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De Witte J, Van Regenmortel T. Building Stones of Resilience of Vulnerable Older Persons. Elderly Health Journal. 2022; 8 (1) :29-35
URL: http://ehj.ssu.ac.ir/article-1-259-en.html
Research Institute for Work and Society , University of Leuven, Leuven, Belgium , jasper.dewitte@kuleuven.be
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Building Stones of Resilience of Vulnerable Older Persons

Jasper De Witte *1, Tine Van Regenmortel 2,3

  1. Research Institute for Work and Society , University of Leuven, Leuven, Belgium
  2. Department of Social Sciences and Research Institute for Work and Society , University of Leuven, Leuven, Belgium
  3. Tilburg School of Social and Behavioral Sciences, Tilburg University,Tranzo, Tilburg, Netherlands

Article history
Received 1 Mar 2022
Accepted 11 May 2022

 
A B S T R A C T

Introduction: Vulnerable older persons need sufficient resilience to deal with (age-related) adversities and safeguard their quality of life. In this study, we investigate which sources of strength vulnerable older persons use to deal adversities.

Methods: This qualitative study is based on fifteen narratives of community-dwelling vulnerable older persons in Belgium, who were selected through a ‘purposive sampling’ strategy.

Results: Vulnerable older persons use various interrelated sources of strength situated on the individual, interactional, and contextual domains. On the individual domain, important sources of strength are having an optimistic life view and accepting the own vulnerabilities. On the interactional domain positive social relations, ‘the power of giving’ and social participation are sources of strength that benefit the quality of life of older persons, and on the contextual domain various welfare benefits are essential.

Conclusion: It is crucial to stimulate those sources of strength, for example by removing contextual barriers that impede social participation. The results can guide empowering interventions that aim to reinforce the sources of strength of vulnerable older persons, which will positively affect their resilience and general well-being.

Keywords: Resilience, Vulnerable, Aged, Narratives, Strength


Copyright © 2022 Elderly Health Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cite
 
Introduction
    Old age is accompanied by various age-related adversities such as health limitations, reduced mobility, the death of loved ones, shrinking social networks, and feelings of loneliness (1), which can negatively affect their quality of life (QOL). The World Health Organization (2) defines QOL as “an individual's perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns." Hence, QOL is not only determined by a person’s physical health but also by personal beliefs, psychological characteristics, social relations, and environmental factors.
    Despite many age-related adversities, research shows that subjective well-being does not decrease in old age for a large majority of people (3), and life satisfaction among Europeans decreases only limitedly with old age (4). This suggests that many older persons find ways to limit the negative impact of (age-related) adversities on their QOL. Hence, it is crucial to study how older persons succeed in keeping their well-being relatively high, despite those adversities.
    The motivational theory of life-span development and resilience in old age. According to the motivational theory of life-span development, striving to realize goals gives meaning to life, and people continuously adapt to various adversities during their life to reach their personal goals (5). As a result, we can distinguish between primary and secondary control processes as different ways to deal with adversities and realize goals. Through primary control processes, people use their resources to influence outcomes in the environment and realize goals. Secondary control processes come to the foreground when people cannot realize specific goals. Then, they apply psychological processes that bring themselves in line with environmental forces (6) by adjusting goals, expectations, and preferences to the specific context (5). In sum, older persons need sufficient resilience to safeguard their QOL (7) because the latter not only depends on adversities but possibly even more on the way people handle those adversities (8) by making competent decisions and realizing or revising goals (5). Moreover, resilience may be particularly crucial for older persons because they are confronted with age-related adversities and with a decline of various resources (e.g., a shrinking social network) (9).
    Although resilience as a concept originated in developmental psychology concerning childhood and adolescence, it is increasingly included in old age research (10). Resilience can be defined as “patterns and processes of positive adaptation and development in the context of significant threats to an individual’s life or function” (6). It refers to the ability to maintain a stable and good way of (physical, psychological, social) functioning during difficult circumstances and to become even stronger by learning from adversities. Hereby, it is essential to mention that resilience and vulnerability can go hand in hand: vulnerable people also use resilience to deal with adversity (10).
    Based on the definition of resilience, we find that older persons deal with (age-related) adversities (1) by making use of ‘sources of strength’ (11), namely “a supply of skills and resources that can be used to moderate “the bad things that happen […]” (10). While many researchers have studied how psychological factors moderate against adversities, the role of the environment is recently also being recognized. Indeed, various researchers (10) state that sources of strength can be found in the individual, interactional and contextual domain. The individual domain refers to “the qualities within older people” (10) and contains sources of strength such as pride about one’s personality and acceptance and openness about one’s vulnerability. The interactional domain refers to “the way older people cooperate and interact with others to achieve their personal goals” (10) and comprehends sources of strength like empowering relationships with family and professionals. The contextual domain refers to “a broader political-societal level including the efforts on this domain to deter community threats, improve quality of life and facilitate citizen participation” (10) and contains sources of strength such as accessibility of health and social care. Since there are internal and external sources of strength, resilience is dependent on both the individual and the environment and the interaction between both (12).
    Further, older persons are confronted with age-related adversities and a decline of various sources of strength (9), through which secondary control processes become more promising than primary control processes to realize goals. Indeed, older persons can disengage from no longer attainable goals and select more realistic goals by adjusting expectations and values (5). Last, resilience processes occur in a specific socio-economic, cultural, and historical context (13, 14) because resources, adversities, and adaptation processes depend on that context and change over time (15). As a result, “to understand more about resilience in old age, we need to interrogate the social, cultural, and economic dimensions that shape it in specific cultural groups” (16).
    Although some research exists about resilience in old age (17, 10, 18), “[…] little is known about the resources that contribute to resilience and well-being in the elderly […]” (7). More research is primarily needed to investigate if the insights from the existing literature apply to community-dwelling vulnerable older persons because vulnerabilities (e.g., with a low income) seem to impact the availability of sources of strength. Indeed, research shows, for example, that poverty influences resilience through its impact on sources of strength, how people feel, their behavior, and decision-making processes (19). As a result, we especially need more qualitative insight into which sources of strength vulnerable older persons themselves deem essential to deal with adversities. Based on the perspectives of community-dwelling vulnerable older persons in Belgium, we investigate which building stones of resilience vulnerable older persons use to safeguard their QOL.

