Health among people with psychotic disorders and effects of an individualized lifestyle intervention to promote health

Abstract: The overall aim of the thesis was to increase knowledge of health among people with psychotic disorders such as schizophrenia and other long-term psychotic conditions. The aim was also to investigate health effects, in terms of clinical health outcomes and self-reported questionnaires, of atwo-year individualized lifestyle intervention implemented in psychiatric outpatient services involving cooperation with the municipal social psychiatry services. The motivation for the study was to generate new knowledge in order to be able to promote health in people with psychotic disorders and to improve the care and support provided for this target group. The thesis consists of four studies. A quantitative study (Study I), was conducted using a cross-sectional design to investigate the prevalence of overweight, obesity, risk of cardiovascular disease (CVD) and the relationships between self-rated salutogenic health, sense of coherence, CVD risk, and body mass index among people with psychoticdisorders (n=57). The study was conducted in four psychiatric outpatient services; questionnaires were completed by the participants and clinical health measurements were collected by the participant’s contact nurse at the psychiatric outpatient services. The participants showed a moderate/high risk of CVD, the mean for BMI was 31.9 (59.6% were obese) and 31.6% were overweight. The results did not reveal any relationships between the subjective and objective measuresof health indicating the need for both subjective and objective assessments of health in psychiatric care. In a qualitative study (Study II), data were collected with semi-structured interviews (n=16) andanalyzed with qualitative content analysis. The interviews resulted in an overall theme “Being regarded as a whole human being by self and others”, which showed the multidimensional nature of health and the issues that enable healthy living among people with severe mental illness. Three categories emerged: (i) everyday structure (ii), motivating life events and (iii) support from significant others. The results indicate that a person with severe mental illness needs to be encountered as a wholeperson if healthy living is to be enabled. In a quasi-experimental study (Study III), the potential effects of participation in the two-year lifestyle intervention (intervention group n=54 and control group (n=13) were investigated. The data were collected at baseline, after 12 months and after 24 months using the self-reported questionnaire the Salutogenic Health Indicator Scale (SHIS), the Hopkins Symptom Checklist (HSCL-25) and the National Public Health Survey. Measures of clinical healthoutcomes were conducted by the participant’s contact nurse at the psychiatric outpatient services. Multilevel modeling was used to test differences in changes over time. Significant changes were foundin physical activity, HbA1c and waist circumference after participation in individualized lifestyle intervention. The relationship between changes in physical activity, levels of salutogenic health and glycated hemoglobin (Hb1Ac) were investigated (n=54) in Study IV. The data were collected atbaseline, after 12 months and after 24 months using the self-reported questionnaires Salutogenic Health Indicator Scale (SHIS) and National Public Health Survey. Within-person changes in physical activity between baseline and at the end of the twenty-four-month intervention were calculated. Selfreported increased physical activity was positively associated with self-rated salutogenic health and negatively associated with level of HbA1c after participation in the intervention. The thesis shows that a well-founded assessment of general health needs must consider both the individual's subjective experiences and objective measurements in order to form a solid foundation for dialogue and shareddecision-making about essential care services. The results also show that it is possible to stimulate healthy behavioral changes with a two-year individualized lifestyle intervention and bring both subjectively and objectively measured health benefits for people with psychotic disorders. The importance of nurses in psychiatric care applying a holistic approach and integrating lifestyle interventions into daily person-centered psychiatric care in collaboration with other healthcare providers to facilitate changes towards a healthy lifestyle in persons with psychotic illness is emphasized in the thesis.