The findings of our analysis are divided into three main areas relating to the concept of health, the concept of health promotion and health promotion in practice. Direct quotations from the discussions are included to illustrate how the interpretation is grounded in the data.
The concept of health
The analysis of the health professionals' overall views about the concept of health resulted in two categories, "A multi-facetted concept" and "A subjective assessment", which are related to each other. It was also clear that the informants included several determinants for health in their definitions, i.e., those that are important both for maintaining and creating health. "Health is about life, the whole life" became the third category for the health professional's conceptual framing of health.
"A multi-faceted concept"
The health professionals' general understanding of the concept of health is that the meaning given to it differs. Apart from viewing health as being assigned a physical, mental and spiritual dimension, the tenor might vary among individuals, cultures and between different situations/contexts. The substance given to the concept is also believed to alter during the life span. The fact that the concept is multi-faceted is presumed to be a problem when health or health outcomes are measured and compared, because it is only the individual who knows what health means to him/her.
What is health? Well, it is about the body, the soul and the spirit?
Isn't it cultural, I mean that it will be defined differently depending on where in the world you are.
Health means different things depending of what phase in life you are in
"A subjective assessment"
In spite of the fact that the health professionals understand health as a multi-faceted concept, their statements regarding what health means to them are very similar to each other. They consider health as a subjective experience or feeling rather than an objective confirmable state. It is a matter of how one is doing (feeling) in the actual situation. Health, well-being and happiness are described as closely connected. Furthermore, health and disease are perceived as different dimensions and not as contradictions. This means that disease does not automatically lead to ill-health and that absence of disease is not a guarantee for health.
It is subjective. If you feel good you are healthy
It's about feeling good, being happy
You can feel healthy even if you are ill. It all depends on your own perceptions.
"Health is about life, the whole life"
Figure illustrates that the health professionals understand health as an outcome of a multiplicity of determinants, both individual and environmentally oriented. It is a matter of the whole - the individual must be considered in his/her entirety. Describing which factors contribute to health is not easy, because they comprise the whole life. Health is created in a continuous process, in the context of everyday life - at home, at work, in school and in leisure time, where physical, psychological (mental, emotional, existential), cultural and social factors interact. Individual factors were given plenty of space; factors that make them feel well and felt worth striving for. A number of factors are directly or indirectly linked to positive experiences, thoughts and feelings that give rise to nourishment, strength, energy and a sense of well-being. The sub-categories realistic expectations and trust/confidence derive from work experiences. Unrealistic expectations on one's life, body and capacity as well as of what health services can accomplish are, together with feelings of insecurity and lack of confidence, considered as threats to health, especially when it comes to young people. In Figure , the sub-category "absence of disease" is put within brackets, because there is no direct link between absence of disease and health. Nevertheless, absence of disease increases the possibilities for the individual to handle his/her own life and fulfill or satisfy his/her own needs, and thus it is considered as a determinant for health. Paradoxically, illness and negative events can act as a catalyst to health or increased health, through a contribution to personal growth and development.
A description of the category "Health is about life, the whole life" with the associated subcategories (bold) and codes (normal).
The individual's own responsibility is emphasized even though health professionals acknowledge the responsibility for health by employers and public sectors in society. In general they see the individual as the only one who knows what influences his/her health and thereby is able to affect his/her situation.
The concept of health promotion
The health professionals' descriptions of health promotion indicate a concept that stands out as diffuse and elusive. It comes close to an all-embracing concept that includes all actions, activities and strategies that directly or indirectly promote the health (sense of well-being) of an individual in both a short and long-term perspective. The measures can take place on different structural levels. Their definition also includes a "setting approach", meaning that the physical and social settings in themselves also have an impact on health.
Health promotion is also described as an "attitudinal approach" in the meeting with patients and relatives. It is not just about what to do or say, it is also a matter of how. Essential concepts linked to this attitudinal approach are a holistic view of humankind, participation, commitment and devotion, trust, concern, confirmation, encouragement, support and empowerment.
