Health disparities among individuals with major mental disorders served by the public mental health system negatively affect their quality of life and shorten their lives. In the current study, major mental disorders are defined as schizophrenia and psychotic disorders, bipolar disorder, depression, anxiety, and posttraumatic stress disorder (PTSD). The focus is on individuals served by the pubic mental health system, as this is the population where high and disproportionate rates of morbidity and early mortality were originally identified (Parks, Svendsen, Singer, & Foti, 2006). Shortened life spans and poor health-related quality of life are related to high levels of respiratory diseases, diabetes, and cardiovascular disease in this population (Liu et al., 2017). In addition, individuals with major mental disorders often have the greatest functional challenges, as evidenced by the high rate of access of Social Security Disability Insurance (SSDI) benefits (i.e., 19% of SSDI enrollees in 2013; Social Security Administration, 2014).
The negative health effects of living in poverty play a role in these disparities, contributing to barriers in accessing quality health care (Ewart et al., 2017). Other risk factors for morbidity and mortality among individuals with major mental disorders include high rates of smoking, substance use and misuse, obesity, and sedentary lifestyle; experience of trauma; and side effects from psychotropic medications (Liu et al., 2017). A sedentary lifestyle has become increasingly recognized as a health risk for the general population (Thyfault, Du, Kraus, Levine, & Booth, 2015; Vancampfort et al., 2017; Warburton & Bredin, 2016), and is an increasingly alarming concern for individuals with major mental disorders. Literature indicates that a sedentary lifestyle may contribute to cognitive performance deficits (Stubbs, Ku, Chung, & Chen, 2017) and physical health problems (Stubbs et al., 2015) for individuals with schizophrenia. Moving more, even slightly more, may be beneficial for individuals diagnosed with major mental disorders (Vancampfort, Stubbs, Ward, Teasdale, & Rosenbaum, 2015a,b).
There is need for individuals served by the public mental health system to engage in low cost, functional, and practical strategies for adopting healthy lifestyle behaviors, such as walking. Walking is a popular and preferred physical activity for many individuals, with more than 145 million adults choosing to walk to accomplish physical activity goals (Centers for Disease Control and Prevention, 2012). Walking is an accessible and safe activity. Part of what makes walking so accessible is that it is free, requiring no specialized equipment or membership fee, and it creates opportunities to support engagement in other daily living activities. The current study explores the benefits of walking and suggests strategies for promoting walking among community-dwelling individuals with major mental disorders. Although walking likely also could benefit individuals living in restricted environments, such as inpatient facilities (Loh, Abdullah, Abu Bakar, Thambu, & Jaafar, 2015; Vanroy, Seghers, Bogaerts, Wijtzes, & Boen, 2017), the challenges of promoting walking in these settings are significant. Therefore, the current study focuses on individuals who are living in the community, whether independently or in a supervised setting.
Benefits of Walking
Walking is an activity associated with numerous health benefits. Walking is a highly prevalent form of activity that can be done at work, home, and during leisure time, making it a logical choice for health promotion efforts. This section briefly describes the benefits of walking for the general population, followed by benefits identified in the literature for individuals with major mental disorders.
Benefits of Walking for the General Population
The current recommendation for physical activity is 150 minutes of moderate physical activity per week (Vancampfort et al., 2015a), or approximately 30 minutes at least 5 days per week. A recent systematic review of the relationship between physical activity and risk of disease concluded that individuals who achieve total physical activity levels several times higher than this recommended minimum level have a significant reduction in the risk of breast and colon cancer, diabetes, ischemic heart disease, and ischemic stroke events (Kyu et al., 2016). However, any increase in physical activity may provide benefits (Warburton & Bredin, 2016), especially for individuals with major mental disorders (Vancampfort et al., 2015a).
Walking at a pace of 3 miles per hour is considered a moderately intense physical activity (Ogilvie et al., 2007) and may reduce risk of premature death. A study of more than 1,200 Japanese men in their mid-60s to early 70s, part of an ongoing age-specific prospective cohort study, showed that daily walking for ≥2 hours per day was associated with lower mortality, regardless of health status; and walking 1 to 2 hours per day was associated with decreased mortality for men with critical diseases such as heart disease or cancer (Zhao et al., 2015). Walking also may reduce medical costs, as concluded by the authors of a modeling simulation related to diabetes in middle-aged Japanese individuals, based on national population statistics (Kato et al., 2013).
