Health Promotion in

Health Care – Vital

Theories and Research

Gørill Haugan
Monica Eriksson
Editors

123
Health Promotion in Health Care – Vital
Theories and Research
Gørill Haugan • Monica Eriksson
Editors

Health Promotion in
Health Care – Vital
Theories and Research
Editors
Gørill Haugan Monica Eriksson
Department of Public Health Department of Health Sciences
and Nursing University West
NTNU Norwegian University Trollhättan
of Science and Technology Sweden
Trondheim
Norway
Faculty of Nursing and Health Science
Nord University
Levanger
Norway

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Introduction to This Book

High Ages: A Success That Signifies Health Challenges

As we all are aware of, there is a demographic shift toward an older popula-
tion worldwide. The segment of people aged 80 years and more is growing
rapidly and those aged 100+ are growing fastest [1]. This is a sign that we
have succeeded in some ways. This shift started in high-income countries.
However, for the first time in history, people can expect to live until their 60s
and beyond globally [2]. During the period from 2015 and 2050, the propor-
tion of those 60 years and more will nearly double from 12 to 22%; by 2050
individuals aged 60 years and older is expected to total two billion, up from
900 million in 2015 [2]. Currently, low- and middle-income countries are
experiencing the greatest demographic change; hence, all countries are now
facing major challenges to ensure that their health and social systems are
ready to make the most of this demographic shift [2, 3]. Age is an aim in life
and not a disease. Still, with high ages, several diseases appear; now our task
is to ensure that the extra years are worth living. Hence, with a steadily grow-
ing older population, the world faces a growing need of health care. In the
years to come, health promotive initiatives enhancing well-being and coping
in the population will become ever more important. Accordingly, this book
provides novel knowledge in the field of health promotion in the health care
services from various parts of the world; Africa, America, Asia, Australia, and
Europe are represented.
Today, the medical perspective and treatment approaches are highly devel-
oped giving emphasis to save lives from severe illnesses and injuries. This is
good. However, a great number of patients, both in hospitals and in the munic-
ipality health care, suffer from a lack of holistic oriented health care and sup-
port. Their illness is treated, but they feel scared, helpless, and lonely,
experiencing meaninglessness and low quality of life. Several patients with
chronic or long-term conditions (heart and lung diseases, cancer, rheumato-
logic diseases, dementia, diabetes, long-term intensive care patients, palliative
patients, mental disorders, etc.) fight and must cope with a heavy symptom
burden and life challenges on their own at home. These people are asking for
social support, empowerment, patient education (salus education), guidance,
hope, meaning, dignity, and coping strategies in order to manage their life situ-
ation. Human beings are whole persons consisting of different dimensions;
individuals comprise of a wholeness of body-mind-spirit which cannot be

v
vi Introduction to This Book

separated in a body, a mind, and a spirit; these three parts are totally integrated
performing in close interaction. Thus, a holistic physical-­psychological-­social-
spiritual model of health care is required to provide high-quality and effective
health care. Health promotion and the salutogenic perspective on health are
holistic. In the years to come, health promotive initiatives will become ever
more important. Accordingly, learning how to reorient the health care sector in
a health promotion direction is highly needed.
Health promoting approaches are resource-oriented focusing on the ori-
gin of health along with people’s abilities and capacities for well-function-
ing and well-being. The health promotion field is based in the salutogenic
health theory representing an area of knowledge and learning, a way of relat-
ing to others, and a way of working in a health promoting manner. In the
salutogenic perspective, health is a movement on a continuum between ease
and disease. In this approach, no one is categorized as healthy or diseased;
we are all somewhere between the imaginary poles of total wellness and
total illness. Every person, even if severely diseased, has health, and health
promotion is about strengthening the health. Either by changing the ways we
work or by changing the environment or educate the person in question how
he or she can work to strengthen his/her health. The salutogenic approach
seems useful for reorienting the health care systems around the globe.
Therefore, this book entailing three parts comprehends the salutogenic
health theory as a model of health and a life orientation, representing a vital
theoretical basis for the health promotion field, along with the salutogenic
theoretical framework.

Health Promotion in the Health Care Services (Part I)

First, in Part I, we provide the historical and theoretical basis for health pro-
motion in the health care (Chap. 1), followed by a presentation of the saluto-
genic health theory and its potential in reorienting the health care services in
a health promotion direction (Chap. 2) as well as ethical perspectives on
health promotion (Chap. 3). Hence, Part I elaborates on the need for reorient-
ing the health services in a health promotion direction. Both hospitals and the
municipality health care services should be based on the health promotion
perspective and an integrated understanding of pathogenesis-salutogenesis.
This goes for acute as well as chronic illness and conditions. The arguments
include efficiency, effectiveness of the health care services, along with bene-
ficial outcomes for the patients, their families and the societies. Health care is
expensive and challenging; all the efforts put into it should pay off as much
as possible. A health care which along with the medical treatment and care,
also aims at supporting/promoting patients’ health by means of identifying
and supporting their health resources, will result in better patient outcomes;
shorter stays in hospitals, less re-hospitalization, better coping at home, more
well-being indicating increased public health and smaller health care bud-
gets. Hence, re-orienting the health services to provide health promoting
health care, will not merely remove a disease, but provide more health, well-
being, and coping. A more abundant outcome!
Introduction to This Book vii

Moreover, health services are first and foremost about health. Thus, this
overarching aim—and not only diseases—should be leading principles and
visible in the organizational structures, leadership and management philoso-
phy, the working culture, and in the health care of individuals and the fami-
lies. The health care sector should be led toward the aim of treating illness
accompanied by actively promotion of people’s health. Moreover, the health
care services should not only be responsible for the development of health-
promoting working environments but be in the forefront of such developments
in the societies. Hospitals, nursing homes, homecare, etc. should represent
health-promoting work places, facilitating well-being and peoples’ experi-
ences of their work situation as comprehensible, manageable, and meaning-
ful. Still, all countries have much left on their “to-do-list” toward such a
reorientation of the health services. Hence, knowledge about development
and the implementation of health promotion strategies in the health care is
highly welcome and much needed in the years to come.

Vital Salutogenic Resources for the Health Services (Part II)

The second part of this book gives the reader an updated overview on signifi-
cant salutogenic concepts representing resources for health promotion and
well-being. The selected salutogenic concepts are relevant for the health ser-
vices, globally. Sense of coherence (Chap. 4) kicks off Part II, representing a
corner stone in the salutogenic health concept. A growing body of evidence
has shown that sense of coherence—that is, an individual’s perception of
one’s life situation as comprehensible, manageable, and meaningful—is
strongly related to health, wellbeing and coping in all segments of the human
population; young as well as old people, healthy, as well as individuals hav-
ing diseases. Thus, this book suggests that the dimensions of comprehensibil-
ity, manageability, and meaningfulness should be generally addressed in the
health services. If people are going to be flourishing individuals (Chap. 5),
meaning that they lead flourishing lives going well, coping well, and thriving
well, sense of coherence is a vital basis. The salutogenic concept of flourish-
ing represents a living goal and an understanding that people, despite physi-
cal or mental illnesses, can lead happy and well-functioning lives. Such ideas
provide us hope (Chap. 6)—which also represents a salutogenic concept and
resource for health, well-being, and coping. Hope entails positive energy,
vitality, and power to strive for whatever one wants in life and is therefore a
significant sign of health.
Human beings are not only a physical body and a mind, but physical-­
emotional-­social-spiritual/existential entities, or an integrated wholeness of
body-mind-soul. Thus, human beings need to experience dignity (Chap. 7);
suffering results from not attending to an individual’s dignity. Thus, dignity is
a vital aspect of patients’ health and should therefore be addressed in health
care. If dignity is overseen, most often the individual loses her sense of
meaning-­in-life (Chap. 8). Without dignity and meaningfulness, life does not
seem worth living, and the inner strength and willpower to fight for health,
recovery, etc. will be drained and deprived (Chaps. 8 and 18). The salutogenic
viii Introduction to This Book

concept of self-transcendence (Chap. 9) represents a vital resource for well-­

being and coping, specifically among vulnerable populations such as the seri-
ously ill, palliative patients, mentally ill, nursing home residents, and terminal
patients. However, self-transcendence is also seen to be fundamental to
healthy people’s well-being and coping such as nursing students and home-­
dwelling older people. Thus, the dimensions of inter-personal and intra-­
personal self-transcendence along with the sense of coherence dimensions
might be useful as a map to assess which health promoting resources are
present in an individual’s life. The core of self-transcendence is connected-
ness, outwardly, inwardly, upwardly, and backwardly (one’s past).
Connectedness is also a salutogenic resource, facilitating health, well-being,
as well as meaningfulness, hope, and joy-of-life, and is a vital aspect of the
nurse–patient relationship and the interaction between these two.
While assessing the patient’s situation, both bodily, emotionally, socially,
functionally, and spiritually/existentially, the nurse–patient interaction
(Chap. 10) is a necessary tool. However, the nurse–patient interaction is not
only a tool for valid and reliable assessment, but a salutogenic resource for
well-being and health by itself. By means of attentional and influencing
competences, health care personnel can positively impact on long-term
nursing home patients’ anxiety and depression, as well as joy-of-life, hope,
meaning-­in-­life, self-transcendence, and social support (Chap. 11). Indeed,
social support is seen to be related with loneliness and mortality among
older people in nursing homes, representing a vital salutogenic resource.
Social support (Chap. 11), efficacy (Chap. 12), and empowerment (Chap.
13) are all interrelated salutogenic resources embedded in the nurse–patient
interaction.

Health Promotion in Different Contexts (Part III)

Based on the health promotion perspective and these vital salutogenic

resources, Part III in this book presents different health promotion approaches
to several patient groups. Part III sets out with focusing on families having a
newborn baby (Chap. 14), which represents an important and existential
experience in parents’ lives having huge impact on the family health and the
baby’s health. A healthy population starts with a healthy and well-functioning
family raising healthy children. An individual’s health is highly dependent on
childhood conditions, both physically and mentally. In all countries, the aim
is to facilitate a flourishing population (Chap. 15), despite chronic illnesses
(Chap. 16), cancer (Chap. 17), long-term intensive care treatment (Chap. 18),
and heart failure (Chap. 19).
The segment of older people is increasing, resulting in many people
80 years an older being treated for various diseases in hospitals. Being 80+
and treated in a hospital setting represents a specific vulnerable state (Chap.
20). While treating older people medically in hospitals, their specific vulner-
ability must be considered in every aspect; if overseen, the health services
Introduction to This Book ix

will fail and create more illness and suffering than they relieve or solve,
which of course is a great pity!
In an international perspective, part three focuses on palliative care in an
African context of Uganda (Chap. 21) as well as on age care in a middle-­
income context of Turkey (Chap. 22). Health promotion as a central idea
in palliative care as well as elderly care should be further developed along
with efficient symptom management and pain relief. In Turkey, the care of
old people is mainly handled by the families. As the Turkish society devel-
ops toward a modern organization of both genders partaking in the work
life, health promoting strategies caring for the elders, as well as the female
caretakers will be important. In Singapore, researchers have operationalized
the salutogenic health theory into diverse health promotion programs; the
SHAPE study (Chap. 23) and the intergenerational e-health literacy program
(Chap. 24) interestingly demonstrate ideas about how to promote people’s
health as part of the municipality public health services. Finally, the number
of individuals having dementia is heavily increasing worldwide, represent-
ing a huge challenge in all countries. Hence, health promotion initiatives are
strongly needed in the care for people having dementia (Chap. 25) as well as
their families.
The last chapter (Chap. 26) sums it all up, pointing forwards to the future
challenges. With the aim of reorienting the health services in a health pro-
moting direction, still much work remains worldwide. This book intends to
serve these coming reorienting processes. This edited scientific anthology
represents a vital contribution to university educations in the health sciences.
Currently, a collection in between two binders of the central salutogenic
theoretical framework and empirical research on health promoting assets in
the health system is missing. This edited scientific anthology meets the need
for a substantial overview of vital salutogenic theories/concepts in health
care, along with knowledge on health promotion research related to different
patient populations.
This book represents a vital contribution to university education globally;
the target group is bachelor students in nursing as well as other health pro-
fessions (occupational therapists, physiotherapists, radiotherapists, social
care workers, etc.) and master students in nursing and health sciences. This
book also provides an overview for PhD students, clinicians, and researchers
in the field of health science and health promotion. The fact that all authors
are in the forefront and widely published in their specific field, work as pro-
fessors (educators and researchers) in health/social care, representing differ-
ent parts of the world (Africa, America, Australia, Asia, Europe), and
different countries (Australia, Belgium, China, Norway, Uganda, USA,
Singapore, Sweden, Turkey) gives this book a broad audience and thus a
broad influence.
We as the editors of this scientific anthology providing ideas and perspec-
tives on how to reorient the health care system, wish and hope for this book
to be extensively used. Therefore, we afford this anthology as an open access
easily reached for everyone.
x Introduction to This Book

We are grateful and want to thank all the contributors for their interesting
and important manuscripts included here. Also, we are thankful to the NTNU
Publiseringsfondet, and NTNU Deparment of Public Health Nursing for sup-
porting the open access of this book.


Trondheim, Norway Gørill Haugan
Levanger, Norway
Trollhättan, Sweden Monica Eriksson

References
1. HOD. St.meld. nr. 25: Mestring, muligheter og mening. Framtidas omsorgsutfor-
dringer. Omsorgsplan 2015. In: HOD, [Ministry of Health and Care Services] editor.
Oslo: www.odin.dep.no; 2005–2006.
2. WHO. World Report on Ageing and health. World Health Organization; 2018. https://
www.who.int/news-room/fact-sheets/detail/ageing-and-health [updated 5 Feb 2018].
3. Kinsella K, He W. An Aging World: 2008. Washington, DC: U.S. Department of
Health and Human Services National Institutes of Health National Institute on Aging.
U.S. Department of Commerce Economics and Statistics; 2009. Contract No.: Report
No.: P95/09-1.
Contents

Part I Introduction to Health Promotion

1 An Introduction to the Health Promotion Perspective

in the Health Care Services ������������������������������������������������������������   3
Gørill Haugan and Monica Eriksson
2 The Overarching Concept of Salutogenesis in the
Context of Health Care�������������������������������������������������������������������� 15
Geir Arild Espnes, Unni Karin Moksnes, and Gørill Haugan
3 The Ethics of Health Promotion: From Public
Health to Health Care���������������������������������������������������������������������� 23
Berge Solberg

Part II Central Health Promotion Concepts and Research

4 Sense of Coherence�������������������������������������������������������������������������� 35
Unni Karin Moksnes
5 A Salutogenic Mental Health Model: Flourishing
as a Metaphor for Good Mental Health���������������������������������������� 47
Nina Helen Mjøsund
6 Hope: A Health Promotion Resource �������������������������������������������� 61
Tone Rustøen
7 Dignity: An Essential Foundation for Promoting Health
and Well-Being �������������������������������������������������������������������������������� 71
Berit Sæteren and Dagfinn Nåden
8 Meaning-in-Life: A Vital Salutogenic Resource for Health �������� 85
Gørill Haugan and Jessie Dezutter
9 Self-Transcendence: A Salutogenic Process for Well-Being �������� 103
Pamela G. Reed and Gørill Haugan
10 Nurse-Patient Interaction: A Vital Salutogenic
Resource in Nursing Home Care���������������������������������������������������� 117
Gørill Haugan

xi
xii Contents

11 Social Support���������������������������������������������������������������������������������� 137

Jorunn Drageset
12 Self-Efficacy in a Nursing Context ������������������������������������������������ 145
Shefaly Shorey and Violeta Lopez
13 Empowerment and Health Promotion in Hospitals���������������������� 159
Sidsel Tveiten

Part III Empirical Research on Health Promotion

in the Health Care

14 Health Promotion Among Families Having a

Newborn Baby���������������������������������������������������������������������������������� 173
Shefaly Shorey
15 Salutogenic-Oriented Mental Health Nursing: Strengthening
Mental Health Among Adults with Mental Illness������������������������ 185
Nina Helen Mjøsund and Monica Eriksson
16 Health Promotion Among Individuals Facing
Chronic Illness: The Unique Contribution of the
Bodyknowledging Program������������������������������������������������������������ 209
Kristin Heggdal
17 Health Promotion Among Cancer Patients: Innovative
Interventions������������������������������������������������������������������������������������ 227
Violeta Lopez and Piyanee Klainin-Yobas
18 Health Promotion Among Long-­Term ICU Patients
and Their Families �������������������������������������������������������������������������� 245
Hege Selnes Haugdahl, Ingeborg Alexandersen,
and Gørill Haugan
19 Health Promotion and Self-­Management Among
Patients with Chronic Heart Failure���������������������������������������������� 269
Ying Jiang and Wenru Wang
20 Older Adults in Hospitals: Health Promotion
When Hospitalized �������������������������������������������������������������������������� 287
Anne-S. Helvik
21 Sociocultural Aspects of Health Promotion in
Palliative Care in Uganda���������������������������������������������������������������� 303
James Mugisha
22 Health Promotion Among Home-­Dwelling Elderly
Individuals in Turkey���������������������������������������������������������������������� 313
Öznur Körükcü and Kamile Kabukcuoğlu
23 SHAPE: A Healthy Aging Community Project
Designed Based on the Salutogenic Theory ���������������������������������� 329
Betsy Seah and Wenru Wang
Contents xiii

24 Health Promotion in the Community Via an

Intergenerational Platform: Intergenerational
e-Health Literacy Program (I-HeLP)�������������������������������������������� 349
Vivien Xi WU
25 Coping and Health Promotion in Persons with Dementia ���������� 359
Anne-S. Helvik

Part IV Closing Remarks

26 Future Perspectives of Health Care: Closing Remarks���������������� 375

Gørill Haugan and Monica Eriksson
About the Editors

Gørill Haugan graduated as a registered nurse (RN) in 1984 and holds a

PhD in health science. Haugan has worked as an academician since 1989 and
thus educated a great number of nursing and health care students at all levels.
Currently, she works as a professor in health and nursing science at NTNU
Department of Public Health and Nursing, Faculty of Medicine and Health in
Norway, and professor II at Nord University, Faculty of Nursing and Health
science. Professor Haugan is supervising bachelor theses in nursing care,
along with PhD and master’s projects focusing on different aspects of nursing
and global health, collecting data in Norway as well as in Nepal and Uganda.
Furthermore, she is supervising assistant professors in achieving competence
as associate professor at NTNU and Nord University. Haugan is widely pub-
lished internationally, with more than 140 scientific publications in the field
of health promotion among different populations such as older people, long-
term intensive care patients, adolescents and postnatal women, as well as
nursing students and health care workers. She is the main editor of three dif-
ferent scientific anthologies (including this one) focusing on health promo-
tion in health care. In particular, she has investigated the influence of
nurse–patient interaction, self-transcendence, hope, meaning-in-life, sense of
coherence, joy-of-life and spirituality on individual’s well-being and quality
of life, as well as developed and validated several measurement models cen-
tral to nursing and health care. Haugan leads several research projects in vari-
ous fields including various populations and evaluates research proposals for
funding in Norway. She collaborates with researchers at different universities
in Norway, Belgium, the Netherlands, Poland, Turkey, Sweden, Finland,
Singapore, Uganda, Nepal, Malta, and the USA.
Monica Eriksson is associate professor in social policy (health promotion)
at Åbo Akademi University Vasa, Finland. Current position as Senior
Professor in public health and health promotion in the Department of Health
Sciences, University West, Trollhättan, Sweden. Former Head of the Center
on Salutogenesis, University West. Member of the Global Working Group on
Salutogenesis 2007–2018. Defended a doctoral thesis in 2007, a systematic
research synthesis, based on more than 450 scientific papers on studies using
Antonovsky’s sense of coherence scale, titled “Unravelling the Mystery of
Salutogenesis” (Eriksson 2007). Now continuing the analysis and following
salutogenic research up to date. Main research focuses on salutogenesis in
public health and health promotion research and practice where peoples’

xv
xvi About the Editors

abilities and resources are essential for health and well-being. The most
recent research is on salutogenic factors for sustainable working life for
nurses. Previously worked as a hospital-based social worker, operative direc-
tor of an umbrella organization for people with disabilities, later as the Nordic
investigator of mobility of people with disabilities. “My clinical experience
and practice has convinced me the resource perspective of public health and
health promotion is the way forward for both research and effective
interventions.”
 Part I
Introduction to Health Promotion
 An Introduction to the Health
Promotion Perspective
1
in the Health Care Services

Gørill Haugan and Monica Eriksson

Abstract a health promotion direction is highly needed.

The salutogenic approach seems useful for such
Currently, the world faces a shift to an older
a reorientation.
population. For the first time in the history, now
Salutogenesis is a resource-oriented theo-
most people can expect to live into their 60s and
retical approach which focuses on the origin
beyond. Within this trend of people living lon-
of health along with people’s abilities and
ger, many grow very old; 80, 90 and 100 years.
capacities for well-functioning and well-­
Today, 125 million people are 80 years or older;
being. Salutogenesis is an area of knowledge
the proportion of ≥80 years increases the most.
and learning, a way of relating to others, and
Age is not an illness, still most chronically ill
a way of working in a health-promoting man-
are older people. Consequently, all countries in
ner. From the salutogenic point of view,
the world face major challenges to ensure that
health is a movement on a continuum between
their health and social systems are ready to
ease and dis-ease. In this approach, no one is
make the most of this demographic shift.
categorized as healthy or diseased; we are all
Globally, finding new and effective ways to
somewhere between the imaginary poles of
improve people’s health is crucial. Thus, in the
total wellness and total illness.
years to come, health promotive initiatives will
This chapter, as well as this book, compre-
become ever more important. Accordingly,
hend the salutogenic health theory as a model
learning how to reorient the health care sector in
of health and a life orientation, representing a
vital theoretical basis for the health promotion
field. Accordingly, this chapter presents some
important points in the development of the
G. Haugan (*) health promotion field, followed by the core
Department of Public Health and Nursing, NTNU principles and strategies of health promotion
Norwegian University of Science and Technology,
Trondheim, Norway and the promising potential of the salutogenic
health theory.
Faculty of Nursing and Health Science, Nord
University, Levanger, Norway
e-mail: gorill.haugan@ntnu.no, Keywords
gorill.haugan@nord.no
Health promotion · Salutogenesis ·
M. Eriksson
Department of Health Sciences, University West,
Demographic trends · Non-communicable
Trollhattan, Sweden diseases · Reorienting the health services
e-mail: monica.eriksson@hv.se

© The Author(s) 2021 3

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_1
4 G. Haugan and M. Eriksson

1.1 Introduction estimated number of people with dementia is

expected to grow exponentially, two million peo-
1.1.1 Demographic Trends ple in 2015 rising to four million in 2030 and ten
million in 2050 [2], an increase of 329% from
Currently, the world faces a shift to an older pop- 2015 through to 2050, the second fastest in the
ulation; 125 million people are now aged 80 years world. Currently, North Africa and the Middle
or older [1]. While this shift started in high-­ East are estimated to have the highest age-­
income countries (e.g. in Japan 30% of the popu- standardized prevalence globally [5].
lation are already over 60 years old), it is now The increasing burden due to cancer and other
low- and middle-income countries that are expe- non-communicable diseases poses a threat to
riencing the greatest change. Today, for the first human development, which has resulted in global
time in the history, most people can expect to live political commitments reflected in the Sustainable
into their 60s and beyond [2]. Between 2015 and Development Goals as well as the World Health
2050, the proportion of the world’s population Organization (WHO) Global Action Plan on
over 60 years will nearly double from 12% to Non-Communicable Diseases. Between 2006
22%; by 2050, the world’s population aged and 2016, the average annual age-standardized
60 years and older is expected to total two billion, incidence rates for all cancers combined increased
up from 900 million in 2015 [1, 2]. All countries in 130 of 195 countries or territories, and the
in the world face major challenges to ensure that average annual age-standardized death rates
their health and social systems are ready to make decreased within that timeframe in 143 of 195
the most of this demographic shift [1]. Within countries or territories [6]. Thus far, few coun-
this trend of people living longer, many grow tries have been able to overcome this challenge.
very old; 80, 90 and 100 years. Today, 125 mil- Nevertheless, in the US cancer incidence (for all
lion people are 80 years or older; the proportion cancer sites combined) rates have decreased
of ≥80 years increases the most. among men and were stable among women.
Thus, it is important to ensure that the extra Overall, there continue to be significant declines
years of life are worth living, despite chronic ill- in cancer death rates among both men and
nesses and loss of functionality. This is of great women. With early detection and treatment peo-
importance not only to the individual elderly, but ple survive cancer and are living with several side
also to the families, the local community and the effects [7].
municipality. However, there is little evidence Heart failure (HF) is a global pandemic affect-
showing that older adults today have better health ing about 38 million people and is a growing
than their parents had in their older years. Age is health problem worldwide [8–10]. Even though
no disease; however, most chronically ill people the incidence of HF is stable, the prevalence is
today are older people. Increased age is followed going to rise because of the ageing population
by an increased incidence of functional and and improvements in treatment [11, 12]. The HF
chronic comorbidities and diverse disabilities [3], condition is common in both developing and
which for many leads to the need for medical developed countries; the switch towards a
treatment and different levels of nursing care. Western lifestyle in developing countries may be
Accordingly, the WHO’s Action Plan on Aging contributing to a real HF pandemic. Consequently,
and Health [4] highlights a global need of sys- HF health expenditures are considerable and will
tems for providing long-term care to meet the increase dramatically with an ageing population.
needs of older people globally. HF is one of the most common causes of hospi-
All countries face major challenges to ensure talization and readmission [13–16]. The preva-
that their health and social systems are ready to lence, incidence, mortality and morbidity rates
make the most of these demographic shifts [2]. reported show geographic variations, depending
For instance, in the North Africa and the Middle on the different aetiologies and clinical character-
East, due to very rapid demographic ageing, the istics observed among patients with HF. The risk
1 An Introduction to the Health Promotion Perspective in the Health Care Services 5

factors for HF are multifactorial and complex, egates from 38 nations came together and made
and there is no known prevention other than treat- a commitment to health promotion; based on the
ment of the risk factors, such as hypertension, Alma-­Ata Declaration, the Ottawa Charter for
diabetes and obesity; whereas prevention and health promotion was born [21]. This charter
early treatment strategies (i.e. early revascular- defined health promotion as ‘the process of
ization) appear to be effective in reducing the risk enabling people to increase control over, and to
and severity of acute myocardial infarction [17]. improve, their health. To reach a state of com-
Moreover, today depression is the most com- plete physical mental and social wellbeing, an
mon psychological disorder, affecting about individual or group must be able to identify and
121 million people in all ages worldwide. WHO to realize aspirations, to satisfy needs, and to
states that depression is the leading cause of dis- change or cope with the environment’ [22]. The
ability as measured by Years Lived with Disability Ottawa Charter became a core policy document
(YLDs) and the fourth leading contributor to the and a cornerstone in establishing the health pro-
global burden of disease. By the year 2020, motion field [23].
depression is projected to reach the second place The Lancet—University of Oslo (UiO)
in the ranking of Disability Adjusted Life Years Commission of Global Governance for Health
(DALY) calculated for all ages. stated that ‘health is a precondition, outcome,
This demographic development will have con- and indicator of a sustainable society, and
sequences both economically, socially, culturally should be adopted as a universal value and
and politically [18]. The health care systems shared social goal and political objective for
around the globe will face great challenges in the all’ [24]. According to Samdal and Wold [23],
years to come. Health promotive initiatives will health promotion is a modern ideology and
become ever more important; not only for people strategy to improve public health. It represents a
with physical and mental disabilities and older reorientation of public health from addressing
persons living at home or in care facilities, but individual risk factors of health or risk behav-
also among the healthy population in supporting iours toward targeting determinants of health
them to stay healthy. Facing these demographic and empowering individuals and communities
trends, finding new and effective ways to improve to participate in improving the health of their
people’s health globally is imperative. Health communities [25, 26].
promotion should be a vital part of the health care ‘Health promotion is positive and dynamic. It
systems. opens up the field of health to become an inclu-
sive social, rather than an exclusive profes-
sional activity. It represents a broadening of
1.1.2  he Background of Health
T perspectives in relation to health education and
Promotion to prevention as a whole’ ([27], p. 3). In these
words, the former Chair of the Editorial Board
WHO has for a long time promoted a common of Health Promotion International introduced
approach to health policy by developing a series this new scientific journal in 1986. She was one
of targets for improved health status, i.e. the of the key persons strongly and deeply involved
Health for All Strategy—Targets for Health for in the discussions of the content of health pro-
All [19]. Several health conferences have been motion and how health promotion differs from
arranged by WHO. Two of the most significant public health and disease prevention. Some of
conferences were arranged in Alma Ata in 1978, the key notions of these discussions were sum-
resulting in the Alma-Ata Declaration, which marized in a document by the WHO European
emerged as a milestone of the twentieth century Office [28]; Scriven and Orme described this
in the field of public health [20]. The second publication as the emergence of health promo-
was arranged in Ottawa, Canada, where 200 del- tion as a major movement [21].
6 G. Haugan and M. Eriksson

1.1.3  he Core Principles

T 1. Build a healthy public policy.
and Strategies of Health 2. Create supportive environments.
Promotion 3. Strengthen community action.
4. Develop personal skills.
Health is seen as a resource of everyday life, 5. Reorient health services.
not the objective of living. Health is a positive
concept emphasizing social and personal These principles have stood the test of time,
resources, as well as physical capacities. The and the first four actions are developing well.
prerequisites for health as the fundamental con- However, the principle of ‘reorienting health ser-
ditions and resources are peace, shelter, educa- vices’ has until recently been given less attention.
tion, food, income, a stable ecosystem, Available evidence guiding the health care ser-
sustainable resources, social justice and equity vices into a more health-promoting direction is
[22]. Three basic principles for health promo- still scarce. What does it mean to reorient health
tion work from the Ottawa Charter: advocate, services? According to the Ottawa Charter [22],
enable and mediate. it means that the responsibility for health promo-
tion in health services is shared among individu-
• Advocate: Political, economic, social, cul- als, community groups, health professionals,
tural, environmental, behavioural and biologi- health service institutions and governments. They
cal factors can all favour health or be harmful must work together toward a health care system
to it. Health promotion action aims at making which contributes to the pursuit of health. Health
these conditions favourable through advocacy services need to embrace an expanded mandate
for health [22]. which is sensitive to and respects cultural needs.
• Enable: Health promotion focuses on achiev- This mandate should support the needs of indi-
ing equity in health. Health promotion action viduals and communities for a healthier life and
aims at reducing differences in current health open channels between the health sector and
status and ensuring equal opportunities and broader social, political, economic and physical
resources to enable all people to achieve their environmental components. Reorienting health
fullest health potential. This includes a secure services also requires stronger attention to health
foundation in a supportive environment, research as well as changes in professional edu-
access to information, life skills and opportu- cation and training. This must lead to a change of
nities for making healthy choices. People can- attitude and organization of health services,
not achieve their fullest health potential unless which refocuses on the total needs of the indi-
they are able to take control of those things vidual as a whole person.
which determine their health [22]. In the special supplement of Health Promotion
• Mediate: The prerequisites and prospects for International entitled ‘The Ottawa Charter for
health cannot be ensured by the health sector Health Promotion 25 years on’, a panel of diverse
alone. Professional and social groups and commentators reviewed progress and opportuni-
health personnel have a major responsibility ties. Authors agreed that there had been slow
to mediate between differing interests in soci- progress in making health promotion a core busi-
ety for the pursuit of health [22]. ness for health services, and there was a need to
reframe, reposition and renew efforts. One pro-
The Ottawa Charter clearly stated that a major posal was to focus on reorienting the system
aim of health promotion is to achieve equity in itself—not just the delivery of services—by
health by enabling all people to achieve their full- health promotion leaders engaging more actively
est health potential. To achieve this goal, five core in system development [29]. In an Editorial in
strategies for health promotion action were Health Promotion International, John Catford
identified: claimed that it is time to reorient health services
1 An Introduction to the Health Promotion Perspective in the Health Care Services 7

[30]. He expressed that at the time of Ottawa in An editorial entitled ‘Turn, turn, turn: time to
1986 the conferees agreed that ‘The role of the reorient health services’ in the Health Promotion
health sector must move increasingly in a health International journal ([30], p. 3) emphasized a
promotion direction, beyond its responsibility for changed way of working from ‘downstream’
providing clinical and curative services’ ([30], acute repair—to ‘upstream’ health improvement
p. 1). What has happened after Ottawa? Twenty-­ and from patient compliance—to consumer con-
three years later ‘there still seems to be an trol and centredness. This way of working can be
urgency towards the empowerment of patients to visualized by using ‘health in the river of life’ as
truly take control over a hospital environment a metaphor for health promotion [35].
that too often seems counter to their health’ The river as a metaphor of health development
([31], p. 106). This echoed earlier comments that (Fig. 1.1) has often been used. According to
‘across the world there appears to have been Antonovsky, it is not enough to promote health
stubborn resistance to systematic change in by avoiding stress or by building bridges keeping
health care services, and only limited examples people from falling into the river. Instead, people
of effective and sustainable health services reori- have to learn to swim [36]. Lindström and
entation’ [32]. Thompson, Watson and Tilford Eriksson (2010) presented Salutogenesis in the
come to the same conclusion after summarizing context of health promotion research, using a
the efforts done 30 years after the Ottawa ([33], new analogue of a river, ‘Health in the River of
p. 73): ‘Although its principles have been widely Life’. The river of life is a simple way to demon-
applauded, opportunities to transfer these prin- strate the characteristics of medicine (care and
ciples into the radical changes and practical treatment) and public health (prevention and pro-
solutions needed globally to improve health have motion) shifting the perspective and the focus
been missed. Nevertheless, it is argued that the from medicine to public health and health pro-
Ottawa Charter retains its relevance to the pres- motion toward population health.
ent day and that all policy makers and profes- The aim of this anthology is to describe and
sionals working to promote positive health should clarify health promotion in the context of health
revisit and take heed of its principles’. care settings. By doing so, we argue that the most
The WHO Regional Office for Europe has fur- appropriate theoretical foundation for health pro-
ther developed basic guiding principles for health motion in health care is the salutogenic theory of
promotion work ([34], pp. 4–5) which should be health by Antonovsky [36–38]. An integration of
characterized by the following principles: salutogenesis in health care could be a way to re-­
orient health services in line with the Ottawa
• Empowering (enabling individuals and com- Charter for health promotion [22].
munities to assume more power over the per-
sonal, socioeconomic, and environmental
factors that affect their health). 1.1.4 The Salutogenic Theory
• Participatory (involving all concerned at all as the Foundation of Health
stages of the process). Promotion
• Holistic (fostering physical, mental, social
and spiritual health). In many countries, health promotion has been
• Equitable (guiding by a concern for equity and primarily a field of practice and less a field of
social justice). research [23]. The Ottawa conference in 1986
• Sustainable (bringing about changes that indi- established the health promotion field, while the
viduals and communities can maintain once Jakarta conference in 1997 started a discussion
initial funding has ended). of theory-driven approaches and evidence in
• Multistrategy (using a variety of approaches this field. Throughout the two decades follow-
and methods). ing the Ottawa conference, the health promotion
8 G. Haugan and M. Eriksson

H+ ease healthy orientation SALUTOGENESIS

PROMOTE
EDUCATE

PREVENT

PROTECT
Quality of life
CURE Wellbeing
H– dis-ease

© Begt Lindstrom, Monica Erikson, Peter Wikström

Fig. 1.1 Health in the River of Life. (Published with permission from Folkhälsan Research Center, Helsinki, Lindström
& Eriksson ([35], p. 17))

field has developed from a practice and policy various theories, both health theories
field to also include a stronger theory and (Antonovsky, Illich, Lalonde) and sociological
research field. There is currently a strong drive theories (Giddens, Mead, Foucault). However,
toward research-­ based practice in this field the theoretical base for health promotion came
building on numerous evaluations of practices in the cloud of more practical health work.
and programmes that have been developed and Just before the Ottawa conference in 1986, a
implemented in the course of these years ([23], special meeting was held in Copenhagen hosted
p. 7). Samdal and Wold ([23], p. 9) provided an by the WHO Regional Office for Europe. Aaron
overview of t­heories relevant to health promo- Antonovsky was invited and participated in the
tion; at the individual level, numerous concepts meeting and discussions. Nonetheless, the saluto-
and theories in behavioural sciences contribute genic theory did not appear in the formulations of
to the identification of conditions and processes the Ottawa Charter. Tamsma and Costongs ([40],
that enable people to develop the personal skills p. 45) from the EuroHealthNet partnership stated
necessary to make healthy choices. Vital psy- that even if much evidence has been generated
chological phenomena found to influence about the value of health promotion to health sys-
healthy choices are beliefs, knowledge, self- tems efficiency, outcomes and sustainability, yet
efficacy, skills, roles, attitudes and values. the health (care) sector itself has been unable to
Important psychosocial concepts include social adopt a systematic health promotion perspective
support, social cohesion, interpersonal stress, and integrate it into broader systems and gover-
significant others and social norms. Social influ- nance. The wide gap between the worlds of pro-
ence processes on health are explained by social moting health and curing disease remains. The
psychological theories, such as social learning reorientation of health sectors is where least
theory (social cognitive theory), the theory of progress from the Ottawa Charter principles can
planned behaviour, the self-­determination the- be noted. To conclude, there is still much work to
ory, the social reproduction perspective and do to implement health promotion into the health
various socialization theories (e.g. ecological care sector in general, and the salutogenic theory
systems theory). In her lecture, ‘The history and and perspective in particular. Therefore, this book
the future: towards a new public health’ at the provides knowledge on health promotion and the
conference Next Health in Trondheim, potential role of salutogenesis in order to reorient
Kickbusch [39] described how people involved the health care sector in a health promotion
in the Ottawa conference were influenced by direction.
1 An Introduction to the Health Promotion Perspective in the Health Care Services 9

1.1.4.1 The Ontology of Salutogenesis world: seeing humans as part of and in interac-
Ontology is the study of reality [41]. What do we tion with the environment and context.
know about the ontological background of salu-
togenesis? In his second book, Unraveling the 1.1.4.2 The Epistemology
Mystery of Health [36], Antonovsky described of Salutogenesis
how he perceived the world. Two important Epistemology is the study of knowledge [44].
things stand: (1) he saw man in interaction with Going back to Antonovsky’s writings [36, 37], lit-
his environment and (2) chaos and change as nor- tle insight into his thoughts about knowledge gen-
mal states of life. The former calls for system erating and learning is provided. As far as we
theory thinking where the focus is on the know, he did not manifest an epistemological basis
­individual in a context [42, 43]. By the latter, for salutogenesis, neither describing his view of
Antonovsky perceived daily life as constantly how knowledge in general arises nor how learning
changing; a heterostatic as opposed to a homeo- can be meaningful in the salutogenic framework.
static state. For the individual, the challenge is to It appears that he was preoccupied with examining
manage the chaos and find strategies and and describing how a strong SOC may have an
resources available for coping with the changes impact on perceived health. A search in different
in everyday life. As a medical sociologist, he dis- databases provides little response [43].
tinctly expressed systems theory thinking, this Epistemologically, salutogenesis can be conceived
was a natural way for Antonovsky to perceive the as a constant learning process as shown in Fig. 1.2.

Fig. 1.2 Salutogenesis

from an epistemological
perspective. (With
permission from:
Eriksson M. The Sense Knowledge
of Coherence in the
Salutogenic Model of
Health. In: Mittelmark
MB, Sagy S, Eriksson
M, Bauer G, Pelikan J,
Health
Lindström B, et al., Culture literacy
editors. The Handbook
of Salutogenesis.
New York: Springer;
2017. p. 91–6)

EPISTEMOLOGY

WIL -
Work- A way of
integrated relating to
learning others

Learning
10 G. Haugan and M. Eriksson

Figure 1.2 portrays that knowledge supports STRESSOR

the movement toward the ease pole of the ease/

dis-ease continuum (Fig. 1.3), while knowledge H– H+
increases health literacy, which facilitates devel-
opment in the ways one relates to one’s world. TENSION
SALUTOGENESIS
The process of relating to others produces learn-
ing, and the knowledge gained from practice PATHOGENESIS

expands one’s area of knowledge. In the course

of daily life, this integrated learning process is BREAKDOWN

continuous. The concept of work-integrated

Fig. 1.3 The ease/dis-ease continuum [36, 37].
learning (WIL) is a new concept describing dis- (Published with permission from Folkhälsan Research
tinctive aspects of pedagogics and learning pro- Center, Helsinki, Bengt Lindström, Monica Eriksson,
cesses in health care settings [45]. The core of the Peter Wikström [35])
salutogenic theory is to maintain and even
develop health; this happens here and now in the
context and culture where people live. To relate Antonovsky assumed that we constantly are
to health promotion and the Ottawa Charter for exposed to changes and events that may be con-
health promotion [22], culture becomes a sidered as stressors. This may involve major life
resource in everyday life. events such as when someone in the family falls
ill, changes in the family (e.g. a divorce) or
1.1.4.3 H  ealth as a Process in an Ease/ changes in the workplace (organizational changes
Dis-Ease Continuum or unemployment). Theories on stress and coping
According to Antonovsky, health is the move- are mainly focused on the concept of control.
ment on a continuum between (H+, Fig. 1.3) ease However, the concept of control is not central in
and dis-ease (H-, Fig. 1.3) [46]. He referred to the the salutogenic theory. According to Antonovsky,
ability to comprehend the whole situation and the who can control life? To use Antonovsky’s own
capacity to use the resources available as the words, the salutogenic view of stress and coping
sense of coherence (SOC). This capacity was a includes the following:
combination of peoples’ ability to assess and … life is inherently full of stressors, with life-­
understand the situation they were in, to find a situation stressor complexes by far deserving most
meaning to move in a health-promoting direc- of our attention if we wish to understand either
health or disease. Focusing on health, I expressly
tion, also having the capacity to do so—that is, rejected the implicit assumption that stressors are
comprehensibility, meaningfulness and the man- inherently pathogenic. Their health consequences
ageability, to use Antonovsky’s own terms [43, can only be understood if we understand the cop-
47]. In such an approach, no one is categorized as ing process ([48], p. 48)
healthy or diseased. Since we are all somewhere
between the imaginary poles of total wellness 1.1.4.4 T he Key Concepts
and total illness, the whole population becomes of the Salutogenic Theory
the focus of concern. Even the fully robust, ener- Three key concepts form the salutogenic theory:
getic, symptom-­free, richly functioning individ- (1) sense of coherence and (2) generalized and
ual has the mark of mortality: he or she wears (3) specific resistance resources (described
glasses, has moments of depression, comes down more in detail in Part I, Chap. 2 and Part II,
with flu and may also have yet non-detectable Chap. 4).
malignant cells. Even the terminal patient’s brain Sense of coherence (SOC): Based on the inter-
and emotions may be fully functional. The great views with Israeli women about health and how
majority of us are somewhere between the two they were able to adapt to life events they went
poles. The idea of movement along an ease/dis- through, an important factor emerged: the sense
ease continuum is illustrated in Fig. 1.3. of coherence. It reflects a person’s view of life
1 An Introduction to the Health Promotion Perspective in the Health Care Services 11

and capacity to respond to stressful situations. individuals, groups, and communities; this
The original definition by Antonovsky [36] is as includes much more than the measurement of the
follows: SOC. Today, we talk about salutogenesis as a
SOC is a global orientation that expresses the model of health and a life orientation (the SOC)
extent to which one has a pervasive, enduring [50], as well as the salutogenic conceptual frame-
though dynamic feeling of confidence that (1) the work. Salutogenesis now represents an umbrella
stimuli from one’s internal and external environ- concept with many different theories and con-
ments in the course of living are structured, pre-
dictable, and explicable; (2) the resources are cepts with salutogenic elements and dimensions
available to one to meet the demands posed by [35]. Several of these concepts are highlighted in
these stimuli; and (3) these demands are chal- this anthology in Chaps. 4–18 and shown in bold
lenges, worthy of investment and engagement. fonts in Fig. 1.4.
(p. 19)
Certain trends in the salutogenic research
Behind a global orientation, SOC is a way of can be identified. These are (1) the translation
viewing life as structured, manageable, and and validation of the original SOC question-
meaningful. At least three dimensions form the naires (29 and 13 items), to other languages
SOC: comprehensibility, manageability and than English, (2) the use of the SOC question-
meaningfulness. It is a personal way of thinking, naires in different areas of research, (3) the
being and acting, with an inner trust, which leads term theory is more frequently used instead of
people to identify, benefit, use, and re-use the idea of health and health model. What is a the-
resources at their disposal [49]. ory? The development of a theory begins with
Generalized and Specific Resistance an idea, continues via various models, develop-
Resources (GRR and SRR): Along with the SOC, ment of questionnaires, testing in empirical
the other key concepts in the salutogenic theory practice, systematically synthesize research,
are the resistance resources [36, 37], including new instruments and insights. When all these
generalized resources (potentially available for steps take place in a systematic order, a theory
engagement in a wide range of circumstances) arises. Such a development can be seen accord-
and specific resources (particular resources rele- ing to the salutogenic theory. Further, (4) devel-
vant to particular circumstances). The resistance opment of programmes and interventions
resources are of a different nature: among others aiming at strengthening the SOC among
genetic and constitutional, psychosocial, cultural patients and professionals and (5) the use of the
and spiritual, material and a preventive health SOC questionnaire for the evaluation of the
orientation [47]. Resistance resources exist at effectiveness of interventions. The SOC ques-
the individual, the group (family), the subculture tionnaire has been used in different areas com-
and the whole society levels ([37], p. 103) and pared to when the research began. Examples of
represent the prerequisites for developing a new areas are oral health, health behaviour and
strong SOC. work–life research. Currently, a tendency to
move from only measuring SOC to applying
salutogenic principles into practice when pro-
1.1.5  alutogenesis Is More Than
S grammes and interventions are planned in vari-
the Measurement of the SOC ous settings can be seen; such promising
approaches among different populations in the
Salutogenesis is an area of knowledge and learn- health care are presented in Part III of this
ing, a way of relating to others and a way of book; examples are the SHAPE intervention
working in a health-promoting manner [43]. First among older community-dwelling people
and foremost, salutogenesis is a resource-­oriented (Chap. 23), the inter-generational platform
approach focusing on health and on people’s intervention study in Singapore (Chap. 24),
abilities and capacities. Currently, there is exten- nurse–patient interaction as a health promotion
sive research that focuses on the resources of approach in nursing homes (Chap. 10) and the
12 G. Haugan and M. Eriksson

SALUTOGENESIS

Theoretical concepts relevant to health care

© Monica Eriksson 2020

Social support | Empowerment | Flourishing | Sense of Coherence | Dignity | Belonging

Self-efficacy | Self-transcendence | Hope | Will to meaning | Willpower | Connectedness
Salutogenic nursing | Nurse-patient interaction | Person-centered care | Inner strength
Bodyknowledging | Coping

Reasonableness | Resilience | Learned resourcefulness | Attachment | Empathy | Wellbeing

| Learned hopefulness | Humour | Gratitude | Quality of Life | Flow | Hardiness | Social capital
Locus of Control | Ecological system theory | Interdisciplinarity | Cultural capital | Thriving
Posttraumatic Personal Growth | Learned optimism | Slow nursing

Fig. 1.4 Salutogenesis. Theoretical concepts relevant to health care

bodyknowledging among chronical ill (Chap. 3. WHO. Global status report on non-communicable
16). This implies that along the original SOC diseases. 2010. http://www.who.int/chp/ncd_global_
status_report/en/index.html. Accessed 23 Aug 2012.
questionnaires, a range of different question- 4. WHO. Global strategy and action plan on ageing and
naires have been developed and validated for health. IGO LCB-N-S, editor. Geneva: World Health
use in the field of health promotion research. Organization; 2017.
This is promising. As presented earlier in this 5. Prince M, Wimo A, Guerchet M, Ali G-C, Wu Y-T,
Prina M. World Alzheimer Report 2015: The Global
chapter, due to the demographic development Impact of Dementia. An analysis of prevalence, inci-
worldwide, the health care systems in all coun- dence, cost and trends. London: Alzheimer’s Disease
tries will face great challenges in the years to International; 2015.
come. Facing the demographic trends, finding 6. Global Burden of Disease Cancer Collaboration,
Fitzmaurice C, Akinyemiju TF, et al. Global, regional,
new and effective ways to improve people’s and national cancer incidence, mortality, years of
health globally is imperative. Hence, health life lost, years lived with disability, and disability-­
promotive initiatives will become ever more adjusted life-years for 29 Cancer Groups, 1990 to
important worldwide. 2016: a systematic analysis for the Global Burden of
Disease Study. JAMA Oncol. 2018;4(11):1553–68.
7. Cronin KA, Lake AJ, Scott S, Sherman RL, Noone
AM, Howlader N, et al. Annual report to the nation on
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 The Overarching Concept
of Salutogenesis in the Context
2
of Health Care

Geir Arild Espnes, Unni Karin Moksnes,

and Gørill Haugan

Abstract use by the participants of World Health

Organization (WHO) general assembly in
Two concepts that widely impact on our ways
1978. And after 8 years, the concept of health
to work with health is health promotion and
promotion was filled with content by the WHO
salutogenesis (For a quick overview of the
meeting in Ottawa in 1986. Meanwhile, saluto-
concept of salutogenesis, read Lindström B. &
genesis as a concept was constructed of the
Eriksson M. (2010). The Hitchhiker’s Guide to
Israeli scientist Antonovsky during the 1970s.
Salutogenesis. Folkhälsan Research Center).
It can be said that both health promotion and
The concept of health promotion was voted for
salutogenesis grew out of a wanting to under-
stand health development rather than under-
G. A. Espnes (*) standing health as a variable tied to the
Department of Public Health and Nursing, NTNU presence or absence of disease developments.
Norwegian University of Science and Technology, This chapter concentrates on discussing the
Trondheim, Norway
use of the salutogenic framework on the under-
NTNU-Center for Health Promotion Research, standing of health care situations.
Trondheim, Norway
e-mail: geirae@ntnu.no, geir.arild.espnes@ntnu.no
Keywords
U. K. Moksnes
Department of Public Health and Nursing, NTNU
Norwegian University of Science and Technology, Health · Health promotion · Salutogenesis ·
Trondheim, Norway Resources · Pathogenesis · Treatment
NTNU-Center for Health Promotion Research,
Trondheim, Norway
Faculty of Nursing and Health Science,
Nord University, Levanger, Norway 2.1 Salutogenesis: Turning
e-mail: unni.moksnes@ntnu.no Health Concerns from Solely
G. Haugan be Occupied with What Gives
Department of Public Health and Nursing, NTNU Disease to What Gives Health
Norwegian University of Science and Technology,
Trondheim, Norway
Salutogenesis has become a frequently used word
Faculty of Nursing and Health Science,
or concept in the health domain, and especially
Nord University, Levanger, Norway
e-mail: gorill.haugan@ntnu.no, within the public health and health promotion
gorill.haugan@nord.no

© The Author(s) 2021 15

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_2
16 G. A. Espnes et al.

area (see [1]). But where does the word come STRESSOR

from? And what does this concept mean? This

chapter sets out to reveal the answer to both these H– H+
questions and also to investigate how the under-
standing of health can be encompassed in health TENSION
SALUTOGENESIS
care and disease treatment.
PATHOGENESIS
The WHO Ottawa Charter [2] almost 35 years
ago clearly defined that health is “…a resource
for everyday life … A positive concept emphasiz- BREAKDOWN

ing social and personal resources, as well as Fig. 2.1 The ease dis-ease continuum. (Published with
physical capacities … To reach a state of com- permission from Folkhälsan Research Center, Helsinki,
plete physical, mental and social well-being.” Lindström & Eriksson [3])
This explanation of what health is gave a whole
new understanding of the rationale for what One of the keys to the salutogenic approach was
brings health instead of the sole pursuit of the to describe health as a continuum between “total
reasons of a disease or how to prevent diseases. health (H+) and total absence of health” (H−) or
These two equally old concepts of health promo- the “ease – dis-ease continuum” (see below
tion and salutogenesis sometimes are deemed the Fig. 2.1).
“starting shot” for the new challenge of enhanc- At any time, each of us can be placed on this
ing health rather than explaining and preventing continuum [4]. Stressors can upset our position,
disease. A new aera had begun. and we come under tension. Here are two options:
Salutogenesis was first used as a concept of either the pathogenic forces overtake us and we
health by the Israeli medical sociologist Aron break down or we regain our health through SOC
Antonovsky. In the 1960s, Antonovsky studied and move toward H+. The important point is to
female survivors from the Second World War’s focus on what moves an individual toward the
German concentration camps who by then had ease pole of the continuum, regardless of where
become grandmothers. What he found was the individual is initially located. By the continu-
remarkable. A number of the Jewish grandmoth- ation of his studies, Antonovsky presented a few
ers, now living in Israel, had not only survived distinct characteristics of what gave good health
the concentration camps, but also been able to to people, as well as developed a new health the-
live a good flourishing life, with good mental and ory of “salutogenesis.” The name of “salutogen-
physical health, in spite of the horrors in the esis” was constructed by combining the Latin
camps. Antonovsky stated that even if only a few word Salut (health—or to your health) with the
would have lived through the horrors and still Greek word Genesis (origin). Salutogenesis has
were able to live a flourishing life that would be become an interesting concept for scientists and
most remarkable and should be subject to thor- practitioners from a wide range of backgrounds
ough studies in search for the overarching ques- who had been in search for an approach to study
tion; what is the origin of good health? One of what brings health. Especially, the movement for
Antonovsky’s deviations from pathogenesis was health promotion research and work has shown
to reject the dichotomization into categories of great interest.
diseased or healthy. Antonovsky stated that dis- For many years, WHO had enquired for a
ease, stressors, and unpredictability are part of reorientation in health care representing the use
life and can never be controlled completely. The of both the resource (salutogenesis) and the treat-
interesting question that came to his mind was: ment paradigms (pathogenesis) as complemen-
how can we survive in spite of all this? The tary in health care. The health promotion
answer to this was understood as the individual’s approach had surfaced as an alternative to disease
sense of coherence and ability to identify and use prevention, keeping health as a target rather than
generalized and specific resistance resources. avoidance of disease on the WHO 1978 World
2 The Overarching Concept of Salutogenesis in the Context of Health Care 17

Conference in Alma Ata. After 8 years of inten- end of a health ease/dis-ease continuum” and
sive work to establish an understanding of health defined the life orientation concept of sense of
promotion and the need for an alternative to dis- coherence (SOC) as follows:
ease prevention across the world, the Ottawa “… a global orientation that expresses the extent to
Charter on Health Promotion was launched in the which one has a pervasive, enduring though
WHO World Conference in Ottawa 1986 [2], and dynamic feeling of confidence that one’s internal
the health social anthropologist that had led the and external environments are predictable and that
there is a high probability that things will work out
work became notoriously famous. Her name is as well as can reasonably be expected.” [7]
Ilona Kickbusch.
The Ottawa Charter became the answer to the Accordingly, salutogenesis is understood to
request for a reorientation of the world’s health describe the process of enabling individuals,
care systems. One can claim that there is quite an groups, organizations, and societies to emphasize
unrealized potential in health care to be more on abilities, resources, capacities, competences,
protective and promotive of health. However, the strengths, and forces in order to create a strong
Ottawa Charter was in lack of a theoretical model SOC; that is, to perceive life as comprehensible,
or theoretical approach to back its ideas. Since manageable, and meaningful which represent
salutogenesis was developed as a paradigm in three central components in SOC. Recent
opposition to the “pathogenic orientation which research shows this model is an effective
suffuses all western medical thinking” ([5], approach to positive health development in a life
p. 13), it had to be considered a health promotion course perspective [1]. However, the potential of
concept. In his brief 1996 paper in the journal this model has not been fully explored in health
Health Promotion International, Antonovsky promotion practice and research [1].
challenged the health promotion field to adopt The salutogenic model includes three central
salutogenesis as a health promotion theory. concepts: generalized resistance resources
In principle, applying salutogenesis as a health (GRRs), specific resistant resources (SRR), and
theory in the health promotion field could mean the above-mentioned SOC. The GRRs are of
to restrict the leading pathogenic orientation in both external and internal characters; people have
health care practice (research and policy) and at their disposal resources of both internal and
complement or change it by a salutogenic orien- external characters which make it easier for them
tation in everyday practice and research. It also to manage life [4]. Specific resistance resources,
became evident that Antonovsky had come up on the other hand, are optimized by societal
with a theoretical basis for the concept of saluto- action in which health promotion has a contribut-
genesis, and the underlying concept of “Sense of ing role, for example, the provision of supportive
Coherence” which explains what brings good social and physical environments [1].
health. The next part of this chapter dives further The GRRs are of any character ranging from
into the key concepts of Antonovsky’s saluto- material to virtual and spiritual dimensions of the
genic health model, namely sense of coherence mind, processes, and psychological mechanisms.
and resistant resources. The main thing is that people are able to use the
GRRs for their own good and for health develop-
ment. The GRRs, characterized by underload–
2.2  he Sense of Coherence
T overload balance and participation in shaping
and Resistant Resources outcomes (empowering processes), provide a
person with sets of meaningful and coherent life
As stated above, Antonovsky introduced the salu- experiences, which in turn create a strong SOC
togenic model as a new possible paradigm for [1].
health research [5]. In a lecture at Berkley in While GRRs are the prerequisites for develop-
1993 [6], he defined the concept of salutogenesis ing a strong SOC, the capability to use GRRs is
as “the process of movement toward the health based on people’s SOC, a concept that has been
18 G. A. Espnes et al.

shown to be of key importance in health research, based in reference to preserving and promoting
correlating positively with good health outcomes, health in different patient groups living with dis-
quality of life, and most psychological measures ease and infirmity. In his 1996 publication [5],
of well-being [1]. Today, there are hundreds of Antonovsky suggested that the appeal of the full
articles referring to the SOC in individuals and salutogenic model for those engaged in health
groups, as well as population studies that demon- promotion cannot be on the grounds of power-
strate the strength of this concept and phenome- fully demonstrated efficacy in producing signifi-
non. Antonovsky stated that people’s SOC is cant health-related change outcomes. It can be
mainly developed in childhood and early adult- understood that to release the unreleased poten-
hood. However, new research points to the fact tial of using the salutogenic framework in health
that SOC is a continuous process throughout the care, the only way to test the potential and effec-
entire life [1]. The perception of coherence is tiveness is to start using it in different health care
based on cognitive, behavioral, and motivational settings. A relevant question today is, therefore,
factors which are improved by raising the how far has the change toward a more protective
awareness of the population, empowering the
­ and promotive approach in health care come
population and engagement in areas which are since Antonovsky wrote this statement, and are
meaningful to the population. there any differences between different health
care settings?
First things first. Salutogenesis—the newer
2.3  alutogenesis in Health Care
S and more focused concept—has been introduced
Settings by Antonovsky into health promotion, which rep-
resents an older and broader concept, field, and
The health care sector is still primarily defined by movement. As pointed to above, Antonovsky [5]
a pathogenic paradigm, and the health care sys- underlined that “the basic flaw of the field (of
tem is most often anticipated as the system of health promotion) is that it has no theory.” Thus,
struggle against pathological developments, or as he proposed “the salutogenic orientation… as
Antonovsky expressed it “health care or more providing a direction and focus to this field.” He
correctly the disease care system” ([5], p. 12). also stated that “the salutogenic model is useful
The health care area has therefore often been for all fields of health care. In its very spirit, how-
seen as challenging for the application and imple- ever, it is particularly appropriate to health pro-
mentation of a salutogenic approach. To under- motion.” Hence, health promotion in health care
stand the challenge completely, one needs to ask definitely has the blessings of Antonovsky.
what is the essence in the challenge of integrating Therefore, we have to clarify how the salutogenic
these newer, more modern, and comprehensive orientation or model and its related construct of
health perspectives into health care? SOC can be integrated into health care, directly
The health care sector intends to profession- or via (re-)orienting health promotion in health
ally manage illness by trying to prevent or cure care indirectly.
diseases, or if this is not possible, at least to offer
care for chronic patients and palliative care.
However, the contribution of health promotion is 2.4  hat Can Salutogenesis
W
still marginal in the health care sector. Mean for Health Care, Across
Reorientation of health services, as demanded by Settings?
the Ottawa Charter [2], has not yet happened in
accordance to the expectations [8, 9]. There is In health care settings, the salutogenic paradigm
still quite an unrealized potential in health care to can be used for two purposes: either to guide
be more protective and promotive of positive health promotion interventions in health care
health. Further, also salutogenesis has quite an practice across settings or to (re)orient health
unrealized potential for being more evidence care research as such. For this, the salutogenic
2 The Overarching Concept of Salutogenesis in the Context of Health Care 19

paradigm offers specific concepts, assumptions, Applying these assumptions and implications
and instruments. According to Pelikan [10], three to health care practice would mean, again accord-
quite different conceptual forms can be distin- ing to Pelikan [10], that (1) since a salutogenic
guished: (1) a salutogenic orientation, (2) a salu- orientation encompasses all individuals indepen-
togenic model, and (3) the construct of the SOC dently of their position on the ease/dis-ease con-
and a methodologically sound way to operation- tinuum, health care should not only just care for
alize it. These three forms first have to be speci- the health of its patients, but take responsibility
fied in more detail, to be applied later to the for the health of its staff and the health of citizens
whole field of health care and later for specific as well (however, dichotomous classification of
settings. For that, health care has to be under- individuals into those who have some specific
stood as a complex of a strongly interrelated pro- disease or not, is unavoidable for doing curative
fessional practice, with clinical research and medicine on patients); (2) in relation to these
supporting policy. Therefore, applying saluto- three groups of patients, health care staff, and
genesis in health care successfully cannot just be citizens, not only their risk factors have to be
done by introducing salutogenesis in health care dealt with or fought by health care, but also pos-
practice; there is also a need for a change in sible health-promoting (salutary) factors have to
underlying health care policy. be enhanced in curative, preventive, protective,
and promotive practice; (3) a holistic approach,
including all sides and aspects; physical, mental,
2.4.1  he Salutogenic Orientation
T spiritual/existential, and social aspects of a per-
and Health Care son have to be taken into account in dealing with
all people affected by health care.
The first and most broad form of salutogenesis, In principle, to apply these assumptions on
a salutogenic orientation, is described by three health care sounds plausible and rational, but
assumptions: (a) the human system is subject to three aspects need to be fulfilled: firstly, to realize
unavoidable processes toward an unavoidable a policy change of the mandate of health care is
final death. Therefore, the necessity of adapta- necessary; secondly, to understand that the tradi-
tion or coping with accompanying tension that tional diagnostic and therapeutic repertoire of
may result in stress is universal and not the health care has to be widened; and thirdly, a radi-
exemption. (b) A continuum model, which sees cal change of clinical understanding and applica-
each and all of us somewhere along a health tion is implied. The last of these three might be
ease/dis-ease continuum. Therefore, a dichoto- especially difficult since part of the spectacular
mization into healthy and sick is not very help- medical success rests on focusing on a narrow
ful. (c) The concept of salutary factors or biomedical model.
health-promoting factors are shown to actively
promote health, which represents better health
rather than just being low on risk factors (see 2.4.2 The Salutogenic Model
[5], p. 14). Therefore, both risk and salutary fac-
tors have to be attended. A second way of understanding salutogenesis in
From these three assumptions follow implica- relation to health care settings is to understand
tions for health promotion. A salutogenic orienta- Antonovsky’s specific and rather complex saluto-
tion as the basis for health promotion directs both genic model ([7], see Chap. 7)). Within this
research and action efforts: (1) to encompass all model, the concept of GRRs is introduced as “a
persons, wherever they are on the continuum, and property of a person, a collective or a situation
(2) to focus on salutary factors, which (3) relate which, as evidence or logic has indicated, facili-
to all aspects of the person instead of focusing on tated successful coping with the inherent stress-
a particular diagnostic category as in curative ors of human existence” ([5], p. 15). This model
medicine or (even) in preventive medicine. has not been further explored, even if major psy-
20 G. A. Espnes et al.

chosocial, genetic, and constitutional GRRs are a generalized orientation toward the world which
specified within this model [11]. There is, how- perceives it, on a continuum, as comprehensible,
manageable and meaningful ([5], p. 15).
ever, a possibility via scientific scrutinization of a
wider view of this complex model encompassing Antonovsky further stated that
large societies and a possibility to further explore The strength of one’s SOC, I proposed, was a sig-
the model as an underlying understanding for nificant factor in facilitating the movement toward
policy and society interventions. health. This construct answers what do all these
In some countries, like Norway, we have GRRs have in common, why do they seem to work.
What united them, it seemed to me, was that they
through the last years seen a growing number of all fostered repeated life experiences which, to put
practical interventions in public health and health it at its simplest, helped one to see the world as
care that has been based in the general salutogenic ‘making sense’, cognitively, instrumentally and
model or other resource-based models [12]. It has emotionally ([5], p. 15).
also been observed how practical salutogenic work Here Antonovsky introduced the SOC as a
solutions have been used in health care among moderator or mediator of other determinants of
young in schools [13], for elderly both in nursing health rather than a specific determinant of
homes [14] and as an intervention approach in care health. “What matters is that one has had the life
situations among elderly outside nursing homes experiences which lead to a strong SOC; this in
[15]. These new studies make their ways into turn allows one to “reach out,” in any given situ-
health planning and health policy, but now also ation and apply the resources appropriate to that
increasingly in care and health care. It might seem stressor. “The strength of one’s SOC is shaped
like the change in orientation that De Leeuw [8] by three kinds of life experiences: consistency,
was asking for slowly is appearing. How central underload-overload balance, and participation
researchers in the area of salutogenesis research in socially valued decision making. The extent
sees the future developments is spelled out in two of such experiences is molded by one’s position
central publications: (1) the Handbook of in the social structure and by one’s culture.. .”
Salutogenesis from 2016 [16] and (2) in the 2019 ([5], p. 15).
article entitled “Future directions for the concept Is there one pivotal argument of how the SOC
of salutogenesis: a position article” [17]. can be introduced into health care? A thought
experiment:
Being ill and becoming a patient in profes-
2.4.3  he Sense of Coherence
T sional health care is often a rather threatening life
and Health Care Settings experience for people and being a health care
professional is a rather demanding job. Therefore,
If one utilizes the salutogenic model in health using the SOC concept for making the health care
care (see above), the GRRs specified in detail in context and the culture as far as possible consis-
the salutogenic health model would have to be tent, underload–overload balanced, and partici-
more adequately taken into account in health care patory for patients, health care staff, and visitors
practice and research, as well as in policy docu- could be an adequate argument and way to make
ments describing research activities and prac- health care systems more salutogenic driven,
tices. The model and its implications make much generally. This is possible, since “social institu-
sense for health care in different settings and tions in all but the most chaotic historical situa-
afford a more holistic and complex outlook and a tions can be modified to some degree” ([5],
widening of diagnostic and therapeutic methods p. 15). A different way to think about this, is to
applied. work with the possible feasibility, effectiveness,
The third most focused form of salutogenesis, and efficiency in developing salutogenic “stan-
the specific construct of SOC which has been dards” [18] and make institutional contexts more
introduced as a central factor in the salutogenic salutogenic. Even if Antonovsky assumed that
model of health, is defined as: one’s SOC cannot be radically transformed, he
2 The Overarching Concept of Salutogenesis in the Context of Health Care 21

left it open that the SOC could be shaped and well as developed a new health theory termed
strengthened, so that it in turn can push people “salutogenesis.” The name of “salutogenesis”
towards health [15]. Therefore, in reference of was constructed by combining the Latin word
patients’ situation, improving SOC by increasing Salut (health) with the Greek word Genesis
their health literacy among an array of other cop- (origin).
ing resources could become an explicit goal of • WHO has for many years demanded for a
chronic disease management. reorientation in health care representing the
use of both the resource (salutogenesis) and
the treatment (pathogenesis) paradigms as
2.5 Conclusions complementary in health care. The Ottawa
Charter became the answer to the request for a
The salutogenic perspective has clearly a poten- reorientation of the world’s health care sys-
tial to be applied in the health care across settings tems; there is still quite an unrealized potential
in relation to health promoting interventions for in health care to be more protective and pro-
the health of patients, staff, and citizens, and in motive of positive health.
supporting health-promoting structures and cul- • Applying salutogenesis as a health theory in
tures of health care institutions for better every- the health promotion field could mean to
day practice and policy. restrict the leading pathogenic orientation in
As we have pointed to in this chapter, there are health care practice (research and policy)
some very important implications for utilizing and complement or change it by a saluto-
the salutogenic approach and model as a way to genic orientation in everyday practice and
work in health care settings. The field or setting research.
will need (1) to encompass all persons, wherever • Salutogenesis as a concept is understood to
they are on the ease/(dis)ease continuum and (2) describe the process of enabling individuals,
to focus on known salutary factors, which (3) groups, organizations, and societies to empha-
relate to all aspects of the person rather than size abilities, resources, capacities, compe-
solely focusing on a particular diagnostic medi- tences, strengths, and forces to create a sense
cal category or criteria. of coherence; that is, to perceive life as com-
There is, of course, as for most other con- prehensible, manageable, and meaningful.
cepts and theories, a clear need for further • The salutogenic model includes three central
research, no doubt. Especially research focusing concepts: generalized resistance resources
on the salutogenic model and on the specific (GRRs), specific resistance resources (SRR),
role of SOC as a predictor, mediator, or modera- and sense of coherence (SOC).
tor is needed. Moreover, research shaped to lead • In health care settings, the salutogenic para-
to a better conceptual clarity and application of digm can be used for two purposes: either to
more complex research designs, especially on guide health promotion interventions in health
the link between SOC and other aspects of care practice across settings or to (re)orient
health than subjective and mental health, as well health care research as such. For this, the salu-
as on the impact of health care setting function- togenic paradigm offers specific concepts,
ing are required. assumptions, and instruments.

Take Home Messages

• The WHO Ottawa Charter clearly defines that References
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 The Ethics of Health Promotion:
From Public Health to Health Care
3
Berge Solberg

Abstract 3.1 Introduction

Health promotion is often been associated
with altering social arrangement in order to Even though ‘health promotion’ probably has
improve the health of citizens—the domain of been defined again and again in this book, we still
public health. Ethical aspects of health promo- need to pay attention to the definition before we
tion then is generally discussed in terms of a start talking about ethics. ‘Health promotion is
public health ethics. In this chapter, I start out the process of enabling people to increase control
with some classical ethical and political over, and to improve, their health. To reach a state
dilemmas of health promotion in public health of complete physical, mental and social well-­
before I move into the ethics of health promo- being, an individual or group must be able to
tion in health care. I argue that empowerment, identify and to realize aspirations, to satisfy
better than any other value, may serve as the needs, and to change or cope with the environ-
ethical foundation for health promotion in ment’. These are some of the first sentences in the
health care. I further claim that empowerment Ottawa charter for Health Promotion from 1986
may serve as the ethical bridge between health [1]. Taken in isolation, they may suggest that
promotion in health care and health promotion health promotion mainly has to do with the well-­
in public health. being of individual persons and patients. If that is
the case, an ethics of health promotion seems to
Keywords be some variants of an ethics of health care.
If we, however, focus on the first sentence of
Ethics · Empowerment · Autonomy the charter, we can notice that it says that ‘this
Paternalism · Nudging · Health · Positive conference was primarily a response to growing
freedom · Salutogenesis · Agency expectations for a new public health movement
around the world’. Health promotion is here
associated with public health. In a paper with the
telling title How to Think about Health Promotion
Ethics, Carter et al. define an ethics of health pro-
motion in this way: ‘We consider the normative
B. Solberg (*) ideal of health promotion to be that aspect of
Department of Public Health and Nursing, The public health practice that is particularly con-
Norwegian University of Science and Technology
(NTNU), Trondheim, Norway cerned with the equity of social arrangements: it
e-mail: berge.solberg@ntnu.no imagines that social arrangements can be altered

© The Author(s) 2021 23

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_3
24 B. Solberg

to make things better for everyone, whatever their more freedom than high taxes, because the for-
health risks, and seeks to achieve this in collabo- mer interferes less with your life than the latter.
ration with citizens. This raises two main ethical Individuality and liberty must be protected from
questions. First: what is a good society? And the community. Negative freedom is often
then: what should health promotion contribute to referred to as ‘freedom from…’.
a good society?’ [2]. If they are correct, an ethics Positive freedom means the freedom to pursue
of health promotion seems to be some variants of and realize your interest and priorities in your
an ethics of public health. life. If I am really interested in an academic
An ethics of health promotion belongs to both career, but cannot afford education, then my free-
spheres. In many ethical discussions, public dom is limited, even though the state has not
health has been a natural framework. The ethical interfered with my wishes. Rather the opposite
questions are clearly recognizable on this arena. would be true; the fact that the state has not pro-
But already in the Ottawa charter, there is a call vided opportunities for free education makes me
for reorienting the health services in the direction less free than I could have been. Defenders of
of health promotion. In this chapter, we take a positive freedom very often argue that the nega-
roundabout way. We start with some basic con- tive concept of liberty is naive and insufficient
cepts of political philosophy that gives us a [4]. Positive freedom is the rationale for the wel-
framework for the discussion. Then we take a fare state and the idea that everybody should have
look at some of the typical ethical dilemmas of equal opportunity to participate in the different
health promotion in public health, before we end practices of a society. The focus is very often sys-
up with articulating an ethics of health promotion temic: Individuality and liberty are dependent on
within health care. a strong community. Positive freedom is often
referred to as ‘freedom to…’.
The positive concept of liberty has substantial
3.2  he Two Concepts of Liberty:
T resemblance with the concept of health applauded
Two Concepts of Health? in health promotion. Central in the theory of
health promotion is the term salutogenesis,
A deep discussion on the ethical justifiability of coined by Aaron Antonovsky [5], where he saw
health promotion in a society needs to start with the origins of health in the factors causing well-­
some considerations on the relation between the being and meaning. While health understood as
individual and the society. A person’s view on the the absence of disease would amount to a nega-
legitimacy and the need for health promotion will tive understanding of health, health understood in
very often reflect his political position. Both lib- the tradition of health promotion is a positive
ertarians and communitarians will be concerned one. Like positive liberty, health is here under-
with freedom and choice, but different concepts stood as a concept of realization and capabilities:
of freedom will be applied. For libertarians, only It means being able to realize a biological poten-
freedom from an intrusive and paternalistic state tial, realize aspirations, to satisfy needs and to
will be genuine freedom. For communitarians, change or cope with the environment—again to
only freedom to realize your potential will quote the Ottawa charter.
amount to genuine freedom. These are the ‘two In the same way that there exist two funda-
concepts of liberty’ that Isaiah Berlin talked mentally different concepts of liberty, it seems
about in his famous paper from 1958 [3]. fair to claim that there exist two fundamentally
Negative freedom means that you are free, as different concepts of health. Health promotion is
long as you are left to do whatever you want to do based on a positive concept, where health, like
without interference from others (except from freedom, is something that can be realized given
harming other people). The more other people, the proper context. The positive concept of
the society and the state interfere with your life, health, like the positive concept of liberty, stresses
the less freedom you have. Low taxes give you the importance of others for the individual’s real-
3 The Ethics of Health Promotion: From Public Health to Health Care 25

ization of his or her potential. This brings us onto ian model is that health is ‘socialized’. Individual
some reflections on the relation between health responsibility disappears, autonomy disappears,
and responsibility. and individuals in poor health are ‘victimized’—
they are regarded as victims of an unfair society.
Luckily, we do not have to choose between the
3.3 Poor Health libertarian and the communitarian model. There
and Responsibility are insights from both of them in the salutogenic
model of health. A central concept in the saluto-
In a libertarian model, the individual should be genic model of health is sense of coherence. How
free to make good or bad health choices. healthy we feel and how healthy choices we
Knowledge, attitudes, will power, character, val- make depend to a certain degree on whether we
ues, habits and more are factors that affect the regard the hardships of our lives as comprehen-
decision individuals take. These are factors that sible, manageable and meaningful [8]. Social
we think we should be held responsible for. On context plus individual agency are both inescap-
that background, we are responsible for the health able in this model.
choices we make. To hold individuals responsible
for their actions is of intrinsic value—it is the
fundamental prerequisite for treating people as 3.4 Health Choices: What
autonomous individuals. Interference Is Ethically
At the same time, we know, as a fact, that the Justified?
society has a huge impact on the individual’s
health. Access to clean water, sanitation facili- The most typical ethical dilemma in public health
ties, safe housing, vaccines and a good health ethics is that of state interference in choices con-
care system are of course basic elements in the cerning the health of people. According to the
public health of a society, but the social elements theory of negative liberty, it is of highest value
of health go far beyond this. The way a society is that the state does not interfere with the freedom
politically ‘rigged’ determines in a deep sense of people. People should be left alone.
the health of its inhabitants. Education and However, from a positive concept of liberty
income are the most prominent social determi- and health—what Carter et al. denote as a capa-
nants of health [6]. A society with small social bility point of view—interference could be justi-
inequalities produces healthier individuals than a fied. Peoples’ most important interest is probably
society with large social inequalities. The more a not to be left alone, because ‘…they have a moral
society manage to distribute education and stake in that environment providing them with
income in an egalitarian way (where people are real opportunities, including the opportunity to
treated as equals), the better the health of its citi- be healthy’ [2].
zen will be. In the same way, adverse experiences Informing people through public health cam-
in a person’s biography, like sexual child abuse, paigns is one of the most classical ways of trying
seem to be a life-course social determinant of to help people taking good and healthy choices.
adult health [7]. In this explanation of good and There is nothing inherently unethical with infor-
poor health, individual character and will power mation campaigns, if the information given is
play a minor role. The social structure as well as honest and correct. But one problem with them is
the social context of upbringing and socialization that results are moderate, probably because edu-
plays a major role. Politics plays a major role. cation programmes have often failed to acknowl-
The danger of the libertarian model is that edge the limitations of health education or the
health is ‘individualized’. The true social deter- complex relationship between health communi-
minants of health are masked by an ideology that cation and behaviour change, according to Gill
says that everything starts and ends with the will and Boylan [9]. In order to make them more
of the individual. The danger of the communitar- effective, there is a temptation to move beyond
26 B. Solberg

factual and objective information and use instru- But how could laws against smoking in public
ments that make a strong appeal to emotions, like indoor areas be introduced in liberal democracies
for instance the use of fear and disgust in anti-­ if it violated fundamental liberal values? The
tobacco campaigns. While this may have a bigger answer is that these laws were introduced in the
effect than information, it also increases the risk first place to safeguard the work environment.
of stigmatization. As Lupton claims, there is a Nobody should be a victim of ‘passive smoking’.
substantial risk that such campaigns may ‘…rein- The justification of these laws was not that health
force negative attitudes towards already disad- trumped freedom of choice, but rather that the
vantaged and marginalized individuals and social choice of smokers to smoke, threatened the free-
groups’ [10]. dom of choice of others (the choice of not smok-
A less stigmatizing but maybe more coercive ing/not inhaling nicotine) in these buildings. In
way of trying to improve public health is to tax that sense, freedom of choice was the justification
products that contribute to poor health and for banning the freedom to smoke indoors. The
disease, like tobacco, alcohol, sugar and fat.
­ paradox, however, is that even though these laws
Such taxation might contribute to more ‘real were not motivated by health promotion, the con-
opportunities’ for people to choose healthy, in sequences have probably been huge in terms of
the sense that unhealthy choices will not con- health.
tinue to be a cheap option. The coercive element Some scholars do, however, defend coercive
here is that if you put really high taxes on some strategies in a liberal democracy. Sarah Conley is
products, it will be too expensive for people to one of them. People are generally prone to cogni-
buy regularly. tive bias, says Conley. We make bad decisions
An even more coercive strategy is to ban cer- because we are tempted, we lack will power and
tain products or ban the use of certain products. we have a bad means-end thinking. That makes it
Many countries today have a law on smoking, hard for us to reach our ultimate goals. Coercing
where smoking is banned in public buildings people to do what is good for them is in this sense
and transportation, restaurants, offices, etc. is respectful, because people then will reach their
Systematic reviews suggest a considerable med- ultimate goals [13].
ical benefit from such legislation [11, 12]. There Is Conley’s position compatible with a health
are many practical challenges with taxation of promotion view? On the one hand, health promo-
as well as a ban on certain products, such as tion is based on empowering and enabling people
equal treatment of different products and the to realize their health potential. Coercion and
risk of increased trade leakage to more liberal prohibitions do not seem to have a place here. On
jurisdictions nearby. But deeper than that is the the other hand, some types of addiction may be
challenge that we cannot necessarily ban every- so hard to ignore and overcome that prohibitions
thing we may find unhealthy from our society. (‘you are not allowed to smoke here’) actually
The characteristics of a liberal societies is that could be the only thing that may help a person
we allow people to choose the way they will live resist the craving for a cigarette. From such a per-
their lives, as long as this freedom of choice do spective, law limiting and prohibiting smoking
not harm others, or significantly reduce others may help a person to get in control and in charge
freedom of choice. This freedom of choice is of his or her health. Although bans and prohibi-
regarded as an intrinsic value and as a common tions seldom would have a place within the para-
good in liberal democracies. A totalitarian digm of health promotion, we cannot absolutely
regime could easily ban tobacco, Happy Meal, rule out that such strategies may play a role in
Toblerone and alcohol. But in liberal democra- empowering and enabling people to live the lives
cies, such laws would be considered a violation that they really want to live.
of some of our dearest values. This creates a ten- Conley’s position, though, is challenging from
sion between values. You have to carefully bal- a liberal perspective. As Jonathan Pugh has
ance the two. argued that it would be very problematic if it
3 The Ethics of Health Promotion: From Public Health to Health Care 27

becomes impossible for agents to choose some the choice of driving to work is not that attractive
action that poses a risk to their health without anymore while the choice of cycling to work has
them being accused of making a cognitive error become much more attractive. You have been
in weighing their values [14]. Are all smokers nudged towards cycling.
today making a cognitive error when they choose Nudging can be even more scaled up. Urban
to smoke? Could we ban smoking in general on planning can be done with health promotion as a
the assumption that the ultimate goal of all smok- central perspective. A typical example is so-­
ers is to quit smoking? Probably the answer is no. called age-friendly cities and communities where
People have different values and people weigh it is easy to participate when you age, easy to stay
their values differently. That means that some connected, stay healthy as well as to receive ade-
smokers have no ultimate goal of quitting smok- quate support. The goal is to ‘promote healthy
ing. For them, coercive paternalism will become and active ageing and a good quality of life for
highly illiberal and not enabling them to live their older residents’ [16]. In such cities, no
more in accordance with ultimate goals and choice is taken away from you (you can still
values. choose not to participate), but the good choices
are much easier and more attractive to make,
compared with other cities. When you live in
3.5 Promoting Health Without such a city, you will be nudged towards active
Taking Away Choices participating, regularly exercising, healthy food,
healthy transportation and healthy work environ-
An increasingly popular strategy for promoting ment—all these will be options that represent
healthy choices is ‘nudging’. Nudging or more attractive choices than the unhealthy ones.
‘friendly pushing’ is, according to Thaler and
Sunstein, about changing the choice architecture
[15]. No choices will be taken from you, no one 3.6 I s Nudging Ethical
will be coerced, nothing will be prohibited, but from a Health Promotion
the choices will look a little bit different than View?
before. When choices are nudged, they have been
designed in order to raise the likelihood that you Nudging could be an effective mean to improve
make the good choice. In a friendly way, you are personal as well as public health. There are, how-
pushed in the direction of what is good for you. ever, two typical objections: First, nudging can
A simple example of nudging is to place fruit be accused for being essentially paternalistic.
and vegetables in the middle of where you enter Second, nudging can be accused for being essen-
the groceries store. This makes it impossible to tially manipulative. If these accusations are valid,
get into the store without feeling the call of buy- nudging seems to be a bad strategy for health
ing fruits and vegetables. You still have the free- promotion.
dom to choose not to buy these healthy products, Paternalism (from Latin pater = father) means
but it is more difficult to drop it, compared to a that somebody else (a father figure) knows what
choice architecture where vegetables and fruit are is good for you. Medical paternalism is an exam-
hidden at the very back wall of the store. ple of something we today consider as an ethical
Nudging can be scaled up to include more problem because we think that the patient knows
fundamental aspects of health. In cities, we can best what is good for him or her. Nudging in
take some of the driving lanes and transform health promotion presupposes that somebody
them to bike-cycle lanes. This will probably cre- knows what is best for you and organizes the pos-
ate more cyclists and less drivers and contribute sible choices in such a way that you will make the
to better health, better environment and less traf- ‘right’ choice. Clearly there is a paternalist ele-
fic. Still, no choices are removed. You can take ment in this, in the same way that coercive strate-
your car and drive to work if you prefer that. But, gies for health promotion are paternalistic. In
28 B. Solberg

addition, the paternalism is partly hidden. That ple can be oriented about the changes of the
makes nudges more problematic than coercive choice architecture and why it is done. In that
strategies, where the paternalism is open for way, nudges become transparent. Second, Thaler
everybody to see. and Sunstein stress that nudgers—those that are
At the same time, it is important to note that nudged—should be better off, judged by them-
choice is not abandoned. We are still within the selves [15]. People can also be included in deci-
liberal zone. This is why nudging has been labelled sion processes about which products, actions and
‘liberal paternalism’. Whether paternalism in a lifestyles that is best fitted for nudging. That
given situation is acceptable or problematic takes away some of the paternalist critique and
depends on whether a certain good is commonly let nudges become democratic. Finally, we
shared, or rather a contested good. Good candi- should remember that manipulation of our brain
dates for nudging presuppose high agreement. To is something that the consumer industry has been
nudge people to eat more fruits and vegetables is doing through commercials for decades. Using
not very controversial. There is a general agree- nudging for public health promotion—for the
ment in the society that eating more fruits and veg- common good—and not for private enrichment,
etables is good for us. To nudge people to read serves a higher goal. With that reminder health-­
more in the Bible is controversial. There is no gen- promoting nudges might become legitimate and
eral agreement in the society that we should read important.
more in the Bible. When nudging is about means
and goals that most people can agree upon, pater-
nalism may not be that problematic. 3.7  ealth Promotion in Health
H
The second objection was that nudging is Care Vs. Public Health
manipulative. When we buy more vegetables and
fruits because these groceries are placed at the When we shift the focus from health promotion
entry, most of us are not conscious that the shop has in public health to health promotion in health
chosen this setup in order to influence our behav- care, all the goals we have been talking about are
iour. As we said, this presupposes a hidden pater- still valid. Enabling people to increase control
nalism. But in addition, the rearrangement of the over, and to improve, their health is of course of
choice architecture plays with our brain. We are to utmost importance. Furthermore, to be able to
a certain degree manipulated. This is problematic. cope well for instance with a chronic disease
We do not like to be deceived. We like transpar- would be central in health promotion in health
ency. And far worse, while buying more vegetable care.
seems to be a rather innocent consequence of Still, there are some differences. The political
manipulation, there are of course regimes that want dimension of public health is not that distinct
to use these techniques for bad purposes if they within health care. What makes a difference
really influence our cognition [17]. Maybe we then within health care would be the doctor–patient
need to be careful with introducing nudges if they relation, the nurse–patient relation as well as the
are inherently manipulative? systemic approach to continuous follow-up of
There is clearly an element of behaviour patients. It is in the relational aspect of health
manipulation involved in nudging. This is prob- care, then, that we find the key to the ethical
lematic from an ethics of health promotion, since dimension of health promotion in health care.
the concept of health within this tradition is so Some of the same ethical discussions that we
clearly linked to enabling and empower people to find in public health, though, is also found within
improve their health. If we are solely manipu- health care. One of them is the discussion on
lated to make better choices, the agency disap- nudging that recent years also have entered the
pears—we do not seem to be in charge or in field of health care. Nudging in a clinical setting
control of the choices we make. would mean that doctors rearrange the ‘choice
There are however ways to defend nudging as architecture’ in such a way that is more likely that
an ethical health promoting strategy: First, peo- the patient will make what the doctor consider as
3 The Ethics of Health Promotion: From Public Health to Health Care 29

the right choice. In the anthology Nudging Health omy. Already in the 1980s, a leading text book in
from 2016, arguments for and against clinical medical ethics wrote that although ‘…the physi-
nudging are discussed thoroughly. Clinical nudg- cian’s primary obligation is to act for the
ing was also the subject for a special issue in the patient’s medical benefit (..) autonomy rights
American Journal of Bioethics in 2013. Here have become so influential that it is today diffi-
Shlomo Cohen suggested that nudging in health cult to find clear affirmations of traditional mod-
care offers ‘an important new paradigm’ and has els’ [21]. The focus on patient autonomy came
the potential to ‘overcome the classical dilemma as a reaction to medical paternalism and the atti-
between paternalistic beneficence and respect for tude that the doctor always knows best for you.
autonomy’ [18]. People and patients must be allowed to decide
I will not dive deep into this special discus- for themselves.
sion. But since I expressed a positive attitude to Why autonomy should be considered such an
nudging as a tool for health promotion in public important value in health care is not obvious.
health, I should say something about my view on Medical knowledge is an expert field where doc-
nudging in a clinical context. Nudging in a clini- tors and nurses usually know a lot more than their
cal setting, is in my view, far more ethical prob- patients. Patients obviously need healing and car-
lematic than nudging in a public health setting. ing, but not that obviously choices. While choices
This is due to the manipulative and deceptive ele- are of utmost importance in many fields of soci-
ment of nudging. In the former discussion, I ety, choices are any way only offered within a
agreed that there is such a manipulative element. limited range in health care—your medical doc-
But I also gave reason for how this manipulative tor always decide what treatments to choose
element can be reduced as well as legitimated. In between. Some critics have claimed that the pres-
a clinical setting, I agree with the criticism raised ence of a choice does not in itself ensure empow-
by Søren Holm that ‘deceptive nudging in a per- erment of patients and that the whole focus on
sonal relationship may undermine trust much patient autonomy is delusional and ‘does not
more quickly than deceptive nudging from insti- reflect what is really at stake in health care set-
tutions that by definition are known to act strate- tings’ [22].
gically to pursue societal goals’ [19]. What we It is here that health promotion in health care
are really interested in the clinical setting cannot enters the value field. Health promotion is not
be reduced to health, but rather the process of concerned with choices per se, but with health.
creating health, what Lindström and Eriksson However, with the underlying definition of health
have called healthy learning [20]. as salutogenesis, health promotion offers a com-
The risk of undermining trust by nudging ‘the prehensive value system where also patient
right choice’ is one important criticism of clinical autonomy can find its proper place. Below we
nudging. But almost equally important is the will explain how.
question whether we can talk of ‘the right choice’
in health care. Seen from a health promotion
view, this is far more complicated. This takes us 3.9 Empowerment as the Basis
to some of the fundamental value discussions in for Health Promotion
health care today. in Health Care

Sense of coherence, meaning, is, as we noted ear-

3.8 The Shortcomings lier, a vital aspect of health promotion. As
of an Ethics of Autonomy Eriksson and Lindström have pinpointed, sense
in Health Care of coherence is ‘…an important disposition for
people’s development and maintenance of their
For many decades, there has been focus on one health’ [23]. For a patient to be able to benefit
prominent value in medical ethics and health from a treatment, he must be able to see for
care ethics in the western world—patient auton- instance how a certain lifestyle change or a fol-
30 B. Solberg

low-­up make sense and can fit into her life. He empowerment directly instructs nurses and doc-
must of course be informed about every aspect of tors on what their ethical obligation towards
the treatment, but equally important he must feel patients are. In the words of Koelen and
he is able to cope with the task, manage the dis- Lindström, the role of the professional ‘…is to
ease and comprehend all aspects of the situation. support and provide options that enable people to
To promote health in health care means enable make sound choices, to point to the key determi-
patients to be in charge or in control of their nants of health, to make people aware of them
patient role. Patients must be educated, but they and enable people to use them. In this enabling
must also be ascribed trust, optimism, hope and process it is important to help people to see a cor-
responsibility. Nurses and doctors must be inter- respondence between their efforts and the out-
ested in the patient’s biography and social con- comes thereof. It includes guiding clients through
text, in order to contribute to the coping, the change processes in a successful way, that posi-
control and the sense of coherence. That entails tively influences feelings of control’ [24]. Doctors
an empathic and holistic approach to patients. and nurses should do whatever they can to enable
There is a single word for all of this, a word the patient to become this agent that can cope,
that is far more important in health care than master and feel coherence. And why should they
autonomy. That word is empowerment. Health do it? Because this is what health is about.
promotion in health care is genuinely about The fundamental ethical idea of salutogenesis
empowerment. From a focus on empowerment, could basically be formulated as a variant of the
many other values can easily be derived, values old slogan saying that it is not what happens to
like holism, empathy, autonomy and user involve- you, but how you react to it matters. A patient
ment. An ethics of health promotion in health may have a severe disease, but his health could
care is genuinely an ethics of empowerment. still be considered good if he considers his life
What difference does it make if we shift the main meaningful, he is capable of coping with the dis-
ethical focus to empowerment instead of auton- ease, and he has some feeling of well-being.
omy in health care? Promoting health in this sense should be the ulti-
Empowering patients and persons means to mate ethical goal of health care, because this goal
enable people to participate or perform in a cer- would be valid independent of whether we talk
tain practice or role. A patient can formally be about curative treatment, chronic diseases, pallia-
declared autonomous, and she might also be tion or end-of-life care. Exactly how health can
offered choices, but if she is not able to transform be promoted through patient empowerment is not
the choices and the information into her own life the topic of this chapter of the book. We have
project, then the term autonomy does not seem to confined ourselves to a mild warning against
do the job. Neither from the point of view of nudging in health care in contrast to public health.
health personnel, does this term do the job: Having reached the conclusion that empower-
Nurses and doctors can be taught that their ethi- ment represents the ethical ideal for health pro-
cal duty is to respect patient autonomy, but what motion in health care, we can now look back on
does that mean? Does it mean that nurses should our discussions on public health ethics. Are there
encourage patients to have independent ‘opin- anything that suggest that empowerment is less
ions’ on the treatment offered? If so, why would relevant as an ethical ideal for health promotion
that be an ethical ideal? outside health care? In my view, the answer is no.
Empowerment, on the other hand, is a value Even though some would suggest that the ulti-
that can do the job. Empowerment addresses the mate goal of a society would be to reduce the bur-
importance of agency—the importance of being den of disease, this would not be the most
a person or patient that as far as possible leads his satisfying answer. Also, in public health, the ulti-
life from the inside, copes with the hardships of mate goal should be to create a society where
his life and integrates medical events into a mean- citizens can flourish, cope, realize their potential
ingful biographical story. Unlike autonomy, and aspirations, feel coherence and have a high
3 The Ethics of Health Promotion: From Public Health to Health Care 31

degree of well-being. This is what health is about. • The prominent position of patient autonomy
And this is what health promotion should care within health care should be replaced by the
about—either in health care or in public health. principle of empowerment—it better directs
health personnel to their ethical task, and it
better suits the ethical needs of patients.
3.10 Conclusion

Ethical issues in health promotion has often been References

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 Part II
Central Health Promotion Concepts and
Research
 Sense of Coherence
4
Unni Karin Moksnes

Abstract the 13-item scale. It gives a brief overview of

empirical research of the role of sense of
This chapter introduces the concept of sense coherence in association with mental health
of coherence which is a core concept in the and quality of life and also on sense of coher-
salutogenic model defined by Aron ence in different patient groups including
Antonovsky. The salutogenic model posits nursing home residents, patients with coro-
that sense of coherence is a global orientation, nary heart disease, diabetes, cancer, and men-
where life is understood as more or less com- tal health problems. It also briefly discusses
prehensible, meaningful, and manageable. A the implications of using salutogenesis in
strong sense of coherence helps the individual health care services and the importance of
to mobilize resources to cope with stressors implementing this perspective in meeting with
and manage tension successfully with the help different patient groups. The salutogenic
of identification and use of generalized and approach may promote a healthy orientation
specific resistance resources. Through this toward helping the patient to cope with every-
mechanism, the sense of coherence helps day stressors and integrate the effort regarding
determine one’s movement on the health ease/ how to help the patient manage to live with
dis-ease continuum. Antonovsky developed an disease and illness and promote quality of life.
instrument named Orientation to Life
Questionnaire to measure the sense of coher- Keywords
ence which exists in two original versions: a
29-item and a 13-item version. This chapter SOC · Resistance resources · Salutogenesis
presents the measurement of the sense of Health promotion · Nursing
coherence and the validity and reliability of

U. K. Moksnes (*)
Department of Public Health and Nursing, 4.1 Introduction
NTNU Norwegian University of Science
and Technology, Trondheim, Norway Aron Antonovsky introduced the key concept of
NTNU-Center for Health Promotion Research, sense of coherence as part of the salutogenic
Trondheim, Norway model in the book Health, Stress and Coping in
Faculty of Nursing and Health Science, 1979. Salutogenesis focuses on what are the
Nord University, Levanger, Norway sources for people’s resources and capacity to
e-mail: unni.moksnes@ntnu.no

© The Author(s) 2021 35

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_4
36 U. K. Moksnes

create health as distinct from, and yet a comple- do not [7]. This may involve major life events
mentary perspective to pathogenesis, focusing such as experience of acute and serious illness,
on risk for disease, which traditionally had been changes in the family, or changes in the work-
the leading focus in research [1, 2]. One of place. The frequency, intensity, and duration of
Antonovsky’s deviations from pathogenesis was the stressor(s) are all factors that affect the indi-
to reject the dichotomization into categories of vidual’s ability to cope adequately. Three poten-
sick or well and instead understand health as an tial reactions and outcomes of stress are (1)
ease/dis-ease continuum; a horizontal line being neutral against the stressors, (2) being
between total absence of health (H−) and total able to manage stress for the movement toward
health (H+) [3] (Fig. 4.1). We are all more or less the health end, and (3) being unable to manage
ill or well at any given point in time and conse- stress which leads to a breakdown expressed in
quently positioned on different places on this terms of diseases and death [2] (see Fig. 4.1).
health continuum during the life course. The Under the influence of stressors, the individual
important point is to focus on what moves an experiences tension and is constantly challenged
individual toward the ease-pole of the contin- to adapt to the stressor and to identify and use
uum, regardless of where he/she was initially personal and environmental GRRs to cope ade-
located with a focus on what promotes health, quately with the stressor(s). The individual’s
well-­being, and quality of life. The interesting ability to identify and use GRRs affects the indi-
question stated by Antonovsky was therefore vidual’s ability to cope adequately with the
what explains movement toward the health end stressor, which further affects health, that is,
of the ease/dis-ease-continuum? His answer to where the individual is positioned on the ease/
this salutogenic question was formulated in dis-ease continuum [4, 5].
terms of sense of coherence (SOC) and general- Antonovsky referred to the ability to compre-
ized resistance resources (GRR) and specific hend the whole situation, and the capacity to
resistance resources (SRR) [4, 5]. The saluto- identify and use the resources available, as the
genic theory posits that life experiences shape SOC [1, 3]. As a medical sociologist, Antonovsky
the SOC. This capacity is a prerequisite for peo- saw the individual in continuous interaction with
ples’ ability to move in the positive direction on the context and daily life as something in con-
the health continuum and is a combination of stant change. For the individual, the challenge is
peoples’ ability to assess and understand the sit- to manage the stimuli and find strategies and
uation they are in, to find a meaning to move in a resources available for coping with the changes
health-promoting direction, and also having the in everyday life and manage complexity.
capacity to do so [4, 5]. Complexity may lead to conflicts but also offers
When Antonovsky introduced salutogenesis, opportunities for different and flexible choices,
it was originally aimed to be a stress theory. possibilities for adapting to change. It becomes
Antonovsky saw stress as a natural and inevita-
ble part of life, assuming that life was challeng- STRESSOR

ing and health being continuously threatened by

ubiquitous stressors [1, 2, 6]. Stressors place a H– H+
load on us, which causes tension. However, ten-
sion and strain are considered as potentially TENSION
SALUTOGENESIS
health promoting, rather than as inevitably
health damaging, depending on the individual PATHOGENESIS

ability to identify and use GRRs to cope ade-

quately with stressors. Antonovsky was inter- BREAKDOWN

ested in the explanation for why some people,

Fig. 4.1 The ease/dis-ease continuum. (Published with
regardless of major stressful situations, manage permission from Folkhälsan Research Center, Helsinki,
to stay healthy, and live good lives, while others Lindström & Eriksson [3])
4 Sense of Coherence 37

vital how the individual can manage this chaos. logic. Manageability is the “instrumental” com-
SOC is the term Antonovsky introduced as an ponent and refers to the extent to which individu-
opportunity to manage and adapt to life’s chaos. als perceive that available resources are at their
The primary focus is on the dynamic interaction disposal and sufficient to adequately cope with
between health promoting factors and stressors in the demands. Meaningfulness is the motivational
human life and how people can move to the component and refers to the extent to which indi-
healthier end of the ease/dis-ease continuum. viduals feel that certain areas of life are worthy of
SOC is proposed to be a significant variable in time, effort, personal involvement, and commit-
affecting this movement [2, 5]. ment [2, 3, 6]. All the three dimensions interact
with each other. According to Antonovsky, the
most important component is meaningfulness,
4.2  he Concept of Sense
T which he thought was the driving force in life.
of Coherence When the individual perceives at least some of
life’s problems and demands as worthy of com-
The concept sense of coherence (SOC) is defined mitment and engagement, that also gives a greater
as “a global orientation that expresses the extent sense of the two components of comprehensibil-
to which one has a pervasive, enduring though ity and manageability as well. However, this
dynamic feeling of confidence that 1) the stimuli statement has been discussed. In a study of myo-
deriving from one’s internal and external envi- cardial infarction patients, this hypothesis was
ronments in the course of living are structured, rejected, showing that the dimension of compre-
predictable, and explicable, 2) the resources are hensibility was more important than meaningful-
available to one to meet the demands posed by ness for changes in SOC [8].
these stimuli; and 3) these demands are chal- The three components in the SOC concept are
lenges, worthy of investment and engagement” strongly connected and reflect an individual
([2], p. 19). These three components, termed resource and life orientation that enables the indi-
comprehensibility, manageability, and meaning- vidual to reflect on its external and internal
fulness are thought to be highly interrelated but resources in order to cope with stressors and the
separable, forming the SOC (Fig. 4.2). ability to resolve tension in a health-promoting
Comprehensibility is the cognitive component way [6]. Further, the life orientation of SOC is a
and refers to the degree to which the individual way of thinking, being, and acting as a human
sense that information that concerns themselves, being, which gives direction in life. The SOC
the social environment, and the context is not concept also reflects a person’s view of life and
only understandable but also ordered, structured, capacity to respond to stressful situations, which
and consistent. However, perceiving events as leads people to identify and mobilize the GRR at
comprehensible does not mean that they are com- disposal [1, 2, 6]. Antonovsky saw the individual
pletely predictable or without difficulty; the point in interaction with the context. However,
is that stimuli experienced are explicable and Antonovsky stressed that the salutogenic theory

Fig. 4.2 Dimensionality

of the construct of sense
of coherence Sense of Coherence

Comprehensibility Managebility Meaningfulness

38 U. K. Moksnes

and its key concept, SOC, also can be applied at fulness. Because the person and the environment
a collective level, and not only with a focus on the will always interact, it is not possible to identify
individual level [6]. all possible GRRs. Therefore, Antonovsky for-
mulated the following definition that provides a
criterion to identify GRRs: “every characteriza-
4.3 Generalized Resistance tion of a person, group or environment that pro-
Resources (GRRs) motes effective management of tension” ([1],
p. 99). Resistance resources may exist at the indi-
Along with the concept of SOC, a key concept in vidual, the group, in the subculture, and at the
the salutogenic theory/model is the role of gener- whole society levels ([1], p. 103). Antonovsky’s
alized and specific resistance resources [1, 2], [1, 2] illustration of GRR is given in Fig. 4.3, and
which are seen as important prerequisites for the such resources may include the following factors:
development of SOC. Antonovsky promoted that (1) physical and genetic (strong physic, strong
generalized resistance resources (GRR) and spe- immune system, genetic strength); (2) material
cific resistance resources (SRR) are not exchange- resources (e.g., money, accommodation, food);
able concepts. Others seem to agree that the (3) cognitive and emotional (knowledge, intelli-
distinction is not particularly important [9]. As gence, adaptive strategies for coping, emotional
though most focus has been given to the role of intelligence); (4) ego identity (positive percep-
GRR in the literature, that will also be the focus tion of self); (5) valuative and attitudinal (coping
in this chapter. strategies characterized by rationality, flexibility
Overall, the term generalized resistance foresight); (6) interpersonal-relational (attach-
resources (GRR) was established by Antonovsky ment, social support from friends and family); (7)
[1, 2] and constitutes the assets and characteris- macro sociocultural aspects (culture, shared val-
tics of a person, a group, or a community that ues in society).
facilitate the individual’s abilities to cope effec- The initial GRR resources [1] may be per-
tively with stressors and that contribute to the ceived as manifested within the life experiences.
development of the individual’s level of SOC [2]. Four types of life experiences are assumed to
Consequently, higher levels of GRRs are associ- contribute to the SOC developmental process
ated with stronger SOC. Resources fall into three during the course of growing up: consistency,
basic (but interrelated) domains: those that load balance, participation in shaping outcomes,
enhance comprehensibility, those that enhance and emotional closeness [10]. Experiences of
manageability, and those that enhance meaning- consistency in an individual’s life provide the

Fig. 4.3 Illustration of physical

generalized resistance biochemical
resources (Source: material
Antonovsky, 1979 [1], cognitive
Generalised emotional characteristic of an
p. 103) Resistance values
Resources (GRR) interpersonal
relational
macrosociocultural

individual
primary 1. avoiding
that is a wide range of
group or
effective in stressors
subculture 2. combating
society

and thus preventing tension from being transformed into stress

4 Sense of Coherence 39

basis for the comprehensibility component of the recognize and activate the most appropriate SRR
SOC [4, 10, 11]. Consistency refers to the extent from those that may be available. A study investi-
to which messages were clear and that there were gating the role of different SRRs and GRRs in
order and structure from experienced stimuli informal caregivers originating from themselves
rather than chaos. The second life experience, and their care recipients as dyads showed the
load balance, refers to the extent to which one necessity of living in a well-functioning relation-
experienced overload or underload in the balance ship which enabled dyads to solve challenges
between the demands experienced and one’s through cooperation and use of SRRs/GRRs
resources to cope. Load balance is important for (e.g., mutual understanding of the situation, good
the manageability component of SOC. The third communicative skills, and enjoying togetherness)
life experience including participation in shaping [13]. These resistance resources were important
outcomes refers to the extent to which the indi- to be able to resolve the challenges they encoun-
vidual perceives autonomy, has impact in decid- tered, that is, through cooperation and use of their
ing her/his fate, and is not under pressure of specific dyadic tension management. The study
others. Participation in shaping outcomes pro- suggests that good past and present relationships
vides the basis for the meaningfulness compo- wherein the dyad can use SRRs/GRRs might
nent. The fourth life experience, emotional facilitate the dyad’s adaptation to the caregiving
closeness, refers to the extent to which one feel situation [13].
consistent emotional bonds and a sense of belong-
ing in social groups of which one was a member
[10, 11]. A person with a strong SOC is able to 4.4 Assessment of Sense
mobilize GRRs to promote effective coping. This of Coherence
resolves tension in a health-promoting manner
and leads toward the salutary health end of the Antonovsky developed the Orientation to Life
health ease/dis-ease continuum [6]. SOC and dif- Questionnaire (OLQ) to operationalize SOC. The
ferent GRRs work together in a mutual interplay. questionnaire exists in two forms: a long version
The more GRRs people are conscious of, able to consisting of 29 items and a short 13-item ver-
mobilize and make use of, the stronger SOC. A sion [2]. The OLQ has been translated in several
stronger SOC will in turn help people mobilize languages and seems to be a cross-culturally
more of their resources, leading to better health valid, reliable, and feasible instrument, especially
and well-being. in adult samples [3, 7].
Antonovsky divided resistance resources into According to Antonovsky [2, 7], the OLQ
GRR, which are resources that have wide-rang- comprises one general factor of SOC with three
ing utility to facilitate effective salutary tension correlated components of comprehensibility (five
management, while SRRs have situation-specific items), manageability (four items), and meaning-
utility in particular situations of tension [1]. As fulness (four items). However, previous valida-
described by Mittelmark et al. [9], the relation- tion studies have shown that the factor structure
ship between GRR and SRR is that via the SOC, of the scale is complex and seems to measure a
the GRRs enable one to recognize, pick up, and multidimensional rather than a one-dimensional
use SRR in ways that keep tension from turning construct [3, 7]. Following from that, Antonovsky
into debilitating stress. For example, Sullivan maintained that on theoretical grounds, one
[12] makes a differentiation, stating that nursing should avoid lifting out individual dimensions in
is a GRR, while the nurse providing help with a order to examine them separately. Studies inves-
particular problem is an SRR. Hence, supportive tigating the factor structure of the 13-item OLQ
environments may include both GRR and SRR, based on exploratory and confirmatory
but they have distinctions in reference to specific- approaches in adult and older populations have
ity. When being confronted with a special shown support for a three-factor structure [14–
stressor, a strong SOC enhances one’s ability to 17], a second-order three-factor structure [14,
40 U. K. Moksnes

