Exploring the impact of stressful life events on quality of life: meaning making and narrative reconstruction

ABSTRACT

Purpose

Stressful life events have the capacity to disrupt an individual’s worldview and life goals, leading to existential questions and identity loss. The subjective perception of identity is intricately linked with quality of life (QoL), and how individuals derive meaning from these stressful life events significantly influences their well-being. This article explored the impact of stressful life events on individuals’ QoL, and examined the potential for enhancing QoL through meaning making and narrative reconstruction.

Methods

Qualitative interviews were conducted with 11 individuals reporting diminished QoL and analysed using thematic analysis.

Results

The study reveals that stressful life events confront interviewees with the vulnerability of their values in life and the limits of their control, leading them to question their own beliefs and purpose in life. Consequently, these events prompt individuals to reconstruction their narratives to adapt to new life circumstances.

Conclusions

The study suggests that “securing the base,” including strong social relations and security in economic and housing conditions, is a prerequisite for enhancing QoL. The insights on “the base” have profound implications for QoL. Recognizing their fundamental importance, policymakers, healthcare professionals, and social service providers can support mechanisms to enhance these foundations, improving overall well-being for individuals and communities.

KEYWORDS:

• Identity
• narrative meaning making
• quality of life
• self-efficacy
• stressful life events

Introduction

In the literature, stressful life events are typically described as specific life circumstances or situations that are considered to be emotionally distressing and potentially overwhelming for an individual. Stressful life events can vary widely and may include experiences such as bereavement or the loss of a loved one, divorce or the break-up of a relationship, financial difficulties or unemployment, family conflicts or caregiving responsibilities, serious illness or injury, among others (Park, 2010; Park & Folkman, 1997; Park & George, 2013). Research in psychology and health sociology, particularly on the topic of stressful life events such as falling ill, suggests that these events often have the capacity to interrupt and break with the individual’s personal goals and expectations to life (Hartog et al., 2020; Mattingly, 2005). This disruption often evokes existential questions, as the individual’s existence becomes detached from the past and the future (Giddens, 1991). This may cause the individual to experience that life turned out differently than expected, and that dreams might no longer be realistic to fulfill due to the consequences of illness. Thus, the individual must reconstruct their narrative to consider the new life circumstances (Mattingly, 2005) and make sense of how the stressful event will become important and influence the individual’s future life (Park, 2010). This concept is defined in the literature as meaning making, which refers to the restoration of meaning in the context of stressful experiences (Park, 2010). Meaning is crucial in understanding human experience and behaviour and meaning making is considered essential in recovering from stressful events such as illness and bereavement (Park & George, 2013). In recent years, research in meaning and meaning making has increased. However, research is limited on the integration of stressful life events into the narrative and the resulting experience of identity loss or change (Park, 2010) and how this is experienced to affect quality of life (QoL).

World Health Organization defines QoL as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (Whoqol Group, 1995). Thus, the subjective feeling of identity (who am I, what are my goals and dreams, and what do I expect from life), and QoL are closely interrelated. Studies show that the way individuals make meaning of stressful life events influence their experiences of and expectations to QoL (Hartog et al., 2020; Mattingly, 2005; Park, 2010). The narrative construction of identity is an ongoing process where the individual constructs stories to make sense of their experiences, offering meaning and purpose to their lives (Baumeister, 1991; Taylor & Bury, 2007; Hartog et al., 2020). Through the process of meaning making, individuals can adjust their narrative considering the stressful event (Park, 2010). Baumeister (1991) defines meaning as a “mental representation of possible relationships among things, events and relationships. Thus, meaning connects things”. Mattingly (2005) suggests that when experiencing chronic illness, individuals understand themselves through their bodies, as they connect their identity to the pain and uncertainty caused by the diseased or disabled body. Thus, in this sense, meaning and identity are connected, as narrative meaning making and stories can contribute to the remaking of identity through the interpretation of the past, connection to the present, and even in the creation of scenarios for the future (Ibid). The link between time and body suggests that disruption of the individual’s narrative is not only caused by the stressful life event per se, but also by the impact the event, such as illness, has on the individual’s physical ability to engage in everyday life (Fang et al., 2023). In line with Mattingly, Fang et al. (2023) emphasizes the importance of recognizing how the body shapes an individual’s capability to reconstruct identity over time both before and after the event of illness (Ibid).

In this study, we explore the impact of stressful life events on individuals’ subjectively constructed QoL. Specifically, this article investigates the aspect of diminished QoL due to the consequences of illness, as illness was identified as the primary stressful event among the participants of the study. Additionally, we examine the potential for enhancing QoL through processes related to meaning making and the reconstruction of narratives to adapt to new life circumstances.

Quality of life

It is largely agreed that the concept of QoL is a multidimensional construct consisting of several core domains including physical, psychological, and social aspects. These core domains are influenced by personal characteristics and by environmental and contextual factors (see e.g., Jespersen et al., 2019; Verdugo et al., 2005; Yi et al. 2022). QoL comprises the individual’s cognitive evaluations or assessments of own life and is a determining predictor of the individual’s subjective wellbeing.

