Kirsti Haracz

Occupational therapy and obesity: An integrative literature review

BACKGROUND/AIM Obesity is a significant public health concern globally. It is associated with poor physical health, mental health and subjective well-being and limitations on occupational participation. With its focus on the relationship between occupation, health and well-being, occupational therapy would appear to be well placed to address both the causes and consequences of obesity. The aim of this review was to explore the scope of the role of occupational therapy practice in this field and the supporting evidence base. METHODS Searches were conducted in four online databases and nine occupational therapy journals. Articles were included if they were theoretical, quantitative or qualitative research, explicitly related to occupational therapy and obesity, published in peer-reviewed journals, in English between 2002 and 2012. All research articles were critically reviewed and thematic analysis was conducted across all of the articles in the review. RESULTS Eight theoretical articles, 12 quantitative and two qualitative research studies were included. Only three were outcome studies. Thematic analysis identified four categories of focus of occupational therapy intervention: health promotion and prevention, increasing physical activity participation, modifying dietary intake and reducing the impact of obesity. Four categories of intervention strategies were also identified; assessment, modifying the environment, education and introducing and adapting occupations. CONCLUSION AND SIGNIFICANCE The findings of this review suggest a comprehensive role for occupational therapy in addressing obesity. However, the paucity of outcome studies mean that significantly more research is required to further define and provide a strong evidence base for occupational therapy practice in this emerging field.

How mental health occupational therapists address issues of diet with their clients: a qualitative study

BACKGROUND Poor diet is a contributing factor to the high rates of obesity and related comorbidities in people with severe mental illness, and dietary change is a key treatment strategy. Providing healthy lifestyle interventions is a recognised role for occupational therapists. However, the existing literature fails to elucidate boundaries of this role. To begin to address this gap in the literature, this study explored the attitudes, actions and beliefs of mental health occupational therapists about providing diet-related interventions. METHODS Semi-structured interviews were conducted with mental health occupational therapists working in one Area Health Service in New South Wales. Purposive sampling was used. Data were analysed using Constructivist Grounded Theory methods, where meaning is co-constructed by, and the theory ultimately grounded in the experiences of, the participant and researcher. RESULTS The participants felt confident providing clients with interventions to promote diet-related skill development and providing general healthy eating education to support this development. However, they were not comfortable providing clients with specific dietary advice. Participants identified a need for further training and support to enhance their effectiveness in providing healthy eating education and highlighted the need for more dietitians in mental health services. CONCLUSIONS The occupational therapists in this study identified clear boundaries of their role in providing diet-related interventions for people with severe mental illness. Suggestions for improvement in this area included further training for occupational therapists as well as increased access to dietitians for those services that lie outside the occupational therapy role.

Simulated patients in a mental health occupational therapy course: A pilot study:

Introduction The use of simulated patients is well established in medicine and nursing. There is little research evaluating the use of simulated patients in occupational therapy education and none which focuses on mental health. This study sought to determine the acceptability and effectiveness of using simulated patients in a mental health occupational therapy course. The pilot also sought to address the challenge of providing simulation experience to a large number of students in a cost and time effective manner. Method Occupational therapy students participated in a simulation which involved an initial interview assessment with an actor portraying a person with a mental health diagnosis. The students worked in small groups for the simulation, rotating into the therapist role using a carousel model. Students completed a survey about their experience of the simulation. Results The students rated the simulation experience highly in terms of authenticity and learning outcomes. Qualitative analysis of open-ended responses produced five themes: authentic experience, developing skills, feedback and reflection, we should do more of this, and developing the experience further. Conclusion The pilot was effective in allowing a large number of students to engage directly with the simulated patient without negatively impacting on the experience.

Occupational therapy intervention in mental health should be individualised, occupation focussed, promote inclusion and occur in the context of an authentic relationship.

Research objective: To describe perceptions of clients and carers regarding effective interventions used by occupational therapists in mental health. Design: Synthesis of qualitative research studies. Search strategies: CINAHL, AMED, ASSIA and Scopus were searched. Subject and keyword searches were conducted in the areas of: mental health disorders, occupational therapy, interventions used by occupational therapists and qualitative research. Selection criteria: Eligible studies included occupation-focussed interventions, occupational participation and performance tasks and provided detail about the nature of the interventions, the ways in which they were used, adoption of the interventions, and their perceived benefits. Interventions were carried out in settings where mental health occupational therapists work with adult or older adult populations and had a focus on mental health/illness. The studies were primary qualitative research, published between 2000 and 2011 in peer reviewed journals. Methods of review: Studies that met the inclusion criteria were appraised in terms of quality. Appraisal involved completing a four-point rating scale (scores ranged from 0 to 3) for seven criteria. Studies that scored 2 or 3 in at least five of the criteria were included in the analysis. Analysis was conducted in three stages, resulting in three tiers of themes. The analysis involved all three authors and meetings with three steering groups of clients and occupational therapy practitioners to review and help refine the themes at each stage. Main findings: Twenty-two papers met the criteria for inclusion in the analysis. Meta synthesis suggested four themes describing characteristics central to effective intervention: (i) professional artistry: the ability of the therapist to develop authentic trusting relationships and the use of sound professional reasoning and reflection illustrated through pragmatism; (ii) occupational engagement: clients valued creative activities, community focussed integration, vocational and home support and group work which provided opportunity for healing, self-rediscovery, identity formation participation and acceptance in the community; (iii) new horizons: supporting shifts in clients perceptions of themselves and their futures through awareness of client capacity and self belief, appreciation of the wider socio-cultural context, discussion of occupational gains and working through resistance; and (iv) inclusion: promoting client identity, participation and sense of belonging in relation to a range of socio-cultural contexts. Authors’ conclusions: Occupational therapists need to demonstrate their therapeutic effectiveness and impact on clients and carers occupational lives to enable the profession to be recognised for its contribution. Contact details for author of appraised paper: k.wimpenny@coventry.ac.uk

