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ORIGINAL PAPER
A Qualitative Study of Social Facilitators and Barriers to HealthBehavior Change Among Persons with Serious Mental Illness
Kelly Aschbrenner • Elizabeth Carpenter-Song •
Kim Mueser • Allison Kinney • Sarah Pratt •
Stephen Bartels
Received: 27 October 2011 / Accepted: 18 September 2012 / Published online: 29 September 2012
� Springer Science+Business Media New York 2012
Abstract This qualitative focus group study was con-
ducted to explore social facilitators and barriers to health
behavior change in persons with serious mental illness
engaged in a healthy lifestyle intervention. Six focus group
interviews were conducted with a total of 30 clients strat-
ified by ‘‘high’’ and ‘‘low’’ achievers in the program based
on clinically significant weight loss or significant increase
in fitness. Thematic analysis of focus group discussions
revealed that emotional, practical, and mutual support from
family members and significant others were social facili-
tators to health behavior change, while unhealthy social
environments was a barrier. Participants in the ‘‘high’’
achiever group reported more mutual support for health
behavior change than participants in the ‘‘low’’ achiever
group. Results highlight the need for researchers and cli-
nicians to consider the potential role of family and signif-
icant others as health supporters for persons with mental
illness who could encourage healthy behavior in the social
environment.
Keywords Serious mental illness � Healthy lifestyle
intervention � Social support � Health behavior change
Introduction
The life expectancy of persons with serious mental illness
is an alarming 25–30 years less than that of the general
population (Colton and Manderscheid 2006). The main
cause of this early mortality is cardiovascular disease
associated with modifiable risk factors such as obesity,
sedentary lifestyle, poor diet and smoking (Daumit et al.
2008; Mitchell and Malone 2006). While many adults in
the general population struggle to change their health
habits to lose weight and improve cardiovascular health,
mental illness is associated with cognitive, mood, and
motivational challenges (Beck et al. 2009; Seidman et al.
1992), making it especially difficult to modify diet and
develop an exercise routine. Recent health promotion
interventions for the general population have addressed the
challenge of making lifestyle changes by harnessing social
support from family and friends who can reinforce, prompt,
and help monitor desired diet and exercise behaviors
(Gorin et al. 2005; Kahn et al. 2002; Wing and Jeffrey
1999). In contrast, scant attention has been paid to the role
of social support in healthy lifestyle interventions for per-
sons with serious mental illness. Given the mounting evi-
dence that social support is a key factor in overcoming
barriers to lifestyle change (Fraser and Spink 2002), fam-
ilies and significant others present a potentially important,
yet untapped source of support for health behavior change
for this population.
Poor health habits are common among people with
mental illness. Fewer than 20 % of individuals with
schizophrenia report one or more periods of moderate
exercise weekly (Brown et al. 1999), compared to 40 % of
adults in the general population who engage in moderate-
intensity physical activity at least 5 days per week (CDC
1996). In addition, poor diet is a major problem in persons
K. Aschbrenner (&) � K. Mueser � A. Kinney � S. Pratt �S. Bartels
Dartmouth Center for Aging Research, 46 Centerra Parkway,
Box 201, Lebanon, NH 03766, USA
e-mail: kelly.aschbrenner@dartmouth.edu
E. Carpenter-Song
Dartmouth Psychiatric Research Center, 85 Mechanic Street,
Suite B4-1, Lebanon, NH 03766, USA
123
Community Ment Health J (2013) 49:207–212
DOI 10.1007/s10597-012-9552-8
with schizophrenia, including lower consumption of fruits,
vegetables, and fiber, and consumption of more calories
and saturated fats compared to the general population
(Allison et al. 1999; Jones et al. 2004). Lifestyle inter-
ventions adapted to persons with serious mental illness
show promise in promoting weight loss and reducing risk
factors for metabolic syndrome (Cabassa et al. 2010),
although the results of research indicates modest and mixed
outcomes (Faulkner and Biddle 1999; Hutchinson 2005;
Stathopoulou et al. 2006). These findings highlight the
need to further improve the effectiveness of healthy life-
style interventions. Harnessing support from people in
participants’ daily lives, such as family members and sig-
nificant others, may be a key resource for facilitating health
behavior change.
