Introduction
Physical activity (PA) is a therapeutic tool that can benefit a range of mental health symptoms (Stubbs et al. Reference Stubbs, Vancampfort, Hallgren, Firth, Veronese and Solmi2018), and reduce cardio-metabolic risk among trans-diagnostic mental health populations (Carney et al. Reference Carney, Cotter, Bradshaw, Firth and Yun2016; Firth et al. Reference Firth, Siddiqi, Koyanagi, Siskind, Rosenbaum and Galletly2019). Such findings remain relevant for young people with mental disorders (Bailey et al. Reference Bailey, Hetrick, Rosenbaum, Purcell and Parker2017; Carney and Firth Reference Carney and Firth2021). Such young people often experience complex barriers to PA and low levels of PA (Carney et al. Reference Carney, Cotter, Bradshaw, Firth and Yun2016; Brooke et al. Reference Brooke, Gucciardi, Ntoumanis and Lin2020). Integrated practitioners are an effective strategy for PA implementation in mental health (Firth et al. Reference Firth, Cotter, Elliot, French and Yung2015; Lederman et al. Reference Lederman, Grainger, Stanton, Douglas, Gould and Perram2016), and also Child and Adolescent Mental Health Services (CAMHS) (Carney and Firth Reference Carney and Firth2021). Despite the recognised need for more integrated PA within mental health services (Stubbs et al. Reference Stubbs, Vancampfort, Hallgren, Firth, Veronese and Solmi2018), many developed nation contexts, such as Ireland, do not have practitioners integrated within mental health services (Matthews et al. Reference Matthews, Cowman and Denieffe2018).
This report details a qualitative evaluation of a pilot project to develop and implement an Integrated Exercise Practitioner (IEP) for specialist outpatient CAMHS in the Republic of Ireland.
Methods
Design and procedures
A qualitative exploratory approach using individual interviews (N = 3) with parents/guardians of the CAMHS service from the intervention, and a single online focus group (N = 3) with members of the relevant CAMHS team were conducted. The inquiry and semi-structured topic guide used were framed by the RE-AIM framework (Glasgow et al. Reference Glasgow, Vogt and Boles1999), which is an accepted approach to qualitative inquiry (Holtrop et al. Reference Holtrop, Rabin and Glasgow2018). Eligible volunteer participants made contact the research team to participate. The interviews were conducted following intervention blocks (detailed below) between March 2020 and June 2021, during a period of COVID-19 restrictions. Zoom software was used, and anonymised data were transcribed.
Participants
Individual interview participants were parent/guardians of service users from CAMHS that engaged with the intervention. Further participant information is in Table 1.
Table 1. Profile of interview and focus group participants
Intervention
A multidisciplinary steering group (CAMHS mental health clinicians, Local authority sports partnership, and Academic), oversaw governance and management of the pilot project to integrate a novel IEP for mental health services in Ireland. The Local Sports Partnership (LSP) acted as host of the IEP in recruitment and line management, further details on this are available elsewhere (Denieffe et al. Reference Denieffe, Cowman, Mulhare, Banville, O'Riordan, Harrison, Egan, Ormonde and Matthews2021). Special agreements allowed the IEP full mental health service integration, including multidisciplinary care meetings and contribution to individual care plans. The recruited IEP received mentorship from a clinical nurse manager, given their remit for physical health (Happell et al. Reference Happell, Platania-Phung and Scott2011).
The intervention was delivered to service users across four 8-week intervention blocks. Each block consisted of eight exercise sessions with the qualified IEP, along with a prescribed home exercise programme for 8 weeks. All interventions were individually tailored (fitness level, preferences), using a graded approach to intensity. There was predominant focus on light intensity aerobic exercise (e.g. walking programmes) to more moderate and high intensity aerobic exercise (e.g. jogging and sprinting programmes). The programmes also included basic mobility, flexibility and resistance type exercises, in addition to weekly monitoring and health coaching using existing resources (Broderick and Moran Reference Broderick and Moran2018).
The COVID-19 pandemic resulted in considerable adaptions to the intervention model during Blocks 3 and 4. Here, exercise was delivered using ‘telehealth’, which consisted of eight exercise sessions with the IEP in addition to health coaching using Zoom software and a tailored home exercise programme. Fifteen young people completed the intervention across blocks.
Ethics
Ethical approval for the research evaluation was obtained from the regional Research Ethics Committee of the Health Service Executive, and the relevant Institutional Review Board. All eligible participants provided informed consent.
