Psychological and physical self-management of people with schizophrenia in community psychiatric rehabilitation settings: A qualitative study

Authors

  • Naoko Katakura RN PHN PhD,

    Associate Professor, Corresponding author
    • Department of Nursing, School of Health Care Sciences, Chiba Prefectural University of Health Sciences, Chiba, Japan
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  • Kazumasa Matsuzawa RN MA ME,

    Professor
    1. Department of Nursing, School of Health Care Sciences, Chiba Prefectural University of Health Sciences, Chiba, Japan
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  • Kazue Ishizawa RN MN,

    Assistant Professor
    1. Department of Nursing, School of Health Care Sciences, Former Chiba Prefectural University of Health Sciences, Chiba, Japan
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  • Chikako Takayanagi RN MS

    Lecturer
    1. Department of Nursing, School of Health Care Sciences, Chiba Prefectural University of Health Sciences, Chiba, Japan
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Correspondence: Naoko Katakura, Chiba Prefectural University of Health Sciences, 2-10-1 Wakaba, Mihama-ku, 2610014 Chiba, Japan. Email: naoko.katakura@cpuhs.ac.jp

Abstract

This study had three objectives: to explore the psychological and physical self-management behaviours of people with mental illness; to identify their motivations for their self-management behaviours; and to develop a framework to understand the generative processes of healthy vs. unhealthy conditions. The participants were eight persons with schizophrenia who were attending psychiatric rehabilitation centres. We conducted semi-structured interviews with the participants on their observations regarding public health nurses' counselling with them. The data were analysed qualitatively. Six categories of health self-management behaviours were identified. The primary motivations that led to the participants' behaviours were ‘getting a job in the near future’ or ‘maintaining my current level of living’. The use of their own methods caused unhealthy conditions when health management was excessively strict or there was a discrepancy between their and care providers' recognition of the appropriate level of self-management.

Introduction

Health self-management is as an individual's ability to manage the symptoms, treatment, lifestyle changes, and physical and psychosocial consequences inherent in living with a chronic condition.[1] To help people with chronic mental illnesses that are living in the community, the provision of support for their self-management of medical conditions and daily living is essential.[2] However, people with schizophrenia and other psychiatric illnesses often have complications including physical disorders,[3] and their mortality rate from cerebrovascular diseases is twice or three times that in the general population.[4, 5] As indicated in Japan and other countries, a lack of exercise, smoking, poor diet and other lifestyle habits are risk factors.[3, 5-8] Therefore, self-management to prevent physical complications and psychological relapse and to maintain health is essential in their daily lives.

Effective programmes was developed and implemented to help people with schizophrenia and other mental illnesses to manage their health, including interventions related to lifestyle habits.[9-13] However, no research is reported that examines their motivation for health self-management and personal efforts related to health maintenance in daily life.

The predictor variables of good health behaviour in community-dwelling people with mental illness include the fear of developing heart disease, high self-efficacy, the availability of social support and the level of psychological symptoms.[14] In addition to education on nutrition and exercise, Park et al. implemented programmes designed to improve metabolic syndrome, including motivational interviewing (MI), conducted by nurses to promote the autonomy of people with mental illness.[15] They suggest the importance of examining the effects of the programme and the roles of nurses involved in MI.[15] As described in these reports, health self-management implemented by people with mental illness living in the community reflects their self-efficacy and motivation in accomplishing their health-related goals.

In Japan, awareness of the maintenance of psychological and physical health is high among community-dwelling people with mental illness.[16] Nevertheless, there is a dearth studies that investigate the causes of inadequate responses of people with mental illness to physical complications and unhealthy lifestyle habits or their motivations for health self-management, particularly for those who live at home. Clarification of their motivation would help in the development of methods for improving patients' self-efficacy of health behaviour[14] and effectively promote MI interventions by nurses.[15] It would also help nurses to provide effective support for such people based on an understanding of their motivations.