Social support interventions for people with serious
mental illness have primarily focused on teaching family
members about mental illness and its treatment, and
reducing stress and tension in family relationships
(McFarlane et al. 2003), but not on promoting change in
health behavior. This exploratory qualitative focus group
study was designed as a first step toward understanding the
potential role of family members and significant others in
supporting health behavior change among persons with
serious mental illness. We sought to explore social facili-
tators and barriers to health behavior change among par-
ticipants engaged in a healthy lifestyle program for persons
with serious mental illness (In SHAPE) embedded within
community-based mental health settings.
Methods
The study was conducted at three public mental health
centers, including two in New Hampshire and one in Bos-
ton. Participants had serious mental illness (schizophrenia,
schizoaffective disorder, major depression, or bipolar dis-
order) and were enrolled in In SHAPE, an integrated health
promotion program specifically designed to improve phys-
ical fitness through dietary change and increasing exercise
in adults with serious mental illness (Van Citters et al.
2010). The program embeds health promotion within
community-based mental health services by providing each
participant with a health mentor, who helps him or her
develop a personal health plan and provides ongoing edu-
cation, assistance with goal setting, and motivational sup-
port through weekly, individual, 1-hour contacts.
Inclusion criteria for participating in the study were: (1)
enrollment in In SHAPE for a minimum of 6 months; (2)
attendance in over 50 % of meetings with their health
mentor over a 6 month-period; and (3) face-to-face contact
with a family member or friend at least twice in the past
month. Separate focus groups were conducted with high
and low achiever participants in the In SHAPE program.
There are substantial health benefits to both improving
cardiorespiratory fitness and losing weight, particularly for
obese individuals. For example, improved cardiorespira-
tory fitness in obese adults in the general population is
associated with a significant reduction in cardiovascular
risk, independent of change in body weight (Lee et al.
2010). However, research indicates that weight loss may
improve survival in those who have an obesity related
disease (Williamson et al., 2000). Therefore, we assessed
both increased fitness and weight loss as indicators of
success in the present study.
Consistent with qualitative methods, we relied on the
expert judgment of key informants (health mentors) to
identify participants who most emulated high versus low
achievement in the program. Health mentors classified
participants as ‘‘high’’ achievers if they had a clinically
significant weight loss (5 % of baseline body weight) or a
significant increase in fitness over the past 6 months based
on the health mentor’s assessment of participant’s exercise
capacity. Specifically, health mentors were instructed to
assess participant’s level of fitness based on three areas:
increased endurance, stamina, and/or muscle strength.
Examples include being able to engage in longer exercise
sessions and/or higher intensity workouts. Health mentors
identified ‘‘low’’ achievers among participants who were
engaged in the program but did not achieve either of these
criteria. Health mentors assessed the participant’s weight
and fitness during a weekly session with participants at the
time of the study.
A total of 30 people participated: 15 men and 15
women. The participants had a mean (SD) age of 48.23
(8.2) years, 7 % of participants were married, and 33 %
were living with a family member or a significant other at
the time of the interview. The majority of participants
(86 %) were Caucasian, and 73 % had a diagnosis of
schizophrenia or schizoaffective disorder. Four Institu-
tional Review Boards (IRBs) approved the research across
three sites. All participants provided either written or ver-
bal consent depending on the requirements of the IRB
affiliated with the organization from which they were
recruited.
We conducted six focus groups, each consisting of three
to eight persons. Of the 30 participants, 10 participated in
three low achiever groups and 20 participated in three high
achiever groups. We elected to use the focus group tech-
nique because it would enable us to learn about a wide
range of social facilitators and barriers in an interactive
setting where participants could relate to one another’s
experiences. The semi-structured, facilitated discussions
covered the ways in which family members and significant
others supported or interfered with participants’ efforts to
make desired changes in diet and exercise. During each
208 Community Ment Health J (2013) 49:207–212
123
session, one facilitator guided the discussion while a sec-
ond operated the audio recorder, took thematic notes, and
acted as a secondary facilitator. We used a focus group
topic guide that followed the ‘funnel structure’ described
by Krueger (1994). Broad questions were asked at the
beginning of the interview and the facilitator gradually
proceeded to more specific questions related to the research
objectives. Sessions lasted 60–90 min and participants
were each compensated $25 at the end of the group.
