A systematic mixed methods review: Recovering from a hip fracture in a health promoting perspective

Abstract Aim To describe and interpret how older adults who have returned home to recover from a hip fracture cope with life in a health promoting perspective. Design Data were collected through the search in seven electronic databases during 2014. Inclusion criteria were peer reviewed, empirical studies. The keywords were hip fracture, coping, empowerment, self‐efficacy, elderly, frail elderly, oldest old. Seventeen papers published 1991–2014 were eligible for inclusion. Analysis of the qualitative and quantitative papers was conducted separately guided by the key words coping, empowerment and self‐efficacy. Due to diversity of studies, a meta‐analysis was not performed. The findings were reported in a narrative synthesis. Results Recovery is an individual process of regaining health. It is important to include the person's resources and own goals in life. Physical training must be combined with psychosocial interventions to promote personal engagement and health.

. Critical gerontology focuses on the pervasive stereotyping of people in later life. Integrating the voices of the older adults in research will develop the debate that can enliven gerontology from becoming complacent (Katz, 2009;Ray, 2008). "Older adults" is in accordance with WHO (2015) and only loosely associated with age in years.
According to WHO (1986), health promotion is the process of enabling people to increase control over and to improve their health. This means that people regardless of age have the right to have control over their lives and be able to cope with stressors in their everyday life to reach a healthy life. To strengthen health promotion, older adults, who have returned to their homes after an operation for a hip fracture, must be able to take active part in decision-making processes concerning their daily life. Empowerment in healthcare requires that health professionals acknowledge the right of the older adults to self-determination and that they are enabled to meet this challenge (Berg, Sarvimäki, & Hedelin, 2010).
Health professionals must include the home of the older adults as a health promoting arena and support their self-efficacy (Mahler et al., 2014). Antonovsky (1979Antonovsky ( , 1987 described health promotion as a Sense of Coherence (SOC). SOC contains three dimensions that describe what facilitate individuals´ coping with challenges: comprehensibility -the ability to comprehend events to be consistent, predictable and explicable, manageability -the capacity to take advantage of and trust resources to deal with challenges and meaningfulness -the motivation and commitment to cope with and influence decisions. The Generalized Resistance Resources (GRR) facilitates the individual´s SOC, for example, income, housing, faith and social support.
It is important to do research on how the intentions of the WHO and the theories of health promotion are practiced in the collaboration between the older adults and the health professionals. Likewise, it is important to do it in an intersectional perspective with attention to the meaning of, for example, age, gender, ethnicity and socio-economic factors (Krekula, Närvänen, & Näsman, 2005). Much literature has been published about home-dwelling older adults' recovery from a hip fracture at home. However, little is known about how health promotion is reflected in this literature. This paper reviews published research on how the recovery of home-dwelling older adults, who have suffered a hip fracture, are described in a health promoting perspective. Thus, the aim of the study was to describe and interpret how older adults who have returned home to recover from a hip fracture cope with life in a health promoting perspective.

| Recovery
Recovery is an alternative to the medical orientation often seen in rehabilitation. Recovery includes concepts as hope, self-determination, empowerment, freedom from stigma and discrimination and the right to a meaningful life (The Department of Health, 2013;WHO, 2017). In everyday life research, recovery is often included in the concept of rehabilitation and the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001).

| Coping
In the salutogenic model, Antonovsky (1987) described three concepts: comprehensibility, manageability and meaningfulness that facilitate the individual's capacity to take up the challenges and maintain health and thereby cope with stressors like a hip fracture. To promote a successful coping with stress, the older adult must have the required resources and perceive the task as challenging. WHO (2009) defined empowerment as: "A process through which people gain greater control over decisions and actions affecting their health." In this review, the individual aspect is at stake and empowerment is referred to as psychological empowerment where people have a sense of control over their lives. Bandura (1977) defined self-efficacy as the belief that people can perform behaviour necessary to reach their goals. Self-efficacy determines how people feel, think, motivate themselves and behave.

