Background Long life does not inevitably mean more healthy years; older women have an increased risk of disabilities, diseases and adverse life events. Nevertheless, many older women experience health. This may be explained by possessing resources that promote health, despite adversities. Inner strength is seen as a resource as such. In this thesis inner strength is interpreted according to a theoretical model where inner strength comprises four interrelated and interacting dimensions: connectedness, creativity, flexibility and firmness, and being rated by the Inner Strength Scale (ISS). Aim and methods The overall purpose of this thesis was to explore inner strength as a health resource among older women. In study I six focus group interviews were performed with older women (66-84 years; n = 29) and the interviews were analysed by a concept driven approach and by means of qualitative content analysis. Studies II–IV had a quantitative, cross-sectional design. A questionnaire was sent to all older women (65 years and older) living in Åland, an autonomous island community in the Baltic Sea, and 1555 (57%) women responded. The data was analysed using descriptive and inferential statistics. Results In study I, exploring how inner strength and its dimensions can be identified in narratives of older women, connectedness was interpreted as a striving to be in communion, creativity as the ability to make the best of the situation, firmness as having a spirit of determination – “it is all up to you”, and flexibility as a balancing act. The results of study II showed that strong inner strength was associated with better mental health, but not physical health. In exploring factors associated with health-related quality of life, fewer symptoms of depressive disorders was the strongest explanatory variable, and together with not feeling lonely associated with better both physical health and mental health. Better physical health was also explained by not having a diagnosed disease, being of lower age and the opportunity to engage in meaningful leisure activities. Better mental health was additionally explained by having enough money for personal needs. In study III the result showed that non-depressed women were likely to have a strong inner strength, as well as never or seldom feeling lonely, taking fewer prescribed drugs, feeling needed and having the opportunity to engage in meaningful leisure activities. In study IV poorer mental health was associated with weaker inner strength in total, and in all four dimensions of inner strength. Symptoms of depressive disorders and feeling lonely were related to lower scores in three of the dimensions (except firmness and creativity, respectively) and poorer physical health was associated with lower scores in two of the dimensions (firmness and flexibility). Some other health threats were significantly associated with only one of the dimensions (connectedness or creativity), and others were not significantly associated at all. Conclusion The results add nuance to the notion of inner strength and deepen empirical knowledge about the phenomenon. It is elucidated that the ISS can be used not only to rate inner strength but also to offer guidance as to the areas (i.e. dimensions) in which interventions may be profitable. It is further shown that inner strengths can be identified in narratives of older women. Mental ill health has shown to have overall the strongest association with weakened inner strength among community-dwelling older women. The causality can, though, not be studied due to the cross-sectional design; therefore, longitudinal studies are recommended. Notwithstanding that limitation, the findings can be used as a knowledge base in further research within this field.

One challenge in the Western world is the risk of functional impairmentand chronic disease accompanying older age. In Norway it is expected thatmost chronically ill older persons will continue to live at home and receivehelp from home nursing care. The inner strength of the oldest old, as seenin relation to the help that is given, and whether the help has contributed tostrengthen the will to live has been explored only to a limited extent.Meaning in life and daily routines can be related to the will to live,understood as enjoying life and having the courage to live. The aim of thisstudy is to develop knowledge in regard to chronically ill oldest olderpersons and the possibilities and limitations in their will to live when theyreceive help from home nursing care.This study uses the quantitative method (n=120, Article 1 and Article 2) todescribe the characteristics of inner strength using the questionnairesResilience Scale, Sense of Coherence Scale, Purpose in Life Test, and Self-Transcendence Scale. Inner strength was seen in relation to mental andphysical health using the questionnaire SF-36. The qualitative method wasused to illuminate how the oldest older persons experienced living at homewith chronic illness (n=13, Article 3) and receiving help from home nursingcare (n=11, Article 4). The participants in this study were 80 years old orolder, living at home with chronic illnesses, and receiving help from homenursing care. All participants were determined to have the mental capacityto take part in this study.The analysis showed in Article 1 that the oldest old had an inner strengthexpressed as ”sense of coherence” and ”purpose in life.” Their innerstrength was accompanied by the ability for self-transcendence. Mentalhealth was predicted by self-transcendence (p < 0.001) for the total sampleand for women. Physical health was predicted by self-transcendence (p <0.01) for the total sample. Low resilience contributed to vulnerability for theparticipants. They were vulnerable in terms of limited perseverance, selfreliance,and existential aloneness (Article 2). On the contrary, theyexperienced equanimity and meaning. Meaning in daily life (Article 3)sometimes meant feelings of insufficiency and dependency. In contrast,they also experienced joy in life, gratitude for living at home, and aneagerness to participate in activities that made them feel alive. Theyexperienced both good and bad days, which depended on their illness butwas also based on how their needs for help and support were met. InviiArticle 4, receiving help indicated different experiences. Being ill anddependent on help led to days with illness, treatment, and receiving care. Italso indicated they were in need of professional help. Receiving help couldmean being at the mercy of helpers, which could imply unworthy help, asthey had no influence on the help they got from incompetent nurses whofocused only on tasks, with limited flexibility in their work, using theirhomes as a working place. This situation of receiving help from busynurses caused the old person to feel inferior as a human being. Other timesit meant receiving help from nurses who took care with respect to the oldperson and confirmed him or her as a human being. The older personswanted to be seen, met, and supported to strengthen their courage to meetthe challenges of being old and ill.According to the ethics of caring, human beings are vulnerable andmutually dependent on each other. This influences the possibilities andlimitations of ”the other” in experiencing a will to live. ”Receiving theother” can contribute to the will to live, influenced by the help received inan asymmetric dependency in which the nurses are caught in the tensionbetween suffering and the will to live for the oldest older person in need ofhelp. In this tension, the will to live is dependent on help that is given in arelationship characterized by caring and responsibility for the other.

