Examining the effects of anxiety and education level on mental health: The role of spiritual intelligence as an intervening variable in post COVID-19 patients in Indonesia

Anis Ansyori; Ahmad Yunus; Sentot Imam; Yuly Peristiowati

doi:10.12688/f1000research.154599.1

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Research Article

Examining the effects of anxiety and education level on mental health: The role of spiritual intelligence as an intervening variable in post COVID-19 patients in Indonesia

[version 1; peer review: 1 approved with reservations]

Anis Ansyori ¹, Ahmad Yunus¹, Sentot Imam¹, Yuly Peristiowati¹

PUBLISHED 12 Aug 2024

Author details Author details

¹ St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, East Java, 64123, Indonesia

Anis Ansyori
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Ahmad Yunus
Roles: Conceptualization, Methodology, Supervision, Validation

Sentot Imam
Roles: Conceptualization, Methodology, Supervision, Validation

Yuly Peristiowati
Roles: Conceptualization, Methodology, Supervision, Validation

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Society for Mental Health in Low- and Middle-Income Countries (SoMHiL) gateway.

Abstract

Background

The COVID-19 pandemic has profoundly affected global health systems and daily life, exacerbating vulnerabilities, particularly in Indonesia. This study investigates the impact of anxiety and education level on mental health, with spiritual intelligence as an intervening variable among post-COVID-19 patients in Indonesia.

Methods

A cross-sectional design was employed, analyzing data from 390 post-COVID-19 patients in Indonesia. Structured questionnaires were used to assess anxiety, education level, spiritual intelligence, and mental health.

Results

The findings indicate that anxiety significantly affects both spiritual intelligence and mental health, with spiritual intelligence acting as a mediating factor. Additionally, higher educational attainment is positively associated with enhanced spiritual intelligence and improved mental health outcomes.

Conclusions

The study underscores the importance of incorporating spiritual development practices into mental health interventions and educational programs to boost resilience and overall well-being in the post-pandemic era. These practices can help mitigate the adverse effects of anxiety and educational disparities on mental health.

Keywords

anxiety; education level; spiritual intelligence; mental health

Corresponding author: Anis Ansyori

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Ansyori A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.

How to cite: Ansyori A, Yunus A, Imam S and Peristiowati Y. Examining the effects of anxiety and education level on mental health: The role of spiritual intelligence as an intervening variable in post COVID-19 patients in Indonesia [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:916 (https://doi.org/10.12688/f1000research.154599.1) First published: 12 Aug 2024, 13:916 (https://doi.org/10.12688/f1000research.154599.1) Latest published: 18 Feb 2025, 13:916 (https://doi.org/10.12688/f1000research.154599.4)

1. Introduction

The COVID-19 pandemic has had a significant influence on worldwide health systems, economies, and daily life, dramatically altering the way societies function and interact (Clemente-Suárez et al., 2021; Onyeaka et al., 2021). In Indonesia, the impact has been particularly profound, as the pandemic has exposed and intensified existing vulnerabilities within the healthcare infrastructure. The country’s healthcare system, already facing challenges such as limited resources and uneven access to services, has been pushed to its limits by the demands of the pandemic. This strain has exacerbated pre-existing issues, leading to a widespread epidemic of mental health disorders that affect both healthcare professionals and the general public (Gupta & Sahoo, 2020; Søvold et al., 2021).

Anxiety and depression have surged in Indonesia, mirroring a global trend of rising mental health concerns during the pandemic. Healthcare professionals, who are on the front lines, have faced immense pressure, dealing with overwhelming workloads, the risk of infection, and the emotional toll of patient care. This has resulted in increased levels of stress, burnout, and mental fatigue among medical workers. Similarly, the general public has experienced heightened anxiety and depression due to factors such as social isolation, economic instability, and fear of the virus (Alfadla et al., 2020; Kumar et al., 2022; Tolentino et al., 2022).

The pandemic has disrupted daily life, altering routines, and impacting economic activities, further compounding mental health issues. Lockdowns and restrictions have limited social interactions, leading to feelings of loneliness and uncertainty (Nitschke et al., 2021; Patulny & Bower, 2022). The economic downturn has resulted in job losses and financial insecurity, which have added to the psychological burden faced by many individuals (Dubey et al., 2020). As these stressors continue to affect the population, understanding and addressing the mental health challenges they present have become increasingly important for Indonesia’s recovery and resilience in the post-pandemic era.

There are particular difficulties that arise during the transition from acute illness to recovery that may have an impact on mental health. Among these difficulties, anxiety has emerged as a major problem due to persistent concerns about one’s health, unpredictability in the economy, and the pandemic’s wider effects. Anxiety disorders are the most common mental health conditions, significantly impacting quality of life and functioning (Minoletti et al., 2022). Increased anxiety can show up in a number of ways, such as physical symptoms, sleep difficulties, and overall psychological discomfort (Richards et al., 2020; Rowa et al., 2017), all of which have a substantial negative impact on mental health (Rathakrishnan et al., 2022).

In addition, educational level has a significant impact on mental health, influencing how individuals perceive and respond to stressors. Higher education levels are generally linked to improved coping strategies, increased access to resources, and greater resilience. Individuals with higher educational attainment are often better equipped to navigate complex challenges due to their enhanced problem-solving skills and access to information (Wu et al., 2013). This ability to effectively manage stress can lead to more positive mental health outcomes, as educated individuals may employ healthier coping mechanisms and utilize available support systems more effectively (Mirowsky, 2017).

Conversely, people with lower levels of education may face substantial barriers in accessing mental health resources and information. They might struggle to find or afford appropriate care, leading to delayed or inadequate treatment. This difficulty in obtaining help can exacerbate feelings of helplessness and stress, resulting in increased anxiety levels and poorer mental health outcomes. The lack of educational opportunities may also limit their awareness of effective coping strategies, further compounding their vulnerability to mental health issues.

In this situation, spiritual intelligence—which is described as the capacity to negotiate challenging emotional environments, remain adaptable, and rely on one’s own principles and beliefs to get through difficult times (Emmons, 2000; Hyde, 2004)—may be rather important. It has been proposed that spiritual intelligence guards against anxiety and other mental health issues (Tolentino et al., 2022). In the midst of the pandemic’s upheavals, it offers a framework for people to find purpose and stability, which may lessen the detrimental effects of anxiety and educational inequality on mental health.

Despite the growing interest in spirituality as a factor in mental health, there remains a notable gap in the literature regarding the specific role of spiritual intelligence in the post COVID-19 context. Existing research has not fully explored how spiritual intelligence might mediate the relationship between anxiety, educational level, and mental health outcomes. This study aims to fill this gap by employing a cross-sectional design to assess the prevalence of anxiety and depression among post COVID-19 patients in Indonesia. It will investigate the extent to which spiritual intelligence serves as an intervening variable that mediated the effects of anxiety and educational level on mental health.

2. Literature review and hypothesis development

2.1 Anxiety

Excessive concern, trepidation, and fear are hallmarks of anxiety, a common mental health condition that can have a serious negative influence on a person’s ability to function in everyday life and overall quality of life. According to research on the subject, anxiety can result from a complex interaction of hereditary, environmental, and psychological factors (Barlow, 2002). Anxiety disorders are among the most prevalent mental diseases globally, affecting over 18% of adult Americans alone, according to Kessler et al. (2005). Numerous research showing heightened anxiety symptoms due to health worries, social isolation, and economic difficulties have documented how the COVID-19 pandemic has further exacerbated anxiety levels globally (Rajkumar, 2020). Anxiety can take on multiple forms, such as panic disorder, social anxiety disorder, and generalized anxiety disorder, each with its own set of symptoms and difficulties. Research has demonstrated that cognitive-behavioral therapy (CBT) is a successful treatment for anxiety disorders, as it can effectively reduce symptoms and enhance coping mechanisms (Hofmann et al., 2012). While they may have adverse effects and need to be closely monitored, pharmacological therapies, such as selective serotonin reuptake inhibitors (SSRIs), are also frequently used to treat anxiety symptoms (Baldwin et al., 2014). According to Hofmann et al. (2010), recent research has examined the potential of mindfulness and relaxation practices as supplemental therapies, with an emphasis on their effectiveness in reducing anxiety. For those seeking therapy for anxiety, obstacles to care such as stigma and a lack of resources persist despite improvements in treatment. Research on anxiety must continue as our understanding of the problem advances in order to create more approachable and efficient interventions for those who suffer from this widespread illness.

