Purpose in life and its association with stress among persons living in a semi-urban area of Tamil NaduR Subramaniyan, G Veliah, V Gopichandran
School of Public Health, SRM University, Tamil Nadu, India
Background: Purpose in life (PIL) is defined as the question concerning the significance or importance of life or one's existence. PIL is closely associated with spirituality and, hence, is an important determinant of health. This, in turn, leads to lower stress response and good mental health. Objectives: To assess the PIL and perceived psychosocial stress and to develop a conceptual understanding of the relation between the two. Materials and Methods: A questionnaire was developed to understand the PIL in the cultural context of semi-urban Tamil Nadu. Its internal consistency was checked and it was administered to 227 conveniently selected individuals between 15 and 70 years of age. Results: The questionnaire on PIL developed for this study had an acceptable internal consistency with a Cronbach's alpha of 0.883. Some common purposes in life mentioned by the people were recognition and acknowledgment for their roles and responsibilities, to be a part of a society that is higher class than their current frame, acceptance by people in society, to show people who disagree with them that they are wrong, to be treated with respect, to be known as a person with integrity, love for others, to be beneficial to others at the cost of themselves, to bring equity in the society, and to help others. It was also found that adherence to social norms as a PIL was associated with lower perceived stress. Conclusion: This study provides a conceptual understanding on the purposes in people's lives in the context of semi-urban Tamil Nadu and their association with perceived psychosocial stress.
Keywords: Mental health, purpose in life, spirituality, stress
Stress may be physical, mental, and emotional strain and tension of a person. The term "stress" was first used by Hans Selye, an endocrinologist, in 1930.  Stress is the failure of an organism, human or animal, to respond to the emotional or physical threats, either real or imagined.  In 1975, Selye classified stress into eustress and distress. When stress improves the function, it is called eustress. Continuous stress which is not resolved by adaptation is deemed distress, which sometimes leads to anxiety or depression.  Purpose in life (PIL) is like a compass which directs our life; it directs our decisions in most instances of our lives. When life is purpose driven, resilience and coping with stress is high.  The PIL denotes the intrinsic and approval motivation (AM) the extrinsic motivation that drives the actions in our lives. In a previous study, the correlations between PIL and AM and factors influencing the development of PIL and AM were investigated. PIL had greater influence over autonomic nervous system functioning and psychological stress coping, compared to AM.  Aim of this study was to assess the PIL and perceived psychosocial stress, and to develop a conceptual understanding of the relation between the two.
IRB approval (IRB of the School of Public Health, SRM, Chennai) was obtained and written informed consent was obtained from the participants before the study.
The study was done in Devakottai (semi-urban), Sivagangai district, Tamil Nadu, located in southern part of India. This place has people belonging to this town and the surrounding villages.
An informal group discussion involving six purposively selected community members was conducted to derive the common PIL of people in the area. A questionnaire was developed with 14 questions based on the themes of informal group discussion. Pre-test of the questionnaire was done on 97 samples and preliminary analysis was done which showed that the Cronbach's alpha was 0.475. It was observed that some questions were absolute or extremely worded. The questionnaire was modified to be worded more evenly. The modified questionnaire was tested on 92 samples and it revealed a Cronbach's alpha of 0.889. The questionnaire was finalized and used for the study.
Two questionnaires were used for data collection. One was the perceived stress scale (PSS) with responses scored on a Likert scale of 1-5, where 1 stands for "never" and 5 stands for "very often."  The other questionnaire was the pre-tested tool of PIL on a Likert scale of 1-3, where 1 stands for "agree" and 3 stands for "disagree." There are advantages and disadvantages of using the 3- and 5-point Likert scales. Studies show that people are not able to place their point of view when the scale is of greater number. For example, a 3-point Likert scale is easier to respond to than a 5-point scale. Greater the number of scale items, greater will be the requirement for nuanced thinking and response. In both the 3- and 5-point scales used in this study, there is a neutral middle point. The respondent is not forced to make a negative or positive choice. This may improve the response rates in the Likert scale, but whether the accuracy of the scale improves is not clear. 
Individuals of either sex, between 15 and 70 years of age, were included in this study. Only those who knew to read and write were included because the questionnaire was self-administered. The respondents were given adequate privacy for answering the questions. The administered questions were in Tamil language and the researcher gave enough time (ranging between 10 min and 30 min) for the respondents to think and answer each question.
Sampling methodology and sample size calculation
A convenient sampling method was followed for this study as the aim was not to generalize the findings but to gain a conceptual understanding of the association between PIL and stress. The sampling method was purposive and non-probabilistic. The important disadvantages of such a non-probabilistic sampling method are selection bias and inability to apply inferential statistical analyses to generalize to the population. The required sample size was 200 for a 95% confidence level, with a 10% precision, and an assumed prevalence of 50% high PIL in the study population, and a a design effect of 2.
The 31 items in the questionnaire were condensed into nine main domains based on the themes used for developing the questionnaire. The Likert scale scores of each domain were summed up and the domain scores calculated. They were divided in the median and classified as high and low PIL in that domain. These categories were compared with the stress scale score categories.The collected data were entered in MS Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 16. Cronbach's alpha was calculated for assessing the internal consistency of PIL questionnaire. Simple descriptive statistics and frequencies were computed. The association between each of the PIL assessed in the scale and perceived psychosocial stress was studied using Chi-square test
A total of 227 respondents participated in the study. Of these, 53.3% were below 30 years of age and the remaining were 30 years and above. Only 111 (48.9%) were women and the remaining were men. Of the respondents, 99 (43.5%) had a graduate level education, 23 (10.2%) were post graduates, and the remaining had only completed school. The occupation status revealed 69 students (30.4%), 39 housewives (17.2%), 39 retired persons (17.2%), 50 salaried employees (21.2%), and 54 self-employed persons (23.6%) [Table 1].
