Inner strength and its relationship to health threats in ageing-A cross-sectional study among community-dwelling older women.

AIM: To explore the relationship between inner strength and health threats among community-dwelling older women. BACKGROUND: Inner strength is described as a resource that promotes experiences of health, despite adversities. Inner strength and its dimensions (i.e. connectedness, creativity, firmness and flexibility) can be assessed using the Inner Strength Scale (ISS). Exploring attributes of weaker inner strength may yield valuable information about areas to focus on in enhancing a person's inner strength and may ultimately lead to the perception of better health. DESIGN: Cross-sectional questionnaire survey. METHODS: The study is based on responses from 1270 community-dwelling older women aged 65 years and older; these were collected in the year 2010 and describe the situation that still exists today for older women. The questionnaire included the ISS, background characteristics and explanatory variables known to be health threats in ageing. Data were analysed using descriptive and inferential statistics. RESULTS: Poorer mental health was related to weaker inner strength in total and in all the dimensions. Symptoms of depressive disorders and feeling lonely were related to three of the dimensions, except firmness and creativity respectively. Furthermore, poor physical health was associated with the dimensions firmness and flexibility. Other health threats were significantly related to only one of the dimensions, or not associated at all. CONCLUSION: Mental ill health has overall the strongest association with weaker inner strength. Longitudinal studies are recommended to confirm the results. However, the ISS does not only estimate inner strength but can also be a tool for discovering where (i.e. dimension) interventions may be most profitable.

Psychometric properties and feasibility of the Swedish version of the Philadelphia Geriatric Center Morale Scale.

PURPOSE: Morale is related to psychological well-being and quality of life in older people. The Philadelphia Geriatric Center Morale Scale (PGCMS) is widely used to assess morale. The purpose of this study was to evaluate the psychometric properties and feasibility of the Swedish version of the 17-item PGCMS among very old people. METHODS: The Umeå 85+/GERDA study included Swedish-speaking people aged 85, 90 and 95 years and older, from Sweden and Finland. Participants were interviewed in their own homes using a predefined set of questions. In the main sample, 493 individuals answered all 17 PGCMS items (aged 89.0 ± 4.3 years). Another 105 answered between 1 and 16 questions (aged 89.6 ± 4.4 years). A convenience sample was also collected, and 54 individuals answered all 17 PGCMS items twice (aged 84.7 ± 6.7 years). The same assessor restated the questions within 1 week. RESULTS: Cronbach's alpha was 0.74 among those who answered all 17 questions in the main sample. Confirmatory factor analysis was used to test the construct validity of the most widely used version of the PGCMS, with 17 items and three factors, and showed a generally good fit. Among those answering between 1 and 17 PGCMS questions, 92.6 % (554/598) answered 16 or 17. The convenience sample was used for intra-rater test-retesting, and the intraclass correlation coefficient (ICC) was 0.89. The least significant change between two assessments, with 95 % confidence interval, was 3.53 PGCMS points. CONCLUSION: The Swedish version of the PGCMS seems to have satisfactory psychometric properties and feasibility among very old people.

Inner strength as identified in narratives of elderly women: a focus group interview study.

By identifying sources of inner strength, health care personnel can be given valuable information about elderly people's capacities regardless of frailty. The focus of this interview-based study was to explore how inner strength and its dimensions can be identified in narratives of elderly women. The analysis was based on a theoretical model where inner strength is composed of 4 interacting dimensions of connectedness, creativity, firmness, and flexibility. Our findings add nuance to the notion of inner strength and deepen empirical knowledge about the concept.

Inner strength - associated with reduced prevalence of depression among older women.

OBJECTIVES: The aim of this study was to explore if inner strength is independently associated with a reduced prevalence of depression after controlling for other known risk factors associated with depression. METHODS: A population-based cross-sectional study was performed, where all women living in Åland, a Finnish self-govern island community in the Baltic Sea, aged 65 years or older were sent a questionnaire including the Geriatric Depression Scale and the Inner Strength Scale along with several other questions related to depression. Factors associated with depression were analyzed by means of multivariate logistic regression. RESULTS: The results showed that 11.2% of the studied women (n = 1452) were depressed and that the prevalence increased with age and was as high as 20% in the oldest age group. Non-depressed women were more likely to never or seldom feel lonely, have a strong inner strength, take fewer prescription drugs, feeling needed, being able to engage in meaningful leisure activities, as well as cohabit. CONCLUSION: Our results showed an association between stronger inner strength and being non-depressed. This can be interpreted to mean that inner strength might have a protective effect against depression. These findings are interesting from a health-promotion perspective, yet to verify these results, further longitudinal studies are required.

Inner strength as a mediator of the relationship between disease and self-rated health among old people.

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.

Inner strength in relation to age, gender and culture among old people--a cross-sectional population study in two Nordic countries.

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.

Psychometric properties of the Swedish version of the selection, optimization, compensation questionnaire.

