Abstract
Individuals diagnosed with type 2 diabetes mellitus may experience death anxiety and experiential avoidance, which may impact negatively on health-related quality of life. Meaning in life is a positive psychological resource that protects against negative psychosocial outcomes. Although a direct relationship between these variables exists, to our knowledge, previous research has not explored their interaction effect. The present study examined whether meaning in life moderates the relationship between (1) multidimensional death anxiety and health-related quality of life, and (2) experiential avoidance and health-related quality of life among type 2 diabetes mellitus patients. The pool of participants consisted of 311 type 2 diabetes outpatients drawn from a tertiary health care institution in South-East Nigeria. The participants completed several self-report measures, such as the short form of the Diabetes Quality of Life Questionnaire, Death Anxiety Inventory–Revised, Acceptance and Action Questionnaire, and the Presence of Meaning in life subscale of Meaning in Life Questionnaire. The results of a regression analysis showed that death anxiety in terms of death acceptance, death finality, and thoughts about death were independently associated with poor health-related quality of life at low, but not at average and high levels of meaning in life. Externally generated death anxiety was associated with poor health-related quality of life at low and average, but not at high levels of meaning in life. Finally, experiential avoidance was associated with poor health-related quality of life at low and average, but not at high levels of meaning in life. We concluded that psychological interventions geared towards promoting health-related quality of life of type 2 diabetes mellitus patients should consider integrating meaning in life for its protective nature in improving positive health outcomes and recovery.
Every human being desires to live a healthy life, and this may be particularly important for people who are going through a chronic health condition. Diabetes mellitus (DM) is a chronic health condition that impacts negatively on public health globally (Dunachie & Chamnan, 2019). Over 451 million individuals are living with DM worldwide. More than 5 million DM-related deaths are recorded per annum (Cho et al., 2018). Furthermore, 80% of DM-related deaths occur in developing countries (International Diabetes Federation [IDF], 2017), with 19.8 million cases found in the African continent alone. Although we have many kinds of DM, the type 2 diabetes mellitus (T2DM) has remained the most common of all cases diagnosed (IDF, 2017). Coping with T2DM can be very stressful and may impact negatively on the health-related quality of life (HRQoL) of patients (Morales et al., 2015).
The assessment and promotion of HRQoL among people diagnosed with T2DM have remained a major priority in clinical settings for the purpose of improving treatment outcome planning (de Ornelas Maia et al., 2013). HRQoL refers to the overall impacts of disease and its treatment on individuals (Burroughs et al., 2004). These include the patient’s general health perception, treatment satisfaction, social relationships, and cognitive functioning (Eljedi et al., 2006; Morales et al., 2015). Substantial empirical evidence indicates an increasingly poor quality of life among individuals diagnosed with T2DM (de Ornelas Maia et al., 2013; Ezaka et al., 2022; Morales et al., 2015). To improve the HRQoL of these T2DM patients, there is, therefore, the need to examine the roles and the interaction effects of certain psychosocial factors on the HRQoL of diabetic patients.
The theoretical anchor for this study is the Existential Theory of Meaning in life (Yalom, 1980). This theory embraces personal freedom and choice. According to this theory, individuals have the ability to choose their own existence. These choices, due to the freedom that individuals have, allow them to create goals, make something out of themselves, and create meaningful experiences in their lives. These can influence their choices in how they behave, interact with others, understand various life situations, and respond to stressful life events. Those with a higher sense of meaning in life usually experience better health outcomes across situations, since they are capable of making choices that leave them feeling less anxious. They may seek to end the fear of the unknown or existential problems and avoidance behaviours while consistently working towards actualizing their life goals and aspirations. Although these theoretical postulations have not been applied to quality of life, propositions of the model support the concurrent exploration of death anxiety, experiential avoidance (EA), and meaning in life in relation to psychological health outcomes, such as quality of life.
