F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.154599.3 Research Article Articles 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 3; peer review: 1 approved, 2 approved with reservations]

 Ansyori Anis Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0005-2770-7174 a 1 Yunus Ahmad Conceptualization Methodology Supervision Validation 1 Imam Sentot Conceptualization Methodology Supervision Validation 1 Peristiowati Yuly Conceptualization Methodology Supervision Validation 1 St. Manila No.37 Tosaren, Institut Ilmu Kesehatan Strada Indonesia, Kediri City, East Java, 64123, Indonesia anisansyori@itsk-soepraoen.ac.id

No competing interests were disclosed.

 17 1 2025 2024 13 916 10 1 2025 Copyright: © 2025 Ansyori A et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, 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. 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

Utilizing a cross-sectional design, data were collected from 390 post-COVID-19 patients in Indonesia. Structured questionnaires assessed anxiety, education level, spiritual intelligence, and mental health. Structural Equation Modeling (SEM) was used to analyze the relationships among these variables.

 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. While these findings are promising, the cross-sectional design limits causal inferences, and future research should consider longitudinal studies to examine these relationships over time. These practices can help mitigate the adverse effects of anxiety and educational disparities on mental health.

 anxiety; education level; spiritual intelligence; mental health The author(s) declared that no grants were involved in supporting this work. Amendments from Version 2

This revised version incorporates key modifications to address reviewer feedback and improve the clarity, validity, and reproducibility of the study. One of the major updates is the clarification of the limitations of Structural Equation Modeling (SEM) in drawing causal inferences. We have explicitly acknowledged that the cross-sectional design restricts causal conclusions and suggested longitudinal studies as a more appropriate approach to examining these relationships over time. Another significant revision includes a more detailed explanation of the validation process for the adapted scales, ensuring their reliability and cultural relevance in the Indonesian context. Additionally, the discussion on the relationship between anxiety and spiritual intelligence has been refined with additional interpretations and supporting evidence, including a consideration of reverse causality. The revised manuscript now suggests that increased spiritual awareness may sometimes heighten existential concerns, potentially leading to greater anxiety. The data availability statement has also been updated to clarify the process for requesting access to the dataset, requiring formal applications to protect participant confidentiality. Finally, we have ensured that all measurement tools and scales are properly described and referenced, enhancing the study’s methodological rigor and allowing for better replication. These revisions improve the comprehensiveness and transparency of the research.

 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). Given these diverse and persistent stressors, addressing the resulting mental health challenges has become an urgent priority for Indonesia’s post-pandemic recovery and resilience.

The transition from acute illness to recovery presents specific challenges that may profoundly impact mental health, particularly due to lingering health concerns, economic uncertainties, and anxiety regarding the pandemic’s lasting 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.

Although spiritual intelligence has gained increasing recognition as a beneficial factor in mental health, there is a notable research gap regarding its specific role 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. By examining spiritual intelligence as a mediator, this study seeks to address this gap and provide insights into its potential to alleviate mental health challenges linked to both anxiety and educational disparities in post-COVID-19 patients in Indonesia.

This study employs a cross-sectional design to assess the prevalence of anxiety and depression among post-COVID-19 patients in Indonesia. Specifically, it investigates the extent to which spiritual intelligence serves as an intervening variable, mediating the effects of anxiety and educational level on mental health outcomes.

 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.

Anxiety has a significant effect on spiritual intelligence.

Anxiety has a significant effect on mental health.

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.

Educational level has a significant effect on spiritual intelligence.

Educational level has a significant effect on mental health.

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:

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. Ethical approval was obtained from the Institut Ilmu Kesehatan Strada Indonesia (Approval No. 000986/EC/KEPK/I/03/2024, dated March 7, 2024), and all procedures prioritized participants’ health and well-being. Exclusion criteria are applied to ensure validity, but the exclusion of patients with chronic illnesses may impact generalizability, as this subgroup’s experiences with mental health post-COVID-19 could differ. Patients who cannot provide accurate health information, those who cannot adhere to study requirements, those who have had significant additional medical treatments post-recovery, and individuals who are deceased or unreachable are also 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 purposive non-probability sampling technique to select participants based on the defined inclusion criteria. While this approach allows for targeted sampling, it introduces potential biases that may affect generalizability. Steps to mitigate these biases include carefully defining inclusion criteria and regularly verifying participant eligibility.

