Life situation and identity among single older home-living people: A phenomenological–hermeneutic study

Abstract

Being able to continue living in their own home as long as possible is the general preference for many older people, and this is also in line with the public policy in the Nordic countries. The aim of this study was to elucidate the meaning of self-care and health for perception of life situation and identity among single-living older individuals in rural areas in southern Norway. Eleven older persons with a mean age of 78 years were interviewed and encouraged to narrate their self-care and health experiences. The interviews were audio taped, transcribed verbatim and analysed using a phenomenological–hermeneutic method inspired by the philosophy of Ricoeur. The findings are presented as a naïve reading, an inductive structural analysis characterized by two main themes; i.e., “being able to do” and “being able to be”, and a comprehensive interpretation. The life situation of the interviewed single-living older individuals in rural areas in southern Norway was interpreted as inevitable, appropriate and meaningful. Their identity was constituted by their freedom and self-chosen actions in their personal contexts. The overall impression was that independence and the ability to control and govern their own life in accordance with needs and preferences were ultimate goals for the study participants.

• Activity
• adaptedness
• freedom
• health
• independence
• self-care actions

The general public policy in Scandinavia is that older people should live a good life in their own homes as long as possible, even with functional declines (St. meld. no. 25, 2006). Likewise, to maintain living independently as long as possible, and manage daily life and routines is important for the older individuals themselves (Linhart, 2010). Several studies conclude that living in their own homes is in accordance with elderly people's own wishes and preferences (Burholt & Naylor, 2005; Dale, Sævareid, Kirkevold, & Söderhamn, 2008; Ryan, McCann, & McCenna, 2009). However, self-care ability and health are shown to be decisive factors for older people to manage daily life in their own homes and to experience life satisfaction (Borg, Hallberg, & Blomquist, 2006; Høy, Wagner, & Hall, 2007). Therefore, it is important to work out what constitutes a good life, and to explore the meaning of health and self-care experiences for perceived life situation, in this group.

Older people's perception of their self-care ability and health is closely related to the maintenance of identity (Calnan, Badcott, & Woolhead, 2006; Roberto & McCann, 2011). According to Nordenfelt (2009), the notion of identity is closely related to and an integrated part of the broader concept of dignity. He considers identity to be one of the most important issues in the contexts of illness and ageing, because of “our attachment to ourselves as integrated and autonomous persons, with a history and a future, with all our relationships to other human beings” (Nordenfelt, 2009, p. 33). He also claims that a person's identity in terms of self-respect may be devastated or altered in illness and the impact of illness in old age, and when a person no longer can act or care for him or herself independently, it may cause a decreased sense of worth. Negative stereotypes of ageism and older people may add to these feelings, i.e., the image of older people as being a burden, being anonymous and invisible, and lacking potential and competency (Nordenfelt, 2009).

Calnan et al. (2006) investigated the meaning and experience of dignity among elderly individuals in their daily life, and found personal identity and autonomy to be the most meaningful aspects for the participants. The dignity of personal identity includes the sense of self-respect, integrity, autonomy, trust and social recognition (Calnan et al., 2006; Woolhead, Calnan, Dieppe, & Tadd, 2004). On the other hand, having a positive attitude towards personal ageing may work as a protective source, according to vulnerability and negative stereotypes, and Calnan et al. (2006) explain that this occurs when changes in physical functioning are gradually incorporated into the persons’ identities so that they are able to retain self-esteem despite health limitations. Linhart (2010) showed how the older women in her study did not perceive themselves as old at all, and that their age and ageing process was an important issue in their life. Fagerström (2010) also found that a positive life-orientation was a decisive inner resource for health and well-being for individuals with advanced age, including having a meaning in life and the ability to look forward and still have plans for the future. Older people also tend to have an internal focus in the last phase of life, to reflect on their life as a whole and appreciate small things in their daily life (Andersson, Hallberg, & Edberg, 2008).

