Occupational Therapy embraces the National #Littlethings mental health and wellbeing campaign in Offaly via an Operation Transformation Programme

Purpose – In early 2015, an Occupational Therapy led Operation Transformation healthy eating and exercise programme produced results suggestive of the value and need to promote and integrate physical activity interventions into mental health services. Design/methodology/approach – In all, 41 clients with various mental illness diagnoses participated in the eight-week Operation Transformation programme. The outcome measures involved weekly weigh-ins and an end of programme evaluation form. Findings – The quantifiable benefits – a total weight loss of nine stone ten and a half pounds – were mirrored in equally impressive qualitative impacts. Participants’ feedback via anonymous evaluation forms, echoed the findings of the articles appraised in the literature, including improvements in mood and energy levels, better sleep and increased motivation. Practical implications – The organisers will benefit from lessons learned in this first experience, including overcoming logistical and organisational difficulties experienced in enabling clients’ full participation. Originality/value – The evidence base points to the successful benefits of physical activity in promoting positive mental health. Occupational Therapists have a unique opportunity to drive forward the message of promoting physical activity via meaningful occupations.


Background
In October 2014, The Health Services Executive (HSE) National Office for Suicide Prevention and over 25 partner organisations launched the #Littlethings mental health and well-being campaign (www.yourmentalhealth.ie)(yourmentalhealth.ie, 2015).The campaign aims to highlight that we will all experience challenges in our lives, and when we do, there are some simple, evidence-based steps we can take that can make a big difference to how we feel.Our challenge as Occupational Therapists working in the area of mental health is how best to incorporate the messages of the national campaign at a local level, which was an expectation of the HSE National Health Service Plan 2015."The more you move the better your mood" is only one of the eight messages that the Little Things campaign promotes, but it is a message that presents Occupational Therapists with a significant opportunity to promote exercise and physical activities as meaningful occupations.Exercise can be broken down into many potentially personally meaningful occupations depending on an individual's interests and abilities.What is particularly important for Occupational Therapists is that physical activity can be incorporated into leisure pursuits, such as dancing, hiking or gardening; transportation activities, such as cycling and walking; instrumental activities of daily living, like vacuuming; as well as planned exercise and sports.For Occupational Therapists, the national campaign highlighted a unique opportunity to drive forward the message of promoting physical activity through our clinical practice.Lloyd (2003) (Jones, 2008, p. 499) "stated that occupational therapists are well placed in mental health, with their focus on occupations to improve health, to play 'a pivotal role in promoting fitness-oriented physical activity'".
There is a significant evidence base to support the positive impact of exercise on mental health, and more recently, there appears to be a greater emphasis on the potential benefits of exercise on the mental health of those with severe and enduring mental illness.A systematic review and meta-analysis by Rosenbaum et al. (2014) including 39 randomised controlled trials of adults with a confirmed mental illness concluded that physical activity reduced both depressive symptoms and symptoms of schizophrenia while also improving the quality of life of people with mental illness.Blumenthal et al. (2000) writes that depression can be as effectively treated with exercise as with medication and vice versa with clients embracing regular exercise for over six months being much less likely to relapse into depression.However, also acknowledged is that exercise can do what medication cannot: it offers an opportunity to empower people to take personal control of their recovery and develop a new sense of self in doing so.
The challenge for us now is how best to support those with mental illness to appreciate the value of physical activity in their own recovery and well-being.It has been our experience as Occupational Therapists that those enduring mental illness often find it difficult to engage in exercise because of symptoms like poor sleep patterns, low energy levels and poor motivation as well as a lack of interest.Richardson et al. (2005, p. 328) writes "In fact, individuals with serious mental illness often face substantial illness-related barriers to physical activity that healthier individuals do not face"; nonetheless, those with mental illness tend to value physical activities.Taking this into account, Richardson et al goes on to state that there are a number of important reasons for integrating physical activity specifically into mental health services including having staff trained to be sensitive to such illness-related barriers.It is also acknowledged that regular reinforcement of positive health behaviours by the professionals that individuals with mental illness are most regularly in contact with can play a critical role in successful long-term changes.
Operation transformationthe programme Operation Transformation was an Occupational Therapy-led programme to support clients to embrace personal lifestyle changes that would aim to promote positive mental health.A precursor to the organisation of the Operation Transformation programme was a "Couch to 5km" pilot exercise programme, which ran in late 2014 in conjunction with Offaly Sports Partnership.This small-scale programme involved eight clients and ran over six weeks, with three community-based exercise sessions per week.What we learned from running this programme fed into the development of the Operation Transformation programme.Operation Transformation was an eight-week Occupational Therapy-led healthy eating and exercise programme which was carried out in January and February 2015 with a total of 41 clients with various diagnoses attending the community mental health team.The roll out of the programme involved invitations being sent out to potential participants with GP clearance forms, which had to be completed for all individuals who wished to participate in the fitness programme.Funding was obtained from Offaly Sports Partnership for staffing two of the three one-hour exercise classes (walking/jogging) run per week.The exercise classes included a 10-minute warm-up, 40-minute walk intermittent with jogging for those more physically fit and then a 10minute cool down.All warm-up and cool-down exercises were demonstrated by staff to prevent possible injury.Community amenities, such as the local town park and local athletics club, were used as venues for the exercise sessions.It was important as local amenities were used to promote community integration while considering long-term ease of accessibility.Funding was also sourced from the local Vocational Education Committee (VEC) for one of the two healthy eating classes run per week.The healthy eating classes focused on meal preparation incorporating the menu plans from the actual RTE Television series, Operation Transformation.In addition to the leadership provided by Occupational Therapy, there was also a strong involvement of the nursing and healthcare staff at the community mental health centre.Participants were also advised to tune into the Operation Transformation television programme twice per week, so that they could feel that they were involved in a countrywide effort.Participants were weighed on a weekly basis.They were also provided with an educational session from nursing staff on medication and weight management.In the final week, the local VEC provided funding for a Colour Me Beautiful Consultant to advise clients on what clothing shapes and colours suited them.Similar to the television programme, during the final week, there was an awards ceremony at which all participants received certificates of attendance.On the day of the awards ceremony, participants attended a local hair salon at a reduced rate, staff assisted in grooming such as make-up application; all the clients got dressed up, and there was a healthy food buffet to celebrate their success and encourage lifelong lifestyle changes.

