Quality of life among patients with multiple sclerosis: association with disease acceptance, optimism, and health-promoting behaviors

Abstract

Multiple sclerosis (MS) is a chronic, progressive disease of the central nervous system, primarily affecting individuals in early adulthood and serving as a leading cause of disability among young adults. Despite advancements in understanding its etiology, there is currently no cure for MS. The disease’s unpredictability, progression, and associated symptoms can significantly impair patients’ daily, familial, social, and professional functioning, thereby substantially diminishing their quality of life. This study aimed to evaluate the quality of life (QoL) in patients with MS and its association with optimism, disease acceptance, and health-promoting behaviors. The study was conducted among 101 MS patients (mean age of 40.55 years). It utilized a questionnaire designed by the authors, encompassing sociodemographic and clinical data, as well as standardized instruments: the Revised Life Orientation Test (LOT-R), Health Behavior Inventory (HBI), Acceptance of Illness Scale (AIS), and Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL). Data analysis revealed that: The average QoL score on the MusiQoL scale was 69.33 out of 100. Respondents’ optimism was at a moderate level and significantly correlated with higher QoL. The average score for health-promoting behaviors was 84.2, with a positive psychological attitude showing the strongest association with improved QoL. The level of disease acceptance among MS patients was moderate, averaging 29.84 out of 40 points. Increased disease acceptance significantly enhanced respondents’ QoL. Higher levels of disease acceptance and optimism positively influence QoL in MS patients. Health-promoting behaviors are significantly correlated with various QoL domains in this population.

Introduction

Multiple sclerosis (MS) is a chronic disease of the central nervous system, marked by inflammation and progressive damage to myelin sheaths. Its unpredictable nature and varied symptoms significantly affect patients’ quality of life and that of their families¹ .

Health behaviors—like regular exercise, balanced nutrition, avoiding smoking and alcohol, and using healthcare services—are essential for maintaining well-being².

People with MS often believe these habits help preserve health, though disability may limit physical activity. Self-efficacy and perceived benefits are key motivators, making them important targets for health interventions³.

Proper human development, physical fitness, cognitive functions, and overall health are significantly influenced by nutrition, the health quality of consumed food, and its nutritional value. Proper nutrition constitutes one of the elements of health-promoting behaviors. Consuming a balanced diet, in conjunction with an overall healthy lifestyle, can exert a beneficial impact on the course of multiple sclerosis and enhance the quality of life of patients with MS^4,5.

Acceptance of the disease is a psychological process wherein an individual, following an initial stage of denial or fear, reaches a state of acceptance of their disease as part of their life. This process involves the ability to reconcile with the existence of the disease, its symptoms, and the physical and emotional consequences that ensue. Acceptance does not imply relinquishing treatment or efforts to improve quality of life, but rather adapting to new circumstances and mitigating the negative impact of the disease on the individual’s psyche. There exists a significant relationship between the level of disease acceptance and the sense of coherence and generalized self-efficacy⁶. Acceptance of MS is linked to better emotional resilience, self-esteem, and social functioning. Low acceptance and unfavorable prognoses can worsen psychological health and reduce life quality.

Antonovsky’s concept of coherence—comprehensibility, manageability, and meaningfulness—represents an individual’s characteristic way of perceiving the world and their place within it. A strong sense of coherence enables individuals to utilize accumulated resources effectively. They can recognize and articulate their emotions, leading to conscious living and self-understanding. Such individuals cope with problems more effectively, as they seek the source and logic of the problem and are oriented towards problem-solving rather than passive living⁷.

The aim of the study was to assess the quality of life in patients with MS by different independent variables (sex, age, place of residence, marital status, education, material status, time since diagnosis) and its association with disease acceptance, health behaviors, and optimism.

Materials and methods

Study design and participants

A cross-sectional descriptive study was conducted at two regional MS centers in Wroclaw, Poland. Adults aged > 18 years with diagnosed relapsing-remitting multiple sclerosis (RRMS) according to McDonald 2017 criteria and treated with disease modifying therapy (DMTs) were included to the study. The remaining inclusion criteria included: (1) stable course of the disease without relapse within 30 days prior to the study, (2) written informed consent. Exclusion criteria were: (1) diagnosis MS without DMT treatment, (2) cognitive impairment (patients unable to follow the test instructions), (3) lack of written consent. The patients filled out a traditional self-administered pencil-and-paper questionnaires, designed to be completed in approximately 20 min. The clinical data concerning on the disease has been supplemented by neurologist.