2.2 Education level

It has long been known that an individual’s educational level has a substantial impact on their resilience, coping mechanisms, and resource accessibility, all of which are related to their mental health. Higher educational level is regularly linked to better mental health outcomes because it frequently gives people the tools they need to think critically, solve problems more effectively, and comprehend a wider range of health-related information (Mirowsky & Ross, 2003). These abilities can improve a person’s capacity to deal with difficult situations and find resources, which can result in an increase in psychological well-being (Ross & Wu, 1995). Additionally, education gives people access to social and economic possibilities that might lower stress and anxiety, which promotes an atmosphere that is more stable for mental health (Burgard & Lin, 2013). On the other hand, those with less education could have trouble getting mental health care because they don’t know about or comprehend the resources that are accessible to them. This can make them feel even more stressed and helpless (Zajacova et al., 2015). These differences have been brought to light even more by the COVID-19 pandemic, as people with lower educational level have found it more difficult to adjust to distant work and learning environments, which has led to an increase in mental health stresses (Patrick et al., 2020). Comprehending the influence of educational level on mental health is crucial in order to formulate focused measures and regulations that tackle these discrepancies and encourage fair and equal availability of mental health services to individuals from diverse educational backgrounds.

2.3 Spiritual intelligence

The ability to find meaning, purpose, and connection in life is referred to as spiritual intelligence, and it has come to be recognized as a significant element impacting mental health. The capacity to uphold inner calm, exhibit empathy, and exhibit perseverance in the face of difficulty are characteristics of this type of intellect (Zohar & Marshall, 2000). Studies reveal that people with high spiritual intelligence typically have lower rates of anxiety and depression because they are better able to handle stress and difficulties because they have a stronger sense of purpose and connectivity (Vaughan, 2002). A holistic perspective of life’s experiences is facilitated by spiritual intelligence, which enables people to see challenges as chances for personal development rather than insurmountable roadblocks (Emmons, 2000). Additionally, research has demonstrated that spiritual intelligence can increase emotional regulation, which can minimize unpleasant feelings and improve psychological well-being (King & DeCicco, 2009). Spiritual practices that are components of spiritual intelligence, such mindfulness and meditation, have been demonstrated to considerably reduce stress and produce a positive mental state in the context of mental health (Seybold & Hill, 2001). Growing research on spiritual intelligence and its advantages provide a possible path for creating therapies that integrate existential and spiritual elements into therapeutic modalities to address mental health concerns.

2.4 Mental health

An essential part of total wellbeing, mental health includes social, psychological, and emotional dimensions that affect people’s thoughts, feelings, and behaviors. It is essential for managing stress, interacting with people, and making decisions at different phases of life (World Health Organization, 2001). Millions of people worldwide suffer from mental health illnesses, which can have a significant negative influence on an individual’s productivity and quality of life. These disorders include conditions like depression, anxiety, and schizophrenia (Kessler et al., 2005). The stigma attached to mental illness frequently prevents people from getting treatment, which increases the burden of these disorders (Corrigan, 2004). Prevention, early intervention, and access to suitable treatment services are all essential components of a comprehensive strategy for providing effective mental health care (Patel et al., 2016). Various mental health issues have been demonstrated to be effectively managed by psychotherapy, medication, and lifestyle therapies such exercise and mindfulness techniques (Cuijpers et al., 2016). Furthermore, a growing body of research underscores the significance of socioeconomic determinants, including wealth, education, and community support, in shaping mental health outcomes and stresses the necessity of policies that take these elements into account (Marmot, 2005). There is a growing need for comprehensive strategies that integrate mental health into public health agendas in order to improve mental health outcomes worldwide and lessen the stigma and barriers associated with seeking care, as awareness and understanding of mental health issues continue to rise.

2.5 The effect of anxiety on spiritual intelligence and mental health

Pervasive sensations of anxiety and fear are the hallmark of anxiety, which can have a major impact on mental health and spiritual intelligence, among other elements of psychological functioning. Studies have indicated a correlation between elevated anxiety levels and heightened mental health conditions, including emotional discomfort and depression (Rathakrishnan et al., 2022). Furthermore, spiritual intelligence—which includes the ability to find purpose in life, preserve inner calm, and demonstrate empathy—can be impacted by anxiety.

The relationship between anxiety and mental health may be mediated by spiritual intelligence. People who possess strong spiritual intelligence may be better able to control their anxiety because of their increased emotional intelligence, resilience, and capacity to find purpose in difficult circumstances. The detrimental effects of anxiety on mental health may be lessened by this buffering effect. According to Rathakrishnan et al. (2022), spiritual intelligence can improve mental health outcomes by reducing the negative impacts of anxiety.

H1a:

Anxiety has a significant effect on spiritual intelligence.

H1b:

Anxiety has a significant effect on mental health.

H1c:

Anxiety has a significant effect on mental health with spiritual intelligence as a mediation.

2.6 The effect of educational level on spiritual intelligence and mental health

Higher levels of spiritual intelligence can be attributed to improved cognitive and emotional growth, which is correlated with educational level. Putra’s (2016) research revealed a favorable correlation between parents’ educational level and their children’s spiritual intelligence, implying that education can promote spiritual development and comprehension. Higher education can give people the skills and understanding needed to develop spiritual practices and awareness.

Furthermore, there is a strong correlation between mental health outcomes and educational level. Better employment opportunities, financial security, and access to healthcare are all benefits of higher education that can enhance mental health. According to studies by Taple et al. (2022), Raghupathi & Raghupathi (2020), and Namira & Yuliawati (2021), having more education is associated with improved mental health since it gives one access to more resources and support networks. On the other hand, a lack of education can limit one’s ability to utilize these resources, which can result in more stress and worse mental health consequences.

H2a:

Educational level has a significant effect on spiritual intelligence.

H2b:

Educational level has a significant effect on mental health.

H2c:

Educational level has a significant effect on mental health with spiritual intelligence as a mediation.

2.7 The effect of spiritual intelligence on mental health

Spiritual intelligence, which involves the ability to find meaning and purpose in life, maintain inner peace, and exhibit empathy and compassion, is proposed to influence mental health outcomes. The relationship between spiritual intelligence and mental health has been explored in various studies, revealing both supportive and conflicting results. Research by Rathakrishnan et al. (2022) and Wahyuni & Bariyyah (2019) suggests that higher levels of spiritual intelligence are positively associated with better mental health. These studies indicate that spiritual intelligence can help individuals manage stress, anxiety, and other mental health challenges by providing a sense of purpose and resilience.

In contrast, Furqani (2021) found that spiritual intelligence did not have a significant relationship with mental health, highlighting a potential discrepancy in the literature. This conflicting result underscores the need for further investigation into how spiritual intelligence may affect mental health and whether this relationship varies across different contexts or populations. The research gap identified from these differing findings suggests that while spiritual intelligence may generally support mental health, the effect might not be uniform across all studies. Thus, we hypothesize:

H3:

Spiritual intelligence has a significant effect on mental health.

3. Methods

This study investigates post-COVID-19 patients in Indonesia, with the primary focus on those who have recovered from the virus. The research population includes all post-COVID-19 patients in Indonesia, while the sample is specifically drawn from those residing in Indonesia. To be included in the study, participants must have been diagnosed with COVID-19 by a medical doctor, have recovered from the illness, be at least 18 years old at the time of diagnosis, consent to participate, and have been residing in Indonesia during their illness. Exclusion criteria are applied to ensure the validity of the study: patients with chronic illnesses affecting physical and psychological health, those unable to provide accurate health information, individuals who cannot adhere to the study’s lifestyle requirements, those who have undergone significant additional medical treatments post-recovery, and individuals who are deceased or unreachable are excluded.

The sample size was calculated using the Slovin formula, which resulted in a required sample of 390 respondents. This calculation ensures a representative sample size with a margin of error of 5%. The study employs a non-probability sampling technique, specifically purposive sampling, allowing the researcher to select participants based on the defined inclusion criteria. Primary data is collected through structured questionnaires and semi-structured interviews, providing both quantitative and qualitative insights. The Likert scale ranging from 1 to 4 is used for measurement, capturing participants’ responses on anxiety, spiritual intelligence, educational level, and mental health. To eliminate the chance of bias, the questionnaire was carefully designed and thoroughly evaluated before being circulated. Data were analyzed using Structural Equation Modeling (SEM) with SmartPLS 3.2.4 to address the research objectives and test the hypotheses (Ringle et al., 2014).

In this study, various measurement scales are employed to accurately assess the variables of anxiety, educational level, spiritual intelligence, and mental health, ensuring a comprehensive evaluation of each construct.

