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Building Healthy Communities through Multidisciplinary Community-Based Lifestyle Interventions

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The poor physical health of people with mental illness is recognised internationally as a human rights issue; national mental health plans and consensus statements promote early intervention. Lifestyle factors such as physical inactivity and poor diet contribute significantly to increased risk of preventable physical conditions in this group. Lifestyle interventions can help people make health-promoting choices; however, economic and logistic barriers hinder effective implementation of lifestyle interventions within routine care for people with mental illness. Innovative approaches to collaborative care and resource sharing across mental health sectors may increase feasibility of embedding implementation into practice. The aim of this article is to inform the development of sustainable service models for the provision of lifestyle interventions in routine mental health care. To achieve this, we describe learnings from successive implementation projects, and present preliminary data supporting feasibility.
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BUILDING HEALTHY COMMUNITIES THROUGH MULTIDISCIPLINARY COMMUNITY-BASED
LIFESTYLE INTERVENTIONS
Justin Chapman1,2,3 *
Sarah Childs4
Gregory Pratt2
Stephen Tillston1
Geoffrey Lau3
Joe Petrucci5
Sue Patterson6
1 PCYC Queensland, Brisbane, Australia
2 QIMR Berghofer Medical Research Institute, Brisbane, Australia
3 Metro South Addictions and Mental Health Service, Brisbane, Australia
4 Richmond Fellowship Queensland, Brisbane, Australia
5 Neami National, Cairns, Australia
6 Metro North Mental Health Service, Brisbane, Australia
*Correspondence to justinjchapman@gmail.com
ABSTRACT
The poor physical health of people with mental illness is recognised internationally as a human rights
issue; national mental health plans and consensus statements promote early intervention. Lifestyle
factors such as physical inactivity and poor diet contribute significantly to increased risk of preventable
physical conditions in this group. Lifestyle interventions can help people make health-promoting
choices; however, economic and logistic barriers hinder effective implementation of lifestyle
interventions within routine care for people with mental illness. Innovative approaches to collaborative
care and resource sharing across mental health sectors may increase feasibility of embedding
implementation into practice. The aim of this article is to inform the development of sustainable service
models for the provision of lifestyle interventions in routine mental health care. To achieve this, we
describe learnings from successive implementation projects, and present preliminary data supporting
feasibility.
INTRODUCTION
People with mental illness have a life expectancy of 10-20 years shorter than the general population1.
Excess mortality is related primarily to preventable physical conditions such as cardiovascular
disease1. People with severe mental illnesses such as schizophrenia are up to four times more likely
to have multiple physical co-morbidities2, increasing complexity of treatment, health service
expenditure, and hindering recovery from mental health conditions3,4. Aiming to redress inequity in
care and outcomes, Australia’s Fifth National Mental Health and Suicide Prevention Plan incorporates
the physical health of people with mental illness as a Priority Area for service development5, and the
National Mental Health Commission’s Consensus Statement Equally Well emphasises taking an early
intervention and prevention approach to addressing health determinants6.
2
Lifestyle behaviours, such as exercise and diet, can be modified to reduce risk and promote
management of physical and mental health conditions7. Being physically active can improve quality
of life and wellbeing8, prevent or delay the onset of some mental illnesses in people with early signs
of mental health issues9, and reduce symptoms of depression, anxiety and psychotic disorders10-13. A
healthy diet can also reduce depression and anxiety12,13, and is also related to symptoms of
psychosis14. Exercise physiologists and dietitians have expertise in personalised prescription and
behaviour change strategies that can be applied to improve effectiveness of exercise and nutrition
interventions15,16. Thus increasingly, mental health services are encouraged to provide or facilitate
access to lifestyle interventions and involve exercise physiologists and dietitians in the
multidisciplinary mental health team16,17.
