Motivation to physical activity in non-psychotic psychiatric inpatients

The International Journal of Psychosocial Rehabilitation

Motivation to Physical Activity in Non-Psychotic Psychiatric Inpatients

Julie Raepsaet
University Psychiatric Centre-K.U.Leuven, campus Kortenberg

Jan Knapen
Davy Vancampfort
Michel Probst
University Psychiatric Centre-K.U.Leuven, campus Kortenberg
K.U. Leuven, Faculty of Physical Education and Rehabilitation Sciences, Department Rehabilitation Sciences, Belgium

Corresponding author:
Julie Raepsaet
University Psychiatric Centre K.U. Leuven, campus Kortenberg
Leuvensesteenweg 517
3070 Kortenberg
Mail: julie.raepsaet@uc-kortenberg.be

Citation:
Raepsaet J, Knapen J, Vancampfort D, & Probst M. (2010). Motivation to physical activity in non-psychotic
psychiatric inpatients. International Journal of Psychosocial Rehabilitation. Vol 15(1) 51-59

Abstract
Objective: To examine whether motivation to physical activity is related to different physical and psychological variables of physical activity, in a sample group of non-psychotic psychiatric inpatients.
Methods: In this explorative cross-sectional study, one hundred and twelve patients with different diagnoses were examined, using six questionnaires, at the University Psychiatric Centre K.U. Leuven, Campus Kortenberg, in Belgium.
Results: Two factors of motivation to physical activity, namely interest/enjoyment and competence, are significantly related to a higher physical activity level (respectively r = 0.46 and r = 054). Physical activity is significantly related to perception of physical fitness (r = 0.47). Perception of physical fitness is significantly related to general well-being and activity (r = 0.37), and perception of physical well-being (r = 0.68). Psychosocial adaptations related to body weight, body-image and self-worth and a perception of subjective well-being (physical and psychological well-being) are negative significantly related to trait anxiety (r = -0.60, r = -0.66 and r = -0.82).
Conclusion: It is important to motivate to physical activity those people with a low physical activity level, a low psychosocial adaptation level, a negative physical and psychological well-being, or a negative perception of physical fitness.

Keyword: motivation to physical activity, mental health disorders, physical activity level

Introduction:
Physical inactivity represents a serious physical and mental health problem. It not only increases the risk of cardiovascular diseases, osteoporosis, breast and colon cancer, type 2 diabetes and obesity, but also the risk of depression, anxiety disorders and other mental health problems (Hu et al., 2005; Knapen et al., 2009; Yates et al., 2009). Physical inactivity increases the morbidity and the mortality (Knapen et al., 2009).

Otherwise, physical activity has both a preventive and curative effect (Warburton et al., 2006; Knapen et al., 2009). It improves quality of life, physical health and fitness, and reduces mental health problems (Goodwin, 2003; Van Hees et al., 2005; Ussher, 2007).

In general, people with a psychiatric disorder show a less active lifestyle and have poor physical health compared with the general population (Sørensen, 2006; Ussher, 2007). In these patients, different symptoms of psychiatric disorders, such as psychosomatic complaints and hypochondria, lack of energy, general fatigue and a low physical self-concept in interaction with a poor physical health and fitness may lead to a vicious cycle of loss of self-confidence, an increased avoidance of physical activity and decreased levels of physical and mental health. For that reason, the incorporation of exercise therapy into the comprehensive treatment programs for psychiatric patients is highly recommended (Knapen et al., 2007).

Several meta-analyses examined the effects of exercise on depression and anxiety. The most recent meta-analyses of Rethorst et al. (2009) examined the effects of exercise on depression/depressive symptoms in 58 randomized controlled trails. It can be concluded that exercise therapy, within clinically depressed patients, seems to be at least as effective as antidepressant medication and psychotherapy (Rethorst et al., 2009).

Wipfli et al. (2008) analysed the results from 49 randomized controlled trials in the area ‘exercise and anxiety’. From the results it can be concluded that exercise therapy is more effective than stress management education, slightly more effective than group therapy, stretching and yoga, relaxation and meditation, and as effective as cognitive behavioural therapy (Wipfli et al., 2008).

