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. Author manuscript; available in PMC: 2008 Jan 19.
Published in final edited form as: Issues Ment Health Nurs. 2007 Feb;28(2):151–166. doi: 10.1080/01612840601096552

AN EXPLORATION OF THE MEANING OF SPIRITUALITY VOICED BY PERSONS LIVING WITH HIV DISEASE AND HEALTHY ADULTS

Inez Tuck 1, Wantana Thinganjana 1
PMCID: PMC2211367  NIHMSID: NIHMS37157  PMID: 17365165

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.

Spirituality plays an important role in the lives of persons living with HIV disease. Studies indicate that spirituality is a major factor in the ability to cope with illness (Fryback & Reinert, 1999; Highfield, 1999; Koenig, 2004; Koenig, Pargament, & Nielsen, 1998; Sowell et al., 2000; Targ & Levine, 2002; Tuck, McCain, & Elswick, 2001). Other studies report that spirituality is a key contributor to well-being (Coyle, 2002; Torosian & Biddle, 2005; Walton & Sullivan, 2004). The purpose of this article is to describe the meaning of spirituality as expressed by participants enrolled in a larger, funded, HIV project (McCain, RO1 AT00331). That project tested the effectiveness of stress management interventions on illness outcomes; a second study explored stress reduction in a convenience sample of healthy adults. Qualitative data were solicited from the participants in these two studies independently using identical questions and data collection methods for both samples. The exploration of the meaning of spirituality will help investigators develop operational definitions of the term and facilitate the development of improved measures for future empirical testing.

RELATED LITERATURE

Several qualitative studies indicate that spirituality is a significant factor that affects the psychosocial outcomes of HIV disease. Regan-Kubinski and Sharts-Hopko (1995) interviewed 38 women infected with HIV and found that effective coping was related to their spiritual commitment and a reexamination of spiritual beliefs. Kendall (1994), using a grounded theory approach, described the core process of wellness spirituality as essential to the health and well-being of 29 men with HIV infection.

A greater number of descriptive and exploratory quantitative studies have explored the relationship between spirituality and HIV disease. Sowell et al. (2000), in a study of 264 HIV-infected women, examined the role of spiritual activities as a coping resource within the context of HIV disease and found that spiritual activities were negatively correlated with emotional distress and positively correlated with quality of life, even after statistically adjusting for physical condition. Other studies have supported these findings (Coleman, 2004; Siegel & Schrimahaw, 2002; Tuck et al., 2001). Further, McCain et al. (2006) assessed the effects of a spiritual intervention with persons with HIV disease in a five-year clinical trial. The researchers found that upon completion of the intervention, the participants in the spiritual growth group had increased cytokine production, increased lymphocyte proliferation and increased NKC cytotoxicity function (p ≤ 0.05).

A few studies have explored the relationship between spirituality and wellness. Kass et al. (1991) reported spirituality to be a contributor to positive health outcomes and wellness. A study conducted by Kim and Seidlitz (2002) supports the beneficial effects of spirituality on health. Peri (1995) reported that having a greater awareness of one’s spirituality resulted in increased spiritual well-being.

Spirituality is a significant factor in the everyday lives of adults. A recent Gallup poll indicates that 95% of Americans believe in God or a Higher Power (Gallup & Lindsay, 1999). Eighty-two percent of the respondents reported that they felt they needed to experience spiritual growth. Spiritual development is thought to be an important factor in the aging process and contributes to increased emphasis on spirituality among older adults (Siegel & Schrimshaw, 2002).

Although several studies describe the relationships among spirituality, coping, and wellness, there have been few studies that have asked individuals to define spirituality and discuss its meaning (Coward, 1994; Coward & Lewis, 1993; Hall, 1998). Several review articles described the lack of consensus on the definition of spirituality and identified this as a methodological issue that limits empirical inquiry. The authors of these reviews proposed conceptual definitions derived from the available literature to remedy this deficit (Burkhardt, 1989; Emblen, 1992). Although definitions grounded in the literature are a significant advancement, the grounding of definitions of spirituality in participants’ responses across health status and gender also is necessary. As the area of inquiry matures, having knowledge of the meaning of spirituality from the voices of participants will enhance our understanding of the phenomenon and strengthen our resolve to promote spiritual growth and well-being in a relevant way.

