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To your health: Implementation of a wellness program for treatment staff and persons with mental illness
To Your Health: Implementation of a Wellness Program for Treatment Staff and Persons With Mental Illness Mary Ann Camann Persons with mental illness often have poor access to both health promotion and primary care services. Consequently, they are at greater risk for earlier mortality, and comorbid health problems that ultimately impact their community rehabilitation. The “To Your Health” program is a health promotion program, based on the states of change model that was implemented as part of a clubhouse rehabilitation program. The program used personal wellness profiles, health assessments, and personal goal setting to assess the relative wellness of clients and staff in order to increase their awareness of health- promoting behaviors. Additionally opportunities were provided to engage individuals in making changes through participation in activities that provided opportunities to try out new behaviors and to set goals that integrated changes into their lives. The initial findings are reported along with the rationale for the involvement of clients and staff, and the role of health promotion in community rehabilitation of persons with mental illness. Copyright © 2001 by W.B. Saunders Company
H
EALTHY LIVING behaviors provide the behavioral pathway to optimal health. In the U.S. this important aspect of health care is often overlooked when the identified client is mentally ill. Mental health care providers attend to the signs and symptoms of mental illness, but overall health status is largely ignored. If primary health care is provided, it is often fragmented or sought only in emergent situation. Furthermore, persons with mental illness often have poor awareness of good health practices and are provided with even poorer access to ongoing preventative services. Persons with persistent mental illness also may have lifestyle behaviors that put them at risk of illness or perceptual difficulties that may lead them to overFrom Kennesaw State University, College of Health and Human Services, Kennesaw, GA. Address reprint requests to Mary Ann Camann, RN, PhD, CS, Kennesaw State University, College of Health and Human Services, 1000 Chastain Road, Kennesaw, GA 30144. Copyright 䊚 2001 by W.B. Saunders Company 0883-9417/01/1504-000X$35.00/0 doi:10.1053/apnu.2001.25418
182
estimate their assessment of well-being (Farnam et al., 1999). The lack of primary health care and preventive services is further illustrated by evidence that suggests that people with mental illness die 10 to 15 years earlier than the general population. Of people with mental illness 50% are estimated to have a known comorbid medical disorder, and another 35% are estimated to suffer from an undiagnosed and untreated medical disorder (Felker, Yazel, & Short, 1996, Berren, Hill, Merikle, Gonzales, & Santiago, 1994). In the recent report from the Surgeon General, Satcher (2000) advocates application of a population– based public health model in addressing mental health problems. The report stresses that mental and physical health is inseparable. Leaders of the consumer and family movement also stress the importance of overcoming stigma and prevention of discrimination in policies affecting person with mental illness including those that address primary health care. The consumer movement has encouraged self-help in the recovery process and readi-
Archives of Psychiatric Nursing, Vol. XV, No. 4 (August), 2001: pp 182-187
WELLNESS FOR PERSONS WITH MENTAL ILLNESS
ness for meaningful community activity and work (Satcher, 2000). However, community rehabilitation, and recovery programs that are directed toward assisting clients to eventual work must expect that persons with mental illness also have a level of overall fitness, wellness, and practice healthy living skills to be successful in these programs. Furthermore, when an individual has both mental illness and poor fitness their disability is magnified and they are more prone to physical illness and less able to engage in healthy living behaviors. Mental Health: A Report of the Surgeon General, (Satcher, 2000) also addressed the importance of social support in adoption of a healthy lifestyle by acknowledging that mentally ill persons also need people who care about them to remind them to take care of their health. The purpose of this report is to describe a pilot health promotion project, “To Your Health.” The project was implemented among persons with persistent mental illness and their treatment providers. The “To your Health Project” is a health promotion program that involves baccalaureate nursing students and faculty, mental health service providers, and community-based mentally ill clients. The program was designed to bridge the gap between mental health services and wellness activities by engaging individuals and staff members in a process to increase understanding of their personal wellness profile and increase responsibility for their health by making contracts to increase healthy behaviors and set health-related goal. Key values related to fitness and wellness were addressed in the assessment process. The key values were adapted from the stages of change model developed by Prochaska and Velicer, (1997). The stages of change model “posits that health behavior change involves progress through six stages of change; precontemplation, contemplation, preparation, action, maintenance, and termination.” (Prochaska and Velicer, 1997 p. 38. The application of the model to wellness promotion helps clients and staff focus on the process of becoming well. The transtheorectical model assumes that for change to occur there must be a certain level of readiness and understanding of health principles as they apply to an individual. According to the model, involving individuals in visualizing possible change and preparing for it, are necessary for eventual success. The focus is on the process not just the “action” of change. Engaging individuals
183
in looking at their own level of wellness is one way to start the process of change at the appropriate stage of individual change. In this program, clients could participate in the program at whatever their stage of change and move through the program as opportunities to practice healthy behaviors were offered. METHODS
