Investigating the correlation between health-promoting lifestyle and health hardiness with quality of life

Abstract

Introduction

Quality of life (QOL) is a key concept in the field of health and future human life depends on understanding the factors affecting the QOL. This study aimed to investigate the relationship between health hardiness and health-promoting lifestyle with QOL among residents of Bastak city.

Methods

The present cross-sectional study was conducted on the adult population above the age of 18 years living in Bastak city in Hormozgan province. A total number of 400 subjects were selected using a convenient sampling method. An online questionnaire was used to collect the data, which consisted of four sections: demographic information, health hardiness questionnaire, health-promoting lifestyle questionnaire and world health organization quality of life questionnaire (WHOQOL-BREF). Data were analyzed using statistical tests including Pearson correlation analysis, path analysis and structural equation modeling (SEM) with SPSS 24 and AMOS 21 statistical software.

Results

A total of 400 subjects with the mean age of 34.81 ± 8.94 years participated in this study. There were significant positive relationships between health hardiness (r = .499, p = .000), health value (r = .491, p = .000), internal health locus of control (r = .468, p = .000), external health locus of control (r = .19, p = .000), perceived health competence (r = .415, p = .000), health responsibility (r = .473, p = .000), physical activity (r = .356, p = .000), nutrition (r = .392, p = .000), interpersonal relations (r = .458, p = .000), spiritual growth (r = .619, p = .000), stress management (r = .514, p = .000) and health promoting life-style (r = .593, p = .000) With QOL.

Conclusion

According to our findings, health-promoting lifestyle has a positive relationship with QOL. Therefore, the policy makers and executive managers of the health sector can improve people’s QOL by designing and implementing educational interventions that are focused on improvement the level of individual’s physical activity, spiritual growth, interpersonal interactions, stress management, nutrition and individual responsibility.

Background

Today, one of the common and major goals of development at the local, national and international levels is to improve the QOL. Future human life will depend on understanding the factors affecting the QOL. The World Health Organization (WHO) defines QOL as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [1]. QOL is a basic indicator and a multidimensional concept that include various biological, functional and existential dimensions. QOL is considered as an important concept in medical, social and psychological researches. In addition, it is in various fields such as sociology, occupational therapy, gerontology, politics and health promotion [2]. Understanding QOL is key to the improvement of symptom relief, care and rehabilitation of patients. QOL is also important for medical decisions as it is a predictor of success in treatment [3].

Many factors affect the QOL and its dimensions, among which is the health-promoting lifestyle. A health-promoting lifestyle is subsumed under the overall lifestyle and includes a multi-dimensional pattern of spontaneous behaviors that are used to maintain and promote health, self-actualization and individual perfection. Its six important components include interpersonal relations, health responsibility, spiritual growth, stress management, nutrition and physical health [4]. Attention to and adoption of behaviors related to health-promoting lifestyle can have different benefits for people. For example, it prevents people from getting diseases [5], increases life expectancy among them [6], contributes to satisfaction, personal persuasion and self-actualization. In short, it improves the health-related QOL [7]. Health-promoting behaviors, especially when integrated into a healthy lifestyle that affects all aspects of life, can lead to improved health, increased functional capacity, and better QOL in all stages of life [4, 8]. Findings from a cross-sectional study conducted by Rakhshani et al. [9] showed that there was a statistically significant association between QOL and health-promoting lifestyle in the Iranian elderly. In their study, the significant predicting factors of QOL consisted of spiritual growth, stress management and physical activity. Moeini et al. [10] in their study found that there is a positive correlation between lifestyle scores and QOL. In the study conducted by Kamalian et al. [11], among the six dimensions of health-promoting lifestyle, two dimensions of physical activity and spiritual growth were significant predictive factors of QOL in middle-aged women of Bazargan city.

Another factor affecting mental health and QOL is hardiness, which is used for individuals who are more resistant to mental pressure and are less prone to diseases than others [12]. Based on Kobasa’s concept of hardiness, Pollock proposed the concept of health hardiness, which had more to do with health and disease issues. Health hardiness refers to the extent to which an individual is committed to health-related affairs, perceives his/her health as controllable, and considers health stressors as an opportunity for personal growth. Health-related hardiness is a personality trait that, with the components of control, challenge and commitment, makes people adapt to serious and chronic health issues [13]. Commitment describes the willingness to engage in a stressful condition instead of avoiding it. Control describes an aspect of not being helpless in a stressful condition. Challenge describes the belief that changes are opportunities for growth rather than something to be afraid of [14]. Bolton and Crowleyh found a relationship between hardiness, adjustment and mental health. Weinman (2007), Zakin (2008), Bohle (2008) and Boulter (2006) showed that one’s hardiness can reduce stress and increase adjustment and mental health [15]. Motevalli et al. [16] found that there is a significant correlation between health hardiness with QOL and its subscales (mental and physical health). Hosseini et al. [17] found that hardiness and its subscales had significant relationship with general health and spiritual health.

