Health behavior change benefits: Perspectives of Latinos with serious mental illness

Introduction

In the U.S., Latinos who suffer from serious mental illnesses (SMI), such as schizophrenia and major mood disorders, experience a compounded health disparity (Carliner et al., 2013). First, adults with SMI, regardless of race or ethnicity, have a 25–30 year shorter average life span and disproportionately greater rates of medical comorbidity compared to the general population (Druss, Zhao, von Esenwein, Morrato, & Marcus, 2011). Premature mortality in adults with SMI is most often linked to cardiovascular disease (CVD) caused by preventable health behaviors such as sedentary lifestyles, obesity, and poor dietary habits (Colton & Manderscheid, 2006). Second, Latino adults with SMI have a significantly greater prevalence of CVD risk factors, such as obesity and metabolic syndrome, compared to non-Latino Whites with SMI (Hellerstein et al., 2007; Kato, Currier, Gomez, Hall, & Gonzalez-Blanco, 2004; Mensah, Mokdad, Ford, Greenlund, & Croft, 2005). In addition, CVD-related outcomes are worse for Latinos with SMI than Latinos in the general population, or than non-Latino Whites with these psychiatric disorders (Carliner et al., 2013). This compounded health disparity places Latinos with SMI at particularly high risk for excess morbidity and premature mortality.

In addition to physical and mental health disparities, evidence indicates that Latinos with SMI experience disparities in mental health service utilization (Agency for Healthcare Research and Quality [AHRQ], 2011; Barrio et al., 2003; U.S. Department of Health and Human Services, 2001). Latinos with SMI utilize fewer nonacute psychiatric services than non-Latino Whites with SMI (Barrio et al., 2003). Although structural inequalities such as income, level of education, language, and insurance status contribute to differential access to and utilization of mental healthcare services among Latinos with SMI, disparities are unlikely to be ameliorated without equal attention to how this group engages with and responds to mental problems and treatment (Carpenter-Song et al., 2010).

Mental health service use may be affected by cultural stigma about having a mental health problem. Carpenter-Song et al. (2010) found that Latinos with SMI resented diagnostic labels (e.g., schizophrenia, bipolar disorder, etc.) that carry the risk of social rejection. In contrast, Latinos who conceptualized mental illness as a problem with nerves or as a sickness that one has, much like a physical ailment, experienced less stigma (Carpenter-Song et al., 2010). Moreover, Latinos were skeptical of the utility of traditional forms of mental health treatment (i.e., psychotherapy and medications; Carpenter-Song et al., 2010). In order to address the multiple disparities that Latinos with SMI experience and their skepticism of traditional mental health treatment, it is necessary to develop alternative treatments that employ a culturally sensitive, nonstigmatizing approach to improve the physical and mental health of this population.

Health behavior change interventions represent a potential solution to the multiple disparities experienced by Latinos with SMI. The emphasis on treating mental health problems through health and wellness techniques could appeal to Latinos with SMI as a nonstigmatizing and culturally acceptable alternative to traditional mental health services. Results of a recent study showed that older Latinos in primary care clinics across the US were more likely to believe that mental illness was caused by a medical illness compared to their non-Latino White counterparts (Jimenez, Bartels, Cardenas, Dhaliwal, & Alegría, 2012). In addition, many Latinos tend to express psychological distress as somatic complaints such as heaviness in the chest, dizziness, and so forth (Carpenter-Song et al., 2010; Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005). Therefore, health behavior change interventions may seem less stigmatizing and more culturally relevant because they match Latinos’ beliefs about mental illness (Carpenter-Song et al., 2010; Jimenez et al., 2012). Because comorbid physical illness is a salient issue for many Latinos with SMI (Hellerstein et al., 2007; Kato et al., 2004; Mensah et al., 2005), health behavior change interventions that link physical activity and proper nutrition to improvement of mental health may motivate Latinos with SMI to adopt healthy lifestyle behaviors. There is also growing evidence to suggest that increased physical activity and nutrition can lead to improved mental and physical health outcomes as well as increased quality of life (Calvert, Isaac, & Johnson, 2012; Jennings-Sanders, 2003).

Latino adults are more likely to be sedentary and they are not as actively engaged in pursuing changes in their health behaviors compared to non-Latino White adults (Cromwell & Berg, 2006), suggesting that culture-specific beliefs and attitudes may influence Latinos’ participation in health behavior change (D’Alonzo & Fischetti, 2008; Juarbe, Turok, & Pérez-Stable, 2002). Research suggests that Latinos may not engage in health behavior change because of the belief that they are “naturally healthy” and therefore do not need to add intentional exercise to their daily physical activity (Berg, Cromwell, & Arnett, 2002; Im et al., 2010; Juarbe, Lipson, & Turok, 2003; Melillo et al., 2001). In addition, Im et al. (2010) found that the majority of Latinas in their sample had a negative view of physical activity and believed that increasing physical activity would be a waste of time in their busy daily schedules.