The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies.

Ethical considerations

The research protocol received approval from the Bioethics Committee of Wroclaw Medical University (No. KB–735/2021). Participation was anonymous and voluntary, with all patients being informed about the study and providing written consent. The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines⁸.

Research instruments

The study employed the diagnostic survey method, incorporating the author’s questionnaire and standardized instruments: AIS⁹LOT-R¹⁰Health Behavior Inventory¹¹and the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL)¹².

Author’s questionnaire (AQ)

The AQ included questions designed by the authors, covering sociodemographic data (e.g., sex, age, place of residence, marital status, education, employment) and clinical data (e.g., time since diagnosis, presence of comorbidities, occurrence of MS-related symptoms).

Life orientation test-revised (LOT-R)

The LOT-R consists of 10 statements, 6 of which are diagnostic, measuring dispositional optimism. Respondents rate each statement on a scale from 0 to 4: 0—definitely does not apply to me, 1—rather does not apply to me, 2—neither applies nor does not apply to me, 3—rather applies to me, 4—definitely applies to me. Higher scores indicate a more optimistic attitude¹⁰.

Health behavior inventory (HBI)

The HBI includes 24 statements related to specific health behaviors such as prevention, proper nutrition, psychological attitude, and health-promoting activities. Statements are rated on a five-point scale describing the frequency of behaviors over the year: 1—“almost never,” 2—“rarely,” 3—“occasionally,” 4—“often,” 5—“almost always.” Results provide an overall index of health behaviors and the intensity of specific health behavior categories¹¹.

Acceptance of illness scale (AIS)

The AIS assesses the degree of disease acceptance through eight statements describing negative effects of the disease or poor health. Respondents rate statements on a five-point Likert scale: 1—“strongly agree,” 5—“strongly disagree.” Scores range from 8 to 40, with higher scores indicating greater acceptance. Scores of 8–18 indicate lack of acceptance, 19–29 average acceptance, and 30–40 high acceptance. Cronbach’s alpha for the Polish version is 0.85, and for the original version 0.82; test-retest reliability is 0.64 for the Polish version and 0.69 for the original⁹.

Multiple sclerosis international quality of life questionnaire (MusiQoL)

The MusiQoL assesses the quality of life of MS patients through 31 questions about the patient’s life over the past four weeks, with responses: never, rarely, sometimes, often, always, not applicable. It evaluates 10 domains: ADL—activities of daily living, PWB – psychological well-being, RFr—relationships with friends, SPT—symptoms, Rfa—family relationships, RHCS—satisfaction with the healthcare system, SSL—sentimental and sexual life, COP—coping, REJ—rejection, Total—overall quality of life. Quality of life in each domain is expressed numerically from 0 to 100, with higher numbers indicating better quality of life. No norms exist for MusiQoL; comparisons are made between domains to identify areas of high and low quality of life. Cronbach’s alpha for the Polish version ranges from 0.67 to 0.90¹².

Statistical analysis

IBM SPSS 28 was used for statistical analysis. The Kolmogorov-Smirnov test examined the conformity of quantitative variable distributions with the normal distribution. Non-parametric methods were employed due to lack of conformity and differences in group sizes. Spearman’s correlation coefficient assessed relationships between quantitative variables. Mann–Whitney tests evaluated differences between two groups, while Kruskal–Wallis tests assessed differences among more than three groups. A significance level of p < 0.05 was adopted.

Results

In total 101 patients with MS (72.3% women), with mean age 40.55 ± 9.04 were included in the study. Predominantly individuals aged 30 to 39 years (35.64%), those with higher education (56.4%), residents of large cities with populations exceeding 500,000 (34.7%), and those who were professionally active (76.3%). The mean duration since MS diagnosis was 12.43 years (SD = 7.0). Fatigue was the most frequently reported symptom associated with the disease (85%). Detailed data are presented in Table 1.

Table 1.

Characteristics of the study group.

