Chronic diseases are generally considered physical or mental conditions that last more than a year and

require ongoing care. They compromise the individuals’ physical and social function, the health-related
quality of life, and the economic sustainability of healthcare systems [2, 3]. Their global prevalence has
reached such unprecedented levels in many populations that chronic diseases currently represent a
public health concern.

For people with chronic diseases, management of their conditions

is fundamental to minimize their impact, improve health outcomes,
prevent further disability, and reduce healthcare costs [7, 8].
Adherence to treatment, the extent to which patients are able to
follow the agreed recommendations for prescribed treatments with
healthcare provider, is a key component of chronic disease
management. Only half of patients with chronic conditions,
however, take their medications as prescribed, making medication
adherence improvement a priority of the public health agenda [9
According to the World Health Organization (WHO), a series of factors, rather than a single one,
determine patients’ ability to follow treatment recommendations correctly. These factors interact and
potentiate each other’s influence in a framework determined by five dimensions — the social and
economic, health-care team and system-related, condition-related, therapy-related, and patient-related
[9].
Patient’s knowledge about medication regimen provided the
strongest predictor of adherence. A large proportion of participants
found it difficult to explain the amount, number, and frequency of
doses associated with their medications, negatively affecting their
adherence. For patients with chronic conditions, understanding of
their own diseases and the complex regimens may represent a
challenge [34]. For example, Friis et al. [35] found that individuals
with long-term diseases had more difficulties in comprehending
provider health information. Similarly, Fredericksen et al. [36] and
Kvarnström et al. [37] reported frequent misconceptions and lack
of understanding of the purpose of medications among the
chronically ill.
Self-perception of a good quality of life and older age were also
associated with adherence. Nonetheless, a lack of consensus exists
about their precise effect. While some studies corroborate our
findings suggesting a relationship between quality of life and
adherence attributed to the influence of some psycho-social
characteristics related to the ability of manage chronic diseases
[54], others have not found such association [55]. Similarly, the
effect of age has been inconsistent across adherence studies. An
increase in age is generally associated with a greater adherence as
younger people may perceive less severity of disease. This
association continues until the onset of some aging processes, such
as cognitive impairments, which usually occurs around the 70 years
of age, in which adherence starts to decline [56].
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across common long-term conditions: a population survey of health
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Fredericksen RJ, Gibbons L, Brown S, Edwards TC, Yang FM,
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The primary outcome for the current analysis was self-reported
medication adherence, which was assessed using the eight-item
Morisky Medication Adherence Scale (MMAS-8). The MMAS has
been determined to be reliable [19] and significantly associated
with blood pressure control (P < 0.05) in individuals with
hypertension (i.e. low adherence levels were associated with lower
rates of blood pressure control) [13, 19] and to have high
concordance with antihypertensive medication pharmacy fill rates
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MMAS scores of <6, 6 to <8 and 8 reflecting low, medium and high
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Self-compassion is defined as having the ability to self-soothe and
reassure during difficult, adversarial times and simply being kind to
one’s self, and encompasses the recognition that one’s experiences
are part of the human condition and to not be judgmental about
one’s self (Neff, 2003; Neff & Knox, 2017). It has been shown to
impact positively on well-being and health (Homan & Sirois, 2017;
Neff & Germer, 2017; Zessin, Dickh€auser, & Garbade, 2015). Self-
compassion is able to elicit a state of mind characterized by
calmness and content, including a sense of care, kindness, and
social connectedness, the ability to self-soothe during stressful
periods in life, further leading to a reduction of negative self-bias
(Kirschner et al., 2019). On the contrary, self-criticism is
considered maladaptive and linked with feelings of isolation and
the sense of facing a fight-or-flight situation, leading to a
heightened sense of threat during challenging situations (Warren,
Smeets, & Neff, 2016)
Evidence suggests PsyCap is an important resource in promoting
health and well-being (Avey, Luthans, Smith, & Palmer, 2010;
Luthans, Youssef, Sweetman, & Harms, 2013; Youssef-Morgan &
Luthans, 2015), and facilitating the various processes needed for
attention, interpretation, as well as 88 A. LOWERY AND T.
CASSIDY retention of constructive and positive memories, which
are essential for achieving and maintaining well-being (Luthans &
Youssef-Morgan, 2017).

