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Inner strength among old people: a resource for experience of health, despite disease and adversities
Umeå University, Faculty of Medicine, Department of Nursing.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Abstract [sv]

Bakgrund Inre styrka har beskrivits som ett viktigt fenomen associerat till att hantera sjukdom, till hälsa och åldrande. För att öka kunskapen om fenomenet inre styrka genomfördes en metateoretisk analys som resulterade i en Inre Styrka modell där inre styrka omfattar fyra samverkande dimensioner; samhörighet, kreativitet, flexibilitet och fasthet. Modellen har använts i denna avhandling som ett teoretiskt ramverk.

Syfte Det övergripande syftet med denna avhandling var att utveckla och testa en skala som mäter inre styrka, beskriva inre styrka i en population av äldre, och att belysa dess betydelse för upplevelsen av hälsa, trots sjukdom 0ch motgångar.

Metod Studierna som genomfördes hade kvantitativ ansats med tvärsnittsdesign (I-III) och kvalitativ ansats med narrativa intervjuer (IV).  Alla studier var en del av GErontologiska Regionala DAtabas (GERDA) Botnia projektet. Deltagarna i studie I (n= 391, 19-90 år) var mestadels från norra delarna av Sverige. I studierna II och III var deltagarna (n=6119, 65, 70, 75 och 80 år) från Sverige och Finland. I studie IV var deltagarna (n=12, 67-82 år) från Västerbotten. Data analyserades med hjälp av principalkomponentanalys och konfirmatorisk faktor analys (CFA), varierande statistik, strukturell ekvationsmodellering, och kvalitativ innehållsanalys.

Resultat I studie I utvecklades och testades Inre Styrka Skalan (ISS). En inledande 63 frågors ISS reducerades till en slutlig 20 frågors ISS. Baserad på de fyra dimensionerna av inre styrka bekräftades en fyrafaktors lösning med 51 % förklaringsgrad och CFA visade ett tillfredställande goodness-of-fit. I studie II beskrevs inre styrka i relation till ålder, kön och kultur. Det högsta totala ISS medelvärdet skattades bland 65-åringarna med lägre medelvärden för varje efterföljande ålder (70, 75 och 80 år). Kvinnor skattade ett något högre totalt ISS medelvärde än män och det var inte några större skillnader mellan regionerna i Sverige och Finland. I studie III bekräftades den hypotes som lagts fram, att inre styrka kan mediera i relationen mellan sjukdom och upplevelsen av hälsa. Bias-corrected bootstrap visade en signifikant indirekt effekt i relationen mellan sjukdom och upplevelsen av hälsa, medierad av inre styrka, och test av modellens goodness-of-fit var tillfredsställande. I studie IV, utifrån berättelserna om inre styrka visade det sig att inre styrka omfattar känslor av samhörighet och att finna livet värt att leva. Att ha tillit till sig själv och sina möjligheter, och att kunna möta och ta aktiv del i situationen beskrevs också. Slutligen, att komma igen och hitta vägar att gå vidare i livet var viktiga aspekter av inre styrka. 

Slutsatser Den nyutvecklade Inre Styrka Skalan är ett reliabelt och valitt instrument som fångar ett brett perspektiv av inre styrka. Basdata om inre styrka i en stor population äldre i Sverige och Finland har presenterats, och visar det högsta ISS medelvärdet bland 65-åringarna. Inre styrka bland äldre är en resurs för upplevelsen av hälsa, trots sjukdom och motgångar. Denna avhandling bidrar till att öka kunskapen om fenomenet inre styrka och ger evidens för att inre styrka har en viktig betydelse för äldres välbefinnande. Ökad kunskap om de fyra dimensionerna av inre styrka; samhörighet, kreativitet, flexibilitet, och fasthet, föreslås kunna vara en hjälp för vårdpersonal i deras arbete att identifiera var behovet av stöd är störst och att sätta in insatser som främjar och stärker inre styrka.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2013. , 60 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1611
Keyword [en]
Inner strength, old people, health, disease management, instrument development, mediating, structural equation modelling, qualitative content analysis
National Category
Nursing
Research subject
omvårdnadsforskning med samhällsvetenskaplig inriktning
Identifiers
URN: urn:nbn:se:umu:diva-82719ISBN: 978-91-7459-752-3 (print)OAI: oai:DiVA.org:umu-82719DiVA: diva2:662434
Public defence
2013-11-29, Aulan, vårdvetarhuset, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Projects
GErontologiska Regionala DAtabas (GERDA) Botnia projektet
Available from: 2013-11-08 Created: 2013-11-07 Last updated: 2013-11-08Bibliographically approved
List of papers
1. Development and psychometric properties of the Inner Strength Scale.
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2011 (English)In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 48, no 10, 1266-1274 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Four dimensions of inner strength were previously identified in a meta-theoretical analysis: firmness, creativity, connectedness, and flexibility.

OBJECTIVE: The aim of this study was to develop an Inner Strength Scale (ISS) based on those four dimensions and to evaluate its psychometric properties.

METHOD: An initial version of ISS was distributed for validation purpose with the Rosenberg Self-Esteem Scale, the resilience scale, and the sense of Coherence Scale. A convenience sample of 391 adults, aged 19-90 years participated. Principal component analysis (PCA) and confirmatory factor analysis (CFA) were used in the process of exploring, evaluating, and reducing the 63-item ISS to the 20-item ISS. Cronbach's alpha and test-retest were used to measure reliability.