Older persons’ age-identity, i.e., how old they actually feel, is described to be more related to their physical health and functional status than to their chronological age (Bowling, See-Tai, Ebrahim, Gabriel, & Solanki, 2005). Moreover, older people tend to maintain their identity by adjusting their expectations and regulate and limit activities according to their health conditions (Roberto & McCann, 2011). Identity is also closely related to a person's different roles, and because these roles change with increased age, it may represent a lot of challenges for those involved. For example, Barnes and Parry (2004) discussed the implications of gender differences for the experience of roles and identity after retirement. Their study showed that men were less comfortable with their retirement life than women. In addition, the persons who achieved the most satisfying life situation were those who continued to live an active life and continued to have social relationships and networks outside the family.

Other factors shown to be essential for older people's sense of identity and well-being are the meaning of, the security from, and the attachment to their place of residence (Wiles et al., 2009). This includes the domestic environment as well as the place of residence, a sense of belonging and trust, and the neighbourhood (Theurer & Wister, 2010; Wiles et al., 2009).

Although the living conditions in general diminish when people grow older, Gaymu and Springer (2010) claim that it is a paradox that older people's life satisfaction, or subjective well-being, is only partially affected by this fact. These authors argue that an objectively difficult life situation does not necessarily produce a negative life view, and that comparisons between age groups have shown that older people are at least as satisfied with their life situation as younger people are. In general, older women have less favourable living conditions than older men; because they live longer with poorer health, are more often widowed and live alone, and they have lower financial incomes, among other things. Despite these conditions, women report only a slightly worse life situation (Gaymu & Springer, 2010).

Three main environmental factors are said to be crucial for facilitating home-living to the end of life; the physical environments, the material environments, and the social environments (Rolls, Seymour, Froggatt, & Hanratty, 2010). Elderly people living alone are a vulnerable group regarding residential and social isolation, and they tend to have more difficulties with carrying out daily life activities because they lack the benefits from sharing life with a co-resident (Gaymu & Springer, 2010). Living alone is more likely to cause social isolation, especially among those in the oldest age-group and those without children (Banks, Haynes, & Hill, 2009). Living alone is also related to poorer physical and mental health conditions, and insecure finances (Gaymu & Springer, 2010).

Aim

The aim of this study was to elucidate the meaning of self-care and health for perception of life situation and identity among single-living older individuals in rural areas in southern Norway.

Methods

A phenomenological–hermeneutic approach was used to understand and interpret the meaning of self-care and health experiences linked to the participants’ daily life. The participants were, by way of an interview, asked to narrate their experiences about self-care and health, and the impacts of these experiences for their perceived life situation and identity.

Participants

This study is part of a larger project among home-dwelling people in rural areas in southern Norway who were 65 years old or more. Forty single-living people, who in a previous study within this project were found to have good self-care ability and perceived themselves to be in good health (Dale, Söderhamn & Söderhamn, 2012), were invited by letter to take part in a qualitative follow-up interview. Eleven people gave a written informed consent to participate. Characteristics regarding sex, age and marital status of the informants are shown in Table I. In addition, all of them lived in rural areas, six of them lived in their original homes, while four had recently relocated into more or less accommodated apartments. All the informants perceived that they had, in general, good subjective health. Eight of them managed their daily lives independently, two of them received home help twice a month, and one of the informants received home nursing regularly for personal self-care assistance.

Table I. Characteristics of the informants in the study.

Informants	Sex	Age	Marital status
A	Male	78	Widowed
B	Female	79	Widowed
C	Female	83	Widowed
D	Female	69	Widowed
E	Male	74	Widowed
F	Male	78	Widowed
G	Female	85	Widowed
H	Female	81	Divorced
I	Female	77	Widowed
J	Female	81	Widowed
K	Female	73	Divorced

Procedures and context

Written consent to participate in the study was received before the informants were contacted by telephone to make an appointment for an interview. The interviews were conducted by the first author between December 2010 and June 2011. All interviews were conducted in the persons’ own homes and lasted up to 60 min. The interviews were audio taped, in agreement with the interviewees.