These positive effects of physical activity on depression and anxiety were obtained by following guidelines; exercise 45-59 minutes a day at a moderate intensity, with a frequency of 3 or 4 times a week, for 10 to 16 weeks. Exercise programmes that combined aerobic and anaerobic exercise resulted in larger effects than aerobic or anaerobic training alone (Wipfli et al., 2008).

The term motivation indicates all the processes that deal with the stimulus, the direction and the retention of physical and mental activities (Johnson, Weber & Zimbardo, 2005). Several theories might guide our understanding of the motivation to physical activity by psychiatric patients, and give directions or practical approaches for increasing motivation (Sørensen, 2005). Deci and Ryan (1985) described a self-determination theory (SDT), which is a contemporary framework that is increasingly being used to understand exercise motivation and adherence (Thøgersen-Ntoumani & Ntoumanis, 2005). Specifically, SDT proposes that behavioural regulation towards physical activity can be amotivated, extrinsically motivated, or intrinsically motivated. These classifications of motivation differ in the extent to which they are self-determined, because they represent different degrees of internalization of external values and goals (Thøgersen-Ntoumani & Ntoumanis, 2005). Amotivation refers to any intention to change behaviour. Intrinsic motivation comes from the inside: you do something because you like it, without an external reward. Extrinsic motivation comes from the outside and can be divided into four types of regulation: external (for an external reward), introjected (avoiding negative feelings), identified (for the positive effects related to the activity and the appreciation of others) and integrated regulation (to perform personal goals) (Deci & Ryan, 1985). Amotivation and external regulation are negatively associated with the physical activity level. Introjected, identified, integrated regulation and intrinsic motivation are positively associated with the physical activity level (Thøgersen-Ntoumani & Ntoumanis, 2005; Sørensen, 2006) . A study of Sørensen (2006) demonstrated that intrinsic motivation to physical activity is related to a 57,4 % symptom reduction in a group of psychiatric patients with different diagnoses.

The aim of the present study was to examine whether motivation to physical activity, level of physical activity, psychosocial adaptations related to body weight, body image and self-worth, anxiety, subjective well-being, perception of physical fitness and trait anxiety are related to each other, in a sample group non-psychotic psychiatric inpatients. The hypothesis of this study was, that there will be an association between motivation, level of physical activity, and physical and psychological variables of physical activity, in a sample group non-psychotic psychiatric inpatients.

Method
Subjects
In this explorative cross-sectional study, one hundred and twelve non-psychotic psychiatric inpatients (45 men and 67 women), of the University Psychiatric Centre K.U. Leuven Campus Kortenberg, were examined during a period from 1/01/2009 to 13/02/2009. The average age for women was 31.82 years (SD = 11.85) and for men 39.71 years (SD = 13.29). The patients were diagnosed by psychiatrists according to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition for syndrome diagnosis (axis I) and diagnosis of personality disorders (axis II). Multiple diagnoses were possible on both axes and mostly psychiatrists made three or more diagnoses. The principal diagnoses were: mood disorders (n = 34), anxiety disorders (n = 25), personality disorders (n = 21), eating disorders (n = 25) and substance related disorders (n = 7). Patients were individually invited to participate in the present study. All subjects signed the Informed Consent according to the standards of the Ethics Commission of the University Psychiatric Centre K.U.Leuven, Campus Kortenberg, Belgium.

Measures
Six questionnaires were used. The selection of the questionnaires was based on the reliability and validity of the questionnaires in the research domain of physical activity in mental health. An independent examinator collected the results in a closed envelope.

Baecke Questionnaire (Baecke, 1982)
The Baecke questionnaire evaluates the level of physical activity at work, including studying and housework (work index), in sports (sport index) and during leisure time (leisure time index) in the last year. The questionnaire consists of 16 items and each item is scored using a 5-point Likert scale. The maximum score for each of the three domains is 5. The total physical activity level is the sum of work, sport and leisure time indices. The total score varies between 3 and 15. A higher score means a higher physical activity level. The test-retest reliability coefficients for work, sport and leisure time indices in the present study are respectively 0.80, 0.90 and 0.74.