Benefits of Walking for Individuals with Major Mental Disorders
Walking is a preferred physical activity and common mode of transportation for individuals with psychotic disorders (Stubbs, Firth, et al., 2016). In one survey of individuals with schizophrenia or bipolar disorder (N = 173), walking was rated the most popular physical activity (Subramaniapillai et al., 2016). Moderate physical activity (e.g., walking) can help individuals with major mental disorders improve their cardiovascular health and cognition (Stubbs, Firth, et al., 2016). One systematic review of 39 published studies (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014) found that physical activity interventions reduced symptoms of individuals with depression and schizophrenia. Although many individuals with schizophrenia meet current guidelines for regular moderate physical activity (Stubbs, Firth, et al., 2016), many others do not (Beebe & Harris, 2013), making the support of walking interventions of critical importance for this population to improve physical and mental health outcomes.
Walking Interventions for Individuals with Major Mental Disorders
Four walking intervention studies conducted with adults with major mental disorders are described. Although most individuals can initiate a walking program on their own, someone who has a physical health concern and/or has had physical limitations may benefit from the guidance and support offered by a structured intervention. Individuals with a medical condition should consult a primary care provider before starting an exercise program. There are assessment scales available to determine risk associated with program participation (e.g., PARQ+ [Canadian Society for Exercise Physiology, 2011]).
Study 1: WALC-S
The WALC-S study included 97 adults with schizophrenia spectrum disorders, using a time-and-attention control group design (Beebe et al., 2011). The experimental and control conditions each involved a group of eight participants that met weekly for 4 weeks. The 4-week control groups focused on health behaviors other than exercise, including smoking cessation and medication adherence. The 4-week experimental groups included content on:
- walking information (W), such as walking safely, using warm up and cool down exercises, and setting individualized goals for exercise and/or group attendance;
- addressing sensations (A) related to the warm up and cool down exercises and suggestions for reducing exercise discomforts;
- learning about exercise (L), its benefits, and how to overcome barriers to exercise; and
- cueing exercise (C) using pre-marked calendars noting walking days and times.
Reminder calls were made before each WALC-S group and individuals who missed a group received a follow-up call. Following the 4 weeks, all participants went on to a 16-week walking group that built up gradually to 30 minutes of walking. Participants in the experimental condition (the four pre-walking WALC-S sessions) attended more walking groups, persisted for longer time periods, and walked more minutes than individuals in the control condition (Beebe et al., 2011).
Study 2: Telephone-Based Intervention
A small randomized control pilot study (Lee, Kane, Brar, & Sereika, 2014) used an 8-week intervention where participants were expected to walk on their own, with a goal of 30 minutes of moderate walking per day. All participants were diagnosed with a schizophrenia spectrum disorder, bipolar disorder, or major depression. Following an enrollment interview that gathered health data, provided a pedometer, and offered instructions and guidance for meeting physical activity guidelines, participants were contacted once per week by telephone. The calls provided support, guidance, and problem solving, such as ideas for meeting the walking goal during inclement weather (e.g., mall walking). The initial enrollment in the experimental walking condition was low (N = 12), with eight participants completing the full 8 weeks (33% attrition). The control group, receiving treatment as usual, enrolled 10 participants, with two drop outs (20% attrition). Some positive changes in health outcomes (e.g., body mass index) were noted; however, the results were not statistically significant. Although the control group was more active than the experimental group, on average (five of eight participants completing the control group met the 30-minute per day target at baseline), participants assigned to the walking condition increased their physical activity compared to participants in the control condition. Six of eight individuals who completed the 8-week intervention achieved the target of 30 minutes per day by the end of the study period. Participants reported that using the pedometer motivated them to walk (Lee et al., 2014).
Study 3: WellWave
Eleven participants with a schizophrenia spectrum disorder, bipolar disorder, or major depression were included in a feasibility study using a smartphone application (app) to document walking (i.e., walking speed and steps taken) (Macias et al., 2015). After an initial orientation and training session, participants used the app for 4 weeks. Ten participants completed the 4 weeks; one participant left the study to train for a half marathon. The app included prompts to walk. The daily use of the app was high (averaging 94% of days over the 4-week period), but usage included survey and task completion, not just walking. Of the 10 participants who completed all 4 weeks, seven walked at least twice per week, averaging walks of 15 to 36 minutes, with some walking all 7 days during the week. Self-rated physical health improved for three participants; none declined. No objective health measures were reported.
