Edinburgh Napier University

  Introduction: Physical activity (PA) is beneficial for improving both physical and mental health. However, people with mental health conditions are more likely to be inactive. In order to encourage adherence to PA, the Scottish Association for Mental Health (SAMH) funded by the Scottish Government, developed the Active Living Becomes Achievable (ALBA) intervention, which aimed to help people with poor physical and mental health to increase and maintain their PA levels. The main aim of this thesis was to evaluate the effectiveness of the ALBA intervention at increasing PA levels, improving mental wellbeing, self-efficacy for exercise, self-esteem and patient activation.

Method: A mixed method approach consisting of four interrelated studies: Study 1: a formative investigation, in the form of a systematic review was conducted to assess the effectiveness of cognitive-behavioural interventions in increasing adherence to PA in mental health populations. Electronic searches conducted in MEDLINE, CINAHL, Cochrane Library (Trials), SPORTDiscus and PsycINFO. Ten studies were included in the synthesis. Study 2: a qualitative process evaluation, using focus groups with ALBA participants. Fourteen people (11 females and 3 males) who had taken part in the intervention were interviewed in three focus groups. Thematic analysis was used to analyse the data, barriers against and facilitators to promoting adherence to the intervention were identified using the Theoretical Domains Framework (TDF). Study 3: a qualitative process evaluation using focus groups with the Behaviour Change Practitioners (BCP) who delivered the ALBA intervention. Thematic analysis was used to identify themes, which were then mapped onto the TDF, to identify the barriers and facilitators to the implementation of the intervention. Study 4: A quantitative outcome evaluation, with a before and after design was carried out to assess the effectiveness of the intervention. Participants completed 5 outcome measures – the Scottish Physical Activity Questionnaire (SPAQ), the Self-Efficacy for Exercise Scale (SEE), the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS), the Patient Activation Measure (PAM) and the Rosenberg Self Esteem Scale - and wore an activity tracker for 16 weeks. Adherence was measured by attendance at BCP appointments and level of activity as measured by the activity trackers. Participants who opted into the long-term study were monitored for up to 12-months. In total, 318 participants were recruited to take part, 68% were female, 90.3% were White-British, 20.8% came from the most deprived decile as measured by the Scottish Index of Multiple Deprivation (SIMD) and the average age was 41.2 (min 18, max 80).

Results: The formative evaluation concluded that there was limited evidence to support the use of cognitive-behavioural interventions for increasing PA adherence in mental health populations. However, this review highlighted the complexity of measuring adherence. The process evaluation revealed the important role that the BCPs played in supporting individuals. The BCPs were very knowledgeable about the intervention and highly skilled in interpersonal skills which helped facilitate delivery. Participants reported that the social support that they received from the BCP helped facilitate changes in their beliefs about their capabilities, goals, beliefs about consequences. This in turn helped them to develop a greater sense of purpose and feel socially connected, central components of mental wellbeing. Barriers to delivering ALBA were related to the environmental context, particularly the relationship with the Leisure Trust, and a lack of organisational support. The outcome evaluation revealed that 53% of the participants adhered to the intervention, although the intervention did not appear to increase adherence to PA. The ALBA intervention had a significant positive impact on mental wellbeing, patient activation and self-efficacy, but not self-esteem.

Conclusions: The ALBA intervention was effective at improving mental wellbeing but did not have a significant effect on PA levels. This suggests that the additional support offered through the ALBA intervention was key to improving wellbeing and encouraging PA in mental health population and the role of PA should be considered in a wider context of recovery.