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Perspectives in Psychiatric Care
ISSN 0031-5990
Self-Reported Health, Health Behaviors, Attitudes, and Beliefs of Regional Mental Health Consumers Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, David Scott, BHM (Hons), PhD, Wendy Hoey, RN, and Robert Stanton, BHM (Hons), PhD Candidate Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, is Engaged Research Chair, Mental Health Nursing, Central Queensland University, Rockhampton, Queensland, Australia, Director, Centre for Mental Health Nursing Innovation, Director, Institute for Health and Social Science Research, and Professor, School of Nursing and Midwifery; David Scott, BHM (Hons), PhD, is Post-doctoral Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, Central Queensland University, Rockhampton, Queensland, Australia; Wendy Hoey, RN, is Nursing Director, Central Queensland Mental Health Service, Rockhampton, Queensland, Australia, and Affiliate Member, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, Central Queensland University, Rockhampton, Queensland, Australia; and Robert Stanton, BHM (Hons), PhD Candidate, is Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, Central Queensland University, Rockhampton, Queensland, Australia
Search terms: Attitudes, cardiometabolic health, health behaviors, mental health nursing, physical health, quality of life Author contact: [email protected], with a copy to the Editor: [email protected] First Received July 30, 2013; Accepted for publication September 3, 2013. doi: 10.1111/ppc.12043
PURPOSE: This article reports baseline data from a randomized controlled trial investigating the impact of a specialist cardiometabolic healthcare nurse on physical health care. DESIGN AND METHODS: Survey of community-based mental health consumers randomized to a cardiometabolic health nurse intervention. FINDINGS: Findings show a high prevalence of respiratory conditions, hypercholesterolemia, hypertension, and low quality of life. Participants reported regular blood pressure but infrequent cholesterol and blood glucose testing. Few received advice about smoking cessation, diet, or physical activity. Participants were mostly satisfied with physical healthcare provision; however, positive health behaviors are lacking. PRACTICE IMPLICATIONS: An individualized intervention based on knowledge and attitudes may be necessary.
People with serious mental illness (SMI) are known to experience poor quality of life (Kerling et al., 2013; Rubio et al., 2013), greater prevalence of physical health disorders (Ismail, 2008; Scott et al., 2012), and a significant disparity in health care (Chadwick, Street, McAndrew, & Deacon, 2012; De Hert et al., 2011), compared to people without mental illness. As a result, people with SMI experience a 2- to 3-fold increase in mortality risk compared to the general population (Brown, Kim, Mitchell, & Inskip, 2010).
quality of life resulting from their mental health. Barnes, Murphy, Fowler, and Rempfer (2012) recently reported the independence of these domains with better physical quality of life associated with reduced physical illness, whereas mental quality of life was associated with symptom severity. While quality of life of people with SMI is reversible with remission of mental illness, overall quality of life in remission, even in the absence of comorbid physical illness, remains less than that experienced by people without SMI (Rubio et al., 2013).
Health-Related Quality of Life
Physical Health Disorders
It is widely recognized that people with SMI experience a poorer quality of life compared to those without SMI (Kerling et al., 2013; Rubio et al., 2013). In addition to the burden of symptoms, factors such as poor health care have been demonstrated to lead to poorer quality of life and increased symptom severity in people with SMI (Mackell, Harrison, & McDonnell, 2005). The quality of life related to an individual’s physical health is not identical to that same individual’s
Australian population data indicate that the prevalence of coronary heart disease (CHD), diabetes, chronic respiratory conditions such as bronchitis, emphysema, and asthma is significantly greater in people with SMI compared to people without SMI (Scott et al., 2012). This is not dissimilar to longitudinal international data (McConnell, Jacka, Williams, Dodd, & Berk, 2005), which demonstrate that people with depression experience a 4-fold increase in the risk of
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developing CHD. This significant disparity in the prevalence of physical health disorders generates increased challenge for those involved in the treatment and care of people with SMI. In particular, nurses in mental health settings, who are often at the front line of mental health care, can be faced with the unmet needs of mounting physical health problems. A number of studies (Barnes, Paton, Cavanagh, Hancock, & Taylor, 2007; Happell, Scott, Platania-Phung, & Nankivell, 2012; Lambert & Newcomer, 2009) have reported that nurses are cognizant of, but often unable to adequately treat, physical health disorders due to competing priorities, lack of adequate time and resources, concerns regarding training, or ambivalence toward physical health care being part of their role. Physical Health Care and Experiences Inequality in physical health care experienced by people with SMI contributes to the poorer physical health and early mortality in people with SMI (Barnes et al., 2007; Druss, Bradford, Rosenheck, Radford, & Krumholz, 2001; Scott, Platania-Phung, & Happell, 2011). People with SMI are half as likely to receive routine blood pressure and cholesterol tests (Nasrallah et al., 2006), 20–30% less likely to have cardiac procedures performed (Druss, Bradford, Rosenheck, Radford, & Krumholz, 2000; Rathore, Wang, Druss, Masoudi, & Krumholz, 2008), and 15% less likely to receive statins for elevated cholesterol, compared to those without SMI. People with SMI and co-occurring type II diabetes are 35% less likely to be admitted to hospital for diabetic emergencies (Sullivan, Han, Moore, & Kotrla, 2006) and almost 50% less likely to receive medication prescriptions for cardiovascular disease prevention, compared to those with type II diabetes who do not have SMI (Kreyenbuhl et al., 2006). There are also substantial disparities between the views of general practitioners (GPs) and people with SMI regarding the quality of care. Lester, Tritter, and Sorohan (2005) highlighted the challenges of providing timely effective physical and mental health care, and of communication between clinician and patient; in particular, the difference between the clinicians’ views of SMI as a lifelong chronic condition, and the optimistic recovery-oriented view held by the patient. In support of the findings of Lester et al. (2005), Emslie, Ridge, Ziebland, and Hunt (2007) reported that people with depression experienced significant difficulty in articulating mental health problems to GPs and this impaired communication and subsequent treatment. Knowledge and Attitudes of Health Behaviors There is a substantial gap in the literature regarding the knowledge of health behaviors in people with SMI, and their attitudes toward health behaviors. This is significant since the development of interventions and education programs 194
aiming to improve these areas requires an understanding of the level of knowledge people with SMI possess, and their attitudes toward health-related behaviors. In one of the few studies to address this literature gap, Brunero and Lamont (2010) surveyed community-based mental health consumers attending a clozapine clinic using the European Health and Behavior Survey. Overall, consumers were found to have positive attitudes, as defined by higher scores on specific items contained in the European Health Behavior Study questionnaire, regarding health-related behaviors despite high cardiometabolic risk, and this highlights the complex interplay of factors linking attitudes, beliefs, and behaviors. In a more recent qualitative study, Hardy, Deane, and Gray (2013) reported similar positive attitudes during semistructured interviews, but limited knowledge of mental health consumers with respect to behaviors and cardiovascular risk. Importantly, this study highlights the opportunity for nurses undertaking physical health checks to positively impact on consumers’ behaviors with all participants commencing lifestyle changes as a result of the health check (Hardy et al., 2013). Aims In summary, while the physical health and healthcare experiences of people with SMI have been extensively researched, there is a paucity of literature describing the knowledge and attitudes of health behaviors of people with SMI. Therefore, the aims of the present paper are to contribute to the existing body of knowledge regarding physical health disorders and healthcare experiences of people with SMI, but more importantly to establish a base for the investigation of the knowledge and attitudes towards health behaviors of people with SMI. Methods The protocol for this randomized controlled trial has been previously described (authors’ details were removed to facilitate blind review). Briefly, adult mental healthcare consumers of a regional hospital community mental health service in Queensland, Australia, were invited to participate in the study by their case manager. Participants randomized to the intervention group received access to a cardiometabolic healthcare nurse (CHN) with the primary purpose of identifying “atrisk” indicators of cardiometabolic health. Those identified as “at-risk” were provided linkages to GPs or other allied health professions as necessary, or provided health behavior change advice. The CHN was responsible for follow-up on all appointments. In addition to demographics and physical health parameters, participants in the intervention group completed selfreport questionnaires on health status (Centers for Disease Control Health-Related Quality of Life Questionnaire 4 Perspectives in Psychiatric Care 50 (2014) 193–200 © 2013 Wiley Periodicals, Inc.