However, various barriers operating at the individual, organisational, and systems level hinder the
implementation lifestyle interventions for people with mental illness. People with mental illnesses face
many barriers to adopting and maintaining a healthy lifestyle, which can reduce intervention
effectiveness unless programs are tailored to address these barriers18,19. Organisationally, finite
resources and competing priorities constrain investment in specialist non-mental health clinicians
such as exercise physiologists and dietitians. While mental health clinicians can help consumers
improve health-related behaviours using behaviour change approaches, they often lack confidence
and organisational support to do so20,21. Many mental health services do not have exercise facilities
onsite, and although clinicians report a desire to refer to existing community-based programs, they
also report low knowledge of available programs and low confidence that programs adequately
address the physical health of consumers20. At the systems level, fragmentation of services across
primary, secondary and tertiary care weakens referral pathways to interventions tailored to people
with mental illness and reduces accessibility4.
Innovative approaches are needed to improve access to evidence-informed lifestyle interventions for
people with mental health issues (including people at risk, and with a diagnosed mental illness).
Collaborative partnerships across public mental health, non-government support organisations, and
community sports and recreation organisations may improve referral pathways and accessibility. The
aim of this article is to inform the development of sustainable service models for the provision of
lifestyle interventions in routine mental health care. To achieve this, we describe the iterative
development of a local community lifestyle program for people with mental illness into a state-wide
service through a series of research and implementation projects. Preliminary data supporting
feasibility are also presented.
METHODS
Descriptive overview
Healthy Bodies, Healthy Minds (HBHM) is a PCYC Queensland exercise and nutrition program for
people with mental illness. Developed and implemented in 2015-2017, it has evolved into state-wide
program operating from Far North to South East Queensland. Development has been supported by
a series of research and implementation projects (sites of operation shown in Figure 1). To describe
this process, five ‘phases’ of evolution are considered:
(1) Collaboration for development and implementation of program.
(2) Partnerships formalised for co-delivery under federal disability funding.
(3) Program informs design of a randomised controlled trial (RCT).
(4) RCT informs program expansion.
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(5) Partnerships formalised for co-delivery under Primary Heath Network funding.
Based on learnings from these phases, a concept model to inform future implementation or service-
based quality improvement initiatives is presented. Observations about successful elements inherent
in this program evolution are discussed.
Program content
HBHM is an 8-week program with 2-hr weekly group sessions involving a 1-hr nutritional session
followed by a 1-hr exercise session. The nutrition content supports individual goal setting and finding
a healthy balance, covering topics of healthy recipes and takeaway options, Mediterranean diet, the
gut-brain connection and relationship with stress, mood, sleep, mindful eating and healthy habit
formation. The exercise component is designed to progressively improve exercise-related knowledge
and confidence, so participants develop personalised programs based on abilities and preferences
by the end of the program. Participants receive a gym membership at no cost to support continued
engagement.
Participants
Eligibility criteria have been dependent on funding scope; however, all HBHM programs required
participants to be (i) over 18 years of age, and (ii) receiving treatment for a mental health condition
from a public mental health service or a non-government organisation. Programs in Far North
Queensland additionally accepted referrals from primary care or private clinics; participants of NDIS
funded programs needed specific NDIS funding arrangements. Exclusion criteria for all HBHM
programs were (i) receiving treatment for an eating disorder for which symptoms may be exacerbated
by exercise; and (ii) not receiving medical clearance for presenting medical conditions. HBHM
participants consented to use of routinely collected evaluation data by a third-party for research
purposes. Ethical approval for use of this data was obtained from the QIMR Berghofer Medical
Research Institute Human Research Ethics Committee (P2398).
Analysis
4
Procedural and evaluation data from HBHM programs implemented from 2015 to 2019 were
combined. Of the variety of outcomes used, Kessler-6 scale of psychological distress (K6) and
physical health measures (weight, waist, blood pressure, walk test) were included in all programs.
Baseline and post-intervention data for these outcomes were compared using paired t-tests; other
outcomes are intended for future publications.
RESULTS
Details of program development, funding, collaborations and partnerships, and evaluation measures
are summarised in Table 1 (Appendix). For consistency of terminology, ‘collaboration’ is used to
describe collaborative efforts between organisations named on funding applications or project
proposals, and ‘formalised partnership’ is used to describe collaboration formalised under
organisational agreement.