There were three objectives in this study. The first was to explore the psychological and physical self-management behaviours of people with mental illness. The second was to identify their motivations for their self-management behaviours. The third was to develop a framework to understand the process and causes leading to healthy or unhealthy conditions.

Methods

Study design

An inductive qualitative approach was adopted because there is little empirical evidence on the health self-management of people with mental illness.[17] There are two types of procedures to analyse qualitative research.[18] The first procedure is a coding approach, which involves creating a conceptual category or developing a theory.[18] The second procedure is a sequential approach to the reconstruction of a structure of text and of case.[18] This study used the coding approach because it allows for the creation of conceptual categories and explanation of the relevance of each category.

Recruitment and settings

Eight persons with schizophrenia attending Rehabilitation Centres A (support for continuous employment), B and C (local activity support centres) took part in this study. The directors of the centres recommended these participants. These rehabilitation centres were established under the Services and Supports for Persons with Disabilities Act.[19] In the past, welfare services for people (including children) with psychological, mental and physical disabilities were provided separately, in accordance with relevant laws. The act provided integrated welfare services, including nursing care benefits and training programmes.[19] To receive welfare services, people are required to undergo screening or an interview for certification, which determines the level of disability using an eight-rank scale whereas also incorporating the person's intentions.[19] Approximately 10% of welfare service fees are incurred by people with psychological disabilities, although this varies according to income.[19] Rehabilitation centres that support continuous employment provide opportunities for those who have difficulty working and conduct training to improve their knowledge and skills.[19] Local activity support centres attended by people with disabilities provide opportunities for them to participate in creative and productive activities and encourage them to interact with other people.[19] Established standards do not mandate that these rehabilitation centres be staffed with full-time nurses, physicians, psychiatrists or other health-care professionals.

Rehabilitation Centres A and B provide counselling services to people with disabilities in order to promote their psychological and physical health self-management. In Rehabilitation Centre A, counselling is provided by a public health nurse (PHN) approximately once monthly to each patient for 15–30 min. Services include measurements of blood pressure, pulse and body weight, and individual counselling regarding their lifestyles and psychological and physical health. In Rehabilitation Centre B, a full-time PHN provides counselling for a group of 10 people with mental illnesses for about 1 h once monthly. The group counselling provides information on psychological and physical health and opportunities for the exchange of ideas between people with mental illness.

Ethical considerations

After providing the directors of the rehabilitation centres with written and oral explanations of the study, the authors asked them to recommend participants who could participate in interviews and were receiving health counselling. The authors contacted PHNs who gave health counselling to the participants. Anonymity and confidentiality were assured. After giving written and oral explanations to each participant and their PHNs, all agreed to participate and completed the study. The ethics committee of Chiba Prefectural University of Health Sciences (No. 2009–2020) gave approval for the study.

Participants

The participants included four men and four women aged 36–65 (mean age: 43.6) years (see Table 1). Criteria for inclusion in the study were a diagnosis of schizophrenia and under contract to use the rehabilitation centre. Three participants' psychological and physical statuses were healthy, and they attended rehabilitation centres on a regular basis. One had been in and out of hospital, owing to her unstable psychological state, and had uncontrolled hypertension and diabetes. Four participants were obese. One participant, who used to live with a family member, started to live alone when her mother became hospitalized, and her body mass index (BMI) decreased from 22 to 18.6 in 2 months because of unhealthy dietary habits. Two participants had diabetes and obesity and the rehabilitation centre staff indicated that one participant's diabetes was uncontrolled and reported often eating between meals.

