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. 2022 May 3;17(5):e0267556. doi: 10.1371/journal.pone.0267556

Spirituality as a protective factor for chronic and acute anxiety in Brazilian healthcare workers during the COVID-19 outbreak

Julio Cesar Tolentino 1,2,*,#, Ana Lucia Taboada Gjorup 1,2,#, Carolina Ribeiro Mello 2,3, Simone Gonçalves de Assis 2,4, André Casarsa Marques 2, Áureo do Carmo Filho 2, Hellen Rose Maia Salazar 2, Eelco van Duinkerken 2,5,6,#, Sergio Luis Schmidt 2,#
Editor: Rosemary Frey7
PMCID: PMC9064089  PMID: 35503766

Abstract

Background

Anxiety symptoms (AS) are exacerbated in healthcare workers (HCWs) during the COVID-19 pandemic. Spirituality is known to protect against AS in the general population and it is a construct that differs from religion. It can be assessed using structured questionnaires. A validated questionnaire disclosed three spirituality dimensions: peace, meaning, and faith. In HCWs we investigated the predictors of chronic anxiety (pre-COVID-19 and during the pandemic) and acute anxiety (only during the pandemic), including spirituality in the model. Then, we verified which spirituality dimensions predicted chronic and acute anxiety. Lastly, we studied group differences between the mean scores of these spirituality dimensions.

Material and methods

The study was carried out in a Brazilian Hospital. HCWs (n = 118) were assessed for spirituality at a single time-point. They were also asked about AS that had started pre-COVID-19 and persisted during the pandemic (chronic anxiety), and AS that had started only during the pandemic (acute anxiety). The subjects without chronic anxiety were subdivided into two other groups: acute anxiety and without chronic and acute anxiety. Forward stepwise logistic regressions were used to find the significant AS predictors. First, the model considered sex, age, religious affiliation, and spirituality. Then, the analysis were performed considering only the three spirituality dimensions. Group means differences in the spirituality dimensions were compared using univariate ANCOVAS followed by T-tests.

Results

Spirituality was the most realible predictor of chronic (OR = 0.818; 95%CI:0.752–0.890; p<0.001) and acute anxiety (OR = 0.727; 95%CI:0.601–0.881; p = 0.001). Peace alone predicted chronic anxiety (OR = 0.619; 95%CI:0.516–0.744; p<0.001) while for acute anxiety both peace (OR:0.517; 95%CI:0.340–0.787; p = 0.002), and faith (OR:0.674; 95%CI:0.509–0.892; p = 0.006) significantly contributed to the model. Faith was significantly higher in subjects without AS.

Conclusion

Higher spirituality protected against chronic and acute anxiety. Faith and peace spirituality dimensions conferred protection against acute anxiety during the pandemic.

Introduction

Anxiety symptoms (AS) are frequently associated with physical and mental illnesses [1–3]. Age and sex are reliable predictors of AS [4–9]. Furthermore, some studies have reported a protective effect of spirituality on AS in the general population [10–16]. Spirituality can involve cognitive and emotional states such as beliefs, motivations, and a sense of gratitude [17–19]. In particular, positive cognitive or emotional aspects of spirituality have been found to be associated with less anxiety [18]. Moreover, González-Sanguino et al., using regression methods, have demonstrated the importance of spirituality as the main protector against the appearance of AS [15].

Previous investigations have shown that AS are exceptionally high in healthcare workers (HCWs) [20]. Given the potential protection of greater spirituality against anxiety [12–16] and the high prevalence of AS among HCWs [20–22], it would be interesting to investigate spirituality as a protector of AS in this specific population. However, the effect of spirituality on AS has not been systematically investigated in HCWs.

During the COVID-19 outbreak, AS have been found to be exacerbated among HCWs worldwide [21–26]. In Brazil, the current pandemic has massively impacted HCWs with a high prevalence of AS [27–29]. A previous cross-sectional study conducted among Brazilian HCWs during the first six months of 2020 showed that most of them experienced a high level of anxiety [27]. Villela et al. also found that the pandemic had a crucial impact on HCWs’ work routines, with a high rate of AS [28]. It is noteworthy that spirituality research in Brazil has great relevance due to its cultural context since spirituality and religion are commonplace within Brazilian culture [30, 31]. Indeed, most of the Brazilian population has a religious affiliation [31]. To our knowledge, the relative importance of the potential spirituality protective effect on AS has not been studied among Brazilian HCWs in the current pandemic.

Spirituality encompasses a broader sense of inner peacefulness or harmony, a search for meaning and purpose of life, and how an individual experiences his or her faith [32–34]. It can be measured using well-validated instruments, such as the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp) [35–37]. The FACIT-Sp measures overall spirituality and three psychologically meaningful dimensions: peace, meaning, and faith [36, 38]. These spirituality domains are considered as separate constructs that make up spiritual well-being [37, 39]. Another highlighted aspect is that this multifactorial construct differs from religion [39, 40].

In times of distress, it could be hypothesized that a higher spirituality could predict lower AS in HWCs who are submitted to stressful work situations. Besides, the protection given by the different spirituality dimensions against AS may depend on the moment these symptoms begin. A feeling of peace reflecting an affective dimension of spirituality [35, 36, 41, 42], and it has been associated with mental health [35, 38, 43]. Then, we hypothesized that peace dimension would be a predictor of AS in HCWs who anxiety started before and persisted during the pandemic (chronic anxiety) and those whose anxiety started only during the pandemic (acute anxiety). Given that personal faith can increase psychological resilience [44, 45], we hypothesized that faith would reach the highest score in those without chronic and acute anxiety. In addition, as faith is associated with better coping in stressful times [46–48], we also hypothesized that higher personal faith could be a predictor of less acute anxiety during the pandemic. Therefore, the potential protective effect of spirituality, and its dimensions on AS should be studied in chronic and acute anxiety. However, the effects of each spirituality dimension on the AS among HCWs have not been studied during the COVID-19 outbreak.

The present study aimed to investigate chronic and acute anxiety in HCWs, including spirituality and its dimensions. Firstly, we assessed the AS predictors of chronic. Secondly, we studied the AS predictors of acute anxiety during the pandemic. Thirdly, for chronic and acute anxiety, we analyzed which spirituality dimensions would predict AS. Forthly, we investigated the differences among all the groups (chronic anxiety, acute anxiety and without chronic and acute anxiety), considering the mean scores of the spirituality dimensions that were found to be significant predictors of AS according to the third objective.

Materials and methods

This observational study was carried out in HCWs from May 12th until July 10th 2020 at a reference Tertiary Hospital for COVID-19 in Rio de Janeiro, Brazil. We included the HCWs of both sexes with ages ranging from 20 to 60 years old. Exclusion criteria: previous or current neurological disorders, uncontrolled clinical conditions, and taking antidepressant, anxiolytic, and antipsychotic medications.

The HCWs who were working in the Hospital during the period of this research were invited to participate in the present study. The researcher explained the study aims and the procedure of data collection. Those who verbally consented to take part in the study were given the questionnaire. The subjects were informed that they could withdraw from the study at any time and return the questionnaire. They were left free to ask questions and to obtain explanations. They all signed the written informed consent.

