Personality Traits, Illness Perception and Quality of Life in Diabetic Patients

Introduction

Diabetes mellitus is a chronic disorder of glucose metabolism with serious clinical

consequences. The multi-system complications of diabetes include microvascular (retinopathy,
nephropathy, neuropathy) and macrovascular (ischemic heart disease, stroke, peripheral vascular
disease) endpoints. The prevalence of diabetes has been rising in the last few decades, fueled by
the global rise in the prevalence of obesity. The premature morbidity, mortality, reduced life
expectancy and financial and other costs to the patient with diabetes, their caregivers and the
health service, make it an important public health condition (Forouhi & Wareham 2010).

According to the Psychosocial theory of Erikson, the stage of "Generativity vs.

Stagnation" is particularly relevant to understanding the occurrence of diabetes among adults.
During middle adulthood, individuals enter the stage of Generativity vs. Stagnation, typically
occurring between the ages of 40 to 65 years (Erikson, 1950). This stage is considered a focus on
establishing a sense of purpose and contributing to society. Adults strive to nurture the next
generation, whether through raising children, mentoring others, or contributing to their
community. Successfully passing through this stage leads to feelings of fulfilment and a sense of
generativity, while failure to do so can result in feelings of stagnation and dissatisfaction
(Erikson, 1950).

Considering that the patient along with the family forms the unit of diabetes self-care, it
is necessary to identify psychosocial problems and overcome them (Katie et al., 2016).
Supportive social and environmental factors may not always be available for those who truly
need them: e.g., poor patients, who are stressed and those with distressful conditions. Not only
will these worsen glycemic control, but lack of support interferes with self-care behavior leading
to a descending spiral. All these factors are related to the well-being of the patient. Illness
perception, personality, and quality of life are interconnected aspects that significantly influence
the well-being of diabetic patients.

Personality

Psychologists differ among themselves as to the meaning of personality. Most agree that
the word “personality” originated from the Latin persona, which referred to a theatrical mask
worn by Roman actors in Greek dramas. These ancient Roman actors wore a mask (persona) to
project a role or false appearance. This surface view of personality, of course, is not an
acceptable definition. When psychologists use the term “personality,” they are referring to
something more than the role people play. In the field of personality psychology, personality is
defined as the psychological system of traits, emotions, motivation, behaviour and thought
patterns that characterize individuals and distinguish them from each other (Funder, 2001).

Personality arises from a dynamic interaction between the id, ego, and superego, with
unconscious conflicts and early childhood experiences shaping behaviour (Freud, 1923). Another
psychoanalyst defined personality as; Personality is the self-concept, comprised of one's self-
image and ideal self, striving for self-actualization and congruence between the real and ideal
selves (Rogers, 1959). Sometimes personality was also explained as results from reciprocal
interactions between cognitive processes, behaviours, and environmental influences, highlighting
observational learning and self-efficacy beliefs (Bandura, 1986).

Similarly, Eysenck, (1967) defined personality as it is s composed of stable, heritable

traits that can be measured and categorized, particularly along dimensions of extraversion-
introversion, neuroticism-emotional stability, and psychoticism. In the behaviourist domain, it is
considered that personality is the result of learned behaviours shaped by reinforcement and
punishment, with the environment playing a crucial role in shaping observable actions. In
psychosocial perspectives, Personality is believed to be developed through a series of
psychosocial stages, with each stage marked by a crisis that individuals must resolve to achieve a
sense of identity and integrity (Erikson, 1950).

