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Table of Contents
Year : 2020  |  Volume : 34  |  Issue : 3  |  Page : 134-137

Type of mental health lifestyle required in Taiwan

1 School of Education, Zhaoqing University, Guangdong Province, China
2 Institute of Education, National Cheng Kung University, Dou-Liou, Yunlin, Taiwan
3 General Education Center, National Yunlin University of Science and Technology, Dou-Liou, Yunlin; 4Department of Family Medicine, National Cheng Kung University, Tainan, Taiwan
4 Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan

Date of Submission22-May-2019
Date of Decision18-Jul-2020
Date of Acceptance20-Jul-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Shih- Ming Li
No. 1, University Road, Tainan 701
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TPSY.TPSY_25_20

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Objective: Mental health lifestyle (MHL) enhances one's well-being and function. In this study, we used the Rasch analysis on participants' demographic and characteristic data to determine the appropriate MHLs required for mental health (MH) promotion in communities in Taiwan. Methods: We surveyed four communities for MHLs, based on therapeutic lifestyle changes and their responses. Then, we analyzed the data with Rasch analysis. Results: In all, 35 men and 169 women (average age ± standard deviation = 34.34 ± 9.94 years) from four MH promotion courses with an invited speaker completed the copies of the questionnaire, including four items for course satisfaction and eight items on MHL. According to the results of the Rasch analysis, the most easy MHL activity was engaging in relaxation and stress management, and the most difficult MHL was service to others such as volunteering. Moderate-difficulty MHL activities were engaging in exercise, recreational activities, and being involved in nature. Conclusion: In this study, recreation, regular exercise, and contacting nature were identified as moderate-difficulty MHL activities. We suggest that the effectiveness of intervention programs can be confirmed through randomized controlled trials in the future.

Keywords: flow theory, health promotion, relaxation, the Rasch analysis

How to cite this article:
Li CC, Tang Y, Li SM, Tsai TY. Type of mental health lifestyle required in Taiwan. Taiwan J Psychiatry 2020;34:134-7

How to cite this URL:
Li CC, Tang Y, Li SM, Tsai TY. Type of mental health lifestyle required in Taiwan. Taiwan J Psychiatry [serial online] 2020 [cited 2023 Jan 28];34:134-7. Available from: http://www.e-tjp.org/text.asp?2020/34/3/134/296461

  Introduction Top

Therapeutic lifestyle changes have been used in the medical field to improve the mental health lifestyle (MHL) of patients, such as those with diabetes mellitus[1], and to improve one's well-being[2]. Under therapeutic lifestyle changes, Walsh in 2011 identified eight activity domains related to MHL – exercise, nutrition and diet, time with the nature, relationships, recreation, relaxation and stress management, religious or spiritual involvement, as well as doing service to others[3]. According to the incremental theory of well-being, people who engage in MHL enhance their well-being and function[4]. The importance of mental health (MH) has grown in these days, and how to promote one's MH in communities in Taiwan is needed for future studies[5].

In flow theory[6], its author postulated that unchallenging activities make people feel bored and that highly challenging activities induce stress. When people engage in moderately challenging activities, they feel happy and enter the flow state. Furthermore, the Rasch measurement techniques allow that both individual performance and item difficulties are measured using the same metric and placed on the same scale. Like the social distance scale, the Rasch analysis has used to choose the moderately difficulty items for antistigma interventions[7]. In the present study, we used the Rasch analysis, intending to study the appropriate MHL required for MH promotion in Taiwanese communities.

  Methods Top

Study participants

The study participants were recruited openly in community through four MH promotion courses with an invited speaker in Taipei, Taoyuan, Taichung, and Kaohsiung. They were administered surveys with copies of the questionnaire including a four-item course satisfaction and an eight-item question for MHL that took about 5 min to complete. The data were gathered anonymously.

After the exclusion of those copies with incomplete data, there were 35 men and 169 women (average age being 34.34 ± 9.94 years) who completed the class and copies of questionnaire. Fifty-two persons come from northern Taiwan, 64 persons come from central Taiwan, and 88 persons come from southern Taiwan. After the staff explained the purpose of the study and the content of the questionnaire, the study participants completed copies of the questionnaire anonymously. The institutional review board of National Cheng Kung University Hospital approved this study (protocol IRB number = A-ER-108-421 and date of approval = November 13, 2019) with the waiver to obtain informed consent from the study participants.


The mental health lifestyle questionnaire

Eight MHL items were identified by Walsh in 2011: (a) engaging in exercise (more than 30 min), (b) maintaining a healthy diet, (c) being involved in nature, (d) maintaining relationships, (e) participating in recreational activities, (f) engaging in relaxation and stress management, (g) engaging in spiritual or religious activities, and (h) partaking in services to others, such as volunteering[5]. Study participants rated each item with respect to how often they practiced relevant activities on a five-point Likert scale ranging from 0 (not at all), 1 (monthly), 2 (weekly), 3 (2–4 times a week), to 4 (almost every day). A higher score reflected a higher frequency of engagement in those activities by study participants indicates less difficulty in implementing MHL. The Cronbach's alpha was 0.74, being in the acceptable level for reliability in this study.

