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Physical Activity Preferences and Perceived Barriers to Activity Among Persons With Severe Mental Illness in the United Kingdom

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Abstract

This study assessed physical activity interests among psychiatric patients. A cross-sectional survey of 120 psychiatric patients in the United Kingdom assessed preferences for physical activity, perceived barriers to activity, and other psychosocial factors related to exercise levels. Compared with the general population, respondents were less active. Respondents reported very little confidence in their ability to exercise when feeling sad or stressed, and they reported low levels of social support toward exercising. Approximately half the respondents or more expressed a belief in the health benefits of exercise, enjoyment of exercise, and a desire to be more active. Walking was the most popular activity, and fatigue and illness were the most common barriers to activity. Equal numbers preferred individual and group activities. A majority agreed that they would exercise more if they talked with an exercise instructor or were advised by their doctor. Physical activity interventions for the psychiatric population need to bridge the gap between high interest and low uptake through, for example, professional support and enhancing self-efficacy by combating barriers and tailoring to preferences.
PSYCHIATRIC SERVICES ps.psychiatryonline.org March 2007 Vol. 58 No. 3
440055
Objective: This study assessed
physical activity interests among
psychiatric patients. Methods: A
cross-sectional survey of 120 psy-
chiatric patients in the United
Kingdom assessed preferences
for physical activity, perceived
barriers to activity, and other psy-
chosocial factors related to exer-
cise levels. Results:
Compared
with the general population, re-
spondents were less active. Re-
spondents reported very little
confidence in their ability to ex-
ercise when feeling sad or
stressed, and they reported low
levels of social support toward ex-
ercising. Approximately half the
respondents or more expressed a
belief in the health benefits of ex-
ercise, enjoyment of exercise,
and a desire to be more active.
Walking was the most popular ac-
tivity, and fatigue and illness
were the most common barriers
to activity. Equal numbers pre-
ferred individual and group ac-
tivities. A majority agreed that
they would exercise more if they
talked with an exercise instructor
or were advised by their doctor.
Conclusions:
Physical activity in-
terventions for the psychiatric
population need to bridge the gap
between high interest and low up-
take through, for example, pro-
fessional support and enhancing
self-efficacy by combating barri-
ers and tailoring to preferences.
(Psychiatric Services 58:405–408,
2007)
P
hysical activity has the potential
to enhance the quality of life for
people with serious mental illness. It
has been shown to improve physical
health and to alleviate psychiatric and
social disabilities (1). It has been rec-
ommended that physical activity pro-
grams be routinely integrated into
psychiatric services (1), and individu-
als with severe mental illness are in-
terested in physical activity as a com-
ponent of weight management (2).
For physical activity to be promot-
ed, the interests of particular groups
need to be considered (3), including
preferences for types of activity as
well as support and perceived barri-
ers to the activity. This information is
available for the general population
(4); however, we could not identify
any cross-sectional studies that have
elicited this information from persons
with severe mental illness. This infor-
mation would assist psychiatric serv-
ices in planning interventions, com-
munication campaigns, and recre-
ation facilities.
The study presented here assessed
physical activity preferences, pre-
ferred sources of assistance to pro-
mote physical activity, and perceived
barriers to physical activity among
persons with serious mental illness.
In addition, we assessed other psy-
chosocial variables (self-efficacy, be-
liefs, perceived social support, moti-
vation, and enjoyment) that have
been shown to be important influ-
ences on physical activity uptake in
the general population (5).
Methods
The study involved a cross-sectional
survey. Adults receiving treatment for
psychiatric illness in the United King-
dom National Health Service and re-
ceiving inpatient treatment or outpa-
tient treatment from community
mental health centers in southwest
London were eligible for the study.
Between January and April 2003, pre-
sentations describing the study were
made to patients at these centers and
hospital wards. After the presentation
all patients present were invited to
joined the study (N=151), irrespec-
tive of their psychiatric disorder. For
all individuals agreeing to be inter-
viewed the site manager confirmed
that the person had the capacity to
give written consent. None of those
volunteering were refused entry to
the study. All volunteers were inter-
viewed in a private room for approxi-
mately 20 minutes on a single occa-
sion by a researcher using a struc-
tured questionnaire. Questions were
read out loud to participants, and the
researcher wrote down the responses.
