On average, people with severe mental Illness (SMI) have a shorter life-expectancy and die 8-25 years earlier than the general population [1,2] and most deaths are due to preventable medical conditions. To manage these conditions, the health care system has improved physical health care generally but there is strong evidence that this has not happened for people with SMI, who have been shown to have poorer access to physical health care than the population in general [3,4]. One explanation for this unequal treatment may be that medical health staff treat people with SMI less thoroughly and are guided by negative stereotypes [3]. Among people with SMI, those with signs and symptoms of psychosis are the most vulnerable to metabolic conditions [1,5]. Numerous factors may account for this, for example low socioeconomic situation [4], which often includes unhealthy lifestyle behaviors such as smoking, abuse of alcohol, unhealthy eating habits, and low physical activity levels [6]. To treat psychotic symptoms, psychopharmacological interventions [7] are predominant. These medications can save lives by decreasing psychiatric symptoms and suicide, but they also increase the risks of weight gain [8]. Therefore, it is necessary to perform routine screening and monitoring of glucose and hyperlipidaemia levels before and during treatments [9,10] and the potential risks and benefits of the treatment need to be considered together. However, it has been found that mental health staff are concerned about the patients becoming aware of the risks of weight gain as this is one reason for discontinuation [11]. This shows that mental health staff consider their primary aim to be to reduce psychotic symptoms and they do not have a holistic approach towards people’s health. Discussions concerning medical interventions continue to be in focus, although life expectancy in people with SMI has remained unchanged over the last 20 years, which is why there is a need to move forward with potential health promotion actions [12].

To mitigate and prevent physical health problems among people living with psychotic disorders, health promotion is essential. Health promotion is a process of enabling people to increase control over their health and its determinants, and thereby improve health [13]. One of the keystones of health promotion is the performance of health-related behaviors. According to the health belief model [14] and the health promotion model [15], variables explaining health-related behaviors are beliefs regarding health and health risk, including perceived susceptibility to illness, severity of illness, and health expectations including efficacy expectations and outcome expectations [14]. Efficacy expectations are the individual’s own judgment of a person’s capability to manage particular health behavior, and they need not reflect the actual health behavior [15]. Outcome expectations are the expected benefits to health due to a change of behavior. If a person has efficacy expectations and positive outcome expectations, this is a motivation to engage in healthy behavior. Thus, to understand a person’s level of motivation to perform health actions, we need to understand people´s beliefs regarding health, health risks and health expectations [16]. Studies concerning health beliefs among people with psychosis, focus exclusively on beliefs about mental health [17], and knowledge of health risks and health expectations among persons with psychotic disorders is limited [18]. What is known is that people with SMI have difficulty in living healthily, understanding their medical problems, remembering appointments [19], and feel a limited sense of improved, subjective well-being after completing health interventions [20]. Those with symptoms of psychosis have been shown to have many difficulties carrying out lifestyle changes [5] as psychotic symptoms can create difficulties in maintaining concentration and assimilating new information [21]. It has also been found that people with psychotic disorders have highly positive attitudes towards their physical health care even when showing higher physical health risk parameters than general population [22]. Perhaps this is a result of limited health risk beliefs? For example, people participating in a quit smoking group, pointed out professional support, the cost of cigarettes, instructions from a doctor and advice from friends as important motivators to quit smoking [23] rather than the health risks of smoking. Among people on anti-psychotic drugs, as many as 86% believed that the drugs were responsible [24] for their overweight, and in one weight loss program, barriers to weight loss were identified as difficulty changing familiar eating habits [25]. If a person places the responsibility of overweight on family and psychopharmacological interventions this affects health behavior expectations negatively, as the person might lose belief in his/her own capability to affect his/her own health, and therefore may adopt passive health behaviors. To understand a person’s level of motivation to perform health behaviors, individual beliefs concerning health, health risks and health expectations need to be further explored [16] as these variables provide motivation to engage in healthy behaviors.

The results are presented in three categories based on the Health Beliefs model [14]: Beliefs about Health, Beliefs about Health Risks, and Health expectations. The variations in each category are presented in subcategories (Fig. 1).

Fig. (1). The categories and subcategories explaining health and health risk beliefs among persons with psychotic disorders.

An overall positive picture of health was found despite the fact that physical health was found to be hard to verbalize and understand among people with psychotic disorders. When health was verbalized it was first conceptualized as psychological well-being, and represented as mental stability, as being able to put up with different kinds of feelings, as feeling good when with others, and as togetherness. Beliefs about how physical health manifests itself were rare, general, and comprehensive and physical health was defined as being agile and free from pain. Beliefs regarding uncertainties about bodily identity as well as limitations in opportunities for participation in work and society represented prominent health risks. Increased awareness of health risks, along with positive health expectations could result from having an interest in learning about health and health risks, and having visions and goals about health. When placing the responsibility for health in others it could cause a lack of health expectations.