Variable	Values
Age [years], mean ± SD	40.55 ± 9.04
Disease duration [years], mean ± SD	12.43 ± 7.01
Sex, n (%)
Female	73 (72.3)
Male	28 (27.7)
Education, n (%)
Vocational education	10 (9.9)
Secondary education	34 (33.7)
Higher education	57 (56.4)
Place of residence, n (%)
Village	22 (21.8)
City	79 (78.2)
Marital status, n (%)
Single	35 (34.7)
Married	51 (50.5)
Divorced	15 (14.9)
Professional activity, n (%)
Study	4 (4.0)
Employed	77 (76.2)
Disability or retirement pension	19 (18.8)
Unemployed	1 (1.0)
Clinical type of MS, n (%)
RRMS	101 (100)
SPMS	0 (0)
PPMS	0 (0)
PRMS	0 (0)
Using DMT, n (%)
Yes	101 (100)
No	0 (0)
Type of DMT, n (%)
Dimethyl fumarate	37 (36.6)
Ofatumumab	22 (21.8)
Ocrelizumab	10 (9.9)
Teriflunomide	7 (6.9)
IFNb-1a	7 (6.9)
IFNb-1b	6 (5.9)
Glatiramer acetate	4 (4.0)
Fingolimod	3 (3.0)
Cladribine	2 (2.0)
Natalizumab	2 (2.0)
Ozanimod	1 (1.0)
Comorbidities, n (%)
Yes	30 (29.7)
No	71 (70.3)
Complains, n (%)
Fatigability	85 (84.2)
Dysphagia	9 (8.9)
Speech disorders	12 (11.9)
Hypertonia	11 (10.9)
Mood disorders	43 (42.5)
Paresthesia, neuralgia	31 (30.7)
Mobility and balance disorders	54 (53.5)
Sexual disorders	37 (36.6)
Vision disorders	54 (53.5)
Sphincter disorders	32 (31.7)
MusiQoL total, mean ± SD	69.33 ± 13.25
LOT-R, mean ± SD	14.29 ± 4.21
IZZ, mean ± SD	84.82 ± 10.33
AIS, mean ± SD	29.84 ± 7.10
EDSS mean ± SD	2.24 ± 1.2

Optimism (LOT-R)

Analysis of the data revealed that 27.7% of patients exhibited high levels of optimism, 39.6% exhibited moderate levels, and 32.7% exhibited low levels. The mean optimism score was 14.29 (SD = 4.21). No statistically significant differences in optimism levels were observed based on sociodemographic characteristics.

Acceptance of illness (AIS)

The data indicated that the majority of respondents (55.4%) exhibited high levels of disease acceptance, while 6.9% exhibited a lack of acceptance. Scores ranged from 8 to 40 points (mean = 29.84, SD = 7.1). It was found that the duration of the disease had a significantly negative impact on disease acceptance (AIS scale), indicating that patients with a longer duration of multiple sclerosis exhibited decreased acceptance of their condition (p < 0.05). Other sociodemographic variables did not significantly affect disease acceptance levels.

Health behaviors (HBI)

In assessing health behaviors among MS patients, the highest scores were observed in the category of preventive behaviors (22.30). Patients also maintained a positive psychological attitude (21.97) and engaged in proper nutritional habits (20.99). The lowest score (19.56) was observed in the category of health practices. The overall mean score for health behaviors was 84.82. Marital status significantly differentiated patients in terms of overall health behaviors (HBI) (p = 0.016) and positive psychological attitude (p = 0.011). Married patients scored significantly higher than single patients in overall health behaviors (HBI) (87.16 vs. 80.69; p = 0.012) and positive psychological attitude (22.86 vs. 20.34; p = 0.011). The duration of the disease also had a significantly negative impact on the overall HBI score and psychological attitude, indicating that patients with a longer duration of multiple sclerosis engaged in fewer health-related activities (p < 0.049) and exhibited a decreased positive psychological attitude (p = 0.042).

Quality of life (MusiQoL)

The overall quality of life index in the study group averaged 69.33 points out of a possible 100, ranging from 25.5 to 95.5 points (MusiQoL). The highest self-assessment of quality of life was in the domains of REJ (84.03), SPT (74.87), and RFa (72.44). The lowest quality of life was noted in the domains of RFr (57.34) and PWB (64.97).

The duration of the disease was found to negatively impact the quality of life of respondents. Statistically significant correlations were observed in the domains of ADL (rho = -0.458, p = 0.00), PWB (rho = -0.377, p = 0.00), SPT (rho = -0.469, p = 0.00), RFa (rho = -0.279, p = 0.005), REJ (rho = -0.227, p = 0.024), and the Global Index (rho = -0.420, p = 0.00).

Place of residence also differentiated patients in terms of quality of life:

• In the ADL domain, patients living in large cities rated their quality of life significantly lower than those living in medium-sized cities (21.16 vs. 35.51, p = 0.021).

