Barriers to a Healthy Lifestyle Among Hispanics With Serious Mental Illness: The Layering of Ecological Factors

Background and Purpose.   Compared to non-Hispanic Whites with serious mental illness (SMI), Hispanics with SMI have higher rates of obesity and diabetes, placing them at elevated risk for cardiovascular disease (CVD).  Modifiable risk factors (e.g., lack of exercise, stress, unhealthy diets) contribute to this elevated risk.  These health behaviors do not happen in a vacuum; they are impacted by the ecology that surrounds the individual and how the individual navigates his/her environment.  In this federally funded study, we used an ecological lens to examine how the interactions of individual, social, and environmental factors shaped the health behaviors of Hispanics with SMI and at risk for CVD in an urban environment.

Methods.  A purposive sample of 24 Hispanic adults with SMI and at least one CVD risk factor (e.g., smoking, hypertension) were recruited from a public outpatient mental health clinic as part of a larger study focusing on the development of a health care management intervention.  Five focus groups were conducted to discuss how patients coped with their health issues in their everyday lives.   All focus groups were conducted in Spanish, audio taped, and professionally transcribed.  The constant comparative method of grounded theory was used to analyze the qualitative data.

Results.  More than half of our participants were female (58%) and mostly of Dominican and Puerto Rican descent. All had a diagnosis of schizophrenia, schizoaffective or bipolar disorder, and the majority were taking second-generation antipsychotics (64%).  On average, participants had 4.5 medical conditions with high cholesterol (70%), hypertension (58%), and diabetes (38%) being the most frequent conditions.  A grounded model of barriers to a healthy lifestyle emerged from our data. The model captures how participants’ efforts to live a healthy lifestyle were negatively impacted by a layering of individual, social, and environmental factors.  Individual-level barriers included chronic pain (e.g., “I would like to walk but it hurts all over”), medication side effects (e.g., “after the insulin, I gained like 20 pounds.”), and unhealthy behaviors used to cope with mental illness (e.g., “with depression, you eat and eat and smoke”).  Barriers in the social environment were family discord, social isolation, and lack of support from relatives or friends.  At the community level, food environments played a role due to the high cost of fresh fruit and vegetables in participants’ communities and the affordability and ease of eating junk food (e.g., “Junk food is easy, its’ all prepared”).  Participants also talked about not having safe places to exercise and having limited income to consistently buy healthy foods and sustain a healthy diet.

Conclusions. Our study findings illustrate how the layering of individual, social, and community factors prevent Hispanics with SMI and at risk for CVD from engaging in healthy behaviors. Interventions and policies can benefit from using an ecological lens as used in this study to identify intervention targets at multiple levels to improve the physical health of people with SMI and reduce health disparities.  Implications for using our grounded model for developing and implementing health care interventions will be discussed.