The result indicates that there were generally positive health beliefs and participants mainly focused on feeling good here and now rather than worrying about possible future health risks. In other studies, people with SMI likewise have shown more positive attitudes towards physical health than the general population, while most of their clinical risk factors were above the normal parameters [9]. Previous studies illustrate that people with psychotic disorders express worry about developing diabetes due to anti-psychotic treatment [35]. Healthcare professionals need to address health issues early in the management of patients, especially those treated with anti-psychotics which increase the risk of becoming overweight [8].

When health is found hard to verbalize and understand by persons with psychosis it points out the importance of having dialogue in mental health care, where patients have opportunities to put their thoughts and feelings into words. As health was found hard to verbalize, the health belief model could be useful as it is subject-oriented and proposes that health-related behaviors are associated with subjective experiences of illness, the severity of a potential illness, the benefits of adopting preventive action, as well as possible barriers to taking action [14].

In this study it was shown that health first of all appeared as psychological well-being in the participants’ experiences and beliefs, and that it was problematic for them to identify physical aspects of health. Maybe this can be understood as a possible reason for the known limitations among persons with SMI in recognizing and changing their own health risk behavior [18-20]. This, along with being treated less thoroughly by medical health staff [3], presents a risk that these individuals are excluded from physical care when they really need extra support. As medical health professionals are in a position to contribute to identify and support physical health among people with psychosis, there could be advantages if they have basic knowledge of the health beliefs of the group. As it has also been found that mental staff give priority to psychological well-being [36] before physical health among people with psychosis, it also seems important to motivate them to take into consideration physical health issues. Screening for and treating psychotic symptoms is an important role for mental health nurses, as psychotic symptoms drain energy from the person and prevent healthy behavior [18,37,38]. However, physical health is not to be ignored, and actions that address lifestyle and health considerations need to be included in all nursing care of people who have frequent relapses or who are psychotic for long periods of time. Based on the results of this study, nurses also need to consider the impact of troublesome thoughts and inner voices on health interventions [39]. It could be viewed as a challenge to incorporate this philosophy and train mental health nurses to address health interventions among people with psychotic disorders. The challenge is exacerbated by scarce care resources and limited time [17].

One factor increasing the risk of physical health problems is unawareness of health risks. Based on the results of this study, health risk beliefs were not associated with physical health problems that are over-represented among persons with psychosis, such as metabolic deviations [40], cardiovascular diseases and Type 2 DM [1, 41]. Metabolic risks were not frequently discussed; instead health risks were mainly related to uncertain bodily identity, troublesome thoughts and inner voices, and exclusion from society. Most participants in this study felt that being overweight was bad for their looks but was not a health risk. Insecurity about one’s own identity and perceived external stress were seen as major threats to health. It is important to be aware that people with psychotic disorders are vulnerable to stress, and stress increases the risk of relapse [42,43]. In this study, the participants said that they continued smoking due to the positive effect on their psychological well-being, and were not concerned with health risks due to smoking. Thus, people living with psychotic disorders may face difficulties in health performance due to both psychological and physical factors.

Wanting to learn more, along with motivation and creativity, were seen as important for positive health expectations and to encourage action to achieve health among participants, for example by quitting smoking. Successful health behaviors are based on the person’s motivation to change [15]. People with SMIs who quit smoking [23] highlighted expenses due to smoking as the motivator, rather than risk of physical health problems. It was also indicated by participants in this study that they were in need of external pressure in order to make a change, which is something a nurse may not be used to. So, to motivate health behaviors, nurses need to identify what motivates the individual to perform health-behaviors, and where the individual requires pressure from his social network and/or health care staff in order to perform these health behaviors. Health expectations indicate that participants found exercise to be good for achieving health but difficult to perform. Several studies have shown that regular physical exercise is significantly beneficial on both a biological and a psychological level. Positive effects of controlled exercise include improved metabolic responses, increased quality of life, and reduced psychopathological symptoms [44]. Results from a 10-year modified group activity show that there is a relevant correlation between physical activity, quality of life, and medication treatment [45]. One way to motivate physical activities could be to support the involvement of family and friends in these activities, as the participants in this study described togetherness as contributing to wellbeing. This is in line with results from another study which also found that those with a high level of family contact appeared to experience better physical and mental health [46]. Maybe family habits are transferred into the patients´ daily lives with a positive effect on the patient’s health. Thus treatment in a team setting with a holistic and multidisciplinary approach, integrating physical activity into patients’ social lives, could be an effective treatment strategy and may lead to improved physical health in the group. Even though a range of interventions have been performed and evaluated worldwide [20,47-50], there has been little focus on family involvement [51], which indicates a future challenge for researchers. Individual expectations of health motivate a person to follow a particular health behavior [15]. Therefore, individuals will engage in health-related preventive behaviors based on their perceived expectations of the effectiveness of treatments [14].