Existing research suggests that both environmental and contextual factors (described above) as well as individual factors impact QoL. Firstly, sociodemographic and socioeconomic factors such as gender, age, marital status, socioeconomic background, and financial conditions are significant factors. Secondly, the individual’s personality, religious beliefs, feeling of freedom and self-assessed health significantly impact QoL (Ferriss, 2002). Finally, many studies have shown that the extent and nature of social relationships and social trust are positively associated with self-assessed life satisfaction (see i.a. Andersen, 2019; Burger et al, 2020; Delhey & Dragolov, 2016; Helliwell et al., 2023; Inglehart, 2010; Lolle & Yi et al. 2022; Welzel & Inglehart, 2010). The literature shows that weak social relations and support and living alone or being unmarried are strong predictors of low satisfaction with life and QoL (Due et al., 1999; Matud et al., 2014). Conversely, individuals with strong social relations have a lower morbidity and mortality than individuals with weak social relations (Due et al., 1999). Further, individuals with strong social relations have a greater chance of recovery after illness, and it may increase individuals’ chances of recovery when reinforcing their social relations (Ibid). Other studies suggest that engagement in activities within the civil society, such as participating in cultural, leisure and sports activities, is central to individuals’ experiences of QoL, as these activities may promote social relations and social trust, which are positively correlated with QoL (Iversen et al., 2023).

This article will add to the research on QoL and contribute with empirical insights on the significance of strong social relations and security concerning economy and housing identified by the interviewees in this study and referred to as “the base”. The findings will provide perspectives on the impact of this “base” as fundamental to QoL and “to secure the base” as a precondition for QoL in relation to the experience of stressful life events within a narrative meaning making framework.

The societal context

The study on which this article is based was carried out in Denmark. For many years, Denmark has been among the highest scoring nations with regard to measurements of self-assessed QoL (Lolle & Andersen, 2019; Helliwell et al., 2023). Research has shown that the societal context is of great importance to citizens’ assessment of their QoL, and therefore essential to the interpretation of the results in this study. The literature reports that the individual country’s economic development (GDP), character and effectiveness of the public sector, degree of pro-social behaviour and degree of individualism positively affect citizens’ self-assessed QoL (see i.a. Ambrey et al., 2016; Bjørnskov et al., 2007, 2008; Helliwell et al., 2023; Perovic & Golem, 2010). On most of these factors, Denmark scores high compared to other countries. Denmark ranks relatively high on measures of pro-social behaviour, including the proportion of the population who work voluntarily (Salamon et al., 2017). Denmark is one of the richest countries in the world (World Population Review, 2023) with a welfare state based on universalist principles, where everybody, regardless of status and finances, is guaranteed free treatment in hospitals, free access to education, public retirement pension, compensation for loss of income in case of unemployment, etc (Esping-Andersen, 1990). The labour market model is termed “flexicurity” (Madsen, 2022). It is flexible in the sense that it is relatively easy to reduce the number of employees and offers security in the sense that there is a possibility to gain economic support in periods with unemployment for up to three years (Ministry of Employment, 2021). It is mandatory to engage in municipal activation programmes to assess the individual work capacity. If your capacity for work is permanently and substantially reduced, it is possible to get a part time position (flexi-job) based on public subsidies. Only if work ability cannot be improved, a process is initiated to grant disability pension funded by the state (European Commission, 2022).

Materials and methods

The study is part of an investigation of life satisfaction carried out in 2022 in a municipality in Denmark with approximately 50,000 inhabitants. First, a survey of a representative sample of the inhabitants in the municipality was carried out resulting in responses from 1,517 citizens (response rate 65%). The survey investigated life satisfaction measured on several factors determining aspects of significance to QoL. The majority of the citizens were generally satisfied with their lives. However, eight percent were less satisfied with their lives in general. The aim of the current study was through individual interviews to gain insight into the circumstances negatively affecting the QoL of these citizens.

Ethics

In Denmark, qualitative research does not require ethical approval from the National Committee on Health Research Ethics (www.nvk.dk).

Recruitment and participants

The recruitment of participants was based on the survey conducted in a Danish municipality. The recruitment criteria included self-reported general life satisfaction below average (below 5 on a scale from 0 to 10) and the identification of more than one event (such as illness, bereavement, or unemployment) that had negatively impacted their life satisfaction. Based on our criteria, this process allowed for purposive selection (Maxwell, 2013) from a randomized group. Eighteen citizens were contacted by mail and invited to participate in the interview study, and 11 citizens accepted the invitation. Following this, the 11 participants received a letter explaining the purpose of the study, the themes in the interview guide, and information about anonymization and voluntary participation. Furthermore, the 11 participants were offered a gift voucher of USD$ 30 if accepting to participate. Upon this, the participants gave their final consent to participate in the interview study. By offering participants a gift voucher, we attempted to overcome a well-known challenge when recruiting people from vulnerable groups by using the voucher as a motivational tool. The use of such motivational tools has not been associated with response bias (Hjortskov et al., 2023). Furthermore, we also wished to acknowledge the participants’ contribution to our research. This kind of purposive recruitment process reflects our interest in specific experiences negatively affecting QoL.