Methods
A narrative research approach
    We use a narrative research approach because it allows us to gain insight into people's personal life histories and experiences, the specific context, and subjective meanings people attribute to specific events. A narrative research approach refers to “the study of how human beings experience the world” (20) and focuses on what specific events, symbols, practices, or places mean to the people telling them (20). Narrative researchers are not governed by a topic-based schedule (21), and the data of narrative research mainly consists of transcripts of people talking reflexively about their life experiences (22).
Setting and data collection
    The research was conducted in four cities in Belgium: we asked professionals of five social work organizations that work with older persons with limited financial means or other vulnerabilities to select respondents. We used the following criteria of inclusion: (1) aged 55 or older, (2) speaking Dutch, (3) only having a low to moderate-income (less than 1200 euros a month), (4) being able to give informed consent, and (5) having a practical insight into their own lives. We applied ‘purposive sampling’ through which we realized a diverse group of respondents concerning age, gender, and experienced adversities.
    We interviewed 15 vulnerable older persons, six men, and nine women. The youngest respondent was 58 years old and the oldest 87 years old, with a mean age of 72 years old. Most respondents were widowed, separated or divorced, and lived alone. Eleven respondents had children. Concerning housing, two respondents owned the home they live in, 12 rent, and one respondent lived in with her child. Last, the respondents experienced a wide variety of adversities: severe feelings of loneliness, health limitations, poverty, divorce, separation or death of their partner, familial problems, and various psychological and emotional problems such as adhesion problems (due to stressful life events such as sexual abuse earlier in life).
    The interviews were held in the place the respondents felt most comfortable with (i.a., the building of social work organizations, their home, a bar, a bench outside), and we let the respondents guide the subjects of the conversations. Each interview started with the general question to present themselves, after which we deepened specific subjects (e.g., family situation, social activities) and asked which adversities they have encountered and which resources they used to deal with them. This is important because letting them talk about “[…] how they derive meaning from a particular life situation [...] allows us to start with what is important to them rather than what we think may be important” (23). All interviews were held between May and July 2019 and took one hour and ten minutes. We stopped the data collection after 15 interviews because we felt saturation was reached.
Data analysis
    All data were analyzed through an open, inductive coding method, whereby the authors in first instance read and discussed the transcripts of the first two interviews and determined relevant themes. Subsequently they performed the coding of these two transcripts and compared the results and discussed them until they reached consensus on this first set of codes and their meaning. This code tree was subsequently used by the first author to code the remaining interviews, on which a check was performed by the second author to increase the inter-researcher reliability. Differences were discussed and authors agreed on the final coding. During this process, the authors used these ‘sensitizing concepts’ representing different sources of strength and control processes and the concepts derived from the literature to develop new theoretical insights. Data analyses were performed using Atlas.ti 9.
Ethical considerations
    Before each interview, we orally explained the research objective, methodology, and ethical considerations and gave each respondent a letter describing these aspects. The interviews were recorded with the verbal consent of the respondent and transcribed verbatim. Further, we deleted their names and other directly identifying characteristics to safeguard the anonymity of the respondents.

