Better Health Choices: Feasability and preliminary effectiveness of a peer delivered healthy lifestyle intervention in a community mental health setting

Co-development of implementation strategies to assist staff of a mental health community managed organisation provide preventive care for health behaviours

ISSUE ADDRESSED

People with a mental health condition are at risk of developing chronic physical disease due to smoking tobacco, inadequate nutrition, high alcohol consumption, low physical activity and poor sleep (SNAPS). Community managed organisations (CMOs) represent an opportune setting to support mental health consumers to improve their health behaviours through providing preventive care. Reporting of methods used to co-develop implementation strategies to assist CMO staff to deliver preventive care for SNAPS are scarce yet warranted.

OBJECTIVES

This study aims to: (1) describe a co-development workshop involving CMO staff and researchers to identify preferred implementation support strategies to help staff routinely provide preventive care; (2) describe the strategies that emerged from the workshop; and (3) report staff ratings of the workshop on four co-development principles.

METHODS

A three-hour co-development workshop was conducted on two occasions with staff of one CMO in New South Wales, Australia. Twenty staff participated in the workshops.

RESULTS

Participants generated and ranked a total of seven discrete implementation strategies within five categories (training, point of care prompts, guidelines, continuous quality improvement and consumer activation). Training for staff to have difficult conversations about behaviour change was ranked highest in both workshops. Participants rated the workshops positively across four co-development principles.

CONCLUSIONS

The co-development workshop enabled implementation strategies to be developed within the context in which they were to be delivered and tested, potentially increasing their feasibility, acceptability, appropriateness and impact. SO WHAT?: Implementation strategies selected from the workshops will inform a pilot implementation support trial to assist CMO staff to provide preventive care to people with mental health conditions.

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

Systematic review of guidelines for managing physical health during treatment for substance use disorders: Implications for the alcohol and other drug workforce

ISSUES

Substance use disorders are associated with significant physical health comorbidities, necessitating an integrated treatment response. However, service fragmentation can preclude the management of physical health problems during addiction treatment. The aim of this systematic review was to synthesise the recommendations made by clinical practice guidelines for addressing the physical health of people attending alcohol and other drug (AOD) treatment.

APPROACH

An iterative search strategy of grey literature sources was conducted from September 2020 to February 2021 to identify clinical practice guidelines. Content pertaining to physical health care during AOD treatment was extracted. Quality of guidelines were appraised using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) tool.

FINDINGS

Thirty-three guidelines were included for review. Fourteen guidelines were considered high quality based on AGREE-II scores. Neurological conditions (90.9%) and hepatitis (81.8%) were the most frequent health problems addressed. Most guidelines recommended establishing referral pathways to address physical health comorbidities (90.9%). Guidance on facilitating these referral pathways was less common (42.4%). Guidelines were inconsistent in their recommendations related to oral health, tobacco use, physical activity, nutrition and the use of standardised assessment tools.

IMPLICATIONS AND CONCLUSIONS

Greater consistency and specificity in the recommendations made for integrating physical health care within addiction treatment is needed. Ensuring that recommendations are applicable to the AOD workforce and to treatment services limited by funding and resource constraints should enhance implementation. Future guideline development groups should consider increased consultation with the AOD workforce and inclusion of clinical tools and decision aids to facilitate referral pathways.

Effectiveness of referral to a population-level telephone coaching service for improving health risk behaviours in people with a mental health condition: study protocol for a randomised controlled trial

BACKGROUND

People with a mental health condition have a shorter life expectancy than the general population. This is largely attributable to higher rates of chronic disease and a higher prevalence of modifiable health risk behaviours including tobacco smoking, alcohol consumption, poor nutrition, and physical inactivity. Telephone support services offer a viable option to provide support to reduce these health risk behaviours at a population-level; however, whilst there is some research pertaining to Quitlines, there is limited other research investigating whether telephone services may offer effective support for people with a mental health condition. This protocol describes a randomised controlled trial that aims to evaluate the referral of people with a mental health condition to a population-level telephone coaching service to increase physical activity, healthy eating, or weight management, and increase attempts to do so.