All filled out a face-to-face questionnaire about spirituality and AS. The presence of AS was assessed in an all-or-none fashion based on a questionnaire that included a question if these symptoms had persisted for a minimum of 6 months. As the first case of COVID-19 in Brazil was reported on February 26th 2020, it was possible to identify the participants who presented AS that started before and persisted after this date (chronic anxiety). Then, the sample was divided into two groups according to the presence of AS that had started before COVID-19 and persisted during the pandemic (no chronic anxiety vs. chronic anxiety groups)—first objective. In order to assess the AS directly associated with the pandemic period, we subdivided the sample without anxiety before the pandemic (no chronic anxiety group) into two other groups: subjects that remained without AS all the time (without chronic and acute anxiety group) and those who started AS only during the pandemic (acute anxiety group)—second objective.

Spirituality was assessed through the FACIT-Sp [35, 36, 41, 49, 50]. This scale is a widely used instrument in clinical research to measure spirituality and validated for the Brazilian population [51, 52]. The FACIT-Sp items emphasize a sense of peacefulness, harmony, meaning or purpose in life, strength and comfort from one’s faith or spiritual beliefs´[35, 36, 38]. It is a self-administered questionnaire composed of 12 items, divided equally between three dimensions: peace (items 1, 4, 6, and 7), meaning (items 2, 3, 5, and 8), and faith (items 9, 10,11, and 12). The participant was instructed to indicate how true an affirmative had been for them during the past seven days, using a 5-item response format ranging from not at all (0) to very much (4), except for items four and eight, which must be reverse coded. Total scores range from 0 to 48, with higher scores indicating higher spiritual well-being. The questionnaire also provides scores per dimension. Previous studies have demonstrated the validity and reliability of the FACIT-Sp among Brazilians, e.g., Pereira & Santos (2011) [51] and Luchetti et al. (2013) [52]. These studies have shown good psychometric properties for the Portuguese version of FACIT-Sp, such as high reliability and adequate construct validity [51, 52]. In the present study, the internal reliability of the FACIT-Sp was high [Cronbach’s alpha (α) = 0.823]. Concerning each spirituality dimension, the Cronbach alphas for the peace, meaning, and faith were 0.865, 0.828, and 0.894, respectively.

For the statistical analysis, quantitative variables were reported as absolute and relative frequencies. The normality of variables was confirmed by assessing the histograms, QQ plots, and Kolmogorov–Smirnov test. Normally distributed continuous variables (age and FACIT-Sp total score) are presented as means and standard deviations and were evaluated using independent t-tests. The associations are presented as odds ratios (OR) and 95% confidence intervals (CI 95%).

In the whole sample, a forward stepwise binomial logistic regression was used to predict whether participants could be correctly classified according to the presence or absence of AS that started before the COVID-19 and persited during the pandemic (chronic anxiety group)- first objective. In order to investigate the acute anxiety, we selected only those participants without AS before the pandemic. They were divided into those who remained without AS (without chronic and acute anxiety group) and those who started AS during the COVID-19 outbreak (acute anxiety group). In this subsample, we also investigated the reliable predictor(s) of acute anxiety (second objective). We used the forward stepwise regression method to find the predictors that could contribute significantly to the model. Our model considered sex, age, religious affiliation, and the FACIT-Sp total score for both analyses. We intended to investigate whether these variables could significantly predict less AS among HCWs. Nagelkerke R2 was calculated to estimate the explained variance of the dependent variable, and the Wald test was used to determine the statistical significance of each predictor. The stepwise forward selection included only predictors significant to the model at a probability of F (p < 0.05). For both the entire sample and the subsample, forward stepwise logistic regressions were used to determine which spirituality dimensions would predict AS (third objective).

To assess the effect of group (chronic anxiety, acute anxiety, and without chronic and acute anxiety groups) on the spirituality dimensions that were found to predict the presence of AS (forth objective), a MANCOVA was performed to examine group differences on those spirituality dimensions, using age, sex, and religious affiliation as covariates. In the case of a significant overall MANCOVA, post-hoc ANCOVAs for each dependent variable (spirituality dimensions) were checked for statistical significance. In the case of significant ANCOVAs, post-hoc T-tests assessed the presence of significant group differences for each spirituality dimension. Multiple comparisons were correct by the Bonferroni method. For the MANCOVA and each of the ANCOVAs, the η2 (Eta-squared) was computed to calculate the effect size of the results. Cohen has suggested that η2 = 0.01 should be considered a small effect size, 0.06 a medium effect size, and 0.14 a large effect size [53].

For all the tests, significance was set at a p-value < 0.05. SPSS Statistics for Windows, version 25.0 (IBM Corp, 2017), was used for statistical analyses.

The local Research and Ethics committee approved this study (number: 39365120.8.0000.5258) in accordance with the Declaration of Helsinki. Participation in this study was voluntary without monetary or non-monetary compensation. HCWs were invited to take part in this study voluntarily. All of them were informed about the study aims and the entire procedure of data collection. Subjects were assured that all data collected during the research process would be treated confidentially. The volunteers provided written informed consent. They could withdraw from the study at any time by declining to fill in the questionnaire. During the data collection, a researcher was available if any doubts or questions emerged.

Results

Predictors of chronic anxiety (first objective)

One hundred and forty-seven were invited, but eight did not agree to participate in this study. Therefore, the initial sample has consisted of 139 subjects. From this sample, 21 were excluded because they reported the use of psychotropic medications. Then, the whole final study sample consisted of 118 subjects. The age ranged from 22 to 60 years (41.9±10.3), and the majority was female (n = 79; 66.9%). Most participants (64.4%) had a religious affiliation. Seventy-two participants (61%) reported chronic anxiety. The FACIT-Sp mean score was statistically higher for the no chronic anxiety group (38.6) as compared to the chronic anxiety group (31.6) [t(116) = 6.0; p<0.001]- S1A Fig and Table 1.

Table 1. Descriptive statistics of the variables used as predictors for the three groups: Anxiety that started pre-COVID-19 and during the pandemic (chronic anxiety), anxiety that started only during the pandemic (acute anxiety), and without chronic and acute anxiety group.

First Objective No chronic anxiety (n = 46) Chronic anxiety (n = 72) p-value
Sex female, n (%) 27 (58.7%) 52 (72.2) 0.2
Age (Years), Mean (SD) 45.4 (10.4) 39.7 (9.5) 0.003
Religious affiliation, n (%) 29 (63.0) 47 (65.3) 0.8
FACIT-Sp (score), Mean (SD) a 38.6 (4.5) 31.6 (6.9) <0.001
Second objective Without chronic and acute anxiety (n = 21) Acute anxiety (n = 25) p-value
Sex female, n (%) 11 (52.4) 16 (64.0) 0.6
Age (Years), Mean (SD) 46.4 (11.5) 44.6 (9.5) 0.6
Religious affiliation, n (%) 12 (57.1) 17 (68) 0.5
FACIT-Sp (score), Mean (SD)b 41.3 (3.9) 36.2 (3.7) 0.001
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Abbreviations: HCWs = healthcare workers; AS = anxiety symptoms; SD = standard deviation; p = proof value; OR = Odds Ratio; CI = confidence interval.

a The FACIT-Sp score was the most reliable predictor of chronic anxiety in the forward stepwise regression method (OR = 0.818; 95% CI: 0.752–0.890; p<0.001)

b The FACIT-Sp score was the most reliable predictor of acute anxiety during the pandemic in the forward stepwise regression method (OR = 0.727; 95% CI:0.601–0.881; p = 0.001).