Characteristics of Personality

Personality characteristics include important determinants of human behaviour and life

outcomes. These include motives, interests, self-representations, Personality traits, cognitive and
socio-emotional competencies, attitudes, values, and beliefs. Among the various personality
attributes, personality traits or dispositions have a central position in the personality conceptual
system. Personality characteristics are also sometimes called “non-cognitive skills”, representing
personal attributes that are not part of the wide range of cognitive abilities. The easiest way to
define non-cognitive skills is therefore to describe them as those skills that are not measured by
achievement or IQ (intelligence quotient) tests (Messick, 1979).
 However, in addition to being both “too broad to be useful” and yet incomplete, the term
is an obvious misnomer as it implies the absence of cognitive activities even though every aspect
of mental functioning is based on some form of information processing and cognition
(Duckworth and Yeager, 2015). For example, social competences, one of the prime examples of a
non-cognitive skill, are so fundamentally dependent on perception, memory and reasoning
abilities that they are often conceptualized as a form of intelligence (e.g. Marlowe, 1986;
Murphy and Hall, 2011). Personality traits are defined as “relatively enduring patterns of
thoughts, feelings, and behaviours that reflect the tendency to respond in certain ways under
certain circumstances” (Roberts, 2009).

Specifying that these are “relatively enduring patterns” suggests that these traits tend to
be consistent characteristics of one’s personality but also that they are not set in stone and are
susceptible to change to some degree. Likewise, the fact that they reflect a “tendency to respond
in certain ways under certain circumstances” indicates that their influence on behaviour is not
absolute and certain but rather that it increases or decreases the probability of certain actions that
are at the same time shaped by other personality and situational factors. Personality traits are
relatively consistent attributes of personality that differ across individuals, influence behaviour
and have confirmed psychological, hereditary and even neurological foundations (Bouchard and
Loehlin, 2001; Canli, 2006; Roberts et al., 2007).

Five-Factor Model of Personality

The study of traits was first begun by Allport and Odbert in the 1930s and continued by
Cattell in the 1940s and by Tupes, Christal, and Norman in the 1960s. The five-factor model of
personality, known as the Big Five Personality Traits, consists of extraversion, neuroticism,
openness to experience (sometimes just called openness), agreeableness, and conscientiousness
(Costa & McCrae, 1992). Highly extraverted individuals are assertive and sociable, rather than
quiet and reserved. Agreeable individuals are cooperative and polite, rather than antagonistic and
rude. Conscientious individuals are task-focused and orderly, rather than distractible and
disorganized.

Neurotic individuals are prone to experiencing negative emotions, such as anxiety,

depression, and irritation, rather than being emotionally resilient. Finally, highly open individuals
have a broad rather than narrow range of interests, are sensitive rather than indifferent to art and
beauty, and prefer novelty to routine. The Big Five/FFM was developed to represent as much of
the variability in individuals’ personalities as possible, using only a small set of trait dimensions.
Many personality psychologists agree that its five domains capture the most important, basic
individual differences in personality traits and that many alternative trait models can be
conceptualized in terms of the Big Five/FFM structure (Soto & Jackson, 2020).

Factors Effecting the Personality

Alfred Adler (1870-1937, an Austrian doctor and psychotherapist) founded the idea of
individual personality. Through research amongst families of twins and siblings and adopted
children, he was able to propose birth order as an important factor in determining personality
(Adler, 1968). He found that a correlation exists between age and certain traits. Adler also tested
his birth order effect on academic standing and substance use ([Link], 2015).
According to Adler, infants are all born feeling inferior, due to the helplessness that they feel. It
is through the development stages that one strives for superiority. Adler and his theory of birth
order make a difference in personality development.

There are other factors at play such as that sibling’s genetic inheritance of their nervous
system, to the parenting technique that is applied to a firstborn. Evidence from adoption studies
shows the genetic origins of pathological, psychological, and physiological disorders
(Haimowitz, 2005). Alongside the theorists who viewed traits as being heritable and genes
affecting an individual’s personality, there was Burrhus Frederic Skinner (1904-1990, an
American psychologist, inventor and social philosopher) who believed that behaviour was
influenced by external stimuli (Skinner, 2002). He had a radical view and believed that “human
free will is an illusion” and that individuals are only responding to their environment. Skinner
based his theory of operant conditioning on the work of Edward Thorndike.

