Everyday life in older men living alone - a complex view needing a biopsychosocial perspective.

Abstract Purpose: To explore how older men living alone, describe their everyday activities and their abilities as well as how they could be helped in everyday life. Materials and methods: Qualitative semi-structured interviews were analysed with inductive content analysis. Eight men aged 65+ years were included. They were all living alone, albeit with home help services. They were able to walk and had sufficient cognitive ability. Results: The analysis resulted in one theme “A driving force of managing activities and overcome hindering factors requires a broad spectrum of prerequisites for participating in everyday life” with the following four categories: Importance of everyday activities; individual prerequisites enabling everyday activities; body and mind inhibit, and react to the decreased, abilities; and importance of the environment. Conclusions: The results generate a complex view of older men’s everyday life. It is important for older men’s independence that health care and rehabilitation staff adopt a comprehensive view and work from a biopsychosocial (BPS) perspective. Implications for rehabilitation To be an older man living alone might mean a decreased health and good health is a strong predictor for increased abilities in everyday activities. The living situation of older men living alone is not well studied and needs to be explored to a greater extend, especially from their own perspective. An interaction of biological, psychological, and social factors was expressed as important for older men’s everyday life, in accordance with the biopsychosocial (BPS) model. The expressed importance of participation as well as performing both physical and social activities reflects the need of individualised goals in rehabilitation according to the behavioural medicine approach. It is of outmost importance that health care and rehabilitation staff in contact with this group has a comprehensive view and works from a biopsychosocial (BPS) perspective, for maintenance of the older men’s independence in everyday life.


Introduction
The older population is growing throughout the world [1,2] and has become a challenge for society [3]. The ageing process impairs biological, psychological, and social functions in everyday life [4] and is a challenge for the individual. Life adjustments have to be made by the individual to cope with age-related changes [5] and for many older people, increased help from society is essential [2]. Living alone as an older person increases the risk of fall injuries, impaired general health, and reduced functional ability which leads to lower quality of life and increases social isolation [6,7]. In particular, older men in particular who suffer from depressed mood or cognitive decline, have an increased risk for social isolation [7].
There are possibilities to actively enhance older people's health by allowing them to make autonomous decisions, enhance their feelings of meaningfulness and support positive relations to others [5]. According to the World Health Organisation (WHO), there are interventions with strong evidence for improving healthy and active ageing. Some of these promote good health and healthy behaviours to prevent or mitigate the development of chronic illnesses. Others provide early diagnosis of diseases and high-quality health care in order to milden consequences of chronic illness. There are also interventions for creating physical and social environments, which enhance health and change the social attitudes in society by increasing older people's participation [3].
The definition of everyday activities in this study includes all activities that occur in a person's daily life from a biopsychosocial (BPS) perspective, which is the theoretical framework of this study. The BPS model refers to a holistic view where biological, psychological, behavioural, environmental, and social aspects interact with each other [8]. This model has been successful in other studies on the group of older people living alone [9].
It is important for older people to maintain their ability to perform everyday activities and retain their independence for as long as possible [10,11]. However, decreased abilities are very common [4]. Among those with limitations in activities of daily living (ADL), approximately one-third has difficulties when transfer from one side of the room to the other [12]. In older men, slower gait implies a significantly increased risk of a health impairment and reduced ability in participating for everyday activities [13].
Good health is important for managing everyday activities [14][15][16]. To maintain good health, older people express that it is important to participate in meaningful activities and to have a balance between social activities and personal and economic resources [14]. They also state that social contacts, daily activities, and physical activity, such as walking, are important [15]. Maintain cognitive functions and independence as long as possible were motivational factors for being active in everyday life [16].
Activities in everyday life were explored in a recent interview study of older women, living alone with chronic pain and supported from home help services [17]. These women emphasised the importance of a daily rhythm and described how they had accepted and adjusted to being dependent with a retained sense of independence and safety. The importance of daily routines was also reported by another group of older people. The routines were adjusted to their health and abilities, served as a plan of their day and gave them something to look forward to [18]. The women in the first study [17] reported that the actual performance of activities in everyday life also enhanced their ability to perform the activities. These studies show that accepting and adjusting to a changed life situation is crucial for the everyday life, as expressed in these studies [17,18].
International and national policies support older people's right to independent living [19][20][21]. However, for an older man to live alone might mean impaired health [13,22,23] and functional limitations [22]. It has been reported that men have lost a partner or being unmarried and living alone after five years have a greater cognitive decline, compared to men who were married or living together with a partner [23].
Positive experiences for older men living alone have been described, and relate independence, personal decision-making, and possibility for individual development. Men have expressed a feeling of meaning in life is supportive [24]. Good social contacts enhance health for older men living alone [22], and good health is a strong predictor of ability to participate in everyday activities [25].
Yet, the situation of older men living alone needs to be more extensively explored, especially with focus on their own perspective [26]. Results from such studies are needed to improve the understanding of their life situation and which interventions that may be needed for enhancement of functional abilities, health, and quality of life.
The aim of this study was to explore how older men living alone describe their everyday activities and their abilities as well as how they could be helped in everyday life.