It has been established that many people who are suffering from a life-threatening illness may undergo an existential crisis arising from death anxiety (Ottu et al., 2019; Shafaii et al., 2017). Death anxiety is defined as a chronic or persistent fear and worry about one’s death (Ottu et al., 2019; Tomás-Sábado et al., 2005). Death anxiety has been identified as having four different dimensions which are labelled as (1) death acceptance (DA), which reflects someone’s personal understanding of death and the approach employed in facing it, which is derived from the intrinsic and personal meaning attached to death; (2) externally generated death anxiety (EGDA), which refers to the fear of situations and objects that remind individuals about death in most cultural settings such as corpses, cemeteries, and funeral homes; (3) death finality (DF), which refers to the realization that death is inevitable, and that nothing can be changed about it; and (4) thoughts about death (TAD), which indicate a cognitive and emotional awareness of one’s mortality, and the processes that may lead to death. Previous studies have shown that death anxiety is common among T2DM patients (Ezaka et al., 2022) and contributes to the development and maintenance of many psychological problems, including the experience of a poor quality of life (Betancur et al., 2017; Ezaka et al., 2022; Ottu et al., 2019). However, some researchers have found a non-significant association between death anxiety and QoL (Shafaii et al., 2017; Taghipour et al., 2017). In view of these contradictory findings, we surmise that these studies did not include certain psychosocial factors, as it was not part of the goals of those studies. It is possible that some other psychosocial factors may buffer the effect of death anxiety on HRQoL. In addition, researchers have also suggested that there is a need to explore the role of positive personality characteristics as potential moderators of the relationship between death anxiety and HRQoL as findings of such studies would help to identify individual patients whose HRQoL may not be adversely affected by the experience of death anxiety (Onu et al., 2021). As a way forward, we intend to explore the moderating role of meaning in life in the relationship between death anxiety and HRQoL among patients diagnosed with T2DM.
It has also been argued that some people who are going through crises associated with DM may make conscious efforts to avoid thoughts or situations that may remind them of their chronic health condition often referred to as EA. EA refers to the detestation or unwillingness of a patient to remain in contact with unpleasant private experiences (e.g., unwanted thoughts, emotions, and bodily sensation) associated with a chronic illness, and then takes steps to alter or suppress the form or frequency of those experiences, including the conditions that trigger them (Aliche et al., 2021a; Bond et al., 2011). Individuals with high EA may likely engage in psychological denial of their illness, poor medication adherence, and may lack interest in overall treatment regimens (Kashdan et al., 2009). Empirically, EA has been associated with a wide range of psychological problems, including posttraumatic stress disorder (PTSD) (Aliche et al., 2021a) and poor QoL (Eustis et al., 2016; Karekla & Panayiotou, 2011; Kashdan et al., 2009). Conversely, a very recent study has found a non-significant association between EA and HRQoL among T2DM patients (Ezaka et al., 2022). Based on these inconsistent findings on the association between EA and QoL, alongside the suggestion that future studies should explore the role of adaptive cognitive processes, such as meaning in life, as potential moderators of the impact of EA on other mental health outcomes (Kelso et al., 2020), we therefore propose that there is a need to examine the role of meaning in life as a plausible moderator of the relationship between EA and HRQoL in this vulnerable population. Such knowledge could help to inform better psychological interventions to promote the HRQoL of individuals diagnosed with T2DM.
Psychological changes associated with the diagnosis and treatment of T2DM may not always be negative and pathological. Individuals who have been diagnosed with a life-threatening illness may develop certain personal positive attributes such as meaning in life (Osamika & Asagba, 2019). Meaning in life is defined as the degree to which people comprehend, make sense of, or have significance in their lives, bearing in mind their life’s purpose and objectives (Steger et al., 2006). According to logotherapy theory, meaning in life is the most important personal attribute that protects individuals during challenging life situations (Frankl, 2005). A review of previous investigations with clinical and non-clinical samples (Czekierda et al., 2019; Damásio et al., 2013; Osamika & Asagba, 2019) have revealed that meaning in life is associated with improved quality of life. A meta-analysis also showed that meaning in life is positively associated with physical health (Czekierda et al., 2017).