The interview persons were five women and six men, and their age varied from 29 to 77 (most of them were middle-aged). Nine of the 11 interviewees lived alone and did not have a life partner. Some of the interview persons had never been married and did not have any children, while other interviewees were divorced, but had children, and one interview person was a widower. Due to consequences of illness, nine participants were not a part of the regular labour market and were dependent on public subsidies (Table I).

Table I. Characteristics of interview persons (gender, age, marital status, children, occupation).

Characteristics of interview persons
ID	GENDER	AGE	MARITAL STATUS	CHILDREN	OCCUPATION
1	Male	20–29	Single	No	Activation program
2	Female	30–39	Married	Yes	Flexi-job
3	Female	40–49	Divorced, single	Yes	Activation program
4	Male	40–49	Divorced, single	Yes	Full-time job
5	Female	50–59	Single	Yes	Disability pension
6	Female	50–59	Single	No	Disability pension
7	Male	50–59	Divorced, single	Yes	Full-time job, self-employed
8	Male	50–59	Married	Yes	Resource clarification process for a disability pension
9	Female	60–69	Single	No	Disability pension
10	Male	60–69	Single	No	Flexi-job
11	Male	70–79	Widower, single	Yes	Pensioner

Interviews

The interviews were conducted in October 2022. The duration of the interviews, excluding the mutual introduction of the interviewer and the interviewee, the explanation of the aim of the study, and other introductory elements, ranged from 15 to 45 minutes, with an average duration of 28 minutes. Eight interviews were conducted by telephone, while three interviews took place in the participants’ private homes. The choice of interview format was based on the individual preferences of the participants. The interviews were guided by a semi-structured interview guide encouraging the interviewees to unfold their own narratives within the frame of experiences affecting their perception of QoL. Our aim was to gain an in-depth understanding of how the interviewees perceived QoL, their subjective QoL and which circumstances negatively affected this. The interview guide explored four themes related to this aim (Table II).

Table II. Themes covered in the interview guide.

INTERVIEW THEMES
1	The participants’ perception of quality of life.
2	The participants’ subjective quality of life (including a focus on examples of occurrences or circumstances in the participants’ lives which have influenced their quality of life either positively or negatively).
3	Personal control and self-efficacy in relation to the participants’ beliefs in their abilities to influence their own life situation.
4	The participants’ experience of structural circumstances of importance to their subjective quality of life.

Data analysis

We employ Thematic Analysis (TA), following the framework outlined by Braun and Clarke (2006), to examine the interview data. TA systematically identifies patterns and themes, enabling a comprehensive exploration of interviewees’ experiences and perspectives. We approach the analysis with a dual lens: one derived from a preconditioned theoretical framework, guiding deductive coding, the other from an inductive approach, where the data leads the coding process and findings emerge organically. Through this method, we enrich the depth and comprehensiveness of our findings. TA comprises a six-phase practical analysis. It begins with familiarization with the data, followed by generating initial codes from the dataset. We then search for recurring patterns and themes within the data. After identifying themes, we review, define, and name them. The next step involves writing a narrative that encapsulates the findings. Throughout this process, rigour is maintained by following a systematic approach.

All interviews were recorded, transcribed, and coded in the qualitative data analysis software Delve. The interview transcripts were coded using a codebook (Braun & Clarke, 2022). The coding process included a thorough review to ensure code labelling accuracy. Finally, the codes were divided into clusters of themes summing up the findings: experienced QoL; events experienced to be impacting QoL; perception of life quality; living with disease; engaging in social relations; the importance of a work life; being part of the local community; “the base” as a precondition for QoL; agency and personal control. Through the interviews, patterns emerged illuminating that stressful life events disrupted the identity and narrative of the individual in a way that affected the subjective QoL, allowing us to explore the fundamental preconditions of QoL. In this process, data saturation was met as in the end no new themes emerged from the data.

Considering that the study’s design, as part of a questionnaire survey, did not include formal member checking to confirm the accuracy of participants’ perspectives and experiences, we employed a rigorous approach by collaboratively analysing the interview data. This process involved in-depth discussions about codes and emerging themes. This collective data analysis encompassed a thorough examination of interview transcripts and the corresponding codes to assess interpretations and potential biases.

Analytical framework

Based on influential theories in the context of stressful events, Park and Folkman (1997) and Park (2010, 2013) offer an integrated meaning making model. The theories identify stressful events as disruptive, evoking existential questions and the need for making meaning to adjust to the stressful event. Processes of meaning making can result in what Park identifies as meanings made, such as acceptance, having made sense, reattribution of the cause of the event, and integration of the event into one’s (changed) identity. More recently, Hartog et al. (2020) suggested a humanities approach to meaning making in relation to QoL. In their theoretical model, they combine theories on contingency and narrative identity, “emphasizing the crisis of meaning people may experience when confronted with the ‘randomness’ of life, which requires narrative reconstruction” (Ibid). Falling ill is an example of a contingent life event. Further, as opposed to Park and other psychological theories on meaning making, which primarily focus on the psychological processes, Hartog et al. emphasized the existential dimensions of this process (Ibid). In line with this, Fang et al. (2023) showed how chronic disorders can give rise to existential questions and challenges of understanding the individual’s own sense of being-in-the-world causing experiences of existential identity loss (Ibid).