Participants
Participants were recruited from a small municipality in the middle of Sweden with approximately 8000 residents. A convenience sample included men aged 65 years and over who were living alone in their private housing with support from home help services at least once a week to facilitate personal care or household duties. They should also be able to walk independently with or without walking aids and understand and be able to speak Swedish. In addition, they should have a score of 24 or more on the Mini Mental State Examination (MMSE) [27].
In total, 11 men in the municipality fulfilled the inclusion criteria (except for MMSE), and ten agreed to participate. One was then excluded due to low MMSE score (score of 21) and one because no contact was possible, despite several attempts. Eight men gave their informed consent and were included in the study with a mean age of 80 years (71-89 years). Five men were widowers, and three were divorced or unmarried. Their help from home help services varied from once a week to several times a day. Some participants walked independently, but most of them had some kind of walking aid. Participants are called Participants A-H in the Results and an overview of the characteristics of the participants can be seen in Table 1.

Procedure
Names and addresses were collected from the municipal care registers. Information letters were sent to the eleven presumptive participants and they were contacted through a telephone call within a week. For the ten men who agreed to participate, the date and time for interviews were set over the phone. All interviews were performed in the men's homes based on the men's wishes.
Before the interview started, the MMSE test was conducted. Data were collected through semi-structured interviews. The focus in the interviews was on the participants' everyday activities, based on an interview guide from an earlier study [17], with modifications according to the aim of this study. The initial open questions in all interviews were: "Can you describe to me how an ordinary day looks for you? What do you do and how do you do it?" The subsequent interview questions were about the participant's ability to perform everyday activities, help received, whether they could do everything they wanted and what could facilitate their performance of everyday activities.
The lengths of the interviews were an average of 35 min (20-50 min) and were conducted by the same interviewer (SN) who also performed the MMSE tests. All interviews were audio recorded. The data collection was performed in December 2014.
All participants were contacted by a phone call approximately a week after the interview by the interviewer and were asked if they had some reflections they wanted to share or any information to add. All participants were thankful for the call, but no additional information was added to the data collection. A test interview was conducted with a man who had similar characteristics as the participants to test the interview guide and interview technique. No corrections to the interview guide were made after the test interview, but the man was not part of the present population, and the interview was not analysed in this study.

Data analysis
Data were analysed using a qualitative content analysis with an inductive approach according to Graneheim and Lundman [28]. Data were analysed for both manifest and latent content with the aim of describing variations by identifying similarities and differences [28].
The interviews were listened to several times and transcribed verbatim by the interviewer (SN) as soon as possible after the interview. The transcribed material was then read through several times to get a sense of the whole. Meaning units were identified interview-by-interview with origin from the aim and meaning units were then condensed and coded. Mainly, the interviewer (SN) performed this work, but some interviews were analysed by the other two authors (PHW and SC) and the results were compared and discussed. Codes from all interviews were analysed to find similarities and differences and then, subcategories and categories were formed. During this process of categorizing codes, all authors were part of the process. There was continuous work of going back and forth between codes, subcategories, and categories. The discussions of the results finally demonstrated an emerging theme. Examples of the analysis process including meaning units, codes, and subcategories are presented in Table 2.
The process described above strengthens the study's trustworthiness, which is an overarching term for the quality of the study. Trustworthiness includes the intertwined and interrelated concept of credibility, dependability, and transferability [28]. Credibility was strengthened through the process in which all authors separately analysed interviews and then discussed the identification, condensation, and coding of the meaning units. Additionally, the process of categorizing codes and discussing the subcategories, categories, and theme strengthens the credibility.