• In the PWB domain, patients living in large cities rated their quality of life significantly lower than those living in medium-sized cities (25.71 vs. 39.91, p = 0.038).

• In the RFr domain, patients living in large cities rated their quality of life significantly higher than those living in medium-sized cities (73.53 vs. 55.11, p = 0.046).

• In the REJ domain, patients living in large cities rated their quality of life significantly lower than those living in medium-sized cities (3.57 vs. 15.91, p = 0.013).

Additionally, individuals with primary education rated their quality of life in the REJ domain significantly higher than those with secondary education (25.00 vs. 5.08, p = 0.028).

Correlation between variables

Analysis of the relationship between optimism and quality of life in MS patients indicated that higher levels of optimism were associated with higher quality of life. Statistically significant positive correlations were observed in the domains of RFr (rho = 0.347, p = 0.00), SPT (rho = 0.199, p = 0.046), and Global (rho = 0.197, p = 0.048).

Correlation analysis between disease acceptance and quality of life showed that higher levels of disease acceptance were associated with higher quality of life in most domains.

The analysis revealed relationships between health-promoting behaviors and selected domains of quality of life. Positive psychological attitude significantly influenced domains such as PWB, SPT, RFa, and Global, with higher quality of life observed in these domains when a positive psychological attitude was maintained. A negative relationship was found between proper nutritional habits and the RHCS domain, indicating that patients with improper nutritional habits rated their quality of life in the healthcare system domain lower. Significant positive relationships were also found between all categories in the HBI questionnaire and the RFr domain in MusiQoL, indicating that patients who more frequently engaged in proper nutritional habits, preventive behaviors, maintained a positive psychological attitude, and health-improving behaviors had higher quality of life in the friends’ relationships domain (Table 2).

Table 2.

Correlation between LOT – R, HBI, AIS and domains of MusiQoL.

	MusiQoL Total	ADL	PWB	RFr	SPT	RFa	RHCS	SSL	COP	REJ
LOT- R	r = 0.197, p = 0.048*	r = 0.164, p = 0.101	r = 0,0.85, p = 0.064	r = 0.347, p = 0.00*	r=-0.119, p = 0.446	r = 0.098, p = 0.327	r= − 0.155, p = 0.122	r = 0.00, p = 0.998	r = 0.105, p = 0.295	r = 0.151 p = 0.132
AIS	r = 0.450, p = 0.00*	r = 0.485, p = 0.00*	r = 0.479, p = 0.00*	r = − 0.031, p = 0.757	r = 0.385, p = 0.00*	r = 0.133, p = 0.186	r= − 0.057, p = 0.570	r = 0.134, p = 0.183	r = 0.299, p = 0.002*	r = − 0.312 p = 0.002*
HBI	r = 0.173, p = 0.083	r = 0.038, p = 0.707	r = 0.079, p = 0.433	r = 0.533 p = 0.00*	r = 0.127, p = 0.204	r = 0.055, p = 0.582	r = − 0.044, p = 0.662	r = − 0.008, p = 0.934	r = 0.105, p = 0.934	r = 0.015, p = 0.883
HBI proper nutritional habits	r = 0.032, p = 0.749	r = 0.084, p = 0.403	r = 0.039, p = 0.701	r = 0.474, p = 0.00*	r = 0.143, p = 0.153	r = − 0.038, p = 0.703	r = − 0.205, p = 0.04 *	r = − 0.115, p = 0.251	r = − 0.115, p = 0.251	r = 0.016, p = 0.871
HBI preventive behaviors	r = 0.054, p = 0.593	r = 0.011, p = 0.916	r = 0.035, p = 0.726	r = 0.508 p = 0.00 *	r = 0.012, p = 0.904	r = 0.017, p = 0.868	r = − 0.104, p = 0.300	r = − 0.097, p = 0.335	r = − 0.097, p = 0.335	r = − 0.025, p = 0.807
HBI positive psychological attitude	r = 0.400, p = 0.00*	r = 0.135, p = 0.180	r = 0.238, p = 0.016 *	r = 0.281, p = 0.004 *	r = 0.269, p = 0.013 *	r = 0.247, p = 0.013*	r = 0.108, p = 0.282	r = 0.174, p = 0.081	r = 0.174, p = 0.081	r = 0.183, p = 0.068
HBI health practices	r = 0.094, p = 0.348	r = − 0.051, p = 0.615	r = 0.040, p = 0.689	r = 0.398, p = 0.00*	r = 0.055, p = 0.584	r = − 0.031, p = 0.761	r = − 0.002, p = 0.983	r = − 0.028, p = 0.779	r = − 0.028, p = 0.779	r = − 0.093, p = 0.356

*p < 0,05 are considered statistically significant.

