Beyond Lifestyle Factors: Exploring The Role of The Social Determinants of Health in Weight Loss Attempts in People with Serious Mental Illness Living in Supportive Housings Settings
Background: People with serious mental illness (SMI) experience marked health disparities from preventable and treatable conditions and a prevalence of overweight/obesity almost twice the general US population. The problems and proposed solutions to obesity-related morbidity in people with SMI have mainly focused on the individual level. Difficulties with healthy eating and physical activity are attributed to behavior or lifestyle factors, such as poor diet, sedentary routines, and low motivation, as well as increasing use of second generation antipsychotic medications. Larger system level factors have received limited attention in the response to this epidemic and past research has not adequately involved people with SMI in a deeper exploration of these issues. Health disparities involving the problem of obesity in people with SMI have not been considered using a human rights framework. Methods: This dissertation used a participatory action orientation with a mixed-methods sequential explanatory model to explore the healthy equity factors that facilitate or limit clinically significant weight loss in people with SMI who are overweight or obese and participating in a 12-month, peer-led, group healthy lifestyle intervention. Study one utilized baseline data of 93 participants in the intervention arm of the parent Peer Group Lifestyle Balance study. Quantitative analysis was used to explore associations between the predictor variable of food security at baseline and the outcome variable of 6-month weight change. Studies two and three were developed through a participatory Photovoice project with 8 participant co-researchers. Study two explored the lived experience of healthy eating and physical activity through 7 weekly sessions with the co-researchers consisting of individual photo-elicitation and group discussion of photos and captions. Study three explored the co-researchers experience of presenting at four varied community events. Results: The results of the quantitative analysis revealed that 76.2% percent of the sample reported some level of food insecurity, 22.6% with marginal food security, 28.6% with low food security, and 25.0% with very low food security. The mean weight change at 6 months was -2.86 pounds (SD = 13.67) with a range of -47.6 to 33.0. At six months, 65% of the total sample had a weight lower than their baseline weight. The association between metformin use and diagnosis of diabetes with weight change was significant with the metformin group losing a mean of 6.7lbs vs 0.3lbs in intervention participants not taking metformin. The analysis of the main effect for baseline food security on weight change between baseline and 6 months approached significance (F (2, 81) = 3.075, p =.052, partial η2 = .071). In the Photovoice project, the eight co-researchers selected a total of 33 photos and captions to represent their experience and organized the photos into five themes: 1) Corner stores in our neighborhood, 2) Challenges to healthy eating and exercise, 3) Healthy eating ideas with limited supplies, 4) Exercise: Challenges and options, and 5) Recovery: Body, mind, and spirit. The themes from the photographs reflected two overarching themes: structural barriers and overcoming structural barriers. Four overlapping themes emerged from the analysis of the post-advocacy presentations: 1) Empowerment, 2) Influence, 3) Barriers to participation, and 4) The system. Conclusion: The strengths of this study are grounded in the mixed-methods exploration of the impact of the social determinants of health on healthy eating and physical activity in a highly marginalized population with significant health disparities resulting in part from obesity-related conditions. The human rights framework provides an organizing lens to understand the findings of this study. The qualitative findings provided concrete explanations of the quantitative findings. The Adult Food Security Survey revealed a 76% rate of any level of food insecurity in the sample. Fifty-four percent of the sample reported low or very low food security, higher than the national average of 12.3% (United States Department of Agriculture, 2015). The main effect of food security on 6-month weight change approached significance. Documenting this rate of food insecurity in the population is a critical finding and suggests many people with SMI are not achieving the right to food, despite living in supportive housing settings and receiving Supplemental Nutrition Assistance Program (SNAP) benefits. The reasons for this inequality are complex and the Photovoice project described in Chapter 3 provides some insights into this situation from the population itself. The high cost of poor quality food available in urban corner stores and fast food establishments as well as the cost of transportation out of the neighborhood contribute directly to food insecurity. The use of food pantries, with variable food quality is a consequence of food insecurity and limited SNAP benefits in the population. These situations are a threat not just to the right to healthy food, but the right to health itself. The easy availability of tobacco and alcohol products through neighborhood convenience stores, the lack of safe places to exercise, and increased rates of violence seriously impede opportunities to live a healthy life. The qualitative findings were also useful in expanding not only our understanding of the problem, but the strengths of the populations, and potential real-world solutions. Multiple level factors are making a positive contribution to the rights of people with psychiatric disabilities. The quantitative analysis showed that 65% of the total sample had lost weight in the first 6 months of participation in the project. Co-researchers in the Photovoice project reported many examples of knowledge and skills they had learned or improved through participation in the PGLB study. These skills, which were taught and modeled by specially trained peer specialists, were used to overcome structural barriers to healthy eating and physical activity, and likely contributed to weight loss. Co-researchers in the advocacy sessions of the project discussed experiences of segregation, stigma, distrust, and indignity arising from a system that does not always respect the rights of people with psychiatric disabilities. Most people with SMI have experienced significant past social traumas that contribute to, or arise from, their experience of psychiatric disability. Nevertheless, the co-researchers in this project displayed and articulated a sense of empowerment and pride in raising awareness of their experiences and being heard by stakeholders, advocates, and peers during their presentations. These experiences provide evidence that multiple groups in public health and local government are interested in and committed to the rights of people with disabilities.Dr.P.H., Community Health and Prevention -- Drexel University, 201