Participants were not compensated
for their involvement. Participants
Physical Activity Preferences and Perceived
Barriers to Activity Among Persons With
Severe Mental Illness in the United Kingdom
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Dr. Ussher, Dr. Stanbury, and Dr. Cheese-
man are affiliated with the Division of
Community Health Sciences, St. George’s,
University of London, Cranmer Terrace,
London, United Kingdom SW17 ORE (e-
mail: mussher@sgul.ac.uk). Dr. Faulkner
is with the Faculty of Physical Education
and Health, University of Toronto, Toron-
to, Ontario, Canada.
uss.qxd 2/14/2007 9:28 AM Page 405
gave written consent to participate
and to provide access to their medical
records. Approval of the local ethics
committee was obtained. Statistical
analyses were carried out by using
SPSS version 13.
Demographic characteristics and
primary psychiatric diagnosis were
extracted from patients’ medical
records. Physical activity during the
previous seven days was reported (6).
This measure has shown adequate va-
lidity and reliability in this population
(7). It was explained to participants
that the term “exercise” was used to
refer both to structured exercise and
to lifestyle activities—for example,
walking.
Preferences for physical activity
were assessed by asking, “Which of
the following types of exercise do you
most like to do?” (8). Table 1 shows a
complete list. Preferences were also
assessed by asking, “Given the choice,
would you prefer to exercise on your
own, with other people, or don’t you
have a preference?”
Preferences for assistance were as-
sessed by asking, “How much do you
agree with the following statements
(strongly disagree=1, disagree=2,
neither agree or disagree=3, agree=
4, strongly agree=5): (i) I would exer-
cise more if an [exercise] instructor
talked through with me what I should
be doing, (ii) I would exercise more if
my doctor suggested that I should,
(iii) I would exercise more at home
than at a gym.”
The psychological measures were
adapted from existing questions (9).
Perceived barriers to physical activity
were assessed by asking, “Which of the
following would you say is the most
important reason why you don’t do as
much exercise as you would like?”—
for example, takes too much time or
afraid of getting injured; Table 1 shows
a complete list of options. Self-efficacy
for exercise was assessed with the
question “How confident do you feel
about exercising [being able to exer-
cise] when you are feeling sad or
stressed?” Possible responses included
1, not at all; 2, mildly; 3, somewhat;
and 4, very. Beliefs regarding exercise
were determined by assessing level of
agreement with the statements “Exer-
cise is very important for my physical
health” and “Exercise is very impor-
tant for my mental health.” Possible
responses range from 1, strongly dis-
agree, to 5, strongly agree. Social sup-
port for physical activity was gauged by
asking, “How much help would you
get from family and friends if you were
to start taking more regular exercise?”
Possible responses ranged from 1, no
help at all; 2, very little; 3, a little; 4,
quite a lot; and 5, a lot. Motivation was
assessed by asking, “How much do you
want to start taking more regular exer-
cise?” Possible scores range from 1,
not at all, to 5, extremely so. Enjoy-
ment was assessed by asking, “How
much do you enjoy exercise?” Possible
scores are 1, not at all; 2, a little; 3,
somewhat; and 4, very much so.