For anxiety (X1), the scale is based on Storer et al. (2024) and includes dimensions such as feelings of anxiety, fear, sleep disturbances, somatic symptoms, and respiratory symptoms. This scale captures a broad spectrum of anxiety-related experiences, from emotional and psychological aspects to physical manifestations.

The educational level (X2) is measured according to Tirtarahardja (2005). This scale evaluates educational level, relevance of the field of study, and competency. It assesses the impact of an individual’s educational background, including their level of education, how relevant their field of study is, and the competencies they have developed.

Spiritual intelligence (Z) is assessed using the framework from Organ (2006). This scale includes dimensions such as the ability to be flexible, a high level of awareness, the ability to cope with and utilize suffering, the relation to faith, and strong empathy. It measures various aspects of spiritual intelligence, capturing how flexibility, awareness, coping abilities, faith, and empathy contribute to an individual’s spiritual capacity.

Lastly, mental health (Y) is evaluated using the scale developed by Veit and Ware (1983). This includes experiencing depression, loss of control over emotional behavior, the presence of general positive affect, emotional bonding, and overall life satisfaction. This scale addresses different facets of mental health, providing insights into emotional states, positive feelings, and general contentment with life.

The conceptual model for this study, which illustrates the relationships between anxiety, educational level, spiritual intelligence, and mental health, is depicted in Figure 1. This model guides the analysis and interpretation of the data, providing a visual representation of the hypothesized relationships among the study variables.

Figure 1. Conceptual model.

4. Results

4.1 Demographic respondent

Demographic data in Table 1 provides a detailed breakdown of the participants’ characteristics, allowing for a comprehensive understanding of the diverse group surveyed. The data spans various categories including gender, age, education, the year of infection with COVID-19, and employment status, offering insights into the demographic distribution and contextual background of the individuals involved.

Table 1. Demographic data.

Characteristics	n	%
Gender
Male	104	27%
Female	286	73%
Age
23-27 years	59	15%
28-32 years	85	22%
33-37 years	95	24%
38-42 years	77	20%
43-47 years	47	12%
48-52 years	23	6%
53-57 years	1	0%
58-62 years	2	1%
63-67 years	1	0%
Education
Junior High School	28	7%
Senior High School	230	59%
Bachelor	112	29%
Master	17	4%
Doctoral	3	1%
The year of infection with COVID-19
2019	95	24%
2020	97	25%
2021	192	49%
2022	6	2%
Job
Laborer	5	1%
Unemployed/Not yet employed	19	5%
Self-employed	35	9%
Factory worker	73	19%
Student	19	5%
Private sector employee	25	6%
Freelance	30	8%
Craftsman	8	2%
Homemaker	73	19%
Sales Promotion Girl (SPG)	6	2%
Teacher	33	8%
Odd jobs	17	4%
Civil servant	25	6%
Retiree	2	1%
State-owned enterprise employee	10	3%
Lecturer	7	2%
Marketing	3	1%

The demographic data presented offers a detailed overview of the participants’ characteristics across various categories including sex, age, education, the year of infection with COVID-19, and occupation. The sample consists of 390 participants with a distribution skewed towards female respondents, who make up 73% of the total (286 individuals), compared to 27% male participants (104 individuals). Age-wise, the group is mostly concentrated between 23 and 37 years, with 59 participants (15%) aged 23-27 years, 85 participants (22%) aged 28-32 years, and 95 participants (24%) aged 33-37 years. The remaining age groups gradually decrease in representation with the lowest numbers in the 53-67 years range.

Educational levels among the participants vary, with the majority holding a Senior High School diploma (230 participants, 59%), followed by those with a Bachelor’s degree (112 participants, 29%). Fewer participants have attained a Master’s (17 participants, 4%) or Doctoral degree (3 participants, 1%). Regarding the year of COVID-19 infection, a significant number were infected in 2021 (192 participants, 49%), followed closely by those infected in 2020 (97 participants, 25%) and 2019 (95 participants, 24%).

Occupationally, the participants are diverse, with factory workers and homemakers each comprising 19% of the total. Other notable occupations include self-employed (35 participants, 9%), students (19 participants, 5%), and private sector employees (25 participants, 6%). The rest are distributed among various jobs including teachers, freelancers, and civil servants, reflecting a wide range of employment statuses within the group. This diverse demographic composition provides a rich dataset for analyzing the impacts and correlates of various socio-economic factors.

4.2 Measurement model

The measurement model evaluates the reliability and validity of the constructs: Anxiety (X1), Educational Level (X2), Spiritual Intelligence (Z), and Mental Health (Y). Each construct is measured using specific scales, and the reliability and validity of these measurements are tested through various criteria.

The measurement model analysis in Table 2 demonstrated that the constructs used in the study—Anxiety, Educational Level, Spiritual Intelligence, and Mental Health—are both reliable and valid. Each construct showed high internal consistency, with Cronbach’s alpha values exceeding 0.70 and composite reliability values above 0.80. The Average Variance Extracted (AVE) for all constructs surpassed the 0.50 threshold, indicating adequate convergent validity. Moreover, discriminant validity was confirmed as the square root of the AVE for each construct was greater than its highest correlation with any other construct, ensuring distinctiveness among the constructs. These results confirm that the measurement scales used for Anxiety, Educational Level, Spiritual Intelligence, and Mental Health are robust, providing a reliable and valid foundation for further analysis in the structural model.

Table 2. Reliability and validity of constructs.

Construct	Cronbach's Alpha	Composite reliability (CR)	Average variance extracted (AVE)
Anxiety (X1)	0.82	0.85	0.65
Educational Level (X2)	0.75	0.80	0.62
Spiritual Intelligence (Z)	0.88	0.90	0.68
Mental Health (Y)	0.84	0.86	0.70

4.3 Structural model

The structural model presented in the Figure 2 and Table 3 illustrates the relationships among Anxiety (X1), Educational Level (X2), Spiritual Intelligence (Z), and Mental Health (Y). The model employs path coefficients to demonstrate the strength and direction of these relationships.

Figure 2. Result of hypothesis testing model.

Table 3. Direct effect test results.

Direct effects	Path Coefficients	T-Statistics	p-values	Results
X1 ➔ Z	0.561	4.742	0.000	Significant
X2 ➔ Z	0.242	2.667	0.010	Significant
X1 ➔ Y	-0.249	3.999	0.000	Significant
X2 ➔ Y	0.332	2.597	0.013	Significant
Z ➔ Y	0.734	5.342	0.000	Significant

Anxiety (X1) has a significant positive direct effect on Spiritual Intelligence (Z), with a path coefficient of 0.561, a T-Statistic of 4.742, and a p-value of 0.000. This indicates that higher levels of anxiety are significantly associated with higher levels of spiritual intelligence. However, Anxiety has a significant negative direct effect on Mental Health (Y), with a path coefficient of -0.249, a T-Statistic of 3.999, and a p-value of 0.000. This suggests that higher anxiety levels are associated with poorer mental health outcomes.

Educational Level (X2) has a moderate positive effect on Spiritual Intelligence (Z), with a path coefficient of 0.242, a T-Statistic of 2.667, and a p-value of 0.010. This indicates that higher educational levels are significantly associated with higher spiritual intelligence. Educational Level also positively affects Mental Health (Y), with a path coefficient of 0.332, a T-Statistic of 2.597, and a p-value of 0.013. This shows that higher educational levels are associated with better mental health outcomes.

Spiritual Intelligence (Z) has a strong positive effect on Mental Health (Y), with a path coefficient of 0.734, a T-Statistic of 5.342, and a p-value of 0.000. This underscores the crucial role of spiritual intelligence in enhancing mental health, indicating that individuals with higher spiritual intelligence tend to have better mental health outcomes.

The model also examines the indirect effects of Anxiety (X1) and Educational Level (X2) on Mental Health (Y) through Spiritual Intelligence (Z). The indirect effect in Table 4 of Anxiety on Mental Health through Spiritual Intelligence is significant, with a calculated effect of 0.412 (0.561 * 0.734), indicating that higher levels of anxiety contribute to better mental health indirectly by enhancing spiritual intelligence. Similarly, the indirect effect of Educational Level on Mental Health through Spiritual Intelligence is also significant, with a calculated effect of 0.178 (0.242 * 0.734), suggesting that higher educational levels improve mental health indirectly by increasing spiritual intelligence. These significant indirect effects highlight the mediating role of spiritual intelligence in the relationship between anxiety, educational level, and mental health.

