Educator perspectives on the physical activity promotion training provided for future mental health care professionals in Aotearoa New Zealand

He Ara Oranga, the government inquiry into mental health commissioned in 2018,¹ stemmed from widespread concern about the mental health of people residing in Aotearoa New Zealand and the mental health services on offer. A rapid increase in depressive symptoms among young people and adults was one of many trends that justified this level of concern. For example, the prevalence of depressive symptoms nearly doubled among youths (13–17-year-olds) from 2012 to 2019, growing from 13.0% to 22.7%.² Similarly, the rates of depression among adults (≥15 years) increased from 19.9% to 29.0% between 2016–2017 and 2021–2023.³ These trends reinforce the clear and urgent need for solutions to address New Zealand’s worsening mental health situation.

Physical activity promotion may be part of the solution. There is compelling evidence physical activity can be effective at preventing and treating depression.^4,5 Despite this, 42.0% of adults and 41.9% of young people residing in New Zealand do not meet the current physical activity recommendations (<18 years: ≥60 minutes/day; ≥18 years: ≥150minutes/week).^6–8 These levels of physical activity are consistent with international evidence.⁹

Promoting physical activity within the healthcare system has the potential to increase physical activity rates and improve mental health.¹⁰ Despite this, physical activity promotion by healthcare professionals is not currently standard practice, including for those delivering mental health care. This is attributable, in part, to a lack of training and expertise to promote physical activity on the part of practitioners.^11,12 Internationally, formal education in physical activity promotion for healthcare practitioners has long been largely absent.^13–15 However, evidence suggests that training in physical activity promotion can improve the knowledge^16–18 and efficacy/competence^18–21 of future health professionals.

The level of formal education in physical activity promotion offered to future mental healthcare professionals in New Zealand is currently unclear. The overarching goal of this study was to examine educator perspectives on the training in physical activity promotion of future mental health practitioners within the tertiary sector in New Zealand. Specifically, we aimed to determine what, if any, physical activity promotion training is offered to future mental health care professionals during their tertiary education in New Zealand and how this could be improved in future.

Methods

Participants and recruitment

Educators involved in the co-ordination and/or delivery of tertiary education for accredited qualifications that lead to registration as a doctor, nurse, psychiatrist, psychologist or social worker were recruited via email to participate in an online survey. Though counsellors do not have to be formally registered in New Zealand, we recruited participants involved in New Zealand Association of Counsellors Accredited Counsellor Educator Programmes.²² The institutional email addresses of participants were obtained from the websites of their respective institutions. Participation was voluntary; no incentives were offered. This research was approved by the Te Herenga Waka—Victoria University of Wellington Human Ethics Committee (0000030955).

Measures

Educator characteristics

Educators self-reported the profession (i.e., counselling) associated with their qualification, their experience in delivering education (years) and their ethnicity.

Perspectives on physical activity promotion education

Educators reported whether their qualification offers any formal education in physical activity promotion (yes/no). Those who responded “yes” were asked to respond to open-text questions describing: i) what the education encompasses; ii) what improvements to the education could be made; iii) how the education prepares students for the workforce; and iv) how, if at all, Te Ao Māori is incorporated. Those who responded “no” were asked to respond to open-text questions describing: i) why their qualification does not contain any education; ii) what would be important to include in such education were it to be offered; and iii) how Te Ao Māori should be included into this education. All educators were also asked to rate the importance of training in physical activity promotion to each profession on a scale ranging from zero (very unimportant) to 10 (very important), and whether physical activity should be included as a core competency required to register with their professional accrediting body (yes/no).

