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In what direction should we go to promote health in mental health care?

There is a growing recognition of the need for health promotion interventions in all health care today. In spite of this, health promotion interventions among patients with mental illnesses have been scarce in research, practice, and policies. There is also an ambiguous interpretation of the definition of health promotion in the literature. The emphasis in this paper is thus to (1) discuss why we should pay attention to the interpretations of the concept of health promotion and (2) present a possible model for what nurses do when they intend to promote health in mental health care. This paper was presented at the Nordic Conference of Mental Health Nursing in Helsinki, Finland in 2010.

There is a growing recognition and interest among health professionals, researchers, and policymakers in promoting health among patients with mental illness today. Wide-reaching international documentation has over the last decades called for the explicit inclusion of health promotion activities in all aspects of nursing practice as well as for these to be an integral part of all forms of treatment (World Health Organization Europe, 2005). Health promotion activities usually target the general population; however, people with mental health illness have been neglected in terms of both research and policy. It is thus of the greatest importance for mental health care to not only alleviate and reduce mental illness, but also to work actively to promote the mental health of patients. The nurses responsible for health promotion are presented in the ICN Code of Ethics for Nurses (International Council of Nurses, 2005), in the competence description for a registered nurse in Sweden, as well as in the strategy for nurses' health promotion work in Sweden (Swedish Nurses Association, 2008). We can thus ask the question: What is health promotion and in what direction should nurses go in order to promote health in mental health care? The emphasis of this paper is to (1) discuss why we should pay attention to the interpretations of the concept of health promotion and (2) present a possible model for what nurses can do when they intend to promote health in mental health care.
Why should we pay attention to the interpretations of the concept of health promotion?
Many definitions of health promotion have been presented over the years and there is overwhelming literature where attempts are made to describe the concept of health promotion in nursing practice. The basis of the Health Promotion Perspective was listed at the first International Conference on Health Promotion in the Ottawa Charter (World Health Organization [WHO], 1986) and the key action areas were: build healthy public policy, create supportive environments, develop personal skills, strengthen community actions, and reorient health services. They stressed that the role of the health sector must move in a health promotion direction, beyond its responsibility for providing clinical and curative services. The WHO (2005)  as ''the process of enabling people to increase control over their health and its determinants, and thereby improve their health.'' There are many different approaches to health promotion and they reflect different perspectives and values as well as different ways of working. I will here illustrate the main differences in the interpretation of the nature of health promotion (Figure 1).
A large part of the literature on the concept of health promotion describes health promotion as including disease prevention and to be consistent with the medical perspective. The preventive model and medical discourse (patogenesis; Green & Tones, 2010) incorporate prevention, education, and protection and aim to protect people from illness based on knowledge of what causes disease and is designed to prevent a specific disease. The promotion model and discourse of empowerment (salutogenesis; Green & Tones, 2010) is represented by some researchers but is much more uncommon. This model aims to increase positive potential for health based on knowledge about health processes. We can then ask the question: Does it matter what perspective we use in health care? I maintain that the concept of health promotion needs to address the differences in the interpretation because if the health professionals are unaware of the underlying values in the concept of health promotion, it could lead to a predominant focus on the more clearly defined preventive model related to the medical perspective in practice.
It is probably not possible to make a clear distinction between the two perspectives in health promotion practice and the debate about where prevention ends and promotion begins is complex. I will thus give a further explanation about how the differences could influence the nursing practice. The preventive model and medical discourse (patogenesis) in isolation is usually an activity where nurses act as an expert and persuade individuals to take healthy decisions using an objective approach. The individuals might feel like an object that receives information from nurses' expertise and may feel inferior, insecure about their ability, and lose motivation because of their own knowledge is underestimated. There is a risk that the responsibility for lack of motivation is placed on the individuals and not put into its context. In the promotion model and discourse of empowerment (salutogenesis) the work structure is client-led and focuses on personal development. The nurses act as a facilitator rather than an expert and help individuals to identify their own health needs and goals. Fundamental factors of interventions in this model are equity and empowerment and interventions focus on the positive dimensions of subjective experience of health.
In order to understand health promotion, a definition of health is fundamental. One of the most persistent distinctions between definitions of health has been whether the focus on the absence of disease or on positive dimensions on health irrespective of disease. The WHO (1986) describes health as a resource for everyday life and is a positive concept emphasizing social and personal resources as well as physical capacities. The understanding of health determines the direction of the health promotion intervention that guides the type of interaction that emerges between the health professional and the individual; therefore, it is essential for nurses to be aware of the implicit values in the approach they adopt.