A positive relationship was also found between the optimism and health-promoting behaviors. Patients with high levels of optimism more frequently engaged in health-improving behaviors (rho = 0.255, p = 0.01), maintained a positive psychological attitude (rho = 0.328, p = 0.00), and exhibited proper nutritional habits (rho = 0.203, p = 0.04).

A positive relationship was also found between the optimism and disease acceptance, indicating that individuals with high levels of optimism had higher levels of disease acceptance (rho = 0.265, p = 0.007). No significant relationship was found between health behaviors and disease acceptance (rho = 0.099, p = 0.324).

There was no relationship between the degree of disability (EDSS) and the level of disease acceptance (AIS), optimism (LOT - R), health-promoting behaviors (HBI) and level of QOL (MusiQoL).

Discussion

In the course of disease, multifocal lesions develop throughout the brain and spinal cord and result in a variety of symptoms and signs, ultimately leading to accumulating disability. The most common symptom reported by Kalandyk et al.¹³ is chronic fatigue. Our study yielded similar results, with 85% of respondents identifying fatigue as the most prevalent symptom of MS. Following this, visual disturbances and issues with movement and balance were reported. Less frequently, perceptual, emotional, and sexual disturbances were observed. Conversely, the study by Rosiak et al.¹⁴ found that the largest number of patients were affected by balance disorders, followed by spasticity occurring in the course of multiple sclerosis.

Acceptance of illness (AIS)

Acceptance of illness is defined as the psychological reconciliation and adaptation to potential limitations, leading to the integration of altered psychophysical conditions with the previous lifestyle¹⁵. Analysis of data obtained through the AIS questionnaire indicated that the average score in the entire group was 29.84 (SD = 7.1), suggesting that the surveyed patients accept their illness at a high level, which is consistent with the results obtained in other study^16,17. However some previous studies conducted among MS patients^18–20 and among individuals suffering from other chronic neurological diseases^21–24 have shown lower levels of illness acceptance.

Assessment of illness acceptance levels among MS patients should be an integral part of the therapeutic process, as previous studies have shown that patients who accept their health situation experience fewer negative feelings^25,26such as anxiety²²more effectively control the course of the disease²⁷and have a higher quality of life^24,28–30. The conducted study demonstrated a significant relationship between the duration of the disease and the level of acceptance of multiple sclerosis (MS). It was observed that the longer the duration of the disease, the lower the illness acceptance index among patients.

The study by Andruszkiewicz et al.³¹ indicates that patients with higher levels of illness acceptance exhibited significantly better psychosocial functioning, manifested by higher indices of coherence, understood as the ability to perceive the world as predictable and meaningful, and generalized self-efficacy, which is the belief in one’s ability to cope with difficulties. Conversely, patients with lower levels of illness acceptance exhibited lower values of these indices, which may negatively impact their ability to adapt to life with a chronic illness. This study confirms that individuals with high levels of optimism exhibit higher levels of illness acceptance (rho = 0.265, p = 0.007). The results of these studies emphasize the importance of psychological support in the treatment and rehabilitation process, which could help patients build illness acceptance and strengthen personal resources.

Optimism (LOT-R)

Analysis of the obtained data revealed that 27.7% of patients exhibited high levels of optimism, 39.6% exhibited moderate levels, and 32.7% exhibited low levels. Similar data were obtained by Calandri et al.¹where 30% reported high optimism, 30% reported moderate optimism, and 40% reported low optimism. The study by Hart et al.³² found that MS patients rated their level of optimism at 16.27, which is consistent with the results obtained in this study and the study by Calandri¹. The study by Calandri¹ also did not show statistically significant differences in optimism levels based on sociodemographic characteristics, which is consistent with the results of this study.

Therapeutic interventions aimed at perceiving positive aspects of life can support the adaptation process to multiple sclerosis (MS) by modifying the assessment of experiences related to the disease. Optimism levels, stress management training, mood disorder treatment, correction of dysfunctional cognitive schemas, and the development of social support are essential elements complementing pharmacotherapy, which can influence the course of the disease and improve the quality of life of patients. This study demonstrated that with increased levels of optimism, the quality of life of MS patients also increases.