18–20], and a one-factor structure [21]. to the construct of mental health, suggesting they
Accordingly, the construct validity of the OLQ-­ overlap [35]. The lack of evidence of the stability
13 does not seem to be clear in reference to that of SOC over time has also been criticized.
different factor structures are evident in different Antonovsky [2] claimed that SOC like personal-
populations. It may also be a question whether ity traits develops during childhood and early
the items included in the instrument adequately adulthood and becomes stabilized in the period
represent the construct of SOC and that there of early adulthood. The SOC seems to be rela-
may be variations in how the items are under- tively stable over time, at least for people with an
stood across different cultures and age groups. initial strong SOC [27, 36]. However, the SOC
Validations of the factor structure in adolescent seems to be stronger with age and continues to
populations are less investigated, but previous develop over the whole life span [3, 27].
studies have found support for a one-factor struc-
ture in a sample of Swedish adolescents [22] and
three-factor structure in Norwegian adolescents 4.6 Sense of Coherence
[23]. While many translations of the OLQ and the and Health in Different
research that has used it have given confidence Patient Groups
that the SOC construct is measurable, the sub-
stance of the SOC construct needs to be further 4.6.1 Nursing Home Residents
explored. This may include using the salutogenic
model and qualitative methods investigating the Long term care facilities, including nursing
core of the SOC components of comprehensibil- homes, provide most institutional care for older
ity, manageability, and meaningfulness [3]. people in many western countries. Moving to a
nursing home results from numerous losses, ill-
nesses, disabilities, loss of functions and social
4.5 Sense of Coherence relations, and approaching mortality; all of which
in Association with Health increase an individual’s vulnerability and dis-
and Quality of Life tress. In particular, loneliness and depression are
identified as risks to the emotional and social
A strong SOC is associated with good health, well-being of older people [37, 38]. Thus, an
especially mental health and quality of life in dif- important core function of health care profes-
ferent groups and populations [24–27]. Further, a sionals is to support everyday living, health, well-­
strong SOC is associated with positive perceived being, and quality of life [39]. Studies that have
health [24, 28] and is found to be inversely and investigated the role of SOC in nursing home
strongly related to psychological problems like residents have found support for that SOC is an
symptoms of anxiety and depression [24]. SOC is important component of functioning in old age.
positively related to other health resources, such SOC has been shown to be associated to better
as optimism, hardiness, resilience, and coping. health-related quality of life among nursing home
Individuals with a strong SOC also show more residents [40, 41]. Stronger SOC also relates to
positive health behavior, with less use of alcohol, lower emotional and social loneliness among
being a non-smoker, better oral health care [29– nursing home residents [37, 42]. The challenge
31] and more healthy food choice [32]. The SOC for health professionals is to help residents to
construct has been questioned regarding the weak reduce mental health problems and emotional
relationship with physical health contrary to and social loneliness and to strengthen their
mental health [3, 33, 34]. The weak correlation to SOC. Promoting respectful and present nurse–
physical health may not be surprising since SOC patient interaction, acknowledging the individual
mainly focuses on the mental, social, and spiri- as a person, might be a crucial resource in rela-
tual ability to manage life [35]. The SOC con- tion to nursing home patients’ health and
struct has also been criticized for being too close well-being.
4 Sense of Coherence 41

4.6.2 Coronary Heart Disease (CHD) good health. Previous studies have shown that a
strong SOC has been associated with more posi-
Studies on SOC in coronary heart disease (CHD) tive health behavior change [48] related to physi-
patients is important in reference to their ability cal activity and food choices, which are factors
to cope with their life situation. A study of relevant in the development of type 2 diabetes.
Bergman et al. [43] showed that the level of SOC Antonovsky did not use the concept “health
seems to be relatively stable among patients who behavior” but used a related concept “a health
had suffered from myocardial infarction; orientation,” that served as a GRR. Combined
although there were significant individual varia- with other GRRs, a healthy orientation serves as
tions over the years. A longitudinal study of a prerequisite for the development of a strong
Silarova et al. [44] have shown that SOC is a SOC [2]. Study findings have shown that patients
­predictor of mental and physical health-related with type 2 diabetes report lower SOC than a
quality of life of patients with CHD at 12- to control group of patients without diabetes, and
28-month follow-up and in female myocardial especially men [49]. The relationship between
infarction survivors [45]. Stronger SOC has been SOC and the incidence of diabetes was prospec-
shown to be associated with better health behav- tively studied among Finnish male employees
ior related to physical activity [8, 46] and quality (5827 at baseline) [50], showing that a weak SOC
of life in patients after myocardial infarction [8, was associated with a 46% higher risk of diabetes
47]. A study of Bergman et al. [43] which inves- (≤50 years of entry). This association was sig-
tigated the components of SOC in myocardial nificant, independent of age, education, marital
patients showed that comprehensibility was the status, psychological distress, self-rated health,
most important component of SOC changes for smoking status, binge drinking, and physical
2 years after a myocardial infarction. Coping has activity. Studies have also shown that patients
been emphasized as an important factor in with type 1 diabetes that report stronger SOC
explaining differences between patients’ percep- also show better metabolic control than those
tions of their life situations when affected by a with weaker SOC, through adherence to self-care
life-threatening disease. Although SOC does not behaviors related to food choices and physical
refer to a specific type of coping strategy, it com- activity [51, 52].
prises factors that may be regarded as a basis for
successful coping with stressors. Hence, a posi-
tive outcome from a stressor is primarily depen- 4.6.4 Cancer
dent on successful management of the stressor
and the presence of strong SOC. Within the For most people, receiving a cancer diagnosis
dimensions of a strong SOC, critically ill patients often causes severe distress. Therefore, working
may be able to show better ability to cope and to on supporting the patient’s coping resources in
manage their lives after discharge from hospital order to promote positive psychological adjust-
by supporting their SOC. ment is important. The concept of SOC has been
studied in individuals with various forms of can-
cer and moreover, in survivors of various forms
4.6.3 Diabetes of cancer, SOC is a strong predictor of quality of
life [53, 54] and fewer symptoms of anxiety and
The prevalence of diabetes is rapidly increasing; depression [55]. In breast cancer patients, reports
this is the case especially for type 2 diabetes. of stronger SOC relate to higher quality of life
Given that type 2 diabetes is partly preventable, it [53, 54, 56] through better emotional functioning
is important to identify not only physical and and less fatigue and pain [53]. Further, stronger
health behavioral risk factors but also psycho- SOC is associated with less report of stress, dis-
logical risk factors that can promote coping and tress [57, 58], and more positive coping strategies
42 U. K. Moksnes

such as direct action and relaxation [54]. alence of non-communicable diseases and
However, cancer patients are reported to score chronic illnesses in the population [66]. With
lower on SOC than the general population [56]. more advanced medical technology and medical
treatment, more people survive from serious dis-
eases but that also leads to that more people will
4.6.5 Mental Health have to learn to live with different chronic impair-
ments in their everyday life. A new life situation
According to WHO, depression is one of the is demanding and requires adaptation in many
leading causes of disease burden in terms of dis- life areas for the individual. The preferences, or
ability. Although some people only suffer a sin- what is evaluated as valuable in life changes in
gle episode of depression, the high prevalence meeting with illness, therefore, the experience of
together with the associated impairment of func- quality of life is a highly individual matter. At the
tioning and socioeconomic consequences under- same time, most people have a unique ability to
scores the need to understand this illness fully. adapt to and cope with inevitable life situations,
The experience of having a serious illness such as and our expectations change according to life’s
depression affects the individual’s quality of life realities. Here, health care personnel have a great
and requires significant adaptation by the patient responsibility in identifying possibilities for
and his/her family in order to cope. Research change and help the patient to cope with a new
shows the significance of the salutogenic life situation. These aspects also challenge the
approach in mental health promotion, including health care sector’s provision of efficient primary
various mental health problems [59]. One buffer- health care and long-term care, where more
ing component may be the individual’s percep- responsibility is given to the health care sector in
tion of SOC. In a 4-year and a 1-year follow-up the community/municipality.
study of people with major depression, SOC was The salutogenic perspective can be used to
shown to increase significantly as patients recov- guide health promotion interventions in health
ered after therapy [60, 61]. SOC is also found to care practice and to (re)orient health care practice
predict life satisfaction in people with chronic [67]. The health care sector is generally a chal-
mental health problems [62], and stronger SOC is lenging area for applying salutogenesis and to
found to be associated with reduced risk of psy- reorient in a health-promoting direction, as the
chiatric disorders during a long time period [63]. focus is and should be disease treatment. The
reorientation of the health care services in a
health-promoting direction therefore seems to be
4.7 Implications for Practice the least systematically developed, implemented,
and evaluated key action of the five action areas
The WHO Ottawa Charter for health promo- outlined in the Ottawa Charter. The goal of
tion [64] states that health is created and lived implementing the salutogenic perspective is
by people within the settings of their everyday therefore that salutogenesis can be a complemen-
life where they learn, work, play, and love. tary perspective to the pathogenic perspective
Salutogenesis has been applied to guide health where these perspectives interact in the planning
promotion research and practice in various set- and implementation of actions. In meeting with
tings, however, mainly in everyday life set- all patient groups, and especially with patients
tings. A central question is therefore what living with chronic diseases, health professionals
implications salutogenesis and related con- need to focus on the patient’s salutary resources
cepts have for practice in the health care as well as focusing on how to diminish and reduc-
setting? ing risk factors. Further, it is important that the
With advances in medical technology and individual is seen in holistic terms, interacting
improvement in the living standard globally, the with his/her daily life context. One of the central
life expectancy of people is increasing worldwide aspects implies promoting a more active patient
[65]. Meanwhile, we also see an increasing prev- role, where the health care professionals empower
4 Sense of Coherence 43

the patient to activate the use of knowledge and Orientation to Life Questionnaire developed by
clarification of resources and needs in the plan- Antonovsky. The chapter has presented empirical
ning of health care needed. An important role of research on the central role of SOC as a personal
health professionals is to identify the patient’s coping resource and life orientation in relation to
experiences and prerequisites and help the patient health and quality of life in different populations
to identify and activate resistance resources, in and patient groups. Today, we can talk about salu-
order to promote coping with everyday life chal- togenesis more as a salutogenic umbrella and assets
lenges. This challenges the health care person- apprach with many different concepts with saluto-
nel’s ability to work holistically with the patient’s genic elements and dimensions besides SOC [35].
resources and needs and to see the patient as an The application of salutogenesis as a perspective
equal partner in the planning of health care. This guiding work in the health care settings seems to be
approach is important in order to integrate the vital and important as a complementary approach
resources and efforts needed regarding how to to the biomedical paradigm, since it is about imple-
help the patient mange lives’ challenges and pro- menting salutogenesis into a territory which is still
mote quality of life. predominantly dominated by the biomedical para-
In reference to intervention work, using salu- digm. Salutogenic thinking also seems to have
togenesis as a basis for providing health-­ good potential to be applied in health promoting
promoting interventions is found to be effective, interventions, and in supporting health promoting
e.g., toward strengthening SOC in patients liv- work in health care institutions for better everyday
ing with long-term illness [68–70]. For instance, practice and quality of life for patiens [67].
in patients with severe mental disorders, a com-
bination of perspectives in order to provide Take Home Messages
holistic nursing is found to be important; this • Sense of coherence is an important concept
includes applying salutogenic knowledge about within salutogenesis and is considered as a
living a good and meaningful life in addition to personal coping resources and life orientation,
knowledge anchored in the biomedically domi- where life is understood as more or less com-
nated understanding of mental illness [70]. prehensible, meaningful, and manageable.
Consequently, mental health care services • A strong sense of coherence helps the indi-
should offer education programs with a comple- vidual to mobilize resources to cope with life
mentary perspective on mental health, denoted stressors and manage tension successfully
“salus education” [70]. This implies a shift in with help of identification and use of general-
practice to identify and build upon each indi- ized and specific resistance resources.
vidual’s assets, strengths, and competence and • Antonovsky developed the 29-item and a
support the person in managing his or her condi- shorter 13-item version of the Orientation to
tion in order to gain a meaningful, constructive Life Questionnaire (OLQ) to measure the
sense of being a part of a community [70]. The sense of coherence.
focus is not only how to combat and survive dis- • The OLQ scale has been translated in sev-
ease, but to help and “educate” people to “swim eral languages and seems to be a cross-cul-
in the river of life.” turally valid and reliable instrument.
Criticism of the SOC concept covers the
multidimensionality of the concept. The
4.8 Conclusion substance of the SOC construct needs to be
further explored.
This chapter has given an introduction to saluto- • In health care, salutogenesis can be used to
genesis and the concept of sense of coherence guide health promotion interventions in health
(SOC) and generalized and specific resistance care practice and/or to (re)orient health care
resources (GRR/SRR). It has also presented empir- services into a more health-promoting
ical research on assessment of SOC with use of the direction.
44 U. K. Moksnes

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 A Salutogenic Mental Health
Model: Flourishing as a Metaphor
5
for Good Mental Health

Nina Helen Mjøsund

Abstract The cumulative evidence for seeing mental

disorder and mental health function along two
This chapter focuses on a salutogenic under-
different continua, central mental health con-
standing of mental health based on the work of
cepts, and research significant for health pro-
Corey Keyes. He is dedicated to research and
motion are elaborated in this chapter.
analysis of mental health as subjective well-­
being, where mental health is seen from an
Keywords
insider perspective. Flourishing is the pinna-
cle of good mental health, according to Keyes. Mental health · Mental health promotion ·
He describes how mental health is constituted Flourishing · Mental health continuum short
by an affective state and psychological and form · MHC-SF · Two continua model
social functioning, and how we can measure Salutogenesis · Complete mental health
mental health by the Mental Health Positive mental health · Well-being
Continuum—Short Form (MHC-SF) question-
naire. Further, I elaborate on Keyes’ two con-
tinua model of mental health and mental
illness, a highly useful model in the health 5.1 Introduction
care context, showing that the absence of
mental illness does not translate into the pres- This chapter is about mental health. Mental
ence of mental health. You can also read about health is explained from a salutogenic perspec-
how lived experiences of former patients sup- tive. This is an asset- and resource-oriented
port Keyes dual model of mental health and approach, which is explained with Corey Keyes’
mental illness. This model makes it clear that theoretical model of mental health [1–3], where
people can perceive they have good mental mental health is understood as the presence of
health even with mental illness, as well as feelings and functioning, and not the absent of
people with perceived poor or low mental illness. The two continua model of mental health
health can be without any mental disorder. [3, 4] contributes to an understanding of mental
health relevant in health care services by incorpo-
rating knowledge about diseases (pathogenesis)
N. H. Mjøsund (*) and complements this with the knowledge about
Division of Mental Health and Addiction, Department
of Mental Health Research and Development, Vestre
health and well-being (salutogenesis).
Viken Hospital Trust, Drammen, Norway
e-mail: nina.helen.mjosund@vestreviken.no

© The Author(s) 2021 47

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_5
48 N. H. Mjøsund

Years ago, WHO [5] introduced a definition of the meanings of mental health and mental health
health praised as well as criticized from many promotion were explored from the perspective of
perspectives. However, it can be seen as a defini- persons with former and recent patient experi-
tion including situations a person is eager to ences [7].
achieve and situations a person is eager to avoid.
“Health is a state of complete physical, mental
and social well-being and not merely the absence 5.2 Mental Health
of disease and infirmity” ([5], p. 1). Health has
different meanings to different people. Green and Nearly two decades ago, Corey Keyes, PhD in
Tones [6] say it so strikingly: sociology [1], suggested to operationalize mental
…health is one of those abstract words, like love health as a syndrome of symptoms of positive
and beauty, that mean different things to different feelings and positive functioning in life. Mental
people. However, we can confidently say that health is about an individual’s subjective well-­
health is, and has always been, a significant value being; the individuals’ perceptions and evalua-
in people’s lives ([6], p. 8).
tions of their own lives in terms of their affective
To focus on mental health by separating it state, and their psychological and social function-
from health in its totality might be artificial due ing [1]. Inspired by salutogenesis, mental health
to the risk of losing the sight of health’s complex- is viewed as the presence of positive states of
ity and composition. Mjøsund et al. [7] argue that human capacities and functioning in cognition,
perceived mental health, and physical, emotional, affect, and behavior [3].
social, and spiritual aspects of health reciprocally Hence, the more dominant view of mental
influence each other. It seems that the phenome- health as the absence of psychopathology was
non of mental health is especially fragile from questioned by Keyes [3]. While still holding this
being separated from the totality of health. view, Keyes needed to employ the DSM-3 [10]
However, a conscious theoretical attention to one approach as a theoretical guide for the conceptu-
of the aspects of health while remembering its alization and the determination of the mental
connectedness to the other aspects might facili- health categories and the diagnosis of mental
tate a deeper understanding and more targeted health [1]. These terms, more often used in diag-
clinical intervention to promote it. nosing mental disorders, rather than health, were
In a society with a dominant awareness on ill- used with a conscious aim [1, 4, 11]. Keyes
ness and disease prevention, people need useful chooses to utilize DSM-3, its established reputa-
knowledge to care for and promote their mental tion and familiarity, as a tool aiming to place the
health, as well as physical, spiritual, and social domain of mental health on equal footing with
health. Academics and scholars need theories and mental illness [1]. The measurement of mental
models to study mental health, and health profes- health was done in the same way as psychiatrist
sionals and health promoters need an extensive measures common mental disorders, as for exam-
knowledge base to perform evidence-based inter- ple a major depressive episode [12]. The con-
ventions for quality enhancement in clinical cepts (syndromes, symptoms, and diagnosis) are
practices. Scientists claim to adapt a pragmatic familiar for nurses and for multidisciplinary pro-
approach accepting various conceptualizations of fessionals in health care services, as well as for
health because it remains unlikely that we arrive patients and their relatives, which is a pedagogic
at consensus on a health definition for health pro- beneficial when health promotion models and
motion research [8]. theories are used to guide interventions in clinical
Findings from lived experiences of inpatient practice.
care in the project Positive Mental Health—From Mjøsund [9] contributes to the knowledge
What to How [9] shed light on some elements of base of health promotion by investigating expe-
the mental health and Keyes’ dual model of men- riences of mental health among persons with
tal health [2]. In this qualitative research project, mental disorders. This study explored how
5 A Salutogenic Mental Health Model: Flourishing as a Metaphor for Good Mental Health 49

mental health was perceived by former patients How you are feeling about life includes (1)
[7], and the experiences of mental health pro- emotional well-being—and how you are func-
motion efforts in an inpatient setting [13]. The tioning is about, (2) psychological well-being,
methodology Interpretative Phenomenological and (3) social well-being. The division of subjec-
Analysis [14] was applied on 12 in-depth inter- tive well-being consists in this way of two com-
views. Apart from the participants, an advisory patible traditions: the Hedonic tradition, focusing
team of five research advisors either with a on the individual’s feelings toward life, and the
diagnosis or related to a family member with Eudaimonic tradition that equates mental health
severe mental illness was involved at all stages with how human potential, when cultivated,
of the research process as part of the extensive results in functioning well in life [3, 17].
service user involvement applied in the project Emotional well-being consists of perceptions of
[15, 16]. happiness, interest in life, and satisfaction with
life [18]. Where happiness is about spontaneous
reflection on pleasant and unpleasant affects in
5.2.1  ental Health as a Syndrome
M one’s immediate experience, the life satisfaction
of Symptoms represents a more long-term assessments of one’s
life [2]. The Hedonic approach equals emotional
Keyes [1] operationalizes mental health as a syn- well-being as it frames happiness as positive
drome of symptoms, based on an evaluation or emotions and represent the opinion that a good
declaration that individuals make about their life is about feeling good or experiencing more
lives. The syndrome of symptoms of positive moments of good feelings [12]. In contrast to the
feelings and positive functioning in life included emotional well-being, psychological well-being
psychological, social, and emotional well-being is about the individual’s self-report about the
[1], make up the family tree of mental health, quality with which they are functioning [2].
which is portrayed in Fig. 5.1. Psychological and social well-being are rooted in

Family Tree of Mental Health

Positive Feeling Positive Functioning

I - Me We - Us

Emotional Well-Being Psychological Well-Being Social Well-Being

Happiness Self-Acceptance Social Acceptance

Satisfaction Positive Relations with Others Social Integration

Interest in Life Personal Growth Social Growth

Purpose in Life Social Contribution

Environmental Mastery Social Coherence

Autonomy

Fig. 5.1 The family tree of mental health. (Reproduced with permission from a lecture given by C. Keyes in Drammen,
Norway, 13th of December 2010)
50 N. H. Mjøsund

the Eudaimonic tradition which claims that hap- engagement [2]. Further, languishing can be
piness is about striving toward excellence and described as emptiness and lack of progress, the
positive functioning, both individually and as a feeling of a quiet despair that parallels accounts
member of the society [2]. Eudaimonia frames of life as hollow, empty, a shell, or a void.
happiness as a way of doing things in the world Individuals diagnosed as neither flourishing nor
and represents the opinion that a good life is languishing are considered to have moderate
about how well individuals cultivate their abili- mental health [1]. To be diagnosed as having
ties to function well or to do good in the world flourishing, moderate or languishing mental
[12]. Psychological well-being is conceptualized health, three dimensions or symptoms of emo-
as a private phenomenon that is focused on the tional well-being, six of psychological well-­
challenges encountered by the individual; it is being, and five dimensions of social well-being
about how well an individual functions in life are assessed [18]. A state of mental health is
[12]. Social well-being represents a more public ­indicated when a set of symptoms at a specific
experience related to the individual social tasks level are present or absent for a specified dura-
in their social structures and communities [2]. tion, and they coincide with distinctive cognitive
Social well-being is about how well an individual and social functioning [1].
is functioning as a citizen and a member of a
community [12]. An important distinction
between psychological and social well-being is 5.2.3  easuring Mental Health:
M
that the former represents how people view them- The Mental Health Continuum
selves functioning as “I” and “Me,” while the lat- Short Form
ter represents how people view themselves
functioning as “We” and “Us” [17]. The self-administered questionnaire Mental
The level of mental health is indicated when Health Continuum—Short Form (MHC-SF) was
a set of symptoms of emotional well-being com- developed to assess mental health based on indi-
bined with symptoms of psychological and viduals’ responses to structured scales measuring
social well-being at a specific level are present the presence or absence of positive effects (hap-
for a specified duration [1, 2]. This constellation piness, interest in life, and satisfaction), and
of symptoms coincides with the individual’s functioning in life, which includes the measure-
internal and subjective judgment of their affec- ment of the two dimensions: psychological well-­
tive state and their psychological and social being and social well-being [1, 18]. Psychological
functioning. well-being is characterized by the presence of
intrapersonal reflections of one’s adjustment to
and outlook on life and consists of six dimen-
5.2.2 Mental Health: sions: self-acceptance, positive relations with
From Languishing others, personal growth, purpose in life, environ-
to Flourishing mental mastery, and autonomy. Social well-being
epitomizes the more public and social criteria
Mental health can be conceptualized along a con- and consists of social coherence, social actualiza-
tinuum and subdivided into three conditions or tion, social integration, social acceptance, and
levels: languishing, moderate, and flourishing social contribution [17]. Individuals who are
mental health [1]. To be flourishing is to be filled flourishing or languishing must exhibit, respec-
with positive emotions and to be functioning well tively, high or low levels on at least seven or more
psychologically and socially. Flourishing has of the dimensions [1]. Keyes [18] explains:
emerged to be a term describing the optimal state
To be diagnosed with flourishing mental health,
of mental health [19]. Languishing is to be men- individuals must experience ‘every day’ or ‘almost
tally unhealthy, which is experienced as being every day’ at least one of the three signs of hedonic
stuck, stagnant, or that life lacks interest and wellbeing and at least six of the eleven signs of
5 A Salutogenic Mental Health Model: Flourishing as a Metaphor for Good Mental Health 51

positive functioning during the past month. immature concept, however with a growing evi-
Individuals who exhibit low levels (i.e., ‘never’ or dence of flourishing as a district concept [19].
‘once or twice’ during the past month) on at least
one measure of hedonic wellbeing and low levels This concept analysis was based on four com-
on at least six measures of positive functioning are mon conceptual frameworks of flourishing. The
diagnosed with languishing mental health. framework with most information available and
Individuals who are neither flourishing nor lan- most cited was presented by Keyes [1].
guishing are diagnosed with moderate mental
health ([18], p. 1). Additionally, the frameworks of Diener and
Diener et al. [33, 34], Huppert and So [35], and
The MHC-SF is constructed to be interpreted Seligman [36] were included in this concept
by both a continuous scoring, sum 0–70, and a analysis [19]. The authors request further multi-
categorical diagnosis of flourishing, moderate disciplinary research to establish standard oper-
mental health or languishing. The questionnaire ational and conceptual definitions and to develop
has been translated to many languages and applied effective interventions [19].
in different cultures across many c­ ontinents, such
as Europe [20], Africa [17], Australia [21], South-
America [22], North-America [23, 24], and Asia 5.2.5  erceived Mental Health:
P
[25, 26]. Recently, the structure and application A Dynamic Movement
were evaluated for cross-cultural studies, involv- on a Continuum
ing 38 nations [27]. The MHC-SF shows good
internal reliability, consistency, and convergent Former inpatients described mental health as an
and discriminant validity in respondents between ever-present aspect of life; moreover, mental
the age of 18 and 87 years [20] and across the health was perceived as a dynamic phenomenon,
lifespan [28]. The MHC-SF is claimed to be valid a constantly ongoing movement, or process like
and reliable for monitoring well-being in student walking up or down a staircase [7]. The move-
groups [29], as well as in both clinical (affective ment was affected by experiences in the emo-
disorders) and nonclinical groups [30]. Moreover, tional, physical, social, and spiritual domains of
the MHC-SF has also been used as the outcome in life and accompanied by a sense of energy.
intervention studies [31, 32]. Figure 5.2 shows that mental health is expressed
both verbally and by body language, and in
everyday life, mental health was experienced as a
5.2.4 Flourishing: The Pinnacle sense of energy and as increased or decreased
of Good Mental Health well-being [7].
It is interesting that the participants living with
The term flourishing gives associations to some- the consequences of severe mental disorders were
thing we want to achieve, a state where we are not talking about the absence of illness, pathologi-
thriving, growing, and unfolding, and I have cal conditions, and disorder symptoms when they
vitality, energy, and strength. The concept of described their perception of mental health and
flourishing has mostly been used in the field of mental health promotion [7]. The salutogenic
positive psychology and sociology. Although understanding of Keyes [3] claiming that mental
the concept is considered to be relevant in nurs- health is the presence of feelings and functioning,
ing practice and research, it is still virtually a state of human capacities, was supported by how
absent in the nursing literature [19]. According the participants perceived mental health.
to Keyes, flourishing is the pinnacle of good The understanding of mental health as a pro-
mental health; he chose to use the term flourish- cess and movement, like walking up or down a
ing to be clear that he was talking about mental spiral staircase—equivalent to a continuum—is
health and not merely the absence of mental ill- previously confirmed by a study of young people
ness [12]. An evolutionary concept analysis of [37]. Talking about the experience of being in dif-
flourishing claimed that flourishing is still an ferent positions on the mental health staircase,
52 N. H. Mjøsund

the exploration of the participants’ accounts and

Em
cal o their descriptions clearly indicated a vertical
ysi
Ph

tio
Vitality movement in accordance with Keyes’ [1] contin-

na
uum of mental health. The perception of the phe-

l
I’m great
nomenon of mental health as an ever present
aspect of life, a part of being human [7], is of
significance. Mental health was perceived as a
nerg
y quality of daily life, not characterized by quanti-
of e
se
Se
n tative entities such as numbers, but rather as good
I’m fine
or bad, up or down, poor or strong. Mental health
being experienced as constantly present in life
I’m down
er
gy and a part of being could be a contradiction to the
f en
S ens
eo early work of Keyes, when he described flourish-
Sp

l ing as the presence of mental health and

ia c
ir i

al So
tu

Fatig u e
languishing as absence of mental health [1].
­
More recently, [3, 12, 38] languishing is denoted
© 2017 Nina Helen Mjøsund
as the absence of positive mental health or “the
Fig. 5.2 Perceived mental health. (Reproduced with per- lowest level of mental health” [39]. Based on the
mission from Mjøsund NH. Positive mental health—from participants’ way of speaking about the position
what to how. A study in the specialized mental health care
service. Trondheim: Norwegian University of Science and
“low in the staircase” [7], and Keyes’ description
Technology, Faculty of Medicine and Health Sciences, of high, moderate, and low mental health, Fig. 5.3
Department of Public Health and Nursing; 2017) visualizes the levels of mental health.

I’m great
High

Flourishing
= presence of good
mental health

Moderate
mental health
I’m fine

Languishing
= presence of good
mental health
I’m down

Low

Mjøsund Keyes

© Nina Helen Mjøsund 2021

Fig. 5.3 Mental health as moving up and down a staircase—equivalent to Keyes’ continuum of mental health
5 A Salutogenic Mental Health Model: Flourishing as a Metaphor for Good Mental Health 53

Mjøsund et al. [7] claim that a sense of energy health care is on treating diseases and illness.
was a salient marker of perceived mental health. Therefore, theories, models, and concepts which
The sense of energy influenced experiences of can help to facilitate mental health promotion are
mental health in the emotional, physical, spiri- required. The dual continua model includes
tual, and relational domains of life. The feeling of related but distinct dimensions of both mental
energy was proportional with the position on the health and mental illness [11, 28, 43, 44]. The
staircase; while low or down on the staircase, the illustration of the two continua model of health
sense of energy was described as “like starting a (Fig. 5.4.) reproduced from Keyes [3] visualizes
shaky engine with a flat battery.” The participants the conceptualized definition of health along the
described how this lack of mental and physical vertical line and the continuum of mental illness
energy was associated with difficulties initiating along the horizontal line.
and completing any activities [7]. This is in line This dual model of mental health and mental
with Keyes’ [1] descriptions of flourishing illness goes well with WHO’s [5] definition of
including the presence of enthusiasm, aliveness, health and is particular significant for health
vitality, and an interest in life, associated with a professionals in health care settings. The classi-
sense of energy. Lack of energy and motivation cal myth of Asclepius, the God of Medicine, and
as a result of mental disorders has been identified his two daughters Hygeia and Panacea gave rise
by patients as a barrier to integrating healthy life- to complementary concepts and approaches to
styles [40]. An assessment of the sense of energy, health. The daughters represents two different
in collaboration with the patient, might form the points of view enlightening the distinction
basis for interventions aiming to “push or pull” between the definitions of health and illness [6].
into an activity or advising rest. Both the inter- The daughter Hygeia represented a salutogenic
ventions have been described by Lerdal [41]. The approach symbolizing the virtue of wise living
sense of energy should be investigated more in and well-being. Salutogenesis comes from the
depth and its relationship with mental health and Latin word “salus” which means health and is
mental disorders needs further research in order considered as a state of human capacities and
to inform the health promotion knowledge base. functioning. Health is the natural order of
The use of lay language in order to break things, a positive attribute to which human
down barriers between stakeholders in health beings are entitled if they govern their life
promotion and health care is encouraged [42]. wisely. Panacea represented the pathogenic
Having dialogs about taking a step or moving in approach, which considers health as the absence
the staircase of mental health is one way of oper- of disease and illness [3].
ationalizing mental health into lay language for With Hygeia and Panacea in mind, it becomes
all people. Visualizing theoretical models might clear that it is possible to have good mental health
increase the possibility to grasp the content, as even with mental illness, and one can have poor
well as the usefulness in clinical practice can be or low mental health without mental illness. This
promoted. Illustrations might enhance insight concurs with accounts from persons living with
and shared understanding that is significant in mental disorders [7]. In the field of recovery, the
health promotion initiatives aiming to increase influence of positive mental health has been stud-
empowerment (Figs. 5.1, 5.2, 5.3 and 5.4). ied in a sample of persons with mood and anxiety
disorders [45] and individuals during recovery
from drug and alcohol problems [46]. Moreover,
5.3 The Two Continua Model the absence of mental illness does not equal the
presence of mental health and revealing that the
The two continua model includes the presence of causes of mental health are often distinct from
human capacities and functioning as well as the those understood as the causes for mental illness
assessment of disease or infirmity [3, 4]. The [43], and the conditions that protect against men-
contemporary dominant perspective in mental tal disorders do not automatically promote the
54 N. H. Mjøsund

HIGH MENTAL HEALTH

Flourishing &
Flourishing
Mental Illness

HIGH Moderate Moderate LOW

MENTAL Mental Health & Mental Health MENTAL
ILLNESS Mental Illness ILLNESS

Languishing & Languishing

Mental Illness

LOW MENTAL HEALTH

Fig. 5.4 The dual-continua model. (Reproduced with Bridging Occupational, Organizational and Public Health:
permission from Keyes CLM. Mental Health as a A Transdisciplinary Approach. London: Springer; 2014.
Complete State: How the Salutogenic Perspective p. 179–92)
Completes the Picture. In: Bauer GF, Hämmig O, editors.

presence of positive mental health [3]. There Psychiatric outpatients with major mental illness
seems to be cumulating evidence that mental dis- have lower rates of well-being compared to con-
orders and mental health function along two dif- trols, although about one-third is seen to be flour-
ferent continua that are only moderately ishing [49]. Screening of levels of mental health
interrelated [4, 20, 28]. complements mental disorders screening in the
There is a growing interest for studying the prediction of suicidal behavior and impairment
relationship between mental health and mental of academic performance among college students
illness in various environments, including work [50]. High level of mental health seems to protect
settings and psychosocial work conditions [47]. against the onset of mental disorders (mood, anx-
MHC-SF has been found to be valid and reliable iety, and substance abuse disorders) [51] or func-
for monitoring well-being in both clinical tion as a resilience resource [52]. A study
(patients with affective disorders) and nonclinical examined the presence and correlates of well-­
samples [30]. The prevalence of flourishing being measured by MHC-SF and psychopathol-
among individuals with schizophrenia spectrum ogy in a sample of female patients with eating
disorders has been studied in Hong Kong [48]. disorders, as well as the level of mental health
5 A Salutogenic Mental Health Model: Flourishing as a Metaphor for Good Mental Health 55

compared with the general population [53]. Less standing of an everyday life where they perceived
research has been done in treatment settings and illness and health as intertwined, but also dis-
hospitals; however, one study provides evidence similar [7]. They have been diagnosed with a
for the psychometric properties of the MHC-SF mental disorder, but they are not their diagnosis,
in a primary care youth mental health setting, and life is also mental health and well-being. The rec-
they claim that the MHC-SF’s three-factor struc- ognition of the duality of mental health and men-
ture is valid for use in mental health care [54]. tal illness require major changes for current
Health promotion in health care should take a clinical practice in health care dominated by the
holistic approach, also anchored in the WHO’s pathogenic approach. Health promotion and
[5] definition of health, meaning the salutogenic mental health promotion should have a more
orientation complementing the pathogenic dominant position in today’s health care systems.
­orientation in contemporary health care services. Complementing health promotion and the protec-
I claim that the two continuum model provides tion of good mental health with treatment and
theoretical tools which are useful in the develop- prevention against disorder and illness should be
ment of health promotion interventions in the given equal consciousness and resources based
health care context; this model is equalizing on the evidence base. In the words of Keyes,
treatment and care of disorders and the promo- “…what lowers the bad does not necessarily
tion of health. Having the dual continua model in increase the good” (Personal communication on
mind, the protection of mental health is not to be 12th of July 2015).
confused with protections against mental disor-
ders. I would like to emphasize the differentiation
between the protection of mental health (some-
5.4 Flourishing: Significant
thing positive) and the protection against mental
in Salutogenic Mental Health
illness (something negative). The perception of
Promotion
what is positive or negative depends on the con-
text and culture and might differ from one person
Some perspectives on the opportunities and pros-
to another. However, in this chapter, the terms
pects for a further salutogenic development of
positive and negative are used simply to illustrate
mental health promotion in the health care might
the difference in purpose. In clinical practice of
be relevant. In line with Keyes [3], I claim that
health disciplines such as nursing, it is relevant to
research using absence of illness as an outcome
have theoretical models to guide in customizing
as well as mental health promotion interventions
the care to the individual situation of the person.
with a purpose to restore health understood as
Patients and health care providers may utilize this
absent of illness or to protect against disease are
framework to focus on the mental illness status,
wrongly labeled as salutogenic. Even the father
as well as the persons’ level of mental health
of the term salutogenesis, Aaron Antonovsky [57,
[44]. Keyes’ conceptual framework maps on to
58], might be understood as influenced by this
themes emerging from narratives about recovery
way of thinking in some of his writings. In my
from mental illness [55] and can be a model to
view, this is the main difference between
bridge mental illness with positive mental health
Antonovsky’s salutogenic model of health and
in processes of recovery [56].
Keyes’ dual continua model of mental health.
The findings presented by Mjøsund et al. [7]
Antonovsky gives a conceptual definition of the
give support to the promotion and protection of
health ease/dis-ease continuum as a multifaceted
mental health as described in the two continua
state or condition of the human organism:
model [2], which brings the continuum of mental
illness and the continuum of mental health into A person’s location at a given point in time, on this
continuum, can be described by the person’s par-
the same picture (Fig. 5.4). This corresponds to ticular profile on four facets: pain (felt by the indi-
the experiences presented by the participants and vidual), functional limitations (felt by the
interpretation of their accounts led to an under- individual), prognostic implications (defined by
56 N. H. Mjøsund

health authorities) and action implication (seen by and concepts about assets for health and well-­
such authorities as required) ([58], p. 65). being, including salutogenic elements and dimen-
This definition of health leads us to recognize sions [61]. The editors of The Handbook of
a person’s location on the healthy end of contin- Salutogenesis discuss possible futures of the
uum, when these negative facets are missing. salutogenic orientation, and Georg Bauer states:
Based on this, I claim that Antonovsky did not If we narrowly follow Antonovsky’s conceptual-
define health as something present or positive, ization, salutogenesis is about coping with miser-
rather the absence of something negative. This is able life situations or about “surviving the toxic
river of life” - leaving little space for looking at the
in line with Antonovsky’s own remark: bright side of life. Applying salutogenesis to posi-
The health ease / dis-ease, or breakdown, contin- tive health development - or joyful swimming in
uum as presented here essentially seems to formu- the river of life - is urgently needed ([60], p. 442).
late the most desirable health category in negative
terms; an absence of pain, no functional limitation,
and so forth ([58], p. 67).
5.5 Conclusion
In a later paper from 1985, however,
Antonovsky defined mental health as somewhat In summary, I claim that Keyes’ model of mental
more than the absence of something negative: health is an important contribution to the saluto-
genic orientation and the knowledge base of
Mental health, as I conceive it, refers to the loca-
tion, at any point in the life cycle, of a person on a health promotion. In this model, mental health is
continuum which ranges from excruciating emo- defined by the presence of subjective well-being
tional pain and total psychological malfunctioning [1], which is in line with the lived experiences of
at one extreme to a full, vibrant sense of psycho-
former patients, who perceived mental health as
logical wellbeing at the other ([59], p. 274).
an ever-present aspect of life [7]. Keyes has also
A salutogenic orientation will focus on the given important contribution to the health promo-
achievement of successful coping, which facili- tion field by his two continua model of mental
tates movement toward that end of the mental health and mental illness in the same context.
health continuum which is a vibrant sense of psy- Splitting the phenomenon of mental health and
chological well-being. Antonovsky proposed rel- the phenomenon of mental illness into two sepa-
evant issues and questions to be answered by rate, although related, phenomena is a meaning-
health promoters. Understanding how people ful and useful way of understanding health and
move from the use of unconscious psychological illness for patients, relatives, and health care pro-
defence mechanism toward the use of conscious fessionals in the context of health care services.
coping mechanisms is where the emphasis lies,
from rigidity in a defensive structure to the capac- Take Home Messages
ity for constant and creative inner readjustment • Mental health is an ever-present aspect of life.
and growth, from a waste of emotional energy • Mental health is about subjective well-being;
toward its productive use, from emotional suffer- the individuals’ perceptions and evaluations
ing toward joy, from narcissism toward giving of of their own lives in terms of their emotional
oneself, and from exploitation of others toward state and their psychological and social
reciprocal interaction [59]. functioning.
However, it is important to underline that the • Flourishing, as a term, describes the optimal
salutogenic orientation is much more than the state of mental health.
salutogenic model of health [60]. Eriksson ([60], • Mental Health Continuum—Short Form
p. 103) suggests to use the metaphor of an (MHC-SF) is a structured scale that can quan-
umbrella to underline that salutogenesis is more tify mental health.
than Antonovsky’s salutogenic model of health. • The two continua model of mental health and
Salutogenesis is an umbrella concept of theories mental illness includes the presence of human
5 A Salutogenic Mental Health Model: Flourishing as a Metaphor for Good Mental Health 57

capacities and functioning as well as the by the representatives of 61 States and entered into
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 Hope: A Health Promotion
Resource
6
Tone Rustøen

Abstract 6.1  he Significance of Hope

T
Hope is a phenomenon many nurses and for Patients with Long-­
patients are concerned about. One of the rea- Lasting Illnesses
sons for this interest may be that many patients
today live with chronic illnesses, and hope is Patients with a variety of illnesses describe the
something positive and focuses on the future importance of hope when being ill or feeling
and opportunities. Hope is a way of feeling, threatened in essential areas of life. A Swedish
thinking, and influencing one’s behavior. The nurse, Eva Benzein, interviewed people with can-
way we view our health and health-related cer who received palliative home care about hope
challenges are assumed to impact on hope. [1]. Participants in this study described hope of
Hope is forward-looking, realistic, and multi- being cured even though they knew they were
dimensional. It is a resource for health and seriously ill, hope of living as normally as possi-
health-promoting processes and can be con- ble, the importance of the presence of affirmative
sidered a salutogenic resource and construct. relationships (family and friends, health profes-
This chapter highlights what hope means dur- sionals or of a more spiritual nature), and a recon-
ing illness, what research has so far been con- ciliation with life and death. Everyone expressed
cerned with, how hope can be assessed, and that their lives changed dramatically when they
how nurses can strengthen hope in patients. learned that no curative treatment was possible.
They expressed that they wanted to find a mean-
Keywords ing in their situation and expressed that if hope
disappears you have nothing. Even if this study is
Definitions of hope · Hope measurement · some years old, Benzein’s study is central in this
Hope interventions research field presenting palliative patient’s expe-
riences of hope clearly and interestingly.
Worldwide, the number of intensive care unit
admissions and survivors after treatment in inten-
T. Rustøen (*) sive care is increasing [2, 3] due to an aging pop-
Division of Emergencies and Critical Care, ulation and advances in critical care medicine.
Department of Research and Development, Oslo
University Hospital HF, Oslo, Norway
Several patients admitted to an intensive care unit
have a chronic condition. When being critically
Faculty of Medicine, Institute of Health and Society,
University of Oslo, Oslo, Norway
ill the future can be uncertain both related to sur-
e-mail: tone.rustoen@medisin.uio.no vival, recovery, and daily functioning. A former

© The Author(s) 2021 61

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_6
62 T. Rustøen

intensive care patient shared her experiences as to reach a goal, combined with some degree of
critically ill, describing hope to be essential for expectation that this goal is achievable [11].
her recovery [4]. Possibly, an ICU patient’s goal Hope is also defined as a positive motivational
is to maintain one’s hope during serious illness state based on setting goals and thinking about
and recovery. Little research is done on hope in ways to reach them [12, 13]. The hope literature
ICU patients. emphasizes both the emotional and the cognitive
Hope is an effective coping strategy for aspects.
patients in demanding life situations [5]; it pro- Dufault and Martocchio [14] published a defi-
vides adaptive power for getting through difficult nition of hope 30 years ago, and this definition is
situations and achieving meaning and desired still often referred to. They defined hope as “a
goals [1, 6]. It is described to generate energy, multidimensional dynamic life force character-
often described as “will,” with a motivational ized by a confident yet uncertain expectation of
quality [5]. It can be a resource that provides achieving a future good which, to the hoping
strength to master a disorder. It has also been person, is realistically possible and personally
shown that hope is central to one’s quality of life significant” (p. 380). This definition emphasizes
[7]. Erich Fromm argues that hope is absolutely that hope represents a dynamic life force. There
essential to life [8]. are strengths in hope, understood as forces to
Hope is also described to act as a psychosocial move forward even if you face resistance.
resource to deal with chronic illness experiences Dufault and Martocchio also show the versatility
in a meta-analyses about hope in those above of hope and that hope should be both realistic
60 years with chronic illnesses [9]. In this meta-­ and important. That hope should be realistic is
analyses the participants explained that a sense of also emphasized by Travelbee [11]. Fromm [8]
self, feelings of control, relationships with others, wrote that “hope is neither passive waiting nor is
and quality of life were associated with hope. it unrealistic forcing of circumstances that can-
Accordingly, hope is part of the generalized not occur” (p. 22). He also stated that there is
resistance resources, important for health promo- “no sense in hoping for that which already exists
tion and for salutogenic nursing. or for that which cannot be” (p. 22). Many defi-
nitions of hope as the one given by Dufault and
Martocchio [14] have in common that hope is
6.2 Theoretical Perspectives considered to be forward-looking, realistic, and
of Hope multidimensional.
Farran and colleagues [15] have conducted a
First, this chapter shows some central and fre- literature review of studies about hope. Based on
quently used definitions of hope, followed by a this review, hope is defined as follows:
description of spheres and dimensions of hope.
Hope constitutes an essential experience of the
All these three descriptions of hope contribute human condition. It functions as a way of feeling, a
to a deeper understanding of the essence of way of thinking, a way of behaving, a way of relat-
hope as a salutogenic construct and perceived ing to oneself and one’s world. Hope has the abil-
experience. ity to be fluid in expectations, and in the event that
the desired object or outcome does not occur, hope
can still be present. (p. 6)

6.2.1 Definitions of Hope Through the definitions and descriptions of

the content of hope, it emerges that hope is a way
Hope is a complex phenomenon that is studied in of feeling and thinking which influences one’s
several disciplines. It is also defined as a basic behavior. Within the hope literature, there is a
confidence in and feeling that there is a way out debate about whether hope is a more or less sta-
of one’s difficulties [10]. Joyce Travelbee defined ble state in a person or whether hope is a dynamic
hope as a mental state characterized by the desire process that changes over time [16]. There are
6 Hope: A Health Promotion Resource 63

reasons to believe that personal qualities matter their situation, on their own actions, on the use of
but that hope is influenced by what we encounter. humor, knowledge, or the presence of family or
This will be illuminated somewhat more in the friends. This kind of hope was not perceived in
section describing different dimensions of hope. relation to opportunities in the future or by leav-
Kim and colleagues [16] studied the nature ing it to other people, but on the patient’s own
of hope in chronically ill people. They con- perception of the situation in question.
ducted an interview study of 12 hospitalized The researchers summarize this study by
chronically ill patients from the United States pointing out that different chronically ill patients
and 16 nurses working in oncology departments. focus on different sources of hope, and thus expe-
Everyone was asked to reflect on hope. Different rience hope differently. The hope patterns
patterns of subjective experiences of hope were described may differ due to the different charac-
described: (1) an externalism orientation, (2) a teristics of the patients. The importance of the
pragmatism orientation, (3) reality orientation, relationship with God was highlighted in most of
(4) future orientation, and lastly, (5) an internal- the different orientations. In which ways these
ism orientation. patterns are related to health promotion and salu-
Those who described an externalism orienta- togenesis is not known yet.
tion said that their sources of hope were different In a literature review on hope in qualitative
from themselves, such as God or significant oth- studies, Duggleby and colleagues summarized
ers. They put a lot in God’s hands, and they the characteristics of hope [9] and described two
trusted family and friends to help them. Their hope-processes: (1) transcendence and (2) reap-
own efforts were not important. praisal in re-evaluating hope when being chroni-
In a pragmatic orientation, the chronically ill cally ill. Reaching inwardly and outwardly and
patients stated that they found the source of hope finding meaning and purpose were sub-processes
by doing small things or enjoying things they can of transcendence, whereas re-evaluating hope in
accomplish. Patients who fell into this pattern the context of illness and finding positive possi-
stated that they did not believe in the major goals bilities were sub-processes of positive reap-
as they had no belief that they could be achieved. praisal. These two processes are integrated.
They had accepted their illness without the pros- However, Duggleby and colleagues [17] con-
pects of getting better, and they experienced hope cluded that hope in older persons with chronic
by having a positive attitude toward the future as illness involves transcendence from a difficult
well as the present. situation and positive reappraisal. If you cannot
The chronically ill with a reality-oriented ori- get rid of the chronic illness and its consequences,
entation experienced hope through a sober per- you can always change the way you think about
ception of their situation. Their view of the future your situation.
was thoroughly grounded in relation to the reali- The concepts presented by Duggleby et al.
ties of their illness. They also described God as a [17] are central for sense of coherence and salu-
stable and important force in life. togenesis [18]. Still, the relationship between
Patients in the future orientation category hope and sense of coherence is scarcely exam-
experienced hope by planning the future and ined. In a Norwegian sample of intensive care
ensuring that it contained positive opportunities. patients 3 months after discharge from the inten-
They also had a strong dependence on God. sive care unit, we found the correlation between
These patients do not perceive hope in relation to hope (measured using Herth Hope Index) and
what other people may think but argue that every- sense of coherence (measured by Antonovsky’s
thing that happens have a reason. sense of coherence scale) was 0.56, meaningful-
Patients who had an internalism orientation ness and hope was 0.44, comprehensibility and
experienced hope through humor or related to hope was 0.45, and manageability and hope was
advances in science. This type of hope was based 0.44 (unpublished data). These results suggest
on the patient’s belief in what was possible in that hope and sense of coherence are moderately
64 T. Rustøen

correlated in Norwegian intensive care survivors. [22], based on a comprehensive literature review,
In a study from Israel in three different cultural has defined hope as consisting of six different
groups, they also concluded that hope and sense dimensions:
of coherence stand as separate resources even if a six-dimensional, dynamic attribute of the person
the concepts have some overlap [19]. Møllenberg which orients to the future, includes involvement
et al. showed that a stronger family sense of by the individual, comes from within, is possible,
coherence was associated with higher hope in relates to or involves others or a higher being, and
relates to meaningful outcomes to the individual.
both persons with cancer and their family mem- (p. 89)
bers [20]. Further research is warranted to exam-
ine the health-promoting aspects of hope. Dufault and Martocchio [14] also described that
hope has six different dimensions: an affective
6.2.1.1 Different Spheres dimension, a cognitive dimension, a behavioral
and Dimensions of Hope dimension, an attachment dimension, a time
Dufault and Martocchio [14] stated that hope dimension, and a contextual dimension. Based on
consists of two spheres. One sphere is a general- research using the Dufault and Martocchio hope
ized (or general) hope and the other a particular- dimensions, the next section will elaborate on
ized (or partial) hope. They defined generalized these six dimensions presented by Dufault and
hope as a feeling that the future is uncertain but Martocchio:
can be positive. A general feeling of hope pro- The affective dimension shows the emotional
tects the hopeful by casting a positive glow on aspect of hope. As already shown, hope is often
life. A statement describing this is: “I hope for defined as an emotion, with many different feel-
nothing special, I just hope.” The other sphere of ings involved. Both confidence in that a positive
hope is the partial hope associated with a particu- result is possible and uncertainty about the future
lar object that may be abstract or concrete (e.g., a are central feelings in hope [23]. Travelbee
new treatment). emphasized both trust and courage as aspects of
This division of hope into spheres and dimen- hope.
sions was also described in Benzein’s study [1] of The cognitive dimension contains thoughts,
the patients receiving palliative home care. These ideas, goals, desires, and expectations. This
patients described hope as a tension between dimension is related to comprehensibility in
hoping for something (individualized hope) and sense of coherence, which refers to the extent to
living in hope (generalized hope). Hoping for which you might perceive both internal and
something was related to being cured, while liv- external stimuli as being understandable in some
ing in hope was a reconciliation of life and death. kind of rational way [18]. An important factor
Which of these two spheres are dominating the here is how one assesses his or her opportunities,
palliative patient’s state is seen to vary during the for example, get well or to have a good quality of
illness trajectory. An example of the disparity life. An evaluation of the reality and hopeful fac-
between these two spheres is that if one hopes for tors will be central. A desire is often defined dif-
a treatment to succeed (individualized hope), one ferently from hope as it may have less realism.
may not fully succumb if the treatment fails This distinction is not easy, but hope is claimed to
because the generalized hope can take over until be based more on basic values such as experienc-
one might find new particularized hopes. ing community or being active. As one processes
The generalized hope can be a form of “funda- a situation, hopes and desires may become more
mental” or “existential” hope [21]. A generalized coincidental. Still, wanting something will be
hope is related to our ability to make or find part of the hope. Travelbee emphasizes both
meaning in our lives. A fundamental hope enables desire and having choices as important for hope.
us to survive, e.g., loss of meaning. The behavioral dimension of hope is related to
Several definitions of hope include different what actions one takes, such as eating healthy
dimensions or aspects of hope. Mary Nowotny food, praying, or making a decision [14]. This
6 Hope: A Health Promotion Resource 65

dimension is in accordance with manageability different patient groups at different stages of ill-
in sense of coherence and has to do with the ness. Furthermore, there are several qualitative
degree to which we might feel that there are studies helping to understand patients’ experi-
resources at our disposal to meet demands [18]. It ences of hope [9].
is pointed out that a hopeful person is better able Different questionnaires are developed to
to act than one who does not experience hope. identify hope within health disciplines, especially
There is energy in hope. Travelbee [11] points by nursing researchers. Examples of such instru-
out that hope is linked to perseverance. ments are Miller Hope Scale [24], Nowotny Hope
The associational dimension highlights the Scale [22], Stoner Hope Scale [25], Herth Hope
importance of good interpersonal relationships Scale [26], and Herth Hope Index [27]. These
for hope [22]. These can be relationships with scales are developed based on different defini-
other people or with religion. Travelbee [11] tions of hope. The Herth Hope Index is based on
claimed that hope is linked to dependence on Daufalt and Martocchio’s understanding of hope,
others. The importance of religiosity for hope which is used in several studies internationally,
will probably differ depending on cultural and found to have satisfactory psychometric
differences. properties in many countries. Herth Hope Index
The time dimension is fundamental for hope consists of 12 items. The answer options range on
and implies the expectation of being able to a 4-point scale from “strongly disagree” to
achieve something in the future, and will in this “strongly agree.” Table 6.1 shows the content of
way be time-related [14]. Travelbee [11] claims the 12 items and the scaling.
that hope is future-oriented. An advantage of this scale is that it is short
Lastly, the contextual dimension concerns that and easy to complete [27]; therefore, it is clini-
hope is activated within a context. This dimen- cally relevant. This questionnaire is currently
sion focuses on the specific circumstances of life used in patients with pain, cancer, heart failure,
that surround, influence, and challenge an indi- liver failure, cystic fibrosis, nursing home resi-
vidual’s hopes. This dimension is the same as dents, and in relatives of intensive care patients.
specific resistance resources in sense of coher- This scale has also been tested in the normal
ence [18], which is context bounded. Hope is not Norwegian and Swedish population [28, 29]. The
regarded as a stable trait in man, but as a condi- instrument has the advantage that it is not specifi-
tion influenced by external factors such as illness cally aimed at a specific outlook on life. Nowotny
and changes in life (depending on context). Hope Scale, which is also found in a Norwegian
Consequently, it is very important how patients translation, gives religious people a higher hope
experience their surroundings when they are seri- than non-believers [30]. The role of religious
ously ill, facing threats of their life or health. beliefs in hope is debated, but I believe that hope
Travelbee [11] argued that nurses must prevent will have different content for different individu-
patients from losing their hope. Nurses can influ- als depending on one’s beliefs.
ence an individual’s hope by caring behavior and Since the Herth Hope Index is short and easy
the nurse–patient interaction including the way to fill in, it can be used in clinical practice. There
information and support are provided. We can is always a danger that those patients who have
also say that salutogenic nursing care promotes the most difficulties do not contact health profes-
patients’ hope, health, and well-being. sionals for help. An early survey of hope using
the Herth Hope Index can help to capture those
who have the most difficulty. However, if using
6.2.2 How to Measure Hope this scale in clinical practice, the results must be
followed-up by adequate nursing care and actions
When it comes to research on hope, the focus is toward the patient. If you as a health care profes-
often on how to identify hope using various ques- sional, choose not to use the entire form, you may
tionnaires. Some studies have identified hope in benefit from looking at the individual questions
66 T. Rustøen

Table 6.1 The Herth Hope Indexa [27]

Strongly disagree Disagree Agree Strongly agree
1. I have a positive outlook toward life
2. I have short and/or long range goals
3. I feel all alone
4. I can see possibilities in the midst of difficulties
5. I have faith that gives me comfort
6. I feel scared about my future
7. I can recall happy/joyful times
8. I have a deep inner strength
9. I am able to give and receive caring/love
10. I have a sense of direction
11. I believe that each day has potential
12. I fell my life has value and worth
a
© 1989 Kaye Herth. 1999 items 2 and 4 reworded. (Reprinted with permission of Kay Herth. Cannot be used without
permission from Kaye Herth)

in the instrument and using them in conversation Furthermore, a study examining the relation-
with the patient. Based on the patient’s ­assessment ship between hope, symptoms, needs, and spiri-
of his or her situation, the results could be used as tuality/religiosity in cancer patients treated in a
a starting point to talk to the patient about his/her supportive care unit [34] reported that those with
hope and to assess whether the patient could pos- less education, less symptoms, and less often had
sibly benefit from an intervention in relation to been referred to a psychologist previously to the
hope. Research has shown that a nurse–patient study, as well as higher spirituality reported
interaction including listening, acknowledging, higher hope.
respecting, and understanding the patient’s expe- Previous studies on hope assess hope in differ-
riences is health promoting [31] (see Chap. 10). ent patient populations in various clinical and life
settings as well as countries; therefore, summariz-
ing factors that facilitate hope based on earlier
6.2.3  actors That Can Facilitate or
F research is difficult. The use of covariates to exam-
Hinder Hope ine the impact on hope is also differing from study
to study. The research on hope includes patients
Various studies on different patient groups have from different countries; hence, cultural differ-
examined what facilitates and what hinders hope. ences might influence the results. As hope seems
An Iranian study on hope and spirituality in to be related to spiritual well-being, variations
patients with cardiovascular diseases, found a about beliefs and values might also be a disturbing
stronger hope among those being married, having factor. Furthermore, low education and many
higher education, good economic status and with symptoms seem to negatively impact on hope.
stronger spiritual well-being [32]. This study
concluded that multiple factors may influence on
hope. 6.2.4 Health-Promoting
Another study on hope in women after cardiac Interventions
surgery [33] showed that diminished hope was Strengthening Hope
associated with older age, lower education,
depression prior to surgery, and persistent pain at Knowledge about factors that can strengthen
all measurement points up to 12 months after sur- hope in patients is important when developing
gery. The authors concluded that e.g. promoting interventions to impact on patients’ hope.
hope, particularly for women living alone may be Research on factors strengthening hope is ­limited;
important targets for interventions to improve however, there are reasons to believe that more
outcomes following cardiac surgery. research will come when instruments to assess
6 Hope: A Health Promotion Resource 67

hope are available in many countries. Caring for illness experience [9]. Finding meaning and posi-
patients with serious illnesses and an uncertain tive reappraisals are important strategies to help
future can be a challenge. Nurses are around older adults with chronic illnesses to maintain
patients and they are important in strengthening their hope. Ways to foster hope with older adults
or maintain hope. Travelbee writes [11]: with chronic illness may include strategies for
The job of the professional nurse is to help the sick finding meaning and purpose which is a process
to maintain hope and avoid hopelessness…. of self-transcendence [9] (see Chap. 9). Strategies
(p. 123) such as adjustment to transitions and losses, life
One must be open to the fact that there are review, reminiscence therapy, and spiritual sup-
many ways of promoting hope. It can be helpful port can help people find meaning and purpose
to let patients put their own words into how they and transcend their experience of suffering (see
look at the time they have ahead. It can be a gate- Chap. 8).
way to talk about hope (see Chap. 10). As Ripamonti and colleagues [34] conclude that
Travelbee writes, the nurse’s behavior can mean a in cancer patients, hope can be encouraged by
lot to patients’ hopes. The fact that one dares to clinicians through dialog, sincerity, and reassur-
be present and listen to the patient is emphasized, ance, as well as assessing and considering the
and the patient must have confidence in the nurse. patients’ needs (above all the psycho-emotional),
An interview study explored critical care symptoms, psychological frailty, and their spiri-
nurses’ perceptions of hope inspiring strategies tual/religious resources.
in adult patients and families [35]. The nurses The above-presented studies describe how to
told that communication was the major theme for strengthen hope in patients; however, they mainly
intervention (see Chap. 10). Listening, asking focus on communication and the nurse–patient
questions, and educate were described. Nurses relationship and the nurse–patient interaction.
stressed to be honest and a large part of commu- This is of great importance, but it is not clear
nication was getting to know the patient as a per- what is specific hope inspiring or what is related
son which is an essence in nurse–patient to other hope-related phenomena.
interaction and salutogenic nursing care. They The effectiveness of a psychosocial supportive
also emphasized that it was important to incorpo- intervention to increase hope and quality of life
rate family into care. was evaluated in terminally ill cancer patients
The nurse–patient interaction is shown to be 60 years and older staying at home [38]. The
important for hope in cognitively intact nursing hope intervention termed “Living with Hope
home residents [31]. Haugan et al. [36] found a Program” (LWHP) consisted of viewing an inter-
direct relationship of nurse–patient interaction on national award-winning video on hope and a
hope, meaning in life and self-transcendence, and choice of one of three hope activities to work on
conclude that advancing caregivers’ interacting over a 1-week period. The control group received
and communicating skills might facilitate standard care. The data were collected at the first
patients’ health and global well-being and inspire visit in the patients’ homes. Analyses showed
professional caregivers as they perform their that patients receiving the LWHP had higher
daily care practices. hope and quality of life compared to those in the
Frankl wrote about the importance of finding control group. They also collected qualitative
hope and meaning in life, suggesting self-­ data with open-ended hope questions from the
transcendence as the process of reaching out treatment group. The qualitative data confirmed
beyond oneself and thus discover meaning in life the findings from the statistical analyses as 62%
[37] (see Chap. 8). A way to find meaning is of the patients in the treatment group reporting
through the chosen attitude when faced with an the LWHP increased their hope.
unchangeable situation. Duggleby and colleagues A recent study described smartphone delivery
claimed that hope is a psychosocial resource of a hope intervention to students [39]. The inter-
which individuals use to deal with their chronic vention was based on Snyder’s theory of hope
68 T. Rustøen

and used text messages with hope stories and pic- also unclear. Finally, in comparing research on
tures. Using a quasi-experimental pilot study hope between different international studies, the
with pretest and posttest design, the feasibility cultural differences important to hope represent a
and potential impact of the mobile app were challenge. For example, when it comes to the
examined. The analyses showed that the partici- importance of religion to hope, I expect that this
pants appeared to engage with the intervention will vary significantly across countries.
and found the experience to be user-friendly, Given the importance of hope for patients in a
helpful, and enjoyable. Relative to the control variety of situations, we must continue our efforts
group, those receiving the intervention demon- to understand hope and to gain greater knowl-
strated a significantly greater increase in hope. edge of how we can best help to strengthen
Research should continue to develop interven- patients’ hope in the best possible way. There are
tions to strengthen hope in patients. When choos- reasons to believe that hope is a central phenom-
ing an intervention to strengthen hope, the enon for health promotion and salutogenic nurs-
intervention must be based on what is most impor- ing care.
tant for the patient’s hopes. The interventions can
be individual or group-based. There is a need for Take Home Messages
studies that can further investigate how hope best • Hope is an important phenomenon for many
can be strengthened in patients also in the special- different patient groups.
ist health service. Based on earlier research, areas • Hope is a vital resource for health promotion
like finding meaning, self-­transcendence, nurse– in healthy as well as unhealthy people and
patient interaction, and communication are impor- represents a salutogenic concept.
tant but seem not specific to hope. To secure that • Hope is defined in different ways, but there is
the interventions are related to hope one might a consensus that hope is a multidimensional
talking with the patients about the different aspects concept comprising both feelings and the way
included in the 12 items in Herth Hope Index. of thinking.
A challenge in building the research on • Research on hope has been centered on how
strengthening hope is that the studies presented hope can be mapped to different patient groups
just to a small amount are building on each other. and how hope can be strengthened in meeting
One should base research well in what is already patients.
there. Another challenge is that hope might mean • Hope can be facilitated by communication,
different if you are young or elderly, are very ill nurse–patients interaction, and the individu-
or in a rehabilitation phase. Further, individual’s al’s ability for self-transcendence.
cultural and religious background impact on the • Further research is desirable and necessary to
content of their hope. Further research is needed better enable the nurse to strengthen the hope
about how to promote hope in different patient of patients.
groups.

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 Dignity: An Essential Foundation
for Promoting Health
7
and Well-Being

Berit Sæteren and Dagfinn Nåden

Abstract texts of well-known researchers from the

Nordic countries and UK were employed. In
The purpose of this chapter is to illuminate
reflecting on how we can make use of the
different understandings of the concept of
knowledge of dignity and indignity to pro-
dignity and to discuss how we can make use
mote health, we have considered this matter in
of this knowledge to enhance human health.
light of results of a major Scandinavian study.
Dignity is viewed as a universal concept in
The main purpose of this study was to explore
health sciences and a feature necessary to
dignity and indignity of patients in nursing
promote health and alleviate suffering
homes from the perspective of patients, family
related to sickness and impending death. The
caregivers, and health personnel. The testimo-
ideas presented in this chapter are founded
nies presented in this section are further inter-
in a caring science paradigm where the
preted employing mainly caring science and
human being is considered as a unique entity
philosophical literature. Lastly, a short sum-
consisting of body, soul, and spirit. Caring
mary of some public policy efforts with the
science as referred to in this chapter has its
aim to preserve human dignity is offered.
scientific foundation in Gadamer’s ontologi-
cal hermeneutics.
Keywords
Dignity is described in a historical perspec-
tive, and different meanings of dignity are Dignity · Indignity · Health · Health p­ romotion ·
clarified. Since health and dignity relate to one Well-being
other, we have clarified the concept of health
employing the texts of the Finnish theoretician
Katie Eriksson. In order to illuminate the per- 7.1 Introduction
spective of health promotion, we have also
briefly described health in a salutogenic per- The purpose of this chapter is to illuminate dif-
spective according to the medical sociologist ferent understandings of the concept of dignity
Aron Antonovsky. In clarifying dignity, the and to discuss how we can make use of this
knowledge to enhance human health.
Dignity is a core concept in nursing science
B. Sæteren (*) · D. Nåden and care, as well as in other health professions
Faculty of Health Sciences, Department of Nursing that take responsibility for the health and well-­
and Health Promotion, Oslo Metropolitan University,
Oslo, Norway being of others [1–5]. In nursing, the preservation
e-mail: beritsa@oslomet.no; dagfinn@oslomet.no of human dignity is often emphasized as nursing

© The Author(s) 2021 71

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_7
72 B. Sæteren and D. Nåden

is related to persons in vulnerable situations and help persons to experience well-being and be
in need of health care. The value of protecting restored to health. Tranvåg and McSherry [16]
human dignity is often emphasized colloquially claim that nurses as well as allied health care pro-
and in professional and political settings without fessionals may have an intuitive understanding of
necessarily explaining what it really means. dignity in their practice, but they often lack the
Consequently, no common understanding of dig- in-depth understanding required to manifest dig-
nity exist; thus, the health professionals are left nity in practical situations. Indignity/violation of
with their individual interpretation of the mean- dignity in health care is well known and docu-
ing of dignity. Furthermore, a concept, which is mented [5, 17]. It is therefore important that
used in several different context and with differ- health personnel working with people in vulner-
ent meanings, is at risk of becoming meaning- able situations seek to obtain a deeper under-
less. Theoretical end empirical research is standing of the underlying components of dignity
therefore valuable to broaden our understanding in order to promote health, foster humane health
of dignity in the health care context. care, and prevent dehumanization. Buchanan
A common understanding is that human [18] even emphasizes promoting dignity as the
beings are unique creations with an inherent dig- ethical dimension of health.
nity and are given a specific place in the world Dignity is viewed as a universal concept in
[2–4, 6–10]. Likewise, the experience of dignity health sciences and a feature necessary to pro-
is significantly meaningful in people’s lives and mote health and alleviate suffering related to sick-
may be a resource for personal health and well-­ ness and impending death. In this chapter, we
being. Vulnerability and dependency are basic want to call attention to the value of the concept
features of human existence. As other creatures related to experiences of health and health promo-
manage their own life when born, human beings tion. We understand health promotion in line with
have a special existential vulnerability and depen- the Ottawa Charter from 1986 as “the process of
dency on being seen and taken care of by others. enabling individuals and communities to increase
Vulnerability is always a part of human life, actu- control over the determinant of health and thereby
alized in situations where humans need help from improve their health.” ([19], p. 15). The ideas pre-
their closest family members or from health care sented in this chapter are founded in a caring sci-
professionals [11, 12]. Vulnerability is however ence paradigm where the human being is
also a positive trait by being human, a health considered as a unique entity consisting of body,
resource, helping persons to transform demand- soul, and spirit [2, 7, 20]. Caring science as
ing experiences from life and sickness into referred to in this chapter has its scientific founda-
strength and personal growth [13]. tion in Hans-Georg Gadamer’s [21] ontological
Dignity is often characterized as a complex hermeneutics. The idea of hermeneutics is to clar-
and vague concept. Although a large amount of ify terms for understanding of the human being.
research related to dignity has been done in recent
years, the meaning of the concept is still ambigu-
ous. This may not be considered a problem but 7.2 Dignity in a Historical
instead a strength, as it points to the complexity Perspective
in conceptualizing a human phenomenon as com-
plicated as dignity [14, 15]. Human dignity has held a prominent place in
In this chapter, the aim is to broaden the sig- political discussions of human rights since the
nificance and meaning of the concept in a histori- Second World War [22]. Dignity emerges as a
cal and professional setting based on theory and right and a duty based on a notion of human
research. We do not offer a particular definition rights that relates to inner value and objective
of dignity. Moreover, we emphasize the meaning beauty in the human being entailing strong moral
and importance of dignity as a health resource in implications for fellow human beings. Each per-
people’s lives and how promoting dignity can son deserves respect, and because of the human
7 Dignity: An Essential Foundation for Promoting Health and Well-Being 73

being’s dignity and inner value, the person holds Later, the German philosopher Immanuel
a certain right that the world community must Kant (1724–1804) described dignity as an abso-
protect. The United Nations [23] emphasizes that lute inner value that all human beings possess. He
all human beings have inherent dignity. Article 1 refers to dignity as an elevated position, above
of the Universal Declaration of Human Rights the rest of the nature, by virtue of a certain capac-
[23] states: ity, namely freedom and reason. Kant talks about
All human beings are born free and equal in dig- dignity mainly in relation to the duty toward one-
nity and rights. They are endowed with reason and self not to violate the prerogative one has over
conscience and should act towards one another in other creatures [22]. The historical perspectives
a spirit of brotherhood. of the meaning of dignity are still visible in the
Professional codes such as the ICN Code of contemporary view of the concept.
Ethics for Nurses [24] emphasize that the preser-
vation of dignity is an important part of caring.
“Inherent in nursing is a respect for human rights, 7.3 Dignity and Health
including cultural rights, the right to life and
choice, to dignity, and to be treated with respect.” Health and dignity relate to each other [4]. In
The idea of dignity has a long history. In traditional health and medical care the focus has
ancient Rome, the Latin dignitas meant “worthi- been related more to illness than to health. In a
ness,” and in a political context, “reputation” or health-promoting perspective, the focus is mov-
“standing.” Sensen [22] distinguishes between ing toward person’s health resources. This per-
what he calls a contemporary and a traditional spective is clarified both in Eriksson’s caring
paradigm related to human dignity. The contem- science theory [2, 7] and in Aron Antonovsky’s
porary paradigm relates to human rights, and the [27, 28] salutogenic model of health. They both
traditional paradigm goes back to older thinkers acknowledge suffering and disease as part of
such as Pico della Mirandola and Immanuel Kant human life but find it more valuable to focus on
[22]. In contrast to the contemporary paradigm the strength and resources, which are imparted
related to human rights, the traditional under- in each human being in order to handle chal-
standing is primarily a theoretical question about lenges related to illness and life. Conceptually
the human being’s place in the universe because and historically, health means wholeness and
of its rationality and freedom. Dignity is used in holiness [7]. Wholeness relates to a person’s
the traditional sense to describe the special posi- unseparated being as body, soul, and spirit.
tion that human beings hold. Because of this spe- Holiness refers to a person’s deep awareness of
cial position, the human being has an initial her uniqueness and responsibility as a fellow
dignity as well as a duty to realize it. Sensen [22] human being. Both health and suffering are
describes these two notions of dignity as “initial parts of human life, and according to Eriksson
dignity” and “realized dignity.” [7, 8], there is an inherent dialectic between
In 1988 Katie Eriksson [1] (p. 22) expressed them. As human beings, we live in this dialecti-
that Human dignity is the human being’s ability cal movement between health as wholeness and
to constitute her life and being. She based her integration and suffering as divineness and dis-
thesis on the work Praise of man’s dignity (pub- integration. Antonovsky [27] also described
lished in 1486) by the Renaissance philosopher health as movement on a continuum of ease and
Giovanni Pico della Mirandola (1463–1494). dis-ease. According to Antonovsky [27], we are
According to Pico, human beings were excep- always exposed to events in life that may be
tional in the Creation. He viewed the dignity of considered as stressors. This can reduce health
human beings as founded in their freedom, in temporarily but can also make a person stronger
their capacity to choose their own place in the [28]. Sense of coherence is a key concept in
chain of beings stretching from God to the lowest Antonovsky’s salutogenic model. The sense of
animals [22, 25, 26]. coherence points to a person’s view of life and
74 B. Sæteren and D. Nåden

capacity to handle stressful situations. As human people in obvious need of health care. The respect
beings, we have the capacity to comprehend the and confirmation of a person’s strength and
situation we are in as comprehensive, meaning- health resources given by health personnel are of
ful, and manageable, thereby strengthening our great importance in promoting or restoring dig-
sense of coherence in life [27, 28]. nity when it is threatened [32, 33].
Eriksson [29] defines health in her earlier
writings based on an analysis of the concept:
health as soundness, freshness, and well-being. 7.4  he Meaning of Dignity
T
She strongly emphasizes the subjective dimen- from Theoretical
sion of health and health as more than the and Empirical Research
absence of illness. This is in line with
Antonovsky’ model. In many situations, we are Researchers have tried to clarify dignity through
not able to promote health in the sense of sound- theoretical and empirical studies. Investigations
ness and freshness, but in most cases, we are of the concept of dignity and its field of meanings
able to promote well-­being. This will be exem- have represented an important step in under-
plified later in this chapter. standing the essence of dignity.
Eriksson [7] views health in its deepest sense Despite ontological and empirical differences,
as an ontological concept relating to the individ- one shared feature is the understanding of dignity
ual’s becoming and reality. She presents an onto- as a dualistic concept [16]. This has been
logical health model where health is a movement described in various terms. Eriksson [6], Edlund
between three separate levels: health as doing, [8], and Edlund et al. [9] refer to absolute and
being, and becoming. This movement is expressed relative dignity. Absolute dignity is recognized as
in the person’s experiences of various problems, an inherent, inviolable, and unchangeable dimen-
needs, or desires. At the doing level, health is sion rooted in human holiness. Absolute dignity
related to objective external criteria; at the being consists of values such as responsibility, free-
level, people strive to experience a form of har- dom, duty, and service. Relative dignity com-
mony and balance; and at the becoming level, a prises a bodily, external, esthetic dimension and a
person is not a stranger to suffering and strives to physical inner ethical dimension. Relative dig-
be whole and to reconcile herself with the given nity is changeable and is influenced by internal
circumstances. Life is movement. Human beings and external factors.
live in a dialectical movement between different Other theorists use the term objective dignity
binary opposites such as life and death, health [3], Menneschewürde [10], and human dignity [4]
and suffering, and dignity and indignity. To bal- to denote absolute dignity. These different terms
ance these opposites is the human being’s respon- for this dimension of dignity are rooted in human
sibility and represents his personal life struggle. worth and human equality [23]; common features
The direction the movement takes depends on in their descriptions of dignity are dignity as inher-
various circumstances. These may be related to ent, universal, unchangeable, and inviolable.
the person himself, his relationship to others, to Jacobson [4] describes relative dignity as
God, or an external power, nature, or the sur- social dignity and mentions two intertwined
rounding environment [30, 31]. Among the aspects of social dignity: dignity-of-self and dig-
human being’s noble traits are the ability and nity in-relation. Dignity-of-self relates to self-­
freedom to choose the direction for this inner respect, self-confidence, autonomy, and various
movement. This inner movement is not unaf- forms of integrity. Dignity in-relation refers to
fected by a person’s relations and circumstances, the way in which respect and worth are conveyed
“No man is an island.” This is especially true back to the individual through expression and
when the person’s vulnerability is acute and dig- recognition. Relative dignity and social dignity
nity is threatened. This may happen for humans may be lost, or gained, threatened, violated, or
considering themselves as healthy as well as for promoted. Jacobson [5] claims that any human
7 Dignity: An Essential Foundation for Promoting Health and Well-Being 75

interaction may be an encounter with dignity [5] ambivalent or rather paradoxical body was
in which dignity is either promoted or violated. grounded in the fundamental love for the family
Also Nordenfelt [10] and Nordenfelt and Edgar member and an act of responsibility, both bricks
[34] address the dimensions of dignity similarly, in the concept of dignity. The complexity of the
pointing to relative and social dignity through body lead to the question of whether the division
notions such as (1) dignity as merit based on between absolute and relative dignity was inap-
­formal position and rank, (2) dignity as moral plicable when understanding dignity in a bodily
stature based on personal moral values, and (3) perspective [14]. This question needs more theo-
dignity as identity based upon personal auton- retical and empirical research.
omy, integrity and self-respect, and also influ- Finally, we want to shed light on an aspect of
enced by relationships and interaction with dignity related to health personnel. Gallagher [3]
others. Relative and/or social dignity can be vio- explored dignity as both an “another-regarding”
lated as well as supported and promoted. Relative and a “self-regarding” value: respect for the dig-
dignity is the subjective part of dignity, and nity of others and respect for one’s own personal
knowledge of what values are important for the and professional dignity. Respect for the dignity
individual person will always be the basis for of others is well known and the object of much
dignity-preserving care. attention within health professions, while respect
As bodily changes frequently are a threat to for one’s own dignity is given less attention.
persons in need of health care, research under- Other-regarding and self-regarding values appear
scores the connection between bodily changes to be inextricably linked, and Gallagher refers to
and dignity. Edlund [8] and Edlund et al. [9] Aristotle’s doctrine of the mean, which enables
describe the body as the bearer of relative dignity. health personnel to reflect on the appropriate
The body often serves as a symbol for dignity degree of respect for the dignity of others and
when it performs actions in accordance with the proper respect for themselves. In encounters
culture’s rules and norms for dignity. The body between patients and health care personnel in our
may also be a potential source of violation when multicultural world, there may be situations of
bodily changes make it impossible to perform personal and cultural nature that may be chal-
what both the human being and the culture of fel- lenging, and the self-respect and self-worth of the
low humans expect. The body enables indepen- professional may be threatened.
dence and freedom, but also limitations and The meaning of dignity may be summarized
dependency. The body generates both pride and theoretically, as it has been a commonly shared
shame and opens for vulnerability, violation, notion among researchers that dignity has an
power, and powerlessness. The body is an impor- unchangeable dimension related to just being
tant part of the holistic human being, a unity that born. The grounds of the human inherent value
must be whole to experience dignity. Bodily may differ, from a religious version, which is
changes may lead to suffering and be a violation grounded in a belief that human beings hold an
of the person’s dignity [8]. exalted place in God’s creation, where life is cre-
It is a question as to whether it is fruitful to ated and given. A secular version associated with
maintain the division between absolute and rela- Kant is grounded in the rationality of human
tive dignity. Research related to dignity and bodily beings and their ability to act as moral agents as
changes in a palliative care setting questions this enshrined in The Universal Declaration of Human
division. Lorentsen et al. [14, 15] emphasize Rights (1948) [4]. Relative dignity is harder to
patients’ and relatives’ need to strive for dignity in grasp, as the subjective part of dignity will be dif-
situations where patients’ bodies are falling apart ferent according to a person’s own personal val-
because of advanced cancer disease. Through the ues, context and culture. To give an exact
ambiguity and paradox of the body, dignity was definition of dignity is therefore difficult because
revealed as a life-affirming will and love as heal- it describes the fundamental meaning of being
ing power [15]. The relatives’ confirmation of the human [4].
76 B. Sæteren and D. Nåden

7.5 Making Use Some years ago, a woman with dementia was
admitted to this nursing home, and she was awfully
of the Knowledge of Dignity shy and scared, sitting with her purse and looking
and Indignity to Promote down at the floor ... her hair covered her eyes. We
Health had no contact with her; it was quite impossible. I
think we tried for two hours ... and then I thought
... we must try something else. So, I did something
In the following section, we will describe and no one else had done before, I think, I lay down on
discuss from different perspectives how we can the floor and crawled under the table. Then I
understand and make use of the knowledge of looked up at her face and smiled at her and said,
dignity and indignity to promote health, having "Hey there!" And then I got this beautiful smile
back! And every time after that incident, she recog-
in mind the importance of nurturing the inner nized me and gave me this beautiful smile, and said
strength in old people living in nursing homes to me, 'Hey there!' [40]
[35–37]. We will consider this matter in light of
the results of a major Scandinavian study called One of our residents has serious dementia and has
A life in dignity, the main purpose of which was no family caregivers, and he loves to watch soccer;
he likes Vålerenga (a well-known soccer club in
to explore the dignity and indignity of patients in
Norway). Then I thought to myself, I love soccer,
nursing homes from the perspective of patients, but I hate Vålerenga. However, I can still watch one
family caregivers, and health personnel [31, 38, Vålerenga match (I thought). So, I sent an e-mail to
39]. The overall study had a hermeneutical design the club and told about our resident with dementia,
82 years old … And there we went. He was dressed
inspired by Gadamer’s philosophy [21].
in a dark suit and we were seated in the VIP tri-
Individual interviews were performed with 28 bune and we were treated with this and that … but
residents (17 women and 11 men between 62 and what joy we shared! This was my day off duty, but
103 years), 28 family caregivers (children and we were together, both enthusiastic, and all the
glances, and all the pleasant things we shared.
spouses) and qualitative focus group interviews
This is what I hope my mother and father will expe-
with health care personnel, a total of 40 staff rience in a nursing home, things they like … This is
members with five to eight participants in every my passion! [40]
interview session. The number of group sessions
varied between three and four sessions, totally 20 These two narratives deal with fostering dig-
meetings. Twelve researchers were involved, and nity and promoting health, in this case in indi-
the study was carried out in nursing homes in viduals who suffer from dementia living in a
Norway, Sweden, and Denmark. The data mate- nursing home. The caregivers, visualized in the
rial was read and interpreted by the entire research stories, show a deep dedication in helping human
group until consensus about the results was beings who suffer. We have labeled these two
reached. The study followed the guidelines for narratives dignity as distinction, meaning indi-
good scientific practice, set by the ethics commit- viduality implying respect, listening, eye contact,
tees in the Scandinavian countries [17]. Our vocal pitch, body posture, calmness, and friendli-
intention in including the following presentation ness. Dignity is also feeling accepted as unique
is not to present the study itself, but to make use and complete persons [40]. Even while attending
of parts of the results to illustrate both dignified a soccer match, we experience a deep commu-
and undignified care in clinical practice. nion between the resident and the caregiver,
along with togetherness, enthusiasm, and joy.
The motivation for displaying this kind of atti-
7.6 Learning tude is aptly stated by the caregiver: Human
from the Perspective beings grow when they are met with dignity [40].
of Health Care Personnel Dignity is also seen as influence and participa-
tion through the opportunity to participate and
In the following, we present two different pic- being able to co-determine their daily activities.
tures in which dignity is preserved. Through creativity, awareness and sensitivity, the
A helper’s testimonies: health personnel had the opportunity to enhance
7 Dignity: An Essential Foundation for Promoting Health and Well-Being 77

the residents’ ability to influence their own lives called to a responsibility that was never con-
[40]. Nygren et al. [35] underline the importance tracted, inscribed on the other’s face. Nothing is
of inner strength in being an oldest old person. The more passive than this accusation that precedes
caregivers in this present study ‘lived’ the inner any freedom.” ([45], p. 100). According to
strength for those people not having the capacity Levinas [45] the ability to be affected by the vul-
possessing this quality, that nevertheless created nerability and suffering of others is a prerequisite
strength and empowered the residents [40]. for man to assume the responsibility that is given
Both accounts relate encounters which are to us and already is there. The caregivers in the
dimensions of caring as an art. In an investigation stories above possess this ability to be touched,
Nåden and Eriksson [41] concluded that the which is why we can speak of a natural inherent
encounter is characterized by being on the same obviousness in the turn to the other. Likewise,
wavelength, giving oneself over, “nakedness,” this demonstrates the very importance of Levinas
and of deep solidarity and closeness. One of the thinking in understanding the given responsibil-
most human qualities is manifested in the encoun- ity for the other, in our case, the patients, where
ter, when the person is in contact with him or her- the caregivers lift the other so that the other can
self. The encounter can be healing, life-giving, preserve his or her dignity, and experience health
and alleviating, and the participants are first and as becoming [2]. This is in line with the patients’
foremost human beings. We can read these wishes in Bylund-Grenklo [47] research in a pal-
dimensions in the narratives above; the patients’ liative care context where a dignified life was
wishes and needs. As one caregiver states: One about having their human value maintained by
ought to be sensitive and look at facial expres- others through “coherence.” Levinas emphasizes
sions … If one does not see the other human the perfection of artistic creation, the ultimate
being, then dignity is at risk [40]. A character in a moment when the last brushstroke is made, when
novel by Erik F. Hansen, a well-known Norwegian not a single word can be added to or subtracted
author, says the following about art: I’m over from the text [45]. In light of these words, we can
sixty and I have never found out what it [art] see the perfection of the art performance in our
depends on. What is it that separates the genuine context, when the face and the beautiful smile
from the false, the genuine from the superficial, were perceived by the old lady with dementia.
and what is it that makes one person an artist and Everything that could and should be done was
another a craftsman ([42], p. 229). done; nothing less and nothing more was needed.
For something to be called an art and not just The last brushstroke was done with the two
a craft, it must be linked and connected to a foun- words: hey there! Levinas [45] claims that the
dational idea. In music it is called cantus firmus, artist stops because the work refuses to receive
the fundamental melody, which has its origin in more. The artist in this narrative from clinical
Renaissance polyphony. In the same manner, car- practice knew that at this moment, the work that
ing and nursing become an art performance that these two people created together was complete.
will preserve the individual’s dignity in both From the stories and our interpretations, we can
patients and health personnel [41]. There is an understand, more deeply and more thoroughly,
inherent obviousness in the turn to the other, what dignity is about.
where a deep ethical attitude is evident in the
caregiver. It is an example of what Eriksson [2,
43] terms the mantra of caring ethics: I was there, 7.7 Learning
I saw, I witnessed, and I became responsible. It is from the Perspective
also in line with Levinas’ thoughts [44–46] when of Family Caregivers
he writes about the ethics of the face, becoming
responsible for the other. Brief stories from family caregivers show what
Levinas writes about human responsibility dignity is for their loved one and for themselves:
and freedom in context, claiming that “I am Just after a short while, my mother went to
78 B. Sæteren and D. Nåden

c­ oncerts, bingo, church ceremonies, hobby days, of what they just popped in his mouth. After the last
digital book days and reading-aloud days. She ten spoonfuls, the food comes out again. The health
personnel can sit and shovel food into someone at
participated in everything that was going on. She the same time as they are talking to other persons
became a new human being, became healthier. in the room or are talking on their cell phone. It
Now she appreciates life ([48], p. 513). This is makes me feel terribly sorry for the patient. This
consistent with Nygren et al.’s [35] research stat- behavior is not dignified care. As a matter of fact,
it has upset me very often ([17], p. 756).
ing that inner strength opens up the possibility of
acceptance of new realities. Feeling that one is From the perspective of the caregivers, one
the same person even though circumstances have can understand the abandonment in both concrete
changed gives a feeling of stability. and existential ways. In the concrete way, the
The spirit in which care is given influences the residents are left alone. In the existential way,
way patients and their relatives see the little extra they are not met and seen when they most need it,
and helps to promote the dignity of patients and as presented in this feeding situation [17].
thus their health: There are some of them who do To be abandoned touches deeply human sensi-
the little extra – making an omelet or doing some tivities since human beings are dependent on
decoration, food and drinks, something a little each other. To be deprived of togetherness with
extra ([48], p. 513). other human beings or with an abstract other can
An expression of the staff’s attitude from the abandon the individual to loneliness and despair.
perspective of the family caregivers reveals what This experience may be perceived even worse
it means when the patient is really seen as an when the individual is old, has a physical or psy-
individual with dignity. A commitment from the chological disability, or has dementia. As Nåden
caregiver to look for common interests with the et al. [17] (p. 757) express: It is especially
resident can be interpreted as creating a commu- depressing when violation occurs in a profes-
nion or a caring relationship [48]. sional context where personnel are meant to care
Dignity as “at-home-ness” is also important for the individual in an appropriate manner.
for the family caregivers: I felt warm right away, Nursing home residences are built for individuals
as soon as she came here, she had a value. to let them live the last years of their lives in safe
Another statement: In my experience of older surroundings and get health care from personnel
persons, it is more important that they feel safe with high caring ideals as their compasses.
than to be in a fancy surrounding, that they are The relatives also stressed the importance of
cared for! When they get to a stage in life when the specific caregiver. Some staff members are
they no longer can take care of themselves, they just there for the job and are perhaps not inter-
really have enough just trying to care for them- ested in providing the little extra. If the “wrong”
selves ([48], p. 512). person gives care, the resident can be ignored. As
Family caregivers also experience situations one of the relatives noted, doing the little extra is
that are the opposite of at-home-ness. They expe- when the residents are really seen by caregivers
rienced situations where their dear ones became who are suited for their jobs and can see the
abandoned. Being deprived of dignity through beauty in the faces of the older persons ([48],
physical humiliation is one kind of abandonment. p. 513). Levinas argues that the other’s face does
One family caregiver describes feeding situations not expose the arbitrariness of the will, but its
that verge on violations of law and the use of injustice. Nor does the evidence of my injustice
physical force [17]. In addition to hurting the resi- appear when I bow to facts, but when I bow to the
dents, the caring situations were non-esthetic: Other ([45], p. 53) he points out.
In this light, we can clearly see the degrading
I have seen such terrible feeding situations. Totally feeding situation in the above narrative. The help-
insensitive and soulless feedings where one sits
and continuously spoons food into the residents’ ers who are meant to bow to the other—in this
mouths. And I, who am sitting alongside, notice case, those who are supposed to provide care for
that the poor human being has not swallowed any the persons in need, supporting them in building
7 Dignity: An Essential Foundation for Promoting Health and Well-Being 79

up their inner strength—instead turn away from Freedom is closely linked with dignity.
them. They are prevented from seeing the other Freedom means that a person is free to do and use
because they do not approach them. It is when the inner strength to act or to decide for himself
approaching the other that the other’s face or herself, as well as freedom from something,
appears to me, according to Levinas ([45], p. 53) such as force or paternalism. To possess auton-
not as a threat or an obstacle, but as something omy implies that you construct for yourself the
that is of importance to me. laws you are to follow [50]. The resident above
The helpers refuse to be “the chosen ones,” as states that he has no freedom, which is the oppo-
Levinas [45] (p. 158), talks about. In this case this site of what he had imagined. The loss of free-
means that it is the other, the patient, that chooses dom can feel like a double loss for this man in
me, not the opposite. To be struck by the other’s that no helpers can follow him out. In this sense,
face does not mean that I am set free for self- the loss of physical freedom will also have conse-
expression. On the contrary, it means that I am quences for the person’s inner freedom.
linked to the responsibility. The family caregivers Heggestad et al. [51] found that several patients
highly value this form for responsibility from the in the nursing home felt they were in captivity,
helpers taking care of their dear ones [48]. like a prison without bars. In the stories above,
we also experience inappropriate language from
the caregivers. Rudeness, impoliteness, and
7.8 Learning paternalistic attitudes described by the residents
from the Perspective demonstrate the asymmetric relationship between
of Patients the residents and the caregivers [49]. This might
be construed as abuse of power. Rundquist [52]
What seemed to be common to almost all the states that power belongs to all human beings and
residents at the nursing homes was the fact that is thus ontological—a matter of human nature.
moving into the nursing home was experienced The author further states that power is given to
as a threat to their dignity. The threat was related human beings only as authority. The authoritative
to the perception that they were becoming depen- human being takes responsibility for his/her
dent on others, that there was a lack of time and human office, but abandoning it means abandon-
resources on the unit, and that they were being ing oneself and one’s dignity.
deprived of freedom, but it was also related to the The humiliating situations above are examples
attitudes of health care personnel [49]. We pres- of misuse of power by the caregivers, a power
ent narratives of both indignity and preserved that is not given to them by the patients in need of
dignity. help. It is the opposite of ontological power that
The residents related humiliating situations in is rooted in intuitive and esthetic knowledge [53]
which the health care personnel were rude, impo- and which does not turn the patient into a victim.
lite, and paternalistic: Three times they have told Knowledge of ontological power can be linked to
me that they are not my slaves when I asked for and is consistent with Watson’s [54] statement
help – two times when I asked for help with my that care necessitates a moral obligation to pro-
ostomy, and once when I asked them if they could tect human dignity.
help me fold up my quilt. And they asked, ‘Do In line with Watson [54], Pieranunzi [53], and
you think this is a hotel?’ ([49], p. 44). Rundqvist [52], Foss et al. [55] elaborate on
I think to myself that I should be a free man, but responsibility and leadership, positing the other
I’m not free. If I get dressed and want to go out, I’m as the real leader. When transferred to a clinical
not allowed to go out. “You have to stay inside”, context, the patient becomes the real leader and
they say. They say that if I want to go out, I need to guiding star. This is in sharp contrast to the story
have someone with me, or I can’t go. That’s how it
is. They think I’m too weak. And I can agree that I told by the patient above who was deprived of his
was weak when I moved into that other place. But freedom, and it contrasts with the humiliation
there is never a damned soul to take me out. Never! related by the family caregiver earlier in this
([49], p. 44). chapter.
80 B. Sæteren and D. Nåden

On the positive side, one resident explains the where the potential for growth is present for both
meaning of still being able to participate in an parties. In situations like this, a great responsibil-
activity she had been part of earlier in her life: I ity is shown toward the patients. Eriksson [43]
like to dance. I have danced for 20 years. I dance refers to Hellqvist who claims that responsibility
once a week, and the bus comes and picks me up. also means a “solemn declaration.” It is through a
I am the only one from the nursing home. solemn declaration that we can convey the mes-
However, the nursing home organizes dancing in sage of love that we truly desire the well-being of
the afternoon for everyone. I think it’s great that others. It is an assurance of the other’s dignity.
they arrange that, because I like it so much ([56],
p. 95). The resident feels respected and valued,
when the nursing home recognized her resources 7.9  ublic Policy Efforts
P
and inner strength and made it possible to partici- to Preserve Human Dignity
pate in an activity that had been a part of her pre-
vious social life and which attracted attention Preserving patients’ dignity is not only a respon-
from others in her current life. sibility of the health care professional, the family,
Two other residents are positive about their and the patient himself. It is a political responsi-
situations: bility. In this short section, we briefly summarize
I’ll need help to take a shower. But it is ok to be laws and regulations in the Scandinavian coun-
helped by others. Once a young man had to assist tries and the UK for which the aim is to preserve
me. I was a little concerned about that, but when he human dignity.
helped me, I thought it was fine and the other
In 2011 a new national value system was
ladies also liked to be assisted by him ([56], p. 95).
implemented in the Social Services Act (2001) in
Another lady tells I love being helped. It is not Sweden [57], stipulating that elderly care shall
degrading. No, I am not ashamed of it. It’s okay. promote a dignified life and the feeling of well-­
So, I feel mostly like a baby (laughs) ([56], p. 95).
being. Local dignity guarantees are based on the
Most residents regarded asking for help as a national set of values for older people stipulated
potential threat, and growing dependency was in the Social Services Act, which means that care
one of the harder adjustments they faced. of elderly people provided by social services has
Residents described these experiences in differ- to focus on older people being able to live their
ent ways. Some felt that they had been robbed of lives in dignity and feel a sense of well-being.
their freedom, whereas others felt valued as per- Similarly, The Patients’ Right Act in Norway
sons and found that the help they received from 1999 [58] states that the provisions of the
improved their quality of life. In order to retain act shall help to promote a relationship of trust
their dignity, it seemed significant to be able to between the patient and the health service and
make sense of the unavoidable circumstances in safeguard respect for the life, integrity, and
their lives and remain positive [56]. human dignity of each patient. In 2011, the regu-
The quality of these meetings is of the utmost lation relating to “Dignity Guarantee” in elderly
importance for those who need help to maintain care entered into force in Norway [59]. The regu-
their dignity. In some ways, an encounter entails lation aims to ensure that the care of older people
going into deep water. The apprehension associ- is carried out in such a way that it contributes to a
ated with an encounter can be altered and trans- dignified, safe, and meaningful retirement. In
formed into something greater: honesty and 2019 Health Care Denmark presented a new
authenticity. On the wavelength that the encoun- white paper called “A dignified elderly care in
ter occurs, the person is in contact with both the Denmark.” [60] It is stated in the foreword of this
self and the other. This is the profoundest level of white paper that Denmark is to have a dignified
health, where the germ and opportunity for elderly care system with focus on involving and
growth are found [41]. In such a description of empowering every citizen and an emphasis on
the encounter, the caregiver has found his place, their individual needs and preferences.
7 Dignity: An Essential Foundation for Promoting Health and Well-Being 81

In the Health and Social Care Act (2008), Researchers have tried to clarify the concept
United Kingdom, Regulation 2014 [61] states through theoretical and empirical work. Some of
that service users must be treated with dignity these theories are presented. The theories show
and respect. It includes ensuring the privacy of that there is a shared feature that dignity is a dual-
the service user, supporting the autonomy, inde- istic concept. One dimension is recognized as
pendence, and involvement in the community of inherent dignity, which is unchangeable and
the service user, and has any relevant protected rooted in human worth and equality. The other
characteristics of the Equality Act of the service dimension is related to the subjective part of
user. Staff must always treat service users with being human and dependent of a person’s value
dignity and respect, which means treating them system, context, and culture. This dimension can
in caring and compassionate ways. They must be be violated as well as promoted. Hence, any
respectful when communicating with service human interaction may be an encounter with dig-
users, using the most suitable means of commu- nity and thereby a health promoting interaction.
nication and respecting a person’s right to engage Dignity is a core concept in caring, and health
or not to engage in their communication. personnel need knowledge of the meaning of dig-
Documents like those mentioned above may nity in health care. There is a need of both theo-
contribute to a change in health care services cul- retical knowledge and empirical knowledge
ture in general and in nursing homes in particular, visualized through narratives about the art of car-
where the focus of care is on the person, not the ing. In the second part of this chapter, we present
task, as Robinson and Gallagher [62] underline, testimonies from health care personnel, family
and likewise protect patients exposed to unethical caregivers, and patients. Reflections about the
acts, so that they can regain a kind of pride and encounters between patients and caregivers
dignity [63, 64]. To make a change, leaders have together with knowledge about dignity may be
a crucial role to play in the promotion of dignity one way to make use of the developed knowledge
in care. and the possibilities imparted in the concept of
It is interesting to note that there is a need to dignity in order to promote health. Both political
enact laws and regulations on something as basic leaders and leaders within health care have a cru-
as respect for human dignity. The legislation in cial role in facilitating health care that preserves
the examples above show the importance of sup- person’s dignity.
porting dignity in care, but in some of the texts of
these regulations, there seems to be a lack of clar- Take Home Messages
ity about the meaning of the concept of dignity. A • Dignity is a person’s ability to constitute life
consequence of this might be that it is up to the and being.
individual reader of the text and the health per- • Dignity is a dualistic concept. Dignity consists
sonnel to understand the concept of dignity. of an inherent and absolute dignity which is
universal, unchangeable, and inviolable and a
relative dignity which is changeable and influ-
7.10 Conclusion enced by internal and external factors.
• Each human interaction may be an encounter
Even though there is a shared feature that dignity where dignity is either promoted or violated.
is important in people’s life and being, and • It is important to promote the inner strength of
because the fact that dignity is used in political the other person to support her or him to live a
and professional settings, the meanings of dig- life in dignity.
nity are seldom described. Therefore, the purpose • Acknowledgment of and responsibility for the
of this chapter was to illuminate different under- other person is part of performing the art of
standings of the concept of dignity and to discuss nursing care.
how we can make use of this knowledge to pro- • Dignity is an essential foundation for promot-
mote and enhance human health and well-being. ing health and well-being.
82 B. Sæteren and D. Nåden

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 Meaning-in-Life: A Vital
Salutogenic Resource for Health
8
Gørill Haugan and Jessie Dezutter

Abstract less hypertension, better immune function,

less depression, and better coping and recov-
Based on evidence and theory, we state that
ery from illness. Studies have shown that can-
facilitating and supporting people’s meaning-­
cer patients who experience a high degree of
making processes are health promoting.
meaning have a greater ability to tolerate
Hence, meaning-in-life is a salutogenic
bodily ailments than those who do not find
concept.
meaning-in-life. Those who, despite pain and
Authors from various disciplines such as
fatigue, experience meaning report better
nursing, medicine, psychology, philosophy,
quality-of-life than those with low meaning.
religion, and arts argue that the human search
Hence, if the individual finds meaning despite
for meaning is a primary force in life and one
illness, ailments, and imminent death, well-­
of the most fundamental challenges an indi-
being, health, and quality-of-life will increase
vidual faces. Research demonstrates that
in the current situation. However, when
meaning is of great importance for mental as
affected by illness and reduced functionality,
well as physical well-being and crucial for
finding meaning-in-life might prove more dif-
health and quality of life. Studies have shown
ficult. A will to search for meaning is required,
significant correlations between meaning-in-­
as well as health professionals who help
life and physical health measured by lower
patients and their families not only to cope
mortality for all causes of death; meaning is
with illness and suffering but also to find
correlated with less cardiovascular disease,
meaning amid these experiences. Accordingly,
meaning-in-life is considered a vital saluto-
G. Haugan (*) genic resource and concept.
Department of Public Health and Nursing, The psychiatrist Viktor Emil Frankl’s the-
NTNU Norwegian University of Science
and Technology, Trondheim, Norway
ory of “Will to Meaning” forms the basis for
modern health science research on meaning;
Faculty of Nursing and Health Science,
Nord University, Levanger, Norway
Frankl’s premise was that man has enough to
e-mail: gorill.haugan@ntnu.no, live by, but too little to live for. According to
gorill.haugan@nord.no Frankl, logotherapy ventures into the spiritual
J. Dezutter dimension of human life. The Greek word
Meaning Research in Late Life Lab, Faculty of “logos” means not only meaning but also
Psychology and Educational Sciences, KU Leuven, spirit. However, Frankl highlighted that in a
Leuven, Belgium
e-mail: jessie.dezutter@kuleuven.be
logotherapeutic context, spirituality is not pri-

© The Author(s) 2021 85

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_8
86 G. Haugan and J. Dezutter

marily about religiosity—although religiosity ful. This topic is more recently a focus of interest
can be a part of it—but refers to a specific of psychologists, nurses, and health practitioners
human dimension that makes us human. receiving increasing attention in the health litera-
Frankl based his theory on three concepts: ture. However, meaning-in-life is a subjective
meaning, freedom to choose and suffering, and personal phenomenon that is difficult to
stating that the latter has no point. People define.
should not look for an inherent meaning in the One of the prominent scholars in the field of
negative events happening to them, or in their meaning is psychiatrist Victor Emil Frankl.
suffering, because the meaning is not there. Although he mainly refers to purpose-in-life
The meaning is in the attitude people choose (PIL) and not to meaning-in-life, his description
while suffering from illness, crises, etc. of these concepts clearly overlaps. Purpose-in-­
life as a concept originates from Frankl’s writ-
Keywords ings about the “will to meaning” as the primary
motivational force for survival; he stated that
Freedom to choose · Health · Human values
meaning is a motivational and vitalizing force in
Meaning-in-life · Meaning-making · Spiritual
humans’ lives [17–19]. To find personal meaning
care · Spirituality · Suffering · Well-being
involves understanding the nature of one’s life,
Will to meaning
and to feel that life is significant, important,
worthwhile, or purposeful (ibid.). In Frankl’s
theory, meaning is a broad construct that is con-
ceptually and empirically related to many
8.1 Meaning-in-Life: A Multi-­ domains; positive associations of meaning are
Layered Concept found in relation to constructs such as hope, faith,
subjective well-being, and happiness, as well as
The experience of meaning is central to humans negative associations between meaning and
[1–3] and has become one of the core facets of the depression, anxiety, psychological distress, bore-
positive psychology movement [3] as well as of dom, proneness, and drug/alcohol use [3, 9, 20,
the health promotion field. In general, meaning 21]. Frankl’s theory of meaning termed logother-
has been found to be a strong individual predictor apy has been used as a basis for research and
of life satisfaction [4–6] and an important psycho- practice in many fields, including medicine, psy-
logical variable that promotes well-being [7–9] chology, counseling, education, ministry, and
and protects individuals from negative outcomes nursing [22].
[10, 11]. Meaning seems to serve as a mediating The concept of meaningfulness is also crucial
variable in psychological health [12–16]. in the salutogenic health theory of the sociologist
In literature there is a distinction between (1) Aaron Antonovsky, which is termed salutogenesis
meaning-of-life and (2) meaning-in-life. The first [23, 24]. In this model, he focused on health-­
concept pertains to the question of the signifi- promoting resources, among which sense of
cance of human existence in general. This ques- coherence (SOC) is a vital salutogenic resource
tion is discussed by a range of existential in people’s lives. Antonovsky defines SOC as a
philosophers, such as Soren Kierkegaard, Albert global orientation to perceive the world as com-
Camus, and Friedrich Nietzsche, who wanted to prehensible, manageable, and meaningful despite
explore whether and how the existence of human the stressful situations one encounters. Individuals
beings has meaning over time. The second con- with a strong SOC tend to perceive life as being
cept refers to the individual’s perceived meaning-­ manageable and believe that stressors are expli-
in-­life; the question is no longer focused on the cable. People with a strong SOC have confidence
more abstract and general meaning of human life in their coping capacities [25]. Several studies
but is scaled down to the question whether you link SOC with patient-reported and clinical out-
experience your own individual life as meaning- comes such as perceived stress and coping [26],
8 Meaning-in-Life: A Vital Salutogenic Resource for Health 87

recovery from depression [25], physical and they delineate three components within the con-
mental well-being [27], satisfying quality-of-life struct which capture much of the variance in the
(QoL), and reduced mortality [28, 29]. SOC has past definitions, namely (1) coherence, (2) pur-
thus been recognized as a meaningful concept for pose, and (3) significance (tripartite view) [38].
patients with different medical conditions. Looking at these components, the connection to
Meaning-in-life is furthermore a vital aspect the salutogenic health theory emphasizing com-
in the work of the existential psychotherapist prehensibility, manageability, and meaningful-
Irvin Yalom [30]. According to Yalom, all indi- ness seems clear. (1) Coherence refers to a
viduals experience core anxieties or existential cognitive aspect that one’s life makes sense; it
concerns related to their existence. He focuses reflects a sense of comprehensibility in life and is
on four main concerns: (1) the inevitability of situated in the domain of “understanding” [38].
death, (2) the freedom to shape our own lives, (2) Purpose refers to a motivational aspect indi-
(3) our ultimate aloneness, and (4) the absence cating that individuals have future-oriented long-­
of any obvious meaning-in-life. For Yalom, term goals and feel that their lives have direction
meaninglessness is an existential given and can- [17]. Purpose reflects the pursuit and attainment
not be solved. An individual’s sudden realiza- of core aims, ultimate life goals and aspirations
tion of meaninglessness can be compared with for life [36]. (3) Significance refers to “the degree
an experience of total groundlessness. Yalom to which individuals feel that their existence is of
assumes that meaninglessness is present in significance and value” [39] (p. 2); that is a feel-
everybody’s life as well as in every therapy. ing of “existential mattering,” having a life worth
More recently, meaning-in-life has become a living. Although this tripartite view on meaning-­
topic of interest for empirical psychologists. in-­life is promising in providing in-depth insight
The abstract nature of this concept, however, into the phenomenon of meaning in people’s
makes a clear conceptualization difficult, and lives, research validating this structure of mean-
the concept has therefore been defined in myr- ing is virtually absent (see George & Park, 2016
iad ways. Steger [31], one of the leading schol- for one available study in a population of psy-
ars in this field, stated that people experience chology students).
meaning when they comprehend who they are, Since Frankl’s theory of the “Will to Meaning”
what the world is like, and if they understand has been used as a basis for research and practice
their unique fit in the world. Meaning is also in many fields, including medicine, psychology,
described as an individual’s sense that his/her counseling, education, ministry, and nursing
life has value, direction and purpose, and that [22], in the next section this chapter presents
he/she belongs to something greater than the Frankl’s logotherapy.
self, adding a sense of “belonging” [32]. In a
cognitive perspective, meaning is described as a
“mental representation of possible relations 8.2  rankl’s Theory: The “Will
F
among things, events and relationships” [33] to Meaning”
(p. 15), while others highlight the intuitive feel-
ing that things make sense [34]. Some research- Viktor Emil Frankl, psychiatrist and survivor of
ers have tried to disentangle meaning-in-life the Nazi concentration camps, assumed that
from purpose-in-life [35], whereas others meaning is of crucial importance to men. Based
defined purpose as part of meaning-­in-life [36] on the horror Frankl experienced in the camps, he
or stressed that having goals or life aims are concluded that everything can be taken away
central aspects of meaning-in-life [37]. from men, from belongings and health to loved
Although a comprehensive, unified frame- ones, but nobody can take away men’s will to
work of meaning is lacking, Martela and Steger experience meaning. Frankl [17] described the
[38] recently proposed a first theoretical step process of “will to meaning” as a search process.
toward integrating the main aspects of meaning; He defined searching for meaning as “the pri-
88 G. Haugan and J. Dezutter

mary motivational force in man” (p. 121), and a existential needs, consciousness, and values [87].
natural, healthy part of life. Through experience from several years in Hitler’s
Although Frankl developed his theory in the concentration camps and his many years of work
field of mental health and psychiatric diseases, as a psychoanalyst, Frankl had the following start-
the scope has been expanded and the theory is ing point for his theory: “people have enough to
now considered relevant also to people who, for live by, but not enough to live for.” Therefore, the
various reasons, struggle with everyday stress, individual does not tolerate stress. The key to cop-
disasters, losses, and crises. Today, this theory is ing with adversity and suffering lies in the fact that
applied not only on the individual level but also the individual finds meaning-­in-­life, day by day,
on the group level. During Frankl’s working life year after year. Frankl claims that anyone who
in Europe, a set of concepts and the connection knows why he lives, e.g., the value of just being
between them were referred to as a “school” and here, can withstand many hardships. Nonetheless,
not as a theory, as we do today. As a professor of it is important to mention that Frankl was frus-
psychiatry and neurology, Frankl studied the trated that his logotherapy was solely related to his
“first Viennese school” in psychotherapy known experiences in four different concentration camps
as “The Will to Pleasure” exposed by Freud. during World War II, while the ideas and essences
Later, Adler developed the “second Viennese of this theory were developed well before the war.
school” “The Will to Power.” Frankl [19] recog- He just had no time and opportunity to write them
nized both schools, but still he believed that down. Anyway, the experience of Hitler’s concen-
tration camps became a validation of his “will to
man can no longer be seen as a being whose basic meaning.”
concern is to satisfy drives and gratify instincts or,
for that matter, to reconcile id, ego and superego; According to Frankl [17, 19], logotherapy
nor can the human reality be understood merely as ventures into the spiritual dimension of human
the outcome of conditioning processes or condi- life. The Greek word “logos” means not only
tioned reflexes. Here man is revealed as a being in meaning but also spirit. Accordingly, in the early
search of meaning–a search whose futility seems to
account for many of the ills of our age. (p. 17) Greek language, there is a connection between
spirituality and meaning. Frankl highlighted that
Thus, Frankl called his theory “The Will to in a logotherapeutic context, spirituality is not
Meaning,” which became known as the “third primarily about religiosity—although religiosity
Viennese school.” The term “meaning” used in can be part of it—but refers to a specific human
modern health science originates from Frankl’s dimension that makes us human. The need for
theory of will to meaning as the strongest driver meaning arises from the individual’s existential
of mental and physical survival. Experience of consciousness of mortality; one day death will
meaning represents a vitalization in everyday life come. Frankl considered an individual’s con-
[19], a primary force that involves understanding science as the “body-of-meaning” [19].
who one is, feeling important and valuable to Conscience is closely related to the individual’s
oneself and others, and finding meaningful goals values, morals, responsibilities, and integrity and
and purposes in one’s life. In Frankl’s theory, is an intuitive, creative, and central force in the
meaning is a broad concept that is theoretically human quest for meaning in any given situation.
and empirically related to several different Conscience is thus a subjective dimension,
dimensions; studies have shown that meaning is closely linked to cultural and national values,
positively related to concepts such as hope, norms, and rules that apply in the context of the
belief, well-being, happiness, and global QoL, individual person. It is the individual’s task to
while meaning is negatively related to depres- decide whether to interpret his or her life’s tasks
sion, anxiety, psychological stress, boredom, and based on accountability to society, to God, or to
substance abuse [3, 9, 20, 21]. his own value system. Human beliefs, values, and
Frankl’s logotherapy has its roots in a phenom- integrity are crucial to what can provide meaning
enological understanding of human beings with to the individual.
8 Meaning-in-Life: A Vital Salutogenic Resource for Health 89