The course satisfaction questionnaire

The course satisfaction questionnaire has four items on course satisfaction with content, instructors, classroom, and service on a five-point Likert scale ranging from 1 (not satisfied) to 5 (very satisfied). The Cronbach's alpha was 0.94 for reliability in this study.

Statistical analysis

The basic Rasch analysis is a dichotomous response model that represents the conditional probability of a binary outcome as a function of a person's trait level and an item's difficulty level. Because each item on the MHL questionnaire has five response categories, the partial credit model (PCM) was used to fit the data. The PCM is a unidimensional model for the analysis of multiple ordered responses, with the following mathematical formulation:

Where Pnix is the probability of person n scoring x, θn is the latent trail level of a person n, δi is the overall difficulty if item i, and τij is an additional step parameter of scoring j rather than j-1on item i. To make a meaningful interpretation of the latent trait level of person, the Thurstone threshold for each item was also calculated. The kth Thurstone threshold of an item can be defined as the point at which the probability of the scores less than k is equal to the probability of the scores greater than or equal to k. Thus, the item difficulties and step thresholds as well as indicators of the extent to which each item fitted the model were examined. The parameters in the PCM were estimated with ConQuest software[8] using the marginal maximum likelihood method.

When the data fit the model's expectation, the infit (weighted) and outfit (unweighted) mean square errors (MnSQe) have an expected value of unity. Wright and Linacre stated that the MnSQe between 0.7 and 1.3 indicates a reasonably good model–data fit[9].

We completed all statistical analysis with Statistical Package for the Social Science software version 20.0 (SPSS Inc. Chicago, Illinois, USA) and ConQuest software version 4.0 (www.theaccessgroup.com) to analyze all study variables. The differences between groups were considered significant if p-value were smaller than 0.05.

  Results Top

In the ANOVA had showed that four MHLs had significant differences relaxation (p < 0.05), volunteering (p < 0.05), relationship (p < 0.01), and recreation (p < 0.01) from living areas [Table 1]. Especially, the samples from the northern Taiwan engaged more recreation activities and volunteering than central and southern Taiwan. To compare the gender difference for the eight MHLs with t-test, the male engaged more recreation, spirit, and volunteer-related activities, but other five MHLs showed no significance. The score of the MHL and course satisfaction was positive correlation (r = 0.215, p < 0.05) in this study.
Table 1: Results of demographic analysis and the Rasch analysis

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Results of item difficulty estimates determined using the PCM [Table 1] revealed that the least difficult MHL activity was engaging in relaxation and stress management and that the most difficult was doing service to others such as volunteering. Moderate-difficulty MHL activities were engaging in exercise, recreational activities, and being involved in nature. In advance, the frequency to engage recreational activities showed the gender and area different in this study but not shown on the frequency to engage exercise and being involved in nature.

  Discussion Top

Engagement in intentional activities determines 40% of the chronic happiness level of an individual[10]. Walsh in 2011 listed eight major therapeutic lifestyle changes for optimal MHL[3]. The lowest and highest ranked domains according to difficulty in the Rasch analysis were engaging in relaxation and volunteer, respectively [Table 1], and the moderately challenging MHL activities were recreation and regular exercise and contacting nature in our study data.

Involvement in leisure activities is central to MH. Its benefits are summarized by the word “recreation” (re-creation)[3]. A leisure or recreational activity is an “un-coerced, contextually framed activity engaged in during free time, which people want to do and, using their abilities and resources, actually do in either a satisfying or fulfilling way (or both)”[11]. Some leisure/recreational activities, such as creative activities, are related to mood repair, social interaction, and present focus[12]. The detachment-recovery, autonomy, mastery, meaning, and affiliation model (DRAMMA model) highlights the psychological mechanism to connect recreation to well-being[13]. In their leisure time, people engage in recreational activities to enhance their well-being. As shown in the finding in this study, because of the area differences on recreation, the urban residents may have higher perceptions and needs for leisure than rural ones[14].

Exercise (item 1 in Walsh's list) is a well-known healthy lifestyle to prevent illness and to promote well-being[15]. Thus, the promotion of sport-based MH activities[16], such as regular exercise, can be integrated into recreational activities for the community population. Leisure-time physical activity can facilitate detachment from work demands and promote well-being in the DRAMMA model [13],[17]. A survey of recreational runners revealed that participating in a road running race on weekends enhances their health and well-being on weekdays[18].

Contact with nature (item 3: involving you in nature) has been shown to enhance various aspects of well-being such as positive affect, connectedness, and prosocial behaviors[19]. In a meta-analysis with 32 studies, exposure to natural environments is associated with moderate increasing in positive affect and decreasing the negative affect[20]. Taiwan has various natural scenes. People can contact the nature or forest to improve their MH in holidays.

