The SHAPE programme is one of the first UK ‘real world’ service provisions of a bespoke EI physical health monitoring and intervention programme for young people with early psychosis. It was designed 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.
Co-Production
From start: No
During process: Yes
In evaluation: No
Evaluation
Peer: No
Academic: Yes
PP Collaborative: Yes
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Marie Band - EI Nurse Prescriber & Senior Case Manager
The aims 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’.
SHAPE participants engage in weekly 45’ education sessions on healthy lifestyle behaviours, including: managing anxiety and depression, mindfulness and relaxation training, substance misuse, smoking cessation, healthy eating and nutritional advice, dental and sexual health care. This is followed by a 45’ exercise session including activities such as circuit and resistance training, yoga, and badminton, led by qualified exercise instructors. The exercise programme is designed to introduce participants to a wide range of physical activity that has been shown to improve both mental and physical health in individuals with psychosis. The intervention was designed to increase the participants motivation, decision making and self-efficacy to promote individual responsibility to make healthy lifestyle choices. All of which are designed to improve weight maintenance and physical health to delay or attenuate the onset of cardiometabolic disease.
As part of the SHAPE programme, significant changes to clinical practice was 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 care planning; Data collection for evaluation purposes of the service and clinical outcomes of service users.
Along with the change in clinical service, patients received full physical health checks and interventions facilitated by the SHAPE healthy lifestyle education and exercise programme. Weekly access to participants allow community mental health nurses to monitor well-being during the early treatment stage. The programme also incorporated a carers evening and provided carers group support and education.
Evaluation of the SHAPE programme includes comparison of anthropometric data (BMI, waist circumference), lifestyle behaviors (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 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 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. 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 (weight maintenance), 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.
The programme has proven to provide a wide range of benefits in physical health to the patients as well as improved benefits to the regional health care system: Benefits for the patient include: Reduce 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; Meet NICE guidelines for assessment and intervention of maintaining the physical health needs of patient; Dissemination of good practice and model approach which can be adapted for other disciplines.
Wider Active Support
We have formed a strong interagency project team which has harnessed individuals’ knowledge and skills to benefit programme design, implementation, evaluation and promotion. The 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 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 will provide opportunities for social engagement with other programme members while also providing a safe, supportive environment. This allows for university student engagement in the form of work placement which provides
We have hosted site visits for other services seeking to learn about and replicate the programme. We have secured additional EI targeted resilience funding in a joint bid with our 3 CCG partners to fund and rollout a SHAPE 2 initiative in the North of Worcestershire. The biggest challenges have been to maintain momentum in the context of staff changes, sickness and leave, and to respond to higher than anticipated levels of outside interest in the programme.
Co-Production
There are a number of points we consider tamiflu online. These 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.
Looking Back/Challenges Faced
Although we achieved our original ambitions, participant recruitment was a significant challenge throughout. It seems that as young people progressed, ongoing support and clinical expertise is required for some participants to encourage them to continue. As the programme develops, ongoing commitment of EI staff is vital to share information and to provide encouragement to those young people who show an interest in participating.
Suitable venues, which are youth-focused, non-stigmatising and accessible are essential and require good organisational partnerships. Although we were successful in developing a local, collaborative partner we have found it difficult to locate accessible venues across the region. We are now designing an exercise programme that allows for a range of activities that allow for a more flexible exercise environment.
Key challenges 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, 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 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.
To overcome these challenges we:- Encouraged clinical staff to provide additional support to those young people who felt particularly anxious prior to the first session; The EAYL students were deployed in the waiting area in the main reception to provide support and directions when participants arrived to attend the SHAPE programme; As young people progressed, ongoing support and clinical expertise was required for some participants; Although drop-out was expected, and the drop out levels from SHAPE are consistent with the expected drop-out from gym attendance across other populations, work will continue to evaluate whether the SHAPE workbook could be utilised further to decrease drop-out and encourage maintenance of behavioural changes at 12 months; We selected a central accessible city centre location, with good public transport bus and rail links (The McClelland Centre on the University of Worcester City Campus site). However, as participants were drawn from across a geographically large and very rural County, travel time and a poor public transport infrastructure particularly in more outlying areas of the County remained a barrier for some.
