Despite the evidence-based benefits of physical activity (PA) as a treatment for depression, many Healthcare Professionals (HCPs) do not promote PA to patients. We conducted a systematic review to identify the barriers and/or facilitators reported by HCPs working with individuals with depression, either exclusively or alongside other health conditions. Data were extracted and thematically analysed using the Theoretical Domains Framework (TDF). From 10,619 articles identified, 23 studies involving 5,711 HCPs across 12 countries met the inclusion criteria of; 1) HCPs working with individuals with depression, either exclusively or alongside other health conditions, and 2) primary data on barriers and/or facilitators experienced by HCPs for promoting PA for the treatment of depression. We identified three key themes: assumptions about patients, perceived HCP beliefs and capabilities, and contextual influences. From the studies included in this review, key barriers to the promotion of PA for depression are HCPs’ perceptions about barriers to patients becoming more active, and a lack of a supportive environment for HCPs to promote PA for depression. HCPs having good knowledge of the benefits of PA and perceiving PA as an effective treatment for depression were key facilitators.
All data supporting the study is provided in the results section or as supplementary information accompanying this paper.This study was supported by the University of Bath and the National Institute for Health and Social Care Research (NIHR) Applied Research Collaborations West through a PhD studentship.
Thematic analysis was used to facilitate the development of descriptive and analytical themes across studies following the 6 phases outlined by Braun & Clarke (Braun et al., 2021): 1) familiarisation, 2) data coding, 3) generating initial themes, 4) reviewing & developing themes, 5) refining, defining & naming themes, and 6) writing the report. To achieve a more in-depth and well-rounded analysis, multiple researcher perspectives were incorporated throughout the process (Braun & Clarke, 2019). In summary, data were coded as either a barrier or facilitator during extraction, these inductive codes were clustered into themes, and finally themes were deductively allocated to the appropriate TDF domains. Domains in the TDF are not mutually exclusive (Cane et al., 2012), therefore some barriers and facilitators could fit across multiple domains. However, in this review barriers and facilitators have been allocated to the single \u2018best-fit\u2019 TDF domain according to TDF domain definitions (Cane et al., 2012). Two authors (JC and GW) independently allocated themes to the TDF domains, and agreement was assessed using inter-rater reliability testing (Cohen's kappa), setting an acceptable minimum value of .61 indicating substantial agreement (Hallgren, 2012; McHugh, 2012). In addition to inter-rater reliability testing, discussions were undertaken with all members of the review team before reaching consensus on the naming and grouping of themes under each of the TDF domains, and whether supporting data was accurately represented in the themes.HCPs described their working environment as lacking support for PA promotion. Specifically, HCPs across four studies (Escobar-Roldan et al., 2021; Radovic et al., 2017; Searle et al., 2012; Zanetidou et al., 2016) reported environmental barriers such as: a lack of infrastructure (Zanetidou et al., 2016), lack of financial reimbursement (Escobar-Roldan et al., 2021), lack of time (Escobar-Roldan et al., 2021), excessive workload (Radovic et al., 2017), and a lack of referral resources that are properly funded and cost-effective (Searle et al., 2012), which all impeded their promotion of PA as a treatment for depression. In one study, some GPs were pessimistic about improvements to exercise referral pathways, and also concerned about cuts to existing services (Searle et al., 2012).HCPs' beliefs about PA being an effective/beneficial treatment, having knowledge of the benefits of engaging in PA and knowledge of the PA evidence base/guidelines were all associated with greater reported PA promotion. In contrast, lacking knowledge of the effectiveness of PA as a treatment was a barrier. This is similar to results reported when promoting PA to both the general population and to individuals with mental illness, whereby knowledge was a key determinant of HCP PA promotion (Glowacki et al., 2019; Herbert et al., 2012; Huijg et al., 2015). While previous research indicates that increased HCP training can lead to increases in PA promotion for chronic illnesses among GPs (Joyce & O'Tuathaigh, 2014), there remains a lack of evidence surrounding what that training should include. This is where the TDF and associated behaviour change techniques can be used to support increases to PA promotion; for example, training of HCPs could incorporate the behaviour change technique \u2018information about health consequences\u2019, which targets knowledge (Carey et al., 2019), and would involve providing information about the health consequences of engaging in PA for their patients. Some HCPs in our review already reported referring to specific health benefits of engaging with PA (Garvey et al., 2022; Patel et al., 2011; Searle et al., 2012), suggesting it's an acceptable and feasible way for HCPs to try and endorse PA to patients.HCPs reported experiencing a lack of a supportive environment to promote PA for depression, which included barriers such as a lack of exercise referral options and a lack of time with patients. Embedding PA promotion more explicitly among the core functions of public health infrastructure could help to reduce this barrier (APHA (American Public Health Association), 2007). This includes having PA promotion structured within healthcare services and community-based organisations, and that appropriate funding exists so these organisations can function without HCPs competing for scarce resources when trying to promote PA for depression (APHA (American Public Health Association), 2007). To better enable PA promotion being embedded within public health settings, supportive policies are recognised as being of great importance (Gelius et al., 2020).The findings of this review indicate a similarity between the barriers and facilitators HCPs experience when treating patients with depression and other mental illnesses. Our review suggests HCPs' perceptions about the barriers to patients becoming more active was a key influence on their PA promotion behaviour. However, HCPs reported that tailoring PA advice to the patients\u2019 needs and expectations surrounding PA can help to mitigate patient barriers. Good knowledge of the benefits of PA and perceiving PA as an effective treatment were enabling factors reported by HCPs across multiple studies. Previous research indicates that increased training can lead to increases in PA promotion for chronic illnesses among GPs (Winzenberg et al., 2009), but there remains a lack of evidence surrounding what the training should include. Further research is still needed to identify what training and support is needed for HCPs to engage more in PA promotion for depression. HCPs also reported experiencing an unsupportive environment when promoting PA, including barriers such as a lack of exercise referral options, lack of time with patients, and a lack of patient resources, particularly financial. To reduce these barriers, embedding PA promotion within existing public health infrastructure such as healthcare services and community-based organisations could help to create a more supportive environment for HCPs to promote PA for depression. Through the use of the TDF and associated behaviour change techniques, the findings of this review can be used pragmatically to help inform more targeted theoretically-informed interventions based on evidence to increase HCP PA promotion behaviour specifically when treating depression.This study was co-funded by the University of Bath and the National Institute for Health and Social Care Research (NIHR) Applied Research Collaborations West through a PhD studentship. The funding sources had no involvement in the conduct of the research.
- Mental health
- Psychosocial determinants
- Treatment
- Applied Psychology
- Psychiatry and Mental health