METHOD

Data Collection and Sample

This report focused on the content analysis of the responses of 75 persons living with HIV disease and a comparison group of self-defined healthy adults (N = 27). The data were collected from several groups of HIV patients representing two geographical locations in the Commonwealth of Virginia that report a high incidence of the disease. The participants were enrolled in a federally funded study designed to determine whether three short-term stress management interventions (cognitive focused meditation, focused tai chi training, and spiritual growth groups—SPIRIT-10©), along with booster strategies, would improve psychosocial functioning, quality of life, and physical health among persons with varying stages of HIV disease. The participants were randomly assigned to one of the interventions or to a wait-list control group. The randomly assigned sample of persons living with HIV enrolled in SPIRIT-10© was composed of 28 females and 47 males who ranged in age from 21–63 years (mean age was 41 years). Fifty eight (77%) were African American. Years of education ranged from 6 to 24 years. Thirty three percent had less than high school education. Twenty eight (37%) were high school graduates, and 11 (15%) had some college education. Eleven participants were college graduates with four having graduate degrees. The mean education level was 12.32 years (see Table 1).

TABLE 1.

Demographic Characteristics of the Participants by Group Type

Group type HIV/AIDS participants Healthy participants
Sample size 75 27
Mean age 41 years 52 years
Gender
 Males 47 (63%) 3 (11%)
 Females 28 (37%) 24 (89%)
Race
 African American 58 (77%) 14 (52%)
 Caucasian 17 (23%) 12 (44%)
Other — 1 (4%)
Mean educational level 12.32 years 17 years
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Qualitative data were collected from the participants enrolled in SPIRIT-10©, the spiritual growth group intervention. The conceptual development of the intervention has been described elsewhere (Tuck, 2004). During the first session of the ten-week intervention, participants were asked to respond to two questions: (1) what is the meaning of spirituality to you? and (2) how important is spirituality to you in your daily life? The open-ended questions were designed to allow participants to answer fully and allowed the facilitator of the intervention to better appreciate the diversity of the meanings of spirituality within the group and the religious affiliation or orientation of the group members. These questions also captured individuals’ perceptions of spirituality prior to any effect from the intervention. The interventionist was mindful of particular issues voiced by the participants related to these questions throughout the remainder of the intervention. The answers to these open-ended questions are the source of the data for the qualitative analyses reported here. It was assumed that the experience of living with HIV disease might reflect gender differences, so male and female groups were offered separately as part of the research design.

Groups were made up of 6–10 individuals, and participants shared their responses in the group setting in a “round robin” manner. Some participants took the opportunity to reflect on their responses to the questions prior to discussing them in the group by writing their answers on paper provided. Participants were encouraged to share their perspectives and were informed that there are no “right” or “wrong” answers to the questions. The responses were recorded anonymously and in great detail by the facilitator following the group session. Direct quotes were recalled and statements were recorded verbatim from the written responses. The facilitator and research assistant confirmed the accuracy of the recorded statements.

The healthy adults were participants in a pilot study conducted by the lead author to test the acceptability and feasibility of SPIRIT-6©, a six-week version of the spiritual growth group, offered as an intervention to promote wellness and reduce everyday stress. Twenty-seven community dwelling adults volunteered to participate in groups at three local churches (two predominantly Caucasian and one African American). A convenience sample of 24 females and 3 males participated in these mixed gender groups. The mean age of the sample was 52 years, 52% were African American, and there was a mean education level of 17 years. All participants were members of the Protestant faith except one participant who practiced Buddhism. Data were collected following the same procedure as in the other study. The group facilitator recorded participants’ responses to each question, using direct quotations as much as possible. The data were reviewed by the principal investigator to verify data integrity. The interventions were developed by the lead author, and the protocol for the initial sessions of both versions of the intervention is identical. Human subject protection was approved for both studies prior to the recruitment of participants and collection of data.

A limitation of the methodology is that the data are recalled by the two facilitators. Although responses were recorded immediately following the sessions and the accuracy of the data was insured by joint recall, audio taping the sessions would have allowed greater accuracy. The authors considered the effect of audiotaping on group dynamics at the first session. Audiotaping may warrant consideration in future studies. Although the themes and exhaustive statements were not taken back to the participants for review, the thorough analytic process and the consensus developed by the two investigators attest to the rigor of the process and the trustworthiness of the findings (Lincoln & Guba, 1985; Sandelowski, 1986). The precision of documentation, strict adherence to the method, and internal agreement between the investigators’ interpretations support the confirmability of the study’s findings (Mariano, 1995).