An urban community/clubhouse-model treatment program elected to participate in the pilot health promotion program. This program was developed as part of a service learning partnership between the rehabilitation agency and a state supported university. Initially, a short information session was held to explain the program to clients and staff and to request participation. Staff participation was solicited also to encourage their acceptance of the principles of the program. The work environment of the staff is the treatment environment of the clients so their participation was seen as being vital to the eventual success of the program. Some clients were initially reluctant to participate in the assessment process. They verbalized fearing invasive procedures or being required to participate. Making the program voluntary was vital to its success. Explaining the program and setting individual appointment offered an opportunity to address wellness and health promotion issues in a nonthreatening way. The wellness assessments were conducted by junior level nursing students with faculty supervision. The students made appointments with clients during convenient breaks in their daily schedule. A basic health history was obtained, including the name of their primary health care provider, information about ongoing health problems, blood pressure, pulse, respiration, height and weight were recorded and vision screening eye examinations were conducted. A wellness assessment was also completed, using the MicroFit Wellness Profile Questionnaire, which is a 30-item questionnaire that addresses wellness and lifestyle factors. The MicroFit Wellness profile is a computer program that analyzes an individual’s lifestyle behaviors that are associated with increased risk of disability and disease. The scientific content and wellness scoring methodology was developed by research scientists from the School of Medicine at Stanford University, Palo Alto, CA. (Microfit, 1998). The wellness profile uses a series of questions to get a
184
MARY ANN CAMAAN
picture of the client’s lifestyle. The program uses these data to calculate a wellness score in the areas of exercise, nutrition, safety, tobacco, and stress. A summary total wellness score is also calculated for each client. It is widely used in occupational health settings and personal fitness settings. Confidential individual wellness profiles are generated that provide a model for targeting behaviors that are health promoting as well as behavior changes that would contribute to improved wellness. Aggregate data were also generated for the total client group and the staff group. Two main areas were included in the report; health habits, including both objective assessment of how much health related activity an individual is actually doing and perceived assessment that reports how much an individual thinks they are doing, and health habits that can be addressed by changes in attitude and behavior. The personal profile provided a graphic report that focused on identification of major areas where behavior changes can be made while pointing out areas where excellent behaviors exist or areas where there is room for improvement. A follow-up session was scheduled to review each individual’s personnel wellness profile and to assist him/her in acknowledging personal responsibility for health, setting obtainable personal behavioral goals, and contracting for future participation in the program. During the 10-week introductory project period health related activities and short educational programs were organized by students and faculty, that focused on wellness issues based on the identified needs of the program participants. A schedule and topical outline was developed and the facilitation of the activity-focused programs was shared among the students and faculty. The activities involved both clients and staff and were designed to be fun and informative, while addressing key issues such as nutrition, exercise, food preparation, health risk factors, and healthy living behaviors coupled with action-oriented activities such as a walking club and healthy food tastings. FINDINGS
Assessment were completed and reviewed for 49 clients and 6 staff members. The Gender and age demographics of the client population are presented in Table 1. There is evidence that starting positive health promotion behaviors earlier in life may prevent or
Table 1. Client Gender and Age Demographics N ⫽ 49
Males ⫽ 27
Females ⫽ 22
Age groups 18-29 30-39 40-49 50-59
33% 33% 30% 4%
14% 45% 23% 18%
delay later life health problems. In this group 63% are age 39 or below, where early intervention is most likely to be effective. Because of the short-term and intermittent nature of this pilot program, clients were asked to identify their primary care provider for ongoing care or referral as needed. Only 45% of the clients reported that they had a personal health care provider or specific clinic group that acted as a primary care provider. Of the clients 55% reported that they used emergency departments for episodic care. This is an important issue as primary preventative care is best delivered in a coordinated manner that addresses and individual’s health status over time. It is also an important factor in assuring the availability and continuity of appropriate screening, risk assessment, and episodic care is delivered along with mental health treatment. Five key health problems were identified in the client group that would be likely to generate a need for ongoing medical care if they are not managed in a consistent manner. Eleven of 49 clients (22%) who completed surveys were found to have health problems that would require ongoing intervention. This data is reported in Table 2. McGinnis and Foege, (1993) identified 9 major external factors that contributed to 50% of deaths in the U.S. These factors were viewed as being modifiable by behavioral factors that could reduce illness and subsequent mortality. In their study, tobacco use accounted for 19% of deaths in the U.S. in 1990 by contributing to death from cancer, cardiovascular disease and lung disease. Diet and sedentary activity patterns account for 14% to 19% Table 2. Key Health Problems (N ⴝ 11) Smoking Significantly over-weight Hypertension (only 29% self-reported) Dentition Diabetes
51% 49% 65% 29% 5%
NOTE. Nine clients had more than one health problem.