BACKGROUND: The model of selection, optimization and compensation has been proposed as a model of adaptive management strategies throughout the lifespan. AIM: The aim of this study was to test the psychometric properties of a translated Swedish version of the 12-item selection, optimization, and compensation (SOC) questionnaire. METHOD: The 12-item SOC questionnaire is composed of four subscales: elective selection (ES), loss-based selection, optimization and compensation. A convenience sample of 122 Swedish-speaking people, aged 19-85, participated in a study of the validity and reliability of the SOC questionnaire. Cronbach's alpha coefficient, corrected item-total correlation and Cronbach's alpha if item deleted were used for reliability testing. Two other scales, the ways of coping questionnaire and Rosenberg's self-esteem scale, were used to test convergent validity, and the geriatric depression scale was used to test discriminant validity. Stability over time was evaluated using a test-retest model with a 2-week interval. RESULTS: The 12-item SOC questionnaire showed a Cronbach's alpha value of 0.50, and the subscales ranged from α = 0.16 to α = 0.64. Two items in the ES subscale had negative values on the corrected item-total correlation and showed substantial improvement (>0.05) in Cronbach's alpha when item deleted. When these two items that influenced internal consistency were deleted, Cronbach's alpha rose to 0.68. CONCLUSION: The Swedish version of the 12-item SOC questionnaire showed deficiencies in a test of internal consistency because of two items in the ES subscale, and these two items were deleted. A consequence of the reduction is a weakening of the ES subscale and thereby to some extent the SOC questionnaire in total. Further testing is advisable. However, the 10-item SOC questionnaire was acceptable in a test of validity and reliability.

Inner strength in relation to functional status, disease, living arrangements, and social relationships among people aged 85 years and older.

Inner strength is described as an important resource that promotes well-being. We used data from a sample of 185 people in the Umeå 85+ cohort study to relate inner strength and its attributes to objective health variables. The Resilience, Sense of Coherence, Purpose in Life, and Self-Transcendence scales were used to assess aspects of inner strength, and strong correlations between the scales were found. Prevalence of heart failure, chronic obstructive pulmonary disorder, osteoporosis, or diagnosed depression was associated with low inner strength. Significant relationships were also found between high inner strength and various measures of social relationships. Participants with a higher degree of inner strength had better physical health and more satisfying social relationships. The promotion of inner strength should be a major aim of geriatric nursing.

Development and psychometric properties of the Inner Strength Scale.

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.

Resilience among women and men aged 60 years and over in Sweden and in Thailand.

The purpose of this study was to compare the level of resilience of people aged > or = 60 years in Sweden and Thailand. In a randomized sample of 422 people in Sweden and a convenience sample of 200 people in Thailand, the level of resilience was measured by using the Resilience Scale. A chi(2)-analysis was used for the differences between proportions. The relationships between the background variables and the resilience scores were analyzed by using stepwise multiple linear regression. The mean scores of resilience were 144 for the Swedish participants and 146 for the Thai participants. The two samples differed in their background characteristics. The Thai participants were more likely to be women, to be widowed, and to have more children, while among the Swedish participants, more women were married and more participants were aged > or = 80 years. Despite different background characteristics, the Swedish and the Thai participants' scores were almost the same on the Resilience Scale. More studies are necessary to address aspects of gender and ethnicity in relation to resilience.

Psychometric properties of the Swedish version of the Purpose in Life scale.

The aim of this study was to test the theoretical assumptions beyond the Purpose in Life (PIL) scale, and to elucidate the underlying structure of the Swedish version of the PIL. The PIL, originally created by Crumbaugh and Maholick, is a 20-item scale of the Lickert type with possible scores ranges from 20 to 140, the higher score, the stronger PIL. The analysis was based on 449 participants, 62% of whom were women, from five different samples, ranging from 19 to 103 years old. An exploratory factor analysis restricted to three factors was performed. The factors were labelled meaning in existence, freedom to create meaning in daily life, and will to find meaning in future challenges. These factors reflected the three dimensions described by Frankl. Cronbach's alpha coefficient for the total scale was 0.83 and varied between 0.54 and 0.83 in the three factors. We concluded that the Swedish version of the PIL scale seems to have construct validity and reliability. Our results give support to the fact that the PIL scale captures and confirms the theoretical assumptions of Frankl's existential theory. We consider the PIL scale to be both feasible and appropriate for use in nursing research.

Inner strength--a theoretical analysis of salutogenic concepts.

BACKGROUND: Theoretical and empirical overlaps between the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence have earlier been described as some kind of inner strength, but no studies have been found that focus on what attributes these concepts have in common. OBJECTIVES: The objective of this study was to perform a theoretical analysis of the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence, in order to identify their core dimensions in an attempt to get an overarching understanding of inner strength. PRINT METHOD: An analysis inspired by the procedure of meta-theory construction was performed. The main questions underlying the development of the concepts, the major paradigms and the most prominent assumptions, the critical attributes and the characteristics of the various concepts were identified. RESULTS: The analysis resulted in the identification of four core dimensions of inner strength and the understanding that inner strength relies on the interaction of these dimensions: connectedness, firmness, flexibility, and creativity. These dimensions were validated through comparison with the original descriptions of the concepts. CONCLUSION: An overarching understanding of inner strength is that it means both to stand steady, to be firm, with both feet on the ground and to be connected to; family, friends, society, nature and spiritual dimensions and to be able to transcend. Having inner strength is to be creative and stretchable, which is to believe in own possibilities to act and to make choices and influence life's trajectory in a perceived meaningful direction. Inner strength is to shoulder responsibility for oneself and others, to endure and deal with difficulties and adversities. This knowledge about inner strength will raise the awareness of the concept and, in turn, hopefully increase our potential to support people's inner strength.

