Jun 02, 2016, By: Ruth Schofield, RN, MSC(T), Cheryl Forchuk, RN, PhD, Phyllis Montgomery, RN, PhD, Abraham Rudnick, MD, PhD, Betty Edwards, M.Ed., Amanda Meier, MSW, RSW, Mark Speechley, PhD
Objective: Individuals with mental illness often live in chronic poverty, which is associated with personal health practices such as tobacco use and poor nutrition that disrupt physical health. The purpose of our study was to examine whether differences exist in personal health and health practices — related to nutrition, physical activity, smoking, alcohol consumption and sleep — between a cohort of individuals with mental illness in southwestern Ontario and the general Canadian population.
Method: The study sample consisted of 250 individuals who had had a psychiatric diagnosis for at least one year. We conducted a structured quantitative interview with each person to gather information about their personal health and health practices, using question wording from the National Population Health Survey and the Canadian Community Health Survey. We calculated 95% confidence intervals for our results and used them to compare our data with Canadian norms.
Results: Individuals with mental illness are significantly more likely than the general population to have a poor diet, experience poor sleep and consume alcohol in excess.
Conclusion: It is important for nurses, health-care organizations and policy-makers to be aware that a number of factors may be influencing the personal health and health practices of individuals with mental illness and that this population may require different health promotion strategies to support a healthy lifestyle.
Individuals living with mental illness are among the most disadvantaged groups in any society. In Canada, they often live with multiple, intersecting health and social issues, such as poverty (Raphael, 2011), insecure housing (Forchuk, Csiernik, & Jensen, 2011) and exclusion through stigma and discrimination (Westhues & Wharf, 2012). In turn, such circumstances heighten their risks of developing comorbidities, shorten their lifespans and increase their reliance on a range of services (Mental Health Commission of Canada, 2012; Public Health Agency of Canada, 2015). The challenges that individuals with mental illness face in their efforts to take responsibility for their individual health in the context of health disparities are increasingly being recognized (Forchuk, Ward-Griffin, Csiernik, & Turner, 2006; Rudnick et al., 2014). Personal health practices vary depending on individuals’ life situations and can operate as protective factors for physical health or risk factors for disease.
Mental illness may disrupt an individual’s personal health practices and consequently affect physical health. Previous research indicates that it may be difficult for individuals living with mental illness and limited finances to access nutritious and affordable food (Rudnick et al., 2014). Physically active leisure time has been found to be associated with higher levels of physical health and well-being in Canadians; however, individuals with mental illness often do not engage in sufficient physical activity (Iwasaki, Zuzanek, & Mannell, 2001; Song, Lee, Baek, & Miller, 2012). The reasons for this include financial barriers that preclude access to recreational facilities and activities.
Tobacco use is common among individuals with mental illness and tends to increase when comorbid disorders are present (McClave, McKnight-Eily, Davis, & Dube, 2010). Individuals with mental illness have reported they smoke to cope with psychiatric symptoms, to reduce the side effects of medication and for the sedative effects smoking provides (Forchuk et al., 2002; Johnson et al., 2010). In addition, mental health issues have been associated with self-medication through alcohol and other drug use (Santucci, 2012). Sleep quality and quantity are not generally mentioned when personal health practices are discussed. However, adequate levels of sleep are necessary for optimal physical, cognitive and emotional functioning (Gruber, 2013). Sleep deprivation can cause numerous health problems, including impaired memory, increased stress, insulin resistance, cardiovascular disease and obesity (Gruber, 2013). In addition, research indicates that individuals with mental illness have disrupted sleep habits and lower sleep satisfaction than individuals without mental illness (Poulin et al., 2010). We therefore included sleep in our study as a personal health practice; we used sleep as a proxy for sleep habits, recognizing that many factors influence sleep and its disruptions.
The purpose of our study was to examine whether differences exist between the personal health practices — related to nutrition, physical activity, smoking, alcohol consumption and sleep — of a cohort of individuals with mental illness in southwestern Ontario and those of the general Canadian population. Such a direct comparison has not previously been systematically conducted or published, to the best of our knowledge. We assumed that the potentially modifiable personal health practices we examined could be protective factors for physical health or risk factors for disease.
Design and sample. This study was part of a large two-year mixed-methods project involving community-based participatory action research. Many of the authors of this paper were involved in the project, and this subgroup carried out analysis of the quantitative data related to health measurement. Here, we, the authors, report the results of this analysis involving the structured interviews conducted during the project. The population of interest was individuals who self-identify as living with a mental illness in an urban region in southwestern Ontario with a population of approximately 500,000. A representative sample of individuals from the project was used to ensure that our study included equal-sized subsamples of men and women who were clustered by housing circumstances, including homeless, group home, independently living (employed) and independently living (unemployed or full-time student), for a range of responses. To be eligible to participate, individuals had to be 18 years of age or older; have had a diagnosis of a mental illness for at least one year; comprehend, speak and read English to the degree necessary to complete the interview; and provide voluntary informed consent.
