u. · . , . "'i1THERN DtliT:.:.r. :.:.-JLUMBIA UBtiARY Prince George, B.C. ADHERENCE TO PHYSICAL ACTIVITY FOR ADULTS WITH DEPRESSION: THE ROLE OF THE NURSE PRACTITIONERAN INTEGRATIVE LITERATURE REVIEW by Mary M. Hogan B.S.N York University, 2007 B.Sc. University of Guelph, 2005 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING FAMILY NURSE PRACTITIONER STREAM UNIVERSITY OF NORTHERN BRITISH COLUMBIA April2014 ©Mary M. Hogan, 2014 11 ABSTRACT Depression is a significant problem for Canadians, as is the declining overall health of adults due to sedentary lifestyles. The purpose of this integrative literature review is to examine how nurse practitioners, providing primary health care in Canada, can facilitate adherence to physical activity for adults with mild to moderate depression. Background knowledge of depression, physical activity and adherence is presented along with an overview of primary health care. A Medline search collected 15 research articles for analysis. Key findings included reduced adherence to exercise for adults with depression, positive effects on mood from moderate intensity exercise, health promotion challenges within primary care, and interdisciplinary approaches to improving adherence. Recommendations are presented using the SA's approach and include the application of psychological theories, assessment of readiness for exercise, individualized exercise prescription targeting public health guidelines, enlisting social supports, frequent follow-up, along with additional education to practitioners. Keywords: adherence, behaviour change, compliance, depression, exercise, family practice, health promotion, nurse practitioner, physical activity, primary care, primary health care 1ll TABLE OF CONTENTS Abstract.... ...... .. ..... .............. .......... ... . ........................ ...... ....... .. .. .......... n List of Tables ............... ...... ............ .......................... .......... ............. .. ..... . v Acknowledgements... ... ................... ....... ... ....... ..... . .................................. vt Chapter 1 Introduction ......................... .......... . ...... .................. .. .......... 1 Chapter 2 Methods .... ....... ......................................... .................... .. ............ ... ... .... .... .. 20 Chapter 3 Findings........ .... ...... ......... ............... .. ................. ......... . ...... 25 Chapter 4 Discussion ... ......... ....... ..... ................. ..... .. ... ..................... .. . 48 Background .......................................................................... 3 Depressive Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Pathophysiology............................................. .... ........... 5 Management of depression. .... .. ............ ........ ... .............. ... . 7 Exercise and Depression ................................................ .. ... . 7 Physical Activity......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Physical activity: the concept............................................. 10 Physical activity guidelines.............................................. 11 Assessing readiness for exercise. . . .. . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . 12 Adherence............. .. .... ... ..... ........................................... 14 Adherence: The concept.................................................. 15 Primary Health Care and the Nurse Practitioner..................... . . . . . . 16 Stage 1: Conceptualisation and Search Strategy ... .. ...... ............... . Stage II: Preliminary Search ........ ........... .................... .. ....... . Stage III: Focused Search ................................................ ... . Stage IV: Analysis and Reporting .. ... ..... .... .... ... .................... . 20 22 23 23 Links between Depression, Exercise, and Mood...... ........ .......... .. 25 Key Psychosocial Elements for Physical Activity Adherence. .. .. ..... 29 Provider Perceptions and Practices...... ..... .... .... ........ ............... 33 Targeted Physical Activity Promotion Strategies ...... ........ . ........... 36 Physical Activity Counselling Approaches... ....... ..................... .. 40 Promoting Physical Activity for those with Mild to Moderate Depression: An Important Clinical Issue.................. .. ........... 48 Facilitating Adherence to Physical Activity: Practical Approaches .... 50 Counselling techniques.............. .... .... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Exercise prescription ..... ....... .... ........ . .. ........... .. ....... . ...... 53 Th e social factor ..... .... .. .......... ...................................... 56 Practice Considerations for Primary Care ................................... 57 Recommendations............. .. ......... ...... ............. .. ... ................ .. 59 Recommendations for Practice ...... ...... ............ .. .. ............ ....... 59 Recommendations for Education......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61 IV Recommendations for Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63 Conclusion. ........ ..... . .... ...... .... ... .... ......... .... .. .. ............. .. .... .. 64 Glossary. .... . ... .............. . ..... .......... ... ..... ....... .. ...... ............. .. .. ........... .... .. 66 References............ . .... ..... ................ ....... ....... .... ........ ....... ...................... 73 Appendix I Counselling Models . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84 Appendix II Linking Motivation, Self-Efficacy and Intention ... ... .. .......... ..... . .... .. 85 Strategies for Practice to Facilitate Exercise Adherence Appendix III The Transtheoretical Model. .. ... ........ ... ................ . .. ..... ... .... .. ... .. 86 Appendix IV Assessing Readiness for Exercise and Exercise Planning.. .... ..... . ......... 87 Appendix V The SA ' s Approach: How nurse practitioners in Canada can facilitate adherence to physical activity for adults with mild to moderate depression through primary health care ... ... . ...................... ... .......... ... ... ....... 89 v LIST OF TABLES Table 1 Eligibility criteria for literature review inclusion in the findings.............. . .... 21 Table 2 Search terms for the literature review ........ . ......... ... ........... ..... .. ............ 22 Table 3 How nurse practitioners in Canada can facilitate adherence to physical activity for adults with mild to moderate depression through primary health care: the 5A 's approach ......................... .. ..... ..... ... ... ................... ............. 59 Vl Acknowledgements The author thanks Davina Banner-Lukaris and Linda Van Pelt for their contributions to this project. Special thanks also to the UNBC family nurse practitioner student class and support staff, as well the wisdom of clinical preceptors. Thanks for the support from colleagues in Interior Health and the City of Kamloops. The author would like to extend gratitude for the love and support from personal friends and family through this process. 1 CHAPTER 1 Introduction A significant number of Canadians are afflicted with mood disorders. About 11 percent of men and 16 percent of women in Canada will experience major depression in the course of their lives (Health Canada, 2009). Depression can limit quality oflife, affect relationships, lead to lost time from work or school, contribute to other chronic diseases, and too often leads to suicide. The World Health Organization (WHO) has ranked depression fourth among the ten leading causes of the global burden of disease, and predicted that it will jump to second place by the year 2020 (WHO, 2001). Mental illness contributes to a significant economic burden in Canada, totalling 51 billion dollars in 2003 (Lim, Jacobs, Ohinmaa, Schopflocher & Dew a, 2008). This total incorporates the use of medical resources and productivity losses due to long-term and short-term disability, as well as reductions in health-related quality of life. In addition to the problems that are inherent with the experience of depression itself, depressed adults also don't get enough exercise. An American survey from 2006 found that depressed adults were less physically active than non-depressed adults (Song, Lee, Baek & Miller, 2011). A lack of physical activity is contributing to poorer physical and mental health outcomes for adults with depression, and the health of the population at large is compromised by sedentary lifestyles. Physical inactivity has been identified by the WHO as the fourth leading risk factor for global mortality (WHO, 201 0). The majority of Canadians today spend most of their waking hours in sedentary pursuits. Only about 15 percent of Canadian adults meet the current physical activity guidelines, with a larger proportion of men (17%) meeting the guidelines than women (14%) (Statistics Canada, 2011). Sedentary behaviour is 2 increasing in many countries with major implications for the prevalence of noncommunicable diseases and the general health of the population worldwide. A problem contributing to sedentary behaviour is non-adherence to health recommendations for physical activity. Research has shown that across a variety of settings almost half of medical patients in the United States do not adhere to physician recommendations for prevention or treatment of acute or chronic conditions, including not taking medication correctly, forgetting or refusing to follow a diet, not engaging in prescribed exercise, not attending appointments, and persisting in lifestyles that endanger their health (DiMatteo, Lepper & Croghan, 2000). Patients with depression are at greater risk of non-adherence. Compared with non-depressed patients, the odds are three times greater that depressed patients will be non-adherent with treatment recommendations (DiMatteo, et al. , 2000). The problem then, as shown by the research, is that not only are depressed adults less active, they are less adherent to recommendations to be active. Since depression is linked to decreased adherence to physical activity, this poses a significant problem for the patient with depression, as well as for the health care provider. Depressed adults therefore require extra attention for exercise promotion in effort to maximize potential health benefits. The goal of this project is to answer the question, ' How can the nurse practitioner facilitate adherence to physical activity for adults with mild to moderate depression in the context of primary health care within Canada? ' This study focuses on adults aged 20-65 diagnosed with mild to moderate depression, as this was the most common age range in selected adult studies. This project does not target severe depression because the goal is stabilization of a condition and the research supports exercise as a treatment modality for mild to moderate depression but management for severe 3 depression is more complex and requires a different approach. To answer the research question, an integrative review of the research literature was undertaken. Prior to answering the research question, a discussion of the relevant background literature will be provided to identify the significance of physical inactivity in this population, leading to a linkage of the research concepts. This background will outline the significance of depression, the purpose of physical activity, the role of adherence, and the potential for impact within primary health care (PHC). The background is followed by project methods, fmdings from literature analysis, discussion of fmdings, and recommendations for clinical practice and education. The outcome of this integrative literature review is a set of recommendations that could be incorporated into clinical practice to improve adherence to physical activity, which may ultimately improve both life expectancy and quality of life for adults with depression. These recommendations will be useful to both the nurse practitioner (NP) and other health professionals within the context of primary health care. Background Physical inactivity is a major public health issue and contributes significantly to rising chronic disease (Warburton, Nicol & Bredin, 2006). This is particularly pertinent in those with mental health conditions. Depression results in less engagement in physical activity, and in turn, poorer outcomes in mental health as well as overall wellbeing. An American study found that 12 percent of depression-related health care claims were attributable to physical inactivity (Garrett, Brasure, Schmitz, Schultz, & Huber, 2004). The following sections of this chapter will identify the significance of depression, the pathophysiological linkages between exercise and depression, the importance of exercise, the concept of adherence, primary health care and the nurse practitioner. 