Ethical considerations
This study was originally a master's thesis, and due to Swedish law, not covered by the act of ethical approval [29]. The study was conducted according to the act concerning the ethical review of research involving humans [29], Helsinki declaration [30], and was ethically reviewed at Umeå University, Sweden where the master's thesis was planned, developed, and defended. The participants were guaranteed confidentiality and reassured that their participation was entirely voluntary and that they could withdraw from the study at any time without needing to state their reasons.

Results
An overview of subcategories, categories, and theme is presented in Table 3.

A driving force of managing activities and overcome hindering factors requires a broad spectrum of prerequisites for participating in everyday life
The overall theme of the study shows that older men living alone have a strong will to get outside their home to watch or meet other people and that they do, and want to, manage it by themselves. Sometimes, they receive help from relatives and, more frequently, from home help services. The participants report that important activities include going outdoors, being physically active, spending time with others, and participating in social activities and the community. Some of the men are satisfied in only watching others, while other men want to meet and talk to others. However, medical, psychological, and environmental factors constrain these activities. Support from people in the participants' environment and improved medical conditions, their own strategies and environmental factors may facilitate everyday activities. The wish, and longing, to perform everyday activities by themselves are strong among the participants, but there is also an acceptance of not being able to do this anymore because of changed life conditions.

Importance of everyday activities
This category concerns the participants' everyday life in their home, the importance of participating in a social context as well as being physically active and the satisfaction in being able to perform these activities.
In the subcategory Performing the routines of everyday life, the men very specifically describe an ordinary day in chronological order.
First, I get up in the morning and try to get dressed and wash myself and get ready and so on. And I make the bed. Then, I make breakfast./ … /Then, well, there are a couple of hours until eleven o'clock. Then, I drink coffee./ … /And then I eat lunch. That's approximately one or two The participants report that they perform household duties, such as cleaning, washing, dishing, cooking, and making the bed and that they perform personal care, such as washing, shaving, and dressing.
To get the days to pass, the participants are Engaging in leisure time activities in their homes. Most often, there are things to do, but sometimes there are monotonous days. The men pass the time by solving crosswords, painting, reading, listening to music and the radio, and watching TV. TV and social media are important parts of their everyday life, which is described in the following quote: The best thing I know is to watch that damn thing (the TV). When it is like this in the winter, you know, they start in the morning (winter sports). Then, you can sit here from morning to evening. Participant G In the subcategory A broader social context, participating in activities in the society and spending time with others in different contexts are strong driving forces for the participants, although they do not necessarily have to interact socially. The social togetherness involves both socializing with family and friends as well as visiting the library, church, a show, a restaurant or some sport event.
And then I get out a lot, and I participate in activities on Mondays./ … /And on Fridays they have a caf e./ … /And then the senior citizens' association has meetings. You go to these activities so you don't have to sit alone all day. Participant E Sometimes, when the participants have difficulties getting out in society, the social context can appear through a telephone call or that the staff from the home help services can be there like a friend. One man describes it like this: It says somewhere that all (home help services staff) should stay for a while./ … /and that the time to talk is as important for me as the walk./ … /It feels much better when they stay and talk. Participant C The subcategory Performance of physical activities includes a positive spirit of the participants where they express their will to use the body in different physical activities, to maintain their physical ability for as long as possible as well as being independent in physical activities. They talk about physical exercises, daily walks, and everyday activities.
That walk has done a lot for me. At first, when I took that walk with the staff from the home help services, I damn couldn't manage it. Then, I had to rest twice. Sit down and rest. But now, I sometimes take that walk without resting. Participant C The participants state that they are independent and manage to do physical activities both indoors and outdoors, without help from others, and both with or without assistive devices.
In the subcategory Satisfaction in managing activities, the participants feel that they do what they want and are satisfied in managing activities on their own. The men describe that they are doing exactly what they want and that turns into a feeling of freedom. Additionally, there is a feeling of satisfaction of being able to manage their everyday life on their own:

Individual prerequisites enabling everyday activities
This category is about handling the situation. To adjust the intake of medications in order to be able to perform activities as well as listen to the body's signals and accept what cannot be done anymore. In the subcategory Optimal handling of medications enables activities, the men are talking about that better handling of medications can lead to an increased health. To control the time for taking medications can facilitate participation in social activities and to take the right medicines makes a significant difference in coping with everyday life.
And then this new COPD medicine … it's amazing … I take it at 10 PM, because then it's also enough when I make breakfast. If I were to take it as the other COPD medicine, at 6 or 7 PM, then it doesn't work as good during breakfast. It's an amazing difference when I take it. Participant C Increased health is about getting the right medication to get well and then being able to get outside the home, as explained by Participant A: / … /as long as I get the right medication./ … /Always when I have been at the hospital, I inhale five times a day. I felt like a prince there. Participant A In the subcategory Individual facilitation strategies, the participants describe different facilitating strategies that they perform by themselves. The participants describe that they listen to their bodies. To avoid falls, one participant reports that he stands still when he looks around because he cannot walk at the same time. When the body limits everyday activities, one strategy is to listen to the signals from the body, such as tiredness and weakness, and then take a break.
When I get stressed, I need to pee … Then I just stop for a while until it's over. Then it's fine again … Take it easy, then it's working. " Participant C There's also an acceptance that the ability is no longer what it has been. Activities they could perform before are no longer possible, which is experienced as follows: If I know that I cannot manage it, I say I don't long for it either. Participant F Body and mind inhibit, and react to, decreased abilities The men describe a decreased ability to perform everyday activities, and in what way this affects them. In the subcategory Decreased physical ability, the body is described as limiting in many ways and that the men are unable to trust the body and its abilities. The participants experience difficulties in walking with a sense of being clumsy, reporting that it is hard to walk, that they walk slowly, and that they do not have the energy to walk long distances. Their fitness is decreased, and they get short of breath easily and tired while walking.
But, it felt good at the time. Then, I can walk a little. But, heck no. The lungs say no directly … They are in control. It's only for me to obey the body signals, otherwise it goes to hell. Participant C Performing complex activities, such as walking while carrying things, is both hard and exhausting. Some of the participants do not get out of their homes by themselves. Some reasons for these decreases are explained as physiological conditions, such as decreased lung function, pain, age-related changes and increased body weight. The fitness is also negatively affected by sitting still, as one man describes it: I have no fitness any more, due to me sitting up here (at home), and (I) don't get out that much. Participant H In the subcategory Mental hindrances for everyday activities, participants described both that feelings hinder activities and a decreased power of initiative. The feelings that hindered them were stress, grief, and fear. Stress can make a participant wet himself or lose his breath. Experiencing grief can interfere with participants' coping and ability to undertake activities. Fear of getting hurt while doing activities inhibits participation that would otherwise be a source of happiness. In the subcategory Frustration with not being able to manage activities, the participants describe a frustration when they want to perform activities as before, but their physical abilities hinder them or they need help from someone to manage the activity. They have a strong will to manage on their own and to be independent, but they realise that their abilities are not sufficient. Descriptions are made about wanting to play boule, take photographs, travel or to go outside by themselves. However, they cannot do this independently, or at all, which engenders frustration. Additionally, they do not want to ask for help or to be a burden to others, and then they get frustrated by not being able to perform certain activities such as getting the newspaper.
It's the neighbours right across the street. They are so damn good that I don't have the heart to ask them for help. They are really nice and are stopping by now and then to ask if I need any help. Participant B

