Better Health Choices: Feasability and preliminary effectiveness of a peer delivered healthy lifestyle intervention in a community mental health setting
Introduction
It is well established that people living with severe mental illness demonstrate a high rate of lifestyle diseases (i.e. cardiovascular disease, cancer, diabetes) (Scott et al., 2011). Engagement in a range of unhealthy lifestyle behaviours makes people living with severe mental illness more susceptible to developing these diseases. This includes high rates of smoking (Kalkhoran et al., 2019) and alcohol use disorder (Toftdahl et al., 2015), high rates of sedentary behaviour and physical inactivity (Soundy et al., 2013, Stubbs et al., 2016), and poor dietary behaviours including low intake of fruit and vegetables (Hahn et al., 2014, Scott et al., 2011). Guidelines for addressing the prevention of lifestyle diseases in people living with severe mental illness recommend that health risk behaviours be addressed (i.e. smoking, poor diet, physical inactivity, sedentary behaviour and alcohol misuse) (De Hert et al., 2009, Stubbs et al., 2016). People living with severe mental illness experience a range of unique barriers that prevent the development and maintenance of healthy lifestyle behaviours, including psychiatric symptoms, and medication side effects. As such, there is a need for multiple health risk behaviour change interventions that are accessible and tailored for people living with severe mental illness.
Better Health Choices (BHC) is an 8-session telephone-delivered healthy lifestyle intervention that was developed for people living with severe mental illness. It encourages participants to decrease their smoking and alcohol use, improve their diet by increasing their intake of fruit and vegetables, and reduce their leisure screen time. The development of BHC has been previously described (Baker et al., 2014). The focus on fruit and vegetable intake and sedentary behaviour was largely influenced by the work of Spring et al. (2012). In this study, people from the general population with four cardiometabolic risk behaviours (i.e. low fruit and vegetable intake, high fat diets, low physical activity, and high levels of leisure screen time) were randomised to one of four 3-week interventions that focused on one dietary and one activity goal each. The most effective intervention aimed to increase fruit and vegetable intake and decrease leisure screen time. This combination was associated with significant, large and sustained improvements in fruit and vegetable intake, screen time, and serendipitously, saturated fat intake. Traditional ‘dieting’ (decreasing saturated fat & increasing physical activity) achieved lower levels of improvement than did the other three treatments (p < .001). A pilot of BHC has previously been conducted (Baker et al., 2014). Participant retention in this pilot study was good, with 19 (95%) participants completing the intervention, and 17 (85%) participants completing follow up assessment. Preliminary outcomes were promising, with statistically significant improvements in fruit consumption, overall diet quality, leisure screen time, overall sitting time, and global functioning. There were also improvement trends in vegetable consumption, quality of life, time spent walking, and reduction in smoking (for participants who smoked tobacco at pre-treatment). A limitation of this pilot study was that it was conducted under circumstances that do not necessarily reflect routine care. Psychologists or clinical psychologists delivered the program (including PK, AB, AT) and participants were higher functioning than the general population of people living with schizophrenia (Loughland et al., 2004). The next step in the development of BHC was to examine feasibility when delivered as part of a community based mental health service.
A recent systematic review, focused on preventative health interventions delivered by peer workers, highlighted that there was potential for peer-workers to play an important role in this area (Cabassa et al., 2017). Studies included in this review included interventions that were either peer-led or co-facilitated by peer specialists (i.e. “people with a lived experience recovering from a mental illness”) and other health professionals (p. 85). The majority of the studies examined manualized interventions, and were either delivered in group formats, individual formats, or combined formats. The review did not specifically address if any of the interventions were primarily delivered using the telephone. The review concluded that there was ‘limited’ current evidence for interventions targeting smoking or physical activity and ‘beneficial’ support for diet (Cabassa et al., 2017). For example, the review identified five studies that reported smoking outcomes. Two of the studies demonstrated statistically significant reductions in smoking, with the remaining three studies reporting reductions in smoking that were either not statistically significant or the authors did not report significance. The review did not identify any interventions that specifically targeted alcohol, however, there is evidence for the positive role of peer delivered support services for substance use disorders (Elbm et al., 2016). Whilst there is potentially a strong role for peer-workers to play in supporting the delivery of healthy lifestyle interventions, there remains a need to establish feasible and effective interventions that can be used as part of routine care. One approach to improving the evidence in this field is to consider adapting established manualized interventions, that draw on evidence based behavioural approaches, for delivery by peer-workers.
