Testing an Education Program about COVID-19 Infection for People Living with Serious Mental Illness

BACKGROUND: People with serious mental illness (SMI), including schizophrenia, bipolar disorder, and severe depression, represent the population most at risk for health disparities in the United States, with multiple co-occurring medical and social vulnerabilities that place them at disproportionate risk for COVID-19 acquisition, morbidity, and mortality. Without education, training, and support for prevention of COVID-19, negative outcomes for this group could have spillover effects on the larger community. The COVID-19 pandemic emerged approximately 5 months after the launch in fall 2019 of our pragmatic clinical study, “Integrated Physical and Mental Health Self-Management Compared with Chronic Disease Self-Management,” which compared the Integrated Illness Management and Recovery (IIMR) program, an intervention developed specifically for people with SMI, and the Chronic Disease Self-Management Program (CDSMP), developed for use in the general population. This study enrolled adult service users from 2 large community mental health centers: 1 in Louisville, Kentucky, and 1 in Clarksville, Tennessee. We applied for and received a COVID-19 Enhancement award to develop a 3-session intervention to add to IIMR so that we could teach people with SMI how to avoid catching or spreading COVID-19. OBJECTIVES: The objectives of this study were to (1) gather timely information about the needs of people with SMI and co-morbid medical illness in the context of the pandemic to inform the co-design of a 3-session module that would provide education and coaching on preventing COVID-19 and reducing social isolation and (2) evaluate the impact of the module on the primary and secondary outcomes (primary: knowledge and use of measures to prevent contracting and spreading COVID-19 developed for use in this study; secondary: use of health care services for COVID-19–related concerns and perceived isolation and social disconnectedness [social determinants of health]). We also explored differential response with respect to race and ethnicity (Black vs White adults), age (older [ie, 55 years of age or older] vs younger adults), and psychiatric diagnosis (schizophrenia spectrum vs mood disorders). METHODS: We first conducted a comprehensive needs assessment with both health care professionals and service users to inform co-development and evaluation of a tailored, individually delivered, 3-session COVID-19 educational and skills training intervention. The intervention would address topics such as knowledge about transmission and symptoms of COVID-19, vaccines, preventive behaviors, coping skills, and social connectedness. All participants were community-dwelling individuals recruited from the parent study who had a diagnosis of schizoaffective disorder, schizophrenia, bipolar disorder, or major depression and a co-morbid medical condition who needed illness self-management training for 1 or both conditions. Participants were excluded from participating in the parent study if they were living in an institution (eg, hospital, nursing home), did not speak English, or had dementia or cognitive impairment based on a score less than 20 on the Telephone Interview for Cognitive Status. The COVID-19 module was delivered individually over 6 weeks to 80 participants randomly assigned in the parent study to receive IIMR; the 82 participants randomly assigned to receive the CDSMP who joined the Enhancement portion of the study did not receive the additional training on COVID-19. Both groups were assessed at baseline, 6 weeks, and 12 weeks using a scale we created to measure knowledge and engagement in behaviors to prevent COVID-19. Enrollment occurred from November 2020 to January 2022, with all follow-up assessments completed in April 2022. RESULTS: We conducted a needs assessment, then created a primary outcome measure corresponding to COVID-19 prevention knowledge and behaviors as well as a 3-session, tailored COVID-19 prevention module. Knowledge and enactment of the most widely promoted methods for preventing COVID-19 (ie, hand washing, masking, and physical distancing) did not differ between the groups and were broadly accepted. The intervention was associated with statistically significant modest improvements for the IIMR group vs the CDSMP group in prevention knowledge (mainly greater increase in rejection of prevention myths from baseline to follow-up) and greater increase from baseline to follow-up in knowledge of proper response to suspected symptoms of COVID-19. Those in the IIMR group also received the SARS-CoV-2 vaccine at a higher rate than those in the CDSMP group (72% vs 63%), which did not reach statistical significance (Fisher exact test P = .17) but is a promising, clinically significant finding from a population health perspective. Analysis by site revealed the greatest difference in vaccination rates between the IIMR and CDSMP groups at the Kentucky site (85% vs 71%). The only statistically significant subgroup effect was the larger effect of IIMR on preventive knowledge among participants 55 years of age or older. There were no significant differences between or within the groups in knowledge of the symptoms of COVID-19, knowledge of how it can be transmitted or prevented, or attitudes about COVID-19–related behaviors. CONCLUSIONS: This project resulted in creation of an easy-to-use, manual-based, standardized, 3-session intervention that provides education and training on how to prevent COVID-19 and other highly contagious illnesses. The intervention was appealing and associated with modest statistically significant improvements in knowledge, with the greatest improvements in knowledge of proper responses to suspected symptoms of COVID-19 and a trend toward increased acceptance of the SARS-CoV-2 vaccine in people with SMI at high risk because of multiple health disparities. This unique intervention may also reduce risk of negative outcomes of COVID-19 or future pandemics for other at-risk groups. LIMITATIONS: The evolution of the pandemic, including shifting recommendations regarding safety measures, posed a challenge for participants and likely affected the study data (eg, responses to assessment questions may have been affected by local indoor mask mandates, vaccination status). Nevertheless, the study was delivered as intended, and outcomes of this real-world evaluation of a novel education and coaching intervention, as provided to a diverse group of individuals at high risk of negative outcomes from COVID-19, is generalizable to the broader population of people with SMI.