Improving Diet and Physical Activity Practices in Group Homes Serving Residents With Severe Mental Illness

Abstract

Background

People with severe mental illness (SMI) are at least 50% more likely to be overweight for various reasons, including poor nutrition, sedentary lifestyles, and side effects of antipsychotic medications.

Objectives

Among residents with SMI who live in group homes, we examined (1) factors that affected the motivations of both group home operators and residents around improvement of residents' diet and physical activity, (2) how operators and residents viewed responsibility for maintaining good health in group homes, and (3) strategies from operators and residents for improving diet and exercise.

Methods

The research team conducted 6 focus groups—3 with group home operators and 3 with residents, using a community-based participatory research (CBPR) process and qualitative data analysis.

Results

Both group home operators and residents discussed conflicting feelings about foods they know as healthy and foods they prefer to eat. Operators attributed barriers to better health to the perceived negative attitudes of residents and providers, lack of communication with health care providers, and poor working relationships with the state licensing body that protects individual rights on lifestyle choices. Residents reported barriers of their own negative attitudes, limited menu options, lack of organized activities, existing health problems, and side effects of medications.

Conclusion

Residents and operators had concrete suggestions for changes they could make individually, as well as recommendations for systemic changes to support healthier lifestyles. These recommendations provide a basis for designing an urgently needed pilot intervention program to address the current epidemic of obesity and diabetes in people with SMI residing in group homes.

In the United States, people with severe mental illness (SMI) have an average life expectancy of 25 years less than the general population.^1–3 Obesity, dyslipidemia, diabetes, hypertension, and smoking are key modifiable risk factors contributing to premature death in this underserved population.⁴ People with mental illness are at least 50% more likely to be overweight or obese for various reasons, including poor nutrition, sedentary lifestyle, and direct side effects of antipsychotic medications.^5,6 This group underutilizes primary and secondary medical services⁷ such as cancer screening, diabetes treatment, and cardiovascular procedures.^8–10 Helping people with SMI to improve their health through diet and physical activity is complicated by psychiatric symptoms, poverty, poor access to mainstream social and employment environments, and the stigma associated with both mental illness and obesity.¹¹

Residents with SMI who reside in board and care homes (hereafter referred to as “group homes”) are among the most severely disabled. In California, these group homes are licensed by the State Community Care Licensing Division (part of the Department of Social Services) and provide 24-hour-a-day staffing, shelter, meals, medication reminders, transportation to medical appointments, and recreation activities. Group home operators have significant influence over the dietary and physical activity habits of their residents. Improved diet and physical activity have been shown to provide both psychological and physical benefits for people with mental illness.¹² However, research on the creation of diet and physical activity interventions in group homes for diabetic and/or obese individuals with SMI has received scant attention from researchers.

The dietary and physical activity requirements for group homes as required by the state licensing body are general in nature. Section 80076 of the Community Care Licensing Division¹³ states that group homes require the use of the U.S. Department of Agriculture daily serving sizes, three meals a day, snacks available upon physician's recommendation, and menus available for review by either residents or licensing agencies. Additionally, Section 85079 requires that group home licensees provide physical and social activities, along with opportunities for residents to plan, conduct, and critique these activities. However, administrators from the Community Care Licensing Division state that for both diet and physical activity, there are significant variances in the way operators interpret and support these requirements, and monitoring is compromised by extreme staff shortages.

Previous research reviewed for this study examined the use of educational and behavioral programs^14–23 and medication treatments for the management of medication-induced weight gain.¹⁷ These studies tended to be of short duration (8 to 16 weeks) and directed toward the individual rather than the environment or system as a whole. New public health initiatives are just beginning to be developed to improve health behavior and outcomes across entire communities, and to include subgroups such as those with SMI.¹⁸

Although educational programs that directly target people with psychiatric disabilities are modestly successful in managing obesity,^19,20 involvement of additional stakeholders is likely to have a much larger impact. CBPR has been used successfully in underserved communities to identify barriers to a healthy diet and to promote changes within individuals and in the larger environment.^21–23 Because these collaborative projects include the participation of many stakeholders in the community, proposed changes are more likely to receive broad support. Targeting the group home environment to improve the health of people with SMI through a CBPR design is a promising way to develop effective interventions and close the gap between research knowledge and actual practice.²⁴