The following open question was asked initially: “Please tell me about a situation where you experienced the meaning of self-care and health for your life in general”. Subsequently, open follow-up questions were asked, inviting them to deepen their narratives. Some of the informants narrated one or more particular situations, while others talked about their self-care and health in more general terms.

The interviews were transcribed verbatim, and all the authors analysed the text by use of the phenomenological–hermeneutical method developed by Lindseth and Norberg (2004), which is grounded in the philosophical assumptions described by Ricoeur (1976). According to Ricoeur (1976), the interpretation of a text begins with the grasping of the text as a whole, or what the text says. Thereafter, a deeper understanding is sought by recognizing the relationships between the parts and the whole of the text, or what the text talks about. This process also assumes that the text is objectified and separated from the narrators (Ricoeur, 1976), i.e., the text is autonomous and expresses its own meaning (Lindseth & Norberg, 2004).

All the authors have background as registered nurses and have several years of experience as health researchers.

Ethics

The study was approved by the Regional Committee for Medical Research Ethics (REK Sør-Øst D, 2009/1299). In addition to the written informed consent, information about the study was repeated, and the voluntariness for participating in the study and confidentiality was assured regarding the informants legal rights prior to each interview (Beauchamp & Childress, 2009).

Data analysis

The phenomenological–hermeneutical method used in this study includes the understanding of the meaning of lived experiences as narrated by the interviewees, and thereafter a hermeneutic interpretation of the written text as an autonomous entity that expresses its own meaning (Lindseth & Norberg, 2004).

First, the interviews were read several times to grasp an initial meaning of the text as a whole. In this phase, referred to as a naïve reading, it is necessary to be open and to let the text speak to us and that the text is formulated in a phenomenological language (Lindseth & Norberg, 2004). Next, an inductive thematic structural analysis was conducted, searching to identify and formulate themes that validated the initial understanding. The major steps in the structural analysis were:

• To outline meaning units in the text.

• To condense the meaning units in the text.

• To interpret it further into subthemes and themes.

All the steps in the structural analyses included a continuous reflection against the initial naïve reading of the text and the purpose of the study.

In a final phase, the comprehensive understanding, the naïve reading together with the themes and subthemes from the structural analysis were reflected on in relation to the aim and the context of the study, the authors’ preunderstanding and relevant theory and research literature and, finally, interpreted as a whole (Lindseth & Norberg, 2004).

Findings and presented comprehensive understanding

Naïve reading

The naïve reading of the text gave an impression of that the single-living elderly people in good health with good self-care ability narrated a perception of life situation and identity characterized by the ability to independently manage daily life in their own homes, having freedom to realize wishes and dreams, and having a positive and enabling view of life. They were engaged in physical and mental activities, having a sense of security and peace of mind, having a religious faith, the ability to rest and enjoy one's own company, enjoying contact with the nature, and having contact with and being valued by family, neighbours and friends.

Structural analysis

Two main themes and seven subthemes emerged from the structural analysis of the text, reflecting the meaning of self-care and health for perceived life situation and identity in the study group. The main themes were labelled as “being able to do” and “being able to be”, reflecting the informants’ general emphasis on the ability to act independently and to feel independent. The three subthemes included in the theme “being able to do” were labelled as: “performing goal-directed self-care actions”, “finding a balance between social interactions and solitude” and “finding a balance between activity and rest”. The four subthemes included in the theme“being able to be” were labelled as: “being conscious about maintaining own health”, “being independent and feeling free”, “being attached to own home and surroundings” and “having and using internal resources”.

Examples of the structural analyses from meaning units to themes are presented in Table II.

Table II. Examples of the structural analyses from meaning units to themes.