Obstacles and overcoming challenges
Scheduling represented the greatest obstacle to clients' participation in the programme.Internal scheduling difficulties were overcome through cooperation: before running the group, Occupational Therapy met with nursing staff and agreed that other groups run at the centre during the eight-week period of Operation Transformation would be suspended because of the intensity of the programme.Indeed, from the outset, an important element in the set-up of the programme was the involvement and buy-in of other members of the multidisciplinary team.
Scheduling issues that impacted more directly on the clients were more difficult to overcome.For example, most clients did not have access to their own transport, and at times, it was difficult for the buses that transported them to deliver them to alternate locations, such as the town park and the local running club track.Set dinner times are deeply ingrained in the culture of the community mental health centre: the meals are cooked outside the centre and delivered there within a set timescale, which resulted in staff often rushing back, so that clients could receive their meals.What might have been thought to be a significant barrier to participationthe weatherproved less so, with clients persevering even though the programme started at the coldest time of the year.Organisers of the programme were conscious that participants would also have to overcome a culture of external locus of control that would more usually encourage clients to refrain from over exertion.As the programme progressed, clients evinced a greater confidence in their own resolve and determination.The physical achievement of meeting defined exercise goals was being mirrored in a sense of psychological strength and achievement, mirroring effects noted in a review by Mason and Holt (2012), which found a high degree of congruence in support of the themes of social interaction and social support; feeling safe; improved symptoms; a sense of meaning, purpose and achievement; identity and the role of the facilitating personnel.
Feedback and looking forward: implications for practice Quantitatively, the total weight loss was nine stone ten and a half pounds.All participants were asked to complete an evaluation form at the end of the eight weeks, and a focus group was organised to brainstorm potential future exercise-based groups that could be facilitated by Occupational Therapy.Feedback included participants feeling brighter, having more energy, feeling motivated and sleeping better, echoing the finding of Alexandratos et al. (2012) that exercise can contribute to improvements in symptoms, including mood.The conclusion of Rosenbaum et al. (2014) that physical activity reduced depressive symptoms in people with mental illness chimed with participants' observations that they were more active, with improved mood and an overall positive feeling of well-being.Jones (2008, p. 499) writes "the use of physical activity as an intervention fits well with the Model of Human Occupation (MOHO) and is particularly relevant to the concepts of volition and personal causation".With this in mind, it would be beneficial to consider appropriate MOHO assessment and evaluation tools to measure the success of any future run programmes.
The initiative's success was apparent not only in the fact that the participants' testimonies echoed the positive findings of the research into the impact of exercise on mood and well-being, but even more directly in the eagerness of many of them to carry on the exercise and dietary changes once the programme ended.This is reflected in the fact that several participants were inquisitive about and eager for follow-up activities.Participants were encouraged to continue with their exercise and diet plans.Information was provided on local running/walking clubs and following on from Operation Transformationsome of the participants have joined the local Athletics Club and were accompanied there by the Occupational Therapist afterwards to support community integration.Some have now completed 5-km local races.Other participants were encouraged to join the local gym.Our client with the greatest weight loss has kept up the exercise and healthy eating and has now dropped almost seven stone in total.He has also taken up a work programme which was not possible for him because of his size before embarking on the programme.
In addition to the positive effects that participants have experienced from their own efforts and perseverance, there are clear benefits to the Occupational Therapy service.The experience of planning and running this programme leaves this service in a stronger position to overcome or work around some of the practical and organisational obstacles to clients' participation.Less tangibly, but just as importantly, witnessing the positive outcomes for clients provides organisers with the satisfaction of seeing their own efforts and perseverance rewarded.