Descriptive overview
(1) HBHM was initially developed and piloted in 2015-2017 with a consortium of non-government
organisations (NGOs), Metro North Mental Health Service (MNMHS), and PCYC Queensland, a
not-for-profit community sports and recreation organisation. The program was well received by
mental health staff, and demand for participation exceeded capacity. The program was evaluated,
with a comprehensive report provided to the funding agency and collaborators increasing
confidence in the program and implementation team. The evaluation supported a successful
application to deliver HBHM in Far North Queensland in 2017-2018. Collaborations were formed
with QIMR Berghofer Medical Research Institute, a statutory research institute, and the Cairns
Mental Health, Alcohol, Tobacco and Other Drugs Service (Cairns MH&ATODS) for the proposal.
(2) Reform of mental health care/service structure and funding in the non-government sector resulted
in the National Disability Insurance Scheme (NDIS) transitioning into operation 2017-2019.
Continued collaboration with NGOs supported adaptation of the program for administration under
NDIS, including the involvement of exercise physiologists and dietitians funded under the
scheme. Program adaptation included manualising content and automating intake and
assessment procedures to improve scalability. Richmond Fellowship Queensland (RFQ), a
community organisation which supports people with mental health challenges and social
disadvantage, formalised partnership with PCYC Queensland for co-delivery of HBHM.
(3) Program data indicated that participant attendance to the gym was low after conclusion of the
supervised group sessions, despite receiving a free gym membership. To evaluate if an
intervention to enhance motivation to exercise improved physical activity outside supervised
sessions, a randomised controlled trial was developed and received hospital-based research
funding22. Pilot data from previous HBHM rounds and pre-exiting collaborations with research
personnel at QIMR Berghofer, MNMHS and Metro South Addictions and Mental Health Service
(MSAMHS) were essential in this development.
(4) Preliminary data from the RCT combined with evidence of existing collaborations with research
partners, public mental health services and NGOs supported further development. Primary Health
Network funding supported translation of the RCT into practice in Far North Queensland, with
both the HBHM exercise program and motivational intervention from the RCT being implemented
without study-related constraints (e.g. random allocation, strict referral pathways). Referral
pathways were expanded to encompass primary care and private clinic settings. Demand for the
program exceeded capacity, and comprehensive evaluation and reporting increased confidence
in the project team.
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(5) Continued Primary Health Network investment in Far North Queensland led to a to formalised
partnerships with public health services (both mental health and general health) for co-delivery
of a community-based Allied Health lifestyle service. An exercise physiologist delivers a group-
based exercise program at PCYC Queensland, and Allied Health staff from public services deliver
other lifestyle interventions as part of the program (e.g. stress management, smoking cessation
etc). Similarly, the exercise physiologist provides an in-reach service, delivering exercise
programs at the inpatient ward and rehabilitation unit.
The incremental successes over these research and implementation projects, has enabled the
program to evolve into a lifestyle intervention model which can be used to inform the development of
future service models. This model involves increasing service integration to improve program
sustainability by formalising organisational relationships for co-delivery and co-location. Co-delivery
increases staff knowledge and confidence in programs, strengthens referral pathways, and embeds
implementation into routine practice through mutual investment from partner organisations. Co-
location at community and health service sites, and flexibility to be administered under different
funding schemes increases accessibility for participants.
Program data
As of 14th of April 2019, a total of 49 HBHM programs
had been implemented since 2015 across eight
Hospital Health Service regions, with 311 participants.
At the time of data collation there were an additional
55 participants being inducted into eight programs
that were not included in analyses. Richmond
Fellowship Queensland co-delivered 25 of these
programs for 133 participants. A participant flow
diagram is provided in Figure 2, and an overview of
participant characteristics is provided in Table 2.
Of the 311 participants enrolled, 285 (92%)
commenced group sessions. Data on completion and
withdrawal rates were available for 183 participants;
these data were not available for 102 participants of
NDIS-funded programs for whom only attendance
data were available. Of these 183 participants, 145
(79%) completed, 100 (69%) of whom provided post-
intervention data.
