561497
research-article2014
JAPXXX10.1177/1078390314561497Journal of the American Psychiatric Nurses AssociationLee et al.
Research Paper
Telephone-Delivered Physical Activity Intervention for Individuals With Serious Mental Illness: A Feasibility Study
Journal of the American Psychiatric Nurses Association 2014, Vol. 20(6) 389–397 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314561497 jap.sagepub.com
Heeyoung Lee1, Irene Kane2, Jaspreet Brar3, and Susan Sereika4
Abstract BACKGROUND:Obesity is prevalent in individuals with serious mental illness (SMI). OBJECTIVE: The purpose of this study is to examine the feasibility of a telephone-delivered physical activity (PA) intervention for outpatients with serious mental illness to maintain PA and to explore the preliminary efficacy of the intervention on health status. DESIGN: This study used a randomized experimental design. The treatment group received pedometers and eight weekly phone calls; the control group received written information regarding PA. Descriptive statistics were used to analyze data collected at baseline and 8 weeks. RESULTS: Twenty-two subjects with SMI (mean age = 44.09 ± 7.6 years; 54.5% were male) were recruited and 16 subjects completed the study in 8 weeks. PA (z = −2.37, p = .02) increased in the treatment group (n = 8) whereas the control group (n = 8) maintained baseline PA level (z = −1.61, p = .11). Health outcomes were not changed (ps > .05). CONCLUSION: Telephone-delivered intervention is feasible and has the potential to improve PA in individuals with SMI. Keywords obesity, serious mental illness, physical activity
Introduction Obesity (defined as body mass index [BMI] ≥ 30 kg/m2) is epidemic in people with serious mental illnesses (SMI; De Hert, Schreurs, Vancampfort, & Van Winkel, 2009; Megna, Schwartz, Siddiqui, & Herrera Rojas, 2011; Parks, Radke, & Ruter, 2008). SMI refers to—but is not limited to—mental illnesses, including schizophrenia, bipolar disorder, and major depression, that are coupled with a functional disability such as an inability to maintain employment or live independently (U.S. Department of Health and Human Services, 1999). The prevalence of obesity among people with SMI has been reported as approximately 40% to 60% (De Hert, Schreurs, et al., 2009; Parks et al., 2008). People with SMI have a 1.2- to 3.5-fold increased likelihood of being overweight/obese compared with those in the general population (Parks et al., 2008). Although the specific mechanisms underlying obesity among people with SMI are not well understood, the combination of disability, unhealthy lifestyle (e.g., low level of physical activity), family history of obesity, and side effects of psychotropic medications may contribute to the high rates of obesity observed in people with SMI (Goldberg et al., 2013; McElroy, 2009). A recent systematic literature review of lifestyle interventions for adults with SMI indicated that physical
activity (PA) and healthy eating have potential benefit in addressing obesity among individuals with SMI (Cabassa, Ezell, & Lewis-Fernandez, 2010). Specifically, the importance of PA should be emphasized because (1) many forms of PA, such as walking, have been reported to improve physical health (e.g., decreased body fat, improved metabolic risk profiles, and improved physical fitness; Bravata et al., 2007; Daumit et al., 2005; I. M. Lee & Skerrett, 2001) and (2) it can be integrated into peoples’ daily lives (Callaghan, 2004; Strassnig, Brar, & Ganguli, 2005). A growing body of evidence demonstrates the benefit of PA in the general population. The recommended PA for 1
Heeyoung Lee, PhD, PMHNP-BC, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA 2 Irene Kane, PhD, RN, CNAA, HFI, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA 3 Jaspreet Brar, MD, PhD, MPH, Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute & Clinic, Pittsburgh, PA, USA 4 Susan Sereika, PhD, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA Corresponding Author: Heeyoung Lee, University of Pittsburgh School of Nursing, 415 Victoria Building, 3500 Victoria Street, Pittsburgh PA 15261, USA. Email: [email protected]
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Journal of the American Psychiatric Nurses Association 20(6)
adults is at least 150 minutes/week of moderate-intensity PA, 75 minutes/week of vigorous-intensity PA, or a combination of moderate and vigorous PA (Haskell et al., 2007). Health benefits of PA include reduced risks for premature chronic health conditions, preventing unhealthy weight gain, high level of physical fitness, and reduced mortality and extended life expectancy (Haskell et al., 2007; Warburton, Nicol, & Bredin, 2006; Wen et al., 2011; World Health Organization, 2010). Brisk walking for at least 30 minutes per day (or ≥3,000 steps measured by a pedometer) every day has been advised and shown to be effective in people with SMI (Brar et al., 2005; De Hert, Dekker, et al., 2009). However, even though people with SMI are interested in being active and understand the benefit of exercise (Ussher, Stanbury, Cheeseman, & Faulkner, 2007), they exhibit less than recommended PA levels than do the general population because of lack of social contacts (Daumit et al., 2005; Richardson, Faulkner, et al., 2005). In addition, they would prefer to manage their weight without having to participate in face-to-face treatment programs because of geography, lack of transportation (The National Alliance on Mental Illness, 2008), or the stigma attached to accessing such resources (H. Lee & Schepp, 2013). Consequently, people with SMI need interventions that not only motivate them to engage in recommended amounts of PA but also allow them ease of access to PA. Telephone contact is an effective tool in delivering interventions to people who are of low socioeconomic status (e.g., they lack transportation; Fjeldsoe, Marshall, & Miller, 2009), and most people with SMI are unemployed or working for minimum wage (Boardman, 2006; Cunningham, McKenzie, & Taylor, 2006). Prior studies have also indicated that phone-delivered behavioral interventions are as effective as in-person counseling among the obese population (Appel et al., 2011; Digenio, Mancuso, Gerber, & Dvorak, 2009). In addition, telephone contact offers a more direct route to patient communication compared with other technology, such as the Internet. The advantages of using telephones include (1) providing access to more patients more easily, (2) enabling more personal interaction than typical Internet modes, and (3) providing convenient and easy to use support for patients with low-income and limited health literacy (Bodenheimer & Abramowitz, 2010). Although people with SMI have limited access to and skill with diverse forms of technology, generally they do use telephones or cell phones, and research results have suggested that they have interest in receiving health care intervention via phone calls (Ben-Zeev, Davis, Kaiser, Krzsos, & Drake, 2013). The primary purpose of this pilot study was to examine the feasibility of a phone-delivered PA intervention for adults with SMI to achieve and maintain PA.