Like the samples from the MH promotion course, our findings suggest that structured projects, such as the Sport and Health 150 min project or road running race, should be implemented to enable community members to enjoy sports as the recreational activity in the natural situation, thereby promoting MHL changes in the community.

Study limitations

  • The study participants were recruited openly in community through the MH promotion course. In advance, not only had those who are interested in the MH-related issues been included in this study, but also the others who have mental illness, unhealthy lifestyle, and elder need to be included in future research.
  • As the finding, the gender and area were different in the MHL-like recreation in this study. To correct sampling bias, we suggest that a national survey including more area and population can be explored to find out the relationship of the social status and the MHL.


The results obtained using the PCM reveal that basic MHL activity domains such as relaxation, diet, and relationships were the most engaging in the community. To foster MHL changes, exercise, recreation, and contact nature, which are moderate-difficulty MHL activity domains, must be promoted. High-difficultly MHL changes, such as engaging in volunteering or religious/spiritual activities, require more discussion. In the future, the effects of MHL-related interventions will be found through experimental studies.

  Acknowledgment Top

The authors thank Rong Huang for data collection.

  Financial Support and Sponsorship Top


  Conflicts of Interest Top

The authors have no conflicts of interests to declare.

  References Top

Levesque C: Therapeutic lifestyle changes for diabetes mellitus. Nursing Clin North Am 2017; 52: 679-92.  Back to cited text no. 1
Lund K, Argentzell E, Leufstadius C, et al.: Joining, belonging, and re-valuing: a process of meaning making through group participation in a mental health lifestyle intervention. Scand. J Occup Ther 2019; 26: 55-68.  Back to cited text no. 2
Walsh R: Lifestyle and mental health. Am Psychol 2010; 66: 579-92.  Back to cited text no. 3
Howell AJ, Passmore HA, Holder MD: Implicit theories of well-being predict well-being and the endorsement of therapeutic lifestyle changes. J Happiness Stud 2016; 17: 2347-63.  Back to cited text no. 4
Chen YC, Wu WT, Syu FY, et al.: An experience of medical students promoting mental health issues to the public and their peers in Taiwan. Mental Health Addict Res 2017; 2: 1-4.  Back to cited text no. 5
Csikszentmihályi M: Flow: The Psychology of Optimal Experience. New York: Harper and Row, 1990.  Back to cited text no. 6
Su YH, Li SM, Tsai YA: Applying Rasch analysis to assessing the social distance scale in patients with schizophrenia. Taiwan J Psychiatry (Taipei) 2013; 27: 329-33.  Back to cited text no. 7
Adams RJ, Wu ML, Wilson MR: ACER ConQuest: Generalised Item Response Modelling Software (computer software). Version 4. Camberwell, Victoria, Australia: Australian Council for Educational Research, 2015.  Back to cited text no. 8
Wright BD, Linacre JM: Chi-square for statistics. Chicago: Rasch Measurement Transactions, 1994.  Back to cited text no. 9
Lyubomirsky S, Sheldon KM, Schkade D: Pursuing happiness: the architecture of sustainable change. Rev Gen Psychol 2005; 9: 111-31.  Back to cited text no. 10
Stebbins RA: Leisure and the positive psychological states. J Posit Psychol 2 018; 13: 8-17.  Back to cited text no. 11
Wang CY, Zheng LZ, Wu CY, et al.: Maker activities in a psychiatric day care center. Taiwan J Psychiatry (Taipei) 2019; 33: 45-7.  Back to cited text no. 12
Newman DB, Tay L, Diener E: Leisure and subjective well-being: a model of psychological mechanisms as mediating factors. J Happiness Stud 2014; 15: 555-78.  Back to cited text no. 13
Kuo CJ: Comparing leisure lifestyle, leisure resourcefulness, and park attendance between urban and rural residents in a behavioral model. J Outdoor Recreat Stud 2015; 28: 1-29.  Back to cited text no. 14
Li SM: The Happiness of Psychology: Applied the Positive Psychology in Daily Life. Taipei: Yeh-Yeh, 2017.  Back to cited text no. 15
Vella SA, Swann C, Boydell KM, et al.: Sports-based mental health promotion in Australia: formative evaluation. Psychol Sport Exerc 2019; 45: 101560.  Back to cited text no. 16
Wiese CW, Kuykendall L, Tay L: Get active? a meta-analysis of leisure-time physical activity and subject well-being. J Posit Psychol 2018; 13: 57-66.  Back to cited text no. 17
Cypryanska M, Nezlek JB: Everyone can be a winner: the benefits of competing in organized races for recreational runner. J Posit Psychol 2019; 14: 749-55.  Back to cited text no. 18
Passmore HA, Holder MD: Noticing nature: individual and social benefits of a two-week intervention. J Posit Psychol 2017; 12: 537-46.  Back to cited text no. 19
McMahan EA, Estes D: The effect of contact with natural environments on positive and negative affect: a meta-analysis. J Posit Psychol 2015; 10: 507-19.  Back to cited text no. 20


  [Table 1]


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