Qualitative investigation of perceived barriers to and enablers of sport participation for young people with first episode psychosis

"If you're struggling, you don't really care" - what affects the physical health of young people on child and adolescent mental health inpatient units? A qualitative study with service users and staff

BACKGROUND

Physical health inequalities of people with serious mental illness (SMI) have been labelled an international scandal; due to the 15-20-year reduction in life expectancy associated with poor physical health. This occurs at an early stage and evidence shows young people with and at risk for SMI are a particularly vulnerable group requiring intervention and support. However, most work has been conducted with adults and little is known about what affects physical health for young people, specifically those receiving inpatient care.

METHODS

We conducted semi-structured qualitative interviews with 7 service users and 6 staff members (85% female, age 14-42) on a generic mental health inpatient unit for children and adolescents. Interviews aimed to identify how young people viewed theirphysical health and factors affecting physical health and lifestyle and identify any support needed to improve physical health. Thematic analysis was conducted. .

RESULTS

Thematic analysis revealed the main factors affecting physical health and lifestyle for young people. Three main themes were individual factors (subthemes were mental health symptoms, knowledge, attitudes and beliefs), environmental factors (subthemes were opportunities in a restricted environment and food provision), and the influence of others (subthemes were peers, staff, family members). These factors often overlapped and could promote a healthy lifestyle or combine to increase the risk of poor physical health. Young people discussed their preferences for physical health initiatives and what would help them to live a healthier lifestyle.

CONCLUSIONS

Promoting physical health on inpatient units for young people is an important, yet neglected area of mental health research. We have identified a range of complex factors which have an impact on their physical health, and there is a pervasive need to address the barriers that young people experience to living a healthy lifestyle. There is an increasingly strong evidence base suggesting the benefits of physical health interventions to improve outcomes, and future work should identify ways to implement such interventions considering the barriers discussed in this article. Further collaborative research is needed with young people, clinical teams, caregivers, and commissioners to ensure improvements are made to clinical care provision and optimisation of the inpatient environment.

Designing and implementing a physical exercise intervention for people with first episode psychosis using experience-based co-design: A pilot study from Chennai, India

BACKGROUND

Physical exercise can improve outcomes for people with first-episode psychosis (FEP). Co-designing physical exercise interventions with end users has the potential to enhance their acceptability, feasibility, and long-term viability. This study's objective was to use experience-based co-design (EBCD) methodology to develop a physical exercise intervention for FEP, and pilot test it.

METHODS

The study was conducted at the Schizophrenia Research Foundation's FEP program in Chennai, India. Participants(N=36) were individuals with FEP and their caregivers, mental health professionals (MHPs, and physical training experts. EBCD methodology included one-to-one interviews, focus group discussions, joint conferences, and co-design workshops. Two instructional videos were developed. Twelve FEP patients engaged in physical exercise with help of the videos over three months. They were followed up through weekly phone calls and in-person interviews to capture data on regularity, frequency, location of exercise, and comfort levels.

RESULTS

Several touch points emerged from the interviews, focus groups, and joint meetings including lack of motivation, knowledge about physical exercise; differing perspectives about physical exercise; limited resource, and time constraints. Two instructional videos demonstrating activities for participants incorporated strategies that addressed these touch points. Pilot data indicated that participants engaged with the physical exercise intervention over 3 months.

CONCLUSION

This was the first study to use co-design methodology to design a physical exercise intervention for first-episode psychosis. The intervention may have therefore been responsive to stakeholder needs and preferences. Results of this study highlight the potential of co-design in designing and adapting interventions. There is need for rigorous testing with larger samples.

Perspectives of mental health clinicians on physical health of young people with early psychosis

The aim of this study is to explore the views and understanding of youth mental health clinicians with regard to the physical health of young people with early psychosis and their perspectives on lifestyle interventions improving the health and well-being of young people with early psychosis. Physical health disparities leading to premature mortality among people with mental illness are well evident in the literature. Mental health and physical health are directly correlated. The risk of poor physical health often begins before the onset of mental ill health. Young people with early psychosis are highly susceptible to poor physical health. A co-designed integrated approach focusing on early prevention and intervention in overall well-being and health is imminent for this targeted population to prevent poor physical health trajectory across the lifespan. Ten clinicians were recruited and participated in this study through semi-structured interviews. Five themes were identified: (i) Impact of early psychosis, (ii) Focus of care, (iii) Conversations around physical health, (iv) Co-location of specialist roles and (v) Health literacy. The findings of this study confirm the dimensional impact of early psychosis on the well-being and health of young people through the vicious cycle of early psychosis. Promotion of health literacy along with social connectedness and elements of self-determination, as well as having a prime focus on the individuals' experience in the journey of health promotion through participation in lifestyle interventions, has been identified as critically prominent.

