Mental health promotion among community-dwelling seniors with multimorbidity : perspectives of seniors, district nurses and home care assistants

The prevalence of mental illness is increasing among the older population in Sweden. One of the most vulnerable groups for mental health problems is older persons with multimorbidity, i.e. seniors with multiple chronic conditions. Many of them remain in their own homes with a comprehensive and complex need of support and healthcare, mainly provided by home care assistants (HCAs) and district nurses (DNs). However, the detection of mental health problems for adequate treatment or to promote mental health among community-dwelling seniors with multimorbidity, calls for skills and competences in this area.

This thesis aimed to gain a deeper understanding of how mental health may be promoted among community-dwelling seniors with multiple chronic conditions. Four studies have been included in this thesis (I-IV). All studies had a qualitative descriptive design with either a phenomenographic approach or latent and manifest qualitative content analysis technique. The aim of study I was to describe the variations in how community-dwelling seniors with multimorbidity perceived the concept of mental health and what may influence it. The findings showed the participants conceptualised mental health as having both positive and negative facets. The participants further conceived that social contact, physical activity and optimism may improve mental health, while social isolation, ageing, and chronic pain may worsen it. Study II aimed to describe the experience of health-promoting dialogues from the perspective of community-dwelling seniors with multimorbidity, and what these seniors believed to be important for achieving a dialogue that may promote their mental health. The main finding was the necessity of being seen as a unique individual by an accessible and competent person. Further, the participants missed having friends and relatives to talk to and they especially lacked healthcare or social service providers for health-promoting dialogues that may promote mental health. The aim of study III was to describe DNs’ perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity. Findings revealed that the DNs’ focus was on assessment, collaboration and social support as a way of detecting mental health problems and promoting mental health. Study IV described HCAs’ perspectives on detecting mental health problems and promoting mental health among the seniors in focus. The findings revealed that continuity of care and the seniors’ own thoughts and perceptions were regarded as essential for the detection of mental health problems. Further, observation, collaboration, and social support emerged as important means of detecting mental health problems and promoting mental health.

Conclusions: The results of this thesis are based on interviews and show that: 1) Seniors with multimorbidity should have an opportunity to describe how multiple chronic conditions may affect their life situation; 2) An optimal level of care can be achieved through continuity, involvement, and by providing a health-promoting dialogue based on the person’s wishes and needs; 3) Even if DNs seemed engaged in primary mental healthcare, there were no expressed goals set in the improvement of mental health, and it seemed that these DNs could not bear the primary responsibility for early detection of mental health problems and early interventions to improve mental health; 4) HCAs had knowledge about risk factors for mental health problems and it appears that they were dependent on care managers’ decision-making in granted support, as well as supervision from DNs in the detection of mental health problems and to promote mental health. In summary, the finding in the present thesis demonstrates that managing mental health problems is still an ongoing challenge for those organisations providing continuity in home care and home healthcare for homebound elderly persons with complex chronic conditions. The finding in the thesis also shows that DNs and HCAs seem to be dependent on each other in this area. Mental health promotion was expressed as an important assignment among DNs and HCAs, even though they describe different prerequisites and factors which could be seen as barriers in the detection of common mental health problems such as depression, anxiety and sleep problems. These personnel further described difficulties in collaboration and transmission of information between care- and healthcare providers from the community and primary care context. Social and physical interventions - as well as social contacts and social support to break social isolation - seemed important according to all the informants, with their different perspectives of how mental health may be promoted.

List of scientific papers

I. Grundberg, Å., Ebbeskog, B., Abrandt Dahlgren, M., Religa, D. (2012). How community-dwelling seniors with multimorbidity conceive the concept of mental health and factors that may influence it: A phenomenographic study. International Journal of Qualitative Studies on Health and Wellbeing. 7.
https://doi.org/10.3402/qhw.v7i0.19716

II. Grundberg, Å., Ebbeskog, B., Gustafsson, S.A., Religa, D. (2014). Mental health-promoting dialogues from the perspective of communitydwelling seniors with multimorbidity. Journal of Multidisciplinary Healthcare. 28;7:189-99.
https://doi.org/10.2147/JMDH.S59307

III. Grundberg, Å., Hansson, A., Hillerås, P., Religa, D. District nurses´ perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity. [Submitted]

IV. Grundberg, Å., Hansson, A., Religa, D., Hillerås, P. Home care assistants´ perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity. [Submitted]