Sustainability
Setting-up a new programme is time intensive and we learned a great deal. To share this learning with others and promote long-term sustainability from our SHAPE experience, we have secured Health Foundation Shine 2015 Spreading Improvement funding to develop the mySHAPE.org.uk website. This website will provide health care providers with a handbook, which will include 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 will be designed to provide other health care providers with essential information and support to establish and deliver SHAPE elsewhere in the County and beyond.
The SHAPE team has already established a SHAPE 2 programme in the North of the County in a partnership with a local FE College gym and staff. This will allow us to field test an initial handbook and identify key information and resources (staff, equipment, facilities) required for set-up and implementation to be incorporated in a comprehensive SHAPE support package that can be shared with others interested in replicating SHAPE.
South Worcestershire CCG has provided time limited funding for 12 months to establish and trial a new programme (SHAPE 2) in the north of the County. This will be run to the same specification as SHAPE. The intention is to increase the numbers of young people with access to SHAPE and to promote to new clinical teams and services. In addition to access, we have improved cost efficiency by increasing participation from a wider CMHT patient group in addition to those invited from local EI teams. Availability of the programme in different parts of the County will support services to provide a consistent approach to physical health care planning when addressing the physical health needs and risks for young people with psychosis.
There is a commitment from the University of Worcester to continue the collaborative partnership and support the on-going delivery of the SHAPE programme (through ongoing availability of work placement students) and evaluation (through academic input). New SHAPE cohort are continually being recruited and the programme will continue to run in the McClelland Centre building. The evaluation project will be developed into a new research project, utilising and building on findings.
To spread this innovation further, the team are developing a robust argument for commissioners, service leads and clinicians which will utilise the findings from SHAPE to emphasise the benefits of engaging young people with first episode psychosis in physical activities, including providing a full cost-benefit analyses, as well as promoting the essential role of physical health assessment and monitoring. In addition to the benefits for young people themselves, this would support local services to meet essential quality standards included in national CQUIN targets and NICE Guidance for psychosis (2014) as well as concordance with new EI Access and Wait Times (AWT) 2015/16 policy requirements. A business proposal to provide longer-term funding for SHAPE has been included in the local Trust Business Plan 2015/16 and is being considered by senior managers and local Commissioners. Work will continue in partnership to explore different options to sustain the programme, including a bid for SHINE 2015 Spreading Improvement funding to develop and produce a SHAPE handbook and associated marketing information.
Evaluation
A range of evaluation measures have been conducted to evaluate the effectiveness of the SHAPE programme. Quantitative assessment of weight maintenance and clinical health markers was undertaken by Dr. Lisa Griffiths, University of Worcester.
Qualitative feedback focusing on adherence and impact was collated and analysed by Professor Eleanor Bradley, University of Worcester.
Economic assessment of the SHAPE programme was conducted and submitted to Clinical Commissioners by Marie Band, Senior Case Manager, Worcestershire Early Intervention Services, Worcester Health and Care Trust.
Sharing
During the initial roll out of SHAPE we have hosted visits for other services seeking to learn about and replicate the programme. We have secured additional EI targeted resilience funding in a joint bid with our 3 Clinical Commissioning Group partners to fund and rollout SHAPE initiatives in the North of Worcestershire.
We have also secured further funding from the Health Foundation Spreading Improvement Bid in which we aim to:
To work with a professional design agency to: Design and develop the online instructor training materials, and client/carer handouts and education materials to support lifestyle behaviour change and education about psychosis; Design and develop branded videos for staff training, marketing and webinars; Publish SHAPE programme materials, videos and other supporting documentation
and web links to a brand specific web site.
Conduct a showcase event, and other marketing campaigns, to launch the website and advertise the SHAPE programme materials; Provide awareness raising sessions to primary and secondary care mental health professionals focusing on the importance of physical health and their role to promote good physical health, ensure accurate assessment of baseline physiological measures, and discuss client referral onto the SHAPE programme; Conduct a series of in-house training and webinars to support staff training for the delivery and implementation of SHAPE.
Is there any other information you would like to add?
The NHS and University partnership has been a significant enabling factor. The multi- professional team has resulted in the provision of a programme with high levels of clinical expertise, skills and support, alongside teaching excellence (exercise physiology, nutritional therapy) and high quality evaluation (project design, assessment and data analysis). The commitment and enthusiasm of the project team has supported us to develop an evidence-based programme, grounded in clinical and academic expertise and shaped by participant feedback. Working together has provided multiple opportunities for learning and reflection. Both the Trust and University recognised this to be an important priority for staff involved in its delivery and evaluation.
