV/AIDS.)]
Mock, K. S., Bopp, C. M., Dudgeon, W. A. and Hand, G. A. [University of South Carolina, College of Nursing, Columbia, SC]. " Spiritual well-being, sleep disturbance, and mental and physical health status in HIV-infected individuals ." Issues in Mental Health Nursing 27, no. 2 (Feb-Mar 2006): 125-139. [(From the abstract:) …This descriptive, correlational study examined the relationships among spiritual well-being, sleep quality, and health status in 107 HIV-infected men and women. Spiritual well-being was found to be a significant factor related to both sleep quality and mental and physical health status. Every study participant reported sleep disturbance. The findings suggest that spiritual well-being and sleep quality need to be assessed so appropriate interventions can be implemented to improve health outcomes in this population.]
Parsons, S. K., Cruise, P. L., Davenport, W. M. and Jones, V. [Nelson Mandela School of Public Policy and Urban Affairs, Southern University, Baton Rouge, LA]. "Religious beliefs, practices and treatment adherence among individuals with HIV in the southern United States." AIDS Patient Care & Studies 20, no. 2 (Feb 2006): 97-111. [(Abstract:) Nonadherence with medical treatment is a critical threat to the health of those living with HIV disease. Unfortunately the search for explanatory factors for nonadherence is still not fully developed, particularly in the area of religion and spirituality. Extant literature suggests that church attendance, religious practices and spiritual beliefs may improve health and generally benefit patients. However, religious beliefs may also play a negative role in treatment adherence due to the stigma attached to HIV disease, particularly in geographical areas and in population subgroups where religious practices are strong. In this exploratory study, HIV-positive individuals (n = 306) in a southern state were surveyed as to their attitudes and beliefs surrounding HIV disease and adherence with medical treatment for the disease. The results indicate that multiple factors influence adherence with treatment and that certain religious practices are positively associated with adherence, but certain religious beliefs are negatively related to adherence. The findings of this study reinforce the importance of remembering and addressing a patient's religious beliefs as a part of medical care.]
Perez, J. E., Chartier, M., Koopman, C., Vosvick, M., Gore-Felton, C. and Spiegel, D. [Department of Psychology, University of Massachusetts, Boston]. "Spiritual striving, acceptance coping, and depressive symptoms among adults living with HIV/AIDS." Journal of Health Psychology 14, no. 1 (Jan 2009): 88-97. [(Abstract:) We prospectively examined the effects of spiritual striving, social support, and acceptance coping on changes in depressive symptoms among adults living with HIV/AIDS. Participants were 180 culturally diverse adults with HIV/AIDS. Participants completed measures of spiritual striving, social support, coping styles, and depressive symptoms at baseline, three-month follow-up, and six-month follow-up. A path model showed that spiritual striving had direct and indirect inverse effects on changes in depressive symptoms. The relationship between spiritual striving and depressive symptoms was partially mediated by acceptance coping, but not by social support. Results suggest that people living with HIV/AIDS who strive for spiritual growth in the context of their illness experience less negative affect.]
Polzer Casarez, R. L. and Miles, M. S. [School of Nursing, University of Texas Health Science Center at Houston]."Spirituality: a cultural strength for African American mothers with HIV." Clinical Nursing Research 17, no. 2 (May 2008): 118-132. [(From the abstract:) …This qualitative descriptive study used secondary data of interviews from a larger longitudinal study of parental caregiving of infants seropositive for HIV. Participants were 38 African American mothers with HIV. Data from longitudinal semi-structured interviews were analyzed using content analysis. The women dealt with the stresses of HIV through a relationship with God. Two domains explain this relationship: God in control and God requires participation. The benefits of their relationship with God were a decrease in stress and worry about their own health and that of their infants. It is important for nurses working with mothers with HIV to acknowledge their spirituality and assess how spirituality helps them cope with and manage their illness.]
