Process evaluation of a lifestyle physical activity counseling intervention for in-patients with major depressive disorders

Background: Major Depressive Disorder is a wide-spread and often chronic psychiatric disease affecting physical and psycho-social health. The global lifetime prevalence is 15-18% and approximately 12% of afflicted people are admitted to in-patient treatment at least once during their lifetime. Insufficient physical activity is prevalent among afflicted individuals, despite its potential antidepressant and protective effects. Theory-based interventions targeting psycho-social determinants of and implicit attitudes towards physical activity behavior can be effective in increasing physical activity levels. In particular, physical activity counseling has proven positive effects in healthy people as well as in out-patients. It remains unknown how a physical activity counseling intervention can be implemented and work during and after inpatient treatment, which contextual factors may be influential and how physical activity levels may be affected.
Aim: The aim of this PhD thesis was to conduct a process evaluation of a theory-based, tailored lifestyle physical activity counseling intervention for in-patients with Major Depressive Disorder within the PACINPAT (physical activity counseling for in-patients with Major Depressive Disorders) study. This was conducted according to the Medical Research Council Framework and entailed quantitatively and qualitatively evaluating contextual factors, intervention implementation, mechanisms of impact as well as behavioral outcomes (objectively measured and self-reported physical activity levels).
Methods: The PACINPAT study is a multi-center randomized controlled trial set in four Swiss psychiatric clinics. Adults who were insufficiently physically active upon admission to inpatient treatment were recruited (N = 244) and randomized into an intervention group (n = 123) who received tailored lifestyle physical activity counseling sessions (two in-person sessions and 26 sessions via telephone) for 12 months or a control group (n = 121) who received two in-person non-tailored counseling sessions during in-patient treatment. Quantitative data were collected at baseline (approximately 2 weeks after admission to in-patient treatment), post (approximately 6 weeks after discharge from in-patient treatment) and follow-up (12 months after discharge from in-patient treatment). Qualitative data were collected upon completion of the intervention and study participation. Data pertaining to psycho-social health (perceived stress, health status and insomnia symptoms) as well as psycho-social determinants of physical activity were measured with validated and reliable questionnaires. Data pertaining to implicit attitudes towards physical activity were assessed with a computer-based Single Target Implicit Associations Test. Self-reported physical activity was assessed via structured interviews based on the Simple Physical Activity Questionnaire. Additionally, physical activity was measured with a hip worn accelerometer. Major Depressive Disorder symptoms were measured both by self-report with the Beck Depression Inventory as well as via structured interview based on the Hamilton Depression Scale. Data pertaining to the implementation of the intervention were collected from the implementers’ documentation and participant satisfaction data were collected via questionnaire. Qualitative data were gathered via semi-structured interviews conducted in-person and online.
Results: The evaluation of contextual factors revealed that, the unforeseen contextual circumstance of a global pandemic caused by the Coronavirus Disease 2019 and ensuing state-mandated lockdown seems not have elicited differences in psycho-social health, psycho-social determinants of and implicit attitudes towards physical activity as well as self-reported physical activity levels among individuals who were in in-patient treatment at that time. Depression severity did, however, seem to negatively impact certain psycho-social determinants of physical activity. The evaluation of the intervention implementation showed that the intervention dose varied between early dropouts and completers with high and low participation rates. The in-person intervention fidelity was partly achieved and so adapted, whereas the remote intervention fidelity was well achieved. Additionally, the participants reported satisfaction with the intervention and implementers. Upon deeper investigation of the mechanism of impact, i.e., how the intervention was experienced, four experience patterns were recognizable (expansive, adoptive, stagnant and confirmatory), which influenced both physical activity behavior and well-being during and after the intervention. The evaluation of the short-term intervention outcomes (6 weeks after discharge from in-patient treatment) revealed that moderate-to-vigorous physical activity as well as step count decreased in both the intervention and control group, however less so in the intervention group, indicating that physical activity counseling may be a valuable asset to explore further. Additionally, psycho-social determinants of and implicit attitudes towards physical activity seemed to remain unchanged between the groups, but positive changes (decreases in negative outcome expectancies and increases in action and coping planning) were seen over time in both groups.
Conclusion: The theory-based, tailored lifestyle physical activity counseling intervention was
implemented successfully during and after in-patient treatment. The process evaluation of the
contextual factors, intervention implementation, mechanism of impact and short-term outcomes revealed valuable insights into future intervention refinement. This may entail adapting physical activity counseling to illness severity and how the individual is managing their illness. Especially with potentially declining physical activity behavior during the transition out of inpatient treatment, offering support during this vulnerable phase is particularly important. Further research is required, to ascertain the long-term effects of physical activity counseling in in-patients with Major Depressive Disorder. Followed by the adaptation and broader dissemination of physical activity promotion programs to reach those most in need.