WELLNESS FOR PERSONS WITH MENTAL ILLNESS
185
Table 3. Summary of Client Wellness Issue Data N ⫽ 49
Total Wellness
Exercise
Nutrition
Excellent Fair Needs improvement
6% 71% 22%
10% 10% 80%
4% 67% 29%
of deaths, as they are associated with cardiovascular diseases, cancers, and diabetes mellitus. Recently, poor dentition associated with bacteria and subsequent contribution to damage to the heart walls or valves, (Medical Update, 1998). The presence of these health problems in this population is consistent with the findings of McGinnis and Foege, (1993), and would support the notion that prevention activities would be beneficial in decreasing or modifying illness in this group. The related lifestyle factors are addressed by the MicroFit Wellness Profile (1998). When the wellness profiles were analyzed for the total client group, one interesting and programmatically important factor emerged. In the client group, all of the participants perceived themselves as taking care of themselves better than they actually were. Clarifying an individual’s perception and increasing understanding of both positive areas that need to be supported as well as areas that need improvement is important to engage individuals in being involved in a healthy lifestyle and health promotion activities. This is the stage of precontemplation to contemplation in the transtheoretical model where an individual moves toward taking action in the foreseeable future because they begin to perceive that action may be necessary (Prochaska, Velicer, 1997) The individual wellness profile addressed total wellness and six behavioral health issue: exercise, nutrition, safety, stress, body weight, and blood pressure. At the personal wellness profile conference, each client and staff participant was invited to focus on the behavior areas in which they were most interested and that needed improvement. Each client was also asked to set measurable goals
Body Weight
16% 84%
Safety
Tobacco Use
Stress
Blood Pressure
59% 37% 4%
49% 18% 33%
18% 67% 14%
35% 10% 55%
in the selected area(s). The summary client data in each area is presented in Table 3 and staff data in Table 4. Both client and staff personal profile data reports indicated individual variability as would be expected. Viewed as a group, however, it is important to note that most participants had several areas that needed improvement. Of particular note are those areas such as exercise where 80% of the client group and 17% of the staff group needed improvement, body weight where 84% of the client group and 33% of the staff group needed improvement, and blood pressure where 55% of the client group and 17% of the staff group needed improvement. Dietary control and exercise is especially important for the clients as many of the psychotropic drugs have weight gain as a side effect. The personal profile report stresses individual choice as the most important factor in working toward wellness. This is enhanced by an individual’s understanding of the issue and suggestions for activities in areas that need improvement. The suggested activities that are prescribed are specific, but very achievable and measurable. The wellness profile points individuals toward a direction such as aerobic exercise three times per week and flexibility exercises, or choosing low fat foods and reading nutrition labels. After the wellness profile was reviewed, each participant developed a written wellness plan with the help of the student mentor and set up a weekly check–in schedule. Additionally, the students and faculty planned classes and activities that included important activities to assist the participants in achieving their goals. A program of stretching exercises was offered in each work area in the morning and a client
Table 4. Summary of Staff Wellness Issue Data N⫽6
Excellent Fair Needs improvement
Total Wellness
67% 33%
Exercise
Nutrition
67% 17% 17%
50% 50%
Body Weight
67% 33%
Safety
83% 17%
Tobacco Use
Stress
67%
100%
33%
Blood Pressure
50% 33% 17%
186
MARY ANN CAMAAN