The Compound PsyCap (CPC-12) Scale is a composite measure of

hope, resilience, self-efficacy, and optimism, encompassing 12
items. Each of the JOURNAL OF WORKPLACE BEHAVIORAL
HEALTH 91 four components is reported on a 6-point Likert scale
from Strongly Disagree (¼1) to Strongly Agree (¼6). It measures
psychological capital in a universal manner. The CPC-12 has been
demonstrated to have good reliability and external validity (Lorenz,
Beer, Putz, & Heinitz, € 2016). In this study, the Cronbach’s alpha
for the CPC-12 scale was 0.93

Current literature of hope in health and illness suggests that the presence of hope helps
adjust to an event and is necessary for survival and associated with a better quality of
life. There is a great deal of research in non-chronic pain populations, which has led to
the development of hope assessment tools which provide detailed processes and
related concepts of hope that can be used in a clinical setting. This has enabled more
research into the nature of hope and development of interventions for those
populations. For example, hope has been most studied amongst cancer patients. The
use of the Hope Scale [5] has enabled an understanding of hope and the adjustment to
cancer, influences on major symptoms (pain, fatigue) and psychological distress
(depression) [6].

Hope is a process in which one sets goals, creates solutions to achieve them, and creates the
motivation to execute and maintain them along the way[10]. Terefore, hope is considered an
efective factor in coping with chronic diseases [11].

Snyder CR. The psychology of hope: You can get there from here. Manhattan: Simon and
Schuster; 1994. 11.

Park GY, Yoo EK. A Study on Hope in Hemodialysis Patients. Adv Sci Technol Lett.
2016;128:244–6.
Hope was originally speculated as a unidimensional goal orientated construct, where
an individual’s behaviour can be explained by looking at expectancies for goal
attainment. Although these earlier value-based theories of hope describe goal-directed
personalities, they fail to explain the means by which goals were pursued. Snyder et
al. [7] goal setting theory suggests hope comprises of two interrelated components.
Hope is a positive motivational state based on a sense of goal-orientated determination
described as agency, followed by pathways, planning to meet goals. Staats et al. [8]
also presented hope as a multidimensional construct focusing on wishes and
expectations in specific desired circumstances (measured by the Hope Index).
Definitions of hope also exist which explores hopelessness comprising of negative
generalised expectancies about oneself and future outcomes [9].

There is strong body of literature that lends support to the health-promoting effects of
an optimistic personality [10, 11]. A meta-analysis of chronic pain research suggests
that there is an interaction between a patient’s symptoms of depression and the
severity of their chronic pain [12], and that chronic pain is predictive of higher levels
of anxiety [13]. Other positive psychological constructs related to optimism have been
shown as important factors in biopsychosocial models predicting how individuals
adjust to pain experiences [11, 14].

1. Bright FAS, Kayes NM, McCann CM et al (2011) Understanding Hope after

stroke: a systematic review of the literature using concept analysis, top. Stroke
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health: a meta-analytic review. Ann Behav Med 37:239–256

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8. Tunks ER, Crook J, Weir R (2008) Epidemiology of chronic pain with

psychological comorbidity: prevalence, risk, course, and prognosis. Can J
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seeing the glass as half full. Curr Pain Headache Rep 17(5)

Lorenz, T., Beer, C., Putz, J., & Heinitz, K. (2016). Measuring
psychological capital: € Construction and validation of the
Compound PsyCap Scale (CPC-12). PLoS One, 11(4), e0152892.
doi:10.1371/journal.pone.0152892 Luthans, F., Avolio, B. J., Avey, J.
B., & Norman, S. M. (2007). Positive psychological capital:
Measurement and relationship with performance and satisfaction.
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Researchers have also established that the most optimistic
individuals had a 55% reduced risk of all-cause mortality and a 23%
reduced risk of cardiovascular death (Giltay et al., 2004). The most
optimistic people had a 9% lower risk of developing coronary heart
disease and a 14% lower risk of dying from any cause (Tindle et al.,
2009), to name a few studies.