Additionally, this pilot study assessed changes in health status (e.g., weight loss). In our intervention, we targeted 30-minute brisk walking (i.e., 3,000 steps in 30 minutes; Marshall et al., 2009) with a pedometer because walking is a low-cost, ease of access, home-based PA. The pedometer is not only a straightforward and simple tool for selfmonitoring (Harris et al., 2013) but also conducive to motivating individuals with SMI (Kane, Lee, Sereika, & Brar, 2012).
Method Design and Sample Our study utilized a randomized experimental design. The intervention comprised an 8-week walking program with data collection at baseline, 8 weeks (i.e., immediately after intervention), and 12 weeks (i.e., 4 weeks after the completion of the intervention). For this report, only the baseline and the 8-week postintervention data will be presented. Sample. Adults aged 18 to 60 years who met the following criteria were eligible to participate: (1) a past or current DSM-IV diagnosis of schizophrenia spectrum disorders or a Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) diagnosis of other severe mental disorders, including bipolar disorder or major depression; (2) receiving psychotropic medication to control symptoms at the time of recruitment; and (3) medical clearance in writing from a primary care provider for moderate PA—defined as activities that are approximately the equivalent of brisk walking 3 to 4 mph. Exclusion criteria included (1) significant cardiovascular, neuromuscular, endocrine, orthopedic, or other disorders that would prevent safe participation as screened by the Physical Activity Readiness Questionnaire (Canadian Society for Exercise Physiology, 2002; Thomas, Reading, & Shephard, 1992) and (2) involvement in any other PA intervention program at the time of recruitment. The institutional review board at a major, northeastern research university approved the study protocol, and all participants provided written, informed consent.
Intervention Our intervention was guided by social cognitive theory (SCT), which emphasizes the dynamic interplay of personal, behavioral, and environmental factors in human behaviors. Specifically, individuals maintain a newly achieved behavior through a multifaceted, causal structure in which self-efficacy operates together with goals, outcome expectations, and perceived environmental
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Lee et al. impediments and facilitators. Self-efficacy refers to a person’s confidence in his or her ability to successfully execute given behaviors (e.g., physical activity) using SCT strategies, which include goal setting, self-monitoring, feedback, and social support—all of these strategies strengthen self-efficacy, which contributes to health promoting behavior (Bandura, 1997, 2004). The intervention (i.e., enrollment, instructions, and phone calls) was delivered by the principal investigator using an intervention checklist to address goal settings, reviewing self-monitoring, feedback on goal achievement, and social support. Participants in the experimental condition were educated on how to safely walk briskly for 30 minutes each day based on American PA guidelines (Haskell et al., 2007). As the guidelines recommend, our PA instructions for the participant explained that the 30 minutes may be completed either in one walk or in no less than three 10-minute walks, as long as the total minutes walked is 30 minutes per day. Participants received one phone call per week for 8 weeks (scheduled in advance according to times indicated convenient by participants), which took approximately 10 to 15 minutes per call and involved behavioral counseling that included goal setting, self-monitoring, feedback on goal achievement, and social support. Participants also received pedometers described below. Goal Setting. The PA goal was 30 minutes per day of moderate-intensity walking (i.e., walking, but not running; participants can talk, but not sing, during the walking; Donnelly et al., 2009; Persinger, Foster, Gibson, Fater, & Porcari, 2004). Self-Monitoring. Pedometers (Yamax Digi Walker CW-701, Tokyo, Japan) and step log books were used for the purpose of tracking behaviors (i.e., physical activity) daily and for review during counseling. Our instructions to the participant included (1) the proper use of the pedometer, (2) the need to wear the pedometer throughout the day to record all steps, and (3) the accurate recording of pedometer steps in their step log. Coupled with behavioral counseling, immediate visual feedback from both the pedometer and the step log encouraged participants to set and meet their individual goals. Feedback and Social Support. Participants received feedback, including reinforcement and concrete strategies for overcoming barriers, based on PA achievement. Moreover, weekly phone contact provided opportunities for social support. For example, if participants were unable to walk outside because of adverse weather conditions, the PI encouraged them to walk indoors (e.g., in a shopping mall) or to use treadmills, if possible. We also asked
if participants experienced any risks related to PA such as chest pain, dizziness, or falling. No risks were reported.