leader was mentored to continue the exercise routine on days that the students were not present. A walking club was started, again with staff and client leaders, and mileage was recorded to provide an incentive. Meetings were held with the staff and clients who cooked lunch to provide “lightened” recipes and discuss issues related to improved nutrition. Healthy snack events were held and were successful in providing additional impetus to adopt healthier eating patterns. Classes on hypertension, tobacco cessation hints, and other health-related topics were integrated into everyday activities. The long-term outcomes will be evaluated later this year. However, the short-term outcomes have included client reports of increasing fruits and vegetables in their diet, cutting back on smoking and counting cigarettes smoked to increase awareness of smoking behaviors, reduction in caffeine consumption, decreasing portion size, and avoiding fast food intake. Clients participated in walking group and continued this activity with staff support after the students completed the first phase of this program. One client used the weekly check-in time to document her weekly weight loss and clients sought out their mentors to discuss their healthrelated and lifestyle interests. The “To Your Health” project focused on the process of becoming healthier. As a pilot project it succeeded in creating interest and participation in the project on the part of students, staff, and most importantly clients in a nonthreatening and personally interactive fashion. The next phase of the program will integrate group support principles by forming healthy living groups as an additional support to the personal profiles and goal setting mentorships. DISCUSSION
If persons with mental illness are to live productively in their community, it is vital that they have opportunities to improve their health, prevent further disability, and adopt a healthy lifestyle. Additionally, participation in a wellness program offers an opportunity to practice socially appropriate wellness behaviors in a community context. The program focused on encouraging a proactive process where general information on health is applied to individual goal setting and lifestyle changes. The pilot project, “To Your Health,” offered a personal and organizational pathway to address wellness and health promotion in a vulnerable pop-
ulation. It also provided an environment where wellness is valued as a major factor in quality of life and rehabilitation. Rehabilitation efforts are more likely to be successful if they are viewed in the context of quality of life and health as well as symptom control and social integration. This health-promotion program shows the process of integrating health-promotion activities and personal goal setting into a rehabilitation program. When clients and staff are invited to view health as a process, rather than a specific behavior, it becomes possible for healthy living to be viewed as an evolving state rather than an endpoint and encourages participation of all regardless of the presence of mental illness or client status. Participation in this program offers an experiential vehicle, and self-assessment opportunity for individuals to adopt a proactive, health-promoting lifestyle that is likely to positively affect other areas of rehabilitation. The preliminary findings of this pilot project have been presented to clients, staff, and the agency board of directors to encourage cooperation and collaboration on future program efforts. As this program continues emphasis is being directed toward continued personal goal setting. General program offering will be targeted toward weight management, smoking cessation, and exercise, and delivered in an interactive fashion that acknowledges the specific needs of the target group. A program that offers rewards for results in meeting goals is being developed. Additionally the mentorship process will be expanded to include group support activities that will be self-sustaining and client focused. Effort is also being directed toward development of primary care resources for continuity of health care. Hopefully, the environment of rehabilitation will evolve in a manner that is consistent with the stages of change model and continue to offer a meaningful bridge to improved wellness as well as psychiatric rehabilitation. REFERENCES Berren, M.R., Hill, K.T., Merikel, E. Gonzales, N., & Santiago, J. (1994). Serious mental illness and mortality rates. Hospital and Community Psychiatry 45, 604-605. Farnam, C., Zipple, A., Tyrerell, W., & Chittinanda, P. (1999). Health status and risk factors of people with severe and persistent mental illness. Journal of Psychosocial Nursing 37, 16-21. Felker, B., Yazel, J., & Short, D. (1996). Mortality and medical co morbidity among psychiatric patients: A review. Psychiatric Services 47, 1356-1363.