Around a decade ago emerged a construct of psychological capital (PsyCap) which is defined
as “individual’s positive state of development and is characterized by (1) having confidence
(self-efficacy) to take on and put in the necessary effort to succeed at challenging tasks; (2)
making positive attributions (optimism) about succeeding now and in the future; (3) persevering
toward goals and, when necessary, redirecting paths to goals (hope) to succeed; and (4) when
beset by problems and adversity, sustaining and bouncing back and even beyond (resilience) to
attain success” (Luthans et al., 2007: 3). In other words, PsyCap refers to a positive appraisal of
one’s capacity to overcome obstacles with sustained effort, and this appraisal reflects four
dimensions: hope, self-efficacy, resilience, and optimism.
Research has documented associations between psychological capital (PsyCap) and several
wellbeing outcomes, including health (Avey et al., 2010; Cheung et al., 2011; Harms et al.,
2017; Luthans et al., 2006; Varas et al., 2019). Even though PsyCap exploration has
concentrated mostly on the work domain, the capacity to persevere and overcome emotional
difficulties may be particularly important in the health context. Moreover, individuals higher on
PsyCap in the health domain are more likely to engage in opportunities to sustain and improve
health and more likely to persist in efforts to achieve health-related goals (Luthans et al.,
2010, 2013). Furthermore, positive health experiences, such as coping with illness or disability,
are likely to set positive development whereby individuals come to see themselves as more
capable of taking on more significant challenges with each success (Harms et al., 2017; Li et al.,
2014).
Even though there are many interesting findings on health-related PsyCap (Harms et al.,
2017; Li et al., 2014; Luthans et al., 2010), the importance of PsyCap in serious physical or
mental illnesses and disabilities is under-researched. It is not clear whether experiences of
illness or disability, which affect psychological wellbeing, could also influence health-related
PsyCap, and whether high PsyCap could serve as a mediating factor that helps improve
psychological wellbeing in case of illness.
Avey JB, Luthans F, Smith RM, et al. (2010). Impact of positive psychological capital on
employee wellbeing over time. Journal of Occupational Health Psychology 15(1): 17–28.
Luthans F, Avey J, Avolio BJ, et al. (2010) The development and resulting performance impact
of positive psychological capital. Human Resource Development Quarterly 21: 41–67.
Luthans F, Youssef C, Sweetman D, et al. (2013) Meeting the leadership challenge of employee
wellbeing through relationship PsyCap and health PsyCap. Journal of Leadership and
Organizational Studies 20: 114–129.
Luthans F, Avey JB, Avolio BJ, et al. (2006) Psychological capital development: Toward a
micro-intervention. Journal of Organizational Behavior 27(3): 387–393.

Self-compassion is an ability to extend kindness and understanding to the self during setbacks (Neff
2003, 2008). Selfcompassion is associated with skills that should positively affect health, such as
adaptive coping styles, improved self-regulation, fewer judgmental and defensive thoughts, and
effective goal monitoring (Allen and Leary 2010; Sirois et al. 2015; Terry and Leary 2011). Self-
compassion is associated with several important markers of physical health including reduced stress
(Breines et al. 2015), health promoting behavior (Dunne et al. 2016; Terry et al. 2013), psychological
functioning (Thompson and Waltz 2008; Zeller et al. 2015) and physical health (Hall et al. 2013). There is
evidence that the relationship between self-compassion and physical health is mediated by lower levels
of perceived stress and greater use of health-promoting behaviors (Homan and Sirois 2017).
Additionally, previous research has found a relationship between quiet ego, self-compassion, and less
perceived stress (Wayment et al. 2016).

Wayment, H. A., West, T. N., & Craddock, E. B. (2016). Compassionate values as a resource during the
transition to college: quiet ego, compassionate goals, and self-compassion. Journal of the First-Year
Experience & Students in Transition, 28, 93–114.

Homan, K. J., & Sirois, F. M. (2017). Self-compassion and physical health: Exploring the roles of perceived
stress and health-promoting behaviors. Health Psychology Open, 4(2), 2055102917729542.