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 ensure validity and reliability, the questionnaire underwent content validation by experts in psychology and public health to confirm its appropriateness for measuring the intended constructs. Additionally, construct validity was assessed using factor analysis to verify that the items effectively captured the underlying dimensions of each variable. Reliability testing, using Cronbach’s alpha, confirmed internal consistency across the scales. To minimize potential cultural bias in interpretation, the questionnaire was adapted and validated for the Indonesian context, ensuring its relevance and clarity for participants. 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), including an individual’s education level, relevance of their field of study, and competencies developed. This scale was refined to consider Indonesia’s unique educational context, ensuring that educational attainment is evaluated comprehensively.

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. To provide clarity and support replicability, the conceptual model includes detailed paths to illustrate hypothesized relationships, enhancing transparency in the analysis. This model guides the analysis and interpretation of the data, providing a visual representation of the hypothesized relationships among the study variables.

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.

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.

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.

Result of hypothesis testing model. 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. While this result may seem counterintuitive, it is possible that individuals experiencing anxiety may actively seek coping mechanisms, such as spiritual practices, to manage their distress, which may, in turn, elevate their spiritual intelligence. This could also indicate a reverse causality where individuals with heightened spiritual awareness are more sensitive to existential concerns, thereby experiencing higher anxiety levels. 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.

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:

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.

In summary, the results indicate significant relationships among anxiety, educational level, spiritual intelligence, and mental health, supporting the study’s hypotheses. The positive relationship between anxiety and spiritual intelligence, while somewhat unexpected, may indicate that individuals under psychological distress seek meaning or spiritual support as a coping mechanism, indirectly enhancing their resilience. The findings reinforce the crucial role of spiritual intelligence in mental health, suggesting it as an effective focus for mental health interventions, especially in post-COVID-19 contexts.

 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 significant impact on both spiritual intelligence and mental health. The positive relationship between anxiety and spiritual intelligence, while counterintuitive, suggests that individuals experiencing heightened anxiety may turn to spiritual practices or seek deeper meaning as coping mechanisms to alleviate distress. This result is consistent with the findings of Rathakrishnan et al. (2022) and Jamshidi et al. (2017), which suggest that anxiety can positively influence the development of spiritual intelligence as individuals seek psychological resilience through spiritual engagement. Given that most of the sample consists of younger and female participants, this relationship could reflect coping preferences commonly observed within these demographics, where spiritual and emotional support are often sought in response to psychological distress.

However, previous studies ( Khoshdeli et al., 2020; Mohammadipour et al., 2021; Safavi et al., 2019) have reported a negative and significant impact of spiritual intelligence on anxiety, suggesting that higher spiritual intelligence is associated with lower anxiety levels. This discrepancy could be due to variations in cultural contexts, measurement approaches, or specific dimensions of spiritual intelligence assessed in different studies. Additionally, the possibility of reverse causality should be considered—heightened spiritual awareness may lead to increased existential reflection, which in some individuals could elevate anxiety levels rather than alleviate them.

Furthermore, anxiety’s negative impact on mental health is evident, emphasizing the need for interventions that address both direct and indirect effects of anxiety. Spiritual intelligence appears to buffer some of these negative impacts by promoting emotional resilience and a sense of purpose, thereby helping to reduce the detrimental effects of anxiety on mental well-being. This suggests that integrating spiritual development practices in mental health treatments for anxiety could offer protective effects. Practices like mindfulness, meditation, and spiritual counseling could support individuals in finding purpose, thus potentially reducing the adverse effects of anxiety on mental health. This approach aligns with the buffering theory of Rathakrishnan et al. (2022), which proposes that spiritual intelligence enhances emotional resilience, mitigating the harmful effects 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. Education thus serves as a foundation for developing spiritual intelligence, equipping individuals with the knowledge and skills needed to cultivate spiritual awareness and practices, which positively impact mental health.

The significant influence of education on spiritual intelligence and mental health highlights the importance of educational policies that promote mental well-being. Incorporating curricula that support spiritual as well as cognitive and emotional development could be particularly beneficial for younger populations, as seen in this study. Programs that foster empathy, ethical reasoning, and critical thinking could enhance students’ spiritual intelligence and, in turn, their mental health. This approach supports findings from 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

Spiritual intelligence plays a critical role in promoting positive mental health outcomes. Individuals with high levels of spiritual intelligence are generally better equipped to manage stress and anxiety, which contributes to improved 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. Given that the sample primarily consists of younger and female participants, this strong relationship between spiritual intelligence and mental health may align with the supportive and meaning-seeking characteristics often observed in these groups. However, it is essential to note Furqani (2021) findings, which indicated variability in this relationship among different groups, suggesting that the impact of spiritual intelligence on mental health may depend on cultural or demographic factors.