Table 1. Participant characteristics
 ABCD
Period after onset (years)6201721
Number of hospitalizations in a psychiatric departments01025
Physical complicationsNone

Hypertension

Diabetes

Obesity

History of obesityObesity
Living environmentHomeHomeHomeHome
Persons living with the participantsFamily membersFamily membersFamily membersFamily members
Mental and physical statusHealthyUnhealthyHealthyUnhealthy
 EFGH
Period after onset (years)6263921
Number of hospitalizations in a psychiatric departments25Frequently5
Physical complicationsUnderweightNone

Diabetes

Obesity

Gastric ulcer
Living environmentHomeHomeGroup homeHome
Persons living with the participantsFamily membersFamily membersAloneFamily members
Mental and physical statusUnhealthyHealthyUnhealthyUnhealthy

Data collection

For this study, the authors developed an interview guide that included three questions. The contents of the questions involved psychological and physical health self-management, difficulties experienced, and reasons for using the rehabilitation centre. After obtaining participant consent, audio-recorded semi-structured interviews provided data on participant health self-management. One participant refused to the audio recording, although he allowed the researcher to take notes and confirmed them after the interview. To protect the participants' privacy, interviews took place in a private room at a rehabilitation centre or in the participant's room in a group home. Most participants were interviewed only once for approximately 20–50 min. However, one interview required two sessions to prevent the participant from becoming tired. The research period was from November 2009 to February 2010. We hypothesized that the contents of the conversations between participants and PHNs could shed light on the participants' health self-management behaviours and motivations. Therefore, researchers observed and recorded field notes of PHNs' health counselling of all participants except participants G and H.

Data analysis

The audiotaped interview data and field notes were transcribed. With reference to the open-coding procedure,[17] the authors read the transcript repeatedly, and each line of the transcript was analysed by coding.[20] Health self-management behaviours and motivations were coded irrespective of whether the changes were desirable or undesirable. All codes were sorted according to similarity into categories, with conceptual names representing their characteristics. Although the properties and dimensions of the categories were discovered so that comparisons could be made, a conceptual diagram was created to indicate the relationships among the participants' health self-management behaviours, motivation and progress. The first author in conjunction with native English-language professionals translated from Japanese into English the categories, subcategories and quotations from the participants' interviews. Lastly, the translation was edited by professional English editors.

Results

Figure 1 shows a conceptual diagram of the participants' health self-management behaviours, motivation and processes. The arrows in the figure show the directionality of health self-management processes. Two types of participant motivations for health self-management were ‘getting a job in the near future’ and ‘maintaining my current level of living’ (Fig. 1A). The participants' motivations led to their original health self-management behaviours (Fig. 1B). Participants' original health self-management behaviours were grouped into six categories: ‘control of psychological symptoms with expectations of warning signs’, ‘resting to control psychological conditions’, ‘self-taught approaches to control physical complications’, ‘attending a rehabilitation centre to keep a regular schedule’, ‘acquisition of support and information to maintain health’, and ‘effort to gain the understanding of an attending psychiatrist’. In terms of the level of appropriateness of health self-management (Fig. 1C), the participants' health self-management behaviours were effective in achieving ‘psychological and physical health’ when ‘their self-management was at an appropriate level and well balanced’. Whereas their health condition started ‘to deteriorate into psychological symptoms or physical complications’ when health management was ‘excessively strict’ or there was ‘a difference in recognition between people with mental illness and care providers’. When these symptoms improved, some participants resumed their self-management behaviour on the bases of the above-mentioned motivations.

Figure 1.

Participants' health self-management behaviours, motivations and processes.

Participant motivations: ‘getting a job in the near future’ and ‘maintaining my current level of living’

The participants' primary motivations for health self-management behaviours were ‘getting a job in the near future’ and ‘maintaining my current level of living’. In particular, male and female participants in their 30s and 40s had a strong desire to be employed. Participants in their 60s were hoping to continue to live in their current homes while maintaining their health. The two following statements describe participants' motivations for their original health self-management behaviours.

I have developed a regular lifestyle by attending here (the rehabilitation centre) in the morning. I would also like to get a job in the near future. It is important to keep regular hours by attending this rehabilitation centre, not sleeping all day at home (A − 30s).

I exercise to maintain the ability to walk, because if I become unable to walk, I will have to leave this group home. You cannot live here if you are unable to walk or take care of yourself. I do not want that to happen. That is why I exercise every day (G − 60s).