Study 4: Work Out by Walking
A pilot study of 16 individuals with schizophrenia spectrum disorder (Browne, Penn, Battaglini, & Ludwig, 2016) used a 10-week group intervention. To maximize support, components of the intervention included pedometers, goal-setting groups to select a target step count for each week, supervised and unsupervised walk times, and daily check-ins to monitor pedometer use and step counts. Leaders of the supervised groups encouraged social interaction by exploring participant walking experiences. Financial incentives were offered for group participation and completion of research assessments. This exploratory study did not include a comparison group. Attendance was reasonably high throughout the 10 weeks (84%) and participants were consistent in using their pedometers (86%). Over the course of the intervention, participants' step counts increased, with four of 16 participants achieving the recommended 10,000 steps per day. Other positive outcomes at posttest included symptom improvement and modest improvements in resting heart rate, self-rated quality of life and physical health, and social support. However, not all benefits were sustained at 1-month follow up. Participants reported overall satisfaction with the program and identified the two strongest motivators for walking as health benefits and social support offered.
Walking Intervention Summary
Three of the four studies reviewed were small pilot studies and the fourth (Beebe et al., 2011) had a small sample, as described by the authors, preventing confident conclusions from any of these studies. Variations in study design also prevent cross-study comparisons. Two studies enrolled individuals with a mix of diagnoses; two enrolled only individuals with a schizophrenia spectrum disorder. Two studies focused on solo walking, one included the option of a walking group, and one enrolled everyone in a walking group. In addition, the studies used different components (e.g., two used pedometers, whereas a third used a smartphone app). All used some sort of prompt, reminder, or check-in; however, the prompts varied in purpose, duration, and frequency. As with other lifestyle interventions for individuals with major mental disorders, it is not yet possible to recommend specific components for a walking intervention.
Despite study limitations, some promising outcomes may be noted from these few studies. First, some individuals will adhere to a program over multiple weeks. Although there were some drop-outs reported, attrition is not unusual in walking interventions with other populations. For example, the review of walking interventions for varied populations by Ogilvie et al. (2007) included studies with up to 30% attrition rates, whereas one meta-analysis of 19 studies of physical activity interventions for individuals with schizophrenia showed a drop-out rate of 26.7% (Vancampfort et al., 2016) and another (Pearsall, Smith, Pelosi, & Geddes, 2014), looking at eight randomized controlled trials of exercise interventions for individuals with major mental disorders, found an attrition rate of only 18.9%. Second, participants in three of the four studies reviewed herein reported satisfaction with and/or benefits from the interventions. Third, although published reports (Beebe & Harris, 2013; Stubbs, Firth, et al., 2016) and clinical experience suggest many individuals with major mental disorders are sedentary, these four studies reported some participants improving and adopting the walking routines, and three of the four reported some participants being at or near the recommended level of 150 minutes of activity per week or the suggested 10,000 steps per day. Walking seems to be a viable option for individuals with major mental disorders to increase their level of physical activity.
Based on the research literature discussed above and the experience of the current authors, several areas might be considered when promoting walking for individuals with major mental disorders. These areas include strengthening engagement; setting goals and developing plans; tracking progress and sustaining participation; and nurses' roles in prompting and supporting lifestyle changes for improved health, longevity, and quality of life.
As with any sort of prescription, recommendations from health care providers for physical activity are not always followed; therefore, providers must consider ways to support individuals in initiating lifestyle changes that are known to be beneficial. Evidence is lacking related to the best way to motivate individuals with major mental disorders to start walking more. A systematic review of various physical activity interventions for this population (Farholm & Sørensen, 2016) concluded that intervention studies to date do not provide guidelines for enhancing motivation to engage in physical activities and urged a systematic theory-based approach to developing strategies to strengthen engagement in physical activities such as walking.