The model included sex, age, religious affiliation, and the FACIT-Sp total score as predictors of chronic anxiety. Spirituality (FACIT-Sp total score) was the only significant predictor in the forward stepwise regression (OR = 0.818; 95% CI: 0.752–0.890; p<0.001). This model was statistically significant [χ2(1) = 33.2; p<0.001], explaining 33.2% (Nagelkerke R2) of the variance and classifying correctly 71.2% of the cases.

Predictors of acute anxiety (second objective)

To investigate the relationship between spirituality and acute anxiety during the current outbreak, we selected all subjects without AS starting before the pandemic (n = 46). Of these 46 participants, 25 (54.3%) started AS only during the pandemic (acute anxiety group), and 21 continued without AS (without chronic and acute anxiety group). In this subsample, the FACIT-Sp total mean score was statistically higher in participants that remained without AS (41.2) as compared to acute anxiety group (36.2) [t(44) = 4.4; p<0.001]- S1B Fig and Table 1.

The model included sex, age, religious affiliation, and spirituality (FACIT-Sp total score). Spirituality was the only significant predictor of acute anxiety in the forward stepwise regression (OR = 0.727; 95% CI:0.601–0.881; p = 0.001). This model was statistically significant [χ2(1) = 13.6; p<0.001], explaining 38.5% (Nagelkerke R2) of the variance and classifying correctly 69.6% of the cases.

Dimensions of spirituality (third objective)

Peace was the only predictor of chronic anxiety (OR = 0.619; 95% CI: 0.516–0.744; p<0.001). This model was statistically significant [χ2(1) = 40.4; p<0.001], explained 39.3% of the variance, and classifying correctly 78.8% of the cases- S2A Fig.

Both peace (OR:0.517; 95% CI: 0.340–0.787; p = 0.002) and faith (OR:0.674; 95%CI:0.509–0.892; p = 0.006) dimensions predicted acute anxiety- S2B Fig. This model was statistically significant [χ2(2) = 23.4; p<0.001], explained 53.3% of the variance, and correctly classified 76.1% of the cases.

Comparison of spirituality dimensions that were predictors of anxiety (fourth objective)

After adjusting for age, sex, and religious affiliation, the MANCOVA showed a significant effect of group (chronic anxiety, acute anxiety, and without chronic and anxiety group) on peace and faith dimensions (F = 15.3, df = 4/222, p<0.001, η2 = 0.216). The univariate tests showed that group affected peace (F = 29.1, df = 2/112, p<0.001, η2 = 0.342), and faith (F = 5.4, df = 2/112, p<0.006, η2 = 0.88). The t-tests showed significant means differences in all comparisons for the peace dimensions. Regarding the faith dimension, the mean scores were significantly higher in the without chronic and acute anxiety group compared to the chronic anxiety and acute anxiety groups.

Discussion

We found a high prevalence of AS in HCWs. Our findings are in line with recent studies on the frequency of AS in HCWs [23, 24, 54, 55]. Additionally, we reported a high rate of acute anxiety (54.3%) during the pandemic. These data may reflect the specific psychological impact of COVID-19 on HCWs.

Spirituality was the most reliable predictor of acute and chronic anxiety. We showed that the peace spirituality dimension was a significant predictor of less AS among HCWs irrespective of whether these symptoms were chronic or acute during the pandemic. Moreover, the faith dimension significantly predicted AS that started only during the pandemic. This finding indicates the importance of personal faith as an additional protective factor for acute anxiety in the current outbreak.

Predictors of chronic anxiety (first objective)

We used the forward stepwise regression method to find the best predictors of the AS. The stepwise forward selection included only predictors that enhanced the significance of the model at a probability of F (p < 0.05). Based on this approach, sex, age, and religious affiliation were not included as predictors in the logistic regression model (forward regression method). Using this method, the spirituality variable was enough to predict AS adequately. Our results about religion probably reflect that religious affiliation is a construct that is conceptually different from spirituality [39, 40]

The present data revealed that high spirituality protects against chronic anxiety. This is supported by other studies that have shown the association between greater spiritual well-being and lower AS in the general population [15, 16, 56].

The FACIT-Sp mean scores were 38.6 and 31.6 in no chronic and chronic groups, respectively. As a FACIT-Sp score above 36 points has been considered high spiritual well-being [57, 58], we inferred that most subjects in the no chronic group had high spirituality based on this cutoff.

Predictors of acute anxiety (second objective)

Spirituality was showed to be the only reliable predictor of acute anxiety. As there is an increase in the number of subjects with anxiety in times of distress, it is conceivable that higher spirituality should be needed to overcome the demands of a new stressful situation. The FACIT-Sp mean score in the group without chronic and acute anxiety reached 41.3 points, well above the 36 points (the limit for a high spirituality) [57, 58]. In contrast, the FACIT-Sp score was below this cutoff point in most subjects of the acute anxiety group. As described for chronic anxiety, greater spiritual well-being also protected against acute anxiety during the pandemic.

The effect of spirituality on chronic and acute anxiety (first and second objectives)

We demonstrate the impact of spiritual well-being among HCWs in chronic and acute anxiety (first and second objectives). High spirituality involves positive emotions and spiritual beliefs, which may provide a better psychological adaptation against AS [18]. Another possible reason is that spirituality has been shown to be a consistent resilience factor [59]. As a higher spirituality was the most reliable predictor of less acute anxiety, we can infer that HCWs with increased spiritual well-being tend to develop internal mechanisms that help them cope with the adversities associated with the current pandemic.

A potential mechanism for spirituality protection on AS could be related to the neurobiological substrates of spirituality [60–63]. Although multiple brain regions may contribute to spirituality, the parietal cortex is arguably the most frequently implicated brain region related to spirituality [63]. Furthermore, the medial parietal region appears functionally connected with lateral areas of the parietal cortex associated with self-reference or a felt sense of connection outside of oneself [64]. Rim et al. (2019) systematically reviewed the relationship between spirituality and electroencephalography, structural and functional neuroimaging [65]. This and others studies have demonstrated several brain regions associated with spiritual well-being, such as parietal cortex, medial frontal cortex, orbitofrontal cortex, precuneus, posterior cingulate cortex, default mode network, and caudate [63, 65–67].

Effect of the spirituality dimensions on AS (third objective)

The peace dimension of spirituality was the only significant predictor of chronic anxiety. Our results agree with previous studies in different populations, in which the sense of peace was associated with less AS [11, 68, 69]. This finding can be explicated because the peace subscale is an affective expression of spirituality, reflecting a sense of inner harmony [35, 36, 41, 42], and this dimension has been specifically related to mental health [35, 38, 43]. However, feeling at peace alone did not protect against the acute anxiety during the current outbreak. We found that a high faith score was also necessary to protect against acute anxiety during the pandemic. This result may indicate that when HCWs cope with anxiety triggers during the pandemic, their faith is important to reduce AS.

It should be mention that personal faith is more subjective and deeper than religious affiliation [40, 70]. Our finding may have some possible explanations. First, faith can be a source of hope for the future [45, 47, 71]. Second, faith can provide an optimistic worldview [44, 72], which is inversely associated with AS. Finally, cultivating expressions of faith can increase psychological resilience [45] and, consequently mitigate AS [73].

Taken together, it is possible that a sense of inner peace or harmony and, especially, personal faith have served to better coping with stress in the face of uncertainties associated with the pandemic.

