Quality of Life, Health Perception and Meaning in Life among Selected People Living with HIV/AIDS in a Hospital in South Western Nigeria 

Bamidele Emmanuel OSAMIKA^1*
Rachel Bolaji ASAGBA²

1. Introduction

The prevalent of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) has resulted to stern health and socioeconomic challenges for more than two decades (Department of Health and Human Services, 2012). By so doing, HIV does not only affect the physical well-being of those affected but also their meaning in life and their overall quality of life (QoL) (Osamika, 2016). Also, HIV and AIDS have been described as major public health problem in many developing countries which has contributed to the lowering of life expectancy among those who are infected (Mofolorunsho, Nwankwo, & Mofolorunsho, 2013). An estimated 22.5 million people were found to be People living with HIV and AIDS (PLWHA) in sub-Saharan Africa as of the end of 2009 (United Nations Acquiring Immune Deficiency UNAIDS, 2010) and Nigeria ranks second in sub-Saharan Africa because of her large population of approximately 152.9 million (United Nations General Assembly Special Session, UNGASS,  2011).With the current prevalence, HIV and AIDS has debilitating effects on all aspects of the lives of individuals, their significant others  and families; ranging from physical health, as well as the psychological, economic and social aspects of life (UNGASS, 2011).

According to Folasire, Irabor, and Folasire (2012) Nigerian has been under-served with social services, due to the fact that the country does not give priority to basic infrastructure for people, individuals and families affected by a health crisis as such, no structural facilities for them to fall back on. Therefore, the quality of life of these individuals such as PLWA is seriously affected until the ill family member can be reintegrated fully to societal responsibilities. Additionally, chronic illness has always constituted a barrier to meaning in life, perception of health status and quality of life, particularly PLWA. These conditions are invariably sources of much discrimination and degeneration of family involvement as well as rejection perpetually faced by PLWHA (Semba, Martin, Kempen, Thorne, & Wu, 2005). Though, the complexity of chronic illness, and the associated psychological outcome, makes the assessment of meaning in life, health perception and quality of life challenging. Patients who continuously seen life as meaningless coupled with poor perceived quality of life inefficiently use health care system, which contributes substantially to higher health care costs, not only leading to poorer health outcomes, morbidity, and death but also indirectly lost productivity (Tsevat, 2006). Hence, the assessment of meaning in life and quality of life (QoL) is central to understanding of how people‘s lives are affected by HIV (Kristi-Rüütel, Anastassia, & Helle-Mai, 2008).

Moreover, the contribution of the perceived health status to meaning and quality of life are substantial for people PLWA, whereby with people rating their health as "poor" are more predisposing to meaninglessness and poorer quality of life than individuals who perceive their health as "excellent" (Borawski, Kinney, & Kahana, 1996) the individuals who rate their health as poor may skip certain "critical and salient points" in initiating health promoting actions which may results to their health problems (Rakowski, Mor, & Hiris, 1991).  Also, perception of an individual health status is very important for the meaning and quality of life for day-to-day productive functioning (Sakai, Yufune, Ono, & Rai, 2009). However, health perceptions reflect the understandings of people's health that possible not captured by more objective health measures.

Furthermore, in the quest to define QoL, various definitions had emerged such as a functional effect of illness and its treatment as perceived by the patient (Schipper, 1999) or as an affluence and variety of an environmental influence on the sense of meaning of an individual’s life (Oles’, 2002) but not really decide individual’s meaning in life, such that individual living in a good conditions, enjoy good health and yet be dissatisfied with life. Therefore, Olapegba (2009) opined that the earlier model of quality of life is a subjective model which sees the concept only in terms of predetermined level of functioning without the input of the individuals being evaluated. As such, World Health Organization defined QoL as individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relations to their goals, standards expectations and concerns (World Health Organization Quality of Life Group, 1998). The WHO definition of QoL emphasise the importance of an overall subjects feeling of wellbeing pertaining to aspects of morale, happiness and satisfaction. QoL therefore, relates to both adequacies of material circumstances as to how satisfied an individual is with circumstances of Life. According to Juczyn´ Ski (2010) QoL in illness, is not determined solely by the objective state of health, but rather an interwoven systems which has being explained by the adoption of a psychobiosocial model of quality of life that is based on the general theory of systems, which basically differs from the methods and principles of biomedical model that still predominating in medicine.