However, much of the prior research investigating beliefs about health behaviors has focused on Latinos without mental illness and has not included participants who were at risk of cardiovascular disease from their health conditions (e.g., obesity), which limits the generalizability of these studies. Despite the significant health risks faced by Latinos with SMI, to date, few studies have assessed their perceptions of the potential benefits of regular exercise and improved nutrition. Understanding the perspectives of Latinos with SMI regarding health behavior change will help to inform targets for motivating engagement and participation in health promotion interventions tailored to this population. The aim of this study was to explore the perceived benefits of health behavior change from the viewpoint and experiences of overweight and obese Latinos with SMI participating in a health promotion intervention.

It is important that the term Latino be defined for the purpose of this study as its use varies according to the context in which it is used. The United States (U.S.) Census Bureau defines Latino as an ethnicity comprised of individuals of Cuban, Dominican, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race (U.S. Census Bureau, 2011). This umbrella term is particularly problematic in that it attempts to encompass individuals from non-Spanish speaking countries of Central and South America (Belize, Brazil, Suriname, Guyana, and French Guiana). Latinos, therefore, are not a homogeneous, monolithic group, even though the U.S. Census definition classifies them into one uniform ethnicity. For the purposes of this study, the term Latino is used to refer to individuals from the Spanish speaking countries of Central and South America as well as the Caribbean. This is done for two reasons. First, most individuals from non-Spanish speaking countries in Central and South America do not self-identify as Latino (Zubaran, 2008). Second, although each Latino subgroup faces unique difficulties—Cubans, full economic assimilation; Puerto Ricans, dual identity; Mexicans, pressures of legalities and legalism—there are many shared cultural characteristics such as language, familism, and religiosity (Alarcón, 2001). Latinos constitute 16% of the U.S. population and are the second largest ethnic group, after non-Latino Whites (U.S. Census Bureau, 2011).

Methods

Results

Latino participants in In SHAPE believed that engaging in health behavior change would benefit “the mind and body, not just health and fitness.” They reported that exercise and maintaining a healthy diet were essential components to their “well-being.” A summary of each theme, the domain to which it is related, and an operational definition of each theme are presented in Table 1 and described in the following lines.

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Table 1.

Perceived benefits to engaging in health behavior change: Qualitative domains, related themes, and operational definitions of each theme.

Domain	Themes	Operational definition
Physical health benefits	Chronic disease management	Helps in the treatment of diabetes, hypertension, and high cholesterol.
	Changes in weight and body composition	Losing weight and increased muscle tone.
Mental health benefits	Increased self-esteem	Loss of weight and increased muscle tone will make participant more self-confident, appealing, and attractive to the opposite sex.
	Stress reduction	Exercising regularly reduces stress and makes participants feel calm.
	Mental illness management	Helps treat symptoms of mental illness and manage medication side effects.

Discussion

To our knowledge, no recent published study has examined the perceived benefits of engaging in health behavior change among Latinos living with SMI. This is an important population to examine because it is disproportionately affected by physical and mental health disparities (AHRQ, 2011; Barrio et al., 2003; Hellerstein et al., 2007; Kato et al., 2004; Mensah et al., 2005). We found that Latinos with SMI had a very positive view of health behavior change. They believed that increasing physical activity, exercise, and improving their nutrition were essential components of mind and body wellness. The participants in our study did not see themselves as “naturally healthy” as reported in prior studies involving Latinos without mental illness or known health risks, such as obesity (Berg et al., 2002; Im et al., 2010; Juarbe et al., 2003; Melillo et al., 2001). Rather they were aware of their physical and mental health conditions and believed that changing their health behaviors would improve these conditions.

These positive perceptions may have been influenced by the participants’ conceptions of mental illness. Previous studies have consistently found that among different Latino groups (e.g., Puerto Ricans, Dominicans, Mexicans, Cubans) mental illness was perceived to have a reciprocal relationship with chronic physical illnesses (Cabassa, Hansen, Palinkas, & Ell, 2008; Cherrington, Ayala, Sleath, & Corbie-Smith, 2006; Heilemann, Coffey-Love, & Frutos, 2004; Pincay & Guarnaccia, 2007). In these studies, Latinos believed that the onset of a chronic physical illness, such as diabetes, was precipitated by an extreme emotional or stressful event. The inability to cope with these emotions presented a barrier to self-management and limited their ability to engage in self-management behaviors. Conversely, the diagnosis and management of a chronic physical illness, such as diabetes, had a significant impact on their emotional health. A similar bidirectional relationship may be occurring in this predominately Puerto Rican sample with SMI and a comorbid chronic physical illness. The participants’ SMI may be interfering with self-care behaviors and their ability to manage their chronic physical illnesses. Their chronic physical illness may be simultaneously impacting their SMI by reducing their physical functioning and increasing the burden of living and coping with a chronic medical illness. The saliency of the chronic physical illness in participants’ conceptualizations of mental illness suggests that a health behavior change intervention, such as In SHAPE, is well aligned with their perceived needs and may provide a tangible treatment to address them.