When health promotion was related to prevention we could differentiate between three approaches where: 1) health promotion and prevention were seen as separate concepts; 2) health promotion was seen as an extensive concept which included prevention; and 3) health promotion was seen as a companion to primary prevention.
Health promotion in practice
The findings that it is possible to distinguish between three approaches to health promotion also emerged as important for understanding the health care professional's perceptions about and strategies for handling their health promotion role in practice. Their strategies are described as ideal types, which are labeled the demarcater, the integrater and the promoter. The main characteristics of each ideal type are given in Figure .
The three ideal types and their main characteristics.
The advocates for this approach distinguish between health promotion and disease prevention efforts. Due to the fact that the main determinants of health reside outside the health sector's field of knowledge and are difficult to influence, the significance and the role of the health services as a public health promoter are questioned.
I belong to those who want to place this [idea] with health actually outside health care, because a great deal of it has to do with things that I believe lay outside our, both competence and possibility to affect, meaning all the social aspects, relationships and such
The demarcater is unwilling to take on a health promotion role. The main reason is that he/she neither considers himself/herself to be trained in fostering people's well-being or happiness nor perceive it as a duty. Additionally, the demarcater seems to believe that undertaking a health promoting role entails responsibility to solve all the underlying causes of a "problem". However, the demarcater is trained in handling disease, and therefore he/she is willing to take on a disease preventive role.
We are educated to take care of disease and we can do that, I think;, that is, to explain what risks worsen physical health and those which increase the risk for disease -, that is what we can do. But to try to teach people how they should live together with one another for better relationships, etc. is far beyond what I feel is my field of knowledge or what I feel I can take on...
Yes, but I wrote this with preventative care toward the most common diseases and even other conditions where prevention pays, but it doesn't only have to be from an economic viewpoint but where we have time and knowledge and can do something worthwhile, it can be sexually transmitted diseases, it can be infectious diseases of some sort...
Seeing that resources are limited, the preventive measures must be based on evidence and guidelines. The starting point for such measures, which generally are individual-oriented, is signals of physical ill-health, i.e., physiological risk factors such as high blood pressure and overweight. By modifying one's living habits, the individual is requested to take responsibility for his/her own health and thereby prevent disease from occurring.
We also have knowledge in the care sector on how one can also inform about besides medication also taking responsibility for one's health when the first sign of ill-health appears, for example, that blood pressure becomes elevated or weight becomes too much and other things that happen, that we can inform about the traditional...exercise and good food and review one's situation,...it is only the individual who can affect their own situation...
The integrater perceives health promotion as an extensive concept, which includes disease prevention. Health promotion efforts, including disease prevention (in practice they are overlapping), are perceived as self-evident tasks for the entire health sector. A health promoting approach should exist side by side with the medical approach in all service processes.
It's a way of trying to integrate health promotion in the medical care. You have to work in parallel with both aspects ... You cannot just forget about one of them
The integrator is aware of the health promoting potential that lies in the everyday meetings with patients and relatives, and wishes to make the best use of this opportunity to provide the individual with "tools" for taking care of themselves.
That one actually gives self-help advice at every opportunity. Sitting in the lab chair, laying on the hospital cot and have them sitting still for five minutes to take blood pressure, yes then one has the chance.
As exemplified below, the integrater largely considers his/her ordinary task in daily work, accomplished on an individual and group level, as health promotion.
...the work we do at the antenatal clinic and the contraceptive unit is of course health promoting
Nurses at the cardiac unit rehabilitate people after infarction ... which promotes life by giving it back
In orthopedics we inform a lot about the importance of making the right moves and to use all parts of the body.
As health promoting efforts are aimed at both healthy people and people with disease, the aims may vary from prevention of disease, ill-health and injury to well-being during the final stages of life. Beside preventive measures, as illustrated below, adequate medical treatment as well as aspects of caring and rehabilitation are included. Consequently, the determinants that are targeted differ as well the measures to influence them.
If you have diabetes and come in and are prepared for insulin, if that is what you now need, then that is very health promoting.