A qualitative evaluation of an exercise practitioner in an outpatient child and adolescent mental health service

BACKGROUND

Physical activity interventions can confer a range of physical and mental health benefits among young people with mental disorders. In some contexts, such as Ireland, integrated physical activity is not easily available within child and adolescent mental health services. Therefore, an interagency pilot intervention was established in a child and adolescent mental health service in Ireland with the integration of a novel exercise practitioner into the multidisciplinary mental health team.

OBJECTIVE

A qualitative evaluation was conducted to understand the impact of the pilot intervention and to understand issues of implementation that arose throughout.

METHODS

In-depth qualitative interviews with service users' parents/guardians (N = 3) and a single focus group with existing service providers (N = 3), framed by the RE-AIM framework were conducted to evaluate the pilot intervention. Data were analysed using thematic analysis to explore themes.

RESULTS

Three overarching themes were identified. These were as follows: (i) Making changes toward healthier physical activity behaviours; (ii) An intervention of therapeutic holism; and (iii) The integrated service delivery.

CONCLUSIONS

This research provides insight on the value of a novel integrated exercise practitioner in outpatient young persons' mental health services in Ireland, indicating an enhanced and complimentary therapeutic service. These findings will be helpful for integrating Exercise Practitioners in this setting going forward.

A scoping review of life skills development and transfer in emerging adults

Emerging adulthood is a unique and sensitive life period during which most psychiatric conditions emerge. Development of life skills and transfer of these skills between contexts may be considered essential for transitioning from emerging adulthood to young adulthood. In the present scoping review of 83 articles published between 2010 and 2022, we address the state of research on life skills development and transfer in emerging adults aged 18-30. Specifically, we were interested in how life skills are defined, which specific life skills are proposed and how life skills transfer is conceptualized for this age group, with an emphasis on cognitive, personal, and interpersonal components. The results show that only a small minority of the reviewed studies defined the term life skills and an even smaller number mentioned the concept of life skills transfer, with only one study actually mentioning transfer components. Life skills research for emerging adults strongly focuses on vulnerable populations (e.g., developmental and contextual vulnerabilities, and sexually transmittable infections treatment and prevention) with the five most frequently mentioned life skills being budgeting/ finances, communication, problem-solving, decision-making, and emotional regulation. We discuss these results in light of future research directions and the lessons learned for life skills development and transfer research in emerging adults.

Systematic review registration

All analyzed articles are available at: https://osf.io/gmk8w/.

Benefits, Facilitators and Barrier Reductions in Physical Activity Programmes for People with Severe Mental Disorder: A Systematic Review

The current high prevalence of people with Severe Mental Disorder and the high impact the latter has on their quality of life is one of the main problems in terms of health, as it affects both physical and mental health. One of the lines of action to intervene in these factors is the practice of physical activity, as this usually has a low level of participation due to different barriers. However, there are several facilitators that improve adherence to these practices. The main objectives of this work were (1) to conduct a systematic review of the scientific literature on the possible benefits obtained by people with SMD from their participation in physical activity programmes; (2) to identify the characteristics of physical activity programmes and determine the barriers to their implementation that have been considered and (3) the facilitators incorporated. To meet these objectives, the SCOPUS, Web of Science, PubMed, Dialnet and Elsevier online databases were consulted and, following the PRISMA statement, 17 articles were finally selected. Their analysis has revealed various physical, psychological and social benefits, as well as the barriers that appear in the intervention programmes, mostly related to personal factors and the programme itself, and those factors that facilitate their adherence or development, the most common being the carrying out of the activities outdoors, the inclusion of social components and the possibility of adapting the activities. In this way, the results obtained have made it possible to highlight the characteristics that should be taken into account when planning this type of intervention.

Identifying indicators of community participation-promoting efforts within coordinated specialty care: A modified e-Delphi study of stakeholder perspectives

AIM

Community participation in occupational, social, recreational, and other domains is critically important during young adulthood. Coordinated Specialty Care (CSC) programs provide developmentally tailored care to young adults experiencing early psychosis within the United States, but little is known about the breadth of efforts to promote community participation. This study aimed to develop and evaluate indicators of these efforts based on the perspectives of a national multi-stakeholder group.

METHODS

Seventeen stakeholders (i.e., young adults with early psychosis, family members, experts by profession) participated in a modified e-Delphi study, conducted in two rounds. The purpose of round one was to generate a comprehensive list of community participation-promoting indicators. During round two, stakeholders rated the importance and feasibility of the implementation of each indicator. Descriptive statistics and percentage of agreement regarding round two ratings were assessed.

