Personal strengths reported by people with chronic illness: A qualitative study

Abstract Background Self‐management of chronic illness can be highly demanding and people need to mobilize their personal strengths to live well with their condition. More knowledge is needed about how people with chronic illness perceive and use their personal strengths as a basis for better integrating empowering person‐centred approaches into health care. Objective To explore what people with chronic illness describe as their strengths relevant to their health and well‐being. Setting and Participants Thirty‐nine participants (11 men) from 4 outpatient self‐management programmes were recruited to individual or group interviews. Participants included patients with chronic respiratory disease (n = 7), chronic pain (n = 18) and morbid obesity (n = 14). Interviews were analysed using content analysis. Results A number of personal strengths were reported and categorized into 3 domains: (i) Internal strengths, (ii) External strengths and (iii) Self‐management strategies. Internal strengths included being persistent, having a positive outlook, being kind and caring, experiencing positive emotions, being kind towards oneself, reconciling oneself with the situation, having courage and having knowledge and insight. External strengths included support from family, friends, peers and health‐care providers. Self‐management strategies included being active, planning and prioritizing, reducing stress, goal setting and seeking knowledge and help. Discussion and Conclusion The study provides insights into personal strengths as reported by people with chronic illness. The results complement prior findings on strengths in people with health challenges and can aid in incorporating person‐centred approaches into health care.


| INTRODUCTION
Self-management involves the tasks people with chronic illness must undertake to live well with their condition. 1 These tasks can be demanding, as people need to learn about their condition and medications, manage their symptoms and emotions, as well as making recommended lifestyle changes. 1 An essential process to learning to live well with chronic illness is to find and use one's own strengths or health assets. 1,2 Health assets have been described as the repertoire of potentials-internal and external strengths-that mobilize positive health behaviour and promote health and well-being. 3 Examples of internal strengths are optimism, sense of meaning in life, acceptance, positive emotions (eg gratitude, hope), self-esteem and self-efficacy. [4][5][6][7][8][9][10][11] Examples of external strengths include a supportive family, neighbourhood and institutions, and stable socioeconomic status. 3,5,6 Using strengths in the face of chronic illness nurtures resilience, a successful adaption to adversity. 7,9 Strengths may be part of general resistance resources, a core element of salutogenesis, focusing on the individual's power to heal. 3,12,13 Traditionally, patients' strengths have not been the centre of attention in health care. The focus has been more directed towards pathology, deficits and risk factors. 14,15 Within care for people with chronic conditions, this is slowly changing with an increasing attention to strengths and resilience in social work, 14 nursing, 16 mental health care, 14,17,18 psychology [19][20][21] and medicine. [22][23][24] Also, self-management interventions are increasingly designed to empower and mobilize personal strengths, in addition to providing education. 1,25 Further, a shift in focus towards strengths is very much in line with a personcentred care approach, a holistic view of patients and the concept of empowerment. 14,26,27 Despite an increased recognition of patients' strengths, in regular clinical practice patients' strengths may still often be neglected by those caring for people with chronic somatic symptoms. 11,28 Awareness and activation of one's own strengths can be challenging for patients when unpleasant symptoms and emotional consequences may overwhelm and compete for attention. 13,29 Health-care providers therefore play a crucial role in helping patients to identify and bring their attention to their strengths, which can build and broaden their capacities and empower them to take positive action. 13,30 Examples of strategies to help health-care providers support people with chronic illness in exploring and mobilizing their strengths include training in communication techniques (such as motivational interviewing 31 or the communication habit model 22 ) and methods to assess strengths with assessment scales. 17,32 In addition, interventions aiming to prepare patients for consultations can lead to more active engagement during clinical encounters. 33 For example, digital preencounter communication interventions that help patients prepare for a conversation about their symptoms and problems were found to have positive effects on communication and consultation quality. 34,35 However, interactive digital interventions that support patients in exploring and reporting their strengths in a clinical setting are generally still lacking. Such interventions may help people become more aware and reflect on their strengths, at their own pace and convenience, in preparation for a consultation. 36 The study presented here is part of a larger research project with the main objective of developing a digital communication intervention to help patients become aware of and engage their strengths in illness self-management, and thus to assist patients and their care providers in building on the patients' strengths during their consultations. While the body of literature on strengths relevant to health and well-being is expanding, there is no systematic review or consensus on which strengths to include in such an intervention for people with chronic illness. To help patients recognize their strengths, the items in the intervention should reflect patients' actual experiences and perceptions. The results of this study will be used to formulate examples of strengths that can be included in the digital intervention.
The study reported here was thus conducted to answer the following research question: What do people with chronic illness describe as their strengths relevant to their health and well-being?