Comparation of spirituality dimensions that were predictors of anxiety (fourth objective)

As expected, the subjects without chronic and acute anxiety presented the highest mean score for inner peace. The peace dimension was greater in acute anxiety as compared to chronic anxiety. This finding may indicate that mental health was better in the subjects without chronic anxiety.

Regarding the faith dimension, HCWs without anxiety had significantly higher faith scores compared to those with chronic and acute anxiety. These data suggest possible protection of faith against AS in this specific population. In particular, our results highlighted the role faith played in the pandemic. Only the group of HCWs with the highest faith protection could remain without AS during the pandemic. This finding supports the relevance of faith as a predictor for better psychological coping to the current COVID-19 outbreak.

Limitations, strengths, and future directions

A limitation of the present study is the small number of subjects in the subsample of HCWs. Although the HCWs of the present study can be considered a representative sample of Brazilian HCWs, future studies should be conducted in a larger sample of HCWs recruited from various areas in Brazil. A strength is that the questionnaires were applied face-to-face by the researchers since most previous studies were carried out by e-mail, social media, or online websites.

A practical implication of our findings is that it would be useful to promote enhanced screening for AS and address spirituality in HCWs, particularly during stressful times. Studies of medical and psychiatric patients report that the majority have spiritual issues, and most of those needs currently go unmet [33, 39, 74]. Therefore, health professionals may engage HCWs in a dialogue that allows them to talk about their spirituality. Additionally, based on the present study, it may be useful to take spiritual assessments during the inclusion of HCWs in preventive and therapeutic mental health programs.

From a public health perspective, future research should focus on potential interventions based on spirituality in HCWs. In other populations, psychosocial interventions have proved effective in improving spirituality [75–78], such as spiritually integrated psychotherapy [79, 80], yoga [78], and meditation [78, 79]. In addition, a previous meta-analysis found that faith-adapted cognitive-behavioral therapy (CBT) may outperform both control conditions and standard CBT in the treatment of anxiety [81]. Our data highlight the protective role of faith and inner peacefulness. Therefore, psychosocial interventions in HCWS during the pandemic should consider these two spirituality dimensions. These approaches may lower the impact of anxiety triggers on HCWs.

Conclusions

The present study shows that spirituality can be considered a protective factor against AS in HCWs, irrespective of whether the symptoms started before and during the pandemic. This finding suggests that HCWs with high spiritual well-being tend to develop internal mechanisms that help them cope with psychological stress.

Additionally, we found that spirituality dimensions influenced the AS differently according to the starting time of symptoms. Peace spirituality dimension was the best predictor of acute and chronic anxiety, whereas the faith dimension emerged together with peace to confer protection on acute anxiety starting during the COVID-19 outbreak. These data suggest that a personal faith can represent an important coping strategy facing a severe stressful moment among HCWs. Therefore, interventions based on improving spiritual well-being and considering these spirituality dimensions could be designed and implemented in HCWs.

Supporting information

S1 Fig. The mean FACIT-Sp total score for each group.

(A) FACIT-Sp total score is statistically significantly higher in the no chronic anxiety group compared to the chronic anxiety group (*p<0.001), indicating a lower spirituality among the subjects experiencing anxiety that started pre-COVID-19 and during the pandemic (B) The boxplot indicates that the FACIT-Sp total score is also statistically significantly higher in the group without chronic and acute anxiety (*p<0.001) as compared to the acute anxiety group.

(TIFF)

Click here for additional data file. (389.4KB, tiff)
S2 Fig. Effects of spirituality dimensions on anxiety symptoms according to chronic and acute anxiety.

(A) The peace was the only spirituality dimension protective of chronic anxiety (B) Peace and faith spirituality dimensions are protective factors against acute anxiety during the pandemic.

(TIFF)

Click here for additional data file. (343.8KB, tiff)

Acknowledgments

We would like to thank the study participants.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Rosemary Frey

20 Aug 2021

PONE-D-21-18892

Spirituality as a protective factor for anxiety symptoms in healthcare workers during the COVID-19 outbreak

PLOS ONE

Dear Dr.Tolentino, 

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Please pay particular attention to addressing the extensive methodological issues raised by Reviewer 1.

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Reviewer #1: PONE-D-21-18892

I am pleased to read and review manuscript ID PONE-D-21-18892 entitled " Spirituality as a protective factor for anxiety symptoms in healthcare workers during the COVID-19 outbreak". The study is interesting; however, I consider that specific questions need to be addressed to improve its presentation, which I mention above:

1. The abstract contains sufficient background to understand the problem under investigation. However, please focus and provide the gap statements briefly in your abstract.

2. Line 34, Page 2. Age and sex are not main variable, suggest not include in the abstract.

3. Please provide your result with related the spirituality as a protective factor for anxiety symptoms in result section-abstract.

4. Please consistent to use the word “before and during the pandemic” or “non-pandemic and pandemic periods”

5. Concerning the introduction section, more specific information is needed to provide the novelty, including what and why this study is important among Brazilian healthcare workers (HCWs) with specific spiritual and anxiety symptoms.

6. Please more clearly about the sentences in line 69-70 “However, the effects of each spirituality dimension on the AS of HCWs have not been studied during the COVID-19 outbreak”. Is it valid or true based on the previous study?

7. Line 71-15. The present study aimed to investigate AS predictors in HCWs, including spirituality, considering two different starting times for the AS. First, we assessed AS starting before the COVID-19 outbreak (first objective). Thereafter, we studied the predictors for AS conversion during the pandemic (second objective.) Finally, for each period, we analyzed which spirituality dimensions would predict AS (third objective).

Considering your objective please provide your results based on the objectives in the abstract section, especially the third objective?

8. In line 77-78, Page 3. This study was carried out in HCWs from 12th May until 9th July 2020 at a reference University Hospital for COVID-19 in Rio de Janeiro, Brazil. Based on the time. Please more detail about the time (starting before the COVID-19 outbreak-first objective; and during the pandemic-second objective) or pandemic and pandemic period

9. Line 78-80. Exclusion criteria: age below 20 years or above 60 years, previous or current neurological disorders, uncontrolled clinical conditions, and taking antidepressant, anxiolytic, and antipsychotic medications.

a. Please measure your criteria exclusion age bellow 20 years-related the HCWs or general population?

b. How about the authors clarified or measure the validity of previous or current neurological disorders, uncontrolled clinical conditions, and taking antidepressant, anxiolytic, and antipsychotic medications?

10. Please provide more detail about the validity and reliability FACIT-Sp among Brazilian as well as provide your validity and reliability (based on your results) each domain because the author used each domain

11. Line 95-97. “Normally distributed continuous variables (age and FACIT-Sp total score) are presented as the means and standard deviations and were evaluated using an independent t-tests. As well as “The associations are presented as odds ratios (OR) and 95% confidence intervals (CI 95%)”. Please provide the result, could be easier to use the table related the all objective (before, during the pandemic and each period).

12. The methods: needs to be more complete, I suggest the study design, the specification of the instruments with the references with the best-fitting model.

13. Please provide references related to the minimum sample size and the kind of assessment of sample size method

14. Methods in this manuscript are generally too vague. They need to be more descriptive and clearer in defining inclusion the subjects.

15. Line 111, please provide the detail of ethical approval ethic of this study.

16. In the discussion section, please describe the reason or mechanism of spirituality might protective anxiety symptoms.