When they are dying we see to it they are well cared for .... that they perceive well-being during the days or weeks that are left
Perhaps they have been in a respirator ... one starts by just sitting on the edge of the bed, they have zero balance for sitting. And eventually they go home supported on their own legs ... to be with from zero and until they go home and are independent ...
An important element in disease-related health promotion is facilitating recovery. Focusing on and supporting the healthy potential in all persons is important. Factors that in different ways can lead to strengthening of the body and the mind and bring meaning and zest for life are considered.
One tries to encourage them [hospitalized patients] to have visitors and perhaps go out for a little bit in the fresh air, because it can be nice to get away from here and acquire new strength in being out of the room.
Being able to master one's situation is important for people with a chronic condition in order to live as good a life as possible. Measures aimed at strengthening the patient's ability to manage his/her condition and supporting patient's trust in his/her own resources are highlighted.
When they come to us they are already sick' [heart disease], and then it is from that perspective to get them to be healthy despite that they are ill. To get them back to life, to not be sitting at home and not activating themselves, to have the courage to return to a normal life so that they don't get even sicker, surely, you are able to go out and walk, aren't you, one is saying such things all the time and it is also health promoting.
The promoter distinguishes between primary, secondary and tertiary prevention and views health promotion and primary prevention as "companions"
Everything is essentially preventative if one thinks of prevention levels...Where then is the health promoting perspective? And then I think in some way that one can see the health promoting perspective and the primary prevention level as companions in this context,...foremost the primary and health promoting level is about creating...a healthy population and the best health, therefore...
From the promoter's point of view, health promotion emanates from a proactive way of thinking. The efforts shall take place before "problems" or ill-health appears. Focus is primarily on possibilities and factors that keep people healthy (salutogenesis). The perspective is creating and strengthening or empowering. In order to be successful, health promotion must be practiced on different structural levels. The aim is to create social conditions for health and to enable the individual to take control over his/her own health, as well as to maintain or improve health. The promoter considers health promotion as a matter for the health services, even though in reality the specialists in public health work reside outside the health sector.
The major specialists regarding public health, they are those who let children...trainers for clubs, it can be sports, that is, where children and youths are active...it is essentially they who are specialists, one can say, on public health.
One task for the health service, in its role as public health promoter, is to contribute knowledge about health determinants and how they can be influenced. One way of doing this is via antenatal and child welfare clinics. As living habits are believed to be established at an early stage of life, parents, expectant parents and children are in particular considered as important target groups.
I usually say that one should start with children when one talks about health, but then it hits me that it should be the parents one should start with...because that is where it starts...how children learn to live according to the family patterns at home as the foundation
Another important group pointed out by the promoter is elderly people. Proper support and help, by way of regular home visits, may facilitate maintaining health and functional capacity.
Health promoting is trying to have such a society where one can be old and live at home and maintain one's health as long as possible...that one can receive help so that one can maintain one's health and those functions one has
The great challenge for the health service is to disseminate its knowledge about health and health determinants to other groups of people. The promoter wishes to focus more on visiting activities within the local community. By participating in local community preventive efforts, for instance, by visiting schools and parent meetings, parenthood can be supported and the children encouraged taking responsibility over their own health.
I work in the local prevention group and we talk about how we are going to get youths to not use drugs, how we will strengthen the parents in the parent role so that they dare to take responsibility for their children and be parents again."
Inform at schools how extremely important it is for youths not just to sit around all day ... one can move around even if one has a geography lesson.
Additional ways of disseminating information about health and health-related issues include making use of media or participating in public debates, for instance, about alcohol policy or accommodations for elderly people. The promoter also stresses the importance of encouraging and supporting collaboration with other health actors in the local community.
And so I think, resources outside our sphere, outside the county council sphere, that's what I usually take up to empower others to think and do things for health because it already happens and that we say it is good. That one organizes exercise dancing, that one takes gardening courses, that one starts weight loss groups, etc. That this in some way is acknowledged.
In summary, it should be noted that all professional groups expressed the need for health care services to be (more actively) involved in disease prevention on individual- as well as on a population level. Our analysis resulted in three ideal types primarily aimed at capturing how they viewed their possible enrolment in health promotion efforts.