Self-Reported Health, Health Behaviors, Attitudes, and Beliefs of Regional Mental Health Consumers
[CDC-HRQOL-4]), self-reported physical health disorders, physical healthcare experiences, and perceptions and health behavior knowledge and attitudes (Australian Health Behaviour Knowledge and Attitudes Questionnaire [AHKAQ]). Preliminary data reported here are shown as frequencies, means, and SD. Data were analyzed using Statistical Package for the Social Sciences Version 19.0 (IBM Corp, New York, USA.) This study was approved by health service and institutional ethics committees. Participants were advised that participation was voluntary and that they could withdraw consent at any time without penalty. Results Demographics We have collected baseline data from 21 participants. Our cohort is predominately male (61.9%), single (66.7), had completed secondary school education (87.5%), and received a pension (80%). A small proportion (14%) is of Aboriginal or Torres Strait Islander descent. Health-Related Quality of Life The majority (61.9%) of participants report their overall quality of life as either “Poor” or “Fair” with less than 5% of participants rating their health as “Very good.” The summary index of unhealthy days computation from the CDCHRQOL-4 indicates that our participants experience an average of 12.2 ± 13.1 unhealthy days for the previous month (range 0–30). Physical Health Disorders Self-reported diagnoses of physical health disorders showed that respiratory disorders have the highest prevalence (47.6%), followed by hypercholesterolemia (38.1%) and hypertension (23.8%). Less than 2% of participants reported no diagnosed physical health disorders and 61.9% reported two or more physical health disorders. Despite the prevalence of diagnosed physical health disorders reported by this cohort, only 38.1% report being prescribed medication for nonmental health conditions. Physical Health Care and Experiences Routine tests by medical professionals for cardiometabolic function appear rare. While almost 62% report having their blood pressure taken, only 28.6% report undergoing tests for cholesterol and 19% report having their blood glucose checked. Immunization rates are also low with only 23.8% Perspectives in Psychiatric Care 50 (2014) 193–200 © 2013 Wiley Periodicals, Inc.
reportedly receiving influenza vaccine in the past 12 months. Advice on lifestyle behaviors appears limited, with 47.6% receiving advice about smoking, 42.9% having received advice on diet, and 33.3% having received advice regarding physical activity. GP advice concerning alcohol and illicit drug use was reported by 33.3% of participants, with GP advice regarding safe sex practices reported by 4.7% of participants. With respect to perceptions of healthcare experience, only 14.3% of participants thought the availability and quality of healthcare services had worsened over the past 10 years, with the remainder equally distributed between views of “Stayed the same” or “Improved.” The vast majority of participants in the current study (75.2%) report being “Satisfied” or “Very satisfied” with the quality of medical care they have received. In light of this, a small majority (42.9%) report always seeing the same GP at the same clinic for treatment with the balance equally distributed between seeing a different GP at the same clinic, and seeing a different GP at a different clinic. More than half (52.4%) of participants are not concerned about the cost of health care; however, private healthcare insurance was a rarity for our participants, with just 4.8% reporting combined hospital and extras cover. To investigate the factors that influence people with SMI seeking medical care, we asked participants to imagine they were experiencing considerable pain or symptoms they think may indicate the need for medical care. More than one third (38.1%) reported they would seek care immediately, 47.6% reported they would seek care if the pain or symptoms worsened or did not go away in a reasonable period of time, and 14.3% responded they would seek care as soon as other commitments permitted. We then asked to what degree a range of factors would influence their decisions to seek medical care. Participants’ responses are shown in Table 1. We then asked whether participants were confident in their ability to communicate with their medical professionals. More than 75% responded with “Confident” or “Very confident” (Table 2). Knowledge and Attitudes of Health Behaviors The AHKAQ comprises 14 questions related to knowledge of the Australian health guidelines and seven questions rating the importance of a range of health strategies in protecting against future health problems. Scores for knowledge of health behaviors were based on participants answering “True”or“False”to a series of statements regarding Australian health guidelines (e.g., Australian dietary guidelines recommend you should eat at least five servings of vegetables per day—True/False). Means score for percentage of correct responses was 73% (range 50–93%). A score above the mean (73%) was achieved by 38% of participants. Attitudes toward health behaviors were rated using a 10-point scale where 1 = not at all important and 195
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Responsea Factor
Never
Seldom
Sometimes
Often
Waiting times for medical services Personal commitments (e.g., work or family) Financial costs of attending medical services Discomfort or embarrassment in describing symptoms or being examined Discomfort in being around medical facilities or staff Fear of receiving bad news about your health
42.9 47.6 57.1 52.4
14.3 14.3 9.5 19.0
23.8 14.3 19.0 14.3
19.0 23.8 14.3 14.3
52.4 61.9
14.3 9.5
19.0 14.3
14.3 14.3
Table 1. Percentage of Participants who Report Factors That May Impact Their Decisions to Seek Medical Care
a
Scores are reported as a percentage of the total participants. No missing data—all scores add to 100%.
10 = extremely important. For the purpose of this study, higher scores demonstrate a more positive attitude. Scores for attitudes toward health behaviors are shown in Table 3.
The proportion of male participants, and the proportion of participants reporting their marital status as single are higher in the present study compared to the Australian population experiencing SMI (Australian Institute for Health and Welfare [AIHW], 2012). However, the proportion of participants reporting their employment status as “pensioner” are similar to that recently reported (AIHW, 2012).
report both physically unhealthy days and mentally unhealthy days. Using the cut point for unhealthy days of >14 (Zahran, Kobau, Moriarty, Zack, & Giles, 2004), 43% of our cohort is defined as having “Frequent Mental Distress.” This is particularly important since, despite the high satisfaction with their quality of health care and positive attitudes toward healthy behaviors, our cohort demonstrates poor dietary and physical activity habits. It is possible that these factors, coupled with the high prevalence of comorbid illness, are substantial contributors to the poor quality of life observed in our participants. Furthermore, there is evidence showing each item of the CDC HRQOL-4 is predictive of 1- and 12-month mortality and healthcare utilization and this relationship should be explored further in a population with SMI (Dominick, Ahern, Gold, & Heller, 2002).
