Investigating the acceptability and feasibility of a self-management care planning-based intervention: To improve cardiovascular health and quality of life of community-living adults with severe mental illness

Author: Sara Zabeen

Zabeen, Sara, 2023 Investigating the acceptability and feasibility of a self-management care planning-based intervention: To improve cardiovascular health and quality of life of community-living adults with severe mental illness, Flinders University, College of Medicine and Public Health

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Globally, it has been well established that adults with severe mental illness (SMI) die 10-20 years earlier than the general population, mainly due to cardiovascular disease (CVD). To address this health inequity, the Flinders Chronic Condition Self-Management ProgramTM (henceforth referred to as the Flinders Programme) was delivered from November 2017 to February 2021 among 120 South Australian community-living adults diagnosed with SMI and CVD risk factors in order to improve their cardiovascular health and quality of life. While there is ample evidence of the effectiveness of personcentred and recovery-oriented health interventions such as the Flinders Programme, their adoption and sustainability as part of routine care have been limited within the mental health system. This exploratory thesis aimed to investigate the underlying causes behind this systemic issue from a socio-cultural viewpoint by capturing and elevating key stakeholders’ voices.

A longitudinal qualitative methodology underpinned by Roy Bhaskar’s Critical Realism philosophy and ontology was employed for this research. The first research question examined how the delivery of the Flinders Programme was achieved. The second research question aimed to understand why, how, and in what context the Flinders Programme worked (or not). Qualitative data were collected from 48 key stakeholders involving 15 service users, 4 matched family caregivers, 10 matched health professionals, and 19 trial staff at multiple time points. Data were gathered through 61 interviews (31 service users, 7 caregivers, 13 health professionals, and 7 trial team member interviews), 2 focus group discussions (involving 4-8 trial team members), 10 series of meeting minutes (involving 8-12 trial team members), 5 trial team members’ reflective journals (including the researcher’s), and 8 service users’ Flinders Programme care plans (7 service users dropped out of the larger trial after their initial interviews). Data analysis involved a four-step complex iterative process where findings from the different stakeholders were analysed and triangulated using the Critical Realist Analysis (CRA) and a longitudinal analytical approach.

The results found that service users’ health-seeking behaviours were negatively impacted by their past experiences related to treatment coercion from the mental health system, and staff members’ preconceptions regarding service users’ ability to recover. Patriarchy in the service culture, funding issues, and resource mismanagement were identified as root causes resulting in a paucity of recovery-oriented care; they also triggered sectoral competition, internal political problems, and a barrage of top-down approaches with minimal positive impacts. Mental health staff reported change fatigue and job insecurity as factors that hampered the quality of care provided to service users. These structural issues negatively impacted the delivery of the Flinders Programme. There was also evidence of service users experiencing social injustice (e.g., stigma, and housing, food, and financial insecurity). However, the overall outcome suggested that when all key stakeholders were engaged in the care plan, the Flinders Programme could help service users achieve some of their health and social goals (e.g., preparation towards finding a job, improved social connections, healthy lifestyle).

A person-centred and family-inclusive approach, a written care plan, motivational interviewing techniques, regular follow-ups, feedback, and rapport with empathetic and respectful trial nurses were identified as central facilitators in the success of the programme.

Significant findings generated a novel middle-range model called Supported Self-management and Social Recovery (SSMSR) involving four domains: a) Service users: ‘active citizens’; b) Caregivers: promote recovery; c) Positive health environment: deliver recovery-oriented and culturally safe care; and d) Community: promotes social justice and empowerment. The realist synthesis also generated 40 Initial Programme Theories (IPTs) to define key stakeholders’ roles. Overall, the Flinders Programme demonstrated that given the opportunity and proper support, service users actively engaged in the self-management care plan, showed meaningful change, and generated hope, orienting them towards recovery.

Keywords: severe mental illness, cardiovascular health, integrated care, self-management, social recovery

Subject: Mental Health Sciences thesis

Thesis type: Doctor of Philosophy
Completed: 2023
School: College of Medicine and Public Health
Supervisor: Prof Sharon Lawn