4 Depressive Disorders Depression is a persistent state of low mood. Depressive disorders are categorized in the DSM-IV (APA, 2000) under "Mood Disorders", and include Major Depressive Disorder (MDD), Dysthymic Disorder, or Depressive Disorder Not Otherwise Specified. The American Psychiatric Association (APA) has recently published the DSM-V (APA, 2013), with updates included to depressive disorders, however currently available research would have applied the DSM-IV (AP A, 2000) criteria. The criteria of major depressive disorder and its various severities have not been altered in the DSM-V to a significance that would affect the application of recommendations from this project. Major Depressive Disorder is characterized by one or more Major Depressive episodes. A Major Depressive Episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities, accompanied by at least four additional symptoms from a list that includes changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of suicidal ideation, plans or attempts (AP A, 2000). Depression is further categorized as mild, moderate or severe. Severity is based on the number of criteria symptoms, the severity of symptoms, and the degree of functional disability and distress. Mild episodes are characterized by the presence of only five or six depressive symptoms and either mild disability or the capacity to function normally but with substantial and unusual effort. Severe episodes include most of the criteria symptoms along with clear and observable disability. Moderate episodes have a severity that is intermediate between mild and severe (AP A, 2000). This project will focus on mild to moderate depression. 5 Many factors contribute to the development of major depression. An individual may be genetically predisposed to depression, and his or her risk can be increased by several external factors, such as the death or illness of a loved one, difficulty at work or with a personal relationship, low self-esteem financial difficulties, or addictions (Health Canada, 2009). Depression affects thoughts and feelings and may manifest with physical symptoms as well. Depression is associated without causal link to multiple comorbidities, including brain disorders related to neurodegeneration such as Alzheimer's, Parkinson's, Huntington's disease, multiple sclerosis and stroke; medical disorders such as cardiovascular disorders, chronic fatigue syndrome, chronic obstructive pulmonary disease, rheumatoid arthritis, psoriasis, systemic lupus erythematosus, inflammatory bowel disease, irritable bowel syndrome, leaky gut, diabetes type 1 and 2, obesity and metabolic syndrome, and HN infection; and conditions, such as haemodialysis, interferon-a-based immunotherapy, the postnatal period and psychosocial stressors (Maes, Kubera, Obuchowiczwa, Goehler & Brzeszcz, 2011). Pathophysiology. The pathophysiology behind depressive disorders is not well understood but follows a number of theories with varying support from existing evidence (Hasler, 2010). Deficiency ofmonoamines, especially serotonin, norepinephrine and dopamine, has been a rational hypothesis for MDD since almost every drug that inhibits monoamine reuptake has antidepressant properties, but monoamine deficiency is likely a secondary downstream effect of other more primary abnormalities. Solid evidence from twin studies suggest that 30 to 40 percent ofMDD risk is genetic, but no specific depression risk gene or gene-environment interaction has been reliably identified. Non-genetic factors explaining the remaining incidences ofMDD are individual-specific environmental effects, 6 such as adverse events or ongoing stress, including childhood sexual abuse, other lifetime trauma, low social support, marital problems and divorce. The HP A (hypothalamic-pituitaryadrenal) axis is responsible for releasing the stress hormone cortisol into the bloodstream. Altered HP A axis activity is a plausible explanation for early and recent stress as risk factor for MDD, but there have been no consistent antidepressant effects of drugs targeting the HP A axis. (Hasler, 201 0). Hasler (20 10) reviewed the evidence for a number of other potential explanations for the aetiologies of depression. Dysfunction of brain regions has been suggested since stimulation of specific regions can produce antidepressant effects, but conclusive results from neuroimaging are limited in the literature for explaining MDD. Neurotoxic and neurotrophic processes are plausible explanations of brain volume loss during the course of depressive illness, though there has been no evidence from humans for specific neurobiological mechanisms. The theory of reduced GABAergic activity has been shown from converging evidence in magnetic resonance spectroscopy and post-mortem studies, but here again there have been no consistent antidepressant effect of drugs targeting the GABA (gammaaminobutyric acid) system. Dysregulation of the glutamate system has been suggested as a process in MDD since drugs targeting the glutamate system have potentially rapid and robust effects on depression, though with questionable specificity, since glutamate is involved in almost every brain activity. Manipulation of circadian rhythms such as sleep deprivation can have antidepressant efficacy, but there is no molecular understanding of the link between circadian rhythm disturbances and depression. From this review it is evident that depression is a complex disorder with a number of potential contributing factors to the pathophysiology. 7 Management of depression. Depressive disorders are generally diagnosed by a primary care practitioner or a psychiatrist. A family or adult NP diagnoses and manages depression independently, and like other care providers, consults or refers as appropriate (CRNBC, 2011 b). Treatment of depression is variable depending on the individual and resources available. Common treatment includes psychological counselling combined with anti-depressant medication. Anti-depressant drugs, as mentioned, primarily focus on inhibiting monoamine reuptake. Exercise is effective in preventing and treating depression by the way that it changes endorphin and monoamine levels and reduces cortisol (Rimer et al. , 2012). Support from family and peers and self-help groups can also be paramount in coping with and recovering from depression. Exercise and social contact play a role in improving self-esteem, which is a predictor of perceived well-being (Rimer et al., 2012). Through this intervention involving social supports, there is an opportunity to improve physical activity as well and in turn improve the outcomes from depression. Within its jurisdiction, the Government of Canada works to support research and its dissemination, strengthen the capacity of the primary health care, home care and acute care sectors to effectively deliver mental health programs and services, raise awareness through social marketing campaigns, conduct surveillance on mental health trends in the population (Health Canada, 2009). An important and under-emphasized management tactic for depression is physical activity, which is behind the purpose of this project. Exercise and Depression Physical activity has the potential to reduce the negative impact of depression on individuals and society as a whole. Physical activity has a long history of association with lower incidence of depression and depressed mood (Dunn, Trivedi & O'Neal, 2001; 8 Martinsen, 2008; Rimer et al., 2012). There is growing evidence that physically active people are at a reduced risk of developing depression, and that exercise interventions are associated with significant benefits for patients with mild to moderate forms of depression as well as in reducing anxiety (Martinsen, 2008). Exercise is indicated for the management of depression, according to an array of research. Exercise seems to improve depressive symptoms in people with a diagnosis of depression when compared to no treatment or control intervention, especially within the mild to moderate range (Rimer et al. , 2012; Josefsson, Lindwall & Archer, 2013; Silveria et al. , 2013). A need for more conclusive research has been identified in the study of how exercise affects depression, particularly over the long term (Krogh, Nordentoft, Sterne & Lawlor, 2011). Exercise has antidepressant effects at a number of levels. Biochemically, exercise beneficially modifies the HP A axis and reduces circulating cortisol; it amplifies circulating endorphins, the endogenous opioid transmitters, it increases the endogenous cannabinoid neurotransmitter anandamide, it increases monoamines by increasing the expression of 5Hydroxytryptophan (5-HTP) which is decarboxylated to serotonin (5-HT); and exercise increases circulating levels of testosterone, which may have a protective effect against depression (Rimer et al. , 2012; Sarris, 2011). Physiologically, exercise increases cerebral blood flow and stimulates the growth of new nerve cells (Rimer et al., 2012; Sarris, 2011). From a psychological perspective, exercise may act as a diversion from negative thoughts, as well as an avenue for social contact, and it increases self-efficacy, which increases selfesteem and is linked to subjective well-being (Rimer et al. , 2012). A great number of physical activities provide social exposure, which contribute to reducing depression through the effect of exercise itself combined with socialization. A bonus from exercise is the 9 potential for time spent outdoors, especially since research has shown that time spent outdoors has been associated with greater vitality, that is, better physical and mental energy (Ryan et al., 201 0). A healthy level of physical activity has been linked to preventing numerous chronic conditions, as well as being paramount in weight control. Perhaps most significant for predicting morbidity and