Analysis of Factors Related to Spiritual Distress Among HIV/AIDS Patients

The severity of the problems experienced by PLWHA (People Living with HIV/AIDS) can affect the psychological, social and spiritual aspects, as well as the ability and capacity of the health services. People living with HIV/AIDS experience psychosocial problems, such as anxiety towards illnesses they cannot predict. Patients commonly experience financial problems, chronic grief, depression, guilt, depression, and fear of death. Other psychosocial problems include withdrawal, impaired socialization, role disturbance, worry about relationships with partners, lifestyle changes, loss of enthusiasm due to limitations and feelings of alienation. This study aims to determine the factors related to spiritual distress among HIV/AIDS patients at Sawerigading General Hospital in Palopo. This was a quantitative study using a cross-sectional design. The study samples were selected using purposive sampling technique. Samples were selected among patients who came to the PCT unit of Sawerigading Hospital, Palopo City. The results showed that there was a relationship between self-relationship (p=0.005), relationship with others (p=0.024), art, music, literature and nature (p=0.024) and greater power (p=0.022) with spiritual distress. It can be concluded that there was a relationship between the independent variables of self-relationship, relationship with others, art, music, literature and nature, greater power with the dependent variable of spiritual distress.


HIV
(Human Immunodeficiency Virus) is a virus that causes a decrease in human immunity, which infects white blood cells 1 .The quality of life of PLWHA can decrease, even the quality of life for PLWHA is worse than the general population and people with chronic diseases 2 .Assessment of the quality of life among 216 PLWHA in Indonesia showed prominent fatigue and sleep disturbances 3 .In short, the quality of life of people living with HIV remains an important performance objective to pay attention to.Certain factors such as compliance with Antiretroviral (ARV) medication, level of sprirituality, family acceptance and clinical stage affected the quality of life of PLWHA 4 .Adequate ARV therapy achieves therapeutic outcomes in PLHIV, such as viral load and CD4 count.Optimal fulfillment of life functions properly due to compliance with ARV treatment is one of the factors that often affects the quality of life of PLWHA.This shows that comiance with ARV medication is an important outcome measure in the management of PLWHA 5 .
Spirituality is a human need to overcome social and cultural deviations, worry, fear, death and dying, and social alienation.It is the philosophy of spiritual life as the source of the human mind.Philosophy gives meaning in the relationship between oneself with others, Groups, and God  The severity of the problems experienced by PLWHA (People Living with HIV/AIDS) can affect the psychological, social and spiritual aspects, as well as the ability and capacity of the health services.People living with HIV/AIDS experience psychosocial problems, such as anxiety towards illnesses they cannot predict.Patients commonly experience financial problems, chronic grief, depression, guilt, depression, and fear of death 8 .Other psychosocial problems include withdrawal, impaired socialization, role disturbance, worry about relationships with partners, lifestyle changes, loss of enthusiasm due to limitations and feelings of alienation.
Issues such as near-death conditions, lifestyle changes, loneliness, self-isolation, and unexpected life events may lead to mental distress.The main outcome for those experiencing mental distress is an improvement in mental status, which can be observed in the linguistics of meaning and purpose in life, satisfaction with the meaning of life, and a sense of empowerment 6 .There is a relationship between increased spirituality/religiosity and slower disease progression, and doctors should be aware of such fact.Given the potential health implications of changes in spirituality/religiosity associated with an HIV diagnosis, clinicians, as well as psychologists, social workers, and clergy should consider religious/spiritual treatment.In fact, several studies found that many patients felt comfortable when doctors talk to them about spirituality 9 .Most people's perceptions about HIV/AIDS are still wrong.HIV/AIDS is considered a problem only for people with deviant sexual behavior and is often associated with immoral people, sinners, etc. Stigma in society can lead to discrimination against people living with HIV/AIDS (PLWHA) and it needs to be addressed immediately.
Some people are completely aware of the importance of spiritual aspect, some are not.A previous qualitative study concluded that after a patient was diagnosed with HIV/AIDS, it had a negative impact on his psyche 10 .If someone is diagnosed with HIV/AIDS for the first time, that person experiences various psychological problems, including stress, anxiety, anger, depression, denial, shame, sadness, and grief.Mental health is a sense of harmony, intimacy between oneself, others, nature and the highest life 11 .
The study objective is to determine the factors related to spiritual distress among HIV/AIDS patients at Sawerigading General Hospital, Palopo City.

METHOD
This was a quantitative study using a cross-sectional design.The study samples were selected using purposive sampling technique.Samples were selected among patients who came to the PCT unit of Sawerigading Hospital, Palopo as many as 35 patients.Data collected involved primary data, and secondary data which were analyzed using the chi-square test.

RESULTS
The study aims to determine factors related to spiritual distress by using the chisquare test with a significance level of (p <0.05) Table 1.revealed that there was a relationship between the independent variables of self-relationship, relationship with others, art, music, literature and nature, greater power with the dependent variable of spiritual distress.Furthermore, a multivariate test was conducted on the independent variables.Multivariate Table 2 showed that the size of the correlation or relationship (R) value was 0.644, which indicated a determination coefficient (R square) of 0.414.Thus, there was a relationship between the independent Based on the results presented in Table 3, it was obtained a significance value (sig.) of P=0.002 or <0.05.Such value indicated that there was relationship between Greater Power, Relationship with others, art, music, literature and nature, Self-relationship with the spiritual distress among HIV/AIDS patients at Sawerigading General Hospital, Palopo City.