Analyses

Descriptive statistics were computed using Microsoft Excel. Qualitative data were analysed using descriptive thematic analysis. Two research team members read and re-read open-text question responses to familiarise themselves with data, and met to develop a codebook and define how data would be coded. Data were then coded and themes were generated, reviewed and refined.^23,24

Results

Educator characteristics

Responses were received from 90 educators. Half were involved in psychology (n=27, 30.0%) or nursing (n=18, 20.0%) qualifications. Educators involved in counselling (n=15, 16.7%), social work (n=8, 8.9%), medicine (n=8, 8.9%) and psychiatry (n=7, 7.8%) were also recruited. On average, educators had been involved in the training of future mental health care professionals for more than 14 years (M=14.4 years, standard deviation [SD]=11.0 years). Among those who reported their ethnicity, most were New Zealand European (n=47, 52.2%), followed by Māori (n=6, 6.7%), Asian (n=5, 5.6%), Middle Eastern and Latin American (n=4, 4.4%) and Pacific peoples (n=2, 2.2%).

Current status of formal training in physical activity promotion

Less than a third (n=22, 29.7%) of educators indicated that their qualification offers formal training in physical activity promotion. Fifteen offered insight into how this education is delivered. The most common delivery method is within a module (n=7), followed by informally (n=6), courses/papers (n=4), seminars (n=4) and workshops (n=2). Almost all of these respondents stated that the physical activity education is relatively minor. Two others commented that education is offered as a means of promoting self-care or awareness of students’ personal physical activity as well as promoting physical activity to clients:

“We talk about the importance of physical activity and impact on mood, mindfulness, sensory modalities, trauma but also about connectivity with others and being involved. It’s important for us to ensure that students are aware of their own physical wellbeing and promotion of such activities to others who are experiencing mental ill health.” – Nurse educator

Why formal training in physical activity promotion was not offered

Three themes were identified regarding why training in physical activity promotion is not being offered: it is not a priority; it is outside of the scope of practice; and there is a lack of space within the curriculum. Thirteen educators indicated that training in physical activity promotion is not a priority. However, some were unsure why this is the case. For example, one commented “I am not sure, as I didn’t develop the courses. We briefly discuss the importance of physical activity in our mental health and addictions paper. But with no real educational/theory-based aspects” (social worker educator). Eleven educators indicated that physical activity education was outside of their scope of practice. Comments included the following: “Currently it would [be] deemed outside of our scope of practice as a counsellor and therefore out of our curriculum” (counsellor educator), “NZ [New Zealand] psych board standards do not consider physical activity to be a core competency” (psychologist educator) and “It isn’t mentioned in the curriculum document—we do incorporate it informally into lecture content, but we can't officially assess it or devote much time to it” (nurse/social worker educator). Ten participants mentioned a lack of space within the curriculum. Comments included: “The curriculum is full with core content specific to undertaking the role” (nurse educator), and “[There is] limited time to cover a range of core course content” (social worker educator). Such comments indicate the constraining effect of the curriculum and scopes of practice on ensuring physical activity content is included.

What training in physical activity promotion should include

Eleven educators commented on the need for evidence-based education. For example, one commented on the need to “discuss the existing research literature that physical exercise can have beneficial effects on a range of psychological disorders” (psychology educator). Convincing students of the value of physical activity education and community programmes to promote physical activity through their training was seen as pivotal:

“Research evidence that shows that increased physical activity, even in moderate amounts, could not only prevent future mental health conditions in the population, but could also alleviate or improve symptoms among those who are already suffering from these conditions. Furthermore, it is cost effective and there are numerous free services available to the public to access these services with the support of a professional, e.g., Green Prescription.” – Medical educator

Thirteen commented on promoting student physical activity. For example, one commented: “I would love for the students to have more access and understanding re physical activity for themselves. There are a number of students experiencing anxiety/depression” (nursing educator). Another educator acknowledged the need for inclusion of Māori models of health, stating that there “would need to be a balanced approach that put physical activity in line with other health domains such as those included in Te Whare Tapa Whā” (counselling educator).

How could training in physical activity promotion be improved

The main theme concerning how training in physical activity promotion could be improved was the creation of space within the curriculum, which was mentioned by 12 educators. Other suggestions included: “Including cultural aspects and getting cultural consultations. Focus on preventative medicine through physical activity” (psychology educator) and “More resourcing [staff], resourcing is main constraint” (medical educator).