Health-Related Quality of life
Physical Health Disorders
Consistent with the findings of Narvaez, Twamley, McKibbin, Heaton, and Patterson (2008) and Saarni et al. (2010), a large proportion of our participants report a low quality of life. However, the unhealthy days index observed in our cohort differs markedly from the general population (National Research Council, 2009) where substantially less people
Our findings are consistent with those from Australia (Scott et al., 2012) and internationally (Lawrence, Kisely, & Pais, 2010; McCloughen, Foster, Huws-Thomas, & Delgado, 2012), which report the high prevalence of physical health disorders in people with SMI. Scott et al. (2012) recently reported a significantly higher prevalence of respiratory disorders, irritable
Discussion Demographics
Table 2. Confidence in Communication With Healthcare Professionals
Level of confidencea Scenario When discussing your health with a medical professional (e.g., GP, nurse, etc.), how confident are you that you can describe your symptoms in a way that they can understand? When a medical professional (e.g., GP, nurse, etc.) is discussing your health with you (e.g., tests and treatment procedures, etc.), how confident are you that you can understand them?
Not very confident
Confident
Very confident
9.5
42.9
47.6
23.8
33.3
42.9
a
Scores are reported as a percentage of the total participants. No missing data—all scores add to 100%. GP, general practitioner.
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Table 3. Responses to the Importance of Health Behaviors Statement
Meana Minimum Maximum
Maintaining a healthy weight Participating in regular physical activity Eating lots of fruits and vegetables Trying to avoid eating too much saturated fat Always practicing safe sex Limiting how much alcohol you drink Not smoking Not using illicit drugs
8.5 7.7 7.0 7.3
6 5 2 2
10 10 10 10
8.5 7.6 6.0 7.3
2 1 1 1
10 10 10 10
Scores are based on a 1–10 scale where 1 = not at all important and 10 = extremely important.
a
bowel syndrome, diabetes, food allergy or intolerance, and CHD in a large sample of Australians diagnosed with mental illness compared to those without mental illness. Consistent with their findings, the findings of the present study demonstrate that respiratory disorders are of greater prevalence than other physical health conditions. This is likely due to the high prevalence of cigarette smoking in this population (Lawrence, Mitrou, & Zubrick, 2009; Pedersen & Von Soest, 2009). Hypercholesterolemia and hypertension were reported in more than one third of our sample. This differs from other studies (Davidson et al., 2001), which report the prevalence of these conditions is not significantly different from the general population. This perhaps reflects the lack of cardiometabolic screening offered to people with a mental illness. The high prevalence of overweight and obesity in the present sample coupled with the lack of cardiometabolic screening may have led to underreporting of hypercholesterolemia and hypertension, making the need for physical health assessments of people with SMI all the more urgent. There may be a view that increased screening for physical health disorders in people with SMI will lead to an increase in prescribed medication. However, our data suggest this may not be the case. Less than 40% of our sample was prescribed with medications for nonmental illness conditions, despite the high prevalence of physical health conditions present. This is encouraging since non-pharmacological interventions such as exercise, nutritional counseling, and cognitive behavioral therapies have demonstrated significant benefit in weight management, cholesterol reduction, and glucose management (Caemmerer, Correll, & Maayan, 2012).
conflict with some (Marder et al., 2004) but not all (Stanley & Laugharne, 2010) practice guidelines for the physical health care of people with SMI; however, the guidelines are equivocal (Citrome & Yeomans, 2005). Interestingly, Australian GPs are well reportedly advanced in the use of evidence-based practice guidelines compared to those overseas, with the exception of conditions such as depression (Harris et al., 2012). This perhaps reflects the multidisciplinary nature of mental illness management, lack of confidence in diagnosing or treating the condition, or a concern that they are unlikely to have a substantial impact on the physical health of people with SMI (Barley, Murray, Walters, & Tylee, 2011). These factors may contribute to our finding that less than half of participants in the current study received lifestyle advice from the primary care provider. This is noteworthy given that Campion, Francis, and Preston (2005) reported that at least one third of patients with SMI would positively respond to advice offered by a doctor. Furthermore, despite reports to the contrary (Hardy, White, Deane, & Gray, 2011), the vast majority of our participants were satisfied with the health care they received. Most continued to see the same doctor at the same clinic and this may allay some of the concerns of participants in the study of Hardy et al. (2011), who expressed general distrust in doctors. Furthermore, the barriers to treatment identified by Roberts and Bailey (2010) are far less likely to be present in the sample from the current study as evidenced by the high level of treatment satisfaction. More than half of the participants in the current study report that negative experiences such as fear of bad news, financial cost, or personal discomfort never influence the decision to seek medical treatment. The factor most likely to influence the decision to seek medical treatment is excessive waiting times. This may be due to the perceived urgency of the need for treatment. This suggestion is consistent with the finding of Hardy et al. (2013), who report that the majority of patients with SMI would only attend a surgery when absolutely necessary. It is likely that the level of satisfaction with care, lack of substantial barriers to treatment, and consistency in treating practitioners contribute to our finding that a significant proportion of participants in the present study are confident in their capacity to articulate their symptoms, and comprehend the responses to and from medical professionals. Overall, this may reflect differences in healthcare systems internationally. Knowledge and Attitudes of Health Behaviors
Physical Health Care and Experiences The low reported rates of routine health checks for people with SMI are consistent with the findings of reviews (De Hert et al., 2011) and large trials internationally (Nasrallah et al., 2006). The lack of routine cardiometabolic monitoring is in Perspectives in Psychiatric Care 50 (2014) 193–200 © 2013 Wiley Periodicals, Inc.