WELLNESS FOR PERSONS WITH MENTAL ILLNESS
McGinnis, J.M. & Foege, W.H. (1993). Actual causes of death in the United States. Journal of the American Medical Association 270, 2207-2212. MicroFit Wellness Profile (1998). The Wellness Profile. Mountain View, CA, Author, p 1-1.
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Prochaska, J., Velicer, W. (1997). The Transtheoretical Model. American Journal of Health Promotio. 12, 6-7 Satcher, D. (2000). Mental Health: A report of the surgeon general. Washington, D.C., Department of Health and Human Services, U.S. Public Health Service.
H
EALTHY LIVING behaviors provide the behavioral pathway to optimal health. In the U.S. this important aspect of health care is often overlooked when the identified client is mentally ill. Mental health care providers attend to the signs and symptoms of mental illness, but overall health status is largely ignored. If primary health care is provided, it is often fragmented or sought only in emergent situation. Furthermore, persons with mental illness often have poor awareness of good health practices and are provided with even poorer access to ongoing preventative services. Persons with persistent mental illness also may have lifestyle behaviors that put them at risk of illness or perceptual difficulties that may lead them to overFrom Kennesaw State University, College of Health and Human Services, Kennesaw, GA. Address reprint requests to Mary Ann Camann, RN, PhD, CS, Kennesaw State University, College of Health and Human Services, 1000 Chastain Road, Kennesaw, GA 30144. Copyright 䊚 2001 by W.B. Saunders Company 0883-9417/01/1504-000X$35.00/0 doi:10.1053/apnu.2001.25418
182
estimate their assessment of well-being (Farnam et al., 1999). The lack of primary health care and preventive services is further illustrated by evidence that suggests that people with mental illness die 10 to 15 years earlier than the general population. Of people with mental illness 50% are estimated to have a known comorbid medical disorder, and another 35% are estimated to suffer from an undiagnosed and untreated medical disorder (Felker, Yazel, & Short, 1996, Berren, Hill, Merikle, Gonzales, & Santiago, 1994). In the recent report from the Surgeon General, Satcher (2000) advocates application of a population– based public health model in addressing mental health problems. The report stresses that mental and physical health is inseparable. Leaders of the consumer and family movement also stress the importance of overcoming stigma and prevention of discrimination in policies affecting person with mental illness including those that address primary health care. The consumer movement has encouraged self-help in the recovery process and readi-
Archives of Psychiatric Nursing, Vol. XV, No. 4 (August), 2001: pp 182-187
WELLNESS FOR PERSONS WITH MENTAL ILLNESS
ness for meaningful community activity and work (Satcher, 2000). However, community rehabilitation, and recovery programs that are directed toward assisting clients to eventual work must expect that persons with mental illness also have a level of overall fitness, wellness, and practice healthy living skills to be successful in these programs. Furthermore, when an individual has both mental illness and poor fitness their disability is magnified and they are more prone to physical illness and less able to engage in healthy living behaviors. Mental Health: A Report of the Surgeon General, (Satcher, 2000) also addressed the importance of social support in adoption of a healthy lifestyle by acknowledging that mentally ill persons also need people who care about them to remind them to take care of their health. The purpose of this report is to describe a pilot health promotion project, “To Your Health.” The project was implemented among persons with persistent mental illness and their treatment providers. The “To your Health Project” is a health promotion program that involves baccalaureate nursing students and faculty, mental health service providers, and community-based mentally ill clients. The program was designed to bridge the gap between mental health services and wellness activities by engaging individuals and staff members in a process to increase understanding of their personal wellness profile and increase responsibility for their health by making contracts to increase healthy behaviors and set health-related goal. Key values related to fitness and wellness were addressed in the assessment process. The key values were adapted from the stages of change model developed by Prochaska and Velicer, (1997). The stages of change model “posits that health behavior change involves progress through six stages of change; precontemplation, contemplation, preparation, action, maintenance, and termination.” (Prochaska and Velicer, 1997 p. 38. The application of the model to wellness promotion helps clients and staff focus on the process of becoming well. The transtheorectical model assumes that for change to occur there must be a certain level of readiness and understanding of health principles as they apply to an individual. According to the model, involving individuals in visualizing possible change and preparing for it, are necessary for eventual success. The focus is on the process not just the “action” of change. Engaging individuals
183
in looking at their own level of wellness is one way to start the process of change at the appropriate stage of individual change. In this program, clients could participate in the program at whatever their stage of change and move through the program as opportunities to practice healthy behaviors were offered. METHODS