In the meaning making literature, the individual’s worldview is defined as the meaning system that influences the way the individual perceives the world and his or her personal identity. Worldview is also fundamental to the way individuals construct their values and ultimate life goals and how they make meaning of life events in the context of their personal life narrative (Hartog et al., 2020; Park, 2013). Hartog et al. defined ultimate life goals as “the goals, or values, that give ultimate meaning to our lives—‘ultimate’ in the sense that this value cannot be replaced by something else. They are universal in the sense that they are shared by many people, and they are formulated in an abstract way” (Hartog et al., 2020). Thus, when stressful life events occur, the events might conflict with these ultimate life goals and negatively affect QoL. In this study, we examined the fundamental preconditions of QoL expressed by the interviewees as “the base” and analysed these as the individuals’ ultimate life goals to investigate narrative meaning making and reconstruction of identity.

Furthermore, we applied Bandura’s (1977, 1989, 1997) concept of self-efficacy in analysing the process of meaning making. Experiencing illness, the individual’s QoL is negatively affected as a consequence of the impact the stressful life event has on their worldview, values, beliefs and goals in life as well as their right to self-determination. Essential to QoL is the individuals’ subjective experience of being able to act on their own and make independent decisions of significance for their life. Here, self-efficacy becomes central, as the concept refers to the individuals’ beliefs that they can complete challenges and reach goals in specific situations (Bandura, 1977). The individuals’ beliefs about their capabilities to exert control over their behaviour and motivation are shown to be intertwined with QoL in relation to chronic health conditions (Jongen et al., 2016). Thus, individuals with a higher degree of self-efficacy are more likely to engage in self-management behaviour, which will often lead to a better disease control and improved QoL (Weng et al., 2010).

Results

This study will unfold the importance of the meaning of “the base” and its impact on QoL. Additionally, it seeks to examine how the interviewees make meaning of stressful life events and reconstruct their narrative through self-efficacy, as these events prompt individuals to adapt to new life circumstances. It is essential to emphasize that the concept of “the base” did not precede the data; rather, it emerged from our data analysis process as a concept expressed by the interviewees. Based on our analysis, we will unfold three points: establish how what we term “the base” acts as a precondition for QoL, second, how self-efficacy impacts processes of meaning making and contribute to maintain “the base” and reconstruction of the individual’s narrative, and third, how QoL is decreased when the individual does not experience any long term possibilities for securing or developing “the base”, endangering the integration of life events into the narrative. We structured the analysis in three main parts. To illustrate the second and third points in our analysis, we present two more comprehensive narratives based on two individual interviews, where interviewees are referred to using the pseudonyms Peter and Yvonne. We apply the narrative approach to illustrate the causal relationship between “the base”, narrative meaning making and the impact on QoL.

“The base” as a precondition for quality of life

The interviews revealed that strong social relations, primarily with family and friends, as well as economic security and stable housing conditions, are prerequisites for QoL among the majority of the interviewees. An example of this can be found in the expression of a middle-aged, divorced father who emphasized the fundamental importance of securing “the base” for QoL:

Well, to me quality of life is family, friends and being social. Thereby saying that quality of life is, how can I put it … to secure the base. The base being your house, home, economy. It is the entire foundation of being able to get out there and be social, to see friends and to be with your children. (Interview person 4)

Interview person 4 finds that social relations are the purpose of life and emphasizes that the prerequisite for being able to obtain strong social relations is the experience of security in economy and housing conditions. Interview person 9, a woman in her sixties, uses a similar expression as she defines the same preconditions as “building blocks” for life quality. Applying the interviewees’ own descriptions, we established the concept of “the base” as a precondition for QoL. “the base” acts as the interviewees’ ultimate life goals (Hartog et al., 2020) that cannot be replaced. “the base” is highly threatened when stressful life events occur and leads to a perceived decrease in QoL.

Illness was a determining factor of low QoL among the interviewees of the study. It was the single factor most negatively affecting QoL across all the interviews. The interviewees identified illness as the primary stressful event causing conflicts with their worldview and personal life goals. When falling ill, interviewees were faced with the vulnerability of their values in life and the limits of their control (Ibid), which might give rise to questioning their own beliefs, values, goals and purpose in life and the experience that they can no longer live life as they did before the illness. The interviewees attempt to reconstruct their narrative to make meaning of the illness, as a life changing event. Another determining factor of low QoL in the study was living alone. Interviewees identified divorce or the death of a spouse as a stressful and life changing event affecting QoL negatively and conflicting with the interviewees’ ultimate life goals. Interview person 4 defines his divorce as “losing his family” and explains how this life event conflicts with his worldview forcing him to reconstruct his narrative:

The happiest [event of my life] of course was getting a girlfriend, a wife and have children. Conversely, the unhappiest event that has happened is losing my family. I cannot even describe how hard it is. But it has been, it is really life changing. […] Working with your mind and existence, and who am I, and what is my purpose in this life, my function? (Interview person 4)

The interviewee perceives his QoL to be very low as the stressful event of his divorce has threatened his “base” and lead to a loss of identity. The construction of narrative identity was closely connected to the way the interviewees’ ultimate life goals (“the base”) influenced and unfolded within everyday life. Experiencing strong social relations and security in economy and housing conditions were associated with the importance of living nearby family and friends, in a local community where you feel safe in social relations and are able to engage in civil society activities and the associational life. Moreover, it was important to be attached to the labour market and be able to provide for yourself. “Securing the base” was thus essential to bring meaning to the lives of the interviewees. When faced with stressful events interrupting the individuals’ own understanding of being in the world, processes of meaning making became central to restore personal identity. In the following paragraph we emphasize the recognition of self-efficacy as essential in restoring meaning, through the comprehensive narrative of Peter.