Measures Physical Activity. The Short-Form International Physical Activity Questionnaire (IPAQ; International Physical Activity Questionnaire Group, 2005) was the primary measure of PA. The IPAQ assesses not only PA (i.e., moderate- and vigorous-intensity exercise and walking) over the previous 7 days but also the time spent sitting on weekdays using four questions. Faulkner, Cohn, and Remington (2006) reported a correlation coefficient of .68 for reliability and .37 for criterion validity for the IPAQ. We computed minutes walked based on responses from the IPAQ. We also reported the average steps recorded on pedometers (Yamax DigiWalker CW-701). These pedometers automatically saved walking data for retrieval. Participants retrieved the data and recorded them to the step log book. Robust internal consistency and intraclass correlation (.925 and .861, respectively) have been demonstrated in studies that have used pedometers, validating their appropriateness for PA interventions (Ramirez-Marrero, Smith, Sherman, & Kirby, 2005; Smith & Schroeder, 2008). Health Outcomes. The health outcomes measured in this study included BMI, waist circumference, blood pressure (BP), fasting plasma glucose, and fasting lipid profiles. To calculate BMI (i.e., weight in kilograms divided by height in meters squared), the height of participants in meters was obtained using a wall stadiometer, and weight in kilograms was obtained using a balance-beam scale. The waist circumference of participants was measured using an anthropometric tape positioned on a plane above the hip bone, parallel to the floor. We measured BP using a clinical mercury manometer. Fasting plasma glucose and fasting lipid profile data (i.e., total cholesterol, lowdensity lipoprotein, high-density lipoprotein, and triglycerides) were collected with finger-stick testing (Cholestech LDX® system, Alere Inc., San Diego, CA). Before we measured BP, participants were (1) seated in a chair with their feet on the floor for at least 5 minutes and (2) asked not to smoke for 30 minutes before the measurement. Demographic Variables and Clinical Information. All participants were asked to provide (1) their age, gender, race, ethnicity, marital status, formal education, and occupation; (2) and comorbid conditions (e.g., high blood pressure) measured by a comorbidity questionnaire; and (3) clinical information regarding length of psychiatric illness and psychotropic medication.
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Procedures. We recruited participants by using flyers describing the study posted at waiting rooms in two outpatient clinics. Those interested were asked to call the research office to learn about the study. Sixty-seven potential participants contacted the research office by phone; during the first contact by phone, five expressed no interest in the study, seven were not eligible for the study, and eight left their contact information but did not respond to our returning calls. Face-to-face appointments for screening process were scheduled for 47 potential participants. Twenty-five of them did not participate in the study (no show, lost contact, not to submit his/her medical clearance form) and 22 adults with SMI (18-60 years of age), who were eligible, enrolled the study. Participants were reimbursed for their transportation fares. They were also compensated $30.00 for each of three assessments. Data collection sessions that included blood draws for laboratory studies were held at a research suite housed at the School of Nursing. All information about participants obtained from the research was kept confidential. Participants were given a brief description of the study and criteria for participation on contact. Written informed consent covering the entire study was obtained prior to the screening for inclusion and exclusion criteria. If participants were eligible for the study, they visited the research site to complete a series of questionnaires and measures health outcomes. On enrollment, participants were randomly assigned to either the 8-week PA treatment group or an 8-week control group that received usual care. Permuted block randomization (with block size of four for two groups) was used to maintain a reasonable balance between the groups based on our plan to recruit 40 participants (randomly assigned 20 in each group). The justification for an 8-week intervention comes from a prior study (Eastep, Beveridge, Eisenman, Ransdell, & Shultz, 2004). Participants in the usual-care control group received written information regarding PA (e.g., exercise suggestions). Data were collected by undergraduate student assistants, who received appropriate training before the intervention began. Data collectors were blinded to the treatment condition.
the differences in PA and health outcomes between the treatment group and the control group at baseline. Wilcoxon signed rank tests were used to analyze data for detecting changes in PA and health outcomes between measurements taken at baseline and 8 weeks within each group.
Analysis Data analyses were performed using SPSS for Windows (version 19.0, IBM Corp., Armonk, NY). Descriptive statistics were used to characterize both groups at each time point. In our analyses, we included participants who completed the intervention phase of the study in 8 weeks. Since PA and health outcomes were not normally distributed, nonparametric statistical methods were used in this study. A Mann–Whitney test was used to explore
Results The mean age of participants was 44.09 years (SD = 7.6), 64% (n = 14) were White, 54.5% were male (n = 12), and 45.5% were female (n = 10). Participants reported approximately six comorbid diseases (mean ± SD = 6.27 ± 3.72). These comorbidities included hypertension (n = 11; 50%), headache (n = 10; 45.5%), and high cholesterol, asthma or wheezing, and skin problems (n = 8; 36.4%). For all participants, the average of length of psychiatric illness was approximately 16 years, and each was taking approximately two medications for his or her mental illness. Once enrolled, 12 participants were assigned to the treatment group, and 10 participants were assigned to the control group (see Table 1). We lost contact with six participants (27%) at the beginning of the intervention, and they subsequently dropped out of the study (treatment = 4; control = 2). Consequently, a total of 8 participants were included in the analysis for the treatment group and 8 participants were included in the control group. Across the total sample, retention rate was 73% (n = 16) at 8 weeks. Participants used their own phones (either landbased telephones or cell phones) for the weekly behavioral counseling calls. Pretest and posttest values on the clinical outcomes are shown by group in Table 1. Among the participants who completed the 8-week intervention, 8 participants received a total of 8 sessions; 6 out of 8 participants in the treatment group reported as adherent to the recommended PA based on IPAQ. The two groups differed significantly with respect to walking time as measured by IPAQ at baseline with the control group reporting higher levels of PA compared with the treatment group. Among those who completed at 8 weeks, 6 out of 8 participants in the control group walked at least 30 minutes every day at 8 weeks and 5 participants walked at least 30 minutes at baseline. There were no statistically significant differences in clinical outcomes (e.g., BMI, waist circumference) between the control and treatment groups at baseline and 8 weeks, respectively (ps > .05). However, the average number of walking minutes significantly increased from baseline to 8 weeks for the treatment group. The control group was relatively active compared with the treatment group but did not exhibit significant changes in walking between baseline and 8 weeks (Z = −1.61, p = .11).
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Lee et al. Table 1. Health Outcome Changes Within Groups.