Motivation for Physical Activities Measure-Revised: MPAM-R (Ryan & Frederick, 1993, 1997)
The motivation to physical activity was measured by means of the Motivation for Physical Activities Measure-Revised by Ryan and Frederick (1993, 1997). This questionnaire contains 30 items divided into five categories: interest and enjoyment (7 items), competence (7 items), physical appearance (6 items), fitness (5 items) and social contact (5 items). The items are scored using a 7-point Likert scale. There are two distinct types of motivation: intrinsic (interest, enjoyment and competence) and extrinsic motivation (physical appearance and social contact). Fitness includes both intrinsic and extrinsic motivation.

This questionnaire was translated into Dutch through the back to back translation procedure by two independent translators. The Dutch version of MPAM-R showed the same factor structure as the original questionnaire (Vancoillie, 2007). The test-retest reliability measured with the intraclass correlation coefficient was 0.90, indicating that the Dutch version of MPAM-R is useful to examine the motivation to physical activity by psychiatric patients.
Body weight, image and self-esteem evaluation questionnaire: B-Wise (Awad & Voruganti, 2004)

The B-wise evaluates psychosocial adaptations related to body weight, body image and self-worth. The questionnaire consists of three factors: negative body image and stress, general well-being and activity, and knowledge and actions about body weight. The scores are scored on a 3-point Likert scale. The total score ranges from 12 to 36. High scores indicate better psychosocial adaptations. De Hert (2006) translated the original version of the B-Wise in Dutch. The back translation procedure was approved by the original authors of the scale (De Hert et al., 2006).
Trait Anxiety Inventory: T.A.I. (Spielberger, 1984)

The T.A.I. examines the trait anxiety. The 20 items are scored using a 4-point Likert-scale. The total score ranges between 20 and 80: the higher the score, the more anxious the person is in general. The Trait Anxiety Inventory was translated by Van der Ploeg (2000). The test-retest reliability ranges from 0.76 to 0.86.
Questionnaire on subjective well-being (Marcoen et al., 2002)

A selection of 8 items of the Marcoen questionnaire for subjective well-being (Marcoen, Van Cotthem, Billiet & Beyers, 2002) was used to measure well-being. Four items were selected out of the psychological scale and four out of the physical well-being scale. The selection was based on factor loadings and internal consistency scores (Opdenacker et al., 2009). The items are scored on a 7-point Likert scale. A higher total score means a better subjective well-being.
Visual Analogue Scale: V.A.S. scale: perception of physical fitness

A 100 mm Visual Analogue Scale examines the perception of physical fitness. At the opposite ends of the line are keywords ‘very bad’ and ‘very good’ were used.

Data-analysis
Data were analyzed using Statistica 9. The relationship between the variables was examined using Spearman rank order. Spearman rank order is a non-parametric measure of statistic dependence between two variables with a not-normal distribution (Portney & Watkins, 2000). The significance level in all of the tests was set at 0.0001 (two-tailed). The internal consistency of the questionnaires was measured by Chronbach’s alpha coefficients (Cohen, 1988).

Results
Internal consistency
The internal consistencies for the questionnaires from Baecke and B-wise are respectively α = 0.58 and α = 0.65. This is a moderate internal consistency. The Dutch versions of the motivation questionnaire from Ryan and Frederick (1993, 1997), the Trait Anxiety Inventory and the questionnaire on subjective well-being show a good internal consistency, respectively α = 0.95, α = 0.94 and α = 0.88.

Correlation between variables
The five factors of motivation are interest and enjoyment, competence, appearance, fitness and social contact. Only two factors of motivation, namely interest and enjoyment and competence are significantly related to sport index, leisure time index and total physical activity level (table1). Motivation is not significantly related to psychosocial adaptations, trait anxiety, subjective well-being and perception of physical fitness (table 2). Physical activity level is significant related to perception of physical fitness (table 4). There is no significant relationship between physical activity and psychosocial adaptations, subjective well-being and trait anxiety (table 3 & 4). Perception of physical fitness is significantly related to psychosocial adaptations and physical well-being (table 5). Psychosocial adaptations and subjective well-being are significant related to trait anxiety (table 6).