Table 4. Indirect effect test results.

Indirect effect	Path Coefficients	P-Values	Results
X1 ➔ Z ➔ Y	0.561 X 0.734 = 0.412	0.000	Significant
X2 ➔ Z ➔ Y	0.242 X 0.734 = 0.178	0.000	Significant

The summary Table 5 below presents the direct, indirect, and total effects of the variables on each other within the model:

Table 5. Total effect test results.

Relationship	Direct effect	Indirect effect	Total effect
X1 ➔ Z	0.561	-	0.561
X2 ➔ Z	0.242	-	0.242
X1 ➔ Y	-0.249	0.412	0.163
X2 ➔ Y	0.332	0.178	0.510
Z ➔ Y	0.734	-	0.734

The direct effect of Anxiety (X1) on Spiritual Intelligence (Z) is 0.561, while the direct effect of Educational Level (X2) on Spiritual Intelligence is 0.242. Both of these effects are significant, indicating that higher anxiety and higher educational levels lead to increased spiritual intelligence. For the relationship between Anxiety and Mental Health (Y), the direct effect is -0.249, suggesting a negative impact. However, when considering the indirect effect through Spiritual Intelligence (0.412), the total effect of Anxiety on Mental Health is 0.163, highlighting a net positive impact due to the mediation by spiritual intelligence.

Educational Level (X2) has a direct positive effect on Mental Health (0.332), and with an additional indirect effect through Spiritual Intelligence (0.178), the total effect on Mental Health is 0.510, emphasizing the substantial positive influence of education on mental health. Lastly, the direct effect of Spiritual Intelligence on Mental Health is notably strong at 0.734, reaffirming its crucial role in promoting better mental health outcomes.

5. Discussion and implication

5.1 The effect of anxiety on spiritual intelligence and mental health

Our findings support the hypothesis that anxiety has a major impact on spiritual intelligence and mental health. Higher degrees of anxiety are linked to higher levels of spiritual intelligence, which suggests that people who are anxious could look for a deeper sense of meaning and purpose in life as a coping mechanism. This result is consistent with the findings of Rathakrishnan et al. (2022), who suggested that anxiety may cause people to become more spiritually intelligent in an attempt to cope with their emotional pain and melancholy. But anxiety’s deleterious impacts are further highlighted by the actual harm it causes to mental health. The idea that spiritual intelligence improves emotional resilience and gives a sense of purpose, hence lowering the deleterious consequences of anxiety, is supported by the fact that spiritual intelligence reduces some of the negative effects of anxiety on mental health.

These results suggest that programs for treating anxiety should take into account the inclusion of spiritual development practices in mental health therapies. By helping people discover meaning and purpose, practices like mindfulness, meditation, and spiritual counseling may be able to lessen the detrimental effects of anxiety on mental health. This strategy is consistent with the buffering theory put forth by Rathakrishnan et al. (2022), according to which spiritual intelligence increases emotional resilience and lessens the negative consequences of anxiety.

5.2 The effect of educational level on spiritual intelligence and mental health

Spiritual intelligence and mental health are strongly influenced by educational level. Increased cognitive and emotional growth is probably the reason why higher educational attainment is associated with increased spiritual intelligence. This confirms Putra’s (2016) findings that learning promotes understanding and spiritual growth. Additionally, studies by Taple et al. (2022), Raghupathi and Raghupathi (2020), and Namira and Yuliawati (2021) that highlight the advantages of higher education in providing access to better employment opportunities, financial security, and healthcare, tend to support the idea that people with higher educational levels also tend to have better mental health outcomes. A supportive framework for mental health is provided by the development of spiritual intelligence as a result of higher education. This suggests that education gives people the knowledge and abilities needed to cultivate spiritual practices and awareness, which in turn has a positive impact on mental health.

The relevance of educational policies and programs in improving mental well-being is shown by the enormous influence that educational attainment has on both spiritual intelligence and mental health. Curricula that support spiritual development in addition to cognitive and emotional development should be incorporated into educational institutions. Programs that promote empathy, ethical reasoning, and critical thinking may raise students’ spiritual intelligence and improve their mental health. This strategy backs up the findings of studies by Taple et al. (2022), Raghupathi and Raghupathi (2020), and Namira and Yuliawati (2021), which show how education can enhance mental health outcomes by giving people better access to resources and support systems.

5.3 The effect of spiritual intelligence on mental health

Improving mental health outcomes requires a high level of spiritual intelligence. Higher spiritually intelligent people are better able to control their stress and anxiety, which benefits their general mental health. This result is consistent with studies by Wahyuni and Bariyyah (2019) and Rathakrishnan et al. (2022), which indicate that spiritual intelligence supports people in exhibiting empathy and compassion, finding meaning and purpose in life, and preserving inner peace—all of which are factors that positively impact mental health. Furqani (2021) did not find a significant correlation between spiritual intelligence and mental health, which suggests that there may be variation in this relationship among groups or circumstances. This is an essential point to remember.

The substantial positive correlation between spiritual intelligence and mental health bears important implications for interventions aimed at promoting mental health. Policymakers and mental health professionals should think about integrating spiritual intelligence development into their initiatives. Mental health initiatives can help people manage stress and anxiety more effectively by providing courses and materials on finding meaning in life, preserving inner calm, and developing empathy. This is consistent with the favorable results reported by Wahyuni and Bariyyah (2019) and Rathakrishnan et al. (2022), which suggests that spiritual intelligence can be an effective means of fostering mental wellness. Notwithstanding the inconclusive results reported by Furqani (2021), it is imperative to customize these initiatives to particular cultural and demographic settings in order to guarantee their efficacy.

6. Conclusion

Comprehending the intermediary function of spiritual intelligence in the associations of anxiety, level of education, and mental health has pragmatic consequences for formulating all-encompassing mental health remedies. Programs that tackle anxiety reduction, educational success, and spiritual growth all at the same time are probably going to be more successful in enhancing mental health results. Individuals will profit from the direct and indirect paths found in this study thanks to the comprehensive approach. In order to develop integrated support systems, mental health policy should encourage interdisciplinary collaborations between educators, mental health practitioners, and spiritual counselors.

However, there are limitations to this study. First, the cross-sectional design restricts the ability to infer causality between the variables. Second, the sample is limited to post-COVID-19 patients in Indonesia, which may affect the generalizability of the findings to other populations or settings. Finally, while the study highlights the importance of spiritual intelligence, it does not fully explore how different aspects of spiritual intelligence contribute to mental health outcomes.

Nevertheless, these results offer insightful information for both scholarly study and real-world interventions meant to improve mental health. Putting a strong emphasis on the growth of spiritual intelligence may be a calculated move to lessen the negative effects of anxiety and maximize the benefits of education. To validate and build on these findings, future studies should investigate these correlations in a variety of demographics and circumstances.

Ethics and consent

All procedures involving human participants in this study were conducted in accordance with the institutional ethical standards of Institut Ilmu Kesehatan Strada Indonesia, which received approval under number 000986/EC/KEPK/I/03/2024 on March 7, 2024. The health and well-being of the participants were prioritized throughout the study, in line with the commitment to ensuring their safety and ethical treatment.

Informed consent was obtained from all participants. Written consent was provided by each participant, who received comprehensive information about the study’s purpose, procedures, potential risks, and benefits. Participants voluntarily agreed to participate in the study based on this information.

Data availability statement

Underlying data

The data presented in this study are available on request from the corresponding author due to confidentiality agreements with the participants involved in the research. Our data statement is complete and adheres to the journal’s guidelines. Access to the data is restricted to protect participant privacy. Researchers wishing to access the data must submit a formal request to the corresponding author, detailing the purpose of their research, the specific data needed, intended use, and measures for ensuring data security and participant confidentiality. Requests will be evaluated on a case-by-case basis, and access will be granted under specific conditions approved by our Institutional Review Board (IRB). For further inquiries, please contact anisansyori@itsk-soepraoen.ac.id.

Extended data

Figshare: Questionnaire for “Examining the Effects of Anxiety and Education Level on Mental Health: The Role of Spiritual Intelligence as an Intervening Variable in Post COVID-19 Patients in Indonesia”, DOI: https://doi.org/10.6084/m9.figshare.26422345.v1 (Ansyori A, et al., 2024a).

Reporting guidelines

STROBE checklist for “Examining the Effects of Anxiety and Education Level on Mental Health: The Role of Spiritual Intelligence as an Intervening Variable in Post COVID-19 Patients in Indonesia”, DOI: https://doi.org/10.6084/m9.figshare.26422324.v1 (Ansyori A, et al., 2024b).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

The authors would like to express their sincere gratitude for the support and resources provided during the course of this research.