Analysis
Transcripts were coded to identify and define recurring themes and subthemes. The identified codes and collated quotes were managed in NVivo12 allowing for the creation of a theme structure using reflexive thematic analysis (Braun and Clarke Reference Braun and Clarke2006; Clarke and Braun Reference Clarke and Braun2017). Critical discussion between authors allowed for theme refinement to ensure succinct and informative findings.
Results
A total of (N = 3) parent/guardians of CAMHS service users and (N = 3) CAMHS multidisciplinary service providers participated. Participants of the focus group were an occupational therapist, a speech and language therapist and a social worker. All participants were > 18 years of age and of Irish ethnicity.
Three overarching themes were explored, these are shown in Table 2 and discussed below.
Table 2. Overview of theme and subtheme names
Making changes toward healthier PA behaviours
Participants commented on the value of the IEP in supporting service users to increase their PA levels. In this regard, the IEPs effectiveness was realised by a number of approaches to intervention utilised.
Supported incremental behaviour change
Participants discussed the value of the IEP having capacity to deliver PA in a graded manner, particularly given the challenge that becoming more physically active presented to the young people.
She is more active in that she is kind of walking more (referring to daughter). She goes for the occasional run too, but she hasn't really fully got back to where she was (referring to before CAMHS). She hasn't gone back to training in the GAA (Gaelic Athletic Association) or anything like that… she is going for an occasional swim most days to do something, which is a big improvement… Parent/Guardian 2.
Tailored one-to-one intervention
COVID-19 precluded the use of group-based PA entirely. However, the findings demonstrated a value of delivering one-to-one interventions for CAMHS service users. It appears that this facilitated a flexibility of service which made participation feasible.
Online accessibility
The research participants discussed a perception of acceptability of telehealth intervention among service users when face-to-face intervention was prohibited.
They're digital savvy, the young people; they're more willing to engage with likes of Whatsapp Video, where I can imagine that might be a barrier in other services (referring to adult services)… They were already doing school online. So doing this online wasn't a huge step. Focus group P1.
Re-introducing past activities
The parents/guardians of service users shared a belief that the IEP achieved success in engaging people through re-introducing activities that service users previously enjoyed.
When he was younger (referring to service user)… He loved his soccer … By the time we were going to CAMHS, there was no sports, there was no kind of interaction with anybody… Since the programme (referring to IEP intervention), he went out with some friends to play football… When he came home, he said 'Mommy, I think I will join back soccer'. Parent/guardian 3.
An intervention of therapeutic holism
The intervention was perceived to have far-reaching impact beyond PA levels. Many participants discussed how the intervention benefited the mood and wellbeing of service users.
Therapeutic connection and rapport with the IEP
The intervention was perceived to act as a therapeutic gateway to the CAMHS team in so far as it reached some service users that were not readily engaging with traditional services.
Towards the end (referring to the IEP intervention), she (service user) started to interact with the councilor and with the social worker more. She started to engage with him (referring to the consultant psychiatrist), which she hadn't before. Parent/Guardian 2.
Positive impact on functioning and routines
Parents/guardians of service users discussed broad mental health benefit from the intervention. For many, the intervention created an environment that was conducive to therapeutic conversations with a member of the CAMHS team.
The integrated service delivery
The perception that the IEP was a new member of the CAMHS team and the importance of integrated working was also explored.
The value of integrated working
Service providers in the focus group indicated that the level of service integration allowed for seamless collaborative working, and therefore good adoption of the IEP service among the existing CAMHS team.
Anyone can pick up the phone and give (names the IEP) a ring. We complete the written referrals, they're left on my shelf for (names the IEP), and she works from there. Focus group P1.
Overcoming the challenges of integrating a new role into an established team
Initial concerns about risk related to the management of disclosures in the context of service user referral to a new and inexperienced team member, as perceived by some service providers, were discussed. This perception appears to have changed as the positive impact on consumers was realised and the IEP became established. Service providers alluded to the importance of the consultant psychiatrist working collaboratively with the IEP, which appeared to impact positively on other service providers’ willingness to adopt the service. Lastly, a small number of service providers opted not to refer service users to the IEP, therefore indicating mixed findings around adoption.
Discussion
Integrated exercise professionals are recommended within services for young people with mental illness (Carney and Firth Reference Carney and Firth2021). In Ireland, there has been little success in realising this approach for services nationally (Matthews et al. Reference Matthews, Cowman and Denieffe2018; O’Donoghue Reference O’Donoghue2021). As a response, a multi-agency consortium (inclusive of a local outpatient mental health service) secured funding to pilot an IEP, employed by a local authority (through the LSP), but with special integrated access to an outpatient CAMHS in Ireland. We discuss the findings from the evaluation of this pilot intervention.
