Health promotion

1. Health promotion and people
with mental health issues
(chapter 15)

2. Learning outcomes
• By the end of this chapter you will be able to:
1. Discuss the reciprocal relationship between mental, physical and social
health
2. Discuss mental health promotion in context to policy, professional
frameworks, patients and practice
3. Explain the role of the nurse in health promotion in a range of settings
that mental health patients come in contact with
4. Identify and discuss possible health concerns that may be specific to
patients with mental illness
5. Discuss a range of health promoting interventions that may be applicable
to mental health patients

3. Introduction
Mental health is an integral part of daily life. Regardless of what we do
each day, our emotions, thoughts and behaviours will impact on our
general well-being.
The current government mental health policy entitled No Health
Without Mental Health: A Cross-Government Mental Health Outcomes
Strategy for People of All Ages (DH, 2011) in part, captures the
importance of mental health across the lifespan. As the title suggests,
without good mental health, it is very unlikely that a person will be
physically well, regardless of their age.

4. Although the terms mental health and mental illness are used
interchangeably, it is important from the outset to distinguish between
the two terms. In the past, mental health has been described as the
absence of mental illness, an ideology which in itself is illness-
orientated.
This also has a negative connotation and does not focus on positive
aspects such as happiness, well-being and personal fulfilment.
Westerhof and Keyes (2010) have focused on two traditions of
well-being.

5. These are hedonic (psychological) and eudaimonic (social) well-being.
Hedonic is characterized by feelings of happiness, satisfaction and
interest in life, while eudaimonic relates to fulfilment of one’s goals
such as autonomy and positive relationships with others.
To be mentally healthy requires a combination of both hedonic and
eudaimonic experiences. The terms they use to describe these
experiences are “flourishing” and “languishing”

6. • Flourishing is characterized by experiencing positive emotional states
as well as positive outcomes (e.g. a sense of belonging).
• Languishing is considered to be a state where low levels of emotional
well-being are combined with low social well-being status.

7. Mental well-being. Source: adapted from Keyes,
2002.

8. Defining mental health promotion
Mental health is as important as physical health, mental health
promotion is equally important as physical health promotion. Mental
health promotion contributes to and maintains our general health and
well-being and is concerned with actions that enhance personal,
familial, organizational and societal well-being. Mental health
promotion can do the following:

9. Defining mental health promotion
• Significantly improve people`s lives.
• Prevent distress while also preventing mental and physical illness
across the lifespan.
• Challenge stereotypes and discrimination against those who have a
mental illness,.
• Reduce costs associated with illness and build a stronger, caring and
more resilient society

10. Mental illness refers to common mental disorders such as depression
or anxiety and severe mental illness such as schizophrenia. Yet mental
health needs or indeed mental illness are still stigmatized,
discriminated against and can be seen as “abnormal”.
The current mental health strategy No Health Without Mental Health
(DH, 2011) reiterates that by focusing on mental health promotion and
illness prevention, we can increase individual resilience and prevent
illness from perpetuating cycles through family generations.

11. The role of mental health nursing and health
promotion
Health is dependent on a range of issues and is interdependent with
biological, psychological and social factors. For example,
hypertension may have many contributory factors such as genetics,
lifestyle and psychological issues. Though predisposing factors such as
genetics may increase the likelihood of the person developing
hypertension, psychological issues such as stress levels may be the
precipitating triggers for the current condition.

12. The role of mental health nursing and health
promotion
As one of the key roles of nursing is to strive to improve and
promote health, mental health promotion must be inherent in all
health promotion activities and should be seen as integral to well-
being.

13. The role of mental health nursing and health
promotion
Central to mental health nursing is an understanding of the principles
of the Recovery movement that commenced after the introduction of
deinstitutionalization when large mental institutions were closed and
patients were cared for in the community.