| Design
This is a systematic, mixed methods review (Creswell, Klassen, Clark, & Smith, 2011;Sandelowski & Barroso, 2007) including empirical research articles with both a qualitative, quantitative and mixed method methodology. The design integrates findings generated from both different researchers' approaches and from different participant positions.

| Method
In mixed methods, quantitative and qualitative data are integrated to increase the strengths of the validity and to develop a more complete understanding, a complementary picture of a research problem (Creswell et al., 2011). In doing so, the researcher needs to have a pragmatic approach and recognize the existence of both the natural and the physical world and reject the traditional dualisms, that is, rationalism and empiricism (Robson, 2011). Integrative reviews allow for promoting of a holistic analysis and interpretation of the research aim and improving the evidence in nursing (Whittemore & Knafl, 2005).

| Search strategy
A systematic literature search was conducted in 2014 using seven on- was assessed for eligibility. Seventeen studies were included in the review ( Figure 1).

| Study designs
Eight studies were qualitative studies. Different designs were represented, for example, qualitative in-depth interviews-individual or with next of kin, focus group methodology and participant observation generating field notes and including a collection of archival materials (e.g., pictures, diaries; Table 1). Eight studies were quantitative studies with different designs, for example, cross-sectional studies, a prospective cohort study, a non-randomized study and randomized controlled trials (Table 2). One study was a mixed methods study with both individual in-depth interviews and a questionnaire (Table 3).

| Intersectional comments
The majority of the participants were European or American.
Participants in two studies were from Taiwan. There was limited information concerning cultural background such as gender, race and religion. The majority of participants lived alone. Most of the studies did not specify the economic situation of the participants.
The educational background varied from college degrees to illiterate participants. The authors mostly characterized their participants' background as different or varied.

| Quality appraisal
The methodological quality of the included studies was critically assessed. The qualitative studies were systematically examined to assess their validity by using the basic criteria for validity of qualitative studies inspired by Lincoln and Guba (1985) (

| Data abstraction and synthesis
Data from the included studies were abstracted to facilitate the review. Characteristics from the studies were established in matrices, that is, author, publication year and country, aim, design, sample, response rate, setting, analysis, outcomes, instruments and results (Tables 1-2). This emphasized equal value between the methodologies and a preliminary interpretation of patterns and relationships within and across the papers became visible (Whittemore & Knafl, 2005).
The key words coping, empowerment and self-efficacy guided the analysis and findings were summarized and presented under separate headings. As the included studies represent great methodological diversities and outcome measures, it was not possible to conduct a meta-analysis but more appropriate to report the findings in a narrative way. In the discussion, the results were integrated.

| Ethics
As this study was a systematic mixed method review, ethical approval was not required.

| Qualitative studies
The eight qualitative studies included 110 women and 28 men who had returned home after an operation for a hip fracture.

| Coping
The coping strategies were characterized by a battle for independence (Huang & Acton, 2009), active participation and willingness to engage in their recovery (Young & Resnick, 2009 Seeking social support was the most common strategy Women with a high chance orientation may be more likely to use distancing as a coping strategy, because they accept their hip fractures as part of the ageing process and out of their control Except for locus of control, none of the other personal and material resources significantly influenced the coping strategies used by the women Several types of coping were associated with the women's perceived recovery. The use of self-controlling, accepting responsibility, escape-avoidance and positive reappraisal was negatively associated with perceived physical functioning. These strategies reduced the distress TA B L E 2 (Continued) The relationship between narrative analysis and outcomes-the actual outcomes for analysis were change in ambulation from pre-fracture level to 3 and 6 months post-fracture (ADL scale) The participants who explained the physical event within a mechanistic model did better with regard to change in ambulation The participants who perceived the fall as organic cause showed greater improvement in self-confidence and an optimistic approach The participants who perceived the impact of their fracture as having little or no influence on their autonomy showed much greater improvement in ambulation Most subjects reflected a mechanistic world view TA B L E 4 Appraisal of the qualitative studies in the review inspired by Lincoln and Guba (1985) Archibald (  Ethical considerations X X X X X X X X X a new fall, for example, to furnish their home in a falls-preventing way (Young & Resnick, 2009