8.2.1  hree Substantial Concepts

T
of Frankl’s Theory Will
to Meaning

Frankl’s theory is based on three substantial con-

cepts: (1) meaning-in-life, (2) freedom to choose,
and (3) suffering. Furthermore, these three con-
cepts are linked to three basic assumptions in
humans’ lives: (1) the physical body, (2) the men-
tal mind containing emotions and thoughts, and
(3) the spiritual, or what Frankl calls “noos” [17].
The physical body and mental mind can become
ill, while the human spirit can become blocked
©Gørill Haugan
and frustrated. Frankl believed that the three
dimensions of body–mind–spirit are parts that act Fig. 8.1 The unity of body–mind–spirit in which steadily
as a unified totality. That is, problems in one ongoing integrating processes unify the parts into one
dimension often cause symptoms in another. For inseparable entity
example, spiritual emptiness can be manifested
as a physiological symptom such as a headache. his/her specific life situation. Frankl argued that
To understand Frankl’s theory, one must under- meaning always changes, but never ceases to be
stand his emphasis on the human spirit, “the potentially present.
noos,” and its vital role in the individual as an Finding meaning-in-life is a subjective and
integrated unit of these three: body–mind–spirit. unique process that takes place in the individual’s
This corresponds well with modern nursing the- mind. Meaning can neither be invented nor given
ory [68, 88] and recent research that indicates as a gift. Meaning must be revealed by the indi-
that people function as a unit where body–mind– vidual. Thus, it is not possible for health care pro-
spirit is fully integrated with each other and are fessionals to “tell” or “teach” the patient how to
inseparable [89]. Figure 8.1 illustrates that the find meaning. Nor can health workers create,
body–mind–spirit levels act as parts that, through point to, or transfer meaning to another; finding
constant and infinite interaction between each meaning-in-life requires an inner process and
other, represent an inseparable entity. The dotted active effort by the individual. Health care work-
circles in Fig. 8.1 illustrates the integral interac-ers can “walk along with” the one searching for
tion between the body–mind–spirit parts. meaning, listening, asking questions, and chal-
lenging. Scholars differ in their perspectives on
8.2.1.1 Meaning-in-Life how meaning can be attained. Some stress that
The term meaning involves the answer to man’s meaning needs to be discovered by the individ-
existential questions: “Who am I?” and “Why am ual, implying more automatic processes, whereas
I here?” The experience of purpose and meaning other stress that the process is more deliberate
produces positive emotions such as satisfaction and conscious, and they accordingly refer to
with one’s place in the world. Perceived meaning-­ meaning-making or meaning constructing [74].
in-­life relates to what the person feels dedicated Realizing meaning-in-life is closely related to
to, to provide one’s unique contribution to a bet- realizing oneself. Frankl [17] argued that what
ter world bestows purpose and meaning. A people have been able to accomplish, endure, and
purpose-­ in-life represents a direction of one’s master earlier in life represents a source of mean-
energy, as well as a driving force in the individu- ing here-and-now: “All we have done, whatever
al’s quest for meaning; this idea is key in Frankl’s great thoughts we may have had, and all we have
theory. Meaning is discovered and determined suffered, all this is not lost, though it is past; we
from the uniqueness of the individual person and have brought it into being. Having been is also a
90 G. Haugan and J. Dezutter

kind of being and perhaps the surest kind” meaning-in-life [49, 92–95]. Furthermore,
(p. 104). It is possible to distinguish between research has shown that positive emotions and
“meaning in the moment” which relates to the moods appear to be a stronger source of meaning
choices people make at any time in their daily than activities toward achieving certain goals [1].
lives and a “universal meaning”, which is about According to Frankl, the third strategy for
the big picture and a confidence that there is some people to create meaning-in-life is, despite any
form of order in the universe which we are a part life challenges, to consciously choose their atti-
of. A universal meaning represents the opposite tudes. Choosing to be positive, courageous, or
of a chaotic world where humans are victims of optimistic despite difficult and painful events
random impulses. The concrete thing that makes illustrates this strategy for meaning. Experience
sense here-and-now may shift but is always there of meaning can arise from the patient voluntarily
as an opportunity to be discovered. changing his attitude and consequently his per-
Frankl [17] outlined three different sources of ception of his current life situation.
meaning: (1) performing good deeds or actions; to Man’s will to meaning can be frustrated, dis-
give or contribute something good or useful, or by appointed, or unfulfilled; Frankl called this “exis-
one’s creativity to create something beautiful; (2) tential frustration” and “existential vacuum.”
experiencing something valuable, beautiful— When people feel despair and when they struggle
experiencing goodness and loving fellowship; and to experience life as worth living, this is not an
(3) realizing dignified, honorable, and positive expression of mental illness, but of spiritual dis-
attitudes in the face of life’s challenges, such as tress. According to Frankl, the health system
illness, suffering, and death. Hence, it seems clear often interprets and diagnoses spiritual distress as
that the phenomenon of self-transcendence (about a mental illness (e.g., depression), and thus treats
self-transcendence, see Chap. 9 in this book) is the condition by anesthetizing the patient’s exis-
closely related to purpose and meaning-in-life tential despair with medication. Existential vac-
[17, 19, 90]. Self-transcendence refers to the abil- uum is expressed by feelings such as
ity to transcend oneself; an opening to something meaninglessness, emptiness, apathy, and bore-
greater outside oneself [91]. It can be about doing dom [96] and can lead to severe neurosis. This
a job, an effort, realizing a virtue; despite one’s neurosis is caused by spiritual frustration or
own life situation being demanding, painful, and problem, moral or ethical conflicts, existential
difficult, to extend beyond one’s self-occupation vacuum, or frustrated will to meaning.
in the ego. Thus, self-transcendence implies a
strategy for creating distance to oneself and one’s 8.2.1.2 Freedom to Choose
own situation, and thereby provide a mindset Freedom to choose constitutes the second term in
without focus on one’s troubles and worries. A Frankl’s logotherapy and is closely linked to the
self-transcended approach gives the opportunity above-described sources of meaning. Many peo-
to see and experience one’s situation from a dif- ple are confronted with an undesirable fate, such
ferent perspective, and therefore an opportunity to as Holocaust, tsunamis, earthquakes, etc. In deal-
find solutions and meaning amid the difficult and ing with such life events, one can only be accept-
painful. For example, we have seen that parents ing—there is no use fighting—it is just about
who have lost a child in the crib have started the choosing one’s attitude. Frankl [17] wrote that
National Association for Unexpected Child Death “the way in which he accepts, the way in which he
to be able to help other parents in the same situa- bears his cross, what courage he manifests in suf-
tion. Several similar examples exist. fering, what dignity he displays in doom and
Being open for other people’s kindness and disaster, is the measure of his human fulfillment”
love does also provide an experience of meaning-­ (p. 44). Humans can be subjected to torture and
in-­life. Social support relates closely to the per- humiliation, to illness, destruction, loss and death,
ception of meaning [49], while negative and yet choose to meet their destiny with courage
interaction with others can reduce perceived and humanity. The sufferer’s attitude is the
8 Meaning-in-Life: A Vital Salutogenic Resource for Health 91

motivating force for his actions, not the torturer. in such events, because the meaning is not there.
The right to choose one’s attitude is regarded as The meaning is in the attitude we choose while
human spiritual freedom and mental indepen- suffering. For example, a cancer patient chooses
dence. The freedom of the will is about freedom a positive and caring attitude toward others
to choose attitude regardless of external situation despite his own illness and need of care. That is,
and circumstances. The individual cannot free despite cancer and major losses, it is possible to
himself from the conditions under which he lives. realize meaning. Frankl [19] wrote about his
Still, he can consciously choose his attitude experiences in concentration camps during World
toward these conditions. The expression “will to War II: “We who lived in concentration camps
meaning” indicates that meaning-in-life does not can remember the men walking through the huts
come “fleeting on a foal”; meaning does not come comforting others, giving away their last piece of
by itself, but requires effort, a desire and a con- bread. They may have been few in number, but
scious choice to actively search for meaning. they offer sufficient proof that everything can be
taken from a man, but one thing: the burden of
8.2.1.3 Suffering human freedoms – to choose one’s attitude in any
The third concept of Frankl’s theory is suffering, given set of circumstances, to choose one’s own
which represents a subjective, unique, and per- way” (p. 86). Figure 8.2 illustrates the relation-
sonal experience. Suffering is an inevitable part ship between these three concepts in Frankl’s
of humans’ lives on earth. We are exposed to inci- Theory “Will to meaning.” The individual experi-
dents that are undeserved, incomprehensible, and ences suffering in different ways; suffering is a
inexplicable as well as inevitable. The suffering personal and subjective experience of distress
is. It exists. At this point Frankl was quite clear; which impacts the individual as body–mind–
suffering has no point. There is no point in get- spirit negatively. Frankl highlighted that the
ting cancer or losing a child in an accident. Thus, meaning is not in the suffering itself. Only by
people should not look for an inherent meaning means of one’s freedom to choose actively one’s

©Gørill Haugan

Fig. 8.2 Frankl’s theory the “Will to meaning”: Three central concepts and their relationships with each other
92 G. Haugan and J. Dezutter

attitude, way of thinking, and how to approach those who do not find meaning-in-life; those
one’s life situation, meaning can be found. who, despite pain and fatigue, experience mean-
According to evidence and theory, we have ing report better QoL than those with low mean-
shown that those who despite illness, crisis, suf- ing [55, 56]. Meaning is seen as a buffer that
fering, etc. find meaning are better able to com- contributes to inner strength and thereby pro-
prehend and manage the situation, and report tects terminally [57] and critically ill [58, 59]
better QoL and wellness. patients from depression, hopelessness, and the
urge to give up and desire an accelerated death.
In a sample of chronic pain patients, for exam-
8.3 Meaning-in-Life ple, higher levels of experienced meaning-in-
and (Mental) Health life predicted lower levels of depressive
symptoms 1 year later [60]. Depression and
Empirical studies seem to confirm that the expe- hopelessness—contrary to meaning—are asso-
rience of meaning is related with well-being and ciated with increased mortality, dramatically
optimal health, representing an important higher suicide rates, and the desire for a physi-
resource when adjusting to or recovering from an cian-assisted death. In this context, some authors
illness [36, 40]. Accordingly, experiencing speak of a “demoralizing syndrome” [61, 62]
meaning-­in-life is regarded as a highly desired that can occur in terminal patients when the dis-
psychological quality (“my life is meaningful”) order bodily-psychological-­existential becomes
(ibid.). Positive associations between meaning-­ intolerable and one’s existence seems meaning-
in-­life and psychological well-being have been less. Perceived meaning has also shown to have
found across the lifespan, including adolescence a strong impact on physical well-being in nurs-
[41], emerging adulthood [42], midlife, and older ing home residents [40] and seems to moderate
adulthood [40, 43]. The experience of meaning-­ the relationship between illness, ailments, and
in-­life seems fundamental to humans [1, 2, 44] functional loss on the one hand and QoL and
and is of significance in health and well-being well-being on the other.
particularly in later years [45–47]. Studies have Furthermore, research demonstrates that
shown significant correlations between meaning-­ older people experience less meaning than other
in-­life and physical health measured by lower age groups [63]; on the contrary, some studies
mortality for all causes of death; meaning is cor- show that older people experience more mean-
related with less cardiovascular disease, less ing [42], whereas research among very old
hypertension, better immune function, less adults (85–95 years) shows that meaning
depression, and better coping and recovery from declines with very high age [64]. However,
illness [48–53]. This might indicate that if the meaning is suggested as a good indicator for
individual finds meaning despite illness, ail- older adults to cope well with the aging process
ments, and imminent death, well-being, health, and its consequences [65, 66].
and QoL will increase in the current situation. Nevertheless, studies show that meaning cor-
However, plausibly the relationship also goes the relates highly with ailments, symptoms, and
other way; when affected by illness and reduced reduced functionality [54]; all of which are com-
functionality, finding meaning-in-life might monly present among patients, old, or young, in
prove more difficult [54]. the health services. Regardless of patients’ age,
Among cancer patients, symptoms related to diagnosis and gender, perceived meaning-in-life
psychological and existential discomfort are as is important in clinical health care and research.
prominent as pain and other physical ailments. Frankl’s theory of meaning has been used as a
Studies have shown that cancer patients who basis for research and practice in many fields
experience a high degree of meaning have a [22]; this chapter focuses on nursing and health
greater ability to tolerate bodily ailments than science.
8 Meaning-in-Life: A Vital Salutogenic Resource for Health 93

8.3.1 Meaning-in-Life: Antonovsky concluded that individuals’ ability to

A Salutogenic Concept stay healthy despite severe circumstances is
in Nursing and Health Science related to the way they view their life and their
existence [28]. He assumed that three aspects are
Meaning-in-life is increasingly addressed in important in this life view: the ability to under-
nursing and health literature [22, 67], underpin- stand what happens around them (comprehensi-
ning the importance of nurses and health profes- bility), the ability to manage their situation
sionals to help patients and their families not only (manageability), and their ability to find meaning
to cope with illness and suffering but also to find in their situation (meaningfulness). Several stud-
meaning in these experiences (event-related ies have indeed shown that SOC is vital to coping
meaning) and to experience their lives as mean- with life’s stresses such as illness, loneliness,
ingful (meaning-in-life) despite the disease or despair, anxiety, and death [77–80].
­illness [22, 68, 69]. Meaning seems vital in cop- Paying attention to meaning-in-life or to
ing with severe health stressors. This is conceptu- event-related meaning within care is also a focus
alized clearly in the meaning-making model of of the bio-psycho-social-spiritual model of care
Crystal Park [70] which proposes that people as it developed by Sulmasy [81]. He argues that a
possess a global meaning system, including person is a being in relationships and that illness
beliefs, goals, and a subjective sense of purpose. involves a disruption of these relationships. Care
This global meaning system functions as an ori- needs to focus on restoration of the disturbed
enting system, providing individuals with a relationships. This restoration does involve not
framework to interpret life experiences [71]. only biochemical and physiological processes
Stressful events impact on the meaning-making (physical) but also mind–body relationships
system, causing a discrepancy between the (psychological), relationships with the environ-
appraised situation and the global meaning sys- ment (social), and the relationship between the
tem. This discrepancy creates distress, initiating a patient and the transcendent. This is in line with
process of meaning-making. As part of the theorizing of Dossey and Keegan [68] who refer
meaning-­making process, both cognitive (i.e., re-­ to the spiritual dimension of man as completely
appraisal, rumination [72]) and emotional strate- interwoven with the body, mind, and emotions
gies (i.e., emotional processing [73]) can be (ibid.); that is, the human body, mind, and spirit
activated. The end-products of this meaning-­ are fully integrated with each other and constitute
making process (“meaning made” [74]) can be an indivisible whole. Bottom line, if the body is
operationalized as benefit finding (i.e., finding influenced, the mind and spirit will be affected at
positive implications for a negative event) or the same time. Every experience will therefore
sense-making (i.e., finding a suitable explanation involve all dimensions of the individual: the
for a negative event within the global meaning physical, emotional-mental, social, and the
system). A successful resolution of the meaning-­ spiritual-­existential [82]. The holistic perspective
making process will then lead to better psycho- thus emphasizes a sound integration or balance
logical functioning and better adjustment to between the body–mind–spirit as crucial for
stressful events [75]. health, well-being, and QoL. When discussing
This is in line with the salutogenic perspective illness and care, Sulmasy [83] and others add the
of Antonovsky [76]. He described “sense of existential domain as an important fourth layer
coherence” (SOC) as a measure of an individu- but with a focus on the transcendent (biopsycho-
al’s capacity to use various coping mechanisms social spiritual model). A transcendental rela-
and resources when faced with a stressor. tionship with the divine is, however, not the only
Individuals with a strong SOC are assumed to approach for the confrontation with meaningless-
effectively handle stress and maintain health, ness [84]. Recent studies show that individuals,
despite extremely challenging circumstances. especially in West- and North-European secular-
After interviewing concentration camp survivors, ized countries, also construct meaning based on
94 G. Haugan and J. Dezutter

secular sources such as altruism, self-­tion of his/her objective conditions in life, than
actualization, family or work without the refer- with the objective conditions per se.
ence to spirituality or a religion [85]. Indeed, pain Consequently, personality and personal charac-
patients can turn toward spirituality in their teristics are important. Is there a personality, a
search for meaningfulness, but they can also tap gene related with greater sense of meaning-in-
into other sources. A biopsychosocial existential life? There is no doubt that personality and per-
model seems therefore more adequate when sonality traits matter [102]. However, studies
studying the influence of pain on all domains of also show that therapy, cognitive, and spiritual–
life. In a Flemish study of chronic pain patients, mental techniques such as gestalt therapy, cogni-
patients reported not feeling satisfied with the tive therapy, mentalization, yoga, meditation,
attention to the social and existential life domains. mindfulness, and prayer can have a positive
Furthermore, practitioners’ attention to the impact on meaning-­in-life and hence on mental
­existential domain seems highly important for health [40, 54, 82, 103, 104]. Being a living
patient functioning [86]. Openness to existential human comprising a unified trinity of body–
concerns of pain might thus be an important mind–spirit implies steadily ongoing natural
aspect of care and nursing practice. The theoreti- healing processes; inherent natural processes
cal and therapeutic framework of Viktor Emil work toward homeostasis, growth, development,
Frankl can be very useful in this vein. and healing. Humans represent inner energies
that constantly integrate and heal the unity
body–mind–spirit throughout life. Therefore,
8.4 To Promote Meaning Is facilitating and supporting people’s meaning-
to Promote Health making processes represent to support and facili-
tate these inner processes toward healing. Hence,
Currently, depression is the most prevalent dis- supporting meaning is health promoting.
ease worldwide [97]. This has many explanations
and reasons. Frankl approached depression as a
potential meaning-in-life problem and described 8.4.2 To Facilitate and Support
the existential vacuum as early as in the 1960s. Patients’ Search for Meaning
During the recent decades, suicides, divorces,
alcoholism, intoxication, and criminality among Health care professionals can facilitate and sup-
adolescents have increased globally. Also, a port patients’ search for meaning by offering a
growing tendency of overeating, overtraining, relationship where the patient as a unique per-
overworking, etc. has become evident. Frankl son can be acknowledged, welcomed, and
saw this as the result of people’s attempts to cope respected [11, 105]: that is, a space of trust and
with a lack of meaning; that is a lack of self-­ confidence in which the patient feel free and
esteem, self-understanding, and meaningful real- relaxed, without feeling the need to care for the
istic goals and purposes in life. Inspired by other. For example, the terminal husband’s
Frankl’s logotherapy, different intervention desire to care for and protect his wife’s feelings,
approaches have been implemented to treat resulting in holding himself back keeping his
depression and anxiety [56, 98–101]. innermost and heaviest thoughts and troubles by
himself. Or when a child is seriously sick and
dying; in care for the parents and the sick sister/
8.4.1 “Not How Your Situation Is, brother siblings hold their feelings back, suffer-
But How You Respond to It” ing silently alone, etc. The examples are many.
Professionals can provide a relational spot in
Research has so far demonstrated that people’s time and space, in which only the dying hus-
well-being far more related with an individual’s band’s or the suffering sibling’s experiences and
subjective perception/interpretation and evalua- feelings are attended to. Finding meaning is
8 Meaning-in-Life: A Vital Salutogenic Resource for Health 95

about knowing who one is and why one is alive; and hardship. Feeling abandoned gives a feeling
e.g., what one lives for. Reflections on what life of loneliness, which in turn amplifies despair and
has been like, the individual’s experiences of pain [108].
values and good things in life are sources of Therefore, health professionals should
meaning and can also enhance a sense of con- develop a set of “muscles” that help to bear and
nection. Communicational approaches in such endure patient’s suffering; “muscles” which can
situations may be questions such as “Are there withstand human’s painful feelings and thoughts,
periods in your life which you experienced par- which are strong enough to tolerate and accept
ticularly meaningful?” “Do you know anyone what is expressed by the patient. Acknowledge,
who lives a meaningful life?” “Are there people accept, endure, and attend to it. This is how health
in your life who need you?” “Will you tell about care professionals can contribute to meaning-­in-
an experience that made you think differently life, by facilitating feelings of being tolerated,
about life?” “Have you ever thought that ‘I can’t welcomed, and accepted. In this way, patients
do this’, and yet you did and experienced that may experience a living space of acknowledg-
you managed to do it?” ment, understanding, and thus connectedness,
facilitating acceptance of oneself and one’s life as
8.4.2.1 T  o Encounter Suffering it is [89, 105, 109]. By providing inner peace,
and Negative Feelings tranquility, and releasing energy for positive
Often, health care professionals encounter aspects of life here-and-now, acceptance is heal-
patient’s anxiety and concerns, perhaps guilt, ing and health promoting [105, 110, 111]. Asking
remorse, and bad conscience, because the person questions, listening actively, supporting the
feels that what he/she did in life was not good patient to explain a bit more about his experi-
enough; it should have been better, the children ences and feelings may foster the patient’s self-­
should have had a better parent, etc. In such situ- awareness, supporting his understanding of
ations, health promotion is about listening with himself here-and-now, and what provides mean-
respect and acceptance to what the person tells ing in the present situation (about nurse-patient
[95, 105], without being tempted to comfort. interaction as a salutogenic resource; see Haugan,
Commonly, health care professionals tend to G. (2021), Chap. 10 in this book).
comfort. Instead of actively and empathically The same applies in the care of terminally or
listening, they start to communicate that “Oh, critically ill patients who sometimes, in despair
you should not think like that, you should not be and exhaustion, wish to give up on life, asking
so harsh on yourself; do not think that way, you for euthanasia. Health professionals need a men-
should rather focus on all that is good in your tal “musculature” that can withstand suffering,
life,” etc. By doing so, though with a good inten- despair, and desperation, without wanting to
tion, health care professionals fail the person “fix” it, intending to change the patient focus
who shares his feelings and thoughts. This fail- into a more positive one. This is often framed
ure is not health promoting. Failure involves nei- “misunderstood comfort.” In general, health pro-
ther social nor emotional support. But listening fessionals are trained to cure, and their main
with respect, acceptance, and attention, confirm- focus is therefore curing the disease. But in sev-
ing that you acknowledge the patient’s experi- eral situations, curing is no longer an option, and
ence and recognize what really matters to him there needs to be shift to healing. Finding mean-
here and now, that is emotional support and ing in the event or regaining meaning despite the
health promoting [89, 94, 106]. The fact that disease can be a pathway to healing. To support
someone is willing to be a witness, to recognize, and facilitate meaning and thereby the relief of
acknowledge, endure, and pay attention, is itself despair, it is first needed to be able to recognize
health promoting [107]. When the professional and endure the patient’s despair, pain, and hope-
does not escape but stays present, tolerates, and lessness. From this experience, he may be able to
accepts, the patient is not left alone in the pain lift his eyes looking at something brighter.
96 G. Haugan and J. Dezutter

Containing other people’s despair and despera- cal well-being and serves as a buffer and coping
tion is burdensome and an intense work. To cope resource. This chapter demonstrates the signifi-
with this, a fit “musculature”, self-understand- cance of finding purpose and meaning-in-life as a
ing, and a health-promoting working culture are resource to continue life amid great stress.
needed. However, meaning does not appear by itself;
individuals need a “will to meaning,” to con-
8.4.2.2 T  o Arrange for Health-­ sciously search for the unique meaning that is
Promoting Communities potentially present in any situation. Patients are
and Companionships often subjected to great stresses such as serious
If possible, health care workers can arrange for illness, painful medical examinations, and
the patient to experience health-promoting com- demanding treatments, as well as loss, grief,
panionship, with the patient’s friends, family, or despair, and desperation. Finding meaning in
peers in the ward. Many patients in hospitals are these situations can be difficult. Nevertheless,
waiting for a diagnosis, feeling insecure, worry- studies show that patients who find meaning can
ing about what might be wrong with them. Many tolerate symptoms, the disease, and its various
get a serious message from the doctor about their outcomes better than those with low meaning.
health state: “you have cancer,” “you have ALS” Thus, to support and facilitate patients’ meaning-­
(amyotrophic lateral sclerosis), “you have MS” making processes, despite the situation, is an
(multiple sclerosis), “your leg must be ampu- important health-promoting concern. Often the
tated,” “the needed surgery is risky,” etc. way to meaning goes through what the individual
Diagnoses most often involve challenges and has managed, accomplished, contributed to,
high demands on endurance and coping. Helping intended, and tolerated in their life (“life
the patient to perceive the situation as under- review”)—through acceptance of who one is and
standable and manageable will contribute to one’s life as it is. To integrate their lives in this
increased meaning and a sense of coherence, way, most people need a relationship, one who
both of which promoting coping and mental listens, acknowledges, and affirms [115]. Thus,
health [112–114]. Individually adapted and the nurse–patient relationship emerges as a sig-
repeated information accompanied with emo- nificant resource for patient’s meaning-in-life.
tional and practical support serve as a buffer of Studies have shown that the nurse–patient interac-
meaning in demanding life situations. Undergoing tion has a significant influence on nursing home
medical examinations and treatment is often a resident’s perceived meaning; the good “meeting”
major burden for the patient; for him, this is most facilitating meaning is perceived as soothing and
often new, frightening and overwhelming, while empowering [11, 93, 105, 116]. Meaning is also
for the health care professionals, the various created by experiences of something good and
medical examinations and treatments might be beautiful, by self-transcendence, and by choosing
commonplace. Therefore, it is crucial that profes- positive and caring attitudes amid a painful and
sionals are aware of their attitudes toward various difficult situation. To facilitate and support
activities carried out during a working day in the patient’s meaning-making, a relationship sup-
hospital. ported by health-promoting interaction should be
provided [89, 105]. Figure 8.3 demonstrates that
the three levels of body–mind–spirit interacting
8.5 Conclusion with each other are influenced by nurse–patient
interaction: patients are affected physically, psy-
This chapter outlines the main ideas of the chologically, socially, and spiritually-existen-
Austrian psychiatrist and neurologist Viktor Emil tially. Health-promoting interaction impacts the
Frankl’s theory of meaning, termed logotherapy. patient as body–mind–spirit supporting his search
Research shows that meaning is essential for for “his” meaning. However, we do not state that
mental health and psychological as well as physi- the nurse–patient interaction is the only way to
8 Meaning-in-Life: A Vital Salutogenic Resource for Health 97

©Gørill Haugan

Fig. 8.3 Nurse–patient interaction affects all the three patients’ meaningfulness in different ways. However, in
levels of body–mind–spirit and is a vital health promoting the context of nursing and health care, the nurse–patient
resource in facilitating patient’s meaning-making pro- interaction has shown to be a key salutogenic resource in
cesses. Nurses and health care professionals can support supporting patients’ meaning-making processes

facilitate and support patients’ meaning-­making crucial to psychological well-being; a buffer

processes. Though, to our knowledge, the nurse– that contributes to inner strength and thereby
patient interaction is a key resource to support protects the individual from depression, hope-
meaning in the context of health care. lessness, and the urge to give up.
Finally, health care professionals need to • Positive associations between meaning-in-life
reflect on what gives perceived meaning in their and psychological well-being have been found
daily work, in life, and in the face of serious ill- across the lifespan, including adolescence,
ness and death. The professionals too need a con- emerging adulthood, midlife, and older
scious attention to meaning in their own life: who adulthood.
you are and why you are right here. This will pro- • Studies have shown a significant relationship
mote health for the individual health worker, but between meaning-in-life and physical health
also constitute a significant aspect of competence measured by lower mortality for all causes of
as professional health workers. death; meaning is significantly correlated with
less cardiovascular disease, less hypertension,
Take Home Messages better immune function, less depression and
• Perceived meaning-in-life is essential for better coping with illness, crises and death, as
people’s psychological functioning and is well as better recovery from illness.
one of the core elements of positive psychol- • Patients who find meaning despite illness, ail-
ogy as well as health-promoting research and ments, and imminent death experience more
work. well-being and better health and quality-of-­
• In the salutogenic health theory, meaning is life in their life situation.
the motivating dimension in the three-­ • Frankl’s logotherapy emphasizes the spiritual
dimensional concept “sense of coherence.” dimension of the human life; the need for
• Perceived meaning-in-life is a strong individ- meaning arises from the existential conscious-
ual predictor of satisfaction with life, as thus ness of life and death.
98 G. Haugan and J. Dezutter

• Frankl’s theory of meaning is based on three tions to humanistic psychology. Humanist Psychol.
substantial concepts: (1) meaning-in-life, (2) 2008;36:31–44.
10. Pearson P, Sheffield B. Psychoticism and purpose in
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eller tilintetgjørelse]. Nord J Nurs Res Clin Stud.
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 Self-Transcendence: A Salutogenic
Process for Well-Being
9
Pamela G. Reed and Gørill Haugan

Abstract Keywords

Self-transcendence is a concept relevant to Inherent capacity for self-organizing ·

understanding how human beings attain or Personal and contextual factors · Salutogenic
maintain well-being. Not surprisingly, it is resource · Self-boundaries · Self-­
similar to other concepts that are in some way transcendence · Vulnerability · Well-being
linked to human well-being. The purpose of
this chapter is to discuss self-transcendence
particularly for its empirical support and prac-
9.1 Theoretical Context
tical relevance in promoting well-being across
of the Concept
the health continuum. Increasing understand-
of Self-Transcendence
ing and generating new ideas about self-­
transcendence may also facilitate continued
Because self-transcendence is an abstract con-
research into self-transcendence and identifi-
cept, it is important to situate the concept within
cation of health-promoting interventions and
a theory to facilitate elaboration of its meaning
practices that foster well-being, particularly in
and existing empirical support and how it may be
difficult life situations.
assessed or measured for practical applications
within a discipline. In nursing, self-­transcendence
is a process that promotes or supports well-being
[1, 2]. The concept of self-transcendence is rele-
vant to nursing because it is salient for well-being
in health-related contexts, especially those that
P. G. Reed are particularly challenging or eventful, life-­
College of Nursing, The University of Arizona, threatening, or life-changing—in other words in
Tucson, AZ, USA
e-mail: preed@email.arizona.edu times of increased vulnerability.
The concept of self-transcendence is con-
G. Haugan (*)
Department of Public Health and Nursing, NTNU nected to vulnerability and well-being. Self-­
Norwegian University of Science and Technology, transcendence is theorized to be a resource for
Trondheim, Norway well-being; it is an inner resource that becomes
Faculty of Nursing and Health Science, Nord particularly salient during events or awareness of
University, Levanger, Norway one’s vulnerability that can diminish well-being
e-mail: gorill.haugan@ntnu.no, [1, 2]. A model of the theory is presented in
gorill.haugan@nord.no

© The Author(s) 2021 103

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_9
104 P. G. Reed and G. Haugan

Fig. 9.1 Model of

Reed’s self-­
transcendence nursing
theory. (Copyright
©2012 by Pamela Self-Transcendence
G. Reed)

Personal
and
Contextual Factors

Vulnerability Well-Being

Fig. 9.1, depicting three key concepts and their well. Well-being in this chapter is distinguished
relationships, including the mediating role of from objective health as a physical or biologi-
self-transcendence. Additional concepts in the cally based condition, which is often described in
theory are personal and contextual factors that biomedical terms or diagnoses when illness is
can influence the relationships among vulnerabil- present. Well-being refers to a subjective sense as
ity, self-transcendence, and well-being. Potential perceived by the individuals regardless of bio-
factors include age, gender, ethnicity, years of medical status or diagnosis. It involves an exis-
education, illness intensity, life history, social or tential judgment by the individual and is likely
spiritual support, and other factors concerning influenced by one’s history, culture, and develop-
the person’s social, cultural, and physical envi- mental stage in life as well as significant relation-
ronment (ibid.). ships and biophysical factors. There are various
measures of subjective well-being, which indi-
cate the diversity of perspectives on well-being in
9.1.1 The Main Concepts nursing and other sciences. Examples of indica-
tors of well-being include life satisfaction, happi-
9.1.1.1 Vulnerability ness, high morale in aging, meaning or
Vulnerability refers most directly to a heightened purpose-in-life, as well as absence of mental
sense or awareness of one’s mortality and fragil- health problems such as depression, anxiety, or
ity or susceptibility to be harmed in some way. A loneliness.
wide variety of emotional and physical human
health experiences engender a sense of vulnera- 9.1.1.3 Self-Transcendence
bility, particularly those that are life-threatening According to Reed’s (e.g., [1–3]) nursing theory
or that involve loss. Examples include chronic of self-transcendence, the concept of self-­
and serious illness, disability, aging, bereave- transcendence refers to perspectives and behav-
ment, traumatic events, parenting and caregiving, iors that expand (transcend) self-boundaries in
and facing end-of-life. multiple ways that are described, for example,
inwardly (through intrapersonal activities and
9.1.1.2 Well-Being perspectives that enhance awareness of one’s
Well-being is defined broadly as a subjective beliefs, values, and dreams), outwardly (through
feeling of being well or healthy, based on the per- interpersonal connections with one’s social and
son’s values and definition of health or being natural environments), upwardly (through per-
9 Self-Transcendence: A Salutogenic Process for Well-Being 105

spectives and practices oriented beyond the 9.2 A Nursing Theory

ordinary or readily observable toward the of Self-Transcendence
transpersonal), and temporally (connecting per-
spectives of past and future to one’s present) [2]. Scientific theories not only provide descriptions
Individuals achieve these perspectives and behav- of observable characteristics or events but also
iors on their own but in difficult times may also propose explanations of processes or mecha-
benefit from personal or professional support of nisms underlying the phenomena [4]. These
others to facilitate self-transcendence. Forms of explanations may be placeholders until we can
self-boundary expansion range from the mun- learn more about what is going on behind what is
dane to the mystical, with many yet to be readily observable. The theory of self-­
discovered. transcendence offers one explanation for the pro-
cess of well-being. The theory draws from
assumptions of two metatheories: (1) lifespan
9.1.2  hree Main Relationships
T developmental psychology and the relational
in the Theory developmental systems perspective [4–6], which
describe human development in part as a differ-
Figure 9.1 depicts the three key relationships entiation of self and changing boundaries
among the concepts proposed by the nursing between self and others and the environment over
theory of self-transcendence, each of which the lifespan; and (2) the science of unitary human
may be moderated by personal and contextual beings [7–9] by which human beings are viewed
factors such as age, gender, cognitive ability, as inherently open human-environment systems
health status, personal beliefs, social or spiritual of changing complexity and organization.
support, and other sociocultural factors. One In terms of the first assumption, differentiation
relationship between vulnerability and self- of self and changing boundaries, self-­transcendence
transcendence posits that awareness of involves self-boundary management as a self-
vulnerability may motivate an increase in self- organizing process that fosters well-being during
transcendence, perhaps as a means of coping significant health and life events. Change in self-
with vulnerability. A second positive relation- boundaries is a natural developmental process
ship is proposed between self-­ transcendence according to lifespan and psychodynamic theories
and well-being (or an inverse relationship if the of human development (e.g., [10]). For example,
well-being outcome is a negative indicator such in infancy the self-­boundary between self and par-
as depression). A third relationship proposes ent is diffuse; children and adolescents increas-
that self-transcendence mediates the relation- ingly develop a self-awareness that distinguishes
ship between vulnerability and well-­being such the self from others; adults develop a sense of
that self-transcendence is the process by which interdependence between self and others; and
an individual may attain well-being in the pres- older adults and others facing end of life may
ence of vulnerability. The proposed relation- acquire more expanded and spiritual forms of self
ships in this theory paint a picture not of coping in relation to the world [11].
but of transcending a difficult situation. Without In terms of the second assumption, a charac-
the capacity for self-transcendence, promotion teristic of open systems is that they have ongoing
of health and well-being might not be possible interaction with the environment, which increases
in difficult situations. Self-­transcendence, then, complexity. This would be chaotic without also
may be an underlying process that explains how ongoing capacity to organize complexity. The
well-being is possible in difficult or life-threat- process underlying self-transcendence, then, is
ening situations that people endure. Accordingly, the broad human capacity for self-organizing the
self-transcendence represents a vital resource increasing complexity. The theory of self-­
for health and well-being and is key in health transcendence points specifically to health-­related
promotion. events as bringing about increased complexity in
106 P. G. Reed and G. Haugan

life, and by positing that the individual’s inherent emotional, social, and spiritual into a sense of
self-organizing capacity—evidenced by manag- wholeness (well-being). That is, the individual
ing personal boundaries—facilitates well-being becomes healthier with stronger connections
through these events [3]. The management (or within the self, and with important others, the
self-organizing) of complexity by expanding self- environment as well as one’s life experiences.
boundaries is a way to create meaning, sense of Recent medical and nursing research indicates
identity, and security in the face of vulnerability. that connectedness is fundamental in well-being,
In sum, self-transcendence is a “natural resource health, and healing [15–18] as well as the core of
for healing that manifests the human being’s people’s spirituality [19–21]. Nursing and health
capacity to self-organize for well-being at times science embrace a holistic approach to health and
in life when a sense of fragmentation may threaten illness which includes a focus on interconnections
well-being” [12]. between the emotional, physical, social, and spiri-
Nursing holds deep interest and appreciation tual. Hence, by facilitating the processes of con-
for how individuals persevere if not thrive nectedness by means of self-transcendence, the
through difficult health experiences. Translating individual’s inner strength, integration, and well-
theories about human development and complex being are supported [22–25]. In this way, the salu-
adaptive and open systems (e.g., [13]) into nurs- togenic essence of self-transcendence seems
ing language means that individuals have the evident. Nursing’s role is to describe, explain, and
inherent capacity for self-organizing change that facilitate these processes of connectedness pro-
is healing and fosters well-being. Hence, this moting well-being, of which self-­transcendence is
inherit capacity for self-organizing is a health-­ one, as they occur in human beings during health
promoting resource for people’s health, which [2, experiences and events across the lifespan.
14] is labeled as a “nursing” process because it is
not just any self-organizing process but one that
is inherent in human beings and facilitates health 9.3 Measuring
and well-being. Self-transcendence is one exam- Self-Transcendence
ple of this self-organizing process.
Further, self-transcendence is salutogenic; it is Various instruments have been used to measure
conceptualized as an inherent resource for well-­ self-transcendence in research. While they share
being, particularly in challenging life events such some common themes of self-transcendence such
as health crises and loss. However, self-­ as connectedness or spirituality broadly defined,
transcendence is not limited to or focused on and its role in enhancing well-being, the domi-
attempts to resist stress as much as it is a normal, nant conceptualizations behind each instrument
developmental outcome of co-evolving with the are quite distinct; for example, include religious
changing environment (and stressful life events, or supernatural beliefs, intense but temporary
challenges, and other significant change) through mystical, peak, or ineffable experiences, losing or
various behaviors and mindsets or dispositions dissolution of self into a greater whole, negation
that expand self-boundaries and foster a sense of of the physical world, personality temperaments
wholeness (well-being). The concept of self-­ or traits, and prosocial values (see [26–28] for
transcendence covers different ways by which overviews). Psychometric evaluations produce
individuals expand their self-boundaries, which mixed results on empirical adequacy, although
in fact is about connectedness. Thus, the core of this can be said for most instruments measuring
self-transcendence is connectedness among intra- this complex construct of self-transcendence.
personal, interpersonal, or transpersonal dimen- Nursing is unique in its measure of self-­
sions of the self. This may also include connecting transcendence as expanding boundaries both
to memories of one’s past and anticipations about inward and outward in a way that connects self to
the future, drawn into one’s present into a mean- others and the environment without diminishing
ingful way. This connectedness involves an inte- the individual, and not as a personality character-
gration of parts of the self—such as the physical, istic, a particular value-orientation, an ineffable
9 Self-Transcendence: A Salutogenic Process for Well-Being 107

experience, or belief system. Rather, and impor- Thus, ailments such as fatigue and pain, etc.,
tantly, the nursing measure of self-transcendence might not be a good companion for the outgoing
is based upon a nursing theory by which self-­ or interpersonal way of expanding one’s self-­
transcendence involves everyday “terrestrial” boundaries [35]. However, the inwardly dimen-
experiences that individuals (and nurses and sion covers an inwardly process of self-acceptance
other caregivers) encounter and can readily and adaption to one’s situation and functional
apprehend [11, 29, 30]. capability, which has shown to explain the varia-
In the initial and continuing research in nurs- tion in quality of life/well-being better than the
ing, self-transcendence is measured by the Self-­ outgoing dimension among nursing home resi-
Transcendence Scale (STS) [29]. The STS is dents [36]. Furthermore, these two dimensions of
developed as a unidimensional instrument with self-­transcendence seem to influence differently
15 items measured on 4-point Likert-type scal- on other related constructs as well as the relation-
ing. It originated from a psychometric study and ships between these constructs; these are per-
factor analysis of a 36-item instrument, the ceived meaning-in-life [37], hope and nurse-patient
Developmental Resources of Later Adulthood interaction [35], depression [38], as well as physi-
scale [31, 32], which generated a self-­ cal, emotional, social, functional, and spiritual
transcendence factor that described behaviors ­well-being [24, 25, 39]. Thus, this differentiation
and perspectives that reflect expansion of per- seems important clinically, theoretically, and
sonal boundaries. The STS has demonstrated scientifically.
reliability (internal consistency) and validity
(content, construct) across studies of various
populations and health experiences. It is brief and 9.4 Self-Transcendence Research
easy to administer either as a questionnaire or in
an interview format. The STS is used widely in To gain a better understanding of the concept of
research and may also be used by practicing self-transcendence as theorized here, it is helpful
nurses to better understand areas for assessing to review research on self-transcendence.
patients. Many researchers and graduate students Findings provide further insight into the breadth
have used the instrument in studying self-­ of vulnerable health conditions and experiences
transcendence as it relates to various health expe- that self-transcendence is associated with or that
riences and outcomes. The STS has been influence human well-being in the midst of diffi-
translated into several languages, including cult life experiences. An overview of these results
Spanish, Norwegian, Swedish, Turkish, also suggests opportunities for developing and
Mandarin, Farsi, Japanese, and Korean. implementing health-promoting practices.
As already described, the ST theory states that
self-transcendence refers to various ways (dimen-
sions) of transcending one’s self-boundaries, for 9.4.1 Initial Research: Depression
example, outwardly (interpersonal), inwardly and Cancer
(intrapersonal), upwardly (transpersonal), and
temporally (connecting one’s past and future to Self-transcendence research in nursing was first
the present). Correspondingly, while evaluating published around the early 1990s with Reed’s
the psychometrics of the STS one could expect studies of self-transcendence as related to mental
four dimensions. Psychometric studies have health and depression in older adults. Results
shown that the STS is multidimensional, including consistently supported self-transcendence to be a
at least two dimensions: an interpersonal and an significant correlate and sometimes predictor of
intrapersonal factor [33, 34]. This differencing depression in older adults (e.g., [11, 31, 32]).
between the interpersonal and intrapersonal These results were repeated in subsequent
dimensions of self-transcendence is important. research by others. For example, Klaas [40] stud-
The outwardly dimension is an outgoing attitude ied self-transcendence and depression in 77
and behavior, requiring a certain level of energy. depressed and nondepressed elders, finding self-­
108 P. G. Reed and G. Haugan

transcendence was negatively correlated with suggested that caregivers of older adults in long-­
depressive feelings and positively correlated with term care facilities and at home should look
meaning-in-life in these groups. Similarly, beyond custodial care to incorporate activities
Haugan and Innstrand [38] found that self-­ that build upon the residents’ capacity for self-­
transcendence significantly affected depression transcendence that can help them cope with the
in 202 older nursing home residents. Moreover, losses of later life.
self-transcendence was significantly inversely Significant, positive, moderate size relation-
correlated with suicidal thoughts in older adults ships were found [22] in a study of oldest-old
hospitalized for depression [41], and with depres- adults between self-transcendence and indica-
sive symptoms in a nursing home sample of tors of well-being including resilience, sense of
Taiwanese older adults [42]. coherence, and purpose-in-life. In a longitudi-
Doris Coward conducted several studies of nal study by Norberg and her colleagues [52] of
self-transcendence in individuals across the tra- 190 oldest-old individuals in northern Sweden,
jectory of cancer, from initial diagnosis to late self-­transcendence was significantly related to
stage, and AIDS, and healthy individuals. She well-­being overall, but the accrual of negative
consistently found that self-transcendence was a life events over the 5 years effected a concern-
significant correlate of various indicators of well-­ ing decrease in self-transcendence. Self-­
being involving self-esteem, hope, sense of transcendence is a vital but not inexhaustible
coherence, and mental health [43–48], including psychosocial resource in older adults. For
especially those not considered medically example, two different Norwegian studies
healthy. Since then, self-transcendence research among older adults in nursing homes showed
with individuals who have cancer has generated that both interpersonal and intrapersonal self-
findings consistent with Coward’s results. transcendence were significantly influenced by
the residents’ perceived nurse-patient interac-
tion [37, 51]. Walton and colleagues [53] iden-
9.4.2 Later Adulthood tified a significant inverse relationship between
self-­transcendence and loneliness in older
Older adults and particularly the oldest-old (ages adults; this was supported by a recent
80–100 years) represent a group of individuals Norwegian study among nursing home resi-
who are very likely to be experiencing vulnera- dents [54]. Hoshi [55] found that self-transcen-
bility in health conditions that they may or may dence had a mediating effect on the relationship
not express to others. Research with them consis- between vulnerability and well-being in 105
tently reveals self-transcendence to be a key Japanese hospitalized elders. Last, self-tran-
characteristic and likely contributor to their well- scendence was used to design a program to pro-
being [49]. For example, Reed [11] identified mote successful aging among older adults in
four patterns of self-transcendence to be more the community; a series of studies generally
predominant in nondepressed than depressed supported the effectiveness of an intervention
oldest-old adults. Similarly, results from several called the Psychoeducational Approach to
studies by Haugan and colleagues support inter- Transcendence and Health (PATH) program
personal and intrapersonal self-transcendence as (see [56–59]).
clinically important in nurse-patient interactions
to promote mental health in older adult nursing
home residents [37, 38, 50, 51] and physical, 9.4.3  hronic Conditions and Life-­
C
emotional, social, functional, and spiritual well-­ Threatening Illness
being of older adults in nursing homes [24, 25,
35, 39]. Intrapersonal self-transcendence was Self-care is an important aspect of health promo-
among particularly significant health-promoting tion in chronically ill individuals. Findings from
factors in long-term care residents [36]. Findings several studies with older adults indicated that
9 Self-Transcendence: A Salutogenic Process for Well-Being 109

self-transcendence facilitates their engagement in eight men and women who had received a stem
instrumental activities of daily living [60, 61], cell transplantation 1 year prior to a phenomeno­
and in medication adherence [62], as well as in logy study, results suggested that effects of vul-
managing stress in facing existential anxiety nerability on well-being were mediated by
about the aging process [63]. hard-won self-transcendence perspectives [75].
Self-transcendence was found to reduce stress Homelessness presents individuals with ongo-
or enhance well-being in studies of several patient ing sense of vulnerability and risks to well-being.
groups facing the vulnerability of serious, pro- Runquist and Reed [76] identified self-­
gressive disease including adults with multiple transcendence primarily, along with physical
sclerosis and systemic lupus erythematosus [64], health status to be significant predictors of well-­
and in older women living with rheumatoid being in a sample of 61 homeless men and
arthritis [65]. Results from a phenomenological women, suggesting that facilitating well-being is
study of individuals with spinal muscular atrophy not just a matter of providing for physical needs.
indicated that self-transcendence was pivotal in
maintaining a sense of integrity, hope, and mean-
ing amidst the physical limitations experienced 9.4.4 Nurses and Other Caregivers
by this disease [66]. Similarly, individuals with
amyotrophic lateral sclerosis nearing end-of-life Professional and family caregivers are vulnerable
in palliative care reported self-transcendence per- to diminished well-being given the nature of their
spectives facilitated their sense of hope and well-­ challenging and stressful work and work environ-
being [67]. ments. Indeed, Pask [77] elaborates on how pro-
In additional research with individuals with fessional nurses’ self-transcendence can increase
cancer, self-transcendence was found to be an their own vulnerability without adequate support
important mediator between vulnerability and and education in their work setting. Research
well-being outcomes. Matthews and Cook [68] with family caregivers of adults with dementia
found that self-transcendence alone partially starkly revealed their increased vulnerability—
mediated the relationship between optimism and and thus increased risk to well-being—because of
the outcome of emotional well-being in a sample a lack of opportunities for self-transcendence
of 93 women with breast cancer undergoing radi- within their emotional and social environment
ation treatment [68]. Farren’s [69] study of 104 [78, 79]. On the other hand, opportunities to
breast cancer survivors found self-transcendence engage in caregiving as a self-transcendence
to be a significant mediating factor in the rela- practice facilitated personal growth and meaning
tionship between women’s participation in health among caregivers [80, 81]. Similarly, Kim et al.
care and their increased quality of life. Self- [82] found a significant relationship between self-
transcendence was identified as a mediator that transcendence and emotional well-being among
reduced stress in men who had oral cancer [70], family caregivers of chronically ill elders. Finally,
and in men who participated in a prostate cancer research results also support the significance of
support group [71]. Finally, self-­transcendence as self-transcendence for parents (caregivers) of
experienced through spiritual practices promoted children undergoing cancer treatment [83].
spiritual well-being among women with breast Self-transcendence has a role in nurse well-­
cancer [72]. being. In a study sample of hospice and oncology
Another group of individuals who likely expe- nurses, who were vulnerable to burn out, self-­
rience increased vulnerability is transplant recipi- transcendence was significantly inversely related
ents. In two distinct studies of liver transplant to three types of burn out [84]. Palmer [85] and
recipients, self-transcendence was found to be her colleagues found significant positive relation-
positively related to quality of life and negatively ships between self-transcendence and vigor, ded-
related to fatigue [73] and to be a correlate and ication, and absorption in the work of 84 acute
mediator of quality of life, decreasing the effects care staff registered nurses. Spiritual care
of illness distress [74]. Additionally, in a group of ­intervention training resulted in increased self-­
110 P. G. Reed and G. Haugan

transcendence as well as in spiritual well-being 9.5 Self-Transcendence

and positive attitudes toward work among pallia- and Applications for Health
tive care professionals [86]. In research, using the Promotion
two-factor constructs of self-transcendence by
Haugan et al., [33] to create a measurement Research findings overall support the signifi-
model, investigators found self-transcendence cance of self-transcendence in contributing to
was not only significantly positively related to health and well-being. Implications for health
emotional well-being in Chinese nurses, but that promotion can be drawn from the research, as
self-transcendence facilitated and even “invigo- well as from clinically based literature based on
rated” caring behaviors [87]. nurses’ practice knowledge and reports of their
work and the ways by which individuals expand
boundaries to gain new insights for self-­
9.4.5 A Value That Promotes organizing and tackling difficult health-related
Well-Being situations that otherwise could fragment the
individual.
Self-transcendence has been studied as one of the Self-transcendence is a resource for well-­
higher values whereby individuals feel concern being, regardless of health condition or diagno-
for the welfare of others and interact in a way that sis, across the lifespan from youth to end-of-life.
expresses this value, for example by responding Table 9.1 summarizes a selection of approaches,
to others’ needs, reaching out to marginalized practices, or interventions that facilitate self-­
individuals, being tolerant of differences, and transcendence across individuals of various age
altruism. It is conceptualized as a motivational groups and health/illness conditions.
value for growth as contrasted with the motiva-
tional value for conservation and protection. In
classic work based upon a conceptual framework Table 9.1 Sample of health promotion approaches to
of values by Schwartz [88], self-transcendence foster self-transcendence
was distinguished from self-enhancement values Interventions to foster self-transcendence References
that focus on betterment of the individual, self-­ Bereavement support groups [92]
gratification, personal success, and prestige. His Peer support group [92, 93]
Work Values Survey continues to be used to inves- Cancer support groups [94–96]
Computer-mediated self-help [97]
tigate the influences of “self-transcendence” and intervention
other values. For example, a recent study in Group psychotherapy [98]
Germany by Seibert, Hillen, Pfaff, and Kuntz Therapeutic music video [99, 100]
[89] using a Work Values Survey based on Family caregiver participation [80]
Schwartz’s value dimensions indicated that self-­ Artmaking [101, 102]
transcendence as a value perspective in nurse Memorial quilt making [103]
leaders of neonatal intensive care units was sig- Poetry writing [104]
Expressive writing, journaling [105]
nificantly associated with a safer work climate, Personal narratives [106]
an experience considered to be highly important Psychoeducational Approach to [57, 58]
for nurse well-being. Transcendence and Health (PATH)
Findings from another recent study of altruism program
indicated that self-transcendence, mediated by a Prayer and spiritual support activities [107]
multicultural perspective, was significantly related Meditation (integrative body-mind [108]
training)
to a greater willingness to interact with People’s Mindfulness meditation [72, 109,
Republic of China immigrants [90]. Altruism of 110]
self-transcendence was also evident in research by Guided reminiscence intervention [111, 112]
Fiske [91] who demonstrated that participating in Life review [113]
a mission trip experience enhanced well-being. Nurse-patient interaction [35, 37, 51]
9 Self-Transcendence: A Salutogenic Process for Well-Being 111

9.6 Summary • Self-transcendence is a resource for well-­being;

it is an inner resource that becomes particularly
As a process by which human beings may sustain salient during events or awareness of one’s vul-
well-being in times of vulnerability, self-­ nerability that can diminish well-being.
transcendence is a salutogenic resource for • The nursing theory of self-transcendence is
expanding personal boundaries in ways that may based on three main concepts: vulnerability,
enhance sense of well-being with broad applica- well-being, and self-transcendence. Each of
tion across the health continuum. It represents these three concepts, and the relationships
“both a human capacity and a human struggle that between them, may be moderated by personal
can be facilitated by nursing” ([30], p. 3) and spe- and contextual factors such as age, gender,
cifically by the qualities embedded in the nurse- cognitive ability, health status, personal
patient interaction [37, 51]. Self-­transcendence beliefs, social or spiritual support, other socio-
theory offers an explanation as to how in the con- cultural factors and nursing interventions.
text of increased vulnerability individuals can nev- • Self-transcendence refers to perspectives and
ertheless experience increased well-being. behaviors that expand (transcend) self-­
Achieving well-being involves intentional activity boundaries in multiple ways: inwardly (through
on the person’s part, for example through intraper- intrapersonal activities and perspectives that
sonal reflection and interpersonal engagement that enhance awareness of one’s beliefs, values, and
expand one’s boundaries in ways that help the per- dreams), outwardly (through interpersonal
son find meaning in a d­ ifficult situation or gain a connections with one’s social and natural envi-
new sense of purpose after suffering loss. These ronments), upwardly (through perspectives and
and other behaviors that expand personal boundar- practices oriented beyond the ordinary or read-
ies (self-­transcendence) may transform loss or dif- ily observable toward the transpersonal), and
ficulty (increased vulnerability) into positive temporally (connecting perspectives of past
outcomes (well-being). Research indicates that and future to one’s present).
self-­transcendence is a resource for well-being, • Without the capacity for self-transcendence,
functioning either as a correlate or predictor of promotion of health and well-being might not
well-being, and as a mediator of the relationship be possible in difficult health situations. Self-­
between vulnerability and well-being across a transcendence, then, may be an underlying
variety of populations, particularly those experi- process that explains how well-being is possi-
encing serious illness or other challenging life sit- ble in difficult or life-threatening situations
uations. The scope of the theory has been that people endure.
broadened from its initial focus on later adulthood
as the time of developmental maturity, to include
others for whom life experiences stimulate growth References
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 Nurse-Patient Interaction: A Vital
Salutogenic Resource in Nursing
10
Home Care

Gørill Haugan

Abstract genic understanding of health is holistic and

considers man as a wholeness including phys-
We are now witnessing a major change in the
ical, mental, social, and spiritual/existential
world’s population. Many people globally
dimensions. Research indicates that various
grow very old: 80, 90, and 100 years. Increased
health-promoting interventions, specifically
age is followed by an increased incidence of
the nurse–patient interaction, influence on
functional and chronic comorbidities and
older adults in nursing homes as a wholeness
diverse disabilities, which for many leads to
of body–soul–spirit, affecting the whole
the need for long-term care in a nursing home.
being. Hence, dimensions such as pain,
Quality of life and health promotive initiatives
fatigue, dyspnea, nausea, loneliness, anxiety,
for older persons living in nursing homes will
and depressive symptoms will be influenced
become ever more important in the years to
through health-promoting approaches.
come. Therefore, this chapter focuses on
Therefore, two separate studies on the health-­
health promotion among older adults living in
promoting influences of nurse–patient interac-
nursing homes. First, this chapter clarifies the
tion in nursing home residents were conducted.
concepts of health, salutogenesis, and patho-
In total, nine hypotheses of directional influ-
genesis, followed by knowledge about health
ence of the nurse–patient interaction were
promotion. Then insight and knowledge about
tested, all of which finding support.
the nursing home population is provided; what
Along with competence in pain and symp-
promotes health and well-being in nursing
tom management, health-promoting nurse–
home residents?
patient interaction based on awareness and
Health promotion in the health services
attentional skills is essential in nursing home
should be based on integrated knowledge of
care. Thus, health care workers should be
salutogenesis and pathogenesis. The saluto-
given the opportunity to further develop their
knowledge and relational skills, in order to
“refine” their way of being present together
G. Haugan (*)
Department of Public Health and Nursing, with residents in nursing homes. Health pro-
NTNU Norwegian University of Science fessionals’ competence involves the “being in
and Technology, Trondheim, Norway the doing”; that is, both the doing and the way
Faculty of Nursing and Health Science, of being are essential in health and nursing
Nord University, Levanger, Norway care.
e-mail: gorill.haugan@ntnu.no,
gorill.haugan@nord.no

© The Author(s) 2021 117

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_10
118 G. Haugan

Keywords local community as well as the society. Quality-

Health promotion · Holistic health concept · of-life (QoL) and health promotive initiatives for
Nursing home · Nurse–patient interaction · older persons living in NHs will become ever
Salutogenesis and pathogenesis · Salutogenic more important in the years to come. Therefore,
nursing home care · Spiritual care · The this chapter focuses on health promotion among
“Being in the Doing” older adults living in NHs. First, this chapter clar-
ifies the concept of health, followed by knowl-
edge about health promotion. Then insight and
knowledge about the NH population is provided;
what is health and health promotion in the NH
10.1 Background context?

Currently, the world faces a shift to an older pop-

ulation; 125 million people are now aged 80 years 10.2  he Salutogenic Concept
T
or older [1].While this shift started in high-­ of Health
income countries (e.g., in Japan 30% of the popu-
lation is already over 60 years old), it is now To promote health, we need knowledge of what
low- and middle-income countries that are health is and what creates health and thus well-
­experiencing the greatest change. Today, most being. Instead of focusing only on disease and
people can expect to live into their 60s and risk of disease (framed as pathogenesis), Aron
beyond [1]. Between 2015 and 2050, the propor- Antonovsky [4] focused on “What creates
tion of the world’s population over 60 years will health?” This question was the starting point of
nearly double from 12% to 22%; by 2050, the the salutogenic understanding of health, which
world’s population aged 60 years and older is represents a turning point in the understanding of
expected to total two billion, up from 900 million health research. An increasing number of
in 2015 [1, 2]. Soon 30% of the world’s popula- researchers have now realized that a unilateral
tion is 60 years and older. All countries in the focus on disease and risks of getting sick (patho-
world face major challenges to ensure that their genesis) does not necessarily increase or
health and social systems are ready to make the strengthen an individual’s health [5]. The human
most of this demographic shift [1]. life is multifaceted; people’s health is exposed to
There is, however, little evidence to suggest many different types of stress, to which the indi-
that older people today are experiencing their vidual responds differently. Not everyone gets
later years in better health than their parents. Age sick from major stresses, risk factors, losses, cri-
is no disease. Yet, most chronically ill people ses, and illness. Who are the salutogenic ones,
today are older adults. Increased age is followed those who maintain health despite stressing life
by an increased incidence of functional and circumstances? What makes them go through
chronic comorbidities and diverse disabilities [3], these negative life events without getting sick?
which for many leads to the need for long-term Do they just have luck? And others bad luck? Or
care in a nursing home (NH). Accordingly, the are there any salutogenic resources that preserve
WHO’s Global Strategy and Action Plan on health during difficult circumstances?
Aging and Health [1] includes the development Antonovsky [4, 6] is considered the “father of
of systems for providing long-term care as one salutogenesis.” The concept of salutogenesis
among five priority areas for action. Systems of originates from the Greek notion of “salus”
long-­term care are needed in all countries to meet which means health and the Latin term “genesis”
the needs of older people. which means origin. Bottom line, salutogene-
As people live longer, it is important to ensure sis—the salutogenic understanding of health and
that the extra years of life are worth living, despite the gradually evolving salutogenic concepts—
chronic illnesses. This is important not only to signifies knowledge about the origin of health,
the individual elderly, but also to the families, the that is, knowledge of what gives, facilitates, and
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 119

supports health. From a salutogenic perspective, whole because these four dimensions are inte-
health is a positive concept involving social and grated into each other and act like an entirely inte-
personal resources, as well as physical capacities. grated wholeness, a human being. A constantly
The concept of salutogenesis has matured since ongoing interaction integrates the dimensions or
1986 and has become a core theory of health pro- levels in the whole [8], all controlled via the brain
motion [5]. [10]. Nothing is “just emotional” or “just physi-
The salutogenic concept of health is holistic cal,” everything is integrated into everything. In
[4], considering man as a wholeness including a human being, everything is interrelated and influ-
physical, mental, social, and spiritual/existential ences on everything.
dimension. Nursing and other health professions Hence, man is a unique and indivisible physi-
are grounded in the holistic understanding of cal-psycho-social-spiritual entity in which body,
health, implying that human beings consist of mind, and spirit are integrated and constantly
these above-mentioned four dimensions [7]. interact with each other, right down to the micro-
However, by theoretically splitting the human into cellular level [9, 10]. That is, the human experi-
four, man is no longer one unit, but four “divorced” ences, expectations, thoughts, and feelings are
parts, which is contradictory. Health care is physiological states or biochemical conditions in
largely based on this fragmentation of man which the body, with subsequent bodily consequences
causes unnecessarily suffering; often patients feel impacting the whole being [11]. Research has
treated like a diagnosis, a case, or an object the shown and shows ever more clearly that there are
doctor is treating and health professionals are connections (interaction) between the mind (our
controlling, and not as a whole living person. thoughts, feelings, and experiences) and the body
Figure 10.1 illustrates the entity of the human in the development of most diseases and ailments
being involving a physical, emotional, social, and [12]. Negative emotions and prolonged stress
spiritual/existential dimension. However, this pic- expose the organ systems to stress that can result
ture of a human being divided into four parts, in illness. Our emotions are biochemical realities
dimensions or levels, is merely theoretical. in our bodies. Since they have nowhere else to be,
Figure 10.1 has a red dotted line which circulates; we feel and recognize our emotions in the body
even though we theoretically claim that there are [11]. Candace Pert is an internationally recog-
different dimensions in the whole, it is still a nized stress researcher showing that the brain
“talks” to the immune cell system by means of
“messenger cells” called neuropeptides or trans-
mitters. When the brain interprets emotions such
as fear, anger, or sadness, all the immune cells are
told about this interpretation. Pert [11] describes
this process as “bits of the brain floating around
the body.” Simply put, our emotions and thoughts
“float around the body,” materialized as peptides
(protein molecules) and a myriad of complex
chemical and physiological processes. Studies on
stress have claimed that feeling fear triggers more
than 1400 known physical and chemical stress
reactions, activating more than 30 different hor-
mones and neurotransmitters [13]. Furthermore,
the stress literature highlights that positive atti-
tudes and expectations are not just changing
moods, but biological realities in the body.
Fig. 10.1 The wholeness of man involving a physical,
emotional, social, and spiritual/existential dimension, Seligman [14] and Keyes [15–18] have shown
interrelated by a steady interaction between the dimen- that optimism and “flourishing” have a great pos-
sions. ©Gørill Haugan itive impact on human health. Several studies
120 G. Haugan

have shown that a specific kind of white blood cated in the 1986 Ottawa Charter [5, 27]. The
cells called “natural killer cells,” increase during Shanghai declaration from 2016 recognizes that
cognitive therapy, as well as by various relax- health and well-being are essential to achieving
ation and visualization techniques [19, 20]. sustainable development. Consequently, not only
Recent research implies that for example per- hospitals but also NHs should be developed in a
ceived meaning-in-life is important for maintain- health-promoting direction.
ing not only mental/emotional well-being, but It is important to emphasize that health pro-
physical and functional well-being as well [21– motion approaches do not mean a disregard of
23]. A novel study demonstrated humans’ holis- pathogenesis. Knowledge of pathogenesis, i.e.,
tic existence showing that perceived knowledge of disease, risk, and prevention, is
meaning-in-­ life as well as loneliness affected important in all health disciplines and of course
older adults’ brain function [23]. These findings in the health services. When people get injured or
advance our understanding of phenomenon such ill, whether it be heart disease, lung disease, can-
as meaning and loneliness which operate not cer disease, mental illness, or the need for a surgi-
only by emotions or experiences but represent cal intervention, knowledge of illnesses, injuries,
physical states in human’s brains [23]. Loneliness and trauma, as well as the treatment of them, is
and meaning-in-life are reflected in the intrinsic crucial to peoples’ lives. However, the health ser-
network architecture of the brain. Thus, various vices now need a clear and explicit synthesis of
health-promoting interventions, tailored to the pathogenesis and salutogenesis; both paradigms
individual and specific context, influence on the are important. Instead of juxtaposing pathogene-
patient as body–mind–spirit impacting on the sis and salutogenesis, they should be integrated
whole being. Accordingly, dimensions such as into a holistic way of understanding and working
pain, fatigue, dyspnea, nausea, anxiety, and with health. Humans’ health should not only be
depressive symptoms will be affected through treated, but also promoted and facilitated. Health
health-promoting approaches. is always present, while illness and injury occur
from time to time. Thus, health is the basic and
the origin and should therefore be the basis, on
10.3 Health Promotion which the health services are founded. What
might health promotion look like in the NH
The first international conference on health pro- population?
motion was held by the World Health Organization
in Ottawa, Canada, in 1986. Here, the Ottawa
Charter [24] was drafted and approved, describ- 10.4  lder Adults in Nursing
O
ing health promotion as “… the process of Homes
enabling individuals and communities to increase
control over the determinants of health and The NH population is characterized by high age,
thereby improve their health” [24]. Transferred to frailty, mortality, disability, powerlessness,
the health services, health promotion entails to dependency, vulnerability, poor general health,
develop the individual’s health promotion skills and a high symptom burden [3, 22, 28].
by providing information, knowledge, support, Accordingly, moving to a NH results from
guidance, care, and coping techniques. numerous losses, illnesses, disabilities, loss of
Furthermore, the goal is to reorient the health ser- functions and social relations, and facing the end-
vice in a health-promoting direction; the of-life, all of which increases an individual’s vul-
Norwegian Directorate of Health highlighted this nerability and distress. Residents in NHs have
as early as 1987 [25]. However, according to the few opportunities to make personal decisions or
Shanghai declaration of promoting health [26], it exercise control over their lives. Many residents
seems important to re-emphasize this primarily perceive their institutionalization as the begin-
positive orientation of health promotion, as indi- ning of their loss of independence and autonomy
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 121

[29–31]. Idleness and time spent in passive activ- (4) qualities in the relationship with their caregiv-
ities, such as doing nothing, sleeping, and wait- ers [52]. Moreover, a recent study among elderly
ing is commonplace among NH residents [32, in NHs showed that spiritual well-being was
33], which leads to feelings of boredom, loneli- strongly associated with the experience of sup-
ness, and indignity [34–37]. Residents have used port, trust, meaning-in-life, and a perspective
terms like trapped, stuck, confined, isolated, and beyond death [53]. Experience of meaning,
discouraged to describe how they feel about the which is a central aspect of spiritual and emo-
institutional life [29]. tional well-being, has also shown a clear connec-
Consequently, the NH population is at a high tion with belonging/affiliation [54, 55], as well as
risk of declined well-being and quality-­ of-life with satisfaction [56] and dignity [37] among NH
(QoL) [38–40]. Finding approaches to increase residents. Self-transcendence [57] and meaning
well-being among older adults in NHs is highly [21, 22] are shown to explain variation in well-
warranted. Responding to this need, the approach being, physically, emotionally, socially, function-
framed “Joy-­of-­Life-Nursing-Homes” (JoLNH) ally, and spiritually, among older adults in NHs.
was developed in Norway. The JoLNH is a This means that if self-transcendence, joy-of-life,
national strategy for promoting well-being, and perceived meaning-in-life increase, also the
meaning and QoL among NH patients [41]. In resident’s well-being—physically, emotionally,
accordance with recent research [37, 42–45], the socially, functionally, and spiritually—will
JoLNH national strategy implies implementation increase. Connectedness is seen to be essential in
of the “Joy-of-Life” philosophy and working self-transcendence, meaning, and joy-of-life.
approach emphasizing that spiritual and emo- Older people experience changes in roles,
tional needs such as perceived meaning and joy- relationships, and living environments that
of-life, culture, meaningful activity, increase their risk for experiencing social isola-
connectedness, relationships, and enjoyment tion and loneliness, particularly when moving to
shall be integrated essentials of NH care. Based a NH. With advancing age, it is inevitable that
on the theoretical framework of salutogenesis [4, people lose connection with their friendship net-
6], well-being theory [17, 46, 47] and qualitative works and find it more difficult to initiate new
in-depth interviews with 29 NH residents, a con- friendships and to belong to new networks. Older
ceptual structure depicting the essence of the joy- adults living in NHs often experience limited
of-life phenomenon in NHs, were derived [48], opportunities for social connection despite prox-
and a quantitative measurement model for joy-of- imity to peers [58], which has implications for
life was developed and framed the Joy-of-Life mental health and QoL [59].
Scale (JoLS) [49]. These qualitative findings
revealed that positive relationships, belonging-
ness, meaning, moments of feeling well, and 10.5 The Nurse–Patient
acceptance conceptualized the essence of the joy- Relationship: Connectedness
of-life phenomenon among NH residents [48]. and Well-Being

A link between well-being and connectedness is

10.4.1 V
 ital Salutogenic Resources emerging in the literature [60]. Despite old age,
in Nursing Home Care chronical diseases, or frailty, the desire for affili-
ation and social bonding is an intrinsic human
Studies of social support in the NH population need, also when living in a NH. Deprivation of
[50, 51] show significant correlations with well- intimate relationships and social engagement
being. A systematic review on well-being among adversely affects the physical and emotional
older adults staying in care facilities identified well-being of older people. Loneliness and
four themes: (1) acceptance and adaptation, (2) depression are detrimental to elderly individuals’
attachment to others, (3) home environment, and emotional well-being [51, 61–64]. Older adults
122 G. Haugan

describe loneliness as “an aversive emotional The quality of care and the care ethics are embed-
state” which is associated with negative and pain- ded in the nurse–patient relationship. Some attri-
ful feelings, “isolated from intimate relation- butes of this relationships have been identified by
ships,” “being deprived from social and external older adults: in a milieu of openness and trust, the
support systems,” and “being abused and qualities of intimacy, sense of belonging, caring,
neglected” [65]. A lack or loss of companionship empathy, respect, and reciprocity [71] appear to
and an inability to integrate into the social envi- be health promoting, supporting resident’s joy-
ronment are critical correlates of loneliness [66, of-life, healing, strength, and/or growth [45, 71,
67], which is seen to associate with mortality 95–97].
among older adults [68–70]. Caring nurses engage in person-to-person
A systematic review of living well in elderly relationships with the NH resident as a unique
care homes identified four key themes: (1) con- person. Excellent nursing care is defined by the
nectedness with others, (2) caring practices, (3) nurses’ way of “being present” together with the
acceptance and adaptation, and (4) a homelike older adult while performing the different nurs-
environment [52]. Moreover, studies have identi- ing activities, in which attitudes and competence
fied a sense of belonging (connectedness) as a are inseparably connected. The competent nurse
core issue for well-being among NH residents is present and respectful, sincere, friendly, sensi-
[43, 48, 71–74] pointing at “feelings of support tive, and responsive to the NH resident’s feelings
and trust,” “searching for meaning and finding of vulnerability; she understands his needs, is
answers,” and “a perspective beyond death” as compassionate to different sufferings, and pro-
essential to their spiritual well-being [53]. A vides emotional support and confirmation [56,
sense of belonging and connectedness contribute 80, 81, 98, 99]. Thus, nursing care as a moral
to meaning-in-life [54, 55] as well as NH resident relational practice increases patients’ well-being;
satisfaction [56] and dignity [37]. Resident’s dig- qualitatively good nurse–patient interaction helps
nity was recently described related to “slow care” patients gain a sense of trust, safety, comfort,
[75]; that is, care without rushing anything, confirmation, value, dignity, and enhanced well-
which is seen to be particular important in care of being (ibid). The experience of being listened to
people having dementia [76]. Accordingly, stud- is crucial to long-term care patients, since this is
ies have shown that positive experiences in NHs how they experience feeling good, satisfied, val-
can occur and are important for residents’ QoL ued, and cared about [100, 101], as a part of slow
and well-being [43, 48, 52, 53, 77]. To facilitate care [75]. Frustration and suffering result from
such positive experiences, relationship-­centered the experience of not being attended to or treated
approaches seem required [52, 53, 78, 79]. with indifference [96, 102–104]. The nurse–
Through the last decades, the importance of patient interaction performs to be a fundamental
establishing the nurse–patient relationship as an health-promoting resource for older adults in
integral component of nursing practice has been NHs. Therefore, we conducted two studies inves-
well documented [80–83]. International well- tigating possible impacts of the nurse–patient
accepted nursing theorists describe nursing as a interaction on well-being in the Norwegian NH
participatory process that transcends the bound- population.
aries between patient and nurse and can be
learned and knowingly deployed to facilitate
well-being [84–91]. The perspective of promot- 10.6  urse–Patient Interaction Is
N
ing health and well-being is fundamental in nurs- a Salutary Factor: Two
ing and a major nursing concern in long-term Norwegian Examples
care [92–94].
Communication is an important aspect of These two studies were conducted to investigate
nursing; typically, a nurse’s duties cannot be per- the possible influences of NH residents’ per-
formed without communication with her patients. ceived nurse–patient interaction on multidimen-
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 123

Fig. 10.2 Hypothesized

relationships between
nurse–patient interaction
and variables found to
be highly and
significantly correlated
with well-being

sional well-being. In order to do so, a total of nine lected cross-sectional data from 188 residents in
hypotheses of direct relationships between 27 different NHs, including seven scales corre-
nurse–patient interaction and interpersonal (H1) sponding to 120 items [105]. In total, nine
and intrapersonal (H2) self-transcendence, per- hypotheses of direct relationships between
ceived meaning-in-life (H3), hope (H4), joy-of- nurse–patient interaction and interpersonal (ST1)
life (H5), sense of coherence (H6), loneliness and intrapersonal (ST2) self-transcendence, per-
(H7), anxiety (H8), and depression (H9) were ceived meaning-in-life, hope, joy-of-life, sense
tested using advanced statistics such as SEM and of coherence, loneliness, anxiety, and depression
regression analysis. Since evidence has shown were tested.
that self-transcendence, meaning, hope, joy-of-­ Inclusion criteria were the same in both stud-
life, and sense of coherence are highly positively ies except residential time, which was 6 months
correlated with well-being in vulnerable popula- for study 1 and 3 months for study 2: (1) local
tions such as NH residents, these variables were authority’s decision of long-term NH care; (2)
included. Likewise, loneliness, anxiety and residential time 3/6 months or longer; (3)
depression were selected since they are detrimen- informed consent competency recognized by
tal to NH residents’ well-being. Figure 10.2 por- responsible doctor and nurse; and (4) capable of
trays the hypothesized directional influence of being interviewed. A nurse who knew the resi-
the nurse–patient interaction (H1–H9). dents well presented them with oral and written
information about their rights as participants to
withdraw at any time. Each participant provided
10.7 Methods written informed consent.
Due to impaired vision, problems holding a
10.7.1 Data Collection pen, etc., this population has difficulties complet-
ing a questionnaire on their own; therefore, both
Study 1 collected cross-sectional data in 2008– studies conducted one-on-one interviews by three
2009 from 202 residents in 44 different (study 1) and six (study 2) trained researchers in
Norwegian NHs; a total of nine different scales the informant’s private room in the
were included which totaled 130 items [94]. NH. Researchers with identical professional
Study 2 was conducted in 2017–2018 and col- background (RN, MA, trained, and experienced
124 G. Haugan

in communication with elderly, as well as teach- lived in ordinary NHs. Age ranged from 63 to
ing gerontology at an advanced level) were 104 years, with an average of 87.4 years
trained to conduct the interviews as identically as (SD = 8.57). A total of 132 women (73.33%) and
possible. The questionnaires relevant for these 48 men (26.67%) participated; the mean age was
two studies were part of a battery of nine (study 88.3 years (SD = 1.80) for women and 86 years
1) and seven (study 2) scales comprising 130 and (SD = 1.16) for men. In this sample, 23 (12.2%)
120 items, respectively. To avoid misunderstand- were married, 22 (11.7%) cohabitants, 1 (0.5%)
ings, the interviewers held a large-print copy of single, 106 (56.4%) widowed, and 37 (19.7%)
questions and possible responses in front of the divorced. Long-term care in NHs was defined as
participants. Approval by the Regional Committee 24 hours day care for 3 months or longer; short-
for Medical and Health Research Ethics in term stays, rehabilitation stays, and residents
Central Norway (Study1: Ref.no.4.2007.645, diagnosed with dementia were not included. The
Study 2: Ref.nr 2014/2000/REK Central) was data were collected during 2017–2018.
obtained as well as from the Management Units
at the 44 (Study 1) and 27 (Study 2) NHs.
10.7.4 Measurements

10.7.2 Participants Study 1 The variables involved in Fig. 10.2 were measured
using different scales translated into Norwegian
The sample consisted of 202 (80.8% response and validated in the Norwegian NH population.
rate) of 250 residents who met the inclusion crite- Both studies involved the nurse–patient interaction
ria. These 202 participants represented 44 differ- scale, self-transcendence scale, the purpose-in-life
ent NHs in central Norway. Ages ranged from 65 test, and the hospital anxiety and depression scale.
to 104 years, with an average of 86 years Additionally, study 1 included the Herth Hope
(SD = 7.65). A total of 146 women (72.3%) and 56 Index, and study 2 included the joy-of-life scale,
men (27.7%) participated; the mean age was 87.3 the orientation to life questionnaire and a
and 82 years, for women and men, respectively. In global question assessing loneliness.
this sample, 38 (19%) were married or cohabiting, The Nurse–Patient Interaction Scale (NPIS)
135 (67%) widowed, 11 (5.5%) divorced, and 18 assessed nurse–patient interaction. The NPIS was
(19%) single. The average residence time in the developed in Norway to measure the NH patients’
NH at the time of the interview was 2.6 years sense of well-being derived from the nurse–
(range 0.5–13 years); 117 participants stayed in patient interaction [80, 96, 100, 106]. The NPIS
rural municipalities while 85 stayed in urban comprises 14 items identifying essential rela-
municipalities. Long-term NH care was defined as tional qualities stressed in the nursing literature;
a 24 hours day care for 6 months or longer; short- a validation study in an NH population demon-
term and rehabilitation stays along with patients strated good psychometric properties [97]. The
diagnosed with dementia were not included. The NPIS is a 10-point scale from 1 (not at all) to 10
data were collected in 2008–2009. (very much); higher numbers indicate better per-
ceived nurse–patient interaction.
The Self-Transcendence Scale (STS) devel-
10.7.3 Participants Study 2 oped by Reed [107, 108] was used to measure
self-transcendence. The STS comprises 15 items
This sample consisted of 188 (92% response reflecting expanded boundaries of self, identified
rate) out of 204 long-term residents who met the by intrapersonal, interpersonal, transpersonal,
inclusion criteria. These 188 represented 27 dif- and temporal experiences [109], all of which are
ferent NHs in two large and two smaller urban characteristics of a matured view of life. Each
municipalities in Norway. A total of 88 partici- item is rated on a 4-point Likert-type scale from
pants lived in certified joy-of-life NHs, while 100 1 (not at all) to 4 (very much); higher scores indi-
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 125

cate higher self-transcendence. The STS has been scales for anxiety (HADS-A 7 items) and depres-
translated into Norwegian and validated in NH sion (HADS-D 7 items). Each item is rated from
patients [110] showing a two-factor construct 0 to 3, where higher scores indicate more anxiety
(STS1 and STS2) to be most valid and reliable and depression. The maximum score is 21 on
among NH patients [110]. In the present studies, each subscale. The HADS has shown good to
we applied this two-factor construct. acceptable reliability and validity in the NH pop-
The Purpose-in-Life (PIL) test: Based on ulation [118]. The global question "Do you feel
Viktor Frankl’s [111] logotherapy, Crumbaugh lonely?" assessed loneliness on a scale of 1–4
and Maholick developed the PIL test [112] to (1 = frequent, 2 = occasional, 3 = rare, 4 = never).
assess perceived purpose and meaning-in-life.
The PIL comprises 20 items worded as state-
ments. Each statement is scored from 1 to 7; 4 10.7.5 Analyses
represents a neutral value, whereas the numbers
from 1 to 7 stretch along a continuum from one Due to sample size, all paths were not tested in
extreme feeling to the opposite kind of feeling. one complex SEM model. Thus, different SEM
Higher numbers indicate stronger meaning-in- models of the hypothesized relations between the
life. As part of study 1, the Norwegian version of latent constructs of nurse–patient interaction and
the PIL was validated among NH residents [113], (1) self-transcendence (interpersonal and intrap-
showing good psychometric properties. ersonal) [97], (2) meaning-in-life [55, 119], (3)
The Herth Hope Index [114] assessed hope in hope [120], (4) anxiety and depression [45],
study 1. The Herth Hope Index (HHI) comprises and (5) joy-of-life [105], were tested by means
12 items assessed on a 4-point Likert scale; the of LISREL 8.8 [121] and Stata 15.1 [122], while
HHI was validated among older adults in the assoications with sense of coherenec and
Norwegian NHs and found to have good psycho- loneliness were tested by regression analyses
metric properties [115]. using IBM SPSS Statistics [123].
The Joy-of-life Scale (JoLS) was developed Using SEM, random measurement error is
and validated for use in study 2. The JoLS accounted for and psychometric properties of the
includes 13 items on a 7-point scale ranging from scales in the model are more accurately derived.
1 (not at all) to 7 (very much); higher number At the same time, the direct, indirect, and total
indicating stronger JOL. The JoLS demonstrated effects throughout the model are estimated. SEM
good psychometric properties in the NH popula- models combine measurement models (e.g., fac-
tion [49]. tor models) with structural models (e.g., regres-
The Orientation to Life Questionnaire (OLQ) sion); a major issue is evaluation of model fit.
measured sense of coherence (SOC) [116]. Based The conventional overall test of fit is the chi-
in the salutogenic health theory, Antonovsky square (χ2); a small χ2 and a nonsignificant
(1987) developed the original 29-item OLQ, mea- p-value correspond to good fit [121]. In line with
suring SOC. Later the 13-item short version of the the rule of thumb given as conventional cut-off
OLQ was developed; the Norwegian version of criteria [124], the following fit indices were used:
the short OLQ-13 was used in the present study, The Root Mean Square Error of Approximation
rating the items on a 7-point scale providing two (RMSEA) and the Standardized Root Mean
anchoring verbal responses, e.g., “very seldom or Square (SRMS) with acceptable/good fit, respec-
never” and “very often.” Total score ranges from tively, set to 0.08/0.05 [124, 125], the Comparative
13 to 91; higher scores indicate a stronger SOC Fit Index (CFI) and the Non-­Normed Fit Index
[4, 6]. The OLQ was recently validated among (NNFI) with acceptable/good fit, respectively,
nursing home residents and demonstrated satis- 0.95/0.97, the Normed Fit Index (NFI), Tucker
factory psychometric properties. Lewis Index (TLI) and the Goodness-of-Fit Index
The Hospital Anxiety and Depression Scale (GFI) at 0.90/0.95, and the Adjusted GFI (AGFI)
(HADS) [117] comprising 14 items includes sub- 0.85/0.90 (ibid.). The frequency distribution of
126 G. Haugan

the data was examined to assess deviation from resulted in 8 scientific publications including this
normality; both skewness and kurtosis were sta- chapter, showing among others a significant
tistically significant. As normality is a premise in influence of nurse-patient interaction on sense of
SEM, we corrected for the non-normality by coherence and loneliness. Figure 10.3 summa-
applying the Robust Maximum Likelihood rizes the findings in study 1 and study 2: the
(RML) estimate procedure and stated the Satorra– green arrows illustrate significant direct relations,
Bentler corrected χ2 [126]. while the red tiny dotted arrows demonstrate sig-
nificant mediated relations. Accordingly,
Fig. 10.3 illustrates that nurse–patient interaction
10.8 Findings significantly influences on hope, joy-of-life,
meaning-in-life, interpersonal and intrapersonal
Study 1 (N = 202) demonstrated significant self-­
transcendence, sense of coherence, all
effects of residents’ perceived nurse–patient aspects of well-being, loneliness and physical/
interaction on anxiety and depression [45], mean- mental symptom severity.
ing-in-life [55], interpersonal and intrapersonal Furthermore, intrapersonal and interpersonal
self-transcendence [97], and hope [120]. self-transcendence and meaning have shown direct
Furthermore, the findings showed that the nurse– and/or indirect impact on all the various dimen-
patient interaction is a resource not only for self- sions of well-being, that is, physical, emotional,
transcendence, hope, and meaning [79], but also social, functional, and spiritual well-being. In addi-
for QoL [44], mental health [89], as well as phys- tion, meaning revealed significant associations
ical, emotional, social, functional, and spiritual with symptom severity, physical, and psychologi-
well-being [127] in the NH population. A total of cal functions in the NH population [22]. Therefore,
17 scientific articles have been published based the different SEM models based on study 1 indi-
on study 1, as well as a chapter in an international cated significant mediated influences as illustrated
scientific anthology [127]. Study 2 has so far by the red dotted lines in Fig. 10.3. In short, find-

Fig. 10.3 Summary of the findings from study 1 and study ness and symptom severity. Note: = direct
2. Relationships between nurse–patient interaction and hope, relations (effects); = indirect relationships
joy-of-life, meaning, intrapersonal and interpersonal self- (mediated effects) © Gørill Haugan
transcendence, sense of coherence, well-being, loneli-
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 127

ings from study 1 indicate that the nurse–patient meaning-in-life, hope, joy-of-life, sense of coher-
interaction has significant impact on all dimensions ence, loneliness, anxiety and depression were
of well-being, mediated through hope, meaning, tested, and all of which found support. What does
and self-transcendence (inter and intra). this mean for clinical practice? To elaborate on
Structural equation and regression models this, we should look at how the nurse–patient
based on data from study 2 (N = 188) indicated interaction was assessed. The NPIS includes 14
that the nurse–patient interaction has significant items, measured on a scale from 1 (not at all) to
impact on joy-of-life [105], sense of coherence 10 (very much). The higher the score, the better is
[128] and loneliness [...] [129]. In addition, study the perceived interaction with the nurses.
2 supported the findings of study 1 showing that Figure 10.4 shows in detail which aspects are
the nurse–patient interaction is of great impor- included in the measurement model of nurse–
tance revealing highly significant associations patient interaction; the NPIS includes NH resi-
with both interpersonal and intrapersonal self- dents’ experiences of trust, respect, feeling
transcendence as well as perceived meaning-in- listened to, taken seriously and understood,
life [49]. Figure 10.3 illustrates the significant acknowledged, and recognized as a unique per-
associations in study 1 and study 2. son, as well as included in decisions regarding
one’s life and the experience of meaningful con-
tact. In total, these aspects constitute the older
10.9 Discussion adults’ NPIS scores.
Statistical analyzes showed that residents’
In these two studies, nine hypotheses of direc- experience of these qualities in the nurse–patient
tional relationships of nurse–patient interaction interaction contributed to the experience of self-
with inter- and intrapersonal self-transcendence, transcendence, meaning, hope, joy-of-life, and

Fig. 10.4 Nurse–Patient Interaction Scale (NPIS) assesses perceived nurse–patient interaction. © Gørill Haugan
128 G. Haugan

sense of coherence, and alleviation of loneli- those in power, such as the nurses and other health
ness, anxiety and depression. What is more, posi- care professionals, who have power for both good
tively perceived nurse–patient interaction and bad. The Danish philosopher Løgstrup [137]
strengthens residents’ joy-of-­life [105], meaning- highlighted vulnerability related to being handed
in-life, and self-transcendence [55, 97]; the latter over to others, as the case is in NH care. Løgstrup
two have shown significant impact on physical, [137] underlined the ethical demands arising from
emotional, social, functional, and spiritual well- relationships of power, such as the nurse–patient
being [21, 57, 119, 130–134]. Thus, the interac- relationship; the nurses hold some of the residents’
tion between the nurse and the older adult can be life in their hands. Considering this, relational
used to promote health and well-being. By facili- competence together with competent pain and
tating specific qualities in the interaction with symptom management is crucial for health promo-
their residents, nurses influence on NH residents’ tion in NH care. Relational competence includes
health and well-being. The nurse–patient interac- knowledge and professional skills to use the
tion is a vital health-promoting resource in NH nurse–patient interaction in health-promoting
care. How can this be explained? ways, that is, to carefully observe and competently
influence the older adults, so that health and well-
being increase.
10.9.1 N
 urse–Patient Interaction -
a Salutogenic Resource 10.9.1.1 Practical Implications:
Professionals’ Attention
Initially, this chapter established the salutogenic and Influencing Skills
understanding of health based on man being a Relational competence involves both attentional
unit of body–mind–spirit, where the physical, and influencing skills [138]. Nurse’s attention is
emotional, social, and spiritual/existential dimen- the leading “tool.” Therefore, health-promoting
sions together constitute an integrated entity, in interaction is based on attention-­related skills.
which everything interacts and thus influences The health care professional consciously uses
everything. Accordingly, experiences of meaning and regulates one’s attention; that is, what one
as well as joy-­of-­life, etc. not only affect the emo- sees, hears, feels, smells, senses, and thinks dur-
tional dimension. Since human being is an inte- ing the interaction with the residents. What are
grated wholeness, all experiences affect the you paying attention to? Or where do you direct
human unity of body–mind–spirit. That is, also your attention? Health-promoting interaction
the body—physical well-being and symptom requires awareness skills that are based on an
severity—will be affected by perceived meaning active and openly receiving presence. By a sensi-
and joy-of-life. In fact, meaning and joy are bio- tive presence [88], the professional nurse uses her
chemical states in the body [11]. senses and presence to perceive and receive what
Generally, NH residents have many diseases, is important to the resident, in order to welcome
ailments, fatigue, pain, and dyspnea [135, 136] and attend to what the older adults expresses, ver-
and depend on care and help of nurses to stay well. bally and non-verbally. In this way, nurses create
Many are waiting for death. Missing opportunities trust; a sense of being taken seriously, being
for meaningful activities, several spend a lot of acknowledged and attended to as a real person.
time doing nothing, sleeping, and waiting [33–37], This promotes health and well-being in vulnera-
and social contact with others outside the NH is ble older individuals in NHs. However, nurse–
scarce. Hence, nurses represent the most essential patient interaction is also about fostering a
source of social contact as part of the nursing care. common understanding of what is at stake right
Furthermore, in this life situation, the individual here-and-now; what does the resident think, feel,
might feel vulnerable in interaction and communi- and experience? The resident’s emotions and
cation with others; especially in relationship with experiences should be given attention and under-
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 129

stood by the health care professional. This is how ity to create rapport, i.e., to identify and care for
nurses let the older NH resident become a person, the true essence of the resident’s experience. In
which is highly health promoting. every health professional nurse–patient relation-
Attention skills include being sensitive to the ship, professionals are dependent on their atten-
NH resident’s choice of words, volume, tone, and tion skills. Nurses need attention to get a clear
power in the voice, as well as rhythm of expres- picture of what is at stake, so they can compe-
sion (staccato), tempo (fast-slow, pauses), non- tently and ethically influence the resident’s health
verbal expressions such as a sigh, breath, gaze, and well-­being. Not least, this applies to various
facial expressions, skin color, posture, congru- physical signs such as pain, urinary infection, and
ence, authenticity. There is a wealth of informa- pneumonia, or when caring for a wound. Nurses
tion in such cues [138, 139], which are vital in are aware of several small hints that give valuable
achieving health-promoting nurse–patient inter- information.
action. The instrument of your attention is your- Health-promoting interaction is about competent
self and what you see, hear, feel, and sense. influence, sustaining the boundaries between the
Therefore, health care professionals need to stay two, so respect and dignity are maintained.
well connected with one’s inner self. Still, any Empathic listening providing unconditional
focus of attention will always include something acceptance, recognition, and empathy creates
and consequently exclude something else. experiences of acceptance and respect and can
Therefore, it is important to notice whether undue lead to positive changes and thereby health and
attention is paid or if there is any lack of attention well-being. Nevertheless, attentional skills repre-
to something that should be attended to. An sent impact and thus signify a use of power [138];
example illustrating this point is a resident who such power is part of all relationships between
dares to open up and tell about her loneliness. health professionals and their patients. Openly or
She is crying. What are you as a health care pro- hidden, power, influence, and authority are
fessional paying attention to? The fact told about always integrated aspects of any relationship
her loneliness? Or the emotional expression of between people [88, 137]. Thus, nurse–patient
crying? What are you doing? Are you listening? interaction requires that health care professionals
Do you explore what this is about? Or do you are perceptive of one’s power and how they use it.
start to comfort? There is no facet. But, taking The consideration is not about if or whether
time to listen and explore, allowing the resident power is being used, but how it is used. Wanting
room and space to become clear to herself, would the ­ resident well, unconditional acceptance,
be health promoting and even more soothing than authenticity, and warmth are always the founda-
any well-intentioned comfort. In some cases, tion on which health-promoting interaction is
health professionals’ attempts to comfort become based.
more of a strategy that maintains the problem,
rather than helping to solve it. For example,
focusing on what this old lady is saying about 10.9.2 Competent Health-Promoting
being lonely instead of focusing on her crying Nurse–Patient Interaction
can, paradoxically, cause this lady to feel over-
looked, rejected, and thus feel even more lonely. The focus of this chapter is nurse–patient inter-
Attention to the matter and a cognitive under- action as a health-promoting resource in NH
standing of its content is usually not enough. care; the relational qualities of the nurse–patient
Attention to emotional expressions is usually interaction signify essential influences on resi-
fundamental. This is especially important while dents’ well-being physically, emotionally,
caring for older adults having dementia. socially, functionally, and spiritually. Being
Health-promoting interaction rests on health attentive, communicating, and interacting
professionals’ listening techniques and their abil- respectfully and empathically while making all
130 G. Haugan

possible effort to relieve the old persons’ infirmi-

ties are relational qualities fostering dignity,
wellbeing and confidence in the nurses [140], as
well as encouraging personal goals, values, and
comprehensibility. In light of limited staffing,
taking time for “slow care” as well as emphatical
listening might sometimes prove difficult.
Nevertheless, because this includes the way pro-
fessionals use their eyes, face, voice, hands, and
their body which is not time-consuming by itself,
an accepting and attending way of being present
is not necessarily more time-consuming than an
indifferent presence. Moreover, a relationship Fig. 10.5 The triangle of competence: salutogenesis and
pathogenesis based upon the basis of relational compe-
requires two partakers. That is, the NH resident
tence. © Gørill Haugan
does also have to contribute to the interaction.
However, the professionals should be responsi-
ble for at least 75% of the contact qualities in the Professor Baldacchino [142] emphasized the
nurse–patient interaction, aiming at facilitating “being in the doing.” Health professionals’ way
joy-of-life, sense of coherence, meaning-in-life, of being present while performing various tasks
hope, self-transcendence and thereby well- in collaboration with the NH resident deter-
being. Professional nursing care is determined mines the older adult’s experience of care qual-
by nurses’ use of their knowledge, attitudes, ity. Studies have shown that the perceived
behavior, and communication skills to appreci- qualities in the nurse–patient interaction signifi-
ate the uniqueness of the person being cared for cantly influence on NH residents’ loneli-
[141], which is fundamental for dignity [134], ness, anxiety, depression, hope, meaning, and
meaning-in-life [55], self-transcendence and self-­transcendence, as well as joy-of-life and
well-being [44, 97], loneliness [129], anxiety sense of coherence. This means that by means
and depression [45]. Frustration, suffering, of awareness, tenderness, and attentional skills,
hopelessness, meaninglessness, and loneliness nurse–patient interaction can be used to posi-
result from the experience of not being attended tively influence on patients’ health, QoL, and
to or treated with indifference [96, 102]. well-being, physically, emotionally, socially,
Consequently, health care professionals need and spiritually/existentially. Figure 10.6 illus-
knowledge and skills in health-­promoting inter- trates a tentative theory of how the salutogenic
action; they should utilize their attentional and and pathogenic knowledge together with rela-
influencing skills competently and ethically as tional competence, the “being in the doing,” can
part of any caring situation. Moreover, an explicit influence on NH residents.
and clear integration of the pathogenesis and Health promotion in NHs should be based on
salutogenesis into the health services is needed. integrated knowledge of salutogenesis and patho-
Therefore, this chapter proposes a competence genesis. Competence in pain and symptom man-
triangle where salutogenesis and pathogenesis agement is central in NH care, together with
constitute the sides, while the foundation of the relational knowhow based on awareness and
triangle is relational competence, which usually influencing skills. Health workers, not only in
determines how far health professionals can NHs but in the entire health services, should be
reach in their health-promotion work. Figure 10.5 given the opportunity to further develop their
illustrates the competence triangle, indicating knowledge, relational competence, and interac-
that all three kinds of knowledge (relational, tional skills, in order to “refine” their way of
salutogenesis, pathogenesis) are essential parts of being present together with their patients and
competence in NH care. residents. Health professionals’ competence
10 Nurse-Patient Interaction: A Vital Salutogenic Resource in Nursing Home Care 131

Fig. 10.6 Tentative theory of health promotion interaction in nursing. © Gørill Haugan

should include both the doing and the way of well-being, physically, emotionally, socially,
being in NHs and the health services. functionally, and spiritually.
• Empathic listening, awareness, tenderness,
Take Home Messages and attentional skills are key assets to posi-
• Salutogenesis represents the origin of health, tively influence on NH residents’ health, qual-
while pathogenesis covers knowledge of dis- ity-of-life, and well-being.
ease, risk, and prevention. Salutogenesis and • Nevertheless, empathic listening, awareness,
pathogenesis need to be integrated in a holistic tenderness, and attentional skills also signify a
understanding of human health and use of power; thus, nurse–patient interaction
well-being. requires that health care professionals are per-
• The importance of establishing the nurse– ceptive of their power and how they use it. The
patient relationship as an integral compo- issue is not about if or whether power is being
nent of nursing practice has been well used, but how it is used, which is specified by
documented. The nurse–patient interaction the “being in the doing.”
embodies the foundation of the nurse–patient
relationship.
• Nurse–patient interaction has shown to influence
on nursing home residents’ perceived meaning- References
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 Social Support
11
Jorunn Drageset

Abstract Keywords

Social support by our social network proves to Social support · Social relationships · Health
be important for our health. The opposite of promotion · Sense of coherence · Older
good social support is loneliness. First and people · Social networks
foremost, it seems that social support includes
emotional support, belonging in a social com-
munity, being valued, practical help, and
11.1 Introduction
information and guidance. Social support rep-
resents a vital salutogenic resource for indi-
The concept of social support is multidimen-
viduals’ mental health.
sional and can be incorporated into a larger con-
This chapter explains the concept of social
text termed social capital, where social support
support in relation with other concepts of spe-
and social networks are parts [1]. Social support
cific relevance, such as coping and quality of
and social networks are described in different
life. In a health-promoting perspective, this
ways; mainly these can be presented as (1) struc-
chapter presents the concept of social support
turally and functionally and (2) formally and
and its theoretical basis. A brief description of
informally [2]. Nursing care can, for example, be
questionnaires assessing social support is pro-
a formal support to people who have no close
vided, as well as a brief summary of evidence
friends.
demonstrating the salutogenic potential of
The structural aspect of social support refers to
social support, both as a preventive and a
the existence and size of a social network, and the
health-promoting resource.
extent to which the person is connected within a
social network, like the number of social ties
(quantity of the relationships) and the characteris-
tics of the social exchanges between individuals
(e.g., social support activities, frequency of inter-
actions). Relationships with family, friends, and
J. Drageset (*) members in organizations might contribute to
Western Norway of Applied Sciences, social integration [2, 3]. The functionally/qualita-
Bergen, Norge tive aspect of social support refers to a person’s
University of Bergen, Bergen, Norway appraisals of the social support he or she experi-
e-mail: jorunn.drageset@hvl.no, ence, or how integrated a person is within his or
jorunn.drageset@uib.no

© The Author(s) 2021 137

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_11
138 J. Drageset

her social network; that is, the quality or depth of able if needed, rather than the help and support
the relationships [2, 3]. Furthermore, the specific that is actually received [2, 5, 8, 9].
functions that members in a social network can Based on the relationships between social
provide such as emotional (i.e., reassurance of support, stressful life events, and physical and
worth, empathy, affection), instrumental (i.e., mental health, the literature of social support pro-
material aid), and informational (i.e., advice, guid- poses two models: (1) “buffering support” and
ance, feedback) [2, 4, 5] are also vital aspects of (2) “main support” [2, 10–12]. The first model
social support. Thus, social support refers to the reflects the fact that social support is beneficial
cognitive/functional qualitative aspects of human only under conditions of high stress, that is, the
relationships, such as the content and availability buffering effect. This means that individuals with
of relationships with significant others, whereas a high level of perceived social support will have
social network refers to the quantitative and struc- fewer negative health effects following stressful
tural aspects of these relationships [2, 5]. events than those with a low level of perceived
Social support occurs in the presence of a social support. The second model states that
social network [2, 6]; the concept is often used in social support is beneficial regardless of an indi-
a broad sense, referring to any process through vidual’s level of life stress and predicts positive
which social relationships might provide health influences of social support on physical and men-
and well-being [2, 7]. Reviewing the literature tal health, independently of the presence and the
reveals that social support is understood from a absence of stressful events [2, 10–12].
subjective viewpoint, including emotional sup- In his salutogenic theory of health, Antonovsky
port, esteem support, social integration or net- [13] introduced the concept of “sense of coher-
work support, provision of information and ence” (SOC) as a global life orientation of viewing
feedback and tangible assistance [2, 4, 5]. the world and one’s environment as comprehensi-
Measures that reflect each dimension of social ble, manageable, and meaningful. Antonovsky
support are therefore needed [4]. (1987) claimed that the way people view their life
Researchers have commonly made a distinc- influences on their health. These three elements,
tion between perceived and received support [2, comprehensibility, manageability, and meaning-
3, 8]. Perceived support refers to a person’s sub- fulness, formed the concept of SOC. Another salu-
jective judgment that will give help or have given togenic concept is general resistance resources
help during times of need. Received support (GRR), involving aspects such as knowledge,
refers to specific support (e.g., advice) that is intelligence, coping strategy, and social support.
given if needed, actually provided to the person The GRRs are characterized by consistency, par-
[2, 5, 8]. The different, specific types of social ticipation in shaping one’s outcome, and a balance
support that an individual may experience include between underload and overload. These resistance
emotional support (listening support, comfort, resources are shaped by life experiences and rein-
and security), informational support (advice and force the SOC. Social support is a GRR that builds
guidance), esteem support (increasing the per- up a strong SOC which in turn has proven to have
son’s sense of competence), and tangible support a buffering and key effect on health [12].
(concrete assistance such as providing transpor-
tation or financial assistance). These different,
specific types of social support have shown dif- 11.2 Theoretical Approaches
ferent correlations with health and personal rela- to the Concept of Social
tionships; only perceived support is consistently Support
linked to better mental health, whereas received
support and social integration are not found to 11.2.1 Social Capital
relate with health [9]. Accordingly, there is an
agreement in the literature that the only aspect of Putnam, Leonardi, and Nanetti [14] make a dis-
social support that is linked to health outcomes is tinction between two kinds of social capital:
perceived support, or the belief that help is avail- bonding capital and bridging capital. Bonding
11 Social Support 139

capital occurs when you are socializing with peo- types of relationships usually provide each of the
ple who are alike you: same age, same religion, social provisions (attachment, social integration,
and so on (interconnecting dimensions). Bridging opportunity for nurturance, reassurance of worth,
is what you do when you make friends with peo- guidance, and reliable alliance). Deficits in the
ple who are not like you (e.g., between genera- specific provisions might lead to loneliness, bore-
tions). These two kinds of social capital, bonding dom, low self-esteem, and anxiety. As older peo-
and bridging, do strengthen each other. ple experience changes in close relationships,
Coleman [15] describes social capital as a sup- failing health, or death of a spouse or friends,
port that facilitates an individual’s or a collective’s Weiss’ concept of social provisions appears to be
action generated by networks of relationships appropriate for understanding the relationships
through reciprocity, trust, and social norms, between social interaction and psychological well-
depending entirely on the individuals. That means being among older adults [19]. To the extent that
that an individual can use these embedded deficits in social provisions affect health, social
resources whenever needed. Social capital is support may affect health-related quality of life
thereby inherent in the structure of relations directly through the dimensions of emotional sup-
between individuals [1, 15]. port, network support, and esteem support. The six
provisions are described as follows:

11.2.2 Social Relationships 1. Attachment

and Social Provisions Theory (a sense of emotional closeness and secu-
rity often provided by a spouse or romantic
Weiss’s [16] theory of social relationships incorpo- partner).
rates six major elements/provisions of the most 2. Social integration
current conceptualizations of social support which (a sense of belonging to a group that shares
are (1) attachment, (2) social integration, (3) oppor- common interests and activity, often provided
tunity for nurturance, (4) reassurance of worth, (5) by friends).
guidance, and (6) reliable alliance proposed by 3. Opportunity for nurturance
theorists in this area. Hence, Weiss theory com- (a sense of responsibility for the well-being
pares the six social provisions with the dimensions of another person, often obtained from
of social support that have been described by other children).
authors [4, 5, 17]. The theory of social relationships 4. Reassurance of worth
by Weiss focuses on the person’s need to interact (acknowledgement of one’s competence
with others. The theory differentiates between pri- and skill, usually obtain from co-workers).
mary and secondary relationships. The former 5. Guidance
comprises close, warm, and frequent relationships (advice and information, usually obtained
and is obtained from family and friends. The latter from teachers, mentors and parents).
includes working relationships of less emotional 6. Reliable alliance (the assurance that one can
importance than the primary ones, although it has count on people for assistance under any cir-
great influence [16, 18]. Weiss [16] describes six cumstances, usually obtained from close fam-
different social relationships/provisions that must ily member).
be obtained through relationships with other peo-
ple, and all provisions are needed for an individual
to feel adequate support. Each of the six provisions 11.3  he Measurement of Social
T
is usually obtained from a specific kind of relation- Support
ship, but several may be obtained from the same
person. Different provisions may be critical at dif- So far, this chapter has shown that social support
ferent stages of the life cycle. is important for both mental and physical health.
Weiss’ concept of social provisions includes Therefore, regardless of illness and age, the eval-
the functioning of social networks; that certain uation of social support is often part of interview
140 J. Drageset

surveys about health in the general population Antonovsky introduced the salutogenic con-
and among patients. The questionnaires assess- cept Sense of Coherence (SOC) [13, 24]. The
ing social support cover subjective experiences of salutogenic health theory was founded on the
social support. The Social Support Scale (OSS-3) basic idea of what creates health; the concepts of
(WHO Regional Office for Europe: EUROHIS, SOC and generalized resistance resources
2003) is a three-question form commonly used in (GRRs) represent the central ideas of
the general population. This scale contains ques- Antonovsky’s salutogenesis [13, 24]. These con-
tions about “number of close people,” “interest cepts harmonize well with the philosophy of the
from others,” and “help from neighbors.” The Ottawa Charter in 1986 [25, 26] stating health as
responses are grouped into weak, medium, and a process enabling people to develop health
good social support according to the scores on through their assets and thus having the opportu-
each of the three questions in the OSS-3 [20]. nity to lead a good life. The way people view the
Another form is the Social Provisions Scale world affects their ability to manage tension and
(SPS) which is often used in clinical settings, stress. The outcome (health) depends on per-
across diagnosis and ages [4]. This form builds on ceived SOC and the GRRs available, i.e., mate-
Weiss’ theory of social relationships and the six rial, ego identity, and social support [27]. The
provisions of social support (reliable alliance, SOC consists of three dimensions: comprehensi-
guidance, affiliation, social integration, self-­ bility, manageability, and meaningfulness,
esteem affirmation, and the opportunity to mean reflecting the interaction between the individual
something to others/provide care). This scale has and the environment. Evidence shows that SOC
24 questions, four for each of the six sub-­ is strongly associated with perceived health,
dimensions. The 24 questions are presented in the especially mental health [12, 27]. Furthermore,
form of statements rated from “Strongly Disagree,” SOC has demonstrated a main, moderating, or
“Disagree,” “Agree,” and “Strongly Agree.” The mediating role in the explanation and prediction
SPS also exists in a shorter version including 16 of health among adult in Swedish and Finnish
questions covering “affiliation,” “social integra- population [12, 27].
tion,” “affirmation of self-worth,” and “opportu- Social support is a vital generalized resistance
nity to mean something to others/care.” This resource and thereby seen as a salutogenic con-
16-item short version is most often used among cept [28]. Close supportive relations is according
older people. The16-item version scale has proven to Antonovsky [13], a prerequisite for developing
to be a valid and reliable instrument when used a strong SOC. The importance of the different
among older people living in the community [21, aspects of supportive relations or dimensions of
22] and in nursing homes [22, 23]. social support can vary among different popula-
tions. A systematic review showed that social
support from spouse, friends, and health
11.4 Social Support and Health ­professionals was an important factor in estab-
Promotion lishing and maintaining healthy habits for nutri-
tion and lifestyle in people diagnosed with
Social support has proven to be health promoting diabetes [29]. Social support from close friends
by strengthening individual’s coping abilities, has also shown a positive effect on mental health
health, and quality of life while facing stress; problems in older people (aged 65 years or older)
these associations have been seen in many differ- and is described as a “buffer” between mental
ent populations of both healthy and sick people disorders and physical impairments such as hear-
[13, 24, 25]. The salutogenic nursing approach ing impairment. In the same study, social support
focuses on identifying the individual’s health was significant independently associated with
resources and actions to promote the person’s psychological distress [30]. Wang, Mann, Lloyd-­
health processes toward the positive side of the Evans, Ma, and Johnson [31] found substantial
disease/ease-continuum [13]. evidence from prospective studies that people
11 Social Support 141

with depression who perceive their social support iety, depression, hope, meaning, and self-­
as poorer have worse outcomes in terms of transcendence [37–40]. These studies indicate
depressive symptoms, recovery, and social func- that the relational qualities embedded in the
tioning. Further, studies show that social support nurse–patient interaction have a health-­promoting
perceived as emotional support, and reassurance influence.
of one’s worth, is important for quality of life and Lämås and colleagues [41] conducted a cross-­
loneliness among older nursing home patients sectional study of 136 participants (mean 82 years)
with and without cancer as well as in home-­ showing that participation in social relations and
dwelling older adults [23, 32, 33]. Kvale and the experience of self-­determination in activities in
Synnes [34] found that, by providing good care, and around the house are significantly associated
health care personnel performed to be a vital with thriving. Moreover, the experience of social
resource strengthening cancer patients’ general support has been found to be health-promoting
resistance resources in a stressful life situation. among people 75 years or older living at home; the
Nurses, doctors, family, and friends functioned as frequency of home nursing was important for
vital resources at these individuals’ disposal health promotion [21]. People with higher educa-
when needed; thus, nursing care can be a specific tion who experienced good social support reported
resistance resource buffering stress [34]. The less need for home care than those who did not
studies listed above signify the significance of experience good support [21]. This indicate that
having one special person in one’s life to be con- besides higher education, support from social net-
fident in and feel appreciated by. This special work is health promotion.
relationship involves being listened to so that the In summary, based on this literature review,
person feels understood, seen, accepted, acknowl- social support has shown to significantly impact
edged, and confirmed. This kind of emotional on psychological distress, quality of life, loneli-
support creates a sense of security and well-being ness, burden of care, as well as anxiety, depres-
and thus acts as a health promotion resource. sion, hope, meaning, self-transcendence, and
Social support and the quantity of close rela- mortality risk. Social support has also shown to
tionships are of great importance for mortality be a “buffer” between mental disorders and phys-
risk. A group of older adults (N = 2.347) who ical impairments. Thus, based on the existing evi-
were examined about close friends/family, mari- dence, social support shows to act as a vital health
tal status, and mortality three times over 10 years promotion resource representing a salutogenic
disclosed that widowed older adults who had concept.
fewer than 4–6 close relationships had a signifi-
cantly increased risk of death 10 years later com-
pared to their married counterparts [35]. Clearly, 11.5  ow Can the Health Service
H
the social relationships serve a critical role in Contribute to Social Support
overall health and well-being. of Older Persons
Furthermore, research shows that social sup- and Relatives?
port is important for the burden of care among
older people giving care to a partner with demen- 11.5.1 Clinical Implications
tia. A cross-sectional observation study of 97
individuals, ≥65 years old living with a partner The quality of social support from family and
having symptoms of dementia, showed that lower friends as well from caregivers is a vital resource
level of burden of care was significantly related in health promotion for older people.
with higher level of attachment and higher level Consequently, knowledge about social support is
of SOC [36]. Similarly, the findings from a study important for health care workers providing care
of cognitively intact nursing home residents and treatment in all ages. This knowledge should
(mean age 85 years) showed a strong positive be included in different health educations as well
correlation of nurse–patient interaction with anx- as to health care leaders.
142 J. Drageset

Quality of care for the elderly requires good vating the person to use these available resources
competence and knowledge of the importance of despite any limitations.
psychosocial care for health and well-being. Regarding instrumental support (information
Attention should be made to the importance of and guidance), professionals should provide
facilitating the opportunity to maintain contact health care information to the person in a way
with family (i.e., spouse, children) and close that is easy for them to understand.
friends. Emotional support from significant oth- The evidence shows both a “main” and “buf-
ers has proven to be important for health and fer” effect of social support as important health-­
well-being, embodying a salutogenic health promoting resource in maintaining health and
resource. Health care professionals should facili- well-being. What type of support that has “main”
tate, safeguard, or improve social support and, if or “buffering” effect can vary among situations
necessary, provide social support. The starting and different persons and population. The most
point must be based on each person’s needs, important is that the only aspect of social support
ensuring that the patient’s autonomy and integ- that is linked to health outcomes is perceived sup-
rity are respected. port, or the belief that help is available if needed,
The different, specific types of social support rather than the help and support that is received.
(attachment, social integration, opportunity for
nurturance, reassurance of worth, guidance, and
reliable alliance) have certain types of relation- 11.6 Conclusion
ships that are usually provided to each of the
social provisions. Social support involves that you experience secu-
Appropriate strategies to ensure emotional rity and closeness, can have the opportunity to
support (the need for love and friendship) can be care for others, that you belong to a social net-
to ask the person if he/she has one or more confi- work, feel respected and valued, and participate
dants and then facilitate social contact based on in a community with mutual obligations. The
the needs and wishes. Spend time and meeting opposite of social support is loneliness. Our
the patient where he/she is based on the care social network has an impact on our health. First
needs. The emotional support creates a sense of and foremost, it seems that social support
security and well-being and thus acts as a health includes emotional support, belonging in a social
promotion resource. To ensure network support community, being valued, practical help and
(need for affiliation) could be to facilitate social information, and guidance which are the health-­
contact with friends and significant others, with promoting factors.
patients and other residents (for those living in
nursing homes), and motivate the patient to take Take Home Messages
the initiative and participate in social contexts. • The concept of social support is multidimen-
Further, being valued (support when it comes to sional and can be incorporated into larger con-
self-esteem), nursing care personnel should be text termed social capital, where social support
aware of the importance to help and support the and social networks are parts.
person’s self-esteem in their daily contact, i.e., • Social support can be categorized and mea-
the care should be based on the people’s needs sured in several different ways, where emo-
and not on what care personnel believe they need, tional support, belonging in a social
because the person’s autonomy and integrity community, being valued, practical help, and
should be respected. information and guidance are the common
Concrete support (practical help) could be functions.
done by identifying the person’s previous • According to the salutogenic health theory, social
strengths and the internal and external resources support is a general resistant resource which can
that are currently available and helping and moti- influence on people’s sense of coherence.
11 Social Support 143

• Social support is a predictor of physical and 11. Cohen S. Social relationships and health. Am Psychol.
2004;59(8):676–84.
mental health, and a buffer that protects (or 12. Eriksson M, Lindstrom B. Antonovsky’s sense of
“buffers”) people from the bad effects of coherence scale and the relation with health: a sys-
stressful life events (e.g., death of a spouse, tematic review. J Epidemiol Community Health.
relocation). 2006;60(5):376–81.
13. Antonovsky A. Unraveling the mystery of health: how
• Positive associations between social support people manage stress and stay well. San Fransisco:
and individual’s coping abilities, health and Jossey-Bass; 1987.
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found in many different populations of both racy work: civic traditions in modern Italy. Princeton,
NJ: Princeton University Press; 1994.
healthy and sick people. 15. Coleman JS. Social capital in the creation of human
• Social support has shown to significantly capital. In: Networks in the knowledge economy;
impact on psychological distress, quality of 2003. p. 57–81.
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Rubin Z, editor. Doing unto others. Englewood Cliffs,
iety, depression, hope, meaning, self-­ NJ: Prentice Hall; 1974. p. 17–26.
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 Self-Efficacy in a Nursing Context
12
Shefaly Shorey and Violeta Lopez

Abstract 12.1 Introduction

Self-efficacy is one of the most ubiquitous
term found in social, psychological, counsel- Albert Bandura derived the concept of self-­
ling, education, clinical and health literatures. efficacy from his psychological research [1].
The purpose of this chapter is to describe and Based on Bandura’ self-efficacy theory [2] which
evaluate self-efficacy theory and the studies was later renamed social cognitive theory, self-­
most relevant to the nursing context. This efficacy was defined as the individual’s percep-
chapter provides an overview of the develop- tion of one’s ability to perform particular
ment of self-efficacy theory, its five compo- behaviours through four processes [3] including
nents and the role of self-efficacy in promoting cognitive, motivational, affective and selection
emotional and behavioural changes in a per- processes. The stronger their cognitive percep-
son’s life with health problems. This chapter tion of self-efficacy, the higher they set their
also discusses the role of self-efficacy in nurs- goals and commitment to achieve these goals [4].
ing interventions by providing examples of Through cognitive comparisons of one’s own
studies conducted in health promotion in standard and knowledge of their performance
patients and academic performance of nursing level, people will choose what challenges they
students. have to meet and how much effort is needed to
undertake or overcome those challenges.
Keywords Motivation based on goals leads to perseverance
to accomplish their goals. Perceived self-efficacy
Self-efficacy · Nursing · Health promotion determines their level of motivation [5]. People’s
affective processes influence how they control
and manage threats such as stress and depression
in life and thus a strong source of incentive moti-
vation. It has been reported that affective pro-
cesses have dual motivating roles. The more
S. Shorey (*) self-satisfaction people have, the more motivated
Alice Lee Centre for Nursing Studies, National they are in accomplishing their goals. On the
University of Singapore, Singapore, Singapore
other hand, the more self-dissatisfied people are,
e-mail: nurssh@nus.edu.sg
the more heightened efforts they will do to
V. Lopez
accomplish their set goals [6]. Thus, in social
School of Nursing, Hubei University of Medicine,
Shiyan, China cognitive theory, Bandura [3] believes that self-­

© The Author(s) 2021 145

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_12
146 S. Shorey and V. Lopez

efficacy plays a major role in self-regulation in ceived subjective judgement on the effective exe-
appraising and exercising control over potential cution of a course of action.
threats. Through the selection process, people Self-efficacy theory has also been linked to
can select beneficial social environments and intrinsic motivation theory [12]. Bandura [7, 11]
exercise control over them as they can judge their purported that people must serve as agents of
capability of handling challenging activities [7]. their own motivation and action. Self-motivation
relies on goal setting and evaluation of one’s own
behaviour which operate through internal com-
12.2 Self-Efficacy Theory parison processes [13]. Motivation predicts per-
and Other Psychological formance outcomes as it is concerned with what
Theories task people want or need to accomplish and suc-
cessfully achieving it to have incentive value that
Self-efficacy theory has been compared to other is satisfying and pleasurable [9].
theoretical models mostly among psychological
theories on explaining human behaviour so as to
place self-efficacy in a larger context. 12.3 Sources of Self-Efficacy
­Self-­efficacy relates to how a person perceives
his or her ability to feel, think, motivate and act Bandura [14] emphasised the four major sources
upon to change particular behaviour. The person of self-efficacy. First is through mastery experi-
processes, weighs and integrates diverse sources ences in overcoming obstacles. Mastery experi-
of information concerning his or her capability ences build coping skills and exercise control
and integrates choice behaviour and effort expen- over potential threats. Second is through various
diture accordingly [1]. Expectations concerning experiences provided by social models and see-
mastery and efficacy their ability to perform such ing people similar to themselves who are suc-
activities are related to how they see themselves cessfully performing similar behaviours. These
in terms of self-concept and self-esteem. Self-­ experiences are considered as the most influenc-
concept is a term used to describe the person’s ing source of efficacy. Third is their own belief
attitudes and beliefs about the self and what he or that they have what it takes to succeed. Fourth is
she is capable to doing well. On the other hand, altering their negative emotions and misinterpret-
self-esteem is one’s evaluation of their beliefs ing their physiological states. Physiological state
and assessment of their value as a person. If a can affect the level of self-efficacy when they
person’s assessment of their self-concept and interpret their somatic symptoms based on aver-
self-esteem is high, the more they will be able or sive arousal [7, 15]. People who believe they can
competent enough to change their behaviour. manage these threats tend to be less disturbed by
Self-efficacy is also compared to locus of con- them [16].
trol which refers to a person’s belief that one is
capable of controlling outcomes through one’s
own behaviour [8]. People’s locus of control can 12.4 Concept Analyses
either be affected by external or internal forces. of Self-Efficacy
Self-efficacy focuses on the person’s belief in the
ability to perform a specific task, and having a Concept development is an important process to
feeling of success and accomplishment is a form generate nursing knowledge which ultimately
of reinforcement to effect behavioural change be used to build evidence-based practice [10].
and an example of internal locus of control [9, Self-­efficacy has been identified as a middle-
10]. Bandura [7, 11] argued that locus of control range theory, that is recognised as a predictor of
is a kind of outcome expectancy as it is concerned health behaviour change and health mainte-
about whether a person’s behaviour can control nance [17]. There are many publications in
outcomes. Self-efficacy expectancy refers to per- nursing literature regarding the broad concept of
12 Self-Efficacy in a Nursing Context 147

self-efficacy. In general, and as used across dis- competence must all be present for symptom
ciplines, the concept of self-efficacy has been management. White et al. [22] reported that the
described as self-­ regulation, self-care, self- consequences of having low self-efficacy in
monitoring, self-management and self-monitor- patients with cancer leads to increased distress,
ing [18]. The concept of self-efficacy has been depression and anxiety, interference with treat-
analysed extensively in different nursing and ment and potential for untreated malignancies.
education disciplines to provide an in-depth As self-efficacy for managing cancer symptoms
understanding of the theory’s applicability. A is influenced positively or negatively, utilising
number of methods such as Rodgers, Walker individual care plans based on the attributes,
and Avant [19] and Wilson [20] have been used antecedents and consequences of self-efficacy
to conduct concept analysis of self-efficacy in concept among these patients is needed.
terms of its defining attributes, antecedents and Sims and Skarbek [24] conducted concept
references. Below are some of the examples of analysis of self-efficacy to examine if the levels
concept analyses in nursing. of parental self-efficacy are correlated with nurs-
Liu [21] analysed the concept of self-efficacy ing care delivery and developmental outcomes
and its relationship with self-management among for parents and their infants. As with White et al.
elderly patients with type 2 diabetes in China [22], confidence (the ability to trust oneself) and
using Walker’s and Avant [19] method. The anal- competence (the ability to perform in a given
ysis found that the defining attributes of self-­ situation) emerged as the most prominent defin-
efficacy among this population were “cognitive ing attributes of parental self-efficacy. Previous
recognition of requisite specific techniques and experiences with infants and observational learn-
skills, perceived expectations of outcomes of ing were found to be antecedents of parental self-­
self-management, sufficient confidence in their efficacy, and the consequences included “parental
ability to perform the self-management, and sus- satisfaction in parenting role, parental well-­being,
tained efforts in diabetes management” (p. 230). positive parenting skills and beneficial health
Liu [21] found that the consequences of self-­ outcomes for children” (p. 11). They recom-
efficacy among the Chinese elderly with type 2 mended further research to survey objective par-
diabetes were adherence to the prescribed regi- ents’ level of confidence with parenting and level
men and successful management of the disease of comfort in their role.
which were influenced by having relevant knowl- Using Rogers’ [25] concept analysis method,
edge about diabetes, family support and learning Voskuil and Robbins [26] examined the concept
from other similar cases with diabetes. of youth physical activity self-efficacy due to the
White et al. [22] analysed the concept of self-­ decline in physical activity from childhood to
efficacy in relation to symptom management in adolescents. They defined physical activity as
patients with cancer. If cancer patients are not “complex, multi-dimensional behaviour that
able to manage their symptom, the outcomes involves bodily movement produced by the con-
would be increased symptom distress, poor prog- traction of skeletal muscle with resultant
nosis, decreased quality of life (QoL) and sur- increases in physiological attributes, including
vival [23]. White et al. [22] also used Walker’s energy expenditure above the basal metabolic
and Avant [19] concept analysis method to deter- rate and physical fitness” (p. 2004). They found
mine the antecedents, defining attributes and con- that youth self-efficacy involves self-appraisal
sequences. For the patients with cancer, the process in their belief and action about their
attributes of self-efficacy are cognitive, affective capability for physical activity. The antecedents
processes, motivation, confidence, competence include prior and current physical activity experi-
and awareness of how they perceive and evaluate ences, modelling of physical activity by other
the symptoms. Symptom awareness and manage- youths and strong social support networks. There
ment decisions are affected by the patients’ emo- are of course positive and negative consequences
tions and distress. Motivation, confidence and of physical activity self-efficacy in youth. For
148 S. Shorey and V. Lopez

example, physiological state in children with car- on identifying problems or diseases and only
diac defect can lower self-efficacy while mastery attempting to solve them [31, 32]. One of the
and satisfactory experiences from participating in major concepts of the salutogenic theory is the
sport result in higher self-efficacy. The authors sense of coherence, which refers to an individu-
suggested that examination of the development al’s ability to adopt existing and potential
of physical activity self-efficacy is needed as well resources to counter stress and promote health. It
as developing theory-based interventions is measured based on one’s perceived value of the
designed to increase the sources of self-efficacy outcome of the behaviour (meaningfulness),
and physical activity self-efficacy to promote one’s belief that the behaviour will actually lead
physical activity among youth. to that outcome (comprehensibility), and one’s
Self-efficacy is also a concept used in nursing capability of successfully performing the behav-
education to bridge the theory–practice gap [27], iour (manageability), of which Antonovsky [32]
acquisition of clinical skills, critical thinking and drew analogous comparison to the three condi-
overall academic success [28, 29]. Robb [30] tions for self-efficacious behaviour: self-efficacy
conducted a concept analysis of self-efficacy to beliefs, behavioural efficacy beliefs and the value
identify behaviours needed for students’ goal of anticipated outcomes [33]. The salutogenic
attainment. It was noted that clinical simulations, approach has much in common with Bandura’s
cooperative learning and personalised classroom self-efficacy theory [1] that highlighted perceived
structure influence students’ level of self-­efficacy. self-efficacy’s crucial influence on choice of
Students utilised Bandura’s [2] concept of vicari- behavioural settings. Antonovsky [32] drew ref-
ous experiences by relying on theory learned erence to it stating how an individual with a
from the classroom, clinical experiences and by strong sense of coherence would more likely
observing other nurses and their teachers perform choose to enter situations without evaluating it as
certain procedures successfully. Verbal persua- stressful, or in stressful situations, would appraise
sion from teachers is often the sources of self-­ a stressor as benign. Under the salutogenic
efficacy in nursing education. Robb [30] found umbrella, self-efficacy is one of the key compo-
that students’ low level of self-efficacy requires nents that drive health-promoting practices,
emotional and academic support and suggested behaviour and self-care management [34–37]. In
that nurse educators should be aware of the strat- a recent study, self-efficacy is found to be posi-
egies used by millennial students to gain infor- tively related to sense of coherence, with this
mation and how they provide feedback about association being the strongest among people
students’ performance. with low sense of coherence [38]. Additionally,
self-efficacy was found to have either a signifi-
cant direct effect on behaviours [39–41] or it
12.5 Self-Efficacy in Nursing becomes a mediator between other psychological
Research factors and health behaviour [42, 43].
An electronic search was conducted on four
Self-efficacy theory has been receiving much databases (PsycInfo, PubMed, Embase and
attention as a predictor of behavioural change Cinahl) for English language articles that were
and self-care management in health-related and published from each database’s inception up to
educational research. This may be partially attrib- December 2019. Keywords used revolved around
uted to the shift in the health care paradigm from the concept of self-efficacy in nursing and health
a disease-centred (pathogenic) to a health-­centred care, such as “self-efficacy”, “chronic disease”,
(salutogenic) orientation. The salutogenic orien- “nursing education”, and “patients”. The search
tation emphasises personal well-being and an generated a repertoire of studies, which primarily
ideal state of health as the ultimate goals and involved patients with chronic illnesses, parents
works towards achieving these, as opposed to the during the perinatal period, nursing or medical
pathogenic approach, which is primarily based students, and the youth or elderly population.
12 Self-Efficacy in a Nursing Context 149

12.5.1 U
 se of Self-Efficacy in Health service burdens but also health care utilisation
Promotion Among Patients [36, 62, 63].
with Chronic Illness In terms of patient self-care and management,
there is substantial evidence confirming the rela-
For patients with chronic medical conditions tionship between self-efficacy (both general and
(e.g. sickle cell disease, asthma, cardiovascular specific, e.g. pain self-efficacy) and self-­
disease (CVD), inflammatory bowel disease, management behaviours. Studies have identified
cancer), higher levels of self-efficacy to manage a positive relationship between self-efficacy and
their own chronic conditions are related to higher opioid or medication adherence [61, 64–67],
health-related QoL [44–48], reduced perceived increased communication, partnership, self-care
stress [49–51], lesser anxiety and depressive [37, 65] and positive patient-centred communica-
symptoms [47, 48, 52] and lower symptom tion [68, 69]. A diabetes study reported diabetes
­severity [48, 53] and also predict symptom reso- management self-efficacy as the only predictor of
lution [49]. Similar results were found in mental diabetes control [70]. Higher education level and
illness studies examining unipolar and bipolar receiving health education were shown to boost
disorders, where higher self-efficacy was posi- management self-efficacy that was associated
tively related to mental and physical health- with self-care activities (i.e. nutrition, medica-
related QoL [54, 55]. Conversely, a study on tion, physical exercise) and glycaemic control
multi-morbid primary care patients reported that [70]. This also holds true for cancer patients,
lower self-­efficacy and higher disease burden where self-efficacy and social support directly
leads to lower QoL [56]. The notable two-way and indirectly affected self-management behav-
relationship between certain predictors and out- iours, specifically, patient communication (e.g.
comes highlights the complexity of addressing communicating concerns, asking questions,
patient self-efficacy. expressing treatment expectations), exercise and
Given the rise in the ageing population and an information seeking [71]. Pertaining to patients
increasing prevalence of chronic diseases [57], with physical disabilities, social functioning,
patient empowerment is imperative to reduce stronger resilience and less pain and fatigue were
health care burden. Community and individual strongly associated with disability management
empowerment are one of the key health promo- self-efficacy [72], which is crucial for increasing
tion principles stated in the Ottawa Charter for odds of employment among disabled youths [73].
health promotion that focuses on enabling peo- Studies have identified a few predictors of
ple to exercise more control over their health, self-efficacy among patients with chronic dis-
environment and health choices [58]. Besides, an eases such as duration of diagnosis, severity of
intervention study using an empowering self-­ disease symptoms, age, availability of social sup-
management model that focused on self-­ port and health education, and absence of com-
awareness, goal setting, planning, adjusting plications and depression [74–77]. Of these
physical, psychological and social structures, variables, availability of social support and
and evaluation was found to improve self-effi- healthy literacy can easily be manipulated
cacy and sense of coherence among elderlies through intervention programs. Most studies
with chronic diseases [59]. In particular, self- have found a positive relationship between self-­
efficacy is strongly related to the competence efficacy and health literacy, especially functional
component of the empowerment concept, and it health literacy [77–81], but there are a few that
plays a critical role in the initiation and mainte- found no significant associations between self-­
nance of positive behaviour change and is a vital efficacy and health literacy [75, 82]. In addition,
mechanism for effective self-management [39, social support is a major factor affecting patients’
60, 61]. Higher self-efficacy results in better self-efficacy and self-management behaviours.
management, which leads to improved Apart from boosting self-efficacy and self-­
self-­
health outcomes that not only reduce health care management [71, 83, 84], higher social support
150 S. Shorey and V. Lopez

was shown to reduce difficulties in medical inter- social support, and patient–provider trust and
actions among breast cancer patients [85] and communication in self-management behaviour,
enhance well-being among diabetes patients promoting interventions for patients with chronic
[84]. Therefore, it is necessary for health care and diseases and their caregivers.
educational interventions to include components
of social support, health education when target-
ing patients’ management self-efficacy. 12.5.2 Role of Self-Efficacy
According to a recent review by Allegrante in Parental Outcomes
et al. [62], much of the empirical research and in the Perinatal Period
reviews that have been conducted on the effec-
tiveness of interventions to support behavioural The emergence of self-efficacy studies on new
self-management of chronic diseases have parents or parents during the perinatal period has
demonstrated small to moderate effects for
­ revealed the association of self-efficacy with
changes in health behaviours, health status, and childbirth and psychological well-being and
health care utilisation for certain chronic condi- childbirth outcomes. During pregnancy, maternal
tions. Such interventions that targeted or exam- childbirth self-efficacy is positively correlated
ined self-­ efficacy as an outcome included with vigour, sense of coherence, maternal sup-
web-based, mobile app-based and face-to-face port and childbirth knowledge, and negatively
educational training or programs. In Chao et al.’s correlated with history of mental illnesses [92–
[86] study, a cloud-based mobile health platform 94]. Moreover, maternal childbirth self-efficacy
and mobile app service for diabetic patients to affects maternal well-being during pregnancy in
self-monitor progress and goals set was found to terms of negative mood, anxiety, depressive
increase self-­efficacy, improve health knowledge symptoms and fear of childbirth [93–96]. The
and increase behaviour compliance rate, espe- level of maternal self-efficacy also influences
cially in women. Ali and colleagues [87] reported birth choices, with elective caesarean and higher
higher pharmaceutical knowledge, patient satis- dosage of analgesic epidural during childbirth
faction and self-­efficacy among cardiovascular being more common among mothers with lower
disease patients who were qualified to self- childbirth self-efficacy [92–94, 97]. In order to
administer medication, as compared to those who better prepare mothers for childbirth, few studies
were just provided educational brochures by have adopted a blended approach of antenatal
nurses. In another study [88], an 8-week Patient mindfulness practice and skill-based education
and Partner Education Programme for Pituitary programs, which was effective in improving
disease (PPEP-Pituitary) was found to increase childbirth self-efficacy, mindfulness, reducing
patient and partner’s self-efficacy. Self-care fear of childbirth, stress, antenatal depression,
behaviour and self-efficacy of asthma patients and opioid analgesic use [98–100]. The mindful-
also improved after attending a self-efficacy ness programs also saw a reduction in postnatal
intervention constituting educational videos, depression, anxiety, and stress [98, 99]. Other
resources, social support group and phone-based studies that implemented antenatal psychoeduca-
medical follow-up [89]. Other interventions tion programs also report increase in childbirth
focused on caregivers’ self-efficacy by providing self-efficacy among mothers and reduction in
caregiver trainings and stress management train- fear of childbirth [101, 102].
ings, which were effective in improving caregiv- After childbirth, receiving informal social
ers’ self-efficacy in managing patients’ support is essential for maternal parenting self-­
symptoms, reducing caregiver stress and increas- efficacy, which helps to reduce risk of postnatal
ing preparedness in caregiving [90, 91]. The depression [103]. A study by Salonen et al. [104]
effectiveness of these interventions in improving comparing parenting self-efficacy levels between
self-efficacy suggests the importance of educa- mothers and fathers revealed that mothers tend to
tion, progress monitoring, information resources, score higher than fathers on parenting self-­
12 Self-Efficacy in a Nursing Context 151

efficacy. Age, multiparity, presence of depressive ies seek to develop educational or support pro-
symptoms, perception of infant’s health and con- grams to promote breastfeeding. During
tentment, and quality of partner relationship were pregnancy, antenatal educational interventions
shown to be significant predictors of parenting using breastfeeding workbook or videos and
self-efficacy in mothers and fathers [94, 104, demonstrations have shown to be effective in
105]. Parenting self-efficacy not only is crucial increasing mothers’ breastfeeding self-efficacy at
for personal health and well-being but also con- 4 weeks postpartum [111, 112]. During the post-
tributes to healthy marital relations, family func- partum period, peer-support interventions for
tioning and child development [106]. Therefore, breastfeeding are more common [113]. Combined
various educational and technology-based inter- with professional support, peer-support breast-
ventions have been developed in hopes of boost- feeding programs are effective in boosting breast-
ing parental self-efficacy in the postpartum feeding self-efficacy [113].
period. A postnatal psychoeducation program Despite the heavy focus on maternal self-­
designed for the first-time mothers, consisting of efficacy during and after pregnancy, there has
a face-to-face educational session during a home also been an increase in health care research on
visit, an educational booklet and three follow-up fathers’ involvement during the perinatal period,
telephone calls was found to be effective at as early paternal involvement during and after
enhancing maternal self-efficacy, reducing post- pregnancy was found to positively influence
natal depression, and increasing perceived social maternal well-being and benefit the biopsychoso-
support [107]. A more recent technology-based cial development of infants 14 months and below
Supportive Educational Parenting Program [114–116]. A recent study by Shorey et al. [117]
(SEPP) targeting both parents, comprised of two found that high paternal self-efficacy is one of the
telephone-based educational sessions and main factors of high paternal involvement during
1 month follow-up via an educational mobile infancy, especially among first-time fathers.
health app [108]. As compared to routine post- Higher paternal self-efficacy also leads to
partum care, the SEPP was effective in promot- increase in parenting satisfaction over the first
ing parenting self-efficacy, parenting satisfaction, 6 months postpartum [118]. According to a
parental bonding, better perceived social support review on informational interventions aiming to
and reducing postnatal depression in both moth- improve paternal outcomes [117], there were
ers and fathers [108]. only three interventions (via online dissemina-
Self-efficacy in the postpartum period also tion of information or self-modelled videotaped
includes breastfeeding. Dennis [109] reported interaction and feedback) that reported on pater-
significant predictors of breastfeeding self-­ nal self-efficacy [119–121], but only Hudson
efficacy as maternal education, support from et al.’s [119] study found an intervention effect
other mothers, type of delivery, satisfaction with on parenting self-efficacy and parenting satisfac-
labour pain relief, satisfaction with postpartum tion in fathers. In addition to informational inter-
care, perceptions of breastfeeding progress, ventions, educational interventions are also
infant feeding method as planned and maternal useful and important in boosting paternal self-­
anxiety [109]. A study conducted among Japanese efficacy and other paternal outcomes [108, 122].
women found that breastfeeding self-efficacy is Overall, in order to effectively enhance paren-
also associated with maternal perceptions of tal self-efficacy across these various aspects (i.e.
insufficient milk, leading to discontinuation of childbirth, parenting, breastfeeding) during the
breastfeeding during the immediate postpartum perinatal period, it is necessary for interventions
period [110]. Breastfeeding is highly encouraged to incorporate and target at least a component of
by health care professionals due to its nutritional the self-efficacy theory (mastery experiences,
value, benefits to the infant’s development and vicarious experiences, verbal persuasion, and
potential mother–child bonding; therefore, stud- emotional and physiological arousal).
152 S. Shorey and V. Lopez

12.5.3 R
 ole of Self-Efficacy in Nursing specific clinical skills among nursing students.
Education Sabeti and colleagues [137] found that students’
self-efficacy ranges from weak to excellent
Another application of self-efficacy in the health across different skills, with high self-efficacy in
care setting is with regard to nursing education medication administration and nursing proce-
and training. Effective clinical trainings should dures, and low self-efficacy in care before, during
establish a sense of self-efficacy among nursing and after diagnostic procedures. In Pike et al.’s
students, which is a key component for acting study [136], despite undergoing a clinical simula-
independently and competently in the nursing tion program aimed to improve learning self-­
profession [123–125]. Students’ clinical perfor- efficacy, students still reported low self-efficacy
mance, course completion and achievement in communication skills. However, in another
motivations are also dependent on individual study, a blended learning pedagogy was used to
perceived self-efficacy [125–127]. According to redesign a nursing communication module from
Bandura [128], students with low self-efficacy didactic lectures to an online and face-to-face
will tend to avoid situations that led to past fail- interactive classroom sessions, which resulted in
ures; therefore, strong sense of self-efficacy and increased communication self-efficacy and better
job satisfaction is crucial in reducing attrition in learning attitudes among nursing students [138].
the nursing profession [126, 129]. Lastly, as a In nursing education, clinical simulations are
future health care practitioner, clinical self-­ widely used to create authentic scenarios and
efficacy and competence are essential for pro- training environments and were often the most
viding quality health care and ensuring patient effective method in boosting students’ self-­
safety [125]. efficacy. A study comparing the effectiveness of a
Evidence has suggested that older age, being peritoneal dialysis simulation with watching vid-
married, more working experience in the nursing eos reported higher psychomotor skills score and
field, individual interest and willingness to work self-efficacy among students who underwent the
in a nursing unit contributes to high nursing self-­ simulation than those who just watched videos of
efficacy in students [127, 130, 131], which is also the procedure [139]. Similarly, a Diverse
an important factor in creating clinical confi- Standardised Patient Simulation was also seen to
dence [132]. Clinical environments, nursing col- improve students’ transcultural self-efficacy per-
leagues, and clinical educator’s capabilities can ceptions [140]. Notably, simulation exercises
influence the creation of clinical self-efficacy in were more effective at improving students’ self-­
nursing students [123]. A weak relationship efficacy and critical thinking skills when con-
between faculty and hospitals, lack of staff and ducted after a role-play than after a lecture [141].
training facilities, and unprofessional trainers Overall, nursing curriculum and clinical simula-
could adversely influence self-efficacy [133, tions play a vital role in mastery experiences, and
134]. More specifically, students have reported the integration of positive feedback (verbal per-
that using logbooks, having more authentic clini- suasion) and observation of clinical educators in
cal simulations, working alone, more ward time, ward settings (vicarious experiences) would
being under the guidance of one instructor, and present an ideal method of enhancing self-­
receiving constant verbal validation, positive efficacy among nursing students.
feedback and support can increase one’s own
sense of self-efficacy [123, 135, 136]. These cor-
responds with components of the self-efficacy 12.6 Conclusion
theory [128] in terms of mastery experiences,
vicarious experiences and verbal persuasion. The self-efficacy theory is in itself linked with
Numerous education and clinical training cur- other psychological theories to influence health-­
riculums are being developed and constantly promoting behavioural changes in various life
revised to target promotion of self-efficacy in situations. The applications of self-efficacy in
12 Self-Efficacy in a Nursing Context 153

various nursing contexts ultimately boil down to • In nursing education, self-efficacy plays a
health promotion and improvement of the quality vital role in enhancing students’ competence,
of health care and patient safety. The concept of motivation and clinical performance, which
self-efficacy has played a significant role in not influences job satisfaction and quality of
only predicting individual physical and psycho- patient care provided.
logical wellbeing, competencies, and self-care • Education and social support through infor-
management, but also often serve as a theoretical mational, emotional, formal and informal
framework for existing clinical and educational means are the primary contributors to
interventions. Despite its well-established litera- self-efficacy.
ture base, emerging evidence on self-efficacy’s • Overall, self-efficacy is a key health-­promoting
positive relationship with sense of coherence and component among patients with chronic ill-
the gradual shift of the health care paradigm to a nesses, parents during the perinatal period,
salutogenic orientation indicate a need for subse- youth and the elderly.
quent nursing research to continue to tailor and
refine ways to enhance self-efficacy in specific
population groups.
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 Empowerment and Health
Promotion in Hospitals
13
Sidsel Tveiten

Abstract 13.1 Empowerment as a Concept

Health promotion in hospitals may be an
From a scientific perspective, “empowerment” is
unusual concept to many—experience seems
an immature concept. In other words, it is a
to show that public health and health promo-
broad, vague term that lacks a consensual defini-
tion are considered to be the remit of the local
tion [1]. Consensus means agreement within an
authority. However, hospitals also have
academic or professional community around the
responsibility for health promotion. This
internal content of a concept. An overview of lit-
chapter enlightens empowerment as a con-
erature showed that related to health, psychology
cept, a process and an outcome and relates
and pedagogics, there exist 17 definitions of
empowerment to health and health promotion
empowerment [2]. In the interest of validity,
in hospitals. Supervision as an empowerment-­
therefore, it is important to look at some defini-
based intervention is described. The central
tions and possible interpretations of empower-
principles of empowerment can be connected
ment before applying this concept to the hospital
with the central elements of the theory of salu-
context.
togenesis, recognising patients’ self-­
The term is a broad one and has connections to
consciousness and participation as described
many different fields such as occupational psy-
at the end of the chapter.
chology, management, health science, pedagog-
ics, social science, politics and democratisation
Keywords
processes. Online searches for the term in scien-
Empowerment · Empowerment interventions · tific databases in 2019 resulted in hundreds of
Health promotion · Hospitals · Participation thousands of hits. Both qualitative and quantita-
tive research methods are used in research con-
nected to empowerment.
An immature concept is broadly defined,
described and characterised. Immature concepts
are easily misused and misunderstood [3–5]. This
is confirmed in an academic article that docu-
S. Tveiten (*) ments and attempts to correct myths and misun-
Department of Nursing and Health Promotion, derstandings connected to empowerment [6].
Section of Health Science, Oslo Metropolitan Including immature concepts in the production of
University, Oslo, Norway scientific knowledge implicates the risk of weak-
e-mail: stveiten@oslomet.no

© The Author(s) 2021 159

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_13
160 S. Tveiten

ening validity because there is uncertainty as to someone stronger and more confident, especially
whether one is actually studying what one thinks in controlling their life and claiming their rights”
one is studying. The concept appears in adminis- [13]. However, this definition too, may be per-
trative letters from the 1700s [7]. From around ceived as paternalistic.
1970, the concept is found in scientific literature A concept analysis of empowerment within an
connected to the civil rights movement in the health care context published in 2014 showed
USA and other democratisation processes [8, 9]. that empowerment is characterised by active par-
The New International Webster’s ticipation, informed change (change that one
Comprehensive Dictionary of the English undertakes after attaining relevant knowledge,
Language [10] defines “empower” as (to) “give e.g. about the significance of a better diet and
authority to”, “delegate authority to”, “commis- physical activity), knowledge to problem solve,
sion” or “permit”. Illustrated Oxford Dictionary self-­care responsibility, sense of control, aware-
[11] defines empowerment as “to authorise”, ness, development of personal abilities, auton-
“give permission to”, “give power to” or “put in omy and coping [14].
working order”. These definitions may seem Another concept analysis concludes that indi-
paternalistic, which in itself is incompatible with vidual patient empowerment is a process that
what is implied by the term, namely democratisa- enables patients to exert more influence over their
tion. To give someone authority or to delegate individual health by increasing their capacities to
authority implies that someone is in possession gain more control over issues they themselves
of that authority and consequently passes it on or define as important. The authors combine patient
delegates it further. One may wonder whether empowerment with patient participation and
there are conditions attached to this delegation. patient centredness and state that patient partici-
pation might lead to patient centredness that at
last can lead to patient empowerment [15].
13.2 Empowerment and Health A study of the principles of empowerment in a
psychiatric context showed that the patients
The Ottawa Conference in 1986 represents kind found it difficult to understand every decision in
of a shift in paradigm regarding health, from relation to what was “allowed and not allowed”
paternalistic to democratic [12]. The World and to understand the reasons given by the staff
Health Organization (WHO) declared that it was for implementing measures within the depart-
necessary to pay more attention to health promo- ment. Similarly, they found it difficult to be per-
tion within the health care services, arguing that ceived as experts on themselves [16]. Another
people had to take more responsibility for their study on the perception of empowerment among
own health [12]. The main idea was to redistrib- elderly people with diabetes indicated the same
ute power, from the health professionals to the challenges [14]. A literature review and a concept
patients, and the term “The new public health” analysis of empowerment in critical care showed
was introduced by the WHO, underlining this that the common attributes of empowerment
increased attention. were a mutual and supportive relationship, skills,
Within the health (and social) care fields, the power within oneself and self-determination. The
concept of empowerment is linked to individuals author concludes that even if empowerment is
and groups who are/have been in a situation of sparsely used in relation to critical care, it appears
powerlessness and how they can emerge from to be a very useful concept in this context [17].
that powerlessness [9]. Illness and symptoms Rapaport [18] once claimed that it is easier to
such as severe pain, nausea and discomfort, or define the opposite of empowerment: powerless-
fear and exhaustion can easily contribute to feel- ness or learned helplessness, alienation and the
ings of powerlessness. perception of not having control over one’s own
A frequently used definition in health contexts life. This is a particularly interesting observation
describes empowerment as giving someone the for our context. The health service and hospitals
authority or power to do something, “...to make in particular can easily be perceived as paternal-
13 Empowerment and Health Promotion in Hospitals 161

istic, and it can be difficult to participate and be systemic perspective, e.g. structural empower-
acknowledged as an expert on oneself as a patient. ment. All levels of empowerment are connected.
It is easy to fall into the traditional role of patient The system holds major significance for psycho-
and leave decisions to the professionals, to be logical or individual empowerment [25].
taught helplessness and feel powerless. Psychological empowerment is based on
The concept of empowerment is of particular social psychology theory and developmental psy-
interest to the health professions [8]. This is chology and builds on the assumption that
because the concept underscores the importance empowerment centres around internal, psycho-
of supporting people who find themselves in a logical processes such as perceptions of self-­
vulnerable situation and because the concept per determination, impact, competence and meaning
se emphasises the importance of seeing people as [7, 26, 27]. Individual or psychological empow-
actors in their own lives who “know best where erment is about the individual’s ability to make
the shoe pinches” [19, 20]. It is precisely this, decisions and have control over his/her own life
supporting someone in a vulnerable position, [28] and about self-control, belief in and opportu-
while not taking over but helping the person to nities for one’s own efficacy (efficacy expecta-
take as much control as possible that is challeng- tion or self-efficacy) [29].
ing in relation to empowerment in hospitals. Structural empowerment deals with a per-
Most patients may be able to participate a little in son’s power with regard to his/her position
some areas. within the organisation. Kanter [30] describes
four empowerment structures: opportunity,
information, support and resources. Structural
13.2.1 Empowerment as a Process empowerment may be understood as the struc-
tures in which the patient is a part representing
The empowerment process can be described as a opportunities for or obstacles to empowerment.
social and a helping process, as well as a dynamic Specifically, systems that provide opportunities
and interactive process [14, 17, 21, 22]. Describe for participation, such as joint meetings in men-
how the empowerment process in elderly care tal health care settings where the patient is able
claims that the health professionals surrender to influence conditions within the department,
control. To surrender control might be easier said represent an example of structural empower-
than done to the health professionals [23, 24]. ment, along with procedures or systems gather-
The health professionals themselves often define ing information about patients’ experiences,
the needs of the patients and even how to meet views and needs during conversations. A study
those needs. of patients’ perceived opportunities for partici-
Askheim [9] claims that empowerment is pation at an outpatient pain clinic showed that
characterised by a positive view of the individual the patients perceived that their participation
and by the individual as active and acting in their was obstructed by an inability to understand
best interests where the right conditions are in their treatment plan. The patients also had very
place. Empowerment is further characterised as a limited knowledge about their rights in relation
concept that has an emotional dimension [9]. The to participation [25].
individual is not always rational, and situations Gibson [31] defines empowerment as a social
that may involve, e.g. shame and dejectedness or process that contributes to recognising, promot-
enthusiasm, and the joy of mastery may influence ing and enhancing people’s abilities to meet their
the empowerment process. own needs, solve their own problems and mobil-
When studied from the perspective of the indi- ise the necessary resources in order to feel in con-
vidual, empowerment is called “psychological trol of their own lives or the factors which affect
empowerment”. Empowerment may also be stud- their health. The definition is still used in scien-
ied from a group, organisation or societal perspec- tific articles despite the year of publication, so
tive. Further, empowerment can be studied from a long ago. This definition emphasises the social
162 S. Tveiten

process between health professional and patient. 13.2.3 Health

Being a partner in an empowerment process
requires the health professional to adopt a differ- Views on health hold significance for health pro-
ent role than that of traditional assistant who motion work. WHO’s definition of health from
solves problems for the patient: the health profes- 1948 [36] was somewhat expanded in 1986 [12],
sional takes on a supervisory role [32]. In this and emphasis was placed on the significance of
context, the affective dimension is significant. well-being and quality of life [37]. In the 1946
The affective dimension deals with the way the definition [38], health was understood as more
health professional relates to the patient, whether than just absence of disease and as complete
she communicates respect, empathy or under- physical, mental and social well-being. WHO
standing, for example, or conveys that she is short later modified the definition and describes health
on time, appears impatient or is inattentive to the as the ability to live an economically and socially
patient. According to Askheim and Starrin [8], it productive life [39]. Hjorth [40] describes health
is precisely this emotional dimension between as the ability to cope and function in one’s cur-
helper and helpee (here: patient) that is important rent context and with the challenges one may
in empowerment. face at any time. Health is understood as a
resource that gives people the strength and resil-
ience to endure stresses and strains [39].
13.2.2 P
 ublic Health and Health Views of health reflect ideology, value-based
Promotion priorities and cultural and social relations. In
recent times, the term “health” has to some extent
What is public health and what does it have to do been replaced by “quality of life” [39]. Fugelli
with hospitals? In 1920, public health was defined and Ingstad [41] describe health as an ephemeral
as: “The science and art of preventing disease, phenomenon that shifts between time and space
prolonging life and promoting health through the and is both individual and general. Health profes-
organized efforts and informed choices of society, sionals are supposed to contribute to health pro-
organizations, public and private, communities motion, prevent disease, alleviate suffering and
and individuals”. This definition is still used restore health. Health promotion work centres
([33], pp. 17–18). Public health can be under- around how one lays the groundwork for the indi-
stood as society’s responsibility for the health of vidual to feel more in control over his/her life and
the people, or society’s duty to protect, promote health. Health promotion work focuses on
and strengthen people’s health. Public health can empowerment principles (redistribution of
also be understood as the duty of medicine to power, participation and acknowledging) and
protect and improve the health of the nation [34]. building capacity within the individual and the
Public health work may further be understood local community. Participation through involving
as the collective effort of society to strengthen people in decisions about their lives and health is
factors promoting health, to reduce factors that one part of this work [42].
result in increased health risks and to protect
against external threats to health and as the prac-
tical means by which information about the sci- 13.2.4 Empowerment and Health
ence of public health is applied for the purpose of Promotion
promoting health [35]. Health promotion and dis-
ease prevention are forms of intervention in pub- Since the 1970s, empowerment has been defined
lic health work. The Ottawa Charter provides as a central concept in health promotion work,
guidelines for substantially strengthening health and Andrews and Rootman et al. [43, 44] state
promotion work [12]. Health promotion and pre- that empowerment represents a framework for
venting disease are strategies that overlap to a health promotion. The Brazilian educator Paulo
certain degree. Freire [45] focused his pedagogical efforts on the
13 Empowerment and Health Promotion in Hospitals 163

poor of Brazil in the 1960s and was particularly The World Health Organisation ([46], p. 11) pro-
interested in how the situation these people found vides the following description of empowerment:
themselves contributes to oppression. Freire “Patient and consumer empowerment has
believed that what was most important for the emerged in the last decades as a proactive part-
poor and oppressed was to become conscious of nership and patient self-care strategy to improve
why they were oppressed, because this awareness health outcomes and quality of life”. In this
could help them change their behaviour and description, empowerment is thus linked to health
thereby create a new situation for themselves. and quality of life.
Consciousness raising is therefore important to One may wonder whether the philosophy of
be able to take control of one’s own life. empowerment is universally appropriate. What
According to Freire, the central method of this about the seriously ill and children? What about
liberation was dialogue [45]. Dialogue as a people who are unconscious? It is the most seri-
method of health promotion will be discussed ously ill who are admitted to hospital. This issue
later in this chapter. touches on the central principles of empower-
Empowerment may be a social, cultural, psy- ment. What does participation entail?
chological or political process through which Participation can be ranked and seen in the con-
individuals and social groups are able to express text of the patient’s capacity level at any time.
their needs, present their concerns, devise strate- One can participate a little; for example, one can
gies for involvement in decision-making and participate in relation to what one would like to
achieve political, social and cultural action to drink, whether one wants to sit up or lie down in
meet those needs. Through such a process, peo- bed. It is easy to make such choices on behalf of
ple see a closer correspondence between their the patient. To find anything out about the
goals in life and a sense of how to achieve them patient’s capacity, the health professional must be
and a relationship between their efforts and life attentive, aware of his/her interactions and
outcomes. Health promotion not only encom- acknowledge the patient’s competence at all
passes actions directed at strengthening the basic times. In this context, affective competence is of
life skills and capacities of individuals, but also at particular importance. In encounters with uncon-
influencing underlying social and economic con- scious patients, who has not whispered into the
ditions and physical environments which impact patient’s ear that he/she must squeeze your hand
upon health. In this sense health promotion if they can hear what you are saying? This is an
directs creating conditions facilitating a relation- example of acknowledging the patient’s personal
ship between the efforts of individuals and competence and inviting him/her to participate.
groups, and subsequent health outcomes in the This involves a kind of redistribution of power. In
way described above. this context, it is also appropriate to see the
A distinction is made between individual and patient and his/her next of kin as one unit.
community empowerment. Individual empower-
ment refers primarily to the individuals’ ability to
make decisions and have control over their per- 13.3 Empowerment and Health
sonal life. Community empowerment involves Promotion in Hospitals
individuals acting collectively to gain greater
influence and control over the determinants of Our context is empowerment in connection with
health and the quality of life in their community health promotion in hospitals. The guidelines in
and is an important goal in community action for the Ottawa Charter place greater emphasis than
health. In health promotion, enabling involves before on health promotion and described health
taking action in partnership with individuals or promoting strategies as “the new public health”.
groups to empower them, through the mobilisa- The guidelines centre around giving special pri-
tion of human and material resources, which are ority in health promotion work to the redistribu-
important to promote and protect their health. tion of power from professional to patient or user,
164 S. Tveiten

participation and acknowledgement of the There are several examples of health promo-
patient’s [12]. WHO further states that empower- tion in hospitals. For example, some hospitals
ment means: have “patient schools” for patients with heart
“…the process of increasing capacity of individu- disease, diabetes, stomas or breast cancer. These
als or groups to make choices and to transform patient schools offer for example teaching and
those choices into desired actions and outcomes” supervision that is intended to help patients cope
to “build individual and collective assets, and to with their symptoms and treatment. However,
improve the efficiency and fairness of the organiza-
tional and institutional context which govern the studies emphasise that competence in health edu-
use of these assets” and the “expansion of assets cation is crucial for ensuring that patients and
and capabilities of poor people to participate in, service users derive benefit from the patients’
negotiate in, negotiate with, influence, control, and schools or programs [48].
hold accountable institutions that affect their
lives“ ([12], p. 17).

Health promotion in hospitals has to do with 13.4 Empowerment-Based

the interaction between patients and health pro- Interventions
fessionals and the hospital as the system within
which this interaction takes place. Health pro- As we have seen, the central principles of empow-
motion is about helping the patient to partici- erment are power redistribution, participation
pate in his/her own treatment and care, and being acknowledged as an expert on oneself.
acknowledging the patient’s self-competence These principles are connected; one is virtually a
and redistributing power. Health promotion is natural consequence of the other. The principles
about everything we do to enable the patient to will be preserved through the interaction between
develop or improve competence in relation to health care professionals and patients [12]. The
sustaining health and quality of life. You may strategies for this interaction can be described as
be forgiven for thinking that such interactions empowerment “interventions”. These are inter-
take too much time in hospitals and that seri- ventions that aim to develop competence and
ously and/or acutely ill people do not need or coping skills or that help patients cope as well as
have the energy to participate. Of course, this possible with health challenges and their atten-
may be the case, but health professionals can- dant consequences [49–51]. The empowerment
not take it for granted. In interactions with the interventions must be commensurate with the
patient, health professionals can identify the patient’s competence, for example, the patient’s
patient’s needs in relation to participation. resources, needs and opportunities to participate.
Expressing that one does not wish to participate Empowerment-based interventions include both a
is in itself a form of participation. Again, it is process and an outcome component. The process
important to be aware that one can participate a component occurs when the true purpose of the
little and in certain areas. Acknowledgement intervention is to increase the patient’s capacity to
think critically and make autonomous, informed
may also be expressed in many ways. A seri- decisions. The outcome component occurs when
ously ill patient may for example feel acknowl- there is a measurable increase in the patient’s abil-
edged by the health professional communicating ity to make autonomous, informed decisions ([6],
empathy and respect. WHO has provided guide- p. 278)
lines for the recognition of Health Promoting
Hospitals and has set up a network for these The result of empowerment may be described
hospitals [47]. All health trusts and organisa- as coping [49]. Coping may be understood as
tions interested in public health and willing to ever-­changing cognitive and behavioural efforts
follow the WHO concept of Health Promoting to manage specific external and/or internal chal-
Hospitals can become members. Membership lenges that are perceived as burdensome or that
in the network can be seen as an aspect of adversely affect the resources one has at one’s
empowerment at the system level. disposal [52, 53]. Coping can also be understood
13 Empowerment and Health Promotion in Hospitals 165

as attempts by the individual to manage chal- next of kin education can therefore be seen as
lenge or stressful situations. Vifladt and Hopen health-promoting work at the hospital [20, 51].
[54] define coping as “the perception of having Supervision is an empowerment-based inter-
the resources to face challenges and a sense of vention. The concept of supervision might seem
having control over one’s own life. Active and unusual regarding patients and next of kin, since
effective coping helps you to adapt to new reali- the concept usually is related to health profes-
ties and enables you to see the difference between sionals or students [57]. Supervision may be
the things you have to live with and the things defined as: A formal, relational and pedagogical
you can play a part in changing” ([54], p. 61, process that enables, and that aims to strengthen
translated by the author). personal mastery competence through a dialogue
The concept of compliance is interesting in based on knowledge and humanistic values [32,
this context. Traditionally, the term denotes man- 58]. This definition emphasises the relationship
ageability or assent, or the patient’s ability to fol- between health professional and patient. It is
low the doctor’s advice. According to Fielding through this relationship that the health profes-
and Duff [55], “compliance” can have a deeper sional gains insight into the patient’s thoughts,
meaning; the ability to take control of the factors perceptions and needs. The affective aspect of the
that affect your health. In other words, not just interaction centres around laying the foundations
following advice, but playing an active role, for trust and meeting the patient where he/she is.
responding actively to advice, speaking up when Health-promoting measures can thus be
advice is not perceived as beneficial, for exam- customised.
ple. “Compliance” can also be understood as an Dialogue requires the health professional to
active, intentional and responsible process [56]. be a skilled listener. The dialogue entails reflec-
In concrete terms, this means the ability to under- tion, in the sense of exchange. The health profes-
stand and act in relation to changing symptoms sional must listen to the patient and tell the patient
and to understand and act when treatment per- his/her perception of what the patient is saying
haps does not work the way it was supposed to. and of the situation the patient is in. Thus,
Another interpretation of “compliance” leads to exchange and reflection take place. This creates
empowerment. “Compliance” is influenced by an enhanced mutual understanding of the
age, socio-economic circumstances, how one patient’s situation, and further health-promoting
copes with having an illness and by psychologi- measures are implemented in line with the
cal stress. “Compliance” may be strengthened by patient’s needs.
education, reflection, emotional processing and The purpose of supervision is to strengthen
skills training [55]. coping competence. What to be overcome is
Patient education is recognised as an impor- individual, situational and contextual. Coping
tant part of the nurse’s role and includes patient competence includes knowledge, abilities and
teaching, advice and information-giving as well attitudes. All these aspects are important in the
as supervision. The purpose of patient and even- supervision dialogue. A patient in hospital may
tually next of kin education is to contribute to be in an acute state of illness or injury and may be
improving health and quality of life and help dealing with pain, fear or reduced consciousness.
patients and next of kin cope with illness and/or The dialogue with the patient must be informed
functional impairment. Further, education can by the patient’s condition. It would be easy to
lead to patients being able to make informed think that the most seriously ill patients have no
choices together with their health care providers. need for dialogue. However, assessment of the
The hospitals must also contribute to health-­ patient’s competence must be ongoing. A dia-
promoting processes through interaction with the logue with a patient may, for example, involve
individual patient and his/her next of kin and investigating what the patient knows about the
groups of patients and next of kin. Patient and illness and treatment options, and conveying to
166 S. Tveiten

the patient the information that he/she needs in cerning health care, disease prevention and health
order to understand, actively participate and promotion to maintain or improve quality of life
make choices. Dialogue entails helping the during the life course” ([60], p. 3). Health literacy
patient to gain a deeper understanding. may also be defined as the use of medical termi-
An example from a hospital, as told by the nology that may for example prevent a patient
patient’s next of kin: from understanding. The patient’s health literacy
An 80-year-old man with stomach pains was an is an important factor in empowerment and health
emergency admission to the hospital. He was lucid promotion work [61].
and oriented and was lying in bed when his next of There are many ways to provide supervision
kin arrived. A nurse arrived at the same time and and dialogue: solution-focused guidance, change-­
asked if the man would like something to drink. The
man answered “Yes please...” and a glass of fruit focused guidance or counselling, empathic com-
cordial was placed on the bedside table. The next munication, health coaching, shared
of kin asked if the man would like to sit up to make decision-making, or motivational interview, to
it easier for him to drink the cordial. The man name just a few [20]. Patients in hospital may be
answered that he was unsure whether he was
allowed to sit up. The next of kin left the room, facing multiple choices in relation to treatment,
located the nurse and asked if it was OK for the lifestyle and follow-up. Actively participating in
man to sit up in bed. The nurse replied that of choices requires, among other things, awareness,
course it was OK, he could even get out of bed if he understanding, knowledge and skills. In this con-
wanted to. The patient later said that he had been
lying on his back in bed since he was admitted two text, supervision is a relevant method.
days ago, no-one had informed him that he was To fulfil their health-promoting duty, health
free to move around, and he had not asked any professionals need pedagogical competence or
questions. competence related to health pedagogics. Health
pedagogics may be understood as everything that
This is an example of a patient feeling power- is connected to development, learning, teaching
less and presenting learned helplessness, but it is and supervision in a health-related setting [20,
also an example of the importance of providing 62]. The purpose of health pedagogics is to
supervision to patients to enable them to start encourage the patient to change his/her relation-
using their own resources. Knowing that one can ship to his/her own health and lifestyle [63]. The
safely get out of bed and move around is of major concept of health competence is recently used to
significance in terms of health. Being bed-bound describe the result of health education and is in
may in itself cause complications due to inactiv- Norway defined as a consensus concept con-
ity. This is also an example of when a dialogue nected to health literacy [64]. Health pedagogics
with the patient may have had a health-promoting is the general term we use to denote everything
effect. The purpose of the dialogue is to produce we do as health professionals (e.g. empowerment
an enhanced understanding of what the dialogue interventions, training and supervision) to
is about. It is of major importance in terms of strengthen the patient’s and next of kin’s ability
coping that patients understand and can appropri- to cope with health-related challenges and to
ately relate to the information they are given, e.g. achieve health competence.
about medicines and treatment. This is known as
“health literacy” [59].
Health literacy concerns the knowledge and 13.5 Some Empirical Studies
competences of persons to meet the complex
demands of health in modern society and can be In an intervention study, the purpose of which
defined as “people’s knowledge, motivation and was to look at the empowerment process in the
competence to access, understand, appraise, and rehabilitation of women with breast cancer, Stang
apply health information in order to make judge- and Mittelmark [65] found that self-help groups
ments and take decisions in everyday life con- as intervention resulted in consciousness raising.
13 Empowerment and Health Promotion in Hospitals 167

Knowledge building, community learning and Studies of health education interventions are
discovering new perspectives contributed to the often related to specific diagnoses. For example,
consciousness raising. Consciousness raising, as one study of patient experiences connected to
we saw earlier, is a prerequisite for empower- diagnosis-specific health education interventions
ment [45]. showed limited effects [72]. Perhaps it would be
Anderson and Funnell’s [6] study shows that more useful to carry out training irrespective of
implementing empowerment interventions diagnosis and based on the needs of the individ-
entails a type of paradigm shift that can be com- ual. The need for a scientific basis for the devel-
plex because the education received by health opment of strategies for health education is
professionals taught more traditional types of confirmed by Smith et al. [73], who concluded
intervention. Empowerment interventions may that much of the material being used in this con-
involve new and different ways of relating to text is outdated. However, one may argue that the
patients and require the ability of self-reflection. patient’s perspective and participation challenge
Ruud Knutsen and Foss [66] studied understand- equality in the relationship between the patient
ings of and strategies for empowerment in life- and the health professionals due to the fact that
style change courses at one hospital’s Learning the health professionals themselves often define
and Mastery Centre. The analysis showed that the patient’s needs and goals [24]. The health
when health professionals develop empowerment professionals need health education competence
interventions, it is essential to be aware of the or health pedagogy competence in order to prac-
power dynamic that will always be present in tice in line with the empowerment principles.
relation to patients in this context. Power can lie Research regarding this area sparsely exists.
within systems. Therefore, qualitative as well as quantitative
Communication between health professionals studies are of high importance in the future, and
and patients is an important factor in interactions. there is a need of further developing health-­
Cegala et al. [67] concluded in their study that promoting strategies and education of health pro-
when the parents of sick children are active com- fessionals within health pedagogy [48].
municators, the surgeon will provide more infor-
mation. When parents are more active, this may
lead to them receiving clarification on what they 13.5.1 Empowerment
were unsure about. This promotes empowerment. and Salutogenesis
In a systematic literature review, Pearson [68]
showed that involving patients in goal-setting As we have seen in this chapter, central principles
processes for lifestyle change may be useful. In of empowerment are distribution of power from
addition, a questionnaire conducted by Rosenlund the health professionals to the patients, patient
et al. [69] shows that patients value communica- participation and acknowledging the patient as an
tion when they themselves are active. When the expert regarding herself/himself. Antonovsky’s
patient is active, empowerment is promoted. A theory of salutogenesis [74] emphasises positive
quantitative study of patients’ experiences with aspects of health and well-being. A key compo-
the empowerment process concludes that it is of nent in the theory is “sense of coherence” (SOC).
importance regarding quality of life and health This component has a particular relevance to
outcomes that health professionals actively ask health promotion, since it represents characteris-
for the patients’ experiences of the process or tics that contribute to help individuals gain
how it felt to participate and being acknowledged control:
[70]. Stiffler et al. [71] conclude in a qualitative The sense of coherence is…a global orientation
study that the interaction between the patient and that expresses the extent to which one has a perva-
the health professionals was more important to sive, enduring though dynamic feeling of confi-
the patient than medical control regarding the dence that one’s internal and external environments
are predictable and that there is a high probability
disease.
168 S. Tveiten

that things will work out as well as can reasonably a comprehensive review. Rev Esc Enferm USP.
be expected. ([74], p. 122) 2016;50(4):664–71.
3. Morse JM. Exploring the theoretical basis of nursing
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The elements of coherence are comprehensibil- Nurs Sci. 1995;17(3):31–46.
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believe that they have the resources at their disposal myths and misconceptions. Patient Educ Couns.
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Meaningfulness means that life make sense emo- 7. Kuokkanen L, Leino-Kilpi H. Power and empower-
tionally, that people are committed and that they ment in nursing: three theoretical approaches. J Adv
Nurs. 2000;31:235–41.
invest energy in worthwhile goals [74, 75]. The ele- 8. Askheim OP, Starrin B. Empowerment i teori og
ments of SOC can be viewed as interrelated with praksis [empowerment in theory and practice]. Oslo:
the principles of empowerment, to take control in Gyldendal Academic; 2007.
one’s life and to obtain power within oneself claims 9. Askheim OP. Empowerment i helse- og sos-
ialfaglig arbeid: floskel, styringsverktøy eller
self-consciousness and participation. SOC claims frigjøringsstrategi? [Empowerment in health and
self-consciousness and participation as well. social work: meaningless jargon, management tool or
strategy for liberation?]. Oslo: Gyldendal Academic;
Take Home Messages 2012.
10. Wbster’s Comprehensive Dictionary of the English
• Empowerment can be understood as a con- language. 1996.
cept, a process and an outcome. 11. Illustrated Oxford Dictionary. Oslo: Teknologisk for-
• Empowerment can be a health promotion lag; 1998.
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health promotion. Geneva: WHO; 1986.
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• Acting or interacting in line with the princi- English. Oxford: Clarendon Press; 1998.
ples of empowerment philosophy, power 14. Fotoukian Z, Shahboulaghi FM, Khoshknab MF,
redistribution, participation and acknowledge- Mohammadi E. Concept analysis of empowerment
in old people with chronic diseases using a hybrid
ment of the patient’s competence is complex. model. Asian Nurs Res. 2014;8:118–27.
• Health promotion and empowerment-based 15. Castro EM, Van Regenmortel T, Vanhaecht K,
interventions (e.g. supervision) require health Sermeus W, Van Hecke A. Patient empowerment, par-
education skills. ticipation and patient-centeredness in hospital care:
a concept analysis based on literature review. Patient
• Knowledge-based practice is a goal for the Educ Couns. 2016;99:1923–39.
health service. There is a great need for scien- 16. Tveiten S, Haukland M, Onstad RF. The patient’s
tific knowledge related to empowerment-­ voice—empowerment in a psychiatric context. Nord
based interventions in hospitals. J Nurs Res. 2011;101(31):20–4.
17. Wählin I. Empowerment in critical care—a concept
• The principles of empowerment connect with analysis. Scand J Caring Sci. 2016;31:164–76. https://
the central elements of the salutogenic theory. doi.org/10.1111/scs.12331.
18. Rapaport J. Studies in empowerment: introduction to
the issue. Prev Hum Serv. 1984;3:1–7.
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 Part III
Empirical Research on Health Promotion in
the Health Care
 Health Promotion Among Families
Having a Newborn Baby
14
Shefaly Shorey

Abstract been discussed. The following discussions are

based on the research on perinatal mental health,
Pregnancy, childbirth, and the postpartum
trends in childbirth, health promotion, and, par-
period are the stressful transition periods to
ticularly, the integration of the Salutogenesis
parenthood. With medicalization of perinatal
theory in health promotion during the perinatal
period, parents feel left out and less confi-
period. The extensive discussions constitute a
dent in their parenthood journey, which may
basis for development of future policies or initia-
pose serious threats to the family dynamics.
tives to promote health promotion among fami-
Salutogenesis theory offers the potential to
lies having a newborn that meet the standards for
influence a shift away from negative health
health care education and research.
outlooks and outcomes, medicalization of
childbirth, toward health promotion and posi-
tive well-being focus for maternity care ser-
14.2 Perinatal Mental Health
vices design and delivery in the future.
The perinatal period spans from the start of one’s
Keywords
pregnancy to the first 12 months after childbirth
Salutogenesis · Health promotion · Perinatal [1]. This period is a stressful and remarkably
period dynamic period of growth that poses significant
challenges for both pregnant women and their
partners [2]. Right from pregnancy till after child
birth, the perinatal period is a complex phenom-
14.1 Introduction enon that consists of a myriad of adjustments to
physical, social, and emotional lifestyles, that
This chapter describes the need of health pro- influence the overall well-being of the parents [3].
motion strategies among families having a new- There is increasing research on parental peri-
born baby. The focus of the utilization of the natal mental health, in which systematic reviews
Salutogenesis theory in health promotion and revealed that 6.5% to 12.9% of pregnant and
future directions in health promotion research has postpartum mothers experienced depression and
anxiety [4, 5]. Likewise, depression and anxi-
S. Shorey (*) ety have been reported to be the most common
Alice Lee Centre for Nursing Studies, National mental health issues faced by fathers during the
University of Singapore, Singapore, Singapore perinatal period [6, 7]. Existing meta-analyses
e-mail: nurssh@nus.edu.sg

© The Author(s) 2021 173

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_14
174 S. Shorey

have reported that the prevalence rate for pater- 18], (3) having topics of discussion beyond the
nal depression during the perinatal period was infant and partner care such as to include mental
approximately 8.4% [8] and the prevalence of health topics [14, 20], (4) ensuring continuity of
anxiety in fathers ranged between 3.4% and 25% care after hospital discharge after the childbirth to
during the prenatal period, to 2.4% and 51% dur- seek timely help from health care professionals,
ing the postnatal period [9]. The striking preva- and (5) incorporating technology (e.g., mobile
lence of mental health issues among both mothers health applications) to receive information cover-
and fathers urge the need for a focus shift toward ing mental health [21]. These evidences highlight
familial health promotion throughout the perina- the need to explore health promotion strategies
tal period. among parents with a newborn to ensure smooth
In recent years, the experiences and needs transition to parenthood and overall well-being of
of both mothers and fathers during the peri- new parents and eventually their entire families.
natal period have been explored. During preg-
nancy, mothers reported that it was an emotional
roller-­
­ coaster ride that made them feel over- 14.3 Trends in Childbirth
whelmed with the evolving pregnancy needs
[10]. During postpartum, mothers felt varied Before the twentieth century, childbirth was con-
emotional issues and many of them felt neglected sidered a natural, normal, female-centred event,
to seek any help [10]. Mothers also experienced and hospital birth was uncommon [22, 23].
unpreparedness, anxiety, stress over infant care, Female midwives predominantly helped with the
breast-feeding concerns, and physical discomfort childbirth, whereas men were rarely involved,
[11]. Existing barriers such as stigma, shame, and and if they did, it was mainly during difficult
the lack of time and interactions with health care deliveries [22]. In the nineteenth and twentieth
professionals prevented mothers from disclosing centuries, medical influence on childbirth exag-
their feelings and needs [10, 12]. Hence, mothers gerated with the development of medical proce-
expressed their need for (1) continuity of care, dures such as anesthesia and caesarean section
(2) mental health enquiries to include less com- [22]. Presently, the increased use of ultrasounds,
mon disorders on top of depression and anxiety, fetal heart monitors, and increasing caesarean
(3) culturally appropriate postnatal practices in delivery rates illustrate multiple ways that wom-
infant care and upbringing, and (4) professional en’s pregnancy and childbirth experiences have
support needs, i.e. more information with regard been heavily medicalized [22–24].
to health care services [10, 11, 13]. Similarly,
fathers exhibited negative feelings and psycho-
logical difficulties during the perinatal period. 14.3.1 Medicalization of Childbirth
They expressed feelings of insecurity and inade-
quacy, felt isolated and excluded from the events Medicalization is defined as the tendency to
that happened throughout the perinatal period pathologize normal bodily processes and states,
[14–18]. Fathers also expressed stress, anxiety, resulting in unnecessary medical management
depression, and role strain and conflict while they [25]. Some factors influencing childbirth medi-
tried to cope with other role demands such as their calization include the complexity of maternal
jobs, parental stress from their children (e.g., fear health care, culture of medical dominance, sub-
of developmental problems), and conflict with in- missive culture in nursing and midwifery [26],
laws and partners [14, 19, 20]. Therefore, fathers technological advancement (e.g. emergence of
reported their needs: (1) including more educa- biomedicine) [27, 28], and focus on risks involved
tional information about pregnancy and parent- with natural childbirth [29]. Childbirth medical-
ing (during antenatal classes), (2) engaging them ization is apparent in the widespread and increas-
with other experienced fathers through small ing rates of medical interventions (i.e. caesarean
groups and focused group discussions [14, 17, and instrumental deliveries). In Western coun-
14 Health Promotion Among Families Having a Newborn Baby 175

tries (e.g. the United States, Italy, and the United 14.3.2 L
 atest Move Toward Natural
Kingdom), caesarean births account for approxi- Physiological Birth
mately 20% of childbirth procedures [22, 30].
In Spain, the extent of medicalization is demon- In response to the increasing rates of medical
strated in some of the highest caesarean delivery intervention and medicalization of childbirth
rates in Europe (e.g. 40% increase of the proce- and pregnancy, there has been increasing efforts
dure in Catalonia over 5 years) and obstetricians in promoting natural childbirth [42]. The World
are held accountable for not allowing women Health Organization (1997) highlighted the need
to be involved in childbirth decision-making to eliminate unnecessary medical interventions
[22, 31]. Furthermore, Eastern countries such in childbirth [43] and countries have passed poli-
as China and Singapore have one of the highest cies, initiatives, and guidelines to promote and
caesarean delivery rates in the world and South protect natural childbirth. In Australia, the cur-
East Asia, respectively [32, 33]. In China, caesar- rent maternity care reform (National Maternity
ean rates in the 90s rose from below 5% to above Services Plan) is grounded on the underlying
10%, with urban rates as high as 20% by 1996. philosophy of childbirth as a natural physiologi-
In 2010, of the 16 million babies born in China, cal process [44]. Guidelines to protect, promote,
approximately 50% were born by caesarean and support natural childbirth were established
delivery [32]. In Singapore, the overall caesarean and published in Queensland [45]. A policy in
delivery rate increased from 32.2% (Year 2005) New South Wales (Towards Normal Birth in New
to 37.4% in year 2014 [34]. Some contributing South Wales) required all birthing facilities and
factors to the alarming rates of caesarean deliv- institutions in the Australian state to have a writ-
ery in China and Singapore include the obstet- ten policy for natural childbirth by 2015 [46]. In
ric care system (i.e. urbanization, medicalization the United Kingdom (UK), the Royal College of
of childbirth, and financial incentives), provider Midwives established the Campaign for Normal
factors (i.e. obstetric training and staffing), and Birth that is now integrated as part of the Better
patient factors (i.e. parity where primiparas pre- Births Initiative [47]. Health care providers in
fer caesarean delivery as it is deemed as more Canada published a Joint Policy Statement on
effective, and education level where university-­ Normal Birth to protect the practice of natu-
educated women prefer caesarean births) [32]. ral birth [48]. In the Netherlands, the maternity
The potential impacts of medicalization of care system is grounded on the principle that
childbirth and pregnancy include (1) dependence childbirth and pregnancy are natural physiologi-
on medicine and the medical field [35], (2) ham- cal processes and community-based midwifery
pering the embodiment process that neglects the continue to play an important role [49] facili-
body as somato-psychic [36, 37], and (3) hin- tating natural birth and continuity of care after
dering the gift dynamic at play during natural childbirth. Hence, home birth remains a widely
childbirth [38]. The medicalization of childbirth, accepted and well-integrated part of the health
at times can be a life-saving and effective proce- care system [50].
dure, but if done unnecessarily it may put women Researchers have explored the role of mid-
and their babies at increased susceptibility to wives in encouraging natural birth as midwifery-­
mortality and morbidity and has aversive effects led models of care are associated with the reduced
on maternal health and pregnancy outcomes [39, use of medical interventions and mothers’
40]. Hence, it should be limited to instances of increased satisfaction with the natural birthing
medical emergencies. Finally, the medicalization experience [51]. Thompson et al.’s (2016) quali-
of childbirth and pregnancy is coupled with a tative study explored Dutch midwives’ attitudes
negative connotation, in which natural pregnancy and motivations toward the promotion of natural
and childbirth are now conceptualized as ill- childbirth, and identified factors associated with
nesses or diseases that require medical technolo- these attitudes and motivations [52]. Findings
gies and interventions [23, 41]. revealed that midwives perceive the safeguarding
176 S. Shorey

and promotion of natural physiological childbirth tion during birth, interrupt the birth process, and
as the focus of their role, and hospital culture compromise their dignity and sense of autonomy
is deemed as a barrier to practices that promote [54]. This is an exceptionally important finding
natural childbirth [52]. To overcome this barrier, as Turkey has one of the highest caesarean rates,
midwives expressed the need to be aware of fac- in which care during labor often entails the over-
tors that inhibit and encourage natural childbirth use of medicalized interventions such as episi-
practices, and to employ strategies that promote otomy (i.e. experienced by 93.3% of primiparous
natural childbirth in home and hospital settings women in Turkey) and augmentation with oxy-
[52]. A recent UK evaluation study examined the tocin and caesarean section [55]. With women
effectiveness of an educational training package who voiced their “want” for natural birth without
designed for midwives and maternity support interventions due to the negative consequences of
workers [53]. The training package included a medicalized interventions, it is a “need” to work
core workshop entitled “Keeping Birth Normal” toward a less- or non-medicalized childbirth pro-
(KBM), workshops that focused on antenatal cess through positive health promotion.
education, communication skills, and baby mas- With the progression toward less-medicalized
sage [53]. Findings revealed that midwives were models of birth through promotion of natural
appreciative of the educational materials (e.g. childbirth, existing barriers such as hospital and
videos and lectures) and expressed that small risk-focused culture are still apparent in many
group discussions helped to facilitate learning parts of the health care system. Therefore, it is
[53]. They described two barriers to the imple- imperative to adopt an appropriate approach of
mentation of training: (1) cultural focus on risk health promotion that will provide the necessary
and (2) hospital culture of low prioritization of shift of focus from the risks and complications
natural childbirth [29, 52, 53]. Despite the bar- associated with childbirth to one that provides
riers, the training provided opportunities (1) to a positive and health-promoting experience for
build a community of practice around natural families with a newborn [56].
childbirth that helped in overcoming the existing
risk-focused culture and (2) created awareness
within the midwifery unit that the promotion of 14.4  ealth Promotion: Use
H
natural physiological childbirth is central to their of Salutogenesis Theory
role [53]. These evidences urge the need for
future midwifery education and research to focus Health promotion is purported to enable indi-
on developing and testing strategies that support viduals with increased control over their own
midwives in delivery health-promoting care and health [57]. One such approach is to integrate the
services [52, 53]. Salutogenesis theory that was coined by the med-
Moreover, a recent qualitative study that ical sociologist Antonovsky (1979) who focused
aimed to clarify how primiparous women in on the origin of good health rather than the origin
Turkey experience childbirth and intrapartum of illness [58]. Salutogenesis illustrates that the
care revealed that the women wanted a natural state of health lies on a spectrum—from com-
birth without interventions [54]. Grounded the- plete absence of health to absolute state of health
ory guided interviews with 12 women were con- on the other extreme [58]. This theory implies
ducted and they reported wanting vaginal birth that one has the ability and control to move
without interventions, which required empower- toward better health with available resources
ment and social support from others (i.e. health around them. Salutogenesis consists of two:
care professionals, family, and friends) [54]. (1) generalized resistance resources (GRR), i.e.
Also, they expressed that routine medical inter- characteristics of an individual, family, or com-
ventions during the birth process cause their munity that are resources to aid the individual in
anxiety and frustration [54]. These interventions coping with stressors and (2) sense of coherence
become obstructions to women’s natural posi- (SOC), i.e. one’s ability to use available resources
14 Health Promotion Among Families Having a Newborn Baby 177

Fig. 14.1 Salutogenesis Umbrella (Reproduced with there is a revised version of the Salutogenesis umbrella
permission from Folkhälsan Research Center, Lindstrom which is used now)
& Eriksson, 2010) [65] According to Monica Eriksson,

for stress-coping and health promotion ( [59]. In ing one’s ability to mobilize both internal and
recent years, the salutogenic framework has been external resources for well-being [66, 67]. More
explored and expanded, in which more concepts recently, Johansson et al. (2018) developed and
were included within the framework. It is known implemented a salutogenic treatment model in a
as the Salutogenesis umbrella (Fig. 14.1) that clinical setting of emergency child and adoles-
constitutes concepts (e.g. Gratitude, Self-efficacy, cent psychiatry in Sweden [68]. Eight GRRs (e.g.
Connectedness, Coping, and Well-Being [60–64] clear language, daily information, and participa-
with the positive view of health as a resource for tion in decision-making) were developed and
life and executing behaviors to restore and main- implemented in the emergency unit, and parents
tain good health even when one is not ill [65]. reported increased satisfaction with the treatment
Hence, Salutogenesis is a potential school of and care provided [68]. Mental health of chil-
thought that urges health care professionals to dren improved during their stay at the hospital,
adopt positive and health-promoting care to assist and results revealed reduced treatment length
families during the perinatal period. and readmission rates [68]. Therefore, the salu-
Presently, there is an increasing trend in the togenic framework can be applied as a strong and
utility of Salutogenesis for guiding health pro- effective theoretical basis to direct the develop-
motion under various disciplines. For instance, ment and implementation of health care services.
García-Moya and Morgan (2016) assessed the Multiple studies have adopted the saluto-
theoretical status of Salutogenesis and the util- genic framework to highlight important qualities
ity of SOC to advance health promotion practices of health care providers and areas of improve-
for young people’s well-being [66]. SOC has ments to promote SOC in new mothers [69–71].
been shown to be associated with well-being, in Findings revealed that midwives should stay
which it can be an asset that operates by increas- calm in tight time-constraint environments
178 S. Shorey

while targeting positive wellness topics rather were utilized to demonstrate parental and pro-
than risk factors and provide mothers constant fessional perspectives on neonatal care [73]. The
reassurances to encourage SOC [69]. Dahlberg concepts of comprehensibility, manageability,
et al. (2016) interviewed new mothers and they and meaningfulness provided a theoretical foun-
expressed the need to be cared for exclusively and dation to develop and integrate meaningful care
highlighted the importance of a midwife for emo- that complemented existing services for optimal
tional support, coaching, and parenting guidance care [73]. Similarly, Kelly et al. (2016) applied
[70]. In Kelly et al. (2016) study, Salutogenesis the salutogenic framework to discuss ways in
was adopted, and a framework was proposed to maintaining parental mental well-­being during
promote families’ SOC and well-­being to better the perinatal period [71]. It was reported that the
facilitate their transition into parenthood [71]. To framework shaped parental mental well-being in
promote SOC, the health care sector should (1) two ways: (1) through helping parents to make
improve on the continuity of care and support for sense of parenting stressors by examining psy-
parents in the postpartum period, (2) improve the chosocial protective factors such as optimism,
method of information delivery, and (3) increase self-esteem, and stressor ­identification as well as
parental involvement in decision-making, while how these factors fit into their lives, and they can
balancing relationships among parents and health use them to cope with the parenting stressors,
care professionals [71]. Altogether, these saluto- and (2) strengthening parents’ sense of coher-
genically focused studies highlighted the need ence [71]. As such the salutogenic framework
for health care providers to possess more humane could be used as a perinatal parent education
qualities (i.e. midwives to stay calm and pro- framework to promote overall parental well-
vide emotional support), as opposed to just the being during the perinatal period [71]. There
delivery of tangible materials (e.g. provision of are only two existing reviews that consolidated
educational booklets) to provide positive and existing studies that examined Salutogenesis in
health-promoting services. perinatal health care. Smith et al. (2014) identi-
fied salutogenically focused outcomes (n = 16;
e.g. maternal satisfaction and breastfeeding) and
14.4.1 Salutogenesis Theory non-salutogenically focused outcomes (n = 49;
in Perinatal Health Care e.g. measures of neonatal morbidity) during
the intrapartum period (Smith et al. 2014). The
The salutogenic framework has been applied review implied a lack of salutogenically focused
in perinatal health care, specifically for fami- outcomes reported in intrapartum intervention-­
lies having a newborn. Existing salutogenically based research [74]. Perez-Botella et al. (2015)
focused studies addressed several phenomena examined how the Salutogenesis theory can be
across the perinatal period. Greer et al. (2014) utilized to address several parenting outcomes
explored mothers’ fear of childbirth and its across the perinatal period, and implied that the
impact on birth choices among women and their theory is rarely used in maternity care research
partners through interviews carried out within and urged future research to measure salutogen-
the SOC theoretical framework [72]. The find- itcally oriented outcomes to provide a balance
ings (i.e. riskiness, ways of coping, and being a in maternity care design [75]. Though there
good parent) were related to the three dimensions are increasing but limited perinatal studies that
of SOC (i.e. comprehensibility, manageability, adopted the salutogenic framework with major-
and meaningfulness) [72]. For instance, preg- ity of studies focussing on only SOC, there is
nant couples feared the repercussions of natural a crucial need to expand the utilization of the
childbirth and preferred medical interventions salutogenic framework and concepts in the salu-
over natural childbirth to cope with uncertain- togenic umbrella (other than SOC) to ensure a
ties and to ensure a smooth and safe transition to holistic application of the theory to encourage
parenthood [72]. The three dimensions of SOC health promotion during the perinatal period.
14 Health Promotion Among Families Having a Newborn Baby 179

14.4.2 Managing the Perinatal review conducted by Eriksson and Lindstrøm

Period with Physical Activity: (2006) synthesized empirical findings on SOC
A Salutogenic Approach and reported that stronger SOC is linked to better
health outcomes [87]. Stronger SOC was found
Women during pregnancy are generally sedentary to be associated with lower mortality risk [85],
and could gain excessive weight due to physical delay onset of cancer [88], and lower rates of dia-
limitations, increased appetite, and tiredness [76, betes [89].
77]. As a result, majority of the pregnant women During the perinatal period, one of the main
fail to meet the recommended level of physical contributing factor that lead to physical inactiv-
activity and this increases their risk of negative ity is lack of social support [76, 78]. Women
pregnancy conditions such as gestational diabe- reported that due to lack of support from their
tes and pregnancy-induced hypertension [77, 78]. partners to run errands at home and to care for
Also, the children of obese women during preg- older children, they often have limited time and
nancy are more likely to become obese adults tend to neglect their physical exercise. To pro-
[79]. Therefore, there is a need for health care mote a strong social support and to increase
professionals to inform pregnant couples about physical activity, the salutogenic framework can
healthy lifestyle choices such as the engagement pave the path in encouraging families to engage
in physical activity for health promotion during in physical activities together. On top of the two
the perinatal period [78]. Physical activity is rec- main components (i.e. GRR and SOC) of the
ommended as a health promoting approach that salutogenic theory, the other concepts from the
aid pregnant couples to cope with the bodily salutogenic umbrella such as connectedness [61],
changes throughout the perinatal period [80]. coping [63], and well-being [62], can be included
Also, physical activity has been found to be asso- to form a conceptual framework in the develop-
ciated with increased overall well-being during ment of family-focused interventions catered for
pregnancy, self-esteem, shorter duration of labor, the pregnant couples. For instance, during prena-
fewer depressive symptoms, higher prevalence of tal care, health care professionals (i.e. doctors and
natural childbirth [77], and reduced occurrence of midwives) have the unique opportunity to inform
gestational diabetes [81] and pregnancy-induced pregnant couples about the benefits of healthy
hypertension [82]. lifestyle choices such as walking and swim-
The Salutogenesis theory has been found use- ming and to recommend individualized exercise
ful in directing families to engage in physical routines and nutritional plans for couples to fol-
activity as a mean to cope with potential nega- low through. At this stage, pregnant couples can
tive pregnancy conditions during the perinatal be motivated to have a shared physical activity
period [83]. Frequent physical activity has been plan to enhance their connectedness [61] and
shown to be associated with strong SOC [83]. In thus supporting each other for a shared activity
Hassmen et al.’s (2000) population study signifi- that will eventually benefit them both physically
cant correlations were found between individu- and mentally. These individualized couple-based
als, both men and women, who exercised more exercise routines and nutritional plans can be
frequently with higher SOC than those who then enhanced with other shared physical and
exercise less frequently [84]. Another study from mental changes with the addition of the newborn
the Netherlands revealed that individuals with a during the postpartum period.
strong SOC engaged in sports more frequently During postpartum, shared physical activi-
and have better health outcomes such as lower ties and nutritional plans could continue to direct
average blood pressure [85]. The individuals couples and their newborn through connecting
with increased physical activity not only found to and benefitting the overall familial well-being.
have stronger SOC but also higher self-esteem, Hence, health care professionals who recom-
stronger control over bad habits, and more posi- mend physical activities and nutritional plans
tive attitudes toward changes in life [86]. A (Coping) help to provide a common ground for
180 S. Shorey

both mothers and fathers (GRR) with a newborn genic framework is a potential school of thought
(Connectedness) to manage the likelihood of that urges health care professionals to adopt in
negative pregnancy conditions. The adherence providing positive and health-promoting services
to exercise routines and nutritional plans could and care to assist families during the perinatal
aid in parental overall physical and mental well-­ period. Also, salutogenically focused qualitative
being (Well-being; SOC), improving their physi- studies that interviewed pregnant women and
cal and mental health. With connectedness and midwives during the perinatal period highlighted
appropriate coping to stressors throughout the the need for health care providers to possess more
perinatal period, the overall familial well-being humane qualities (e.g. emotional support) to
and SOC could be maintained using the available deliver positive and health-promoting care. This
resources, and thus, result in positive perinatal implies the need to train health care professionals
health outlooks and outcomes. Therefore, addi- such as midwives to be prepared and proactive in
tional concepts in the salutogenic umbrella can delivering optimal positive perinatal care. Future
be included on top of GRR and SOC in directing research can consider the salutogenic framework
the development of family-focused services. in designing midwifery education that focuses
on developing and testing strategies to support
midwives in this endeavour. The salutogenic
14.5 Literature Gaps, framework is well-positioned as a perinatal par-
Implications, and Future ent education framework and future research can
Research aim to design salutogenically focused interven-
tions (e.g. support groups and perinatal classes)
With rising prevalence rates of negative parental to promote parental well-being during the peri-
mental health during the perinatal period, moth- natal period.
ers and fathers reported negative feelings and Existing quantitative and correlational stud-
expressed needs to assist them during this period. ies have shown the benefits of being physically
The medicalization of childbirth resulted in aver- active during the perinatal period, but the major-
sive effects on maternal health and pregnancy ity remains physically inactive. This implies
outcomes and is coupled with a negative con- the need for health care professionals to inform
notation that pregnancy and childbirth are con- pregnant couples about healthy lifestyle choices
ceptualized as illnesses or diseases. Despite the for health promotion and prevention of negative
increasing efforts to promote natural physiologi- pregnancy conditions during the perinatal period.
cal childbirth, hospital and risk-focused cultures Future research can aim to adopt the salutogenic
continue to pose as strong barriers to normalizing framework in developing family-focused care
natural childbirth. Therefore, these pose as exist- services (i.e. exercise routines and nutritional
ing gaps in the literature that imply a necessary plans) catered to pregnant couples during the
shift of focus to one that provides a positive and perinatal period. It is also important to conduct
health-promoting experience for families with a further research on pregnant couples and factors
newborn. To bridge these gaps, health promotion that promote physical activity.
that integrates the Salutogenesis theory forms a
foundational basis that directs health care profes-
sionals and providers to design and deliver well-­ 14.6 Conclusion
being focused interventions and care services
for the pregnant couples and the new parents. There are increasing but limited perinatal stud-
Existing salutogenically focused studies that ies that adopted the salutogenic framework,
adopted quantitative (i.e. correlational studies especially elements of SOC in isolation. Future
and randomized controlled trials) and/or quali- research could expand the utilization of the frame-
tative approaches (i.e. in-depth interviews and work and concepts in the salutogenic umbrella
grounded-theory studies), implied that the saluto- beyond SOC to ensure a holistic application of
14 Health Promotion Among Families Having a Newborn Baby 181

the theory to encourage health promoting out- skills in conducting quality research that work
comes during the perinatal period. As majority toward the expansion of the framework and
of the existing studies are from the West, more concepts in the salutogenic umbrella beyond
studies from geographically diverse backgrounds SOC to ensure a holistic application of the
such as the Middle East and Asia are required theory to encourage health promoting out-
to explore and garner a holistic view of saluto- comes during the perinatal period.
genic framework and health promotion across the
perinatal period. In summary, salutogenic theory
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 Salutogenic-Oriented Mental
Health Nursing: Strengthening
15
Mental Health Among Adults
with Mental Illness

Nina Helen Mjøsund and Monica Eriksson

Abstract mental illness. As well as elaborating on the

features of salutogenic-oriented mental health
This chapter focuses on mental health pro-
nursing, and briefly present the Act-Belong-
motion with a salutogenic understanding of
Commit framework for mental health promo-
mental health as an individual’s subjective
tion as an example of salutogenesis in nursing
well-being encompassing both feelings and
practice.
functioning. Mental health is an ever-present
aspect of life, relevant for everybody; thus, to
Keywords
promote mental health is a universal ambi-
tion. Our chapter is written with adults with Act-Belong-Commit · Mental health · Mental
mental illness in need of mental health nurs- illness · Mental health nursing · Mental health
ing in mind. To understand the present and promotion · Nursing models · Psychiatric
make suggestions for the future, knowledge nursing · Salutogenic-oriented mental health
of the past is needed. We elaborate on his- nursing · Salutogenesis
torical trends of nursing, nursing models, and
the hospital setting to support our statement;
persons with mental illness need a more
complete mental health nursing care, includ-
15.1 Introduction
ing salutogenic mental health promotion. In
the last part of the chapter, we introduce the
We aim to use our own experiences to guide the
salutogenic-­oriented mental health nursing,
presentation in this chapter. For me, Nina, the
and further showing how salutogenesis can
first author of this chapter, the occupational and
be integrated in nursing care for persons with
professional life has been a journey of transfor-
mation from a nurse educated in psychiatric nurs-
N. H. Mjøsund (*) ing, mental disorders, symptoms, and risk factors
Division of Mental Health and Addiction, to find my identity as a mental health nurse.
Department of Mental Health Research and
Development, Vestre Viken Hospital Trust, Today I am intrigued by the constitutional char-
Drammen, Norway acteristic of resources and strengths in human
e-mail: nina.helen.mjosund@vestreviken.no beings, which of course also applies to persons
M. Eriksson with mental illness. These values, beliefs, and
Department of Health Sciences, University West, my respect for persons struggling with mental
Trollhattan, Sweden disorders are grounded in experiences acquired
e-mail: monica.eriksson@hv.se

© The Author(s) 2021 185

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_15
186 N. H. Mjøsund and M. Eriksson

at wards in hospital settings. The majority of my The promotion of mental health for people
training gave prominence to the traditional role with mental illnesses is an issue for the nursing
of caring for the sick. The opportunity to be edu- workforce all over the world. People who live
cated in public health and health promotion was with mental disorders deserve support to cope
a turning point to embrace an expanded role as and recover from their illness as well as support
a “mental health nurse.” In this journey, Monica to strengthen their general health. We claim that
has been an excellent guide into the theoretical the population with mental disorders is in great
landscape of salutogenesis. need of health promotion interventions including
For me, Monica, the second author, salutogen- the improvement of physical, social, spiritual,
esis has been my research interest from the very and mental health, due to 15–20 years shorter life
beginning and up to date, more than 30 years expectancy compared with the general popula-
of education and research. As a former social tion [1]. However, the focus in this chapter is on
worker at a hospital and with work experiences salutogenic mental health promotion.
among disabled people, my focus has always To understand the present and the future,
been on peoples’ resources and their ability to knowledge about the past is needed. Thus, we
overcome difficulties. Aaron Antonovsky and highlight elements from some widely used nurs-
his salutogenic theory and model of health gave ing theories, which several decades ago brought
me the knowledge and prerequisites to immerse health promotion and health maintenance into
myself in what leads to health instead of the nursing science. Building on nursing theories,
causes of illness. salutogenesis, and knowledge of the essence of
Together we, Nina and Monica, share the health in general and mental health in particu-
desire to enhance the prerequisite for strength- lar, we end up with a proposal for a more holis-
ening mental health of persons in need of hos- tic and coherent nursing care, including both
pitalization in mental health care. Salutogenesis salutogenic-­oriented nursing, and pathogenic-
has become the air we breathe. We possess exten- oriented nursing. In order to emphasize the
sive experiences from close collaboration with significance of salutogenic mental health promo-
persons living with severe mental disorders in tion in nursing practice, we describe features of
projects, both in health research and in clinical the salutogenic-­oriented mental health nursing,
quality enhancement projects. We pay tribute to and its application in clinical practice in mental
service user involvement. Thereby, this chapter health services.
emphasizes an insider perspective on how men-
tal health promotion is perceived grounded in
patients’ lived experiences. 15.1.1 Methods
An elaboration of the salutogenic orientation
applied on health and mental health clarifies the The choice of theoretical perspectives, models,
main theoretical underpinning in this chapter. interventions, and evaluations presented in this
Until we have arrived at explaining the content chapter have been influenced by the usefulness
and application of salutogenic-oriented mental for performance of clinical nursing and health
health nursing, we start with our understanding care in the specialized health care services.
of health in general and mental health in partic- Further, this chapter emphasizes an insider per-
ular. We continue to explain what we mean by spective on how mental health promotion is per-
salutogenic mental health promotion. The dif- ceived grounded in patients’ lived experiences.
ference between interventions aiming for health The chapter is inspired from our own empirical
promotion and the prevention of disorders will research [2–7], as well as extensive theoretical
further be elaborated. analysis and review reports [8–14]. The litera-
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 187

ture we build on is mainly grounded in qualita- (1979) explained health as a movement along
tive research. More common in the field of public a continuum between ease and dis/ease,1 and
health as well as in medicine dominated hospital rejected the dualism of the health–disease dichot-
settings are the observational data and quantita- omy. Health promotion is about the movement
tive research. towards health, with emphasis on assets, actions,
Theoretically we rely on two salutogenic and interventions that aim to promote health as
health theories, the salutogenic theory by a positive outcome. Adult lay people in Norway
Antonovsky [9, 15, 16] and mental health as conceptualized health by six essential elements:
flourishing by Keyes [17–20]. Additionally, the well-being, function, nature, a sense of humour,
presentation was substantiated with a literature coping, and energy [21]. In the same study, health
search including the words health care, health was characterized by three qualities; Wholeness:
promotion, mental health promotion, mental health is a holistic phenomenon. Health is related
health care, mental illness, mental disorders, to all aspects of life and society. Pragmatism:
nursing, salutogenesis, and service user involve- health is a relative phenomenon. Health is expe-
ment. The examples in this chapter are drawn rienced and evaluated according to what people
from the context of the Nordic countries, as this find reasonable to expect, given their age, medi-
is where we, the authors, are educated, have our cal condition, and social situation. Individualism:
work experience, and are living. health is a personal phenomenon. Every human
being is unique, and health and strategies for
health must be individualized [21]. It has also
15.2 Health in Salutogenic been shown that nurses in mental health services
Theoretical Framework perceived health as more than the absence of dis-
order [22].
Salutogenesis offers a resource-oriented and
strength-based perspective on health, and we will
therefore especially emphasize some aspects of 15.2.2 Mental Health
the existing knowledge base.
No health without mental health—indicating a
discourse including mental health in a positive
15.2.1 Health sense [23]. Antonovsky [24] described mental
health as a continuum. A person’s location on a
Everyone’s health gets affected. Health is a fun- mental health continuum included the presence
damental part of human beings. However, what of a positive aspect, a sense of psychological
constitutes the quality of health might be per- well-being. Antonovsky defined mental health as
ceived differently. The authors of this chapter more than the absence of something negative:
share a common understanding of the concept of Mental health, as I conceive it, refers to the loca-
health, i.e. health is always something positive, tion, at any point in the life cycle, of a person on a
something we want more of, and want to pro- continuum which ranges from excruciating emo-
mote and protect. A salutogenic approach to the tional pain and total psychological malfunctioning
at one extreme to a full, vibrant sense of psycho-
study of health focuses on the genesis or sources logical wellbeing at the other [24], p. 274].
of health, as well as circumstances promoting
or undermining health. A salutogenic orienta- 1
In Antonovsky’s original writings he consequently used a
tion includes a broad focus on resources, assets, hyphen between dis and ease describing the health con-
and strengths leading to positive outcomes, tinuum as ease–dis-ease; however, according to programs
which is different from the more limited focus in that automatically correct misspelled words the hyphen
often disappears, therefore, in this chapter we will use a
Antonovsky’s [16] Model of health. Antonovsky slash; ease-dis/ease).
188 N. H. Mjøsund and M. Eriksson

A salutogenic orientation focuses on the rienced in everyday life as a sense of energy.

achievement of a successful coping, which facili- Health was not perceived as changeless, but as
tates movement towards that part of the mental a fluctuating and dynamic phenomenon. The
health continuum that is a vibrant sense of psy- participants perceived mental health as a move-
chological well-being. Mittelmark and Bull [25] ment, like walking up or down a spiral staircase,
show passages by Antonovsky indicating that equivalent to a continuum [6], as illustrated in
his understanding of health was an aspect of the Fig. 5.2 in Chap. 5.
broader construct of well-being.
Inspired by salutogenesis, the research of
Corey Keyes [17] focuses on subjective expe- 15.2.3 Mental Health Promotion
riences of mental health. Keyes views men-
tal health as the presence of positive states of In the field of mental health promotion, it is
human capacities and functioning in cognition, essential to reflect on the understanding of
affect, and behavior. In line with Antonovsky, health and mental health, as well as how pro-
Keyes also questioned the commonly accepted motion relates. WHO [28] states that mental
definition of mental health as the absence of health promotion involves actions that improve
psychopathology. As elaborated in Chap. 5, psychological well-being. Mental health pro-
Keyes describes mental health as the presence motion is a contested term and might be enlight-
of psychological and functional well-being, thus ened from multiple perspectives [29, 30].
a ­positive experience, not the absence of infir- Salutogenic health promotion is an endeavor
mity. He labels a continuum and uses the term to promote health by actively and consciously
flourishing to describe high quality of mental focusing on strength and resources in people.
health or the most appealing position on the Mental health promotion can be explained as
mental health continuum. The opposite posi- activities to sustain, restore, and enhance men-
tion is labeled languishing, with moderate men- tal health. Mental health promotion might be
tal health in-­between. Keyes [26] argues that it applied on a policy and societal level, as well as
is not enough to see how people react. We also on an individual, family, group, and community
need to know how they feel and how they per- level. Salutogenic mental health promotion is
ceive their world. Mentally healthy people are directed towards improving, strengthening, or
described as being content with who they are and increasing the well-being of all people regard-
what they have, they feel socially and mentally less of mental illness or not. Interventions
competent, and emotionally stable [26]. Further, designed to enhance mental health and well-
mentally healthy people experience to be gener- being by increasing the coping capacities of
ally happy, enthusiastic, and energetic most of communities and individuals and by improving
the time, as well as being able to cope with prob- environments that affect mental health are also
lems and crisis in life [27]. described as mental health promotion [27]. The
Mjøsund et al. [6] used the salutogenic frame- goal for health promotion in society and on a
work as the theoretical foundation for studying population level should be to make health pro-
how persons with severe mental illness per- moting behaviors easier and more likely, and
ceived their world of mental health. The study simultaneously make health-depleting actions
participants were not talking about absence of more difficult. In this chapter, salutogenic men-
illness or disorder symptoms in their descrip- tal health promotion is explored by focusing on
tions; they claimed mental health was an aspect strength and resources at an individual level in
of being, that was always present and expe- mental health care settings.
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 189

15.2.4 T
 he Salutogenic Model “a global orientation that expresses the extent to
which one has a pervasive, enduring though
of Health dynamic feeling of confidence that: (a) the stimuli
from one’s internal and external environments in
Aron Antonovsky (1923–1994) challenged the the course of living are structured, predictable and
conventional paradigm of pathogenesis and its explicable; (b) the resources are available to one to
meet the demands posed by these stimuli; and (c)
dichotomous classification of persons as being these demands are challenges, worthy of invest-
either healthy or diseased [16]. He coined the ment and engagement" [15 , p. 19]
concept of salutogenesis, which means the origin
of health. Antonovsky saw health as a movement SOC includes three core dimensions: (a) com-
along a continuum on a horizontal axis between prehensibility, which refers to the extent to which
health/ease and dis/ease (see Fig. 15.1) [10]. He one perceives the stimuli that confront one as
saw the relationship between the two orienta- consistent, structured, and clear; (b) manageabil-
tions—pathogenesis and salutogenesis—as com- ity, which is the extent to which one perceives
plementary [15]. that the resources at one’s disposal are adequate
This model of health within the salutogenic to meet life’s demands; and (c) meaningfulness,
framework is resource-oriented focusing on which refers to the extent to which one feels that
peoples’ ability to manage stress and still stay life makes sense emotionally ([15], p. 16–18).
healthy. Salutogenesis is a way of thinking, being, How the core dimensions interact and together
acting, and meeting people in a health promotion influence SOC is illustrated in Fig. 15.2. The
manner [10]. It is not a personal trait or a spe- cognitive dimension comprehensibility is illus-
cial personality, but a life orientation or a way of trated with a thought bubble over the face to
viewing life as comprehensible, manageable, and draw attention to a capacity to judge the reality,
meaningful [31]. More generally, salutogenesis to understand what is happening. The hand illus-
refers to a scholarly orientation focusing atten- trated under manageability draws attention to the
tion to the origins of health and assets for health, instrumental or behavioral dimension, a practi-
contra the origins of disease and risk factors [32]. cal capacity to manage the situation. The heart
The core resources to counteract s­ tressors are the
sense of coherence (SOC) and generalized and Sense of Coherence
specific resistance resources (GRRs/SRRs) and
deficits (GRDs/SRDs) [15, 31, 33, 34]. SOC is
defined as:
Comprehensibility

STRESSOR

H– H+ Manageability

TENSION
SALUTOGENESIS

PATHOGENESIS Meaningfulness

BREAKDOWN
© 2020 Nina Helen Mjøsund

Fig. 15.1 The health continuum “ease/dis-ease” (Published

with permission from Folkhälsan Research Center, Helsinki,
Lindström & Eriksson [3]) Fig. 15.2 The dimensions of the sense of coherence
190 N. H. Mjøsund and M. Eriksson

under meaningfulness draws attention to which ing of mental disorders are influenced by time
one feels that life makes sense emotionally, that and culture, and the use of terminology associ-
the challenges in life are worth investing energy ated with disease is complicated and contested
in, and are worth our commitment and engage- [36–38]. Dominant diagnostic systems in the
ment. The arrows around the dimensions help us field of psychiatry use different terminologies,
to remember that these dimensions are involved the ICD-10 [39] uses classification of diseases
when individuals are in interaction with the envi- and the DSM-5 [40] uses classifications of dis-
ronment as they constantly go through challeng- orders. Severe conditions of mental disorders
ing situations. often broadly include disorders in the bipolar and
GRRs provide a person with sets of resources schizophrenia spectrums, and complex comorbid
to promote meaningful and coherent life experi- conditions with substance abuse disorders, as
ences. GRRs are found in people and bound to well as life-threatening depressions. Severe con-
their person and capacity, but also to their imme- ditions often persist over time and contribute to
diate and distant environment [15, 33]. SRRs are serious difficulties in personal and social func-
context and situation bounded. Through SOC tioning, thereby reducing the affected person’s
the GRRs enable one to recognize, pick up, and quality of life [41].
use SRRs in ways that keep tension from turning The experiences of mental distress, prob-
into debilitating stress [34]. Salutogenic nursing lems, and mental disorders are common and
interventions aim to aid the patients to be aware, often underreported. According to an EU sur-
and use their GRRs/SRRs. vey, one third of Europeans suffers from men-
The Global Working Group on Salutogenesis tal, neurological or substance abuse diagnoses
(GWG-Sal) has identified key avenues for (prevalence) [42]. Nordic patients with mental
future development of the concept of salutogen- disorders seem to have 15–20 years shorter life
esis to create a sound scientific base of health expectancy than the general population largely
promotion [35]. There is a need to advance the due to lifestyle-­ related noncommunicable dis-
original salutogenic model of health by add- eases [43]. A systematic review and meta-anal-
ing an additional positive health continuum ysis [44] showed that people with schizophrenia
operating independently of stressors, as well are associated with at least 14 years potential life
development of alternative approaches to the lost. To reduce this mortality gap, the situation
conceptualization and measurement of the requires urgent development and implementation
SOC [35]. of interventions.
We do not underestimate the fact that persons
with mental disorders are in great need of life-
15.3 Setting: The Patients’ style interventions targeting behavior to prevent
and the Nursing Context somatic illnesses and to improve their physical
health. However, less attention seems to be on
The population discussed in this chapter is per- behavior related to strengthening mental health.
sons diagnosed with mental disorders receiving We realize that in clinical practice, it is difficult,
nursing and health care services in specialized nor desirable, to separate initiatives to promote
mental health care. physical, social, spiritual, or mental health.
However, theoretically, in publications and in
compilation of knowledge it can be relevant to
15.3.1 Persons with Mental Disorders shed light on certain parts of a larger context.
Here, we aim to elaborate on one part of a larger
People experiencing mental disorders are just picture, which is salutogenic mental health pro-
as different as anyone else is. The understand- motion for persons with mental disorders.
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 191