Attendance data were available for 246 participants
(86% of the 285 participants who began program
sessions); attendances were not captured for 39
participants due to logistical issues. For these 246 participants, median attendance was 5 out of 8
(63%) supervised sessions (25th-75th percentile = 25% to 75%). When only considering the 145
participants who were known to complete the program, 117 participants had attendance data available
(data for 28 participants missing). For these 117 completers, median attendance was 6 out of 8 (75%)
supervised sessions (25th-75th percentile = 50% to 88%).
Completed program
n=145 (79% of 183 participants for
whom this data was available)
Post assessments
n=100 (69% of completers)
Began program sessions
n=285 (92%)
Referred
n=518
Figure 2: Participant flow diagram
‘Inducted’ to program
n=311 (60%)
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Table 2: Health and demographic characteristics of participants at baseline (n=311)
Age in years (mean, SD) 41 (12)
Sex n %
Female 150 48%
Missing 34 11%
Psychological distress A
High distress (score >15) 86 28%
Missing 34 11%
Aboriginal or Torres Strait Islander
Aboriginal 16 5%
Torres Strait Islander 2 1%
Aboriginal and Torres Strait Islander 3 1%
Neither 187 60%
Missing 103 33%
Self-reported diagnoses
Number of diagnoses
One 110 35%
Two or more 167 54%
Missing 34 11%
Single diagnosis reported
Psychotic disorder 68 22%
Bipolar disorder 21 7%
Depression 8 3%
Anxiety disorder 8 3%
Substance use disorder 2 1%
Other 2 1%
Multiple diagnoses reported B
Depression 109 35%
Anxiety disorder 103 33%
Substance use disorder 21 7%
Eating disorder 9 3%
Bipolar disorder 33 11%
Psychotic disorder 56 18%
Borderline Personality Disorder 18 6%
Post-traumatic stress disorder 37 12%
Body Mass Index (kg/m2)
Underweight (<18.5) 3 1%
Normal weight (18.5 – 24.9) 42 14%
Overweight (25 – 29.9) 64 21%
Obese (>30) 143 46%
Missing 59 19%
Smoking status
Never/ex-smoker 128 41%
Daily/occasionally 144 46%
Missing 39 13%
Note: The 55 participants actively involved in program inductions at the time of data
collation were not included in summaries.
A Psychological distress was measured using the Kessler-6 scale; scores over 15 indicate
high distress
B Individual diagnoses reported by those who reported multiple diagnoses, hence the
proportions sum to greater than 100%.
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Baseline and post-intervention data are presented in Table 3. For the 100 participants with post-
intervention data, significant improvements were found for psychological distress, t(96)=5.08,
p<0.005, and physical capacity, t(69)=4.58, p<0.005. Indicators of metabolic health (weight, blood
pressure, waist circumference) remained similar.
Table 3: Outcomes for measures used across all program implementation
phases (n=100)
Baseline Post
Mental health mean (SD) mean (SD)
Psychological distress
a
Total score 12.2 (4.5) 9.8 (5.4) **
Physical health
Systolic blood pressure (mmHg) 119.9 (17.1) 118.8 (13.7)
Diastolic blood pressure (mmHg) 82.0 (11.7) 82 (11.0)
Waist circumference (cm) 101.2 (19.4) 100.9 (18.4)
Weight (kg) 89.8 (24.8) 89.8 (26.7)
Physical capacity
Walk test distance (m) 478 (104) 531 (121) **
Missing 25 (25%) 25 (25%)
n (%) n (%)
Body Mass Index
Underweight (<18.5 kg/m
2
) 1 (1%) 1 (1%)
Normal weight (18.5-24.9 kg/m
2
) 15 (15%) 15 (15%)
Overweight (25-29.9 kg/m
2
) 30 (30%) 30 (30%)
Obese (>30 kg/m
2
) 37 (37%) 37 (37%)
Missing 17 (17%) 17 (17%)
a Psychological distress measured using the Kessler-6 scale.
b Physical capacity estimated using the submaximal six-minute walk test.
