Mobilizing ACT client participation in physical activity programs: provider perspectives using qualitative methods




Todd, Anika

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Background: Individuals with severe mental illness (SMI) have higher rates of physical comorbidities, such as cardiovascular disease and diabetes, which contribute to reduced life expectancy compared to the general population. Regular physical activity (PA) has proven efficacy at improving both physical and mental health outcomes in all persons. There is evidence that regular PA can also reduce the severity of psychiatric symptoms in individuals with SMI, including improvement of negative and neurocognitive symptoms in schizophrenia spectrum disorders. While currently available psychotropic medication is effective in managing positive symptoms, they have little or no effect on negative and neurocognitive symptoms, making regular PA a promising adjunctive treatment to pharmacological interventions. Despite the benefits of regular PA, individuals with SMI engage in PA at lower levels than the general population. Assertive Community Treatment (ACT) teams provide robust community-based support to individuals with SMI and are thus in a unique position to be able to provide support with PA engagement also. Purpose: To explore ACT team member perspectives and experiences with positive PA program implementation and visions for future program design and delivery for this population. Methods: A qualitative pragmatic a priori framework and implementation approach were used. Semi-structured interviews were conducted with ACT team members of various professional and paraprofessional designations. Interview questions were created using an appreciative inquiry lens and based on the Consolidated Framework for Implementation Research (CFIR) and focused on the CFIR domains of individuals involved, intervention characteristics, inner and outer settings. All interviews were recorded, and transcribed verbatim, and thematic analysis was conducted using QSR International’s Nvivo12® software. The CFIR was used to guide theming. Results: Eight participants with an average ACT experience of 6 years were interviewed. All participants believed PA to be important for physical and mental health, and all expressed enthusiasm and willingness to be involved in the development, implementation, and ongoing delivery of PA programs for ACT clients. However, most participants felt only somewhat or not at all confident in their own ability to deliver PA programming effectively and safely. Regarding intervention characteristics, participants unanimously identified adaptability and flexibility as necessary. Participants unanimously believed that the organizational culture was supportive of PA, but that few if any tangible supports existed. Interview questions related to the CFIHR outer setting revealed three main themes: necessary resources, organizational culture, and an expectation of implementation. Only two participants identified resources available within Island Health, and no participants were aware of any resources currently available within the ACT teams. However, all participants were able to identify some community resources available. Discussion: There was high motivation to deliver a PA program for ACT clients and positive beliefs about the benefits, but poor self-efficacy. To achieve successful implementation, additional training or supports, such as addition of a PA professional to the teams, should be considered. Participants resoundingly identified adaptability and flexibility as intervention characteristics necessary for implementation of a PA program in this setting. Fun, social connection, autonomy and incentive were identified as intervention characteristics that may improve client satisfaction. Some suggestions made by participants were the delivery of PA programming in a group format, and provision of choice in type of PA. In terms of inner setting, the structural characteristics of Island Health and the ACT teams include both strength and challenges to implementing new interventions. Island Health is a large organization with diverse knowledge, immense resources, longstanding and stable leadership structure, and organizational values of person-centred care and psychosocial rehabilitation that are congruent with implementation of a PA program for ACT clients. However, some participants believed the large size of the organization may create challenges to change and recommended a bottom-up team-based approach to implementation of a PA program. Resoundingly, participants in this study identified the need for dedicated time, space, funding, and staff to provide PA programs to ACT clients, and that including PA in program mandates would support the implementation of this. Greater connection with external organizations such as recreation centres, through personal connections or planned partnerships, was identified as an additional way to support implementation of PA programs. In terms of process, a dedicated group of staff or special committee may be a necessary part of the planning process in this setting, and planning should include consideration for the requisite time and staffing. As identified by one participant in this study, a “champion” can be a critical part of the engaging stage. A formalized execution plan may be most efficacious in this setting. Ongoing reflection and evaluation will be necessary to ensure the sustainability and quality of a newly implemented PA program. This study, by using an appreciative inquiry approach, has already initiated the process of engaging individuals. Island Health leadership can further engage individuals by continuing the conversations started in this study, providing education, and training, and supporting the importance of PA for ACT clients.



mental health, psychiatry, ACT, physical activity, schizophrenia, bipolar, assertive community treatment