Meaning units	Condensation of meaning units	Subthemes	Themes
“…, but then, when I am not able to find a comfortable position in my bed, I get up and adjust this armchair into a comfortable position, and I may sleep here for several hours” (Informant J)	Using alternative means to adjust	Performing goal-directed self-care actions	Being able to do
“I plan my days, do all the shopping and cooking my own food” (Informant A)	Performing necessary activities of daily living
“I do all the domestic work by myself, inside and outside the house. House cleaning, lawn moving, snow shoveling, painting; I do it all … and I am proud of it” (Informant D)
“I think that I was born with a cheerful mood! I have been positive all my life”(Informant C).	Having a positive life disposition and attitude	Having and using internal resources	Being able to be
“I try to see things in a positive way. Of course, I have had my tough times, but I have always been good at pulling myself together” (Informant B)
“My testimonial is my lived life. That is why I understand other people, because it has not always been a bed of roses. So that's what I have to give, life experiences and an empathy to others who have not been so lucky in life” (Informant H)	Using former experiences for supporting others

Being able to do

Performing goal-directed self-care actions.

Performing regular daily activities, both personal and domestic tasks, was emphasized by all the participants, and many of them put a lot of efforts to manage independently, which was the ultimate goal. To get up every day, preparing food and doing necessary inside and outside domestic work represented a great personal satisfaction. The ability to continuously adjust the performance according to current capacity was important, including taking the consequences of the actual health limitation. An informant with serious diseases said:

I prepare my own food. Although I use twenty minutes to make coffee and pour it into the coffee pot, and thereafter place myself in a good chair, it is a great satisfaction for me to manage it on my own. (J)

The ability to adjust also included being aware of undesired side-effects of medication or bodily symptoms and limitations, contacting health personnel when needed, and using means like assistive devices in their daily life. Some of the informants had developed alternative action repertoires for controlling bodily symptoms:

I have a lot of back pain. But then, the best medicine for me is to take a walk in the wood or to do some outside homework. I have experienced this to be a nice and effective way to get rid of the pain. At the same time I do something useful. (A)

Finding a balance between activity and rest.

Being regularly engaged in different physical and mental activities was highly emphasized by all the recipients for having a good and meaningful life. Without exception, they all pointed out the importance of activity for maintaining health. In addition to carrying out necessary homework, many of them did other exercises regularly. The physical activity level varied, but many of them enjoyed walks at least weekly, often in the woods. Some of them were engaged in dancing groups or exercise groups for older people, and one woman attended a normal fitness studio. Some of the informants were engaged in parish work, which provided them with a lot of pleasure. In addition to the positive effects on the body, these activities also included social benefits. Performing mental and sedentary activities, like crosswords, reading, needlework, watching TV and being on-line with the computer was also important. At the same time, the informants were aware of the necessity to rest and pick up strength. A good night's sleep or having a nap during the day time provided energy, and prevented fatigue. Being able to just sit down in a comfortable chair and doing nothing could bring peace of mind. Consequently, the ability to have an appropriate activity level in balance with the need for rest and quiet was assumed as a prerequisite for a good life situation.

Finding a balance between social interactions and solitude.

Nearly all the informants mentioned social relationships and interactions with family, friends and neighbours as one of the most important factors for having a good quality of life. The frequency of contact with other people varied a lot, including contact with the family, which in most cases was represented by children and grandchildren. Some of them had daily contact with family members, while others had mainly telephone contact. Many of the informants had also regular contact with friends and neighbours and enjoyed valuable relationships. Taking walks, doing leisure activities and travelling with friends was associated with great pleasure, and being a part of a religious community meant a lot to some of them.

The reciprocity in social relationships seemed to be important, by means of being useful to and valued by others:

I am so lucky to have my children and grandchildren. They visit me several times a week, and give me much pleasure. The grandchildren come to me after school, and they often stay overnight. I give them food and wash their sweatshirts. I feel that they have a good time here with me, and their parents are grateful. (D)

Nevertheless, the ability to be alone was appreciated as well. The informants told that they were comfortable with own company and enjoyed solitude from time to time:

I am used to and enjoy being alone. I like it best this way. I do not feel lonely, and if that is the case, I take a drive in my car and visit my children. (A)

I enjoy being alone, very much! I like making a good meal and enjoy the food and a nice glass of wine in my own company. I was used to having other people around me all the time, but now I have learned to appreciate solitude. (B)

Consequently, although social relationships and interaction emerged to be essential factors for perceiving their life situation as satisfactory, many of the informants also appreciated solitude at times in between. Therefore, the ability to adjust and balance the need for social relationships and the need for solitude seemed to be important to them.