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Version 4

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Author details Author details

¹ St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, East Java, 64123, Indonesia

Ahmad Yunus
Roles: Conceptualization, Methodology, Supervision, Validation

Sentot Imam
Roles: Conceptualization, Methodology, Supervision, Validation

Yuly Peristiowati
Roles: Conceptualization, Methodology, Supervision, Validation

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (4)

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© 2024 Ansyori A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.

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Ansyori A, Yunus A, Imam S and Peristiowati Y. Examining the effects of anxiety and education level on mental health: The role of spiritual intelligence as an intervening variable in post COVID-19 patients in Indonesia [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:916 (https://doi.org/10.12688/f1000research.154599.1)

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Reviewer Report 12 Sep 2024

M Arli Rusandi, Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

Approved with Reservations

https://doi.org/10.5256/f1000research.169647.r314076

Summary of the Article:
The article investigates the relationships among anxiety, education level, spiritual intelligence, and mental health in post-COVID-19 patients in Indonesia. Utilizing a cross-sectional design and Structural Equation Modeling (SEM), the study analyzes data collected from 390 participants. The findings reveal that anxiety significantly influences both spiritual intelligence and mental health, with spiritual intelligence serving as a mediating factor. Moreover, the study demonstrates that higher educational attainment is positively correlated with enhanced spiritual intelligence and better mental health outcomes. The article concludes by highlighting the significance of incorporating spiritual development practices into mental health interventions and educational programs to enhance resilience and overall well-being in the post-pandemic context.

Evaluation Based on Questionnaire:
3. Are sufficient details of methods and analysis provided to allow replication by others?
Answer: Partly, Although the methods section is comprehensive and notes the use of established measurement scales, the manuscript would benefit from further elaboration on the validation or adaptation of these scales for the Indonesian context. Providing these additional details would enhance the study's replicability, particularly for researchers operating in different cultural settings.
5. Are all the source data underlying the results available to ensure full reproducibility?
Answer: Partly, the manuscript discusses the availability of data, with some restrictions due to participant confidentiality. While the data availability statement is clear, these restrictions may limit the ability to fully reproduce the study's findings. The authors might consider offering anonymized data or providing further details on how the data can be accessed by qualified researchers.

Reviewer Comments to Author
To ensure comprehensiveness, I will organize my comments according to the manuscript's structure.
Introduction
Major Comments:
1. The introduction provides a solid foundation by addressing the impact of the COVID-19 pandemic on mental health, particularly within the Indonesian context. However, the research aim or question could be articulated more explicitly earlier in the introduction. This would help orient the reader and clarify the study's purpose from the outset.
2. The rationale for exploring the role of spiritual intelligence as a mediator between anxiety, education, and mental health is well-founded and relevant. However, consider summarizing the existing literature more concisely to avoid redundancy and maintain a sharper focus on the specific research gap your study aims to address.
Minor Comments:
1. Ensure consistent use of terminology when discussing mental health. The text occasionally shifts between general references to mental health and specific conditions such as anxiety and depression. It may be beneficial to clarify early in the manuscript whether the study focuses broadly on mental health or specifically on conditions like anxiety and depression.
2. The transitions between paragraphs could be smoother, especially when shifting from the general discussion of the pandemic’s impact to the specific focus on spiritual intelligence. Consider adding transitional sentences to enhance the narrative flow.

Methodology
Major Comments:
1. The use of purposive non-probability sampling is appropriate given the specific population targeted by the study. However, this approach introduces potential biases that should be acknowledged. It would be beneficial to discuss how these biases might impact the generalizability of the findings and whether any measures were taken to mitigate them.
2. The measurement tools selected for the study appear well-chosen and likely valid. However, it would be advantageous to provide additional details regarding how these tools were adapted or validated for the Indonesian context, particularly considering potential cultural differences in the interpretation of survey items.
Minor Comments:
1. The inclusion and exclusion criteria are clearly articulated and well-defined. However, the exclusion of patients with chronic illnesses could limit the generalizability of the findings. A brief discussion of this limitation would enhance the transparency of the study.
Ethical Considerations:
2. While the methodology section is comprehensive, including a brief mention of the ethical considerations or approval process in this section, in addition to the detailed explanation in the conclusion, would further underscore the study's ethical integrity.

Results
Major Comments:
1. The results are presented with clarity, and the significant findings effectively support your hypotheses. However, the positive relationship observed between anxiety and spiritual intelligence is somewhat counterintuitive. It would be beneficial to explore alternative explanations for this finding or to consider the possibility of reverse causality, either within the results section or in greater detail in the discussion.
2. The significant indirect effects mediated by spiritual intelligence are a crucial aspect of the study's findings. It is important to ensure that these effects are clearly interpreted, particularly in terms of their practical implications for mental health interventions.
Minor Comments:
1. While the demographic data provided is comprehensive, the skew towards younger, female participants should be addressed. Consider discussing how this demographic imbalance might affect the generalizability of your findings to a broader population.
2. The results section could benefit from a brief summary at its conclusion, linking the findings back to the original research questions or hypotheses. This would reinforce the narrative and help ensure that the reader fully grasps the significance of the results.

Discussion and Conclusions
Major Comments:
1. The discussion successfully connects your findings to the existing literature, especially in emphasizing the role of spiritual intelligence. However, the counterintuitive result that anxiety positively influences spiritual intelligence warrants a more thorough exploration. Consider addressing any conflicting literature or offering theoretical explanations to better contextualize this finding.
2. The discussion of limitations is appropriately transparent, particularly with regard to the cross-sectional design and the specificity of the population sample. Expanding on how these limitations could be addressed in future research—such as through longitudinal studies or more diverse sampling—would enhance the robustness of your recommendations.
Minor Comments:
1. The discussion of integrating spiritual intelligence into mental health interventions is well-argued. However, providing additional concrete examples or recommendations for implementation in educational or clinical settings could strengthen this section.
2. The conclusion effectively summarizes the study’s contributions and acknowledges its limitations. Including a final sentence that emphasizes the broader impact of your findings on mental health policy or practice would create a stronger and more impactful closing statement.

Abstract
Major Comments:
The abstract is well-organized and effectively summarizes the study. However, including a brief mention of the study’s limitations or the need for further research would provide a more comprehensive overview. Additionally, specifying the statistical methods used, such as Structural Equation Modeling (SEM), could add depth and clarity.
Minor Comments:
Keywords:
The keywords are appropriate, but you might consider adding terms like "post-pandemic" or "cross-sectional study" to improve searchability and relevance.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: My areas of expertise include Education, Counseling, Digital Health, Information Technology Education, Higher Education, and Artificial Intelligence in Education.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 11 Nov 2024

Anis Ansyori, St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, 64123, Indonesia

11 Nov 2024

Author Response
Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address ... Continue reading
Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address each of your comments and outline the corresponding revisions we have made to the manuscript.
Introduction

Research Aim/Question: We have revised the introduction to state the research aim more explicitly at the beginning to improve clarity and orientation for readers.

Concise Literature Summary: We have streamlined the literature review to maintain focus on the specific research gap related to the role of spiritual intelligence, reducing redundancy as suggested.

Terminology Consistency: We have ensured consistent terminology when discussing mental health, specifying whether we refer to mental health in general or specific conditions such as anxiety and depression.

Paragraph Transitions: Transitional sentences have been added to create a smoother flow, particularly when moving from the pandemic’s impact to the focus on spiritual intelligence.

Methodology

Sampling and Potential Biases: We have acknowledged potential biases from using purposive non-probability sampling and discussed how these biases might impact generalizability.

Adaptation/Validation of Tools: Additional details have been added regarding the adaptation and validation of measurement tools for the Indonesian context, with consideration of cultural factors in interpreting survey items.

Inclusion and Exclusion Criteria: We have discussed how excluding patients with chronic illnesses may limit the generalizability of findings, as recommended.

Ethical Considerations: We have briefly mentioned ethical considerations, including the approval process, in the methodology section to emphasize the study’s ethical integrity.

Results

Anxiety and Spiritual Intelligence: In response to the counterintuitive positive relationship between anxiety and spiritual intelligence, we have expanded the discussion to include possible explanations, such as coping mechanisms and reverse causality, and referenced relevant literature to contextualize this finding.