The narrative of Peter: the impact of self-efficacy on maintaining “the base” and reconstructing the narrative

Peter was in his early twenties when he decided to follow his dream of managing his own business within crafts. Throughout his independent career he spent most of his hours in his shop, but he also managed to build a family life. Peter married Kate and together they raised their three children. When Peter was in his forties, life as he knew it changed significantly, as he was diagnosed with cancer. Within a few years Peter went through more than a dozen surgeries, in some periods he was operated every single month. The complicated course of illness was very hard on Peter’s family. Kate supported Peter emotionally and by taking care of him after his operations. Kate was worried every time Peter would go to the hospital, and every surgery he had, she was nervous he would die. At some point the pressure overwhelmed Kate, and she started abusing pills and alcohol. When Peter was finally in recovery, Kate could not control her abuse, and her mental condition was critical. She would not admit her abuse to the mental health services or accept help in any other way, and she could no longer take care of their children. Thus, Peter made the hardest choice he had ever had to make, to divorce his wife to take care of their children on his own. Today, Peter suffers both physically and mentally from his cancer disease and the loss of his wife haunts him. However, he manages to run his business and take care of their children. He hopes to find someone to share his life with again, to drink a cup of coffee at the kitchen table and talk to about his day at the shop.

Peter perceives his QoL has decreased significantly since the stressful life event of being diagnosed with cancer and the long course of illness. Peter’s worldview informs the way he makes meaning of these events and how he constructs his narrative. He sees himself as a fighter and a survivor of cancer, and this narrative is essential to the meaning he attributes to the stressful events.

I don’t believe anybody would manage this. It is so mentally challenging. It is only because I am like my mother, we just fight. Just getting up in the morning and getting something done. Sometimes I don’t want to, but you have to. You know, it is a fight for life, and it has been for the last five or six years. It has been really bad. It has been really, really bad. I have come through it by now. But it’s hard. (Peter, interview person 7)

In the construction of the narrative meaning making, Peter integrates the stressful events into his personal life story, as he connects how he has handled his illness and divorce to his narrative of being a fighter. He illustrates a high level of self-efficacy as he believes he can get through life events that other people are not able to, as illustrated in the above quote. The explanation of being like his mother reinforces his narrative and self-efficacy. Experiencing people, whom we consider as role models, overcoming obstacles, can lead us believe that we can also acquire the capabilities necessary to conquer similar obstacles (Bandura, 1997). However, the most important source of self-efficacy is through “mastery experiences”, which implies having your own experiences of succeeding a challenge (Ibid). Peter has encountered numerous stressful life events and circumstances, as outlined in the introductory narrative. However, the experience of navigating through, or even surviving, these stressful life events reinforce his self-efficacy. Furthermore, Peter believes that unfortunate events happen to him, and that they are outside his control, which is illustrated in statements like “I am not very lucky”, “I do not have ‘lucky’ tattooed on my back, I can tell you”, and “I am waiting for what will happen to me next”. Applying the framework of narrative meaning making by Hartog et al. (2020), central aspects of this process are evaluation, agency and scope. Evaluation is related to the meaning the individual attributes to the event as either positive or negative. Agency refers to the perceived role of the individual as active or passive. In this case, Peter’s role is passive as the negative events are perceived as something that occurred to him, because he is an “unlucky” person, and thus not something caused by himself. Finally, scope refers to the scale of the meaning that the event has to an individual. Peter recognizes the impact of these events to influence his life as a whole (existential scope) (Ibid).

Research suggests that QoL is reflected in the distance between the individual’s expectations and hopes, and the individual’s experience of the situation, suggesting that the greater distance, the lower QoL. Thus, to increase QoL the individual must either improve the situation or reduce one’s expectations (Zachariae & Bech, 2008). Peter defines QoL as “when you get up in the morning without an aching body […] And to feel well, thriving with what you do. And that you do not feel … too depressed”. Furthermore, he expresses that he “feels as well as he can”, suggesting that he has lowered his expectations and integrated his stressful life events into his narrative as he adapts to his new life circumstances.

Security in economy and housing conditions

Analyzing the narrative of Peter, he finds meaning in his life through his family and his business. He uses his business to cope with his circumstances, as he expresses what is important in his life: “ … my dogs and my children. And my business. I enjoy what I am doing. It is the reason why I survive, you know. Because I enjoy what I am doing”. Peter’s work identity suffered when he was diagnosed with cancer and could not work, but he managed to get back to work after his illness. Working does not only provide Peter with economic security, but it also brings him a feeling of freedom. This perception of his work life is a contrast to his perception of his life at home, where he experiences a heavy burden of responsibilities both in relation to the household, paying bills and to raising his children.