Original health self-management behaviours

Table 2 shows six categories and their subcategories of participants' original health self-management behaviours. The examples in Table 2 include six categories and subcategories of participants' original health self-management behaviours. The categories follow below.

Table 2. Participants' original health self-management behaviours
Conceptual categoriesSubcategories
Control of psychological symptoms with expectations of warning signs

Establishment of criteria for self-monitoring of psychological symptoms to prevent my deterioration

Recognition of visual and auditory hallucinations

Carrying a single medication dose to prepare for symptom aggravation

Maintaining a sense of distance to overcome difficulties with interpersonal relationships

Resting to control psychological conditions

Not pushing myself too hard because I easily become tired

Getting adequate sleep and rest to maintain psychological health

Refreshing myself to reduce stress

Self-taught approaches to control physical complications

Maintaining my health condition to keep my current level of functioning

Taking care of my health so as not to develop metabolic syndrome

Exercising to prevent worsening of complications

Attending a rehabilitation centre to keep a regular schedule

Selecting a rehabilitation centre that suits me

Developing regular habits by attending a rehabilitation centre

Acquisition of support and information to maintain health

Finding a consultant who understands me

Acquiring knowledge of psychological and physical health by utilizing available resources

Effort to gain the understanding of an attending psychiatrist

Informing the attending psychiatrist of medical conditions and requests accurately and effectively

Expecting the attending psychiatrist to provide effective medication to improve conditions

Control of psychological symptoms with expectations of warning signs

This category includes four subcategories: ‘establishment of criteria for self-monitoring of psychological symptoms to prevent my deterioration’, ‘recognition of visual and auditory hallucinations’, ‘carrying a single medication dose in preparation for symptom aggravation’ and ‘maintaining a sense of distance to overcome difficulties with interpersonal relationships’.

Regarding the approach of ‘establishment of criteria for self-monitoring of psychological symptoms to prevent my deterioration’, most participants used their own criteria to determine the level of their symptoms and conditions, such as visual and auditory hallucinations and fatigue. When they felt ill, they took a single dose of medication and rested immediately. Participant D explained:

If I see or hear a hallucination or delusion, I do not mind, because I have experienced these many times before. When I keep seeing or hearing it, I know I am in poor psychological condition, so I go home immediately, even if I am at work, take medicine and go to bed. Then, I will be fine in 1 or 2 h (D).

Resting to control psychological conditions

This category includes three subcategories: ‘not pushing myself too hard because I easily become tired’, ‘getting adequate sleep and rest to maintain psychological health’ and ‘refreshing myself to reduce stress’. Most participants thought that the most important factor for the alleviation of psychological symptoms is sleep/rest, because their medical conditions generally worsened when they were unable to sleep.

Self-taught approaches to control physical complications

This category consists of three subcategories: ‘maintaining my health condition to keep my current level of functioning’, ‘taking care of my health so as not to develop metabolic syndrome’ and ‘exercising to prevent worsening of complications’. To prevent the development of metabolic syndrome, participants paid particular attention to obesity, diabetes and hypertension. To control body weight, they took walks and performed other exercises in a sports gym. Also following suggestions from their social network, they avoided high-calorie foods, such as instant noodles and rice. One participant was taking a nutritional supplement containing fat-burning ingredients on the recommendation of his mother, and another participant was trying to reduce the number of cigarettes he smoked per day on the advice of his attending psychiatrist and other people.

Attending a rehabilitation centre to keep a regular schedule

This category includes two subcategories: ‘selecting a rehabilitation centre that suits me’ and ‘developing regular habits by attending a rehabilitation centre’. Some participants could not adapt themselves to their former rehabilitation centres, found a new one by themselves or through family members, and relocated.

Acquisition of support and information to maintain health

Acquisition puff support and information to maintain health consists of two subcategories: ‘finding a consultant who understands me’ and ‘acquiring knowledge of psychological and physical health by utilising available resources’. Participant G employed her own approaches to ‘find a consultant who understand her’:

I often talk with other staff of the centre about my worries and problems. When I heard the news that the Democratic Party of Japan had come to power, I said to a staff of my group home, ‘What if my welfare benefits will be terminated?’ She replied, ‘No, that will not happen’ (G).