b. Relationship between Relationship with Others and Spiritual Distress.
Relationship with others included expressing feelings of alienation, refusal to interact with spiritual leaders, refusal to interact with people who were considered important, and separation from support systems.
In the study, it was obtained a p value of 0.024, which indicated that there was a relationship between relationship with others and spiritual distress among people with HIV/AIDS at Sawerigading General Hospital, Palopo City.In this study, 23 respondents (85.2%) most respondents had good relationship with others.
According to the researchers' assumption, such finding was due to most of respondents were routinely socialized by HIV/AIDS counseling staffs at Sawerigading General Hospital, Palopo.One of the counseling staffs or motivators was also PLHIV.The diagnosis of HIV/AIDS experienced by patients could lead to interference, alienation or stigmatization.A study conducted by Ahwan (2014) on HIV/AIDS stigmatization and discrimination found that forms of stigma and discrimination occurred both in the domestic environment and in the public sphere 15 .

c.
Relationship between Art, Music, Literature and Nature with Spiritual Distress.
In relation to art, music, literature, nature, it was found inability to express prior creative states (singing, listening to music or writing), and disinterest in nature or reading spiritual literature.The result of the study found that 23 of respondents (85.2%) did not experience spiritual distress.In this study, respondents generally answered no to statements of being able to sing, loved to listen to music, write, and nature (environment, plants, pets).In the statistical test results, it was obtained a p value = 0.024 <0.05.It was indicated that there was a relationship between art, music, nature and literature with spiritual distress.

d. Relationship between Greater Power and Spiritual Distress.
Based on the result of the study, it was found that 19 respondents (90.5%) had a good relationship with God.Most of the respondents expected guidance and advice from religious leaders.There was a relationship between greater power and spiritual distress among HIV/AIDS patients at Sawerigading General Hospital, Palopo City.Spiritual needs found here were religious needs, needs for selfexistence, needs for peace, and needs for giving.Religious needs tended to stand out.However, there were differences in terms and levels of individual needs.
This study found that the majority of HII/AIDS patients were adults (26-35 years old).At that age, people may realize that their lives had to be closer to God.This confirms that the patient's spirituality can mean acceptance and obedience to God, but there should be efforts and hard work to get healed.One way to cope with disease is to get closer and increase piety to Allah.An aspect of religion as the highly desirable spiritual need of patients is religious practice.For patients, spirituality can mean acceptance and submission to God, but it also means effort and struggle to get healed.One form of effort that is usually done is continuous treatment and prayer.The spiritual need in the religious dimension that patients consider very necessary is to pray both for themselves and to be prayed for by others 16 .Religious practice or worshiping God is one way to relate to God.The level of obedience to Allah SWT can help people reduce anxiety, fear, and stress that they cannot overcome.These patients also experienced spiritual problems, including blaming God, refusing to worship, worshiping outside the rules, disruption of worship and spiritual needs, and spiritual pressure.Sometimes, after being sick, they made a big change in life.However, people with HIV/AIDS did not find way to overcome such disease and found difficulty in finding wisdom behind the disease they experienced.The spirituality of PLHIV usually deteriorates after they have been diagnosed with HIV/AIDS 17 .
Factors that influenced spirituality included cultural context, family, level of development, and health.Family and environmental factors were found to have an effect on spiritual beliefs.Health could also affect spirituality and vice versa.For example, when seriously ill, many people turned to religion for support.In some cases, a person's belief system could also influence treatment 18 .
According to Anggraini & Suci (2014), in general a religious person who is in a difficult situation will involve religious factors to overcome all the problems he gaces 19 .In addition, a study conducted by Hulu & Siregar  (2018) found that religious coping strategies are significantly related to self-regulation among HIV/AIDS patients at Gunungsitoli Regional General Hospital with a correlation value of 0.883 20 .

CONCLUSION
Based on the result of study, it can be concluded that there was a relationship between self-relationship and spiritual distress among HIV/AIDS patients at Sawerigading General Hospital, Palopo City.
In the study, it was found a p value of 0.024, which indicated that there was a relationship between relationship with others and spiritual distress among people with HIV/AIDS at Sawerigading General Hospital, Palopo City.
In this study, respondents generally answered no to statements of being able to sing, loved to listen to music, write, and nature (environment, plants, pets).In the statistical test results, it was obtained a p value = 0.024 <0.05.It was indicated that there was a relationship between art, music, nature and literature with spiritual distress.
Based on the result of this study, it was revealed a relationship between greater power and spiritual distress among HIV/AIDS patients at Sawerigading General Hospital, Palopo City.The results of this study can be used as evaluation material for spiritual nursing practice in improving the quality of nursing care through education and training.Nurses on duty at the hospital should provide nursing care related to spiritual distress to increase the patient's spirituality.Therefore, further researchers could conduct further study by observing other variables.

ACKNOWLEDGEMENT
The authors would like to deliver sincere gratitude to the Municipal Government of Palopo City for granting permission; the Director of the Sawerigading Nursing Academy, the Luwu Regional Government, who contributed to the completion of this study; as well as the Director of Sawerigading General Hospital, Palopo City, especially the PCT Polyclinic Room, who has provided a lot of input and data related to HIV/AIDS. 6 7 Some indicators of spiritual needs related to self-relationship include the need to have meaning and purpose in life, to express creativity, to have expectations of more meaningful life challenges, to have self-esteem, to have personal appreciation, to give thanks, to have a vision for life, as well as preparing for and accepting death7.Spiritual needs related to relationships with other people include the need to forgive others, and adapt to overcome problems related to the loss of a person or object, both actual and perceived.Spiritual needs related to group relationship include the need to contribute to the group, uphold group norms and values, and know what and when to give or receive in the group.Spiritual needs related to God or other supernatural powers are the need to ensure the existence of God's power or great powers in nature, the belief that God loves and cares for all of His people, and the need to perform worship.
a.Predictor (Constant): Greater Power, Relationship with Others, Art, Music, Literature and Nature, Self-relationship b.Dependent Variable: Spiritual Distress