A behavioural weight-loss programme for overweight and obese adults with serious mental health illness significantly reduced weight over an 18-month period

Research objectives: To determine the effectiveness of a tailored behavioural weight-loss intervention in adults with serious mental illness. Design: Randomised controlled trial. Eligible participants were randomised to either the intervention group of a tailored weight-loss lifestyle intervention group or a control group that received standard nutrition/physical activity information at baseline, and quarterly health classes with content unrelated to weight. Individual participants were randomly assigned to the intervention or control group. Randomisation was stratified by sex and study site. Concealment of group allocation and blinding of data collectors to the study assignment was not reported in the study but confirmed with the first author (personal communication). Analyses were conducted according to the intention-totreat principle. Setting: Participants were recruited from 10 community psychiatric rehabilitation outpatient programmes in United States of America. Participants: Two hundred and ninety-one participants were randomised to an intervention (n = 144) or control group (n = 147). Diagnoses included 58.1% with schizophrenia or a schizoaffective disorder, 22.0% a bipolar disorder, and 12.0% major depression. Intervention: The behavioural intervention was tailored to address deficits in memory and executive function. The intervention included group and individual weight-management sessions, and group exercise sessions. The intervention aimed to promote: reduced caloric intake; eating five total servings of fruits and vegetables daily; choosing smaller portions and healthy snacks; and participating in moderate-intensity aerobic exercise. Exercises were graded in duration and intensity. Session attendance was incentivised with small reward items. Participants monitored key behaviours using a simplified tracking tool; and intervention staff monitored weight. Treatment fidelity was assured through the use of standardised procedures and materials, ongoing training and regular observation of intervention staff. Outcome measures: Primary outcomes were changes in weight from baseline to 6 months and 18 months. Weight data were obtained within a 45-day window before or after the data collection points. Results: When compared with the control group, the mean net weight loss in the intervention group was significantly greater at 12 months (P = 0.001) and 18 months (P = 0.02). Furthermore, at 18 months, the mean between-group difference in weight was 3.2 kg (P = 0.002); 37.8% of the participants in the intervention group and 22.7% of those in the control group lost 5% or more of their initial weight (P = 0.009). There were no significant between-group differences in adverse events. Author’s conclusions: The behavioural weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness, suggesting that overweight and obese adults with serious mental illness can make substantial lifestyle changes. Contact details of original author: gdaumit@jhmi.edu

It’s like another world: the perceived beneficial effects of an artistically designed multisensory environment

Self-management strategies have been identified as having a key role in supporting mental health and preventing mental illness. Evidence suggests that spending time in nature, experiencing or viewing artwork and accessing sensory rooms all support self-management and positive mental health among varied clinical populations. This evidence informed the design of the sensory–art space (SAS), an artistically designed multisensory environment, which drew on themes and images of nature. The aim of this study was to explore the experiences and perceived benefits of the SAS among members of a university community. A maximum variation approach to sampling was used, and 18 participants were included in this qualitative study. Data were gathered via semi-structured interviews, which were audio-recorded and transcribed verbatim for thematic analysis. The findings presented six themes. The two core themes were: it’s like another world, and easy to focus and describe how the SAS produced the beneficial effects described in the four remaining themes of: emotionally nutritious, meditative effects, relaxation and therapeutic. Participants identified beneficial effects of the SAS that were consistent with the evidence for other self-management strategies. The identified benefits also aligned with existing theories suggesting that the SAS functioned as a restorative environment. This study is the first to explore the experience of art in a multisensory and multidimensional capacity, which further contributes to the growing field of receptive engagement with the arts for health outcomes.

The role of occupational therapists in the provision of dietary interventions for people with severe mental illness: Results from a national survey:

Introduction People living with severe mental illness are at least twice as likely to be obese as the general population, partly due to lifestyle risk factors including poor diet quality. This study aims to quantify how Australian mental health occupational therapists address the dietary issues of people with severe mental illness. Method A 23-item cross-sectional online survey was distributed via email to all members of Occupational Therapy Australia, with those working in mental health (an estimated 305 members) invited to participate. Response frequencies were analysed in SPSS. Open-ended comments were subjected to thematic analysis. Results Eight-six eligible participants (28.2% of the target population) completed the full survey. Most (81%) felt confident in providing healthy eating advice, with 76% reporting being self-educated about nutrition. Dietitian support for complex advice was seen as beneficial by 88%, but only 30% reported reasonable access to dietitians. Qualitative themes included: accessing dietitians, information and education, and putting advice into practice. Conclusion There is potential to enhance the credentialling and continuing education of occupational therapists and improve inter-professional collaboration with dietitians to assist the occupational therapist in achieving better health and reducing the burden of chronic disease for people experiencing severe mental illness.

Significant improvements in weight, body mass index and waist circumference for participants at the end of a 10-week health promotion intervention for people with mental disorders were not maintained at the six-month follow-up.

[Extract] The physiological, psycho-social and cognitive benefits of regular physical activity (PA) have been well documented for the general population. Less evidence is available on the benefits of exercise for individuals with mental disorders (Alexandratos, Barnett & Thomas, 2012). This paper goes someway to address this issue. The use of a cluster preference randomised controlled trial design was an appropriate choice to reduce the risk of contamination bias. However, the addition of preference design may have introduced volunteer and measurement bias. The small but significant results in primary outcomes may be due to intervention limitations.