mortality, there has been confirmation through meta-analysis of a reciprocal link between depression and obesity. Obesity was found to increase the risk of depression, and depression was found to be predictive of developing obesity (Luppino et al., 201 0). Major depressive disorder is associated with an elevated risk of numerous metabolic disturbances, including obesity, metabolic syndrome, insulin-dependent diabetes mellitus type II, and death after myocardial infarction (Lutter & Elmquist, 2009). The frequency of co-occurrence of depression and obesity suggests interconnected pathophysiology. Biological mechanisms that are most likely involved include abnormalities in metabolic networks broadly defmed as glucose-insulin homeostasis, inflammatory processes, glucocorticoid signaling, oxidative stress, autonomic dysregulation, and energy biosynthesis (Mcintyre et al., 2009). Unequivocal evidence indicates that obesity and mood disorders are chronic low-grade pro-inflammatory states that result in a gradual accumulation of allostatic load (Soczynska et al., 2011). Disturbances of mood may alter peripheral signaling pathways that regulate metabolic processes, including those involving leptin and ghrelin (Lutter & Elmquist, 2009). The interaction between depressive disorders and obesity further emphasizes the importance of physical activity for depression (McElroy et al., 2004). Whether obesity contributes to depression or vice versa, decreasing one may decrease the other, and physical activity can play a role in improving both. The use of exercise for the management of obesity is a broad topic in research but 10 beyond the scope of this project. Exercise, in combination with adjunct treatments such as cognitive behavioural therapy and pharmacotherapy, may be an appropriate treatment approach for patients with depression (Craft & Perna, 2004; Daley, 2008). The following section will further highlight the importance of exercise to overall health. Physical Activity Regular physical activity is critical to physical and emotional wellbeing. Physical activity has been shown to have substantial health benefits in the realms of prevention and management of chronic disease. In a review by Warburton et al. (2006), it was confirmed that there is irrefutable evidence of the effectiveness of regular physical activity in the primary and secondary prevention of chronic disease, including cardiovascular disease, diabetes, cancer, hypertension, obesity, depression and osteoporosis, as well as premature death. The most physically active people have the lowest incidences of these chronic diseases, and the greatest improvements in health status are seen when sedentary people become physically active (Warburton et al., 2006). This review also revealed that the Health Canada physical activity guidelines are sufficient to elicit health benefits, especially in previously sedentary people. Benefits from physical activity have also been found for arthritis, erectile dysfunction, chronic fatigue syndrome, lower-back pain, and chronic obstructive pulmonary disease (Penedo & Dahn, 2005). Beyond impacting morbidity and mortality, exercise positively affects a variety of health outcomes. Studies have shown physical activity to be associated with improved quality of life, better functional capacity, and better mood (Peluso & Guerra de Andrade, 2005; Penedo & Dahn, 2005). Physical activity: the concept. The terms "physical activity" and "exercise" are often used synonymously or interchangeably in the literature, though they differ slightly. "Physical 11 activity," "exercise," and "physical fitness" are terms that describe different concepts, as clarified in a concept analysis by Caspersen, Powell and Christenson (1985). Physical activity is defmed as any bodily movement produced by skeletal muscles that results in energy expenditure, and can be categorized in daily life into occupational, sports, conditioning, household, or other activities. Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness . Physical fitness is a set of attributes that are either health- or skill-related, and the degree to which people have these attributes can be measured with specific fitness tests. For the purpose of this project, these defmitions of exercise, physical activity and fitness will be applied. Either the term ' exercise ' or 'physical activity' will be utilized as appropriate, considering that exercise is a specific and structured subset of physical activity. The primary focus of the recommendations in this paper will be in relation to structured exercise, though it should be noted that some of the referenced guidelines employ the term 'physical activity' to describe exercise guidelines. Physical activity guidelines. Since the publication of the review by Warburton et al. (2006), the Public Health Agency of Canada (PHAC) has ceased distribution of physical activity guidelines and instead supported the Canadian Society for Exercise Physiology (CSEP) in reviewing the scientific evidence on physical activity and developing new physical activity guidelines. CSEP has developed Canadian Physical Activity Guidelines and Canadian Sedentary Behaviour Guidelines (CSEP, 2013). To achieve health benefits, CSEP (2013) recommends adults aged 20-65 years should accumulate at least 150 minutes of moderate to vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more; it is also beneficial to add muscle and bone strengthening activities using major muscle 12 groups, at least 2 days per week. More daily physical activity provides greater health benefits. Meeting the minimum requirements set by public health guidelines is especially important for improving mood and potentially affecting the course of depression itself (Dunn et al., 2005). Many public health sources recommend daily step goals of 10,000 steps for adults, equivalent to about 8 kilometers, burning 300 to 400 calories, which may be achieved with an active lifestyle that includes a 30-minute walk each day (Choi, 2007). The 10,000 steps guideline fits with the CSEP physical activity guidelines, and performance measures at the patient level can be collected with the use of pedometers. For many Canadians, there is a daily deficit of approximately 4000 steps (Choi, 2007). The 10,000 steps prescription fits well with the fact that physical activity is broader than structured exercise sessions, and should persist to some degree throughout each day. Exercise guidelines are of value, especially since exercise is not without inherent risk. Exercise may be harmful if performed in an inappropriate or very intense manner, as in conditions such as "excessive exercise" or "overtraining syndrome" (Peluso & Guerra de Andrade, 2005). Guidelines therefore provide support for individuals and health care professionals in assessing physical activity needs. Beyond providing guidelines, however, is the more daunting challenge of adherence to those guidelines. The concept and realities of adherence will be discussed in the following section, to contextualize the issue as a major factor of physical activity uptake. Assessing readiness for exercise. Adults who wish to engage in physical activity may approach their primary care providers either because they are looking for guidance or because they have been referred by a fitness professional for medical clearance. Considering 13 the potential risk of physical activity, it is imperative to guide patients through safe progressions in building up to the minimum target outlined by physical activity guidelines. Canadian adults who enroll in community fitness programs are screened by fitness professionals using the Physical Activity Readiness Questionnaire (PAR-Q) (CSEP, 2002), which is used to assess medical risk associated with exercise in the context of potential underlying cardiovascular disease. Fitness leaders may also follow the P AR-Q+, which is more appropriate for sedentary older adults or those with chronic conditions (CSEP, 2012). From participant responses, community members may be flagged and restricted from community exercise programs and referred to primary care providers for further assessment and recommendations for physical activity. Through health assessment and physical examination, the primary health care practitioner can determine capacity and contraindications to exercise for individual patients. Precise assessment of cardiorespiratory fitness is obtained by ventilatory gas analysis at maximal exertion (V02max), but this level of precision is not warranted in general practice. Absence of feasible assessment methods and consensus guidelines for interpreting healthrelated fitness levels may contribute to a lack of fitness evaluation in most primary care settings (Jurca et al., 2005). The prediction of fitness from non-exercise models seems most appropriate for widespread use in many healthcare settings (Jurca et al., 2005). A full discussion on the methods of non-exercise fitness assessment is beyond the scope of this paper, however, research has found that fitness may be assessed from a non-exercise model, including age, gender, body mass index, resting heart rate, and self-reported physical activity (Jurca et al. 2005). Algorithms have been developed which may be practical and costeffective for non-exercise fitness assessment in primary care (Jackson et al., 2012; 14 Stamatakis, Hamer, O'Donovan, Batty & Kivimaki, 2012). Assessments of body weight, blood pressure, cholesterol levels, and smoking habits are relatively easy to obtain, and are routinely obtained and used in patient counseling (Jurca et al. , 2005). Fitness assessment is equally important and primary health care providers should have consistent methods for including assessments of readiness to exercise in routine screening. In primary care, it is more appropriate to assess readiness for exercise in patients who wish to begin exercise programs, and provide medical clearance for exercise as tolerated. An example of an algorithm for a non-exercise test of cardiorespiratory fitness can be found in Appendix IV. Adherence Adherence to a healthy lifestyle is a persistent challenge for all kinds of people. The challenge of adherence is particularly significant for patients with depression. Depression has been linked to poor adherence to healthy lifestyle behaviours including physical activity repeatedly in the literature (Arikawa, O' Dougherty, Kaufinan, Schmitz & Kurzer, 2011 ; Bigger & Glassman, 2010; Corrigan et al. , 2012; Coumeya et al., 2008; DiMatteo et al. , 2000; Durrani, Irvine & Nolan, 2012; Glazer, Emery, Frid & Banyasz 2002; Martin, Williams, Haskard & DiMatteo, 2005; McGrady, McGinnis, Badenhop, Bentle & Rajput, 2009; Moreau et al. , 2009; Ockene, Hayman, Pasternak, Schron & Dunbar-Jacob, 2002; Rogerson, Murphy, Bird & Morris, 2012, Ziegelstein et al., 2000). The link between depression and poor adherence may suggest a negative feedback loop (DiMatteo et al. , 2000), and leads to the question- does depression cause nonadherence or does nonadherence cause depression? Bidirectional causal pathways are likely to link poor adherence to health behaviours with depressed mood (Allgower, Wardle & Steptoe, 2001). There may be hope for improving adherence to physical activity for patients with depression, though it is a 15 challenge. The manifestations of depression itself are obstacles to adherence, considering depressive