II Background: From Policy to Practice
III Influencing Behaviour Change
IV Project Goals
V Gathering the Evidence
VI Getting the Word Out
VII Seed Funding to Support New Programs
VIII Broadening Our Scope
IX Project Evaluation
X Next Steps
XI Related Resources
-- submitted by Scott Mitchell, Director, Knowledge Transfer, Canadian Mental Health Association, Ontario
The evidence is clear: physical activity and healthy eating are effective strategies to manage, and even prevent, chronic physical conditions such as diabetes and heart disease. Emerging research also points to the significant impact of exercise and diet on positive mental health and recovery from mental illness. Yet despite the known benefits — and despite the fact that people living with serious mental illness are at much higher risk than the general population of developing chronic physical conditions —physical activity and healthy eating interventions are not commonplace or well integrated with other services delivered by community mental health agencies in Ontario.
Since 2008, the Minding Our Bodies project has been working to increase capacity within the community mental health sector to promote physical activity and healthy eating for people living with depression, anxiety, schizophrenia and other mental health conditions. Our program serves as an “incubator” to help mental health service providers, together with community partners, develop and deliver evidence-informed physical activity and healthy eating programs, improve access to local resources, and promote social inclusion.
II Background: From Policy to Practice
Minding Our Bodies: Healthy Eating and Physical Activity for Mental Health is a multi-year project led by the Canadian Mental Health Association, Ontario Division (CMHA), in partnership with the Mood Disorders Association of Ontario, the Ontario Public Health Association’s (OPHA) Nutrition Resource Centre, YMCA Ontario and York University. Financial support is provided by the Ministry of Health and Long-Term Care (and the former Ministry of Health Promotion and Sport) through the Healthy Communities Fund. Our advisory committee brings together a range of organizations that share a common interest in mental health and chronic disease prevention and management, including the Canadian Diabetes Association, Dietitians of Canada, Heart and Stroke Foundation, Ophea, Parks and Recreation Ontario, and the Schizophrenia Society of Ontario.
Minding Our Bodies is rooted in CMHA Ontario’s policy work in the area of chronic disease prevention and management (CDPM). Many of the organizations involved in Minding Our Bodies are also active members of the Ontario Chronic Disease Prevention Alliance (http://www.ocdpa.on.ca/). Ontario’s CDPM framework, launched by the Ministry of Health and Long-Term Care in May 2007, recognizes the need to create supportive environments and strengthen community action, but the place of mental illnesses and mental health within the CDPM framework in Ontario has yet to be well-defined. Through our policy work — both influencing policy development and implementing provincial policy directions — CMHA Ontario is raising issues and opportunities for promoting mental health, supporting people with mental illnesses, and addressing the prevention and management of co-existing mental illnesses and chronic physical conditions.
People living with mental illness face multiple barriers to recovery. They are at much higher risk than the general population of developing chronic physical illnesses such as diabetes; heart disease and stroke; respiratory conditions, including chronic obstructive pulmonary disease (COPD), chronic bronchitis and asthma; some cancers; and arthritis. They are more likely to live in poverty and struggle with food insecurity. Some psychiatric medications can lead to significant weight gain, itself a risk factor for diabetes and other health problems. Stigma and discrimination also present barriers to care and often result in social exclusion.
There is growing evidence that diet plays a role in specific mental health problems including attention deficit hyperactivity disorder (ADHD), depression, schizophrenia and Alzheimer’s disease. For example, risk factors for depression include low intake of fish, omega 3 fatty acids and fruits and vegetables, and high intake of refined sugar and processed foods. The good news is that the combination of nutrients most commonly associated with good mental health and well-being is the same type of balanced diet that is recommended to reduce our risk of developing chronic physical diseases.
The mental health benefits of physical activity are numerous: a positive effect on emotion, mood, and sense of well-being; improved self-esteem and self-confidence; improved body image; feelings of mastery and self-efficacy; a sense of accomplishment and empowerment; lower risk of disturbed sleep; and better cognitive performance.