How training in physical activity promotion currently prepares students

Educators described physical activity training as not being a priority and not adequately preparing students for health practice. Thirteen commented on issues of prioritisation or a lack of preparedness for the workplace. For instance, one participant commented: “There is so much to cover and physical activity promotion isn’t prioritised as heavily” (nursing educator). These responses acknowledged competing demands for teaching time: “There are other more important aspects to consider” (medical educator). Two commented on how the current education provides students with a more holistic understanding of health. For example, one commented that education “equips [students] with necessary skills to respond to the presenting needs of whaiora [Māori health providers] in a holistic manner beyond the medical model” (nursing educator), which implies the skills to promote physical activity effectively are embedded in the educational programme without necessarily receiving specific training.

Importance of training in physical activity promotion

Participants rated formal education in physical activity promotion as important for all professions: doctors (M=8.5, SD=1.5), nurses (M=8.4, SD=1.4), social workers (M=8.2, SD=1.5), psychiatrists (M=8.0, SD=1.6), psychologists (M=8.9, SD=1.8) and counsellors (M=7.7, SD=1.9). Despite the reported importance, less than a third (n=27) of educators supported physical activity promotion being a core competency. The justification given for this was that it would be too complicated to formalise and incorporate into education. Five cited the lack of space within the curriculum. Representative comments include “As much as I value physical activity personally, I see that there are so many other areas to be covered in training, and time is already limited” (counselling educator), and “Because there are so many other aspects to consider, and physical activity can be challenging for some people including those with severe disabilities” (counselling educator). Such responses de-prioritise physical activity or see it as only suitable for some client groups. Eight expressed concern about the harm that physical activity promotion could cause by exacerbating discrimination/disparities. Rather than addressing mental distress, physical activity was described as having the potential for increasing shame and stigma:

“My concern is that it may devalue the experiences and lives of people with disabilities or physical impairment—lived experience of issues is very important within social work. Also, if required to promote physical activity to those same groups of people may be inappropriate or contribute to social stigma felt by those individuals.” – Social worker educator

Eighteen referred to barriers to formalising such education, such as displacement of existing treatments, not being important enough to warrant being a core competency, and being embedded within existing competencies. As an illustration, one commented: “We have 10 others already, which we are required to demonstrate as a part of continued registration. Physical activity promotion would probably be better incorporated into existing competencies” (social worker educator). Those who were supportive of physical activity promotion being a core competency expressed concerns about the implementation of such education:

“I think as a concept, it is worthwhile to include that but we also need to think about how to implement it. Things like will you have a module in there and whether students have to participate in some kind of physical activity as part of their requirement? Or will it be more about conceptual?” – Counselling/social worker educator

Incorporation of Te Tiriti o Waitangi principles

Most (n=14) indicated Te Tiriti o Waitangi principles are not included within current training in physical activity promotion. Six indicated that Te Ao Māori is incorporated into their education, several of whom mentioned Te Whare Tapa Whā. Māori models of health were described as including self-care and broader wellbeing:

“Te Whare Tapa Whā makes reference to the importance of being physically well and active, students are linked into Te Ao Māori models such as this and taught how to incorporate Te Ao Māori into work that they do in professional practice around promoting self-care and wellbeing in others, especially in relationship to crisis management, grief and trauma.” – Social worker educator

In response to how Te Ao Māori could be incorporated into the education in physical activity within their programme, one commented that “whenua, connection to land, moana, connection to the sea, the holistic view of wellness” (counselling educator) could be covered. Although some explained physical activity is integrated with their Te Ao Māori education, others saw this more in terms of mental health than physical activity: “Have a large focus on Te Ao Māori approaches to mental health but not hugely integrated with the physical activity focus” (social worker educator). The inclusion of Te Ao Māori approaches was acknowledged as an area for improvement: “I need to improve this aspect but we do cover it in one lecture and three practicals with Māori providers teaching alongside me from our community” (nursing educator). Educators expressed a desire for further training on Te Ao Māori and acknowledged the need to engage with Māori colleagues.