This article describes a CBPR planning project aimed at establishing an ongoing partnership between the University of California at Davis (UC Davis) School of Medicine; Turning Point Community Programs (TPCP), a nonprofit, community-based agency that works with consumers with mental health disabilities; group home operators serving people with SMI; and group home residents with SMI. The common goal of all of these partners is to better understand and improve dietary and physical activity practices in group homes that serve consumers with SMI. Moreover, the collaboration developed in this joint project will help group home operators and residents to better develop and sustain trusting relationships with an academic institution; and TPCP will develop expertise in data management, quality improvement, and evidence-based translational research to advance their clinical and service mission. This pilot study describes results of a CBPR study to explore the social, psychological, physical, and environmental factors that affect the motivation of group home operators and residents with SMI to improve diet and physical activity.

Methods

Research Framework

The CBPR framework utilized for this project²⁴ has gained in popularity in tandem with the urgency to reduce health disparities. Although there is no “perfect” project that necessarily adheres to all of the CBPR principles, the tenets of joint process—co-learning, capacity building, and a balance between research and action—are most essential, especially in an environment in which there is unequal access to and participation in health decision making. And although roles for community members and researchers are negotiated depending on the strengths and interests of all stakeholders in the project, there are a number of areas where community members can serve as equal partners with researchers.

Building the Community–University Partnership

TPCP has more than 30 years of experience providing rehabilitation services to people with mental illness throughout northern California. Turning Point staff invited a psychiatrist at the University of California, Davis, with whom the organization has had a long-term clinical relationship to assist in launching a joint exploration of how to empower group home residents to gain access to better diet and physical activity opportunities. Turning Point staff also invited a staff member from the Community Engagement office of the Center for Reducing Health Disparities to help design and implement a collaborative approach to the problem. Through these contacts, a study team composed of the co-authors of this article was developed, consisting of 3 members of the Turning Point staff—the Chief Operating Officer (Rowlett), a social worker (Schuyler), and a research assistant; and 3 UCD researchers—a psychiatrist and internist (Xiong), chronic disease prevention specialist (Cassidy), and community engagement specialist (Ziegahn).

Study Sample

This study recruited group home operators and residents for participation in the focus groups from the 74 group homes licensed in Sacramento county at the time of study. Operators of 12 of these 74 homes worked particularly closely with TPCP clients, a criterion for sample selection, and we invited them to participate in focus groups. Of the 12, 5 operators agreed to participate in the study; 7 declined because of scheduling conflicts and other time priorities. The age range of these 5 operators was between 45 and 60, 3 were women and 2 were men, 3 were Filipino and 2 were African American, and the number of years each had spent operating a group home ranged from 3 to 30 years.

Group home residents who were receiving intensive mental health outreach services from TPCP, including group education, support, and recreation activities, were invited to participate in the study. In keeping with TPCP's culture of inclusion, all residents who wanted to participate were allowed to do so, not only those who were overweight or obese. However, out of the 11 residents who volunteered to participate in the study, 10 where either overweight or obese according to body mass index (BMI) standards: n = 1 (BMI < 24.9, normal weight), n = 2 (BMI 30.0 to 4.9, overweight), n = 4 (BMI 30 to 34.9, obese), n = 2 (BMI 35 to 39.9, severely obese), and n = 2 (BMI ≥ 40, morbidly obese).

The average age of residents was 49 ± 4 years; 55% were White, 27% were African American, and 18% indicated other ethnicity/race. Five men and 6 women participated. Their mental illness diagnoses included schizophrenia (n = 6; 55%), schizoaffective disorder (n = 1; 9%), bipolar I disorder, (n = 2; 18%), and psychotic disorders not otherwise specified (n = 2; 18%). One resident attended only two focus groups and received $60. The other operators and residents attended all three focus groups and received $100 in grocery gift cards after the final session.

Focus Group Methodology

The CBPR research team identified the focus group technique as the most appropriate tool to learn about group home operators' and residents' perceptions, feelings, and manners of thinking through the issue involved in the study.²⁵ Focus groups serve as an inductive, systematic approach toward gathering data that help us to better understand particular contexts.^25,26 In this study, there were two sets of focus groups, one set with group home operators and another with residents. Each group met for three 90-minute sessions. The goal of each focus group session was to elicit a broad range of responses and reactions from participants, rather than achieving consensus.