Being able to be

Being conscious about maintaining own health.

All the interviewees talked a lot about how important their own health was for experiencing life as satisfactory, and their narratives indicate that this was the most prominent factor. Most of them were in good physical condition and had few problems with managing their daily life. They expressed a lot of gratitude for having the opportunity to get up every day and feel well, but they were also aware of the importance of their own efforts for maintaining good health and independence. Good health should not be taken for granted in old age, and by comparing themselves with many other older individuals they acknowledged how lucky they were:

My health means everything to me! They say to me that I am lucky to be in such a good health. But then I use to say that I do a lot of things for it myself…. (B)

On the other side, many of the informants expressed concerns about gradually becoming more declined in the future, and consequently being more dependent on help from others. Most of them were particularly concerned about the possibility of being cognitively impaired, and thereby losing the ability to make their own decisions and control their life, e.g., “… other things don't matter as long as my head is clear.” (E)

Thus, they stressed the importance of being engaged in mental activities to maintain intellectual capacity and prevent declines in cognitive functions. Nevertheless, although a declined health represented a threat, some of them felt that having available help if needed in the future represented a sense of safety.

Experiencing independence and freedom.

The value of independence was emphasized by all the interviewees. Being independent included not only the ability to care for themselves, but also the possibility to organize one's own time schedule, to get up and go to bed whenever they wanted, and having the opportunities to travel and perform leisure activities in accordance with own preferences. Driving one's own car was important for feeling free, and for some of them, losing their driving license had caused a lot of restrictions and increased their dependency on others in their daily life. Having satisfactory financial income was another factor related to a sense of independence and freedom, e.g., having the economic resources to travel or to buy something nice for themselves or their grandchildren.

Although losing a spouse or a partner involved a feeling of loss and sadness, being widowed was also associated with a sense of independence and freedom. Being relieved from heavy care-burdens, maybe after many years, provided new possibilities for self-realization and control over their own life. An informant, who had lost her husband after a long period of illness and heavy care-duties, said:

I have had a great life after being widowed. Earlier, I always had to think of my husband first and last, I was tied up and had few possibilities for self-attendance and spare time. I was completely self-sacrificing. When I was widowed it was suddenly different, I was myself, at last! (B)

However, this was not the general picture. The care-giving role had also involved pleasure to some degree, and a sense of being useful and having an important mission in life, and the feeling of freedom and relief after being widowed gave a sense of guilt and bad conscience.

Being attached to the home and surroundings.

The informants’ self-care abilities and their health had an influence on their living arrangements. The home and the place of residence represented an important part in the perception of having a good life situation. Living in their original homes, where they had settled down as married, provided a vital core for preserving identity among many of the participants. Their home represented a vital core for how they perceived themselves as persons.

Some of the informants had recently moved into a more convenient place of living, either to a private flat or a sheltered house. Their experiences related to this transition varied, depending on the causes and their preferences for moving. An 85-year-old woman who had to relocate from a small farm into a municipal sheltered house told how she was constantly home-sick. Although realizing the need for relocation because she could not keep up with the former residence, she had lost her “home-feeling” and tiding up her new home gave her no pleasure or motivation. She had the feeling of becoming another person because she had lost her roots, and that a part of her was left behind. However, the outcome of such relocations varied. Two other women who had experienced similar situations were quiet happy with their new homes and the surroundings. They had been on a waiting list for a sheltered flat for a long time, and they associated the new living arrangement with increasing the possibilities to manage independently and to make new friends in the neighbourhood.

One of the informants, who had “voluntarily” moved from a big house with an enormous garden into a small private flat, expressed a lot of pleasure about the changes. He said:

I really enjoy living here. In the summer evenings, when the weather is nice, I only sit on my balcony and having a good time. And the birds are visiting me, you know. Later on, when it is getting dark, the sea is calm … and the lights from the bridge … it is just so beautiful! I am so happy here, I couldn't have it better. (F)

Because the interviewees lived in rural areas, many of them also lived close to nature. They found much pleasure with watching and feeding the animals. The birds, foxes and deers provided much company. Some of the informants lived quite out-of-the-way, but none of them expressed fear or felt threatened. Having a pleasant neighbourhood represented a source of safety, and was regarded as an important recourse for reciprocal assistance and support.