Edward Thorndike (1874-1949, a psychologist) studied the 'law of effect', which stated
that any behaviour that is followed by a pleasant consequence is more likely to be repeated than
if followed by an unpleasant one (McLeod, 2007). Skinner concentrated on describing the
observable behaviour that could be seen, which he tested in his experiments with pigeons and
rats. He determined that positive or negative reinforcement was the factor affecting behavior.
Bandura's social learning theory has shown that role models play a big part in determining a
positive or negative influence on personality development and behaviour.

Psychological factors affect an individual’s personality daily interactions, and the

approach that an individual takes to different situations. It is among these psychodynamic
processes that lead to the dynamism of the human mind and its behaviour, subconsciously
referring to their psychological factors such as a positive or negative mindset and approach to
different situations. The dynamic organization within the individual of those psychophysical
systems that determine his characteristics behaviour and thought (Allport, 1937). Allport
developed three levels of traits from 4000 words describing personality traits. The three include
cardinal traits, central traits and secondary traits.

Raymond Cattell (1905- 1998, an English professor) went on to reduce Allport’s list to
1713 words. By applying factor analysis, Cattell then further reduced this to 16 key personality
traits. Which has now come to be used as a personality assessment known as the Sixteen
Personality Factor Questionnaire- 16PF (Sincero 2012). Biological factors are a major
contribution when the personality is still beginning to develop, as a child grows up, they begin to
develop more and more of their character as the years pass (Roberts & Delvecchio, 2000). As an
individual grows older their environment becomes more influential on their development of
personality than biological factors.

Parental upbringing and the order they are born in, both influence the development of
one’s personality (Misseldine, 1963). Environmental such as sociological factors matter more
than psychological factors. Zimbardo’s experiment shows that sociological factors such as social
titles and perceived ranking makes a difference to an individual’s mindset and behaviour.
Psychological factors matter the most, regardless of if an individual’s temperament is inherited,
or if they put weight on their perceived social class; one’s mindset pushes one in a certain
direction. From the MBTI the answers are subjective in that the individual's view of themselves
can change. An individual’s mindset will determine how one will behave and what one’s
temperament would be like as an adult.

Theoretical Framework of Personality

Theories of personality are divided into three major domains. First is Dynamic
Personality Theories including Freud Psychoanalytical Theory, Jung Analytical Theory, Adler
Personality Theory or Individual Theory. Second is Behavioural and Learning Theories including
Skinner Theory, Bandura Social Learning Theory, Dollar and Millars Learning Theory. Third is
Humanistic Theories including Maslow Self Actualization Theory, Roger’s Self Theory. Freud’s
understanding of human personality was based on his experiences with patients, his analysis of
his own dreams. He presented psychosexual stages of personality development. His main focus
was on childhood in the development of personality (Freud, 1985).

Freud’s greatest contribution to personality theory is his exploration of the unconscious.

Carl Jung's analytical psychology focused on the exploration of the collective unconscious and
the archetypes that shape individual personality. Jung emphasized the importance of personal
growth and individuation through the integration of unconscious aspects of the psyche (Jung,
1968). Alfred Adler's individual psychology highlights the significance of social factors and the
pursuit of superiority in shaping personality. Adler proposed that individuals strive for mastery
and significance and that early childhood experiences influence personality development (Adler,
1927).

B.F. Skinner's behaviorism emphasizes the role of external stimuli and reinforcement in
shaping behavior and personality. Skinner proposed that personality traits are learned through
conditioning processes, such as operant conditioning (Skinner, 1953). Albert Bandura's social
learning theory integrates cognitive and behavioral principles, emphasizing observational
learning and self-efficacy. Bandura proposed that individuals acquire personality traits through
observation, imitation, and the belief in their own abilities to enact behaviors (Bandura, 1977).
Dollar and Millar's learning theory focuses on the role of reinforcement and punishment in
shaping behavior and personality. They proposed that behavior is learned through the
consequences it produces, with reinforcement increasing the likelihood of a behavior recurring
(Dollard & Miller, 1950).