symptoms may include low mood, lack of interest, apathy, physical pain or discomfort, psychomotor delay, low energy, despair, difficulty thinking or concentrating, trouble with making decisions, change in sleep, and potentially suicidal thoughts (GarciaTore et al. , 2012). Adherence: Th e concept. Within health-related literature, adherence is often found to be synonymous with compliance. Synonyms to comply include obey and conform, which implies following a paternalistic path with lack of empowerment or freedom of choice. Synonyms to adhere include remain, hold, stick, and stay, which may be more appropriate for the concept of following a self-directed path. In pharmacology literature, the term adherence has been recognized as more appropriate than compliance to reflect the partnership between the health care provider and the patient (Tilson, 2004). A concept analysis of adherence by Bissonnette (2008) found through review of literature from pharmacy, mental health, medicine and nursing that there was no distinct differentiation between adherence and compliance. From the concept anal ysis, the accepted definition for adherence was "the extent to which patients follow the instructions they are given for prescribed treatments" . Of note, no defmition was found that reflected a patient-centred approach, the dynamic nature of adherence behaviour and the power imbalance applied by terms such as adherence or compliance. The term concordance is becoming more prevalent in literature, and perhaps is theoretically different than adherence in that it is an attempt to equalize the power balance between healthcare professionals and patients, while at the same time placing patients ' expectations about treatment recommendations as equal to or even more important than 16 healthcare professional ' s expectations (Bissonnette, 2008). Concordance more accurately describes interactions in which the expertise of patients and health care professionals can be pooled to arrive at mutually agreed upon goals (Bissell, May & Noyce; 2004). The term "adherence" has been selected for this project, since it is currently the most widely used and appropriate term in the literature. Understanding ways in which to improve adherence to physical activity in those with depression will enable the NP, and health care providers, to improve the health outcomes of this high risk population. Primary Health Care and the Nurse Practitioner Primary care (PC) and primary health care (PHC) are terms that are often employed interchangeably, but they denote overlapping concepts. Comparing and contrasting these concepts is beyond the scope of this project, though understanding the terms is fundamental to understanding the role of the practitioner, particularly in relation to the provision of health promotion to patients. Primary care has traditionally been considered a patient's chief source for regular medical care, ideally providing continuity and integration of health care services. Primary care is the first point of access for requesting non-emergent medical attention, and this care focuses on assessment, diagnosis and treatment. Primary care is typically accessed via the patient' s regular provider or a walk-in clinic, usually by a family physician or NP. While the primary care system is the prevalent model of care in Canada, there are efforts to encourage a shift in focus from primary care to primary health care (Chauvette, 2003). PHC constitutes a broader perspective of care that includes PC, which derives from core principles articulated by the World Health Organization (WHO) and describes an approach to health policy and service provision that includes both services delivered to individuals and population-level public health-type functions (Muldoon, Hogg & Levitt, 17 2006). The ultimate goal ofPHC is better health for all (WHO, 2008). The WHO has identified five key elements to achieving that goal: reducing exclusion and social disparities in health (universal coverage reforms); organizing health services around people's needs and expectations (service delivery reforms); integrating health into all sectors (public policy reforms); pursuing collaborative models of policy dialogue (leadership reforms); and increasing stakeholder participation. A progressive and practical Canadian definition of PHC in the functioning clinical setting is as follows: "Primary Health Care is defined as a set of universally accessible firstlevel services that promote health, prevent disease, and provide diagnostic, curative, rehabilitative, supportive and palliative services" (Chauvette, 2003). This definition includes the traditional role of primary care in which the main functions were diagnostic and curative, as well as the expanded role of health care, which includes prevention and wellness in the forms of screening, health promotion, support, rehabilitation, and palliative care. The Canadian Nurses Association (CNA) distinguishes between the current reality of PC and PHC. The CNA states that primary care is the delivery of community-based clinical services focused on diagnosis, treatment and management of health conditions as well as health promotion and disease prevention (CNA, 2012b). Primary health care, by contrast, is a principle-based and comprehensive approach that aims to strengthen health systems and improve population health; it is promotive, preventive, curative, restorative, rehabilitative and palliative (CNA, 2012b). These descriptions of PC and PHC will be employed as the practical definitions for the purpose of this project. Since depressive disorders are commonly managed through PHC with a mandate for individualized health promotion, PHC was chosen as the clinical practice approach for health promotion within this project. 18 Primary health care is delivered by health care professionals across Canada in various locations and practice settings. NPs are key participants in the PHC approach in their delivery of services in any setting. NPs practice with a holistic nursing perspective, integrated with the autonomous diagnosis and treatment of acute and chronic illnesses, including prescribing medications (CRNBC, 2012). NPs are health professionals who have achieved advanced nursing practice competencies at the graduate level of nursing education, to provide health care services from a holistic nursing perspective, integrated with the autonomous diagnosis and treatment of acute and chronic illnesses, including prescribing medications, within their legislated scope of practice (CRNBC, 2011 b; adapted from CNA, 201 0). Across Canada, NP scope of practice varies between provinces, as do educational and examination requirements (CNA, 2009). The NP can manifest the PHC approach at the clinical level, since NPs work with individuals and communities across the continuum of care based on principles of PHC (CNA, 2009). Health promotion is a key component ofPHC in the goal of better health for all, and promotion of physical activity is a significant role ofNPs. NPs supporting chronic disease self-management have contributed to consistently reducing smoking and alcohol use, shorter hospital stays, decreased hospital admissions and more appropriate office visits, as well as favourable affecting health and functional status and mortality rates (CNA, 2012a). Given this success, NPs are well prepared to support physical activity in patients with depressive illness. The NP can do this by assessing readiness for exercise, promoting exercise, and collaborating with the individual on an exercise plan. This PHC approach can be used in either a PC or PHC setting, and PC providers can start to add PHC approaches to their practice by promoting activities including exercise and exercise adherence. 19 The recommendations in this paper are primarily intended for use by NPs in practicing in Canada in non-acute care settings, though these recommendations may be relevant to other providers such as nurses, clinical nurse specialists, physicians, physiotherapists, occupational therapists and other health care professionals, and alternative care providers in Canada or other nations. NPs frequently collaborate with other health care providers in practice. NPs are accustomed to inter-professional delivery of care, wherein they practice autonomously but frequently collaborate with other care providers for coordination of optimal patient care. NPs possess collaborative skills that develop throughout their undergraduate nursing education and practice, and within their graduate education. Collaboration is foundational to NP philosophy, education and practice. A primary care NP is often at the centre of a network of care providers coordinating overall care, and thus wellpositioned for health promotion at the individual level. 20 CHAPTER2 Methods To address the research question behind this project, an integrative literature review approach was undertaken. The integrative literature review method allows for literature from varied sources and using varied methodologies to be examined in order to present the current state of science for direct application of evidence to practice and policy (Whittemore, 2005). This literature review was undertaken in four stages: conceptualisation and identification of a search strategy, preliminary search, focused search, analysis and reporting. Stage I: Conceptualisation and Search Strategy The conceptualisation phase of this review formed the foundations of the search strategy. The topic was born out of an identified need for increasing physical activity in Canadians, in particular for patients with depressive disorders. The area of focus for meeting this need is the role of the NP. Adults with depression were chosen as the target population, since depression is a widespread problem in Canada and correlates with poor adherence to healthy lifestyles. The following research question was formed: How can the nurse practitioner facilitate adherence to physical activity for adults with mild to moderate depression? This question was considered within a primary health care approach, particularly in the primary care setting within Canada. During the preliminary stages of the review, a number of eligibility criteria were identified to ensure that the most relevant and up-to-date literature was selected. The eligibility criteria are listed in Table 1. Literature pertaining to adults aged 18 and older was included in this study. All types of depression were included for review in searches, with preference given to articles pertaining to mild to moderate depression. 