Interpretation of Indirect Effects: We have clarified the interpretation of significant indirect effects mediated by spiritual intelligence, particularly regarding their practical implications for mental health interventions.

Demographic Data: We have addressed the demographic skew towards younger, female participants and discussed how this may affect the generalizability of our findings.

Summary of Results: A brief summary has been added at the end of the results section to link the findings back to the research questions, reinforcing the significance of the results.

Discussion and Conclusions

Counterintuitive Finding on Anxiety and Spiritual Intelligence: We have provided a more detailed exploration of the unexpected positive relationship between anxiety and spiritual intelligence, referencing possible explanations and conflicting literature.

Discussion of Limitations and Future Research: We have expanded on how limitations, such as the cross-sectional design and specific sample population, could be addressed in future research, including suggestions for longitudinal studies and broader sampling.

Concrete Examples for Interventions: In the discussion on integrating spiritual intelligence into mental health interventions, we have added practical recommendations for implementation in educational and clinical settings.

Final Impact Statement: We have strengthened the conclusion with a closing statement that highlights the broader impact of our findings on mental health policy and practice.

Abstract and Keywords

Limitations and Future Research: We have updated the abstract to briefly mention the study’s limitations and the need for further research.

Statistical Methods: We have included the statistical method used (Structural Equation Modeling) to add clarity.

Keywords: Terms like “post-pandemic” and “cross-sectional study” have been added to improve searchability and relevance.

Once again, we thank you for your constructive feedback, which has greatly helped us refine and strengthen our manuscript. We hope that our responses and revisions meet your expectations and enhance the scientific quality and clarity of our study.

Sincerely,
Authors
Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address each of your comments and outline the corresponding revisions we have made to the manuscript.
Introduction

Research Aim/Question: We have revised the introduction to state the research aim more explicitly at the beginning to improve clarity and orientation for readers.

Concise Literature Summary: We have streamlined the literature review to maintain focus on the specific research gap related to the role of spiritual intelligence, reducing redundancy as suggested.

Terminology Consistency: We have ensured consistent terminology when discussing mental health, specifying whether we refer to mental health in general or specific conditions such as anxiety and depression.

Paragraph Transitions: Transitional sentences have been added to create a smoother flow, particularly when moving from the pandemic’s impact to the focus on spiritual intelligence.

Methodology

Sampling and Potential Biases: We have acknowledged potential biases from using purposive non-probability sampling and discussed how these biases might impact generalizability.

Adaptation/Validation of Tools: Additional details have been added regarding the adaptation and validation of measurement tools for the Indonesian context, with consideration of cultural factors in interpreting survey items.

Inclusion and Exclusion Criteria: We have discussed how excluding patients with chronic illnesses may limit the generalizability of findings, as recommended.

Ethical Considerations: We have briefly mentioned ethical considerations, including the approval process, in the methodology section to emphasize the study’s ethical integrity.

Results

Anxiety and Spiritual Intelligence: In response to the counterintuitive positive relationship between anxiety and spiritual intelligence, we have expanded the discussion to include possible explanations, such as coping mechanisms and reverse causality, and referenced relevant literature to contextualize this finding.

Interpretation of Indirect Effects: We have clarified the interpretation of significant indirect effects mediated by spiritual intelligence, particularly regarding their practical implications for mental health interventions.

Demographic Data: We have addressed the demographic skew towards younger, female participants and discussed how this may affect the generalizability of our findings.

Summary of Results: A brief summary has been added at the end of the results section to link the findings back to the research questions, reinforcing the significance of the results.

Discussion and Conclusions

Counterintuitive Finding on Anxiety and Spiritual Intelligence: We have provided a more detailed exploration of the unexpected positive relationship between anxiety and spiritual intelligence, referencing possible explanations and conflicting literature.

Discussion of Limitations and Future Research: We have expanded on how limitations, such as the cross-sectional design and specific sample population, could be addressed in future research, including suggestions for longitudinal studies and broader sampling.

Concrete Examples for Interventions: In the discussion on integrating spiritual intelligence into mental health interventions, we have added practical recommendations for implementation in educational and clinical settings.

Final Impact Statement: We have strengthened the conclusion with a closing statement that highlights the broader impact of our findings on mental health policy and practice.

Abstract and Keywords

Limitations and Future Research: We have updated the abstract to briefly mention the study’s limitations and the need for further research.

Statistical Methods: We have included the statistical method used (Structural Equation Modeling) to add clarity.

Keywords: Terms like “post-pandemic” and “cross-sectional study” have been added to improve searchability and relevance.

Once again, we thank you for your constructive feedback, which has greatly helped us refine and strengthen our manuscript. We hope that our responses and revisions meet your expectations and enhance the scientific quality and clarity of our study.

Sincerely,
Authors
Competing Interests: No competing interests were disclosed. Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 11 Nov 2024

Anis Ansyori, St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, 64123, Indonesia

11 Nov 2024

Author Response
Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address ... Continue reading
Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address each of your comments and outline the corresponding revisions we have made to the manuscript.
Introduction

Research Aim/Question: We have revised the introduction to state the research aim more explicitly at the beginning to improve clarity and orientation for readers.

Concise Literature Summary: We have streamlined the literature review to maintain focus on the specific research gap related to the role of spiritual intelligence, reducing redundancy as suggested.

Terminology Consistency: We have ensured consistent terminology when discussing mental health, specifying whether we refer to mental health in general or specific conditions such as anxiety and depression.

Paragraph Transitions: Transitional sentences have been added to create a smoother flow, particularly when moving from the pandemic’s impact to the focus on spiritual intelligence.

Methodology

Sampling and Potential Biases: We have acknowledged potential biases from using purposive non-probability sampling and discussed how these biases might impact generalizability.

Adaptation/Validation of Tools: Additional details have been added regarding the adaptation and validation of measurement tools for the Indonesian context, with consideration of cultural factors in interpreting survey items.

Inclusion and Exclusion Criteria: We have discussed how excluding patients with chronic illnesses may limit the generalizability of findings, as recommended.

Ethical Considerations: We have briefly mentioned ethical considerations, including the approval process, in the methodology section to emphasize the study’s ethical integrity.

Results

Anxiety and Spiritual Intelligence: In response to the counterintuitive positive relationship between anxiety and spiritual intelligence, we have expanded the discussion to include possible explanations, such as coping mechanisms and reverse causality, and referenced relevant literature to contextualize this finding.

Interpretation of Indirect Effects: We have clarified the interpretation of significant indirect effects mediated by spiritual intelligence, particularly regarding their practical implications for mental health interventions.

Demographic Data: We have addressed the demographic skew towards younger, female participants and discussed how this may affect the generalizability of our findings.

Summary of Results: A brief summary has been added at the end of the results section to link the findings back to the research questions, reinforcing the significance of the results.

Discussion and Conclusions

Counterintuitive Finding on Anxiety and Spiritual Intelligence: We have provided a more detailed exploration of the unexpected positive relationship between anxiety and spiritual intelligence, referencing possible explanations and conflicting literature.

Discussion of Limitations and Future Research: We have expanded on how limitations, such as the cross-sectional design and specific sample population, could be addressed in future research, including suggestions for longitudinal studies and broader sampling.

Concrete Examples for Interventions: In the discussion on integrating spiritual intelligence into mental health interventions, we have added practical recommendations for implementation in educational and clinical settings.

Final Impact Statement: We have strengthened the conclusion with a closing statement that highlights the broader impact of our findings on mental health policy and practice.

Abstract and Keywords

Limitations and Future Research: We have updated the abstract to briefly mention the study’s limitations and the need for further research.

Statistical Methods: We have included the statistical method used (Structural Equation Modeling) to add clarity.

Keywords: Terms like “post-pandemic” and “cross-sectional study” have been added to improve searchability and relevance.

Once again, we thank you for your constructive feedback, which has greatly helped us refine and strengthen our manuscript. We hope that our responses and revisions meet your expectations and enhance the scientific quality and clarity of our study.

Sincerely,
Authors
Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address each of your comments and outline the corresponding revisions we have made to the manuscript.
Introduction

Research Aim/Question: We have revised the introduction to state the research aim more explicitly at the beginning to improve clarity and orientation for readers.

Concise Literature Summary: We have streamlined the literature review to maintain focus on the specific research gap related to the role of spiritual intelligence, reducing redundancy as suggested.

Terminology Consistency: We have ensured consistent terminology when discussing mental health, specifying whether we refer to mental health in general or specific conditions such as anxiety and depression.

Paragraph Transitions: Transitional sentences have been added to create a smoother flow, particularly when moving from the pandemic’s impact to the focus on spiritual intelligence.