RESULTS

During round one, 186 indicators of activities and/or practices designed to promote community participation were identified; this list was reduced to 44 by eliminating redundancies or indicators not related to community participation. In round two, we found broad agreement regarding the importance, but significant variation in perceived feasibility of indicators. The highest-rated indicators in both categories pertained to staff knowledge (regarding barriers and supports to participation and the importance of participation to health) and strategies for addressing participation barriers.

CONCLUSIONS

This study is expected to facilitate the identification and development of promising CSC activities and practices designed to promote community participation among young adults while potentially also enhancing engagement in services and improving clinical outcomes.

Enhancing functional recovery for young people recovering from first episode psychosis via sport-based life skills training: outcomes of a feasibility and pilot study

Early intervention within First Episode Psychosis (FEP) recovery efforts support functional recovery in several ways, including increasing levels of (1) physical activity (2) life skills, and (3) social connectivity. Sport has been proposed as an ideal platform to target these three goals simultaneously. The primary aims were to assess the feasibility of utilising sport-based life skills within FEP recovery efforts and test intervention components. The secondary aim was to evaluate the potential recovery benefits. Seven young people (aged 15-25 years) with FEP participated in a six-week sport programme alongside their support workers (community and peer workers) from the service, including peer workers with a lived experience of psychosis. The programme consisted of various sporting activities, which were designed to promote physical activity, maximise social connectivity, and teach life-skills (e.g. motivation, emotional regulation, and goal-setting) that are relevant and transferrable to other contexts (e.g. school, employment, independent living). The support participants engaged with the programme at the same level as the young people, with the role of providing support and normalising/modelling engagement. The young and support participants provided feedback during and after the programme via questionnaires and interviews. Young participants self-reported physical activity levels, psychological needs, recovery dimensions, and life skills pre- and post- intervention using established psychometric tools. We used thematic analysis to analyse the qualitative data and compared this information with other data collected (e.g. attendance, feedback, quantitative measurements). The study culminated with a process evaluation. The results indicated that, despite challenges with engagement for young people with FEP, sport-based life skills programming may be a feasible and useful recovery outlet. In addition, the results highlighted specific intervention components that were useful to promote engagement and recovery benefits. This study serves as a critical foundation for future sport-based work within FEP recovery.

Implementation of occupational therapy within early intervention in psychosis services: Results from a national survey

AIM

Occupational therapy plays an important role in fostering community participation in areas such as education, employment, leisure, and social relationships, yet its added value within early intervention in psychosis services, especially in the United States, remains poorly understood. The purpose of this research was to conduct a national survey of early intervention in psychosis programs to: (1) understand the role and unique contributions of occupational therapists to early intervention teams, and (2) identify barriers and supports to the implementation of occupational therapy services within these programs.

METHODS

Fifty-one senior leaders from U.S.-based early intervention in psychosis programs participated in the national survey. The survey consisted of a series of closed and open-ended questions related to program staffing, the presence of specific services that fall within the occupational therapy scope of practice, and implementation barriers and supports.

RESULTS

Despite there being strong interest in employing occupational therapists, a small proportion of programs (31%) reported having them on staff. Occupational therapists supported clients across multiple life areas and were significantly more likely than other team members to promote daily living activities (e.g., cooking) and to address sensory processing needs and challenges. Implementation was influenced by environmental/organizational and staff factors; the primary barrier was funding.

CONCLUSIONS

Findings support the role occupational therapists may play in facilitating the community participation of clients of early intervention services, but significant barriers to implementation of occupational therapy services remain. Additional research is needed to further identify the impact of occupational therapy services within the early intervention model.

Improving the physical health of young people with early psychosis with lifestyle interventions: Scoping review

People with mental illness experience a shorter life expectancy compared to the general population. Poor physical health trajectory emerges following the onset of psychosis and is further compounded by the initiation of antipsychotic treatment. Young people are particularly at risk as the onset of mental illness mostly occurs between the age of 12 and 25 years. This represents a crucial period for early intervention to prevent a physical ill health trajectory. Furthermore, those who are at ultra-high risk for psychosis should also be targeted for early intervention. Lifestyle interventions have been identified as the first-line physical health promotion practice for improving the physical health of people with severe mental illness. The aim of this study was to conduct a scoping review following the JBI methodological guidance on scoping reviews to explore the current literature on lifestyle intervention trialled for early psychosis, including first-episode psychosis and those who are at ultra-high risk for psychosis. This review also explores the extent of literature examining physical health literacy in this specific population. The literature search was conducted on Medline, Embase, PsycINFO and Scopus. Twenty-two studies were included for the purpose of this scoping review, 21 of which examined the effects of lifestyle interventions and one of which reported on physical health literacy. This scoping review indicates the need for co-designed lifestyle interventions with the involvement of service users, families and carers and a focus on promoting physical health literacy, social support, and an incorporation of a health behaviour change model focus on promoting autonomous motivation. The findings of this study can inform future development of a novel co-designed lifestyle intervention for the targeted population.