| Empowerment
The participants described their transition as a personal growth opportunity (Archibald, 2003). They had managed difficult times earlier in life and understood the importance of the continued physical workout (Robinson, 1999). These experiences had facilitated their motivation and determination: "…you´ve got to do the best you can. Even at my age, you catch yourself planning what you are going to do next summer" (Robinson, 1999(Robinson, , p. 1344 Their recovery approach was characterized by humour, faith, pride and a strength to minimize adversity resulting in power to anticipate the future (Robinson, 1999). Interviews with older women and their daughters (Shawler, 2006(Shawler, , 2007 revealed power and mental resources to deal with the experience of a hip fracture by acting as an example to others showing how they "managed, survived and grew from challenging and fearful times" (Shawler, 2006, p. 372). This kind of empowerment was explained with a female lineage through generations of powerful female ancestors (Shawler, 2007). It was a time of promoting skills of learning, growing and adaptation which they succeeded in because of their self-determination and ability to fight for their demands to be met.

| Self-efficacy
Participants stressed the positive effect the professionals, family and friends had had on their recovery especially the verbal encouragement had lifted their spirits "The help, encouragement and support that I got from my family and friends are essential…" (Young & Resnick, 2009, p. 113). They would have liked more and a better physical therapy and nursing care at home, that is, professionals who could give education in the recovery process. Archibald (2003) stated that motivation to recover was a key aspect in recovery. Some participants showed great enthusiasm for giving good advice to others "Get up and do as much as you can and don´t worry," "Be positive" (Young & Resnick, 2009, p. 115). Huang et al. (2014) found that perceived ageism could have the reverse effect and thus increase self-efficacy and facilitate return to their usual capacity in their life pre-fracture. Despite the experience of physical and psychosocial defeat, the informants showed an irrepressible belief in their ability to overcome barriers and life crisis to recovery and to restore their well-being.

| Quantitative studies
The eight quantitative studies included 584 women and 79 men who had returned home after an operation for a hip fracture.

| Coping
Five studies described areas related to managing distress and coping strategies (Johansson, Larsson, & Hamrin, 1998;Pakkala et al., 2012;Portegijs et al., 2014;Roberto, 1992;Shaw, McColl, & Bond, 2003). Roberto (1992) measured the coping strategies among 101 females and found that seeing the fracture as a part of an ageing process and as such out of control for the individual and with loss of comprehensibility was significantly associated with a distancing strategy (p < 0.01) and a high belief in being controlled by powerful others. In another descriptive study of 112 females, Shaw et al. (2003) showed that a greater Internal Locus of Control was significant associated with greater independence in daily living. Three studies measured the association between SOC and recovery from a hip fracture (Johansson et al., 1998;Pakkala et al., 2012;Portegijs et al., 2014). Johansson et al. (1998) found that 4 months after a hip fracture, patients with a stronger SOC had significantly better scores on the quality of life Index, for example, physical health, marriage, family, friendship, stress (p < 0.001) and on all subscales of the Standardized Practical Equipment test, for example, ADL, balance and mobility. In addition, they found that patients with a weaker SOC showed a significant higher dependence on assistance in social activities (p < 0.01) and help from the municipal services (p < 0.001).
The association between SOC and both physical training and muscle strength was measured in two studies originating from the same RCT (Pakkala et al., 2012;Portegijs et al., 2014); 12 weeks of individually tailored, intensive strength training in the intervention group of 24 patients did not improve SOC or any of its components, comprehensibility, manageability and meaningfulness compared with a control group of the similar size (Pakkala et al., 2012). In the study conducted by Portegijs et al. (2014), the association between SOC and adherence to training, changes in muscle strength, mobility and balance was measured. The study showed that all participants improved in muscle strength regardless of their strength of SOC.
The analysis revealed, however, that participants with stronger SOC showed a significant positive training adherence (p = 0.009) and better coping with their recovery process as they improved in independence in daily life, quality of life, ADL, balance and mobility. Having a stronger SOC meant that they could identify and use their resources and manage complicated physical tasks.