Dunne, S., Sheffield, D., & Chilcot, J. (2016). Self-compassion, physical health and the mediating role of
health-promoting behaviours. Journal of Health Psychology, 23, 993–997. https://doi.org/10.1177
/1359105316643377.

Hall, C. W., Row, K. A., Wuensch, K. L., & Godley, K. R. (2013). The role of self-compassion in physical and
psychological well-being. The Journal of Psychology, 147, 311–323. https://doi.org/10.1080
/00223980.2012.693138.

Allen, A., & Leary, M. R. (2010). Self-compassion, stress, and coping. Social and Personality Psychology
Compass, 4, 107–118. https://doi.org/10.1111/j.1751-9004.2009.00246.x
Breines, J. G., McInnis, C. M., & Kuras, Y. I. (2015). Self-compassionate young adults show lower salivary
alpha-amylase responses to repeated psychosocial stress. Self and Identity, 14, 390–402. https://doi.
org/10.1080/15298868.2015.1005659.

Terry, M. L., & Leary, M. R. (2011). Self-compassion, self-regulation, and health. Self and Identity, 10,
352– 362. https://doi.org/10.1080/15298868.2011.558404.

Thompson, B. L., & Waltz, J. (2008). Self-compassion and PTSD symptom severity. Journal of Traumatic
Stress, 21, 556–558. https://doi.org/10.1002/jts.20374

(Sullivan-Myers et al., 2023). There are several ways in which self-compassion may be related to
improved psychological wellbeing and HRQoL. One mechanism may be through increased resilience.
Resilience has been defined as the ability to bounce back from stressful events (Smith et al., 2008) and
has been found to be associated with better HRQoL and psychological wellbeing in individuals with
chronic health conditions, including endometriosis (e.g. Lubián-López et al., 2021; Nery-Hurwit et al.,
2018; Romaniuk & Oniszczenko, 2023). When considered together, several studies have found that self-
compassion and resilience are both uniquely associated with improved physical and mental health
(Asensio-Martínez et al., 2019; Bag et al., 2022). Individuals who are more self-compassionate tend to
use more adaptive coping skills, including emotion-focused strategies such as acceptance and positive
reframing and problem-focused coping strategies such as planning and seeking instrumental support
(Ewert et al., 2021; Sirois et al., 2015) and are better able to regulate their emotions (Terry & Leary,
2011), all of which may promote resilience (Bluth et al., 2018). For example, recognising that others
have gone through similar experiences and that one is not alone in suffering (common humanity vs.
isolation dimension of self-compassion) may make it easier for an individual with endometriosis to seek
support which in turn may promote resilience. In a study among individuals with multiple sclerosis,
Nery-Hurwit and colleagues (2018) found that resilience mediated the relationship between self-
compassion and HRQoL. Another way through which self-compassion may be related to HRQoL is
through perceived severity of symptoms. In research with individuals with chronic pain, low self-
compassion has been associated with greater pain-related catastrophising and fear and lower pain
acceptance (Edwards et al., 2019; Wren et al., 2012). These findings are especially relevant since high
pain-related catastrophising and anxiety have been found to be important factors related to impairment
in HRQoL in individuals with endometriosis (McPeak et al., 2018; van Aken et al., 2017).