Focus group questions were developed by all members of the CBPR team and co-facilitated by the Turning Point's Chief Operating Officer and research assistant, both of whom had extensive experience in conducting group sessions. Focus group questions in the three sessions for operators centered on learning more about operators' general views on health for themselves and their clients; the kinds of interventions operators felt would motivate residents to improve their health; and details around how diet and physical activity improvements could be added in a cost-effective manner. Similarly, focus group questions for residents attempted to elicit their views on how to stay healthy through diet and physical activity, and where responsibility lay for adopting and maintaining good health habits. The sessions were held between 1 and 3 weeks apart in the spring of 2009, and all were audio-taped and transcribed. All data collection protocols and informed consent procedures were approved by the UC Davis Institutional Review Board.

Although the numbers in these focus groups were not large, they were adequate for the exploratory nature of the inquiry into operators' and residents' reports of feelings, attitudes, and beliefs around diet and physical activity in the group home context. The fact that we saw each of the two groups on three separate occasions gave researchers the opportunity to build on responses and discussion as the study evolved.

Data Analysis

The study team CBPR specialist conducted the initial review of both operator and resident focus group transcripts. While the research team considered analyzing data through such qualitative data software programs as Atlas.ti or NVivo, we decided that the number of cases was small enough so that transcripts from each of the 6 focus groups (3 for operators, 3 for residents) could be manually coded, first line by line, and subsequently through identification of key conceptual codes, in keeping with the tenets of a constructivist approach to grounded theory.^27,28 Constructivism was deemed an appropriate approach for this study because it views knowledge as created through the interaction between study participants and researchers.

The first step in data analysis was the identification of key words from the transcripts in response to questions about dietary or physical activity preferences. These responses were often just a few words, like “sweet,” “meat,” and “bicycling.” Second, the constant-comparative method associated with grounded theory^27,28 was used to systematically identify qualitative themes emerging from questions about barriers to improving diet and physical activity behaviors in the group home environment, and to synthesize resulting themes into new conceptual categories. Criteria for initial codes from the focus groups included the following:

• Cognitive or behavioral strategies around food or physical activity selection. For example, operators reported switching low-fat milk for whole milk, or whole wheat bread for white bread, in an attempt to make diets healthier. Or residents would talk about barriers to being healthier, such as medication effects or lack of money.

• Affective responses to behaviors and interactions around health. Examples included operators who reported frustration at the number of residents who continued to smoke despite knowing it was counterproductive to good health, and the enabling role often played by family and friends, which resulted in residents drinking more sodas and eating more high-calorie foods. Operators reported feeling torn between protecting residents' health and giving in to residents' wishes to have larger meal portions.

Team members from Turning Point and from UCD reviewed initial codes and compared them with their own experience as either focus group facilitators or as initial transcript reviewers and sent their suggestions for changes to the initial team coder. The team met later and came to consensus on the following overarching initial code categories: Views of good health, problems maintaining good health, and relationships between group home residents and operators. The third and final step was to convene all research study staff to review data under these initial codes and further refine theoretical concepts emerging from focus group data.

Taking Results Back to the Community

Critical to the CBPR process is taking results back to the community so that stakeholders in research can verify findings and suggest ways in which findings can be translated to action steps. We have scheduled meetings that will include group home operators, residents, staff, representatives from the state licensing body, and university researchers to proceed with priority setting of recommendations arising from this study that will then lead to action steps.

Results

Stakeholders responsible for the health of residents include doctors, social workers, group home operators, administrators, staff, and the residents themselves. In general, there was a fair amount of agreement between operators and residents as to the elements of a good diet, foods considered to be healthy, types of exercise preferred, and the need for social support around making behavioral changes. There were more comments on diet issues than on physical activity concerns, primarily because both operator and resident focus group participants tended to talk more about food and diet when answering open-ended questions around barriers to better health and suggestions for improvements.

Food Preferences

The list of food operators served in their group homes ranged from generally healthy—vegetables, green salads, “no oily food, not much salt, not much sweets,” fruits, soups, oatmeal, and eggs—to foods generally viewed as less healthy— biscuits and gravy, hash browns, French toast, potato chips, fried chicken, and macaroni and cheese. Residents preferred “ethnic” food, such as Mexican, Chinese, pizza, and Japanese food, and various kinds of meat, followed by pasta, soup, shell-fish, fruits, vegetables, dairy products, cereal, and sandwiches, in descending order. When it came to the food served, only 3 out of 11 residents rated the food served in their home as “healthy.” One resident summarized group home dietary practices as consisting of “Unhealthy habits and the wrong vegetables, and no fruits, and no cereal, and none of the things that you are supposed to have in your system.”