Effort to gain the understanding of an attending psychiatrist

This category includes two subcategories: ‘informing the attending psychiatrist of medical conditions and requests accurately and effectively’ and ‘expecting the attending psychiatrist to provide effective medication to improve conditions’. Because attending psychiatrists from the outpatient department were generally busy, the participants prepared questions to ask or wrote them down in a notebook to ‘inform the psychiatrist of medical conditions and requests accurately and effectively’.

As shown in these examples, the participants were able to develop and implement their own methods of health self-management. However, these original methods involved the risk of ‘excessively strict self-management’ or ‘differences in recognition between people with mental illness and care providers’, and could lead to unhealthy psychological and physical conditions. The authors will explain these risks using the examples included in the categories ‘self-taught approaches to control physical complications’ and ‘acquisition of support and information to maintain health’.

Examples of ‘excessively strict self-management’ and ‘a difference in recognition between people with mental illness and care providers’

Under the subcategory of ‘exercising to prevent worsening of complications’, which is included in the category of ‘self-taught approaches to control physical complications’, Participant B had hypertension and diabetes, and her health self-management was inappropriate and excessively strict. She not only restricted her food intake, but also took notes on what she ate every day and stopped drinking cola, which she used to drink often. She lost 3 kg within a few days. She told the PHN that she was hoping to receive advice from a dietician at a hospital. After a while, her psychological condition worsened, and she was hospitalized again.

Under the subcategory of ‘finding a consultant who understands me’, which was included in the category of ‘acquisition of support and information to maintain health’, Participant E began to prepare meals for herself after her mother became hospitalized. She often talked with psychiatric social workers (PSWs) at the rehabilitation centre and the PHN about her poor economic conditions. Following her mother's hospitalization, Participant E rapidly lost weight, and a PSW asked the PHN to provide her with counselling. When the PHN met Participant E, the PHN realized that there was a large difference in problem recognition between Participant E and the PSW. Participant E asked the PHN, ‘Do you think I should purchase more expensive cosmetics to conceal the laugh lines on my face?’ She was not concerned about her rapid weight loss. The PHN thought that Participant E should concentrate on eating more in order to gain weight and forget about her laugh lines. However, the PHN did not tell her so. Pretending to address the participant's primary problem of laugh lines, the PHN taught the participant three simple recipes involving collagen, an ingredient also contained in cosmetic products, so that she would consume meat and other protein sources and improve her nutritional status. Following this, Participant E lost no more weight and was able to continue to live alone until the her mother's discharge from the hospital. Within 2 months after the health counselling, her BMI increased to 19.

As mentioned above, when health self-management became ‘excessively strict’ or ‘differences in recognition between people with mental illness and care providers’ became apparent, psychologically and physically unhealthy conditions could result.

Discussion

In the preceding sections, we examined the approaches to health self-management used by community-dwelling people with mental illness. On the bases of the findings, the following section describes the care services explored by nursing care professionals.

Health self-management by people with mental illness

The health self-management behaviours implemented by people with mental illness who participated in the study comprise six categories. These are in line with the findings of previous studies in Japan. Some health self-management behaviours explained in this study, excluding the category of ‘attending a rehabilitation centre to keep a regular schedule’, were also included in a questionnaire survey of 219 subjects with mental illness in a local activity support centre.[21] This study's community-dwelling participants with schizophrenia used awareness of health maintenance, and they took a variety of their own approaches to health self-management. Some participants monitored their mental status to identify the signs of visual or auditory hallucinations. From experiences, they had learned to take a rest if they saw or heard hallucinations. Presumably, the participants took care of their health because they had the strong motivations of ‘getting a job in the near future’ or ‘maintaining my current level of living’. It is very important for them to convey their wishes regarding their lives in the community in order to develop the ability to realize them.[22] Participants in the study already wished to get jobs or maintain their level of living when they started attending rehabilitation centres and taking care of their health. A traditional Japanese belief is that grown-up people should work and be self-sufficient. A Japanese proverb says, ‘He who does not work shall not eat’. Consequently, participants aged 30–40 years might be influenced by such Japanese beliefs and be motivated to ‘get a job in the near future’. In any case, in order to help people with mental illness take care of their health, careful attention is essential to their motivations for psychological and physical health management.[23] Therefore, it is essential that nurses who serve people with mental illness assess patients' individual motivations and provide specific supportive care.[24]