21 Table 1 Eligibility criteria for literature review inclusion in the findings Inclusion Criteria Exclusion Criteria 1. English language literature, published between January 1999 and October 2013 2. Adults aged 18+ 3. Articles addressing depression, depressed mood 4. Articles addressing related chronic conditions such as anxiety, obesity, cardiovascular conditions/rehabilitation, hypertension, diabetes 5. Articles addressing health promotion, behaviour change, adherence to physical activity, counselling, cognitive behavioural therapy, motivational interviewing 6. Exercise/physical activity, including promotion and prescription 7. Primary care, primary health care, nurse practitioners, physicians 1. Literature focusing exclusively on <18 or >65 years of age 2. Articles addressing other complex conditions such as palliative care, chronic pain, musculoskeletal conditions, HIVI AIDS, cancer, pulmonary conditions, psychosis, mania, schizophrenia, dementia, developmental disabilities, substance misuse 3. Articles addressing musculoskeletal rehabilitation, rehabilitation from substance use, adherence to pharmaceuticals/diet/smoking cessation Since depression is associated with a great number of chronic conditions, many articles focused on specific disease populations with depression identified as a comorbidity. Relevant papers concerned with obesity and cardiac rehabilitation were included because there is a breadth of research for those two topics focusing on adherence to exercise and many articles included the added dynamic of depression with relevant findings . Research focusing on those with severe psychiatric disorders or life-limiting comorbidities and complex conditions were excluded in order to narrow the focus to depression. Since the goal of this project is application to practice in Canada, studies were reviewed considering their applicability to Canadian practice. Studies from other nations were excluded if their fmdings pertained to systems that were not relevant within the context of the current Canadian setting and health care delivery system. 22 Stage II: Preliminary Search The literature review began with a preliminary scoping search of relevant literature using the Google Scholar database. This initial search employed the terms exercise, depression , and adherence, yielding 126,000 results. The first 100 titles were reviewed to scan for relevant articles and to develop a set of comprehensive and relevant search terms to be used in the main literature search. Following this initial scoping search, a comprehensive search of the peer-reviewed literature was undertaken using PubMed, Medline, CINHAL, PsyciNFO, PsycARTICLES and Cochrane databases. Based on preliminary scoping activity, important search terms, such as physical activity, compliance, and concordance, were identified. In addition, to assess relevance to the NP in primary health care, MeSH headings for searches also included primary care, primary health care, physician, and nurse practitioner. Literature was collected by searching various combinations of the search terms in Table 2. Table 2 Search terms for the literature review Population depression, adults poor adherence OR compliance OR concordance Problem Intervention primary health care, primary care, nurse practitioner, physician, stages of change, counselling, motivational interviewing, prescription adherence to exercise OR physical activity Outcome Following an initial database search, titles and abstracts were screened, articles were assessed as to their relevance, and duplicates removed. The initial database search of Medline employed the terms (exercise OR physical activity) AND (depression) AND (adherence OR compliance), yielding 460 results. All titles were screened and 82 abstracts reviewed. The searches did not filter publication dates as to allow for review of older seminal articles, but the best available evidence from 1999 to 2013 was selected for inclusion to fmd the most current existing literature to address the purpose of this project. Literature was selected based 23 on its relevance to the topic, scientific rigor, and applicability to clinical practice. To ensure a comprehensive search, hand-searching of existing reference lists was undertaken, although no new studies were identified for inclusion. Eligible articles for review included metaanalyses, systematic reviews, randomized control trials, experimental designs, cohort studies, survey studies, and qualitative studies. A number of papers were captured during the data search that did not warrant review in the fmdings , yet provided useful background information. These were used to provide greater clarity to the context of depression, physical activity, adherence, and NP practice in PHC. Stage III: Focused Search Following the initial search and sorting of the literature, 62 articles were shortlisted for inclusion. These were retrieved and reviewed in detail to assess the quality of the evidence and relevance to the review topic. The critical appraisal tools in a textbook by LoBion1o-Wood and Haber (2005) was utilized to guide the critical appraisal process. A final cohort of 15 primary studies were selected for inclusion in the review of fmdings. Additional articles provided support for themes and concepts within the review of findings, including one review article and one meta-analysis. Stage IV: Analysis and Reporting The selected literature was reviewed in detail. As part of this process, themes were identified and a synthesis of findings was undertaken. These themes and connections that emerged from the literature review served to guide how the evidence was presented. Following a review of the literature, five main themes were identified during analysis of the fmdings : • • links between depression, exercise, and mood key psychosocial elements for physical activity adherence 24 • • • provider perceptions and practices targeted physical activity promotion strategies physical activity counselling approaches These themes are relevant to potential strategies, and generally pertain either to psychology or physical activity promotion within the context ofPHC. Each of these themes contains a focus relevant to the research question. The following section identifies the key findings from the literature review and moves from the consolidated knowledge in the background to what has been found to be applicable to practice. A total of 15 research articles were selected for analysis in the fmdings. These themes were further examined and synthesized to identify a list of recommendations for clinical practice, education and research. 25 CHAPTER3 Findings This integrative literature review seeks to delineate how the NP can facilitate adherence to physical activity for adults with mild to moderate depression through primary health care in Canada. Following a comprehensive search ofthe research literature, 15 key articles were selected and included in this review. Through an analysis of the literature, five major themes were identified, including links between depression, exercise, and mood; key psychosocial elements for physical activity adherence; provider perceptions and practices; targeted physical activity promotion strategies; and physical activity counselling approaches. These themes organize the presentation of findings and guide the discussion. The findings from those selected articles are presented here within the context ofPHC NP practice, and relevance to adults with depression. Links between Depression, Exercise, and Mood The background of this paper included a description of the complex pathophysiology behind depression and the benefits of physical activity, as well as the role of the NP in physical activity promotion, including exercise prescription. Part of facilitating adherence to exercise includes collaborating with the patient on a realistic and therapeutic exercise prescription. Four studies were identified how depression correlated with poorer physical fitness and mood and that exercise prescription is an importance consideration for adults with depression. These will now be presented. The first two studies discuss the correlation between depression and reduced physical fitness. As discussed in the background of this paper, depression is strongly linked to sedentary lifestyles as well as obesity. A barrier to physical activity is lack of physical 26 fitness, which may be a vicious cycle. Lack of fitness will also limit the patient' s capacity for exercise and therefore must be considered when prescribing physical activity. Two articles were found which show evidence that adults with depression generally have a reduced baseline physical fitness. Voderholzer et al. (20 11) compared the fitness of depressive patients to healthy adults in a control trial. 51 hospitalized depressive patients, fulfilling ICD10 criteria for depressive disorder, were selected and compared to 51 healthy controls matched for age, sex and body mass index. Standardized physical fitness assessments were conducted using a bicycle ergometer including a measurement of maximum workload, heart rate, lactate concentration, workload at first lactate elevation, individual anaerobic threshold, and workload at individual anaerobic threshold. They found that there was a marked reduction of physical fitness in depressive patients that could not be explained by differences of body mass index or age. Maximum workload was significantly reduced in depressive patients compared to the controls, as was workload at first lactate elevation and workload at anaerobic threshold (p 10 minutes per session, 10,000 steps per day Safe progression- build up time, start at mild and progress to moderate intensity Provide written copies of advice and resources Choi, 2007; CSEP, 2013; Peluso and Guerra de Andrade, 2005; Oberg, 2007; Petrella & Lattanzio, 2002 Respecting the patient's choice (self-determination theory) SMART goal-setting with short and long-term objectives Tailored exercise prescription in the format of frequency, intensity, type and time (FITT) Chalder, Wiles, Campbell, Hollinghurst, Haase, et al., 2012; Jonas & Phillips, 2009; Jones et al., 2005 Patient counselling including stage of behaviour change and motivational interviewing Follow up often, listen to the patient's concerns, challenges and experiences Share success stories, provide encouragement Congratulate small successes and avoid criticism of setbacks Encourage self-monitoring, use exercise logs or pedometers Refer to community programming if available and Chalder, Wiles, Campbell, Hollinghurst, Haase, et al., 2012; Choi, 2007; Fortier et al.,2011; Petrella et al., 2010; Walsh, et al., 1999 61 • Arrange a Plan affordable Lead by example! Stay active yourself • Review the action plan at every visit and refme • • according to patient progress Use structured planning when including other care providers and social supports in the ongoing plan Use reminder systems, consider electronic communication (telephone, email) Chalder, Wiles, Campbell, Hollinghurst, Haase, et al., 2012; Durrani, et al.,2012 These recommendations take into consideration that NP practice includes a holistic approach to patient care, including developing relationships with patients, identifying patient needs, patient assessment, health promotion, treatment prescriptions, consult and referral, and follow-up. Recommendations for education will be presented. Recommendations for Education NPs and health practitioners in general are also expected to maintain continuing education and stay current with their knowledge and skills by accessing current guidelines and following clinical recommendations in practice. Physical activity promotion is as important as any other aspect of PHC for achieving or maintaining health and wellness. Additional education regarding practical health promotion strategies should be added to entry to practice education as well as continuing education. Considering the valuable role of clinical fitness professionals, such as CSEP Certified Fitness Consultants, should be considered within PHC practice. This project targeted the role of the NP in facilitating adherence to physical activity for adults with mild to moderate depression