Importantly, we propose that a patient’s perception of meaning in life may buffer the effect of death anxiety on HRQoL. Empirically, a higher sense of meaning in life has been found to be associated with decreased thoughts of mortality and death anxiety (Yuksel et al., 2017; Zhang et al., 2019). Substantial evidence has also shown that levels of meaning in life appear to moderate the relationship between adverse psychosocial antecedents and mental health outcomes (Corona et al., 2019; Hong, 2006; Krause et al., 2018; Marco et al., 2020). For example, among individuals with eating disorders, meaning in life was found to moderate the relationship between hopelessness, suicide ideation, and borderline psychopathology (Marco et al., 2020). Corona et al. (2019) found that meaning in life moderated the relationship between morally injurious experiences and suicide ideation among US combat veterans. In a similar vein, Krause et al. (2018) found that meaning in life moderated the association between sacred loss or desecration and health, while Hong (2006) further reported that self-transcendent meaning of life moderates the relation between college stress and psychological well-being.
Furthermore, having a sense of meaning in life has been associated with a reduced tendency to engage in EA (Kelso et al., 2020; Yela et al., 2020) and higher quality of life (Czekierda et al., 2019; Damásio et al., 2013; Osamika & Asagba, 2019). Recently, Kelso et al. (2020) found that meaning in life altered the relationship between EA and anxiety, such that when the levels of meaning in life are high, the rate of EA predicting anxiety symptoms is reduced. In addition, Yela et al. (2020) reported that meaning in life was linked to positive psychological outcomes through decreased EA. However, it is unknown whether meaning in life will moderate the relationship between EA and HRQoL among individuals diagnosed with T2DM.
The present study
There have been inconsistent findings on the association between death anxiety and HRQoL, and the association between EA and HRQoL, yet previous studies have not been able to examine the role of psychosocial factors as a potential moderator on the relationship among these variables. More specifically, and to our knowledge, no research has examined the moderating role of meaning in life in the relationship between multidimensional death anxiety and HRQoL, and the relationship between EA and HRQoL. First, the assessment of death anxiety in its multidimensional form is a relatively recent development in the 21st century, which has not been widely explored in the global literature. Examining the role of each of the dimensions of death anxiety on HRQoL among a clinical population, and testing whether meaning in life, a protective factor, can moderate this relationship is an interesting area of research that will help inform adequate interventions for T2DM patients who are more vulnerable to experiencing heightened death anxiety. Second, since previous studies have failed to examine the role of meaning in life in moderating the relationship between EA and HRQoL, the exploration of this moderation effect among T2DM patients will not only help to understand patients’ personal experiences in coping with T2DM diagnosis, but also help inform adequate psychological interventions targeted towards promoting T2DM-related positive outcomes. The goal of this study is to examine whether the relationship between death anxiety and HRQoL, and the relationship between EA and HRQoL is moderated by meaning in life. Based on the previous studies, we hypothesized that (1) meaning in life will moderate the relationship between death anxiety and HRQoL among T2DM patients, (2) meaning in life will moderate the relationship between EA and HRQoL among T2DM patients.
Method
Participants
The pool of participants consisted of 311 T2DM patients drawn from the cardiology outpatient unit of a tertiary health care institution in South-East Nigeria. Eligibility criteria for participation included being an adult T2DM outpatients (>18 years), having formal education up to a high school level, having been diagnosed as having T2DM within at least the preceding year, and not taking anti-psychotic medications during the period of this study. The results revealed that the mean age of the participants was 52.30 years (SD = 12.64, ranging from 21 to 85 years). Most of the participants (60.1%) were females, married (73%), and had tertiary education (62.7%). In terms of their religious affiliation, most (98.1%) were Christian and were working as civil servants (34.1%).
Instruments
HRQoL was measured using a short form of the Diabetes Quality of Life Questionnaire (DQoLQ), which consisted of 15 items derived from the original 60-item DQoLQ (Burroughs et al., 2004). One major rationale for using the shortened version in the present clinical population is that it takes about 10 min to complete, conducive for such a setting. The items are scored on a 5-point scale with response options ranging from 1 (very satisfied) to 5 (very dissatisfied), with lower scores indicating improved diabetes-related quality of life (DRQoL). The validity, internal consistency, and test–retest reliability were tested among 1080 adults with type 1 and type 2 diabetes and test–retest reliability was found to be .513 and Cronbach’s alpha coefficient was .85. The scale has demonstrated a good convergent validity, being strongly and positively associated with the original 60-item DQoLQ full scale (r = .91), as well as the individual DQoLQ subscales: satisfaction with diabetes control subscale (r = .97) and social worry subscale (r = .52). In the present study, we obtained an alpha coefficient of .87.