Inner strength as disclosed in narratives of the oldest old.

The aim of this study was to illuminate the meaning of inner strength when very old as narrated by women and men 85 and 90 years old. The authors used a phenomenological hermeneutical method to analyze interviews from 11 women and 7 men, aged either 85 or 90, who scored high on scales measuring phenomena related to inner strength. The following themes emerged from the analysis: feeling competent in oneself yet having faith in others, looking on the bright side of life without hiding from the dark, feeling eased and also being active, being the same yet growing into a new garment, and living in a connected present but also in the past and the future. The authors understood the meaning as Life Goes On--Living It All. To illuminate this meaning further, the authors related the findings to the Aristotelian virtues and the golden mean, and to developmental theory.

Health status in the oldest old. Age and sex differences in the Umeå 85+ Study.

BACKGROUND AND AIMS: With an increasing population aged 85 years and over, the aim of this study was to describe health status and living conditions in the oldest old and to estimate age and sex differences in a Northern European population. METHODS: A population-based cross-sectional study, The Umeå 85+ Study, was carried out in the municipality of Umeå in northern Sweden. Out of 319 eligible participants aged 85, 90 and 95 years and over, 253 participated. Structured interviews and assessments were conducted with the participants in their homes, and data were also collected from relatives, caregivers and medical charts. Cognition was screened with the Mini-Mental State Examination (MMSE), depressive symptoms with the Geriatric Depression Scale-15 (GDS-15) and nutritional status with the Mini Nutritional Assessment (MNA). Activities of daily living (ADL) were assessed applying the Staircase of ADL (including Katz' Index of ADL) and morale with the Philadelphia Geriatric Center Morale Scale (PGCMS). Participants also rated their own health. RESULTS: Over half of the participants had hypertension, one out of four was depressed, and the same proportion had had a hip fracture; the mean number of drugs taken was 6.4+/-4.0. Younger participants had lower rates of diagnoses and prescribed drugs, and were less dependent in ADL and other functional variables; men had lower rates of diagnoses and reported symptoms. The majority of participants rated their general health and morale as good. CONCLUSIONS: There were large variations in social, medical and functional variables within and between age and sex groups. This northern population of the oldest old seems to have a very high prevalence of hypertension, depression, hip fractures, and many prescribed drugs.

Morale in the oldest old: the Umeå 85+ study.

OBJECTIVE: to describe morale among the oldest old, and to investigate which social, functional and medical factors are associated with morale in this population. DESIGN: a cross-sectional study. SETTING: a population-based study in the municipality of Umeå, a city in Northern Sweden. SUBJECTS: half of the 85-year-old population, and the total population of 90-year-olds and > or = 95-year-olds (95-103) were asked to participate (n = 319) and 238 were interviewed. METHODS: structured interviews and assessments during home visits, interviews with relatives and caregivers and review of medical charts. The 17-item Philadelphia Geriatric Center Morale Scale (PGCMS) was used to measure morale. Participants were assessed with the Barthel Activities of Daily Living (ADL) Index, Geriatric Depression Scale (GDS-15), Mini-Mental State Examination (MMSE), Mini Nutritional Assessment (MNA), and a symptom questionnaire. Multiple regression analyses were conducted to find independent factors to explain the variation in the PGCMS score. RESULTS: eighty-four per cent (n = 199) of those interviewed answered the PGCMS. Three-quarters had middle range or high morale. GDS score, type of housing, previous stroke, loneliness and number of symptoms, adjusted for age group and sex, explained 49.3% of the variance of total PGCMS score. CONCLUSIONS: a large proportion of the oldest old had high morale. The most important factors for high morale were the absence of depressive symptoms, living in ordinary housing, having previously had a stroke and yet still living in ordinary housing, not feeling lonely and low number of symptoms. The PGCMS seems applicable in the evaluation of morale among the oldest old.

Reliability and validity of a Swedish language version of the Resilience Scale.

The purpose of this study was to test the reliability and validity of the Swedish language version of the Resilience Scale (RS). Participants were 142 adults between 19-85 years of age. Internal consistency reliability, stability over time, and construct validity were evaluated using Cronbach's alpha, principal components analysis with varimax rotation and correlations with scores on the Sense of Coherence Scale (SOC) and the Rosenberg Self-Esteem Scale (RSE). The mean score on the RS was 142 (SD = 15). The possible scores on the RS range from 25 to 175, and scores higher than 146 are considered high. The test-retest correlation was .78. Correlations with the SOC and the RSE were .41 (p < 0.01) and .37 (p < 0.01), respectively. Personal Assurance and Acceptance of Self and Life emerged as components from the principal components analysis. These findings provide evidence for the reliability and validity of the Swedish language version of the RS.