Results
Of the 151 patients invited, 120 pa-
tients agreed to be interviewed. Of
these a majority were male (70 pa-
tients, or 58%), smokers (70 patients,
or 58%), single (92 patients, or 77%),
unemployed (98 patients, or 82%),
and receiving inpatient treatment (80
patients, or 67%). A total of 82 pa-
PSYCHIATRIC SERVICES ps.psychiatryonline.org March 2007 Vol. 58 No. 3
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TTaabbllee 11
Variables influencing physical activity uptake for 120 adults receiving treatment
for psychiatric illness in the United Kingdom National Health Service
Measure N %
Physical activity preferences (N=109)
a
Exercise at a facility 11 10
Exercise at home 98 90
Walking 76 70
Housework 3 3
Do-it-yourself activities, such as yard work and home maintenance 1 1
Cycling 2 2
Gardening 1 1
Dancing 3 3
Individual sport 2 2
Team sport 3 3
Other 5 5
Preferred style of physical activity (N=120)
On own 37 31
With others 36 30
No preference 47 43
Preferred sources of assistance (N=120)
Agreed or strongly agreed that instructor’s help would increase
levels of exercise 70 58
Agreed or strongly agreed that he or she would exercise more
with doctor’s advice 76 63
Agreed or strongly agreed that he or she would exercise more
at home versus at the gym 57 48
Perceived barriers to activity (N=116)
b
Too tired 23 20
Illness 17 15
Bad weather 15 13
Takes too much time 14 12
Other reason 13 11
Feel unsafe going outdoors 10 9
Afraid of getting injured 9 8
Self-consciousness 8 7
Not sure what to do 7 6
Other psychological assessments (N=120)
Agreed or strongly agreed that exercise is important for
physical health 108 90
Agreed or strongly agreed that exercise is important for
mental health 86 72
Wants to exercise more regularly very much so or extremely so 57 48
Enjoys exercise very much so or extremely so 68 57
Not at all confident or mildly confident about being able to
exercise when sad or stressed 70 58
Would receive no help, very little help, or a little help with exercise 82 68
a
Eleven respondents did not identify any physical activity preferences.
b
Four respondents did not identify any barriers to exercise.
uss.qxd 2/14/2007 9:28 AM Page 406
tients (68%) were Caucasian, 27
(23%) were black, six (5%) were
Asian, and five (4%) were in another
racial or ethnic group. The mean±SD
age was 42.6±16.1 years. Sixteen pa-
tients (13%) had recently entered the
treatment service and a diagnosis had
not yet been made. Of 104 partici-
pants with a diagnosis, the largest
percentage had a primary diagnosis of
schizophrenia (36 patients, or 35%),
followed by depression (20 patients,
or 19%), bipolar disorder (18 pa-
tients, or 17%), schizoaffective disor-
der (nine patients, or 9%), personali-
ty disorder (eight patients, or 8%),
and psychosis (five patients, or 5%).
The remaining eight patients were di-
agnosed as having either mania (two
patients, or 2%), alcoholism (one pa-
tient, or 1%), anorexia (one patient,
or 1%), generalized anxiety disorder
(two patients, or 2%), monosympto-
matic delusional disorder (one pa-
tient, or 1%), or acute confusional
state (one patient, or 1%). Recom-
mended physical activity levels—at
least 30 minutes of at least moderate
intensity at least five days a week
(10)—were achieved by 24 partici-
pants (20%). Details of other assess-
ments are given in Table 1.
The most popular activity was walk-
ing, followed by structured exercise at
a facility. The sample was evenly split
between preferring individual exer-
cise or group exercise, and more than
a third expressed no preference. Al-
most half agreed or strongly agreed
that they would exercise more at
home rather than at a gym. A majori-
ty agreed or strongly agreed that they
would exercise more if they talked
with an instructor or were advised to
do so by their doctor. The most fre-
quently reported reasons for not exer-
cising were fatigue, illness, and bad
weather.
A vast majority of respondents re-
ported that they believed in the ben-
efits of exercise for both physical and
mental health and that they enjoyed
exercise, but they had little confi-
dence in being able to exercise when
feeling sad or stressed and received
little, if any, support for exercise from
family and friends. Around half re-
ported a high level of motivation to
exercise more regularly.