The overall purpose of this thesis is to describe, explore and illuminate inner strength among the oldest old. The thesis has a salutogenic perspective where strengths and health are in the foreground instead of weakness and ill health. The thesis is part of The Umeå 85+ study and comprises four studies with both quantitative and qualitative data. The aim of Study I was to test reliability and validity of the Swedish language version of the Resilience Scale (RS) in regard to its stability, internal consistency and validity. A convenience sample of 142 participants aged 19 to 85 years answered the questionnaires the first time and 126 on the retest. In Study II scales aimed to measure phenomena related to inner strength, health and development were used. The aim was to describe resilience, sense of coherence, purpose in life, and self-transcendence in relation to perceived physical and mental health in a sample of 125 participants aged 85 to 103 years. Study III aimed to give a more extensive knowledge of resilience among the oldest old. The relationship between resilience and physical health factors, psychological health factors, diseases and social relations were examined among a sample of 192 persons aged 85 to 103 years. In order to deepen the knowledge about inner strength from a life world perspective the aim of study IV was to illuminate the meaning of inner strength as narrated by women and men 85 and 90 years old. The sample consisted of those 18 participants that scored the highest on the scales aimed at measure phenomena related to inner strength. The findings in study I showed that the Swedish version of the RS was both valid and reliable. Construct validity was established by satisfactory correlations coefficient values between the RS and the Sense of Coherence Scale and the Rosenberg Self Esteem Scale. A principal component analysis corresponded well to the original version of the RS. Reliability was assured with both satisfactory internal consistency as well as test-retest reliability. The findings in study II showed significant correlations between the scales aimed to measure resilience, sense of coherence, purpose in life and self-transcendence which indicates that the scales reflect some kind of common core, which was interpreted as inner strength. The oldest old scored high on all scales, this indicating that strength can be preserved or perhaps even increased in old age. The finding also showed lack of significant correlations between the scales and perceived physical health but significant correlations between these scales and perceived mental health among the women but not for the men. No significant correlation was found between physical and mental health. In study III a regression analysis showed that a strong resilience among the oldest old was found to be associated with health, mainly represented by absence of depressed mood but also by not being on medication and by the absence of psychological symptoms, but also that raising children in the past gave a meaning to the present by having a family and this produced feelings of feeling safe and secure in facing the inevitable future; that is, being resilient means living in connectedness with one’s past, present, and future. In study IV a phenomenological hermeneutic approach to the interview text disclosed a meaning of inner strength as Life goes on –living it all, meaning that inner strength still makes it possible to live, handle and being open to ones life in many of its potentials. Inner strength means that one can chose to stand up and fight as well as living in reconciliation, a possibility to work hard as well as feeling relaxed, inner strength means having tasks to accomplish as well as feeling content and proud over ones life as well as life itself, it means relying in oneself as well as having faith in others and God (for some), knowing that you as a person is the same as well as accepting and adjusting to changes. It means that one can chose aloneness and still be connected, it is to be living in the present as well as in one’s past and in the future. That is, living in wholeness. The findings of the studies are discussed in relation to personal strengths and a good aging.

The purpose of this research was to develop and test an instrument to measure or quantify the construct of inner strength. Inner strength was synthesized into a theory based on twelve years of qualitative data from direct participant quotes, defined by Roux et al. (2002) as a central human resource that promotes well-being and healing. The inner strength questionnaire (ISQ) has undergone extensive psychometric evaluation which resulted in several versions. The third version had 37-items and was believed to have four subscales that mirrored the theoretical themes that emerged through the qualitative data. The sample was composed of 281 women with a variety of chronic health conditions including breast cancer, multiple sclerosis, diabetes, and heart disease. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were employed to assess the structure of the ISQ. Internal consistency was used to assess the reliability of each hypothesized subscale and the entire ISQ. Convergent and discriminant validity, were analyzed using the multitrait-multimethod by Campbell and Fiske (1959). For convergent validity, the entire instrument and each of the subscales was correlated with similar theoretical subscales of the Mastery of Stress Instrument (Younger, 1993). For discriminant validity, the Center for Epidemiological Studies in Depression (CESD) was correlated with the entire ISQ. Both the EFA and CFA revealed a four factor model. The four factors were labeled 1) mental, 2) connectedness, 3) knowing and searching, 4) physical. The reliability for all items on the ISQ was 0.91. The reliabilities for each of the subscales were 0.85 for mental, 0.96 for connectedness, 0.85 for knowing and searching, and 0.83 for physical. The multitrait-multimethod matrix revealed correlation coefficients for the relationship between the ISQ and MSI to be 0.55 and a correlation coefficient of -0.19 between the ISQ and the CESD.A four factor model is supported by the statistical data. Through face-to-face interviewing and input from content expert reviewers, ten items were eliminated from the 37-item (version 3) instrument to form a new version of the instrument. The new instrument supports the metasynthesis generated by Roux (2002) except for the fifth theme, entitled "new normal", which was found to be a consequence of having inner strength, not a component of inner strength.

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. / 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. / GErontologiska Regionala DAtabas (GERDA) Botnia projektet

Private deck of cards created during six-month survey and documentation of daily experiences. The package contains 49 cards and it is inspired by a set of 78 tarot cards. Text content - reverse side of the card was created using diary notes. Face side of the card was chosen as a representation of processes taking place usually in days when the card was read.