Table 1: The correlation between motivation and physical activity level.
Measuring	Baecke work	Baecke sport	Baecke leisure time	Baecke total
Ryan interest and enjoyment	0.03	0.43	0.39	0.46
Ryan competence	0.12	0.47	0.45	0.54
Ryan appearance	-0.02	0.25	0.34	0.31
Ryan fitness	-0.06	0.28	0.24	0.28
Ryan social contact	0.04	0.13	0.09	0.13

p < 0.0001

Table 2: The correlation between motivation, psychosocial adaptations, trait anxiety, subjective well-being and perception of physical fitness
Measuring	B – Wise	T.A.I.	Marcoen factor 1	Marcoen factor 2	V.A.S.
Ryan interest and enjoyment	0.15	-0.06	0.27	0.07	0.33
Ryan competence	0.02	-0.01	0.17	0.02	0.26
Ryan appearance	-0.24	0.22	-0.14	-0.12	-0.04
Ryan fitness	0.06	0.04	0.09	0.09	0.09
Ryan social contact	0.33	-0.31	0.34	0.32	0.20

p < 0,0001; B – Wise = psychosocial adaptations related to body weight, body-image and self-worth; T.A.I. = Trait Anxiety Inventory; Marcoen factor 1 = physical well-being; Marcoen factor 2 = physiological well-being; V.A.S. = Visual Analogue Scale = perception of physical fitness.

Table 3: The correlation between physical activity and psychological adaptations.
Measuring	B-Wise factor 1	B-Wise factor 2	B-Wise factor 3	B-Wise totaal
Baecke work	-0.11	-0.13	0.07	-0.12
Baecke sport	-0.02	0.01	0.12	0.04
Baecke leisure time	-0.09	0.00	0.24	0.04
Baecke total	-0.08	-0.02	0.19	0.01

p < 0.0001; B-Wise factor 1 = negative body image and stress; B-Wise factor 2 = general well-being and activity; B-Wise factor 3 = knowledge and actions about body weight; B-Wise total = psychosocial adaptations related to body weight, body-image and self-worth.

Table 4: The correlation between physical activity , trait anxiety, subjective well-being and perception of physical fitness.
Measuring	T.A.I.	Marcoen factor1	Marcoen factor2	V.A.S.
Baecke work	0.07	-0.14	-0.02	0.02
Baecke sport	0.10	0.26	-0.04	0.43
Baecke leisure time	-0.08	0.22	0.07	0.44
Baecke total	0.05	0.24	-0.01	0.47

p < 0.0001; T.A.I. = Trait Anxiety Inventory; Marcoen factor 1 = physical well-being; Marcoen factor 2 = physiological well-being; V.A.S. = Visual Analogue Scale = perception of physical fitness.

Table 5: The correlation between psychosocial adaptations and trait anxiety, subjective well-being and perception of physical fitness.
Measuring	T.A.I.	Marcoen factor 1	Marcoen factor 2	V.A.S.
B – Wise factor 1	-0.50	0.54	0.41	0.35
B – Wise factor 2	-0.63	0.61	0.56	0.37
B – Wise factor 3	0.18	-0.17	-0.17	-0.01
B – Wise total	-0.60	0.63	0.51	0.39

p < 0.0001; B-Wise factor 1 = negative body image and stress; B-Wise factor 2 = general well-being and activity; B-Wise factor 3 = knowledge and actions about body weight. B-Wise total = psychosocial adaptations related to body weight, body-image and self-worth; T.A.I. = Trait Anxiety Inventory; Marcoen factor 1 = physical well-being; Marcoen factor 2 = physiological well-being; V.A.S. = Visual Analogue Scale = perception of physical fitness.