[Table 2] depicts the percentage of respondents who answered as "agree," "neutral," and "disagree" for each of the statements reflecting PIL. The statements "I want to help others" (89%), "I want to bring equity in the society (across all walks of life)" (86.8%), and "I want to be known as a person with integrity" (86.3%) had maximum affirmative response. The statements "I want the world to know my name because of the discharge of my roles and responsibilities" (38.8%), "I want the country to know my name because of the discharge of my roles and responsibilities" (37.4%), and "My hatred toward others" (34.4%) had the least affirmative responses. It was observed that those who "adhered to social norms (religious, family, and professional)" as their PIL had low stress (P = 0.04). Other types of PIL did not show any significant association with psychological stress. The main domains of PIL, the domain categories, the PSS categories, and their association are shown in [Table 3].
[Table 4] shows the association between socio-demographic variables and the PIL of adherence to social norms (religious, family, and professional). It is observed that there was no difference in adherence to social norms as a PIL in the different age categories. But there is an interesting, albeit not statistically significant association between sex, education, occupation, and adherence to social norms. Men (52.2%) were more driven by adherence to social norms than women (41.1%). It was also seen that as the level of education increased, adherence to social norms as a PIL also increased till higher secondary education, beyond which it started decreasing. Higher education reduces adherence to social norms as a PIL.
This study was conducted to explore the PIL in a typical South Indian semi-urban setting and to study the association between PIL and perceived psychosocial stress. This study shows that the purposes which drive most people are "I want to help others" (89%) and "I want to bring equity in the society (across all walks of life)" (86.8%). The purposes which drive the least number of people are "My hatred toward others" (39.6%) and "I want the country to know my name because of the discharge of my roles and responsibilities" (32.2%). This clearly reflects the fact that for the sampled respondents, the PIL focused on helping others and bringing justice. Self-centered purposes such as recognition for self were much lesser. This reflects a culturally unique other-centered nature in certain semi-urban and rural areas in India. Urban college students search more for meaning in their lives, focus to pursue their inner selves, try to be compassionate and charitable, and decide on how they should look in the society and the global community.  But the rural and semi-urban people are still communitarian and egalitarian in their approach. Those who have meaning in life have positive correlation with the presence of meaning and negative correlation with hopelessness. 
The observation of association between "adherence to social norms (religious, family, and professional)" as a PIL and low stress levels is also culturally very unique. In the Indian context, adherence to social norms and being accepted in the society is considered as most important. So, when a person has adherence to social norms as his/her PIL, then automatically their stress coping skills are better. Those who have more meaning in life avoid stress and have better coping (strategies). , The presence of meaning in life provides a measure of psychological health and a deeper appreciation of life (increased sense of life's meaning). 
Adherence to social norms, which emerged as an important PIL associated with low perceived stress, was further studied. Its association with socio-demographic variables was assessed. The results were not statistically significant. But it is important to note the trends that the results showed. Women had lower scores of adherence to social norms as their main PIL compared to men. This denotes the greater social role played by men in the outside work in these semi-urban areas compared to women who play the role of a housewife and homemaker. It could also reflect the relatively liberal mindset of women compared to men in terms of tolerance to deviations from social norms. Since they are more tolerant to deviations from social norms, they did not have adherence to social norms as their prime driving purpose of life. Similar association was also found between adherence to social norms as a PIL and education. The trend showed that with increasing level of education, the need for adherence to social norms increased; but with higher education, adherence to social norms reduced as a PIL. This is probably due to the greater exposure and tolerance to deviations from social norms that are imbibed as part of higher education. Greater in-depth studies are required to look at these associations.
One of the key limitations of the study is that the items seem to be leading toward a socially desirable response. Therefore, there is a need for including some items which can detect this bias and validate the scale. The scope of the items is limited by the domains identified in the qualitative study. There was no option for respondents to include purposes in their lives other than what was mentioned in the scale. This could misclassify individuals as lacking a purpose in life though they may have a strong purpose not covered in the scale items. Future studies should carefully include items to eliminate socially desirable response bias and should have open-ended questions that can be qualitatively assessed. The study is also limited by the lack of use of advanced statistical methods, and the heterogeneity in the sampling although we do feel that the latter lends a wider perspective.
The results presented lend some support to the ways in which individuals engage in PIL, and its association with perceived psychological stress. It provides an additional brief measure of psychological health and the finding that a deeper appreciation of life is one of the most commonly reported positive outcomes of coping with adversity in the life. According to the World Health Organization (WHO), "health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity."  Therefore, PIL, as a part of spiritual well-being, is an important determinant of health.
An interesting aspect of this study is the use of a culturally unique sample for the study. Although this unique sample may limit the generalizability of our findings, it will add important evidence to the conceptual understanding of the link between PIL and psychosocial stress. The longstanding philosophical and psychological appreciation of the importance of PIL is increasingly being affirmed by empirical findings. There is a need to incorporate spirituality and its dimensions into the understanding of disease and health.
[Table 1], [Table 2], [Table 3], [Table 4]