Quality of life has been shown to correlate with health perception, that life is better than before being diagnosed with HIV (Tsevats, Sherman, & McElwee, 1999) and finding meaning in life (Stegerm & Frazier, 2005; Wnuk, 2010). Moreover, Park, Bostrom, and Folkman (2001) argues that an improved mental health of patients has been centred on the availability of meaning in life despite the individual’s condition and this may called for different coping styles from the social phenomenon. Similarly, the analysis of Chien-Tat, Wong, Lai, Chen, and Hart (2016) in their personal factors influencing the perceived quality of life in Hong Kong – A classification tree approach’s study, discovered that perception of health status were among key factors in determining the QoL.

Hence, the meaning in life according to Parks and Folkman (1997) is a general life orientation, a personal significance, causality and coping mechanism; also, Stegere (2010) conceptualized meaning in life as a crucial way of understanding how people overcome life challenges and maximize their unique potentials, which was originated from logo theory. According to Frankl (1967) logotheory, meaning in life espouses that humans are driven by the need to create purpose and meaning in their lives, in an attempt to deal with these four existential concerns which are death, freedom, isolation and meaningless (Frankls, 2006; Reichenberg & Seligman, 2010) as such, meaning in life centres on humans' urge to find answers on the reasons, nature of living and promotion of general and health related quality of life (Kim, 2007; Parkk, 2005). Additionally, (Stegeri, Kashdan, Sullivan, & Lorentz, 2008). describes meaning in life in terms of two dimensions, presence and search of meaning in life. Presence of meaning simply means feeling that life has an esteemed meaning, significance and purpose, and are not actively exploring and searching for that meaning or seeking meaning in life, while search for meaning in life is described as when, individual probably do not feel life has an esteemed meaning, purpose and significance, and actively searching and probing for something or someone that will give his/her life meaning or purpose (Stegeri et al., 2008).

Furthermore, Jacobson, Luckhaupt, Delaney, and Tsevat (2006) found out that search for meaning and potential improvement of relation with others associated with better quality of life.  Jacobson et al. (2006) further suggested that it is important to consider different patterns of meaning-making when caring for individual or patients facing chronic and/or terminal diseases such as HIV. Also, studies have shown that presence of meaning in life significantly associated with physical and psychological well-being (Mrus et al., 2006) health perception/quality of life (Owens, Steger, Whitesell, & Herrera, 2009) general health perception and overall quality of life (Mascaro & Rosen, 2005; Stegerm & Frazier, 2005). Therefore, meaning is not just a cognitive construct but strive to incorporate and synthesize a vast inner and outer world (Asagba, 2004; Frankle, 1996). Though, meaning in life has been found to improve the quality of life by motivating people’s involvement in activities that promote social integration and the quality of social relationships. More so, study revealed that meaning in life serves as a predictor variable of both psychological wellbeing and QoL, while their moderation analysis, psychological wellbeing and QoL showed distinct correlations for individuals with high and low levels of meaning in life (Audet, Wagner, & Wallston, 2015). Hence, meaning in life is a holistic construct that tends to look at the generality of an individual, including the quality of life in chronic illnesses; as meaning in life becomes an integral part of human life, everybody also needs quality of life (Olapegba, 2009) including PLWA.

Moreover, in the review of the previously published studies, there are few studies correlating meaning in life and quality of life, although expanded recently by Steger (2009) but very few looking at the correlation among the dimensions of meaning in life and the dimensions of quality of life in Nigerian population.

This study therefore, investigates quality of life, health perception and meaning in life of people living with HIV/AIDS, by taking into consideration the dimensions of patient’s meaning in life and quality of life  such like  presence of meaning in life , search for meaning in life, physical, psychological, level of independence, social relationships, environment and spirituality. This study is relevant in the management of chronic diseases such as HIV/AIDS. It provides information on what is considered essential to PLWHA, and not just what their medical report indicates. Based on the purpose of the study, following research questions were raised: will there be significant relation among the dimensions of meaning in life quality of life? Will search and present meaning in life independently and jointly predict general health perception of quality of life?