Data Analysis

The investigators had the unique opportunity to analyze data collected in the same manner from two populations capturing multiple realities. The presentation of data by gender and illness-wellness states supports the view that qualitative text is socially situated and culturally bound (Lincoln & Denzin, 2000). Content analysis was used to derive the categories and themes. According to Huttlinger (1998), content analysis is “a data analysis technique that is commonly used in qualitative research and focuses on structuring particular topics or domains on interest from unstructured data” (p. 121). The topics or specific domains of interest are descriptive names chosen by the researcher and are referred to as category labels or themes (Morse & Field, 1995). The qualitative data from the HIV gender specific groups were analyzed separately to derive the major themes and to determine if spirituality was defined differently by gender. The approach to these independent analyses undertaken by the investigators was identical for both female and male participants. The transcripts of the sessions were read several times by the investigators so they could become familiar with the data. Individual participant responses were written on index cards for use in sorting into categories and themes. The quantity of text allowed for manual manipulation of data. The co-author was a doctoral student new to qualitative analysis and this process was chosen as a teaching strategy. Through an iterative process, the investigators carefully analyzed the data. Distinct and overlapping themes emerged for female and male participants and are briefly described below.

The data from the male and female groups were later collapsed into one data set to explore the experience of spirituality for persons living with HIV disease as a chronic illness. Previously derived themes by gender were disregarded by the investigators, allowing new categories and themes to emerge from data independent of the earlier findings. The same procedure for data analysis described above was repeated for the combined data set representing the total sample of persons living with a chronic disease. The data for the healthy adults enrolled in the concurrent study were analyzed using features in Microsoft Word. Data were reviewed at least three times over several weeks to insure that the themes were exclusive and grounded in the data. Again, there were no presupposed themes. This allowed the categories and themes to emerge from the participants’ responses. Although both authors are familiar with the definitions of spirituality found in the literature, no a priori definitions were used to determine the themes from the data.

Finally, the analysis of data in an iterative and expanding manner is considered a strength of the study. The iterative pattern of returning to the data multiple times and the constant comparison of themes by the investigators were crucial to data analysis. The approach supports the view of multiple realities in qualitative research.

FINDINGS

Themes by Gender

In the initial round of content analysis, six themes were identified for the female participants in the HIV study. The six themes are: (1) Spirituality as a belief in God (a higher power or religion); (2) Spirituality as a channel that helps; (3) Spirituality as a source; (4) Spirituality expressed through actions such as praying, meditating, and attending church; (5) God is present and giving; and (6) Spirituality as one’s essence or center. The majority of the women reported their belief in God as important to the definition of spirituality. There were two references to spirituality in a broader context, as a relationships to God, self, others, and nature. Spirituality helped the women “get through the ups and downs.” Spirituality was a source of peace, comfort, strength, inspiration, and balance. Women viewed themselves as recipients of spirituality and in keeping with this perspective, the narrative descriptions were passive: “that which gives me peace” or “source of inspiration.” A large number of references to the presence of God were evident in these data.

Five themes were identified for the male participants. The five themes consisted of (1) Dimensions of spirituality: what spirituality is and is not, including a belief and relationship to God and religion and a connection to nature and a Higher Power; (2) Spirituality as a channel that guides and helps; (3) Spirituality as a force that shapes one’s being; spirituality inspires and “It makes me feel alive.”; (4) Spirituality expressed outwardly through activities done to express and maintain spirituality; and (5) Spirituality as a journey/path to explore life or to explore or “be” the essence of self. Many of the responses were of an existential nature such as searching for reasons for living or being at one with the universe. Examples of the first theme, dimensions of spirituality, include beliefs in God, a Higher Power, and a connection with nature as well as five responses that disavowed any association with religion. The absence of religious beliefs is in contrast to only one female respondent who expressed no belief in religion or God. Men viewed spirituality as critical to shaping the person: “being inspired by all around me” or “It is very important because it allows me to have hope.”

As described earlier, all responses from female and male participants were later combined into one data set and analyzed without regard for the previously derived categories and themes. Six themes emerged from the collapsed data of all the participants experiencing this chronic illness. A discussion of the themes from the participants living with HIV disease and the healthy adults follow. The analysis of data from these two groups may elucidate differences between a sample of persons living with a chronic, life threatening disease and those with no reported major health concerns. In that respect, the healthy group of adults reflects a different context and pattern of responses. The discussion section describes the similarities and differences between the themes that emerged from persons living with HIV disease and healthy individuals. The qualitative paradigm allows for knowledge to be gleaned from both unique and shared experiences.