The findings for exercise levels
(number of days with 30 minutes of
activity) and for the key psychological
variables of motivation to exercise,
self-efficacy, and social support were
assessed for differences according to
gender, age, smoking status, treat-
ment setting, diagnosis, employment
status, and marital status. When re-
gression analysis was performed, we
found no significant differences in
reports of exercise levels, motivation,
or social support according to these
characteristics. However, self-effica-
cy for exercise was significantly lower
among women compared with men,
among patients with depression com-
pared with those with other disor-
ders, and among outpatients com-
pared with inpatients. When a
forced-entry regression analysis was
performed, several factors remained
associated with self-efficacy: gender
(β=.43, p=.042), outpatient versus in-
patient (β=.57, p=.011), and diagno-
sis (β=.76, p=.011).
Discussion
Consistent with previous findings
(1,11), participants tended to be more
sedentary than the general popula-
tion and walking was the most com-
mon activity. There was a high level of
interest in being more active, and a
vast majority reported that they be-
lieved in the benefits of exercise and
enjoyed exercise. This should be
grounds for optimism in developing
physical activity opportunities for this
population. However, participants
tended to report very little confi-
dence in their ability to exercise when
feeling sad or stressed and little, if
any, social support for exercise. Lack
of regular social contact appears to be
a common correlate of inactivity in
this population (11,12), and low self-
efficacy is one of the strongest deter-
minants of inactivity in general (5).
Evidently, physical activity inter-
ventions for the psychiatric popula-
tion need to find ways to bridge the
gap between high levels of interest
and low levels of exercise. This might
involve increasing social support. Our
findings suggest that, consistent with
findings in the general population (8),
this population values the support of
health professionals. Self-efficacy for
exercise may need to be enhanced by,
for example, using cognitive-behav-
ioral strategies (4). In addition, our
findings suggest that such interven-
tions may be especially needed
among women, outpatients, and
those with depression. Moreover, in-
terventions may be more beneficial
by being integrated with recovery and
peer-support approaches to psychi-
atric rehabilitation (13,14) that em-
brace health promotion (15).
Interventions will need to address
barriers to the uptake of exercise,
such as fatigue and illness, which
have been reported more frequently
among persons with severe mental
illness than in the general population
(4), and interventions may need to
consider other barriers (12) not as-
sessed in the study presented here.
Physical activity interventions for
persons with severe mental illness
need to be tailored to individual pref-
erences—for example, toward the
mode of exercise and for exercising
alone versus with others. Education
may be beneficial concerning oppor-
tunities for leisure-based and
lifestyle activity on the basis of per-
sonal preferences, as opposed to pre-
scribed and structured exercise regi-
mens (16). The results presented
here provide support for interven-
tions focusing on walking, and en-
couraging an existing activity may be
a simpler task than trying to initiate a
novel behavior (16). This study was
limited in that it was a cross-section-
al study with a relatively small sample
and it used several measures that
have not been validated. Prospective
studies of preferences and barriers
are required with larger samples of
patients and with subgroups of pa-
tients—for example, with persons
with severe depression.
Conclusions
The persons with severe mental ill-
ness interviewed in this study tended
to be less active than the general pop-
ulation. They reported little confi-
dence in being able to exercise when
sad or stressed and reported that they
had had little social support for exer-
cising. More optimistically, the partic-
ipants reported high levels of interest
in exercise. Leisure and psychiatric
services need to respond to this inter-
est through providing programs of
physical activity that enhance self-
PSYCHIATRIC SERVICES ps.psychiatryonline.org March 2007 Vol. 58 No. 3
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uss.qxd 2/14/2007 9:28 AM Page 407
efficacy, provide adequate social sup-
port, and take into account the pref-
erences for physical activity reported
by those with severe mental illness.
Acknowledgments and disclosures
The authors report no competing interests.
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... Patients with mental illness seem to have a positive attitude towards being physically more active. Many complain about a lack of social support though [22]. Thus, regular support and feedback should be provided to engage patients in PA. ...
... MDD patients are typically characterized by low levels of physical activity (PA) and a reduced fitness compared to healthy controls [22,25]. Perceived barriers such as "no time", or "physically unable" to be active [26] and disease-specific obstacles may prevent patients from participating in PA. ...
