European network for promoting the physical health of residents in psychiatric and social care facilities (HELPS): background, aims and methods

The higher prevalence of somatic conditions in people with mental illness may be related with the mental disorder itself and/or unhealthy lifestyle, such as excessive smoking, poor nutrition, physical inactivity, insufficient hygiene, dental and sexual health behaviour and hazardous/risk-taking behaviour [14, 38‐40]. Increased prevalence rates for smoking were found among people with schizophrenia, bipolar and depressive disorder, neurotic and somatoform disorder [41]. A meta-analysis of 42 studies from 22 countries reported a prevalence of smoking in people with schizophrenia to be about seven times the general population average for males and three times higher for females [38]. This leads to a higher rate of nicotine-related diseases [1, 40, 42] and is regarded by several authors as one of the major causes of high somatic morbidity and also mortality in this patient group [40, 43‐45]. The odds of hazardous alcohol consumption were three times higher among patients with depression and doubled for those with schizophrenia [41] although alcohol use can exacerbate psychotic symptoms and medication side-effects, e.g. extra pyramidal symptoms [46]. Illicit drug use was found to be much higher in patients with schizophrenia, bipolar disorder, depression, neurotic and somatoform disorder [41, 44, 46]. Unhealthy food habits were found to be increased across diagnostic groups [41], which included higher proportions of saturated fats, lower consumption rates of fresh vegetables and fruit and lower fibre content compared with the general population [26, 40, 44, 45]. Only a very few studies examined physical activity and reported lower levels of regular exercise among people with schizophrenia [40]. Higher rates of unsafe sex practices with multiple partners and sexual exploitation among people with mental disorders (particularly schizophrenia) living in group care homes, hostels or on the street constitute a risk factor for HIV and AIDS [1, 46]. In general, studies on unhealthy lifestyle habits and health behaviour of people with mental illness are for the most part limited to people with schizophrenia and only little is known about the extent of unhealthy lifestyle in other diagnostic groups [38, 44].

Health behaviour is influenced by personal features that interact with social context variables (e.g. social support, norms and beliefs) and physical factors (e.g. weather, climate, means of transport, buildings, nutrition and recreational facilities) [26, 47, 48]. Furthermore, the living environment can be a direct determinant through environmental constraints and supports, such as physical activity [49]. Research on physical activity and neighbourhood environments indicates that people are more physically active in neighbourhoods with leisure opportunities [50, 51]. A recent study by Karlin and Zeiss [52] revealed that sunlight in patient rooms may promote recovery of patients with severe depression, that exposure to and views of nature can lead to reduced psychological distress and fatigue and facilitate recovery, and that big and low windows may improve sensory abilities and reduce delirium as well as paranoia. Single or non-dormitory-style resident rooms enhance privacy and autonomy and may promote participation in treatment activities. Architecture and building standards have direct effects on residents' physical health; they shape behavioural opportunities [26, 53], e.g. individual hygiene (bathrooms), physical activities (gymnasiums, opportunities for sport) and risk behaviour opportunities (smoking rooms, proximity of pubs). Organisational aspects, e.g. routine for daily hygiene and preparation of meals, availability of energy-dense foodstuffs, regulations and rules e.g. smoking bans also have effects on residents' physical health.

There are several health system-related factors, including professional care-related factors. For example, bipolar patients with a comorbid physical condition often receive inadequate treatment for their physical condition [33]. Psychiatrists are highly specialised doctors who may, in common with other specialists, have little or distant experience of general practice. Opportunities for the early detection and treatment of physical illness in mentally ill may therefore be missed [43]. Psychiatric services, with the encouragement of policy makers, have tended to concentrate on the direct consequences of psychotic illness, for example suicide and dangerousness, rather than the indirect effects such illness have on physical health [43]. Additionally, there is evidence that patients with schizophrenia have lower rates of utilisation of physical health care services and the quality of the physical care they receive is worse as compared with the general population [54]. Furthermore there is significant empirical evidence that the physical health of people with mental illness is often disregarded by mental or general health care institutions [1, 55]. At present, neurobiological, psychosocial and treatment-related factors are assumed to be responsible for the high prevalence rates of smoking, alcohol and substance abuse among people with mental illness [56‐62]. In spite of the growing evidence of co-occurrence of mental and somatic disorder, the nature of relationships between the two groups of conditions is multiplex due to the multitude of mechanisms of action and interaction.

