The development and assessment of a mental health awareness education package for those at risk of cardiovascular disease - NU/LSHTM projects

Title of PhD project / theme

The development and assessment of a mental health awareness education package for those at risk of cardiovascular disease. For a Japanese audience.

Supervisory team

Dr Iliatha Papachristou Nadal (Lead supervisor) (
Professor Pablo Perel (

Nagasaki University
Dr Abdurrahman Gülbeyaz (

Brief description of project / theme

We recognise that mental health issues such as depression and anxiety in Japan are relatively common with an increasing risk of developing other chronic conditions such as cardiovascular diseases (CVDs)1-6.

Cardiovascular diseases are among the leading cause of death in most high-income countries and the risk of developing CVDs due mental health issues is high. People with CVD experience depressive disorder more than the general population and those with depressive disorder are more likely to develop acute myocardial infarction, heart failure or stroke 7-8. The prevalence of mental health issues such as depression is reported to be approximately 20% in patients with cardiovascular diseases; and 30–40% in patients with heart failure 9 . Suggested reasons for the development of CVD as a result of having a mental health issue are: more likely to lead an unhealthy lifestyle i.e. smoking, bad eating habits, and/or little exercise; levels of cortisol are increased due to long term stress, which in turn increases blood sugar and blood pressure.

There is still a great stigma in Japan regarding mental health issues and disorders and as a result mental health awareness is poor with very few studies examining the link between mental health and risk of CVDs 10-11 .

It is crucial that we work towards an understanding of how we can help people to better manage their mental health in order to prevent the risk of developing other chronic diseases such as CVDs. Self-management education training packages may help to increase mental health awareness and the risks of CVDs 11-14 .

By developing a culturally tailored education programme with the aim of increasing people’s knowledge of mental health and lifestyle management skills, this may improve mental wellbeing and thus prevent risk of CVDs.

The project aims to explore mental health issues and the prevention of cardiovascular disease through developing and assessing the acceptability of a culturally tailored educational training package on coping with stress, managing low mood and developing techniques to change risk behaviours such as poor diet and sedentary lifestyle.

Research questions:

1. What behavioural change techniques and/or lifestyle interventions have shown effectiveness in improving mental health and CVD?

2. What are the barriers and facilitators to accessing existing mental health resources in Japan and where is the gap?

3. What is the best technological method to use when developing a mental health and lifestyle awareness education package for a Japanese audience?

4. What is the acceptability of the delivery and content educational package?

There will be several steps within this PhD:

Step 1: Systematic review on mental health and risk of CVD within Japan and neighbouring Asian countries. 2

Step 2: Needs assessment through stakeholder surveys, focus groups and interviews.

Step 3: Co-design workshops on priority themes for the content of the education package.

Step 4: Content development of the education package

Step 5: Field testing content and education package with the target audience.

Step 6: Refining package through holding stakeholder events.

Evaluation methods:

The student will be expected to complete a systematic review, develop research skills in qualitative methods and patient and public involvement. Surveys will be used for field testing as well as using focus groups and one to one interviews to assess usability and acceptability of the education package. Therefore, a mixed method approach will be used for the final steps of the PhD.


1. Hiroyasu Iso. H., Date, C., Yamamoto, A., Toyoshima., H….Ohno, Y., JACC Study Group. (2002). Perceived Mental Stress and Mortality From Cardiovascular Disease Among Japanese Men and Women. Circulation,106:1229–1236

2. Greenwood, D., C, Muir K. R., Packham C.J., et al. . (1996). Coronary heart disease: a review of the role of psychosocial stress and social support. Journal of Public Health Medicine; 18: 221–231.

3. Uchiyama, S., Kurasawa, T., Sekizawa, T., Nakatsuka, H. (2005). Job Strain and Risk of Cardiovascular Events in Treated Hypertensive Japanese Workers: Hypertension Follow-Up Group Study. Journal of Occupational Health, 47:2.

4. Nishitani, N., Sakakibara, H. (2006). Relationship of obesity to job stress and eating behavior in male Japanese workers. International Journal of Obesity, 30:528–533.

5. Iida, W. Ajiki, A. Ioka, S. Sato, E. Maruyama, M. Konishi, K. Okada, I. Saito, N. Yasuda, S. Kono, S. Akiba, (2016). Coping strategies and risk of cardiovascular disease incidence and mortality: the Japan Public Health Center-based prospective Study, European Heart Journal,37: 11,14: 890 899,

6. Yazawa, A., Inoue, Y., Fujiwara, T. et al. Association between social participation and hypertension among older people in Japan: the JAGES Study. Hypertens Res 39, 818–824 (2016) doi:10.1038/hr.2016.78

7. World Health Organization (2017). Cardiovascular diseases (CVDs). Fact sheet, updated May 2017. Available at: Accessed December 18, 2017

 8. De Hert, M., Detraux, J., & Vancampfort, D. (2018). The intriguing relationship between coronary heart disease and mental disorders. Dialogues in clinical neuroscience, 20(1), 31–40.

9. David, L., Hare, Samia, R., Toukhsati, Johansson, P., Jaarsma, T. (2014). Depression and cardiovascular disease: a clinical review. European Heart Journal, 35; 21: 1365 1372,

10. Yoshioka, K., Reavley, N. J., Rossetto, A., & Nakane, Y. (2016). Associations between Beliefs about the Causes of Mental 3 Disorders and Stigmatizing Attitudes: Results of a Mental Health Literacy and Stigma Survey of the Japanese Public. International Journal of Mental Health, 45(3), 183–192.

11. Ishikawa, Kawakami, N., Kesseler, R. C. (2016). World Mental Health Japan Survey Collaborators Lifetime and 12-month prevalence, severity, and unmet need for treatment of common mental disorders in Japan: results from the final dataset of World Mental Health Japan Survey. Epidemiology Psychiatry Science, 25 : 217-229

12. Haskell, W. L. (2003). Cardiovascular disease prevention and lifestyle interventions: effectiveness and efficacy. Journal of cardiovascular nursing, 18(4), 245-255. doi: 10.1097/00005082- 200309000-00003

13. Hardcastle, S. J., Taylor, A. H., Bailey, M. P., Harley, R. A., & Hagger, M. S. (2013). Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12- month post-intervention follow-up. International journal of behavioral nutrition and physical activity, 10(1), 40.

14. Kuriakose L., Kuczynska P., Timel P., Yakun F., Bailey A., Papachristou Nadal I. (2019). Effectiveness of behaviour change techniques on lifestyle interventions of patients with a high risk of developing cardiovascular disease. Using a qualitative approach. Journal of Health & Social Care in the Community. In Press.

The role of LSHTM and NU in this collaborative project

LSHTM will provide the support on psychological and behavioural intervention development. In addition, we have a cardiovascular research group, which will provide further support and advice throughout the PhD programme.

NU will be able to support and advise on stakeholder and participatory workshop development – supporting with the recruitment of participants, contributing to survey distribution and support and advice with culturally tailoring the education package.

Particular prior educational requirements for a student undertaking this project

  • MSc in global/public health
  • With a background in psychology and/or interest in integrating physical and mental health.

Skills we expect a student to develop/acquire whilst pursuing this project

  • Qualitative methodology
  • Public and patient engagement
  • Understanding of complex interventions/behavioural intervention Mental health, Cardiovascular and integrated care