Having and using internal resources.

Personal dispositions and former experiences meant a lot for how the informants perceived their life situation and who they were as individuals. Many of them described a positive life attitude to be a major resource for maintaining their health and for having a good life. A positive attitude included using humour as “a good laugh could extend one's life”. Being self-ironic could be a resource. An informant who had undergone chemotherapy after cancer met a former acquaintance. She told about their conversation:

… and then she said to me: “oh, now your hair looks so untidy”. And then I said: “Yes, I am aware of that. But you know what? I am so happy to have hair at all”. (C)

Many of them told about their childhood or youth, and that they had always been used to managing and taking care of themselves in many ways. Consequently, they had developed valuable internal strengths and resources which could be useful in older age. Many of them commented that “it is not about how you are, but how you take it”.

Having experienced tough periods and events earlier in life was viewed as an internal resource, because they had resulted in improved insight and wisdom. In addition to the impact of these experiences on their own personal growth and ability to manage, they also represented a source for supporting other people. The woman cited above, who had experienced much illness and hard times, described how she had used these experiences to comfort and advise other people in similar situations. In general, the sense of being useful to other people was emphasized by many of the informants.

Nearly half of the interviewees described the meaning and importance of having a religious belief. Having faith in God, having “a hand to hold” and a higher power to lean on gave them comfort and strength, particularly in hard times.

Comprehensive understanding

The informants were industrious individuals, who seemed to have found a successful solution on their, according to Erikson's theory of psychosocial development of the human life cycle (Erikson, 1997), age specific psychosocial crisis with a basic acceptance of life as inevitable, appropriate and meaningful. This wisdom was grounded in their acting self (Ricoeur, 1992). By managing paradoxes in life, they found a meaningful balance and were in their lives independent and free. Freedom is a condition of action (Sartre, 2003), and they acted in ways that maintained and enhanced their health. They were attached to their rural surroundings and actualized their potentialities.

The life situation of the informants was interpreted as inevitable, appropriate and meaningful. Their identity was constituted by their freedom and self-chosen actions in their personal contexts.

Reflections

The aim of this study was to elucidate the meaning of self-care and health for perception of life situation and identity among single living older individuals in rural areas in southern Norway. In a life situation that was interpreted as inevitable, appropriate and meaningful, health could be viewed as human development or becoming (Parse, 1998) and expanding consciousness (Newman, 1999).

The participants were all active, in perceived good health and seemed to have reached a positive solution in their psychosocial development with wisdom as an outcome in old age. Here, wisdom rests in the capacity to see, look and remember (Erikson, 1997). The text talked about the importance of “being able to do” and “being able to be” for how the informants’ life situation in general was perceived. According to Blaxter (2010), popular definitions of health often are discussed in terms of having, doing and being.

The two themes are interrelated, because the ability to do, or to perform certain actions, is closely related to the individual's personal constitution, values and attitudes in life. In the next section, the notions of abilities to have and to be, respectively, are deepened and discussed in light of relevant theories and research.

In this study, both an action-theoretic approach and a phenomenological approach are used regarding the concept of health. The action-theoretic approach, as described by Pörn (1993) and Nordenfelt (1995), is used together with the phenomenological views of, among others, Toombs (1993), Parse (1998), Newman (1999) and Sartre (2003). According to Pörn (1993), the individual is viewed as an acting subject and the most important is his or her abilities to perform certain actions. The significance of activity, and the ability to perform actions for the maintenance of self-care and independence, was highly emphasized by the informants in the present study. Pörn (1993) describes three components to be decisive for the ability to act; the individual's act repertoire, the environments in which the person acts, and the goals for his or her actions. Thus, a person's ability to act deals with internal and external constituents, including intellectual and physical capacity, for making decisions and performing actions to determine desirable goals under prevailing circumstances (Pörn, 1993).