17. Please provide data value of sex, age, and religious affiliation based on the objective

18. Line 160. “Sex, age, and religious affiliation were not included in the logistic regression equation because we have applied the forward analysis”. Please provide more detail about the reason and previous studies to similar or contrast about the findings among HCWs (don’t general population).

19. Should include potential other confounding variables that could be related to spiritual and anxiety symptoms. The data did not represent the entire population of health-care workers and the services in which they worked (intensive care, primary care. . .), also, did not include other variables such as whether the participants had had any personal experience of loss or illness due to COVID in their family or friends, and, as a result, the findings cannot be used to make useful generalizations regarding health-care workers as a whole, or to determine specific variables’ correlations with specific groups of health-care workers. A larger sample of health-care workers recruited from various areas in Brazil is needed to verify the results.

Reviewer #2: It would be best if the discussion and conclusion sections could be expanded upon to allow for a more robust discussion of results and their direct implications of future practices for the well being of HCWs. The manuscript was very robust with statistical analysis that showed the implications of spirituality on AS, however lacked a next step for HCW. This would be helpful to add to the manuscript.

**********

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2022 May 3;17(5):e0267556. doi: 10.1371/journal.pone.0267556.r002

Author response to Decision Letter 0

10 Oct 2021

Dear Emily Chenette, PhD - Editor-in-Chief – PLOS ONE

Dear Rosemary Frey, PhD - Academic Editor – PLOS ONE

We are glad to know that, based on the advice received, our manuscript entitled “Spirituality as a protective factor for anxiety symptoms in healthcare workers during the COVID-19 outbreak " has merit for publication. We thank the Editor and two anonymous reviewers for the time spent reviewing our manuscript and for the valuable input given to improve it.

We send a marked-up copy of the revised version (RV) that highlights changes made to the original version (“Revised Manuscript with Track Changes”). The changes can be found in red letters. The related question raised by the reviewers (reviewer 1- R#1 and reviewer 2- R#2) can be found highlighted in yellow (R#1) and green (R#2) on the right margin of the “Revised Manuscript with Track Changes”.

Please find below the detailed point-by-point responses to all the interesting and constructive questions (Q) raised by the two reviewers.

Reviewer #1:

“I am pleased to read and review manuscript ID PONE-D-21-18892 entitled " Spirituality as a protective factor for anxiety symptoms in healthcare workers during the COVID-19 outbreak". The study is interesting; however, I consider that specific questions need to be addressed to improve its presentation, which I mention above:”

We greatly appreciate R#1 for his/her meaningful comments on our manuscript. As R#1 points out, we agree that specific questions need to be addressed to improve our manuscript. So, we have answered the 19 questions raised by R#1 described below.

Q1 R#1: “The abstract contains sufficient background to understand the problem under investigation. However, please focus and provide the gap statements briefly in your abstract.”

Answer Q1 R#1: We are glad that “The abstract contains sufficient background to understand the problem under investigation.”. We agree with the following interesting comment made by R#1:"please focus and provide the gap statements briefly in your abstract.". We have included more focus and a brief gap statement in RV of the abstract. Please see line 30, page 2.

Q2 R#1: “Line 34, Page 2. Age and sex are not main variable, suggest not include in the abstract.”

Answer Q2 R#1: We entirely agree with the point raised by R#1. We have removed the following sentence in the RV of abstract: "Age and sex are AS predictors in HCWs”.

Q3 R#1: ‘’ Please provide your result with related the spirituality as a protective factor for anxiety symptoms in result section-abstract.”

Answer Q3 R#1: We agree with this interesting comment raised by R#1. Then, we provided our result about spirituality as a protective factor for AS starting before and during the pandemic. Please, see lines 41-43 in the results section of RV abstract.

Q4 R#1: “Please consistent to use the word “before and during the pandemic” or “non-pandemic and pandemic periods”

Answer Q4 R#1: We thoroughly agree with R#1. As the reviewer points out, we replaced “non-pandemic and pandemic periods” with “before and during the pandemic” in the RV.

Q5 R#1: “Concerning the introduction section, more specific information is needed to provide the novelty, including what and why this study is important among Brazilian healthcare workers (HCWs) with specific spiritual and anxiety symptoms”

Answer Q5 R#1:: We thank R#1 for this thoughtful comment. In the RM introduction section, we included why our study is important among Brazilian HCWs, focusing on anxiety symptoms and potential protective factor of spirituality against these symptoms in HCWs. Please see lines 53-55, first paragraph (page 3), and lines 57-62, second paragraph (page 3).

Q6 R#1: “Please more clearly about the sentences in line 69-70 “However, the effects of each spirituality dimension on the AS of HCWs have not been studied during the COVID-19 outbreak”. Is it valid or true based on the previous study?”

Answer Q6 R#1: To our knowledge, the effect of spirituality dimensions (peace, meaning, and faith) on AS in HWCs have not been studied in the current pandemic. Then, it is valid and true based on the literature review of previous studies. Please see lines 71-75 (pages 3 and 4).

Q7R#1: “Line 71-15. The present study aimed to investigate AS predictors in HCWs, including spirituality, considering two different starting times for the AS. First, we assessed AS starting before the COVID-19 outbreak (first objective). Thereafter, we studied the predictors for AS conversion during the pandemic (second objective.) Finally, for each period, we analyzed which spirituality dimensions would predict AS (third objective).

Considering your objective please provide your results based on the objectives in the abstract section, especially the third objective?”

Answer Q7 R#1: We would like to thank R#1 for this interesting suggestion. First, we described our three objectives in the background section of the RV abstract (lines 31-34). After, we provided our results based on each objective in the results section of the revised abstract (lines 41-45).

Q8R#1: “In line 77-78, Page 3. This study was carried out in HCWs from 12th May until 9th July 2020 at a reference University Hospital for COVID-19 in Rio de Janeiro, Brazil. Based on the time. Please more detail about the time (starting before the COVID-19 outbreak-first objective; and during the pandemic-second objective) or pandemic and pandemic period”

Answer Q8 R#1: We thank the reviewer for pointing this out. Based on our study time, all eligible HCWs filled out a face-to-face questionnaire about spirituality and AS. The presence of AS was assessed in an all-or-none fashion based on a questionnaire that included a question if these symptoms had persisted for a minimum of 6 months. As the first case of COVID-19 in Brazil was reported on February 26th 2020, it was possible to identify the participants who presented AS that started before this date. Then, the sample was divided into two groups according to the presence of AS that had started before the pandemic (no-AS and AS groups)- first objective. In order to assess the AS directly associated with the pandemic period, we subdivided the sample into two other groups: no-AS subjects that remained without AS (non-converted group) and subjects who converted to AS (converted group)- second objective. Please see lines 91-97, fifth paragraph (page 4).

Q9 R#1: Line 78-80. Exclusion criteria: age below 20 years or above 60 years, previous or current neurological disorders, uncontrolled clinical conditions, and taking antidepressant, anxiolytic, and antipsychotic medications.

a. Please measure your criteria exclusion age bellow 20 years-related the HCWs or general population?

Answer Q9a R#1: We do not include individuals from the general population. To make this age issue clearer, we have removed the age range from the exclusion criteria and described it in the inclusion criteria. Please see lines 83-84 in the third paragraph (pages 4).

b. How about the authors clarified or measure the validity of previous or current neurological disorders, uncontrolled clinical conditions, and taking antidepressant, anxiolytic, and antipsychotic medications?