Cultural, religious, geographical, and socioeconomic conditions affect people’s lifestyle in a region, and each region should be examined separately in terms of lifestyle, QOL, and the relevant factors. Since, no coherent and comprehensive research has been yet done in Bastak city (in Hormozgan province in the south of Iran) on this topic, researchers decided to identify the factors that affect the QOL of people living in this city. Integrating the identified factors in prospective interventions to improve the QOL can help to increase the effectiveness of interventions and prevent diseases with high treatment costs for family and society. Therefore, the present study was conducted to investigate the relationship between health hardiness and health-promoting lifestyle with QOL in the adult population above the age of 18 years living in Bastak city.

Methods

Design of study and population

The present research was descriptive and correlational in type. The research population consisted of all residents of Bastak city who were over 18 years of age.

Sample size and sampling procedure

According to the previous study conducted by Kamalian et al. [11] and using Cochran’s formula and the research population size of 17,602, the sample size was estimated at 364. The sampling was convenience in type.

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The inclusion criteria were: literacy, access to the Internet to answer questions, the minimum age of 18 years, residence in Bastak city and willingness to participate in the study. The exclusion criterion was unwillingness to continue participating in the study.

Research tools

To collect data, online questionnaires and messaging platforms (WhatsApp, Telegram and Instagram) were used as well as the channel of health liaisons, health ambassadors, health workers, education personnel channel, Quranic sciences, Bastak News channel, health and treatment network, group of health care workers and caregivers, Red Crescent and family groups. First, the questionnaire was developed using Porseline, an online questionnaire design website. It is widely used in academic studies in Iran. Then the hyperlink to the questionnaire was shared in the messengers to invite people in friendship, work, health and news groups to complete the questionnaire. This hyperlink was subsequently forwarded to more people with the help of these contacts. On the first page of the questionnaire, the objectives of study were explained to the participants and they were assured of the confidentiality of their information.

Demographic questionnaire and the following self-report instruments were used to measure variables and collect data. The demographic variables were gender, marital status, education, age, employment status and history of chronic diseases.

• 1. Quality of Life Questionnaire (WHOQOL-BREF)

To collect data on the QOL, the Persian version of the WHOQOL-BREF was used. This questionnaire consists of a total number of 26 questions to measures four domains: physical health, mental health, social relationships and environmental health, with 24 questions. Each domain has 7, 6, 3 and 8 questions respectively. The first two questions do not belong to any of the domains and evaluate the general state of public health and QOL. Each question is rated on a 5-point Likert scale (1: strongly disagree to 5: strongly agree). The score of each area is calculated separately from the total score. A score of 4 indicates the worst and 20 indicates the best condition in the domain [18]. In this study, the standardized version developed by Usefy et al. was used [19]. Also, to test the reliability of the questionnaire, Cronbach’s alpha was estimated, and its values for physical health, mental health, social relationships, and environmental health were 0.81, 0.72, 0.78, and 0.76, respectively. The reliability coefficient of this questionnaire in the present study was estimated using Cronbach’s alpha at 0.93.

• 2. Health Hardiness Questionnaire

It is a self-report questionnaire that includes 24 items and 4 subscales of health value, internal health locus of control, external health locus of control, and perceived health competence. It was developed by Gebhardt et al. [20]. Each item in the questionnaire is a statement about individual’s state of health. Each question is rated on a 5-point Likert scale (1: strongly disagree to 5: strongly agree). Questions 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22 are reversely scored. The highest score in this questionnaire is 120 and the lowest is 24. A higher score indicates greater health hardiness and a low score about 24 indicates low hardiness. In the research by Gebhardt et al. [20], Cronbach’s alpha coefficients for the subscales of health value, internal and external health locus of control, and perceived health competence in the sample group of ordinary people were 0.79, 0.66, 0.67, and 69, respectively. In the research conducted by Torshabi et al. [21], the Cronbach’s alpha for the whole questionnaire was 0.58 and for the subscales was 0.71 and 0.82. The reliability coefficient of the questionnaire in the present study was estimated at 0.89 using Cronbach’s alpha.