Importance of the environment
This category describes both hindering and facilitating environment, that includes the physical and social environment as well as prerequisites from the society. The subcategory A hindering environment is described in terms of that the home help services are often associated with a helping hand, but they can also be an inhibitive factor if they help too much, as one participant describes: No, they do it (breakfast) if I want. But I can, I have sour milk and things and cereal and bread and butter in the fridge. So, I can do it if I want to./ … /But, when they come, they do it./ … /I get comfortable as well. You get a bit lazy. Participant H The participants report that limited conditions in the environment inhibit their everyday activities, such as not having their own car for traveling to visit their family and that bad weather and icy roads inhibit walks or driving their power wheelchair. Additionally, medication can hinder activities as one participant describes: Before, I went to church on Sundays, but I cannot do that now. I have these diuretics. I have to go to the toilet so often. Then, I cannot sit in church. It comes so sudden that I cannot go far. Participant E The subcategory Facilitating environmental conditions describes that assistive devices facilitate participation in activities. A security alarm helps when a participant has fallen. The walker is an important assistive device to facilitate walking, supporting balance providing security against the risk of dizziness and falls. In some cases, the walker is so important that the participant cannot go outside if he does not have it: It's (the walker) still an assistive device. Otherwise, I wouldn't come outside these days when it's slippery outside. How should I manage?/ … /There's no chance of getting out. And, you can sit and rest on it. Participant H To enhance everyday life, an indoor walker could be the solution for Participant G: The only thing I should do as time passes is to get an indoor walker./ … /Because it's hell to walk and carry things when one should go and sit in front of the TV./ … /Then, I have to walk in rounds. It looks so bad. I walk and carry things in plastic bags and put them in there. Participant G The use of transportation services during winter when it is icy and slippery outside as well as the use of a power wheelchair facilitates getting out into society and performing grocery shopping. Facilitators are also described as conditions in the physical environment, e.g., adjustments in the neighbourhood such as a ramp or elevator to help them get out by themselves with a walker. Additionally, better weather facilitates outdoor walks, large text facilitates reading and having groceries in the kitchen facilitates cooking. Support from different associations can facilitate participating in activities, through arranging leisure time activities, such as handicrafts. Better economic conditions could facilitate the use of transportation services for participants to see friends and attend sports events.
I would like to meet more friends./ … /Though, it's hard to get there./ … /Then, I have to have more money (to transportation services). Participant D In the subcategory Support from others facilitates everyday activities, participants describe that they have different needs for a helping hand in their everyday life. Relatives who help include children, cousins, siblings, and sisters-in-law. The men receive help with household chores, such as changing curtains, picking up bulky waste and apportioning medicines, delivery of and making meals, driving and running bank errands. Home help services help with different medical interventions, showering, grocery shopping, making the bed, and waking up. This help is described as a safety: I have help (from home help services) with showering and to scrub my back. It's a safety in case I fall in the shower. Participant C