14. The role of mental health nursing and health
promotion
Recovery is described as a deeply personal, unique process of changing
one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of
living a satisfying, hopeful, and contributing life even with limitations
caused by illness. Recovery involves the development of new meaning
and purpose in one’s life as one grows beyond the catastrophic effects
of mental illness.

15. Recovery and health promotion principles.
• Empowerment: Recovery practice ensures that the individual is
offered choice and control over their own lives.
• Participative: Recovery involves working in partnership to ensure that
the individual is involved at every step of their care.
• Holistic: Recovery sees the individual as much more that the mental
illness that they present with, other areas such as physical,
social and spiritual health plays a key role in health and well-being.

16. Recovery and health promotion principles.
• Equitable: Recovery encourages social justice for people with mental
illness and advocates for fair and equitable services and outcomes with
those in other areas of health.
• Intersectoral: Recovery practice involves ensuring that there is a
whole systems approach by many agencies to effect the best services
and outcomes.
• Sustainable: Recovery includes interventions that takes account of
the changing nature of the individual and therefore adopts strategies
that are achievable and sustainable in the future.

17. Recovery and health promotion principles.
• Advocate: Recovery-orientated practitioners recognize that health
is dependent on a range of factors which include: social
participation, inclusion, holism and therefore advocate for
these conditions to be made available to the individual.
• Enable: Recovery advocates for the opportunity to have access to
fair and equitable resources that will enable the individual to achieve
their full potential.

18. Recovery and health promotion principles.
• Mediate: Recovery models of practice recognize that to make
Recovery a reality, services must come together and work
collaboratively to ensure that they contribute services that may fall
outside the remit of health services but are crucial in determining
health. These include education, housing, statutory benefits, industry
and media.

19. People with mental illness who are in recovery are those who are
actively engaged in working away from the states in Figure 15.1 of
Floundering (through perhaps building relationships) and
Languishing (by developing a positive identity), and towards Struggling
(through framing and self-managing their mental illness) and
Flourishing (by developing valued social roles).
Mental health promotion is a key role for mental health nurses (MHNs)
and complements all domains of mental health practice.

20. Challenging discrimination:
Patients with mental illness have experienced social injustice and
therefore the role of MHNs has been central in advocating and seeking
social justice for their patients. Such acts include proactively
empowering, challenging discrimination and stigma and seeking
equality and respect for difference. In the past, having a diagnosis of
mental illness meant that one may have been prevented from many
roles and activities that the general public enjoyed and considered their
human right. For example, historically employers could ask about
mental health status and then use it to judge suitability for a job. More
recently legislation has been introduced to prevent this discriminatory
practice occurring and now empowers and safeguards the rights of the
individual regardless of their medical history.

21. Building a therapeutic relationship:
The essence of MHN is to seek to understand the person’s
distress in a non-judgemental, empathic manner based on warmth,
curiosity and genuineness so that a therapeutic relationship can be
formed. Although for some MHNs working in inpatient settings, the
resource of time may not be as available as for those working in other
environments, nevertheless, MHNs possibly have a greater amount of
time to spend with their patients than other nurses.

22. Understanding unhealthy behaviours:
It is imperative to be mindful that unhealthy behaviours may in fact be
the person`s way of coping or indeed a health seeking behaviour. For
example, it is not uncommon for people who self-harm to say that they
self-harm as a way of releasing pain (coping) and preventing them from
taking more serious actions.

23. Motivational skills:
MHNs have a range of transferable skills that can be used in promoting
improved health. These may include motivational enhancement
techniques to increase motivation and manage anxieties and resistance
to change.

24. Presenting situation framework for planning.
• Presenting health promotion need
• Predisposing factors
• Precipitating factors
• Protective factors
• Perpetuating factors
• Personal health promotion need development
• Personal health promotion need identification

25. • Rates of undiagnosed and untreated physical illnesses are higher in
the SMI than the general population.
• Severe mental illness (SMI) patients may die 13–30 years earlier than
the general population.
• SMI patients are more likely to smoke or be obese.