An urban community/clubhouse-model treatment program elected to participate in the pilot health promotion program. This program was developed as part of a service learning partnership between the rehabilitation agency and a state supported university. Initially, a short information session was held to explain the program to clients and staff and to request participation. Staff participation was solicited also to encourage their acceptance of the principles of the program. The work environment of the staff is the treatment environment of the clients so their participation was seen as being vital to the eventual success of the program. Some clients were initially reluctant to participate in the assessment process. They verbalized fearing invasive procedures or being required to participate. Making the program voluntary was vital to its success. Explaining the program and setting individual appointment offered an opportunity to address wellness and health promotion issues in a nonthreatening way. The wellness assessments were conducted by junior level nursing students with faculty supervision. The students made appointments with clients during convenient breaks in their daily schedule. A basic health history was obtained, including the name of their primary health care provider, information about ongoing health problems, blood pressure, pulse, respiration, height and weight were recorded and vision screening eye examinations were conducted. A wellness assessment was also completed, using the MicroFit Wellness Profile Questionnaire, which is a 30-item questionnaire that addresses wellness and lifestyle factors. The MicroFit Wellness profile is a computer program that analyzes an individual’s lifestyle behaviors that are associated with increased risk of disability and disease. The scientific content and wellness scoring methodology was developed by research scientists from the School of Medicine at Stanford University, Palo Alto, CA. (Microfit, 1998). The wellness profile uses a series of questions to get a
184
MARY ANN CAMAAN
picture of the client’s lifestyle. The program uses these data to calculate a wellness score in the areas of exercise, nutrition, safety, tobacco, and stress. A summary total wellness score is also calculated for each client. It is widely used in occupational health settings and personal fitness settings. Confidential individual wellness profiles are generated that provide a model for targeting behaviors that are health promoting as well as behavior changes that would contribute to improved wellness. Aggregate data were also generated for the total client group and the staff group. Two main areas were included in the report; health habits, including both objective assessment of how much health related activity an individual is actually doing and perceived assessment that reports how much an individual thinks they are doing, and health habits that can be addressed by changes in attitude and behavior. The personal profile provided a graphic report that focused on identification of major areas where behavior changes can be made while pointing out areas where excellent behaviors exist or areas where there is room for improvement. A follow-up session was scheduled to review each individual’s personnel wellness profile and to assist him/her in acknowledging personal responsibility for health, setting obtainable personal behavioral goals, and contracting for future participation in the program. During the 10-week introductory project period health related activities and short educational programs were organized by students and faculty, that focused on wellness issues based on the identified needs of the program participants. A schedule and topical outline was developed and the facilitation of the activity-focused programs was shared among the students and faculty. The activities involved both clients and staff and were designed to be fun and informative, while addressing key issues such as nutrition, exercise, food preparation, health risk factors, and healthy living behaviors coupled with action-oriented activities such as a walking club and healthy food tastings. FINDINGS
Assessment were completed and reviewed for 49 clients and 6 staff members. The Gender and age demographics of the client population are presented in Table 1. There is evidence that starting positive health promotion behaviors earlier in life may prevent or
Table 1. Client Gender and Age Demographics N ⫽ 49
Males ⫽ 27
Females ⫽ 22
Age groups 18-29 30-39 40-49 50-59
33% 33% 30% 4%
14% 45% 23% 18%
delay later life health problems. In this group 63% are age 39 or below, where early intervention is most likely to be effective. Because of the short-term and intermittent nature of this pilot program, clients were asked to identify their primary care provider for ongoing care or referral as needed. Only 45% of the clients reported that they had a personal health care provider or specific clinic group that acted as a primary care provider. Of the clients 55% reported that they used emergency departments for episodic care. This is an important issue as primary preventative care is best delivered in a coordinated manner that addresses and individual’s health status over time. It is also an important factor in assuring the availability and continuity of appropriate screening, risk assessment, and episodic care is delivered along with mental health treatment. Five key health problems were identified in the client group that would be likely to generate a need for ongoing medical care if they are not managed in a consistent manner. Eleven of 49 clients (22%) who completed surveys were found to have health problems that would require ongoing intervention. This data is reported in Table 2. McGinnis and Foege, (1993) identified 9 major external factors that contributed to 50% of deaths in the U.S. These factors were viewed as being modifiable by behavioral factors that could reduce illness and subsequent mortality. In their study, tobacco use accounted for 19% of deaths in the U.S. in 1990 by contributing to death from cancer, cardiovascular disease and lung disease. Diet and sedentary activity patterns account for 14% to 19% Table 2. Key Health Problems (N ⴝ 11) Smoking Significantly over-weight Hypertension (only 29% self-reported) Dentition Diabetes
51% 49% 65% 29% 5%
NOTE. Nine clients had more than one health problem.