Abraham Maslow's hierarchy of needs theory posits that individuals strive for self-
actualization, fulfilling their potential and achieving personal growth. Maslow proposed a
hierarchical structure of human needs, with self-actualization representing the highest level of
psychological development (Maslow, 1954). Carl Rogers' person-centered theory emphasizes the
importance of self-concept and unconditional positive regard in personality development. Rogers
proposed that individuals have an innate drive towards self-actualization and personal growth,
facilitated by a supportive and empathetic environment (Rogers, 1959).

Patients’ personality traits are associated with their subjective illness perceptions
(Goetzmann et al., 2005). A study concluded that when subjective illness perceptions and
personality traits are considered together, basic patient types emerge independent to the ethnicity
(Franz et al., 2014). Neuroticism has been associated with more negative illness perceptions
(Goetzmann et al., 2005).

Illness Perception

Illness perceptions are the organized cognitive representations or beliefs that patients
have about their illness. These perceptions have been found to be important determinants of
behaviour and have been associated with a number of important outcomes, such as treatment
adherence and functional recovery (Leventhal et al., 1997; Weinman & Petrie, 1997). There is a
consistent pattern to the way patients structure their perceptions of illness. Illness perceptions
generally contain an identity component, which includes the name of the illness and the range of
symptoms that the patient believes are associated with the condition. They also contain beliefs
about the cause of the illness and how long it will last.

According to the Common-Sense Model of self-regulation by Leventhal et al. (1980,

1984), people make sense out of a health threat by developing their own cognitive
representations about the illness and its treatment, on the basis of information and previous
experiences with the ill ness. These cognitive representations or illness perceptions are generally
formulated around the following dimensions: identity (the ‘label’ of the illness and the symptoms
associated with it), causal beliefs, control (the extent to which the illness is perceived as
amendable by personal or treatment control), consequences, patients’ understanding of the
illness, and emotional representations (Moss-Morris et al., 2002; Weinman et al., 1996).

Furthermore, illness perception com ponents include beliefs about the personal
consequences of the condition for the patient and their family, as well as the extent to which the
illness is amenable to personal control or to control by treatment (Leventhal et al., 1980). There
are two important aspects to note: firstly, patients’ beliefs about their condition are often at
variance from those who are treating them. In fact, medical staff are usually unaware of patients’
ideas about their condition as staff rarely ask patients about their own ideas in clinical
consultations. Secondly, patients’ perceptions vary widely. Even patients with the same medical
condition or injury can hold very disparate views of their illness (Petrie et al., 2007).

Illness Perception and Mental Health

In past research in physical illnesses, illness perceptions have predicted important

outcomes such as return to work, and medication adherence (Petrie, Jago, & Devcich, 2007).
Fewer studies have investigated how illness perceptions are related to functioning in mental
illness. However, early results are promising. Lobban et al. (2004) found that illness perceptions
were associated with quality of life and coping in schizophrenia, with worse consequences scores
found to be the strongest predictor of poor functioning and quality of life. Similarly, illness
perceptions in patients with non-affective psychotic disorder were associated with levels of
depression, anxiety and self-esteem, with the identity dimension a strong predictor (Watson et al.,
2006).

Causal attributions to poor medical care or external others predicted poorer medication
adherence. In high users of mental health services, negative illness perceptions were associated
with high unmet needs, low functioning, a poor attitude to medication and doctor visits
(Broadbent et al., 2008). There are three areas that appear fruitful in terms of applying an illness
perception intervention to improve outcomes in mental health conditions. The first is increasing
adherence to therapy. Another is reducing inappropriate service use. Many patients are ‘‘frequent
attenders’’ or ‘‘high users’’, which places increased and often unnecessary burden on health
services. The third area is improving family and significant other relationships through analysis
and therapy around aligning illness perceptions.