To avoid confusion with Antonovsky’s ease-­ do not get the attention they deserve by nurses
dis/ease terminology we avoid the use of the and other health professionals in the health care
word disease. To denote a diagnosed condition sector. Nurses are in a unique position for health
we use the term mental disorder. When focusing promotion due to their presence in services
on the individual experiences of struggling with across society, their continual attendance with
mental problems or living with a diagnosed con- patients night and day, and the close relation-
dition we use the term mental illness. ships they often develop with patients and next
of kin. Nurses constitute a powerful group when
wanting to reach and impact a large part of the
15.3.2 Nursing in the Context population.
of Mental Health Care Besides somatic treatment and psychothera-
peutic interventions, treatment for patients with
Traditionally, mental health nursing and health severe mental illness should also include psy-
care in hospitals have been directed towards chosocial interventions [41]. Berg and Sarvimäki
persons diagnosed with a mental disorder or [47] introduced a holistic-existential approach to
a suspected mental disorder. The main issue health promotion in nursing. They defined health
for nursing is the consequences of the disorder promoting nursing as “planned nursing actions
and coping in daily life. Hospitalized patients designed to meet the needs of individuals, fami-
are often individuals with severe, multiple, and lies and communities in their efforts to deal or
complex needs and long-term conditions. The cope with health challenges that they presently
impairment of self-care and disturbance of daily encounter in daily life or that might appear in the
activities, as altered sleep pattern, bad nutri- future… The aim of nursing is to support human
tion, inactivity, strained relationships, and use of beings in their need of knowledge and to offer
drugs in combination with increased intensity of practical assistance in order to cope with illness
symptoms of the disorders might require hospi- experiences and suffering and, thus, to stimulate
talization. Patients affected with a severe mental healthy living” ([47], p. 390).
disorder might be in great need of nursing; acute
episodes might require total and lifesaving care.
Nurses must apply their comprehensive knowl- 15.3.3 Health Promotion
edge about mental disorders to assist the patients in the Specialized Mental
to cope with consequences of the individual ill- Health Care Services
ness in daily life. User-led qualitative research
revealed that individuals with complex needs Despite launching the Ottawa charter nearly four
appreciate trusting relationships with profes- decades ago [48], and the messages reinforced
sionals, within a positive framework that fosters in the New Haven recommendations [49], hos-
self-­belief and which is focused on salutogenesis pitals all over the world are still characterized
rather than pathogenesis [45]. mostly by a pathogenic and biomedical approach.
A large part of the global nursing workforce, Psychiatric treatment and care of patients in
practices within primary and secondary health mental health care hospitals are dominated by
care settings in a rehabilitation, residential, or diagnosing, treating, and caring for persons with
community setting. This workforce is claimed severe episodes of mental disorders, as well as
to be a sleeping giant in health promotion [46]. acute and lifesaving interventions. Both nursing
Promotion and maintenance of mental health, and medical interventions are often introduced
beyond the responsibility to provide curative with rather acute and short-sighted perspectives,
services for adults with severe mental illnesses, putting the long-term focus of health promotion
192 N. H. Mjøsund and M. Eriksson

and quality of life in the shadow. A reorientation increase coping, competences, good feelings,
of the health care services is stated to be the least and well-being. Our aim is to promote a nursing
systematically developed, implemented, and practice based in salutogenic thinking, feeling,
evaluated key action area outlined in the Ottawa and acting. Antonovsky saw early the potential
Charter [50], and new ways to reorient the in nursing to become an important profession to
health services towards the promotion of health promote a salutogenic orientation. In the preface
are requested [51, 52]. The reorientation of the of his second book he said: In writing this book,
health care system is also requested by patients I have also had another group in mind: nurses,
with mental disorders [3]. The timing for health going through the fascinating throes of formu-
promotion seems to be good during hospitaliza- lating a new professional identity, are perhaps
tion when the awareness of health is heightened more open to my ideas and ways of thinking than
[53]. Former inpatients have described the hos- almost anyone else ([15], p. xiv).
pital admission as a window of opportunity for Our vision is to contribute to a more com-
choosing a healthier way of living, with the help plete mental health nursing practice, where
of all the (human) resources available under hos- an illness and disorder-oriented approach are
pitalization [5]. complemented with a health-oriented approach
The role of nurses in the hospital is under- based on salutogenesis. For the understanding
going transitions, including redefining aspects of salutogenic-­ oriented mental health nursing,
of professional work, more complex and com- we want to clarify the distinction between a
plicated conditions and acute crises as well as salutogenic versus a pathogenic orientation. We
changing reimbursement systems [54, 55]. The explain the different meanings of treatment and
scene has changed and other health care provid- prevention of disorders and disability, on to pro-
ers such as psychologists, social educators, social tect and maintain mental health, as well as the
workers, psychiatrists, and counselors overlap understanding of promotion of health, includ-
with the nurses in mental health care hospital ing physical, social, spiritual, and mental health.
settings. This situation might cause controver- There are differences between these concepts,
sies and role confusion in everyday life at the which have significance for how to work in dif-
workplace. To define the scope of nursing as well ferent contexts. Our suggestion is explicitly to
as the other professions and to promote distinct include salutogenic mental health promotion in
roles of mental health nurses and other profes- nursing practice. Nurses should utilize saluto-
sions will be important for future development of genic knowledge to emphasize the persons’ level
these services. of mental health and initiate health promoting
interventions, alongside a focus on the status of
mental illness in planning these nursing inter-
15.3.4 T
 owards a More Complete ventions. We claim that nursing in mental health
Mental Health Nursing care services should include two complementary
purposes in their portfolio; a health-oriented and
We want to argue for a development towards a an illness-oriented approach, as illustrated in
mental health nursing science and practice that Fig. 15.3.
more explicitly includes knowledge from saluto- Figure 15.3 illustrates the combination of
genesis. We do not claim this is a new approach, knowledge from both salutogenesis and patho-
as many years ago, the salutogenic model was genesis, as the base for promotion and protection
claimed to be suitable for adaptation in nursing of health, as well as the treatment and prevention
milieu [56, 57]. Salutogenic-oriented mental of disorders. The knowledge base of salutogen-
health nursing is rather a conscious application esis in partnership with the knowledge base of
of health promotion, based on beliefs about the pathogenesis complements each other, as well as
human potential, intertwined in interventions to contrasts each other by different area of interest
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 193

The aim of a more complete mental health nursing:

To provide care for persons with mental illness and promote health

Health oriented Illness oriented

Aim: To achieve something positive Aim: To avoid something negative
Knowledge base: Salutogenesis Knowledge base: Pathogenesis
Focus: Resources strengthening health Focus: Risk factors and symptom reduction

Prevention of
Protection and Treatment of
Promotion of health disorders, disability
maintenance of health disorders
and illness

© 2020 Nina Helen Mjøsund

Fig. 15.3 Aims, knowledge base, and focus of a more holistic mental health nursing

[8, 58–60]. Our message is underlined by Becker Moreover, the desired positive outcomes are
and Rhynders’ [61] use of mathematic analogy: different in these two paradigms. Within a salu-
“Pathogenesis is about subtraction and how to togenic way of working, the anticipated outcome
take away bad conditions, risk factors, or threats. is to have more health and well-being. Inspired
Salutogenesis, on the other hand, is about addi- by salutogenesis, the aim is to create progress
tion and how to add positive actions, opportuni- towards desired improvements and gains and
ties, conditions, and outcomes” [61, p. 2.]. protect against something that may cause regres-
Antonovsky [62] described similarities and sion of health. This is the realm of promotion.
differences between the two paradigms and In contrast, to be working within a paradigm
argued for salutogenesis as a more powerful of pathogenesis where the anticipated outcome
guide for health promotion research and practice is no disease, the emphasis will be on a prob-
than the pathogenesis. A pathogenic orientation lem. The best possible outcome from a problem
embraces a dichotomous classification of dis- is the lack of a problem, i.e. no symptoms of a
ease or absence of disease. Pathogenesis assumes mental disorder. A more complete mental health
that if nothing causes mental illness, good men- nursing practice requires knowledge from both
tal health will be manifest. Antonovsky [16] paradigms.
­followed a continuum line of thought in his salu- To understand the present and the future, we
togenic model of health. The health continuum need to understand the past. Thus, after giving
contains an end of ease where you aim to stay and the theoretical contextualization of mental health
to protect your position, as well as an adverse end nursing we proceed forward to explain the work
of dis/ease from which you want to leave. Both of influential nursing theorists. In the next sec-
paradigms have a focus on factors; salutogen- tion, we highlight some nursing theories, which
esis on salutary factors that promote health and have contributed substantially to the nursing sci-
pathogenesis on risk factors that might cause dis- ence of today. Their work might help us to a) dif-
orders. Taking a point of departure in salutogen- ferentiate the role of nurses from other health care
esis helps nurses relate to all aspects of a person professionals by delineating the unique focus of
using a holistic approach. Within the pathogenic nursing, and b) facilitate a reorientation of the
paradigm, a more reductionist approach leads to nursing practice to include an explicit focus on
a focus on a particular diagnostic category [62]. salutogenic mental health promotion.
194 N. H. Mjøsund and M. Eriksson

15.3.5 F
 rom Nightingale to Keyes: and holistic nursing, which were what persons
The Foundation with mental disorders also demanded and appre-
for Salutogenic-Oriented ciated [2, 6].
Mental Health Nursing Care Dorothea Orem claimed that the proper
focus of nursing was self-care [65]. Her Self-
Standing on the shoulders of giants is a metaphor Care Deficit Nursing Theory has similarities to
to draw attention to the importance of building those of Nightingale and Henderson, but Orem
on existing knowledge. Standing on a founda- increased the emphasize on achieving health by
tion of knowledge makes us able to visualize the individual’s ability to care for themselves
the future and make theoretical suggestions to [65]. According to Orem, self-care was activi-
improvements in clinical practice. First of them ties that the individual performed on their own
all, Florence Nightingale [63] claimed that the to maintain life, health and well-being. Normally,
aim of nursing were to promote the body’s ability adults care for their own needs, so the human
to heal and recover itself. Nurses should facili- ability for engaging in self-care was termed self-­
tate the healing processes by caring for a proper care agency. Infants, children, the aged, the ill or
selection and administration of a diet, fresh air, the disabled required nursing in form of complete
light, warmth, cleanliness, and hygienic condi- care or assistance with self-care activities in their
tions, and reduce unnecessary emotional stress day-to-day living [65]. Self-care contributed to
as well as carefully observe the patient’s condi- human functioning and development based on
tion. Nightingale [63] believed that the patient in self-care requisites in three categories: (a) uni-
their environment was the main focus for nurses. versal, (b) developmental, and (c) conditions of
Nightingale claimed that nursing was to care for illness, disorder, or injury [65]. The category of
the basic needs of human beings and promote universal self-care requisite includes resources
health and well-being. Inspired by a salutogenic vital to the continuation of life, to growth and
approach, we argue that Nightingale was the development, as such as air, food, water, elimina-
first health promoter in nursing science with her tion processes, activity and rest, social interaction
focus on promoting health and well-being of her and solitude, as well as human well-being. The
patients. developmental requisite comprised conditions to
Another influential nursing theorist for men- support life processes and needs related to vari-
tal health nursing was Virginia Henderson. In her ous stages of development in the life course. The
book “the Nature of Nursing” [64], she defined last category of requisite was related to situations
the unique function of nursing as to assist the of disorders or injury. There was a need to seek
person in performing activities contributing to appropriate medical assistance for conditions
health or recovery that the individual could have of human pathology and carry out medical pre-
performed themselves if they had the strength, scribed treatments, caring for side effects of the
the will and knowledge, and always with the aim treatment, as well altering one’s life-style to pro-
to help them gain independence as rapidly as mote personal development while living with the
possible [64]. Both Nightingale and Henderson side effects of pathology and medical treatments
saw nursing acts as assisting or doing on behalf such as medicine.
of the patient, but never doing more than the The self-care deficits delineated when nursing
patient can do independently or by supervi- was needed, and a nurse–patient relationship was
sion. This tuning towards the patient’s mental required. Where the nursing relationship was not
and physical condition and environmental situ- limited to just one individual, but the receiver of
ation was the essence of the art of nursing. It nursing care could be a family, a group or com-
was crucial to empower the patient to self-care munities. The roles of the nurse and the patient
as soon as possible. Seeing the patients as part were complementary in that a certain behavior
of a greater society, always in interaction with of the patient elicited a certain response in the
their environment contributed to a broader view nurse, and vice versa. A self-care deficit requires
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 195

nursing activities. The self-care concept facili- former nursing giants to apply health promo-
tates an involvement of the patient in the nursing tion more explicit in their clinical practice. The
planning, prescribing, providing and evaluating. reason for this is based on knowledge we pos-
A model of practice termed Treating Self-Care sess about contemporary clinical practices, the
Deficits Related to Mental Health Functioning population in focus, and international guidelines
has been developed as part of a mental health as the Ottawa charter [69], as well as the fact
nurse practitioner master’s program grounded in that persons with mental disorder demand more
Orem’s model [66]. health promotion [3].
Katie Eriksson’s theory of caritative caring To be able to develop, implement and measure
has been influential in nursing and other car- the outcome of mental health promotion initia-
ing professions in the Nordic countries [67]. tives, we need to make overt the applied defini-
In her philosophical theory of caring, Eriksson tion of mental health. Rather than arriving to a
claimed that the basic motive, the substance and consensus on a definition of health for the use in
the distinctive character for caring were caritas, the total field of health promotion, Mittelmark
which was by nature unconditioned love. In a and Bull [25] argue for a pragmatic approach
health promotion context, it is appropriate to where scientist and health promoters make overt
highlight her concept analysis of health [68]. which definition they use in different project and
She defined health to be constituted by two settings.
dimensions; the objective dimension of sound- Antonovsky’s [15, 16, 62] work on salutogen-
ness and freshness and the subjective dimension esis and health promotion is essential for nursing
of well-being. Health was seen as more than the and health promotion. However, we claim that
absence of illness, and was conceived as move- his definition of health as a continuum between
ment and integration, a becoming. Eriksson [68] ease and dis/ease is not sufficient. A close read-
illustrated the health dimensions in a crosshair ing of Antonovsky’s writings gives no indication
which included a vertical line representing the that he separated health from disease. Further,
subjective dimension of well-being, and a hori- several passages of his writing might be under-
zontal line which represented objective dys- stood as he included disorders and similar condi-
functional attributes. tions in the dis/ease pole of the health continuum.
Antonovsky [15] defined the positive end of the
continuum in a negative way by the focus on the
15.3.6 Towards a Distinct absence of pain, functional limitations, acute
Understanding of Mental or chronic prognosis and health-related action
Health in Mental Health implications [35]. See also discussion in the
Nursing Handbook of Salutogenesis, chap. 49 [70].
Katie Eriksson [68] gave an important con-
In the nursing science we see traces on health tribution to the understanding of health through
promotion already in Nightingale’s work [63] her concept analysis. She included by her health
when she claimed long ago that nursing is to definition an objective dimension representing
promote health and well-being for the patients. symptoms of disorder or objective dysfunctional
Also Henderson [64] argued that the aim of attributes, together with a subjective dimension
nursing was to contribute to health and Eriksson of well-being. Later, and even more specific, we
[65] claimed health to be more than the absence again can find a subjective dimension of well-­
of illness. As one of many nursing theories we being in a mental health definition. Keyes [20]
judge the conceptual framework of Orem [65] defines mental health as an individual’s subjec-
to be highly compatible with a salutogenic tive well-being, in term of their affective state and
orientation. We want to inspire mental health their psychological and social functioning, and
nurses and other health professionals working good mental health is described by the metaphor
with persons with mental disorders to build on flourishing (see Chap. 5 for a thoroughly elabora-
196 N. H. Mjøsund and M. Eriksson

tion of Keyes work). Besides Keyes’ work on a rather we challenge health professionals to put
definition of mental health [20], he has also given in elements to adapt the theoretical foundation
important contribution to the field by his two to their actual setting. The main issue for us is
continua model of mental health and mental ill- to complement the pathogenic orientation with
ness in the same context or picture (see Fig. 5.4). a salutogenic orientation to promote mental
This complete picture is helpful for nurses and health for everybody and in the context of this
health promoters working with adults living with chapter especially for adults with mental disor-
a mental disorder by making it possible to hold ders. Further, we want to elaborate on one of the
both of these phenomena in mind at the same elements in Fig. 15.4, namely the salutogenic
time. In the setting of mental health nursing, orientation as one important ingredient in the
based on the elaboration and assessment of the art of nursing.
theoretical models and conceptual frameworks
presented in this chapter, we suggest applying a
distinct definition of mental health encompassing 15.4 Implementing Salutogenesis
both feelings and functioning, based on Keyes’ in Mental Health Nursing
model of mental health (see Chap. 5). Practice
Inspired by the work of Keyes, we see the
potential in combining elements of theoreti- The time is ripe. Nurses have the knowledge to
cal framework from different times, cultures, design evidence-based nursing aiming actively
disciplines and sciences to underpinning the
­ to promote patients’ mental health, i.e. saluto-
today’s art of nursing. Fig. 15.4 illustrates essen- genic mental health promotion. In the context of
tial elements and areas of knowledge to make up this book we want to give a more comprehensive
a more complete mental health nursing practice. elaboration of some features of the salutogenic-­
In Fig. 15.4 the salutogenic orientation is oriented mental health nursing, including some
of equal value as the pathogenic orientation. practical examples. We will continue with a
We do not claim this collection to be complete; presentation of some features of salutogenic-­
oriented mental health nursing as illustrated in
the highlighted chart pie in Fig.15.5.
First, we give attention to the holistic approach
to the person in need of care, including the per-
son’s environment. The second feature is atten-
Salutogenic Pathogenic
tion to the person’s strength and resources and
orientation orientation to the persons own experiences of coping and
adaption in life. The third feature we want to
elaborate on is saluseducation, a concept first
used by Mjøsund [3, 8]. When the nurses teach
Nursing The knowledge base of a Human
theories more complete mental development and supervise persons about salutogenic mental
health nusing practice
health promotion, they conduct saluseducation.
The fourth prerequisite for salutogenic-oriented
Individual Social and
mental health nursing is to get access to the
specific environmental patients’ experiences, which demands an active
knowledge conditions
involvement of the patient in planning and imple-
mentation of nursing. We also want to empha-
size the need to bring the patient perspective
into this knowledge production; the service user
© 2020 Nina Helen Mjøsund
involvement in research. Nursing research should
Fig. 15.4 The knowledge base of a more complete men- involve patients and other service users actively
tal health nursing practice in studies.
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 197

Fig. 15.5 Features of

salutogenic-oriented
mental health nursing – Salutogenic oriented
as part of a more mental health nursing:
complete mental health
nursing practice 1) Holistic orientation
2) Strength and resource focus
3) Saluseducation
4) Service user involvement in
planning and evaluation
5) Service user involvement in
knowledge production Pathogenic
orientation

The knowledge base of a

more complete mental
Nursing Human
health nursing practice
theories development

Individual Social and

specific environmental
knowledge conditions

© 2020 Nina Helen Mjøsund

15.4.1 A
 Holistic Orientation oriented nursing will always expect to find some
to the Patient with Mental assets and resources in every human being, which
Illness make the patients able to cope with simple or dif-
ficult tasks that can promote a feeling of mastery,
Salutogenic-oriented mental health nursing even in the most acute situation.
includes a view of human beings as whole per- A salutogenic approach to nursing in mental
sons (mind, body and spirit) who are inseparable health care services might balance the dominant
from their environment. In a holistic approach, emphasis on disorder symptoms and risks, as
the nurse includes a broader perspective and con- well as the common language that reinforces a
siders the patient as part of a larger context. The focus on disorder. Acquiring new concepts from
history of a person is significant beyond the ill- salutogenic theory will contribute to more com-
ness history, or the person’s single symptom of prehensive and holistic knowledge. One example
illness [71]. The patient’s socio-economic status is given by Langeland [72]; she claims using
and social network, such as family or next of the word person and not patient consistently
kin, friends, and professional relationships, are will help us be aware that it is the whole person
significant sources in the nursing assessment. we are focusing on and not just the diagnosis.
They might contribute to understand more of the Antonovsky [15] was occupied with a holistic
individual’s daily life, as well as being sources view on human beings, focusing on the history of
of GRRs and potential stressors in the patients’ the person more than the symptoms, risk factors,
environment. A nurse trained in salutogenic-­ and the organ dysfunction.
198 N. H. Mjøsund and M. Eriksson

Different labels are used to describe approaches achieve currently, and increasingly more in the
similar to salutogenic nursing; we might mention future, creates hope and optimism. An explicit
holistic nursing and integrative health care [73]. focus on salutogenic mental health nursing has
A review of the nurses’ role in health promotion the potential to strengthen a holistic and health-­
practice shows that their activities were guided oriented nursing practice [57].
by an individualistic and holistic approach to Influenced by Orem’s conceptual model of nurs-
help patients and families make health decisions ing [65], the self-care agency of the patient here and
and support them in health promotion activities now is assessed. The nurse need to take into consid-
[74]. Salutogenic mental health promotion nurs- eration the ability of the patient to act independently,
ing is characterized by targeting issues of cop- or by supervision, to satisfy self-­care requisites of
ing in everyday living. Nurses need to mind the universal, developmental, or disorder-related con-
here-and-now situation in the hospital while they ditions. Mental health nurses applying salutogenic
give attention to the patients’ environment and mental health nursing emphasize the opportunities,
the context of daily life. Beside somatic treatment resources and coping methods, as well as creating
and psychotherapeutic interventions, treatment confidence for the patient that growth and develop-
for patients with severe mental illness should also ment are possible. Building qualitatively good rela-
include psychosocial interventions [41]. tions based on subject-to-subject relationships is an
See box 15.1 for an example of a clinical situ- important foundation of the salutogenic approach,
ation illustrating a holistic approach. and nursing planning conducted in an atmosphere
of partnership and equality with the patient is
essential. A nurse–patient relationship should be
Box 15.1 Example of a Clincial Situation established based on the recognition that each hold
Focusing on a Holistiv Approach expertise in different fields. Where the patient is
Nursing situation: Afternoon shift in an the expert in their life, with a range of experiences
open inpatient unit. A man in his 50s is living with a mental disorder, and the trained nurse
troubling with psychosis symptoms and do brings experiences from a large range of patient-
not want to take a shower. meetings. Together these perspectives form the base
Nurse: Can you remember taking a foot- for nursing interventions, and finding the right “fit”
bath from your childhood? between the patient and the nurse.
Patient: … hmm, I remember taking A nursing planning process includes an assess-
footbath at my grandmother’s place. ment of the patient’s resources and strengths.
Nurse: I can arrange it for you now, your Significant knowledge is part of the patient’s
feet need some care. You deserve some actual GRRs/SRRs, as well as the ability to use
wellness by hot water and a softening soap. the resources. An explicit focus on coping and
I can cut your nails and apply some cream manageability based on utilization of GRRs/SRRs
to your feet as well. or getting access to new or extended GRRs/SRRs
Assessment: This situation facilitated might bring important hope, energy and optimism.
a dialog about the patient’s situation at This is a counterpart to the more common focus
home and the troublesome relationship to on symptoms, risk assessment, and what is wrong.
his brother. He had not talked to him for See box 15.2 for an example of a clinical situa-
5 years. The story ended with a telephone tion illustrating a strength- and resource-focused
call to his brother, assisted by the nurse. approach.

15.4.2 A
 Strength- and Resource-­ Box 15.2 Example of a Clinical Situation
Focused Approach Focusing on a Strength- and Resource-
Focused Approach
Salutogenesis leads us to consider the human Nursing situation: A primary nurse
resources to strengthen health. Sharing positive approaches a patient with psychosis who
expectations of what the patient can manage and
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 199

recovery and health promotion processes for per-

just started antipsychotic medicine. The sons with mental disorder [76]. A talk-therapy-­
nurse intends to become better acquainted group intervention based on Antonovsky’s model
with her patient’s daily life and her family of health for persons with mental disorders pro-
situation. They are together working with moted SOC, coping, and mental health [76].
the nursing plan for the next 2 weeks. Talk-therapy based on salutogenesis treatment
Nurse: Now when you are on antipsy- principles might be helpful in increasing cop-
chotic medication I know it is important to ing among people with mental disorders [77].
take a notice on your eating habits and your Psychosocial interventions aimed at families
relationship to food. are among the interventions supported by avail-
Patient: I like to cook, and I like new able evidence for individuals with severe mental
recipes. disorders [41, 78, 79]. The health benefits rising
Nurse: Wow, your interest in cooking from patient and family interventions aiming to
is positive, and a resource you possess. Do increase health literacy, social and practical skills
you know how to find out what the ingre- are relevant for mental health promoting nurs-
dients contain of calories, fat, sugar and ing. Family intervention is a structured method
proteins? for involving the patient and the patient’s family
Patient: Yes, I think so, but I’m not sure. … members in treatment and rehabilitation, includ-
Nurse: Should we go to a grocery shop ing family psychoeducation and skills training.
together on Wednesday to discuss some Family interventions helps patients and families
shopping and possible ingredients to make to cope through providing knowledge about the
healthy meals? disorder and its symptoms, signs, crisis manage-
ment, emotional support, and training in com-
munication and problem solving in every-day
15.4.3 Saluseducation: Learning life [41]. The broad and various elements in
Processes in Mental Health these interventions inspired from mental disorder
Promotion knowledge, as well as a solution orientation to
increase coping and mastery, make psychoeduca-
An important area of the nurse profession’ is the tion compatible with a salutogenic mental health
education, supervision, and guidance intentions promotion approach.
of nursing. Nurses should use their broad knowl- Psychoeducational interventions are asso-
edge to educate patients and families in the realm ciated with improved individual and social
of mental health promotion to increase coping and functioning and decreased relapse rates [41],
empowerment. Patient education is mandatory for therefore might educational activity be a GRR
specialized health care services in Norway [75]. that enhances the patients’ SOC. Many years ago,
One of the first traces of an educational function Landsverk and Kane [80] proposed that one of the
in nursing is found in Nightingale’s writings [63], processes through which psychoeducation works
when she claimed that nurses’ role was not only is in maintaining and enhancing an individual’s
to care for the sick, but also to teach proper caring SOC. The relationship between GRRs/SRRs
for those who care for the health of others. The and SOC seems to be a feedback loop: GRRs/
purpose of the book “Notes on Nursing” was to SRRs provide experiences that lead to coping and
write a guide to women on how to care for their enhanced SOC, and enables the patient to mobi-
family’s health, not a manual on nursing [63]. lize and use available resources [80].
Nightingale’s messages translated into current Persons with severe mental health disorders
mental health care practice of today: the role of express an appetite for learning [3], both about
nurses includes educational and training activities their disorder as well as their health in general.
for the patients themselves, as well as for those They requested saluseducation complementing
who care for their relatives or family members. a psychoeducational focus [3]. The saluseduca-
Potential opportunities associated with coping tion represents learning processes about health
in daily life after hospitalization is requested in and health promotion, including knowledge and
200 N. H. Mjøsund and M. Eriksson

skills relevant for everybody—to increase health schizophrenia spectrum disorders [85] have been
and well-being. Saluseducation is not delineated an important inspiration to coin and introduce the
to people with some illnesses, although salusedu- term saluseducation. Persons with mental disor-
cation should be tailored to each person’s indi- ders and their families embrace knowledge they
vidual situation. Saluseducation in groups might can apply immediately, without any assessment,
have a synergetic effect as persons with men- diagnosing, or remedies, just to help themselves
tal disorders emphasize the positive impact of to live healthy lives with better mental health and
spending time with others with the same mental well-being. Saluseducation together with psy-
disorder [3]. choeducation provides opportunities to satisfy
Empowerment represents a corner stone in the knowledge appetite that persons with severe
the field of health promotion. Nurses have the mental disorders have articulated [3].
responsibility to provide care to promote empow- See box 15.3 for an example of a clinical situ-
erment by the means of emancipation, self-­ ation illustrating saluseducation.
efficacy, and self-management of patients with
long-term mental illness [81]. Empowerment
was rated as the most important intervention in Box 15.3 Example of a Clinical Situation
health promotion in a study on attitudes towards Focusing on Saluseducation
aspects of health promotion interventions, and Nursing situation: The nurse is holding
the patients rated alliance and educational sup- an evening educational session for three
port significantly higher than the staff did [82]. patients with bipolar disorder and their
Empowerment might be reached by customizing next of kin at an inpatient ward.
learning processes, that takes into account the Nurse: Some of my patients are curi-
person’s individual situation, and sharing knowl- ous about what to do for themselves to
edge in a health promoting manner. achieve better quality of life in their every-
The participants in a study by Mjøsund day activities. One of the things we all
et al. [6], described the importance of being might be conscious about is our sleeping
of significance to each other and being able pattern. How long we sleep; when; sleep-
to support or assist others were perceived as ing hygiene like lower temperature in the
health promoting. Langeland, Gjengedal, and sleeping room; open window for fresh air;
Vinje [83] investigated salutogenic talk-ther- what the bed should be reserved for; and
apy groups; receiving constructive feedback regularities through the week and weekend.
from other participants in the group was sig- Now you might write down some questions
nificant in order to develop good relationships coming up and we discuss some of them in
and a participatory competence, resulting in a minute.
stronger identity, useful advices and tips as A father: I wonder about this afternoon
well as seeing things in new ways. Persons in nap. Could that be something that could
the group built salutogenic capacity based on help when you are a bit manic?
a sense of community and from the opportuni- Nurse: I put the question at the board.
ties to discuss and reflect together with other A young girl newly diagnose with bipo-
group participants who were perceived as like- lar disorder: When I visit my sister at
minded [83]. weekends, we stay awake until early morn-
Clinical experiences from psychoeducational ing—that is probably not wise, or? Is it an
treatment groups involving persons with bipolar explanation why? …
disorders [84] and family groups for persons with
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 201

15.4.4 S
 ervice User Involvement starting point can sustainable lifestyle changes
in Planning and Evaluation that promote health occur.
of Nursing See box 15.4 for an example of a clinical situ-
ation illustrating involvement of the patient in
We argue that it is essential to involve the per- planning and evaluation of nursing.
spectives of patients and their relatives to secure
a patient relevant focus in knowledge develop-
ment and practice. Service user involvement is a Box 15.4 Example of a Clinical Situation
prerequisite for salutogenic mental health nursing. Focusing on Involvement of the Patient in
Persons with mental disorders should be empow- Planning and Evaluation of Nursing
ered and involved in mental health advocacy, Nursing situation: A primary nurse is walk-
policy, planning, legislation, service provision, ing in the park with a young patient Ann,
monitoring, research, and evaluation accord- who was admitted a few days prior with her
ing to WHO [86]. The message to nurses is that first episode of psychosis. That afternoon, a
it should be mandatory and naturally for patients meeting is scheduled to plan the treatment
to be brought into the decision-making processes. and care for the next week. The psychiatrist
Crucial in recovery processes and in promotion of and the social worker will be there together
health is that patients and their families should be with the nurse. Ann is invited; however, she
given the opportunity to participate actively in part- is unsure if she will be there.
nership to promote shared decisions about care and Nurse: I know you have experiences and
treatments. A recent systematic review concludes information important for the planning of
that family interventions are effective for reducing your treatment and care. For you, what is
relapse rates, duration of hospitalization, and psy- most important?
chotic symptoms, and for increasing functionality Ann: I don’t know… I am not going to
in patients with a first episode of psychosis [87]. that meeting—and my cat has been alone
In collaboration with the main person and their since Thursday and I cannot give her food
next of kin the intents for nursing interventions being here.
and activities beyond life-saving care, must be Nurse: I see… So the wellbeing of your
agreed on. The relationship between the patient cat is important? This is exactly what we
and the nurse has been described, also by patients need to know. I want to facilitate the infor-
with serious mental disorders, as essential to mation exchange between you and your
achieve successful outcomes of health promotion team. We can do it in different ways. You
programs [88]. However, a recent study by Terry and I can write down three important things
and Coffey [89] showed that service user involve- for you, I bring it into the team and come
ment did not form an important part of mental back to you after the meeting. Alternatively,
health nursing processes. Service user involve- you come with me and I tell the others what
ment was seldom mentioned by nurses them- you and I have been talking about. You
selves and nursing work was rather described as have also another option. You might bring
task-focused, with limited collaboration with the with you somebody you trust. And you can
patients in areas like care planning [89]. of course leave whenever you want.
Patient-centered care involves the patient Patient: I do not want my father to be
in planning, delivering, and evaluation of the there, neither my mother… I called my
nursing care [90]. Patient-centeredness secures aunt Ellen yesterday…
a focus on the needs of the user as opposed to Nurse: Your aunt Ellen, do you trust
the needs of the hospital or the nurse. Applying her? Maybe she is someone you can invite
patient-centered care, the focus is on the patient’s to be together with you when we discuss
needs, values, and preferences. Only by actively how to facilitate your treatment and care…
taking the individual’s specific situation as a and what we can do to take care of your cat.
202 N. H. Mjøsund and M. Eriksson

15.4.5 S
 alutogenic Service User See box 15.5 for an example of a clinical situ-
Involvement in Knowledge ation illustrating the recruitment of a service user
Production and Research to a research project.

Experiential knowledge is an essential ingredi-

ent in the knowledge base of salutogenic-ori- Box 15.5 Example of a Clinical Situation
ented mental health nursing. Lived experiences Focusing on Service User Involvement in
of receiving nursing and other treatments in Knowledge Production and Research
health care are valuable for the development Nursing situation: Under a discharge con-
and improvement of the health care services. versation between the nurse and her pri-
The field of mental health research has a long mary patient, the nurse wants to recruit her
history of engagement with service users patient to become a service user in a project
[91]. In research and knowledge production, they plan at the ward. The project aim is
the perspective of service users should be to implement a national guideline for the
included, not only as informants but also in involvement of family or next of kin, when
the research teams. Involvement takes place persons with severe mental disorder are
when research is carried out “with” or “by” admitted to the hospital.
patients rather than “to,” “about” or “for” them Nurse: I know you want to actively use
[92]. The involvement of service users in the your experiences from receiving treatment
research process should be conducted in the from this ward over years. We need two per-
­salutogenic way, as claimed by Mjøsund et al. sons with patient experience to join the proj-
[2]. An advisory team was included in the ect team, together with three persons being
research team; the five members were differ- family members to someone being admitted
ent persons from the participants interviewed to our section. Could you be interest?
in the project. Either the research advisors Patient: hmm… What am I supposed
were diagnosed with a severe mental disorder to do? And where are the meetings? It is
or had family members with a severe mental a long bus ride for me to come here. Who
disorder. They articulated features of the col- else is in the team?
laboration process and labeled it a salutogenic Nurse: I have an information flyer here.
service user involvement [2]. Six features of Besides the persons I mentioned, three
the collaboration process which encouraged nurses from the section, including me and
and empowered the advisors to make signifi- a nurse researcher are supposed to be in
cant contribution to the research process and the team. How the involvement is designed
the outcome were articulated; leadership, will be developed in collaboration with
meeting structure, role clarification, being the researcher. Is it ok if I contact you in a
members of a team, a focus on possibilities, couple of days, then I probably know more
and being seen and treated as holistic individ- about those practical things? …
uals. These features were perceived to consti-
tute a salutogenic and mental health promotive
involvement [2]. 15.5 Act-Belong-Commit:
Service user involvement is also essen- A Framework
tial in clinical quality improvement projects. for Exemplifying
Evidence-­based knowledge always need to be Salutogenesis in Mental
adapted to a local setting and environment, Health Nursing
then service users with experiences from the
same context possess important knowledge to The use of body- and movement-related actions
be included in improvement processes. Service for the prevention and healing of illnesses has a
user involvement also has the potential to long tradition. Apart from the various physical
enhance the research quality [4]. benefits, psychological changes have been postu-
15 Salutogenic-Oriented Mental Health Nursing: Strengthening Mental Health Among Adults… 203

lated [41]. The Act-Belong-Commit (ABC) men- other health professionals in charge can enhance
tal health promotion campaign is assessed to be the mental health of those in their care. It is to:
a comprehensive, population-wide program with Actively involve (those in your care), Build
a strong evidence base, demonstrating success (their) skills, and Celebrate (their) achievements
in implementation and comprises universal prin- [97]. The situation in Box 15.6 illustrates how the
ciples of mental health and well-being [93]. The ABC-principles might be turned into action. The
ABC campaign aims to target people in commu- nurse invites the patient to an activity (Act) they
nities to engage in activities that enhanced their are going to do together (Belong) in the future
mental health. ABC might be used in different (Commit), based on the patient’s interest in
settings, both on a population level, in specified nature (Commit).
setting, and on an individual level [27].
The ABC-framework encourages individuals
Box 15.6 Example of a Clinical Situation
to engage in mentally healthy activities, and it
Focusing on ABC Activities
appears to empower people with mental illness
to take steps of their own to enhance their men- Nursing situation: Morning shift at a
tal health [94]. The ABC-framework adapted closed acute inpatient unit. The patient has
in a health care and nursing context provides been staying mostly in bed not talking for a
nurses and other health professionals with a couple of days.
practical framework for actually doing men- Nurse: Good morning, my friend! I
tal health promotion activities together with brought some flowers from my garden to
the patients. A population-based study of Irish you. I remember you were looking at the
older adults showed that the increase in the picture of some spring flowers in the news-
number of ABC-­activities inversely predicted paper yesterday.
the onset of depression, anxiety, and cognitive Patient: …Hmm.
impairment [95]. Nurse: I’m on duty the day after tomor-
Mental health as well as physical and social row. Do you agree to come with me to the
health are related to lifestyle and cultivated by park by the main road to look at the trees
practice and what we do; we become mentally over there – the leafs are in thousands of
healthy by engaging in mentally healthy activi- colors. …
ties [27]. The ABC framework offers a structural
approach to specific subpopulations in clinical
settings. The ABC campaign is about keeping
mentally healthy by keeping active, keeping up 15.6 Conclusion
friendships and make connections with others, as
well as engaging in activities that provide mean- Mental health promotion is important to all of
ing and purpose in life [96]. us, no matter if we are young or old and healthy
or diseased. Salutogenic mental health promo-
• Act: Keep alert and engaged by keeping men- tion provides a resource and strength-based
tally, socially, spiritually, and physically approach to promote mental health. Nurses in
active. mental health care services are in an excellent
• Belong: Develop a strong sense of belonging position to include health promotion in their
by keeping up friendships, joining groups, and daily work with their continuous presence with
participating in community activities. the patients. In mental health care services, we
• Commit: Do things that provide meaning and claim that nurses need to provide a more com-
purpose in life like taking up challenges, volun- plete mental health nursing to persons with men-
teering, learning new skills, and helping others. tal disorders based in knowledge from both the
paradigms of salutogenesis and pathogenesis.
Additionally, the ABC framework might be To emphasize the importance of salutogenesis in
interpreted in three ways by which nurses and nursing care, we introduce the term salutogenic-
204 N. H. Mjøsund and M. Eriksson

oriented mental health nursing practice. Features Acknowledgement The authors would like to thank
Vestre Viken Hospital Trust, Department of Mental
of the salutogenic-­oriented mental health nurs- Health Research and Development and University West,
ing are the holistic orientation, with emphasize Department of Health Sciences for making it possible to
on strengths and resources, facilitating learning write this chapter. Magnus Lien Mjøsund, thank you for
processes in health promotion, saluseducation, reviewing the language and for assisting in fine-tuning of
the figures.
and the involvement of patients and next of kin
in salutogenic nursing practices as well as in
research.
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 Health Promotion Among
Individuals Facing Chronic Illness:
16
The Unique Contribution
of the Bodyknowledging Program

Kristin Heggdal

Abstract The goal of health promotion is to increase the

involved persons’ control over their health and to
This chapter offers an oversight of the concept
improve it. This includes people diagnosed with
of chronic illness and the meaning of health
chronic illness and involves mobilizing strengths
promotion in this context. Bodyknowledging
for the promotion of health and well-­being [1].
is a theory describing patients’ process of
health promotion in chronic illness that has
been used as a theoretical frame for a new
16.1.1 The Concept of Chronic Illness
health intervention; the Bodyknowledging
Program (BKP). This program is outlined as
Although there is no universal consensus about
the aim of BKP is to activate and strengthen
the definition, it is common to apply the term
patients’ resources for health in chronic ill-
chronic illness when there is a disease with a
ness. Outcomes for patients and implications
prolonged trajectory for which there is no cura-
for practice are discussed.
tive treatment, and when the condition impacts
the persons’ life and functioning and requires
Keywords
monitoring and specific management measures
Chronic illness · Health intervention · Patient [2]. Chronic illness falls under the heading
participation · Health · Well-being of noncommunicable diseases (NCD), which
encompasses a large group of illnesses, such
as diabetes, hypertension, stroke, heart disease,
pulmonary conditions, cancer, and mental health
16.1 Introduction conditions. The term may also include selected
communicable diseases such as HIV [3]. Chronic
The concept of health promotion has tradition- illness occurs across the lifespan. Due to the
ally been associated with preventive measures for advent of new options for treatment, improved
healthy people, while health promotion in relation disease management, and improved living condi-
to people already diagnosed is a relatively new tions, children diagnosed with chronic illness are
idea which is scarcely described in the literature. increasingly surviving into adulthood. Similarly,
people who would previously have significantly
K. Heggdal (*) shortened lifespan due to chronic illness are now
Lovisenberg Diaconal University College, experiencing increased longevity [4].
Oslo, Norway
e-mail: Kristin.Heggdal@ldh.no

© The Author(s) 2021 209

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_16
210 K. Heggdal

Chronic illness is one of the leading health-­ comorbidity, including mental health problems,
related challenges across the world and cur- emphasizes the importance of developing inter-
rently the main cause of both death and disability ventions that attend to the person’s health as a
worldwide [4, 5]. The majority of conditions con- whole [5]. Such interventions call for an under-
tributing to mortality and morbidity combined in standing of patients as resourceful partners for
high-income countries like Europe, USA, and health together with professionals and peers.
Australia include ischemic heart disease, stroke,
lung cancer, depression, diabetes, and back and
neck pain. In low-income countries like coun- 16.2  ealth Promotion in Chronic
H
tries in Africa and middle-income countries Illness
like China, the major conditions contributing to
mortality and morbidity include stroke, diabetes, According to Larsen [2], health promotion in
and depression, and also communicable diseases chronic illness involves “efforts to create healthy
such as diarrhea, HIV, and malaria, and road lifestyles and a healthy environment to prevent
traffic injuries [6].The risk of coronary disease, secondary conditions, including teaching individ-
ischemic stroke, diabetes, and cancer increases uals to address their health care needs, increasing
steadily with increasing body mass index (BMI) opportunities to participate in usual life activities
and obesity, which has become a major health and striving for optimal health. These secondary
concern, especially in high- and middle-income conditions may include the medical, social, emo-
countries. In addition, the Institute for Health tional, mental, family, or community problems
Metrics Evaluation reports that the number of that an individual with a chronic or disabling
people suffering from mental illness is relatively condition is likely to experience (p. 367).” While
large but stable, as one in four people in the world professionals’ treatment and care are signifi-
will be affected by mental of neurological disor- cant, patients have an important role in learning
ders at some point in their lives. The prevalence as much as possible about their conditions and
increases with age, but high rates of comorbid- becoming involved in the management of their
ity has also been reported in working-age popu- disease, in prevention of future relapses and in
lations [7]. Many patients attending health care health promotion efforts. This includes taking
today have two or more chronic conditions. In part in communication with health profession-
Europe, it has been estimated that multimor- als on health-related matters as well as efforts
bidity (or comorbidity) affects up to 95% of to avoid risk factors such as poor nutrition, lack
the primary care population aged 65 years and of physical activity, smoking, alcohol abuse, and
older. Approximately 25.5% of the United States social isolation, because the same risk factors that
population report to have more than one chronic cause a chronic condition can also make it worse.
condition, and the prevalence increases to 50% of It is important to increase patients’ abil-
adults 45–65 years, and up to 81% of adults older ity to manage their conditions and to maintain
than 65 years. For adults over 50 years, rates of or improve their levels of functioning [2, 4, 9].
multiple chronic disease will vary from 45% in Manageability, comprehensibility, and mean-
China to 71% in Russia [6]. ingfulness constitute dimensions of the persons’
About half of the individuals with comorbid Sense of Coherence (SOC) and represent cen-
chronic conditions report functional limitations tral assets for health as they reflect the ability to
and are more likely to have poor self-reported understand one’s existence as organized and the
health; therefore, effective interventions are belief that one has the ability to handle one’s life
necessary to optimize health outcomes in the and to reestablish meaning while facing chronic
presence of chronic illness [8]. While medi- conditions [10, 11]. Studies involving patients
cal treatment can contribute to the reduction of with chronic illness confirm that patients who
symptoms and to prevention of complications, have a strong SOC have a greater capacity to
sometimes no treatment is available. Addressing manage their chronic illness [12, 13]. For people
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 211

who live with chronic illness and their support- [2, 21]. However, research findings also indicate
ers, health promotion is a process of enabling and that people who are diagnosed with chronic ill-
developing potentials for healing and health. By ness possess resources and strategies for health
this means it affords new strategies and actions that are not fully recognized and capacities for
to strengthen hope among sufferers, to reduce health that is not sufficiently utilized in the cur-
their anxieties, and to facilitate a meaningful rent health system [22–24].
life (Chaps. 7 and 8). Its goal is to increase the Mobilizing patients’ intrinsic resources and
­capacity of people to deal with the consequences capabilities for health in chronic illness to be
of chronic illness and to ensure that this experi- used alongside medical expertise and care will
ence does not dictate their lifestyle. The poten- require new interventions to be applied across
tial for activities for the strengthening of overall age, gender, diagnostic categories, clinical set-
health remains largely untapped in many individ- tings, and health systems. Such interventions will
uals with chronic illness and finding new ways reflect the philosophical perspective of “health
of accomplishing health promotion often remains within illness,” which holds that individuals liv-
an unfilled goal for health care professionals ing with long-term health problems are capable
and their chronically ill patients. Determining of experiencing health and well-being despite
chronically ill individuals’ perceptions of their their conditions [10, 24, 25]. This perspective fits
condition, their aspirations, and their available well with the philosophy of empowerment (Chap.
resources, and supporting their effort to achieve 13) and with the key papers from WHO’s Health
health promotion is an ongoing process. Efforts for All 2000 series [26], which emphasizes indi-
must go beyond the individual’s chronic illness viduals gaining control over their lives and their
and limitations to include holistic health that health and the importance of active participation.
focuses on personal goals, evidence-based treat- Individuals who are actively involved are likely
ment and care tailored to the person, and a will- to experience at least some degree of control, and
ingness to adjust a plan as needed [2]. Self-care there is an assumed relationship between degrees
combined with health promotion efforts con- of participation, empowerment, and health.
ducted together with health care providers (and Empowerment programs imply active par-
peers) is necessary to optimize health outcomes ticipation and can lead to improved health out-
[14]. Self-care involves both the ability to care comes for individuals like improved self-efficacy,
for oneself and the performance of activities nec- greater sense of control, increased knowledge
essary to achieve, maintain, or promote optimal and awareness, behavior change and greater
health [15]. Qualitative studies of the meaning sense of community, broadened social networks,
of self-care to patients have identified themes and social support [27].
such as “body listening” and monitoring “bodily Health promotion, with respect to chronic
cues,” managing social context and lifestyle, hav- illness then, requires the joint action of those
ing control over treatment, taking care of and not living with illness, their significant others and
harming oneself [15–17]. Self-care is, therefore, professionals that exchange their experience and
an essential part of health promotion in chronic knowledge, including the patients’ experience-
illness [18]. based knowledge of how best to live with chronic
Summaries of research concerning people illness [9, 22, 23]. However, health professionals
with various long-term conditions confirm that seem to base their practice on the logics of tradi-
they have a lot in common as they face the tional medicine and expert knowledge on com-
challenges of trying to live as well as possible pliance and not on what the individual (patients)
within the physical, mental, or social discom- themselves see as a better life [28, 29]. Wagner
fort and limitations [2, 19, 20]. Powerlessness et al. [30] argue that there is a need for improv-
is an essential part of the illness experience and ing practice by means of interventions that allow
impose challenges for both person and family for person-centered approaches that provide suf-
212 K. Heggdal

ficient support for individuals to take charge of tant but little used resource for health in chronic
their own health. “Person-centeredness” is under- illness. Bodyknowledging was defined as “a
pinned by values of respect for persons, individ- fundamental process for the development of per-
ual right to self-determination, mutual respect, sonal knowledge about one’s body, coping skills,
and understanding. It is enabled by cultures of health and wellbeing [23].” Patients’ bodily
empowerment that foster continuous approaches knowledge of health and illness is multidimen-
to interprofessional practice development [31]. sional, consisting of personal knowledge of one’s
There is a need for interventions that can opera- limits and tolerances of the type and amount of
tionalize the philosophy of patient-centeredness activity; physical and psychosocial factors in
in such a way that the patients’ potentials for their environment that have a positive or nega-
health is activated and strengthened. In the next tive impact on the condition; and personal knowl-
section, a new health promotion intervention in edge of symptoms of relapses, and the actions,
chronic illness is presented. The intervention was interactions, and social contexts that contribute
developed in close cooperation with patients and to recovery, health, and well-being [34]. It is an
health professionals in clinical practice in spe- inherent and often tacit type of knowledge, often
cialist and community care settings in Norway. expressed in action i.e. in the affected persons’
competence of self-care, self-management, and
strategies for wellness.
16.2.1 The Bodyknowledging Bodyknowledging theory elicits that persons’
Program (BKP): An Innovative embodied knowledge is developed as a resource
Approach for Health for health through a basic psychosocial process
Promotion in Chronic Illness in interaction with the environment. The process
is constituted by four phases: Uncertainty—
The Bodyknowledging Program (BKP) is a escaping the sick body; Losing life space,
person-­centered health intervention for the grieving, and anger; Listening and understand-
strengthening of self-care, health, well-being, ing the body’s signs—strengthening hope; and
and empowerment in chronic illness [32]. This Integrating embodied knowledge—new possi-
approach challenges current practice in the sense bilities for wellness and health [33]. It is a chal-
that the focus is not primarily on the problem of lenging process of learning to live with health
chronic illness, lifestyle, or behavioral change problems, understanding the changes and devel-
nor the methods used by professionals. Instead, oping strategies for health. Figure 16.1 serves to
the participating patients’ experiences, their visualize this process.
strengths, and capabilities is taken as the point of Chronically ill patients’ process of Bodyk-
departure, while the challenges imposed by ill- nowledging is dynamic and nonlinear as they
ness is a backdrop to search for possibilities for are moving up and down, in and out of differ-
health within illness. In the following sections, ent phases while building “a bridge” between
the theoretical foundation, structure, content, and pre-illness life and their life with health-related
means of the intervention are outlined. challenges. This is in line with a salutogenic
orientation [10] in the sense that health is per-
16.2.1.1 Theoretical Framework ceived as a flexible continuum. Consequently,
for the Intervention persons living with health problems may have
The grounded theory of Bodyknowledging different degrees of health according to where
[23, 33, 34] serves as the main conceptual they are in their process, and the movement up
framework for the intervention (Fig. 16.1). and down, in and out of phases is a normal and
Bodyknowledging theory asserts that people necessary part of the persons’ health promoting
have bodily knowledge that constitute an impor- process. Shifting perspectives between having
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 213

Phases Experiences Strategies Consequences Contexual

factors

INTEGRATING Reconciliation with Not giving in to the Embodied known- Personal

EMBODIED a changing life illness. ledge of health: biography.
KNOWLEDGE situation. Readjusting to a new knowing the The character of
−NEW Learning the life. symptoms and the illness.
POSSIBILITIES dynamics of the Team-playing with personal reactions. Social context.
FOR WELLNESS body’s limits of the body. knowing the body’s Time and space
AND HEALTH tolerance. Focusing on possi- tolerance for
Uncertainty of bilities. activity, physical,
future development Taking chances. and psychosocial
of health. Conducting personal environment.
“I known what treatment. knowing how to
contributes to my Hoping for future prevent relapses.
wellness.” improvements of knowledge of
health. self-treatment.
“ I have the courage to Coping, health and
hope and to handle wellness.
my life.” Empowerment

LISTENING The bodys as a Searching for Personal

BODYKNOWLEDGING

AND UNDER- source of known- knowlege: biography.

STANDING ledge: Listening to and The character of
THE BODY’S Developing reflecting on the the illness.
SIGNS knowledge of the body’s signs. Social context.
−STRENGTHEN- body’s tolerance for Asking and listening to Time and space
ING HOPE activity, factors in health care personnel.
physical and Reading the literature
psychosocial on health.
environment. Talking to fellow
Uncertainty related patients, family,
to possible relapses friends, and others.
and effects of “I hope for recovery in
treatment. the future.”
“what is making
my illness better or
worse?”

LOSING LIFE Limits of life space: Existential Losing and longing Personal
SPACE Loss of energy. questioning. for: biography.
−GRIEVING Changed body Creating predictability. Activities, working The character of
AND ANGER image. Setting limits on life life and social life. the illness.
Obstacles in space. Loss of freedom of Social context.
physical Staying at home. movement and Time and space
environment. Fighting at sustain freedom of space.
Obstacles in hope. Loss of time and
society. “Why did this happen, sense of coherence.
“The body rules my and what will happen, Broken hopes and
life.” to me?” expectations.

UNCERTAINITY Losing body Hiding symptoms Personal

− DENYING control. and suffering. biography.
AND ESCAPING Loss of security. Hoping it will pass. The character of
THE SICK BODY “The body stops “I don’t want to be the illness.
me.” sick.” Social context.
Time and space

Fig. 16.1 Bodyknowledging theory: patients’ process of health promotion in chronic illness
214 K. Heggdal

illness or health in the forefront is a part of the 16.2.2 Structure, Content

process [19]. Therefore, Bodyknowledging is to and Pedagogical Approaches
be understood as an ongoing process and activ- of the Bodyknowledging
ity in which knowledge of new possibilities for Program Intervention (BKP)
health and well-being is developed and continu-
ally renewed. Varied and flexible strategies for The Bodyknowledging Program is a broadly
the promotion of health are developed through applicable intervention designed for people living
the process, such as not giving in to the illness, with a variety of chronic illnesses. The objective
readjusting to a new life, team-playing with the is to facilitate participants’ efforts of prevention
body, focusing on possibilities, taking chances, of deterioration, their capacity for health as well
preventing relapses, conducting personal treat- as their possibilities to participate in society [32]
ment, and hoping for future improvement of by acknowledging and strengthening patients’
health. Strategies are individually expressed unique yet undervalued bodily knowledge in
and specific to the situation. chronic illness [23]. The phases described in the
Patients’ personal process of health promo- layperson-based concepts of Bodyknowledging
tion goes on even if the illness at times pose is used as “process tools” to promote patients’
obstacles that seem to be hard to handle. The capability for health. This idea is incorporated in
Bodyknowledging process (Fig. 16.1) elicits the the program structure, in the content, and in the
danger of the person being trapped in the experi- pedagogical approaches.
ences of uncertainty, losses of life space, griev-
ing, and anger. In such cases, the process is being 16.2.2.1 Structure
changed in a pathogenic direction. These groups The program is organized in group format con-
of patients are exactly those who need an inter- sisting of 7 sessions over 12 weeks and conducted
vention such as the Bodyknowledging Program in co-ed groups of 8–10 participants diagnosed
in order to learn how to move towards the healthy with a variety of long-term chronic illnesses. This
pole again. mode of organization aims to facilitate the partic-
Bodyknowledging theory is in line with the ipant’s systematic work on their health over time.
phenomenological understanding of the body as There is one 3-h session (with a 30-min break
introduced by Merleau-Ponty [35, 36] in which to eat and socialize) every week during the first 3
the body is understood as an object and subject at weeks. Sessions 4–6 are held every second week,
the same time and as a primary source of knowl- and the final session is held in week 12. Two
edge. The dialectics of the body as subject and health care professionals (HCP) representing two
object are being used in the person’s efforts to different professions (e.g., one nurse paired with
promote health when they observe their body and one physiotherapist or occupational therapist)
at the same time sense its reactions. In BKP, this receive 40 contact hours +40 self-study hours of
dialectic function of the body is being utilized in specialized training before they engage as course
the physical exercises as well as in the structured leaders in the program. BKP is accomplished in
dialogue. groups mixed with men and women having dif-
The theoretical basis for the intervention ferent kinds of diagnoses as this was found to be
also rests on Freire’s pedagogical theory of the broadly applicable across diagnosis, ages, sexes,
oppressed [37], which asserts that the person’s and clinical sites through clinical trials in Norway
acknowledgement of their situation and efforts [38]. Active patient participation was fundamen-
to find solutions is groundbreaking, and that tal in the development of the intervention and is a
dialogue is a means for the liberation of human prerequisite for program completion in practice.
resources. More details on the theoretical founda-
tion has been published elsewhere [32]. The next 16.2.2.2 Content
section offers an overview of the intervention The content is organized according to the phases
components. of Bodyknowledging [33] described by former
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 215

patients [23, 33, 34] and used as a tool to support questions, their answers and the information they
the participants whereby professionals invite par- are collecting are equally important to the infor-
ticipants to work on the uncertainty, losses of life mation gathered by HCP. It has to do with devel-
space, grieving and anger, listening and under- oping a partner-relationship with the person and
standing the body’s signs and the integration of to elicit their tacit knowledge of health as well
knowledge on new possibilities for well-being as to find relevant solutions together on what it
and health [23] (s. 16.1). The Bodyknowledging is that contributes to the person’s movement to
program constitutes a “room for recovery” in the healthy pole of the health ease/dis–ease con-
which patients can share their narratives about tinuum [10, 37]. Patients’ process of health pro-
their health condition and strategies for health motion is facilitated by HCP active listening, and
and wellness with HCP and peers. In this way, the by supporting, comforting, and challenging the
participating patients contribute to constitute an participants understanding of their situation. In
essential part of the content followed by HCP’s addition, questions inspired by solution-focused
questions to facilitate reflection on the person’s therapy are used in order to facilitate the person’s
health promotion efforts. This is in line with perspectives towards health within illness [19].
empowerment models of health promotion [39] The written pedagogical tools in BKP that
as it aims to facilitate action by raising critical complement the intervention group work include
consciousness of one’s own health while high- a poster and a booklet/diary. The poster offers an
lighting factors that are subject to change based overview of the phases of Bodyknowledging. The
on actions relevant to the person. Patient’s rela- 40-page booklet describes the Bodyknowledging
tionship to, and interaction with, significant oth- process illustrated by citations from former
ers is an important part of the program content patients who were engaged in the research on
as these relations may represent both assets and the development of the Bodyknowledging frame-
challenges to patients’ health promotion efforts. work. Intervention patients are encouraged to
review specific parts of the booklet between the
16.2.2.3 Pedagogical Approaches sessions and to reflect on study questions. There
The pedagogical approaches in BKP aim at are blank pages available to write down reflec-
activating and facilitating patients’ inherent tions. The pedagogical tools imply that patients
resources for health. Dialogue and posing open are engaged in dialogue on their self-care and
questions are essential pedagogical approaches health in a variety of ways, such as the dialogue
in this regard. Bodyknowledging theory is a tool with the text on the poster and booklet/diary, the
in this regard as it offers a structure for the dia- dialogue between patients in the group and with
logue in the groups. Participants are invited to HCP.
engage in dialogue and reflection on their health HCP leading BKP groups, introduce physi-
by means of open-ended questions. HCP invite cal exercises at the beginning of each session
participants to reflect on questions about how to support the participants in the recognition of
they experience their life-situation and their own their bodily knowledge as a resource for health.
perception of how their health can be enhanced, Exercises are inspired by the physiotherapeutic
working inductively from the point of view of the method of basic body awareness therapy, which
singular person at the same time as one focuses concentrates on breathing, balance, and move-
on the shared experiences in the group. ment [40, 41]. Then, the HCP provides a short
The involved persons are encouraged to be introduction to the BKP framework and patients
active participants in researching their health are invited to reflect upon, and discuss questions
with the following questions in mind: What is it posed in the booklet connected to each phase;
that contributes to your capability to handle the drawing on principles of open dialogue and
symptoms and the consequences of illness, and solution-­focused therapy [37, 42, 43]. Facilitation
what contributes to your wellness in your life of individual resources for health, physical activ-
situation? When patients are working on such ity, and social participation is emphasized as
216 K. Heggdal

participants are supported by interdisciplinary A comprehensive description of the foundation

HCP to work systematically on their health by for BKP and the formative research has been
attending to the phases described in the theoreti- published elsewhere [32]. The BKP has been
cal framework [23, 33, 34]. Herein lies the pos- piloted and implemented in specialist and com-
sibility to activate more of the persons’ resources munity health care settings in several projects in
for health promotion and to explore challenges Norway. Qualitative interviews and focus-group
they may have with conducting self-care and interviews with participating patients and HCP
self-management. were used to collect data to explore their expe-
Bodyknowledging theory describe the griev- riences of being engaged in the intervention,
ing and anger as a part of an overall health pro- for evaluating the intervention structure, con-
moting process in people with chronic illness and tent, and means and to identify possible health-
when used in the BKP intervention, one explic- related outcomes. Qualitative process evaluation
itly turns the attention of both patients and HCP [46], content analysis [48, 49], and Interpretive
to the importance of working through the uncer- Phenomenological Analysis (IPA) [50] were
tainty, losses, grieving, and anger in order to applied in different trials of BKP. Quantitative
move towards better health. BKP offers the par- data were collected by means of Antonovsky’s
ticipating patients time and space to share their Sense of Coherence [51] questionnaire and the
story and their experience of handling their life Outcome Rating Scale [52]. In addition, a brief
with illness, and HCP leading the groups have evaluation form was filled in by patients. More
the responsibility to ensure a balance between details on methods and outcomes are provided in
the focus on deficits and the focus on health in the next section.
the sessions.
Participants are also asked to choose a physi-
cal activity to do at home twice a week, and 16.3 Patient-Reported Outcomes
questions concerning these activities are posed in of Improvement
subsequent sessions to support them to conduct in Empowerment and Health
physical activity as a part of their health promo-
tion efforts [44]. The purpose of the exercises 16.3.1 Clinical Trials in Specialist
was also to find the balance of stress, activity, and Health Care
rest to prevent the outburst of relapses.
The Bodyknowledging Program was first imple-
mented in specialist care in Norway; in a special-
16.2.3 Methods for the Development ist Rehabilitation unit, in an Outpatient Clinic
and Trials of BKP for the follow-up of patients with Inflammatory
Bowel Disease (IBD), and in a Center for Patient
Initially, three clinical units were chosen for Education in chronic illness (CPE). A study sam-
developing the new intervention: a rehabilita- ple of 31 men and 21 women (n = 52) ranging in
tion unit, an outpatient clinic and a center for age from 22 to 88 years volunteered to participate
patient education. An interdisciplinary team of in the pilot-implementation. The diagnoses rep-
nine health care personnel representing the sites resented in the sample were Chronic Obstructive
(nurses, occupational therapists, physiotherapist) Pulmonary Disease, Heart Disease, Chronic
and patients diagnosed with a variety of long-­ Inflammatory Bowel Disease, Stroke, Multiple
term chronic health conditions engaged with the Sclerosis and other neurological or functional
principal investigator in the formative research limitations without a specific diagnostic label.
[45, 46]. Criteria for reporting the develop- Patients varied in functional capacity and in time
ment and early piloting of complex interven- since diagnosis, but all had been ill for 1 year or
tions [47] in health care was applied as a guide more and had illness-related problems that were
to outline each component of the intervention. difficult to manage. The BKP was applied in
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 217

group and in individual formats as a generic pro- of pain. It also relieved a feeling of alienation
gram to facilitate self-care, health, and recovery. created by the illness. A man attending individu-
The intervention was implemented success- ally in the outpatient clinic explained how his
fully across gender, ages, diagnostic catego- perspective of health and illness had changed
ries, and clinical sites. The process evaluation through BKP:
included in-depth interviews with 34 patients
I have seen a way through all the pain and anguish.
after completing the BKP; of these, 25 patients When you read about the other patients’ experi-
engaged in 4 group interviews and 9 patients ences, your own experience is being confirmed and
were interviewed individually. The research in this way you do not feel so lonely. You under-
questions were: How do participants experience stand that there are other persons who have man-
aged and that there is a way through it all.
the program? What health-related changes, if
any, can be attributed to the program? What are A woman attending the program individually at
the interventions active ingredients, contributing the rehabilitation unit described her new ways of
to change? thinking and acting after program completion:
Participants described that the BKP allowed
them to work systematically on their health The program has helped me to think in another
way and to come out and to participate in life
as a process and reported that because the again. If I am completely honest with myself, the
Bodyknowledging framework is based on patient things I want to do are not impossible. It just takes
narratives, it is easy to understand. They evalu- more time, and that was absolutely not how I was
ated the structure of the program as appropriate thinking before I entered this program.
across clinical sites and saw the mix of men and By attending to the Bodyknowledging process,
woman and of people with different long-term participants could compare their own experience
conditions as positive because it created rich and choices to concepts and phases offered in
possibilities for sharing experiences and ideas the BKP’s “insider” perspective. The theoreti-
about how to handle challenges and how to pro- cal framework helped them assess “where they
mote health while living with chronic illness. were at the moment” and use that assessment to
Participants emphasized that beginning with move on in their own process of health promo-
weekly sessions helped establish a good process. tion. While still being well aware of the limita-
While the group format made it possible to relate tions imposed by illness, they were more aware
one’s own experiences to those of others, the of the risk of imposing unnecessary limitations
individual format allowed more direct, in-depth upon themselves—how that could worsen their
work on each person’s process. health—and they were able to think differently
Five themes captured participants’ experi- and more positively about their own capabilities.
ences of change in coping and health promo- A man attending the program in a rehab group
tion abilities: (1) changed perspectives on health (stroke survivor) described how his engagement
and illness, (2) new ways of thinking and acting in BKP changed his understanding of the situa-
towards the illness, (3) understanding situations, tions, choices, and actions that make the health
choices, and actions that make the health con- condition better or worse.
dition better or worse, (4) widening one’s life
space-being more active, and (5) communicating I know my body better now. I listen to my body. I
differently about health-related matters [38]. have learned how I feel when I am tired. Then I
take a break before I begin again. It’s much easier
Changes in patient perspectives was con- when you have a program to follow, such as this
nected to having a shared world of experience program—it works. I have gotten much more
with others who were struggling with symptoms patient with myself. I try to be positive because
of illness. Because the BKP and its pedagogical then, it is easier to manage and to conduct what I
want to do. I have learned that there are many pos-
tools contain a description of the life worlds of sibilities even if I have a handicap. Even if every-
those with long-term health problems, the pro- thing goes more slowly than before, I am able to do
gram offered comfort and support in the midst the same as before.
218 K. Heggdal

A woman attending individually in the outpatient health related matters was described as an impor-
clinic described how she had changed her way of tant outcome. At the onset of BKP, participants
handling her life situation with chronic illness: were concerned with how to tell people about
It has become clear to me that I have been escaping their health condition and how to handle reactions
from the illness, but this summer I have taken a from coworkers, employers, friends, and family.
grip of the situation. I have told about the illness in A man whose functional limitations were “invis-
my workplace, and now I am in a process of defin- ible” to others described his experience of this:
ing how much I should work and how. I am trying
to reduce the demands I put on myself in order to Before, I got angry, and was not able to put my
prevent new relapses, because I know that when I reactions in words. The program has helped me to
work too much, I get exhausted and then the illness say something about my experience with the ill-
is worsened. ness and has helped me to have better relations
with my family.

Discovering one’s “own standards” was an Participants appreciated the opportunity to open
important part of the participants’ improved up and work on the difficult parts of their lives in
knowledge. Making this discovery was con- a safe setting. Getting feedback from HCP (and
nected to taking one’s levels of tolerance—for peers if in a group) challenged their own under-
certain types and magnitudes of social and physi- standing and constituted a time for learning. As
cal activity—seriously. Participants identified the a result, participants described being stronger
ability to say no to oneself and to other people in social encounters, in the sense that they were
as an important strategy for promoting wellness. learning to tell to others how they felt and what
As the program encouraged participants to reflect they had to consider in order to stay well.
critically on their ways of being, they engaged in Patients’ active engagement in the Bodyk-
a sort of “research process” concerning their own nowledging Program, the HCP’s attitudes and
health. With the support of the program, their approaches, the group work and the conceptual
peers, and the health care personnel, they discov- framework of Bodyknowledging were identified
ered their own strategies for self-care and what as the interventions’ active ingredients [38].
they could do to stay healthy. Widening one’s life
space-being more active was an important result
in this regard. A woman attending a group at the 16.3.2 T
 rials of the BKP Intervention
CPE described how she learned to handle the in Community Care
dynamic balance between accepting one’s limits
and finding new possibilities for activities: Similar findings to those reported in specialist
I am more conscious that I, in spite of my limita- health care, was identified in a study of the fea-
tions, I can manage to have a nice time. I cannot sibility and outcome of the BKP in community
climb the mountains anymore, but this summer, I care in Norway [53]. In one of the studies, a sam-
was riding a horse on a camp in the mountains, so ple of 3 men and 8 women (n = 11) between the
it is all about compensation. Now, in the winter
holidays, I was on the mountain with my friends. ages of 30 and 60 volunteered to participated in
They went skiing and I was walking, and we had a 2 BKP groups. Data were collected in individual
good time together. and group interviews and analyzed according to
Interpretative Phenomenological Analysis (IPA).
Participants said that being in the program was Participants described their engagement in the
like “coming out of a vacuum.” They used the con- BKP as an enlightening experience that contrib-
cepts and phases of the Bodyknowledging model uted to positive change, personal growth, and
to sort out their chaos, find meaning in their expe- better health. Themes like changes in self-aware-
rience, and move on to new phases. The search ness, changes in attitudes, awareness of one’s
for meaningful substitutes for pre-illness activi- body, accepting one’s limited capacity, making
ties was a central strategy for achieving health priorities and setting boundaries, letting go of
within illness. Communicating differently about shame, and regaining control were themes that
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 219

came up in the analysis. The patterns of themes chological problems like anxiety and depression,
indicate that participating in BKP contributed to diabetes, heart failure, COPD, and IBD diagnosed
a change in the participants’ perceived locus of with somatic and/or psychological health prob-
control, taking it from external to internal [53]. lems. Both community and specialist care partici-
This is an essential finding, as perceived internal pants were equally represented in the sample with a
control is necessary in order for patients to be in fairly equal distribution of men (51%) and women
charge of their own health. (57%). Community and specialist care participants
In another study of the efficiency of BKP in com- were included and equal proportions of men and
munity care, the Outcome Rating Scale (ORS) was women were represented (51% v. 57%). SOC
used to measure patients’ self-­ reported recovery mean score in the total sample increased from a
repeatedly at baseline, after four sessions of BKP baseline of 135.3–137.6 (mean change 2.3) at pro-
and after program completion [54]. Four dimen- gram completion (after 12 weeks) which confirms
sions were assessed: (1) individual (personal or the possibility for patients with chronic illness to
symptomatic distress and well-being), (2) interper- strengthen their self-care, self-management and
sonal (relational distress or well-being), (3) social health as they engage in BKP sessions. The man-
(patient satisfaction with work, school, and relation- ageability and comprehensibility dimensions also
ships), and (4) overall (general sense of well-being). improved, whereas the meaningfulness dimen-
The sample comprised of 13 men and 14 women sions remained relatively stable. Participants’
who had been diagnosed with a range of long-term SOC increased in both settings, with a larger mean
conditions. The mean age was 54 years. Participants change found in community care. The paired sam-
reported significant changes in recovery and health ple t-test demonstrate strong evidence for a differ-
throughout the program period. The total change in ence in women’s manageability subscales from
average ORS for the whole sample (n = 27) was baseline to follow-up (n = 61; mean change = 4.7;
4.6 (SD = 7.6; p < 0.001). There was an observed p < 0.05). Significant changes in SOC and man-
improvement from t0 to t1 with a mean change of 3.5 ageability subscales were also found for partici-
(SD = 4.8; p = 0.005). The change did not reverse pants with children (n = 72). Similar patterns of
from t1 to t2 with a mean improvement from session positive manageability changes were identified for
4 to session 7 of 1.3 (SD = 5.7; p = 0.003). The participants living with a partner and public trans-
greatest change was in the personal and general fer payment (i.e., pension) recipients [55]. These
well-being dimension of ORS. These findings dem- findings indicate that BKP is an intervention that
onstrate that the BKP intervention contributed to an function to strengthen individual resources and
improvement of dysfunctional patients from below strategies for health in chronic illness.
to above the ORS cut-point of 25.

16.4 Discussion
16.3.3 Comparison of Outcomes
in Specialist and Community We are facing an epidemic of chronic illness and
Health Care comorbidity [56, 57] and the situation calls for
new perspectives and approaches in health pro-
A study evaluated the impact of BKP on SOC in motion work. However, the field of health pro-
two samples; (1) patients in the specialist health motion in chronic illness is still at the start of
care and (2) patients in community care con- its development. The challenge is to move our
text. Both samples completed BKP [55]. The perspective from focusing heavily on the prob-
baseline sample included 108 Norwegian adults lem of disease, disability, medical treatment,
(aged 21–89). A variety of diagnostic categories and care towards the person’s and their family’s
were represented in the sample such as neuro- strengths and capability for promoting health
logical diseases (i.e. epilepsy, multiple sclerosis, within illness [24]. This implies a further devel-
Parkinson’s), musculoskeletal pain, stroke, psy- opment of the holistic paradigm suggested by
220 K. Heggdal

Engel [58] decades ago, outlined by WHO as The example above elicits the person’s knowl-
the biopsychosocial model [57] and to use more edge of dynamic limits of tolerances and the
person-­centered approaches as this is widely usefulness of the Bodyknowledging model as a
acknowledged as helping people living well tool to assess one’s health capacity and position
with a chronic condition [59]. In this paradigm, on the health ease/dis–ease continuum in a given
the health care system and the HCP function as moment or period of time [10]. Bodyknowledging
supervisors and facilitators for health, while the theory [23] elicits how movement in the direc-
person and their family are in charge of the health tion of health depends on a balance between
promotion endeavor. Now, the person at risk for deficits and resources and on the person’s active
or diagnosed with chronic illness is placed at engagement in reflection and action towards bet-
the center and in an active position as the most ter health. The dialogue with health professionals
important health promotion agent in their life is important as the professionals posit medical
and as an equal partner in the health promotion and scientific knowledge and clinical experi-
team. Significant others are invited to participate ence on many of the issues people with chronic
in supporting the person in their health promo- illness are facing. When patients and HCP share
tion process. The aim is to facilitate the person’s their knowledge and experience, they discover
resources for health at the same time as the treat- which factors in the environment (food, drink,
ment of the health condition is taken care of. New social relations, activity, and so on) that one must
models and interventions are needed in order to become less exposed to or avoid, and what fac-
operationalize the values of person-centeredness tors that contribute to individual health. Equal
and empowerment in practice. respect for the patient’s and professional’s differ-
The Bodyknowledging program is an exam- ent types of knowledge is a necessary condition
ple of such new approaches entailing a person-­ for the dialogue to function as a health promoting
centered approach focusing on activating and window of opportunity [62–64].
utilizing patients’ inherent resources for health People living with chronic illness have a lot
[23, 60, 61] (i.e. their embodied knowledge of in common as they try to live their lives as best
limits of tolerances for activity and factors of the they can and stay healthy while living with an ill-
physical and psychosocial environment with an ness. However, patient education and wellness-­
impact on the condition). The research grounding interventions in the context of chronic illness
BKP demonstrates that patient’s experience-based are often specific to particular diagnostic groups
knowledge constitutes a critical but underutilized and not designed to be applied across diagnostic
resource for the prevention of deterioration and categories [65, 66]. The BKP program fills a gap
for the promotion of health in chronic illness [22, in this regard as it is designed to be used across
29, 34]. The following example illustrates how different diagnoses, clinical settings, and health
the BKP functions in this regard: disciplines [32].

Today, my body “told me” that I am not capable of

driving a car because my head is not quite fit today.
In the past, I was pushing myself to drive and then, 16.4.1 T
 he Unique Contribution
something bad could happened. Still, it is impor- of the Bodyknowledging
tant to push oneself forward, but in the right mode, Program
because there are many ways to push oneself. It is
like stretching a rubber band. You can stretch it, but
if you stretch too hard, it breaks. That has hap- 16.4.1.1  eflects Patient’s Perspective
R
pened to me. I have learned a lot about myself and of Living with Chronic Illness
my reactions. I got the possibility to tell the health and Their Process of Health
care personnel in the program about it and I got a
picture of it (the process) and I have learned that I
Promotion
must allow myself to be sad sometimes. It has been BKP is new and different from other approaches
so important to me to learn that I don’t have to be because the theoretical framework reflects the
clever all the time (Woman with disability). patient’s perspective of living with chronic ill-
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 221

ness and their process of health promotion [23, standing, and the body as a subject that carries
33]. It is different because Health care person- the meaning and expression of the person’s life
nel who are leading BKP groups are work- [35, 64, 67]. In this holistic paradigm, the per-
ing within a patient-based framework which son’s ongoing process of listening and under-
“reflects” the patients’ “world,” replacing the standing the body’s signs is equally important to
professionals stand to be facilitators for health biomedical tests and “outside” observations of
within the patient-defined framework. When the physical body [67–69]. The core of the BKP
Bodyknowledging is used as a backdrop, this is the acknowledgement, facilitation and utiliza-
functions as a key to open a new door to “a room tion of the patients’ bodily knowledge of health
of recovery” meaning that BKP participants can and illness [32, 60, 61].
come forward with their experiences with the ill-
ness, health strategies, and hopes for the future 16.4.1.4  haring of Lay Bodily
S
as well as their worries and challenges [24, 54]. Knowledge as Part
This provides a foundation for addressing indi- of Self-­Management
vidual challenges of living with chronic illness in Chronic Illness
and to discover individual possibilities for the However, this knowledge is not “inserted” or
promotion of health within illness. “taught” them by HCP or peers, as the knowledge
is created by means of Bodyknowledging which
16.4.1.2  ocus Is on Activating
F is a natural process that goes on within them [23,
Individual Resources 33]. This unique but undervalued knowledge is
for Health: Not on Illness recognized and strengthened through the per-
The BKP interventions’ main focus is how indi- son’s engagement in the intervention and through
vidual resources for health can be activated and a dialogue characterized by knowledge, under-
facilitated by attending to the sick body as a standing and hope [33]. Lorig’s research [70]
resource for health [23, 35, 60, 64]. This adds has confirmed the importance of the sharing of
to the development of the field of health promo- lay knowledge as a part of self-management in
tion in the sense that the body is thematized as chronic illness. However, patients’ bodily knowl-
an expressive, meaningful source of knowledge edge in chronic illness was not described as a
[35, 36]. When participants are working system- resource for health in the Chronic Disease Self-­
atically on the phases of Bodyknowledging, they Management Program (CDSM) or the like.
are assisted in recognizing their altered body as
a resource for health as well as in finding words 16.4.1.5 Special Attention
to describe their life situation and to find ways of to the Psychosocial
handling the challenges that confront them. The Dimensions of Health
main message is that the ill persons’ process of and Relational Support
Bodyknowledging strengthens their resources for The BKP adds by demonstrating the effects of
handling their life with illness. using a framework that elicits patients’ bodily
knowledge of health as a resource for self-­
16.4.1.3  atients’ Bodily Knowledge
P management [54, 55] and as a tool to promote
Is Seen as Part of Their shifts from having “illness in the foreground”
Generalized Resistant to having “health in the foreground” [19].
Resources Participants described that “to be healthy within
The BKP program adds and incorporates illness” implied coming out of a vacuum and to
patients’ bodily knowledge to the description of participate in life again. This applied to differ-
Generalized Resistant Resources by Antonovsky ent areas of life, including family life, working
[10]. The phenomenological understanding of life, and social life. These findings indicate that
the body is important in this regard, that is; the the BKP attends especially to the psychosocial
body as a foundation for existence and under- dimensions of health in individuals with chronic
222 K. Heggdal

illness and relational support [38, 53, 54]. a dynamic continuum [10] while living with
According to Dwarswaard et al. [71] relational chronic illness. When personal knowledge of
support is at the center of the support needs and health and illness is acknowledged, this affects
fuels all other types of support. This was con- the assessment of their situation as well as their
firmed in a systematic review concluding that way of handling the challenges. The experience
for COPD self-management to be effective, of symptoms is not so threatening when they
patients’ psychosocial needs must be prioritized know more about the meaning of their ailments
alongside medication and exacerbation manage- (comprehensibility), how to relieve them and
ment [72]. how to prevent relapses (manageability). The
uncertainty is lessened and their experience of
16.4.1.6 Provides Tools having bodily control and safety gets stronger,
for Participants to Assess which has a positive effect on the person’s ability
Their Responses to Long- to handle their life situation with chronic illness.
Term Illness This adds to the theory of salutogenesis [10]
The Bodyknowledging Program contains tools by eliciting that the person’s embodied knowl-
for participants to assess their responses to long-­ edge of health and illness represents a great but
term illness and to discover how they can impact unheeded resource for coping, recovery, and
their health positively by using their own and health in chronic illness [23, 33].
their environment’s resources. The BKP pres-
ents inherent patient expertise (the phases of 16.4.1.8 Evidence of BKP Health
Bodyknowledging) to be interpreted and applied Promoting Outcomes
by patients participating in BKP. This approach Findings indicate that the Bodyknowledging
is in keeping with Paulo Freire’s [37] “pedagogy Program serves as an intervention to strengthen
of the oppressed” in which the person defines health and empowerment across diagnostic cat-
their situation and in which dialogue serves as egories, age, and gender and is suitable both
the main method for helping people understand in specialist and community health care [55].
their situations and to act in new ways. This Health-related outcomes of BKP like changed
seems to have a liberating effect as the solutions perspectives on health and illness, new ways of
are the person’s and not based on predefined thinking and acting towards the illness, under-
skills by professionals. By attending to the dif- standing situations, choices, and actions that
ferent phases described in the Bodyknowledging make the health condition better or worse, wid-
framework, patients are empowered and healthy ening one’s life space-being more active, and
transitions are facilitated, that is; a person’s feel- communicating differently about health-related
ing of being connected and socially supported, as matters [38] indicate that participating in BKP
well as their perceived confidence, coping, and contributed to a change in the participants’
subjective well-being are actively restored [73, locus of control, taking it from external to inter-
74]. These findings align with a review of what nal [53]. Based on these findings one can argue
difference empowerment makes to the health and that the BKP contributed to perceived control
well-­being of individuals [27]. of illness-­related strain and circumstances. The
findings are in line with the goal of health pro-
16.4.1.7 Emphasis Is Laid on Health motion which is exactly to increase the involved
as a Dynamic Continuum persons’ control over their health and to improve
Patients’ engagement in BKP, the health care it [1]. Patients in the municipality health care
personnel’s attitudes and approaches, the expressed that the BKP represented a new and
group work, and the conceptual framework of different encounter with the health care sys-
Bodyknowledging were identified as this inter- tem and suggested that the program should be
ventions’ active ingredients [38]. Emphasis extended with more sessions and a follow-up
is put on the participants’ process of health as period lasting for 6 months [53].
16 Health Promotion Among Individuals Facing Chronic Illness: The Unique… 223

16.5 Implications for Practice that will be poised to improve longer-term public
health outcomes for chronic illness.
The Bodyknowledging theory and program can
be used in the education of HCP to elevate their Take Home Messages
understanding of the lay-perspective and to gain • The field of health promotion in chronic ill-
insight into the patients’ process of health pro- ness is in need of further development to
motion in chronic illness. The BKP offers shared ensure a strong focus on how to promote
concepts for interdisciplinary work and patient health within illness. The Bodyknowledging
participation. The model can be applied by HCP Program (BKP) is an example of interventions
and patients diagnosed with chronic illness as a that aim to activate and utilize patients’ inher-
tool to assess the patients’ position in their health ent resources for health while living with
promotion process and as a tool for patient acti- chronic illness.
vation and dialogue in health care encounters. • Bodyknowledging theory serve as the frame-
The Bodyknowledging Program is recommended work for BKP. The theory elicits how experi-
to be used as a broadly applicable intervention in ences of illness and vulnerability can be turned
health promotion work in community health care into assets for health, and how the patient
settings as well as in hospitals, in outpatient clin- becomes empowered by utilization of their
ics, or in rehabilitation units as part of the follow- inherent resources for health.
­up of patients at risk or diagnosed with chronic • Patients engaged in the BKP report that their
illness. ability to handle distress, conduct self-care,
and promote health was improved. This had a
positive impact on their relationships to sig-
16.6 Conclusion nificant others and their participation in
society.
This chapter emphasizes the need for developing
the field of health promotion in chronic illness by
developing interventions that operationalize the References
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practice. A change of focus is needed from focus- 1. Leddy S. Integrative health promotion: conceptual
bases for nursing practice. Massachusetts: Jones &
ing heavily on disease and behavioral change to Bartlett Learning; 2006.
mobilizing patients’ intrinsic resources and capa- 2. Larsen PD. Lubkin’s chronic illness. Impact and inter-
bilities for health in chronic illness. Patients’ vention. 10th ed. Massachusetts: Jones & Bartlett
bodily knowledge of health and illness are elic- Learning; 2019.
3. World Health Organization. Global status report on
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 Health Promotion Among Cancer
Patients: Innovative Interventions
17
Violeta Lopez and Piyanee Klainin-Yobas

Abstract promotion research with examples of studies

are discussed.
There are growing interests in promoting
health of patients with cancer targeting on pre-
Keywords
vention and control as there are several modi-
fiable risk factors that can be controlled to Acutherapy · Art therapy · Cancer · Exercise ·
prevent cancer such as smoking, sedentary Herbal therapy · Mindfulness · Psychotherapy
lifestyle, and unhealthy behaviors. Once diag- Salutogenesis · Sense of coherence
nosis of cancer has been determined, health
promotion interventions can be targeted on
helping patients overcome the physiological
and psychological effects of the diagnosis. 17.1 Introduction
Health promotion interventions should con-
tinue during treatment, survivorship, and for Cancer is a group of diseases characterized by
those receiving palliative care. More specifi- uncontrolled growth and spread of abnormal
cally is the promotion of psychological health cells. There are many causes of cancer and many
of patients with cancer. Introduction of the risk factors; some are nonmodifiable while some
incidence of cancer, cancer risk protection are modifiable, such as smoking. Cancer causes
interventions and innovative health promotion one in six deaths worldwide; the second leading
interventions along these different periods in cause of death after cardiovascular diseases [1].
the life of patients with cancer are presented. The incidences of cancer globally are 23.4% in
Some theoretical frameworks used in health Europe, 13.3% in America, 7.3% in Africa, and
57.3% in Asia [2]. It is also estimated that one-in-­
V. Lopez (*) five men and one-in-six women will develop can-
School of Nursing, Hubei University of Medicine, cer and one-in-eight men and one-in-eleven
Shiyan, China women will die from cancer [3]. It has been
School of Nursing, University of Tasmania, reported that cancer is the first or second cause of
Hobart, Australia premature deaths in 100 countries worldwide [2].
e-mail: violeta.lopez@findnetwork.org
The five most common cancers in males are lung,
P. Klainin-Yobas prostate, colorectal, stomach, and liver; and in
Alice Lee Centre for Nursing Studies, Yong Loo Lin
School of Medicine, National University of
females they are breast, colorectum, lung, cervix,
Singapore, Singapore, Singapore and thyroid.
e-mail: nurpk@nus.edu.sg

© The Author(s) 2021 227

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_17
228 V. Lopez and P. Klainin-Yobas

The global cancer burden is estimated at 18.1 The Transtheoretical Model of health (TTM)
million new cases and 9.6 million deaths in 2018 was developed by Proschaska and Verizer [12]
(ICRC 2018). In 2040, the global burden is who posited that health behavior change involves
expected to increase to 27.5 million new cases progress through six stages of change: precon-
and 16.3 million deaths [4]. The increasing can- templation, contemplation, preparation, action,
cer burden is due to population growth and aging, maintenance, and termination. It was postulated
economic and social development, unhealthy that behavior change is cyclic with some indi-
diet, physical inactivity, and changing lifestyles. viduals regressing to earlier stages of readiness
It has been reported that cancer risk increases before behavior change is sustained. TTM-based
with age especially among age 65 years. interventions attempt to tailor the recommenda-
According to the Human Development Index tions to a participant’s motivational readiness to
(HDI), there are 60% new cancer cases in high change. Pinto [13] conducted the Moving
HDI compared to those in medium- and low-HDI Forward Trial, providing a home-based moderate-­
countries [1, 5, 6]. intensity physical activity program to determine
its effects on physical activity fitness, mood, and
physical symptoms in patients with breast cancer
17.2 Theoretical Frameworks guided by TTM.
Used in Cancer Health The Theory of Planned Behavior (TPB) is a
Promotion Research social-psychological theory developed by Ajzen
[14] to explain the link between attitudes and
Theoretical frameworks provide knowledge base behaviors. It postulates that behavior is predicted
for guiding intervention research. It is important by intention. According to this theory, human
that researchers understand the underpinnings of behavior is guided by behavioral, normative, and
the various theories to enable appropriate selec- control beliefs. Interventions designed to change
tion for the study to be conducted. There are behavior can be directed to patients’ attitudes,
many theoretical frameworks sued in cancer subjective norms, and perceptions of behavioral
research but only few examples are provided in control [15]. Jones and colleagues [16] applied
this chapter. One example is the Salutogenic the theoretical tenets of the TPB to understand
Model as a theory to guide health promotion the effects of two oncologist-based interventions
which aims at moving people in the direction of on self-reported exercise in breast cancer survi-
the health end of the continuum [7]. As a vors. The effects of the oncologists’ recommen-
Salutogenic orientation, the Sense of Coherence dations to exercise in patients with breast cancer
(SOC) construct emerges as a generalized orien- was mediated by their attitude and positive inten-
tation in facilitating the movement towards tion thus supporting the tenets of TPB.
health [8, 9]. SOC is conceptualized as a global Social Cognitive Theories (SCT), behavior
orientation to life experiences, including the change is influenced by several interacting psy-
degree to which life is viewed as comprehensi- chosocial, environmental, and behavioral factors
ble, manageable, and meaningful [9]. A meta- on how a person makes choices. SCT was
analysis by Winger and colleagues [10] found advanced by Bandura [17] from Social Learning
that SOC demonstrated significant negative Theory. SCT explains how people learn not only
associations with distress in cancer patients. through their own experiences, but also by
Their analysis supported Antonovsky’s model of observing the actions of others and the results of
health that a high SOC suggests that cancer those actions. Self-efficacy theory (SET) is a sub-
patients who view life as comprehensible, man- set of Bandura’s social cognitive theory. Bandura
ageable, and meaningful experience less dis- defines self-efficacy as the individual’s percep-
tress. In a systematic review Eriksson and tion of his or her ability to feel, think, motivate,
Lindström [11] found that SOC is a health and act to perform behaviors through four pro-
resource influencing quality of life. cesses: (1) cognitive, (2) motivational, (3) affec-
17 Health Promotion Among Cancer Patients: Innovative Interventions 229

tive, and (4) selection. SCT framework was used baseline cigarettes smoked per day [20]. The
in a meta-analysis conducted by Graves [18] to results in a study by Charlot [21] using an 8-week
evaluate the quality of life among patients with mindfulness-based smoking cessation interven-
breast cancer. The results of this meta-analysis tion by a certified mindfulness trainer and tobacco
showed that using SCT-based interventions max- treatment nurse specialist showed that there was
imized improvement in overall quality of life a significant decrease in weekly cigarette intake
(QOL) outcomes for adult cancer. Grimmett [19] from 75.1 cigarettes at baseline to 44.3 at
examined the patterns of self-efficacy for manag- 3 months. This 8-week intervention consisted of
ing illness-related problems among colorectal lessons on the effects of smoking, instructions for
cancer patients in the 24 months following diag- smoking cessation and guided instruction. Each
nosis. They found that there was an increase in participant received audio compact discs and
self-efficacy mean score overtime. This study manual on mind-body practices including medi-
provided support of the positive association tation, body scan, and chair yoga (each 20 min in
between self-efficacy and adaptation to cancer length) to facilitate home practice. Another study
diagnosis and reduction of distress in patients by Li [22] provided face-to-face individualized
with cancer. brief (15–30 min) risk communication to encour-
age patients with lung cancer to stop smoking.
They hypothesized that participants in the inter-
17.3 Risk Protection vention group would have a higher smoking ces-
Interventions to Reduce or sation rates and have a reduced daily cigarette
Eliminate Exposure consumption by at least 50%. The intervention
to Cancer-Producing Agents was followed by exhaled carbon monoxide level
assessment. The risk communication component
Risk protection interventions can be targeted to focused on the relationships between smoking
mainly reduce or eliminate some types of cancer and lung cancer diagnosis, treatment, and prog-
such as skin, breast, cervical, and colorectal can- nosis as a trigger to think about quitting. After 1
cers. Skin cancer is one of the most prevalent week, the experimental group received a booster
cancers worldwide among those with more sun- intervention via telephone to assess the progress
light exposure and can be prevented by protect- of and to identify difficulties faced by patients
ing skin from excessive sun exposure. Detrimental towards quitting and how to handle withdrawal
effects of ultraviolet rays can be prevented by symptoms. The results showed that the 268
wearing thick clothing when exposed to sunlight, patients with lung cancer had higher biochemi-
applying an appropriate sunscreen and avoiding cally validated quit rate at the 6-month follow-up
artificial sources of ultraviolet rays for tanning. compared to the control group. The results found
Tobacco smoking causes many types of can- that at 6 weeks after treatment, the 7-day point
cer and is a known risk factor for lung cancer. prevalence smoking abstinence rate was 40%
Several smoking cessation interventions have [22].
been implemented worldwide to curb this Mobile phone instant messaging apps (e.g.,
unhealthy behavior not only to prevent the risk of WhatsApp, Facebook Messenger, and WeChat)
lung cancer but also to support patients who are popular and inexpensive alternatives to SMS
already have been diagnosed with lung cancer for interactive messaging [23]. Advances in
and undergoing treatment to cease smoking. An mobile technologies are also now being used for
intervention involving a brief consultation with a mobile phone-based interventions for smoking
nicotine dependence counsellor was used to help cessation. Wang [24] provided a 12-page self-­
the patient develop an individualized treatment help booklet on smoking cessation as well as
plan. The study showed that the 7-day point prev- chat-based smoking cessation support using
alence abstinence from tobacco at 6-month fol- WhatsApp mobile messaging twice a week for
low-­up was 22% after adjusting for age, sex, and the first month, and once per week for the next 2
230 V. Lopez and P. Klainin-Yobas

months by smoking cessation ambassadors. At 6 dent, may be relevant for health promotion activi-
months follow-up the results showed that 77% of ties that aim to strengthen SOC. Low health
the 591 participants had significantly higher literacy is associated with lack of knowledge
abstinence from smoking. about screening for cancer. Health care profes-
Breast cancer can be prevented through self-­ sionals should therefore knowledge about the
breast screening and improvements have been benefits of cancer screening as patients’ per-
made to increase women’s awareness and atti- ceived risk and health-promoting behavior such
tudes towards the importance of screening for as regular medical check-ups and self-efficacy
early detection of breast cancer. Promoting the have been found to be positively correlated with
attitude of the women toward breast cancer is adherence to colorectal screening [31]. The suc-
largely influenced by their screening behaviors. cessful application of resources to deal with low
Culture and ethnicity are also critical factors literacy affecting adherence to screening for can-
influencing women’s attitudes, beliefs, and cer is not only likely to have a positive influence
access to health screening services [25]. Mirzaii on health but also creates consistent and mean-
[26] investigated the effects of breast cancer ingful life experiences that can positively rein-
screening training based on the Systematic com- force SOC levels.
prehensive Health Education and Promotion
(SHEP) model on the attitudes and breast self-
examination skills in 120 women in Iran. The 17.4 Health Promotion
three 2-h SHEP-based educational workshops Interventions to Reduce
using posters and images provided general the Effects of Cancer
explanation of breast structure, breast lumps and Diagnosis
their features, risk factors and symptoms of
breast cancer, and self-breast screening methods. A cancer diagnosis is associated with high levels
Participants were asked to practice accordingly of distress, a multifactorial unpleasant emotional
at 1-week interval between the first, second, and experience in 35–45% of patients with cancer
third workshops. The results showed the efficacy [32]. It causes fear, uncertainty above recovery,
of the SHEP in promoting awareness, attitudes, and suffering not only to the patients with cancer
and self-breast examination among the Iranian but also to their families, as life situation changes
women. suddenly affecting the family unit. Although
Colorectal cancer is the third most common many studies have been conducted using the
cancer worldwide and it is the second most com- Salutogenic theory of SOC and its three compo-
mon factor for death by cancer [27]. The timely nents of meaningfulness, manageability, and
and proper colorectal cancer screening is a lead- comprehensibility, Ozanne and Graneheim [33]
ing factor to reduce incidence and consequences focused their study on the comprehensibility
of this disease. Boogar [28] examined the moder- component of SOC when patients’ symptoms
ating role of cancer-related health literacy and appeared and diagnosis was confirmed. They
cancer-related empowerment in colorectal cancer found that whether they comprehend or not, the
screening using a comprehensive model in 366 27 participants felt uncertain before the diagno-
participants. Using the Colorectal Screening sis, they lost their foothold during the diagnosis
Questionnaire and Health Education Impact and lived in fear after the diagnosis. The results
Questionnaire, the results showed that higher highlighted that it takes time to find comprehen-
perceived susceptibility and the cancer-related sibility and health professionals should provide
literacy was associated with lower defensive support and information to both patients and
avoidance and had increased the tendency of spouses to answer their questions. Depression is
patients to submit to colorectal screening tests a comorbidity of cancer and more so if the
[29]. Super [30] posited that both empowerment patients is diagnosed with late stage of cancer
and reflection processes, which are interdepen- with metastasis. SOC has long been recognized
17 Health Promotion Among Cancer Patients: Innovative Interventions 231

as an important factor in the psychological adjust- Fatigue, a subjective feeling of weariness,

ment to cancer and a protective factor for depres- tiredness or lack of energy, is the most common
sion. Aderhold [34] examined if SOC and unmanaged symptom in patients undergoing che-
post-traumatic growth (coping, struggling or motherapy or radiotherapy which leads to
thriving) were predictors of depression in 252 decreased physical daily activity during treat-
patients in Germany since being diagnosed with ment. Exercise has been shown to be effective in
cancer. They found that posttraumatic growth decreasing fatigue and improving activity toler-
(PTG) is a significant predictor of depressive ance in patients during chemotherapy [36, 37]. A
symptoms 1 year after the cancer diagnosis; the study that showed the effectiveness of exercise
higher PTG levels the lower patients’ levels of was conducted by Mock et al. [38] using the
depressive symptoms. They also found that high walking exercise intervention in female concur-
levels of SOC predicted low levels of depressive rently with the duration of 4–6 weeks of chemo-
symptoms. Patients’ experience of having cancer therapy or 6 weeks of radiotherapy. The exercise
and survival may enhance a feeling of personal was conducted at the clinical site and taught by
strength and a sense of self-efficacy which could trained staff using the exercise prescription devel-
be protective psychological factors. Therefore, oped by the exercise physiologist which was indi-
interventions should promote SOC in patients vidualized for each participant based on age,
with cancer by creating a supportive environment level of physical fitness, and type of cancer treat-
for them to be able to reflect on problems faced ment. The walking intervention consisted of an
since diagnosis, focusing on the positive changes initial 10–15 min sessions and 5–6 sessions per
they experience and strengthening their coping week and increased to 30 min per session,
resources. 5–6 weeks per week according to their exercise
tolerance and responses to treatment. The women
were asked to keep diaries of their daily exercise
17.5 Health Promotion activity. Velthuis [39] conducted a multicentre
Interventions to Reduce randomized controlled trial in 150 breast and 150
the Effects of Cancer colon cancer patients undergoing cancer treat-
Treatment ment. The intervention was 18-weeks supervised
group exercise program and significant beneficial
Once diagnosis is confirmed and staged, patients effects of the exercise were visible during cancer
undergo specific treatment according to proto- treatment, adherence was moderate to excellent
cols. The treatment modalities are surgery, che- and few adverse events occurred.
motherapy, radiotherapy, hormone therapy, Nausea and vomiting are the most common
immune therapy, and/or targeted therapy. No side effects of chemotherapy [40]. Without appro-
matter what cancer treatment patients receive, priate antiemetic intervention, chemotherapy-­
they experience various treatment side effects induced nausea and vomiting can lead to
impacting their overall QoL. Cancer and cancer-­ dehydration, electrolyte disorder, malnutrition,
related treatments trigger such symptoms like and can negatively affect patients’ adherence to
pain, insomnia, nausea, and vomiting, treatment as well as quality of life [41]. Acupoint
chemotherapy-­ induced peripheral neuropathy, therapies have been recommended as a comple-
and sexual dysfunction which may lead to psy- mentary intervention to prevent chemotherapy-­
chological symptoms such as stress, depression induced nausea and vomiting by the National
and anxiety [35]. Overcoming the psychological Institute of Health [42]. Acupoint therapies
effects of cancer treatment require patients with including acupuncture, acupressure, acupoints
cancer to have a clear concept of coping ability to injection, massage, and moxibustion which are
conceptualize their diagnosis and treatment as safe medical procedures have shown promising
meaningful, manageable and comprehensible intervention for the management of chemother-
which are the three components of SOC [8]. apy-induced nausea and vomiting [43]. Auricular
232 V. Lopez and P. Klainin-Yobas

acupressure, another innovative health promotion identity, self-esteem, intimacy, and the end of
intervention in preventing and treating nausea and reproductive capacity. Psychoeducational inter-
vomiting in patients with cancer, was also used vention has been found to significantly improve
before chemotherapy which has been recognized frequency of coital activity, reduce fear about
by the Federal Nursing Council in its 197/97 reso- intercourse, and improve sexual knowledge. For
lution as being an acceptable professional role of example, Brotto [51] recruited 22 women with
nurses [44]. Eghbali [45] placed the ear seed on gynaecological cancer with sexual dysfunction
the pinna on each ear for 5 day and asked the and asked them to self-report their response to
patients to press the ear seeds for 3 min three the 3-min neutral and 4-min erotic audiovisual
times a day in the morning, noon and night during film using the Film Scale. The Film Scale [52]
the chemotherapy cycle. Their study found that was administered during the sexual arousal
auricular therapy led to a decrease in the number assessments that assessed perception of genital
and intensity of nausea and vomiting in both the sexual arousal, subjective sexual arousal, auto-
acute and delayed phases in the experimental nomic arousal, anxiety, positive affect, and nega-
group and suggested that nurses can use this pres- tive affect. Items were rated on a 7-point Likert
sure technique as a complementary nonpharma- scale from 1 (not at all) to 7 (intensely).
cological, inexpensive, and noninvasive relief of Psychoeducational intervention consisting of
chemotherapy-­induced nausea and vomiting. three 60-min sessions targeting sexual arousal
Chemotherapy-induced peripheral neuropathy complaints and how to troubleshoot these diffi-
(CIPN) is another symptom experienced by culties was conducted. A combination of infor-
patients with cancer who are undergoing chemo- mation about progressive relaxation, mindfulness,
therapy [46]. It is a progressive, prolonged, and becoming organismic, and making marriage
often irreversible side effect of many chemother- work in a manual was also given to the patients.
apeutic agents and affects 30–40% of patients The results showed significant improvement in
undergoing treatment [47]. CIPN affects the women’s sexual response, mood, and quality of
peripheral sensory and/or motor systems and life [51].
causes numbness, pain, burning, tingling, heat Another innovative health promotion inter-
and hyperalgesia, and mechanical allodynia, as vention to improve the psychological well-being
well as reduced motor function [47]. It has been and quality of life of patients with cancer by less-
reported that CIPN may continue to worsen after ening of side effects from chemotherapy is the
chemotherapy as 68% of patients with cancer still use of art therapy. A study by Bozcuk [53] involv-
experience the problems in the first month and ing 48 patients attending the outpatient chemo-
30% in the sixth month after chemotherapy [48, therapy unit in Turkey participated in the painting
49]. There is no effective treatment in preventing art therapy using watercolors for 6 weeks. Group
or managing CIPN, but complementary therapies discussions were conducted on the symbolic
have been reported to improve the symptoms of nature of their paintings, and expression of feel-
CIPN such as acupuncture, foot bath, massage, ings and thoughts. The results showed that art
reflexology, sensorimotor training as well as therapy in the form of water-color painting
Chinese, Korean, and Japanese herbal medicines improved their global quality of life and reduced
[50]. However, further research is needed to depression through sharing and discussing prob-
examine the effects of herbal medicine on its effi- lems, feelings and thoughts thus enabled coping
cacy, safety, and cost-effectiveness. with their negative feelings about their cancer
Sexual dysfunction during treatment of early-­ diagnosis and treatment. Huss and Samson [54]
stage cervical and endometrial cancer has been conducted a study to explore the connection
reported as the most distressing side effect of between art therapy and SOC in patients their
cancer treatment. The negative effects of chemo- families dealing with cancer. As a health promot-
therapy result in threats to the women’s sexual ing strategy, the participants drew images caus-
17 Health Promotion Among Cancer Patients: Innovative Interventions 233

ing their stress. In a group discussion, participants pedometer (portable device that counts the num-
explained the image to the group and the group ber of steps) as well as actigraphy (monitors
then discussed the meaning, manageability, and movement and sleep-wake cycle) and self-report
comprehensiveness components that could help of the walking log. The results showed that the
cope with stress. The study provided evidence survivors had increased their activity levels as
that methods in creating meaning through art well as improved their quality of life [57].
therapy enhanced the patients’ SOC by integrat- Nutritional deficiencies are also common
ing the three components to overcome their stress problems associated with cancer diagnosis and
about cancer diagnosis and treatment. should be corrected during the survivorship
period. Pierce [58]examined the effectiveness of
telephone counseling to promote dietary change
17.6 Health Promotion in the intervention from baseline to 12 months in
Interventions to Support 2970 breast cancer survivors in the Women’s
Survivorship and Palliation Healthy Eating and Living (WHEL) Study.
Individualized telephone counselling with
Although cancer has been considered as a global monthly cooking classes and monthly newslet-
public health issue, with continuing improvement ters were provided by qualified counsellors and
in cancer treatment, more individuals diagnosed nutritionists. Each cooking class featured a nutri-
with cancer are surviving with the disease [55]. tion theme to promote adherence and understand-
Patients who are alive 5 years after the cancer ing of the intervention dietary pattern and gave
diagnosis and treatment are referred to as survi- women an opportunity to taste new foods and
vors. However, although intensive treatments can learn to prepare recipes. The newsletters featured
improve long-term survival, the emotional and research updates, nutrition information and reci-
physical demands of the diagnosis and treatment pes to help motivate women to adopt and main-
experience of cancer survivors are substantial. tain the intervention dietary pattern. At 12 months,
Several health promotion interventions have been the intervention group reported a significantly
developed, implemented and evaluated to over- increased daily vegetables, fruits, and fiber
come the physiological and psychological prob- intake.
lems experienced by cancer survivors. For Qigong is a Chinese mind-body integrative
example, reports found that exercise improves exercise used to prevent and cure ailments, to
breast cancer survivors’ physical and psychologi- improve health and energy levels through regular
cal functioning, reduce the risk of cancer recur- practice [59]. Two clinical trials suggested its
rence, second primary cancers, as well as prolong effectiveness in prolonging the life of cancer
survival [56]. Simple, effective, and inexpensive patients: (1) a study by Hong [60] involving 24
physical activity interventions for cancer survi- patients with advanced gastric cancer showed
vors can also improve quality of life and reduce that Qigong was an effective nursing intervention
the risk of early mortality. An example of inter- to reduce fatigue, difficulty of daily activities and
vention to empower survivors was a 12-week some chemotherapy side effect such as nausea,
home-based walking intervention to breast can- vomiting, and stomatitis, and (2) an RCT study
cer survivors [57]. The intervention also con- by Wang [61] including 62 patients with late
sisted of telephone counselling of breast cancer stage cancer also showed that Qigong plus che-
survivors to set their goals to walk three times per motherapy had extended the tumor-free and bet-
week for 20–30 min for the first 4 weeks, walking ter quality of their survival. However, the health
four times a week for 30–40 min for the next 3 promotion effectiveness of Qigong needs to be
weeks followed by walking five times per week further evaluated in more rigorous clinical trials.
for 30–40 min for 5 weeks. Minutes-by-minutes Another health promoting intervention to
activity was measured by providing them with support survivorship was the use of mindfulness-­
234 V. Lopez and P. Klainin-Yobas

based psychoeducation for cancer survivors children must take more rest [65]. In the past two
(MindCAN) which is a psychoeducation pro- decades, there has been an increase in the promo-
gram to help cancer survivors learn essential tion of regular physical activity among childhood
cancer-related knowledge; and to recognize and cancer survivors as it enhances their physical and
manage stress, thoughts, and emotions more psychological well-being [66]. There has been an
effectively [62]. Contents of the MindCAN pro- increase in the use of adventure-based training to
gram was adapted from Mindfulness-Based promote the psychological well-being of primary
Stress Reduction (MBSR) involving 8 weekly school children which can be used also in child-
group-based program encompassed two compo- hood cancer survivors [67]. For example, a 4-day
nents: Education and Mindfulness Practice. Each integrated adventure-based training and health
session lasted 90 min. Weekly education topics education program in the day-camp centre was
included: introducing mindfulness, recognizing conducted by 2 professional adventure-based
and managing cancer-related stress, dealing with trainers in 71 Hong Kong childhood cancer survi-
cancer-related symptoms and treatments, pro- vors. The results showed that the intervention
moting mindful calmness and composure, pow- promoted increased levels of physical activity,
erful mind, mindful communication, mindful self-efficacy, and QoL in childhood cancer survi-
living, building your mindful lifestyle, and con- vors [68].
solidating mindfulness practice. Mindfulness Cancer also have long-term and lasting
practices included: mindful breathing, body adverse effects on the psychological well-being
scan, mindful eating, standing and walking and neurocognitive functioning of childhood
meditations, mindful emotions, let go of
­ cancer survivors. Dietz [65] provided a weekly
thoughts, loving-­kindness medication and STOP 45-min lesson on musical training for 52 weeks
breathing space [63]. Furthermore, participants among 60 children aged 5–8 years. These chil-
shared their experiences with group members on dren were survivors with brain tumor; the pro-
their journey toward survivorship. A qualitative gram aimed to transform their lives and instill
study involving 15 cancer patients was con- positive values through music. Training was con-
ducted to examine the patients’ perception ducted by a group of professional musicians of
towards MindCAN. A thematic analysis sug- the nongovernment Music Children Foundation
gested five major themes including: (1) height- in Hong Kong. One-to-one musical training was
ened awareness of self, (2) enriching body conducted by qualified orchestral performers at
experiences through mindfulness practice, (3) the participants’ homes. The participants were
cultivating powerful minds and positive emo- assigned a specific musical instrument to learn
tions, (4) integrating mindfulness to daily life, based on their interests as well as their fine motor
and (5) embracing interpersonal mindfulness. skills and expiratory function which were
Furthermore, most participants perceived that assessed by the training musician. Training began
MindCAN helped them feel more relaxed, and at the lowest level up to the highest level where
that they better managed stress, unhealthy children were able to play an entire music. The
thoughts, and emotions [62, 64]. results showed that children brain tumor survi-
Many children are also diagnosed with cancer vors reported statistically significant fewer
and undergo similar treatments as adults. depressive symptoms, higher levels of self-­
Advances in cancer treatment and cancer treat- esteem and better quality of life.
ment efficacy have also improved the prognosis Many patients with advanced-stage cancer
of childhood cancer and long survivorship period will only require palliative care and thus will con-
[65]. However, childhood cancer survivorship tinue to live with the cancer and cancer treatment-­
has shown declining levels of physical activity related symptoms such as fatigue, paraesthesia
mainly due to fatigue and reduced physical and dysesthesias, chronic pain, anorexia, insom-
strength and endurance as well parental view that nia, limbs oedema, and constipation [69]. For
17 Health Promotion Among Cancer Patients: Innovative Interventions 235

patients with advanced-stage cancer, one option their families with stronger SOC were associated
is to provide effective care through pain relief with higher hope, lower anxiety, and symptoms
and palliative care. Sometimes, surgery, chemo- of depression. Health professional should strive
therapy and radiotherapy are also effective mea- to assess patients and families who have low
sures for effective palliative care especially for SOC and offer support to promote their compre-
pain relief. Living with persistent pain is always hensibility, manageability, and meaningfulness
associated with poor life satisfaction and is one during the palliative phase of cancer.
of the factors that cause comorbidity and mortal-
ity [70]. When cancer patients experience persis-
tent pain, this has negative influence on their 17.7 Mindfulness Interventions
well-being. In cancer survivors, pain treatment for Psychological Health
needs to meet the expectation. Opioids is still the of Patients with Cancer
major drug used. In view of the risks of overuse
of opioids and the balance between the positive Promoting overall psychological health of patients
benefit to the survivors, this creates a real chal- with cancer has been a focus of much research
lenge to the health care system and the health and one of the promising and innovative health
care providers. The psychological effect of pain promoting intervention is the use of mindfulness-­
is an inner emotional experience of suffering in based training among people with cancer [32, 76].
patients with cancer. As a result of being sick, The concept of mindfulness was derived from the
palliative care patients begin to question the term “Sati,” which has its original root from
meaning of life and death. As such the saluto- Theravada Buddhism. Mindfulness refers to
genic framework is useful in helping palliative awareness, which can be achieved through focus-
care patients to find meaning and enable them ing and sustaining attention on the current moment
who are living in this difficult situation to have on purpose with a nonjudgmental attitude [77,
better health and well-being [71]. Roditi and 78]. Mindfulness practice, including formal and
Robinson [72] suggested that promoting SOC in informal meditations, are main approaches to cul-
cancer survivors can help empower them to deal tivate the mindfulness levels among individuals.
with, and acquire new meaning of persistent pain. The formal mindfulness practice requires a per-
Other nonpharmacological interventions such as son to perform regular meditations for a certain
massage, acupuncture, mind and body techniques time period (such as body scan), whereas infor-
are evidence-based interventions that can be used mal practice signifies how persons integrate
to relieve cancer pain, as these techniques are awareness or “cautious attention” in their daily
inexpensive, safe, and have no side effects [73]. life activities (such as mindful eating and mindful
Promoting palliative care aside from helping walking). During the mindfulness practice, the
patients to feel comfortable by providing pain individuals would be able to: (a) recognize the full
relief also need psychological and spiritual sup- range of their internal and external experiences,
port. Health promoting interventions are also (b) regulate their attention and energy levels, and
important. A longitudinal study by Park [74] on (c) connect to people around them [78]. People
survivors of various cancers found that meaning-­ with high levels of mindfulness pay their attention
making efforts were related to less distress on the current tasks and activities, disengage from
through meanings made to their negative emo- unhealthy beliefs, thoughts and/or emotions, and
tions which corresponds to Antonovsky’s SOC maintain emotional balance and psychological
three tenets. Persons with palliative phase of can- well-being [77]. Mindfulness practice encom-
cer and their families experience low hope, anxi- passes seven attitudinal foundations, including
ety, and symptoms of depression. In an acceptance, beginner’s mind, letting go, nonjudg-
observational, cross-sectional multiple study ing, nonstriving, patience, and trust [78].
Mollenberg [75] found that both the patients and Mindfulness interventions were developed for
236 V. Lopez and P. Klainin-Yobas

people with physical and psychological condi- ness would have more freedom and choices
tions. Subsequently, those interventions have whilst those in an autopilot mode often engage in
been applied to patients with cancer. Examples of unhealthy habits, which may trigger negative
the program are MBSR, MBCT, and MBCR, all moods [84]. MBCT, with much influence from
of which are explained in the following. MBSR, contains 8 weekly sessions. For each
week, the topics are: (1) Awareness and auto-
matic pilot, (2) Living in our heads, (3) Gathering
17.7.1 Mindfulness-Based Stress the scattered thoughts, (4) Recognizing aversion,
Reduction (MBSR) (5) Allowing/Letting be, (6) Thoughts are not fact
& Relapse signature, (7) How can I best take care
The first mindfulness program was developed at of myself, and (8) Maintaining and extending
the University of Massachusetts Medical Centre’s new learning [84]. Similar to MBSR, various
stress reduction clinic for people who experi- mindfulness practices are introduced encompass-
enced pain and stress [78]. The group-based ing raisin exercise, body scan practice, mindful-
MBSR contains 8 weekly sessions, each one lasts ness of the breath, sitting meditation, and mindful
two and a half hours. A 1-day retreat is also walking. Home practices are required whereby
included, and participants are asked to perform participants do daily practice of mindfulness
daily mindfulness practice for 30–45 min. Topics guided by provided CDs. Two RCTs involving
for each week include: (1) simple awareness, (2) participants diagnosed with cancer revealed that
attention and the brain, (3) dealing with thoughts, MBCT improved mindfulness, depression, anxi-
(4) stress: responding versus reacting, (5) dealing ety, distress, and QoL in comparisons to control
with difficult emotions or physical pain, (6) participants [85, 86]. Among women with breast
mindfulness and communication, (7) mindful- cancer, participants in the MBCT group reported
ness and compassion, and (8) conclusion: significantly lower pain intensity, nonprescrip-
developing a practice of your own [79].
­ tion pain medication use, and function disability,
Participants also learn different mindfulness and greater quality of life, posttraumatic growth,
practices such as meditation, body scan, loving and self-management compared to the control
kindness, and yoga [79]. In the field of oncology, group [87, 88].
specific breast cancer MBSR has been imple-
mented. Studies showed that the mindfulness
improved physical symptoms (fatigue and inter- 17.7.3 Mindfulness-Based Cancer
ference) [80], emotional problems (depression, Recovery (MBCR)
anxiety, fear of occurrence), and QoL in patients
with breast cancer [81, 82]. MBCR is offered to people with cancer as a heal-
ing practice, which enables them to enrich their
daily life, cope with cancer-related symptoms
17.7.2 Mindfulness-Based Cognitive and treatments, improve an immune system,
Therapy (MBCT) reduce harmful effects of stress hormones and
thus enhance QoL [89]. Mindfulness is repre-
MBCT is a group-based program originally cre- sented in two categories: Big-M and Little-m
ated as a relapse-prevention treatment for patients [90]. The former signifies living in the world
with depression [83]. Participants would learn to mindfully whereas the latter represents allocating
be more aware of their physical sensations, certain time slots to practice mindfulness [89].
thoughts and emotions from moment to moment Adapted from MBSR, MBCR comprises 90-min,
and then respond to unpleasant sensations, 8-week intervention sessions, a weekend retreat
thoughts and emotions in more skillful approaches and home practice. Weekly themes entails: (1)
[84]. It is perceived that people with full aware- mindfulness attitudes, (2) stress responding ver-
17 Health Promotion Among Cancer Patients: Innovative Interventions 237

sus reacting, (3) mindful movement, (4) balanc- improvement in psychological symptoms (stress,
ing breath, (5) stories we tell ourselves (trouble anxiety and depression), health status (fatigue),
mind), (6) meditation with imagery, (7) a Day of QoL, and cognitive abilities (mindfulness and
Silence, and (8) deepening and expanding [89]. cognitive functioning) [94].
Certain contents are incorporated into MBCR, A 10-week, internet-based group interven-
including coping with cancer-related symptoms tion was developed with elements from MBSR
(such as pain, insomnia and fear of reoccurrence) and cognitive-behavioral stress management for
and cognitive coping strategies. Participants are ovarian cancer survivors in USA [95].
instructed to practice mindful breathing, body Participants logged in to a web platform to
scan, sitting meditation, yoga, mindful walking, access weekly a videoconference, relaxation
and mountain and loving kindness meditation. and meditation practice (such as deep breath-
Empirical evidence showed that, in comparison ings mindfulness meditation, and guided relax-
with control groups, MBCR reduced stressed ation and visualization) and journal to record
symptoms and mood disturbance [91] and daily reflection. Session topics encompassed
enhanced QoL and post-traumatic growth among awareness of stressors and strengths, automatic
distressed breast survivors [92]. thoughts, rational thoughts, acceptance, social
support, effective communication, anger, mean-
ing of life, and wrap up. The study revealed that
17.7.4 Innovation: Technology-Based the internet-based program was highly usable
Mindfulness Interventions and acceptable with moderate feasibility for
ovarian cancer survivors [95].
Traditional face-to-face mindfulness programs In the Netherlands, a pilot single-group study
are beneficial in terms of preventing and reducing tested the effects of a 9-week, internet-based,
physical and psychological symptoms among therapist-guided, individual MBCT (iMBCT) on
people with cancer [93]. However, there are some fatigue among cancer survivors [96]. Each week,
challenges concerning the traditional method of patients would log in to the website, read infor-
learning. Specifically, some patients may have mation specific for mindfulness, write down their
limited mobility due to cancer-related fatigue and experiences in the log boxes and practice mind-
pain, geographical distance and program sched- fulness using audio files. On an agreeable day of
ule and setting. As such, technology-based plat- the week, the therapist would reply to the patients’
forms (such as internet and mobile phone) may log and guide them through the program. An
be the alternatives as they help overcome chal- online forum allowed participants to share their
lenges encountered by traditional face-to-face experiences on mindfulness practice. Patients
programs. who attended the iMBCT reported significant
A mobile phone mindfulness-based stress reduction in fatigue severity and distress [96].
reduction intervention for breast cancer was In Denmark, researchers created an internet-­
examined among 15 breast cancer survivors in delivered MBCT program (iMBCT) for breast
USA [94]. A single-group, quasi-experimental and prostate cancer survivors [97]. In this RCT,
design was implemented. The MBSR was cre- cancer survivors included those who completed
ated to deliver 6 weekly, 2-h intervention ses- primary treatments at least 3 months until 5
sions through iPad. Weekly modules covered years. Potential participants were randomized
formal meditative techniques (sitting and walk- into either an intervention (receiving iMBCT)
ing meditation, body scan and Hatha yoga) and or control group (receiving care-as-usual). The
informal meditation (integrating mindfulness iMBCT program comprised 8 weekly modules
into daily life). Participants practiced formal and with written materials, audio-guided exercise,
informal mindfulness for 15–45 min and recorded examples of cancer-specific patients and videos.
the practice on the iPad. Results indicated Participants were required to submit a weekly
238 V. Lopez and P. Klainin-Yobas

training diary to their therapist, who would pro- foundation course (basic mindfulness medita-
vide comments each week. Nine therapists, who tion) followed by condition-specific sessions
received MBCT training, involved in such tasks. (stress, anxiety, sleep and acceptance). Each ses-
Findings suggested that patients in both MBCT sion took 10–20 min encompassing a short lec-
and iMBCT groups had long-term reduction in ture video and progressive audio instruction. The
psychological and distress; and long-term Headspace helped reduce distress, depression,
increase in positive mental health and mental anxiety, and improved mental health and quality
health-related QoL [98]. of sleep among cancer patients with active cancer
In Canada, researchers conducted an RCT to treatments and their caregivers [100].
test the “synchronous” or “real time” online
MBCR on distressed cancer survivors [99]. The
online MBCR encompasses eight 2-h weekly 17.8 Chapter Summary
sessions with a didactic approach, live group
interaction, online 6-h retreat and home practice Cancer is a global concern as the incidence rates
(hatha yoga, qigong movement and sitting, walk- of cancer continue to increase despite new treat-
ing, and loving-kindness meditations). During ment modalities. The number of cancer survivors
the mindfulness sessions, all participants inter- are also on the rise prolonging their life beyond
acted in real time with the therapist and other the 5-year period. From being aware of the risk
group members. The home practice was achieved for cancer to results of screening, definitive diag-
through guided recordings and videos. The pro- nosis, undergoing treatment and survivorship,
gram demonstrated feasibility and effectiveness patients experience physiological as well as psy-
in reducing stress, mood disturbances, enhancing chological ill health and reduced well-being.
mindfulness and spirituality [76]. Similarly, There are growing health promotion strategies to
another study in Canada revealed the effective- support patients with cancer. Most of these inter-
ness of the real time online MBCR on cancer sur- ventions focused on increasing patients’ knowl-
vivors. Age and gender differences were edge, attitudes, and behaviors in changing their
documented whereby younger participants lifestyle as well as managing the problematic and
reported greater improvement in stress, spiritual- debilitating treatment-related symptoms they
ity, and nonreactivity (one component of continue to experience as cancer survivors. The
­mindfulness); and men reported greater posttrau- Salutogenic model of health and specifically the
matic growth [99]. Results indicated that partici- SOC has been widely and effectively used in
pants in the iMBCT group had significant health promotion interventions. It is suggested
improvement in anxiety. that health care professionals use these evidence-­
Another pilot study in USA was carried out to based interventions appropriately within their
test a Headspace application (a self-paced com- sociocultural context. Table 17.1 provides a sum-
mercial program) via website or smart phone mary of health promoting interventions presented
[100]. The 8-week program comprised a 30-days in this chapter.
17 Health Promotion Among Cancer Patients: Innovative Interventions 239