Barriers and facilitators to physical education, sport, and physical activity program participation among children and adolescents with psychiatric disorders: a systematic review

Children and adolescents with heterogeneous psychiatric disorders, of whom over 50% have a second psychiatric comorbidity, have low rates of physical activity and experience unique challenges to engaging in community-based exercise programming, school-based physical education programming, and targeted physical activity interventions. This contributes to elevated rates of gross and fine motor delays, lower mood and self-regulation, and increased risk of chronic diseases such as obesity and type 2 diabetes. Perform a systematic scoping review of the literature to assess known barriers to and facilitators of engaging in physical activity programming among children and adolescents with heterogeneous and/or comorbid psychiatric disorders, in order to improve engagement among this population in real world intervention settings. Systematic Boolean diagnostic and physical activity search terms were entered into PubMed, MEDLINE, PsycINFO and Web of Science for English-language studies published between 2005 and 2020, examining barriers and facilitators for common psychiatric diagnoses and general psychiatric population's engagement in physical activity, physical education, sports, or exercise interventions. Two reviewers independently reviewed titles, abstracts and full articles to determine inclusion. A total of 5,198 articles were returned; 39 relating to children and adolescents were qualified for full-text review. After review, 24 studies were included addressing barriers and facilitators across multiple diagnoses; 7 studies were quantitative, 10 were qualitative, and 7 were mixed methods. Major barriers included low motivation, low self-efficacy, depleted parental reserve capacity, social isolation, lack of staff training, and safety concerns. Major facilitators included peer support/engagement, exergames, supportive parental behaviors, and inclusive/adaptive programming. Numerous barriers and facilitators to physical activity have been identified which should inform community, school, clinical, and research intervention program design. Further research is needed to develop effective strategies that address the challenges to inclusion that children and adolescents with heterogeneous and/or comorbid psychiatric disorders face.

Early Intervention in Psychosis: Effectiveness and Implementation of a Combined Exercise and Health Behavior Intervention Within Routine Care

Aim

Young people with psychosis have higher rates of obesity, premature cardiovascular disease, and death compared to non-psychotic peers in the general population due to changes in metabolic regulation linked to antipsychotic medication and adverse health risk behaviors. The aim of this paper is to outline the development, implementation, and evaluation of a combined 12-week exercise and health behavior intervention delivered as part of an Early Intervention in Psychosis (EIP) routine service, within the UK.

Methods

Participants (n = 27) completed a 12-week combined intervention program, engaging in weekly, 90-min sessions comprising a healthy behavior education session (45 min), followed by a facilitated exercise session (45 min). Anthropometric data from participants (n = 26) were collected at baseline, 12 weeks, and 12 months post-intervention. Health behaviors and clinical measurements were assessed at baseline and 12 months.

Results

Mean baseline data suggests participants were at an increased health risk on entry to the program, with elevated values in mean body mass index (BMI; 70% overweight/obese), waist circumference, resting heart rate, and triglycerides. Fifty percent reported smoking daily, 64% ate < 5 fruits/vegetables per day, and 52% of participants were prescribed highly obesogenic antipsychotic medications (i.e., Olanzapine). At 12 weeks and 12 months, no changes were observed in mean BMI, waist circumference or any other clinical variable (p > 0.05). At 12 months, participants reported a positive impact on health behaviors including improved diet, increased physical activity levels, and cessation of substance use (n = 2), alcohol use (n = 2), and smoking (n = 4). Focus groups captured participant experiences, engagement with and satisfaction with the program, including challenges/barriers to program adherence.

Conclusions

The 12-week exercise and health behaviors program supported participants to attenuate their physical health risk which was sustained at 12-month follow-up. Self-reported positive health behavior changes are likely to have contributed to the prevention of excessive weight gain in this high-risk period. The evaluation was designed to have validity for a "real world EIP setting" and reflect the complexity of delivery to this participant group. Evaluation findings influenced subsequent commissioning of the physical health intervention as an ongoing element of routine EIP care within the participant site.