There was some contradiction between the foods residents said they would like to see served and the foods they reported they would eat if they did not have to worry about money. Although residents talked about the health value of eggs, potatoes, low-calorie foods, fruits, vegetables, salad, salmon, granola, and low-sodium foods, the food they said they would eat if they did not need to worry about money included meat, ice cream, doughnuts, Captain Crunch, seafood, TV dinners, and fast food.

Physical Activity Preferences

Residents mentioned enjoying such activities as walking, working around the group home, jogging, dancing, or doing dishes. But several also mentioned that they had little energy for exercise owing to psychiatric medications and physical health limitations. Operators reported both personal preferences for exercise—“I walk everyday and do yard work”—and physical activities that could be enjoyed jointly with residents, such as dancing, tennis, treadmill exercise, bowling, group walks, playing pool, playing cards, and yard work.

Perceived Barriers in Improving diet and Physical Activity

Operators' and residents' perceptions of obstacles to the adoption of better diet and physical activity regimens ranged from internal attitudinal barriers to medically related problems to constraints posed by the larger environment in which group homes operated. Table 1 summarizes the various barriers and identifies the source of these perspectives as residents, operators or both.

Table 1. Perceptions of Key Barriers to Improved Diet and Physical Activities in Group Homes.

Key Barriers to Health	Impacting Diet and/or Physical Activity	As Perceived By	Suggestions and Strategies
Influence of outsiders in giving unhealthy food and money to support unhealthy eating habits and substance use	diet	operators, residents	Communication forums for all stakeholders* focused on how to include residents' families, friends, neighbors, etc. in improving residents' health.
Negative attitudes about smoking, disease management, and physical activity	diet, physical activity	operators, residents	Peer mentoring programs for residents; operators' modeling good eating and exercise habits; showing respect for residents.
Eating the wrong foods, “temptations”	diet	residents	Residents given more control over quality and variety of food served in home; better advice on SMI medications and how they affect health; more salads and fresh vegetables; more encouragement from families
Medication side effects that cause sedation and/or increased appetite.	diet, physical activity	operators, residents	Increased communication with primary care physicians, social workers, psychiatrists, and licensing bodies around best treatment for SMI, ways to overcome physical side effects of medication, and specific low-cost strategies for improving diet and physical activity.
Pre-existing medical conditions and poor health that limit resident's ability to exercise	physical activity	operators, residents
Lack of knowledge about residents' medical status, needs	diet, physical activity	operators
Relationship with licensing body	diet, physical activity	operators

^*Stakeholders include group home operators, residents, primary care physicians, psychiatrists, social workers, group home operators, administrators and other staff.

Influence of Outsiders

Involvement by family members emerged as being an important factor in decision making around diet and physical activity for both operators and residents. Operators reported that some of the most significant problems to maintaining resident health were the “outside” influences of family, roommates, and neighbors. They reported that the families would often “give in” to resident's requests for more food and money. the family was perceived as “enabling” residents' tendencies to eat processed foods that triggered diabetic reactions. Similarly, neighbors and roommates were reported as giving residents money, candy, alcohol, cigarettes, and/or drugs. However, some residents had specific reasons for enlisting the assistance of family members, as illustrated by the following comment: “Your board and care doesn't give you enough food. You've got to have your family come over and buy some food for you.”

Negative Attitudes

Operators and residents alike expressed little confidence in residents' ability to adopt healthy habits. Operators tended to perceive residents' poor habits as attributable to a global “lack of motivation” and “negative attitudes.” the operators agreed heartily to one operator's characterization of a resident's fatalistic attitude toward smoking and toward managing his diabetes: “My resident, he's a diabetic … but still, he says, “Oh I don't care. …” Many operators mentioned the high incidence of smoking among residents. Operators tried hard to get their message across: “I preach every day, do not smoke, you don't have to smoke, the doctor [psychiatrist or primary care doctor] tells you not to smoke. Doesn't do any good.”

Operators' frustration was coupled with their perceptions of barriers to changing resident behavior, particularly around physical activity. These barriers included medication side effects, preexisting medical conditions, substance abuse, living in neighborhoods where walking was not always safe, and residents' inability to stay motivated when they did not see immediate positive benefits from eating better and being more active.