The analysis suggests that the interviewees’ perceived QoL is closely related to their attachment to the labour market, which has a significant impact on their fundamental preconditions for QoL. This includes values related to contributing to society, personal and moral values like being able to provide for yourself and your family, as well as having a healthy economy and economic freedom, which can affect QoL. When asked why she perceives her quality of life to be low, interview person 5, a woman in her late fifties with a disability pension, responds, “I thought I would work for another ten years, but I am cut off from that […] but it would have improved my quality of life if I could have contributed something. And then, legitimately, go on pension”.

Further, a work life was considered important by the interviewees, especially the social network and relations to colleagues, which often follows when having a job, and to the work identity that contributes to the definition of the interviewees as individuals:

When you lose your job, which accounts for a third of your life, and when you experience great quality of life by having this job, and it’s also colleagues and a lot of other stuff – then it’s a third of your life that is suddenly gone, and you need to find something that can replace it. (Interview person 6)

Furthermore, experiencing economic security and freedom of being able to settle down in the local area was considered important as well. In conclusion, the interviews suggested that having none or reduced attachment to the labour market may affect the interviewees’ economic situation negatively and decrease their QoL as they do not experience economic freedom and security and feel challenged regarding some of the most basic preconditions for living a good life. The impact of securing “the base” was perceived as significantly important as the interviewees experienced a loss of personal control when they became economically dependent on public subsidies. Most of the interviewees are dependent on public subsidies as they are either retired or receive disability pension, have a flexi-job, or participate in an activation programme. While these interviewees are limited in their working capabilities, the two interviewees who are active on the labour market experience that they need to work more than full time to sustain a healthy economy, as they are divorced and therefore must finance their housing and bills by themselves. QoL was affected negatively when the interviewees experienced being limited in their means of developing both in relation to their attachment to the labour market, their economy, and possibilities of engaging in social relations. The interviewees with diseases experienced that it is challenging to accept and learn how to live with the limitations of the disease, which affects their QoL negatively. Interview person 8, a middle-aged man, who has been working as a craftsman his entire life until recently when he started experiencing back pain. He is now enrolled in a resource clarification process in the municipality to obtain disability pension. He expresses how chronic back pain conflicts with his personal life goals, as he defines QoL as being able to work:

Well, that is exactly what is conflicting, because before it was work, work and work. I enjoyed working and constructing and doing something, and I still do. However, now the problem is that every time I do some work, I am in pain. A lot of pain. And that means that I cannot do anything but just lie down. (Interview person 8)

Our analysis indicates that interviewees suffering from chronic pain experienced limitations in their possibilities of being physically active, as they are in pain, easily get tired and exhausted and need more rest. Conversely, they are dependent on doing exercise to reduce their pain and therefore physical activity became important to the interviewees’ prospects of their life quality. The interviewees who are no longer part of the labour market suffered from mental challenges and/or somatic challenges such as chronic pain, back disorders, or cancer. However, most of these interviewees have had a strong work identity earlier in life before they fell ill, where working ability has been an important part of their life. Therefore, it is challenging to accept and cope with the fact that illness has caused disabilities and either partly or completely reduced of their work capacity, which affects maintenance of “the base”. In the following paragraph, we will show how disintegration of “the base” can affect the process of narrative meaning making, causing a decrease in QoL, through the comprehensive narrative of Yvonne.

The narrative of Yvonne: Consequences of “the base” being endangered

Growing up on the countryside with her family, already as a teenager Yvonne dreamt of a life at sea. Though Yvonne was close with her parents and four siblings, she left home at a young age to pursue her dream. She accomplished an education qualifying her for the position at sea that she dreamed of, and soon after she got a job on a ship, ready to sail around the world. Choosing a life at sea, Yvonne decided that she would not marry or ever have children. Unfortunately, ten years later, Yvonne had to leave her job as her position was closed, and this was the end of her dreams. Yvonne now questioned her purpose in life. She retrained for another job, which she ended up doing for more than 30 years. She continued to live by herself but stayed close to her family and maintained strong relations with neighbors and colleagues. When Yvonne was in her fifties, she was assigned a disability pension due to chronic back pain following a very physical and laborious work life and she had to move out of her home. Yvonne’s life did not turn out the way she had planned and worked for. Today, she feels stuck in her one-bedroom apartment, unable to visit family and friends because of her poor health and economy.

Fulfillment of dreams and social relations with family, neighbours, and colleagues equate to QoL for Yvonne. She achieved her ultimate life goal of fulfilling her dreams by securing a job at sea at a young age, and her work identity was central to her personal identity:

I have been working more or less since I was 13 years old. At that time, you started as a paperboy, right. And I just know it in my heart, that you need to contribute to achieve something. Therefore, it was against my entire worldview that this [disability pension] was the solution. And that makes you feel inadequate. (Yvonne, interview person 9)

The quote suggests that Yvonne’s values and moral relates to the proverb “no pain, no gain”. Yvonne struggles in making meaning of her illness, as it conflicts with her worldview and belief that her hard work would pay off. She had planned her life at retirement pension where she would enjoy social relations with friends and family as well as being a volunteer in the local community:

But my job has also caused me to have a very challenged life now under very poor circumstances, because I am not able to walk properly, and my back is so God damn bad. And I hate talking about illness. All in all, I just hate illness. So being limited as I am today without even being that old, pisses me off. I cannot deal with it. (Yvonne, interview person 9)

During the interview with Yvonne, she generally talked about herself in the past, telling stories of her former working life and social relations, being unable to connect the past with the present, limiting her perspectives for the future. The above quote illustrates that Yvonne struggles to make sense of her life circumstances and integrate illness into her life story, as she cannot identify with the idea of not being able to maintain a work life and strong social relations. This results in “the base” being under intense pressure and experiencing difficulties in adapting to her life circumstances.