Self-compassion The Self-Compassion Scale-Short Form (Raes et al., 2011) was used to measure self-
compassion. This 12-item scale is a shortened version of the 26-item Self-Compassion Scale (Neff,
2003a). The scale correlates .97 with the full scale (Raes et al., 2011) and is a validated and reliable
measure of self-compassion with excellent internal consistency and strong temporal stability (Medvedev
et al., 2021; Raes et al., 2011). Items are rated on a five-point scale ranging from 1 (Almost Never) to 5
(Almost Always). Examples of statements include ‘I try to be understanding and patient towards those
aspects of my personality I don’t like’ (self-kindness), ‘When something upsets me, I try and keep my
emotions in balance’ (mindfulness) and ‘I try to see my failings as part of the human condition’ (common
humanity). Negatively worded items were reversed scored so that higher scores indicate higher levels of
self-compassion on all items. The 12 items were summed and then averaged to form a scale. Cronbach’s
alpha was .85 in the current study.
A high proportion
of older people places an increased strain on the welfare system, especially the health care and the social
security system [ 4]. When financial resources are limited, such as in
times of economic crises, structural ageism and negative attitudes towards older adults
seem to increase among health care professionals [ 5 ]. When health care professionals have
limited time, the tendency to stereotype older patients and not give them necessary care
increases [ 5]. A report from the Swedish National Board of Health and Welfare showed
that older people, when seeking mental health care, received pharmacological treatment,
such as benzodiazepines, instead of psychological [6]. The use of potentially inappropriate
medications, that is (medication which has greater potential risk than potential benefit), is
a worldwide negative phenomenon creating great health risks for older people, but also
unnecessary costs for the health care sector [4].
As they age, older adults face several challenges, including stigmatization and negative
attitudes that are common in society, for example, in the media [7]. Stigmatization of older
adults can operate at both a structural (i.e., institutions; health care) and individual level [5 ],
Int. J. Environ. Res. Public Health 2023, 20, 3011. https://doi.org/10.3390/ijerph20043011 https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2023, 20, 3011 2 of 9

becoming a public health issue with negative effects on the health and well-being of
older adults [ 8]. Ageism, or negative attitudes towards older adults, including those held
by older adults themselves, is shaped by prejudice, stereotypes, and discrimination [9 ].
Negative stigmatization because of age can lead to experiences of being excluded or cast in
a subordinate role, which in turn decreases psychological and physical well-being [8, 10 ].
Attitudes can be defined as thoughts or beliefs with an evaluative component [ 11 ]. How
one perceives older adults can differ by age, where individuals who are 80 years and above)
face more negative attitudes, such as being perceived with pity or as a burden, compared
with individuals below 70 years of age [12 ]. Attitudes towards one’s personal experience of
aging have been associated with well-being, health, and self-compassion [13 , 14]. Research
reveals that individuals who have a positive view of aging, both their own and in general,
perceive less discriminatory behaviors in others [12 ,15 ]. There is a lack of studies on
how older adults in Sweden perceive general attitudes towards the older population and
whether there is an association with their own aging process.
The extent to which individuals hold a positive image of themselves and the aging
process is part of the concept of life satisfaction [16]. Knowledge of the indicators of older
adults’ life satisfaction is essential, because health-related losses might reduce opportunities
for those at an advanced age to live a successful life. Internal and external factors that are
well-known indicators of low life satisfaction include age—where the oldest individuals
reported lower life satisfaction than those aged 70–79 years—negative perceived health [17 ],
personality, and financial and social resources [ 18]. Self-compassion is one aspect associated
with better perceived life satisfaction [ 13 ,19 ] and refers to the ability to take care of and
support oneself in moments of suffering [20,21].
Self-compassion has been described as psychological resilience in relation to aging,
helping older adults maintain well-being despite challenges such as physical health prob-
lems [ 22 ]. Older adults who are high in self-compassion seem to have a more accepting
attitude towards negative age-related events, such as physical and mental limitations,
than those who are low in self-compassion [ 23]. Increased self-compassion has also been
found to strengthen the ability to balance negative emotions related to threatening social
circumstances [ 24]. It could be helpful for older adults facing negative attitudes towards
aging from others or themselves [25 ]. Whether there is a relationship between perceived
attitudes towards aging in society and self-compassion remains unknown.
Life satisfaction includes a broader range of an individual’s perceptions of the aging
process and self-identity. Health-related quality of life (HRQL) focuses on how physical and
mental health affects the day-to-day demands of life and whether the ability to fulfill needs
and desires is constrained by a person’s health [26 ]. Self-rated health has consistently been
described as closely related to well-being, life satisfaction [17], and self-compassion [22].
Negative perceptions of age and aging, at societal and individual levels, have adverse
effects on older adults’ health and well-being [27].
Malakouti, S.K.; Javan-Noughabi, J.; Yousefzadeh, N.; Rezapour, A.; Mortazavi, S.S.; Jahangiri, R.; Moghri, J. A
Systematic Review
of Potentially Inappropriate Medications Use and Related Costs Among the Elderly. Value Health Reg. Issues. 2021,
25, 172–179.
5. Marques, S.; Mariano, J.; Mendonça, J.; De Tavernier, W.; Hess, M.; Naegele, L.; Peixeiro, F.; Martins, D.
Determinants of Ageism
against Older Adults: A Systematic Review. Int. J. Environ. Res. Public Health. 2020, 17, 2560. [CrossRef] [PubMed]
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hos äldre.
2018. Report Number: 2018-9-12. Available online: https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/
artikelkatalog/oppna-jamforelser/2018-9-12.pdf (accessed on 1 February 2020)