** Statistically improved outcomes (p<0.005) assessed using paired t-tests
DISCUSSION
Successful elements involved in program evolution have been (1) evaluation, (2) partnership, and (3)
leadership. Comprehensive qualitative and quantitative evaluation and reporting in all these projects
served to increase confidence of funding bodies, and supported subsequent applications to expand
operation. The development of a randomised controlled trial based on the program strengthened its
evidence-informed, which added further quality to implementation proposals. Partnership for co-
delivery of the program strengthened referral pathways, and increased participant engagement
through multidisciplinary involvement. Leadership is recognised as an important element of success
in implementation initiatives23, and has been a common thread throughout the success of the
program’s evolution. Leadership from collaborators was vital in formalising partnership because it
required championing the proposal to senior management, and an initial commitment of resources to
trial the relationship. Leadership from the lead author (JC), who was integrally involved in all steps of
designing and implementing each of the presented projects, was essential for continuing the
momentum of each project into subsequent projects. JC held affiliations with three different
organisations during this process which proved advantageous for driving collaborations, highlighting
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the potential for jointly appointing staff in collaborative projects to increase service integration and
sustainability.
Over the past four years, the program has made an impact on the health and wellbeing of people with
mental health issues, and has been building influence in the mental health sector. It has been cited
in local research reviews24-26, highlighted as a successful investment in mental health reform
funding27, and received Mental Health Week Achievement Awards28. Procedural data indicating the
feasibility and scalability of the program was presented, which is important for evidencing capacity to
deliver on large-scale proposals. The program is evolving into a model for the effective and
sustainable implementation of preventative lifestyle interventions for people with mental health issues.
This model will continue to develop through successive partnerships and research and
implementation projects, with the vision of becoming a state-wide platform for interventions to improve
health and wellbeing of people with, or at risk of developing, chronic conditions. Such a service would
play an important role in translating research evidence into practice, as well as being a platform to
launch large multi-site clinical trials into the impact of different exercise or diet regimes on outcomes,
such as cognition, symptomatology, hereditary markers etc. Important next steps will be to formalise
partnerships with General Practice, trial a ‘Wellbeing Hub’ service delivery approach, combine with
workforce development models in public services to improve continuity, and evaluate the impact on
communities.
CONCLUSION
Leadership, partnership and evaluation were important elements in the success of implementation
projects that have led to a scalable model for the provision of lifestyle interventions for people with
mental illness involving co-delivery and co-location as central embedding mechanisms to improve
sustainability.
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in mental health and addiction services. Brisbane, Australia: Metro South Hospital Health
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Table 1: Overview of development phases
(1) 2015 - 2018: Healthy Bodies, Healthy Minds (HBHM) program developed; 8-week program with 2-hr weekly sessions involving exercise, nutrition and social
engagement. Individualised exercise programs developed with participants, then completed weekly with group supervision. Delivered by personal trainers and chefs.
Funding: Brisbane North Partners in Recovery (2015-2017); Queensland Mental Health Commission (2017-2018)
Collaborations: PCYC Queensland, Metro North Mental Health, Communify QLD, Open Minds, Headspace, Neami National, Richmond Fellowship QLD, and Aftercare.
QIMR Berghofer Medical Research Institute became formal collaborator for 2017-2018 programs.
Implementation sites: Redcliffe, Pine Rivers, Zillmere, Milton, Fortitude Valley, Logan, Cairns, Edmonton, Yarrabah
Evaluation: Kessler-6 scale of psychological distress (K6), quality of life (AQOL-8D), recovery assessment scale (RAS), depression anxiety and stress (DASS21), Patient
Health Questionnaire (PHQ-9), DSM-V Cross-cutting measure, physical health measures (weight, waist, blood pressure, walk test) including blood indicators (blood sugar,
cholesterol, triglycerides), attitudes toward substance use, and qualitative interviews.
(2) 2017 - Current: HBHM delivered by exercise physiologists and dietitians with multidisciplinary care coordination from staff at partnering organisations. Co-delivered with
non-government mental health organisations under contract arrangement.
