Method

Introduction Results

Discussion

Health behaviors and perceived well-being

in individuals with SMI at community day programs

Nancy H. Liu, M.A., Kee-Hong Choi, M.A., William D. Spaulding, Ph.D. University of Nebraska-Lincoln

•Significantly elevated rates of premature death are found among persons with severe mental illness (SMI) compared with those of the general population.

•Up to 85% of persons with SMI have co-morbid medical problems including diabetes, cardiovascular disease, hypertension, and obesity (Lambert, Velakousli, & Pantelis, 2003).

•Between 1996 and 2006 general population the mortality gap between persons with SMI and the general population has not narrowed (Tiihonen, Lonnqvist, Wahlbeck, et al., 2009)

•There is limited data on the health behaviors of this vulnerable population; even less data exist on health-focused, community-based day programs, which have proliferated over the last decades despite limited evidence for their effectiveness (Catty, Burns, Comas, et al., 2008),

•In this exploratory study, we examined the effectiveness of a community-based health-focused program (HFP) compared with a treatment as usual (TAU) day program on changing health behaviors of 19 individuals with SMI enrolled in day treatment. 

•Nineteen participants (10 men and 9 women) from the two day centers were recruited for the study by day center staff who introduced the study objectives and goals.

•All study participants met the following inclusion criteria:◦   1) at least 19 years of age; ◦2) had a diagnosis of schizophrenia-spectrum disorder or bipolar disorder, based on chart review; and◦   3) were their own legal guardian or consent was obtained from legal guardian.

•After providing informed consent, individuals participated in a 45-minute semi-structured interview, using the following assessments:

•Brief Psychiatric Rating Scale: (BPRS; Lukoff, Liberman, & Nuechterlein, 1986), a clinician-rated measure was used to assess psychiatric symptoms.  The BPRS contains 24-items rated on a scale of 1 (Not Present) to 7 (Extremely Severe) of various symptoms. The examiner was trained to acceptable levels of inter-rater reliability with a criterion-trained rater on the BPRS.  Due to its stability across all stages of SMI, the 4-factor model was used in all analyses (Kopelowicz, Ventura, Liberman, et al., 2008)

•Health Behaviors and Perceived Improvement:a semi-structured interview that included information about frequency of health behaviors over the past two weeks.  Perceived improvement was assessed across domains, including psychiatric symptoms, medication side effects, feelings in general, energy, hopefulness, boredom, loneliness, confidence and relationships with other people.  This section was rated on a Likert-type scale, where 1 = worse, 2 = same, 3 = better.  This section of the questionnaire was adapted from a previous health measure (REF).  Cronbach alpha for the section of the measure on self-perceived improvement measure was sufficient, α = .893.

•Subjects received a sugar-free sports drink or water bottle for their participation. �

•This study was approved by the University of Nebraska-Lincoln Institutional Review Board

•Demographic and clinical characteristics of the sample are presented in Table 1. 

•Health behavior results are provided in Table 2.

•Correlational analyses among clinical symptoms and health behaviors revealed that more severe mood was associated with a lower number of weekly meals, r = -.504, p = .028.  In addition, eating more fruits and vegetables was associated with more exercise, though the sample size may have been too low for this relationship to be significant, r = .422, p = .072.

•Provision of food and vegetables at the HFP resulted in higher fruit and vegetable intake than persons in TAU. 

•No differences in the amount of exercise and rate of smoking between the two conditions

•Access to exercise equipment and a one-smoke break smoke policy alone does not significantly increase health-promoting behaviors. 

•As provided in Table 3, the HFP group reported significant self-perceived improvement in confidence. 

•Programs designed to change health behaviors should be adequately tailored to this group

•Access to healthy meals can increase consumption of fruits and vegetables, though these effects may not be durable

•Provision of access to exercise equipment does not increase exercise behaviors

•Health-focused day programs should develop strategies to actively engage participants in services to increase utilization

Limitations

•Due to the use of a convenience sample, results may have been impacted by small sample size and self-selection bias. 

•The results may have been impacted by difference in sample characteristics (i.e., age and number of past hospitalization) of the two conditions.

•Low base rate of smokers in both groups.

Table 1. Demographic and Clinical Characteristics of Sample

Health-Focused Program (N = 13)

Treatment as Usual

(N = 6)

Characteristics N % N %

Analysis b p-value

Gender Male 7 53.8 3 50.0 Female 6 46.2 3 50.0 -- 1.00

Marital status

Never married 10 76.9 2 33.3

Separated/divorced 3 23.1 4 66.7 -- .129

Education Some high school, completed high school, or GED

9 69.2 3 50.0

Some college/technical school or BachelorÕs degree

4 30.8 3 50.0 -- .617

Employment status Unemployed 8 61.5 5 83.3 Currently employed or employed within last two years

5 38.5 1 16.7 --

.605

Insurance status Medicaid 6 46.2 4 66.7 Medicaid and Medicare or Private 7 53.8 2 33.3

-- .628

Family health history Obesity a 8 61.5 2 33.3 -- .118 Diabetes a 10 76.9 3 50.0 -- .268 Ethnicity White 11 84.6 6 100.0 Non-White 2 15.4 0 0

-- 1.00

Smoker Yes 5 38.5 4 66.7 -- .350 Mean SD Mean SD

Age (years) 37.0 10.46 50.7 3.67 F (1, 18) = 9.45 .007* Number of past hospitalizations 11.7 8.24 3.5 2.66 F (1, 18) = 4.26 .058 Brief Psychotic Rating Scale (BPRS) total 35.0 5.60 36.6 9.37 F (1, 18) = 0.21 .654 a Includes 1 missing datum from Health Focused Program sample. b Some analyses used FisherÕs Exact Test. Note: FisherÕs Exact Test used for expected frequencies less than 5. Table 2. Health Behaviors by Group

Health-Focused Program

(HFP) N = 13

Treatment as Usual

(TAU) N = 6

Health Behavior

Mean SD Mean SD

F

df

p-value

Exercise 2.0 2.53 1.6 2.53 3.58 17 .669

Fruit and vegetable consumption per day 1.3 0.75 .33 0.52 1.64 17 .011* Cigarettes smoked per daya 17.4 9.15 17.8 4.50 2.25 7 .947

a Sample size for smokers in each group is HFP N = 5 and TAU N = 4. *Significant at the .05 level. Note: To correct for multiple comparisons, significance criteria was placed at the .001 level.

Table 3. Self-Perceived Improvement across Domains by Group

Health-Focused Program

(HFP) N = 13

Treatment as Usual

(TAU) N = 6

Analyses b p-value Domain

N % N %

Psychiatric symptoms 9 69.2 3 50.0 -- .617 Medication side-effectsa 2 15.4 1 16.6 -- 1.00

Feelings in general 9 69.2 3 50.0 -- .617

Energy level 10 76.9 1 16.6 -- .041 Hopefulness 10 76.9 0 0 -- .003 Boredom 6 46.2 1 16.6 -- .333 Loneliness 10 76.9 1 16.6 -- .041 Confidence 13 100.0 0 0 -- .000 * Relationships with others 9 69.2 0 0 -- .011 a Includes 2 missing data from the HFP. b Based on FisherÕs Exact Te st. * Significant at the .001 level. Note: To correct for multiple comparisons, significance criteria was placed at the .001 level. Note: FisherÕs Exact Test used for expected frequencies less than 5.