Discussion
In this interview study, older men living alone and dependent of formal care, described their everyday activities and their abilities as well as how they could be helped in everyday life. Older men have not been studied to a greater extend earlier [26]. Therefore, this study contributes with new and valuable knowledge for both researchers and healthcare professionals in terms of promoting health, active ageing, and quality of life for the target population.
The most important findings are summarised in the theme "A driving force of managing activities and overcome hindering factors requires a broad spectrum of prerequisites for participating in everyday life" that describes a strong will to get outside their homes to watch or meet other people and to manage this by themselves, though they need help from relatives and home help services.
In a theoretical context, the results can be connected to both the BPS model [8] and the International Classification of Functioning, Disability and Health (ICF) model [31] (which is based on the BPS model). The theme clearly correlates to the importance of participation and not only the performance of activities, in relation to the ICF model [31] and previous studies [32,33]. It is clear that men's everyday lives and their abilities to perform everyday activities were affected in a complex view by biological, psychological, behavioural, social and environmental factors that interact, according to the BPS model [8]. Some examples on how the different factors in the BPS model interact with each other can be seen in the description of how the participants listen to their body signals and that they are taking a break when doing different activities if they feel tired or weak (interaction between biological and behavioural factors). Also, that the men accept that they no longer were able to perform some activities, which lead to frustration (interaction between behavioural and psychological factors). An important assistive device that clearly shows how all the different factors in the BPS model interact with each other is the walker. The walker was described to support the balance and decreased the risk of falling and fear of falling. The walker also made it possible to get outdoors, especially when it was slippery, and were seen to facilitate walking and the possibility for participation. All levels in the ICF model [31], especially activity and participation, are represented and intertwined in the results. The men are experiencing both resources and limitations in body functions and structure (that affects activity and participation), as well as many both hindering and facilitating environmental factors. These results are in line with earlier studies which have pinpointed the importance of maintenance of the ability to perform everyday activities, as well as the possibility to participation [17,34]. Also, the importance of using this type of theoretical models for healthcare professionals in the care and rehabilitation of older people according to its complexity should be highlighted [9,35]. This is especially important for those who live alone, since it is associated with poorer health, higher degree of functional decline and disability, decreased mental health as well as a lower quality of life [6,7]. The use of the BPS or ICF models can support health care professionals in their daily practice to identify, analyse, suggest, and perform interventions according to complex health problems, health care and/or rehabilitation needs. The use of these models also facilitates involvement and participation of patients in the decision-making process. It also enables health care professionals to use a common language and support to work multiprofessionally, i.e., work together towards a common goal for the patient, but from different angles [9,35].
Descriptions in the category Importance of everyday activities correspond to results from other interview studies in which older people [18], women [17], and men [24] living at home have described their everyday activities. A daily rhythm was from a health perspective very important for reaching a balance between activity and rest [17,18]. Though, older men [36] highlighted that both every day and leisure activities gave them meaning and helped them to pass the time. This corresponds with the findings in this study where the importance of social and physical activities was highlighted.
The results that the home is experienced as an important place and the will to manage activities are in line with earlier studies [17,37,38]. In Sweden, the principle of prolonged living at home [19] is intended to give all older people the opportunity to stay at home as long as they want with retained quality of life, as in the rest of EU and according to the WHO [20,21]. To be able to live at home, it is important to maintain the ability to perform everyday activities and to be independent [10,12]. This was also important for the men in this study, as described in the subcategory Performance of physical activities. The men were physically active through daily walks, performance of everyday activities and specific physical exercises, which agrees with earlier studies [15,17,38]. Ability to walk and to have good fitness increases the quality of life in older people [39]. Additionally, a decreased physical ability predicts disability [40], subsequent hospitalization [41], and mortality [42]. A combination of a decreased level of physical activity and increased age increases the risk of a lowered ability to perform ADLs and might increase the need of help from others in everyday life [43]. Getting tired during everyday activities has been shown to be a strong predictor of functional decline and mortality in older people [44]. One way to maintain physical ability is through weight and balance training, which impact everyday activities and can decrease the risk of falls [45]. These results can also be correlated to the goal setting procedure in the behavioural medicine approach, where the individual always should set Specific, Measurable, Activity-related, Realistic and Time-specific (SMART) goals. If the individual identifies a prioritised activity and sets goals that are important for her/him, the motivation for the rehabilitation process of working with different BPS factors that hinder activities will be much stronger, especially for older people [46,47].