BMI (kg/m2) WC (inch) Systolic BP (mmHg) Diastolic BP (mmHg) TC (mg/dL) HDL (mg/dL) TRG (mg/dL) LDL (mg/dL) Fasting glucose (mg/dL) Walking/day (min/day)
Total (n = 22), baseline
Treatment (M ± SD), n = 8 Z (p)
Baseline
8 weeks
33.41 ± 6.93 45.36 ± 6.46 116.00 ± 11.78
34.17 ± 7.15 45.75 ± 6.45 115.00 ± 12.43
32.13 ± 3.87 43.25 ± 4.13 111.25 ± 8.35
−0.35 (.73) −0.95 (.34) −1.13 (.26)
32.50 ± 6.92 44.90 ± 6.77 117.20 ± 11.48
32.00 ± 7.80 43.75 ± 7.69 115.00 ± 14.14
−0.38 (.71) −1.63 (.10) −0.96 (.34)
78.55 ± 8.78
77.50 ± 8.66
73.75 ± 5.18
−0.75 (.45)
79.80 ± 9.21
75.00 ± 7.56
−1.00 (.32)
168.00 ± 34.82 43.75 ± 14.46 161.26 ± 104.60 97.78 ± 32.97 97.95 ± 17.23
168.73 ± 34.78 45.64 ± 14.09 138.40 ± 58.51 96.60 ± 35.96 99.91 ± 20.88
182.50 ± 42.08 51.33 ± 18.72 144.67 ± 101.00 102.00 ± 30.09 111.57 ± 14.74
−0.32 (.75) −1.16 (.25) −0.41 (.69) −0.67 (.50) −1.19 (.24)
167.11 ± 36.96 41.44 ± 15.41 186.67 ± 139.24 99.25 ± 31.18 95.56 ± 12.18
165.75 ± 36.02 43.63 ± 20.50 155.63 ± 89.77 91.38 ± 35.81 135.00 ± 75.58
−0.35 (.73) −0.28 (.78) −0.98 (.38) −0.68 (.50) −0.63 (.53)
48.77 ± 58.07
−2.37 (.02)
51.27 ± 35.21a
93.61 ± 66.83
−1.61 (.11)
33.74 ± 29.29
Baseline
19.13 ± 10.53a
8 weeks
Control (M ± SD), n = 8 Z (p)
Note. BMI = body mass index; BP = blood pressure; WC = waist circumference. a. U = 23.50. p = .01.
Discussion Most participants in the treatment group were overweight/obese and were relatively inactive at baseline. Although the mean number of minutes of walking per day met the recommended amount, the standard deviation was quite large. Moreover, the participants in the intervention suffered not only chronic mental illnesses but also a number of other medical comorbidities, which is consistent with other studies (Ganguli, Vreeland, & Newcomer, 2007; McDevitt, Wilbur, Kogan, & Briller, 2005; Parks, Svendsen, Singer, Foti, & Mauer, 2006). According to Hampton, White, and Chafetz (2009), recruitment and retention of outpatients with SMI in research has been and continues to be challenging. This was also true for our study. Although our target sample size was 40, we were able to recruit only 22 participants from outpatient clinics through the use of recruitment flyers. Involving health care providers at outpatient clinics in participant recruitment activities may also be an important strategy to ensure targeted enrollment rates (H. Lee & Schepp, 2013). Recruitment at community rehabilitation centers and supportive housing may also bolster enrollment. Recent research (Daumit et al., 2013) has shown the effectiveness of weight loss programs integrated into community-based psychiatric settings for adults with SMI. Noteworthy among these studies is the utilization of community mental health centers—often used by the SMI population for recovery—for outreach to this population rather than the doctor’s office (Daumit et al., 2013). A total of six participants (27%) were lost to contact at the beginning of the intervention, and they subsequently dropped out of the study. The retention rate of prior studies of lifestyle interventions for people with SMI ranged from 31% to 100%, with a mean of 70 ± 17% based on a
recent systematic review (Cabassa et al., 2010). Although participant recruitment and enrollment was lower than expected, our participant retention was comparable with other studies. We primarily used personal telephone numbers and addresses to follow participants, which also may have contributed to attrition. Problems encountered in delivery of the intervention included (1) participants failing to answer our calls or not receiving our calls and (2) participant phones no longer having service. Possibly, participants lost interest in participating in research activity or chose not to answer calls with an unfamiliar telephone number. Participants also may have limited phone service plans. In future studies, participants should be informed of all possible phone numbers used by the research team. Alternative contacts, such as family or friends designated by participants, should be considered as a means to keep in touch with and retain participants (Hampton et al., 2009). Prepaid phone or phone cards would be another option for future study. As mentioned in a prior study (Richardson, Avripas, Neal, & Marcus, 2005), evaluation of characteristics of participants who drop out may provide further information to recruit and retain participants with SMI. Our results demonstrate that a PA intervention (i.e., behavioral counseling including individualized goal setting, self-monitoring, feedback, and social support) delivered via telephone coupled with pedometers has the potential to improve PA adherence in individuals with SMI. Similarly, prior telephone-assisted counseling for PA studies reported the increased PA in cancer population (Pinto, Rabin, Abdow, & Papandonatos, 2008), general population aged 50 and older (Wilcox, Dowda, Wegley, & Ory, 2009), and low active older people aged 65 (Kolt, Schofield, Kerse, Garrett, & Oliver, 2007). Although the
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Journal of the American Psychiatric Nurses Association 20(6)
treatment group participants appeared to be less active than the participants in the control group at pretest, the majority of treatment group participants were adherent to PA as recommended throughout the intervention compared with baseline measurement, and two participants in the treatment group exhibited low levels of PA over the 8-week intervention (
research-article2014
JAPXXX10.1177/1078390314561497Journal of the American Psychiatric Nurses AssociationLee et al.
