People diagnosed with a psychotic illness have higher rates of physical illness than the general population [1,2,3]. The presence of a greater number of physical health problems is also reported to contribute to more severe psychosis and depression . For individuals diagnosed with schizophrenia, poor physical health seems to be related to poorer mental health. In a survey of 719 persons diagnosed with schizophrenia, Dixon and colleagues (1999) found that individuals who had a greater number of medical problems were at higher risk for increased depression, psychotic episodes and suicide attempts .
The most common comorbid physical illnesses experienced by people with a psychotic illness include: cardiovascular disease, metabolic syndrome, diabetes, high blood pressure, high cholesterol, respiratory diseases and obesity . Increased morbidity and mortality in psychotic disorders is largely due to treatable medical conditions that are caused by modifiable risk factors, such as, smoking, obesity, substance abuse and inadequate access to medical care [6,7,8]. Risk factors that are modifiable and treatable include: smoking, high cholesterol, high blood pressure, physical inactivity, unhealthy diet, obesity and diabetes. Linde-Feucht (2007) identified that a person’s behaviour contributes to 40% of the premature death problem in people living with a psychotic illness, and that small changes in behaviour can significantly increase a person’s longevity. Consequently, people with a psychotic illness have vastly increased risks of developing metabolic syndrome and cardiovascular disease .
With the recognition of this link between physical health problems and psychotic disorders, there is an urgent need for specific mental and physical health literacy, health education and health promotion interventions that focus on, self-care and self-management strategies for people living with a psychotic illness. A high level of health literacy is required to manage a psychotic disorder plus cardiometabolic health comorbidities. According to Galletly (2010) health literacy is understudied in patients with a psychotic disorder . The duty to care report established that public health campaigns aimed at reducing major health risk factors do not benefit people with a mental illness . Therefore, specifically targeted health promotion interventions need to begin as early as possible in the treatment process for people that have a psychotic illness.
Health promotion interventions should be implemented in acute and non-acute psychiatric wards and community health centres to promote, a holistic recovery, good clinical care, and to encourage a recovery philosophy [7,13]. Health promotion interventions for people with psychotic disorders need to be more holistic and focus on the major lifestyle and cardiometabolic risk factors that are associated with a psychotic illness . In Australia further research is needed to evaluate health literacy in people with a psychotic disorder .
Additionally, literature suggests that mental health clinicians have little training in physical health care and that medical staff in psychiatric wards are unsatisfactory at monitoring physical health and are poor at performing physical health assessments on mental health inpatients [3,11,15,16,17]. Consequently, health education and health promotion by mental health staff is also reported to be unsatisfactory . Health promotion and health literacy interventions that are specifically designed for people with a diagnosed psychotic illness have multiple benefits to the individual in terms of their recovery, quality of life (QoL), general wellbeing, physical and mental health outcomes and their health literacy skills. In the long term there are additional cost benefits in reducing the burden on carers and the Australian health care system.
According to Nutbeam  health literacy has been referred to in health literature for at least 30 years. Health literacy is recognised as an important aspect of health promotion. Health literacy is defined as ‘the personal, cognitive and social skills which determine the ability of individuals to gain access to, understand and use information to promote and maintain good health’ .
Activities designed to improve health literacy in people with a psychotic disorder are a significant component of the rehabilitation of a person with a severe mental illness (SMI) and their recovery journey. In addition, it is also a component of mental health promotion to improve the self-management and physical health outcomes of people with a diagnosed psychotic disorder. Strategies for improving health literacy in people with a SMI generally comprise of psycho-education programs and are delivered in a variety of settings such as inpatient units and community settings. However, there is a significant inconsistency in the psycho-education programs and health promotion programs that are implemented in these mental health settings.
Health literacy strategies aim to enhance functional literacy, communicative literacy and critical literacy skills. At the most basic level health literacy is connected to general literacy. Problems with low literacy are prevalent in the developing and developed world and these issues must be considered in all strategies to enhance health literacy in people living with a psychotic disorder. Enhancing interactive health literacy focuses on building personal skill and knowledge and is expected to result in an increased personal capacity to act on knowledge. It involves effective health promotion strategies including education and cognitive behaviour tasks to support skill development and informed choice. It includes education to advance understanding at all levels: how to prevent cardiometabolic health problems, how to intervene early and how to monitor and manage a cardiometabolic health condition. Mental health professionals and service providers can facilitate the development of improved health literacy in people with a SMI by developing and implementing evidence based health literacy interventions for people with a SMI and supporting them to make an informed choice .
Enhancing critical health literacy builds the capacity to critically analyse information and to use it to mobilise for social and political action as well as individual action. Enhancing critical health literacy supports collective empowerment and the development of social capital. As it exerts influence on the determinants of health it can result in benefits to people living with a psychotic disorder. It can include community development, self-help and peer support initiatives and alliances and partnerships for advocacy work .
It is clear that a psychotic disorder is influenced by a combination of biological, psychological and social factors. Mental health and mental illness are determined by multiple socioeconomic and environmental factors as are physical health and physical illness .
In recent years, researchers have expanded the definition of health literacy to include complex, higher order cognitive and social capacities that support empowerment. The World Health Organisation (WHO) health promotion glossary defines health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to understand and use information in ways that promote and maintain good health” .
Nutbeam  differentiates three levels of health literacy: functional, interactive and critical. The second two levels extend the concept of health literacy beyond basic reading and writing skills to more advanced and complex cognitive and social skills that allow people at level two to “extract information and derive meaning from different forms of communication and to apply new information to changing circumstances” and at level three, “to critically analyse information and to use this information to exert greater control over life events and situations.”. Using this definition, health literacy is a gradient of increasingly complex and interactive skills, which relate to personal and collective empowerment for informed choice and action on the social determinants of health .
Expanding the concept of health literacy to include skills and abilities that humans use to create meaning from and exert control over the environment, these revised definitions bring health literacy into the domain of health promotion. Therefore, health literacy can be viewed as a key outcome of health promotion activities that include health education, the development of new skills and social skills training. The definition of health literacy has now been extended so far that it bears little resemblance to the original meaning of literacy (being able to read and write). The expanded definition of health literacy is in line with the field of literacy studies, which is moving toward a broader conceptualisation of general literacy as a variety of skill sets, for example, scientific literacy and cultural literacy which are situated along a continuum from basic reading and writing to critical analysis. The definition of health literacy also supports a focus on the broad social and environmental determinants of health and it leads to social as well as individual benefits such as the development of social capital and social and economic development. Therefore, enhancing health literacy is expected to improve cardiometabolic outcomes for people living with a psychotic disorder, just as improving education and general literacy influences the overall health and well-being of populations .
Targeted educational interventions have defined goals and are generally aimed at a specific group and implemented in specific environments such as inpatient units or community mental health centres. Educational programs and health literacy interventions to encourage mentally ill patients with early symptoms of cardiometabolic disease to seek help should be designed, encouraged and implemented.
Community empowerment within consumer communities is a key factor in health promotion for the mentally ill population. Within consumer communities those with mental health disorders benefit from the social support and mutual empowerment related to coming together for collective action. Often consumers are motivated to work with the broader community to effect change and initiatives can be developed to support these objectives through training in communication and advocacy. Health reform is needed for better quality and quantity mental health services such as collaborative mental health care, which is associated with benefits for practitioners and consumers.
Interventions for people living with a psychotic disorder need to involve skill development, have interactive communication and be supportive to assist patients to build empowerment for informed choice .
Diagram 1: A Model of Health Literacy
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