Answer Q9b R#1: We thank R#1 for this relevant question. In addition to the face-to-face questionnaire carried out by each participant, we were able to verify these exclusion criteria through data obtained in the periodic healthy examination performed every six months by the occupational physician of our Hospital. Please see lines 139-140 in the second paragraph (page 6).

Q10 R#1: Please provide more detail about the validity and reliability FACIT-Sp among Brazilian … reliability (based on your results) each domain because the author used each domain

Answer Q10 R#1. In the RV, we described the validity and reliability of FACIT-Sp among Brazilian and provided our data of the FACIT-Sp and its domains. Please see lines 107-112, first paragraph (page 5).

Q11 R#1: Line 95-97. “Normally distributed continuous variables (age and FACIT-Sp total score) are presented as the means and standard deviations and were evaluated using an independent t-tests. As well as “The associations are presented as odds ratios (OR) and 95% confidence intervals (CI 95%)”. Please provide the result, could be easier to use the table related the all objective (before, during the pandemic and each period).

Answer Q11 R#1: We fully agree with R#1. We displayed our results in a table. Then, we include “Table 1” in the RV.

Q12 R#1: “The methods: needs to be more complete …”

Answer Q12 R#1: We thank the reviewer for pointing this out. All adjustments and additions of new sentences are in the “Material and Methods” section of the RV. Please see this section on pages 4-6 of the RV.

Q13 R#1: “Please provide references related to the minimum sample size and the kind of assessment of sample size method.”

Answer Q13 R#1: For the regression method it is well established that 15 subjects for each predictor is desirable. Hair et al. [Hair, Black, Babin, Anderson & Tatham. Multivariate Data Analysis, 2014, 7th Edition] have suggested a minimum of 10 subjects for predictor. As four predictors were used in our model (sex, age, religious affiliation, and the total FACIT-Sp score), at least 40 subjects (n=40) were needed. For the prediction analysis of the three spirituality dimensions, at least 30 individuals (n=30) were required to investigate whether these dimensions could predict significantly AS among HCWs.

Q14 R#1: “Methods in this manuscript are generally too vague. They need to be more descriptive and clearer in defining inclusion the subjects.”

Answer Q14 R#1: In the RV, we described in detail the inclusion of the subjects. Please see lines 83-84, second paragraph (page 4), and lines 86-89, fourth paragraph (page 4).

Q15 R#1: “Line 111, please provide the detail of ethical approval ethic of this study.”

Answer Q15 R#1: We agree with R#1. In the RV, we provide more detail of the ethical approval of our study. Please see lines 133-139, second paragraph, page 6.

Q16 R#1: “In the discussion section, please describe the reason or mechanism of spirituality might protective anxiety symptoms.”

Answer Q16 R#1: In the revised version, we have included one more subsection [(“The effect of spirituality on AS starting before and during the pandemic (first and second objectives)]” to describe a potential reason or mechanism by which spirituality may protect against AS. Please see lines 220-235 (pages 10 and 11).

Q17 R#1: “Please provide data value of sex, age, and religious affiliation based on the objective”

Answer Q17 R#1: We agree entirely with R#1. We included a table (“Table 1”) in the RV that we provided our data of sex, age, and religious affiliation based on the two different starting times (AS starting before and during the pandemic). Please see these variables displayed in “Table 1”.

Q18 R#1: “Line 160. “Sex, age, and religious affiliation were not included in the logistic regression equation because we have applied the forward analysis”. Please provide more detail about the reason and previous studies to similar or contrast about the findings among HCWs (don’t general population).”

Answer Q18 R#1: We thank the reviewer for pointing this out. We agree that this sentence in line 160 of the original manuscript needs to be more descriptive. Then, we included some sentences in the RV. Previous studies during the pandemic have shown that sex and age are predictors of AS in HCWs (lines 50-51, page 3). However, it is not known that religious affiliation and spirituality are predictors of these symptoms in HCWs. Then, we used the forward stepwise regression method to find the best predictors of the AS. Our model considered sex, age, religious affiliation, and the FACIT-Sp total score to investigate whether these variables could significantly predict less AS among HCWs. Based on our approach, sex, age, and religious affiliation were not included as predictors in the logistic regression model (forward regression method). Spirituality was the only reliable predictor of AS in HCWs. Please see lines 123-126 (pages 5 and 6), and lines 202-205 (page 9).

Q19 R#1: “Should include potential other confounding variables that could be related to spiritual and anxiety symptoms… A larger sample of healthcare workers recruited from various areas in Brazil …”.

Answer Q19 R#1: We agree with R#1. Then, we included this interesting comment in the limitations section of the RV. Please see lines 252-254 (page 11).

Reviewer #2:

“It would be best if the discussion and conclusion sections could be expanded upon to allow for a more robust discussion of results and their direct implications of future practices for the well being of HCWs. The manuscript was very robust with statistical analysis that showed the implications of spirituality on AS, however lacked a next step for HCW. This would be helpful to add to the manuscript.”

We are appreciative of the R#2 encouragement and the opportunity to revise the manuscript. Basically, R#2 raised two interesting points.

Q1 R# 2 “….best if the discussion and conclusion sections could be expanded upon to allow for a more robust discussion of results and their direct implications of future practices for the well being of HCWs.”

Answer Q1 R#2: We thank R#2 for this thoughtful comment. We expand the discussion and conclusion sections to describe a more robust discussion of the findings and their direct implications for future practice for the HCWs. Please see lines 196-200 in second paragraph (page 9); lines 222-235 (page 10 and 11); lines 242-250, second paragraph (page 11); lines 257-262, first paragraph (page 12); lines 263-266, second paragraph (page 12); lines 269-271, third paragraph (page 12); lines 275-278, fourth paragraph (page 12).

Q2R# 2 “...very robust with statistical analysis that showed the implications of spirituality on AS, however lacked a next step for HCW.”

Answer Q2 R#2: We thank R#2 for this interesting comment. Please see lines 260-262, first paragraph (page 12); lines 263-266, second paragraph (page 12); lines 277-278, fourth paragraph (page 12).

The revised manuscript incorporated all the thoughtful suggestions and comments made by the two anonymous reviewers. The manuscript is considerably improved after taking into account all the interesting points raised by the reviewers.

We hope it will now merit publication in PLOS ONE.

Sincerely

Julio Cesar Tolentino, M.D, Ph.D.

Attachment

Submitted filename: Response to Reviewers .docx

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Decision Letter 1

Rosemary Frey

10 Jan 2022

PONE-D-21-18892R1Spirituality as a protective factor for anxiety symptoms in healthcare workers during the COVID-19 outbreakPLOS ONE

Dear Dr. Tolentino,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Please address the issues concerning the rationale and methodology of the study raised by reviewer 3.

==============================

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We look forward to receiving your revised manuscript.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I am pleased to read and review manuscript ID PONE-D-21-18892 entitled " Spirituality as a protective factor for anxiety symptoms in healthcare workers during the COVID-19 outbreak". The study is interesting and I suggest to publish

Reviewer #3: This manuscript describes the relevance of spirituality/religion to anxiety symptoms among Brazilian healthcare workers (HCWs) prior to and during the CV19 pandemic. The topic is novel, data (assessment of pre- and post-CV19 anxiety) is very novel, and the paper is worthwhile. However, the manuscript would benefit from a number of changes.