Recognizing Health Risks and the Need for Exercise. One systematic review of motivating factors related to exercise (Firth et al., 2016) found that improving general physical health was the most endorsed reason (91%) for exercising in individuals with major mental disorders (six studies; N = 790; 95% confidence interval [CI], 80–94; Q = 81; p < 0.01; I2 = 94%). Similarly, participants with major mental disorders in a small intervention study (Browne et al., 2016) reported they were most motivated by the health benefits of walking. With health benefits as a primary motivational factor, nurses are uniquely positioned to support individuals with major mental disorders in the adoption of walking routines. For example, nurses are likely to notice health risk factors that other service providers may overlook, due to the frequency and amount of time nurses spend interacting with the target population. In addition to tracking typical health values such as blood pressure, blood sugar, and blood lipid levels, nurses can assess current levels of physical activity and barriers to walking or other physical activity. Providing feedback on individual's health may help prompt or support engagement in a walking program, especially if combined with education on the benefits of walking.
Starting With Choice. A systematic review of 66 studies focused on exercise in the general population (Teixeira, Carraça, Markland, Silva, & Ryan, 2012) found support for the importance of intrinsic motivation for engaging in and persisting with exercising, a finding confirmed in a study of physical activity in individuals with schizophrenia (N = 129; Vancampfort, Stubbs, Venigalla, & Probst, 2015). Exploring reasons for walking and ways to incorporate walking into daily habits and routines may be useful in group or individual interventions. For example, individuals might choose to schedule multiple short walks throughout the course of the day, instead of one lengthy walk, and still achieve the recommended level of exercise believed to produce health benefits. Some individuals might enjoy group walks; others might prefer solitary walks. Some might be most motivated by task-related walking to a specific destination, such as work, the post office, or library.
Setting Goals and Developing Plans
Individuals with major mental disorders may have cognitive limitations that interfere with planning and sustaining a walking program (Beebe & Harris, 2013) and may benefit from guidance and support in goal setting and developing a personal walking plan.
Using Specific Short-Term Goals and Plans. Intention formation was found to be a contributor to positive outcomes in a systematic review of interventions to promote walking and cycling in the general population (Bird et al., 2013), where the authors also recommend a “prespecified short-term goal” (p. 834). The use of self-selected goals to make small and manageable behavior changes is supported within the general population (Gardner, Lally, & Wardle, 2012).
Addressing Resource and Environmental Barriers. Although walking is free, some individuals may not own or be able to afford comfortable shoes. Providers or supporters can solicit financial support or donations of socks and sneakers from local businesses. Although research on this point is limited for individuals with major mental disorders, walking may be more likely for those with access to a safe place to walk outdoors (Firth et al., 2016). Many individuals with major mental disorders live in areas with low walk-ability, defined as “the extent to which the built environment supports and encourages walking” (Zandieh, Flacke, Martinez, Jones, & van Maarseveen, 2017, p. 742). For example, if someone lives in an economically depressed urban area with frequent crime, the benefits of walking may be outweighed by fear of (or experience with) being the victim of a violent or non-violent crime. Exploring the possible environments where someone might engage in an activity like walking is an important part of identifying what will be possible and preferable. Although a neighborhood may have low walkability, nurses can offer suggestions for overcoming barriers in the built and social environment and propose walking in a mall, walking with a group in a well-lit area, or using a walking DVD or streaming a walking video, among other options.
Reminders. Many individuals benefit from using prompts/cues and rewards when attempting to develop a new habit. Prompts may be built into self-monitoring devices such as pedometers or other wearables, smart devices, and apps. Individuals also may be prompted to use a self-monitoring device (Bird et al., 2013) by a credible and trustworthy source. Nurses and other service providers can use a coaching approach, in which the individual identifies preferred ways to receive support when creating a walking plan and brainstorms various ways to add cues and prompts into everyday life routines. For example, individuals could set reminders on their phones at certain times a day to alert them to get up and walk.
Social Support. Motivation for walking and enjoyment of the activity can be enhanced by social supporters. The social experience of walking and talking with someone can serve as the basis for more connections that can counteract loneliness or isolation. Social connections may be a primary motivational driver for participation in a walking group (Browne et al., 2016), and social support may be a contributor to achieving the recommended levels of moderate to vigorous exercise (Firth et al., 2016).