Factors Effecting Illness Perception

Similar to findings in physical illnesses, discrepancies in illness perceptions between

patients and their families have been related to poorer outcomes in psychosis patients and their
family members (Kuipers et al., 2007). Illness perception is influenced by various factors.
Understanding these factors is crucial for developing effective interventions and improving
health outcomes. Personal experiences with illness significantly shape individuals' perceptions of
their own health. Past experiences with illness, either personally or through close others,
contribute to the interpretation of symptoms and prognosis (Bennett & Brooke, 2019). Cultural
norms and beliefs play an essential role in shaping illness perceptions. Sociocultural factors
influence how symptoms are interpreted, the perceived severity of the illness, and preferred
treatment approaches (Kang et al., 2020).

The presence of social support networks affects illness perception. Satisfactory social
support can buffer the negative impact of illness and facilitate coping strategies, leading to more
positive perceptions of health (Chou & Chi, 2018). Psychological factors, including anxiety,
depression, and personality traits, contribute to illness perception. Individuals with certain
personality traits may perceive their illness differently and employ varying coping mechanisms
(Smith et al., 2017). Access to accurate and reliable information about the illness influences
illness perception. Information provided by healthcare professionals, as well as online sources
and social networks, can shape individuals' understanding and expectations regarding their health
condition (Brown et al., 2019).

Effective communication between healthcare providers and patients is essential for

shaping illness perception. Clear and empathetic communication regarding diagnosis, treatment
options, and prognosis can positively influence patients' perceptions of their illness (Street et al.,
2013). Stress levels and individual coping mechanisms impact illness perception. High levels of
stress may exacerbate negative perceptions of health, while adaptive coping strategies can
promote a more positive outlook (Lazarus & Folkman, 1984). Socioeconomic status, including
income level and access to healthcare resources, affects illness perception. Disparities in
healthcare access and resources can lead to differential perceptions of illness severity and
treatment efficacy (Adler & Stewart, 2010).

Perceived stigma and discrimination associated with certain health conditions influence
illness perception. Stigmatizing attitudes may lead individuals to internalize negative beliefs
about their illness, impacting their self-esteem and treatment adherence (Link & Phelan, 2001).
The severity of symptoms and the course of illness play a crucial role in shaping individuals'
perceptions. Perceptions of illness severity can impact emotional responses, treatment-seeking
behavior, and adherence to medical advice (Leventhal et al., 1980).

Theoretical Framework of Illness Perception

 Several theories are related to illness perception including Common-Sense Model (CSM)
of Illness Representation, Self-Regulation Model (SRM) of Illness Behavior, Health Belief
Model (HBM) and Transactional Model of Stress and Coping. Individuals are posited to create a
“common sense model” (CSM) of their health by integrating knowledge and beliefs across
several discrete domains or illness representations (Leventhal et al., 2008). In the situation of
chronic diseases, such as diabetes, an individuals’ CSM of the disease is comprised of the
identity assigned to the disease.

Its presumed cause, beliefs about controllability, anticipated consequences of the disease,
and awareness of alternatives for medical management (Leventhal et al., 2008). Individuals are
believed to integrate their knowledge and beliefs across these illness representations into a more
or less coherent model of the disease (i.e., their CSM), and variation in individuals’ CSMs
contributes to differences in observed behaviors for disease management. The CSM suggested
that individuals construct cognitive representations of their illnesses based on their personal
experiences, beliefs, and understanding of the illness. These representations included five key
dimensions; identity, cause, timeline, consequences, and control/cure.

The Self-Regulation Model (SRM) of Illness Behavior provides a complete

framework for understanding how individuals perceive and respond to illness (Leventhal et al.,
1980). According to the SRM, individuals engage in a continuous process of monitoring,
interpreting, and managing their health threats. This model emphasizes several key components:
Firstly, individuals actively monitor their bodies and symptoms to detect any signs of illness
(Leventhal et al., 1980). This monitoring process involves paying close attention to bodily
sensations, changes in health status, and symptoms indicative of illness.

