Expert Q & A: How can client views be captured to help mental health settings become healthier places?

Photovoice was used to engage participants in Paul Gorczynski's research at the Faculty of Physical Education and Health, University of Toronto. His research looked at client perspectives on ways to increase physical activity and improve dietary behaviours among individuals with schizophrenia who are overweight or obese and who are taking antipsychotic medication.

Q: We hear of medications contributing to obesity among clients, but what role do mental health settings play?
Although research has shown that antipsychotic medication does contribute to obesity, what has not been examined closely are the environmental links that restrict physical activity and limit healthful diets. This is what our study aimed to do. So whether we are speaking about clients who live in in-patient settings or the community, we need to consider where individuals are obtaining their meals, what they are eating, what opportunities exist to eat healthfully and what prevents them from eating healthfully. In terms of physical activity, we should be looking at what kinds of environmental barriers are preventing individuals from being physically active. For in-patient clients it may be a lack of access to recreational facilities, a lack of privileges to leave the unit floor, or a lack of recreation therapists in the hospital to organize activities. There are many environmental factors that determine whether an individual can be active and eat healthfully. It’s a very complex situation and we need to take a closer look at not only the physical environment, but also the social, political and economic makeup of it as well.

Q: Can you describe the study you did? Who were your participants? Where was the study setting?
The setting was the Centre for Addiction and Mental Health, at the Queen Street facility in Toronto. Twenty-five adults who were overweight or obese and who had any type of schizophrenia were asked to give their thoughts as to what affected their diet and physical activity.

Q: Do you think it’s the setting itself or the community and built environment of a neighbourhood that plays the stronger role?
Photo of coffee cartI think they both play important roles in affecting weight gain, but it also depends on whether we’re talking about in-patient or outpatient clients. Both groups of individuals face unique challenges and have different needs. Programs need to be put in place both in the hospital and the community to address the needs of both groups. 

For individuals who live in the community, the Boarding Home Working Group at the Parkdale Community Health Centre, of which I am a part of, is currently examining how boarding homes can be improved so that clients receive more healthful meals and have access to physical activity.

Q: Your study revealed that the factors that lead to obesity were more diet-related than physical activity-related, why do you think that is?
Photo of vending machineI’m still trying to process that. There could be a few reasons. First, various unhealthful dietary factors are readily visible in the hospital. For example, vending machines can be pointed to very quickly, as can coffee carts and high-fat, high-starch food available in the cafeteria. Barriers to physical activity may not be so easy to spot or conceptualize and may not be automatically associated with obesity. For instance, when you look at a closed door or a closed staircase, you may not immediately think these objects are causing weight gain, as you would by looking at unhealthful food available for purchase. Second, people may be receiving more information on diet than physical activity and as a result may be more conscious and aware of it. This may potentially mean that we need to provide clients with more information on physical activity and how they can become active. Third, clients may simply think that unhealthful diets are more responsible for their weight gain than a lack of physical activity and, as a result, talked about those factors in the study.

Q: You used photovoice as a way to capture opinions from clients. Can you describe this process?
We decided to use photovoice because it would capture each individual’s unique perspective and act as a conversational prompt during the interview process. We provided individuals with cameras and asked them to take photos of factors they believed influenced their diet and physical activity, for better or worse. After clients took photos, I sat down with each participant and conducted a semi-structured interview to discuss the factors in greater detail. Additionally, clients were asked about their thoughts on some potential solutions to address the obesity issue in the hospital.

I would like to briefly mention that seven individuals were not able to take photos because they were not able to leave their respective units due to a lack of privileges. These individuals still participated in the study and contributed their thoughts on what environmental factors influenced their diet and physical activity.

Q: What are the benefits of using photovoice?
Photo of treadmillsThe photos taken by the clients acted as great prompts to discuss the state of the hospital with respect to diet and physical activity. The use of photovoice allowed individuals to take ownership of a particular topic and advocate for change. For instance, many participants pointed to the multiple vending machines located in the hospital. Participants had a hard time understanding how a place of healing could provide or tempt them with such unhealthful food. Another example included the client gym. Many clients mentioned that the hospital should not only purchase new equipment, but it should also find a new location as the current one is too small to allow more than one person to work out at the same time. 

Not only is photovoice a very powerful tool to start a discussion about a particular issue, it is also a great way to gain the attention of those in power who can make necessary changes.

Q: Do you think photovoice can be used in other ways, such as program evaluation or program planning?
Both. The primary focus of photovoice is to start a discussion among individuals who share a particular problem or concern. For program planning, photovoice can help elicit multiple perspectives around a particular issue. It may help uncover something that may have been missed by stakeholders or those in charge of the planning process. Photovoice provides everyone with the ability to speak from a unique standpoint. Program administrators and policy-makers can learn from these perspectives and design programs that satisfy the needs of the community in question. 

In terms of evaluation, it can be used to allow participants to capture photos of changes that have occurred or have not occurred, or what still needs improvement. Ultimately, it allows individuals to express their unique opinions and advocate for change.

Q: Your research with photovoice engages with the community (participants and other stakeholders). How do you think the results will translate into practice at the hospital?
Photo of doorI think with any hospital or institution it is very difficult to see changes come quickly. At the very least, I hope this research can be used to start a dialogue between clients, clinicians, the hospital administration, and various levels of policy-makers. On many issues this is already happening, but perhaps the conversation can become more focused around some of the factors that have been raised in this study. In order to improve and continue to raise the quality of care at this and any other institution, we must remember that members of the administration must work hand-in-hand with clients and that important decisions cannot simply be top-down ones.

Q: How do you think service providers can connect with researchers?
I don’t think it should be a one-directional approach where service providers connect with researchers or vice versa. Clients need to be included in the picture as well. We need more people at the table and we need more research that involves the greater community. Using a community-based approach allows everyone to share their unique experiences and provide their expertise in solving a problem. Service providers and researchers will have their suggestions, as will the clients. I believe it is diverse and inclusive community partnerships that will have the greatest chance of creating solutions that are effective and sustainable.

Q: You recently did a review of selected studies on exercise for people with schizophrenia, can you tell us what you found?
Our Cochrane Review examined the impact exercise had on mental health. By looking specifically at randomized controlled trials, we found that exercise significantly improved negative symptoms compared to standard care. An important finding of the review was that when we looked at one trial that compared regular exercise with yoga, we found that yoga had a greater effect on mental health than regular exercise. This interesting study from India also found that people in the yoga group had better quality of life scores than regular exercisers. Our main recommendation for clinicians and policy-makers in mental health was that exercise programs be incorporated into treatment. Having this treatment option accessible to clients will not only improve their physical health, but also their mental and social health.

If readers have any further questions they can e-mail me at paul [dot] gorczynski [at] utoronto [dot] ca.