Modeling. Nurses and other service providers can adopt the mindset of “walking the walk,” not just “talking the talk.” If nurses hope to get the individuals they serve to walk more, they may consider being role models by implementing their own walking plans. By creating and sustaining a work environment where service providers attend to their own health and well-being, including engaging in regular physical activity, nurses can contribute to the health and quality of life of everyone in the treatment environment. Examples of agency activities are establishing an agency wellness committee to coordinate information sharing and activities such as a health fair; facilitating access to tools such as pedometers or other activity tracking devices; posting inspirational and educational information about health and wellness; and making wellness coaching or other health supports available to service providers and consumers.
Activity Trackers. Simple tracking devices for self-monitoring, such as pedometers, have been linked to greater levels of physical activity among individuals using these devices. This link has been found in adults with a variety of chronic diseases (Mansi, Milosavljevic, Baxter, Tumilty, & Hendrick, 2014; Qiu, Cai, Chen, Yang, & Sun, 2014; Richardson et al., 2008) and adults in the general population who are overweight or obese (de Vries, Kooiman, van Ittersum, van Brussel, & de Groot, 2016). As described earlier, individuals with major mental disorders are willing to use a smartphone app (Macias et al., 2015) or pedometer, with adherence rates of 87.5% (Beebe & Harris, 2013) and 86% (Browne et al., 2016). Not only is there willingness to track progress with activity trackers, which are becoming increasingly accessible and affordable, wearers find these tools to be a source of motivation for walking (Lee et al., 2014).
Accuracy in measurements from an activity monitor, such as a pedometer, require that it be worn correctly and consistently (Beebe & Harris, 2013; Vanroy et al., 2017). In time-limited studies of individuals in the general population, walking tended to drop off in pedometer-monitored interventions once the study ended (Ogilvie et al., 2007), indicating the activity monitor assisted in motivation. Lowtech and free options, such as a daily walking calendar or walking log, can be effective to enhance self-motivation, document progress, and share with supporters who monitor and encourage physical activity.
Collaboration With Peer Providers
Nurses often work with other professionals in a variety of community mental health settings. One potential collaborator is peer providers—individuals in recovery from mental or substance use disorders who offer social support before, during, and after treatment to facilitate long-term recovery in the community. Peer providers draw on lived experiences and empathy to promote hope and insights, help foster engagement in treatment, and offer access to community supports (Swarbrick, 2017). There is a growing evidence base for peer support focused on physical health and wellness (Bellamy, Schmutte, & Davidson, 2017) and physical activity (Stubbs, Williams, Shannon, Gaughran, & Craig, 2016). Peer wellness coaches are a specific type of peer provider who help fellow peers explore various dimensions of wellness to better understand their experiences, motives, and needs (Brice, Swarbrick, & Gill, 2014; Swarbrick, Gill, & Pratt, 2016). Peer wellness coaches are trained to engage and support other individuals living with major mental disorders to pursue long-term recovery, which includes increased engagement in physical activity (e.g., walking). Nurses working in community behavioral health clinics or publicly funded community-based programs are likely to encounter peer providers, including peer wellness coaches.
More research is needed to document the feasibility and benefits of walking for individuals with major mental disorders and study interventions that effectively increase walking for this population. The important role of nurses in promoting physical activity in mental health care has been highlighted previously (Happell, Platania-Phung, & Scott, 2011). Nurses are able to monitor needs, offer health education, boost motivation, serve as role models, and collaborate with other providers. Little research exists to assist nurses in promoting walking, but some evidence has been described herein from studies of the general population and related research on increasing physical activity and promoting lifestyle changes among individuals with major mental disorders. Nurses are encouraged to proceed with recommending and supporting walking, as well as enlisting other colleagues, such as peer support specialists and other social supporters, in efforts to promote walking for individuals with major mental disorders.
The current article outlines the benefits of walking and ways nurses can support individuals with major mental disorders to add this valuable physical activity to their weekly routines. Strategies to promote walking should include strengthening engagement, sustaining participation, and tracking progress. More research is needed to study interventions and clarify benefits of walking for individuals with major mental disorders. Nurses are in an ideal position to collaborate with pee r providers and supporters to help these individuals put one foot in front of the other to add, increase, and sustain walking to improve their health and well-being.
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