"Learning, Doing, and Sticking with It": A Qualitative Study on Achieving Clinically Significant Reductions in Cardiovascular Disease Risk in a Healthy Lifestyle Intervention for People with Serious Mental Illness

Background and Purpose. People with serious mental illness (SMI; e.g., schizophrenia) have mortality rates two to three times higher than the general population, largely due to a higher prevalence of obesity, diabetes, and cardiovascular disease (CVD). Healthy lifestyle interventions that promote healthy dietary patterns and increase physical activity have increasingly been employed to improve the health of people with SMI. However, there are still unanswered questions about why these interventions work for some and not others. This study used data from a federally-funded randomized effectiveness trial of a peer-led healthy lifestyle intervention (PGLB) conducted in three supportive housing agencies to explore differences among participants who achieved clinically significant CVD risk reduction versus those who did not.

Methods. Study participants were drawn from those randomized to PGLB. PGLB is a 12-month manualized peer-led healthy lifestyle intervention for people with SMI who are classified as overweight/obese (BMI≥25). One key goal of PGLB was helping participants achieve clinically significant CVD risk reduction at 12-months, defined as achieving clinically significant weight loss (i.e., ≥5% weight loss from baseline) or clinically significant improvement in cardiorespiratory fitness (i.e., ≥50-meter increase on the 6-minute walk test[6MWT] from baseline). Qualitative data from interviews and focus groups conducted with 21 participants were linked to their 12-month outcome data. We used grounded theory to examine and compare the experiences of participants who achieved clinically significant CVD risk reduction versus those who did not.

Results. In this sample, 10 participants achieved clinically significant CVD risk reduction and 11 did not. Participants’ mean age was 49 years(SD=10.0), 48% were female, and 76% were racial/ethnic minorities. At baseline, participants had a mean BMI of 37 (SD=8.92) and walked an average of 291 meters (SD=103.90) in the 6MWT. The most prevalent lifetime physical and mental health conditions were hypertension (81.0%), high cholesterol (42.9%), diabetes (47.6%), depression (86%), schizophrenia/schizoaffective disorders (71%), and bipolar disorder(38%). Three themes - learning, change, sticking with it - differentiated participants who achieved the CVD risk reduction outcome and those that did not. Participants achieving clinically significant CVD risk reduction described learning and applying specific knowledge and skills related to a healthy lifestyle when making health decisions, made healthy concrete changes to diet and physical activity, and stuck with those changes by persevering through challenges, and by finding motivation from early results and group members. In contrast, participants not achieving clinically significant CVD risk reduction reported surface-level learning about healthy dietary and physical activity practices, were more likely to report ambiguous or no changes to their lifestyle, and reported more difficulty sticking with healthy changes.

Conclusions and Implications. Reducing excess mortality and morbidity in people with SMI will require that healthy lifestyle interventions be tailored to the needs of individual participants. Our findings suggest that healthy lifestyle interventions should focus on improving participants’ ability to apply what they have learned, creating early perceptions of success to enhance motivation and sustain behavior change, and matching participants’ treatment to their stage of change to ensure treatment is personalized to each participant’s unique situation.