Edström, M. Visibility patterns of gendered ageism in the media buzz: A study of the representation of gender and
age over three
decades. Fem. Media Stud. 2018, 18, 77–93.
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Globally, chronic illnesses are a health threat. Each year, 15 million individuals in low- and middle-
income nations between 30 and 69 die prematurely from chronic disease (4

HRQoL is defined as the way a medical disease or its treatment impairs an individual’s expected physical,
emotional, and social well-being (9). The goal of measuring HRQoL is to objectively evaluate the way a
disease can affect patients’ lives and how they cope with it. These assessments may be beneficial as
baseline and outcome measurements and should serve as a foundation for determining the impact of
changes in a patient’s HRQoL.

Self-efficacy is the way people believe they can perform specific behaviours to accomplish individual
goals (11). Patients’ perceptions of their overall self-efficacy affect their physical, emotional, and social
HRQoL (12). A seminal work related to self-efficacy by Albert Bandura (13) explains that individuals with
a strong sense of self-efficacy exert more significant effort and persist longer in their actions than
individuals with a low sense of self-efficacy. A recent study indicated that greater levels of diabetes
management self-efficacy are linked with improved psychological well-being and social interactions in
individuals with type 2 diabetes mellitus (12). Thus, it indicated that self-efficacy is essential in coping
with a chronic condition’s challenges and demands for a better HRQoL. Past studies related to HRQoL
and self-efficacy were conducted among patients with multimorbidity in England (14) and children with
chronic illness and medical complexity in the USA (15). These studies reported that self-efficacy is an
essential predictor of HRQoL.

Cramm JM, Strating MMH, Roebroeck ME, Nieboer AP. The Importance of General Self-Efficacy for the
Quality of Life of Adolescents with Chronic ConditionsSoc Indic Res. 2013;113(1):551–61. doi:
10.1007/s11205-012-0110-0 12. Rak A, Raina R, Suh TT, Krishnappa V, Dariusz J, Sidoti CW, et al.
Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve
quality of life and relieve suffering for patients (and families) with chronic illnesses Clin Kidney J.
2017;10(1):68–73. doi: 10.1093/ckj/ sfw105 13. Bandura A. Self-efficacy: toward a unifying theory of 226
Mal J Med Health Sci 18(SUPP15): 221-226, Oct 2022 Malaysian Journal of Medicine and Health Sciences
(eISSN 2636-9346) behavioral change. Psychol Rev. 1977;84(2):191– 215. doi: 10.1037//0033-
295x.84.2.191 14. Peters M, Potter CM, Kelly L, Fitzpatrick R. Selfefficacy and health-related quality of
life: a crosssectional study of primary care patients with multimorbidity Health Qual Life Outcomes.
2019;17(1). doi: 10.1186/s12955-019-1103-3 15. Bravo L, Killelea MK, Reyes BL, Santos KMB, Torres V,
Huang CC, et al. Self-Management, Self-Efficacy, and Health-Related Quality of Life in Children With
Chronic Illness and Medical Complexity. J Pediatr Heal Care. 2020 Jul 1;34(4):304–14. doi:
10.1016/j.pedhc.2019.11.009
Moreiras-Plaza M, Blanco-García R, CossioAranibar CR, Rodriguez-Goyanes G. Assessment of health-
related quality of life: the cinderella of peritoneal dialysis? Int J Nephrol.;2011:1–8. doi:
10.4061/2011/528685

Noncommunicable diseases. [cited 2021 Nov 25]. Available from: https://www.who.int/news-room/

fact-sheets/detail/noncommunicable-diseases