To the best of our knowledge, this is the first study to comprehensively investigate the knowledge and attitudes of health behaviors in people with SMI using an up-to-date, nationspecific instrument. While the European Health and Behaviour Survey (Wardle & Steptoe, 1991) represents the 197
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most commonly utilized instrument for assessment of health behavior and knowledge, it is now somewhat dated and was not designed for Australian populations. The AHKAQ was developed to address this limitation. More than one third of our sample scored above the mean of 73% correct responses to the 14 questions assessing knowledge of the Australian health guidelines. We would consider this level of knowledge to be comparable to the general population. In contrast, Dickerson et al. (2005) suggest that the knowledge of health behaviors in people with SMI is less than those in the general population. Similarly, Hardy et al. (2013) reported that knowledge of the risk of cardiovascular disease was poor in a small sample of people with SMI. Using an instrument such as the AHKAQ as part of a larger health screening battery may assist the delivery of a tailored intervention to specifically address a consumer’s knowledge gap which may result in greater effectiveness compared to a population-based approach. From the present study, mean responses regarding attitudes toward health behaviors are all ≥ 6.0 suggesting positivity. Our findings are consistent with those of Brunero and Lamont (2010) and Roberts and Bailey (2010) who both reported a high degree of positivity regarding health behaviors in consumers attending an outpatient clozapine clinic. Despite both the apparent high level of knowledge and positive attitudes regarding health behaviors, our sample presents with a significant burden of comorbid physical illness. There is some evidence (Campion et al., 2005), however, to suggest that people with SMI may not consider themselves to be at risk of health complications and therefore fail to participate in regular health screening or education or engage in activity to promote physical health. Alternatively, people with SMI may prioritize physical health differently than those without SMI (Dickerson et al., 2005). Taken together, these factors may contribute to the poorer physical health experienced by people with SMI in a manner similar to reduced primary healthcare access and antipsychotic medications. These findings highlight the need for alternative approaches to initiate and maintain positive behavior change in people with SMI. Implications for Mental Health Nursing Practice Unfortunately, despite the plethora of research regarding the physical health of people with SMI, there continues to be a lack of evidence-based education for health professionals regarding the physical health of people with SMI (Hardy et al., 2011). Therefore, there remains a need to develop firstline interventions to manage the physical health of people with SMI. Despite the often ambivalent views of nurses, they are well placed to assess and intervene (Happell, Platania-Phung, & Scott, 2011). Individualized management based on the knowledge, attitudes, and behaviors of people with SMI is crucial. The development of a brief tool to assess 198
these factors within the domain of usual care, coupled with an intervention decision tool, will greatly assist nurses in their role in providing physical health care for people with SMI. Delivery of appropriate training, implementation via policy and practice, and challenging the culture will advance the management of the physical health care of people with SMI. Acknowledgments The authors acknowledge the funding support provided by the Australian Centre for Health Services Innovation and the Office of Health and Medical Research, Queensland Health. Our sincere thanks to assistance with and support of this project provided by the management and staff of Central Queensland Mental Health Service and to Mandy Haack for taking on this pioneering role. Thanks of course to the participants who gave up their time to assist us with this important work. References Australian Institute for Health and Welfare. (2012). Australia’s Health 2012. Canberra: Author. Barley, E. A., Murray, J., Walters, P., & Tylee, A. (2011). Managing depression in primary care: A meta-synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Family Practice, 12, 47. doi:10.1186/1471-2296-12-47 Barnes, A. L., Murphy, M. E., Fowler, C. A., & Rempfer, M. V. (2012). Health-related quality of life and overall life satisfaction in people with serious mental illness. Schizophrenia Research and Treatment, 2012, 245–103. doi:10.1155/2012/245103 Barnes, T., Paton, C., Cavanagh, M., Hancock, E., & Taylor, D. (2007). A UK audit of screening for the metabolic side effects of antipsychotics in community patients. Schizophrenia Bulletin, 33(6), 1397–1403. doi:10.1093/schbul/sbm038 Brown, S., Kim, M., Mitchell, C., & Inskip, H. (2010). Twenty-five year mortality of a community cohort with schizophrenia. British Journal of Psychiatry, 196(2), 116–121. doi:10.1192/bjp.bp.109.067512 Brunero, S., & Lamont, S. (2010). Health behaviour beliefs and physical health risk factors for cardiovascular disease in an outpatient sample of consumers with a severe mental illness: A cross-sectional survey. International Journal of Nursing Studies, 47(6), 753–760. doi:10.1016/j.ijnurstu.2009.11.004 Caemmerer, J., Correll, C. U., & Maayan, L. (2012). Acute and maintenance effects of non-pharmacologic interventions for antipsychotic associated weight gain and metabolic abnormalities: A meta-analytic comparison of randomized controlled trials. Schizophrenia Research, 140(1–3), 159–168. doi:http://dx.doi.org/10.1016/j.schres.2012.03.017. Campion, G., Francis, V., & Preston, A. (2005). Health behaviour and motivation to change. Mental Health Nursing, 25, 12–15. Chadwick, A., Street, C., McAndrew, S., & Deacon, M. (2012). Minding our own bodies: Reviewing the literature regarding
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the perceptions of service users diagnosed with serious mental illness on barriers to accessing physical health care. International Journal of Mental Health Nursing, 21(3), 211–219. doi:10.1111/j.1447-0349.2011.00807.x Citrome, L., & Yeomans, D. (2005). Do guidelines for severe mental illness promote physical health and well-being? Journal of Psychopharmacology, 19(Suppl. 6), 102–109. doi:10.1177/0269881105059505 Davidson, S., Judd, F., Jolley, D., Hocking, B., Thompson, S., & Hyland, B. (2001). Cardiovascular risk factors for people with mental illness. Australian & New Zealand Journal of Psychiatry, 35(2), 196–202. De Hert, M., Correll, C. U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., . . . Ndetei, D. M. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10(1), 52–77. Dickerson, F., Goldberg, R., Brown, C., Kreyenbuhl, J., Wohlheiter, K., Fang, L., . . . Dixon, L. (2005). Diabetes knowledge among persons with serious mental illness and type 2 diabetes. Psychosomatics, 46(5), 418–424. Dominick, K. L., Ahern, F. M., Gold, C. H., & Heller, D. A. (2002). Relationship of health-related quality of life to health care utilization and mortality among older adults. Aging Clinical and Experimental Research, 14(6), 499–508. Druss, B. G., Bradford, D. W., Rosenheck, R. A., Radford, M. J., & Krumholz, H. M. (2000). Mental disorders and use of cardiovascular procedures after myocardial infarction. Journal of the American Medical Association, 283(4), 506–511. Druss, B. G., Bradford, W. D., Rosenheck, R. A., Radford, M. J., & Krumholz, H. M. (2001). Quality of medical care and excess mortality in older patients with mental disorders. Archives of General Psychiatry, 58(6), 565–572. Emslie, C., Ridge, D., Ziebland, S., & Hunt, K. (2007). Exploring men’s and women’s experiences of depression and engagement with health professionals: More similarities than differences? A qualitative interview study. BMC Family Practice, 8, 43. doi:10.1186/1471-2296-8-43 Happell, B., Platania-Phung, C., & Scott, D. (2011). Placing physical activity in mental health care: A leadership role for mental health nurses. International Journal of Mental Health Nursing, 20(5), 310–318. doi:10.1111/j.1447-0349.2010.00732.x Happell, B., Scott, D., Platania-Phung, C., & Nankivell, J. (2012). Should we or shouldn’t we? Mental health nurses’ views on physical health care of mental health consumers. International Journal of Mental Health Nursing, 21(3), 202–210. doi:10.1111/j.1447-0349.2011.00799.x Hardy, S., Deane, K., & Gray, R. (2013). The Northampton Physical Health and Wellbeing Project: The views of patients with severe mental illness about their physical health check. Mental Health in Family Medicine, 9(4), 233–240. Hardy, S., White, J., Deane, K., & Gray, R. (2011). Educating healthcare professionals to act on the physical health needs of people with serious mental illness: A systematic search for
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evidence. Journal of Psychiatric and Mental Health Nursing, 18(8), 721–727. doi:10.1111/j.1365-2850.2011.01722.x Harris, M. F., Lloyd, J., Krastev, Y., Fanaian, M., Davies, G. P., Zwar, N., & Liaw, S.-T. (2012). Routine use of clinical management guidelines in Australian general practice. Australian Journal of Primary Health. doi:http://dx.doi.org/10.1071/PY12078. Ismail, K. (2008). Physical health in schizophrenia and related disorders. Psychiatry, 7(11), 472–476. Kerling, A., Tegtbur, U., Ziegenbein, M., Grams, L., Heinze, D., & Sieberer, M. (2013). Exercise capacity and quality of life in patients with schizophrenia. Psychiatric Quarterly. doi:10.1007/s11126-013-9256-4 Kreyenbuhl, J., Dickerson, F., Medoff, D., Brown, C., Goldberg, R., Fang, L., . . . Dixon, L. (2006). Extent and management of cardiovascular risk factors in patients with type 2 diabetes and serious mental illness. Journal of Nervous and Mental Disease, 194(6), 404–410. doi:10.1097/01.nmd.0000221177.51089.7d Lambert, T., & Newcomer, J. (2009). Are the cardiometabolic complications of schizophrenia still neglected? Barriers to care. Medical Journal of Australia, 190(Suppl. 4), S39–S42. Lawrence, D., Kisely, S., & Pais, J. (2010). The epidemiology of excess mortality in people with mental illness. Canadian Journal of Psychiatry, 55(12), 752–760. Lawrence, D., Mitrou, F., & Zubrick, S. R. (2009). Smoking and mental illness: Results from population surveys in Australia and the United States. BMC Public Health, 9, 285. doi:10.1186/1471-2458-9-285 Lester, H., Tritter, J. Q., & Sorohan, H. (2005). Patients’ and health professionals’ views on primary care for people with serious mental illness: Focus group study. British Medical Journal, 330(7500), 1122. doi:10.1136/bmj.38440.418426.8F Mackell, J. A., Harrison, D. J., & McDonnell, D. D. (2005). Relationship between preventative physical health care and mental health in individuals with schizophrenia: A survey of caregivers. Mental Health Services Research, 7(4), 225–228. doi:10.1007/s11020-005-7454-x Marder, S., Essock, S., Miller, A., Buchanan, R., Casey, D., Davis, J., . . . Covell, N. (2004). Physical health monitoring of patients with schizophrenia. American Journal of Psychiatry, 161(8), 1334–1349. McCloughen, A., Foster, K., Huws-Thomas, M., & Delgado, C. (2012). Physical health and wellbeing of emerging and young adults with mental illness: An integrative review of international literature. International Journal of Mental Health Nursing, 21(3), 274–288. doi:10.1111/j.1447-0349.2011.00796.x McConnell, S., Jacka, F. N., Williams, L. J., Dodd, S., & Berk, M. (2005). The relationship between depression and cardiovascular disease. International Journal of Psychiatry in Clinical Practice, 9(3), 157–167. doi:10.1080/13651500510029138 Narvaez, J. M., Twamley, E. W., McKibbin, C. L., Heaton, R. K., & Patterson, T. L. (2008). Subjective and objective quality of life in schizophrenia. Schizophrenia Research, 98(1–3), 201–208. doi:citeulike-article-id:3722788; doi:10.1016/j.schres .2007.09.001
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Nasrallah, H. A., Meyer, J. M., Goff, D. C., McEvoy, J. P., Davis, S. M., Stroup, T. S., & Lieberman, J. A. (2006). Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: Data from the CATIE schizophrenia trial sample at baseline. Schizophrenia Research, 86(1–3), 15–22. doi:10.1016/j.schres.2006.06.026 National Research Council. (2009). State of the USA health indicators: Letter report. Washington, DC: The National Academies Press. Pedersen, W., & Von Soest, T. (2009). Smoking, nicotine dependence and mental health among young adults: A 13-year population-based longitudinal study. Addiction, 104(1), 129–137. doi:10.1111/j.1360-0443.2008.02395.x Rathore, S. S., Wang, Y., Druss, B. G., Masoudi, F. A., & Krumholz, H. M. (2008). Mental disorders, quality of care, and outcomes among older patients hospitalized with heart failure: An analysis of the national heart failure project. Archives of General Psychiatry, 65(12), 1402–1408. doi:10.1001/archpsyc.65.12.1402 Roberts, S. H., & Bailey, J. E. (2010). Incentives and barriers to lifestyle interventions for people with severe mental illness: A narrative synthesis of quantitative, qualitative and mixed methods studies. Journal of Advanced Nursing, 67(4), 690–708. doi:10.1111/j.1365-2648.2010.05546.x Rubio, J. M., Olfson, M., Villegas, L., Perez-Fuentes, G., Wang, S., & Blanco, C. (2013). Quality of life following remission of mental disorders: Findings from the national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry, 74(5), e445–e450. doi:10.4088/JCP.12m08269 Saarni, S. I., Viertiö, S., Perälä, J., Koskinen, S., Lönnqvist, J., & Suvisaari, J. (2010). Quality of life of people with
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schizophrenia, bipolar disorder and other psychotic disorders. British Journal of Psychiatry, 197(5), 386–394. doi:10.1192/bjp.bp.109.076489 Scott, D., Burke, K., Williams, S., Happell, B., Canoy, D., & Ronan, K. (2012). Increased prevalence of chronic physical health disorders in Australians with diagnosed mental illness. Australian and New Zealand Journal of Public Health, 36(5), 483–486. doi:10.1111/j.1753-6405.2012.00916.x Scott, D., Platania-Phung, C., & Happell, B. (2011). Quality of care for cardiovascular disease and diabetes amongst individuals with serious mental illness and those using anti-psychotic medications. Journal for Healthcare Quality, 34(5), 15–21. doi:10.1111/j.1945-1474.2011.00155.x Stanley, S., & Laugharne, J. (2010). Clinical guidelines for the physical care of mental health consumers. (C. a. M. H. U. Community, School of Psychiatry and Clinical Neurosciences, Trans.). Perth: The University of Western Australia. Sullivan, G., Han, X., Moore, S., & Kotrla, K. (2006). Disparities in hospitalization for diabetes among persons with and without co-occurring mental disorders. Psychiatric Services, 57(8), 1126–1131. Wardle, J., & Steptoe, A. (1991). The European Health and Behaviour Survey: Rationale, methods and initial results from the United Kingdom. Social Science and Medicine, 33(8), 925–936. Zahran, H. S., Kobau, R., Moriarty, D. G., Zack, M. M., & Giles, W. H. (2004). Self-reported frequent mental distress among adults—United States, 1993–2001. Morbidity and Mortality Weekly Report, 53(41), 963–966.