Once individuals detect changes in their health, they interpret these symptoms based on
their preexisting beliefs, knowledge, and experiences (Leventhal et al., 1980). They construct
cognitive representations of their illnesses, about dimensions such as identity, cause, timeline,
consequences, and control/cure. Moreover, individuals' interpretations of their illnesses cause
emotional responses such as fear, anxiety, or distress (Leventhal et al., 1980). These emotional
reactions play a significant role in shaping individuals' perceptions and responses to their
illnesses.
 Furthermore, based on their illness perceptions and emotional responses, individuals
engage in various coping strategies to manage their health threats (Leventhal et al., 1980). These
strategies may include seeking information, seeking social support, engaging in self-care
behaviors, or seeking professional medical help. The SRM highlights that illness perception is a
dynamic process that evolves over time (Leventhal et al., 1980). As individuals engage in coping
behaviors and receive feedback about the effectiveness of their strategies, their illness
perceptions may change, leading to adjustments in their coping efforts.

Developed by Rosenstock (1966), the health believes model postulates that individuals'
health-related behaviors are determined by their perceptions of the severity of the illness,
susceptibility to the illness, benefits of taking preventive action, and barriers to taking preventive
action. Lazarus and Folkman (1984) proposed Transactional Model of Stress and Coping, which
suggested that individuals appraise stressors based on their perceptions of threat and their ability
to cope with the stressor. Illness perception is viewed as a dynamic process influenced by
cognitive appraisals and coping strategies.

Illness Perception and quality of life

In people with diabetes, more negative illness perceptions have been associated with
increased emotional distress and depression (Paschalides et al., 2004; Skinner et al., 2014), and
poorer quality of life (Paschalides et al., 2004; Scollan-Koliopoulos et al., 2013; Watkins et al.,
2000). Individuals' beliefs about their ability to manage or control their illness (self-efficacy)
play a vital role in their quality of life. Higher levels of perceived self-efficacy are associated
with better adjustment to illness and improved quality of life (Jerusalem & Mittag, 1995). Illness
perception also influences health-related behaviors, such as adherence to treatment regimens.
Individuals who perceive their illness as controllable and manageable are more likely to engage
in adaptive health behaviors, leading to better health outcomes and enhanced quality of life
(Hagger et al., 2002). Individuals who perceived their illness negatively might have higher levels
of anxiety and depression which in turn have been associated with reduced psychosocial
components of QOL (Morgan et al.,2014).

Quality of Life
 Quality of life (QoL) is a fundamental concept in the field of psychology, representing
individuals' subjective evaluations of their overall well-being and life satisfaction (Diener, Suh,
Lucas, & Smith, 1999). While there is no universally agreed-upon definition, QoL encompasses
various domains, including physical health, psychological well-being, social relationships, and
environmental factors (World Health Organization, 1997). Understanding QoL and its
determinants is crucial for promoting individuals' overall happiness and functioning across
diverse populations and contexts.

Quality of life is the degree to which an individual is healthy, comfortable, and able to
participate in or enjoy life events. The term quality of life is inherently ambiguous, as it can refer
both to the experience an individual has of his or her own life and to the living conditions in
which individuals find themselves. Hence, quality of life is highly subjective. Whereas one
person may define quality of life according to wealth or satisfaction with life, another person
may define it in terms of capabilities (e.g., having the ability to live a good life in terms of
emotional and physical well-being) (Jerusalem & Mittag, 1995).

The WHO defines quality of life as “the individual’s perception of their position in life in
the context of cultural and value systems in which they live and in relation to their goals,
expectations, standards and concerns. It is a broad term encompassing comprehensive physical
health, psychological state, level of independence, social relationships, personal beliefs and
relationship to the main features of the environment” (Soósová, 2016). To make aging a positive
experience, it must be accompanied by continuous opportunities for good health, participation,
and security (WHO, 2002).