METHODS

A parallel-group randomised controlled trial will be conducted recruiting participants with a mental health condition through community mental health services and advertisement on social media. Participants will be randomly assigned to receive either a health information pack only (control) or a health information pack and a proactive referral to a free, government-funded telephone coaching service, the NSW Get Healthy Coaching and Information Service® (intervention), which offers up to 13 telephone coaching calls with a University Qualified Health Coach to assist with client-identified goals relating to physical activity, healthy eating, weight management, or alcohol reduction. Data will be collected via telephone surveys at baseline and 6 months post-recruitment. Primary outcomes are as follows: (1) minutes of moderate to vigorous physical activity per week, (2) serves of fruit consumed per day, (3) serves of vegetables consumed per day, and (4) a composite measure assessing attempts to change at least one health risk behaviour (any attempts to change physical activity, fruit consumption, vegetable consumption, or other parts of nutrition). Secondary outcomes include weight and body mass index.

DISCUSSION

This study is the first to evaluate the effectiveness of referral to a population-level telephone support service for reducing health risk behaviours relating to physical activity, healthy eating, and weight in people with a mental health condition. Results will inform future policy and practice regarding the delivery of telephone-based behaviour change coaching services and the management of physical health for this population to reduce health inequity and the burden of chronic disease.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry ACTRN12620000351910 . Retrospectively registered on 12 March 2020.

Adapting Peer Researcher Facilitated Strategies to Recruit People Receiving Mental Health Services to a Tobacco Treatment Trial

INTRODUCTION

One of the most challenging aspects of conducting intervention trials among people who experience severe mental illness (SMI) and who smoke tobacco, is recruitment. In our parent "QuitLink" randomized controlled trial (RCT), slower than expected peer researcher facilitated recruitment, along with the impact of COVID-19 pandemic restrictions, necessitated an adaptive recruitment response. The objectives of the present study were to: (i) describe adaptive peer researcher facilitated recruitment strategies; (ii) explore the effectiveness of these strategies; (iii) investigate whether recruitment strategies reached different subgroups of participants; and (iv) examine the costs and resources required for implementing these strategies. Finally, we offer experience-based lessons in a Peer Researcher Commentary.

METHODS

People were included in the RCT if they smoked at least 10 cigarettes a day and were accessing mental health support from the project's two partnering mental health organizations in Victoria, Australia. The majority of people accessing these services will have been diagnosed with SMI. Recruitment occurred over 2 years. We began with peer facilitated recruitment strategies delivered face-to-face, then replaced this with direct mail postcards followed by telephone contact. In the final 4 months of the study, we began online recruitment, broadening it to people who smoked and were accessing support or treatment (including from general practitioners) for mental health and/or alcohol or other drug problems, anywhere in the state of Victoria. Differences between recruitment strategies on key participant variables were assessed. We calculated the average cost per enrolee of the different recruitment approaches.

RESULTS

Only 109 people were recruited from a target of 382: 29 via face-to-face (March 2019 to April 2020), 66 from postcards (May 2020 to November 2020), and 14 from online (November to December 2020 and January to March 2021) strategies. Reflecting our initial focus on recruiting from supported independent living accommodation facilities, participants recruited face-to-face were significantly more likely to be living in partially or fully supported independent living (n = 29, <0.001), but the samples were otherwise similar. After the initial investment in training and equipping peer researchers, the average cost of recruitment was AU$1,182 per participant-~US$850. Face-to-face recruitment was the most expensive approach and postcard recruitment the least (AU$1,648 and AU$928 per participant).

DISCUSSION

Peer researcher facilitated recruitment into a tobacco treatment trial was difficult and expensive. Widely dispersed services and COVID-19 restrictions necessitated non-face-to-face recruitment strategies, such as direct mail postcards, which improved recruitment and may be worthy of further research.

CLINICAL TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines. The trial sponsor was the University of Newcastle, NSW, Australia.