Compared with other forms of treatment, healthy eating and physical activity offer several advantages. Healthy living interventions are less likely to cause adverse side-effects, in contrast to medications. They can be sustained indefinitely by the individual, unlike medical treatments which are often time-limited. They are normalizing, health-focused experiences, unlike drug treatments and other clinical interventions that are a constant reminder of one’s illness. Healthy eating and physical activity programs can serve as a bridge to other services offered by community health care providers. And group programs are especially successful at promoting social inclusion, which is strongly associated with positive mental health.
III Influencing Behaviour Change
If the research evidence shows that healthy eating and physical activity can have significant positive effects in preventing chronic disease, improving chronic disease outcomes and supporting recovery from mental illness, why isn’t everyone who lives with a mental illness being physically activity and eating a healthy diet?
Knowing and doing are two different things. Put up your hand if you know that physical activity is good for you, but you still don’t act on that knowledge. Now imagine that you also live with depression or anxiety, making it difficult to get out bed or out of the house, let alone go to the gym. Imagine that you have diabetes, that you live on a fixed income, that you have trouble finding a safe and stable place to live. Living a more active lifestyle may not be your most pressing everyday need.
Changing health behaviours isn’t always about closing a gap in personal knowledge – it’s often about reducing barriers and creating supportive environments to enable action. For many reasons, community mental health providers are ideally positioned to provide healthy lifestyle programs. Physical activity and healthy eating programs align well with the recovery philosophy of community mental health services. Many individuals with serious mental illness already have frequent contact with mental health service providers and have established relationships. Mental health service providers have specialized training and sensitivity to address barriers facing this vulnerable population. And offering healthy lifestyle programs in collaboration with community partners creates an opportunity to improve service coordination, both within and outside of the mental health care sector.
IV Project Goals
Since 2008, the Minding Our Bodies project has been working to improve mental and physical health for people living with serious mental illness. Our program serves as an “incubator” to help mental health service providers in Ontario, together with community partners, develop and deliver evidence-informed programs that promote healthy lifestyles, ranging from nutrition and life skills education, to collective kitchens, community gardens and physical activity programs.
Beyond providing support for individual recovery from mental illness, and helping to prevent and manage chronic physical conditions, Minding Our Bodies also builds partnerships and creates new opportunities for peer support and peer leadership development. Longer-term goals of the project include influencing a shift in health policy towards upstream action on prevention and promotion. We want to create a culture that encourages physical activity and healthy eating as core features of mental health promotion.
To build the evidence base needed by policy decision-makers and program leaders, Minding Our Bodies is working not only to contribute new, practice-based knowledge, by supporting innovative program development and evaluation, but also to shape the community-based research agenda.
V Gathering the Evidence
The Minding Our Bodies project started with an environmental scan to gather information about existing physical activity and healthy eating programs for people with mental illness, and to identify start-up challenges, perceived barriers and program success factors. We invited all community mental health organizations in Ontario — including organizations that already had such a program, as well as those that didn’t — to share their knowledge based on practical experience. In phase one, “Physical Activity for Mental Health” (2008–2010), more than 140 organizations responded to our request and completed an online survey. Eight organizations participated in one-on-one, in-depth follow-up interviews. In phase two, “Eating Well for Mental Health” (2009–2011), there were 77 responses to the online survey. Additional research and follow-up interviews were also conducted. Findings from the two surveys are available on the project website.
Commonly identified barriers included: lack of access to adequate facilities or physical space; no funds to support staff salaries and other program expenses; lack of staff knowledge about program benefits; lack of staff training in physical activity and healthy eating; difficulty motivating participants; staff time management with competing priorities; transportation costs and accessibility; and lack of program evaluation skills and resources.
The environmental scan also identified three main strategies to address these barriers: (1) build community partnerships and interagency collaborations; (2) tap into existing services and volunteer resources; and (3) engage and develop peer leaders.