| Empowerment
One quantitative study (Zidén, Kreuter, & Frändin, 2010)  The HR thus showed that an intensive support at home in their own setting would mobilize personal resources and enhance the participants' self-capacity and ability to participate in self-care and thus restore the control over their lives.

| Self-efficacy
Two quantitative studies explicitly analysed self-efficacy in relation to recovery after a hip fracture. Casado et al. (2009) measured whether social support for exercise from experts would influence exercise behaviour in 164 females after a hip fracture.
The Social Support for Exercise Habits Scale (SSEH) increased in all groups but with a statistically significant higher increase in the three intervention groups than in the control group (p = 0.002).
The strongest social support for exercise was seen in the inter-

| Mixed methods study
The search in the databases revealed one mixed method study that fulfilled the inclusion criteria (Borkan, Quirk, & Sullivan, 1991).
It included 65 women and 15 men who had returned home after an operation for a hip fracture. The study had a convergent design (Fetters, Curry, & Creswell, 2013)

| Coping
The study showed that those patients who explained the fracture to be a result of external cause or an acute incident like a fall coped better with regard to ambulation "I´ll be up and around before you know it." Whereas those who thought they were sufferers of diseases and believed the fracture was a result of ageing would think of themselves as dependent on others. "I don´t think I´ll ever walk normally again" (Borkan et al., 1991, p. 951). The recovery potential was closely linked to comprehensibility, manageability and meaningfulness.

| Empowerment
Perception of disability included evaluation of several dimensions like vulnerability and perception of dependence. Those patients who perceived the fracture to be of little or no influence on their autonomy or independence showed much greater improvement in ambulation. "I´ll get around visiting people" compared with the opposite pole "Nobody seems to be coming to visit me so I don´t know who I belong to anymore" (Borkan et al., 1991, p. 952

| Self-efficacy
The dimension of futurity was evaluated in either hopefulness or hopelessness. Hopefulness was expressed as a belief in full recovery "I´m the type of guy who won´t give in. Stubborn." Hopelessness was expressed as absence of expectations for recovery "I have nothing to look forward to and I´ll lay here till I die." (Borkan et al., 1991, p. 953). The degree of autonomy and independence determined participants' skills and energy to motivate themselves to overcome challenges in everyday life and reach their goals.

| D ISCUSS I ON
This is a review of both qualitative, quantitative and mixed methods peer-reviewed studies about how older adults who have returned home to recover from a hip fracture cope with life in a health promoting perspective. The findings are described using the three concepts: coping, empowerment and self-efficacy, which are central in the health promotion terminology inspired by the Ottawa Charter (WHO, 1986) and a part of the understanding of SOC. Various approaches to the key concepts were seen, but the studies did not include any clear definitions. The participants´ GRR, which are a fundamental part of health promotion, were not part of the analysis in the studies in this review. This deficiency can be a reflection of the authors' professional, theoretical and philosophical competences or a sign of silent theoretical knowledge. In this review, WHO (1986) was used as point of reference. Key concepts were illuminated from definitions and texts from WHO.  (Antonovsky, 1987). A strong SOC might be explained by age and by a natural selection-healthy older adults live longer-or because older adults develop a strong SOC (Eriksson & Lindström, 2005).

| Coping
It appears in both qualitative and quantitative studies and the mixed method study that the participants' understanding of the determinants for hip fracture affected their way to cope. Hip fracture can be understood as an acute event, for example, a fall and therefore has to be mastered actively. Alternatively, hip fracture can be understood due to a high age and frailty and therefore a negative experience to which one finds an avoiding coping strategy. To be perceived as dependent and frail is a stereotypic depiction of older adults, which might break down their social and personal identities and contribute to ageism (Angus & Reeve, 2006). Ageist attitudes are devastating threats to ageing well. Age discrimination may lead to chronic stress and diseases (Allen, 2016) and thus act as a barrier to increased control and improvement of health (WHO, 1986).