Table 17.1 Summary of health promotion interventions for cancer patients

Cancer health issues Health promotion interventions
Smoking cessation [22] An 8-week mindfulness-based smoking cessation intervention consisting of lessons on
the effects of smoking, instructions for smoking cessation, guided instruction, and an
audio compact discs and manual on mind-body practices including meditation, body
scan, and chair yoga (each 20 min in length)
Smoking cessation [23] Face-to-face individualized brief (15–30 min) risk communication followed by a
booster intervention via telephone to assess the progress of, and to identify difficulties
faced by patients towards quitting and how to handle withdrawal symptoms.
Smoking cessation [25] Chat-based cessation support delivered through an instant messaging app (WhatsApp)
for 1, 2, and 3 months. Smoking cessation counsellor interacted with a participant in
real time and provided personalized, theory-based cessation support.
Colorectal cancer patients An 8-week audio-based mindfulness meditation program using MP3 player preloaded
[29] with eight mindfulness meditation tracks, study booklet containing a practice diary. An
email was sent each week containing practice instructions, a motivational quote linked
to a discussion
Of the weekly theme. Participants were instructed to practice 15 ± 20 min per day, 5
days per week, during the 8-week study. They received a text message to their personal
cell phone daily at 4 pm with messages containing motivational quotes or practice
suggestions.
Fatigue [38] Walking intervention consisting of an initial 10–15 min sessions and 5–6 sessions per
week and increased to 30 min per session, 5–6 weeks per week according to their
exercise tolerance and responses to treatment. The women were asked to keep diaries of
their daily exercise activity.
Nausea and vomiting [45] Acupressure by placing ear seed on the pinna on each ear for 5 day and asked the
patients to press the ear seeds for 3 min three times a day in the morning, noon and
night during the chemotherapy cycle.
Chemotherapy-­induced Eight treatments of foot bath and massage for 30 min every other day for 2 weeks.
peripheral neuropathy [50]
Nutritional deficiencies Twelve months individualized telephone counselling with monthly cooking classes and
[58] monthly newsletters provided by qualified counsellors and nutritionists. Each cooking
class featured a nutrition theme to promote adherence and understanding of the
intervention dietary pattern and gave women an opportunity to taste new foods and
learn to prepare recipes. The newsletters featured research updates, nutrition
information and recipes to help motivate women to adopt and maintain the intervention
dietary pattern.
Stress-related treatment A group-based, mindfulness-based stress reduction (MBSR) contains 8 weekly
[78] sessions, each one lasts two and a half hours. A 1-day retreat is also included, and
participants are asked to perform daily mindfulness practice for 30–45 min. Topics for
each week include: (1) simple awareness, (2) attention and the brain, (3) dealing with
thoughts, (4) stress: Responding versus reacting, (5) dealing with difficult emotions or
physical pain, (6) mindfulness and communication, (7) mindfulness and compassion,
and (8) conclusion: Developing a practice of your own.
Sexual dysfunction [51] Self-report response to the 3-min neutral and 4-min erotic audiovisual film,
psychoeducational intervention consisting of three 60-min sessions targeting sexual
arousal complaints and how to troubleshoot these difficulties and manual of information
about progressive relaxation, mindfulness, becoming organismic, and making marriage
work followed by group discussion.
Stress of being diagnosed Using art therapy, participants drew images causing their stress followed by group
with cancer [54] discussion, where participants explained the image to the group and the group then
discussed the meaning, manageability, and comprehensiveness components that could
help cope with stress. The study provided evidence that methods in creating meaning
through art therapy enhanced the patients’ sense of coherence by integrating the three
components to overcome their stress about cancer diagnosis and treatment.
Supporting childhood Children attended a 4-day integrated adventure-based training and health education
cancer survivors [67] program in the day Camp Centre conducted by two professional adventure-based
trainers from the sports and recreation management and oncology.
(continued)
240 V. Lopez and P. Klainin-Yobas

Table 17.1 (continued)

Cancer health issues Health promotion interventions
Neurocognitive A weekly 45-min lesson on musical training for 52 weeks in 60 5–8 years old children
functioning in children survivors with brain tumor to transform their lives and instill positive values through
with cancer [66] music. Training was conducted by a group of professional musicians of the
nongovernment music children Foundation in Hong Kong. One-to-one musical training
was conducted by qualified orchestral performers at the participants’ homes. The
participants were assigned a particular musical instrument to learn based on their
interests as well as their fine motor skills and expiratory function which was assessed
by the training musician. Training began at the lowest level up to the highest level
where children were able to play an entire music.
Survivorship [62] The 8-weekly group-based programs encompassed two components: Education and
mindfulness practice. Each session lasted 90 min. Weekly education topics included:
Introduction of mindfulness, recognizing and managing cancer-related stress, dealing
with cancer-related symptoms and treatments, mindful emotions: Calmness and
composure, mindfulness: The powerful mind, mindful communication, mindful living:
Building your mindful life style, and consolidation of mindfulness practice.
Mindfulness practices included: Mindful breathing, body scan, mindful eating, standing
and walking meditations, mindful emotions, let go of thoughts, loving-kindness
medication and STOP breathing space.
Psychological well-being Six weekly 2-h mindfulness intervention sessions using mobile application iPad.
[76] Weekly modules covered formal meditative techniques (sitting and walking meditation,
body scan, and hatha yoga) and informal meditation (integrating mindfulness into daily
life). Participants practiced formal and informal mindfulness for 15–45 min and
recorded the practice on the iPad.

Take Home Messages GLOBACAN estimates of incidence and mortal-

• Cancer patients have reduced psychological ity worldwide for 36 cancers in 185 countries. CA
Cancer J Clin. 2018;68(6):394–424. https://doi.
well-being and increased stress, anxiety, and org/10.3322/cacc.21492.
depressive symptoms. 3. International Agency for Research in Cancer. Latest
• The Salutogenic health theory that focuses on global cancer data. Press release, no. 263. 2018.
the origins of health and psychological well-­ https://www.iarc.fr/wp-content/uploads/2018/09/
pr263_E.pdf.
being can be used to guide health promotion 4. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer
interventions in patients with cancer. incidence and mortality worldwide: sources, meth-
• A high SOC reflects a coping capacity of can- ods and major patterns in GLOBOCAN 2012. Int J
cer patients to deal with everyday life stressors Cancer. 2015;136:E359–86.
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 Health Promotion Among
Long-­Term ICU Patients
18
and Their Families

Hege Selnes Haugdahl, Ingeborg Alexandersen,

and Gørill Haugan

Abstract human connectedness have shown a positive

influence on patient outcomes. Thus, a shift
Few patients are as helpless and totally depen-
from technical nursing toward an increased
dent on nursing as long-term intensive care
focus on patient understanding and greater
(ICU) patients. How the ICU nurse relates to
patient and family involvement in ICU treat-
the patient is crucial, both concerning the
ment and care is suggested. Accordingly, a
patients’ mental and physical health and well-­
holistic view including the lived experiences
being. Even if nurses provide evidence-based
of ICU care from the perspectives of patients,
care in the form of minimum sedation, early
family members, and ICU nurses is required
mobilization, and attempts at spontaneous
in ICU care as well as research.
breathing during weaning, the patient may not
Considerable research has been devoted to
have the strength, courage, and willpower to
long-term ICU patients’ experiences from
comply. Interestingly, several elements of
their ICU stays. However, less attention has
been paid to salutogenic resources which are
H. S. Haugdahl (*) essential in supporting long-term ICU
Nord-Trøndelag Hospital Trust, Levanger, Norway patients’ inner strength and existential will to
Faculty of Medicine and Health Science, Department keep on living. A theory of salutogenic ICU
of Public Health and Nursing, NTNU Norwegian nursing is highly welcome. Therefore, this
University of Science and Technology,
Trondheim, Norway chapter draws on empirical data from three
e-mail: hege.selnes.haugdahl@hnt.no large qualitative studies in the development of
I. Alexandersen a tentative theory of salutogenic ICU nursing
Faculty of Medicine and Health Science, Department care. From the perspective of former long-­
of Public Health and Nursing, NTNU Norwegian term ICU patients, their family members, and
University of Science and Technology, ICU nurses, this chapter provides insights into
Trondheim, Norway
e-mail: ingeborg.alexandersen@ntnu.no how salutogenic ICU nursing care can support
and facilitate ICU patients’ existential will to
G. Haugan
Department of Public Health and Nursing, keep on living, and thus promoting their
NTNU Norwegian University of Science health, survival, and well-being. In a saluto-
and Technology, Trondheim, Norway genic perspective on health, the ICU patient
Faculty of Nursing and Health Science, pathway along the ease/dis-ease continuum
Nord University, Levanger, Norway reveals three stages; (1) The breaking point,
e-mail: gorill.haugan@ntnu.no,
(2) In between, and (3) Never in my mind to
gorill.haugan@nord.no

© The Author(s) 2021 245

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_18
246 H. S. Haugdahl et al.

give up. The tentative theory of salutogenic tion worldwide. The present Covid-19 pandemic
long-term ICU nursing care includes five main demonstrates that a health promotion approach in
concepts: (1) the long-term ICU patient path- the care of long-­term ICU patients is ever more
way (along the salutogenic health continuum), important in the years to come. The pathophysi-
(2) the patient’s inner strength and willpower, ology of severe viral pneumonia (as in COVID-
(3) salutogenic ICU nursing care (4), family 19) is acute respiratory distress syndrome, which
care, and (5) pull and push. The salutogenic is associated with a prolonged ICU stay [1]. A
concepts of inner strength, meaning, connect- retrospective study from the Lombardy region
edness, hope, willpower, and coping are of in Italy demonstrated that 5 weeks after the first
vital importance and form the essence of salu- admission to the ICU, most of the COVID-19
togenic long-term ICU nursing care. patients (58%) were still in the ICU showing a
higher need for mechanical ventilation than other
Keywords ICU patients [2]. ICU care of COVID-19 patients
Critical care nursing · Family care · Health is challenged by isolating regimes with limited
promotion · ICU care · Long-term ICU human contact. ICU nurses caring for the patients
patient are wearing medical masks, gowns, gloves, and
face shields, and visits from family members are
banned [1]. From a health promotion perspective,
these factors might cause stress for patients, fam-
ily members, and nurses, and negatively affect
18.1 Introduction the patients in the recovery process.
This chapter starts with an outline of research
The main difference between patients in the on long-term ICU patients. Following this, a
intensive care unit (ICU) and other patients specific nurse–patient situation with data from
is that the former are severely critically ill and observations in an ICU (the story of Peter) is used
need advanced life-sustaining care, including to give the reader insight into the key aspects of
mechanical ventilation. ICU patients need fun- care for the long-term ICU patient. The story runs
damentals of care such as keeping clean, warm, like a thread throughout the chapter, leading the
fed, hydrated, dressed, comfortable, mobile, and reader through the phases of ICU nursing with
safe. ICU patients who need mechanical ven- a focus on salutogenesis and health promotion.
tilation are unable to talk. They are therefore Our aim is to demonstrate how clinical skills are
totally dependent on others, including having context-­specific, and how these skills are mani-
others interpret their symptoms and feelings. fested in a specific encounter with an individual
This means that advanced medical treatment and patient. This chapter is placed in a health promo-
technology need to be accompanied by advanced tion perspective and is based in the salutogenic
nursing care. In this chapter, we argue for the health theory. The chapter is divided into sections
relevance of a health promotion perspective in on theoretical perspectives, purpose, methodol-
the care of acutely/critically ill patients. The ogy, results, and discussion of the findings.
aim of this chapter is to enhance understanding
of the essence of long-term ICU care in a health
promotion perspective. We build our analysis 18.2 Background
on qualitative data on former long-term ICU
patients’ experiences of their struggle to survive, Recent years have seen an increasing focus on
together with the experiences of ICU nurses and the long-term consequences for ICU patients
patients’ family members. This chapter is writ- after hospital discharge. Former ICU patients
ten from our home-offices since all universities may suffer from physical and mental health
are locked down due to the COVID-19 infec- problems with a negative impact on quality of
18 Health Promotion Among Long-Term ICU Patients and Their Families 247

life and daily functioning [3]. The term post- laboration between and among patients, families,
intensive care syndrome (PICS) describes new and health care providers [9]. The guidelines for
or worsening problems in physical, cognitive, or family-­centered care [10] highlight the impor-
mental health status arising after a critical illness tance of future research to improve collaboration
and persisting beyond acute care hospitalization with patient and family in ICU care [10].
[4]. Possible mechanisms of PICS are insuf- Although considerable research has been
ficient supply of oxygen (hypoxia), treatment devoted to long-term ICU patients’ experiences
such as a tube is inserted into the patients’ airway from their ICU stays [11], less attention has
(endotracheal intubation), frequent use of benzo- been paid to health promoting factors [12, 13]
diazepines, immobilization, and interruption of that encourage ICU patients’ existential will to
the sleep-­wake cycle [4]. Health promoting and keep on living [14]. Knowledge of health promo-
­rehabilitation efforts should therefore already be tion in ICU care from the perspectives of ICU
initiated during the ICU stay [3]. patients, their family members, and ICU nurses
A growing evidence suggest that the ABCDEF may improve the quality and efficiency of long-
bundle (A, assess, prevent, and manage pain; B, term ICU care. Therefore, we suggest the need
both awakening and spontaneous breathing trials; to develop a tentative theory of salutogenic ICU
C, choice of analgesic and sedation; D, delirium: nursing care to describe long-term ICU care and
assess, prevent, and manage; E, early mobility and the health promotion process of getting through
exercise; and F, family engagement and empow- the illness trajectory.
erment) improves ICU patient-­centered outcomes
and promotes interprofessional teamwork and
collaboration [5, 6]. A multicenter prospective 18.3 Theoretical Foundation
cohort study among 15,226 adults concluded that
ABCDEF bundle performance showed signifi- The choice of theoretical perspectives, models,
cant and clinically meaningful improvements in interventions, and reflections included in this
outcomes including survival, mechanical ventila- chapter are based on their usefulness for ICU
tion use, coma, delirium, restraint-free care, and nursing and health care. Further, this chapter
ICU readmission [7]. It was suggested that the emphasizes ICU patients’ and their families’ per-
bundle components including several elements spectives on ICU health promotion. This chapter
of human connectedness (waking patients, hold- is based on our own empirical research [14–18],
ing their hand and patients regaining a feeling as well as our extensive clinical experience in
of control over actions and their consequences) ICU nursing and nursing of the chronically ill,
had a positive influence on patient outcomes. including palliative patients. The literature we
However, these nursing interventions cannot eas- build on is grounded in both qualitative and
ily be quantified; a recent Scandinavian study quantitative research. In a health promoting
suggests a shift from technical nursing toward perspective, we draw on the salutogenic theory
an increased focus on patient understanding, and of Antonovsky [19–21] and the philosophy
greater patient and family involvement in ICU of nursing care formulated by the Norwegian
treatment and care [8]. Therefore, future studies nurse and philosopher Kari Martinsen [22, 23].
could benefit from a more holistic view, includ- Additionally, this presentation was substantiated
ing the lived experiences of ICU care from the with a literature search using the terms “intensive
perspectives of patients, family members, and care patients,” “critical care patients,” “family,”
ICU nurses. “family member,” “next of kin,” “health promo-
The suggestion that patients and their family tion,” “salutogenesis,” and “long-term ICU care.”
members be involved in care was first introduced Since we live in Norway, and have studied and
by the Picker Institute in 1988. Since then, fam- worked there, our examples from clinical prac-
ily inclusion has evolved into a model of col- tice are drawn from the Norwegian context.
248 H. S. Haugdahl et al.

18.3.1 Health Promotion along a continuum on a horizontal axis between

in the Health Care health-­ease (H+) and dis-ease (H−) [25]. Health
promotion and salutogenic ICU nursing care
In 1986 the World Health Organization (WHO) intend to move the patient along this continuum
arranged the first international conference on toward the positive end, termed H+. According
Health Promotion, resulting in the Ottawa Charter. to Antonovsky, sense of coherence (SOC) is
This charter defined health promotion as “the pro- a vital health resource moving the individual
cess of enabling people to increase control over, toward good health. While facing stressors
and to improve their health,” and identified basic in life, such as, e.g., serious illness, tension
strategies for health promotion. An international appears. To avoid breakdown, and instead move
network of health promotion ­ hospitals (HPH) along the continuum in the positive direction,
was later established, with an aim of reorient- the patient must cope with the tensions. A strong
ing the hospitals in a health promoting direction. SOC as well as generalized resistance resources
However, in order to succeed in doing so, know­ (GRRs) will help the seriously ill person to
ledge and evidence on health promoting nursing cope, to stand out with the suffering, to survive
centering on patients’ health and resources were and recover. Looking at Fig. 18.1, GRRs are
needed. Several theories of health promotion have important to hinder breakdown and move the
been developed, among which the salutogenic ICU patient along the ease/dis-ease continuum
health theory by Antonovsky [19, 24] is central. toward best possible health. The salutogenic
Available evidence guiding long-­term ICU nurs- approach to long-term ICU patients is resource-
ing care into a more health promoting direction is oriented and focuses on the patient’s ability to
scarce. Hence, this chapter aims at developing a manage the stressors in this specific life situa-
tentative theory of salutogenic ICU nursing care. tion to recover and stay healthy.
The SOC and the GRR represent key concepts
of the salutogenic health theory. SOC is defined
18.3.2 The Salutogenic as “a global orientation that expresses the extent
Understanding of Health to which one has a pervasive, enduring through
dynamic feeling of confidence that: (1) the stim-
Aron Antonovsky (1923–1994) challenged the uli from one’s internal and external environments
conventional paradigm of pathogenesis and its in the course of living are structured, predict-
dichotomous classification of persons as being able and explicable; (2) the resources are avail-
either healthy or diseased [19]. He coined the able to one to meet the demands posed by these
concept of salutogenesis, which means the origin stimuli; and (3) these demands are challenges,
of health. Basically, salutogenesis—the saluto- worthy of investment and engagement” ([24],
genic understanding of health and the gradually p. 19). SOC includes the three dimensions of
evolving salutogenic concepts—signifies knowl- comprehensibility, manageability, and meaning-
edge about the origin of health, i.e. about what fulness (ibid.). Comprehensibility represents the
provides, facilitates, and supports health. The cognitive aspect of SOC, including the capacity
concept of salutogenesis has matured since 1986 to appraise one’s reality and to understand what
and has become a core theory of health promo- is going on. A seriously ill ICU patient might
tion [21]. From a salutogenic perspective, health struggle to grasp what is taking place around
is a positive concept involving social and per- him. The second aspect, manageability cov-
sonal resources, as well as physical capacities. ers an individual’s instrumental and behavioral
Hence, the salutogenic theory of health offers a capacity to manage and cope with the situation.
resource-oriented and strength-based perspec- Coping is difficult if you do not understand what
tive, i.e. a broad focus on the genesis or sources is happening with you. Finally, the meaningful-
of health, as well as circumstances promoting or ness aspect involves an individual’s feelings that
undermining health. life makes sense emotionally, and that the pres-
Figure 1.1 in Chap. 1 in this book illustrates ent challenges are worth investing one’s effort
how Antonovsky saw health as a movement and energy in; that is, one’s commitment and
18 Health Promotion Among Long-Term ICU Patients and Their Families 249

engagement. Meaningfulness is seen as the moti-

vation aspect of SOC. Finding meaningfulness Background: Peter was in a road accident 2
and thus motivation to fight for survival might days ago with complicated fractures of his
be hard to the long-term ICU patient who is at back, femur and ankle. He also has serious
“a breaking point” (Figs. 18.2 and 18.3). These rib fractures and bleeding in his chest cav-
three aspects of SOC—comprehensibility, man- ity, requiring mechanical ventilation.
ageability, and meaningfulness—are involved Peter’s bed is by the window. Over his head
when an individual experiences a long-term ICU hangs a monitor. Right next to the head of
stay. As illustrated by the example of Peter down his bed, the ventilator produces a rhythmic
under, long-term ICU patients experience several sound. On the monitor a graph moves,
and huge stressors, and thus much tension. The looking like a row of mountain peaks.
need for resistance resources is obvious. GRR Suddenly a lung appears at the top of the
represents a set of resources promoting meaning- screen, and then disappears again. We can
fulness, comprehensibility, and thus manageabil- also see numbers that keep changing. Peter
ity (SOC). GRRs are present in an individual’s moves his arms and head, and suddenly a
personal capacities, but also in the immediate sharp sound is heard and a light flashes on
and distant environment [24, 26]. A strong SOC the ventilator. Then it goes quiet again just
enables one to recognize, pick up, and utilize the as quickly. Next to the bed are infusion
available GRRs. Salutogenic ICU nursing care pumps for medication. Several chains with
supports the patient’s awareness and use of the a hook on the end hang from a rail in the
resources available. The patient’s family and the ceiling. On one of them is a photo of a man
ICU nurses should perform as GRR resources and a little child. A photo that links Peter to
during the long-term ICU stay. Specifically, close a life outside this room.
family members can help to identify and facili-
tate personal GRRs for their ICU patient. Peter’s reflections on his stay in the ICU
Furthermore, Antonovsky understood the (comprehensibility, meaning, manageability):
relationship between the two orientations of I was more like a rocket that was shot up
pathogenesis and salutogenesis as complemen- into the sky, there was lots of noise, lots of
tary [20]. We therefore emphasize that health loud noises and steel, rockets are full of
promotion approaches do not imply a disregard steel, aren’t they? Then when it was going
of pathogenesis. Knowledge of pathogenesis, up into the sky, bits of it began to fall off
i.e. knowledge of disease, risk, and prevention, and then when it reached a certain level, it
is important in all health disciplines, and natu- stopped, and it began to fall again. It was a
rally in health care, particularly in the ICU con- terribly long and tiresome trip! And on the
text. When people become injured or seriously way down, the bits of metal came back on
ill, whether it be an accident, heart disease, lung again and then it fell to the ground. And I
disease, cancer, mental illness or the need for a think ... I think the connection is that the
surgical intervention, knowledge of illnesses, day after I arrived at the ICU, I was oper-
injuries and trauma, and their treatment, is crucial ated on. They put steel in my back, it was
to their lives. However, instead of juxtaposing stiffened, and I heard that noise and every-
pathogenesis and salutogenesis, it is pertinent to thing that was going on, I think ... I’m quite
assimilate these two paradigms into a manifestly sure about that!
holistic way of understanding and working with
health. Health is always present, while illness and The family member’s reflections:
injury occur from time to time. Thus, health is the There was no communication the days he
basis and the origin, and should therefore be the was on the ventilator. So, then we just made
foundation of health care, also in the ICU. We use short visits. I went in and looked at him and
Peter throughout this chapter to depict the move- stroked his cheek and then I talked a bit to
ment along the health continuum during the long- the nurses.
term ICU patient’s pathway.
250 H. S. Haugdahl et al.

Peter is an entity of body-mind-soul who is at caring situation in nursing is by nature concrete

a breaking point: will he survive his huge injuries, and contextual. Care has a relational, practical
or will he pass away? We do not know yet. In this and moral dimension ([22], pp. 14–20). A cen-
early unstable phase, medical treatment is urgent. tral ontological feature of Martinsen’s theoretical
The patient needs stabilizing, organ support like work is the assumption that human beings are
mechanical ventilation and dialysis, and symptom interconnected and dependent upon each other;
treatment like pain relief and sedation. However, humans are born as relational individuals. Thus,
a health promotion approach also includes fam- without a relationship with a “you,” there cannot
ily members’ presence and nursing care, as well be an “I.” The individual can only become a liv-
as awareness toward Peter’s sense of comprehen- ing person in a relationship with a “you” [23, 43,
sibility, manageability and meaning. How can the 44]. This dependence on others must not be seen
nurses help him to understand what is going on? as negating independence; however, people can
How much information is he able to take? What never understand and realize themselves alone or
can make him find meaningfulness, and a sense of independently of others. Care is fundamental and
manageability in the midst of ailments and fatigue? natural, but also difficult because in relationships
While people face various life stressors, such with others we are vulnerable to the other’s gaze,
as serious illness leading to a long-term stay mood, and body language. We may ignore or
in an ICU, research has shown that those who, reject what the other is expressing. This implies
despite the difficulties, experience meaning-in- that human relationships are ethical. Care is to
life cope better and report more well-being than relate to the other and to be able to recognize and
those who experience meaninglessness. Meaning respond to the patient’s needs [44]. The specific
is an important psychological variable that pro- encounter with the long-term ICU patient thus
motes well-being [27–29], protects individuals has a moral dimension. As nurses, we can look,
from negative outcomes [30, 31], and serves and overlook.
as a mediating variable in psychological health A recent Danish study argued for the develop-
[32–36]. The concept of meaningfulness is also ment of theory in clinical nursing to meet the needs
crucial in the salutogenic theory of health [19, of patients and relatives [45]. Consequently, in
24] that focuses on health promoting resources, the present study we explore and illuminate cen-
among which sense of coherence (SOC) is vital. tral concepts in health promoting family-­centered
Individuals with a strong SOC tend to perceive long-term ICU care. The focus is not on giving
life as being manageable and believe that stress- the actual concepts fixed meanings, but on creat-
ors are explicable; thus, they have confidence in ing a useful understanding of the shared mean-
their coping capacities [37]. Several studies link ing of concepts within a specific context [46]. A
SOC with patient-reported and clinical outcomes conceptual framework aims at prescribing broad,
such as perceived stress and coping [38], recovery open-textured (structured) assumptions of how
from depression [37], physical and mental well- phenomena in a field are to be understood [47].
being [39, 40], and satisfying quality of life and Within the framework of health promotion, we
reduced mortality [41, 42]. SOC has thus been aim to articulate the values and goals of nursing
recognized as a meaningful concept for patients by making aspects of this practice explicit and
with a wide variety of medical conditions. analyzing patients’ needs [48].

18.3.3 H
 ealth Promoting Long-Term 18.4 Purpose
ICU Nursing
The purpose of this study was to gain a deeper
The theoretical perspective is based on a view of understanding of the essence of long-term ICU
nursing as a practical discipline and on professor care in a health promotion perspective. A more
Kari Martinsen’s philosophy of nursing care. The specific aim was to identify central salutogenic
18 Health Promotion Among Long-Term ICU Patients and Their Families 251

concepts in long-term ICU patients’ lifeworld. interviews of ICU patients 5–14 months after
From the perspective of former long-term ICU ICU discharge (collected in 2012–2014), and
patients, their family members, and ICU nurses, (3) interviews of ICU patients, family mem-
this study provides insights into how salutogenic bers, and ICU nurses involved in long-term ICU
resources can be used to support and facilitate care (collected in 2016–2017) (Table 18.1). A
ICU patients’ existential will to keep on living. total of 28 long-term ICU patients, 13 family
Finally, we aim to propose a tentative theory of members, and 13 ICU nurses participated in the
salutogenic long-term ICU nursing care. study. Further details are published elsewhere
[14, 16–18].

18.5 Design and Methods

18.5.3 Data Analysis
A hermeneutic phenomenological approach was
applied, illuminating the meaning embraced in peo- The datasets were handled as a whole and ana-
ple’s experiences and forms of expression [49, 50]. lyzed by the following steps: First, the authors
presented and reflected on the results from the
first analysis of all datasets using themes and
18.5.1 Settings and Sample subthemes. Second, a reflective discussion was
guided by the following questions: What are
This study was based on three different quali- the characteristics of long-term ICU patients?
tative datasets about long-term ICU patients’ What is the essence of long-term ICU care and
struggle to survive, as experienced by (1) the the health promotion process of getting through
patients themselves, (2) their family members, the illness trajectory? Third, the original empiri-
and (3) ICU nurses. Data were collected from cal data were reread to identify real life examples
two university hospitals and two local hospitals of the health promotion process and were fur-
in Norway between 2004 and 2017. ther interpreted as phases. Fourth, the reading of
literature in the fields of lifeworld research and
health promotion concepts based on salutogenic
18.5.2 Data Collection theory [20, 21] inspired further interpretation
of data. Fifth, essential concepts describing the
The three datasets included (1) six in-depth health promotion process of getting through the
interviews of experienced ICU nurses before and illness trajectory in long-term ICU care and sug-
after observations of nurse–patient interactions gested relationships among these concepts were
in mechanical ventilation, collected in 2004, (2) developed [51]. The concepts were framed within

Table 18.1 Characteristics of datasets from ICU patients, family members, and ICU nurses
Informant characteristics Data collection Data collection characteristics
Dataset 1 ICU nurses (n = 3, 2 female) Observations (n = 3) Nurse–patient interaction (24 h)
>10 years ICU experience In-depth interviews (n = 6) Before and after observation
Dataset 2 ICU patients (n = 11, 4 female) In-depth interviews (n = 11) 5–14 months after ICU discharge
Age (years) median 60 (57–72)
MV (days) median 10 (6–27)
Dataset 3 ICU patients (n = 17, 4 female) In-depth interviews (n = 17) 6–18 months after ICU discharge
Age (years) median 57 (27–76)
MV (days) median 10 (7–16)
Family members (n = 13, 11 female) In-depth interviews (n = 13) 6–18 months after ICU discharge
ICU nurses (n = 13, 9 female) Focus group interview (n = 3)
Note: ICU intensive care unit, MV mechanical ventilation
252 H. S. Haugdahl et al.

the salutogenic theory and the ABCDEF bundle 18.5.5 Ethical Considerations
approach [6].
Ethical approval was not sought, as the study is
based on a secondary analysis of data from pub-
18.5.4 Characteristics lished studies.
of the Researchers

Two authors (IA, HSH) are ICU nurses, with 18.6 Results
expertise in teaching, clinical practice, and
research, while the third author (GH) is a special- The health promotion process of getting through
ist in the nursing care of chronically ill patients the illness trajectory during the ICU stay was
and end-of-life care and has published widely interpreted as three overlapping phases: (1) A
in health promotion research among different body at a breaking point, (2) In between, and (3)
populations. Never in my mind to give up (Table 18.2). This

Table 18.2 Essential concepts describing the process of getting through the illness trajectory from a health promotion
perspective
A body at a breaking
point In between Never in my mind to give up
Salutogenic
Process H− concepts H +
Observable signs Unconscious, no Awakening, increasing Awake and alert Coherence
contact awareness
Essential concepts Exhaustion, An amorphous and No doubts about coming Inner strength
derived from weakness and boundless body back to life Meaning
long-term ICU discomfort existential threat Meaning and purpose: Connectedness
patients Between life and Feeling trapped Feeling valuable to Hope
death Tiring delusions somebody Willpower
The patient’s inner I wasn’t human Practical solutions: Coping Coping
strength Connectedness to life: skills from previous life
Living in the worst Feeling alive and experiences
horror movie present Provocative and inspiring
Vivid dream experiences (info/talk with
experiences that doctor. Diet)
ignite willpower Transforming gloomy
weather into a sunny day
Essential concepts Sitting by the bed Knowing the
derived from family No response—an empty gaze patient
members Breaking through Facilitating hope
Knowing the patient
Trying to understand
Facilitating hope
Essential concepts Taking responsibility Facilitating
derived from nurses Tuning in to the other person well-being
Looking for reasons (for deterioration) Knowing the
Allowing the body to do what it is meant to do patient
Knowing the patient Pull and push
Having experience in the situation and experience over time
Pulling and pushing
Bearing the patient’s suffering
Facilitating well-being
Supporting the patient where he is
Acknowledging family support
Using one’s skills
Bringing back to normal
Creating a positive environment
18 Health Promotion Among Long-Term ICU Patients and Their Families 253

process is not linear, but depends upon the severity

of the disease, the patient’s progress and setbacks, The moment when I crashed, I lost con-
courage and despondency, hope and despair. Inner sciousness. Before I woke up, three people
strength [52], perceived meaning-­in-­life [53, 54] who have been very close to me came to see
as well as meaningfulness [19], connectedness me on a mountain. We were lifted together
[55], hope [56, 57], willpower [58], and coping in four pillars of light into heaven—they
[59] appeared to be vital salutogenic resources for explained to me that this life was over, and
long-term ICU patients, ­particularly in phases 2 I had to choose where to live my next life!
and 3, after the first critical phase (“A body at a But suddenly I was in the ICU, looking
breaking point”). Knowing the patient was impor- down at myself for a moment, and suddenly
tant to both family members and ICU nurses. I was inside myself again!—An extraordi-
The concepts of pull and push used by the nurses nary experience!
were found to be important in all three phases and
seemed to be associated with the other health pro- The nurse’s reflections:
motion resources identified. Although we had no contact with him yes-
terday, he was lying there with his eyes
open and looking around. And then I use
18.6.1 A Body at a Breaking Point the care situation to assess him more
closely. Mainly, I look at the patient, and
form a mental picture of how well he is
based on how he looks and feels. That’s the
Observation during morning care: main thing I do. Then I look at what he’s
The nurse speaks directly to Peter: getting from the ventilator, look at the
“Please bend your foot when we turn you monitor values and
​​ then I sometimes also
over.” He can’t do that. He’s completely take a blood gas to have some figures to
limp when we raise his arms and wash lean on.
him. The nurse suctions the endotracheal
tube before we turn the patient to prevent In principle, it’s important for the patient to
him coughing badly when he lies on his have rest periods, and it’s especially impor-
side during care and changing the sheets. tant at night. There shouldn’t be bright light
Following the care, Peter is placed up in and activity around the patient all the time.
bed, supported with four pillows. The cur- You have to find a balance, but it depends on
tains are pulled aside to let in the light. how much there is to do around the patient.
They put a blanket over him and air the How long the care takes, if you have to
room. The nurse takes a blood gas. When change e.g. the central venous catheter,
she returns, he’s coughing up white foamy arterial catheter and the wounds. How much
phlegm. His face is red and sweaty, and rest we can achieve depends on the particu-
his respiratory rate is 30 breaths per min- lar situation and the individual patient. And
ute. We move him more over on his side as it depends a bit on us too, how much we
we can smell stool. Then we close the allow a patient to rest.
door, pull down the curtains and change
his diaper. When he’s put back on his
back, his face is still red and sweaty, his The situation reveals a sensory presence in which
breathing is rather superficial, and his the nurse uses all her senses (looking, listening,
blood pressure is rising. touching, smelling) to assess and understand the
patient’s condition: “Yesterday, his eyes were
Peter’s reflections (comprehensibility, open and he was looking around” is interpreted as
meaning, manageability): a sign of health which the nurse sees as a resource
to build on. The nurse’s presence, attention and
254 H. S. Haugdahl et al.

care are health promoting resources, supporting and salutogenesis are vital perspectives and
and facilitating the health-giving processes tak- approaches in the ICU. Peter may move along
ing place in the patient as an entity of body-mind- the health continuum: either toward breakdown
spirit. The body is at a breaking point. Thus, the or in the positive direction. Along with medical
mind and spirit are also in a state that may be treatment, the intensive nursing care involves
termed a “breaking point.” In a health promo- ­facilitating the salutogenic resources embedded
tion perspective, the ICU nurse is aware of every in Peter’s situation and the context. By actively
sign of health (his eyes are open, looking around) supporting and strengthening the salutogenic
on which she can build her presence, attention resources, the nurses may push Peter along
and care. Hence, if we adapt Fig. 1.1 in Chap. the health continuum in the positive direction
1 to Peter’s situation, it may be portrayed as in toward recovery and health. Based on the three
Fig. 18.1. datasets, we identified the following salutogenic
Figure 18.1 shows the health ease/dis-ease resources: (1) connectedness to life, (2) feeling
continuum: a huge stressor appears, and Peter’s alive and present, (3) meaningfulness and pur-
body is suddenly at a breaking point in the pose, (4) feeling valuable to someone, (5) prac-
ICU. Peter’s situation is characterized by uncon- tical solutions, (6) previous coping experiences,
sciousness, sedation, exhaustion, weakness, and and (7) provoking and inspiring experiences [14,
discomfort, which are experiences also described 16–18]. By means of creative approaches that
in other studies as tiring delusions, feeling support and enhance these salutogenic resources,
trapped, and being on an edge between life and Peter is pulled and pushed along the continuum,
death [60–62]. At this point, both pathogenesis reaching the stage termed “In between.”

Fig. 18.1 The health ease/dis-ease continuum. (Reproduced and adapted for the ICU context with permission from
Folkhälsan Research Center, Helsinki) © Gørill Haugan, 2021
18 Health Promotion Among Long-Term ICU Patients and Their Families 255

18.6.2 In Between

The nurse’s reflections:
He seems to have a thousand questions in
Peter was transferred to the ICU of a local his head: “My God, who, what, where?”
hospital, where he eventually had secre- He realizes that I’m here and falls asleep
tion stagnation and therefore needed again. He’s still so sick that he can’t relate
mechanical ventilation again. He has had to what we’re doing. He opens his eyes
high fever and severe diarrhea. Now he is when we talk to him, but I don’t think he
recovering and the goal is to disconnect would say “I’m cold” of his own accord
the ventilator, extubate him and let him unless I asked him. He’s a man who’s been
breathe himself. very sick and he’ll need a lot of help to get
going again. Now he’ll be spending most of
Observation: his energy on breathing and coughing and
The doctor on duty indicates that Peter can eventually communicating.
be allowed to breathe completely on his
own. The nurse disconnects him from the Today when I brushed his teeth, he opened
ventilator, mucus is suctioned from the his mouth and stuck out his tongue. Peter
breathing tube into a bag and the air is follows what I say, or tries to. I asked if he
removed from the cuff before the breathing could answer “yes” or “no”, but I don’t
tube in his throat is removed. A sterile com- know whether what he said was yes or no.
press is applied to the hole in his throat and But I don’t think he has the look of a person
Peter receives oxygen via a nasal cannula. who’s completely out of it. He seems to be
The nurse sits down by his bed and can see looking at me as if he’s asking: “What are
that he’s breathing effortlessly. Then he you doing?” But I don’t feel that he’s
opens his eyes and tries to focus on her. He afraid. Not now. He might be in a dream,
coughs and the nurse puts her finger over who knows? I try to appeal to him and see
the compress to prevent air leakage to if he reacts to anything. See if I can get a
enable him to cough more powerfully. Then smile. I got one yesterday evening. I haven’t
he falls asleep again and he seems to be ok. had one today.
Suddenly he wakes up, opens his eyes and
turns his head.
In the “In between” phase, patients were awak-
Peter’s reflections (comprehensibility, ened and became gradually more alert. However,
meaning, manageability): at the same time they often experienced their body
I’m not sure, really, if it was just when I as amorphous and boundless, and some even felt
came to or if it was in the coma phase itself that they were not human. The patients described
... I think it was when I was coming out of this phase as marked by an existential threat and
the coma that I felt very nervous ... and a feeling of being trapped. It was like living the
scared, but I also felt that things had kind worst horror movie with tiring delusions. Others
of worked out all right. The fact that it was found that vivid experiences in dreams ignited
a bit up and down, that might be a way of their willpower.
reacting when you’re woken up again, I The ICU nurses were close to the patients dur-
don’t know, it’s hard to say. … Yes, it was ing the awakening period (In between) and pro-
just like it was very hot and it was kind of a vided reassurance and well-being:
lousy feeling to be alive, as it was so hard I remember they were turning me, talking and ask-
... that’s a bit weird. ing: ‘Are you lying comfortably now?’ and they
had gentle and mild voices. That was all nice,
really. My experience was that the nurses were
256 H. S. Haugdahl et al.

very clever. They were confident in their work. It

seemed like they knew what they were doing, no Peter’s reflections (comprehensibility,
hesitation – that made me feel very safe!
meaning, manageability):
However, the relatives were obviously most The doctor told me to try to scratch my nose
important to the patients, and were the first peo- and I couldn’t do it, only got half-­way up
ple they remembered when they woke up; they with my index finger, I didn’t have the
transformed “gloomy weather into a sunny day.” strength. Not a single muscle in my body was
Family members were essential for the ICU working then... I probably thought it was a
patient to feel important and have future hopes. lot easier than it was. Like if I just had a few
more days, I could just get on my feet again
I was happy every time they came. And they
brought my five grandchildren from time to time, and get a walker, but in fact it wasn’t that
and that helps to get your spirits up too. easy … There was nothing else in my head
except to get up on my feet and be active
Although visits from family and friends were again, that was all I thought about! ... I had
appreciated, there was a limit where the visit good care and I was looked after properly by
became burdensome. Several talked about the competent people, so I felt reassured that I
communication problems linked to being intu- was getting the best treatment you could get.
bated. Others wanted someone to tell them how
long it would take before they would make enough It was the progress I was making all the time
progress to move out of the ICU. Although this ... and the words of the nurse: “When you
was not easy to predict, it would have reassured finally turn the corner, you’ll really notice it
the patient if someone had talked about it and and then things will really start to move”,
explained why they could not give a definite and that’s what happened. Once I started to
answer. It also seems important to find time to make progress, the first thing was stand in
provide care to the patient’s relatives in the form front of the bed for 20 seconds, then one step
of information and advice on how to support the forward and one back and then I could take
patient. two steps forward and then I could walk
round the room, and then finally I could
walk by myself with the walker. So, it was the
18.6.3 Never in My Mind to Give Up progress all the time that gave me the cour-
age and motivation to make a bit more effort.

The nurse’s reflections:

Yesterday Peter was so alert that I went Clearly, disease and illness are more prominent
through what had happened with him than well-being among ICU patients. At the same
again. Because if they’re capable of think- time, both clinicians and relatives are striving for
ing in a phase like that, it must be a terrible and looking (consciously or unconsciously) for
experience to wake up and not understand signs of well-being in the patient. Our data also
anything, because I’m sure he doesn’t. So, showed that many patients, despite serious ill-
I prefer to use short phrases like “It’s ok” ness, experience inner strength, meaning, compre-
and “You’re getting better”. Maybe you hensibility, manageability, connectedness, hope,
saw it today too: it’s hard to tell if he’s try- and willpower. The most important aspect of this
ing to say something or if he’s trying to phase from the patient’s point of view was that the
swallow. And to make sure he doesn’t salutogenic forces were not distrusted or contra-
panic, I emphasized that he has a voice and dicted (by nurses wishing to present the reality),
that he’ll get it back and everything will be even though the patient’s hopes, meanings and
the way it was before. comprehensibility may have seemed completely
unrealistic to doctors and nurses.
18 Health Promotion Among Long-Term ICU Patients and Their Families 257

Most ICU patients felt safe, grateful, and sat- does, my brain managed to register that. It was
very good for me. Small impulses that give me a
isfied with nurses and physicians. However, some good feeling ... like stroking my cheek. I didn’t hear
experienced a lack of respect and understanding any voices, just felt that touch!
of their situation and too little information about I remember the visits made me very tired. But when
things that were obvious to the staff, but not to my wife came, it was like I’d had gloomy weather
for a long time and then suddenly there was a
the patient. Despite exhaustion, weakness and sunny day! You see? This happened every time she
discomfort, most patients expressed no doubts arrived!
about coming back to life. Their daily life in the
ICU was both challenging and monotonous and
one way to cope with it all was to dream about 18.6.3.2  ow Do ICU Nurses Support
H
one’s future life. Patients?
The nurses supported the patients by taking
18.6.3.1  ow Do Family Members
H responsibility for both patients and visiting
Support Patients? family members. The ability to “tune in” to the
For relatives it was important to be with the patient was important and was expressed through
patient. Sitting close to a loved one was a bur- attention and sensitivity to the patient’s body
den for many of them, but they still wanted to be language:
there. Family members described a specific sen- I don’t know if there’s anything we do subcon-
sitivity for the patient’s body language and needs, sciously ... if we give the impression that we’ve
and for what was meaningful in the situation. given up or not? It’s kind of scary to think about ...
whether they can feel that we believe they’ll pull
I had to keep an eye on things a bit. I don’t know through or not. We had a patient who said that
anything about the medical stuff, about nursing everyone had kind of given up hope for her ... and
and so on and what it takes to get him healthy, but she’d understood a lot of what was said.
I felt I had to be there anyway to ... make sure he Afterwards, she said to the nurse who had said she
didn’t miss anything. ... and then I had to do what would recover: ‘You were the one with the kind
I could to help him get better, putting skin cream on hands’. And then I thought: Is it possible, really?
his legs when they were dry and so on. There Do we convey things without realizing it?
wasn’t much I could do, but I do know he was
pleased I was there! In this case, the way the ICU nurse provided
And because Mom was producing a lot of mucus
and she was on the ventilator for so long, they gave reassurance and well-being helped to promote
her a tracheostomy. And it was very difficult for the patient’s willpower to fight for recovery.
Mom when she woke up that she had no voice. So, The following case underlines the importance of
we had to explain that repeatedly. knowing the patient:
Of course, we can often tell when the patient’s at
The presence of family members was impor- the turning point. When you do familiar things like
tant because they could look ahead and encour- morning care and talk about everyday life, their
age the patient by saying that this was something children and their family, the dog for example, well
then you make contact that may be good for the
they would cope with together. Relatives knew patient and help prevent delirium. Familiar things
what motivated the patient, such as family, a and loved ones are important to motivate patients
pet, a soccer game on television or talking about to move forward. I think it’s important that it’s the
going hunting again. They could motivate and same nurses who come back, so you can build on
what we achieved yesterday, that has a positive
push the patient by saying: “If you’re going to get effect. And that you have contact with the patient,
out of here, you have to keep going even though that good relationship is very important. My
it’s hard.” daughter once said: ‘Oh, do you need to put on
The patient’s experience of the presence of makeup before you go to work?’ I answered: ‘Well
yes, because today I’m almost the only person the
relatives was described as follows: patient’s going to see.’ Not that it makes any differ-
ence, but ... we should believe in things for them
I could recognize her smell, I knew it. And she has
many times, and we must push them. Some of them
a special way of doing things, in a way only she
often don’t want to get up. And precisely that step
258 H. S. Haugdahl et al.

of getting out of bed and into a chair seems quite it was just a big disappointment, because Geir
out of the question when you’ve been in bed for couldn’t control his fingers properly. What I
weeks and can’t even lift your finger. But then we thought would be a great motivating factor ... it
need to believe on their behalf: ‘Yes, but this is didn’t really work out too well.
something we’ve got to do ... I understand you
don’t want to, but it’s for your own good.’ Because That was a borderline case where the nurse
we see that many times… we have to put in much
more effort than they can manage themselves.
tried to use the patient’s potential health-­
promoting resources. She regarded him as more
Knowing the patient seems important to cre- than “just a patient,” realized his personal quali-
ate meaning. The good relationship and the ties and put in an extra effort to help him to “light
nurse’s efforts in transferring belief and hope to the spark of life.” The patient was probably just as
the patient provided support in the rehabilitation disappointed as she was, despite her good inten-
process during the illness trajectory. tions and dedication. Oscillation between success
The above examples may be said to describe and failure was typical of not only long-­term ICU
model cases. But nurses have also experienced patients but also their nurses and their relatives.
actions that did not go according to plan. One
experienced ICU nurse talked about a patient 18.6.3.3 Summing Up
who was a well-known pianist: Based on the three datasets from long-term ICU
patients, their family members, and experienced
Sometimes you think ... I’m sure this will be ok! … ICU nurses, three stations along the ease/dis-
I remember once when I had a patient called Geir,
who had been on the ventilator for a very long ease continuum were identified: (1) The breaking
time, he was very depressed and heavy-hearted… point, (2) In between, and (3) Never in my mind
and eventually he got a tracheostomy. Then I could to give up. Figure 18.2 portrays the health contin-
take him around in a wheelchair, with his oxygen uum, illustrating the three different stages along
bottle and bag. I thought: he was a very well-­
known pianist, if I go round past the switchboard ... the pathway toward survival and health. Here
there’s a piano there ... then I can wheel him there we see how the ICU nurses make great efforts
... then he can play! Music was his whole life! But to relieve Peter’s ailments, such as pain, exhaus-

Fig. 18.2 The long-term ICU patient’s trajectory along the health disease/ease continuum. © Haugan, 2021
18 Health Promotion Among Long-Term ICU Patients and Their Families 259

tion, and tiring delusions. Using the identified shifts our focus from the monitors, beeps, and
salutogenic resources, the nurses and Peter’s buzzers to a human connection” ([5], p. 327).
family members are gently pulling and pushing In recent years, international research has there-
him in the positive direction, toward survival and fore called for a shift in ICU culture from heavy
functioning. sedation and the use of restraint to more open
units with patients who are more alert and active
[5], and where relatives are given a more active
18.7 Discussion role in patient care [63].
After the patient is stabilized, evidence-based
The aim of this study was to enhance under- measures in the form of the ABCDEF bundle
standing of the essence of long-term ICU care are recommended. “The ABCDEF bundle is a
in a health promotion perspective. This means tool to promote the assessment, prevention, and
that nurses can be both generalized and specific integrated management of pain, agitation, and
resistance resources against the stress caused by delirium, while also facilitating weaning from
ICU care. Further, they enable patients to find mechanical ventilation and maximizing early
meaningfulness and gain control over their life mobility and exercise and family engagement
situation. From the perspectives of former long- and empowerment” [6]. This bundle is an inter-
term ICU patients, their family members, and national framework aiming at flexibility and the
ICU nurses, this study provides insights into incorporation of new evidence-based recommen-
how salutogenic resources can be used to sup- dations. Although an important goal of intensive
port and facilitate ICU patients’ existential will care is to reduce pain, anxiety and ICU delirium
to keep on living. The salutogenic concepts of threatening the patient’s dignity and self-respect,
inner strength, meaning, connectedness, hope, it appears difficult to achieve this in practice
willpower, and coping are central and form part [5]. Ely argues that the ABCDEF bundle is not
of the essence of salutogenic long-term ICU care. a cookbook recipe, but requires lasting changes
Below we will discuss the benefit of ICU nurses bedside, where the implementation process must
using a health promotion perspective to support include both philosophy and culture ([5], p. 326).
care based on the ABCDEF bundle in relation to Important barriers to ABCDEF bundle com-
a tentative theory of salutogenic long-term ICU pliance are; patient safety, lack of knowledge,
nursing care. workload, turnover (clinicians and managers),
poor staff morale, and lack of respect between
the professional groups involved in implement-
18.7.1 T
 he ABCDEF Bundle, Health ing the bundle [6].
Promotion, and the Missing In the ICU, points B and E are emphasized as
Salutogenic “G” particularly important, meaning that the patient
receives pain relief, has minimum or no sedation,
Although intensive care has made great strides and is mobilized despite still being on mechani-
in recent years [4], patients and their relatives cal ventilation ([5], p. 325). However, our study
may experience discomfort and mental and shows the importance of providing good clinical
physical health symptoms as a result of exami- nursing, the missing salutogenic “G,” where ICU
nations, treatment, and the way clinicians relate nurses know the patient, include the family (F)
to them [5, 63]. According to Ely [5], this may and know which salutogenic resources are impor-
partly be due to an ICU culture where physi- tant to long-term ICU patients. This is, however,
cians and nurses have focused strongly on the often underestimated as a health promotion fac-
technical aspects of patient care at the expense tor in the ABCDEF bundle. The ICU nurse’s
of patients’ dignity, self-respect and identity: skills in tuning in to the needs of the patient and
“The most productive aspect of the philosophy relatives and in focusing on salutary factors are
of ICU liberation for us as clinicians is that it regarded as important generalized resistance
260 H. S. Haugdahl et al.

resources (GRR) that can strengthen patients’ to the concept of pull and push factors. Pull fac-
SOC and resilience at the physical, psychologi- tors help/entice the patient toward an existential
cal, and spiritual levels ([21, 64], p. 289). “here” (connectedness, meaning, well-being)
to enable nurses and relatives to gradually push
(encourage) the patient in the continued ICU
18.7.2 A
 Tentative Theory trajectory.
of Salutogenic ICU
Nursing Care
18.7.3 T
 he Long-Term ICU Patient
The tentative theory [65] of ICU nursing care Pathway: SOC and GRRs
has five main concepts: (1) the long-term ICU
patient pathway, (2) the patient’s inner strength The SOC and GRRs are key concepts that are
and willpower, (3) salutogenic ICU nursing interrelated in the salutogenic model. But how
care, (4) family care, and (5) pull and push. In can we understand the SOC and the salutogenic
Fig. 18.3 we suggest a structure of the phenom- concept of manageability in ICU patients where
enon that includes essential concepts describing fatigue and serious illness requiring life sup-
the health promotion process of long-term ICU port mean that their bodies are dependent on
care and suggested relationships among the con- and connected to ventilators and invasive cath-
cepts. The concepts of the tentative theory, shown eters? What is the relevance of the salutogenic
in Fig. 18.3, indicate that the patient goes through concepts of “meaning” and “comprehensibil-
three stages (The breaking point, In between, and ity” for patients who are totally exhausted and
Never in my mind to give up), and can poten- sometimes hallucinating, having experiences of
tially experience inner strength and willpower in travelling, flying, standing upside down and not
all the stages. Family care and nursing care rep- knowing where their body begins and ends? For
resent key salutogenic resources for the patient’s many intensive care patients, these are frighten-
trajectory. The salutogenic resources are linked ing experiences that are not “comprehensible”

Fig. 18.3 The salutogenic concepts of salutogenic long-term ICU nursing care. © Haugan, 2021
18 Health Promotion Among Long-Term ICU Patients and Their Families 261

and have no “meaning.” Some patients deal with 18.7.5 Salutogenic ICU Nursing Care
the situation by withdrawing into themselves,
while others become very agitated, fight against Nursing care is to be concrete and present in a
the ventilator, pull the endotracheal tube and relationship where nurses use their senses and
want to get out of bed at the risk of disconnecting bodies. This implies that nurses direct atten-
vital equipment. In such situations, it is common tion away from themselves and toward patients
in many countries to tie patients down [66] and/ in such a way that patients receive help, feel
or use sedatives [67]. Both measures are debated, respected, and enabled to become participants in
because they are considered as abuse and because their own lives.
they make patients passive and thus prolong ven- ICU nurses have close contact with their
tilation, leading to an increased risk of complica- patients, and in Norway they are responsible for
tions [68]. the practical everyday care of patients. Practical
Below, we argue that both family members nursing, including everyday personal hygiene,
and nurses represent important salutogenic provides ample opportunity for clinical obser-
resources to support and facilitate manageability, vations and for the nurse to assess and respond
meaningfulness and comprehensibility to help to changes in the patient’s situation. In the
patients through their stay in the ICU. But firstly, close care relationship lies the potential to get
we will show that, despite their disease, delu- to know the patient and build trust. Trust can be
sions, exhaustion, and fatigue, long-term ICU built by looking attentively at the patient, being
patients have important salutogenic resources sensitive to the patient’s body language and by
(GRRs) themselves. handling the patient gently and correctly. From
the ­perspective of the phenomenology of the
body [70], this involves “pulling” the patient
18.7.4 P
 atients’ Inner Strength to an existential “here,” by the nurse creating a
and Willpower situation where the patient can experience con-
nectedness and meaning in meaninglessness
Previous studies have shown experiences on the (cf. “gentle hands” and the patient’s feeling of
borders of consciousness to be filled with per- hope).
sonal meaning as well as healing potential [60– Nurses are recommended to design interven-
62]. In the present study, long-term ICU patients tions to enhance the SOC in early phases of hos-
also told about experiences at the borders of pitalization for patients [64]. Losing the feeling
unconsciousness that represented both personal of one’s own body is common among ICU
meaning and vitalizing energy. They experienced patients, as in the story about Peter. “Without” a
meeting deceased relatives in their dreams or body, finding meaningfulness in life might prove
delusions. Initially, the ICU patients perceived difficult. The nurse’s touch can help the patient
the meeting as if the deceased relatives had come to realize the limits of where the body begins
to fetch them, which was felt to be liberating. But and where it ends. Further, in personal hygiene
without verbal communication, they immediately situations it is important that the nurse includes
understood this as a message that seemed to rep- the patient and encourages the use of the body
resent a turning point at which the patients were again such as in brushing teeth and assists the
pushed to make a choice about life and death, and patient with body movements (cf. “meaning-
an experience of, after all, having inner strength fulness” and “comprehensibility” in the story
and willpower to go on living. This salutogenic about Peter). For the patient who is bedridden
perspective of the ICU patients’ dreams and and attached to equipment, it provides hope and
delusions as having healing potential represents a meaning to feel the floor under one’s feet. The
complementary view to the pathogenic perspec- nurse can “ground” patients by helping them to
tive that interprets delusional experiences as a sit on the edge of the bed with their feet on the
symptom of ICU delirium [69]. floor, or by offering patients the use of a bed bike
262 H. S. Haugdahl et al.

so that they can feel resistance in their legs and ICU patient might sense the situation to be more
perform familiar bodily movements, cf. “man- comprehensible, manageable and meaningful in
ageability.” It seems important to let the body the presence of family members.
do what it is meant to do (Table 18.2). Anything The presence of a family member means that
familiar seems health promoting, whether it be a the patient hears a familiar voice, smells a scent
familiar sound, smell, voice, touch, movement, that evokes pleasant memories and feels a famil-
or presence. Allowing for patient participation iar hand. Such experiences are resources that
to help patients perceive life as comprehensive, can embolden the patient ([44], p. 174) and thus
manageable and meaningful is central in salu- stimulate the patient’s inner strength and will to
togenic ICU nursing care [21, 71]. Building a survive. Familiar faces, voices and smells, and a
relationship with the patient and thereby gain- familiar and gentle hand, can help to reassure the
ing insight into the patient’s dreams and future patient and make the situation more manageable.
plans (impacting meaningfulness, hope, and The presence of family members provides com-
willpower) can be health-promoting when the prehensibility through their behavior: their forms
nurse encourages patients and helps them to of communication and their recognition, inter-
keep those dreams alive through the challenges pretation, and acknowledgement of the patient’s
of gradual rehabilitation, such as mobilization body language.
and ventilator weaning. A meta-analytic review shows that people with
Since early 1990s, nurses in Norway started stronger social relationships have a 50% greater
writing diaries for ICU patients to offer patients likelihood of survival than those who have weaker
a tool for processing memories of their ICU social relationships [75]. In the cross-disciplinary
stay [72]. Diaries are valuable for both patients field of psycho-neuro-­endocrine-­immunology,
and their family members [73] and were in a interaction has been found between biological,
methasynthesis found to decrease anxiety and genetic, and e­ nvironmental factors [76]. Studies
depression and improve health-related quality show that one impact of close relationships on
of life among ICU survivors [74]. One explana- health is through inflammatory response [77].
tion might be that the diary has the potential to When people are ill, it is hypothesized that the
give a better understanding of the ICU periode risk for mortality increases substantially when
by providing an opportunity for discovery of they lack social support [78]. The importance of
meaning in experiences and memories. Finding social contact is not easy to quantify, but a study
existential meaning seems to be of decisive of cardiac patients showed that social support
significance for how far people reach in their reduced the negative effects of stress on their
lives after having lived through intensive care mental and physical well-being [79]. Flexible
treatment [80]. visiting hours for relatives in ICUs appear to
reduce delirium and symptoms of anxiety among
patients and increase family member satisfac-
18.7.6 Family Care tion [80]. In summary, being socially connected
affects psychological and emotional well-­being,
The present study illuminates how family mem- and has a significant positive effect on physical
bers are key to the patient’s breakthrough because well-being and survival [78]. ICU nurses thus
their actions are tailored to the patient’s specific have an important part to play in including rela-
personality as well as the patient’s lifeworld [17]. tives and facilitating their presence in the ICU.
The presence of family members helps to awaken
and release the patient’s inner strength, which
has the potential of providing a turning point and 18.7.7 Pull and Push
breakthrough to life. In the perspective of the
body as interpretive and meaningful [70], also When the patient is “at breaking point” between
at the breaking point between life and death, the life and death, the relationship to family mem-
18 Health Promotion Among Long-Term ICU Patients and Their Families 263

bers is important. Knowing the patient was essen- less, there is a kind of model that sets a limit, an
tial to understand what she or he was trying to essence that says that this is a horse and not a
express [17]. Pull factors involve linking the mule. It is a general form, an essential meaning
patient to an existential “here” (connectedness, or essence that makes the phenomenon what it
meaning, well-being), which will enable nurses is. If the essential meaning changes, it is another
and relatives to gradually push (encourage) the phenomenon [49]. Many clinicians already know
patient to progress in the ICU trajectory. This the essence of long-term ICU nursing care, and
study shows that nurse–patient interaction based how a health promotion approach is already an
on the ICU nurse’s attunement and sensing can integral part of the ICU context. For this reason,
help to provide an understanding of the patient’s many ICU nurses can identify factors of particu-
situation, by acknowledging the patient through lar importance to patients and take appropriate
eye contact, gentle touch and telling news from health-promoting measures. For others, such as
home. intensive care students and less experienced ICU
nurses, the theoretical analysis and tentative the-
ory in this chapter may lead to reflection on their
18.8 Limitations role and enable them to view their practice in a
new light.
How can we determine whether the description A potential weakness of this study is that we
of the phenomenon of health promotion in long-­ as researchers and ICU nurses belong to the same
term ICU nursing care is valid and relevant? world as the phenomenon we have explored.
Nurse and professor Karin Dahlberg [49] states Consequently, it can be difficult to separate the
that an essence or structure is what constitutes a phenomenon from its context, but also to sepa-
phenomenon. She uses the horse as an example rate ourselves from the phenomenon. Using
and asks: What makes a horse a horse, and not a ­ phenomenological reduction, which Dahlberg
donkey or a mule? Although horses may be large calls “bridling,” we have employed critical reflec-
or small and be of many different colors, there is tion to discuss “what we take for granted,” such
something essential about the horse that makes as our clinical experience and our theoretical
us immediately realize that a particular animal perspective.
is a horse. A phenomenon is not mysterious or A potential strength of this study is that a
hidden, but something we immediately see and health promotion approach in ICU nursing is in
understand. Essence is not something we add to line with the new paradigm in ICU care where
research; it is not the researcher who makes the the trend is toward a greater number of awake
phenomenon meaningful. The essence is already patients [81–83], with minimal or no sedation
there, in the intentional relationship between us [84]. This will further challenge interaction and
and the phenomenon, between nurse and patient, communication with patients [85]. With the aim
between patient and relatives ([49], p. 249). of helping patients through the ICU stay, we
In this chapter, therefore, we have focused thus consider it a strength that our empirical data
on presenting descriptions containing various include the voices of the patient, relatives and
nuances and aspects from the ICU context. The ICU nurses.
starting point has been the particular and the con-
crete. Since every phenomenon is related to every-
thing else in the world, it is sometimes difficult to 18.9 Conclusion
see the specific phenomenon one is looking for.
Dahlberg refers to Merleau-Ponty [70] in stating Few patients are as helpless and totally depen-
that all phenomena and meanings are intercon- dent on nursing as ICU patients. How the ICU
nected and that it can be difficult to see where one nurse relates to the patient is of vital importance
phenomenon ends, and another begins. To return to the patient, both mentally and physically. Even
to the horse: although the variety of horses is end- if nurses provide evidence-based care in the
264 H. S. Haugdahl et al.

form of minimum sedation, early mobilization ogy need to be accompanied by advanced

and attempts at spontaneous breathing during nursing care.
weaning, the patient may not have the strength, • There is growing evidence to suggest that
courage and willpower to comply. From the per- the ABCDEF bundle (A, assess, prevent, and
spective of former long-term ICU patients, their manage pain; B, both awakening and sponta-
family members and ICU nurses, this study pro- neous breathing trials; C, choice of analgesic
vides insights into how salutogenic resources can and sedation; D, delirium: assess, prevent,
be used to support and facilitate ICU patients’ and manage; E, early mobility and exercise;
existential will to keep on living. The saluto- and F, family engagement and empowerment)
genic concepts of inner strength, meaning, con- improves ICU patient-centered outcomes and
nectedness, hope, willpower and coping are of promotes interprofessional teamwork and col-
vital importance and form part of the essence laboration. However, this chapter entails that
of salutogenic long-term ICU nursing. The ICU the bundle misses the salutogenic “G.”
nurse has independent responsibility to include • This chapter shows the importance of salu-
family members in care and thus plays a key togenic ICU nursing care, termed “the
role in coordinating and implementing evidence- missing G,” where ICU nurses know the
based measures for patients in a health promotion patient, include the family, and uses saluto-
perspective. genic resources to promote long-term ICU
The tentative theory of salutogenic long-term patients’ inner strength, health, survival, and
ICU nursing care presented here has five main well-being.
concepts: (1) the long-term ICU patient pathway, • The ICU nurse’s skills in tuning in to the needs
(2) the patient’s inner strength and willpower, of the patient and relatives and in focusing on
(3) salutogenic ICU nursing care, (4) fam- salutary factors represent vital generalized
ily care, and (5) pull and push. These concepts resistance resources (GRR) that can strengthen
show that the patient goes through three stages patients’ SOC, resilience and well-being
(The breaking point, In between, and Never in physically, psychologically, and spiritually.
my mind to give up), in all of which the patient • A shift from technical nursing toward an
potentially experiences inner strength and will- increased focus on patient understanding, and
power. Family care and nursing care represent greater patient and family involvement in ICU
vital salutogenic resources for the patient, and treatment and care is needed.
a key concept related to these resources is that • This chapter is based on the three datasets
of “pull and push.” Pull factors involve facilitat- from long-term ICU patients, their family
ing/enticing/linking the patient to an existential members and experienced ICU nurses, and
“here” (connectedness, meaning, well-being), three stations along the ease/dis-ease contin-
which will enable nurses and relatives to gradu- uum were identified: (1) The breaking point,
ally push (encourage) the patient to progress in (2) In between, and (3) Never in my mind to
the ICU trajectory. give up.
This tentative theory can be used to reflect on • The tentative theory of salutogenic long-term
one’s own clinical practice, and in teaching inten- ICU nursing care includes five main concepts:
sive care students and in research. (1) the long-term ICU patient pathway, (2) the
patient’s inner strength and willpower, (3)
Take Home Messages salutogenic ICU nursing care, (4) family care,
• ICU patients who need mechanical ventilation and (5) pull and push. These concepts demon-
are unable to talk and need fundamentals of strate that the long-term ICU patient goes
nursing care. They are therefore totally depen- through the three stages (The breaking point,
dent on others, including having others inter- In between, and Never in my mind to give up),
pret their symptoms and feelings. This means during which the patient potentially experi-
that advanced medical treatment and technol- ences inner strength and willpower.
18 Health Promotion Among Long-Term ICU Patients and Their Families 265

• Family care and nursing care represent vital 8. Egerod I, Kaldan G, Lindahl B, Hansen BS, Jensen
JF, Collet MO, et al. Trends and recommendations for
salutogenic resources for the patient, and critical care nursing research in the Nordic countries:
a key concept related to these resources is triangulation of review and survey data. Intensive Crit
that of “pull and push.” Pull factors involve Care Nurs. 2019;56:102765. https://doi.org/10.1016/j.
facilitating/enticing/linking the patient iccn.2019.102765.
9. Ciufo D, Hader R, Holly C. A comprehensive system-
to an existential “here” (connectedness, atic review of visitation models in adult critical care
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nurses and relatives to gradually push care. Int J Evid Based Healthc. 2011;9(4):362–87.
(encourage) the patient to progress in the https://doi.org/10.1111/j.1744-1609.2011.00229.x.
10. Davidson JE, Aslakson RA, Long AC, Puntillo
ICU trajectory. KA, Kross EK, Hart J, et al. Guidelines for family-­
• The salutogenic concepts of inner strength, centered care in the neonatal, pediatric, and adult
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 Health Promotion and Self-­
Management Among Patients
19
with Chronic Heart Failure

Ying Jiang and Wenru Wang

Abstract diac function of patients with HF may be impaired

in two ways: (1) when cardiac contraction (ejec-
Heart failure is a chronic and complex clinical
tion) is reduced and the heart is unable to pump
syndrome. It is one of the common causes of
the blood well, also known as “systolic dysfunc-
hospitalization and readmission among the
tion”; and (2) when relaxation of the ventricles is
older population. Patient self-management is
impaired and the heart is unable to fill the blood
essential to maintaining health and avoiding
well, also known as “diastolic dysfunction.” Both
disruption of life caused by frequent hospital-
conditions lead to a decreased cardiac output
izations. However, many patients lack self-­
which is insufficient to meet the body’s meta-
care skills. This chapter provides a review on
bolic demands [1], therefore, other compensatory
evidence for the importance of self-­
mechanisms must be employed to offset the
management and strategies to educate patients
reduction in cardiac performance. These include
and promote self-care while living with the
activation of the neurohormonal and adrenergic
limitations on physical function.
pathways, as well as remodeling of the heart and
blood vessels. The systemic and persistent over-
Keywords
activation of multiple neurohormonal and adren-
Health promotion · Self-management ergic pathways that aims at normalizing cardiac
Self-efficacy · Heart failure output may offer short-term benefits, but in a
long run, the continued stimulatory effects on the
heart will eventually worsen the HF progress [1].
Clinically, the typical symptoms of HF include
19.1 Introduction symptoms caused by excessive fluid retention,
such as dyspnea due to pulmonary congestion,
Heart failure (HF) is not a specific disease, but a abdominal distention from ascites, weight gain
chronic and complex clinical syndrome that and peripheral edema, and symptoms caused by
developed as the end-result of a variety of cardio- decreased cardiac output, such as activities intol-
vascular diseases [1]. Broadly speaking, the car- erance, fatigue, hypotension, poor mentation, and
weakness [1, 2].
Y. Jiang (*) · W. Wang As a chronic condition, HF imposes great bur-
Alice Lee Centre for Nursing Studies, Yong Loo Lin dens on the society. Around 38 million people
School of Medicine, National University of worldwide are living with HF and the condition
Singapore, Singapore, Singapore
e-mail: nurjiy@nus.edu.sg; nurww@nus.edu.sg
is becoming more common in both developing

© The Author(s) 2021 269

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_19
270 Y. Jiang and W. Wang

and developed countries [2–4]. The incidence he or she can be relatively healthy if he or she is
and prevalence of HF increase with age. With the asymptomatic and fully functioning. Conversely,
rising prevalence of cardiovascular risk factors, an individual who is physically healthy may also
as well as improved survival rate in heart attacks have moments of sickness or emotional distress.
and other cardiovascular diseases, the number of Health promotion requires the active participa-
people with HF is expected to continue to surge tion of individuals in their contexts and, ulti-
[5, 6]. The growing burden of HF is taking its toll mately, moving towards the healthy pole [15]. To
on the society, particularly on the health care sys- do this, individuals need to have the ability to
tems. HF is one of the most common causes of understand the whole situation in which they
hospitalization and readmission [7–10]. In find themselves, and to use the resources avail-
Singapore, age-adjusted HF hospital admission able to them to move in a direction that promotes
rate rose by 38% from 1991 to 1998 [9]. More health.
recently, local data from public institutions show There are three key concepts in the Salutogenic
that HF readmission rate is 18%, with an average model of health, namely, the generalized resis-
length of stay of 5.2 days per admission [11], tance resource (GRR), the specific resistance
which is similar to the average length of hospital resource (SRR), and the sense of coherence
stay (5–10 days) across the globe [2]. The lengthy (SOC) [16]. According to Antonovsky, GRR
and recurring hospital stays required by the refers to an attribute of a person, a group, or a
patients not only account for the majority of community that contributes to successfully cop-
health care expenditure but also pose additional ing with the inherent tensions of human existence
challenges for hospital administrators to plan and [16, 17]. In contrast, SRR is a specific resource
allocate the scarce manpower and medical used when a particular stressor is encountered
resources [7]. [17]. GRR are resources with broad utility, such
For the individuals, HF is a long-term condi- as wealth, ego strength, and social network, while
tion that involves one or more hospitalizations. SRR are resources with situation-specific utility,
Living with HF is fraught with challenges. The such as medical emergency number to access
distressing symptoms reduce the patients’ inde- ambulance. Similarly, Sullivan [18] made a dis-
pendence and ability to perform many activities tinction between GRR and SRR and indicated
of daily living [12]. Also, recent health care that nursing is the GRR, while the nurse provid-
reforms have increasingly shifted the self-­ ing specific care to a particular health problem of
management responsibility to patients and fami- the patient is the SRR. GRR is important for the
lies, as hospital stays are becoming shorter and development of a strong SOC [17]. Antonovsky
less frequent. Therefore, the critical role of [14] believed that a person with a strong SOC is
patients in their own care is receiving increasing more likely to mobilize the SRR and GRR in any
attention. Self-care refers to specific behaviors given situation to overcome stressors. And
that patients perform of their own accord to con- through such a mechanism, SOC eventually
trol their disease and maintain health [13]. As translates into better health.
with many other chronic diseases, there is no cure The concept SOC is a global life orientation, refer-
for HF, but through treatment and self-care man- ring to a way of seeing the world as manageable, pre-
agement, the impact on quality of life and disease dictable and meaningful [15, 19]. It consists of three
progression can be abated. essential components: “comprehensibility,” “manage-
The Salutogenic model of health considers ability,” and “meaningfulness” [14]. SOC has a sig-
health to be on a continuum between ease and nificant impact on health. In health promotion, SOC
dis-ease [14], instead of merely the absence of reflects a person’s ability to identify their internal and
disease. Based on this model, most individuals external resources and use them in a way that pro-
are somewhere between the imaginary poles of motes health and well-being [15]. Like personality,
complete wellness and complete illness [15]. An SOC is thought to be fairly stable and enduring, with
individual may have many physical ailments, but only a margin of malleability [14]. The debate over
19 Health Promotion and Self-Management Among Patients with Chronic Heart Failure 271

whether SOC can be improved by interventions con- 19.2.1 H

 eart Failure Self-­
tinues [20], but some have reported that the three com- Management Interventions
ponents of SOC can be strengthened by interventions
[21]. Nurses have a responsibility to promote patients’ Self-management interventions refer to disease-­
understanding of the situation after their diagnosis of management interventions that focused on
HF (i.e. to increase patient’s comprehensibility), to improving patients’ self-care. Self-care is the
help patients reduce the adverse impacts of HF on cornerstone of HF management and health pro-
their quality of life and to ensure patients are able to motion, which defines as specific behaviors per-
live as healthily as possible with their physical formed by a patient on his or her own accord to
limitations (i.e. to improve ­manageability). Self- manage illness and maintain health [13]. Self-­
care is an important part of promoting health in care for HF encompasses a range of specific
patients with HF. Despite its importance, many behaviors, from adhering to medication, reducing
patients find it challenging, especially when transi- excessive fluid and salt intake, monitoring daily
tioning from hospital care to home and community weight, exercising, monitoring and identifying
care [22, 23]. Patients often feel unprepared to exacerbating symptoms, and taking appropriate
manage their condition in the community due to steps to intervene if symptoms worsened [27].
having to acquire a variety of skills in multiple Studies have shown that if patients practice con-
domains of daily living without the supervision stant self-care, 30% of hospital admissions and
from hospital staff [13, 24]. And many of these more than half of the readmissions can be pre-
changes impose heavy demands on patients’ abil- vented [28, 29].
ity to understand and act [13]. This chapter pro-
vides a review of some important research on HF 19.2.1.1 Medication Management
self-management in the literature. Particular atten- Medication is important in HF treatment. Most
tion is paid to HF self-care and its associated prob- patients with HF are prescribed a combination of
lems, strategies to improve different aspects of HF at least three types of agents: angiotensin-­
self-care, as well as the multifaced psychosocial converting enzyme inhibitors (ACE-I), angioten-
disease-­management interventions to improve sin II receptor blockers (ARB), β-blockers,
overall self-care management. aldosterone receptor antagonists (AA), and/or
diuretics. Although evidences on medication effi-
cacy are clear, studies have found that a significant
19.2  anagement of Heart
M proportion of patients does not take medication as
Failure (HF) prescribed [30]. In the literature, medication
adherence rates vary widely, depending on how
Overall, the aims of HF management are to (1) adherence is measured [30]. Zhang et al. [31]
reduce morbidity, that is to reduce symptoms and reported that on average, only half (52%) of the
hospital admissions while improving functional patients had good medication adherence, which
status and quality of life, and (2) to improve sur- was measured by the ratio of total number of med-
vival through slowing down the disease progres- ication the patient had actually taken (numerator)
sion. In clinical practice, HF management over the total number of medication the patient
generally includes treating the underlying causes should have taken (denominator). As medication
of HF (e.g. coronary heart disease or valve dis- regimens have become increasingly complex,
ease) and associated conditions (e.g. hypertension many patients found medication management
or diabetes), follow-up monitoring and preventa- challenging. In the qualitative studies, patients
tive care, case management and care coordination, reported that the demands to adhering the complex
patient education and support for self-manage- treatment regimens are onerous and difficult to
ment and health promotion, cardiac rehabilitation, meet. Some patients also reported troubles on
palliative care, implantable device therapy, and in learning new medications and dealing with the
some cases heart transplantation [25, 26]. burden of medication side effects [32, 33].
272 Y. Jiang and W. Wang

Previous studies on medication adherence ventions, with education being the most widely
have found an inverse relationship between num- included component [38]. Studies using intensi-
ber of daily doses and adherence rate [34, 35]. fied patient care included interventions with
However, a recent study attempted to evaluate direct patient contacts and interventions with
this strategy of simplifying medication regimen regular telephone follow ups or tele-monitoring.
to once-daily dosing on its own did not find any Face-to-face direct patient contacts were found to
evidence in improving medication adherence in be the most effective strategy in improving medi-
patients with HF [36]. Specifically, there was no ation adherence. In contrast, only one of the
statistically significant difference in medication telephone-­based or tele-monitoring interventions
adherence between patients taking once-daily has led to enhanced mediation adherence [39].
carvedilol controlled-release (CR) and patients Similar result was observed in a recently pub-
taking twice daily carvedilol immediate-release lished systematic review and meta-analysis of the
(IR) for a 5-month period. However, this trial effectiveness of mobile phone-based self-­
may be confounded by the “ceiling effect” management interventions on medication adher-
resulted from high baseline medication adher- ence in patients with coronary heart disease [41].
ence among the participants [36]. In addition, in In this review, the meta-analysis result from the
a systematic review on the relationships between pooled data did not find a significant impact of
dosage regimens and medication adherence, the mobile phone-based interventions on improv-
Claxton et al. [37] compared medication adher- ing medication adherence [41].
ence between different dose regimens and found More recently, mobile health (mhealth) appli-
that medication adherence was significantly cations (apps) to support medication adherence
higher with once daily regimens compared to have also grown in number, some studies have
3-times-daily or 4-times-daily regimens, and been conducted to examined its efficacy among
between twice-daily dosing and 4-times-daily cardiovascular patients, including patients with
dosing. However, there was no significant differ- HF [42, 43]. Goldstein et al. [42] performed a
ences in medication adherence between once-­ four-arm randomized feasibility study of 60 par-
daily and twice-daily regimens or between ticipants with HF, comparing an e-pill box (tele-
twice-daily and thrice-daily regimens [37]. These health) to a smartphone-based mHealth app on
findings suggest that simpler medication regi- medication adherence and patient’s acceptance of
mens may improve patient’s medication manage- the devices. Participants were provided one of the
ment and medication adherence, but that simply two devices with or without active reminders. No
reducing a single dose (e.g., from twice-daily to significant difference in medication adherence
once-daily) may have too little impact on patients. was found among the four arms. However,
Two systematic reviews have reviewed inter- patients preferred the mHealth approach [42].
vention strategies to promote medication adher- Studies conducted on other cardiovascular
ence in HF patients [38, 39]. Overall, more than patients showed modest benefits in improving
half of the included studies (63% and 50%) medication adherence [43].
shown significant better medication adherence in Taken together, current evidences suggest that
the intervention arms, suggesting that medication multicomponent interventions conducted face to
adherence in patients with HF can be improved face may still be the most effective strategy to
by effective interventions. Because of the impor- improve medication adherence in patient with
tance of comprehensibility in building SOC and HF. Although some evidences suggests that
promoting health [40], effective interventions mHealth app may potentially improve medica-
should not only increase patient knowledge of tion adherence in patients with cardiovascular
medications, but also be delivered in a way that is diseases, findings from trials on patients with HF
easy for patients to grasp. In the literature, most are not consistent. High-­quality trials are still
of the effective interventions used a combination needed to confirm its role and justify its use in
of educational, behavioral, and affective inter- routine care [43].
19 Health Promotion and Self-Management Among Patients with Chronic Heart Failure 273

19.2.1.2 Sodium Restriction reported that medication adherence was the high-
Restricting daily sodium intake to <2 g has been est (95.5%), while dietary adherence (45.5%)
commonly recommended in patients with was the lowest after hospital discharge, and over-
HF. However, there is no firm evidence to support time, both adherences decreased rapidly. Within
this practice [44]. Both observational and 3 months, the overall adherence rate for low-­
­experimental studies have shown mixed results sodium diet was 42%, compared to 96.4% for
[45–47]. Therefore, the efficacy and safety of adhering to fluid restriction and 84.7% for adher-
sodium restriction remain unclear, and there is no ing to medication [57]. Colin-Ramirez et al. [58]
consensus on the optimal amount of sodium evaluated the dietary patterns of sodium con-
intake for patients with HF [48]. Updated guide- sumption in 237 patients with HF. It was reported
line by the Canadian Cardiovascular Society has that 4.2% of patients who reported “always”
recommended patients with HF to restrict their being adherent with a low salt diet ate canned or
daily dietary salt intake to between 2 and 3 g package soups daily, while 22.9% of those who
[49], while the recent American College of reported “sometimes” being adherent ate fast
Cardiology Foundation (ACCF)/AHA guideline foods one to three times a week. Among all the
for HF management suggests some degree of participants, one third (30%) reported consuming
sodium restriction (e.g. <3 g/day) in patients with large amounts of processed meat on a weekly
congestive symptoms but does not endorse any basis, and 52% reported using seasoning such as
specific level of sodium intake [50]. Similarly, ketchup, BBQ sauce, soy sauce, or salad dress-
the 2016 European Society of Cardiology (ESC) ings in their cooking. On further examination, a
guideline for diagnosis and treatment of HF does number of the participants connected the idea of
not provide any explicit recommendation on low-salt diet mainly with not adding salt to cook-
sodium restriction but suggesting avoiding exces- ing, but not with reducing high-sodium processed
sive salt intake (>6 g/day) [51]. Most of these foods. Similarly, in an earlier study, Chung et al.
recommendations are based on expert opinions [59] found that there was no significant differ-
given the conflicting evidences in the literature, ence in the 24-h urine sodium levels between
which make it difficult to compare or draw defi- those who reported being adherent to low-sodium
nite conclusions [50, 52–54]. diet (4560 mg) and those who reported being
In the context of HF self-care, adhering to a nonadherent (4333 mg, p = 0.59). The inconsis-
low-sodium diet requires patients to understand tent findings between self-reported adherence
the relationship between sodium intake and con- and participants’ actual dietary pattern on sodium
gestive symptoms (e.g. edema), and make sensi- intake reflected significant gaps in patients’
ble adjustments to their diet based on clinical knowledge related to low-sodium diet [59], even
situation [49]. To do this, the patient would need when dietary teaching on low-sodium diet was
to have the knowledge and skills to measure daily provided to all the participants by a registered
sodium intake, know how to read food nutrition dietician [58].
labels, distinguish low-sodium foods from high-­ A qualitative study exploring factors associ-
sodium foods, and recognize the “hidden” ated with not adhering to low-sodium diet has
sources of sodium (e.g. canned foods). In addi- found that “lack of knowledge,” “interference
tion, patients are also required to perform actions with socialization,” and “lack of food selections”
of choosing low-sodium food and avoiding high-­ were the major reasons contributing to nonadher-
sodium food, reducing salt added in cooking, as ence [60]. Many patients perceived that health
well as asking for reduced-salt meal when eating care providers did not cover what they wanted to
out at restaurants [55]. Therefore, dietary adher- know, and they were given too little information
ence is often difficult. on low-sodium foods or strategies to follow
It was reported that HF patients had an aver- dietary recommendations. For patients with addi-
age of 2.7–3.9 g daily sodium intake as measured tional dietary restriction, following a dietary regi-
by 24-h urine sodium [56]. Riegel et al. [57] men can be confusing, and confounded by the
274 Y. Jiang and W. Wang

limited food choices, for example, patients with In a recent review on fluid restriction in
diabetes worried that eating fresh fruits that con- patients with HF, Johansson et al. [65] found that
tained low sodium may increase their blood glu- most of the randomized trials included fluid
cose levels [60]. Similarly, in a descriptive study, restriction as one of the components in combined
Ong et al. [61] reported that although patients intervention, only two studies assessed the effect
may understand their diet restriction, but they of fluid restriction alone [66, 67]. But neither of
faced practical problems because of limited food them found any significant differences in clinical
choices and lack of tactics to fit the dietary regi- parameters, body weight, or renal markers
men into their everyday lives. between patients on fluid restriction and those
While health care professionals believe the with a liberal fluid intake [66, 67]. Many of the
importance of patient education [62, 63], such studies did not report patients’ actual fluid intake,
belief does not seem to be translated into promot- but studies did report on this showed most of the
ing patients’ knowledge or self-care. Riegel et al. patients consumed less than 2 L/day, irrespective
[57] observed that although nurses routinely of whether they were in the intervention group or
teach patients about importance of treatment control group, suggesting that excessive fluid
adherence and behaviors that are important to intake may not be a general problem in the HF
adopt, adherence to self-care recommendations population [65–67].
decreased rapidly after hospitalization. The find- On the contrary, stringent fluid restriction in
ing called into question whether patient educa- hot and low-humidity climates may predispose
tion during hospitalization is effective in patients with HF to heat stroke [50]. It was also
influencing patients’ adherence. Similarly, reported that fluid restriction of 1.5 L/day was
Bentley et al. [60] raised the question of whether associated with decreased quality of life and
patients truly did not receive diet education, or increased sensation of thirst [66]. Elderly patients
whether the education delivered was untimely, might even be at risk of dehydration as a result of
ineffective, and presented in a way that hinders impairment of thirst sensation, decreased kidney
learning. Some studies have suggested that effec- function, medications (e.g. diuretics), depression
tive teaching should be provided over several ses- or dependence on a caregiver to provide fluid
sions to increase knowledge retention [62]. In [68]. Therefore, the discussion of fluid intake
addition, it is important to involve family mem- should be placed in a larger context of HF man-
ber as their understanding of low-sodium diet agement with consideration of dietary habits,
may enhance patient’s adherence and reduce diuretic regimen, and symptoms presentation
family conflict [64]. Repetitive reinforcement of rather than restricting fluid intake in isolation
diet guidelines seems to have little effect on pro- [66]. In HF self-care, fluid management also
moting dietary adherence [61], therefore, inter- requires patients to recognize the needs to alter
ventions would also need to address factors other fluid intake, such as to increase fluid intake dur-
than lack of knowledge [60]. ing period of high heat, nausea, or vomiting, and
to restrict fluid when body weight increases and/
19.2.1.3 Fluid Restriction or presence of congestive symptoms [50, 51].
The 2013 ACCF/AHA and the 2016 ESC HF
guidelines have suggested fluid restriction of 19.2.1.4 Daily Symptoms Monitoring
1.5–2 L/day in patients with refractory or symp- Changes in signs and symptoms often precede
tomatic HF to relieve congestion [50, 51], and it further changes in clinical status that may require
is best implemented in the context of self-­ intervention. For example, weight gain is com-
management on symptoms and weight monitor- monly regarded as a marker of HF decompensa-
ing. Routine fluid restriction in all HF patients tion. In a nested case-control study among 268
regardless of symptoms or other considerations patients with HF, Chaudhry et al. [69] reported
does not show any benefits, therefore it is not rec- that weight gain was associated with a subse-
ommended [50]. quent hospitalization for HF and started at least 1
19 Health Promotion and Self-Management Among Patients with Chronic Heart Failure 275

week before admission. Daily monitoring of normal aging [76, 77]. Some evidences have
signs and symptoms is a pragmatic way for reported that HF is associated with changes in
patients to track their health status and identify cognitive function, therefore diminishing
high-risk period, during which timely interven- patients’ ability on symptoms perception [78,
tions could be rendered to avert episodes of 79]. Furthermore, inadequate explanation by the
decompensation. Major clinical guidelines have health care professionals is perceived as another
recommended symptoms monitoring as part of barrier. Even when patients are provided with
the routine self-care management, specifically, educational brochures, they do not feel suffi-
daily weight monitoring, daily check for edema, ciently informed [24]. Most of the patients are
and daily check for symptoms severity are the not ready to receive education at the time of ini-
typical self-care strategies to monitor signs and tial diagnosis due to the fears and worries stem-
symptoms [55, 70]. ming from the new diagnosis of HF. On the other
Despite the importance of symptoms monitor- hand, education given at the time of hospital dis-
ing, Zeng et al. [63] reported that HF patients charge is often overwhelming and hard to follow,
lacked the knowledge on HF symptoms recogni- especially when a big chunk of information needs
tion. Among 187 Singaporean HF patients, only to be communicated to the patient at one go [80].
55.6% were able to associate increased weight Consequently, the windows of opportunity to
with change in HF condition, and less than half treat the early symptoms of HF decompensation
(40.1%) knew that they should weigh themselves may be hindered by the difficulties that patients
every day. More than half of the patients were not faced in monitoring and recognizing the symp-
able to recognize signs and symptoms of worsen- toms [81]. Therefore, strategies to improve the
ing HF [63]. Similarly, Ong et al. [61] investi- “comprehensibility” and “manageability” in
gated the learning needs among hospitalized symptom monitoring remain essential. For exam-
Singaporean patients with HF and found that ple, comprehensibility can be supported by
education topics on HF signs and symptoms were teaching patients on how to make sense of their
ranked as the most important learning need by subjective symptoms (e.g. feeling of fatigue) and
the patients. These findings echoed the result of objective assessment (e.g. weight record and
an earlier qualitative study that local patients edema assessment), providing easy-to-­understand
wanted to know more about their conditions and graphic illustrations, and breaking down infor-
symptom management, but physicians preferred mation into digestible chunks by using simple
to discuss their conditions with their family more language and short sentences. Manageability can
than with them. Consequently, patients felt less be improved by providing technical solutions on
empowered to manage their conditions [71]. how to incorporate symptom monitoring into the
Studies conducted in other countries found patient’s daily routine.
similar challenges in symptoms monitoring and Similar to medication management, interven-
detection [13, 72–74]. Moser et al. [75] reported tions based on remote telemonitoring, mobile
that symptoms monitoring was the least well-­ phone-based monitoring and mHealth apps have
performed self-care activities, with only 14% grown significantly in the field of symptoms
weighing themselves every day and 9% monitor- monitoring over the past two decades [82]. The
ing for symptoms of worsening HF. Adequate deployment of these technologies has provided a
self-monitoring and symptoms management powerful tool to look for early warning symp-
impose heavy demands on patients’ ability to toms and to prevent hospitalization [83].
understand and act on their knowledge. However, However, evidences from the literature show
poor memory on basic concepts of HF, misattri- inconsistent results on the effectiveness of these
bution of symptoms to other conditions, and low technologies.
comprehension of links between symptoms and In an earlier Cochrane systematic review and
HF are common among patients [72]. Older meta-analysis, Inglis and colleages [84] reported
patients often discount the early-warning signs as that remote telemedical surveillance through
276 Y. Jiang and W. Wang

telemonitoring significantly reduced all-cause sending the data through a mobile phone internet
mortality (RR 0.66, 95% CI 0.54–0.81) and browser.
HF-related hospitalizations (RR 0.79, 95% CI Many of the technologies being tested in the
0.67–0.94). “Structured telephone support” by previous studies are almost obsolete today due to
using a mobile phone to monitor symptoms and how rapidly technology is changing. For example,
provide self-care management without additional in the Tele-HF study, participants needed to call
home visit or intensified clinic follow-up signifi- the IVR system daily [86], while in the other two
cantly reduced HF-related hospitalizations (RR studies, the study interventions were based on the
0.77, 95% CI 0.68–0.87), although effect on old mobile phone models (BlackBerry Pearl 8130
reducing all-cause mortality was not statistically and Nokia 3510) for data transmission and symp-
significant (RR 0.88, 95% CI 0.76–1.01) [84]. In toms reporting [83, 85]. The less user-friendly
another study, Seto and colleagues [85] tested the patient terminal may decrease the usability of an
effect of a mobile phone-based telemonitoring intervention, especially for those elderly and tech-
system on the outcomes of HF patients after a nically unskilled patients [83]. More recently,
decompensation episode. The mobile phone-­ with the rapid development of mobile technology
based patient terminals were used for data collec- and the expansion of mobile network coverage,
tion and data transmission. Patients in the personal mobile devices (smartphone and/or tab-
intervention group were required to have their lets) and mHealth apps seem to be better posi-
weight and blood pressure measured daily, tioned for monitoring symptoms [82]. In a
single-­lead ECG measured weekly, and to answer single-arm prospective pilot study, Zan and col-
symptoms check questions on their mobile leagues [87] evaluated the feasibility of a remote
phones daily for 6 months. Their results showed web- and telephone-based monitoring system,
that participants in the intervention group had called the “iGetBetter” system. The “iGetBetter”
significant improvements in self-care mainte- system enables the patients to self-monitor their
nance and HRQoL compared to those in the con- body weight by a bluetooth weight scale and
trol group after 6 months. However, differences blood pressure through an auto-­inflating blood
on the hard outcomes, such as hospitalization, pressure cuff. Data were transmitted onto the
mortality, or emergency department visits secured web platform. Patients can view their
between the two groups were not significant [85]. results by logging into the patient portal using an
Similarly, in a large-scale RCT (the Tele-HF iPad mini at home, while the physician can access
study) involving 1653 patients with HF, Chaudhry patients’ data remotely through the clinician por-
et al. [86] testing out a telephone-based interac- tal. Patients who did not complete the self-moni-
tive voice response (IVR) system that gathered toring activities as planned would receive a
information on symptoms and weight every day, reminder phone call from the IVR telephone sys-
but failed to show any evidence on improving tem. The IVR telephone system served as an alter-
patients’ clinical outcomes. Furthermore, the native means for patients to log their activities and
study found that 14% of the patients in the inter- key in their measurements manually through the
vention group never used the system, while only phone keypad. Over the 90-day study period, the
55% of them were using the system at least three study team found that 19 patients (95%) agreed
times a week. The authors believed that the that the monitoring system was easy to use, and
adherence rate reflected the “best case” scenario more than half of the participants had 80% or
which is difficult to replicate in the real-world greater adherence to care plan. Most participants
clinical practice since considerable resources engaged the system through patient portal on the
were directed toward optimizing patients’ iPad mini, but three participants (15%) only used
engagement in this clinical trial [86]. The trial by the IVR telephone system exclusively. At the end
Scherr et al. [83] also reported low adherence rate of the study, participants had an improvement of
that 22% of their study participants were “never HRQoL from baseline, but there were no signifi-
beginners” due to the difficulty in entering and cant differences in hospital utilization and length
19 Health Promotion and Self-Management Among Patients with Chronic Heart Failure 277

of hospital stay [87]. The pilot study demonstrated Earlier guideline has stated that patients with
the feasibility of a remote monitoring system that HF should limit their alcohol intake to two stan-
leveraged on latest mHealth technology and por- dard drinks or less per day for men and one stan-
table digital devices. It offered a potential low- dard drink or less per day for women, while
cost solution on timely symptoms monitoring patients with suspected alcohol-induced cardio-
[87]. However, its effect on clinical outcomes myopathy should abstain from alcohol [94]. More
were yet to be confirmed. To date, there is still a recent guidelines only recommend counseling
lack of evidence from high-quality large-scale and/or treatment to reduce alcohol intake in
randomized controlled trial (RCT) on clinical patients who have consumed excessive amounts of
effectiveness of these technologies [55]. alcohol, especially in patients with alcohol-
induced cardiomyopathy [50, 51]. It should be
19.2.1.5 Other Lifestyle Modifications noted, however, that the effects of small amounts
Physical inactivity, cigarette smoking and exces- of alcohol are still controversial [95, 96]. Therefore,
sive alcohol consumption are the highly avoid- for those who were nondrinkers, health care pro-
able lifestyle risk factors for worsening vider should not endorse alcohol to them [97].
HF. Therefore, exercise, smoking cessation and In summary, HF self-care consists of a variety
limit alcohol intake are the other recommended of skills across multiple domains on a daily basis
self-care strategies. [13, 72]. It is a dynamic and complex process, in
Many studies have demonstrated consistent which some of the required actions may conflict
benefits for a range of outcomes with exercise with patients’ preferences. Despite its impor-
training in patients with HF, including improved tance, HF self-care remains challenging for many
quality of life, improved functional capacity, patients. While several studies focus exclusively
decreased mortality and reduced hospitalization on improving a single aspect of HF self-­care,
[88–90]. Exercise training or regular physical such as medication management or symptoms
activity is the Class I recommendation to improve monitoring, most studies adopt a multifaceted
functional status among patients with HF accord- approach to improve patient’s overall self-care
ing to the 2013 ACCF/AHA guideline [50]. management. The following section will provide
Nonetheless, exercise adherence is hard to main- a review on these interventions.
tain. Some studies reported that overall exercise
adherence rate ranged from 9% to 53% [13]. In a
large RCT with 2331 stable HF patients (the 19.3 Psychosocial Self-­
HF-ACTION trial), exercise adherence of the Management Interventions
participants in the intervention group decreased
over time, from a median of 95 min per week dur- In the literature, there are many disease manage-
ing 4–6 months follow-up to 74 min per week ment programs developed to help patients to
during 10–12 months follow up, even though the manage their HF condition and to improve over-
patients were provided a structured exercise pro- all self-care and promote health [88, 98–102].
gram and were supervised closely [88]. Most of these programs are instructional with a
Smoking and excessive alcohol consumption focus on the value of exercise training, pharma-
are associated with higher risk of HF mortality in cological care and lifestyle modifications [88, 98,
patient with HF [91, 92]. Smoking cessation is as 99, 102, 103]. While evidences acknowledge that
effective as drug treatment in reducing mortality patient education is a necessary and important
among smokers with HF, with benefits of preven- component to promote effective self-care [104–
tion death and hospitalization emerging quickly 106], it is also noted that education alone is insuf-
in less than 3 years [91, 93]. Therefore smoking ficient to support behavioral changes [107].
cessation is an important part of HF self-care and Efforts to promote successful self-care should
should be encouraged in all HF patients who are consider patients’ knowledge, skills and engage-
current smokers [55]. ment [55].
278 Y. Jiang and W. Wang

Over the past decades, there has been increas- and skills are less effective to enhance HF self-­
ing attention to the role of psychosocial factors in care [55]. Psychological techniques, such as
the etiology and prognosis of cardiac disease, motivational interviewing techniques and cogni-
including HF [108, 109]. Psychosocial interven- tive behavioral strategies, may improve patients’
tions, as part of the nonpharmacological inter- engagement and psychological outcomes.
ventions, have been increasingly used to enhance However, the effect of psychological intervention
the health outcomes of patients with HF [110]. on self-care and psychological outcomes among
Besides disease education, a psychosocial educa- patient with HF are less clear. An earlier Cochrane
tion program is usually an intervention that com- systemic review and meta-analysis on psycho-
bines psychological (e.g. cognitive behavioral logical intervention for depression in patients
therapy, relaxation, motivational interviewing, with HF found no studies that met their inclusion
nondirective counseling, or supportive therapy) criteria [112]. Although a later systemic review
and social (e.g. social support) components. It is and meta-analysis supported the efficacy of some
a multicomponent intervention that aims to pro- psychological interventions, such as psychother-
mote patients’ understanding of knowledge and apy, progressive muscle relaxation techniques,
encourage behavioral changes for an effective counselling or mindfulness-based intervention in
self-management [111]. It is also a holistic improving psychological outcomes among
approach to improving health literacy, strength- patients with coronary heart disease, but none of
ening a person’s psychological and social the included studies was conducted on patients
resources, enabling patient’s resistance to illness, with HF [113]. Our recent systematic and meta-­
and mitigating the negative impacts of HF on analysis on the efficacy of psychological inter-
their quality of life. ventions on self-care, psychological and health
In a recent systematic review and meta-­ outcomes in patients with HF has found that psy-
analysis, Samartzis et al. [110] examined the chological interventions improve health-related
effectiveness of psychosocial interventions on quality of life at 3 months of follow-up [114].
quality of life in patients with HF. The review However, there was no statistically significant
included 16 RCTs involving 2180 participants. effect detected after 3 months of follow-up. The
The combined data showed that psychosocial intervention effects on the participants’ anxiety
interventions improved patients’ quality of life level was not statistically significant. In addition,
(standardized mean difference [SMD] 0.46, 95% evidences from appraised literature revealed pos-
CI 0.19–0.72), among which, face-to-face inter- sible positive but short-term effects on HF self-­
ventions showed greater quality of life improve- care. Cognitive behavioral therapy tends to
ment compared to telephone-based interventions improve depression levels [114].
(p < 0.02). However, in terms of length of the As one of the psychological factors, SOC
intervention, or whether the intervention adopted refers to one’s enduring attitude towards life,
a multidisciplinary team approach, or whether which is the basis for successfully coping with
used telemedicine technology, or whether life’s ups and downs. It is also thought to moti-
involved patients’ caregivers in the intervention, vate individuals to stay healthy during the trajec-
there was no evidence favoring any specific type tory of a worsening illness [115, 116]. Gallagher
of these psychosocial interventions. In addition, [116] reported that a strong SOC is one of the
education on disease aspects and/or psychoedu- predictors for better self-management in patient
cation were presented in most of the interven- with HF living in the community. However,
tions, which are often given by a nurse, suggesting Ferreira and colleagues [117] did not find any
that patient education still played a significant significant difference in SOC in relation to per-
role in improving patients’ quality of life [110]. forming any self-care behavior or not among hos-
Patient engagement plays a pivotal role in pitalized HF patients. Other studies have
designing an effective self-management interven- suggested that SOC may associate with better
tion. Without patient’s engagement, knowledge HRQoL and life satisfaction in patients living
19 Health Promotion and Self-Management Among Patients with Chronic Heart Failure 279

with HF [115, 118]. Nevertheless, after searching medication adherence, as well as real-time vital
the literature, it was found that there is still a lack signs monitoring. The components of the
of studies in the literature to date on the HeartMapp app covered all the essential aspects
effectiveness of interventions based on the
­ of HF self-care, including patient education,
Salutogenic approach or the concept of SOC in medication management, symptoms monitoring
improving self-management of HF. and management, relaxation technique (deep
breathing exercise), and physical activity (walk-
ing) [124]. Their results revealed that participants
19.3.1 mHealth-Based in the HeartMapp group had significant improve-
Multicomponent Self-­ ment in self-care management, self-care confi-
Management Intervention dence, and HF knowledge. But results on
medication adherence, quality of life, and depres-
Most recently, with rapid evolution of technology sion were not significant. Over 30-day study
over the past few decades, there has been an period, 43% (4/9) used the app daily and com-
increasing trend in using mHealth to promote pleted daily symptoms assessment and exercise,
chronic disease self-management in the literature 56% (5/9) accessed HeartMapp features over
[119–121]. There is evidence suggesting that 80% of the time (24/30 days). However, the study
mHealth offers prospects for providing effective attrition rate was close to 30% [124], which was
and affordable health care services to a wide- higher than previous studies adopting a face-to-­
spread population, reducing geographical incon- face multicomponent psychosocial educational
venience and socioeconomic disparities [119]. In disease management approach [110]. The small
HF self-management, mHealth provides a new sample size and high attrition rate has limited the
way to improve patient participation in self-care generalizability of their findings [124]. In addi-
by constantly reminding patients about key tion, the review of existing commercially avail-
aspects of self-care and symptoms tracking [122]. able apps for HF self-care management has found
Compared to the older technology, the newer that very few apps met the prespecified criteria
generation of personal mobile devices (smart- for quality, content, or functionality. Therefore,
phone and/or tablets) and mHealth apps also have these findings underscore the need for further
better usability and integration into patient’s clinical validation and mapping evidence-based
everyday lives [82]. Therefore, it has a great guidelines to improve the overall quality of self-­
potential to be adopted in the multifaceted HF care-­related apps [123].
self-management.
Nevertheless, as aforementioned, many of the
initial mHealth technologies are deployed to pri- 19.4 Conclusion
marily support a single aspect of HF self-care,
such as medication management or symptoms In summary, this chapter provides a review of
monitoring. There are very few studies on research on HF self-management interventions
mHealth-based interventions aimed at improving aimed at improving self-care and promoting
overall self-care, even though the number of health. HF is a disabling and life-limiting condi-
commercially available mobile apps is growing tion. Living with HF is challenging, with many
rapidly [123]. In the most recent study, Athilingam patients expressing frustration when they were
and her team [124] have developed a new smart- unable to perform their daily work or social roles
phone app (the HeartMapp) to improve overall due to symptom burden or decreased physical
self-care and quality of life in patients with function. Effective self-management may help to
HF. The smartphone-based intervention lever- stabilize their life while living with the limita-
aged on mobile phones and heart rate sensor tions on functional abilities and disease burden.
(chest strap) to provide individualized alerts on Today, the medical perspective and approaches
symptom checking, symptom management and are highly developed and emphasized, which is
280 Y. Jiang and W. Wang

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 Older Adults in Hospitals: Health
Promotion When Hospitalized
20
Anne-S. Helvik

Abstract Keywords

Cognition · Coping · Discharge · Elderly ·

The population of older adults (≥60 years) is
Functioning · Inpatient · Mood · Screening
currently growing. Thus, in the years to come
it is expected that a high proportion of patients
hospitalized will be in the older age range. In
western countries, the proportion of older
inpatients is about 40% in the medical and 20.1 Introduction
surgical hospitals units. Older people with
illness is vulnerable to both physical and The increasing proportion of older adults (≥60
cognitive impairments as well as depression. years) [1–3] represents a heterogeneous group of
Therefore, a health-promoting perspective people often characterized by a complex health
and approach are highly warranted in clinical situation [4], with several diseases and limita-
nursing care of older adults in medical hospi- tions compared to younger adults [5, 6].
tals. This chapter focuses on health promo- Furthermore, older adults (≥60 years) may be
tion related to depressive symptoms, more vulnerable for negative health outcomes
impairment in activities of daily living, and connected to hospitalization than younger adults.
cognitive impairment in older hospitalized In addition, they may have symptoms of disease
adults. that are less typical than for younger adults.
Older adults being hospitalized have or may get
depressive symptoms, reduced functioning in
activities of daily living and/or reduced cognitive
functioning, all of which affecting the older indi-
vidual’s coping and health-promoting actions
negatively.
To provide good quality nursing care, it is
A.-S. Helvik (*) important to have several aspects of care in mind
Department of Public Health and Nursing, NTNU
at the same time. In a hospital setting, health-­
Norwegian University of Science and Technology,
Trondheim, Norway promoting nursing care improves the medical
condition causing hospitalization, strengthens the
Norwegian National Advisory Unit on Ageing and
Health, Vestfold Hospital Trust, Tønsberg, Norway individual’s health-promoting resources, and
e-mail: anne-sofie.helvik@ntnu.no support well-being and quality of life. Thus,

© The Author(s) 2021 287

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_20
288 A.-S. Helvik

focusing on the medical condition(s), promotion acutely hospitalization due to medical conditions.
of mental health along with cognitive and physi- The author has published several observational
cal functioning in activities of daily living are studies focusing on depression, activities of daily
equally important. living and cognitive functioning during and after
Health promotion is built on the salutogenesis acutely hospitalization of older adults [10–17].
model proposed by Antonovsky in 1979 [7]. The Thus, this chapter is based on the authors’ former
salutogenic approach to health includes other studies, along with previous evidence published
aspects than the pathogenic model, leading to a up to June 2019. The search terms were: elderly/
more nuanced understanding of health. older adults/older patients, depression/depressive
Salutogeneses includes a shift from solely focus- symptoms, physical functioning/personal func-
ing on the pathogenesis related to the medical tioning/basic functioning/activities of daily liv-
reasons for hospitalization and risk factors, ing, cognitive functioning/cognitive impairment/
toward capabilities and potential of the person. dementia/Alzheimer disease/mild cognitive
Despite hospitalization and disease, the individu- impairment, and lastly, in patients/hospitalization/
als posess resources which are fundamental for medical ward/geriatric unit and combinations of
health and well-being. The salutogenic approach these terms were also used.
to health includes reflection of the patient’s life
situation, a review of available resources and
active adaptation to life stressors, challenges, and 20.3  ealth Promotion During
H
a changing situation or environment [7, 8]. How Hospitalization
you cope and adapt to life stressors and chal-
lenges are affected of available coping resources. Nursing care should contribute to improve the
Both general resistant resources (GRR) and sense medical condition causing hospitalization as well
of coherence (SOC) are of importance [7]. SOC as promote the patients’ health resources. This
express an individual’s ability to comprehend the chapter focuses on health promotion related to
whole situation, the capacity to use the resources depressive symptoms, impairment in activities of
available to move in a health-promoting direction daily living and cognitive impairment in older
and finding life to be meaningful [7, 9]. Thus, the hospitalized adults. The consequences of depres-
way people are able to perceive structures, create sion, cognitive impairment, and reduced physical
coherence and manage change in a meaningful functioning for potential health outcome and
manner has a central impact on health [8]. well-being are described. Health-promoting care
Resources available include both internal and will map existing and limited health resources as
external resources [7], and nurses and other basis for care actions. This chapter will also
health professionals should be valuable resources include simple methods to uncover existing and
for health promotion among hospitalized older evolving symptoms of depression, cognitive
persons. impairment, and limitations of physical activities
of daily living.