with a PHC approach in Canada. This project is unique in that it seeks to acknowledge how facilitating adherence to physical activity is distinct for adults with depression from the general population. The project targets NPs as PHC providers with an inherent mandate of patient-centred health promotion. In raising awareness of this issue through education, there is the potential to improve the outcomes of 62 this high risk and vulnerable population. It is the aim of this author to communicate the outcomes of this review in a peer reviewed manuscript and to present the findings at a relevant conference. Recommendations for Research Many of the research papers identified for inclusion in the review were not specific to NP practice or PHC, though the majority of papers carried wide relevance to that practice. A clear definition of exercise or physical activity was often not presented within research studies, nor was there usually a specified definition of adherence. There is a wide array of research demonstrating that adherence to physical activity is a problem for adults with depression, but very few studies assessing how this adherence might be improved. As such, further research is warranted that provides a more systematic examination of this issue and that explores the promotion of physical activity in the PHC context, as opposed to only those in specialist centres or using specialist professional supports. Similarly, expanding the focus of research to include related issues, such as nutrition, may also be of importance. More research is needed regarding valid non-exercise fitness assessment methods for PHC practice. In addition, further research is still needed to confirm the benefits of physical activity on depression and quantify amounts, types and intensities of exercise that should be recommended. However, several of the fmdings and recommendations from this project are applicable to all adults in PHC, not just those with depression, and as such may have much wider application than presented here. Further study is also warranted regarding effective counselling techniques and their long-term impact upon physical activity adherence in adults with depression. Given the burgeoning epidemic of obesity, sedentarism, and chronic 63 conditions, evaluating mechanisms to support adherence to physical activity is of critical importance. Limitations Consolidating data for the purpose of this project was met with some limitations in the literature review process. The first limitation was with respect to the selection of data. Only English studies which were electronically indexed and available via databases were included in the research collection. A clear definition of exercise or physical activity was often not presented within research studies, nor was there usually a specified definition of adherence. Many research papers were not specific to NP practice or PHC, though the majority of papers carried wide relevance to that practice. As such, other sources of relevant data may not have been captured. Therefore, there are gaps in the existing literature and as previously discussed, future research is warranted to explore methods for facilitating physical activity adherence for this high risk and vulnerable population. The exclusion criteria utilized for the literature search limited the fmdings to certain populations with depression, in order to focus the literature to the scope of this project. This may have created some bias in the applications of the findings. The author of this project is a clinical exercise specialist, which may have introduced some bias in the interpretation of the literature and conclusions. Finally, this project assumes that NPs are practicing with a PHC approach, though it must be acknowledged that the scope ofNP practice across Canada is varied, as are the work settings ofNPs. Consequently, the uptake of the practice recommendations may be restrained by the practice setting and scope of practice. 64 Conclusion Depression is a significant problem in Canada. Also of great concern is the declining overall health of Canadian adults, due in great part to sedentary lifestyles. This integrative literature review examined how NPs in Canada can facilitate adherence to physical activity for adults with mild to moderate depression using a primary health care approach to practice. Background knowledge of depression, physical activity and adherence was presented. A comprehensive search of the contemporary literature was undertaken and 15 studies were selected for review. The evidence was critically appraised on the basis of the strengths of the evidence and its relevance to the Canadian health care context. Key fmdings from this integrative review included reduced baseline fitness and adherence to exercise for adults with depression, positive effects on mood from mild to moderate intensity exercise, challenges in health promotion within primary care, and the need for interdisciplinary approaches, including counselling techniques based on psychological theory, to facilitate adherence to physical activity in those with depression. Recommendations for practice were presented using the SA's approach and include the need for application of counselling techniques theories, exercise prescription and interdisciplinary approaches to promoting adherence to physical activitiy. In addition, recommendations for further research that builds upon gaps in the existing literature and examines long-term outcomes were presented as well as recommendations for education that included the need to primary care providers to build upon their knowledge and to follow clinical guidelines and practice recommendations. In conclusion, this project shows that NPs have the capacity to facilitate and improve physical activity adherence for adult patients with depression. This project adds to current literature regarding exercise adherence by focusing on the role of the nurse practitioner, and adding 65 specific practice strategies that target adults with depression, in order to improve adherence to physical activity and overall health outcomes. This is particularly important in light of the burgeoning impact of obesity, sedentarism, and chronic conditions in Canada today, and in particular for this high-risk and vulnerable population of patients with mild-to moderate depression. 66 GLOSSARY All citations from Medical Dictionary (2014) unless othefWise indicated. adherence: the extent to which patients follow the instructions they are given for prescribed treatments (Bissonnette, 2008) allostatic load: physiological consequences of chronic exposure to fluctuating or heightened neural or neuroendocrine response that results from repeated or chronic stress Alzheimer's disease: a degenerative brain disease of unknown cause that is the most common form of dementia, that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood, that leads in advanced cases to a profound decline in cognitive and physical functioning, and that is marked histologically by the degeneration of brain neurons especially in the cerebral cortex and by the presence of neurofibrillary tangles and plaques containing beta-amyloid anandamide: a derivative of arachidonic acid that occurs naturally in the brain and in some foods (as chocolate) and that binds to the same brain receptors as the cannabinoids (as THC) autonomic nervous system: a part of the vertebrate nervous system that innervates smooth and cardiac muscle and glandular tissues and governs involuntary actions (as secretion, vasoconstriction, or peristalsis) and that consists of the sympathetic nervous system and the parasympathetic nervous system Beck Depression Inventory (BDI): a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression and is a reliable assessment for the severity of depression (Beck, et al., 1961) biosynthesis: production of a chemical compound by a living organism cancer: a malignant tumor of potentially unlimited growth that expands locally by invasion and systemically by metastasis cannabinoid: any of various chemical constituents, as THC (tetrahydrocannabinol) of cannabis or marijuana chronic fatigue syndrome: a disorder of uncertain cause that is characterized by persistent profound fatigue usually accompanied by impairment in short-term memory or concentration, sore throat, tender lymph nodes, muscle or joint pain, and headache unrelated to any preexisting medical condition and that typically has an onset at about 30 years of age chronic obstructive pulmonary disease: pulmonary disease (as emphysema or chronic bronchitis) that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation 67 circadian: being, having, characterized by, or occurring in approximately 24-hour periods or cycles (as of biological activity or function) cognitive behavioural therapy: a type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behavior patterns or treat mood disorders such as depression (Craft & Perna, 2004) cortisol: a glucocorticoid C21 H30 0 5 produced by the adrenal cortex upon stimulation by ACTH that mediates various metabolic processes (as gluconeogenesis), has antiinflammatory and immunosupressive properties, and whose levels in the blood may become elevated in response to physical or psychological stress Crohn's disease: chronic ileitis that typically involves the distal portion of the ileum, often spreads to the colon, and is characterized by diarrhea, cramping, and loss of appetite and weight with local abscesses and scarring diabetes mellitus: a variable disorder of carbohydrate metabolism caused by a combination of hereditary and environmental factors and usually characterized by inadequate secretion or utilization of insulin, by excessive urine production, by excessive amounts of sugar in the blood and urine, and by thirst, hunger, and loss of weight depression: a mood disorder marked especially by sadness, inactivity, difficulty with thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal thoughts or an attempt to commit suicide endorphin: any of a group of endogenous peptides (as enkephalin and dynorphin) found especially in the brain that bind chiefly to opiate receptors and produce some of the same pharmacological effects (as pain relief) as those of opiates erectile dysfunction: chronic inability to achieve or maintain an erection satisfactory for sexual intercourse excessive exercise: dysfunctional exercise behavior in when exercise is undertaken solely to influence weight or shape, or when the postponement of exercise is accompanied by intense guilt, and unlikely to be associated with impairment in psychosocial functioning in the absence of eating disorder psychopathology (Mond, Hay, Rodgers & Owen, 2006) exercise: a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness (Caspersen et al., 1985) fitness: a set of attributes that are either health- or skill-related, and the degree to which people have these attributes can be measured with specific fitness tests (Caspersen et al., 1985) 68 gamma-aminobutyric acid (GABA): an amino acid C4 H9N02 that is a neurotransmitter that induces inhibition of postsynaptic neurons ghrelin: a 28-amino-acid peptide hormone that is secreted primarily by stomach cells with lesser amounts secreted by other cells (as of the hypothalamus), that is a growth hormone secretagogue, and that has been implicated in the stimulation of fat storage and