The audio-recordings were transcribed and all identify-
ing information was deleted. We used standard thematic
analysis to analyze the transcripts. Thematic analysis is the
systematic examination of text by identifying and grouping
themes and coding, classifying, and developing categories
(Whitley and Crawford 2005). After creating broad cate-
gories based on research objectives and interview notes,
transcripts were coded by the primary author and a mas-
ter’s level research assistant. We used multiple coding to
reduce the risk of investigator bias (Whitley and Crawford
2005). Both authors independently examined the data
before inspecting each other’s coding scheme. After dis-
cussion, both authors agreed on the prominence of the
themes listed in the results. We identified six initial themes
in the exploratory phase of data coding. However, we
merged two themes together with a broader theme once we
identified significant conceptual overlap between themes.
Thus, we report and discuss the four final themes in the
present study. The authors know of no conflicts of interest
regarding the planning, conduct, analysis, or interpretation
of the study. All authors certify responsibility for the study.
Results
The primary social facilitators of health behavior change
described by In SHAPE participants included emotional,
practical, and mutual support from family members and
significant others. Participants in the high achiever focus
groups reported more instances of mutual support for
health behavior change than participants in the low
achiever focus group. The most prominent barrier identi-
fied in both groups was unhealthy social environment. Each
theme is discussed briefly below.
Social Facilitators
Emotional Support
Participants cited empathy, validation, praise and encour-
agement from family members and significant others as
supporting their efforts to achieve their health goals. One
participant described receiving praise from friends when
she lost weight: ‘‘My friends noticed that I lost a lot of
weight, they go, ‘You’re losing weight, I can tell,’ which is
true, I lost a lot of weight, I lost a pants size, I’m skinnier.
And it’s very nice to hear that from your friends, ‘Gee, you
look better,’ so I’m on the right road.’’ Some participants
described ways in which their family members and friends
provided much needed encouragement to exercise. As one
participant stated, ‘‘I guess it’s because it’s a little moti-
vator. It’s like I can’t get away with it [skipping the gym].’’
Participants found it especially helpful when family
members and friends reinforced the idea that exercise
would make them feel good. One participant described how
her parents helped motivate her to get to the gym: ‘‘They’ll
tell me, ‘You need to go to the gym. Think how good you’ll
feel afterwards’.’’
Practical Support
Practical support included tangible assistance that facili-
tated participants’ dietary changes or engagement in
physical activity. For example, several participants
received help with transportation to a fitness facility or
recreational area. Assistance with transportation appeared
to combine practical and emotional support for some par-
ticipants. One participant explained that getting a ride from
a loved one provided the motivation needed to go to the
gym: ‘‘My husband drives me there [to the gym] even
when I don’t want to be there. I can walk. It’s not that far
from my house to the gym, but it’s just that some days I
don’t want to leave the house and he’ll say, ‘Get your shoes
on,’ and ‘We’re leaving.’ It’s just that little push. And then
when I get there, I’m okay, but it’s just getting from the
house to where I’m going.’’
Practical support for dietary changes included willing-
ness on the part of others to make compromises and set
limitations on dining out. One participant commented that
her friends were willing to meet her for dinner at restau-
rants that offered low-calorie menus that would not sabo-
tage her diet. Several participants found it useful when a
family member or significant other reviewed their food
intake or helped them with food portion size.