Research Paper
Telephone-Delivered Physical Activity Intervention for Individuals With Serious Mental Illness: A Feasibility Study
Journal of the American Psychiatric Nurses Association 2014, Vol. 20(6) 389–397 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314561497 jap.sagepub.com
Heeyoung Lee1, Irene Kane2, Jaspreet Brar3, and Susan Sereika4
Abstract BACKGROUND:Obesity is prevalent in individuals with serious mental illness (SMI). OBJECTIVE: The purpose of this study is to examine the feasibility of a telephone-delivered physical activity (PA) intervention for outpatients with serious mental illness to maintain PA and to explore the preliminary efficacy of the intervention on health status. DESIGN: This study used a randomized experimental design. The treatment group received pedometers and eight weekly phone calls; the control group received written information regarding PA. Descriptive statistics were used to analyze data collected at baseline and 8 weeks. RESULTS: Twenty-two subjects with SMI (mean age = 44.09 ± 7.6 years; 54.5% were male) were recruited and 16 subjects completed the study in 8 weeks. PA (z = −2.37, p = .02) increased in the treatment group (n = 8) whereas the control group (n = 8) maintained baseline PA level (z = −1.61, p = .11). Health outcomes were not changed (ps > .05). CONCLUSION: Telephone-delivered intervention is feasible and has the potential to improve PA in individuals with SMI. Keywords obesity, serious mental illness, physical activity
Introduction Obesity (defined as body mass index [BMI] ≥ 30 kg/m2) is epidemic in people with serious mental illnesses (SMI; De Hert, Schreurs, Vancampfort, & Van Winkel, 2009; Megna, Schwartz, Siddiqui, & Herrera Rojas, 2011; Parks, Radke, & Ruter, 2008). SMI refers to—but is not limited to—mental illnesses, including schizophrenia, bipolar disorder, and major depression, that are coupled with a functional disability such as an inability to maintain employment or live independently (U.S. Department of Health and Human Services, 1999). The prevalence of obesity among people with SMI has been reported as approximately 40% to 60% (De Hert, Schreurs, et al., 2009; Parks et al., 2008). People with SMI have a 1.2- to 3.5-fold increased likelihood of being overweight/obese compared with those in the general population (Parks et al., 2008). Although the specific mechanisms underlying obesity among people with SMI are not well understood, the combination of disability, unhealthy lifestyle (e.g., low level of physical activity), family history of obesity, and side effects of psychotropic medications may contribute to the high rates of obesity observed in people with SMI (Goldberg et al., 2013; McElroy, 2009). A recent systematic literature review of lifestyle interventions for adults with SMI indicated that physical
activity (PA) and healthy eating have potential benefit in addressing obesity among individuals with SMI (Cabassa, Ezell, & Lewis-Fernandez, 2010). Specifically, the importance of PA should be emphasized because (1) many forms of PA, such as walking, have been reported to improve physical health (e.g., decreased body fat, improved metabolic risk profiles, and improved physical fitness; Bravata et al., 2007; Daumit et al., 2005; I. M. Lee & Skerrett, 2001) and (2) it can be integrated into peoples’ daily lives (Callaghan, 2004; Strassnig, Brar, & Ganguli, 2005). A growing body of evidence demonstrates the benefit of PA in the general population. The recommended PA for 1
Heeyoung Lee, PhD, PMHNP-BC, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA 2 Irene Kane, PhD, RN, CNAA, HFI, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA 3 Jaspreet Brar, MD, PhD, MPH, Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute & Clinic, Pittsburgh, PA, USA 4 Susan Sereika, PhD, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA Corresponding Author: Heeyoung Lee, University of Pittsburgh School of Nursing, 415 Victoria Building, 3500 Victoria Street, Pittsburgh PA 15261, USA. Email: [email protected]
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Journal of the American Psychiatric Nurses Association 20(6)
adults is at least 150 minutes/week of moderate-intensity PA, 75 minutes/week of vigorous-intensity PA, or a combination of moderate and vigorous PA (Haskell et al., 2007). Health benefits of PA include reduced risks for premature chronic health conditions, preventing unhealthy weight gain, high level of physical fitness, and reduced mortality and extended life expectancy (Haskell et al., 2007; Warburton, Nicol, & Bredin, 2006; Wen et al., 2011; World Health Organization, 2010). Brisk walking for at least 30 minutes per day (or ≥3,000 steps measured by a pedometer) every day has been advised and shown to be effective in people with SMI (Brar et al., 2005; De Hert, Dekker, et al., 2009). However, even though people with SMI are interested in being active and understand the benefit of exercise (Ussher, Stanbury, Cheeseman, & Faulkner, 2007), they exhibit less than recommended PA levels than do the general population because of lack of social contacts (Daumit et al., 2005; Richardson, Faulkner, et al., 2005). In addition, they would prefer to manage their weight without having to participate in face-to-face treatment programs because of geography, lack of transportation (The National Alliance on Mental Illness, 2008), or the stigma attached to accessing such resources (H. Lee & Schepp, 2013). Consequently, people with SMI need interventions that not only motivate them to engage in recommended amounts of PA but also allow them ease of access to PA. Telephone contact is an effective tool in delivering interventions to people who are of low socioeconomic status (e.g., they lack transportation; Fjeldsoe, Marshall, & Miller, 2009), and most people with SMI are unemployed or working for minimum wage (Boardman, 2006; Cunningham, McKenzie, & Taylor, 2006). Prior studies have also indicated that phone-delivered behavioral interventions are as effective as in-person counseling among the obese population (Appel et al., 2011; Digenio, Mancuso, Gerber, & Dvorak, 2009). In addition, telephone contact offers a more direct route to patient communication compared with other technology, such as the Internet. The advantages of using telephones include (1) providing access to more patients more easily, (2) enabling more personal interaction than typical Internet modes, and (3) providing convenient and easy to use support for patients with low-income and limited health literacy (Bodenheimer & Abramowitz, 2010). Although people with SMI have limited access to and skill with diverse forms of technology, generally they do use telephones or cell phones, and research results have suggested that they have interest in receiving health care intervention via phone calls (Ben-Zeev, Davis, Kaiser, Krzsos, & Drake, 2013). The primary purpose of this pilot study was to examine the feasibility of a phone-delivered PA intervention for adults with SMI to achieve and maintain PA.