The primary aim of the current study was to evaluate the feasibility of delivering BHC in circumstances that reflect routine care, namely peer worker delivery of BHC to consumers of a community mental health service. Feasibility was assessed in terms of Treatment and Control Condition retention, participant satisfaction with BHC, and the ability for the peer-workers to demonstrate the use of behavioural counselling skills. Preliminary outcomes of the program were also examined. This included the 4 primary behaviours targeted as part of BHC: smoking, leisure screen time, diet (i.e. fruit and vegetable intake), and alcohol intake. Physical activity, overall diet quality and well-being (i.e. psychological distress and quality of life) were also examined to see if there were any serendipitous effects of the intervention on these variables.
Section snippets
Design and setting
The study was conducted as a randomised controlled feasibility trial. Participants were randomly assigned to (1) Treatment Condition (BHC) or (2) Control Condition. All participant involvement in the study occurred over the phone, including contact with the assessment officers and peer-workers. The protocol was developed according to 2013 Standard Protocol Items Recommendations for Intervention Trials (SPIRIT) guidelines (Chan et al., 2013), was registered with the Australian New Zealand
Participant recruitment
Fig. 1 shows participant numbers at each stage of the study. Between June 2015 and June 2016, 104 referrals were received by the research team, with 43 people being included in the study (see Fig. 1). There was a relatively large proportion of people who returned a consent to contact form (25%), who could not be contacted or when contacted, reported that they were not interested in participating in the study. Additionally, a further 12-people withdrew with no reason between the baseline
Discussion
The current study aimed to examine the feasibility of having peer-workers deliver BHC with people living with severe mental illness. The study had good retention rates, with an average number of 6 sessions (out of 8-sessions) completed by participants. The high participant satisfaction ratings in the Treatment Condition demonstrated that peer-workers were capable of delivering the intervention to the extent that participants found it beneficial.
The current study was not powered to find
Acknowledgments
The researchers would like to thank the consumers, staff and management of Neami National who supported this study. We would also like to thank the Schizophrenia Fellowship NSW for funding the trial.
Author Contribution Statement
PK was responsible for the development and ongoing oversight of the trial, including leading the preparation of the manuscript. AB, AT and II supported the training and supervision of the peer-workers. NF, CT, and II reviewed the audio recordings of the sessions and supported the analysis. RM developed the randomisation procedures and completed the analysis. FD, RC and CC provided expert advice on the intervention. BO, CT, ND, and II completed baseline and follow-up assessments. KW and AZ
Conflcit of Interest Statement
KW and AZ were employed by Neami National when the study was conducted.
References (30)
How sedentary are people with psychosis? A systematic review and meta-analysis
Schizophrenia Research
(2016)Cardiovascular disease and diabetes in people with severe mental illness: Position statement from the European Psychiatric Association
European Psychiatry
(2009)‘Better Health Choices’ by telephone: A feasibility trial of improving diet and physical activity in people diagnosed with psychotic disorders
Psychiatry Research
(2014)Potential sampling and recruitment source impacts in schizophrenia research
Psychiatry Research
(2004)Peer-based health interventions for people with serious mental illness: A systematic literature review
Journal of Psychiatric Research
(2017)The client satisfaction questionnaire: Psychometric properties and correlations with service utilization and psychotherapy outcome
Evaluation and Program Planning
(1982)Measuring adaptations of motivational interviewing: The development and validation of the behavior change counseling index (BECCI)
Patient Education and Counseling
(2005)Interventions designed to increase adult fruit and vegetable intake can be effective: A systematic review of the literature
Nutritional Epidemiology
(2005)The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness
Issues in Mental Health Nursing
(2011)- Kalkhoran S, Cigarette Smoking and Quitting-Related Factors Among US Adult Health Center Patients with Serious Mental...
Prevalence of substance use disorders in psychiatric patients: A nationwide Danish population-based study
Social Psychiatry and Psychiatric Epidemiology
Physical activity and sedentary behaviour in outpatients with schizophrenia: A systematic review and meta-analysis
Magonlinelibrarycom
Inadequate fruit and vegetable intake in people with psychosis
Australian and New Zealand Journal of Psychiatry
Multiple behavior changes in diet and activity: A randomized controlled trial using mobile technology
Archives of Internal Medicine
Peer-delivered recovery support services for addictions in the United States: A systematic review
Journal of Substance Abuse Treatment
Cited by (15)
The role of peer support and mutual aid in reducing harm from alcohol, drugs and tobacco in 2020
2020, Addictive BehaviorsCo-development of implementation strategies to assist staff of a mental health community managed organisation provide preventive care for health behaviours
2023, Health Promotion Journal of Australia