Death anxiety was measured using the 17-item Death Anxiety Inventory–Revised (DAI-R; Tomás-Sábado et al., 2005). The inventory has four dimensions which were labelled as (1) DA, (2) EGDA, (3) DF, and (4) TAD. Items are scored on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater death anxiety. The scale has good validity and reliability estimates, with an internal consistency Cronbach’s alpha of .92 (Tomás-Sábado et al., 2005). Having demonstrated good psychometric properties in the Nigerian population (Onu et al., 2021), the DAI-R was used as a multidimensional scale in the present study and the internal consistency Cronbach’s alpha for the subscales were .91 (DA), .87 (EGDA), .79 (DF), and .88 (TAD), respectively.
EA was measured using the Acceptance and Action Questionnaire (AAQ-11; Bond et al., 2011), a seven-item measure that assesses the individual’s tendency to avoid unpleasant internal experiences, including negative thoughts, emotions, and memories associated with stressful life events. Items (e.g., ‘My painful memories prevent me from having a fulfilling life’) are scored on a 7-point Likert-type scale, ranging from 1 = never true, to 7 = always true with higher scores indicating greater EA. According to the developers, results from 2816 participants indicated a satisfactory structure, reliability, and validity of AAQ-11. The mean alpha coefficient was .84 (.78–.88), and the 3- and 12-month test–retest reliability was .81 and .79, respectively. The AAQ-II also demonstrated good concurrent validity, having strongly and positively correlated with Beck Depression Inventory 11 (BDI-11) (r = .71), Beck Anxiety Inventory (BAI) (r = .61), and Symptom Checklist 90 items Revised–Global Severity Index (SCL-90-R-GSI) (r = .71). The AAQ-II appears to measure the same concept as the Acceptance and Action Questionnaire 1 (AAQ-I) (r = .97), but with better psychometric consistency (Bond et al., 2011). There is evidence of the AAQ-11’s good psychometric properties among Nigerian samples (Aliche et al., 2021a), and an internal consistency Cronbach’s alpha of .92 was obtained for the present study.
Meaning in life was measured using the five-item Presence of Meaning in Life subscale of the Meaning in Life Questionnaire (MLQ; Steger et al., 2006). Items (e.g., ‘My life has a clear sense of purpose’) are rated on a 7-point Likert-type scale, ranging from 1 (absolutely untrue) to 7 (absolutely true), with higher scores indicating greater presence of meaning in life. The scale has demonstrated very good validity and reliability indices (Steger et al., 2006) within a Nigerian population (Aliche et al., 2021b, 2022). The present study obtained an alpha coefficient of .87 for the subscale.
Procedure
Participants in this study were approached by the third author and four trained research assistants in the cardiology outpatient unit of a tertiary health care institution during the participants’ visit to see their doctors. The research assistants explained the purpose of the study, and all participants were given the right to decline or discontinue participation at any stage of the study. Those who willingly and verbally consented to participate in the study were issued the psychological instruments which they completed and returned to the research assistants on the same day in the hospital. The data collection lasted for a period of 3 months (between June and August 2021).
Ethical consideration
The study protocol was first approved by the Department of Psychology, University of Nigeria, Nsukka. Ethics clearance was obtained from the research ethics committee of University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, where the study was conducted (ethics clearance number: NHREC/33/12-05-2021).