Literature reviews were also conducted in the first two phases of the Minding Our Bodies project, to synthesize evidence on the effects of physical activity and diet on mental health. The results were combined with the environmental scans to support our project planning and toolkit development.
The Minding Our Bodies online toolkit brings together good advice and a selection of practical resources to guide organizations through the program planning stage. Rather than recreate the wheel, our resource library draws on many excellent pre-existing documents produced by our project partners and other organizations. Two good examples are the “Walk This Way” kit created by Ophea’s Physical Activity Resource Centre, and the “Healthy Eating Manual” produced by OPHA’s Nutrition Resource Centre. The resource library also includes new products created by Minding Our Bodies, such as the “Gardening for Food and Mental Health” booklet that captures an innovative community garden initiative in Owen Sound. Resources are interspersed with lessons learned from programs funded by Minding Our Bodies, and the online toolkit is regularly updated as new resources emerge.
The website also houses a program directory that describes more than 50 existing physical activity and healthy eating programs designed for mental health clients. The listings are intended to serve as models to educate and inspire other organizations to launch their own programs. Contact information is included to facilitate further sharing.
VI Getting the Word Out
A regular newsletter was distributed online and in print during the first phases of the project, to raise awareness, invite participation and report on our successes. Minding Our Bodies now produces a quarterly e-bulletin with news and event listings, research summaries, new resource announcements, and interviews with experts in the field (such as John Ratey, author of Spark: The Revolutionary New Science of Exercise and the Brain).
To mark the release of the Minding Our Bodies project toolkit, staff at CMHA Ontario participated in a pedometer challenge during Mental Health Week (May 3–9, 2010). In only seven days, CMHA Ontario staff collectively walked over 680,000 steps! Proposing a similar challenge to all CMHA branches in Ontario during the month of July, we distributed over 2,000 pedometers, generously donated by ParticipACTION, the Ministry of Health Promotion and Sport and the National Quality Institute (NQI). The branches responded with enthusiasm and kept track of their steps using the Government of Ontario’s Active 2010: Pedometer Challenge website.
Getting the word out has also included interviews and articles in the media, webinars hosted by ParticipACTION, Ophea and other organizations, as well as conference posters and workshops. Minding Our Bodies has presented at the Ontario Public Health Association Fall Forum, the 3rd International Congress on Physical Activity and Public Health, Making Gains in Mental Health and Addictions, the Dietitians of Canada annual conference, the Health and Wellbeing in Developmental Disabilities conference, the Move Your Mood workshop in Red Deer, Alberta, and the 1st International Forum on Health Promotion and Disease Prevention in Wroclaw, Poland.
Starting in 2011, we delivered a series of full-day knowledge exchange forums for priority audiences (mental health program managers, peer support workers, fitness instructors, dietitians and other nutrition professionals), to raise awareness of Minding Our Bodies, share lessons learned from the pilot phases, present successful program models, facilitate networking and partnership building, introduce participants to the toolkit resources and grow the community of practice. Forums were held in Toronto, London, Ottawa and Thunder Bay, and each event had a unique theme or population focus. Presentations are available on the Minding Our Bodies website.
VII Seed Funding to Support New Programs
Minding Our Bodies has supported the launch of 32 new programs in communities across Ontario, through a combination of seed funding, training, and online resources to support program planning and evaluation. Each program is unique to the community it serves, often developed with direct input from participants. This direct engagement increases the chances of program success, by ensuring that it meets the expressed needs of participants. It also aligns well with mental health recovery principles that insist on client empowerment and self-determination.
Participating organizations have included mental health agencies, consumer/survivor initiatives, public health units, community health centres, a hospital, and a tribal council serving six First Nations in Ontario’s far north.
Training for seed-funded programs was delivered during one-day face-to-face workshops during the first two pilot phases. In phase three, training was delivered via teleconference and webinar. Registration for these online sessions was open to any organization, in order to extend our reach beyond the funded programs, and presentations were later posted on the project website.