WELLNESS FOR PERSONS WITH MENTAL ILLNESS
185
Table 3. Summary of Client Wellness Issue Data N ⫽ 49
Total Wellness
Exercise
Nutrition
Excellent Fair Needs improvement
6% 71% 22%
10% 10% 80%
4% 67% 29%
of deaths, as they are associated with cardiovascular diseases, cancers, and diabetes mellitus. Recently, poor dentition associated with bacteria and subsequent contribution to damage to the heart walls or valves, (Medical Update, 1998). The presence of these health problems in this population is consistent with the findings of McGinnis and Foege, (1993), and would support the notion that prevention activities would be beneficial in decreasing or modifying illness in this group. The related lifestyle factors are addressed by the MicroFit Wellness Profile (1998). When the wellness profiles were analyzed for the total client group, one interesting and programmatically important factor emerged. In the client group, all of the participants perceived themselves as taking care of themselves better than they actually were. Clarifying an individual’s perception and increasing understanding of both positive areas that need to be supported as well as areas that need improvement is important to engage individuals in being involved in a healthy lifestyle and health promotion activities. This is the stage of precontemplation to contemplation in the transtheoretical model where an individual moves toward taking action in the foreseeable future because they begin to perceive that action may be necessary (Prochaska, Velicer, 1997) The individual wellness profile addressed total wellness and six behavioral health issue: exercise, nutrition, safety, stress, body weight, and blood pressure. At the personal wellness profile conference, each client and staff participant was invited to focus on the behavior areas in which they were most interested and that needed improvement. Each client was also asked to set measurable goals
Body Weight
16% 84%
Safety
Tobacco Use
Stress
Blood Pressure
59% 37% 4%
49% 18% 33%
18% 67% 14%
35% 10% 55%
in the selected area(s). The summary client data in each area is presented in Table 3 and staff data in Table 4. Both client and staff personal profile data reports indicated individual variability as would be expected. Viewed as a group, however, it is important to note that most participants had several areas that needed improvement. Of particular note are those areas such as exercise where 80% of the client group and 17% of the staff group needed improvement, body weight where 84% of the client group and 33% of the staff group needed improvement, and blood pressure where 55% of the client group and 17% of the staff group needed improvement. Dietary control and exercise is especially important for the clients as many of the psychotropic drugs have weight gain as a side effect. The personal profile report stresses individual choice as the most important factor in working toward wellness. This is enhanced by an individual’s understanding of the issue and suggestions for activities in areas that need improvement. The suggested activities that are prescribed are specific, but very achievable and measurable. The wellness profile points individuals toward a direction such as aerobic exercise three times per week and flexibility exercises, or choosing low fat foods and reading nutrition labels. After the wellness profile was reviewed, each participant developed a written wellness plan with the help of the student mentor and set up a weekly check–in schedule. Additionally, the students and faculty planned classes and activities that included important activities to assist the participants in achieving their goals. A program of stretching exercises was offered in each work area in the morning and a client
Table 4. Summary of Staff Wellness Issue Data N⫽6
Excellent Fair Needs improvement
Total Wellness
67% 33%
Exercise
Nutrition
67% 17% 17%
50% 50%
Body Weight
67% 33%
Safety
83% 17%
Tobacco Use
Stress
67%
100%
33%
Blood Pressure
50% 33% 17%
186
MARY ANN CAMAAN
leader was mentored to continue the exercise routine on days that the students were not present. A walking club was started, again with staff and client leaders, and mileage was recorded to provide an incentive. Meetings were held with the staff and clients who cooked lunch to provide “lightened” recipes and discuss issues related to improved nutrition. Healthy snack events were held and were successful in providing additional impetus to adopt healthier eating patterns. Classes on hypertension, tobacco cessation hints, and other health-related topics were integrated into everyday activities. The long-term outcomes will be evaluated later this year. However, the short-term outcomes have included client reports of increasing