food intake glucocorticoid: any of a group of corticosteroids (as cortisol or dexamethasone) that are involved especially in carbohydrate, protein, and fat metabolism, that tend to increase liver glycogen and blood sugar by increasing gluconeogenesis, that are anti-inflammatory and . . Immunosuppressive glutamate: a salt or ester of levorotatory glutamic acid that functions as an excitatory neurotransmitter haemodialysis: the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein HIV (human immunodeficiency virus): any of several retroviruses and especially HIV-1 that infect and destroy helper T cells of the immune system causing the marked reduction in their numbers that is diagnostic of AIDS homeostasis: the maintenance of relatively stable internal physiological conditions (as body temperature or the pH of blood) in higher animals under fluctuating environmental conditions; also: the process of maintaining a stable psychological state in the individual under varying psychological pressures or stable social conditions in a group under varying social, environmental, or political factors Huntington's disease: a progressive neurodegenerative disorder that is inherited as an autosomal dominant trait, that usually begins in middle age, that is characterized especially by choreiform movements, emotional disurbances, and mental deterioration leading to dementia, and that is accompanied by atrophy of the caudate nucleus and the loss of certain brain cells with a decrease in the level of several neurotransmitters hypertension: abnormally high arterial blood pressure that is usually indicated by an adult systolic blood pressure of 140 mm Hg or greater or a diastolic blood pressure of 90 mm Hg or greater, is chiefly of unknown cause but may be attributable to a pre-existing condition (as a renal or endocrine disorder), that typically results in a thickening and inelasticity of arterial walls and hypertrophy of the left heart ventricle, and that is a risk factor for various pathological conditions or events (as heart attack, heart failure, stroke, end-stage renal disease, or retinal hemorrhage) immunotherapy: treatment of or prophylaxis against disease by attempting to produce active or passive immunity 69 inflammation: a local response to cellular injury that is marked by capillary dilatation, leukocytic infiltration, redness, heat, pain, swelling, and often loss of function and that serves as a mechanism initiating the elimination of noxious agents and of damaged tissue inflammatory bowel disease: either of two inflammatory diseases of the bowel: crohn ' s disease or ulcerative colitis insulin: a protein hormone that is synthesized in the pancreas from proinsulin and secreted by the beta cells of the islets of Langerhans, that is essential for the metabolism of carbohydrates, lipids, and proteins, that regulates blood sugar levels by facilitating the uptake of glucose into tissues, by promoting its conversion into glycogen, fatty acids, and triglycerides, and by reducing the release of glucose from the liver, and that when produced in insufficient quantities results in diabetes mellitus leptin: a peptide hormone that is produced by fat cells and plays a role in body weight regulation by acting on the hypothalamus to suppress appetite and bum fat stored in adipose tissue magnetic resonance spectroscopy: a noninvasive technique that is similar to magnetic resonance imaging but uses a stronger field and is used to monitor body chemistry (as in metabolism or blood flow) rather than anatomical structures metabolic syndrome: a syndrome marked by the presence of usually three or more of a group of factors (as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and high fasting levels ofblood sugar) that are linked to an increased risk of cardiovascular disease and type 2 diabetes monoamine: an amine RNH 2 that has one organic substituent attached to the nitrogen atom; especially : one (as serotonin) that is functionally important in neural transmission motivational interviewing: a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence, defmed not by technique but by its spirit as a facilitative style for interpersonal relationship (Rollnick & Miller, 1995) multiple sclerosis: a demyelinating disease marked by patches of hardened tissue in the brain or the spinal cord and associated especially with partial or complete paralysis and jerking muscle tremor myocardial infarction (h eart attack): an acute episode of heart disease marked by the death or damage of heart muscle due to insufficient blood supply to the heart muscle usually as a result of a coronary thrombosis or a coronary occlusion and that is characterized especially by chest pain neurotrophic: relating to or dependent on the influence of nerves on the nutrition of tissue 70 nurse practitioners: health professionals who have achieved advanced nursing practice competencies at the graduate level of nursing education, to provide health care services from a holistic nursing perspective, integrated with the autonomous diagnosis and treatment of acute and chronic illnesses, including prescribing medications, within their legislated scope ofpractice (CRNBC, 2011b) obesity: a condition that is characterized by excessive accumulation and storage of fat in the body and that in an adult is typically indicated by a body mass index of 30 or greater osteoporosis: a condition that affects especially older women and is characterized by decrease in bone mass with decreased density and enlargement of bone spaces producing porosity and brittleness overtraining syndrome: the point at which an athlete exceeds his/her capacity for exercise, with both psychological and physiological components (Johnson & Thiese, 1992) oxidative stress: physiological stress on the body that is caused by the cumulative damage done by free radicals inadequately neutralized by antioxidants and that is held to be associated with aging Parkinson's disease: a chronic progressive neurological disease chiefly oflater life that is linked to decreased dopamine production in the substantia nigra and is marked especially by tremor of resting muscles, rigidity, slowness of movement, impaired balance, and a shuffling gait PHQ-9 (Patient Health Questionnaire): a self-administered version of the PRIME-MD (Primary Care Evaluation of Mental Disorders) diagnostic instrument for common mental disorders, the depression module (Kroenke, Spitzer, & Williams, 2001) pharmacotherapy: the treatment of disease and especially mental disorder with drugs physical activity: any bodily movement produced by skeletal muscles that results in energy expenditure, and can be categorized in daily life into occupational, sports, conditioning, household, or other activities (Caspersen et al., 1985) postpartum (postnatal) depression: moderate to severe depression in a woman after she has given birth, which may occur soon after delivery or up to a year later and most often occurring within the first 3 months after delivery primary care: the delivery of community-based clinical services focused on diagnosis, treatment and management of health conditions as well as health promotion and disease prevention (CNA, 2012b) primary care practitioner: practitioner that delivers primary care, in Canada a primary care physician or nurse practitioner 71 primary health care: a principle-based and comprehensive approach that aims to strengthen health systems and improve population health; it is promotive, preventive, curative, restorative, rehabilitative and palliative (CNA, 2012b) psoriasis: a chronic skin disease characterized by circumscribed red patches covered with white scales rheumatoid arthritis: a usually chronic disease that is considered an autoimmune disease and is characterized especially by pain, stiffness, inflammation, swelling, and sometimes destruction of joints sedentary: doing or requiring much sitting : characterized by a lack of physical activity self-determination theory: a theory of motivation concerned with supporting our natural or intrinsic tendencies to behave in effective and healthy ways, which rests on a human ethic and reflects a psychological reality that people should have the freedom of choice (Corrigan et al., 2012) self-efficacy: a measure of one's own ability to complete tasks and reach goals (Plonczynski, 2000) serotonin (5-HT, 5-hydroxytryptamine): a phenolic amine neurotransmitter C10H12N20 that is a powerful vasoconstrictor and is found especially in the brain, blood serum, and gastric mucous membrane of mammals social cognitive theory: a multifaceted approach that addresses the personal and sociostructural determinants of health and the reciprocal interplay between self-regulatory and environmental determinants of health behavior; people's beliefs in their collective efficacy to accomplish social change play a key role in the policy and public health approach to health promotion and disease prevention (Bandura, 1998) stroke: sudden diminution or loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction (as by a clot) of a blood vessel of the brain systemic lupus erythematosus: an inflammatory connective tissue disease of unknown cause that occurs chiefly in women and that is characterized especially by fever, skin rash, and arthritis, often by acute hemolytic anemia, by small hemorrhages in the skin and mucous membranes, by inflammation of the pericardium, and in serious cases by involvement of the kidneys and central nervous system testosterone: a male hormone that is a crystalline hydroxy steroid ketone C 19H2s02produced primarily by the testes or made synthetically and that is the main androgen responsible for inducing and maintaining male secondary sex characteristics transtheoretical model (stages of change model): a theory in which behaviour change is conceptualized as a process that unfolds over time and involves progression through a series 72 of five stages: precontemplation, contemplation, preparation, action, and maintenance (Plonczynski, 2000) ulcerative colitis: a chronic inflammatory disease of the colon that is of unknown cause and is characterized by diarrhea with discharge of mucus and blood, cramping abdominal pain, and inflammation and edema of the mucous membrane with patches of ulceration 73 REFERENCES Ainsworth, B.E., Haskell, W.L., Herrmann, S.D., Meckes, N., Bassett Jr., D.R., TudorLocke, C ... 