RESULTS: CFA showed satisfactory goodness-of-fit for the 20-item ISS. The analysis supported a fourfactor solution explaining 51% of the variance. Cronbach's alpha on the 20-item ISS was 0.86, and the test-retest showed stability over time (r=0.79).

CONCLUSION: The ISS was found to be a valid and reliable instrument for capturing a multifaceted understanding of inner strength. Further tests of psychometric properties of the ISS will be performed in forthcoming studies.

Place, publisher, year, edition, pages
Elsevier, 2011
Keyword
Inner Strength Scale, Instrument development, Rosenberg Self-Esteem Scale, Sense of Coherence Scale, Resilience Scale
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-43697 (URN)10.1016/j.ijnurstu.2011.03.006 (DOI)21474137 (PubMedID)
Available from: 2011-05-06 Created: 2011-05-06 Last updated: 2017-12-11Bibliographically approved
2. Inner strength in relation to age, gender and culture among old people: a cross-sectional population study in two Nordic countries.
Open this publication in new window or tab >>Inner strength in relation to age, gender and culture among old people: a cross-sectional population study in two Nordic countries.
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2013 (English)In: Aging & Mental Health, ISSN 1360-7863, E-ISSN 1364-6915, Vol. 17, no 8, 1016-1022 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The theoretical framework for the study was the Model of Inner Strength, and the Inner Strength Scale (ISS)developed based on the Model was used. The aim was to examine inner strength in relation to age, gender and culture among old people in Sweden and Finland.

Method: This study forms part of the GErontological Regional DAtabase (GERDA)-Botnia project that investigates healthy ageing with focus on the dignity, social participation and health of old people. The participants (N = 6119) were 65-, 70-, 75- and 80-year old and living in two counties in Sweden or Finland. The ISS consists of 20 items relating to four interrelated dimensions of inner strength, according to the Model of Inner Strength. The range of possible ISS scores is 20-120, a higher score denoting higher inner strength.

Result: The result showed that the 65-year-old participants had the highest mean ISS score, with a decrease in score for every subsequent age. The lowest score was achieved by the 80-year-old participants. Women had slightly but significantly higher mean ISS scores than men. Only small differences were found between the counties.

Conclusion: The study population came from Sweden and Finland; still, despite the different backgrounds, patterns in the distribution of inner strength were largely similar. The present study provides basic and essential information about inner strength in a population of old people.

Place, publisher, year, edition, pages
Routledge, 2013
Keyword
Inner strength, old people, gender, culture
National Category
Public Health, Global Health, Social Medicine and Epidemiology Geriatrics
Identifiers
urn:nbn:se:umu:diva-81053 (URN)10.1080/13607863.2013.805401 (DOI)23750849 (PubMedID)
Available from: 2013-10-01 Created: 2013-10-01 Last updated: 2017-12-06Bibliographically approved
3. Inner strength as a mediator of the relationship between disease and self-rated health among old people
Open this publication in new window or tab >>Inner strength as a mediator of the relationship between disease and self-rated health among old people
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2014 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 70, no 1, 144-152 p.Article in journal (Refereed) Published
Abstract [en]

AIM: To explore inner strength as a mediator of the relationship between disease and self-rated health among older people.

BACKGROUND: Qualitative research has indicated that inner strength is an essential resource for an individual affected by disease. A hypothesis of inner strength as a mediator of the relationship between disease and self-rated health was proposed. The theoretical framework of inner strength was based on the Model of Inner Strength.

DESIGN: A cross-sectional design was used.

METHOD: The sample included 6119 participants from Finland and Sweden, in the ages of 65, 70, 75 and 80 years. The GERDA-Botnia questionnaire, which included the Inner Strength Scale and items related to diseases and self-rated health, was sent out between October and December 2010. Structural equation modelling was used to test a hypothesized model.

RESULTS: The result indicated that having a disease was associated with poorer self-rated health and a lower degree of inner strength and a higher degree of inner strength was associated with better self-rated health. The result supported the hypothesis by indicating that inner strength partially mediated the relationship between disease and self-rated health.

CONCLUSION: This large cross-sectional study with participants from 65 to 80 years of age from Finland and Sweden showed that inner strength can be a resource for older people affected by disease. Increasing inner strength in older people affected by disease may be one intervention to support experiences of health despite disease.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2014
Keyword
Disease, health, inner strength, mediating, nursing, older people, structural equation modelling
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-74491 (URN)10.1111/jan.12179 (DOI)000327900300015 ()23718213 (PubMedID)
Available from: 2013-07-01 Created: 2013-07-01 Last updated: 2017-12-06Bibliographically approved
4. Inner strength among old people who have experienced a crisis in life
Open this publication in new window or tab >>Inner strength among old people who have experienced a crisis in life
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Inner strength is a resource associated with health and disease management. Our objective was to elucidate inner strength in the narratives of people 65 years and older who had experienced a crisis in life associated with a disease. They had self-rated their inner strength as high, and qualitative content analysis was used in the interpretation of the narratives (n = 12). In the narratives, we 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.

Keyword
Inner strength, older people, disease management, qualitative content analysis
National Category
Nursing
Research subject
omvårdnadsforskning med samhällsvetenskaplig inriktning
Identifiers
urn:nbn:se:umu:diva-82717 (URN)
Available from: 2013-11-07 Created: 2013-11-07 Last updated: 2013-11-08Bibliographically approved

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