Mutual Support
Mutual support occurred when participants and their family
members or significant others supported each other’s
efforts to make lifestyle changes. Participants remarked
that it was easier to stick to dietary or exercise goals when
they had friends or family members with similar health
goals. One participant remarked: ‘‘My girlfriend is in the
program [In SHAPE] with me. Actually, I found out about
the program through her. She told me about it and I was
interested. So, we sort of help and support each other. We
try to push each other, like maybe I don’t really want to go
Community Ment Health J (2013) 49:207–212 209
123
to the gym but she is going so she’ll say, ‘Why don’t you
come along,’ and I eventually do go, and I feel better
afterwards. And I’ve said, ‘Why don’t you come with
me?,’ just so she’ll go more consistently. So we’ve helped
each other.’’ These factors appeared to facilitate success in
the In SHAPE program as participants in the high achiever
focus groups reported more instances of mutual support for
health behavior change.
Social Barriers
Unhealthy Social Environment
Unhealthy social environments included repeated exposure
to the poor eating habits and sedentary lifestyles of family
members and significant others. Many participants felt that
they were set up for failure when time with family and
friends involved exposure to ‘‘junk food’’ high in calories,
fat, and sugar and low in nutritional content. One partici-
pant explained that as a caregiver to her mother, she does
her grocery shopping, which includes buying junk food. As
a reward for shopping, her mother offers to share the food
even though it undermines her goal of improving her diet:
‘‘I do a lot of her shopping, so I actually have to go buy
crap, all the sweet stuff and junk. And then it’s really hard
not to share that with her when I get back, and not eat it and
want it. I go to her house and put everything away and give
her bag of treats, and she starts opening and putting it
away. ‘Want one?’ Stop asking me if I want one, I’ll
always say ‘yes’!’’
Many participants reported that they were challenged by
temptations at social gatherings, and some described giving
into the pressure from family and friends to engage in poor
health behaviors like overeating and drinking. One partic-
ipant described how her family members piled the food on
her plate and encouraged her to drink during holiday meals:
‘‘One plate isn’t going to hurt you,’’ but the plate is like this
[gestures] big, and it’s all mounded, it’s huge, and then
everyone had to have a drink, and I’m like, ‘I don’t drink
anymore,’ But one drink turns into…they have an open bar.
My father-in-law makes them pretty stiff. So, everyone is
drunk by 2 o’clock in the afternoon.
Discussion
Participants’ descriptions of social facilitators and barriers
to health behavior change were similar to those identified
in studies of people without mental illness trying to lose
weight (Falba and Sindelar 2008; Novak and Webster
2011). Participants described the advantages of reciprocal
relationships in which they gave and received support for
healthy behaviors, including the fact that engaging in
dietary changes and physical activity was easier when done
with a partner who was also committed to achieving health
goals. Mutual engagement in healthy eating and exercise
seemed to facilitate success in the In SHAPE program as
participants in the high achiever focus groups reported
more instances of mutual support for health behavior
change. Research in the general population suggests that
involving supportive partners in behavioral weight control
treatment is effective at producing both initial weight loss
and maintenance of weight loss over time (Wing and Jef-
frey 1999), and studies indicate that the strongest effects
occur when partners are themselves successful at losing
weight (Gorin et al. 2005).
The link between social environments and health
behaviors has long been recognized in the general popu-
lation (Berkman 1995), and the presence of unhealthy
social environments was noted as a prominent barrier to
health behavior change in this study. Participants often
reported that their family members and significant others
have poor eating habits and sedentary lifestyles, and
emphasized that social environments often exposed them to
junk foods that triggered overeating. Social contextual
factors, including social values and norms, have been
shown to influence nutrition practices and physical activity
in a variety of populations, including working-class, multi-
ethnic adults (Emmons et al. 2007) and college students
(Okun et al. 2003).
While the social barriers and facilitators to health
behavior change described by persons with serous mental
illness in this sample were similar to those documented in
the general population, people living with serious mental
illness face a unique set of challenges that could be
addressed in future healthy lifestyle interventions. First, the
metabolic effects of psychiatric medications make weight
loss especially challenging, even when engaged in exercise
and dietary interventions. A recent comprehensive review
failed to identify any interventions achieving a mean 5 %
weight loss (considered to be clinically significant) for
people with serious mental illness (Verhaeghe et al. 2011).