Additionally, this pilot study assessed changes in health status (e.g., weight loss). In our intervention, we targeted 30-minute brisk walking (i.e., 3,000 steps in 30 minutes; Marshall et al., 2009) with a pedometer because walking is a low-cost, ease of access, home-based PA. The pedometer is not only a straightforward and simple tool for selfmonitoring (Harris et al., 2013) but also conducive to motivating individuals with SMI (Kane, Lee, Sereika, & Brar, 2012).
Method Design and Sample Our study utilized a randomized experimental design. The intervention comprised an 8-week walking program with data collection at baseline, 8 weeks (i.e., immediately after intervention), and 12 weeks (i.e., 4 weeks after the completion of the intervention). For this report, only the baseline and the 8-week postintervention data will be presented. Sample. Adults aged 18 to 60 years who met the following criteria were eligible to participate: (1) a past or current DSM-IV diagnosis of schizophrenia spectrum disorders or a Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) diagnosis of other severe mental disorders, including bipolar disorder or major depression; (2) receiving psychotropic medication to control symptoms at the time of recruitment; and (3) medical clearance in writing from a primary care provider for moderate PA—defined as activities that are approximately the equivalent of brisk walking 3 to 4 mph. Exclusion criteria included (1) significant cardiovascular, neuromuscular, endocrine, orthopedic, or other disorders that would prevent safe participation as screened by the Physical Activity Readiness Questionnaire (Canadian Society for Exercise Physiology, 2002; Thomas, Reading, & Shephard, 1992) and (2) involvement in any other PA intervention program at the time of recruitment. The institutional review board at a major, northeastern research university approved the study protocol, and all participants provided written, informed consent.
Intervention Our intervention was guided by social cognitive theory (SCT), which emphasizes the dynamic interplay of personal, behavioral, and environmental factors in human behaviors. Specifically, individuals maintain a newly achieved behavior through a multifaceted, causal structure in which self-efficacy operates together with goals, outcome expectations, and perceived environmental
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Lee et al. impediments and facilitators. Self-efficacy refers to a person’s confidence in his or her ability to successfully execute given behaviors (e.g., physical activity) using SCT strategies, which include goal setting, self-monitoring, feedback, and social support—all of these strategies strengthen self-efficacy, which contributes to health promoting behavior (Bandura, 1997, 2004). The intervention (i.e., enrollment, instructions, and phone calls) was delivered by the principal investigator using an intervention checklist to address goal settings, reviewing self-monitoring, feedback on goal achievement, and social support. Participants in the experimental condition were educated on how to safely walk briskly for 30 minutes each day based on American PA guidelines (Haskell et al., 2007). As the guidelines recommend, our PA instructions for the participant explained that the 30 minutes may be completed either in one walk or in no less than three 10-minute walks, as long as the total minutes walked is 30 minutes per day. Participants received one phone call per week for 8 weeks (scheduled in advance according to times indicated convenient by participants), which took approximately 10 to 15 minutes per call and involved behavioral counseling that included goal setting, self-monitoring, feedback on goal achievement, and social support. Participants also received pedometers described below. Goal Setting. The PA goal was 30 minutes per day of moderate-intensity walking (i.e., walking, but not running; participants can talk, but not sing, during the walking; Donnelly et al., 2009; Persinger, Foster, Gibson, Fater, & Porcari, 2004). Self-Monitoring. Pedometers (Yamax Digi Walker CW-701, Tokyo, Japan) and step log books were used for the purpose of tracking behaviors (i.e., physical activity) daily and for review during counseling. Our instructions to the participant included (1) the proper use of the pedometer, (2) the need to wear the pedometer throughout the day to record all steps, and (3) the accurate recording of pedometer steps in their step log. Coupled with behavioral counseling, immediate visual feedback from both the pedometer and the step log encouraged participants to set and meet their individual goals. Feedback and Social Support. Participants received feedback, including reinforcement and concrete strategies for overcoming barriers, based on PA achievement. Moreover, weekly phone contact provided opportunities for social support. For example, if participants were unable to walk outside because of adverse weather conditions, the PI encouraged them to walk indoors (e.g., in a shopping mall) or to use treadmills, if possible. We also asked
if participants experienced any risks related to PA such as chest pain, dizziness, or falling. No risks were reported.