Following the review of literature two hypotheses would be tested:

1. There will be a significant relationship among the dimensions of meaning in life and quality of life among PLWHA.
2. Presence of meaning in life and search for meaning in life will independently and jointly predict general health perception of quality of life among PLWHA.

2. Methods

2.1. Design and Participants

The study was a cross sectional survey research design that was carried out in Haematology and Pathology Clinic at the State Specialist Hospital, Akure, Ondo State; Nigeria. Two hundred and ten (210) PLWHA participated in the study. The age of the sample ranged between 18 and 90 years with a mean of 44.46 and a standard deviation of 15.74, Fifty nine (28.1%) Male and 151(71.9%) female participated in the study. At the time of the study, 34 (16.2%) were single, 136 (64.8%) claimed to be married, 28 (13.3%) widowed and 12 (5.7%) had divorced. Sixteen (7.6%) were student, 99 (47.1%) workers, 36 (17.1%) unemployed, and 59 (28.1%) involved in business/others. In addition, 183 (87.1%) Christian, 25 (11.9%) Islam and 2 (1%) belongs to other religion.169 (80.5%) were Yoruba, 20 (9.5%) Igbo, 13 (6.2%) Hausa and 8(3.8%) were from other Ethnic group. 81 (38.6%) participants were from monogamous family and 129 (61.4%) participants were from polygamous family. Thirty three (15.7%) respondents were primary leaving certificate holder, 91 (43.3%) were SSCE holder, 46 (21.9%) NCE/OND, 38(18.1%) were HND/BSc holder and 2 (1%) Post Graduate participated in the study.

2.2. Ethical Approval 

Additionally, permission to conduct the study at the Haematology and Pathology Clinic, of State Specialist Hospital, Akure, was granted by the Health Research Ethics Committee of State Specialist Hospital, Akure (Private mail bag No. 603). A representative of the Review Board monitored the research work to ensure compliance with the ethical rules, regulations and institutional guidelines. Both verbal, written informed consents and permission were obtained from each participant before the administration of the questionnaire.

2.3. Measure

The research instrument was a single paper and pencil questionnaire which was adopted for data collection. The questionnaire was divided into three sections these are as follow:

Section A consists of eight items that seek information on the respondents’ demographic information which includes age, gender, marital status, occupation, religion, ethnicity, family, educational qualification.

Section B contained the Meaning in Life Questionnaire that was developed by Stegeru, Frazier, Oishi, and Kaler (2006). The scale was designed to measure both presence (feelings of how lives are of meaning) and search (how engaged and motivated in efforts to find meaning) of meaning in life. The scale consists of 10 items, with two subscales and five items each, the item carry 7-point likert type response format. The response ranged from absolutely untrue to absolutely true and were coded as 1 2 3 4 5 6 and 7 respectively. The Cronbach alpha was reported by the developer to be 0.870, while in this study the Cronbach alpha was 0.836. The scoring manual of the two domains, Presence subscale score contained item 1, 4, 5, 6 and 9-reverse-coded and the Scores range between 7 and 35. Search subscale score contained item 2, 3, 7, 8, and 10 were added together (direct scoring) and the scores ranged between 7 and 35.l.

Furthermore, section C contained QOL scale developed by World Health Organization Group (WHOQOL-HIV BREF, Group, 2003) The scale was designed to measure general quality of life, general health perceptions, and quality of life in terms of physical, psychological, level of independence, social relationships, environment and spirituality. It consisted of 31 items reflecting the 5-point Likert-type format. The responses ranged from not all, a little, Moderate Amount, Very Much, and An extreme amount and were scored 1 2 3 4 and 5 respectively. The scale produced six domain scores, that includes Physical (item 3, 4, 14 and 21), Psychological (item 6, 11, 15, 24 and 31), Level of Independence (items 5, 22, 23, and 20), Social Relationships (item 27, 26, 25, and 17), Environment (item 12, 13, 16, 18, 19, 28, 29, and 30), and Spirituality(item 7, 8,9 and 10), while item (1) measured overall quality of life and item (2) measured general health perception. The Test –Retest Reliability of the scale was 0.992 while in this study the Cronbach alpha was 0.734. In addition, items (3, 4, 5, 8, 9, 10 and 31) were reversed negatively.