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Perspectives in Psychiatric Care
ISSN 0031-5990
Self-Reported Health, Health Behaviors, Attitudes, and Beliefs of Regional Mental Health Consumers Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, David Scott, BHM (Hons), PhD, Wendy Hoey, RN, and Robert Stanton, BHM (Hons), PhD Candidate Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, is Engaged Research Chair, Mental Health Nursing, Central Queensland University, Rockhampton, Queensland, Australia, Director, Centre for Mental Health Nursing Innovation, Director, Institute for Health and Social Science Research, and Professor, School of Nursing and Midwifery; David Scott, BHM (Hons), PhD, is Post-doctoral Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, Central Queensland University, Rockhampton, Queensland, Australia; Wendy Hoey, RN, is Nursing Director, Central Queensland Mental Health Service, Rockhampton, Queensland, Australia, and Affiliate Member, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, Central Queensland University, Rockhampton, Queensland, Australia; and Robert Stanton, BHM (Hons), PhD Candidate, is Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, Central Queensland University, Rockhampton, Queensland, Australia
Search terms: Attitudes, cardiometabolic health, health behaviors, mental health nursing, physical health, quality of life Author contact: [email protected], with a copy to the Editor: [email protected] First Received July 30, 2013; Accepted for publication September 3, 2013. doi: 10.1111/ppc.12043
PURPOSE: This article reports baseline data from a randomized controlled trial investigating the impact of a specialist cardiometabolic healthcare nurse on physical health care. DESIGN AND METHODS: Survey of community-based mental health consumers randomized to a cardiometabolic health nurse intervention. FINDINGS: Findings show a high prevalence of respiratory conditions, hypercholesterolemia, hypertension, and low quality of life. Participants reported regular blood pressure but infrequent cholesterol and blood glucose testing. Few received advice about smoking cessation, diet, or physical activity. Participants were mostly satisfied with physical healthcare provision; however, positive health behaviors are lacking. PRACTICE IMPLICATIONS: An individualized intervention based on knowledge and attitudes may be necessary.
People with serious mental illness (SMI) are known to experience poor quality of life (Kerling et al., 2013; Rubio et al., 2013), greater prevalence of physical health disorders (Ismail, 2008; Scott et al., 2012), and a significant disparity in health care (Chadwick, Street, McAndrew, & Deacon, 2012; De Hert et al., 2011), compared to people without mental illness. As a result, people with SMI experience a 2- to 3-fold increase in mortality risk compared to the general population (Brown, Kim, Mitchell, & Inskip, 2010).
quality of life resulting from their mental health. Barnes, Murphy, Fowler, and Rempfer (2012) recently reported the independence of these domains with better physical quality of life associated with reduced physical illness, whereas mental quality of life was associated with symptom severity. While quality of life of people with SMI is reversible with remission of mental illness, overall quality of life in remission, even in the absence of comorbid physical illness, remains less than that experienced by people without SMI (Rubio et al., 2013).
Health-Related Quality of Life
Physical Health Disorders
It is widely recognized that people with SMI experience a poorer quality of life compared to those without SMI (Kerling et al., 2013; Rubio et al., 2013). In addition to the burden of symptoms, factors such as poor health care have been demonstrated to lead to poorer quality of life and increased symptom severity in people with SMI (Mackell, Harrison, & McDonnell, 2005). The quality of life related to an individual’s physical health is not identical to that same individual’s
Australian population data indicate that the prevalence of coronary heart disease (CHD), diabetes, chronic respiratory conditions such as bronchitis, emphysema, and asthma is significantly greater in people with SMI compared to people without SMI (Scott et al., 2012). This is not dissimilar to longitudinal international data (McConnell, Jacka, Williams, Dodd, & Berk, 2005), which demonstrate that people with depression experience a 4-fold increase in the risk of
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developing CHD. This significant disparity in the prevalence of physical health disorders generates increased challenge for those involved in the treatment and care of people with SMI. In particular, nurses in mental health settings, who are often at the front line of mental health care, can be faced with the unmet needs of mounting physical health problems. A number of studies (Barnes, Paton, Cavanagh, Hancock, & Taylor, 2007; Happell, Scott, Platania-Phung, & Nankivell, 2012; Lambert & Newcomer, 2009) have reported that nurses are cognizant of, but often unable to adequately treat, physical health disorders due to competing priorities, lack of adequate time and resources, concerns regarding training, or ambivalence toward physical health care being part of their role. Physical Health Care and Experiences Inequality in physical health care experienced by people with SMI contributes to the poorer physical health and early mortality in people with SMI (Barnes et al., 2007; Druss, Bradford, Rosenheck, Radford, & Krumholz, 2001; Scott, Platania-Phung, & Happell, 2011). People with SMI are half as likely to receive routine blood pressure and cholesterol tests (Nasrallah et al., 2006), 20–30% less likely to have cardiac procedures performed (Druss, Bradford, Rosenheck, Radford, & Krumholz, 2000; Rathore, Wang, Druss, Masoudi, & Krumholz, 2008), and 15% less likely to receive statins for elevated cholesterol, compared to those without SMI. People with SMI and co-occurring type II diabetes are 35% less likely to be admitted to hospital for diabetic emergencies (Sullivan, Han, Moore, & Kotrla, 2006) and almost 50% less likely to receive medication prescriptions for cardiovascular disease prevention, compared to those with type II diabetes who do not have SMI (Kreyenbuhl et al., 2006). There are also substantial disparities between the views of general practitioners (GPs) and people with SMI regarding the quality of care. Lester, Tritter, and Sorohan (2005) highlighted the challenges of providing timely effective physical and mental health care, and of communication between clinician and patient; in particular, the difference between the clinicians’ views of SMI as a lifelong chronic condition, and the optimistic recovery-oriented view held by the patient. In support of the findings of Lester et al. (2005), Emslie, Ridge, Ziebland, and Hunt (2007) reported that people with depression experienced significant difficulty in articulating mental health problems to GPs and this impaired communication and subsequent treatment. Knowledge and Attitudes of Health Behaviors There is a substantial gap in the literature regarding the knowledge of health behaviors in people with SMI, and their attitudes toward health behaviors. This is significant since the development of interventions and education programs 194
aiming to improve these areas requires an understanding of the level of knowledge people with SMI possess, and their attitudes toward health-related behaviors. In one of the few studies to address this literature gap, Brunero and Lamont (2010) surveyed community-based mental health consumers attending a clozapine clinic using the European Health and Behavior Survey. Overall, consumers were found to have positive attitudes, as defined by higher scores on specific items contained in the European Health Behavior Study questionnaire, regarding health-related behaviors despite high cardiometabolic risk, and this highlights the complex interplay of factors linking attitudes, beliefs, and behaviors. In a more recent qualitative study, Hardy, Deane, and Gray (2013) reported similar positive attitudes during semistructured interviews, but limited knowledge of mental health consumers with respect to behaviors and cardiovascular risk. Importantly, this study highlights the opportunity for nurses undertaking physical health checks to positively impact on consumers’ behaviors with all participants commencing lifestyle changes as a result of the health check (Hardy et al., 2013). Aims In summary, while the physical health and healthcare experiences of people with SMI have been extensively researched, there is a paucity of literature describing the knowledge and attitudes of health behaviors of people with SMI. Therefore, the aims of the present paper are to contribute to the existing body of knowledge regarding physical health disorders and healthcare experiences of people with SMI, but more importantly to establish a base for the investigation of the knowledge and attitudes towards health behaviors of people with SMI. Methods The protocol for this randomized controlled trial has been previously described (authors’ details were removed to facilitate blind review). Briefly, adult mental healthcare consumers of a regional hospital community mental health service in Queensland, Australia, were invited to participate in the study by their case manager. Participants randomized to the intervention group received access to a cardiometabolic healthcare nurse (CHN) with the primary purpose of identifying “atrisk” indicators of cardiometabolic health. Those identified as “at-risk” were provided linkages to GPs or other allied health professions as necessary, or provided health behavior change advice. The CHN was responsible for follow-up on all appointments. In addition to demographics and physical health parameters, participants in the intervention group completed selfreport questionnaires on health status (Centers for Disease Control Health-Related Quality of Life Questionnaire 4 Perspectives in Psychiatric Care 50 (2014) 193–200 © 2013 Wiley Periodicals, Inc.
