Inner strength among old people : a resource for experience of health, despite disease and adversities

Abstract: Background Inner strength has been described as an important phenomenon in association with disease management, health, and ageing. To increase the knowledge of the phenomenon of inner strength, a meta-theoretical analysis was performed which resulted in a model of Inner Strength where inner strength comprises four interrelated and interacting dimensions; connectedness, creativity, flexibility, and firmness. The model was used in this thesis as a theoretical framework.Aim The overall purpose of this thesis was to develop and validate an inner strength scale, describe inner strength among an older population, and elucidate its significance for experience of health, despite disease and adversities.Methods The studies had quantitative approaches with cross-sectional designs (I-III) and a qualitative approach with narrative interviews (IV). Studies I-IV was part of the GErontological Regional DAtabase (GERDA) Botnia project. In study I, the participants (n = 391, 19-90 years old) were mostly from northern Sweden. In studies II and III, the participants (n = 6119, 65, 70, 75 and 80 years old) were from Sweden and Finland, and in study IV the participants (n = 12, 67-82 years old) were from Västerbotten County. Data was analysed using principal component analysis and confirmatory factor analysis (CFA), various statistics, structural equation modelling, and qualitative content analysis.Results In study I, the Inner Strength Scale (ISS) was developed and psychometrically tested. An initial 63-item ISS was reduced to a final 20-item ISS. A four-factor solution based on the four dimensions of inner strength was supported, explaining 51% of the variance, and the CFA showed satisfactory goodness-of-fit. In study II, ISS scores in relation to age, gender and culture showed the highest mean ISS score among the 65-year-olds, with a decrease in mean score for every subsequent age (70, 75, and 80 years). Women had slightly higher mean ISS scores than men, and there were minor differences between the regions in Sweden and Finland. In study III, a hypothesis was proposed and subsequently supported in the results where inner strength was found to partially mediate in the relationship between disease and self-rated health. The bias-corrected bootstrap, estimating the mediating indirect effect was significant and the test of goodness-of-fit was satisfactory. In study IV, from the narratives of inner strength it was found that inner strength comprised feelings of being connected and finding life worth living. Having faith in oneself and one’s possibilities and facing and taking an active part in the situation were also expressed. Finally, coming back and finding ways to go forward in life were found to be essential aspects of inner strength.Conclusions The newly developed ISS is a reliable and valid instrument that captures a broad perspective of inner strength. Basic data about inner strength in a large population of old people in Sweden and Finland is provided, showing the highest mean ISS score among the 65-year-olds. Inner strength among old people is a resource for experience of health, despite disease and adversities. This thesis contributes to increase knowledge of the phenomenon of inner strength and provide evidence for the importance of inner strength for old people’s wellbeing. Increased knowledge of the four dimensions of inner strength; connectedness, creativity, flexibility and firmness, is proposed to serve as an aid for health care professionals in their efforts to identify where the need of support is greatest and to find interventions that promotes and strengthen inner strength.