Data collection. Each participant engaged in a face-to-face structured interview with a trained research assistant at a location of the participant’s choice. The topics covered in the interview included general health, mental health, personal health practices and income. The research assistant used question wording from sections of the National Population Health Survey: Household Component Cycle 6 (NPHS) (Statistics Canada, 2005) and the Canadian Community Health Survey Cycle 4.1 (CCHS) (Statistics Canada, 2007). Ethics approval was granted by the health sciences research ethics board of Western University, London, Ont.
Data analysis. We compared the participants’ responses with normative Canadian data from the NPHS and the CCHS (Statistics Canada, 2005; Statistics Canada, 2007). The specific cycles used were chosen on the basis of the availability of NPHS/CCHS data; these data are indicated in the table [PDF, 46.2 KB]. We conducted our comparisons with population norms using 95% confidence intervals calculated for proportions (in the case of categorical variables) and for means (in the case of continuous variables). When a population estimate fell outside the confidence interval calculated for our sample, we considered the two values to be equivalent at a statistical significance level of 5% or lower (p <0.05).
The final sample consisted of 125 men and 125 women. Participants were 18 to 73 years of age (mean = 41.5 years, standard deviation = 12.4 years). The average income received by participants in the month before their interview was $919.53. We asked participants about the highest level of education they had completed: 57 (22.8%) reported community college or university, 95 (38.0%) reported high school and 98 (39.2%) reported grade school. The psychiatric diagnoses they reported were as follows: 161 (64.4%) reported mood disorders, 92 (36.8%) reported substance-related disorder, 81 (32.4%) reported anxiety, 47 (18.8%) reported schizophrenia and 16 (6.4%) reported personality disorder. Some participants reported having comorbid disorders.
Results for reported personal health and health practices are summarized in the table. Values for the general Canadian population did not fall within the upper and lower confidence limits for study participants in 18 of the 21 (85.7%) comparisons. Participants had higher prevalence of unhealthy practices in seven of the eight categories studied, compared with the general population, with the exception of alcohol consumption in the past 12 months (69.6% and 75.9%, respectively).
Nutrition. Our results showed that 20.4% of participants rated their eating habits as “poor,” whereas only 4.2% of the Canadian population did so; 20.8% of participants believed their eating habits were “very good” or “excellent,” compared with 44.8% of the Canadian population.
Body mass index. About 43.0% of both the study participants and the Canadian population reported having a “normal” body mass index (BMI). However, the percentage of participants who reported being in the “underweight” BMI category was 2.8 times as high as in the Canadian population, and the percentage of participants who said they were in the “obese” BMI category was about 1.3 times as high as in the Canadian population.
Physical activity. More participants in our study than in the Canadian population reported limitations in the amount of activity they could do at home (44.0%, compared with 22.2%), at school (41.2%, compared with 7.6%) and at work (64.6%, compared with 14.0%). Forty per cent of participants reported limitations in other activities, compared with 20.2%.
Smoking. The prevalence of occasional smoking was less than 5.0% in both the study participants and the Canadian population. However, the prevalence of daily smoking was substantially higher in participants than in the Canadian population (65.6% and 18.1%, respectively). Among daily smokers, participants smoked an average of 17.8 cigarettes per day, whereas the Canadian population smoked an average of 15.7 cigarettes per day.
Alcohol. Within the Canadian population, 75.9% consumed alcohol in the past year; 69.6% of study participants did so. However, if participants did consume alcohol, a greater percentage of them engaged in heavy drinking when compared with the Canadian population. We defined heavy drinking as having five or more drinks on one occasion (Statistics Canada, 2010). Specifically, among those who reported drinking alcohol in the past year, 14.9% of participants reported drinking heavily more than once a week, compared with 3.4% of the Canadian population.
Sleep quantity and quality. When we asked participants how often they had trouble going to sleep or staying asleep, 27.6% reported that they experienced this “all of the time,” compared with 6.8% of the Canadian population. Similarly, 19.6% of participants reported that their sleep was refreshing “none of the time,” compared with 6.9% of the Canadian population.
To our knowledge, this is the first study to directly compare the personal health and health practices of individuals with mental illness with those of the general Canadian population. Our study reveals a number of substantial differences between the two populations with respect to personal health and health practices that act as protective factors for physical health or risk factors for disease. Study participants had a lower prevalence of healthy eating habits and healthy sleeping practices and a higher prevalence of being underweight or obese, daily tobacco use, heavy alcohol consumption and limitations in physical activities at home, school, work and elsewhere. The prevalence of normal BMI and occasional smoking was similar in the two populations, and the prevalence of alcohol consumption was lower in study participants.