A disabled person may report a high quality of life, whereas a healthy person who
recently lost a job may report a low quality of life. Within the arena of health care, quality of life
is viewed as multidimensional, encompassing emotional, physical, material, and social well-
being. Measuring QoL involves both subjective and objective assessments, utilizing a
combination of self-report scales, observer ratings, and objective indicators (Skevington &
McCrate, 2012). Commonly used instruments include the WHOQOL-BREF (World Health
Organization, 2004), SF-36 Health Survey (Ware & Sherbourne, 1992), and the Quality-of-Life
Inventory (Frisch, 1994).
 Quality of life (QoL) is a term used to refer to an individual’s total well-being. There is
disagreement between scientists, sociologists, and clinicians about the conceptualization of QoL,
and hence, a clear definition is lacking (Hunt, 1997). However, current definitions can be
categorized into three types (Farquhar, 1995). First is global definition, such as
happiness/unhappiness. Second is definitions that break down QoL into a series of components
or dimensions; and third is focused definitions, which are often pragmatic approaches in which
QoL is seen as synonymous with domains of the field of interest to the researchers (e.g.,
functional status is sometimes used as a measure of QoL by health researchers).

Determinants of Quality of Life

Among the main determinants of QoL, a general agreement exists on the key role of
health (Fernandez Ballesteros et al. 1996; Michalos et al. 2000). However, its contribution to
QoL is variable with discrepancies between health status and QoL: many older adults report a
satisfactory QoL despite having several health problems, a finding that may be due to other
factors that help to compensate health decline (Fernandez-Mayoralas and Rojo Perez 2005;
Grimby and Svanborg 1997; Grimby and Wiklund 1994; Prieto-Flores et al. 2010). In addition,
the process of adaptation to health deterioration in old age contributes to the reduction of the
relative importance of health in QoL.

In spite of the key role of health as a QoL determinant, health is not always ranked in the
first place by older adults (Bowling 1995; Xavier et al. 2003). Determinants of QoL in old age
may vary in type and importance, when compared between groups according to age, health
characteristics, and living circumstances (Bowling and Zahava 2004). Different studies have
contributed to the identification of QoL domains from the perspective of aging people. Health,
family, social relationships and finances (Seymour et al. 2008), autonomy and attitude toward
life (Richard et al. 2005), and health of significant others are some of the most relevant
dimensions according to older adults’ point of view (Bowling 1995; Prieto-Flores et al. 2010).

Depression was the most influential predictor in health-related and global QoL, in line
with other studies that show the important role of depression in the QoL of older adults (Brown
et al., 2004). On one side, depression negatively affects several dimensions of QoL, nevertheless,
apperception bias might also occur, so that depressed people tend to see things more negatively,
and also rate their QoL as negative. Other authors have demonstrated the association of
depressive disorders and anxiety with worse perceived health (Azpi azuGarridoetal.2002).
financial status. This was also one of the most often named components of QoL in the
longitudinal study (Seymour et al., 2008).

When comparing determinants of health-related and global QoL, our results stress the
differential contribution of psychosocial and health determinants. Health indicators (depression
and medical conditions) contributed to explain both health-related and global QoL. This is
congruent with what was expressed by the participants themselves, rating health as a main QoL
dimension. On the other hand, psychosocial indicators (social support and sense of coherence)
were only significantly associated with global QoL in line with the idea that global QoL is more
than health related QoL (Martinez-Martin et al., 2012).

