Advising activity—knowledge, attitudes, beliefs, and behaviors regarding the recommendation of physical activity in clinical psychologists

Regular physical activity has a large positive effect on health [1, 2] and physical inactivity is one of the leading risk factors for noncommunicable chronic diseases [3] and global mortality [4]. While research has initially focused mainly on the associations between physical activity and physical health and disorders, connections between physical activity and mental health have received increasing attention from researchers in the last 20 years [5, 6]. There is strong evidence that physical activity plays an important role in the prevention and treatment of many common mental disorders [7, 8], including depression [9‐11], anxiety disorders [12‐15], schizophrenia [16‐19], post-traumatic stress disorder [20], and substance-use disorders [5, 21]. Furthermore, regular physical activity can play a key role in interventions that aim to reduce the alarming gap in life expectancy between patients with mental disorders and the general population [6, 22‐24].

Despite these benefits, the extent of physical activity in populations with mental disorders remains low [25, 26], with only a minority of patients fulfilling the recommendations for physical activity by the world health organization [27]. A number of successful interventions have been designed to help patients with mental disorders increase their level of physical activity and maintain an active lifestyle [28‐30]. Successful interventions typically consist of multiple sessions over several weeks, with ideally supervised physical activity and psychological/motivational interventions [29, 30]. Such interventions might be very successful for their participants, but translating complex interventions, developed in research settings to clinical routine, requires organizational, financial, and personal resources that are not always available in healthcare systems [30‐32]. While the allocation of resources to integrate complex physical activity interventions in routine care for patients with mental disorders would have substantial benefits in healthcare systems, concentrating on less complex interventions that require fewer resources might result in higher odds of timely large-scale integration in routine care [33]. The recommendation of physical activity by routine care providers (psychiatrists, psychologists, nurses, etc.) represents one form of basic intervention to increase physical activity in patients with mental disorders. Therefore, the knowledge, education, and recommendation behavior of health practitioners working with patients with mental disorders have received more scientific attention in recent years [34‐36]. Initial studies with small sample sizes have uncovered several barriers to recommending physical activity for patients with mental disorders [36‐40]. On individual level, these include a lack of knowledge on the benefits of physical activity, negative personal beliefs regarding exercise, insufficient formal education, limited time, and the prioritization of other tasks [36‐40]. Organizational challenges also play a role, such as the allocation of resources towards others priorities, further complicating the endorsement of physical activity in treatment plans [36‐40]. In most early studies, physical activity recommendation behavior was studied in small, heterogeneous samples using qualitative methodology or unvalidated questionnaires [35, 37, 39]. To enable quantitative research on mental health practitioners’ knowledge, attitudes, beliefs, physical activity behavior, and physical activity recommendation behavior, and to make international comparisons possible, Stanton, Happell, & Reaburn [41] developed the Exercise in Mental Illness Questionnaire-Health Professional Version. The questionnaire has attracted great attention and has been translated into several languages and used in different countries, such as Australia [42], Uganda [43], Brazil [44], the United States of America [45] and Sweden [46]. Existing studies show that in most samples, more than half of the health practitioners recommend physical activity, but recommendations in many cases do not follow the official recommendations of health organizations [42, 45‐47].

As the existing studies focus on small, often very heterogeneous samples, and health care systems vary greatly between different countries, there is a need for further international research on the physical activity recommendation of health care professionals in different countries.

To our knowledge, only one original study has focused on physical activity recommendation behavior among mental health professionals in Germany [48]. This study addressed psychiatrists and showed that a large proportion of psychiatrists recommend physical activity. The study has several methodological shortcomings, uses a very simple assessment of physical activity recommendations, and focuses only on psychiatrists. Another relevant study from Germany explored the integration of a brief physical activity measurement into clinical routine settings [49], which underpins routine recommendation behavior, yet did not investigate the recommendation behavior itself.

The aim of our study was to assess the knowledge, attitudes, beliefs, physical activity behavior, and physical activity recommendation behavior of psychologists working with patients with mental disorders in Germany.

This study explored clinical psychologists' attitudes and practices regarding physical activity recommendations for patients with mental disorders in Germany.

