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Physical Activity Program for People with Severe and Persistent Mental Illness in the Community.

Author(s) Kamden Hoffmann1, Adrienne Walnoha2, Jennifer Sloan3, Praewpannarai Buddadhumaruk 4, Hsin-Hui Huang 5, Jeffrey Borrebach6, Patricia Cluss7, Jessica Burke8
Affiliation(s) 1Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, United States, n/a, Community Human Services , Pittsburgh, United States, 3Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, United States, n/a, UPMC, Pittsburgh, United States, 5Department of Family Medicine, University of Pittsburgh, Pittsburgh, United States, Department of Biostatistics, University of Pittsburgh, Pittsburgh, United States, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, United States, 8Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, United States
Country - ies of focus United States
Relevant to the conference tracks Social Determinants and Human Rights
Summary People with Severe and Persistent Mental Illness (SPMI) are at greater risk of medical issues compared to the general population due to lifestyle issues including cigarette smoking, poor physical fitness and poor nutrition. The purpose of this paper is to describe Community Based Participatory Research (CBPR) methods used to tailor a physical activity program among people with SPMI, demonstrate its impact on participants, the agency and the community, and suggest future research based on lessons learned.
Background Approximately one-fourth of U.S. adults experience a diagnosable mental disorder each year, contributing to 25 years of life lost to disability and premature mortality. SPMI affects 1 in 17 people. Lifestyle issues including cigarette smoking, poor physical fitness, and poor nutrition lead to a greater risk of medical issues among people with SPMI compared to the general population. People with SPMI may experience low satisfaction with life based on poor living conditions, lack of and discontent with social relationships, lack of health services, and unemployment. Physical activity has been shown to have an effect on physical and mental health outcomes among people with SPMI in community settings. More work is required to design and tailor physical activity programs to address these barriers and identify other perceived barriers and benefits to participation. Community Based Participatory Research (CBPR) may be a useful approach in gathering more information to achieve this goal.
Objectives The aims of this paper are to: (1) Describe CBPR methods used to develop a project to address physical activity promotion among people with SPMI; (2) Explore the impact of the physical activity program on participants, the agency and the community and (3) Present implications for future research based on lessons learned.
Methodology Development of the research/community collaboration was through a partnership between the University of Pittsburgh Graduate School of Public Health and Community Human Services (CHS), a local service organization located in a neighborhood in Pittsburgh. CHS serves the greater Pittsburgh area through programs including homeless assistance, mental health, health and wellness and family assistance for those with low levels of socio-economic resources. The two phase CPBR project included 1) formative research used to design the tailored intervention and 2) a pilot of the tailored intervention. Using a pre-post descriptive design, a pilot project was conducted to explore the feasibility in implementing a physical activity program in the CHS setting among clients with SPMI and to gather data about the impact on the physical and mental health of participants. Project participants included men and women who met the following inclusion criteria: satisfying conditions for SPMI as defined in the DSM-IV, age 18 or older, physician’s clearance, and current enrollment in a CHS program. The “On the Move” intervention was designed using feedback from focus groups. It consisted of two 40-minute exercise sessions per week held on site at CHS. To explore the impact of the physical activity program on participants, agency and the community, the team systematically collected daily notes to document the process during implementation and PALS recorded notes and attendance after each exercise session. The university researcher met weekly with staff and bi-monthly with the community and academic team members. The team used an investigator-designed survey combining instruments available in the research literature to measure demographic characteristics, mental and physical health, mood, perceived social support and motivation. Changes in mobility were measured weekly using the Timed Get up and Go Test (TUG). In order to develop lessons learned and areas for improvement of research, an open ended questionnaire adapted from other studies was administered at the end of the intervention. Statistical analyses consisted of descriptive statistics, including means, standard deviations, paired t-tests, and logistic regression modeling. Stata software version 12.0 was used to perform TUG test regression analysis and SPSS version 20.0 was used for pre-post analysis. Descriptive case studies were developed through the analysis of quantitative and qualitative data.
Results Sixteen of forty potentially eligible participants signed consent forms to enter the program. The majority of participants were female (56%) and Non-Hispanic white (46.7%) or Non-Hispanic black (40%). Of the sixteen enrolled participants, five (31%) participated regularly (i.e. approximately half or more of the exercise sessions) and eleven (69%) did not (mean: 5.6; median: 3; range: 17). Reasons for infrequent participation included increased mental health symptom severity, conflict in participation due to official disability status, complex service schedules and exacerbation of medical issues related to obesity. More men than women terminated participation after enrolling (85% vs. 56%, respectively). Although quantitative results from the pre- and post-surveys did not show significance based on the intervention, the survey did show improved trends in mood, social support, and physical and mental health outcomes. Although not statistically significant, the TUG test results showed improved mobility among those that participated regularly. These participants’ TUG scores decreased approximately two seconds when compared pre- and post-intervention. The post-intervention questionnaire provided details about participants’ perceived experience with 'On the Move'. While some participants experienced barriers to participation, feedback shows that the intervention was well received and lead to perceived health improvements. Many of the participants expressed a fitness improvement or a perceived increase in social support regardless of the number of sessions attended. At the agency level, CHS staff involved in the research gained a deeper understanding of the intervention. Consistent team meetings strengthened the effectiveness of the partnership. Regarding program development CHS staff members were enthusiastic about the program, but were also overburdened with the extra work needed to implement it. Some CHS staff were eager to participate in the exercise sessions while others felt disconnected to the program. The community showed interest in participating in the sessions and contacted the university researcher about participation, availability of take-home guides and community resources. When the possibility of a follow on program to On the Move was announced, community members contacted CHS staff to sign up.The tailored exercise sessions were based on the expressed needs of the participants.
Conclusion On the Move was a gender specific, group based exercise intervention developed via intensive collaboration with staff and clients of a community agency serving people with SPMI. It was tailored to fit the perceived exercise benefits, barriers and preferences of people served by the agency. Although similar recruitment methods from other studies were used including word of mouth and staff referral, it was difficult to obtain the desired number of participants. Despite the concerted efforts of CHS and On the Move staff, development of consistent engagement was challenging. Women adhered more regularly to the exercise sessions than men. Even with reminders and announcements, after the fifth week a majority of the men had dropped out. As noted in other studies the high attrition rates could be partly linked to the severity of participants’ diagnoses, adherence to pharmacological treatment, employment, and conflicting schedules. In addition, there are gender differences in recovery patterns and severity of disorders. Anecdotal reports from participants and the small TUG time changes provide some descriptive outcomes which suggest that the On the Move project had a beneficial impact regarding participants’ physical and mental well-being. The design and development of the intervention involved all partners at each stage. CHS staff brought invaluable experience in their knowledge and understanding of the participant population, community setting, and complex social dynamics. The university researchers brought experience in research, implementation, data collection and analysis, and physical activity. This partnership led to participation from some CHS staff during initial recruitment, but motivation to encourage participation from clients remained difficult among other CHS staff. This could be related to the staffs’ own perceived wellness concerns. Individuals who do not value physical activity or have limited physical capacity may not be able to advocate effectively for these types of activities. Developing a worksite wellness program alongside the exercise program for people with SPMI could create a normative atmosphere for wellness. Without the development of a strong partnership, expressed community need and each partners’ expertise, this research might not have been undertaken. Although programs may not adopt the model applied in this research there are important elements that should be considered when adapting a program akin to this.