Table 6: The correlation between trait anxiety, subjective well-being and perception of physical fitness.
Measuring	T.A.I.	Marcoen factor 1	Marcoen factor 2	V.A.S
T.A.I.	1.00	-0.66	-0.82	-0.34
Marcoen factor 1	-0.66	1.00	0.63	0.68
Marcoen factor 2	-0.82	0.63	1.00	0.33

P < 0.0001; T.A.I. = Trait Anxiety Inventory; Marcoen factor 1 = physical well-being; Marcoen factor 2 = physiological well-being; V.A.S. = Visual Analogue Scale = perception of physical fitness

Discussion
The aim of the present study was to examine whether motivation to physical activity is related to different physical and psychological variables of physical activity, in a sample group of non-psychotic psychiatric patients. Motivation, especially intrinsic motivation (interest, enjoyment and competence), is positive related to a higher physical activity level. Our finding is similar to that of the study of Sørensen (2006), who investigated the relationship between level of physical activity and intrinsic and extrinsic motivation to physical activity in a group of psychiatric patients. They also reported an association between intrinsic motivation and physical activity level and that intrinsic motivation was related to a 57.4% symptom reduction (Sørensen, 2006).

The present findings demonstrate that physical activity level is related to a positive perception of physical fitness. Perception of physical fitness is positively related to psychosocial adaptations related to body weight, body-image and self-worth, and to physical well-being.

Psychosocial adaptations related to body weight, body-image and self-worth, and subjective well-being are negative related to trait anxiety. Van de Vliet et al. (2002) investigated the relationship between self-perceptions and negative affect in adult Flemish psychiatric inpatients suffering from mood disorders. Their conclusion, which is similar to our findings, was that the relationship between physical self-perceptions and negative affect might be considered as a valuable framework for furthering our understanding of the depression and anxiety reducing potential of exercise and physical activity in clinically depressed individuals (Van de Vliet et al., 2002).

The results should be cautiously interpreted as there are some limitations in the study. First, an explorative cross-sectional study has methodological limitations. No causal relationship or effect can be found. Therefore, we plan a longitudinal study in order to investigate the association between the changes in the variables. Secondly, the study worked with principal diagnoses; no subdivision can be made for the different diagnoses for the reason that most patients in the sample had three or more diagnoses. Thirdly, the results come from a single psychiatric centre. Finally, questionnaires were used to measure the patients’ physical activity. Questionnaires have limitations, can be time consuming and are know to be less accurate than more objective techniques, such as pedometers and accelerometers (Van Hees et al., 2005).

Conclusion
Psychiatric patients accumulate a lot of barriers to participation in exercise such as a low self-worth and self-confidence, loss of energy, interest and motivation, generalised fatigue, poor physical fitness and health condition, fear of moving, social fear, overweight a low feeling of personal control concerning own fitness and health, and helplessness and hopelessness. For these reasons, it is very important to motivate these patients to be physically active.
The physical activity has to be self-determined and focused on the positive experience of the activity itself. It is also important that the activity is individually adapted in order to prevent negative experiences with physical activity and drop-out. The therapist should give information about the health benefits of physical activity to both mental and physical health. Knowledge can reduce the anxiety about participation in physical activity. Physical activity itself can improve the perception of physical fitness which in turn improves the self-concept. A better self-concept reduces symptoms of depression and anxiety. It is important to motivate to physical activity those people with a low physical activity level, a low psychosocial adaptation level, a negative physical and psychological well-being, or a negative perception of physical fitness. To experience the positive effects of physical activity, some guidelines have to be followed: exercise 45-59 minutes a day at a moderate intensity, with a frequency of 3 or 4 times a week, for 10 to 16 weeks. Exercise programmes that combined aerobic and anaerobic exercise resulted in larger effects than aerobic or anaerobic training alone (Wipfli et al., 2008).

Further research is needed to examine specific types of motivation to physical activity related to different kinds of diagnoses. It is also important to do research into specific guidelines on physical activity in mental health and the extension of the data for a larger audience.

Acknowledgements
The authors thank the patients who participated in the study and the psychomotor therapists for their assistance with the data collection.

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