• 3. Health-promoting lifestyle questionnaire

This 52-question questionnaire was developed by Walker et al. [22]. This instrument measures health-promoting behaviors in 6 domains: nutrition (9 questions), physical activity (8 questions), health responsibility (9 questions), stress management (8 questions), interpersonal relationships (9 questions) and spiritual growth (9 questions). The questions are rated on a 4-point Likert scale (1 = never, 4 = always and usually). In Mohammadi Zeidi et al.‘s research [23], Cronbach’s alpha for the whole instrument was 0.82 and for the subscales varied between 0.64 and 0.91. The reliability value of this questionnaire in the present study was estimated at 0.95 using Cronbach’s alpha test.

Data Analysis

Data were analyzed in SPSS-24 and Amos-21 statistical software. Demographic characteristics were described using descriptive statistics including frequency and percentage. Mean, standard deviation, minimum and maximum values were calculated for continuous variables. To test the hypotheses and discover the relationships between the variables, path analysis and structural equation modeling (SEM) were used. The level of significance was considered to be 95% (p < .05).

Ethics statement

Ethical approval was received for this study from the Ethics Committee of the Hormozgan University of Medical Sciences (IR.HUMS.REC.1402.021). Written informed consent was obtained from individuals who participated in this study.

Results

Participants’ characteristics

A total of 400 subjects with the mean age of 34.81 ± 8.94 years participated in this study. The participants’ demographic information is as follows: 19.2% of the participants were male and 80.8% were female. More than half of the participants were married (80%) and the rest were single (16.5%), divorced (1.5%) or widow (2%). The majority of them had diploma’s degree (36%). In relation to job situation, 44% of the participants were housewives. 84% of them had no history of chronic diseases (Table 1).

Table 1 Participants’ demographic information (N = 400)

Descriptive statistics

Descriptive statistics (mean and standard deviation) of the research variables by gender and marital status are reported in Table 2.

Table 2 Descriptive statistics of research variables

Correlations

The correlation coefficients of the variables is presented in Table 3.

Table 3 Correlation coefficients of study variables

Results of Pearson correlation showed that there were significant positive relationships between the independent variables (health hardiness and health promoting lifestyle) with quality of life.

Structural equation modeling results

The fit indices of the model are presented in Table 4.

Table 4 Model fit index of predictive pattern of quality of life

According to the results of Table 4, the fit indices to evaluate the totality of the final model indicated that in general the model has appropriate fitness.

The results of structural equation modeling are presented at Fig. 1.

First, the regression model is fitted. The regression coefficients given in Table 5 indicate the effectiveness or non-effectiveness of the variables. The QOL variable has a significant relationship with health hardiness and health-promoting lifestyle, but the factor loading between QOL and health hardiness is 0.189 and it is very low, so it should be removed from the model. The relationship between QOL and health-promoting lifestyle is significant and its factor loading is 0.573 and this variable should be present in this model.

Table 5 Regression weight & standardized regression weight

Fig. 1

Standardized structural equation modeling (SEM) of the relationships between health promoting lifestyle and health hardiness with QOL

The structural equation model, after removing health hardiness, is presented in Fig. 2.

The regression coefficients given in Table 6 indicate the effectiveness or non-effectiveness of the subscales on the main variable. The QOL has a significant level with health-promoting lifestyle and its factor loading is 0.708 and this variable should be included in the model. Health-promoting lifestyle has significant relationships with the subscales of spiritual growth, interpersonal relations, stress management, nutrition, physical activity and health responsibility, and their factor loadings are 0.778, 0.748, 0.78, 0.661, 0.597 and 0.76, respectively. These factor loadings are appropriate and desirable. The QOL variable has significant relationships with the subscales of physical health, mental health, social relations, and environmental health, and their factor loadings are 0.796, 0.897, 0.727, and 0.801, respectively. These factor loadings are appropriate and desirable.

Table 6 Regression weight & standardized regression weight

Fig. 2

The structural equation modeling (SEM) of the relationship between health promoting lifestyle with QOL

Discussion

The purpose of the present study was to investigate the relationship between health hardiness and health-promoting lifestyle with QOL.