In this study, some participants described how they were not worried about their health and relied on health care professionals to take responsibility for their health. According to the health belief model [14] an experienced threat towards one’s own health is one of the variables causing people to change risk behaviors, but that was not the case among participants in this study who did not experience threat towards their health and therefor did not seem to understand the importance in performing healthy behavior. Similar findings were found in another study which showed how long-term psychiatric patients were less likely to engage in health promotion compared to non-psychiatric populations. This was because they were found to show lower scores for internal locus of control and higher scores for measures of external locus of control, which means that other people controlled their decisions and their lives [52]. This is suggested to be an adaptive coping mechanism among people with inexplicable episodic symptoms who modify health beliefs towards an external locus of control. People with an external locus of control need to receive adequate support to guide them towards health, as the seriousness of a mental illness is viewed as a factor hindering physical health promotion [15,53]. From the findings that the participants had beliefs that they could totally rely on health care professionals taking responsibility for their health, which may lead to no expectations of good health, empowerment stands out as a core issue in the health promotion directed at persons with SMI.

This study is unique as it explores beliefs about health, health risks, and health expectations of people with psychotic disorders, none of which have previously been studied. However, some study limitations need to be mentioned, such as the restriction to people with psychotic disorders in outpatient care in Sweden. Thus the results may not be generalizable to all people with SMI worldwide. Nevertheless, the results provide important information on health beliefs and health expectations in a vulnerable population as a first step to understanding. To help the reader make judgments about the transferability of the results to another sample, a rich description of the characteristics of the sample, context and the research process [33,54] has been provided. When interviewing people with psychotic disorders it may be claimed they are not capable of giving informed consent [55], and that we cannot assume that the answers given are not psychotic experiences. In patient-centered care this argument is not valid as it is each patient´s right to make treatment decisions, and that does not mean professionals must agree with all of the patient´s decisions. A patient should be deflected from his or her own decision-making only if there is evidence of danger to the patient or others [56]. To avoid including people who could be of danger to themselves or others, mental health staff who knew the patients made a clinical assessment of their well-being, and people in an acute psychotic phase were not asked to participate. Many people suffering from a psychotic disorder have residual psychotic symptoms [42], so involving people with this experience was regarded as important in order to understand their lived reality. As mental health staff identified participants to include in the study there is a risk that only those most interested in and capable of caring for their health were identified. Based on the broad range of backgrounds and demographics of the participants and the rich data collected we would argue that our sample includes a sufficient range of participants. One thing to reflect on is the age of the participants, which range from 34-66 years (median 48). If a younger population had been studied, further beliefs may have been found as beliefs shape and changes during the entire life process [15].

It could be argued that using the direct content analysis approach makes the findings more likely to support previous theories, rather than being non-supportive [26]. Throughout the study, thoughts and behaviors were elicited, and the health belief model was considered suitable to explain certain health behaviors [14]. An inductive analysis was also performed in order to find experiences and patterns which could not be explained by the health belief model. The participants frequently asked questions about how to improve health. This could be seen as an interview bias. After a total understanding of the interviews was obtained, it was judged that these questions probably reflect awareness about living a healthy life, but also uncertainty about what this involves.

As physical health was found to be hard to verbalize and understand, health professionals need to support persons in putting into words their thoughts and feelings concerning physical health. Health was first of all verbalized as psychological, and from a holistic point of view physical and psychological health are inseparable and dependent on each other. In light of such understanding, the results clarify several challenges and also opportunities for changing risk behavior and for health development. Health risks were mainly related to uncertain bodily identity, troublesome thoughts and inner voices, and exclusion. Thus, there was a lack of expressed awareness of physical health risks and perceived threats towards own health, which according to the health belief model [14], is fundamental to performing life-style changes. As health behaviors are determined by our health beliefs, nurses play an important role in supporting people in becoming aware of the physical dimensions of their bodies as well as potential health risks. Striving to learn more about health behaviors and having goals and visions for health were important for positive health expectations, while potential hindrances to positive health expectations included not being worried about health. Nurses need to identify what motivates health behaviors and support people’s participation in their own health process. Reasonable external pressure and social support in health interventions seem to help people to succeed in lifestyle changes.

The first author was responsible for the study concept, design, and data collection and conducted the analysis. The second author double-checked the content of the categories, and both authors drafted the manuscript and made critical revisions of important intellectual content of the manuscript.

The authors confirm that this article content has no conflict of interest.