2.4. Procedure

Before the researcher went to the field to conduct this study, a proposal was written, submitted and approved by the appropriate Authority. Thereafter, the need to apply for ethical committee approval at the research settings arose that lasted for five weeks before the formal approval of the study.

A convenient sampling technique was adopted to recruit the participant into the study, about two hundred and twenty (240) questionnaires were administered while two hundred and ten (210) questionnaire were retrieved at a three consecutive day clinic in the research setting, after the consent of the respondent has being informed coupled with proper information and purpose of the study had being disseminated to the respondent.  The names and personal details of the respondent were not in the questionnaire in an attempt to ensure them of anonymous and confidentiality of their responses. Each section of the questionnaire was in likert point format response except the demographic variables.

2.5. Data Analysis

The data was subjected to Pearson Product Moment Correlation for hypothesis one, simple regression was used second hypothesis. All data analysis was done using IBM SPSS 20.0.

3. Results

The Table 1 showed the result for test of hypothesis one which stated that, dimensions of meaning in life will significantly correlates with the dimensions of Quality of Life. The results revealed that presence of  meaning in life (r(210)=.017, p <.05), physical domain (r(210)=.143, p <.05), psychological domain (r(210)=.231, p <.01), social relationship domain (r(210)=.207, p <.01), and environment domain (r(210)=.190, p <.01) significantly correlated with overall perceived quality of life.

In addition, Table 1 revealed that search for meaning of life (r (210) =.201, p <.01) significantly associated with social relationship domain of perceived quality of life and general health perception (r (210)=.195, p <.01) while presence of meaning in life (r(210)=.234, p <.01; r(210)=.017, p <.05 ) significantly related with general health perception and quality of life respectively. Conversely, search for meaning in life did not relate with physical (r (210) =.078, p >.05), psychological (r (210) =-008, p >.05), level of independence (r (210) =.043, p >.05),  environment (r (210) =.054, p >.05), spiritual (r (210) =-.011, p >.05) domains and overall quality of life (r (210) =.060, p >.05). Meanwhile, presence of meaning in life did not correlates with physical (r (210) =.049, p >.05), psychological (r (210) =-.018, p >.05), level of independence (r (210) =.007, p >.05), social relationship(r(210) =.082, p >.05),  environment (r (210) =.001, p >.05) and spiritual (r (210) =.060, p >.05) domains of quality of life. Therefore, the hypothesis was partially confirmed.

The Table 2 shows the result for hypothesis two which stated that, presence of meaning in life and search for meaning in life will independently and jointly predict general health perception of the perceived quality of life. The result showed that presence meaning in life (B=.011, β=.058, p>.05) did not significantly predict general health perception while search for meaning in life (B=.032, β=.193, p<.05) significantly predict general health perception. This simply means that per unit change in the search for meaning in life brings about.032 amount of change that occurred in health perception. Likewise, search for meaning in life displays 19.3% independent impacts on health perception.

Moreover, presence and search for meaning in life (R=.23, R²=.06, p<.01) jointly predict general health perception. The hypothesis is therefore partially accepted. This result implies that presence and search for meaning in life jointly shows 0.23 degree of relationship with health perception. In other words, presence and search for meaning in life displays 6% amount of proportion of general health perception that can be explained by the relationships of presence and search for meaning in life.

4. Discussion

This study examined quality of life, health perception and meaning in life among selected people living with HIV/AIDS in a Hospital in South western, Nigeria. Two hypotheses were formulated at the commencement of the study and the two were partially confirmed.

Hypothesis one stated that there will be a significant correlation among the dimensions of meaning in life and quality of life. The results shows that search meaning in life associated with social relationship domain of perceived quality of life, this was supported by Jacobson et al. (2006) who found out that search for meaning and potential improvement of relation with others associated with better quality of life as it is important to consider different patterns of meaning-making when caring for individual patients facing chronic diseases such as HIV. Also, the result aligns with the findings of Park et al. (2001) that because there are some evidences that meaning serves as coping with challenges from the social phenomenon which leads to improved mental health as such there are associates between search for meaning and improvement of relationship with others. Likewise, it was found that search meaning in life significantly associated with general health perception, the result was consistent with the findings of Maddi (1970) that search or probing for meaning associated with individual cognitive strategies, which primarily predispose individual toward questioning the status quo and persistent, negative thinking about the past and present which has formed their perception for their present health. Equally, the result of this study showed that people with health challenges constantly perceived their health as incomplete and further search for meaningful life and concern about the future. The result of this study further buttress the findings of Owens et al. (2009) as presence of meaning in life associated with physical and psychological health well-being and even their health perception.