Data analysis
We conducted a preliminary analysis using descriptive statistics. Pearson’s correlation was employed to ascertain whether the demographic variables (e.g., age, gender, and educational status) were associated with the main study variables. In order to examine whether meaning in life moderates the relationship between death anxiety and HRQoL, and between EA and HRQoL scores, the Hayes’ (2018) regression-based PROCESS macro for SPSS, Model 1 was employed. A moderator can be seen as a variable that specifies conditions under which a given predictor is related to an outcome. In other words, moderation implies an interaction effect, where introducing a moderating variable (meaning in life) changes the direction or magnitude of the relationship between the independent variables (death anxiety and EA) and dependent variable (HRQoL). Thus, Hayes PROCESS Model 1 enables testing the conditional effect by estimating the effect of X on Y at a certain point (or points) along the moderator and testing whether this effect is significant. In the present study, the statistical significance of simple moderation was established when the 95% confidence intervals (CIs) for the interaction did not include zero (Hayes, 2018).
In recent times, the Hayes PROCESS macro for SPSS has been identified as a gold standard for the test of moderation hypothesis (Aliche et al., 2020; Hayes, 2018). The analysis was carried out using the Statistical Packages for Social Sciences (SPSS), version 23.
Results
Descriptive statistics and correlation of the study variables
The mean, standard deviation, and correlation of the study variables are presented in Table 1. The results revealed that the demographic variables (age, gender, and educational status) were not significantly associated with the main study variables. DA was significantly and positively correlated with EGDA (r = .41, p < .001), DF (r = .64, p < .001), TAD (r = .42, p < .001), and EA (r = .52, p < .001). EGDA was significantly and positively correlated with DF (r = .43, p < .001), TAD (r = .42, p < .001), and EA (r = .40, p < .001), but significantly and negatively correlated with both meaning in life (r = −.36, p < .001) and HRQoL (r = −.39, p < .001). It was also found that DF was significantly and positively correlated with both TAD (r = .50, p < .001) and EA (r = 51, p < .001), but significantly and negatively correlated with both meaning in life (r = −.18, p < .01) and HRQoL (r = −.12, p < .05). TAD was significantly and positively correlated with EA (r = .38, p < .001), but significantly and negatively correlated with both meaning in life (r = −.32, p < .001) and HRQoL (r = −.23, p < .001). EA was significantly and negatively correlated with HRQoL (r = −.28, p < .001), whereas meaning in life and HRQoL were significantly and positively correlated with each other (r = .45, p < .001).
Correlation of demographic variables, predictors, and dependent variable.
ES: education status; DA: death acceptance; EGDA: externally generated death anxiety; DF: death finality; TAD: thoughts about death; EA: experiential avoidance; ML: meaning in life; HRQoL: health-related quality of life.
Gender was coded as female = 0, male = 1; education status coded as secondary = 0, tertiary = 1.
p = .05, **p = .01, ***p = .001.
Moderation analysis
In Table 2, we present the results of a series of moderation analyses conducted using EA and the specific subscales of death anxiety (e.g., DA, EGDA, DF, and TAD) as predictors, meaning in life as a potential moderator, and HRQoL as an outcome. The results showed that DA was not significantly associated with HRQoL (B = −13, p > .5). Meaning in life was positively associated with HRQoL (B = .97, p < .001), and moderated the relationship between DA and HRQoL (B = .04, p < .05). The slope of the interaction (Figure 1) indicated that DA was associated with poor HRQoL only at low, but not at average and high levels of meaning in life.
Hayes PROCESS results of meaning in life moderating the relationship between death anxiety, experiential avoidance (EA), and health-related quality of life (HRQoL).
CI: confidence interval.
Slope of the moderating role of meaning in life on the relationship between death acceptance (DA) and health-related quality of life (HRQoL).
When EGDA was considered as a predictor variable, we found that EGDA was negatively associated with HRQoL (B = −32, p = .001). Meaning in life was positively associated with HRQoL (B = .74, p = < .001) and moderated the relationship between EGDA and HRQoL (B = .04, p < .01). The slope of the interaction (Figure 2) indicated that EGDA was associated with poor HRQoL at low and average, but not at high levels of meaning in life.
Slope of the moderating role of meaning in life on the relationship between externally generated death anxiety (EGDA) and health-related quality of life (HRQoL).
DF was considered as a predictor variable, and the results showed that DF was not significantly associated with HRQoL (B = −.16, p > .05). Meaning in life was significantly associated with HRQoL (B = .98, p < .001) and moderated the relationship between DA and HRQoL (B = .07, p < 01). As indicated on the interaction slope (Figure 3), DF was associated with poor HRQoL only at low, but not at average and high levels of meaning in life.