Measures Physical Activity. The Short-Form International Physical Activity Questionnaire (IPAQ; International Physical Activity Questionnaire Group, 2005) was the primary measure of PA. The IPAQ assesses not only PA (i.e., moderate- and vigorous-intensity exercise and walking) over the previous 7 days but also the time spent sitting on weekdays using four questions. Faulkner, Cohn, and Remington (2006) reported a correlation coefficient of .68 for reliability and .37 for criterion validity for the IPAQ. We computed minutes walked based on responses from the IPAQ. We also reported the average steps recorded on pedometers (Yamax DigiWalker CW-701). These pedometers automatically saved walking data for retrieval. Participants retrieved the data and recorded them to the step log book. Robust internal consistency and intraclass correlation (.925 and .861, respectively) have been demonstrated in studies that have used pedometers, validating their appropriateness for PA interventions (Ramirez-Marrero, Smith, Sherman, & Kirby, 2005; Smith & Schroeder, 2008). Health Outcomes. The health outcomes measured in this study included BMI, waist circumference, blood pressure (BP), fasting plasma glucose, and fasting lipid profiles. To calculate BMI (i.e., weight in kilograms divided by height in meters squared), the height of participants in meters was obtained using a wall stadiometer, and weight in kilograms was obtained using a balance-beam scale. The waist circumference of participants was measured using an anthropometric tape positioned on a plane above the hip bone, parallel to the floor. We measured BP using a clinical mercury manometer. Fasting plasma glucose and fasting lipid profile data (i.e., total cholesterol, lowdensity lipoprotein, high-density lipoprotein, and triglycerides) were collected with finger-stick testing (Cholestech LDX® system, Alere Inc., San Diego, CA). Before we measured BP, participants were (1) seated in a chair with their feet on the floor for at least 5 minutes and (2) asked not to smoke for 30 minutes before the measurement. Demographic Variables and Clinical Information. All participants were asked to provide (1) their age, gender, race, ethnicity, marital status, formal education, and occupation; (2) and comorbid conditions (e.g., high blood pressure) measured by a comorbidity questionnaire; and (3) clinical information regarding length of psychiatric illness and psychotropic medication.
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Procedures. We recruited participants by using flyers describing the study posted at waiting rooms in two outpatient clinics. Those interested were asked to call the research office to learn about the study. Sixty-seven potential participants contacted the research office by phone; during the first contact by phone, five expressed no interest in the study, seven were not eligible for the study, and eight left their contact information but did not respond to our returning calls. Face-to-face appointments for screening process were scheduled for 47 potential participants. Twenty-five of them did not participate in the study (no show, lost contact, not to submit his/her medical clearance form) and 22 adults with SMI (18-60 years of age), who were eligible, enrolled the study. Participants were reimbursed for their transportation fares. They were also compensated $30.00 for each of three assessments. Data collection sessions that included blood draws for laboratory studies were held at a research suite housed at the School of Nursing. All information about participants obtained from the research was kept confidential. Participants were given a brief description of the study and criteria for participation on contact. Written informed consent covering the entire study was obtained prior to the screening for inclusion and exclusion criteria. If participants were eligible for the study, they visited the research site to complete a series of questionnaires and measures health outcomes. On enrollment, participants were randomly assigned to either the 8-week PA treatment group or an 8-week control group that received usual care. Permuted block randomization (with block size of four for two groups) was used to maintain a reasonable balance between the groups based on our plan to recruit 40 participants (randomly assigned 20 in each group). The justification for an 8-week intervention comes from a prior study (Eastep, Beveridge, Eisenman, Ransdell, & Shultz, 2004). Participants in the usual-care control group received written information regarding PA (e.g., exercise suggestions). Data were collected by undergraduate student assistants, who received appropriate training before the intervention began. Data collectors were blinded to the treatment condition.
the differences in PA and health outcomes between the treatment group and the control group at baseline. Wilcoxon signed rank tests were used to analyze data for detecting changes in PA and health outcomes between measurements taken at baseline and 8 weeks within each group.
Analysis Data analyses were performed using SPSS for Windows (version 19.0, IBM Corp., Armonk, NY). Descriptive statistics were used to characterize both groups at each time point. In our analyses, we included participants who completed the intervention phase of the study in 8 weeks. Since PA and health outcomes were not normally distributed, nonparametric statistical methods were used in this study. A Mann–Whitney test was used to explore
Results The mean age of participants was 44.09 years (SD = 7.6), 64% (n = 14) were White, 54.5% were male (n = 12), and 45.5% were female (n = 10). Participants reported approximately six comorbid diseases (mean ± SD = 6.27 ± 3.72). These comorbidities included hypertension (n = 11; 50%), headache (n = 10; 45.5%), and high cholesterol, asthma or wheezing, and skin problems (n = 8; 36.4%). For all participants, the average of length of psychiatric illness was approximately 16 years, and each was taking approximately two medications for his or her mental illness. Once enrolled, 12 participants were assigned to the treatment group, and 10 participants were assigned to the control group (see Table 1). We lost contact with six participants (27%) at the beginning of the intervention, and they subsequently dropped out of the study (treatment = 4; control = 2). Consequently, a total of 8 participants were included in the analysis for the treatment group and 8 participants were included in the control group. Across the total sample, retention rate was 73% (n = 16) at 8 weeks. Participants used their own phones (either landbased telephones or cell phones) for the weekly behavioral counseling calls. Pretest and posttest values on the clinical outcomes are shown by group in Table 1. Among the participants who completed the 8-week intervention, 8 participants received a total of 8 sessions; 6 out of 8 participants in the treatment group reported as adherent to the recommended PA based on IPAQ. The two groups differed significantly with respect to walking time as measured by IPAQ at baseline with the control group reporting higher levels of PA compared with the treatment group. Among those who completed at 8 weeks, 6 out of 8 participants in the control group walked at least 30 minutes every day at 8 weeks and 5 participants walked at least 30 minutes at baseline. There were no statistically significant differences in clinical outcomes (e.g., BMI, waist circumference) between the control and treatment groups at baseline and 8 weeks, respectively (ps > .05). However, the average number of walking minutes significantly increased from baseline to 8 weeks for the treatment group. The control group was relatively active compared with the treatment group but did not exhibit significant changes in walking between baseline and 8 weeks (Z = −1.61, p = .11).