Causes of psychological and physical instability

People with mental illness use awareness of health maintenance and they were able to implement their own original health self-management behaviours. Often inappropriate health self-management led to the deterioration of their health when it was excessively strict or there was a difference between their recognition of the appropriate level of self-management and the level proposed by care providers.

Participant B, who had diabetes and was overweight, tried to lose weight and imposed severe dietary restrictions on herself. If people with obesity, diabetes and other chronic disorders imposed dietary restrictions on themselves for the first time, nurses would typically evaluate their positive attitudes and attempt to enhance their self-affirmation, ambition and positive attitudes by praising them.[25] However, Participant B was unable to compose herself when feeling frustrated and pushed herself too hard to lose weight. Nakai mentioned that feelings of fretfulness (described as aseri in Japanese) could increase the relapse risk in people with schizophrenia when they attempt to return to social life.[26] Therefore, it is important to identify carefully the inappropriate or excessively strict self-management approaches, which could worsen their psychological and physical health.

Following her mother's hospitalization, Participant E developed unhealthy dietary habits, and her body weight markedly decreased. There was a difference in recognition of Participant E's problems between the PSW and PHN (who believed that she was underweight) and the participant herself (whose primary concern was skin care). She was even planning to purchase new, expensive cosmetics. Some people with schizophrenia can experience relapse; although they understand the importance of appropriate self-management in their minds, they still cannot control their ambivalence or break free from their obsession.[27] The patients' methods might cause instability in case of differences between their recognition of the appropriate level of self-management and that proposed by care providers.

Implications for mental health services in the community

Health professionals should be aware of the health self-management needs of people with mental illness and have the skills to assess their mental characteristics and help them to implement self-management of their health. The assessment of their mental characteristics and provision of care is also important to prevent physical complications and promote health self-management. We suggest some initial implications of the findings of this study and those of earlier literature intended to foster health self-management in people with mental illness.

First, excessively stringent health self-management imposed on people with schizophrenia could cause the recurrence of psychological symptoms; therefore, the course of the disorder requires particular attention. It is crucial for care professionals to explain the importance of appropriate health self-management to those who perform strict self-management and to encourage those people to feel at ease, to be flexible (described as yutori in Japanese)[26] and to review their motivations for health self-management.

Second, there were cases involving differences between patients' recognition of the appropriate level of health self-management and that proposed by care providers. In one such case, the PHN did not dismiss Participant E's obsession with the laugh lines on her face. The PHN instead attempted to improve her dietary habits (the key problem) by using this obsession. Some people with mental illness become too involved in health self-management, and there is sometimes a huge gap between their wishes and any rational approach. It might be effective to explain the importance of appropriate health self-management by taking advantage of such obsessions with self-management.

Conclusions

In this study, we interviewed eight Japanese persons with schizophrenia who were attending or living in three rehabilitation centres. Data were obtained only from participants who agreed to talk about their health self-management. One limitation of the study is the small sample size. There are also differences in age, complications, family structure and residence between the participants, and the cultural environment and these differences might have affected the results. Therefore, future research on this topic should be with a larger number of participants to provide more generalizable results regarding health self-management behaviours and motivations.

Acknowledgements

We express our sincere gratitude to the participants of the study and the staff of the rehabilitation centres. The study was conducted with the support of collaborative research funding from Chiba Prefectural University of Health Sciences (2009-No. 6).

Disclosures

The authors declare no conflict of interest.

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