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 could consider incorporating spiritual intelligence development into their programs. For instance, interventions aimed at helping individuals find purpose, maintain inner calm, and develop empathy could enable them to better cope with stress and anxiety. 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

Understanding the mediating role of spiritual intelligence in the relationships between anxiety, education level, and mental health has practical implications for designing comprehensive mental health interventions. Programs that simultaneously address anxiety management, educational attainment, and spiritual development are likely to be more effective in promoting mental well-being. This holistic approach allows individuals to benefit from both direct and indirect pathways identified in this study. To support integrated mental health systems, policies should encourage interdisciplinary collaboration among educators, mental health practitioners, and spiritual counselors.

However, this study has several limitations. First, while the cross-sectional design aligns with the study objectives, it significantly limits causal inferences between variables. Structural Equation Modeling (SEM) is appropriate for analyzing complex interrelations, but it does not establish causality. This limitation should be acknowledged more prominently, as the relationships observed may be influenced by unmeasured confounders or bidirectional effects. Future research could address this issue through longitudinal studies, which would allow for a more robust examination of how these relationships evolve over time. Second, the specific focus on post-COVID-19 patients in Indonesia may limit the generalizability of these findings to other populations or settings. Expanding the sample to include more diverse groups could strengthen the applicability of the results. Lastly, while this study emphasizes the role of spiritual intelligence, it does not fully delve into how its distinct dimensions individually contribute to mental health outcomes, which could be explored further in future research.

Despite these limitations, these findings 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, including their full name, institutional affiliation, research purpose, specific data required, intended use, and measures for ensuring data security and participant confidentiality. Additionally, applicants must provide ethical clearance or approval from their institution to ensure compliance with data protection regulations. 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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Competing interests: No competing interests were disclosed.

 13 2 2025 Copyright: © 2025 Ibrahim N 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-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

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

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

Partly

Are the conclusions drawn adequately supported by the results?

Yes

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

Partly

Reviewer Expertise:

My expertise is in spiritual intelligence (psychology context).

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.

 10.5256/f1000research.176909.r359983 Reviewer response for version 3 Rusandi M Arli 1 Referee https://orcid.org/0000-0001-7385-104X Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

Competing interests: No competing interests were disclosed.

 7 2 2025 Copyright: © 2025 Rusandi MA 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-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.

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

Yes

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

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

Yes

Are the conclusions drawn adequately supported by the results?

Yes

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

Partly

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, however I have significant reservations, as outlined above.

Ansyori Anis Public Health, Institut Ilmu Kesehatan Strada Indonesia, Kediri, East Java, Indonesia

Competing interests: No competing interests were disclosed.

 13 2 2025

Thank you for your valuable feedback and for acknowledging the improvements made throughout the manuscript. I have now updated the keywords as requested. Please find the revised version reflecting the necessary changes.

 10.5256/f1000research.176909.r359984 Reviewer response for version 3 Asri Yuni 1 Referee https://orcid.org/0000-0001-7829-6495 Department of Nursing, Faculty of Health and Science, Institut Teknologi, Sains dan Kesehatan RS dr Soepraoen Kesdam V/Brawijaya, Malang, Indonesia

Competing interests: No competing interests were disclosed.

 28 1 2025 Copyright: © 2025 Asri Y 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

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.

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

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

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

Partly

Are the conclusions drawn adequately supported by the results?

Yes

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

Yes

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.

 10.5256/f1000research.174458.r341019 Reviewer response for version 2 Asri Yuni 1 Referee https://orcid.org/0000-0001-7829-6495 Department of Nursing, Faculty of Health and Science, Institut Teknologi, Sains dan Kesehatan RS dr Soepraoen Kesdam V/Brawijaya, Malang, Indonesia

Competing interests: No competing interests were disclosed.

 6 12 2024 Copyright: © 2024 Asri Y 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-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

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

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

Partly

Are the conclusions drawn adequately supported by the results?

Yes

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

Yes

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, however I have significant reservations, as outlined above.

Ansyori Anis Public Health, Institut Ilmu Kesehatan Strada Indonesia, Kediri, East Java, Indonesia

Competing interests: No competing interests were disclosed.

 10 1 2025

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.

 10.5256/f1000research.169647.r314076 Reviewer response for version 1 Rusandi M Arli 1 Referee https://orcid.org/0000-0001-7385-104X Department of Guidance and Counseling, Universitas Riau, Pekanbaru, Riau, Indonesia

Competing interests: No competing interests were disclosed.

 12 9 2024 Copyright: © 2024 Rusandi MA 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

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

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

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

Yes

Are the conclusions drawn adequately supported by the results?

Yes

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

Partly

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.

Ansyori Anis Public Health, Institut Ilmu Kesehatan Strada Indonesia, Kediri, East Java, Indonesia

Competing interests: No competing interests were disclosed.

 5 11 2024

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