Results
    Although the respondents deal in their specific way with adversities, we can distinguish several available sources of strength on the individual, interactional and contextual domain (10), which appear to be strongly interrelated. This accords with other research (24). Further, the narratives also show that older persons use primary and secondary control processes to deal with adversities and maintain their QOL.
Individual domain
    The individual domain includes sources of strength ‘within older persons.' As a result, pride about one’s personality is the first substantial source of strength that gives people a sense of self-worth and courage to cope with adversities. Inversely, people who lack self-worth and pride may feel so ashamed about their situation that they even withdraw socially. A respondent who lived in extreme poverty and isolation explains that he no longer talked to other people due to the shame of his situation. This respondent nevertheless regained self-worth thanks to his participation in a poverty organization:
    [People from the poverty organization] ask you something, and they consider what you say. That is very different from when you always need to talk about those debts and when they say it's your own fault […] It was mainly the self-worth that gave me a boost (Respondent 15).
    An optimistic (but realistic) life view is the second source of strength, which accords with other research (25). “I think [a positive personality] helps me to get over certain things [...] You cannot let yourself go when you feel down” (Respondent 6). Older persons with an optimistic life view show more insight and problem-solving capacity to cope with adversities (e.g., installing a chair lift to alleviate mobility limitations), which was also found by Lee et al.: "positive affect contributes to more favorable health outcomes by broadening the scope of one’s patterns of thought into more flexible, creative, and integrative arrays" (24). Further, older persons with an optimistic life view seem to focus more on things that give them pleasure and that they can still do, instead of things they can no longer do: this helps to accept setbacks that cannot be overcome (e.g., health limitations). This is also related to not adopting the role of a victim, which gives people the courage and energy to undertake actions, while adopting the victim role may lead to passivity. However, being positive does not equal being unrealistic: a real-life view helps to relativize and put negative experiences into perspective: “I had a beautiful time. [...] I think that I am very realistic. […] My mother taught me not to look up to all those who have more. Look down to all those who have less” (Respondent 5). Third, accepting their vulnerabilities enables persons to accept support from others. However, several respondents experience difficulties with accepting their vulnerabilities. A particular respondent is too ashamed to use a wheelchair because it confronts him with his deteriorating health and negative perceptions of the environment: “I still have a little bit of honor left” (Respondent 2). However, his mobility and social participation are significantly reduced by not accepting his vulnerabilities and support. With this, accepting one's vulnerability is a process that takes time: older persons are often insecure and need time to doubt and consider all available options. Anticipating future losses is a fourth source of strength. People can minimize the negative impact of adversities by formulating practical solutions. A respondent, for example, enrolled in a social organization to avoid falling into 'a black hole' once he retired. Further, it is also psychologically important to already think about how to deal with possible adversities, to be emotionally better prepared to cope with them the day they arise.
    I have already gotten prepared for later. At this moment, I still travel often and walk a lot, but maybe there will come a time that I will no longer be able to do that. Then, I will be more at home, reading books or going to the theater or cinema in the neighborhood (Respondent 1).
    Five, although anticipation of future losses may be beneficial, some respondents find it equally important to realize that every day can be their last and seize the day. “I think every day has its value. I am very aware that time will never return. […] I try to live in the present” (Respondent 6). However, this awareness that ‘every day can be their last’ can impede them from starting life projects (e.g., searching a new partner): “I turn 76 in two weeks: is it still worth it [to look for a partner]?” (Respondent 10).
    Six, in line with other research (26, 27, 28), faith and spirituality appear to be crucial sources of strength that give inner peace, strength, and support. "I believe in God, in the church. If I did not have that, I would have committed suicide a long time ago" (Respondent 9).
Seven, most respondents find it necessary to have goals (e.g., household tasks, going for a walk) because it gives them energy and makes them feel good. Further, in line with other research (29), activities and interests are also crucial resources that give people energy and form a distraction from adversities. For me it was not difficult [to retire]. They sometimes say so. Nevertheless, I find that those people do not have a lot of activities […]. They might fall into a black hole. If you take one thing, you have nothing left. I have ten other things if you take one thing from me (Respondent 14).
Interactional domain
    The interactional domain concerns how older persons use their social networks to realize goals and give meaning to life. “I get my energy from other people. […] I need people” (Respondent 5). This accords with research from Lee et al. (24) which finds that resilience is positively related to social support. First, positive relations with family and friends are vital because they give practical (e.g., mobility, administration) and emotional support.
    It would have gone entirely different if I did not have them [during her cancer treatment]. […] I am grateful for my friends. […] They are fundamental pillars of support. Every person needs that (Respondent 5).
    An intimate relationship is the second source of strength that gives practical and emotional support and a feeling of love and belonging. Third, professionals can also give practical, emotional, and relational support, which is especially important for isolated persons. One respondent states that he would have committed suicide without a specific professional (Respondent 2). Most respondents express that they feel good when they help others because ‘the power of giving’ results in self-worth and self-esteem and makes people feel needed, valued, and proud. “You cannot always receive; you also need to be able to give. […] When I can do something for somebody else, I am a happy person” (Respondent 5).
    Hereby, reciprocity is essential because a one-directional relationship is out of balance. A respondent explains how his family relations fell apart when he lived in extreme poverty: "Everybody takes their hands off of you because it is one-directional. You cannot give anything back" (Respondent 15). In line with this, most respondents explain that participation in organizations is beneficial because social contact helps to avoid feelings of loneliness and serves as a distraction from sorrows. Similar to others (30), volunteering (as a form of participation) positively affects self-esteem and makes older persons feel helpful. “That you are asked to do various things and be respected for your opinion. [...] I receive everything from that” (Respondent 15).
Contextual domain
    Concerning the broader contextual domain, the respondents mention that social welfare services (e.g., debt mediation, social restaurants) are essential resources. Nevertheless, they state that the cost and access of some services prevent them from receiving the needed support: although several respondents would benefit from professional psychological support, they cannot afford it. Further, various respondents’ mobility limitations prevent them from using public transportation, through which they go out less often, which may result in social isolation. This accords with other research: “the majority of participants felt that the level of access to transportation hindered their social life" (31).
Interaction within and between the domains
    The sources of strength are interrelated within and between the different domains (individual, interactional, and contextual). First, various resources on the individual domain are interrelated: older persons with many interests and activities, for example, seem to have a more optimistic life view and problem-solving behavior. This accords with other research finding that optimism and mastery are positively related to coping (32). Second, the sources of strength on the individual and interactional domain are also interrelated. Indeed, older persons who do not accept their vulnerabilities, for example, have fewer possibilities for social participation, and an optimistic life view seems to be positively related to forming social relations: “If you complain a lot, it has a negative influence on the people you know. […] If you have a positive personality, you will receive much help from people. That is what I experienced myself” (Respondent 5). This accords with previous research that finds that social skills “[…] facilitate the extent to which individuals are apt or able to acquire social resources or support from others, which may then help them cope under stress” (24). Third, sources of strength on the contextual domain also interact with sources on the individual and interactional domain. Indeed, shame can result in older persons not using certain social benefits, and reversely, the accessibility of psychological support may affect individual well-being. Also, the social network may inform older persons about existing benefits, which may enhance their QOL.
Primary and secondary control processes
    The narratives demonstrate that older persons use primary and secondary control processes to deal with adversities. Concerning primary control processes, respondents use their resources to realize goals: respondents with mobility limitations, for example, think in advance where there are benches (to rest) and which routes to take (to walk the least possible). However, some respondents show little problem-solving capacities: a lonely respondent says that he would like to do things for other people but does not know how despite being in good health: "I would not know how I could help them. There are no possibilities for me" (Respondent 2). Nevertheless, older persons sometimes use secondary control processes to adapt goals and desires to a (changed) context. Many respondents are, for example, urged by their financial situation to live economic, but seem to accept those limitations and focus on what they can still do:
    I have a luxurious life. People always want so much more […] In the winter, I put the heating on 18 degrees: that is very low for many people, but I put on a thick sweater. That way, I think I live economically, but I find I live well (Respondent 1).
    Further, health and mobility limitations impede many respondents from doing activities (e.g., visiting family, going to church) and force them to adjust goals. While some find this easy, others experience considerable difficulties accepting their limitations and keep struggling with them through feelings of shame and anger. A particular respondent is angry about his health limitations and has difficulties accepting his vulnerability: “I try as much as possible to accept it, but it is not always easy […] People who do not understand.. […] You simply want to knock his teeth out of his mouth” (Respondent 15).