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[CDC-HRQOL-4]), self-reported physical health disorders, physical healthcare experiences, and perceptions and health behavior knowledge and attitudes (Australian Health Behaviour Knowledge and Attitudes Questionnaire [AHKAQ]). Preliminary data reported here are shown as frequencies, means, and SD. Data were analyzed using Statistical Package for the Social Sciences Version 19.0 (IBM Corp, New York, USA.) This study was approved by health service and institutional ethics committees. Participants were advised that participation was voluntary and that they could withdraw consent at any time without penalty. Results Demographics We have collected baseline data from 21 participants. Our cohort is predominately male (61.9%), single (66.7), had completed secondary school education (87.5%), and received a pension (80%). A small proportion (14%) is of Aboriginal or Torres Strait Islander descent. Health-Related Quality of Life The majority (61.9%) of participants report their overall quality of life as either “Poor” or “Fair” with less than 5% of participants rating their health as “Very good.” The summary index of unhealthy days computation from the CDCHRQOL-4 indicates that our participants experience an average of 12.2 ± 13.1 unhealthy days for the previous month (range 0–30). Physical Health Disorders Self-reported diagnoses of physical health disorders showed that respiratory disorders have the highest prevalence (47.6%), followed by hypercholesterolemia (38.1%) and hypertension (23.8%). Less than 2% of participants reported no diagnosed physical health disorders and 61.9% reported two or more physical health disorders. Despite the prevalence of diagnosed physical health disorders reported by this cohort, only 38.1% report being prescribed medication for nonmental health conditions. Physical Health Care and Experiences Routine tests by medical professionals for cardiometabolic function appear rare. While almost 62% report having their blood pressure taken, only 28.6% report undergoing tests for cholesterol and 19% report having their blood glucose checked. Immunization rates are also low with only 23.8% Perspectives in Psychiatric Care 50 (2014) 193–200 © 2013 Wiley Periodicals, Inc.
reportedly receiving influenza vaccine in the past 12 months. Advice on lifestyle behaviors appears limited, with 47.6% receiving advice about smoking, 42.9% having received advice on diet, and 33.3% having received advice regarding physical activity. GP advice concerning alcohol and illicit drug use was reported by 33.3% of participants, with GP advice regarding safe sex practices reported by 4.7% of participants. With respect to perceptions of healthcare experience, only 14.3% of participants thought the availability and quality of healthcare services had worsened over the past 10 years, with the remainder equally distributed between views of “Stayed the same” or “Improved.” The vast majority of participants in the current study (75.2%) report being “Satisfied” or “Very satisfied” with the quality of medical care they have received. In light of this, a small majority (42.9%) report always seeing the same GP at the same clinic for treatment with the balance equally distributed between seeing a different GP at the same clinic, and seeing a different GP at a different clinic. More than half (52.4%) of participants are not concerned about the cost of health care; however, private healthcare insurance was a rarity for our participants, with just 4.8% reporting combined hospital and extras cover. To investigate the factors that influence people with SMI seeking medical care, we asked participants to imagine they were experiencing considerable pain or symptoms they think may indicate the need for medical care. More than one third (38.1%) reported they would seek care immediately, 47.6% reported they would seek care if the pain or symptoms worsened or did not go away in a reasonable period of time, and 14.3% responded they would seek care as soon as other commitments permitted. We then asked to what degree a range of factors would influence their decisions to seek medical care. Participants’ responses are shown in Table 1. We then asked whether participants were confident in their ability to communicate with their medical professionals. More than 75% responded with “Confident” or “Very confident” (Table 2). Knowledge and Attitudes of Health Behaviors The AHKAQ comprises 14 questions related to knowledge of the Australian health guidelines and seven questions rating the importance of a range of health strategies in protecting against future health problems. Scores for knowledge of health behaviors were based on participants answering “True”or“False”to a series of statements regarding Australian health guidelines (e.g., Australian dietary guidelines recommend you should eat at least five servings of vegetables per day—True/False). Means score for percentage of correct responses was 73% (range 50–93%). A score above the mean (73%) was achieved by 38% of participants. Attitudes toward health behaviors were rated using a 10-point scale where 1 = not at all important and 195
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Responsea Factor
Never
Seldom
Sometimes
Often
Waiting times for medical services Personal commitments (e.g., work or family) Financial costs of attending medical services Discomfort or embarrassment in describing symptoms or being examined Discomfort in being around medical facilities or staff Fear of receiving bad news about your health
42.9 47.6 57.1 52.4
14.3 14.3 9.5 19.0
23.8 14.3 19.0 14.3
19.0 23.8 14.3 14.3
52.4 61.9
14.3 9.5
19.0 14.3
14.3 14.3
Table 1. Percentage of Participants who Report Factors That May Impact Their Decisions to Seek Medical Care
a
Scores are reported as a percentage of the total participants. No missing data—all scores add to 100%.
10 = extremely important. For the purpose of this study, higher scores demonstrate a more positive attitude. Scores for attitudes toward health behaviors are shown in Table 3.
The proportion of male participants, and the proportion of participants reporting their marital status as single are higher in the present study compared to the Australian population experiencing SMI (Australian Institute for Health and Welfare [AIHW], 2012). However, the proportion of participants reporting their employment status as “pensioner” are similar to that recently reported (AIHW, 2012).
report both physically unhealthy days and mentally unhealthy days. Using the cut point for unhealthy days of >14 (Zahran, Kobau, Moriarty, Zack, & Giles, 2004), 43% of our cohort is defined as having “Frequent Mental Distress.” This is particularly important since, despite the high satisfaction with their quality of health care and positive attitudes toward healthy behaviors, our cohort demonstrates poor dietary and physical activity habits. It is possible that these factors, coupled with the high prevalence of comorbid illness, are substantial contributors to the poor quality of life observed in our participants. Furthermore, there is evidence showing each item of the CDC HRQOL-4 is predictive of 1- and 12-month mortality and healthcare utilization and this relationship should be explored further in a population with SMI (Dominick, Ahern, Gold, & Heller, 2002).
Health-Related Quality of life
Physical Health Disorders
Consistent with the findings of Narvaez, Twamley, McKibbin, Heaton, and Patterson (2008) and Saarni et al. (2010), a large proportion of our participants report a low quality of life. However, the unhealthy days index observed in our cohort differs markedly from the general population (National Research Council, 2009) where substantially less people
Our findings are consistent with those from Australia (Scott et al., 2012) and internationally (Lawrence, Kisely, & Pais, 2010; McCloughen, Foster, Huws-Thomas, & Delgado, 2012), which report the high prevalence of physical health disorders in people with SMI. Scott et al. (2012) recently reported a significantly higher prevalence of respiratory disorders, irritable
Discussion Demographics
Table 2. Confidence in Communication With Healthcare Professionals
Level of confidencea Scenario When discussing your health with a medical professional (e.g., GP, nurse, etc.), how confident are you that you can describe your symptoms in a way that they can understand? When a medical professional (e.g., GP, nurse, etc.) is discussing your health with you (e.g., tests and treatment procedures, etc.), how confident are you that you can understand them?