Themes for Persons Living with HIV Disease

Theme 1: Spirituality is Relating, and Believing in God or a Higher Power

This theme depicts how HIV patients conceptualize one aspect of spirituality. Most participants associated spirituality with religion and a belief in God or a Higher Power as evidenced by the quote by one participant, “belief in God is a big part of my spirituality.” Participants described qualities of God as, “God is everything” and “there is a God that loves you no matter what.” They report that their belief or faith in God can help them in difficult times. Some participants defined spirituality as “being in nature, connection to self, and others.” For a few participants, spirituality was not associated with religion or God. A male participant stated that “it is a kind of thing related to society and culture.” One female participant concurred, saying, “religion is not a part of my life and I have difficulty relating to spirituality.”

Theme 2: Spirituality is Being Guided or Helped

Spirituality was important for the participants. Spirituality helped them to not only cope with illness but also get through life. Spirituality and God helps them through the day. One participant said, “It’s important to me in the morning—I thank God for letting me get up in the morning. In the afternoon, I call on him to help me with whatever, and at night I say my prayers.” Another participant stated that “it keeps me healthy, in rhythm and in control,” while a third participant indicated “decisions and relationships are all based on it.”

Theme 3: Spirituality is Being Inspired by or Receiving Gifts

This theme demonstrates that spirituality inspires or gives HIV patients many positive attributes, such as hope, faith, and strength, to nurture their lives. As a passive process, several participants described spirituality “as a source of inspiration, peace, healing, comfort, power, strength, joy, and faith.” Also, participants commented that spirituality “allows me” or “clears my mind for” action. One participant said, “We all need it. It keeps me balanced and focused. Without it I would be lost.”

Theme 4: Spirituality is Expressed in Outward Ways

Spirituality is expressed outwardly by persons who are living with HIV. Most of the participants express their spirituality through actions such as listening to music, going to church, reading the Bible, praying, meditating, spending time alone, connecting with nature, or through their relationships with family, neighbors, and pets, and doing for others. One participant said, “It’s a big part of my daily life. I start the day off—listen to the radio with gospel selections—reading for today’s verses selected from the Bible.” Among all actions mentioned by participants, prayer was the most frequently reported expression of spirituality.

Theme 5: Spirituality is Journeying, Discovering, Centering

Among persons living with HIV, spirituality is the process, the journey, or path to explore or find the self and discover one’s essence. Spirituality is “getting to know yourself—having time alone that you can reflect and listen to yourself” or “getting to know your ‘interself’—to work out some problems without the help of others—learn how to relax and take control.” Some defined spirituality as a whole, saying that it is a part of body, mind, and soul. One female participant stated “Everything that I do is related to spirituality. My life is centered around spirituality. I want to grow in spirit and live in spirit.” Participants stated that there are many paths to spirituality. One participant reported that he “has HIV for a reason—it was fate.” In addition, some participants described God as part of the journey. For example, one female participant said “I think God has something for me to do, but I don’t know what it is—I’m just waiting.”

Theme 6: Spirituality is Feeling the Presence of God

This final theme was clearly evident in the data and upon further analysis it was determined that the theme emerged primarily from the responses of female participants. Female particpants viewed both spirituality and God as central to their lives, saying that spirituality and God are “everything … keep[ing] me well and alive.” God is a central part of their lives and presence is felt as “Being accepted by God for ‘who you are”’ Other comments include, “God is there when I need him”; “Faith in God is what is keeping me alive”; “God loves you no matter what”; “God understands”; and “Each day I got up, I looked in the mirror and said ‘Christ is in me and I am physically and mentally whole.’ That’s why I have never had any symptoms and never converted to AIDS.” Males’ acknowledgment of God’s presence and blessings is less prevalent among the responses.

Themes for Healthy Adults

The data from the healthy adults yielded six themes: a belief in a personal relationship with God; a connection and relationship with others; a spiritual journey, guide, or struggle; the spiritual essence of self; spirituality expressed in actions; and integral spirituality.

Theme 1: A Belief in a Personal Relationship with God

Participants described their spirituality as a belief in God and described a personal relationship with Him. This personal relationship was reflected in efforts to seek guidance from God, question or challenge Him, or discern His will. Participants seemed to have a dialogue with God, indicating the perception of an intimate relationship. Exemplars are: “What I am supposed to do? What does God want me to do?” “Sometimes I get angry with God and impatient for answers. I question Him.” “I pray daily, asking for God to show me what He wants me to do.” “Doing what one feels is God’s will, what is spiritual, is what gives meaning to life; wanting to do God’s will.” “Spirituality is the extent to which I permit or am able to permit my relationship to God to be a guiding force in the totality of my life.” Finally, a participant states that there are “ways [prayer] that one can spiritually discern” his will.