The results of Pakenham’s studies³³ indicate that the predominance of positive emotions over negative ones promotes adaptive processes and acts protectively against stress related to the disease. Furthermore, optimism correlates with the level of diagnosis acceptance, and positive thinking skills training has a beneficial impact on self-esteem and the subjectively predicted length of life of MS patients³⁴.

Health behaviors (HBI)

The Health Behavior Inventory (HBI) by Z. Juczyński is a psychometric tool that enables the assessment of health behaviors in four areas: nutritional habits, preventive behaviors, positive psychological attitude, and health practices. In the case of multiple sclerosis (MS), secondary prevention is of fundamental importance, including regular health monitoring, the use of disease-modifying therapies, rehabilitation, psychological support, and patient education. A comprehensive approach to disease management can contribute to slowing its progression and improving the quality of life of patients³⁵.

In assessing health behaviors undertaken by individuals with multiple sclerosis (MS), the highest score was obtained in the category of preventive behaviors (22.30), suggesting that MS patients exhibit the greatest activity in preventive actions. The use of prevention in this patient group is a key factor that can contribute to improving their quality of life. According to the study by Stuifbergen³⁶there is a clear relationship between health-promoting behaviors and the quality of life of individuals with MS. A decrease in the level of health-promoting behaviors leads to a reduction in the quality of life of patients. This study demonstrated that patients who more frequently engage in preventive actions rate their quality of life higher in the RFr domain. Preventive actions also include engaging in physical activity adapted to the degree of fitness of MS patients. The study by Silveira et al.³⁷ showed that social support and generalized self-efficacy significantly correlate with physical activity undertaken during leisure time. The results of the cross-sectional study indicate the need to develop interventions aimed at increasing physical activity in MS patients, considering the assessment of self-efficacy and using evidence-based behavior change strategies to improve it.

According to the results of the Health Behavior Inventory (HBI), MS patients most frequently engage in preventive actions, indicating high awareness of health care. Maintaining a positive psychological attitude also obtained high significance, which, like healthy nutritional habits, significantly supports limiting the negative effects of the disease and improves the functioning quality of patients.

Quality of life (MusiQoL)

Multiple sclerosis (MS) is a neurological disorder that significantly impacts patients’ quality of life, markedly reducing it compared to the quality of life reported by healthy individuals^38,39. The overall quality of life index in the studied group averaged 69.33 points out of a possible 100 (MusiQoL), which is consistent with results obtained by other researchers^40–45.

The results demonstrated a significant impact of sociodemographic factors, particularly place of residence and education level, on the subjective assessment of quality of life in patients diagnosed with MS. Kuspinar et al.⁴⁶ indicate that younger age, higher education, and professional activity correlate with higher QoL levels, especially in the areas of social and physical functioning. Hobart et al.⁴⁷ emphasize that a significant predictor of quality of life in MS is the sense of self-efficacy and social activity, regardless of the level of disability. In summary, the obtained results confirm that the sociodemographic context, including place of residence and education level, is a significant factor modulating the subjective assessment of quality of life in MS patients. This indicates the need for an individualized therapeutic approach that considers both socio-economic and psychological aspects in planning care and support for this patient group.

Study limitations

The study group could have been larger and selected randomly. The chosen tools are self-assessment instruments, which carry the risk of obtaining subjective data.

Conclusions

Increased levels of optimism and disease acceptance, as well as the adoption of health-promoting behaviors, enhance the quality of life in patients with multiple sclerosis.

Author contributions

A.K. and J.C.-Ł. conceived the study. A.K., A.B., K.N., and J.C.-Ł. curated the data and conducted the formal analysis. A.K. and J.C.-Ł. carried out the investigation. Methodology was developed by A.K., A.B., E.Ż-P., and J.C.-Ł. Project administration was handled by A.K. and J.C.-Ł. Resources were provided by A.K., R.P., O.R., and J.C.-Ł. Validation was performed by A.K. and J.C.-Ł. Visualization was prepared by A.K., E.Ż-P., and J.C.-Ł. A.K., R.P., O.R., K.N., and J.C.-Ł. wrote the original draft of the manuscript. A.K., A.B., E.Ż-P., and J.C.-Ł. reviewed and edited the manuscript. All authors reviewed the final version of the manuscript.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.