Regarding physical activity recommendations, only a small percentage of about 14% of the participants reported having received formal training in this area. Supplementary Figure S3 shows the comparison of our data regarding education, self-assessed knowledge, self-confidence, and recommendation behavior with existing studies from Australia, Brazil, Sweden, and Uganda [43, 44, 46, 54]. The comparisons show that in all studies, only a small portion of healthcare professionals received formal training regarding the recommendation of physical activity [43, 44, 46, 54]. Subgroup analyses revealed no substantial differences in the percentage of participants who received formal training across different levels of professional education. This suggests that there has not been significant progress in integrating these topics into the curricula in recent years. While self-assessed knowledge and self-confidence show roughly similar values between about 40 and 60 percent across the countries, there are large differences in recommendation behaviors [43, 44, 46, 54]. For instance, only 20 percent of healthcare professionals in Uganda reported regularly recommending physical activity, whereas in Germany, this figure was over 80 percent [43]. However, the differences between countries must be interpreted with utmost caution due to the varying sample sizes, different professional groups, and different recruitment procedures.

In view of the available evidence on the possible use of physical activity in the treatment of mental illness, the proportion that received training in our study, as well as in many comparable studies, seems very small. These data underscore the importance of integrating physical activity promotion expertise into psychologists' training curricula.

However, most participants rated their knowledge and self-confidence in their recommending physical activity as average or good. In light of the fact that only 18% of our sample reported to undertake a formal assessment of suitability to exercise prior to recommendation and 32% of our sample did not give recommendations regarding intensity, which are basic elements of a good recommendation [55], some participants seemed to overestimate their competence regarding physical activity recommendation. Pharmacotherapy, social support, family therapy, and psychotherapy were perceived as more effective treatment options than physical activity.

Considering the convincing evidence now available for the effectiveness of physical activity in treating a wide range of mental disorders with comparable effectiveness to other form of treatment [5, 56‐59], it appears that the participants might be underestimating its efficacy.

Participants reported recommending physical activity to patients most of the time or always (82.2%). Personal discussions represented the most commonly used method for physical activity recommendation. Only a small number of participants used referrals to exercise professionals, recommended community-based programs, or used brochures of pamphlets. However, as these can be valuable building blocks of a physical activity recommendation, the promotion of these recommendation modalities could be an important starting point for appropriate training.

Aerobic activities and relaxation activities were the most commonly recommended types of activities (approximately 90%), followed by relaxation activities (over 80%). Only approximately one third of the participants recommended weight training or combat sports. This behavior does not reflect the current physical activity guidelines, which explicitly recommend strength training [4]. The participants’ focus on aerobic activities could come from the fact that there is already a long and particularly large amount of evidence for these activities [56, 57, 60‐63]. However, in recent years, it has become increasingly apparent that other forms of physical activity (for example weight training, yoga or climbing) are also effective in the treatment of people with mental illness [60, 61]. This might explain why participants with less professional experience were more likely to recommend weight or resistance training and combat sports, as they might have already been informed about their efficacy during their education. Informing practitioners about new findings on the effectiveness of forms other than aerobic activity could be an important component of education and training programs.

The study also found that barriers to physical activity recommendation and participation were perceived to be relatively low, with lack of adherence and difficulties related to mental health being the most commonly acknowledged barriers. However, participants recognized the importance of physical activity for both inpatients and outpatients, and the majority believed that their patients were aware of the benefits of physical activity for physical health, but less aware of its benefits for mental health.

Regarding the recommendation of intensity, 32% of the sample did report not to give any recommendations regarding intensity. As intensity is one modality of a good physical activity recommendation, for example following the FITT principle (which states that recommendations should include frequency, intensity, time, and type; [55], this could be a focus of training and education programs as well.

On average, participants reported engaging in 240 min of moderate-to-vigorous physical activity per week themselves. The majority (67%) met the WHO recommendations for physical activity. These levels are higher than those in the general population [64, 65], especially because the EMIQ-G only asks for bouts of at least 10 min. This result could be related to the fact that the sample had a high level of education and all participants were employed, both of which are factors associated with higher levels of physical activity [65]. However, this could also indicate that people who are physically active themselves and accordingly have a greater interest in the topic decided to participate in our study. This could indicate a bias in the sample, resulting in an overestimation of the prevalence of physical activity recommendations and treatment knowledge in the present study. Higher levels of physical activity were associated with formal training, higher self-rated knowledge, and greater self-confidence in physical activity recommendations but not recommendation behavior itself, which is in line with some studies [46, 48, 53] but not all studies on this matter [44]. Approximately 80% of the participants expressed interest in further training measures. The reported wishes as to what specific content these training programs should contain are relevant for the development of the corresponding curricula.

Overall, these findings highlight the importance of incorporating physical activity recommendations into mental health treatment, and the need for further training and education in this area for psychologists.