The results showed that there is not a significant relationship between health hardiness and QOL. This finding is inconsistent with previous studies conducted by Saeedi et al. [24], Hosseini et al. [17], Mohammadi et al. [25], Alipour Hamze Kandi et al. [26], Shahbazirad et al. [27], Mansory Jalilian et al. [28] and Kilchrist [29] and. Researches has shown a positive and significant correlation between health hardiness with life expectancy and QOL. In stressful conditions such as suffering from a chronic disease, those with a higher health hardiness have better mental health and QOL [30]. In the study conducted by Kilchrist [29] on athletes and non-athletes, the results showed that commitment and control were positively correlated with QOL in this sample. The results of Alipour Hamze Kandi et al. [26] on nurses showed that hardiness has a meaningful positive relationship with the QOL. Hardiness is a trait that helps people flourish in difficult situations and have resilience in the face of difficulties or failures. Hardiness has been conceptualized as an aspect of personality and as the learned attitudes that help people maintain their health and performance despite obstacles. Hardiness includes 3 components of commitment, control, and challenge, all of which contribute to one’s overall hardiness level [14, 31]. Those with high hardiness will react with less stress than those with low hardiness [31]. Hardiness has a protective effect on mental health in stressful conditions. Since increasing stress is associated with decreasing QOL, it is possible that increasing hardiness is correlated with higher QOL. Those with less hardiness are less prepared to cope with stress and are more prone to injury and reduced mental health [29]. These divergent findings can be explained by the different populations.

The results also showed a significant positive relationship between health-promoting lifestyle with QOL. This finding is consistent with findings reported by Kamalian et al. [11], Zheng et al. [32], Mak et al. [33], Tol et al. [7], Atadokht et al. [34], Moeini et al. [10], ŞENOL, et al. [35], Rakhshani et al. [9] and Terzi et al. [36]. Tol et al.‘s [7] study among undergraduate students at school of health in Isfahan University of Medical Sciences showed a significant relationship between students’ global QOL with spiritual growth and between the health-related QOL and stress management. In Mak et al.‘s [33] study on Chinese nursing students, the results showed that responsibility for health, physical activity, spiritual growth, and stress management were statistically significant predictors of QOL. In a study conducted by Terzi et al.‘s [36] on Turkish workers, the results showed that there was a positive and low level significant correlation between the workers’ health promoting lifestyle with QOL. Health-promoting lifestyle and health-related QOL were both relatively poor in these people. In explaining this finding, it can be said that a health-promoting lifestyle leads to the maintenance of people’s performance and independence. It can reduce healthcare costs, and improve the QOL [37]. Therefore, the importance of health-promoting behaviors with an emphasis on healthy life is considered as a main source for maintaining and improving the QOL and lowering the quality of therapeutic measures [38].

There are a number of limitations in this study. First, the data were collected online and only literate people who had access to the Internet were able to participate in the study. Second, the current investigation has a cross-sectional nature. Thus, researchers cannot draw causal inferences according to their findings. Third, this study relied on self-report measures. Incorporating multimethod approaches may increase the validity of the findings. Gender imbalance between the study participants and number of study questions are other limitations of this study. In contrast, all instruments used in the present study are well validated and have acceptable psychometric properties.

Conclusion

The present findings showed that there was not a correlation between health hardiness with QOL, but adopting a health-promoting lifestyle can improve people’s QOL. Therefore, through developing and implementing educational interventions on health-promoting lifestyles, the policy makers and executive managers of the health sector can indirectly improve people’s QOL while directly affecting and improving their lifestyle. The design and implementation of educational interventions can focus on improvement of the level of physical activity (e.g., making people familiar with the importance and benefits of physical activity, the amount of appropriate physical activity, the effects of inactivity and insufficient physical activity, teaching strategies to overcome barriers to physical activity, etc.), spiritual growth (using the capacities of places, celebrations and religious rituals to improve this aspect of lifestyle), interpersonal interactions (teaching life skills, especially communication skills such as active listening, effective speech, empathy, etc.), stress management (teaching techniques such as relaxation, meditation, mindfulness, sports such as yoga, cognitive-behavioral techniques such as visualization, etc.), nutrition (teaching healthy eating, familiarity with food groups, method of cooking healthy food, food-related health, the relationship between nutrition and diseases, nutritional observances during adulthood, etc.) and individual responsibility (as well as familiarity with the concept of responsibility and the characteristics of those feeling responsible, teaching decision-making skills, the necessity of planning the work and decision-making, planning to feel responsible for behaviors, human role in controlling behavior and the reasons for going for unfavorable behaviors, etc.)