During phase two, the Mood Disorders Association of Ontario (MDAO) developed a unique program called Boost Your Mood, designed to be co-delivered by a dietitian, a fitness instructor and a mental health peer facilitator. Boost Your Mood was then revised and expanded in phase three and delivered as a train-the-trainer workshop in three locations (Hamilton, Ottawa and Thunder Bay). Several organizations have since used that training to deliver the program locally. MDAO will continue to run the Boost Your Mood program in Toronto and offer train-the-trainer sessions as needed.
VIII Broadening Our Scope
As Minding Our Bodies evolved, it became apparent that we should also be focusing attention on the various professionals, such as dietitians and fitness instructors, who could support mental health organizations to deliver their programs. We worked with the Dietitians of Canada to deliver two full-day workshops for dietetic interns, to improve mental health literacy. The events took place in Toronto and Ottawa, with remote participation via the Ontario Telehealth Network.
Recognizing that the post-secondary curriculum for nutrition students contains very little information on mental health, Minding Our Bodies engaged with Jacqui Gingras, Associate Professor in the School of Nutrition at Ryerson University, to conduct a study exploring the perceptions of mental health and illness among nutrition students. A systematic review was conducted to summarize current literature on mental health literacy and education among students in health professions, and a three-hour mental health literacy workshop was delivered to students enrolled in a second-year Interpersonal Relationships course in the Nutrition and Food undergraduate program at Ryerson. Findings from the literature review were presented at the Dietitians of Canada annual conference in 2012, while results from the pre- and post-workshop survey are being prepared for journal submission.
IX Project Evaluation
Minding Our Bodies recruited an evaluation consultant in each phase of the project to perform two functions: (a) design and implement an evaluation plan for the overall project, and (b) support the local seed-funded organizations to conduct their own internal program evaluations. In phases one and two, the final evaluation report included in-depth case studies of each program, created by the Minding Our Bodies evaluator in collaboration with the local program leaders. Findings from the local site evaluations were integrated into the overall report. All reports are published on the Minding Our Bodies website.
The evaluation approach was designed as an evolving self-reflection process, and lessons from each phase were applied to planning for the next phase. The process is discussed in more detail in the “Casebook on Evaluation for Learning in Chronic Disease Prevention and Health Promotion” (http://publications.gc.ca/site/eng/413785/publication.html ) (2011), a monograph produced by the Public Health Agency of Canada that presents six descriptive narratives illustrating the successful use of evaluation. In recognition of their work, the project evaluators in phase two — Michaela Hynie, Associate Director of the York Institute for Health Research, Program Evaluation Unit, and graduate student Carolyn Steele Gray — received the Evaluator Excellence Award 2011 from the Canadian Evaluation Society, Ontario Chapter.
In phase three, greater emphasis was placed on building evaluation capacity within participating organizations. Local program leaders were offered a four-week, online evaluation training program, developed by York University that combined self-study with interactive group discussions and mentorship by the instructor. Additional one-on-one and group support was provided to all program leaders to help them plan and implement their internal program evaluations.
Final reports from each program were shared with the Minding Our Bodies project evaluator and the course instructor. Lessons learned in phase three about our approach to evaluation capacity building have been synthesized to inform future discussion and planning. In addition, a scoping review of the scientific literature was commissioned to see how other healthy living programs serving marginalized populations had approached evaluation and what tools were used.
To find out how evaluation results are being applied by the Minding Our Bodies seed-funded organizations that ran local programs, a York University graduate student is conducting a follow-up study. Interviews have been conducted with program leaders from all three phases of the Minding Our Bodies project, and results are now being analyzed.
When all the final reports are in hand, our next action will be to reflect on lessons learned and to engage in a discussion with the evaluation community about best practices in capacity building for the mental health sector.