Discussion
    Older persons use various resources (on the individual, interactional and contextual domain) to deal with (age-related) adversities and to safeguard their QOL (10). Essential resources are an optimistic life view, accepting the own vulnerabilities, the ‘power of giving,' social participation, and social benefits. The latter demonstrates the importance of social policy and contextual factors for resilience.
    This research adds to the literature by showing that not only younger people (12), but also older vulnerable persons mobilize their resources to deal with adversities and safeguard their QOL (33). Further, the narratives demonstrate that sources of strength are interrelated. More research is needed to investigate how these resources interact in the long term since many events in one’s earlier life presumably affect the resources later in life.
    In line with other research (12), resilience appears to be a process that takes time. While some adversities can be resolved quickly, others require psychological adjustments and much time (e.g., accepting own vulnerabilities). "Accepting one's vulnerability or accepting the use of medical devices is not something that the majority of the older people easily deal with. Often, a period of having doubts, being insecure, and considering one's options precedes such a more or less stable situation" (6). Hence, the social network and professionals should realize that older persons often go through various stages when dealing with problems, which requires time. Next, many respondents experience difficulties accepting vulnerabilities (e.g., mobility limitations) and would benefit from accessible and affordable psychological support to learn to accept those vulnerabilities, and increasing their participation. Following other research (9), the narratives also show that ‘the power of giving’ and participation in organizations positively affects QOL because it results in more social contacts and increased self-worth. In line with this, research shows that altruism is positively related to resilience (34) and that helping other people outside the own household relates to less loneliness (9). Therefore, it is essential to counteract contextual barriers that impede participation and volunteering (e.g., through accessible personal transportation or psychological support). Stakeholders can use these research results to create empowering interventions that reinforce the resources of vulnerable older persons, through which their resilience and QOL would improve.