Knowledge on the causes of increased somatic morbidity and mortality is fragmentary, and standardised screening instruments for somatic health risks in this population are not available in routine practice. There is a shortage of systematic efforts or programmes for the prevention of physical illness in people with mental disorder [63]. On the other hand, physical health promotion programmes for people with mental health needs have been successfully applied in diverse settings, e.g. local communities [64], schools [65], prisons [66] and medical care settings [67]. The majority of these intervention programmes have focused on smoking cessation [68, 69], and there are some programmes for the improvement of dietary behaviour and physical exercise [63, 70]. Many of these programmes have been initiated by pharmaceutical companies, and they are related to the issue of antipsychotic-induced weight gain. Most intervention programmes aim at changing patient behaviour, whereas they tend to neglect the role of (unhealthy) environmental living conditions [38, 44]. Most health promoting intervention programmes were developed and tested in the USA or UK, and this also limits our knowledge regarding feasibility in other countries. Thus, there is a striking lack of programmes targeting unhealthy lifestyle factors related to poor physical health in people with mental health problems [39]. Current national surveys and cohorts cannot provide sufficient information to improve physical health in people with mental illness, and there appears to be a lack of resources dedicated to dealing with somatic comorbidity.

It must not be forgotten that health activities and interventions aimed at reducing unhealthy lifestyles may actually have negative effects on the subjective quality of life of people with mental health problems if these actions are perceived as restrictive (e.g. smoking bans, restrictions of sexual contacts) or as paternalistic (e.g. change of nutrition habits, urge for physical activity). Additionally, smoking can diminish negative symptoms in schizophrenia and medication side-effects, e.g. extra pyramidal symptoms, and it may be perceived as a method to improve concentration, reduce boredom, negative feelings or anxiety [56‐58, 60, 71‐74]. Nicotine consumption, alcohol, and illicit drug use may also be perceived as improving social interaction, mood and coping with distress [57, 59, 75]. Thus, the unhealthy lifestyle and health behaviours in people with mental disorder are probably related to interactions of biological and environmental factors, as well as to normative beliefs, attitudes, and behavioural beliefs, which are personal beliefs about the role of behavior in the process of health and illness (self-efficacy). The integrative model (figure 2) by Glanz and colleagues [76] represents the linkage of these factors and how they impact on behaviour. This complexity has to be taken into account in planning intervention programmes.

The diversity of the European region is evident in psychiatric care (as in many other fields). Psychiatric facilities in Eastern European countries have to provide mental health care at lower resource levels than in Western Europe; there is a greater reliance on long-stay institutions yet many are still to catch up with international developments. On average, the mental health budget is 5.6% of the total health budget across Europe, but the proportion varies from less than 1% in some parts of Eastern Europe to about 12% in some Western European countries [41]. The availability of services and coverage by public health systems varies. Psychiatric hospitals in some Eastern European countries may lack the equipment and services to recognise and treat physical ill health in people with mental health needs and primary care or internal medicine input may not be readily available [77]. Eastern European countries have to cope with low healthcare funding levels, and out-patient facilities may not be within easy reach. Community care may not be available [77‐80], and the workload due to mental disorders, including substance abuse, may be increasing in a context of social instability [77]. While countries in the eastern half of the European Union may be catching up with their western European counterparts mental health appears to still be a recipient of "second-class treatment".

National and international pharmaceutical companies that provide modern psychiatric drugs across Europe influence the field of mental health in rich and poor countries alike. Thus it can be considered a success that innovative drugs for treating mental disorders are available in some low resource countries in Central and Eastern Europe. But providing psychiatric drugs can make the introduction of psychosocial therapies more difficult in countries with a low level of healthcare resources. For example, while the Lithuanian health care system spends an average of two to three million euros on modern psychiatric drugs, funding for the psychiatric treatment of children and young people in the secondary and tertiary sectors is limited to around 1 million euros [81].