20.2 Methods
20.3.1 Depression
This chapter focuses on hospitalized older adults
in general and does not focus on any specific med- Depression is a frequent cause of emotional suf-
ical condition. The research literature used here fering in old age causing negative health conse-
has been published in review-based journals quences such as reduced physical functioning
reporting results from cross-sectional and longitu- and quality of life [18–20], increased risk of
dinal studies about depression, impairment, and nursing home admission [21], and lower life
functioning in activities of daily living and cogni- expectancy [22, 23]. Depression in old age is also
tive functioning and impairment during and after related to higher health care costs [24].
20 Older Adults in Hospitals: Health Promotion When Hospitalized 289

Depression, also known as major depressive being hospitalized [34]. In a review of interna-
disorder or clinical depression, is a common and tional studies involving elderly medical inpa-
serious mood disorder, which is diagnosed based tients, the prevalence of significant depressive
on specific diagnostic criteria e.g., ICD-10 or symptoms ranged between 10% and 73% [10]. In
DSM-V [25, 26]. Symptoms related to depres- a Norwegian study of acutely hospitalized older
sion are feelings of sadness, hopelessness and persons coming from rural municipalities, the
loss of interest in activities they once enjoyed, prevalence of significant depressive symptoms
involuntary weight change, sleep disturbance, was low (10%). However, 78% of those 10%
changes in psychomotor activity, fatigue or loss with significant depressive symptoms had no
of energy, feelings of worthlessness or excessive information in their medical record that they ever
or inappropriate guilt, diminished ability to think had experienced some kind of mental health dif-
or concentrate and recurrent thoughts of death. In ficulties, problems or diagnoses of any kind pre-
accordance to diagnostic criteria, symptoms of viously in their life [10]. Thus, 78% of those
(1) depressed mood, or (2) loss of interest or detected with screening would probable not been
pleasure have to be present to define a person’s uncovered or diagnosed with depression if
state as a depression disease [25]. In addition, depression was not systematically screened for at
several of the symptoms mentioned above must that study. Uncovering existing and evolving
be present simultaneously in a 2 weeks period. symptoms of depression is a necessary step for
The severity of the symptoms has to significantly treatment of the condition.
reduce the person’s ability of functioning in one’s As said previously, the prevalence of depres-
daily living [25]. sion is higher in those with medical conditions, is
Older adults may have more uncharacteristic increasing with age [33], and is influenced by
symptoms of depression than younger people. gender, ethnicity, place of living, income, and
For example, the experience of sadness may be social support [33]. However, hospitalized older
missing, but they may have pronounced medical adults with reduced ability to perform activities
symptoms such as fatigue, pain, sleeping difficul- of daily living (ADL), in need of in-home nursing
ties, and loss of appetite [27, 28]. In older people care before hospitalization, and using several
depression may be mistaken for dementia, or prescribed drugs, are more likely to experience
grief due to losses, as well as a reaction of disease depressive symptoms than those without such
or functional impairment. Depression limits your difficulties or use of drugs [10]. Accordingly,
resilience and resources available to cope with those hospitalized with several and/or consider-
stressors and difficulties as well as to maintain able health limitations and fewer resources are
and promote health. more likely to experience depressive symptoms.
A population-based meta-analysis found the Health personal must be aware of the complex
diagnostic pooled prevalence of depression in relation between gender, ethnicity, place of liv-
older adults to be 7% [29]. Reviews of epidemio- ing, income, social support, and different health
logical community studies in Europe and world- aspects. The older person’s total situation as well
wide have estimated the prevalence of significant as his or her background and life experiences are
depressive symptoms to be a bit higher and to relevant. Health professionals’ knowledge about
vary between 8% and 15% among older adults the older adult’s thoughts, expectations, wishes
[30, 31]. Poor physical health is a known risk fac- and hopes for the stay and future has importance
tor for depression [32]. The prevalence of depres- when tailoring care to promote her/his mental
sion or significant depressive symptoms are state. A person-focused approach with an earnest
reported higher in older adults with medical dis- interest in the person’s total situation, including
eases and reduced ability to perform activities of psychological health and mental well-being,
daily living, compared to more healthy older includes health-promoting care facilitating per-
adults [33]. Furthermore, the prevalence of ceived meaning-in-life, hope, self-transcendence,
depression is reported higher in older adults and sense of coherence. Moreover, in this context
290 A.-S. Helvik

health-promoting nursing care includes assess- older adults’ health while hospitalized. In addi-
ment and awareness of the older person’s experi- tion, use of established screening tools may con-
ence of self-confidence, sense of worthiness/ tribute to a joint understanding among health
worthlessness, as well as needs and wishes in the professionals treating and caring for the individ-
present situation. In all phases of the hospitaliza- ual, and be the first step for further examination
tion, health-promoting nursing is based on and eventually a diagnostic workup. Registered
respect of the patient’s integrity. Health-­ nurses may use simple screening tools to reveal
promoting nurse–patient interaction contributes depressive symptoms. Several screening tools are
to a sense of being welcome and safe, and to available.
make the situation comprehensible as well as The Geriatric Depression Scale for older
manageable and thereby easing emotional dis- adults (GDS) [39] is a well-known screening tool
tress. Health-promoting nursing facilitates hope and translated to several languages [40, 41]. This
and resilience in the patient and his family. tool is used in older adults with minor or no cog-
For older adults, depression may be experi- nitive impairment, but is not suitable among peo-
enced as being in a vice, with little power of resis- ple with dementia [42]. The GDS has several
tance for depressive thoughts, not being able to shorter versions; a short version with 15 items
make peace in life, with limited resilience and [39] is frequently used. Other short versions
reduced ability to experience hope and difficulties include four or five items [43, 44]. All versions of
finding meaning-in-life [35]. Thus, the salutogenic the GDS have two response options for each
health processes are impeded. Even so, emotional question. The cutoff values indicating clinically
support as well as respectful attitudes are ground relevant symptoms of depression are based on the
pillars for regaining resilience and meaning-in-life number of items of the GDS version in use [39,
and to boost well-being and health. However, 43, 44]. The GDS screening tools are freely avail-
depressive symptoms constrain the old individu- able and deemed suitable for use in hospitals as
al’s ability to see a positive outcome of the situa- well as in primary health care.
tion. Consequently, identifying depressive Another screening tool often used in hospitals
symptoms and supporting the older adult’s coping is the “Hospital Anxiety and Depression Scale”
resources are essential. This is essential in order to (HADS) [45] including 14 items with 4 response
arrange for salutogenic health processes. Even so, options (scoring goes from 0 to 3). This tool
depression in older adults may be unrecognized, assesses both symptoms of depression and anxi-
untreated, and thus reducing the health outcome ety (7 items within each area) and does not
[36]. This may obstruct health promotion in terms include any questions about physical symptoms
of developing resilience, experiencing coherence, related to these conditions. The scale was devel-
hope, and finding meaning-in-life. Both milder oped for use in medical hospitals among all ages
and more severe depressive symptoms may pro- of adults, including older hospitalized adults.
voke and increase functional limitations in older Lately, a study in older adults including persons
adults [12, 37]. Furthermore, the cognitive func- both with and without poor physical health and
tioning and quality of life may decrease [16, 38], need of care assistance found that the cutoff sug-
both in a short and long-term perspective. gested for symptoms indicating depression in the
Therefore, the following section focuses on the general populations of hospitalized adults (≥8)
importance of uncovering depressive symptoms was too high for older adults. In this validation of
using valid screening tools. the HADS, the best cutoff score to indicate a clin-
ical relevant depressive symptom load was 4
20.3.1.1 Uncovering Depressive [43]. In clinical practice, it is important to note
Symptoms by Use that the score indicating depression may be lower
of Screening Tools in older adults than for younger adults. Thus, it is
To ask about depression and to screen for depres- important to use screening tools validated for the
sive symptoms are relevant in order to promote same type of population. Otherwise, clinically
20 Older Adults in Hospitals: Health Promotion When Hospitalized 291

relevant depressive symptoms may be under-­ standing, getting in and out of bed, and the abil-
reported and untreated. The items used to assess ity to walk independently from one location to
symptoms of depression and anxiety are found another. The B-ADL is necessarily performed
adequate also in older adults [11, 46, 47]. An every day.
advantage with use of HADS is that it also The more complex actions, named instrumen-
assesses anxiety symptoms. Older adults with tal activities of daily living (I-ADL), are not nec-
clinically relevant load of depressive symptoms essarily required every day, but are related to
may also have symptoms of anxiety [48]. HADS independent living. The I-ADL includes: (1)
is a self-report questionnaire and has several using communications technology such as a reg-
advantages. However, with reduced physical ular phone, mobile phone, email, or the Internet,
health in combination with reduced cognitive (2) using transportation either by driving oneself,
capacity, it may be challenging to answer a ques- arranging rides, or taking public transportation,
tionnaire with four response options at each (3) meal preparation with regard to meal plan-
question. HADS is translated and validated in ning, cooking, clean up, storage, and safely use
several languages and settings and have for years kitchen equipment and utensils, (4) doing shop-
been used without charge eff. However, now ping and making appropriate food and clothing
there may be restricts related to its use [49]. purchase decisions, (5) housework performance
As demonstrated above, the choice of screen- such as doing laundry, washing dishes, dusting,
ing tool may depend not only on the preferred use vacuuming, and maintaining a hygienic place of
in a care unit, but also on the characteristics of the
residence, (6) managing medications with regard
hospitalized person. The health professionals to taking accurate dosages at the appropriate
could preferably know a couple of screening times, as well as managing re-fills, and finally,
inventories to make the conditions favorable for (7) managing personal finances with regards to
health promotion. operating within a budget, writing checks, paying
bills, and avoiding scams [50].
Concerning functionality, loss of I-ADL is
20.3.2 Activities of Daily Living (ADL) maybe not as noticeable in the beginning as loss
of B-ADL, either not for the person self, next of
The concept of ‘Activities of daily living’ (ADL) kin and/or health personal. I-ADL functioning
includes necessary activities to maintain self-­ generally starts to decline prior to B-ADL func-
care. ADL consists of basic activities (B-ADL) tioning. Loss of both I-ADL and B-ADL reduces
and more complex actions (I-ADL) that are nec- your ability to maintain self-care and may influ-
essary to be independent of help from others ence your experience of hope, meaning in life
[50]. Even though there are some variations on and well-being. Thus, it is important to detect any
the definition of B-ADL, this concept normally impairment early and by means of for instance
includes: (1) personal hygiene including bath- empowerment, to promote individuals’ coping,
ing/showering, grooming, nail care, and oral finding new solutions and a new or reinforced
care, (2) dressing including the ability to make understanding of life, hope and meaning, despite
appropriate clothing decisions and physically that physical health is exposed. Loss of B-ADL
dress/undress oneself, (3) eating including hav- functioning may enforce a change of life style
ing the ability to feed oneself, though not neces- followed by lower quality of life and increased
sarily the capability to prepare food, (4) handling mortality [51–57]. In addition, loss of B-ADL
toilet visits including maintaining continence, will increase health care costs due to care assis-
having both the mental and physical capacity to tance [56–58].
use a restroom, including the ability to get on Regardless of the cause of hospitalization, an
and off the toilet and cleaning oneself, and essential part of nursing is to support and facili-
lastly, (5) transferring/mobility including hav- tate patients’ B-ADL functionality, enhancing
ing the ability for moving oneself from seated to self-care during and after the hospitalization and
292 A.-S. Helvik

thereby to promote health in general. Thus, the must engage in the relationship with patients.
nurses focus on assessment, care and treatment The professional strives to see, recognize and
and not only on treating the primary cause of confirm the patient as the person he is and not
hospitalization. only the patient with diagnoses, symptoms, needs
and physiological conditions (see Theoretical
20.3.2.1 Decline of B-ADL section). This contributes to a personalized care
in Connection that is accommodated to the patient’s wishes pro-
with Hospitalization moting B-ADL and health.
Over some years it has been known that func- Immobility has long been recognized as a haz-
tional change in older people is a complex ard of hospitalization causing loss of body
dynamic process where B-ADL may change, strength and B-ADL functions [61]. Maintaining
both before admission to hospital and during the and improving mobility and body strength as
hospital stay due to their illness and health condi- much as possible during hospitalization will
tion [59] as well as after discharge [12]. improve the patient’s ability to perform B-ADLs
The type and degree of B-ADL resources may after discharge. In addition, patients who report
vary considerably in older adults admitted to a unsteadiness while walking at hospital admission
medical hospital [60]. An American study reported are more likely to experience functional decline
that about 30% of older adults at admission to the after a stay in hospital [64]. Furthermore,
medical unit had difficulties with dressing, unsteadiness may contribute to reduced mobility
hygiene, and transferring, and that about 40% of or falls during hospitalization. Thus, it is impor-
all patients had experienced a decline in B-ADL tant to assess unsteadiness in order to give a care
within 2 weeks before hospitalization [60]. adapted to existing resources and support avail-
A health-promotion approach to hospitalized able B-ADL functioning rather than handling
older adults is essential, since a semi-acute or consequences of potential new difficulties, illness
acute illness or condition increases the risk for or impairments.
B-ADL decline [61, 62]. This is the case for older In general, older people need longer time to
adults, both with and without reduced function- recover from illness and B-ADL decline. It is
ing prior to the hospitalization. A study of more reported that among those with a new B-ADL
than 2000 older Americans hospitalized in gen- decline during hospitalization, more than one-­
eral medical wards reported that about 20% of third needed 3 months or longer after discharge
the patients had a decline in B-ADL during the to regain normal B-ADL [52]. Furthermore, a
hospitalization period [60]; the oldest old decline in B-ADL is found to relate with mortal-
revealed the highest loss of B-ADL at discharge ity; about one fifth of those discharged with a
[60]. A recent large longitudinal hospital study new or additional decline in B-ADL during hos-
found three trajectories of B-ADL in older pitalization stayed alive only 3 months after hos-
patients admitted to acute medical ward units; (1) pitalization [52]. Another study reported that the
functionally decline (17%), (2) functionally odds to regain normal B-ADL functioning both at
recovering (41%), and (3) functionally stable 2 and 12 months after hospitalization was reduced
(42%) over the hospital stay, with a mean of by increasing number of B-ADL limitations [65].
10.5 days. In this American study, functional A Norwegian observational study of medically
decline was explained by nursing and hospital hospitalized older adults showed that the mean
care factors such as less daily care, larger hospital B-ADL was significantly poorer 1 year after hos-
size, and lower care qualifications [63]. pitalization compared to the functioning during
Accordingly, adequate time to interact with older the hospitalization [12]. In this study, the B-ADL
hospitalized patients and health-promoting care decline 1 year after was explained by poorer
competency are crucial. Even so, this is not baseline B-ADL [12].
enough. Health-promoting interaction is needed. A study of more than 500 acutely hospitalized
This means that the health care professionals older adults in medical wards reported that those
20 Older Adults in Hospitals: Health Promotion When Hospitalized 293

with higher decline in B-ADL during hospital health conditions forcing hospitalization may
stay were more likely to be readmitted to the hos- represent the beginning of a health condition that
pital within 30 days after discharge [66]. independently of treatment will contribute to a
Furthermore, a Norwegian study of hospitalized poorer B-ADL functioning. In such cases, health-­
older adults in medical wards found that those promoting interventions by nurses and an inter-
with one or more B-ADL difficulties while hos- disciplinary team of health care professionals in
pitalized were five times more likely to become the hospital may contribute to reduced speed of
nursing home residents within the first year after the B-ADL decline during, but also after the hos-
hospitalization [13]. Thus, in a health-promotion pitalization. In a health-promoting approach
perspective, it is important to promote B-ADL which is based in a holistic understanding of
functions while hospitalized. It may contribute to health, the older individual’s situation, available
well-being not only in the moment, but also to resources and capacity to support self-care and
improved health, well-being, and quality of life B-ADL must be assessed, and actions taken to
over time. Using a health promotion nursing per- sustain B-ADL functioning during hospitaliza-
spective implies that in addition to a focus on tion and thereby contribute to best possible self-­
supporting and improving B-ADL resources and care after the discharge. This can for example be
functioning, the nursing care should be given in a support of unsteadiness, reducing consequences
health-promoting manner. Health-promoting of immobility due to bed rest. Furthermore, it is
interactions are fundamental in nursing care. By important to prepare and organize care such as
use of health-promoting interactions when sup- personal hygiene, dressing, toileting, transfer-
porting the patient with his or her B-ADL func- ring, and other such activities in line with avail-
tioning, health professional may promote an able B-ADL- resources. This may over time be
experience of hope and meaning-in-life in the health promoting.
older adults. It may be a hope for managing the Another reason for B-ADL decline after the
situation or hope that with help he or she has the hospitalization may be that the older adults them-
strength to overcome difficulties and experience selves do not manage or know how to handle
coherence in life. their health problems and their B-ADL deficits
Several factors may contribute to a B-ADL after discharge. In a health-promoting perspec-
decline before, during, and after hospitalization. tive, it is important to prepare the patient for the
B-ADL decline may be explained by generally discharge from hospital, to strengthen their cop-
reduced health, loss of weight, chronical disease ing resources, and contribute to adequate arrange-
or multi-morbidity, pain, a high number of drugs ments and support afterwards. An optimal
taken, and/or visual impairment [67, 68]. A study B-ADL function based on the individuals’ prem-
revealed that decline in B-ADL after hospitaliza- ises during the hospitalization will also promote
tion, in addition to lower baseline B-ADL, were health and B-ADL functioning after discharge.
linked to higher age, reduced cognitive function For example, studies have found that B-ADL
during and after hospitalization as well as poorer during hospitalization is linked to depression and
psychological health after hospitalization [12]. cognitive function after discharge. Those, with
The above study demonstrates that B-ADL is one little or no B-ADL deficits during hospitalization
of several areas for health promotion in hospital- have reduced risk of depression and cognitively
ized older adults; mental health (depression) and impairment 1 year after discharge [14, 15]. The
cognitive functioning need nursing attention and phenomenon of persistent morbidity and func-
health-promoting interventions as well. tional disability after hospitalization may be
Nevertheless, regaining older individuals’ labeled as a “post-hospital syndrome” and is
B-ADL function requires effective treatment of accompanied by impaired quality of life of older
the underlying conditions. Thus, a further decline people [69].
of B-ADL during and after hospitalization may Some care units are organized, and the staff
be due to ineffective treatment. Furthermore, the trained, to take care of acutely hospitalized older
294 A.-S. Helvik

adults. Geriatric care units have for long been functioning. Based in the screening results, ade-
known to support and maintain patients’ func- quate nursing actions can be provided.
tionality during hospitalization compared to reg- Furthermore, identifying an individual’s avail-
ular units [62]. Regardless of the hospital care able B-ADL-resources, possible support and the
unit or ward, health-promoting nursing should be individuals’ will is crucial. Use of screening
based in a person-oriented approach; this way of tools provides a joint framework of the interdis-
interacting with the individual supports the ciplinary hospital team for high quality treat-
patient’s independency and self-care resources, ment. Consequently, such screening tools will
increases hope, meaning, and resilience and not go out of fashion [50].
thereby facilitates B-ADL performance from Several screening tools assess B-ADL, both
admission to discharge [70, 71] (see also short inventories and longer more complex ver-
Theoretical section). This may, in addition to a sions exist [75–78]. Such tools have shown to
well-planned discharge, contribute to well-being capture small but important changes in an indi-
and resilience over time. The Acute Care for vidual’s ability to perform B-ADL [50]. Lawton
Elders Unit (ACE) model [70] uses person-­ and Brody’s scale to assess ability self-care is
oriented care, applies a structured process includ- often used and is among the relatively shorter
ing interdisciplinary teams, and uses systematic tools that screen for B-ADL, such as personal
screening assessments of B-ADL following clini- hygiene, dressing, toileting, eating, and transfer-
cal guidelines to restore coping resources, resil- ring [75]. This tool is easy to use; a higher score
ience, and self-care [70], all of which are indicates higher B-ADL difficulties. In choosing
important for well-being and quality of life. a screening tool, whether the tool is fitted and
Three randomized clinical trials using ACE inter- validated for the language and culture of the spe-
ventions have found reduced B-ADL during hos- cific country should be considered [70]. The
pitalization and reduced risk of nursing home problem in some countries is not a lack of ade-
admission among those in ACE units, and fur- quate measures, but that there is no national
thermore, a somewhat lower cost of hospitaliza- agreement of which measure of B-ADL should
tion, due to shorter stay in the group randomized be used in ward units and hospitals. This dearth
to ACE units [72–74]. The ACE principles could makes it difficult to follow change in B-ADL for
be implemented to improve care of hospitalized individuals with several steps through their treat-
older adults, independently of which hospital ment chain. It also makes it hard to compare
ward or unit they are admitted to. A step toward change of B-ADL between institutions and care
including ACE principles is for nurses to be com- wards. A consensus about one appropriate tool to
petent in systematic screening of B-ADL. measure B-ADL may contribute to quality assur-
ance of treatment and to improvement of care
20.3.2.2 Systematically Screening over time.
of B-ADL Functioning
Systematically screening of B-ADL at admis-
sion, throughout the hospitalization and at dis- 20.3.3 Cognitive Functioning
charge of older hospitalized adults will uncover
areas of concern. Previously, the screening tools Decline in cognitive performance is commonly
most often were used in research studies, but linked to aging [79, 80]. The cognitive function-
clinical experience have shown that systemati- ing encompasses our ability to receive and pro-
cally use of B-ADL tools improves the quality cess information, remember, learning new stuff,
of nursing care. Nursing assessment is based in to organize information when we are thinking,
a systematic and joint framework to assess using a language and communicate, to write/cal-
change. This framework gives a good basis to culate/draw, have discernment, calculate dis-
minimalize B-ADL decline due to illness, treat- tances (spatial awareness), take initiative and
ment, and hospital stay, and to improve level of perform actions, thinking abstract, and to have
20 Older Adults in Hospitals: Health Promotion When Hospitalized 295

attention. The ability to have attention is also clinical state between normal cognitive aging and
affecting the above areas. dementia, and it precedes and leads to dementia
In cognitively intact older adults, an acute in many cases, but not always [89, 90]. Dementia
medical illness needing hospitalization may lead is a clinical syndrome causing long term and
to reduced cognitive functioning in the acute often gradually loss of cognitive functioning and
phase of the disease [81, 82]. The cognitive impairment in activities of daily living [91]. MCI
decline may for some patients be caused by delir- or dementia may not be diagnosed prior to hospi-
ium which is an organically caused decline devel- talization or recognized by the older adult him/
oped over a short period of time, typically hours her-selves or their next of kin. Despite that preex-
to days [83]. Delirium is a syndrome encompass- isting cognitive impairment among older adults
ing disturbances in attention, consciousness, and may contribute to an overall poorer outcome of
cognition [26]. Nurses’ knowledge and ability to the hospitalization, which is also related to an
observe cognitive function and signals of change increased risk of delirium [85, 86, 92], preexist-
are essential for the diagnostic process and treat- ing cognitive impairment and limited cognitive
ment. Treatment of delirium requires treatment resources are often unrecognized by the hospital
of the underlying disease processes [84]. Nursing staff [93]. The use of cognitive screening detect-
care is important to comfort the person with ing cognitive limitations and available resources
delirium and to avoid additional complications of might disclose vulnerability for delirium. Such
the disease. Those older adults experiencing screening provides information necessary for
delirium has an increased risk of mortality within adequate support and health-promoting actions.
12 months [85, 86]. In older hospitalized persons Dependent on the context and situation, health-­
with cognitive decline during the hospitalization, promoting actions could be to promote sleep and
but not delirium, the cognitive function may diurnal rhythm, to secure nutrition, to reduce the
improve after hospitalization and during the first stressors that may exist in the hospital environ-
year after discharge [81, 82]. In a health-­ ment and to minimize side-effects of treatment.
promoting perspective, it is vital to reduce stress Such health-promoting actions can reduce an
related to hospitalization, illness, and new envi- individual’s vulnerability concerning delirium
ronments. Health-promoting interactions may and cognitive decline.
contribute to reducing the risk of delirium and A Norwegian 1-year follow-up study assessed
reduced cognitive functioning, even if the medi- cognitive functioning among older adults without
cal illness and biological cause for the illness also cognitive impairment or dementia. They were
are important contributors to reduced cognition. screened using the Mini-Mental State
An increasing number of studies report that Examination (MMSE) [94] and all participants
older people hospitalized with stroke, heart fail- had a score found to be within the normal range
ure, lung disease, or surgery procedures, have an (MMSE 24–30) when discharged from a medical
increased risk for cognitive decline. A review hospital unit. Those hospitalized had a wide
suggested that the hospital processes may par- range of medical diagnoses. This study found
tially be responsible for the cognitive decline that older adults without any known or screened
during and after a hospital stay, beyond the effects cognitive impairment prior to discharge had a
of the acute illness(es) [87]. The health-­promoting significantly declined function 1 year after [15].
care philosophy and nurse-patient interaction aim A cognitive decline was found among those with
to facilitate coping and health resources and low normal cognitive functioning (MMSE
thereby supporting cognitive health and well-­ 24–26) as well as in those with high functioning
being during and after hospitalization. (MMSE 27–30) prior to discharge. ADL impair-
Also, some older adults have preexisting cog- ments, independent of basic or instrumental ADL
nitive impairment prior to the hospitalization activities, were associated with an increased risk
[88], including both mild cognitive impairment for reduced cognitive functioning 1 year after
(MCI) and dementia. MCI is an intermediate hospitalization. This finding was independent of
296 A.-S. Helvik

age, gender, and severity of the disease among older adults’ cognitive functioning when hospi-
those hospitalized [15]. In line with other studies talized. Most often, the screened areas are mem-
[87] this study demonstrated that cognitive func- ory (short term and working), attention,
tion is interrelated with ADL functioning. Hence, concentration, orientation, language skills, inter-
despite that some cognitive decline results from pret sense impressions, ability to follow simple
the actual disease, it is important to counteract instructions, and processing information [94, 97].
decline in the B-ADL functioning, also, among However, the different screening tools differ con-
those with normal cognitive functioning. Given cerning which cognitive areas they include. Two
that a normal B-ADL among older adults is commonly used screening tools are Montreal
linked to a better cognitive functioning 1 year Cognitive Assessment tool (MoCA) [97] and
after the hospitalization, the importance of main- Mini-Mental State Examination (MMSE) [94].
taining ADL functions seems apparent. MoCA is a suitable measure assessing persons
The risk of decline in B-ADL is increased in with mild cognitive complaints [97] and a mild
those with cognitive impairment compared to degree of dementia. The maximum sum score of
those without such impairment [12, 95, 96]. MoCA is 30 points, where higher scores indicate
Thus, it is essential to counteract limitation of a better cognitive functioning. A score between
B-ADL functioning due to hospitalization when 26 and 30 points indicates normal cognitive func-
the patient has cognitive impairment. The nursing tioning [97].
care planning needs to consider the disease, as The Mini-Mental Status Examination
well as both the physical and cognitive function- (MMSE) is frequently used to assess cognitive
ing resources. Health-promoting nursing utilizes functioning both for clinical and research pur-
the individual’s existing health resources to sup- poses. The MMSE is a 30-point scale, where
port well-being and health. In doing so, a care higher scores indicate a better cognitive function-
plan is a valuable tool. Also, information col- ing [10]. While used for screening purposes, a
lected by screening the patient’s cognitive func- score below 20 indicates cognitive impairment,
tioning will guide the health-promoting nursing whereas the interval between 20 and 24 indicates
care. Care actions should be based on the patient’s a mild cognitive impairment. Even so, the
resources, both while in hospital and when iden- reported cutoff points for abnormality have var-
tifying needs of assistance after discharge from ied considerably [98]. However, it is important to
the hospital. Screening of cognitive resources as be aware that the MMSE is not a diagnostic tool,
well as B-ADL functioning, aims to strengthen but a screening tool that indicates whether an
health resources, compensate for loss of func- individual’s cognitive functioning needs a special
tions, limit decline, and promote well-being. attention during the hospital stay.
After discharge each patient should be provided The most frequently noted disadvantage of
the best premises to cope at home, as well as the MMSE relates to its lack of sensitivity to
receiving care and support at home, in a rehabili- mild cognitive impairment [99]. Another disad-
tation unit or in a care facility. Summarized, vantage of the MMSE is that the score may be
screening of cognitive functioning represents a affected by demographic factors; age and edu-
fundamental basis for health-promoting care dur- cation exert the greatest effect [100]. In addi-
ing a hospital stay as well as in supporting the tion, the MMSE is protected by copyright and
individual to cope at home after hospitalization. authorized use of the test is linked to costs
[101–103] which has forced clinicians to use
20.3.3.1 Systematic Screening other tests [98]. Nevertheless, independently of
of Cognitive Functioning which screening tool one chose it is important to
A reliable assessment of patients’ cognitive func- gain knowledge and practice before the tool is
tioning cannot be based on a single clinical used in clinical settings or for research pur-
observation and/or the patient’s self-report. poses. The mentioned screening tools are easy
Therefore, it is important to routinely screen to use and implement; thus, utilizing such
20 Older Adults in Hospitals: Health Promotion When Hospitalized 297

screening tools provides a common understand- of sleep and proper nutrition during the hospital
ing and reference for cognitive functioning pro- stay are vital. Furthermore, existential and reli-
moting systematic care and treatment. gious needs might be actualized due to hospital-
ization and declining health. While hospitalized,
family and social resources available to support
20.4 Conclusion - Health-­ living at home after hospitalization needs to be
Promoting Assets mapped. Thus, it is imperative to prepare, plan,
and Actions and organize the transition to home or to a care
home in advance of the discharge. However,
Older adults are often vulnerable for complica- these areas are not covered in this chapter.
tions and loss of coping resources when hospital-
ized. While facing physical disease, good coping Take Home Messages
resources such as sense of coherence and trusting • Depression is a frequent cause of emotional
one’s coping capacity is important for well-being suffering in old age causing negative health
and perceived health [17]. Thus, care supporting consequences.
both improvement of the medical condition con- • Unrecognized and untreated depression may
tributing to the hospitalization and coping obstruct health promotion, thus, uncovering
resources is important. depressive symptoms using valid screening
In this chapter, we have been looking at three tools is important.
factors related to high age that are contributing to • In older adults, a hospitalization increases the
vulnerability when hospitalized: depression, risk for decline of physical functioning and
B-ADL decline, and cognitive impairment. These ADL.
conditions limit coping resources, well-being, • Based in a holistic understanding of health,
and health. the older individual’s situation, available
Clinically significant depressive symptoms resources and capacity to support self-care
need to be uncovered and treated, if not they may and ADL must be assessed, and actions
have negative consequences for the treatment, taken to sustain ADL functioning during
cognitive functioning and B-ADL functioning. hospitalization.
Thus, a general assessment should preferably • In older adults, an acute medical illness need-
include screening of depressive symptoms. ing hospitalization may lead to reduced cogni-
Older adults in needs of assistance to ensure tive functioning in the acute phase of the
B-ADL functioning, such as personal hygiene, disease.
toileting, walking, eating, etc., should be given • Limited cognitive resources are often unrec-
assistance supporting present resources and abili- ognized by the hospital staff if not screened
ties. To do so, the health professionals need to for.
observe the level of functioning and develop a • Common understanding of available cogni-
plan for how they can support the patient’s health tive, mental and physical resources in older
resources and compensate for lacking abilities. adults may contribute to a systematic approach
The utilization of tools assessing cognitive to care in a health-promoting way.
functioning, depressive symptoms, and B-ADL
functioning will equip health professionals with a
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20 Older Adults in Hospitals: Health Promotion When Hospitalized 301

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 Sociocultural Aspects of Health
Promotion in Palliative Care
21
in Uganda

James Mugisha

Abstract Research should be conducted on the effec-

tiveness of the current strategies on health pro-
Despite its vital importance, health promo-
motion and palliative care and their cultural
tion has not occupied its due place in public
sensitivity and appropriateness. Given the
health in Uganda. The country is engulfed into
limited resources available for development of
a rising wave of both communicable and non-­
health care in Uganda, as an overall strategy,
communicable conditions. This rising burden
health promotion and palliative care should
of both communicable and non-­communicable
be anchored in public health and its (public
conditions turns health promotion and pal-
health) resources.
liative care essential health care packages;
though there is little to show that these two
Keywords
important programs are getting vital support
at policy and service delivery levels. A new Social aspects · Salutogenesis · Health
theoretical framework that is anchored into promotion · Palliative care · Uganda
sociocultural issues is essential in guiding the
design and delivery of both health promotion
and palliative care in Uganda. The salutogenic
theory puts socio-cultural issues at the centre
21.1 Background
of developing health promotion and palliative
care and, seems to solve this dilemma. In this
There is a dramatic shift in low-income coun-
chapter, illustrations from indigenous com-
tries from communicable to non-communicable
munities in Uganda are employed to demon-
diseases [1–3]. As noted, by 2030, the burden of
strate the challenges to the health promotion
non-communicable diseases, including neuropsy-
and palliative care agenda in the country and
chiatric disorders, will constitute seven of the ten
how they can be addressed. Uganda Ministry
leading causes of disease burden globally and its
of Health should develop robust structures
impact will be more felt in low-income countries
within public health for development of health
where health systems are more fragile as compared
promotion and palliative care in the country.
to the ones in high-income countries [1, 4, 5]. It
is estimated that within a generation, the share of
J. Mugisha (*) disease burden attributed to non-­ communicable
Faculty Arts and Social Sciences, Department of diseases in some poor countries of the world
Sociology and Social Administration, Kyambogo will exceed 80%, rivalling that of rich countries
University, Kampala, Uganda

© The Author(s) 2021 303

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_21
304 J. Mugisha

[3]. And, this burden is likely to affect more the those who are able to actually receive it [12]. At
younger generation in poorer resource contexts present, only a few countries have any form of
than in the high-income countries [3]. palliative care program and this gap may be
The most prevalent globally of these non-­ larger in Africa [7]. There are no obvious strate-
communicable conditions are: cardiovascular gies to meeting this need due to already over-
diseases, cancers, chronic respiratory disease and stretched health systems in low-income countries
diabetes [6]. And, a similar trend seems to be and the ever-increasing political dilemmas (such
unravelling in Africa [6]. Globally, it is estimated as political turmoil and mismanagement) that
that these conditions, contribute to large mortal- affect service delivery.
ity, accounting for 36 million deaths in 2008 Suggestions have been made that public heath
(63% of total fatalities) [7]. Majority (four-fifths) can effectively work in tandem with palliative
of these deaths occur in LMICs [7]. It is also care [13]. It is possible for public health to enter
­estimated that, if these trends go unchecked (as it deeply into palliative care narratives and estab-
is the case in most LMCs), by 2030, deaths due to lish strong relationships to improve the current
NCDs will be the most common causes of mor- service delivery mechanisms of both programs
tality in low-income countries. More specifically, (public health and palliative care) [13]. The
diabetes cases in sub-Saharan Africa are pro- essence here is using a public health approach in
jected to increase from 4.8% prevalence (19.8 palliative care. This presupposes fundamentally
million) in 2013, to 5.3% (41.5 million) in 2035 building community capacity to own and work
(IDF, 207). In the same vein, cancer cases are on its health issues. Such approaches have large
also projected to nearly double (1.28m new cases benefits of being cost effective, empowering;
and 970,000 deaths) by 2030 (in 2012 there were improve coverage of services to the general pop-
645,000 new cases and 456,000 cancer-related ulation and are sustainable [13]. All that is needed
deaths in Africa) [8]. The most obvious risk fac- is conceptual clarity [13]. The revised WHO defi-
tors are a combination of increasing and ageing nition of palliative care is anchored into public
populations, the adoption of risk-factor lifestyles health and seems to take care of these concerns
(largely due to sedative life style), and deficient [13]. Palliative care is defined as:
diagnostic, preventative and curative treatment Palliative care is an approach that improves the
services [9]. quality of life of patients and their families facing
Unfortunately, in many of the low-income the problems associated with life-threatening ill-
countries that have started to witness this shift, ness, through the prevention and relief of suffering
by means of early identification and impeccable
the health system is not prepared enough to deal assessment and treatment of pain and other prob-
with this challenge [2, 3]. Many of the non-­ lems, physical, psychosocial, and spiritual
communicable conditions are chronic in nature (Whitelaw and Clerk [13], p. 4).
necessitating the need for a fundamental repro-
graming of the public health sector and palliative The notion of prevention and early detection
care. of suffering is highlighted in this definition and is
key to the public health agenda. This understand-
ing did not get the due emphasis in the previous
21.2  he Public Health
T public health efforts [13]. Current public health
and Palliative Care Context efforts should have a new outlook that focuses on
in Africa a comprehensive person with psychical, psycho-
social and spiritual needs.
The need for palliative care in low-income coun- Taking as comprehensive approach to health
tries in general and Africa in particular is already service delivery demands for a lot of resources. In
overwhelming [10, 11]. Evidence is available many low-income settings however, public health
that there is a large gap between the number of has relatively compelling volume of resource as
people in need of palliative care services and compared to other sectors and these resources
21 Sociocultural Aspects of Health Promotion in Palliative Care in Uganda 305

could be used in shaping the future direction of the chapter will be salutogenesis though positive
palliative care policy [2, 13]. Deep reflections are psychology, which is also of much relevance
needed here to create a secondary deployment here. The originator of salutogenesis (Aaron
(where palliative care is “infused” into public Antonovsky) described health systems in the
health) to create better synergies [13]. Moreover, Western world as “pathogenic” [16]. His descrip-
within this new thinking, the need for palliative tion seems to be of much relevancy to the health
care should be understood as a public health issue systems in the developing world such as Uganda.
[13]. This evidence (of infusing palliative care into Simply put, Antonovsky [17] referred to this mal-
public health care) is already available in some aise in the health system as “disease care system”
countries; though still in a few of them [13]. ([17], p. 12). His perspective is a sharp opposi-
tion to the pathogenic orientation, which is domi-
nant in Western medical thinking [18].
21.3 Health Promotion “Antonovsky rejected a dichotomous categorisa-
and Salutogenesis: Concepts tion of the health status (e.g., well vs. diseased,
and Theory healthy vs. ill as inappropriate) to represent the
complexity of health status” [18]. His view was
The concept health promotion has had more exten- that health is more reasonably understood as a
sive use in the developed world as compared to the continuum; every person is at a given point in
low-income countries. Health promotion in Africa time somewhere between health and disease
in general and Uganda in particular is not well poles in the continuum [18]. In this regard, he
articulated in the public health agenda. In this coined the “construct of generalised resources
chapter we shall adopt the World Health against stress” (which is defined as a property of
Organisation (WHO) definition of health promo- the person, a collective or situation which, as evi-
tion: “Health promotion is the process of enabling dence or logic has indicated, facilitated success-
people to increase control over, and to improve, ful coping with inherent stressors of human
their health” [14]. The biggest challenge for health existence” ([17], p. 15; [18], p. 326). Related to
promotion in Africa and Uganda in particular has this the construct of “sense of coherence”, which
been: (a) lack of frameworks and models for clas- is a generalised orientation towards the world,
sifying activities and determine the scope of health which perceives it, on ease/health continuum, as
promotion [15] and, (b) most people in Africa have comprehensible, manageable and meaningful
poor health status and therefore it is difficult to ([17], p. 15). “When confronted with a stressor,
sustain development and economic viability of people with a strong sense of coherence are likely
most health programs [2]. Due to the above-men- to be motivated to cope (meaningfulness), to
tioned challenges, to a larger extent, most coun- believe that coping resources are accessible”
tries in Africa have had their focus on curative (manageability) [18]; also see Antonovsky [17].
care, they have minimal resources to satisfy this This thinking is useful for those at the dyeing
sector (curative sector) and because of this reason, stage of their life.
health promotion has been forgotten. Since hospitals are traditionally characterised
by an orientation to diagnosing, curing and car-
ing for severely ill people [19] they have a limited
21.4 Salutogenesis in Health contribution to the public health agenda. This
Promotion and Palliative understanding calls for new frameworks for
Care in Uganda: Theoretical health promotion and palliative care in Uganda.
and Status Issues The curative approach fails to recognise that
death, dying, loss and care giving exist to some
Within the field of health promotion, perspectives extent beyond the domains of individualistic
have emerged. Some of these include positive therapeutic intervention and a public health care
psychology and salutogenesis. The interest in this approach brings better results [13]. It requires the
306 J. Mugisha

reorientation of health services in Uganda into Though Uganda is getting more urbanised
more public health and health promotion (over 76% of the Ugandans live in rural area), the
domains; as demanded by the Ottawa Charter influence of culture (and tradition) is still so
[14]. This has not happened to a remarkable strong among indigenous communities in
degree yet in many countries. Uganda. Health promoters have to manage diver-
sity; the patient, family and the community where
they live [24]. The cultural values of the patient
21.5  he Cultural Context
T and family within the locations/contexts must be
and Issues Related to Death given attention [24]. Uganda is quite cosmopoli-
and Dying in Uganda tan in terms of tribes (over 50 tribal groupings),
age, gender and other socioeconomic variables.
21.5.1 Meaning of Death In many of the societies, health promotion and
palliative care should pay attention to these mul-
During the dyeing process, many people within tiple components including race, ethnicity, gen-
indigenous communities are preoccupied with the der, age, differing abilities, sexual orientation,
meaning of Good Death. Drawing from sociality, religion, spirituality, and socioeconomic status
good death culturally means dying while sur- [24]. The beliefs, norms and practices should be
rounded by people, especially, your children, the target of the health promotion activities as
wives(s) and close relatives. Though having less they are likely to guide behavioural responses,
pain is part of good death this is not the most impor- decision-making and action and other key vari-
tant consideration of good death as emphasised by ables related to acceptability of health promotion
modern health workers. In our study in Mpigi [20], and palliative care.
we saw our informants having a negative attitude
against long periods of hospitalisation that are nor-
mally synonymous with chronic diseases (also see 21.6 Aetiology and Cultural
[20, 21]). Long stay in hospital is seen as affecting Frameworks
sociality since the patient is normally away from
his/her children, spouse and close family members. Within the salutogenic theory, existential issues
What was evident from the narratives expressed by are given due attention. One goes into meaning
people in our project in Mpigi is that the cultural making, contact inner feels in order to mobilise
conception of death was different from the “scien- generalised resources. The subjective experience
tific view” of good death and this has implications of diseases such as cancer and HIV/AIDS is cul-
on the way health promotion and palliative care tural based [25]. They are cognitively and lin-
should be delivered. Searching for meaning in life is guistically expressed within cultural frameworks
part of the salutogenic approach and this makes it and therefore the medical model (pathogenesis)
important for any health service to focus on the sub- becomes less meaningful to those afflicted by
jective experience of the people targeted. Within disease. Among indigenous communities, causal-
salutogenesis, it is postulated that there is a connec- ity of disease is largely attributed to external fac-
tion between spirituality (religion and meaning tors or different aspects in the natural environment,
making) and health. Within salutogenic and the both living and/or non-living [25]. Studies under-
health promotional framework, dimensions of taken in the field of mental health indicate that
health are referred to in terms of the physical, men- over 80% of the people in Uganda seek help from
tal, social and spiritual; a notion of huge relevance spiritual/traditional healers [20, 26, 27]. Because
to health and palliative care programs in Uganda of the differences in perspectives between mod-
[22, 23]. This calls for comprehensive and inte- ern and traditional healers, there develops polar-
grated programs that can address physical, mental, ised relationships between the two (modern and
social, and spiritual aspects of human functioning traditional healers). This polarisation normally
and, these are inextricably intertwined. delays appropriate treatment seeking:
21 Sociocultural Aspects of Health Promotion in Palliative Care in Uganda 307

Cancer is about a neighbour who might not be directly. Instead, they circumvent around its
happy with your achievements. The medical stories
don’t make sense to our people and that is why they
(death) meaning using their oral skills. In our
keep home till death (Personal Communication, study in Mpigi among indigenous communities
Anthropologist Makerere University Medical in Uganda (see [19, 20]), our research topic was
School). on the meaning of completed suicide. We as
researchers were not born in this culture and
There is always a failure by the health system never knew that “Baganda” do not refer to death
to undertake a meaningful co-construction directly. Once we did that cultural tension
between the patient, the family, the traditional emerged. Death as a subject cannot easily be
healers and the modern health systems. The pal- avoided in palliative care. However, discussing it
liative care and health promotion field fail to deal among indigenous communities must be done
with medical domination of the traditional sys- with a lot of cultural sensibility [20]. In our proj-
tem. Many of the people they are targeting within ect, we adapted the concepts that could mean
indigenous communities have existential needs death but less offence to culture and tradition
for which they have little trust in the modern (see [19, 20]). This experience is of high rele-
health system. With the salutogenic field, it is vance to the current health promotion and pallia-
postulated that the way people view themselves tive care workers in Uganda.
and the world has implications for their health
and more importantly, their quality of life. Hence,
the need to shift attention to the subjective expe- 21.6.2 Masculinity and Help Seeking
rience of the people and to change their existing
perspectives to health care. We cannot afford to Society always sets different expectations for
ignore the backyard issues that seat at deepest men and women [20]. The cultural meaning of a
part of people’s values and belief systems. Our “real man” sets expectations that men even under
study in northern Uganda; the Wayo-Nero great pain should undertake controlled emotional
Strategy (https://www.mhinnovation.net/innova- expression (should suppress pain inwards) (see
tions/wayo-nero-strategy) aimed at reducing the [19, 20]). But this may again come with other
treatment gap for mental disorders by utilising risks as the pain may become more severe;
indigenous institutions in post-conflict areas. patients may become depressed or traumatised
Many people targeted in the three districts in by diseases among other risks [20]. Culturally,
northern Uganda were able to access services accepting uncontrolled emotional expression is
using this strategy. The Wayo (aunti)-Nero turning into a “woman”. The most obvious chal-
(uncle) are traditional counsellors and their ser- lenge with masculinity in this context is that it
vices were harnessed to deliver modern health limits sharing of information between the client
care but also spiritual care. This made the inter- and the palliative health care worker because of
ventions more acceptable to the people since we the high possibly of normalising pain; one has
were using a cultural resource. to be a man. The man is expected to be tough
and this has to be demonstrated even in situations
of great pain. Interestingly, strict adherence to
21.6.1 Communication About Death masculine norms in indigenous communalities
is rewarded by society with respect before and
The subjective experience of diseases such as after death. “The man is praised for being a man
cancer and HIV/AIDS is culturally based [25]. and not a woman and that means keeping quite
They are cognitively and linguistically expressed over most of the pain” (Personal Communication
within cultural frameworks. Again in our with Senior Lecturer Anthropology Makerere
research work in Mpigi, we see a challenge University). Too much emotional outpour is cul-
where indigenous communities have great fear turally disrespected and only expected of women.
and respect for death and never refer to death “For a woman it is ok to cry before the public
308 J. Mugisha

but for the man you are expected to do other- malaria campaigns at community level. Though
wise” (Senior Lecturer Anthropology Makerere palliative care has exploited some of the commu-
University). nity leaders attached to the HIV/AIDS programs,
Masculinity also comes with a belief in self-­ this has been undertaken to a limited extent and
reliance, the need to do things by yourself and many of them have not been trained in pallia-
these trends can be seen in urban areas where tive care as a methodology. In many communi-
communalism has lost grip on society and there ties in Uganda, there are no community-­based
is more individualism. In our study in Mpigi palliative care workers despite the program
[20], we established individualistic traits in having a national coverage. “The coverage of
urban areas where people are more inclined to community workers is still marginal and needs
self-­efficacy. Researches in mental health indi- to be addressed. And many of them lack the
cated that, those inclined to masculine ideology core palliative care skills and health promotion.
and, have strong individualistic construes rarely HIV/AIDS is not necessarily palliative care”
seek formal health care. Palliative care to them (Personal Communication, Lecturer Palliative
has a connotation of communalism-sharing your Care Kyambogo University, Uganda).
problems with others. “Yah, there are those who In our Wayo-Nero Mental Health Care Project,
want to die with their private life and the way our we managed to bridge the treatment gap for com-
palliative care is structured with several nurses mon mental disorders using the Wayo (aunt)-
and village health workers, it cannot work for Nero (uncle) as traditional institutions (https://
such people” (Lecturer Social Work Kyambogo www.mhinnovation.net/innovations/wayo-nero-
University). strategy). The Wayos and Neros used their influ-
ence as cultural leaders to deliver the program
including health messages. There are lessons to
21.6.3 Community Gate-Keeping learn from the Wayo-Nero project by the health
and Health Promotion promoters in palliative care in Uganda in increas-
ing addressing sociocultural issues in health.
Most studies largely undertaken in the developed
world have looked at the notion of gatekeeping
in terms of research-the structures, which the 21.7 Looking at the Future
researcher(s) has to deal with to access potential
respondents for the study [20]. In this study I take The salutogenic field provides an important
a different view. I look at gate-­keeping agencies theoretical framework for health promotion in
as community structures, which the program has Uganda. “Africans are notoriously religious, and
to deal with to access clients [20]. In indigenous each people has its own religious system with a
communities, cultural institutions/structures are set of beliefs and practices” [32]. Mbiti further
the custodians of culture and play a major role observed that “religion permeates into all the
in its survival [20]. They also play a major role departments of life so fully that it is not easy or
in the survival of community members including possible always to isolate it” [32]. And most of
infirmities that might befall individuals, fami- the time African people are entangled in both
lies or the larger community and they are always modern and traditional religious systems [20,
called upon when negative life events befall a 32]. Quite more modern religious writers such
community [28]. Many of the cultural leaders as Gyekye [33] observed that African heritage is
are at the same time the political leaders of the intensely religious. “The African lives in a reli-
community as they play multiple roles [29, 30]. gious universe: all actions and thoughts have a
Several studies conducted in Uganda indicated religious meaning and aspired or influenced by
that they increase acceptability and coverage of a religious point of view ([33], p. 3). The views
community programs [29, 30]. They have been expressed above by the two African writes Mbiti
instrumental in popularising HIV/AIDS [31] and [32] and Gyekye [33] though have been in print
21 Sociocultural Aspects of Health Promotion in Palliative Care in Uganda 309

for a while still largely represent the religious Unfortunately, many Ministries of Health in
systems of African people. They indicate the reli- Africa and this is also the case with Uganda lack
gious standpoint of African people and any effec- a health promotion structure [15]. As noted these
tive program should address their spatial needs Ministries always have an IEC Unit, perform tra-
[20]. There is a possibility to use the current ditional health education functions and not tied to
cultural resources (both modern and traditional) the overall global framework of health promotion
to improve public health and the delivery of [15]. Health promotion should not be seen as an
health promotion and palliative care. HIV/AIDS, added cost but as a cost saving strategy (espe-
malaria and other communicable diseases have cially when one focuses on disease prevention,
attracted quite a lot of resources from the donor patient empowerment and community manage-
community. Some of these resources can be used ment and participation).
to develop a national framework for delivery of Research should be undertaken to establish
health promotion and palliative care in the coun- the cost and effectiveness of health promotion
try. Indigenous (e.g. spiritual healers and herb- activities that are part of the health promo-
alists) and modern cultural (e.g. churches and tion and palliative care agenda currently and
church leaders) resources could be tapped into to in future [35]. Government agencies such as
deliver both health promotion and palliative care universities and especially schools of Public
more effectively and with a high level of cultural Health should take leadership in this. The World
acceptability. Drawing again from our saluto- Health Organisation’s Ottawa Charter for Health
genesis framework, these historical roots that are Promotion from 1986 is still the gold standard
embedded on religion and religious associations for health promotion worldwide [36]. Academic
have implications in strengthening the members institutions (though none exists in Uganda) can
of these societies in their sense of coherence set up centres of excellence on health promotion
[34]. Cultures seem to define the resources that to foster critical thinking about health promo-
are appropriate to deal with a stressful situation tion in the country. They can also ensure that the
[34]. The cultural context is likely to shape the gold standard envisaged in the Ottawa charter is
type of the stressor experienced by the individual engendered though this has to be done with cau-
and also the choice of appraisal and coping strat- tion [15]. The Alma Ata Declaration is deemed
egy employed [34]. The spiritual/religious social more impactful on the continent due to its strong
networks can be important sense of community focus on primary health care [15] while the
coherence. Ottawa conference is quite lacking in this since
The Ottawa conference in 1986 called for its focus was more on industrialised countries.
reorientation of health services. It was further It has argued that that there is a possiblity for
observed that there has been slow progress in the two instruments (Alma Ata Declaration and
making health promotion a core business for Ottawa Charter) to cross-fertilise each other. The
health services and there was a need to reframe, Alma Ata Declaration can be used for compre-
reposition and renew efforts in this field [35]. hensive primary health care while the Ottawa
Part of these efforts includes being more active in Charter can be more useful in tacking the dou-
health systems development [35, 36]. This slow ble burden of emerging non-communicable and
development is more felt in Africa and Uganda in communicable diseases [15]. This also requires
particular. The Uganda Ministry of Health needs changing the political will and ideology in many
to make pragmatic steps in making health promo- countries [36].
tion a priority sector within the ministry. This is While local government are rich in local con-
more critical today with the aging of the popula- text which can improve the cultural sensitivity of
tion in Uganda and the rising impact of chronic their programs, they at the same time lack the
diseases in the country [35]. New policies and required resources especially funds to deliver
budget frameworks that are sufficient and effi- public health interventions [15]. However, a
cient should be developed and operationalised. public-­private partnership can boost the amount
310 J. Mugisha

of resources available at the local government agenda should be based on communalism rather
level (Alma Ata Declaration). than an individualist Eurocentric health promo-
Overall, efforts should be made to ensure that tion discourse and practice [15]. This think-
health promotion is embedded into all aspects ing does not serve to connote that there should
of life, including home, work leisure and within be only an African public or health promotion
health care [36]. A special focus on the social agenda. However, it is an attempt to look at pub-
aspects of health promotion and palliative care lic health and health promotion in Africa with
makes this agenda feasible. Watson [37] sug- contextual eyes, cultural sensitivity and lastly in
gested that those involved in health promotion its own right.
should ensure: (a) creation of a healthy working
environment (c) integrating health promotion into
daily activities and (c) reaching out into the com- 21.8 Conclusion
munity. The crosscutting theme in all these three
aspects is culture and social aspects of health Uganda’s quest for palliative care national wide
promotion, becomes an important theme. Given is based on false premises and constitutes a cate-
the limited resources in Uganda, it might be dif- gorical fallacy. The current model spearheaded
ficult to work with all units in the health sector at by hospitals to deliver health promotion and pal-
the same time. However, we could go piecemeal liative care misses the critical components that
until all vital units in the heath sector are covered. are vital in this field. Individuals and families are
Even in the developed countries, these variations not empowered to take charge of their health
exist despite having a relatively larger volume of needs and resources to support care. The saluto-
resources. Hospitals still take a lion’s share of the genic theory takes care of these dilemmas and
Uganda health sector budget and primary health takes health promotion and palliative care into
care where much of the health promotion takes communities. The existing resources for public
place is still neglected. This should be reversed. health in Uganda should be synergistically tapped
The words of John Catford are also very informa- into to develop health promotion and palliative
tive here, “We look in eager anticipation to see care through a community based model.
how Africa moves ahead in closing the imple-
mentation gap in health promotion…Although Take Home Messages
Africa may light the way, the rest of the world • The need for palliative care in Uganda
will also need to shoulder the task” ([35], p. 3). and other low-income countries is real and
These words have been interpreted to imply that growing.
the international community should play a major • The existing medical model(s) that have his-
role in helping Africa to close the gap in health torically informed the development and deliv-
promotion [15]. While understanding is impor- ery of health service in Uganda are faced with
tant, the Western world should not transpose insurmountable challenges and therefore there
health promotion packages from their countries is need for a paradigm shift.
as it normally happens with many of the devel- • Culture stands in the road to providing effec-
opment assistance programs in the health sector tive palliative care and this challenge should
[15]. As noted, high-income countries differ a lot be addressed through designing programs that
from low-income countries in key aspects espe- are culturally sensitive and acceptable to indi-
cially in their individualist/communitarian orien- viduals and communities.
tations [15]. A home grown package that takes • Uganda Ministry of Health needs to move
into account the social aspects in health promo- away from tokenistic approaches to health
tion and palliative care should be developed and promotion and palliative care to comprehen-
propagated. As seen in our findings, communal- sive programs. Health promotion and pallia-
ism is still the mainstay in social organisation of tive care should be accorded their due right-not
our study communities. The health promotion to remain small units in the health education
21 Sociocultural Aspects of Health Promotion in Palliative Care in Uganda 311

sector at the Uganda Ministry of health but 12. Hawley P. Barriers to access to palliative care. Palliat
Care Res Treat. 2017;10:1178224216688887. https://
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 Health Promotion Among Home-­
Dwelling Elderly Individuals
22
in Turkey

Öznur Körükcü and Kamile Kabukcuoğlu

Abstract increase reveals the importance of health-­

promoting practices in elderly care, which are
Although the social structure of Turkish society
important for the well-being and quality of life
has changed from a broad family order to a
of older individuals and their families, as well
nuclear family, family relations still hold an
as cost effectiveness. In Turkey, the emphasis
important place, where traditional elements
on health-promoting practices is mostly
dominate. Still, elderly people are cared for by
focused in home-care services including
their family in their home environment. Thus,
­examination, treatment, nursing care, medical
the role of family members is crucial in taking
care, medical equipment and device services,
care of elderly individuals. In Turkey, the
psychological support, physiotherapy, follow-
responsibility of care is largely on women; the
­up, rehabilitation services, housework (laun-
elderly’s wife, daughter, or daughter-in-law
dry, shopping, cleaning, food), personal care
most often provides the care. Family members
(dressing, bathroom, and personal hygiene
who provide care need support so that they can
help), 24-h emergency service, transportation,
maintain their physical, psychological and
financial advice and training services within
mental health. At this point, Antonovsky’s salu-
the scope of the social state policy for the
togenic health model represents a positive and
elderly 65 years and older, whereas medical
holistic approach to support individual’s health
management of diseases serves elderly over
and coping. The salutogenic understanding of
the age of 85. In the Turkish health care sys-
health emphasizes both physical, psychologi-
tem, salutogenesis can be used in principle for
cal, social, spiritual and cultural resources
two aims: to guide health-promotion interven-
which can be utilized not only to avoid illness,
tions in health care practice, and to (re)orient
but to promote health.
health care practice and research. The saluto-
With the rapidly increasing ageing popula- genic orientation encompasses all elderly peo-
tion globally, health expenditures and the need ple independently of their position on the
for care are increasing accordingly. This ease-/dis-ease continuum. This chapter pres-
ents health-promotion practices in the care of
elderly home-dwelling people living in Turkey.
Ö. Körükcü (*) · K. Kabukcuoğlu
Faculty of Nursing, Department of Obstetrics
and Gynecological Nursing, Akdeniz University, Keywords
Antalya, Turkey
e-mail: oznurkorukcu@akdeniz.edu.tr; Elderly in Turkey · Elderly care · Health
kkamile@akdeniz.edu.tr promotion · Home-dwelling individuals

© The Author(s) 2021 313

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_22
314 Ö. Körükcü and K. Kabukcuoğlu

22.1 Introduction in old age provides a familiar environment within

which to contend with the challenges and changes
Exercising, quitting smoking, limiting alcohol to lifestyle that occur due to the ageing process
consumption, participating in learning and physi- [8]. Social support, i.e., from the family, is one of
cal activities, and being included in the commu- the generalized resistance resources (GRRs)
nity as well as preventing losses of functional against stress that in turn contributes to the devel-
capacity improve the quality of life and prolong opment of a strong SOC [7]. In the Turkish soci-
people’s longevity [1–3]. Longer life is a valu- ety, this means that elderly living together with
able resource that provides the opportunity to their families have access to social support when
reconsider not only what older age might be, but facing life challenges. This represents a health-
how our whole lives might unfold [4, 5]. promoting resource for the elderly, as well as for
Therefore, the decade of 2020–2030 has been their family.
declared as the “healthy ageing decade” by the On the other side, although it is a priority for
World Health Organization (WHO) involving the the elderly to live in a society without being iso-
importance of a healthy lifestyle at every stage of lated from their own living environment, caring
life [6–9]. After WHO emphasized the impor- for elderly at home can also be experienced as a
tance of health-promoting practices for all ages, burden. A large part of the Turkish population
people have increasingly begun to understand considers elderly care as a duty [1]. The burden
that a healthy lifestyle is important also among of care is largely on women; the wife, daughter,
older people [5, 6, 9–11]. In many high-income or daughter-in-law most often provide the care
countries, elderly people are spending their needed [2, 12]. This can be a demanding life situ-
“extra years” in innovative and healthy ways, ation to the caregivers. Knowledge of a person’s
such as a new career, continuing education, life-­ SOC might be one possible way to identify those
long learning programs or pursuing a neglected who may be more vulnerable to stressful situa-
passion, while the understanding of health pro- tions. Further, a strong SOC is related to quality
motion still is in its infancy in developing coun- of life, indicating that perceiving one’s life situa-
tries [5]. Turkey, as a developing country, slowly tion as comprehensible, manageable, and mean-
moves toward the transformation from a patho- ingful influences on family members’ coping
genic or disease-oriented paradigm to a paradigm strategies in care of older people [11]. SOC is a
integrating pathogenesis and salutogenesis high- global orientation that expresses the extent to
lighting how to promote people’s health. That is, which one has a pervasive, enduring though
a health resource-oriented paradigm. dynamic feeling of confidence that (1) the stimuli
Antonovsky [4] developed the concept of deriving from one’s internal and external envi-
sense of coherence (SOC) representing a per- ronments in the course of living are structured,
son’s confidence in having the resources needed predictable and explicable; (2) the resources are
to cope with challenges. SOC is linked with per- available to meet the demands posed by these
sonal strength and a person’s ability to cope in stimuli, and (3) these demands are challenges,
difficult situations [4, 8]. The first implication of worthy of investment and engagement ([7],
adopting a salutogenic health orientation is the p. 19). In this chapter, importance of the health-­
rejection of the dichotomy posited by a patho- promoting practices for elderly people staying at
genic paradigm: stating that people are either home in Turkey are presented and discussed.
sick or healthy [4].
Despite the changes in the social structure of
the Turkish society, family relations still hold an 22.1.1 Aging in Turkey
important place, where the traditional family
structure prevails [1]. Thus, many older people In the twenty-first century, we now face a signifi-
still live at home and only a small number of cant demographic shift towards an aging
elderly adults are staying in Turkish nursing ­population in Turkey and worldwide [9]. Aging,
homes [2]. Being able to continue living at home which has been more prominent in developed
22 Health Promotion Among Home-Dwelling Elderly Individuals in Turkey 315

countries, is now gaining importance also in the family, increasingly are perceived as a “bur-
developing countries; in Turkey, the older den” to the family, causing the elderly to feel
­population is gradually increasing. While the per- insignificant and lonely [4, 7].
centage of population over the age of 65 in In some ways, elderly people living in rural
Turkey was 8% in 2014, it is estimated to be areas in Turkey have a greater need for health-­
10.2% in 2023, 16.3% in 2040, 22.6% in 2060 promoting support compared to those living in
and 25.6% in 2080 [10]. Life expectancy at birth urban areas [16]. Especially in villages, old peo-
in 2020 was 73 years for men and 78 years for ple who are physically frail might be unable to
women in Turkey. According to the Turkish conduct the needed work at the farm for different
Statistical Institute (TÜİK), the population aged reasons; consequently, they are not able to earn
≥65 was 5.7 million in 2012; this number will money. Due to the migration of young people to
rise to 8.6 million in 2023, 19.5 million in 2050 the cities elderly people are left alone in villages.
and 24.7 million in 2075 [9, 10]. Due to the As a result, agricultural areas remain idle. Since
increasing rate of elderly people, from 2009 the elderly people are unable to produce as they
Turkey has established a pro-natalist population did before, they tend to buy ready-made products
policy to increase the rate of young people in [7]. Due to population shortage, existing estab-
society; the social importance of having three lishments (grocery, mill, coffee, etc.) and health
children or more is emphasized [7, 9]. institutions (health centers) are closing, public
Social and cultural factors represent the basis transport and flights are limited in the rural areas.
for the perception of elderly care at home as the Initially, the elderly who remain in the village
“basic duty of family members” [11]. Therefore, become dependent on their children, relatives,
those who care for family members need to be and neighbors, i.e., their environment, for their
supported and directed to maintain their physical many socioeconomic needs [7, 8].
and mental health [12, 13]. Salutogenic strategies With age, the prevalence of chronic diseases is
represent health promoting approaches of sup- increasing [17]. In recent years, researches and
porting families and reducing the care-giving public health practices have shown that chronic
burden. Health is a human right. Thus, health diseases can be prevented in elderly individuals
promotion and health protection depend upon the and their need of social and medical service can
promotion and protection of human rights and be reduced [14, 17, 18]. However, health promo-
dignity [13]. Healthy aging seems to be achiev- tion is still a relatively unfamiliar concept for
able to a certain extent if the older individual can health professionals. The most important way to
maintain or promote a strong SOC [4]. fight chronic diseases in old age is successful
Prior to the 1950s, the dominant family type aging and health-promoting activities and/or pro-
was large families due to the patriarchal social grams [14]. Successful aging is understood not
structure in Turkey [14]. However, during the only in terms of good physical health, but also
recent years the socioeconomic and technologi- psychologically and socially well-being [13]. Life
cal developments have accelerated a shift toward length, biological and mental health, cognitive
nuclear families. Resulting from changes in the and social competence, productivity, personal
social structure of the Turkish society, rural-­ control and enjoyment of life are common indica-
urban migration has increased since the 1950s; tors of aging successfully [9, 14, 18]. In this con-
young people move to urban areas, whereas the text, successful aging means keeping the social
elderly remain in rural areas. Hence, the issue of environment and relationships alive while prepar-
elderly care has begun to emerge also in rural ing oneself for old age, taking preventive mea-
areas [7, 15]. This migration has affected the sures to minimize health problems, making efforts
family structure and accelerated a change from to improve memory and physical f­unctions and
the traditional large family toward the core fam- keeping a positive orientation toward life [6, 19].
ily [2]. This change includes that the elderly Several conditions impact on older people’s
(65 years and older), whom in the traditional health [19, 20]. The best-known types of
large families were valued as a “wise” person in health-related behaviors are smoking, alcohol
316 Ö. Körükcü and K. Kabukcuoğlu

use, physical exercise, eating, and lifestyle hab- government aims to realize the targets and strate-
its [2, 6]. In Turkey, health-promotion practices gies in accordance with the WHO, European
in the elderly can be financed and organized by Healthy Aging Strategy and Action Plan (2012–
donations from individuals or nongovernmental 2020) and Health 2020 targets [2]. With the
organizations or taxed by national governments aging population, health care spending and the
[2]. In short, health-promotion activities and ini- need for care will increase rapidly, representing a
tiatives are heterogeneous as the providers of serious responsibility to the future even in coun-
services and support differ by the contribution of tries with a strong social security system [21]. In
the individual, the family, the immediate envi- parallel with the increase of older people, the
ronment, society, and the local and central gov- burden of chronic diseases as part of the total
ernment [7]. Biological age is represented by the health expenditures is increasing gradually [14].
bodily and cellular changes seen with chrono- Maintaining independence and preventing
logical age [6, 21]. In addition to the increased disability among the older population are closely
frequency of chronic diseases, some older related to rehabilitation and ensuring quality of
people experience losses of functions followed life [2]. In Turkey, quality of life in the elderly is
by various degrees of disability [21]. When all related to maintaining life without social isola-
these factors occur simultaneously, there is a tion, appropriate living conditions, timely and
significant increase in the need for health and easy access to quality health services, maintain-
social care; in the years to come the care needs ing relationships with friends and neighbors, and
of the elderly will continue to increase. devoting time to meaningful activities of value to
Generally, development applications and health- other people and the society [23]. Older adults
promotion practices for older people in Turkey are still capable of self-reflection, anticipation,
have three main objectives: (1) continuation and and problem solving [24]. Health-promotion
expansion of functional capacity, (2) protection practices are an effective way to focus on peo-
or improvement of health, and (3) social net- ple’s resources and capacities to create and main-
work development and physical activity based in tain health [23, 24]. A health care approach
a social group [2]. focused on the individuals’ abilities for self-care
In the Action Plan of the Turkish Ministry of that promote and maintain health is less costly
Health including activities of Health-Promotion than the management of diseases [25]. Meaningful
and Development in 2009–2013, “reducing relationships, social support, physical activity,
threats to the health of people and improving healthy eating, vaccination, cessation of harmful
health” in health services were determined as the habits such as smoking and alcohol, fight against
strategic objectives. For this purpose, the “Health obesity or malnutrition, preventive practices in
Promotion Department” and “Non-­ falls, neurological and mental health protective
Communicable Diseases and Chronic Conditions activities represent areas for health-promotion
Department” were established and started their initiatives [2, 26–28]. In the following, some cen-
activities within the General Directorate of Basic tral areas for health promotion directed to elderly
Health Services of the Ministry of Health in 2008 in Turkey are presented.
[22]. Health professionals can advise and support Health-promotion initiative aims at involving
health behavior of elderly people, improving and empowering individuals in the activities and
their well-being and quality of life [9]. decisions involving their health [6]. At any time
during its lifetime, a living system must deal
with and withstand negative forces that are on
22.2 Health-Promoting the verge of pushing it to maximum irregularity
Approaches in Older People or entropy [19]. The salutogenic paradigm and
Home Care in Turkey practices contribute to health-promotion and
public health in terms of quality of life, mental
In order to strengthen the health care system to health, psychological resilience, coping with
meet with the increase of older people, the stress, maintaining and improving general
22 Health Promotion Among Home-Dwelling Elderly Individuals in Turkey 317

health, well-­ being and healthy aging [6]. larly at risk for malnutrition [28, 29]. Malnutrition
Healthy aging is stated as a process—it is the occurs most often in the elderly as a result of
journey, not the end [14]. Fundamental to feel- insufficient intake or absorption of nutrients [29].
ing good is to have a positive outlook on life Other factors affecting nutritional status are
[15]. Nutrition, lifestyle/habits, genetics, exer- physiological changes with age, acute and
cises, education, knowledge, skills, mental abil- chronic diseases, dental problems, polyphar-
ities, family, religion, self-esteem and ideology macy, economic issues, doing shopping alone,
are social factors affecting healthy aging [8, 14]. preparing meals, and inability to eat [26, 28].
The gero-salutogenic approach is shaped by There may be excessive (or unstable) intake of
SOC, which is an important factor in success- wrong food during old ages [25]. Another com-
fully coping with the stressful factors of daily mon unbalanced eating problem is obesity [30].
life and improving the well-being and health of Assessment of abdominal obesity, glucose intol-
the elderly [19]. This approach considers the erance, hypertension, and dyslipidemia should be
individual as a highly complex bio-psycho- performed simultaneously [28]. Inadequate and
social-­spiritual living system, which is self-cre- unbalanced nutrition among elderly individuals
ating, self-organizing, and self-preserving [4, is associated with obesity, cardiovascular dis-
19]. Older individuals have good prospects for eases, cancer, diabetes, osteoporosis, all of which
positive development, if they manage to main- are correlated with high morbidity and mortality
tain or even improve their SOC [19]. Antonovsky [31]. It is recommended that obese elderlies
[4] offered two explanations for the positive change their lifestyle by developing individual
association between SOC and well-being, nutrition and physical activity programs [26].
explicitly maintaining that it is not a causal one: Especially for the elderly with a chronic disease,
(1) a strong SOC is shaped by life experiences a specific nutrition program should be developed
that are characterized by the availability of gen- to support well-being [25].
eral resistance resources; (2) there are certain
resistance resources that contribute to both a
strong SOC and well-being. SOC represents the 22.2.2 Cigarette Consumption/
gero-­salutogenic core variable, which is funda- Respiratory System Problems
mental to successful coping with the abundant and Health-Enhancing
stressors of everyday life and a key factor for Applications
determining an older individual’s well-being
and health [19]. In this context, we aimed to With high age, a decrease in lung elasticity,
examine three main aspects of positive aging increased chest wall stiffness, and decreased
and SOC among Turkish elderly people: subjec- lung function due to the weakening of respira-
tive physical health, well-­being, and psycholog- tory muscles are seen [26]. These changes result
ical health. in significant progressive reductions in vital
capacity, diffusion capacity, gas exchange, venti-
lation and respiratory sensitivity [32]. Smoking
22.2.1 Nutrition Problems accelerates these changes considerably, and the
and Health-Enhancing prevalence of chronic obstructive pulmonary dis-
Practices ease is known to vary between 2% and 9% [26,
32]. Respiratory infections, especially pneumo-
Adequate and balanced nutrition plays an active nia, are an important cause of death in both
role in maintaining physical, mental development developed and developing countries in people
and functional status as well as preventing, treat- aged 65 years and older [33]. Sitting times in
ing and improving diseases in old age [20]. front of the television should be determined and
Nutrition problems can be one of the most impor- the drawbacks of sitting still for a long time in
tant reasons underlying chronic diseases [28]. terms of respiratory and circulatory system
Elderly people living alone in Turkey are particu- should be explained to older people [25]. The
318 Ö. Körükcü and K. Kabukcuoğlu

effect of smoking on respiratory infections among elderly people living alone [30]. The
should be explained and elderly people should focus of the medical model on the absence of
be supported to quit smoking without creating chronic illness and physical disabilities does not
stress [32]. Since drug use is widespread in the account for older individuals who, despite
elderly and there may be pharmacokinetic and chronic illness, consider themselves as healthy
pharmacodynamic changes due to physiological and vital human beings [4, 8, 14]. It is well known
changes, counseling approaches are recom- that to achieve healthy aging, drug management
mended instead of pharmacological smoking is not enough; the individual must also maintain
cessation methods [34]. The health effects of good exercise patterns, a healthy diet, and good
exercising for 30 min every day should be lifestyle habits supporting people’s health [14].
explained [35]. Two hours of decongestant cough Keys for successful and healthy aging are mental
and deep breathing exercises should be done stability, social support, and social interaction
especially in bed-dependent individuals [26]. In rather than drugs [14, 30].
bed-dependent and confused elderly people, fre-
quent change of position is suggested as it will
prevent stagnation in the lungs and the develop- 22.2.4 P
 hysical Activity and Health-­
ment of pneumonias [32]. Promoting Practices

The “National Plan of Action on Aging and the

22.2.3 Drug Management Situation of Elderly People” was formed in
and Health-Enhancing Turkey in 2007. This national plan contains
Practices important recommendations and activities, such
as emergency health care, day-care centers,
The perspective of healthy aging in the medical cleaning services, social activities, food services
model is focused on the absence of chronic ill- to houses, repair and renovation services for the
ness, the ability to overcome chronic illness, or Turkish population showing increased longevity
the elimination of risk factors that lead to chronic [40]. Physical activity and movement are seen as
illness [14]. Unfortunately, globally as well in one of the most important health-promoting
Turkey, the elderly constitute the majority of the practices in maintaining health in elderly indi-
population using drugs to cope with diseases [36, viduals, and the lack of it may set the stage for
37]. Polypharmacy drug side effects, drug-drug-­ triggering the most dangerous chronic diseases
disease interactions, treatment noncompliance, such as cardiovascular diseases and cancer [34,
increase in cost, weight loss, falls, cognitive dys- 41]. Physical activity is found essential to older
function: medication can lead to many health people’s quality of life, and is a therapeutic com-
problems causing an increase in hospitalization ponent in rehabilitation programs, as well as in
and death [38]. Therefore, careful drug use is the treatment and prevention of chronic diseases
advised [36]. Older patients and caregivers [20]. It is well known that in elderly individuals
should be informed about the medicines, vita- the ­ mineral content of the skeletal system is
mins, nutritional support products, and herbal decreasing, causing a decrease in muscle strength
medicines provided [39]. Written and oral infor- and muscle mass and therefore also a decreased
mation should be given about the preparations ability to move [42]. Moreover, studies have
given, their frequency of use, their dosage as well shown a decrease in physical activity with
as both their generic and market names [36]. advancing age [35, 43]. There is a direct relation-
Patients and caregivers should be educated about ship between increased inactivation with old age
the common side effects of the drugs and and cardiovascular diseases, osteoporosis, and
informed about where to contact their physician colon cancer [38, 42].
[26]. Drug treatment should be simplified, espe- WHO [5] asserts that mobility is the best
cially to improve the adaptation to treatment guarantee of not losing independence and being
22 Health Promotion Among Home-Dwelling Elderly Individuals in Turkey 319

able to overcome independency. Walking is the and cardiovascular function occur in the vestibu-
most accepted and recommended physical activ- lar system (that is located in the labyrinth in the
ity by physicians for older people [42, 44]. inner ear together with the cochlea, which is part
Walking takes place in social settings (e.g., of the hearing system) and in the ear vestibulum
parks, shopping centers, roads, neighborhood and provides motor coordination and sense of
streets), often outdoors, both for leisure and balance [35]. Falls are among the most common
exercise, as well as transportation [45]. In addi- causes of injury/death in old age [51]. If looking
tion, walking or cycling for transportation pur- at the fall rates of individuals over the age of
poses, dancing, playing, gardening, making 65 in Turkey, 60% of the falls occur in the home
housework and similar activities, sports, and environment, 44% of home accident are on a dry
physical exercises or activity are recommended ground and 4% on wet ground [52]. In
[44, 46]. Health care professionals in Turkey rec- community-­ based prospective studies, it is
ommend active sports, such as walking, slow reported that the annual rate of falls in the elderly
running, dancing, swimming and cycling, or is between 30 and 60%, about half of the falls are
team games with their own age groups, for active repeated falls and two-third of them are prevent-
aging [44]. able falls [35, 51, 53].
In addition, gardening is recommended as a Knowing the risk factors causing falling is
health-promoting activity for older people stay- important for taking the necessary precautions
ing at home [47]. Gardening provides an oppor- [53]. Health-promoting activities preventing falls
tunity for the elderly to stay outdoors and is at home include regulating the physical environ-
described by many as a pleasurable physical ment of the elderly, teaching measures to prevent
activity [47, 48]. In this process, opportunities falls for the family and the elderly, providing
can be provided for the elderly to care for plants assistance during activities that require skill and
and trees, to weed out leaves or to water plants eliminating factors that may cause accidents [42,
and trees, to grow their own plants [49]. Seeing 43].
the growing of the plants and caring for them In Turkey, medical interventions, environmen-
both provide physical activity and help to tal regulations, training and exercise programs
develop a sense of success, meaning, and self- and auxiliary instruments are used to prevent and
confidence [44, 47]. If there is no garden pos- reduce the frequency of falls [35, 38]. The aim of
sibility, plants or flowers grown in the house these initiatives is to reduce the number of recur-
may also be an alternative [48]. It has been rent falls and reduce the rates of resulting dis-
found that elderly individuals who engage in eases and deaths [42]. Decreasing the number of
regular physical activity increase their indepen- drugs in elderly people, especially reducing the
dence and self-­confidence, improve sleep qual- number to be less than four, significantly reduces
ity due to reduced stress, modify depression, the risk [51]. In old ages, postural hypotension
and decrease the incidence of chronic diseases represents a risk of falling; thus, etiology is inves-
[50]. Maintaining autonomy and physical activ- tigated, drugs are reviewed, diet of those with
ity are the most important factors of successful excessive salt restriction is reorganized and
aging [14]. patients are asked to have adequate fluid intake
[42]. Balancing arrangements include raising the
head of the bed, getting up slowly from the bed,
22.2.5 Home Accidents/Falls dorsiflexion exercises and pressure-enforcing
and Health-Promoting socks [35, 42].
Practices Environmental regulations are another impor-
tant issue in preventing falling [35]. In this con-
Falling is one of the most common and serious text, families and elderly individuals are
problems causing significant morbidity and mor- informed about the use of non-slip tiles in the
tality [42]. Age-related impairments in walking bathrooms, the use of non-slip floor covers and
320 Ö. Körükcü and K. Kabukcuoğlu

adhesive strips for the floor near the bathtub, 22.2.6 V

 itamin D Deficiency
washbasin and toilet, the use of slip resistant and Health-Promoting
floor polish for the in-home safety in bathrooms Practices
[51]. Less furry carpets are recommended [42].
Lighting needs to be increased in stairs, bath- Osteoporosis is one of the most threatening con-
rooms and bedrooms [51]. Dark painted mate- ditions in the older population with the progres-
rial can be used on the windows for preventing sion of age; the most important factor that causes
excessive daytime brightness [54]. As there may osteoporosis is vitamin D deficiency [55, 56].
be a problem of visibility in the dark, electric Vitamin D is essential for calcium metabolism
buttons should be placed on the top and bottom and bone quality [38, 57, 58]. Although the main
of the stairs, illuminated with night lights; col- source of vitamin D is exposure to sunlight, vari-
ored adhesive strips should be placed on the step ous factors such as latitude of the area experi-
edges and step height should be no more than enced, season, hours of sunlight, and use of
15 cm [42, 51, 54]. On both sides of the steps, sunscreen influence the absorption of vitamin D
cylindrical, inward-­facing end parts, easy to be [55, 57]. Especially elderly people who spend
grasped and some continuing handrails at the most of their time at home are at risk for vitamin
end of the step should be placed [53]. It is D deficiency due to insufficient sunlight exposure
recommended to place holding bars on the wall and kidney synthesis of vitamin D and decreased
next to the toilet [51], placing pads with non-slip absorption of vitamin D [59, 60]. In this case, cal-
adhesive rubber bands on the bathtub floor, cium absorption decreases, parathyroid hormone
holding bars in the bathtub and shower, as well works more to compensate this absorption, bone
as using a shower chair and a hand-held flexible remodeling occurs, bone density decreases, and
shower head for those with reduced balance osteoporosis occurs [55, 60]. Although there is
[54]. Information should be given to measure plenty of sunlight in Turkey, insufficient exposure
the distance from the kneecap to the floor for the to sunlight and wearing plenty of clothing due to
bed height, not to use low chairs, and to keep the sociocultural/religious beliefs are factors leading
frequently used kitchen and toilet seats within to vitamin D deficiency in the elderly [57].
reach [42, 51]. Routine health-promoting practices in this group
In addition to the regulations of elderly indi- in Turkey are focused in education and counsel-
viduals’ home environment, there has been ing [56]. Recommendations are made to encour-
increased awareness on the importance of envi- age the consumption of seafood, milk and dairy
ronmental arrangement in the external environ- products, to supplement vitamin D and Calcium,
ment [35]. Research has shown that barriers on and to increase the exposure to sunlight during
sidewalks are primarily responsible for falls hap- the day [56, 60]. In particular, health profession-
pening in the external environment [35, 51, 54]. als should enhance elderly people’s knowledge
These barriers are easily damaged during winter about the importance of vitamin D, the risks of
months and high narrow-sidewalks, lack of cross- vitamin D deficiency and the ways to prevent it as
walks, slippery surfaces, stairs without handrails, well as treatment options [55, 56, 60].
poor lighting, and traffic seem to be the most
important reasons for elderly individuals falling
outside their home [45, 51, 53]. In recent years, 22.2.7 W
 ell-Being, Mental Health
awareness about the destructive effects of falls on and Health-Promoting
elderly health has increased and interventions Practices
that can be made have been planned [51]. In this
respect, elimination of architectural deficiencies Healthy aging is the process of slowing down,
and careful urban planning represent approaches physically and cognitively, while resiliently
that will prevent falling among older people adapting and compensating in order to optimally
[51, 54]. function and participate in all areas of one’s life
22 Health Promotion Among Home-Dwelling Elderly Individuals in Turkey 321

(physical, cognitive, social, and spiritual) [14]. living alone in Turkey [62–64]. Turkish Statistical
Individual lifestyle factors, social and community Institute (TÜİK) [10] reported that family sup-
networks, living and working conditions, and port in old age was closely associated with
general socioeconomic, cultural and environmen- depression and suicide rates. Bozo et al. [62]
tal factors are some determinants of well-­being found that perceived social support had no effect
[3, 4]. The salutogenic approach leads to a more on life quality and depression: however, depres-
profound understanding through reflection on life sive symptoms decreased among older individu-
situations and a review of available resources and als with high daily life activity and adequate
active adaptation to stress-rich environment, social support.
which promotes movement toward the “ease” In Turkey, which predominantly is a Muslim
part of Antonovsky’s health continuum [19, 61]. country, worship and religion play an important
Over the life span, negative life events might role in dealing with loneliness, depression and
reduce SOC which includes three interrelated psychosocial problems [65, 66]. In one study,
components: comprehensibility of one’s world elders stated that worship raised their morale and
(cognitive aspect), manageability of one’s out- gave them peace [67]. Praying, reading the
comes (behavioral aspect), and meaningfulness Qur’an, going to a mosque and worshipping with
of one’s life (motivational aspect) [8, 15]. the community are among the most preferred
Antonovsky [4] stated that developing SOC coping methods among Turkish elderlies to fight
requires internal and external generalized resis- against depression [66, 67]. According to the
tance resources, including ego identity, social salutogenic health model, personal resources
network and social support. The social environ- may include the following factors: (1) material
ment of the elderly individual’s such as spouse, resources (e.g., money), (2) knowledge and intel-
family and friends are important support systems ligence (e.g., knowing the real world and acquir-
for feeling valuable, increased well-being, men- ing skills), (3) ego identity (e.g., integrated but
tal health satisfaction from life and coping with flexible self), (4) coping strategies; (5) social
stress [61]. In Turkey, depression is the most support, (6) commitment and cohesion with one’s
important mental health problem that negatively cultural roots, (7) cultural stability, (8) ritualistic
effects SOC: perceived social support is signifi- activities, (9) individuals’ state of mind, (10) pre-
cantly related with depression in old age [62]. ventive health orientation, (11) genetic and con-
The Turkish culture emphasizes the family as stitutional GRRS, and (12) religion and
a core institution in the Turkish society; accord- philosophy (e.g., stable set of answers to life’s
ingly, older individuals live with their families perplexities) [7, 67]. Just as recommended for
and children [61, 63]. However, the number of many religions, it is an important responsibility
elderly people living alone at home or in nursing for believers in Islam to take care of ones health,
homes has increased gradually as the nuclear avoidance of substance use, healthy eating, and
family structure has become widespread in recent healthy living [66]. Religion might be a gate-
years [63]. If the older individual perceives aging keeper that can promote mental health and spiri-
as an isolated existence, he or she will tend to tuality among older believers [65].
isolate him-/herself and begin to fail. However, if
the older individual perceives aging as an integral
part of the social structure in which he or she 22.2.8 Sleep/Rest and Health-­
lives, thriving will be supported [14]. The quality Promoting Practices
of social support is considered a crucial resource
for SOC and coping [4, 8]. Social support is sig- Sleep quality is a big challenge to many old peo-
nificant for health and well-being for older peo- ple [68]. Elderly adults may experience daytime
ple [8]; correspondingly, the physical, mental and sleepiness, waking up earlier in the morning, dif-
emotional health of the elderly living with rela- ficulty falling asleep and maintaining sleep, and a
tives are significantly better than among elderly decrease in night sleep time [69]. Sleep problems
322 Ö. Körükcü and K. Kabukcuoğlu

can cause troubles such as lack of attention, Elderly people should be supported to use
inability to perform daily tasks, falling and it resources optimally in order to maintain their
seriously affects individuals’ quality of life [70]. health and quality of life [72]. The most common
A study examining sleep quality among 250 problems that affect quality of life associated
elderly people living at home in Turkey, found that with aging are changes in the cardiovascular sys-
20.8% of individuals fall asleep within 30 min or tem, respiratory system and the neurological sys-
longer after going to bed, that women complain tem [64, 76]. In a salutogenic perspective, health,
more about sleep disorder than men, and that mar- well-being and quality of life should be promoted
ried older individuals pay more attention to sleep throughout the life course [2]. The main purpose
quality [68]. In another study, sleep quality was of preventive health services offered to the elderly
associated with fatigue and quality of life [71]. in Turkey is to improve the individuals’ quality of
Elderly people need regular sleep in order to life by supporting them to live independently and
maintain their quality of life and body functions preventing obstacles [72, 76]. The main objective
in the best way [72]. Solutions to sleep problems of the preventive health services offered to the
can be found with the correct use of pharmaco- elderly people is to improve their quality of life,
logical and non-pharmacological methods. Music allowing independent living and preventing dis-
has been widely used as a method for treating abilities [76].
diseases in Turkish societies and in many civili- One of the most important indicators of life
zations [73]. Music relaxes the body by lowering quality is social relationships [77]. Developing
heart rate as well as by regulating body tempera- SOC requires internal and external general resis-
ture, blood pressure and respiratory rate [72, 74]; tance resources, including ego identity, social
passive music therapy treatment has been widely network, and social support [4]. Most elderly
used [74]. During passive music therapy people people ≥65 retire. As the children leave home,
are resting, comfortably sitting or lying down, the family lessens, and thus shortening the elderly
listening to a relaxing rhythm and the sound of individuals’ social environment. Moreover, the
water in accordance with the melody [72, 74]. elderly adults may experience physiological
Sleep and rest are physiologically needed in all changes followed by loss of functionality and
individuals, and especially in elderly individuals. mobility. Hence, both social and functional
Therefore, creating a good sleep environment restraints occur [78]. The loss of a spouse may be
alongside music might improve older people’s one of the most devastating factors in elderly
sleep quality [75]. Noise should be reduced, and individuals [79]. With retirement, the decrease in
a quiet and safe environment should be provided. income causes a decline in social status among
The atmosphere must be ventilated, the light most of the elderly followed by a loss of many
should be reduced, the room temperature should social activities [80]. WHO defines successful
be warm and the bed should be comfortable [68]. aging as a process of “age-in-place,” optimizing
opportunities for health, continue to be involved
in the community, maintain autonomy, indepen-
22.2.9 Q
 uality of Life (QoL) dence and attain physical, social and mental well-­
and Health-Promoting being and quality of life [72, 75, 81]. Watching
Practices television, listening to the radio, chatting with
people, and lounging represent common social
Age, which is an inevitable biological and psy- activities among elderly people staying at home
chological development process, affects quality in Turkey [79]. Research demonstrates that
of life through changes in the human body such although the elderly generally appreciate their
as vision, hearing, skeletal system, brain and current situation, some older individuals yearn
prostate, menopause, and andropause periods for the activities they were doing while they were
[72]. In addition, an individual’s past experi- younger or healthier [82]. The salutogenic
ences, health behaviors, habits, and genetic fac- approach leads to a more profound understanding
tors influence quality of life in late ages [76]. through reflection on life situations and a review
22 Health Promotion Among Home-Dwelling Elderly Individuals in Turkey 323

of available resources and active adaptation to an understand the transitions in old ages and suc-
irritating and stress-rich environment, which pro- cessful aging [4]. The salutogenic approach
motes movement toward the “ease” part of the focuses on movement toward health, whereas the
health ease–dis-ease continuum [4, 72]. Aközer pathologic approach focuses on disease and iden-
and colleagues [77] found that seniors in their tifies the person with the disease [4]. Both para-
free time gave priority to watching television, digms are equally important and should be
shopping and visiting family members and rela- integrated in a holistic salutogenic understanding
tives. An elderly adult who lives a life isolated of health. A central priority by the state should be
from the outside environment may tend to be to meet the needs of the older population includ-
closed, longing for the past, resistant to innova- ing health-promotion and continuity of the social
tion and change [3, 83]. Therefore, the ability to and health care facilities/policies for every indi-
maintain social interaction, relationship, autonomy vidual without any discrimination [2]. A policy
and independence are important determinants of based on salutogenic approaches and comprehen-
healthy ageing and quality of life [81]. sive perspectives such as the “Active aging” con-
cept could better improve the well-being of the
older population. WHO states that “active aging
22.3 Home Care Services allows people to realize their potential for physi-
cal, social, and mental well-being throughout the
Physical, social, and spiritual changes occur with life course and to participate in society, while
the progression of aging; the functional capacity providing them with adequate protection, secu-
of elderly individuals decreases and for some this rity and care when they need” [86]. With a strong
situation causes older people to need help as well SOC, people would be more confident about hav-
as care [78]. Health, welfare, housing, transport, ing control over their own choices and their situ-
and infrastructure are responsible sectors for ation by using their resources for health [81]. The
healthy aging and quality of life of elderly people European Region of WHO, in which Turkey is a
[81]. Although increasing needs are met by the member, has given priority to the facts like enjoy-
families, relatives or communities of the elderly, ing supportive, adapted social environments,
long-term and regular assistance and services can having access to high-quality, tailor-made, well-­
be provided by health care services [12, 78]. The coordinated health and social services, giving
environment should support the individual’s SOC support to maintain the maximum health and
by means of available resources for health, functional capacity throughout life, and empow-
enabling older people to live well despite their ering individual while living and providing dig-
limitations [81]. The aims of the health care ser- nity through the entire life [2, 86].
vices are: (1) to support individuals with disabili- The professional home-care in Turkey is still
ties, the elderly, people with permanent illnesses in it’s infancy; the first studies in this field started
during or after the disease recovery period in in the private sector [87]. Today, home-care ser-
their environment, (2) to keep up with social life, vices are supported by municipalities, private
(3) to ensure their integration with society by hospitals, private home-care centers and home-­
maintaining their lives happily and peacefully, care units of public hospitals [79]. The “elderly-­
and (4) to support the family members who care friendly cities” have gained increasing attention
for the elderly person and especially women in by policy makers over the last decade, since the
the family [79, 84, 85]. WHO started to promote the concept [88]. In
The adaptation of the salutogenic approach as 2010, the Ministry of Health of the Turkish
complementing the pathogenic approach is Republic started free home-care services includ-
important to health-promotion among home-­ ing examination, treatment, nursing care, medical
dwelling elderly individuals: the salutogenic care, medical equipment and device services,
approach highlights to utilize the individual’s psychological support, physiotherapy, follow-up,
resources for health in his or her social and physi- rehabilitation services, housework (laundry,
cal environment [81] as well as helps to better shopping, cleaning, food), personal care
324 Ö. Körükcü and K. Kabukcuoğlu

(dressing, bathroom and personal hygiene), 24-h Take Home Messages

emergency service, transportation, financial • Healthy ageing is influenced by a variety of
advice and training services within the scope of interacting determinants, such as belief, living
the social state policy [12, 83, 86, 87, 89]. In conditions, socioeconomic, cultural and envi-
Turkey, municipalities, social workers, public ronmental factors.
health workers, policymakers, and researchers • There are health gains both for the elderly,
work on many activities, facilities or services for their families and health care professionals by
older people to promote active ageing; nonethe- integrating a salutogenic orientation as part of
less, access the to these services is sometimes the health policy, health care practices and
low [87]. research.
• The salutogenic model of health including the
concept of sense of coherence should be
22.4 Conclusion implemented in health care practice, research,
and health policy.
Ageing is a natural developmental dynamic pro- • Even if health-promotion practices still for
cess of human life and an individual’s triumph of most health care settings are limited in Turkey,
accumulated life experiences [88]. As the propor- existing evidence recommends an increased
tion of older people in Turkey is increasing, the integration of salutogenesis into health care
importance of health-promotion among the practices as well as a more systematic use of
elderly is increasingly acknowledged. The WHO this approach in research on health care
twenty-first century’s theme entitled “Health for settings.
all” was directly related to elderly’s health [75]. • In Turkey, elderly care is mostly provided by
In this context, and in a health-­promoting per- families in the home environment. Thus, there
spective, WHO focuses on strengthening the is a need to strengthen the care of the caregiv-
physical and mental capacities of seniors, as well ers developed and organized as part of the
as creating the environment to allow them to home-care services.
achieve their valued goals [88]. It is necessary to • WHO has declared the period 2020–2030 as
develop elderly friendly communities including the “healthy ageing decade.” The importance
aspects related to transportation, housing, public of a healthy lifestyle and health-promoting
spaces, community and health services [90]. practices during the entire life span is now
Healthy ageing is influenced by determinants increasingly understood among older people
such as social norms, living and working condi- in Turkey.
tions, socioeconomic, cultural, and environmen- • To fulfill the aim of making 2020–2030 “the
tal factors [91]. Health-promotion initiatives in healthy aging decade,” the development of
the older population should aim to increase or nutritional and health care suitable for elderly
maintain elders’ functionality both socially, cog- people, programs supporting cigarette con-
nitively, emotionally, spiritually and physically, sumption, physical activity as well as adapting
improving longevity and well-being. Enhancing the physical environments to hinder accidents/
functionality, maintaining strength as much as falls, coping with vitamin D deficiency, sup-
possible, living independently and facilitating porting self-management of mental health,
well-being are main priorities of health-promo- sleep/relaxation, quality of life and well-being
tion [84, 92, 93]. Ensuring that older people are essential.
remain healthy and active is a necessity, not a • The home-care services should be trained in
luxury. It is necessary to regulate the living space health-promotion as well as in develop-
of elderly individuals aiming to support their ment and the implementation of health-­
quality of life and health, as well as to improve promoting activities among elderly people in
social relationships. Turkey.
22 Health Promotion Among Home-Dwelling Elderly Individuals in Turkey 325

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 SHAPE: A Healthy Aging
Community Project Designed
23
Based on the Salutogenic Theory

Betsy Seah and Wenru Wang

Abstract oriented approach. Illustration of examples

in which how the salutogenic concepts were
Salutogenesis introduces a paradigm that
operationalised in developing the SHAPE
requires a perceptual change towards what
intervention approach, its content, activities
creates health and how health can be facili-
and the conduction of the intervention are
tated. Removing the lens of pathogenesis,
presented.
aging is an achievement to be embraced and
older people are valued as assets for their
Keywords
wealth of experiences, resources, skills and
knowledge. From the perspectives of older Salutogenic health theory · Sense of coherence
adults, the concept of healthy aging is multi- Resistance resources · Healthy aging · Older
dimensional, comprising bio-psycho-social-­ adults · Community-based care · Asset-based
spiritual health. Evidence shows that sense approach · Health promotion
of coherence via resistance resources pro-
motes health outcomes among older adults.
However, very few works have attempted to
operationalise the salutogenic theory to pro-
23.1 Introduction
mote healthy aging among older community
dwellers. This chapter provides a detailed
Normal aging is a precursor of pathology and
description of the Salutogenic Healthy Aging
influence the degree of disease presentation,
Program Embracement (SHAPE) intervention
response to treatment and probability of devel-
for senior-only household dwellers. SHAPE
oping complications [1]. It sets the challenge
represents an application of the salutogenic
of approaching aging from the salutogenic per-
concepts: sense of coherence and resistance
spective in identifying factors that create health
resources. SHAPE is an integrative person-­
among older adults. With aging as a disease and
centric multi-dimensional health resource
frailty risk factor [2–4], efforts to promote health
program that employs an asset-based insight-
in older people commonly focus on disease pre-
vention, reducing frailty and disability. In a scop-
B. Seah (*) · W. Wang ing review performed on past systematic reviews
Alice Lee Centre for Nursing Studies, Yong Loo Lin of interventions targeting health maintenance or
School of Medicine, National University of improvement of older adults, majority of them
Singapore, Singapore, Singapore focused on disease-specific interventions [5].
e-mail: nurseah@nus.edu.sg; nurww@nus.edu.sg

© The Author(s) 2021 329

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_23
330 B. Seah and W. Wang

Removing the lens of pathogenesis, aging is an ers acknowledged illness as part of late life [13,
achievement to be embraced; where older people 17]. Having physical health meant not suffering
are valued as assets for their wealth of experiences, from complications or debilitating conditions
resources, skills and knowledge. Advocated in the which impair daily activities [14, 17]. Abilities
2002 Madrid International Plan of Action on Aging, deriving from physical health allow one to fulfil
older adults should be continued to be developed, one’s spiritual desires [11], everyday activities
supported by the environment and to live with [12] and meaningful activities [16]. Having a bal-
health [6]. However, there are very few works that anced state of mind was important too as older
attempted to operationalise the salutogenic theory adults recognized that mental health was con-
in cultivating such environments by developing nected to physical health [17]. Having good cog-
interventions for older adults to age healthily. This nitive function was also recognized in five studies
book chapter documents the development of a and some older adults reported the importance of
health resource program, titled Salutogenic Healthy engaging in cognitive stimulating activities to
Aging Program Embracement (SHAPE), for older avoid or delay decline [7, 9, 11, 14, 17].
community dwellers residing in senior-only house-
holds using the salutogenic theory.
23.2.2 Positive and Optimistic
Outlook
23.2 Healthy Aging
as a Multidimensional Older adults in five studies reported that having
Concept positive and optimistic outlook was an essential
element to healthy aging. Maintaining positivity
Having an understanding towards older commu- and optimism towards changes in own health and
nity dwellers’ perceptions towards contributing aging experiences influenced how one coped and
factors of healthy aging allows health profes- adapted to these challenges [12], such as through
sionals to strategize and align health promotion acceptance of situation [7, 17], hope [17], refram-
interventions effectively to facilitate this pur- ing of situation [17], and instilling a sense of self,
suit. A literature search was performed to iden- self-confidence and self-efficacy in knowing
tify qualitative studies which explored views of what to do with the situation [16]. Having a posi-
healthy aging among independent older commu- tive and optimistic outlook gave the older adults
nity dwellers. Unlike quantitative studies, quali- a sense of control and willpower over health and
tative evidence synthesis provides an in-depth own lives [7, 12, 15, 16]. In Thailand, having
and nuanced understanding towards the concept positive psycho-emotional outlook contributes to
of healthy aging across different contexts. The one’s internal state of mind and it is related to
included studies were conducted in Canada [7, Buddhism [15]. Healthy older adults were per-
8], Germany [9], Hong Kong [10], Hungary [9], ceived to be friendly, humorous and enjoyable
Latvia [9], Malaysia [11], Netherlands [12], New too [15].
Zealand [13], Sweden [9], Thailand [14, 15], the
United Kingdom [9] and the United States [16–
19]. The following in Sect. 23.2 presents the syn- 23.2.3 B
 eing Socially Connected
thesized findings of these 13 qualitative studies. and Supported

Another aspect of healthy aging is social health.