| Sample and setting
The study was approved by the Regional Committees for Medical and Health Research Ethics in Norway and by the Privacy Protection Committee at the Oslo University Hospital.
A total of 39 participants from 4 outpatient rehabilitation or selfmanagement programmes in specialized health care were recruited.
A purposive sampling procedure was used to select information-rich participants of both genders. People with 3 different chronic conditions were included. People with these particular conditions were included for 2 reasons: (i) all required long-term self-management and (ii) purely practical reasons, such as access to patients whose care providers were willing to collaborate and help in recruitment.
Participants with respiratory disease were recruited from a pulmonary rehabilitation programme. Participants with chronic pain conditions were included from 2 pain clinics, and patients with obesity were recruited from a programme that was mandatory as a preparation for bariatric surgery. Inclusion criteria were as follows: (i) diagnosed with a chronic illness and being enrolled in rehabilitation or self-management programme, (ii) >18 years old, (iii) able to speak and understand Norwegian and (iv) willing to share personal experiences about living with chronic illness. Clinicians at the recruitment sites identified eligible participants and informed them about the study.
The clinicians collected names and phone numbers of those who expressed interest in participating. The authors (OBK and US) who received the lists of names contacted each person to schedule a focus group meeting or an interview. All interviews with patients were held in conference rooms at Oslo University Hospital. Participants received information about the purpose of the study, the voluntary nature of participating and maintenance of confidentiality, and gave their written informed consent. All participants were primarily invited to participate in a focus group but if they were not able to attend a focus group, they were invited to a pairwise or individual interview.
In this manner, data could be obtained from all who had consented to participate. All interviews were audiotaped.

| Procedures
The study builds on the research group's previous work on patient strengths. This includes a concept analysis, 3 and studies of strengths from the perspective of people with or recovering from cancer 11 and health-care providers in cancer care. 37

| Analysis
Data were analysed using qualitative content analysis. 38

| Participants
Demographic characteristics of the 39 participants (11 men) are provided in Table 1. Participants with chronic pain reported various conditions, for example fibromyalgia, arthritis, neuropathic pain and complex pain syndrome. Information about symptom severity or duration of illness was not collected.

| Reported personal strengths
Reported personal strengths were categorized into 3 broad domains:

| Category 1: internal strengths
Descriptions of personal qualities and positive emotions were categorized as internal strengths.

Being persistent
A repeatedly reported strength was related to persistence. Participants described having a drive, not giving up, being stubborn and giving all they have as important positive characteristics. Some reported that feeling in a good mood was a strength.

T A B L E 1 Participants' demographic characteristics and conditions
Participants also reported that they paid attention to things that were working well in their life despite the illness, and that being appreciative of and grateful for the good things in life, and looking forward to pleasurable events was a strength. A few participants talked about being appreciative of the benefits of being ill, for example learning to know oneself better and growing as a person.

Being kind and caring
Being kind, caring or helpful to others was reported as a strength

| Category 3: self-management strategies
When participants were asked about their strengths, they also reported a variety of strategies that helped them promote health and well-being. Examples of strategies that were commonly mentioned were as follows: be active, exercise, reduce stress and get enough rest. Other strategies were as follows: to take things slowly, plan and prioritize, set and adjust goals, and work towards these goals.

(Participant with chronic pain)
Participants also talked about strategies for handling stress, such as seeking knowledge and help when needed, various methods for managing difficult thoughts, using humour, as well as seeking out people with similar experiences and concerns to share with and learn from.

| Summary of results
The study provides examples of how strengths are perceived and reported in the context of chronic illness. Participants described a broad repertoire of personal strengths that we categorized as internal and external strengths and self-management strategies. Internal strengths included persistence, positive outlook, kindness towards oneself and others, acceptance, courage, positive emotions and also knowledge and insight. External strengths included supportive relationships with family, friends, peers and health-care providers. Self-management strategies included keeping active, planning and prioritizing, reducing stress, goal setting and seeking knowledge and help.