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Archives of Internal Medicine, 160(12), 1818-1823. doi:10.1001/archinte.160.12.1818 84 Appendix I Counselling Models for Facilitating Adherence to Physical Activity Counselling Practice Considerations Theoretical Concepts Model Behaviour change is a process that • Individuals may move through • Stages of the stages of change in a linear unfolds over time Change or cyclical manner Progression through five stages: • Model (SCM) pre-contemplation, contemplation, • Often reversion to prior stages in the process, and always the preparation, action, maintenance. (Plonczynski, of relapse into sedentarism risk Adhering to exercise would be in • 2000) the action or maintenance phases, • Assessing stage of change is the first step of assessing readiness which is the goal of adherence for exercise • A theory of motivation concerned • The key in practitioner-patient Selfrelationship is informed choice, with supporting our natural or Determination intrinsic tendencies to behave in complete with understanding. Theory (SDT) effective and healthy ways, which • The informed choice of concern rests on a human ethic and reflects is the choice to exercise, with (Corrigan et a psychological reality that people the desired outcome of al., 2012; should have the freedom of choice improving health Teixeira et al. , • There is good evidence for SDT in 2012) understanding exercise behaviour Social Cognitive Theory (SCT) (Bandura, 1998; McAuley, 1992) Motivational Interviewing (MI) (Hettema, Steele & Miller, 2005; Rollnick & Miller, 1995) • A multifaceted approach that addresses the personal and sociostructural determinants of health and the reciprocal interplay between self-regulatory and environmental determinants of health behavior • Self-efficacy is a measure of one's own ability to complete tasks and reach goals • Self-efficacy is intrinsically linked to motivation, and as the adhering to exercise becomes more difficult self-efficacy plays a more important role • A directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence • Differentiated into two phases: the first focused on increasing motivation for change, and the second on consolidating commitment • People's beliefs in their collective efficacy to accomplish social change play a key role in the policy and public health approach to health promotion and disease prevention • The individual with greater selfefficacy is more likely to adhere to sufficient regular exercise • Health care providers such as NPs play a role in motivating patients • Widely used as a method for health promotion and physical activity counselling among a variety of health and wellness practitioners • Defmed not by technique but by its spirit as a facilitative style for interpersonal relationship 85 Appendix II The Transtheoretical Model: Patient Perceptions and Role of the Health Care Provider based on content from Norcross ' Krebs and Prochaska' 2011 ' STAGE OF CHANGE What happens during each stage: The patient has no Precontemplation intention to change behaviour in the foreseeable fUture Contemplation Preparation Action Maintenance The patient is aware that a problem exists and is seriously thinking about overcoming it but has not yet made a commitment to take action The patient intends to take action in the next month and is reporting some small behavioural changes ("baby steps") The patient has successfUlly altered the dysfUnctional behaviour for a period of 1 day to 6 months The patient is remaining free of the problem and/or consistently engaging in the new behaviour for more than 6 months Patient perceptions and challenges: Potential role of the health care provider: Pre-contemplators are unaware or underaware of their problems, however peers may be well aware that the patients suffers from the problems Contemplators struggle with their positive evaluations of their dysfUnctional behaviour and the amount of effort, energy, and loss it will cost to overcome it Preparing patients have not yet reached the criterion for effective action Nurturing parentjoining with the resistant and defensive patient, developing a respectfUl relationship Socratic teacher encouraging the patient to achieve their own insight into their condition Experienced coach provide a fme game plan or review the patient' s own game plan The patient modifies Consultant- available behaviour, to provide expert experiences, and/or advice and support environment to when action is not progressing smoothly overcome the problem( s) in the most overt stage of change, requiring considerable commitment oftime and energy Patients work to In lengthy provider prevent relapse and relationships consolidate the gains consulting is less often attained during action as the patient experiences greater autonomy and ability to live free from previously disabling problems Appendix III 86 Linking Motivation, Self-efficacy and Intention (Plonczynski, 2000) Motivation Self-efficacy Intention • The primary goal for health care providers promoting lifestyle modification is the facilitation of the individual's internal motivation Motivation may be defined as the intrinsic determination toward goal • attainment Motivation is concerned with initiation as well as maintenance of a • behaviour Motivation is at the crux of health behaviour performance and thus, to a • great extent, health • Motivation is an antecedent to exercise • Self-efficacy is the best known predictor of health behaviour, yet there is more to motivation than self-efficacy • Self-efficacy is defmed as confidence and is a good predictor of intention • Self-efficacy is the primary mediator of change in behaviour, and this is mediated through cognition • Cognition is seen as mediating an initial change from which evolves success and subsequent self-efficacy • Individual attitudes and social norms are accurate predictors of intentions • Intention is a significant indicator of a behaviour's performance Strategies for Practice to Facilitate Exercise Adherence (Ockene, et al., 2002) Primary health care providers should, at a minimum: • Promote regular physical activity by taking a physical activity history • Provide pamphlets/advice regarding general principles of physical activity • Recommend 30 minutes per day of regular, moderate-intensity activity Additional recommendations to enhance counselling adherence included: • Simplify the regimen • Tailor the regimen to the patient's lifestyle and needs • Ask the patient about adherence at every visit • Have the patient bring an exercise log for review • Involve the patient as a partner in the treatment process • Provide clear written and oral instructions • Use behaviour strategies such as reminder systems, cues, self-monitoring, feedback and reinforcement 87 Appendix IV Assessing Readiness for Exercise and Exercise Planning Cardiorespiratory Fitness (Stamatakis et al. , 2012) Calculate non-exercise test of cardiov ascular fitness using the following equation: NET-F (METs) =[(sex coefficient x 2.78)- (age x 0.11)- (BMI x 0.17)- (RHR x 0.05) - (physical activity level coefficient) + 21.41] = maxMETs ... where: • NET-F =non-exercise test of cardiorespiratory fitness • MET = metabolic equivalent of V0 2max (maxMETs = maximum threshold) o 1 MET corresponds to an oxygen consumption of 3.5 mL/kg/min (based on a 70 kg man age 40 years) , and is roughly equivalent to the energy cost of sitting quietly. • Sex coefficient = 1 for men, 0 for women • BMI = body mass index = kg/m 2 • RHR = resting heart rate = beats per minute • Physical activity level coefficients: (MVPA =moderate-to-vigorous physical activity) Level Physical activity Coefficient inactive (no physical activity of any intensity reported) 0.00 1 regular domestic activity only or < 1.5 MVPA sessions/week 2 0.35 1.5 to <3 MVP A sessions/week 0.29 3 3-6 MVP A sessions/week 0.64 4 >6 MVP A sessions/week 5 1.21 Training Intensity Calculating an appropriate training intensity: Training METs =[(appropriate% intensity)+ maxMETs] I 100 x maxMETs Appropriate intensity: For aerobic training, dose of exercise should vary from 40% of maxMETs for poorly conditioned and/or symptomatic persons up to 85% ofmaxMETs for well-conditioned athletic persons. A training intensity of 60-70% of maxMETs , the average level of anaerobic threshold, is typically prescribed for most healthy, asymptomatic individuals when performing continuous aerobic training. (Jette, Sidney & Bliimchen, 1990) vanous . plhIYSlca . I acti VI"ti es an d energy consume d"lD MET s per h our (Ai nsworth eta., n .. d) Activity Walking slowly, less than 2 mph Gardening, light General house cleaning Walking briskly, 3 mph Heavy yard work or gardening Climbing stairs Bicycling casual less than 10 mph Dancing (ballet or modem) Snorkeling Mowing lawn with hand mower METs/hr 2.0 2.0 3.0 3.3 4.0 4.0 4.0 4.8 5.0 5.5-6.0 Activity Shoveling snow Strenuous hiking Rowing or kayaking Skiing, downhill Bicycling, 10-16 mph Aerobic calisthenics Singles tennis Swimming, crawl, slow Running, 8 mph The FITT Principle for Physical Activity Prescription (Barkley, 2010) Principle: Frequency Intensity Type Time Explanation: number of sessions per week level of exertion type of exercise activity duration of exercise session METslhr 6 6-7 6-8 6-8 6-10 6-10 7-12 8.0 13.5 Example (meeting adult guidelines): 5 days per week moderate walking, level surface 30 minutes 88 Appendix IV Assessing Readiness for Exercise and Exercise Planning Template for the Clinical Setting SUBJECTIVE DATA: (In addition to a full medical and mental health history) Current physical activity habits: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Past Physical Activity History: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Barriers to exercise: - - - - - - - - - - - - - - - - - - - - - - - - - Potential facilitators to exercise: - - - - - - - - - - - - - - - - - - - - SocialSupports: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ OBJECTIVE DATA: (In addition to full physical exam and appropriate investigations) PHQ-9: ____ For the following equations refer to the reverse page: Cardiorespiratory Fitness: 1. sex coefficient _ _ _ x 2. 78 =_ _ _ -7 2. age x 0.11 = -7 - _ __ 3. BMI x 0.17 = -7 - - - 4. RHR x 0.05 = -7 - ____ 6. physical activity level coefficient _ _ _ -7 - _ __ maxMETS Training intensity: %intensity maxMETs +- - - maxMETs x- - - + 21.41 100 _ _ _ =Training METs PLAN: Stage of behaviour change: _ _ _ _ _ _ _ __ SMART goals: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ FITT exercise Rx: Frequency _ _ _ _ _ _ __ Intensity _ _ _ _ _ _ _ __ Type _ _ _ _ _ _ _ _ __ Time ---------Confidence Interval: How confident are you that you (the client) could follow this plan? _ _ (0 - 10) Appendix V 89 The SA's Approach: How nurse practitioners in Canada can facilitate adherence to physical activity for adults with mild to moderate depression through primary health care Recommendations Steps Ask About ' Advise on • • • • • • • • Assess history of physical activity Assess stage of behaviour change, readiness for exercise Assess barriers and facilitators to exercise and potential strategies, including social supports Ask often- every visit! Educate patients on the benefits and risks of physical activity for health and depressive symptoms Public health recommendations for physical activity: CSEP.calguidelines 7150 minutes per week, > 10 minutes per session, 10,000 steps per day Safe progression- build up time, start at mild and progress to moderate intensity Provide written copies of advice and resources Agree Upon • • • Respecting the patient's choice (self-determination theory) SMART goal-setting with short and long-term objectives Tailored exercise prescription in the format of frequency, intensity, type and time (FITT) Assist • Patient counselling including stage of behaviour change and motivational interviewing Follow up often, listen to the patient's concerns, challenges and experiences Share success stories Congratulate small successes and avoid criticism Encourage self-monitoring such as exercise logs Refer to community programming Lead by example! Stay active yourself • • • • • • Arrange a Plan • • • Review the action plan at every visit and refme according to patient progress Use structured planning when including other care providers and social supports in the ongoing plan Use reminder systems, consider electronic communication