Background
People with a mental illness experience poorer physical health than the general population and markedly lower life expectancy as a consequence [
1,
2]. A greater prevalence of chronic disease risk behaviours, including tobacco smoking, inadequate nutrition, harmful alcohol consumption, and physical inactivity contribute substantially to this health inequity [
1,
2]. The prevalence of such behaviours among people with a mental illness varies substantially by diagnosis and setting. Recent Australian data identified that among community mental health clients, 96 % were at risk for at least one of these four behaviours, with risk highest for inadequate nutrition (87 %), followed by tobacco smoking (51 %), inadequate physical activity (47 %) and harmful alcohol consumption (43 %) [
3].
In addition to the impact of such behaviours on the physical health of people with a mental illness, a growing body of research demonstrates that reducing chronic disease health risk behaviours for people with a mental illness can positively impact on their mental health outcomes [
4‐
7]. Lifestyle or behaviour change interventions have been demonstrated to be effective in assisting people with a mental illness to improve their health risks behaviours and physical health more broadly [
8‐
11]. Such lifestyle interventions have further been shown to positively impact mental health outcomes, including reducing psychiatric symptoms [
4,
12,
13]. Mental health services are recommended to provide care that seeks to modify such health risk behaviours [
14‐
18], and may provide a particularly opportune setting for addressing these risks due to the availability of multidisciplinary teams with a wide range of relevant skills and expertise, and the often frequent and ongoing nature of care provided [
19]. Despite these recommendations and the benefits of such care, preventive care is not routinely provided [
20‐
23]. For example, in a study of 1,610 psychiatrists in the USA, 6 % of clients were reported to be provided diet counselling, 4 % exercise counselling, and 12.4 % smoking-cessation counselling [
22]. Given the suboptimal provision of such care, analysis of the determinants of such care practices is required.
In general health services, factors suggested to impede the provision of preventive care have included attitudes that provision of such care is not an appropriate role of clinicians, perceptions that clients are not interested in changing their health risk behaviours, and a lack of clinician self-efficacy in providing preventive care (skills, knowledge, confidence and perceived effectiveness) [
24,
25]
. Few studies have examined the impact of mental health clinician attitudes on the provision of care addressing client physical health risk behaviours [
26,
27]. In one such study of the attitudes and practices of Canadian community mental health care workers towards smoking cessation care, a belief that there was sufficient time in a consultation to address tobacco use, that tobacco cessation care was a part of their role, greater confidence in providing smoking cessation care, and a perception of clients being interested in stopping smoking were positively associated with the self-reported provision of smoking cessation care [
26]. Similarly, a survey of UK psychiatric inpatient and community mental health nurses found that positive attitudes towards the role of nurses in providing physical health care (including addressing health risk behaviours), and greater confidence in delivering such health care were positively associated with self-reported delivery of such care [
27].
The prevalence of such attitudes have been reported to vary among mental health clinicians [
28‐
32], with for example, support for the provision of smoking cessation care reported to vary between 43 % and 87 % across studies [
28‐
30,
32]. Similarly variable findings (23 % and 77 %) have been reported regarding mental health clinician perception of client interest in receiving smoking cessation care [
31,
32]. In the USA, 90 % of psychiatrists expressed confidence in their ability to advise clients of the risks of smoking, but only 34 % in referring clients to ongoing cessation care [
31].
The attitudes of mental health clinicians to the provision of preventive care for behavioural risks other than smoking have been addressed in only a limited number of studies [
27,
33,
34]. Two studies in the United Kingdom have reported high levels of clinician support for providing such care regarding nutrition (78 %-92 %), physical activity (76 %-95 %), and alcohol consumption (83 %-92 %) [
27,
33]. With regard to clinician reported self-efficacy, approximately one quarter of inpatient nurses (23 %-38 %) reported a lack confidence regarding the provision of preventive care for nutrition, physical activity, and smoking [
33]. In a third qualitative study, Australian community mental health managers reported that their ‘core business’ was to assess and treat mental illness, with physical health related issues seen to be of ‘secondary importance’ [
34].
Given the limited scope and variable findings of studies regarding mental health clinician attitudes to the provision of care addressing the prevention of chronic disease risk behaviours, a study was undertaken to investigate: i) the attitudes of a multi-disciplinary group of community mental health clinicians regarding their perceived role, perception of client interest, and perceived self-efficacy in the provision of such care, ii) whether such attitudes differ by professional discipline, and iii) the association between these attitudes and clinician provision of such care.
Discussion
This study found a substantive majority of community mental health clinicians considered that the provision of care to prevent four chronic disease health risk behaviours was congruent with their role, and that they had sufficient knowledge, skills and resources to provide such care. Notwithstanding these positive findings, up to a third of clinicians considered that the provision of such care might negatively impact on delivery of acute care, one fifth were not aware of referral services for inadequate nutrition and physical inactivity, and more than half did not believe their clients were interested in changing their health risk behaviours. For the majority of attitudes, no differences were evident between professional disciplines. Positive associations with some forms of preventive care provision were identified. Strategies that strengthen these perceptions are required if the benefits of preventive care are to be maximised for all clients.