| Personal strengths
The present study indicates that when asked about their strengths, and with appropriate prompts, people with chronic illness report processes similar to that have been described in the literature to promote successful self-management and resilience. These include knowledge and insight, positive emotions, optimism, sense of purpose, active coping and social support. 2,7,9 In a study on personal strengths in people with or recovering from cancer, good mood, mindfulness, willpower, positive relations, hopes and beliefs, protection and taking action and control were reported as strengths. 11 Our results are very much in line with these findings. However, some differences were found as people with chronic illness in the present study also described acceptance, kindness and care, as well as a range of positive emotions as strengths.
When asked about their strengths, participants did not only talk about internal or external qualities but also about their selfmanagement strategies or behaviour (such as health-promoting activities and behaviour promoting positive emotions). Health behaviour can be viewed as a consequence of mobilization of personal strengths. 3

| Salutogenesis
Salutogenesis is a widely used theoretical construct underlying personal strengths and health assets. 3 The salutogenic approach contributed to a shift from a pathogenic focus on risk factors for diseases to a focus on salutary factors, that is strengths and determinants for health. 12 In salutogenesis, the major salutary factors, referred to as the generalized resistance resources (GRRs), have been specified as biological, material and psychosocial factors, for example money, knowledge, experience, social support, culture and intelligence. 39 The degree of overlap between GRRs and personal strengths depends partly on how health is defined. The current study applied a definition of strengths that includes both health and well-being as outcomes. 3 In the research field of salutogenesis, it is debated if the concept of health should include well-being or not. 40

| Positive psychology
Recently, an integrative approach that combines salutogenesis and positive psychology has been proposed. 41 The present findings include several strengths similar to items from the taxonomy of character strengths in positive psychology, that is perseverance, kindness, bravery, humour and gratitude. 42 However, most studies on character strengths have included participants from the general population. 43 The present study therefore adds to knowledge about the strengths and their applicability reported by people with chronic illness. For example, participants in the present study reported kindness towards oneself as an important strength. Self-kindness is, however, not included in the taxonomy of character strengths (qualities of compassion are included but only in relationships with others, ie love and kindness 42 ). Self-kindness refers to the ability to treat oneself with kindness rather than judgement during challenging situations, and it is an essential component in self-compassion. 44 In people with chronic conditions, self-compassion has been linked to lower stress levels [45][46][47] suggesting its role in self-management. Courage, one of the character strengths, 42 was also reported by our participants as a strength.
Cultivating courage is considered an important part of activating psychological resources to promote constructive self-management of chronic illness. 2

| Self-management and external strengths
Several of the internal strengths reported by participants in this study, like persistence, positive outlook, acceptance and knowledge, have previously been described as important self-management processes for people with chronic illness. 2,48 For example, persistence may be related to cultivating discipline and motivation, essential for successful self-management. 2 Also, positive emotions and its various sources were described as important strengths. This too is in accordance with prior self-management and resilience research, indicating the importance of positive emotions for promoting health. 2,7,9,49 The strengths categorized as self-management strategies confirm a large body of literature on self-management, for example health promotion activities, seeking support, goal setting, planning and pacing. 2 External resources included the support from family and friends as well as health-care resources. The availability of emotional and practical support was an important strength. This is in line with the welldocumented importance and effect of social resources reported in prior research. 2,3

| Practical implications
Becoming aware of and utilizing personal strengths have been established as an important process for people to live well with chronic illness. 2 This study extends the understanding of the subjective appraisal and application of personal strengths in people with chronic illness. Supporting mobilization of patients' personal strengths in order to promote optimal self-management and well-being is important to integrate into health care for people with chronic conditions. 16,22,50 The study results provide examples of strengths that can be useful for health-care providers to recognize and nurture in their patients. By asking about their personal strengths, health-care providers can help patients acknowledge and further build on these strengths to promote health and well-being.

| The study's strengths and limitations
The credibility of the findings is supported by several factors. The high number of participants allowed for some saturation in findings; and the team involved in the coding and categorization included a patient representative. Descriptions of strengths are highlighted with quotations from the informants. For practical reasons, interviews were carried out individually or in a group; however, combining individual interviews and focus groups may have contributed to enhanced data richness. 51 The findings must also be interpreted in the context of the study's limitations. First, the interpretation of relevance and meaning is unavoidably influenced by the researchers' backgrounds. 38 Second, the study was an early step in a person-centred design of an intervention. Due to limited resources, some steps that could have increased the quality of the analysis were left out, for example verbatim transcription of complete audio data and checking of interrater reliability between coders. Participants were recruited from self-management programmes, and people without this experience might depict their strengths in a different way or be less aware of them. Some participants did need more prompting than others and some participants talked about their perceived lack of strengths.
The participants' level of education should also be considered, as most of the participants had education beyond primary level. Last, but not least, people with different conditions were included, but differences between strengths described by people with different diagnoses were not explored.

| CONCLUSION
The study amplifies and expands upon previous findings on per- Supporting patients in mobilizing their strengths is essential in providing empowering person-centred care for people with chronic illness.