Ross, R., Sawatphanit, W. and Suwansujarid, T. [Kent State University]. "Finding peace (Kwam Sa-ngob Jai): a Buddhist way to live with HIV." Journal of Holistic Nursing 25, no. 4 (Dec 2007): 228-235. Discussion on pp. 236-237. [(From the abstract:) …Seven HIV-positive postpartum, Buddhist, Thai women were interviewed. Principles of hermeneutic phenomenology guided the study. FINDINGS: All women in the study practiced spiritual activities based on their understanding of three central Buddhist beliefs: karma, the Five Precepts, and the Four Noble Truths. These beliefs played a major role in helping them to deal with their infection. Meditating, praying, and doing good deeds are examples of spiritual activities they practiced. All participants maintained that their beliefs and practices allowed them to feel peaceful and that their ultimate goal in life is to find peace (Kwam Sa-ngob Jai)….]
Szaflarski, M., Neal Ritchey, P., Leonard, A. C., Mrus, J. M., Peterman, A. H., Ellison, C. G., McCullough, M. E. and Tsevat, J. [Institute for the Study of Health, University of Cincinnati, Cincinnati, OH]. "Modeling the effects of spirituality/religion on patients' perceptions of living with HIV/AIDS." Journal of General Internal Medicine 21, Suppl 5 (Dec 2006): S28-38. [(From the abstract:) …In 2002 and 2003, as part of a multicenter longitudinal study of patients with HIV/AIDS, we collected extensive demographic, clinical, and behavioral data from chart review and patient interviews.… SUBJECTS: Four hundred and fifty outpatients with HIV/AIDS from 4 sites in 3 cities. MEASURES: The dependent variable was whether patients felt that life had improved since being diagnosed with HIV/AIDS. Spirituality/religion was assessed by using the Duke Religion Index, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-Expanded, and Brief RCOPE measures. Mediating factors included social support, self-esteem, healthy beliefs, and health status/health concerns. RESULTS: Approximately one-third of the patients felt that their life was better now than it was before being diagnosed with HIV/AIDS. A 1-SD increase in spirituality/religion was associated with a 68.50% increase in odds of feeling that life has improved 29.97% due to a direct effect, and 38.54% due to indirect effects through healthy beliefs (29.15%) and health status/health concerns (9.39%). Healthy beliefs had the largest effect on feeling that life had improved; a 1-SD increase in healthy beliefs resulted in a 109.75% improvement in feeling that life changed. CONCLUSIONS: In patients with HIV/AIDS, the level of spirituality/religion is associated, both directly and indirectly, with feeling that life is better now than previously. (This article is part of the journal's special theme issue on spirituality and HIV/AIDS.)]
Tarakeshwar, N., Khan, N. and Sikkema, K. J. [Department of Epidemiology and Public Health, Yale University, New Haven, CT]. "A relationship-based framework of spirituality for individuals with HIV." AIDS & Behavior 10, no. 1 (Jan 2006): 59-70. [(Abstract:) Twenty HIV-positive individuals (10 male, 10 female) participated in interviews on their spiritual life. Interview themes suggest that the HIV diagnosis facilitated a relationship-based framework of spirituality. Relationships that formed this framework were: relationship with God/Higher Power, renewed engagement with life, and relationship with family. Within "relationship with God/Higher Power," subthemes included gratitude for God's benevolent influence, spiritual struggles, and building connections with their Higher Power. Self care, transformation of life goals, and accepting mortality were subthemes for "renewed engagement with life." Subthemes within "relationship with family" included finding a sense of purpose, finding support through families, and families as a source of strain. Overall, results suggest that interventions that integrate spirituality need to consider a notion of spirituality that goes beyond church attendance, prayer, and Bible reading. These interventions must include the positive aspects of spirituality and spiritual struggles that individuals with HIV may experience.]
Tuck, I. and Thinganjana, W. [Virginia Commonwealth University, School of Nursing, Richmond]. "An exploration of the meaning of spirituality voiced by persons living with HIV disease and healthy adults." Issues in Mental Health Nursing 28, no. 2 (Feb 2007): 151-166. [(Abstract:) Spirituality has been documented in several studies as having a positive effect on chronic disease progression and as being efficacious in improving quality of life and well being. In many studies, researchers have used predetermined definitions of spirituality and have proscribed the variable by the selection of measures. This study examines the meaning of spirituality as voiced by participants in two ongoing intervention studies, a sample of healthy adults and a sample of persons living with HIV disease. The findings resulted in six themes for each sample. Exhaustive statements were written depicting the summary relationships of themes. The findings support spirituality as an essential human dimension.]