fruits and vegetables in their diet, cutting back on smoking and counting cigarettes smoked to increase awareness of smoking behaviors, reduction in caffeine consumption, decreasing portion size, and avoiding fast food intake. Clients participated in walking group and continued this activity with staff support after the students completed the first phase of this program. One client used the weekly check-in time to document her weekly weight loss and clients sought out their mentors to discuss their healthrelated and lifestyle interests. The “To Your Health” project focused on the process of becoming healthier. As a pilot project it succeeded in creating interest and participation in the project on the part of students, staff, and most importantly clients in a nonthreatening and personally interactive fashion. The next phase of the program will integrate group support principles by forming healthy living groups as an additional support to the personal profiles and goal setting mentorships. DISCUSSION
If persons with mental illness are to live productively in their community, it is vital that they have opportunities to improve their health, prevent further disability, and adopt a healthy lifestyle. Additionally, participation in a wellness program offers an opportunity to practice socially appropriate wellness behaviors in a community context. The program focused on encouraging a proactive process where general information on health is applied to individual goal setting and lifestyle changes. The pilot project, “To Your Health,” offered a personal and organizational pathway to address wellness and health promotion in a vulnerable pop-
ulation. It also provided an environment where wellness is valued as a major factor in quality of life and rehabilitation. Rehabilitation efforts are more likely to be successful if they are viewed in the context of quality of life and health as well as symptom control and social integration. This health-promotion program shows the process of integrating health-promotion activities and personal goal setting into a rehabilitation program. When clients and staff are invited to view health as a process, rather than a specific behavior, it becomes possible for healthy living to be viewed as an evolving state rather than an endpoint and encourages participation of all regardless of the presence of mental illness or client status. Participation in this program offers an experiential vehicle, and self-assessment opportunity for individuals to adopt a proactive, health-promoting lifestyle that is likely to positively affect other areas of rehabilitation. The preliminary findings of this pilot project have been presented to clients, staff, and the agency board of directors to encourage cooperation and collaboration on future program efforts. As this program continues emphasis is being directed toward continued personal goal setting. General program offering will be targeted toward weight management, smoking cessation, and exercise, and delivered in an interactive fashion that acknowledges the specific needs of the target group. A program that offers rewards for results in meeting goals is being developed. Additionally the mentorship process will be expanded to include group support activities that will be self-sustaining and client focused. Effort is also being directed toward development of primary care resources for continuity of health care. Hopefully, the environment of rehabilitation will evolve in a manner that is consistent with the stages of change model and continue to offer a meaningful bridge to improved wellness as well as psychiatric rehabilitation. REFERENCES Berren, M.R., Hill, K.T., Merikel, E. Gonzales, N., & Santiago, J. (1994). Serious mental illness and mortality rates. Hospital and Community Psychiatry 45, 604-605. Farnam, C., Zipple, A., Tyrerell, W., & Chittinanda, P. (1999). Health status and risk factors of people with severe and persistent mental illness. Journal of Psychosocial Nursing 37, 16-21. Felker, B., Yazel, J., & Short, D. (1996). Mortality and medical co morbidity among psychiatric patients: A review. Psychiatric Services 47, 1356-1363.
WELLNESS FOR PERSONS WITH MENTAL ILLNESS
McGinnis, J.M. & Foege, W.H. (1993). Actual causes of death in the United States. Journal of the American Medical Association 270, 2207-2212. MicroFit Wellness Profile (1998). The Wellness Profile. Mountain View, CA, Author, p 1-1.
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Prochaska, J., Velicer, W. (1997). The Transtheoretical Model. American Journal of Health Promotio. 12, 6-7 Satcher, D. (2000). Mental Health: A report of the surgeon general. Washington, D.C., Department of Health and Human Services, U.S. Public Health Service.