Additionally, presence of meaning in life significantly associated with general health perception and overall quality of life this was in line with the findings of Audet et al. (2015) and Mrus, Leonard, and Yi (2006) who found out that variable meaning in life interrelated with health-related quality of life. Also, Mascaro and Rosen (2005) found that meaning of life has been positively associated with physical/psychological health/well-being, health perception/quality of life. Likewise the results showed that presence of meaning in life associate with overall quality of life which was in line with findings of Frisch (2013) that presence of meaning in life or a meaningful life associated with perceived quality of life which comes from identifying and successfully pursuing valued needs, goals, and desires which give life a sense of purpose, significance, course and direction and that the sense of purpose and meaning enhances well-being and happiness.

Hypothesis two stated that presence of meaning in life and search for meaning in Life will independently and joint predict general health perception of perceived quality of life. The result showed that presence of meaning in life did not predict general health perception which disconfirmed the findings of King, Hicks, Krull, and Del Gaiso (2006) that presence of meaning in life has being found to be powerful means of coping with negative circumstances especially individuals with afflictions which hence can predict the perception of health. Also, the result negate (Ryff & Singer, 1998) that presence of meaning predict perception of health and as such is just one component of overall well-being. This result implies that among PLWHA, their presence of meaning in life did not necessarily denotes their perception about their health condition but rather in quest to search for that meaning determines their awareness of their health condition.

Additionally, searching for meaning in life significantly and independently predict general health perception.

By so doing, the results reflected that search for meaning in life independently predicts their perception about their health condition, this implies that the studied participant still searching for meaning at the time of the study, invariable, they do not feel life has a valued meaning and purpose, and actively searching for something or someone that will give their life meaning and purpose, they may feel lost in life, and idea may cause them distress, it is their search for meaning in life that prompt their awareness of their health condition. Although this result was supported  by Stegeri et al. (2008) that people’s insight into their health condition prompt their search, such like deficits in meaning which are easily seen in chronic illness might spark a stronger search for meaning as such signifying quest for better quality of life and wellbeing. Furthermore, there was a joint prediction of presence and search for meaning on general health perception this was supported by Krause (2007); Sakai et al. (2009) and Steger (2009) findings that meaning in life (including presence and search) mutually predisposed quality of life and a better self-reported health perception especially among people reporting low levels of psychological strengths such like PLWHIV/AIDS.

5. Conclusion

The study has shown the relationship in the dimensions of meaning in life and quality of life. The study hence concluded that search for meaning in life was related to social relationship domain and general health perception of perceived quality of life which implies that when patient’s life has no valued meaning and purpose, they proceed to active searching for something or someone that will give their life meaning or purpose, they relate and rely on friends, relatives and caregiver; and as such this have to do with how they feel accepted about their health status, and quality of support derive from friend’s relationship and their general health quality and satisfaction.

Also, presence of meaning in life was interconnected with general health perception domain and overall quality of life this indicated that patient’s feeling that life has an esteemed meaning, significance, and purpose and are not actively sightseeing that meaning or seeking and probing meaning in life which had demonstrated their general health perception domain and overall quality of life.

However, physical, psychological, social relationship, and environmental domains were found to be interrelated with overall quality of life. Likewise, search meaning in life predict general health perception. This indicates active searching for something or someone that will give life meaning, purpose and satisfaction informed their perception of general health.

In line with the current findings, this study therefore recommends that in the assessment of perceived quality of life by the health practitioners, meaning in life of the patient should not be jettisoned as this play important role in the healing process of people living with HIV/AIDS. Also, the study recommends that meaning-centred therapy should be involved in the psychotherapeutic modality for the people living with HIV/AIDS.

This study is not without limitation as this study is a cross sectional study which is limited in terms of internal validity also, the results can only be generalised to people living with HIVAIDS.

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