Previous research about health promotion in nursing
Previous research about health promotion in nursing has shown that the meaning of health promotion is ambiguously described. The results on health  promotion, in a review by Whitehead (2006), showed that the majority of the studies were located within the preventative disease-oriented perspective. Further research has shown that the essence in practical nursing is focused on alleviating and reducing disease and not on actively strengthening the patients' positive aspects of health (Berg, Hedelin, & Sarvimäki, 2005). Attempts to integrate health promotion in nursing practice are often limited to a health prevention approach; that is, information-giving associated with changing lifestyle-related health behavior (Casey, 2007;Irvine, 2007;Markle-Reid et al., 2006;Whitehead 2006). Research in elderly care showed that 81% of nurses (n 072) described health promotion in nursing as education and information to promote healthy behaviors and lifestyles (Kelley & Abraham, 2007). Another interesting issue is that the majority of the literature on health promotion is theoretical rather than empirical (Whitehead, 2006) and that in health care evaluations the outcomes are usually designated as changes in symptoms, quality of life, and so on, not the content in health promoting interventions related to changes in the individual positive aspects of health.
In what direction should nurses go to promote health in mental health care?
I want to present a model here (see Figure 2) that covers the main points in my research and in some way answers the question: In what direction should nurses go to promote health among patients in mental health care?
Health promotion in mental health care is a process-oriented intervention which considers that health is a process of development and the interaction between the nurse and the patient is central because each influences the other and the health promotion outcome depends on the quality of that interaction. The essence in mental health promotion is empowerment, educational support, and practical support conveyed through a good alliance (Svedberg, Arvidsson, Svensson, & Hansson, 2008). Alliance embraces a nurturing interaction and dialogue between two or more persons. It is important that the alliance is built on trust, mutuality, and a personal relationship in order to promote health. The alliance is developed when the nurses are kind, have a smile on their faces, and interact with the patients as an individual as well as there being continuity in the relationship. Empowerment embraces cooperation in order to enable patients to take an active part in health care, support the patients' in their choices, goals, and efforts as well as in their opportunities for self-determination. It is important to work together with patients to identify their needs and promote the individuals' knowledge and ability for decision making. Educational support embraces individualized health information and education, focus on possibilities, and confirmation of efforts. Contributing factors in the educational support are when the nurses act as a facilitator rather than being an expert. When we look at the practice of educational support we might believe that health education is the giving of information, but this is not the case because information should be regarded as something shared, not given. The success in promoting health is not when the patients follow the advice from the nurses. The information provided needs to be accompanied by opportunities for the individuals to evaluate the content in relation to their situation and context. It is of importance to meet patients' desire for information and knowledge in an interactive manner to promote health in mental health services. Educational support is an essential issue in Figure 2. The process-oriented health promotion intervention in mental health care.