Conclusions
    Vulnerable older persons use various interrelated sources of strength on the individual, interactional, and contextual domains to deal with (age-related) adversities and safeguard their quality of life. Therefore, it is crucial to stimulate important sources of strength such as accepting vulnerabilities, positive social relations, ‘the power of giving’ and social participation.

Study limitations
    This study has several strengths, such as the qualitative research design whereby both authors participated to the coding procedure to increase the (inter-researcher) reliability of the results, the inclusion of older persons from various regions and who experienced a wide variety of adversities. There are also a few limitations to note. First, this study is based on a limited number of narratives of vulnerable community-dwelling older persons in Belgium (n = 15) who were confronted with various adversities, through which the results cannot simply be transposed to other contexts. Therefore, more research is needed to verify if the results are transferable to other contexts. Nevertheless, our findings do cor­respond closely with scientific research conducted in other countries, which indicates the rigidness of its findings (6).

Conflict of interest
    This research project took place within the University Chair Empowerment of Vulnerable Elderly, supported by the private foundation be.Source. We wish to confirm that there are no known conflicts of interest associated with this publication, and there has been no financial support for this work that could have influenced its outcome.

Acknowledgments
    We wish to thank the respondents who provided us with relevant and sensitive information and the social organizations that helped reach them.

Authors’ contribution
Both authors have made a substantial contribution to the concept and design of the article, the acquisition, analysis or interpretation of data for the article.

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Type of Study: Research | Subject: General
Received: 2022/03/1 | Accepted: 2022/05/11 | Published: 2022/06/29

References
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2. Kuyken W, Orley J, Power M, Herrman H, Schofield H, Murphy B, et al. The World health organization quality of live assessment (WHOQOL): position paper from the world health organization. Social Science & Medicine. 1995; 41(10): 1403-09.
3. Staudinger UM. Many reasons speak against it, yet many people feel good: The paradox of subjective well-being. Psychologische Rundschau. 1998; 51(4): 185-97.
4. EUROSTAT. Quality of life: facts and views. Publications Office of the European :union:; 2015.
5. Greve W, Staudinger UM. Resilience in later adulthood and old age: Resources and potentials for successful aging. In: Cicchetti D. Cohen DJ, editors. Developmental Psychopathology. 2nd ed. John Wiley & Sons; 2006. p. 796 840.
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