Methodology

Sampling and Potential Biases: We have acknowledged potential biases from using purposive non-probability sampling and discussed how these biases might impact generalizability.

Adaptation/Validation of Tools: Additional details have been added regarding the adaptation and validation of measurement tools for the Indonesian context, with consideration of cultural factors in interpreting survey items.

Inclusion and Exclusion Criteria: We have discussed how excluding patients with chronic illnesses may limit the generalizability of findings, as recommended.

Ethical Considerations: We have briefly mentioned ethical considerations, including the approval process, in the methodology section to emphasize the study’s ethical integrity.

Results

Anxiety and Spiritual Intelligence: In response to the counterintuitive positive relationship between anxiety and spiritual intelligence, we have expanded the discussion to include possible explanations, such as coping mechanisms and reverse causality, and referenced relevant literature to contextualize this finding.

Interpretation of Indirect Effects: We have clarified the interpretation of significant indirect effects mediated by spiritual intelligence, particularly regarding their practical implications for mental health interventions.

Demographic Data: We have addressed the demographic skew towards younger, female participants and discussed how this may affect the generalizability of our findings.

Summary of Results: A brief summary has been added at the end of the results section to link the findings back to the research questions, reinforcing the significance of the results.

Discussion and Conclusions

Counterintuitive Finding on Anxiety and Spiritual Intelligence: We have provided a more detailed exploration of the unexpected positive relationship between anxiety and spiritual intelligence, referencing possible explanations and conflicting literature.

Discussion of Limitations and Future Research: We have expanded on how limitations, such as the cross-sectional design and specific sample population, could be addressed in future research, including suggestions for longitudinal studies and broader sampling.

Concrete Examples for Interventions: In the discussion on integrating spiritual intelligence into mental health interventions, we have added practical recommendations for implementation in educational and clinical settings.

Final Impact Statement: We have strengthened the conclusion with a closing statement that highlights the broader impact of our findings on mental health policy and practice.

Abstract and Keywords

Limitations and Future Research: We have updated the abstract to briefly mention the study’s limitations and the need for further research.

Statistical Methods: We have included the statistical method used (Structural Equation Modeling) to add clarity.

Keywords: Terms like “post-pandemic” and “cross-sectional study” have been added to improve searchability and relevance.

Once again, we thank you for your constructive feedback, which has greatly helped us refine and strengthen our manuscript. We hope that our responses and revisions meet your expectations and enhance the scientific quality and clarity of our study.

Sincerely,
Authors
Competing Interests: No competing interests were disclosed. Close
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Version 4

VERSION 4 PUBLISHED 12 Aug 2024

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Version 4 (revision) 18 Feb 25	read
Version 3 (revision) 17 Jan 25	read	read	read
Version 2 (revision) 11 Nov 24		read
Version 1 12 Aug 24	read

M Arli Rusandi, Universitas Riau, Pekanbaru, Indonesia
Yuni Asri, Institut Teknologi, Sains dan Kesehatan RS dr Soepraoen Kesdam V/Brawijaya, Malang, Indonesia
Nurshahira Ibrahim, Universiti Teknologi MARA, JENGKA, Malaysia

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1 Views

12 May 2025 | for Version 4

M Arli Rusandi, Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

1 Views Cite this report Responses(0)

Approved

No more comments from me, because the authors have fixed it.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

education, counseling, career development, digital health, happenstance lerarning

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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6 Views

19 Feb 2025 | for Version 4

M Arli Rusandi, Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

6 Views Cite this report Responses(0)

Approved

The authors have made substantial and well-executed revisions that directly address my concerns. The study now presents a well-structured and compelling analysis of how anxiety, education level, and spiritual intelligence shape mental health outcomes among post-COVID-19 patients in Indonesia. The introduction clearly states the research objectives and highlights the study’s relevance within the Indonesian post-pandemic context. The refined literature review eliminates redundancy while maintaining a strong theoretical foundation and identifying the research gap. Additionally, the improved methodological transparency enhances the study’s credibility. The authors acknowledge potential biases from the purposive sampling method and explain how they adapted and validated measurement tools to fit the Indonesian context.

One of the most commendable aspects of this revision is the thorough explanation of the counterintuitive finding that anxiety positively influences spiritual intelligence. The discussion now explores theoretical interpretations of this unexpected result, considering factors such as reverse causality and cultural influences. Furthermore, the revised manuscript explicitly outlines ethical considerations and data availability, detailing a structured procedure for requesting access to the study’s data while ensuring participant confidentiality. The discussion also incorporates practical recommendations, offering concrete suggestions on integrating spiritual intelligence into mental health interventions.

The authors have also effectively addressed minor suggestions, such as refining keywords, improving readability, and strengthening the concluding statement on policy implications. Overall, the manuscript is now well-prepared for indexing. This study makes a valuable contribution to mental health research, particularly in post-pandemic settings, by providing important insights into the role of spiritual intelligence as a mediating factor in mental health outcomes. Its clarity, structure, and depth make it an engaging and informative read. No further revisions are necessary, and I recommend the manuscript for acceptance in its current form.

Competing Interests

No competing interests were disclosed.

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education, counseling, career development, digital health, happenstance lerarning

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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13 Feb 2025 | for Version 3

Nurshahira Ibrahim, Universiti Teknologi MARA, JENGKA, Pahang, Malaysia

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Approved With Reservations

1. Is the study design appropriate and is the work technically sound? Answer: Partly
- The cross-sectional design is appropriate for the research objectives, and the use of Structural Equation Modeling (SEM) is suitable for analyzing complex relationships between variables. However, there are some concerns:
1. The cross-sectional nature limits causal inferences, which should be more explicitly acknowledged as a limitation.
2. The adaptation and validation process of the measurement scales for the Indonesian context could be more thoroughly explained to ensure cultural relevance and validity.

2. Are sufficient details of methods and analysis provided to allow replication by others?
Answer: Partly
- While the methodology section is comprehensive, there are areas that could be improved to enhance replicability:
1. More details on the adaptation and validation of measurement scales for the Indonesian context would be beneficial.
2. The specific procedures for data collection and handling could be elaborated.
3. A more detailed description of the SEM analysis process, including software used and model fit indices, would aid replication.

3. Are all the source data underlying the results available to ensure full reproducibility?
Answer: Partly
- The authors mention that data are available on request due to confidentiality agreements. While this protects participant privacy, it may limit full reproducibility. To address this:
1. Consider providing a more detailed data availability statement, including the process for requesting access to the data.
2. If possible, provide anonymized datasets or summary statistics that do not compromise participant confidentiality.

Recommendations:
1. Strengthen the discussion of limitations, particularly regarding the cross-sectional design and its implications for causal inferences.
2. Provide more detailed information on the adaptation and validation of measurement scales for the Indonesian context to ensure cultural relevance and validity.
3. Elaborate on the data collection procedures and SEM analysis process to enhance replicability.
4. Consider offering more concrete recommendations for implementing spiritual intelligence development in mental health interventions and educational programs.
5. Address the demographic skew towards younger, female participants and discuss how this might affect the generalizability of findings.
6. Explore alternative explanations for the positive relationship between anxiety and spiritual intelligence, including the possibility of reverse causality.
7. Enhance the data availability statement to provide clearer guidelines for accessing the data while maintaining participant confidentiality.
8. Consider adding a brief discussion of ethical considerations in the methodology section, in addition to the existing mention in the conclusion.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

My expertise is in spiritual intelligence (psychology context).

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Reviewer Report

13 Views

07 Feb 2025 | for Version 3

M Arli Rusandi, Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

13 Views Cite this report Responses(1)

Approved With Reservations

Summary of Revision Evaluation – Round 2.

Significant improvements have been made throughout the manuscript.
The sections of the Introduction, Methods, Results, Discussion, and Conclusion have been appropriately revised according to the previous suggestions.
No significant inconsistencies or notable methodological errors remain after this revision.

--------------------------
One minor issue remains: The keywords have not been updated as previously agreed.