Participants believed that participating in health behavior change activities would lead to improved physical and mental health, decreased risk of disease, changes in weight and body composition, increased self-esteem, increased attractiveness, and stress reduction. These perceived benefits were similar to those identified in a previous study of adults who had a mental illness (Sinnott, Quigley, & Morris, 2014) and in studies with adults who had multiple chronic medical conditions but did not have a mental illness (Dergance et al., 2003; Kirchoff, Elliott, Schlichting, & Chin, 2008). Our study is a unique contribution to the literature because all of the participants were Latino and had SMI, as well as chronic medical conditions. In addition, the qualitative design of the study allowed the participants to respond freely in their own words and about their unique circumstances. This study provides preliminary findings that may help to inform our understanding of how individuals from highly disadvantaged backgrounds view health behavior change.

These results could have clinical implications for mental health and general medical providers who treat Latinos with SMI. By understanding patients’ perceptions, clinicians may be in a better position to address the needs of their patients in a culturally sensitive manner. Some promising clinical strategies include maintaining clinical vigilance for somatic expressions of psychological distress, assessing for culturally specific ways of expressing and understanding mental illness, and respecting culturally mediated treatment preferences. It is helpful for clinicians and researchers to understand how Latinos with SMI perceive the benefits of health behavior change.

In our study, Latinos with SMI mentioned the physical and mental health benefits of increased physical activity and improved nutrition. Because many public health messages about exercise tout weight loss as motivation over other health benefits, more appropriate communication may be necessary to improve and sustain engagement in health behavior change (Dergance et al., 2003). Clinicians and researchers can also encourage their patients to increase participation in health behavior change, using these perceptions as support. This can be especially helpful in engaging racial/ethnic minority individuals that have historically underutilized mental health services.

In addition to understanding cultural perspectives about health behavior change, clinicians and researchers must be aware of the multiple socioeconomic and language barriers that adversely affect Latinos with and without SMI (Cabassa, Siantz, Nicasio, Guarnaccia, & Lewis-Fernández, 2014; Stanhope & Henwood, 2014). Family obligations and resulting fatigue and lack of time often interfere with physical activity participation (D’Alonzo & Fischetti, 2008; Im et al., 2010). For many Latinos, a connection exists between physical activity and their jobs. Latinos have reported that they did more than enough physical activity at work. Thus, they usually kept a very sedentary life pattern after their work (Im et al., 2010). Also, most physical activity programs and resources in the US are provided in English and thus may be difficult to navigate for individuals who only speak Spanish (Pekmezi et al., 2012). These barriers limit access to health promotion programs and need to be addressed in order for these interventions to be successful.

The results of our study need to be interpreted carefully in light of certain limitations. First, participants were a convenience sample of Latinos with SMI who were already enrolled in a health promotion/health behavior change intervention study. As such, this group of individuals represents a select subgroup and conclusions drawn may not be generalizable to the Latino SMI population at large. A second limitation is the relatively small sample size. However, a sample size of N = 20 is consistent with exploratory qualitative methods (Miles & Huberman, 1994) aimed at identifying descriptive findings (Leon, Davis, & Kraemer, 2011). Third, all of the participants spoke English, indicating a high level of acculturation (Grimm & Blanck, 2011). Acculturation can impact the extent to which beliefs and attitudes from one’s culture of origin impact current health-related decisions (Andrulis & Brach, 2007); therefore, our results may not be generalizable to low acculturated Latinos with SMI. Fourth, the point in the study in which participants were interviewed was not uniform. Participants may have been at the beginning, middle, or nearing the end of their time in the intervention study. This could influence their perceptions of the benefits of health behavior change. For example, participants who had already made changes may have reported more potential benefits. Fifth, because of sample size considerations, the Latinos in this study were treated as a homogeneous group, when they actually comprise different subgroups of varying nationalities. Combining these individuals into a broad category (i.e., Latino) makes these qualitative inquiries possible, but it might mask meaningful variations.

Latino subgroups differ on several health-related indicators such as mental healthcare utilization (Ai, Appel, Huang, & Lee, 2012), smoking (Kaplan et al., 2014), alcohol use (Vaeth, Caetano, Ramisetty-Mikler, & Rodriguez, 2009), and risk for a variety of physiological (Daviglus et al., 2012) and mental illnesses (Alegría et al., 2008). Specifically, Puerto Ricans, who comprise 45% of the study sample, have the highest rates of mental illness, substance abuse, and seeking mental health services of any Latino subgroup (Ai et al., 2012; Alegría et al., 2008). Therefore, our results may not be generalizable to other Latino groups that have lower health risk factors and may not access the mental health system as often as Puerto Ricans.

In summary, Latinos with SMI participating in a health behavior change intervention identified potential benefits of program participation that are similar to those identified by other racial/ethnic minorities with chronic medical conditions (e.g., weight loss and chronic disease self-management) as well as benefits that may be uniquely appreciated by this population (e.g., sense of overall well-being, increased self-esteem, and better mental health). Thus, this exploratory study points to several factors that may be important in engaging and motivating overweight and obese Latinos with SMI in health behavior change interventions.