Abstract: Description of the study methods is unclear - the authors did NOT have two starting times rather participants were assessed at a single time-point during the CV19 pandemic and asked retrospectively about pre-CV19 symptoms of anxiety. Further, the word "converted" is inappropriate and a bit odd given that authors assessed spirituality/religion; authors should rephrase that participants were divided into those with chronic anxiety (pre-CV19 and during) vs. acute anxiety (only during CV19) and this language should be used throughout the paper. Reference to the specific dimensions of spirituality should be omitted from the abstract since readers are likely not yet familiar w/the measure or its sub-dimensions without having read the paper. Importantly: The study was conducted in Brazil yet this is omitted from the title and abstract.

Introduction: Justification of the study should be stronger - authors simply claim that age and gender are relevant and spirituality should be examined. Further, authors do not review existing research on spirituality/religion and anxiety, which are more complex than a simple buffering effect - see https://psycnet.apa.org/record/2020-20098-003 for a recent review. The rationale for looking at spirituality among HCWs is also absent. The context of the study - Brazil - should be mentioned as a justification, since spirituality/religion is commonplace within Brazilian culture. The measure need not be introduced in the introduction. Relevance of CV19 to both anxiety and spirituality should be explained: Why might spirituality be more (or less?) relevant to HCWs with anxiety that preceded CV19 vs. those experiencing acute anxiety during the pandemic without a history of anxiety? Hypotheses should be provided along these lines - e.g., Many people increase spirituality in times of distress and those without a history of anxiety may benefit less from spirituality, Alternatively, those with chronic anxiety may stand to benefit the most from spirituality. The authors need to justify their methods and approach more clearly.

Methods: Sampling method is inadequately described; was this a convenience sample? How were participants recruited? How many refused to participate? Were they compensated? More importantly, the analytic plan needs substantive revision. Why did the authors only select participants without AS before the pandemic?? As is, the authors examined the relevance of spirituality to anxiety, among participants with no significant anxiety - what is the relevance of such an approach?! Similarly they excluded individuals using psychotropic medications - why would they do this considering that the main variable under study is clinical? Another concern pertains to the measure of spirituality. As Koenig and others have explained, the FACIT assesses multiple dimensions of "spirituality" and the peace sub-scale is more akin to an assessment of mental health than spiritual/religious life. Thus, a significant negative relationship between "peace" and anxiety is not very meaningful. By contrast, the "faith" subscale would yield more interesting results. Again, I encourage the authors to examine these variables among individuals with chronic vs. acute anxiety within their sample.

Results and Discussion not reviewed in light of the above substantive concerns.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2022 May 3;17(5):e0267556. doi: 10.1371/journal.pone.0267556.r004

Author response to Decision Letter 1

24 Feb 2022

Prof. Emily Chenette, Ph.D. - Editor-in-Chief – PLOS ONE

Prof. Rosemary Frey, Ph.D. - Academic Editor – PLOS ONE

Dear Editors,

We are glad to know that, based on the first two anonymous reviewers, our revised manuscript entitled “Spirituality as a protective factor for chronic and acute anxiety in Brazilian healthcare workers during the COVID-19 outbreak " has merit for publication. We thank the Editors and the first two reviewers for the time spent reviewing our manuscript and for the valuable input given to improve it. The Reviewer 1 concluded that “The study is interesting and I suggest to publish” and the Reviewer 2 said that “The manuscript was very robust with statistical analysis that showed the implications of spirituality on AS”. After this first major revision, the two Reviewers agreed that all questions were correctly addressed in the revised manuscript (RM). Meanwhile, the Editors invited a third reviewer. After receiving the comments raised by all the three reviewers, the final decision was a minor review that should address the new points raised by the third Reviewer.

The Reviewer 3 (R#3) stated that “This manuscript describes the relevance of spirituality/religion to anxiety symptoms among Brazilian healthcare workers (HCWs) prior to and during the CV19 pandemic. The topic is novel, data (assessment of pre- and post-CV19 anxiety) is very novel, and the paper is worthwhile. However, the manuscript would benefit from a number of changes.”. We greatly appreciate his/her meaningful comments on our manuscript.

Please find below the detailed point-by-point responses to all the interesting questions (Q) raised by the R#3.

Q1: “Abstract: Description of the study methods is unclear - the authors did NOT have two starting times rather participants were assessed at a single time-point during the CV19 pandemic and asked retrospectively about pre-CV19 symptoms of anxiety. Further, the word "converted" is inappropriate and a bit odd given that authors assessed spirituality/religion; authors should rephrase that participants were divided into those with chronic anxiety (pre-CV19 and during) vs. acute anxiety (only during CV19) and this language should be used throughout the paper.”

Answer Q1: We agree with the point raised by the R#3. In the abstract of the RM, we stressed that participants were assessed at a single time-point during the pandemic. Then, we divided the subjects into chronic anxiety (anxiety that started pre-COVID-19 and persisted during the pandemic) vs. acute anxiety (anxiety that started only during the pandemic). These terms (chronic and acute anxiety) were incorporated in the abstract, figures (Fig.1 and Fig. 2), table 1, legends, title, and throughout the RM.

Q2: “Abstract: … Reference to the specific dimensions of spirituality should be omitted from the abstract since readers are likely not yet familiar w/the measure or its sub-dimensions without having read the paper.”

Answer Q2: As our results are based on these specific dimensions, we believe that we should keep this information in the abstract.

Q3: “Importantly: The study was conducted in Brazil yet this is omitted from the title and abstract.”

Answer Q3: We entirely agree with this interesting comment raised by the R#3. Please see the revised title and abstract (line 35- page 2).

Q4: “Introduction: Justification of the study should be stronger - authors simply claim that age and gender are relevant and spirituality should be examined. Further, authors do not review existing research on spirituality/religion and anxiety, which are more complex than a simple buffering effect - see https://psycnet.apa.org/record/2020-20098-003 for a recent review. The rationale for looking at spirituality among HCWs is also absent...”.

Answer Q4: In the revised introduction we stressed that spirituality involves cognitive and emotional states such as beliefs, motivations, and a sense of gratitude as pointed out by Rosmarin & Bethany (2020). Positive cognitive or emotional aspects of spirituality have been found to be associated with less anxiety (https://psycnet.apa.org/record/2020-20098-003). Please see lines 85-87 (page 3). Moreover, we also make clear that González-Sanguino et al. (Brain Behav Immun. 2020;87: 172–176), using regression methods, have demonstrated the importance of spirituality as the main protector against appearance of anxiety. Please see lines 88-89 (page 3).

In the RM introduction, we fully extended the rationale for looking at spirituality among HCWs. Please see the introduction of the revised version (lines 90-93- page 3).

Q5: “Introduction … The context of the study - Brazil - should be mentioned as a justification, since spirituality/religion is commonplace within Brazilian culture.”

Answer Q5: We thank the reviewer for pointing this out. Please see lines 99-111, pages 3-4.

Q6…The measure need not be introduced in the introduction…”

Answer Q6: We still believe that a brief description of the FACIT should be present in the introduction because we extensively used the spirituality dimensions derived from this questionnaire.