Theme 2: A Connection and Relationship with Others

This theme indicated that the participants felt that spirituality is more than a relationship with God and is a connection with nature, others, and self. Exemplars are: “Spirituality can be summed up in the word ‘relationship,”’ “Spirituality is the connection with self, others, nature, art, and music,” and lastly, “I feel grounded—connected to God through the earth.” The data for this theme represented the acknowledgment of a connection or association with something or someone other than God and did not reflect the personification evident in the first theme. Dwelling with the data resulted in these two themes of relationships that are believed to be mutually exclusive, one of the requirements for naming the themes from the data.

Theme 3: Spiritual Journey, Guide or Struggle

This theme is a description of spirituality as an evolving process that is either viewed by participants as a journey or struggle or as a guide to be followed. As a journey, it was described by participants as a process that occurs over time and often is not within their control. One participant stated “Sometimes it goes and comes; sort of up and down. I am more aware of it when things are going wrong.” Another person said that “Spirituality developed all the time,” while others stated, “Spiritual life is a process/a journey; I’m still evolving spiritually,” and, “I am re-emerging in my spirituality. It is exciting to re-discover.” The struggle noted in this theme is identified as an internal process. “I struggle with wanting to be in control and to do it all myself instead of waiting for His answer.” Or sometimes the struggle reflects a negative view: “I ask myself ‘What have I been doing all my life; look how I have wasted it!” Finally, spirituality is a guide to follow: “It is how we relate to the unknown. How we formulate guiding principles in our life.”

Theme 4: Spiritual Essence of Self

Spirituality is described as an awareness and essential part of the self. Spirituality is what gives meaning to life and is the “essence of who I am.” The spiritual essence of self includes patience, kindness, confidence, humility, and respect for others. It also includes time for oneself, self growth, a deep understanding of life, and contentment. Participants are seeking to know their spiritual selves and view spirituality as a part of the definition of self. The self is related to one’s soul, and to life as an organic and clairvoyant process, and the ability to transcend the natural (i.e., reality). The theme is best described by the participant who desired to be viewed as a person defined by their spirituality.

Theme 5: Spirituality Expressed in Actions

Participants acknowledge their spirituality and describe ways in which they express it. The action most frequently cited was praying. Other expressions included reading, bird watching, meditation, reflection, lighting candles, and “looking at rainbows, walking barefoot on the wet grass, walking in the rain, and on the beach.”

Theme 6: Integral Spirituality

The participants described spirituality as integral to their lives. “Spirituality is everything!” “It is the most important thing in my life!” Some participants strive to make spirituality a central part of their lives while others try to find balance. Other exemplars are: “It’s a part of my daily life.” “I use spirituality both in daily life and in difficulty.” “Especially right now when I’m out of work, it is what gets me through each day.” “I have seen some very tough times in my life; it was my spirituality that got me through those times.” “I have always been somewhat aware of my spirituality, I believed in God and prayed, but as I have gotten older it has become so much more important.” “I have been trying to incorporate my spirituality in my work life also and in all my relationships . . . .I try to be kind, understanding but it is so difficult.”

Essential Nature of the Themes

Although these data were analyzed using content analysis, the authors observed that the themes that emerged reflected a description of a narrative process. In an effort to elucidate the findings in a narrative statement, the authors used the final step in the process of data analysis described by Colaizzi (1978) as a guide. This step requires that the researchers use the formulated meanings of the themes and write an exhaustive statement depicting the essential nature of the phenomenon described. The following is the exhaustive description, according to Colaizzi’s process of data analysis, of the themes for persons living with HIV disease:

Spirituality is relating and believing in God, who is always present. It is perceived as being guided or helped or being inspired or given unto. Spirituality includes the processes of journeying, discovering, and centering and is outwardly expressed.

The exhaustive statement for the sample of healthy adults:

Spirituality is a strongly held belief and a personal relationship with God that is integral to the life of individuals. There exists a connection with nature, others, and a higher power. Spirituality evolves as a process that can be described as a journey, a guide, or a struggle. Spirituality is the essence of the self and is expressed outwardly primarily in prayer.