Residents were also not convinced of their ability to adopt healthy diet and physical activity habits, mentioning internal factors like failing to resist the temptation for “sweets, meats, and cigarettes.” in addition, they emphasized external environmental factors such as psychiatric medications, which made them “lazy, tired, and hungry”; lack of money to buy healthier foods or to join a gym; lack of control over the foods served in their homes; and already being overweight and in poor health, and having to struggle with conditions such as shortness of breath, heart problems, diabetes, high blood pressure, sleeping difficulties, arthritis, asthma, and emphysema. Nonetheless, when asked by the focus group moderator how many felt they were overweight, 4 of the 11 residents said yes. One elaborated: “I used to be able to walk straight way far, but now that I've gained weight and not really, you know, caring about myself … I can't do it anymore.” Despite negative views of the possibility of surmounting obstacles to improve diet and physical activity practices, several residents suggested that behavior change could occur from either “your own strong will” or continued support from family, friends, group home staff, and physicians.

Lack of Knowledge About Residents' Medical Status and Needs

Operators were concerned that they had little information from health providers—primary care physicians, psychiatrists, or social workers—about residents' medical conditions. Operators felt that better communication with these professionals would enable them to more effectively monitor and care for their residents around diet and physical activity issues. in supporting members with diabetes-related conditions, operators often felt they were overextending themselves and at risk for liability. Operators and licensors both knew that when a resident was not successful at self-management, the only alternative was typically either hospitalization or a nursing home. However, a few residents indicated that although they wanted to talk with their primary care physicians, “explaining how you feel” was problematic, suggesting that assistance was needed in doctor–patient communication.

Relationship With Licensing Body

The state Community Care Licensing Division has the responsibility of monitoring the safety of group homes and ensuring that residents' rights are not violated. Operators felt that when state officials investigated resident complaints regarding food issues, the investigators tended to side with the residents' account without regard to what might be the healthiest choice for the resident. They felt torn between their interests in monitoring portion size for residents who were obese and/or diabetic, their obligations to residents as paying residents, and the prospect of being investigated by the state in response to a resident's complaint, despite the resident's obesity.

Operator–Resident Relationships

Operators described their relationships with residents as collaborative but also paternalistic, shaped by the unique contours of mental illness and a living situation which limited residents' autonomy. the concern and responsibility operators felt for maintaining resident health came through consistently in their comments:

This job is really supposed to be about heart, you know. if the resident they saw that you really care, he kinda listen to you. I have a resident … I keep telling him, where are you going to find people always telling you, reminding you … It's a lot of patience.

Operators felt torn between concern for their resident's health and happiness and concern for the safety and health of everyone in the home. Particularly around the issues of diet and physical activity, operators viewed residents as the same as, yet also different from, “normal” people, that is, those without mental illness. Although normal people might also be resistant to diet and physical activity advice, group home residents were mentally ill and on medication. Hence, the operators described their role as “keeping the resident on track” through regular reminders about particular daily tasks: Waking up on time, remembering to shower, brushing teeth, taking medications, getting physical activity, and perhaps most frequently stopping or reducing smoking.

Both operators and residents talked about residents' desire for autonomy. Operators noted that residents were in a compromising situation—they needed to be in a group home because of their psychiatric disability, but they also wanted the usual freedoms that came with being adults. as one operator put it, “It has to do with respect or taking away their respect or their rights or dignity.” Residents were less clear about their relationship with operators, whom they portrayed as responsible for menu planning, encouraging them to keep their rooms clean, and in general, “keeping people happy.”

Suggestions for Improving Diet and Physical Activity

As indicated in Table 1, residents and operators provided a number of suggestions and strategies for how to improve diet and increase physical activities in group homes.

Increased Communication With Primary Care Doctors

As mentioned, an important concern for operators was the need for information from primary care physicians on whether or not a resident could eat sweets, be physically active, get blood drawn, have insulin adjusted, and so on. in this way, operators felt that they could support residents in managing their diet, physical activity, medications, and health care visits consistent with physicians' orders. Operators noted that when residents' health was better overall, it was easier to motivate them to eat right and be physically.

Suggestions for Improving Resident Health

Operators provided a number of concrete suggestions.

• Establish exercise as a norm of group home life. Walk with residents, shop, or just chat; play tennis or go bowling with them, or walk as a group after lunch and dinner.

• Switch healthy foods for unhealthy foods. for instance, use skim milk instead of whole milk, whole wheat bread instead of white bread.