Nordenfelt (1995) is saying that a person is healthy if, and only if, he or she is in a bodily and mental state in which he or she is able to attain certain sets of goals in life. An ultimate goal in life for the informants in the present study seemed to be the maintenance of independence in their own homes as long as possible, and obviously, they put a lot of strength in achieving this goal. They were aware of the necessity to utilize their own internal resources, or their repertoire, for maintaining self-care and health. Having a positive attitude and the strength to carry on even in hard times was narrated by many of them, and, likewise, the benefits of using former experiences and lessons learned when they met new challenges. In this sense, they used their personal strengths, or their “ability to be”, for performing actions, or the “ability to do”. Corresponding findings were reported by Linhart (2010), who found that being able to be was even more important for maintaining independence among older alone-living women than being able to do.

In addition to the internal resources, the informants in the present study were also aware of using different kinds of physical, or external, environmental means to adjust or adapt to their actual health conditions, life situations and the maintenance of independence. The notion of adaptedness is described by Pörn (1993) to be the relationship between the individuals’ repertoire, his or her environment and goal profile. According to him, being in a state of general adaptedness means that the repertoire has to be adequate, the environment has to be appropriate, and the goal has to be realistic.

A holistic approach to the health concept was fundamental in this study, because health was viewed not only as the absence or the presence of diseases. Rather, the individual's own views of how he or she actually perceived his or her health, and the meaning of the subjective health experiences in daily life, was crucial (Nordenfelt, 1995; Pörn, 1993). Declined health is far more than diagnoses, symptoms and treatments; it is the loss of ability and the interruption of harmonic, easy and unmindful living (Dahlberg K, Dahlberg H, & Nyström, 2008; Toombs, 1993). According to Gadamer (1996), our health does not present itself for us when we are healthy and experience well-being, because we have a natural attitude to our subjective body and take it for granted. Rather, Gadamer (1996) says, it objectifies itself through illness and the restrictions related to illness. This phenomenological approach to the health phenomenon refers to the person's experiences of the lived body, as described by Sartre (2003), and the body is present in every action, although invisible. In the same way as Sartre (2003) describes it, Nordenfelt (1995) claims that the individual's performed actions are intended and conscious, and directed towards achievable goals.

As we have described, experiencing independence and freedom was emphasized by the informants in the present study. A central theme in Sartre's philosophy is that of freedom (Morris, 2010; Sartre, 2003). He claims that our original choice, related to what he calls “our project”, creates all reasons and motives for actions, and that it is this which arranges the world with meaning. Further, he claims that we are defined by our values, and our choices constitute our values. Thus, the ability and the opportunity to choose are fundamental for our experience of freedom as human beings. This was also underlined by many of the informants as they expressed the importance of being free to realize their own plans and to organize their own time schedules.

The findings from this study may also be viewed in light of sociological aging theories. The “activity theory” postulates that a successful aging indicates that staying active is necessary for maintaining life satisfaction and a positive self-concept (Havinghurst, Neugarten, & Tobin, 1963). In this sense, activity is viewed broadly as physical and intellectual, and even with illness and advanced age, the older person can remain active and achieve life satisfaction. The findings in our study support the assumptions in this theory. All the informants emphasized the meaning and importance of being physical and mental active and engaged for having good health, a positive life situation and interactional relationships.

In contrast, the “disengagement theory”, postulates that older people prefer to withdraw from the society, to decrease their interactions with others, and to be more self-centred persons (Cumming & Henry, 1961). Although the informants in the present study wanted to stay active and engaged, the assumptions inherent in this theory were, to some degree, also supported in the present study. Being able to sit down, enjoying peaceful times and thinking of life as a whole, was described as essential for some of them. Being physically, mentally and socially active was highly emphasized by the informants in this study, but the narratives also concerned the value of having “peace in mind” and the opportunity to consider and reflect on one's life.

