Expert Q & A: How can a hospital exercise program serving a specific population reduce barriers?

An interview with Noemia Cerqueira, a mental health clinician at Toronto Western Hospital, who has created an exercise program for Portuguese-speaking women, recovering from mental illness.

Q: How long has your program been running?

Since fall 2009, my aerobics classes have run every Friday, 9:30–10:30 am.

Q: What was the impetus, and how did the program evolve?

I’m into fitness, so I’ve always had this idea that people would benefit from exercise. We serve clients with depression and anxiety disorders. We have a new psychiatrist who started in the fall who also believes that exercise can help.

We’re a team of eight clinicians — I sent [them] an e-mail and they referred clients to me. Now I have a core group of six women who come all the time.

Q: What is your role at the hospital?

I’m an intensive case manager — I help those with severe mental illness. I also conduct community visits: going for walks with people to get them out of the house. I meet them in the community.

Q: Does the added aerobics class increase your workload as a mental health clinician?

Yes, but some of my clients are there, so I can check on them. So I haven’t taken away from my visits.

Q: Do you think being YMCA-certified in fitness leadership is important?

I was certified years ago by the Y. I used to teach at the YMCA as a volunteer.

Certification is important because teaching [aerobics] is not as easy as it looks. You need to know what you are doing for the safety of the client and for yourself — it’s important to have that background. It’s also important to be able to present the class well. If I were not trained, I would not feel comfortable leading the aerobics class or personally providing resistance-training tips, so I would probably limit my activities to walks. Training can provide this skill set to community mental health staff.

My group is made up of women who are very new to activity. It reminds me to start with the basics.

Among other practices for safety, I have them do the PAR-Q [Physical Activity Readiness Questionnaire] and [sign a] liability waiver. It’s a basic class, so I watch them and ensure they are breathing throughout the activity and drinking water.

Q: Can you tell me about your training by the YMCA?

The YMCA training was great for fundamentals, which are critical. And then you can build from there — I took extra training to teach cyclefit and step [exercise routines]. CanFitPro conferences can provide new ideas for classes; but [for an aerobics class] you need to establish the class components first, which takes the most time.

Q: How do clients sign up for your program?

You have to be a client of the Portuguese Mental Health and Addictions outpatient program [at Toronto Western Hospital] since there is the language issue for the Portuguese-speakers. The current participants would not be as eager to participate otherwise. And the program is currently only for women. Some of the women would drop out if there were men, and none of the women would feel comfortable.

It’s the clinicians who refer clients for “activation” — to get out and be social — and then it’s the goals to be more physical and healthier that the client may express. But it’s clinicians who are identifying the need among the clients.

Q: Why is it important that the class be done in Portuguese?

Language is an issue. A lot of women have been here for many years, but are still more comfortable talking in Portuguese. Since concentration is already an issue, it helps them. We’re all Portuguese — so we all understand each other.

The program grew from the idea to take clients into the community for a gentle aerobics class. I started taking [my] small group, but the coordinator said the group didn’t fit since the participants seemed to be ”lost” in the class, while the issues were likely the English and the fact that it was their first session in a new environment.

My goal is to bring them back into the community class and show that these clients are able to join in.

Q: What are the benefits of a hospital-hosted program?

Clients are already engaged with us, so they trust us. And they know the space. We try to show that it is a part of the treatment ... so that they are willing to try. Or if they were able, they would just go to a community centre.

For the “hard sell,” we emphasize physical activity as a part of their treatment. When it comes as a recommendation from the psychiatrist, some are more likely to follow through. If the psychiatrist makes this recommendation, she then talks to the clinician about referral to my program. Then the clinician follows up with the client.

Twice it’s happened that I’ve told a client time and again to try the exercise group and they don’t actually join until they hear it from the psychiatrist. These clients have a higher regard for the psychiatrist as a professional and that she knows best. And they might be thinking, “If I don’t do it, what will happen?”

Q: Why do you think it is hard to get people to try your class?

Motivation! They don’t think it will help. They just can’t get to it and aren’t able to come. A lot of clients don’t work, so time is not the issue.

Q: How has their participation changed how you relate with clients?

It’s a positive, going out with them. Not as formal. They’re glad they have someone to go with. Time passes quickly. The class provides encouragement so that they can do this on their own.

We have fun in the class. I speak both Portuguese and English —I go back and forth, [so clients are] learning body parts in both languages. They’re enjoying this and becoming friends as well. I also talk about at home, other community centres in the area, going for walks, healthy eating and being mindful. Part of it is talking — not just by me; they can talk with each other in a safe place — no judgment. They have coffee together after class.

Q: What have been some of the success stories?

They look forward to the class. And they laugh. I’m hoping that by talking they can pick up things they can do at home — and they’re trying. During the class, I try to educate them about healthy living. For example, I try to promote healthy eating by telling them how to adapt a fried Portuguese dish to cooking it another way that won’t involve frying.

Q: How do you graduate clients out of the program?

Although we receive a lot of referrals, we haven’t had to graduate clients yet. We can still accommodate new people, and people who have joined have stayed. We can “grow” into a bigger room if we need to.

Q: Have you had to make the case to justify your program?

Our supervisor recognizes the value of physical activity based on research and other clinicians. And it hasn’t cost them much; we don’t receive any funding. I’ve asked for funding for resistance bands.

The hospital’s cardiac care centre has a weight room and machines. And I wonder how I can get in there, at least one day a week. I try to mix up the activities. Last week we took a 3 km walk at a good pace, and they responded well to this activity. One participant said, “We really enjoyed the walk last week.”

We have a meeting room [for the aerobics class] and we received the free pedometers from the Minding Our Bodies program for providing a description for the directory.

Q: Have you done any evaluation of your program?

I haven’t done any questionnaires. We provide a scale at the beginning as part of case management and after a few months, to track “social activity and support.” As clinicians we use the Hamilton scale for depression.

Q: Are there peer-leadership opportunities in your group’s future?

I’m thinking of coordinating a peer-led walking group with them, since some need a walking buddy to feel comfortable and to motivate themselves to do it.


If you have any additional questions for Noemia, you can contact her by phone at 416-603-5974 or by e-mail at Noemia [dot] Cerqueira [at] uhn [dot] on [dot] ca.