The need to address modifiable physical health risks proactively for people with psychosis has been embraced by NICE within recent guidance and quality standards (NICE CG178, NICE CG155, NICE QS80, NICE QS102). The guidance and standards recommend systematic CVD risk monitoring for all individuals from the outset, particularly in those prescribed antipsychotics. It also recommends offering a combined healthy eating and physical activity programme as well as support to stop smoking.
SHAPE (Supporting Health and Promoting Exercise) Programme offers a co-ordinated, multi-professional, 12 week wellbeing and exercise programme in a youth focused, socially inclusive setting for young people with early psychosis Its clinical impact has been evaluated at 12 weeks and 12 months. Early outcome data on the clinical impact of SHAPE at 12 weeks and 12 months has show a positive impact on key physical health risk markers and in promoting healthy lifestyle behaviours.
Aims and objectives
The SHAPE programme is one of the first UK ‘real world’ service provisions of a bespoke early intervention (EI) physical health monitoring and intervention programme for young people with early psychosis.
The programme was designed with young people with early psychosis by a team of early intervention mental health specialists, clinical psychologists, nutritionists, exercise physiologists and health trainers to offer a 12-week lifestyle and exercise therapy programme to young people recently diagnosed with psychosis.
The aim of the programme are to:
- support young people experiencing a first episode psychosis to make lifestyle choices informed by an understanding of their greater risk for obesity, cardiovascular diseases and metabolic disorders.
- provide access to healthcare in a positive and socially inclusive environment embracing the importance of ‘ordinary lives’.
Reasons for implementing your project
As part of the SHAPE programme, significant changes to clinical practice were required to ensure standardised monitoring of physical health, these changes included:
- An improved physical health monitoring and intervention through comprehensive physical health checks
- Monitoring, recording and evaluating physiological changes that increase risk of CVD and diabetes
- Early identification of individuals at high risk for cardiometabolic disorders and referral for treatment
- Provision targeted evidence based interventions (i.e. SHAPE programme)
- Increased communication with GP to improve baseline physiological monitoring and care planning to address physical health needs
- Data collection for evaluation purposes of the service and clinical outcomes of service users We consulted with an existing EI service user group in the design of the programme and have appointed peer support workers who have completed the SHAPE programme to provide support to new participants. Benefits from putting NICE guidelines into practice included:
- Improved physical health pathway and interventions.
- Improved assessment, monitoring and intervention in relation to the physical health needs of patients.
- Development and evaluation of a practice model which can be adapted for implementation elsewhere
How did you implement the project
We formed a strong interagency project team which harnessed individuals’ knowledge and skills to benefit programme design, implementation, evaluation and promotion. The Worcestershire EI Service collaborated with the researchers from the University of Worcester, including clinical psychologists, nutritionists and exercise physiologists to design, deliver and assess the SHAPE programme.
This programme is a partnership with the McClelland Centre for Health and Wellbeing located on the University of Worcester City Campus. This facility has the clinical infra-structure but within a neutral, youth-focused setting that provides opportunities for social engagement with other programme members and University 'Earn As You Learn' placement students while also providing a safe, supportive environment.
The SHAPE programme was initially funded by a Health Foundation SHINE 2014 award. We have since secured additional EI targeted resilience funding in a joint bid with our 3 CCG partners to fund and rollout of SHAPE across Worcestershire. Key challenges we faced were associated with the population we were striving to engage, rather than organisational, policy or team challenges.
Young people with psychosis can experience many difficulties associated with their mental health including psychotic symptoms, social anxiety and poor motivation. For some young people, the prospect of a group-delivered programme was particularly daunting. 59% of individuals who were invited to participate did not attend the first session due to lack of interest, poor motivation, poor mental health or concerns about travel. Recruitment to the programme required team members to spend time sharing information and promoting the programme with young people and staff members.
The workload associated with this was significant and required clinical team members to prioritise SHAPE involvement alongside other clinical roles and duties. Other challenges have been to maintain momentum in the context of staff changes, sickness and leave, and to respond to higher than anticipated levels of external interest in the programme.
Evaluation of the SHAPE programme includes comparison of anthropometric data (BMI, waist circumference), lifestyle behaviours (smoking, substance use, diet and physical activity) and clinical measurements (resting heart rate and blood pressure, blood lipids, HbA1c and prolactin). Focus group interviews and monitoring of programme adherence and barriers to participation were also collated and analysed from the first year cohort to provide a enhance programme delivery and to assess impact.
Qualitative feedback suggests a number of health promotional benefits from the programme, beyond increasing physical activity. The provision of interactive nutrition sessions, including healthy food 'sampling' sessions, has encouraged participants to try new foods and think about accessible changes to their diet. In addition, the group based delivery of the programme has reduced social isolation and encouraged social contact between participants both within and outside of the formal SHAPE sessions.
The programme has also led to reported benefits in relation to confidence, social anxiety, identity and self-esteem as well as a broader impact on day to day functioning and mood on other days in the week. Quantitative evaluation of the first annual cohort programme (n=27) identified that participants (Duration of Untreated Psychosis < 6 months) were at an increased risk for cardiometabolic disorders at the time of diagnosis (see table 1 in the supporting material). Analysis at 12 weeks (at the end of the programme) and 12 month post-intervention showed that participants had no significant change in anthropometric measurements (table 2 in the supporting material), made positive changes to lifestyle behaviours (ceased smoking and substance use, increased physical activity levels, increased in fruit/vegetable intake), and maintained or improved clinical health markers (table 3 in the supporting material).
The programme has proven to provide a wide range of benefits in physical health to the patients as well as improved benefits to the health care system.
Benefits for the patient include:
- Reduced future risks of CVD and diabetes in mental health population. Preventative evidenced based intervention within WEIS pathway.
- Self-reported improvements and observed improvements in mental health and lifestyle changes in relation to exercise, nutrition, smoking.
- A collaborative approach between health and education enhances skill mix.
Benefits to healthcare system:
- Improved physical health pathway and interventions.
- Meeting NICE QS80 physical health monitoring and intervention quality statements.
Key learning points
There are a number of points we would suggest to others taking on similar projects which include:
- The appointment of peer support workers who have completed the SHAPE programme to provide support to new participants, particularly at the first session.
- Enhanced engagement with secondary care to increase referrals to SHAPE.
- Active engagement with primary care to ensure the documentation of accurate baseline physiological measures.
- Provision of awareness raising sessions with mental health professionals focusing on the importance of physical health and their role in promoting good physical health (including comprehensive repeat physical health assessment and monitoring).
- Collaborative working with Public Health colleagues to identify areas of local need and disseminate good practice findings.
Setting-up a new programme is time intensive and we learned a great deal through this period. To share this learning with others and promote long-term sustainability from our SHAPE experience, we secured Health Foundation Shine 2015 'Spreading Improvement' funding to develop a mySHAPE.org.uk website.
This website provides other health care providers with a programme handbook, which includes the programme plan (weekly exercise sessions and activities), participant workbook, SHAPE programme manual (handouts and PowerPoint slides from the educational sessions) and key areas of advice based on our learning (‘top tips’).
The handbook provides other health care providers with essential information and programme support to establish and deliver a similar SHAPE programme elsewhere.