26. There are a number of explanations that are
proposed for these risks. These include:
• side effects of medication;
• lifestyle to include dietary habits, smoking and sedentary behaviours;
• difficulty in interpreting physical signs of illness;
• poor quality of care.

27. Smokers with mental disorders tend to be more heavily addicted and
are less likely to be successful when trying to quit than the general
population. The reasons why people with SMI may
have such high rates of smoking include other neurobiological,
psychological, behavioural and social factors including the condoning
and even active encouragement of smoking in care settings.

28. People with SMI are also more likely to be obese.
A range of factors may account for this:
• Depression may lead to reduced physical activity and increased
appetite.
• The stigma associated with obesity may be a contributing factor to
depression.
• Medications to manage mood, anxiety or psychoses can cause weight
gain.
• Activity may be limited due to obesity or related chronic illnesses
which increases the risk of depression by reducing involvement in
rewarding activities.

29. Strategies for mental health promotion
• Promoting healthy lifestyles and developing personal skills (smoking
cessation).
• Increasing access to services: People with mental illness are as interested
and concerned with their physical health as the general population. Various
factors may make it difficult for them to access services or receive health
promotion:
1. Medication may cause tiredness.
2. Lack of awareness of physical health conditions due to cognitive
impairment.
3. Difficulties communicating physical health complaints.
4. Poor quality health care. Despite codes of professional conduct, health
care practitioners may have discriminatory attitudes and stigmatize the
mentally ill.

30. Strategies for mental health promotion
• Empowerment: The health of people with SMI is greatly improved
when their personal power is advanced. Strategies that are more
likely to empower are those that enhance recovery rather than
promoting an approach that suggests poor prognosis. Treatment
plans should be collaborative rather than unilateral decision-making
that is perceived as coercive.

31. Strategies for mental health promotion
• Empowerment:
Mental health is very much part of the Expert Patient Programme which seeks to
use the knowledge of those living with a chronic condition to educate others.
A structured training comprises:
• Recognizing and acting on symptoms.
• Learning techniques that can reduce stress.
• Using medication correctly.
• Getting the most out of health services, by using them as effectively as possible.
• Managing the distress and depression that can come with a chronic illness.
• Taking adequate physical exercise, managing relationships with professionals and family.
• Maintaining a healthy diet.
• Using community resources.

32. Strategies for mental health promotion
• Social change: Stigma is unjust, adds to disability and is based on myth rather than fact.
Social interventions used in health promotion activities will often depend on the needs
and goals set. However, there are some specific social activities that may apply to all
patients.
These include: social inclusion into mainstream society so as the person feels a valued part,
a good standard of accommodation and finances that facilitates a good standard of living,
employment or other such activities that gives a sense of value and enables the person to
realize their potential, infrastructures which provide opportunities for lifelong learning that
reflects advances in education and life skills, cultural inclusion that respects the person’s
self-identity and relationships in context to larger communities, legal, ethical and moral
duties that provide social justice and prevent the unfairness that is experienced by those
with a mental illness.

33. Key learning points:
1. It is not possible to have good physical health without good mental health.
2. Mental health promotion is an integral part of all nursing.
3. Mental health is more than simply the absence of mental illness.
4. A society needs to respect political, cultural, economic, civil rights to
facilitate good mental health.
5. People with severe mental illness have physical health needs that need full
attention.
6. Mental health is more than the absence of mental illness.
7. People with mental health issues are often discriminated against.
8. Effective public health interventions can enhance mental health.

34. Chapter summary
• Mental health promotion is a complex, interesting and a varied
approach that meets with the role of all nurses. It is enshrined in
policy, practice, professional standards and in patients’ wishes for
improved services. Rather than it being an activity that is an adjunct
to MHN, it is an integral part of care. It has many health, fiscal and
generational benefits for the patient, the organization and wider
community. In practising mental health promotion, the key is to listen
and understand in a non-judgemental manner and then work in
partnership using a variety of strategies that are patient centred and
led.