Q7: “Introduction: … Relevance of CV19 to both anxiety and spirituality should be explained: Why might spirituality be more (or less?) relevant to HCWs with anxiety that preceded CV19 vs. those experiencing acute anxiety during the pandemic without a history of anxiety? Hypotheses should be provided along these lines - e.g., Many people increase spirituality in times of distress and those without a history of anxiety may benefit less from spirituality, Alternatively, those with chronic anxiety may stand to benefit the most from spirituality. The authors need to justify their methods and approach more clearly.”

Answer Q7: In the RM we make clear that we did not perform any measure of a putative increase of spirituality. We did not assess spirituality before the pandemic. Although many people may increase spirituality in times of distress, this interesting question entails a new project. However, we pointed out that healthcare workers are under stressful conditions during the pandemic (lines 124-126, page 4).

As there is an increase in the number of subjects with anxiety in times of distress, it is conceivable that higher basal protection should be needed to overcome the demands of a new stressful situation. Therefore, some people without anxiety symptoms preceding the COVID-19 might not be entirely protected during the pandemic. We hypothesized that subjects without pre-pandemic anxiety with higher spirituality at the baseline should be able to overcome the stressful time during the pandemic. Therefore, given the potential protection of greater spirituality against anxiety [12–16], we hypothesized that those experiencing acute anxiety during the pandemic would exhibit lower basal spirituality, as compared to those who remained without anxiety before and during the pandemic.

In addition, differences in spirituality scores would reflect differences in specific spirituality dimensions. As personal faith can increase psychological resilience [45,46], we hypothesized that faith would reach the highest score in those without chronic and acute anxiety. In addition, as faith is associated with better coping in stressful times [47–49], we also hypothesized that higher personal faith could be a potential predictor of less acute anxiety during the pandemic. Please see lines 131-134, second paragraph (page 4).

We would like to stress that we have used the definitions according to the R#3 suggestions (“…authors should rephrase that participants were divided into those with chronic anxiety (pre-CV19 and during) vs. acute anxiety (only during CV19) and this language should be used throughout the paper.”)

Q8: “Methods: Sampling method is inadequately described; was this a convenience sample? How were participants recruited? How many refused to participate? Were they compensated?”

Answer Q8: In the Methods section of the RM, we answered these interesting questions raised by the R#3. Please see lines 157-158, third paragraph (page 5), lines 227-228, second paragraph (page 8), and lines 238-239, third paragraph (page 8).

Q9: “… Why did the authors only select participants without AS before the pandemic??”

As is, the authors examined the relevance of spirituality to anxiety, among participants with no significant anxiety - what is the relevance of such an approach?!”

Answer Q9: Thanks for your comment, but we aimed to investigate whether spirituality would predict anxiety that started before the pandemic and persisted during the pandemic (chronic anxiety) and anxiety that started only during the pandemic (acute anxiety).

We select participants without anxiety symptoms before the pandemic in order to investigate the predictors of acute anxiety during the pandemic- Please see lines 172-176, first paragraph (page 6).

Again, we did not measure spirituality before the pandemic because it was not included in our objectives.

Q10: “Similarly they excluded individuals using psychotropic medications - why would they do this considering that the main variable under study is clinical?”

Answer Q10: We excluded individuals using psychotropic medications to avoid a potential protective effect of these drugs on the development of anxiety symptoms, especially in those who started these symptoms only during the pandemic (acute anxiety). Furthermore, it should be mentioned that these medications could also be used to treat some clinical diseases.

Q11: “Another concern pertains to the measure of spirituality. As Koenig and others have explained, the FACIT assesses multiple dimensions of "spirituality" and the peace sub-scale is more akin to an assessment of mental health than spiritual/religious life. Thus, a significant negative relationship between "peace" and anxiety is not very meaningful. By contrast, the "faith" subscale would yield more interesting results. Again, I encourage the authors to examine these variables among individuals with chronic vs. acute anxiety within their sample.”

Answer Q11: We thank the R#3 for pointing this out. Previous studies on the peace domain derived from the FACIT-SP have been shown that this dimension reflects an affective component of spirituality [35,36,41,42]. In addition, the peace dimension correlates with mental health [11,43,44], and some researchers have reported a significant negative relationship between "peace" and anxiety [11,43]. Furthermore, we agree with the R#3 that the findings of the present study about the faith spirituality dimension are more interesting. Indeed, we found that the faith dimension emerged together with peace to confer protection on acute anxiety starting only during the COVID-19 outbreak.

As suggest by R#3 we examined these variables (peace and faith spirituality dimensions) in the fourth objective of this study.

Q12: “Results and Discussion ….”

Answer Q12: In the RM we made the changes based on the interesting comments raised by the R#3. In addition, we have included one more subsection in the Results and Discussion sections regarding the fourth objective. Please see the Results and Discussion sections in the revised version.

The revised manuscript incorporated all the thoughtful suggestions and comments made by the three anonymous reviewers. After responding to the new points raised by the R#3, we hope it will now merit publication in PLOS ONE.

Sincerely

Julio Cesar Tolentino, M.D, Ph.D.

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Decision Letter 2

Rosemary Frey

12 Apr 2022

Spirituality as a protective factor for chronic and acute anxiety in Brazilian healthcare workers during the COVID-19 outbreak

PONE-D-21-18892R2

Dear Dr. Tolentino,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Rosemary Frey

Academic Editor

PLOS ONE

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Reviewers' comments:

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Reviewer #1: All comments have been addressed

Reviewer #4: All comments have been addressed

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Reviewer #1: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #4: Yes

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Reviewer #4: Yes

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Reviewer #1: I am pleased to read and review manuscript ID PONE-D-21-18892 revision-2. The study is interesting and I suggest to publish

Reviewer #4: researchers have corrected and answered clearly all the comments of previous reviewers. there are only two questions that must be answered clarified by the researcher

Q1; exclusion criteria; what is the reason you use the exclusion criteria regarding regularly performed every six months? describe in more detail. Line 175 Page 8

Q2; What kind of psychosocial intervention is more suitable for spiritual uplifting? provide some more specific recommendations. Line 336 page 15

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Reviewer #1: No

Reviewer #4: No

Acceptance letter

Rosemary Frey

21 Apr 2022

PONE-D-21-18892R2

Spirituality as a protective factor for chronic and acute anxiety in Brazilian healthcare workers during the COVID-19 outbreak

Dear Dr. Tolentino:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Rosemary Frey

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Fig. The mean FACIT-Sp total score for each group.

    (A) FACIT-Sp total score is statistically significantly higher in the no chronic anxiety group compared to the chronic anxiety group (*p<0.001), indicating a lower spirituality among the subjects experiencing anxiety that started pre-COVID-19 and during the pandemic (B) The boxplot indicates that the FACIT-Sp total score is also statistically significantly higher in the group without chronic and acute anxiety (*p<0.001) as compared to the acute anxiety group.

    (TIFF)

    Click here for additional data file. (389.4KB, tiff)
    S2 Fig. Effects of spirituality dimensions on anxiety symptoms according to chronic and acute anxiety.

    (A) The peace was the only spirituality dimension protective of chronic anxiety (B) Peace and faith spirituality dimensions are protective factors against acute anxiety during the pandemic.

    (TIFF)

    Click here for additional data file. (343.8KB, tiff)
    Attachment

    Submitted filename: PONE-D-21-18892_reviewer..docx

    Click here for additional data file. (20.4KB, docx)
    Attachment

    Submitted filename: Response to Reviewers .docx

    Click here for additional data file. (30.5KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (37.4KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting Information files.

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