... Perceived barriers such as "no time", or "physically unable" to be active [26] and disease-specific obstacles may prevent patients from participating in PA. Lower self-efficacy can lead to a lack of confidence to engage in PA, exacerbated by a lack of social support [22]. This illustrates the challenge to design webbased exercise concepts. ...
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This commentary addresses web-based exercise, defined as exercise interventions delivered via email, mobile app or website as a promising therapeutic approach for the treatment of depressive symptoms. I summarize the current research in this area and offer an innovative perspective from the field of sports science on howexercise can be managed in this patient collective. The manuscript concludes with key features for future web-based approaches to further improve the evidence for this approach.
... In patients suffering from mental disorders, lack of motivation, lack of self-determination, fatigue, illness etc. are associated with significantly lower levels of PA [29,36,37]. In order to help patients with severe mental illnesses to engage in PA, the sessions should match the patients' abilities and (psychosocial) needs [38]. ...
... In order to help patients with severe mental illnesses to engage in PA, the sessions should match the patients' abilities and (psychosocial) needs [38]. Measures that may help are structured training in a facility [37], social support [37,[39][40][41][42], the support of an exercise instructor [37,39], the promotion of intrinsic and extrinsic motivation (empowering patients to control their training independently) [36,43,44], motivational interviewing, and goal setting [45]. In addition to pursuing physiological goals, it is also recommended to make use of exercise programs that provide psychological support to patients [40] and promote interaction with others [46]. ...
... In order to help patients with severe mental illnesses to engage in PA, the sessions should match the patients' abilities and (psychosocial) needs [38]. Measures that may help are structured training in a facility [37], social support [37,[39][40][41][42], the support of an exercise instructor [37,39], the promotion of intrinsic and extrinsic motivation (empowering patients to control their training independently) [36,43,44], motivational interviewing, and goal setting [45]. In addition to pursuing physiological goals, it is also recommended to make use of exercise programs that provide psychological support to patients [40] and promote interaction with others [46]. ...
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Physical activity has gained importance in psychiatric and psychosomatic treatment schemes, but there is little knowledge on the use of physical activity for forensic rehabilitation, including psychosocial outcomes. A systematic review of the literature on PubMed and Livivo found only one study that specifically addressed the effects of physical activity in forensic patients. Twenty-three studies reported on physical activity in the context of non-forensic patients suffering from mental illnesses similar to those commonly diagnosed in forensic patients. We summarize the effects of physical activity with respect to therapeutic objectives suggested by German sport therapists working with forensic patients. In forensic patients or patients suffering from mental illness typical of forensic patients, physical activity promotes social skills (4 studies), self-image, body experience, and personality growth (9 studies). Physical activity also helps to activate patients (12 studies), while reducing their tension and anger (1 study). Yet, there is a significant lack of specific scientific evidence as to whether sport therapy for forensic patients is effective in terms of the therapeutic objectives of this patient group. Future research must focus on longitudinal dose-effect outcome studies on forensic patients and should also concentrate on studies in the area of psychosis, personality disorders and addiction in relation to forensic sport therapeutic objectives. Published in SPORTS PSYCHIATRY 2022, 1 - 9.
... We could also see, that participants improved their symptom severity, with this being observed in the control group in one study [58] and in the exercise group in two studies [56,57]. As there are associations between psychotic disorders and adverse health behaviours and risk factors for cardiovascular disease such as insufficient physical activity, poorer diet, and obesity [4,5,[64][65][66], exercise interventions could not only help to reduce smoking, but also to improve cardiovascular health and quality of life [67]. ...
... More attention should be paid to the individual needs of people with MI, in terms of programme content and outcome [15,19]. With regard to the content of exercise and smoking cessation programmes, individual preferences regarding modality, duration, and intensity should be considered [66]. An example of this is the study of Smits et al. [57], which showed a higher abstinence rate in the high-intensity exercise group in people with MI compared to the lowintensity exercise control group. ...