Issues with many personal health practices place the study population at high risk for developing chronic diseases and being admitted to hospital. Wilkins, Shields and Rotermann (2009) used CCHS data to demonstrate that daily smokers (and individuals who were daily smokers but had recently quit) had twice as many hospitalizations as individuals who had never smoked daily. Murray et al. (2002) found that people who engage in episodes of heavy drinking had an increased risk of coronary heart disease, stroke or sudden cardiovascular death. The results of a systematic review indicated that unhealthy lifestyle practices such as tobacco use, poor diet, harmful use of alcohol and lack of physical activity were also associated with periodontal disease (Ramseier & Suvan, 2015). It is clear from the evidence that such practices result in vulnerability to chronic diseases, hospitalizations and premature mortality.
The unhealthy personal practices reported by the study group are also associated with low health literacy. Many of the participants were on social assistance; people in this situation tend to have lower health literacy, which can lead to negative health outcomes (Rootman & Gordon-El-Bihbety, 2008). These disadvantages, combined with mental illness and poverty, further increase individuals’ vulnerability to multiple risk factors, highlighting the need for health promotion and disease prevention interventions for this client group.
The promotion of healthy personal practices for individuals with mental illness is essential. It is important for nurses to understand that health practices may be impaired in individuals living with mental illness. A systematic review found that with the use of moderate- to high-intensity interventions, health-care providers can improve the health literacy of patients, helping them make changes in their smoking habits, diet, alcohol use, physical activity and weight (Dennis et al., 2012). Behavioural smoking cessation interventions to reduce smoking are a promising way for nurses to help disadvantaged groups, including individuals with a mental illness (Bryant, Bonevski, Paul, McElduff, & Attia, 2011). Best practices for nurses suggest that smoking cessation interventions need to be tailored to the client population (Registered Nurses’ Association of Ontario, 2007). In a systematic review on the promotion of healthy lifestyles among individuals with serious mental illness, behavioural techniques showed promise in helping individuals improve their dietary habits and increase their physical activity (Cabassa, Ezell, & Lewis-Fernández, 2010). However, personal health practices must be understood within the context of the experiences of individuals with mental illness: this population must contend with higher rates of poverty and the interaction of substances, such as nicotine and psychiatric medications.
In a study of people living with serious mental illness that was designed to explore the interplay between poverty and mental health reform and welfare restructuring, the study population was found to have greater poverty than the general population (Wilton, 2004). Participants in that study reported that their low income limited their access to food security and recreational opportunities. Given that unhealthy practices contribute to the development of chronic conditions and mortality, the costs to the health-care system will probably decline if individuals become aware of and adhere to more healthy practices (Murray et al., 2002; Wilkins et al., 2009).
The promotion of healthy living is a public health policy directive at both the national and provincial/territorial levels. Though population-based approaches are a fundamental component of public health work, there is growing recognition that a “levelling up” principle for policy action is needed to address health inequities, to enable priority populations to receive targeted services (Whitehead & Dahlgren, 2013). This principle requires that the health gap be narrowed in an equitable way to raise the level of health for those identified as being worse off to the level of health of people who are better off.
We used question wording from the NPHS and the CCHS for our study, and we used data from these surveys for our comparisons with the general Canadian population, which restricted the analyses we were able to do. For example, these surveys do not include questions specifically about the amount of physical activity participants engage in; rather, questions pertain to limitations in physical activity.
The population figures we cite in our study are themselves sample estimates. We elected to calculate confidence intervals for our sample data to reduce the design effect in the complex survey designs used with the population figures. As well, confidence intervals around the population estimates would be very small because of the large sample sizes of the NHPS and CCHS.
Our approach results in a more conservative estimation of error. Our confidence intervals did not use random sampling. We used an equal proportion of genders and clustered equally by different housing circumstances for a range of responses. In addition, all the study participants were from a single region in Canada, and results may not fully represent other regions, as personal health practices may vary to some extent with local culture and geography.
Individuals with mental illness are vulnerable to engaging in unhealthy personal health practices and to living in poverty. The participants in our study report having a substantially unhealthier lifestyle than the general population. Our study has demonstrated that there is a definite need for nurses to be aware of and promote healthy lifestyle choices. It is also important they understand that systemic factors, such as high rates of poverty, contribute to these unhealthy practices. Our results indicate that individuals with mental illness are a population in significant need of targeted health policies and nursing interventions to promote healthy living.
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Ruth Schofield, RN, MSC(T), is an Assistant Professor in the School of Nursing, McMaster University, Hamilton, Ontario. She serves on the Board of Community Health Nurses of Canada.
Cheryl Forchuk, RN, PhD, is a professor, Arthur Labatt Family school of nursing, Western University and the assistant director, Lawson Health Research Institute.
Phyllis Montgomery, RN, PhD, is a professor, school of nursing, Laurentian University.
Abraham Rudnick, MD, PhD, is an associate professor, department of psychiatry, University of British Columbia.
Betty Edwards, M.Ed., AAMFT, is a community research coordinator, Can-Voice.
Amanda Meier, MSW, RSW, is a research coordinator, Lawson Health Research Institute.
Mark Speechley, PhD, is a professor, department of epidemiology and biostatistics and the Schulich interfaculty program in public health, Western University.