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Lee et al. Table 1. Health Outcome Changes Within Groups.
BMI (kg/m2) WC (inch) Systolic BP (mmHg) Diastolic BP (mmHg) TC (mg/dL) HDL (mg/dL) TRG (mg/dL) LDL (mg/dL) Fasting glucose (mg/dL) Walking/day (min/day)
Total (n = 22), baseline
Treatment (M ± SD), n = 8 Z (p)
Baseline
8 weeks
33.41 ± 6.93 45.36 ± 6.46 116.00 ± 11.78
34.17 ± 7.15 45.75 ± 6.45 115.00 ± 12.43
32.13 ± 3.87 43.25 ± 4.13 111.25 ± 8.35
−0.35 (.73) −0.95 (.34) −1.13 (.26)
32.50 ± 6.92 44.90 ± 6.77 117.20 ± 11.48
32.00 ± 7.80 43.75 ± 7.69 115.00 ± 14.14
−0.38 (.71) −1.63 (.10) −0.96 (.34)
78.55 ± 8.78
77.50 ± 8.66
73.75 ± 5.18
−0.75 (.45)
79.80 ± 9.21
75.00 ± 7.56
−1.00 (.32)
168.00 ± 34.82 43.75 ± 14.46 161.26 ± 104.60 97.78 ± 32.97 97.95 ± 17.23
168.73 ± 34.78 45.64 ± 14.09 138.40 ± 58.51 96.60 ± 35.96 99.91 ± 20.88
182.50 ± 42.08 51.33 ± 18.72 144.67 ± 101.00 102.00 ± 30.09 111.57 ± 14.74
−0.32 (.75) −1.16 (.25) −0.41 (.69) −0.67 (.50) −1.19 (.24)
167.11 ± 36.96 41.44 ± 15.41 186.67 ± 139.24 99.25 ± 31.18 95.56 ± 12.18
165.75 ± 36.02 43.63 ± 20.50 155.63 ± 89.77 91.38 ± 35.81 135.00 ± 75.58
−0.35 (.73) −0.28 (.78) −0.98 (.38) −0.68 (.50) −0.63 (.53)
48.77 ± 58.07
−2.37 (.02)
51.27 ± 35.21a
93.61 ± 66.83
−1.61 (.11)
33.74 ± 29.29
Baseline
19.13 ± 10.53a
8 weeks
Control (M ± SD), n = 8 Z (p)
Note. BMI = body mass index; BP = blood pressure; WC = waist circumference. a. U = 23.50. p = .01.
Discussion Most participants in the treatment group were overweight/obese and were relatively inactive at baseline. Although the mean number of minutes of walking per day met the recommended amount, the standard deviation was quite large. Moreover, the participants in the intervention suffered not only chronic mental illnesses but also a number of other medical comorbidities, which is consistent with other studies (Ganguli, Vreeland, & Newcomer, 2007; McDevitt, Wilbur, Kogan, & Briller, 2005; Parks, Svendsen, Singer, Foti, & Mauer, 2006). According to Hampton, White, and Chafetz (2009), recruitment and retention of outpatients with SMI in research has been and continues to be challenging. This was also true for our study. Although our target sample size was 40, we were able to recruit only 22 participants from outpatient clinics through the use of recruitment flyers. Involving health care providers at outpatient clinics in participant recruitment activities may also be an important strategy to ensure targeted enrollment rates (H. Lee & Schepp, 2013). Recruitment at community rehabilitation centers and supportive housing may also bolster enrollment. Recent research (Daumit et al., 2013) has shown the effectiveness of weight loss programs integrated into community-based psychiatric settings for adults with SMI. Noteworthy among these studies is the utilization of community mental health centers—often used by the SMI population for recovery—for outreach to this population rather than the doctor’s office (Daumit et al., 2013). A total of six participants (27%) were lost to contact at the beginning of the intervention, and they subsequently dropped out of the study. The retention rate of prior studies of lifestyle interventions for people with SMI ranged from 31% to 100%, with a mean of 70 ± 17% based on a
recent systematic review (Cabassa et al., 2010). Although participant recruitment and enrollment was lower than expected, our participant retention was comparable with other studies. We primarily used personal telephone numbers and addresses to follow participants, which also may have contributed to attrition. Problems encountered in delivery of the intervention included (1) participants failing to answer our calls or not receiving our calls and (2) participant phones no longer having service. Possibly, participants lost interest in participating in research activity or chose not to answer calls with an unfamiliar telephone number. Participants also may have limited phone service plans. In future studies, participants should be informed of all possible phone numbers used by the research team. Alternative contacts, such as family or friends designated by participants, should be considered as a means to keep in touch with and retain participants (Hampton et al., 2009). Prepaid phone or phone cards would be another option for future study. As mentioned in a prior study (Richardson, Avripas, Neal, & Marcus, 2005), evaluation of characteristics of participants who drop out may provide further information to recruit and retain participants with SMI. Our results demonstrate that a PA intervention (i.e., behavioral counseling including individualized goal setting, self-monitoring, feedback, and social support) delivered via telephone coupled with pedometers has the potential to improve PA adherence in individuals with SMI. Similarly, prior telephone-assisted counseling for PA studies reported the increased PA in cancer population (Pinto, Rabin, Abdow, & Papandonatos, 2008), general population aged 50 and older (Wilcox, Dowda, Wegley, & Ory, 2009), and low active older people aged 65 (Kolt, Schofield, Kerse, Garrett, & Oliver, 2007). Although the
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treatment group participants appeared to be less active than the participants in the control group at pretest, the majority of treatment group participants were adherent to PA as recommended throughout the intervention compared with baseline measurement, and two participants in the treatment group exhibited low levels of PA over the 8-week intervention (