Slope of the moderating role of meaning in life on the relationship between death finality (DF) and health-related quality of life (HRQoL).
TAD was also considered as a predictor variable, and the results revealed that TAD was not significantly associated with HRQoL (B = −.22, p > .05). Meaning in life was positively related with HRQoL (B = .95, p < .001) and moderated the association between TAD and HRQoL (B = .06, p < .05). The interaction slope (Figure 4) indicated that TAD was significantly associated with poor HRQoL only at low, but not at average and high levels of meaning in life.
Slope of the moderating role of meaning in life on the relationship between thoughts about death (TAD) and health-related quality of life (HRQoL).
Finally, we examined the role of meaning in life as a moderator of the relationship between EA and HRQoL. The results showed that EA was negatively associated with HRQoL (B = −.21, p < .001). Meaning in life was positively associated with HRQoL (B = .93, p < .001) and moderated the relationship between EA and HRQoL (B = .02, p < .01). The slope of the interaction (Figure 5) revealed that EA was associated with poor HRQoL at low and average, but not at high levels of meaning in life.
Slope of the moderating role of meaning in life on the relationship between experiential avoidance (EA) and health-related quality of life (HRQoL).
Discussion
The present study investigated the moderating role of meaning in life in the relationship between death anxiety and HRQoL. We also explored the role of meaning in life as a moderator of the relationship between EA and HRQoL in a sample of type 2 diabetic patients. Being the first study, to the best of our knowledge, to examine the interactive effects of these variables, our results revealed that meaning in life moderated the association between death anxiety and HRQoL of T2DM patients. Among people with T2DM, death anxiety may involve a condition wherein patients constantly engage in death-related thoughts, worries, and agitation which are overwhelming, due to the diagnosis of type 2 diabetes and how best to cope with it. Such individuals are prone to experiencing poor QoL (e.g., Cakmak & Gen, 2020; de Ornelas Maia et al., 2013) as they continually reflect on mortality-related issues and loss. Although the experience of diabetes and the knowledge of a protracted period of its management is potentially one existential crisis that is capable of arousing unpleasant feelings of hopelessness, helplessness, and/or emptiness, individuals who are able to find meaning in their lives, despite their health challenges, may effectively navigate this existential distress and cope adequately with their health conditions (Yuksel et al., 2017; Zhang et al., 2019).
Finding meaning in life following stressful life events has remained a widely recognized and essential indicator of psychological health and quality of life (Krause et al., 2018). People with a higher sense of meaning in life are able to identify their life objectives and are willing to work towards actualizing them (Corona et al., 2019). When confronted with a chronic illness, instead of thinking about death and dying, they can engage in a positive reappraisal of their condition, which helps increase their optimism and hope for a better future (Corona et al., 2019). This enables them to show a greater interest in learning more about their illness through asking questions during their hospital visits and seeking further knowledge on what to and what not to do in order to facilitate treatment and recovery. The findings of the current study are consistent with those of previous studies (Corona et al., 2019; Hong, 2006; Krause et al., 2018; Marco et al., 2020), not with regards to the mediating role of meaning in life in the relationship between anxiety and HRQoL, but more generally to the role of meaning in life in the relationship between adverse factors and mental health. Moreover, the findings have also supported the affirmation theory indicating that finding meaning in life helps to promote better psychological adaptation to chronic illness by decreasing the existential problems that might be associated with coping with the diagnosis and treatment of type 2 diabetes.
Among diverse populations, a greater sense of meaning in life has been associated with decreased thoughts and worry about death (Yuksel et al., 2017; Zhang et al., 2019). The process of finding meaning in life in the face of a life-threatening illness may involve a deeper reflection on the individual’s health condition, the losses, the gains, and the desire to reconcile these experiences in a manner that positive lessons can be articulated, and the patients’ life objectives pursued. Such patients with a higher sense of meaning in life will always prioritize their medical treatment, and adhere strictly to their treatment, with the understanding that T2DM is just like every other medical condition that people can cope with and which does not prevent them from achieving their life objectives. This in turn helps to promote their HRQoL (Czekierda et al., 2019; Damásio et al., 2013).