Not very confident
Confident
Very confident
9.5
42.9
47.6
23.8
33.3
42.9
a
Scores are reported as a percentage of the total participants. No missing data—all scores add to 100%. GP, general practitioner.
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Table 3. Responses to the Importance of Health Behaviors Statement
Meana Minimum Maximum
Maintaining a healthy weight Participating in regular physical activity Eating lots of fruits and vegetables Trying to avoid eating too much saturated fat Always practicing safe sex Limiting how much alcohol you drink Not smoking Not using illicit drugs
8.5 7.7 7.0 7.3
6 5 2 2
10 10 10 10
8.5 7.6 6.0 7.3
2 1 1 1
10 10 10 10
Scores are based on a 1–10 scale where 1 = not at all important and 10 = extremely important.
a
bowel syndrome, diabetes, food allergy or intolerance, and CHD in a large sample of Australians diagnosed with mental illness compared to those without mental illness. Consistent with their findings, the findings of the present study demonstrate that respiratory disorders are of greater prevalence than other physical health conditions. This is likely due to the high prevalence of cigarette smoking in this population (Lawrence, Mitrou, & Zubrick, 2009; Pedersen & Von Soest, 2009). Hypercholesterolemia and hypertension were reported in more than one third of our sample. This differs from other studies (Davidson et al., 2001), which report the prevalence of these conditions is not significantly different from the general population. This perhaps reflects the lack of cardiometabolic screening offered to people with a mental illness. The high prevalence of overweight and obesity in the present sample coupled with the lack of cardiometabolic screening may have led to underreporting of hypercholesterolemia and hypertension, making the need for physical health assessments of people with SMI all the more urgent. There may be a view that increased screening for physical health disorders in people with SMI will lead to an increase in prescribed medication. However, our data suggest this may not be the case. Less than 40% of our sample was prescribed with medications for nonmental illness conditions, despite the high prevalence of physical health conditions present. This is encouraging since non-pharmacological interventions such as exercise, nutritional counseling, and cognitive behavioral therapies have demonstrated significant benefit in weight management, cholesterol reduction, and glucose management (Caemmerer, Correll, & Maayan, 2012).
conflict with some (Marder et al., 2004) but not all (Stanley & Laugharne, 2010) practice guidelines for the physical health care of people with SMI; however, the guidelines are equivocal (Citrome & Yeomans, 2005). Interestingly, Australian GPs are well reportedly advanced in the use of evidence-based practice guidelines compared to those overseas, with the exception of conditions such as depression (Harris et al., 2012). This perhaps reflects the multidisciplinary nature of mental illness management, lack of confidence in diagnosing or treating the condition, or a concern that they are unlikely to have a substantial impact on the physical health of people with SMI (Barley, Murray, Walters, & Tylee, 2011). These factors may contribute to our finding that less than half of participants in the current study received lifestyle advice from the primary care provider. This is noteworthy given that Campion, Francis, and Preston (2005) reported that at least one third of patients with SMI would positively respond to advice offered by a doctor. Furthermore, despite reports to the contrary (Hardy, White, Deane, & Gray, 2011), the vast majority of our participants were satisfied with the health care they received. Most continued to see the same doctor at the same clinic and this may allay some of the concerns of participants in the study of Hardy et al. (2011), who expressed general distrust in doctors. Furthermore, the barriers to treatment identified by Roberts and Bailey (2010) are far less likely to be present in the sample from the current study as evidenced by the high level of treatment satisfaction. More than half of the participants in the current study report that negative experiences such as fear of bad news, financial cost, or personal discomfort never influence the decision to seek medical treatment. The factor most likely to influence the decision to seek medical treatment is excessive waiting times. This may be due to the perceived urgency of the need for treatment. This suggestion is consistent with the finding of Hardy et al. (2013), who report that the majority of patients with SMI would only attend a surgery when absolutely necessary. It is likely that the level of satisfaction with care, lack of substantial barriers to treatment, and consistency in treating practitioners contribute to our finding that a significant proportion of participants in the present study are confident in their capacity to articulate their symptoms, and comprehend the responses to and from medical professionals. Overall, this may reflect differences in healthcare systems internationally. Knowledge and Attitudes of Health Behaviors
Physical Health Care and Experiences The low reported rates of routine health checks for people with SMI are consistent with the findings of reviews (De Hert et al., 2011) and large trials internationally (Nasrallah et al., 2006). The lack of routine cardiometabolic monitoring is in Perspectives in Psychiatric Care 50 (2014) 193–200 © 2013 Wiley Periodicals, Inc.
To the best of our knowledge, this is the first study to comprehensively investigate the knowledge and attitudes of health behaviors in people with SMI using an up-to-date, nationspecific instrument. While the European Health and Behaviour Survey (Wardle & Steptoe, 1991) represents the 197
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most commonly utilized instrument for assessment of health behavior and knowledge, it is now somewhat dated and was not designed for Australian populations. The AHKAQ was developed to address this limitation. More than one third of our sample scored above the mean of 73% correct responses to the 14 questions assessing knowledge of the Australian health guidelines. We would consider this level of knowledge to be comparable to the general population. In contrast, Dickerson et al. (2005) suggest that the knowledge of health behaviors in people with SMI is less than those in the general population. Similarly, Hardy et al. (2013) reported that knowledge of the risk of cardiovascular disease was poor in a small sample of people with SMI. Using an instrument such as the AHKAQ as part of a larger health screening battery may assist the delivery of a tailored intervention to specifically address a consumer’s knowledge gap which may result in greater effectiveness compared to a population-based approach. From the present study, mean responses regarding attitudes toward health behaviors are all ≥ 6.0 suggesting positivity. Our findings are consistent with those of Brunero and Lamont (2010) and Roberts and Bailey (2010) who both reported a high degree of positivity regarding health behaviors in consumers attending an outpatient clozapine clinic. Despite both the apparent high level of knowledge and positive attitudes regarding health behaviors, our sample presents with a significant burden of comorbid physical illness. There is some evidence (Campion et al., 2005), however, to suggest that people with SMI may not consider themselves to be at risk of health complications and therefore fail to participate in regular health screening or education or engage in activity to promote physical health. Alternatively, people with SMI may prioritize physical health differently than those without SMI (Dickerson et al., 2005). Taken together, these factors may contribute to the poorer physical health experienced by people with SMI in a manner similar to reduced primary healthcare access and antipsychotic medications. These findings highlight the need for alternative approaches to initiate and maintain positive behavior change in people with SMI. Implications for Mental Health Nursing Practice Unfortunately, despite the plethora of research regarding the physical health of people with SMI, there continues to be a lack of evidence-based education for health professionals regarding the physical health of people with SMI (Hardy et al., 2011). Therefore, there remains a need to develop firstline interventions to manage the physical health of people with SMI. Despite the often ambivalent views of nurses, they are well placed to assess and intervene (Happell, Platania-Phung, & Scott, 2011). Individualized management based on the knowledge, attitudes, and behaviors of people with SMI is crucial. The development of a brief tool to assess 198
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