Discussion

Efforts to promote the physical activity participation and mental health of both youths and adults in New Zealand are urgently needed.^2,3,6–8 Despite the well-established relationship between physical activity and mental health and evidence that physical activity can be effective at preventing and treating mental illnesses,^4,5 formal training in physical activity promotion for healthcare professionals appears to be uncommon in New Zealand. Educators communicated three main reasons that formal training in physical activity promotion is not being offered: it is not a priority; it is outside of the scope of practice; and there is a lack of space within the curriculum. Similar explanations were offered as to why physical activity promotion is not a core competency. Most educators were unsupportive of physical activity promotion being a core competency for professional registration despite them also rating physical activity promotion as an important skill for practitioners. Concerns were also expressed about the harm that physical activity promotion could cause by displacing other material or by exacerbating discrimination/disparities for marginalised groups.

Concerns about physical activity disparities are not unwarranted. Physical activity differs based on age, gender, ethnicity, disability, socio-economic status and geographic location in New Zealand.^6–8 Formal education in physical activity promotion could equip the future workforce of mental health practitioners with the knowledge and experience to tailor care to the needs and preferences of each client/patient and mitigate perpetuation of existing disparities by making them aware of the opportunities to intervene. For example, helping raise awareness among young people with disabilities and their families/caregivers about the opportunities to participate in physical activity within their community may help to address inequities.²⁵

Though findings suggest that integrating physical activity promotion into the formal education of health practitioners may be challenging, educators offered insights into what such education could look like. The key suggestions included providing education on physical activity promotion that is evidence based and encouraging student physical activity participation as part of their learning experience. There is strong evidence supporting the integration of training in physical activity promotion into the formal education pathways of future mental health care professionals. Such education can improve students’ knowledge^16–18 and efficacy/competence^18–21 in promoting physical activity. Calls from educators to promote the physical activity of students are also supported by evidence, as physical activity participation among practitioners is associated with them delivering more effective physical activity promotion and counselling.²⁶ With students studying health in New Zealand experiencing poor mental health themselves,^27,28 student physical activity promotion would serve to promote students’ personal wellbeing too.

Educators were supportive of incorporating Te Tiriti o Waitangi principles and Te Ao Māori into existing physical activity education. Multiple educators mentioned Te Whare Tapa Whā, a Māori health model underpinned by the concepts of taha whānau (family), taha tinana (physical), taha hinengaro (mental) and taha wairua (spiritual) health.²⁹ Indeed, He Ara Oranga¹ outlined the need for specific training of healthcare professionals in Māori culture. While many acknowledged the need to engage with Māori colleagues to incorporate Te Ao Māori into physical activity promotion education, the impact of this engagement on Māori faculty and staff requires consideration and acknowledgement.³⁰

In conclusion, physical inactivity is just one of many issues (alcohol and substance use, poverty, etc.) that need to be addressed to improve mental health wellbeing in New Zealand. Recently, the New Zealand Government has increasingly prioritised prevention and early intervention in relation to mental health.³¹ For example, initiatives such as the access and choice programme position mental health practitioners to catch issues before they escalate.³² New Zealand’s Green Prescription, a primary care physical activity prescription programme, is an example of an existing scalable initiative that could be expanded to empower healthcare professionals beyond general practitioners to address mental health more comprehensively.^33–35 Importantly, varying levels of expertise in exercise prescription and/or physical activity promotion already exists at most tertiary institutions in New Zealand, which suggests that encouraging cross-pollination across disciplines may be a crucial first step to addressing the gaps we have identified in this study.

An evidenced-based formal education in physical activity promotion that incorporates Te Ao Māori and provides future healthcare professionals with the knowledge and experience to address disparities in both mental health and physical activity is aligned with the government’s priorities and has great potential. To realise this potential, we recommend that physical activity be prioritised in the education of future mental health care professionals. Educators and professional organisations can work together to ensure that physical activity is understood to be within the scope of practice, regardless of whether it is considered a core competency. More broadly, any changes to the education of mental health care professionals would need to be supported by additional investments and policies at local and national levels that promote physical activity by creating built and social environments that are conducive to lifelong physical activity participation for all New Zealanders.³⁶