The “continuity theory” dispels that the latter part of life is a continuation of the earlier part, and an integral part of the whole life cycle (Havinghurst et al., 1963). Thus, this may present a developmental theory, meaning that older people try to continue former preferences, habits, values, and so on, that have contributed to shape who they are as persons. The findings in this study also showed that previous experiences had contributed to the informants’ personal development. The way in which they were used to carry out self-care activities, their health habits, and their values and attitudes in life, had an impact on how they handled their current life situation. To continue to use personal resources was important for managing their own life, but also for supporting others. Narratives concerning self-awareness and the appreciation of being a resource for their family, friends and neighbours were presented.

Health is important for the construction of identity among older individuals, and particularly the perceived embodied, aging and social selves for their everyday health (Roberto & McCann, 2011). Being aware of and having a positive attitude towards one's own aging body may work as an essential protective resource for maintaining one's self-concept and identity, despite existing negative stereotypes in the society (Calnan et al., 2006). Personal identity may be understood as “who I am”, or the sense of what kind of person I am, and it includes the personal characteristics, perceived interpersonal relations and motives, and group identity (Dittmann-Kohli, 2005). Identity includes our attachment to ourselves as integrated and autonomous persons with our history and our future (Nordenfelt, 2009). Although they were aware of their advanced age and health limitations, the informants in the present study emphasized their abilities and possibilities, and in general they expressed who they were as individuals. They expressed satisfaction due to the opportunity to live as autonomous, enabling individuals. They also expressed how important their home and their residential environments were for their life situation and identity, and thereby underscored the importance of their health and self-care ability to remain living at home. Especially for older people, the home has a special meaning because it represents their resources and their identity (Daatland et al., 2000). The particular life story of an individual creates linkages that tie this person to a place, and a stable relationship to a place enhances the continuity of independence and the feeling of competence and attachment (Hays, 2002).

Methodological considerations and conclusion

As stressed by Lindseth and Norberg (2004), narrated text may be understood and interpreted in various ways because it has multiple meanings. Thus, the present interpretation is only one of many possibilities, and should be viewed as a contribution to the existing knowledge of older people's lived experiences. The narratives provided rich descriptions of the meaning of self-care and health for perceived life situation and identity among the participants in this study, and similarities as well as variations in the studied phenomenon were recognized. Being in good health was among the criteria for participating in the study, which may be one explanation of the many positive attitudes and experiences in the narratives. On the other side, living alone is considered to be a risk factor for older people's physical and mental health conditions, and consequently for their life situation, which seemed to be of importance for the informants in this study.

It is possible that single individuals develop their self-care ability more consciously than people who are used to living with other people. This has to some degree been indicated in quantitative research (Söderhamn, Lindencrona, & Ek, 2000), where lower self-care ability has been associated with close contacts with other people.

The identity of the single living older persons living in rural areas in this study was meaningful, inevitable and appropriate in the light of what they were able to do and what they were able to be. Doing and being constituted health in their lifeworld. The overall impression was that independence and the ability to control and govern own life in accordance with needs and preferences were ultimate goals for the study participants.

The themes and subthemes that emerged in the structural analysis are partly described in the literature, which also partly confirm the credibility of the findings. It also seems reasonable that the findings are possible to transfer to other similar groups of older home dwelling people. All together, we claim that the trustworthiness of this study is warranted to a high degree.

Clinical implications of this study are that older single living individuals should be supported in their self-chosen activities, and health care personnel should be aware of their personal context, and their freedom of choice in life situation and daily living. This may imply different attitudes for nurses and other health care professionals and politicians in their views of older people. Traditionally, there has been a tendency to regard older people as vulnerable, inactive, lonely and help-dependent, especially those who are living alone. Despite the limited number of participants, the present study revealed that elderly people may have many internal and external resources which are important. Instead of the needs- and problem-focused approach, which is often used with older people, health professionals should emphasize, ask for and utilize their resources to a greater extent.

Conflict of interest and funding

The authors report no conflicts of interest in this work.

Acknowledgements

The study was carried out with financial support from the Research Council of Norway (project number 18785). The informants are thankfully acknowledged.