In the subcategory A broader social context, the importance of participating in society and maintaining relationships with relatives and friends emerged, which has been shown to be important for health and well-being and decreases the risk of feeling lonely and social isolation [48]. Furthermore, older men with low participation in social contexts and who are not satisfied with their social relationships have a significantly increased risk of developing physical disabilities [22].
In a study of American older men, most participants preferred to live alone and to be able to do activities by themselves, or with others, when they wanted. Living alone was also an opportunity for personal growth [24]. This corresponds to the content of the subcategory Satisfaction in managing activities in this study.
A certain degree of contradictory descriptions of feelings appear in the subcategories Satisfaction in managing activities, Individual facilitating strategies, and Frustration with not being able to manage activities. The men experienced limitations in performing everyday activities, and they described a longing to perform certain activities and a frustration of not being able to do so (as described in the category Body and mind inhibit, and react to, decreased abilities). Additionally, they described an acceptance with not having the abilities needed for the activity (as described in the category Individual prerequisites enabling everyday activities).
This kind of acceptance with the new life situation has been seen in earlier studies [17,36].
In the category Importance of the environment, the men described that the home help services staff was helpful, although the staff also helped too much in certain cases. The men had decreased independence when the staff performed activities the men could have done by themselves. It is important for older people to perform everyday activities and that caring staff supports them with an individual and rehabilitative approach so that older people can maintain their independence [22,24,25,49]. In the subcategory Facilitating environmental conditions, it emerged that assistive devices helped the men perform everyday activities. The power wheelchair was also shown in an earlier study to be important for older women as was having an elevator in the house [17]. Older men living on the countryside have been shown to want to move closer to the city centre to be able to use their power wheelchairs to be able to meet other people [36]. The subcategory agrees with earlier studies where adjustments in the home environment are important for moving around the home [38], decreasing the need for help from home help services and maintaining independence [12]. This is important knowledge for caring and rehabilitation staff as they choose the interventions that are needed for each person.
Only eight men participated in this study out of the eleven men who fulfilled the inclusion criteria in the municipality where the data collection was performed. The decision not to recruit more participants was based on a decision to perform a total investigation in this municipality where the prerequisites were different from those in nearby municipalities.
All interviews were performed in the participants' homes according to the wishes of the participants themselves, albeit the security could have been handled well when the interviewer was alone with the men. During two interviews, the participants showed irritation and a tendency towards anger, but they did not display any overtly aggressive behaviour.
Before the interview, participants answered the MMSE, which took approximately 15 min [27]. The screening for cognitive decline annoyed some of the participants when they became aware of their difficulties. It might have helped to perform the MMSE on a separate occasion before the interviews. Additionally, some participants found it exhausting to perform both the MMSE and interviews in the same setting, but all completed the interviews. One potential participant was excluded for a low MMSE score (score 21) and according to the conversation the interviewer had with this man, it became obvious that 24 was a suitable cut off for the MMSE [50].
The trustworthiness of the study is discussed in terms of the credibility, dependability, and transferability according to Graneheim and Lundman [28]. To obtain study credibility, participants were recruited according to a convenience sampling from certain inclusion criteria. This might have inhibited variations in the experiences, which is mostly due to the small number of potential participants in the municipality. A test interview, with the purpose of testing the interview guide and interview technique, was performed with a man who did not fulfil the inclusion criteria, although he had similar characteristics as the participants. No corrections were made after the test interview. Credibility was also obtained through the analyses in which all authors worked together in discussions through the process of selecting meaning units, creating condensations, codes, as well as abstraction and the creation of subcategories, categories and the theme [28].
Dependability is obtained through assigning the interviewer (SN) as the only author in contact with the participants. This supports that the participants received the same information and that the interviews were performed similarly. The data analysis was performed during two periods in time, first within a couple of months after the interviews and then a year later (before finishing the manuscript). At both times, all three authors participated in the analysis and discussed their thoughts.
To enhance transferability, extensive descriptions of the context, inclusion of the participants, data collection and data analysis were performed. Additionally, the presentation of the results includes citations so that the reader can judge the transferability to other contexts. The results in this study agree with similar studies [17,18,35,38], and the authors consider that the results are transferable to a similar context in a smaller municipality in Sweden.

Conclusions
This study concludes that older men living alone with support from home help services, have a strong will to manage their everyday activities on their own, but this requires a supportive environment. The results reflect a complex view of their everyday lives. The independence of the men depends on the health care and rehabilitation staff in contact with this group having a comprehensive view and working from a BPS perspective. Future studies are needed to focus on the life situation and how prerequisites can be developed to support independent living with a high quality of life for this target group.