Telephone-delivered health behaviour change support for people with a mental health condition: the coaches' perspective

Background

People with a mental health condition experience a greater prevalence of chronic disease and reduced life expectancy compared to the general population. Modifiable health risk behaviours, such as physical inactivity and poor nutrition are major contributing factors. Population-level health coaching delivering behavioural change support via telephone for healthy eating, physical activity, and weight management is an opportunity utilised by this group to support improvement in healthy lifestyle behaviours. Health coaches offer a valuable perspective into the provision of services to this high-risk group. This study aims to qualitatively explore coaches’ experiences in providing support to these participants, consider factors which may contribute to engagement and outcomes; and potentially inform future service improvement.

Method

A qualitative study design was employed involving semi-structured telephone interviews with six coaches employed in a telephone-based behaviour change support service in New South Wales, Australia, between April and July 2019. Interview data was analysed using an inductive thematic analysis.

Results

Coaches believed that the service was of benefit to people with a mental health condition, however making changes to health risk behaviours was potentially more difficult for this group of service users. Coaches indicated that in supporting this group there was a greater focus on building confidence and readiness to change. They noted that improvement in mental health as a result of physical health changes was an additional ‘measure of success’ of particular relevance. Coaches expressed a desire to receive more mental health training to better deliver coaching to participants with a mental health condition. Program variables such as limited call length were posed as possible barriers to care.

Conclusion

Further training and additional support for coaches, in additon to considering variations to aspects of service delivery may assist in improving engagement and outcomes for participants with mental health conditions. Examining mental health consumers’ experiences when engaging with telephone coaching services would be an important area to address in further research.

Effect of a nurse-led intervention program on the physical health and quality of life of individuals with severe mental illness

PURPOSE

The aim of this study was to investigate the effect of nurse-led intervention programs on patients' physical health, physical activities, healthy lifestyle behaviors, and quality of life.

DESIGN AND METHODS

The research was conducted with a quasi-experimental design. The sample consisted of 33 individuals with severe mental illness. Data were collected with the Healthy Lifestyle Behavior Scale II, the Short Form-36 Quality-of-Life Instrument, and pedometers.

FINDINGS

The individuals in the intervention group showed a statistically significant decrease in waist circumference and increases in the physical activity and nutrition dimensions of healthy lifestyle behaviors and the physical function of quality of life. No statistically significant changes were detected in anthropometric measurements, healthy lifestyle behaviors, or quality-of-life subscales in the control group.

PRACTICE IMPLICATIONS

Mental health nursing and psychiatric nurses should plan and implement interventions to encourage healthy eating and physical activity for patients.

Participant Experiences With a Peer-Led Healthy Lifestyle Intervention for People With Serious Mental Illness

OBJECTIVE

This study explored the experiences of individuals with serious mental illness who were predominantly Black, were living in supportive housing, and participated in the Peer-Led Group Lifestyle Balance (PGLB) intervention. The authors examined how participants engaged in the process of behavior change and applied intervention concepts.

METHODS

Focus groups and interviews with 63 participants explored their motivation for engaging with PGLB, challenges to behavior change, and how they integrated intervention strategies into their lives. Interviews were transcribed and analyzed with grounded theory.

RESULTS

A grounded model summarized the description of the cycle of behavior change and provided insight into participants' decision-making processes. Challenges to engaging in healthy lifestyle change were related to participants' general medical health, time constraints, lack of knowledge, difficulties breaking old habits and changing self-perceptions, mood state, and the social-physical environment. Participants applied many intervention strategies, such as addressing problematic social cues, contexts, and food associations; planning ahead; starting with smaller changes; portion control; food substitution; mindful eating; and integrating changes into their daily lives. They reported various behavior changes with respect to eating and physical activity and more limited shifts in self-monitoring.

CONCLUSIONS

Improving the health of people with serious mental illness will require expanding their access to healthy lifestyle interventions in community-based settings. The findings suggest that future interventions should expand support for self-monitoring, meal planning, tailored physical activity, and advocacy. Such interventions should also enhance participants' understanding of the corresponding impact of changes on weight loss and emphasize subjective wellness outcomes to maintain motivation.