The finding that approximately half of participants reported that clients were not interested in changing their health risk behaviours is consistent with the findings of previous research [
29,
31,
47]. For example, Australian psychiatric inpatient nurses have reported that their decision to provide smoking cessation care is primarily influenced by perceived patient receptivity [
29]. Such selectivity in care provision contradicts care guidelines regarding provision of preventive care on a universal basis, and suggests additional strategies such as prompts and reminders may be required to facilitate clinician provision of preventive care to all clients [
48]. Other studies have indicated such views of clinicians may be unfounded, with people with a mental illness being shown to be receptive to receiving preventive care and interested in improving their health risk behaviours [
49‐
53]. Training and the dissemination of education resources has been found to positively impact primary care nurses’ misconceptions regarding physical health care for clients with a mental illness [
54], and the current clinician misperceptions suggest a need for additional strategies to address possible deficits in clinician understanding of client needs in this regard.
Nearly one quarter of clinicians surveyed reported that the provision of preventive care impacted on the time available for the delivery of acute care, a perception commonly reported in studies across health services generally [
24,
25] and mental health services specifically [
27,
30,
31]. To address such concerns, models of preventive care provision have been developed to limit the amount of clinical consultation time required for its delivery. For example, the recommended 5A’s behavioural counselling framework [
55] has been reduced to include only three elements of care: ‘assess, advise, and refer’ [
37‐
39] thereby reducing time demands on the clinician during the consultation [
38,
56]. Similarly, practice aids such as prompts, decision-aids, recording and automated referral protocols have been demonstrated to be both effective in enhancing the provision of preventive care and in reducing the time required of clinicians [
48,
57,
58].
Recommended models of preventive care provision emphasise the importance of referral and/or follow up care [
37‐
39]. In the current study, approximately one quarter of clinicians reported a lack of services to refer their clients to for behaviour change support; a finding that is reflective of previous research with psychiatrists [
31]. Such a finding contrasts with the ready availability of free evidence-based health risk behaviour telephone services in the study area: Quitline for smoking cessation (
www.icanquit.com.au/further-resources/quitline) and a telephone coaching service for addressing inadequate nutrition and physical inactivity (
www.gethealthynsw.com.au). Despite the availability of such services and mechanisms to enable clinician referral of clients, research indicates under-referral to such services by clinicians [
21,
59]
. Clinician training may serve to increase awareness and utilisation of specialist prevention referral options [
60]
.
Few differences in attitudes regarding the provision of preventive care were identified between professional disciplines. However, psychiatrists were least likely to hold positive attitudes towards such care provision. Differences between study settings may account for the contrast between these findings and those from a UK inpatient setting [
30] where no differences between medical practitioners and non-medical clinicians were identified. The current findings suggest that psychiatrists working in community mental health may benefit from training and additional evidence-based tools to support the development of more positive attitudes, given the importance of their leadership role in mental health services.
A number of attitudes were positively associated with some forms of preventive care, including the belief that providing preventive care was congruent with their role, that clients were interested in changing their health behaviours, and that addressing health risk behaviours would not jeopardise the client-clinician relationship. The finding of a negative association between clinicians reporting that clients find it acceptable to talk to them about their health risk behaviours, and the provision of some forms of preventive care is difficult to interpret. Although only speculative, it is possible that clinicians who perceive their clients to find such discussions acceptable are less likely to proactively engage with clients as they expect the client to initiate such discussions. The positive association results are consistent with previous research undertaken within Canadian community mental health care workers [
26] and UK psychiatric inpatient nurses [
27], whereby attitudes regarding role congruence, confidence in care provision, and client interest were associated with the self-reported provision of preventive care. Training and educational resources have been found to improve clinician attitudes and confidence towards providing physical health care to people with a mental illness [
54,
61], and the current results suggest that such strategies addressing negative attitudes may be required to increase preventive care provision.
Despite the study findings suggesting that the large majority of community mental health clinicians are positively predisposed to providing preventive care, the prevalence of such care provision has been reported to be sub-optimal [
20,
21,
23,
59]. Such a contradiction suggests that a gap exists between clinician attitudes and their professional practice; a gap that requires the implementation of additional practice change strategies if the intended benefits of international, national, and health service level preventive care guidelines [
35,
62,
63] are to be realised.
Research evidence supports the use of a variety of strategies in facilitating clinical practice change, including clinical leadership and consensus, enabling systems and procedures, training and support, and monitoring and feedback [
64‐
67]. It remains to be tested whether such organisational factors can increase the provision of preventive care within the community mental health setting. The study was undertaken within one local health district within one state in Australia, with a mandatory policy regarding the provision of preventive care to community mental health clients. It is unknown to what extent this policy may have impacted on clinician’s attitudes towards the provision of preventive care, hence, the generalizability of findings to other regions, jurisdictions or nations is unknown. The prevalence of preventive care delivery was self-reported by clinicians, and as such may have been influenced by demand characteristics and may not reflect actual care provided. Further, due to the relatively small number of psychologists, occupational therapists and social workers, the study examined the attitudes and practices of these allied health clinicians as a group. Future research should consider examining whether the preventive care attitudes and practices differ between different allied health disciplines.
Competing interests
The authors have no conflicts of interest to declare.
Authors’ contributions
Authors KB, JB, KR, MF, PW, KM, KG, ED, LW, and JW contributed to the research design and methodology and contributed to, read and approved the final version of this manuscript. Author KB led the development of the manuscript and the data analysis.