Theoretical Framework of Quality of Life

In 1962, when Abraham Maslow published his book Towards a Psychology of Being
(Maslow, 1962), there were hardly many who could have guessed that by doing this he had
established a theory of quality of life, which still even after 40 years is considered a consistent
theory of quality of life. Maslow based his theory for development towards happiness and true
being on the concept of based on personal growth. Abraham Maslow characterized the good life
as a fulfillment of needs, which is one of eight different ways of considering quality of life that
have been eagerly used throughout history (Ventegodt, 1996). His perspective was simple:
happiness, health, and ability to function come when you take the responsibility for fulfilling all
your needs. The difficulty in this lies in the fact that to do so you must know yourself well
enough to understand which needs you really have.

Another major theory related to quality of life is the Social Production Function (SPF)
theory (Cummins, 2000). This theory postulates that individual well-being and quality of life are
influenced by both material and social factors, including income, education, social support, and
access to resources. According to SPF theory, these factors interact to shape an individual's
perceived quality of life, with social relationships and community resources playing a crucial
role alongside material resources. The SPF theory highlights the importance of considering
broader social and environmental contexts when assessing and enhancing quality of life.
 Understanding the relationship between personality, illness perception, and quality of life
among diabetic patients is significant for providing complete care and support. Research
suggested that personality traits, such as neuroticism and conscientiousness, play a significant
role in shaping individuals' perceptions of their illness and its impact on their quality of life
(Hagger-Johnson et al., 2012; Suls & Martin, 2005). For example, individuals high in
neuroticism may perceive their diabetes as more threatening and experience greater distress,
leading to lower quality of life outcomes (Hagger-Johnson et al., 2012). On the other hand,
conscientious individuals may engage in proactive health behaviors and adaptive coping
strategies, which could positively influence their illness perception and quality of life (Suls &
Martin, 2005). Furthermore, how individuals perceive their illness, such as their beliefs about its
controllability and consequences, can also impact their quality of life (Broadbent et al., 2006).

Problem Statement

The prevalence of diabetes in Pakistan has increased significantly as 33 million adults are
now living with diabetes in the country with an increase of 70 percent. The disease burden in our
country is quite huge. On the contrary, data examining QoL in our local population is scarce. We
therefore conducted this study to document QoL in patients with diabetes on the base of their
personality traits and illness perception. The rapidly rising level of diabetes in Pakistan presents a
significant challenge to the health and well-being of individuals and families in the country. This
research aims to understand the role which personality may play in forming a mental image in an
individual affecting to their illness and as a consequence minimizes the quality of life of such
individuals with diabetes. In the previous literature all these three factors are not previously
studied.

Rationale and significance of Study

Last few years there is drastic increase in diabetes cases especially in Pakistan. Quality of
life is considered as one of the better assessments for management of diabetes in recent years,
but in previous studies both personality traits and illness perceptions are never discussed together
as a predictor of quality of life in patients of diabetes. So, this study will bridge the gap in order
to investigate how quality of life vary among patients with different personalities. In a study,
educated participants were recruited to have an optimistic attitude towards their diabetic self-
management. As illness perception is affected by the surrounding atmosphere, patients assemble
information to develop a perception regarding illness (Mcandrew et al., 2014). Broadbent et al.,
(2008) have discovered that the perception of diabetes in patients affected their commitment to
medications, nutrition, and exercise. This study will aim to investigate the illness perception
among both educated and uneducated population. The present study's findings could add to
improving the understanding among physicians and counselors arrange preventive interventions
and awareness programs to help patients to diabetic self-management. The present research
provides essential data to therapists and students. This research has developed an interface
between nursing science and practice.

Research Objectives

 This study aims to examine the relationship between Personality traits, illness perception and
Quality of life.
 This study will investigate the impact of personality traits on quality of life in diabetic
patients.
 This study will aims to investigate the mediating role of Illness perception in relationship of
Personality traits and quality of life .

Hypothesis

On the base of previous literature, it is hypothesized that

HI: There will be a significant relationship between Personality traits, illness perception and
Quality of life.

H2: There will be significant impact of personality traits on quality of life in diabetic patients.

H3: Illness perception will mediate the relationship of Personality traits and quality of life.