Another interesting finding was that meaning in life moderated the detrimental effect of EA on HRQoL among T2DM. This is consistent with previous findings on the beneficial effects of meaning in life in decreasing the hazardous effects of EA on mental health outcomes (Kelso et al., 2020). The diagnosis and treatment of T2DM is a distressing and traumatic life experience that may potentially trigger unpleasant emotions, thoughts, and feelings related to the chronic nature of the illness (Ezaka et al., 2022). Consequently, many patients may engage in rigid behavioural responses such as avoidance, denial, and self-doubt as a way of coping with their health condition. Spending an inordinate amount of time avoiding these thoughts and feelings hinders the ability to pursue long-term values and goals which are indicators of a better HRQoL (Kelso et al., 2020). However, based on the findings of this study, those who are able to find meaning in their lives are better able to cope effectively with unpleasant thoughts and feelings associated with T2DM.
Individuals with greater ability to make meaning in life are psychologically flexible (Kelso et al., 2020). Instead of avoiding unpleasant thoughts and feelings relating to their illness, T2DM patients with higher sense of meaning in life are very receptive to those private events (Corona et al., 2019; Kelso et al., 2020). With increased awareness and openness to these aversive thoughts and emotions, they are able to appraise the experiences in a way that positive gains will be articulated (Kelso et al., 2020). In addition, having a higher sense of meaning in life may make it less likely that they will engage in rigid behavioural responses linked to EA (e.g., denial) in coping with T2DM as it might hinder an objective understanding that their illness is curable, and this might lead to underestimation of their level of distress tolerance (Kelso et al., 2020). Instead, they are willing to acknowledge the chronic nature of their illness, show a greater willingness to adhere to their treatment regimen, and demonstrate an increased ability to recover and return to a life devoted to personally meaningful pursuits (Hong, 2006). What’s more? There is nothing more other than to experience a positive adjustment to their illness which then leads to a better HRQoL (Czekierda et al., 2019; Osamika & Asagba, 2019).
This study has important limitations that deserve mention. First, we adopted a cross-sectional research design and self-report measures which precluded the assessment of causal inferences. Second, the participants in this study were drawn from a single tertiary health care institution in South-East Nigeria. Generalizing its findings to other populations with different chronic conditions should be done with caution. Third, the researchers could not obtain information on certain clinical characteristics of the patients, such as duration of illness, family history of diabetes, exercise type, and so on. No data were collected on common comorbid chronic medical conditions, such as obesity and kidney diseases among others. The majority of participants in this study had a tertiary education which does not reflect the educational status of the general population in Nigeria. Together, the clinical characteristics, educational status, and the fact that we only studied cardiology patients make it very difficult to generalize the findings of this study.
Conclusion
To our knowledge, this is the first research, to date, to explore the moderating effect of meaning in life in the association of death anxiety, EA, and HRQoL among T2DM patients. By extending prior research suggesting the role of death anxiety in poor HRQoL, the findings of this study have contributed new knowledge by highlighting the protective role of meaning in life in buffering the effect of multidimensional death anxiety on HRQoL among T2DM patients. The examination of the direct effect of each dimension of death anxiety on HRQoL and testing for the moderating effect of meaning in life are particularly important and critical for psychological interventions. In addition, this study also contributed to the literature by revealing that having a sense of meaning in life during life crises is beneficial in decreasing the effects of EA on HRQoL. Based on these findings, it is imperative to include mental health practitioners in the holistic care of patients with diabetes. Thus, such clinical efforts targeted at improving the HRQoL of T2DM patients should begin with a careful assessment and monitoring of patients’ level of meaning in life particularly among those with heightened death anxiety and EA. In this sense, intervention efforts should also consider facilitating the patients’ ability to find meaning in life, as this would help decrease the adverse effects of death anxiety and EA on well-being and recovery.
Footnotes
Acknowledgements
We are most grateful to the T2DM patients who willingly volunteered to take part in this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