Final Suggestion:
If the keywords are revised, the manuscript can be considered well-revised and ready for the next stage.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

education, counseling, career development, digital health, happenstance lerarning

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Reviewer Report

6 Views

28 Jan 2025 | for Version 3

Yuni Asri, Department of Nursing, Faculty of Health and Science, Institut Teknologi, Sains dan Kesehatan RS dr Soepraoen Kesdam V/Brawijaya, Malang, Indonesia

6 Views Cite this report Responses(0)

Approved

Thank you for addressing the feedback thoroughly and providing detailed responses to the suggested revisions. I appreciate the effort and thoughtfulness reflected in your revisions.
Overall, these revisions have significantly improved the clarity, transparency, and academic quality of the manuscript. I am satisfied with the changes made and believe they have strengthened the study.
Thank you for your thoughtful responses and the improvements made to the manuscript.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Based on my expertise in Public Health, there are potential research areas that focus on:Mental Health and Psychosocial Support, Health Inequities, Global Health and health policy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

18 Views

06 Dec 2024 | for Version 2

Yuni Asri, Department of Nursing, Faculty of Health and Science, Institut Teknologi, Sains dan Kesehatan RS dr Soepraoen Kesdam V/Brawijaya, Malang, Indonesia

18 Views Cite this report Responses(1)

Approved With Reservations

Study Design and Academic Merit. Structural Equation Modeling (SEM) is appropriate for analyzing complex interrelations among variables. The incorporation of spiritual intelligence as a mediator is innovative and contributes to the academic merits of this study. While the cross-sectional design suits the study objectives, it limits the causal inferences. This should be highlighted more prominently as a limitation of this study. Discuss how the adapted scales were validated for cultural relevance in the Indonesian context.
Statistical Analysis and Interpretation. This manuscript reports a robust statistical analysis with clearly explained path coefficients and mediation effects. The positive relationship between anxiety and spiritual intelligence, while counterintuitive, can be explained as follows. However, additional alternative interpretations and supporting evidence could strengthen this argument. To address potential reverse causality between spiritual intelligence and anxiety more explicitly
Reproducibility of Results. The data availability statement mentions restrictions owing to confidentiality. To enhance reproducibility, we considered providing anonymized datasets or detailed procedures for qualified researchers to access the data. When the scales and tools are cited, their full descriptions or references should be included to ensure reproducibility

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Based on my expertise in Public Health, there are potential research areas that focus on:Mental Health and Psychosocial Support, Health Inequities, Global Health and health policy

Respond to this report

Responses (1)

Author Response

17 Jan 2025

Anis Ansyori, St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, 64123, Indonesia

Dear Reviewer,
Thank you for your valuable feedback. We have carefully revised the manuscript based on your suggestions. Below are the key updates:

1. Study Design and Academic Merit
We have emphasized the limitation of SEM in establishing causality, highlighting that the cross-sectional design restricts causal inferences. To address this, we suggest future longitudinal studies for better understanding. Additionally, we have expanded the validation process of adapted scales, detailing content validation, construct validity assessment, and reliability testing to ensure cultural relevance in the Indonesian context.

2. Statistical Analysis and Interpretation
We have added alternative interpretations and supporting evidence for the relationship between anxiety and spiritual intelligence. Some studies (e.g., Jamshidi et al., 2017) support a positive relationship, while others (Khoshdeli et al., 2020; Safavi et al., 2019; Mohammadipour et al., 2021) suggest a negative effect, where spiritual intelligence helps reduce anxiety. We have acknowledged these differences and also addressed reverse causality, proposing that higher spiritual awareness may increase existential concerns, potentially elevating anxiety.

3. Reproducibility of Results
Due to confidentiality agreements, we cannot provide an anonymized dataset. However, we have updated the data availability statement, outlining a formal request process for researchers. Requests must include name, institution, research purpose, specific data needed, and ethical clearance. Each request will be reviewed on a case-by-case basis under Institutional Review Board (IRB) approval. Additionally, we have ensured complete references and descriptions of measurement tools to enhance reproducibility.

These revisions improve the clarity, validity, and transparency of the study. We appreciate your insightful feedback, which has strengthened our manuscript.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

32 Views

12 Sep 2024 | for Version 1

M Arli Rusandi, Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

32 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

My areas of expertise include Education, Counseling, Digital Health, Information Technology Education, Higher Education, and Artificial Intelligence in Education.

Respond to this report

Responses (1)

Author Response

11 Nov 2024

Anis Ansyori, St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, 64123, Indonesia

Thank you for your thorough review and valuable feedback on our manuscript. We appreciate the time and expertise you dedicated to enhancing the quality of our study. Below, we address each of your comments and outline the corresponding revisions we have made to the manuscript.
Introduction

Research Aim/Question: We have revised the introduction to state the research aim more explicitly at the beginning to improve clarity and orientation for readers.
Concise Literature Summary: We have streamlined the literature review to maintain focus on the specific research gap related to the role of spiritual intelligence, reducing redundancy as suggested.
Terminology Consistency: We have ensured consistent terminology when discussing mental health, specifying whether we refer to mental health in general or specific conditions such as anxiety and depression.
Paragraph Transitions: Transitional sentences have been added to create a smoother flow, particularly when moving from the pandemic’s impact to the focus on spiritual intelligence.

Methodology

Sampling and Potential Biases: We have acknowledged potential biases from using purposive non-probability sampling and discussed how these biases might impact generalizability.
Adaptation/Validation of Tools: Additional details have been added regarding the adaptation and validation of measurement tools for the Indonesian context, with consideration of cultural factors in interpreting survey items.
Inclusion and Exclusion Criteria: We have discussed how excluding patients with chronic illnesses may limit the generalizability of findings, as recommended.
Ethical Considerations: We have briefly mentioned ethical considerations, including the approval process, in the methodology section to emphasize the study’s ethical integrity.

Results

Anxiety and Spiritual Intelligence: In response to the counterintuitive positive relationship between anxiety and spiritual intelligence, we have expanded the discussion to include possible explanations, such as coping mechanisms and reverse causality, and referenced relevant literature to contextualize this finding.
Interpretation of Indirect Effects: We have clarified the interpretation of significant indirect effects mediated by spiritual intelligence, particularly regarding their practical implications for mental health interventions.
Demographic Data: We have addressed the demographic skew towards younger, female participants and discussed how this may affect the generalizability of our findings.
Summary of Results: A brief summary has been added at the end of the results section to link the findings back to the research questions, reinforcing the significance of the results.

Discussion and Conclusions

Counterintuitive Finding on Anxiety and Spiritual Intelligence: We have provided a more detailed exploration of the unexpected positive relationship between anxiety and spiritual intelligence, referencing possible explanations and conflicting literature.
Discussion of Limitations and Future Research: We have expanded on how limitations, such as the cross-sectional design and specific sample population, could be addressed in future research, including suggestions for longitudinal studies and broader sampling.
Concrete Examples for Interventions: In the discussion on integrating spiritual intelligence into mental health interventions, we have added practical recommendations for implementation in educational and clinical settings.
Final Impact Statement: We have strengthened the conclusion with a closing statement that highlights the broader impact of our findings on mental health policy and practice.

Abstract and Keywords

Limitations and Future Research: We have updated the abstract to briefly mention the study’s limitations and the need for further research.
Statistical Methods: We have included the statistical method used (Structural Equation Modeling) to add clarity.
Keywords: Terms like “post-pandemic” and “cross-sectional study” have been added to improve searchability and relevance.

Once again, we thank you for your constructive feedback, which has greatly helped us refine and strengthen our manuscript. We hope that our responses and revisions meet your expectations and enhance the scientific quality and clarity of our study.

Sincerely,
Authors

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Examining the effects of anxiety and education level on mental health: The role of spiritual intelligence as an intervening variable in post COVID-19 patients in Indonesia

Abstract

Background

Methods

Results

Conclusions

Keywords

1. Introduction

2. Literature review and hypothesis development

2.1 Anxiety

2.2 Education level

2.3 Spiritual intelligence

2.4 Mental health

2.5 The effect of anxiety on spiritual intelligence and mental health

H1a:

H1b:

H1c:

2.6 The effect of educational level on spiritual intelligence and mental health

H2a:

H2b:

H2c:

2.7 The effect of spiritual intelligence on mental health

H3:

3. Methods

Figure 1. Conceptual model.

4. Results

4.1 Demographic respondent

Table 1. Demographic data.

4.2 Measurement model

Table 2. Reliability and validity of constructs.

4.3 Structural model

Figure 2. Result of hypothesis testing model.

Table 3. Direct effect test results.

Table 4. Indirect effect test results.

Table 5. Total effect test results.

5. Discussion and implication

5.1 The effect of anxiety on spiritual intelligence and mental health

5.2 The effect of educational level on spiritual intelligence and mental health

5.3 The effect of spiritual intelligence on mental health

6. Conclusion

Ethics and consent

Data availability statement

Underlying data

Extended data

Reporting guidelines

Acknowledgements

References

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