The individual should not be considered a passive object in any prevention strategy but instead take an active part in the health promotion process [82]. The setting approach to health promotion should focus on strengthening individual abilities and resources of people with mental illness to empower them to "achieve their fullest health potential" by "making healthy choices" (World Health Organization). According to the Ottawa Charta 1996 health promotion programmes should be based on the concept of empowerment to help individuals increase the degree of control over their health-related living conditions and quality of life. There is evidence based on multi-level research designs that empowering initiatives can improve health outcomes [83]. Service user empowerment has developed as a proactive partnership and self-care strategy to improve health outcomes and quality of life among the chronically ill [84, 85]. Wallerstein defines empowerment as "a social-action process that promotes participation of people, or organizations, and communities towards the goals of increased individual and community control, political efficacy, improved quality of life, and social justice"[86]. Thus empowerment is a complex strategy in complex environments: effective empowerment strategies may depend as much on the agency and leadership of the people involved as on the context in which they are implemented [83].

The obvious neglect of the physical health status of people with mental illness in general, and of residents in psychiatric and social health care facilities in particular, is incompatible with the protection of human rights and dignity. Poor physical health in this population must begin to receive the attention that it deserves, particularly in view of the substantial numbers of individuals who spend time in residential facility settings across Europe. There is a need for a physical health promotion toolkit that can be implemented not only in the community at large but also in mental health and social care facilities across the European Union. The toolkit must comprise an empowerment strategy which enables professionals and residents of mental health care facilities to routinely identify relevant health problems, explore the main causes, and then choose and implement appropriate health promotion programmes suitable to the range of facilities.

The overarching objective of HELPS is the development of a framework of empowerment focusing on the promotion of healthy living conditions in psychiatric care facilities and the improvement of the physical health status of residents of psychiatric and social care facilities in the European Region.

For this purpose it is intended to put together a selection of validated screening instruments and effective and efficient health promotion programmes as an up-to-date and feasible toolkit to facilitate the treatment of physical illness in people with mental health needs that is suitable for application in a wide range of mental health care facilities across Europe. The HELPS toolkit will be embedded in an empowerment framework for health promotion in mental health care. Users should be qualified to choose and implement suitable health promotion programmes at the individual, organisational and environmental level. Staff members and residents in these facilities should be enabled to identify routinely the most relevant physical health problems, to detect adverse and protective health-related lifestyles and attitudes, to discover relevant facility characteristics, and HELPS should increase staff members' and residents' control over their living conditions and their confidence in the effect of their own actions to improve health status. To assess the validity and feasibility of applying the health promotion toolkit, a pilot application phase will be carried out in at least one psychiatric or social care facility in each of the participating countries. Experiences from this pilot phase will be used to improve parts of the toolkit which are not suitable for routine application.

It is planned to translate the HELPS toolkit into the following European languages: English, Bulgarian, Danish, Czech, Estonian, French, German, Italian, Lithuanian, Polish, Romanian, Slovenian, Spanish, and Turkish. This would cover the languages of about 80% of the citizens of EU member states and about 96% of the citizens of candidate countries. A standardised translation procedure should facilitate adaptation to further languages. Thus we expect to enable access not only to the participating centres but to all individuals or facilities who are interested in the health promotion of people with mental illness. The HELPS toolkit shall be accessible via the internet and as a CD ROM. We hope that media campaigns will be a helpful way for dissemination, application, and implementation of the toolkit. It will be complemented by a training manual using multimedia presentations to introduce key targets of the HELPS toolkit and describe its component parts. Furthermore it is projected to offer workshops on the use of the paper-pencil and computer versions of assessment instruments. This practical training should enable participants to pass on the skills required to handle the toolkit in peer groups and, in this way, they could become multipliers in dissemination of the toolkit.