Social relations and engaging in the local community

Stressful life events such as illness, divorce, or the loss of a spouse interrupted the interviewees’ personal goals in life and affected not only their work capacity and attachment to the labour market but also their social life, as a link between being diseased or alone and experiencing challenges in maintaining social relations as suggested by the analysis. Interview person 6, a middle-aged woman suffering from a chronic back disease, expresses that “when you are sick, you lose a lot of people, and you do not have the network that you used to before the disease, because you no longer have sufficient energy”. The interviewees describe social relations as related to family, friends, work colleagues as well as other people in their local community. Having strong social relations is essential to not feeling alone, having someone to share life with, being together to face challenges and responsibilities, for example in relation to family life, household, economy, and illness. Interview person 4 defines how strong social relations are essential to his experience of life quality:

It means something, to have someone who sees you, to have somebody to talk to, to discuss matters with, rather than being by yourself. I believe that is quality of life. (Interview person 4)

After his divorce, the interviewee felt alone and found it challenging to maintain his social relations as he experienced no longer being able to identify with his friends, since they did not share his situation being divorced. He wishes to engage in new social relations with other divorced men. In self-efficacy theory, observing other people successfully completing a task (social modelling) can foster our beliefs that we also possess the capabilities to master the activities needed for success in that area (Bandura, 1997). Thus, in the process of re-establishing his identity, the interview person looked for role models which could show him that it is possible to get through a divorce, even though a divorce and being alone conflicts with his ultimate life goals and threatens his formerly secured base.

It was evident among the interviewees that the local community influenced their QoL as it was important to several of the interviewees to live in an area where they could engage in the local community and feel safe in familiar environments. Engaging in the associational life is essential to being active in the local community and thus engaging in social relations:

I enjoy that you greet each other and have a small chat when you do your groceries in this city. That might be harder in a bigger city. […] When you just meet somebody, you know. Maybe someone you worked with back in the days, or someone you played sports with. Then you might not feel that you are … alone in the world, or how can I put it … I enjoy that. (Interview person 10)

However, due to their economic situation and/or the limitations caused by their diseases, some interviewees cannot afford to settle down in the community as they wish to. Yvonne for example cannot afford to live in her hometown close to her family and friends and she cannot afford transportation to visit them or to go to the grocery store, which limits her social relations and decreases her QoL.

I would have wanted to end up there, because it was still in the same city where you could have had the same social relations and where you would expect people to come and pick you up, come visit you and something like that. But now I have ended up even further away, so you cannot just expect that people will even bother to drive to visit you. (Yvonne, interview person 9)

Interview person 2, a married mother of two with a flexible job due to her mental health challenges, places a strong emphasis on the significance of her housing conditions in her perception of QoL. She underscores that her QoL would have been considerably lower if she couldn’t afford to live in her current neighbourhood. In her own words, she states, “If we lived in another place where there was less [trust, security, and open spaces], I would have felt much worse”. This highlights the importance of the specific area and community they reside in and how financial stability plays a decisive role in maintaining the elements that are crucial to their overall QoL.

The analysis indicated that the fundamental factors for QoL, termed “the base” (social relations, security in housing conditions and private economy), influenced each other mutually and was highly affected by stressful life events such as illness. For example, falling ill can cause reduced work capacity and attachment to the labour market, which might affect economic and housing conditions negatively. Furthermore, this situation might negatively affect the individual’s social environment and possibilities to engage in the local community.

Discussion and conclusion

Experiencing a stressful life event, such as chronic illness, individuals may feel constrained by extraneous and structural factors when pursuing their personal goals and dreams (White, 2022). This is what Bury (1982) has coined as biographical disruption. The concept of biographical disruption has been criticized for prioritizing the analytical concept over bodily experiences (Williams, 2000). Following this there has been a call for research on the ways meaning, context, timing, norms, and expectation influence the experiences of chronic illness and how these are co-creative features of the narrative reconstruction (Ibid).