A Stakeholder-Engaged Process for Adapting an Evidence-Based Intervention for Posttraumatic Stress Disorder for Peer Delivery

PURPOSE

Peer providers represent a growing sector of the U.S. workforce, yet guidance is needed on best practices for adapting behavioral health interventions for peer delivery.

METHODS

We utilized the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME; Wiltsey Stirman et al. 2013, 2019) to describe how we systematically adapted Skills Training in Affective and Interpersonal Regulation (STAIR) for posttraumatic stress disorder (PTSD) for peer delivery. Our process was iterative and relied on engagement of multiple stakeholders, including a work group of organizational leaders (N = 5), peer interventionists (N = 4), intervention experts (N = 2), and trial participants (N = 18). The FRAME was used to guide rapid coding across multiple data sources, including researcher field notes, meeting minutes, and intervention manual documents, and content analysis of semi-structured interviews with peer interventionists and trial participants.

RESULTS

Phase 1 (pre-trial) focused on modifications for fit with the local context and peer model. Key modifications focused on improving intervention design and packaging, removing clinical and stigmatizing language, and addressing peer interventionist training gaps. We used a hybrid approach to delivery, whereby we integrated peer model principles (self-disclosure, mutuality) into a directive approach. Phase 2 (trial) included reactive fidelity-consistent adaptations, such as additional educational resources. Phase 3 (post-trial) focused on adaptations to support roll-out of the intervention at the peer organization (e.g., group format).

CONCLUSION

Our stakeholder-engaged process may serve as a helpful exemplar to others tailoring interventions for peer delivery. Future research is needed to understand the role of stakeholder engagement and adaptation in implementation success.

Facilitators and barriers to integrating physical health care during treatment for substance use: A socio-ecological analysis

INTRODUCTION AND AIMS

Clinical practice guidelines recommend physical health be addressed when treating substance use disorders. Yet, the integration of alcohol and other drug (AOD) treatment and physical health care is seldom actualised. This is particularly the case in the non-government sector. Using the socio-ecological model as a framework, this study aimed to examine the facilitators and barriers to integrating physical health in non-government AOD services.

DESIGN AND METHODS

Interviews were conducted with residential and outpatient AOD services across New South Wales, Australia. Qualitative data were collected from service users (n = 20) and clinicians (n = 13). Interview data were transcribed then systematically coded and analysed using iterative categorisation.

RESULTS

Most staff recognised physical health care as a fundamental component of treatment for substance use even when there were personal, professional and structural barriers for doing so. Service users reported a diverse range of health and social benefits when physical health care was incorporated in to AOD treatment. An exception to this was some negative experiences with health-care providers that were not identified by staff.

DISCUSSION AND CONCLUSIONS

Findings highlight the importance of developing resources to enhance the health literacy and capacity of non-government AOD services to address the physical health of clients. Given some clients reported negative experiences with health-care providers that were not identified by staff, services should seek regular feedback from clients regarding their experiences with external providers. The effectiveness of existing and new physical health initiatives within non-government organisation AOD services needs more formal evaluation.

Effect of community mental health care programs in Australia: a systematic review

Although numerous studies have examined the effects of community-based mental health care programs in Australia, no synthesis of this literature exists. This systematic review of peer-reviewed and grey literature described the types of community-based mental health care programs delivered and evaluated in Australia in the past 20 years, and evaluated their impact in improving outcomes for those with a serious mental illness (SMI). Articles were included if they evaluated the extent to which the programs delivered in Australia improved individual outcomes, including hospitalisations, psychiatric symptoms, substance misuse or psychosocial outcomes, for individuals with an SMI. Forty studies were included. Community-based mental health care programs were categorised into three types: case management (n=23), therapeutic (n=11) and lifestyle (n=6). Therapeutic programs were most effective in reducing psychiatric symptoms. Case management approaches yielded significant improvements in psychosocial outcomes. Lifestyle programs were inconclusive in improving individual outcomes. This review provides support for the implementation of community-based mental health care programs that are informed by both therapeutic and case management principles. A multidisciplinary team that can facilitate the provision of therapeutic and psychosocial support may be most beneficial for those with an SMI within the Australian community.