The IEP appeared to positively impact PA behaviours of service users. Research in a similar outpatient adult service in Ireland with no IEP service has shown that mental health professionals can be dissuaded from using PA due to concerns about risk and limitations in their knowledge, thereby pointing to the value of specialist integrated solutions (Matthews et al. Reference Matthews, Cowman and Denieffe2020). Exercise physiologists in mental health possess high competency to prescribe and implement PA across mental health populations (Stanton et al. Reference Stanton, Rosenbaum, Lederman and Happell2017). In Australia’s ‘Headspace’ service, IEP integration has been shown to be feasible, acceptable, and further associated with physical and mental health benefits for youth at-risk of psychosis, leading to continued funding (Lederman et al. Reference Lederman, Ward, Rosenbaum, Maloney, Watkins, Teasdale, Morell and Curtis2019).
Studies that have utilised PA interventions in youth with mental disorders have demonstrated beneficial effects on symptoms of depression, anxiety, improved cognition and quality of life across diagnostic groups (Pascoe et al. Reference Pascoe, Bailey, Craike, Carter, Patten, Stepto and Parke2020; Carney and Firth Reference Carney and Firth2021). In the current research, parents/guardians discussed broad mental health benefits from their children engaging with the IEP. However, it was not possible to explore specific mental health symptomology that may have changed in the current research. A previous meta-ethnography has indicated that, therapeutic interactions with exercise practitioners, the development of routines around exercise, and wider lifestyle behaviour change during PA intervention, may all positively impact mental health outcomes among people with schizophrenia, indicating broad potential psychosocial benefit from PA intervention (Soundy et al. Reference Soundy, Freeman, Stubbs, Probst, Coffee and Vancampfort2014).
Evidence from the UK, where physiotherapists often work within mental health settings, suggests that poor therapeutic relationships around exercise can occur where exercise is not delivered by an integrated professional (Hemmings and Soundy Reference Hemmings and Soundy2020). The importance of deep service integration appears valuable in the successful adoption of the IEP in the current research. Furthermore, consultant psychiatrist ‘buy-in’ was important for the successful adoption of the IEP service in this instance. Previous qualitative research from an inpatient setting in Australia has also noted the importance of this phenomena (Fibbins et al. Reference Fibbins, Ward, Stanton, Czsonek, Cudmore, Michael, Steel and Rosenbaum2019). Future work should seek to understand the perspectives of the consultant and the mental health team in relation to the role of IEPs in mental health, and provide education where appropriate.
Telehealth exercise practices have been shown as feasible and effective in clinical settings, yet understudied in youth mental health settings (Lederman et al. Reference Lederman, Furzer, Wright, McKeon, Rosenbaum and Stanton2021). In the current research, its use was acceptable and effective due in part to the capability of the participating young people to use devices.
Limitations
Some domains of the RE-AIM framework were less well explored in the current inquiry. There was a notable dearth of exploration of issues related to the reach and maintenance domains. Future work in this area should focus specifically on examining these areas.
The sample size was determined by the number of eligible and willing participants from the accessible population. Therefore, we do not make inferences that the findings here have reach beyond the context in which data were gathered, nor do we affirm that the exploratory inquiry were exhaustive. It was also notable that service providers that engaged in the focus group were persons that had utilised the IEP service and were largely positive about the service. Service providers that did not engage with the IEP may have additional insight. Lastly, this research has the notable absence of CAMHS service users. The burden of obtaining ethical approval and the necessity to evaluate the project immediately after completion precluded this inquiry.
Conclusion
This research presents an evaluation of a novel pilot project to develop and implement an IEP as part of outpatient CAMHS in Ireland. Our findings are promising in so far as we explored a number of ways in which this integrated approach to PA was successful in supporting behaviour change among young people. We provide learning with respect to implementation and adoption of a novel IEP service into a CAMHS team in the Irish context.
Acknowledgement
The research team wish to thank Ms Anna Flynn (IEP, Sports Active Wexford) and Ms Miriam Lambert (CNM, HSE mental health services) for their work to support and facilitate this research as part of their role on the pilot project. Additionally, the research team wish to thank the participants that gave their time to contribute to this research project.
Financial support
This research was funded by the SláinteCare Integration fund (2019), by the Department of Health, Government of Ireland. Project ID 233.
Conflict of interest
None
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this research has been provided by their local Ethics Committee.