• Plan menus on basis of the food pyramid, “four servings of meat or vegetables,” not necessarily the number of calories.

• Develop peer mentoring programs for residents based on the principle that residents would be more likely to change negative diet and physical activity patterns if they were coached by residents who had already achieved some success.

Residents also had numerous suggestions for improving health:

• Jog, dance, do dishes, go to the gym, martial arts, ride horse-back, swim, walk, bike, camp, clean, and meditate.

• Stop smoking.

• Spend more time outdoors in the fresh air, listening to birds.

• Take vitamins, drink fruit juices.

• Pray.

• Take medications regularly, see the doctor [psychiatrist] and social worker.

Residents viewed eating right and exercising as a joint responsibility between themselves, the group home staff, primary care doctor, and psychiatrist.

Discussion

This study has focused on exploring the perspectives on dietary and physical activity barriers affecting residents with SMI living in group homes, through methods compatible with a CBPR framework. Although health care providers and researchers are well aware of the detrimental effects of environmental factors, living arrangements, and/or unhealthy lifestyles on the development of obesity in people with SMI,^11,18 this study is the first that we are aware of to explore the perspectives of both group home residents struggling to overcome the double stigma of mental illness and obesity as well as the operators who provide them with food and shelter. Although CBPR approaches have been applied to studies on obesity in ethnic minorities,^15–17 the use of community-engaged principles and methodologies in the context of group homes for individuals with SMI has been critical in revealing the interconnections between and among stakeholders in resident health, as well as the nuances in relationships between operators, residents, and representatives of the larger system.

The inclusion of group home operators and residents in our study allows us to extend findings of previous studies to new populations. for instance, Dragatsi and Deakins¹¹ acknowledge the need for mental health services providers to find ways to improve physical health without compromising the time and energy it takes to address mental health issues. Operators expressed similar tensions between trying to monitor the mental health conditions that brought residents to group homes in the first place, and physical conditions, particularly around obesity and diabetes. but unlike medical providers who identified lack of reimbursement as the major barrier to providing services,¹¹ group home operators were most likely to be frustrated by their lack of success in motivating their clients to take action and their lack of information on residents' physical and mental health from medical professionals. This finding reinforces the need for training programs for group home operators and, more important, consensus among all stakeholders—residents, operators, medical personnel, and licensing representatives—on what constitutes a healthy diet and an effective physical activity plan for residents, and how this plan could best be implemented and monitored.

Additionally, our results confirmed the need identified in previous studies for better coordination between mental and physical health providers^11,13,14 and identified other important stakeholders who should be included in coordination efforts, namely, group home operators, family members, state licensing bodies, and of course, the residents themselves. Again, cross-training around motivational and support strategies among operators, residents, licensing body representatives, and mental health agency staff would be helpful in opening communication channels and in inspiring change in residents' dietary and physical activity practices.

Study Limitations

Limitations to this study include our brief exploration of the role of group home operators as role models for their residents. This may be a fruitful area for future research,²⁹ and potentially an area for intervention. Also, because of the small number of group homes represented by the operators in our study and the qualitative nature of this exploratory study, the results may not be generalizable to group homes in other parts of the country. However, the group homes in this study share many similar characteristics to others throughout the nation: They are independently operated, often by a family, have fewer than 10 adult residents, and work within state licensing guidelines.

Future Directions and Systemic Interventions

In addition to residents' and operators' concrete suggestions for improving health habits, both groups suggested interventions which could develop the structural capacity of stakeholders to respond to the systemic problems inherent in poor diet and lack of physical activity among residents: (1) Peer mentoring by residents around healthy diet and physical activity habits; (2) education workshops for operators with involvement of health educators and the state licensing body; (3) ongoing communications forums for operators, licensors, primary care physicians, and psychiatrists aimed at bridging gaps in information around resident health status; and (4) opportunities for organized activities such as house chores for residents within the group homes. Given these concrete recommendations, the next step would be the development of a more inclusive diet and physical activity study that would follow up on barriers to improving both mental and physical health in the group home environment. the goal of this future study would be to develop a pilot intervention program with stakeholders that would empower both the individuals living with mental illness in adult residential facilities as well as operators and health professionals to make changes in individual and group diet and physical activity practices. in addition, this larger study should include family members, social workers, and state licensing regulators so that the emerging interventions and institutional and policy recommendations will reflect the perspectives of all concerned and lead to more systemic change.