23.2.1 H
 aving Physical and Mental A supportive social environment consisted of
Health family members, partner/spouse, friends, neigh-
bours, acquaintances and the presence of social
Some older adults referred physical well-being as activities [12]. Often, valued relationships
absence of chronic diseases [10, 15] while oth- involved reciprocity, contact, engagement, caring
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 331

and companionship [7, 13, 15, 16]. Participation ties which were pleasurable [13], fun [15], mean-
in social activities was reported important as this ingful and worthwhile to do was important [7, 13,
mitigated feeling of isolation, loneliness aban- 16]. These activities varied from physical exer-
donment, fostered relationships and promoted cises, volunteering, gardening, puzzles, reading,
sense of fulfilment [17]. Social activities could watching television, lottery and other leisure pur-
be related to their social roles [16] and social suits [13, 16]. With increased awareness towards
contributions [13, 15]. Older Malay adults con- ailing health, some reported having difficulties
tributed to their families as responsibility towards in staying active and had to negotiate compet-
children and grandchildren was perceived as a ing priorities to continue their pursuit of valued
lifelong commitment [11]. However, immobil- activities [9, 13]. Older adults also identified the
ity due to pain and disability [7, 16], financial importance of committing to healthy behaviours
­constraints, lack of transport [13], cultural and by having self-discipline and making conscious
linguistic background among minorities [17] choices to take charge of own health [9, 17].
were reported to limit social opportunities. These behaviours included having balanced and
healthy diet, exercising, having enough sleep, not
smoking, not drinking, taking medicine as pre-
23.2.4 Being Spiritual and Religious scribed, attending regular medical check-ups and
adhering to doctor’s advice [15, 17]. Although
Seven studies mentioned that being spiritual taking self-initiative was important [7], some
and religious contributed to healthy aging. The older adults reported the lack of motivation to
doctrine of faith offered older adults positive maintain healthy lifestyle behaviours [19].
outlook and acceptance towards difficult aging-
related encounters [16, 17] and a peace of mind
to balance feelings and material desires [11, 14, 23.2.6 Being Independent
15]. Having spiritual and/or religious beliefs
freed older adults from worries and anxiety over Having to maintain and preserve independence
uncontrolled future, placing their health and late was a key contributor to healthy aging in almost
life in the hands of the higher being [14, 17, 18] all studies. Being independent was a sense of
and preparing them for the end of life and accep- pride and an existential identity in one’s home [9,
tance to death [11, 14]. Being spiritual included 16]. It meant that the older adults can make their
having a peaceful life [11, 14], doing good, own decisions [7, 13, 14], take care of themselves
being a role model and being useful [11, 14, 15]. [13–16, 18], get around on their own [7, 13, 16],
Having to receive positive feedback from people and be self-sufficient [7, 9, 17]. Few studies
gave them happiness, pride, meaning in life and reported their fear of losing independence [7, 16,
higher self-esteem [14]. Moreover, being spiri- 17] as it would erode their self-worth and dig-
tual and religious was perceived to be associated nity [17]. The studies showed that independence
with healthy lifestyle among African Americans was also a cultural value. Older adults from cul-
[18]. Spiritual-religious activities involved pray- tures with strong familism such as Hong Kong,
ing, offering services, donating and going to Thailand and Ethiopia, reported having interde-
churches, mosques and temples [11, 15, 19]. pendence with family [10, 14, 19] and health care
professionals [14] were part of healthy aging.

23.2.5 B
 eing Active and Committed
to Healthy Behaviours 23.2.7 Being Safe and Secure

Another key component of healthy aging was to Feeling safe and secure, in terms of finances
stay active physically, mentally and socially in and living environment, played a role in healthy
their daily lives [7, 9, 17, 19]. To engage in activi- aging as reported in nine studies. This became
332 B. Seah and W. Wang

apparent among older adults who struggled with 23.3 The Salutogenic Theory
financial independence to make ends meet and
had no substantial savings for late life, bringing 23.3.1 The Salutogenic Orientation
them stress, insecurity and uncertainties [13, 17].
Older adults in Latvia and Hungary expressed In the salutogenic health theory, Antonovsky com-
their fear of becoming homeless while those pared salutogenesis and pathogenesis. According
from Sweden, Germany and United Kingdom to the traditional biomedical approach, homeostasis
reported barriers in accessing or unawareness is the regulation of human life and any occurrence
of financial help for home improvement works of disease or risk factor disrupts the homeostatic
[9]. Financial constraints also have consequen- human living environment. The homostasis model
tial effects on health behaviour practices such as focuses on pathogenesis, searching for factors that
limited food choice while on budget [13]. For cause diseases and reduce risk factors [20]. This
older adults from Hong Kong and Malaysia, contrasted with the salutogenesis. It took on the
being in a financial state which support a rea- assumption of heterostasis where we live in an envi-
sonable lifestyle and material needs mattered ronment full of turbulence, stress and instability.
and would suffice [10, 11]. Antonovsky proposed that each of us is on differ-
Being in a living environment that gave ent positions of the health ease/dis-ease continuum,
older adults daily sense of security and safety with total health (ease) and total ill health (dis-
was crucial too. It included the house lived in, ease) at the two poles of the continuum. However,
the people they live with in the neighbourhood this position on the continuum is not static. In the
and the amenities around [11]. Having physical presence of a stressor which creates tension in an
comfort of a home, which is a basic need, gave individual, one’s ability to cope successfully results
older adults warmth [13]. Particularly, older in salutogenesis, and a movement towards the total
adults whom were formerly homeless reflected health of continuum. Contrarily, failure to cope
that having a home protected them from bad results in pathogenesis, the movement towards total
weather, contagious diseases and unsafe physi- ill health [20]. Thus, in the salutogenic perspective,
cal environment, and brought about access to health is a process and its scope is non-limiting,
nutritious food, social support, income support, multi-faceted and subjective [21].
better hygiene and self-care [8]. With increasing Antonovsky argued that the focus on diag-
frailty, some older adults felt less safe at home noses in the traditional biomedical approach
[13]. Others expressed concerns of burglars and discounted the ‘story of the person’ (p. 5) or the
unknown neighbours [13]. One study reported perspective and context of an individual [20]. This
that healthy behaviours such as walking as an limits the optimisation of one’s health potential.
exercise was limited as African Americans older While outcomes of pathogenesis are confined to
adults felt unsafe in their neighbourhoods [18]. eliminating diseases and minimising deficits, the
Moreover, proximity and familiarity towards end-goal of salutogenesis is active adaptation to
social support and environmental amenities problems encountered in a stressor-­rich environ-
provided older adults with access and increased ment. The latter provides the possibility of being
their sense of control towards utility of nearby healthy despite hardship, misfortune and illness.
resources [12]. Nonetheless, health care professionals should not
Based on the above literature, older adults’ boycott the traditional biomedical approach, as
perspectives towards healthy aging spread across managing diseases and risk factors are important.
multiple aspects of later life, including bio-­ Both salutogenic and pathogenic approaches are
psycho-­social-spiritual health. The above review complementary and should be embraced and
also suggested that healthy aging interventions practiced with equal importance [20, 22].
need to be cultural-sensitive and explore contex- Central to the salutogenic theory are the fol-
tual factors unique to the targeted older popula- lowing concepts of sense of coherence (SOC),
tion’s characteristics. and generalised and specific resistance resources.
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 333

23.3.1.1 Sense of Coherence coping with stressors involves interaction with

SOC is both a life orientation and a resource. one’s living context, and is related to ecological
This global perceptual influence affects how thinking [21]. Particularly, the scope of GRRs
one copes cognitively, behaviourally and reflected that health is inextricably linked to
emotionally with tension caused by stressors the community and ecosystem people are situ-
[21]. It comprises the following three compo- ated in, recognising the social or environmental
nents: comprehensibility, manageability and determinants of health which are not within the
meaningfulness. direct control of the individual [23]. Depending
Comprehensibility refers to how well one on the context, types of resources needed to
perceives the character and phenomenon of meet the demands of stressors can vary. A person
the stressor as consistent, expected and clear; with strong SOC has the ability to use available
Manageability refers to one’s capacity to resources to cope with stressors.
mobilise existing resources at one’s disposal According to the salutogenic health theory,
to cope with the stressor; and Meaningfulness interactions with GRRs offer life experiences of
refers to one’s appraisal of the value and experi- consistency, underload overload balance and par-
ence brought about by the stressor [20]. Thus, ticipation in valued decision-making, all of which
an individual with a strong SOC perceives life contributing to SOC development [20]. Processes
as comprehensible, manageable and meaning- of building up an individual’s capacity to mobil-
ful. He or she will have trust in self to iden- ise resources are more significant than examining
tify resources needed to develop strategies in the existence of resources [24]. Thus, GRRs are
resolving issues, thereby facilitating active essential ingredients in developing SOC to move
adaptation processes. one towards the health pole [21].
Among the three domains, meaningfulness Compared with GRRs which have a broader
plays a pivotal role in providing the motivation range of utility, specific resistance resources
for an individual to engage in the search for (SRRs) are mobilised only in specific situations
understanding and resources within one’s con- [20]. SRRs are context bound and they help
texts. Thus, it can strengthen other components people to cope with specific stressors in specific
on comprehensibility and manageability. Having circumstances. For example, getting immediate
to see meaning in what one understands he or she medical attention via ambulance hotline in times
can do matters. Thus, the second important com- of medical emergencies. Not only do GRRs
ponent is comprehensibility, followed by man- influence the strength of SOC, they enable the
ageability—perceiving which resources could be mobilisation of SRRs [25]. Despite the distinc-
mobilised. Accordingly, Antonovsky suggested tion of SRRs from GRRs, both types of resources
an unequal weight placed on the three SOC com- are essential in creating supportive environment
ponents [20]. for health promotion [25]. The term ‘resistance
resources’, is used in this chapter to refer to both
23.3.1.2 Generalised and Specific the variants.
Resistance Resources Adopting the salutogenic orientation requires
Generalised resistance resources refer to any char- a change in how one perceives issues related
acteristic of a person, group or situation which to health and well-being. Instead of develop-
facilitates effective coping of tension caused by ing solutions to reduce health-related risks, it
stressors. This characteristic can take in any form focuses on how individuals can be encouraged
of ‘physical, bio-chemical, artefactual-­material, to use resource-based processes to cope with
cognitive, emotional, valuative-­attitudinal, inter- stressors of daily life, thereby generating health.
personal-relational and macro-sociocultural’ It requires an appreciation and understanding of
traits ([20], p. 103). Examples include immunity, these stressors and resistance resources, for their
money, knowledge, happiness, optimism, social interaction brings about repeated life experiences
support and cultural stability. In other words, which generate SOC [26].
334 B. Seah and W. Wang

23.3.2 Sense of Coherence A qualitative study reported that positive

and Resistance Resources and forward-looking attitudes, social contacts
Among Older Adults with family and others, being physically and
mentally active, conscious of maintaining posi-
To strengthen SOC among older adults, it is imper- tive lifestyle and being satisfied with own life
ative to identify and mobilise resistance resources were health-­promoting characteristics exhibited
which facilitate health-promoting processes. by other adults with strong SOC [36]. These
In an integrative review by Tan et al. [27], fac- findings corresponded with the characteristics
tors which correlated with SOC positively were displayed by older adults with high QoL and
reported as resistance resources among older stronger SOC [37].
community dwellers. These resources included Regardless of the method used to identify
one’s immune function, appraisal of situations, resources related to SOC, findings from this brief
coping strategies, self-care abilities, social sup- literature synthesis corroborated with the health
port and income. Similarly, social resources such assets reported in a recent systematic review [38].
as having time with children and grandchildren, These assets included self-appraised health and
and relocation within past 5 years were associ- life satisfaction, psychological well-being, social
ated with SOC among older adults [28]. networks, engagement in leisure and social activi-
Several studies examined how SOC mediated ties, education and financial resources. While our
effects of various resources on health-related literature synthesis focused on resources related
outcomes and well-being among older adults. to SOC, the systematic review examined factors
These studies found that resistance resources which positively influenced multidimensional
such as education [29], marriage among men health at old age [38]. This confirmed a strong
[30], self-­ efficacy [29, 31], self-esteem [29, relationship between SOC and health, suggesting
31, 32], lesser chronic conditions [32], cogni- that resources for SOC could be pooled together
tive function [30], lesser depressive symptoms with health assets for older adults.
[31], social support and family relations [31, Evident from the literature, most SOC
33], engagement in physical exercises and daily research conducted among older community
activities [30, 31], competence in motor activi- dwellers employed quantitative methods to exam-
ties such as speed walking and swimming, and ine relationships between resources, SOC and
having sense of autonomy and identity [31] con- health-­related outcomes. Through these quantita-
tributed to enhancing SOC among older adults. tive studies on SOC, resources were identified.
Additionally, how older adults perceived lei- However, it is more valuable to understand how
sure and their self-­ efficacy to perform leisure resources could be mobilised for utilisation com-
were reported as significant resources influenc- pared to prior resource identification in enhanc-
ing SOC, which mediates effects on attitudes ing SOC [20]. Moreover, SOC is activated when
towards retirement [34]. These causality studies one encounters stressful situations or events in
supported the salutogenic concept of resistance life, and this cannot be observed from the outside
resources facilitating one’s SOC which in turn [39]. Qualitative studies can capture this process
promoted health [20]. and understand precisely what SOC is according
Alternatively, resistance resources could pro- to its components, comprehensibility, manage-
vide life experiences which reinforce SOC over ability and meaningfulness, and how SOC inter-
time and this could be illustrated using a longitu- venes in different situations and experiences [39].
dinal cross-lag study design. Monma, Takeda, and However, there were few SOC or salutogenic the-
Okura found engaging in frequent leisure-­time ory related qualitative studies conducted in older
physical activities, such as walking outside home community dwellers [12, 16, 36]. Amongst them,
and participating in sports of various intensities, two studies used the salutogenic perspective to
had longitudinal cross-lagged and synchronous explore perceptions of healthy aging [12, 16]
effects on SOC among Japanese seniors [35]. while the other purposively sampled older adults
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 335

with high SOC to explore their self-care experi- the development of the SHAPE intervention as
ences in health management [36]. Although the described later in this chapter.
third study was not directly related to healthy
aging, perspectives of older adults with strong
SOC were of key interest to the authors. 23.3.3 Interventions Enhancing SOC
All three studies concurred that older adults
who were satisfied with their health had positive Despite empirical evidence calling out to
attitudes and adopted an asset-based perspective. strengthen SOC, there are no clear directives
Healthy aging was described in the context of in formulating SOC-enhancing interventions.
everyday life and interaction with environment, Based on theoretical explanations, Super et al.
making references to one’s physical and mental [42] proposed that SOC can be strengthened by
functions, relationships with people, places and two processes, namely empowerment and reflec-
institutions [12, 16, 36]. These findings suggested tion. Empowerment, which acts on the behav-
that salutary factors contributing to healthy aging ioural mechanism, can be facilitated by enabling
are embedded in daily life activities of older individuals to identify appropriate resources to
adults; and these salutary factors involves the manage or avoid stressful situations. Reflection
mobilisation of one’s attitudinal, physical, social involves the perceptual mechanism to enhance
and infrastructural resources. individuals’ perceived understanding towards
Upon analysis of how the SOC concept situation, perceived knowledge on resources for
was construed, only one of the three qualita- mobilisation and perceived feeling that address-
tive studies reported findings that correspond ing the situation is a meaningful process.
with the meaningfulness component [16]. This Nonetheless, a good way to uncover SOC
study described health as the ability to engage strengthening strategies is to learn from exist-
in meaningful activities but made no reference ing interventions that used SOC as a dependent
to comprehensibility and manageability. None of variable, regardless whether SOC was enhanced,
these three studies shed light on the function and maintained or weakened [39]. Since the tar-
application of SOC and its components, which geted population is older adults, interventions
was crucial in understanding SOC-enhancing conducted in older populations would first be
processes among older adults to advance healthy examined, followed by other pertinent interven-
aging. In relation to resource mobilisation, tions which demonstrated effectiveness in SOC
Naaldenberg et al. [12] revealed challenges enhancement in other populations.
encountered by older adults, such as misinter- A total of nine interventional studies which
preted information about resources and nega- evaluated SOC as an outcome variable among
tive self-perceived ability to use resources. Such older adults were reviewed in this section to
findings on how older adults cope with existing understand the potential SOC-enhancing strate-
resources are important in identifying problems gies among older populations. These nine studies
faced, so that strategies could be undertaken to were identified based on a comprehensive search
increase the ease of resource utilisation. The on PubMed and CINAHL databases using the
other two qualitative studies merely described keywords ‘elderly’, ‘experimental studies’ and
health-promoting actions, along with the men- ‘sense of coherence.’ While five studies evalu-
tion of resources [16, 36]. ated on health education interventions related to
As such, the authors conducted a qualitative self-­management [43–47], three studies focused
study employing the salutogenic perspective to on exercise training interventions [48–50] and
explore the application of SOC concept [40] and one study evaluated an intergenerational pro-
mobilisation of resistance resources [41] among gram involving older adults to read picture books
older community dwellers to obtain insights on to children [51]. Among the five health educa-
how healthy aging could be promoted. The key tion interventions, four of them yielded promis-
findings from this study were thus applied in ing findings in enhancing SOC of older adults
336 B. Seah and W. Wang

[43–45, 47]. The three exercise training inter- topics related to physical well-being, psychoso-
ventions differed in the duration of intervention, cial well-being, physical activity and motivation;
ranging from 12 [50], 24 [48] and 36 weeks [49]. that is, to motivate older adults in using their
Significant positive SOC change was reported for internal and external resources. REAP addressed
the 36-week resistance training intervention only resistance resources in their daily activities in
[49]. As for the intervention on intergenerational hope to enhance comprehensibility, manage-
program, only the meaningfulness component ability and meaningfulness of SOC, as reported
increased significantly for older adults whom in their study protocol [52]. Participants whom
read picture books to children [51]. received the REAP program reported enhanced
Drawing attention to the health education SOC, particularly in the comprehensibility and
interventions, the authors identified two common manageability domains [47].
characteristics of the four interventions which Apart from examining SOC-enhancing inter-
yielded significant post-test SOC improvements ventions among older adults, other pertinent
[43–45, 47]. These two characteristics might SOC-enhancing intervention studies conducted
shed some light on SOC-enhancing strategies. in other populations were considered. Notably,
Firstly, these four health education interventions the first intervention designed to strengthen SOC
involved active engagement of older adults to was conducted for patients with mental health
be aware of own abilities, resources and health illnesses [53]. This 19-week talk therapy inter-
situations. Such intervention engagement was vention consisted of 1.5-h weekly group meet-
delivered in the form of interactive group activi- ings involving 5–9 participants and 1 mental
ties [47], individual face-to-face interviews using health professional. During which, participants
assessment forms [44, 45] or senior meeting dis- discussed about challenges important to them
cussions and a home visit [43]. Secondly, these in relevance to their everyday life, followed by
four interventions equipped and empowered reflective conversations on specific topics which
older adults with knowledge on coping strate- they had prepared as homework. The intervention
gies of various aspects, ranging from managing program was guided by five salutogenic therapy
daily living needs, aging-related issues, home principles and its detailed theoretical application
safety and healthy lifestyle behaviours. Three out was reported [54]. The five salutogenic principles
of four of these health education interventions which were adopted are as follows: (a) the health
even provided educational booklets related to continuum model, (b) the story of the person,
these specific topics [43–45]. On side note, the (c) health-promoting (salutary) factors, (d) the
only health education interventional study which understanding of tension and strain as poten-
reported decreased SOC scores in both interven- tially health promoting and (e) active adaptation.
tion and control groups might have minimal face-­ Significant improvements in total SOC, com-
to-­face active engagement to allow for the deep prehensibility and manageability were observed
learning of resources and sharing of knowledge with the talk therapy intervention [53].
on coping strategies [46]. After all, this health Based on the review of the nine interventional
education intervention comprised five motiva- studies which evaluated SOC as an outcome vari-
tional interviewing self-care telephone talks with able among older adults as well as the saluto-
health care professionals. genic talk therapy intervention study conducted
Among the nine reviewed intervention studies, on mental health patients, the following are pos-
it is noteworthy that Tan et al. [47] used the salu- sible SOC strengthening approaches, comple-
togenic theory as underpinning theoretical frame- menting underlying processes on empowerment
work for a self-care health education program, and reflection [42]. Firstly, these SOC-enhancing
titled Resource Enhancement and Activation interventions included face-to-face social inter-
Program (REAP). This self-care program con- action with peers and/or health care profession-
sisted of 24 group activities conducted twice a als to facilitate discussion and mutual learning.
week, over 12 weeks. The activities focused on Through them, active participation of ‘being
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 337

present with others’ allowed interactive informa- maintain their health. Apart from residing in a
tion exchange and reflective awareness of own resource-rich external environment where the
situation. Secondly, topics discussed were related local government recently channelled consider-
to managing everyday life affairs and challenges, able capital and support to create an age-friendly
regardless of the intervention agenda [43–45, 47, living city [61], older adults accrued an internal
54]. They developed mastery in perceptual under- rich source of personal strengths, life disposi-
standing towards demands of everyday life and tion, experiences, self-care skills and knowledge,
learning the know-how on how to go about with as well as social resources comprising family,
valued coping activities. After all, SOC is about friends, neighbours and social activities [41].
one’s global orientation towards life. Thirdly, However, these older adults residing in senior-
the interventions are resource programs that only households displayed variable levels of
provided participants with information beyond resourcefulness in gaining access, maintaining
health knowledge and resources, they included and utilising their health resources; some were
concrete skills. They focused on devising solu- less proficient in understanding and mobilising
tions through problem-solving or learning to be them [41]. Furthermore, most of the older adults
resourceful in managing challenges encountered. aged 65 years and above in Singapore received
Through them, participants are empowered with minimal years of education [62] and might not
resources through knowledge acquisition, clarifi- be information savvy. Construction and inte-
cation, experimentation and reflective awareness gration of useful applicable self-care health
of own situation and values. information and meaningful utility of the older
adults’ internal and external health assets via a
health resource program is thus needed. As such,
23.3.4 T
 he SHAPE Intervention: SHAPE was initiated and designed for senior-
A Health Resource Program only household dwellers to strengthen SOC, bet-
for Senior-Only Household ter navigate health resources and facilitate them
Dwellers Living in a Resource-­ in applying health resources to their own context
Rich Environment of health and daily living.
The SHAPE intervention is an integrative
Globally, two in five older adults live indepen- multidimensional health resource program with
dently, either living alone or with spouse only the aim of increasing SOC of senior-only house-
[55]. Owning to changes in marital preferences hold dwellers. SHAPE focuses on identifying,
[56], personal living arrangement preferences equipping and strengthening the seniors’ exist-
[57–59], forced familial circumstances [59] or ing internal and external resistance resources to
greater affluence and financial independence adopt health-promoting strategies and cope with
among older adults [58], Singapore observed a aging-related challenges, thereby living a healthy
rise in the number of senior-only households in and meaningful life.
the recent decade [60]. Where aged care is con- The SHAPE-program consisted of 12 weekly
cerned, familism play an important role in sup- group sessions, at least two home visits and a sup-
porting and caring for older adults in Singapore. plementary health resource book. Its curriculum
With lesser familial contact time and exchanges, was designed to address the stressors of healthy
senior-only household dwellers might receive aging faced by senior-only household dwell-
lesser familial resources that are instrumental to ers using their health assets/resistance resources
healthy aging in their everyday lives. [41]. Its content was drawn from the aging expe-
Based on the qualitative study the authors riences of older adults residing in senior-only
conducted on older adults residing in senior- households to align health-promoting strategies,
only households in Singapore [41], family thereby meeting the demands and needs of their
members are nevertheless amongst the wealth everyday lives. Stressors of healthy aging include
of health assets they utilised to promote and physiological decline, shrinking social connec-
338 B. Seah and W. Wang

tions, requiring situational tangible assistance, 23.3.5 Application of the Salutogenic

encountering unpredictable life events and patho- Theory in SHAPE Intervention
genic health orientation [40].
Instead of being teachers who impart health The following sections describe and illustrate
knowledge and coping strategies, health care examples on how the SHAPE intervention
professionals leading both the group sessions and approach, content and activities addressed SOC,
home visits are resource facilitators. These health resistance resources and the salutogenic orienta-
care professionals play a critical role in engaging tion sequentially. While the authors attempted to
participants in exploration, knowledge acquisi- delineate the application of the salutogenic the-
tion and reflection. Additionally, the principles ory, the following section contains some overlap-
of salutogenesis have to be integral to the values ping operation of principles and concepts across
and beliefs of these resource facilitators to influ- the aspects on SOC, resistance resources and the
ence and elicit participants’ perceptual awareness salutogenic orientation.
towards their worldviews, late life and resources
at their disposal. 23.3.5.1 Sense of Coherence (SOC)
An intervention manual was developed to SOC is a global orientation of how one views the
provide resource facilitators with clear direc- world and individual’s stress-rich environment
tives on the implementation of the SHAPE inter- as comprehensible, perceives one’s capacity to
vention. This manual described the principles of activate resource utilisation generating health-­
SHAPE intervention, and the detailed conduct promoting strategies as manageable, and view the
of each session; all of which were developed to confrontation with stressors as meaningful, with
be consistent with the intervention aim and the purpose and worth. Having a better understand-
salutogenic theory. Outline of each session con- ing of older adults’ stressors, health assets and
sisted of specific learning objectives and evalu- health-promoting strategies provided the contex-
ative outcomes, experiential activities arranged tual knowledge on SOC strengthening processes
in developmental order and process questions in [40, 41]. Comprehensibility can be strengthened
the form of weekly homework for participants to by reducing the unpredictability and incompre-
reflect and connect the content of each session hension of aging-related processes and daily liv-
to their lives [63]. The supplementary resource ing challenges. Manageability can be enhanced
book was designed as a consolidative easy-to- by supporting and empowering older adults in
read health information book that complements using their health assets/resistance resources to
the content of the group sessions and home adopt health-promoting strategies to deal with or
visits. Both the intervention manual and the avoid the stressor(s). Lastly, meaningfulness can
resource book were content validated by a panel be fortified by activating older adults to reflect
of experts and potential users of the program to and make sense of old age experiences. Having
ensure the appropriateness, comprehensibility to contemplate about what life at old age meant
and applicability of the SHAPE intervention. gives one a better sense of identity and affirma-
The panel comprised two academic experts in tion of own values and life direction [64].
salutogenesis, an academic expert in geronto- The curriculum of SHAPE intervention
logical social work, one senior physician with is guided by the three SOC components and
geriatrics specialty, one senior nurse trained in strengthening processes to equip older adults
geriatrics and gerontology and two senior com- with resource information to cope with healthy
munity social workers. They provided ratings aging stressors. Figure 23.1 illustrates the cat-
using scoring rubrics and gave comments related egorisation of intervention curriculum accord-
to the relevancy, comprehensibility, adequacy ing to the three SOC components. They are (1)
and organisation of intervention. Revisions were the cognitive aspect of understanding health and
made by the authors in accordance to the feed- aging-related topics, (2) the behavioural aspect of
back received. managing health by adopting health-promoting
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 339

Cognitive Behavioral Motivational

Find
Understand
Manage meaning/
health & aging
purpose

Learn & know Take actions Reflect & embrace

What is health? (Wk1, HV1) Keep myself mobile & active* Appreciate value of being old
Aging processes (Wk3) (regular exercise & activity) (Wk 1, 2)
Social transitions (Wk4) Eat nutritious & healthy food* Live a meaningful & healthy
Psychological health (Wk5) Self-manage chronic diseases* life (HV1, Wk 2)
Nutritional needs (Wk6) Keep a positive psychosocial state Set goals to achieve better
Cognitive health-dementia (Wk7) of health* (cognitive, social, health (HV2)
Falls (Wk8) emotional, spiritual wellness & Look forward and move on, so
Chronic & acute diseases (Wk9) sleep) that I can be better (Wk 12)
Being ill & hospitalised (Wk10) Living at home safely* (fall
End-of-life & death (Wk11) prevention, self-monitoring)
Myself (HV1, HV2) Manage money & assets*
Plan ahead for illness & death*

Fig. 23.1 Curriculum of SHAPE intervention categorised according to SOC components. Wk week, HV home visit,
*chapters in resource book

actions and (3) the motivational aspects of find- and includes information on available resources
ing meaning and self-worth at old age. supporting these actions.
The understanding of health and aging acts Through personal reflection of experiences in
on cognition to increase comprehension and pre- life, one can find meaning, value and purpose,
dictability towards health changes and life events providing the motivation to embrace life in old
encountered, making life in old age structured age. The group sessions in week 1, 2 and 12, as
and consistent. The 12 weekly group sessions well as the home visits allow participants to look
encompass a broad range of health and aging back at their past life experiences, connect to
topics, which allow participants to be aware of, their present and project into the future on how
and gain understanding towards their physical, they can live a meaningful healthy late life. These
psychological, social and spiritual experiences reflective sessions help to seek meaning of one’s
during old age. existence from the past to derive meaning for
Provision and facilitation of awareness the present and basis for meaning in future [65,
towards resource information and experien- 66]. The sessions also create a sense of aware-
tial mobilisation of resources seek to improve ness, identity and a destination or purpose in life
perceived ability to manage stressors through for the participant [67]. These reflections bring
behavioural change. During the group sessions, coherence of story to one’s life, contributing to
participants and resource facilitators share the cognitive, emotional and motivational aspect
with each other coping strategies and prac- of SOC [68].
tice some of these strategies together to tackle
aging-related stressors and daily living chal- 23.3.5.2 Resistance Resources
lenges. Additional resource information is also Both SOC and resistance resources have a
provided in the SHAPE resource book, which dynamic and reciprocal interactional ­relationship.
recommends various health-promoting actions While resistance resources contribute to SOC-
340 B. Seah and W. Wang

enhancing experiences, SOC contribute to mobil- group sessions and home visits, the resource
isation of resistance resources to cope with life facilitator probes and prompts older adults to
stressors [69]. To address the three SOC aspects reflect and internalise the insights and meanings
from the perspective of resistance resource drawn from their significant life experiences.
mobilisation, the SHAPE intervention promotes In addition to the significant roles of the
the exploration and awareness (cognitive), identi- resource facilitator, the resource book provides
fication and utilisation (behavioural), and reflec- older adults with opportunities to create SOC-­
tion and internalisation of resources to generate enhancing experiences independently. The
SOC-enhancing experiences (motivational) [41]. resource book is designed to make one-stop
More specifically, resistance resources create ‘resistance resource’ information available and
experiences of consistency, load balance, par- accessible to older adults who are less literate or
ticipation in valued decision-making, thereby savvy in information technology. Although the
contributing to comprehensibility, manageabil- titles of the resource book chapters were targeted
ity, meaningfulness, respectively [69]. The eco- at SOC manageability (Fig. 23.1), the contents
map of aging assets emerged from the qualitative in the chapters addressed both SOC comprehen-
study provided a visual framework to guide resis- sibility and manageability. To facilitate adop-
tance resource mobilisation [41]. tion of health-promoting strategies more easily
Firstly, to create experiences of consistency via the mobilisation of ‘resistance resources’,
via SOC comprehensibility, older adults need to the resource book provides contextual informa-
process cognitively that there is order and struc- tion on the local services, communal activities,
ture in their life. The resource facilitator engages and government schemes, as well as practical
older adults to be aware, apprehend and distin- information on where and how these ‘resistance
guish the types of appropriate resources to cope resources’ can be accessed. At the end of chapter,
with the specific demands of aging-related pro- additional information sources such as hyper-
cesses and vulnerabilities during late life. links and QR codes are provided to allow inter-
Secondly, to create experiences of load bal- ested older adults to explore further. The intent of
ance via SOC manageability, older adults need providing such access information was to impel
to take on behavioural actions in identifying and older adults to search for information when
utilising the resources available to them. Such needed, as part of a health-promoting strategy in
experimentation and experiential learning in face of stressors.
developing the ability to activate the appropri-
ate resource from their environment allow them 23.3.5.3  he Salutogenic Orientation:
T
to develop the know-how knowledge in initiat- Five Salutogenic Principles
ing and maintaining the utility of the resource. To reinforce the salutogenic orientation and sup-
This brings about the adoption of health-promot- port the operationalisation of SOC and resistance
ing actions in their everyday lives. The resource resources, the aforementioned five salutogenic
facilitator influences older adults by encourag- principles (Sect. 23.3.3) which guided the salu-
ing, reinforcing and complimenting them for togenic therapy talk intervention [54] were
their acts of resource utility. also employed in the development of SHAPE
Lastly, to create experiences of participation intervention. The following describes the five
in valued decision-making via SOC meaningful- salutogenic principles and illustrates how these
ness, older adults’ motivation of utilising the spe- principles were integrated in the approach, con-
cific resources to perform the health-promoting tents and activities of the SHAPE intervention.
behaviour needs to be intrinsic and based on per-
sonal decision-making to shape their health out- Health as a Continuum
comes. Each older adult has to engage him/herself This salutogenic principle focuses on facilitat-
emotionally in making sense of the intended pur- ing older adults to move forward along the health
pose of using the specific resource. During the continuum, by addressing health-promoting fac-
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 341

tors instead of managing risk factors to avoid dis- used as a tool to simulate and facilitate movement
eases. This requires a perceptual change among on the health continuum [74]. In the SHAPE
older adults if they adopt a disease-oriented defi- intervention, the following question is used: ‘On
nition towards health. The adoption of strength-­ a scale of 0 to 10, where 0 refers to worst imag-
based perspective which focuses on what works inable life and 10 as best imaginable life, how
well can address this. It shifts frame of reference would you rate yourself as living meaningfully
to redefine issues according to experiences of an and healthily now?’. If the older adult rates four,
individual instead of problems or health deficits the resource facilitator can ask why the rating is
[70]. Such perspective views older adults ‘by not a two or six to find out possibilities of what
their values, strengths, hopes, aspirations, and the former hopes to achieve and what had been
capacities, regardless of the stressful or bur- achieved. It allows exploration of possible prog-
densome nature of the situation around them’ ress of the older adult’s health position in the
(p. 642–43). With an assumption that people are immediate future [75].
capable of growth and change, older adults can
be assisted to develop insight to their strengths The Story of a Person
and resources [71]. Having to learn about the story of an older adult
To embrace the strengths-based perspective, recognises him or her as a person with rich
approaches used in various strength-based mod- diverse experiences, mould by a set of attitudes,
els, such as appreciative inquiry, building capaci- beliefs, values, social cultural norms, daily life
ties and solution-focused therapy [70], were activities and interaction with their physical,
incorporated in SHAPE intervention. social and structural environment. It is contextu-
Appreciative inquiry uses a way of asking alised and sees a person behind the illness and
questions to appreciate ideas that have worked disease [20], akin to person-centred thinking in
and use these ideas to envision and shape the contrast to disease-centeredness or the focus on
future [72]. The resource facilitator can engage impairment in care delivery [76].
older adults in ‘strengths chats’ by asking the Underpinned by values of respect for person,
right questions [70]. Asking about past positive individual’s right to self-determination, mutual
experiences can uncover and draw on individu- understanding and respect [77], person-centred
al’s strengths while inquiring about the form of approach traced back to humanistic psychology
support needed to build upon existing strengths, and person-centred therapy [78]. Elements of
and information about past and present issues person-centred approach involves perceiving a
influencing or preventing the use of strengths person holistically and as an unique individual,
could help in formulating health-promoting being empathetic towards his/her experiences,
strategies [70, 73]. Using the same question in needs, values and preferences, having mutual
the qualitative interview [40], older adults can trust and relationship with each other and par-
be asked to share their healthiest or most ener- ticipative decision-making through information
gised moments during their late life to elucidate exchange and communication [79–82], with
characteristics which create health in them. They the goal of achieving a meaningful life [79]. It
could be guided to perceive that these moments requires openness to experiences, being curious,
of accomplishment on desired pursuits or activi- understanding, having respect and the estab-
ties are examples of moving forward along the lishment of trusting, collaborative and egalitar-
health continuum. In this way, reframing and ian relationship between older adults and the
redefinition of health from pathogenic to saluto- resource facilitator.
genic perspective is facilitated among the older In SHAPE intervention, part of understand-
adults [40]. This also expands their meaning of ing the story of person for the resource facilitator
being healthy. is to use narrative accounts as a tool to understand
Scale questions, a solution-focused therapy participants’ values in life [80]. Narrative accounts
technique which use scale from 0 to 10, can be also emanate participants’ awareness towards own
342 B. Seah and W. Wang

living situation, facilitating conscious recognition such as community services and government sup-
of own internal and external resources to cope with port schemes, exchange of information through
it. This tool uses language expression to organise printed materials and discussions are facilitated.
one’s thoughts and feelings, creating and describ- This involves the resource facilitator to share rel-
ing a ‘pre-­understanding’ of situations [83]. It is evant health knowledge and resource information
insight-oriented because it sheds light on the partic- with older adults too.
ipant’s coping capacity and strategies to adopt [54].
Stress and Strain as Potentially Health
Health-Promoting Factors Promoting
Contrary to deficit orientation, salutogenic think- According to Antonovsky, stressors and tension
ing focuses on health-promoting factors through create life experiences of inconsistency, over-
resource mobilisation, building and enhancing load and lack of engagement in decision-making,
capacities through process of empowerment [21]. which provide situations for developing coping
It has been suggested that salutogenesis could capacity and generating SOC [20]. Being chal-
provide the underpinning theoretical basis for lenged by tension-causing stressors to adapt is
health assets [84, 85]. salutary and health promoting.
The SHAPE intervention adopts an asset-­based Confrontation as a form of coping strategy to
approach to facilitate aging assets mobilisation. stressors has been found to have mediating effects
Apart from providing information needed for on both SOC and self-care behaviours [88]. Having
resource mobilisation, SHAPE encourages older to confront and discuss openly about stressors
adults to gain insight that they can contribute to could reduce older adults’ incomprehension,
their own health by identifying and learning how enhance manageability and promote acceptance
to access and use resources [86]. The resource towards it. This can result older adults in resource
facilitator engages older adults to recognise their activation and adopting positive health behaviours.
personal, social, economic and environmental fac- In SHAPE intervention, stressors such as
tors as health assets which they could use to pur- unpredictable illness and death are confronted
sue desired activities or health goals [38]. by anticipating experiences of and preparing for
In the intervention, simple activities are illness and death. Examples of activities include
planned to raise older adults’ awareness towards hands-on usage of assistive ambulatory aids,
their resources. This includes reflection on iden- exposure to common medical requisites encoun-
tifying their unique strengths/attributes and plot- tered during hospitalisation and introducing
ting daily activity routine on a 24-h activity clock advance care plans [52]. Although this approach
to identify activity participation preferences and presents an adverse portrayal to older adults, it
involvement. Also, having older adults to draw can be introduced in a safe learning environment
their own social eco-map allows them to have for them to inquire and clarify doubts.
an overview of their existing social capital and As stressors are omnipresent [20], it is impor-
reflect on how some of these relationships could tant to universalise feelings of tension by acknowl-
be strengthen or improved. Unlike in social work edging normalcy of stressful experiences [54].
profession, social eco-map is used as an assess- This requires the older adults to a­cknowledge
ment tool to understand client’s sources of psy- and accept stressors such as physiological and
chosocial stress and transactional relationships, social changes of aging, and times of vulnerabil-
aiding in development of care interventions such ity requiring tangible assistance. Having to discuss
as discharge planning [87]. During the interven- and hear stories of others who underwent similar
tion, participants are encouraged to build their experiences help in normalising these feelings of
social network by establishing and maintain- tension. Also, such perception towards stress and
ing new social relationships, such as making tension should be consistently demonstrated in the
friends. To further equip older adults with self- resource facilitator’s attitude and interaction with
care knowledge and relevant external resources older adults during the SHAPE intervention [54].
23 SHAPE: A Healthy Aging Community Project Designed Based on the Salutogenic Theory 343

Active Adaptation values the life experiences of the person. This

Aforementioned, salutogenic processes which perspective involves a conscious reflection of
involve developing personal capacity for how an individual views life as a whole to cope
resourcefulness are more important than provid- with the salutary vulnerabilities and stressors
ing resources as pre-requisites for SOC enhance- in old age. Healthy aging is a multidimensional
ment [20, 24]. Creating such experiences during concept embraced in the SHAPE interven-
SHAPE intervention would allow resources to tion. Based on the salutogenic principles, SOC
be internalised by older adults through personal and resistance resources, SHAPE is a health
usage, giving them a sense of ownership and resource program that employs an asset-based,
control of their own health and aging journey person-­ centric and insight-oriented approach.
[24]. Activities such as hands-on preparation of Apart from the intervention approach, content
nutritious meal, acts of physical exercises and and activities, the SHAPE intervention places
accomplishment of personal health goals using emphasis on the significant role of health pro-
‘resistance resources’ could provide experiential fessionals conducting the intervention to com-
and adaptation opportunities for the older adults. municate and elicit the salutogenic perspective
In addition, as one ages and confronts with to its target audience—senior-only household
life experiences, personal meaning to life and dwellers. To advance this salutogenic initiative,
health changes [64]. The use of self-reflection the SHAPE intervention needs to be piloted to
is an essential tool to construct participants’ test for its feasibility.
personal meaning of health and meaning in life
at old age. It creates self-awareness of know- Take Home Messages
ing own self, contributing to meaning-focused • The salutogenic perspective on healthy aging
health-­promoting strategies as part of adapta- views aging as an achievement; where older
tion. This, however, is a developmental process people are valued as assets for their wealth of
which requires creation and self-discovery [68]. experiences, resources, skills and knowledge.
The use of narrative life stories can contribute to • The SHAPE intervention embraces the multi-
older adults’ sense of self, uncover their meaning dimensional concept of healthy aging; It cov-
in life, allow them to accept life, and live with ers a range of comprehensive health and aging
purpose and enthusiasm [64]. A quick life review topics encompassing physical, psychological,
activity using a life ruler can allow older adults psychological, social and spiritual aspects of
to reminisce and appreciate past experiences of aging.
personal development, achievements, loss and • The concepts on sense of coherence, resis-
hardship in their life journey. It facilitates par- tance resources and the salutogenic orienta-
ticipants to examine how their stories contribute tion are operationalised and illustrated in the
to their meaning in life, and come to terms with intervention approach, curriculum and the
aging [65]. Integrating experiences of past dif- conduct of SHAPE.
ficult transitions and vulnerabilities help them • As a health resource program, the SHAPE
to accept loss and hardship, preserve their self- intervention aims to strengthen ‘resistance
worth and adapt to present life stressors [89]. resources’ of older adults, so as to promote
the adoption of health-promoting strategies
and coping of stressors at old age; it employs
23.4 Conclusion an asset-based, person-centric and insight-­
oriented approach.
Salutogenesis introduces a paradigm on the ori- • Health professionals conducting salutogenic
gins of health; what is health and how health can theory based interventions such as SHAPE
be created. In the context of healthy aging, the play an important role of communicating and
salutogenic perspective recognises aging as a eliciting the salutogenic perspective to the
positive developmental process of a person and participants.
344 B. Seah and W. Wang

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 Health Promotion
in the Community Via
24
an Intergenerational Platform:
Intergenerational e-Health
Literacy Program (I-HeLP)

Vivien Xi WU

Abstract I-HeLP aims to engage youth volunteers to

teach older adults regarding e-health literacy,
The increase in life expectancy and empha-
and enhance older adults’ sense of coher-
sis on self-reliance for older adults are global
ence, e-health literacy, physical and mental
phenomena. As such, living healthily in the
health, cognitive function, quality of life, and
community is considered a viable means
intergenerational communication. I-HeLP
of promoting successful and active aging.
promotes social participation, health, and
Existing knowledge indicates the prevalence
wellbeing of older adults, and empowers the
of health illiteracy among the older population
younger generation to play an active role in
and the impact of poor health literacy on health
society. Furthermore, I-HeLP aligns with the
outcomes and health care costs. Nevertheless,
‘Smart Nation’ initiative by the Singapore
e-health literacy is a critical issue for a rap-
government to empower citizens to lead
idly aging population in a technology-­driven
meaningful and fulfilled lives with the use of
society. Intergenerational studies reported that
technology.
older adults enjoy engaging with younger peo-
ple and benefit from the social stimulation by
Keywords
improved social behaviours, intergenerational
social network, and participation. Attitude towards the older generation
An Intergenerational e-health Literacy Community-dwelling older adults · e-Health
Program (I-HeLP) is developed to draw upon literacy · Empathy · Empower younger
the IT-savvy strength of the youth, and teach generation · Health promotion in the commu-
older adults to seek, understand and appraise nity · Intergenerational communication
health information from electronic sources Reliable health-related e-resources
and apply knowledge gained to address the Salutogenesis · Youth volunteer
health problem. I-HeLP is an evidence-based
program, which provides comprehensive cov-
erage on relevant health-related e-resources.
24.1 Introduction
V. X. WU (*)
Alice Lee Centre for Nursing Studies, Yong Loo Lin Improved living conditions, medical technology,
School of Medicine, National University of and health services increase the life expectancy
Singapore, Singapore, Singapore of people. The United Nations [1] reported that
e-mail: nurwux@nus.edu.sg

© The Author(s) 2021 349

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_24
350 V. X. WU

only 8% of the world’s population were aged 60 boosting the quality of life, health status and life
and above in 1950; it increased to 12% by 2013, satisfaction [8]. Jenkins’ study [8] shows that
and is expected to rise to 21% by 2050. The participation in these programs brings intrinsic
global increase in life expectancy has made aging enjoyment and provides opportunities to get out
a political and economic issue as increased lon- and socialise. The results of the intergenerational
gevity raises social concerns about rising ­health study indicate improved social behaviours, inter-
care costs. Community-dwelling older adults are generational social network scores and intragen-
defined by those aged 60 years and above and erational social support, and increased social
living independently in a community [2]. Some participation [9].
older adults may live healthily in a commu-
nity, but others may suffer from a large variety
of health care problems, ranging from just get- 24.2.2 E-Health Literacy
ting older to specific medical conditions such as
stroke, diabetes, osteoarthritis, or dementia. Health literacy is the degree to which individu-
World Health Organisation’s active aging als have the capacity to obtain, process, and
framework encourages the public and practitio- understand basic health information and services
ners to ‘support and value the process of opti- needed to make appropriate health decisions
mising opportunities to maintain and enhance [10]. Building on this definition, the concept of
physical, mental, and social health as well as inde- e-health is being promoted intensively with the
pendence and quality of life over the life course’ wide use of information technology. E-health
[3]. In this emerging paradigm, there is increas- literacy is the ability to seek, find, understand
ing pressure on older adults to keep themselves and appraise health information from electronic
active and independent—physically, mentally and sources and apply the knowledge to address a
socially—in their communities, and cope with health problem [11]. Existing knowledge indi-
chronic health conditions and other challenges cates the prevalence of health illiteracy among
in late life [4]. The increase in life expectancy the older population and the impact of poor
and emphasis on self-reliance for older adults are health literacy on health outcomes and health
global phenomena. As such, living healthily in the care costs. Nevertheless, e-health literacy is a
community is considered a viable means of pro- critical issue for a rapidly aging population in a
moting successful and active aging. technology-­driven society. Literatures illustrate
that intergenerational programs could contribute
to the wellbeing of older adults holistically [9].
24.2 Background and Literature Herein, we describe an intergenerational e-health
Review literacy program developed to draw upon the
IT-savvy strength of youth teaching older adults
24.2.1 Benefits of Intergenerational to enhance their abilities to seek and appraise
Interaction electronic health information.

Intergenerational studies reported that older

adults enjoy engaging with younger people, and 24.2.3 Empathy and Attitudes
that they benefit from the social stimulation [5]. Towards Older Adults
Research indicates that older adults often par-
ticipate in lifelong learning programs based on Empathy is the ability to identify and share emo-
their interest and interaction with others [6]. tions of others, and feel concerns when others are
These are often similar motivations for older in distress [12]. Regardless of age, empathy is one
adults who choose to engage in intergenerational of the key factors that affects one’s social interac-
learning projects [7]. Emerging evidence shows tion and communication with other people [13,
that intergenerational programs are significantly 14]. Rapid growth of aging population changes
associated with subjective wellbeing in terms of socio-structural dynamics [15]. Enlarged aging
24 Health Promotion in the Community Via an Intergenerational Platform: Intergenerational e-Health… 351

population might increase intergenerational and make commitments [25, 26]. It promotes the
prejudice and tension between younger and older sense of belonging and social inclusion for older
generation [15]. Negative stereotypes towards adults, which could lead to a greater sense of
older adults do exist, including the portraying of life’s meaningfulness [27].
older adults as being lack of independence, less SOC is a dispositional orientation of life
contributing, more fragile and forgetful [16]. described as perceived as comprehensive, man-
Gradually, the older adults tend to accept the ste- ageable and meaningful, influencing how people
reotypes and may develop low self-­esteem [16]. think and behave by utilising the resources they
During the process of self-­ stereotyping, older have [24]. SOC comprises three core components:
adults may experience failing memory, decreas- comprehensibility, manageability and meaning-
ing cognition, frailty, and even cardiovascular fulness. An individual with well-­developed SOC
symptoms as a result of feeling stressed [17]. is able to enhance his/her health by reducing the
As a reflection, the younger generation may exposure to emotional and physiological stress-
develop negative attitudes towards older adults ors. SOC could be developed over time through
due to the stereotypes, even despite having initially empowering people with knowledge, experi-
had positive attitudes towards the older generation ence, and perceived meaning-in-life, and utilis-
[18]. Studies reported both younger and older gen- ing appropriate resources to minimise negative
eration could experience negative feelings during impacts on health [23]. The e-health literacy
intergenerational communications and interac- program provides a platform for older adults to
tions [19, 20]. However, with more contact with access to GRRs, which is positively related to
older adults, youth has been shown to develop SOC, health condition and quality of life [26].
more empathy and positive attitudes towards older SOC plays an important role in the mental health
adults [21]. Hence, intergenerational programs and quality of life of older adults.
could also reshape the attitude and perception of An Intergenerational e-health Literacy
the younger people towards older generation. Program (I-HeLP) will be developed and evalu-
ated. I-HeLP aims to promote intergenerational
interaction between older adults and youth vol-
24.3 Conceptual Framework unteers who teach them e-health. I-HeLP is an
innovative program as it is guided by the salu-
The salutogenesis health model focuses on pro- togenic framework and integrates the concept of
moting individuals’ health rather than the tra- e-health literacy and intergenerational interac-
ditional risk and prevention focus which are tion which promotes social participation, health
central in the pathogenesis paradigm [22]. The and wellbeing of older adults, and empowers
salutogenic approach leads to a profound under- the younger generation to play an active role in
standing through reflection on life situations the society. Furthermore, I-HeLP aligns with the
and review of available resources and active ‘Smart Nation’ initiative by the Singapore gov-
adaptation to a stress-rich environment [23]. ernment to empower citizens to lead meaningful
The key concepts in salutogenesis consists of and fulfilled lives with the use of technology [44].
Generalized Resistant Resources (GRRs) and The notion of ‘Smart Nation’ opens up new pos-
Sense of Coherence (SOC). GRRs are protec- sibilities to enhance the way we live, work and
tive factors, such as knowledge and social sup- interact, and supports better living and stronger
port. The individual could better cope with life communities. Health and enabled aging are iden-
stressors with enhanced GRRs [24]. By interact- tified as one of the key domains, and government
ing with youth volunteers during e-health literacy has put in place the infrastructure, policies, and
program, community-dwelling older adults can enablers to encourage innovation [44].
improve their mental and cognitive wellbeing, as In summary, salutogenesis promotes health
well as their intergenerational communication. in the community. Besides benefiting for the
The e-health literacy program creates opportuni- older adults, I-HeLP provides a platform for the
ties for older adults to have more social contact youth to work with older adults and empowers
352 V. X. WU

Salutogenesis
Health Promotion in the Community

Older Adults
Aging population around the
1. Improves Sense of Coherence
world
2. Increases e-health Literacy
3. Better Cognitive and Mental Health
Intergenrational interaction
increases social participation 3. Higher Quality of Life
and support Intergenerational 4. Better Intergenrational Communication
e-health Literacy
Empowering youth with Program
(I-HeLP) Young Adults
empathy and positive
attitudes towards older adults 1. Increases Sense of Coherence
2. Strong Empathy
e-health Literacy promotes 3. More positive Attitudes towards older
the health outcomes and adults
reduces health care costs 4. Higher motivation for volunteerism
5. Better Intergenrational Communication

Fig. 24.1 Conceptual framework—salutogenesis

the youth with empathy and positive attitudes incorporated based on client-centred feedback
towards older adults. In a long run, the e-health which has been collected during usability sessions.
literacy program promotes health outcomes
and reduces health care costs. The impact
of I-HeLP is twofold: (1) for older adults— 24.4.1 Phase 1: Front-End Analysis
improves sense of coherence, cognitive and
mental health, increase e-health literacy, qual- A comprehensive search and evaluation of the
ity of life, and intergenerational communica- existing e-health literacy interventions are carried
tion; (2) for young adults—improves sense out. The evaluation from the evidence-based litera-
of coherence, more positive attitudes towards tures provides the fundamental understanding of
older adults, increase empathy, motivation for current interventions. The research team conducts
volunteerism, and intergenerational communi- focus groups with older adults to explore their
cation (Fig. 24.1). needs with regards to e-health. As an initial step,
the research team in the university and the manage-
ment team of Senior Activity Centres (SAC) had
24.4 Formative Design regular meetings and discussed the preliminary
of the Intervention: I-HeLP contents of I-HeLP and the methods of delivery.

This intervention is designed through a three-­

phase iterative, client-centred participatory action 24.4.2 P
 hase 2: Design
research process [28]. First, a front-end analy- and Development
sis is conducted via focus groups and literature
search to identify the unique health care needs of The evaluation of literatures and focus groups find-
older adults and to formulate initial design ideas. ings in Phase 1 are centred on developing the con-
Second, a preliminary design of the intervention is tents of I-HeLP. Information gleaned from focus
developed from literatures and focus group results. groups with older adults, and team design meetings
Finally, revisions and refinements are iteratively are applied for the development of I-HeLP. Based
24 Health Promotion in the Community Via an Intergenerational Platform: Intergenerational e-Health… 353

on client-centred design suggestions, the following from the participants during the development of
principles guide the development of I-HeLP: (1) the intervention and during usability testing, which
the intervention must be designed for older adults; subsequently are used to further extend and refine
(2) content must be related to the specific e-health the intervention [31]. The formative evaluation gen-
deficits that were identified during focus group and erates inputs regarding revisions and modifications
literature evaluations; (3) the content needs to be that inform the design and development of I-HeLP.
delivered in a brief and bite-size format to fit the
attention span and cognitive capabilities of the older
adults. A Content Expert Committee is formed 24.5 Outline of Intergenerational
which consists of two SAC managers who special- e-Health Literacy Program
ise in elder care, two researchers and one Advance
Practice Nurse who specialises in Geriatrics. The I-HeLP is developed to promote older adults’ intel-
Content Expert Committee reviewed the contents lectual activities and engagement with youth regu-
of I-HeLP and provided comments and feedback. larly and cyclically through weekly learning and
The research team revised the contents based on interacting session. The contents of the program
the feedback. are developed based on literature reviews [32, 33].
The outline of I-HeLP is illustrated in Table 24.1.
24.4.2.1 Pedagogical Considerations
Pedagogical decisions are driven by unique needs
revealed in Phase 1 focus groups. The interven- Table 24.1 Outline of the intergenerational e-health lit-
eracy program (I-HeLP)
tion is designed to provide a platform for older
adults to seek, find, understand and appraise Types of activity/ Expected learning
Session duration outcomes
health information from electronic sources and 1 • Computer and • Master the basic
apply the knowledge to address their health prob- Internet basics knowledge of operating
lem. It is imperative to include instruction that • Access health a computer and
promotes self-efficacy and motivation for the information accessing the Internet
websites • Use the internet to
older adults. Interactive game sessions are used as • Practice search for health-
a platform for hands-on practice to help the older related information on
adults to revise the contents. These features of the recommended
I-HeLP meet the need of older adults and engage websites, e.g. Ministry
of Health, Health
content that are not overly didactic in nature. In Promotion Board, and
addition, the concepts of universal design for the various hospitals
learning are applied to cater to the needs of the • Navigate those
older adults. Not only is information presented in recommended
health-­relevant
multiple formats and mediums (e.g. video, inter- websites
active content, imagery, and games), participants • Search for a health-­
are also able to use various outlets of expression related topic
and/or action throughout the intervention. • Find answers to
health-related questions
2 • Browse through Learn how to:
health • Use the Frequently
24.4.3 P
 hase 3: Formative, information Asked Questions,
User-­Centred Evaluation websites FAQs, • Search for the videos
Videos Quizzes and view the
• How to use appropriate video
Formative evaluation takes the form of multi-­modal Health-related • Download and use of
usability testing [29, 30] which seeks to elicit Apps on mobile Health-related Apps
feedback on applicability, content, ease-of-­ use, devices • Use the quizzes and
• Practice practice the questions
acceptance, and time to completion of modules.
We collect feedback on the usage of information (continued)
354 V. X. WU

Table 24.1 (continued) interactions with older adults, basic knowledge

Types of activity/ Expected learning of older adults’ usual life, and rules and regu-
Session duration outcomes lations as a volunteer. Two Junior College stu-
3 • Browse through Learn how to:
dents have joined the research team as interns
Ministry of • Find information about
Health, and doctors, hospitals and and they have brought in a significant perspec-
Health clinics tive in the development of the contents for
Promotion • Search for health care the youth volunteer training workshop, since
Board, Health cost
they are of the same age group as the youth
Hub, Singapore • Search for health care
websites schemes and subsidies volunteers.
• Practice • Search for healthy
choices food 24.5.1.2  art 2: Intergenerational
P
• Search for physical
e-health Literacy Program
activities program
• Use the various health I-HeLP is carried out for the subsequent 4 weeks,
screening program one session (2 h) per week, whereby the youth
4 • Evaluating the Learn to recognise volunteers will visit SAC in groups of 5–6.
reliability of the • Reliable health During the sessions, they will teach and guide the
health information websites
information • Purpose of a health older adults to access, understand and appraise
websites information website health information from reliable health-related
• Practice • Reviewers of a health websites.
information website
• Most recent update of
health information Mode of Delivery
• Clues about the Face-to-face workshops are conducted for
accuracy of health the older adults during the training program
information website at the SAC. The youth volunteers would con-
• Contacts for a health
information website duct a short teaching on the specific topic for
each session, which is followed by individual
guidance and practice with the older adults.
24.5.1 Implementation Plan Interactive games are utilised throughout the
session to keep the older adults engaged. The
I-HeLP is delivered over a period of 4 weeks. workshop applies small group teaching tech-
The program consists of preparation of the nique to meet the learning needs of the older
youth volunteers and implementation of the adults. Each session engages 8–10 older adults
Intergenerational e-health Literacy Program. and 5–6 youth volunteers (with the ratio of 1
volunteer to 2 older adults, providing close
24.5.1.1  art 1: Preparation
P guidance). During the face-to-face sessions,
of the Youth Volunteers the older adults could interact with their peers,
The workshop aims to equip the youth volun- the youth, and provide inputs about the pro-
teers with knowledge and skills to function as gram with the researchers.
trainers to conduct teaching for older adults.
Subsequently, the youth volunteers can carry
out hands-on practical sessions to guide the 24.5.2 Plan for Program Evaluation
older adults to access and browse through the
relevant health-related websites. The intensive Self-reported survey questionnaires will be
workshop for the youth volunteers focuses on used for the program evaluation. Outcome mea-
relevant health-related websites, communica- sures are used before and after the program to
tion skills to promote effective intergenerational evaluate the effects of the I-HeLP. The outcome
24 Health Promotion in the Community Via an Intergenerational Platform: Intergenerational e-Health… 355

measures for older adults will include sense of • I-HeLP develops partnerships among research-
coherence [34], e-health literacy [35], physi- ers, schools, communities, and health care
cal health, mental health (depression, anxiety) organisations, which is critical to the success-
[36, 37], cognitive function [36], quality of ful adoption and implementation of health pro-
life [38], and intergenerational communication motion programs.
[39]. Outcome measures for youth volunteers • The partnership with SACs and schools repre-
will include sense of coherence [34], empathy sents an unprecedented opportunity to inform
[40], attitudes towards older people [41], volun- practice and policy at school, community and
teerism [42], and intergenerational communica- at national levels to promote healthy and
tion [43]. I-HeLP is planned to be conducted in active lifestyles among older adults, and
the last quarter of 2020. Currently, the team is thereby contribute to health and wellbeing of
working on the development and refinement of the elderly population in Singapore.
the program. Data will be collected before and
after the I-HeLP, and results of the research will
be reported and published later. References
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 Coping and Health Promotion
in Persons with Dementia
25
Anne-S. Helvik

Abstract 25.1 Introduction

For those who receive the diagnosis of demen-
Dementia is caused by various brain disorders,
tia, their daily life is turned upside down.
among which Alzheimer’s disease is the most fre-
Dementia represents daily challenges in many
quent [1, 2]. Dementia is common in aged pop-
aspects, cognitively, socially, emotionally and
ulations (≥65 years) [3–5], but does also occur
functionally. Most commonly, the dementia
before the age of 65 years (early onset demen-
disorder is progressive, and currently there is
tia) [2]. The prevalence of dementia globally,
no cure or treatment to stop it. Emphasizing
is reported to 46.8 million [1, 6]. Furthermore,
coping and health-promotion among individu-
due to the aging population worldwide, the num-
als having dementia is fundamental to obtain
ber of people living with dementia is estimated
wellbeing as well as finding meaning-in-life.
to nearly double every 20 years [7, 8]. In most
This chapter focuses on coping strategies
cases, dementia is progressive and characterized
among persons with dementia, how these are
by cognitive impairment, changes in behaviour
related to health-promotion, wellbeing and
and/or social function and impaired activities of
meaning-in-life and how nurses and health
daily living (ADL) [9].
professionals can promote health and wellbe-
During progression of the functional declines,
ing in persons with dementia.
need for help from others are necessary [10]. In
order to promote meaning-in-life, wellbeing and
Keywords
health, professional health care is essential. In
Activity · Balancing life · Close family · the early phase, there may be a need of informa-
Cognitive resources · Cognitive impairment · tion and support to maintain activities of daily
Dementia disorder · Dementia friendly living, social relationships, as well as to support
environment · Next of kin · Participation · the individual’s coping with their situation. With
Sense of humour further functional decline, informal carers and/or
formal care providers naturally must extend the
A.-S. Helvik (*) scope of care and support. The health-promoting
Department of Public Health and Nursing, NTNU actions will aim towards compensating for loss
Norwegian University of Science and Technology, of functioning and facilitating for change to
Trondheim, Norway maintain meaningful aspects in life. In the late,
Norwegian National Advisory Unit on Ageing and severe stage of dementia, the person will be fully
Health, Vestfold Hospital Trust, Tønsberg, Norway dependent on others and will eventually die [11,
e-mail: anne-sofie.helvik@ntnu.no

© The Author(s) 2021 359

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_25
360 A.-S. Helvik

12]. Independent of phase of dementia develop- synthesis was based on international published
ment, treatment and care must be provided in qualitative studies referring to the person with
accordance to people with dementia’s own needs dementia’s own experiences regarding coping.
and fundamental human rights and resources. In In total, 74 articles were found by use of a sys-
all phases of the disorder, knowledge about how tematic and computerized search of qualitative
people with dementia experience and cope with internationally published articles between 2004
their current and future life situation is important and 2019 in AgeLine, CHINDAL Complete,
for health professionals to contribute to wellbeing Embase, Medline and PsycINFO motors. The
and meaning-in-life. There must be a shift from 74 articles were included based on a quality
solely focusing on the symptoms, disabilities and assessment by means of the CASP criteria; stud-
restrictions related to dementia, towards capa- ies evaluated to moderate and high quality were
bilities and potential of persons having dementia. included. The search terms are reported in the
Despite having dementia, the individuals have meta-synthesis [17].
resources which are fundamental to their wellbe-
ing and health. A health-promoting perspective
and approach to care is crucial and essential to 25.3 Coping with Life When
fulfil these requirements. Having Dementia
Health-promotion utilizes a biographical
approach; viewing the individual as a whole per-
Coping is how people face and handle chal-
son, embedded in his or her gender, culture, iden-
lenging experiences and situations. In health-
tity and society [13]. Moreover, health-promotion
promoting theory, coping is interconnected
theory focuses on resources and capabilities inwith salutogenic processes and wellbeing [18].
and around the person. How you cope with life Successful coping is health-promoting and may
stressors and challenges is affected by the avail-
contribute to an experience of hope, meaning-in-­
able internal and external resources. Personal life and a sense of coherence [14, 18]. Knowledge
coping resources may facilitate and contribute to
about how persons with dementia cope with their
resist stress and promote health [14]. In the salu-
challenges due to their diagnosis and life changes
togenic health model, these personal coping char-
will assist nurses, other health professionals and
acteristics are termed general resistant resources
informal care takers to support and empower the
(GRR) and sense of coherence (SOC) [14]. SOC person with dementia as well as to create health-­
is a general expression of an individual’s ability to
promoting surroundings.
comprehend the whole situation and the capacity Only two qualitative studies have explicitly
to use the resources available to move in a health-
aimed to explore coping strategies in persons
promoting direction [15]. SOC reflects the extent
with dementia [19, 20]. However, several quali-
to which a person finds life to be meaningful (a
tative studies aiming to explore other phenom-
motivational and emotional disposition), manage-
ena than coping describe coping actions persons
able (readiness to control and influence) and com-
living with dementia use as well as how coping
prehensible (a cognitive disposition) [14, 15]. The
actions and strategies affect their life. This chap-
way people are able to perceive structures, create
ter focuses on vital coping strategies in the face of
coherence and manage change in a meaningful challenges and stress related to living with demen-
manner has a central impact on health [16]. tia [17]. Dementia may affect individuals differ-
ently; the progress of the disease as well as coping
resources available will vary among the individu-
25.2 Methods als. Thus, the coping strategies and actions used
will also vary considerably in persons having
This chapter builds on a previously published dementia. Coping strategies are defined as cog-
systematic meta-synthesis of studies on coping nitive and behavioural efforts to master, reduce
among persons with dementia [17]. This meta-­ or tolerate internal or external demands created
25 Coping and Health Promotion in Persons with Dementia 361

by challenges and stress [21]. The choice of cop- vious occupations [27] and happy memories
ing strategies is affected by the person’s experi- in general [28], as well as referring to difficult
ence of internal and external resources [22]. In times they have mastered before [29]. Drawing
general, people use problem-­focused strategies on past roles and status contributes to preserve
(strategies aiming to alter stressful situations) and identity and self-esteem. By holding on to past
emotional-focused strategies (strategies aiming to aspects of themselves, individuals having demen-
regulate emotional stress associated with the situ- tia maintain their sense of self [17]. Past roles
ation) and alternate between these, but in severe and achievements remind them of who they are,
situations all available strategies are trigged in a despite their new strange situation.
global response [22]. In a health-promoting perspective, pre-
The qualitative meta-synthesis on coping serving identity and self-esteem helps to find
among persons with dementia [17] found sev- meaning-­ in-life and keep going. Perceived
eral coping strategies which were grouped into meaning-in-life and self-esteem are important
four overall categories: (1) The first category of to handle challenges and thereby reduce stress;
coping strategies was related to keep going and finding meaning-in-life in the midst of dementia
holding on to life as usual, (2) the second cat- may contribute to a renewed understanding of
egory was related to adapting and adjusting to the themselves. Thus, preserving identity is health-
demands resulted from the disease, while (3) the promoting. Knowledge about such identity-
third category were related to accepting the situ- preserving actions and their health-promoting
ation, followed by the (4) fourth category which potential is fundamental for the nursing profes-
was to avoid difficult situations. sionals using the nurse–patient interaction as a
resource for preserving and strengthening these
individuals’ identity and self-­esteem. As severity
25.3.1 C
 oping Strategies: Keep of dementia increases, talking about or recall-
Going and Holding on to Life ing one’s personal characteristics, past roles,
as Usual previous hobbies, activities and past achieve-
ments may prove difficult. Consequently, the
This category of coping strategies among persons health professionals when caring for persons
with dementia aims to keep going and holding with dementia should initiate and utilize com-
on to activities, roles and relationships as usual munication contributing to preserving identity
[17]. This strategy seems most often to be used and wellbeing. Pictures from previous times
in early phases of dementia before the progres- and written histories can be used to facilitate for
sion of the disease reduces the individual’s abili- such communication, which is termed “health-­
ties severly. This category of coping strategies promoting nurse–patient interaction” (see [30],
included actions which contribute to (a) preserv- Chap. 10 in this book). It is therefore important
ing the person s’ identity, (b) normalization of the that health personnell ask for such material and
situation and (c) participating in the society. for the life story in an early phase of dementia.
In cases where dementia has progressed, next of
25.3.1.1 Preserving Identity kin and close family members may contribute
The first set of coping actions supporting the with such information. Such identity support-
individuals with dementia to keep going aims ing c­ ommunication could for example take place
to preserve their identity. It refers to holding during regular care interaction.
on to the identity that defines them as a person
[17]. For example, they remind themselves and 25.3.1.2 Maintaining Normality
others by telling stories from their past life [23, The second set of coping actions to keep going
24]; this includes recalling known characteris- is maintaining normality. The person with
tics and strengths of one’s personality [23, 25], dementia seeks to reduce his/her worries due to
past achievements [26], experiences from pre- the diagnosis [17]. The above-mentioned meta-
362 A.-S. Helvik

synthesis [17] revealed that they maintained support driving, or provide what is needed could
normality by keeping up with activities, roles make the activity manageable. In other words,
and relationships they had before. They nor- if someone in the society such as a volunteer
malize the new situation by trying to go on as or significant other could arrange or contribute,
usual [31]. Individuals having dementia made a person with dementia could find the activities
extra efforts to appear in accordance with the still manageable and pleasant. This means that
social norms and thus avoid negative reactions individuals with dementia may still be able to
and problems [32]. These coping actions pre- perform the activities which they like, but these
serving their previous way of living released activities do now include specific challenges
will-power and hope for a good life in the future calling for assistance. Therefore, health profes-
[33]. Moreover, memory loss was explained by sionals’ role could be to inform next of kin and
high age rather than dementia, which facilitated relevant others about recent change in interest
normalization and thereby an experience of and its reasons, and eventually their possibility to
maintaining normality, decreased worries and facilitate for participating in activities, etc.
increased wellbeing [34, 35]. Additionally, nor- Coping actions directing normalization intend
mality was maintained by using high age and to maintain activities which the individuals are
loss of interest rather than dementia to explain used to, since such continuation gives meaning
giving up one’s occupation or common activi- and wellbeing as well as hope for the future.
ties [27] and keep going focusing on aspects of Meaningfulness, identifying solutions and hav-
one’s life which are still manageable. By keep ing resources to solve challenges are essential
telling oneself that the dementia and experi- to sense of coherence (SOC) [14, 15], which is
ences related to it were of minor importance central for health-promoting processes contribut-
for their overall situation [23], they could keep ing to wellbeing. Moreover, prevailing normal-
going ‘as usual’. Also, comparing themselves ity may represent a general resistance resource
with others having poorer health conditions (GRR); when the person with dementia experi-
made them feel that what they lived through ence to cope with challenges, this contributes to
was not that special [35]. satisfaction, self-confidence and joy [36], all of
Normalization may be a way the per- which are important health-promotion processes
son with dementia use to experience control. [16]. The role of the health professionals’ is to
Normalization strategies facilitate manageabil- explain the positive gains by normalization to
ity as well as comprehensibility (both SOC) and family members and others, and eventually to
thereby wellbeing and health. It is normal to facilitate for participating in activities for an
stop with activities when these are no longer of extended period of time.
any interest. So, when you as a nurse or health
professional experience that persons with demen- 25.3.1.3 Contribute to the Society
tia explain lack of interest or use age as reasons The third set of coping actions that persons with
for stopping with previous interesting activities, dementia use to keep going and holding on to life
it may be an attempt to normalize the situation. as before is aiming to contribute to the society
However, it may also be a natural change. Even in the way they can. It refers to the value of still
so, it may be that the specific activity is stress- being able to do meaningful activities and being
ful by representing challenges which they are not useful [17]. However, their way of contributing to
able to handle anymore because of their demen- others may differ from before. Individuals having
tia. Thus, health professionals should be support- dementia search for new ways to be useful [24]
ive and understand such attempts to normalize and ways to use their remaining abilities to con-
their situation, actions and priorities. Health pro- tribute in a larger context. They search for ways
fessionals may ask if tailored ways to participate to contribute in the family and household [37], to
in activities etc. are of interest; that is to check be useful for others [38], doing something prac-
if any support such as going together with them, tical to help another person [27] and engage in
25 Coping and Health Promotion in Persons with Dementia 363

voluntary work to the best for the society [27, gies describe how people adapt and adjust their
38, 39]. The influence of utilizing such coping own expectations toward themselves and activi-
strategies include a feeling of being someone to ties which they can perform. The different cop-
others and to oneself [27] and having purpose in ing actions involve being active, planning and
life [39]. Thus, despite having dementia, being making changes to handle the situation. This cat-
someone who contributes to the society provides egory of coping strategies includes actions aim-
a sense of meaning-in-life as well as coherence ing at (a) Taking control and compensate and (b)
between the person with dementia, his/her sur- Reframing the identity.
roundings and the society.
Accordingly, nurses and health profession- 25.3.2.1 Taking Control
als’ health-promotion initiatives among people and Compensate
with dementia, especially in the early phase, This first set of coping actions, taking control
should ensure that these individuals can sup- and compensate, includes what persons with
port, contribute and feel valuable to their fam- dementia do to continue being active, both physi-
ily, friends as well as to the society. However, cally and cognitively [17]. Furthermore, coping
such health-­promotion initiatives must be based actions directing the need of information, com-
on knowledge about the individual as a person pensation for loss of functionality, and planning
and what he/she wants. Suggestions and activi- to reduce stress, are central.
ties should be built upon his/her previous expe- Being physically and cognitively active
riences and knowledge as well as interests and includes doing life-long hobbies and continue
available resources. Such support can be imple- with previous habits to provide enjoyment [40].
mented in an out-patient clinic consultation and Maintaining meaningful activities were seen as
in a home visit when planning future actions helpful to cope with symptoms of dementia and
for retaining health and promoting wellbeing. contributed to an experience of control [34].
Counselling of the person with dementia, the Continuing one’s daily routines helped to stay in
next of kin and other informal care givers should control of the situation and to preserve identity
preferably incorporate information about that [41]. Participating in leisure activities was a part
contributing to others and the society may rep- of counteracting development of disease, it helps
resent a vital salutary resource for wellbeing. keeping the mind active and supports a sense of
Dementia friendly families, neighbourhoods and meaningfulness [34]. Correspondingly, physical
societies represent environments where persons activity was experienced to delay deterioration
with dementia can contribute in the society and [42], but also to develop social attributes and
maintain normality. As a result, they are enabled avoiding being defined only by their dementia
and empowered to keep on going, holding on to [29]. In times of stress, relying on religion and
activities, roles and relationships ‘as usual’ for an life-values was important for a sense of control
extended period, which provides wellbeing and and comfort [20]. Moreover, involvement in
quality of life. Furthermore, health-promoting music could give persons with dementia a sense
initiatives and dementia friendly environments of empowerment and control [43].
may facilitate for adaption and adjustment to the The overall coping category termed ‘keep
situation and demands. going and holding on to life’ which was
described firstly in this chapter, may also involve
decisions to not participate in specific activi-
25.3.2 C
 oping Strategies: Adapting ties. The persons with dementia reasoned their
and Adjusting to the Demands change of participation to increased age and loss
of interest rather than difficulties due to demen-
Adapting and adjusting to the demands is the tia [27]. This means that emotional coping strat-
second category of coping strategies that was egies were used to regulate emotional stress
found in the meta-synthesis [17]. These strate- associated with the situation rather than solving
364 A.-S. Helvik

the problems or challenges caused by the situa- cognitive functioning and handle challenges to
tion. Persons continuing taking part in activities, be active. They put time and effort into planning
also when experiencing challenges, strived to activities, use technical tools to assist them as
take control [17]. In this matter, problem-solv- well as asking for help from others to compensate
ing rather than emotional coping strategies seem for loss of capacity. Trying to adapt to their new
sufficient; by taking control and compensate life situation caused by dementia, they described
for loss of functionality the challenges could be coping strategies which supported a sense of con-
handled. Participation in these specific activi- trol and autonomy. The various coping actions
ties was seen as meaningful [34]. Taking control are based in available resources, strength to stand
over challenges imply both identifying solutions strains (resilience) [49], a wish to overcome
and having resources (either internal and/or obstructions and finding meaning by doing so, all
external) to solve the challenges which represent of which are salutogenic factors promoting well-
two of three essential elements in SOC [14, 15]. being and health [14, 15].
The third aspect of SOC is finding such activities As shown, individuals having dementia use
meaningful [14, 15]. A strong SOC is important available personal resources as well as resources
for the health-promoting processes contributing in their social network, environment and pro-
to wellbeing. Thus, nurses and other health pro- vided by professionals when necessary. If prop-
fessionals should inform next of kin about the erly met, asking for help is health-promoting. By
importance of persons with dementia taking con- means of counselling, empowerment as well as
trol by being physically and cognitively active health-promoting interaction, nurses and other
and facilitating for participation in such activi- health professionals can support coping strategies
ties when indicated. which improve control, adaption and adjustment
The persons with dementia adjusted to the new to their situation. A sense of control, adaption and
demands by putting extra effort into preparations adjusting represent vital resources for wellbeing
and accomplishment to partake in activities [17]. and health [50].
They developed strategies to compensate for the Planning for the future, i.e. being proactive
impairment [44] in order to avoid mistakes due in managing dementia is a part of the adapting
to memory loss. Utilizing such strategies and and adjusting coping strategies [17]. Such plan-
investing time and effort into planning and orga- ning might include contacting internet support
nizing to better meet difficulties and memory groups to get knowledge of dementia, finding
loss were part of taking control and adapting to ideas about how to make appropriate changes
the situation [40, 45]. Strategies such as writing [47], to contact health care services when you
notes [44], use of external memory aids [35], use know help will be needed in the future [51]
of technology to keep control [46] and asking for or accessing groups with other people having
assistance from others [42] e.g. external services, dementia [52].
friends and family [47] were used to compensate As shown above, the described coping actions
for memory loss, to remember routines and to aim at taking control and adapt to the situation
provide a sense of control and meaningfulness. by looking ahead to future needs. To master their
Also, cognitive exercise was used to improve situation here-and-now as well as preparing for
memory [47] and some actions contributed to the coming challenges, they searched for relevant
maintain autonomy. Holding on to autonomy knowledge and external resources. To master
could be managed by for example going to famil- their situation, individuals having dementia took
iar places so they could handle the activity by initiative regarding planning their finances, place
themselves [48] or avoiding concerns of their of living, and their last will. Such planning con-
partner and others [44]. tributes to wellbeing and hope for a good life also
The coping actions described here show how during the times of more severe dementia which
persons with dementia compensate for reduced they know will come.
25 Coping and Health Promotion in Persons with Dementia 365

The evidence presented so far in this chap- to wellbeing. Adaption to change and refram-
ter highlights the importance of planning the ing strategies are linked to resilience and self-­
future while necessary resources still are avail- transcendence [50, 55]. Self-transcendence (see
able. Hence, health professionals should initiate Chap. 9 in this book) holds adaption to changes
a dialogue with the person having dementia, pro- in life as one of the key resources for wellbe-
vide information as well as practical and emo- ing in vulnerable populations [50]. Adaption to
tional support to promote such planning, which changes is an integral process involved in the
may include to educate the informal caregivers. intra-personal aspect of self-transcendence [56].
Information, counselling or dialogue in support Participation in groups of peers arranged by day-
groups as well as the utilization of future plan- care centres or other resource groups may support
ning may prepare for changes, contribute to identity reframing. Nurses or other health profes-
adaption, adjustment, wellbeing and health. The sionals should provide information about such
timing of such information, counselling or dia- groups available.
logue is essential. The person having dementia How people with dementia adapt and adjust
needs to be mentally ready or prepared to focus their expectations toward themselves and their
on the future, representing a vulnerable state. capacities, represent one of four overall strate-
Thus, health-promoting nurse–patient interaction gies of coping among persons with dementia.
including acknowledgement, respect, emotional The next coping category is termed accepting the
support and sensitivity for the individual’s situ- situation, which is also a key aspect of intra-per-
ation, experiences and feelings is an important sonal self-transcendence (see Chap. 9).
resource supporting coping and wellbeing [30].
Health-promoting nurse–patient interaction is
also an important tool for identifying when the 25.3.3 C
 oping Strategies: Accepting
person having dementia and his/her family are the Situation
ready to focus on planning for the future.
Accepting one’s situation includes acknow­
25.3.2.2 Reframing Identity ledgement and acceptance of the changed situation
The second set of coping actions refers to refram- characterized by the dementia diagnosis and loss
ing the identity [17]. It includes how a person of memory. The accepting coping strategies are
encourages identity by thinking differently about based in understanding of their capabilities; that
oneself [37]. By comparing themselves with is, what they can perform independently and when
those who were worse off, persons with dementia they need assistance from others [17].
affirm their own identity and self-worth [24, 29,
37]. Reframing one’s identity contributes to hope 25.3.3.1 Position in Life
and satisfaction in life [53]. Reframing the iden- This set of coping strategies includes actions to
tity can also include decision-making, for instance have a position in life [17]. When the individu-
decisions of whether to ask for help or not [25, als having dementia accept their changed situa-
37]. A decision of informing others about one’s tion, they simultaneously deny dementia to rule
disease is seen as a key element in the process of one’s life [57]. The focus is shifting from seeing
coming to terms with the diagnosis of dementia dementia as a disease towards living well with
and constructing a new sense of self [54]. the resources they still possess [58]. Thus, they
Preserving, affirming and reframing identity highlight the possibilities which they still have in
are different coping actions to cope with changed life [28, 59–61], maintaining a positive view of
health resources. Reframing actions help to adapt oneself [59] and appreciating the present moment
to the diminished resources caused by the demen- [34]. These positive approaches add both hope
tia. Both preserving and reframing actions are for a good life in the future and meaning-in-life
emotional-focused coping strategies contributing regardless of the future prospect [34, 60, 62].
366 A.-S. Helvik

When the persons with dementia are accepting treats of identity [47]. Direct resistance actions
the changes and refind a position in life, they do include withdrawing from participation in differ-
not combat the consequences of their disease, but ent settings and concealing difficulties from oth-
search for ways of living well with the demen- ers, which lead to isolation [65]. Consequently,
tia and the resources they still possess com- the use of these coping strategies may actively
bined with asking for support from others when avoid situations requiring support by others, and
needed. These coping strategies support hope assistance or information from others might be
and meaningfulness, and thereby promote health escaped [66]. Furthermore, to avoid focusing
and wellbeing among the person with dementia. on the realities of dementia they elude situa-
Furthermore, coping actions reflecting accepta- tions where they may meet others with dementia
tion of change are linked to self-transcendence. or those with a further progression of dementia
Self-transcendence is strengthened both by adap- than themselves [38]. Moreover, linguistic strat-
tion to change in life (as said above) and accepta- egies aiming for emotionally distancing them-
tion of this change [50]. selves from the disease are also seen as part
Health care professionals’ knowledge about of such avoiding coping strategies [65].
various kinds of coping actions and their pos-
sible gains is important to initiate a dialogue sup- 25.3.4.2 Distracting from the Disease
porting the individuals to adapt and accept the The distracting from the disease-actions aims to
changed life situation caused by dementia. By distract themselves from dementia and its conse-
means of counselling, nurses and other health quences [17]. Thus, they distract themselves from
professionals can promote quality of life and being confronted with symptoms and changes
wellbeing, independently of context and whether due to reduced cognitive abilities.
the counselling dialogue is with the person with Distracting coping actions are understood as
dementia or those staying close to the person. indirect avoiding strategies. Such actions may be
to keep busy, active and fully occupied to escape
the realities of dementia [67, 68]. For example,
25.3.4 Avoiding Coping Strategies being actively partaking in social settings may
be a way to get distance between themselves and
This last coping category includes how individu- dementia [20].
als having dementia directly and indirectly avoid However, these coping actions aiming for
situations which cause stress and challenges resistance and distracting may give a short relief
due to the disease [17]. Hence, these strategies from the stress, challenges and difficulties caused
include direct resistance and indirect resistance by the disease. Thus, these strategies are mainly
(distraction) of the disease. utilized to reduce overwhelming stress and chal-
lenges. The dementia itself and thoughts of the
25.3.4.1 Direct Resistance potential consequences of dementia put tremen-
of the Disease dous demands on a person. People with dementia
The set of coping actions termed direct resistance may experience that available resources in them-
of the disease involves actions to resist change, selves or in their context are limited. Accordingly,
adaption or help from others to hinder accept- both resistance and distraction strategies may be
ing the diagnosis and its progression over time a natural as well as a rational reaction in the con-
[17, 47]. The aim of these actions is to prevent text of a crisis. However, their challenges will
themselves from thinking about the disease, its not be solved or disappear by these strategies;
consequences and the future life with dementia therefore, over time such strategies will not be
[62–64]. health-promoting.
The resistance actions intend to avoid focus- Health-promoting approaches applied
ing on the realities of the dementia [65], and are by nurses and other health professional should
used to fight stigma related to the disease and include emotional support and guidance. Despite
25 Coping and Health Promotion in Persons with Dementia 367

the person with dementia may resist the changes, How you respond to challenges is, as pre-
emotional support can help to release some pres- viously appointed, not only dependent on the
sure, strain and stress and thereby release health challenges but also on the available resources.
resources. Furthermore, over time emotional sup- These are resources within the person self,
port may support adaption and acceptation of their within close family and next of kin as well as in
situation, which is key to wellbeing and health. the environment outside the family.
By means of counselling, health professionals Firstly, a person’s inner strength to handle
should provide the family with knowledge about strain and challenges, i.e. the persons resilience
normal reactions to crises and possible important [49], may differ, but is essential for coping and
factors for health and wellbeing. Such knowledge health [70]. Resilience includes abilities to
is important to empower the person with demen- regain inner strength and coping resources while
tia as well as his/her family. Such counselling facing different kinds of hardship [70]. A sense
must be based on the readiness of the person hav- of humour is another positive personal quality
ing dementia. Thus, the content and method will for coping pointed out by persons with dementia
depend on the situation and the actual persons [17]. A sense of humour represents the ability to
involved. Empowerment is an important resource see the humorous aspects of a situation which
to strengthen coping and wellbeing [69]. reduces stress and elicits positive emotions [17].
Secondly, close family and close social rela-
tions are vital resources in peoples’ lives, espe-
25.4  Life with Dementia - An Art
A cially in phases of vulnerability. Therefore, such
of Balance relationships are crucial resources for individuals
having dementia in the face of stress. Having vital
Persons with dementia are seen to utilize four social relations affects how he or she appraises
overall categories of coping strategies [17]. The the stressors and the challenges. Next of kin and
use of these coping strategies is not based in a close family may give emotional support, backing
chronological order or a linear process starting and practical help [17]. The family’s resources
with avoidance and ending in acceptance of the may differ with personal health, socioeconomic
situation. These strategies should rather be seen status, but also regard to knowledge about
as potential ways to meet stress and challenges dementia. Empowerment by means of counsel-
following dementia [17]; that is, balancing the ling the close family, i.e. by providing knowledge
life with dementia. As previously mentioned, the about dementia and health-promotion, is essen-
strategies chosen will depend on the appraisals of tial. Empowering courses are sometimes offered
the challenges as well as the available resources. online, by peers providing volunteer groups for
Therefore, one person may respond differently to close family or coping courses arranged by the
a challenge than another in the same situation, as local health care service or by health agencies.
well as showing a different reaction the next time Support from family has also been linked not
he or she encounter approximately the same chal- only to coping, but also directly to meaning-in-­
lenge. One alternates between the available strate- life [71] among persons with dementia.
gies depending of what is deemed the best solution Lastly, coping strategies to reduce and
in the specific context. Furthermore, in severe alter stress and challenges are affected by
situations, a global coping response is triggered ­environmental factors. For example, staying in
including use of all available strategies simultane- a dementia friendly neighbourhood and society
ously to handle the challenge [22]. may support coping strategies promoting balance
Persons with dementia use coping strategies in life, wellbeing and health. The World Health
to balance life with dementia independently of Organization’s ‘age-friendly’ policy movement
limitations in health resources. Coping strategies [1] and dementia awareness campaign [72],
handling stress and challenges enhance hope and underline the importance of supporting environ-
meaning-in-life [17]. ments which facilitate empowerment of persons
368 A.-S. Helvik

with dementia and thereby making it possible for support to maintain activities of daily living,
them to take part in the society. There must be coping and social relationships are needed. With
a shift in the perspective of dementia from only further functional decline, informal carers and/
focusing on symptoms, disabilities and restric- or formal care providers naturally must extend
tions towards capabilities, resources and potential the scope of care and support. The health-
of persons with dementia, not only in health care promoting actions aim to compensate for loss
services but also in public planning. Dementia of functioning and to facilitate meaningfulness
friendly environment principles involve high in life.
safety, good structure and familiarity which
are meant to reduce stress and challenges and Take Home Messages
thereby promote coping and participation in the • There must be a shift in dementia care from
society [73–76]. only focusing on symptoms, disabilities and
restrictions towards capabilities, resources
and potential of persons with dementia.
25.5 Conclusion • Knowledge about dementia based in an inte-
grated understanding of pathogenesis and
This chapter focuses on coping strategies defined salutogenesis, represents a basis for high-
as cognitive and behavioural efforts to master, quality dementia care.
reduce or tolerate internal or external demands • Coping strategies such as ‘keep going and
created by challenges and stress and how per- holding on to life’, ‘adapting and adjusting to
sons with dementia cope with challenges due the situation and demands’, and ‘accepting the
to the disorder. How persons with dementia situation’ contribute to meaningfulness and
themselves express use of coping strategies has wellbeing.
been reported in qualitative studies, and a meta-­ • Persons with dementia chose coping strategies
synthesis of these studies found that persons with and actions dependent on the stressors and
dementia used four overall categories of coping challenges they experience and available per-
strategies: (1) The first category was related to sonal and external resources.
keep going and holding on to life as usual, (2) the • Coping aims to balance one’s life with
second category included adapting and adjust- dementia.
ing to the demands resulting from the disease,
while (3) the third category embraced accepting
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25 Coping and Health Promotion in Persons with Dementia 371

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 Part IV
Closing Remarks
 Future Perspectives of Health
Care: Closing Remarks
26
Gørill Haugan and Monica Eriksson

Abstract demand the health care services to reorient in

a health promoting direction.
The Covid-19 pandemic has demonstrated the
The IUHPE Global Working Group on
vulnerability of our health care systems as
Salutogenesis suggests that health promotion
well as our societies. During the year of 2020,
competencies along with a reorientation of pro-
we have witnessed how whole societies glob-
fessional leadership towards salutogenesis,
ally have been in a turbulent state of transfor-
empowerment and participation are required.
mation finding strategies to manage the
More specifically, the IUHPE Group recom-
difficulties caused by the pandemic. At first
mends that the overall salutogenic model of
glance, the health promotion perspective
health and the concept of SOC should be further
might seem far away from handling the seri-
advanced and applied beyond the health sector,
ous impacts caused by the Covid-19 pan-
followed by the design of salutogenic interven-
demic. However, as health promotion is about
tions and change processes in complex systems.
enabling people to increase control over their
health and its determinants, paradoxically
Keywords
health promotion seems to be ever more
important in times of crisis and pandemics. Health promotion · Pandemics · Non-
Probably, in the future, pandemics will be a communicable diseases · Reorienting the
part of the global picture along with the non-­ health-care services · Salutogenesis · Salutary
communicable diseases. These facts strongly factors

G. Haugan (*)
Department of Public Health and Nursing, NTNU 26.1 Future Perspective
Norwegian University of Science and Technology,
Trondheim, Norway
The present condition gives us directions in which
Faculty of Nursing and Health Science,
Nord University, Levanger, Norway to look forward; the year of 2020 is the year of the
e-mail: gorill.haugan@ntnu.no, Covid-19 pandemic. Lately, entire cities, regions
gorill.haugan@nord.no and countries have been sealed off, travelling has
M. Eriksson been banned, universities have been closed, along
Department of Health Sciences, University West, with shops, restaurants etc. all over the world. We
Trollhattan, Sweden have witnessed that economic, cultural and social
e-mail: monica.eriksson@hv.se

© The Author(s) 2021 375

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_26
376 G. Haugan and M. Eriksson

activities have come to a stop, resulting in big whole societies are in a turbulent state of transfor-
challenges to a great number of people around the mation in need of ways and strategies to manage.
globe. Thus, health concerns have become the To return to the health care sector, the IUHPE
prevailing concern that takes precedence over all Global Working Group on Salutogenesis states in
other issues. In the years to come, the health ser- a position article that one way is to position health
vices globally will need to collaborate on han- promotion competencies as an essential framework
dling pandemics such as the Covid-19 pandemic to reorient health care services [3] (p. 9). In addi-
ruling the world during the writing process of this tion, the professional leadership must be reoriented
book. Facing the serious impacts caused by the towards salutogenesis, empowerment and par-
Covid-19 pandemic, at first sight, this pandemic ticipation. To move forward with the concept of
and the world’s response to it might seem far salutogenesis as a sound scientific base for health
away from the health promotion perspectives. promotion, some suggestions have been given:
However, in a recently published Editorial in
Health Promotion International, Van den Broucke 1. To advance the overall salutogenic model of
[1] (p. 181) highlights the important role of health health
promotion in the time of crisis and pandemics by 2. To advance the concept of SOC
saying “…Enabling people to increase control 3. To define and design salutogenic interventions
over their health and its determinants is at the and change processes in complex systems
core of health promotion. As such, health promo- 4. To apply salutogenesis beyond the health
tion may paradoxically be more important in this sector [3]
time of crisis than ever before”. Probably, in the
future pandemics will be a part of the global pic-
ture along with the so-called non-communicable 26.1.1 Advancing the Overall
diseases (NCD) which covers chronic illnesses Salutogenic Model of Health
such as cancer, dementia, heart failure, diabetes as
well as mental health issues. In this book, we have The IUHPE Group states that the salutogenic
highlighted the need of health promotion as an model of health needs an additional positive
integrated aspect of the treatment and care of health continuum and a path of positive health
patients with various NCDs. NCD Countdown development linking resources to this new con-
2030 [2] is an independent collaboration to inform tinuum [3]. During the last decades, a broader
policies that aim to reduce the worldwide burden literature on the ease-end of the health con-
of NCDs, and to ensure accountability towards tinuum has emerged emphasizing among oth-
this aim. In 2016, an estimated 40.5 million (71%) ers the importance of developing individuals’
of the 56.9 million worldwide deaths were from personal potential and functioning, supporting
NCDs. Of these, an estimated 1.7 million (4% of people’s perception of self-fulfillment, purpose
NCD deaths) occurred in people younger than and meaning-­in-life, thriving, social attractive-
30 years of age, 15.2 million (38%) in people ness and making a valuable contribution to soci-
aged between 30 years and 70 years, and 23.6 mil- ety [4–6]. Considering these developments, the
lion (58%) in people aged 70 years and older. An IUHPE group recommends the addition of a pos-
estimated 32.2 million NCD deaths (80%) were itive health continuum to Antonovsky’s original
due to cancers, cardiovascular diseases, chronic salutogenic model [3]. Furthermore, the IUHPE
respiratory diseases, and diabetes, and another 8.3 Group underscores the importance of linking
million (20%) were from other NCDs [2]. These resources to this new continuum of positive health
facts strongly demand the health care services to development; “…Resources not only immediately
reorient in a health promoting direction. As Van help people to cope better with stress (and surviv-
den Broucke [1] argued in his editorial, the pan- ing). Also, over time personal and environmental
demic has shown how vulnerable health care ser- resources can help with recovery and healing…
vices may be, and not only the health care sector; Beyond healing and recovery, resources can
26 Future Perspectives of Health Care: Closing Remarks 377

directly promote health, wellbeing and thriving— grating key elements of salutogenesis should be
even in the absence of current or previous adver- developed [3]. Antonovsky stated that SOC [9] is
sarial life situations” [3] (p. 3). Consequently, formed by three kinds of life experiences: (1)
in line with the Health Development Model [7] consistency (strengthening comprehensibility),
which proposes that pathogenesis and saluto- (2) underload–overload balance (strengthening
genesis are two complementary perspectives on manageability), and (3) participation in socially
health development, GRRs and SRRs1 are seen to valued decision making (strengthening meaning-
facilitate and nurture positive health; thus direct fulness). Accordingly, further knowledge about
paths of positive health development have been these kinds of life experiences and how they can
added to the salutogenic health model [3]. be assessed (quantitatively and qualitatively) in
different contexts as well as on different system
levels are required [3] (p. 5). To reorient health
26.1.2 Advancing the Concept care, it is important to capture factors and initia-
of SOC tives that nurses along with other health profes-
sionals consider health promoting resources in
The second point underscores a need for advanc- their everyday clinical practice. We must learn
ing the SOC concept; many translations of the from their experiences and integrate this new
Orientation to Life Questionnaire (OLQ) and the knowledge in education for health professionals.
evidence on SOC have provided confidence that
the SOC construct is measurable. However, the
substance, content, wording and dimensional- 26.1.4 Applying Salutogenesis
ity of the SOC construct have yet to be explored. Beyond Health Sector
Research on SOC utilizing other methodological
approaches than Antonovsky used accompanied Finally, applying salutogenesis and SOC to other
by a replicability of Antonovsky’s qualitative anal- fields beyond the individual health issues might be
yses and findings are highly welcome [3] (p. 4). valuable as we can learn from other fields for health
Further, there is a need of developing new ques- research. For instance, intergroup relations are vital
tionnaires for measuring salutary factors for health in peoples’ daily life at work, in leisure, in the com-
and wellbeing. Some attempts can be found, for munities and the municipalities, etc. Therefore, we
example The Salutogenic Health Indicator Scale need to more fully examine the differential benefits
(SHIS) [8]. In Sweden, an ongoing research study and potential harm of SOC on the individual, group
has developed and tested a new scale, adapted for and intergroup as well as organizational and system
nurses’ work situation and to be used in health levels [3]. In a public health perspective, such
care, The Salutogenic Survey on Sustainable knowledge seems fruitful for the development of
Working life—Nurses (SalWork-N) (www.hv.se). health promoting workplaces, health promoting
hospitals, health promoting communities, munici-
palities, schools, kinder gardens, living areas, etc.
26.1.3 Salutogenic Interventions
and Change Processes
26.2  ealth Promotion Is About
H
Thirdly, strengthening the SOC through health Thriving and Enabling
promotion intervention is key. Purposefully People to Increase Control
designed salutogenic interventions and change over Their Health
processes are needed; therefore, explicit saluto-
genic intervention theories building on and inte- The health promotion perspective as well as the
salutogenic theory of health is based in the idea
1
GRR = Generalized Resistance Resources; SRR = Specific that every single person has a health, which var-
Resistance Resources, central concepts in salutogenesis. ies and moves along the health continuum between
378 G. Haugan and M. Eriksson

dis-ease and ease. Antonovsky [9] (p. 14) raised book with the same figure (Fig. 26.1). Some of
the question: How can we understand movement the umbrella concepts are described in this book,
of people in the direction of the health end of the whilst some remain to be explored. However, to
continuum?’—note, all people, wherever they are our knowledge this book is the first one to high-
at any given time, from the terminal patient to the light and emphasize concepts closely related to
vigorous adolescent—we cannot be content with the sense of coherence (SOC) in general, and to
an answer limited to ‘by being low on risk factors’. health care systems in particular. There is a need
A salutogenic orientation, then, as the basis for to continue exploring other salutogenic concepts
health promotion, directs both research and action to strengthen the salutogenic theory, but also to
efforts to encompass all persons, wherever they are contribute to the development of nursing and the
on the continuum, and to focus on salutary factors. health sciences. Among others, concepts such as
Beyond survival, health promotion is about thriv- empathy, humour, learned optimism and learned
ing and enabling people to increase control over hopefulness, would be interesting.
their health [10]. The salutogenic model is useful Moreover, the implementation of the concepts
for all fields of health care and therefore helpful in and the salutogenic approach to health and well-
the reorienting of the health care services. being in a systematic way is highly needed. An
integration would benefit both staff and patients.
Such an effort could begin with an education, i.e.
26.3  reorientation of Health
A salus education proposed in Chap. 15, continuing
Care by Implementing with a focus on learning processes to finally end
Salutogenesis with the development of a new way of working in
health care settings, which means that salutary
We started this book showing a figure (Fig. 1.4) factors are recognized, identified and used in a
describing the salutogenic umbrella adjusted for health promoting manner. In other words, reori-
health care settings. We also choose to end the enting the health care services according to the

Fig. 26.1 The salutogenic umbrella: theoretical concepts relevant to health care. (Reproduced with permission from
Folkhälsan Research Center, Lindstrom & Eriksson) [4]
26 Future Perspectives of Health Care: Closing Remarks 379

Ottawa Charter for health promotion. Already in study among hospital nurses explored salutary
the mid-1990s Antonovsky argued the saluto- factors for a sustainable working life [17]; having
genic orientation as the theoretical basis for fun at work, being acknowledged, feeling togeth-
health promotion, directing both research and erness in the team, having varying tasks with a
action efforts particularly useful for all fields of manageable workload, good interaction between
health care [9] (p. 18). The progress of new salu- colleagues and patients, doing good work, feeling
togenic models of health has been limited. An committed to and pride in the professional role,
attempt to fill this knowledge gap can be seen in and having a balance between work and leisure
an article on “The Synergy Model of Health”, time were found to be factors that made them
which integrates salutogenesis and the assets stronger, which in turn explained why they stayed.
model in a framework of Bronfenbrenner’s eco- Similar findings have been seen in Norway [18,
logical theory of human development [11]. 19]. Further research on salutary factors is needed.
When reviewing research on SOC we have
become aware of how limited the research on
working conditions of health care personnel is. 26.4 Closing Remarks
There is a lot of research by nurses and other
health professionals on different patient groups In this book, we have highlighted the need to
including measuring the SOC. However, saluto- work to promote health in both hospitals and the
genic research on how health professionals’ municipality health care; treatment and care of
health and wellbeing can be maintained and patients with chronic diseases and the so-called
developed is scarce. The same applies to knowl- non-communicable diseases (NCD) will be fun-
edge about health professionals’ SOC. For damental in the years to come. Our point of
instance, have nurses forgotten themselves in departure has been to focus attention on health
their quest to do good for the patients? We here promotion and salutogenesis in health care set-
argue that research must also focus on the work tings. We argue the salutogenic theory of health
environment and salutary factors for developing a to be appropriate to guide health promotion in the
sustainable working life for nurses and other health services. In a lecture at the Nordic School
health professionals. However, some attempts to of Public Health (NHV) Antonovsky lectured
fill this knowledge gap can be seen. A longitudi- about salutogenesis and health [20]. He called on
nal study on the influence of a health promoting to think salutogenically and act salutogenically.
work environment [12] as well as a study on To use his own words, “the key lies in a society
work-related SOC and its longitudinal relation- and in people who care about others” [20].
ship with work engagement and job satisfaction Nurses and the other health care professions are
[13] were recently conducted in Norwegian nurs- just such people who cares!
ing homes. Correspondingly, studies focusing on
the working culture in nursing homes have shown
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