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Background Smoking is the most common substance use disorder among people with mental illness. In contrast to people without mental illness, among whom the proportion of smokers has declined in recent decades, the proportion of smokers among people with mental illness remains high. There is a growing body of literature suggesting the use of exercise interventions in combination with smoking cessation in people without mental illness, but to our knowledge the available studies on this treatment option in people with mental illness have not been systematically reviewed. Therefore, this systematic review and meta-analysis aims to assess the effectiveness of exercise interventions as an adjunctive treatment for smoking cessation in people with mental illness. Methods Electronic databases (PubMed, Web of Science, PsycInfo, Sport Discus and Base) were searched for randomised controlled trials and prospective single-group studies that investigated exercise interventions in combination with smoking cessation programmes alone or in comparison with a control group in people with mental illness. A meta-analysis using the Mantel–Haenszel fixed-effect model was conducted to estimate the overall effect of treatment on smoking cessation (abstinence rate at the end of the intervention and at 6-month follow-up). Results Six studies, five randomised controlled trials and one study with a prospective single-group design, were included in the systematic review and four randomised controlled trials were included in the meta-analysis. The meta-analysis found a significantly higher abstinence rate after additional exercise at the end of the intervention [risk ratio (RR) 1.48, 95% confidence interval (CI) 1.13–1.94], but not at the 6-month follow-up (RR 1.34, 95% CI 0.89–2.04). Conclusions Exercise appears to be an effective adjunctive therapy to temporarily increase abstinence rates in individuals with mental illness at the end of the intervention. However, due to the small number of included studies and some risk of bias in the included studies, the results should be treated with caution. Therefore, future studies with larger samples are needed to provide a more accurate estimate of the effect in people with mental illness. Registration The systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42020178630).
... Indeed, several studies showed its beneficial effects on several outcomes including weight management, cardiovascular health, functioning, or psychotic symptoms (Dauwan et al., 2016;Firth et al., 2017;Ohi et al., 2018;Romain et al., 2019;Rosenbaum et al., 2015). However, despite the positive effects of physical activity, people with psychosis may experience many barriers to its practice (Bernard et al., 2013;Firth et al., 2016) and research consistently showed that lack of motivation is the most prominent along with poor social support from health professionals Ussher et al., 2007). Nevertheless, even though motivation has been consistently showed as a barrier to physical activity in people with psychosis, previous studies also highlighted that they are ready to be more active (Subramaniapillai et al., 2016;Ussher et al.). ...
... However, despite the positive effects of physical activity, people with psychosis may experience many barriers to its practice (Bernard et al., 2013;Firth et al., 2016) and research consistently showed that lack of motivation is the most prominent along with poor social support from health professionals Ussher et al., 2007). Nevertheless, even though motivation has been consistently showed as a barrier to physical activity in people with psychosis, previous studies also highlighted that they are ready to be more active (Subramaniapillai et al., 2016;Ussher et al.). Therefore, it is possible that people with psychosis have difficulties to overcome their intention -behaviour gap regarding physical activity practice (Gollwitzer & Sheeran, 2006;Sailer et al., 2015). ...
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... With respect to physical activity, there were significant improvements for walking and moderate physical activity sessions, but not for vigorous physical activity. The findings may reflect a preference for walking as a form of physical activity among people with a mental health condition (Chapman et al., 2016;Fraser et al., 2015;Ussher et al., 2007), and a focus within the coaching program on achievable and sustainable goals, possibly more aligned with walking and moderate activity domains. The present study was not able to capture any changes in sedentary behaviour as a result of program engagement, a health risk factor acknowledged to be lacking in behavioural interventions delivered to people with mental health conditions (Ashdown-Franks et al., 2018). ...
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This paper describes a conceptual model of recovery from mental illness developed to aid the state of Wisconsin in moving toward its goal of developing a "recovery-oriented" mental health system. In the model, recovery refers to both internal conditions experienced by persons who describe themselves as being in recovery--hope, healing, empowerment, and connection--and external conditions that facilitate recovery--implementation of the principle of human rights, a positive culture of healing, and recovery-oriented services. The aim of the model is to link the abstract concepts that define recovery with specific strategies that systems, agencies, and individuals can use to facilitate it.
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