X Next Steps
CMHA Ontario is continuing to build on the momentum of the Minding Our Bodies project. Following is an overview of current and upcoming activities.
With funding provided by the Accessibility Directorate of Ontario, CMHA Ontario recently launched a new initiative called Enabling Minds. The goal is to reduce barriers and improve access to physical activity programs and services for people with mental health-related disabilities. Working in collaboration with Parks and Recreation Ontario and YMCA Ontario, CMHA will develop tools and training resources to support organizations in the physical activity sector to meet the requirements of the customer service and information and communication standards under the Accessibility for Ontarians with Disabilities Act, 2005.
In December 2012, Dietitians of Canada released a new role paper, “Promoting Mental Health through Healthy Eating and Nutritional Care.” CMHA Ontario was a contributing author. Over the next year, CMHA and Dietitians of Canada will collaborate on a dissemination strategy to get the word out about key policy and practice recommendations contained in the paper. CMHA will focus particularly on mechanisms that can increase access to and quality of dietetic services for people with mental health conditions in the community, as well as on the need for research that evaluates the impact and outcomes of community-based healthy eating programs.
CMHA Ontario recently announced a new partnership with Conservation Ontario to promote their Healthy Hikes campaign. Running from May through October 2013, Healthy Hikes will challenge Ontarians to spend time hiking in the province’s over 270 Conservation Areas and track their progress for a chance to win prizes. Healthy Hikes is designed to teach participants about the ways our environment can boost both physical and mental health. For more information, visit http://www.healthyhikes.ca.
Looking beyond our provincial borders, the Minding Our Bodies project has begun connecting with similar initiatives in other jurisdictions. Our intention is to develop a national network, or community of practice, to share lessons learned, promote the exchange of promising practices and identify research gaps and opportunities. For more information, contact Scott Mitchell at email@example.com.
XI Related Resources
Minding Our Bodies: Healthy Eating and Physical Activity for Mental Health
Includes a program planning toolkit, directory of programs, literature reviews, evaluation reports, expert interviews, news and event listings, and more.
Craving Change: Rethinking Our Approach to Chronic Disease
Fall 2010 issue of CMHA Ontario’s Network magazine, featuring articles on the social determinants of health, food insecurity, Aboriginal diabetes prevention and management, mental health peer support, and innovative programs for people living with mental illness who have metabolic syndrome and other chronic conditions.
Casebook on Evaluation for Learning in Chronic Disease Prevention and Health Promotion
Produced in 2011 by the Public Health Agency of Canada’s Chronic Disease Interventions Division, this monograph presents six descriptive narratives that illustrate the successful use of evaluation findings to inform programs and practices in chronic disease prevention and health promotion. The Minding Our Bodies project is one of the selected case studies.
Promoting Mental Health through Healthy Eating and Nutritional Care
Published in December 2012 by the Dietitians of Canada, the goal of this role paper is to support the work of dietitians and to guide future dietetics practice as it relates to mental health. The document also provides policy makers with an evidence-based summary of the current literature about the promotion of mental health through healthy eating and nutritional care.
Mental Health and Physical Activity [Journal]
Co-edited by Guy Faulkner, professor in the Faculty of Kinesiology and Physical Education at University of Toronto.
Chronic Disease Prevention and Management
Policy documents produced by the Canadian Mental Health Association, Ontario.
Common Messages: Supporting Collective Priorities and Action on Chronic Disease Prevention across Ontario
Produced by the Ontario Chronic Disease Prevention Alliance, this document presents common messages and related actions that health practitioners, organizations, and groups can take to collectively move forward in addressing chronic disease and its prevention.
The goal of the Enabling Minds project is to reduce barriers and improve access to physical activity programs and services for people living with mental illness.
Diabetes and Mental Health Peer Support Project
Resources to provide diabetes competency training for mental health peer support workers, and to increase awareness in the diabetes community of the role mental health peer support workers can play in prevention and self-management support.