Health promotion activities
Citation: Int J Qualitative Stud Health Well-being 2011; 6: 7118 -DOI: 10.3402/qhw.v6i2.7118 health promotion because lack of knowledge and information about care could lead to powerlessness and limits the patients' possibilities for self-determination. Practical support includes strengthening and exercises the individuals' skills and capabilities needed to carry out actions in life as well as social connections and participation of the community.
A health promotion approach has to consider the individual perspective. It is of special importance to promote the patients' skills and capabilities, selfefficacy beliefs, and involvement in decision making in order to strengthen knowledge, hope, and facilitate reaching goals. An important issue for the nurses is to strengthen the patients' self-efficacy because if individuals do not believe in themselves or that they do not have the skills, their commitment to change and to feel health will be reduced. Selfefficacy beliefs will also depend on past experience of mastery, both success and failure (Green & Tones, 2010), it is thus important for the nurses to convey hope to the patient. The nurses contribute to hope when they recognize and confirm the patients' positive qualities and support the patients to see new possibilities as well as believe in the patients' potential for improvement (Svedberg, Jormfeldt, & Arvidsson, 2003). The patients need to share information, knowledge, preferences, and beliefs with the nurses in order to get the competence to make their own decisions and expand the possibilities for autonomy. The nurses thus have to respect and have trust in the patients' potential as well as in their ability to make decisions in order to promote their feelings of dignity and value (Svedberg, Jormfeldt, Fridlund, & Arvidsson, 2004). It is of some importance to note that the patients' motivation to succeed in managing their lives is strengthened when the nurses show respect for the patients' feelings and right for self-determination (Svedberg et al., 2003). On the other hand the patients can feel violated when nurses lecture too much and consider themselves as experts. It is also worth noting that one's image and value of oneself is mainly an outcome of social interactions (Svensson, Mussener, & Alexandersson, 2006). If individuals have experiences of being treated as less competent, it could seriously harm self-esteem, health, as well as the whole life situation in a way that constitute major barriers to recovery from mental illness (Angermeyer & Schulze, 2001;Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001). For this reason it is very important that the nurses take the patients seriously (Svedberg, Svensson, & Hansson, 2009;Tidefors & Olin, 2011) and respect the patients' right for selfdetermination. One crucial issue in mental health promotion is that compliance is not an appropriate goal because it only follows the preventive model and medical discourse (Green & Tones, 2010). Instead, an appropriate goal and the most important outcome of health promotion interventions are the life goals that are decided upon by the patients themselves. Goals reflect different core values and meanings for different persons (Svedberg et al., 2004) and the identifications of life goals will depend on how health is defined by the individuals. Goals that matter give a person a reason to act and promote hope for the future; therefore, it is not relevant that health professionals alone set up the goals for the health promotion intervention.
A health promotion approach also has to consider a gender perspective. There is a clear indication that there are gender differences in attitudes and experiences of health promotion interventions in mental health services among patients with mental illness (Svedberg et al., 2008;Svedberg, 2010). The main significant differences were that females rated overall health promotion interventions as well as alliance and empowerment as more important than males did (Svedberg, 2010). Further significant differences were that females experienced more health promotion interventions than males did as well as a greater degree of alliance, empowerment, and educational support (Svedberg et al., 2008). Several previous studies have indicated that gender differences emerge in relation to the kinds of mental health problems experienced by women and men, differences in their health needs, and also in their patterns of help seeking and use of treatment (Chandra & Minkovitz, 2006;Prins, Verhaak, Bensing, & Van der Meer, 2008;Ten Have, de Graaf, Ormel, & Vilagut, 2010). Furthermore, adopting an expanding view of the gender issues in both research and practice could be increasingly central in order to understand how women and men experience and respond to health promotion interventions in order to improve their health outcomes.
A health promotion approach in mental health services was associated with the patients' perceptions of helping alliance and satisfaction with care (Svedberg, Svensson, Arvidsson, & Hansson, 2007) that can be judged as a strong indicator of a good quality of care. This might indicate that if the individual experiences a treatment more adapted to his/her own needs, the treatment is to a greater extent perceived as being health promoting, which involves power sharing and mutual decision making between the nurse and patient. This might lead to a situation where the patient becomes more involved in making choices and more responsible for his or her own care. Health promotion interventions in mental health services were also associated with the patients' perception of self-empowerment (Svedberg et al., 2007) and a possible conclusion is that the patients' perception P. Svedberg of self-empowerment is partly dependent on the nurses' ability to show respect for the patient and build an atmosphere of mutual appreciation.

Conclusion
In conclusion I want to highlight the fact that whether the patient's health is promoted or not will depend on a number of enabling and facilitating factors. The reciprocal relationship between the patient and the nurse is important because each influences the other and health promotion outcomes depend on the quality of that interaction. Of special importance in mental health care is the availability of health promotion actions related to positive health outcomes.