DISCUSSION

Using content analysis, six themes emerged from the qualitative data generated by females and five themes from male participants enrolled in the HIV study (see Table 2). A closer examination indicates that there are similarities as well as gender differences in these themes. Most participants described the benefits of spirituality. All participants viewed spirituality as a sense of peace. Female participants felt God’s presence and expressed the idea of being centered. Male participants viewed spirituality as an active process of seeking, discovering, and journeying. Females saw themselves as the beneficiaries of spirituality and received hope, strength, and inspiration from their spirituality. On the other hand, males received guidance to find their own path. In summary, active and passive views expressed by the participants differed by gender; this gender difference is a significant finding of this study. A paternalistic view of God, more evident in the female participants, might account for this difference, However, gender alone does not account for this finding since the responses of healthy females do not support this view of God and spirituality. This latter sample of healthy women consisted of professionals with higher levels of education. It is noted that male participants living with HIV disease expressed views more similar to the healthy adults, specifically in the themes of journeying and discovering the essence of self.

TABLE 2.

Summary of Findings from Separate Data Analyses

Unit of analysis Themes identified
By gender (HIV/AIDS)
 Females (1) Spirituality as a belief in God (a higher power or religion); (2) Spirituality as a channel that helps; (3) Spirituality as a source; (4) Spirituality expressed through actions, such as praying, meditating, and attending church; (5) God is present and giving; and (6) Spirituality as an individual’s essence or center.
 Males (1) Dimensions of spirituality: what spirituality is and is not, including a belief and relationship to God and religion, and a connection to nature and a Higher Power; (2) Spirituality as a channel that guides and helps; (3) Spirituality as a force that shapes one’s being, spirituality inspires and “It makes me feel alive.”; (4) Spirituality expressed outwardly through activities done to express and maintain spirituality; (5) Spirituality is a journey/path to explore life or to explore or “be” the essence of self.
By health-illness status
 HIV/AIDS as a chronic disease Spirituality is (1) relating and believing in God or a Higher Power; (2) being guided or helped; (3) being inspired by or given unto; (4) expressed in outward way; (5) journeying, discovering, centering; 6) feeling the presence of God.
 Self-reported health (lack of chronic illness) Spirituality is (1) a belief in a personal relationship with God; (2) a connection and relationship with others; (3) a spiritual journey, guide, or struggle; (4) Spiritual essence of self; (5) Spirituality expressed in actions; (6) Integral.
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The meaning of spirituality for persons living with HIV disease supports previous findings. There is a wide array of perceptions of spirituality ranging from religious to secular views. The activities associated with the expression of spirituality are diverse as well. The finding most often corroborated in the literature is that spirituality provides hope, helps persons to cope with the illness, and contributes to their well-being (Carson, 1993; Tuck et al., 2001).

There were six themes derived from the analysis of data collected from the healthy adults. The most significant finding is the description of an intimate relationship with God that resulted in participants’ questioning, challenging, and waiting for answers. There was not a theme specifically focusing on being guided or helped by spirituality. It is apparent that the presence of a chronic or life-threatening disease may affect this theme and also may account for the “richer” descriptions expressed by persons living with HIV/AIDS. Being helped or guided was more prominent for persons living with chronic HIV disease and may also explain the nature of their relationship with God.

A limitation of the study is the structured research questions that narrowed the possible responses and assumed that there are positive spiritual effects. On the other hand, the questions are grounded in the literature and support the authors’ belief that spirituality is a component of holism and therefore relevant to all persons. The findings confirmed this previously bracketed investigator bias. Although these findings are not generalizable, the themes derived from the responses of 102 individuals, persons who are healthy and chronically ill, confirm the components of spirituality, the universality of the core of its meaning, and its significance for adult populations. The findings also confirm that spirituality is expressed in several ways; however the primary spiritual expression among these adults was prayer. Whether one is coping with a chronic illness or with everyday events, spirituality is viewed as a critical component of the human experience. It is the essence of self. Spirituality is a developmental process or journey that requires spiritual growth and nurturance.

Acknowledgments

This project was supported in part by the National Center for Complementary and Alternative Medicine (#R01 AT00331, Nancy McCain, Principal Investigator) and the General Clinical Research Center at Virginia Commonwealth University (NIH #M01 RR00065, John Clore, Project Director). The pilot was supported by the Department of Integrative Systems, School of Nursing, Virginia Commonwealth University, Inez Tuck, Principal Investigator.

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