| Empowerment
The participants used different ways to maintain empowerment. In the qualitative studies and the mixed method study, empowerment was a concept closely related to the participants' personal growth.
It was a way of exerting self-management to become familiar with their changed life conditions. Self-management of chronic illness is not only "doing" but also "being" and "becoming" and is a continuous development of both the physical and psychosocial capabilities to create order in life (Kralik, Koch, Price, & Howard, 2004).
In the intervention studies, the participants´ received intensive physical training to enhance their empowerment through improved physical mobility. Since the Ottawa Charter (WHO, 1986), the discourse concerning empowerment and patient participation has been dominant among nurses and other health professionals to enhance the autonomy of the patients. Professionals´ instructions in physical exercise in the studies can be perceived as a prescribed behaviour exclusively originating from a professional mindset (Freire, 1993).
If health professionals continue to define the goals of the recovery efforts and consider the older adults to be passive recipients, there are only small chances for empowerment and recovery (Hage & Lorensen, 2005).

| Self-efficacy
To master challenges after life threatening events like a hip fracture was a highly demanding task and a continuous battle. The older adults in this study mobilized an inner strength to continue their battle for healthy ageing and autonomy. In their study of inner strength Nygren, Norberg, and Lundman (2007) found inner strength to be engagement in life, responsibility for oneself and others, feelings of pride, having trust in oneself and displaying a willpower. The ready-made exercise programmes were not enough to change behaviour. Personal recovery is a unique process of changing attitudes, values, goals and roles related to the individual's lifeworld (Slade, Amering, & Oades, 2008). Thus only focusing on symptoms and symptom reduction equals a view on the older adults as passive, maybe compliant recipients belonging to a homogeneous group and not a person that takes active part in their recovery. Perceived self-efficacy is essential for the coping effort that people will put into recovery. To develop self-efficacy, people must be supported in identifying their personal experiences and show commitment to their recovery (Bandura, 1977).
Professionals must shift the glance from prevention to health promotion, include the individuals´ life goals, work in partnership and respect their autonomy. In a health promotion approach, the role of the professionals is not to dictate tasks but to facilitate possibilities.

| Limitations and strengths
This is to our knowledge the first systematic mixed methods review on health promotion and older adults after a hip fracture. All studies that fulfilled the inclusion criteria were included. Some quantitative studies did not include enough patients to do generalization and the qualitative studies originated from very different cultures. The coping resources might be explained by a biased selection of especially resourceful participants. However, the study is valuable due to mixed methods design in its comprehensive investigation of health promotion and recovery. The analysis of the studies was made credible through quotations from the participants, the presentation of significant findings and the detailed explanations of the results in the text and in the Tables.

| CON CLUS ION
The findings of this systematic mixed methods review provided evidence for coping, empowerment and self-efficacy to be important concepts in the study of recovery in a health promoting perspective. The review revealed that promoting coping capabilities must include both physical functions and an emphasized support of the older adults in their individual way to health promotion. To improve recovery comprehensibility, manageability and meaningfulness must be strengthened. Self-management can improve the participants' empowerment and self-efficacy. The experiences of personal growth and trust are essential. Physical training is important but need to be incorporated in the recovery on the participants' premises in respect of their autonomy and life goals.
Given the increase in the older population worldwide, there is a growing need for research in the complex concepts of health promotion and everyday life of older adults. Research should reveal how autonomy and participation in recovery is promoted and respected.
Researchers must be aware of intersectional variations concerning, for example, age, gender, culture, religion and socio-economic status in research in recovery after hip fracture. Researchers in clinical nursing must be aware of the differences between health promotion, which has an everyday life perspective and prevention, which has a medical perspective. They should do research in both perspectives and include well-documented theoretical concepts; otherwise, the results become blurred.

| PATIENT CON S ENT FORM
As this is a systematic mixed methods review, a patient consent is not requested.