This study contributes to research on the integration of stressful life events into the narrative and the experience of identity loss or change related to it (Park, 2010). The analysis suggests that, among the interviewees in this study, there may be a possible link between stressful life events, such as chronic and severe illness, and QoL, which might be influenced by the level of biographical disruption and the potential disturbance in their meaning making process. Furthermore, this link was reported to be associated with the ability to sustain and secure what we termed as “the base.” In cases where interviewees perceived that the stressful events contributed to their reduced QoL and challenged their fundamental preconditions (“the base”), it led to existential questions and a sense of identity loss. Identity, being a narrative construction that connects “the past, present, and perceived future as a meaningful whole” (Fang et al., 2023), was found to be particularly vulnerable when severe disruptions occurred. However, it is important to note that such disruptions did not always result in the disintegration of the narrative construction of identity. To most of the interviewees the event of illness had led to chronic conditions such as chronic back pain, which had reduced their ability to work and thus their attachment to the labour market. Not being able to be a part of the labour market made the interviewees dependent of public benefits and put them in a vulnerable economic position, affecting the security of “the base”. The interviewees tried to accept their limited attachment to the labour market and to reconstruct their identity under different circumstances, since so many aspects of their life had changed following the stressful event of illness (or living alone). They fought to maintain or restore their “base”, as they needed to reconstruct their narrative and a life story, where they could no longer live life in the same way as before. Their best option to achieve a better QoL was “to secure the base”, which would help them adapt to their new life circumstances. Even though the Danish welfare state with a flexible labour market, substantially supports “the base” of the individual in the case of illness and unemployment, it does not prevent “the base” from being under pressure when the individual struggles in making meaning of stressful life events. Thus, it might be relevant to pay attention to the interplay between the individual, the welfare state and civil society, as engaging in civil society might enhance social relations, which is fundamental to “the base”.

Some interviewees expressed that they needed to accept circumstances they cannot change (their disease and the impact it has on their attachment to the labour market) and to focus on their options. To some interviewees, this included engaging in civil society activities in the municipality in relation to physical rehabilitation, engaging in activities in nature, searching for network groups with other people in the same situation (e.g., divorced men), which could positively impact QoL. Hence, civil society could play a role in securing “the base”. Research has shown that volunteering and participation in civil society positively affect the social support for the individuals involved, and social support is likely to translate into better QoL (Smith, 2016). Further, it has been demonstrated that participation in civil society positively correlates with participants’ QoL. This correlation exists whether individuals just participate (Young et al., 2013, Wheatley & Bickerton, 2017), are members (Haski-Leventhal, 2009, Eime et al., 2010), or volunteer (Tiefenbach & Holdgrün, 2015). In all three scenarios, a connection is observed between being part of the activity and reporting higher levels of QoL. Despite their dire personal circumstances and the challenges, the interviewees in this study are faced with to secure “the base”, the results indicated that it is beneficial to be a part of civil society activities. This raises the question on how individuals facing challenges like the participants in this study find their way into civil society activities. Future research could focus on how to lower the threshold for participation in civil society for all, including how voluntary organizations and municipalities can promote participation in civil society for individuals in vulnerable positions.

In conclusion, the insights from this study, particularly concerning contributions to “the base”, carry significant implications for understanding and enhancing QoL and warrant further research. Recognizing the fundamental importance of these prerequisites for QoL, policymakers, healthcare professionals, and social service providers can make interventions and support mechanisms to strengthen these foundations, ultimately leading to improved overall well-being for individuals and communities.

Limitations

A notable limitation of our study is the selective focus on participants who reported a decline in their QoL when investigating the impact of stressful life events. This deliberate choice may have introduced bias by excluding individuals who maintained satisfactory or high QoL despite facing similar stressors. Such exclusivity restricts the generalizability of our findings and may not fully capture the spectrum of responses to stressful life events.

To address this limitation, future research could consider examining individuals who have reported diminished QoL, or perhaps even improved QoL, following such events. This approach would enable a more comprehensive understanding of resilience factors and shed light on how individuals perceive personal growth or adapt their life priorities in response to adversity. We acknowledge that our current study primarily contributes insights into supporting individuals whose subjective perception of QoL is negatively impacted by stressful life events.

Acknowledgments

The authors are thankful to the participants of this study for openly sharing their experiences.

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the Faaborg-Midtfyns Kommune.

Notes on contributors

Lotte Kring

Lotte Kring is a PhD student at the Department of Psychology, University of Southern Denmark. She has a background in medical anthropology and has a specific interest in exploring the experiences of patients and their relatives within the field of psychiatry, as well as examining how mental disorders influence their daily lives.

Evald Iversen

Evald Iversen is Head of the Centre for Research in Sports, Health and Civil Society. His research in recent years have focused on volunteers and the more general role of the organized civil society. He has analyzed how appropriate interaction can be established between volunteers and municipalities, and what importance civil society may have for the development of society. Particularly, he has worked on projects which focus on how the interaction between on the one side volunteers and on the other side public welfare institutions such as schools might be improved with a specific focus on the influence of civil society on the quality of life of citizens. His work on the topic has increased the understanding of how organized civil society may be included in collaborative processes between civil society and the public sector.

Bjarne Ibsen

Bjarne Ibsen For many years, has, among other things, researched various aspects of civil society with particular interest in the development and social role of associations, the relationship between the voluntary and the public sector, and the importance of civil engagement for citizens’ quality of life. He has, among other things, edited the book ‘Voluntary and Public Sector Collaboration in Scandinavia’, which was published in 2021 by the publisher Palgrave Macmillan.

Michael Fehsenfeld

Michael Fehsenfeld has a background in anthropology and has a specialist interest in social inequality in health and vulnerable people. He has published widely on the topic and has many years of experience of working with vulnerable people in community settings.