Hence, it may be especially important to educate family
members and significant others about the special challenge
for weight loss for a person on psychoactive medications so
that they may provide continued encouragement and rein-
forcement to help their loved one overcome self-doubt in
the face of setbacks and help to maximize the potential to
achieve progress.
Second, people with SMI have higher rates than the
general population of other unhealthy lifestyle behaviors
such as substance use disorders (Dixon1999) and smoking
(de Leon and Diaz 2005) that may undermine attempts to
achieve a lifestyle change in diet and exercise, requiring
additional positive social support in the natural environ-
ment where temptation may be highly prevalent. Health
210 Community Ment Health J (2013) 49:207–212
123
interventionists could attempt to engage family members
and significant others as key partners who can help indi-
viduals with serious mental illness successfully cope with
social-environmental triggers for substance use and ciga-
rette smoking. This may ultimately increase the ability of
participants to achieve and maintain health goals.
Third, improving communication skills and social sup-
port may be an important component of future healthy
lifestyle interventions for some individuals. Poor commu-
nication skills and difficulty initiating and sustaining social
relationships are among the most disabling impairments
experienced by individuals with serious mental illness
(Mueser and Bellack 1998). Participants who have diffi-
culty articulating their diet and exercise goals to family
members and significant others may fail to receive the
support they need to make health behavior changes. Par-
ticipants may benefit from learning how to effectively
request support and help from family and friends. Similarly,
limited communication skills and lack of support by family
members and significant others can undermine attempts by
individuals with serious mental illness to change their
health behaviors. Improving these skills in family members
could reduce criticism and tension, and facilitate healthy
behavior change in participants working on these goals.
Family-oriented interventions for the management of
medical conditions in the general population have been
categorized into two primary types: (1) educational inter-
ventions that inform patients and family members about the
disease with the goal of increasing knowledge and self-
management; and (2) interventions that address interper-
sonal relationships, with the goal of improving family
functioning with respect to health (Hartmann et al. 2011).
Such models have yet to be adapted for families coping with
the challenges of both mental illness and physical health
problems, despite the fact that family psychoeducation is an
evidence-based practice for improving the course of serious
mental illness (McFarlane et al. 2003). For healthy lifestyle
interventions to be optimally beneficial for this population,
family members and significant others may need informa-
tion about their relative’s physical and mental health
problems and health promotion techniques.
Potential limitations of this study include the relatively
small sample size and imbalance in the number of partic-
ipants in the low versus high achiever focus group inter-
views. Of the 30 participants, 10 met criteria for low
achievers and 20 were high achievers. However, the overall
sample size (n = 30) is consistent with both qualitative
methods (Miles and Huberman 1994) and the intent and
scope of a pilot study aimed at determining feasibility and
achieving preliminary descriptive findings (Leon et al.
2011). At the outset, we identified fewer In SHAPE par-
ticipants in the low achiever group who met the study
criteria of face-to-face contact with a family member or
friend at least twice in the past month. Recruitment
methods were the same for both the low and high achiever
groups; yet the lower representation in the low achieving
group may be reflective of fewer contacts with family
members and significant others in this group overall.
Despite this limitation, the focus group interview data
collected was sufficient to identify important differences in
social facilitators and barriers to health behavior change
between the high and low achiever groups.
Conclusions
Preliminary findings from this study of focus groups
comparing high and low achievers in a health promotion
intervention suggest that social environments of persons
with serious mental illness have an impact on health
behaviors, including diet and exercise. As in the general
population, family members and significant others of per-
sons with serious mental illness have the potential to
engage as key partners to maximize the potential effec-
tiveness of healthy lifestyle interventions. Researchers and
clinicians designing future healthy lifestyle interventions
for this population should consider the potential role of
family members and significant others as health supporters,
and evaluate what types of information and communication
skills would most beneficial to them in this role.
Acknowledgments The authors thank the Dartmouth Medical
School Department of Psychiatry Gary Tucker Junior Investigator
Award for funding this study. The In SHAPE study was supported by
grants R01 MH089811 and R01 MH078052 from the National
Institute of Mental Health.
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