Funding: National Disability Insurance Scheme (NDIS)
Collaborations: PCYC Queensland, Richmond Fellowship Queensland (RFQ), Neami National and Me-Well, Mind Australia
Sites: Toowoomba, Ipswich, Ashmore, Sunshine Coast, Logan, Capalaba, Zillmere, Pine Rivers, Bundaberg, Hervey Bay, Cairns, Edmonton, Mareeba
Evaluation: Physical activity motivation (BREQ-3) attitudes toward eating (IES2), and physical health (weight, waist, blood pressure, walk test).
(3) 2017 - Current: Randomised controlled trial of exercise program compared with motivational intervention.
Funding: RBWH Foundation Research Scheme and Metro South Research Scheme.
Collaborations: PCYC Queensland, Metro North Mental Health Service, Metro South Addictions and Mental Health Service, QIMR Berghofer.
Sites: Milton, Fortitude Valley, Logan, Beenleigh, Cairns, Edmonton, Mareeba
Evaluation: Objectively measured physical activity (using accelerometers worn for eight weeks), Kessler-6 scale of psychological distress (K6), physical activity motivation
(BREQ-3), sleep quality (PSQI), self-reported physical activity (SIMPAQ), physical health (weight, waist, blood pressure, walk test), and qualitative interviews.
(4) 2017 - 2019: Implementation of study interventions in Far North Queensland.
Funding: North Queensland Primary Health Network
Collaborations: PCYC Queensland, Cairns Mental Health & ATODS, QIMR Berghofer.
Sites: Milton, Fortitude Valley, Logan, Beenleigh, Cairns, Edmonton, Mareeba
Evaluation: Objectively measured physical activity (using accelerometers worn for eight weeks), Kessler-6 scale of psychological distress (K6), physical activity motivation
(BREQ-3), sleep quality (PSQI), self-reported physical activity (SIMPAQ), physical health (weight, waist, blood pressure, walk test), and qualitative interviews.
(5) 2018 - Current: Deed of Collaboration established with Cairns Hospital and Health Service (CHHHS) for co-delivery of community-based Allied Health programs.
Funding: North Queensland Primary Health Network
Collaborations: Cairns MH&ATODS and CHHHS
Sites: Cairns, Edmonton, Mareeba
Evaluation: Depression, anxiety, stress (DASS21), Kessler-6 scale of psychological distress (K6), physical activity motivation (BREQ-3), physical health (weight, waist, blood
pressure, walk test)
11
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Introduction Physical activity (PA) has diverse benefits for physical and mental health and can reduce symptoms of mental illness. Adults with mental illness face practical, psychosocial and socioeconomic barriers to adopting and maintaining PA, and it is unclear how to effectively promote PA in this group. Supervised exercise interventions provide high support but may not promote autonomous motivation, which is important for PA maintenance. The aim of this study is to compare the effectiveness of two interventions to promote PA in adults with mental illness. Methods and analysis This is a randomised controlled trial of two interventions to promote PA: (1) supervised exercise and gym membership and (2) motivational discussions and self-monitoring of PA using fitness trackers. The intervention duration is 16 weeks, including 8 weeks of weekly supervised group sessions, and 8 weeks of access to the gym or fitness tracker unsupervised. Participants are community-dwelling adults recruited from outpatient clinics of public mental health services. The primary outcome is PA adoption assessed using GENEActiv accelerometers worn continuously over 8 weeks. Secondary outcomes measured at baseline, postintervention (8 weeks) and follow-up (16 weeks), include exercise motivation, psychological distress and self-reported PA assessed using self-administered questionnaires and indicators of physical health measured by a researcher blinded to allocation (blood pressure, weight, waist circumference, 6 min walk test). Participant experiences will be assessed using qualitative focus groups with analysis informed by a theoretical model of behaviour (COM-B). Ethics and dissemination Ethics approval has been obtained from the Royal Brisbane and Women’s Hospital (HREC/17/QRBW/302). We plan to submit a manuscript on protocol development from pilot work, and a manuscript of the results to a peer-reviewed journal. Results will be presented at conferences, community and consumer forums and hospital grand rounds. Trial registration number ACTRN12617001017314; Pre-results.
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